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Contents Page
Performance Report Overview – Chief Executive Statement 3
About Us 6
Vision, Ambitions & Strategic Objectives 6
1. Delivering Against our Duties 7
2. Development Activity 19
3. Trust Organisational Development Strategy 23
4. Performance Summary 25
5. Performance Analysis 41
6. Sustainability Performance 2016-17 56
Appendix 1 – Performance Trend Analysis 2016-17 Summary 66
Appendix 2 – Progress against our Three Year Plan 81
Appendix 3 – Equality Annual Monitoring Report 88
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Performance Report overview
Chief Executive Statement - Mr. Steve Ham Velindre NHS Trust is a unique organisation within NHS Wales, delivering highly specialised services that are broad, complex, focused on excellence and keeping our patients and donors at the heart of everything we do. Underpinning everything about our business is our commitment to Quality, Care and
Excellence, ensuring patients, donors and the hospitals we supply all benefit from the highest
standards of care, innovation and professionalism across the dedicated range of services we
deliver.
Like the rest of NHS Wales, we are facing the combined challenge of rising costs and
increasing demand, while striving to continue improving the quality of care and patient /
donor outcomes. Inevitably, how to maintain these improvements, while continuing to meet
the needs of our population for Cancer, Blood and Transplant Services, is firmly at the
forefront of our thinking and planning for the coming year.
Our commitment, however, is to make sure we maintain our focus on providing an excellent
service and I am confident I speak for the whole Trust when I reassure you that we are up to
the challenge.
2016 - 17 has been a busy, productive and successful year for us and how we move forward
in delivering services into the future is an area we intend to build on during 2017 - 18. It is our
collective ownership of measures that will enable us to show how successful we are in
delivering our services in new and innovative ways, both in the coming year and beyond.
We recognise that the new Well-being of Future Generations (Wales) Act 2015 will have a transformative effect on our organisation. The Act has allowed us to consider the impact of what we do from a new, distinct perspective. Embedding the principles of sustainable development will likely lead us into exciting new areas and innovative, invigorating partnerships. The Act sets an expectation that we will work in different ways. We will embrace the opportunity that the Act provides to seek greater collaboration with other bodies. New strategic and operational relationships will result in the more effective integration of services and, also, to long term improvements to the well-being of the Welsh population. We have included within our three year plan and within this performance report our first well-being statement and set of well-being objectives. We anticipate that our objectives will evolve in future years as our appreciation of the wide reaching effects of the Act develops and as the sustainable development principles at the heart of the legislation are more thoroughly embedded across the organisation.
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This Performance Report and our Annual Quality Statement, provide wide ranging details
about our performance. Some of the highlights this year include:
The introduction of a pan Wales Blood Service. In May 2016, the Welsh Blood Service
took over responsibility for collecting blood donations in North Wales, making it a truly
national service for the whole of Wales for the first time. Coordinating the merger was a
huge challenge, and that the transition was seen through so smoothly and professionally
is testimony to the commitment and hard work of staff on all sides. To find out how our
service will operate as a national service please visit the Welsh Blood Service website via
the following link: https://www.welsh-blood.org.uk/about-us/all-wales-blood-service/
We have developed a Strategic Outline Programme (SOP), which was submitted to Welsh
Government, outlining our ideas on how cancer services in South East Wales could look
in the future. Welsh Government has given approval for us to take this programme
forward, which is excellent news and, to help shape a shared vision on how we should
develop these plans, we are now engaging with a range of stakeholders involved in cancer
services in South East Wales. The Programme Business Case (PBC) is being finalised.
Further information is available from the Velindre Cancer Centre website via the following
link: http://www.velindrecc.wales.nhs.uk/introduction
I am delighted to report that in June 2016, the Trust, in accordance with the set statutory
duty, had its Integrated Medium Term Plan (IMTP) covering the period 2016-17 to 2018-
19 approved by the Welsh Government. Having an approved IMTP in place is a key way of
demonstrating to all of our stakeholders that the organisation possesses the requisite
level of maturity to plan and deliver our services with confidence over a three year
period. The IMTP is refreshed on an annual basis and approved by our Board in March
each Year.
The IMTP for 2017 - 2020 reflects on progress against the key priorities, performance and
ambitions from the year 2016 - 2017, confirming that delivery/progress against objectives
was broadly in accordance with forecasts. This was submitted to Welsh Government in
March 2017. You can find our latest plan using the link below;
Delivering Excellence: our three year Integrated Medium Term Plan (IMTP)
In respect of our financial performance we reported a small surplus position for the year
ended 31st March 2017, as reflected in the Annual Accounts section of the Annual Report.
I am also pleased to report that we had yet another extremely successful year in 2016-
2017 with the Velindre NHS Trust Charity raising circa £2.7 million.
Our focus on excellence has seen us continue to improve the high quality services we provide
to our patients and donors. The details contained in this report show that we are maintaining
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and improving our performance in a range of vital areas however there is more to do and
areas that need further attention.
We will need to challenge ourselves and we intend to be bold. We will continue to develop our
Cancer Services in the context of the Transforming Cancer Services (TCS) programme and the
Blood and Transplantation services building on the establishment of a national service for
Wales. Our plan also highlights the importance we attach to innovation, research and
development. Work in these areas will have a positive effect on the health of the Welsh
population and will continue to raise the profile of both Wales and the Trust.
Our staff, volunteers, fundraisers and partners are firmly committed to delivering our goal of
‘Quality, Care and Excellence’. I am certain that by focusing on providing the best possible
patient and donor care in the most efficient way, we can continue to meet the challenges
ahead in 2017-18.
Signed:
Mr. Steve Ham
Chief Executive
Date: 22.6.2017
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About us
Established in 1994, Velindre NHS Trust (the Trust) provides a range of specialist services
at local, regional and all Wales levels. We provide two core services which includes Velindre
Cancer Centre and The Welsh Blood Service. We also host a number of organisations on behalf
of Welsh Government and NHS Wales.
You can find out more about our Service Divisions and Hosted Organisations in the
Accountability section of the Annual Report document.
Vision, ambitions and strategic objectives
We aim to clearly articulate our organisational vision, ambitions and strategic objectives to
deliver high quality services and care for our patients, donors, staff and stakeholders.
Our vision is that:
‘Velindre NHS Trust will be recognised locally, nationally and
internationally as a renowned organisation of excellence for patient and
donor care, education and research’
We have developed a set of overarching objectives that will enable us to achieve our
vision. These are:
Equitable and timely services;
Providing evidence based care and research which is clinically effective;
Supporting our staff to excel;
Safe and reliable services;
First class patient /donor experience; and
Spending every pound well;
Our vision and our objectives, alongside a range of national and local policies drive our
planning process. Last years’ approved Integrated Medium Term Plan provided a strong
foundation for the development of a clear set of actions for the next three years.
Underpinning our vision and overarching objectives we are in the process of embedding our
four core Organisational Values - BE Accountable, BE Bold, BE Caring and BE Dynamic. We
believe that by adopting these values into the heart of the organisation we will enable a
culture that supports transformational change to achieve world class services for our patients
and donors.
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1. Delivering against our Duties
National policy and drivers
The focus and direction of the Trust’s Integrated Medium Term Plan is determined by a range
of drivers which bring together national policy, Local Health Boards local needs assessment (in
their capacity as commissioners of our services) and the need to comply with statutory
requirements.
There are a number of important national strategies and policies which guide the
development and delivery of the services we provide and these are not all named explicitly
within the plan; we have instead focused on a few fundamental policies and principles in our
Delivering Excellence: our three year Integrated Medium Term Plan (IMTP).
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1.1 Equality, Diversity & Human Rights
This last year has seen recognition of the progress made by the Trust in achieving its Strategic
Equality Objectives. These objectives set out how the Trust will meet its duties under the
Equality Act 2010, building on its commitment to improve the lives of both its staff and
service users and set out actions to promote equality in health services.
Equality Objective/Outcome Action
The Trust has worked in partnership with other Local Health Boards and Third Sector organisations to promotes and provide awareness sessions, information, training and workshops for key awareness events such as Carers Week, Black History Month, Lesbian, Gay, Bisexual, Transgender (LGBT) History Month and Sensory Loss Awareness Month.
Development of short film for International Women’s Day https://youtu.be/qpz1mBWH2_k
Dignity training rolled out to all staff.
Domestic Abuse training and awareness available to all staff.
Velindre Cancer Centre Dignity Group to support dignified care.
Cares information and training provided.
Provide personalised care and treatment for patients.
Provide appropriate support for patients with Dementia and cognitive impairments.
Provide Mental Health First Aid training to key staff.
Development of staff equality training film with Iris in the Community.
Total Recurl was developed and made by Velindre Staff.
Velindre Trust is Stonewall Diversity Champions, raising 32 places
within the workplace index.
People are and
feel respected;
this includes staff,
patients, donors,
carers and family
members.
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We communicate
with people in ways
that meet their
needs (whether this
is via written
communication, face
to face, signage,
Welsh or other
community
languages including
British Sign
Language)
Improve collection of language information and communicate effectively with patients, their carers, donors and families in the language of their choice.
Access Matters group – improve all areas of access and communication at Velindre Cancer Centre including signage.
Development of British Sign Language (BSL) online training for staff.
Development of technology to meet the needs of patients and donors with Sensory Loss – i.e. Patient Buzzer, British Sign Language (BSL) Avatar project.
Development and publishing Welsh Bilingual strategy.
Improve accessibility and information on Trust, divisions and hosted websites.
Development of Velindre Equality Facebook page to share
good news stories and access staff support groups.
Equality Objective/Outcome Action
Action Equality Objective/Outcome
People receive
care and access
services that
meet their
individual needs.
Equality and dignity questions to be included in the monthly patient surveys
Partnership project using English as Second Language (ESOL) classes to provide Cancer and Health information
Transforming Cancer Service Equality Impact Assessment recommendation to engage with community groups in the design and refurbish facilities to explicitly meet the needs of patients, donors and visitors. Focus groups help and equality built into design reference groups
Welsh Blood Service – Use of accessible bleed chairs on sessions
Welsh Blood Service – Review data categories to look at accurate recording of gender to include transgender data.
Review and development of a further six books in the Caring for my family with cancer children’s books. To include more diverse families.
Bilingual, audio and British Sign Language Versions of the books launched.
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As a result of all this work the Trust has been recognised and shortlisted for a number of awards, such as:
Awards
Nursing Times Cancer Nursing.
Patient Experience Network (PEN) National Awards.
Corporate Health Standard Platinum. Shortlisted
Iris in the Community Short Film Awards.
Royal College of Nursing Institute (RCNi) Cancer Nurse Awards (May 2017).
Excellence Wales Awards (May 2017).
We have also taken the opportunity to inlcude our equality annual monitoring report data and
information at Appendix 3 of the Performance Annual Report.
Action
Analysis of staff equality data to assist in identifying actions if pay gap exists or a need for specialist training and positive action programmes.
Ensure all new positions undergo job evaluations.
Workforce and Organisational Development to look at Talent Management and succession planning.
Ensure all staff receive Personal Development Plans in a timely manner.
Support personal and professional development.
Review staff survey responses to measure improvements.
Staff are paid
fairly
Equality Objective/Outcome Action
Equality and dignity questions to be included in the monthly patient surveys.
Partnership project - Cancer Education via English as Second Language (ESOL).
All Wales Blood Service to work with community groups, to improve awareness and increase donations.
Work in partnership with Local Health Boards, Community Health Councils and the third Sector to identify need and patient and donor experiences.
Trust took part in community events such as Health Fairs, Pride and 3rd Sector events.
Transforming Cancer Services stakeholder and engagement event continuing to take place.
Improved
engagement
with public,
patients and
Donors
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1.2 Welsh Language
Supporting people to use their language of choice
We know that communication tailored to an individual’s needs is
an essential part of providing good quality and safe
care. Sometimes we care for patients and donors who speak a
different language, or use sign language. We use the Wales
Interpretations and Translation Service (WITS) to help us.
We have a Welsh Language Scheme to support provision of bilingual services to patients and
donors who wish to communicate in Welsh. During 2016/17 we have continued to promote
Welsh Language across our services. We ran Welsh language ‘Meet and greet’ courses in
partnership with Cardiff University, and some of our staff started a one year Welsh language
course.
We have focussed on the Welsh Language Strategic Framework, ‘More than just words…’ and
the introduction of the new Welsh Language Standards to ensure we can begin to provide an
‘active offer’ service to those who need Welsh language services. We see this as part of our
commitment to continuously strengthen our ability to provide individualised and patient and
donor centred care. We also ran an intense Welsh Language course for over 15 members of
staff to ensure Welsh language services can be increased.
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1.3 The Wellbeing of Future Generations Act - Our approach to the
Well-Being of Future Generations Act & Our Well-Being Statement
In April 2016, the Well-Being of Future Generations (Wales) Act came into effect. We see the
Act as an opportunity to ensure our services are not only fit for the future but that everything
we do is framed (without impacting current services) for the long term, considering
prevention, integration, collaboration and involvement.
Below, we have taken the opportunity to publish the Trust’s well-being objectives. Our
objectives have been developed in accordance with the sustainable development principle
defined in the Act and are intended to demonstrate how we will contribute to the realisation
of the shared well-being goals.
In a time of economic austerity and other constraints, the Act has provided us with an
opportunity to take stock and to consider what we can do to help make Wales a better place
in which to live in the decades to come. We believe that the objectives that we have set will
challenge us, individually and as an organisation, to think differently, to develop novel ways of
working and, simply, to do more.
The Act should promote tangible change in how we, and other public bodies across Wales,
operate. We are a provider of key, specialist health care services. Fulfilling this crucial role has
always been our principle focus, but we already do so much more. As the Chief Medical
Officer (CMO) for Wales has remarked in his annual report for 2015-16, Rebalancing
healthcare, the NHS in Wales has a far broader role than the delivery of healthcare services.
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We recognize that we are a major employer and we care about the well-being of our
colleagues and their families. We care about the communities in which we live and work and
the impact that we have on our environment. The Act and our own objectives give us licence
to challenge the status quo and to challenge ourselves, as never before, to think differently
about what we do and the potential consequences of our activities for future generations.
Our Well-Being objectives
1. Reduce health inequalities, make it easier to access the best possible healthcare when it is needed and
help prevent ill health by collaborating with the people of Wales in novel ways
2. Improve the health and well-being of families across Wales by striving to care for the needs of the whole
person
3. Create new, highly skilled jobs and attract investment by increasing our focus on research,
innovation and new models of delivery
4. Deliver bold solutions to the environmental challenges posed by our activities
5. Bring communities and generations together through involvement in the planning and delivery of
our services
6. Demonstrate respect for the diverse cultural heritage of modern Wales
7. Strengthen the international reputation of the Trust as a centre of excellence for teaching, research and
technical innovation whilst also making a lasting contribution to global well-being
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Health
• Welsh Blood Service Anaemia Management
• Caring for Carers, Patient Knows Best & Every Contact
Counts
Environment
• Obtain Building Research Establishment Environmental Assessment Method (BREEM)
sustainability rating of ‘Outstanding’ for all future
building developments
• Positive impact of better transport planning
Wales and the World
• Collaboration overseas - work in Ghana, Peru, Uganda and
elsewhere
• Palliative care course in collaboration with Cardiff
University
How our objectives were developed
We strive to do more than just treat disease. Our desire to constantly improve the quality of
the care that we provide and to increase the scope of that care is fundamental to what we do.
This concern has also been an important motivating factor in the development of our well-
being objectives. We also wanted to use the process of developing our objectives as an
opportunity to address our wider role in society. We aspire to deliver holistic care to our
patients and donors, but we want to do more to support families and wider communities. This
ambition is in line with the sustainable delivery principle.
We considered that an important step in our development process was to identify the extent
to which the sustainability principle was, in reality, already a key impetus for us, whether or
not we would actually describe such motivating factors in the same terms as the Act now
does. Recognising the extent to which we already work in a sustainable way helped us arrive
at a new appreciation of the potential power of our individual and collective actions if they
could be directed in a clear, concerted manner. The new way of thinking that the Act
promotes will help us channel our efforts to maximum effect, but the realisation that
sustainability is not an alien concept has been and will continue to be useful in communicating
and embedding the new ways of working across the Trust.
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Work which already supports the well-being goals
Our determination to do more to support the health of our patients, our donors, their families
and their communities illustrates the contribution we already make and will continue to make
to the achievement of several of the well-being goals. By treating ill health, we help people to
remain in, and return to, employment. This is fundamental to the well-being of our
population, as illustrated by the Chief Medical Officer’s recent report, and also directly
supports the realisation of a prosperous Wales. Allowing people to continue contributing in a
positive manner to society will support the vision of a Wales of cohesive communities.
Our efforts to support the children of families affected by cancer, provides just one example of
our concern for the long term health and well-being of the people of Wales. The Rebalancing
healthcare report references an extensive evidence base that points to the potential harm
that adverse childhood experiences can cause to both individuals and the wider community in
the long-term. This, in part, motivated colleagues at the Velindre Cancer Centre to produce
the children’s book, Caring for my Family with Cancer. We intend to produce more in this
series, to translate the books into other languages and to release an audio book. We are
confident that the series will prove to be a valuable resource in promoting the well-being of
young people dealing with often traumatic events. This work lends weight to our efforts to
create a healthier Wales, but we hope that it will have longer-term benefits, contributing
towards a resilient Wales and a Wales of cohesive communities.
We are a major employer. The well-being of our staff and their families is important to us. We
want to create more highly skilled jobs across our organisation. Our renewed attention on
research, development and innovation can be a focus for improved collaboration with other
health care providers and educational institutions. We intend to develop a Centre for Learning
on the site of our new cancer centre and we will also host Health Technology Wales. Our
approach should attract investment and serve as a catalyst for job creation which will also help
the effort to create a prosperous Wales. It is our intention that this work will directly benefit
the health of future generations in Wales and beyond. The achievement of our ambition to be
acknowledged internationally as a centre for research excellence will help boost the nation’s
reputation and is absolutely in line with the vision of a globally responsible Wales.
The Welsh Blood Service already has extensive international links and colleagues from
Velindre Cancer Centre have conducted health needs assessment work in Uganda in
collaboration with Public Health Wales. This work has provided valuable learning that, in turn,
has benefited not only the people of Uganda, but our own population and serves to illustrate
the value of cooperation.
We are acutely aware of the positive impact that we can have on our environment. Currently,
we operate an extensive estate and we have ambitious plans to build a new cancer centre.
This is a large scale investment with long term implications for our patients, our staff and the
communities in which we work. We intend to pursue this development in an environmentally
sensitive manner, adhering to the strictest environmental guidelines and employing innovative
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construction techniques. We also want to involve the local community in the development
process.
What next?
Over the course of the next year, we will work to raise awareness of the well-being goals, our
own well-being objectives and to embed the principle of sustainable development. Legislation
is an important lever for effecting change, but making the well-being goals reality will take
more. We will encourage behavioural and cultural change. In everything that we do, in the
case of every relationship, we want to ensure that a sustainable approach is our default
position. We are determined to make sustainability the norm. The Act is ground breaking and
it is helping to create an exciting new public service environment in Wales. As we embark on
our journey, we expect to make false steps, to take wrong turns, but the safeguarding of our
future is just too important an issue for us not to be ambitious in promoting the well-being
agenda.
Our intention is to focus our initial efforts on a set of the goals that relate to areas in which we
can have an immediate impact. The ambitious scope of our objectives and the imperative to
think in a genuinely long-term manner inevitably means that these objectives will evolve over
time. We are determined to develop new partnerships and it is likely that our own perception
of what we can do to improve well-being in Wales will change as a result of these new
relationships.
As an organisation, we continue to actively contribute to the formation of a new national
sustainability network which is developing out of the existing Sustainable Development Co-
ordinators Cymru peer resource for local authorities and national parks. This and other fora
have served as useful spaces in which we have been able to initiate positive conversations on
collaboration and partnership working with other public sector bodies, particularly those from
outside the healthcare ambit.
We have already begun to explore the possibilities for collaboration with other public sector
bodies in Wales. Positive initial discussions have been held with Cwm Taf University Health
Board with a view to cooperating on the development of a health promotion agenda. We have
also opened discussions with Public Health Wales.
In addition to the novel schemes to be delivered in conjunction with other healthcare
organisations which are beginning to take shape, we are excited by the potential that the Act
offers for partnership with bodies operating in other fields. We have had positive
conversations with the Pobl group, a major provider of housing, care and support services
across south Wales, about possible co-operation. We have also begun to take forward work
with the National Museum of Wales. With the Museum, we hope to share learning on
volunteering and to explore possibilities for advancing work in social prescribing.
Our intention is that this activity will have the effect of helping to reduce the dependence of
the population on services provided by NHS Wales by promoting well-being in ways that we
haven’t previously attempted, with partners that we may not have considered working with
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previously. This is in keeping with the Chief Medical Officer’s call for a greater emphasis on
public, community and individual involvement in the maintenance of good health outlined
Rebalancing healthcare. Our ambition has been informed by the Act and we are confident
that our work in these areas will contribute towards the realisation of the well-being goals.
Measuring our progress
We believe that it is important to acknowledge that our objectives represent only a first
attempt to define how we will support efforts made across the public sector to realise the
vision described by the well-being goals. This is a reality about which we want to be totally
transparent.
We recognise that measuring progress against our objectives may present some challenges in
the short term. The work to realise the well-being goals set out in the Act will likely take place
over decades. The impact of some of our sustainable activity, particularly with a longer-term
scope, may be difficult to interpret. We are, however, intent on developing a robust
sustainability component that will integrate meaningfully with our existing performance
management framework. This will help us understand our working environment, the possible
effects of proposed actions and will offer our stakeholders an acceptable level of
transparency.
In measuring progress against our objectives we will, where
appropriate, adopt indicators that we already collect.
Elsewhere, we will consider how best to appraise our
progress and will develop new measures where possible.
Matrices and tools have been developed by organisations
concerned with sustainable development in the UK and
elsewhere which aid reporting on sustainability focused
performance. The adoption of existing tools or the
development of our own are approaches that we intend to
explore, most likely in partnership with other bodies.
In the short term, we intend to identify a number of new projects and areas of work in the
coming year that we will be able to develop as case-studies which can be used to illustrate and
interrogate progress against our well-being objectives.
1.4 Community Health Councils (CHC)
The Trust maintains excellent working relationships with all Community Health Council’s
within South East Wales as demonstrated by examples such as involvement with the
Transforming Cancer Services Programme, complaints resolution etc.
There is Community Health Council (CHC) representation at Trust Board which invites
contribution to service delivery and objectives as discussed at these meetings. The Executive
Team attends Cardiff & Vale CHC meetings on a regular basis.
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The Trust, in particular the Velindre Cancer Centre, is also subject to regular unannounced
visits from the Community Health Councils (CHC’s) as well as planned Hospital Environment
Assessment Team audits. The results of these have, on the whole, been very positive.
1.5 International Health Development
The Trust hosts the South Wales Sierra Leone Cancer Care Group which consists of staff from
oncology, palliative care and paediatric cancer services from across South Wales. Through the
South Wales Sierra Leone Cancer Care Group a partnership between Velindre Cancer Centre
and Connaught Hospital in Freetown, Sierra Leone, was established in 2010. Visits to Sierra
Leone stopped during the Ebola outbreak but restarted early in 2016. Grant funding was
secured to enable five visits for the delivery of training programmes about cancer care, pain
management, ultrasound and chemotherapy. A Burkitts lymphoma treatment pathway has
been developed, the National Cancer Registry at Connaught Hospital in Freetown established,
and members of the Group have worked with the surgical department at Connaught Hospital
to develop a protocol for the management of breast cancer.
We supported the following staff, through ‘Hub Cymru’ grants, to provide training on cancer
care to health workers in Sierra Leone:
8 Consultants
4 Nurses
1 Pharmacist
1 Radiographer
5 visits
1.6 Long Term Expenditure Trends
Long term expenditure trends have been included in the Accountability Report section of the
Annual Report on page 50.
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2.0 Development Activity
2.1 Supporting children and young people
Last year we told you about our award winning children’s book
‘Caring for my family with cancer’. This year we have established
a specialist service aimed at supporting children and young
people when a parent, care giver or family member has cancer.
The Service, established in partnership with One Wales and
Macmillan Cancer Support, focuses on helping parents and care
givers to continue to support and care for their children whilst also coping with the impact of
cancer. We know from research studies that many people with cancer find it very difficult to
talk about their diagnosis and treatment plans. Fear of saying the wrong thing, or fear about
causing upset and distress can make it hard for families to do this.
2.2 Research and Development
The delivery and management of high quality research is a strategic priority within Wales, and
viewed by the Trust as the second priority after clinical care. Research drives changes in
healthcare, enabling us to translate innovation into practice and provides our patients with
the best in care and quality, often allowing access to treatments that would otherwise not be
possible.
As a research active centre, we are key contributors to the local and national cancer
recruitment targets. Velindre Cancer Centre holds a diverse portfolio of research across
various disease sites, a mix of commercial and non-commercial studies. As of December 2015,
there are 102 open studies (approximately 1/3 are commercial) and 387 recruited
participants.
The Research & Development (R&D) team support our Investigators to achieve 100% of the
Welsh Government Key Performance Indicator: provide NHS permission to open to
recruitment within 40 days of submission. Work is ongoing, in collaboration with internal
departments and external stakeholders, to continue to improve process and working practice
to ensure an efficient, effective, high quality service is provided. Examples of continuous
improvement include working collaboratively with R&D offices to set up overarching
agreements that have reduced time to start recruiting, and cross-organisational support for
the handling of tissue samples; both changes reduce timeframes and open up swifter access
for all patients.
2.3 Early Phase Trials
Participation in Early Phase trials provides patients with access to novel treatments, often in
situations where there are no other treatment options. This service is a first for Wales;
previously, Welsh patients have needed to travel to English Cancer Centres to access these
treatments. As of December 16, the early phase team recruited 35 patients into 11 trials, and
are planning further expansion, and collaboration with colleagues at other centres.
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2.4 Radiotherapy
Research within Radiotherapy, and Medical Physics, continues to develop in both the clinical
area and in the technical side. A number of new projects have opened, and are in
development.
Dr Tom Crosby, Consultant Oncologist, was invited to bid for a charitable donation from the
Moondance Foundation, and successfully secured £1.5 million, which was then matched by
the Velindre Charity. The money will be used to support a multi-professional team to
undertake Research & Development, service improvement, and establish new treatments
and therapies. It is anticipated that the funding will innovate radiotherapy treatment.
2.6 Digital Health: Information Management & Technology
(IM&T)
During 2016/2017 the Informatics departments across Velindre NHS Trust have delivered a
number of successes in terms of application enhancements, infrastructure resilience changes,
establishment of core principles and processes for the management of business intelligence,
and the introduction of new skills sets.
Welsh Blood Service Following the successful implementation of the Blood Establishment Computer System (BECS)
in May 2015, the Welsh Blood Service (WBS) became a national service in May 2016. The
transition of services from NHS Blood & Transplant to WBS required a significant IM&T
programme to be delivered utilising various IM&T resources and skill sets in order to deliver:
New BECS functionality for the provision of a stock holding unit in North Wales
Migration of approximately 90,000 donor records from NHSBT systems
Development of an in-house Hospital Web Ordering Solution
Development of an in-house Donor Appointment System
Development of an automated algorithm for donor eligibility
Reconfiguration of a Donor Contact Centre
Transition of the WBS website to a mainstream content management system
Deployment of a new IM&T infrastructure in North Wales, working in collaboration with Betsi Cadwaladr University Health Board (BCUHB)
In addition to this the Welsh Blood Service continued in its provision of ongoing project
management and software development support for the implementation of the all-Wales
Laboratory Information Management System (LIMS) for Blood Transfusion, Histocompatibility
and Immunogenetics and Welsh Bone Marrow Donor Registry modules.
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Velindre Cancer Centre Velindre Cancer Centre has also continued to make good progress against infrastructure and
project plans for the period, which are delivering improvements for staff, patients and the
public who visit the hospital. During 2016/2017 the Cancer Centre has support the upgrade of
core infrastructure for its primary electronic patient management system, Canisc. This is a
substantial programme of work that has spanned two financial years and will be completed in
Quarter 2 of 2017/2018.
Additional successes during 2016/2017 were as follows:
Delivery a new data communication room within the Cancer Centre
Refresh of infrastructure and cabling to its network nodes rooms in the Cancer Centre
Design stage of the Acute Oncology Mobile Application
Meeting the amended Welsh Government targets for timely completion of clinical coding
Completed design, build and initial rollout at VCC of central Managed Print Service, to improve printer standardisation; printer security; rationalisation of devices; reduce toner stocking; toner consumption and the volume of prints that are printed but not collected
Readiness work underway to support the Welsh Imaging Archive System Pilot
Implementation of management processes to support the National Intelligent Integrated Audit Solution (NIIAS)
Change of patient address details proforma implemented to ensure patient demographics held by the organisation remain accurate and kept up to date
Business Intelligence
Business Intelligence has been an ambition for both divisions of the Trust for a number of years. In 2016/2017, the appointment of key individuals into divisional leadership roles has seen significant progress in this area.
The key highlights are:
Completed Procurement and initial build of the Trust Data Warehouse Service to provide a modern information service backbone
Initiated Data Warehouse Service design for delivery of dashboards
Initiated designs and builds of regular Data Extracts from Canisc to Data Warehouse Service in order to maintain accessibility to our legacy data and establish dashboard views of historic data
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Infrastructure enhancements
Supported by a significant capital investment from Welsh Government, the informatics team
have been able to enhance devices across the Trust, improve its IT security provision and
develop enhanced resilience for some of its core services.
The key highlights are:
Agreed national design and procured for Wales Microsoft Office licensing as first steps towards revenue licensing model and cloud services (move away from historically capital funded licenses)
Procured Web Content Filtering service to refresh and extend existing service functionality
Continued IMT infrastructure replacement programme to improve network resilience and wireless access as support for handheld computing/mobile design and mobile telephony;
Continued Trust IMT Equipment Replacement - Procurement of PCs, laptops
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3. Trust Organisational Development Strategy
3.1 Workforce Planning
Our Organisational Development (OD) Strategy, Building Excellence, outlines how over the
next 3-5 years the Trust will develop a culture that enables each of us to be great and achieve
the delivery of ambitious and exciting service change plans. Through conversations with staff
we know we need a values driven culture where world class services are delivered by a
workforce that understands the difference it makes to the donor and patient experience. The
Trust will deliver this through its resilience and flexibility, and a culture that encourages
ambition and improvement and is agile and responsive to change.
With patient/donor care central to everything we do, we have articulated through our
Integrated Medium Term Plan (IMTP) a future that involves significant change to the scope
and expectations of service delivery. With change comes the opportunity to modernise and
redesign services and the workforce, and further strengthen collaborative relationships with
patients and stakeholder organisations. Through the application of the prudent healthcare
principles across the Trust, moving forward we will continue to excel in the delivery of care
and clinical services that are uniquely ours, while understanding how to use the skills of our
staff and available resources most effectively to continue to improve.
During 2016, the Trust has established ‘Think Tanks’ or ‘cross functional working groups’ to
form the backbone to the implementation of the ‘Building Excellence Strategy’. They are a
chance for every member of staff to get their ‘thinking cap on’ and directly help to influence
the transformational agenda required across the Trust over the next 3-5 years. One of the
seven think tanks is Workforce Planning, this group will be tasked with identifying what
‘excellence’ looks like in this area by researching evidence based best practice both within the
NHS as well as exploring what other high performing public and private sector organisations
do.
3.2 The story behind our values
Between April and July 2015, the Trust met with 145 staff
in team meetings, received 164 online Building
Excellence questionnaire submissions, 250 online Staff
Pulse Survey submissions, and carried out interviews
with 96 staff as part of our Investors in People
reaccreditation process.
Everything that staff have told us has been distilled into
four organisational values, these values are for all staff,
whether staff are working at the Welsh Blood Service,
Velindre Trust HQ or Velindre Cancer Centre.
We are working to explore new ways of working and making the best use of people and
advanced roles to provide better services.
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3.3 Healthy Working Wales Corporate Health Standards
We achieved Gold in the Healthy Working Wales Corporate Health
Standards for many years, and this year we were very pleased to be
awarded a Platinum award. The Corporate Health Standard supports the
development of policies that promote good practice to assist businesses
and organisations to take active steps to promote the health and well-
being of staff. The Standard is awarded at different levels: Bronze, Silver,
Gold and Platinum. It begins at bronze level recognising where activities
and policies that comply with legislation and address key workplace risks
to employee health are in place. Platinum is reserved for exemplar
employers who demonstrate business excellence and take full account of
their corporate social responsibility.
2016 NHS Wales Staff Survey: Staff answered more positively than in the last survey in 2013 on 90% of questions asked, and 78% of our scores exceeded the overall NHS Wales score. Key survey themes for the Trust include:
We are particularly proud that 75% of staff would recommend the Trust as a place to work, 93% say that if a friend or relative needed treatment, they would be happy with the standard of care provided by the organisation, and 87% of colleagues say that they are proud to tell people they work for The Trust.
The majority of scores relating to line and senior managers have improved since 2013 e.g. 82% of staff say that their line manager treats them with respect (up from 76% in 2013); and 76% of staff say that senior managers are committed to patient care (up from 66% in 2013).
84% of staff say that they know who senior managers are in the Trust, but only 32% say that communication between senior managers and staff is effective and we need to address this.
Many scores on health, well-being and safety at work have improved since 2013, but there are still areas for us to review e.g. 13% of staff say that they have experienced harassment, bullying or abuse at work from their manager/team leader or other colleagues.
Levels of work-related stress have improved slightly since 2013, so this is an area that we will maintain focus on in the coming year.
60% reported that they are able to make improvements happen in their area of work.
We are proud of our positive results, but remain committed to focussing on areas that staff have said could, and should, be improved.
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4. Performance Summary
4.1 Velindre Cancer Centre
4.1.1 Core activity during 2016 – 2017
The following info graphics provide a snapshot of the core activity of Velindre Cancer Centre
for the period 2016 - 2017.
The Velindre Cancer Centre provides
specialist non-surgical oncology services to
patients from South East Wales, including
chemotherapy, radiotherapy and specialist
palliative care.
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4.1.2 Velindre Cancer Centre - Assessment of 2016/2017
Successes, key issues and risks
2016/2017 has been an extremely busy and successful year for the cancer centre; we have
continued to deliver excellent care and support to our patients, their carers and their families
despite increasing demand and pressure upon key services. This is a testament to our
hardworking, caring and dedicated staff who continue to go the extra mile to ensure high
quality care; we are extremely proud to look back over the year and see all of our
achievements in improved patient care and treatment techniques.
Velindre Cancer Centre: Summary of key achievements in 2016/17
Implementation of new radiotherapy techniques
Improving patient accommodation and services
Implementation of a second Stereotactic Body Radiation Therapy (SBRT) capable
Linear accelerator
Introduction of the STAMPEDE trial
The PR07 trial
Early phase trials
CHHiP
Development of key strategies
Improved horizon scanning and commissioning of new drugs
Implementation of new radiotherapy techniques: we have continued to treat patients
that would have previously travelled to England for Stereotactic Body Radiotherapy
(SBRT) and Stereotactic Radiosurgery (SRS), we have achieved our target of treating
35% radical patients with Intensity Modulated Radiotherapy (IMRT) and have increased
the use of Image Guided Radiotherapy (IGRT) through clinical trials and local initiatives.
Improving patient accommodation and services: we have completed the
refurbishment of First Floor inpatient ward and have provided free Wi-Fi for all people
within the Velindre Cancer Centre.
Implementation of a second SBRT capable Linear accelerator:
In October 2016 we successfully implemented a new linac
with SBRT functionally. We are one of only a small number of
cancer centres in Europe with this functionality.
Introduction of the STAMPEDE trial: the outcomes of this trial identified a change in
drug treatment (Docetaxel) that will improve outcomes with a recommendation to
change standard of care.
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The PR07 trial: the results of this trial reported benefit in survival and firmly
establishes the role of radiotherapy in the treatment of men with locally advanced
prostate cancer.
Early phase trials: participation in Early Phase trials provides patients with access to
novel treatments, often in situations where there are no other treatment options. This
service is a first for Wales; previously, Welsh patients have needed to travel to English
cancer centres to access these treatments.
CHHiP: we have been involved in the largest ever study of prostate radiotherapy.
Results have shown a significant improvement in outcomes through the halving of
toxicity and relapse rates, which have a significant impact upon patient outcomes and
well-being.
Development of key strategies: we have developed and published two key strategies
which will help drive the service forward.
‘Shaping the Future Together 2016 – 2026’ sets out five strategic aims and how they will be
delivered:
1. Equitable and consistent care, no matter where. 2. Access to state-of-the-art, world-class, evidence-based treatments. 3. Improving care and support for patients to live well with cancer. 4. To be an international leader in research, development, innovation and
education. 5. To work in partnership with stakeholders to improve prevention and earlier
detection of cancer.
‘Shaping the Future of Radiotherapy 2016 – 2026’ sets out the Cancer Centre’s ambition to
become an internationally recognised Centre of Excellence for Radiotherapy. The Strategy is
underpinned by seven aims and sets out how they will be achieved:
1. Every patient has access to the best treatment appropriate for them, which is
timely and delivered in the most efficient and effective way possible.
2. The radiotherapy service will be at the forefront of technological advances
through its continual assessment and adoption, for the benefit of all patients.
3. An integrated and empowered workforce that is motivated, values driven and
innovative.
4. A service that is maintained and future proofed with effective and appropriate
funding to enable clinical, technological and research developments.
5. To expand radiotherapy research through effective leadership, resources and
investment.
6. A high quality service which utilises comprehensive data, evidence based practice
and research to drive forward innovations.
7. Establish a culture of collaborative working and partnership that reflects and
prioritises the values of the organisation.
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Improved horizon scanning and commissioning of new drugs: the unprecedented
number of new additional drugs becoming available to NHS Wales during 2016/2017
identified the need for improved horizon scanning and planning for the introduction of
drugs, given their capacity implications.
Ongoing challenges
There are a number of challenges we face as an organisation, how we are addressing these
can be found in our three year plan but they have an impact on how our services deliver and
perform.
There are a number areas that have not progressed as we had planned during 2016/2017 for
various reasons. These include:
Delivering chemotherapy at home and in the community - Whilst this piece of work
was delayed at the start of the year, we are currently exploring the possibility of
progressing procurement as a standalone organisation.
Radiotherapy capacity: The most significant risk in the immediate to medium term is
the ability to deliver the required levels of service for patients requiring
Cancer incidence is increasing
There is variation in cancer related outcomes throughout Wales and we need to help close the gap
There is growing demand for services and we must ensure that we have the ability to treat and care for patients
Treatments are becoming more complex and new advances are always emerging
More people are living with and beyond cancer and need to achieve best possible quaility of life and experience
Resources are scarce and we must make the best of our resources
We are working within a wider policy context and must ensure we are aligned
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radiotherapy. The increasing demands on the radiotherapy service, both in terms
of patient numbers and complexity/time, cannot be met consistently within existing
resources and through existing service models.
The immediate risk is that with current radiotherapy resources we will be unable to
continue to absorb the circa 4% annual increasing demand for radiotherapy in Wales
and also the historical peaks in demand during September/October and
January/March. The impact of this will mean that we will be unable to provide
Radiotherapy treatment to patients within the waiting time targets. Inability to
achieve these waiting times may compromise clinical quality, patient outcomes
and patient experience as patients may be required to wait longer for their
treatment. Trust officers are currently pursuing a range of actions to mitigate this
risk and explore new and more efficient ways of working. The Trust developed a
Business Case during 2016/17, in collaboration with Local Health Boards, for
approximately £1 million per annum in revenue funding to staff an additional Linear
Accelerator (LINAC). This is still under discussion with commissioners.
Increase radiotherapy access to the appropriate rate for patients with cancer within
our resident population - This work slowed down at the beginning of the year due to
competing priorities and limited capacity and resource to take forward the work,
however, a bid was submitted to the Cancer Pathway Innovation Fund to provide
project support which was successful.
Chemotherapy capacity: For several years demand for Systemic Anti-Cancer Treatment
(SACT) has been growing, requiring increasing levels of capacity and resources to
deliver the service. This has proved challenging, but manageable within Velindre
Cancer Centre (VCC) ways of working, including delivery of services within outreach
settings. We believe that 2017/2018 will be the year in which a ‘step-change’ will
occur, and that actual demand will outstrip the projected 5% per annum demand
increase due to the increasing number of approvals for new drugs/indications and the
significant service implications associated with delivering these particular drugs. Until
late summer of 2015, there was sufficient capacity in the service for VCC to absorb the
incremental increases in workload that were felt from the introduction of new drugs to
NHS Wales. However, as the SACT service is currently working to capacity, absorbing
increased demand without additional funding will not be possible without
compromising patient safety, staff morale and service performance.
There is therefore risk that Velindre Cancer Centre will be unable to deliver new
indications within the guideline period following publication given the lead in time to
secure funding and recruit staff.
We are working with our partners in the challenging task of improving joint horizon
scanning of new drug approvals, identifying opportunities to deliver care closer to
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home or at home where appropriate and to further develop processes for
modelling the implications of new drug approvals across patient pathways.
An example of this is the planned introduction of docetaxel chemotherapy for patients
with prostate cancer which has required the Velindre Cancer Centre to write a
business case to seek funding from the local health boards.
Junior Medical Staffing. The current levels of medical staffing are not considered
optimal in relation to the provision of training for all junior doctors, including new
entrant levels (Senior House Officer (SHO). Work has commenced to identify
optimum staffing levels and operational day to day activities that will assist in
achieving the highest level of training and work experience for all staff. The situation
is being monitored monthly and plans are being developed to fill the current gaps in
the rota. However, despite a number of pressures on the service, the Cancer Centre
has continued to meet many of its performance ambitions for the year.
Pressure ulcers: although low in number we have experienced an increase in
pressure ulcers. We continue to undertake a root cause analysis for each incident
and monitor themes that emerge.
Hand hygiene: we will continue to seek to improve hand hygiene standards through
close monitoring and targeted action plans.
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4.2 Welsh Blood Service
4.2.1 Core activity during 2016-2017
The following info graphics provide a snap shot of the core activity of the Welsh Blood Service
for the period 2016-2017.
The Welsh Blood Service collects voluntary donations from the general public across Wales
which are processed, tested and distributed to customer hospitals. The Welsh
Transplantation & Immunogenetics Laboratory, within the WBS, operates the Welsh Bone
Marrow Donor Registry and provides direct support to providers of Renal and Stem cell
transplantation.
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4.2.2 Welsh Blood Service Assessment of 2016-2017 Successes, key issues and risks 2016/17 has been an extremely busy and successful year. We have continued to deliver excellent
care and support to our donors. Some of our achievements are noted below.
Welsh Blood Service: Summary of Key Achievements in 2016/17
Implementation of a pan Wales Blood Service
Delivered a safe and effective supply to hospitals in Wales
Delivered a Modern Donor Contact Centre
Significantly increased Blood Stem Cell Donations
Maintained Quality and Safety
Listened from Donor Feedback
The implementation of a pan Wales Blood Service: successfully achieved in May 2016. This
represents a major programme that has seen the Welsh Blood Service expand to cover the
whole of Wales with an increase in its geographic coverage by over 33%; increased the
provision of our services to an additional 676,000 people; serve the largest university health
board in Wales; and sees us process approximately 25% additional units of blood at our Talbot
Green headquarters. The benefits of this change are now coming to fruition which include an
annual saving of £500,000 for the NHS in Wales, has created 16 jobs and more effective
national planning across NHS organisations.
Delivered a safe and effective supply to hospitals in Wales: we have safely delivered the
required amount of red blood cells, platelets and commercial products worth over £8m via a
Good Manufacturing Practice (GMP) compliant cold chain to hospitals.
Delivered a Modern Donor Contact Centre: a project to improve telephony and donor contact
services to support the recruitment and retention of donors throughout Wales has delivered a
redesigned staffing model which provides multi-functional roles.
This is improving the efficiency and effectiveness of the Welsh Blood Service (WBS) donor
contact services and increasing the capacity for Welsh Language services. We also introduced
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significant technological advancements to support this service change which included
improved contact management systems, enhancements to the website, and improvements to
our Information Technology (IT) infrastructure and the introduction of an electronic in house
appointment system as the initial stages of a programme of ongoing digital development.
Online Appointment Booking Service: in January 2017 the Welsh Blood Service launched an
Online Appointment Booking Service for blood donors. The new service has been well received
by donors, and 2518 appointments were made using the system in its first full month of
operation. It is hoped that the online appointment booking service will help bolster the
number of new and returning blood donors, new platelet donors, and people willing to sign up
to the bone marrow register.
Significantly Increased Blood Stem Cell Donations: During the year we marked the 1000th
bone marrow donation collected in Wales since 1989. The achievement was celebrated at the
‘Wales in the World’ event held at the Senedd. The Welsh Bone Marrow Donor Registry
(WBMDR) supports patients world-wide. Currently, the WBMDR has over 64,500 potential
donor volunteers on the register and receives around 24,000 search requests each year. Stem
cells and bone marrow is exported to over 30 countries across the globe. WBS Director Cath
O’Brien said: “We are truly inspired and proud of our 1000 donors whose generous donations
have helped so many patients in Wales and all over the world. This special event celebrated
what is an amazing achievement by everyone involved with the Welsh Registry.”
Maintained Quality and Safety: we successfully retained all operating licenses and made good
progress to further extend our external accreditation. This is testament to the dedication and
commitment of our staff to continually raise standards for quality improvement year on year.
In addition, we have continued to provide specialist advice and support to a number of other
NHS Wales organisations.
Delivered Additional Testing: following new advice from the Advisory Committee on the
Safety of Blood Tissues and Organs we introduced testing for Hepatitis E on a selection of our
products, delivering an additional 11,000 tests.
Listened and Learned from Donor Feedback: our donor feedback has been instrumental in
changes we have made to clinic opening times and has been used to support the introduction
of appointment systems at an additional number of our clinics. Donor feedback has also been
factored into further improvements to our new blood establishment computer system.
Work is also continuing to support embedding donor feedback in wider service improvements.
For example, at Port Talbot we have extended our opening hours to make it easier to donate in
the early evening. Being able to make an appointment suits an increasing number of our
donors and as a result we have introduced appointments for the first time at several venues
such as Brecon and Carmarthen as well as launching a live on-line booking system. This system
enables bookings to be made 24/7 for all sessions with appointments and donors are able to
search venues by date and distance to provide them the widest choice.
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The Welsh Blood Service R&D Strategy was approved by the Trust Board on 24th November 2016. The strategy seeks to advance donor care and transfusion and transplantation medicine through inception and participation in high quality health services research. The strategy has four themes:
Donor Care and Public Health
Transplantation
Products
Therapies. The WBS wants to be an organisation where high quality research and development is performed as part of normal day-to-day activity and a
programme of research and development. By the end of 2017 we aim to build Research & Development capability and capacity across the WBS, and set out a programme of collaborative projects in each of the above themes. A new Blood Health Plan has been developed to provide renewed focus to activity to maximise
the appropriate use of blood components and products. There are three core aims which lie at the
heart of this plan. They draw on the principles of prudent healthcare and the unique
characteristics of NHS Wales, a planned system with quality at its core:
1. Supporting individuals to manage their health and wellbeing, avoiding unnecessary
intervention.
2. Using evidence and transparent data to drive service planning and improvement to reduce
inappropriate variation.
3. Avoid harm, placing safety and quality at the core of care.
Ongoing challenges
The Donor Panel is shrinking
We must meet demand for blood and blood products
We must meet stringent blood selection guidelines and regulatory
requirements
Science and the scientific workforce is changing
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We recognise that there are still considerable challenges to meet in ensuring the service remains
fit for purpose now and for the future. Work needs to be taken forward in a number of areas:
Alignment of blood collection models: we will continue to work to fully align the service
models for blood collection in north and south Wales to embed a truly national service.
Blood Establishment Computer System (BECS): further development is required to streamline
the system’s current functionality and meet the ever increasing regulatory burden.
Declining Blood Donation Rates: we need to address the decline in rates of blood donation
that is being observed by the WBS, a phenomenon that blood services around the globe are
currently experiencing. Key to this is the need to review the donor experience and to update
the technology we use to engage with donors.
4.2.3 Mitigating and managing risk
Where appropriate key risks are escalated to the Trust Risk Register. Further information on the
risk management strategy and key risks on the risk register as at the 31st March 2017 are
contained within the Governance Statement section of the Accountability Report, see page 25
onwards.
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4.3 Listening and learning from patient / Donor feedback
Velindre Cancer Centre
We believe that patient experience is not just about a survey or a buzzword.
This is about a shared commitment to listening & learning across the whole organisation. It is
fundamental that everyone understands and values the importance of delivering an excellent
patient experience which is embedded within our culture.
Real Time
All-Wales Patient Experience Survey
(face to face interviews)
I want great care
Fundamentals of Care
Observations of Care for Protected Mealtimes
Evaluations & Taste Testing for Oral Nutrition
Supplements
CHC and patient attendance at Trust Board
Meetings
Retrospective
All Wales Radiology Patient Satisfaction Survey
All Wales Patient Menu Survey
Velindre Improvement Process
Departmental Surveys
Treatment Outcomes are measured by individual
professionals and across Site Specialist Teams
Proactive / Reactive
All Wales Patient Survey (online and hard copies to
be made available)
Patient Experience website page to be refreshed
Patient Concerns
Comment Cards
Visitors comment books
VCC Facebook page
VCC Twitter Channel
Balancing
Patient Stories
Patient Liaison Group
3rd party surveys (e.g. Community Health Council,
MacMillan)
Walkrounds (e.g. Older Persons Commissioner,
Community Health Council, Executive Walkarounds)
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Someone Else’s Shoes: The Velindre Cancer Centre launched a new audio podcast called Someone
Else’s Shoes. The podcast aims to increase understanding and enable learning and opportunities
for improvement through sharing patient, care and staff stories. In the first podcast David talked
about his diagnosis and the importance of his faith. In the second, Linda shared her experience of
A&E, radiotherapy at Velindre Cancer Centre, and the Macmillan Activity Programme. You can
listen and subscribe here. You can view Welsh Blood Service patient and donor stories here.
I have been attending Velindre since September ‘16, first for chemotherapy and now for
radiotherapy. The care and kindness are second to none, they really sum up the phrase Tender
Loving Care.
I’ve just finished 20 sessions of radiotherapy. I was in LA5 and the team were amazing! They
made me feel so relaxed and unafraid of the whole process. I really enjoyed seeing them every
day. I will miss them dearly.
Creating a good Patient Experience …..
1. Every role matters
2. Every interaction matters
3. Every perception matters
4. You matter
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Patients' Overall Experience
Rated 9 or above % Target
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Welsh Blood Service
Our volunteer donors are the heart of the Welsh Blood Service - we could not provide our
lifesaving blood donation programme without them. We know that to secure their ongoing
support we need to ensure that each donor has a positive experience of our blood collection
service each time they donate.
How are we listening?
At clinics - either face to face with our staff or via
compliment and concern cards.
Social Media - Our Twitter and Facebook feeds have
donors regularly interacting with the service.
Website - Our website offers both a donor enquiry form
and direct email access to the Welsh Blood Service.
Donor Survey - A proactive donor satisfaction
questionnaire sent to donors via email,
5 days after their attendance at a clinic.
We asked:
Was there anything that we could
change to improve your
experience?
Patients said:
‘Better TVs’
‘A map to find my way around’
‘Display waiting times
We did:
Purchased TVs for the day unit;
Introduced clear signage and maps
Fitted display screens in the
reception areas of the outpatient and
radiotherapy departments that will
be used to show waiting times.
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‘@givebloodwales 53rd donation today in Rhiwbina. Good service and great Staff!
Thank you #feelgoodfriday’
‘The lady who was training to put needles in on the 16th in Port Talbot did a cracking job, no bruise. Well Done.’
We asked:
Was there anything that we could change to improve your experience?
We used donor feedback to:
Make changes to clinic opening times
Introduce an appointment system in some clinics
Inform some improvements to our new blood establishment computer system
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4.4 Learning from concerns
During 2016/17 we investigated all complaints and concerns in accordance with the NHS
Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011, and shared our
findings openly and honestly with patients, their families, donors and staff. As in previous years
we noted that complaints about the Cancer Centre were often complex and related to more than
one issue. Many of the concerns about the Welsh Blood Service were about clinic opening and
waiting times.
We view each complaint as an opportunity to learn and improve our services. Examples of changes
we have made following a complaint include:
Increasing the availability of the chemotherapy pager service to provide 24 hour access for
patients with treatment related symptoms or concerns
Introduced a standard for blood glucose monitoring in pancreatic cancer patients to enable
prompt detection and treatment of diabetes
Enabled donor feedback and concerns to be considered as part of an ongoing review of
clinic efficiencies and accessibility.
All lessons learned from concerns are reviewed by our Organisational Learning Committee. Within
the Welsh Blood Service we have developed a donor compliments and concerns dashboard to
improve shared learning across all of our blood collection teams.
0
5
10
15
20
25
Trust Concerns Received During 2016-2017
VCC WBS Corporate
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5. Performance Analysis
We have developed a wide range of measures which are routinely used to monitor the quality and
performance of our core services.
The core measures for Velindre Cancer Centre and the Welsh Blood Service are included in the
tables below.
Performance trends in respect of these targets are included in Appendix 1. The performance
summaries are explored further with supporting narrative in the Trusts performance reports
received by the Trust Board. These papers are available on the Trusts internet site via the
following link: http://www.velindre-tr.wales.nhs.uk/current-trust-board-2016-meetings-1.
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5.1 Velindre Cancer Centre (VCC)
Performance metric Target 14/15 15/16 16/17
Radiotherapy % of patients commencing radical Radiotherapy within 28 days
98% 95% 98.5% 98%
% of patient commencing palliative Radiotherapy within 14 days
98% 95% 98.5% 99%
% of patient commencing emergency Radiotherapy within 2 days
100% 99% 100% 100%
Linac Up-time 95% 96% 95% 98%
SACT % of patients commencing non-emergency chemotherapy within 21 days
98% 98% 99% 99%
% of patients commencing emergency chemotherapy within 5 days
100% 95% 100% 100%
Death within 30 days of Chemotherapy rates
<2% N/A 1.5% 1.6%
Outpatient % of Outpatients seen within 20 mins n/a 43.5% 49% 50.2%
% of Outpatients seen within 60 mins n/a 79% 88% 87.2%
% of Outpatients seen within 90 mins n/a 87% 96% 96%
Workforce Velindre Cancer Centre Sickness absence rate
3.54% 3.61% 4.1% 3.7%
Infection, Prevention &
Control
No. of Velindre acquired infections – MRSA
0 0 0 0
No. of Velindre acquired infections – MSSA
0 2 5 2
No. of Velindre acquired infections – C.Difficile
0 8 3 1
No. of Velindre acquired Pressure Ulcers 0 12 19 30
Hand hygiene compliance – Inpatient areas
95% 93% 81% 82%
Hand hygiene compliance – Non-inpatient areas
95% 77% 88% 85%
Patient Experience
% of patients overall experience rated 9 or above
>80% N/A 85% 85%
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5.2 Welsh Blood Service (WBS)
Performance metric 2014/15 2015/16 2016/17
Target Actual Target Actual Target Actual
7,300 new Bone Marrow Volunteer
(BMV) registrations
3,000 6,090 3,000 2,359 3,294 3,313
100% of new Bone Marrow
Volunteers (BMV) samples aged
18-30 *
30% 56% 100% 100% 100% 100%
≥98% of commercial product
requests met
≥98% 99% ≥98% 98% ≥98% 196%
≥90% deceased donor typing / cross
matching reported within 6 hours
≥90% 100% ≥90% 100% ≥90% 100%
≥90% Anti-D & -c Quantitation
results provided to customer
hospitals within 5 working days
≥90% 97% ≥90% 98% ≥90% 97%
≥90% routine antenatal patient
results provided to customer
hospitals within 3 working days
≥90% 97% ≥90% 96% ≥90% 99%
≥80% samples referred for red cell
reference serology work up provided
to customer hospitals within 2
working days
≥80% 86% ≥80% 88% ≥80% 82%
Reduce number of reportable SABRE
events from (8) to (5)
6 3 5 4 5 3
Maintain 100% to close SABRE
reports to MHRA within 30 days
100% 100% 100% 100% 100% 100%
≥71% of blood donors scoring 5 or 6
out of 6 for satisfaction with overall
service
69% 74% 70% 75% 71% 89%
≥100 % of concerns answered within
30 days
100% 97% 100% 100% 100% 100%
<7% time expired platelets <7% 4.6% <7% 4.3% <7% 11.29%
<0.5% volume of waste (red cells) <0.5% 0% <0.5% 0.1% <0.5% 0.5%
<6% total losses prior to issue
previously 5
<9% 8% <6% 5.2% <6% 4.4%
1 This was due to a national shortage of a specific wholesale product
44 | P a g e
5.3 Progress against our three year plan
The Trust has made considerable progress and achievement with the objectives and priorities it
set out to deliver during 2016/17. Some areas such as Information Technology systems have
progressed slower than we expected with some issues outside the Trust’s direct control. These
objectives have been strengthened and refined for the 2017 - 2020 plan.
Further detail is available in “Our Three Year Plan - 2017 - 2020” which is available on the Trust
Internet Site via the following link: http://www.velindre-tr.wales.nhs.uk/key-publications
Progress against our three year plan objectives are reported to the Planning & Performance
Committee and Trust Board in our “Delivering Excellence Performance Report”. These reports
for are available on the internet site via the following link http://www.velindre-
tr.wales.nhs.uk/current-trust-board-2016-meetings-1.
5.4 Progress against Performance
Progress against: Equitable and timely access targets
Performance during 2016/17 has been of a high standard and is in line with our continued
intention to deliver the best possible services. Areas not meeting set levels have been and are
subject to continued scrutiny and actions are being taken forward to improve. Appendix 1 sets out
the key measures and performance trend over 2016/17.
Progress against: Waiting times and access to services
During the year we saw increased demand for radiotherapy and chemotherapy services
provided in the Velindre Cancer Centre. Our staff worked hard to meet the increase in demand
and we are exploring new ways of working to reduce waiting times and improve access to our
services.
Progress against: Radiotherapy
We achieved our target of seeing 100% of people referred for emergency radiotherapy within 2
days every month but we know that we didn’t always see people referred for radical and
palliative radiotherapy as speedily as we would have liked to. We have been trying out different
staffing models and extended opening hours to test if they make a difference to waiting times
and will continue to explore new ways of working in addition to a business case for an additional
Linear Accelerator (LINAC) to increase our capacity. We are still having discussions with our
commissioners to increase capacity.
45 | P a g e
90%
92%
94%
96%
98%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Radical Radiotherapy
% within 28 days % Target
90%
92%
94%
96%
98%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Palliative Radiotherapy
% within 14 days % Target
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Emergency Radiotherapy
% within 2 days % Target
46 | P a g e
Utilisation of Linear Accelarator (LINAC) time was good during 2016/17 and this ensured waiting
times for patients were maintained whilst minimising disruption for patients where-ever possible.
90%
92%
94%
96%
98%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Linear Accelerator Availability - PD Uptime
PD Uptime % Target
90%
92%
94%
96%
98%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Linear Accelerator Availability - Linac Uptime
Linac Uptime % Target
47 | P a g e
Progress against: Chemotherapy
The charts below show we have mostly been able to start chemotherapy within the target time that
we set for ourselves. We are always striving to continuously improve our services. For example we
are currently reviewing our pharmacy services to see if a different way of working will help with
the chemotherapy waiting times. The increase in approval of new drug and treatment regimens
has increased pressure on the service but we have continued to explore how we can deliver these
services to patients.
Progress against: Access to therapy services
During 2016/17 we have undertaken a review into therapy waiting times and are in the process
of introducing a revised collection process focussing on patient outcome in addition to access to
services.
90%
92%
94%
96%
98%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Emergency Chemotherapy
% within 5 days % Target
90%
92%
94%
96%
98%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Non-Emergency Chemotherapy
% within 21 days % Target
48 | P a g e
Progress against Safe and reliable services target
Hospital Acquired Infections: We have continued to maintain our low rates of hospital acquired
infections.
C.Difficile:
Methicillin-Resistant Staphylococcus Aureus (MRSA): Methicillin-Sensitive Staphylococcus Aureus (MSSA): Compliance with our Skin Care bundle has been varied during 2016 - 17 however this is an area
where we have been undertaking action and will continue to work on.
There are measures at Velindre Cancer Centre where further work is ongoing to improve what we
do but the overall services provided by the Velindre Cancer Centre and Welsh Blood Service
continue to be of a high quality, focusing on excellent patient and donor care.
49 | P a g e
Progress against: Collecting enough blood
Thanks to the amazing support from our loyal and dedicated donors throughout the year we
always collected enough blood and platelets to meet the demand from hospitals in Wales.
Progress against: Bone Marrow Donations
In last year’s Annual Quality Statement we told you how pleased we were with the increasing
number of people volunteering on the Bone Morrow register. The number of donations fell
during 2015/16 but we are pleased to say that towards the end of 2016/17 we increased the
number of people we recruited above our anticipated level.
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Hand Hygiene Compliance - In-Patient Areas
First Floor ASU CIU % Target
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Hand Hygiene Compliance - Non In-Patient Areas
CDU RDU CTU Outpatients Radiology Radiotherapy % Target
0
200
400
600
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Number of New Bone Marrow Volunteer Registrations - South Wales
New Bone Marrow Volunteers (BMV) registrations per month in South Wales
Target (292 per month as of September '16)
50 | P a g e
Progress against: Welsh Blood Service meeting demand
During 2016/17 demand for whole blood and platelets has been met.
Progress against: Meeting Transplant services requests
Performance was met for this measure during 2016/17.
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
% Red Cell Supply Meeting Demand
Collections Stock Importation from NHSBT % Target
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
% Platelets Supply Meeting Demand
% Platelets Supply Meeting Demand % Target
0%
50%
100%
2016-17 Q1 2016-17 Q2 2016-17 Q3 2016-17 Q4
Turnaround Times (Deceased Donor Typing/Crossmatching Reported within 6 Hours)
% Deceased Donor Typing/Crossmatching Reported within 6 hours % Target
51 | P a g e
Co-ordination and importation of national and international haematopoietic stem cell donations
for patients transplanted in Wales performance continues to exceed the target with all reports
issued within the timeframe for this critical service which is delivered 24/7. 2016/17 saw a record
number (38) of allogeneic transplants supported by the Histocompatability & Immunogenetics
(H&I) lab and Welsh Bone Marrow Donor Registry (WBMDR).
Turnaround times remain on track and above targeted performance levels.
Progress against: Red cells issued
WBS has set itself a target of 60% of all red cells issued to be less than 14 days old to allow
sufficient storage time for our customer hospitals to manage appropriate stock levels.
Performance lower than 60% is due to higher collections and the transitional support being
supplied by NHS Blood and Transplant leading to high stock levels in preparation for go-live of the
Pan Wales Blood Service Programme in May 2016.
Part bags - work continues to reduce part bags where-ever possible. There are various reasons
that a donation may need to be stopped before reaching the required volume including
venepuncture technique, donors feeling unwell or an equipment failure.
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Red Cells Issues less than 14 Days Old
Red Cells Issues % Target
0.0%
1.0%
2.0%
3.0%
4.0%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
% Part Bags
% Part Bags % Target
52 | P a g e
Unsuccessful venepuncture, maintaining this target for venepuncture is essential in ensuring
sufficient blood is delivered to meet service need. This is an excellent achievement during
2016/17.
Progress against: First class patient and donor experience target
Our patient and donor feedback is largely positive. The Trust has worked to improve the way it
collects and receives feedback from those who use our services. Work to understand, and collate
themes to allow improvement in areas is critical in terms of using patient views, comments and
suggestions to make changes and develop services. Only two months during 2016/17 was below
required levels.
Concerns, incidents and severity - whilst numbers have been low the Trust takes its resonsibility to
learn from and take action from any concern or incident.
0.0%
1.0%
2.0%
3.0%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Unsuccessful Venepuncture
% Unsuccessful Venepuncture % Target
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Patients' Overall Experience
Rated 9 or above % Target
53 | P a g e
Welsh Blood Service donor satisfaction durng 2016/17 has mostly been above the set level. The
importance of learning from donor feedback remains paramount.
Progress against: Supporting our staff to excel target
Our workforce measures for sickness absence and Personal Appraisal Development Reviews
(PADR) were not met during 2016/17; this is an important area that the Trust is working to
improve. Detailed analysis to understand areas that need particular focus has been undertaken
and actions are in place to try and improve. These measures are also subject to scrutiny at
committee and Trust Board level.
0
50
100
150
200
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
VCC Concerns
Incidents Complaints Claims
0%
20%
40%
60%
80%
100%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Donor Satisfaction
% Donors scoring 5 or 6 out of 6 for satisfaction % Target
54 | P a g e
Sickness rates - work is ongoing to ensure sickness rates improve and that staff are supported
across the Trust.
0% 20% 40% 60% 80%
100%
May-15 to
Apr-16
Jun-15 to
May-16
Jul-15 to
Jun-16
Aug-15 to
Jul-16
Sept-15 to
Aug-16
Oct-15 to
Sept-16
Nov-15 to
Oct-16
Dec-15 to
Nov-16
Jan-16 to
Dec-16
Feb 16 to
Jan-17
Mar-16 to
Feb-17
Apr-16 to
Mar-17
Trust (excl. hosted) PADR's
% Reviews Complete % Target
0%
20%
40%
60%
80%
100%
May-15 to
Apr-16
Jun-15 to
May-16
Jul-15 to
Jun-16
Aug-15 to
Jul-16
Sept-15 to
Aug-16
Oct-15 to
Sept-16
Nov-15 to
Oct-16
Dec-15 to
Nov-16
Jan-16 to
Dec-16
Feb 16 to
Jan-17
Mar-16 to
Feb-17
Apr-16 to
Mar-17
VCC PADR's
% Reviews Complete % Target
0%
20%
40%
60%
80%
100%
May-15 to
Apr-16
Jun-15 to
May-16
Jul-15 to
Jun-16
Aug-15 to
Jul-16
Sept-15 to
Aug-16
Oct-15 to
Sept-16
Nov-15 to
Oct-16
Dec-15 to
Nov-16
Jan-16 to
Dec-16
Feb 16 to
Jan-17
Mar-16 to
Feb-17
Apr-16 to
Mar-17
WBS PADR's
% Reviews Complete % Target
55 | P a g e
Progress against: Spending every pound well target
The Welsh Blood Service measures under this area remained low which was positive during
2016/17.
A summary of performance trends are captured in Appendix 1 of this report on page 66.
3.0%
3.5%
4.0%
4.5%
5.0%
5.5%
Apr-15 to
Mar-16
May-15 to
Apr-16
Jun-15 to
May-16
Jul-15 to
Jun-16
Aug-15 to
Jul-16
Sept-15 to
Aug-16
Oct-15 to
Sept-16
Nov-15 to
Oct-16
Dec-15 to
Nov-16
Jan-16 to
Dec-16
Feb 16 to
Jan-17
Mar-16 to
Feb-17
Trust (excl. hosted) Sickness/Absence Rates
Velindre NHS Trust (excluding hosted) Velindre Cancer Centre
Corporate Services Welsh Blood Service
0%
5%
10%
15%
20%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Time Expired Platelets
Time Expired Platelets % Target
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Volume of Waste (Red Cells)
% Volume of Red Cells Waste % Target
56 | P a g e
6. Sustainability Performance 2016-2017
The Trust recognises that in our day-to-day operations we impact upon the environment in a
number of ways and therefore should report upon our potential impacts in a responsible manner.
Sustainability reporting is an essential part of organisational governance in the public sector in
Wales and the Welsh Government’s aim is to enable integrated reporting. For 2016/17 public
bodies in Wales, which report under the FReM (Financial Reporting Manual), are required to
produce a FReM Sustainability Report.
The environmental sustainability agenda is taken forward in a structured manner and supported
by strong governance arrangements. The Director of Planning, Performance and Estates is the
lead officer for environmental sustainability within the Trust. One of the Trust Board Independent
Members is the Environment Champion and works closely with the Director of Planning,
Performance and Estates and Trust Board to progress this important agenda. The Assistant
Director of Estates, Environment and Capital Development and the Environmental Development
and Compliance Officer, provide the Trust with additional capacity and capability to take forward
the ambitious work programme. The planning and delivery arrangements related to sustainability
within the Trust are set out below.
The following tables, data and narrative set out the Trusts’ performance in sustainability for
2016/17 and compare it against previous years.
In the reporting of emissions the revised 2013/14 to 2016/17 Defra grid average conversion
factors have been applied. This has been adopted to enable more accurate annual emission
comparisons and will continue in future reports following Defra guidance.
Trust Board
Action Lead Director / Independent Member
Champion
Trust Sustainability Group
Divisional / Cancer Centre Quality and Safety Group
Divisional / Hosted Organisation Energy and Environmental Forum
Planning and Performance
Committee
Objective/Outcome
Quality and Safety Committee
57 | P a g e
The Trust recognises the need to establish robust and accurate data to enable it to set realistic
targets and manage data effectively. The Trust continues to make progress in this area but
recognises there is more work to be done.
Comparison of 2016/17 data against data prior to 2015/16 identified the following data anomalies:
Additional data has now been included for NHS Wales Informatics Service (NWIS) and NHS
Wales Shared Services Partnership (NWSSP) for both 2015/16 and 2016/17, except NWSSP
waste data for 2015/16 due to data availability issues. As this data has only been included in
the 2016/17 report a number of indicators have shown a significant increase when an annual
comparison has been applied. In order to allow a direct comparison against the previous year’s
data, a comparison that excludes NWIS and NWSSP organisation data has also been included in
the report (shown in brackets).
Gas, water and waste data for leased buildings has been estimated due to no information
being available as part of the lease agreement.
Green House Gas Emissions 2013-14 2014-15 2015-16 2016-17
Non-Financial
Indicators
(1,000 tCO2e)
Total Gross Emissions 3.851,2 4.041,2 5.861,2 4.811,2
Total Net Emissions 3.851,2 4.041,2 5.861,2 4.811,2
Gross Emissions Scope 1
(direct) 0.93 0.91 1.06 1.16
Gross Emission Scope 2 &
3 (indirect) 2.92 3.13 4.81 3.66
Related Energy
Consumption
(million kWh)
Electricity: Non
Renewable
5.23 4.61 8.58 5.85
Electricity: Renewable 0 0.79 0.79 1.78
Gas 4.842 4.762 5.522 6.052
LPG 0 0 0 0
Other 0.02 0.02 0.02 0.02
Financial
Indicators
(£million)
Expenditure on Energy £0.82m2 £0.83m2 £1.25m2 £1.36m2
CRC License 0 0 0 0
Expenditure on
Accredited Offsets e.g.
GCOF
0 0 0 0
Expenditure on Official
Business Travel £0.95m3 £0.80m3 £0.75m3 £0.82m3
58 | P a g e
1In the reporting of emissions the revised 2013/14 to 2016/17 Defra grid average conversion
factors have been applied. This has been adopted to enable more accurate annual emission
comparisons and will continue in future reports following Defra guidance.
2For leased buildings with no information available on gas consumption, estimated figures have
been used for cost, consumption and emissions.
3Business mileage figure includes NWIS and NWSSP (as per previous year’s submission).
4For leased buildings with no information available on water consumption; estimated figures have
been used for cost and consumption.
5Water data provided for NWIS and NWSSP this year. As this data has only been included in the
2016/17 report a number of indicators have shown a significant increase when an annual
comparison has been applied. However, an update has been provided within the submitted
narrative, utilising the data collected and comparing last year’s data with the same data set for
2016/17.
Finite Resource; Water Consumption 2013-14 2014-15 2015-16 2016-17
Non-
Financial
Indicators
(000m3)
Water
Consumption
(Office)
supplied 1.024 1.024 24.284 38.124,5
abstracted N/A N/A N/A N/A
Per FTE N/A N/A N/A N/A
Water
Consumption
(Non-Office)
supplied 23.46 20.63 22.08 22.27
abstracted N/A N/A N/A N/A
Financial
Indicators
(£million)
Water supply
costs (Office) £0.001m4 £0.001m4 £0.039m4 £0.053m4,5
Water supply
costs (Non-
Office
£0.032m £0.029m £0.030m £0.030m
59 | P a g e
6For leased buildings with no information available on waste disposal; estimated figures have been
used for both cost and tonnage.
7Data collected during 2016/17 includes estimated waste information for the hosted organisation
NWSSP. This data was not previously captured and therefore the figures provided in the ‘Waste’
table for 2016/17 cannot be directly compared to the previous years. However, an update has been
provided within the submitted narrative, utilising the data collected and comparing last year’s data
with the same data set for 2016/17.
Waste 2013-14 2014-15 2015-16 2016-17
Non-Financial
indicators
(tonnes)
Total Waste 352.08 334.48 1076.696 895.536,7
Landfill 162.40 145.25 504.576 393.806,7
Re-used / Recycled 73.01 116.96 513.276 431.826,7
Composted 0 0 0 0
Incinerated with
Energy Recovery 21.29 72.27 58.84 69.916,7
Incinerated without
Energy Recovery 95.38 0 0 0
Financial
Indicators
(£million)
Total Disposal Cost £0.13m £0.105m £0.115m6 £0.126m6,7
Landfill £0.04m £0.026m £0.026m6 £0.028m6,7
Re-used / Recycled £0.01m £0.038m £0.051m6 £0.045m6,7
Composted 0 0 0 0
Incinerated with
Energy Recovery £0.01m £0.041m £0.038m £0.053m6,7
Incinerated without
Energy Recovery £0.07m 0 0 0
60 | P a g e
6.1 Carbon Management
In 2013 a Trust Carbon Reduction Strategy was developed in conjunction with the Carbon Trust.
The implementation of the strategy aims to reduce the carbon emissions created by the Trusts’
services over a five year period (2014 to 2019).
During 2014 the Trust entered into workshops with the Carbon Trust to look at “Behavioural
Change” within the NHS. Following these workshops it set a potential outlook for a utility
consumption saving of 10% over a five year period (2014 to 2019), based on a 2013/14 financial
year baseline and in accordance with ‘Section 3: Targets & Business Case’ of the Trust Carbon
Reduction Strategy. The following table identifies the annual percentage target reduction in
electricity, gas and water consumptions and emissions and provides an explanation as to why each
target has been set. This year’s performance target is highlighted in green.
Financial Year Percentage Target (%) Reason for Percentage Target
2014 - 2015 1%
This target was set in November 2014. It is a
low percentage due to the target being set
over half way through financial year 2014/15.
2015 - 2016 3%
Energy awareness strategies and targets with
suitable monitoring, being delivered by
behavioural change.
2016 - 2017 3%
Energy awareness strategies and targets with
suitable monitoring, continual emphasis on
behavioural change.
2017 - 2018 2% Investment required to maintain on-going
savings.
2018 - 2019 1.5%
Diminishing savings as investment required to
further increase savings. Extra 0.5% to ensure
10% overall five year target is achieved.
61 | P a g e
6.2 Energy and Water Management
During 2016/17 the Trust did not achieve an overall reduction in electricity consumption (non-
renewable and renewable), showing an increase of 3.72 % compared to 2015/16.
The Trust’s annual electricity consumption, excluding NWIS and NWSSP organisations, produced a
net increase of 1.46 %, compared with similar data of the previous year.
The current Trust target, as shown in the ‘Annual Percentage Target Reduction’ table, is based on
electricity consumption established in 2014/15, excluding NWIS and NWSSP organisations. The
performance against this target shows an increase of 11.51 %.
During 2016/17 the Trust did not achieve an overall reduction in gas consumption, showing an
increase of 9.47 % compared to 2015/16.
The Trust’s annual gas consumption, excluding NWIS and NWSSP organisations, produced a net
increase of 5.41 %, compared with similar data of the previous year.
The current Trust target, as shown in the ‘Annual Percentage Target Reduction’ table, is based on
gas consumption established in 2014/15, excluding NWIS and NWSSP organisations. The
performance against this target shows an increase of 9.13 %.
Factors that have impacted on the Trust overall performance include:
Additional Bangor and Wrexham All Wales sites at WBS.
Addition of NWIS and NWSSP organisations in Trust reporting.
Increased operational hours within divisions, in particular of linear accelerators (LINACS)
providing patient radiation treatment and associated equipment at the Velindre Cancer Centre
(VCC).
Limited promotion and monitoring of energy awareness and education within the larger
divisions of the Trust (WBS and VCC).
Continued use of older, less energy efficient equipment such as linacs and refrigerators.
During 2016/17 the Trust did not achieve an overall reduction in water consumption, showing an
increase of 30.26 % compared to 2015/16.
The Trust’s annual water consumption, excluding NWIS and NWSSP organisations, produced a net
decrease of 0.95%, compared with similar data of the previous year.
The current Trust target, as shown in the ‘Annual Percentage Target Reduction’ table, is based on
water consumption established in 2014/15, excluding NWIS and NWSSP organisations. The
performance against this target shows an increase of 0.31 %.
62 | P a g e
Factors that have impacted on the Trust overall performance include:
Additional Bangor and Wrexham All Wales sites at WBS.
Addition of NWIS and NWSSP organisations in Trust reporting.
Increased water flushing regimes in VCC.
Increased operational hours at VCC.
The Trust will continue to work towards achieving a significant reduction in its carbon emissions by
focusing on the following:
Reducing electricity and gas consumptions through embedding ‘Don’t Waste at Work’ energy
and waste campaigns and improving meter reading and data capture at all divisions / hosted
organisations. Staff, patients and visitors all have a role to play in achieving these reductions.
Reviewing extended hours of use and use of equipment at divisions and ensuring this is taken
into account in future year comparisons.
Replacement of inefficient boilers.
A pilot energy saving lighting scheme has been installed at VCC to reduce its operational
impact on the environment. This scheme will be monitored and if the predicted reductions are
achieved it could potentially be expanded across VCC as well as other sites.
The Building Management System at each site will be re-configured to ensure energy efficiency
is optimised.
Ensure that gas heating is switched off during the summer period or BMS controls are
amended correctly to reflect summer temperatures.
A PC shutdown software initiative has been trialled at The Trust Headquarters. The initiative
involved an automatic shutdown of all PCs at 8pm every night, in an effort to stop energy
being unnecessarily wasted overnight when PCs are not in use, prolonging the life of PC
software as equipment is not on all the time and because it’s the right thing to do. After a
successful trial, The Trust Headquarters will now be used as a case study with the hope to roll
the initiative out to other Trust divisions and hosted organisations over the next twelve
months, in line with our Environmental Management System.
Water and gas monitoring and leak detection good practice will continue over the next twelve
months to ensure future targets are achieved.
Business cases will be developed for chosen installations and funding sourced, working with
Welsh Government. Further reductions in energy consumption and emissions need to be
realised, alongside the behavioural change of staff, patients, donors, visitors and contractors.
63 | P a g e
6.3 Travel and Transport
During 2016/17 the Trust’s overall expenditure on official business travel increased by 9.2 %
compared to 2015/16, to £817,038.00. Trust overall official business mileage increased by 7.86 %,
to 1,843,161 miles.
Factors that have impacted on the Trust overall performance include:
Additional staff across the various divisions and hosted organisations of the Trust.
The Trust continues to work towards achieving a significant reduction in its carbon emissions by
requesting that all staff, visitors and contractors consider the ‘Travel Hierarchy’ when arranging
travel for commuting, meetings, conferences and visits. This includes:
Videoconferencing facilities are available across Trust sites, allowing people at two or more
locations to see and hear each other at the same time, minimising travel. Staff will be
supported to make better use of these facilities to reduce unnecessary travel.
Walking is good for your health, improves mood and boosts self-esteem. Many Trust sites are
located within a short distance to green areas such as the Taff Trail. Staff will be supported to
make better use of these facilities.
A ‘cycle to work’ scheme has been introduced at the Trust to make it easier for staff to
purchase a bike. Secure bike shelters and showers are also available to encourage cycling to
work. These options will be further promoted to staff to reduce unnecessary use of vehicles.
Bus and train services are included when directing staff, patients, donors, visitors and
contractors to each division / hosted organisation, public transport must be made the first
choice for staff conference travel.
Car sharing will be further encouraged, as well as using the journey for multiple purposes
where possible (e.g. delivery of reports and papers).
Travel options will be made available to all staff throughout the Trust through a site specific
environmental awareness factsheet, with particular focus on staff that have not considered
changing their travel habits before.
In line with the roll out of ISO14001 certification across all Trust Divisions and Hosted
Organisations, a ‘Trust Travel Plan’ has been developed and launched. This includes details and
achievements from the VCC, WBS and Trust Headquarters as well as hosted organisations. The
Trust Travel Plan will actively encourage the reduction of single occupancy car journeys, with
initiatives such as:
Video conferencing / conference calls rolled out across all sites.
64 | P a g e
Shared occupancy journeys, with a designated car parking facility for registered car sharers at
its VCC site.
Maintain the cycle to work scheme for the purchase of bikes and providing good cycle
facilities.
Improve and increase the number of bike shelters and showers on site at VCC and WBSs.
Support working from home.
Look into the use of lower carbon options for transport.
Actively encourage the use of public transport.
Actively support the use of alternative fuel vehicles for travel, including LPG, Bi-Fuel, Hybrid,
and Zero Emission.
The Trust-wide Travel Plan will acknowledge the above principles together with guideline
documents such as the ‘Active Travel (Wales) Act 2013’, ‘Wellbeing of Future Generations (Wales)
Act 2015’ and the ‘Good Practice and Guidelines: Delivering Travel Plans’, commissioned by the
Department for Transport, in consultation with Communities and Local Government, to give
further impetus to the use of travel plans as a means of promoting sustainable travel. The Travel
Plan will also support the ‘Trust Environmental Policy’ and associated procedures.
The Trust Travel Plan will deliver a wide range of benefits. For developers, it will make a site more
accessible and smooth the planning process. The benefits for local authorities include helping
achieve wider local government objectives and managing demand across travel modes. The Travel
Plan will assist in bringing a wide range of benefits to the wider community such as:
Reducing peak time congestion.
Reducing harmful transport emissions and reducing energy use, therefore helping to tackle
climate change and provide environmental benefits.
Improving public transport, accessibility and tackling social exclusion.
Offering pleasant surroundings for pedestrians in and around Trust buildings.
As part of the Trust Capital Build design process, all major construction schemes will be reviewed
in line with the Welsh Government’s ‘Architectural Design Evaluation Toolkit’ (AEDET). As part of
this process consideration is given and scores awarded for proximity to public transport services.
The Trust will work with both Local Authorities on the provision of its The Trust Travel Plan,
ensuring that all public transport options, including cycling are integrated into new schemes.
65 | P a g e
6.4 Waste Management
Data collected during 2016/17 includes waste information for the hosted organisation NWSSP.
This data was not previously captured and therefore the figures provided in the ‘Waste’ tables for
2016/17 cannot be directly compared to the previous years.
The Welsh Government has set a target for all organisations to recycle at least 70 per cent of
waste by 2025. The Trust has set a target for 2016/17 of 57 % recycling of its waste materials, as it
moves towards the 70 % goal.
The Trust’s chosen clinical waste contractor is now recovering residual waste (flock) from clinical
waste treatment plants. Therefore the Trust will now include any alternative treated and energy
recovery incinerated clinical waste as recycled waste.
During 2016/17, the Trust did not achieve its overall annual recycling percentage target of 57 %,
with a performance of 56.13 %. However, the rate of recycling had increased by 2.99 % compared
to the previous year performance of 53.14 %.
The Trust’s annual recycling rate, excluding NWIS and NWSSP organisations, is 61.40 %, showing a
net increase of 4.65 % compared with similar data of the previous year.
The Trust will continue to work towards increasing its recycling rate by focusing on a wide range of
opportunities that include:
The Trust Environmental Compliance Officer has been working closely with divisions within the
Trust to prepare for the implementation of a ‘Bin the Bin’ initiative. The initiative involves
removing desk-side bins and having central waste stations’ in an effort to increase recycling,
encourage source segregation of waste in line with government legislation, minimise the
amount of waste bags used and encourage networking, movement and staff wellbeing. During
full implementation over the next 12 months, each division will need to overcome several
obstacles including addressing staff concerns, promoting the benefits of the initiative and
encouraging staff participation throughout the Trust. Full implementation of the initiative will
aid in the continual improvement of the Trust’s Environmental Management System.
Continued implementation of the ‘All-Wales NHS’ waste contract and improved data collection
procedure, whilst promoting and monitoring waste awareness and education across the Trust.
The Trust Environmental Development and Compliance Officer working with the Estates and
Operational Services departments at all divisions to analyse the data capture method of waste
weights to ensure that the correct calculations are being used.
The Trust Environmental Development and Compliance Officer is engaging with hosted
organisations in developing initiatives and producing more accurate information.
66 | P a g e
Appendix 1: Performance trends over 2016-2017 – Summary
Service Performance measures
Green Target achieved this month
Red Target not achieved this month
Equitable and timely access
Velindre Cancer Centre Level 1
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 001 – 98% of patients commencing radical radiotherapy within 28 days
98% 98% 98% 98% 97% 97% 97% 96% 99% 100% 100% 97%
VCC 002 -98% of patients commencing palliative radiotherapy within 14 days
98% 100% 100% 100% 94% 99% 100% 98% 98% 99% 98% 98%
VCC 003- 100% of patients commencing emergency radiotherapy within 2 days
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
VCC 116- 95% Linear Accelerator Uptime
94% 97% 99% 97% 97% 97% 97% 97% 99% 98% 95% 95%
VCC 117- 98% Patient Disruptive Uptime
97% 100% 100% 99% 99% 100% 99% 100% 100% 100% 96% 96%
67 | P a g e
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 017- 100 % of patients commencing emergency chemotherapy within 5 days
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
VCC 018- 98% of patients commencing non-emergency chemotherapy within 21 days
99% 99% 100% 99% 98% 100% 100% 99% 97% 99% 98% 97%
VCC 118- All SACT referrals within turnaround
99% 99% 100% 99% 98% 100% 100% 99% 97% 99% 98% 97%
Level 2
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 130- CR Inpatients (within 1 working day)
90% 87% 98% 98% 98% 98% 85% 90% 98% 97% 98% 99%
VCC 131- CT Inpatients (within 1 working day)
95% 100% 100% 100% 100% 95% 87% 100% 100% 100% 100% 100%
VCC 132- MRI inpatients (within 1 working day)
100% 100% 100% 100% 100% 100% 100% 66% 100% 100% 75% 100%
VCC 133- US inpatients (within 1 working day)
100% 100% 100% 100% 100% 100% 100% 88% 100% 100% 90% 75%
VCC 134- CR Outpatients (within 7 days)
100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
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Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 135- CT Outpatients (within 7 days)
100% 100% 100% 100% 100% 100% 100% 97% 98% 100% 98% 98%
VCC 136- MRI Outpatients (within 7 days)
100% 99% 100% 100% 100% 100% 100% 100% 100% 100% 96% 100%
VCC 137- US Outpatients (within 7 days)
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Welsh Blood Service Level 1
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
292 (from Sept) new
Bone Marrow Volunteers
(BMV) registrations per
month
261 311 182 218 188 239 318 468 272 289 342
528
69 | P a g e
Supporting our staff to excel
Velindre NHS Trust
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
COR 007- 3.54%
Sickness Absence
rate (Trust Wide)
4.33% 4.28% 4.22% 4.18% 4.14% 4.11% 4.19% 4.18% 4.14% 4.15% 4.17% 4.24%
COR 006- 85%
PADR (Trust
Wide)
59.7% 64.2% 66.2% 72.2% 75.1% 77.6% 77.6% 70.8% 71.8% 70.0% 68.9% 67.0%
COR 007- 3.54%
Sickness Absence
rate (Corporate
Services)
4.11% 4.20% 4.27% 4.17% 4.64% 4.90% 4.91% 4.86% 4.98% 4.89% 4.72% 4.62%
COR 006- 85%
PADR (Corporate
Services)
42.9% 62.8% 68.5% 72.9% 76.4% 77.4% 77.4% 74.3% 73.2% 71.6% 76.8% 85.7%
70 | P a g e
Velindre Cancer Centre
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
COR 006- 85% PADR Rate
56.2% 59.4% 61.1% 71.3% 74.1% 75.7% 75.7% 66.6% 65.1% 62.2% 61.4% 59.4%
COR 007- 3.54% Sickness absence rate
4.08% 4.05% 4.00% 3.91% 3.73% 3.59% 3.60% 3.56% 3.50% 3.53% 3.59% 3.70%
Welsh Blood Service
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
85% PADR Rate 70.1% 73% 74.3% 73.5% 76.4% 77.4% 80.7% 76.3% 81.5% 81.2% 78.0% 73.4%
3.54% Sickness absence
rate 4.82% 4.67% 4.58% 4.63% 4.67% 4.74% 4.94% 5.00% 4.94% 4.93% 4.94% 4.99%
71 | P a g e
Estates
Level 1
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
COR 024a-
Electricity (kWh)
COR 024b- Gas
(kWh)
COR 025a-
Electricity (CO2)
COR 025b- Gas
(CO2)
COR 026- Water
Usage (m3)
72 | P a g e
Safe and reliable services
Velindre Cancer Centre
Level 1
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 025- Death within 30 days of chemotherapy
Metric under development
VCC 032a- 0 C.diff cases
0 0 0 0 0 0 0 0 1 0 0 0
VCC 032b- 0 MRSA cases
0 0 0 0 0 0 0 0 0 0 0 0
VCC 032c- 0 MSSA cases
0 0 1 0 0 0 0 1 0 0 0 0
VCC 033- 0 Velindre hospital acquired pressure ulcers
1 3 3 4 5 0 5 4 3 0 1 1
VCC 138- 0 unexpected inpatient deaths
0 0 0 0 0 0 0 0 1 0 0 0
VCC 139- 95% Compliance with CAUTI insertion care bundles
83% 100% 86% 88% 83% 100% 75% 100% 72% 100% 100% 69%
VCC 140- 95% Compliance with CAUTI maintenance care bundle
100% 100% 95% 100% 95% 100% 88% 100% 85% 93% 100% 88%
VCC 141- 100% compliance with CVC insertion care bundle
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
73 | P a g e
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 142- 100% compliance with skin care bundle
67% 67% 93% 67% 100% 67% 100% 100% 100% 100% 83% 78%
VCC 034a 90% patients to have a documented thromboproxphylaxis risk assessment on admission
69% 46% 55% 63% 27% 46% 48% 91% 96% 96% 96% 89%
VCC 034b 100% eligible patients prescribed thromboprophylaxis
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Level 2
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 143- 95% hand hygiene compliance (average- non inpatient areas)
87% 93% 86% 90% 88% 92% 60% 75% 91% 86% 87% 71%
VCC 144- 95% hand hygiene compliance (average- inpatient areas)
78% 79% 78% 86% 80% 95% 79% 80% 81% 82% 75% 72%
VCC 036- Mortality Review of 100% of inpatient deaths
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
74 | P a g e
Level 3 Highlighted Measures
Level 3
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 146- Antibiotic Prescribing- 100% compliance with documenting duration/review date
60% 86% 41% 42% 76% 100% 100% 100% 100% 100% 100% 100%
75 | P a g e
Welsh Blood Service
Level 1
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
100% Red cell supply
meeting demand 111% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100% of platelets
supply meeting
demand
141% 114% 102% 106% 121% 119% 108% 112% 124% 114% 120% 119%
98% of commercial
product requests
met
99% 96% 100% 99% 91% 91% 98% 99% 95% 95% 99% 92%
≥90% deceased
donor typing / cross
matching reported
within 6 hours
(quarterly metric)
100% 100% 100% 100%
100% delivery of
Haemotopoietic
Stem Cell (HSC)
internal targets
stakeholders in full
135.6% 135.6% 155% 136% 155% 116.3% 136% 155% 116.3% 96.9% 96.9% 38.8%
76 | P a g e
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
100% facilitation /
import of HSC
products for patients
in Cardiff and Vale
UHB
75% 50% 100% 75% 125% 100% 50% 75% 71% 50% 100% 125%
≥90% Anti-D & -C
Quantitation results
provided to
customer hospitals
within 5 working
days (quarterly
metric)
96% 99% 95% 91%
≥90% routine
antenatal patient
results provided to
customer hospitals
within 3 working
days
(quarterly metric)
99% 99% 99% 98%
77 | P a g e
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
≥80% samples
referred for red cell
reference serology
work up provided to
customer hospitals
within 2 working
days (quarterly
metric)
81% 82% 82% 77%
Level 2
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
60% red cells issued
less than 14 days
old
40% 28% 30% 31% 39% 53% 69% 61% 44% 46% 55% 31%
≤3% part bags
collected 3% 3% 3% 3% 3% 3% 3% 3% 3% 3% 3% 4%
≤2% unsuccessful
venepuncture 2% 2% 1.4% 1% 2% 2% 1% 2% 1% 2% 1% 1%
78 | P a g e
First class patient and donor experience
Velindre Cancer Centre
Level 1
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 044- >80% patient overall experience rated 9 and above
94% 85% 81% 85% 80% 77% 72% 89% 86% 92% 90% 89%
Level 2
Metric Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
Nov 16
Dec 16
Jan 17
Feb 17
Mar 17
VCC 046- On the day waiting times in outpatients less than 20 minutes
45% 49% 59% 45% 52.3% 44.4% 50.2% 48.8% 54% 54% 53% 53%
VCC 058- 100% of palliative care patients have an POS-S or equivalent assessment within 24 hours of referral
100% 100% 80% 100% 100% No data provided
100% 100% 100% 100% 100% 100%
79 | P a g e
Welsh Blood Service
Level 1
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
≥71% of blood donors
scoring 5 or 6 out of 6
for satisfaction with
overall service
89% 88% 91% 90% 90% 88% 93% 94% 91% 92% 92% 92%
≥100 % of concerns
answered within 30
days
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Level 2
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Whole Blood: 1.25
units collected by WTE
per hour
1.13 1.12 1.01 1.01 1.13 1 0.97 1.16 1.04 1.1 1.14 1.17
Apheresis: 2.15
Average Adult
Therapeutic Dose
(ATD) per Donation
2.1 2.11 2.1 2.06 2.07 2.08 2.08 2.07 2.03 2.06 2.02 2.06
80 | P a g e
Spending every pound well
Metric Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sept
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
<7% time expired
platelets 16.7% 16.5% 16.3% 13.9% 16.2% 7.9% 5.1% 6.0% 10.3% 9.5% 11.0% 11.0%
<0.5% volume of
waste (red cells) 0.1% 0.7% 1.5% 0.9% 0.8% 0.4% 0% 0.0% 0.1% 0.1% 0.1% 0.2%
<6% total losses
prior to issue 6.1% 5.8% 5.5% 5.3% 5.6% 5.5% 5.3% 6.2% 5.3% 3.8% 5.8% 6.1%
81 | P a g e
Appendix 2: Progress against our three year plan
Delivery again Plan objectives
Green Actively managed processes proceeding as planned - no major risks or issues identified
Amber Problems have surfaced, considered manageable in the normal course
Red Serious problems have surfaced – make Senior Management Team aware
Closed
Purple Major issues remain unsolved- “on hold” until resolved - senior executive engaged
Grey Deliverable activity at feasibility/initiation stage
At a Glance Summary – Progress against 3 Year Plan Objectives
Area Objective Level Status Forecast
Status Risk
Wo
rkfo
rce
an
d
Org
anis
atio
nal
De
velo
pm
en
t WOD01 – Leadership & Management Capability 2
WOD02 – Quality & Continuous Improvement 2
WOD03 – Diversity & Inclusiveness 2
WOD04 – Staff Engagement & Well Being 2
WOD05 – Collaborative & Partnership working 2
Serv
ice
Imp
rove
me
nt SI 01 – Stimulate generation of the ‘right’ ideas to take forward
2
SI 02 – Strengthening the arrangements for our international health links 2
82 | P a g e
Area Objective Level Status Forecast
Status Risk
SI 03 – Enable the spread of learning 2
Re
sear
ch a
nd
De
velo
pm
en
t
VCC059 – Provide patients with timely access to the latest anti-cancer treatments through participation
in clinical trials 2
VCC 060 – Actively promote the benefits of participating in research to staff and patients 2
VCC 065- Develop department level strategies that are aligned to the VCC R&D strategy 1
VCC 071- Continue to develop the national leadership position of the RTTQA group 1
VCC 077- Increase recruitment into clinical trials activity in line with and beyond national targets where
possible 1
VCC 078- Increase tissue collection for the Wales Cancer Bank 1
VCC080 - Develop Nurse and AHP research leads and research programs 2
VCC 081- Develop strategic collaborations and engagement 2
RD 001 – Actively promote the benefits of participating in research of staff, donors and patients 2
RD 002 – Re-design of R&D governance structure 1
RD 003 – Operationalise the R&D Strategy
2
83 | P a g e
Area Objective Level Status Forecast
Status Risk
Org
anis
atio
nal
Le
arn
ing OL 01 - Provide opportunities for patients, donors and carers to provide feedback in order to help staff
build effective care partnerships 2
OL 02 - Have in place fully functional reporting systems to enable collection and analysis of patient,
donor and carer feedback in order to facilitate learning 2
OL 03 - Develop communication structures to enable the spread of learning across the organisation 2
Esta
tes
COR 022- Undertake a review of the Trust’s Statutory Compliance across divisions and hosted
organisations. Achieve and maintain a Trust Statutory Compliance Target of 90 %. 1
COR 023 – At least 50% of Trust properties and all Trust hospital sites certified to ISO14001 by the end of
the financial year. 1
Velindre Cancer Centre - At a Glance Summary - Progress against 3 Year Plan Objectives
Strategic Theme
Objective Level Status Forecast
Status Risk
Equ
itab
le a
nd
Tim
ely
Acc
ess
to
Se
rvic
es VCC 001-003 – Consistently achieve waiting times recommendations for patients receiving Radiotherapy 1 Progress reported in Section 2
VCC 004- Develop a strategic plan for radiotherapy services including advanced radiotherapy 1
VCC 005- Increase radiotherapy access to the appropriate rate for patients with cancer within our resident
population 1
VCC 008- Repatriate all appropriate activity from England and increase the provision of SBRT and SRS 1
VCC 113 – To work with Health Boards and WHSSC to develop systems for the approval and funding of Emergency
Access to Medicines (EAMs) schemes 1
VCC017-019 – Consistently meet waiting times targets for emergency and non-emergency chemotherapy patients 1 Progress reported in Section 2
VCC 020- Patients to receive parental SACTs as close to their homes as possible within environment which are
appropriate for safe administration 1
VCC 083- Disaster Recovery Plans (DRP) in place to support service in the event of an incident, ensuring a clear
process in place in line with timely resolution 1
84 | P a g e
Strategic Theme
Objective Level Status Forecast
Status Risk
VCC 006 – Increase provision of Intensity Modulated Radiotherapy (IMRT) to 35% of radical plans 2
VCC 007- Develop the use of Image Guided Radiotherapy (IGRT) techniques across tumour sites 2
VCC 022- Strengthen links with primary care: Review processes by which patients can receive care within local
communities and utilise local resources 2
VCC 023 - Strengthen links with primary care: Review processes by which patients can be reviewed by oncology staff
(VNHST) in primary care (or closer to home) 2
VCC024 – Maximise use of available information intelligence within medicine management systems to support
service development and clinical and financial audit 1
VCC 031- Review of Clinical nurse specialists and key workers to ensure appropriate service provision 2
VCC 082- Support infrastructure in situ including sufficient capacity and resilience for the provision of continuous
service 2
VCC 085- Explore technology to underpin service in line with service improvements, and change in
workflows/practices 2
VCC104 – Implement the agreed recommendations from the internal pharmacy review, the Welsh Audit Office
report and the MHRA inspection report in order to improve the quality of the medicines management service. This
is collectively termed the “Medicines Management Action Plan” 2016 to 2017
2
Safe
an
d R
elia
ble
Se
rvic
es
VCC032 – Reduce healthcare associated infections to zero 1 Progress reported in Section 2
VCC033 – Reduce Velindre acquired pressure ulcers to zero 1 Progress reported in Section 2
VCC034 – Ensure that all inpatients received documented thrombosis risk assessments on admissions 1 Progress reported in Section 2
VCC 040- Development of Acute oncology services across SE Wales 1
VCC 090- Implementation of Welsh Clinical Portal (which includes Medicines Transcriptions and Electronic Discharge (MTedD)) with National Test Requesting and Results Reporting (TRRR)
1 Change Control
VCC 039- Improve oversight of medication related errors to comply with NHS Wales standards 2
VCC 088- Implementation of National Image Sharing- Vendor Neutral Archive (VNA) Project to support the care of cancer patients via cross organisation image sharing
2
VCC120 – Strengthening business continuity and emergency planning resources, processes and plans
Firs
t C
lass
Pat
ien
t
Exp
eri
en
ce VCC 012- Evaluate current waiting times targets for radical specific patient groups including lung and radical
neurology patients 2
VCC 013- Implementation of Royal College or Radiologist guidance on management of interruptions for category 2 patients
2
VCC 028- Ensure that patients who take oral SACTs are able to make fully informed decisions to facilitate 2
85 | P a g e
Strategic Theme
Objective Level Status Forecast
Status Risk
medication adherence
VCC044 – Increase positive patient experience levels through the collection of views and opinions from a wider sample of patients including outreach settings
1
VCC 045- Ensure that people living with and beyond cancer have a personalised assessment, information and care plan and are empowered to manage their condition
2
VCC050 – Establish an assessment unit at VCC 2
VCC 057- Increase the number of patients that die in their preferred place. Increase the number of patients who access their preferred place of care.
2
VCC058 – 100% of palliative care patients have an POS-S (palliative care outcome scale) or equivalent assessment within 24 hours of referral
2
VCC111 – Improve feedback mechanisms for patients 2
Pro
vid
ing
Evid
en
ce B
ase
d C
are
an
d R
ese
arch
VCC 100- Maintain required standards for timeliness and completeness of clinical coding in line with targets set by the Welsh Government
1
VCC 014- Implement image guided brachytherapy for appropriate gynaecology cancer patients 2
VCC 029- Introduce and evaluate use of oncotype testing 2
VCC 096 – Improving the data quality within the electronic patient record – Provision of accurate and up to date information by the Medical Records Department
2
VCC 097- Development of an organizational informatics function to inform service improvement plans, benchmarking, mandatory returns, data extraction and validation
2
VCC 098- Implementation of the National Intelligent Integrated Audit Solution (NIIAS) 2
VCC 099- Implementation of Mobile Device Management Solution 2
VCC103 – Increase capacity on the chemotherapy day case unit in order to meet growing demand (approximately 250 additional patients per year) as a result of the introduction of Docetaxel chemotherapy for prostate cancer.
1
VCC109 – Develop service to provide Radium 223 to patients with prostate cancer as per NICE appraisal 1
VCC114 – To provide Cetuximab treatment to patient population in line with AWMSG directive. 1
VCC115 – To develop a business case for the provision of Zometa for breast patients 1
VCC117 – To develop a business case for the provision of new lines of therapies (as per anticipated NICE publications) for patients with Melanoma Cancer
1
VCC118 – Review structure and resources for Quality and Safety support provided by Cancer Services Management Offices
2
86 | P a g e
Welsh Blood Service- At a Glance Summary - Progress against 3 Year Plan Objectives Strategic
Theme Objective Level Status
Forecast
Status Risk
Equ
itab
le
and
Tim
ely
Acc
ess
to
Serv
ice
s
WBS001 – Improve recruitment and retention of whole blood donors 1
WBS002 – Recruit and retain new Bone Marrow Volunteers (BMV) donors, especially young donors 1
Safe
an
d R
elia
ble
Se
rvic
es
WBS004 – Meet all Blood component demand in line with clinical need 1
WBS 005 – Meet all Transplant Service requests 1
WBS 006 – Meet all diagnostic service requests 1
WBS007 – Maintain external regulatory compliance: (MHRA/HTA/EFI/WMDA) 1
WBS 008 - Keep abreast of mandated changes to testing and emerging clinical priorities including: (I) PAS and NAT HEV,
and (ii) Pathogen Inactivation 1
WBS009 – Existing Systems Maintenance & Support 1
WBS010 – Retain wholesaling license 2
WBS 011 - IM&T Infrastructure Improvement Programme inc. ‘disaster recovery’ 2
WBS 012 - Provision of technical support for Operational Project Delivery Programme (Software & Infrastructure) 2
WBS 013 - Develop and implement cross departmental and organisational processes for quality management inc.
training records 2
Firs
t
Cla
ss
Do
no
r
Exp
eri
en
ce
WBS 014 - Continue to improve satisfaction ratings from our donors 1
WBS 015 - Respond to all concerns in a timely and effective way (links to donor satisfaction) 1
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Strategic
Theme Objective Level Status
Forecast
Status Risk
WBS 016 – Continue to improve donation experience 2
WBS 017 – Keep abreast of advancements in technology for WTAIL 2
Sup
po
rtin
g o
ur
staf
f to
exc
el WBS 021 – To deliver new service models through an engaged and empowered workforce 2
WBS 022 – To ensure optimal flexible working patterns to support new service models 2
WBS 023 – To develop a flexible laboratory workforce using ‘Modernising Scientific Careers’ 2
Spe
nd
ing
Eve
ry
Po
un
d
We
ll
WBS 024 – Reduce volume of ‘production waste’ (namely Collections and Laboratories) 1
WBS025 – Improve optimization of Estates Infrastructure 2
88 | P a g e
Appendix 3: Equality Annual Monitoring Report Data and Information
Introduction
We are pleased to present Velindre NHS Trusts Equality Monitoring report for April 2016- March
2017; this report provides the equality monitoring data in line with our duties under the Equality
Act 2010.
Legal Context
The Public Sector Equality Duty (PSED) requires that all public authorities covered under the
specific duties in Wales should produce an annual equality report by 31st March each year. The
Trust published the report for 2015-16 for the March deadline 2017. The information in this
report therefore covers the following year to bring it in line with the Trust Wide Annual report.
The essential purpose of the specific duties under the Equality Act, in relation to monitoring, is
to help authorities to have better due regard to the need to achieve the 3 aims of the general
duty, which are to;
eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the Act;
advance equality of opportunity between people who share a protected characteristic and people who do not share it; and
foster good relations between people who share a protected characteristic and people who do not share it.
Therefore, as a specific duty itself, the role of annual reporting is to support the Trust in meeting
the general duty. It also has a role in setting out achievements and progress towards meeting
the other specific duties.
In particular, the annual report supports the Trust to have a better due regard to the duties by
providing an opportunity to;
Monitor and review progress
Monitor and review the effectiveness and appropriateness of arrangements
Review objectives and processes in light of new legislation and other new developments
Engage with stakeholders around these issues, providing partners and the public with transparency.
89 | P a g e
Equality Data
In the pie charts below you will find the breakdown of equality data in several areas;
Staff in post by their protected characteristic
All staff breakdown by grade o Each grade broken down by gender
Working pattern broken down by gender
Employment assignment broken down by gender
Recruitment applications by their protected characteristics
All staff breakdown upon leaving the Trust o Leavers by their protected characteristics
The Trust made a decision to use pie charts to convey the equality data as tables created
identifiable information, due to small numbers. Therefore to be able to publish information and
perform valid analysis the Trust has agreed to use pie format to display information.
What the data does demonstrate is that for a number of the more sensitive equality areas, many
staff have either decided that they would prefer not to say or the data has not been captured at
all. This is an area that has been identified for improvement and confidence in how the Trust will
be using the data should over time, which will hopefully see the data gaps close.
Please note that the Full Time Equivalent (FTE) data may differ to that reported in the accounts
as it is captured on a snapshot model.
Age Band
Age Band Headcount % FTE
<20 12 0.31 11.33
20-25 207 5.34 198.80
26-30 530 13.66 503.66
31-35 541 13.94 490.65
36-40 452 11.65 409.30
41-45 501 12.91 452.10
46-50 527 13.58 489.01
51-55 533 13.74 486.06
56-60 367 9.46 327.97
61-65 158 4.07 133.87
66-70 39 1.01 29.01
71+ 13 0.34 7.35
3,880 100.00 3539.11
0.31%
5.34%
13.66%
13.94% 11.65%
12.91%
13.58%
13.74%
9.46% 4.07%
1.01%
0.34%
Age Band
<20 20-25 26-30 31-35 36-40 41-45
46-50 51-55 56-60 61-65 66-70 71+
90 | P a g e
By Gender
Gender Headcount % FTE
Female 2,393 61.7 2099.75
Male 1,487 38.3 1439.36
Grand Total
3,880 100.0 3539.11
By Religious Beliefs
Religious Belief
Headcount % FTE
Atheism 511 13.17 486.28
Buddhism 9 0.23 8.29
Christianity 1,574 40.57 1441.32
Hinduism 32 0.82 29.86
Islam 59 1.52 54.95
Judaism 1 0.03 1.00
Not Disclosed
552 14.23 520.70
Other 283 7.29 261.32
Sikhism 2 0.05 1.60
Unspecified 857 22.09 733.81
Grand Total
3,880 100.00 3539.11
By Sexual Orientation
Sexual Orientation
Headcount % FTE
Bisexual 13 0.34 12.60
Gay 28 0.72 26.93
Heterosexual 2,648 68.25 2454.44
Lesbian 12 0.31 11.53
Not Disclosed
345 8.89 323.29
Unspecified 834 21.49 710.31
Grand Total 3,880 100.00 3539.11
62%
38%
Gender
Female
Male
13.17%
0.23%
40.57%
0.82% 1.52%
0.03%
14.23%
7.29%
0.05%
22.09%
Religious Belief
Atheism
Buddhism
Christianity
Hinduism
Islam
Judaism
Not Disclosed
Other
Sikhism
Unspecified
0.34% 0.72%
68.25%
0.31%
8.89%
21.49%
Sexual Orientation
Bisexual
Gay
Heterosexual
Lesbian
Not Disclosed
Unspecified
91 | P a g e
By Employee Category
Employee Category
Headcount % FTE
Full Time 2,849 73.43 2849.00
Part Time 1,029 26.52 689.11
Unspecified 2 0.05 1.00
Grand Total
3,880 100.00 3539.11
By Employee Category by Gender
Female Male
Unspecified 0.03 0.03
Part Time 23.09 3.43
Full Time 38.56 34.87
73.43%
26.52%
0.05%
Employee Category
Full Time
Part Time
Unspecified
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
Female Male
Unspecified Part Time Full Time
92 | P a g e
By Disability
Disability Flag
Headcount % FTE
No 2,532 65.3 2342.21
Not Declared
205 5.3 189.57
Unspecified 1,052 27.1 923.63
Yes 91 2.3 83.70
Grand Total
3,880 100.0 3539.11
Yes Disability Type FTE Headcount Headcount %
Learning disability/difficulty 4.80 5 5.7
Long-standing illness
11.29 13 13.5
Mental Health Condition 5.03 6 6.0
Other 6.00 6 7.2
Physical Impairment 1.40 2 1.7
Sensory Impairment 5.80 6 6.9
Yes - Unspecified 49.37 53 59.0
65% 5%
27%
3%
Disability
No
Not Declared
Unspecified
Yes
5%
14%
7%
7%
2% 7%
58%
Disability Learning disability/difficulty
Long-standing illness
Mental Health Condition
Other
Physical Impairment
Sensory Impairment
Yes - Unspecified
93 | P a g e
By Ethnic Origin
Ethnic Group Headcount % FTE
White 3,141 81.1 2,868 White Other 158 4.1 146 Ethnic Minority 186 4.7 173 Not Stated 146 3.8 135.51 Unspecified 249 6.4 216.93 Mixed 28 0.7 26 Asian 102 2.6 93 Black 27 1 26 Chinese 16 0 15 Other 13 0 13
81%
4%
5%
4%
6%
Ethnicity
White
White Other
Ethnic Minority
Not Stated
Unspecified
15%
55%
14%
9% 7%
Ethnicity
Mixed
Asian
Black
Chinese
Other
94 | P a g e
By Pay scale by Gender
89%
11%
Band 1
Female Male
46% 54%
Band 2
Female Male
70%
30%
Band 3
Female Male
72%
28%
Band 4
Female Male
63%
37%
Band 5
Female Male
63%
37%
Band 6
Female Male
60%
40%
Band 7
Female Male
53% 47%
Band 8a
Female Male