Velindre NHS Trust Annual Performance Report

2016 - 2017

2015

2015/16

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Contents Page

Performance Report Overview – Chief Executive Statement 3

About Us 6

Vision, Ambitions & Strategic Objectives 6

1. Delivering Against our Duties 7

2. Development Activity 19

3. Trust Organisational Development Strategy 23

4. Performance Summary 25

5. Performance Analysis 41

6. Sustainability Performance 2016-17 56

Appendix 1 – Performance Trend Analysis 2016-17 Summary 66

Appendix 2 – Progress against our Three Year Plan 81

Appendix 3 – Equality Annual Monitoring Report 88

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Performance Report overview

Chief Executive Statement - Mr. Steve Ham Velindre NHS Trust is a unique organisation within NHS Wales, delivering highly specialised services that are broad, complex, focused on excellence and keeping our patients and donors at the heart of everything we do. Underpinning everything about our business is our commitment to Quality, Care and

Excellence, ensuring patients, donors and the hospitals we supply all benefit from the highest

standards of care, innovation and professionalism across the dedicated range of services we

deliver.

Like the rest of NHS Wales, we are facing the combined challenge of rising costs and

increasing demand, while striving to continue improving the quality of care and patient /

donor outcomes. Inevitably, how to maintain these improvements, while continuing to meet

the needs of our population for Cancer, Blood and Transplant Services, is firmly at the

forefront of our thinking and planning for the coming year.

Our commitment, however, is to make sure we maintain our focus on providing an excellent

service and I am confident I speak for the whole Trust when I reassure you that we are up to

the challenge.

2016 - 17 has been a busy, productive and successful year for us and how we move forward

in delivering services into the future is an area we intend to build on during 2017 - 18. It is our

collective ownership of measures that will enable us to show how successful we are in

delivering our services in new and innovative ways, both in the coming year and beyond.

We recognise that the new Well-being of Future Generations (Wales) Act 2015 will have a transformative effect on our organisation. The Act has allowed us to consider the impact of what we do from a new, distinct perspective. Embedding the principles of sustainable development will likely lead us into exciting new areas and innovative, invigorating partnerships. The Act sets an expectation that we will work in different ways. We will embrace the opportunity that the Act provides to seek greater collaboration with other bodies. New strategic and operational relationships will result in the more effective integration of services and, also, to long term improvements to the well-being of the Welsh population. We have included within our three year plan and within this performance report our first well-being statement and set of well-being objectives. We anticipate that our objectives will evolve in future years as our appreciation of the wide reaching effects of the Act develops and as the sustainable development principles at the heart of the legislation are more thoroughly embedded across the organisation.

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This Performance Report and our Annual Quality Statement, provide wide ranging details

about our performance. Some of the highlights this year include:

The introduction of a pan Wales Blood Service. In May 2016, the Welsh Blood Service

took over responsibility for collecting blood donations in North Wales, making it a truly

national service for the whole of Wales for the first time. Coordinating the merger was a

huge challenge, and that the transition was seen through so smoothly and professionally

is testimony to the commitment and hard work of staff on all sides. To find out how our

service will operate as a national service please visit the Welsh Blood Service website via

the following link: https://www.welsh-blood.org.uk/about-us/all-wales-blood-service/

We have developed a Strategic Outline Programme (SOP), which was submitted to Welsh

Government, outlining our ideas on how cancer services in South East Wales could look

in the future. Welsh Government has given approval for us to take this programme

forward, which is excellent news and, to help shape a shared vision on how we should

develop these plans, we are now engaging with a range of stakeholders involved in cancer

services in South East Wales. The Programme Business Case (PBC) is being finalised.

Further information is available from the Velindre Cancer Centre website via the following

link: http://www.velindrecc.wales.nhs.uk/introduction

I am delighted to report that in June 2016, the Trust, in accordance with the set statutory

duty, had its Integrated Medium Term Plan (IMTP) covering the period 2016-17 to 2018-

19 approved by the Welsh Government. Having an approved IMTP in place is a key way of

demonstrating to all of our stakeholders that the organisation possesses the requisite

level of maturity to plan and deliver our services with confidence over a three year

period. The IMTP is refreshed on an annual basis and approved by our Board in March

each Year.

The IMTP for 2017 - 2020 reflects on progress against the key priorities, performance and

ambitions from the year 2016 - 2017, confirming that delivery/progress against objectives

was broadly in accordance with forecasts. This was submitted to Welsh Government in

March 2017. You can find our latest plan using the link below;

Delivering Excellence: our three year Integrated Medium Term Plan (IMTP)

In respect of our financial performance we reported a small surplus position for the year

ended 31st March 2017, as reflected in the Annual Accounts section of the Annual Report.

I am also pleased to report that we had yet another extremely successful year in 2016-

2017 with the Velindre NHS Trust Charity raising circa £2.7 million.

Our focus on excellence has seen us continue to improve the high quality services we provide

to our patients and donors. The details contained in this report show that we are maintaining

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and improving our performance in a range of vital areas however there is more to do and

areas that need further attention.

We will need to challenge ourselves and we intend to be bold. We will continue to develop our

Cancer Services in the context of the Transforming Cancer Services (TCS) programme and the

Blood and Transplantation services building on the establishment of a national service for

Wales. Our plan also highlights the importance we attach to innovation, research and

development. Work in these areas will have a positive effect on the health of the Welsh

population and will continue to raise the profile of both Wales and the Trust.

Our staff, volunteers, fundraisers and partners are firmly committed to delivering our goal of

‘Quality, Care and Excellence’. I am certain that by focusing on providing the best possible

patient and donor care in the most efficient way, we can continue to meet the challenges

ahead in 2017-18.

Signed:

Mr. Steve Ham

Chief Executive

Date: 22.6.2017

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About us

Established in 1994, Velindre NHS Trust (the Trust) provides a range of specialist services

at local, regional and all Wales levels. We provide two core services which includes Velindre

Cancer Centre and The Welsh Blood Service. We also host a number of organisations on behalf

of Welsh Government and NHS Wales.

You can find out more about our Service Divisions and Hosted Organisations in the

Accountability section of the Annual Report document.

Vision, ambitions and strategic objectives

We aim to clearly articulate our organisational vision, ambitions and strategic objectives to

deliver high quality services and care for our patients, donors, staff and stakeholders.

Our vision is that:

‘Velindre NHS Trust will be recognised locally, nationally and

internationally as a renowned organisation of excellence for patient and

donor care, education and research’

We have developed a set of overarching objectives that will enable us to achieve our

vision. These are:

Equitable and timely services;

Providing evidence based care and research which is clinically effective;

Supporting our staff to excel;

Safe and reliable services;

First class patient /donor experience; and

Spending every pound well;

Our vision and our objectives, alongside a range of national and local policies drive our

planning process. Last years’ approved Integrated Medium Term Plan provided a strong

foundation for the development of a clear set of actions for the next three years.

Underpinning our vision and overarching objectives we are in the process of embedding our

four core Organisational Values - BE Accountable, BE Bold, BE Caring and BE Dynamic. We

believe that by adopting these values into the heart of the organisation we will enable a

culture that supports transformational change to achieve world class services for our patients

and donors.

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1. Delivering against our Duties

National policy and drivers

The focus and direction of the Trust’s Integrated Medium Term Plan is determined by a range

of drivers which bring together national policy, Local Health Boards local needs assessment (in

their capacity as commissioners of our services) and the need to comply with statutory

requirements.

There are a number of important national strategies and policies which guide the

development and delivery of the services we provide and these are not all named explicitly

within the plan; we have instead focused on a few fundamental policies and principles in our

Delivering Excellence: our three year Integrated Medium Term Plan (IMTP).

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1.1 Equality, Diversity & Human Rights

This last year has seen recognition of the progress made by the Trust in achieving its Strategic

Equality Objectives. These objectives set out how the Trust will meet its duties under the

Equality Act 2010, building on its commitment to improve the lives of both its staff and

service users and set out actions to promote equality in health services.

Equality Objective/Outcome Action

The Trust has worked in partnership with other Local Health Boards and Third Sector organisations to promotes and provide awareness sessions, information, training and workshops for key awareness events such as Carers Week, Black History Month, Lesbian, Gay, Bisexual, Transgender (LGBT) History Month and Sensory Loss Awareness Month.

Development of short film for International Women’s Day https://youtu.be/qpz1mBWH2_k

Dignity training rolled out to all staff.

Domestic Abuse training and awareness available to all staff.

Velindre Cancer Centre Dignity Group to support dignified care.

Cares information and training provided.

Provide personalised care and treatment for patients.

Provide appropriate support for patients with Dementia and cognitive impairments.

Provide Mental Health First Aid training to key staff.

Development of staff equality training film with Iris in the Community.

Total Recurl was developed and made by Velindre Staff.

Velindre Trust is Stonewall Diversity Champions, raising 32 places

within the workplace index.

People are and

feel respected;

this includes staff,

patients, donors,

carers and family

members.

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We communicate

with people in ways

that meet their

needs (whether this

is via written

communication, face

to face, signage,

Welsh or other

community

languages including

British Sign

Language)

Improve collection of language information and communicate effectively with patients, their carers, donors and families in the language of their choice.

Access Matters group – improve all areas of access and communication at Velindre Cancer Centre including signage.

Development of British Sign Language (BSL) online training for staff.

Development of technology to meet the needs of patients and donors with Sensory Loss – i.e. Patient Buzzer, British Sign Language (BSL) Avatar project.

Development and publishing Welsh Bilingual strategy.

Improve accessibility and information on Trust, divisions and hosted websites.

Development of Velindre Equality Facebook page to share

good news stories and access staff support groups.

Equality Objective/Outcome Action

Action Equality Objective/Outcome

People receive

care and access

services that

meet their

individual needs.

Equality and dignity questions to be included in the monthly patient surveys

Partnership project using English as Second Language (ESOL) classes to provide Cancer and Health information

Transforming Cancer Service Equality Impact Assessment recommendation to engage with community groups in the design and refurbish facilities to explicitly meet the needs of patients, donors and visitors. Focus groups help and equality built into design reference groups

Welsh Blood Service – Use of accessible bleed chairs on sessions

Welsh Blood Service – Review data categories to look at accurate recording of gender to include transgender data.

Review and development of a further six books in the Caring for my family with cancer children’s books. To include more diverse families.

Bilingual, audio and British Sign Language Versions of the books launched.

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As a result of all this work the Trust has been recognised and shortlisted for a number of awards, such as:

Awards

Nursing Times Cancer Nursing.

Patient Experience Network (PEN) National Awards.

Corporate Health Standard Platinum. Shortlisted

Iris in the Community Short Film Awards.

Royal College of Nursing Institute (RCNi) Cancer Nurse Awards (May 2017).

Excellence Wales Awards (May 2017).

We have also taken the opportunity to inlcude our equality annual monitoring report data and

information at Appendix 3 of the Performance Annual Report.

Action

Analysis of staff equality data to assist in identifying actions if pay gap exists or a need for specialist training and positive action programmes.

Ensure all new positions undergo job evaluations.

Workforce and Organisational Development to look at Talent Management and succession planning.

Ensure all staff receive Personal Development Plans in a timely manner.

Support personal and professional development.

Review staff survey responses to measure improvements.

Staff are paid

fairly

Equality Objective/Outcome Action

Equality and dignity questions to be included in the monthly patient surveys.

Partnership project - Cancer Education via English as Second Language (ESOL).

All Wales Blood Service to work with community groups, to improve awareness and increase donations.

Work in partnership with Local Health Boards, Community Health Councils and the third Sector to identify need and patient and donor experiences.

Trust took part in community events such as Health Fairs, Pride and 3rd Sector events.

Transforming Cancer Services stakeholder and engagement event continuing to take place.

Improved

engagement

with public,

patients and

Donors

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1.2 Welsh Language

Supporting people to use their language of choice

We know that communication tailored to an individual’s needs is

an essential part of providing good quality and safe

care. Sometimes we care for patients and donors who speak a

different language, or use sign language. We use the Wales

Interpretations and Translation Service (WITS) to help us.

We have a Welsh Language Scheme to support provision of bilingual services to patients and

donors who wish to communicate in Welsh. During 2016/17 we have continued to promote

Welsh Language across our services. We ran Welsh language ‘Meet and greet’ courses in

partnership with Cardiff University, and some of our staff started a one year Welsh language

course.

We have focussed on the Welsh Language Strategic Framework, ‘More than just words…’ and

the introduction of the new Welsh Language Standards to ensure we can begin to provide an

‘active offer’ service to those who need Welsh language services. We see this as part of our

commitment to continuously strengthen our ability to provide individualised and patient and

donor centred care. We also ran an intense Welsh Language course for over 15 members of

staff to ensure Welsh language services can be increased.

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1.3 The Wellbeing of Future Generations Act - Our approach to the

Well-Being of Future Generations Act & Our Well-Being Statement

In April 2016, the Well-Being of Future Generations (Wales) Act came into effect. We see the

Act as an opportunity to ensure our services are not only fit for the future but that everything

we do is framed (without impacting current services) for the long term, considering

prevention, integration, collaboration and involvement.

Below, we have taken the opportunity to publish the Trust’s well-being objectives. Our

objectives have been developed in accordance with the sustainable development principle

defined in the Act and are intended to demonstrate how we will contribute to the realisation

of the shared well-being goals.

In a time of economic austerity and other constraints, the Act has provided us with an

opportunity to take stock and to consider what we can do to help make Wales a better place

in which to live in the decades to come. We believe that the objectives that we have set will

challenge us, individually and as an organisation, to think differently, to develop novel ways of

working and, simply, to do more.

The Act should promote tangible change in how we, and other public bodies across Wales,

operate. We are a provider of key, specialist health care services. Fulfilling this crucial role has

always been our principle focus, but we already do so much more. As the Chief Medical

Officer (CMO) for Wales has remarked in his annual report for 2015-16, Rebalancing

healthcare, the NHS in Wales has a far broader role than the delivery of healthcare services.

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We recognize that we are a major employer and we care about the well-being of our

colleagues and their families. We care about the communities in which we live and work and

the impact that we have on our environment. The Act and our own objectives give us licence

to challenge the status quo and to challenge ourselves, as never before, to think differently

about what we do and the potential consequences of our activities for future generations.

Our Well-Being objectives

1. Reduce health inequalities, make it easier to access the best possible healthcare when it is needed and

help prevent ill health by collaborating with the people of Wales in novel ways

2. Improve the health and well-being of families across Wales by striving to care for the needs of the whole

person

3. Create new, highly skilled jobs and attract investment by increasing our focus on research,

innovation and new models of delivery

4. Deliver bold solutions to the environmental challenges posed by our activities

5. Bring communities and generations together through involvement in the planning and delivery of

our services

6. Demonstrate respect for the diverse cultural heritage of modern Wales

7. Strengthen the international reputation of the Trust as a centre of excellence for teaching, research and

technical innovation whilst also making a lasting contribution to global well-being

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Health

• Welsh Blood Service Anaemia Management

• Caring for Carers, Patient Knows Best & Every Contact

Counts

Environment

• Obtain Building Research Establishment Environmental Assessment Method (BREEM)

sustainability rating of ‘Outstanding’ for all future

building developments

• Positive impact of better transport planning

Wales and the World

• Collaboration overseas - work in Ghana, Peru, Uganda and

elsewhere

• Palliative care course in collaboration with Cardiff

University

How our objectives were developed

We strive to do more than just treat disease. Our desire to constantly improve the quality of

the care that we provide and to increase the scope of that care is fundamental to what we do.

This concern has also been an important motivating factor in the development of our well-

being objectives. We also wanted to use the process of developing our objectives as an

opportunity to address our wider role in society. We aspire to deliver holistic care to our

patients and donors, but we want to do more to support families and wider communities. This

ambition is in line with the sustainable delivery principle.

We considered that an important step in our development process was to identify the extent

to which the sustainability principle was, in reality, already a key impetus for us, whether or

not we would actually describe such motivating factors in the same terms as the Act now

does. Recognising the extent to which we already work in a sustainable way helped us arrive

at a new appreciation of the potential power of our individual and collective actions if they

could be directed in a clear, concerted manner. The new way of thinking that the Act

promotes will help us channel our efforts to maximum effect, but the realisation that

sustainability is not an alien concept has been and will continue to be useful in communicating

and embedding the new ways of working across the Trust.

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Work which already supports the well-being goals

Our determination to do more to support the health of our patients, our donors, their families

and their communities illustrates the contribution we already make and will continue to make

to the achievement of several of the well-being goals. By treating ill health, we help people to

remain in, and return to, employment. This is fundamental to the well-being of our

population, as illustrated by the Chief Medical Officer’s recent report, and also directly

supports the realisation of a prosperous Wales. Allowing people to continue contributing in a

positive manner to society will support the vision of a Wales of cohesive communities.

Our efforts to support the children of families affected by cancer, provides just one example of

our concern for the long term health and well-being of the people of Wales. The Rebalancing

healthcare report references an extensive evidence base that points to the potential harm

that adverse childhood experiences can cause to both individuals and the wider community in

the long-term. This, in part, motivated colleagues at the Velindre Cancer Centre to produce

the children’s book, Caring for my Family with Cancer. We intend to produce more in this

series, to translate the books into other languages and to release an audio book. We are

confident that the series will prove to be a valuable resource in promoting the well-being of

young people dealing with often traumatic events. This work lends weight to our efforts to

create a healthier Wales, but we hope that it will have longer-term benefits, contributing

towards a resilient Wales and a Wales of cohesive communities.

We are a major employer. The well-being of our staff and their families is important to us. We

want to create more highly skilled jobs across our organisation. Our renewed attention on

research, development and innovation can be a focus for improved collaboration with other

health care providers and educational institutions. We intend to develop a Centre for Learning

on the site of our new cancer centre and we will also host Health Technology Wales. Our

approach should attract investment and serve as a catalyst for job creation which will also help

the effort to create a prosperous Wales. It is our intention that this work will directly benefit

the health of future generations in Wales and beyond. The achievement of our ambition to be

acknowledged internationally as a centre for research excellence will help boost the nation’s

reputation and is absolutely in line with the vision of a globally responsible Wales.

The Welsh Blood Service already has extensive international links and colleagues from

Velindre Cancer Centre have conducted health needs assessment work in Uganda in

collaboration with Public Health Wales. This work has provided valuable learning that, in turn,

has benefited not only the people of Uganda, but our own population and serves to illustrate

the value of cooperation.

We are acutely aware of the positive impact that we can have on our environment. Currently,

we operate an extensive estate and we have ambitious plans to build a new cancer centre.

This is a large scale investment with long term implications for our patients, our staff and the

communities in which we work. We intend to pursue this development in an environmentally

sensitive manner, adhering to the strictest environmental guidelines and employing innovative

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construction techniques. We also want to involve the local community in the development

process.

What next?

Over the course of the next year, we will work to raise awareness of the well-being goals, our

own well-being objectives and to embed the principle of sustainable development. Legislation

is an important lever for effecting change, but making the well-being goals reality will take

more. We will encourage behavioural and cultural change. In everything that we do, in the

case of every relationship, we want to ensure that a sustainable approach is our default

position. We are determined to make sustainability the norm. The Act is ground breaking and

it is helping to create an exciting new public service environment in Wales. As we embark on

our journey, we expect to make false steps, to take wrong turns, but the safeguarding of our

future is just too important an issue for us not to be ambitious in promoting the well-being

agenda.

Our intention is to focus our initial efforts on a set of the goals that relate to areas in which we

can have an immediate impact. The ambitious scope of our objectives and the imperative to

think in a genuinely long-term manner inevitably means that these objectives will evolve over

time. We are determined to develop new partnerships and it is likely that our own perception

of what we can do to improve well-being in Wales will change as a result of these new

relationships.

As an organisation, we continue to actively contribute to the formation of a new national

sustainability network which is developing out of the existing Sustainable Development Co-

ordinators Cymru peer resource for local authorities and national parks. This and other fora

have served as useful spaces in which we have been able to initiate positive conversations on

collaboration and partnership working with other public sector bodies, particularly those from

outside the healthcare ambit.

We have already begun to explore the possibilities for collaboration with other public sector

bodies in Wales. Positive initial discussions have been held with Cwm Taf University Health

Board with a view to cooperating on the development of a health promotion agenda. We have

also opened discussions with Public Health Wales.

In addition to the novel schemes to be delivered in conjunction with other healthcare

organisations which are beginning to take shape, we are excited by the potential that the Act

offers for partnership with bodies operating in other fields. We have had positive

conversations with the Pobl group, a major provider of housing, care and support services

across south Wales, about possible co-operation. We have also begun to take forward work

with the National Museum of Wales. With the Museum, we hope to share learning on

volunteering and to explore possibilities for advancing work in social prescribing.

Our intention is that this activity will have the effect of helping to reduce the dependence of

the population on services provided by NHS Wales by promoting well-being in ways that we

haven’t previously attempted, with partners that we may not have considered working with

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previously. This is in keeping with the Chief Medical Officer’s call for a greater emphasis on

public, community and individual involvement in the maintenance of good health outlined

Rebalancing healthcare. Our ambition has been informed by the Act and we are confident

that our work in these areas will contribute towards the realisation of the well-being goals.

Measuring our progress

We believe that it is important to acknowledge that our objectives represent only a first

attempt to define how we will support efforts made across the public sector to realise the

vision described by the well-being goals. This is a reality about which we want to be totally

transparent.

We recognise that measuring progress against our objectives may present some challenges in

the short term. The work to realise the well-being goals set out in the Act will likely take place

over decades. The impact of some of our sustainable activity, particularly with a longer-term

scope, may be difficult to interpret. We are, however, intent on developing a robust

sustainability component that will integrate meaningfully with our existing performance

management framework. This will help us understand our working environment, the possible

effects of proposed actions and will offer our stakeholders an acceptable level of

transparency.

In measuring progress against our objectives we will, where

appropriate, adopt indicators that we already collect.

Elsewhere, we will consider how best to appraise our

progress and will develop new measures where possible.

Matrices and tools have been developed by organisations

concerned with sustainable development in the UK and

elsewhere which aid reporting on sustainability focused

performance. The adoption of existing tools or the

development of our own are approaches that we intend to

explore, most likely in partnership with other bodies.

In the short term, we intend to identify a number of new projects and areas of work in the

coming year that we will be able to develop as case-studies which can be used to illustrate and

interrogate progress against our well-being objectives.

1.4 Community Health Councils (CHC)

The Trust maintains excellent working relationships with all Community Health Council’s

within South East Wales as demonstrated by examples such as involvement with the

Transforming Cancer Services Programme, complaints resolution etc.

There is Community Health Council (CHC) representation at Trust Board which invites

contribution to service delivery and objectives as discussed at these meetings. The Executive

Team attends Cardiff & Vale CHC meetings on a regular basis.

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The Trust, in particular the Velindre Cancer Centre, is also subject to regular unannounced

visits from the Community Health Councils (CHC’s) as well as planned Hospital Environment

Assessment Team audits. The results of these have, on the whole, been very positive.

1.5 International Health Development

The Trust hosts the South Wales Sierra Leone Cancer Care Group which consists of staff from

oncology, palliative care and paediatric cancer services from across South Wales. Through the

South Wales Sierra Leone Cancer Care Group a partnership between Velindre Cancer Centre

and Connaught Hospital in Freetown, Sierra Leone, was established in 2010. Visits to Sierra

Leone stopped during the Ebola outbreak but restarted early in 2016. Grant funding was

secured to enable five visits for the delivery of training programmes about cancer care, pain

management, ultrasound and chemotherapy. A Burkitts lymphoma treatment pathway has

been developed, the National Cancer Registry at Connaught Hospital in Freetown established,

and members of the Group have worked with the surgical department at Connaught Hospital

to develop a protocol for the management of breast cancer.

We supported the following staff, through ‘Hub Cymru’ grants, to provide training on cancer

care to health workers in Sierra Leone:

8 Consultants

4 Nurses

1 Pharmacist

1 Radiographer

5 visits

1.6 Long Term Expenditure Trends

Long term expenditure trends have been included in the Accountability Report section of the

Annual Report on page 50.

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2.0 Development Activity

2.1 Supporting children and young people

Last year we told you about our award winning children’s book

‘Caring for my family with cancer’. This year we have established

a specialist service aimed at supporting children and young

people when a parent, care giver or family member has cancer.

The Service, established in partnership with One Wales and

Macmillan Cancer Support, focuses on helping parents and care

givers to continue to support and care for their children whilst also coping with the impact of

cancer. We know from research studies that many people with cancer find it very difficult to

talk about their diagnosis and treatment plans. Fear of saying the wrong thing, or fear about

causing upset and distress can make it hard for families to do this.

2.2 Research and Development

The delivery and management of high quality research is a strategic priority within Wales, and

viewed by the Trust as the second priority after clinical care. Research drives changes in

healthcare, enabling us to translate innovation into practice and provides our patients with

the best in care and quality, often allowing access to treatments that would otherwise not be

possible.

As a research active centre, we are key contributors to the local and national cancer

recruitment targets. Velindre Cancer Centre holds a diverse portfolio of research across

various disease sites, a mix of commercial and non-commercial studies. As of December 2015,

there are 102 open studies (approximately 1/3 are commercial) and 387 recruited

participants.

The Research & Development (R&D) team support our Investigators to achieve 100% of the

Welsh Government Key Performance Indicator: provide NHS permission to open to

recruitment within 40 days of submission. Work is ongoing, in collaboration with internal

departments and external stakeholders, to continue to improve process and working practice

to ensure an efficient, effective, high quality service is provided. Examples of continuous

improvement include working collaboratively with R&D offices to set up overarching

agreements that have reduced time to start recruiting, and cross-organisational support for

the handling of tissue samples; both changes reduce timeframes and open up swifter access

for all patients.

2.3 Early Phase Trials

Participation in Early Phase trials provides patients with access to novel treatments, often in

situations where there are no other treatment options. This service is a first for Wales;

previously, Welsh patients have needed to travel to English Cancer Centres to access these

treatments. As of December 16, the early phase team recruited 35 patients into 11 trials, and

are planning further expansion, and collaboration with colleagues at other centres.

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2.4 Radiotherapy

Research within Radiotherapy, and Medical Physics, continues to develop in both the clinical

area and in the technical side. A number of new projects have opened, and are in

development.

Dr Tom Crosby, Consultant Oncologist, was invited to bid for a charitable donation from the

Moondance Foundation, and successfully secured £1.5 million, which was then matched by

the Velindre Charity. The money will be used to support a multi-professional team to

undertake Research & Development, service improvement, and establish new treatments

and therapies. It is anticipated that the funding will innovate radiotherapy treatment.

2.6 Digital Health: Information Management & Technology

(IM&T)

During 2016/2017 the Informatics departments across Velindre NHS Trust have delivered a

number of successes in terms of application enhancements, infrastructure resilience changes,

establishment of core principles and processes for the management of business intelligence,

and the introduction of new skills sets.

Welsh Blood Service Following the successful implementation of the Blood Establishment Computer System (BECS)

in May 2015, the Welsh Blood Service (WBS) became a national service in May 2016. The

transition of services from NHS Blood & Transplant to WBS required a significant IM&T

programme to be delivered utilising various IM&T resources and skill sets in order to deliver:

New BECS functionality for the provision of a stock holding unit in North Wales

Migration of approximately 90,000 donor records from NHSBT systems

Development of an in-house Hospital Web Ordering Solution

Development of an in-house Donor Appointment System

Development of an automated algorithm for donor eligibility

Reconfiguration of a Donor Contact Centre

Transition of the WBS website to a mainstream content management system

Deployment of a new IM&T infrastructure in North Wales, working in collaboration with Betsi Cadwaladr University Health Board (BCUHB)

In addition to this the Welsh Blood Service continued in its provision of ongoing project

management and software development support for the implementation of the all-Wales

Laboratory Information Management System (LIMS) for Blood Transfusion, Histocompatibility

and Immunogenetics and Welsh Bone Marrow Donor Registry modules.

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Velindre Cancer Centre Velindre Cancer Centre has also continued to make good progress against infrastructure and

project plans for the period, which are delivering improvements for staff, patients and the

public who visit the hospital. During 2016/2017 the Cancer Centre has support the upgrade of

core infrastructure for its primary electronic patient management system, Canisc. This is a

substantial programme of work that has spanned two financial years and will be completed in

Quarter 2 of 2017/2018.

Additional successes during 2016/2017 were as follows:

Delivery a new data communication room within the Cancer Centre

Refresh of infrastructure and cabling to its network nodes rooms in the Cancer Centre

Design stage of the Acute Oncology Mobile Application

Meeting the amended Welsh Government targets for timely completion of clinical coding

Completed design, build and initial rollout at VCC of central Managed Print Service, to improve printer standardisation; printer security; rationalisation of devices; reduce toner stocking; toner consumption and the volume of prints that are printed but not collected

Readiness work underway to support the Welsh Imaging Archive System Pilot

Implementation of management processes to support the National Intelligent Integrated Audit Solution (NIIAS)

Change of patient address details proforma implemented to ensure patient demographics held by the organisation remain accurate and kept up to date

Business Intelligence

Business Intelligence has been an ambition for both divisions of the Trust for a number of years. In 2016/2017, the appointment of key individuals into divisional leadership roles has seen significant progress in this area.

The key highlights are:

Completed Procurement and initial build of the Trust Data Warehouse Service to provide a modern information service backbone

Initiated Data Warehouse Service design for delivery of dashboards

Initiated designs and builds of regular Data Extracts from Canisc to Data Warehouse Service in order to maintain accessibility to our legacy data and establish dashboard views of historic data

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Infrastructure enhancements

Supported by a significant capital investment from Welsh Government, the informatics team

have been able to enhance devices across the Trust, improve its IT security provision and

develop enhanced resilience for some of its core services.

The key highlights are:

Agreed national design and procured for Wales Microsoft Office licensing as first steps towards revenue licensing model and cloud services (move away from historically capital funded licenses)

Procured Web Content Filtering service to refresh and extend existing service functionality

Continued IMT infrastructure replacement programme to improve network resilience and wireless access as support for handheld computing/mobile design and mobile telephony;

Continued Trust IMT Equipment Replacement - Procurement of PCs, laptops

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3. Trust Organisational Development Strategy

3.1 Workforce Planning

Our Organisational Development (OD) Strategy, Building Excellence, outlines how over the

next 3-5 years the Trust will develop a culture that enables each of us to be great and achieve

the delivery of ambitious and exciting service change plans. Through conversations with staff

we know we need a values driven culture where world class services are delivered by a

workforce that understands the difference it makes to the donor and patient experience. The

Trust will deliver this through its resilience and flexibility, and a culture that encourages

ambition and improvement and is agile and responsive to change.

With patient/donor care central to everything we do, we have articulated through our

Integrated Medium Term Plan (IMTP) a future that involves significant change to the scope

and expectations of service delivery. With change comes the opportunity to modernise and

redesign services and the workforce, and further strengthen collaborative relationships with

patients and stakeholder organisations. Through the application of the prudent healthcare

principles across the Trust, moving forward we will continue to excel in the delivery of care

and clinical services that are uniquely ours, while understanding how to use the skills of our

staff and available resources most effectively to continue to improve.

During 2016, the Trust has established ‘Think Tanks’ or ‘cross functional working groups’ to

form the backbone to the implementation of the ‘Building Excellence Strategy’. They are a

chance for every member of staff to get their ‘thinking cap on’ and directly help to influence

the transformational agenda required across the Trust over the next 3-5 years. One of the

seven think tanks is Workforce Planning, this group will be tasked with identifying what

‘excellence’ looks like in this area by researching evidence based best practice both within the

NHS as well as exploring what other high performing public and private sector organisations

do.

3.2 The story behind our values

Between April and July 2015, the Trust met with 145 staff

in team meetings, received 164 online Building

Excellence questionnaire submissions, 250 online Staff

Pulse Survey submissions, and carried out interviews

with 96 staff as part of our Investors in People

reaccreditation process.

Everything that staff have told us has been distilled into

four organisational values, these values are for all staff,

whether staff are working at the Welsh Blood Service,

Velindre Trust HQ or Velindre Cancer Centre.

We are working to explore new ways of working and making the best use of people and

advanced roles to provide better services.

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3.3 Healthy Working Wales Corporate Health Standards

We achieved Gold in the Healthy Working Wales Corporate Health

Standards for many years, and this year we were very pleased to be

awarded a Platinum award. The Corporate Health Standard supports the

development of policies that promote good practice to assist businesses

and organisations to take active steps to promote the health and well-

being of staff. The Standard is awarded at different levels: Bronze, Silver,

Gold and Platinum. It begins at bronze level recognising where activities

and policies that comply with legislation and address key workplace risks

to employee health are in place. Platinum is reserved for exemplar

employers who demonstrate business excellence and take full account of

their corporate social responsibility.

2016 NHS Wales Staff Survey: Staff answered more positively than in the last survey in 2013 on 90% of questions asked, and 78% of our scores exceeded the overall NHS Wales score. Key survey themes for the Trust include:

We are particularly proud that 75% of staff would recommend the Trust as a place to work, 93% say that if a friend or relative needed treatment, they would be happy with the standard of care provided by the organisation, and 87% of colleagues say that they are proud to tell people they work for The Trust.

The majority of scores relating to line and senior managers have improved since 2013 e.g. 82% of staff say that their line manager treats them with respect (up from 76% in 2013); and 76% of staff say that senior managers are committed to patient care (up from 66% in 2013).

84% of staff say that they know who senior managers are in the Trust, but only 32% say that communication between senior managers and staff is effective and we need to address this.

Many scores on health, well-being and safety at work have improved since 2013, but there are still areas for us to review e.g. 13% of staff say that they have experienced harassment, bullying or abuse at work from their manager/team leader or other colleagues.

Levels of work-related stress have improved slightly since 2013, so this is an area that we will maintain focus on in the coming year.

60% reported that they are able to make improvements happen in their area of work.

We are proud of our positive results, but remain committed to focussing on areas that staff have said could, and should, be improved.

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4. Performance Summary

4.1 Velindre Cancer Centre

4.1.1 Core activity during 2016 – 2017

The following info graphics provide a snapshot of the core activity of Velindre Cancer Centre

for the period 2016 - 2017.

The Velindre Cancer Centre provides

specialist non-surgical oncology services to

patients from South East Wales, including

chemotherapy, radiotherapy and specialist

palliative care.

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4.1.2 Velindre Cancer Centre - Assessment of 2016/2017

Successes, key issues and risks

2016/2017 has been an extremely busy and successful year for the cancer centre; we have

continued to deliver excellent care and support to our patients, their carers and their families

despite increasing demand and pressure upon key services. This is a testament to our

hardworking, caring and dedicated staff who continue to go the extra mile to ensure high

quality care; we are extremely proud to look back over the year and see all of our

achievements in improved patient care and treatment techniques.

Velindre Cancer Centre: Summary of key achievements in 2016/17

Implementation of new radiotherapy techniques

Improving patient accommodation and services

Implementation of a second Stereotactic Body Radiation Therapy (SBRT) capable

Linear accelerator

Introduction of the STAMPEDE trial

The PR07 trial

Early phase trials

CHHiP

Development of key strategies

Improved horizon scanning and commissioning of new drugs

Implementation of new radiotherapy techniques: we have continued to treat patients

that would have previously travelled to England for Stereotactic Body Radiotherapy

(SBRT) and Stereotactic Radiosurgery (SRS), we have achieved our target of treating

35% radical patients with Intensity Modulated Radiotherapy (IMRT) and have increased

the use of Image Guided Radiotherapy (IGRT) through clinical trials and local initiatives.

Improving patient accommodation and services: we have completed the

refurbishment of First Floor inpatient ward and have provided free Wi-Fi for all people

within the Velindre Cancer Centre.

Implementation of a second SBRT capable Linear accelerator:

In October 2016 we successfully implemented a new linac

with SBRT functionally. We are one of only a small number of

cancer centres in Europe with this functionality.

Introduction of the STAMPEDE trial: the outcomes of this trial identified a change in

drug treatment (Docetaxel) that will improve outcomes with a recommendation to

change standard of care.

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The PR07 trial: the results of this trial reported benefit in survival and firmly

establishes the role of radiotherapy in the treatment of men with locally advanced

prostate cancer.

Early phase trials: participation in Early Phase trials provides patients with access to

novel treatments, often in situations where there are no other treatment options. This

service is a first for Wales; previously, Welsh patients have needed to travel to English

cancer centres to access these treatments.

CHHiP: we have been involved in the largest ever study of prostate radiotherapy.

Results have shown a significant improvement in outcomes through the halving of

toxicity and relapse rates, which have a significant impact upon patient outcomes and

well-being.

Development of key strategies: we have developed and published two key strategies

which will help drive the service forward.

‘Shaping the Future Together 2016 – 2026’ sets out five strategic aims and how they will be

delivered:

1. Equitable and consistent care, no matter where. 2. Access to state-of-the-art, world-class, evidence-based treatments. 3. Improving care and support for patients to live well with cancer. 4. To be an international leader in research, development, innovation and

education. 5. To work in partnership with stakeholders to improve prevention and earlier

detection of cancer.

‘Shaping the Future of Radiotherapy 2016 – 2026’ sets out the Cancer Centre’s ambition to

become an internationally recognised Centre of Excellence for Radiotherapy. The Strategy is

underpinned by seven aims and sets out how they will be achieved:

1. Every patient has access to the best treatment appropriate for them, which is

timely and delivered in the most efficient and effective way possible.

2. The radiotherapy service will be at the forefront of technological advances

through its continual assessment and adoption, for the benefit of all patients.

3. An integrated and empowered workforce that is motivated, values driven and

innovative.

4. A service that is maintained and future proofed with effective and appropriate

funding to enable clinical, technological and research developments.

5. To expand radiotherapy research through effective leadership, resources and

investment.

6. A high quality service which utilises comprehensive data, evidence based practice

and research to drive forward innovations.

7. Establish a culture of collaborative working and partnership that reflects and

prioritises the values of the organisation.

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Improved horizon scanning and commissioning of new drugs: the unprecedented

number of new additional drugs becoming available to NHS Wales during 2016/2017

identified the need for improved horizon scanning and planning for the introduction of

drugs, given their capacity implications.

Ongoing challenges

There are a number of challenges we face as an organisation, how we are addressing these

can be found in our three year plan but they have an impact on how our services deliver and

perform.

There are a number areas that have not progressed as we had planned during 2016/2017 for

various reasons. These include:

Delivering chemotherapy at home and in the community - Whilst this piece of work

was delayed at the start of the year, we are currently exploring the possibility of

progressing procurement as a standalone organisation.

Radiotherapy capacity: The most significant risk in the immediate to medium term is

the ability to deliver the required levels of service for patients requiring

Cancer incidence is increasing

There is variation in cancer related outcomes throughout Wales and we need to help close the gap

There is growing demand for services and we must ensure that we have the ability to treat and care for patients

Treatments are becoming more complex and new advances are always emerging

More people are living with and beyond cancer and need to achieve best possible quaility of life and experience

Resources are scarce and we must make the best of our resources

We are working within a wider policy context and must ensure we are aligned

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radiotherapy. The increasing demands on the radiotherapy service, both in terms

of patient numbers and complexity/time, cannot be met consistently within existing

resources and through existing service models.

The immediate risk is that with current radiotherapy resources we will be unable to

continue to absorb the circa 4% annual increasing demand for radiotherapy in Wales

and also the historical peaks in demand during September/October and

January/March. The impact of this will mean that we will be unable to provide

Radiotherapy treatment to patients within the waiting time targets. Inability to

achieve these waiting times may compromise clinical quality, patient outcomes

and patient experience as patients may be required to wait longer for their

treatment. Trust officers are currently pursuing a range of actions to mitigate this

risk and explore new and more efficient ways of working. The Trust developed a

Business Case during 2016/17, in collaboration with Local Health Boards, for

approximately £1 million per annum in revenue funding to staff an additional Linear

Accelerator (LINAC). This is still under discussion with commissioners.

Increase radiotherapy access to the appropriate rate for patients with cancer within

our resident population - This work slowed down at the beginning of the year due to

competing priorities and limited capacity and resource to take forward the work,

however, a bid was submitted to the Cancer Pathway Innovation Fund to provide

project support which was successful.

Chemotherapy capacity: For several years demand for Systemic Anti-Cancer Treatment

(SACT) has been growing, requiring increasing levels of capacity and resources to

deliver the service. This has proved challenging, but manageable within Velindre

Cancer Centre (VCC) ways of working, including delivery of services within outreach

settings. We believe that 2017/2018 will be the year in which a ‘step-change’ will

occur, and that actual demand will outstrip the projected 5% per annum demand

increase due to the increasing number of approvals for new drugs/indications and the

significant service implications associated with delivering these particular drugs. Until

late summer of 2015, there was sufficient capacity in the service for VCC to absorb the

incremental increases in workload that were felt from the introduction of new drugs to

NHS Wales. However, as the SACT service is currently working to capacity, absorbing

increased demand without additional funding will not be possible without

compromising patient safety, staff morale and service performance.

There is therefore risk that Velindre Cancer Centre will be unable to deliver new

indications within the guideline period following publication given the lead in time to

secure funding and recruit staff.

We are working with our partners in the challenging task of improving joint horizon

scanning of new drug approvals, identifying opportunities to deliver care closer to

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home or at home where appropriate and to further develop processes for

modelling the implications of new drug approvals across patient pathways.

An example of this is the planned introduction of docetaxel chemotherapy for patients

with prostate cancer which has required the Velindre Cancer Centre to write a

business case to seek funding from the local health boards.

Junior Medical Staffing. The current levels of medical staffing are not considered

optimal in relation to the provision of training for all junior doctors, including new

entrant levels (Senior House Officer (SHO). Work has commenced to identify

optimum staffing levels and operational day to day activities that will assist in

achieving the highest level of training and work experience for all staff. The situation

is being monitored monthly and plans are being developed to fill the current gaps in

the rota. However, despite a number of pressures on the service, the Cancer Centre

has continued to meet many of its performance ambitions for the year.

Pressure ulcers: although low in number we have experienced an increase in

pressure ulcers. We continue to undertake a root cause analysis for each incident

and monitor themes that emerge.

Hand hygiene: we will continue to seek to improve hand hygiene standards through

close monitoring and targeted action plans.

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4.2 Welsh Blood Service

4.2.1 Core activity during 2016-2017

The following info graphics provide a snap shot of the core activity of the Welsh Blood Service

for the period 2016-2017.

The Welsh Blood Service collects voluntary donations from the general public across Wales

which are processed, tested and distributed to customer hospitals. The Welsh

Transplantation & Immunogenetics Laboratory, within the WBS, operates the Welsh Bone

Marrow Donor Registry and provides direct support to providers of Renal and Stem cell

transplantation.

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4.2.2 Welsh Blood Service Assessment of 2016-2017 Successes, key issues and risks 2016/17 has been an extremely busy and successful year. We have continued to deliver excellent

care and support to our donors. Some of our achievements are noted below.

Welsh Blood Service: Summary of Key Achievements in 2016/17

Implementation of a pan Wales Blood Service

Delivered a safe and effective supply to hospitals in Wales

Delivered a Modern Donor Contact Centre

Significantly increased Blood Stem Cell Donations

Maintained Quality and Safety

Listened from Donor Feedback

The implementation of a pan Wales Blood Service: successfully achieved in May 2016. This

represents a major programme that has seen the Welsh Blood Service expand to cover the

whole of Wales with an increase in its geographic coverage by over 33%; increased the

provision of our services to an additional 676,000 people; serve the largest university health

board in Wales; and sees us process approximately 25% additional units of blood at our Talbot

Green headquarters. The benefits of this change are now coming to fruition which include an

annual saving of £500,000 for the NHS in Wales, has created 16 jobs and more effective

national planning across NHS organisations.

Delivered a safe and effective supply to hospitals in Wales: we have safely delivered the

required amount of red blood cells, platelets and commercial products worth over £8m via a

Good Manufacturing Practice (GMP) compliant cold chain to hospitals.

Delivered a Modern Donor Contact Centre: a project to improve telephony and donor contact

services to support the recruitment and retention of donors throughout Wales has delivered a

redesigned staffing model which provides multi-functional roles.

This is improving the efficiency and effectiveness of the Welsh Blood Service (WBS) donor

contact services and increasing the capacity for Welsh Language services. We also introduced

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significant technological advancements to support this service change which included

improved contact management systems, enhancements to the website, and improvements to

our Information Technology (IT) infrastructure and the introduction of an electronic in house

appointment system as the initial stages of a programme of ongoing digital development.

Online Appointment Booking Service: in January 2017 the Welsh Blood Service launched an

Online Appointment Booking Service for blood donors. The new service has been well received

by donors, and 2518 appointments were made using the system in its first full month of

operation. It is hoped that the online appointment booking service will help bolster the

number of new and returning blood donors, new platelet donors, and people willing to sign up

to the bone marrow register.

Significantly Increased Blood Stem Cell Donations: During the year we marked the 1000th

bone marrow donation collected in Wales since 1989. The achievement was celebrated at the

‘Wales in the World’ event held at the Senedd. The Welsh Bone Marrow Donor Registry

(WBMDR) supports patients world-wide. Currently, the WBMDR has over 64,500 potential

donor volunteers on the register and receives around 24,000 search requests each year. Stem

cells and bone marrow is exported to over 30 countries across the globe. WBS Director Cath

O’Brien said: “We are truly inspired and proud of our 1000 donors whose generous donations

have helped so many patients in Wales and all over the world. This special event celebrated

what is an amazing achievement by everyone involved with the Welsh Registry.”

Maintained Quality and Safety: we successfully retained all operating licenses and made good

progress to further extend our external accreditation. This is testament to the dedication and

commitment of our staff to continually raise standards for quality improvement year on year.

In addition, we have continued to provide specialist advice and support to a number of other

NHS Wales organisations.

Delivered Additional Testing: following new advice from the Advisory Committee on the

Safety of Blood Tissues and Organs we introduced testing for Hepatitis E on a selection of our

products, delivering an additional 11,000 tests.

Listened and Learned from Donor Feedback: our donor feedback has been instrumental in

changes we have made to clinic opening times and has been used to support the introduction

of appointment systems at an additional number of our clinics. Donor feedback has also been

factored into further improvements to our new blood establishment computer system.

Work is also continuing to support embedding donor feedback in wider service improvements.

For example, at Port Talbot we have extended our opening hours to make it easier to donate in

the early evening. Being able to make an appointment suits an increasing number of our

donors and as a result we have introduced appointments for the first time at several venues

such as Brecon and Carmarthen as well as launching a live on-line booking system. This system

enables bookings to be made 24/7 for all sessions with appointments and donors are able to

search venues by date and distance to provide them the widest choice.

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The Welsh Blood Service R&D Strategy was approved by the Trust Board on 24th November 2016. The strategy seeks to advance donor care and transfusion and transplantation medicine through inception and participation in high quality health services research. The strategy has four themes:

Donor Care and Public Health

Transplantation

Products

Therapies. The WBS wants to be an organisation where high quality research and development is performed as part of normal day-to-day activity and a

programme of research and development. By the end of 2017 we aim to build Research & Development capability and capacity across the WBS, and set out a programme of collaborative projects in each of the above themes. A new Blood Health Plan has been developed to provide renewed focus to activity to maximise

the appropriate use of blood components and products. There are three core aims which lie at the

heart of this plan. They draw on the principles of prudent healthcare and the unique

characteristics of NHS Wales, a planned system with quality at its core:

1. Supporting individuals to manage their health and wellbeing, avoiding unnecessary

intervention.

2. Using evidence and transparent data to drive service planning and improvement to reduce

inappropriate variation.

3. Avoid harm, placing safety and quality at the core of care.

Ongoing challenges

The Donor Panel is shrinking

We must meet demand for blood and blood products

We must meet stringent blood selection guidelines and regulatory

requirements

Science and the scientific workforce is changing

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We recognise that there are still considerable challenges to meet in ensuring the service remains

fit for purpose now and for the future. Work needs to be taken forward in a number of areas:

Alignment of blood collection models: we will continue to work to fully align the service

models for blood collection in north and south Wales to embed a truly national service.

Blood Establishment Computer System (BECS): further development is required to streamline

the system’s current functionality and meet the ever increasing regulatory burden.

Declining Blood Donation Rates: we need to address the decline in rates of blood donation

that is being observed by the WBS, a phenomenon that blood services around the globe are

currently experiencing. Key to this is the need to review the donor experience and to update

the technology we use to engage with donors.

4.2.3 Mitigating and managing risk

Where appropriate key risks are escalated to the Trust Risk Register. Further information on the

risk management strategy and key risks on the risk register as at the 31st March 2017 are

contained within the Governance Statement section of the Accountability Report, see page 25

onwards.

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4.3 Listening and learning from patient / Donor feedback

Velindre Cancer Centre

We believe that patient experience is not just about a survey or a buzzword.

This is about a shared commitment to listening & learning across the whole organisation. It is

fundamental that everyone understands and values the importance of delivering an excellent

patient experience which is embedded within our culture.

Real Time

All-Wales Patient Experience Survey

(face to face interviews)

I want great care

Fundamentals of Care

Observations of Care for Protected Mealtimes

Evaluations & Taste Testing for Oral Nutrition

Supplements

CHC and patient attendance at Trust Board

Meetings

Retrospective

All Wales Radiology Patient Satisfaction Survey

All Wales Patient Menu Survey

Velindre Improvement Process

Departmental Surveys

Treatment Outcomes are measured by individual

professionals and across Site Specialist Teams

Proactive / Reactive

All Wales Patient Survey (online and hard copies to

be made available)

Patient Experience website page to be refreshed

Patient Concerns

Comment Cards

Visitors comment books

VCC Facebook page

VCC Twitter Channel

Balancing

Patient Stories

Patient Liaison Group

3rd party surveys (e.g. Community Health Council,

MacMillan)

Walkrounds (e.g. Older Persons Commissioner,

Community Health Council, Executive Walkarounds)

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Someone Else’s Shoes: The Velindre Cancer Centre launched a new audio podcast called Someone

Else’s Shoes. The podcast aims to increase understanding and enable learning and opportunities

for improvement through sharing patient, care and staff stories. In the first podcast David talked

about his diagnosis and the importance of his faith. In the second, Linda shared her experience of

A&E, radiotherapy at Velindre Cancer Centre, and the Macmillan Activity Programme. You can

listen and subscribe here. You can view Welsh Blood Service patient and donor stories here.

I have been attending Velindre since September ‘16, first for chemotherapy and now for

radiotherapy. The care and kindness are second to none, they really sum up the phrase Tender

Loving Care.

I’ve just finished 20 sessions of radiotherapy. I was in LA5 and the team were amazing! They

made me feel so relaxed and unafraid of the whole process. I really enjoyed seeing them every

day. I will miss them dearly.

Creating a good Patient Experience …..

1. Every role matters

2. Every interaction matters

3. Every perception matters

4. You matter

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Patients' Overall Experience

Rated 9 or above % Target

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Welsh Blood Service

Our volunteer donors are the heart of the Welsh Blood Service - we could not provide our

lifesaving blood donation programme without them. We know that to secure their ongoing

support we need to ensure that each donor has a positive experience of our blood collection

service each time they donate.

How are we listening?

At clinics - either face to face with our staff or via

compliment and concern cards.

Social Media - Our Twitter and Facebook feeds have

donors regularly interacting with the service.

Website - Our website offers both a donor enquiry form

and direct email access to the Welsh Blood Service.

Donor Survey - A proactive donor satisfaction

questionnaire sent to donors via email,

5 days after their attendance at a clinic.

We asked:

Was there anything that we could

change to improve your

experience?

Patients said:

‘Better TVs’

‘A map to find my way around’

‘Display waiting times

We did:

Purchased TVs for the day unit;

Introduced clear signage and maps

Fitted display screens in the

reception areas of the outpatient and

radiotherapy departments that will

be used to show waiting times.

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‘@givebloodwales 53rd donation today in Rhiwbina. Good service and great Staff!

Thank you #feelgoodfriday’

‘The lady who was training to put needles in on the 16th in Port Talbot did a cracking job, no bruise. Well Done.’

We asked:

Was there anything that we could change to improve your experience?

We used donor feedback to:

Make changes to clinic opening times

Introduce an appointment system in some clinics

Inform some improvements to our new blood establishment computer system

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4.4 Learning from concerns

During 2016/17 we investigated all complaints and concerns in accordance with the NHS

Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011, and shared our

findings openly and honestly with patients, their families, donors and staff. As in previous years

we noted that complaints about the Cancer Centre were often complex and related to more than

one issue. Many of the concerns about the Welsh Blood Service were about clinic opening and

waiting times.

We view each complaint as an opportunity to learn and improve our services. Examples of changes

we have made following a complaint include:

Increasing the availability of the chemotherapy pager service to provide 24 hour access for

patients with treatment related symptoms or concerns

Introduced a standard for blood glucose monitoring in pancreatic cancer patients to enable

prompt detection and treatment of diabetes

Enabled donor feedback and concerns to be considered as part of an ongoing review of

clinic efficiencies and accessibility.

All lessons learned from concerns are reviewed by our Organisational Learning Committee. Within

the Welsh Blood Service we have developed a donor compliments and concerns dashboard to

improve shared learning across all of our blood collection teams.

0

5

10

15

20

25

Trust Concerns Received During 2016-2017

VCC WBS Corporate

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5. Performance Analysis

We have developed a wide range of measures which are routinely used to monitor the quality and

performance of our core services.

The core measures for Velindre Cancer Centre and the Welsh Blood Service are included in the

tables below.

Performance trends in respect of these targets are included in Appendix 1. The performance

summaries are explored further with supporting narrative in the Trusts performance reports

received by the Trust Board. These papers are available on the Trusts internet site via the

following link: http://www.velindre-tr.wales.nhs.uk/current-trust-board-2016-meetings-1.

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5.1 Velindre Cancer Centre (VCC)

Performance metric Target 14/15 15/16 16/17

Radiotherapy % of patients commencing radical Radiotherapy within 28 days

98% 95% 98.5% 98%

% of patient commencing palliative Radiotherapy within 14 days

98% 95% 98.5% 99%

% of patient commencing emergency Radiotherapy within 2 days

100% 99% 100% 100%

Linac Up-time 95% 96% 95% 98%

SACT % of patients commencing non-emergency chemotherapy within 21 days

98% 98% 99% 99%

% of patients commencing emergency chemotherapy within 5 days

100% 95% 100% 100%

Death within 30 days of Chemotherapy rates

<2% N/A 1.5% 1.6%

Outpatient % of Outpatients seen within 20 mins n/a 43.5% 49% 50.2%

% of Outpatients seen within 60 mins n/a 79% 88% 87.2%

% of Outpatients seen within 90 mins n/a 87% 96% 96%

Workforce Velindre Cancer Centre Sickness absence rate

3.54% 3.61% 4.1% 3.7%

Infection, Prevention &

Control

No. of Velindre acquired infections – MRSA

0 0 0 0

No. of Velindre acquired infections – MSSA

0 2 5 2

No. of Velindre acquired infections – C.Difficile

0 8 3 1

No. of Velindre acquired Pressure Ulcers 0 12 19 30

Hand hygiene compliance – Inpatient areas

95% 93% 81% 82%

Hand hygiene compliance – Non-inpatient areas

95% 77% 88% 85%

Patient Experience

% of patients overall experience rated 9 or above

>80% N/A 85% 85%

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5.2 Welsh Blood Service (WBS)

Performance metric 2014/15 2015/16 2016/17

Target Actual Target Actual Target Actual

7,300 new Bone Marrow Volunteer

(BMV) registrations

3,000 6,090 3,000 2,359 3,294 3,313

100% of new Bone Marrow

Volunteers (BMV) samples aged

18-30 *

30% 56% 100% 100% 100% 100%

≥98% of commercial product

requests met

≥98% 99% ≥98% 98% ≥98% 196%

≥90% deceased donor typing / cross

matching reported within 6 hours

≥90% 100% ≥90% 100% ≥90% 100%

≥90% Anti-D & -c Quantitation

results provided to customer

hospitals within 5 working days

≥90% 97% ≥90% 98% ≥90% 97%

≥90% routine antenatal patient

results provided to customer

hospitals within 3 working days

≥90% 97% ≥90% 96% ≥90% 99%

≥80% samples referred for red cell

reference serology work up provided

to customer hospitals within 2

working days

≥80% 86% ≥80% 88% ≥80% 82%

Reduce number of reportable SABRE

events from (8) to (5)

6 3 5 4 5 3

Maintain 100% to close SABRE

reports to MHRA within 30 days

100% 100% 100% 100% 100% 100%

≥71% of blood donors scoring 5 or 6

out of 6 for satisfaction with overall

service

69% 74% 70% 75% 71% 89%

≥100 % of concerns answered within

30 days

100% 97% 100% 100% 100% 100%

<7% time expired platelets <7% 4.6% <7% 4.3% <7% 11.29%

<0.5% volume of waste (red cells) <0.5% 0% <0.5% 0.1% <0.5% 0.5%

<6% total losses prior to issue

previously 5

<9% 8% <6% 5.2% <6% 4.4%

1 This was due to a national shortage of a specific wholesale product

44 | P a g e

5.3 Progress against our three year plan

The Trust has made considerable progress and achievement with the objectives and priorities it

set out to deliver during 2016/17. Some areas such as Information Technology systems have

progressed slower than we expected with some issues outside the Trust’s direct control. These

objectives have been strengthened and refined for the 2017 - 2020 plan.

Further detail is available in “Our Three Year Plan - 2017 - 2020” which is available on the Trust

Internet Site via the following link: http://www.velindre-tr.wales.nhs.uk/key-publications

Progress against our three year plan objectives are reported to the Planning & Performance

Committee and Trust Board in our “Delivering Excellence Performance Report”. These reports

for are available on the internet site via the following link http://www.velindre-

tr.wales.nhs.uk/current-trust-board-2016-meetings-1.

5.4 Progress against Performance

Progress against: Equitable and timely access targets

Performance during 2016/17 has been of a high standard and is in line with our continued

intention to deliver the best possible services. Areas not meeting set levels have been and are

subject to continued scrutiny and actions are being taken forward to improve. Appendix 1 sets out

the key measures and performance trend over 2016/17.

Progress against: Waiting times and access to services

During the year we saw increased demand for radiotherapy and chemotherapy services

provided in the Velindre Cancer Centre. Our staff worked hard to meet the increase in demand

and we are exploring new ways of working to reduce waiting times and improve access to our

services.

Progress against: Radiotherapy

We achieved our target of seeing 100% of people referred for emergency radiotherapy within 2

days every month but we know that we didn’t always see people referred for radical and

palliative radiotherapy as speedily as we would have liked to. We have been trying out different

staffing models and extended opening hours to test if they make a difference to waiting times

and will continue to explore new ways of working in addition to a business case for an additional

Linear Accelerator (LINAC) to increase our capacity. We are still having discussions with our

commissioners to increase capacity.

45 | P a g e

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Radical Radiotherapy

% within 28 days % Target

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Palliative Radiotherapy

% within 14 days % Target

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Emergency Radiotherapy

% within 2 days % Target

46 | P a g e

Utilisation of Linear Accelarator (LINAC) time was good during 2016/17 and this ensured waiting

times for patients were maintained whilst minimising disruption for patients where-ever possible.

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Linear Accelerator Availability - PD Uptime

PD Uptime % Target

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Linear Accelerator Availability - Linac Uptime

Linac Uptime % Target

47 | P a g e

Progress against: Chemotherapy

The charts below show we have mostly been able to start chemotherapy within the target time that

we set for ourselves. We are always striving to continuously improve our services. For example we

are currently reviewing our pharmacy services to see if a different way of working will help with

the chemotherapy waiting times. The increase in approval of new drug and treatment regimens

has increased pressure on the service but we have continued to explore how we can deliver these

services to patients.

Progress against: Access to therapy services

During 2016/17 we have undertaken a review into therapy waiting times and are in the process

of introducing a revised collection process focussing on patient outcome in addition to access to

services.

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Emergency Chemotherapy

% within 5 days % Target

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Non-Emergency Chemotherapy

% within 21 days % Target

48 | P a g e

Progress against Safe and reliable services target

Hospital Acquired Infections: We have continued to maintain our low rates of hospital acquired

infections.

C.Difficile:

Methicillin-Resistant Staphylococcus Aureus (MRSA): Methicillin-Sensitive Staphylococcus Aureus (MSSA): Compliance with our Skin Care bundle has been varied during 2016 - 17 however this is an area

where we have been undertaking action and will continue to work on.

There are measures at Velindre Cancer Centre where further work is ongoing to improve what we

do but the overall services provided by the Velindre Cancer Centre and Welsh Blood Service

continue to be of a high quality, focusing on excellent patient and donor care.

49 | P a g e

Progress against: Collecting enough blood

Thanks to the amazing support from our loyal and dedicated donors throughout the year we

always collected enough blood and platelets to meet the demand from hospitals in Wales.

Progress against: Bone Marrow Donations

In last year’s Annual Quality Statement we told you how pleased we were with the increasing

number of people volunteering on the Bone Morrow register. The number of donations fell

during 2015/16 but we are pleased to say that towards the end of 2016/17 we increased the

number of people we recruited above our anticipated level.

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Hand Hygiene Compliance - In-Patient Areas

First Floor ASU CIU % Target

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Hand Hygiene Compliance - Non In-Patient Areas

CDU RDU CTU Outpatients Radiology Radiotherapy % Target

0

200

400

600

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Number of New Bone Marrow Volunteer Registrations - South Wales

New Bone Marrow Volunteers (BMV) registrations per month in South Wales

Target (292 per month as of September '16)

50 | P a g e

Progress against: Welsh Blood Service meeting demand

During 2016/17 demand for whole blood and platelets has been met.

Progress against: Meeting Transplant services requests

Performance was met for this measure during 2016/17.

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

% Red Cell Supply Meeting Demand

Collections Stock Importation from NHSBT % Target

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

% Platelets Supply Meeting Demand

% Platelets Supply Meeting Demand % Target

0%

50%

100%

2016-17 Q1 2016-17 Q2 2016-17 Q3 2016-17 Q4

Turnaround Times (Deceased Donor Typing/Crossmatching Reported within 6 Hours)

% Deceased Donor Typing/Crossmatching Reported within 6 hours % Target

51 | P a g e

Co-ordination and importation of national and international haematopoietic stem cell donations

for patients transplanted in Wales performance continues to exceed the target with all reports

issued within the timeframe for this critical service which is delivered 24/7. 2016/17 saw a record

number (38) of allogeneic transplants supported by the Histocompatability & Immunogenetics

(H&I) lab and Welsh Bone Marrow Donor Registry (WBMDR).

Turnaround times remain on track and above targeted performance levels.

Progress against: Red cells issued

WBS has set itself a target of 60% of all red cells issued to be less than 14 days old to allow

sufficient storage time for our customer hospitals to manage appropriate stock levels.

Performance lower than 60% is due to higher collections and the transitional support being

supplied by NHS Blood and Transplant leading to high stock levels in preparation for go-live of the

Pan Wales Blood Service Programme in May 2016.

Part bags - work continues to reduce part bags where-ever possible. There are various reasons

that a donation may need to be stopped before reaching the required volume including

venepuncture technique, donors feeling unwell or an equipment failure.

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Red Cells Issues less than 14 Days Old

Red Cells Issues % Target

0.0%

1.0%

2.0%

3.0%

4.0%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

% Part Bags

% Part Bags % Target

52 | P a g e

Unsuccessful venepuncture, maintaining this target for venepuncture is essential in ensuring

sufficient blood is delivered to meet service need. This is an excellent achievement during

2016/17.

Progress against: First class patient and donor experience target

Our patient and donor feedback is largely positive. The Trust has worked to improve the way it

collects and receives feedback from those who use our services. Work to understand, and collate

themes to allow improvement in areas is critical in terms of using patient views, comments and

suggestions to make changes and develop services. Only two months during 2016/17 was below

required levels.

Concerns, incidents and severity - whilst numbers have been low the Trust takes its resonsibility to

learn from and take action from any concern or incident.

0.0%

1.0%

2.0%

3.0%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Unsuccessful Venepuncture

% Unsuccessful Venepuncture % Target

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Patients' Overall Experience

Rated 9 or above % Target

53 | P a g e

Welsh Blood Service donor satisfaction durng 2016/17 has mostly been above the set level. The

importance of learning from donor feedback remains paramount.

Progress against: Supporting our staff to excel target

Our workforce measures for sickness absence and Personal Appraisal Development Reviews

(PADR) were not met during 2016/17; this is an important area that the Trust is working to

improve. Detailed analysis to understand areas that need particular focus has been undertaken

and actions are in place to try and improve. These measures are also subject to scrutiny at

committee and Trust Board level.

0

50

100

150

200

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

VCC Concerns

Incidents Complaints Claims

0%

20%

40%

60%

80%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Donor Satisfaction

% Donors scoring 5 or 6 out of 6 for satisfaction % Target

54 | P a g e

Sickness rates - work is ongoing to ensure sickness rates improve and that staff are supported

across the Trust.

0% 20% 40% 60% 80%

100%

May-15 to

Apr-16

Jun-15 to

May-16

Jul-15 to

Jun-16

Aug-15 to

Jul-16

Sept-15 to

Aug-16

Oct-15 to

Sept-16

Nov-15 to

Oct-16

Dec-15 to

Nov-16

Jan-16 to

Dec-16

Feb 16 to

Jan-17

Mar-16 to

Feb-17

Apr-16 to

Mar-17

Trust (excl. hosted) PADR's

% Reviews Complete % Target

0%

20%

40%

60%

80%

100%

May-15 to

Apr-16

Jun-15 to

May-16

Jul-15 to

Jun-16

Aug-15 to

Jul-16

Sept-15 to

Aug-16

Oct-15 to

Sept-16

Nov-15 to

Oct-16

Dec-15 to

Nov-16

Jan-16 to

Dec-16

Feb 16 to

Jan-17

Mar-16 to

Feb-17

Apr-16 to

Mar-17

VCC PADR's

% Reviews Complete % Target

0%

20%

40%

60%

80%

100%

May-15 to

Apr-16

Jun-15 to

May-16

Jul-15 to

Jun-16

Aug-15 to

Jul-16

Sept-15 to

Aug-16

Oct-15 to

Sept-16

Nov-15 to

Oct-16

Dec-15 to

Nov-16

Jan-16 to

Dec-16

Feb 16 to

Jan-17

Mar-16 to

Feb-17

Apr-16 to

Mar-17

WBS PADR's

% Reviews Complete % Target

55 | P a g e

Progress against: Spending every pound well target

The Welsh Blood Service measures under this area remained low which was positive during

2016/17.

A summary of performance trends are captured in Appendix 1 of this report on page 66.

3.0%

3.5%

4.0%

4.5%

5.0%

5.5%

Apr-15 to

Mar-16

May-15 to

Apr-16

Jun-15 to

May-16

Jul-15 to

Jun-16

Aug-15 to

Jul-16

Sept-15 to

Aug-16

Oct-15 to

Sept-16

Nov-15 to

Oct-16

Dec-15 to

Nov-16

Jan-16 to

Dec-16

Feb 16 to

Jan-17

Mar-16 to

Feb-17

Trust (excl. hosted) Sickness/Absence Rates

Velindre NHS Trust (excluding hosted) Velindre Cancer Centre

Corporate Services Welsh Blood Service

0%

5%

10%

15%

20%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Time Expired Platelets

Time Expired Platelets % Target

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Volume of Waste (Red Cells)

% Volume of Red Cells Waste % Target

56 | P a g e

6. Sustainability Performance 2016-2017

The Trust recognises that in our day-to-day operations we impact upon the environment in a

number of ways and therefore should report upon our potential impacts in a responsible manner.

Sustainability reporting is an essential part of organisational governance in the public sector in

Wales and the Welsh Government’s aim is to enable integrated reporting. For 2016/17 public

bodies in Wales, which report under the FReM (Financial Reporting Manual), are required to

produce a FReM Sustainability Report.

The environmental sustainability agenda is taken forward in a structured manner and supported

by strong governance arrangements. The Director of Planning, Performance and Estates is the

lead officer for environmental sustainability within the Trust. One of the Trust Board Independent

Members is the Environment Champion and works closely with the Director of Planning,

Performance and Estates and Trust Board to progress this important agenda. The Assistant

Director of Estates, Environment and Capital Development and the Environmental Development

and Compliance Officer, provide the Trust with additional capacity and capability to take forward

the ambitious work programme. The planning and delivery arrangements related to sustainability

within the Trust are set out below.

The following tables, data and narrative set out the Trusts’ performance in sustainability for

2016/17 and compare it against previous years.

In the reporting of emissions the revised 2013/14 to 2016/17 Defra grid average conversion

factors have been applied. This has been adopted to enable more accurate annual emission

comparisons and will continue in future reports following Defra guidance.

Trust Board

Action Lead Director / Independent Member

Champion

Trust Sustainability Group

Divisional / Cancer Centre Quality and Safety Group

Divisional / Hosted Organisation Energy and Environmental Forum

Planning and Performance

Committee

Objective/Outcome

Quality and Safety Committee

57 | P a g e

The Trust recognises the need to establish robust and accurate data to enable it to set realistic

targets and manage data effectively. The Trust continues to make progress in this area but

recognises there is more work to be done.

Comparison of 2016/17 data against data prior to 2015/16 identified the following data anomalies:

Additional data has now been included for NHS Wales Informatics Service (NWIS) and NHS

Wales Shared Services Partnership (NWSSP) for both 2015/16 and 2016/17, except NWSSP

waste data for 2015/16 due to data availability issues. As this data has only been included in

the 2016/17 report a number of indicators have shown a significant increase when an annual

comparison has been applied. In order to allow a direct comparison against the previous year’s

data, a comparison that excludes NWIS and NWSSP organisation data has also been included in

the report (shown in brackets).

Gas, water and waste data for leased buildings has been estimated due to no information

being available as part of the lease agreement.

Green House Gas Emissions 2013-14 2014-15 2015-16 2016-17

Non-Financial

Indicators

(1,000 tCO2e)

Total Gross Emissions 3.851,2 4.041,2 5.861,2 4.811,2

Total Net Emissions 3.851,2 4.041,2 5.861,2 4.811,2

Gross Emissions Scope 1

(direct) 0.93 0.91 1.06 1.16

Gross Emission Scope 2 &

3 (indirect) 2.92 3.13 4.81 3.66

Related Energy

Consumption

(million kWh)

Electricity: Non

Renewable

5.23 4.61 8.58 5.85

Electricity: Renewable 0 0.79 0.79 1.78

Gas 4.842 4.762 5.522 6.052

LPG 0 0 0 0

Other 0.02 0.02 0.02 0.02

Financial

Indicators

(£million)

Expenditure on Energy £0.82m2 £0.83m2 £1.25m2 £1.36m2

CRC License 0 0 0 0

Expenditure on

Accredited Offsets e.g.

GCOF

0 0 0 0

Expenditure on Official

Business Travel £0.95m3 £0.80m3 £0.75m3 £0.82m3

58 | P a g e

1In the reporting of emissions the revised 2013/14 to 2016/17 Defra grid average conversion

factors have been applied. This has been adopted to enable more accurate annual emission

comparisons and will continue in future reports following Defra guidance.

2For leased buildings with no information available on gas consumption, estimated figures have

been used for cost, consumption and emissions.

3Business mileage figure includes NWIS and NWSSP (as per previous year’s submission).

4For leased buildings with no information available on water consumption; estimated figures have

been used for cost and consumption.

5Water data provided for NWIS and NWSSP this year. As this data has only been included in the

2016/17 report a number of indicators have shown a significant increase when an annual

comparison has been applied. However, an update has been provided within the submitted

narrative, utilising the data collected and comparing last year’s data with the same data set for

2016/17.

Finite Resource; Water Consumption 2013-14 2014-15 2015-16 2016-17

Non-

Financial

Indicators

(000m3)

Water

Consumption

(Office)

supplied 1.024 1.024 24.284 38.124,5

abstracted N/A N/A N/A N/A

Per FTE N/A N/A N/A N/A

Water

Consumption

(Non-Office)

supplied 23.46 20.63 22.08 22.27

abstracted N/A N/A N/A N/A

Financial

Indicators

(£million)

Water supply

costs (Office) £0.001m4 £0.001m4 £0.039m4 £0.053m4,5

Water supply

costs (Non-

Office

£0.032m £0.029m £0.030m £0.030m

59 | P a g e

6For leased buildings with no information available on waste disposal; estimated figures have been

used for both cost and tonnage.

7Data collected during 2016/17 includes estimated waste information for the hosted organisation

NWSSP. This data was not previously captured and therefore the figures provided in the ‘Waste’

table for 2016/17 cannot be directly compared to the previous years. However, an update has been

provided within the submitted narrative, utilising the data collected and comparing last year’s data

with the same data set for 2016/17.

Waste 2013-14 2014-15 2015-16 2016-17

Non-Financial

indicators

(tonnes)

Total Waste 352.08 334.48 1076.696 895.536,7

Landfill 162.40 145.25 504.576 393.806,7

Re-used / Recycled 73.01 116.96 513.276 431.826,7

Composted 0 0 0 0

Incinerated with

Energy Recovery 21.29 72.27 58.84 69.916,7

Incinerated without

Energy Recovery 95.38 0 0 0

Financial

Indicators

(£million)

Total Disposal Cost £0.13m £0.105m £0.115m6 £0.126m6,7

Landfill £0.04m £0.026m £0.026m6 £0.028m6,7

Re-used / Recycled £0.01m £0.038m £0.051m6 £0.045m6,7

Composted 0 0 0 0

Incinerated with

Energy Recovery £0.01m £0.041m £0.038m £0.053m6,7

Incinerated without

Energy Recovery £0.07m 0 0 0

60 | P a g e

6.1 Carbon Management

In 2013 a Trust Carbon Reduction Strategy was developed in conjunction with the Carbon Trust.

The implementation of the strategy aims to reduce the carbon emissions created by the Trusts’

services over a five year period (2014 to 2019).

During 2014 the Trust entered into workshops with the Carbon Trust to look at “Behavioural

Change” within the NHS. Following these workshops it set a potential outlook for a utility

consumption saving of 10% over a five year period (2014 to 2019), based on a 2013/14 financial

year baseline and in accordance with ‘Section 3: Targets & Business Case’ of the Trust Carbon

Reduction Strategy. The following table identifies the annual percentage target reduction in

electricity, gas and water consumptions and emissions and provides an explanation as to why each

target has been set. This year’s performance target is highlighted in green.

Financial Year Percentage Target (%) Reason for Percentage Target

2014 - 2015 1%

This target was set in November 2014. It is a

low percentage due to the target being set

over half way through financial year 2014/15.

2015 - 2016 3%

Energy awareness strategies and targets with

suitable monitoring, being delivered by

behavioural change.

2016 - 2017 3%

Energy awareness strategies and targets with

suitable monitoring, continual emphasis on

behavioural change.

2017 - 2018 2% Investment required to maintain on-going

savings.

2018 - 2019 1.5%

Diminishing savings as investment required to

further increase savings. Extra 0.5% to ensure

10% overall five year target is achieved.

61 | P a g e

6.2 Energy and Water Management

During 2016/17 the Trust did not achieve an overall reduction in electricity consumption (non-

renewable and renewable), showing an increase of 3.72 % compared to 2015/16.

The Trust’s annual electricity consumption, excluding NWIS and NWSSP organisations, produced a

net increase of 1.46 %, compared with similar data of the previous year.

The current Trust target, as shown in the ‘Annual Percentage Target Reduction’ table, is based on

electricity consumption established in 2014/15, excluding NWIS and NWSSP organisations. The

performance against this target shows an increase of 11.51 %.

During 2016/17 the Trust did not achieve an overall reduction in gas consumption, showing an

increase of 9.47 % compared to 2015/16.

The Trust’s annual gas consumption, excluding NWIS and NWSSP organisations, produced a net

increase of 5.41 %, compared with similar data of the previous year.

The current Trust target, as shown in the ‘Annual Percentage Target Reduction’ table, is based on

gas consumption established in 2014/15, excluding NWIS and NWSSP organisations. The

performance against this target shows an increase of 9.13 %.

Factors that have impacted on the Trust overall performance include:

Additional Bangor and Wrexham All Wales sites at WBS.

Addition of NWIS and NWSSP organisations in Trust reporting.

Increased operational hours within divisions, in particular of linear accelerators (LINACS)

providing patient radiation treatment and associated equipment at the Velindre Cancer Centre

(VCC).

Limited promotion and monitoring of energy awareness and education within the larger

divisions of the Trust (WBS and VCC).

Continued use of older, less energy efficient equipment such as linacs and refrigerators.

During 2016/17 the Trust did not achieve an overall reduction in water consumption, showing an

increase of 30.26 % compared to 2015/16.

The Trust’s annual water consumption, excluding NWIS and NWSSP organisations, produced a net

decrease of 0.95%, compared with similar data of the previous year.

The current Trust target, as shown in the ‘Annual Percentage Target Reduction’ table, is based on

water consumption established in 2014/15, excluding NWIS and NWSSP organisations. The

performance against this target shows an increase of 0.31 %.

62 | P a g e

Factors that have impacted on the Trust overall performance include:

Additional Bangor and Wrexham All Wales sites at WBS.

Addition of NWIS and NWSSP organisations in Trust reporting.

Increased water flushing regimes in VCC.

Increased operational hours at VCC.

The Trust will continue to work towards achieving a significant reduction in its carbon emissions by

focusing on the following:

Reducing electricity and gas consumptions through embedding ‘Don’t Waste at Work’ energy

and waste campaigns and improving meter reading and data capture at all divisions / hosted

organisations. Staff, patients and visitors all have a role to play in achieving these reductions.

Reviewing extended hours of use and use of equipment at divisions and ensuring this is taken

into account in future year comparisons.

Replacement of inefficient boilers.

A pilot energy saving lighting scheme has been installed at VCC to reduce its operational

impact on the environment. This scheme will be monitored and if the predicted reductions are

achieved it could potentially be expanded across VCC as well as other sites.

The Building Management System at each site will be re-configured to ensure energy efficiency

is optimised.

Ensure that gas heating is switched off during the summer period or BMS controls are

amended correctly to reflect summer temperatures.

A PC shutdown software initiative has been trialled at The Trust Headquarters. The initiative

involved an automatic shutdown of all PCs at 8pm every night, in an effort to stop energy

being unnecessarily wasted overnight when PCs are not in use, prolonging the life of PC

software as equipment is not on all the time and because it’s the right thing to do. After a

successful trial, The Trust Headquarters will now be used as a case study with the hope to roll

the initiative out to other Trust divisions and hosted organisations over the next twelve

months, in line with our Environmental Management System.

Water and gas monitoring and leak detection good practice will continue over the next twelve

months to ensure future targets are achieved.

Business cases will be developed for chosen installations and funding sourced, working with

Welsh Government. Further reductions in energy consumption and emissions need to be

realised, alongside the behavioural change of staff, patients, donors, visitors and contractors.

63 | P a g e

6.3 Travel and Transport

During 2016/17 the Trust’s overall expenditure on official business travel increased by 9.2 %

compared to 2015/16, to £817,038.00. Trust overall official business mileage increased by 7.86 %,

to 1,843,161 miles.

Factors that have impacted on the Trust overall performance include:

Additional staff across the various divisions and hosted organisations of the Trust.

The Trust continues to work towards achieving a significant reduction in its carbon emissions by

requesting that all staff, visitors and contractors consider the ‘Travel Hierarchy’ when arranging

travel for commuting, meetings, conferences and visits. This includes:

Videoconferencing facilities are available across Trust sites, allowing people at two or more

locations to see and hear each other at the same time, minimising travel. Staff will be

supported to make better use of these facilities to reduce unnecessary travel.

Walking is good for your health, improves mood and boosts self-esteem. Many Trust sites are

located within a short distance to green areas such as the Taff Trail. Staff will be supported to

make better use of these facilities.

A ‘cycle to work’ scheme has been introduced at the Trust to make it easier for staff to

purchase a bike. Secure bike shelters and showers are also available to encourage cycling to

work. These options will be further promoted to staff to reduce unnecessary use of vehicles.

Bus and train services are included when directing staff, patients, donors, visitors and

contractors to each division / hosted organisation, public transport must be made the first

choice for staff conference travel.

Car sharing will be further encouraged, as well as using the journey for multiple purposes

where possible (e.g. delivery of reports and papers).

Travel options will be made available to all staff throughout the Trust through a site specific

environmental awareness factsheet, with particular focus on staff that have not considered

changing their travel habits before.

In line with the roll out of ISO14001 certification across all Trust Divisions and Hosted

Organisations, a ‘Trust Travel Plan’ has been developed and launched. This includes details and

achievements from the VCC, WBS and Trust Headquarters as well as hosted organisations. The

Trust Travel Plan will actively encourage the reduction of single occupancy car journeys, with

initiatives such as:

Video conferencing / conference calls rolled out across all sites.

64 | P a g e

Shared occupancy journeys, with a designated car parking facility for registered car sharers at

its VCC site.

Maintain the cycle to work scheme for the purchase of bikes and providing good cycle

facilities.

Improve and increase the number of bike shelters and showers on site at VCC and WBSs.

Support working from home.

Look into the use of lower carbon options for transport.

Actively encourage the use of public transport.

Actively support the use of alternative fuel vehicles for travel, including LPG, Bi-Fuel, Hybrid,

and Zero Emission.

The Trust-wide Travel Plan will acknowledge the above principles together with guideline

documents such as the ‘Active Travel (Wales) Act 2013’, ‘Wellbeing of Future Generations (Wales)

Act 2015’ and the ‘Good Practice and Guidelines: Delivering Travel Plans’, commissioned by the

Department for Transport, in consultation with Communities and Local Government, to give

further impetus to the use of travel plans as a means of promoting sustainable travel. The Travel

Plan will also support the ‘Trust Environmental Policy’ and associated procedures.

The Trust Travel Plan will deliver a wide range of benefits. For developers, it will make a site more

accessible and smooth the planning process. The benefits for local authorities include helping

achieve wider local government objectives and managing demand across travel modes. The Travel

Plan will assist in bringing a wide range of benefits to the wider community such as:

Reducing peak time congestion.

Reducing harmful transport emissions and reducing energy use, therefore helping to tackle

climate change and provide environmental benefits.

Improving public transport, accessibility and tackling social exclusion.

Offering pleasant surroundings for pedestrians in and around Trust buildings.

As part of the Trust Capital Build design process, all major construction schemes will be reviewed

in line with the Welsh Government’s ‘Architectural Design Evaluation Toolkit’ (AEDET). As part of

this process consideration is given and scores awarded for proximity to public transport services.

The Trust will work with both Local Authorities on the provision of its The Trust Travel Plan,

ensuring that all public transport options, including cycling are integrated into new schemes.

65 | P a g e

6.4 Waste Management

Data collected during 2016/17 includes waste information for the hosted organisation NWSSP.

This data was not previously captured and therefore the figures provided in the ‘Waste’ tables for

2016/17 cannot be directly compared to the previous years.

The Welsh Government has set a target for all organisations to recycle at least 70 per cent of

waste by 2025. The Trust has set a target for 2016/17 of 57 % recycling of its waste materials, as it

moves towards the 70 % goal.

The Trust’s chosen clinical waste contractor is now recovering residual waste (flock) from clinical

waste treatment plants. Therefore the Trust will now include any alternative treated and energy

recovery incinerated clinical waste as recycled waste.

During 2016/17, the Trust did not achieve its overall annual recycling percentage target of 57 %,

with a performance of 56.13 %. However, the rate of recycling had increased by 2.99 % compared

to the previous year performance of 53.14 %.

The Trust’s annual recycling rate, excluding NWIS and NWSSP organisations, is 61.40 %, showing a

net increase of 4.65 % compared with similar data of the previous year.

The Trust will continue to work towards increasing its recycling rate by focusing on a wide range of

opportunities that include:

The Trust Environmental Compliance Officer has been working closely with divisions within the

Trust to prepare for the implementation of a ‘Bin the Bin’ initiative. The initiative involves

removing desk-side bins and having central waste stations’ in an effort to increase recycling,

encourage source segregation of waste in line with government legislation, minimise the

amount of waste bags used and encourage networking, movement and staff wellbeing. During

full implementation over the next 12 months, each division will need to overcome several

obstacles including addressing staff concerns, promoting the benefits of the initiative and

encouraging staff participation throughout the Trust. Full implementation of the initiative will

aid in the continual improvement of the Trust’s Environmental Management System.

Continued implementation of the ‘All-Wales NHS’ waste contract and improved data collection

procedure, whilst promoting and monitoring waste awareness and education across the Trust.

The Trust Environmental Development and Compliance Officer working with the Estates and

Operational Services departments at all divisions to analyse the data capture method of waste

weights to ensure that the correct calculations are being used.

The Trust Environmental Development and Compliance Officer is engaging with hosted

organisations in developing initiatives and producing more accurate information.

66 | P a g e

Appendix 1: Performance trends over 2016-2017 – Summary

Service Performance measures

Green Target achieved this month

Red Target not achieved this month

Equitable and timely access

Velindre Cancer Centre Level 1

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 001 – 98% of patients commencing radical radiotherapy within 28 days

98% 98% 98% 98% 97% 97% 97% 96% 99% 100% 100% 97%

VCC 002 -98% of patients commencing palliative radiotherapy within 14 days

98% 100% 100% 100% 94% 99% 100% 98% 98% 99% 98% 98%

VCC 003- 100% of patients commencing emergency radiotherapy within 2 days

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

VCC 116- 95% Linear Accelerator Uptime

94% 97% 99% 97% 97% 97% 97% 97% 99% 98% 95% 95%

VCC 117- 98% Patient Disruptive Uptime

97% 100% 100% 99% 99% 100% 99% 100% 100% 100% 96% 96%

67 | P a g e

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 017- 100 % of patients commencing emergency chemotherapy within 5 days

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

VCC 018- 98% of patients commencing non-emergency chemotherapy within 21 days

99% 99% 100% 99% 98% 100% 100% 99% 97% 99% 98% 97%

VCC 118- All SACT referrals within turnaround

99% 99% 100% 99% 98% 100% 100% 99% 97% 99% 98% 97%

Level 2

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 130- CR Inpatients (within 1 working day)

90% 87% 98% 98% 98% 98% 85% 90% 98% 97% 98% 99%

VCC 131- CT Inpatients (within 1 working day)

95% 100% 100% 100% 100% 95% 87% 100% 100% 100% 100% 100%

VCC 132- MRI inpatients (within 1 working day)

100% 100% 100% 100% 100% 100% 100% 66% 100% 100% 75% 100%

VCC 133- US inpatients (within 1 working day)

100% 100% 100% 100% 100% 100% 100% 88% 100% 100% 90% 75%

VCC 134- CR Outpatients (within 7 days)

100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

68 | P a g e

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 135- CT Outpatients (within 7 days)

100% 100% 100% 100% 100% 100% 100% 97% 98% 100% 98% 98%

VCC 136- MRI Outpatients (within 7 days)

100% 99% 100% 100% 100% 100% 100% 100% 100% 100% 96% 100%

VCC 137- US Outpatients (within 7 days)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Welsh Blood Service Level 1

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

292 (from Sept) new

Bone Marrow Volunteers

(BMV) registrations per

month

261 311 182 218 188 239 318 468 272 289 342

528

69 | P a g e

Supporting our staff to excel

Velindre NHS Trust

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

COR 007- 3.54%

Sickness Absence

rate (Trust Wide)

4.33% 4.28% 4.22% 4.18% 4.14% 4.11% 4.19% 4.18% 4.14% 4.15% 4.17% 4.24%

COR 006- 85%

PADR (Trust

Wide)

59.7% 64.2% 66.2% 72.2% 75.1% 77.6% 77.6% 70.8% 71.8% 70.0% 68.9% 67.0%

COR 007- 3.54%

Sickness Absence

rate (Corporate

Services)

4.11% 4.20% 4.27% 4.17% 4.64% 4.90% 4.91% 4.86% 4.98% 4.89% 4.72% 4.62%

COR 006- 85%

PADR (Corporate

Services)

42.9% 62.8% 68.5% 72.9% 76.4% 77.4% 77.4% 74.3% 73.2% 71.6% 76.8% 85.7%

70 | P a g e

Velindre Cancer Centre

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

COR 006- 85% PADR Rate

56.2% 59.4% 61.1% 71.3% 74.1% 75.7% 75.7% 66.6% 65.1% 62.2% 61.4% 59.4%

COR 007- 3.54% Sickness absence rate

4.08% 4.05% 4.00% 3.91% 3.73% 3.59% 3.60% 3.56% 3.50% 3.53% 3.59% 3.70%

Welsh Blood Service

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

85% PADR Rate 70.1% 73% 74.3% 73.5% 76.4% 77.4% 80.7% 76.3% 81.5% 81.2% 78.0% 73.4%

3.54% Sickness absence

rate 4.82% 4.67% 4.58% 4.63% 4.67% 4.74% 4.94% 5.00% 4.94% 4.93% 4.94% 4.99%

71 | P a g e

Estates

Level 1

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

COR 024a-

Electricity (kWh)

COR 024b- Gas

(kWh)

COR 025a-

Electricity (CO2)

COR 025b- Gas

(CO2)

COR 026- Water

Usage (m3)

72 | P a g e

Safe and reliable services

Velindre Cancer Centre

Level 1

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 025- Death within 30 days of chemotherapy

Metric under development

VCC 032a- 0 C.diff cases

0 0 0 0 0 0 0 0 1 0 0 0

VCC 032b- 0 MRSA cases

0 0 0 0 0 0 0 0 0 0 0 0

VCC 032c- 0 MSSA cases

0 0 1 0 0 0 0 1 0 0 0 0

VCC 033- 0 Velindre hospital acquired pressure ulcers

1 3 3 4 5 0 5 4 3 0 1 1

VCC 138- 0 unexpected inpatient deaths

0 0 0 0 0 0 0 0 1 0 0 0

VCC 139- 95% Compliance with CAUTI insertion care bundles

83% 100% 86% 88% 83% 100% 75% 100% 72% 100% 100% 69%

VCC 140- 95% Compliance with CAUTI maintenance care bundle

100% 100% 95% 100% 95% 100% 88% 100% 85% 93% 100% 88%

VCC 141- 100% compliance with CVC insertion care bundle

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

73 | P a g e

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 142- 100% compliance with skin care bundle

67% 67% 93% 67% 100% 67% 100% 100% 100% 100% 83% 78%

VCC 034a 90% patients to have a documented thromboproxphylaxis risk assessment on admission

69% 46% 55% 63% 27% 46% 48% 91% 96% 96% 96% 89%

VCC 034b 100% eligible patients prescribed thromboprophylaxis

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Level 2

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 143- 95% hand hygiene compliance (average- non inpatient areas)

87% 93% 86% 90% 88% 92% 60% 75% 91% 86% 87% 71%

VCC 144- 95% hand hygiene compliance (average- inpatient areas)

78% 79% 78% 86% 80% 95% 79% 80% 81% 82% 75% 72%

VCC 036- Mortality Review of 100% of inpatient deaths

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

74 | P a g e

Level 3 Highlighted Measures

Level 3

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 146- Antibiotic Prescribing- 100% compliance with documenting duration/review date

60% 86% 41% 42% 76% 100% 100% 100% 100% 100% 100% 100%

75 | P a g e

Welsh Blood Service

Level 1

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

100% Red cell supply

meeting demand 111% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

100% of platelets

supply meeting

demand

141% 114% 102% 106% 121% 119% 108% 112% 124% 114% 120% 119%

98% of commercial

product requests

met

99% 96% 100% 99% 91% 91% 98% 99% 95% 95% 99% 92%

≥90% deceased

donor typing / cross

matching reported

within 6 hours

(quarterly metric)

100% 100% 100% 100%

100% delivery of

Haemotopoietic

Stem Cell (HSC)

internal targets

stakeholders in full

135.6% 135.6% 155% 136% 155% 116.3% 136% 155% 116.3% 96.9% 96.9% 38.8%

76 | P a g e

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

100% facilitation /

import of HSC

products for patients

in Cardiff and Vale

UHB

75% 50% 100% 75% 125% 100% 50% 75% 71% 50% 100% 125%

≥90% Anti-D & -C

Quantitation results

provided to

customer hospitals

within 5 working

days (quarterly

metric)

96% 99% 95% 91%

≥90% routine

antenatal patient

results provided to

customer hospitals

within 3 working

days

(quarterly metric)

99% 99% 99% 98%

77 | P a g e

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

≥80% samples

referred for red cell

reference serology

work up provided to

customer hospitals

within 2 working

days (quarterly

metric)

81% 82% 82% 77%

Level 2

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

60% red cells issued

less than 14 days

old

40% 28% 30% 31% 39% 53% 69% 61% 44% 46% 55% 31%

≤3% part bags

collected 3% 3% 3% 3% 3% 3% 3% 3% 3% 3% 3% 4%

≤2% unsuccessful

venepuncture 2% 2% 1.4% 1% 2% 2% 1% 2% 1% 2% 1% 1%

78 | P a g e

First class patient and donor experience

Velindre Cancer Centre

Level 1

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 044- >80% patient overall experience rated 9 and above

94% 85% 81% 85% 80% 77% 72% 89% 86% 92% 90% 89%

Level 2

Metric Apr 16

May 16

Jun 16

Jul 16

Aug 16

Sept 16

Oct 16

Nov 16

Dec 16

Jan 17

Feb 17

Mar 17

VCC 046- On the day waiting times in outpatients less than 20 minutes

45% 49% 59% 45% 52.3% 44.4% 50.2% 48.8% 54% 54% 53% 53%

VCC 058- 100% of palliative care patients have an POS-S or equivalent assessment within 24 hours of referral

100% 100% 80% 100% 100% No data provided

100% 100% 100% 100% 100% 100%

79 | P a g e

Welsh Blood Service

Level 1

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

≥71% of blood donors

scoring 5 or 6 out of 6

for satisfaction with

overall service

89% 88% 91% 90% 90% 88% 93% 94% 91% 92% 92% 92%

≥100 % of concerns

answered within 30

days

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Level 2

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Whole Blood: 1.25

units collected by WTE

per hour

1.13 1.12 1.01 1.01 1.13 1 0.97 1.16 1.04 1.1 1.14 1.17

Apheresis: 2.15

Average Adult

Therapeutic Dose

(ATD) per Donation

2.1 2.11 2.1 2.06 2.07 2.08 2.08 2.07 2.03 2.06 2.02 2.06

80 | P a g e

Spending every pound well

Metric Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sept

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

<7% time expired

platelets 16.7% 16.5% 16.3% 13.9% 16.2% 7.9% 5.1% 6.0% 10.3% 9.5% 11.0% 11.0%

<0.5% volume of

waste (red cells) 0.1% 0.7% 1.5% 0.9% 0.8% 0.4% 0% 0.0% 0.1% 0.1% 0.1% 0.2%

<6% total losses

prior to issue 6.1% 5.8% 5.5% 5.3% 5.6% 5.5% 5.3% 6.2% 5.3% 3.8% 5.8% 6.1%

81 | P a g e

Appendix 2: Progress against our three year plan

Delivery again Plan objectives

Green Actively managed processes proceeding as planned - no major risks or issues identified

Amber Problems have surfaced, considered manageable in the normal course

Red Serious problems have surfaced – make Senior Management Team aware

Closed

Purple Major issues remain unsolved- “on hold” until resolved - senior executive engaged

Grey Deliverable activity at feasibility/initiation stage

At a Glance Summary – Progress against 3 Year Plan Objectives

Area Objective Level Status Forecast

Status Risk

Wo

rkfo

rce

an

d

Org

anis

atio

nal

De

velo

pm

en

t WOD01 – Leadership & Management Capability 2

WOD02 – Quality & Continuous Improvement 2

WOD03 – Diversity & Inclusiveness 2

WOD04 – Staff Engagement & Well Being 2

WOD05 – Collaborative & Partnership working 2

Serv

ice

Imp

rove

me

nt SI 01 – Stimulate generation of the ‘right’ ideas to take forward

2

SI 02 – Strengthening the arrangements for our international health links 2

82 | P a g e

Area Objective Level Status Forecast

Status Risk

SI 03 – Enable the spread of learning 2

Re

sear

ch a

nd

De

velo

pm

en

t

VCC059 – Provide patients with timely access to the latest anti-cancer treatments through participation

in clinical trials 2

VCC 060 – Actively promote the benefits of participating in research to staff and patients 2

VCC 065- Develop department level strategies that are aligned to the VCC R&D strategy 1

VCC 071- Continue to develop the national leadership position of the RTTQA group 1

VCC 077- Increase recruitment into clinical trials activity in line with and beyond national targets where

possible 1

VCC 078- Increase tissue collection for the Wales Cancer Bank 1

VCC080 - Develop Nurse and AHP research leads and research programs 2

VCC 081- Develop strategic collaborations and engagement 2

RD 001 – Actively promote the benefits of participating in research of staff, donors and patients 2

RD 002 – Re-design of R&D governance structure 1

RD 003 – Operationalise the R&D Strategy

2

83 | P a g e

Area Objective Level Status Forecast

Status Risk

Org

anis

atio

nal

Le

arn

ing OL 01 - Provide opportunities for patients, donors and carers to provide feedback in order to help staff

build effective care partnerships 2

OL 02 - Have in place fully functional reporting systems to enable collection and analysis of patient,

donor and carer feedback in order to facilitate learning 2

OL 03 - Develop communication structures to enable the spread of learning across the organisation 2

Esta

tes

COR 022- Undertake a review of the Trust’s Statutory Compliance across divisions and hosted

organisations. Achieve and maintain a Trust Statutory Compliance Target of 90 %. 1

COR 023 – At least 50% of Trust properties and all Trust hospital sites certified to ISO14001 by the end of

the financial year. 1

Velindre Cancer Centre - At a Glance Summary - Progress against 3 Year Plan Objectives

Strategic Theme

Objective Level Status Forecast

Status Risk

Equ

itab

le a

nd

Tim

ely

Acc

ess

to

Se

rvic

es VCC 001-003 – Consistently achieve waiting times recommendations for patients receiving Radiotherapy 1 Progress reported in Section 2

VCC 004- Develop a strategic plan for radiotherapy services including advanced radiotherapy 1

VCC 005- Increase radiotherapy access to the appropriate rate for patients with cancer within our resident

population 1

VCC 008- Repatriate all appropriate activity from England and increase the provision of SBRT and SRS 1

VCC 113 – To work with Health Boards and WHSSC to develop systems for the approval and funding of Emergency

Access to Medicines (EAMs) schemes 1

VCC017-019 – Consistently meet waiting times targets for emergency and non-emergency chemotherapy patients 1 Progress reported in Section 2

VCC 020- Patients to receive parental SACTs as close to their homes as possible within environment which are

appropriate for safe administration 1

VCC 083- Disaster Recovery Plans (DRP) in place to support service in the event of an incident, ensuring a clear

process in place in line with timely resolution 1

84 | P a g e

Strategic Theme

Objective Level Status Forecast

Status Risk

VCC 006 – Increase provision of Intensity Modulated Radiotherapy (IMRT) to 35% of radical plans 2

VCC 007- Develop the use of Image Guided Radiotherapy (IGRT) techniques across tumour sites 2

VCC 022- Strengthen links with primary care: Review processes by which patients can receive care within local

communities and utilise local resources 2

VCC 023 - Strengthen links with primary care: Review processes by which patients can be reviewed by oncology staff

(VNHST) in primary care (or closer to home) 2

VCC024 – Maximise use of available information intelligence within medicine management systems to support

service development and clinical and financial audit 1

VCC 031- Review of Clinical nurse specialists and key workers to ensure appropriate service provision 2

VCC 082- Support infrastructure in situ including sufficient capacity and resilience for the provision of continuous

service 2

VCC 085- Explore technology to underpin service in line with service improvements, and change in

workflows/practices 2

VCC104 – Implement the agreed recommendations from the internal pharmacy review, the Welsh Audit Office

report and the MHRA inspection report in order to improve the quality of the medicines management service. This

is collectively termed the “Medicines Management Action Plan” 2016 to 2017

2

Safe

an

d R

elia

ble

Se

rvic

es

VCC032 – Reduce healthcare associated infections to zero 1 Progress reported in Section 2

VCC033 – Reduce Velindre acquired pressure ulcers to zero 1 Progress reported in Section 2

VCC034 – Ensure that all inpatients received documented thrombosis risk assessments on admissions 1 Progress reported in Section 2

VCC 040- Development of Acute oncology services across SE Wales 1

VCC 090- Implementation of Welsh Clinical Portal (which includes Medicines Transcriptions and Electronic Discharge (MTedD)) with National Test Requesting and Results Reporting (TRRR)

1 Change Control

VCC 039- Improve oversight of medication related errors to comply with NHS Wales standards 2

VCC 088- Implementation of National Image Sharing- Vendor Neutral Archive (VNA) Project to support the care of cancer patients via cross organisation image sharing

2

VCC120 – Strengthening business continuity and emergency planning resources, processes and plans

Firs

t C

lass

Pat

ien

t

Exp

eri

en

ce VCC 012- Evaluate current waiting times targets for radical specific patient groups including lung and radical

neurology patients 2

VCC 013- Implementation of Royal College or Radiologist guidance on management of interruptions for category 2 patients

2

VCC 028- Ensure that patients who take oral SACTs are able to make fully informed decisions to facilitate 2

85 | P a g e

Strategic Theme

Objective Level Status Forecast

Status Risk

medication adherence

VCC044 – Increase positive patient experience levels through the collection of views and opinions from a wider sample of patients including outreach settings

1

VCC 045- Ensure that people living with and beyond cancer have a personalised assessment, information and care plan and are empowered to manage their condition

2

VCC050 – Establish an assessment unit at VCC 2

VCC 057- Increase the number of patients that die in their preferred place. Increase the number of patients who access their preferred place of care.

2

VCC058 – 100% of palliative care patients have an POS-S (palliative care outcome scale) or equivalent assessment within 24 hours of referral

2

VCC111 – Improve feedback mechanisms for patients 2

Pro

vid

ing

Evid

en

ce B

ase

d C

are

an

d R

ese

arch

VCC 100- Maintain required standards for timeliness and completeness of clinical coding in line with targets set by the Welsh Government

1

VCC 014- Implement image guided brachytherapy for appropriate gynaecology cancer patients 2

VCC 029- Introduce and evaluate use of oncotype testing 2

VCC 096 – Improving the data quality within the electronic patient record – Provision of accurate and up to date information by the Medical Records Department

2

VCC 097- Development of an organizational informatics function to inform service improvement plans, benchmarking, mandatory returns, data extraction and validation

2

VCC 098- Implementation of the National Intelligent Integrated Audit Solution (NIIAS) 2

VCC 099- Implementation of Mobile Device Management Solution 2

VCC103 – Increase capacity on the chemotherapy day case unit in order to meet growing demand (approximately 250 additional patients per year) as a result of the introduction of Docetaxel chemotherapy for prostate cancer.

1

VCC109 – Develop service to provide Radium 223 to patients with prostate cancer as per NICE appraisal 1

VCC114 – To provide Cetuximab treatment to patient population in line with AWMSG directive. 1

VCC115 – To develop a business case for the provision of Zometa for breast patients 1

VCC117 – To develop a business case for the provision of new lines of therapies (as per anticipated NICE publications) for patients with Melanoma Cancer

1

VCC118 – Review structure and resources for Quality and Safety support provided by Cancer Services Management Offices

2

86 | P a g e

Welsh Blood Service- At a Glance Summary - Progress against 3 Year Plan Objectives Strategic

Theme Objective Level Status

Forecast

Status Risk

Equ

itab

le

and

Tim

ely

Acc

ess

to

Serv

ice

s

WBS001 – Improve recruitment and retention of whole blood donors 1

WBS002 – Recruit and retain new Bone Marrow Volunteers (BMV) donors, especially young donors 1

Safe

an

d R

elia

ble

Se

rvic

es

WBS004 – Meet all Blood component demand in line with clinical need 1

WBS 005 – Meet all Transplant Service requests 1

WBS 006 – Meet all diagnostic service requests 1

WBS007 – Maintain external regulatory compliance: (MHRA/HTA/EFI/WMDA) 1

WBS 008 - Keep abreast of mandated changes to testing and emerging clinical priorities including: (I) PAS and NAT HEV,

and (ii) Pathogen Inactivation 1

WBS009 – Existing Systems Maintenance & Support 1

WBS010 – Retain wholesaling license 2

WBS 011 - IM&T Infrastructure Improvement Programme inc. ‘disaster recovery’ 2

WBS 012 - Provision of technical support for Operational Project Delivery Programme (Software & Infrastructure) 2

WBS 013 - Develop and implement cross departmental and organisational processes for quality management inc.

training records 2

Firs

t

Cla

ss

Do

no

r

Exp

eri

en

ce

WBS 014 - Continue to improve satisfaction ratings from our donors 1

WBS 015 - Respond to all concerns in a timely and effective way (links to donor satisfaction) 1

87 | P a g e

Strategic

Theme Objective Level Status

Forecast

Status Risk

WBS 016 – Continue to improve donation experience 2

WBS 017 – Keep abreast of advancements in technology for WTAIL 2

Sup

po

rtin

g o

ur

staf

f to

exc

el WBS 021 – To deliver new service models through an engaged and empowered workforce 2

WBS 022 – To ensure optimal flexible working patterns to support new service models 2

WBS 023 – To develop a flexible laboratory workforce using ‘Modernising Scientific Careers’ 2

Spe

nd

ing

Eve

ry

Po

un

d

We

ll

WBS 024 – Reduce volume of ‘production waste’ (namely Collections and Laboratories) 1

WBS025 – Improve optimization of Estates Infrastructure 2

88 | P a g e

Appendix 3: Equality Annual Monitoring Report Data and Information

Introduction

We are pleased to present Velindre NHS Trusts Equality Monitoring report for April 2016- March

2017; this report provides the equality monitoring data in line with our duties under the Equality

Act 2010.

Legal Context

The Public Sector Equality Duty (PSED) requires that all public authorities covered under the

specific duties in Wales should produce an annual equality report by 31st March each year. The

Trust published the report for 2015-16 for the March deadline 2017. The information in this

report therefore covers the following year to bring it in line with the Trust Wide Annual report.

The essential purpose of the specific duties under the Equality Act, in relation to monitoring, is

to help authorities to have better due regard to the need to achieve the 3 aims of the general

duty, which are to;

eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the Act;

advance equality of opportunity between people who share a protected characteristic and people who do not share it; and

foster good relations between people who share a protected characteristic and people who do not share it.

Therefore, as a specific duty itself, the role of annual reporting is to support the Trust in meeting

the general duty. It also has a role in setting out achievements and progress towards meeting

the other specific duties.

In particular, the annual report supports the Trust to have a better due regard to the duties by

providing an opportunity to;

Monitor and review progress

Monitor and review the effectiveness and appropriateness of arrangements

Review objectives and processes in light of new legislation and other new developments

Engage with stakeholders around these issues, providing partners and the public with transparency.

89 | P a g e

Equality Data

In the pie charts below you will find the breakdown of equality data in several areas;

Staff in post by their protected characteristic

All staff breakdown by grade o Each grade broken down by gender

Working pattern broken down by gender

Employment assignment broken down by gender

Recruitment applications by their protected characteristics

All staff breakdown upon leaving the Trust o Leavers by their protected characteristics

The Trust made a decision to use pie charts to convey the equality data as tables created

identifiable information, due to small numbers. Therefore to be able to publish information and

perform valid analysis the Trust has agreed to use pie format to display information.

What the data does demonstrate is that for a number of the more sensitive equality areas, many

staff have either decided that they would prefer not to say or the data has not been captured at

all. This is an area that has been identified for improvement and confidence in how the Trust will

be using the data should over time, which will hopefully see the data gaps close.

Please note that the Full Time Equivalent (FTE) data may differ to that reported in the accounts

as it is captured on a snapshot model.

Age Band

Age Band Headcount % FTE

<20 12 0.31 11.33

20-25 207 5.34 198.80

26-30 530 13.66 503.66

31-35 541 13.94 490.65

36-40 452 11.65 409.30

41-45 501 12.91 452.10

46-50 527 13.58 489.01

51-55 533 13.74 486.06

56-60 367 9.46 327.97

61-65 158 4.07 133.87

66-70 39 1.01 29.01

71+ 13 0.34 7.35

3,880 100.00 3539.11

0.31%

5.34%

13.66%

13.94% 11.65%

12.91%

13.58%

13.74%

9.46% 4.07%

1.01%

0.34%

Age Band

<20 20-25 26-30 31-35 36-40 41-45

46-50 51-55 56-60 61-65 66-70 71+

90 | P a g e

By Gender

Gender Headcount % FTE

Female 2,393 61.7 2099.75

Male 1,487 38.3 1439.36

Grand Total

3,880 100.0 3539.11

By Religious Beliefs

Religious Belief

Headcount % FTE

Atheism 511 13.17 486.28

Buddhism 9 0.23 8.29

Christianity 1,574 40.57 1441.32

Hinduism 32 0.82 29.86

Islam 59 1.52 54.95

Judaism 1 0.03 1.00

Not Disclosed

552 14.23 520.70

Other 283 7.29 261.32

Sikhism 2 0.05 1.60

Unspecified 857 22.09 733.81

Grand Total

3,880 100.00 3539.11

By Sexual Orientation

Sexual Orientation

Headcount % FTE

Bisexual 13 0.34 12.60

Gay 28 0.72 26.93

Heterosexual 2,648 68.25 2454.44

Lesbian 12 0.31 11.53

Not Disclosed

345 8.89 323.29

Unspecified 834 21.49 710.31

Grand Total 3,880 100.00 3539.11

62%

38%

Gender

Female

Male

13.17%

0.23%

40.57%

0.82% 1.52%

0.03%

14.23%

7.29%

0.05%

22.09%

Religious Belief

Atheism

Buddhism

Christianity

Hinduism

Islam

Judaism

Not Disclosed

Other

Sikhism

Unspecified

0.34% 0.72%

68.25%

0.31%

8.89%

21.49%

Sexual Orientation

Bisexual

Gay

Heterosexual

Lesbian

Not Disclosed

Unspecified

91 | P a g e

By Employee Category

Employee Category

Headcount % FTE

Full Time 2,849 73.43 2849.00

Part Time 1,029 26.52 689.11

Unspecified 2 0.05 1.00

Grand Total

3,880 100.00 3539.11

By Employee Category by Gender

Female Male

Unspecified 0.03 0.03

Part Time 23.09 3.43

Full Time 38.56 34.87

73.43%

26.52%

0.05%

Employee Category

Full Time

Part Time

Unspecified

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Female Male

Unspecified Part Time Full Time

92 | P a g e

By Disability

Disability Flag

Headcount % FTE

No 2,532 65.3 2342.21

Not Declared

205 5.3 189.57

Unspecified 1,052 27.1 923.63

Yes 91 2.3 83.70

Grand Total

3,880 100.0 3539.11

Yes Disability Type FTE Headcount Headcount %

Learning disability/difficulty 4.80 5 5.7

Long-standing illness

11.29 13 13.5

Mental Health Condition 5.03 6 6.0

Other 6.00 6 7.2

Physical Impairment 1.40 2 1.7

Sensory Impairment 5.80 6 6.9

Yes - Unspecified 49.37 53 59.0

65% 5%

27%

3%

Disability

No

Not Declared

Unspecified

Yes

5%

14%

7%

7%

2% 7%

58%

Disability Learning disability/difficulty

Long-standing illness

Mental Health Condition

Other

Physical Impairment

Sensory Impairment

Yes - Unspecified

93 | P a g e

By Ethnic Origin

Ethnic Group Headcount % FTE

White 3,141 81.1 2,868 White Other 158 4.1 146 Ethnic Minority 186 4.7 173 Not Stated 146 3.8 135.51 Unspecified 249 6.4 216.93 Mixed 28 0.7 26 Asian 102 2.6 93 Black 27 1 26 Chinese 16 0 15 Other 13 0 13

81%

4%

5%

4%

6%

Ethnicity

White

White Other

Ethnic Minority

Not Stated

Unspecified

15%

55%

14%

9% 7%

Ethnicity

Mixed

Asian

Black

Chinese

Other

94 | P a g e

By Pay scale by Gender

89%

11%

Band 1

Female Male

46% 54%

Band 2

Female Male

70%

30%

Band 3

Female Male

72%

28%

Band 4

Female Male

63%

37%

Band 5

Female Male

63%

37%

Band 6

Female Male

60%

40%

Band 7

Female Male

53% 47%

Band 8a

Female Male

95 | P a g e

44% 56%

Band 8b

Female Male

46% 54%

Band 8c

Female Male

47% 53%

Band 8d

Female Male

29%

71%

Band 9

Female Male

67%

33%

Medical and Dental

Female Male

44% 56%

Other

Female Male