pembrokeshire - health in wales · pembrokeshire local health board, unit 4 ... chris le breton ......

PEMBROKESHIRE LOCAL HEALTH BOARD

annual report 2008|2009

Contact usPembrokeshire Local Health Board, Unit 4 – Merlin’s Court,Winch Lane, HAVERFORDWEST, Pembrokeshire, SA61 1SBTel: 01437 771220 & Fax: 01437 771222

Email: fi [email protected] for complaints, compliments and comments to:[email protected]

www.pembrokeshirelhb.wales.nhs.ukFrom 1 October 2009, the Pembrokeshire LHB website will no longer exist. Please visit the website of the new organisation – Hywel Dda Health Board at: www.hywelddalhb.wales.nhs.uk

Design: reddotdesign.co.uk

Print: www.just-print.co.uk

AcknowledgementsSome photographs within this report provided courtesy of PembrokeshireCounty Council and Hywel Dda NHS Trust.

Hygiene facts from “Teach germs a lesson.”

Clean Your Hands Campaign Imagesprovided courtesy of National PatientSafety Agency.

Contents1 Welcome2 Who’s Who on the Board3 Committee Structure3 LHB Website3 Emergency Planning4 Corporate Health Standard5 Continuing NHS Health Care & Continuing Health & Social Care.5 Diabetes6 Involving the Public and Patients7 Medicines Waste Information Campaign8-10 Listening to your Concerns and Putting Things Right11 Resporting and Responding to Incidents12 Pembrokeshire Local Health Board Review Process 2008/0912 Individual Patient Commissioning (IPC)12 NHS Funded Nursing Care13 Promoting Equality and Diversity13 Welsh Language14 Text Messaging Access to Public Services for the Profoundly Deaf Community15 Healthcare Associated Infections (HCAI)/1000 lives15 Freedom of Information16 Vaccination and Immunisation17 Clinical Governance18 Unscheduled Dental Services18 NHS Dental Practices in Pembrokeshire18 Estates Development in GP Practices19 Quality Outcomes Framework (QOF)20 Care on Call

20 Investors in Carers21 Medicines Management21 3 Counties Medicines Waste Campaign22 Healthcare Standards for Wales22 Improving the Health of Homeless and Specifi c Vulnerable Groups22 Moving More Often in Pembrokeshire23 Unscheduled Care24 1000 Lives Campaigne25 Health Challenge Pembrokeshire26 Should Children Be Protected From Smoke?27 Hannah’s Smoke Free Message28 Healthy Hearts28 Pembrokeshire Family Challenge update29 The First Access Team30 Well-being Activity Grant31 Development work receives recognition32 Substance Misuse33 The National Service Framework (NSF) for Older People (Pembrokeshire)33 The Children, Young People and Maternity Services National Service Framework34 The All Wales End of Life Care Pathway35 Three Counties Planning Forum40 Commissioning41 Financial Statements43 Making the Connections47 Report of the Auditor47 Remuneration Report48 Salaries and Pensions

100%recycledThis publication is printedon 100% recycled paper

Made in WalesPlease recycle this publication after use

This report will be made available on a wide basis through health care premises, libraries, on request from the Local Health Board offi ces, through our website and will be available in hard copy, electronically on CD Rom and large print or other format. If you would like this Annual Report in large print or another format the Local Health Board will arrange for an alternative version of the Annual Report to be produced to meet your requirements.

Note. Local Health Board is referred to as LHB throughout this document. Hywel Dda Health Board is the operational name of Hywel Dda Local Health Board.

In order to make best use of the management resources available to us we have combined senior posts in Pembrokeshire with Ceredigion LHB and have combined committee meetings and development sessions. This has enabled us to work closely with and develop already existing relationships with our colleagues in Ceredigion LHB, sharing good practice and expertise. We will continue to develop this model with our colleagues in Carmarthenshire LHB, laying the foundations to ensure that we have a community focus for health services when the Hywel Dda LHB is created from the existing four organisations on 1 October 2009.

Delivering improvements to services within the resources available to us in 2008/09 has been a challenge. We would like to pay tribute to the health professionals, managers, partner organisations and staff of the LHB and National Public Health Service (NPHS) and thank them for their hard work, dedication and achievements on behalf of patients and our communities during the past year.

We are proud to present this Annual Report in a year when, despite the challenges, we have achieved much and continued to build strong relationships with our partners in the community and at regional and national levels.

Key achievements during the year are highlighted in the main body of the report. We would like to formally acknowledge the support and assistance provided to us by a wide range of partner organisations, in particular Pembrokeshire County Council, Pembrokeshire Community Health Council, and Pembrokeshire Association of Voluntary Services, colleagues within Primary Care, our NHS Trusts and our community Partnerships.

Welcome to the 2008/09 Annual Report for Pembrokeshire Local Health Board

Together with a wide range of voluntary and community groups and organisations we are confident that we have provided a firm platform to deliver safe and sustainable services for the future in Pembrokeshire.

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Listening to your concerns and putting things right

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Who’s Who on the BoardOffi cer MembersChris Martin - Chairman (until 31st July 2008) Janet Hawes - Chairman (from 1st August 2008)Bernardine Rees - Chief Executive Karen Miles - Deputy Chief Executive Director of Finance & Commissioning Sarah Williams - Director of Primary CareHelen Williams - Nurse DirectorJune Picton - Medical DirectorLyn Harris - Director of Local Public HealthLouise O’Connor - Business & Operations Manager& Secretary to the Board

Non-Offi cer Members Ian Jones - Dental MemberSam Lewis - GP MemberPhil Parry - Pharmacy MemberMollie Roach - Lay MemberCaroline Mason - Carer MemberJulie Hughes - Nurse MemberPeter Irvine - Voluntary Sector MemberChris Le Breton - Voluntary Sector MemberJulia Ritchie - Therapy MemberRobin Baker - Optometrist MemberCllr Sian James - Pembrokeshire County Council MemberCllr David Wildman - Pembrokeshire County Council MemberJon Skone - Pembrokeshire County Council MemberDavid Gale - Trade Union Congress Representative

Associate MembersAshley Warlow - Pembrokeshire Community Health CouncilCaroline Oakley - Hywel Dda NHS Trust RepresentativeDorian James - Wales Ambulance Trust

Co-opted Members(In attendance)David Roberts - Local Medical Committee

Board MeetingsThe Board meets in public every other month. Members of the public are welcome to attend and those wishing to ask questions of the Board may do so by submitting their request in writing 48 hours in advance to the Local Health Board. Details of meetings held in public are advertised in the local press and on the LHB’s website www.pembrokeshirelhb.wales.nhs.uk.

Declarations of InterestLHB Board members and staff are required to declare any outside interests that might infl uence their role. A register of those interests is maintained and is available to the public for inspection. Members of the Board must also declare any interests at Board meetings in public.

Committee StructureA review of the Committee Structure for both Ceredigion and Pembrokeshire Local Health Board’s (LHB’s) was undertaken to ascertain whether there was scope for more effi cient ways of working. We had already put in place arrangements for joint Pembrokeshire/Ceredigion meetings of the Audit and Complaints Committees, ensuring that the core business of the individual responsible bodies was protected. The joint arrangement has been successful in streamlining the work for both LHB’s and made better use of the resources available to both organisations.

As a result of the review, the joint arrangement was extended to the whole of the Committee and working group structure to support both LHB’s. As a result of this new arrangement members have benefi ted from sharing good practice. Organisations have benefi ted by being able to share information which has enabled a broader understanding of the challenges facing the NHS in delivering safe and sustainable services.

The model has been developed and used in other NHS organisations to ensure the best use is made of skills, knowledge and expertise.

The joint statutory committees which report direct to the Board and their Chairs were as follows:

• Integrated Governance Committee Chair: Cllr David Wildman (Local Authority Member)

• Audit Committee Chair: Chris LeBreton (Voluntary Sector Member)

• HR, Remuneration and Terms of Service Committee Chair: Janet Hawes (LHB Chairman)

LHB Website From 1 October 2009, the Pembrokeshire LHB website will no longer exist. Please visit the website of the new organisation – Hywel Dda Health Board atwww.hywelddalhb.wales.nhs.uk

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Mission Statement“Our Mission is to continuously improve the health and wellbeing of the people of Pembrokeshire by working with others to deliver quality healthcare, value people, protect the health of the population, achieve excellence, engage people and communities and ensure continuous improvement”.

Emergency PlanningAs we move towards the new Hywel Dda Local Health Board, Emergency Planning arrangements have been reviewed and strengthened in a number of ways:

• An Emergency Planning Lead has been appointed to cover the Hywel Dda health community.

• Business Continuity Plans have been reviewed and strengthened.

• Major Incident Plans are under review to refl ect new structures.

• Pandemic Infl uenza Planning has progressed signifi cantly as the move was made from pre-pandemic into declared pandemic phase. Existing pandemic plans have been activated and developed according to local need.

• Multi-agency working has been essential in responding to the pandemic and relationships, plans and processes greatly strengthened as a result.

• Training and exercises have been undertaken on a range of emergency scenarios, with health participating as a key partner.

Continuing NHS Health Care & Continuing Health & Social CarePembrokeshire LHB has a statutory duty to fund the care of individuals who are eligible for Continuing NHS Healthcare.

Pembrokeshire LHB has been working together with Ceredigion LHB and continues to ensure that appropriate health care packages are provided for patients within the counties of Ceredigion and Pembrokeshire based on their clinical needs.

The LHB’s have maintained ongoing training programmes for community hospital and district nursing staff.

A bilingual public information leaflet has been developed entitled ‘Continuing NHS Healthcare Explained’. This can be obtained from the LHB and is available on our website.

Since January 2008 the Continuing NHS Health Care and NHS Funded Nursing Care teams across both Ceredigion and Pembrokeshire have worked as an integrated team with a single management structure. This has facilitated better communication and joint working between the teams with shared policy and procedure development, streamlining of processes and documentation.

Both LHB’s have Continuing NHS Health Care panel meetings which are held weekly, this is where the decisions are made in relation to eligibility to receive NHS funding. Both panels have a multi-agency membership which includes the Local Authority and NHS Trust.

During the year, a total of 491 requests were considered by the Panel. These requests included funding for specialist equipment, nursing home care and care at home. Out of the 491 cases considered in Pembrokeshire, a total of 448 were approved.

The Local Authority and the LHB have developed a joint protocol for the joint funding and commissioning of learning disability care packages. Both organisations now meet on a fortnightly basis to discuss joint funded cases and any issues of concern.


Corporate Health StandardIn July 2008 Pembrokeshire LHB successfully achieved the Corporate Health Standard (CHS) GOLD award. The award ceremony was held in Cardiff and 3 members of staff represented the LHB to receive the award on behalf of their colleagues.

The good work continues with several in-house events promoting the health, fitness and well-being of staff. Staff provided many of the ideas, such as:

ÿ Bowel, breast and cervical screening, undertaken on site advising staff of what signs to be aware of and where to get advice.

ÿ Health Checks – Providing advice to staff on nutrition and physical activity, assessed fitness levels and recommended weight levels.

ÿ Nordic Walking – several staff experienced the summer training activity of cross country skiers (see page 30).

ÿ Ten pin Bowling – Many families enjoyed an evening together whilst at the bowling alley.

ÿ Rowing – This has proved to be one of the most successful promotions undertaken with many staff now fully fledged members of a local rowing club.

ÿ Healthy Soups – Staff brought in home made healthy soups to taste and shared lots of new and healthy recipes.

ÿ Coastal Walk – Many walks were organised and staff and their families enjoyed the beauty of Pembrokeshire.

For Charityÿ Jeans for Genes – Staff donned their jeans for one

day and paid a fee.

ÿ Children in Need – ‘Cakeathon’! staff brought in home made cakes and sold them to raise funds.

Policy development and contributing to improving procedures has continued in consultation with all LHB staff.

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Chairman and Chief Executive – Message to Staff We are proud of ALL of our staff for their continued commitment to the LHB; for working at all times in the best interests of the population of Pembrokeshire; for organising, participating and enjoying all of the health and well-being promotions; and for the fundraising for various charities; and most of all, for working together as a team.

Emma Haycocks, Corporate Services Facilitator – has worked in the NHS since 1992 and has held a corporate role within the LHB since 2007. Emma currently has specific responsibility for Health and Safety and Freedom of Information requests, and co-ordinates an effective administrative team. She successfully assisted in leading the LHB to accomplishing the Gold Award of the Corporate Health Standard in June 2008.

DiabetesBringing together the former Local Diabetes Services Advisory Groups from Ceredigion, Carmarthenshire and Pembrokeshire the new Hywel Dda Diabetes Clinical Network was formed. The network has an agreed structure, terms of reference and has identified priority work areas to progress the Diabetes agenda, share best practice and develop future services.

The network comprises of a wide range of health professionals from both primary and secondary care, together with managerial staff, Diabetes UK, and patient representatives whose valued input ensures the voice of the patient is heard and provides a two way communication link to the Diabetes Patient Reference Groups.

The Network has also established links to associated bodies such as the Diabetic Retinopathy Screening Services for Wales, Education and the Welsh Assembly Government.

The development of the Network has strengthened the Diabetes Service and profiled it as forward thinking and dynamic in its approach.

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Involving the Public and PatientsPembrokeshire LHB is committed to creating a culture where patient and public involvement is a central part of the way we work, ensuring it is essential to LHB planning, delivery and reviewing of our local health services. The LHB is also very committed to working in partnership with local organisations.

Involving and consulting with the public and patients of Pembrokeshire requires ongoing development, and is an important aspect of clinical governance, and how we meet our quality standards.

The ways we have involved and informed the public and patients of Pembrokeshire during 2008/09 are as follows:

Citizens’ Panel We continue to work with our partners Dyfed Powys Police, Pembrokeshire County Council, Hywel Dda NHS Trust and Pembrokeshire Coast National Park Authority, to gain your views through the Citizen’s Panel. Around 1000 Pembrokeshire residents participate in a survey 3 times a year; the results are considered by the organisations to improve your services.

Following results from one of the surveys, it was established that the majority of respondents thought that a paper-based directory of services would be inadequate to meet their information needs. Following on from this there has been work to set up joint electronic information services.

Further development of electronic information has included working together with the deaf community to find out their preferences for receiving information by text, and a pilot is due to start in the Summer 2009 – see page 14.

Argyle Street Counselling Service Following feedback from patients, GP’s and service users, the successful pilot Service will continue to be supported with LHB funding. This project was originally funded through the Health, Social Care Well Being project monies.

GP Services in Crymych Public meetings were held in October 2008 and March 2009 on the re-provision of general medical services in

Crymych following the retirement of the single handed GP. The meeting was chaired by the Chief Officer of the Community Health Council and Executives from the LHB were present to answer queries from the public. The public meeting was widely publicised in the local press and in Post Offices and approximately 300 people attended.

A public consultation is currently underway to engage the views, and the community have expressed a wish that the new service did not become a branch surgery.

Board Meetings We encourage and welcome the general public to attend our Board Meetings, which are all held in public and advertised beforehand in the local press. We feel that you should be fully aware of all decisions that are made which could affect your services. All Board papers, agendas and minutes are published on our website: www.pembrokeshirelhb.wales.nhs.uk

South East Pembrokeshire Community Health Network The first meeting of the Network was held on 26 February 2009 in Tenby Cottage Hospital, and was an ideal opportunity for people who live or work in the south east Pembrokeshire area to meet with representatives of local health service organisations.

THINK BEFORE YOU ORDERAsk in your pharmacy or GP

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Medicines Waste Information Campaign A Medicines Waste campaign was launched on 6 March 2009 across Carmarthenshire, Ceredigion and Pembrokeshire to raise awareness with the public and health professionals of the significant amount of returned and unused medicines. The campaign highlights patient safety, clinical effectiveness and cost issues and attracted media attention. Roadshows were held at pharmacies where the public could ask for more information, and information leaflets were provided with prescriptions highlighting key messages to help people think about their use of medicines. See page 21.

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Principle 1Getting it RightWhilst we strive to get things right fi rst time around, if a mistake does happen, the important thing is to put it right, and to use the experience for further learning and the continuous improvement of services. In short, we see each concern raised by you as an opportunity to make things better and to produce a reasonable and fair remedy for your concern.

Principle 2Being Customer FocusedLHB staff will try to understand your concerns, explain the complaints management process, and keep you up to date with developments as required. Any information you provide will be kept in the strictest confi dence, and only shared with those who really need to know with your permission/consent.

Principle 3Being Open and AccountableThe LHB provides reporting of its concerns and compliments throughout the year, which includes information on the remedies and outcomes applied. The department is accountable to the Compliments, Complaints and Incidents Committee which provides a level of scrutiny before reporting directly to the Public Board. All Board papers are available on the LHB website for review.

Three cases this year were referred to the Independent Complaints Secretariat (ICS). The ICS decided to only investigate one of these cases further and the practice was asked to write an apology letter to the complainant. The Public Services Ombudsman for Wales has investigated 2 complaints. One investigation is still ongoing and a Public Interest Report (No 200702139) detailing the second case can be accessed from the LHB offi ce or by accessingwww.pembrokeshirelhb.wales.nhs.uk. An Action Plan was produced as a result of the Ombudsman’s Report and many of the actions have already been achieved.

Community Health CouncilThe CHC provides a free complaints advocacy and support service to you if you have any problems with, or complaints about NHS services.

The CHC also: • ensures that your views and needs infl uence the policies and plans put in place by health providers in your area • monitor the quality of NHS services from your point of view • give you information about access to the NHS.

The CHC can be contacted on (01646) 697610 or08456 650763 (advocacy line).

Dental ServicesThere were 28 dental concerns received this year – 6 related to practice administration for example, scheduling of appointments, 18 related to clinical/treatment issues such as treatment planning, extractions and the fi tting of dentures, and 4 related to accessing NHS dental services.

The LHB also received a total of 19 orthodontic complaints this year, primarily regarding concerns over waiting times to begin treatment. Considerable work has been undertaken so far this year to establish robust services for the County.

Listening to your Concerns and Putting Things RightIn March 2008, the Public Services Ombudsman for Wales published the guide entitled ‘Principles for Remedy.’ The document set out the 6 principles of good practice for the remedy of your concerns.

GP ServicesWe received 22 complaints about GP services. Concerns related to general administration matters, appointment systems and some clinical concerns regarding prescribing and referrals for treatment.

Out of Hours –Pembrokeshire Care on CallWe received 15 complaints about the service. Concerns related to administrative issues, time waiting to see a GP and telephone systems.

CommissioningWe received 25 general commissioning complaints. These covered a range of issues associated with Dermatology, Cardiac, Stroke and MRI services.

Principle 4Acting fairly and proportionatelyThe LHB will strive to deal with complaints and complainants consistently, and will treat you without bias or prejudice. If you feel that you have not been treated fairly or your complaint has not been dealt with professionally then you will have the opportunity to take your complaint to the next stage of independent review to the Independent Complaints Secretariat or the Public Services Ombudsman for Wales.

Set in the context of a population of approx 118,000, during the year we received 153 complaints (not including numbers of concerns raised directly with the hospital or with the Community Health Council). This number includes complaints you asked the LHB to co-ordinate (with your consent) about primary care such as your GP, Dental, Pharmacy and Optometry services.

Complaints from ChildrenWe have received a great deal of feedback from children this year following the distribution of the new ‘Do You Live in Pembrokeshire’ leafl et which was specifi cally aimed at children and young people. The leafl et was developed last year in association with the Gennex Youth Project and the leafl et has encouraged children to contact the NHS with their views and concerns. Our current focus is on the development of eff ective procedures to manage issues raised by children and to feedback to them any positive action as a result of their input.

the County.

Complaints from ChildrenWe have received a great deal of feedback from children this year following the distribution of the new ‘Do You Live in Pembrokeshire’ leafl et which was specifi cally aimed at children and young people. The leafl et was developed last year in association with the Gennex Youth Project and the leafl et has encouraged children to contact the NHS with their views and concerns. Our current focus is on the development of eff ective procedures to manage issues raised by children and to

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Principle 5 Putting things right The LHB will ensure that any complainant/patient who has suffered any hardship as a result of maladministration will receive a full apology and explanation of any resulting remedial action.

Principle 6 Seeking continuous improvement Lessons learnt from effective complaints handling can feed into the continuous improvement of the organisation, and play a significant part in improving service delivery.

Examples of improvements made as a result of complaints handling include:

¸ Following your concerns last year regarding the provision of wound care services, this service is now to be provided once again by your local GP practice from1 June 2009.

¸ Dental access was much improved for the County this year with the LHB commissioning extra dental provision. Almost 10,500 residents were allocated a dentist this year.

¸ The employment of a Dental Advisor who has advised and mentored a number of dental practices with regard to complaints handling and patient care.

¸ Complaints CD-Rom training has been issued to GP practices within the County to form part of staff development and to ensure your concerns are dealt with effectively at source.

¸ The LHB has written to GP practices who were not automatically transferring callers to the Out of Hours Service, encouraging them to do so.

¸ New guidance has been issued regarding Continuing Health Care processes, reflected in LHB policy and procedure.

¸ Palliative care training has been undertaken.

¸ The LHB is working alongside the Hywel Dda NHS Trust to implement a number of orthodontic initiatives including clear referral guidance for Dental Practitioners.

Managing Complaints The Government sets response targets for acknowledging your concerns. This year, we achieved 100% acknowledgement response target (within 2 working days), and were able to respond to 74% within target (20 working days) for a full response.

This year we have adopted a new joint working Complaints Policy and Procedure with Ceredigion LHB with a central team co-ordinating complaints for both counties. This year, there will be a focus on training and information for primary care practices on effective local resolution of and learning from your concerns.

This will be further improved next year, with the reorganisation of the health service, when a single point of contact will be created for all healthcare concerns.


LHB continues to welcome feedback and the detail of your concerns and compliments. You can contact the team on 01437 771 260/289 or e-mail: [email protected].

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Reporting and Responding to IncidentsThe LHB is fully committed to reducing, as far as possible, the number of adverse incidents, hazards and near misses; to ensure that corrective action is taken; and lessons shared throughout the LHB and with Primary Care contractors in order to reduce the likelihood of recurrence.

All staff need to acknowledge that the risks within the LHB and Primary Care will be reduced if everyone adopts an attitude of openness and honesty. All necessary effort must be made to acknowledge incidents and mistakes, and the overall approach within the LHB and Primary Care should be one of help and support to each other, rather than recrimination and blame. The LHB Board is committed to this approach.

The Incident and Hazard Reporting Policy aims to identify and record incidents and near misses. It encourages prompt reporting by investigating and implementing appropriate corrective action to prevent recurrences. The total number of incidents reported during April 2008 - April 2009 for Pembrokeshire was 78 and for Ceredigion 46.

Incidents fall broadly into the following categories:

ÿ Medication Error

ÿ Delay in Patient Care

ÿ Communication

ÿ Staffing issues

ÿ Patient Related Incidents

ÿ Confidentiality

ÿ Equipment

ÿ Health & Safety and

ÿ Serious Untoward Incidents to the Region.

Solutions often include revising and improving procedures and protocols; ensuring more robust systems are put in place; and undertaking training in certain areas.

All incidents reported to the LHB are entered into the Datix Incident Reporting System and checked to ensure immediate actions have been undertaken to minimise any possible harm.

The Compliments, Complaints and Incidents Committee meet on a quarterly basis to go through all complaints, incidents and near misses. They decide if further investigation is required and:

• ensure all necessary immediate action was undertaken;

• agree what lessons can be learnt;

• ensure everyone who needs to know has been informed of the lessons learnt and the necessary changes made.

All reported information and any identified ongoing risks are reported to the LHB Board and the Clinical Governance Committee. This process ensures that everything possible is done to reduce harm that might arise from an incident and that the risk of recurrence is greatly reduced.

All untoward serious incidents are reported to the Welsh Assembly Government Regional Office. The Regional Office is also updated on a quarterly basis of the outcomes and progress of all these.

Sonia Luke, is our Quality Facilitator and visits GP practices to conduct QoF visits, as well as managing incidence reporting and NPSA alerts. The team also visits dental practices to review some issues pertinent to the Dental Reference Service reports.

Pembrokeshire Local Health Board Review Process 2008/09During the year approx 150 continuing health care reviews have been carried out in nursing homes within the County. This process ensures that patients placed within care homes are receiving appropriate and safe care.

Ten retrospective reviews have been completed, 8 for presentation to the Local Patient Management Panel and 2 for the All Wales Review Panel co-ordinated by Powys LHB.

During 2008/09 the method of recording information for retrospective reviews has been under review and modified to ensure all information is accurately recorded and easily accessible.

Good working relationships have been forged with the Community Mental Health Team and the Community Team for Learning Disabilities. This has resulted in a more efficient approach to client reviews to ensure the client’s needs are met in an appropriate way through joint working.

NHS Funded Nursing CareNHS Funded Nursing Care involves providing a funding contribution for the registered nursing care provided within a care home. The rate for 2008/09 is £117.66 per week.

During the year, Nurse Assessors carried out a total of 124 initial assessments, 27 quarterly assessments and 222 annual assessments across the 14 care homes with nursing within Pembrokeshire.

A comprehensive nursing assessment document has been developed which is Unified Assessment compliant.

Individual Patient Commissioning (IPC)Individual Patient Commissioning is the process when a GP or NHS Consultant makes a request for funding for certain treatments which are not currently available locally, on an individual patient basis. The Ceredigion and Pembrokeshire LHB Individual Patient Commissioning Panel has met bi-monthly since April 2008 and considered a range of funding requests from Ceredigion and Pembrokeshire residents to access specialist treatments/assessments. This included (but not exclusively) specialist high cost drugs, specialist equipment, and specialist treatment/surgery.

Funding decisions are made by a panel of professionals based on patient need and clinical evidence. The numbers of cases brought before the Individual Patient Commissioning (IPC) and Prior Approval (PA) panel from 1 April 2008 to 31 March 2009 are as follows:

A Three Counties IPC Policy was ratified by the Board in January 2009 and has been distributed to all appropriate clinicians in Carmarthenshire, Ceredigion and Pembrokeshire. It is anticipated that from September 2009 the LHB will also facilitate the IPC process for Carmarthenshire.


This is now being routinely used by Nurse Assessors in Ceredigion and Pembrokeshire, who undertake assessments and reviews in the nursing homes.

A bilingual public information leaflet has been developed entitled ‘NHS Funded Nursing Care Explained’. This can be obtained from the LHB and is available on our website.

The Care Home Managers Forum continues to provide managers and nurses in care homes in Pembrokeshire with a forum to discuss relative issues, provide peer support and for professional development.

Welsh LanguageThe LHB is committed to the principle that in the conduct of public business it will treat the English and Welsh languages on the basis of equality and this will be reflected in the way it carries out its public duties. The revised Welsh Language Scheme for the LHB received approval by the Welsh Language Board on 6 March 2009.

To strengthen Welsh Language provision within NHS services in Wales, in September 2008, a Welsh Language Unit was established to support the 7 LHBs in the Mid & West Wales Region. The Unit aims to ensure effective implementation of the Welsh Language Scheme in all the LHBs, by promoting language awareness and bilingualism, providing a translation service and increased support to the LHB staff. The Unit also provides regular guidance and staff newsletters and has developed a staff intranet to support this.

Work has progressed this year by providing bilingual complaints correspondence, and providing Welsh and other languages spoken by primary care contractors such as GP’s on the LHB website.

Over the last year the LHB has made progress against the five pledges.

These were identified within the revised Welsh Language Scheme. This includes providing guidelines to staff on the requirements of the Welsh Language Scheme, assist staff with creating bilingual e-mail signatures and out of office replies; providing a weekly Welsh language class and developing work with the Human Resources Department to identify Welsh language skills required in posts.

It is intended to progress the delivery of bilingual services with a planned review of the Welsh Language Scheme by the new Hywel Dda Local Health Board.

Promoting Equality and DiversityDuring the year the focus has been on the development of a Single Equality Scheme, in response to the Equality Act 2006. Work has been undertaken on combining the work of the LHB’s in the counties of Carmarthenshire, Ceredigion and Pembrokeshire and the Hywel Dda NHS Trust, which has provided an opportunity to bring together good practice from each of the organisations. The new scheme will set out how the Health Board will continue to meet its legal duties for race, gender and disability. The scope of the scheme has also been extended to incorporate religion or belief, sexual orientation, age and human rights.

The Scheme will provide information and guidance to employees, patients, partner organisations and the general public on how the organisation will fulfil its duties under equality and human rights legislation. All employees, agents and contractors undertaking work on behalf of the organisation will be responsible for implementing the Scheme.

The organisation is committed to the principle that all individuals from all communities and groups should have equal rights and access to health and social care when needed. The organisation is also committed to ensuring that staff will be confident in their ability to deliver the best healthcare possible within a truly supportive environment.

The draft Single Equality Scheme is available from the LHB’s website. For further information or to contribute to the scheme please contact Jackie Hooper, Equality and Diversity Advisor on 01267 227014.

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319 IPC - Pembrokeshire 147 PA - Pembrokeshire

223 IPC - Ceredigion 120 PA - Ceredigion

Healthcare Associated Infections (HCAI)/1000 livesHealthcare Associated Infections are one of the key content areas for the 1000 lives campaign, and continue to cause substantial patient deaths, cost to the health service and individual cost to patients.

However, there is good evidence that a proportion of these infections may be preventable through careful attention to infection control procedures.

As part of the 1000 lives campaign and in response to implementing the “Healthcare Associated Infection Community Strategy” WAG (2007), the 3 LHB’s have been working with NPHS and the Hywel Dda NHS Trust to establish local service delivery and action plans.

Achievements for 2008/09 included:• Establishment of a local HCAI multi agency group to

address issues and develop action plans.

• The clarifi cation of roles, responsibilities and accountability in relation to HCAI’s within community and primary care services.

• Training needs assessments undertaken across primary care and care homes.

• Infection Control training sessions delivered to primary care and care homes. National e-learning programme actively promoted with good uptake.

• Engagement with primary care practices and care homes to undertake audits and implement infection control standards using evidence based practice and tools from the NPHS.


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�� Freedom of InformationFreedom of Information in the NHSThe Freedom of Information Act 2000 gives the public a general right of access to all types of recorded information held by public authorities. The purpose of the Act is to encourage greater openness by public bodies.

Since the introduction of the FOI Act, Pembrokeshire LHB provided many responses to requests. Examples of the requests received include information on:

ÿ Prescribing Formularyÿ Mental health commissioningÿ Senior management structure & staffi ng structureÿ Diabetes servicesÿ Wheelchair provisionÿ Prescriptions

Between 1 April 08 and 31 March 09 we received 26 requests for information under the Act.

This scheme is available on our website atwww.pembrokeshirelhb.wales.nhs.uk or alternativelya hard copy is available by contacting the LHB.

If you need help with your request please contact the Freedom of Information Offi cer, Ceredigion and Pembrokeshire LHBs, Y Bryn, North Road, Lampeter, Ceredigion. SA48 8AZ or [email protected]

and the LHB will respond promptly.

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Text Messaging Access to Public Services for the Profoundly Deaf CommunityMany public services and Councils are already taking advantage of the relatively inexpensive method of text communication for their citizens and have understood and embraced the signifi cance of this technology which is readily available.

Following the results of a Citizen’s Panel survey (see page 6), a bid to the Welsh Assembly Government for the ‘Making the Connections Improvement Fund’ was successful. The bid was to obtain funding to carry out a study to explore how to make information more accessible, via texting, email, voicemail and digital TV.

Pembrokeshire LHB and Pembrokeshire County Council considered the use of text messaging in the areas of: sexual health services, mental health services and the profoundly deaf community.

In discussions with Pembrokeshire County Council’s Hearing Impairment Team, it was identifi ed that service users would welcome text messaging access to public services as a positive step forward.

The pilot text messaging service will be implemented for the profoundly deaf and hard of hearing communities in Pembrokeshire for a 12 month period from June 2009. At the end of the 12 months, a review will be carried out to assess impact and gain feedback on the service from users. If the service proves successful a full roll-out of a text messaging service will be considered, for all Pembrokeshire residents and visitors across a range of services and public bodies.

Service preferences for SMS by Deaf CommunityCouncil Tax bill enquiries/errors999 enquiriesAnti-Social Behaviour reportingReporting dangerous dogsOrange bagsRefuse collection – missed bin reporting, days to be collectedStreetlight outagesRequest meetings with council and other offi cers and to arrange signer to be present

Table 1 illustrates the sorts of services that were thought appropriate for the use of texting by the deaf community

Tricia Rees, Information Development Offi cer has worked in the NHS since 1991 and has been with the LHB since the beginning in April 2003. Primarily responsible for developing and maintaining the Internet/Intranet websites and IT/Information based systems. Tricia has also been responsible for co-ordinating the publication of the LHB Annual Report for the last 5 years.

The Committee has met as scheduled, with the exception of one cancellation due to inclement weather. All documents presented were reviewed, and approved or commented on as required. There has been a good attendance at the Committee with representation from a wide range of professionals which has enabled the group to maintain a broad perspective when reviewing documentation. The Committee has also gained a greater understanding of clinical issues and events which has enabled discussions around how we can engage with other organisations to find solutions.

Clinical Governance Newsletter A Clinical Governance Newsletter was produced to update and inform Primary Care contractors on ways to improve patient care through good practice and disseminate lessons learnt from events. It is hoped that this will become more frequent in the future and contractors will be encouraged to contribute.

Audit of Dental Nurse Qualifications In August 2008 the registration of dental nurses became a mandatory requirement from the General Dental Council. In response to this an audit has commenced regarding dental nurse qualifications. The replies so far have confirmed the current requirements that all dental nurses should either be qualified or in training, have been met.

National Institute for Health and Clinical Excellence (NICE) The Joint NICE Advisory Group continued to meet regularly to look at the implementation of NICE Guidance. This is a joint group with members from the Hywel Dda NHS Trust, Ceredigion and Pembrokeshire LHB’s. In the future the group will be reviewed to include Carmarthenshire LHB.

Clinical Governance Toolkit The GP Clinical Governance Toolkit remains an effective way of helping GP surgeries assess their level of clinical governance within their practice but further work needs to be carried out to support practices in its completion.

Clinical GovernanceWhat is Clinical Governance? Clinical Governance means:

“providing the right care to patients, by the right staff, in the right way, at the right time, and always aiming to provide the best service”. (Clinical Governance in Wales – WAG Leaflet 2008).

The LHB has a duty to ensure that the quality of care received by the patient is maintained and improved upon. The LHB Clinical Governance Team is in place to encourage all healthcare professionals within primary care to continually examine the way they work and compare their procedures with best practice.

The Clinical Governance Committee This work is monitored by the Clinical Governance Committee, which has met 3 times over the last year. The last meeting was a joint meeting covering both Ceredigion and Pembrokeshire. The Committee initially reported direct to the Board and from December 2008 to the Integrated Governance Committee. The standard of care is measured by the Welsh Healthcare Standards.

The Clinical Governance Committee has been asked to scrutinise reports and policies across the wide spectrum of Clinical Governance.

These included the following areas: ÿ clinical governance around consent ÿ NICE guidance and medicines management ÿ infection control ÿ research approval ÿ public and patient involvement ÿ prescribing and pharmaceutical audits ÿ copying of letters ÿ substance misuse and ÿ vulnerable adults


The LHB Clinical Governance Team is in place to encourage all healthcare professionals within primary care to continually examine the way they work and compare their procedures with best practice.

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Sonia Briggs, is currently seconded to the Clinical Governance Managers post having been employed by the LHB for 3 years. In addition to this role, Sonia also has delegated responsibility for Palliative Care issues and manages the Macmillan Education post; and NSF for Older People. Sonia is a Corporal within the RAF Reserve Service and has been on active deployment to Afghanistan.

Julie Kilford, is the Clinical Governance Administrator and deals with much of the communication for the Clinical Governance Team including the running of the Clinical Governance Committee and the production of the Clinical Governance Newsletter. Julie is also involved in the process of approval of Research within primary care.

Vaccination and ImmunisationThree Counties Vaccination and Immunisation Group In November 2008 the first meeting of an integrated 3 Counties Vaccination and Immunisation Group with support from the NPHS, was held to develop and implement a partnership programme to increase the uptake of all childhood and adult vaccine programmes across the Hywel Dda Community.

Human Papilloma Vaccine (HPV) The HPV was introduced into the National Immunisation Programme by WAG in October 2007, which offered the vaccine to girls aged 12 to 13 years from September 2008. The schedule has been delivered through a school based programme with positive uptake results:

Ceredigion Pembrokeshire HPV1 84.6% HPV1 85.3% HPV2 84.3% HPV2 84.7% HPV3 60.2% HPV3 0.0%

(COVER 90 NPHS May 2009).

An extension to the programme commenced in January 2009 to vaccinate young women born between 1 September 1990 and 31 August 1991. This programme is being delivered by GP practices. The LHB has been involved with ongoing support, education, training and advice for all practice staff.

Measles An outbreak of measles in South Ceredigion, Pembrokeshire and Carmarthenshire was identified in October 2008. The LHB worked closely with NPHS, Hywel Dda NHS Trust and GP practices to co-ordinate a promotion of the MMR vaccine to encourage an increase in uptake.

The Hywel Dda NHS Trust and the LHBs developed an Action Plan, which included an MMR media campaign with posters and information packs which were distributed across the 3 communities.

Training Annual vaccination and immunisation training continues across Carmarthenshire, Ceredigion and Pembrokeshire in accordance with and to meet the National Minimum Standards as recommended by the Health Protection Agency (2006). An ongoing programme has been developed to provide equality in the information and education across the 3 communities.

Karen Thomas, is an Registered General Nurse with 30 years experience working in the NHS. Based in South Pembrokeshire Hospital for 25 years she gained experience in Rehabilitation, Medical and Palliative Care. Following completion of her degree, Karen joined the LHB in August 2005, and is currently the Individual Patient Commissioning Co-ordinator for Pembrokeshire, Carmarthenshire and Ceredigion. Her role involves processing all Individual Patient Commissioning and Prior Approval funding requests and taking them panel. Her role is both varied and interesting.

The monitoring and QOF visits across both Ceredigion and Pembrokeshire has led to enhanced quality and holistic patient care.

Quality Outcomes Framework 2008/09 (QOF)The LHB continually reviews the quality of care which GP practices provide to patients. This is part of the GP Contract and the review mechanism is known as the Quality Outcome Framework.

The annual QOF visits for all GP practices in Pembrokeshire and Ceredigion have been completed. The purpose of the visits was to monitor the records of the patients who are receiving care, especially those with long term conditions, and through discussions this can lead to possible changes or improvements in how they are treated.

Specifi c areas discussed with practices were:ÿ Audit activity, in particular National Patient Safety

Agency (NPSA) and 1000 Lives, Minor Surgery Audits and the Audit+ tool which is available to practices to enable understanding of what is happening to patients under their care.

ÿ Clinical Incidents and Signifi cant Events and reporting via the Datix Incident Reporting System and NPSA e-form;

ÿ Involvement of practice nurse and health care workers in the QOF process

ÿ Patient Safety in relation to the work currently carried out by the NPSA and the 1000 Lives Campaign.

The use of drugs or medicines in the care of patients is key to improving the long term outcome. The LHB Medicines Management Team works with practices to ensure the most appropriate use is made of medicines and this forms a basis of discussion of all aspects of care.

This monitoring process helps to ensure that all patients, especially those with the most ill health, receive the best treatment as well as ensuring money is spent appropriately.

The visits were welcomed by practices, and fulfi lled the purpose of checking clinical and non-clinical evidence, as well as providing opportunities to raise any issues and concerns they may be experiencing, so that possible solutions could be found.

When should we wash our hands?Everyone should wash their hands;

• whenever they look dirty• after using the toilet or helping a child to use the toilet• immediately before handling any food and immediately after handling raw food (especially poultry)

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Unscheduled Dental ServicesDid you know…. That there are approximately 91 dental appointments per week available for unregistered Pembrokeshire patients who are indental pain?

Between Monday and Fridays there are a number of dental practices in Pembrokeshire who also off er emergency dental treatment for unregistered patients. These appointments are off ered on a fi rst come basis.

Patients who are not registered with an NHS dentist can access emergency dental treatment on a Saturday morning at Winch Lane, Haverfordwest and on Sunday mornings and Bank Holidays at Tenby Cottage Hospital.

For information on how to access any of the above services please telephone the NHS Direct Dental Information Line on 0845 60 10 128.

NHS Dental Practices in PembrokeshireSince October 2003 Pembrokeshire LHB has been maintaining a database of patients who are not registered with an NHS dental practice, with the intent of providing names to NHS Dental Practices who have capacity to accept new patients.

Between April 2008 and March 2009 the LHB has forwarded almost 10,500 patient names to NHS dentists throughout Pembrokeshire.

Patients are allocated to an NHS dentist on a fi rst come fi rst seen basis. Once you reach the top of the database you will be allocated to the next practice accepting patients in Pembrokeshire.

On average, 550 names per month are added onto the database for unregistered dental patients.

If you require an NHS dentist please contact Christine Green - Dental Services Administrator on (01437) 771257 or email [email protected] who will be pleased to add your details onto the database.


Estates Development in GP PracticesWork is underway in practices within Pembrokeshire to improve access for disabled persons.

Disability access works classifi ed as “urgent” and “important” will continue into the Summer of 2009 when it is hoped access to our GP premises will be considerably improved.

Crymych Health Centre has continued to be a priority for development. During early 2009, funds were secured to extend the existing portakabin as a temporary measure. It is anticipated the new temporary building will be up and running by the Autumn 2009. The work will then focus on securing new premises for Crymych patients.

Other GP surgery improvements during 2008 included the replacing of CCTV equipment in St Thomas Surgery. Extensions are also planned for Fishguard Health Centre and Winch Lane Surgery – applications will be submitted to Welsh Assembly Government in the Summer 2009.

Christine Green, Dental Services Administrator is responsible for maintaining the database which allocates you to an NHS Dentist. This is a very rewarding role and Christine enjoys speaking to the many patients who ring to add their name or check their position on the list.

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Medicines ManagementThe aim of the Medicines Management Team is to ensure that people within Pembrokeshire receive the best quality medicines management and pharmaceutical advice and care possible within the available financial resources.

Prescribing of medication is the most common approach taken when treating patients in the NHS. Effective medicines management promotes improvements in clinical outcomes and reduces risk of error.

In Pembrokeshire we now have a number of nurses and pharmacists who have qualified as supplementary and independent prescribers. This qualification enables them to prescribe medication for patients within their field of expertise.

This year, in addition to providing prescribing advice and education to GPs in the County, the Medicines Management Team has provided additional support to community pharmacists and nurses.

One example is the provision of emergency hormonal contraception (EHC) by accredited pharmacists, which is available in many pharmacies throughout the County. This service is free of charge and provides immediate assistance to the patients, and valuable advice and guidance regarding general sexual health and contraceptive options. If additional healthcare issues have been identified, or raised by the patient within the consultation, then referrals can then be made to GPs.

The Medicines Management Team continued to visit practices within Pembrokeshire to discuss issues which may have been highlighted from the practice prescribing information, and to discuss clinical and educational issues which affect prescribing. A set of objectives is agreed upon and progress against these is measured.

The Medicines Management Team is involved in a number of wide ranging activities helping to ensure that medicines are prescribed and used in a safe, efficient and cost effective manner.

3 Counties Medicines Waste CampaignAcross Carmarthenshire, Ceredigion and Pembrokeshire unused/returned prescription medicines are costing approximately £1.5 million a year – which is equivalent to the cost of employing 30 more community nurses or performing 1,609 cataract operations. Pembrokeshire LHB Medicines Management Team worked together with Carmarthenshire and Ceredigion LHB’s to focus on this issue and in March 2009 the Medicines Waste Campaign was successfully launched across the 3 counties.

The events launching this Campaign were covered by national television networks and local press, and highlighted the potential savings if patients only obtained medicines which were needed. The campaign was embraced by community pharmacy and medical practices throughout the 3 Counties and their feedback on the quality of the campaign material and content was very positive. The key messages of the campaign were clear and simple:

• Only order what you need • Wasted medicines waste money • Unused medicines cannot be recycled

Posters and leaflets were distributed to all community pharmacies, GP practices, and patients received leaflets within their prescription bags. See page 7.

Community pharmacy continues to be involved in health promotion campaigns and provides feedback for each campaign, which helps the LHB with future initiatives.

Our aim – patients receive the right medicines, for the right reasons and for the right length of time to achieve the best outcomes.

How do we do this? – we try to do this by supporting our GP practices and community pharmacies to maximise their skills and resources, as well as the NHS.

Medicines Management Team June Picton, Medical Director Delyth Simons, Pharmaceutical & Prescribing Manager John Shuttleworth, Prescribing Support Pharmacist Patricia Hogg, Medicines Management Support Officer Anna Williams, Prescribing Support Pharmacist


Care on CallCare on Call, the GP Out of Hours service in Pembrokeshire, is now in its 5th year of operation.

The service managed:

ÿ approximately 39,000 calls last year

ÿ resulting in 14,000 patients being seen at treatment centres across Pembrokeshire and Ceredigion

ÿ 5,000 patients being seen in their own homes

ÿ In addition, a total of 8,000 calls were resolved with telephone advice by a Registered GP or a qualified practitioner, and

ÿ 9,000 calls resolved by advice from a trained nurse.

In the North of the County, the clinical arm of the service has been co-located with A&E at Withybush Hospital for almost a year, lending opportunities for shared working, in preparation for the integration of both services from 1 October 2009. There have also been opportunities for closer working with Ceredigion Out of Hours service since January 2009, when the Ceredigion service came under the management umbrella of the Pembrokeshire LHB.

Work is continuing on the Unscheduled Care Project, with several staff being involved in drawing services together. It is planned to integrate the 3 Out of Hours Services of Carmarthenshire, Ceredigion and Pembrokeshire from October 2009. This will give opportunities to work across boundaries, improving access to care for all patients within the Hywel Dda community.

On Line Clinician (OLC) was introduced successfully into the treatment centres during Autumn 2008. OLC is an electronic system that enables the clinicians to enter consultation data directly onto the Out Of Hours computer system rather than writing the notes onto paper call sheets. Concerns had been raised by GP practices that the hand-written call sheets were sometimes difficult to read and the printed call sheets generated by OLC have alleviated this problem for treatment centre consultations.

Other benefits have included:

ÿ consolidating the information produced (and used) by the service into a single record of care,

ÿ greater clarity of notekeeping and

ÿ improved transmission of patient information to surgeries the following day.

Investors in Carers Pembrokeshire Association of Voluntary Services (PAVS) secured funding from the local authority and worked with the LHB to launch a pilot scheme to 3 GP practices in the County, called ‘Pembrokeshire Investors in Carers’ (PiiC).

The PiiC Scheme is an accredited award for GP practices, which measures the standards of good practice and support to carers within the County.

There are many benefits of the scheme to both GP practices and carers in order to help meet national legislation, and local strategies for carers, ensuring help and support in their caring role, including for their own health.

The 3 practices who piloted the scheme were Newport, Tenby and Argyle Street in Pembroke Dock, and were successfully awarded the Bronze level certificate at an Awards Ceremony January 2009.

Eleri Burton is the Manager of the Out of Hours services in Pembrokeshire and Ceredigion. She started working for Pembrokeshire LHB in 2005, whilst continuing to work for Pembrokeshire and Derwen NHS Trust as Project Manager for the A&E Business Case until 2007. Eleri’s background is nursing and management in the hospital setting, predominantly operating theatres.

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Moving More Often in PembrokeshirePembrokeshire Local Public Health Team has been busy setting up a Moving More Often scheme in the County as part of a national initiative led by the Welsh Assembly Government.

Thirteen instructors have now been trained across the County and the Cleddau River Day Unit in Pembroke Dock is the first to adopt the scheme. Sessions run daily and are popular with centre users and staff alike, generating much enjoyment and laughter.

Unscheduled CareUnscheduled Care is the delivery of emergency and urgent Health and Social Care on a 24 hours a day, seven days a week basis. It involves all Health and Social Care partners, including Primary and Community Care, Mental Health, Local Authority, Social Care and Voluntary Agencies in partnership with the users of services.

A Local Delivery Plan (2009-2011) has been approved to deliver Unscheduled Care within the 3 counties of the new Hywel Dda Health Board. To serve the population of West Wales, there will be:

Three Emergency and Urgent Care Centres in:ÿ Bronglais Hospital in Aberystwyth,

ÿ Withybush Hospital in Haverfordwest and

ÿ West Wales Hospital in Carmarthen

Three Urgent Care Centres in:ÿ Llandysul,

ÿ South Pembrokeshire Hospital, Tenby and

ÿ Llanelli

Unscheduled Care is not simply ‘an out of hours activity’; it involves ‘in hours services’ providing access for urgent care from 8.00 am until 6.30 pm Monday to Friday.

GP services and Social Care Services will have to develop systems for improving access to routine and urgent care ‘in hours’ to ensure that patients get urgent care continuously throughout the working week.

Services at West Wales and Bronglais General Hospitals are being redesigned with new buildings and staffing arrangements to support Unscheduled Care.

Unscheduled Care will bring together services to provide better local Emergency and Urgent Care, with senior staff diagnosing and treating the sickest patients first in the minimum time and ensuring if they cannot be managed in their local hospital, that they are transferred to specialist care as rapidly as possible.

Improving Unscheduled Care meets the nationally set policy objectives and will allow better use of staffing, resources and tax payer funds and result in improvements in the delivery of scheduled, planned and routine care.

New services will be supported by the Individual Health Record from mid 2010 which enables clinicians to access the health record of each patient with their consent, to improve the effectiveness and safety of care.

A major public engagement and information campaign will support the changes in care delivery across the 3 counties.


A major building programme is underway to provide state of the art buildings and support services. The new Withybush Emergency and Urgent Care Centre, planned for mid 2010 will integrate the Emergency Department, Primary and Community Teams, Clinical Decision Units and OOH services, focusing on delivering care quickly and effectively using a team approach.

The Out of Hours services will merge into a single system to serve the community commencing in October 2009.

Healthcare Standards for WalesThe Healthcare Standards for Wales set out the Welsh Assembly Government’s common framework to support the NHS and its partners in providing effective, timely and quality services across all healthcare settings.

The Healthcare Standards are used by Healthcare Inspectorate Wales as part of their processes for assessing the quality, safety and effectiveness of healthcare providers and commissioners across Wales.

There are 32 Healthcare Standards covering 4 domains which are:

ÿ Patient Experience

ÿ Clinical Outcomes

ÿ Healthcare Governance and

ÿ Public Health

All healthcare providers are assessed against the standards. Progress against the quality and patient safety improvement areas was regularly monitored throughout the year. All reports relating to the self assessment can be found on our website.

Improving the Health of Homeless and Specific Vulnerable groupsThe Health and Homelessness Standards are the Welsh Assembly Governments’ next step towards improving and addressing the health needs of all ages of homeless people and specific vulnerable groups.

In this context, the specific vulnerable groups include people who are homeless, asylum seekers and refugees, gypsy-travellers and migrant workers.

The approach to meeting their health needs will involve:

• Improving service delivery

• Improving strategic direction within the health service.

The LHB is the lead agency for the Standards, however crucial to the delivery will be good partnership working across the NHS, Local Authority and the voluntary sector.

In Pembrokeshire, a multi-agency group is being set up to collate the views of those who are homeless and specific vulnerable individuals. It is hoped that this work will inform and support the development of service provision for homeless and specific vulnerable groups.

If you would like to find out more about ‘Moving More Often’ in Pembrokeshire contact Mike Thomas on 01437 771237.

Moving More Often is a low intensity physical activity programme designed by the British Heart Foundation specifically for frailer older people and is ideal for people living in residential care or who attend a day centre. The aim of Moving More Often is to encourage the uptake of gentle exercise through the use of games and group activities.

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Dr Iain Robertson-Steel first came to Pembrokeshire in 1979 as an RAF Medical Officer. Iain and his family moved to live in Solva permanently 3 years ago. Iain has extensive previous experience as a GP and Consultant with an interest in Immediate and Emergency Care. Iain is the Associate Medical Director for the Out of Hours and Unscheduled Care and is working with the NHS and Social Care teams to deliver safe and effective services for the population in the future.

Health Challenge PembrokeshireThis year saw the approval of the Health, Social Care & Well-being Strategy for 2008-2011 which is jointly produced by the LHB along with Pembrokeshire County Council. It is delivered in partnership with the National Public Health Service, Hywel Dda NHS Trust and Pembrokeshire Association of Voluntary Services. The highlights of the first year are:

ÿ Food and Health Strategy for Care Homes and Community Meals Services was launched in January 2009, following a successful pilot project. The purpose of the Strategy is to provide a consistent approach to food and health for older people living in care settings across Pembrokeshire. It promotes nutritionally balanced meals, snacks and drinks to those who are well and meeting any changes in nutritional or fluid requirements during illness or disease. In recognition of the work, the project has received an ‘Award for Food Action Locally’ (AFAL) from the Food Standards Agency.

ÿ The Swim Surf project encourages children to take more exercise; linking the swimming programme with outdoor aquatic activity and the natural environment. During 2008, a number of local partners, led by the Local Authority Leisure Services, held 5 Swim Surf days where 200 children attended.

ÿ A pilot project is currently being developed looking at innovative ways of engaging with young people by communicating in a visual language that they are familiar with. The project group is looking at using new forms of information technology which embraces the concepts of the Bluetooth technology in mobile phones. Once developed the technology could be used to get a number of public health messages across to the target audience.

ÿ Pembrokeshire Family Challenge is a free fun programme, for the whole family to enjoy together. A personal lifestyle coach is allocated to support the families and to agree a twelve week programme of home based activities to improve their diet and levels of physical activity. They also have the opportunity to join in activities with the other families taking part.

We look forward to continuing to work together to improve the health and well-being of people of Pembrokeshire through providing quality services and supporting people to take responsibility for their own health.

Photograph Caption:Family Challenge beach dayNordic Walking with Steps2Health

1000 Lives CampaignThis campaign was launched in April 2008 involving the Welsh Assembly Government, the Wales Centre for Health, the National Leadership and Innovations Agency for Healthcare, the National Public Health Service and the National Patient Safety Agency. It takes forward a number of actions from the Healthcare Quality Improvement Plan: Designed to Deliver 2006 (QuIP) and presents an opportunity to involve front-line staff in the quality and safety agenda.

The aim is to save 1000 lives and to avoid up to 50,000 episodes of harm in Welsh healthcare in 2 years from the launch date in April 2008.

The Campaign will build on the excellent work already underway in Wales and accelerate these efforts around patient safety and quality of healthcare.

Pembrokeshire LHB along with all LHBs in Wales signed up to the campaign. The medicines management teams within Ceredigion and Pembrokeshire LHB’s have been working together on the evidence-based content areas, which have been developed by clinicians working together in Wales, in the following areas:

Further details Visit the Campaign website at: www.1000livescampaign.wales.nhs.uk today or email [email protected]

During 2008/09, a number of projects were funded including:

• Nordic Walking taster sessions through the Steps2Health project • The development of a Traffic Free Guide • The delivery of support sessions on healthy cooking; swimming sessions; meditation and gym visits through Pembrokeshire MIND.

The partners supported a number of local events during the year including:

• Narberth Food Festival, Education Day • Keep Well This Winter Campaign • Pembrokeshire County Show • Pembrokeshire Advocacy Leaning Disability Event • Stroke Association Event


It is important that the improvements we will see reflect all of the local and national initiatives, and the 1000 Lives Campaign will bring together these current and proposed initiatives; add value to them and ensure all healthcare organisations are working closely together.

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+ “Liquid soap is better than solid

soap because it is less likely

to become contaminated.”

• Improving Leadership for Quality – Enhancing and promoting quality and patient safety across the whole health community. One example of a practical way this can be achieved is through visits or ‘walkarounds’ to GP practices, care homes and hospitals where senior managers, together with non-officer Board members engage staff in a two-way exchange of communication. Issues raised can be addressed quickly and efficiently.

• Reducing Health Care Associated Infections – focusing on practical ways to reduce infections, for example implementing good hand hygiene procedures for staff and patients.

• Improving Medicines Management – focussing firmly on medicines and how they are managed in all situations across the healthcare community, such as how medication is prescribed and dispensed and how the patient is monitored and assisted with taking the medication to achieve the best health outcomes

• Improving General Medical and Surgical Care – looking at how long term chronic conditions such as heart failure, are managed and monitored.

For the duration of the Campaign, Trust and LHBs will have the responsibility of ensuring that best practice is shared, that the impact of any changes is monitored and information shared with other healthcare organisations.

Further details Visit the Campaign website at: www.1000livescampaign.wales.nhs.uk today or email [email protected]

Family Challenge Beach Day

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Hannah’s Smoke Free MessageA North Pembrokeshire primary school pupil won a prize trip to Haverfordwest’s new leisure centre for herself and her classmates.

Hannah Stephens, a year 4 pupil at Ysgol Clydau in Tegryn, won a poster competition highlighting the dangers of smoking.

The competition was run by Pembrokeshire Leisure - the leisure arm of Pembrokeshire County Council - and Smokebugs, the smoke free club for youngsters.

Over 500 members of Smokebugs from 20 Pembrokeshire schools entered the competition with prizes of one year’s junior membership to Pembrokeshire Leisure facilities given to the winners of Years 4, 5 and 6 categories.

Eight year old Hannah, the overall winner, brought her class on a special visit to the new Haverfordwest Leisure Centre as part of her prize. The 36 pupils enjoyed a morning of junior circuits and swimming topped off with lunch in the centre’s cafe.

Enfys Howells, Head Teacher of Ysgol Clydau, said the competition had made the children think about the

benefits of never trying cigarettes and they had enjoyed putting their creative ideas onto paper.

“Thanks to Hannah’s efforts, we have had a wonderful day out at the new Centre - the welcome and facilities were wonderful,” he said.

Pauline Turner, Centre Manager said it was wonderful to see children taking an active role in combating smoking. “The posters they produced are very powerful and get over the message that smoking can damage your health. I congratulate all the youngsters, who took part,” she said.

Funded by Welsh Assembly Government and organised locally by the National Public Health Service in conjunction with Hywel Dda NHS Trust, Smokebugs is a national club for youngsters aged between 8 and 11 years, who want to stay smoke free.

School Health and Community Dental teams take advantage of their visits to schools to discuss with children the benefits of staying smoke free and the links between smoking and bad teeth and gums as well as other illnesses.

“Smoking is very bad for young people trying to stay fit and healthy,” said Ian Scale, Principal Public Health Officer. “So we decided to mark the opening of the new Leisure Centre with this special competition.”

Should Children Be Protected From Smoke?The smoking ban in public and work places was successfully introduced 2 years ago. Non-smokers and smokers said they are generally happy with the ban and there have been many benefits – including a reported drop in heart attack victims in hospital emergency departments.

Many vulnerable people are still exposed to other people’s smoke every day, and many of our young people are brought up in a smoky atmosphere at home. A local survey was carried out this year to ask them what they thought.

The Local Public Health Team commissioned 2 consultation survey’s with young people in Pembrokeshire to ask if they understood and believed the information about the harmful effects of Environmental Tobacco Smoke (ETS or passive smoke) and also what right they thought they should have to be protected.

The children’s consultation team of Pembrokeshire County Council carried out one survey which involved 112 young people aged 7-18 years. This included:

• Two workshops run with looked after children, young people and Young Carers

• Smoke Free Homes activity packs sent out to community youth forums and school councils

• Opportunities for young people to act as Smoke Free Homes researchers to go and consult with other children and young people in their community

• A poll question was put onto www.pembrokeshireyouthzone.co.uk for young people to contribute to.

The Specialist Smoking and Youth Project, Ffaith, from ASH Wales, also undertook a series of special workshops with young people of Tanyard Youth Club, Pembroke Dock and Monkton Outreach Centre which looked at the opinions and beliefs the young people share about smoking, the smoking ban and Environmental Tobacco Smoke. They were asked what they believe can be done to alleviate the ill health caused to young people, adults and pets by breathing in second hand smoke. Twenty seven young people aged 10-17 years took part.

The results of the consultation will be available soon and some of the young people will be asked to present to the Pembrokeshire Tobacco Control Forum to see what can be done to help protect children and young people from ETS in the future.


28 29

Basic Hygiene PrecautionsWe can all take basic hygiene precautions to minimise the spread of germs. This includes:-• Covering your nose and mouth when coughing or sneezing, using a tissue when possible.• Disposing of dirty tissues promptly and carefully.• Maintaining good basic hygiene, for example washing hands frequently with soap and water to reduce the spread of the virus from your hands to face or to other people.• Cleaning hard surfaces (e.g. door handles) frequently using a normal cleaning product.• Helping your children follow this advice.

“Disposable paper towels are the best

option for drying hands because

damp towels can harbour germs”

+

The First Access Team;‘Two Years On’ service update The First Access Team continues to deliver a service for people with mild to moderate mental health issues within their local GP surgery, off ering a range of talking therapies including:

ÿ Cognitive Behavioural Therapy - using techniques to challenge negative thoughts and change the wayyou think, feel and behave.

ÿ Brief Solution Focused Therapy – using techniquesto focus on fi nding solutions to problems and workingon them.

This busy service is delivered in most practices throughout Pembrokeshire, demand continues to be high and has now taken over 1,900 referrals since the start of the Service in January 2007.

We are now in the process of analysing the outcomes of the ‘six session model’ with the Clinical Eff ectiveness Team. We currently off er this to all clients using the Service and measure the clients’ performance by assessing anxiety and depression levels at the beginning of the block of sessions and then repeating at the end.

Early indications are that 90% of clients who complete the ‘six session model’ show improvement, with the majority feeling their symptoms have either subsided, completed or are more manageable. The sessions concentrate on enabling clients to fulfi l their best hopes which allow them to be in control of what they want from the sessions, encouraging realistic and achievable goals in the amount of time off ered.

The service has piloted Stresspac, which is a six week tutor led Stress Management Class, in the community and hope to continue this as an ongoing programme. We also hope to provide a service in the 3 outstanding practices by the end of this year.

Healthy HeartsDuring 2008/09, the scheme to support individuals after a coronary event (Cardiac Rehabilitation) has been further developed and extended to work seamlessly with the local Exercise Referral Scheme.

Cardiac Rehabilitation has 4 phases, from Phase 1 which includes advice and information for patients in hospital after a heart attack and psychological support, through to Phase 4 which includes a supervised exercise programme along with lifestyle advice, angina management, relaxation and occupational therapy support.

Exercise Referral is a scheme to support people to get back to health through activity. Operating in leisure centres across the County, these sessions are for people who have been prescribed exercise as part of their recovery program by their GP or other health professional. Activities in each session are designed for people who are overcoming health problems. Many participants in the scheme go on to become regular users of the facilities once their recovery has been completed, benefi ting both physically and socially from this experience.

The LHB, Pembrokeshire County Council and National Public Health Service support these 2 schemes. The Healthy Hearts Steering Group aids the work of the Exercise Referral Coordinator and the specialist Coronary Heart Disease professionals of Hywel Dda NHS Trust.

Pembrokeshire Family Challenge. . . updateThe Pembrokeshire Family Challenge project is part funded by the National Lottery through the Big Lottery fund as part of the Way of Life initiative which runs until early 2012.

Pembrokeshire Family Challenge is open to all families living in Pembrokeshire, who have at least one child under 12, who are interested in improving the food they eat and the amount of exercise they take.

Following an extensive training programme 5 Healthy Lifestyle Coaches were employed in January 2009 to work with 37 families for a minimum of 12 weeks. Elements of the programme include health assessments and a range of sessions on nutrition.

If you and your family would like to take part, or you have contact with a family for whom you would like to make a professional referral, please visitwww.healthchallengepembrokeshire.co.uk or contact Katie Daly Tel No: 01437 775113 or Email:[email protected]

Photo – HEALTH WORKERS 1

Photo caption: Cllr Sian James, Cabinet Member for Health and Well-being and the Voluntary Sector, is pictured with Healthy Lifestyle Coaches Nicky Shanklin, Helen Stewart, Andrew Kirkhouse and Katherine Devonald. Coach Margaret Edwards is not pictured]

Published in Health Challenge Pembrokeshire Partners’ Newsletter.

A six month evaluation of the ‘Client Satisfaction Questionnaire’provided the following information:-


30 31

“From doing this challenge and having the things you sent me, my child now has an interest in trying diff erent foods”

“I would like to thank everyone who was involved . . . it was very interesting and fun”

“Myself and the children enjoyed it thoroughly”

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Question Clients responseHow did you fi nd the service? 89% very helpfulWould you attend in mental health clinic? 77% yes they wouldWas the staff member approachable and welcoming? 98% very approachable Interventions, advice and information suffi cient? 83% very usefulEnough opportunity to discuss issues/concerns? 95% ample opportunitySix-eight sessions enough? 88% sessions right

Cllr Sian James, Cabinet Member for Health and Well-being and the Voluntary Sector, is pictured with

Healthy Lifestyle Coaches Nicky Shanklin, Helen Stewart, Andrew

Kirkhouse and Katherine Devonald. Coach Margaret Edwards

is not pictured.

• THINK Road Safety DVDs The national THINK campaign provides a focus for road safety messages. Grant funding has enabled Pembrokeshire County Council’s public protection unit to work with licensed premises to encourage the screening of the THINK Road Safety DVD.

Further information is available from Sarah Oliver as before.

• Weight management skills Grant funding has been used to support the MEND project, a practical, interactive scheme to equip children and parents with the skills to manage weight.

Further information on MEND is available on www.healthchallengepembrokeshire.co.uk

From April 2009, Health Challenge Pembrokeshire will be inviting applications for Well-being Activity Grant funding for 2009–2010.

Projects will be required to show how they help to implement the well-being elements of the current Health Challenge Pembrokeshire Strategy. Further information on the strategy and action plans can be found on www.healthchallengepembrokeshire.co.uk

Well-being Activity GrantOver the past 12 months, Health Challenge Pembrokeshire has used the Well-being Activity Grant to support a range of projects that have helped to deliver the well-being element of the Health Challenge Pembrokeshire strategy.

The Grant is made available by the Welsh Assembly Government, and support has been provided for the following, over the past financial year:

• Improved mental health support Pembrokeshire MIND has been working to develop activities to motivate and enable people to take responsibility for their own health and well-being.

Further information is available from Pembrokeshire MIND on 01437 769982 or email [email protected]

• Nordic Walking opportunities The Steps2Health project has been able to expand the range of walking opportunities available, through the purchase of equipment and provision of Nordic Walking taster sessions.

• Play equipment The Well-being Activity Grant has enabled Pembrokeshire Family Challenge’s healthy lifestyle coaches to purchase play equipment to help with their work with local families.

Further information on Pembrokeshire Family Challenge is available on: www.healthchallengepembrokeshire.co.uk

• Production of a Traffic Free Guide Pembrokeshire County Council’s Transportation and Environment Directorate has been able to move ahead with the production of a Traffic Free Guide to highlight safe and attractive traffic-free routes in Pembrokeshire.

Further information is available from Paul Smith, Walking, Cycling and Horseriding Officer, Pembrokeshire County Council on 01437 775435 or email [email protected]

• Random testing of drinks Pembrokeshire County Council’s public protection unit has had funding to undertake random tests on what young people are drinking in the streets.

Further information is available from Sarah Oliver, Senior Environmental Health Officer, on 01437 775274 or email [email protected]


Information on forthcoming Nordic Walking sessions can be found on: www.pembrokeshire.gov.uk/events

Further information on the Well-being Activity Grant is available from Pam Owen, Health and Well-being Manager, on 01437 776612 or email [email protected]

Development work receives recognitionThe Health Challenge Pembrokeshire Scheme was launched in November 2003 to recognise individual or team contribution to local nutrition initiatives that have made a positive impact on the diet or eating habits in the communities they serve. The awards are given in recognition of some of the ground-breaking development work being undertaken.

The Health Challenge Wales Trophy is awarded to a project judged to have made the best local response to Health Challenge and serves to highlight some of the positive benefits that can be gained from close partnership working.

Health Challenge Pembrokeshire recently awarded the Health Challenge Wales Trophy to the Oral Health and Nutrition Project.

“I am delighted that the hard work of all those involved in this project has been recognised in this way”.*

Cllr Sian James Cabinet Member for Health and Well-being and the Voluntary Sector

* source Health Challenge Pembrokeshire Partners’ Newsletter.

32 33

Nordic Walking with Steps to Health

Sam Threlfall of the LHB accepts the Health Challenge

Wales Trophy for the Oral Health and Nutrition Project

from Cllr Sian James.

Substance MisuseInvestment into managing substance misuse has increased across Wales and funding has been increased in Pembrokeshire into a wide range of services provided locally, including:

ÿ education and prevention projects for young persons and adults

ÿ community based interventions

ÿ inpatient detoxifi cations

ÿ residential rehabilitation

ÿ and Specialist Young Persons Drinking and Drugs Services

Pembrokeshire LHB supports the Criminal Justice Substance Misuse Services specifi cally for those clients who have Drug Rehabilitation Requirements imposed upon them through the Criminal Justice System. This is in line with the Government’s strategy for reducing the use of illegal drugs and associated crime and links to the Drug Interventions Programme which aims to help adultdrug-misusing off enders out of crime and into treatment.

Community Safety Partnerships manage substance misuse on a local level. Pembrokeshire LHB, as one of the responsible authorities forming the Community Safety

Partnership, is committed to addressing the root causes of substance misuse, protecting our local communities and to providing treatment and support to those who most need it.

Pembrokeshire Substance Misuse Joint Commissioning Group provides a mechanism through which eff ective local service provision can be researched, developed, purchased and monitored for Pembrokeshire. The group makes recommendations on the commissioning of substance misuse services to the Community Safety Partnership and the LHB based on evidence and best practice. Local needs have been identifi ed and prioritised in Pembrokeshire’s Substance Misuse Commissioning Strategy. This document set out the approach for future action in Pembrokeshire based upon a clear vision with supporting aims and objectives. A 3 year implementation plan forms the operational document for reporting progress on these priorities.


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�� The National Service Framework (NSF) for Older People (Pembrokeshire)National Service Frameworks are designed to improve standards and equity of access to health and social services across the Country. The NSF for Older People addresses the health and social care needs of people from the age of 50 onwards, recognising that preparation for a healthy, active and independent old age needs to start early and that the transition into ‘old age’ needs consideration and management. This NSF was developed and presented following the Strategy for Older People in Wales, launchedin 2003.

The NSF for Older People was subsequently launched in May 2006, setting out a 5-10 year programme to bring all services up to a minimum standard in the shorter term, and to share and spread good practice to continuously improve services and strive towards excellence.

The monitoring of the NSF is managed within each County via a Self Assessment Tool which is completed on a 3 monthly basis and submitted to the Regional Offi ce. Completion of the Self Assessment Tool is managed by identifi ed leads on a partnership basis and includes social care, local authority members, health (acute and community/primary care) and the voluntary sector. The Local Authority is responsible for overseeing the NSF.

The NSF end of year report for Pembrokeshire was very positive, with the scores agreed at 5.43 (compared to the Welsh Median being 5.37). This was a successful year in Pembrokeshire and much work is required over the coming years to continue this progress.

The Children, Young People and Maternity Services National Service FrameworkIn Pembrokeshire the LHB has worked in partnership with children, young people, families and service providers from a number of organisations both voluntary and statutory to develop the First Pembrokeshire Children’s and Young Peoples Plan (CYPP).

Building on good practice, the CYPP focus is on jointly agreed priorities to deliver modern, innovative and eff ective services across the county, with work progressing on the following key areas;

• A Children’s Complaints Process ~ A children’s leafl et has been produced and circulated to GP Surgery’s, dental practices, schools etc. The responses are managed and processed by the Patient Support Services Department of the Hywel Dda NHS Trust at Withybush Hospital.

• The Children and Adolescent Mental Health Services (CAMHS) has continued to focus on continuity of services provided and ensuring that all needs are met for young people moving from children’s services to adult service’s.

All achievements are reported to the Welsh Assembly on an annual basis and the fi ndings of the current NSF review being undertaken will be published in the near future.

34 35

Wendy Herbert, Substance Misuse Commissioning Coordinator has worked for the LHB since 2004. She represents the LHB in the planning of eff ective local drug and alcohol services. The LHB has invested considerably in these services to assist people to lead healthier lives and live in a safer community.

There has also been considerable investment into assisting individuals who have addressed theirsubstance misuse to reintegrate into communities, education and employment.

The Care Home Project has ensured training for qualified nurses and health and social care workers within nursing homes. Over a 2 day period they look at areas such as:

ÿ principles of palliative care; ÿ palliative care emergencies; ÿ communication; ÿ team working; ÿ cultural and religious issues; ÿ pain and symptom management; ÿ drug conversions ÿ and the grieving process.

To enable and promote the training process, the project nurse has been supported by the nurses within the Macmillan Team.

The project is supported by a steering group including all key partners with representatives from Social Care, Macmillan Cancer Support, Palliative Medicine, Care Homes, Voluntary Sector, Out of Hours GP Services, Care & Social Services Inspectorate Wales.

The project, to date, has been very successful within nursing homes and Domiciliary Care Agencies. The feedback from participants has been extremely positive.

The All Wales End of Life Care PathwayThe Pembrokeshire Care Home Project commenced in September 2007. It is a 3 year project funded by Macmillan Cancer Support with additional monies from a Welsh Assembly Government Grant, which enabled the inclusion of Domiciliary Care Agency staff.

The overall aim of the project is to: “improve the quality of care for patients with cancer and other life limiting diseases, through the development and implementation of palliative care educational programmes (incorporating the Care Pathway for the Last Days of Life) for providers of care within Care Homes and Domiciliary Care Agencies”.

Within Pembrokeshire, education and training had already been conducted within the hospital setting and district nursing service. Additional work was conducted with Pembrokeshire GP’s, with all but one practice now using the Care Pathways.


Three Counties Planning Forum1. Remit The Planning Forum is established to consider and bring forward proposals on the service model needed to support services and hospital configuration for the 3 counties. The Forum continues to meet bi-monthly and has wide stake-holder involvement.

2. Service Groups From February 2007 to date, a total of 20 Service Groups have been set up for individual clinical specialty areas, with the over-riding aim to develop plans for integrated services across Carmarthenshire, Ceredigion and Pembrokeshire. The Service Planning Groups include:

• Breast care • Cardiology • Chronic Pain • Community Services • Critical Care • Dementia • Dermatology • Diabetes • ENT • Mental health Unscheduled Care • Ophthalmology

• Orthodontics • Out of Hours Primary Care • Palliative Care • Stroke care • Substance Misuse • Transport • Unscheduled care • Upper GI Surgery • Workforce Planning

All Service Groups are at varying levels of development and all have presented progress/proposals for consideration to the Planning Forum. A number of these ‘task and finish’ groups have made their recommendations as to the most appropriate service model for the three counties and have now been disbanded. This work is being taken forward within the Trust.

3. Key Achievements Examples of key achievements are:

3.1 Ophthalmology The Planning Forum endorsed the business case for a ‘Wet’ Age-related Macular Service within the 3 Counties. This involved a staged approach to setting up the service, firstly at Amman Valley Hospital in June 2008 and in February 2009 within Aberystwyth. This approach has ensured services are now accessible to patients in all parts of the 3 counties with a view to setting up a Pembrokeshire service if there is the appropriate demand.

Marilyn Wilkinson, has held the post of Project Manager for the Three Counties Planning Forum since September 2007. She moved to this position following many years in Directorate Management positions within Medicine, Women and Children and Mental Health Services within Bro Morgannwg Trust. This enables her to bring to the post an indepth background knowledge and experience in service development within a variety of clinical specialties. Marilyn has also significant experience in Human Resource Management.

3736

Nurses who attended the training said:

“I have a greater understanding about palliative care needs”

“The content of the course was well planned and held people’s interest”

“The whole course was comprehensive and thought provoking. There were issues identified within the training that we weren’t previously aware of. For example, palliative care emergencies”

“We as a nursing home team now have a greater understanding of the importance around good team working, we learnt new things and found the days to be interactive and enjoyable”.

As part of the Trust Staff Award Scheme, the Wet Age-related Macular Service has received

the Chief Executive’s Award for Outstanding Service Innovation and

Excellence in Improving Patient Care.


Age-related Macular Degeneration causes severe visual loss and is the commonest form of blindness in persons over 50 years of age.

The service in Aberystwyth is expanding; there are now over 90 patients within the service with 16-18 patients receiving injections each.

In Amman Valley Hospital there are over 130 patients from Pembrokeshire and Carmarthenshire being treated within 2 lucentis clinics per week.

There has been an extremely positive response from patients and quotes include:

‘It is wonderful to have my sight restored’

‘I can now see to read’

‘I can see the clock on the mantelpiece’

‘Thank you for giving me my eyesight back’

‘I will now be able to do my Christmas shopping’

‘You must be very proud to have achieved an award and have photographs of your team displayed in the Carmarthen Journal’

‘My vision is improving’

‘At least my vision is stable and no worse now’

‘The injection looks like colourful metallic paint swirling down at me’

‘Since having the injections my hallucinations have disappeared’

3.2 Mental Health Unscheduled Care To ensure patients suffering with Mental Health problems receive the highest quality treatment when accessing emergency services, a rapid assessment tool has been developed by the Service Group for use by all staff providing A+E and Unscheduled Services across the 3 counties.

A continuous training programme is being provided to all staff on this newly developed rapid assessment tool

ensuring assessment processes are consistent with all staff asking the same questions. There has been improved engagement with ‘Out of hours’ GPs and there has also been significant developments regarding the electronic patient record for this service ensuring patient details are shared.

The training programme has now been further enhanced and a training dvd and package has been produced and launched. The dvd has now been made available to all staff working within:

• Ambulance Service

• GP ‘Out of Hours’

• Accident and Emergency

The dvd was produced from within existing budget making the most efficient use of resources by using staff as the actors. This package is currently being evaluated.

3.3 Diabetes Following on from the Diabetes Service Group recommendations, 5 main areas are being progressed by the Diabetes Clinical Network:

Patient Sub-group• Patient reference groups for each county are well

established and are represented on the Network, in an attempt at capturing the needs, problems and opinions of people with diabetes in one group

• A Tele-health project is planned looking at the health care professionals’ time saving and patient satisfaction outcome in a group of diabetic patients who will regularly transmit their blood glucose readings to the HCP’s computer via a modem phone connection.

Information Sub-group• Existing diabetes website for Carmarthenshire will be

expanded and updated for the 3 counties.

• The Network is working with Informing Healthcare to select an all Wales 2y care system which links with GP and district Pharmacy systems and could also incorporate renal and cardiovascular requirements. It is hoped that Withybush and Bronglais Hospitals will be pilot sites for this all Wales Diabetes EPR.

Patient Education As part of an education programme for people to manage their diabetes, structured group education courses for type 1 diabetes (DAFYDD)(4 days) and type 2 diabetes (XPERT)(3 days), are being delivered by dieticians and diabetes nurses. So far, <5% of eligible patients have done these courses.

Professional Training Training of Primary Care staff is an essential pre-requisite for the net movement of chronic disease care from hospitals to the community. Training plans include the following:

• GPs and practice nurses from Pembrokeshire are now attending the Swansea University Masters level diabetes course locally and there are plans to run a similar course next year in Aberystwyth.

• The 4th annual Carmarthenshire Diabetes Update Day for primary care was held in the Halliwell Centre on 18 June with over 100 attendance for all over West Wales.

• The Carmarthenshire Local Enhanced Service in Diabetes required completion of a basic diabetes course by a GP and a practice nurse from each Practice. As a result, all but 2 of the Carmarthenshire practices now provide the diabetes care for all uncomplicated Type 2 diabetics on diet/oral medication.

Specialist Services Developments will be required to be undertaken for the following specialist services:

• Paediatric and young people’s diabetes services • Diabetic foot and vascular services • Renal and diabetic retinopathy services • Diabetic pregnancy

3.4 Palliative care A multi-disciplinary Service Planning Group for Palliative Care is established. To set the scene, a Palliative Care Services Workshop was held on the 12 December 2008, as a first step to take services forward with an integrated approach within Hywel Dda. Baroness Professor Finlay presented the recommendations within the ‘Sugar’ report and outlined the ‘blueprint’ for the planning of future services.

The Group is working collaboratively to ensure the delivery of an equitable palliative care service across the health community. There are a number of work-streams taking work forward which will include:

• 24 hour consultant cover in the region

• The development of a robust Communication Policy

• 7 day working/access to clinical nursing services within Hywel Dda

• Funding for Allied Health Professionals to support primary health care

• Rapid Discharge Policy

To reduce duplication, at the last Palliative Care Coalition Group meeting it was agreed that both the Coalition Group and the Planning Group would merge as the intended aims for both were for the development of services in palliative care.

3.5 Community Services - Rehabilitation/ Intermediate Care Rehabilitation/Intermediate Care Service Development is being taken forward by one of the sub-groups of the Community Services Planning Group. A multi-agency ‘Minding the Gap’ workshop was held in April 2009 with over 50 operational staff and managers. There was extremely positive feedback following this workshop with joint principles and future development issues agreed.

Building on the work from this workshop, a Rehabilitation Strategy is in the process of being developed and a further workshop is planned for 24 September 2009, to take forward the key issues.

3.6 Critical Care The overall aim of the 3 counties group is to determine a clear framework of future delivery of critical care services to the residents of the 3 counties and to identify developments in line with Quality Requirements for Adult Critical Care in Wales. The following progress has been made:

• An action plan has been formulated to address shortfalls against quality standards, however, there is a significant funding deficit.

Louise O’Connor, joined the NHS in 1992 and has worked for the LHB since its inception in 2003. Louise has responsibility for the business and operations management within the organisation, including areas such as corporate governance, claims and complaints and legal services. Louise also provides support to the LHB Board and enjoys the varied responsibilities of the role.

38 39

• A regional sub-group is taking forward transport development for critically ill patients.

• The most pressing issue is currently planning for the potential spread of pandemic flu which includes doubling capacity for the critically ill patients.

• A regional sub-group is taking forward questionnaire design to ensure appropriate and consistent feedback from patients and relatives.

• An Information Sub-Group is analysing all existing data collection method, IT databases, format and the timeliness of data reporting.

• The shape of future services is dependant on the outcome of key decisions re trauma and major surgery provision within the Trust. Options are currently being discussed.

3.7 Chronic Pain Within the Planning Group, services within the 3 counties are being assessed against the WAG ‘Designed for Pain’ document principles which include:

• Encouragement of patient self-help initiatives.

• Utilisation of a wide variety of currently available facilities outside the NHS, especially those of Local Authority Leisure Centres.

• The employment of triage techniques once NHS services are sought, to identify those people requiring specific management, for example because of acute medical problems or adverse psycho-social factors. This ensures that resources, including those of the GPs, are efficiently utilised.

• Provision of services, as far as possible, within the community rather than hospital.

• Establishment of management programs based on cognitive-behavioural techniques (CBT).

All Wales Map of Medicine pathways are now drafted, and the Planning Group are contributing to this development. Engagement with primary care colleagues continues to be undertaken.

During September 2009, WAG is to undertake a service audit and the work completed on the above analysis will enable the Trust to respond in a robust fashion.

The over-riding aim is the Devolution of Pain Management Services from secondary care into the Community. The Group is to apply for a funding award from NAPP Pharmaceuticals to pump prime this transition.

Welsh Pain Advisory Board Guidance is awaited, which will continue to inform the Development Plan. The successful outcome of the bidding process will assist in expediating developments, however, the devolution to Community Services will still be perceived as a key service priority.

The next stage is for the group to appraise the service options for the establishment of an integrated service model for Chronic Non-malignant Pain, establishing the logistical and financial obstacles and recommend the service model for Hywel Dda Health Community.

3.8 Cardiology The Service Group has delivered a Strategy (adhering to NSF CHD Quality Requirements and National Standards) for a clinically networked Cardiology service operating across 4 hospitals within the 3 counties. A ‘hub and spoke’ service model is proposed, the hub to be based in West Wales General Hospital (WWGH), Carmarthen with local general hospitals providing core services. There will be timely access to core and specialised clinical services and a large part of care is to be closer to patients’ homes.

Local hospital service will include:

• Rapid in-patient assessment and stabilisation

• Work effectively with tertiary centre

• All have a Critical Care Unit

• Provide Core Diagnostic services

• New and follow-up out patients services

• Develop primary care referral pathways

The Forum constitution has proved to be task and relationship orientated and has enabled a very positive partnership and wide ranging engagement. The Forum has ensured a dynamic process, creating an agenda for change focusing on best practice and innovation addressing the complex task of achieving the right balance of services provided on a local/centralised basis.

This collaborative and reflective process provides a firm platform for both future service development and engagement process with local communities and partner organisations. Service development has needed to be incremental in its approach and the Forum has not underestimated the time that is required to achieve service change.

Arrangements for managing the future work of the Planning Forum are being reviewed in the light of the establishment and emerging structures of the new Hywel Dda LHB. It is imperative work is taken forward through the Trust Clinical Services Strategy within a financial framework with links into tertiary service requirements and the development plans of ABM and other neighbouring Trusts. This would provide the opportunity for the Health Board to ensure a whole systems approach to planning and service development.


40 41

Emma Cadman, Health Planning Manager - has worked for the LHB since 2004. She works with a range of agencies to prepare bids to the Welsh Assembly to develop new GP premises for the County or develop existing GP practice premises. She finds working with GP practices very rewarding.

Julie Cole, Administration and Committee Services Officer joined the LHB in 2004, starting as a PA, and now responsible for organising Committees, taking and producing minutes at the meetings and any associated work. Julie enjoys liaising with Board Members, members of the public and Officers in her role.

Enhanced services at West Wales General will include:

• A Cardiac Catheter Laboratory

• Enhanced Diagnostic (stress echo, perfusion imaging)

• Permanent Pacing

Tertiary services will continue to be provided with ABMU

NHS Trust and include:

• Angioplasty

• Cardiac Surgery

• A ‘Treat and Return’ process

3.9 Transport The Planning Group has a new Service Lead and membership. Tangible objectives have been agreed as follows:

To plan an improved quality and whole systems non-emergency Transport Service for patients, through the integration of Trust, Local Authority and Voluntary transport service provision.

Data is in the process of being collected and collated from all Health, Social Care and Voluntary providers of non-emergency transport services within the 3 counties.

This data includes:• vehicles

• staff

• resources

• expenditure

• type and scope of services

• patients/clients

This information will form the baseline for further work with the over-riding aim of establishing an integrated non-emergency transport service. The Norfolk service will be benchmarked.

A Sustainable Travel Plan is being pulled together for the Trust for submission to WAG.

CommissioningDuring 2008/09 the LHB’s guiding principles for the commissioning and delivery of patient services were as follows:-

ÿ To develop a multi-agency Modernisation & Innovations Register and Local Delivery Plans; supporting partner organisations and existing Service Development Plans;

ÿ To support and prioritise key modernisation and service improvements by utilising service reviews outcomes and public and patient involvement;

ÿ To direct and monitor the commissioning agenda on a regional level for secondary care services and a local level for primary care services;

ÿ To develop the strategic framework and direction of commissioning across all sectors of the LHB’s, in line with the Health Social Care and Wellbeing Strategies;

ÿ To oversee the preparation of the LHB’s Annual Operating Framework and to ensure robust performance monitoring was implemented.

The focus for 2008/09 was the achievement of waiting times targets, commissioning and service modernisation, which are set out in ‘LHB’s Annual Operating Framework’. As part of delivering the above, the LHB has taken the following actions:

ÿ Across the 3 Counties there has been a review of Primary Care Enhanced Services to ensure that there is uniformity in the delivery of care pathways across the 3 Counties.

ÿ Unscheduled Care Model - The construction of a new Emergency and Urgent Care Centre at Withybush Hospital is underway with a completion date in March 2010. The Emergency Department is working very closely with Pembrokeshire Care on Call. Withybush Hospital established a new Adult Clinical Decision Unit and Paediatric Clinical Decision Unit using temporary accommodation.

ÿ Pembrokeshire LHB produced “One Vision One Pembrokeshire” on behalf of the health and social care community. This shows how a Community Services Framework will be developed within Pembrokeshire, within a strong partnership framework. The document reflects the existing services, strategies and partnerships which provides a model of care enabling the residents of Pembrokeshire to be supported through age and ill health whilst reflecting what is also happening across the 3 Counties.

ÿ The LHB jointly funded a business case for the provision of Wet Aged Macular Degeneration -Wet(AMD) Service from the Hywel Dda NHS Trust. Wet(AMD) represents the most common cause of blindness in the UK and the benefits of the service are the maintenance or improvement of vision for patients with this condition. The service is currently

provided from two treatment centres, namely Bronglais Hospital (in Ceredigion) and Amman Valley Hospital (in Carmarthenshire) .

ÿ The LHB and Hywel Dda NHS Trust jointly funded a 4th Ear Nose & Throat (ENT) Consultant in order to ensure that the shared ENT service between Carmarthenshire and Pembrokeshire is sustainable.

2008/09 Achievements in Patient Numbers and Waiting Times The diagram below sets out the number of appointments/procedures that have been delivered for Pembrokeshire residents across Hywel Dda, Swansea and Cardiff & Vale NHS Trusts.

In terms of patient care delivered to Pembrokeshire residents, our 3 main NHS Trust providers are:

ü Hywel Dda NHS Trust - 96% of all procedures/ appointments;

ü Swansea NHS Trust - 3% of all procedures/appointments

ü Cardiff & Vale NHS Trust - 1% of all procedures/appointments

In order to ensure that waiting time targets were achieved during 2008/09 the LHB purchased extra Orthodontic and Oral Surgery and second offer spinal orthopaedic services for Pembrokeshire residents waiting at Cardiff & Vale NHS Trust.

Wet Aged Macular Degeneration Wet(AMD) Service from the Hywel Dda NHS Trust.

The LHB was pleased to hear the above Scheme won first place in the Trust Staff Best of Health Award Scheme.

The project was recognised for its successful partnership working, collaboration and team building.

The Award is due to the dedication, hard work and co-ordination of all staff involved with the project, which has brought benefits to patients.

79,000 Outpatient A

ppoi

ntm

ents

24,000 Inpatie

nt P

roce

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s

23,000 Day Case P

roce

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s

OurMainNHSTrusts*

3

The table below shows the LHB’s achievements in waiting times over the last year for Hywel Dda NHS Trust, with the latest waiting times target of 10 weeks for outpatient appointments and 14 weeks for inpatient and daycase treatments.

WAITING TIMES

Total0-10weeks

0-14weeks

0-22weeks

InpatientAt 31/03/2009 N/A 890 890

At 31/03/2008 N/A N/A 905 905

DaycaseAt 31/03/2009 N/A 1,339 1,339

At 31/03/2008 N/A N/A 1,147 1,147

OutpatientAt 31/03/2009 3,930 N/A 3,930

At 31/03/2008 N/A N/A 6,090 6,090

Operating Cost Statement and Achievement of Operational Financial Balance for the year ended 31st March

2009£(000)

2008£(000)

Primary Health Care 49,682 47,479

Secondary and Community Healthcare 133,693 117,445

Other Programme Expenditure 1,324 1,459

Administration Costs 2,031 2,002

Total Expenditure 186,730 168,385

Miscellaneous Income (2,370) (2,160)

Net Operating Costs 184,360 166,225

Less: Non Discretionary Expenditure 629 707

Net Operating Costs less NonDiscretionary Expenditure

183,731 165,518

Revenue Resource Limit 183,756 165,583

Operational Financial Balance 25 65

Balance Sheet as at 31st March

2009£(000)

2008£(000)

Fixed Assets 34 50

Current Assets

Debtors 1,103 629

Cash at Bank and in Hand 12 34

Total Current Assets 1,115 663

Creditors: Amounts falling due withinone year

9,959 9,056

Net Current Assets/Liabilities (8,844) (8,393)

Creditors: Amounts falling due after more than one year

0 0

Provisions for Liabilities and Charges 1,005 285

Total Net Assets (9,815) (8,628)

FINANCED BY

General Fund and Revaluation Reserve (9,815) (8,628)

Cash Flow Statement for the Year Ended 31st March

2009£(000)

2008£(000)

Net Operating Costs (184,360) (166,225)

Adjustment for Non cash Transactions 539 16

Adjustments for movements inWorking Capital other than cash

429 740

Utilisation of provisions (125) 0

Net cash Outflow from operating activities

(183,517) (165,469)

Payments to Acquire Fixed Assets 0 0

Capital Expenditure andFinancial Investment

0 0

Financing:

Assembly Revenue Funding 183,495 165,407

Net cash inflow/(outflow) from financing

183,495 165,407

Increase/(decrease) in cash (22) (62)

The amount received by each Local Health Board is set out in the table below.

This additional income does not form part of the normal recurring income that the Hywel Dda Trust can expect from the Local Health Boards in the Health Community.

The LHB’s Statement of Recognised Gains and Losses shows a nil return.

Local Health Board £m

Carmarthenshire LHB 2.1

Ceredigion LHB 0.8

Pembrokeshire LHB 9.1

Total 12.0

IntroductionPembrokeshire LHB is required, and indeed has met, the two key statutory financial targets in the financial year 2008/09, which are:

• Not to exceed the LHB’s notified resource limit ; and • Not to exceed the LHB’s cash limit.

An abridged set of accounts for the LHB is set out below. Full copies of the LHB’s annual accounts can be obtained from Louise O’Connor on 01437 771220.

Summary Financial Statements

The LHB’s accounts are prepared using Government Resource Accounting principles as stipulated by Welsh Assembly Government in the ‘LHB Manual for Accounts 2008-09’.

The LHB receives over 98% of its income from Welsh Assembly Government in the form of a resource limit amounting to £183.756m, and non discretionary income of £0.629m.

The LHB received £0.950m of resource in the current financial year that had been brokered forward from the 2007/08 Financial Year by Welsh Assembly Government.

In March 2009 the Local Health Boards in the Hywel Dda Health Community received an additional non recurring resource allocation of £12.0m from Welsh Assembly Government on behalf of the Hywel Dda NHS Trust, which they paid over to the Trust as part of the Trust’s Long Term Agreement income.

Financial StatementsPembrokeshire LHB Annual Accounts 2008/09

42 43

NHS Managers Pay The LHB can confirm that pay rises for NHS senior managers in 2008/09 did not exceed 2.75%.

Pensions Details of the LHB’s pension costs can be found in Note 4.7 of the LHB’s Annual Accounts.

External Audit The LHB’s external auditor is the Wales Audit Office. The auditor was remunerated £69,000 for the statutory audit work, including Value for Money audits, carried out during the year.

Public Sector Payment Policy – Measure of Compliance Welsh Assembly Government requires the LHB to pay non–NHS trade creditors in accordance with the CBI prompt payment code and NHS bodies in accordance with Government Accounting rules. The target is to pay 95% of creditors within 30 days of receipt of goods or a valid invoice (whichever is later) unless other payment terms have been agreed with the supplier. No amounts have been included in the accounts arising from claims made by small businesses under the Late Payments of Debts Commercial (Interest) Act 1998.

Public Sector Payment Policy

Number of Invoices

Value of Invoices

£(000)

Non-NHSTotal bills paid 2008-09 49,010 21,414

Total bills paid within target 48,808 20,981

Percentage of bills paidwithin target

99.6% 98.0%

NHSTotal bills paid 2008-09 675 111,368

Total bills paid within target 642 111,236


95.1% 99.9%

TotalTotal bills paid 2008-09 49,685 132,782

Total bills paid within target 49,450 132,217


99.5% 99.6%

£49,682,000 Primary Care

£133,693,000 Secondary & Community Health Care

£1,324,000 Other Programme Expenditure

£2,031,000 Administration Expenditure

Expenditure

Primary Care

£19,552,000 GMS

£4,274,000 Pharmaceutical

£4,261,000 GDS

£1,024,000 GOS

£1,351,000 Other

£19,220,000 Drugs

Financial Position for 2008/09 During the year the LHB spent £186.7million on services. Of this £133.7million was spent on secondary and community care, such as hospital services, community services, continuing care, and the voluntary sector. £49.7million was spent on primary care services such as GP’s, dentists, opticians, and pharmacists. £1.3million was spent on Other Programme Expenditure including £0.735m on buying public health and health promotion services from the National Public Health Service. £2.0million was spent on administrative costs including £0.801m which was used to buy services from the NHS Business Services Centre Wales. This is shown in the pie chart below:

Primary Care Primary Care Expenditure includes payments for the cost of drugs, General Medical Services (GMS), Pharmaceutical services, Out of Hours GP cover, General Ophthalmic Services (GOS), General Dental Services, and other expenditure.

Included in Other Expenditure are payments for the primary care mental health team, and Clinical Governance in Primary Care.

A pie chart showing the LHB’s investment in the primary care sector is set out below. As can be seen, just under half the LHB’s expenditure in this area relates to drugs prescribed by Pembrokeshire GPs, as follows:

Secondary and Community Care £110,307,000 Hywel Dda NHS Trust

£11,887,000 Continuing Healthcare

£1,895,000 NHS Funded Nursing Care

£9,604,000 Other

Cash Releasing

£(000)

Non Cash Releasing

£(000)

Investment

£(000)

Net Savings

£(000)

Procurement 0 269 269 0

Support Services 0 1,180 1,180 0

Reshaping/reconfigurationof services

0 659 659 0

Better use of staff 0 1,001 1,001 0

Total 0 3,109 3,109 0

Secondary Care A pie chart showing the LHB’s investment in the secondary and community care sector is set out below. It is worth noting that expenditure in this area accounts for over 70% of the LHB’s expenditure.

The LHB commissions Secondary & Community services for Pembrokeshire residents from all Trusts to the value of £117.4m. Within this, the value of the Hywel Dda NHS Trust contract is £110.3m. This is the LHB’s main provider of health care, and this contract amounts to 59% of the LHB’s total expenditure and 83% of its expenditure on secondary and community care.

The LHB’s other two main providers of secondary care are the ABMU NHS Trust, and the Cardiff and Vale NHS Trust.

The LHB spent £13.8m on the provision of Continuing Care and NHS Funded Nursing Care in Pembrokeshire and increase of £4.1m compared to 2007/08.

Other expenditure includes the commissioning of healthcare from voluntary organisations, Local Authorities, and the private sector.

Making the Connections Making the Connections is a Welsh Assembly Government sponsored initiative which looks to all organisations in the public sector in Wales to eradicate duplication; dovetail service delivery and either increase productivity or make savings through working together.

The scope which the Pembrokeshire LHB has for implementing the above initiative needs to be viewed in the context of the fact that two thirds of the entire budget is utilised in the commissioning of secondary care services as previously mentioned. These services are already subject to national ministerial targets for increased productivity set within the Annual Operating Framework, as well as cash releasing savings within the inflationary uplift that is the National Finance Agreement.

Pembrokeshire LHB, in common with other LHBs in Wales, procures its support services from the NHS Wales Business Services Centre on a shared services basis. By this means the LHB can demonstrate that it has streamlined the provision of support services for Human Resources, Finance, Information Management Technology and Primary Care Contractor Services. Similarly, the LHB also procures Public Health and Health Promotion services on an All-Wales shared basis from the National Public Health Service.

The LHB is currently forecasting that it made productivity gains of £3.109m in 2008/09 for an investment of £3.109m. The LHB’s achievements under the Making the Connections initiative are summarised in the table below:

44 45

Statement of Internal Control1. Scope of responsibility The Board is accountable for internal control. As Accountable Officer and Chief Executive for this Board, I have the responsibility for maintaining a sound system of internal control that supports achievement of the organisation’s policies, aims and objectives, whilst safeguarding the public funds and this organisation’s assets for which I am personally responsible, in accordance with the responsibilities assigned by the Accounting Officer of NHS Wales.

Overall accountability and responsibility for risk management, including controls assurance, lies with the Board and Chief Executive. The Board is responsible for the LHB’s system of internal control, including risk management. It is therefore the Board’s responsibility to ensure that there are proper and independent assurances given on the soundnesss and effectiveness of the systems & processes in place for meeting the LHB’s objectives which are derived from the Welsh Assembly Government’s (WAG) Annual Operating Framework, and delivering appropriate outcomes.

Following the introduction of the Joint Management Structure with Ceredigion the previous financial year, during 2008/09 a joint review of the committee structure was undertaken in order to ensure that the reporting structures at the LHB were capable of providing a robust scrutiny process during a time of substantial change in light of the pending NHS Reorganisation in Wales. Integral to this process are the Audit Committee and the Joint Integrated Governance Committee. Under the LHB’s Standing Orders specific responsibilities have been devolved to the Audit Committee, from which the Board receives regular reports. The Joint Integrated Governance Committee has delegated authority from the Board to adopt all policies, procedures etc., relating to clinical standards, risk management, complaints and performance management. This committee reports both directly to the Board and in retrospect to the Audit Committee, in order for the Audit Committee to fulfill its overall role for scrutiny on behalf of the Board.

The responsibilities and accountabilities of each committee are specified within the individual Terms of Reference and are also included in the Risk Management Strategy & Policy. The LHB’s Risk Management Strategy & Policy include principles derived from the Treasury’s Risk Management Framework and from the Welsh Risk Pool on behalf of WAG.

The Welsh Assembly Government is kept fully informed on the risk management processes in place within the organization through the Annual Operating Framework and Service and Financial Framework where significant risks are noted. In addition, financial risks are highlighted within the monthly financial monitoring returns submitted to the Welsh Assembly Government and at regular review meetings.

2. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of organisational policies, aims and objectives, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in the organisation for the year ended 31 March 2009 and up to the date of approval of the annual report and accounts, and accords with Welsh Assembly Government guidance.

3. Capacity to handle risk The Board has in place a robust system of Internal Control with committee structures in place to support the Board and its activities in ensuring Corporate Governance. The organization’s Risk Management Policy & Strategy defines the structures for the management and ownership of risk and also includes the delegation of certain responsibilities and accountabilities with regard to risk, to specific committees and individuals. These include the Audit Committee and the Joint Integrated Governance Committee together with some of the working groups and sub committees, such as the Risk Working Group, Joint Clinical Governance Committee, and Compliments, Complaints and Incidents Committee, which underpin the main Committees of the Board.

The LHB recognizes that embedding risk management into its core business processes, i.e. creating a culture where effective risk management is an integral and natural part of the way most people work, is a key objective for the organization. The Risk Management Policy & Strategy which has been approved by the Board therefore reflects these principles. It includes both individual & corporate responsibilities surrounding effective decision and policy making and the ability to manage risks inherent with the successful delivery of policies and initiatives. It also recognizes that services and projects are increasingly being delivered through or in conjunction with partner organizations, and that good risk management is integral to delivering successful partnerships.

The Risk Management Policy & Strategy is supported by a detailed Risk Management Procedure and Desk Top Procedure for Risk Management. The desk top procedure for identifying risks and preparing action plans for inclusion on the risk register also accommodates both amendment to and removal of risks from the register, leaving a clear audit trail for each risk identified. All staff are made aware of the availability of these documents and are also informed of any updates.

Both the Integrated Governance Committee & Board receive periodical updates on the risk profile of the organization and staff are also informed of these updates. These factors combined have contributed to a risk based approach to the achievement of the LHB’s objectives during the year.

Executive Directors & Senior Managers are also responsible for ensuring that staff understand and apply the LHB policy and strategy in relation to risk management. This is further reiterated in the job descriptions of all staff which makes reference to the individual’s responsibility in having a proactive role in the management of risk. The induction programme for all new staff includes the individual’s responsibility towards risk management with an information sheet included in the Induction Packs. During the year, training sessions were delivered on Financial Governance, Risk Management and Counter Fraud in order to provide regular updates on the subject to all staff. The sessions were designed to ensure that all staff are aware of the importance of financial governance, to ensure risk register awareness & the risk management process, incident & hazard reporting, and counter fraud processes. Further to Board approval to a revision of delegated financial limits, the Scheme of Delegation and authorized signatories list was disseminated to all staff, thus ensuring that all staff are equipped to manage risk in a way appropriate to their authority & duties.

4. The risk and control framework The LHB’s Policy Statement on Risk Management is driven by the recognition that effective risk management is a key component of corporate and clinical governance & is integral to the delivery of its objectives in service provision. The risk management strategy has been developed & implemented to adapt to the changing regulatory environment, including the introduction of Healthcare Standards and to ensure that the principles derived from the Treasury’s Risk Management Framework and the Welsh Risk Pool’s Risk Management Toolkit are incorporated. These factors combined, ensure that an integrated approach to risk management is embedded into the activities of the organisation. The risk management strategy recognizes that risk is inherent in all the organisation’s activities and that it is imperative that responsibilities and accountabilities are clearly defined. The strategy outlines responsibilities for managing risk from the Board down to individual staff, and identifies the corporate accountability arrangements within the LHB towards managing risk. These responsibilities include managing risks associated with the development and delivery of new services/activities and those associated with working with partners/stakeholders.

A documented framework exists which prioritizes risks according to their impact and probability and this is supported by an organisational risk register developed by analyzing the LHB’s corporate and departmental objectives.

The introduction of healthcare standards reflects a performance approach to risk management and assessment of the adequacy of the actual processes in place at the LHB. During 2008/09 the LHB has continued with its consistent and systematic application of the standards throughout the organisation. This has included cross referencing Committee & Board papers, SaFF, Annual Operating Framework & Risk Register reporting requirements to the appropriate Healthcare Standard. This ensures that due diligence is therefore given to the healthcare standards across the whole of the organisation’s activities.

In assessing the Healthcare Standards submission for 2007-08, HIW were specifically looking at whether improvements had been made for those 9 Standards where the LHB were assessed as being Aware or Responding at one or more of the three levels of assessment in 2006-07. It was concluded that although the LHB had made some progress in improving its maturity, with each of these 9 Standards assessed at Responding, the LHB still needed to focus on these during 2008-09. One of the main criticisms was the lack of current & appropriate evidence to support the narrative in the responses and evidence of practical application & evaluation was not apparent. Although from the LHBs perspective the overall HIW conclusion was disappointing, it was encouraging in that it was also concluded in the report that the LHB had taken progressive steps to embed the Healthcare Standards into the organisation’s governance processes and had demonstrated commitment to the Healthcare Standards agenda & assessment process. With specific reference to those Standards that underpin the management of risk, none had been subject to Independent Validation by HIW. The Internal Audit validation of Standards 27 & 28 had confirmed levels of Developing & Practising, whilst Standards 14 & 16 had both been self assessed as Practising.

Further to the 2007/08 self assessment and the HIW verification of performance, the Board approved a Healthcare Standards Improvement Plan, which was also agreed by the Regional Office of WAG. Following the assessment, HIW participated in a workshop and have been working with the LHB in order to improve its maturity in those 9 areas which required strengthening. The Board is presented with regular updates of progress against the improvement plan by means of a traffic light status report and a Healthcare Standards Improvement Plan Progress Report is also submitted to Regional Office on a quarterly basis . Both show significant progress made against all the 9 areas requiring improvement.

The LHB has completed its self-assessment against the healthcare standards for 2008/09 which will be reviewed by Health Inspectorate Wales at a later date. This has been a process which has seen significant Board engagement and staff involvement. In order to ensure that the healthcare standards are embedded in the culture of the organization, all staff were issued with a pro forma containing all 32 Standards and were asked either individually or as a team, to indicate where & how elements of the individual/team role contributed to the Standards.

46 47

A team of Lead Officers, in conjunction with the relevant Executive & Officer input were then assigned to complete the Standards, a process which has involved to some extent all staff within the organisation.

The Board agreed to a scrutiny process which has involved each Non Officer Member being given responsibility for 2/3 standards. Any scrutiny comments received from the Non Officer Members have been fed back to the Leads Officers for further action. Final scrutiny, in the form of a workshop, was placed with the Joint Integrated Governance Committee on behalf of the Board, prior to sign off.

The LHB’s Internal Auditors have also been involved in the scrutiny process, working to an All Wales minimum programme of work as agreed with HIW. An Internal Audit review has been undertaken on a sample of Standards in order to ensure that the evidence adequately supports the responses and that the self assessed score is appropriate in consideration of the maturity matrix requirements. The sample included Standards 14, 16, 27 & 28 which underpin this Statement of Internal Control. The Internal Audit review also considered whether the Board was appropriately engaged and the level of scrutiny involved in the process, both of which were deemed to be effective.

In completing the self assessment for 2008/09, progress made against the HCSIP, as reported quarterly to Regional Office, has enabled the LHB to assess itself as either Responding or Developing in those areas previously deemed weak. With reference to the standards integral to the SIC, the position has either been maintained or improved from the previous verified position. Performance against these 4 Standards has been assessed as follows:

14 - Level 4, Practising16 - Level 3, Developing 27 - Level 4, Practising28 - Level 4, Practising

As Accountable Officer, I am reassured by the positive feedback that all the necessary processes, together with the action plans are now in place and provide sufficient evidence that the LHB is doing its reasonable best to manage itself against risks of all kinds, and therefore meets all the requirements of acceptable internal control.

5. Review of effectiveness As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the executive officers within the organisation who have responsibility for the development and maintenance of the internal control framework, and comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee, Integrated Governance & Clinical

governance Committees and a plan to address weaknesses and ensure continuous improvement of the system is in place.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

In order to reflect the joint management structure with Ceredigion LHB, a further review of the committee structure was undertaken during 2008/09, concluding in a Joint Committee Structure with clear Leads & Support assigned to deliver the LHBs objectives. This Board approved revised structure provides the necessary assurances regarding the system of internal control.

The Risk Management Policy & Strategy has also been revised and approved by the Integrated Governance Committee on behalf of Board to accommodate the changes necessitated by the review of Committee Structure and to ensure that it remains appropriate & current. The Risk Working Group during the course of the year has ensured that the Board is kept informed of the risks facing the organisation and the action plans to control such risk. Clinical Governance principles, processes and systems are monitored by the Joint Clinical Governance Committee and encompassed within the Healthcare Standards Improvement Plan. The LHB employs a Clinical Governance Officer whose remit encompasses all clinical risks facing the organization, whilst the Finance Manager is the designated Risk Co-coordinator.

The Audit Committee has played a significant role during the year in ensuring that adequate probity and openness has been the ethos of the LHB in conducting all of its business.

The LHB receives Internal Audit Services via a Service Level Agreement with the Internal Audit Agency managed by Hywel Dda NHS Trust and has been actively involved in the assessment of the Healthcare Standards self assessment submission.

Signed: B.Rees Date: 10th June 2009 Chief Executive (on behalf of the Board)

Report of the Auditor General for Wales to the National Assembly for Wales on the Summary Financial StatementsI have examined the summary financial statements of Pembrokeshire Local Health Board’s statutory financial statements set out on pages 41 to 46.

Respective responsibilities of the Board and auditor The Accounting Officer is responsible for preparing the Annual Report. My responsibility is to report my opinion on the consistency of the summary financial statements with the statutory financial statements. I also read the other information contained in the Annual Report and consider the implications for my report if I become aware of any misstatements or material inconsistencies with the summary financial statements.

Basis of opinion I conducted my work in accordance with Bulletin 1999/6 ‘The auditor’s statement on the summary financial statements’ issued by the Auditing Practices Board for use in the United Kingdom.

Opinion In my opinion the summary financial statements are consistent with the statutory financial statements of Pembrokeshire Local Health Board’s for the year ended 31 March 2009 on which I have issued an unqualified opinion.

Jeremy Colman Auditor General for Wales 15th June 2009

Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ

Remuneration Report Remuneration and Terms of Service Committee In 2008/09 Pembrokeshire LHB operated a joint Remuneration Committee with Ceredigion Local health Board. The members of the LHB’s Remuneration and Terms of Service Committee from Pembrokeshire LHB were as follows:

Mr Chris Martin, Chairman (until 31st July 2008) Mrs Janet Hawes Chairman (from 1st August 2008) Ms Julia Ritchie, Therapies Representative (until 25th Nov 2008) Mr Chris LeBreton, Chairman, Audit Committee/Voluntary Sector Representative Mr David Wildman, Local Authority Representative Mrs Bernardine Rees, Chief Executive, was a member of the Remuneration Committee except for matters relating to her own remuneration and terms and conditions.

Policy for the Remuneration of Senior managers From October 2004, the NHS Agenda for Change process was introduced to achieve consistency in contracts and terms and conditions across NHS Wales. New contracts are currently being drafted. Executive Directors are not part of this process and a review is being undertaken on the possibility of aligning these posts with the Agenda for Change process. Senior managers are currently paid on a local senior management pay scale, any cost of living increases are subject to ratification by the Remuneration Committee as well as any additional remuneration changes. Executive Directors are on standard contracts with pay bandings based on guidance issued by Welsh Assembly Government for the remuneration of LHB Executive Directors. Any uplifts or awards to Executive Directors are also subject to ratification by the Remuneration Committee. Notice periods fluctuate depending on the type of contract from one month to three months. Very senior manager’s have to provide 3 months notice. No termination payments were made during the year 2008/09. As previously reported, pay rises for NHS senior managers in 2008/09 did not exceed 2.75%. In addition, no directors waived their right to remuneration during the year and no directors were paid allowances in lieu of remuneration. No directors received performance related bonuses during the year.

48 49

Service Contracts of Non Executive Directors Non officer members are appointed for a term of between 3 and 5 years, the term is staggered to ensure consistency in LHB Board decision-making. Non officer members are required to sign an accountability agreement, which is the agreed contract between the Board and its members for the purposes of their employment.

2008-09 2007-08

Name and Title

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Executive DirectorsMrs Bernardine Rees - Chief Executive 40-45 0 15 55-60 0 44

Mrs Karen Miles - Director of Finance & Commissioning 35-40 0 0 45-50 0 0

Mrs Jenny Bowen - Nursing Director 0 0 0 10-15 0 0

Mrs Alison Kedward - Nursing Director 0 0 0 20-25 0 0

Mrs Helen Williams - Nursing Director 20-25 0 0 5-10 0 0

Dr June Picton - Medical Director 85-90 0 0 80-85 0 0

Ms Sarah Williams - Director of Community & Primary Care 30-35 0 0 40-45 0 0

Mrs S. Hurds - Director of Corporate Strategy 20-25 0 0 15-20 0 0

Non Officer MembersMr C Martin - Chair (until 31/07/08) 10-15 0 0 25-30 0 0

Mrs J Hawes - Chair (post 31/07/08) 15-20 0 0 0 0 0

Mr I Jones - Dental Member 0-5 0 0 5-10 0 0

Dr S Lewis - GP Member 5-10 0 0 5-10 0 0

Mr E P Parry - Pharmacist Member 5-10 0 0 5-10 0 0

Mrs C L Mason - Carer Member 5-10 0 0 5-10 0 0

Mr C Le Breton - Voluntary Sector Member 5-10 0 0 5-10 0 0

Ms J Ritchie - Therapy Member 5-10 0 0 5-10 0 0

Mr R Baker - Optometrist Member 0-5 0 0 5-10 0 0

Ms M Roach - Lay Member 5-10 0 0 5-10 0 0

Mr P Irvine 5-10 0 0 5-10 0 0

Mrs J Hughes - Nursing Member 5-10 0 0 5-10 0 0

Cllr S James - Pembrokeshire County Council 0 0 0 0 0 0

Cllr D Wildman - Pembrokeshire County Council 0 0 0 0 0 0

Mr J Skone - Pembrokeshire County Council 0 0 0 0 0 0

Mr P Bevan - Pembrokeshire County Council 0 0 0 0 0 0

Ms M Barnaby - Pembrokeshire and Derwen NHS Trust 0 0 0 0 0 0

Mrs C Oakley - Pembrokeshire and Derwen NHS Trust 0 0 0 0 0 0

Mr A Warlow - Pembs Community Health Council 0 0 0 0 0 0

Mr D James - Welsh Ambulance Services NHS Trust 0 0 0 0 0 0

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£000 £000 £000 £000 £000 £000 £000 £00

Bernardine Rees 2.5-5.0 7.5-10.0 40-45 130-135 976 684 192 0

Karen Miles 2.5-5.0 10.0-12.5 20-25 65-70 356 237 79 0

June Picton (15.0)-(12.5) (40.0)-(37.5) 35-40 110-115 763 796 (37) 0

Sarah Williams 2.5-5.0 7.5-10.0 5-10 25-30 194 96 67 0

Sue Hurds (2.5)-0 (2.5)-0 20-25 60-65 394 305 56 0

Helen Williams 7.5-10.0 25.0-27.5 20-25 65-70 343 226 78 0

Pensions Benefits

Salary and Allowances

Signed: B.ReesDate:10th June 2009Chief Executive(on behalf of the Board)

50

pembrokeshire - health in wales · pembrokeshire local health board, unit 4 ... chris le breton ......

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