Hywel Dda University Health Board Annual Plan 2017 - 18 Action Plans YR HYWEL DDA A GAREM ... (PDFDrive)

Hywel Dda University Health Board
Annual Plan 2017/18
Action Plans
SUBMISSION TO WELSH GOVERNMENT

31st MARCH 2017
YR HYWEL DDA
A GAREM
THE HYWEL DDA

WE WANT
1
Contents
Action Plan Page

Prevention and Public Health 3
Primary and Community Care 8
• Carmarthenshire 8
• Ceredigion 12
• Pembrokeshire 14
• Primary Care 16
A Regional Collaboration for Health (ARCH) 21
Mid Wales Healthcare Collaborative 22
Strategic Objectives 24
• SO1 Risk Taking Behaviours 24
• SO2 Overweight and Obesity 25
• SO3 Cardiovascular Disease 26
• SO4 Cancer Prevention) 27
• SO5 Diabetes 28
• SO6 Respiratory 30
• SO7 Mental Health 32
• SO8 Frailty and Dementia 34
Nursing Quality and Experience Improvement Plans 36
Service Improvement 51
Workforce and Organisational Development 53
Research and Development 59
Equality and Diversity 61
Governance 68
Communication and Engagement 75
Welsh Language 79
Carers 81
2
PREVENTION AND PUBLIC HEALTH
(1) Action delivered on the Wellbeing of Future Generations Act and 2017/18 plans.
Ambition: to ensure comprehensive planning for the Act, and the undertaking of the new assessment.
What we planned to do in 2016/17 What we did What we are going to do in

2017/18
To provide professional support to the The Public Health Directorate were Provide professional support to the
Public Service Board (PSB) and active members of a number of local Public Service Boards (PSBs) and
Regional Partnership Board (RPB) in and regional groups driving forward Regional Partnership Board (RPB) in
the development of local and regional the activity required to develop the the development of the Area Plan
Needs Assessments Population and Wellbeing and Local Wellbeing Plans to ensure
assessments. The voice of the that the impact on health is taken
citizen was central to our engagement into account when considering and
approaches and a regional toolkit was agreeing priorities for local and
developed to ensure a consistent regional action.
approach to gathering views on the
state of wellbeing or the care and
support needs of our current
populations.
Support integration of public health Delivery of awareness raising Continue to promote the ACEs
priorities within county level strategic sessions at county level and regional research and work with partners to
partnership structures and plans strategic partnership meetings on the agree collaborative action, through
impact of Adverse Childhood the development of Area Plans and
Experiences (ACEs). Local Wellbeing Plans that will
proactively tackle ACEs.
(2) Action delivered on Smoking Cessation and Tobacco Control and plans for 2017/18
Ambition: Our ambition as a University Health Board is reduce smoking prevalence in the population through
increasing service capacity to support smoking cessation through expansion of the Hospital Smoking Cessation
Service and ensuring wide ranging uptake and full implementation of Community Pharmacy Level 3 Smoking
Cessation Services
What we said we would do in What we have done. What we will do in 2017/18.

2016/17.
Continue to recruit pharmacists to 34 pharmacists recruited • Ongoing recruitment
provide smoking cessation support • Train pharmacy Technicians
as detailed in the Additional Funding • Undertake audit to review service
for Primary Care Delivery Agreement delivery
• Support development of an
integrated smoking cessation
service (all local providers)
Continue to develop and deliver the Developed a joint approach between • Support development of an
in-hospital smoking cessation service UHB Respiratory Services and Public integrated smoking cessation
as detailed in the Additional Funding Health Directorate. service (all local providers).
for Primary Care Delivery Agreement. • Support pilot of patient
management systems.
Continue to deliver the Early Years Midwives have received training and • Continues to support Midwifes
Smoking Cessation programme as equipment to ensure compliance with through training/.
detailed in the Additional Funding for NICE Guidance 26 • Audit Maternity Record to ensure
Primary Care Delivery Agreement. compliance with CO monitoring
guidance
• Work with Health Visiting service
to identify training needs in
relation to smoking cessation and
smoke free homes and cars.
• Work with School Health Nursing
teams to develop brief advice
training to support their role in
promoting smoking cessation.
3
(3) Action delivered for Alcohol and Substance Misuse and plans for 2017/18
Ambition: To reduce alcohol consumption and substance misuse in line with the new Welsh Government strategy
and promote a healthier conversation around these topic areas.
What we said we would do in 2016/17 What we have done What we will do in 2017/18
Lead on commissioning, partnership • Provided programme and Continue to provide commissioning,

development, financial management, project management to financial and programme and project
strategy programme planning and review the annual delivery management support to the regional
project management support for the plans in line with the new WG partnership for drug and alcohol
regional partnership for drug and alcohol Delivery Plan. misuse, the Area Planning Board and
misuse (the Area Planning Board) and • Governance workshops held implementation of the priorities
the Health Board. • Draft partnership agreement identified via the Commissioning
between APB partners Strategy for Drug and Alcohol Misuse
• Commenced work on the which will include:
development of the third - Tackling Alcohol related Brain
commissioning strategy. damage
• Submitted a business case - Co-occurring substance misuse
for the pilot of an alcohol and mental health pathways
screening and brief - Developing a more co-ordinated
intervention service within a approach to drug and alcohol
Pharmacy setting. education for young people within
schools, NEETS and home
schooled
Development and implementation of • Estates strategy produced Continue to develop and lead on the
APB Estates Strategy and capital work and submitted to Welsh estates planning for drug and alcohol
programme Government. service delivery, including securing of
• Service base in Abertyswyth, long term bases in Llanelli and
Ceredigion secured for a Pembrokeshire.
further five year period.
• Options for Pembrokeshire
and Llanelli still being
explored.
Establish, develop, implement and • Multi agency action plan in Continue to take action to ensure a
manage a robust processes for the place to tackle drug related reduction in drug related deaths
review of both fatal and non fatal drug deaths through a robust process for the
overdoses and lead on multi agency • Multi agency case reviews review of fatal and non fatal
case review process on behalf of the undertaken with lessons overdoses.
APB learned reports produced.
• Development discussions
held over role out of
‘Prenoxad’ across hospital
sites .
Provide support for the further Business case submitted for Continue to provide support for the
development and roll out of the Alcohol funding for an Alcohol Liaison further roll out of the Alcohol Liaison
Liaison Nurse scheme in secondary care Nurse in Withybush in order to Service.
settings in the UHB. ensure equitable service delivery
4
(4) Action delivered on the overweight and obesity agenda and plans for 2017/18
Ambition: Our ambition as a University Health Board is to work with our partners to ”turn the curve‟ in the upward
trend in individuals being overweight and to support families to give the next generation a greater chance of health.
What we said we would do in 2016/17 What we have done What we will do in 2017/18
Work in collaboration with other partners Concept of ‘10 Steps to a healthy Continue to develop and embed ‘10
of the public health system to develop, weight’ launched, promoted and Steps to a healthy weight’ across
deliver and support existing programmes embedded within all three county children’s and parents’ setting in
which aim to promote a healthy weight, 3 Healthy and Sustainable Pre- conjunction with all public health
especially in the first 1000 days (from School schemes. Directorate work plans with
conception to 2 years old – pregnancy Additional resources secured. additional focus on the promotion of
and early years). physical activity.
Continue to deliver the Early Years Joint approach between Public • Continue to develop and extend
Obesity Prevention programme, as Health, Midwifery services and the service and extend reach
detailed in the Additional Funding for local authority Exercise Referral across the 3 counties.
Primary Care Delivery Agreement. developed. Training and referral • Ensure all ‘Baby Let’s Move’ staff
systems established. are trained in the new ‘Foodwise
Publicity materials developed. in Pregnancy’ training package.
Services launched with referral • Monitor and evaluate.
now being received through
Midwives.
Qualitative research into Work with School Health Nursing
professional perceptions of teams to develop brief advice training
overweight and obesity in to support their role
maternal and early years Work with Health Visiting service to
conducted. Report finalised in identify training needs in relation to
November 2016. promoting healthy weight.
Development of a short film and • Develop communications
poster promoting healthy eating in plan
pregnancy, particularly to those • Monitor reach and evaluate
with lower literacy levels. feedback from pregnant
women and Midwives.
Continue to further develop the Lifestyle First year programme complete Second year programme agreed with
Advocates programme within primary and evaluated positively. Primary Care Clusters .
care clusters.
Develop and implement services for Business cases for adult services Continue to provide evidence and
Obesity Pathway Level 2 and 3 for at Level 2 and Level 3 developed information for the need to develop
children and adults. and submitted for consideration appropriate services across the levels
and prioritisation. of the All Wales Obesity Pathway
framework.
Continue to work in partnership to Walking initiatives promoted and Continue to work with partners,
support initiatives that increase physical bilingual resources developed. particularly in Primary Care and Local
activity and reduce sedentary behaviour. Playful walks promoted for Authority Leisure Services to promote
children and families in physical activity opportunities,
conjunction with partners. including targeted interventions for
Physical activity for older adults young people and frail elderly.
promoted.
Physical activity promoted as
positive for mental health and
wellbeing.
Local authority partners
supported to deliver physical
activity programme for young
people disengaged from team or
group activities.
5
(5) Action delivered on increasing survival rates for cancer through prevention, screening, earlier diagnosis,
faster access to treatment and improved survivorship programmes and plans for 2017/18
Ambition: Our ambition as a University Health Board is to work with our partners to decrease mortality rates from
cancer in the general population, and to increase survival rates of those who have been diagnosed with cancer.
What we said we would What we have done What we will do in 2017/18

do in 2016/17
Prevention of cancer Work underway on obesity, alcohol, sexual See separate sections on smoking,
health and smoking – see other sections. obesity, alcohol and sexual health.
Early detection • Screening: The Screening for Life campaign • Bowel Screening Uptake project
in 2016 aimed to raise awareness of cancer will be carried out across four of
and improve uptake of bowel, breast and seven GP Cluster areas
cervical cancer screening programmes. • Promote uptake of screening
Action is targeted on improving bowel through Screening for Life 2017
screening rates through joint working with campaign
primary care clusters and the third sector. • Explore business case
• Bowel Cancer Screening uptake – patient opportunities for additional
participation project. Working with the Third investment in campaigns to raise
Sector and community groups we undertook awareness of symptoms among
638 conversations with individuals within the general population
the target age group to explore views on
uptake of the screening programme192
structured questionnaires were completed,
13 case studies were gathered, and focus
group discussions were held. The results
will inform the Screening for Life 2017
campaign.
• Commitment secured from 4/7 Primary
Care Clusters to work to increase the
uptake of Bowel Screening invitations.
• Appointment of Hywel Dda Macmillan
funded GP Cancer lead.
Survivorship • We conducted a scoping review of the • During 2017/18 we will establish a
literature on survivorship which will inform Task and Finish Group on
the work of the survivorship Task and Finish survivorship, to review services in
group in 2017/18 place once patients are
discharged from cancer treatment
services, and identify
opportunities for the third sector to
get involved, to improve patients’
experiences and quality of life
post-treatment.
6
(6) Action delivered on the early years agenda and plans for 2017/18.
Ambition: To provide comprehensive coverage of the universal health services as per the Healthy Child Wales
Programme, and work with partners to deliver innovate services for our families and children.
What we said we would What we have done What we will do in 2017/18.

do in 2016/17
Promoting the principles of Commenced Implementation of the Welsh Deliver the HCWP within allocated
effective partnership Government (WG) Healthy Child Wales Health Visiting and School Nursing
working to improve health Programme (HCWP) 0-7 years from October 1st resource.
outcomes Health Visiting Workforce trained in Maternal Undertake MIMHS assessment for
Infant Mental Health (MIMHS) all new born parent and baby as Part
of the HCWP
Continued partnership working with the 3 Local Continue partnership working
Authorities delivering the Health Visiting element alignment Flying Start Health Visiting
on the Flying Start Agenda 0-4 years Programme with the HCWP.
Representation from the School Nursing Implementation of the revised
Management Team on WG Task and Finish framework including identification of
review of the School Nursing Framework. workforce resource.
Provide a comprehensive accessible to school
aged children and young people within the
community
Work with Local Authority Contributed to the development of Families First Continue to deliver the Flying Start
partners to deliver Welsh plans and Flying Start programme plans in Health Visiting programme and
Government tackling conjunction with the Local Authorities to ensure partnership projects focused on
poverty programme that there are a range of projects which will responding to the needs of the most
activities across the deliver on the WG population indicators, vulnerable young people e.g. HDUHB
Health Board including health outcomes. Youth Health Team.
The above is simply an illustration of the range of activities underway. We also have significant ambitions and
achieved significant progress in the following areas:
Mental wellbeing - Ambition: To promote healthier mental wellbeing amongst our communities, and promote the
Five Ways to Wellbeing approach within the organisation and with partners.
Immunisation and Vaccinations - Ambition: Our ambition as a University Health Board is to support our partners
in primary care to increase the uptake of immunisations and vaccinations in eligible populations. This ambition
extends to both childhood and adult schedules of vaccinations with a particular focus on actions to reach Tier 1 Welsh
Government targets.
Community Resilience – Ambition: We want to see our communities growing in resilience and to develop greater
self care approaches.
Sexual Health – Ambition: To develop an up-to-date strategy on sexual health and wellbeing for our population and
to transfer the service hub to a more modern environment.
7
PRIMARY AND COMMUNITY CARE
Carmarthenshire
Carmarthenshire
Objective 1: Community, Universal and Prevention (the Currently well person)
Service
Task Action Q1 Q2 Q3 Q4
area
To consider WG response to Population Needs Assessment
√
submitted
Locality Leadership Teams to co produce Locality Plans with
Population Areas Plans / √ √ √
all stakeholders
Needs Cluster and
Measurables: Monthly Locality Leadership Group Meetings in
Assessment Locality Plans √
place
Draft Locality Plan produced and shared for consultation and
√
signed off
‘Proof of Concept’ service evaluated and substantive service
√
established
Single Point of Performance Framework developed and reporting
Access √
mechanisms established
Performance reviewed monthly and assurance provided √ √ √
IAA
Independent
ILC ‘goes live’ √
Living Centre
‘Dewis’ established and information quality assured and
Directory of √ √ √ √
updated
Service
Performance monitored as per governance outlined √ √ √ √
Evaluate CUSP pilot from Q4 16 / 17 in Llanelli and extend to
Social √
Community 3Ts and Amman Gwendraeth
Prescription /
resilience Evaluate position against agreed performance measures and
PIVOT / CUSP √ √ √
its wider impact
Lifestyle Primary Care
advocates
Public
Obesity
Health & Public Health
pathways
Engagement
Smoking
Public Health
cessation
Evaluate current provision ‘Strength and Balance’ programmes
√
in the community
Develop plan for improving and extending to other specialist
National √
populations
Exercise
Leisure Implement plan for specialist populations √
Referral
Scheme Review performance across provision √
Evaluate current position and consider proposals for future
√
development
Submit proposals for future development for 2018/19 √
Submission of proposals to ICF to enhance ‘Care and Repair’
resource based on ‘proof of concept’ Information, Advice and √
Assistance and its impact on increased referrals to the service
Housing / Care and
Implement proposed ICF plans if approved by Integrated
Equipment Repair √
Services Board
Review performance across provision √
Social Worker appointed to support ‘Carers Information
√
Service’
Assessment Establish baseline position and develop the role to meet
√
and Support agreed targets
Review performance and improvement √ √
Carers
To progress GP practices from bronze level to silver level √ √ √ √
Investors in across all practices in Carmarthenshire.
Carers Develop / Identify ‘carer’ training opportunities √ √ √ √
To appoint carer champions. √ √ √ √
8
Objective 2: Intermediate Care (Living with an ongoing condition)
Service area Task Action Q1 Q2 Q3 Q4
Implement new ‘short term assessment & acute response’ √
pathway based on intelligence gathered during Q4 ‘proof of
concept’ outlined in narrative above
Implement ‘long term care pathway’ based on intelligence √
gathered during Q4 ‘proof of concept’ outlined in the
narrative above
Recruitment to support the implementation of the pathways √
is ongoing in Q3 / Q4 16 / 17
Introduce ‘Care 2 Move’ into community hospitals. √
Recruitment of X4 HCSW ongoing in Q3 / Q4 16 / 17
Implement new ‘short term assessment & acute response’ √

Community pathway based on intelligence gathered during Q4 ‘proof of
Resource concept’ outlined in narrative above
Teams Implement ‘long term care pathway’ based on intelligence √
narrative above
Implement ‘long term care pathway’ based on intelligence √
narrative above
Recruitment to support the implementation of the pathways √
is ongoing in Q3 / Q4 16 / 17
Introduce ‘Care 2 Move’ into community hospitals. √
Recruitment of X4 HCSW ongoing in Q3 / Q4 16 / 17
(Multi
professional /
Review pathways against agreed measures and impact on √ √ √
multi skilled)
regional unscheduled care position
Workforce
Go Live’ at end of March 2016 for Carmarthenshire √
Service specification for ‘111’ in Carmarthenshire is being √

developed alongside the ‘proof of concept’ programme for
IAA and Community services outlined in the narrative
above. The service specification contains robust care
bundles which allow rapid access to support the following:
• Blocked catheters, √
• Frail adults ‘off their legs’ due to acute episode, √
• Palliative Care, √
111
• Mental Health, √
Consolidate implementation of pathways to ensure √

avoidance of conveyance. Monthly ‘highlight’ meetings with
WAST and ‘111’ to monitor position and response
Monthly ‘highlight’ meetings with WAST and ‘111’ to √ √ √

monitor position and response
Review pathways against agreed measures and impact on √ √ √
Consider proposals for service improvement in 17 / 18 √
Reablement and Recommissioned provider services to commence and √
Rapid Response deliver against agreed standards.
Joint
Domiciliary Care
Commissioning
Carmarthenshire Introduce ‘Care 2 Move’ into community hospitals. √
/ Pooled
Integrated Recruitment of X4 HCSW ongoing in Q3 / Q4 16 / 17
Budgets
Community Consider recommendations of regional review and develop √
Equipment Store action plan as appropriate
9
(CICES) ‘pooled budget’ in shadow format √
‘Pooled
Budgets’ for Review pathways against agreed measures and impact on √ √ √
Older adult regional unscheduled care position
services Review pathways against agreed measures and impact on √ √ √
To ensure recruitment completed against agreed proposals

√
for 16 / 17
ICF Initiatives
To review existing programme against national and √ √ √ √
regional priorities and consider planning for 18 / 19
To review existing service and report against agreed √ √ √
measures. Monitor impact locally and regionally against
TOCALS; AAA;
unscheduled care targets.
MAST
To consider service enhancements and potential proposals
√
for ICF 18 / 19
To implement service in Glangwili General Hospital √
To review service through monthly ‘highlight’ meetings and
√
Rapid Access report against agreed measures.
Frailty Service To review impact of service on unscheduled care targets √
To evaluate service and consider enhancements for 18 /
√
Responsive 19
and To review existing service and report against agreed √ √ √
Proportionate measures. Monitor impact locally and regionally against
CCCT unscheduled care targets.
To consider service enhancements and potential proposals
√
for ICF 18 / 19
Project Implementation Document completed √
Regional Project Manager Appointed and Regional Project √

WCCIS; WCCG;
Board established and meetings progressing to implement
e-referrals
WCCIS across region by April 2018
Progress and exception reporting against timescales to √ √ √
Project Board
Objective 3: Long Term Care (The frail and vulnerable to losing life skills)
Service
area
Progress the ‘Releasing Time 2 Care’ initiative – this ensures √
that we reduce double handed care and high frequency calls
Long term where appropriate.
Prudent
conditions Review impact of initiative against unscheduled care targets √ √ √
commissioning
(including and national DTOC position
of long term
frailty; Evaluate outcomes at year end √
care
dementia)
Consider improvement proposals to submit √
Pilot of the Implement Pilot - To strengthen service in relation to hospice

√
Palliative Amber care at home model throughout the 24 hour period
care and bundles in √ √
Review impact of the pilot
End of Life PPH and
Care WGH for one Consider substantive implementation of the bundles and
√
ward each site submission of proposals to support resourcing for 18 / 19
Core curriculum training to continue 4 times a year in Carms. √
Advance Specialist Wider community nursing to access specific training – to √

care palliative care achieve 25% by end Q1
planning team CDM nurses to be actively involved √
50% wider community nursing and CDM nurses attended √
10
training
75% wider community nursing and CDM nurses attended

training √
100% wider community nursing and CDM nurses attended

training √
To evaluate existing service at year end and consider

√
enhancements as appropriate
√ √ √
To monitor effectiveness against agreed targets
In house
model To evaluate existing service at year end and consider
√
Continuing √ √ √
To monitor effectiveness against agreed targets
Health Care ‘Step Up /
Step Down’ To evaluate whether current provision and its resourcing is
√
Assessment adequate
beds To evaluate existing service at year end and consider
√
11
Ceredigion
Ceredigion
Service Task Action Q1 Q2 Q3 Q4
area
Population Ceredigion Assessment of Assessment of local well-being going out for public √
Needs Local Well-being consultation
Assessment Mid Wales Collaborative Assessment going out for public consultation √
Assessment of Population
Needs
Primary Care Cluster Both cluster plans agreed √
Plans Cluster plans built upon √ √ √
IAA Single point of access Follow agreed development plan √

Single point of access for Follow agreed development plan √
rd
Core 3 Sector CRT
Community Social Prescription Implementing and monitoring social prescription √
resilience models
Pilot IT solutions Evaluating rally round √
Public Lifestyle advocates Increase the number of patient contacts √ √ √ √
Health and
Engagement
rd
3 sector facilitators Increase the number of professionals contacts
Leisure
Housing / Maintaining independence Dependent upon 2017-18 ICF Funding √
equipment through provision of
accommodation based
solutions
Carers Assessment and Support Increase the number of assessments undertaken √ √ √ √
Investors in carers Increase the number of GPs obtaining Silver award √ √ √ √

(Multi Core Community TUPE of staff √
professional / Resource Team Review and development of Service Spec and √
multi skilled) development of KPIs
Workforce Improvement in KPIs √ √
Community falls clinic Increase the number of patients seen √ √ √ √
√ √ √ √
rd
3 sector facilitators Increase the number of professional contacts made
Joint Core Community TUPE of staff √
commissioning Resource Team Review and development of Service Spec and √
/ pooled development of KPIs
budgets Improvement in KPIs √ √
Joint stores Continued good performance of Section 33 √ √ √ √
agreement
√ √ √ √
rd
Core 3 sector CRT Increase the uptake of service users with improved
outcomes
Learning Disability / Increase the uptake of service users with improved √ √ √ √
Mental Health outcomes
Community Resource
Team
Responsive TOCALS; AAA; MAST Increase in the number of patients turned around at √ √ √ √
and the front door, reduced the LOS post MF date
Proportionate Residential Assessment Increase the improved outcomes for patients √ √ √ √
Beds
Nursing Assessment Increase the improved outcomes for patients √ √ √ √
Beds
√ √ √ √
rd
Core 3 Sector CRT Increase the uptake of service users with improved
outcomes
ICT WCCIS; WCCG; e-
12
referrals
Service
area
Long term Dementia Supportive Continue the evaluation work associated with √ √ √ √
conditions Communities Dementia Supportive Communities
(including
frailty;
dementia)
√ √ √ √
rd
Palliative Links with 3 Sector Meet the needs of palliative patients
care and Providers
End of Life
Care
Advance Continuation of the Increase numbers of ACP √ √ √ √
care education programme
planning in relation to ACP
Continuing Assessment beds Increase percentage of patients who are being √ √ √ √
Health Care assessed in an appropriate setting
13
Pembrokeshire
Pembrokeshire
Service
area
Pembrokeshire Assessment Assessment of local well-being going out for
√
of Local Well-being public consultation
Mid Wales Collaborative
Population Assessment of Population Assessment going out for public consultation √
Needs Needs
Assessment
Primary Care Cluster Plans Both cluster plans agreed √
√ √ √
Cluster plans built upon
Single point of access Follow agreed development plan √
IAA Directory of Service guide to
Follow agreed development plan √
better care and support
Social Prescription Implementing and monitoring models √
Luncheon clubs Implementing and monitoring models √
Community
Good neighbour scheme Implementing and monitoring models √
resilience
50 plus forum Implementing and monitoring models √
Community connectors Implementing and monitoring models √
√ √ √ √
Lifestyle advocates Increase the number of patient contacts
Public Public health initiatives e.g. √ √ √ √
Health and smoking cessation; obesity Increase the number of patient contacts
Engagement pathway
rd √ √ √ √
3 sector facilitators Increase the number of professionals contacts
√ √ √ √
Leisure NERS Increase the number of patient contacts
Housing / Care and repair; equipment; Dependent upon 2017-18 ICF Funding √
equipment PIVOT
Assessment and Support Increase the number of assessments √ √ √
Services undertaken √
Carers
Increase the number of GPs obtaining Silver √ √ √ √
Investors in carers
award
14
Review and development of Service Spec and
Core Community √
(Multi development of KPIs
Resource Team
professional / Improvement in KPIs √ √
multi skilled) Community falls √ √ √ √
Increase the number of patients seen
Workforce clinic
Reablement Increase the number of professional contacts made √ √ √ √
Reablement Improvement in KPIs √ √ √ √
Joint stores Continued good performance of Section 33 agreement √ √ √ √

Joint
commissioning ICF programme Increase the uptake of service users with improved √ √ √ √
/ pooled of works outcomes
budgets Learning Draft joint Learning Disability strategy out for consultation √
Disability / Mental √ √ √
Health Increase the uptake of service users with improved
Community outcomes
Resource Team
Increase in the number of patients turned around at the √ √ √ √
MAST
front door, reduced the LOS post MF date
Intermediate care Increase the improved outcomes for patients √ √ √ √
beds / Hillside
Responsive
residential home /
and
Bro Preseli extra
Proportionate
care flats
Nursing Increase the improved outcomes for patients √ √ √ √
Assessment Beds
WCCIS; WCCG;
ICT
e-referrals
Service
area
Long term Dementia Continue the evaluation work associated with Dementia √ √ √ √
conditions Supportive Supportive Communities
(including Communities –
frailty; frailty; heart failure;
dementia) leg ulcers
Palliative Meet the needs of palliative patients √ √ √ √
rd
care and Links with 3
End of Life Sector Providers
Care
Advance Cluster funded Increase numbers of ACP √ √ √ √
care programme in
planning relation to ACP
Continuing Increase percentage of patients who are being assessed √ √ √ √
Assessment beds
Health Care in an appropriate setting
15
Primary Care
Primary Care
area
Population Locality Development Review of achieved actions 2016/17 and submission √
Needs & Planning of annual reports
Assessment Development and implementation of 2017/18 annual √
plan
Implementation of annual plan and investment / √ √ √
service improvement plan
Developing primary Pending national update – once the portal has been √
care portal to support refreshed this will be available to all Localities
peer review and
discussions on clinical
variation
Community Primary Care Estates PIG funds allocated to practices based on application √
resilience strategy development and prioritisation exercise
& implementation GMS Estates audit completed and GP surgeries √
prioritised for investment
Primary and Community Estates strategy in √ √
development
GMS Estates audit fed into strategy development √
PIG schemes completed and practices reimbursed √
before the end of the financial year
Aberaeron development discussions commence √
Aberaeron development ongoing √ √ √
Cross Hands development discussions commence √

Cross Hands development ongoing √ √ √
Building Coaching Network Coaching cohort 4 √

√
st
Integration 1 Coaching network meeting
Capacity Coaching cohort 5 √
√
nd
2 Coaching network meeting
Coaching cohort 6 √
√
rd
Coaching cohort 7 √
√
th
Locality backfill support Pending availability of training places from PCID √
for independent
contractor leaders
Locality development Review of locality training to date √
training - project
management, Locality coaching and short development training – √
evaluation, facilitation North Ceredigion and Amman Gwendraeth
Development and implementation of plan aligned to √
PCID Hub
Implementation of plan √ √
Integrated Education Development of integrated education plan for the √

University Health Board subject to available funding
within annual plan
Implementation of education plan √ √ √
Access Sustainable GMS 7 pillars model to be refreshed √ √ √ √

Services
Review and update sustainability support information √ √ √ √
subject to evaluations of projects
Manage contact changes as required √
Develop sustainability priority plan for discussion with √
16
LMC
Big proactive care event to share learning and √ √
develop networks
Develop sustainability plans in each locality √
Identify sustainability support for next IMTP √
Collaborative / Review learning from North Ceredigion and share √
Federations / Mergers with all localities
Review learning from North Pembrokeshire and √
share with all localities
Review learning from Amman Gwendraeth and share √
with all localities
Develop a plan for next IMTP to maximise impact of √
learning
Primary Care Support Recruitment of additional GPs √ √ √ √
Team
Recruitment of additional roles – 1 Project Manager; √
1 Bank Admin
Charging tariff in place and implemented √
Evaluation of Primary Care Support Team in line with √
National Pacesetter Programme
EHEW and LVWS Pending resource to support monitoring and service √
development improvement for this newly devolved work
Increased dental Commence newly commissioned dental activity √
capacity Undertake further commissioning subject to funding √
availability
Increased orthodontic Commence newly commissioned dental activity √
capacity Undertake further commissioning subject to funding √
availability
Community Pharmacy Develop further triage and treat pharmacies √ √ √ √
unscheduled care
access schemes Develop further emergency dispensing pharmacies √ √ √ √
Develop further common ailment pharmacies √ √ √ √
Paediatric GA access Pending review of work from ABMU & new Clinical √
and pathway Lead
Implement new pathway √
Monitor & evaluate √
Present changes to BPPAC in order to consider √
further development in 18/19
Unscheduled care Evaluate initial 2 pilots and develop a business case √
telephone consultation for broader implementation
project Present outcomes to PCSC, LMC & BPPAC √
Develop service subject to business case & resource √
Increased uptake of Share delivery information with all practices through √ √ √ √
MHOL Locality Network – understand implementation plans
& limitations
Choose well Locality Choose Well leaflets to be recirculated and √
key tourist information areas.
Argyle Schools Project- Choose Well Input √
Summer Social Media Campaign x 3 √
Attendance at a minimum of 3 freshers fairs to √

promote Choose Well and available services
Christmas Social Media Campaign x 3 messages √
Involvement in Winter wise campaign √
Winter Wise social media campaign √
Welsh language Develop plan with Welsh Language Team √

17
development in Benchmark Community Pharmacy, Dental and √
primary care Optometric capacity
Review whole Primary Care Plan & Implement √
Shifting Vasectomies Develop business case for shift with Urology team √
settings of Implement subject to resource availability √
care out of Dermatology Develop business case for shift with Dermatology √
hospital team
Implement subject to resource availability √
INNU Develop business case for shift with Referral √
Management team
Follow Up care Develop business case for shift with Secondary Care √
team
Public Patient Participation PPG Development Network Meeting to coincide with √
Health & Networks & PPG Awareness Week – June 2017
√
nd
Engagement Engagement 2 Round of Patient Engagement Framework
Awards- Application Process Open
PPG Development Network – December 2017 √
Big Proactive Care Big Proactive Care Event √ √
Events
Design 2 smile Monitor delivery through DPPDB – update plan as √ √
appropriate
CVD & Diabetes Review learning from Locality project to date and √
screening develop new plan subject to resource available
Lifestyle advocates Continue delivery of team based approach √ √ √ √
programme
Smoking cessation Continue to develop community pharmacy based √ √ √ √
services
Carers Investors in Carers - Continue to implement programme with Carers team √ √ √ √
GMS, CP

(Multi Integrated workforce Pending clarification of available resource √
professional / planning
multi skilled)
Workforce Centralised Re-launch of Hywel Dda Primary Care recruitment √
recruitment support strategy/framework
Overseas GP Evaluation of Process established in last qtr and √
programme
full implementation.
Development of exchange programme and √
opportunities for overseas doctors
Recruitment fair in Netherlands √
Community chronic Evaluation of existing pilots √
condition / frailty
nurses
Advanced paramedic Joint business case for the development of Advanced √
practitioners paramedic practitioners pipeline
Primary Care OTs Primary Care OT role to be implemented √
Primary Care Primary Care physiotherapist role to be implemented √
Physiotherapists (non-MSK)
Academic & Post CCT Minimum of 1 academic fellow to commence working √
Fellowships (application dependent)
Physician’s Swansea University based Physician’s Associates to √
Associates commence placements in Primary Care
Practice nurse Implement Practice Nurse bank subject to available √
development resource
HCA development Review training and development plan with Practice √
Development Team
Implement plan subject to resources and approval √
18
Clinical Pharmacist Review training and development plan with Medicines √
role development Management Team
Implement plan subject to resources and approval √
Widening access Evaluation of schools programmes undertaken in last √
/future skills quarter
1 schools enterprise day √ √
Long term Special Care Dental Finalise pathway OCP √

conditions pathway Implement pathway subject to approval √
(including Anti-coagulation one Review following communication of national √
frailty, stop shop service anticoagulation enhanced service negotiation
dementia) Community Heart Evaluate and report outcome of pilot to PCSC; LMC √
Failure clinics and BPPAC
Develop business case or implementation as √
appropriate
Community Evaluate and report outcome of pilot to PCSC; LMC √
dermatology clinics and BPPAC
appropriate
Diabetes Enhanced Review following communication of national diabetes √
Service enhanced service negotiation
Phlebotomy services Review following communication of national √
phlebotomy enhanced service negotiation
Patient education Continue to implement programmes across three √ √ √ √
programmes counties
Pulmonary Evaluate and report outcome of pilot to PCSC; LMC √
rehabilitation & and BPPAC
COPD+ Develop business case or implementation as √
appropriate
Respiratory MUR+ Evaluate and report outcome of pilot to PCSC; LMC √
and BPPAC
appropriate
LD and MH reviews in Review current benefits of enhanced service √
primary care Develop implementation plan √
Negotiate with providers and LMC – submit business √
case for further funding if required
Dementia early Evaluate and report outcome of pilot to PCSC; LMC √
diagnosis and shared and BPPAC
care Develop business case or implementation as √
appropriate
Glaucoma follow up Evaluate and report outcome of pilot to PCSC; LMC √
and BPPAC
appropriate
Wet AMD follow up Evaluate and report outcome of pilot to PCSC; LMC √
and BPPAC
appropriate
Frailty clinics Evaluate and report outcome of pilot to PCSC; LMC √
and BPPAC
appropriate
ICT Tele dermatology Pending resource availability √
Microsoft LYNC to Evaluate and report outcome of pilot to PCSC; LMC √
support remote and BPPAC
working Develop business case or implementation as √
appropriate
Vision 360 Evaluate and report outcome of pilot to PCSC; LMC √
and BPPAC
appropriate
Electronic discharge Pending roll out by IM&T team √
19
summaries
WCCG Advice & Pending roll out by IM&T team √
Guidance
Pharmacy, Dental & Pending roll out by IM&T team √
Optom NHS network
Palliative Advanced care Evaluate and report outcome of pilot to PCSC; LMC √
rd
care and End planning with 3 and BPPAC
of Life Care sector Develop business case or implementation as √
appropriate
Palliative care Evaluate and report outcome of pilot to PCSC; LMC √
medication in CP and BPPAC
appropriate
Advance Multi-disciplinary Evaluate and report outcome of pilot to PCSC; LMC √
Care patient reviews and BPPAC
Planning Develop business case or implementation as √
appropriate
Care homes DES Review following communication of national Care √
Homes enhanced service negotiation
Anticipatory care Evaluate and report outcome of pilot to PCSC; LMC √
plans and BPPAC
appropriate
Risk stratification Pending feedback on MSDi utilisation as part of frailty √
schemes
Service
area
As above This overlaps with As above √ √ √ √
most of the issues
raised above -
Reason 2 smile Develop plan and business case for implementation - √
support for care present to DPPDB and PCSC
homes Implement as agreed √
Care Homes DES Review following communication of national Care √
Homes enhanced service negotiation
20
A REGIONAL COLLABORATION FOR HEALTH
As per the ARCH Portfolio Development Plan (Annex Document)
21
MID WALES HEALTHCARE COLLABORATIVE (MWHC)
Priority Action Q1 Q2 Q3 Q4
MWHC
Continuation of the MWHC, with revised Formalise the chairing arrangements for a further 12 
support arrangements, for a further 12 months (March 2017 to March 2018) for the two
months, as a transitional arrangement, existing Independent co-chairs.
for the period March 2017 to March 2018. Review and revise MWHC support arrangements 
(led by Chief Executives of the NHS organisations)
Secure the required funding and resources for 
support arrangements.
Bronglais General Hospital
Implementation of a Clinical Strategy for
Development of a joint workforce model
across Mid Wales for Unscheduled Care.
Establish a new closed MRI scanner
servicing all specialities.
Telehealth
Develop a Technology Enabled Care & • Identify and maximise the opportunities for
Support (TECS) Strategy and Bronglais General Hospital to reach outwards
Implementation Plan (three year) for Mid via TECS services;
Wales. • Identify and maximise opportunities for people
to reach inwards to Bronglais General Hospital
via TECS services;
• Identify opportunities for Clinician to Clinician
communication and collaboration via TECS
services including primary care and the
community;
• Establish Bronglais General Hospital as a
Telemedicine learning centre for Clinical staff
across Wales.
On-going implementation of the following • Home Monitoring and Follow Up for Patients
4 projects which have been allocated with Pacemakers and Implantable Cardiac
funding: Devices.
• Home Monitoring and Follow Up for • Utilise a mobile telemedicine unit for the use of
Patients with Pacemakers and foetal, neonatal and paediatric population in all
Implantable cardiac monitors Welsh hospitals
• Utilising a mobile telemedicine unit for • Home UV-Phototherapy for Chronic Skin
the use of foetal, neonatal and Disease in Rural Wales
paediatric population in all Welsh • Hub & Spoke Technology Enabled Care
hospitals Outpatient Department Clinics. Links to Hub
• Home UV-Phototherapy for Chronic and Spoke development above. (This links to
Skin Disease in Rural Wales 3.1 above)
• Hub & Spoke Technology Enabled
Care Outpatient Department Clinics
Palliative Care / End of Life
Implement the overarching
recommendations scoping report.
Primary and Community Care
Establish an integrated community Development of an intermediate oral surgery service
focused dental service across the Mid for complex extractions.
Wales area with key priorities being: Development of a joint General Anaesthetic list
(involving Community Dental Service staff) in
Bronglais General Hospital.
Development of a maxillofacial service which avoids
the unnecessary use of secondary care services.
All parts of the Mid Wales area to have
ready access to an integrated health and
social care service which seeks to (a)
prevent the unnecessary admission of
patients to hospital; and (b) the speedy
and safe return to the community of
22
Priority Action Q1 Q2 Q3 Q4
those who are been necessarily
admitted. All such services to have the
pivotal involvement of GPs and the full
support of community nursing, therapies,
social care and the third sector.
Access and Transport
Strengthen our approach to management
of frequent callers into the ambulance
services, ensuring that patients are
managed in accordance with their needs
on a multi agency based approach.
Ensure better alignment between clinic
times/Day Surgery and patient transport.
Incorporate learning from the four
Community paramedic pilots across
Wales (one in Powys) to other parts of
Mid Wales.
Delivery of the new model of NEPTS
services, lining WAST and other provider
of patient transport, including learning
from the pilot in North Wales
Mental Health and Learning Disabilities
Develop local crisis / recovery beds in
Aberystwyth with potential Service Level
Agreements across Health Boards for
clinical pathways.
Health and Well-being
Develop the Green Prescribing project to
optimise environmental health and
wellbeing benefits.
Develop the Community Resilience

project to promote and developing
resilience within our local communities.
Develop the Carers Resilience Project to
build carers resilience and help maintain
their wellbeing.
Centre for Excellence in Rural Health and Social Care
Continue the work of establishing a
Centre for Excellence in Rural
Healthcare, with a particular focus on
research, development and
dissemination of evidence in health
service research which addresses the
particular challenges of Mid Wales.
Communications, Engagement and Involvement
Develop a co-design strategy for Mid
Wales.
23
STRATEGIC OBJECTIVES
Strategic Objective 1 – To encourage and support people to make healthier choices for
themselves and their children and reduce the number of people who engage in risk taking
behaviours.
Strategic Objective 1

area
Tobacco Continue to recruit Ongoing recruitment. √ √
control pharmacists to provide Train Pharmacy Technicians. √ √
smoking cessation Support development of an integrated smoking √ √
support as detailed in the cessation service.
Additional Funding for Undertake audit to review service delivery. √ √
Primary Care Delivery
Agreement.
Continue to develop and Support development of an integrated smoking √ √
deliver the in-hospital cessation service (all local providers).
smoking cessation service Support pilot of patient management systems. √ √
as detailed in the
Additional Funding for
Primary Care Delivery
Agreement.
Continue to deliver the Continues to support Midwives through training. √ √
Early Years Smoking Audit Maternity Record to ensure compliance with √ √
Cessation programme as CO monitoring guidance.
detailed in the Additional Work with Health Visiting service to identify training √ √
Funding for Primary Care needs in relation to smoking cessation and smoke
Delivery Agreement. free homes and cars.
Work with School Health Nursing teams to develop √ √
brief advice training to support their role in
promoting smoking cessation.
Drug and Development and Securing of long term bases in Llanelli and √ √
Alcohol implementation of APB Pembrokeshire.
Misuse Estates Strategy and Continue to develop and lead on the estates √ √
capital work programme. planning for drug and alcohol service delivery,
including securing of long term bases in Llanelli and
Pembrokeshire.
Establish, develop, Multi agency action plan in place to tackle drug √
implement and manage a related deaths.
robust process for the Multi agency case reviews undertaken with lessons √ √
review of both fatal and learned reports produced.
non fatal drug overdoses Development discussions held over roll out of √ √
and lead on multi agency Prenoxad across hospital sites and progress
case review process on implementation of Information Sharing Protocol for
behalf of the APB non fatal overdoses.
progressing work on implementation of the √
Information Sharing Protocol for non fatal
overdoses.
Sexual Improve the collection of Define targets for sexual health based on new data √ √
Health accurate sexual health capture arrangements
data for Hywel Dda. Evaluate new data. √
Publish QA data. √
24
Strategic Objective 2 – To reduce overweight and obesity in our local population.

To continue to deliver the early years obesity prevention
programme funded by Primary Care development √ √ √ √
funding
Monitor and evaluate the ‘Baby Lets Move’ service
√ √ √ √
(Referral to exercise in pregnancy)
Develop and deliver comms plan to promote healthy
√
eating and physical activity in pregnancy
Develop and deliver brief intervention training for Health
√ √
Visitors and School Health Nurses
Public Health Team to work with dietetic service to
Community
deliver specialist healthy eating advice for HVs and SNs √ √
based prevention
following research findings
and early
Continue to develop and embed national ’10 steps to a
All Wales intervention- √ √
healthy weight’ across children’s and parent’s settings
Obesity Early
Continue to deliver Nutrition Skills for Life training
Pathway Years/Children √ √
(nutrition and dietetics)
Level 0/1 and Young
Commence delivery of practical cooking skills‘ Get
People √
Cooking’ programme
Continue to deliver Healthy Schools and Healthy Pre-
schools Schemes to promote environments that support √
healthy weight
rd
Continue to work local authorities and 3 sector
colleagues to support initiatives that increase physical √
activity and reduce sedentary behaviour.
Continue to deliver Healthy Schools and Healthy Pre-
schools Schemes to promote environments that support √
healthy weight
rd
Continue to work local authorities and 3 sector
Adults/Older
colleagues to support initiatives that increase physical √
Adults
activity and reduce sedentary behaviour.
Community and Continue to roll out ‘Foodwise for Life’ programme √ √
primary care
Level 2 weight Business case for adult Level 2 service developed and
n/a
management submitted for consideration and prioritisation
services
Continue current (limited) Level 3 MDT intervention for
Specialist MDT √
adults (detail to follow)
weight
Level 3 Business case for extension of adult Level 3 service
management
developed and submitted for consideration and n/a
Service
prioritisation
Specialist
Continue appropriate MDT referral to ABMU (WISMOS)
Level 4 medical and √
bariatric surgery service.
surgical services
25
Strategic Objective 3 – To improve the prevention, detection and management of
cardiovascular disease in the local population.
Governance Establish overarching governance framework to take forward √
SO3 and reporting process
Establish an SO3 steering group √
Re-establish group to take forward the heart disease delivery √
plan
Establish clear links with current Health Board wide stroke √
steering group
Confirm and develop input into the All Wales groups on Heart √
Disease and Stroke
Measures √
Groups established with clear terms of reference √
Membership on all Wales groups with clear reporting through to √
local groups
Regular reports through Committee structure √
Clear plans developed through groups √
Dashboard of monitoring √
Local delivery plans and SO3 objectives clearly aligned √
Monitoring of plans and appropriate reporting √ √
Improvement trajectories defined and in place √
Refresh of plans for next year √
Plans approved for 18/19 IMTP √
Cardiovascular risk Commence Living Well Living Longer Programme in South √
reduction programme Pembs Cluster
Roll out to one other cluster (TBC) dependent upon level of √
funding available
Business plan to roll out across the HB for inclusion in 18/19 √
IMTP
Monitoring of programme √
Audit Agree plan for full compliance with MINAP audit √
Implement plan √
Continuous monitoring √
Working with Primary Directive to primary care pharmacists to optimise prescribing for √
Care and Community AF
Services Develop a Business Case to ensure AF Community Nurses in √
post in all counties
Work with clusters to identify further opportunities to improve on √
QOF targets
Heart Failure Consider a specific aim for Heart Failure √
Action plan for Heart Failure building from Heart Failure audit √
26
Strategic Objective 4 - To increase survival rates for cancer through prevention, screening,
earlier diagnosis, faster access to treatment and improved survivorship programmes.
What we What we have done What we will do in 2017/18

said we
would do in
2016/17
Prevention of • see Strategic Objective 1 for achievements in reducing See plans for Objective 1 for 2017/18
cancer smoking prevalence and alcohol consumption, and
improving sexual health
• see Strategic Objective 2 for achievements in preventing See plans for Objective 2 for 2017/18
and reducing overweight and obesity; and promoting
healthy diet and physical activity
Early • Screening: The Screening for Life campaign in 2016 • Bowel Screening Uptake project
detection aimed to raise awareness of cancer and improve uptake will be carried out across four of
of bowel, breast and cervical cancer screening seven GP Cluster areas
programmes • Promote uptake of screening
• Action is targeted on improving bowel screening rates through Screening for Life 2017
through joint working with primary care clusters and the campaign
third sector. • Explore business case
• Bowel Cancer Screening uptake – patient participation opportunities for additional
project. Working with the Third Sector and community investment in campaigns to raise
groups we undertook 638 conversations with individuals awareness of symptoms among
within the target age group to explore views on uptake of the general population
the screening programme192 structured questionnaires
were completed, 13 case studies were gathered, and
focus group discussions were held. The results will
inform the Screening for Life 2017 campaign.
• Commitment secured from 4/7 Primary Care Clusters to
work with public health and the Third Sector to increase
the uptake of Bowel Screening invitations.
• Appointment of Hywel Dda Macmillan funded GP Cancer
lead. Post is part of the Framework for Cancer (F4C)
Programme, funded by Macmillan Cymru (through the
Cancer Network) to help deliver primary care clinical
leadership for cancer services, to improve integration of
services between primary and secondary care, and aid
service development and quality improvement.
Survivorship • We conducted a scoping review of the literature on • During 2017/18 we will establish a
survivorship which will inform the work of the Task and Finish Group on
survivorship Task and Finish group in 2017/18 survivorship, to review services in
place once patients are
discharged from cancer treatment
services, and identify
opportunities for the third sector to
get involved, to improve patients’
experiences and quality of life
post-treatment.
27
Strategic Objective 5 – To improve the early identification and management of patients with
diabetes, improve long term wellbeing and reduce complications.
Appoint funded leads for • Triumvirates in post √
Triumvirate appointments • Substantive
• Consultant Lead • Admin support for triumvirate
• GP Lead Improvements in podiatry and dietetics services show reduction √
• CNS Lead in amputation rates for people with diabetes
Deliver recommendations • Agree priorities for implementing per review √
of paediatric peer review recommendations.
• Increase number of PDSN’s to meet safe staffing
requirements.
• Provide admin support.
• Increased number of CYP accessing education. √
• Monitor access to paediatric diabetes team within 24 hours
of admission for newly diagnosed.
Ensure increase in MDT members in recommended ratios to √
allow dieticians and psychologists to have protected time to
work with CYP
Review PROMS and PREMS data to understand of increased √
access to relevant teams have improved the patient experience
Improve support across Over see health board wide access to pre diabetes screening √ √ √ √
primary and community and food wise for Life programmes.
care for detection and Review cardiovascular risk screening programme for staff and √
management of those at agree a plan for continued roll out throughout 2017/18
risk of diabetes Monitor number of programmes and outcomes for Food wise on √ √
considering current and a quarterly basis
previous work in the area Review of lifestyle changes and improvement in HBA1C √
measured.
Review primary care audit. Agree action plan to improve √
completion of eight care processes
Participate in national inpatient audit and review data. Prepare √ √
action plan against identified improvement areas.
Review inpatient audit to see improvements and plan next √
improvements
• Identify number of secondary care staff undertaken √
ThinkGlucose training.
• Review agreed outcomes for each team.
Review community DSN activity and out comes √
Deliver community Agree outcomes for this service √
podiatry model across Monitor increased access to podiatry services √
whole health board Monitor reduction in amputation rates √
Monitor reduction in Diabetes foot ulcers √ √
Development of a Agree outcomes and workforce for equitable service across all √
community workforce three counties
diabetes Implement agreed service model √
Evaluate and monitor outcomes √ √
Monitor improvements in annual reviews by community DSN’s √ v √ √
Ongoing support for the Lead Primary care GP to discuss with GP clusters and support √
delivery of the Diabetes further work around LES
LES in primary care Implements an further training required for primary care in √
support of LES
Increased uptake of LES and use of injectables √
Development of diabetes Review current provision and plan 2017/18 minimum √
education delivery requirements for XPERT and DSMP
28
capacity & enhance Review current uptake of Pocketmedic films on prescription. √ √ √ √
structured programme to Review and update monitor numbers on a quarterly basis. √ √ √ √
include psychological Work with Psychology service to identify the needs of the √ √ √
impact of diabetes diabetes population and the support required
A fully functioning NICE Review current weight management service against NICE √ √
compliant level 3 obesity guidance and Agree actions to comply
service. Identify relevant changes needed to implement as per NICE √ √ √
Diabetes Planning and Ensure quarterly meeting of group √ √ √ √
Delivery Group working to Review terms of reference. √
comply with standards set Identify senior manager to report back to executive on a regular √
by the Diabetes Delivery basis
Plan 2017-2020 Set up small strategic group to review objective and targets and √
support DPDG to action work to ensure outcomes
Implement agreed model of care and monitor targets and v √ √ √
outcomes
29
Strategic Objective 6 – To improve the support for people with established respiratory illness,
reduce acute exacerbations and the need for hospital based care.
Every person with COPD Accurate diagnosis for every person with COPD √ √ √ √
attends a self At least one health care is ARTP accredited in undertaking √ √ √ √
management programme spirometry and reading the results
Identify number of people on GP list for COPD with an MRC √ √ √ √
score of 1 and 2 and offer them of them a programme.
Identify those who don’t attend and offer alternatives e.g. online √ √ √ √
support, e digital films.
Agree target numbers for each quarter and number of √ √ √ √
programmes.
Quarterly reporting on numbers and those who make √ √ √ √
improvements through Shuttle walk testing and confidence
questionnaires for MRC1 and 2 patients
Quarterly review of uptake for each cluster. √ √ √ √
Work with BLF Wales to review use of self management plans √
Implement EPP SBAR resources for increased number of √
courses to be offered
Complete year end report √
Every person with Identify population √
respiratory disease has a Agree which condition should be targeted first √
self management plan Agree outcomes to be measured on a quarterly basis √
-COPD √
-Asthma adults Agree which self management plans to be used across Hywel √
-Asthma Paediatrics Dda
-Sleep Prepare a roll out plan of education sessions to support the use √
- IPF of self management plans for each condition.
-Bronchiectasis Quarterly review of work √ √
Monitor numbers – identify and solve issues √ √
Review admissions and readmissions to see if any impact. √
Review numbers and issues √
Complete a report. √
Every person who smokes Review current service including secondary care service, √
and is admitted to hospital community pharmacy initiative and Stop Smoking Wales
is offered smoking service.
cessation services Work with teams and Clinical Lead to agree targets and √
monitoring for 17/18.
Monitor agreed outcomes every quarter √ √ √
Every person admitted to Specialist respiratory nurses to agree plan with outcomes to √ √ √ √
hospital with an ensure all COPD admissions are referred to the relevant CNS
exacerbation of their for follow up. This includes implementing COPD discharge
COPD has at least one bundle.
review by a specialist Agree monitoring of admissions compared to those seen post √ √ √ √
nurse after discharge discharge by both secondary care CNS’s in outpatients and
community CNS’s in patients homes
Review numbers seen by CNS post discharge. Review numbers √ √ √
of those seen once and those needing further follow up
Review those seen as outpatient and those needing home √ √
review
All patients admitted with This area will not be looked at during year one please see below
an exacerbation of COPD as this area need to be delivered first
to attend a pulmonary
rehabilitation programme
within 2 months of 30
discharge
All patient fitting criteria SBAR completed to identify the needs of this service to comply √
for pulmonary with national guidance and ensure equity across all three
rehabilitation should be counties.
offered a programme Implement SBAR. √
within 3 months of referral Implement pilot for VC service to Tregaron Hall. √
Complete report on VC pilot and make recommendations for √
rollout
Agree minimum number of pulmonary rehabilitation √
programmes to run every quarter.
Agree reported outcomes for all pulmonary rehabilitation √
programmes.
Monitor waiting times for attending a pulmonary rehabilitation √ √ √ √
programme
Plan improvements in service and milestones for year 17/18 √
Review data quarterly. √ √ √
Monitor service in line with national guidance. √ √ √
Annual report and recommendations for year 2 √
Research, evaluation and Undertake COMPACT research study to assess value of
monitoring to be COPD+ programmes
embedded in respiratory Identify inequalities of service provision across the health board
services and report
Identify resource requirements for required services

-IPF
-Pulmonary Rehabilitation
-Paediatric Asthma
Develop longer term plan for respiratory services
Review admission and readmission data for respiratory √ √ √ √
conditions use to plan improvements
Monitor admissions and discharges √ √
31
Strategic Objective 7 – To improve the Mental Health and Wellbeing of our local population
through improved promotion, prevention and early intervention Mental Health and Learning
Disabilities

Access to timely LPMHSS To consider WG response to Population Needs √
assessment for assessments Assessment submitted.
children, young undertaken in 28 days Progress a plan for commissioning of Tier 0 √ √ √
rd
people and all interventions with the 3 sector.
adults
Access to timely LPMHSS Therapeutic Apply the findings of the gap analysis of √
Treatment for interventions started psychological skills through a clear training
children, young within 28 days strategy.
people and all Implement new model of integrated psychological √ √
adults therapy services across age providing equity of
- access regardless of age
Access to timely 48 hour urgent target Sustain current achievement of target √
assessment for 28 day routine target Develop a trajectory of demand and measure √
children and young service capacity against this
people for Make service redesign recommendations to meet √
specialist any projected increase in demand
secondary mental Implement any service redesign recommendations √
health care to meet any projected increase in demand
Access to timely 26 week target for Continue to improve the legacy position of people √
assessment for assessment waiting over 26 weeks by at least 10%
children & young continue to improve the legacy position of people √
with suspected waiting over 26 weeks by at least 20%
neurodevelopment continue to improve the legacy position of people √
disorder waiting over 26 weeks by at least 30%
Achieve target time for new referrals √
Access to timely Increasing % of Finalised development of GP pilot in Llanelli & 2% √
assessment for people diagnosed improvement in diagnostic rate
people with with dementia on GP Live GP led diagnostic & 2% improvement in √
suspected registers diagnostic rate
dementia Implement recommendations from a whole system √
MAS review & 2% improvement in diagnostic rate
2% improvement in diagnostic rate √
Individualised All residents in receipt Progress outcome of transforming Mental Health √ √
patient care of secondary MH consultation.
for children, young services with a Care Complete mapping of current access pathways √ √
people and all & treatment plan across all services and localities
adults • Agree Single point structure and process
• Implement revised structure and process
Develop a strategy for peer review of compliance √ √
with mental health measure
Timely re-access Patient receipt of Progress outcome of transforming Mental Health √ √
to services and outcome assessment consultation.
transparent reports Develop a strategy for peer review of compliance √ √
outcomes with mental health measure.
Access to Advocacy services Clear commissioning and review arrangements √ √
independent offered based on population needs assessment.
advice
Emergency mental Inpatient admissions Link closely with work on Dewis’ to ensure √
32
health access receive a gate- information and advice in crisis is clear and
keeping assessment available to all
by CRHT Progress outcome of transforming Mental Health √ √
consultation.
Work with partner agencies in developing and √ √
agreeing the estates strategy and plan for section
136 suites.
Have 24/7 crisis services including those for √
children & young people.
Access to timely Maintain maximum Performance Framework developed and reporting √
Treatment therapy waiting time mechanisms established
Monitor impact on activity, capacity, waiting times √
and patient outcomes
Access to timely Maintain maximum Performance Framework developed and reporting √
Treatment outpatient waiting mechanisms established
time Monitor impact on activity, capacity, waiting times √
and patient outcomes
Better mental 10% increase in the Implement full model of Peri natal mental health in √ √
health and Access detection and line with national pathway.
to timely diagnosis of maternal
Treatment mental health
problems
Better mental Reduce the % of Link closely with work on Dewis’ to ensure √ √
health adults with a common information and advice on self help and Teir 0 and
mental disorder in line Teir 1 clear and available to all
with the National Develop website content with suitable approved √ √
levels materials to link to all relevant search criteria fro
common mental health conditions
Promote and support Whole school approaches to √
promoting mental health and wellbeing through
CAMHs primary care services
Emergency mental Reduce the use of Work with partner agencies in developing and √ √
health access Police custody as a agreeing the estates strategy and plan for section
place of safety for 136 suites.
√
rd
Section 136 by 60% Consider the role of 3 sector organisations role
in supporting mental health crisis management as
part of the work of transforming mental health.
Better mental 10% reduction in the Consider the development of social collaborative √
health Health Board suicide opportunities in collaboration with Community
rate per 100,000 Mental Health service and partners
population Link closely with work on Dewis’ to ensure √
information and advice in crisis is clear and
available to all
Continue to engage actively in Time to Change √ √ √ √
Wales work to tackle stigma and discrimination
33
Strategic Objective 8 – To improve early detection and care of frail people accessing our
services including those with dementia specifically aimed at maintaining wellbeing and
independence.
Frailty Programme Development Engagement event and follow up to agree whole √
system pathway
Clinical engagement event with Professor Ian √
Sturgess & link to ECIS work
Capacity and demand modelling for √ √
implementation of agreed pathway (including
Discharge to Assessment)
Communicate Q2 priorities for USC local plans √
Agree reporting measures and develop dashboard √
Present first report to USC Board √
Deliver Business Case to Board for frailty pathway √

investment requirements (incorporating current
service reconfiguration)
Confirm 2 year plan √
Pathway Implementation - Maintain Align with delivery of SSWBA requirements √ √ √ √

Independence & Wellbeing (Help Me including DEWIS (information engine) - to provide
Choose) information to support self management and
problem solving
Agree standard approach to delirium screening √
Phased Implementation of delirium screening √ √ √
Agreement with primary care re roll out √ √

mechanism for over 75s functional screening
Social prescribing (led by social care) timescales
tbc
Pathway Implementation - Stable Agree framework and data set for Stay Well √
Healthcare & Support (Support Me to Plans
Support Myself) Roll out Stay Well plans across HB √ √ √
(incorporating Advance Care Planning in care
homes)
Pathway Implementation - Support & Develop an agreed HB model for Frailty Clinics √
monitor to keep me at home - including care (learning from the PPH and Pembs initiatives)
homes (Assess & Monitor Me Closely) Roll out agree Frailty Clinic model across the HB √ √
Consolidate community case management √ √ √ √
Review of reablement services and capacity

(timescales tbc)
Pathway Implementation - Rapid Access to Roll out 111 pathways, starting in Carms
Emergency Support to Stay at Home (Step (timescale tbc)
Up My Care) Rapid response reablement √ √
Rapid response domiciliary care √ √
Model intermediate care bed requirements (incl √

place of safety)
Commission IC beds √ √
34
GP access to rapid diagnostics/specialist advice √ √
Night sitting √ √
Pathway Implementation – Hospital Care Train 85% of 'front door' staff to use Scottish √
that does not remove life skills (Take Me to Frailty Screening Tool
Hospital) Embed use of SFST across HB √ √ √ √
A&E triage to ambulatory care (Link to USC

timescales)
Agree process, proforma & range of appropriate √
people to undertake assessment based on CGA
principles
Confirm capacity & availability of assessment √
Agree 7 day cover (within current resource √

envelope
Agree & publish go-live dates √
Roll out CGA assessment to patients screened as √ √ √

likely to benefit
Agree model for Acute Frailty Beds √
Pilot AFB on one site √
Evaluate pilot & roll out agreed model across HB √
Standardised frailty in-pt model agreed √
Incorporate roll out plan in 2 year programme √
Implement This Is Me or equivalent (align with
USC timescales)
Pathway Implementation – Safe and Timely Capacity & Demand Modelling for D2A as above √
Discharge (Get Me Home Safely) Embed CGA-based assessment & care planning √ √ √ √
into Ward Rounds, Board Rounds & explicit √ √ √ √

Discharge Plans (links to USC Programme and
work on SAFER bundle, Green/Red days etc)
35
NURSING, QUALITY AND EXPERIENCE IMPROVEMENT
Nursing, Quality and Experience Improvement
Departmental Task Action Q Q Q Q
Objective 1 2 3 4
The patient and • The lessons learnt Evaluate the use of patient stories √
carers voice is from Patient Implement a revised protocol/ guidelines for use √
listened to by the Stories result in of patient stories
Health Board and demonstrable Develop a central library/ resource of stories √
patient feedback changes which Implement a programme of training for √
is used to improve the directorates/ services on the recording and use of
influence change patient experience. patient stories
to service • Continue to listen Plan agreed with each directorate for √
improvement and to patient Incorporating stories into departmental meetings /
delivery stories/feedback at lessons learnt mechanisms, including assurance
all relevant Health on actions taken as a result of the patient stories
Board meetings to improve patient experience
and at statutory Further Evaluation of the use of patient stories √
committee & sub- Consider ways of developing patient story √
committee levels mechanisms, such as patient experience
patient/staff panels
Continue to Implement Electronic FFT PE feedback pilot to be √
a range of feedback commenced
methods to gain PE Feedback system in place for Women & √
service user feedback, Children’s services
in accordance with the Recruit information & support volunteers √
WG framework to Arrangement in place to regularly Publish √
assure and improve feedback
service user 10% increase in volume of feedback received √
experience. from baseline 2015/16
Update on ‘real time’ survey feedback √
(commenced in WGH) & implementation
Plan provided to IE sub-committee √
Training of staff and volunteers in survey and √
feedback methods
Evaluation of electronic PE pilot √
Review of Datix to incorporate PE feedback √
Formalise link to external feedback sites such as √
patient opinion
20% increase in volume of feedback received √
‘real time’ survey feedback in place across acute √
sites
Business case considered for electronic PE √
system
Implement system for promotion of feedback √
cards
Via established feedback stations √
30% increase in volume of feedback received √
Real time survey feedback extended to √
community facilities
Implement electronic PE system √
40% increase in volume of feedback √
Continue to embed the Evaluate the approach being undertaken as part √
principles of of the Bevan Commission Exemplar work
appreciative inquiry Present findings of the project to the IE Sub- √
into patient experience Committee
and service Agree areas for wider implementation √
improvement Expand scope and range of services utilising the √
approach
Develop and Consultation with staff of proposed measure on √
implement across the draft measure developed in previous yea
HB a Patient Agreement of performance measure by IE Sub- √
Experience Committee and BPAC
36
Performance Measure Training and implementation across operational √
– incorporated into teams
performance Continued training and support to operational √
management systems teams
across the HB Collection of evidence / feedback from √
performance measure
Evaluate effectiveness of measure √
Establish integrated Secure accessible location for team at GGH √
patient experience /PPH/BGH (front of hospital)
team (PALS/Patient Implement. and training of revised procedures √
Experience/Informatio Further develop KPI’s / outcomes √
n and advocacy Publish information/ raise awareness amongst √
services) – initial pilot staff, public and all
in Carmarthenshire Stakeholders √
Undertake a formal launch of the service √
Further Implementation of training for staff and √
volunteers
20% reduction in the number of formal concerns √
investigated in GGH/PPH due to early resolution
and alternative ways to provide feedback
10% Reduction in no of PALS cases referred to √
complaints investigation
√
st
1 evaluation report to be considered by IE Sub-
Committee
Publish first feedback report for public and √
individual service areas
30% reduction in the number of formal concerns √
in GGH/PPH due to early resolution and
alternative ways to provide feedback
20% Reduction in no of PALS cases referred to √
complaints investigation
√
nd
2 evaluation report to be considered by IE sub-
Committee
Publish second feedback report and annual √
report
Proposal considered by IE Sub-Committee for √
expansion to all acute hospital & community sites
All patients and Establish a process for Business case submitted for all Wales proposal √
carers receive the development and Develop local plans for improvement of patient √
good quality, quality assurance of information
accessible and patient information Agree leads within each directorate for patient √
clinically within the Health information
approved Board Develop and implement quality assurance √
information about process for patient information used across all
their care and sites/ departments
treatment Continue to implement quality assurance of √
patient information
Ensure everyone Develop referral process for cancer patients to √
affected by cancer Macmillan information & support service
receives the Develop plans to secure long term provision of √
information and information & support service
support they need No of contacts with the service increase by 15% √
from 15/16 baseline
No of contacts with the service increased by 30% √
from baseline
Compliance with Implementation of Continue to provide training and guidance to staff √
legislation and revised guidelines and on revised policies/ procedures and investigation
guidance to procedures for skills
manage concerns concerns investigation
and claims as set and management; Raise awareness of support and guidance √
out in the Putting redress process and available to staff and resources for investigation
Things Right claims management Audit compliance with agreed process and agreed √
arrangements procedure, based on key performance indicators
37
all Wales guidance Assurance report to IE Sub-Committee and √
QSEAC
Include in AQS and Annual Report √
Collate evidence of compliance for Welsh Risk √
Pool
Concerns are 20% Reduction in no of concerns open over target √
reported, acted upon 30% Reduction in no of concerns open over target √
and responded to in a 50% Reduction in no of concerns open over target √
timely manner 70% Reduction in no of concerns open over target √
Improve 15% decrease from 15/16 baseline in no of cases √
communication and prematurely referred to PSOW due to delays
involvement of 20% decrease from 15/16 baseline in no of cases √
persons raising prematurely referred to PSOW due to delays
concerns in the 25% decrease from 15/16 baseline in no of cases √
investigation process prematurely referred to PSOW due to delays
30% decrease from 15/16 baseline in no of cases √
prematurely referred to PSOW due to delays
Improve outcomes of 15% decrease from 15/16 baseline in no of cases √
concerns referred to PSOW for review & taken into formal
investigations investigation
referred to PSOW for review & taken into formal
investigation
investigation
investigation
15% decrease in no of cases re-opened √
Implement a robust Task and finish group established to define √
system for learning processes
lessons, which is used Procedure which demonstrates how the Board √
to improve services learns from feedback and learning from events
Approved by QSEAC
Training and implementation of procedure √
Review groups established to review implications √
of lessons learnt – evidence of clear
Action plans in place. √
Assurance reporting process through Committee √
structure
Lessons learnt are clearly reported through the √
governance framework and published
Audit and monitoring of lessons learnt to be √
reviewed by IESG and QSEAC
Results incorporated in AQS and annual report √
There is openness and Agreement of OD Plan √
honesty with people Training for Board on Duty of Candour/ Being √
when something goes Open
wrong with their care Review process for serious case review/ √
and treatment and management
where appropriate Guidelines on being open developed and √
redress is offered endorsed by Board
Guidelines to be issued and Information to be √
made available on intranet
Update clinical counsellor/ √
being open training for relevant staff √
With support of workforce & od, Training √
programme to be implemented across HB for all
staff
38
Implement • Identify dedicated Continued reduction in number of reported HATs √
processes which resource in SI against Tier 1 target
ensure that all team for HAT Baseline audit designed and undertaken √
patients receive • Maintain reporting Audit results presented to Site management √
appropriate of actions on teams
assessment and RCAS for Tier 1 Clinical champions identified √
treatment to target HAT implementation groups established on each √
prevent Hospital • Identify clinical site.
Acquired champions on Localised action plans agreed and implemented √
Thrombosis and each acute site Repeat Clinical Audit. √
that all incidents • Establish audit Review and adjust local implementation plans √
are identified programme on Clinical audit identifies that appropriate processes √
investigated and each site against maintained to achieve compliance with HAT
appropriate HAT standard standard
action taken to • Engage hospital Hospital management teams own RCAS in √
mitigate management relation to HAT
reoccurrence teams in
where ownership of HAT
appropriate Tier 1 target
• Fully implement
HAT Action plan
on all sites
Support clinical • Develop an Woking with the Nursing and Assurance and √
teams to deliver improvement plan Quality Teams take the lead on establishing the
rapid response to for early detection current position and best practice in relation to the
improve and treatment of 4 workstreams
outcomes of Sepsis Design an improvement plan based on the √
Critical Illness • Develop an identified KPIs
improvement plan Achieve clinical and managerial agreement on the √
for early detection improvement plans.
and treatment of Agree an implement process for each √ √
Acute Kidney improvement plan and with the Nursing,
Injury Assurance and Quality teams set targets for
• Develop an 2017/18, ensuring that assurance reporting
improvement plan mechanisms are clearly identified
which ensures
compliance with
DNAR processes
• Develop an
improvement plan
for the reduction of
delayed transfers
of care to and from
ITU.
Contribute to the • Establish a Training programme designed with 100lives team √
development of a programme for Junior doctor quality Improvement forums √
culture of internally delivered established on all sites
Continual quality and Big room processes and Scrums established on √
Organisational Service all sites
Improvement Improvement Annual Quality Statement produced and √
evidenced in Training approved.
quality and safety • Establish Health Proposal for Board Quality Improvement Walk √
metrics and Board wide arounds produced
performance and Learning from Improvement Network established with Swansea √
financial targets Events processes University and ABMU
• Consolidate Training programmes are delivered. √
contribution and Quality improvement successes entered for NHS √
engagement with awards
national Virtual network of internal quality improvement √
improvement champions established.
networks, Quality and Service Improvement Website √
relationships and established
forums Health outcome data quality and usefulness √
39
• Show case identified.
improvement Health Board contributes an agenda item at each √
successes National Quality and Safety Forum
nationally First Board Quality √
• Maximise co- Improvement Walk arounds undertaken. √
production Health outcome data used to inform Quality and √
capabilities and Service improvement targets and focus
utilisation in all
Quality and Service Improvement Conference √
areas of quality
held
and service
All improvement projects are supported by health √
improvement
outcome data.
• Ensure that all
disciplines and
services are
engaged in Quality
and service
improvement
• Explore systems
and available data
on Health outcome
measures
Ensure the • Establish Clinical CAOG established and meets monthly √
organisation Audit Operational Baseline assessment completed √
demonstrates Group(CAOG) as Business case agreed with Executive team √
year on year a subgroup to the Resources in place to deliver data validation and √
improvement in Effective Clinical input compliance with all 29 audits
all 29 mandatory Practice Processes in place to deliver compliance with all √
National Clinical • Committee Sub 29 audits
Audits. • Baseline
assessment of Processes in place to identify and deliver action s √
current compliance in response to clinical audit outcomes
and capacity Improvement actions in place following publication √
• Develop business of audits as per national audit timetables.
case to address
compliance gaps
• Engage Site
Clinical leads in
ownership of
contribution to
data submissions
and audit
outcomes
• Develop
programme to
address outcomes
of all audits
Full • Develop and agree Develop and agree a local health board policy and √
implementation of Board Round SOP for board rounds
Multidisciplinary Standard Engagement with senior managers √
Board Rounds Operating Create pilot wards, testing SOP and policy, which √
across all acute procedure with are ‘gold standard’ and develop assessment and
inpatient areas Clinical Executive measurement tools to evaluate impact of board
which contributes Directors rounds
to a 1day • Executive and Training of members of the board rounds for pilot √
reduction in Hospital wards
average lengths management Following robust implementation of gold standard √ √ √
of stay across all teams mandate board rounds on pilot sites, training to commence
inpatient the board round with wards across the sites dependent on on
episodes and a process in all adult Improve √ √ √
10 % reduction in inpatient areas. Support and further training to be given as an √ √ √
readmission rates • Provide training ongoing method for implemen
over next 3 years. and delivery Aim for at least 25% of wards to have the gold √
support to all acute standard board rounds embedded and where not,
40
inpatient areas risk and barriers identified and communicated
• Monitor outcomes Aim for at least 50% of wards to have the gold √
from Borad rounds standard board rounds embedded and where not,
and their impact risk and barriers identified and communicated
on ALoS and Aim for at least 75% of wards to have the gold √
readmission rates standard board rounds embedded and where not,
risk and barriers identified and communicated
Support the Develop templates to Templates developed for top 5 incidents √
effective support services in Templates piloted and launched in selective areas √
Investigation of investigations, such as 30% of wards using templates √
Incidents safeguarding 60% of wards using templates √
templates, falls
templates
Support the Provide ward based Dashboards in place for 40% of general wards √
improvement in dashboards to allow Dashboards in place for 100% of general wards √
timeliness of proactive incident Dashboards in place for all wards and √
incident handling and support departments
investigation performance Dashboards in place for all community settings √
improvement
Support the use Wards provided with Dashboards in place for 40% of general wards √
of Incident data to analysis of date of Dashboards in place for 100% of general wards √
drive service data to support Wards assisted with further analysis tools √
improvement improvement (Measles diagrams etc
Data run charts in place to support ward driven √
improvement
Promote learning Support for ward Ward based case studies developed √
from events and based training and Program of ward based training sessions in place √
appropriate learning Learning posters produced to promote √
training engagement
Reflective Practice events to review progress √
Ensure the Provide analysis of Develop more robust and factual codes for √
potential Level 4 & 5 incidents lessons learnt
information within to determine Analyse lessons learnt codes with wards and √
the Incident contributory factors departments to determine validity of codes
reporting system and lessons learnt Link lessons learnt codes to ward based √
is being used improvements
effectively
41
Nursing, Quality and Experience Improvement
Departmental Task Action Q Q Q Q4
Objective 1 2 3
Governance, Ensure access to Develop Clinical Supervision Access √
Leadership and clinical supervision implementation plan
Accountability. for Nursing &
Workforce HCS 7.1 Midwifery Staff via a 10% nurses and midwives have regular access √
CNO priorities risk-assessed rollout to a clinical supervisor
2016-21 plan 20% nurses and midwives have regular access √
To have nurse & to a clinical supervisor
midwifery leaders 30% nurses and midwives have regular access √
who live the values to a clinical supervisor
and communicate Ensure every Nurse 80% RN’s and RM’s compliant with annual √
the vision of the & Midwife PADR
University Health understands their 80% RN’s and RM’s compliant with annual √
Board. professional role & PADR
Nurse & Midwifery responsibilities; and 85% RN’s and RM’s compliant with annual √
leaders will be clear are aware of and act PADR
about their on their 85% RN’s and RM’s compliant with annual √
accountability and accountability in line PADR
will focus on with the NMC code
delivering high of conduct: Enact
standards of care. this through
Professional participation in the
Leadership:HCS:4. PADR process and
1/ HCS 7.1 CNO professional
priorities 2016-21 reflective discussions
To maintain annually
professionalism All Registered 100% RN’s and RM’s employed in HB are √ √ √ √
within Nursing & Nurses & Midwives registered by last day of month when renewal
Midwifery there is to renew their NMC falls due
requirement to have registration in a
in place robust re- timely manner
registration/revalidati All Registered 100% RN’s and RM’s employed by the HB √ √ √ √
on processes. Nurses & Midwives successfully revalidate in the month/year their
to be aware of and revalidation falls due
compliant with NMC
3-yearly revalidation
requirements
Assuring Quality To develop a Nursing Assurance Framework tested & agreed on one √
Workforce HCS: 7.1 & Midwifery site.
CNO Priorities Assurance Framework implemented fully on one site and √
2016-21 Framework aligned being rolled out to second site
Ensure clear to the UHB Framework implemented on two sites, √
accountability and Performance implementation across further acute sites
scrutiny of Nursing & Management Framework implemented across all acute sites √
Midwifery Care in Framework. and rolled out into community setting
order to provide To contribute Finalise review of current core ED √
assurance of good proactively to the documentation used within the UHB ; ensure
standards of care. national work to effective rollout and share with All-Wales group
develop an electronic Monitor/audit implementation of/compliance with √
nursing care / patient revised ED documentation. Progress finalisation
information system of short stay / day case documentation and plan
whilst maintaining a implementation
safe nursing record Monitor /audit compliance with daycase/short √
keeping system stay documentation
within the UHB Review status of HDUHB documentation and √
record keeping standards and utilise findings for
both internal and external learning and
progression towards electronic records
Continue to contribute to progress pilot of Early √ √ √ √
warning alert systems across UHB and feed into
national epatient flow programme
42
Improving The nursing and Collaborate with the development work being √
Organisation / midwifery workforce led by patient experience team
Person will support the Ensure that KPI’s being developed can fit into √
Centeredness HCS delivery of any and form an integral part of the Nursing
6.3 patient experience Assurance Framework (NAF)
The Nursing & work, linking closely Proactively support the implementation of the √ √
Midwifery workforce with the patient Patient Experience Monitoring plan and utilise
will support the experience teams the KPI’s agreed as part of
delivery of person
centred care by
listening to patient
feedback
Workforce HCS. 7.1 Ensure a full and Comply with key landmarks of implementation √
Staff & Resource: detailed understand plan in relation to April 2017 requirements of the
The University the requirements of act
Health Board will the Nurse Staffing Take progress / exception report to Board at end √ √ √
comply with the (Wales) Act and of quarter
Nurse Staffing develop and take Comply with key landmarks of implementation √ √
(Wales) Act / CNO forward an approved plan.
Priorities 2016-21 implementation plan Comply with key landmarks of implementation √
in response to plan and ensure organisational readiness for
ensure compliance April 2018 requirements of the Act
with statutory Take annual report including progress / √
requirements exception report to Board at end of year
Workforce HCS 7.1 • All Professional Drive the active recruitment of overseas nurses √
Staff & Resource Nursing & whilst supporting a ‘grow your own’ philosophy
Nursing & Midwifery Midwifery Leads to in conjunction with Further Education Colleges
Profession to understand and and CHHS at Swansea University aimed at
contribute to the actively plan their ensuring the maximum numbers of students
UHB leadership workforce who undertake pre-registration programmes
capacity and establishments via translate into future workforce by continuing to
succession planning effective forward live and work in HDUHB area.
/ CNO Priorities planning on a Initial research and discussions with operational √
2016-21 quarterly basis. professional leads and AD Workforce and O/D
• Contribute to the and develop proposals for clinical leadership
development and development programmes that are
delivery of a ‘fit for complementary to the management
purpose’ development programmes underway in Health
leadership Board
development Programmes underway to ensure that by √ √
programme (to 2019/20 , the registered nursing staff In-post
include skills and have potential to equal over 85% of funded
knowledge in establishment
improvement Programmes underway to ensure that by √ √
methodology) for 2019/20 , the registered nursing staff In-post
all nurse leaders have potential to equal over 90% of funded
establishment
Commence implementation √
planning/commitment of resources/ agree
criteria that will demonstrate programme is ‘fit for
purpose’ and establish an evaluation
framework
Support delivery of programme(s) √
Commence evaluation work and demonstrate √
that the programme is at least 75% fit for
purpose; and make changes associated with
remaining elements
Managing risk and • Policies and All guidance as published from WG is received √
promoting health procedures and reviewed at the Strategic safeguarding HB
and safety: within HB will Committee, relevant polices/guidance updated,
Safeguarding need to be or revised to support changes.
Children and updated as Work with W&OD to ensure training in relation to √
Safeguarding act is built into training strategy.
43
Adults HCS. 2.7 guidance is Corporate Dashboard to support capture of data √
received required as a result of Act
The University • Appointment of Safeguarding level Training within HB updated √
Health Board will Band 7 to to capture relevant changes within Safeguarding
comply with the support Adult as a result of the Act to date
Statutory safeguarding Identify key performance indicators to √
requirements in the requirements set understand
Social Services & out within how Act is being operatioalised and implications √
Well Being (Wales) legislation of Act
2014 and any Need to improve data capture of referrals under √
National safeguarding.
developments and Build module into DATIX system to support data √
policies capture.
requirements Introduce exception reporting by services to √
pending full Strategic safeguarding Committee
legislation for adult Strategic safeguarding Committee to receive √
and children exception reports on quartile basis from
safeguarding operational service
Strategic Safeguarding Committee to review √
Corporate Dashboard on quarterly basis
Continue update at Strategic Safeguarding √
Committee to be received from Heads of
Safeguarding in relation to any new guidance
received from WG
Managing risk and The UHB will Feedback required from ABMUHB which is pilot √
promoting health develop an site for implementation of this act is required
and safety: implementation plan prior to development of HB local plan
Safeguarding for the Violence Base line assessment within HB to be √
Children and against women, undertaken identifying requirements for plan
Safeguarding Domestic Abuse and KPI’s to be developed and reported to Strategic √
Adults HCS. 2.7 Sexual Violence Act Safeguarding Committee
(Wales 2015). Update report to be given to strategic √
The University safeguarding committee in relation to
Health Board will compliance with act
comply with the
“Violence against
women, Domestic
Abuse and Sexual
Violence Act”
(Wales 2015).
Managing risk and Pressure damage Sustained reduction in Healthcare Acquired √ √
promoting health Reduce the number Pressure Ulcers <17month
and safety HCS:2 of avoidable Sustained reduction in Healthcare Acquired √ √
Safe and Clinically incidents of pressure Pressure Ulcers <16month
effective care damage.
HCS:3 (A draft tissue
Dignified Care HCS viability plan has
4.1 been produced)
Pressure damage 40% reported PU’s have All Wales Pressure √
To improve on the All Pressure Ulcers damage investigation tool completed
prevention, (PU) identified within 50% reported PU’s have All Wales Pressure √
detection, care and hospital and damage investigation tool completed
management of all community settings 60% reported PU’s have All Wales Pressure √
patients and in are subject to Root damage investigation tool completed
particular, frail Cause Analysis 70% reported PU’s have All Wales Pressure √
elderly patients, by using the All Wales damage investigation tool completed
improving on: Pressure damage
• Pressure investigation tool
damage completed.
prevention and Continence Commence review of Policy and Pathway √
management Improve patient guidance available within HB and ensure
HCS:2.2 experience of evidence based clinical guidelines available.
• Continence continence care Assess care indicators currently in use and √
44
HCS: 4.1 through improved review robustness/suitability for continued/wider
• Falls compliance with the routine implementation
prevention and Continence Care Finalise review Policy and Pathway guidance √
management Pathway/care bundle available within HB and ensure evidence based
HCS: 2.3 in in-patient settings clinical guidelines available
• Hydration & Publish and raise awareness of approved √
Nutrition care evidence based Policy and Pathway guidance
HCS: 2.5 across the HB. This will include ensuring an
• Diabetes care : understanding and implementation of KPI’s
HCS 2 (and methods of data capture) to be used for
• Medicines demonstrating care performance
Administration Review the baseline data relating to continence √
Safety HCS care performance and support development and
• Response to implementation of improvement plans as
the unwell/ appropriate
deteriorating Continence Confirm currency of evidence based guidance √
patient: Reduce usage of to support achievement of best practice
short term indwelling standard
urethral catheters Agree guidance, implementation plan and role √
responsibilities to support standard and rollout
Participate in national prevalence study to √
assess incidence of short term catheter use and
assess trends across past 4 years. Develop
further improvement plan according to findings
Implement improvement plan including regular √
use of agreed KPI’s
Falls Requirement to review current policy in light of √
Compliance with the National Audit of in
falls policy. Support development of an improvement plan √
for all in
Contribute to the review of the Key Performance √
Indicators to ensure the Key Performance
Indicators (KPI) reflect policy and best practice.
Support the implementation of the improvement √
plan
Further work to support improvement plan and √
Work with AD for Quality and Governance to
update the reporting system to ensure it
provides reporting against the revised KPIs
Ensure a monitoring systems is in place to √
support scrutiny of compliance and delivery of
Improvement plans by all Inpatients areas
Hydration Continue rollout of the implementation in 16 in- √
Lead participation in patient areas, utilising national materials. Agree
local implementation and develop tools for monitoring mechanisms
of national hydration and KPI’s to be used
awareness and Support implementation of the improvement √
delivery initiative, plans agreed for each acute site, linking work to
(and ensure links in planning for AKI work stream.
place to actions to Support measuring of current performance √
Acute Kidney Injury Further implementation of the improvement √
(AKI) work stream). plans agreed for each acute site and embedding
of the data capture methods to monitor
performance; along with structures for scrutiny
of performance data in line with emerging
nursing assurance systems
Improvements in compliance with fluid balance √
monitoring; patient experience of hydration care
reported against baseline data: Set ‘realistic but
stretch’ targets for improvement in performance
during 2017/18
Nutrition Support development of improvement plans to √
Compliance with achieve and maintain all in-patient areas at
45
Nutritional Risk greater than 85% compliance with national
Assessment indicator
Screening Tool Provide ongoing support for the implementation √ √ √
of improvement plans to achieve and maintain
all in-patient areas at greater than 85%
compliance with national indicator
Nutrition Plan for the completion of a HB wide audit. √
Ensure compliance Lead the implementation of the care quality √
with the All Wales elements of the WAO catering and Nutrition
Nutrition care Review Management Improvement plan
Pathway. Undertake the HB wide audit of the All Wales √
Pathway .
Continue to implement the WAO catering and √
Nutrition Review Management Improvement
plan
Analysis of audit results and preparation of √
report
Continue to implement the WAO catering and √
Nutrition Review Management Improvement
Scrutiny and improvement planning on basis of √
audit findings; and undertake review of progress
against the WAO Review action plan and refresh
improvement plan as appropriate to findings
Diabetes Further embed the diabetes care systems √
Improve compliance across the University Health Board through
with diabetes care Think Glucose improvement plan.
systems for in- Confirm the KPI’s to be used in relation to √
patients and improve monitor care system compliance
compliance Commence testing/ implementation in use of √
demonstrated within KPI’s
the National Continue to lead improvement plan √
Diabetes In-Patient implementation Test utility of KPI’s and tools
Audit. (NaDIA) used for data capture
Continue to lead improvement plan √
implementation Undertake 2016 Nadia audit
Refine KPI’s for regular inclusion in Assurance √
Framework.
Review NaDia data and analyse both data √
sources to refresh improvement plan for 2018/19
Medicines Contribute to development of a multi- √
Administration disciplinary improvement plan that aims to
Safety deliver a reduction in medication administration
Ensure that a work errors
programme is in Implement the improvement plan and monitor √
place and robustly medication administration errors qualitatively
monitored in order to and quantitatively , ensuring systems for
support learning and sharing lessons from any
improvements to incidents are robust
patient medication Continue to implement the improvement plan √
safety through and monitor medication administration errors
evidence based qualitatively and quantitatively , ensuring
nursing practice learning and sharing lessons from any
incidents takes place
Continue to implement the improvement plan √
and monitor / ensure action in response to a
reduced number (against the initial validated
data made available during 2016/17) ) of
medication administration errors.
Response to the Support the establishment of a clear baseline √
unwell/deteriorating position across the HB in relation to care
patient: systems and performance in recognition and
Contribute to a multi- management of sepsis, Acute Kidney Injury,
faceted approach to DNA5PR and deteriorating patients.
46
improvement in the Contribute to the development of a draft √
detection and improvement plan, utilising pertinent current
response of KPI’s in place where possible and continuing to
deteriorating patients prioritise work already underway pertaining to
these themes
Support the programme of action required to √
achieve operational and clinical team
engagement within the work plan
Support the systematic implementation of the √
work plan and the embedding /integration of the
systems for the KPI’s relating to each work
stream
Infection and For C.difficile - Compliance with Tier 1 targets for Clostridium √ √ √ √
prevention ensure a rate of no difficile.
HCS: 2.4 more than
The UHB will receive 28/100,000
assurance that safe population
and effective policies For S.aureus Compliance with Tier 1 targets for √ √ √ √
for Infection bacteraemias - Staphylococcus aureus.
Prevention & Control ensure a rate of no
are in place. more than
20/100,000
population.
Work towards a 50% Target to be set by Welsh Government √ √ √ √
reduction in
Escherichia coli
bacteraemias.
Learning Ensure ongoing Establish baseline of research active nurses √
Organisation compliance with the Identify implementation plan to increase √
Quality Nursing, Midwifery compliance
Improvement, and AHP Research & Increase research active nurses by 10%. √
Research Development Increase research active nurses by 30%. √
Innovation HCS 3.3 Strategy/Action Plan.
/ CNO Priorities Ensure effective and Utilisation of 25% of contract value. √
2016-21 targeted use of Utilisation of 50% of contract value √
University Health Utilisation of 75% of contract value. √
The Nursing Board Contract with Full utilisation of 100% of contract value √
Workforce will be Swansea University
competent & (College of Human &
confident in Health Science) to
responding to the improve clinical and
care needs of academic skill base
patients now and of nursing &
into the future. midwifery workforce.
HCS 1 Ensure the Engage with appropriate stakeholders and √
development and through a process of co-production, commence
Nurses and monitoring of a development of an improvement plan focusing
midwives will specific, on a small number of agreed priorities which
proactively engage professionally led reflect organisational priority objectives
with and develop development plan Complete development of an improvement plan √
specific plans to through which to focusing on a small number of agreed priorities
contribute to drive greater which reflect organisational priority objectives.
improving Health engagement and Confirm reporting route for assurance of
and Well being focus on the nursing compliance with plan. Commence
through improved and midwifery role in implementation of plan
promotion, prevention and Continue to implement improvement plan, √
prevention and early health promotion (i ensuring key milestones are achieved and
intervention particular to obesity reported on as agreed
reduction and Continue to implement improvement plan, √
smoking cessation) ensuring key milestones are achieved and
reported on as agreed
47
Quality and Patient Experience Improvement
Departmental Task Action Q1 Q2 Q3 Q4
Objective
Implement • Identify Continued reduction in number of reported HATs √
processes which dedicated against Tier 1 target
ensure that all resource in SI Baseline audit designed and undertaken √
patients receive team for HAT Audit results presented to Site management √
appropriate • Maintain teams
assessment and reporting of Clinical champions identified √
treatment to prevent actions on RCAS HAT implementation groups established on each √
Hospital Acquired for Tier 1 target site.
Thrombosis and that • Identify clinical Localised action plans agreed and implemented √
all incidents are champions on HAT implementation groups established on each √
identified each acute site site.
investigated and • Establish audit Localised action plans agreed and implemented √
appropriate action programme on Clinical audit identifies that appropriate √
taken to mitigate each site against processes maintained to achieve compliance
reoccurrence where HAT standard with HAT standard
appropriate • Engage hospital Hospital management teams own RCAS in √
management relation to HAT
teams in
ownership of
HAT Tier 1 target
• Fully implement
HAT Action plan
on all sites
Support clinical • Develop an Woking with the Nursing and Assurance and √
teams to deliver improvement Quality Teams take the lead on establishing the
rapid response to plan for early current position and best practice in relation to
improve outcomes detection and the 4 workstreams
of Critical Illness treatment of Design an improvement plan based on the √
Sepsis identified KPIs
• Develop an Achieve clinical and managerial agreement on √
improvement the improvement plans.
plan for early Agree an implement process fpr each √
detection and improvement plan and with the Nursing,
treatment of Assurance and Quality teams set targets for
Acute Kidney 2017/18, ensuring that assurance reporting
Injury mechanisms are clearly identified
• Develop an
improvement
plan which
ensures
compliance with
DNAR processes
• Develop an
improvement
plan for the
reduction of
delayed transfers
of care to and
from ITU.
Contribute to the • Establish a Training programme designed with 100lives √
development of a programme for team
culture of Continual internally Junior doctor quality Improvement forums √
Organisational delivered established on all sites
Improvement Improvement Big room processes and Scrums established on √
evidenced in quality Training all sites
and safety metrics • Consolidate Annual Quality Statement produced and √
and performance contribution and approved.
and financial targets engagement with Proposal for Board Quality Improvement Walk √
national arounds produced
48
improvement Improvement Network established with Swansea √
networks, University and ABMU
relationships and Health outcome data sources will be explored √
forums Training programmes are delivered. √
• Show case Quality improvement successes entered for √
improvement NHS awards
successes Virtual network of internal quality improvement √
nationally champions established.
• Maximise co- Quality and Service Improvement Website √
production established
capabilities and Health outcome data quality and usefulness √
utilisation in all identified
areas of quality Health Board contributes an agenda item at √
and service each National Quality and Safety Forum
improvement First Board Quality √
• Ensure that all Improvement Walk arounds undertaken. √
disciplines and Health outcome data used to inform Quality and √
services are Service improvement targets and focus
engaged Quality and Service Improvement Conference √
improvement held
• Explore systems All improvement projects are supported by √
and available health outcome data
data on Health
outcome
measures
Ensure the • Establish Clinical CAOG established and meets monthly √
organisation Audit Operational Baseline assessment completed √
demonstrates year Group(CAOG) as Business case agreed with Executive team √
on year a subgroup to Resources in place to deliver data validation √
improvement in all the Effective and input compliance with all 29 audits
29 mandatory Clinical Practice Processes in place to deliver compliance with all √
National Clinical • Committee Sub 29 audits
Audits. • Baseline Processes in place to identify and deliver action √
assessment of s in response to clinical audit outcomes
current Improvement actions in place following √
compliance and publication of audits as per national audit
capacity timetables
• Develop
business case to
address
compliance gaps
• Engage Site
Clinical leads in
ownership of
contribution to
data submissions
and audit
outcomes
• Develop
programme to
address
outcomes of all
audits
Full implementation • Develop and Develop and agree a local health board policy √
of Multidisciplinary agree Board and SOP for board rounds
Board Rounds Round Standard Engagement with senior managers √
across all acute Operating Create pilot wards, testing SOP and policy, √
inpatient areas procedure with which are ‘gold standard’ and develop
which contributes to Clinical assessment and measurement tools to evaluate
a 1day reduction in Executive impact of board rounds
average lengths of Directors Training of members of the board rounds for √
stay across all • Executive and pilot wards
inpatient episodes Hospital Following robust implementation of gold √
49
and a 10 % management standard board rounds on pilot sites, training to
reduction in teams mandate commence with wards across the sites
readmission rates the board round dependent on on-site engagement and
over next 3 years. process in all commitment
adult inpatient Improvement measures to be used to monitored √
areas. compliance to SOP and impact as wards train
• Provide training and develop the gold standard board rounds
and delivery Support and further training to be given as an √
support to all ongoing method for implementation
acute inpatient Aim for at least 25% of wards to have the gold √
areas standard board rounds embedded and where
• Monitor not, risk and barriers identified and
outcomes from communicated
Borad rounds Training to commence with wards across the √
and their impact sites dependent on on-site engagement and
on ALoS and commitment
readmission Improvement measures to be used to monitored √
rates compliance to SOP and impact as wards train
and develop the gold standard board rounds
Support and further training to be given as an √
ongoing method for implementation
Aim for at least 50% of wards to have the gold √
standard board rounds embedded and where
not, risk and barriers identified and
communicated
Training to commence with wards across the √
sites dependent on on-site engagement and
commitment
Improvement measures to be used to monitored √
compliance to SOP and impact as wards train
and develop the gold standard board rounds
Support and further training to be given as an √
ongoing method for implementation
Aim for at least 75% of wards to have the gold √
standard board rounds embedded and where
not, risk and barriers identified and
communicated
50
SERVICE IMPROVEMENT
Service Improvement
Departmental Task Action Q1 Q2 Q3 Q4
Objective
To radically re-frame • Continue with Admin validation of all waiting list √
and design a model local Outpatient KPIs established √
of access to Improvement To engage with our public and staff supporting √
specialist advice, Steering Group the wider transformation work and co-design a
diagnosis and • Be involve with model together
treatment which the National To understand our current processes to identify √
provides the patient Outpatient areas of high impact improvement across each
with equitable and Steering Group site
timely access to work Transformation plans agreed for high risk √
specialist diagnosis • Design specialties.
and treatment transformation Alternative IT solutions explored √
planned around plan for key Work with other HBs to share good practice and √
them and their specialties learning
communities, • Assess impact of To engage with our public and staff supporting √
delivered as locally revised referral the wider transformation work and co-design a
as possible, and pathways on model together
utilising tele-health commissioning To understand our current processes to identify √
solutions where arrangements areas of high impact improvement across each
possible • Consult on site
transformation Transformation plans agreed for high risk √
plans with specialties.
primary care and Alternative IT solutions explored √
service users Work with other HBs to share good practice and √
• Implement learning
transformation For Ophthalmology Urology, Dermatology and √
plan starting with colorectal:-
identified • Consultation with Primary care.
specialties • Consultation with service users
• Produce • Impact assessment of current
business cases commissioning arrangements.
for IT systems to • Transformation plans implemented.
support pathway • Tender for alternative It solutions
changes Updates on progress provided to
• Meet management teams and through
requirements of executive team PMO processes
Welsh Audit For all other specialties:- √
Office review on
• Baseline assessments completed
Outpatient
• Transformation plans agreed
appointments
For all other specialties:- √
(October 2015)
• Consultation with Primary care.
• Consultation with service users
• Impact assessment of current
commissioning arrangements.
• Transformation plans implemented.
• Follow up position in identified high risk
specialities reduced by 50%
To ensure optimal Produce PID for Theatre improvement based on √
use of operating the Productive
theatre capacity and Review outcomes and actions following Theatre √
resources, Reviews 2014/15
maximising Use Scheduled Care Resource Utilisation √
operating theatre (SCRUMS) processes to design and implement
performance and changes with site based theatre teams
avoiding cancelled Monitor and analyse data to demonstrate √
operations in order improvements and provide assurance reports
to provide high which demonstrate and improvement
quality, safe and Theatre Productivity Project Board Established √
51
timely health care to and meets monthly led by Director of Operations
patients admitted for PID produced √
surgery. Data sets agreed and monitored √
Improvement Plan agreed √
Theatre SCRUMS in place on all sites which √
meet weekly and are attended by theatre
management teams and lead clinicians
Improvement plans agreed with Hospital √
Management Teams
Improvement Plans communicated to individual √
Theatre teams
Theatre reviews repeated to establish √
improvements since 2014/15
Updates on progress provided to management √
teams and through executive team PMO
processes
Improvement plans implemented √
To implement the • Dedicated Secure current band 5 post √
national vision for resource from Continue roll out to all 4 sites √
orthopaedic services the Q&SI Team Monitor progress of roll out, through continuous √
to meet the future • Scope the engagement and audit
demand, securing current process Manage problems and issues on a daily basis √
reductions in waiting on each site Plan long term sustainability – look at equipment √
by developing more • Ensure needed etc
sustainable, long- compliance with GPs satisfaction survey undertaken √
term solutions. To E-discharge Monitor roll out ensure all departments √
see CMATs as a key through audit /specialities are using E-discharge
part of the vision by • Ensure Audit all areas monthly providing support where √
developing a robust sustainability needed
clinically driven through Engage with GP’s – monitor quality of letters √
sustainable service commitment of Set up improvement training as needed √
senior managers Pharmacy capacity to be re-discussed √
and training of Ensure sustainability √
Junior Doctors
Continually monitor compliance and address √
• Ensure full through training and support
engagement with
Monitor MTeD position in the Health Board. √
GPs re quality
E discharge in place on all sites which results in √
and timeliness of
95% of discharge summaries being sent within
summaries
1 day of discharge in all specialties
• Expedite
GP satisfaction with discharge summaries √
implementation
improves by 50% in all areas.
of MTED on all
sites
52
WORKFORCE & ORGANISATIONAL DEVELOPMENT
THEME ACTION 2017/18 2018/ 2019/
2019 2020
Q1 Q2 Q3 Q4
Values and Further develop our behaviours √
behaviours framework to underpin all other work
Redesign the PADR / appraisal process √
to enable a conversation based on
values
Roll out Values Based Recruitment to √ √
wider areas
Review induction to ensure its content is √ √ √
appropriate, reflects organisational and
personal values and gives all new staff a
full understanding of HB core priorities.
Ensure all staff are offered support √ √ √ √ √ √
throughout workforce management
processes and that their wellbeing is
considered at all stages.
Staff Health and Reduce stress related sickness absence √
Wellbeing by 2%
Reduce general sickness absence in √
line with All Wales target
Manage Time to Change Wales √
employer plan
Survey workforce to monitor mental √ √ √
health attitude & experience
Develop & deliver staff health and well √ √ √
being monitoring programme
Revalidate platinum Corporate Health √
Standard
Improve communication processes and √
timeliness of the provision of Occ Health
advice;
Identify appropriate new pathways to
address sickness absence;
Develop Health promotion programme to
improve workplace health
Develop guidance for managers and √
staff to deal with managing chronic
condition absences.
Develop staff engagement dashboard to √
include wellbeing measures
Draft of Self Care and Wellbeing at Work √
Develop the ethos of psychological √ √ √
safety within the organisation
Culture Carry out 10 pulse surveys and 10 √ √ √ √
follow up surveys per year to assess
management competence and staff
engagement.
Develop action plans to address findings √
from national and pulse surveys and
monitor progress
Encourage staff feedback √ √ √ √ √ √
Hear 1 staff story per quarter at W&OD √ √ √ √ √ √
Sub Committee
Establish a mechanism to follow up all √ √ √
staff appointed within 12 months to
receive feedback on their experience.
Staff Experience Continue to provide and enhance Staff √ √ √ √ √ √
benefits schemes by 2 per year
53
THEME ACTION 2017/18 2018/ 2019/
2019 2020
Q1 Q2 Q3 Q4
Support staff to undertake volunteering √ √ √ √ √ √
within our local communities
Review induction process to deliver √ √ √
engaging and welcoming induction
programme
Employee Manage employee relations caseload √ √ √ √ √ √
Relations appropriately and in accordance with
legislation, policy and best practice
Embed the new UPSW Policy √
Policy Develop and review workforce policies √ √ √ √ √ √
Development to reflect legislation and best practice
Maintain Job matching and evaluation √ √ √ √ √ √
process
Partnership Maintain good working relationships with √ √ √ √ √ √
Working TU representatives and ensure
partnership working is embedded in the
organisation culture
Medical Staffing Provide specialist advice and support for √ √ √ √ √ √
the GMs and Medical Director in all
matters relating to the medical workforce
Electronic Staff Review Roll-out plan and revise where √
Record appropriate
Interrogate and analyse the data √
reported on the NHS staff survey.
Drive the implementation of the Hire to √
Retire Programme
Review and refresh the information √
currently presented to organisation and
develop a revised suite of reports and
mechanisms for distribution
Performance support managers to improve PADR √ √ √ √ √ √
Management compliance to maintain 85% recorded
on ESR
Manage pay progression in line with All √ √ √ √ √
Wales policy
Review new PADR template to include √
core objectives for all.
Maintain medical appraisal compliance √ √ √ √ √ √
>90%
Support managers to understand the All- √
Wales Capability Policy and in terms of
addressing shortfalls in performance
Develop new ways to deliver mandatory √ √ √ √ √ √
training across HB to achieve 85%
compliance
Staff Establish mechanism to drive and √ √ √ √
Development deliver of the All Wales HCSW Careers
framework
Undertake establishment reviews within √ √ √

therapy services
Review recruitment training to support √ √ √ √ √ √
the roll out of values based recruitment
Develop and further enhance clinical √
skills programmes including focus on
frailty/dementia
Develop cross sector training √ √ √ √ √ √
programmes where appropriate
Recruitment Recruit to baseline establishment levels √ √ √ √ √ √
in accordance with individual health
54
THEME ACTION 2017/18 2018/ 2019/
2019 2020
Q1 Q2 Q3 Q4
professional plans
Where appropriate and suitable support √ √ √ √
retire and return applications
Manage overseas recruitment √ √ √ √ √ √

programme for nursing posts
Develop innovative recruitment solutions √ √ √ √ √ √
as appropriate
√ √ √ √
rd
Recruit Newly Qualified nurses in 3
year of training
Ensure induction programme support √ √ v v √ √
new recruits identified in recruitment
plan
Develop a nursing recruitment strategy √
to include return to nursing, return to
acute care and programmes to support
overseas nurses residing in the UK to
obtain registration.
Develop a medical recruitment strategy √
for medical posts linked to overseas
recruitment and the further development
to the overseas training programme.
Develop service profiles to support √ √ √ √ √ √
recruitment to attract doctors to work for
the HB
Variable Pay Undertake Job Planning review √
Reduction Develop targeted recruitment plans √
linked to vacancies and high cost
locums.
Develop workstreams to reduce and √ √
where possible eradicate nursing
agency usage and reduce variable pay
spend.
Develop workstreams to reduce and √
where possible eradicate nursing
agency usage and reduce variable pay
spend.
Reduce and where possible eradicate √
non-nursing and non-medical agency
usage and reduce variable pay spend.
To develop robust bank provision to √
avoid the need to utilise agency workers.
Eradicate HCSW agency √
Reduce nurse agency √
Review all agency staff with each √

service being tasked with completing a
risk assessment for each booking, with
authorisation at Director level.
Targeted recruitment plans linked to

vacancies and bank/overtime usage
Identify external factors that may √

influence the need to use additional
staffing (e.g. waiting list
initiatives/additional sessions).
Introduce StaffFlow/TempRE to HCS √

55
THEME ACTION 2017/18 2018/ 2019/
2019 2020
Q1 Q2 Q3 Q4
and Therapy areas
Cease use of premium agency √
Monitor roster efficiency √ √ √ √ √ √
Undertake comprehensive pay spend √
analysis
Primary Care Further improve workforce data to √ √ √ √ √ √
provide robust intelligence
Share good practice successful models √ √ √ √ √ √
into clusters
Provide a skills analysis and develop √

plan to meet need
Provide OD support and Leadership √ √ √ √ √ √
Development Support through existing
HD teams and All Wales initiatives
including PiP programme for
pharmacists
Support practices to achieve and √ √ √ √ √ √
maintain >95% compliance with
revalidation and appraisal
Recruit 1 GP per cluster to the PCST √
Enhance the PCST Primary Care √ √ √
Support Team
OUR COMMUNITIES (includes actions identified in workforce section above)
THEME ACTION 2016/17 2017/ 2018/

2018 2019
Future Recruit 20 additional volunteers per √
Workforce year
Increase LIFT placements offered to 20 √ √ √
– 25. Run 10 additional sessions
supporting LIFT candidates with job
interview skills
Develop links with local FE institutions √
and Universities to provide development
opportunities in partnership
Increase work experience opportunities √ √ √ √ √ √
by 10% and support to secondary
schools & further education institutions
throughout the 3 counties.
OUR FUTURE (includes actions identified in workforce section above)
THEME ACTION 2016/17 2017/ 2018/

2018 2019
Organisational Develop a robust and consistent √ √ √ √ √ √
Change approach to considering service
integration, which will challenge norms
and overcome barriers
Provide specialist technical advice and √ √ √ √ √ √
support for the implementation of service
change
Developing new Create an Advanced, Extended and new √ √ √ √ √
workforce roles at all levels
models Develop ‘grow your own’ nursing project √ √
56
THEME ACTION 2016/17 2017/ 2018/
2018 2019
Extend opportunities for HCSW Band 4 √ √
Career Pathway
(nursing , therapy, Pathology, EMBE)
Investigate potential opportunities to √ √
work with University partners and FE
Colleges to develop employment and
career pathways
Continue work to develop 7 day working √ √ √ √ √
across services
Develop new and innovative roles in √ √ √ √ √ √
primary care
Equality Agenda Drive the implementation of bilingual √ √
skills strategy across the workforce.
Undertake annual equality report for √ √ √
workforce
Working with OD, support a range of √ √
initiatives bi-lingually
Collaboration Develop the Collaborative Institute for √ √ √
Learning and Development as a
workstream of the University Partnership
Board.
Oversee implementation of Bevan √
innovators
Take full and participator roles within √ √ √ √ √ √
ARCH, Bevan, Mid Wales Collaborative,
Mid Wales Regional Workforce
Development and University Partners
Take an active role in the ARCH √ √ √ √
workforce skills workstream including
HCSW,
Develop the OD Innovation hub with √
links to Bevan Commission
Leadership Improve succession planning/talent √ √ √ √
management strategies
Scope out and cost implications of √ √ √ √ √
current skills gap
Refine leadership programmes √
Develop and deliver a ‘Band 7’ √ √ √
programme to support 40 clinical leaders
Develop and implement clinical √ √ √ √ √ √
leadership programmes
Support 8 staff to attend Academi Wales √ √ √
Summer School
Deliver Consultant Leadership √ √ √
Programme
Developing our Develop and deliver an ‘aspiring √ √
leaders and consultant’ programme for middle
managers grades and locums for 20 staff (each)
Deliver the OD strategy 10 High Impact √ √ √ √ √ √
Interventions
Undertake a regular management skills √ √
analysis
Expand managers passport and √ √ √ √ √ √
increase capacity by 20
managers/supervisors each year
Develop and deliver bespoke team √ √ √ √
improvement programmes as part of the
OD strategy
Developing a Provide access to coaching for senior √ √ √ √ √ √
Coaching staff collaboration with other public
Culture sector partners
57
THEME ACTION 2016/17 2017/ 2018/
2018 2019
Develop a coaching network within √ √ √
Hywel Dda
Train 20 staff in coaching √ √ √ √
Create 15 medical Mentors per year √ √ √
Strengthen the newly created peer √ √
support network for consultant mentors
Mentoring Increase number of nurse mentors to √ √ √
Scheme support NQN and overseas recruitment
and grow your own scheme
Develop a non-medical mentoring √
scheme
Skills Offer apprenticeship training √
development programmes to all staff who fall within
the 18-25 age range
Deliver 5 apprenticeship places in √
estates/hotel facilities areas
Deliver healthcare apprentice training to √ √
new HCSW staff and existing staff to
support delivery of the HCSW Career
Framework and maximise the use of
apprentice opportunity
Deliver apprenticeship programmes at √ √
level 4 and above
Deliver psychological well being √ √ √ √ √ √
programmes to 100 staff (eg ‘you matter
development programme).
Develop and deliver “Great customer √
experience” training
58
RESEARCH AND DEVELOPMENT
Research and Development
Departmental Action Q1 Q2 Q3 Q4
Objective
Improve patient Develop a mechanism for patients with a given disease/condition to √
outcomes through provide input to research projects e.g. explore their own ideas to
participation in develop solutions to help them manage or improve their own health
research and through As part of the R&D approval process, ensure that potential benefits √
maximising impact from participation in research are clearly articulated in research
from research results. protocols and patient information sheets.
Continuously monitor the outcomes of research studies and check √
with patients/research subjects if their own requirements have been
met.
Use feedback from patients and patient groups to continuously √
improve the focus of research studies to ensure that resources are
prioritised towards patient centred care.
Promote the value of Facilitate the HDdUHB research communities’ involvement in the √
research through Research Practice and Innovation Conference.
communication Produce statistics showing the cost benefits of running research √
strategies (patients, studies in HDdUHB e.g. grants captured, cost savings where clinical
staff and trial drugs are provided free of charge.
collaborators). Participate in the Research Practice and Innovation Conference (July √
2017).
Disseminate R&D good news stories via R&D intranet and internet √
pages.
Demonstrate how taking part in research can benefit some patients √
by enabling access to novel therapies.
Liaise with Health and Care Research Wales’ Communications Team √
to develop a local R&D Communications Strategy
Develop the R&D intranet and internet pages and set up R&D Twitter √
and FaceBook sites.
Launch a R&D quarterly newsletter / bulletin via global emails and via √
email to external partners.
Expand patient and public involvement in various R&D initiatives via √
the Involving People network.
Ensure research feeds Involve the research community in discussions of how to implement √
into the organisation’s this across HDdUHB.
mechanisms for Explore mechanisms for implementing this at the Research and √
uptake of best Development Sub-Committee meeting in May 2017.
practice, innovation
and service change
Meet the Key Monitor the current status of each of the 26 KPIs/targets at monthly √
Performance R&D Operational Team meetings, and report any concerns to the
Indicators and Targets R&D Senior Team.
set out in the Delivery Present a clear and outcome-focused strategic plan to meet and √
Framework for maintain the KPIs /Targets to Health and Care Research Wales
Performance (Welsh Government), to inform HDdUHB’s Annual Performance
Management of NHS (RAG report).
R&D. Continuously improve ways of working between the R&D √
Governance/ Strategy and Research Delivery (Workforce) teams to
collectively meet KPIs and Targets.
Present KPI summary reports biannually to HDdUHB’s University √
Partnership Board, and discuss concerns, achievements and trends.
Maintain an up-to-date Define the strategic direction of R&D in HDdUHB in the context of √
R&D Strategy which maintaining it’s University Health Board status, and as a stakeholder
defines how HDdUHB in ARCH.
will take the
Commercial and Non- Review and update the current R&D Strategy (2016-2020) to deliver √
Commercial R&D the expectations of both UPB and ARCH.
agenda forward Develop 1 year, 5 year and 10 year operational plans. √
(locally, nationally and Periodically review and redefine strategic objectives and update the √
in collaboration with its R&D Strategy implementation plans.
research partners).
59
Ensure there is clear Obtain information on HDdUHB’s innovation, knowledge mobilisation √
integration into the and quality improvement agendas in order to explore how R&D can
wider organisation’s be integrated into these.
innovation, knowledge
mobilisation and
quality improvement
agendas.
Provide visible Explore ways to enhance the current arrangements recognising that √
leadership and there is clear leadership and communication between R&D and its
actively integrate R&D representative on the Board (Medical Director and Director of Clinical
into local planning, Strategy).
financial and decision
making structures
including
representation of R&D
on the Board.
Promote a culture that The R&D Director will continue to be involved in the recruitment of √
values and promotes medical staff, where candidates’ research experience and future
research through aspirations are discussed and explored at/prior to interview.
leading and/or hosting The forthcoming All Wales Research Capability Statement (led by √
studies, ensuring that Health and Care Research Wales) will be adopted in HDdUHB.
all staff recognise and This area will be further progressed through closer links with the √
understand the role Health and Care Research Wales Support Centre, to include
that research plays in marketing and promotion of R&D in HDdUHB as part of the wider
increasing and NHS Wales R&D signposting service.
delivering good quality
care, including staff
recruitment, retention
and development.
Provide equity of A scoping exercise will be undertaken to outline existing centres of √
access to research excellence across the different HDdUHB hospital sites.
opportunities that Any potential to fill gaps in research capability/expertise will be √
enable participation in explored with ABMUHB.
research for patients Feasibility of expanding HDdUHB’s research portfolios to include √
and service users, under-researched populations will be assessed, as opening some
especially in under- research studies (e.g. commercial) is dictated by the likely number of
researched subjects recruited, and the number of potential participants may be
populations such as limited across HDdUHB.
children and young Opportunities to expand Telehealth capability across HDdUHB will be √
people explored as a means of providing equity of access to research
studies being run at other hospital sites
Feasibility of expanding research themes to cover all four hospital √
sites (where sufficient potential numbers of patients exist) will be
explored; this may require input from the workforce planning team
Have transparent and The R&D team will continue to develop its R&D Costing Process √
efficient mechanisms (incorporating Cost Recovery and Income Distribution models) in line
to allocate resources with national Policy.
and recover costs A new Grants and Innovations Manager will be appointed to oversee √
from relevant sources grant applications and this will facilitate recovery of research costs
(industry, research from external partners.
grants The Grants and Innovations Manager will be expected to increase the √
amount of external grant capture year on year.
Novel mechanisms to identify, protect and exploit HDdUHB’s √
Intellectual Property Rights (IPR) will be developed by the Grants and
Innovations Manager.
Have an evidence- Explore mechanisms for implementing this at the Research and √
based decision Development Sub-Committee meeting in May 2017.
making culture of
which R&D is a key
component.
60
EQUALITY AND DIVERSITY
Equality and Diversity
Directive Objective Task Action Q1 Q2 Q3 Q4
Integrate equality, Encouraging Executives Positive messages around equality and √
diversity and human and Independent diversity to be posted in global email/
rights considerations Members to treat Hywel’s Voice etc. To produce weekly √
into core functions equality as “business as equality and diversity emails.
and mechanisms of usual” and encourage Involvement in embedding UHB’s Values √
the health board robust scrutiny and into core ways of working through
discussion of equality equality training programmes. Values to
aspects of decisions be measured through one to ones and
made at Board. PADRs.
Delivery of Integrated Impact √
Assessment.
Deliver 6 of training sessions to staff on √
IIA.
Monitoring of Integrated Impact √
Assessment to ensure equality issues are
given due consideration and feed in to
review, planning, development and
delivery mechanisms.
Increasing the number to ensure 100% √
of IIA.re taken as appropriate
Annual Board Development Day on √
Equality & Diversity for Board members.
Annual Board Development Day on √
Equality Impact Assessment and
Integrated Impact Assessment.
Train 50% board members on EIA. √
Monitoring values/ staff and patient √
experience in order to influence weekly
meetings
Fewer complaints or no increase in √
concerns/ complaints relating to equality
and diversity. Complaints reduced from
xx to xx
Integrated Impact assessments √
completed as appropriate.
100% of required staff are completing IIA √
Staff at all levels and across the √
organisation demonstrate a pro-active
approach to equality and diversity
To raise the completion of the treating me √
fairy e learning package to 90%
Increased social media activity relating to √
equality and diversity.
Produce weekly Tweets on equality and √
diversity
Increase number of Confirmed programme of meetings which √
Patient Stories presented will receive a patient story
to Health Board Work with existing groups to encourage √
meetings and at statutory feedback and involvement in providing
committee and sub- patient stories.
committee levels, which To collect a minimum of one piece of √
include examples from feedback from each quarter from each
protected groups; and protected characteristic group.
ensure patient feedback Work with Head of Public & Patient √
is used to influence Experience to facilitate inclusion of
change to service stories from protected groups being
improvement and heard at each Board/ Quality, Safety &
delivery (Tie in with Experience Assurance Committee,
Public and Patient Improving Experience Sub-Committee
61
Engagement (PPE) Plan) meeting.
Develop and agree protocol/ guidelines √
for use of patient stories
Stories heard at all agreed committee √
meetings
Recorded actions taken as a result of the √
feedback provided
Plan agreed with each directorate for √
incorporating stories into departmental
meetings. Ensure x% of team meeting
include patient stories
Develop a central library/ resource of √
stories from protected groups
Evaluation of the use of patient stories, √
including evidence of improvement in
relation to protected groups.
Review of evaluation to inform √
programme for following year. Actions to
be agreed pending evaluation
Establish baseline Monitor use of and completion of equality √
numbers for feedback data monitoring forms in public
from protected groups in engagement events
engagement events and To change the Siared Ieched/ Talking √
work with PPE Team to Health application forms in light of
increase participation of feedback from’ Sparkle’ To review all
protected groups. public facing forms to ensure they meet
current requirements
Develop mechanism for identifying √
feedback from protected groups
Undertake assessment of feedback from √
protected groups
No new actions in this quarter. √
Analyse results of assessment and report √
to Improving Experience Committee
Ensure action towards increasing √
participation of relevant protected groups
is built in to individual engagement plans
as appropriate. Ensure 100% of plans
include as appropriate.
Encourage and support Identify key events and attendees as √ √ √ √
Health Board appropriate.
representation at local Produce an overarching Communication, √
and national events Engagement and Equality and Diversity
celebrating diversity e.g. Plan.
Stonewall Annual
Conference, Swansea
Sparkle, Cardiff Pride
and any local events
across the three counties
Contribute to the Integrated Impact Assessment √
development of an (IIA)implemented
Integrated Impact WFGA Task and Finish Group and √
Assessment tool to programme of meetings ongoing
assist with compliance Develop mechanism to monitor √
with the Well-being of implementation of IIA. To increase the
Future Generations implementation of IIA from 0% to 100%xx
(Wales) Act 2015 Assurance provided to Board regarding √
(WGFA); and to ensure Integrated Impact Assessment activity.
the Board is assured that Develop quarterly reports in order to √
all relevant and monitor the IIA activity
legislative factors
(including equality) have
been considered prior to
62
a decision being taken.
• Build capacity of Develop training package around √
staff involved in Integrated Impact Assessment – possible
developing, planning joint training with Local Authorities
and reviewing Continue bespoke one to one training √
policies and services and support for staff undertaking EqIA
to undertake Equality Undertake Training Needs Analysis for √
Impact Assessment EqIA and identify key staff requiring
• Outcome – training
increased Establish ongoing Training programme √
awareness of for EqIA
equality issues
affecting staff,
service users and
carers
Ensure that Board NHS CEHR/Public Health Wales √
members (both Governance and Scrutiny Guide
Executive Directors and circulated to Board Members and
Independent Members) published on Health Board’s website
are aware of their Re-circulate Scrutiny Guide to Board √
responsibilities for robust Members to inform new members and
scrutiny of proposals refresh existing members
from an equality Annual Board Development Day on EqIA √
perspective and that they Annual Board Development Refresher √
know what questions to Days
ask to be fully assured
that services are high
quality, safe and deliver
a high level patient and
carer experience for
those protected under
the Equality Act 2010
Ensure equitable Introduce the Sensory Conduct and Review pilots on selected √
access to services Loss Friendly Awards Mental Health Wards across Hywel Dda
and information for all across the Health Board If successful outcomes from pilots, roll √
groups to help wards and out Awards programme incrementallY
departments to work Continue roll out of Awards programme √
towards meeting the All across all UHB.
Wales Standards for Increase in Wards and Departments √
Information and participating in programme from xx to xx
Communication for
People with Sensory
Loss
Introduce the Sensory Actions to be determined
Loss Friendly Awards
across the Health Board
to help wards and
departments to work
towards meeting the All
Wales Standards for
Information and
Communication for
People with Sensory
Loss
Improve communication Engage with representativestaff from √
and involvement of primary and secondary care comprising a
persons from protected cross section to include professional,
groups raising concerns administrative and auxiliary staff across
in the investigation all directorates
process Develop engaging and effective training √
programmes for staff.
Feedback from training sessions is 80% √
good.
Provide training and information on the √
63
equality and diversity web page, in order
to improve patient experience and reduce
complaints
Undertake audit of complaints and √
concerns process to access accessibility
Increase the amount of quality √
engagement website visits from 0 to a
minimum of 10,000 per year
Report on results of accessibility audit √
and identify any further actions
Evaluate data on complaints from √
protected characteristic groups
Adapt training sessions in light of √
feedback
Implement a robust Attend support groups in order to target √
system for learning feedback from protected characteristic
lessons in relation to the groups
experience of service Equality Team to meet with Patient √
users and carers from Experience Manager to discuss input
protected groups from protected groups.
accessing our services , Evaluate the feedback collected from √
which is used to improve attending support groups.
services To increase the amount of feedback √
received from protected characteristic
groups to a minimum of 9 pieces per
quarter
System established for identifying √
feedback received relating to equality and
diversity
Service users from protected groups √
have an equitable method for giving
feedback.
Patient feedback surveys indicate √
increased satisfaction from protected
groups.
Make links with hard to reach groups √
working alongside the PPE team
Develop links with the Introduce equality data Develop a data monitoring sheet to be √
population we serve, monitoring for public used at engagement events
identifying where engagement events to Extend equality data monitoring √
there are gaps and enable Health Board to depending on results of pilot
seeking to forge new analyse reach of Analyse data monitoring results and √
links where possible engagement with identify gaps
protected groups and Carry out targeted engagement via √
identify any gaps. Link in support groups.
with work on Well-being Report to Improving Patient Experience √
of Future Generations Sub-Committee on spread of protected
(Wales) Act 2015 groups’ attendance at staff and public
engagement events.
Find ways of increasing Analyse Stakeholder reference groups to √
engagement with BME identify where gaps exist
and faith groups, people Develop actions to increase engagement √
who are considering, are with marginalised groups
undergoing or who have Meet with Unity in order to develop an √
undergone gender ongoing relationship
reassignment, younger Attend groups and visit 4 gypsy and √
people and Gypsy traveller encampments in order to collect
Travellers feedback
Evaluate the feedback received from √
visits
Increase knowledge Ensure that the particular Check arrangements for Health and √
in relation to the needs of protected Wellbeing Group
health needs of groups are taken into Attend reconfigured Staff Psychological √
64
groups within our consideration in Wellbeing Group (SPWG)
communities and initiatives to improve the Assist and facilitate the SPWG in √
work towards well-being of staff. (Tie engaging with and getting feedback from
reducing inequalities in with actions on staff from protected groups.
in health Stonewall Workplace Utilise the result of the Stonewall √
Equality Index (WEI) and Workplace Equality Index Survey and
developing Frameworks NHS Staff Survey to identify key areas for
of good practice for all action
protected groups) Check arrangements for Health and √
Wellbeing Group
Assist the SPWG to develop an inclusive √
action plan to improve the well-being of
staff. Analyse workforce reports for any
identifiable trends in relation to particular
protected groups
Development of good practice √
Frameworks in relation to protected
groups (see Stonewall Workplace
Equality Index)
Produce a staff survey in order to drill √
down the results of Stonewall Equality
Index Survey
Assist the SWPG in implementing action √
plan
Complete annual Stonewall Workplace √
Equality Index submission to work
towards placemen within the tops 100 .
To maintain current position of 188 or
improve year on year on the Stonewall
Workplace Equality Index submission
Ensure that 50% of departments are √
meeting the requirements of the good
practice Framework
Produce a plan in order to improve our √
listing on the Stonewall Equality Index
Survey
Produce a plan for staff engagement √
(Link to 1.4).
Develop a dignity role model or dignity √
hero programme in order to engage staff
in equality and diversity
Identify a minimum of 4 dignity heroes √
across all sites in HDUHC
Resend the Stonewall staff survey in √
order to measure the distance travelled
• Utilise the Stonewall Framework available to key staff √
Health Champions Embed Framework recommendations √
Framework more into inclusive practice across the UHB
effectively to embed monitored through Standards for Health
good practice in the in Wales 6.2 and 6.3 and Concerns and
provision of Complaints Monitoring
equitable and Establish Task and Finish Group to √
inclusive services for assist with implementation and
LGB&T service assessment of progress
users and their Audit of progress towards embedding
families. recommended good practice
• Refresh Equality & Establish Task and Finish Group to √
Diversity Training assist with implementation and
Sessions assessment of progress
Audit of progress towards embedding
recommended good practice
Report to Improving Experience Sub- √
Committee on progress towards
65
embedding recommended good practice
Engage with identified dignity heroes √
staff in order to collect best practice
stories
Utilise and adapt the Incremental adaptation of Framework to √
above Framework to embed recommended good practice
embed good practice in across all protected groups monitored
relation to all protected through Standards for Health in Wales
groups. 6.2 and 6.3 and Concerns and
Complaints Monitoring
Report to Improving Experience Sub- √
Committee on progress towards
embedding good practice
Work collaboratively with Establish links with Public Health Team √
Public Health colleagues and have Equality & Diversity
on awareness raising representation at meetings as appropriate
campaigns to facilitate Establish baseline data on awareness √
contact with protected raising amongst protected group and any
groups, particularly any evidence of reduction in health
that are traditionally most inequalities
marginalised to improve Strong links with Public Health Team √
access to advice on established to facilitate increased
healthy lifestyle choices collaborative working evidenced by input
and reduce health in to Public Health Wales Awareness
inequalities Raising Campaigns
Support staff to • Formulate Training Engage with workforcr and od staff to find √
ensure that in programme for out training needs of staff within the UHB
carrying out their identified staff. identified within PADR process and other
duties they promote • Implement the training needs analysis activities
equality and good outcome of the Develop Training Needs Analysis (TNA) √
relations, dignity and training needs. Tool
respect and eliminate Produce training sessions in light of the √
discrimination evidence from the TNA and feedback
from staff
Analyse results of Training Needs √
Analysis
Monitor feedback on training sessions √
ensuring staff satisfaction is 80%
• Utilise the Stonewall Receive feedback on WEI submission for √
Workplace Equality 2017 listing
Index (WEI) Gather evidence to support Stonewall √
Framework to WEI submission for 2018 and utilise
embed good practice feedback to inform submission
in creating an Meet in order to start discussions about √
inclusive workplace becoming a Trans inclusive workplace
for LGB&T staff Prepare and submit Stonewall WEI √
• Maintain or increase submission for 2018 Listing –deadline
score/improve September 2017
placing on Stonewall Ask Trans*form to attend a Board √
Workplace Equality Seminar
Index year on year Result of Stonewall Workplace Equality √
• Outcomes: Index 2018 – published January 2018
o Increase Display LGBT and Trans flag on website. √
numbers of Obtain buy-in from W+OD to fully utilise √
staff Stonewall WEI Framework to embed
declaring good practice and improve staff
sexual experience
orientation in Feedback on WEI submission from √
workplace Stonewall Workplace Officer
o Increased Feedback to IEC √
numbers of Develop action plan to address gaps in √
staff good practice identified from 2018 WEI
completing submission
66
Stonewall Welcome applications from LGBT √
Workplace community
Equality
Index Staff
Survey with
more
positive
feedback.
Utilise and adapt the Obtain buy-in from Workforce & OD to √
above Framework to adapt and fully utilise Stonewall WEI
embed good practice in Framework for other protected groups to
relation to all protected embed good practice and improve staff
groups. experience
Develop good practice Frameworks for all √
protected groups incrementally
Tie in with work of Staff Psychological √
Wellbeing/Health and Wellbeing Group
Feedback progress to Improving √
Experience Sub-Committee
Develop regular Equality Develop action plan to produce a √
& Diversity Newsletter quarterly Newsletter and regular Equality
and include at least one & Diversity Communications
article focusing on Engage with staff to ensure the √
aspects of equality, newsletters are meeting xx% of their
diversity human rights in needs
each issue of Hywel’s First edition of’ Take Ten’ to be issued to √
Voice to raise managers. To be distributed via global
awareness of good email and be available through the Siarad
practice Ieched/ Talking Health page.
Refresh Equality & Ensure 6 meetings take place between √
Diversity training Equality & Diversity Team and relevant
provision to further Workforce & OD colleagues per annum
integrate into existing Equality & Diversity representation at √
programmes and identify relevant Workforce & Learning &
where gaps exist OD/Learning & Development Team
meetings to facilitate integration into
existing training
Engage with staff to evaluate the √
difference
Set up a diversity group in order to drive √
the values and equality and diversity
Get staff to sign up to a value as their √
new years resolution
Identify 20 staff in order to sign up for a √
value as their New Year’s Resolution
67
GOVERNANCE
Directorate Objective Task Action Q1 Q2 Q3 Q4
Deliver a high quality • Review Committee Further review and refresh √
committee services performance, including undertaken as part of the year
framework ensuring identifying and clarifying and end process reporting to June
the Board receives the overlaps/duplication and 2017 Extraordinary Board
appropriate level of ensuring they are operating Meeting to ensure Committees
assurance as Assurance Committees remain fit for purpose
and that each Committee, Review undertaken as part of the
Sub-Committee and Group is year end process reporting to
clear on how to deliver on June 2017 Extraordinary Board
their Terms of Reference. Meeting
• Committees to undertake a Further review and refresh √
review of their self- undertaken as part of the year
effectiveness leading to end process reporting to June
potential amendments to the 2017 Extraordinary Board
TORs, committee Meeting to ensure Committees
development plans and remain fit for purpose
informing the annual reports. Review undertaken as part of the
• Building into the Internal Audit year end process reporting to
Programme an independent June 2017 Extraordinary Board
review of the effectiveness of Meeting
the committee framework. Review undertaken by Internal √
Audit with recommendations
featuring in the 2017/18
governance plan
Reviewing the Board agenda and Business cycle approved by the √
business cycle to ensure the Board
Board allocates the correction Board workplan scrutinised at √ √ √ √
proportion of time on the four key each Board meeting
areas – strategy, performance ,
risk and behaviour
• Undertake and seek Board Board approved documentation in √
approval of Standing Orders, place
SFIs, Scheme of Delegation All Sub-Committee Terms of √
and Committee Terms of Reference approved by their
Reference following full parent Committee
review by the Audit Risk and Year end review of Board √
Assurance Committee. decisions and outstanding actions
• Ensure Terms of Reference Business cycle approved by the √
and work programme for the Board
sub-committees have been
reviewed by the parent
committee and that all sub-
committees are operating in
accordance with the
recommendations contained
within the External
Governance Review.
• Develop a Board business
cycle and tracking mechanism
for approval by the Board to
ensure all decisions made by
the Board and Board level
Committees are implemented
in accordance with the agreed
timescale.
Design an innovative use of Board Seminar days to be held on √
Public Board and Board Seminar hospital sites with the potential to
days include Board Member
Rotation of Public Board and walkabouts.
QSEAC meetings across Training programme for IMs on √
community venues for the mandatory training in place
68
2017/2018 year. Public Board meetings rotated √
across community venues in
place. QSEAC meetings
potentially to the same time
frame.
• Implement training and On-going support and training √ √ √ √

support programme for provided on the Standard
Executive leads, Committee Operating Procedure(SOP) on the
and Sub-Committee support Management of Board &
officers and those who write Committees and accompanying
reports to ensure that they are toolkit guidance to various fora
confident and clear of their such as Manager’s Passport,
roles and the expected Manager’s Passport Plus
standard of committee Opportunities taken to promote √ √ √ √
business and report writing. the SOP and to update guidance
• Implement the Standard within the toolkit as necessary
Operating Procedure and
associated guidance
documents within the toolkit to
support officers in producing
Board and Committee Papers
and etiquette in meetings
• Develop an integrated impact Integrated impact assessment √
assessment tool to ensure the tool designed by the WFGA Task
Board is assured that all & Finish Group approved by ET
relevant and legislative and in place.
factors have been considered New reporting template included √
prior to a decision being taken within the SOP toolkit guidance.
including equalities, privacy,
financial, legislation,
Wellbeing of Future
Generations Act etc
• Develop a new reporting
template incorporating the
integrated impact
assessment, health and care
standards and prudent
healthcare principles and
incorporating relevant
guidance and templates
within the Standard Operating
Procedure
Maintain the central resource for Central function for committee √
servicing Board and Board services in place servicing the
assurance committees to improve Board and the Board level
consistency, flow and reporting assurance Committees.
standards, and extend where Put in place committee secretariat √
necessary to service the strategic arrangements for strategic arm of
arm of the Health Board. the Health Board.
Review and options appraise the Option appraisal completed in √

requirements of IM’s and respect of electronic issue of
Executives receiving Board and Board and Committee papers in
Committee papers including the readiness for Board approval.
option for an electronic Board Implementation of electronic √
Room and propose a way Board & Committee solution.
forward.
Work across the organisation and Incorporated within the SOP √
external organisations at the toolkit
frontline to develop the key
questions the Board and
Committees need to ask to be
69
fully assured that services are
high quality, safe and deliver a
high level patient and carer
experience.
Develop a shared repository of Board & Committee papers on √
information (corporate library) for internet (electronic Board &
Board papers, governance Committee reporting hosts a
material, risk management central repository function)
information, etc, accessible to all Risk Management manual on staff √
Board members. Information intranet
Asset list for governance team
• Design and Delivery of a Board Development plan in place, √
Board Development supported by Academi Wales,
Programme with Executive and to be rolled in accordance
Directors and Independent with the dates incorporated within
Members together. the plan
• Undertake the Academi Assessment √
Wales High Performance
Capability Self Assessment
Model
• Develop an annual business
cycle for the Board Seminar
• Development session with the Dates incorporated within the plan √
Executive team focused on Executive Team Development
team dynamics and maturity Programme in place
to facilitate a cohesive
approach to individual and
collective responsibilities.
• Deliver Academi Wales
development programme
• Deliver an induction Induction Programme delivered √
programme for new
Independent Members Induction Programme delivered √
• Provide the opportunity for all
Independent Members to
undertake the planned
development training with
Academi Wales
Develop a succession plan for Succession plan developed √
Independent Members including
reviewing the IPR process and IPR process reviewed √
committee membership rotation
Membership and Chairmanship of √
committees reviewed
Recruitment process for new √
Independent Members completed.
• Review the balance of IMs Role Descriptions developed √
roles in particular relating to Membership and Chairmanship of √
committee chairmanship, committees reviewed
committee membership, panel
chairmanship.
• Develop a role description for
the Board Champion roles
and review refresh and rotate
the current allocation of roles
and responsibilities.
Develop a robust • Ensure the Board Assurance Board approved BAF in place √
framework of Framework based on the Updated Legislative Assurance √
assurance for the Strategic Objectives is Framework presented to ARAC
organisation submitted to every Board Internal Audit plan in place and √
meeting. approved
• Provide training to the Training Package developed √
70
Independent Members to Reviewed at each Board meeting √ √ √
improve understanding of the
Board Assurance Framework
and its purpose to the Board.
• Review the legislative
assurance framework
providing assurance to the
ARAC and Board in respect of
compliance with associated
legislation.
• Work with Internal Audit to
align the annual plan to the
Board Assurance Framework
and Risk Register.
Implementing recommendations Tracker reviewed at ARAC √ √ √ √
from Structured Assessment 2016 meeting quarterly
to improve the mechanisms for
tracking audit reports and other
key documents within the
organisation including ensuring
recommendations are
implemented in accordance with
agreed timescales.
• Lead the organisational Review Governance & Leadership √
structured assessment Accountability Standard to ensure
process enabling the any areas for improvement are
production of the Annual Audit progressed prior to assessment
Letter by WAO. Structured Assessment Complete √
• Support the Board to
undertake a self assessment Governance and Leadership √
against the Governance and Accountability Standard complete
Leadership Accountability AGS drafted in readiness for √
Standard leading to the Board approval.
production of a development
plan and overall conclusion
being an integral part of the
Annual Governance
Statement
Further develop working Relationship meetings in place √ √ √ √
relationships with key regulators
including WAO, HIW,
Commissioners and Internal Audit
to ensure the organisation is
working alongside the regulators
and delivering improvements in
accordance with the agreed
timescales
Improve governance Reporting & governance √
arrangements and reporting arrangements reviewed by Board
arrangements for joint Secretaries Network and reported
committees, hosted bodies and to the Chair’s Group
the collaboratives across NHS
Wales
Review the corporate governance Initial assessment undertaken √
elements of the health and care Develop action plan from 2017/18 √
standards ensuring these are assessment for Directorate
embedded within the Improved compliance with √
organisation. governance elements of the
health and care standards.
Maintain and review the Pursue action to increase √
processes in relation to standards reporting of interests, gifts,
of business conduct hospitality, sponsorship and
honoraria
71
Increased reporting √ √ √
Ensure all recommendations Action plan reviewed at each √ √ √ √

contained within the External ARAC meeting
Governance review has been fully
implemented in agreed with the
agreed and revised timescales.
Ensure all year end Board approval of all year end √
documentation is produced, documentation
consulted upon and approved in Draft documentation in place. √
accordance with the year end
reporting:
• Governance related
Health and Care
Standards
• Annual review of
Ministerial Directions and
WHCs
• Assessment of
compliance against the
Corporate Governance
Code
• Governance, Leadership
and Accountability
Standard
• Committee Annual
Reports/Self Assessments
• ARAC Annual Report
• Corporate Risk Register
• Annual Quality Statement
• Annual Governance
Statement
Drive forward a culture • Review Risk Appetite Risk Appetite and tolerance levels √
of good risk Statement and tolerances to to be reviewed and agreed and
management align with the strategic approved at Board level
throughout the priorities.
organisation including • Review Risk Management Revised Risk Management √
developing a robust Strategy. Strategy in place.
process for the co- Develop a Risk Management Develop a new risk management √
ordination of risks Manual which will incorporate section on the staff intranet page
procedures and guidance for risk
assessment, risk registers, risk Review and update Risk √ √ √
appetite statements & tolerance Management Manual
levels, risk classification matrix,
roles & responsibilities for
individuals, committees/sub-
committees/groups.
Continue to strengthen internal Risk management training at √ √ √ √
risk management processes to corporate induction, Manager’s
ensure risks are properly Passport, Manager’s Passport
captured, recorded, managed and Plus
reported across the organisation.
Develop guidance for Committees √
Continued scrutiny of risks over √ √ √ √
tolerance levels at ARAC and
through Committee structure and
feedback provided to risk leads
Continue to implement a new risk Project Plan in place. √
management system using the System under development √
DATIX module to support good
risk management across the Datix Module implemented across √
organisation. the organisation
72
• Develop a plan for driving Risk management training at √ √ √ √
forward a culture of good risk corporate induction, Manager’s
management throughout the Passport, Manager’s Passport
organisation and a Plus
programme of training and 121 support available on any √ √ √ √
support. aspect of risk management or
• Provide extra support to those Datix
who need to build their
confidence and ability to
understand risk management.
Develop a robust Deliver an approved Partnership Planning approaches to the √
partnership Governance Framework for our Partnership Governance
governance ‘significant’ partnerships including Framework approved by the
framework the development of joint risk Board
registers and risk appetite Board approved Partnership √
statements. Governance Framework in place
Integrate the performance of Revised Integrated Performance √
partnerships and Joint Assurance Report in place and
Committees (including risk) into reported upon as regular Board
the Integrated Performance item
Assurance Report.
Annual Report/Review of the Annual Report/Review of the √
University Partnership Board University Partnership Board
(UPB) Strategy Strategy in place
Monitor work against the Through UPB quarterly meetings √ √ √ √
University status revalidation
submission to ensure University
Health Board status is on track
and maintained.
Representation at Public Service On-going support in place for the √ √ √ √
Boards to support Chair & Chief work of the PSBs
Executive in Partnership working Regular attendance at PSB √ √ √ √
across the public sector Network Forum
To build the capacity • Develop a plan for driving Corporate governance training √ √ √ √
and capability to forward a culture of good delivered at Corporate Induction
deliver a culture of governance throughout the
good governance organisation and a Monthly or bi-monthly governance √ √ √ √
throughout the programme of awareness briefings in place issued via
organisation raising on how we do Global E-mail
business and make decisions Through on-going promotion, √ √ √ √
in line with our values support and guidance on the SOP
• Produce monthly governance Review of success of programme √
briefing including ‘hot topics’ and continued roll out in 2018/19
for distribution across the
Health Board
• Build organisational capacity
to achieve a basic level of
governance awareness
among staff through provision
of guidance and advice and
advice to support this
process.
Approve a working protocol for Approved protocol in place. √
the relationships between the
Board Secretary and Director of
Governance, Communications &
Engagement ensuring the
independence of the Board
Secretary is not compromised.
Professional development for Outcome from Personal √ √ √ √
specialist teams (Professional Development Needs (PADR)
membership and CPD)
73
Ensure core governance skills for Quarterly Team meetings √ √ √ √
all staff across the governance
team
Clear objectives, PDR’s, team Objectives set and agreed for the √
meetings and 1:1 meetings will be year
delivered 1:1 meetings scheduled monthly √
for the whole year
Six month review √
PDRs completed √
74
Communication and Engagement
Directorate Task Action Q1 Q2 Q3 Q4
Objective
Deliver a high Deliver a communications and Activity delivered, captured and evaluated √ √ √ √
quality engagement calendar for the in report on ongoing basis
communications year to capture Quarter 1 activities to include: √
and communications and • Deliver at least 2 chairman
engagement engagement events, activities, commendations (Comms Plan 1)
service to our milestones and campaigns. • National Nurses Day – May
patients, This will be a live document. • Volunteer Week - June (Comms Plan
families, carers, 1)
staff and To tailor the calendar to • Formal consultation on Transforming
stakeholders prioritise engagement and Mental Health (Comms Plan 3)
communications support for • Choose Well Easter information
the: (Comms Plan 4)
- 10 strategic objectives • Bowel Screening – April (Comms Plan
- Integrated Medium Term 5)
Plan
• Carers Week – June (Comms Plan 5
- Clinical Services Strategy
Quarter 2 activities to include: √
- Transforming Mental
• Deliver at least 2 chairman
Health Services
commendations (Comms Plan 1)
programme
• Summer wellness information (Comms
- Transformation
Plan 4 and 5)
programme
• World Heart Day and blood pressure
Communications team to awareness – September (Comms Plan
prioritise and deliver five key 5)
communication campaigns to Quarter 3 activities to include: √
support all of the above, in • Deliver at least 2 chairman
areas which will have the commendations (Comms Plan 1)
biggest impact in supporting • Winter wellness campaign (Comms
the organisation to achieve its Plan 4 and 5)
annual plan. • Support for national recruitment events
during Oct (Comms Plan 2)
Proposed campaigns (tbc): • Flu campaign (Comms Plan 5)
1. Valuing our staff ( annual • World mental health day – Oct (Comms
programme to celebrate Plan 5)
staff achievement and • World Diabetes Day Nov (Comms Plan
value their contribution) 5)
2. Recruitment • Alcohol campaign Nov (Comms Plan 5)
3. Engaging and Quarter 4 activities to include: √
communicating service • Deliver at least 2 chairman
change (to include clinical commendations (Comms Plan 1)
service strategy and • Support promotion and communication
transformation work) activity at staff awards (Comms Plan 1
4. Choose Well (to include all date tbc)
aspects of improving • Winter wellness campaign (Comms
public awareness on how Plan 4 and 5)
to navigate the local • Flu campaign (Comms Plan 5)
healthcare system) • National obesity week )Comms Plan 5)
5. Keeping ourselves well
• No Smoking Day (Comms Plan 5)
(public health campaigns
and self-care support)
Review and maintain the Review and update databases √ √ √ √
engagement activity database
to capture all public and staff
engagement around service
planning, improvement and
redesign across the
organisation
Review and maintain key
databases(Stakeholder and
75
SI/TH) to ensure effective
communication and
engagement can take place
Development and testing of a Retrospective evaluation of engagement √
continuous engagement tool to activity over the past year
measure the effectiveness of Design of a forward thinking continuous √
continuous engagement and engagement plan
inform future engagement Monitor planned activity √ √ √
activities Retrospective analysis of activity over the √
year
Maintain communication’s Provide service and ensure business √ √ √ √
reactive desk (Mon-Fri 9-5) continuity
dealing with global emails,
staff bulletins, media enquiries,
staff mythbusters, reputational
risks, and social media
Build the Professional development for Send representative to NHS Wales √ √ √ √
capacity and specialist teams (Profession Communications Study Day
capability to membership and CPD) Send representative to Participation Cymru √ √ √ √
deliver high engagement officers network morning
quality CIPR membership and commencement of √
communications CPD
and Key engagement staff to undertake Risk √
engagement Assessment Training
across the Key engagement staff to work towards the √ √ √ √
organisation Consultation Institute Certificate of
Professional Development (CPD) and
Advanced Practitioner Certificate (APC)
Send representative to annual PPI and √
equality conference
Ensure core communications, Directorate Away Day Learning Opportunity √ √
engagement and governance Senior Leadership Team Development √ √ √ √
skills for all staff across the Promotion of ‘How to stay digitally safe’ √ √
directorate campaign
Provision of core Board Development Session on Risk √
communications, media and Analysis
engagement skills for the Leaders responsible for service change to √
organisation’s ‘talking heads’ undertake risk analysis training
and selected senior leaders. Media interview training and media training √
To focus on developing the Welsh / English delivered by independent
following key skills: media provider or partner
interview (Welsh and English), Deliver i-movie training for comms staff and √
core communication skills in wider staff with evidenced skills in
clear messaging and communication
presentation , public facing
and participatory engagement
events
Build organisational capacity to Test checklists developed in practice, √ √ √ √
achieve a basic level of review their effectiveness and amend
communication and accordingly
engagement among all staff Identify and work with key teams / √ √ √ √
through the development of directorates to build capacity
tool kits and the provision of To create a toolkit to support staff and √
guidance and advice to teams who can evidence a need for a
support this process. Set the bespoke digital channel to engage with
parameters of what staff can either staff of public.
and can’t do in isolation, what
must go through the central
corporate teams and what the
corporate teams will deliver on
the organisation’s behalf
Where appropriate and cost Identify opportunities throughout the year to √ √ √ √
effective, to commission work with partners
76
partners to undertake
elements of engagement and
communications work on our
behalf
Clear objectives, PDR’s, team Objectives set and agreed for the year √
meetings and 1:1 meetings will 1:1 meetings scheduled for the whole year √
be delivered Progress of objectives monitored through √ √ √ √
regular 1:1 meetings
Six month reviews scheduled and take √
place
PDRs completed √
Develop a Delivery of the engagement One BIG conversation theme to be √ √ √
culture of programme. arranged
shared decision SRG meeting / – participatory engagement) √ √ √
making and a One virtual event √ √ √ √
programme of
engagement
using a mixture
of traditional
and new
innovative
models
Develop and Support the Stakeholder Revamp the SRG to become the focal point √
nurture Reference Group (SRG) to for our public and patient engagement
productive meet its key purpose and play activities.
stakeholder an active role in supporting SRG participatory engagement activity √ √ √
relationships engagement activity across the
university health board.
More effective use of Siarad Newsletter publication √ √ √ √
Iechyd / Talking Health as an Align Siarad Iechyd focus groups / √ √ √ √
engagement tool workshops to the organisational strategic
priorities
Survey work √ √ √ √
Reader’s Panel work √ √ √ √
Maintain and improve an Proactive media meetings with Chair and √ √ √ √
ongoing relationship with key Chief Executive to discuss emerging issues
media outlets
Represent the health board in Attend meetings √ √ √ √
communication networks
across Wales (i.e. NHS Wales
Communications Group /
Welsh NHS Confederation
Communications Group/NHS
Wales Digital Group) as a
means to influence policy
making enabling the health
board to better meet its
strategic objectives
Greater collaboration with Share engagement calendar with CHC and √
public sector and CHC partners for us to determine joint
partners around opportunities
communication and Deliver joint opportunities where √
engagement opportunities appropriate e.g. Cylch Caron
Work with partner NHS Mid Wales Healthcare Collaborative √ √ √ √
organisations and healthcare Engagement Events
collaboratives (e.g. Mid Wales
Healthcare Collaborative and ARCH
ARCH) to ensure appropriate
engagement and Major Trauma
communication on
developments and initiatives.
Maintain a calm Test and evolve Participate in All-Wales or Dyfed Powys √ √ √ √
and communication capacity in a emergency planning exercises – in
77
professional major incident absence of exercise – undertake internal
advice service desktop exercise once a quarter to test
to ensure public resilience
confidence and Contribute and enact actions Attend meetings √ √ √ √
business from Dyfed Powys LRF
continuity warning and informing group
Optimise the Maintain and improve Improve A-Z directory of services, by √ √ √ √
use of digital accessibility to service developing two new areas
communications information on our public Auditing information once a month √ √ √ √
and Internet To have completed review and √
engagement implemented change to improve
accessibility on the home page
Use of digital media as an One virtual event √ √ √ √
innovative engagement tool To test webinar as means of engagement √
with staff
To deliver staff video to Board as means of √
providing staff with opportunity to get their
voice heard at Board
To create a toolkit to support staff and √
teams who can evidence a need for a
bespoke digital channel to engage with
either staff of public.
To test webinar as means of engagement √
with public
Create more engaging content Evidence and evaluate new content for √ √ √ √
for websites and digital media communication campaigns (i.e. video,
animation, virtual tours, polls etc)
Launch new mental health portal (supplied √
by Tyne and Wear) with 22 self-help
resources
To have completed improvement review of √
digital screen process with goal of ensuring
improved accuracy and relevance of
information
Enhance the Deliver key corporate Hywel’s Voice √ √ √ √
reputation and publications Siarad Iechyd / Talking Health newsletter √ √ √ √
strengthen the Carmarthenshire News √ √ √ √
identity of Team Brief √ √ √ √
University Stakeholder Briefing √ √ √ √
Health Board Provide support to Head of Corporate √
through high Executive Projects for publication of:
quality • Annual Report and Summary
communication • Annual Governance Statement
and • Annual Quality Statement
engagement Maintain brand identity and Advice and ongoing support as and when √ √ √ √
integrity through supporting the requested
organisation to follow
guidelines
Support the organisation to Advice and ongoing support as and when √ √ √ √
reach a high standard in all requested
published information and in all
public and patient
engagement.
78
WELSH LANGUAGE
Objective
Workforce: Induction – continue to Record number of sessions attended and √ √ √ √
Support staff to present at weekly number of staff in attendance
ensure that in Induction Session
carrying out their Evaluate feedback and amend/alter √ √
duties they promote Outcome: to ensure all presentation, if required
Welsh Language new staff understand why
and recognise that language is important for
patients receive patient care and patient
care in their first experience. Welsh Language awareness sessions for √ √
language as a key existing staff members – record number of
patient experience Outcome: Gain sessions presented and number of staff in
and quality of care confidence: to ensure that attendance
issue new UHB staff who have
Welsh Language skills
(More than Just have the confidence to use
Words (MTJW) – those skills at whatever
3.1;4.1; 6.1; 6.7) level appropriate to their
role.
Learn Welsh – provide/ Schedule courses for 2017/18 (available √
facilitate a broad late April onwards)
programme of learning 10 hour on-line course for Board members √
Welsh Language courses Monitor and evaluate feedback from √ √
for all groups of staff courses – to review needs for 2018/19
across UHB Mouse mats – to support staff to increase √ √ √
the use of the Welsh Language in the
workplace. Design, produce and
disseminate to staff
Appoint fixed term part- Advertise and recruit √
time Welsh Language tutor Welsh Language tutor to work specifically √ √
(Band 6 on 6-month Pilot with staff that have Level 3 Welsh
Project) Language skills and above
Evaluate post √
Collate Skills – continue to Work and support the Workforce & OD √ √ √ √
collate Welsh Language Team to encourage staff to complete and
skills of entire workforce return their Welsh Language Sills Audit -
within UHB increase total by 2% each quarter (baseline
taken 31.03.17)
Continue to work with Monitor the implementation of the Bilingual √ √ √ √
Workforce & OD Skills Strategy
Directorate to implement
the Bilingual Skills Strategy
Support Recruitment Attend Recruitment Fairs; translate √ √ √ √
documentation and provide advice
Advertising posts as Welsh Essential/ √ √ √ √
Desirable – providing advice to managers
on what level of Welsh (0-5) is needed
Patient Improve patient experience Speech & Language Therapy letters to be √
Experience: within Children’s Services bilingual
Ensure that patients
can access Welsh Distribute Welsh stickers to clinics √
Language services
without obstacles Link into Cymraeg i Blant, where applicable √ √
and embed the Patient Experience Evaluate St David’s Day video and share √
principle of the Videos/Audio good practice across national network
Active Offer into Consider any other areas to be targeted √
contacts with Focus Group Actions to be confirmed
patients at all levels Improving Experience Sub- Escalating good practice and √ √ √ √
(not a choice but a Committee challenges/reporting on compliance
need) Annual Quality Statement Work with all Wales Welsh Language leads √ √
(MTJW 7.1) to identify appropriate measures
79
Correspondence Work with Operational Teams to support all √ √ √ √
appointment letters to be issued bilingually
(following Welsh Language Commissioner’s
Investigation).
Meet with Operational Team Managers – √ √ √ √
review patient letters and how patient
language choice is recorded (two (2) per
quarter)
Communicate with staff the importance of √ √ √ √
bilingual appointment letters and translation
service available – through Global emails
and face-to-face
Primary Care: Continue to support and Continue with GP surgery visits and share √ √ √ √
Promote the use of share good practice information/resources
Welsh Language Develop relationships with Attend Cluster Meetings and work with √ √ √ √
within Primary Care Community Pharmacists UHB Pharmacy Lead
settings Collate Skills of Primary Lessons learnt from GP Annual Return √
Care Providers’ workforce Attend Cluster Meeting - Pembrokeshire √
Attend Cluster Meeting - Carmarthenshire √
Attend Cluster Meeting - Ceredigion √
Explore how to record Work with Primary Care leads √ √
patient language choice
within Primary Care
Support Primary Care with Support Primary Care to implement any √ √ √ √
Welsh Language actions from Welsh Language
Standards (date is Commissioner’s meeting with Directors of
currently unknown – Primary Care (April 2017)
thought to be autumn)
Translation : Continue to maintain and Deliver the internal translation service √
Provide a deliver a robust translation timeframe
comprehensive service for the whole of the
translation service UHB
for the whole of the Develop a Prioritisation Ensure that 85% of translation requests are √ √
organisation Framework for translation delivered to agreed timescales
responses and monitor
responses to ensure Ensure that 90% of translation requests are √ √
agreed target met delivered to agreed timescales
Welsh Language Strategic Framework for Present Annual Monitoring Report to Welsh √
Standards / More Welsh Language Services Government
than just words / in Wales: More than just Represent All Wales Welsh Language √ √
Well-being of words Officers at the Welsh Language in Health
Future and Social Services Partnership Board
Generations Represent the UHB at the All Wales Welsh √ √ √
(Wales) Act 2015 Language Officers meeting
Continue to represent the UHB at Dyfodol √ √ √ √
Dwyieithog (Ceredigion) and Fforwm Sirol
(Carmarthenshire)
Welsh Language Scheme Present Annual Monitoring Report to Welsh √
Language Commissioner
Welsh Language Respond in a timely manner to the √ √
Standards compliance notice and prepare the
organisation for the forthcoming Standards
Be an active member of Evaluate and monitor the number of √ √ √ √
the Well-being of Future Integrated Impact Assesments that have
Generations Task & Finish considered the Welsh Language
Group and lead on the
Welsh Language element
of the Integrated Impact
Assessment
80
CARERS

Objective
Workforce Promote existing training Record number of staff undertaking e- √ √ √ √
opportunities via the e- learning
Support staff to learning package
ensure that in Gain feedback on the difference the
carrying out their Outcomes: to learning has made.
duties they identify ensure staff Progress the development of a broader √ √
and support understand why training strategy
Carers at the Carers are
earliest important for Implement/evaluate strategy √ √
opportunity, patient care and
recognising Carers patient Launch of updated intranet site setting out √ √ √
as partners to experience latest guidance and information for Carers.
involve them in Possibility for this to be supplemented by a
‘transfer of care’. A Task and Finish Group physical information hub in hospital
(Passing the will explore more broadly settings.
Baton) training within the Health
Board. This is an existing Build on internal staff surveys. Key piece
Help identify our group that has already of work to be undertaken regarding staff √ √ √
own working met. within our own workforce who might be
Carers and juggling employment and caring
provide Outcomes: An internal responsibilities.
signposting and training strategy
support as Work in progress includes reviewing
appropriate. The Carers Advisory existing policy documents, working with
Team will re-fresh the occupational health.
Awareness of staff intranet and internet
Carers issues by sites, plus undertake work This is working towards Carers being an
team leaders and on internal policy. underpinning and cross cutting issue
managers is key if across all service areas. This standalone
this objectives is to This needs to ensure section is therefore only part of the full
be delivered. reach across the HDUHB response.
organisation in terms of
awareness.
Partnership This will be via fresh Maintain current commissioning of √ √ √ √
governance through the services, working toward pooled budgets
Following the West Wales Regional and evaluating impact
Population Needs Partnership Board and Work with colleagues in finance to define √ √ √ √
Assessment and will work closely with all resources allocated to Carers work, for
on receipt of partners in the Local example respite, to show opportunities for
Welsh Authority and third sector service re-modelling and return on
Government organisations, including investment
transition funding, Carers representatives. Develop with partners a forward work √ √
progress the programme that balances locally sensitive
second year of the Outcomes : A regional delivery with regional added value. The
transition from work programme for plan will be consistent with the anticipated
Carers Measure to Carers from October Welsh Government Carers Strategy
Social Services 2017 onwards which (anticipated Nov 2017) and take into
and Well-being provide a high quality, account other relevant policy frameworks,
(Wales) Act 2014. cost-effective and notable the Wellbeing of Future
Formal sustainable response for Generations (Wales) Act 2015. Also
confirmation of Carers, taking into opportunity to build on local experience
funding to Health account the diversity of around Carers resilience pilot project and
Boards anticipated needs within the 50,000 key pieces of work, for example around
April 2017. Carers and the resources supporting Young Carers (including Young
available Adult Carers). Links to be made here with
Public Health Wales.
81
Service delivery The success in primary Maintain current Investors in Carers (IiC) √ √ √ √
care settings needs to be work within primary care. There is a
The Investors in maintained, indeed standalone IiC plan.
Carers (IiC) enhanced, whilst there is
Programme is also a need to ensure this
progressing an is taken forward
effective project internally.
within primary care
and increasingly in Outcomes: Re-focusing
other Health and the primary care delivery Develop, implement and evaluate the IiC √ √ √ √
Social Care to ensure good practice action plan for 2017/18 and beyond.
settings. Based embedded will allow more Annual targets include 33% of GP
on the Population resource to be put against surgeries working toward silver level.
Needs the internal work needed Spread equally over quarters so 8%.
Assessment, it is within our wards, clinics
clear that more and departments.
needs to be done
on service Develop an ambitious reform programme √ √
delivery. The within the Health Board, working
objective is to particularly with senior nurse colleagues
maintain existing (John’s campaign)
provision and
recognise a large Implement this programme and evaluate √ √
hidden population. impact
Services may
need expanding or Ensure the opportunities to embed the √ √ √ √
re-modelling. Carers programme as part of our core
work, for example mainstreaming this
through initiatives such as the Dementia
Plan. This will be ongoing and measured
by demonstrating the influence the Carers
agenda has on other activities being
progressed within the Health Board.
Discussions also started with Welsh
Ambulance Services NHS Trust regarding
the unscheduled care agenda.
Communication There is an opportunity to Specific activities for Carers as part of √ √ √ √
and engagement build on previous success national campaigns – as required
working across the
Link to other campaigns, for example √ √ √ √
During the course regional footprint which
November is the sensory loss awareness
of the year, there has been progressed
month, so could have an initiative with
will be various positively with our
respect to Carers with and cared for with
initiatives to partners.
sensory loss. Already some good
progress, such as
communications through media to support
Carers Outcomes: Whilst
this which will be maintained.
Week/Carers recognising the
Rights Day and opportunity to continue to This potential is there to share good √ √ √ √
Young Carers work with our partners, practice – or indeed practice that needs to
Awareness Day. the potential exists for the be improved upon – within our internal
Health Board to progress committees.
The opportunity some appropriate
also exists to bring activities within our We will review the provision of information
forward examples wards, clinics and in our hospitals, for example notice
of practice to departments. Potential to boards.
internal build on work on
Committees within identifying Carers In addition, linking to the need to progress
the Health Board. Leads/Champions. the Investors in Carers programme
internally, we can promote new initiatives
to staff and patients through updates on
the websites.
82
Appendix C - IMTP Mandatory & Discretionary Templates 2017/18 to 2019
Mandatory Templates - Sheets

C1 Outcomes Framework - Delivery of Measures
C2 Service Shift from Secondary to Primary and Community Care
C3 Finance - Plan Summary
C4 Finance – Resource Planning Assumptions
C5 Finance – Statement of Comprehensive Net Income/Expenditure – 3 yrs
C6 Finance – Statement of Comprehensive Net Income/Expenditure – Profiles
C7 Finance – Revenue Resource Limit Assumptions
C8 Income and Expenditure Assumptions (Wales NHS)
C9 Finance – Year 1 Savings Plan
C10 Finance – Years 2 & 3 Savings Plan
C11 Finance – Risks and Mitigating actions
C12 Asset Investment Summary
C13 Asset Investment Detail
C14 Revenue Funded Infrastructure
C15 Workforce - WTE
C16 Workforce - £'000
C17 Workforce - Recruitment Difficulties
C18 Educational Commissioning information
C18.1 Undergraduate Education
C18.2 PostGraduate Education
C18.3 Assistant Practitioners & HCSW
C18.4 Medical & Dental
Discretionary Template - Sheet

C19 Delivery - LHB & Trust Specific Internal Service Delivery Plans & Measures
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 Contents

NHS Organisation Hywel Dda University Health Board UPDATED
NEB Dashboard areas Delivery will be measures against agreed profiles and achievement of identified quarterly specific actions
STAYING HEALTHY - I am well informed & supported to manage my own physical & mental health
Profile
Measure Target Projected end of
March 2017 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
position
The percentage of adult smokers make a quit attempt
5% annual target 2.2% 2.4% 2.6% 2.8% 3.0%
Quarterly via smoking cessation services
assessment The percentage of those smokers who are co-validated
40% annual target 40% 40.0% 40.0% 40.0% 40.0%
as quit at 4 weeks
Quarterly specific actions to ensure delivery and sustainability of Smoking prevention targets :
Q1
Q2
Q3
Q4
TIMELY CARE - I have timely access to services based on clinical need & am actively involved in decisions about my care
Profile
position
The percentage of patients waiting less than 26 weeks
95% 81% 81% 81% 81% 81% 81% 81% 81% 81% 81% 81% 81% 81%
for treatment
The number of patients waiting more than 36 weeks for
0 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000
treatment
The number of patients waiting more than 8 weeks for
0 0 0 0 0 0 0 0 0 0 0 0 0 0
a specified diagnostic test
The percentage of patients who spend less than 4
hours in all major and minor emergency care (i.e. A&E)
95% 84% 84.7% 84.7% 84.7% 84.7% 84.8% 84.9% 84.9% 85.0% 84.7% 84.7% 84.7% 85.5%
facilities from arrival until admission, transfer or
discharge
The number of patients who spend 12 hours or more in

all hospital major and minor care facilities from arrival 0 379 379 375 371 367 364 360 356 353 353 353 353 341
until admission, transfer or discharge
The percentage of emergency responses to red calls

65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65% 65%
arriving within (up to and including) 8 minutes
Number of ambulance handovers over one hour 0 82 82 81 80 79 79 78 78 78 77 77 76 76
The percentage of patients newly diagnosed with

cancer, not via the urgent route, that started definitive
Monthly 98% 98% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0%
treatment within (up to and including) 31 days of
diagnosis (regardless of referral route)
The percentage of patients newly diagnosed with

cancer, via the urgent suspected cancer route, that
95% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%
started definitive treatment within (up to and including)
62 days receipt of referral
<4 hours = direct admission to

58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0% 58.0%
Acute Stroke ward
% compliance with <12hrs = CT scan The most recent SSNAP UK 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%
stroke QIMs: *Assessed by Stroke Consultant National quarterly average 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%
within 24 hours Trajectory
*Thrombolysed patients with Door
to Needle <= 45 minutes - New 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
Measure
The percentage of mental health assessments
undertaken within (up to and including) 28 days from 80% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
the date of receipt of referral
The percentage of therapeutic interventions started
within (up to and including) 28 days following an 80% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
assessment by LPMHSS
Quarterly specific actions to achieve and sustain planned care targets:
Q1 Finalising Service Level Agreement to commission out Tier 0 work being undertaken by the LPMHSS to increase capacity for assessment and interventions
Q2 Progressing commissioning of 3rd sector servive to undertake work outlined in Service Level Agreement
Q3 Commissioned Service to go live and commence delivery
Q4 Commissioned Service to achieve full delivery of service specification
Quarterly specific actions to achieve and sustain cancer access targets:
Q1
Q2
Q3
Q4
Quarterly specific actions to achieve and sustain Unscheduled care targets:
Q1
Q2
Q3
Q4
Quarterly specific actions to achieve and sustain Stroke targets:
Q1
Q2
Q3
Q4
INDIVIDUAL CARE - I am treated as an individual, with my own needs & responsibilities

Profile
position
The percentage of health board residents in receipt of
secondary mental health services (all ages) who have a 90% 90% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
valid care and treatment plan (CTP)
Monthly All health board residents who have been assessed

under part 3 of the mental health measure to be sent a
copy of their outcome assessment report up to and 100% 90% 90.0% 90.0% 92.0% 92.0% 92.0% 95.0% 95.0% 95.0% 95.0% 100.0% 100.0% 100.0%
including 10 working days after the assessment has
taken place
The percentage of hospitals within a health board

6 monthly
which have arrangements in place to ensure advocacy 100% 1000% 100.0% 100.0%
assessment
is available for all qualifying patients
Quarterly specific actions to achieve and sustain Mental Health measures:

Q1 The service will contiue to audit the measure engaging staff to increase understanding of the best practice that drives the target and to increase ownership & review any services approach to part 3 if they have missed achieving the target more than once on 2016/17
Q2 Improvement actions will then be agreed from Q1 review of services who breached part 3 more than once in 2016/17
Q3 Peformance management against improvement actions
Q4 Peformance management against improvement actions
SAFE CARE - I am protected from harm & protect myself from known harm
Profile
Projected end of
Measure Target
position
The rate of laboratory confirmed c.difficile cases per
28 per 100,000 population 40 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0
100,000 population
Monthly The rate of laboratory confirmed S.aureus
bacteraemias (MRSA and MSSA) cases per 100,000 20 per 100,000 population 40 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0
population
Quarterly specifications to achieve and sustain DToC targets:
Q1
Q2
Q3
Q4
Quarterly specific actions to achieve and sustain Hospital Acquired infections targets:
Q1 - Project Plan to progress ANTT, Proposal for implementing Feacal Transplantation in Hywel Dda UHB, Hand Hygiene Campaign - validation audits Finalise managemetn plan for CPE & other MDROs
Q2 - Pilot Antimicrobial Drug Charts in Secondary Care, Conduct European Point Prevalence Survey, Extend work done with South Ceredigion Cluster -UTI Identification & Prevnetion
Q3 - Influenza vaccination of In-patients in Secondary Care, Medical Devices Audit - Intravnenous catheters & Indwelling Urinary Catheters, EarlyRecognisiton of Sepsis Project Plan
Q4 - Review of progress with 'When Should I Worry Leaflet - Health Visitors, Co-Prodcution Strategy raelting Infection Prevention/Health Promotion.
Profiles required against monitoring periods-specific actions may be requested if delivery trajectory and achievement is not felt to be sufficient
STAYING HEALTHY - I am well informed & supported to manage my own physical & mental health
Profile
position
The rate of emergency hospital admissions for basket 8
1,209 1,209 1,209 1,209 1,209 1,209 1,209 1,209 1,209 1,209 1,209 1,209
chronic conditions per 100,000 population
Reduction
The rate of emergency hospital multiple admissions
(12 month trend)
(within a year) for basket 8 chronic conditions per 239 239 239 239 239 239 239 239 239 239 239 239
100,000 population
Monthly
Of the practices capable of offering My Health on Line,
30.0% 40% by March 2018
the percentage who are offering appointment bookings
Improvement
(12 month trend)
Of the practices capable of offering My Health on Line,
62.0% 75% by March 2018
the percentage who are offering repeat prescriptions
% uptake of the 65 year olds and over 64% 67.0%

influenza vaccine in Under 65's in at risk groups 75% 43% 48.0%
the following Pregnant women Not collected Not collected
groups: Healthcare workers 50% 46% 50.0%
Percentage of pregnancies where the initial assessment

Annual improvement We are currently reviewing this and action plan is being developed which will impact on the measures
was carried out by 10 completed weeks of pregnancy
Annual
assessment Percentage of eligible children being provided with
access to universal service component of Healthy Child
Annual improvement 100.0%
Wales Programme assessed by socio-economic
quintiles
The percentage of people (aged 16+) who found it

Annual improvement No currently measured
difficult to make a convenient appointment with a GP
The percentage of children who received the following

scheduled vaccinations at age 4:
Quarterly
4 in 1 pre school booster 95% 85% 95.0% 95.0% 95.0% 95.0%
assessment
HibMenC Booster
Second MMR dose
EFFECTIVE CARE - I receive the right care & support as locally as possible & I contribute to making that care successful
Profile
position
Delayed transfer of care delivery per 10,000 LHB
4.2 3.8 3.8 3.7 3.7 3.6 3.6 3.6 3.5 3.5 3.5 3.5 3.4
population – mental health (all ages) Reduction
Delayed transfer of care delivery per 10,000 LHB (rolling 12 months)
64 59.5 58.7 58.0 57.2 56.4 55.7 54.9 54.2 53.4 52.6 52.1 51.4
population – non mental health (aged 75+)
Percentage of episodes clinically coded within one Improvement
Monthly month post episode end date (12 month trend)
Reduction
Crude hospital mortality rate (less than 75 years of age)
(12 month trend)
Percentage of deaths which had a universal case note
Improvement
review (stage 1) undertaken within 1 month of the
(12 month trend)
death
Indication of progress against the 21 criteria for the
Still under development nationally
operational use of the NHS number
Percentage of clinical coding accuracy attained in the
Annual NWIS national clinical coding accuracy audit 88% 91.5%
Annual improvement
assessment programme
Percentage of staff who have undergone information

44% 55.0%
governance training as outlined in C-PIP Guidance
TIMELY CARE - I have timely access to services based on clinical need & am actively involved in decisions about my care
Profile
position
The number of patients waiting for an outpatient follow- Reduction
26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970
up who are delayed past their agreed target date (12 month trend)
Monthly
Percentage of survival within 30 days of emergency Improvement
admission for a hip fracture (12 month trend)
Percentage of GP practice offering daily appointments

89% Access workstreams underway to improve the rates and projected position 90% in March 2018
Annual between 17:00 and 18:30 hours
Annual improvement
assessment Percentage of GP practices open during daily core
79% Access workstreams underway to improve the rates and projected position 80% in March 2018
hours or within 1 hour of daily core hours
Quarterly Percentage of the health board population regularly Improvement
46.35% 46.5% 47.0% 47.0% 48.0%
assessment accessing NHS primary dental care (4 quarter trend)
INDIVIDUAL CARE - I am treated as an individual, with my own needs & responsibilities

Profile
position
Rate of calls to the mental health line CALL (Community
Advice and Listening Line) by Welsh residents per
100,000 of the population
Quarterly Improvement
assessment Rate of calls to the Welsh dementia helpline by Welsh (4 quarter trend)
residents per 100,000 of the population (aged 40+)
Rate of calls to the DAN 24/7 helpline by Welsh

residents per 100,000 of the population
DIGNIFIED CARE - I am treated with dignity & respect & treat others the same
Profile
position
The percentage of patients who had their procedures

postponed on more than one occasion for non clinical
Improvement
Monthly reasons with less than 8 days notice and are
(12 month trend)
subsequently carries out within 14 calendar days or at
the patient’s earliest convenience
Percentage of people with dementia in Wales aged 65

years or over who are diagnosed (registered on a GP Annual improvement 53% Average % of patients on a QOF register within Hywel Dda is 0.53%. The aim is to increase to 0.65% by March 2018
QOF register)
Percentage of GP practice teams that have completed

Practices have until March 2018 to claim for providing this service and are under no obligation contractually to inform us of their intention to provide, however the aim
mental health Direct Enhanced Services (DES) in Annual improvement 11%
is to be at 20% by March 2018
dementia care or other directed training
The average rating given by the public (aged 16+) for

Annual Annual improvement Not currently measured
the overall satisfaction with health services in Wales
assessment
Percentage of adults (aged 16+) who reported that

they were very satisfied or fairly satisfied about the Annual improvement Not currently measured
care that they received at their GP/family doctor
Percentage of adults (aged 16+) who reported that

they were very satisfied or fairly satisfied about the Annual improvement Not currently measured
care that they received at an NHS hospital
Percentage of NHS employed staff who come into

Bi-annual
contact with the public who are trained in an 75% Not currently measured but will form part of our Strategic Objective 8 Not currently measured
assessment
appropriate level of dementia care
SAFE CARE - I am protected from harm & protect myself from known harm
Profile
position
Number of Patient Safety Solutions Wales Alerts that
20% 20% 15% 15% 10%
were not issued within the agreed timescales
0
Number of Patient Safety Solutions Notices that were
10% 10% 10% 10% 5%
not assured within the agreed timescales
The number of preventable hospital acquired Reduction

4.35% 4.0% 3.8% 3.5% 3.3%
thrombosis (4 quarter trend)
Quarterly Fluoroquinolone items as a percentage of total
assessment antibacterial items prescribed
Cephalosporin items as a percentage of total
antibacterial items prescribed
Co-amoxiclav items as a percentage of total Lower quartile or reduction
antibacterial items prescribed towards quartile below
Non steroid anti-inflammatory drug (NSAID) average

daily quantity per 1,000 STAR-PUs (specific therapeutic
group age related prescribing unit)
Percentage of serious incidents assured within the

90% 35% 36% 38% 40% 42% 44% 46% 48% 50% 52% 54% 56% 58%
agreed timescales
Number of new Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Percentage of in-patients with a positive sepsis
screening who have received all elements of the " Improvement
Sepsis Six" first hour care bundle within one hour of (12 month trend)
Monthly
positive screening
Percentage of patients admitted to the emergency

Department with a positive sepsis screening who have Improvement
received all elements of the " Sepsis Six" first hour care (12 month trend)
bundle within one hour of positive screening
Percentage of GP practices that submit one (or more) Lower quartile or reduction
no absolute figure - aiming for improvement towards appropriate quartile as per WG guidance
yellow card per 2,000 practice population towards quartile below
Annual
assessment
Continuous periods of hospital care with any mention
of self harm for children and young people (aged 10- Annual improvement
24 years), rate per 100,000 population
Percentage of NHS employed staff who have
Bi annual improvement 50.0% 54.0% 57.0% 61.0% 64.0% 68.0% 71.0% 74.0% 77.0% 79.0% 81.0% 83.0% 85.0%
Bi-annual completed safeguarding training
assessment Percentage of NHS staff who have been checked by the
Bi annual improvement 69.80%
Disclosure and Barring Service
OUR STAFF & RESOURCES - I can find information about how the NHS is open & transparent on its use of resources & I can make careful use of them
Profile
position
Reduction
Percentage of sickness absence rate of staff 5.16% 5.05% 4.99% 4.97% 4.95% 4.93% 4.91% 4.89% 4.87% 4.85% 4.83% 4.81% 4.79%
(12 month trend)
The percentage of patients who did not attend a new This varies by
outpatient appointment Reduction speciality
The percentage of patients who did not attend a follow- (12 month trend) This varies by
up outpatient appointment speciality
Improvement
Percentage of staff undertaking performance appraisal 51.0% 54.0% 57.0% 61.0% 64.0% 68.0% 71.0% 74.0% 77.0% 79.0% 81.0% 83.0% 85.0%
(12 month trend)
Reduction
Rate of patients who did not attend a GP appointment Not currently measured
(12 month trend)
Number of ENT procedures that do not comply with

NICE "Do Not Do" guidance for procedure of limited 0
Monthly effectiveness (as agreed by the Planned Care Board)
Number of opthalmology procedures that do not

comply with NICE "Do Not Do" guidance for procedure
0
of limited effectiveness (as agreed by the Planned Care
Board)
Number of orthopaedics procedures that do not
comply with NICE "Do Not Do" guidance for procedure
0
of limited effectiveness (as agreed by the Planned Care
Board)
Number of urology procedures that do not comply with

NICE "Do Not Do" guidance for procedure of limited 0
effectiveness (as agreed by the Planned Care Board)
Percentage of inhaled corticosteroids prescribed in

primary care that are low strength inhaled Improvement
Quarterly
corticosteroids
assessment
Percentage of staff completing statutory and Improvement
51.00% 58.0% 65.0% 75.0% 85.0%
mandatory training (4 quarter trend)
Percentage of those who are undertaking performance

appraisal who agree it helps them feel valued and Bi annual improvement 61% 65.0% 68.0%
improves how they do the job
Bi-annual
Percentage of staff who are engaged Bi annual improvement 63% 68.0% 70.0%
assessment
Percentage of staff who would be happy with the

standards of care provided by their organisation if a Bi annual improvement 67% 70.0% 73.0%
friend or relative needed treatment
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C1. Delivery
SERVICE CHANGE & SHIFT OF SERVICES / ACTIVITY / WORKFORCE / FINANCE FROM SECONDARY CARE TO PRIMARY & COMMUNITY CARE - HIGH LEVEL MILESTONES
This template can be adjusted to suit local need. What is important that service change and service shift priorities and the key risks, benefits and milestones associated with them are identifiable.
LIST IN ORDER OF PRIORITY / IMPORTANCE
Expected impact on
activity in different Workforce changes to Financial consequences -
settings of care (volume deliver service change funding service change
CHANGE/SCHEME & Ref in Status & Timetable (see and type of activity) and and service shift (FTEs and service shifts and Key Risks & Mitigating
ID IMTP Detailed description of Service Change & Service Shift Note) pathway stage. and skill mix) costs/savings Actions Measurable Benefits
1
2
3
4
etc.
NOTE
1 Status & Timetable
Status - What is currently being implemented and what is in the pipeline (forward look)
Timetable - expected timetable for implementation and completion.
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C2. Service Change & Shift
Hywel Dda ULHB Enter Date of Submission: 31 March 2017
INTEGRATED MEDIUM TERM PLAN SUMMARY - 2017/18 to 2019/20
This Table is currently showing 0 errors
2017/18 2018/19 2019/20
£'000 % of Budget £'000 % of Budget £'000 % of Budget
1 Revenue Resource Limit (RRL) LHB only (positive values) 743,956

2 Income (For Trusts)/Other Income (positive values) 46,966
3 Total Revenue Allocation/Income 790,922 0 0
High Level Summary
4 1. Underlying Position b/f

5 Previous Year Forecast Position : Surplus (positive)/Deficit (negative) (51,815)
Less (negative values):
6 Non Recurring Income (14,445)
7 Accountancy Gains
8 Non Recurring Savings (To include CIPs from 2017/18 onwards) (9,700)
9
10 Full Year Effect of Recurring Cost Pressures (3,976)
11
12
13
14
15
Add (positive values):
16 Non Recurring Expenditure
17 Full Year Effect of Recurring Savings Schemes
18 Treatment Fund 1,900
19
20
21
22
23 Total Underlying Position b/f: Deficits and Cost Pressures (negative)/ Surplus (positive) (78,036) -9.9% 0 0.0% 0 0.0%
24 2. New Cost Pressures (negative values)

25 2.1 Cost Growth
26 Pay Inflation
27 - Pay Award (5,215)
28 - Increments
29 - Pensions & Other Pay Oncost Changes (729)
30 - Terms & Conditions (incl T&S)
31 Apprenticeship Levy (1,514)
32
33
34
35 Sub Total Pay Inflation (7,458) -0.9% 0 0.0% 0 0.0%
36 Non pay Inflation (2,100)

37 Statutory Compliance and National Policy
38 Continuing Heath Care (1,019)
39 Funded Nursing Care
40 Prescribing (2,019)
41 GMS (1,484)
42 Quality & Safety Developments
43 LTA (1,640)
44 Community Pharmacy
45 Specialist Services (2,185)
46
47
48
49
50 Total Inflationary/Cost Growth (17,905) -2.3% 0 0.0% 0 0.0%
51 2.2 Demand / Service Growth (negative values)

52 NICE and New High Cost Drugs (3,645)
53 Continuing Heath Care (1,161)
54 Funded Nursing Care
55 Prescribing
56 Specialist Services
57 Demographic / Demand on Acute Services: Please Specify below
58 General HCHS 10,915
59 Mental Health 1,608
60 Winter Pressure (300)
61
62
63
64
65
66
67
68
69
70
71 EASC/LTA (1,376)
72
73
74
75
76
77
78 Total Demand/Service Growth 6,041 0.8% 0 0.0% 0 0.0%
79 2.3 Local Service/Cost Pressures (negative values)

80 Local cost pressures (1,000)
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95 Total Local Cost Base Challenge (1,000) -0.1% 0 0.0% 0 0.0%
96 Total Opening Financial Challenge (Deficit)/Surplus (90,900) -11.5% 0 0.0% 0 0.0%
97 3. Identified Savings Plans (positive values)

98 Continuing Care and Funded Nursing Care
99 Commissioned Services
100 Medicine Management (Primary and Secondary Care) 3,088
101 Non Pay 931
102 Pay 5,946
103 Primary Care
104 Total Identified Savings Plans 9,965 1.3% 0 0.0% 0 0.0%
105 Total Savings Yet To Be Identified (postive value) 18,035 2.3% 0.0% 0.0%
106 Total Net Income Generation (positive value) 0.0% 0.0% 0.0%
107 Total Planned Accountancy Gains (positive value) 4,000 0.5% 0.0% 0.0%
108 Total Unallocated Reserves (positive value) 0.0% 0.0% 0.0%
109 Total In Year Performance/Position Before Repayment of Prev Years Deficit - (Deficit)/Surplus (58,900) -7.4% 0 0.0% 0 0.0%
110 4. Repayment of Previous Years Deficit (negative value)
111 Total In Year Performance/Position After Repayment of Prev Years Deficit - (Deficit)/Surplus (58,900) -7.4% 0 0.0% 0 0.0%
112 5. Revenue Assistance Requested (positive values)

113 Recurring
114 Non Recurring
115 Total WG Assistance 0 0.0% 0 0.0% 0 0.0%
116 Net Financial Challenge - (Deficit)/Surplus (58,900) -7.4% 0 0.0% 0 0.0%
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C3.Fin Plan Summary
Hywel Dda ULHB 31 March 2017
Resource Planning Assumptions
Local Resource Planning Assumptions

All Wales Resource Planning Assumptions Used Commentary on local material difference/update/refinement on all Wales assumptions
2017/18 2018/19 2019/20 2017/18 2018/19 2019/20
Inflationary Pressure % Cost % Cost % Cost % Cost % Cost % Cost
1 Cost Growth
2 Pay Inflation (inc. awards, T & Cs inc. Travel etc) 1.22% 0.96% 0.98% 1.20% 0.94% 0.94%
3 Incremental Drift
4 Pensions & Other Pay Oncost Changes 0.30% 0.33% 0.75% 0.26% 0.23% 0.70%
5 Non pay Inflation 0.66% 0.66% 0.66% 0.55% 0.55% 0.55%
6 Statutory Compliance and National Policy
7 Continuing Heath Care 0.19% 0.21% 0.22% 0.34% 0.36% 0.39%
8 Funded Nursing Care 0.01% 0.01% 0.01%
9 Prescribing
10 GMS
11 Quality & Safety Developments
13 Total Cost Growth 2.38% 2.17% 2.62% 2.35% 2.08% 2.58%
14 Demand / Service Growth

15 NICE and New High Cost Drugs 0.63% 0.50% 0.50% 0.65% 0.65% 0.65%
16 Continuing Heath Care 0.23% 0.25% 0.28% 0.20% 0.22% 0.24%
17 Funded Nursing Care 0.02% 0.02% 0.02%
18 Prescribing 0.27% 0.28% 0.29% 0.36% 0.41% 0.42%
19 Specialist Services 0.48% 0.34% 0.42% 0.48% 0.34% 0.42%
20 Demographic / Demand on Acute Services 0.59% 0.59% 0.59% 0.65% 0.65% 0.65%
GMS 0.44% 0.44% 0.44% 0.83% 0.80% 0.80%
Community Pharmacy 0.06% 0.06% 0.06% 0.13% 0.08% 0.09%
21 Total Demand / Service Growth 2.72% 2.48% 2.60% 3.30% 3.15% 3.27%
22 Total Inflationary Pressure 5.10% 4.65% 5.22% 5.65% 5.23% 5.85%
2017/18 2018/19 2019/20

Pay Related Cost Assumptions - Local £'000 % £'000 % £'000 %
1 Pay Awards
2 - A 4 C Staff 4,206 0.75% 0.00% 0.00%
3 - Misc Pay (Non AfC / Non Medical) 0.00% 0.00% 0.00%
4 - Junior Medical Staff 0.00% 0.00% 0.00%
5 - Staff Grades / Associate Specialists 0.00% 0.00% 0.00%
6 - Consultants 0.00% 0.00% 0.00%
7 Total Pay Awards 4,206 0.75% 0 0.00% 0 0.00%
8 Increments £'000 % £'000 % £'000 %

9 Cost of Increments
10 - A 4 C Staff 1,009 0.18% 0.00% 0.00%
11 - Misc Pay (Non AfC / Non Medical) 0.00% 0.00% 0.00%
12 - Junior Medical Staff 0.00% 0.00% 0.00%
13 - Staff Grades / Associate Specialists 0.00% 0.00% 0.00%
14 - Consultants 0.00% 0.00% 0.00%
15 - Consultant Commitment Awards 0.00% 0.00% 0.00%
16 Total Increments 1,009 0.18% 0 0.00% 0 0.00%
17 Pensions & Other Pay Oncost Changes £'000 % £'000 % £'000 %

18 1- Auto Enrolment
19 from Oct 2017 - part year 645 0.11% 0.00% 0.00%
20 2 - Apprenticeship Levy
21 From April 2017 1,514 0.27% 0.00% 0.00%
22 3 - NHS Pensions Administrative Charges
23 From April 2017 84 0.01% 0.00% 0.00%
24 4 - NHS Pension Discount Rate Change - 3.0% to 2.8%
25 From 2019/20 0.00% 0.00% 0.00%
26 Total Pensions 2,243 0.40% 0 0.00% 0 0.00%
27 Comparator 561
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C4. RP Assumptions
STATEMENT OF COMPREHENSIVE NET INCOME/EXPENDITURE
Annual Annual Annual

Plan Plan Plan
2017/18 2018/19 2019/20 Validations
Revenue/Income (positive entries) £'000 £'000 £'000
1 Revenue Resource Limit 743,956 2017/18 Revenue Resource Limit (Cell C13) agrees to the RRL Assumptions (Cell C79) Ok
2 Miscellaneous Income - Capital Donation\Government Grant Income 300 2018/19 Revenue Resource Limit (Cell D13) agrees to the RRL Assumptions (Cell D79) Ok
3 Miscellaneous Income - Other (including non resource limited income) 21,767 2019/20 Revenue Resource Limit (Cell E13) agrees to the RRL Assumptions (Cell E79) Ok
4 Welsh NHS Local Health Boards & Trusts Income 22,214
5 WHSCC Income 2,290
6 Welsh Government Income 395
7 Total Revenue/Income 790,922 0 0
Operating Expenses (positive entries)

8 Primary Care Contractor (excluding drugs, including non resource limited expenditure) 113,210
9 Primary Care - Drugs & Appliances 69,323
10 Pay 363,615
11 Non Pay (excluding drugs & depreciation) 61,949
12 Secondary Care - Drugs 37,137
13 Healthcare Services Provided by Other NHS bodies 129,098
14 Non Healthcare Services Provided by Other NHS bodies 83
15 Continuing Care and Funded Nursing Care 49,865
16 Other Private & Voluntary Sector 3,231
17 Joint Financing and Other 3,253
18 Depreciation 14,450
19 Other 4,608
20 Total Operating Expenses 849,822 0 0
21 Forecast Surplus/(Deficit) (58,900) 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C5.SCNI.E 3 Year
SCNI/SCNE Profiles
Year 1 Forecasts - 2017/18

Apr May June Jul Aug Sep Oct Nov Dec Jan Feb Mar Total
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
1 Total Revenue/Income (SCNI/SCNE Lines 1 - 6) (positive entries) 65,910 65,910 65,910 65,910 65,910 65,910 65,910 65,910 65,910 65,910 65,910 65,910 790,922
2 Operating Expenses (positive entries)
3 Primary Care (Lines 8-9) 15,211 15,211 15,211 15,211 15,211 15,211 15,211 15,211 15,211 15,211 15,211 15,211 182,533 2017/18 Total Revenue/Income (Cell O10) agrees to the SCNI.E 3 Year (Cell C19) Ok
4 Pay (Line 10) 30,301 30,301 30,301 30,301 30,301 30,301 30,301 30,301 30,301 30,301 30,301 30,301 363,615 2017/18 Total Primary Care Expenditure (Cell O12) agrees to the SCNI.E 3 Year (Cell C22+ C23) Ok
5 Non Pay (Lines 11 -12) 8,257 8,257 8,257 8,257 8,257 8,257 8,257 8,257 8,257 8,257 8,257 8,257 99,086 2017/18 Total Pay Expenditure (Cell O13) agrees to the SCNI.E 3 Year (Cell C24) Ok
6 Healthcare Services Provided by Other NHS bodies, CHC/FNC & Private/Voluntary Services (Lines 13, 15 & 16) 15,183 15,183 15,183 15,183 15,183 15,183 15,183 15,183 15,183 15,183 15,183 15,183 182,194 2017/18 Total Non Pay Expenditure (Cell O14) agrees to the SCNI.E 3 Year (Cell C25 + C26) Ok
7 Non Healthcare Services Provided by Other NHS bodies, Joint Financing & Other (Lines 14, 17 & 19) 662 662 662 662 662 662 662 662 662 662 662 662 7,944 2017/18 Total HCS and CHC\FNC and Priv Voluntary Expenditure (Cell O15) agrees to the SCNI.E 3 Year (Cell C27 + C29 + C30) Ok
8 Depreciation (Line 18) 1,204 1,204 1,204 1,204 1,204 1,204 1,204 1,204 1,204 1,204 1,204 1,204 14,450 2017/18 Total Non HCS, Joint Financing & Other Expenditure (Cell O16) agrees to the SCNI.E 3 Year (Cell C28 + C31 + C33) Ok
9 Total Operating Expenses 70,819 70,819 70,819 70,819 70,819 70,819 70,819 70,819 70,819 70,819 70,819 70,819 849,822 2017/18 Total Depreciation Charge (Cell O17) agrees to the SCNI.E 3 Year (Cell C32) Ok
2017/18 Outturn Position (Cell O20) agrees to the SCNI.E 3 Year (Cell C36) Ok
10 Forecast Surplus/(Deficit) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (4,908) (58,900)
2018/19 Total Revenue/Income (Cell G29) agrees to the SCNI.E 3 Year (Cell D19) Ok
2018/19 Total Primary Care Expenditure (Cell G31) agrees to the SCNI.E 3 Year (Cell D22 + D23) Ok
2018/19 Total Pay Expenditure (Cell G32) agrees to the SCNI.E 3 Year (Cell D24) Ok
2018/19 Total Non Pay Expenditure (Cell G33) agrees to the SCNI.E 3 Year (Cell D25 + D26) Ok
2018/19 Total HCS and CHC\FNC and Priv Voluntary Expenditure (Cell G34) agrees to the SCNI.E 3 Year (Cell D27 + D29 + D30) Ok
Year 2 Forecasts - 2018/19 Year 3 Forecasts - 2019/20 2018/19 Total Non HCS, Joint Financing & Other Expenditure (Cell G35) agrees to the SCNI.E 3 Year (Cell D28 + D31 + D33) Ok
Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 2018/19 Total Depreciation Charge (Cell G36) agrees to the SCNI.E 3 Year (Cell D32) Ok
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 2018/19 Outturn Position (Cell G39) agrees to the SCNI.E 3 Year (Cell D36) Ok
11 Total Revenue/Income (SCNI/SCNE Lines 1 - 6) (positive entries) 0 0
12 Operating Expenses (positive entries) 2019/20 Total Revenue/Income (Cell L29) agrees to the SCNI.E 3 Year (Cell E19) Ok
13 Primary Care (Lines 8 -9) 0 0 2019/20 Total Primary Care Expenditure (Cell L31) agrees to the SCNI.E 3 Year (Cell E22+ E23) Ok
14 Pay (Line 10) 0 0 2019/20 Total Pay Expenditure (Cell L32) agrees to the SCNI.E 3 Year (Cell E24) Ok
15 Non Pay (Lines 11 -12) 0 0 2019/20 Total Non Pay Expenditure (Cell L33) agrees to the SCNI.E 3 Year (Cell E25 + E26) Ok
16 Healthcare Services Provided by Other NHS bodies, CHC/FNC & Private/Voluntary Services (Line 13, 15 & 16) 0 0 2019/20 Total HCS and CHC\FNC and Priv Voluntary Expenditure(Cell L34) agrees to the SCNI.E 3 Year (Cell E27 + E29 + E30) Ok
17 Non Healthcare Services Provided by Other NHS bodies, Joint Financing & Other (Lines 14, 17 & 19) 0 0 2019/20 Total Non HCS, Joint Financing & Other Expenditure (Cell L35) agrees to the SCNI.E 3 Year (Cell E28 + E31 + E33) Ok
18 Depreciation (Line 18) 0 0 2019/20 Total Depreciation Charge (Cell L36) agrees to the SCNI.E 3 Year (Cell E32) Ok
19 Total Operating Expenses 0 0 0 0 0 0 0 0 0 0 2019/20 Outturn Position (Cell L39) agrees to the SCNI.E 3 Year (Cell E36) Ok
20 Forecast Surplus/(Deficit) 0 0 0 0 0 0 0 0 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C6.SCNI.E Profiles
Revenue Resource Limit Assumptions
LHB COMPLETION ONLY 2017/18 2018/19 2019/20

£'000 £'000 £'000
1 RRL used in SCNE profiled analysis 0 0 0
Made up of:-
2 Allocation Letter/ Resource Planning Figure 743,956
3 Plus the following additional anticipated allocations:-

4 DEL- Funded in Previous Years:
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24 Sub Total - Funded in Previous Years 743,956 0 0
25 DEL New Funding Issues

26 1.Recurring
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43 Sub Total - New Funding Issues - Recurring 0 0 0
44 2. Non Recurring
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59 Sub Total - New Funding Issues - Non Recurring 0 0 0
60 AME
61 Donated Depreciation
62 Impairments
63 Other…specify
64
65
66
67
68 Sub Total - AME 0 0 0
69 Total RRL used in SCNE profiled analysis 743,956 0 0
70 Check total = zero 743,956 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C7.RRL Assumptions
31 March 2017
Hywel Dda ULHB
Income and Expenditure Assumptions (Wales NHS)
A. Annual Forecast 2017/18

Contracted Non Contracted Contracted Non Contracted Total
Income Income Total Income Expenditure Expenditure Expenditure
LHBs / Trusts £'000 £'000 £'000 £'000 £'000 £'000 Validations
1 Abertawe Bro Morgannwg 4,630 4,630 30,205 3,120 33,325
2 Aneurin Bevan 631 631 311 311 2017/18 Annual Welsh NHS Income (Cell E22) agrees to the SCNI.E Year 1 (Cell C16 + C17) OK
3 Betsi Cadwaladr 4,420 4,420 317 317 2018/19 Annual Welsh NHS Income (Cell E39) agrees to the SCNI.E Year 2 (Cell D16 + D17) Ok
4 Cardiff & Vale 893 893 5,999 5,999 2019/20 Annual Welsh NHS Income (Cell E56) agrees to the SCNI.E Year 3 (Cell E16 + E17) Ok
5 Cwm Taf 351 351 265 265
6 Hywel Dda 0 0 0 0
7 Powys 7,595 7,595 437 437
8 Public Health Wales 1,727 1,727 1,791 1,791
9 Velindre 1,828 1,828 7,586 7,586
10 Welsh Ambulance 141 141 3,214 3,214
11 WHSSC 2,290 2,290 79,486 79,486
12 Total 24,504 0 24,504 129,611 3,120 132,731
B. Annual Forecast 2018/19

LHBs / Trusts £'000 £'000 £'000 £'000 £'000 £'000
13 Abertawe Bro Morgannwg 0 0
14 Aneurin Bevan 0 0
15 Betsi Cadwaladr 0 0
16 Cardiff & Vale 0 0
17 Cwm Taf 0 0
18 Hywel Dda 0 0
19 Powys 0 0
20 Public Health Wales 0 0
21 Velindre 0 0
22 Welsh Ambulance 0 0
23 WHSSC 0 0
24 Total 0 0 0 0 0 0
C. Annual Forecast 2019/20

LHBs / Trusts £'000 £'000 £'000 £'000 £'000 £'000
25 Abertawe Bro Morgannwg 0 0
26 Aneurin Bevan 0 0
27 Betsi Cadwaladr 0 0
28 Cardiff & Vale 0 0
29 Cwm Taf 0 0
30 Hywel Dda 0 0
31 Powys 0 0
32 Public Health Wales 0 0
33 Velindre 0 0
34 Welsh Ambulance 0 0
35 WHSSC 0 0
36 Total 0 0 0 0 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C8.Income & Expend Assumpti

NOTE: Tables to be populated with indentified savings plans only
YEAR 1 SAVINGS PLANS - All Positive Entries
To include Cost Improvement & Cost Containment schemes
Savings Plans:- Year 1 - 2017/18
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
1 Continuing Care and Funded Nursing Care 0
2 Commissioned Services 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Medicine Management (Primary and Secondary Care) 193 206 133 203 223 233 273 283 299 310 353 379 3,088
4 Non Pay 65 65 83 68 71 75 79 75 75 77 75 123 931
5 Pay 86 99 144 162 175 539 565 555 640 676 694 1,611 5,946
6 Primary Care 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Total Savings Plans 344 370 360 433 469 847 917 913 1,014 1,063 1,122 2,113 9,965
Pay Savings: Analysis
Year 1 - 2017/18
Pay Category Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
8 Changes in Staffing Establishment 0
9 Variable Pay 86 99 144 162 175 539 565 555 640 676 694 1,611 5,946
10 Locum 0
11 Agency / Locum paid at a premium 0
12 Changes in Bank Staff 0
13 Other (Please Specify in Narrative) 0
14 Total Pay Savings: Analysis 86 99 144 162 175 539 565 555 640 676 694 1,611 5,946
15 Check - Agrees to Savings Plan Line 5 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
64,659.11 65,228.38 83,345.38 67,726.38 71,265.38 75,400.38 78,883.38 75,400.38 75,400.38 76,695.38 75,400.38 122067.1
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C9.Year 1 Savings Plan )

NOTE: Tables to be populated with indentified savings plans only
YEAR 2 & 3 SAVINGS PLANS - All Positive Entries
To include Cost Improvement & Cost Containment schemes
Savings Plans:- Year 2 - 2018/19 Year 3 - 2019/20
Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
1 Continuing Care and Funded Nursing Care 0 0 Validations
2 Commissioned Services 0 0
3 Medicine Management (Primary and Secondary Care) 0 0 Quarterly Pay Savings reported in Plan (Line 5) agrees to Total Pay Savings Plan Analysis on Line 14 ok
4 Non Pay 0 0
5 Pay 0 0
6 Primary Care 0 0
7 Total Savings Plans 0 0 0 0 0 0 0 0 0 0
Pay Savings: Analysis
Year 2 - 2018/19 Year 3 - 2019/20

Pay Category Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
8 Changes in Staffing Establishment 0 0
9 Variable Pay 0 0
10 Locum 0 0
11 Agency / Locum paid at a premium 0 0
12 Changes in Bank Staff 0 0
13 Other (Please Specify in Narrative) 0 0
14 Total Pay Savings: Analysis 0 0 0 0 0 0 0 0 0 0
15 Check - Agrees to Savings Plan Line 5 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C10.Year 2 & 3 Savings Plan
Overview Of Key Upside & Downside Risks

Financial Challenge 2017/18 Financial Challenge 2018/19 Financial Challenge 2019/20
Worse Most Best Worse Most Best Worse Most Best
Case Likely Case Case Likely Case Case Likely Case
Downside (negative entries)/Upside (positive entries) £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
1 Financial Challenge Reported in SCNI/SCNE (58,900) (58,900) (58,900) 0 0 0 0 0 0
2 Gains on in year allocation 3,900
3
4 Risk of recurrent reserve release (2,000)
5 Pensions autoenrolment risk (729)
6 Non Pay Inflation - assessed potential (949)
7 Specialist Services - Risk Share gain delayed (250)
8 Winter Pressures - FYE 16/17 Plan (1,300)
9
10 Service Cost Pressures @ £5m (4,000)
11 Savings - risk of non delivery (17,000)
12
13
14
15
16
17
18
19
20
21 Total Risks 3,900 0 (26,228) 0 0 0 0 0 0
22 Financial Challenge (55,000) (58,900) (85,128) 0 0 0 0 0 0
Actions to Mitigate Risks 2017/18 2018/19 2019/20

Worse Most Best Worse Most Best Worse Most Best
Case Likely Case Case Likely Case Case Likely Case
Actions (positive entries) £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42 Total Mitigating Actions 0 0 0 0 0 0 0 0 0
43 NET POSITION (55,000) (58,900) (85,128) 0 0 0 0 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C11.Risks & Mitigation
Hywel Dda ULHB
Property & Asset Investment
Summary
2017-18 2018-19 2019-20 2020-21 2021-22
£m £m £m £m £m
Gross Capital Expenditure 39.2145 65.555 50.802 27.162 21.721
less: Receipts -0.205 -0.725 -0.85 0 0

Net Capital Expenditure 39.0095 64.83 49.952 27.162 21.721
2017-18 2018-19 2019-20 2020-21 2021-22

£m £m £m £m £m
Welsh Government Funding
Discretionary (Group 1 - CRL / CEL) 7.421 7.421 7.421 7.421 7.421
Approved Schemes (Group 2 - CRL / CEL) 8.918 0.08 0 0 0
WG Funding Required (approved) 16.339 7.501 7.421 7.421 7.421
Funding for identified schemes not approved by Welsh Governme 22.576 57.754 43.081 19.441 14.000
Key Performance Indicators
2015-16 as 2020-21
per EFPMS Forecast
£m £m
High Risk Backlog Maintenance
% %
Physical Condition: % in Category B or above 87 90
Statutory, Safety & Compliance: % in Category B or above 88 90
Fire Safety Compliance : % in Category B or above 92 90
Functional Suitability: % in Category B or above 92 90
Space Utilisation: % in Category F or above 99 92
Energy Performance: % with Energy B or better N/A N/A
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317C12. Asset Investment Summa
Hywel Dda ULHB
Property & Asset Investment
Capital Expenditure Revenue Implications (Incremental consequences)

DISCRETIONARY 2017-18 2018-19 2019-20 2020-21 2021-22 Discretionary Non Cash Costs 2017-18 2018-19 2019-20 2020-21 2021-22
£m £m £m £m £m £m £m £m £m £m
IT 1.000 1.000 1.000 1.000 1.000 Discretionary Other Revenue Costs
Equipment 1.000 1.000 1.000 1.000 1.000 Discretionary Revenue Savings
Statutory Compliance 1.000 1.000 1.000 1.000 1.000 Discretionary Net Revenue
Estates 2.500 2.500 2.500 2.500 2.500
Other 1.921 1.921 1.921 1.921 1.921
Sub total DISCRETIONARY 7.421 7.421 7.421 7.421 7.421
Included within the Prioritisation 2017-18 2018-19 2019-20 2020-21 2021-22 2017-18 2018-19 2019-20 2020-21 2021-22
APPROVED SCHEMES Exercise - June 2014 £m £m £m £m £m Approved Schemes £m £m £m £m £m
Lift Bronglais Yes 2.657 0.080 Lift Bronglais
Scheme 1 - Non Cash - DEL 0.024 0.049 0.049 0.049 0.049
Scheme 1 - Non Cash - AME 1.286
Scheme 1 - Other Revenue Costs
Scheme 1 - Revenue Savings
Scheme 1 - Net Revenue
Women & Children Phase II Yes - Full Business Case Fees 0.859 Women & Children Phase II
Scheme 2 - Non Cash - DEL
Scheme 2 - Non Cash - AME
MRI BGH Yes 1.125 MRI BGH

total scheme will exceed this value due to Scheme 3 - Non Cash - DEL 0.112 0.224 0.224 0.224
construction costs and some costs will flow Scheme 3 - Non Cash - AME 1.500
into 18-19 Scheme 3 - Other Revenue Costs
Antiligature Schemes No 2.024 Antiligature Schemes

2nd Theatre BGH No 2.153 2nd Theatre BGH

Pharmacy No 0.100 Pharmacy

Scheme 7 - INSERT TITLE Yes / No Scheme 7 - INSERT TITLE








Sub Total Approved Schemes Total 8.918 0.08 0 0 0
Included within the Prioritisation 2017-18 2018-19 2019-20 2020-21 2021-22 2017-18 2018-19 2019-20 2020-21 2021-22
UNAPPROVED SCHEMES Exercise - June 2014 £m £m £m £m £m Unapproved Schemes £m £m £m £m £m
HDHB Energy Project Phase 2 Yes 0.920 0.876 0.018 HDHB Energy Project Phase 2
Cardigan Yes 5.604 10.982 1.603 Cardigan

Ground works 0.100 Scheme 2 - Non Cash - DEL 0.351
Cardiac Cathetarisation Laboratory GGH Yes 0.500 2.000 3.000 Cardiac Cathetarisation Laboratory GGH
Ward Refurbishments & Statutory &

Infrasructure Issues - all sites No 5.500 8.500 10.500 9.500 Ward Refurbishments & Statutory & Infrasructure Issues - all sites
Aseptic Unit No 0.400 1.600 Aseptic Unit

Scheme 5 - Non Cash - DEL 0.039 0.077 0.077 0.077
Mental Health - Acute Inpatient Redesign No 0.250 1.429 Mental Health - Acute Inpatient Redesign
Cylch Caron Yes OBC now approved Cylch Caron

Women & Children Phase II FBC Development 1.783 10.929 7.925 Women & Children Phase II
Primary Care & Community Yes / No 3.000 3.500 3.000 2.000 Primary Care & Community
Aberaeron 0.798 0.798 Scheme 9 - Non Cash - DEL
North Road 0.632 Scheme 9 - Non Cash - AME
Carmarthen Town 0.750 Scheme 9 - Other Revenue Costs
Crosshands Scheme 9 - Revenue Savings
Health Board Wide Health Board Wide

Medical & Non Medical Equipment
Replacement 2.000 3.000 3.000 2.500 2.500 Scheme 10 - Non Cash - DEL
Catering No 0.100 Scheme 10 - Non Cash - AME
IM&T 5.239 7.045 7.535 2.441 Scheme 10 - Other Revenue Costs
Estate Development supporting
Performance and Flow 2.000 2.000 Scheme 10 - Revenue Savings
Withybush Site Development No Withybush Site Development

Ward 9&10 Refurbishment Withybush 0.500 2.000 Scheme 11 - Non Cash - DEL 0.031 0.031 0.031 0.031
MRI Scanner Scheme 11 - Non Cash - AME
Surgical Assessment Unit Scheme 11 - Other Revenue Costs
Prince Philip Site Development No Prince Philip Site Development

PPH Endoscopy - JAG Accreditation 0.500 0.500 Scheme 12 - Non Cash - DEL 0.108 0.165 0.165 0.165
Day Surgery Prince Philip Hospital 1.000 1.000 Scheme 12 - Non Cash - AME
PreAssessment Scheme 12 - Other Revenue Costs
Dermatology COE Scheme 12 - Revenue Savings
Acute Respiratory Unit Scheme 12 - Net Revenue
Glangwili Site Development Glangwili Site Development

Site Master Plan Development No 0.500 1.000 Scheme 13 - Non Cash - DEL
Temporary Ward Decant No Scheme 13 - Non Cash - AME
Women & Children Phase III No TBC TBC Scheme 13 - Other Revenue Costs
Multi Storey Car Park No 1.970 5.000 Scheme 13 - Revenue Savings
Post Graduate Facilities No TBC TBC Scheme 13 - Net Revenue
2nd CT No 1.000 1.000
Bronglais Site Development No Bronglais Site Development

BGH MRI 1.125 Scheme 14 - Non Cash - DEL
Chemotherapy Day Unit 1.000 1.000 Scheme 14 - Non Cash - AME
Post Graduate Facilities TBC TBC Scheme 14 - Other Revenue Costs
Sub Total unapproved Schemes Total 22.576 57.754 43.081 19.441 14.000
Other Capital Expenditure: Other Capital Expenditure:

Donated Assets Additions 0.300 0.300 0.300 0.300 0.300 Non Cash Costs
Capital Grants Other Revenue Costs
Other Revenue Savings
Sub Total Other Capital Expenditure 0.300 0.300 0.300 0.300 0.300 Net Other Capital Expenditure
Gross Capital Expenditure 39.2145 65.555 50.802 27.162 21.721
Receipts
Land & Property Disposals (list individually) 0.205 0.725 0.85 0 0
Capital Grants Received
Donations
Other
Sub Total Receipts 0.205 0.725 0.85 0 0
Net Capital Expenditure 39.0095 64.83 49.952 27.162 21.721
2017-18 2018-19 2019-20 2020-21 2021-22

Land and Property Disposals £m £m £m £m £m
CPU Bryntirion, Llanelli On the market 0.205
Ael y bryn, (Finance Offices BGH) 0.200
Cardigan Hospital 0.440
Cardigan HC, Cardigan 0.410
Cross Hands HC, Cross Hands 0.350
Pond St. Clinic, Carmarthen 0.175
Scheme 7
Scheme 8
Scheme 9
Scheme 10
etc
Total 0.205 0.725 0.850 0 0
0 0 0 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C13. Asset Investment Detai
Revenue Funded Infrastructure (including Primary Care and innovative /
third party funded investments)
Scheme Annual Revenue Repayment

Capital
Value 2017-18 2018-19 2019-20 2020-21 2021-22
Prioritised Schemes (to be named
individually) £m £m £m £m £m £m
Scheme 1
Scheme 2
Scheme 3
Scheme 4
etc
Total 0 0 0 0 0 0
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C14. Rev Funded Infrastruct
Health Board XXX
Workforce Plans - WTE
A B C D E F F G
Actual
Workforce @ Planned WTE @ 2017/18 Profiled Workforce at end of each Quarter Workforce at end of
31/12/2016 31/03/2017 30/06/2017 30/09/2017 31/12/2017 31/03/2018 31/03/2019 31/03/2020
WTE WTE WTE WTE WTE WTE WTE WTE
Core workforce:-
Board Members 20.70 20.70 20.70 20.70 20.70 20.70
Medical & Dental 623.64 623.64 623.64 623.64 623.64 623.64
Nursing & Midwifery Registered 2615.98 2626.98 2641.98 2717.98 2731.98 2727.98
Additional Professional, Scientific and Technical 267.47 267.47 267.47 267.47 267.47 267.47
Healthcare Scientists 153.29 153.29 153.29 153.29 153.29 153.29
Allied Health Professionals 496.13 496.13 515.13 515.13 515.13 515.13
Additional Clinical Services 1569.55 1569.55 1569.55 1569.55 1569.55 1569.55
Administrative and Clerical (inc Senior Managers) 1374.18 1374.18 1374.18 1374.18 1374.18 1374.18
Estates and Ancillary 789.67 789.67 789.67 789.67 789.67 789.67
Students 12.00 12.00 12.00 12.00 12.00 12.00
Sub total 7922.61 7933.61 7967.61 8043.61 8057.61 8053.61 0 0
Variable Workforce:-
Board Members 0.00 0.00 0.00 0.00 0.00 0.00
Medical & Dental 0.00 0.00 0.00 0.00 0.00 0.00
Students 0.00 0.00 0.00 0.00 0.00 0.00
Sub total 426.48 426.48 426.48 426.48 426.48 426.48 0 0
Agency/Locum:-
Board Members 0.00 0.00 0.00 0.00
Medical & Dental 87.70 87.70 87.70 87.70 87.70 87.70
Students 0.00 0.00 0.00 0.00
Sub total 374.05 363.05 348.05 272.05 258.05 258.05 0 0
Total workforce plans 8723.14 8723.14 8742.14 8742.14 8742.14 8738.14 0 0
NOTES
Column A: Baseline actual WTE
Column B - G: Projected WTE (funded/budgeted WTE)
Core Workforce: Total Staff WTE with a contract of employment including fixed term, temporary and contracted locums
Variable Workforce: Hours worked above contract including additional hours worked at plain time, overtime, bank, additional sessions for medical staff.
Agency/Locum: WTE estimate of agency/locum use.
NB
THESE FIGURES CANNOT CAPTURE THE POTENTIAL IMPACT OF THE ESTABLISHMENT REVIEWS IN NURSING ASSOCIATED WITH THE REQUIREMENTS WITHIN THE NURSE STAFFING ACT AS THE REVIEW IS UNDERWAY CURRENTLY
THE TABLES DO NOT REFLECT THE FINANCIAL SAVINGS TARGETS ASSOCIATED WITHT THE REDUCTION IN VARIABLE PAY.
THE TABLED DO REFLECT THE RECRUITMENT TRAJECTORIES FOR NURSING AND MIDWIFERY STAFF REPORTED IN THE ANNUAL AND ENABLING WORKFORCE PLAN IN DETAIL.
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C15. Workforce WTE
Health Board XXX
Workforce Plans - £'000
2017/18 Workforce Quarterly Profile Workforce Annual

Qtr 1 Qtr 2 Qtr 3 Qtr 4 2018/19 2019/20
£'000 £'000 £'000 £'000 £'000 £'000
Core workforce:-
Board Members 495 495 495 495
Medical & Dental 17,043 17,043 17,043 17,043
Nursing & Midwifery Registered 27,223 27,799 27,905 27,875
Additional Professional, Scientific and Technical 2,594 2,594 2,594 2,594
Healthcare Scientists 1,795 1,795 1,795 1,795
Allied Health Professionals 5,423 5,567 5,567 5,567
Additional Clinical Services 10,219 10,219 10,219 10,219
Administrative and Clerical (inc Senior Managers) 10,315 10,315 10,315 10,315
Estates and Ancillary 5,331 5,331 5,331 5,331
Students 30 30 30 30
Sub total 80,468 81,188 81,294 81,264 0 0
Variable Workforce:-
Board Members
Medical & Dental 1,578 1,578 1,578 1,578
Additional Professional, Scientific and Technical 24 24 24 24
Healthcare Scientists 86 86 86 86
Allied Health Professionals 30 30 30 30
Additional Clinical Services 1,454 1,454 1,454 1,454
Administrative and Clerical (inc Senior Managers) 78 78 78 78
Estates and Ancillary 80 80 80 80
Students - - -
Sub total 4,511 4,511 4,511 4,511 0 0
Agency/Locum: -
Board Members
Medical & Dental 3,761 3,761 3,761 3,761
Additional Professional, Scientific and Technical 69 69 69 69
Healthcare Scientists 161 161 161 161
Allied Health Professionals 397 254 254 254
Additional Clinical Services 752 752 752 752
Administrative and Clerical (inc Senior Managers) 99 99 99 99
Estates and Ancillary 13 13 13 13
Students - -
Sub total 9,221 8,770 7,216 6,929 0 0
Total workforce plans 94,199 94,469 93,021 92,704 0 0
NOTES
Core Workforce: Total staff £ - with a contract of employment including fixed term, temporary and contracted locums
Variable Workforce: £ hours worked above contract including additional hours worked at plain time, overtime, bank, additional sessions for medical staff
Agency / Locum £
NB
THESE FIGURES CANNOT CAPTURE THE POTENTIAL IMPACT OF THE ESTABLISHMENT REVIEWS IN NURSING ASSOCIATED WITH THE REQUIREMENTS WITHIN THE NURSE STAFFING ACT AS THE REVIEW IS U
THE TABLES DO NOT REFLECT THE FINANCIAL SAVINGS TARGETS ASSOCIATED WITHT THE REDUCTION IN VARIABLE PAY.
THE TABLED DO REFLECT THE RECRUITMENT TRAJECTORIES FOR NURSING AND MIDWIFERY STAFF REPORTED IN THE ANNUAL AND ENABLING WORKFORCE PLAN IN DETAIL.
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C16. Workforce £'000
Integrated Planning Framework - Recruitment Difficulties Summary
This pro-forma links to Planning Stage 1
In the below section, a recruitment difficulty is defined as a post/specialty which you

have advertised for recruitment more than once, with no appointment having been made
due to:
• no applications being received;

• no suitable candidates being identified from those who did apply; or
Reason / impact
Professional Group Role Specialty Band / Grade
Additional Clinical
Services
Additional Professional,
Scientific & Technical
PHYSIOTHERAPISTS BAND 5,6 LOCAL COMPETITION OFFERING BAND 7

PRIMARILY IN PEMS AND CEREDIGION
SLT BAND 5,6,7
(RURALITY ISSUE)
Allied Health PRIMARILY IN PEMS AND CEREDIGION
PATHOLOGY BAND 5,6,7
Professionals (RURALITY ISSUE)
ENGINEERS THESE ARE LIKELY TO BE DIFFICULT TO

CARPENTERS RECRUIT IN CEREDIGION IN FUTURE AS THE
ALL GRADES
LABOUR MAKET HAS CHANGED THERE
LOOKING TO 'GROW
WITH 2 LARGE STORES OPENING AND
OUR OWN THROUGH
OFFERING BETTER PAY FOR INDIVIDUALS
Admin & Estates (Inc. PLUMBERS APPRENTICESHIPS
WHO MAY BE INTERESTED N SUPPORT
Managers, Senior WORKER ROLE
Managers and VSMs) MOST OF SENIOR
TEAM PLANNING TO
SENIOR MANAGER
RETIRE WITHIN NEXT
5 YEARS
MEDICAL SECRETARIES
THESE ARE LIKELY
TO BE DIFFICULT TO
RECRUIT IN
SUPPORT
HCA and Support Staff GENERAL CEREDIGION IN
WORKERS FUTURE AS THE
LABOUR MAKET HAS
CHANGED THERE
G
Health Care Scientists
Acute physicians
Respiratory
Gastroenerology
Cardiologist
Emergency medicine
Consultant
Haematology
Radiology
Cellular path
Diabetes and Endocrinology
Medical & Dental ENT
Trauma & Orthopaedics
Clinical Fellow General Surgery
Emergency medicine
General Med Care of the
Elderly
Emergency Medicine
Specialty Doctor
General Surgery
Opthalmology
Psychiatry Gen Adult
RECRUITING FROM LOCAL TRAINEES

RGN BAND 5/6 SUCCESSFULLY, BUT INSUFFICIENT TO
GENERAL MEET SERVICE VACANCIES AND
Nursing & Midwifery ITU BAND 5,6,7 VERY LOW APPLICATION NUMBERS
THEATRES BAND 5,6,7 VERY LOW APPLICATION NUMBERS
CCU BAND 5,6,7 VERY LOW APPLICATION NUMBERS
EMERGENCY DEPT BAND 5,6,7 VERY LOW APPLICATION NUMBERS
In addition, please specify any posts or specialties that you anticipate future difficult to recruit:
Reason / impact
Professional Group Role Specialty Band / Grade
Additional Clinical
Services
Additional Professional,
Scientific & Technical
Allied Health
Professionals
Admin & Estates (Inc.

Managers, Senior
Managers and VSMs)
THESE ARE LIKELY TO BE

DIFFICULT TO RECRUIT IN
CEREDIGION IN FUTURE AS
THE LABOUR MAKET HAS
CHANGED THERE WITH 2
HCA and Support Staff LARGE STORES OPENING
AND OFFERING BETTER PAY
FOR INDIVIDUALS WHO MAY
BE INTERESTED N SUPPORT
WORKER ROLE
Health Care Scientists
Medical & Dental
Nursing & Midwifery
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C17. Recruitment Difficulti
For Academic intake 2017/18
Advanced Practice/Extended Skills
Numbers
Full MSC Title Duration Year of Output HEI/Provider
required
MSc Critical care (ACCP) 3 years 2020 5 Cardiff University
MSc Advanced Clinical Practice 3 years 2020 14 CHHS, Swansea University
MSc Diabetes 3 years 202 1 Cardiff University
MSc Health Care Management 3 years 2020 4 CHHS Swansea University
MSc leadership, Management Health Care Innovation 3 years 2020 1 Cardiff University
BSc Falls and Fraility 2020 1 Derby University

Full Module Title Credits Numbers required HEI/Provider
Endoscopy 30 6 CHHS Swansea Univserity
Diabetes 30 8 CHHS Swansea University
Foundations in Pfysiology 30 5 CHHS Swansea University
Assessment of the Older person (BSc/MSc) 30/30 eight/six CHHS Swansea University
Numbers Indicate any Recruitment Difficulties / Reason for

Course Title Course duration Year of output
Required commissions
PRESCRIBING
Full Independent Prescribing 1 year 2019 10
Supplementary Prescribing 1 year 2019 0
Limited Independent Prescribing 1 year 2019 10
Non Authorisation of Blood transfusion 1 year 2019 2

New Graduates Indicate any
Required - New Graduates Required -
Recruitment
Course Title Course duration Year of output Employed Independent Sector/ Local
Difficulties / Reason for
Workforce - Authority (see note below)
commissions
Head count
COMMUNITY HEALTH STUDIES
District Nursing (Part-time) 2 years 2020 10
District Nursing Modules (in modules) 3-6 months 2019 20
Practice Nursing (Part-time) 2 years 2020 5
Practice Nursing Modules (in modules) 3-6 months 2019 10
Community Paediatric Nursing (Part-time) 2 years 2020 1
Community Paediatric Nursing Modules (in modules) 3-6 months 2019 5
CPN (Part-time) 2 years 2020 3
CPN Modules (in modules) 3-6 months 2019 5
CLDN (Part-time) 2 years 2020 2
CLDN Modules (in modules) 3-6 months 2019 4
Additional Modules 1 year 2019
Return To Practice 6 months 2019 20

Required - New Graduates Required -
Recruitment
Course Title Course duration Year of output Employed Independent Sector/ Local
Difficulties / Reason for
Workforce - Authority (see note below)
commissions
Head count
NURSING & MIDWIFERY
Bachelor of Nursing (B.N.) Adult 3 years 2021 125 48
Bachelor of Nursing (B.N.) Child 3 years 2021 15
Bachelor of Nursing (B.N.) Mental Health 3 years 2021 15
Bachelor of Nursing (B.N.) Learning Disability 3 years 2021 8
if this is the WEDS
programme which
HCSW access at
year 2 then these
Shortened Nursing Degree Programme-Adult 2 years 2020
places need to be
funded with a
secondment salary
10 alongside the fees
Shortened Nursing Degree Programme-Child 2 years 2020 3
Shortened Nursing Degree Programme-Mental Health 2 years 2020 8
Shortened Nursing Degree Programme-Learning Disability 2 years 2020 2
Bachelor of Nursing (B.N.) Adult (Part-time) 4 years 2022 10
Bachelor of Nursing (B.N.) Child (Part-time) 4 years 2022 3
Bachelor of Nursing (B.N.) Mental Health (Part-time) 4 years 2022 8
Bachelor of Nursing (B.N.) Learning Disabilities (Part-time) 4 years 2022 2
B.Sc. Midwifery Direct Entry 3 years 2021 15
B.Sc. Midwifery Conversion Programme 18 months 2020 5
Health Visiting (Full-time) 1 year 2019 6
Health Nursing (Part-time) 2 years 2020 0
Health Visiting Modules (in modules) 1 year 2019 0
School Nursing (Full-time) 1 year 2019 2
School Nursing (Part-time) 2 years 2020 1
School Nursing Modules (in modules) 3-6 months 2019 0
Occupational Health (Full-time) 1 year 2019 1
Occupational Health (Part-time) 2 years 2020 0

Indicate any
Level 4
Level 2 Numbers Level 3 Numbers Recruitment
Programme Numbers Comments
required required Difficulties / Reason for
required
commissions
HEALTHCARE SUPPORT WORKER
350 (507 ACTUAL IN 2016/7 THE PROJECTED NUMBERS ARE
HCSW Clinical Induction BASED ON KNOWN PLANNED
PROJ FOR 18/19 900)
150 (ACTUAL 5 16/17 PROJ 40 150 (ACTUAL 5 16/17 PROJ 40 RECRUITMENT PROGRAMME
Diploma in Health and Social Care PROJECTIONS AND IN ORDER TO
2017/18) 2017/18)
MEET THE NEW FRAMEWORK
8( ACTUAL 0 2016/17 (PROJ 50 14( ACTUAL 2016/17 (PROJ 50
Diploma in Clinical Healthcare Support REQUIREMENTS HOWEVER THERE
2017/18) 2017/18)
WILL BE A HUGE
10 (ACTUAL 0 IN 2016/17 RESOURCE/CAPACITY ISSUE IN
Diploma in Maternity and Paediatrics Support
PROJ 12 FOR 2017/18) DELIVERY - TRAINER (B4)/TIME
6 ( ACTUAL 0 16/17 PROJ 10 RELEASE/COLLEGE CAPACITY YET
Diploma in Perioperative Support
2017/18 - TO BE WORKED THROUGH IN
Units for learning specific to role 50 SAME PROJ NEXT YR 50 SAME PROJ NEXT YR
DIPLOMA IN OT SUPPORT 40 IN HOUSE
Additional / new education requirements
Please complete the table below with details of any additional / new education requirements
Numbers
Course Title and Educational Level Course duration Year of Output
Required
Year of Numbers
Full MSC Title Duration HEI/Provider
Output required
1 in liverpool
PHYSIOTHERAPY 2 YRS 9 (3 continuation)
Podiatry 1 (continuation)
OT 3 4
Dietetics

Numbers
Full Module Title Credits HEI/Provider
required
Physiotherapy 40 6 outside wales liverpool, salford, london
Podiatry 2 University of Bournemouth
OT 4

Indicate any Recruitment
Course Year of Numbers
Course Title AHP Staff Group Difficulties / Reason for
duration output Required
commissions
PRESCRIBING
Full Independent Prescribing 1 year 2019 4 3x Physio, 1x Podiatry
Supplementary Prescribing 1 year 2019 2 2 dietetics
Limited Independent Prescribing 1 year 2019
Non Authorisation of Blood transfusuion 1 year 2019

New Graduates New Graduates
Required - Required - Indicate any Recruitment
Course Year of
Course Title Employed Independent Sector/ Difficulties / Reason for
duration output
Workforce - Head Local Authority (see commissions
count note below)
ALLIED HEALTH PROFESSIONALS
B.Sc. Diagnostic Radiography 3 years 2021 20
B.Sc Therapy Radiography 3 years 2021 0
B.Sc. Human Nutrition - Dietician 3 years 2021 7
PG Diploma Human Nutrition - Dietician 2 years 2020 0
PG Diploma Medical Illustration 2 years 2020 0
B.Sc. Occupational Therapy 3 years 2021 12
PG Diploma Occupational Therapy 2 years 2020 10
Degree in ODP 3 years 2021 10
B.Sc. Physiotherapy 3 years 2021 30
B.Sc. Podiatry 3 years 2021 2
B.Sc Orthoptist 3 years 2021 0
PhD Clinical Psychology Doctorate 3 years 2021 8
B.Sc. Speech & Language Therapy 3 years 2021 6
2 IF RUN IF NOT
B.Sc. Speech & Language Therapy - Welsh Language 3 years 2021 INCREASE ABOVE BY
2
Ambulance Paramedics 2 years 2020
Ambulance Paramedics - EMT conversion 1 year 2019

New Graduates New Graduates
Required - Required - Indicate any Recruitment
Course Year of
Course Title Employed Independent Sector/ Difficulties / Reason for
duration output
Workforce - Head Local Authority (see commissions
count note below)
RADIOGRAPHY - Assistant Practitioners
Assistant Practitioners Radiography - Diagnostic 1 year 2019 XX TBC
Assistant Practitioners Radiography - Therapy 1 year 2019 XX TBC

Level 2 Level 3 Indicate any Recruitment
Level 4 Numbers
Programme Numbers Numbers Comments Difficulties / Reason for
required
required required commissions
HEALTHCARE SUPPORT WORKER
HCSW Clinical Induction 50 10 10
Diploma in Health and Social Care
Diploma in Clinical Healthcare Support
Diploma in Dietetics Support 4 4
Diploma in Occupational Therapy Support 5
Diploma in Physiotherapy Support
Certificate in Clinical Imaging
Units for learning specific to role
Course Year of
Course Title and Educational Level Numbers Required
duration Output
Indicate any Recruitment
Course Year of New Graduates Required - Employed
Course Title Difficulties / Reason for
duration output workforce - Head count
commissions
Direct Applicant In service Applicant
HEALTHCARE SCIENTIST
Physiological Science - PTP
B.Sc. (Hons) Healthcare Science - Cardiac Physiology 3 years 2021 3
B.Sc. (Hons) Healthcare Science - Audiology 3 years 2021 4
B.Sc. (Hons) Healthcare Science - Respiratory and Sleep Science 3 years 2021 1
B.Sc. (Hons) Healthcare Science - Neurophysiology 3 years 2021 9
Physical and Biomedical Engineering - PTP
B.Sc. Clinical Engineering in Rehab 3 years 2021 0
B.Sc. (Hons) Healthcare Science - Nuclear Medicine & Radiotherapy Physics 3 years 2021 0
Life Science - PTP
B.Sc. (Hons) Healthcare Science - Biomedical Science - Blood, Infection 3 years 2021 0
B.Sc. (Hons) Healthcare Science - Biomedical Science - Infection 3 years 2021 0
B.Sc. (Hons) Healthcare Science - Biomedical Science - Cellular 3 years 2021 0
B.Sc. (Hons) Healthcare Science - Biomedical Science - Genetics 3 years 2021 0

Course Title and Educational Level Comments
duration Output Required
STP CARDIAC PHYSIOLOGY 1 ASAP
New Graduates
Course Year of Required - Independent Recruitment Difficulties
Course Title Band Required - Employed
duration output Sector/ Local Authority / Reason for
Workforce - Head count
(see note below) commissions
Pre Reg Pharmacy -Hospital programme 1 year 2020 5 4 Pharmacy workforce is expanding rapid
Pre Reg Pharmacy - Combined programme 1 year 2020 5 4 4 Pharmacy workforce is expanding rapid
Pharmacy Diploma 2 years 2021 6 8 Pharmacy workforce is expanding rapid
Pharmacy Technician 2 years 2020 4 6 Pharmacy workforce is expanding rapid
Course Year of Numbers Indicate any Recruitment Difficulties / Reason

Course Title
duration output Required for commissions
PRESCRIBING
Full Independent Prescribing 1 year 2019 8 ated to be 'IP' ready on graduation we need to increase opportunities for exisiting staff to obtain q
Supplementary Prescribing 1 year 2019 0
Limited Independent Prescribing 1 year 2019 0
Non Authorisation of Blood transfusion 1 year 2019 0

Course Title and Educational Level
New
Indicate any
Graduates
Recruitment
Course Year of Required -
Course Title Difficulties /
duration output Employed
Reason for
Workforce -
commissions
Head count
PhD Clinical Psychology Doctorate 3 years 2021

Diploma in Dental Hygiene 2 years 2020
Degree in Dental Hygiene & Therapy 3 years 2021
Physicians Associates 2 years 2021

Indicate any
Course Year of Numbers Recruitment Difficulties
Course Title Staff group
duration output required / Reason for
commissions
PRESCRIBING
NURSE +
Full Independent Prescribing 1 year 2019 15 +2
PODIATRIST
Supplementary Prescribing 1 year 2019 5 NURSE
Limited Independent Prescribing 1 year 2019 5 NURSE
Non Authorisation of Blood transfusion 1 year 2019

Course Title and Educational Level
ODP 10
Medical and Dental
Information to inform education commissioning of Medical & Dental Staff

Information on organisations’ anticipated future requirement for medical and dental staff is needed to
inform education commissioning decisions. In addition to the information on Practice Nurses and
Dental Care Practitioners requested in the previous pages, please complete the tables overleaf.
Please note:
• In each of the tables, please record what your organisation anticipates will be the net change of its medical/dental workforce during the next three
• “Net change” means the anticipated increase/decrease in the size of that workforce (in Full Time Equivalent) compared to the previous years.
- In other words, if an organisation anticipates that it will simply replace all retirees /
leavers on a “one for one” basis (i.e. with a new doctor/dentist of the same
grade/specialty), then the “net change” would be zero.
- However, if the organisation anticipates that it will replace all retirees/leavers on a “one
for one” basis and also recruit an additional doctor (1.0FTE) in a particular specialty,
then the “net change” for that specialty would be +1.0FTE.
• The following should be excluded from the tables on the next few pages:
o Training grade doctors entering/leaving an organisation as a normal part of their rotation.
o Doctors moving organisations under TUPE arrangements.
• Please record all figures as Full Time Equivalent (FTE)
PLEASE NOTE THAT THE FIGURE COLLATED BELOW ARE BASED ON

1) Medical/Dental Consultants (FTE) CURRENT CLINICAL SERVICE STRATEGY DEVELOPMENT AND HAVE
YET TO BE FULL APPROVED OR SUPPORTED WITHIN SERVICE
BUSINESS CASES.
Anticipated net change in the size of the workforce during each year Projected change
Recruitment
Group Specialty
(Full Time Equivalent) 2023 Difficulties / Reason
2017 2018 2019
Acute Medicine
Allergy
Audiological Medicine
Cardiology 5
Clinical Cytogenetics &
Molecular Genetics
Clinical Genetics
Clinical
Neurophysiology
Clinical Pharmacology
& Therapeutics
Dermatology
Endocrinology &
Diabetes
Gastroenterology
General (Internal)
Medicine Medicine
Genito-Urinary
Medicine
Geriatric Medicine 4 (Frailty)
Infectious Diseases
(& Tropical Medicine)
Medical Oncology
Neurology 3
Occupational Medicine
Palliative Medicine
Rehabilitation
Medicine
Renal Medicine
Respiratory Medicine
Rheumatology
Sport & Exercise
Medicine
Chemical Pathology
Haematology 1
Histopathology
(includes
Pathology
Neuropathology)
Immunology
clincial scientist 1
Medical Microbiology
Paediatrics
Paeds Paediatric Cardiology
Paediatric Neurology
Child & Adolescent
Psychiatry
Forensic Psychiatry
General Psychiatry
Psychiatry
Old Age Psychiatry
Psychiatry of Learning
Disability
Psychotherapy
Clinical Oncology
15.6 in addition to
Radiology Clinical Radiology
current vacancies(7.4)
Nuclear Medicine
Cardiothoracic Surgery
General Surgery
Surgery Neurosurgery
Maxillofacial Surgery
Otolaryngology (ENT)
2) Medical/Dental Consultants (FTE) (continued)

Recruitment
Group Specialty
2017 2018 2019
Paediatric Surgery
Plastic Surgery
Surgery (cont’d) Trauma & Orthopaedic
Surgery
Urology
Anaesthetics
Intensive Care
medicine
Emergency Medicine
Obstetrics &
Other medical specialties Gynaecology
Ophthalmology /
Medical
Ophthalmology
Public Health
(excluding Dental)
Dental Public Health
Dental & Maxillofacial
Radiology
Endodontics
Oral Surgery
Oral & Maxillofacial
Pathology
Dental specialties Oral Medicine
Oral Microbiology
Orthodontics
Paediatric Dentistry
Periodontics
Prosthodontics
Restorative Dentistry
Special Care Dentistry
TOTAL CONSULTANT WORKFORCE 10 0 0
2) GPs and Dentists (excluding Consultants) (FTE)
These figures should include all GPs and Dentists, including those working in independent GP/dental
practices and those directly employed by the Health Board/Trust (including locums).
• The only exception is for Consultants working in the Hospital Dental Service (HDS), who should be recorded in the table above.
• Commissioning requirement for Dental Care Practitioners and Practice Nurses should be recorded
on pages 1-2 of this document.
Anticipated net change in the size of the workforce during each year (Full
Projected change Recruitment Difficulties /
Type of doctor/dentist Time Equivalent)
Reason
2017 2018 2019 2023
General Practitioners (GP)
General Dental Service (GDS) Dentists

Community Dental Service (CDS) Dentists)
Other Dentists (excluding HDS Consultants)
3) Non-Consultant doctors (FTE) (all specialties combined)
Please give a broad overview of how your organisation’s overall non-consultant medical workforce is
likely to change in size during the next three years. It is recognised that the size of an organisation’s
training grade workforce is not entirely within its control; the forecasts provided by organisations will
therefore be triangulated against information from the Wales Deanery.
While specialty-specific information has not been requested below, please feel free to provide
additional information (e.g. if the bulk of the forecasted increases/decreases are anticipated to be in
specific specialties)
Anticipated net change in the size of the workforce during each year (Full Recruitment
Total
Type of doctor Time Equivalent) Additional Comments Difficulties / Reason
2017 2018 2019 (2017-2019) (Please specify specialty)
Non-Consultant Career Grade doctors

Training Grades: Foundation Grades
Training Grades: Core level
(ST1-ST2)
Training Grades: Higher level (ST3+)
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 Medical & Dental
C23.1: Undergraduate Education / Initial Preparation
* Note: You are asked to project forward beyond the lifespan of the IMTP to identify undergraduate education requirements for 2020/2021.

New Graduates Required New Graduates Required -
Course Title Course duration Year of output - Employed workforce - Independent Sector/ Local
Head count Authority (see note below)
Ambulance Paramedics 2 years 2019
Ambulance Paramedics - EMT conversion 1 year 2018
DENTAL
Diploma in Dental Hygiene 2 years 2019
Degree in Dental Hygiene & Therapy 3 years 2020
NURSING & MIDWIFERY
Bachelor of Nursing (B.N.) Adult 3 years 2020
Bachelor of Nursing (B.N.) Child 3 years 2020
Bachelor of Nursing (B.N.) Mental Health 3 years 2020
Bachelor of Nursing (B.N.) Learning Disability 3 years 2020
B.Sc. Midwifery Direct Entry 3 years 2020
B.Sc. Midwifery Conversion Programme 18 months 2019
Health Visiting (Full-time) 1 year 2018
Health Nursing (Part-time) 2 years 2019
School Nursing (Full-time) 1 year 2018
School Nursing (Part-time) 2 years 2019
School Nursing Modules (in modules) 3-6 months 2018
HEALTHCARE SCIENTIST
Physiological Science - PTP
B.Sc. (Hons) Healthcare Science - Cardiac Physiology 3 years 2020
B.Sc. (Hons) Healthcare Science - Audiology 3 years 2020
B.Sc. (Hons) Healthcare Science - Respiratory and Sleep Science 3 years 2020
B.Sc. (Hons) Healthcare Science - Neurophysiology 3 years 2020
Physical and Biomedical Engineering - PTP
B.Sc. Clinical Engineering in Rehab 3 years 2020
B.Sc. (Hons) Healthcare Science - Nuclear Medicine &
3 years 2020
Radiotherapy Physics
Life Science - PTP
B.Sc. (Hons) Healthcare Science - Biomedical Science - Blood,
3 years 2020
Infection, Cellular and Genetics
Clinical Scientist - STP
M.Sc. in Blood Sciences - Clinical Biochemistry 3 years 2020
M.Sc. in Blood Sciences - Genetics 3 years 2020
M.Sc. in Clinical Science - Medical Physics 3 years 2020
M.Sc. in Clinical Engineering 3 years 2020
M.Sc. in cellular Sciences - Reproductive Sciences - Clinical
3 years 2020
Embryology and Andrology
M.Sc. in Infection Science - Clinical Microbiology 3 years 2020
M.Sc. in Blood Sciences - Clinical Immunology, with a variation
3 years 2020
to support Histocompatibility & Immunogenetics
M.Sc. Clinical Science in Neurosensory Sciences - Audiology 3 years 2020
RADIOGRAPHY
B.Sc. Diagnostic Radiography 3 years 2020
B.Sc Therapy Radiography 3 years 2020
ALLIED HEALTH PROFESSIONALS
B.Sc. Human Nutrition - Dietician 3 years 2020
PG Diploma Human Nutrition - Dietician 2 years 2019
PG Diploma Medical Illustration 2 years 2019
B.Sc. Occupational Therapy 3 years 2020
PG Diploma Occupational Therapy 2 years 2019
Degree in ODP 3 years 2020
B.Sc. Physiotherapy 3 years 2020
B.Sc. Podiatry 3 years 2020
B.Sc Orthoptist 3 years 2020
PhD Clinical Psychology Doctorate 3 years 2020
B.Sc. Speech & Language Therapy 4 years 2021
B.Sc. Speech & Language Therapy - Welsh Language 4 years 2021
OTHER
Physicians Associates 2 years 2020

Commission Requests in
Course Title Course duration Year of output
Band Full Time Equivalent (FTE)
Pre Reg Pharmacy 1 year 2019
Pharmacy Diploma 2 years 2020
Course Title and Educational Level Course duration Year of Output FTE Numbers Required Comments
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C18.1 Undergraduate Education
C23.2: CPD / Post Graduate Education
Note: Please identify post graduate education requirements including extended skills and advanced practice - please be aware of the
1. Community Nursing
Numbers required - Numbers required-
Course Title Course duration Year of output Employed workforce - Independent Sector/ Local
Head Co nt A thorit
NURSING & MIDWIFERY
Return To Practice 6 months 2018
COMMUNITY HEALTH STUDIES
District Nursing (Part-time) 2 years 2019
District Nursing Modules (in modules) 3-6 months 2018
Practice Nursing (Part-time) 2 years 2019
Practice Nursing Modules (in modules) 3-6 months 2018
Community Paediatric Nursing (Part-time) 2 years 2019
Community Paediatric Nursing Modules (in modules) 3-6 months 2018
CPN (Part-time) 2 years 2019
CPN Modules (in modules) 3-6 months 2018
CLDN (Part-time) 2 years 2019
CLDN Modules (in modules) 3-6 months 2018
Additional Modules 1 year 2018
2. Non Medical Prescribing

PRESCRIBING
Full Independent Prescribing 1 year 2018
Supplementary Prescribing 1 year 2018
Limited Independent Prescribing 1 year 2018
3. Extended Role / Advanced Practice Requirements

Identify and prioritise by staff group how many staff you require to undertake Masters level modules
Clinical Area (Highest priority first) Course Duration Year of output Numbers required Staff group University
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
3-6 months 2018
Identify and prioritise by staff group how many staff you require to undertake Full Masters
Clinical Area (Highest priority first) Course duration Year of output Numbers required Staff group University
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
2 years 2019
4. Additional / new education requirements
Please complete the table below with details of any additional CPD / post graduate new education requirements
Course Title and Educational Level Course duration Year of Output Numbers Required Comments
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C18.2 PostGraduate Education
C23.3: Initial Preparation: Level 4 Education & below
Assistant Practitioners

Numbers required - Numbers required -
Course Title Course duration Year of output Employed workforce Independent Sector/ Local
Head Count Authority
PHARMACY
Pharmacy Technician 2 years 2019
RADIOGRAPHY
Assistant Practitioners Radiography - Diagnostic 1 year 2018
Assistant Practitioners Radiography - Therapy 1 year 2018
LEVEL 4
Certificate in Higher Education 2 years 2019
Healthcare Support Workers (HCSW)
Level 2 Numbers Level 3 Numbers

Programme Comments
required required
HCSW Clinical Induction
Diploma in Health and Social Care
Diploma in Clinical Healthcare Support
Diploma in Occupational Therapy Support
Diploma in Physiotherapy Support
Certificate in Clinical Imaging
Units for learning specific to role
Course Title and Educational Level Course duration Year of Output Numbers Required Comments
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C18.3 Asst Practitioners & HCSW
Medical and Dental
Information to inform education commissioning of Medical & Dental Staff

Information on organisations’ anticipated future requirement for medical and dental staff is needed to
inform education commissioning decisions. In addition to the information on Practice Nurses and
Dental Care Practitioners requested in the previous pages, please complete the tables overleaf.
Please note:
• In each of the tables, please record what your organisation anticipates will be the net change of its medical/dental workforce during the next three
• “Net change” means the anticipated increase/decrease in the size of that workforce (in Full Time Equivalent) compared to the previous years.
- In other words, if an organisation anticipates that it will simply replace all retirees /
leavers on a “one for one” basis (i.e. with a new doctor/dentist of the same
grade/specialty), then the “net change” would be zero.
- However, if the organisation anticipates that it will replace all retirees/leavers on a “one
for one” basis and also recruit an additional doctor (1.0FTE) in a particular specialty,
then the “net change” for that specialty would be +1.0FTE.
• The following should be excluded from the tables on the next few pages:
o Training grade doctors entering/leaving an organisation as a normal part of their rotation.
o Doctors moving organisations under TUPE arrangements.
• Please record all figures as Full Time Equivalent (FTE)
PLEASE NOTE THAT THE FIGURE COLLATED BELOW ARE BASED ON

1) Medical/Dental Consultants (FTE) CURRENT CLINICAL SERVICE STRATEGY DEVELOPMENT AND HAVE
YET TO BE FULL APPROVED OR SUPPORTED WITHIN SERVICE
BUSINESS CASES.
Recruitment
Group Specialty
2017 2018 2019
Acute Medicine
Allergy
Audiological Medicine
Cardiology 5
Clinical Cytogenetics &
Molecular Genetics
Clinical Genetics
Clinical
Neurophysiology
Clinical Pharmacology
& Therapeutics
Dermatology
Endocrinology &
Diabetes
Gastroenterology
General (Internal)
Medicine Medicine
Genito-Urinary
Medicine
Geriatric Medicine 4 (Frailty)
Infectious Diseases
(& Tropical Medicine)
Medical Oncology
Neurology 3
Occupational Medicine
Palliative Medicine
Rehabilitation
Medicine
Renal Medicine
Respiratory Medicine
Rheumatology
Sport & Exercise
Medicine
Chemical Pathology
Haematology 1
Histopathology
(includes
Pathology
Neuropathology)
Immunology
clincial scientist 1
Medical Microbiology
Paediatrics
Paeds Paediatric Cardiology
Paediatric Neurology
Child & Adolescent
Psychiatry
Forensic Psychiatry
General Psychiatry
Psychiatry
Old Age Psychiatry
Psychiatry of Learning
Disability
Psychotherapy
Clinical Oncology
15.6 in addition to
Radiology Clinical Radiology
current vacancies(7.4)
Nuclear Medicine
Cardiothoracic Surgery
General Surgery
Surgery Neurosurgery
Maxillofacial Surgery
Otolaryngology (ENT)
2) Medical/Dental Consultants (FTE) (continued)

Recruitment
Group Specialty
2017 2018 2019
Paediatric Surgery
Plastic Surgery
Surgery (cont’d) Trauma & Orthopaedic
Surgery
Urology
Anaesthetics
Intensive Care
medicine
Emergency Medicine
Obstetrics &
Other medical specialties Gynaecology
Ophthalmology /
Medical
Ophthalmology
Public Health
(excluding Dental)
Dental Public Health
Dental & Maxillofacial
Radiology
Endodontics
Oral Surgery
Oral & Maxillofacial
Pathology
Dental specialties Oral Medicine
Oral Microbiology
Orthodontics
Paediatric Dentistry
Periodontics
Prosthodontics
Restorative Dentistry
Special Care Dentistry
TOTAL CONSULTANT WORKFORCE 10 0 0
2) GPs and Dentists (excluding Consultants) (FTE)
These figures should include all GPs and Dentists, including those working in independent GP/dental
practices and those directly employed by the Health Board/Trust (including locums).
• The only exception is for Consultants working in the Hospital Dental Service (HDS), who should be recorded in the table above.
• Commissioning requirement for Dental Care Practitioners and Practice Nurses should be recorded
on pages 1-2 of this document.
Anticipated net change in the size of the workforce during each year (Full
Projected change Recruitment Difficulties /
Type of doctor/dentist Time Equivalent)
Reason
2017 2018 2019 2023
General Practitioners (GP)
General Dental Service (GDS) Dentists

Community Dental Service (CDS) Dentists)
Other Dentists (excluding HDS Consultants)
3) Non-Consultant doctors (FTE) (all specialties combined)
Please give a broad overview of how your organisation’s overall non-consultant medical workforce is
likely to change in size during the next three years. It is recognised that the size of an organisation’s
training grade workforce is not entirely within its control; the forecasts provided by organisations will
therefore be triangulated against information from the Wales Deanery.
While specialty-specific information has not been requested below, please feel free to provide
additional information (e.g. if the bulk of the forecasted increases/decreases are anticipated to be in
specific specialties)
Anticipated net change in the size of the workforce during each year (Full Recruitment
Total
Type of doctor Time Equivalent) Additional Comments Difficulties / Reason
2017 2018 2019 (2017-2019) (Please specify specialty)
Non-Consultant Career Grade doctors

Training Grades: Foundation Grades
Training Grades: Core level
(ST1-ST2)
Training Grades: Higher level (ST3+)
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C18.4 Medical & Dental
LHB & Trust Specific Internal Service Delivery Plans & Measures
Each Trust should identify their proposed delievery areas from both the national outcome/delivery domains and their local needs assessment
NOTE - Discretionary Template
Profile
Projected
Measure Target
end of March Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
2017 position
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Quarterly assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
Annual assessment
NHS Planning Framework 2017-18 to 2019-20 - Appendix C - Templates v160317 C19. Delivery - Local Specific
Carmarthenshire Health and Wellbeing Services
Gwasanaethau Iechyd and Lles Sir Gar
November 2016
Tachwedd 2016
Hywel Dda University Health Board Meeting 24th November 2016
Cyfarfod Bwrdd Iechyd Prifysgol Hywel Dda 24ain Tachwedd 2016

Carmarthenshire Health & Wellbeing Services Nov 2016 LW/RD Report Page 1
Contents
1. Background 3
2. Primary Care and Community Services 5

2.1 Prevention 5
2.2 Community Health and Social Care Services 5
2.2.1 Community Nursing Services 9
2.2.2 Palliative Care Services 11
2.2.3 Social Work Services 13
2.2.4 Carmarthenshire Integrated Community Equipment Store (CICES) 13
2.2.5 Welsh Government Intermediate Care Fund (ICF) 14
2.2.6 A Regional Collaboration for Health (ARCH) 19
2.2.7 Psychology Services 19
2.3 GMS and GP Cluster Developments 19
2.3.1 Amman Gwendraeth 20
2.3.2 2Ts 21
2.3.3 Llanelli 23
2.4 GP OOHs 23
2.5 Community Pharmacy 24
2.5.1 Community Pharmacy Influenza Vaccination Service 24
2.5.2 Community Pharmacy Smoking Cessation Service 24
2.5.3 Return of Patients Sharps 24
2.5.4 Emergency hormonal contraception 24
2.5.5 Triage and Treat Service 25
2.5.6 Investors in Carers 25
2.5.7 Emergency Supply 25
2.5.8 Respiratory MUR+ 25
2.6 General Ophthalmic Services 25
2.7 Capital Schemes 25
3. Hospital Services 26
3.1 PPH 26
3.2 GGH 33
4. Mental Health Services 35

4.1 Transforming Mental Health Programme 35
4.2 Community Mental Health Team 36
4.3 Bryngolau Ward (Prince Philip Hospital) 36
4.4 Bryngofal Ward 36
4.5 Substance Misuse Services 36
4.6 Memory Service 37
Background
It has been recognised that, in ensuring the sustainability of our health and social care
provision in the future, improving efficiency solely at the operational level is unlikely to be
sufficient. A more fundamental transformation in service models will be needed, with a
greater emphasis on prevention, shifting care upstream, better integration and co-
ordination of care, and an ongoing focus on maximising value for patients. The Social
Services and Wellbeing (Wales) Act (2014) (SSWBA) became legislation on the 6th April
this year. This sets out new duties and responsibilities for Local Authorities, Local Health
Boards and other partner agencies and provides a foundation on which to transform our
current service models.
The Act dictates the requirement to change our focus from providing services to a focus on
prevention. This acknowledges that the impact on health and social care organisations both
in terms of cost and demand now, and in the future, could be minimised by delaying or
reducing an individual’s care and support needs. The Act also hopes to achieve a change in
practice and culture, in terms of working collaboratively (‘doing with’ rather than ‘doing for’)
with individuals, with professionals being less risk averse and encouraging individuals to
focus on individuals’ strengths (including those within their wider circle such as friends,
families and neighbours). There is a move away from professional judgement being imposed
on individuals, and instead a focus on ‘what matters to the person’ and working co-
productively with individuals in terms of meeting their care and support needs; a standard
that is also a key principle of Prudent Health Care.
Assessments for care and support under the Act are proportionate to the person’s needs
and more outcome orientated, with a focus on the community being able to meet the
person’s outcomes rather than being service led. To achieve the concepts of prevention
and early intervention and promoting a person’s independence and wellbeing, the Act
acknowledges that a multi-agency approach to meeting a person’s needs is required and
hence adult social care assessment has duly been replaced by the requirement for
integrated assessments for care and support.
The wellbeing of the individual and the population is also a core element of the Act. It
recognises that not only pertinent to the expressed needs of the population but also
accessible in the community within which they live. This concept is mirrored in the
Primary Care Plan for Wales (2014) and also in Together for Health (2011) where ‘Care
Closer to Home’ underpins their strategic intent. It is recognised that improving the health
of populations, however, is dependent on robust partnership working between the Local
Authority and the Local Health Board. Part 9 of the SSWBA, therefore, focuses on
partnership working and furthering integration between these organisations across their
regional footprints.
A Regional Partnership Board for West Wales which reports directly to Welsh
Government has been established with representation from Health Board Executives and
Directors of Social Services to ensure effective working across the region and to ensure
any duties related to the Act are implemented. These include:
 Population Needs Assessment / Planning

 Promote Establishment of Pooled Funds
 Implementation of Regional Priorities
o Information, Advice and Assistance
o Regional Commissioning Arrangements
o Pooled Budgets
o Integrated Systems e.g Welsh Community Care Information Solution (WCCIS)
o Remodelling of mental health and learning disability services
The Carmarthenshire Integrated Services Board reports directly to the West Wales
Regional Partnership Board and ensures that regional priorities for both organisations are
delivered efficiently and effectively at an operational level.
The Act also presents the requirement that organisations should ensure that we build into
our planning and delivery welsh language services which are offered to welsh speakers
without them having to request it. Carmarthenshire are, therefore, incorporating the
strategic framework for welsh language services in health, social services and social care
and actively implementing into practice. The County are currently contributing to both
the Health Board and Local Authority’s scoping into our current position relating to these
standards which will inform planning going forward.
This report will provide an update to the Board on Health Services in Carmarthenshire. It
will reflect our position in relation to the implementation of the SSWBA and its strategic
intent in relation to implementing a preventative approach in support of improving
outcomes at individual and organisational level across the ‘whole system’.
1.0 Primary Care and Community Services
2.1 Prevention
The Population Needs Assessment (as required by section 14 of the Act) is currently being
undertaken jointly by the Health Board and its Local Authority partners. Once the Population
Needs Assessment has been completed (by end March 2017), the Health Board along with its
Local Authority partners are required to produce an area plan setting out the range and level
of support available across the region to address the needs identified in the population needs
assessment. It is recognised, however, that Carmarthenshire is a County of diverse
geographical contrast including urban, rural and post industrial areas. As such, for some time,
the County has been divided into three Localities (Aman Gwendraeth, Llanelli and the Tywi,
Teifi and Taf) with each Locality having its own population needs assessment and plan
outlining the range and level of support available to meet the need identified. These plans
also include the Primary Care Cluster Plans outlined in the GMS section below.
These Locality Plans are owned by our Locality Leadership Teams which consist of a GP Lead,
Locality Manager (integrated health and social care manager) and Clinical Lead Nurse. The
plans acknowledge the need to improve health and wellbeing across the lifecourse for the
Locality’s population and to delay onset of dependency and ill health while also ensuring that
those individuals who have existing care and support needs are provided with the necessary
support to reduce the risk of further deterioration where possible. Our approach in
Carmarthenshire adopts such a preventative approach at Locality level; our focus is on
empowering people and developing stronger and resilient communities while ensuring our
community health and social care services promote independence and deliver a sustainable
improvement to wellbeing.
2.2 Community Health and Social Care Services.
The case for Integrated Care has been well documented in national and local policy for
some years. It clearly evidences the need to develop robust multi disciplinary working
between health and social care professionals and wider teams in order to optimise the
independence and wellbeing of our population. This is particularly prevalent in relation to
the increasing demand and complexity related to the increasing prevalence of frailty
associated with our most elderly. Person centred care and integration of community
services has, therefore, been a key driver for Carmarthenshire over the years and is
demonstrable in terms of the level of maturity in relation to integration in our community
services across health and social care.
Carmarthenshire has had an overarching Section 33 agreement in place since 2007. This
provided the necessary governance to develop an integrated community health and social
care service infrastructure to support the health and wellbeing of older adults and adults
with physical disabilities and / or sensory impairment. The Head of Integrated Services
reports to both the Director of Communities (Carmarthenshire County Council) and to the
County Director and Commissioner (Hywel Dda University Health Board) and has joint
responsibility for both health and social care community services. Similarly, each Locality has
its own integrated health and social care manager who is responsible for both health and
social care provision in the Locality.
The Section 33 agreement places Carmarthenshire in a robust position to explore further

opportunities for ‘pooling’ of health and social care budgets in accordance with Part 9 of the
Act. Carmarthenshire has been identified as the ‘pace setter’ for the regional priority around
pooling funds and, with agreement from both organisations’ Chief Executives,
Carmarthenshire is progressing plans at pace to pool health and social care budgets for older
adults by April 2018.
In planning to deliver ‘Care Closer to Home’, the County strives to efficiently manage the
significant pressure on healthcare provision due to the increased prevalence of chronic
conditions and level of frailty. It cannot achieve this without effective collaborative working
with our public and voluntary sector organisations. Our joint management arrangements with
Carmarthenshire County Council offers the unique opportunity to influence prevention in
relation to the wider determinants of health and their impact on the wellbeing of our
population. The Council’s Director of Communities is responsible for leisure, housing and
public protection as well as social care giving us the opportunity to influence decision making
in relation to ensuring transport, housing and leisure facilities optimise the wellbeing of
individuals across the lifecourse.
To manage the health and wellbeing of the population of Carmarthenshire’s Localities and
reduce unscheduled care pressures, the Health Board’s Primary Care and Community
Services, in partnership with Carmarthenshire County Council and the voluntary sector,
provide a wide range of services and interventions. These broadly fall into three tiers of
Figure 1.
prevention (figure 1.):
Tier One: Services and Interventions that promote independence, wellbeing, community
engagement and social inclusion. These services include:
 Vibrant Third Sector and community led support services (see also Community
Resilience section below).
 Single point of access to information, advice and assistance.
• Range of public funded community based services including leisure, regeneration,
housing departments of the County Council that support health promotion and
reduction in health inequalities.
• Self Care programmes such as Expert Patient Programme (EPP) delivered by lay
members, and XPert which is disease specific and currently delivered by registered
nurses.
Tier Two: These services provide targeted intervention by a multidisciplinary team for
individuals to regain previous levels of independence and wellbeing following an acute
episode or injury and can also support avoidance of hospital admission. These services
work closely with Tier 1 services to ensure ongoing health and wellbeing support from
their own community (see figure 2 below).
Tier Three: Provision of service at this level focuses on supporting individuals who have
long term and specialist care needs. Services in this tier will liaise with services in tier 2 to
ensure that, at times of injury or acute episodes of illness, people regain their previous
level of independence. Services in tier three also ensure that where possible individuals
remain connected to their communities (see figure 2).
The group of GP practices in each Locality are known as Clusters and these are supported
by their own Community Resource Teams (CRTs) which provide this tiered approach to
prevention and wellbeing. It is acknowledged that there is significant diversity in relation
to each Locality’s demographic, geographic and epidemiological profile as well as its
related health and social care needs. As such, the CRTs, while operating to the same
principles, will source bespoke solutions to meet the specific needs of the Locality.
The Community Resource Teams consist of Community Nursing, Occupational Therapy,

Physiotherapy and Social Work practitioners who work alongside GP colleagues as a
multidisciplinary team to support the assessment and care planning for individuals
requiring support.
Figure 2.
Following assessment, the teams are able to access care provision in their community if
appropriate. This includes:
 Reablement – a programme of interventions of up to 6 weeks to support the
individual to return their previous level of independence following acute illness or
trauma. Interventions can include domiciliary social care, rehabilitation support
workers and assistive technology.
 Residential Reablement (Convalescence) – There are 20 step up / step down beds
available in two Local Authority residential care homes: Llys y Bryn in Llanelli and
Maes Llewelyn in Newcastle Emlyn. As with reablement above, individuals will
receive a programme of interventions prescribed by multidisciplinary professionals
including 24/7 social care for a period of up to 6 weeks. The aim of this service is for
the individual to return home.
 Long Term Domiciliary Care – social care for individuals with ongoing and complex
‘care and support’ needs
 Long Term Residential & Nursing Care – 24/7 care for individuals with ongoing and
complex ‘care and support’
 Interim Assessment Beds – Step Up / Step Down beds to support admission avoidance
and support efficient discharge from hospital
 Community Hospitals – There are two community hospitals in Carmarthenshire
which provide medical, nursing, palliative/end of life care and/or therapeutic
interventions over and above the level that can be provided within their own homes.
This service is intended to support the effective patient flow from the acute
hospitals once the patient’s condition has stabilised however requires ongoing
rehabilitation, therapy, nursing and medical care prior to discharge. This unit will
also ensure timely and effective discharge planning for complex cases. The
community hospitals also provide a step up facility directly from the community to
avoid admission into the acute hospitals from the community:-
o Amman Valley Hospital - This is a 28-bedded unit. There are 14 GP beds and 14
Consultant led beds. A typical month has an 87% bed occupancy. The League
of Friends at Amman Valley Hospital are currently leading a fundraising
campaign to purchase new X-Ray equipment for the Hospital.
o Llandovery Community Hospital - This is a 16 bedded unit. There are 8 GP
beds and 8 consultant led beds. A typical month has an 84% bed occupancy.
In addition the hospital has a Minor Injuries Unit which is open between the
hours of 9am – 5pm Monday to Friday. During 2015, the X-Ray department
was refurbished and is furnished with state of the art X-Ray facilities. These
are utilised effectively to ensure patients do not need to be transported in
excess of 25 miles to access such diagnostic support in Glangwili General
Hospital. There is capacity for this service to be further utilised as an
outpatient service.
For those individuals, who, despite primary care and community intervention, continue to be
at risk of increasing levels of dependency and/or hospital admission, there is also rapid access
to frailty clinic. The South Carmarthenshire Rapid Access Multidisciplinary Service (SCRAMS)
is based in Prince Philip Hospital as part of the ‘Front of House’ model. SCRAMS offers
Comprehensive Geriatric Assessment (CGA) by a geriatrician and multidisciplinary community
team within 48 hours of referral. At the appointment, patients have immediate access to
diagnostics such as CT, MRI, Echocardiogram and haematology, biochemistry if appropriate.
Following assessment, patients are reviewed in their own home by our Community Resource
Teams and the patient’s GP. This service has been operating for three years and has
demonstrated a reduced admission / readmission rate. It has also reduced falls risk for those
recurrent fallers attending the service.
Care pathways have been developed in partnership with the Welsh Ambulance Services NHS
Trust (WAST) that mitigate the need to convey individuals when clinically appropriate. These
include Falls, Resolved Hypoglycaemia and Resolved Epilepsy. Most recently, working with
colleagues in mental health, the Emergency Departments, care homes and the Out of Hours
GP service, WAST and the Community Resource Teams have implemented a Frequent Caller
pathway. This pathway ensures that the appropriate services work together to develop a
plan that provides WAST with alternatives to conveying regular inappropriate attendees to
the Emergency Department and /or GP Out of Hours service.
The Community Resource Teams (CRTs) play an instrumental role in reducing length of stay in
hospital through efficient discharge planning. Discharge Liaison Nurses (DLNs) ensure robust
communication between the wards and the CRTs to ensure timely assessment and safe
transfer of care back to the community. Community team representatives are currently
delivering Complex Discharge Pathway Guidance training to all ward areas and staff groups
in the hospitals. The DLNs and recently appointed Community Unscheduled Care
Coordinators in both sites will ensure that this guidance is implemented into practice.
2.2.1 Community nursing is an integrated team of registered nurses and health care support
workers (HCSW). The teams within the service have specific functions to support the diverse
needs of the population on a 24/7 basis to provide care within clients’ homes to reduce the
risk of admission as well as facilitating early discharge. The teams comprise core
community nursing, Acute Response Team, Chronic Disease Management Nurses,
Continuing Care Team, and all work within one whole professional structure.
The core community nursing services operates 7 days a week 8am to 6pm. This service
provides a broad range of nursing expertise within the home environment, private or local
authority residential accommodation, health centres/clinic/hospital and nursing homes. The
registered specialist practitioner (the District Nurse) holds the specialist practitioner
qualification (SPQ), is the team leader and is accountable for maintaining a high standard of
registered nursing care, supporting patients and their families/carers. The service responds
to both reactive and proactive health care needs. There is a total staffing of 96.82 wte.
In September 2016, the total number on the caseload was 4,245 and the number of face
to face contacts was 14,026.
Our ageing population has resulted in a significant increase in frail individuals living in our
communities. This vulnerable group are at high risk of sudden deterioration following even
the most minor of episodes including stress, anxiety, a change in social circumstances or
infection. Frailty is a specialist clinical area and, as such, we have appointed Community
Nurses with a specialist interest in frailty for each locality. These nurses support the
geriatricians in the SCRAMS clinic outlined above as well as ensuring that all community
nurses adopt a gerontological focus to their practice through training and education.
This year has seen the shift from primary care to community with regard to the provision of
leg ulcer management which has necessitated an additional level of expertise within the
community services providing this service. 3 wte appointments have, therefore, been made
for registered nurses to target tissue viability. These have been instrumental in leading this
service which has seen a significant improvement in healing rates, with a quarter of all these
patients being discharged from the caseload monthly. The leg ulcer service is delivered in
community venues to deliver ‘care closer to home’.
A further 3 wte appointments have been made for registered nurses with a special
interest in continence. These nurses have undergone additional training and are leading
on the improvement of incontinence rates. Similarly their role is to identify those people
who frequently attend hospital presenting with urinary tract infections with the intention
being to proactively manage their care within the community.
More recently the service has developed an additional three nurses with a special interest
in palliative care which will further support care in the community and proactively identify
those patients entering their final year of life and then support the individual and their
family during this time.
All the additional posts have educational components to their roles and the intention is
for them to actively engage in health promotion and prevention within the community.
In addition to these posts, three Assistant Practitioners (Band 4 Health Care Support Workers)
have been appointed. Through additional training and education, these individuals will carry
out tasks requiring an increased level of skill and competence than traditional
health care support workers and allowing Registered Nurses to focus on patients with
more complex needs. Given the current challenges within registered nurse recruitment,
these Assistant Practitioners will be able to access a shortened course within university to
become registered nurses. We intend to recruit further into such roles to ensure we have
a sustainable and skilled workforce to meet the increased needs and demands within the
community with our ageing demographic.
The Acute Response Team (ART) provides a 24/7 acute nursing service in the community. It
provides acute nursing interventions to patients within the community who, without the
service, would require inpatient treatment in a hospital bed. Interventions include
intravenous antibiotics, re-hydration therapies, blood and platelet transfusions and rapid
out of hour access to nursing support for palliative and terminally ill patients. The teams
are based in each acute hospital to ensure effective and timely facilitated discharges or to
support admission avoidances and work closely to bridge the gap between community
and acute sector. There is a total staffing of 23.93 wte. Welsh Government Intermediate
Care Funding has allowed us to further enhance this resource by 3.4 wte.
In a typical month, the ART receive 312 referrals, this results in 292 admission avoided, 20
facilitated discharges and involves 1,119 interventions.
The Chronic Conditions Management (CCM) Team ensure that patients receive high quality,
evidence based specialist nursing care in the community setting. They aim to improve the
management and care of patients with chronic conditions across primary and secondary
care, working in partnership with the patient, carers and multi-professional teams
including the voluntary sector. The team deliver education, support and high quality care
to patients with chronic conditions in a variety of settings and work with carers and other
health professionals to maintain a seamless approach to chronic conditions management.
The CCM Team comprise 9 wte registered nurses. The team integrates with GP practices
and secondary health care professionals to provide a seamless service for those patients
with a diagnosis of Diabetes, COPD and Heart Failure living within the Carmarthenshire
area and registered with a GP practice in Carmarthenshire. This service is provided from
9am to 5pm Monday to Friday.
The Continuing Care Team (CCT) is a skilled team of senior Health Care Support Workers
(HCSW) offering a range of skilled interventions to patients in their own home who are
eligible for Continuing NHS Healthcare (CHC) funding for their provision of care. The CCT
provides a highly responsive service to patients at the end of their lives, patients who are
entering terminal phase, and patients with long term chronic conditions. There are a total
of 29.8 wte within the team who work in partnership with the Marie Curie Nursing Service
to provide this service over the 7 day a week period. Additional investment from Welsh
Government ‘Together for Health Delivery Plans’ for Palliative Care has provided
additional hours to strengthen Hospice at Home.
2.2.2 Palliative Care Services in Carmarthenshire are exemplar:

Ty Bryngwyn is a consultant led 6 bedded inpatient specialist palliative care unit based on
the Prince Philip Hospital site in Llanelli. This unit supports patients with complex and un-
resolving symptoms either physical or psychological with the intention of supporting these
patients to return to their homes or within the community. This service is well utilised
with admissions from both the acute and community settings. A proposal is being
developed for a 7th bed to be funded by Ty Bryngwyn Hospice Committee to meet the
needs of the younger adult.
Specialist Palliative Care Services are provided for patients and their families with
moderate to high complexity of palliative care need. This can be defined as anyone with a
diagnosis of a serious life limiting disease and is not limited to cancer. Referral criteria to
the team is that the patient has uncontrolled and unresolving symptoms either physical or
psychological. In addition, the team acts as a support and resource for anyone seeking
information or help related to palliative care. The service is delivered by a team of
doctors, nurses and therapists with demonstrable expert skills, knowledge and education
in palliative care. It includes 1.2 wte consultants in palliative care, 4 sessions of a GP with
Special Interest in palliative care and 5 wte clinical nurse specialists. The team participates
in the Health Board wide 7 day working Clinical Nurse Specialist (CNS) rota. Through direct
and indirect interventions the team delivers and promotes a holistic, supportive, caring
and professional service. It is delivered anywhere within the primary or secondary setting
to meet identified need and operates 09.00hrs - 17.00hrs, 7 days a week including bank
holidays. During the out of hours period there is access to specialist support and advice
from a consultant in palliative care if required.
The team works with the other health and social care professionals, especially the primary
care providers such as the GP and District Nurse. Each nursing home in Carmarthenshire has
a named CNS who they can contact for advice, support and to access education. The service
is providing education and training on the new ‘Care Decisions for the Last Days of Life’
which will replace the ‘Integrated Care Priorities for End of Life’ and to date has trained
approximately 200 people. During a recent evaluation throughout Wales Carmarthenshire
had the most effective compliance with the returns for the care decisions’ documentation
which demonstrates the quality of the service.
The team strives to constantly evaluate and improve the service. This is undertaken by
developing and participating in initiatives such as the ‘All Wales I Want Great Care
questionnaire’ and local audit. The outcomes of these initiatives demonstrate that the
service is valued and effective.
Through Welsh Government ‘One Wales’ funding, investment was secured to employ
dementia nurses which was commissioned through our Marie Curie partners. The purpose of
this investment was to increase access for patients with dementia to specialist palliative
care. This has been successful as recent reports confirm that there is an increasing referral
from patients with dementia to specialist palliative care.
The Carmarthenshire Children’s Bereavement Support Service offers a professional

counselling service to bereaved children, young people and their families at Ty Cymorth,
Glangwili General Hospital and Ty Bryngwyn, Prince Philip Hospital. It also offers
information, supervision, training and support for professionals working with bereaved
children such as School Nurses, Health Visitors, Paediatricians and Teachers.
The Service aims to empower and enable children and their families to have a normal
grief process following the loss of their loved one.
Following referral, parents/carers are invited to attend an initial assessment to discuss

the needs surrounding their own and their child’s grief. This is then followed up with
regular appointments with a designated counsellor that supports both parents and child
through the process. The use of memory boxes, memory jars, books and other recognised
supportive resources are used to enable the child or young person to express their grief
and normalise their feelings. Additionally parents can also access the Adult Bereavement
Service if appropriate.
The Service also has received funding for anticipatory grief work with children whose
parents have been diagnosed with a life limiting illness. This support service enables
children and young people to be supported within their distress and sadness when they
require it. The support is given by specialist counsellors.
Children’s Bereavement Counselling Services are also available in Ceredigion and

Pembrokeshire.
The Service has recently been working in partnership with the charity ‘2 Wish Upon A
Star’ to provide counselling support through both one-to-one and groups. This charity
offers memory boxes in A&E/ICU to all parents who lose a child traumatically as well as
initial support.
Palliative Day Care operates at Ty Cymorth on the Glangwili General Hospital site and Ty
Bryngwyn on the Prince Philip Hospital site to support patients who have life limited
conditions and require support. The service in Ty Cymorth has recently been reviewed and
the focus has shifted from a day care service to a therapeutic model which offers sessional
appointments with the intention being to return these individuals to their communities for
further support if required. This has resulted in a greater throughput of individuals who have
reported greater outcomes and greater resilience. This will be evaluated and rolled out to Ty
Bryngwyn following consultation. The palliative day care consists of therapist, nurses and
counsellors who support this client group.
2.2.3 Social Work

Social work services for older people and physically disabled younger people are delivered
by 3 teams in the Locality based Community Resource Teams. Two hospital-based teams
were integrated into the localities approximately 2 years ago. There is currently no
specialisation, apart from one social worker and 3 CMAs who work with people who have
sensory impairment.
The teams consist of a team manager, senior practitioners, social workers, assessor care
managers (ACM) and care management assistants (CMA). Each GP surgery in the Locality
has a named Social Worker who works closely with the GPs to support anticipatory care.
Current Social Work Workforce (excluding Sensory Impairment staff)
WTE in Post 3Ts WTE in Post AG WTE in Post Llanelli
Senior Practitioners 4 3 2.81
Social Workers 14.5 10.12 13
CMAs & ACMs 5.4 6 5.24
2.2.4 Carmarthenshire Integrated Community Equipment Services (CICES) was established

in 2009 as a partnership between Carmarthenshire County Council and Hywel Dda
University Health Board. A Section 33 agreement was set up between the two partners in
2006.The partnership is funded by a pooled budget with the split being CCC - (32%),
HDdUHB - (68%). The service delivers a wide range of community equipment into clients
own homes within the county of Carmarthenshire. The range of equipment is used to
keep clients safe in their own homes, to facilitate discharge from hospital or keep a
person in their own home for longer, in order to avoid a residential care setting admission
where possible. We currently have 660 beds out in the community and 440 dynamic
mattresses which demonstrates the level of complexity and care being delivered to
individuals within their own home.
2.2.5 Welsh Government Intermediate Care Fund (ICF)
ICF is a recurring source of revenue (with some Capital) to develop community services.
Administrating this fund and ensuring that it is used to meet population and organisational
objectives is overseen by the County’s Integrated Services Board. This Board is jointly chaired
by the County Director and Commissioner, Hywel Dda University Health Board, and the
Director of Community Services (including Social Care), Carmarthenshire County Council and
reports to the Regional Integrated Services Performance Board.
The chart below sets out the Carmarthenshire ICF Programme for 2016/17:
Intermediate Care Fund (ICF)

INTERMEDIATE CARE FUND – Supporting older people to maintain their independence and remain in their
own homes
Component 1 – Prevention in the Community
Third Sector led community prevention model (CUSP) including Locality £200,391
Community Resilience Co-ordinators
Vascular and Diabetic Foot pathway £56,919
Health & Social Care Support Worker Project £20,132
Health Activity Co-ordinator for Specialist Populations £18,550
Component 2 – Reablement at the Core
Additional Reablement Occupational Therapy capacity £56,920
Cartref Cynnes Assessment Beds £40,000
Component 3 – Reducing Admissions, De-escalation and Accelerating Discharge
Community Care Proactive Care Review Team £238,690
Carmarthenshire Health & Wellbeing Services Nov 2016 LW/RD Report v5 Page 14
Rapid Response Domiciliary Care Team £500,000
Transfer of Care Advice and Liaison Service (TOCALS) £628,158
Increased Occupational Therapy and Physiotherapy £77,760
Frailty Support Workers – Continuation of pilot on Ward 1, PPH and extension of £136,140
programme across ward 3, PPH and Dewi Ward, GGH
INTERMEDIATE CARE FUND – Children and adults with learning disabilities and complex needs
Sensory Integration Pathway Project £33,458

Behavioural Intervention Service £69,531
Assessment and Respite Service £101,297
Regional planning and commissioning for children and young people with £38,000
complex needs
INTERMEDIATE CARE FUND – Capital
Carmarthenshire Integrated Equipment Service (including releasing time to care) £200,000

Independent Living Centre £120,000
Sensory Integration Pathway £20,132
Behaviour Intervention Service £20,000
Co-location of the Integrated Team £100,000
Assessment & Respite Service for Adults with complex needs and learning disabilities £80,000
Supported Living provision for individuals with a Learning Disability £100,000
INTERMEDIATE CARE FUND – Post Election funding for Prevention and IAA
Adult Services Review Team £118,000

Band 6 Nurse for IAA Proof of Concept £15,000
Joint Commissioning of Nursing and Residential Step up/Step down beds £186,000
Enhancement of the British Red Cross ‘Home from Hospital’ Service to 7 day working £69,000
Convalescence Beds £200,000
Continuing Care Team £200,000
Enhance Acute response team (ART) capacity £29,000
Therapeutic Intervention in Community Hospitals £23,000
Pathway redesign for care management process £10,000
Enhancing our community model has been made possible through the Welsh Government
Intermediate Care Fund (ICF) which has allowed us to strengthen services across the three
tiers of care provision as outlined above. Specific areas of improvement include:
• Our current model of care in Wales is, in the main, reactive based upon provision of
support when problems arise and this can lead to the creation of dependency. We
recognise the need to continue to provide reactive services where appropriate but also
the need to shift our focus more toward facilitating community based service
development and signposting to alternatives which promote health and wellbeing,
prevent or limit deterioration and support recovery following a period of crisis.
Community Resilience is about communities using local resources and knowledge to help
themselves. In partnership with colleagues in Public Health we have developed a
Framework for Action to progress and implement a community resilience strategy in the
County. ICF has allowed us to support growth of support networks in the community
which can go some way to providing individuals with improved wellbeing. In an
innovative approach, public health, community health and social care and the third
sector is working with primary care to develop a social prescription scheme. This means
that GPs will prescribe patients with an appointment to see a community development
worker who will work with them to support their wellbeing. This is done through time-
banking scheme, where credit notes are issued to the patients to spend time in the
community doing things that keep them well. This initiative is delivered through SPICE
Time Credits and evidence has shown that Time Credits lead to sustainable improvements
in quality of life. 65% of members reported that Time Credits have helped to improve their
quality of life within the first year, and this figure rises to 75% for people who have been
members for 18 months to three years.
 ICF has also allowed us to appoint Community Resilience Coordinators for each Locality
area. The aim of these posts is to map health and social care needs of the Cluster
population and available services in the community and voluntary sector to meet low
level needs and promote / sustain wellbeing of the community. These post holders also
identify gaps in service provision and work in partnership with grant funding
organisations and Carmarthenshire Association of Voluntary Services to ‘broker’
resources to meet this gap.
 Transfer of Care Advice & Liaison Service (TOCALS) - Dedicated Multi-disciplinary teams
(MDT) are based at both acute hospital sites and support the rapid assessment, care &
discharge planning for people who are at increased risk of long term reduced level of
function as a result of a hospital admission. This initiative reflects prudent health care
principles of ‘do no harm’.
 Rapid Response Domiciliary Care – 24 WTE Rapid Response staff in post, two staff on
duty throughout the day in each of the three localities between 7am and 10pm working to
ensure that frail adults who are functionally compromised following acute episodes of
illness or trauma are able to recover at home. The Rapid Response service also supports
admission avoidance where appropriate at the ‘front door’ of the hospitals.
 Cartref Cynnes - Enabling the lease of two apartments’ within the Cartref Cynnes Extra
Care Facility in Johnstown, Carmarthen. This increases the range and number of
intermediate care beds available that provide a ‘residential reablement’ service to the
people of Carmarthenshire. The beds allow frail older adults to enhance functional
capacity which has been compromised through acute episodes of illness or following
trauma and support either admission prevention or timely discharge from hospital.
 Step Down Residential and Nursing Assessment Beds – These are commissioned
according to need in order to support reduced delayed transfers of care for frail adults
whose complex needs require ongoing care and who do not require acute intervention.
These beds also provide an alternative environment to hospital for ongoing assessment
needs. To support these beds and to ensure these patients do not become dependent,
additional multidisciplinary resource has also been funded to ensure a programme of
reablement and/or rehabilitiation is delivered during their stay in these facilities by their
care providers.
 Integrated Health and Social Care Worker – This initiative embraces prudent healthcare
principles of ‘only do what only you can do’ and provides the opportunity to challenge
models of care delivery and tests the transferability of skills that have traditionally been
provided by health care workers to social care workers. Social care workers have received
training and accreditation to undertake non complex wound care in the residential care
setting. Similarly, social care workers have been trained to manage
Percutaneous endoscopic gastrostomy (PEG) feeding. This initiative has been identified as
a Bevan Exemplar and as such shared across Wales as best practice.
 WG has instructed all health and social care providers across Wales to support
implementation of the Welsh Community Care Information Solutions (WCCIS). This IT
technology is currently being promoted throughout Wales as a system to promote mobile
working and more effective care. It provides the ability for IT to connect with other
systems, thereby ensuring that the multidisciplinary teams have access to appropriate
clinical, nursing, therapeutic and social care information. This system has been
implemented in Ceredigion and Bridgend. A Project Board has been established with
partner organisations from our region being represented from Carmarthenshire County
Council and Pembrokeshire County Council. It is proposed that WCCIS is implemented
across the whole region by April 2018.
 Capital Funding will facilitate the development of the existing Community Integrated
Equipment Store (CICES) into an Independent Living Centre (ILC) where individuals are
able to get advice on and view aids and adaptations that are available to support them to
maintain their independence. It is anticipated that the ILC will also provide the
opportunity for the public to purchase equipment.
 Establishment of Specialist Vascular Podiatrists (x3 wte) within the existing vascular team
to provide early identification of lower limb peripheral artery disease and preventing
escalation of need.
 For some years Carmarthenshire has benefited from a single point of access known as
‘Careline’ within the Local Authority. ‘Careline’ is the only 24/7 contact centre in Wales
and provides ease of access to the Community Resource Teams in each Locality.
‘Careline’ also hosts the Telecare (Lifeline) response centre for Carmarthenshire and
neighbouring authorities. In accordance with the duty under the new Act, in recent
months, with ICF we have been transitioning our ‘Careline’ service into
Carmarthenshire’s Information, Advice and Assistance (IAA) service. For adult services in
Carmarthenshire, this ‘front door’ will provide an integrated multidisciplinary point of
contact which provides a real opportunity to transform our community service model:
o A greater emphasis on prevention through the timely provision of advice and

assistance to empower people to ‘help to help themselves’
o Pathfinder for national ‘111’ service (‘Go Live’ in Carmarthenshire March
2017)
o Enhanced use of assistive technology
o Shift care and service provision upstream
o Enhanced multidisciplinary assessment at first point of contact
o Early identification of sudden functional decline and access to rapid
intermediate care assessment and intervention
o Improved co-ordination of care by the appropriate disciplines
Figure 3. below provides diagrammatic outline of our redesigned service model.
All Enquiries
(Public, ‘111’, Hospitals, GPs)
IAA SERVICE
(IAA Officers, Occupational
Therapist, Physiotherapist, Social
Worker, Community Nurse & 3rd
Sector)
Information Advice Assistance

(Proportionate (Integrated
Assessment) Assessment)
Sudden
Functional
Decline?
Yes No
*CRT – *CRT –
Short Term Progressive
Assessment & Complex
& Acute Long Term
Response Care
Pathway Pathway
*Community Resource Team (Short Term Assessment and Acute Response Pathway) –
Therapy and Nurse led intermediate care assessment (including TOCALS). Support may include
Rapid Response Domiciliary Care, Acute Response Team, Access to Step Up Beds, Supported
discharge from hospital home or step down beds and SCRAMS
*Community Resource Team (Progressive and Long Term Care Pathway) – social care or
health led assessment. Support may include long term domiciliary or residential care provision
for either social care or health needs. These individuals will also have access to short term
assessment and acute response pathway following illness or trauma
2.2.6 A Regional Collaboration for Health (ARCH)
ARCH is a unique collaboration project between the three partners of Abertawe Bro
Morgannwg University Health Board, Hywel Dda University Health Board and Swansea
University. It spans six local authority areas of Ceredigion, Pembrokeshire, Carmarthenshire,
Bridgend, Neath Port Talbot and Swansea. Work is progressing at pace on this initiative in
Carmarthenshire particularly in relation to the development of the Llanelli Wellbeing Village
in Delta Lakes and is exploring innovative solutions to sustaining health and social care in
rural areas focusing on Llandovery.
2.2.7 Psychological Services

Strong evidence base indicates mental health difficulties in chronic conditions significantly
impacts self management and results in poorer health and increased health care use.
Prevalence studies of co-morbid psychological difficulties with chronic conditions report
between 45 - 75% incidences of depression with chronic conditions. This increases as the
number of conditions a person has increases. Carmarthenshire has invested in a three
counties proposal to invest in psychological services that aims to promote improved
management of chronic conditions.
2.3 GMS Services including GP Cluster Developments
25 Practices provide GMS services across the County. There are significant workforce
challenges facing all practices across Wales and this is also felt locally. Practices across the
County are looking at how they can optimise capacity through introducing new appointment
systems as well as developing alternative workforce models including the employment of
pharmacists and Advanced Paramedic practitioners to the primary care team.
The Board will be aware of the retirement of a single handed GP Practice in Andrews Street,
Llanelli on the 30th September 2015. The Health Board awarded a new GMS Contract to the
Rosedale Medical Group who took over responsibility for GMS services for the patients of
Andrews Street surgery on the 1st October. The Health Board has been working closely with
the new Practice to develop new, modern, GP premises in the Dafen area. In the meantime
the Practice operates from Health Board occupied estate within Llwynhendy Health Centre,
with the aim to be in new premises by March 2017.
Amman Tawe Practice formed in 2015 through the merging of Amman Valley and
Cwmllynfell surgeries. The Practice has embraced a new, diverse approach to workforce
development by employing an Advanced Nurse Practitioners, an Advanced Paramedic
Practitioner and a Practice Based Pharmacist as part of the primary care team.
Meddygfa Minafon, Kidwelly, became a Health Board Managed Practice in 2015. In

September 2016 remodelling of the services has commenced with the introduction of a
more integrated primary and community approach. The practice has employed Nurse
Practitioners, a Prescribing Respiratory Nurse Specialist and a Practice Based Pharmacist,
who work closely with the GP’s in practice. An Advanced Paramedic Practitioner and
Advanced Physiotherapist Practitioner are also on secondment to pilot working in General
Practice. A GP led frailty service with a multi disciplinary team will also be commencing in
November 2016.
All GP practices have achieved the Bronze Level Investors in Carers Award scheme with
one Practice having achieved Silver. Approximately ten other surgeries are working on
their silver level. All surgeries have a Carer Lead within their practice, this person is a key
link person for Carers who are registered at the surgery as well as encouraging ’hidden
Carers’ to come forward for further help and support.
The new Primary Care Plan for Wales sets out a clear vision and reform agenda for
primary care. Welsh Government is supporting the implementation of the plan with a new
£10m Primary Care Fund which is being allocated in two ways: £6m to Cluster Networks
and £4m for pathfinder projects across Wales. The purpose of the cluster funding is to
accelerate the development of primary care cluster networks to drive community focused
service reform in response to identified local needs. The funding is intended to resource
local solutions which improve access to and the quality of care, more effectively meet
demand, and most importantly help redesign how services are delivered to ensure
sustainable models. The funding has been distributed based on global sum weighted
registered population.
There are seven (7) Clusters/Localities in Hywel Dda. Each Cluster has a GP Lead, a Primary
Care Locality Development Manager and a Practice Manager Representative. As mentioned
above there are three Clusters in Carmarthenshire namely ‘Aman Gwendraeth’, ‘Llanelli’
and ‘Tywi/Taf (2Ts)’ which are supported by Public Health Wales and Medicines
Management. In partnership with Carmarthenshire’s community integrated health and
social care teams, the aim is to ensure that the Clusters address the Ministerial priorities
within the Primary Care Plan.
As part of the £6m funding for cluster networks, in 2015/16 Amman Gwendraeth received
£122,407, 2Ts £114,110 and Llanelli £121,391 - this is recurrent funding for 3 years.
The Clusters, in conjunction with partners, have agreed that the funding will be utilised on
the following areas in 2016 – 17 and in some instances for the three year period:
2.3.1 Amman Gwendraeth :-
 Cluster Pharmacist – Amman Gwendraeth have recruited a cluster pharmacist who

will work with the GP practice based teams to undertake for example medication
reviews particularly in high risk groups such as: frail elderly and poly pharmacy .
 Dermatology Clinic – Amman Gwendraeth have funded an additional 50 procedures

to take place in the Dermatology clinics run at a practice in the Gwendraeth area.
 Frailty Pilot in Care Homes

This service provides care home patients with access to the same level of high
quality care, where the GP can be more pre-emptive. It provides a higher quality
and more consistent level of care across local care homes by promoting proactive
case management and therefore avoiding costly hospital admissions.
It is delivered by a primary care team led by a named GP, Nurse Practitioner and
Pharmacist who are responsible for ensuring the provision of an enhanced service
for the frail and elderly patients resident in the specified Amman Gwendraeth
cluster care homes.
 GP Dementia Service
This service is a GP led post diagnostic clinic in a community setting, aimed at
reducing the stigma of dementia and increasing early diagnosis, reducing admissions
to hospital and care homes, with the aim for people to live independently for longer.
 Primary Care Phlebotomy

This service is delivered by Phlebotomists to support GP practices in improving the
delivery of patient care. The service is held in GP practices across the cluster and
provides a much more convenient service for patients, who require blood tests
and supports the pressure on the secondary care service.
2.3.2 2Ts
 Frailty
Frailty is the most significant growth area of patient need within the Health Board
and was identified as one of the main challenges in the 2014/15 Cluster Plan. These
are the patients most likely to be admitted and re-admitted to hospital. Managing
these patients more effectively and pro-actively in their own home will enhance
their experience of care, improve their outcomes and reduce acute care costs and
bed days. As part of the funding proposal, practices were asked to nominate a
clinical frailty lead and to identify frail patients utilising a practice based IT Risk
Stratification System. The MSDi (software) tool will be used to risk stratify patients.
Patients identified are to have a written stay well plan which includes details of
carer, health and social care summary, optimisation and maintenance plan, and
escalation and urgent care plan.To date over 800 stay well plans have been
completed.
The proposal also identified optimising Multi-disciplinary Team (MDT) working

through the adoption of the MDT best practice guidance and the appointment of a
generic Occupational Therapy/Physiotherapy (OT/PT) Technician to attend Practice
MDT meetings and accept direct GP referrals to undertake low level assessments.
Since commencement in post in November 2015 to the end September 2016, 292
direct GP referrals have been made to the Generic Technician and 322 follow up
visits have been undertaken to 124 patients. Outcomes include:
 Home exercise plans put in place

 Utilisation of 3rd sector organisations e.g red cross for wheelchair hire.
 Provision of equipment such as zimmer frames, commodes, grab rails and
soft collar.
 Onward referral where required e.g. SALT, social services, hydrotherapy.
 Nine patients declined assessment when offered
Since November 2015 the Community OT and physiotherapy waiting lists have
seen a reduction from 13 week to 10 weeks
Lifestyle Advocates Programme - GP practices within the cluster have identified

twelve lifestyle advocates who are currently undertaking training with Public Health
Wales. The aim of the Lifestyle Advocates project is to embed a healthy lifestyle and
prevention ethos and practice within primary care clusters, by identifying
enthusiastic individuals to become skilled advocates of lifestyle behaviour change.
This is a three year project which covers: Year 1 - delivery of the Lifestyle Behaviour
Change Interventions training; Year 2 - undertaking further training as identified by
the advocates e.g. Mental Health First Aid; Foodwise; Alcohol Brief Intervention;
Smoking Cessation; etc.
Twyi /Taf received an extra £103,173 funding allocation for 2016/17 and in
addition to last year’s funded projects which it continues to build upon, the cluster
has invested funding in:
The development of a COPD + Programme in the Cluster to improve access to
community based combined education and exercise classes for people with COPD
in order to slow progression of the disease process.
The cluster is working with Public Health and Third Sector partners to increase
uptake of screening programmes (particularly bowel). This will be a, participative,
evaluated project to target individuals and communities in the Tywi / Taf practices
area. The cluster is providing funding to train Third Sector staff to talk about
screening in their every-day contacts – with the knowledge skills and confidence to
advocate for these programmes in appropriate (and sensitive) ways.
The prevalence of diabetes in the cluster is between 6-7% and continues to rise
annually. The projection for Hywel Dda is a prevalence of 11% within 10-15 years.
Whilst NHS England have an NHS health check programme, no such investment has
been offered in Wales and we currently do not have an approved screening
programme for those at high risk of diabetes. The cluster has invested funding for a
pre diabetes screening programme for those patients at the highest identified risk.
This includes each practice developing a diabetic screening protocol, offering an
annual Hba1C and onward referral to exercise and foodwise programmes. In
conjunction with the pre diabetes screening programme, the cluster is
commissioning foodwise education programmes for those patients identified as
being at risk of diabetes. Each course will be two hours for one session a week for
eight weeks.
The cluster has employed three part-time (2 wte) practice based pharmacists, to
work in each practice on a rotational basis; their role will include:
Repeat prescriptions, liaising with healthcare professionals and patients; sorting
out medicines-related problems and helping with patient triage in practice. Clinics
for medication use reviews, screening and management of long term conditions,
such as diabetes, asthma, COPD and hypertension.
2.3.3 Llanelli:-
The Llanelli cluster is working with the wider community team to ensure that funding is
used effectively to provide an integrated approach to improvements. The cluster
continues to build on the projects that were successfully funded in the previous year:
 Community Phlebotomy
The Cluster developed a community based phlebotomy clinic in Llanelli and
funded accommodation for the service in the Antioch Centre, Llanelli from
which the appointment system is also currently run. The Antioch Centre
accommodation also provides a hub for other community services that are
identified as a priority by the Cluster including a Leg Ulcer clinic. The Cluster
funding is for a 12 month period with a view to the Health Board continuing
the service thereafter, including the running of the appointment system. One
of the aims of the service is to reduce waiting times and demand at the Prince
Philip Hospital phlebotomy site and thus reduce complaints and increase
patient satisfaction. Feedback has been very positive.
 Chronic Obstructive Pulmonary Disease (COPD) Plus Exercise Programme

The Cluster has invested in order to expand the programme it developed using
Prescribing Savings Money. The aim is to improve access to community based
combined education and exercise classes for people with COPD in order to
slow progression of the disease process.
 The clusters continues to support the Lifestyle Advocates
Project. This year the cluster has also agreed to fund:
 Cluster Pharmacist
 Public Health Bowel Screening Support
 Resilience training for front line staff
Further proposals for the funding are in developing with the cluster which include a
community dementia service.
2.4 GP OOHs
The current GP ‘Out of Hours’ service in Carmarthenshire is provided through a range of GPs
on salaried and sessional contracts with telephone triage provided by Primecare. The Welsh
‘111’ Service is being introduced across Wales. The unscheduled care system in Wales,
indeed across the whole of the UK, is complex, difficult to navigate, and often results in
patients taking the easiest and most easily accessible route into our health services. The
Welsh ‘111’ Service must therefore be seen as a vital service to help people with urgent care
needs get the right advice in the right place, first time. Ultimately, this free to use number will
be an instantly recognised brand for NHS (and other parts of the wider health and social care
system in Wales) which can offer support and advice to patients and their carers 24/7.
Carmarthenshire is a pathfinder on the national ‘111’ initiative and as such, anticipated to ‘go
live’ in March 2017 and a project board has been established to progress our implementation.
Our developments around the Information Advice and Assistance service outlined above
presents a good foundation to support ‘111’.
2.5 Community Pharmacy
There are 49 Community Pharmacies within Carmarthenshire which represents almost

50% of the 99 pharmacies within Hywel Dda. Community pharmacies provide a range of
essential, enhanced and advanced services and are very often the only regular contact
that individuals have with a health care professional. The traditional role of community
pharmacists as dispensers of pills and creams is becoming outdated with the profession
eager and keen to play a more involved part in developing services that can support the
health and wellbeing of their community. Pharmacies are often best placed to deliver
services for patients as they offer local access to healthcare without the need for
appointments and many are open on Saturdays and some on Sundays. Across
Carmarthenshire, we have a number of pharmacies who have worked with the Health Board
and with the wider Community Pharmacy agenda to deliver new services over the last few
years. Examples of services being delivered by Community Pharmacy in Carmarthenshire
include:
2.5.1 Community Pharmacy Influenza Vaccination Service - 25 of the 49 pharmacies in

Carmarthenshire provide an NHS influenza vaccination service for patients over 65, those
that are in at risk group, and Health Board Staff. This service provides an additional access
point for patients to receive their flu vaccination. Over 700 patients have been vaccinated to
date at pharmacies in Carmarthenshire for this season which commenced on 1 st October
2016.
2.5.2 Community Pharmacy Smoking Cessation Service- 36 pharmacies provide a service in

conjunction with Stop Smoking Wales which allows the supply of nicotine replacement
therapy (NRT) to patients who wish to give up smoking. Additionally 21, pharmacies are able
to offer a one-stop smoking cessation service which includes both counselling and supply of
NRT products.
2.5.3 Return of Patients Sharps – 47 of the 49 pharmacies accept 1 Litre sharps boxes for safe
disposal. This provides for good access for patients.
2.5.4 Emergency hormonal contraception – 74% (36) of the pharmacies provide access to the
morning after pill (subject to specific criteria), to women aged 13+. The long opening hours of
pharmacies, together with weekend opening, is vital in areas where access to Family Planning
Clinics might be limited.
2.5.5 Triage and Treat Service- The service was piloted in 2 pharmacies in South
Pembrokeshire in 2014 and is now being extended to other areas. Following training events in
March, there are currently 4 pharmacies providing the service in Carmarthenshire. The aim of
the service is to offer patients a local service for low level injuries reducing the need to attend
a GP practice or A&E service. The service has had positive feedback from patients who have
appreciated the locally provided service and the professionalism of the staff involved. It
should be noted that this is the first service of its kind in Wales.
2.5.6 Investors in Carers - Three of the pharmacies within Carmarthenshire have achieved the
Bronze Level Award for Investors in Carers.
2.5.7 Emergency Supply – currently 12 pharmacies provide the Emergency Supply of

Prescribed Medication service which commenced in March 2016. The service allows a
pharmacy to supply prescribed medication (subject to certain conditions) without the need
for a prescription. This service is aimed at patients who have an immediate need for their
medication who have been unable to access their usual medical practice. Patients will need to
evidence to the pharmacist that they have been prescribed the medication previously e.g.
empty packet / container with name label.
2.5.8 Respiratory MUR+ (Medicines Use Reviews) - currently there are 26 pharmacies
providing the Respiratory MUR+ service which commenced in January 2016. The service aim is
to support respiratory patients to manage their condition and maximise the patient’s quality
of life. To improve outcomes for patients who have received a respiratory targeted MUR, by
provision of advice and improved management of their condition as a result of appropriate
inhaler technique.
2.6 General Ophthalmic Services
We have a total of 22 optometric practices across Carmarthenshire providing General

Ophthalmic Services under the NHS. Of these 22 practices, 17 are accredited to provide
enhanced examinations under the Eye Health Examination Wales (EHEW) service, and 14
practices are accredited to provide Low Vision Service Wales assessments for patients who
have difficulties with their sight that cannot be corrected by wearing glasses.
2.7 Capital Schemes
Within community services, the two key capital schemes are the development of Primary and
Community Resource Centres. In Carmarthen, the ambition is to replace Pond Street Clinic
and potentially a local GP Practice. The accommodation at Pond Street is in a very poor state
of repair and there is an urgent plan to identify alternative accommodation for the services
within the clinic which includes Sexual Health Services, Community Dental and Podiatry. The
opportunity is being explored to identify alternative accommodation that would also
accommodate additional community services. Within the Gwendraeth Valley, the proposal is
to develop a Primary, Community Health and Social Care Resource Centre at Cross Hands. This
will replace the current Cross Hands Health Centre along with two local GP Practices.
Discussions are in place with Carmarthenshire County Council who will lead on this innovative
partnership development.
3.0 Hospital Services
3.1 Prince Philip Hospital Profile
Prince Phillip is a busy, modern and well-equipped hospital which opened in 1990. There
are approximately 200 acute and elective inpatient beds, supporting Acute and Elective
General Medicine and Elective General Surgery, Orthopaedics, and Urology. The hospital
provides surgical day case theatres, endoscopic suite, Radiology and Laboratory support
and palliative care facilities, including a new hospice facility. It also provides for a range of
specialist outpatient clinics including Haematology, Respiratory, Gastroenterology,
Cardiology, Elderly Care, Endocrinology, Sleep medicine, Rheumatology, ENT, General
Surgery, TIA clinics. It is also the site of the Breast Unit and the Rapid Access Lung cancer
clinic.
Prince Phillip is lead by a triumvirate team that consists of
 Dr Robin Ghosal, Hospital Director of Clinical Care

 Gill Webber, Acute Hospital Nurse Manager
 Brett Denning, General Manager
Front of House - Clinicians in a multidisciplinary team at the hospital have developed a

new model of urgent and emergency care for patients with acute medical problems,
minor injuries and minor illnesses. The new model has 2 key elements:
1. A new Acute Medical Assessment Unit (AMAU) has been developed that can accept
patients either by ambulance, or GP referral
2. A new Minor Injuries Unit (MIU) where patients who walk in to the hospital are
assessed and treated by GPs and Emergency Nurse Practitioners
The new AMAU became operational in April 2016 with huge initial success. The President of
the Royal College of Physicians has highly commended the clinicians for the service model
they have developed. This new model has improved access for the sickest patients with a
new resuscitation unit within AMAU comprising of two resuscitation beds and a bed for
treatment of patients suspected of having a stroke. Patients arrive in AMAU through a newly-
created ambulance area and go straight to the medical team, allowing the sickest patients to
be identified and treated in the shortest possible time and being seen by senior clinicians
sooner. The AMAU has a dedicated six-bed area for monitoring patients and a six-chair
ambulatory care area for patients who do not require a bed but need some treatment to
enable them to go home.
Initial results demonstrate that the new model has significantly improved patient flow
within the Hospital. This is against a background of high levels of medically fit, above
average emergency admissions, and the reliance on Agency Nursing and key elements of
Improvement in the Percentage of Patients Who

Wait 4 hours or Less in Minor Injuries Unit
4 hour waits Welsh Target
100%
95%
90%
85%
80%
75%
the model not yet in place.
The department of Respiratory Medicine in Hywel Dda UHB is undergoing significant and
exciting re-design and development, in addition to 3 new NHS posts, Professor Keir Lewis
has been appointed the Chair of Respiratory Medicine in Hywel Dda. With this
appointment, there will be a significant increase to the already very active research
portfolio within the health board.
Rapid Access Lung Cancer (RALC) and Interventional Bronchoscopy – Prince Philip Hospital is
one of two sites in the health board that now has 3 highly skilled lung cancer Physicians who
provide Rapid Access Lung Clinics providing a one-stop clinic for the assessment, diagnostic
investigations and early treatment of suspected lung cancers. Supporting this function, the
unit is able to undertake Interventional Bronchoscopy and Physician-led ultrasound guided
biopsies. Thoracoscopy and EBUS (Endobronchial ultrasound) are also performed by the
lung cancer physicians. The Interventional Bronchoscopy service led by Dr Robin Ghosal is
based in Prince Philip Hospital and is one of only two in Wales, providing advanced
techniques for patients throughout the Health board, with locally advanced tumours
causing airway compromise, and involves tumour resection and/or tracheobronchial stent
insertion under conscious sedation. Both the interventional and EBUS service has gained
recognition throughout Wales and has received referrals from neighbouring Health boards
for WHSCC funded therapeutic procedures and more complex EBUS cases. Dr Ghosal
developed the EBUS service in Hywel Dda in 2011 and has trained a number of consultants
from ABMU, Aneurin Bevan University Health Board and Hywel Dda in the procedure. The
success of the EBUS and Interventional bronchoscopy service has led to the development of
a highly sought after Interventional Fellowship, based in Prince Philip Hospital, for senior
higher specialist trainees, with links to University College London.
The Research and Development Team in Hywel Dda has grown considerably with new
managerial, secretarial and coordinator posts advising and streamlining the permissions
process. There are new research nurse appointments in all 4 hospitals with dedicated
funding to pathology, radiology and pharmacy to support research-active clinicians. There is
also a new post to manage portfolio trials and a research nurse dedicated to running
pharmaceutical-sponsored trials. A National Institute for Social Care and Health Research
funded, 8-room dedicated Clinical Research Centre was opened in 2012 here in Prince
Philip. This now provides laboratory space for biomedical projects (post-doctoral
placements) as well as pharmaceutical and bio-engineering trials. This centre complements
cancer and surgical trials in Glangwili, Withybush and a rural-health unit in Bronglais where
clinicians are working with academics in Aberystwyth, Swansea, Lampeter and Trinity St
David’s Universities.
Leading Sleep and NIV for the Health board - Professor Keir Lewis is an expert in Sleep and
Non-Invasive Ventilation (NIV), and has agreed to lead these functions for the Health
Board from PPH in order to provide sustainable safe services for the future, reducing risks
to patients and Health Board.
This involves ensuring adequate training and retraining for all staff involved with NIV
provision, standardisation of equipment (NIV machines), monitoring of patients started on
NIV for 24+ hrs and equipment cost, providing Clinical Governance Protocols/guidance
and clear lines of responsibility and general workforce improvement both clinically and
from a nursing perspective. In addition Professor Lewis supports all complex sleep
patients on a Hub/Spoke model of care to the other Hywel Dda main sites.
We have a purpose-built Breast Care Unit, equipped with the latest state of the art
equipment including three-dimensional mammography. This was the first such machine in
the world to come into general clinical use and was paid for by our charitable funds. Instead
of open wards we have individual rooms. The clinic suite gives women access to specialist
doctors (Surgeons, Radiologists, Genetics and Oncologists), specialist nurses in breast care,
post operative recovery and chemotherapy, as well as a lymphoedema service and access to
the latest research. Wherever possible and safe we encourage minimal surgery using
advanced techniques such as sentinel node biopsy and intra-operative node analysis.. We are
conducting research with 2 other local hospitals that has allowed us to be the first in Europe
to test all women with early disease routinely for cancer gene activity (Oncotype Dx TM).
There is an expectation that this will reduce the need for chemotherapy, safely avoiding it in
women with a very low risk of future problems.
In partnership with community services and with Welsh Government Intermediate Care
Funding, we have introduced the new role of Frailty Support Workers. The initiative was
supported with bespoke training and competency programme which was delivered by
members of the Multi Disciplinary Team. These Band 3 HCSWs work 7 days a week under the
direction of the registered nurses, therapists and dieticians. The initiative aims to reduce
length of stay and hence reduce risk of long term care requirement through ensuring that
frail patients are adequately hydrated and nutritionally optimised, improve
nutrition/hydration, recognise delirium and improve communication between the nursing
staff, doctors and therapist. The team consists of three full time band 3 Frailty Support
Workers.
Our Stroke services aim to provide very high quality stroke care for our patients. The twice
weekly Rapid Access TIA (Transient Ischaemic Attack) clinics with immediately available
diagnostics, targets the low, moderate and high risk groups who may end up having a major
stroke if untreated. When patients present, we have a well organised acute stroke care
services including a 5 bedded acute stroke unit, a structured 24 hour stroke thrombolysis
pathway, rapid multidisciplinary team assessment, all of which are well supported by
rehabilitation services. With an enthusiastic team behind our stroke services we have made
a significant impact in keeping up with national standards which is reflected by the national
stroke audit data (SSNAP). We link up with other acute stroke services in the country
including Cardiff, Swansea and North Wales on a weekly basis through video conferencing.
Our vibrant stroke unit provides educational and research opportunities aimed at trainee
doctors, nurses and therapists. The stroke association supported health care co-ordinator
plays an important role in providing vital feedbacks from the patients discharged into the
community.
The Diabetes unit has been short listed for NHS Wales awards 5 times including this year
2016/17. The team is led by Dr Sam Rice with support from a specialist trainee in diabetes
and an academic F2 doctor and highly experienced and approachable specialist nurses. As
well as the acute services, the team also provides a community diabetes service in Amman
Valley and Cardigan Hospitals. PPH consultants sit on the all Wales diabetes implementation
group and National Specialist Advisory Group (NSAG) for diabetes, specialist training
committee for diabetes and undertake work for the deanery. There are close links to
Swansea and Aberystwyth University and a number of on-going research projects are being
undertaken through the clinical research unit here.
The Prince Philip Hospital Diabetes unit provides insulin pump and antenatal diabetes
services, and leads health board wide diabetes network and the “Think Glucose“
programme. Also in the last three years the diabetes centre has developed patient
education programmes now available across Wales and we lead the work being done on
the diabetes diploma course for the Health Board.
As a result of the work done as a diabetes UK clinical champion, Dr Sam Rice was invited
onto the All Party Parliamentary group for diabetes and was on an expert panel at an
international conference on diabetes in February.
The Cardiology unit in Prince Philip Hospital provides cardiopulmonary exercise testing
equipment, ECG stress testing, echocardiography, trans-oesophageal echocardiography, CT
coronary angiogram facilities, 24 hour Holter monitoring and PAM recording. There are
currently 2 consultants, Dr Phil Avery and Dr Lena Izzat, with a vision to appoint a third. The
cardiology ward consists of a 20 bedded ward with an additional 6 bedded cardiac day case
unit and a 4 bedded Coronary Care Unit. Within Prince Philip is the provision of trans-
oesophageal echocardiography, standard echocardiography, temporary pacing facilities,
diagnostic angiography and a developing CT angiogram service. There is access to Glangwili
Hospital for permanent pacing and Morriston Hospital for more advanced techniques.
The Radiology department provides services including a range of invasive procedures as

well as MRI, whole body CT scanning and Digital Vascular Imaging.
The Day Care Unit has a Central treatment Suite designed for Endoscopy. Equipped with
36 endoscope (viz Gastroscopes, Colonoscopes, Bronchoscopes, Duodenoscopes,
Hysteroscopes and Cystoscopes) video and training attachment. There will be exciting
developments with a new unit over the next 12-24 months.
PPH is a significant key location from where elective Urology Services are delivered to the
whole of Hywel Dda. The hospital has seen the expansion of urological services particularly
with regard to day case and in patient theatre provision. Complex stone patients including
those who require Percutaneous Nephrolitnotomy (PCNL) and laser flexible ureteroscopy
procedures are treated here as well as a wide range of general urological operations which
are carried out on a day case or in-patient basis. Female urology procedures including
Transobturator Tape (TOT) sling procedures, Botox bladder injection and Percutaneous
posterior tibial nerve stimulation are carried out here. Recently, we have established the
first MRI/Ultrasound fusion targeted biopsy service in Wales for the detection of prostate
cancer. We are seeking to introduce Green Light laser for the treatment of enlarged
prostate in the next 12 months.
Prince Philip Hospital provides a health board wide elective orthopaedic surgery. There are
two dedicated and fully equipped laminar airflow theatres and a ring fenced 28 bed
exclusively orthopaedic unit has been recognised by the “Getting It Right First Time”
report and the current low infection and revision rate for arthroplasty have been
published in the National Joint Registry and the Wales Audit Office. Multidisciplinary
clinics, Enhanced Recovery programs, procedure specific patient information booklets
were developed to improve patient centred care. These have attracted both national and
international recognition.
The alcohol liaison service in PPH is unique in Wales for its level of intervention with this
patient group who have complex needs.
The Medical Education Department is an integral feature of Prince Philip Hospital, and is
easily accessible from all wards and departments. The department is the central focus of
all Medical Education and provides a positive environment for learning. The department
supports Medical Students from Swansea and Cardiff Universities, Junior Doctors in training,
Trust doctors, Staff Grade doctors, and Consultants over all aspects of their education,
training and continuing professional development. The Department runs a full weekly
schedule of teaching programmes for all doctors that includes, Journal Clubs, Grand Rounds,
curriculum teaching for foundation and core trainees, across site department teaching, and
clinical skills and simulation. The Clinical Skills Laboratory enables junior doctors to develop
their practical skills in a safe environment. The department supports the hosting of the All
Wales Practical Assessment of Clinical Examination Skills (PACES) course for medical doctors
from across Wales. Full Induction programmes are run by the department for all new junior
doctors joining the Health Board.
The Education Centre comprises of a large lecture theatre with capacity for seating 60
doctors, fully equipped with video conferencing, PowerPoint for presentations, and full
access to hospital systems for teaching purposes. There are two other Seminar Rooms
with video conferencing facilities and PC /projector available for teaching purposes. We
also have a Clinical Skills Laboratory set up nearby in the corridor to the Doctors Mess with
a full range of teaching equipment available for medical students and junior doctors.
Clinicians and the PPH management team are actively involved in the Llanelli Wellness
Village development.
Main Areas for Improvement
There are a number of areas of focus where we are developing action plans to improve
the quality and efficiency of the services provided although it should be noted that many
of these issues will require investment to address.
The limited capacity of the therapy services in an ongoing problem in Prince Phillip
Hospital for example there is only one occupational therapist for all the acute wards. The
Board will be familiar with this Health Board wide issue from previous Board reports.
In terms of unscheduled care a number of challenges exist including
 The lack of a clinical bed manager during the day who’s duties would include liaison
and coordination of patient flow with GPs, ambulance control, Minor Injuries Unit,
Acute Medical Assessment Unit, Wards and Theatres.
 There is no surge area to increase beds at times of pressure
 The full front of house clinical model has not been implemented as the final costs
exceeded existing budgets. In particular this includes rolling out the frailty clinics to
5 days a week. The frailty clinic service currently runs twice a week and accepts
referrals from GPs. It is designed to reduce hospital admissions through the
proactive management of people with long term conditions, especially people with
multiple conditions. A 5 day a week service would be able to take referrals from
Minor Injuries Unit and the Acute Medical Assessment Unit
• When there are peaks in demand in the Minor Injuries Unit the waits for triage can
exceed 1 hour as there is only one band 5 nurse providing triage
 ICF funding for the frailty support workers described above ends in March 2017
In terms of scheduled care the challenges include:
 Maintaining elective services in the face of increased emergency medical demand.

There has been a reduction in the beds available to for elective surgical and
orthopaedic patients over the last year as a result of this
 There is insufficient theatre storage
 The physical environment of the endoscopy unit does not meet the endoscopy
standards as is it not possible to separate pre and post procedure patients within the
space available.
 The day case surgery facilities in PPH are insufficient to meet the needs for day case
surgery. The facilities are limited in size as there is only one operating room and
provide a sub-optimal patient experience specifically with regard to limited privacy
and dignity.
 The Pre Operative Assessment Unit has only two rooms which is insufficient for the
demand and there is no waiting area
Nurse Recruitment is an ongoing area of focus as there is the need to recruit to nurse
vacancies across the hospital and reduce the need for bank and agency staff.
Recruitment of GPs to work in the Minor Injuries unit is an ongoing priority. On several
occasions it has required the A&E consultants from GGH to work in the MIU in order to keep
the unit open.
Estate Developments
Within the Prince Phillip Hospital estate the following areas have been highlighted for further
development which in part address the challenges highlighted above:
 A fully accredited Endoscopy Unit

 Improved and expanded Day surgical facilitates
 Develop surge areas that do not impact on elective capacity
 The introduction of an equipment library that safely stores things like pumps and
mattresses
 The developments of specialist gastroenterology and cardiology wards
 Pre-assessment facilities
 Storage facilities in main theatre
 Office accommodation for increased clinical staff
 Patient Liaison and Advice Service Office
3.2 Glangwili General Hospital Profile
Glangwili General Hospital is a 392 bedded hospital comprising of emergency and general
surgery, paediatrics, maternity services, ITU, ENT, ophthalmology, urology, general
medicine, trauma and orthopaedics. It provides a regional HDUHB service for emergency
Gastro Intestinal (GI) bleeds, pacemaker insertion, Transeosophageal Echocardiogram
(TOE) and Dobutamine Stress Echocardiogram (DSE), thoracoscopy, ENT, ophthalmic
emergencies, urological emergencies and consultant led maternity services.
Tertiary services, for example complex cardiology, renal and neurology, are provided
under Service Level Agreement (SLA) from ABMU.
Glangwili Hospital is led by a triumvirate team that consists of Dr Eiry Edmunds, Hospital
Director of Clinical Care, Sarah Perry, General Manager and Gwenlais Chandler, Interim
Acute Hospital Nurse Manager. Bethan Lewis commences post 27/1/17 as the substantive
Hospital Nurse Manager.
Acute physicians are being recruited to GGH in order to provide an enhanced Clinical
Decision Unit consultant led model. By the end of November 2016 there will be three acute
physicians in post. Rota’s are being developed to ensure senior presence on the unit and to
release the medical consultants from post take duties to concentrate on specialist work.
Weekly implementation meetings are commencing from 14/11/16 to ensure optimum
service cover and performance reports have been developed to assess progress. CDU is
supported by a dedicated TOCALs team including physiotherapy, occupational therapy and
social worker team. They assess patients post admission for suitability for early supported
discharge, working closely with the community ART team and district nursing services.
Respiratory services are provided from Glangwili and Prince Philip Hospitals which also
provide cover to Withybush General Hospital and as part of the respiratory plan this will
include Bronglais General Hospital.
Improvements to the stroke pathway are in place and in November saw the introduction of a
4 bedded acute stroke bay to provide enhanced care for the first 72 hours of the stroke
pathway. This has been supported by additional trained staff to ensure patients receive the
care and treatment they require during the acute phase of their illness. Weekly stroke
meetings are in place to review all stroke admissions and whether they achieved the 4 hour
target of arrival to admission. All patients that do not meet this time standard are reviewed to
ensure pathway improvements.
Full diagnostic services are provided on both hospital sites with Glangwili General Hospital
having commenced an Out of Hours MRI emergency cover from April 2016.
Gastroenterology services are being reviewed with the retirement of a consultant January
2017. Recruitment to the post is underway and locum cover will be sought in the interim
as this will leave a single handed consultant for GGH.
Meetings have continued with clinical leads and estates to review the Glangwili General
Hospital site due to the age of the buildings built in 1949 and also due to the increased
demand for emergency and routine medical, surgical and diagnostic services. This will form
the IMTP for 2017/18. The key areas for review are:-
 Outpatient capacity
 Radiology footprint
 Pathology footprint
 Pharmacy footprint
 Surgical wards and day surgery
 Cardiology Catheter Lab and permanent pacing lab is progressing and a business
justification case has been undertaken which is being led by a HDUHB Project
Management Group.
 Office accommodation for increased clinical staff
 Phase 2 Women’s and Children services where work has commenced to further
develop services on the site
 Expansion of the A&E department to relocate the minors area into the CDU ambulance
entrance. This will allow separation of the minors pathway and create additional space
in the emergency department. Buildings costs and redesign have been completed
along with an SBAR which is now waiting executive approval and subject to capital
money availability.
The boundary changes from Withybush (Tenby, Saundersfoot, Kilgetty and Narbeth areas)
reverted back on 1/9/16.
However the boundaries from GGH to PPH (Ammanford and Gwendraeth Valley) are still in
place with activity and bed capacity being reviewed on a weekly basis.
Recruitment is ongoing with the 2 medical middle grades having started post in November
2016 leaving a gap of 2 middle grades on the medical rota which is out to locum cover.
Recruitment is an ongoing area of focus as there is the need to recruit to nurse vacancies
across both hospitals and reduce the need for bank and agency staff. January 2016 saw a
recruitment campaign to the Philippines where staff have been recruited and currently
awaiting to go through the on-boarding process. 36 staff have been identified for GGH for
January 2017 however exact numbers are to be confirmed due to confirmation of visa
requirements and passing ILETS tests.
GGH is focussing on achieving the 4 and 12 hour Tier 1 standard which currently is below the
national standard and trajectoryAn extensive 4 hour action plan has been developed and
actions are being progressed. Performance month to date to 10/11/16 is 82.21%.
There are weekly A&E and Operational Performance Meetings to review all Tier 1 targets and
the patient flow through the hospital.
Weekly meetings with the department and WAST are in place to review ambulance
handover performance, regular attenders and pathway development to avoid hospital
conveyance.
A recent A&E staffing review has been completed which recommends additional trained
and support staff alongside Emergency Nurse Practitioners to further improve the quality
and timeliness of patient care.
Car parking continues to be an issue for both patients and staff. A task and finish group is
in place to oversee actions and improvements. Named parking spaces will be removed in
November 2016 and replaced by a generic parking area. Further park and ride options are
being explored with local businesses to provide alternative options to parking on site.
Accommodation on the site remains an issue due to the age of the buildings also housing
increased services and staff. A utilisation review is underway of all office areas to assess
where there are opportunities for further space or for sharing. A review of all services and
staff is underway to assess which can be provided away from the main hospital site.
Pathology services are working in a cramped restricted environment alongside a review

under the ARCH project to look at where some services can be centralised e.g. cellular
pathology also to local alternative accommodation where some services could be
relocated that do not need to be provided on the main hospital site.
In summary GGH is focussed on maintaining and improving services for patients with a
dedicated team of clinicians and managers which will be defined in the IMTP for planned
service change.
4.0 Mental Health Services
4.1 Transforming Mental Health Programme

A Mental Health Programme Group (MHPG) was formed in April 2015 which has been
overseeing the co-production of the Transforming Mental Health Services programme.
The MHPG has agreed that the following principles should be at the core of any new
service redesign:-
 to have a 24 hour/7 day a week service,

 to have no waiting lists,
 to move away from hospital admission and treatment to hospitality and time out
 to provide meaningful day time opportunities for our service users.
The MHPG has engaged with a wide range of staff and stakeholders to understand
people’s experience of the current services, and to co-design a future, needs led service
which adheres to these principles.
The formal engagement period for the programme was undertaken from the 1 st of
October 2015 to the 31st of January 2016. The engagement events undertaken have
involved a wide range of staff and stakeholders, service users, carers, the Third Sector,
Community Health Council and Local Authority. Alongside the engagement events the
MHPG have been working closely with West Wales Action for Mental Health (WWAMH) in
order that an independent service user and carer perspective on alternative models of
care is used to inform any service transformation.
The MHPG commissioned an independent evaluation of the engagement programme by

the University of Wales, Trinity Saint David, to test the robustness of the process and
identify themes from the feedback received.
The vision for the redesign of mental health services is set out within the Mental Health &
Learning Disabilities (MHLD) Directorate’s Integrated Medium Term Plan. At the centre of
the Welsh Government’s strategy for mental health and wellbeing in Wales, Together for
Mental Health (2012), is a commitment to build a well designed and fully integrated
network of care that responds promptly and holistically to contemporary health and social
needs.
4.2 Community Mental Health Team

Following a move from a leased base in Llangadog, a sub-team moved to Llandovery
Hospital to ensure effective service provision to the population of Llandovery and
Llandeilo. This is not a long-term position and alternative options are being explored.
4.3 Bryngolau Ward

Recruitment has improved significantly in the last few months and the Ward Manager has
reported having a full complement of staff for the first time in a long period of time. In
addition, new funding received during 2015/16 to improve the Occupational Therapy
resource and therapeutic activity has made a significant different to the service. The ward
moved to open visiting hours and staff and families have recognised the benefits of this on
patient experience.
4.4 Bryngofal Ward

The ward environment has deteriorated due to its high volume use. Estates are progressing
improvement work in particular to en-suite bathrooms and flooring. The clinical demands
on the ward are significant and continuous. Staff are working hard to ensure standards of
care remain high. On a recent un-announced visit by the Directorate Management Team,
patients reported being well care for. Recruitment has improved but remains a constant
challenge.
4.5 Substance Misuse Services

The Health Board commissioned substance misuse services based in Llanelli works in an
integrated service model. There are significant estates issues which are being progressed
through the Area Partnership Board structure and may result in a service move to more
appropriate accommodation.
4.6 Memory Service
There have been significant challenges providing timely medical assessment within this
service. A waiting list initiative has been extended to enable the service to move
towards a 28 day target for assessment.
Materion Gofal Iechyd yng Ngheredigion/
Health Care Matters in Ceredigion
Cyfarfod Bwrdd Iechyd Prifysgol Hywel Dda 22ed Medi 2016 /

Hywel Dda University Health Board Meeting 22nd September 2016
Update on Healthcare Services in Ceredigion September 2016
Contents
Preventative Services .......................................................................................................... 5
Healthy Activity (Foundations for Change) ....................................................................... 5
Flu vaccination uptake...................................................................................................... 6
Mind Your Heart ............................................................................................................... 7
Obesity ............................................................................................................................. 7
School schemes ............................................................................................................... 8
General Medical Services .................................................................................................... 8
Cluster Network Working .................................................................................................. 8
North Ceredigion Locality ............................................................................................. 8
South Ceredigion and Teifi Valley Locality ................................................................... 9
Community Pharmacy .................................................................................................... 11
Triage and Treat Service ............................................................................................ 11
Community Pharmacy Flu Vaccination Service .......................................................... 12
Community Pharmacy Smoking Cessation Service .................................................... 12
Return of Patients Sharps ........................................................................................... 12
Emergency hormonal contraception ........................................................................... 12
General Dental Services (GDS) ..................................................................................... 12
Ceredigion Mental Health Services .................................................................................... 13
Transforming Mental Health Project - Awel Deg ............................................................ 13
Older People Mental Health Services............................................................................. 13
Funding Streams ............................................................................................................... 14
Community Services .......................................................................................................... 15
Ceredigion Core Community Resource Model ............................................................... 15
Cardigan Core Community Nursing Service ................................................................... 17
Interim beds ................................................................................................................... 18
Interim placement scheme .......................................................................................... 18
Interim assessment beds ............................................................................................ 19
Community nursing ........................................................................................................ 19
Nurse leads for the cluster areas ................................................................................ 19
Community Nursing Cluster Teams ............................................................................ 20
Community Nurse Posts ............................................................................................. 20
Frailty and Chronic Disease Nurse Posts ................................................................... 21
Additional Clinical Services ................................................................................................ 21
2
Home oxygen service ..................................................................................................... 21
Minor Injuries Unit .......................................................................................................... 21
Leg Ulcer Clinic .............................................................................................................. 22
Tregaron Community Hospital ........................................................................................ 23
Psychological services in long term condition management .............................................. 23
Objectives for the service in the first year 2016/17 are as follows; ................................. 24
Sustainable Communities .................................................................................................. 25
Falls Clinics .................................................................................................................... 25
Keeping Ceredigion‟s elderly and vulnerable safe, warm and secure in their homes ..... 25
Llandysul ........................................................................................................................ 25
Palliative Care ................................................................................................................ 27
Partnership working........................................................................................................ 27
Syrian refugees .............................................................................................................. 28
Therapeutic services for patients with learning disabilities and complex needs ............. 28
Understanding Dementia in Cardigan and Tregaron ...................................................... 28
Mid Wales Collaborative .................................................................................................... 29
Cross Boarder Discharge Liaison Nurse ........................................................................ 30
Technology Enabled Care .............................................................................................. 30
Capital Schemes ................................................................................................................ 30
Cylch Caron Project ....................................................................................................... 30
Cardigan Integrated Care Project ................................................................................... 31
Aberaeron Hospital......................................................................................................... 32
Bridging between community and acute services .............................................................. 32
Assessing alternatives to admission (AA2A) .................................................................. 32
Complex discharge pathways ........................................................................................ 34
Dashboards .................................................................................................................... 34
Frequent Fallers, Callers and Flyers Group ................................................................... 35
„Home of Choice‟ policy .................................................................................................. 36
Information Technology to support management information ........................................ 36
Occupational Therapy Services in Ceredigion ............................................................... 36
Acute Services in Ceredigion ............................................................................................. 38
Consultant Recruitment .................................................................................................. 38
Physician Associates...................................................................................................... 38
“Y Banwy” ....................................................................................................................... 39
Older People Mental Health Services............................................................................. 39
“Front of House” Development ....................................................................................... 39
3
Theatre Refurbishment ............................................................................................... 39
Outpatients ................................................................................................................. 39
Ante-natal ................................................................................................................... 39
Ty Geraint ................................................................................................................... 40
Parking ....................................................................................................................... 40
Electronic Payments ................................................................................................... 40
Bronglais Improvement Week ..................................................................................... 40
Site Development Plans ............................................................................................. 41
New MRI scanner ....................................................................................................... 41
Chemotherapy Day Unit ............................................................................................. 41
Visits............................................................................................................................... 41
4
Preventative Services
Healthy Activity (Foundations for Change)
The Wales Deanery has issued activity guidance which includes the following benefits
associated with daily activity:
 Reduces risk of a range of diseases, e.g. coronary heart disease, stroke, type 2
diabetes;
 Helps maintain a healthy weight;
 Helps maintain ability to perform everyday tasks with ease;
 Improves self-esteem;
 Reduces symptoms of depression and anxiety.
Whilst most health professions are aware of the benefits of regular exercise, they do not
always undertake regular activity.
The Foundations for Change framework has been used to establish this piece of research.
Purpose of the research

Determine a framework which encourages staff to undertake daily activity by
demonstrating the benefits to their personal general wellbeing.
Approach
Aberystwyth University‟s Department for Sports and Exercise Science have devised an
approach to determine a baseline of general fitness which is portable. The baseline
analysis enables a personalised activity plan to be developed. It was essential that the
approach was portable to ensure the framework could be rolled out further if successful.
This initial baseline includes:
 Weight
 Body Mass Index
 General strength
 Leg and back strength
 Flexibility
Aberystwyth University‟s Psychology Department has created an in-depth questionnaire

which is also completed at the start of the program. This information is not only used to
obtain a baseline of emotional wellbeing, but is also used to determine what approaches
may motivate individuals.
Hywel Dda University Health Board County Management Team is supportive of the work
and has committed itself to lead by example, therefore being the first group to participate
in the research.
As the information is being analysed differing approaches and technologies will be tested
to prompt and motivate the participants. This may include team targets, competition, text
messaging etc.
5
The initial research will take place over a year and participants include:
 Members of the County Management Team
 Service managers from the therapies departments
 Service managers from the County Council
 Senior nursing managers
Flu vaccination uptake

Background
Ceredigion has a continued low flu vaccination uptake for citizens over 65 and those under
65 with chronic conditions. Uptake levels for 65+ were the worst of all local authority areas
in Wales according to Public Health Wales data for the 2014-15 season.
Public Health Wales commissioned a piece of work from Ceredigion Association of

Voluntary Organisations (CAVO), under the following brief.
Aims
This project set out to explore any particular cultural issues or beliefs in Ceredigion that
contribute to low uptake and whether a different approach to promoting flu vaccination
might better meet local needs, values and cultures.
Method
This project was conducted using a participatory, peer methodology.
 Key third sector, local authority, care homes and General Practice surgery
representatives were invited to attend community researchers training sessions to
explore the facts and myths about flu and the vaccination, and develop a guided
conversation brief to find out people‟s views.
 Stakeholders conducted 86 guided conversations with members of the public.
 Key findings gathered were tested and further discussed at a Flu Summit.
The key emergent findings were as follows:

 Many considered themselves resilient to colds and flu;
 Few realised the impact of being a flu carrier;
 Few made the connection between flu and risk to life;
 Many shared personal negative experiences and retold the experiences of others;
 There is an imbalance in the perceived risk of the vaccine against the real risk of flu;
 Those who are well didn‟t come across information at GP surgeries;
 Promoting the vaccine for personal protection may not resonate with adults who
perceive themselves as healthy, resilient and self-reliant, who don‟t want to „waste‟
healthcare resources;
 Few participants realised that they would protect the community by being
vaccinated.
6
Conclusions
 Great value in engaging with the public in conversation and investing time to
understand what matters to them;
 The term influenza needs to be used to emphasise severity;
 Community flu activators need to be identified and informed of the facts and myths
around flu and the vaccination to ensure that the right message is cascaded from
trusted individuals;
 Initiate a „Team Ceredigion‟ flu promotion campaign to encourage those who are
well to consider the protection of their family and wider community;
 Promotional material needs to be local, relevant and visible where people gather
socially to reach those who are well;
 „Flu Clinics‟ need to be interactive Wellbeing Fairs and link to other key community
activities to reach the harder to engage.
Mind Your Heart

Mind Your Heart (MYH) provides healthier lifestyles training and materials specifically
tailored to people with mental health problems. It trains and supports staff, volunteers and
organisations who work with people with enduring mental health problems in Ceredigion to
improve the advice and support they are able to give their clients. In the year 2014/15 the
service:
 Implemented an audit of skills and healthy opportunities provided by mental health
organisations completing 5 audits;
 Provided in-depth health improvement support for 7 organisations and Health Board
teams;
 Delivered 25 hours of training to 43 participants including the MYH Foundation
course and Public Health Wales‟ Brief Intervention and Alcohol course and 21
people completed the 6 hour MYH Foundation course whilst a further 5 completed
the first part – the core Brief Intervention skills.
 Developed a business care which proposes to extend this programme into the other
two counties of Hywel Dda.
Obesity
Through primary care development funding we have been able to commission a National
Exercise on Referral Scheme (NERS) in Pregnancy „Baby Let‟s Move‟ Service. All
pregnant women with a Body Mass Index of 30 and over can be referred by their midwife
to this service. It is provided by National Exercise Referal Scheme Professionals and runs
in various locations throughout the county. We have also used this finding to produce a
short film that promotes healthy eating in pregnancy especially for those with low literacy
levels – this film will be launched and promoted shortly across Hywel Dda. A piece of
research was also commissioned and undertaken last year to give us insight into the
perceptions of overweight and obesity of health professionals who work with clients in the
maternal and early years. The findings of this research are being used to address the
issues it has raised.
7
School schemes
Both the Healthy Schools and Pre-schools Schemes continue to thrive in Ceredigion.
All primary and secondary schools are active members of the Healthy Schools Scheme,
creating supportive environments that promote healthy lifestyles for staff, pupils and the
community. There are currently 40 settings taking part in the Healthy Pre-schools Scheme,
with others actively seeking to join. Extra funding has been received from Public Health
Wales this year to promote a healthy weight in this age group through the promotion of the
„10 Steps to a healthy weight‟.
General Medical Services

Currently there are thirteen practices providing General Medical Services (GMS) across
Ceredigion, a reduction of one in North Ceredigion Locality since the last Board report. A
further practice has served notice of closure in the South Ceredigion Locality, however the
Health Board is working very closely with the practice to ensure that access to services are
still available to patients likely to be affected. Like the rest of Wales, Ceredigion has
significant workforce pressures and difficulties in recruiting professionals to the area, as
well as being unable to obtain locum cover have proven to be catalysts in destabilising
practices. Work on wider recruitment campaigns are in progress across the whole health
board and wider across Wales.
Cluster Network Working

North Ceredigion Locality
As part of the £6m funding for cluster networks, North Ceredigion received £81.324k. This
is recurrent funding is for 3 years. Although this financial year the cluster has received an
additional £54,216.
The cluster agreed to continue with their project to provide pre-diabetes care. The aim of
this integrated project is to reduce the risk of developing diabetes for those at high risk of
becoming diabetic within the Ceredigion population. To date the following has been
delivered:
 Last year 709 patients received a 30minute face to face consultation;
 6 Foodwise programmes were delivered via the lifestyle advocates;
 The results from these programmes was very positive despite the low numbers
attending;
 19 people completed course;
 72% (n=13) achieved weight loss;
 17% (n = 3) gained weight;
 11% (n = 2) maintained weight;
 1 person had no pre and post weight recorded;
 15 reported feeling more confident or much more confident about managing their
weight after attending Foodwise;
 13 reported making positive changes to their diet;
 13 reported making positive changes to their activity or exercise levels.
8
This year the cluster has modified the delivery of Foodwise programmes by allowing the
Education for Patients Programme to run this programme. We anticipate that this will
increase the numbers of people attending each programme.
The cluster has also agreed to continue to support and grow the lifestyle advocates to
support patients in making healthier lifestyle choices.
The cluster is also supporting Public Health Wales with their screening programme, by
giving the team some funds to undertake screening projects in the locality.
Last year the cluster purchased C-Reactive Protein testing machines to test patients at the
surgery that have a respiratory infection but who do not necessarily need antibiotics. The
cluster is working with Public Health Wales to evaluate the benefit of using these tests in
Practice. So far it is proving very useful in guiding antibiotic prescribing.
With this year‟s extra funding the cluster are looking to appoint a cluster pharmacist to
support GPs workload. This is to replicate the model already been delivered in the south.
The cluster is also working on a project with Public Health Wales to use video-
conferencing equipment to introduce the option of telehealth based cessation support
alongside other existing options for smoking cessation services. Church Surgery is
currently piloting the concept.
In the autumn the cluster will be embarking on an additional project with Professor Lewis
and secondary care colleagues, to pilot pulmonary rehabilitation programmes in the
community via video-conferencing facilities. This will allow the senior healthcare
professional to be based in one location whilst delivering the education to patients in a
rural setting. The patients will be in a different location with a junior staff member to
support them completing the set exercises etc. Tregaron will pilot this initiative at their local
community hall.
The cluster is also working with the Health Board to pilot having a physiotherapist working
in practices to support GP workload.
With any slippage money from the pharmacist post the cluster would like to purchase
some software to enable all the practices to link together. This will enable better
collaborative working and provide future cross cover across the cluster.
South Ceredigion and Teifi Valley Locality

The South Ceregion Primary Care Locality continues to build on established work. One
established area of work was around case managing and identify groups of people with
long term conditions / complex needs, at a high risk of unplanned hospital admission with
the aim of reducing unplanned admissions and improving health outcomes for that group.
To undertake this work the cluster purchase the MSDi (software) tool to risk stratify this
cohort of patients who are registered patients at the cluster practice. In addition to this the
cluster successfully appointed 2 part-time cluster frailty and chronic disease pharmacists
and 1 cluster frailty and chronic disease nurse.
9
The benefits of this would be the reduction of unplanned admissions and improving health
outcomes for people with long term conditions / complex needs, at a high risk of
unplanned hospital admission. It is anticipated this targeted intervention of patients will
improve access to GMS services as a large cohort of patients will be managed proactively
and not reactively. This will enable practices to manage workload more effectively and
create future sustainability. In addition practices will be able to undertake medication
reviews for agreed cohorts of patients in line with Prudent Prescribing principles e.g. poly-
pharmacy, co-production and the promotion of evidence based clinically and cost effective
medicines.
Due to the success of the initative the cluster agreed in their meeting of the 23rd June 2016
that the additional £66,000 for the cluster would be spent on pharmacy hours, and an
additional frailty chronic disease cluster nurse, in order to share the workload with the
existing nurse. These additional posts will be on a temporary basis for the next 18 months
as there was roll-over of budgets from last year which will support this financially for this
required this length of time and potentially longer.
The cluster advanced practitioner paramedic had been offered a permanent position - a
consequence of this was the funding allocated for this post became available in April for
consideration by the cluster again. It was agreed that the current cluster pharmacists
should be offered an additional day a week to ensure appropriate use of this unexpected
available finance.
One of our part-time (2 days a week) cluster frailty and chronic conditions pharmacists
obtained promotion following a successful interview and will return to secondary care on a
permanent basis in September.
What is the progress?

Practice development plans were received on the 30th June 2016, there were no significant
changes in the plans this year to what had been previously indicated.
Cluster staff met with Carolyn Poulter from Mid & West Wales Regional Co-ordinator
Wales Centre for Pharmacy Professional Education and the cluster pharmacists have
provisionally agreed to work closely with her to undertake potentially train the trainers on
AIT training with care homes etc.
Further develop their role working with community pharmacy and GPs. Working with GPs
and pharmacists to see how they can undertake some of the minor ailments work currently
seen at GP practices and also look at improving the use with feedback on MURs.
Potentially publishing the outcomes of the work the pharmacist has undertaken and to
make use of all the information gathered to date.
Pharmacists continue to undertake interventions at care homes; cost saving of stopping

medications amounting to £5,727.83 for the last quarter.
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Frailty Chronic Disease Cluster Nurse
All care homes received their training. Feedback has been positive and the care staff very
motivated to increase their knowledge. Supplies of urinalysis sticks, microbiology forms
and bottles have been distributed along with the supporting protocol and audit sheets. In
addition to the training session education leaflets for care staff on prevention of urinary
infection and how to correctly take a specimen have been given out for staff to refer to if
they need more guidance. A brief summary discussion has taken place with district nursing
teams who visit the homes weekly of what we covered in case the care staff need further
support until they gain experience in this area.
What are the key learning points?

Staffing cluster posts on temporary or secondments basis whilst attracting staff has not
been without challenges.
Clusters are an unknown entity and in their infancy, staff working alongside General
Medical Services (GMS) providers within the cluster having sustainability issues may have
a bearing on the attractiveness of cluster posts at this time.
The definitive confirmation of funding was not received until June created a loss of
momentum during the month of May which potentially could have contributed to one of the
team leaving for a more secure position as this could not be guaranteed.
Roles are contributing significantly to the pressures of GMS.
Community Pharmacy
There are 20 community pharmacies across Ceredigion who provide a range of essential,
advanced and enhanced services. There is a rise in community pharmacies that are keen
and enthusiastic to develop services within the community and are often best placed to
deliver services for patients providing local access to healthcare without the need for
appointments or to travel. Pharmacy services are available at 16 locations on Saturdays
and up until 3 on Sundays. All 20 pharmacies have a consultation room for patient use,
either for confidential conversations or for specific enhanced services. Two of the
pharmacies, have also achieved the Bronze Level Award for Investors in Carers. Across
Ceredigion, there are a number of pharmacies who have worked with the Health Board
and with the wider community pharmacy agenda to deliver new services. Examples of
services being delivered by community pharmacy in Ceredigion.
Triage and Treat Service

This service allows for accredited pharmacy staff to offer treatment for low level injuries
reducing the need to attend a GP practice or A&E service. There are currently 5
pharmacies offering the service at Aberystwyth, Aberaeron, Cardigan, Aberporth and
Lampeter. Patient feedback continues to be positive. Further training is planned for later in
2016 to increase the number of pharmacies taking part in the service.
11
Community Pharmacy Flu Vaccination Service
13 out of the 20 pharmacies offer an NHS influenza vaccination service for eligible patients
(over 65‟s, those that are in at risk group and Health Board staff). This service provides an
additional access point for patients to receive their flu vaccination. Since the start of the flu
vaccination season on the 1st October, 658 patients have been vaccinated at pharmacies
in Ceredigion. It is expected that the same number of pharmacies will be offering a flu
vaccination service in the 2016/17 season.
Community Pharmacy Smoking Cessation Service

11 pharmacies provide a service in conjunction with Stop Smoking Wales for patients who
wish to give up smoking. This service allows for the free supply of nicotine replacement
therapy (NRT) products, e.g. patches, gum etc. over a 12 week programme. 5 pharmacies
also offer a complete one-stop service of counselling and supply of NRT. The one-stop
service, branded as “I Quit” with Hywel Dda Pharmacies is a relatively new service and the
numbers trained to offer the service is expected to increase by the end of 2016/17.
Return of Patients Sharps

19 of the 20 pharmacies accept 1 litre sharps boxes for safe disposal. This provides good
access for Ceredigion residents.
Emergency hormonal contraception

Half of the pharmacies provide access to the morning after pill (subject to specific criteria),
to women aged 13+. The long opening hours of pharmacies, together with weekend
opening, is vital in areas where access to family planning clinics might be limited.
General Dental Services (GDS)

There are a number of practices across the county that have recently experienced a
shortage of dentists. A number of successful recruitment process have taken place, most
practices expect to return to normal staffing levels by the end of 2016.
Patients that do not have a dentist and seeking routine care, are advised to contact the
Health Board‟s dental services team
Urgent Dental Service – The service remains available locally across the county Monday
to Friday, patients should contact NHS Direct to access, with weekend cover available in
Carmarthenshire and Pembrokeshire only at present, the provision of urgent detal services
at weekends in Ceredigon remains a priority.
General Dental Services – A number of practices have recently taken on new NHS
patients. Patients looking for long term dental care, can contact the Health Board‟s dental
services team for more information.
Community Dental Services maintains it‟s dental service for vulnerable people, from:
 Aberystwyth (North Road Clinic) - 5 days per week
 Cardigan Health Centre - 2 days per week
 Lampeter - 1 day per week.
 Domiciliary care remains available Monday to Friday.
12
The Community Dental Service hopes to relocated from North Road Clinic, into a new
dental surgery to be situated in Bronglais General Hospital site later this year.
Ceredigion Mental Health Services

Transforming Mental Health Project - Awel Deg
The core principle of the Transforming Mental Health Project is the development of an
enhanced community mental health service model, providing improved opportunities within
services for service users and the improvement of access/pathways in to services. An
opportunity has recently arose within Ceredigion to explore the possibility of developing
Awel Deg, Llandysul, as a mental health centre, adhering to the key principles of the
project.
Currently, health and social care services in Ceredigion are delivered from dispersed
settings throughout the County and beyond. The possibilities of co-locating those staff
based in the south of the Ceredigion area into a single, integrated site at Awel Deg, would
provide benefits for Health, Social Care and the service users. These would include
reduced duplication of care, better access to services and efficiency savings from
operating out of a single site. Further, the exploring of enhanced community mental health
service model, in conjunction with partners, would also meet with the requirements of the
Social Services and Wellbeing (Wales) Act 2014, in terms of preventative services, social
enterprises and exploring community asset transfer.As such, a feasibility study has been
commissioned by Ceredigion County Council and the Health Board on the possibilities of
this development.
Older People Mental Health Services

The Older Adult Mental Health (OAMH) Community Team have had their staffing
establishment uplifted in order to ensure they are able to meet the increasing demand for
OAMH services, this includes providing memory assessment services in both the north
and south of the county. The team has been through a period of recruitment and is now
fully established. Designated community psychiatric nurses are linked to GP clusters and
routinely attend multi-disciplinary team meetings and cluster meetings supporting
collaborative and seamless working.
New Welsh Government funding has allowed for the provision of a dedicated specialist
occupational therapy support worker on Enlli ward in BGH, to provide a flexible approach
to provision of meaningful activities for inpatients. Funding has also been provided by
Welsh Government for a dementia support worker based in the county to support patients
for up to 12 months following a diagnosis of dementia; the post is commissioned via the
Alzheimer‟s Society and they work closely with the Ceredigion Memory Assessment
Service team and GP practices.
A funding allocation has been made by Welsh Government to the Health Board to develop
psychiatric liaison services across all the district general hospitals. Current liaison is
provided via the older adult mental health community team with a designated 0.5WTE
liaison nurse and medical support. The psychiatric liaison service is under development
13
and will aim to provide a multi-disciplinary approach to mental health Liaison within
Bronglais hospital. Additionally funding has been allocated to develop a hospital based
flexible resource team within each district general hospital, a funding proposal has been
submitted which outlines the provision of specialist support workers who will provide
training, advice and support to acute care staff in the management of patients with a
dementia or cognitive impairment who present with behaviour that challenges.
Funding Streams
Considerable work has been undertaken due to the opportunities associated with
additional funding streams. The following table illustrates the additional funding streams
for 2016-17 and the projects supported.
Intermediate Care Fund (INTERMEDIATE CARE FUND)

INTERMEDIATE CARE FUND – Supporting older people to maintain their
independence and remain in their own homes
Accessing Alternatives to Admission (AA2A) £339,671
3rd Sector Integration Facilitators £42,732
Ceredigion 3rd Sector Core Community Resource Team (Caring £131,555
Communities)
Interim Placement Scheme (Spot Purchase of Beds) £241,430
Community Falls Clinic £38,043
INTERMEDIATE CARE FUND – Children and adults with learning disabilities and
complex needs
HDUHB Behavioural Intervention (3 County Initiative- funding split in £18,968
line with INTERMEDIATE CARE FUND)
Therapeutic services for patients with learning disabilities and £75,567
complex needs
INTERMEDIATE CARE FUND – Capital (awaiting approval from Welsh Government)
Keeping Ceredigion‟s elderly and vulnerable safe, warm and secure £189,748
in their homes
IT equipment to support INTERMEDIATE CARE FUND and Joint £62,506
working
IMTP
Psychology Service (operating across the 3 Counties and funded by £187,884
Ceredigion)
Community Nursing Service £283,902
Frailty Nurse for North Cluster £46,000
IMPT Primary Care Development Fund
Community Resilience (following on from the work in Llandysul) £30,000
Rural Development Programme
Understanding Dementia in Cardigan and Tregaron (Funding spread over 3 £30,000
years)
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Community Services
Ceredigion Core Community Resource Model
Challenges within inpatient services in Ceredigion initiated changes in the way we deliver
our services, particularly in Cardigan and surrounding area, the emphasis on care closer to
home and the revenue associated with the Integrated medium term plan (IMTP), the
IntermediateCare Fund (ICF) and primary care cluster funding has provided an opportunity
to further change and develop services.
The principles established by Ceredigion Health and Social Care Community Services are
in line with the Social Services and Well-being (Wales) Act, providing integration of teams
and the opportunity for pooled budgets.Key to the development of the community resource
team model in Ceredigion is the Ceredigion Core Community Resource Team (CCCRT).
The Ceredigion Core Community Resource Team (CCCRT) forms part of an integrated
intermediate care service which is paid for through health, social care, Intermediate Care
Fund and external funding. It is a free to the service user at point of use and time limited
to a maximum of six weeks. If ongoing health or social care needs are identified during
this time, referrals to the appropriate health or social care professional will be arranged
with the service user‟s agreement, for which financial charges may be made and an
assessment carried out.
Learning District and

Disabilities Specialist
[CATEGORY
NAME]
Therapies Social Care
Core
Equipment, Teleca
Community
Resource 3rd Sector
re / telehealth
Team
Mental Health Primary care
Specialists /
Diagnostics Consultants
15
Service aims
To maximise independence by providing a time limited targeted intervention following a
specialist therapeutic assessment by a multi-disciplinary team, therefore:
 Reducing dependency on long term domiciliary care;

 Reducing avoidable hospital admission;
 Facilitating timely discharge from acute institutions;
 Reducing admissions to long-term residential or nursing care.
Service objectives
The key objective is to assist people who have reduced independence in their place of
residence as a result of accident, disability, illness or age to achieve their optimum level of
independence, thereby enhancing their quality of life.
Service principles
 To recognise that service users can have complex physical, mental and emotional
needs and to appropriately respond to those needs.
 To recognise that service users may use a range of communication methods to
express themselves.
 To take account of, and be sensitive to, the race, religion and cultural backgrounds
of the service user.
 To recognise the importance of adopting a person centred approach in all
decisions.
 To recognise that some decisions involve risk.
 To maintain the dignity, privacy, confidentiality and human rights of the service user
at all times.
 To establish and maintain close cohesive working between all those involved in the
care of the service user.
Service criteria
Adult residents of Ceredigion (where capacity allows the service may be offered in the Teifi
Valley and into neighbouring authority areas) who:
 Are experiencing a deterioration in the independence and unable to undertake their

usual daily activities due to illness, disability, age or accident;
 Require care;
 Are able to be safely medically managed in their own homes.
All new referrals into the service will go through the Single Point of Access (SPA):
Work and review is underway to consolidate conditions of service and streamline

governance processes, regardless if team members are employed by either Ceredigion
County Council or Hywel Dda University Health Board.
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Cardigan Core Community Nursing Service
This service is managed by an experienced senior nurse. The resource not only gives
additional capacity to the existing community nursing services, but also allows a greater
flexibility of services delivered to ensure timely discharge from hospital or hospital
avoidance. This has included supporting other teams such as the Targeted Intervention
Service, the Ceredigion and Carmarthen Continuing Health Care Teams, Marie Curie,
existing district nursing teams and Tregaron Hospital (capacity to enable training to take
place).
The concept of establishing a flexible service was to understand the demands onto other
services and therefore develop an integrated team which can support other teams as well
as having its own case load.
The service operates across the South Ceredigion Locality and will go as far north as
Aberaeron, east to Lampeter and south into North Pembrokeshire Locality when capacity
allows.
Any Health or Social Care professional may refer into the services. Referrals are reviewed
for appropriateness, completeness of information and then allocated to the team.
Patients are usually active on the team‟s case load up to a maximum of six weeks (in
keeping with other core community resource activity), although exceptions can be made in
assessed circumstances.
Monitoring and review of capacity and workload is on a continuous basis.
Use of the service

In the year before Cardigan Hospital closed, 50 patients were admitted as in-patients.
In the 28 months this service has operated (March 14 – end of July 16) 1754 referrals into
the service have been made for the following purposes:
Hospital
Reason for the referral
avoidance
11%
Palliative
Support hospital
care
discharge
33%
22%
Support the DN
team
34%
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User outcomes
Nursing
care Location for discharge from the team
6% Residential
care
6% DGH
9%
Home
79%
Interim beds
Interim placement scheme
This service is a part of the Community Resource Model of care closer to home and is
known as the Interim Placement Scheme (IPS).
The professional support for the IPS beds is provided by the Community Resource
Nursing, Therapies and Social Care element of the CRT. Since commencement, the
number of beds purchased through the scheme has flexed between four and nine
(additional beds are „spot purchased‟ and funded from (Intermediate Care Fund) to meet
patient demand.
The IPS is managed by two senior community nurses who take referrals into the scheme
from both hospitals (step down) and community (step up). All referrals will be scrutinised
by the two senior nurses who will apply a multi-disciplinary approach, liaising with social
workers and the nursing home to ensure the home can meet patient needs, enabling
timely assessment and joint working associated with discharge planning.
At least by week four, ongoing discharge arrangements will be made as the maximum stay
on the scheme is six weeks.
There is no cost to the service user.
User outcomes
Just over 100 patients have used the scheme from March 2014 – (end of) June 2016.
Those patients were discharged to the following locations:
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IPS Location for Discharge March 2015
- June 2016
Residential
Care
6%
RIP
DGH 12%
5%
Nursing care
45%
Home
32%
These patients would have occupied a hospital bed if the scheme had not been
operational and their outcomes may well have differed detrimentally as a result.
The opportunity of enabling timely assessment ensures the patient is discharged to the
most appropriate location to meet their needs.
The process has demonstrated that the Health Board continues to support the patient and
their family when the location of care is stepped down from the acute care and into the
community.
Interim assessment beds

Work is well underway with Ceredigion County Council to introduce interim assessment
beds in a limited amount of council run residential homes.
The process for managing the beds will mirror that for the interim placement scheme,
however these patient needs will be more around acts of daily living rather than nursing
needs.
It is anticipated that a limit number of beds will be available from October 2016.
Community nursing
Nurse leads for the cluster areas
The two nurses are in post and are embedded in the community structure andthey are
funded through the IMTP framework.
Preliminary work associated with their roles is being strengthened:

 Multi Disiplinary Team – Bronglais General Hospital asssessmet paperwork been
utilised and complex discharge pathways are being developed. These tracks
progress against all patients requiring community care and safe transfer of care on
discharge;
 Communication has improved between acute and community services which has
assisted patient flow and timely discharge;
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 These posts are critical in the effective co-ordination of community services
including the operational management and governance of the community nurses;
 To reflect the extended nursing service available in the South Ceredigion Locality it
is anticipated that the community nursing service in the north will develop in the
next year. The extended service available in the South Ceredigion Locality has
demonstrate a positive impact for patients by supporting timely discharge,
avoidance of unnecessary admissions to hospital, improved access to palliative and
end of life care services;
 Cross border working – to improve on patient flow for patients out of Bronglais
General Hospital back to Powys and Gwynedd fortnightly meetings have been
established to ensure improved communication. The aim of the meetings is to
improve patient flow with the aim of reducing inappropriate bed use, assist with
repatriation and to discuss individual patients. This work contributing to the various
work streams associated to the Mid Wales collaborative;
 Meetings with Welsh Ambulance Service Trust (WAST) have commenced to look at
frequent attendees to A&E. Also looking at potential patient pathways with primary
care for those patients who are regularly calling out ambulances and are being
taken to A&E;
 GP MDT‟s – A programme of MDT‟s have been developed across a number of GP
practices within the North and South Localities in Ceredigion;
 Community resource integration of organisations – The nursing team will become
core elements of the integrated community CRT both North and South Localities.
This will involve a host of disciplines, integrated line management, central referral
process, care management and care planning. This involves the re-alignment of
existing teams, e.g. acute response team, core community nursing, social care,
domiciliary care and therapies to develop this integrated model of service.
Community Nursing Cluster Teams

These two roles are critical for the care co-ordination of patients. They are funded through
the IMTP framework. The nurses are now in post.
The south of the county post provides a co-ordination function between district nursing
service and the core community team.
The role strengthens and supports primary care with MDT working.
It provides ongoing support of the management of the leg clubs and the overseesthe
management of complex care in the community.
It ensures that services are maintained in the absence of the team leader.
Community Nurse Posts

The purposes of these roles are to increase capacity in order to deliver the community
resource service. It is funded through the IMTP framework. The aim of the role is to:
 Provide an additional resource to ensure care closer to home is avaialble;

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 Support additional clinics that are being provided within community nursing to
support primary care services.
Frailty and Chronic Disease Nurse Posts

The post is funded through the IMTP framework.
The aim of this post is to work with the North Primary Care Locality to case manage an
identified group of people with long term conditions / complex needs, at a high risk of
unplanned hospital admission with the aim of reducing unplanned admissions and
improving health outcomes for that group.
Additional Clinical Services

Home oxygen service
As part of the Hywel Dda UHB home oxygen service there exists two community
respiratory specialist nurses who look after those people on home oxygen in the
community and any difficult cases of COPD.
 North Ceredigion 0.8 WTE – Number of patients on Caseload = 112
 South Ceredigion 1.0WTE - Number of patients on Caseload = 145
Minor Injuries Unit

The Minor injuries unit in Cardigan (MIU) has been historically staffed with one emergency
nurse practitioner (ENP) per day. However, following a dramatic increase in attendances
during 2015-16 and to provide more care closer to home, a decision was taken to move
towards having two ENP‟s on duty per day. This not only ensures safer care by relieving
the workload on individual ENP‟s however also provides peer support and reduces the
risks associated with isolated working.
The recruitment process is now completed and additional ENP‟s are now in post.
Unfortunatly due to sickness and bereavement the MIU has been limited during the last
few months. Plans are in place to rreinstate a full service on an incremental basis over
September 2016. It is acknowledged that further recruitment is required to enable
extended hours going into the new model which will be delivered form the new Integrated
Care Center.
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Cardigan MIU attendees
350
300
250
200
150
100
50
0
Total attenders New adults New children
The following chart demonstrates the reason for attendence and how it was managed:
300
250
200
X-ray requested
150 Escalated
Managed by MIU
100
Deescalated
50 Inappropriate attenders
0
Oct-14
Oct-15
Jan-14
Jan-15
Jan-16
Jul-14
Jul-15
Jul-16
Apr-14
Apr-15
Apr-16
As demonstarted in the table above the majority of patient cases were managed in their
entirity by the MIU. The red escalated line is where the patient was sent on to A&E, onto a
DGH or video conference with acute sites was used to support patient care. The purple
de-escalation line potrays the position after initial examination whenthe patient was
advised to see their own GP, practice nurse or clinic. X-ray requestshave been singled out
due to the prevailing volume.
Leg Ulcer Clinic

Leg ulcer clinic have been developed in North and South Ceredigion Localities in response
to GP practices reducing wound management treatment at their surgeries, which was
provided to non housebound patients.
The Aberystwyth clinicserves 7 surgeries in the north and is held in a Local Authority
residential home.The Cardigan clinic, which was the pilot, serves 7 surgeries in the south
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with the Aberaeron area overlapping both clubs. The south clinic is held at Cardigan
Hospital.North PembrokeshireLocality patients also have access to the Cardigan clinic.
The leg clinics are manned by district nurses who have a rota to ensure equality
throughout the teams. Thus providing a safe environment for training and personal
development. Both clinics are supported by a community tissue viability nurse.
Trials have been carried out under the supervision of the tissue viability nurse which has
been positive in the healing process.
Questionnaires have provided the clubs with positive feedback which has enabled the
teams to develop the services.
Aberystwyth Cardigan
Referrals in 55 108
Discharged 26 26
Healed/PN/DN
RIP 1 2
Total contact to date 1,248 2,020
DNA or non concordance 0 19
Skin care discharged to carers 2 0
Tregaron Community Hospital

The nursing team are fully engaged and building on skills required in preparation for the
delivery of services in the community, within the community resource team model. The
ward consistently meets high standards in a range of audits including HIW audits, 100%
compliance with PADR.
The throughput and length of stay of patients has improved considerably with a length of
stay averaging 18 days compaired to an average of 25 in 2014-15. This demonstrates the
efficiency of the service, providing a good focus on clincal outcomes and early discharge
planning from the hospital.
Psychological services in long term condition management

A strong evidence base indicates mental health difficulties in chronic conditions
significantly impacts self-management and results in poorer health and increased health
care use. Prevalence studies of co-morbid psychological difficulties with chronic conditions
report between 45-75% incidence of depression with chronic conditions. This increases as
the number of condition a person has increases.
Ceredigion host this Three County Psychogical Service and the IMTP funding has
provided additional resources. This recruitment process is underway. Three psychologists
will be operational by March 2017 with a consultant psychology lead.
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The population concerned is large; therefore the development of a uni-directional referral
system to specialist psychologists would be both unsustainable and impossible as demand
would drastically outweigh capacity. The strategic vision is to develop low intensity
psychological skills within existing health, social care and third sector workforce to help
meet the demand.
Over the past year the consultant lead has been involved in strategic planning and service
developments whilst piloting certain areas of work for proof of concept. One pilot study
demonstrated positive clinical and cost outcomes through training the existing workforce to
improve depression in chronic conditions to meet NICE guidelines (CG91) for
psychological treatment of depression within long term conditions.
Objectives for the service in the first year 2016/17 are as follows;
Development of the service to raise awarness and the profile of psychological issues
within those with chronic conditions, particularly in relation to the impact on self-
management and the level of demand on health and social care within primary care,
community care, and secondary medical services.
Develop networks across sectors of care and integrate psychological services into delivery
plans.
Continue to develop links between Welsh Government (major health conditions division) to
strengthen the strategic direction.
Improve access to psychological services, by developing a stepped care model,this will

allow the minimum intervention and early intervention. This will commence within primary
and community services, providing the skills for professionals to apply at an early stage,
with access to specialist psychological services as required.
A training and supervision model will be introduced, providing low-intensity psychological

approaches that can be delivered more effectively by a range of professionals working with
individuals with chronic conditions.
This will be introduced on the basis of previous and existing examples of work and will be
extended to the three counties. Existing examples include the following:
 As a result of an earlier pilot training scheme, a number of professionals continue to

recieve group consultation and supervision, including chronic condition nurses in
Pembrokesire and respiratory specialist nurses in Carmarthenshire;
 Continued working with the occupational therapy team in Carmarthenshire, for
those patients with cardiac and repiratory conditions.Psychology input into multi-
disciplinary meetings within the community resource team in Carmarthenshire, to
enhance the holistic approach to care through psycholgocial formulation
development;
 Continued scope for the development of psychological services in specific areas of
health care, including:
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o Chronic pain service, following the recent appointment of a specialist pain
psychologist,input will assist in the transformation of this service;
o Obesity service, where recruitment is in progress;
o Smoking cessation, consultation is integrated into he business case to
enhance the governance of psychological practice.
Sustainable Communities
Falls Clinics
Intermediate Care Fund funding has been obtained to pilot community falls clinics across
Ceredigion. The clinics will be therapy led and supported by health care support workers
and medicines management. The Intermediate Care Fund is also being used to increase
capacity with the National Exercise on Referral Postural Stability Instruction programme
which is a 48 week programme designed specifically for patients who fall.
The pilot clinics will run for a year to determine the value and uptake to this vulnerable
group of patients. The key performance indicator is to stabilise the number of fractured
neck of femurs in Ceredigion which has been on the rise in previous years.
Keeping Ceredigion‟s elderly and vulnerable safe, warm and secure in their homes
Funding has been sought through 2016-17 Intermediate Care Fund to support a new
initiative which will bridge some of the gaps in accommodation based solutions.
The aim of the programme is to provide accommodation based solutions, including access
to vulnerable people‟s homes through assessing the safety and suitability of these homes
(privately owned, privately rented and social rented) which will ultimately reduce demands
and costs on the NHS and social care services; the programme works across the statutory
and 3rd sector provisions.
The provision will offer a seamless service across statutory and 3rd sector whereby
patients / vulnerable people may access differing routes to access home safety
assessments, benefits checks and financial assistance depending upon tenure. This
scheme enables the statutory provider and the 3rd sector to work together to determine
the most appropriate pathway to meet individual needs thus preventing admissions to
hospital and demands on community and social care services as well as assisting early
discharge.
The county is still awaiting approval from Welsh Government for the scheme.
Llandysul
Communities in Ceredigion require some support and further encouragement to enable
them to become more self-resilient. There is also a shift in legislative direction following
the implementation of the Wellbeing of Future Generations Act 2015 and Social Services
and Wellbeing Act 2014. The principles and goals in both Acts are comparable and
challenge us to design and deliver services embracing the following principles;
Long term thinking – balancing short-term pressures with long-term needs;

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Co-production – placing people and communities at the centre of decision making which
affect their well-being and reflect diversity and uniqueness of community assets;
Collaboration – strong working relationships between key organisations and consider the
impact of decisions on others.
The way we engage with our communities to co-design and co-deliver sustainable frontline
services needs to transform to meet this challenge.
Primary Care Development Fund for the Public Health Directorate of the Health Board
enabled a pilot to take place to engage with the community, identify community resilience
and consider the possibility of community asset transfer and sustainable and effective
service re-design.
A small cross organisational group made up of representation from Hywel Dda University
Health Board, Ceredigion County Council and Ceredigion Association of Voluntary
Organisations was established to drive the project forward. Although it was agreed to
focus the work of the pilot in Llandysul, it is anticipated that the lessons learned will be
transferable to other communities and the results of this work will inform the redesign of
services - placing local citizens at the heart of their design and delivery.
Key findings
When considering past and present approaches taken to implement essential changes in
public services and positive protenial of co-designing sustainable services with the
community, the following principles became apparent.
Positive Communication
We need to listen intensely to our communities and understand that all voices matter.
Investing time in talking to residents helps us gain a better understanding of what matters
to the community and generates enough trust between service provider and service
recipient to start the journey of supporting and transforming recipients to become the
designers and deliverers of services. Understanding public resistance and having an
informed dialogue will help mobilise the community to work alongside, rather than against,
decision makers and will present an opportunity to change behaviours.
Conversations with the community need to start at the earliest possible opportunity, before
any decision has been made. If we want residents to be part of the solution and make a
contribution as experts through experience they need to understand the situation, be
presented with full and accurate facts and be considered as critical friends and equal
partners from the outset.
In an age where our lives are being transformed by new digital developments, sharing
relevant up-to-date information with the wider public continues to be a challenge.
Improved tools need to be considered to ensure that citizens are aware of the services
available to support them and their neighbours and to promote events and activities. An
improved communication framework could also be used as a platform to share key
messages with communities.
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Recommendations:
 The value of conversations is immense, time needs to be invested to truly
understand and explore what matters to people and why. On occasion this may
best be done by an impartial body with an understanding of the situation who can
gain the trust and respect of the community.
 Early, honest and positive conversations need to be held with the community before
any decisions are taken to explore opportunities.
 Accurate facts and figures need to be shared with key community activators to
ensure that informed decisions can be made and robust business plans developed.
Palliative Care
We continue to work in partnership with Seven Hospice and Marie Curie in delivering
hospice at home services across Ceredigion. In July 2016 Seven Hospice appointed six
Hospice at Home health care support workers, who will work alongside the specialist
palliative care multidisciplinary team in Ceredigion to provide the hospice at home service.
Training has been provided by the palliative care team into independent nursing homes in
north Ceredigion to strengthen links and work together to deliver care in the appropriate
place. It is anticipated this training programme will be rolled out across Ceredigion and will
also include residential homes.
Care decisions for the last days of life training to primary, secondary and private sector are
ongoing and to date a total of 129 health and social care professionals have undertaken
the training.
Partnership working
Ceredigion has established a subgroup of the Health Social Care and Wellbeing Executive
Group to oversee the Intermediate Care Fund funding process. The panel is made up of
representatives from:
 HDUHB County Management Team

 Ceredigion County Council Social Care Commissioning team
 Ceredigion County Council Housing and Environmental Health Team
 Ceredigion Association of Voluntary Organisations (CAVO)
With equal representation from both HDUHB and Ceredigion County Council.
This panel has terms of reference and reports to the Health Social Care and Wellbeing
Executive Board and ultimately to the newly formed Public Service Board. It reviews all
applications associated with the Intermediate Care Fund, and agrees which will be
supported and which will not. The panel documents all decisions and supporting rationale.
This framework enables joint productive working and shared, sustainable responsibility for
the decisions associated with Intermediate Care Fund regardless of which organisation (in
that particular year) is responsible for drawing the money down.
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The panel also has responsibilities associated with monitoring and evaluation of schemes
funded through Intermediate Care Fund.
Syrian refugees
Ceredigion was the first county in Hywel Dda to welcome the resettlement of Syrian
refugees and one of the first in Wales.
In December 2015 eleven Syrian refugees arrived following joint working across HDUHB,
the Local Authority, Registered Social Landlords and the 3rd Sector.
Primary care welcomed the refugees‟ despite the LES not being established at that point.
Mental health services have been supported by volunteers to help with translation during
sessions and an SBAR report has been raised in the anticipation that some of the funding
available to secondary care can be used for mental health translation services in order to
have a sustainable model.
Therapeutic services for patients with learning disabilities and complex needs
Funding has been agreed through the Intermediate Care Fund framework for a scheme
which aims to provide practical activities to enable patients / clients to cope better with
living in the community, offering people the opportunity to build their self-confidence and
skills in order to move on to access mainstream social, educational and employment
services. For some it offers a stepping stone for people to re-build their lives. The scheme
will be managed by CAVO (Ceredigion Association for Voluntary Organisations).
The funding will enable Ceredigion to offer therapeutic services such as arts, crafts and
dance to LD clients across Ceredigion. New services will need to be sustainable and
equitable. The baseline is low; therefore progress can only be made by piloting solutions
with pump priming.
Intermediate Care Fund funding will enable third sector services to work up and test
delivery methods which meet the overall aims. The schemes will be fully evaluated to
determine appropriate models of service delivery which meet needs and embrace
community resilience.
Understanding Dementia in Cardigan and Tregaron

Background
Intergenerational Community Resilience was identified as a priority theme of Hywel Dda
University Health Board‟s Foundation 4 Change programme and work stream of
Ceredigion‟s Older People‟s Partnership. With key health and social care developments in
two locations in Ceredigion, an opportunity was established to promote dementia friends in
these two towns and supporting them to become dementia supportive. A crucial element
of this project seeks to establish how perceptions of dementia and experiences of those
living with dementia and their carers alter over a 3 year period.
Funding has been secured from the Rural Development Programme to support this
project.
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Aims
The project aims to ensure individuals living with dementia and their carers are able to
continue to feel part of their community. It sets out to establish what elements work well in
relation to raising awareness of dementia and how experiences differ through the course
of the project.
Through improving awareness of dementia and the supporting services available, it is

hoped that there is a positive shift in accessing early intervention and timely referral onto
appropriate serves. This will contribute to continued independent living and use of their
towns and local services, helping those living with dementia and their carers, to continue to
feel part of their community. In so doing, this will prevent unnecessary deterioration in
health that could create a need for increased care.
Practice undertaken
The person and community are placed at the centre of the process through engaging with
service users and their carers, encouraging participation in a baseline assessment. This
will establish how they currently perceive their communities, recording their experiences
and explore how this changes over time. Furthermore, following focused work within these
communities to raise awareness of dementia and challenging any stigma associated with
dementia; an additional survey will be undertaken with local residents and businesses to
establish how their opinions and behaviours change over the course of the 3 year project.
Key to this is, is delivery of the Alzheimer Society‟s dementia friends information sessions
and increasing the number of dementia champions in the county. With the intention that
this will be a sustainable way in which to continue with the dementia friends work and
make the communities more resilient over time.
Results / Outcome
The project was formally recognized as a community project in June 2016 and partnership
has been created with Aberystwyth University, the Health Board, Local Authority,
Ceredigion‟s Association of Voluntary Organisations and Alzheimer‟s Society to enhance
the work with both communities.
Mid Wales Collaborative

Work streams within the Mid Wales Collaborative are beginning to gain momentum.
Ceredigion County Management Team is leading the following priority areas:
 Establishing an enhanced community focussed service which support the timely

discharge / transfer of „medically fit‟ patients from Bronglais Hospital;
 Establishing an Admiral Nursing Service for those with dementia in the MWHC
area.
Ceredigion Management Team is involved with the following priority areas:
 Up-skilling the primary care workforce to help deal with the increasing pressures
relating to the management of long-term conditions;
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 Establishing the role of Physician Associate across the MWHC area;
 Rolling out the concept of the „virtual ward‟ to all parts of the MWHC area;
 Establishing an integrated community focussed dental service across the MWHC
area;
 Supporting further development of community pharmacist independent prescribing
in the MWHC area;
 Establishing an optometry led ophthalmology triage service in Mid Wales.
Cross Boarder Discharge Liaison Nurse

Funding has been secured to employ a discharge liaison nurse to support discharges from
Bronglais General Hospital back into Powys. The joint post will not only enable timely
transfers of care, however also enable a better communication of the challenges facing
both organisations.
Technology Enabled Care

Within the Mid Wales collaborative there is a sub group established to support the
implantation of telehealth and telemedicine. Currently there is a trial with Borth surgery
using technology to allow lesions and moles to be assessed remotely by trained GPSIs
and plans to further develop this are under discussion.
Pocket medic digital self-management films licence has been bought by the North
Ceredigion Primary Care Locality and all GPs signed up to prescribing these films. They
include Type 2 diabetes, COPD, anxiety and depression, living well after cancer. South
Ceredigion Locality GP‟s have access to Type 2 diabetes films as the licence for these has
been bought on an All Wales basis.
Funding has been received to explore providing pulmonary rehabilitation using

telemedicine into the north Ceredigion area in Tregaron.
Capital Schemes
Cylch Caron Project
The Cylch Caron Project is a joint project between Hywel Dda University Health Board and
Ceredigion County Council, being managed by the Ceredigion Local Service Board. It
brings together primary and community health care services, social care and housing
services in a very rural part of Ceredigion.
Objectives:
 To provide a service that supports independent living through the provision of
accessible high quality care and support services for the Cylch Caron population;
 To reduce the necessary health and social care spend per capita through an
enabling care and support service;
 To improve within existing revenue, the level of activity, range of needs and
increased numbers of people receiving a service;
 To deliver a leaner model with sustainable services for a deeply rural population
that can accommodate the projected increase in demand for services from the 65
30
and over population which is set to increase from 27% of the Cylch Caron
population in 2014 to 31% by 2026;
 To meet appropriate care standards, legislative standards and energy efficiency
standards.
Project Benefits:
 Provides a multi agency community resource model responsive to the health, care
and housing needs of the Tregaron community today and for future generations;
 Provides a model that will also work with the community, 3rd and private sector to
develop resilience and wellbeing within the community;
 Provides asustainable innovative partnership approach to service delivery designed
around the needs of the individual, bringing services to people rather than people to
services in the rural heartland of Ceredigion.
Developments and achievements this month:

 Tender evaluation and report to Cabinet complete;
 Appointment of delivery partner;
 Initial meeting with delivery partner.
Targets for next month:

 Procure design team and develop design
 Commence detailed design work.
Cardigan Integrated Care Project

The new integrated care centre, located on the Bathhouse site, will provide a modern, fit
for purpose healthcare service for the local population, bringing care closer to home and in
the community. A wide range of integrated health and social care services will be delivered
by Hywel Dda University Health Board, GP‟s, the third sector, local authority and partner
organisations. The new facility will replace the existing Cardigan Hospital and Cardigan
Health Centre.
Objectives:
 Provide appropriate service capacity
 Facilitate delivery of new care model
 Improve local access to services
 Provide a high quality physical environment
 Others as included within the full business case
Project Dependencies:
 Approval of the full business case by Welsh Government/confirmation of All Wales
capital funding
 Resolution of issues regarding adjoining site
Developments and achievements this month:

 Discussions on going with adjoining site landowner and HB legal advisors
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 Full business case scrutiny questions responses sent to Welsh Government.
 Excellent feedback received from the Welsh Government Gateway Review Team
 Ongoing capital project audit
 Planned benefits realisation workshop undertaken
 Discussions regarding future proofing primary care provision with Ashleigh GP
Surgery
Targets for next month:

 Update the Health Board regarding on going discussions
 Completion of benefits realisation register and submission to Welsh Government
 Executive meeting between Hywel Dda UHB and adjoining property owners
Risks
Impact on project timescales resulting from issues regarding additional ground
investigation work and ongoing discussions with landowner.
Risk mitigation
Discussions remain on going with the landowner. The Health Board are working in
partnership with the adjacent landowners to ensure that any necessary corrective work is
carried out to ensure the site is safe for the new development and minimise impact on
project timescales.
Aberaeron Hospital
Aberaeron Hospital is located near the centre of Ceredigion and sits in the North
Ceredigion Locality. It has been recognised for some time that Aberaeron Hospital as a
facility is not fit for purpose and not conducive to the provision of modern day health care
provision.
A staged approach has been adopted to address some of the issues identified. The first
stage will see the relocate of staff from the first floor of the building to Felin Fach.
Community outpatients‟ services will continue to be delivered from the ground floor of the
building but a scoping exercise is been undetaken looking at alternative sites within the
Aberaeron area.The model of community services developed for Ceredigion reinforces the
need for services to remain in the Aberaeron area.
Bridging between community and acute services

Assessing alternatives to admission (AA2A)
The Accessing Alternatives to Admission team are funded through Intermediate Care Fund
and are based in Bronglais Hospital.
Purpose
To facilitate the continued development and implementation of an effective pathway within
Ceredigion‟s acute general hospital for vulnerable adults. This acknowledges the
significant risk of permanent loss of function associated with vulnerable adults being
admitted to an acute general hospital and that morbidity and mortality increases with long
32
lengths of stay. Moreover, the complex discharge planning and care requirements can also
further impact on long lengths of stay and hence compromise patient flow and
organisational performance.
Prevent hospital admission at the front door for vulnerable adults who require rapid MDT
assessment and community support to mitigate immediate risk and longer term problem
solving of their co-morbidity and functional decline.
Reduce length of stay by adopting a co-ordinated approach to problem solving, care co-
ordination (supporting comprehensive assessment). Acknowledging that for some people
admission may not lead to a change in long term medical management, but can pose
significant risk of long term reduction in functional ability (increased dependency), to
support a minimalist (prudent) approach to admission.
The work will align with the primary care MDT approach to ensure a holistic approach to
the patient journey.
Approach
The AA2A is a multidisciplinary approach to supporting staff and patients to safely avoid
hospital admission if there is not a medical need and to safely support timely discharge.
The service is made up of:

 A discharge liaison nurse
 Health care support workers
And is supported by:
 Pharmacy (currently being recruited)
 Physiotherapist
 Occupational therapists
 Community nurse
 3rd Sector integration facilitator - formally known as 3rdsector broker
 Social worker (currently being recruited)
 Assessing / Review Officer (currently being recruited)
The overall responsibility of patient care and discharge remains the responsibility of the
ward and consultant with the AA2A resource enabling access to a breadth of community
services.
The MDT will meet twice a day for an hour to discuss patients. These two meetings will
take place every day, seven days a week.
The purpose of the meeting is to discuss patients where the AA2A input will be pivotal to
ensuring the patient is being cared for in the appropriate place of care in a timely fashion; it
will not be to discuss all patient discharges or where a full MDT approach is not required.
The outcome of each patient discussed will be an action plan with specific timed actions to
be documented and allocated to any of the professions within the AA2A or the ward staff.
33
Criteria
The patients whom the AA2A will discuss are as follows:
 For patients attending the Clinical Decision Unit;
 Who are an adult resident in Ceredigion, Gwynedd or Powys;
 Who do not require admittance on medical grounds;
 Who do not have challenging behaviour due to delirium, dementia or confusion;
 Where there is a concern about them going home because of personal safety and /
or who require immediate multidisciplinary planning to meet their ongoing care
needs due to a change in their functional ability or change in their personal
circumstance.
For patients who have been admitted into hospital and have been identified by the wards
as being a complex multidisciplinary discharge due to:
 Changes in their functional ability or change in personal circumstances or;
 Complex planning and delivery to meet ongoing care needs.
Complex discharge pathways

Complex discharge pathways have been developed and enable a framework for
structuring the timeframe for actions across acute, community and social care services.
Inter-agency development of the pathways has enabled improved communications
between the department/agencies to better understand challenges and work together to
overcome them.
Introduction of the pathways will enable monitoring of adherence associated with tasks.
Ceredigion has led the development of these pathways which are set to be trialled on two
wards in Bronglais Hospital from mid-September 2016.
Dashboards
Three county dashboards have been developed and introduced at county level. The
dashboards are made up of:
 Daily, with information relating to:

o Bronglais Hospital (supplied by the AA2A team)
o Community bed availability (collated by the AA2A team)
 Weekly, with information relating to:
o Targeted Intervention Team (collated by Social Services)
o AA2A (collated by the AA2A team)
o Interim placement scheme (information collated by Ceredigion County
Management Team)
o Joint Care Beds (information supplied by Social Services and collated by
Ceredigion County Management Team)
o District nursing and Acute Response Team (with all teams supplying
information and collated by Ceredigion County Management Team)
o Tregaron Hospital
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 Monthly, with information relating to:
o Complaints, incidents, risks (collated by the County Management Team)
o Staffing (collated by the County Management Team and human resources)
o Targeted Intervention Team (collated by Social Services)
o Interim placement scheme (information collated by County Management
Team)
o Joint Care Beds (information supplied by Social Services and collated by
Ceredigion County Management Team)
o AA2A (collated by the AA2A team)
o District nursing and Acute Response Team (with all teams supplying
information and collated by Ceredigion County Management Team)
o Tregaron Hospital
Systems are being developed to enable full data collection.
Ceredigion Social Services are one of the first counties to implement the Wales
Community Care Information System (WCCIS) in Wales. The system will allow the
reduction of data duplication thus increase the capacity in services such as the Core
Community Resource Team in time, however as with any change in core IT infrastructure,
challenges and delays have been associated with producing consistent reporting for the
dashboards. WCCIS was introduced in August 2016, it is anticipated that the teething
troubles will be overcome over the next few months.
Frequent Fallers, Callers and Flyers Group

A group made up of:
 Welsh Ambulance Service Trust (WAST)

 Police Community Safety Partnership
 Hywel Dda University Health Board (HDUHB) Community Clinical Nurse Leads
 HDUHB Bronglais General Hospital Unscheduled Care Services / Accessing
Alternatives to Admission
 Ceredigion County Council (CCC) Adult Social Services
 North Ceredigion Primary Care Locality Practice Manager Lead
 HDUHB Ceredigion County Management Team
 HDUHB Mental Health Team
Has been established with the following aims:

 Identification of service users who are common to more than one of the emergency
and care services in order to ensure appropriate services co-ordinate an individual
care plan.
 Safeguarding both vulnerable patients and staff by improving inter-agency / service
information sharing through a transparent process.
The group is meeting monthly and is currently involved with:
 Developing a Welsh Accord for Sharing Persional Information (WASPI) Information
Sharing Protocol (ISP) to enable transparent information exchance;
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 Working with the North Locality Primary Care group and a residential home to
identify trends and work together to determine solutions.
„Home of Choice‟ policy

Ceredigion has led the work on the „Home of Choice‟ Policy which is now being considered
at executive level within the Health Board. It is anticipated that the „home of choice‟ policy
will reduce the delayed transfers of care associated with patient / carers either being
indicate around which home they wish to go to or alternatively waiting for a specific bed to
become available.
This policy will utilise the interim assessment beds and interim placement schemes.
Information Technology to support management information

Funding has been sought from Intermediate Care Fund to supply both hardware and
training for initiatives either funded by Intermediate Care Fund or services which are jointly
operated such as Core Community Resource Teams.
The new Welsh Community Care Information System will enable existing joint managed
project to work more effectively but only with access to the system. For example the AA2A
service would work more efficiently if staff assessing patients at the front door had access
to the WCCIS system in order to support this assessment by having background
information, this can be achieved with the purchase of tables as well as awareness raising
/ training on the new system. This access will also enable the team to have real time
access to DEWIS and signpost into the 3rd sector.
Whilst a bid for Intermediate Care Fund funding to support access to IT has been made,
Ceredigion is currently awaiting a decision from Welsh Government as to its allocation.
Occupational Therapy Services in Ceredigion

Occupational therapy in Hywel Dda University Health Board is managed as a three county
service, professionally led by single head of service and hosted in Ceredigion County. The
service covers a range of specialties, encompassing services across adults, children‟s,
acute, community, mental health and learning disability services and incorporates
specialist as well as generalist areas of practice.
Occupational therapy services in Ceredigion have been developed over time and in
response to local initiatives and drivers to address user needs and supports county
developments across acute care, primary care, CRT‟s, interim and community beds as
well as being integral to developments within mental health services. A focus on proactive
care and developments regarding integrated community resource teams are informing the
future model of occupational therapy provision in the county with the aim of improved user
outcomes and experience.
Occupational therapy service aims to;
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 Undertake functional assessments – provision of rehabilitation; any necessary
equipment, and adaptations to address functional decline across settings and
specialities / diagnostic pathways;
 By addressing functional deterioration, maximize / maintain independence in
preferred home environment and resolve health and social issues at an early stage,
therefore minimizing crisis situations that result in hospital admission;
 Prevention of falls / other injuries;
 Prevention of unnecessary hospital admissions;
 Provide self-management strategies for chronic conditions, empowering individuals
to manage their health conditions;
 Improve access to occupational therapy in primary care that truly prioritizes
prevention and support for maintaining independence;
 By offering proactive input to help people manage their conditions stay as active as
possible and continue with their daily lives;
 Working in partnership with other professionals to help respond to crises in the
home and prevent unnecessary hospital admissions;
 Support the delivery of integrated intervention for people with dementia and support
early identification of needs.
Update on current developments

 Occupational therapy services have been established at the front door of all 4 acute
hospitals, including Bronglais Hospital. Working as part of the team funded by
Intermediate Care Fund, Assessing Alternatives to Admission (AA2A), occupational
therapists have provided a new service to A&E/CDU focussing on development of
frailty pathway, supporting comprehensive multidisciplinary assessment to reduce
unnecessary acute admissions and supporting people to return to and remain at
home.
 Supporting reduced length of stay for those admitted to hospital:
o Enabling people to remain independent whilst in acute care
o Developing partnership working with over border occupational therapy
services i.e. Powys and Gwynedd
o Contributing to the provision of integrated proactive primary care which can
reduce the strain on local health services as core members of frailty MDTs in
the South Ceredigion Locality
o Working with mental health services to establish occupational therapy as part
of psychiatric liaison service in Bronglais Hospital.
o Developing a Health Board wide specialist community neuro-rehabilitation
team, supported by occupational therapist for neurological rehabilitation in
Ceredigion, delivering care closer to home.
 Delivery of specialist stroke and neurological training at Hywel Dda UHB, including
Ceredigion, supported by a successful bid to the Welsh Stroke Flexibilities Fund.
o Successful recruitment to vacant posts. 2 x longstanding vacancies filled in
2015/16 with no advertised vacancy remaining unfilled in acute and
community services at end of March 2016.
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 Level 3 Diploma in occupational therapy support established as preferred training
programme, with support staff in Ceredigion undertaking the programme. This
supports the Health Board to meet requirements of NHS Wales Developing
Excellence in Healthcare framework.
Acute Services in Ceredigion

As previously reported, the location of acute services in Ceredigion and significant
distance from the next acute centre in any direction requires Bronglais Hospital and North
Road Clinic in Aberystwyth to provide a broad range of services to remote rural
populations in Ceredigion, Powys and Gwynedd.
The priority for the service is to maintain 24/7 emergency medical and surgical services to
ensure patients receive timely, life-saving treatment and the emerging clinical strategy for
the site will help direct investment to deliver this requirement.
Updates on developments and progress since the last report to Board in January 2016 are
set out below.
Consultant Recruitment
There were a considerable number of hits on the consultant posts advertised in January
and the Health Board appointed substantively to the surgical physician post.
Work has commenced on re-branding Bronglais General Hospital in the context of its
clinical success, work/life balance opportunities and the uniqueness of the roles that a
remote site offers. A recent workshop collaborative with Aberystwyth University, the Mid
Wales Health Care Collaborative, local partner organisations and Welsh Government
explored opportunities for partnership and there is significant potential to offer research
opportunities as part of consultant job plans which would increase the attractiveness of the
posts.
Physician Associates
Bronglais General Hospital has established a link with Birmingham University and is now
providing clinical attachments for training physician associates (PAs) and is the first
hospital in Wales to become involved in this training programme. Additional training
programmes will be established in Wales in the autumn with Hywel Dda linking with
Swansea University to provide clinical placements in primary and secondary care.
Thus far, Bronglais has taken PAs in psychiatry, general medicine and paediatrics with
placements in accident and emergency to start soon. The feedback from the 2 PAs in
medicine who spent 14 weeks at Bronglais was very positive. Currently we are exploring
placement opportunities within Bronglais Hospital and with the Mid-Wales Collaborative
after qualification. It is expected that this new member of the medical workforce will
contribute positively to delivering our clinical services.
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“Y Banwy”
The Y Banwy discharge assessment and reablement unit opened at the end of February
and provides 12 single rooms for patients who are medically fit, but who have complex
needs and are awaiting services to be provided for them in the community. Initial
indicators in terms of discharge and lengths of stay are encouraging and there has been
an improvement in 4-hour waits and a reduction in cancellation of electives due to lack of
beds. The additional capacity has not, however, led to attainment of the 95% target and
improvement work in other areas is underway to address this.
Y Banwy also provides a discharge lounge that supports patients on the day of discharge
so that their bed can be released earlier in the day.
Elin Jones AM visited Y Banwy on 15 July and talked to staff about the care provided and
its holistic approach to wellness and service provision.
Older People Mental Health Services

Following the „Trusted to Care‟ spot check review in December 2014 and the Welsh
Government Delivery Unit‟s review in February 2016, Enlli Ward in Bronglais Hospital has
worked to a robust action plan to improve the environment of care and quality of service
delivery for patients who may be admitted to the ward. The ward has had new furniture,
been redecorated, and had a new assisted bathroom installed. Ward routines have been
reviewed and extended visiting hours have been put in place.
Both Enlli ward and the Ceredigion Older Adult Community Mental Health Team (CMHT)
have achieved the Investors in Carers bronze award in recognition for all the work done to
support carers and involve them in the care journey of the patient.
“Front of House” Development

Theatre Refurbishment
Works have commenced on the main theatre refurbishment project and are scheduled to
be complete in 9 months. The requirement for a theatre fire lift has been identified by
Estates and a business case has been submitted to Welsh Government for consideration.
The works for the construction of the lift, if approved, will result in a closure of the Caradog
Road access to the site for approximately 5 months.
Outpatients
The refurbished outpatient department opened in July together with a new coffee shop.
There have been positive comments from staff and patients about the improvements in the
environment and the temporary pedestrian diversions around the hospital have now all
been removed.
Ante-natal
The ante-natal department moved into its new accommodation adjacent to outpatients on
level 2 in July and provides a first class environment for the provision of services for mums
to be.
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Ty Geraint
Ty Geraint palliative care centre celebrated its 10th Birthday on 15 July with a birthday
party attended by staff past and present, families of patients in addition to local
dignitaries.Plans for agreeing development and continued success of the unit are ongoing
and this important contirbutionwill continue to be support by the Ceredigion team.
Listening to Patients
Parking
From 5 September 2016, the multi-storey car park and the parking spaces in the area
outside of A&E will be reserved for patients and members of the public visiting patients
only. Spaces in the upper car park (adjacent to management offices) will be reserved for
peripatetic staff only. All other staff have been asked to park off-site. This is an important
improvement for patients who often cite difficulties in parking with stories of some patients
returning home and missing appointments and others turning up in the morning in order to
be able to park for an afternoon appointment. The timetable for the Staff Park and Ride
service to and from the Staff car park at the top of Penglais Hill has been modified to
ensure staff are able to use the car park between the hours of 06:40 and 21:50 hours.
The access closures during the first two weeks of September will allow access to the site
to be controlled and an assessment made of the impact and any modifications required or
opportunities presented to further improve patient experience.
Electronic Payments
In response to concerns raised by dining room staff who had to refuse to serve patients
and visitors who do not have sufficient cash, a „Chip and Pin‟ machine went live in the
dining room during July. This has been met with universal approval of both staff and
patients and discussions are underway to install a cash point as part of the new retail unit
in the outpatients departing.
Bronglais Improvement Week

The first week of August saw the first “Leading to Change Improvement Week” at
Bronglais facilitated by the Improvement Director.
Managers from hospital, community services and Local Authority came together to listen to
staff on two wards explain what they felt the challenges were in promoting patient flow.
This exercise resulted in 19 areas for potential improvement from which the group
prioritised for action:
 Clean team
 Mobility symbols
 Flow into and out of Y Banwy
 Red/Green days
 Weekend medical plans
 CDU complex discharge
 CT scanning support
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In the latter half of the week, a significant number of the local social services team joined
the event and significant progress was made in fostering partnerships and identifying
challenges and opportunities to address these working in partnership across the whole
care system including:
 Advocacy
 Pooled resources
 Christmas planning
 Capacity for Discharge to Assess
 Community bed base to reduce medically fit levels in hospital
 Trial of Cylch Caron model
Work continues on the development of plans and implementation of these improvement

areas.
Site Development Plans

There are two priority schemes for development on site:
New MRI scanner

The installation of a new scanner requires the relocation of the health records department.
Structural surveys are currently underway to assess the suitability of the identified site for
the new health records department with the results expected in early September. Welsh
Government have allocated capital funds for the purchase and installation of the scanner,
but additional capital will be required to relocate the health records service. Once
complete, the DxA scanner will be able to be relocated within the main radiology
department which will allow the provision of a dedicated procedure room adjacent to CT
for stroke thrombolysis.
Chemotherapy Day Unit

There is an urgent need to improve the chemotherapy day unit environment with its current
location being identified as a concern in the cancer peer review process. In addition, there
is a need for an improved environment for the medical day unit and the rehabilitation and
mobilisation of patients post stroke on Ystwyth Ward. An initial proposal for a two-storey
extension to the Leri/Ystwyth floors would allow significant redesign and improvement to
all these services in line with the need to provide hyper acute stroke services and
rehabilitation to the relativly isolated population in mid Wales, this proposal is in the initial
stages of discussion and has not reached a planning phase at this stage.
Planning is in early stages in finding solutions for the relocation of North Road services,
including community dental and sexual health so that North Road becomes a community
ophthalmology unit with improved accomadation and throughput.
Visits
Dr Andrew Goodall visited Bronglais Hospital on 10 February and met with senior
clinicians. The visit coincided with a day when the site was experiencing high levels of
demand and patient acuity and challenges with flow. Staff at the hospital demonstrated
41
the highest levels of professionalism and agility and gave a practical example of the
highest levels of care and compassion despite the significant pressure they were working
under.
Eluned Morgan, Mid and West Wales Regional Assembly Member and Baroness of Ely
visited the maternity unit, ante natal facility and paediatric wards at Bronglais on 20 th July.
Baroness Morgan was impressed by the state of the art facilities provided on Gwenllian
Ward and in the ante-natal unit and commented on the welcoming, although dated feel of
Angharad Ward. Baroness Morgan asked about the challenges in staffing Bronglais
Hospital and, in light of her campaign for patients to recognise the contribution of NHS
workers from overseas, showed interest in the international solutions being explored by
the Health Board.
Dr. Jean White, the Chief Nursing Officer for Wales, visited Bronglais on 12 th August and
was taken on a tour of various departments by the newly appointed Head of Nursing,
Dawn Jones. This visit continued with a vist to Tregaron Community Hospital where Dr.
White was accompanied by Community & Primary Care Nurse Manager, Tracey Evans.
Dr. Phil Jones has recently been appointed as Hospital Director for Bronglais Hospital and
has already taken up his new duties.
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Materion Gofal Iechyd yng Sir Benfro/
Health Care Matters in Pembrokeshire
Elly’s Pembrokeshire Flag

This image is provided courtesy of Elly Neville, age 6.
The flag has been used by Elly and her family
to fundraise for Ward 10 at Withybush General Hospital
Cyfarfod Bwrdd Iechyd Prifysgol Hywel Dda 26ain Ionawr 2017 /

Hywel Dda University Health Board Meeting 26th January 2017
Update on Healthcare Services in Pembrokeshire 2016/17
Contents
Preventative Services in Pembrokeshire ............................................................................. 4
Health Promotion.............................................................................................................. 4
Living Well, Living Longer – Cardiovascular Risk Reduction Programme ........................ 7
British Heart Foundation Educational Programme ........................................................... 7
Solva Care ....................................................................................................................... 8
Primary Care Services in Pembrokeshire ............................................................................ 9
GMS Services .................................................................................................................. 9
North Pembrokeshire Cluster Network ............................................................................. 9
South Pembrokeshire Cluster Network .......................................................................... 12
Pembrokeshire Mental Health Services ............................................................................. 15
Transforming Mental Health Programme ....................................................................... 15
Community Mental Health Teams in Pembrokeshire ..................................................... 15
St Caradog Ward............................................................................................................ 16
St Non’s Ward ................................................................................................................ 16
Learning Disability Residential Units .............................................................................. 16
Child and Adolescent Mental Health Services ................................................................ 16
Community Services .......................................................................................................... 16
Multi Assessment Support Team.................................................................................... 16
Acute Response Team ................................................................................................... 17
Discharge Liaison Nurse Service ................................................................................... 17
District Nursing ............................................................................................................... 18
Community Resource Teams ......................................................................................... 18
Community Clinical Nurse Specialists/Nurse Practitioners/Advanced Nurse Practitioners
....................................................................................................................................... 19
Frailty Service................................................................................................................. 19
Leg Ulcer Clinics in Pembrokeshire................................................................................ 23
Community Hospitals ..................................................................................................... 24
Sunderland Ward ........................................................................................................ 24
Cleddau River Day Unit .............................................................................................. 24
Joint Review of South Pembrokeshire Hospital, Health & Social Care Resource Centre
....................................................................................................................................... 24
Pembrokeshire Care at Home Team .......................................................................... 25
Local Data/Information/Intelligence ................................................................................ 25
National Audit Intermediate Care (NAIC) Wales 2016.................................................... 26
2
Community Pharmacy .................................................................................................... 26
Palliative Care ................................................................................................................ 28
Eye Care Services in Hywel Dda ................................................................................... 28
Therapies ........................................................................................................................... 30
Occupational Therapy Services in Pembrokeshire ......................................................... 30
Pembrokeshire Physiotherapy Service........................................................................... 31
Speech and Language Therapy Services ...................................................................... 34
Nutritian and Dietetics .................................................................................................... 37
Withybush General Hospital Services ................................................................................ 38
Background .................................................................................................................... 38
General Medicine ........................................................................................................... 39
WGH Medical Recruitment Campaign............................................................................ 39
Capital Developments .................................................................................................... 40
Ophthalmology Unit – Outsourcing................................................................................. 42
Pharmacy and Medicines Management ............................................................................. 43
Strategic Partnership Working ........................................................................................... 45
Demand Mapping ........................................................................................................... 45
Releasing Time to Care: Occupational Therapy Review of Domiciliary Care ................. 46
Identified Services to Support Delivery of Intermediate Care Fund (ICF) Objectives ..... 47
West Wales Population Assessment .............................................................................. 52
A Regional Collaboration for Health (ARCH) .................................................................. 52
3
Preventative Services in Pembrokeshire
Health Promotion
In conjunction with Public Health Wales (PHW), a range of Health Promotion interventions
continue to support the population of Pembrokeshire this year. Particular action includes
addressing the UHB Strategic Objectives:
• Influencing behaviour that may prevent a range of diseases and encourage happier,
healthier lives (SO1)
• Programmes to reduce overweight and obesity – through action on diet, physical
activity and mental wellbeing (SO2)
• Early detection of cancers and other conditions through national screening
programmes (SO4)
Action also continues against key Tier 1 Targets:
• Smoking cessation support

• Promotion of immunisations and vaccinations: As of 28th December 2016, influenza
vaccination uptake in Pembrokeshire within eligible groups is as follows: over 65’s
63% and those between 6 months and 64 years in at risk groups 42.1%. These
figures are set against the Hywel Dda UHB average of 61.8% of over 65’s and
40.6% of those between 6 months and 64 years in at risk groups. Therefore, at this
time Pembrokeshire GP practices are performing better than the UHB overall
figures. In particular, the North Pembrokeshire cluster is currently the best
performing in the UHB for under 65’s in at risk groups and the second best
performing cluster for over 65’s
• Tackling the rate of overweight and obesity among children
Particular action in Pembrokeshire:
• Being smoke free
o Smoking Cessation The ‘iQuit+’ hospital based Smoking Cessation service

is now operating at Withybush to provide support for smokers wanting to quit
smoking across Pembrokeshire. Available for any smoker wanting to talk
about quitting, it also specifically targets pregnant women, those with chronic
conditions, those waiting for an operation, and NHS staff. Clinics are
available for one to one appointments at all acute and community hospital
sites across the county, where clients will receive behavioural support and
free nicotine replacement therapy products.
o Smoke Free Environment An innovative new method of reminding visitors

to Withybush General Hospital that it is a smoke free environment has been
introduced. This involves a PA announcement system that plays pre-
recorded messages to anyone seen smoking near hospital entrances to
4
remind them that it is a smoke free site, and to ask them to extinguish their
cigarette. The system is activated by a ‘push button’ located just inside the
entrance to the hospital, enabling anyone to activate the messages
anonymously. Early evaluation of the scheme suggests that it is having a
positive effect on reducing the numbers of people smoking at the entrance.
The announcements were developed and recorded by pupils from Ysgol Cas
Blaiodd, Wolfscastle.
• Health Promoting Primary Care
o Lifestyle Advocates Staff across the two Primary Care Clusters are
involved in innovative Health Promotion work. The Lifestyle Advocates:
Promoting Health in Practice project works to embed a healthy lifestyle and
health promotion ethos within surgeries and pharmacies. Eight GP Practices
from across Pembrokeshire nominated members of staff to undertake the
first year of the project. Staff members (ranging from receptionists to nurse
practitioners) undertake training and fact finding to be able promote healthy
lifestyle through their settings. Knowledge of voluntary sector services makes
signposting to community solutions more likely, increases partnership
between the NHS and the Third Sector and passes power back to individuals
to build on their own assets and resilience.
Following a positive evaluation, the second year of the project started in

Autumn 2016, and links closely with the new Healthy Lifestyle Advisers
employed by the South Pembrokeshire Cluster (See Page 13).
• Pembrokeshire Healthy Schools and Pre-schools
o ACEs The Healthy School Scheme Practitioner has been raising awareness
of Adverse Childhood Experiences (ACEs) with presentations to Head
teachers, local authority partners and other professionals. Going forward
tackling ACEs within schools will be a priority, with a move from awareness
to response.
o Infection control Primary and Secondary school pupils will be learning more
about microbes through teacher training from Healthy Schools using a new
e-bug resource. The training will include:
Useful and harmful microbes
Spread of infection – hand, respiratory, food and farm hygiene
Infection prevention
Vaccinations and oral hygiene
Antibiotic use and antibiotic resistance
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o Choose Well Healthy Schools is working with Argyle Street Surgery and
Pembroke Dock Community School on a proof of concept involving pupils
and parents looking at why children get sick and what they can do to ‘choose
well’. Pupils will be given a tour of the surgery and be given an opportunity
to interview members of staff about their role in the practice.
o Healthy Weight The Healthy and Sustainable Pre-school Scheme has been
promoting the national ’10 steps to a healthy weight’ initiative in nurseries,
playgroups and childminders to address childhood obesity in the county.
o Smoke free Both school and pre-school schemes have provided Primary
Schools and childcare settings across Pembrokeshire with smoke free gates
signage with pupils monitoring impact.
• Mental Wellbeing
o West Wales Natural Health Services Network Pembrokeshire National

Park and West Wales Action for Mental Health are jointly leading the
development of a new Network for those interested in the mental health
benefits of green activity/ nature-basedintervention/ecotherapy.
o Mind Your Heart The staff in MIND Pembrokeshire have completed Mind
Your Heart foundation training. This course gives staff in mental health
services increased skills and confidence to engage in helpful conversations
with people about health behaviour change. The training is evidence based,
participative and allows staff to reflect on their own habits as well as how
best to support health and wellbeing in their client group.
• Healthy weight in pregnancy
o ‘Baby Let’s Move’ Service Local Authority Exercise Referral (NERS) staff
are delivering the new ‘Baby Let’s Move Service’ – an exercise referral
programme for pregnant women.
• Reducing the impact of alcohol use
o Communities Together – Fishguard and Goodwick Alcohol Project This

Big Lottery funded project takes a community development and asset based
approach to addressing issues related to alcohol use in the Fishguard and
Goodwick areas. It will come to an end in March 2017. Communities
Together is a project about facing up to alcohol, but one that didn’t begin with
questions about alcohol. Described as an example of putting into practice the
Prudent Healthcare principle of “achieving health and wellbeing...as equal
6
partners through co-production”, local people discussed and picked the
project priorities. Poetry, football, and ballroom dancing have been just some
of the unexpected outcomes. An evaluation report has been produced by
Participation Cymru which highlights a range of positive outcomes from the
initiative and an event is planned for 1st March at the Phoenix Centre,
Goodwick in order to share this learning more widely.
Living Well, Living Longer – Cardiovascular Risk Reduction Programme

The University Health Board has put in a proposal to the National Inverse Care Law
Programme to deliver the Living Well Living Longer Programme (LWLL) cardiovascular
risk reduction programme initially in South Pembrokeshire. The aim of the National Inverse
Care Law Programme is to support each Health Board in Wales to develop and implement
Cardiovascular Disease risk assessment pilots in a Cluster area by March 2018.
The initial focus of the programme is to support Health Boards in Wales to reduce
premature mortality and emergency admissions from cardiovascular disease in deprived
areas by improving the identification and management of cardiovascular risk factors.
£300k has been provided by the Heart Disease, Stroke and Diabetes Implementation
Groups to support an all Wales approach.
The LWLL programme is a community base programme that invites all eligible adults in
the age range 40 to 64 to attend for a Healthcheck by a Health Care Support Worker
(HCSW). The HCSW, using point of care testing sets goals with the client and sign posts
them to other programmes such as Stop Smoking and Foodwise as required. Clients with
“red flags” will be referred to the primary care providers.
The South Pembs cluster has identified cardio vascular disease as a priority and have
invested their cluster money into Lifestyle Advisors and Lifestyle Advocates. The roll out of
LWLL into South Pembs would greatly enhance the plans that they already have and allow
them to deliver faster and within an established infrastructure. Discussions were held with
the South Pembs cluster at their Cluster meeting on 24 November and they fully supported
the business case proposal. Notification is awaited on the proposal from National Inverse
Care Law Programme Board.
British Heart Foundation Educational Programme

Locality Managers and Primary Care Locality Development Managers have engaged in
discussions with the British Heart Foundation (BHF) regarding its offer of a free
Educational Programme for healthcare and admin/clerical staff around cardiovascular
disease (CVD) and care. The Programme which is scheduled to commence in April 2017
will deliver a suite of educational sessions to Primary and Community health and social
care staff across Pembrokeshire, including:
• Registered staff - 2 hour educational sessions each month for 12 months

• Non-registered staff - 2 hour educational sessions each month for 6 months
7
• Admin & Clerical staff – two 2 hour sessions around chest pain awareness and
communication over consecutive months
The key objectives of the programme is to:
• To increase knowledge and awareness of CVD and care among Primary and
Community Registered staff, with a view to improving the quality of care provided to
this significant chronic condition patient group
• To increase awareness of local CVD specialist services, local specialists etc among
Primary and Community Registered staff, with a view to supporting effective referral
pathways / more seamless patient care
• To increase the awareness of CVD red flags that require escalation among Health
care Support Workers, with a view to taking needed preventative approaches to
managing CVD patients and preventing deterioration/admission
• To increase the awareness of / actions to be taken by admin, clerical and reception
staff when patients/public present with/report chest pain, with a view to ensuring
patients with Myocardial Infarction are managed promptly by A&E/ WAST
• To provide an opportunity for Primary and Community staff to engage in a shared
learning experience, with a view to enhancing local integrated working /
relationships
• To develop ‘CVD Champions’ in teams for the purpose of cascade
training/awareness, on-going liaison with BHF trainers and maintenance of
knowledge/ awareness gained
Solva Care
Solva Care is a whole community project working together to care for those in the Solva
community who need help. A 2013 survey showed enthusiastic support for a proposal to
trial the project. Solva Care successfully applied for grant funding and appointed a Project
Co-ordinator in June 2015. The funding comes to an end in March 2017 and the project is
currently seeking funding for the next phase.
Solva Care is a not for profit community initiative. It has been operating a pilot scheme
since June 2015 to offer local support and help to those who need it in Solva Parish. The
Pilot Project is funded by a grant from WAG, administered locally by the Pembrokeshire
National Parks Sustainable Development Fund (£23,408 over 2 years).
The aim is to improve health and wellbeing by enabling residents to stay in their own
homes, to remain a part of the community, offering a way to counteract loneliness,
isolation and social disadvantage and to provide extra support to family carers. The
services are provided by local volunteers, coordinated by a part-time paid Co-ordinator.
Solva Care is governed by a Management Committee responsible to Solva Community
Council. The scheme is a really good example of the positive benefits of community
resilience.
8
Primary Care Services in Pembrokeshire
GMS Services
Currently there are 14 GP Practices providing General Medical Services (GMS) across
Pembrokeshire, nine of which are in the North Pembrokeshire Cluster and 5 in the South.
In line with national recruitment challenges, we have a similar challenge in Pembrokeshire
in attracting GPs to the area.Difficulties in recruiting to the area, as well the difficulties in
obtaining locum cover has had a significant impact on practices and is causing some
concern. A focus on wider recruitment is being progressed across the whole Health
Board. Recruitment campaigns have been undertaken locally, nationally and in Ireland.
However the situation still remians tenious.
The Board will be aware of the significant workforce challenges being faced at Goodwick
Surgery, this remains a Health Board managed practice. The last remaining salaried GP
left the practice at the end of December 2016 and the practice is currently run solely by
locum GPs. GP Triage is being provided daily for Goodwick patients ensuring that patients
are seen by an appropriate clinican, this approach does not always require a GP.
Medicines Management support is provided five days per week at the practice and an
Advanced Nurse Practitioner joined the practice in July 2016.
The Health Board is working with practices within the North Cluster to develop a new
service model to help to build a resilient rural model of general practice, ensure a
sustainable workforce model which provides support, development and delivery of patient
need. This will enable care to be delivered in the right place by the most appropriate
clinician in the most timely way and create a positive environment for providers and
patients, including effectively managing care outside of the hospital environment and
closer to home.
North Pembrokeshire Cluster Network

North Pembrokeshire received £206,319 funding for cluster networks. This has been
invested in the following projects:
Paul Sartori Foundation Advanced Care Planning Nurses

Continuation of the project implemented in the first year to assist practices in identifying
people for whom Advanced Care Planning (ACP) might be most urgent and relevant, and
working with those patients to complete ACPs. This project aims to ensure that patient’s
maintain their dignity and autonomy while being offered support with care directed by the
patient’s wishes.
During the period October 2015 to September 2016 Paul Sartori Foundation have reported
that they have received 101 referrals. Men accounted for 45% and women 55% with the
average age being 76.8. The range of ages were between 55 and 101. The total number
of contacts was over 600.The biggest referrers into the service were GPs (29%). Self and
family referrals were high at a combined 45% - but many of these had been prompted by
9
GPs. Other referrers were a wide range of Clinical Nurse Specialists (CNSs), social
workers, therapists and hospital doctors.
The team have participated in many awareness raising events with care homes, assisted
living housing schemes and community groups. The Registered Nurses (RNs) led or
supported a range of community events for Byw Nawr/Dying Matters week in May for
community groups and health and social care professionals. Over 500 health and social
care professionsals and 300 members of the public have attended educational sessions.
Community Phlebotomy
Continuation of the project implemented in the first year where the key objective was to
provide an efficient, caring and professional phlebotomy service for house-bound patients,
where patients would be seen by the appropriate person at the appropriate time. A survey
of Phlebotomists and District Nurse Team Leaders reports the following specific benefits:
• Positive patient feedback regarding the Phlebotomy Service

• Improved patient experience and patient sense of being ‘valued’
• Greater efficiency in terms of timely successful venepuncture, delivery of bloods to
lab and results reporting to GP for review / clinical action
• Reduced spoilt / damaged blood samples
• Reduced errors / missed venepunctures
• Improved coordination, planning and continuity of phlebotomy care
• Phlebotomist provision of advice / information regarding bloods test and in
addressing patient concerns / questions
• Integration of the phlebotomy service within District Nursing / GP Practice has
facilitated escalation of others patient needs / signposting to other professionals /
services
A key objective was to prioritise this service to community phlebotomy and thereby
increase the capacity of the District Nursing team to prioritise patients with more complex
needs and thus provide support to GP Practices. A survey of District Nurse Team Leaders
reported specific benefits allowing community nurses to focus their time on interventions
that improved patient outcomes.
The introduction of the Community Phlebotomy Service has been an enormous benefit to
Primary and Community Care. Although the introduction and development of this service
incurred some challenges in terms of recruitment, staff retention and sickness, reported
activity and feedback from staff and patients evidences this benefit and supports the need
for continued funding beyond the current GP funding commitment to March 2017.
Pembrokeshire Counselling Service

Continuation of funding for the project has covered the running costs of Pembrokeshire
Counselling Service enabling it to continue its primary stated aims of providing free
counselling for people living in Pembrokeshire and thereby ensuring continued and easy
access for referred patients from Hywel Dda Health Board services.
10
In the period January to September 2016 the service received 196 referrals and had 826
patient contacts. 127 patients received counselling from the service and 48 patients were
signposted to alternative services.
The service is provided at a low cost for professionally delivered and supervised
counselling by appropriately qualified and trained counsellors. Pembrokeshire Counselling
are able to do this by capitalising on the resource of volunteer counsellors undertaking
professionally accredited training courses from Universities who require local placements.
Costs are further reduced by the utilisation of rooms in appropriate venues within
Pembrokeshire. Administration is undertaken through an e-based organisation not
requiring premises.
Cluster Pharmacists
The cluster has invested in 1.8wte Pharmacists to work with practices. The postholders
who commence in post in January 2017 will work as part of a multi-disciplinary team
across the cluster, providing expert pharmaceutical advice to all health professionals and
patients within the cluster as well as undertaking medication reviews for an agreed cohort
of patients in line with Prudent Prescribing principles.
Home Visiting Service

The cluster has invested in a three month pilot to run an Acute Home Visiting Service to
address an element of GP workload, release practice capacity for other work, and develop
shared clinical services across practices. Home visiting places an additional demand on
practice resources because of rurality issues and the growth in our older population. The
pilot aims to consider whether organisational / professional barriers can be overcome and
if further work is worthwhile considering. Home visits will be carried one day per week
throughout the pilot by a locum GP and an Advanced Paramedic Practitioner.
Vision 360, Wifi for Practices & Ipads

Implementation of Vision 360, the installation of WiFi at practices and provision of iPads –
these projects work hand in hand allowing clinicians remote access patient records whilst
undertaking a home visit, share patient records and appointment details within practice
and clusters. These projects are also linked in with the Cluster Pharmacist, the Home
Visiting pilot and the frailty pilot as this will allow access to records from any location and
will also allow consultation details to be written back to the patient’s registered practice.
Pembrokeshire Young Persons Counselling Service

The cluster has funded a project which will enable the building of an online website for the
Young Peoples Counselling Service (YPCS) with direct access for GPs into ‘YPCS’.
This will alleviate pressures and reduce waiting times via existing GP referral routes, allow
for speedy appointment confirmation and booking and will eliminate potential crisis
elements eg waiting for someone to return a call if the telephone is not manned. Clients
will be able to commit to appointments whilst with the GP or independently via the online
self referral booking process. This tool will enable accurate monitoring of behaviors/issues,
support the recognition of trends and booking patterns within geographical areas. This will
11
enable YPCS to deliver an evidence based targeted service consistently that meets future
needs.
Frailty Clinic
The cluster has invested in a six month pilot of joint working between primary, secondary
and community clinicians to evaluate the benefits of the addition of a sessional GP to the
current Community Frailty Clinics. (See evaluation of frailty services, page 19).
Screening
The cluster has invested in a project which focuses on increasing screening uptake –
working with Public Health and the Voluntary Sector to increase the uptake in screening
focusing on bowel screening but also including breast, abdominal aortic aneurysim (AAA)
and cervical screening.
South Pembrokeshire Cluster Network

The South Pembrokeshire cluster has received £179,566 2016/17 financial year. The
Cluster has invested in the following initiatives:
Cluster Pharmacist
The cluster employed a Pharmacist who commenced in post in April 2016 and is working
with all practices within the cluster. She has visited all nursing homes within the practices
boundaries. The nursing homes are positive about the service and value the support for
patients from a medicines management perspective. The plan is for the nursing homes to
be visited at least annually. The cluster is supporting to fund the Cluster Pharmacist with
her Independent Prescribing course at Cardiff University with mentorship being provided
by 2 GPs from Argyle Medical Group.
The pharmacist is undertaking medication reviews in one practice seeing up to 20 patients

a week, medication reviews would usually have been undertaken by a GP; this approach
is freeing up valuable GP appointments. Issues around polypharmacy are being
considered in all practices and the pharmacist has commenced reviews with patients who
receive multiple medications. The role also involves supporting practices with clinical
audits and also supporting the practice pharmacists in two of the practices. The cluster
pharmacist will be presenting all her polypharmacy findings to the cluster as part of the
cluster meeting in February 2017.
Occupational Therapists
A pilot project supported by Primary Care pacesetter funding provided to Hywel Dda
University Health Board has been undertaken in Argyle Medical Group in Pembroke Dock.
An Occupational Therapist was based within the Practice as part of the practice team and
the practice introduced an alternative proactive model of care for patients. GPs referred
104 patients over a 6 month period. People were seen on average within 2 working days,
ranging from same day response to six days for one non urgent referral whilst the OT was
on leave. Each patient was seen by the occupational therapist on average 4 times.
12
There were additionally 39 patient related queries from GPs, those patients then received
advice or signposting from the occupational therapist. Prior to the pilot 13 GP referrals
from the practice were made to the community occupational therapy during the previous
six months period.
All of the referrals to the occupational therapist from the practice followed a request for a
GP home visit were the GP identified concern or evidence of functional decline. As the
service evolves it is envisaged that some initial home visits could potentially be undertaken
by an occupational therapist.
In Summary Demonstrable benefits have included;
• Reducing demand on general practitioners by addressing and resolving underlying

issues that are the root cause of multiple and regular contacts
• Releasing GPs, practice and community nursing staff time to focus on doing what
only they can do
• Proactively resolving health and social issues at an early stage, minimizing crisis
situations that result in presentation/admission to the acute hospital
• Sustaining people at home following discharge from hospital
• Reducing falls, improving safety and confidence enabling people to engage in daily
life
• Releasing professional capacity by enabling people to maximise their own potential,
promoting self management, preventing ill health and dependency
Following the positive benefits of the pilot the cluster has funded 2 fulltime Advance
Occupational Therapists to work with the cluster practices. There will be ongoing
performance indicators and measured for the next stage of development as the service is
rolled out to 5 practices covering 55,243 patients. Argyle Medical Group, the Primary Care
Team and the Occupational Therapy service have received a lot of interest in this project
from local MPs, AMs and Welsh Government.
Healthy Lifestyle Advisors

The cluster has also invested in two Healthy Lifestyle Advisors to cover all cluster
practices. The role of the Healthy Lifestyle Advisor is to support clients who require
focussed intervention to make changes to their lifestyle that will improve their health. The
vision is that the adviser will support the client (and their family where appropriate) to make
positive and sustained changes towards healthier lifestyle choices.
Much of the focus of the Advisers caseload will be on weight management (including diet
and physical activity), smoking cessation, with additional input to the Immunisation and
Vaccination agenda for both seasonal campaigns (e.g. season flu vaccination) and
targeted interventions (childhood immunisations). Additional support will be provided to
patients around improving their mental well being, and to support for healthy ageing. The
Healthy Lifestyle Advisor will also work closely with the Advocates within practice and will
be supported through Public Health Wales.
13
The Cluster has also been involved in the business case for Living Well Living Longer
Project -inverse care law Cardio Vascular Disease Risk Assessment programme.
(Outlined earlier in this paper) This will then work alongside the cluster Healthy Lifestyle
Advisors in co production & social prescribing.
Lifestyle Advocates Programme

The cluster has also agreed to continue to support and grow the lifestyle advocates to
support patients to make lifestyle changes and this will also link into our Healthy Lifestyle
Advisor Project.
Employment of Community Phlebotomists

The cluster continues to support the community phlebotomist service which covers the
South Pembrokeshire Cluster practices, the three Community Phlebotomists who are
attached to the District Nursing Teams provide a 55 hours direct service a week.
Paul Sartori Advance Care Planning Project

The cluster has agreed to fund this project for another 6 months from Sept 2016 to March
2017. Awareness raising tea parties have been held in various nursing homes within the
cluster area, Paul Satori Foundation have also raised awareness through Argyle Medical
Group Carers’ Day during Dying Matters Week and proactive care events held through the
Primary Care Team. Each of these has generated just one or two referrals for one to one
advance care planning.
Screening Project
The cluster is a supporting the screening project with Public Health Wales looking to
increase the uptake of screening particularly bowel, but also breast, AAA and cervical
screening.
Extra Project
The Extra Project links with obesity and is offered to children who attend Pembroke
School. The initiative is designed to get teenagers active and has run for 12-month as a
pilot programme undertaken at Pembroke Leisure Centre ending in Dec 2016. The project
was run by PCC (Pembrokeshire Leisure) in collaboration with Communities First and the
South Cluster. There will feedback to the cluster in March 2017.
Scope Project
This is a Joint project with PCC and the South Cluster to fund a delivery of evidence based
exercise into Day and Residential Care Homes in Pembrokeshire addressing the Frailer
Older Adult agenda. The project will use qualified members of NERS to deliver an eight
week evidence based exercise that will evaluate levels of exercise and emotional
response. This project has been implemented in four care homes to date. There will
feedback to the cluster in March 2017.
EMIS or Vision 360

The cluster is currently considering adopting EMIS mobile / anywhere or Vision 360
systems to improve ways of working with practices when clinical professionals are out
visiting patients within the community to improve the delivery of care closer to home. This
14
would allow medical records to be accessed and provide up to date information when
visiting patients at home. Clinicians would be able to securely access patient records and
share records between practices, book appointments, plan visits effectively, add
consultations look at x-rays, test results, prescribe medications and access real time
patient alerts and warnings.
CRP Machines
Last year the cluster purchased C - Reactive Protein testing machines to test patients at
the surgery where antibiotic therapy is being considered or where there is a consideration
that the patient does not necessarily need antibiotics. The cluster is looking forward to
working with Public Health Wales to evaluate the benefits of using these tests in practice.
Pembrokeshire Mental Health Services

Mental health services have seen significant new investment in the last financial year. This
has given opportunity to strengthen existing services and develop some new ones to meet
local needs and it has been important to ensure all these develop in line with the key
principles called out in the Transforming Mental Health Programme.
Transforming Mental Health Programme

A Mental Health Programme Group (MHPG) was formed in April 2015 which has been
overseeing the co-production of the Transforming Mental Health Services programme. The
MHPG has agreed that the following principles should be at the core of any new service
redesign:-
• to have a 24 hour/7 day a week service,

• to have no waiting lists,
• to move away from hospital admission and treatment to hospitality and time out
• to provide meaningful day time opportunities for our service users.
The MHPG has engaged with a wide range of staff and stakeholders to understand
people’s experience of the current services, and to co-design a future, needs led service
which adheres to these principles.
Community Mental Health Teams in Pembrokeshire

There are two adult community mental health teams in Pembrokeshire. One Team Leader
retired in late 2016 and no appointment was made following the post being advertised. A
secondment opportunity is being explored to help sustain leadership of the service whilst
longer term options are considered. The same challenge may arise in the second team as
the current post holder is nearing retirement. Work is commencing on development of
clinical staff across the service to improve future succession planning.
There had been a significant wait to see a psychiatrist in the summer of 2016, this has
been addressed and the target of no-one waiting over 10 weeks has more recently been
achieved.
15
St Caradog Ward
Recruitment has improved significantly in the last few months and the Ward Manager has
reported having a full complement of staff for the first time in a long period of time and that
the quality of the team is excellent. The introduction of a member of staff to focus on
sustaining community activities and contacts has helped ensure good continuity of care in
the face of sustained bed pressures and acuity.
St Non’s Ward
The ward have a strong focus on quality improvement and the results of this are very
evident. The ward has introduced meal vouchers they gift to people who are confused and
think they need to pay with a view to reducing their anxiety about needing to find money to
pay. There has been a significant focus on distraction aids that help people with dementia
concentrate. In addition, new funding received during 2015/16 to improve the Occupational
Therapy resource and therapeutic activity has made a significant difference to the service.
The ward moved to open visiting hours and staff and families have recognised the benefits
of this on patient experience.
Learning Disability Residential Units

Health Inspectorate Wales have undertaken a national review of Learning Disability
services including all inpatient and residential units in Hywel Dda. Two of these are in
Pembrokeshire and positive feedback on the quality of care was given and the service are
working on those areas where further improvements can be made.
Child and Adolescent Mental Health Services

There has been significant new investment in this service which is positive it has however
meant the current estate provision is not fit for purpose and in 2017/18 a better solution will
need to be identified for a staff base and the delivery of clinic services.
Community Services
Multi Assessment Support Team
The Multi Assessment Support Team (MAST) based within the Accident and Emergency
Department at Withybush General Hospital exists to facilitate discharge in patients
identified with complex health and social care needs but where acute admission is
preventable through the provision of supportive measures in the community.
The MAST team’s multidisciplinary composition includes District Nurses, Physiotherapists,

Occupational Therapists and Social Workers, supported by the Integrated Medium Term
Plan (IMTP) and Intermediate Care Fund (ICF) funding.
Additionally, nursing staff engage with Welsh Ambulance Service Trust (WAST) in
reviewing relevant ‘frequent callers’ as a means of preventing A&E attendance /
admissions for vulnerable and frail individuals.
16
MAST is benefiting from a more structured and joined-up approach in terms of the review,
monitoring, development, management and leadership of the service since the recent
establishment of its Steering Group which has identified the following service priorities for
2017:
• Review of MAST’s future model, scope, remit and optimisation of service

• Development of MAST Operational Policy;
• Task & Finish Group review of documentation, patient assessment tools and clinical
communications
• Task & Finish Group review of systems relating to activity data, outcomes and
performance
• Integration with Community Resource Team developments
Acute Response Team

Pembrokeshire’s Acute Response Team (ART) operating from Withybush General
Hospital exists to prevent admission and facilitate discharge through the delivery of acute
nursing interventions within the patient’s home. The service will see 3.27 WTE additional
nursing resource to its establishment over the coming months (ICF funding), providing the
Team with an opportunity to review its current service specification and consider the
following service developments for 2017:
• Improved ‘in-reach liaison’ with acute wards to identify patients appropriate for ART
• Increased staffing levels to meet predictable high discharge pressures pre and post
weekends and evenings
• Improved liaison with GP Out Of Hours Service and establish pathways for OOH
care in preparation for the introduction of 111
• Review and prioritisation of Intravenous antibiotic regimes – time releasing
• Introduction of home-based Intravenous Diuretic Therapy for Heart Failure patients
• Streamline referral process with WAST to avoid unnecessary hospital/A&E
admissions
• Further development of current ART Health Care Support Worker Band 3 role
• Review of measures that better identify sepsis in community patients managed by
ART
• Review of documentation and clinical communications
A ‘3 Counties ART Group’ established in November 2016 is scheduled to meet quarterly to

better facilitate sharing of best practice and development of more consistent ways of
working across the Health Board.
Discharge Liaison Nurse Service

The Discharge Liaison Nurse (DLN) role based within both the acute and community
hospital settings is pivotal to maintaining effective patient flow and timely care pathway
17
from admission through to discharge on ongoing care. Current priorities of the DLN
service include:
• Recruitmaent of an additional DLN to meet service demand, due to commence

January 2017
• A move to more integrated DLN working across acute and community sites
• Review of current data collection processes and processes around escalation
• Clarification of future operational priorities for DLN service
• Linking in and supporting the Demand Mapping exercise
District Nursing
As it has done historically, District Nursing continues to play a ‘front-line’ role in responding
to the complex care needs of an increasingly ageing and frail population across
Pembrokeshire. This, set against the need to provide care closer to home, represents a
considerable priority for District Nursing services to be planned and delivered in such a
way that ensures they are fit for purpose, sustainable and achieve optimal outcomes for
patients.
In recognition of this priority, Locality Managers are currently supporting Pembrokeshire’s

District Nursing Team Leaders in working through a number of service priorities which
include:
• Review of systems relating to activity data, outcomes and performance

• Review of workforce capacity to meet evolving service needs (linked to recent
Welsh Government Nursing Principles exercise)
• Succession planning to maintain appropriate skill mix / clinical expertise
• Development of current District Nursing Health Care Support Worker Band 3 role
• Link Community Phlebotomy – skills/Time Release
• Continue to implement recommendations of the Welsh Audit Office report
Community Resource Teams

Locality Managers have led a number of stakeholder engagement workshops in 2016 with
a view to re-establishing Community Resource Teams (CRT) across Pembrokeshire in
2017. An initial CRT Steering Group Meeting held in October 2016 identified the following
actions necessary for the implementation of CRT working in 2017:
• Visits to CRTs in other areas in Wales to learn lessons from local implementation
and development
• Scoping of current services within Pembrokeshire
• Focussed integration/Professional Working
• Development of Operational Policy for ratification
• Recruitment of CRT Coordinator
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Community Clinical Nurse Specialists/Nurse Practitioners/Advanced Nurse
Practitioners
Pembrokeshire County currently has a number of Clinical Nurse Specialists (CNS), Nurse
Practitioners (NP) and Advanced Nurse Practitioner (ANP) roles working in community
settings with the aim of optimising care management, admission avoidance and facilitating
discharge in specific patient areas / specialities which include:
• Heart Failure
• Chronic Conditions
• Frailty
• Palliative Care and CNS
• Complex wounds and leg ulcer management
The Palliative Care CNS team had one vacant post for a period of time this year,
however this post has been successfully recruited to
A ‘Community CNS/NP/ANP Forum’ established in December 2016 has been established

to better facilitate sharing of best practice and development of more consistent ways of
working across specialities. The Forum identify the following as shared service objectives
for 2017:
• Review of Operational Policies

• Review of documentation and clinical communications
• Review of systems relating to activity data, outcomes and performance
Frailty Service
The Older Adults Assessment and Liaison (Frailty) Service in Pembrokeshire has been
operational since February 2016, with a 6 month review into frailty services provided to
patients in Pembrokeshire for Hywel Dda University Health Board undertaken
Aims / Objectives of the Service

To provide holistic comprehensive geriatric assessments to frail older adults to prevent
avoidable hospital admissions and proactively maintain patients independence with the
support of a multi-disciplinary team.
Clinics
Clinics in South Pembrokeshire are run every Tuesday morning between 9am and 1pm
across two locations on alternative weeks.
A. Tenby Cottage Hospital (TCH) Frailty Clinic - 2nd and 4th Tuesdays of each month
B. South Pembrokeshire Hospital (SPH) Frailty Clinic – 1st and 3rd Tuesdays of each
month
Each clinic has capacity to see 4 patients per session with the current format allowing for 3
routine appointments and 1 urgent / rapid access appointment. There is currently no
19
waiting list for clinic appointments and all urgent patients can be offered an appointment
within 1 week of referral.
Comprehensive Geriatric Assessment / Documentation

All patients who attend clinic are provided with holistic and comprehensive geriatric
assessment looking at all aspects of health and social care needs with the emphasis on
early identification of issues relating to frailty and provision of detailed clinical management
plans to the patients general practitioner.
Patients are discussed by the MDT at the end of clinics and identified needs, problem list
and management plans are made with agreement of the whole team and then
communicated to the wider health and social care teams.
The type of patient that is typically seen at the clinic are those who will be able to be
discharged from care at the end of the assessment with a clear plan in place, not those
patients who will need an immediate hospital admission or referral on to another specialty.
The whole focus of the clinics is on working proactively with patients to prevent
unnecessary admissions to hospital and maintain patients’ independence as much as
possible.
Home visits / Domiciliary

Patients who are housebound or those that are unable to attend clinic for any reason are
offered a domiciliary visit by the Advanced Nurse Practitioner (ANP). They receive the
same comprehensive geriatric assessment as patients attending clinic and any patients
requiring more specific occupational therapy or physiotherapy input are referred into the
services as required. The ANP can contact the Medical Consultant for advice or support
for patients seen at home and also discuss these patients at the weekly clinic MDT where
necessary.
Admission avoidance visits can usually be provided within 1-2 working days, however,
patients seen at home are not case managed on a regular basis, rather crisis intervention
is provided when needed on a short basis to avoid a crisis or admission and then the
patient is discharged with a clear and detailed clinical management plan.
Locations for clinical assessment

Clinic (TCH) 29 (commenced 9th February 2016)
Clinic (SPH) 5 (commenced 21st June 2016)
Home 24
Nursing Home 4
Residential Home 3
Community Hospital 1
20
Source of referrals
Source of referrals
Therapy services 4
Social Services 1
District Nurses 3
CMHT / Memory Clinic 5
CCNP's 2
Acute hospital 9
GP 41
0 10 20 30 40 50
Reason for Referral

The majority of patients referred into the Frailty service had more than one reason for
highlights the need for holistic and comprehensive geriatric assessment using an MDT
approach for frail older adults.
1st reason 2nd reason for 3rd reason for Total

for referral referral referral number of
referrals
Advance care 1 3 2 6
planning
Cognition 10 10 3 23
Falls 36 7 0 43
Immobility 13 15 1 29
Incontinence 1 1 2 4
Polypharmacy 1 7 2 10
Social 2 14 6 22
Weight 1 0 0 1
loss/swallow
>2 admissions 0 1 2 3
Most common reason for primary referral was falls, followed by concerns relating to
immobility – ‘off legs’ unstable, unsteady, poor balance etc as well as a common
correlation between falls as a referral and immobility or cognition as a secondary reason.
21
Cognition (confusion, delirium, dementia) accounted overall for the 3rd most common
reason for referral and a number of patients seen in clinic by Dr Puffett were confirmed to
have dementia.
Social issues for referral such as carer breakdown, carer crisis, patients not coping
accounted for a large number of second referral reasons and again were associated with
cognitive concerns or immobility issues.
Referrals generated by clinic or home assessments
Referrals following clinical assessment

20
18
16
14
12
10 19
8
6
4 7 6
2 4 5 3
0 2 1 1 2 1 1 2 2
Series1
Continence
A bladder scanner has been purchased by South Cluster GP’s for use in clinic.
Number of referrals to continence team for advice and support following assessment in
clinic or on home visit: 4
Cognition
Patients who felt they had problems with their memory or cognition were offered screening
using a cognition screen tool. Patients with a confirmed diagnosis of dementia or cognitive
impairment were not screened.
Out of 65 patients reviewed 49 had no diagnosis of dementia or cognitive impairment and

out of these 48 had 6CIT screening with an average score of 8.75 (moderate cognitive
impairment) and 4 patients were referred onto Memory clinic following screening.
Geriatric depression scale was used for patients who stated they felt low in mood or
depressed on asking. 7 patients completed the GDS, with 4 patients scoring highly for
depression.
22
Future developments and actions
• North Pembrokeshire Frailty Clinics Over the last 6 months there has been an
increasing awareness of the Frailty service and the benefits this service can provide
to patients, carers and their families. We were aware that there was a disparity in
provision of services across Pembrokeshire with Clinics only being provided in the
South, this has now been addressed and clinics will commenced in North
Pembrokeshire in September 2016.
Leg Ulcer Clinics in Pembrokeshire

District Nurse teams are now delivering leg ulcer management for patients previously seen
by Practice Nurses within 11 GP Practices across Pembrokeshire. There are presently 6
clinic bases delivering a total of 13 clinics per week which represents approximately 63
hours clinic time per week. There are currently 61 patients registered with and attending
the 6 clinics. Since the first clinic opened, an overall total of 167 patients with venous leg
ulcers have been managed within the clinics with an average healing rate of 66%.
In November 2016, a band 6 Community Nurse for Complex Wounds and Leg Ulcer
Management was appointed to assist in the management of the Leg Ulcer Clinics in
Pembrokeshire. Since the appointment, all patients have been fully reassessed, a new
individualised treatment plan has been devised for each patient, all the Leg Ulcer
Pathways up dated and all patients have had a Doppler ultrasound within the last 3
months. The band 6 has worked closely with all staff working within the clinics, supporting
and training to improve their leg ulcer management skills.
Training needs have been identified to enhance skills and this will be addressed in 2017
by providing workshops on documentation, bandaging skills, Doppler training, skin care
and hosiery selection. There will also be training days for the new Dressing Formulary that
is hoped to be launched in March 2017.
A Snapshot of data for one month:
Total Leg Ulcer Clinic 401

Appointments
Total Interventions 389
Caseload 62
No of Clinics 55
Referrals 9
Healed 7
23
Leg Ulcer Clinic (non
Core District Nursing
July Aug Sept Oct Nov Total
Number of referrals 10 12 14 45 3 84
Number of discharges 3 7 10 39 7 66
Number of clinic
attendances 143 224 307 375 191 1240
A business case is being developed for Leg Ulcer Clinic / care across the Health Board.
Community Hospitals
Both Community Hospitals, South Pembrokeshire and Tenby Cottage Ward continue to
support patients requiring inpatient care admitted from the community and transfers from
District General Hospitals.
Sunderland Ward
Sunderland is a Community Ward with 40 beds, 35 Health and 5 Social Care. It has been
experiencing significant difficulties in maintaining safe staffing levels due to vacancies and
sickness. An additional Band 6 Junior Sister has recently been appointed to join the ward
team. Safe staffing levels within the community ward is under review .with support from the
corporate nursing team.
A daily working list comparable to the Acute Hospital has recently been implemented for
the community hospital sites. A Community Discharge Liason Nurse has been appointed
to ensure efficient patient flow is achieved.
Sunderland Ward has recently been involved in the hospital review which has involved all
of South Pembs Hospital staff.
Cleddau River Day Unit

Cleddau River Day Unit has been involved with providing information and data to inform
the hospital review.
The Team Leader Band 7 position is now vacant and Resource Centre Manager is
providing this function to ensure the service is effectively managed.
Joint Review of South Pembrokeshire Hospital, Health & Social Care Resource
Centre
The joint review of South Pembrokeshire Hospital and Social Care resource Centre has
been undertaken. Hywel Dda University Health Board and Pembrokeshire County Council
have reviewed care and support provided from South Pembrokeshire Hospital Health and
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Social Care Resource Centre to consider whether improvement or changes are required to
meet changing patient or customer need. The review has considered services and activity
that are jointly funded and is talking to staff, patients, partners and stakeholders about their
needs and ideas about future service provision. The Community Health Council and staff
side representative from health and social care were members of the review group.
The reviewincluded a comprehensive review of:
• Day care and rehabilitation/reablement for adults, including therapy input

• Inpatient services, which include 35 health and 5 social care beds
• Support services, including administration, estates, hotel services, transport
• Accomodation space for health and social care staff and provision within the area
for visiting services
The review took a close and prudent look at our services to ensure that they are working
in the best interests of our patients and population and to consider any potential changes
and improvements that could be made. The 3 work streams have been reported and
considered by the Health Board and Pembrokeshire County Council, the
recommendations will be considered in conjunction with the Delivery Unit report on
Discharge within Community Hospitals December 2016, and the outcome of the National
Audit of Intermediate Care Community Services audit. This work will be consolidated by
the end of January 2017. A number of improvements have already been made as a result
of the service review.
Pembrokeshire Care at Home Team

This is a new service in the early stages of implementation, the team will provide end of life
care for patients in their own homes. A Care at Home Co-ordinator has been appointed to
facilitate the introduction of a team comprising of 10 WTE experienced Senior Health Care
Support Workers partially funding by ICF funding. The Coordinator role will involve leading
the team of Senior Health Care Support Workers in the provision of end of life care to
patients in the Community setting. A Training programme will involve The Skills to Care
programme, placement with the District Nursing Team and a palliative care study day.
A task and finish group has been set up to oversee implementation of the service which
will be commence on the 10th January.
Local Data/Information/Intelligence
Locality Managers are currently reviewing data collection tools / systems across all locality
services to ensure they are fit purpose, deliver the needed information for day to day
operational management and provide the necessary intelligence for future planning of
services. A Locality Dashboard is being developed to capture data from the following
services in the first instance:
• District Nursing
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• Acute Response Team
• MAST
• Chronic Condition Nurse Practitioners
• Community Hospitals
National Audit Intermediate Care (NAIC) Wales 2016

Sunderland Ward and Tenby Cottage Ward has participated in the NAIC Wales 2016
service user audit This audit was aimed at enabling Welsh Government to understand
more fully the need for and provision of intermediate care services for the population of
Wales. The audit comprises of a Service User Questionnaire and a Patient Reported
Experience measure. The aim is to demonstrate prevention of unnecessary acute
admissions and premature admissions to long term care and to receive patients from
acute hospital settings for rehabilitation and to support timely discharge from hospital.
Community Pharmacy
General Overview
There are 30 Community Pharmacies within Pembrokeshire, which equates to 2 for every
medical practice. All pharmacies have to provide Essential Services as set out in the NHS
Pharmaceutical Service Regulations. Essential services include, dispensing of medication,
disposal of unwanted/unused medicines, promotion of healthy lifestyles, support for self-
care and a range of Clinical Governance requirements. In addition to Essential Services,
community pharmacies can also provide Advanced and Enhanced Services.
Advanced Services includes Medicine Use Reviews (MURs) and Discharge Medicine
Reviews (DMRs). Both of these Advanced services are aimed at ensuring patients
understand the purpose of medication that has been prescribed and that they take it in the
most effective way. Twenty eight of the 30 pharmacies in Pembs offer these Advanced
Services. In order to undertake MURs a pharmacy must have a private consultation area
that allows for a patient and the pharmacist to sit down and converse at normal volume
without being overheard. Only 2 pharmacies in Pembrokeshire do not currently have a
consultation room. These are Medical Hall, Clunderwen and Kilgetty Pharmacy.
Enhanced Services are provided by 27 of the 30 Pembrokeshire pharmacies. There is a

wide range of enhanced services that are commissioned and some of these are outlined
below. Community pharmacies are eager to be recognised as a key provider of primary
care services and are often best placed as the first point of contact for advice, self-care
and even some treatment. They offer good access with 25 out of the 30 pharmacies open
on Saturdays. Examples of services being delivered by Community Pharmacies in
Pembrokeshire are:
Triage and Treat Service

This service enables trained pharmacy staff to assess low level injuries and where
appropriate carry out treatment. This innovative service, which is unique to Hywel Dda
Health Board, was piloted in 2 pharmacies in South Pembrokeshire in 2014 and has now
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rolled out to an additional 6 pharmacies in Pembrokeshire. 72 patients have accessed the
service via Pembrokeshire pharmacies to date in 2016/17. The aim of the service is to
offer patients a local service for low level injuries to be treated reducing the need to attend
a GP practice or A&E service. The service has had positive feedback from patients who
have appreciated the locally service and the professionalism of the staff involved. Triage &
Treat was shortlisted in the Innovations in Primary Care category of the Health Service
Journal Awards in 2016.
Influenza Vaccination Service

Over half (17) of the pharmacies in Pembs offer NHS Influenza vaccinations to eligible
patients. These pharmacies can also offer the vaccination to Health Board staff to provide
access outside of working hours and hospital sites. Up to mid-December 1,418 influenza
vaccinations had been carried out by community pharmacies in Pembrokeshire. This
compares to a total of 1,367 vaccinations carried out in the 2015/16 influenza season.
Smoking Cessation Services

In conjunction with Stop Smoking Wales, 18 pharmacies offer supply of Nicotine
Replacement Therapy (NRT) products to support quit attempts. Patients have to attend
sessions with Stop Smoking Wales Counsellors in order to access the supply of NRT e.g.
nicotine patches, sprays, gum etc. In addition 8 pharmacies in Pembs provide a one-stop
service of counselling and supply of NRT over a 12 week programme.
Respiratory MUR Plus

16 pharmacies have staff trained in Advanced Inhaler Technique and can offer support
and demonstrations to patients who use inhalers as to their proper and effective use. This
aims to support respiratory patients to manger their condition and maximise their quality of
life.
Emergency Hormonal contraception

Emergency Hormonal contraception (EHC) is more commonly known as the morning after
pill. The free supply of EHC is available in 14 pharmacies across Pembrokeshire subject
to a consultation with an accredited pharmacist.
Emergency Supply of Prescribed Medication

This service was introduced in March 2016 in a limited number of pharmacies in Hywel
Dda, 18 of which are located in Pembrokeshire. It enables pharmacists to supply
prescribed medication (subject to certain conditions) without the need for a prescription.
This supports patients who have an immediate need for medication who have been unable
to access their usual medical practice.
Palliative Care Medication Service

Three pharmacies within each county have been commissioned to hold specific quantities
of drugs used for palliative care. The aim is to have known sites for community staff to
access when these are required at short notice. Many of these drugs are not routinely
stocked by pharmacies and would have to be ordered from suppliers, which could take 24
/ 48 hours to obtain. This service commenced in December 2016.
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Pharmacy Pharmacy Address Postcode Opening Hours Telephone
No.
Boots UK Unit 2, Withybush SA61 2PY Mon-Fri: 9am-8pm 01437

Ltd Retail Park, 762422
Haverfordwest Sat: 9am-7pm
Sun: 9am-5.30pm
Lloyds 39 High Steet, SA67 7AS Mon-Sat: 9am-5.30pm 01834

Pharmacy Narberth 860486
Boots UK Jasperley House, SA70 7HD Mon-Sat: 8.30am-1pm 01834

Ltd & 2pm-5.30pm 842120
High Street, Tenby
Sun: 10am-4pm
Common Ailments Service

There is a national programme managed by NHS Wales Informatics Service to commence
the roll out of the community pharmacy Common Ailments Service (CAS) during 2016/17.
This service covers a range of common conditions e.g. nappy rash, head lice, hay fever,
athlete’s foot, scabies, haemorrhoids etc. The aim of the service is to make community
pharmacy the first port of call for provision of advice and where necessary treatment of
common illnesses. It will offer easy access to consultations, advice and medicines for
specified conditions, encourage patients to visit the pharmacy rather than the GP and
promote self-care of these conditions.
The roll out is due to commence in Hywel Dda on the 1st February 2017. The first cohort
of pharmacies to take on the Common Ailments Service will be those in Pembroke,
Pembroke Dock and Neyland.
Palliative Care
A substantive Consultant in Palliative Medicine has been appointed, Annette Edwards.
The new Consultant takes up post in January 2017.The Pembrokeshire Palliative Care
and End of Life Steering Group has been established and is in line with the Hywel Dda
Palliative Care and End of Life Strategic Group. The Pembrokeshire group has inclusive
membership to reflect all of the public sector, voluntary sector and third sector provision in
the County.
Eye Care Services in Hywel Dda

Throughout Hywel Dda we have 51 practices providing General Ophthalmic Services
through the NHS to patients. This is split as Carmarthenshire 25 practices, Pembrokeshire
16 practices and Ceredigion 10 practices.
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Enhanced Services
Eye Health Examination Wales (EHEW) is unique to Wales and offers eye examinations
for patients with an acute eye problem that needs urgent attention or those at increased
risk of eye disease or who would find losing their sight particularly difficult. These services
are free at the point of contact and are applicable if:
• You have an eye problem that needs urgent attention

• You have sight in one eye only
• You’re registered as sight impaired
• You have a hearing impairment and are profoundly deaf
• You suffer from retinitis pigmentosa.
• You are of Black or Asian ethnicity
• Your GP has referred you because they think you may have an eye problem
EHEW examinations are carried out by optometrists who have undertaken further training
and accreditation and in practices with the equipment required to perform these enhanced
examinations.This service is now availble in 14 practices in Pembrokeshire.
Low Vision Services

Low Vision Service Wales (along with EHEW) forms part of the Welsh Eye Care Services
(WECS) and is a unique service in Wales.
In a low vision assessment a practitioner will try to determine what a person with a visual
impairment needs and wants to do. They will then assess the person's visual function and
using this information the practitioner will determine if any low vision aids are available to
help the patient do the things they want. This service is now available within 10 practices
in Pembrokeshire.
Wet AMD Service

A small number of practices in Pembrokeshire are currently working with the Hospital Eye
Service to provide follow up of patients who have wet Age Related Macular Degeneration.
This pilot has been running since September 2016 and allows patients to be assessed by
an EHEW accredited optometrist, who has taken further training and accreditation and
whose practice has the relevant equipment, to provide their follow up examination in the
high street practice compared to travelling many miles to access the service at one of the
hospital eye departments.
Ophthalmology Follow Up Backlog

Currently we have 23 EHEW accredited optometric practices working with the Hospital
Eye Service (HES) to provide follow up assessments for patients who have not been able
to access their routine hospital follow up in a timely manner. Optometrists perform a follow
up examination on behalf of the HES and provide a written report and recommendation for
the continued care of the patient.This services is currently available in 6 practices in
Pembrokeshire.
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Therapies
Occupational Therapy Services in Pembrokeshire
Occupational therapy services in Pembrokeshire continue to develop and adapt in
response to local initiatives and drivers to address individuals needs and supports county
developments across acute, community and primary care including community resource
teams (CRT’s), interim and community beds as well as being integral to developments
within mental health and learning disability services.
A focus on proactive care and developments regarding integrated community resource

teams are informing the future model of occupational therapy provision in the county with
the aim of improved outcomes and experience for people who access services.
Update on current developments

Occupational therapy services have been established at the front door of all 4 four acute
hospitals, with Occupational Therapists at Withybush Hospital working as part of the
MAST team across seven days. Working as part of MAST (multidisciplinary assessment
support team) funded by the Intermediate Care Fund, occupational therapists have
continued to provide a new service to A&E/ACDU focussing on development of frailty
pathway, supporting comprehensive multidisciplinary assessment to reduce unnecessary
acute admissions and supporting people to return to and remain safely at home. There is
also Occupational Therapy support to reduce the length of stay for those admitted to
hospital and enabling people to remain as independent as possible whilst in acute hospital
care.
Occupational therapy services in Pembrokeshire are working to provide an integrated

proactive primary care approach which can reduce the strain on local health and social
care services as core members of frailty MDTs in the North and South Pembrokeshire
Locality. The service also supported the development of frailty and falls clinics within the
County, providing occupational therapy input at home, as part of the multidisciplinary team
approach to address falls risks.
The developing partnerships with GP clusters in Pembrokeshire has introduced new roles
for occupational therapists within practices, supporting GP’s to respond proactively to
patients presenting with frailty, helping them to manage their conditions and remain safely
at home. The service being delivered at Argyle Medical Group has featured in a National
report Reducing the Pressures on Hospitals: A Report on the Value of Occupational
Therapy in Wales. The report illustrates how the shift of occupational therapy resource to
frontline care in Primary Care, A&E, primary and community services can reduce the
pressure on acute hospital admissions.
Work by occupational therapy in primary care in South Pembrokeshire is recognised as

innovative practice within national College of Occupational Therapists report on reducing
pressures on hospitals, which was launched at the Senedd and publicised on BBC Wales
Report and radio.
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The Occupational Therapy service is supporting the expansion and development of the
intermediate care/reablement beds in Hillside Residential Home, Goodwick, providing
individual reablement programmes focussing on functional independence to enable people
to return home and avoid the necessity for long term care placements. This development
has been supported by by ICF investment.
The OT service is currently working with mental health services to establish occupational
therapy as part of the new psychiatric liaison service in Withybush Hospital.
As part of the development of a Health Board wide specialist community neuro-

rehabilitation team, we have recently appointed a community Occupational Therapist to
the team in Pembrokeshire.
Occupational therapists worked with Holly House to advise on introducing assistive

technology to support more children and young people to gain independent living skills as
part of a refurbishment funded through the Intermediate Care Fund – ICF.
The Pembrokeshire Occupational Therapy team have led a project funded through ICF to
support single handed care approach, which aims to improve access to individualised and
dignified care at home as well as releasing the time of care staff to support more people to
return home and live as independently and safely as possible.
The team is supporting the delivery of multi disciplinary specialist stroke and neurological
training locally, supported by a successful bid to the Welsh Stroke Flexibilities Fund and
Neurological delivery plan.
Pembrokeshire Physiotherapy Service

Within Pembrokeshire, physiotherapists work as members of teams with other healthcare
professionals. The service also works in partnership within schools; with social care and
with the third sector e.g. Paul Sartori.
Service Provision
Pembrokeshire Physiotherapists work across all age ranges from babies to frail and
elderly i.e. birth to end of life. This includes working across all levels of health and social
care dependency and clinical specialism. Services are in generalist and specialist clinical
areas.
Adult services include:
• Acute Hospitals Physiotherapy plays a vital role in maintaining life and preventing
physical deterioration e.g. respiratory status, thus reducing care needs and
accelerating patients out of critical care units or preventing requirement for
intervention in these clinical areas. The service provides a 7 day on call respiratory
service at Withybush in order to provide rapid response to saving life e.g.
respiratory management to clear secretions. A small team of physiotherapists work
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across scheduled and unscheduled care services i.e. critical care, medical and
surgical wards.
• The acute physiotherapy service is also one of the main services supporting the
unscheduled care pathway by improving patient flow, preventing avoidable
admission, reducing length of stay and facilitating a safer discharge. Service
provision includes front door service, and stroke units and orthopaedic wards.
Within clinical areas the service focus is rehabilitation.
• Community Rehabilitation and Frailty Teams The service is part of an integrated

health and social care service within people’s homes, clinics, day hospitals,
community hospitals and convalescent beds. The service “inreaches” into acute
hospitals to “pull” people back to be managed closer to or within their home. The
service significantly supports follow up from the acute hospital as part of a
continuous programme of care e.g. stroke follow up. Referrals to the service are
accepted from any health or social care professionals as well as self referrals. The
physiotherapists liaise closely with other team members to advise and support
physical recovery and rehabilitation. A rehabilitative approach significantly
influences equipment provision, packages of care as well as people’s independence
and quality of life.
Recruitment and Retention

This year 5 new staff members have been appointed to work in Pembrokeshire and 6
existing staff have been successful in gaining promotion to advanced and specialist roles
within Pembrokeshire.
Clinical Service Improvement/Successes

There have been a number of successes & recognition of value of physiotherapy. These
include specific physiotherapy services and those where physiotherapy is an essential
component of the multi-disciplinary team
Acute Hospitals
• Supporting Tier 1 targets with admission avoidance service in all counties MAST
• Targeted weekend working in Withybush Hospital focussed on hospital front door
services and weekend discharges.
• Actively contributed to ward bullet rounds to improve communication and discharge
planning.
• Stroke Performance maintained against SSNAP acute targets.
• Support worker led clinical group sessions implemented in acute stroke
rehabilitation.
Community rehabilitation team

• Continuation of strong representation in the MAST service with urgent follow up
assessments completed in over 90% of patients within 48hours.
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• Reablement pathways developed in Pembrokeshire, enabling physiotherapists to
commission reablement care both in the community and for hospital discharge.
This eliminates the requirement for social worker involvement & duplication involved
with a social care assessment for some patients
• Frailty clinics commenced and expanded in Pembrokeshire, currently active in 5
sites and further expansion planned . This multidisciplinary review of older people
has resulted in rapid diagnosis and optimal medical and functional capabilities.
• Early assessment and intervention to patients admitted to Hillside reablement beds,
with collaborative joint working with Occupational therapists and social services
• Development of support worker led chair based exercise classes in Hillside
• Active participation in weekly GP multidisciplinary meetings within Argyle Surgery.
This service proactively manages frail patients who are at risk of hospital admission
• Development of neurology outpatient services in all 3 day hospitals
• Standardisation and expansion of falls and balance classes in all 3 day hospitals
• Development of Gait analysis clinics in partnership with Podiatry /orthotoics
• Development of multiple sclerosis clinical groups in Tenby Cottage Hospital
• Development of FES training for physiotherapists (functional electrical stimulation)
and services for neurology patients
• Engagement in the development of CRT for Pembrokeshire
• Engagement in the development of Falls clinics in partnership with the
orthogeriatrician
• Enagement in the releasing time to care project through prescription of new manual
handling kit
Specialist Community
• Development of physiotherapy led spasticity service within Pembrokeshire, with
reduced costs and improved patient experience. Previously patients requiring this
intervention frequently travelled to Abertawe Bromorgannwg University Health
Board. This intervention was delivered by a consultant. The introduction of a local
physiotherapy service improved access for patients and allowed the consultant to
focus on complex case management.
• Physiotherapists worked closely with the British Lung Foundation to develop

integrated breatheasy groups to support patient self management of their chronic
condition in Pembrokeshire.
• Top to toe assessments of all patients admitted to St Non’s ward, to assess chest
and MSK systems. The aim is to pick up any increased risk of falls and
management of the same, better / appropriate pain management and to ensure
undiagnosed injuries or MSK problems are identified early in patients who are
unable to describe due to cognitive or behavioural presentations. A robust
management plan is developed and implemented.
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Paediatrics
Developed service level agreements and funding from Education Authority to extend the
paediatric service in Pembrokeshire. This further developed our integrated and holistic
approach for children within schools i.e. Portfield School.
Pulmonary Rehabilitation (SO6)

Evidence based multi disciplinary programme (on GP QOF) promoting self management of
chronic respiratory conditions with evidence of impact on reducing
admissions/readmissions to acute care. Currently delivered in Pembrokeshire by limited
multidisciplinary staffing establishment.
Speech and Language Therapy Services

The SLT service is responsible for the assessment, evaluation, differential diagnosis, and
treatment planning and implementation for adults and children at risk from speech,
language and communication and/or swallowing/feeding impairments.
Effective and timely speech and language therapy provision is proven to result in
significant health, educational and psycho-social benefits.
As such the service can contribute significantly to supporting the UHB’s population health
objectives, as well as the more general drivers of Prudent Healthcare, the Dignity agenda,
and patient and public engagement and empowerment. Other drivers include the new
Additional Learning Needs and Education Tribunal (Wales) Bill, the restructuring of the
SLT training course at Cardiff Metropolitan University, Flying Start, and the implementation
of the Healthy Child Wales programme.
In addition to substantive funding from the UHB, Speech and Language Therapy Services
are commissioned by Local Education Authorities, Flying Start, individual schools, and
Third sector organisations (i.e. MacMillan). Although these initiatives are successful, and
have resulted in a number of awards and acknowledgement of the service as sector
leading, the external funding presents significant challenges to the service in the current
economic climate.
Flying Start/Healthy Child Wales both have strong emphasis on language, communication
and adult child interaction, which involves SLT in supporting the prevention agenda.
The Adult Learning Disabilities service is managed through the Mental Health and
Learning Disabilities Directorate, with professional links to the core SLT service. The team
operates a Total Communication philosophy, encouraging communities to support adults
with learning disabilities to lead independent lives, including participation in the
Volunteering for Health project.
Service improvement, development and change

Implementation of the Therapy Outcome Measure (TOM, a system of measuring outcomes
from therapy using the International Classification of Functioning domains of Impairment,
Activity, Participation and Wellbeing) is ongoing, with full usage across the service to
34
begin in January 2017. Work to develop consistent use of Myrddin across the service in
order to support the implementation of TOM is progressing well. This will enable us not
only to report more meaningfully on outcomes from our interventions, but to compare
outcomes across SLT services in Wales.
We are also working closely with Pembrokeshire Education service in order to share
outcome measures for children attending schools in Pembrokeshire. This work is proving
to be extremely worthwhile and has allowed us to track children’s progress in a way that is
meaningful to both health and education professionals. The children with the most severe
communication needs receive an enhanced service model, which was implemented in
September 2012 in response to the closure by the local authority of speech and language
units. An evaluation of the first three years has just been completed and reveals a high
level of satisfaction amongst parents of children receiving the provision with 90% feeling
that their child had made ‘a lot’ or ‘quite a lot’ of progress with communication skills. A
presentation on this was made at the RCSLT good practice day in October 2016, and has
been accepted for publication in the professional journal. Representatives from Cardiff &
Vale UHB have visited Pembrokeshire shortly in order to find out about our integrated
service delivery model for children with specific language impairments.
A screening tool and interventions in the form of a handbook for school and early years
staff has been developed for nursery aged children which is now in 96% of all primary
schools with nurseries and all playgroups with 3 year funding. School staff have been
trained in its use. An audit is underway to look at reliability of identification and
effectiveness of the interventions and preliminary figures are very positive.
Models of service delivery for secondary school pupils need to be very different from the
models that are effectively used for younger children. The development of innovative
models that can be delivered across the curriculum without requiring pupils to be
withdrawn from class is ongoing. A presentation about service delivery in maths lessons
was presented at the RCSLT transforming services UK conference in October 2016.
We have implemented a new model of service delivery to Learning Resource Centres

across Pembrokeshire. This will ensure more equitable service delivery and more robust
parent engagement, and has been well received by parents and school staff. The model is
being continuously evaluated, with a report to be published at the end of the summer term
2017.
The service has been fortunate to receive additional funding to enable support for neonatal
services and ASD diagnosis. Despite this, demand continues to exceed capacity. As well
as our involvement with the new Neurodevelopmental Team, our Autism Spectrum
Conditions Professional Practice Group has developed a service wide protocol for ASC.
This is currently being consulted upon within the service.
Flying Start SLTs have driven the roll out of the WellComm screening tool for babies of 9-
12 months with further tracking at 18-23 months and 35-37 months. This will further
35
support the robust measurement of outcomes, but is likely to cause a change in patterns of
referral, with more work needed to support early parent/child interaction.
The service is represented on working groups for:
• All Wales AAC service development

• Redesign of undergraduate SLT training in Wales
• All Wales Information System
Members of the SLT service recently attended the ‘Celebrating Children’s Public Health
Nursing and Partnerships’ conference, and was able to display some of the material and
research that has been developed over the last year.
The Adult service is now fully integrated across Hywel Dda. This allows cross-cover and
improves flexibility and equity of service delivery. This model will allow for better support of
Community Resource Teams, where SLT has been recognised as a key element, though
not part of the core CRT. In order to achieve equity across the 3 counties, the Adult SLT
Service has now established a single point of referral.
The service has successfully developed a number of training programmes for a number of
different patient groups and locations. For example,
• training for nurses to carry out swallow screens for stroke patients. A recent
successful bid to the SRiF has resulted in additional short term funding to train
nursing staff to implement a more objectively valid swallow screen.
• training for care home staff to support frail residents with swallowing difficulties. In
order to: maximise the residents’ ability to eat independently and as safely as
possible; reduce risk of aspiration pneumonia and malnutrition; enable staff to better
manage the nutritional needs of residents; improve understanding of when there is
a need to access the Speech and Language Therapy service.
A joint project with Macmillan and ABMU has been very successful in delivering
telemedicine to improve access for head and neck cancer patients. 74 patients were seen
by this service in the first 18 months, with numbers increasing year on year. The majority
of these patients are in Pembrokeshire. The project has allowed us to significantly improve
skills in working with Head & Neck cancer patients. However the service is at significant
risk due to maternity leave and the resignation of the hub SLT from ABMU who was
providing support. Work to resolve this situation is ongoing.
Additional funding has been secured for a specialist post for neuro-rehabilitation. This is a
Hywel Dda-wide role to support the wider neuro-rehabilitation team.
Challenges
Provision of objective assessments (Videofluoroscopy) for both children and adults with
dysphagia is currently not available within the UHB, and is causing some concern. We are
working with colleagues in other directorates to seek a solution.
36
Recruitment and retention, particularly in specialist areas such as hearing impairment and
stammering. In an attempt to address recruitment challenges we have been engaging
proactively within the WEDS led task and finish group for clinical education, supporting a
change in student placement arrangements that mean Hywel Dda will have access to an
increased number of pre registration students.
Welsh Language Service provision

Over the past few years, the service has been successful in significantly increasing the
number of staff who can deliver services through the medium of Welsh. Whilst we are now
able to provide assessment and therapy through the medium of Welsh, there continue to
be challenges in relation to working in Welsh medium schools with children who have
English as their home language. We have developed a protocol for this. Work is under way
to explore the feasibility of a pilot project for bilingual service delivery in schools in
Carmarthenshire. This would support Carmarthenshire’s ‘Welsh Language in Education’
plan, and evaluate a model that could be rolled out in Pembrokeshire and Ceredigion.
A number of concerns have been raised about SLT provision for deaf children, and work is
under way to explore demand and support for this group, as there has never been a
formally-commissioned SLT service for deaf children.
Nutritian and Dietetics

Prevention The Nutrition and Dietetic service continue to support training and education
of others supporting positive lifestyle change in relation to healthy eating / weight
management. The service, following development of the 'Foodwise for life' programme has
during 2016 trained 3 individuals (training commenced for a further 10) to deliver the
programme in Pembrokeshire. (this is now delivered across the 3 counties of the HB).
A total of 5 programmes have been delivered over 2016 supporting 28 individuals. All
participants completed, of which 89% lost weight (11% more than 5%). Evaluation showed
all participants have a positive and inspiring experience, and, when asked what has been
most useful for them, common themes are gaining knowledge on portion sizes, food
labels, cooking methods, and understanding the importance of activity. All participants felt
they gained new knowledge around healthy eating and/ or activity and most felt much
more or more confident in healthy eating and making the healthier choices within their
daily routines. Overall, participants reported that they ate a healthier diet which has
transferred to their family, consume more fruits and vegetables, less high sugar and high
fat foods and now eat regular meals.
Community As part of the generic Health and Social care project (Carms), quality assured
competency based training was developed and implemented supporting the management
of gastrostomy feeding for patients in the community (disability and respite settings). The
outcomes include improved knowledge and confidence of staff, improved patient
experience, enabling access to services previously unable to access and a reduction in
delayed discharge of patients. This work recently received recognition of excellence
37
through receipt of an accolade by the Bevan Commission. Additionally this work has been
referenced as part of the development of WG guidance on third party delagation.
Acute Frailty Healthcare Support worker project has been piloted (Carms) on several
wards to date, providing functions additional to baseline staffing establishment. Focus
being on meeting nutrition and hydration needs of patients and maximising mobility and
independance. Outcomes to date have demonstrated a reduction in nutritional risk,
improvement in weight, reduction in nutritional product prescribing, improvement in
functional ability (i.e grip strength) and reduction in hospital length of stay by approximately
2 days. Plans to roll this out to Pembrokeshire imminently supported through ICF funding.
Paediatrics Development and implementation of a Health Board paediatric infant nutrition

formulary including a pathway for managing suspected cows milk protein allergy. This is
supporting consistent evidence based practice and appropriate, cost effective prescribing.
Neonates The neonatal dietitian has been instrumental in the development and
implementation of a Health Board neonatal parenteral nutrition (PN) guideline; enabling
timely optimisation of infant nutrition, and therefore growth and development, when enteral
feeding (via the gut) cannot be used. This also reduces the need for transfer to tertiary unit
for PN.
Withybush General Hospital Services

Background
Withybush General Hospital is lead by a recently established triumvirate team:
• Dr Iain Robertson-Steel – Hospital Director

• John Evans – General Manager
• Janice Cole-Williams – Acute Hospital Nurse Manager
Withybush currently provides unscheduled care services for the population of

Pembrokeshire (est 130,000) and provides core services to manage common medical and
surgical conditions arising in the population.
Withybush has 76 surgical beds and 95 medical funded beds to serve a population of
130,000 people.
The hospital also operates an ITU/HDU facility. Unscheduled care is supported by a 17

bedded ACDU (plus two cubicles for assessment).
The A&E department contains 4 resus bays, 4 major cubicles, 3 specialist rooms, 2
paediatric dedicated assessment areas supported by paediatric waiting room plus minors,
triage and assessment room.
38
General Medicine
Funding has been approved for 12 Consultant posts at Withybush Hospital which is a
substantial increase on the core number of 8 Consultants in place at the end of 2015.
Discussion with the Consultant Physicians in July 2016 resulted in agreement that the 12
posts should be allocated as follows:
4 x Care of the Elderly
3 x Gastroenterology
2 x General Medicine and Diabetes
1 x Respiratory
The Consultants have agreed to operate a 1:12 rota and have opted to provide support to
the ACDU without the appointment of 2 Acute Physicians.
The consensus view was that Withybush would require a resident Consultant in
Respiratory Medicine but the remainder of the respiratory service could be integrated with
Glangwili General Hospital.
We have been successful in recruiting two Care of the Elderly Consultant Physicians and
an Ortho-geriatrician within the last 18 months. We have also successfully recruited a
palliative care and end of life consultant commencing on the 6th February 2017.
WGH Medical Recruitment Campaign

In December 2016 a discrete WGH Medical Recruitment Campaign has been created to
urgently address the shortfall in Medical staffing. Initially this group will target General
Medicine but will eventually open up to A&E and Surgical specialties. The group is being
led by the newly appointed Associate Medical Director for Medical Recruitment Dr Chris
James.
The campaign is focussing on:
• Targeted recruitment of Middle Grade and Consultant Physicians focussing upon

Medical Education and the high level of support and teaching provided by the
Hospital and evidencing testimonials of such success to date.
• Creation of a WGH Medical Education webpage to act as the central focal point of
the campaign and sign-post candidates to information on Education,
accommodation and support for families.
• Complete re-write of medical Job descriptions and job adverts to modernise and
target the benefits of applying to Withybush Hospital and HDUHB.
39
• Creation of a Medical Education Service Recruitment Video – to bring to life Medical
Education in WGH.
• Creation of Testimonials – to evidence the success and development of current

candidates who have followed this route.
• Development of a designated Interviewing Room which will provide suitable remote

interviewing of candidates with modern technology that allows for clear and
professional communication.
In August 2015, WGH successfully recruited and trained 9 international graduates as

junior doctors in General Internal Medicine.
Capital Developments
Paediatric Ambulatory Care Unit
On the 17th December 2016 –the Paediatric Ambulatory Care Unit was opened to patients
and is intended to work effectively within the proximity of the Emergency Department.
A task and finish group is in progress to resolve the staffing issues for Paediatricians with
the intention of restoring 12 hour / 7 day a week services early in 2017.
Opportunities are being explored for closer join working and integrated triage between
A&E, GP Out of Hours and PACU.
Pembrokeshire Haematology and Oncology Day Unit (PHODU) at Withybush

General Hospital
On 28th January 2016, the UHB Board Meeting agreement was reached to relocate the
Chemotherapy Day Unit to the Ward 6 area of Withybush General Hospital. The building of
a new “Pembrokeshire Haematology and Oncology Day Unit” represented phase 1 of
plans to improve cancer services provided at Withybush General Hospital. The funding
sources for the new PHODU are Adam’s Bucketful of Hope, Withybush Hospital CDU
Appeal, Pembrokeshire Cancer Services fund (UHB charitable funds), Pembrokeshire
Cancer Services fund – Adam’s Bucketful of Hope (UHB charitable funds), Hywel Dda
University Health Board – Discretionary Capital.
The scheme has gained momentum over the last 12 months with key charities working
closely with the University Health Board to ensure the new PHODU is a success. The
building works have now been completed on schedule and on budget and will go live from
the 6th February 2017.
An opening ceremony will be held on the morning of 28th January 2017 where invited
guests (mainly charities, staff and those who have made large donations to this scheme)
will be given the opportunity to have a guided tour of the new Unit prior to it being
operationally occupied. The Lord Lieutenant of Dyfed, Sara Edwards, will formally open
the new Unit and presentations will then be delivered by key representatives. A more
40
informal open afternoon event will also be held on 28th January for patients, family
members, carers and members of the public to visit the new Unit.
Designated Specialist Palliative Care, Oncology and Haematology Ward (Ward 10) at
Withybush General Hospital
Phase 2, is the refurbishment of the current Withybush General Hospital Ward 10 area as
a designated Specialist Palliative Care, Oncology and Haematology inpatient facility. The
scheme will be subject to Welsh Government funding and a Business Justification Case
(BJC) is currently being developed.
As with the PHODU scheme, floor plans for the area have been developed by our staff and
shaped with our stakeholders via an engagement exercise conducted in the early summer
2016. The Community Health Council has also conducted its own patient survey of the
Ward area and has been incorporated into the draft BJC. Key messages from this
engagement were around the poor environment leading to a decrease in patient dignity
and privacy.
The refurbished 18 bedded Ward would contain an increase in single ensuite facilities,
improved family facilities and smaller bedded bays. A day room would be provided in the
refurbished area along with a dedicated treatment room and a discharge lounge
(positioned at the end of the Ward). The Ward will also offer facilities for bariatric patients
and be dementia friendly.
At the time of preparing this update, the BJC documentation is being compiled with a view
to it going to the Business Planning Performance and Assurance Committee in February
2017.
In addition to the Welsh Government funding being sought, the following funding sources
are available from Pembrokeshire Cancer Services (UHB charitable funds: T905),
Pembrokeshire Cancer Services (UHB charitable funds: T905 LEGACY), Elly’s Ward 10
Flag Appeal (for patient benefit).
Future Developments
• In Progress and funded is the completion of a permanent Medical Day Unit adjacent
to the Midwifery Led Unit and the PHODU. This will be completed early spring 2017.
• Discharge Lounge – this will be relocated to the old Chemotherapy Day Unit in
spring 2017.
• Ward 9 – Draft plans have been prepared offering a range of options for the
development of Ward 9 as an 18 bedded Medical Unit. This is intended to relieve
winter bed pressures for acute medical admissions and to redress the serious
shortage of acute beds serving the ageing population which is currently well below
the current national minimum number of beds per 1,000 population.
41
• In order to enable the completion of the Ward 10 redevelopment, Ward 9 must be
reinstated as a decant facility to enable the scheme.
• In the long term, plans are being developed for a rolling Ward refurbishment
programme to fit the future clinical model for a HDUHB.
• A full estates survey is being carried out to identify optimal accommodation fit and
to identify major areas of spending required to ensure that the fabric of the Estate is
maintained.
• A major area of spending which is currently being costed is the re-roofing of the
main building at circa £3m.
Ophthalmology Unit – Outsourcing

A temporary site has been identified in WGH on the location of the old temporary renal unit
to deliver the outsourcing of the backlog of cataracts operations to the HDUHB population.
Key Challenges
• WGH has been operating at well in excess of 100% occupancy since mid-2015.
• The intention is to increase the number of available beds for medicine by 18 to

reduce exit block and delays in A&E. This will help improve patient care and the
achievement of the Tier 1 targets.
• Full establishment of permanent medical and nursing staff is a key objective to

reduce the locum costs and the bank and agency costs considerably.
• Working arrangements will also be reviewed and consideration given to avoiding

prolonged periods of closure of key health services at public holidays.
• The hospital continues to experience pressures on beds, this is mirrored across

Wales and it is evident that effective Joint working between the acute hospital,
community hospitals, community teams and social services and the 3rd sector is
critical to reducing the number of patients delayed in hospital when their acute
episode is completed. Investment has been made through the Intermediate Care
Fund to strengthen the interface between and across services. As predicted Winter
Pressures have and continue to impact on the overall ability to manage capacity
42
and demand across the whole system. Plans for a multi-agency workshop to be
held early in 2017 are under discussion, with a view to identifying and evaluating
our current Winter Planning arrangements and potential future solutions.
WGH has made considerable progress in the past 18 months with Capital Developments
and the recruitment of key staff.
The team have demonstrated resilience and the capability to maintain services while
delivering service change in partnership.
Pharmacy and Medicines Management

Acute
The HDdUHB Medicines Informaion (MI) service based in Withybush was asked to lead on
the development of a Drug Library (DERS) for the roll out of the new Braun infusion
devices. The inclusion of DERS improves the quality and safety of patient care when it
comes to the administration of intra-venous (IV) drugs. An adult drug library, in
collaboration with clinicians, nurses and pharmacists based in Withybush was developed
in 6 weeks and successfully went LIVE on all new pumps back in March of this year.
Over 200 hours of pharmacist time was devoted to developing the first adult draft. A great
deal of feedback was received from nursing staff using the new pumps to further develop
and improve the adult library. Using this information an updated version of the drug library
went live in Bronglais, then Prince Phillip Hospital. The MI team then met extensively with
clinicians and nursing staff in Glangwilli to make further improvements to the library along
with new drugs coming onto the formulary, and planned updates of the library.
To date there are over 200 drug monographs on the software and it goes a long way to
reducing the unwarranted variation in practice across the health board for IV drug
administration. The next version of the library is planned to be installed in 2017. The MI
team in Withybush have also developed a draft Paediatric library and Neonatal library
which goes LIVE early in 2017.
The Withybush MI team presented the work as a poster at the UKMi Practice Development
Seminar in Birmingham. It generated a lot of discussion and interest on the implementation
process.
A new age-related macular degeneration (AMD) service set up in Pembrokeshire has been
supported by the Withybush Pharmacy Service and has resulted in two new clinics being
set up in Pembrokeshire with a third being planned.
Urology and further development of Medical Day Unit activity has substantially increased
the workload within Pharmacy
As part of a national initiative to improve discharge information from secondary care to

primary care the use of the Medicines Transcribing and electronic Discharge (MTeD)
system was introduced onto one ward at Withybush and similarily at other hospitals in
43
HDdUHB during 2016. In March 2016 MTeD was introduced on ward 7 at WGH. The
system requires information to be entered to reconcile a patient’s medication when a
patient is admitted to hospital. The record is updated during the episode and amended
appropriately during the inpatient stay, adding explanations to amendments as
appropriate. At the point of discharge an accurate, legible electronic Discharge Advice
Letter (eDAL) can be generated which contains clinical information summarising the
inpatient stay and a complete list of medication for discharge with any intentional changes
to medication during the inpatient stay annotated. The eDAL is sent electronically to the
patients GP four hours after discharge to allow a prompt update of the patients’ medication
record held in primary care. Previous paper based systems often proved to be illegible
and late arriving at GP surgeries leading to incorrect information being added to a patients
GP record. It is intended that the system will be rolled out to all wards in 2017.
Withybush Aseptic Facilities Upgrade and change of work process to incorporate

sporocidal disinfection guidance issued by MHRA IN 2016, ensures quality assurance of
end products improving patient safety and reducing risk. The Aseptic services at
Withybush now prepare subcutaneous chemotherapy for patients which is administered by
ART.
South Pembrokeshire cluster appointed a whole time pharmacist who started work in April
2016.
Medication records were reviewed for patients in residential and nursing homes for each
surgery, rationalising medication and ensuring that records are consistent and accurate
across the homes, the surgeries and the community pharmacies.
Similarily pharmacists are to start in North Pembrokeshire in January with work areas to be
agreed with individual practices.
Pharmacist support has been provided to the Practice Support Team at Goodwick
Surgery. The main area of work is in re-authorisation of repeat medication ensuring routine
monitoring is up to date and medication review are undertaken with patients.
A training course for prescription clerks has been prepared to ensure that staff have a
good grounding in some of the legislation around medication and understand the need for
a safe and effective repeat medication system.”
A redesign of the way in which patients are reviewed and access their continence products
(catheters) in the community has been launched across Pembrokeshire. Working
collaboratively between Medicines Management and the Specialist Continence nurses to
implement, the service removes the need for a GP to prescribe products. This
responsibility is transferred to the Specialist Continence nurse team ensuring a proactive
service in which patients are reviewed and monitored more closely and ensures timely
access to appropriate products for patients. transferred all patients over to the new
system. Early data is indicating a reduction of urinary tract infections and subsequent GP
44
appointment, reduced need for antibiotics or A&E /impacting positively on patient, further
data is being collated to determine if this is a sustained effect.
Strategic Partnership Working

Pembrokeshire County Council has a new Director of Social Services and Leisure. He is
Jonathan Griffiths who has been the Authority’s Head of Adult Care since September of
last year. He came to Pembrokeshire from Newport City Council where he spent nine
years, latterly as Head of Adult and Community Services. Jonathan succeeds Pam
Marsden who retired in August 2016. Jonathan has been very proactive in support of joint
working in Pembrokeshire and has worked effectively to support improved patient/ client
outcomes across the County.
Demand Mapping
Background
Pembrokeshire County Council is currently mapping demand for Adult Social Care
services. Using data gathered from sources including Carefirst IT system and Contact
Centre, they have generated high level data illustrating pathways through services. This
charts client pathways, from first contact, through referrals and assessments to service
provision and subsequently on to service exit.
In collaboration with the County Team, Pembrokeshhire County Council will expand on this
data to consider interaction with Health services by incorporating referrals and other
Health-related service data. This will help both organisations to understand flows of clients
through our services.
Proposal
Working with systems at Withybush General Hospital, will enable us to source data to feed
into the client pathway mapping. In the first instance, it is proposed to undertake a trial
data gathering exercise, focussing on gaining a snapshot of an identified pilot ward to map
patients’ journeys through the system. It is proposed to undertake this initial exercise
within the last quarter of 2016/17. If successful, future work may include a larger scale
data modelling exercise.
Particular areas of interest may include:
• Reason for initial admission

• Reason for hospital stay (ie, is this the same as the reason for admission?)
• Whether admission could have been avoided by a community response
• Whether there are any gaps in the community response
• Length of stay
• Discharge destination
• Type and level of care and support provided on discharge – for example,
45
o Universal services / self-care / family / community
o Primary care
o Third sector support
o Reablement
o Social care
Domiciliary care
Residential care
Day opportunities
o Health service support
District nursing
Funded nursing care
Continuing Healthcare
• Place of residence and level of care one month post discharge
Expected outcomes
It is anticipated that by gathering this data, it will inform PCC and HDUHB with a better
understanding of the patient journey, from reasons for admission and discharge
arrangements to community response for the pilot ward area. This data will be used to
help inform future service planning, any new models for management of demand and
inform commissioning decisions.
Releasing Time to Care: Occupational Therapy Review of Domiciliary Care

To review current manual handling practices within Pembrokeshire & release time to care.
This project is part of delivering the Service Improvement plan 2016/17. Based on
evidence from other UK authorities the cost of care can be significantly and safely reduced
by changing existing working practices in relation to manual handling. In other areas this
has been achieved by focusing increased occupational therapy capacity to review existing
care packages, be involved in the assessment of new requests for double handed care
and influencing a change in practice in the wider workforce and care providers. The end
user experience is also significantly enhanced when a single carer is present when
compared to 2 carers with evidence showing that people have more meaningful
interactions and better satifaction rates. The current custom and practice of providing 2
carers for most manual handling tasks will require a whole system approach to change
with engagement needed from across the spectrum of heath and social care & provider
services, training and equipment provision.
46
Identified Services to Support Delivery of Intermediate Care Fund (ICF) Objectives
Section 1: Frail and Older People
Total region allocation
£4,064,920 (Net, after deductions for regional programme coordination and

Carmarthenshire area coordination)
Identified services to support End of year projected 2016-17

delivery of ICF objectives – ICF Outcome(s) for each service funding
Guidance paragraph 2.2 refers allocation –
ICF Guidance
refers
Review of high cost packages • People are supported with £139,260

(Pembrokeshire) maximum care that meets their
individual needs and maximises
Project Lead: PCC Jo-Anne
independence
Jones
PIVOT, Care and Repair and • Inappropriate admissions £234,836

Community Support Workers avoided
• Timely and effective discharges
(Pembrokeshire)
• Improved opportunities for
Project Lead: PAVS Michelle independent living in the
Copeman community
• Improved quality of life for
service recipients
• Improved integrated working
with the 3rd sector
• Reduction in social isolation for
individuals
Community innovation and • Increased community capacity £30,000

resilience grants to support independent living
(Pembrokeshire)
Project Lead: PAVS Michelle

Copeman
Additional step up/ step down • People regain their £189,315

independence closer to home in
47
beds Hillside and Bro Preseli a supportive environment that
helps build their confidence.
(Pembrokeshire) • People are supported to
improve or learn new skills to
Project Lead: PCC/HDUHB Claire
support their independence with
Sims
the support of trained
professionals
• Integrated service provision
utilising shared resources
Extension of reablement contract • Minimisation of DTOC for £174,598

patients requiring reablement
(Pembrokeshire)
support in the community
Project Lead: PCC Chris • Saved bed days through timely
Harrison discharges
• Positive impact on quality of life
of those who have received the
service
Push/ pull post for reablement/ • Individuals enabled to regain/ £30,553

hospital interface maintain optimum independence
• Control, choice and dignity in
(Pembrokeshire)
care
Project Lead: PCC Jason • LA care resources used
Bennett effectively
• Reduction in care provision for
individuals
• Efficient use of staff knowledge,
skills and capacity
• Reduced risks with moving and
handling
• HB resources shifted towards
community from acute provision
• Released resources and
capacity
Multi Agency Support Team • Reduction in hospital £254,000

(MAST) admissions
• Improved personal and
(Pembrokeshire)
functional outcomes for people
Project Lead: PCC/HDUHB Claire using the service
48
Sims
Care at Home Team • Development of the In house £205,024

Team
(Pembrokeshire) • Match capacity with demand of
End of Life and complex
Project Lead: HDUHB Sonia Hay packages
• Contain commissioning budget
within resource, with 1%
savings identified in Quarter 4.
Total: £1,257,586
Section 2: Learning Disability and Complex Needs
£487,558 (Net, after deductions for regional programme coordination)

ICF Guidance
refers
Learning Disability Service • People with learning disability £130,869

remodelling are able to live more
independent lives
(Pembrokeshire)
• People with learning disability
Project Lead: PCC J Griffiths and have greater choice and control
C Harrison in how their needs are met
• People with learning disability
have a greater voice and say in
services
Total £130,869
Section 3: Other (Revenue)
49
£80,786

ICF Guidance
refers
Total £0
Section 4: Capital
£1,301,00

ICF Guidance
refers
PIVOT, Care and Repair and • Timely and effective discharges £30,000
Community Support Workers • Improved opportunities for
independent living in the
(Pembrokeshire)
community
• Improved quality of life for
service recipients
• Improved integrated working
with the 3rd sector
• Reduction in social isolation for
individuals
Community innovation and • Increased community capacity £30,000

resilience grants to support independent living
(Pembrokeshire)
50
Community Equipment • More people supported to live at £104,000
home
(Pembrokeshire)
• Increased independence and
quality of life for individuals
• Individuals signposted to
appropriate community services
using mobile technology
• Community resilience increased
through development of
services
• Reduction in hospital
admissions through use of
mobile technology
• Improved personal and
functional outcomes for people
using the service
Housing Adaptations • People are supported in the £90,000

community through reablement,
(Pembrokeshire)
on discharge from hospital and
avoiding unnecessary
admissions; to maintain
independence.
• People are supported to live
independently as part of a
transition pathway
• To reconfigure existing in house
residential provision to enable
people to transition into adult
services in a supportive way,
which allows people to develop
skills and confidence which will
enable them to live more
independently
Predictive software for GPs and • More responsive and timely £20,000
IT enhancement to support agile services
working for health staff
(Pembrokeshire)
51
Learning Disability Service • People with learning disability £125,822
remodelling are better equipped to lead
independent lives and are
(Pembrokeshire)
supported by their local
communities through
employment, skills
development, training and
volunteering opportunities
Total £399,822
West Wales Population Assessment

On 15th December 2016, the Regional Partnership Board approved the Population
Assessment and agreed that it should pass through the decision making process of the
statutory partners for their endorsement. Members of the Board acknowledged the
considerable work which had gone into the document and noted the benefits of the
regional, collaborative approach that was taken in understanding the Assessment and
agreed it provides a sound foundation for future collaboration.
A Regional Collaboration for Health (ARCH)

ARCH is a unique collaboration project between the three partners of Abertawe Bro
Morgannwg University Health Board, Hywel Dda University Health Board and Swansea
University. It spans six local authority areas of Ceredigion, Pembrokeshire,
Carmarthenshire, Bridgend, Neath Port Talbot and Swansea. Recent meetings of the
County Team and Dr Rebecca Hill - Well being lead will support the priortiy of Goodwick
and Fishguard.
52
Annual Plan 2017/18
Supporting and Enabling Plans
IM&T Strategic Outline Programme

March 2017
YR HYWEL DDA
A GAREM
THE HYWEL DDA

WE WANT
Version: 2.0
Date: November 2016 Page 1 of 59
Hywel Dda University Health Board - Strategic Outline Programme
Document Location
The source of the document will be found on the Information Services shared network folder
under:
C:\Users\an092307\Desktop\Working Documents\Strategic Outline Programme.docx
Revision History
Date of this revision:
Version No. Revision date Summary of Changes Changes

marked
1.0 01/08/2016 Initial document -
2.0 07/11/2016 Updated following comments from the Senior Informatics No
Team
Approvals
This document requires the following approvals.
Signed approval forms are filed in the Management section of the project file.
Name Date of Version

Approval
Karen Miles, Director of Planning, Performance and Commissioning
Anthony Tracey, Assistant Director of Informatics
Distribution
This document has been distributed to
Name Date of Issue Version

Karen Miles, Director of Planning, Performance and Commissioning
Anthony Tracey, Assistant Director of Informatics
Executive Team
IM&T Steering Group
Information Governance Sub-Committee (IGSC)
Clinical Informatics Group
Business Planning and Performance Assurance Committee
Capital Estates and IM&T Sub-Committee
Version: 2.0
Contents
1 Executive Summary.................................................................................................... 4
1.1 Introduction ............................................................................................................... 4
1.2 Recommendation ....................................................................................................... 6
2 Purpose ..................................................................................................................... 7
3 The Strategic Case ...................................................................................................... 8
3.1 Organisational Overview ........................................................................................... 8
3.2 National Context ........................................................................................................ 8
3.3 Business Strategies .................................................................................................... 9
3.4 Delivering the benefits of Digital Healthcare within Hywel Dda ............................. 13
3.5 Programme Investment Objectives ......................................................................... 14
3.6 Existing Arrangements ............................................................................................. 15
3.7 Business Needs......................................................................................................... 16
3.8 Potential Business Scope ......................................................................................... 17
3.9 Service Requirements............................................................................................... 18
3.10 Programme Benefits Realisation ............................................................................. 18
3.11 Programme Risks ..................................................................................................... 30
3.12 Programme Constraints and Dependencies ............................................................ 30
4 The Economic Case................................................................................................... 32
4.1 Critical Success Factors ............................................................................................ 32
4.2 Main Options ........................................................................................................... 32
4.3 Preferred Way Forward ........................................................................................... 33
4.4 Deliverables and Timescales.................................................................................... 35
5 The Commercial Case ............................................................................................... 39
5.1 Commercial Strategy ............................................................................................... 39
5.2 Procurement Strategy .............................................................................................. 39
6 The Financial Case .................................................................................................... 40
6.1 Indicative Capital Requirements .............................................................................. 40
6.2 Affordability ............................................................................................................. 42
7 The Management Case ............................................................................................. 43
7.1 Programme and Project Management Arrangements ............................................ 43
7.2 Programme/Project Reporting Structure ................................................................ 44
7.3 Programme Milestones ........................................................................................... 44
7.4 Programme Assurance............................................................................................. 45
Appendix 1 ......................................................................................................................... 47
Version: 2.0
1 Executive Summary
1.1 Introduction
This Strategic Outline Programme (SOP) document sets out a programme of strategic
investment in Information and IM&T to enable the provision of high quality care and
support service change and modernisation across Hywel Dda University Local Health Board.
This SOP details the technical infrastructure and information required to deliver the Health
Board’s Integrated Medium Term Plan (IMTP) and is, therefore, integral to the success of
the Health Board’s strategic plan for clinical services.
The SOP will provide the capital investment required to deliver the benefits of Digital
Healthcare and Information Governance within Hywel Dda Strategic Change Programme;
• Providing patients with electronic access to the information needed to better

manage and control their personal health outcomes
• Providing patients with confidence that their personal health information is
managed in a secure, confidential and tightly controlled manner
• Ensuring the right patient health information is electronically made available to the
right person at the right place and time to enable informed care and treatment
decisions
• Ensuring that the IM&T digital strategy is an integral part of the transformation
agenda in order to assist operational improvement.
• Enabling electronic access to appropriate healthcare services for consumers within
remote, rural and disadvantaged communities
Specifically the capital will be used to support, but also recognises and augments the
development and delivery of national IM&T products and services provided by the NHS
Wales Informatics Service (NWIS) by dovetailing with the “National Informed Health and
Care Strategy”. The Welsh Government vision is set out in four areas, and the high level
vision for Hywel Dda has been matched against the national context;
National Informed Health and Care Strategy Hywel Dda IM&T Strategy
Information for you
People will be able to look after their own well-being • Providing patients with electronic
and connect with health and social care more access to the information needed to
efficiently and effectively, with online access to better manage and control their
information and their own records; undertaking a personal health outcomes
variety of health transactions directly, using
technology, and using digital tools and apps to • Providing patients with confidence that
support self-care, health monitoring and maintain their personal health information is
independent living. managed in a secure, confidential and
tightly controlled manner
Improvement and innovation

The health and social care system in Wales will make • Ensuring the right patient health
better use of available data and information to information is electronically made
improve decision making, plan service change and available to the right person at the right
drive improvement in quality and performance. place and time to enable informed care
Version: 2.0
National Informed Health and Care Strategy Hywel Dda IM&T Strategy
Collaboration across the whole system, and with and treatment decisions
partners in industry and academia, will ensure digital
advances and innovation is harnessed and by opening
up the ‘once for Wales’ technical platform allow
greater flexibility and agility in the development of
new services and applications.
Supporting professionals
Health and social care professionals will use digital • Ensuring that the IM&T digital strategy
tools and have improved access to information to do is an integral part of the transformation
their jobs more effectively with improvements in agenda in order to assist operational
quality, safety and efficiency. A ‘once for Wales’ improvement.
approach will create a solid platform for common
standards and interoperability between systems and
access to structured, electronic records in all care
settings to join up and co-ordinate care for service
users, patients and carers.
A planned future
Digital health and social care will be a key enabler of • Enabling electronic access to
transformed service in Wales. Joint planning, appropriate health care services for
partnership working and stakeholder engagement at consumers within remote, rural and
local, regional and national level will ensure that the disadvantaged communities
opportunities and ambitions outlined in this strategy
are prioritised, with planning guidance issued by
Welsh Government in 2015.
This SOP sets the capital budget envelope at £25m and a revenue implication of £10m over
the five year period 2016-17 to 2021-22. This investment will be phased over the five years
and will address areas of IM&T infrastructure and clinical systems investment in support of
delivery of the Health Board’s IMTP. It is recognised that this will be an ongoing Programme
of work which will under the Governance arrangements outlined within the document. In
essence, the SOP is aligned with the IMTP and the Digital Health Strategy, and these will be
operationalised on a yearly basis to ensure delivery of projects, via the production of an
IM&T Operational Plan.
Individual business cases for major elements of the SOP, will be submitted to Welsh
Government for consideration and investment. The SOP has been approved by the Capital
Estates and IM&T Group and the Executive Team and has the formal support of the Health
Board.
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1.2 Recommendation
It is recommended that the Welsh Government continue to support the proposals set out in
this SOP so that the Health Board can progress to the next stage of Business Case
development for each of the programmes.
Signed:
Date:
Karen Miles
Executive Director of Planning, Performance and Commissioning
Senior Responsible Owner
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2 Purpose
The purpose of this document is to seek approval of the strategic context and the approach
to delivering a programme of IM&T development, which is key to the implementation of
Hywel Dda’s Integrated Medium Term Plan,
This document will facilitate the setting of strategic budgets and the timely production and
submission of supporting Business Cases for specific and phased elements of the
programme.
The SOP has been prepared using:

• Welsh Government - Revised Capital Guidance for the NHS in Wales (18th June
2013).
• Welsh Government - Green Book Guidance on Public Sector Business Cases using the
Five Case Model (October 2012).
• Welsh Health Circular (2007) 052 - Public Sector Business Cases using the Five Case
Model: A Toolkit Guidance and Templates.
• HM Treasury - The Green Book: Appraisal and Evaluation in Central Government:
Treasury Guidance (2003) and supplementary Green Book guidance.
• The Capital Investment Manual (DH, 1994) - plus subsequent updates.
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3 The Strategic Case

This case sets out the national and local context within which this programme has been
developed and demonstrates that the programme has been informed by and will address
both the national and local drivers for change.
3.1 Organisational Overview

Hywel Dda's Healthcare System is currently delivered through four Acute Hospitals, seven
Community Hospitals, eleven health centres, and numerous other locations and settings.
Primary Care Services are delivered by 54 GP Practices some on multiple sites, 67 Dental
Practices, 99 Community Pharmacies; and 52 Optometry premises. By far the majority of
patient contacts are provided in these community settings and in patient’s own homes, with
links to critical clinical and diagnostic services in the main hospital sites, and outside the
Health Board boundaries. This complexity requires dynamic and agile digital capability to
meet the needs of a rapidly changing health service.
Hywel Dda, as with health services internationally, faces a set of increasingly significant
challenges in continuing to deliver high standards of health outcomes, which present the
first set of challenges. These include:
• A large and growing ageing population

• An increasing incidence of chronic disease
• Increasing consumer demand for more costly, complex and technologically advanced
procedures
• Significant differences between the health outcomes for advantaged and
disadvantaged,
• The supply and deployment of skilled health and social care staff
• The challenge of ensuring service delivery across a highly rural geography
Together these challenges are driving increased demands upon healthcare services, costs
and complexity, and are already testing the limits of the financial, physical and human
resources of the Hywel Dda health system. The second set of challenges relates to the way
information is stored, shared and used across the Hywel Dda health system. Healthcare is
fundamentally a knowledge based activity with information being central to all aspects of
patient care planning, management and delivery. Despite this, and with significant progress
in digital implementation, healthcare remains.
3.2 National Context

In developing this Programme we have considered the National Guidance, including:
• Informed Health and Care – A Digital Health and Social Care Strategy for Wales
(2015)
• Bevan Commission Report 2008-11 NHS Wales – Forging the Future
• Together for Health, 2011
• Working Differently – Working Together 2012
• Delivering Local Healthcare 2013
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• NHS Wales Delivery Framework 2013-14

• The Williams Commission January 2014
• Setting the Direction 2009
• 1000 Lives Programme 2010
• Delivering Safe Care, Compassionate Care NHS Wales August 2013 (Welsh
government’s response to the Francis Report)
• Keogh Mortality Review 2013
• The Robert Powell Investigation October 2012
• Delivering a Digital Wales: the Welsh Assembly Government’s outline framework for
action December 2010
• Informing Healthcare 2003 /04
In addition, the Health Board is actively engaged with the national informatics planning
processes and, therefore, local and national informatics plans are fully aligned.
The documents highlighted above emphasise the need to:

• Provide high quality, real-time information in order to reduce waste, variation and
harm
• Ensure that information plays a positive role in informing the public; supporting
patient choice and highlighting accountability and inadequate performance
• Develop integrated systems with common information practices
• Confidently and competently use data and other intelligence for the forensic pursuit
of quality improvement: making the information held currently in paper record
available and accessible will support the delivery of the ‘ambition.
• Promote communication to ensure continuity of care
• Support involvement and communication with patients and their families
• Respond more effectively and improve patient experience
• Ensure close alignment between the health needs of the local population and the
services delivered
• Deliver safe, high quality services, which demonstrate efficiency and value for money
• Become more outcomes focused
• Develop integrated health and social care services for patients and alongside this
care closer to home
• Improve opportunities for self-management and access to healthcare information
• Maximise innovation and new technologies to deliver efficient and effective care
• Work in partnership with NWIS in the co-production of national IM&T products.
3.3 Business Strategies

3.3.1 Changing for the Better
The Health Board’s Integrated Medium Term Plan 2014-2017 sets out to achieve major
transformational change.
This strategic programme is based on an initial vision for IM&T in the Health Board that
takes account of the current position and future potential of IM&T in the organisation and
the national strategy and IM&T programme in Wales
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The diagram below illustrates the functions at a patient, profession and organisation level,
and the interaction between them is at the heart of the Health Board’s Vision.
Nuffield 2016
The above framework outlines the future development of the programme in that we will
allow for the a greater level of dialogue across the organisation of how the IM&T Strategy
can be shaped as a key enabler to the delivery of the emerging Clinical Strategy. Also how
IM&T will need to support the organisation with the delivery of IMTP Programmes,
particularly high priority programmes delivered through the proposed Programme
Management Office.
3.3.2 Five key areas of Opportunity

In initiating the dialogue within the organisation we can set out 5 areas of opportunity for
the Health Board
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Key Opportunity Examples

1. More systematic, Improve the use of clinical information The implementation of MTeD (Medicines
high-quality care to support decision making, to deliver Transcription and eDischarge) will
high-quality care. improve clinical decision making. – Pilot
already underway, further roll out 2016-
18
2. More proactive Use real-time patient monitoring to Bed side observations, electronic patient
and targeted care deliver more proactive and targeted flow systems – Pilot already underway,
care, reducing costs and improving further roll out following an assessment
outcomes. of the pilot. If approved implementation
2016-19
3. Better coordinated Reduce the cost and harm that come Improved use of WCCG (Welsh Clinical
care from poor communication and Communications Gateway) and advice
fragmented care by developing emails between Primary and Secondary
information technology systems to Care – Anticipated during 2016/17
integrate and coordinate care.
GP Test requesting improving the quality
of the test request, and the results going
directly back to the GP system. –
Completion date Dec 2016
Welsh Community Care Information

Solution (WCCIS). The integration of
Primary / Secondary / Mental Health and
Adult / child service through WCCIS. – No
date agreed. Ceredigion LA going live in
July 2016, discussions underway with all
parties (Local Authority / Health Board)
to bring forward the proposed date of
2018
4. Improved resource Improved resource management to Outpatient Modernisation, Service level
management plan staff rosters and patient flow, reporting, improved budget
match capacity to demand and management, eRostering, etc – Work to
improve scheduling. begin during 2016/17, however this will
span a number of years.
5. Improved access to Use telehealth to reduce costly Extending the use of telehealth and
specialist expertise referrals, avoid admissions and Skype within the Health Board –
unnecessary appointments, and Anticipated during 2016/17
improve the ability of professionals to
get things right first time by providing Improvements in direct diagnostics
access to specialist expertise and (Pathology / Radiology) removing the
advice easily and in real time. need for possible duplication of tests –
Work to begin during 2016/17
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Strategically the above will need to be supported by
3.3.3 Culture change and new ways of working to connect, adopt and deliver
change
User-centred design to shift the focus from delivery of national systems to the needs and
requirements of patients and professional users
Support interoperability both within Hywel Dda and across organisational and geographical
borders through shared planning
3.3.4 Strong information governance

Operationally the above will be supported by embracing the following as key enablers of the
strategy delivery;
3.3.5 Transformation and Culture Change

Transformation comes from new ways of working, not the technology itself. A
transformation programme supported by technology is needed.
How – Using the QIPP process to drive change in working practices which in turn utilises
technology as the enabler.
How – Improvements in engagement with clinicians (Drs / Nurses / Therapists) as well as

patients.
How – The IM&T Strategic Outline Programme (SOP)
3.3.6 Investment in analytics

Improving productivity requires extensive redesign of work processes, the use of predictive
models to reduce variation, allocate resources, and anticipate demand. None of this is
achievable without analytical tools available to clinicians in real time and sophisticated
support for planning, performance management and improvement.
How – Investment within the Information analytical function
3.3.7 Strong information governance

Data sharing requires strong data governance and security, particularly in the face of a
growing threat from cyber-attacks. Action is required at national and local levels to help us
hold and share data safely, and also to enable citizens to own and share information if they
choose to.
How – Improved Information Governance presence, use of such tools like WIIAS (Welsh
Intelligent Integrated Audit Solution).
How – Using Information Governance to drive clinical change and behaviours
How – Adoption of the latest Information Governance Toolkit, ISO 27001 etc in order to
embed best practice
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The vision therefore outlined in this chapter is designed to give the overall sense of
direction, but also recognises that any IM&T strategy needs to be dynamic and agile to
respond to the rapidly changing clinical and technological environment.
Benefits
Patient: Professional: Organisational
Connect, Adopt, Deliver
Joint Patient
Integration and Flow and
Experience and Governance
Planning Communication
Modernisation Productivity
Enabling Infrastructure Investment
3.4 Delivering the benefits of Digital Healthcare within Hywel Dda
3.4.1 Principles
The strategy is built on best practice and is based on a number of key principles which are
outlined below:
• Utilising IM&T as a critical enabler to support service modernisation
• Supporting the redesign of administrative and clinical processes to maintain high levels
of data quality, ensure information is accurate and up to date, and help deliver safer
patient care
• Focusing on recording information for clinical purposes (primary use of data) rather than
cleansing existing data outputs for secondary purposes
• Automating and streamlining processes wherever possible
• Reducing transcription and duplication of data recording
• Providing a patient-centred view of information by linking clinical records held on
different departmental systems
• Providing a shared view of information across primary, secondary and social care
wherever possible
• Investing in a robust, reliable and resilient IM&T infrastructure which supports access to
information at the point of care.
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• Utilising intuitive and interactive reporting tools to access key organisational information
• Identifying opportunities to move from paper to paper light electronic records.
Over the next five years, we aim to implement a range of technology solutions to maintain
our existing infrastructure and systems, to grow our capacity and capability and to embrace
innovative technologies. These solutions are required to support the delivery of Integrated
Medium Plan over the next five years and will support significant service modernisation and
efficiencies across primary, secondary and community care. All are based on the
fundamental premise that high quality care in the 21st century cannot be delivered with
paper based information recording and delivery.
The scale of the investment required to ensure delivery of more efficient, effective and
sustainable informatics services across primary and secondary care is not supportable under
Hywel Dda’s discretionary programme. Hywel Dda therefore plans, through this SOP, to
seek financial support from the All Wales Capital Programme to fund a number of
technology solutions. The Health Board also recognises that the future level of discretionary
capital investment into IM&T will need to increase beyond historical levels.
It is proposed to phase these technology solutions over a five year time frame. The
timescale for implementation has been informed by the delivery plans for the Strategic
Change Programmes. Section 4 the Economic Case sets out the proposed phasing for the
proposed technology solutions included in this SOP, but this will be subject to available
funding and approval timescales.
3.5 Programme Investment Objectives

The investment objectives reflect the strategic objectives of the IMTP and specifically the
objectives of the Digital Health Programme. From an informatics perspective this involves
access and recording of electronic information in real-time, which underpin the principles
set out in the all Wales Digital Health Strategy, and represent best industry practice.
Investment Description
Objective
Improve access To maintain and develop the IM&T infrastructure to provide access to
information at the point of care across healthcare settings for staff,
patients and carers
Increase To ensure technical infrastructure is robust, resilient, sustainable and
robustness and highly available for access to clinical resources at all times.
resilience
Provide patient To provide joined-up electronic information at the point of care and
centred significantly reduce the need for the paper casenote and the associated
electronic risks, which in turn will increase electronic recording.
record
Streamline and To significantly reduce, duplication, error and process inefficiencies by
automate automating and streamlining current working practices through the
processes better use of Information, Communication and Technology.
(clinical and
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Investment Description
Objective
non-clinical) To innovate and respond rapidly to clinical developments with effective
tools for recording and displaying information that support operational
workflow.
Support To significantly reduce clinical risks by providing instant access to
improvements complete and up-to-date information. Improve the way we collect and
in patient analyse information so that it is available to clinicians, managers, the
safety and Board and the public when it is needed to aid decision making, improve
quality standards and hold individuals and services to account
Alignment with To ensure products and services support the delivery of national and
national Health Board priorities.
strategy
3.6 Existing Arrangements

Primary care IM&T services are provided and supported by NWIS on a national basis and are
comparatively well resourced. Hywel Dda works with GPs on the electronic transfer of
information to and from primary care utilising the national product, Welsh Clinical
Communications Gateway (WCCG). All GP practices within the Hywel Dda area have the
facility to send electronic referrals, however only 40-50% of referrals are currently being
sent electronically.
From a secondary care perspective, IM&T is less well resourced (IM&T spend accounts for
<0.8% of total revenue). Priority is given to ensuring that the technical infrastructure is
refreshed and maintained to provide robust and resilient access to existing clinical and
administrative systems as well as consolidating systems to provide common platforms
across the Health Board wherever possible. Where capital investment has been provided
over recent years, it has been used to replace aging personal computers, laptops, printers,
servers/systems, networks and telephony equipment. There are currently over 2,500 PCs
and laptops that are more than five years old, meaning that they operate slowly in
comparison to newer devices. An immediate investment is required to address the backlog
of equipment to ensure that no equipment is over 5 years old and then a funding of
approximately £2.0m per annum for the next five years to continue the refresh cycle. The
refresh programme will form an integral part of the SOP and will be a specific programme of
work which will not only cover replacement of PCs, but will cover the wider infrastructure,
i.e. networks, telephony and servers.
There is a wireless infrastructure in three of the four main hospital sites although some core
components are over seven years old and at the end of their recommended life. One site as
little or no wireless infrastructure which is hampering the innovation of that site.
Maintaining the existing IM&T estate continues to be a challenge in the current economic
climate. From a systems perspective, there remains much work to be done to consolidate
systems across Hywel Dda, following Trust merger in 2008. A significant milestone was
achieved with the implementation of a single Patient Administrative System (Myrddin – the
national PAS) across the Health Board in November 2013.
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Service modernisation and changes to patient pathways have moved ahead without having
fully in place the technology and information required to support these new ways of
working. Enthusiastic clinicians have developed or purchased electronic solutions to
enhance some services, but this information is not always joined up or available outside of
the department. From a patient record perspective, the paper case note continues to be the
primary record of care. There is considerable inefficiency in the current processes, where
the paper note is transported from site to site to support new patient pathways where
many patients are now moving between sites for different components of their care. It is, of
course, not possible to move paper quickly or efficiently between sites and the lack of an
electronic record means that sharing information is problematic. Many components of the
health record (pathology and radiology results, referral, clinic and discharge letters, for
example) are available electronically. Recording information in real time is almost
exclusively a paper based process.
Investment in IM&T in community services is more limited and generally available only from
practice bases. Patient notes are in paper format and therefore access is limited. There is
limited access to health systems from social services and vice versa.
3.7 Business Needs

The following table highlights the business need for the SOP and how the improvement
Investment Current Position and associated problems

Objective
Improve access Ageing technical infrastructure in routine operational use, which carries significant
increasing risk of system outage/failure. The lack of sufficient capital investment results in a
targeted replacement programme. Of the 8,400 devices currently in use over 3,000 are over
5 years old, which means they are more prone to failure and have slow response times.
In order to deliver the service changes outlined in the Health Board IMTP, increasing access
to devices in patient’s settings and particularly on the hospital wards is a key priority along
with expanding the availability of Wi-Fi across all sites within the Health Board, inclusive of
Mental Health and Learning Disabilities.
Community staff currently only have access to IM&T at their base, and the primary record is
contained on paper in the patient’s home. Our aim is to provide integrated community
based services for our population underpinned by effective mobile technology solutions.
Increase Historic investment in backend systems and storage means that the Health Board has robust
robustness and and highly available systems. It is essential that these continue to be replaced in line with
resilience warranty periods. Increased use of electronic systems will require additional systems and
storage capacity to meet demand and ensure systems remain highly available.
The underpinning network has received significant investment in the core network (essential
to the running of the whole network) but the edge equipment which delivers network
services and telephony to departments is on old and unsupported equipment. Any failure in
this equipment means lack of access to computer services and telephony in a particular
area, for example an outpatient building.
Provide patient Whilst the Health Board has made some progress in consolidating systems and increasing
centred electronic ways of working, the main patient record in secondary and community care
electronic settings remains paper based. The Health Board has 2,100,000 paper casenotes which are
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Investment Current Position and associated problems

Objective
record increasingly more difficult to make available as services are now routinely delivered across
many healthcare settings and sites.
Where we are now in hospital settings:

• Paper casenotes are the only place where the majority of patient information is
collected together to support patient care.
• New patient information continues to be created on paper on a daily basis
• Multiple disparate electronic systems not centred around the patient and often not
integrated
Where we need to be:

• Structured approach to the digitisation of the paper records to deal with the legacy.
• Eliminate the reliance on paper by ensuring that new patient information is
captured electronically at the point of care.
• Single electronic portal of patient records containing all patient specific information
from multiple sources in one intuitive, clinically focused live view.
Streamline and The Health Board is still heavily reliant on paper, faxed based systems and ineffective use of
automate email in both clinical and administrative processes.
processes
(clinical and There are huge opportunities for improved efficiencies through the implementation of
non-clinical) structured electronic data capture and workflow systems and processes, for example:
Introduction of the real time recording of admissions, discharges and transfers will facilitate
the effective flow of patients through their hospital stay.
Support The move from paper to electronic records will significantly reduce clinical risk by providing
improvements instant access to complete and up-to-date information. In addition, the live view of patients
in patient described above, will enable the recording of clinical information such as electronic
safety and requesting and reporting of diagnostic tests, patient observations and clinical alerts,
quality electronic prescribing and pathway delays.
Alignment with In order to adhere to the national strategies, policies and guidance identified in section 3.2,
national there is a significant requirement to provide effective solutions through the use of
strategies technology. The need for innovation is unprecedented, and prioritising across competing
demands has been, and continues to be, a huge challenge.
The way forward must be to continue to work closely with NWIS in the delivery of national
products and services. Where solutions need to be deployed locally, the joint working
described above will ensure strategic fit and alignment with the national strategy.
3.8 Potential Business Scope

This SOP includes all services currently provided by Hywel Dda and supported by IM&T.
Some of the proposed technology solutions will also extend the scope of the current
‘customer base’ to include organisations working with Hywel Dda to deliver integrated
services and patients and the public accessing future ‘customer facing’ IM&T related
services.
For clarification:
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• Investment for GP devices and systems is already provided through the National
Programme.
• There is central investment provided by NWIS for a number of national solutions e.g.
LIMS, PACS, IHR & WCP
In order for Hywel Dda to progress towards 2030 it must focuses on four specific changes.
Two developments involve harnessing the power of knowledge to improve care.
Improvements in digital technologies to enable the use of personalised medicine. New

digital technologies also allow people to track and analyse their own health data, and to
share this and other health knowledge with others in ways that will aid prevention and
management of long–term illnesses.
Two developments making better use of the power of people.

• Social innovation is the key to a revolution in how people are involved in their own
care and that of others, improving the quality of care.
• New insights into human behaviour will improve clinical quality and make it easier
for people to lead healthy lifestyles.
This is not to say that there will not be other innovations in healthcare in the coming 15
years: medical science will of course advance, new drugs and devices will be developed, and
management practices will evolve. Any future strategy for the health service will need to
make the most of these too. It will also need to address head–on issues like the relationship
between how services are designed and inequalities in the health of the Hywel Dda
population. Tackling public health issues like obesity will need sustained engagement with
the food and drink industry and new approaches to regulation
3.9 Service Requirements

Appendix 1 summarises the Informatics requirements across the Health Board by Strategic
Change Programmes that will be included within the SOP
3.10 Programme Benefits Realisation

This strategic enabling programme requires investment to provide for better and more
widespread access to and use of electronic information in support of the plans for clinical
service development and modernisation set out in the Hywel Dda IMTP. Whilst there will
undoubtedly be benefits directly associated with the delivery of this programme (cash
releasing savings from the availability of electronic health records for example), the majority
of benefits (both financial and non-financial) will be attributed to the introduction of new
service models that the Informatics SOP enables. These financial benefits are being used to
support the costs of delivering transformational change across the Strategic Change
Programmes. Any additional revenue required to support new IM&T services will be
provided from the savings accrued from the delivery of these new clinical service models.
The table below outlines the benefits to be delivered by each technology solution.
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Programme of Work Service Improvements / Requirements Benefit

Community Technology Project - Provide improvements to community and social care services Support the implementation of an integrated service model for
inc Telehealth through the use of technology. The aim of the proposed project is health & social care - Enables detailed record of community
to improve health and social care for older people by: intervention to link to Primary and secondary care events and
systems.
• sharing information in order to better coordinate care and • Community Information available at hospital admission sites
utilise resources more effectively offers alternative care option and facilitates earlier discharge.
• providing support and active monitoring that allows clients to • Maximising staff time for direct care and removing duplication
remain in their own home or care setting and reduce the and travel reduces costs and increases capacity.
need for admission to hospital • Standardised electronic information enables outcome and
• enabling earlier intervention to support and maintain health performance reporting.
and well being • Referral to assessment pathway electronically tracked.
• supporting carers to manage clients effectively within existing
settings without the need to admit to hospital
MTeD MTeD (Medicines Transcribing and e-Discharge) is an electronic Medicines Transcribing (MT) will improve medicines management by
way of recording a list of medications for a patient and adding allowing hospital pharmacists to transcribe patient medications
them to an electronic discharge advice letter (e-DAL). The e-DAL is electronically. This will support the patients from admission to
then sent to the patient’s GP as soon as they leave the ward, via discharge. e-Discharge (eD) will enable clinicians to record a
the Welsh Clinical Communications Gateway. summary about a patients hospital stay. The DAL (Discharge Advice
Letter) will then be transmitted electronically to GPs via the Welsh
Clinical Communications Gateway (WCCG).
MTeD will help to establish a consistency in discharge

communication from secondary to primary care
In addition to the above;

• Improved compliance with national/local standards
• Additional devices to improve access for clinicians to the
electronic discharge summary system
• Significantly improve completion of high quality discharge
communication to GPs
• Improved availability of summary information to increase
coding completion and meet Tier1 target rates
Community Care Information Implementation of the community care solution across Health and Health and social care practitioners will be able to make more
Solution Social care. informed, appropriate and timely decisions regarding patient’s
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treatment and care.
The increasing availability of patient / client information will allow
practitioners to provide services to a greater proportion of their
patients / clients - safely and confidently.
A consistent method for creating or viewing data and common

administrative processes will increase the overall speed and
efficiency of information processing within health and social care
services.
Additional benefits will be;

• Support the implementation of an integrated service model for
health & social care - Enables detailed record of community
intervention to link to Primary and secondary care events and
systems.
• Community Information available at hospital admission sites
offers alternative care option and facilitates earlier discharge.
• Maximising staff time for direct care and removing duplication
and travel reduces costs and increases capacity.
• Standardised electronic information enables outcome and
performance reporting.
• Referral to assessment pathway electronically tracked.
Implement Clinical Portal to Development, integration and implementation of the National Patient safety – Doctors will have more information when they are
provide patient flow Clinical Portal to provide patient flow management, single view of treating the patient. This will support decisions and reduce the
management, single view of patient records and enable electronic ways of working such as chance of inappropriate treatment or error.
patient records and enable ePrescribing, test requesting, electronic observations, digital
electronic ways of working such dictation, live ward management across Hywel Dda, and improve Patient focused care – information from a variety of systems and
as ePrescribing, test requesting discharge summary timeliness and quality. sources are brought together.
and electronic observations
Increased efficiency - Clinicians working in different hospitals will be
able to undertake clinical processes in the same way where ever
they work. For example, requesting a blood test for a patient will
follow the same online process in all hospitals.
Single log-on – clinicians will only need to log on once to access
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information taken from a number of clinical systems.
Positive patient outcomes increased - Easy access to relevant clinical

information increases speed and relevance of diagnosis, care
treatment planning and onward referral.
Implement Transactional Enterprise Content Management will form the basis of collecting A dedicated infrastructure will provide a platform for access to and
Infrastructure - Portal, Forms, clinical and administrative data in a structured format enabled by input of information on mobile devices and fits in with the Health
Workflow, Document rapid forms development with workflow for assigning tasks or sign Board's strategy on mobility which will bring huge change to the way
Management and Intranet off. we deliver healthcare services. This will also provide collaborative
Replacement. opportunities by using Knowledge gathered through experience and
shared through the social platforms in order to improve decision
making and reducing chances of committing errors.
Uses will include: supporting direct patient care such as the Pre-
Assessment process; and also in non-clinical areas such as human
resource workflows.
Outpatients Modernisation Reduce paper-based working by introducing across the HB Make doctors start sessions on time.
(Including patient self-service electronic patient check in services, electronic recording of patient Do not create a pool of patients at the start of the clinic.
checking in system) information and outcomes. Develop electronic workflow and clinic Ensure that doctors are not disturbed during sessions.
views between clinicians and admin support. Provide patients with Improve appointment/patient scheduling.
electronic interfaces with the OPD service to include appointment Educate doctors and others about effective operation of the system.
booking and reminders and provide information and general Provide better facilities for waiting patients.
communications. Investment in equipment in years 2 and 3.
Additional benefits to be seen are as follows;
• Implement patient focused booking -to increase clinic
utilisation rates; increase efficiency of outpatient booking
processes and reduce waste
• Reduce waiting times(increase compliance with RTT) through
more effective use of clinic slots
• Improved patient throughput and experience through faster
check in and out processes
• Reduction in Reception resources
• Single view of patient electronic documents across the
organisation: referral letters, clinic letters, discharge
summaries, results and images etc
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• Increased availability and timeliness of clinical information
• Reduced clinical time spent trawling through volumes of notes
• Reduction in transport/ admin costs
Workflow Automation Development of linked processes, push data updating and The following benefits will be released from this programme of
intermediary applications to iteratively improve the workflows work;
across the whole health sector use of automation software to
codify manual transactions and support using virtual 'robots' • Improved management and efficiencies in the provision of pre-
assessment services
• Improved availability of pre-assessment information to support
improvements in surgical pathways
Provide better information Development of digital Dashboards to support automated The benefits of a digital dashboard custom built for the Health Board
through the use of digital information delivery for Patient Flow, Unscheduled Care, Planned can provide a live stream of information to top level personnel. A
dashboards Care, Maternity Services, Theatres, etc. dashboard will allow end users to work with complex data
relationships and monitor key performance indicators even if they
are not trained data analysts. Immediate, critical awareness of
essential company information gives a distinct edge in the decision
making and management process.
All of the data that goes into a digital dashboard is already available
through other tools and reports. The advantage of using a Digital
Dashboard is that even immensely complex information collected
across multiple sources can be evaluated and digested quickly.
In addition the following benefits will be seen;

• Improved performance information through the use of digital
dashboards, supporting robust service improvement decision
making
Electronic prescribing and Implementation of Electronic Prescribing and Medicines Strategic reasons for undertaking an EPMA implementation are
Medicines Administration Administration (EPMA) across Hywel Dda. EMPA replaces the mostly around patient safety:
current paper prescription and administration record chart
normally completed for every in-patient, as well as discharge and • Improving the quality of prescribing and medicines
outpatient prescription forms. administration processes and records.
• Reducing some of the risks associated with prescribing and
medicines administration process
• Reducing the occurrence of adverse events associated with
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prescribing and medicines administration.
Electronic White Boards/ Patient Procurement and implementation of patient observation & flow The electronic boards are “a bed management solution; its core
Flow management solution, to facilitate robust and effective functionality compliments and drives the patient journey, ensuring
management of hospital at night priorities, and to provide timelier responses and improved quality of care. In turn, this drives
Wireless & Integrated electronic observation recording and management. bed management and provides real time indicators of current bed
Communications. Patient Flow state right across the Health Board.
management across three major It is recognised that patients flow through different settings within
hospital sites the Health Board and the data collected at each part of their In addition to the above, the following will be noted;
journey does not always flow seamlessly with them. The need for • Improved performance information through the use of digital
accurate and real time data has been identified and one way of dashboards, supporting robust service improvement decision
achieving this is electronic patient’s boards that not only link the making
wards, but feedback live data into the clinical systems.
Making the patient record Develop and implement a Clinical Electronic Records Management The aim is to provide assurance for Information Governance around
available to the clinician System, moving from a manual paper health records system to an record storage by scanning and also bringing back records to Health
whenever necessary, either electronic scanning viewing and creating of records system. Board bases (or electronically via scanning) that are currently held
directly as an electronic record or (and financed) off site.
via a scanned image of a paper
record The benefits can be noted as
• Improving Accessibility
• Improvement in the tracking of records.
• Audit trail.
• Cannot be mislaid.
• Paper Light.
• Effective use of staff.

• Single view of patient records across the organisation
• Reduction in missing notes/cancelled patient appts / increased
utilisation of clinic slots
• Reduced clinical time spent trawling through volumes of notes
• Reduction in transport/ admin costs
• Improved Health & Safety environment for staff / reduced
claims
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• Increased capacity in OP
• Availability of record for unscheduled care reducing clinical risk
• Reduce future capital requirement for health records storage /
freeing capacity in acute hospital sites over time
• Reduction in Health Records staff over time
Electronic Observations Procurement and implementation of patient observation Research has shown that the benefits of electronic observations at
management solution, to facilitate robust and effective the bedside have been noted as;
management of hospital at night priorities, and to provide
electronic observation recording and management. • All patients in the trial had their bedside observations
performed in a timely fashion
• Patients recovered their health faster than previously
• There was a 20% reduction in hospital length of stay
• The use of critical care was less
• No patient had a cardiac arrest in the intervention phase of the
trial
• There was a reduction in mortality of 2%

• Real time access and recording of patient information – live
information available for secondary uses e.g. centralised bed
management, nurse rostering; doctors locating their patients
on wards; integrated electronic discharge system
• Live view of NEWS scores for clinical staff to enable earlier
alerts & interventions for the sickest inpatients
• Live recording and viewing of observations, drug prescribing
and administering, test requesting and reporting
• Availability of live patient information for community staff /
reduction in wasted home visits/ repeat tests etc
• Streamlining & automation of test requesting process =
reduction in resources
Roll out of wireless devices to The upgrades will enable staff to become more efficient and The benefit will be seen by clinicians that need smart, portable,
support clinical care effective and ultimately help to improve patient care. point-of-care solutions for capturing and transmitting data, as well
The new infrastructure will increase wireless access points and as routine communication. They also want technology to reduce
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enable staff greater choice on mobile devices – laptops, tablets demand on nursing time by eliminating waste in care resulting from
and windows based mobile devices. inefficient workflows.
It will also support a planned rollout of mobile, clinical applications

across the Health Board.
Procure and implement a single The implementation of a single emergency department clinical • Paperless system in order to manage the flow of patients
ED system across the information system across South Wales. The system has been through the ED,
organisation identified by a National competitive dialogue procurement • Availability of real time info in order to identify bottlenecks in
process. the ED pathway and improve the compliance on ED Tier 1
targets
• Improved provision of communication to GPs
• Potential to manage ED status across South Wales to support
effective management of unscheduled care services
• Improved management of child protection and 'frequent flyer'
issues across Wales
National Health Records The WCRS will enable the creation and storing of a wide range of The benefits of the WRCS include the standardisation of
Repository (Welsh Care Record documents in the Welsh Clinical Portal including letters, referrals, documentation and establishing a Welsh Records Service is
Service) discharges, assessments and case notes. therefore the key to enabling the quality agenda, reconfigurations
and the transformation of services closer to home.
Patient Feedback System This provide instant feedback on healthcare and services provided To enable proactive feedback to be captured, processed at scale and
Capturing patient information by the Health Board and will link to the SBR initiative. Initially the in real time as well as ensuring that the information is provided to
built on the implementation of feedback will be completed on patient owned devices the service area in which relates to. Enabling improved transparency
surveys and the provision of free (smartphones and tablets). Investment in devices in 2016/17 will of feedback on experience received by the Health Board enabling
Wi-Fi in Hospitals. provide access to surveys on Health Board owned equipment for uploads of regular summaries and feedback on line to promote
patients that would not have access to personal devices. inclusion and improvements in service provision.
Investment in 2016/17 is for large screens on wards to display live
reporting from surveys and complaints to provide an instant view
on ward performance based on feedback.
Sensory Loss Several of the projects detailed in this plan have an element of Enabling those with sensory loss to access information that can
sensory impairment considerations (central contact centre support them on their care journey. Providing additional channels of
booking systems, text messaging, Wi-Fi expansion etc), as such communication to support care.
IM&T are looking at possible developments we can support to
enable those with sensory impairment to access information that
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can support them and their care journey.
Wi-Fi Expansion We currently have some wireless access in Withybush, Prince A pervasive wireless network across the organisation will become
Philip, Bronglais and Glangwili General Hospitals but it is not more critical to support our mobile workforce, bring your own
pervasive and there are some major gaps. This project will replace device scheme and a proliferation of mobile devices (carts, tablets
our end of life central wireless infrastructure (controls access, etc.) to support bedside access to information and clinical systems
security and manages the wireless access points) and funding (ePrescribing, Test Requesting, Welsh Care Records Service). A
permitting will enable a complete wireless network in Bronglais pervasive wireless network would also deliver “The Cloud” for
and some mental health areas across the Health Board. To expand patient / guest access across the whole Health Board.
across the whole Health Board this project would have to be
repeated for a number of years
Switchboard Consolidation The Health Board currently has 4 switchboard operator locations These include:-
in service (Glangwili, Prince Philip, Bronglais and Withybush
(provide by Welsh Ambulance Service)). This project is to review • Reduction in WTE releasing revenue savings to the Health
the switchboard functions across the Health Board and deliver a Board.
paper of options to the Board with recommendations on how the • Standardisation of working practices
switchboard service should be structured to deliver the best • Reduction in training requirements
service to our staff and patients but also to deliver the best value • Implementation of new technology with the potential to
for money. improve contacts with patients
Telemedicine The various telemedicine projects provide advice and support to These include:-
develop and establish innovative approaches to the delivery of
healthcare services across the Health Board using • Enables remote measuring and monitoring of vital signs
videoconferencing and ‘store and forward’ technologies. Enabling parameters
consultations between a patient and a clinician at different • Provide health information to patients to encourage
locations saving travel costs and time. increased self-management
• Remind patients of upcoming appointments or medications
due.
• The clinician is able to undertake patient review at a
remote location.
• To enable out of hours teams to access information about
patients.
• Increase care in community
Data Centres Movement to a Co-located Data Centre, either private or public Provide Tier 2 standards which could not be done internally.
Uptime guaranteed by SLA's. In line with Welsh Government Data
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sector Centre strategies. Reduction in ongoing capital outlay
Opportunities to adopt Private / Public Cloud technologies
Reduction in power consumption at our main acute hospitals
Infrastructure / Hywel Dda has a large and complex infrastructure containing Reduction in risks associated with our Infrastructure.
Telecommunications Refresh servers, videoconferencing and telemedicine equipment. This is of • 5 year investment plan for our infrastructure
varying age, with some now end of life and support, which • Improved resilience off IT services.
increases risks to the organisation.
Telephony services are critical to the daily operations of the Health

Board and investment is required to leverage modern advances in
communications such as the use of Apps and ensuring old and
legacy equipment is replaced.
Telemedicine and Videoconferencing is used extensively

throughout the Health Board supporting MDT's for Cancer, remote
patient consultations and various meetings. In addition this
technology is a key enabler for the Health Boards IMTP.
Network Refresh Our network supports 6,500 active Hywel Dda users across all our Reduction in risks associated with our Infrastructure.
60 sites and is in some places 10+ years old. This project is to put • 5 year investment plan for our infrastructure
in place a new design for our 4 acute hospitals and a 5 year • Improved resilience off IT services.
framework in place to refresh our network (will require significant
funding). It is envisaged the 2015/2016 discretionary capital The network is critical for the delivery of new and upcoming
programme will enable us to start work at Glangwili General services such as electronic observations, mobile computing and
Hospital. This will be critical development for our users, the
monitoring and alerting of patients.
network is fundamental for delivery of critical clinical services and
as we move towards digitisation of health records, ePrescribing
and electronic discharge it will only become more so.
Equipment End User Timely replacement of personal computers, mobile devices, Reduction in risks associated with old equipment.
Replacement - Procurement of laptops and printers is essential to providing robust and reliable
PCs, Laptops, and Printers access to computer systems which the heath board is becoming Ensuring end user productivity is not impacted by slower devices
increasingly reliant on in order to deliver first class patient care. which require replacement. Reduction in support costs.
Failure to replace this equipment will cause major disruption to Ensures equipment is fit for purpose as the use of IT services
increase
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patient and administrative services.
Single Sign On & Context Sharing Implementation of single sign on toolset to enable clinicians to Time savings for frontline staff (previous studies have shown 45
maximise their working time at commencement of sessions minutes a day)
In addition the context sharing will facilitate a smoother work flow
between solution islands prior to the WCP being sufficiently Reduction in IT support calls for password resets. Reduction in
developed to accommodate this visual data normalisation password sharing leading to improvements in Information
Governance compliance.
Patient Portal to enable; Patient Portal: • Provides information to support the population in taking
• Provide patients within a view of their information held greater ownership of their health and wellbeing
• Access to and add to their within GP systems • Ensures that we are delivering care and access to care using
record • Provide patients with an update of their key contact details methods expected by our population (e.g. digitally, easily & at
• Manage their care better and information times on demand)
• Allow communication with • Provide patients with a view of letters related to their care • Reduces the number of DNAs outpatients, diagnostics, home
clinical staff to allow them • Enable patients to carry out self-health assessments, visits, GP consults etc
access to greater enriched satisfaction surveys and report their experiences and • Facilitates the UHB, local authorities, primary care etc working
healthcare data outcomes of the care services they have received better together.
• Enable patients to book GP appointments online • Saves patient time
• Enable patients to order repeat prescriptions online
• Enable patients to view medication information
• Enable patients to view test results
• Enable patients to view information held in hospital,
community and social care systems such as outpatient
appointments, notifications and other correspondence
• Publish and make available trusted online sources of
information for people to use
Clinical Informatics Programme Creation and application within clinical and resource information • Should markedly reduce health inequality as interventions will
and management systems of a library of ‘authenticated’ support be targeted on individual profiles rather than on individual’s
tools and decision algorithms for use by the patient and clinicians likelihood of demanding services.
in the management of symptoms and conditions which draw on • Supports an individual’s confidence and knowledge in self
evidence and MBL/big data to improve effectiveness of care and management, reducing demand on the more expensive care
reducing untoward variation. services
• Supports precision medicine enabling greater efficiencies and
Programme seen as a combination of validation of existing tools impacts from treatments to be realised thus improving clinical
and development of apps, algorithms and tools based on NHS and cost effectiveness & reducing variation
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Wales data (i.e. over time will include the PROMs data • Will speed up research being translated into treatment,
reducing drug costs
Intended to be delivered via a federated all Wales programme • By supporting junior clinicians improves effectiveness of care
(HSIU) and clinical outcomes
• Reduces errors and variance in clinical practice
• Reduces the resource required to perform a clinical event,
improving productivity and sustainability of services
• Enhances support provided to staff and promotes a desire to
research, innovate and improve care and services
• Done at All Wales scale offers significant financial savings
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3.11 Programme Risks

The key organisational risk when considering this Informatics SOP is not investing in the key
enabler for change and therefore compromising the organisations ability to deliver it’s
IMTP.
There are also key risks associated with the maintenance of the current technical
infrastructure and informatics resources. These are included in the Hywel Dda risk
management framework and identified within the Hywel Dda Corporate Risk Register.
When considering growth and innovation, from a programme perspective, the key risks are
associated with:
• Resources, Capacity and Capability – adequate levels of capital, revenue and suitably
skilled individuals will be required to deliver this ambitious programme of work. Capacity
and capability will take time to grow.
• Increased reliance on the developing information and technology base – more
electronic working will incur additional costs for running new services; these will be
funded from service efficiencies. In addition, more reliance on electronic working will
mean that IM&T services will need to be highly available. This will mean an increased
pressure on equipment maintenance and replacement together with the need for
immediate technical support both in and out of office hours.
• Wider Organisational Capacity – the organisation is undertaking a significant
programme of service development and change. The scale and pace of organisational
change will impact on the effective implementation of technology to support new ways
of working and the delivery of benefits to sustain the growth in IM&T required.
• Insufficient Pace of Change – any delay in the timescales associated with the
introduction of electronic ways of working may result in operational pressures. For
example, a failure to move quickly from paper-based health records will result in the
urgent need for more storage and transportation. In addition as this programme is a key
enabling project for many of the Health Board’s strategic changes, any delays may
directly impact the ability for other Strategic Change Programmes to release savings.
More detailed identification and management of risk will be undertaken as a key

component of each of the individual projects covered by this SOP. The identification of risks
and development of mitigation plans will be a core component of the development of
individual business cases.
3.12 Programme Constraints and Dependencies

3.12.1 Constraints
The main constraints and dependencies are as follows:
• Availability of capital and revenue funding throughout the life of this programme of
investment.
• Delivering a cost effective and value for money solution within the programme
timetable and budget
• Organisational capacity to support implementation of new ways of working whilst
maintaining existing operational services.
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3.12.2 Dependencies
There are number of key dependencies:
• Reliance on NWIS capacity for delivery of national products for key projects could
influence the pace and timeliness of delivery of the programme.
• Supporting delivery of the Strategic change programmes i.e.
• Underpinning the delivery of integrated health and social care. You cannot provide
seamless care to the patient with partial, fragmented or separate records.
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4 The Economic Case

In accordance with the Capital Investment Manual and requirements of HM Treasury’s Green
Book (A Guide to Investment Appraisal in the Public Sector) this case demonstrates that the
most economic option has been selected. This option meets the service needs, realises the
most benefits and optimises value for money.
4.1 Critical Success Factors

The critical success factors (CSFs) for the programme are as follows:
Critical Success Factors

CSF Description
Strategic Fit and The solution must fit with national and local strategies
business needs
Benefits optimisation The solution must support the Health Board in delivering the
benefits of the Strategic Change Programmes
Potential value for The solution must support the Health Board to reduce overall
money costs and through these cost reductions support the overall
investment costs of the Strategic Change Programmes.
Capacity and The ability to:
compliance • Deliver a sustainable and resilient solution
• Ensure capacity for the future
• Comply with statutory requirements
Potential affordability The solution must be affordable
4.2 Main Options

The long list of options related to this SOP have been generated through the consultation
process which was undertaken. The options framework has been adopted to assist with
presenting the options and will be used in greater depth during the production of each
business case to support each of the investments.
4.2.1 Service scope:

• Option 1: Do Minimum. Provide essential improvements to support existing Hywel
Dda acute clinical services. Discount
• Option 2: All Health Board services and sites. Modernise IM&T infrastructure,
systems and devices to support the patient environment and delivery of integrated
services to support the delivery of the IMTP - Changing for the Better. Preferred.
4.2.2 Service solutions:

• Option 1: Do Nothing. Maintain existing technical infrastructure, systems and
devices through the existing refresh programme, funded by discretionary capital
funding which is a reducing pot. Discount
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• Option 2: Do Minimum: As option 1 plus prioritise key developments in order to

progress, concentrating on essential acute services. Possible
• Option 3: Develop and Innovate. Maintain existing infrastructure, systems and

devices to an industry standard refresh programme. Build on existing technical
infrastructure and products, to deliver major systems and infrastructure
improvement programme. Prepares the organisation for greater electronic and
integrated working. Builds readiness where appropriate for the adoption of national
products as they become available. Preferred
• Option 4: National Solutions Only. Maintain existing infrastructure, systems and

devices and only use National Solutions to support service development and
innovation. Discount
• Option 5: Local Solutions Only. Maintain existing infrastructure, systems and devices
and only use Local Solutions to support service development and innovation.
Discount
4.2.3 Service Delivery

• Option 1: In house. Discount
• Option 2: Outsource: Existing resources unlikely to provide existing levels of service

with loss of expertise and control. Does not fit with the political or informatics
strategy. Discount
• Option 3: Blended approach. A mixture of In house and outsourcing, as appropriate

for each project Preferred
4.2.4 Implementation
• Option 1: Single Phase. Discount
• Option 2: Phased over 3 years. Discount
• Option 3: Phased over 5 to 7 years. Preferred
4.2.5 Funding
• Option 1: Private Finance. Discount
• Option 2: Public. Preferred
4.3 Preferred Way Forward

The preferred way forward for delivering this programme’s objectives is the Service Solution
Option 3 Develop and Innovate.
The identification of the main components of the preferred way forward at this stage will
comprise a composite range of investments identified by risk rating and ability to satisfy the
investment aims and CSFs.
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Table 2: Service Solution Options evaluated against Investment Objectives and CSFs
Investment Objectives Option 1 Do Option 2 Option 3 Option 4 Option 5
Nothing Do Minimum Develop & National Local
Innovate Solutions Only Solutions Only
Improve access 1 2 4 2 4
Increase robustness and
1 2 4 3 3
resilience
Provide patient centered
2 3 4 2 3
electronic record
Streamline and automate
processes 1 2 4 3 2
(clinical and non-clinical)
Support improvements in
1 3 4 3 3
patient safety and quality
Alignment with national
1 2 4 4 1
strategy
Sub total 7 14 24 17 16
Critical Success Factors Option 1 Do Option 2 Option 3 Option 4 Option 5

Nothing Do Minimum Develop & National Local
Innovate Solutions Only Solutions Only
Strategic Fit and business
1 2 4 4 1
needs
Benefits optimisation 1 2 4 3 3
Potential value for money 1 2 4 3 3
Capacity and compliance 4 4 4 4 4
Potential affordability 3 2 2 2 2
Sub total 10 12 18 16 13
Total 17 26 42 33 29
Rank 5 4 1 2 3
Key:
Description Score
Does not achieve 1
Partially achieves 2-3
Mostly achieves 4
Fully achieves 5
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Table 3: Overall Summary of Service Solution Options

Service Solution Outcome Reason for Inclusion or Exclusion
Option
1. Do Nothing Discount This option does not achieve any of the Investment Objectives
and does not meet the requirements for modernisation outlined
in Changing for the Better and the IMTP.
2. Do Minimum Possible Although this option would provide minimal development in an
acute hospital setting, there would be no developments within
the community and social care settings.
3. Develop & Preferred Way This is the preferred way forward, as it allows the development
Innovate Forward of major transformational change as outlined in Delivering the
benefits of Digital Healthcare. It will also align with National
solutions where appropriate
4. National Discount Although this option would be an improvement on the do
Solutions Only minimum, there are some areas which are not currently subject
to national solutions i.e. improve access and the patient centred
single record
5. Local Solutions Discount This option has been discounted as it would fail to meet in many
Only ways the streamlining and automation of clinical and non-clinic
processes.
4.4 Deliverables and Timescales

The Programme will deliver a number of projects over the next 3 years which will be
supported by a number of Business Cases to be submitted to the WG. The table below
describes at a summary level the proposed main investments and deliverables from this
programme can be found in Appendix 1.
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Proposed Implementation Plan

Strategic Change
Programme of Work 2016/17 2017/18 2018/19
Programme 2019 -
2021
Qtr. 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 1 Qtr. 2 Qtr. 3 Qtr. 4
Community Technology Project - inc

Telehealth
MTeD
Community Care Information Solution
Implement Clinical Portal to provide patient

flow management, single view of patient
records and enable electronic ways of Subject to a further business case and benefits realisation
working such as ePrescribing, test requesting
and electronic observations
Integration and
Modernisation Implement Transactional Infrastructure -
Portal, Forms, Workflow, Document
Management and Intranet Replacement.
Outpatients Modernisation
Workflow Automation Subject to a further business case and benefits realisation
Provide better information through the use

of digital dashboards
Electronic prescribing and Medicines

Subject to a further business case and benefits realisation
Administration
Electronic White Boards/ Patient Flow.

Pilot in 2 sites - Bronglais / Draft Business
Wireless & Integrated Communications. Implementation within all Wards
Flow and Glangwili Case
Patient Flow management across three major
Productivity hospital sites
Making the patient record available to the

clinician whenever necessary, either directly
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Strategic Change
Programme 2019 -
2021
as an electronic record or via a scanned

image of a paper record
Draft Business
Electronic Observations Pilot in Withybush Implementation within all Wards
Case
Roll out of wireless devices to support clinical

care
Procure and implement a single ED system

across the organisation
National Health Records Repository (Welsh

Care Record Service)
Patient Feedback System Capturing patient

information built on the implementation of
surveys and the provision of free Wi-Fi in
Hospitals.
Research and Development and Innovation
Expansion of data warehousing,

infrastructure and capacity
Enhanced quality performance and

benchmarking, computer-assisted coding,
real time clinical analysis
Improved Clinical Coding timeliness Subject to a further business case and benefits realisation
Sensory Loss
Patient
Experience & Wi-Fi Expansion
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Strategic Change
Programme 2019 -
2021
Communication Switchboard Consolidation Development of Business Case Implementation
Improvements in Improvements in Improvements in peripheral

Telemedicine
Bronglais Withybush sites
Bring Your Own Device (BYOD) system to

improve access to clinical information,
clinical resources and administrative systems.
Enabling 1500 devices to access email and
web based applications.
Data Centres Development of Business Case Implementation
Infrastructure / Telecommunications Refresh
Network Refresh Development of Business Case Implementation
Equipment End User Replacement -

Enablers Procurement of PCs, Laptops, and Printers
Draft Business
Single Sign On & Context Sharing Pilot in A&E
Case
Implement Microsoft SharePoint - Portal,

Forms, Workflow, Document Management Subject to a further business case and benefits realisation
and Intranet Replacement.
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5 The Commercial Case

This case sets out how this Programme will be procured through a series of separate
business cases.
5.1 Commercial Strategy

The Commercial Strategy for this Programme involves each project being delivered through
a competitive tendering process specific for each project.
5.2 Procurement Strategy

Each project will require a dedicated business case, with the type of case being determined
by the level of investment required. The Health Board will work with Shared Services and
NWIS procurement department to explore the potential for wider application of the
proposed design solutions across Wales.
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6 The Financial Case

This case sets out the indicative cost implications of the preferred way forward.
6.1 Indicative Capital Requirements

The Health Board currently spends between 0.9% - 1.1% of its budget on IM&T, when
compared to industry this is a low percentage, reflected in the relative lack of pace in
adoption of IT. There is also a considerable backlog in investment that is demonstrated by
the lack of resilience in the IT infrastructure and ageing end user terminals.
As identified in the strategy the Health Board is faced with very significant risk in resourcing
it’s infrastructure on a sustainable basis. The infrastructure has seen a significant increase in
recent years with no increase in support resources and no planned replacement
programme. This places the Health Board at severe risk, as highlighted on the IM&T Risk
Register, despite the best efforts of the IM&T Department to continually modernise and
improve processes. In order to successfully take forward the IM&T Strategic Programme we
must first invest in the sustainability of our infrastructure and secondly, in the revenue
resource it assigns to IM&T development.
It is recognised that funding is a restrictive barrier for delivery of the IM&T strategy. Work is
being undertaken to complete the documentation for the Welsh Government IM&T
Strategic Outline Programme (SOP), which will request significant capital from Welsh
Government to support the delivery of projects. Capital funding will be used to acquire
staffing resources to deliver projects.
To deal with all the current backlog issues and progress with this development work, the
Health Board will require around £23.4m of capital and £8.4 of revenue over the next 5
years, which will be the subject of a Strategic Outline Programme. The organigram below
illustrates how the proposed programmes will be delivered, and the respective capital and
revenue commitments;
IM&T Strategic Outline Programme
Patient experience
Integration and Flow and
and Enablers
Modernisation Productivity
communications
Funding Funding
Requirements Requirements
(Capital) (Revenue)
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Funding Funding
Requirements Requirements
(Capital) (Revenue)
Integration and Modernisation £ 3,755,000 £ 2,939,700
Flow and Productivity £ 9,110,224 £ 2,455,600
Patient Experience and Communication £ 1,049,000 £ 370,396
Enablers £ 9,577,000 £ 2,610,000
Total £ 23,491,224 £ 8,375,696
A full breakdown of the schemes and their respective costs can be found in Appendix 1. A
pragmatic and innovative approach to stimulating investment in high priority computer
systems and tools that can deliver tangible benefits to Hywel Dda consumers, care providers
and healthcare managers will be required that at the end of five years will see a 3% spend of
revenue on IM&T.
The approach to be taken will need to include:
• Recognising the capacity constraints within the current IM&T infrastructure, the
level of capacity required for ‘business as usual’ and clearly defining developmental
capacity
• Clear prioritisation processes for IM&T investment with outcomes that are
corporately supported and communicated across the organisation
• Development of business cases for new business, that map out the full costs of
implementation, alongside any associated revenue savings
• Working with NWIS to ensure that new developments proposed for
implementation are fully prioritised and costed
• Developing a more robust approach to securing capital from both the Discretionary
Capital Allocation and the All Wales Capital Programme, for strategic investment,
including the submission of a Strategic Outline Programme for Capital Investment
to help the shift away from use of end of year finance to more strategic investment
in IM&T
• Clear consideration of capital vs revenue based solutions for investment
• Securing business partners for IM&T development from the commercial sector to
support specific projects
• Ensuring the IM&T investment requirements are considered in all business cases
submitted internally and Welsh Government.
• European Funding
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In summary the capital and revenue costs requirements over the period of the SOP are as
follows;
2017/18 2018/19 2019/20 Total

Funding Requirements (Capital) £12,284,346 £7,535,078 £3,671,800 £23,491,224
Funding Requirements (Revenue) £3,317,166 £2,125,132 £2,933,398 £8,375,696
6.2 Affordability
A full assessment of affordability will be made as individual Business Cases are progressed.
The programme requests capital investment of £23.4m (including non-recoverable VAT) to
be allocated by the Welsh Government over the next five years.
The programme is revenue resource neutral for the Health Board with realisable ‘savings’
being re-invested into the Strategic Change Programme Fund.
Support for additional depreciation costs will be required from WG and will be firmed up in
individual Business Cases.
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7 The Management Case

This case details the plans for the successful delivery of the programme to cost, time and
quality.
7.1 Programme and Project Management Arrangements

The investment process is being organised and managed in accordance with guidance
contained in the Capital Investment Manual and is consistent with the Office of Government
Commerce’s Managing Successful Programme’s standard:
• The Senior Responsible Owner is Mrs Karen Miles, Executive Director of Planning,
Performance and Commissioning
• The Programme Director is Mr Anthony Tracey, the Assistant Director of Informatics,
who will have responsibility for managing the overall delivery of this programme of
modernisation. The Programme Director is supported by the following Informatics
Heads of Service, who will be responsible for overseeing the day-to-day
management and delivery of individual projects:
o Head of Information Services and Development
o Head of Information Governance
o Head of ICT
o Head of Informatics Projects and Clinical Systems
o Informatics Business Manager
IM&T Steering Group

This Group meets bi-monthly and each Programme and respective supporting projects will
be required to produce monthly Highlight reports, which document:
• Progress against key deliverables, which are RAG rated.
• Achievements planned for the period but not completed.
• Achievements planned for the next period.
• Programme risks, by category and recording mitigating actions.
• Programme issues and identifying actions.
• Programme milestones and forecast completion date, recording confidence and
status
• Programme Manager comments
Information Governance Sub-Committee (IGSC)

The purpose of the Information Governance Sub-Committee is to provide assurance to the
Business Planning & Performance Assurance Committee, which is a Committee of the Board,
on compliance with information governance legislation, guidance and best practice, and to:
• Provide evidence based and timely advice to assist the University Health Board in
discharging its functions and meeting its responsibilities with regard to the quality
and integrity; safety and security; and appropriate access and use of information
(including patient and personal information) to support its provision of high quality
healthcare.
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• Provide assurance in relation to the Board’s arrangements for creating, collecting,

storing, safeguarding, disseminating, sharing, using and disposing of information in
accordance with its stated objectives; legislative responsibilities, eg, the Data
Protection Act and Freedom of Information Act; and any relevant requirements and
standards.
• Provide assurance that risks relating to information governance are being effectively
managed across the whole of the University Health Board’s activities (including for
hosted services, through partnerships and Joint Committees as appropriate).
Clinical Informatics Group

The purpose of the Clinical Informatics Group is to provide assurance to the IM&T Steering
Group that clinicians are being made aware of plans, changes to existing systems, new
systems and that clinicians are given the opportunity to raise concerns or questions relating
to Informatics, and to:
• Provide an Informatics communications forum for the Health Board.
• Inform clinicians of the Informatics Operational Plan including upcoming or proposed
projects not yet formally on the plan
• Monitor progress of the Informatics Programme.
• Inform clinicians of the forward schedule of change (within the limitations of a
quarterly meeting)
• Obtain feedback from clinicians regarding risks and issues relating to Informatics
• Links to Quality Indicators Group – measurement of harm and variation, QI group
will feed systems or data requirements to the Clinical Systems Group.
• Enabling innovation in IM&T to support delivery of the IMTP.
• Ensuring that IM&T services are safe and sustainable or that risks are being assessed
and managed effectively
• Securing excellent working relationships with partner organisations including NHS
Wales Informatics Services (NWIS) supporting effective communication and
engagement
• Supporting arrangements to assess and deliver benefits of innovative technology and
information for use in decision making
The structure has been developed in order to have the shortest possible reporting lines
while ensuring that there is a sufficient capacity and processes in place to control the
delivery of the programme.
7.2 Programme/Project Reporting Structure

The programme will continue to be managed under the structure outlined above, i.e. with a
Programme Director, Project Director and Project Managers with key responsibilities for
managing all areas of design, construction and commissioning.
7.3 Programme Milestones

Subject to SOP approval, it is anticipated that implementation will be phased over five years.
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7.4 Programme Assurance

Well established and effective Capital, IM&T and Finance team working is key to this level of
performance and both teams share information on Projects in real time on a single
Information Portal.
Strengthening the IM&T governance regime will enable effective coordination, oversight
and delivery of IM&T activities. There is therefore an implicit requirement to ensure there is
effective leadership, coordination and oversight of the national digital health work program
ran by NWIS. This section focuses on the establishment of appropriate governance
structures and mechanisms based on the following principles.
Governance Principle Description

Ensure clear decision making accountability and provide all stakeholders with
Clarity of accountability
clarity regarding their roles and responsibilities
Transparency Provide widespread visibility of the progress of Hywel Dda IM&T activities
Appropriate stakeholder Provide a forum for representation across all key stakeholder groups. Ensure
representation broad ownership and a balanced approach to the delivery of IM&T
Implement a governance model that will not be unduly impacted by changes
Sustainability
to the political or stakeholder environment
Support for activity at Recognise that IM&T governance will need to support initiatives that deliver
multiple levels IM&T capability at differing levels of granularity
Effective leadership and Effective leadership and coordination of the range of activities that need to
coordination occur across all national IM&T work streams
Balance local innovation and Continue to encourage local innovation while ensuring that the development
national outcomes of IM&T solutions supports national IM&T outcomes
The new arrangements will mean that the projects and programmes for IM&T will directly
report into the IM&T Steering Group which in turn report to the Executive Team.
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The full governance structure is highlighted below;
Business Planning
and Performance
Assurance
Committee
Information
Governance Sub- Executive Team
Committee (IGSC)
Advice Clinical Informatics

IM&T Steering Group
Group
National Groups
National Informatics • Strategic Delivery Group Meeting
Management Board Senior Informatics • Heads of Information
(Executive Leads) Managers Meeting • Infrastructure Management Board
• Programme Leads
• Information Governance Managers
Group
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Appendix 1
Strategic Proposed
Capital Revenue
Change Programme of Work Service Improvements / Requirements Benefits Implementat
Commitment Commitment
Programme ion Year
Integration and Community Provide improvements to community and Support the implementation of an £175,000 £28,000 Start Date –
Modernisation Technology Project - social care services through the use of integrated service model for health & 2016/17
inc Telehealth technology. The aim of the proposed social care - Enables detailed record of
project is to improve health and social care community intervention to link to End Date –
for older people by: Primary and secondary care events and 2020/21
systems.
• sharing information in order to better
coordinate care and utilise resources • Community Information available at
more effectively hospital admission sites offers
• providing support and active alternative care option and
monitoring that allows clients to facilitates earlier discharge.
remain in their own home or care • Maximising staff time for direct care
setting and reduce the need for and removing duplication and travel
admission to hospital reduces costs and increases
• enabling earlier intervention to capacity.
support and maintain health and well • Standardised electronic information
being enables outcome and performance
• supporting carers to manage clients reporting.
effectively within existing settings • Referral to assessment pathway
without the need to admit to hospital electronically tracked.
MTeD MTeD (Medicines Transcribing and e- Medicines Transcribing (MT) will improve £450,000 £155,000 Start Date –
Discharge) is an electronic way of recording medicines management by allowing 2016/17
a list of medications for a patient and hospital pharmacists to transcribe
adding them to an electronic discharge patient medications electronically. This End Date –
advice letter (e-DAL). The e-DAL is then will support the patients from admission 2020/21
sent to the patient’s GP as soon as they to discharge.
leave the ward, via the Welsh Clinical
Communications Gateway. e-Discharge (eD) will enable clinicians to
record a summary about a patients
hospital stay. The DAL (Discharge Advice
Letter) will then be transmitted
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Strategic Proposed
Capital Revenue
Programme ion Year
electronically to GPs via the Welsh
Clinical Communications Gateway
(WCCG).
MTeD will help to establish a consistency

in discharge communication from
secondary to primary care
Community Care Implementation of the community care Health and social care practitioners will £1,500,000 £2,000,000 Start Date –
Information Solution solution across Health and Social care. be able to make more informed, 2016/17
appropriate and timely decisions
regarding patient’s treatment and care. End Date –
2020/21
The increasing availability of patient /
client information will allow practitioners
to provide services to a greater
proportion of their patients / clients -
safely and confidently.
A consistent method for creating or

viewing data and common administrative
processes will increase the overall speed
and efficiency of information processing
within health and social care services.
Implement Clinical Development, integration and Patient safety – Doctors will have more £0 £0 To be
Portal to provide implementation of the National Clinical information when they are treating the confirmed
patient flow Portal to provide patient flow management, patient. This will support decisions and
management, single single view of patient records and enable reduce the chance of inappropriate
view of patient electronic ways of working such as treatment or error.
records and enable ePrescribing, test requesting, electronic
electronic ways of observations, digital dictation, live ward Patient focused care – information from
working such as management across Hywel Dda, and a variety of systems and sources are
ePrescribing, test improve discharge summary timeliness and brought together.
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Strategic Proposed
Capital Revenue
Programme ion Year
requesting and quality.
electronic Increased efficiency - Clinicians working
observations in different hospitals will be able to
undertake clinical processes in the same
way where ever they work. For example,
requesting a blood test for a patient will
follow the same online process in all
hospitals.
Single log-on – clinicians will only need to

log on once to access information taken
from a number of clinical systems.
Positive patient outcomes increased -

Easy access to relevant clinical
information increases speed and
relevance of diagnosis, care treatment
planning and onward referral.
Implement Enterprise Content Management will form A dedicated infrastructure will provide a Costs included Costs included Start Date –
Transactional the basis of collecting clinical and platform for access to and input of within other within other 2016/17
Infrastructure - Portal, administrative data in a structured format information on mobile devices and fits in Projects Projects
Forms, Workflow, enabled by rapid forms development with with the Health Board's strategy on End Date –
Document workflow for assigning tasks or sign off. mobility which will bring huge change to 2020/21
Management and the way we deliver healthcare services.
Intranet This will also provide collaborative
Replacement. opportunities by using Knowledge
gathered through experience and shared
through the social platforms in order to
improve decision making and reducing
chances of committing errors.
Uses will include: supporting direct
patient care such as the Pre-Assessment
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Strategic Proposed
Capital Revenue
Programme ion Year
process; and also in non-clinical areas
such as human resource workflows.
Outpatients Reduce paper-based working by introducing Make doctors start sessions on time. £1,480,000 £400,000 Start Date –
Modernisation across the HB electronic patient check in Do not create a pool of patients at the 2017/18
services, electronic recording of patient start of the clinic.
information and outcomes. Develop Ensure that doctors are not disturbed End Date –
electronic workflow and clinic views during sessions. 2019/20
between clinicians and admin support. Improve appointment/patient
Provide patients with electronic interfaces scheduling.
with the OPD service to include Educate doctors and others about
appointment booking and reminders and effective operation of the system.
provide information and general Provide better facilities for waiting
communications. Investment in equipment patients.
in years 2 and 3.
Workflow Automation Development of linked processes, push data Costs included Costs included Start Date –
updating and intermediary applications to within other within other 2017/18
iteratively improve the workflows across Projects Projects
the whole health sector use of automation End Date –
software to codify manual transactions and 2019/20
support using virtual 'robots'
Provide better Development of digital Dashboards to The benefits of a digital dashboard £150,000 £356,700 Start Date –
information through support automated information delivery for custom built for the Health Board can 2016/17
the use of digital Patient Flow, Unscheduled Care, Planned provide a live stream of information to
dashboards Care, Maternity Services, Theatres, etc. top level personnel. A dashboard will End Date –
allow end users to work with complex 2020/21
data relationships and monitor key
performance indicators even if they are
not trained data analysts. Immediate,
critical awareness of essential company
information gives a distinct edge in the
decision making and management
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Strategic Proposed
Capital Revenue
Programme ion Year
process.
All of the data that goes into a digital

dashboard is already available through
other tools and reports. The advantage
of using a Digital Dashboard is that even
immensely complex information
collected across multiple sources can be
evaluated and digested quickly.
Electronic prescribing Implementation of Electronic Prescribing Strategic reasons for undertaking an £0 £0 Start Date –
and Medicines and Medicines Administration (EPMA) EPMA implementation are mostly around 2019/20
Administration across Hywel Dda. EMPA replaces the patient safety: Costs of Costs of
current paper prescription and National National End Date –
administration record chart normally • Improving the quality of prescribing Programme Programme 2020/21
completed for every in-patient, as well as and medicines administration not available not available
discharge and outpatient prescription processes and records.
forms. • Reducing some of the risks
associated with prescribing and
medicines administration process
• Reducing the occurrence of adverse
events associated with prescribing
and medicines administration.
Flow and Electronic White Procurement and implementation of patient The electronic boards are “a bed £918,451 £150,000 Start Date –
Productivity Boards/ Patient Flow observation & flow management solution, management solution; its core 2016/17
to facilitate robust and effective functionality compliments and drives the
Wireless & Integrated management of hospital at night priorities, patient journey, ensuring timelier End Date –
Communications. and to provide electronic observation responses and improved quality of care. 2020/21
Patient Flow recording and management. In turn, this drives bed management and
management across provides real time indicators of current
three major hospital It is recognised that patients flow through bed state right across the Health Board.
sites different settings within the Health Board
and the data collected at each part of their
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Strategic Proposed
Capital Revenue
Programme ion Year
journey does not always flow seamlessly
with them. The need for accurate and real
time data has been identified and one way
of achieving this is electronic patient’s
boards that not only link the wards, but
feedback live data into the clinical systems.
Making the patient Develop and implement a Clinical Electronic The aim is to provide assurance for £6,300,000 £450,000 Start Date –
record available to Records Management System, moving from Information Governance around record 2017/18
the clinician a manual paper health records system to an storage by scanning and also bringing
whenever necessary, electronic scanning viewing and creating of back records to Health Board bases (or End Date –
either directly as an records system. electronically via scanning) that are 2020/21
electronic record or currently held (and financed) off site.
via a scanned image
of a paper record The benefits can be noted as
• Improving Accessibility
• Improvement in the tracking of
records.
• Audit trail.
• Cannot be mislaid.
• Paper Light.
• Effective use of staff.
Electronic Procurement and implementation of patient Research has shown that the benefits of £306,773 £1,441,600 Start Date –
Observations observation management solution, to electronic observations at the bedside 2016/17
facilitate robust and effective management have been noted as;
of hospital at night priorities, and to provide End Date –
electronic observation recording and • All patients in the trial had their 2020/21
management. bedside observations performed in
a timely fashion
• Patients recovered their health
faster than previously
• There was a 20% reduction in
hospital length of stay
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Strategic Proposed
Capital Revenue
Programme ion Year
• The use of critical care was less
• No patient had a cardiac arrest in
the intervention phase of the trial
• There was a reduction in mortality
of 2%
Roll out of wireless The upgrades will enable staff to become The benefit will be seen by clinicians that £525,000 £210,000 Start Date –
devices to support more efficient and effective and ultimately need smart, portable, point-of-care 2016/17
clinical care help to improve patient care. solutions for capturing and transmitting
The new infrastructure will increase data, as well as routine communication. End Date –
wireless access points and enable staff They also want technology to reduce 2020/21
greater choice on mobile devices – laptops, demand on nursing time by eliminating
tablets and windows based mobile devices. waste in care resulting from inefficient
workflows.
It will also support a planned rollout of
mobile, clinical applications across the
Health Board.
Procure and The implementation of a single emergency Not known at Costs not Start Date –
implement a single ED department clinical information system present known at 2018/19
system across the across South Wales. The system has been present but
organisation identified by a National competitive circa £170k End Date –
dialogue procurement process. 2020/21
National Health The WCRS will enable the creation and The benefits of the WRCS include the £0 £0 Start Date –
Records Repository storing of a wide range of documents in the standardisation of documentation and 2017/18
(Welsh Care Record Welsh Clinical Portal including letters, establishing a Welsh Records Service is Costs of Costs of
Service) referrals, discharges, assessments and case therefore the key to enabling the quality National National End Date –
notes. agenda, reconfigurations and the Programme Programme 2020/21
transformation of services closer to not available not available
home.
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Strategic Proposed
Capital Revenue
Programme ion Year
Patient Feedback This provide instant feedback on healthcare To enable proactive feedback to be £650,000 £74,000 Start Date –
System Capturing and services provided by the Health Board captured, processed at scale and in real 2017/18
patient information and will link to the SBR initiative. Initially the time as well as ensuring that the
built on the feedback will be completed on patient information is provided to the service End Date –
implementation of owned devices (smartphones and tablets). area in which relates to. Enabling 2019/20
surveys and the Investment in devices in 2016/17 will improved transparency of feedback on
provision of free Wi-Fi provide access to surveys on Health Board experience received by the Health Board
in Hospitals. owned equipment for patients that would enabling uploads of regular summaries
not have access to personal devices. and feedback on line to promote
Investment in 2016/17 is for large screens inclusion and improvements in service
on wards to display live reporting from provision.
surveys and complaints to provide an
instant view on ward performance based on
feedback.
Research and To integrate the strands of work emanating £300,000 £120,000 Start Date –
Development from Clinical Trials, research contracts, 2016/17
implementation of academic
recommendations. End Date –
2020/21
Expansion of data To extend the current data warehousing £75,000 £0 Start Date –
warehousing, and place it into a more accessible format 2017/18
infrastructure and utilising current approaches to support all
capacity staff in their day to day role. End Date –
2017/18
Enhanced quality To increasingly support busy clinicians £35,000 £10,000 Start Date –
performance and undertake better data capture whilst 2016/17
benchmarking, generating clinical audit data, clinical history
computer-assisted summaries and contribute towards the R&D End Date –
coding, real time strategy. 2017/18
clinical analysis
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Strategic Proposed
Capital Revenue
Programme ion Year
Improved Clinical Provide more timely clinical information to Subject to a Subject to a Subject to a
Coding timeliness support monitoring and flagging of key further further further
patient safety indicators to support service Business Case Business Case Business
improvement. Use of Natural Language Case
Processing.
Patient Sensory Loss Several of the projects detailed in this plan Enabling those with sensory loss to £11,000 £5,000 Start Date –
Experience & have an element of sensory impairment access information that can support 2016/17
Communication considerations (central contact centre them on their care journey. Providing
booking systems, text messaging, Wi-Fi additional channels of communication to End Date –
expansion etc), as such IM&T are looking at support care. 2017/18
possible developments we can support to
enable those with sensory impairment to
access information that can support them
and their care journey.
Wi-Fi Expansion We currently have some wireless access in A pervasive wireless network across the £332,000 £66,396 Start Date –
Withybush, Prince Philip, Bronglais and organisation will become more critical to 2016/17
Glangwili General Hospitals but it is not support our mobile workforce, bring your
pervasive and there are some major gaps. own device scheme and a proliferation of End Date –
This project will replace our end of life mobile devices (carts, tablets etc.) to 2020/21
central wireless infrastructure (controls support bedside access to information
access, security and manages the wireless and clinical systems (ePrescribing, Test
access points) and funding permitting will Requesting, Welsh Care Records Service).
enable a complete wireless network in A pervasive wireless network would also
Bronglais and some mental health areas deliver “The Cloud” for patient / guest
across the Health Board. To expand across access across the whole Health Board.
the whole Health Board this project would
have to be repeated for a number of years
Switchboard The Health Board currently has 4 These include:- £250,000 Start Date –
Consolidation switchboard operator locations in service 2016/17
(Glangwili, Prince Philip, Bronglais and • Reduction in WTE releasing revenue
Withybush (provide by Welsh Ambulance savings to the Health Board. End Date –
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Strategic Proposed
Capital Revenue
Programme ion Year
Service)). This project is to review the • Standardisation of working practices 2020/21
switchboard functions across the Health • Reduction in training requirements
Board and deliver a paper of options to the • Implementation of new technology
Board with recommendations on how the with the potential to improve
switchboard service should be structured to contacts with patients
deliver the best service to our staff and
patients but also to deliver the best value
for money.
Telemedicine The various telemedicine projects provide These include:- £456,000 £119,000 Start Date –
advice and support to develop and establish 2016/17
innovative approaches to the delivery of • Enables remote measuring and
healthcare services across the Health Board monitoring of vital signs parameters End Date –
using videoconferencing and ‘store and • Provide health information to 2018/19
forward’ technologies. Enabling patients to encourage increased
consultations between a patient and a self-management
clinician at different locations saving travel • Remind patients of upcoming
costs and time. appointments or medications due.
• The clinician is able to undertake
patient review at a remote location.
Bring Your Own Building on the investment of wireless £0 £180,000 Start Date –
Device (BYOD) system access within the Health Board. 2016/17
to improve access to Procurement of software and licences to
clinical information, provide access to email, clinical and End Date –
clinical resources and administrative web based systems on 2018/19
administrative personally owned devices. Based on growth
systems. Enabling of 500 devices per annum to 1500 devices
1500 devices to within 3 years. Mobile devices provide the
access email and web basis for transforming healthcare and
based applications. improving patient outcomes.
Enablers Data Centres Movement to a Co-located Data Centre, Provide Tier 2 standards which could not £70,000 £1,150,000 Start Date –
either private or public sector be done internally. 2016/17
Uptime guaranteed by SLA's. In line with
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Strategic Proposed
Capital Revenue
Programme ion Year
Welsh Government Data Centre End Date –
strategies. Reduction in ongoing capital 2020/21
outlay
Opportunities to adopt Private / Public
Cloud technologies
Reduction in power consumption at our
main acute hospitals
Infrastructure / Hywel Dda has a large and complex Reduction in risks associated with our £1,872,000 £0 Start Date –
Telecommunications infrastructure containing servers, Infrastructure. 2016/17
Refresh videoconferencing and telemedicine
equipment. This is of varying age, with • 5 year investment plan for our End Date –
some now end of life and support, which infrastructure 2020/21
increases risks to the organisation. • Improved resilience off IT services.
Telephony services are critical to the daily

operations of the Health Board and
investment is required to leverage modern
advances in communications such as the
use of Apps and ensuring old and legacy
equipment is replaced.
Telemedicine and Videoconferencing is

used extensively throughout the Health
Board supporting MDT's for Cancer, remote
patient consultations and various meetings.
In addition this technology is a key enabler
for the Health Boards IMTP.
Network Refresh Our network supports 6,500 active Hywel Reduction in risks associated with our £3,200,000 £0 Start Date –
Dda users across all our 60 sites and is in Infrastructure. 2016/17
some places 10+ years old. This project is to
put in place a new design for our 4 acute • 5 year investment plan for our
hospitals and a 5 year framework in place to infrastructure
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Strategic Proposed
Capital Revenue
Programme ion Year
refresh our network (will require significant Improved resilience off IT services. End Date –
funding). It is envisaged the 2015/2016 2020/21
discretionary capital programme will enable The network is critical for the delivery of
us to start work at Glangwili General new and upcoming services such as
Hospital. This will be critical development electronic observations, mobile
for our users, the network is fundamental computing and monitoring and alerting
for delivery of critical clinical services and as of patients.
we move towards digitisation of health
records, ePrescribing and electronic
discharge it will only become more so.
Equipment End User Timely replacement of personal computers, Reduction in risks associated with old £3,530,000 £250,000 Start Date –
Replacement - mobile devices, laptops and printers is equipment. 2016/17
Procurement of PCs, essential to providing robust and reliable
Laptops, and Printers access to computer systems which the End Date –
heath board is becoming increasingly reliant Ensuring end user productivity is not 2020/21
on in order to deliver first class patient care. impacted by slower devices which
Failure to replace this equipment will cause require replacement. Reduction in
major disruption to patient and support costs.
administrative services. Ensures equipment is fit for purpose as
the use of IT services increase
Single Sign On & implementation of single sign on toolset to Time savings for frontline staff (previous £105,000 £840,000 Start Date –
Context Sharing enable clinicians to maximise their working studies have shown 45 minutes a day) 2016/17
time at commencement of sessions Reduction in IT support calls for
In addition the context sharing will facilitate password resets. Reduction in password End Date –
a smoother work flow between solution sharing leading to improvements in 2018/19
islands prior to the WCP being sufficiently Information Governance compliance.
developed to accommodate this visual data
normalisation
Implement Microsoft Enterprise Content Management will form Subject to a Subject to a Subject to a
SharePoint - Portal, the basis of collecting clinical and further further further
Forms, Workflow, administrative data in a structured format Business
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Strategic Proposed
Capital Revenue
Programme ion Year
Document enabled by rapid forms development with Business Case Business Case Case
Management and workflow for assigning tasks or sign off.
Intranet SharePoint 2013 will provide a platform for
Replacement. access to and input of information on
mobile devices and fits in with the Health
Board's strategy on mobility which will bring
huge change to the way we deliver
healthcare services. SharePoint will also
provide collaborative opportunities by using
Knowledge gathered through experience
and shared through the social platforms
within SharePoint in order to improve
decision making and reducing chances of
committing errors.
Uses will include: supporting direct patient

care such as the pre-assessment process;
and also in non-clinical areas such as human
resource workflows.
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Annual Plan 2017/18
Supporting and Enabling Plans
NHS Outcomes Operational Directorate Plans

March 2017
YR HYWEL DDA
A GAREM
THE HYWEL DDA

WE WANT
Urgent and Emergency Care
Activity Pressures: The University Health Board’s unscheduled care system remains extremely
challenged. Monthly attendances to A&E departments across the University Health Board in the
first 8 months of 2016/17 compared to 2015/16 have increased by +5.3% (+3,973) (data excludes
Prince Philip Hospital (PPH). Emergency admissions to hospitals is also increasing (2% between
2015 and 2016) (data excludes Prince Philip Hospital) and ambulance attendances have
increased by 0.04%.
Performance: Headline performance measures for 2016/17 have shown some improvement but
with significant challenges remaining to achieve the standards that are aspired to and that our
patients should expect. Headline performance levels for 2016/17 year to date are as follows:
Red Calls in 8 minutes

The national target of 65% has been met in the first 8 months of 2016/17 the system remains
challenged by delays relating to University Health Board ambulances being drawn into ABMU to
service patients bound for Morriston Hospital. Performance is further impacted on by busy days
when Hywel Dda ambulance crews are outside of area.
Ambulance Handovers over 1 hour

Ambulance handover time is generally good and is something that has been prioritised
consistently as a University Health Board. When compared to the remainder of Wales Hywel Dda
normally accounts for less than 5% of the delays across the system. Performance at the
beginning of 2016/17 was in line with plan. Since July 2016 performance has missed the target
every month since. As matters presently stand the difference between plan and performance
for over 1 hour waits is growing with the November target being missed by 47 patients. The larger
volume of delays are specific to Glangwili General Hospital (GGH) and Withybush General
Hospital (WGH) and generally relate to A&E departments that are full, largely due to bed
pressures within those hospitals. Whilst performance locally has not met the required levels more
generally the data compares well with the rest of Wales (second best in Wales). Key challenges to
address performance in this area are based on 3 key areas of focus – A&E staffing levels, A&E
environments and hospital capacity. The University Health Board regularly hosts patients
overnight at its A&E departments resulting also in significant numbers of 12 hour breaches.
Despite the hard work of A&E staff the University Health Board realises that the care provided
during these times is sub-optimal (due to, for example, a lack of bathrooms) yet this has become
the accepted norm at some hospitals, leaving insufficient capacity for off-load of ambulances.
4 Hour Performance
Monthly performance continues to be above the all Wales trend in the first 7 months of 2016/17
and in October 2016, performance was ranked as being the second best in Wales. The
breakdown by acute centre was as follows:
• Bronglais General Hospital (BGH). Plan was 95%; performance improved to a high in Nov-
16 to 93.7%.
• Glangwili General Hospital. Plan was 90%; however performance has reached only 82.8%
• Prince Philip Hospital. Plan was 97%; this is generally being consistently met since the new
front of house model was implemented.
• Withybush General Hospital. Plan was 85%; however performance has only managed to
get above 80% on two occasions this year.
Performance is captured graphically below:

12 Hour Performance
12 hour performance remains a significant challenge and is as a direct consequence of insufficient
capacity within hospitals and patients waiting inappropriate amounts of time in A&E departments,
particularly overnight. This is a key priority for the University Health Board to address in 2017/18
as the A&E department is not the appropriate setting to care for patients for long periods of time.
Performance improved from a high of 436 delays reported in Apr-16 to a low of 252 in Jul-16.
However, volumes returned to circa 400 in Nov-16 which is significantly behind plan and leaves
the University Health Board in a fourth ranked position across Wales. The University Health Board
retains its ambition to completely eliminate 12 hour waits in its A&E departments.
It is clear from the data above that despite some improvements the University Health Board has
much work to do at Glangwili and Withybush Hospitals if it is to sustainability improve its 4 hour
performance and reduce 12 hour waits at A&E departments. In this connection there are a
number of challenges faced at the University Health Board including:
• workforce availability and capacity across the whole of the unscheduled care system (both
availability of permanent staff and establishment levels);
• limited embedded frailty plans;
• key environmental challenges within our A&E departments;
• limited assessment unit functionality;
• limited optimised WAST pathways;
• limited hospital bed capacity;
• availability of out of hospital capacity which compromises the University Health Board’s
ability to implement agreed discharge standards and increases length of acute hospital stay.
The unscheduled care programme aims to resolve these issues on a sustainable basis.
Winter planning arrangements

The University Health Board has made good progress with the ongoing development of its winter
planning arrangements for 2016/17 with improved processes and greater integration across the
whole system. However we know there remains more to be done as it approaches preparations for
winter 2017/8 and to this end has invested in an academic study of the effectiveness of its 2016/17
preparations through Swansea University. The University Health Board plans to use the learning
from this evaluation to inform its planning and preparations for winter 2017/18.
Unscheduled care plans

The need to significantly improve the unscheduled care system across the whole of the University
Health Board’s service is clear from analysis of current performance levels as set out above. The
impact on wider services from unscheduled care is considerable and this also impacts on the
ability to provide an effective elective care service due to the interdependency of the two systems.
In 2016/17 the University Health Board continued to have to resort to cancelling significant
volumes of planned elective work due to the unscheduled care demand and the devastating
impact that this can have on patients and their families is recognised.
The impact and importance of the unscheduled care system across our hospitals is illustrated in
the graph below which demonstrates that bed capacity across the University Health Board is
almost entirely dominated by over 60 year old adults utilising hospital beds on an unscheduled
basis.
In providing better and more appropriate care settings for these patients the University Health
Board is confident it could transform its hospital systems, improve quality of care, improve access
to those beds for those that need them, reduce harm, improve patient experience and reduce cost
impact on the University Health Board.
To date the University Health Board’s approach to improving its unscheduled care system has
been governed through the unscheduled care programme. This is a cross system group of
managers and clinicians established with the following key objectives:
• To provide a platform across primary, community, voluntary third sector and secondary care
including an interface with tertiary care. This will be achieved by the Programme Board
working between the University Health Board, WAST, Local Authorities, the third sector and
other key stakeholders.
• To ensure alignment across all partner agencies to achieve this programme of work.
• To improve quality and efficiency by redesigning unscheduled care pathways to meet the
clinical challenges and demographic demands of the future in a financially challenging
environment in line with strategic direction. This will also encompass national guidance and
service reviews e.g. Delivery Unit/HIW.
• To advise on the clinical services model based on ‘whole system’ patient pathways in liaison
with all stakeholders and 3-year Integrated Medium Term Plan as appropriate, ensuring that
proposed pathways and service redesign has both multi-disciplinary and multi-agency
stakeholder support prior to making recommendation to the respective Board.
• To provide advice to the University Health Board on the prioritisation of service
developments that will provide the earliest, largest and most sustained improvements in
quality and safety for patients.
• To contribute to the development and implementation of the University Health Board’s
Clinical Services Strategy as part of a five year framework.
• To monitor performance of Unscheduled Care targets in line with the work programme.
• To be a vehicle for partner agencies to ensure they meet key performance and delivery
targets.
The programme meets monthly and is chaired by the University Health Board’s Director of
Operations/ Deputy Chief Executive who draws on significant input across the whole system. The
programme is overseen through county and site specific 12 week rolling plans. In 2016/17 the
programme focussed on the following key areas:
Informatics
The principal informatics aim has been to establish a robust information process that enable whole
system understanding of what is happening across the unscheduled care system. This work has
developed slowly with lack of dedicated unscheduled care analytical resource but monthly
dashboards are now produced which highlight:
• system performance;
• the progress being made in relation to key patient pathways;
• community service resource levels and responses;
• key acute hospital flow metrics;
• bed models (although much more work is needed to ensure these are reliable);
• discharge performance metrics - evidence of delays in hospital discharge processes are
clear from this work as are length of stay in hospital beds which are too high. Key actions
looking forward will need to address these challenges.
This work will need to continue to be resourced and developed as part of our plans for 2017/18.
Patient flow
The University Health Board’s patient flow aim is to develop and implement a clear plan for each
hospital which sets out how each will ensure every patient has the right intervention every day.
This work has focussed on key areas including assessment unit operating models, how patient
flow is being managed at each ward, how each site is achieving and addressing ambulatory care
standards and success in achievement of meaningful target discharge dates (expected date of
discharge).
Again this work has been slow to develop and the focus on in-hospital flow has not been as
successful as was hoped during 2016/17. Some length of stay reductions are evident but the
University Health Board has not progressed its ambulatory care work quickly enough, assessment
unit models are not fully defined for all areas, hospital support to the “front door” needs to be
improved and the methodology has variable levels of sign-up from medical clinical teams within
the acute hospitals. A key focus of this work as 2017/18 approaches will be the development of
standards for implementation in 2017/18 using a clear and proven evidence base.
Discharge Performance
The objective of this work has been to develop and implement detailed and agreed standards for
complex discharge which embrace the pathway interdependencies between Local Authority
partners and the University Health Board. This will be followed by measurement of performance
against these standards. Effective performance measurement will in turn enable the University
Health Board to ensure accountability for improvement is clear and that it can better understand
any reasons for delays and employ actions to address.
Performance measurement of discharge performance is intended to help the University Health

Board understand when patients are referred to the next stage in their care pathway, the time
taken for elements of the care pathways to work and to understand the patient destinations so that
the correct out of hospital capacity can be provided.
This work has been challenging to implement during 2016/17. This has been mainly due to the
time taken to train hospital and community teams on the standards and their responsibilities as
well as the ability to properly understand performance, due to limited data capture resource. The
University Health Board has yet to effectively and fully understand the capacity needed to address
the delays experienced in the acute hospitals. The work is also challenging as a result of
workforce issues, arising from many ward sisters continuing to be required to work numerous
clinical shifts to cover resource gaps at their wards and hence unable to devote adequate time to
management action such as board rounds. The University Health Board also continues to engage
significant numbers of temporary nurse staff which further impacts the roll out. Alongside this the
University Health Board has yet to finalise its ‘Choice Policy’, and ensure a consistent roll out of its
standards and continue to support teams with training and development. This remains a key area
of renewed focus for 2017/18.
Locality development
This work supports the objective of the University Health Board to deliver care closer to home the
shifting the focus of care from acute to community in order to improve outcomes at individual and
organisational level. This work has aimed to ensure locality systems have clear plans and
resources to meet the community and out of hospital need. The aim of this work stream reflects
the University Health Board’s position that 80% of work in unscheduled care happens across
primary, community and out of hours services and as an organisation the University Health Board
needs to better understand the services supporting its patients out of the hospital setting and
support its localities in different ways to care for patients outside of hospital where appropriate.
National policy identifies integration as a legal requirement within the Social Services & Wellbeing
Act and the University Health Board has established localities as the foundation for improving
population health and wellbeing. This has not been a significant focus of the unscheduled care
programme during 2016/17 although work continues across the county and locality systems. The
integration of this work with the secondary care unscheduled care system will need to be
significantly strengthened if the University Health Board is to achieve its unscheduled care
ambitions during 2017/18.
Workforce development
For both acute and community the programme aims to understand better the unscheduled care
workforce and make recommendations on future requirements. Some progress has been made
utilising Integrated Care Funding and embedding medical structures within hospital settings. The
out of hours workforce has also been strengthened through new pay arrangements and the
transfer of the Carmarthenshire Primecare contract into the ‘Care-on-call’ service operated from
Pembrokeshire. The A&E review conducted during 2016/17 has also outlined the progress
needed on A&E staffing levels.
Frailty
During 2016/17 the University Health Board recognised that improving clinical outcomes for
people who live with frailty and/or dementia is a critical component of its unscheduled care work.
Frailty is one of the ten Strategic Objectives of the University Health Board which serves a
growingly ageing population and whilst a range of initiatives have been developed over time to
address their needs, it is recognised nationally that a whole systems approach is required to
support people to live well in the face of the effects of ageing. Frailty is a distinctive health state
related to (but not an essential feature of) the ageing process in which multiple body systems
gradually lose their in-built reserves. For older people living with frailty, a precipitating event such
as an infection or new medication can lead to a decline in function and trigger long term disability.
The most common event to have this impact is admission to hospital. Evidence is emerging that
frail elderly people are at significant risk of developing dependencies which occur as a
consequence of the nature of the care they receive (acquired/iatrogenic disability), as well as due
to delays in accessing the most effective care and support to enable them to maintain a
reasonable level of independence.
Admission to hospital can lead to sudden catastrophic functional decline. This acquired
dependency not only restricts how people live their lives, but also increases the burden on both
health and social care for ongoing care and support. This acquired dependency also increased
likelihood of re-admission and increases mortality.
During 2016/17 the University Health Board undertook a baseline assessment of its current
service (across acute hospitals and counties) followed by a gap analysis and stakeholder input
into current service provision. A stakeholder group has been established and during 2017/18 the
University Health Board will implement a more cohesive approach to developing frailty services.
For example the Q1 event plans to co-create a Frailty Clinical Pathway, identify what works well
that can be scaled up more rapidly, as well as support a more reliable approach to leading change
in the acute hospitals.
Welsh Ambulance Services

This work recognises the critical interface between the University Health Board and the ambulance
service and the significant contribution that WAST make to the unscheduled care system. Through
a jointly funded post the University Health Board has made good progress in 2016/17 to
implement the following:
• University Health Board Infection Prevention & Control Algorithm - Implemented by WAST
1st November 2016 – to date the pathway is being followed however there has not been a
large scale outbreak to fully test pathway effectiveness.
• Mental Health Algorithm - Following the successful implementation of a direct access
pathway for people calling WAST with mental health issues at Cardiff & Vale University
Health Board a stepped approach has been agreed at Hywel Dda. This pathway is in line
with the principle set out in the transforming mental health programme for mental health
services to be accessible 24 hours a day
• Frequent Callers - Currently frequent caller groups exist across all 3 counties, however
there is no common dataset or process for the management of these patients. In order to
develop a consistent process, the Carmarthenshire Frequent Callers group will initially be
the primary focus and once a process has been implemented this will be rolled out across
the remaining counties.
• Alongside the WAST frequent attenders work has commenced analysing the attenders
accessing A&E services within the University Health Board. The RCEM guidelines define
frequent attenders as 3 or more attendances within a 12 month period. The information
team is currently preparing a report on all attenders accessing A&E services within the
University Health Board who have attended more than 9 times in 2016 in order to scope out
the size of the issue across the University Health Board. This will be expanded to look at all
those who fit the RCEM guidelines following the initial scoping exercise.
• Patients Conveyed by WAST to A&E and Discharged - An audit is currently being
undertaken to review the past 3 months data across all acute centres involving patients who
were conveyed to A&E via ambulance transport and then subsequently discharged with no
obvious reason for admission. A sample of patient journeys will be jointly reviewed by
WAST and the University Health Board and recommend actions as required.
This work will continue to be developed during 2017/18 recognising the critical interface between
ourselves and the Ambulance Service and the impact on unscheduled care services.
2017/18 Plans
It is clear from performance and progress in 2016/17 that there remains significant action required
to improve the unscheduled care system across the University Health Board. Greater focus,
attention to detail and clarity of plans and expectations will be required if the necessary in-roads
expected are to be realised.
There is significant advice and best practice available to the University Health Board following a
number of service reviews undertaken over the past few years and hence what is needed to done
to improve our current systems should be clear. It is imperative the University Health Board
remains open minded to new challenges and opportunities as they emerge through its
transformation programme.
There remain recommendations outstanding that were identified by the Delivery Unit in earlier
years and require urgent mobilisation. During 2016/17 the University Health Board received
further reports on A&E staffing levels, discharge audits, unscheduled care benchmarking, Delivery
Unit 6 monthly review, ambulance handovers and assessment units.
The focus in 2017/18 needs to be on implementation and action of longstanding reports and
advice that has been provided. The Delivery Unit report of 2016/17 advises that operational
change processes have taken too long to commence and are not followed through with sufficient
focus. The Delivery Unit further reported that capacity (and sometimes capability) restricts the
ability of good people to implement sound plans and that if the University Health Board is to
successfully achieve a sustainable unscheduled care system these underlying issues must be first
resolved.
For 2017/18 a focussed programme management approach will continue to be adopted with 13
weekly rolling plans developed for each hospital and prepared jointly with the respective county
team. Ownership of plans and delivery of trajectories are the accountability of the County Director
and Hospital General Manager. Over the early part of the year the University Health Board will
ensure its plans are embedded within the transformation programme as delivery of the actions
within this programme will have the single biggest impact on clinical service delivery.
At a corporate level there will remain an expectation that as well as local actions being developed
by each site, all of the key recommendations previously made will be incorporated into 13 week
rolling plans as well as some overarching corporate programmes of work. Key themes for inclusion
in plans for 2017/18 are set out below at a University Health Board, individual site and county
levels. Further detailed actions will be developed on a 13 week rolling programme basis as part of
the programme governance arrangements.
Key themes and associated actions for delivery in 2017/18 that are considered enablers to the
more detailed action that will be overseen at a system level are shown in the table that follows.
Action By When Associated Costs

Objective - Clear governance arrangements established and resourced.
Appointment of programme manager. June 2017 Yes PMO funded
Appointment of information analyst. March 2017
Consolidate with Transformation Programme. June 2017 Included in
Transformation
Budget
Engagement with intensive support team in England to provide March 2017 Possible
advice and clinical challenge and to work towards implementation of
SAFER bundle for all hospital sites.
Objective - Clear understanding of capacity and demand within the unscheduled care system
Establish robust data set for programme. June 2017 Some IT capital
may be needed
Establish bed modelling capacity within the Capita contract. March 2017 Funded
Establish robust bed model for University Health Board. June 2017 In house
Establish robust data collection for in-hospital flow June 2017 Some IT capital
may be needed
Agree clear capacity gaps across community and social care to August 2017
determine the out of hospital capacity gaps we believe exist for
discharge
Objective – Support and build localities as a guiding principle and develop out-of-hospital services
to support the unscheduled care system and specifically to reduce admissions to hospital.
Review of community hospital role, functions and performance. March 2017 In house
Establish task and finish group to implement new operating June 2017 In house
standards for community hospitals.
Agree ICF investments to continue with benefits realised. March 2017 In house / ICF
Review process for 2017/18 ICF. April 2017 In house / ICF
Evaluate winter plan. March 2017 Swansea
University £8k
Primary care – evaluate and develop proposals for roll out at scale of June 2017 Yes – but invest to
pacesetter and cluster money programmes. save
Review management arrangements of locality systems. June 2017 TBA
Objective – To have clear and consistent standards for all that we do and measure performance to
take corrective actions.
MAST / TOCALS / AA2A June 2017 SI support funded
Out of hours. June 2017
Discharge standards. June 2017
Transport arrangements – review and implement new arrangements. April 2017 Within existing
team
Assessment Units. June 2017 SI support funded
Ward rounds. June 2017
Board rounds. June 2017
Ambulatory care. June 2017
Objective – agree workforce investments for fragile areas that will improve NHS Outcomes
Framework performance.
Finalise and conclude therapy investment plans. June 2017 Yes, agree with
Implementation of the recommendations of the A&E staffing review June 2017 executive team
undertaken in 2016/17. plan by March
2017
Implementation of supernumerary ward status to support March 2017 Will need
development of in hospital actions. agreement with
executive team,
important enabler
Objective – to ensure 100% patients over 75 years will have frailty screening using Scottish Frailty
Tool (baseline to improve discharge planning); implement CGA (BGS British Geriatric Society
version) within 24 hrs (100% screened patients); embed CGA into Ward Rounds, Board Rounds &
Discharge plans to enable an individual Ward LOS Reduction / bed days per over 75 population (to
be defined); Increase stay well plans.
All front of house staff to receive an introduction to the frailty 2017/18 Within current
screening tool. resources
Process to be embedded (forms to be provided to CGA assessors). 2017/18
Agree process / range of appropriate people to undertake 2017/18
assessments.
Agree 7 day cover (within current resource envelope). 2017/18
Go-live dates agreed and published. 2017/18
Link to detailed plans for Board Round Standards / RED & GREEN / 2017/18
EDD's.
Confirm stay well methodology / criteria. 2017/18
Amend criteria to increase number of patients with stay well plans by 2017/18 Yes primary care
(query) 10% funds needed to
make this happen
Objective – reduce falls admissions, reduce A&E attenders, reduce frequent flyer attenders,
improve ambulance delays.
I-Stumble implementation for care’/ residential homes. June 2017 Within current
‘111’ launch. March 2017 resources
Mental Health pathway. Feb 2017
Frequent attenders. June 2017
Conveyance. June 2017
HCP calls. June 2017
Objective - To ensure unscheduled care hospital facilities are fit for purpose
Minors’ facility for Glangwili Hospital £400k (c)
£550k (rr)
Review of discharge lounges Ongoing Possible
Development of an ambulatory care unit Withybush Hospital to align £220k capital plus
with ACDU and fast-track through ED 2 x RN
Development and implementation of out of hours action plans June 2017 Contain within
following out of hours review completed during 2016/17 budget
Detailed Summary of Plans

Glangwili Hospital / Carmarthenshire
Performance in Glangwili for 2016/17 has been extremely challenging. Bed capacity and A&E
staffing are significant factors in this. There remains a significant variation in performance by day.
• In the period 2017/18 Glangwili will endeavour to reduce 1 hour ambulance delays down to
47 by March 2018.
• It is planned to reduce 12 hour ED breaches at Glangwili to 181 by March 2018. Although
this is a relatively high number this is a planned reduction from December 2016 of 217.
• The aim for the 4 hour target is to improve to a year-end position of 80.1% (1%
improvement over the average outturn during April 16: January 2017)
• There is no projected average length of stay improvement included in this plan.
Key actions to achieve forecast performance Cost

Separate minors’ area in CDU entrance to enable see and treat for minors patients and Capital cost of building
increase in capacity of the majors cubicles. works
A&E staffing review
The CDU acute physician model is developing with 3 acute physicians and 2 part time In house
GPs commencing next month. There is a weekly operational meeting to review activity,
performance and improvements in the patient pathway. Development of ambulatory care
and ring fencing to ensure beds are not used overnight. Admission avoidance is being
developed in CDU with frailty and hot clinics being set up to enable consultant review and
acute follow up of patients avoiding hospital admission.
There is a recruitment campaign in development to increase the medical and nurse In house
staffing, which is being supported by the strategic resourcing team. Reducing the large
number of agency and locum staff and increasing substantive staff is pivotal to improve
both the quality and timeliness of patient care.
There is a weekly A&E meeting and site performance meeting which reviews the In house
previous week’s activity and performance on all NHS Outcomes Framework standards.
Actions are put in place to improve performance and patient pathways.
There is a wider Unscheduled care improvement plan to improve performance which is In house
based on ECIP, ambulatory care protocols and safer patient flow bundle with a significant
focus on strengthening the board round process and outcomes.
Length of Stay (LOS) is key to deliver improvements in NHS Outcomes Framework Dependent upon therapy
performance. A trajectory for improvement has been calculated on acute improvements, investments
additional therapy staff and a reduction in the medically number of patients and their
associated length of stay. Red and green day process will support and focus the
escalation and action on acute and community delays.
Additional therapists and a full complement discharge liaison nurses to develop a full Dependent upon therapy
team to enable the discharge patients to community facilities with a focus on maintaining investments and full
the medically fit list to 20-25. complement of DLNs
Glangwili works with all 3 Counties as Ceredigion, Pembrokeshire and Llanelli patients In house
are treated in the hospital which requires closer and timelier engagement to ensure
effective discharge. Length of stay reduction will be targeted by ward area based on
16/17 actual LOS with interventions to support the reduction.
Big room including all ward managers to focus on key areas of improvement to deliver In house
NHS Outcomes Framework performance including discharge lounge usage, board
rounds and improved flow throughput the hospital.
Weekly meetings with WAST to improve handover times and a focus on pathways to In house
avoid hospital attendance where appropriate and focus on WAST arrivals which are
discharged from A&E
Prince Philip Hospital / Carmarthenshire

The introduction of the new unscheduled care services pathway in April 2016 has seen a
significant improvement to unscheduled care performance at Prince Philip Hospital. Performance
has seen improvement through average length of stay for emergency medical patients.
• In the period 2017/18 Prince Philip Hospital aims to deliver 100% performance of the 1 hour
ambulance handover target, however, due off-load space, an average of 3 breaches per
month has been set.
• It is planned to reduce eliminate 12 hour Emergency Department breaches, however, due
to seasonal variation a yearend outturn of 4 has been set.
• The aim for the 4 hour target is to outturn at 98% performance by March 2018.

The 4 hour target the performance will be sustained primarily through matching capacity to A&E staffing review
demand by hour of the day in the minor injuries unit in particular triage capacity [revenue
impacts]. Further incremental developments will be achieved by improvement projects
identified by and led by the staff working in minor injuries unit.
The University Health Board plans to test a range of improvements to flow within the acute Capital and revenue
medical assessment unit and the following changes are due to be tested in early 2017/18, impacts.
for example:
• Including the introduction of band 3 workers to support medical teams by undertaking
tasks currently carried out by medical staff’s initial assessment of patients (e.g. taking
bloods)
• A new triage system to include identifying patients suitable for ambulatory care
treatment.
• Introduction of frailty screening for all patients.
• Creation of additional surge capacity to reduce the impact the emergency pressures
have on elective work at Prince Philip Hospital. 2 schemes are currently being
developed.
Development of ward round and board round standards that build on existing good practice In house
using national guidance e.g. Safer Bundles.
Mobile computing solutions to aid decision making at the bedside. Capital
Increase the OT provision from just 1 WTE for all the general wards. Revenue
Roll out of frailty support workers. Revenue
Withybush Hospital / Pembrokeshire

A review of 2016/17 performance for Withybush Hospital shows seasonal improvement with a
decline at the point where the required 96 substantive beds insufficiently met demand. In addition
the removal of the border divert in September 2016 created an immediate impact on the 4 hour
target of circa 5%.
• In the period 2017/18 Withybush Hospital will endeavour to reduce 1 hour ambulance
delays down to 12 by March 2018. (In December 2016 there were 26).
• We intend to positively impact the 12 hour ED breach performance to 130 by March 2018.
• The aim of for the 4 hour target is to improve performance to 77% by March 2018.

Ring-fencing of minor’s activity through development of more ‘see and treat’ capacity – area Minimal
has been identified within the current ED dept (minimal cost).
Development of an Ambulatory Care Unit to align with ACDU and fast-track through ED and C £220k capital + 2 x
facilitating accelerated discharge. RNs
Creation of additional surge capacity in Ward 9 (part of Ward 10 BJC) which will allow a Capital + Revenue
dedicated surge area for winter pressures, improving the flow of activity from ACDU into winter costs
Ward admissions – thus removing the Exit barriers from ED.
Targeted recruitment campaign led by Dr. James to improve substantive medical staffing In house
and reduce the level of locums and agency staff usage.
Roll-out of ECIP and Safer Bundles to address current cultures and timely discharges that In house
will facilitate greater fluency of patient flow and reduce delays in transferring Ward
admissions.
Additional therapies and discharge liaison nurses to develop an MDT-team approach to ICF
discharging patients to community facilities with a focus on capping medically fit list to 12.
Additional ART capacity and improved assessment and identification of care packages. ICF
Established A&E Improvement group focussing on time and motion studies to review all In house
aspects of the process and ensure any delays or barriers are addressed, implemented and
monitored going forward.
Bronglais Hospital / Ceredigion

During 2016/17, Bronglais Hospital delivered performance that was amongst the best in Wales
and, at times, was amongst the best in the UK. The number of patients presenting at ED rose by
6% and continues the year on year increase in demand for the service. Annual performance
against the 4 hour target in 2016/17 is expected to be just over 90%. Cooperation and
collaboration between acute and community services resulted in periods of challenging demand
and case mix being responded to proactively across the wide geographical area that Bronglais
serves. Partnership with Powys and Betsi Cadwalader Health Boards is of particular importance
to Bronglais with approximately 40% of its patients coming from these areas. Significant attention
has been given to partnerships with social service to improve joint working and establishment
mechanisms to reduce delays in discharge and the fruits of this work will become more bountiful
as time progresses.
• In the period 2017/18 Withybush Hospital will endeavour to reduce the 1 hour ambulance
delays down to 14 per month (average) by March 2018. Although offload delays are
specifically targeted, current service constraints with just 6 offload spaces do not always
allow this target to be achieved when the arrival profile of the vehicles is concentrated around
a specific time period. At these times, however, assessments of patients will continue to be
made on the ambulances so that diagnostic and medical care can continue.
• Bronglais aims to deliver 99% performance against the 12 hour target with 25 breaches at
year end. One particular area for improvement in order to deliver this is increasing the
number of side rooms available for infection control purposes across the site. Because the
ED provide 4 separate cubicles, it is sometimes the safest clinical area to care for patients
who need to be barrier nursed until a room on the appropriate ward becomes available.
• Bronglais aims to deliver a 1% improvement on the average outturn witnessed between April
16: January 2017 to 90.5% by March 18.

Improvements in discharge through partnership working with Betsi, Powys and the local In house
care services.
Review of model of care at Front of House (Clinical Decisions/A&E/Trauma and the Additional clinical audit
associated pathways) time
Development of ambulatory care pathways to promote rapid assessment, treatment and In house
discharge.
Focussed recruitment campaign for medical, nursing and therapy staff to ensure stability In house
and sustainability of services.
Implementation of Red and Green days across the site combined with electronic white Capital – flow
boards to delivery meaningful information to both the service and management. programme
Implementation of 24/7 Clinical Site and Bed Management function for the site to ensure A&E staffing model
clinical decision informs operational decision making at all times.
Recruitment of a social worker to the AA2A team and working towards a trusted assessor ICF
model of service for therapy and social workers to remove barriers/perceived barriers
across borders.
Performance Trajectories for 2017/18
The percentage of emergency responses to red calls

arriving within (up to and including) 8 minutes (Target
65%)
66%
64%
62%
60%
58%
56%
54%
52%
50%
Number of Ambulance Handover's over 1 hour

Trajectory 2017/18
84
82
80
78
76
74
72
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
17 17 17 17 17 17 17 17 17 18 18 18
HDUHB 82 80.5 80 79.5 79 78.5 78 77.5 77 76.5 76 76
% Patients Waiting less than 4 hours - HDUHB
Trajectory 2017/18
100.0%
95.0%
90.0%
85.0%
80.0%
75.0%
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Seen within 4 Hours 84.7% 84.7% 84.7% 84.7% 84.8% 84.9% 84.9% 85.0% 84.7% 84.7% 84.7% 85.5%
Number of Patients Waiting over 12 Hous - HDUHB

Trajectory 2017/18
390
380
370
360
350
340
330
320
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
17 17 17 17 17 17 17 17 17 18 18 18
HDUHB 379 375 371 367 364 360 356 353 353 353 353 341
STROKE SERVICES
Background
Stroke is a preventable and treatable disease. It is the leading cause of adult disability in Wales,
and the third most common cause of death, after cancer and heart disease. Over the past two
decades a growing body of evidence has overturned the traditional perception that stroke is simply
a consequence of ageing that inevitably results in death or severe disability. It is a devastating
condition that changes lives and can have a huge effect on people and their families. Every year
there are approximately 152,000 stroke cases in the UK – that equates to a stroke every five
minutes. One in four of people who have had a stroke are under the age of 65. The University
Health Board’s priority areas for stroke improvement are defined within the following themes for
action.
Stroke Actions
• Preventing stroke (including neurovascular services)
• Detecting stroke quickly
• Delivering fast, effective care (and secondary prevention).
• Delivering intensive rehabilitation aimed at functional improvement
• Supporting life after stroke
• Improving information
• Targeting research
Changing stroke services across an integrated University Health Board is a complex process due
to the range of patient groups, divisions, services and partner organisations involved. The Royal
College of Physicians guidelines also include early supported discharge, community rehabilitation,
systematic follow up, palliative care and long term support.
Stroke Services
Hywel Dda has four acute stroke units which provide all the necessary components of hyper-
acute, acute and rehabilitation stroke care. All are grossly underfunded and struggle to meet the
current clinical standards. The table below illustrates the current medical/nursing establishment
and bed position within Hywel Dda:
First 72 Post 72 hours CNS Actual budget for Consultants Ave

hours (hyper (acute / registered nurse (sessions per strokes
acute / acute rehabilitation whole time equivalent week) per month
stroke beds) beds/medical beds) (wte) establishment
WGH 4 14 1.1 WTE 18.15 WTE 2 18
PPH 5 24 0.2 WTE 19.94 WTE 2 19
GGH 4 16 0.8 WTE 17.22 WTE 7 24
BGH 4 14 0.8 WTE 17.68 WTE 3 13
Total 17 68 2.9 WTE 72.99 WTE 14 72
Key to the care and outcomes of stroke patients are the allied health professionals (physiotherapy,
occupational therapy, speech and language and dietetics) who support the stroke service across
all acute centres. The table below illustrates the distribution of allied health professionals across
the University Health Board.
Number of Number of physio OT SALT Dietetic Psychology

physiotherapists assistants
WGH 2.0WTE 0.5WTE 1.0WTE 2.0WTE (INC SPH) 0.24WTE 0.WTE
PPH 1.3WTE 0.3WTE 0.5WTE 0.9WTE 0.03WTE 0.WTE
GGH 2.0WTE 0.5WTE 1.0WTE 1.2WTE 0.05WTE 0.WTE
BGH 0.8WTE 0.5WTE 0.5WTE 0.7WTE 0.12WTE 0.WTE
Total 6.1WTE 1.8WTE 3.0WTE 4.8WTE 0.44WTE 0.WTE
All four acute centres have a designated ward for stroke care; however patients without a
diagnosis of stroke are sometimes admitted to these wards as a result of unscheduled care
pressures. Bronglais Hospital is the only unit within Hywel Dda to have a stroke unit embedded
within an acute medical ward. Sometimes this can be advantageous for flexibility of bed availability
however the acuity of the ward can be unpredictable. Frequently within Glangwili Hospital access
to acute stroke unit beds can be problematic. As a consequence of this, patients can often be
cared for in acute medical or care of the elderly (COTE) wards where stroke multi disciplinary care
is not necessarily the focus.
The four stages of stroke care are as follows.

Hyper Acute
One of the key aspects of hyper-acute stroke care is a need for timely delivery of thrombolysis
treatment where clinically indicated. For patients not eligible for thrombolysis their admission
would be through emergency care. For patients who are eligible for thrombolysis, Withybush and
Bronglais Hospital have a pathway that facilitates patients going directly to CT hence avoiding the
emergency department. This supports rapid treatment as time is critical. Prince Philip Hospital
stroke patients are admitted to a dedicated acute stroke assessment bed on AMAU where care is
prioritised. Patients that have been thrombolysed are admitted to CCU at Prince Philip, Glangwili
and Withybush Hospitals for the first 24 hours post thrombolysis. At Bronglais Hospital patients are
admitted directly to the stroke unit. All four stroke units have a designated area comprising of beds
specifically for stroke patients care in the first 72 hours.
The development of a thrombectomy service, where a clot is removed from a patient’s artery is in
its infancy within Wales however Cardiff are now providing a Monday to Friday 8am-5pm service
for which all four acute centres at Hywel Dda have an agreed referral process in place. The
University Health Board also has an agreed pathway to Cardiff for hemi-craniectomy (surgical
technique used to relieve the increased intracranial pressure). Patients are then repatriated to the
University Health Board for rehabilitation.
Discussions are ongoing regarding the possible development of a HASU at Morriston Hospital,
Swansea. If this goes ahead there will be significant impact on hyperacute services throughout
Hywel Dda. If a service is developed at Morriston Hospital which meets all RCP guidelines for
hyperacute care our population must have full access and the University Health Board must be
involved with any development from inception. Hyperacute stroke services will continue at
Bronglais and Withybush Hospitals for at least the medium term. They have already demonstrated
ability to rapidly manage acute stroke and travelling times to other units in Hywel Dda or a HASU
at Morriston Hospital preclude changing acute admission destination. After initial management
patients could be treated and transferred to a HASU if they would benefit.
For the population of Llanelli, Carmarthen town and south of Carmarthen a Morriston HASU would
be within acceptable travelling time and patients (a significant number including TIAs stroke
mimics etc) would be directly admitted to the regional centre. The possible development of a
HASU at Morriston Hospital is a longer term plan, will be very costly and manpower recruitment far
from straightforward. The University Health Board is therefore likely to be admitting acute stroke
patients to both Glangwili and Prince Philip Hospitals for some years and hence must aim to meet
RCP guidelines regarding stroke acute care in the intervening period.
Acute Phase
All four acute centres within Hywel Dda provide a comprehensive stroke service. Care during the
acute phase of stroke care is currently provided at all four sites. The level of acuity of these
patients is higher in the first 72 hours and requires level 2 (HDU) level care. Regular senior clinical
assessment is key within this phase in order to anticipate and prevent neurological deterioration
which may impact upon our patient outcomes. Therapy assessments and treatment should be
initiated within 24 hours of admission and should support a multidisciplinary team approach from
the point of admission.
Acute / Rehabilitation
Most patients are transferred from a level 2 type bed area after 72 hours providing they are
considered clinically stable. Following assessment within the first 24 hours of admission, therapy
intervention continues depending upon the patient’s needs. Patient’s acuity of need within this
area is often underestimated. Close physiological monitoring is no longer the priority however it is
often the case that patients will have complex physiological and psychological needs and must
therefore receive appropriate multi disciplinary team input.
Across Hywel Dda a five day stroke rehabilitation service is provided; this service differs according
to site, for example, whereas Withybush Hospital provides in essence a five day service they have
rehabilitation assistants supported through the nursing budgets but guided by therapists to provide
goal specific therapy and group therapy at weekends.
Each of the four sites provides different opportunities for patients due to environmental challenges,
for example Bronglais Hospital’s stroke unit has no day room or therapy room on the unit,
however, Withybush Hospital has an area dedicated to group therapy and a day room for
activities.
Once it is deemed that a patient has met their potential following inpatient rehabilitation they will
be discharged home with support as necessary. There are patients that may be eligible for early
supported discharge if the service is available. Following their period of stroke rehabilitation some
patients, who are not expected to benefit from further rehabilitation, have more complex needs
and require an extended period of general rehabilitation, a care package in the community, or
palliative care.
Delays in promptly locating these patients in an appropriate setting for their care needs often affect
patient flows and contributes to ‘bed-blocking’, often with extended lengths of hospital stay.
Community Reablement
Carmarthenshire
All three localities have multi-disciplinary community teams which include physiotherapy,
occupational therapy, community nurses and social workers. There is also a team of therapy
support workers available providing re-ablement services. These community services provide a
generalist model and are not stroke specific.
Ceredigion
There is a service which includes a team of occupational therapists, social workers and domiciliary
carers providing short term care needs up to six weeks post-discharge. Physiotherapy is managed
separately by health and the referral process is via acute care. Community nursing teams are also
available. These community services provide a generalist model and are not stroke specific.
Pembrokeshire
Local authority provides a re-ablement service which is comprised of rehabilitation assistants,
domiciliary carers and social care assessors. Occupational therapy and physiotherapy is provided
by health and the referral process is via acute care. These community services provide a
generalist model and are not stroke specific.
Life After Stroke

Upon discharge from hospital, patients are reviewed at six weeks and six months. The six week
review is carried out by physicians in outpatient stroke clinics. At some sites, this is supported by
a stroke specialist nurse and at others it is not. The six month reviews are in their infancy of
development and there is a lack of consistency at present across all sites. The University Health
Board had a service level agreement with the stroke association since 2014 who provided life after
stroke and communication support services across the three counties. It has been agreed to
extend this agreement until March 2018 to enable further evaluation of the current service and
plan for the future life after stroke service model to meet the needs of the population of Hywel Dda.
Governance
The University Health Board’s approach to improving stroke services to date has been governed
through the stroke steering group. This is a cross system group of managers and clinicians with
representation from all stages of the stroke pathway and across all of our hospital and community
systems. The programme meets monthly and is chaired by the University Health Board’s Director
of Operations/ Deputy Chief Executive with significant input from across the whole professional
system.
Performance
Stroke is a NHS Outcomes Framework priority with performance measured and reported monthly
to Welsh Government via Quality Improvement Measures (QIMs). Other measures include
statutory national audits for stroke care. These measures include:
Royal College of Physicians (RCP):

• Sentinel Stroke National Audit Programme (SSNAP)
- continuous audit
- performance reports 3 times per year
• Acute Organisational Audit
- Bi-annual audit
- performance reports bi-annually
Performance against the Quality Improvement Measures, SSNAP and Acute Organisational Audit
are summarised below:
• In relation to current compliance against Welsh Government NHS Outcomes Framework
targets for stroke the University Health Board is performing reasonably well. Admitting
patients to the stroke unit within 4 hours is challenging, with less than half of the patient
cohort meeting this target over the past 12 months. There is however, a general trend of
improvement in the measure over time, with 72.7% of patients meeting this target in
December 2016. This is the University Health Board’s best performance to date, and is
comparable with the best performance in Wales in this measure. The University Health
Board continues to perform well with regard to scanning patients within 12 hours, remaining
at 100% for the second consecutive month.
• SSNAP performance is variable across sites with Glangwili / Bronglais scoring a ‘D’ (mainly
low scoring domains) and Prince Philip and Withybush Hospitals scoring a ‘C’ (mainly
average domains) in the last round of results. The annual summary for these score highlights
the domains for improvement with increased therapy resources required across all 4 acute
centres to support further improvements in stroke services.
• The 2016 Acute Organisational Audit report summary clearly evidences resource deficits
across the University Health Board impacting on the standard and type of stroke services we
are able to provide. The audit scores progress against 10 key indicators that represent
important aspects of an acute stroke service. For example the University Health Board does
not have a clinical psychology service or a stroke/neurology early supported discharge team
available for its population. In 2016 the University Health Board’s scores out of 10 are –
Withybush Hospital - 3; Bronglais Hospital - 3; Glangwili Hospital - 3; Prince Philip Hospital -
1.
Mortality
In July 2016 the Acting Chief Medical Officer wrote to the University Health Board stressing
concerns over stroke mortality data. For two consecutive years the crude mortality in Glangwili
Hospital has been the highest in Wales (19% in 2013/14 and 23% in 2014/15) and is the fifth
highest in the UK (as measured by SMR). Since this time the 2015/16 data has been made
available and the crude mortality rate in Glangwili Hospital has reduced by 5% although it remains
the highest crude mortality in Wales. Each acute hospital at Hywel Dda has a relatively low rate of
admission compared to major HASU centres and so the effect of small numbers of events on
small total numbers must be borne in mind.
The results of the 2015/16 data gathering across Wales is set out in the table below.
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
SMR by site (red horizontal line indicates (roughly) the current UK SMR)
None of the stroke units at Hywel Dda are reported as outliers for mortality. In response to previous
reports and concerns raised, the Medical Director requested a review of stroke mortality across the
University Health Board; initially at Glangwili Hospital for 2014/15 to help explain the cause of the
findings, and identify learning and opportunities for service improvement.
The Glangwili Hospital stroke mortality review has been completed with recommendations made
and an action plan developed. The action plan is being led by the Glangwili Hospital triumvirate
management team and a multidisciplinary stroke team with support from the service delivery
manager. A formalised process is being followed through the Quality, Safety and Experience
Assurance committee, with a paper planned for presentation to the February 2017 meeting.
The University Health Board’s Vision for Stroke Services

The future for stroke services is high-quality stroke care equalling ‘best-in-class’ and aspiring to
benchmark to world class standards, provided equitably and for all patients. The University Health
Board believes in:
• Minimising the risk of stroke.
• Providing the best quality of care and support so that patients get the best possible
outcomes.
• Returning patients home as quickly as possible with the necessary support in place.
Our local Stroke Delivery Plan reflects the principles set out in Welsh Government’s National
Stroke Delivery Plan which aims to:
• Prevent stroke
• Detect stroke quickly
• Deliver fast, effective, treatment and care
• Support life after a stroke
• Improve information
• Target research
The University Health Board’s task is to help people minimise the risk of having a stroke; and
when stroke does occur, to provide the best quality care and support to maximise survival and
return to independence as quickly as possible. Significant improvements have been made in
stroke care across Hywel Dda in recent years through local stroke teams delivering service
improvements linked to evidence based care with little or no investment. However there are now a
number of urgent requirements to address concerns, shortfalls and risks within the stroke service
and these predominantly relate to staffing levels.
The stroke steering group and stroke teams are acutely aware of and acknowledge the University
Health Boards financial situation and challenge. If there is to be no investment in stroke services
over the next year the impact will be that the benefits to performance, outcomes and quality as
evidenced in the details in this report will not be achieved.
If the University Health Board is to see material improvements in its performance against national
stroke standards the below must be addressed.
Staffing levels
Dietetics
Approximately 30% of stroke survivors have malnutrition, poor dietary intake and dehydration.
These conditions can lead to higher incidence of death, disability, chest infection and longer
hospital stay. Dieticians also reduce dependency on artificial nutrition through effective
management and rehabilitation of artificial and oral nutrition intake. Dieticians work closely with
SLT in the management of dysphagia, establishing and monitoring nutrition care plans to improve
recovery and outcomes. Dieticians can reduce length of stay in hospital by up to 5.5 days through
collaborative working with SLTs to manage nutritional intake. An additional 1.61 WTE dieticians
are required to meet RCP guidelines.
Occupational Therapy
The Occupational Therapy supports the recovery of ability to carry out everyday activities. This is
achieved through delivering a staged programme that acknowledges diverse clinical presentation,
premorbid living pattern and person preference. The programme incorporates strategies to support
recovery of movement and cognitive ability as well as compensatory strategies. The frequency
that these activities are repeated in early recovery impact on pace and level of improvement as
well as length of stay. A minimum of 45 minutes of occupational therapy five days a week is
recommended, but there is increasing recognition that 7 day intervention improves rate of
recovery. An additional 11.93 WTE Occupational Therapists are required to meet RCP guidelines.
Physiotherapy
Physiotherapy very early after stroke (mobilisation within 24hrs) and at high intensity leads to
improved outcomes and recovery of movement and is evidently cost-effective. A minimum of 45
minutes of physiotherapy five days a week is recommended. Some physiotherapy departments
provide weekend services to maximise the impact of the intervention. The RCP and NICE
recommends intensive rehabilitation immediately after stroke, across a seven-day service, with a
skilled multidisciplinary team to limit disability and improve outcomes. An additional 10.44 WTE
Physiotherapists are required to meet RCP guidelines.
Speech and Language Therapy

Communication and swallowing problems are both common after a stroke. It is estimated that
around a third of people will have some level of communication difficulty (aphasia or dysphasia)
after a stroke. At least 40 per cent of stroke survivors will initially experience some difficulty
swallowing. Whilst many people recover their swallow quite quickly, early assessment and
appropriate management is essential to reduce risk of aspiration pneumonia. An additional 5.62
WTE SLTs are required to meet RCP guidelines.
Psychology
Following stroke, most patients will have some degree of cognitive impairment affecting their
memory, language, perception and attention to problems and reasoning, problem-solving,
planning, organising and inhibition difficulties. One in three has significant intellectual
impairments, 30% suffer from depression and a significant minority experience personality change
and behavioural problems. Access to specialist psychological services should be integral to
assessment, rehabilitation and longer-term adjustment. An additional 2.76 WTE psychologists are
required to meet RCP guidelines.
Nursing
Each stroke unit needs the right resources to provide high quality specialist clinical care,
compassion and rehabilitation to people with stroke and their families. Across the UK there is a
consensus that the nursing workforce should use a combination of evidence based staffing tools,
consideration of patient acuity and professional judgement to ascertain safe staffing levels. In
Wales the Nurse Staffing Levels (Wales) Act 2016 became law on 21 March 2016 and defines this
consensus. There is a strong body of international evidence that inpatient outcomes are affected
by the numbers of registered nurses on duty. In relation to stoke care, two recent studies by Bray
et al (2014) and Myint et al (2016) showed a direct relationship between registered nurse/bed
ratios and mortality. The 2016 National Clinical Guideline for Stroke gives recommendations for
whole time equivalent (WTE) stroke nursing levels per bed for hyper acute and acute stroke
services. These are:
• Hyper acute: 2.9 WTE per bed (80:20 registered: unregistered)
• Acute: 1.35 WTE per bed (65:35 registered: unregistered)
The ratios have been based on observational evidence and expert opinion. There are no
recommendations for combined units, rehabilitation or early supported discharge nursing levels.
There are multiple factors to consider when planning nurse staffing in stroke units and include:
• Patient dependency and acuity.
• Type of stroke service – Hyper acute (thrombolysis and 1st 72hrs) /Acute/ Rehabilitation/
Combined unit.
• Ward layout and design.
• Patient throughput/bed utilisation.
• Number of support staff available.
• Direct care contact time/rehabilitation activities.
• Indirect contact time – Multidisciplinary meetings, complex discharge meetings,
communication with families, goal planning meetings, referrals to agencies/teams.
• Knowledge, competency and training needs of nurses.
• Requirement for research activity/data collection/audit.
First 72 hours (Hyper acute)

Stroke patients will have compromised cerebral function and a potential for sudden deterioration,
including those patients who on initial assessment seem clinically stable. Intensive physiological
and neurological monitoring for up to 72 hours is required to ensure appropriate management and
the action to be taken should deterioration occur. Care in the first 72 hours requires a higher
intensity of nursing equal to high dependency unit acuity, known as ‘level 2’. The Department of
Health (2000) defines this level of care by stating “Patients requiring more detailed observation or
intervention including support for a single failing organ system or post-operative care and those
‘stepping down’ from higher levels of care”.
Post 72 hours (acute/rehabilitation)

Both acute and rehabilitation requires a similar number and skill mix despite the clinical settings
being different. Patients who are deemed medically stable often require the same level of nursing
resource as acute stroke patients. Rehabilitation services often care for the most physically and
cognitively dependent patients with complex nursing needs, requiring the skills and expertise of a
nurse with specialist stroke competencies and knowledge.
It is expected that approximately 10-15% of patients will die in the first 30 days following a stroke.
Delivering quality, supportive end of life care is likely to increase nursing staffing requirements.
Each combined stroke unit within Hywel Dda has a multitude of factors to consider when setting
safe nurse staffing levels. Below are descriptions of some of the relevant factors relating to each
stroke unit and the table that follows shows the current nursing establishment together with the
recommended safe nurse staffing establishment.
Glangwili Hospital
Gwenllian ward is the dedicated stroke unit at Glangwili Hospital. The ward has 20 beds, 4 are
allocated for the first 72 hours care and 16 are for stroke rehabilitation. The 4 beds allocated for
the first 72 hours care are mixed sex with a higher nurse to patient ratio and has been in operation
since October 2016. Patients in these beds have cardiac monitoring with telemetry boxes which
are monitored by coronary care unit staff. The average length of stay over a 12 month period is
18.9 days. An additional 10.61 WTE Registered Nurses and an additional 1.91 WTE HCSW are
required to meet recommended staffing levels.
Prince Philip Hospital

Ward 9 at Prince Philip Hospital comprises of 29 beds. The ward layout is made up of 4 bays with
6 beds in 3 bays and 5 beds in ASU, 6 side rooms, the bottom 2 side rooms are at a distance
from the nursing station and from view, these are not suitable for patients at high risk of falls or
with confusion as they cannot be monitored safely. In July 2015 following a visit from the Delivery
Unit, an acute stroke unit comprising of 5 beds was opened within Ward 9 (1 bed was lost bringing
the bed numbers down from 30 to 29). The 24 beds on the main ward area are used for patients
transferred out from the stroke unit and general rehabilitation patients. The Acuity and
Dependency Audit in June 2016 recorded the highest score within the University Health Board for
Ward 9, indicating that the whole time equivalents needed for the area was 55.70. The average
length of stay over the past year is 20.8 days and currently admissions to the ward are circa 70 –
78 per month. An additional 13.82 WTE Registered Nurses are required to meet recommended
staffing levels.
Bronglais Hospital
Ystwyth ward is 18 bedded acute stroke/stroke rehabilitation/acute medical ward (combined stroke
unit). There are 4 hyper acute type stroke beds located opposite the nurse’s station. These 4
beds are for the care of patients in the first 72 hours post stroke and have cardiac monitoring and
a higher nurse to patient ratio. Admission numbers are variable, on average the University Health
Board admits 45 patients onto Ystwyth ward every month, with an average of 12 of those being
stroke patients. The length of stay for each patient varies significantly depending on individual
patients. The average length of stay over the last year is 10.1 days. An additional 7.92 WTE
Registered Nurses and an additional 2.54 WTE HCSW are required to meet recommended
staffing levels.
Withybush Hospital
Ward 11 is the dedicated combined stroke unit at Withybush Hospital. The ward has 18 beds
which includes an acute 6 bedded stroke unit consisting of a male and female bay with 4 hyper-
acute type stroke beds which provide continuous physiological monitoring, cardiac monitoring and
2 step-down beds. On ward 11 there are 12 stroke rehabilitation beds divided between two bays
and three side rooms. There is an established gym for patients on the ward and a therapy area
where daily group therapies are conducted. The average number of admissions per month is 16.
The average length of stay over a year is 18.6 days. An additional 5.42 WTE Registered Nurses
and an additional 2.84 WTE HCSW are required to meet recommended staffing levels.
Specialist stroke nurses

The role of the specialist stroke nurse is key to the stroke care pathway. The specialist stroke
nurses often attend A&E and provide support to nursing teams to undertake initial assessments
and correct management of people with acute stroke. Specialist nurses provide leadership,
facilitate evidence based practice and stroke specific education, support multi-disciplinary team
working, provide stroke specific information to patients and their families as well as a key point of
contact and lead with research and audit activity across the stroke pathway. The specialist stroke
nurses across the sites work differently depending on the services provided and the set up of
these services. There is evidence that supports having increased numbers of specialist skilled
nurses within stroke care is linked to mortality. It is clear that the University Health Board needs
more skilled nurses that can provide specialist stroke nurse cover 7 days per week 8am-8pm at
each hospital site. Below is a table to demonstrate a staged approach to this implementation.
Hywel
GGH PPH BGH WGH
Dda
Current WTE CNS nursing 0.8 0.2 0.8 1.1 2.9
CNS Mon – Fri 9-5pm (365 days per year) 1.27 1.27 1.27 1.27 5.08
Additional Nursing required to achieve recommended
0.47 1.07 0.47 0.17 2.18
staffing Mon – Fri 9-5pm (365 days per year)
CNS Mon – Fri 8-8pm (365 days per year) 2.03 2.03 2.03 2.03 8.12
1.23 1.83 1.23 0.93 5.22
staffing Mon – Fri 8-8pm (365 days per year)
CNS 7 days per week 8-8pm + management time.
3.04 3.04 3.04 3.04 12.16
(365 days per year)
2.24 2.84 2.24 1.94 9.26
staffing 7 days per week 8-8pm (365 days per year)
Senior Nurse Role

The development of a senior nurse role in stroke services to work as part of a triumvirate stroke
service leadership team is being proposed. This senior stroke nurse role will work closely with the
clinical lead and service delivery manager to deliver an improving stroke service across the
University Health Board. This role is key to developing equitable service improvements and
provides stroke specific leadership to facilitate and support the development of the stroke
specialist nurses. The role will be a full time post covering across 4 acute sites and 3 counties,
supporting the development of stroke services throughout Hywel Dda.
Consultant Ward Rounds

The RCP guideline for a hospital admitting acute stroke for immediate care is for 24/7 availability
of a trained stroke physician (6 Thrombolysis trained physicians on a rota as a minimum). The
physical presence OF a stroke physician 7 days per week for all 4 hospitals of the University
Health Board is not possible due to rurality factors. Telemedicine for uncertain cases 24 hours
/day must therefore be made available and a rota set up to review patients at weekends – whether
this be University Health Board wide or from a regional HASU.
Early Supported Discharge (ESD)

For stroke patients in hospital, input from an ESD service (that provides early assessment in
hospital, co-ordinated discharge home, and post-discharge support) can accelerate their discharge
home and increase their chances of being independent in the longer term. The best results are
likely to be seen with well resourced and co-ordinated ESD teams and with patients with less
severe stroke symptoms.
The evidence indicates that the positive impact of ESD is:

• Reduced risk of death or dependency.
• Fewer adverse outcomes for every 100 patients receiving an ESD service.
• Up to 8 days shorter hospital stays for patients assigned ESD services compared to those
assigned conventional care.
• Significant improvements in scores on the extended activities of daily living scale and in the
odds of living at home and reporting satisfaction with services.
• The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD
team and in stroke patients with mild to moderate disability and deliver a time limited
intervention of 6 – 12 weeks.
ESD consensus published 2010 by NHS National Institute for Health Research recommendations
the following staffing for an ESD team:
• Physiotherapy 3.5 WTE;
• Occupational therapy: 3.5 WTE;
• SLT: 1.2 WTE
• Psychology: 1.5 WTE.
2 year stroke plan

Actions
Theme Action By When Associated
Costs
Staffing Meeting minimum nurse staffing requirements in all 4 hospitals. Agree by Yes
March 2017
Equalising the Specialist Stroke Nurse provision (these are a hugely Agree by Yes
valued resource that will drive better care). March 2017
A psychological service for stroke. Agree by Yes
March 2017
Meeting SLT/dietetics requirements at Glangwili Hospital following Agree by Yes
the recent mortality audit. March 2017
Achieve staffing reflecting the median identified through this year’s Agree by Yes
SNNAP Organisational Audit - This would result in the stroke service March 2017
still not achieving the stroke standards in current national guidance,
but would result in provision that would result in reduction of harm,
improved patient outcomes and reduced Length of Stay.
Staffing increases again to reflect evidence based recommendations 2018/19 Yes
in the most recent stroke guidance i.e. a study has been completed to
confirm staffing that achieves best clinical outcomes and reduced
Length of Stay etc.
Facilities Dedicated stroke unit in Glangwili Hospital. 2017/18 Yes capital

Pathways Work constructively with all Wales pathways on Hyper Acute stroke Ongoing None
units.
Explore telehealth model to improve consultant cover. September Capital
2017
Extend ‘stop a stroke’ campaign for University Health Board for Atrial 2017/18 yes – funded
fibrillation (AF). by national
stroke monies
ESD service 2018/19 Yes -
significant
Work to achieve Royal College standards for TIA - “patients with 2017/18 Possible
acute neurological symptoms that resolve completely within 24hrs
(i.e. suspected TIA) should be given aspirin 300mg immediately and
assessed urgently within 24 hours by a specialist physician in a
neurovascular clinic or an acute stroke unit
Implement standard approach for mortality reviews for University June 2017 No
Health Board
Conclude mortality review process at Glangwili and oversee action Ongoing No
plan implementation
Extend and agree SLA with stroke association March 2017 No
Performance Trajectories for 2017/18 without Investment

Stroke Quality Improvement Measures
100%
80%
60%
40%
20%
0%
Access to a Stroke Unit within 4 hours 58% 58% 58% 58% 58% 58% 58% 58% 58% 58% 58% 58%
CT scan in 12 hours 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
Assessed by a Stroke Consultant in 24 hours 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
Thrombolysed patients with Door to Needle
35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
<= 45 minutes
Performance Trajectories for 2017/18 with Investment

It is clear that investment in stroke services will support improved performance and outcomes for
stroke patients. The performance benefits and trajectories can be seen below. The trajectories are
dependent on the investment priorities highlighted in this plan.
It is important to note that the measures are bundles of indicators and therefore rely on in all
indicators in the bundle to give an overall compliance percentage. This can be seen in the 24 hour
measure where compliance includes patients being seen by a stroke consultant within 24 hours of
admission. At present we are unable to provide 7 day a week stroke consultant cover, and are
unlikely to be able to provide this with our current general medical consultant model.
Other considerations relating to the trajectories include:
• Recruitment and retention of specialist workforce
• Small admission numbers creating large fluctuations in performance data
• Capacity of support services i.e. radiology
Acute Stroke Quality Improvement Measure - HDUHB

4 Hour Compliance
100.0 %
80.0 %
60.0 %
40.0 %
20.0 %
0.0 %
May-16
Nov-16
May-17
Nov-17
Mar-17
Mar-18
Jul-16
Oct-16
Jul-17
Oct-17
Jun-16
Jun-17
Apr-16
Sep-16
Dec-16
Apr-17
Jan-17
Feb-17
Sep-17
Dec-17
Jan-18
Feb-18
Aug-16
Aug-17
Actual Trajectory Target

12 Hour Compliance
100.0 %
50.0 %
0.0 %
Oct-16
Oct-17
Dec-16
Jan-17
Dec-17
Jan-18
Nov-16
Nov-17
May-16
Aug-16
May-17
Mar-17
Aug-17
Mar-18
Jun-16
Jul-16
Jun-17
Jul-17
Apr-16
Apr-17
Sep-16
Feb-17
Sep-17
Feb-18

24 Hour Compliance
100.0 %
80.0 %
60.0 %
40.0 %
20.0 %
0.0 %
Oct-16
Oct-17
Dec-16
Jan-17
Dec-17
Jan-18
May-16
Nov-16
May-17
Nov-17
Aug-16
Mar-17
Aug-17
Mar-18
Jun-16
Jul-16
Jun-17
Jul-17
Apr-16
Apr-17
Sep-16
Feb-17
Sep-17
Feb-18

72 Hour Compliance
100.0 %
80.0 %
60.0 %
40.0 %
20.0 %
0.0 %
Oct-16
Oct-17
Dec-16
Jan-17
Dec-17
Jan-18
Nov-16
Nov-17
May-16
May-17
Aug-16
Mar-17
Aug-17
Mar-18
Jun-16
Jul-16
Jun-17
Jul-17
Apr-16
Apr-17
Sep-16
Feb-17
Sep-17
Feb-18
RCP - Clinical audit (SSNAP):

SSNAP reports stroke performance in a grade with E being the lowest and A being the highest.
Withybush General Hospital

July – Oct – Jan – Apr – Aug – Dec – Mar Apr – Aug – Dec – Mar
Sept Dec Mar July Nov 2016 / July Nov 2017 /
2015 2015 2016 2016 2016 2017 2017 2017 2018
Actual D C C C
Trajectory C C C B B

2015 2015 2016 2016 2016 2017 2017 2017 2018
Actual C D D D
Trajectory D D D C C
Glangwili General Hospital

2015 2015 2016 2016 2016 2017 2017 2017 2018
Actual D D D D
Trajectory D D D C C
Prince Philip Hospital

2015 2015 2016 2016 2016 2017 2017 2017 2018
Actual D C D C
Trajectory C C C B B
RCP Acute Organisational Audit:
The organisational audit 2016 focuses on 10 key indicators and is scored out of 10.
RCP Organisational Stroke Audit

10
K
9
e
y 8
7
I
n 6 Bronglais
d 5 Glangwili
i
4 Prince Philip
c
Withybush
a 3
t
2
o
r 1
s 0
2016 Actual 2018 prediction
PLANNED CARE
Background
The University Health Board continues to experience significant challenges in achieving the
referral to treatment standard. At the end of 2014-15 there were 4,595 36-week breaches. This
reduced to 4,281 breaches in 2015/16. The current plan for 2016/17 is to achieve a breach
position of less than 4,000 at year end. The University Health Board received a performance
related allocation from Welsh Government in 2016/17 totalling £6.3m dependent upon no more
than 4,500 breaches and no 8 week diagnostic breaches.
Context for scheduled care

The current context within which the University Health Board is working to deliver its RTT targets
is extremely challenging. The main issues being:
• Bed reconfiguration decisions have resulted in significant loss of activity compared to
previous years.
• Significant vacancies or service fragility issues exist across a range of services within
scheduled care.
• The University Health Board bed model shows a significant shortfall in elective beds.
• Elective services are not sufficiently ring-fenced or protected resulting in medical
emergency pressures frequently comprising elective care.
• Management capacity has been extremely limited but recruitment is ongoing to establish
the full team for scheduled care.
• Support capacity in planning, performance and finance has been limited due to resource
constraints.
• The teams involved in RTT delivery have other key priorities (particularly follow-ups) placing
further demand and pressure onto the same clinical / management teams.
• The financial context is difficult with funds required exceeding available budgets and no
guarantee of funding forthcoming.
• The changing shape of the waiting list results in more expensive stage 4 treatments are
now required where capacity issues are significant and more difficult to resolve.
The impact on patients and their families of long waiting lists with long treatment times is high and
can be devastating. The reputational risks of non-achievement in relation to the RTT target are
high for the University Health Board. The expectations of Welsh Government and the Board are
clear in relation to continuous improvement year on year in reducing 36 week breaches.
Development of Plans
Developing RTT plans for 2016/17 and 2017/18 has been a significant challenge. The exercise
itself is complex as it requires a detailed understanding of core capacity split between treatment
stages (which is complicated by large vacancies), and the ability to understand the consultant, site
and sub specialty waiting lists which is not routinely collected. For example, whilst there may be
sufficient capacity in total within a specialty (say general surgery) this may be in the wrong place
(Bronglais Hospital may have more than it needs and Prince Philip Hospital not enough) –
resulting in a site imbalance. Alternatively there may be a sub specialty imbalance; where for
example there may be sufficient general capacity but not enough for venous patients. There also
remains significant capacity issues in terms of informatics and finance support needed to develop
an integrated plan that links together waiting lists, workforce, physical capacity, efficiency and
money across the sites. The University Health Board continues to receive extensive support from
the Delivery Unit (DU) to plan and from external validation resources to validate waiting lists.
Funding
The funding set aside by the University Heath Board, in excess of core established budgets, to
address the referral to treatment challenge during 2016/17 is £6.8m. This is consistent with the
funding level set aside in 2015/16. In the financial 2016/17 £1.8m of these available funds were
utilised to offset the acute services productivity and efficiency challenge leaving a residual fund
available for RTT totalling £5m. This budget was not sufficient to achieve the estimated year end
delivery of 4000 cases and following receipt of performance monies from Welsh Government
£8.3m was committed (an additional £3.3m RTT allocation) to secure less than 4000. Whilst this
resulted in the requirement for additional funding of £3.3m for RTT this is as a direct result of our
requirement to deal with higher cost treatment backlogs as the profile of our waiting list backlog
shifts to treatment stages and the need for higher cost backfill and outsourcing. The summary
estimated finances associated with delivering RTT for 2016/17 is £8.3m in excess of established
budgets.
Capacity and Capability

Looking ahead it is essential that the University Health Board continues to build capacity and
capability within scheduled care to urgently start to address the improvement opportunities across
the specialties. There remains significant and unexploited opportunity through improved
management grip of booking, redesign of administrative systems, redesign of clinic templates,
referral management, development of pathways, virtual clinics, telemedicine etc. The University
Health Board has already reorganised the scheduled care directorate and made significant
progress in terms of management capacity. Whilst arrangements are still being finalised this
includes a significant increase in service management resource, a new general manager, a new
clinical director, a new head of nursing, dedicated management presence on Bronglais Hospital,
additional management and nursing resource for ophthalmology. In addition to this, the clinical
director for scheduled care is reorganising the clinical lead structure to ensure there will be
dedicated clinical leadership for each of the key specialty areas.
Alongside this the University Health Board is working with the Finance Director to enhance the
performance and finance support for scheduled care. This is essential if capacity and capability
are to be stabilised in the longer term. The Delivery Unit have continued to support the University
Health Board as it plans for 2017/18 and specifically to develop an operational academy to support
teams to develop the skills needed to work at service delivery manager level and beyond. A clear
plan to address the Delivery Unit recommendations is required. The University Health Board is
also moving at pace with specific development programmes including management passport plus
and the pulse programme commencing during 2016/17.
Improvement Programmes
Alongside the development of operational capacity and capability the new transformation
programme being established within the University Health Board is focussed on a number of areas
that will support the improvement of the scheduled care system. The key programmes to support
scheduled care are being mobilised around a new transformation and improvement programme
with specific focus on outpatients, theatres and orthopaedic improvements. The key principles
being to support teams to understand and diagnose current system and processes; identify areas
of greatest variation which are having the biggest impact on the system; develop, test and
implement solutions which have a measureable impact with the front line teams and patients;
sustain change through staff and patient ownership.
Planned care programme

The University Health Board has also re-invigorated and re-launched the national planned care
programme. This programme aims to spread best practice across four key specialties – ENT,
ophthalmology, orthopaedics and urology. These are also to be extended to include dermatology.
These remain key areas of concern and a local planned care board, chaired by the Director of
Operations/ Deputy Chief Executive Officer, is in place to oversee progress.
Data quality within waiting lists

There remains significant improvement opportunity to improve data quality by undertaking a
targeted validation process in order to improve and assure the data quality of associated waiting
times and waiting lists inclusive of follow-up patients who have passed their target date and the
clinical reliance placed on this information. The University Health Board has commissioned
targeted support in this area but needs to build further capacity and expertise during 2017/18 so
data quality assurance is available at all times. The short term validation exercise needs to deliver
key improvement actions at pace and the focus will be on training and development and
implementing standard operating procedures which can be embedded in system development
within the validation team. This work will assure the Board that waiting lists/ Patient Tracking Lists
(PTL) is valid and accurate and will identify errors to determine whether causes are rooted in
process or capacity issues. In turn this will support the development of standardised PTL
operating procedures and make recommendations to the informatics team on steps required to
maintain data quality improvement.
The University Health Board’s planning approach for 2017/18

Supported by the Delivery Unit the University Health Board plans to develop 3-year plans for each
specialty for RTT. The intention is to set out a 3-year programme of work to eliminate 36-week
waiters and to achieve the 26 week standard. This will involve building into plans the benefits from
improvement work as well as taking medium term tactical decisions to reduce reliance on
discretionary pay with the aim of building sustainable specialty services. For 2017/18 the
approach is set out as follows:
Phase 1 capacity model

• Understand what is currently funded and committed out of the RTT Funds and what
additional activity the capacity is buying.
• Agree baseline budgets to be sure what from RTT has now been included as core and
balance remaining.
• Cross reference core activity calculated against what has actually been delivered over the
last few years and sense check.
• Understand as part of this process any back fill activity and funding source for this
activity. This is important as some activity delivered is being done through backfill. This
may be funded from existing vacancies, RTT reserve or as recurrently funded within
baseline budgets.
• Prepare capacity plans by site and by sub specialty and in total based on core activity
provision. This should enable delivery plans to be produced for each sub specialty by each
site.
Phase 2 demand model
• Calculate derived demand from previous 12 months delivered activity and waiting lists – 1st
October to 30th September; based on opening waiting lists, activity delivered and closing
waiting lists.
• Sense check for any full year effects i.e. increasing demand in second part of year.
• Sense check for conversions from outpatients to inpatients based on backlog reduction.
Phase 3 closing the gap
• Compare demand and capacity calculations based on core activity and validated demand.
• Review demand for any referral opportunities.
• Review capacity for any efficiency opportunities including changing templates, utilization,
new to follow up changes.
• Calculate investment plans needed to bridge the gap including substantive proposals, short
term proposals through agency/waiting list initiatives, non recurrent outsourcing.
• Include what we can do re backlog reduction.
Phase 4 diagnostics planning
• Demand and capacity calculations as above to be completed for all diagnostic activities.
• Sense check against RTT demand and capacity plans above; i.e. ensure growth and
conversions considered including back log reduction.
• Calculate investment plans to meet revised gap including substantive proposals, short term
proposals through agency/waiting list initiatives, non recurrent outsourcing. To include
backlog reduction.
Phase 5 – Follow ups
• Develop follow up plans for each of the key clinical risk speciality included costed
administration validation, clinical validation, clinics to reduce backlog to improve levels on
2016/17.
Phase 6 – Long term plans
• Linked to the clinical strategy work and improvement programmes create 3-year demand
and capacity plans to reduce current backlogs.
Governance
Working with the Welsh Government’s Delivery Unit, the specialty teams have moved towards
weekly meetings to oversee the management of waiting lists. This allows for better planning and
use of clinical resources more effectively across the four acute centres within Hywel Dda. In
addition a monthly planned care board is active and oversees progress against the planned care
programme and various other improvements groups such as outpatients, theatres, orthopaedics,
eye care group, critical care delivery group, and other clinical working groups such as urology as
sub groups of the planned care programme board.
Enabling actions
In addition to developing specific actions for each specialty within scheduled care the University
Health Board continues to progress a number of enabling actions as set out in the table below.
Theme Action By When Associated Costs

Capacity for Bed modelling June 2017 In house
scheduled
care
Reorganisation of services at Glangwili Hospital. June 2017 Capital
Solution to lost elective capacity at Prince Philip Hospital. 2017/18 Capital Welsh
Government funded
Complete refurbishment of theatres at Bronglais Hospital. 2017/18 Capital Welsh
Government funded
Prince Philip Hospital Endoscopy scheme 2017/18 Capital Welsh
Government funded
Develop and implement outsourcing options where we do March 2017 Yes include as part of
not have internal capacity to deliver. final RTT plan
Team Address the capacity and support in planning, performance June 2017 Yes new operational
and finance which has been limited due to resource business partners as
constraints and address Delivery Unit plans. part of corporate
teams
Finalise scheduled care structures March 2017 Funded
Development plans in place for all team members including March 2017 In house
sign up to Passport, Passport Plus and Pulse.
Improvement Programmes and actions plans in place supported by March 2017 Transformation Team
transformation team for outpatients funding
Programmes in place and action plans supported by March 2017 Transformation Team
transformation team for theatres. funding
Programmes in place and action plans supported by March 2017 Transformation Team
transformation team for orthopaedics. funding
Clinical sub groups in place for planned care programme. March 2017 In house
Critical care delivery group. 2017/18 In house
Eye care group. 2017/18 In house
Working with ABMU re vascular surgery improvements. 2017/18 Some costs
Agree funding for communication with patients and activate March 2017 Budget 2017/18
plan.
Agree funding for referral acknowledgement and activate March 2017 Budget 2017/18
plan.
Finalise and update our waiting list policy including clarity June 2017 In house
and agreement on our treatment of ‘Could Not Attend’
(CNA) and ‘Did Not Attend’ (DNA)
Validation recurrent plan in place including standard June 2017 RTT funds
operating procedures.
Plans 2017/18
These plans remain subject to validation by Finance and Informatics.
The University Health Board plans to end 2016/17 with less than 4,000 x 36 breaches. The
University Health Board is aware that a significant proportion of these breaches are now likely to
be stage 4 across orthopaedics, ophthalmology, general surgery and urology. This is despite
significant outsourced activity in ophthalmology. Achievement of the planned 2016/17 year end
position has been significantly compromised in recent weeks by elective cancellations due to
unscheduled care pressures. Plans looking forward assume these can be mitigated.
For 2017/18 and following the process outlined above plans assume WIP/TBA (further planning
and financial support is needed to achieve this). Separately the University Health Board intends to
undertake a strategic review of its orthopaedic service and develop a recovery plan, subject to a
separate business case, to return orthopaedic backlog to zero over a given period. Given the
backlog volumes this is likely to need a 3-year investment plan to recover and will include options
for backlog reduction through emerging treatment centre options.
The cost of achieving this plan for 2017/18is summarised in the table below – WIP/TBA (further
planning and financial support is needed to achieve this).
Specialty Item Value

Pain Management Funding previously agreed team £470,000
Cardiology Waiting list initiatives (156) / additional clinics and Diagnostic costs needed to £384,000
maintain current service levels (employ x3 recurrent staff) / replace unfunded
locum consultant cardiologist (WLI £156,000 + Locum sessions £96,000 +
£132,000 Echo staff)
Respiratory Waiting list initiatives (210) / additional clinics /Zero hours contract for £230,000
Withybush Consultant (£20k)
Diabetes No RTT issues but significant follow up problem to address £0
Neurology Continued outsourcing – weekend sessions via Medinet (£282k) (Need to try £322,000
and move to more substantive workforce with x3 neurology appointments)
Additional £40,000 to phase in substantive appointment
Gastroenterology Waiting list initiatives / additional clinics (38) £38,000
Care of the elderly Waiting list initiatives / additional clinics (138) £138,000
Ophthalmology TBA / WIP
Urology TBA / WIP
General surgery TBA / WIP
ENT Locum consultant (core (4) + 1.5 extra clinics per week all covered by locum £120,000 +
consultant) plus implementation of audiology plan audiology
Orthopaedics TBA / WIP
Radiology Maintaining current 8 week waits through agency / overtime / reporting £450,000
Endoscopy Provision TBA £300,000
All Core funding as per top slice last year £1,658,000
Follow-up pilots (see below) – estimated £250,000
Total Costs
Available recurrent budget (£5,115,700)

Additional funding required
Performance Trajectories for 2017/18
RTT - Patients Waiting 36 weeks & Over

5000
4000
3000
2000
1000
0
Apr-17May-17Jun-17 Jul-17 Aug-17Sep-17Oct-17Nov-17Dec-17Jan-18Feb-18Mar-18
Apr- May- Jun- Aug- Sep- Oct- Nov- Dec- Feb- Mar-
Jul-17 Jan-18
17 17 17 17 17 17 17 17 18 18
RTT - Patients Waiting 36 weeks &
4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000
Over
Follow Ups
In this version of the plan the University Health Board has yet to establish a plan for follow-up
care. At the end of December 2016 there were 31,728 follow-up patients passed scheduled target
dates and not booked.
During 2016/17 some work commenced to start to address follow-up backlogs in key specialties
but this has not been delivered to a sustainable level.
The University Health Board is presently undertaking an exercise to administratively review all
delayed follow-up cases which will be completed before the end of March 2017. It is assumed that
this will reduce the backlog figures by a minimum of 15% taking the year end position to 26,970.
Alongside this, plans for outpatient improvement will aim to transform the outpatient systems
including working with secondary and primary care clinicians to look at alternatives to follow-up
processes and to modernise traditional follow up pathways and so improve efficiency and
productivity. Alongside this the University Health Board plans to:
• Continue validation of follow-up waits
• Undertake a baseline assessment of outpatient processes and follow up pathways for key
specialities
• Produce a delivery plan for all specialties
• Assess impact of revised referral pathways on commissioning arrangements
• Consult on transformation plans with primary care and service users
• Implement transformation plan starting with identified highest risk specialties
• Produce business cases for IT systems to support pathway changes
• Meet the requirements of Welsh Audit Office
Further reductions can be anticipated through the transformation work which be specialty led but
until such time that the administration validation work is complete it will not be possible to quantify
the numeric impact. It is therefore suggested for year 1 that an allocation for outpatient follow-ups
is considered to meet the costs of a GP pilot. . This has been included in RTT budget plan above.
Number of Patients Waiting for F/up delayed past target date -
HDUHB Trajectory 2017/18
30,000
25,000
20,000
15,000
10,000
5,000
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2017/18 Trajectory 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970 26,970
Diagnostics
Current Performance
At the end of December 2016 the University Health Board achieved the agreed standards with no
patients waiting more than 8 weeks for diagnostic tests across all modalities. This is a significant
achievement for the University Health Board as many of its services face significant workforce
challenges and remain fragile. Weekly review of patient numbers continues to take place to ensure
gaps in capacity are identified and covered however this is often done through overtime and
temporary solutions.
Plan for 2017/18

For 2017/18 the University Health Board remains committed to continuing to achieve the 8 week
standard and to improve this where possible. To support this process, a comprehensive demand
and capacity plan will be developed for all modalities and the development and agreement of a
longer term strategy for radiology will be progressed. The cost of achieving the 8 week diagnostic
standard is greater than the core funding available within the University Health Board. A budget
allocation of circa £1m has been allowed within the RTT budget allocation above to cover
additional costs of cardiology diagnostics, radiology and endoscopy. This remains at a level similar
that allowed in 2016/17.
CANCER
Performance Overview
This section describes the University Health Board operational plan to support delivery of the
Welsh Government (WG) NHS Outcomes Framework performance targets in respect of Urgent
Suspected Cancers (USC) and Non-Urgent Suspected Cancers (NUSC).
Welsh Government NHS Outcomes Framework USC & NUSC performance targets are as follows:
• Urgent Suspected Cancers (USC) – 95% of patients to receive treatment within 62 days of
referral
• Non-Urgent Suspected Cancers (NUSC) – 98% of patients to receive treatment within 31
days of an agreed decision to treat following diagnosis
USC Performance 2016/17:

The University Health Board has demonstrated a continuous trend in monthly performance
improvement since June 2016 and ranked 1st amongst the 6 Health Boards in Wales at the end of
December 2016 with performance exceeding 92%. This represents the highest monthly
percentage performance achieved during the year to date.
Forecast performance for the remainder of 2016/17 is expected to show consolidation of this
improvement with yearend performance close to or in line with profile.
NUSC Performance 2016/17

Performance year to date has generally exceeded or been within 1% of target. Performance in
November 2016 fell sharply to 94.6%. This reduction in performance was exclusively due to
capacity pressures and associated treatment delays within the tertiary oncology and surgical
service. Performance for December 2016 recovered to target level
Forecast performance for the remainder of 2016/17 is expected to lead to year end performance
above target level.
This Operational Plan:
• Sets out the Hywel Dda USC & NUSC performance trajectories for 2016/17
• Provides a summary review of performance during 2015/16 and progress achieved in each
tumour site
• Explains the methodology and assumptions underpinning the performance trajectories for
2016/17
• Describes the operational governance and assurance mechanisms in place to monitor and
support performance improvement
Describes the operational improvement plans by tumour site, highlighting short term and longer
term actions
Review of 2016/17 Performance Challenges

Notwithstanding the significant improvements in performance achieved during the year, further
improvement in performance in respect of the USC NHS Outcomes Framework target has been
compromised by the following challenges:
• The impact of local capacity pressures experienced in key high risk breach tumour
pathways which has compromised timely access to 1st outpatient appointments and
subsequent diagnostic / treatment pathways.
• Action to reduce the ‘backlog’ of patients awaiting treatment (both locally and in the tertiary
centres) which adversely affects reported monthly performance
• Patients undergoing lengthy, complex diagnostic pathways involving multiple diagnostic
investigations, multi disciplinary team discussions, externally provided specialist imaging
and/or multiple tumour site investigations
• The impact of diagnostic and treatment capacity pressures and delays at the tertiary
centres.
The vast majority of Hywel Dda patients on the NUSC pathway receive their treatment within 31
days of an agreed decision to treat if treatment (surgical or chemotherapy) is delivered locally at
hospitals within the University Health Board. Predominantly, NUSC pathway breaches for Hywel
Dda patients occur due to treatment capacity pressures and delays at the ABMU tertiary centre.
Without these tertiary centre breaches, Hywel Dda would routinely achieve the NUSC NHS
Outcomes Framework performance target.
Local Capacity Pressures

This plan outlines the action currently being pursued by the University Health Board to mitigate the
risks of long-standing clinical capacity pressures affecting key tumour pathways including Lower
GI, Urology, Dermatology, Lung and supporting Diagnostic services. These include short and long
term measures. Pressures experienced during the early Summer period 2016/17 have
compromised the University Health Board’s performance in respect of the timely assessment and
diagnosis of USC referrals and consequently, the timely referral of some patients for tertiary centre
care.
A key priority for all specialties / tumour sites is to ensure patients referred on the urgent
suspected cancer pathway receive their 1st outpatient appointments within 10 days of referral. As a
result of targeted action during 2016/17, we have achieved significant improvement in waiting
times for 1st outpatient appointment for patients referred via the USC pathway. The graphs below
illustrate the indicative waiting times (measured in days) for 1st outpatient appointments for USC
referrals by specialty and hospital as at the end of December 2016.
The above graphs indicate that recent improvements in the majority of specialties / tumour
pathways for USC 1st OP appointments are being sustained at each hospital within the University
Health Board. As at the end of December 2016, the only tumour pathway reporting waits for USC
1st OPAs in excess of 10 days was Colorectal (at Glangwili General Hospital) which reflected a
peak in referral demand received during the Christmas/New Year period. The colorectal team
have arranged additional clinic capacity to manage this demand.
Backlogs
During 2016/17, Hywel Dda prioritised a series of actions to achieve reductions in the backlog of
patients on the USC pathway. Whilst it is noted that a significant proportion of the backlog of
Hywel Dda patients await treatment in the tertiary centres, the University Health Board has made
significant progress in reducing the overall backlog during Autumn 2016 and the volume of
patients waiting remains amongst the lowest of all Health Boards across Wales.
The profile of Hywel Dda patients in both the 63 Day + and 53-62 Day backlog cohorts for the
period April to December 2016 is shown below:
A sustained reduction in the number of patients in the 63 Day + and 53-62 Day USC backlogs is
essential if performance is to improve in line with agreed profiles.
Patients in the 63 Day + cohort include those following complex / lengthy clinical pathways,
patients who are clinically suspended and those waiting for tertiary centre treatment. The cohort
also includes a significant number of patients who do not have confirmed diagnoses of cancer and
will not necessarily breach the 62 day target. Both cohorts are dynamic in nature i.e. patients are
added to / removed from either cohort on a daily basis depending on their progression along their
individual pathway.
Complex Diagnostic Pathways

Hywel Dda performance in key specialties is compromised by the complex nature of the diagnostic
pathway for some patients, particularly in respect of Lung, Haematology, Head & Neck and Upper
GI pathways. Definitive treatment for many patients in these specialties (including radiotherapy) is
delivered outside of the University Health Board in the tertiary centres and the volume of patients
for whom the diagnostic and treatment pathway is categorised as complex frequently exceeds the
monthly 5% tolerance available to the University Health Board to guarantee consistent delivery of
the USC NHS Outcomes Framework target.
Tertiary Centre Capacity Pressures

Due to the specialist nature of some treatments for cancer, a significant number of Hywel Dda
patients receive their surgical / oncological treatments at the tertiary centres based at Abertawe
Bro Morgannwg or Cardiff & Vale University Health Boards. Both tertiary centres experience
significant capacity pressures due to recruitment difficulties in key specialties and the impact on
unscheduled care pressures on available hospital bed and theatre capacity. Pathway delays for
Hywel Dda patients at ABMU occur primarily in the lung (thoracic surgery), gynaecology &
oncology (radiotherapy) specialties as follows:
Lung (Thoracic Surgery)

• Issue reflects a core capacity shortage within the Thoracic surgery service which has been
escalated to WHSSC (commissioners) and Welsh Government
• As a result of University Health Board escalation, WHSSC is currently leading a project to
outsource Thoracic surgery to external providers in England to help ease capacity
pressures within the two surgical centres in South Wales. This is expected to have a
positive impact in reducing delays for Thoracic surgery during 2017/18.
Gynaecology
• Issue reflects long term sickness/absence within the ABMU Gynaecology Cancer Surgical
service at Morriston Hospital.
• Throughput is also compromised by access to theatre time and bed availability at Morriston
Hospital.
• Resolution of this capacity pressure within the Tertiary Gynaecology Cancer Surgical
service is expected to resolve during 2017/18.
Oncology (Radiotherapy)
• Issue reflects chronic, long term Consultant Oncologist recruitment / capacity challenges
within the South West Wales Cancer Centre (SWWCC) hosted by ABMU
• Patients who require Radiotherapy as the first definitive treatment are at risk of breaching
the USC / NUSC targets due to capacity pressures
• ABMU have been unable to successfully recruit replacement and additional consultant
capacity although locum and substantive recruitment attempts are continuing.
Progress / Achievements during 2016/17

Notwithstanding the above pressures, Hywel Dda has achieved significant progress during
2016/17 across a number of tumour sites in improving existing pathways, reducing avoidable
pathway delays and through the provision of additional capacity to support quicker access to first
outpatient assessments.
A summary assessment of progress achieved by tumour site is described below together with
areas for further action and improvement during 2017/18.
Gynaecology
Achievements:
• Review of systems and procedures to address delays in first out patient appointments and subsequent failure to
refer to tertiary centre by day 31 of pathway.
• One stop clinics formally established.
• Gynaecology 1 OPA performance has significantly improved and University Health Board is consistently
st
referring patients for tertiary care before day 31 of pathway.

• Joint MDT working with ABMU MDT to streamline referral pathways and operational protocols.
Areas to improve:
Capacity pressures at tertiary centre continue to compromise treatment of some patients referred for tertiary level
treatment by Day 62 of pathway.
Lower GI
Achievements:
• Additional clinics and endoscopy lists provided to deal with referral demand has achieved some success in
reducing waiting times for first outpatient appointments and subsequent investigations although pressures
continue due to overall volume of demand.
• Close monitoring of clinic slots to ensure backfill of all available capacity.
• Communication campaign via MDT to remind clinicians to use USC radiology for Suspected cancer only and
Urgent requests to be submitted on the non USC form. Posters displayed in out patient suites with resultant
improvement in appropriateness of diagnostic referrals.
Areas to improve:
• High pressure tumour pathway due to volume of referrals and vacancies within clinical team at Glangwili Hospital
resulting in continuing challenges in securing first outpatient appointment and CT colon investigations within
required timescales with subsequent impact on ability to refer patients for tertiary level care (as appropriate) by
day 31 of pathway.
• Changes in NICE guidance could potentially impact on the number of referrals with rectal bleeding being sent in
to secondary care with resultant additional pressures on outpatient and diagnostic capacity.
• Recruitment of locum / substantive Consultant Gastroenterologist following recent departure from Bronglais
Hospital.
Upper GI
Achievements:
Initial review of current pathway has supported University Health Board ability to minimise breaches, noting complexity
of diagnostic pathway for some patients.
Areas to improve:
• Complexity of diagnostic pathway with patients discussed at local and Regional MDTs.
• Recruitment of additional CNS capacity to support patients on Cancer pathways via provision of enhanced clinic
capacity for review patients and increased ability to provide key worker support for patients.
Urology
Achievements:
• Additional clinics and diagnostic lists provided to deal with referral demand has achieved some success in
reducing waiting times for first outpatient appointments and subsequent investigations although pressures
continue due to overall volume of demand.
• Review of service / diagnostic processes and pathways has led to improvements for some aspects of the
pathway (reduced waits for TRUS biopsies)
Areas to improve:
• High pressure tumour pathway due to volume of referrals and vacancies within clinical team resulting in
continuing challenges in securing first outpatient appointment and diagnostic investigations within required
timescales with subsequent impact on ability to refer patients for tertiary level care (as appropriate) by day 31 of
pathway and/or secure treatment by day 62 of pathway
• Significant increase in demand noted for Robotic Assisted Laparoscopic Prostatectomies (RALP) service
delivered via tertiary centre with resultant delays for access to tertiary level surgery.
Dermatology
Achievements:
• Additional clinics and minor op treatment lists provided to deal with referral demand has achieved some success
in reducing waiting times for first outpatient appointments and subsequent investigations although pressures
continue due to single handed consultant and lack of success in recruiting additional capacity to support service.
• Partnership working with ABMU for joint assessment and grading of referrals to improve efficiency with which
USC referrals are assessed.
• Development programme commenced to support development of middle grade clinical capacity and replacement
GPs with special interest.
• Excellent regional MDT links with ABMU.
Areas to improve:
• High pressure tumour pathway due to volume of referrals and vacancies within clinical team resulting in
continuing challenges in securing first outpatient appointments and minor op treatments within required
timescales with subsequent impact on ability to refer patients for tertiary level care (as appropriate) by day 31 of
pathway and/or secure treatment by day 62 of pathway.
• Achievement of a sustainable service model in view of current vacancies and repeated unsuccessful recruitment
attempts.
Lung
Achievements:
• Escalation of University Health Board concerns re Thoracic Surgery delays to Welsh Government /WHSSC with
resultant uplift in contracted activity for lung cancer resections from April 2016.
• Continuous improvement in local diagnostic pathways as reflected in Peer Review assessment
Areas to improve:
• High pressure tumour pathway due to complex and prolonged nature of diagnostic pathway and vacancies within
clinical team with subsequent impact on ability to refer patients for tertiary level care (as appropriate) by day 31
of pathway.
• Major Thoracic surgery capacity pressures within tertiary centre resulting in excessive delays for surgery.
• Secure implementation of a sustainable Respiratory service across the University Health Board area through
substantive recruitment of 4 additional consultant posts.
• Provision of additional CNS capacity to support assessment of patients and provide key worker support to
patients.
Breast
Achievements:
Continued good performance in respect of both USC & NUSC pathways with breaches of either target as an
exception.
Areas to improve:
Achievement of a sustainable Breast Radiology service which is currently based on 1 Breast Radiologist across the
University Health Board
Head & Neck

Achievements:
Initial review of pathway and reduction in delays for outpatient assessments and diagnosis through provision of:
• Additional USC clinics
• Additional operating lists
• Additional nodal biopsy capacity
• Centralised USC referral process
Areas to improve:
• Achievement of a robust and sustainable H&N service model ensuring timely access for USC/NUSC patients and
efficient progress along the cancer pathway.
• Capacity pressures within tertiary oncology service leading to delays for access to radiotherapy treatments.
General Issues
Achievements:
• Partnership Working with ABMU including University Health Board membership of ABMU Cancer Commissioning
Board and joint senior / operational and clinical level partnership working to secure ongoing improvements in
cancer pathways.
• Significant increases in Chemotherapy delivery at local hospitals as a consequence of joint service planning with
ABMU.
• Collaborative working with South West Wales Cancer Centre to facilitate introduction of electronic booking form
for Chemotherapy.
• Establishment of a South West Wales Safety Anti-Cancer therapy Safety Group – ABMU led, working to shared
protocols. This has allowed patients previously treated at the South West Wales Cancer Centre to be treated
closer to home in Hywel Dda.
• Improved clinical engagement through establishment of MDT Clinical Leads Group.
Areas to improve:
Achievement of sustainable Oncology service for South West Wales and prevention of delays in access to
radiotherapy treatments at South West Wales Cancer Centre in Swansea.
Governance & Assurance

Hywel Dda operational performance in respect of Welsh Government NHS Outcomes Framework
USC & NUSC performance targets will be managed and coordinated via the following
mechanisms:
Daily
• Monitoring of ‘10 day’ OPA waits and diagnostic access (Service Delivery Managers)
• Prioritisation of patients identified on USC & NUSC primary targeting lists (PTLs) – (Service
Delivery Managers)
• Updating of individual patient clinical progress via Canisc system (Cancer MDT Co-ordinators)
• Early escalation & identification of remedial actions to address potential pathway delays
(Cancer MDT Co-ordinators & Service Delivery Managers)
• Daily communication between cancer patient tracking teams at each University Health Board
Weekly
• Cancer Watchtower attendance (Service Delivery Managers)
• Focus on backlog reduction (Service Delivery Managers)
• VC review with ABMU of all Hywel Dda patients referred for tertiary care at SWWCC (Joint
Cancer Teams)
• Review of patients on PTL by tumour site MDT leads (MDT Leads)
Monthly
• Attendance at ABMU Cancer Coordinating Board Meeting (GM, Cancer Services)
• Learning from individual patient breach reports (Service Delivery Managers)
• Directorate Performance Assurance Reviews (GM, Cancer Services)
• Performance reports to Board and Business Planning & Performance Assurance Committee
(BP&PAC) – (GM, Cancer Services)
Quarterly
• Cancer Improvement Board, supported by Executive leadership to drive further improvements
To supplement the above, the following systems and processes are in place to manage the risk of
harm to patients whilst undergoing assessment and treatment on the USC & NUSC pathways:
• All complaints, concerns and incidents in relation to Cancer and Oncology services are
routinely reviewed to assess the impact of pathway delays on patient care. It should be noted
that the volume of complaints, concerns and incidents reported in respect of cancer and
oncology services is low.
• All patients on USC/NUSC pathways are tracked via the University Health Board’s PTL and the
progress of all patients is monitored via dedicated Cancer Services co-ordinators. Clinical
progress information received from diagnostic services and the tertiary centres is monitored by
the Cancer Services co-ordinators and advised to the relevant tumour site MDT.
• Patients experiencing delays waiting for tertiary care are monitored and escalated on a daily
basis.
• All patients on a USC/NUSC pathway have direct access to their specialty consultant and/or
specialist nurse.
• Dedicated 24hour out of hours advice service / helpline to provide urgent clinical advice and
coordinate urgent/emergency treatment for patients who become unwell as a consequence of
the cancer treatment. This service is provided in partnership with the South West Wales
Cancer Centre at ABMU.
• With funding support from Macmillan, we have commenced implementation of an Acute
Oncology Services through the appointment of 4 specialist oncology nurses at each hospital
within the University Health Board who will work in partnership with acute medical teams to
coordinate the timely care of patients who present with urgent / emergency clinical conditions.
2017/18 Plans
The following section summarises the immediate and medium / longer term improvement actions
identified by tumour site.
Tumour Site Key Challenges 2016/17 Action / Status
• •
rd
Delays for surgical treatment at the 3 ABMU surgeon appointed (now in post)
tertiary centre in Swansea • Updated advice from ABMU suggests
• Situation had improved during the early consultant sickness / absence is not expected
part of 2016 to resolve until New Year.
Gynaecological • Deterioration during Summer 2016 • Above actions are expected to restore capacity
reflects sickness / absence with the to pre June 2016 levels and facilitate increased
ABMU Gynaecology consultant team capacity and reduced delays by February 2017.
and continuing bed capacity pressures
at Morriston Hospital
• Major capacity pressures due to • Two surgeons have now returned from
sickness absence of two consultant absence
surgeons and extended leave of one • Remedial action has been taken to provide
surgeon short term additional clinic and diagnostic
•
st
Breaches primarily reflect the impact of capacity (as reflected in 1 OPA performance
Lower GI
reduced capacity in previous months all sites)
• Service also heavily dependent upon • Pressures on tertiary oncology service
tertiary oncology service (for escalated at Executive Level with ABMU
radiotherapy treatments) actively seeking additional locum cover to
reduce delays.
• Delays for tertiary Thoracic surgery • WHSSC has agreed to commission additional
• Further deterioration noted during early capacity - ABMU delivering to contracted level
2016 • Hywel Dda escalation to WHSSC and formal
• Reflects waits for outpatient assessment request for temporary outsourcing of activity –
and surgery via the tertiary centre WHSSC chaired Thoracic Surgery Project
Lung
Board is developing a plan to outsource
capacity from February 2017
• Recent improvements in waits for Thoracic
outpatient assessments have been noted since
Hywel Dda escalation of concerns
• Unusually high number of patients • Subject to continuous monitoring
following complex diagnostic pathways
which mitigated against delivery of
Upper GI
treatment within 62 days of referral
• Complex breaches in June 2016
equalled 2015/16 total
• Fragile service model due to continuing • Additional weekly transrectal ultrasound
consultant, middle and junior grade (TRUS) biopsy capacity arranged for Bronglais
vacancies across the University Health • Recent performance shows reduced breaches
Board area. compared to previous months
Urology • Capacity challenges are also •
st
1 OPA performance has improved
compounded by sickness within the
clinical nurse specialist (CNS) team
• Resultant delays in outpatient and
diagnostic assessments
• Outpatient assessment delay due to • Capacity deficit now resolved
Breast temporary capacity deficit within service
• Breaches are rare within this pathway
• Higher than projected volume of patients • Long term tertiary centre Consultant Oncologist
following complex diagnostic pathways recruitment / capacity challenges continue
which mitigated against delivery of • Pressures on tertiary oncology service
treatment within 62 days of referral escalated at Executive Level with ABMU
Head & Neck
• Issue compounded by impact of delays actively seeking additional locum cover to
for radiotherapy treatments due to reduce delays
significant tertiary centre oncology
service capacity pressures
• Significant delays for outpatient • Recruitment of experienced locum SAS doctors
assessments and minor operations due • Appointment of locum consultant
Skin
to consultant capacity pressures • Partnership approach with ABMU to jointly
assess and grade USC referrals
• Further development of GPs with special
interest
Performance Trajectories 2017/18

NHS Outcomes Framework – Urgent Suspected Cancer (USC)
Reflecting the current trend in performance improvement achieved during 2016/17 and the
additional actions per tumour site described above, the University Health Board expects to
maintain performance during 2017/18 at 93% as reflected below:
2017/18 USC April May June July Aug Sept Oct Nov Dec Jan Feb Mar
Performance
Trajectory 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%
NHS Outcomes Framework – Non-Urgent Suspected Cancer (NUSC)

Reflecting the current trend in performance improvement achieved during 2016/17 and the
additional actions per tumour site described above, the University Health Board expects to
maintain performance during 2017/18 at 98% as reflected below:
April May June July Aug Sept Oct Nov Dec Jan Feb Mar
2016/17
NUSC Performance Trajectory
98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98%
Appendix 2
West Wales Population

Assessment
March 2017
1
CONTENTS
WEST WALES POPULATION ASSESSMENT REPORT 2016..................................................... 1
FOREWORD ......................................................................................................................................... 5
1. EXECUTIVE SUMMARY .......................................................................................................... 6
1.1. OVERVIEW AND PURPOSE............................................................................................................. 6
1.2. WEST WALES POPULATION PROFILE ............................................................................................... 6
1.3. HOW WE UNDERTOOK THE POPULATION ASSESSMENT ...................................................................... 7
1.4. RECOMMENDATIONS................................................................................................................... 8
1.5. THEMATIC REPORTS .................................................................................................................. 10
2. INTRODUCTION ...................................................................................................................... 16
2.1. STRUCTURE OF THE REPORT ........................................................................................................ 16
2.2. BACKGROUND .......................................................................................................................... 17
2.3. PURPOSE OF THE POPULATION ASSESSMENT ................................................................................. 18
2.4. HOW WE UNDERTOOK THE POPULATION ASSESSMENT .................................................................... 19
2.5. KEY RELEVANT STRATEGIES AND PLANS ......................................................................................... 21
2.6. DELIVERING NATIONAL OUTCOMES .............................................................................................. 22
2.7. REFERENCES ............................................................................................................................ 25
3. CONSULTATION AND ENGAGEMENT .............................................................................. 26
3.1. APPROACH .............................................................................................................................. 26
3.2. WELLBEING ASSESSMENT ........................................................................................................... 26
3.3. HIGHLIGHTS FROM THE FINDINGS ................................................................................................ 27
4. CROSS CUTTING THEMES ................................................................................................... 31
4.1. OVERVIEW............................................................................................................................... 31
4.2. DELIVERING SERVICES IN THE WELSH LANGUAGE ........................................................................... 31
4.3. MINORITY AND MARGINALISED GROUPS ....................................................................................... 33
4.4. PREVENTION ............................................................................................................................ 35
4.5. SAFEGUARDING ........................................................................................................................ 36
4.6. PROMOTING SOCIAL ENTERPRISES, COOPERATIVES, USER LED SERVICES AND THE THIRD SECTOR ............. 37
4.7. REFERENCES ............................................................................................................................ 38
5. RECOMMENDATIONS............................................................................................................ 39
5.1. VOICE AND CONTROL................................................................................................................. 39
5.2. PREVENTION AND EARLY INTERVENTION ....................................................................................... 39
5.3. WELLBEING ............................................................................................................................. 39
5.4. CO-PRODUCTION ...................................................................................................................... 39
5.5. COOPERATION, PARTNERSHIP AND INTEGRATION ........................................................................... 40
6. WEST WALES POPULATION PROFILE ............................................................................. 41
6.1. OVERVIEW............................................................................................................................... 41
6.2. ALL CAUSE MORTALITY RATES...................................................................................................... 45
6.3. DEPRIVATION AND LIFESTYLE FACTORS.......................................................................................... 45
6.4. FURTHER INFORMATION ............................................................................................................ 47
6.5. REFERENCES ............................................................................................................................ 48
7. CARERS ..................................................................................................................................... 49
7.1. OVERVIEW AND KEY MESSAGES .................................................................................................. 49
7.2. DEMOGRAPHICS AND TRENDS ..................................................................................................... 49
7.3. CURRENT AND FUTURE SUPPORT NEEDS....................................................................................... 50
7.4. CURRENT SUPPORT PROVISION ................................................................................................... 53
7.5. GAPS AND AREAS FOR IMPROVEMENT.......................................................................................... 55
2
7.6. REFERENCES ............................................................................................................................ 59

8. CHILDREN AND YOUNG PEOPLE ....................................................................................... 62
8.1. OVERVIEW AND KEY MESSAGES ................................................................................................... 62
8.3. CURRENT AND FUTURE CARE AND SUPPORT NEEDS ......................................................................... 63
8.4. CURRENT CARE AND SUPPORT PROVISION ..................................................................................... 64
8.6. REFERENCES ............................................................................................................................ 72
9. HEALTH AND PHYSICAL DISABILITIES ............................................................................ 73
9.3. CURRENT AND FUTURE CARE AND SUPPORT NEEDS........................................................................ 76
9.4. CURRENT CARE AND SUPPORT PROVISION .................................................................................... 77
9.6. REFERENCES ............................................................................................................................ 83
10. LEARNING DISABILITY AND AUTISM ................................................................................ 84
10.6. REFERENCES ............................................................................................................................ 93
11. MENTAL HEALTH .................................................................................................................... 94
11.5. GAPS AND AREAS FOR DEVELOPMENT ........................................................................................ 103
11.6. REFERENCES .......................................................................................................................... 106
12. OLDER PEOPLE ..................................................................................................................... 108
12.1. OVERVIEW AND KEY MESSAGES ................................................................................................ 108
12.2. DEMOGRAPHICS AND TRENDS ................................................................................................... 108
12.3. CURRENT AND FUTURE CARE AND SUPPORT NEEDS...................................................................... 113
12.4. CURRENT CARE AND SUPPORT PROVISION .................................................................................. 116
12.5. GAPS AND AREAS FOR IMPROVEMENT........................................................................................ 120
12.6. REFERENCES .......................................................................................................................... 122
13. SENSORY IMPAIRMENT ...................................................................................................... 127
13.6. REFERENCES .......................................................................................................................... 138
14. SUBSTANCE MISUSE ........................................................................................................... 141
3
14.5. GAPS AND AREAS FOR DEVELOPMENT ........................................................................................ 143

14.6. REFERENCES .......................................................................................................................... 145
15. VIOLENCE AGAINST WOMEN, DOMESTIC ABUSE AND SEXUAL VIOLENCE ..... 146
15.6. REFERENCES .......................................................................................................................... 157
16. APPENDICES ........................................................................................................................... 159
16.1. APPENDIX 1 LIST OF FIGURES AND TABLES ................................................................................... 159
TO BE COMPLETED ............................................................................................................................... 159
16.2. APPENDIX 2 GROUP MEMBERSHIP AND ACKNOWLEDGEMENTS ....................................................... 160
4
West Wales Population Assessment Executive Summary
Foreword
The Social Services and Wellbeing (Wales) Act places a strong emphasis on
cooperation and partnership working between agencies, and with citizens, to ensure
that the very best help is available to those that need care and support within our
communities. Two core principles lie at the heart of the West Wales Care Partnership
and all that it seeks to achieve: Firstly, that the citizen’s voice must be paramount in
shaping the way in which care and support is delivered in our region and secondly
that by working collaboratively local authorities, the NHS and our partners in the third
and independent sectors we can become both more efficient and responsive to the
needs of the individuals and communities we are all here to serve.
Undertaking our first Population Assessment has been a major priority for the
Regional Partnership Board over the past 9 months. We sought from the outset to
ensure that the process was inclusive by bringing managers and practitioners from
each of the partner agencies together to consider the needs of our population, what
these mean in terms of the care and support that should be available, the extent to
which current services meet those needs and shared challenges for the future.
Equally, we took the opportunity to engage with residents, through the wellbeing
survey and follow-up events, and in so doing received some clear messages about
what people feel they need and how they want to see these needs addressed.
As a result we have, for the first time, a comprehensive overview of care and support
needs across the region, examples of innovation and good practice and numerous
pointers in terms of where we still need to improve. We are clear that this is just the
start of a much longer process. Not only will the Assessment form the basis for our
Area Plan, we will also ensure that it feeds into local improvement plans within
individual agencies and is used as a baseline against which the partnership can
assess its progress over the coming months and years.
We will also reflect further on how the Assessment was undertaken and look to
improve on this, not only for future iterations but in the intervening period as we seek
to further develop cooperation across the partnership and ensure that the citizen’s
voice is taken into account at all stages in the planning and delivery of care and
support. In so doing we are confident that we will build strong, resilient communities
in which people work together to deliver positive outcomes and all play a part in
supporting and protecting those most in need.
Sue Darnbrook,
Strategic Director, Care, Protection and Lifestyle, Ceredigion County Council
Chair of the West Wales Regional Partnership Board
5
1. Executive summary
1.1. Overview and purpose
This Population Assessment provides a high level strategic analysis of care and
support needs of citizens and support needs of carers across West Wales. It
assesses the extent to which those needs are currently being met and identifies
where further improvement and development is required to ensure that individuals
get the right support and are able to live fulfilled lives.
The Assessment has been undertaken to meet new requirements under Part 2 of the
Social Services and Wellbeing (Wales) Act 2014. Section 14A of the Act requires that
local authorities (LAs) and Local Health Boards (LHBs) jointly carry out an
assessment of the needs for care and support, and the support needs of carers, in
the LA’s area. These assessments must then be combined into a single report for the
LHB footprint before being signed off by each of the LAs and the LHB.
The Population Assessment will be a key driver for the integration and transformation
of care and support in West Wales over the coming period. The Regional Partnership
Board (RPB), which has been established under Part 9 of the Act and has
responsibility for promoting integration and a partnership approach to service
improvement, will use the Assessment to test its existing priorities and identify other
areas on which it needs to focus. Over the next few months the RPB will lead on the
development of an Area Plan which will set out those areas of change identified
within the Assessment which will be addressed collaboratively over the coming three
to five years. The Area Plan will link with existing strategic plans of the partner
agencies and wider wellbeing goals and actions overseen by the three Public Service
Boards (PSBs), thus ensuring a focused, consistent approach to change.
Population Assessments will be undertaken every five years and will be refreshed
mid-cycle, allowing unforeseen changes in need to be addressed and progress to be
monitored. This will enable us to accelerate the pace of change where necessary and
to share examples of success across the region and beyond.
1.2. West Wales population profile

The West Wales region covers three LA areas – Carmarthenshire, Ceredigion and
Pembrokeshire - and is coterminous with the Hywel Dda University Health Board
(HDUHB) footprint. The population of the region is estimated at 384,000. 47.9% of
the population live in Carmarthenshire, 20.7% in Ceredigion and 31.4% in
Pembrokeshire.
The total population is predicted to rise to 425,000 by 2033, with a rise in those aged
over 65 from 88,200 in 2013 to 127,700 by 2033.
There are fewer people aged 25-44 and more people aged over 55 compared with
the rest of Wales. Similarly, there is a higher ratio of people aged 75 and over (10.3%
6
compared with 8.9% in Wales as a whole). Life expectancy for both males and
females is broadly in line with the rest of Wales at 78.9 and 82.7 years respectively.
Areas of deprivation centre on parts of Llanelli in Carmarthenshire, Pembroke Dock

in Pembrokeshire and Cardigan in Ceredigion.
People living in West Wales have generally healthier lifestyles than is typical across
Wales. However there are particular challenges to address, for example higher rates
of alcohol consumption in Ceredigion and rates of obesity above the national average
in Carmarthenshire and Pembrokeshire.
More information is provided in Chapter 6 of the main report.
1.3. How we undertook the Population Assessment

The Assessment was undertaken collaboratively by all partners in the region and has
been agreed by the RPB. It has also been endorsed by the three LAs and the UHB,
signifying a shared commitment across partner agencies to address its findings.
Cross-agency groups were established to undertake a detailed assessment of care

and support needs for different user groups, using a common template to provide
consistency and allow full consideration of the characteristics of the group, likely care
and support needs, the extent to which these are currently being met and where
change is most needed. The results of these individual assessments were collated
into thematic reports. The benefits of this process should not be underestimated. The
positive impact of bringing people from across the region together to consider shared
challenges and learn from current practice has been considerable and provides a firm
foundation for collaboration moving forward.
Opportunities were taken to engage with people needing care and support and their
carers across West Wales. Questions relating to people’s experience of care and
support and their thoughts on how things might be improved were included in the
Wellbeing Survey conducted across the region during August and September 2016 to
inform the Wellbeing Assessment required under the Wellbeing of Future
Generations (Wales) Act. Residents were given the chance to discuss relevant
issues in a range of consultation events held over the autumn. We also engaged
where possible with other stakeholders such as providers in the third and
independent sectors. A summary of the outcomes from this engagement is provided
in Chapter 3 of the main report (pages 26 – 30). This, combined with the use of
information from previous consultation and engagement, provides us with an
invaluable insight into the views of our local population but needs to be consolidated
through further engagement as we develop our Area Plan and refresh the
Assessment in mid-cycle.
A range of quantitative data was used to provide a comprehensive picture of current

and future care and support needs and how these are currently being met. To
maximise the usability of the Assessment we have included high level, indicative data
relating to the region and the constituent LA areas. A comprehensive data repository
7
is being established to retain additional data which will support improvement planning
and inform future Assessments.
The Assessment has drawn on a range of existing strategies and plans in place
across the region, thus providing an opportunity to review strategic intent at regional
and local level. It will be important to ensure that these are reviewed in the light of the
Assessment’s findings and that the resulting Area Plan aligns with and complements
existing plans where appropriate.
In undertaking the Assessment, close reference was made to the National Outcomes
Framework for people who need care and support and carers who need support
(Welsh Government, 2016). For example, the principle of people being empowered to
understand their own needs, articulate these, take an active part in decisions
affecting their lives and having access to the right information to improve their
wellbeing, is a consistent theme throughout the thematic reports.
Consideration was also given to a range of cross-cutting issues which need to

underpin our journey of improvement and change, namely:
 The need to ensure provision of care and support through the medium of Welsh
for those who need it and to ensure that the requirements of the Welsh Language
(Wales) Measure 2011 and the ‘More than Just Words’ strategy are fully met
 The importance of recognising the particular needs of minority and marginalised
groups in developing care and support; we undertook a simple Equalities Impact
Assessment (EIA) as part of the Assessment and are committed to undertaking
further, detailed EIAs as the Area Plan is developed
 The centrality of prevention and the need to ensure that the principles of
prevention underpin the range of care and support available, thus improving
personal outcomes, promoting independence and reducing or delaying people’s
need for ongoing care and support
 The vital importance of safeguarding in the provision of care and support, in terms
of ensuring people are protected from abuse and neglect and the effective
exercise of new powers in relation to adults at risk
 Duties under the Act regarding the promotion of social enterprises, user-led
services and the third sector and the need for a focused and strategic approach in
growing such provision to ensure greater diversity of public services and
empowering people and communities through a co-productive approach
1.4. Recommendations
Whilst specific areas for improvement are identified in each of the thematic reports,
a number of generic recommendations have been identified for consideration
by the RPB and its constituent agencies. These are set out below under the core
principles of the Act:
Voice and control
1. Ensure that maintaining people’s dignity and protecting individuals from neglect
and abuse must lie at the heart of all services.
8
2. Ensure all services are available in Welsh for those who require them.
Prevention and early intervention
3. Build on the considerable foundations in place across the service areas covered
in this assessment to ensure appropriate services are available to prevent or
delay the need for ongoing care and support and that the prevention ethos
underpins all levels and types of care. Specifically, opportunities should be taken
to develop consistent preventative frameworks across services, which build on
existing good practice, facilitate transition between children and adult’s services
and demonstrably reduce the need for ongoing care and support.
4. Invest in the development of community-based preventative services, including

social enterprise, cooperatives, user-led and third sector provision thus building
the resilience of communities and, thereby, of people needing care and support.
5. Align the Intermediate Care Fund (ICF) and Cluster Development Change
Programmes to build consistent, whole system change on the ground.
Wellbeing
6. Prioritise support for carers, enabling them and those they care for to live fulfilled
and independent lives for as long as possible.
7. Further improve transition services to facilitate effective planning across services

and ensure that young people continue to receive appropriate care and support
into early adulthood.
Co-production
8. Ensure that people needing care and support and carers are involved
meaningfully at all stages in the planning, delivery and review of services. This
needs to happen at strategic level, engaging with citizens over the future shape of
care and support and expectations on individuals to promote their own wellbeing
and operationally, ensuring that assessment and care planning allows people to
express personal outcomes and influence decisions regarding the support needed
to attain them.
Cooperation, partnership and integration
9. Create an environment which permits radical change and encourages innovation

rather than trying to do more of the same with less.
10. Use the population assessment as the basis for the development of integrated
commissioning across service areas, based on a common understanding of need.
9
11. Develop consistent delivery models across service areas and the region, based
on a shared strategic vision and the principles within the Act; ensuring common
standards to all residents in West Wales.
12. Use this population assessment as a basis for detailed modelling of future
scenarios to understand the interdependencies and impact on care and support
services of, for example, demographic increases in the older population, and
expected increases in known carers and victims of violence against women,
domestic abuse and sexual abuse. There is a need to understand how future
conditions in the area might impact on social services provision and the extent
and diversity of needs for social services over the next 10 -25 years.
13. Pool funds and other resources where appropriate to optimise their impact and
support seamless delivery.
14. Engage strategically with providers across all sectors to develop services and
build sustainable markets for the future.
15. Work with partners across the public sector and others to embed a preventative
approach, promote wellbeing, optimise resources and address specific challenges
such as accessibility of services in a predominantly rural area.
1.5. Thematic Reports

Key messages within the thematic reports are provided below.
Carers
 All of us will have our lives touched by caring at some point: 3 in 5 of us will be
carers and many of us will also need care in our lifetime (Carers UK, 2001).
Carers are the mothers, fathers, sons, daughters, siblings, spouses, friends and
neighbours who provide unpaid care, caring at home, picking up prescriptions,
changing dressings, providing much needed emotional support and much more,
and often neglecting their own health and wellbeing needs. Carers are vital to
those they care for and to the foundation of the health and social care system.
 Around 1 in 8 people in West Wales, many of them young people, are providing
unpaid care with a significant proportion providing between 20 to 50+ hours of
unpaid care per week.
 The provision of unpaid care is becoming increasingly common as the population
ages, with an expectation that the demand for care provided by spouses and adult
children will more than double over the next thirty years (see for example
Personal Social Services Research Unit).
 Based on a national calculation conducted by carers UK and Sheffield University
in 2015 (Carers UK, 2015), the cost of replacing unpaid care in West Wales, can
be estimated at £924m. This exceeds the NHS annual budget for the region which
is almost £727m (Hywel Dda University Health Board 2016).
10
Gaps and areas for improvement in relation to carers are listed on pages 55 - 58 of
the main report.
Children and Young People
 Children and young people make up approximately 22.2% of the population in the
West Wales region. The number of young people is expected to stay relatively
stable over the next 15 years
 The region has a lower number of Looked After Children (LAC) than the national
average
 Care and support needs span a wide range from universal, through early
intervention, multiple needs and remedial intervention
 Partner agencies have adopted a broadly consistent continuum of care and
support for children and families with a focus on prevention
 Areas for improvement include further development of preventative and early
intervention services, building on established programmes such as Family
Information Services, Families First and Team Around the Family; refocusing
managed care and support to promote independence and wellbeing; improving
multi-agency working and improved collaboration across the region to bring
services to a consistent level and standard
 Collaborative action should also be considered to address strategic challenges
such as reducing budgets, workforce development and the establishment of user-
led preventative services
Gaps and areas for improvement in relation to children and young people are listed
on pages 69 - 71 of the main report.
Health and Physical Disabilities
 A significant proportion of people in the 18-64 age group will not be accessing
care and support directly to address specific needs. However, they will benefit
from general public health information and programmes aimed at encouraging
healthy lifestyles and reducing risks to their health brought about by factors such
as smoking and obesity. More generally, adults in Wales will also benefit from
combined approaches across sectors and within communities to improve the
social, economic and cultural wellbeing of Wales in response to the Wellbeing of
Future Generations (Wales) Act 2016.
 Where people within this age range have specific needs because of physical
disability or chronic health conditions, proportionate, person-centred and
responsive care and support may be required to help them achieve positive
personal outcomes and live as independently as possible.
 A range of ‘accelerating factors’ have been identified within people’s
environments that might increase the likelihood of them developing an ongoing
health condition, or aggravate the effects of existing conditions, and against which
mitigating action should be taken. These include unemployment, low wages and
poor housing conditions.
 Effective promotion of public health, targeted care and support for those with
specific needs and more general support for people particularly at risk should
11
combine to optimise the quality of people’s lives and their participation within their
communities.
 Supporting people to live active and healthy lives will reduce their needs for care
and support and lead to improved outcomes at an individual and community level.
The contribution of care and support services must be complemented by a range
of collaborative approaches to improve people’s social, economic, environmental
and cultural wellbeing.
 Public Health has an important role in providing the population with general
information and advice on healthy life choices and support in areas such as diet
and smoking cessation. This needs to start in the early years but should be
sustained where possible across the range of age groups.
Gaps and areas for improvement in relation to health and physical disabilities are
listed on pages 80 - 82 of the main report.
Learning Disability and Autism
Learning Disability can be defined as:
 A significantly reduced ability to understand new or complex information and to

learn new skills (impaired intelligence)
 A reduced ability to cope independently (impaired social functioning); or
 These are in evidence before adulthood and have a lasting effect on
development
The way in which the needs of people with a Learning Disability are met has changed
over the last twenty years. People who would historically have been placed in
institutional care are increasingly being supported to live in their communities. Health
and social care services along with the third sector collaborate to maximise the
independence and potential of those who use our services.
Although Autism is not a learning disability it has been included in this section as
services for people on the spectrum are generally provided from within learning
disability teams or community mental health teams and NICE guidance (2008, 2016)
provides standards for provision of services.
Gaps and areas for improvement in relation to learning disability and autism are listed
on pages 91 – 92 of the main report.
Mental Health
 The care and support needs of adults aged 16 + with mental health needs have
been considered in this section of the Assessment.
 According to the Mental Health Foundation (2015) in any year one in four of us
experience a mental health problem, yet three quarters of people with mental
health problems receive no treatment.
 Many of us will require support with respect to our mental health throughout our
lives whether this is low intensity support for difficulties such as low level anxiety /
depression or longer term support.
12
 Mental illness can develop from a number of factors including social traumas,
illegal drug use and genetic predisposition. Mental health does not discriminate
and can affect anyone often leading to debilitating conditions.
 Early intervention is crucial and this can take the form of providing information or
referral to community or third sector services. Admissions to inpatient services
may occur in extreme situations, where the individual cannot be treated in the
community and presents a risk to themselves and / or others.
 It has been estimated that the economic and social costs of mental health
problems in Wales is estimated to be £7billion a year (Cyhlarova, 2010).
 In 2015-16, the WG ring-fenced £587m for mental health services across Wales –
up from £389m in 2009-10. Earlier this year, Government announced an
additional £15m of new funding is being made available for mental health services
in Wales every year.
Gaps and areas for improvement in relation to mental health are listed on pages 103
- 105 of the main report.
Older People
 According to the Office for National Statistics, the population of West Wales has a
higher proportion of older people than the Welsh average, and that already high
proportion is predicted to increase significantly in the coming years, as average
life expectancy in the region follows the national upwards trend.
 The change in the profile of the population will undoubtedly have an impact on
health, as older people are statistically more likely to have a life limiting health
condition (Office for National Statistics, 2011) These changes will significantly
impact on the health and social care services provided, as demand for hospital
and community services by those aged 75 and over is in general more than three
times that from those aged between 30 and 40 (Parliamentary
Select Committee on Public Service and Demographic Change, 2013).
 A number of ‘accelerating factors’ add to the challenge of providing effective
services to older people in West Wales, from pockets of significant deprivation to
large areas of rurality and high levels of migration of older people to certain
areas.(Wales On-line, 2012)
 In 2013-14 an estimated £91 million was spent in West Wales on services
specifically for older people including Tier 1 – Community, Universal and
Prevention Services, Tier 2 - Early Intervention and Reablement and Tier 3 -
Specialist and Long Term Services.1 Across the UK public expenditure related to
older people is expected to rise from 20.1% of GDP in 2007-08 to 26.7% in 2057.
(Mid and West Wales Health and Social Care Collaborative, 2015) The Office for
Budget Responsibility (2011) has noted that ‘public finances are likely to come
under pressure, primarily as a result of an ageing population.’
Gaps and areas for improvement in relation to older people are listed on pages 120 -
121 of the main report.
13
Sensory Impairment
 Sensory impairment can be a significant life limiting condition and its incidence
increases with age. This means the challenges associated with the condition are
likely to grow over coming decades
 The condition includes sight loss, hearing loss, and dual sensory loss (deafblind).
 Accelerating factors in relation to sight loss include diabetes and obesity
 People with sensory impairment have a range of care and support needs. Early
identification is vital, as is prevention, support to reduce loneliness, isolation and
promote mental health and wellbeing and measures to support access to
employment
 Effective care and support is likely to reduce other risks associated with age and
frailty, such as falls
 A range of services is available across West Wales. These provide a foundation
for improvement in the future
 Improvements need to focus on further development of generic and specialist
services and improving access to other services for people with a sensory
impairment. This will require collaborative approaches to ensure consistency and
that common challenges are addressed
Gaps and areas for improvement in relation to sensory impairment are listed on
pages 134 – 136 of the main report.
Substance Misuse
 The care and support needs of those affected by alcohol and drug misuse have
been considered. The effects of these are far reaching; impacting on children,
young people, adults, whole families and communities. Partnership work to
address this agenda is taken forward through the Dyfed Area Planning Board for
Substance Misuse who are developing their own comprehensive needs
assessment to inform their new strategy and action plan.
 A ten year strategy (Welsh Government, 2008) provides the framework for partner
organisations in West Wales to tackle the harms associated with drug and alcohol
misuse across four key themes;
 Preventing harm
 Support for those that misuse drugs and alcohol in order to improve their
health and aid and maintain recovery
 Supporting and protecting families
 Tackling availability and protecting individuals and communities via
enforcement activity
 Those at risk of harm from alcohol misuse come from across the spectrum of
society. They include chronic heavy drinkers, adults at home drinking hazardous
or harmful levels and children and young adults who suffer from the
consequences of parental alcohol misuse. The health impact of misuse of alcohol
is considerable; more people die from alcohol related causes than from breast
cancer, cervical cancer and MRSA infection combined. Foetal alcohol syndrome
is also a risk to the babies of mothers who use alcohol. Most recent data on
hospital admissions for Hywel Dda University Health Board show that over 5,000
14
bed days were taken up by patients with alcohol related conditions at a cost to the
Health Board of over £5.2million per year in in-patient treatment alone.
 Misuse of drugs, both legal and illegal, and other mind-altering substances such
as solvents, can damage health in a variety of ways. These include fatal
overdoses, addition, mental health problems, infections caused by injecting and
the toxic effects of the many substances that dealers mix with the active
substance. Although the greatest harms are associated with the use of illicit
drugs, the misuse of prescription only medicines and over the counter medicines
continues to be a problem.
Gaps and areas for improvement in relation to substance misuse are listed on pages
142 - 143 of the main report.
Violence Against Women, Domestic Abuse and Sexual Violence
 Violence against women, domestic abuse and sexual violence is a fundamental

violation of human rights, a cause and consequence of inequality and has far
reaching consequences for families, children and society as a whole (Welsh
Government, 2016)
 Domestic Abuse costs Wales £303.5m annually. This includes £202.6m in service
costs and £100.9m to lost economic output. If the emotional and human cost is
factored in there are added costs of £522.9m (Welsh Women’s Aid, date)
 The cost, in both human and economic terms, is so significant that marginally
effective interventions are cost effective (Welsh Government, 2016)
 New requirements under the Wellbeing of Future Generations (Wales) Act 2015,
Social Services and Wellbeing (Wales) Act 2014, and Violence Against Women,
Domestic Violence and Sexual Abuse Act, 2015 impact this area and are likely to
increase the number of cases of domestic abuse identified
 Improving partnership responses to survivors could reduce the levels of need for
specialist services
Gaps and areas for improvement in relation to violence against women, domestic
abuse and sexual violence are listed on pages 151 - 155 of the main report.
A full list of colleagues who contributed to the Population Assessment is provided in

Appendix 2.
15
West Wales Population Assessment Introduction
2. Introduction
2.1. Structure of the report
This report provides a high level summary of the population assessment undertaken
for the West Wales region between June and November 2016. It sets out key findings
from this intensive piece of regional work.
Whilst illustrating variations and differing challenges in different parts of the region,
the report focuses intentionally on shared opportunities and areas for improvement,
where it is felt most benefit will be gained in developing collaborative approaches
through the forthcoming Area Plan. As well as the Area Plan, the report will also be
available to inform future commissioning strategies and other similar activity across
the region.
The report is structured around the following chapters:
Chapter 1: Executive summary
Chapter 2: Introduction sets out the background to and purpose of the assessment;
our approach to undertaking the assessment, and examples of high level strategies
and plans that have informed or will be informed by the assessment.
Chapter 3: Consultation and engagement describes our approach to consultation

and engagement for the population assessment, areas for further development, and
an overview of the feedback from consultation and engagement.
Chapter 4: Cross cutting themes discusses a number of these that emerged during
the assessment that are common to most or all of the thematic reports including
delivering services in the medium of Welsh and key challenges, for example,
finances and resources and recruitment and retention.
Chapter 5: Recommendations set out against the core principles of the Social
Services and Wellbeing Act (2014)
Chapter 6: Demographics and trends describes the population of West Wales

including age and sex profile, life expectancy, all-cause mortality rates and areas of
deprivation.
Chapters 7-15: Thematic reports for each of the Core Themes at the heart of the
population assessment, namely:
 Carers
 Children and Young People (C&YP)
 Health and Physical Disabilities
 Learning Disabilities and Autism
 Mental Health
 Substance Misuse
 Older People
 Sensory Impairment
16
 Violence Against Women, Domestic Abuse and Sexual Violence (VAWDASV)
Each thematic report contains a demographic profile, a description of care and

support needs, current and future care and support provision, and gaps and areas for
development.
Chapter 16: Appendices containing a list of figures and tables used in the report,
membership of the cross-agency groups involved in undertaking the assessment and
a glossary.
2.2. Background
The Social Services and Wellbeing (Wales) Act 2014 (SSWB) provides a new
legislative framework for care and support in Wales, aimed at improving the wellbeing
of people who need care and support, and carers who need support, and for
transforming the way in which services are commissioned and delivered. A number of
core principles underpin the Act:
 Voice and control – putting the individual and their needs, at the centre of their
care, and giving them a voice in, and control over reaching the outcomes that help
them achieve wellbeing
 Prevention and early intervention – increasing preventative services within the
community to minimise the escalation of critical need
 Wellbeing – supporting people to achieve their own wellbeing and measuring the
success of care and support
 Co-production – developing ways of working whereby practitioners and people
work together as equal partners to plan and deliver care and support
 Cooperation, partnership and integration – improving the efficiency and
effectiveness of service delivery, providing coordinated, person centred care and
support and enhancing outcomes and wellbeing
Part 9 of the Act requires local authorities (LAs) and Local Health Boards (LHBs) to
establish Regional Partnership Boards (RPBs) to manage and develop services to
secure strategic planning and partnership working and to ensure effective services,
care and support are in place to best meet the needs of their respective population.
RPBs are required to promote the integration of services, prioritising those for older
people with complex needs and long-term conditions, including dementia; people with
learning disabilities; carers; families through Integrated Family Support Services; and
children with complex needs due to disability or illness. Implicit in this is the
requirement to remodel services to meet the needs of the population and to meet the
aspirations of the Act. Merely doing more of the same in a more joined up way is
unlikely to deliver the wellbeing outcomes which underpin the legislation.
Key to achieving this will be RPBs understanding the needs of their population,
assessing the effectiveness of current services and identifying where further change
and improvement is needed. Part 2 of the Act requires that local authorities and LHBs
must jointly carry out an assessment of the needs for care and support, and the
support needs of carers in the local authority’s (LA’s) area. The assessment must
identify:
17
 The extent to which those needs are not being met

 The range and level of services required to meet those needs
 The range and level of services required to deliver the preventative services
required in section 15 of the Act; and
 How these services will be delivered through the medium of Welsh
In common with areas covered by the other six LHBs in Wales, partners in West
Wales have established a RPB which brings together senior representatives of the
three local authorities (Carmarthenshire, Ceredigion and Pembrokeshire County
Councils), Hywel Dda University Health Board, the third and independent sectors and
user and carer representatives. The RPB builds on strong foundations of
collaborative working across health and social care in West Wales, in relation to
areas such as intermediate care, integrated family support, adoption, substance
misuse, shared lives for adults and safeguarding. Building on these, it has agreed
initially the following strategic priorities, underpinned by a commitment to improving
engagement with citizens and developing a workforce equipped to meet future
challenges:
 Integrated commissioning of older people’s services

 Pooled budgets
 Information, Advice and Assistance/ prevention
 Implementation of the Wales Community Care Information System (WCCIS); and
 Integration of mental health and learning disability services
These priorities complement and support a wider range of activity underway across
the region to reshape services and improve the way in which they are commissioned
and delivered. The Population Assessment has provided an invaluable further ‘test’ of
both the Board’s priorities and the wider activity and these will be refined as
necessary in light of its findings. During 2017 the RPB will oversee the development
of a comprehensive combined Area Plan linked to internal agency plans and setting
out those areas of change identified within the Assessment that will be addressed
collaboratively over the coming 3 to 5 years.
2.3. Purpose of the Population Assessment

The Population Assessment provides a high level strategic analysis of care and
support needs, and support needs of carers across West Wales. It assesses the
extent to which those needs are currently being met and identifies where further
improvement and development is needed to ensure that individuals get the services
they need and are supported in living fulfilled lives.
The Assessment draws on existing strategies in place across West Wales and for the
first time brings together the views of citizens, service data and research evidence in
a single, regional document. In highlighting shared issues and challenges, as well as
successful approaches already in place, it provides an invaluable basis for the RPB
in taking forward transformational change. Such change is all the more important in
view of the projections within the Assessment, which point towards increased volume
and complexity of care and support needs in the region over the next two decades.
18
Completing the Assessment is only the first step in a much longer process. We are
required under Section 14A of the SSWB Act to respond to the Population
Assessment by developing an Area Plan for our region. This will contain actions
designed specifically to address the challenges we have identified. Linking with the
UHB’s Integrated Medium Term Plan (IMTP), local authority (LA) plans and those of
other partners, the Area Plan will be a key driver for change over the coming period
and delivery will be overseen by the RPB. We will look to pool resources wherever
possible across agencies to support delivery of the Area Plan and will ensure that
additional funding such as the Intermediate Care Fund (ICF) is focused on those
areas where most change is needed and the greatest benefit can be gained for
people who need care and support.
We recognise the contribution of other services to the wellbeing of people who need
care and support and will work with the three Public Service Boards (PSBs) in the
region to ensure that the needs we have identified are reflected in wider wellbeing
goals and actions across West Wales.
The RPB will undertake new population assessments every five years and will ensure
that existing assessments are refreshed mid-cycle. This will provide an opportunity
not only for identifying unforeseen changes in the level and type of need for care and
support within the region but also for assessing the extent to which the required
improvements are happening on the ground. This will enable us to accelerate the
pace of change where necessary and to share examples of success across the
region and beyond.
2.4. How we undertook the Population Assessment

The Assessment was undertaken collaboratively by all partners in the region and has
been agreed by the RPB. It has also been ratified by the three local authorities and
the Local Health Board, signifying a shared commitment across partner agencies to
address its findings.
To ensure a genuinely collaborative approach, our existing regional Integrated

Programme Delivery Board (IPDB), comprising senior representatives from all
partner agencies, took on the role of Joint Committee for the purposes of the
Assessment. All partners committed to engaging fully and providing time and
resources to ensure the Assessment was completed on time and contained relevant
information from all parts of the region. Carmarthenshire County Council took a lead
agency role, coordinating the process and securing external project management
capacity to steer the assessment process and ensure legislative requirements were
met.
Key partners in the Assessment, alongside Carmarthenshire County Council, were:
 Ceredigion County Council

 Hywel Dda University Health Board
 Pembrokeshire County Council
 Public Health Wales
19
Cross-agency thematic groups were established to undertake a detailed assessment

for each user group, each focusing on one or more sections of the population. A
common template was followed to help partners fully consider the characteristics of
the user group, likely care and support needs, the extent to which these are currently
being met, where change is most needed and how this needs to be taken forward
over the coming period. The thematic groups also identified specific issues in relation
to areas such as market sustainability and workforce and these are aggregated in the
Chapter 4.
The IPDB received regular updates on progress and contributed directly to the
drafting of the report before recommending to the RPB that it be approved.
In undertaking the Assessment opportunities were taken to engage with people

needing care and support and their carers across West Wales. Questions relating to
people’s experience of care and support and their thoughts on how things might be
improved were included in the Wellbeing Survey conducted across the region during
August and September to inform the Wellbeing Assessment required under the
Wellbeing of Future Generations (Wales) Act. Residents were given the chance to
discuss relevant issues in a range of consultation events over the autumn. Where
possible we also used recent consultation findings and intelligence gained from
individual service users and user and stakeholder groups to inform the detailed
assessments contained within the thematic reports. Further detail on our approach to
consultation is provided in the Consultation and Engagement chapter.
We also sought to speak with other stakeholders such as providers within the third
and independent sector in the course of our assessment, thereby looking to obtain as
wide a perspective as possible on need, current provision and priorities for change. In
addition, specific research undertaken by academic institutions and organisations
representing users and carers has been referenced where appropriate.
Whilst this engagement activity played a key role in our assessment, it has been less
extensive in some cases than we had hoped, largely due to the challenging
timescales in which we were required to complete our work. We are confident,
however, that we have established firm foundations for ongoing engagement as we
develop our Area Plan and work towards the refresh of the Assessment by 2020. The
RPB has made specific commitments to improve regional arrangements for citizen
and provider engagement over the coming period, providing potential opportunities
for a rich ongoing dialogue with all stakeholders as we take forward change in West
Wales.
Robust quantitative data on our current and projected population and how services
are currently provided has been another key element of our Assessment. We have
extracted this from a range of sources, including among others a comprehensive data
catalogue compiled on our behalf by the Local Government Data Unit, Daffodil
Cymru, 2011 census data and statutory performance returns submitted by partner
agencies. In analysing the data we have adopted an epidemiological approach,
looking at the size and composition of different groups within our region currently and
how this is predicted to change in the future, resulting levels of need and the ability of
current services to meet those needs. Where appropriate we have also used
comparative data to illustrate prevalence in West Wales compared with other parts of
20
the country and, in some cases, significant variances across different parts of our
region. Although some data is available at NHS locality and cluster levels, this is not
the case for all services. For this reason the majority of data is presented at regional
and LA level. In developing the Area Plan, it will be important for partners to examine
more local data to ensure responsiveness to local need and the right focus for
investment.
We took the decision not to include detailed data on current performance of services
within our Assessment. We considered it more important to consider the extent to
which current service models and approaches met current need, rather than to
assess how well we were providing those services. Of course, performance data is
and will continue to be important in assisting managers to identify problems in
services and areas for improvement and it will continue to be used in this way to
ensure that those needing care and support at the current time get the best possible
services. An exception to this was our decision to incorporate early findings from the
user surveys circulated by local authorities during the summer of 2016 to assess the
extent to which nationally identified outcomes are being achieved for individuals.
Details are provided in the Consultation and Engagement chapter.
To keep the report manageable, we have had to select the most pertinent data to
each of the user groups; however a comprehensive data repository has been
established to retain data not cited directly within the report but which nevertheless
will have a role in supporting service planning and informing future assessments.
2.5. Key relevant strategies and plans

The Population Assessment has intentionally drawn on a range of existing strategies
and plans in place across the region and provided an opportunity to review strategic
intent at regional and local level in the light of identified and projected needs.
Partners have already articulated shared strategic intentions in a number of service

areas, for example for older people in the Statement of Intent for the Integration of
Services for Older People with Complex Needs (Mid and West Wales Health and
Social Care Collaborative, January 2014a), and subsequent Market Position
Statement for older people’s services (Mid and West Wales Health and Social Care
Collaborative, November 2015) and for learning disabilities in the regional Statement
of Intent (Mid and West Wales Health and Social Care Collaborative, October
2014b). These intentions have been tested and in most cases reaffirmed in the
Population Assessment. Equally, partners have committed to revising existing plans
where necessary to ensure they fully address the findings of the Assessment.
Similarly, there is significant alignment between the themes emerging from the
Population Assessment and those that underpin local plans such as the UHB’s IMTP,
LA improvement plans and a range of service strategies developed on the LA
footprints.
When work begins on the development of the Area Plan it will be important to
maintain this alignment, ensuring its commitments reflect those within existing plans
(adjusted and refocused where necessary) and vice versa. This will help ensure a
21
consistent focus across agencies on the priorities and challenges that have been
identified.
Each of the thematic reports includes further details of existing strategies and plans
that are relevant to that particular user group.
2.6. Delivering national outcomes

The need to achieve improved wellbeing for people in need of care and support lies
at the core of our Population Assessment and will underpin our resulting Area Plan.
Services across the statutory, third and independent sectors need to continue to work
in partnership to build on people’s strengths and abilities and enable them to maintain
an appropriate level of independence and realise their personal goals.
To support services in achieving this, the Welsh Government (WG) has developed a
National Outcomes Framework for people who need care and support and carers
who need support. This framework sets out a series of national wellbeing outcomes
which people who need care and support and carers should expect in order to lead
fulfilled lives. A series of national outcome indicators are identified for each of the
outcomes and the framework will be a key driver in identifying evidence-based
national priorities for improvement. The national wellbeing outcomes are listed in the
following table.
22
Figure 2:1 National Wellbeing Outcomes

What wellbeing means National wellbeing outcomes
Securing rights and entitlements  I know and understand what care, support
Also for adults: Control over day-to-day and opportunities are available and use
life these to help me achieve my wellbeing.
 I can access the right information, when I
need it, in the way I want it and use this to
manage and improve my wellbeing.
 I am treated with dignity and respect and
treat others the same.
 My voice is heard and listened to.
 My individual circumstances are
considered.
 I speak for myself and contribute to the
decisions that affect my life, or have
someone who can do it for me.
Physical and mental health and  I am healthy and active and do things to
emotional wellbeing keep myself healthy.
Also for children: Physical, intellectual,  I am happy and do the things that make
emotional, social and behavioural me happy.
development  I get the right care and support, as early
as possible.
Protection from abuse and neglect  I am safe and protected from abuse and
neglect.
 I am supported to protect the people that
matter to me from abuse and neglect.
 I am informed about how to make my
concerns known.
Education, training and recreation  I can learn and develop to my full
potential.
 I do the things that matter to me.
Domestic, family and personal  I belong.
relationships  I contribute to and enjoy safe and healthy
relationships.
Contribution made to society  I engage and make a contribution to my
community.
 I feel valued in society.
Social and economic wellbeing  I contribute towards my social life and can
Also for adults: Participation in work be with the people that I choose.
 I do not live in poverty.
 I am supported to work.
 I get the help I need to grow up and be
independent.
 I get care and support through the Welsh
language if I want it.
23
What wellbeing means National wellbeing outcomes

Suitability of living accommodation  I live in a home that best supports me to
achieve my wellbeing.
Source: Welsh Government, 2016
The Population Assessment has taken the National Outcomes Framework into
account in considering the care and support needs of different user groups, the
extent to which these are being met and areas for improvement. For example, the
principle of people being empowered to understand their own needs, articulate these,
take an active part in decisions affecting their lives and having access to the right
information to improve their wellbeing is a consistent theme throughout the thematic
reports. Similarly, physical health, mental health and emotional wellbeing, protection
from abuse and neglect, access to appropriate educational and recreational
opportunities and support in developing strong personal and community relationships
have been important considerations in assessing support needs of particular groups
and the type of care and support that should be available.
24
2.7. References
Mid and West Wales Health and Social Care Collaborative (2014a). Statement of
Intent for the Integration of Services for Older People with Complex Needs [online].
Available at: http://www.wwcp.org.uk/documents/
Mid and West Wales Health and Social Care Collaborative (2014b). Regional
Statement of Intent [online]. Available at: http://www.wwcp.org.uk/documents/
Mid and West Wales Health and Social Care Collaborative (2015). Market Position
Statement for older people’s services [online]. Available at:
http://www.wwcp.org.uk/documents/
Welsh Government (2016). National outcomes framework for people who need care
and support and carers who need support [online]. Available at:
http://gov.wales/docs/dhss/publications/160610frameworken.pdf
25
West Wales Population Assessment Consultation and engagement
3. Consultation and engagement

3.1. Approach
Our approach to consultation and engagement to support the Population Assessment
was underpinned by the principle to identify gaps and avoid duplication and
engagement fatigue by:
 Linking in with the Wellbeing Assessment undertaken regionally by the three

PSBs in the region to meet the requirements of the Wellbeing of Future
Generations (Wales) Act 2015, thus utilising consultation and engagement
opportunities for mutual benefit
 Identifying existing provider, service user and carer forums that could contribute to
and support the assessment
 Using intelligence from relevant international, national, regional and sub-regional
consultation and engagement activities and events undertaken in the recent past
 Undertaking additional engagement where it was agreed that there was a
significant gap in our understanding of needs to support the development of the
Population Assessment
3.2. Wellbeing Assessment

We worked with the PSBs of Carmarthenshire, Ceredigion and Pembrokeshire to co-
ordinate public engagement activities on the Population Assessment and WBA. This
provided a framework for a consistent, regional approach and promoted the
interconnectedness of the two key pieces of legislation, using shared engagement
activities for mutual benefit.
The key components of the regional engagement approach were:
 A survey directed at residents

 An agreed toolkit for undertaking direct engagement work through focus groups or
in less formal settings across the region
 Media campaign activities including social media posts, press releases,
newsletters articles, staff briefings
A survey was developed and a series of questions were formulated under the
Wellbeing themes of economic, environmental, social and cultural wellbeing
respectively. A further section was developed which explored the importance of
health to individuals in order to ascertain the views of respondents to the care and
support needs that they have and how these are currently met. For the purposes of
the Population Assessment our engagement activities were focused on developing
our understanding of:
 The extent to which people need care and support or carers need support
 The extent to which needs are not being met
 The range and level of services required to meet the care and support needs of
people including the support needs of carers
26
 The range and level of preventative services required

 The actions required to provide the range and level of services needed to be
provided through the medium of Welsh
Alternative versions of the survey were produced in order to ensure accessibility

across a wide range of age groups and abilities, namely a younger person’s version
and an easy read version. In total 7,006 surveys were completed across the region
which has provided a wealth of information about the views and needs of residents.
A regional engagement toolkit was also developed and included a series of

documents to help organisers in running events and focus groups. A wealth of
qualitative data has been gathered as a result of engagement with members of the
public or specific patient/service user groups. This activity included:
 Attendance at community events, for example county shows and over 50s forums
 Drop-in sessions on hospital sites and schools
 7 ‘Let’s Talk Health’ events
 3 Siarad Iechyd events; and
 A number of focus groups, including with Youth Forums, Equality
Carmarthenshire and Disability Coalition
Taking a regional and collaborative approach to engagement with our communities in

the development of the Wellbeing and Population Assessments has resulted in an
excellent survey response rate providing both quantitative and qualitative data. It is
acknowledged that some specific population groups may be under-represented both
within the survey respondents and the qualitative data gathered through focus
groups/community activities. However, we believe that engagement and participation
is a fundamental underlying principle of service development and delivery and whilst
specific activities have taken place to support this Population Assessment it is
important to ensure an ongoing dialogue with service users, families and carers as
this represents the ethos of co-production.
3.3. Highlights from the findings

Whilst the response rate was good, the findings from the Wellbeing Assessment and
engagement events will only provide a snapshot in time of residents’ perceptions and
identified need. However, combined with recent consultation data and ongoing
engagement activity, they make an invaluable contribution to our understanding of
needs and views across our communities.
Key messages emerging from the resident’s survey align with the issues highlighted
in our population assessment and, particularly, the areas identified as priorities for
future development and improvement. A sample of these messages is provided
below.
A significant number of respondents identify themselves as having caring

responsibilities: 34% of respondents in Carmarthenshire, 35% in Ceredigion and
36% in Pembrokeshire stated this to be the case. Given that 78% of Carmarthenshire
respondents, 62% of Ceredigion respondents and 67% of Pembrokeshire
27
respondents had no dependent children (reflecting the high age profile generally of
those that responded), it would appear that the majority of those identifying as carers
are caring for other adults. It is particularly important to note that these figures
significantly exceed the number of carers formally known to partner agencies, as set
out in Chapter 7 of this assessment. There are clear implications in terms of ensuring
appropriate support to those carers to ensure wellbeing and prevent future demand
on core services.
Around a third of respondents claimed to have a health issue that affected their
wellbeing (32% in Carmarthenshire, 24% in Ceredigion and 32% in
Pembrokeshire). Possibly, the variation across the region reflects the existence of
pockets of deprivation within Carmarthenshire and Pembrokeshire which are not
present in Ceredigion. However, across the three counties, the incidence of such
health issues increases markedly with age. In the 75-84 age group, 49% of
respondents in Carmarthenshire, 47% in Ceredigion and 53% in Pembrokeshire said
they had a health issue affecting their wellbeing. Corresponding figures for the over
85s were 72%, 67% and 67%. These figures underscore the messages within
Chapter 12 relating to the implications of an ageing population and the need for
effective preventative services to help people maintain a good quality of life and
prevent or delay their need for intensive support.
Many people needing care and support are receiving this from their families.
The proportion of respondents claiming this to be the case was 81% in
Carmarthenshire, 71% in Ceredigion and 85% in Pembrokeshire. This contrasted
strongly with the numbers reporting to be in receipt of LA care, the corresponding
figures being 6%, 8% and 11%. Interestingly, 76% of respondents in
Carmarthenshire receiving support from their families felt this was adequate,
suggesting a significant proportion who might need more formal care support now
and in the future. This reinforces the need to build low level capacity at community
level to supplement the care and support provided by families, support carers
themselves and keep people as independent as possible.
A range of responses were received in relation to care not meeting needs.

These included:
 Care visits at unsuitable times and at infrequent intervals

 Long waiting lists for LA care
 Changes in benefits reducing individuals’ capacity to purchase support privately
 Unmet need for emotional support and for practical help following slips and falls
 Lack of training and support for family members, for example in relation to mental
health
Once again these comments provide a clear indication of the need for and value of
low level support to keep people independent and maintain their wellbeing within their
communities, as well as the need to manage demand for more formal care to ensure
that those in need of this receive timely and responsive support.
People go to a variety of places for information and advice in relation to care

and support. In Carmarthenshire, most people said their preference would be to go
to their GP, followed by family and then the Internet; in both Ceredigion and
28
Pembrokeshire the Internet was the preferred route, followed by GP then family
member. Implications from this include:
 The need to ensure information contained on the Internet is accessible and

accurate (the implementation of the Dewis Cymru database across the region in
2017 will play a key role in this)
 The need to ensure access to the Internet is adequate across the region and to
promote digital inclusion
 The need to partner with primary care and GPs to ensure consistent and
appropriate information and advice on wider care and support is provided at this
point of entry into the system
Discussions at the engagement events which followed circulation of the Wellbeing

Survey provided a useful insight into the thoughts and perceptions of those residents
that participated. Once again a number of these reflect the core premise of this
population assessment. A selection of comments made during discussions is
provided below:
What does wellbeing look like?
 Support from friends, family and professionals

 Freedom to make choices
 Mental health and wellbeing – especially children
 Connectedness
 Information/ support to make decisions
 Confidence, knowing you are not alone
 Maintaining social links in later life
 Local services that you can reach easily
What are the cultural and social factors that are important to the wellbeing of
your community?
 Supporting communities to help themselves

 Everyone has something to offer
 Valuing carers
 Sound information in a variety of media
 Access to someone who can give information on preventative measures to avoid
ill health and helping to make healthy lifestyle choices – pharmacist, advisers at
the gym etc
 Opportunities for befriending and intergenerational links, e.g. schools ‘adopting’
care homes
 Community hubs
 Welsh language and culture
 Getting services in the language we want to speak
 A community that works together
What improvements are needed to care and support?
 Put patient at the heart of things

29
 Specialist clinics in the community and closer to people’s homes

 Proactive care events
 Transport and access to services
Full reports have been produced on the findings of the Wellbeing Assessment,
including those questions included specifically relating to health and wellbeing in the
resident survey, and qualitative feedback from the consultation events. These reports
will be made available when this assessment is published.
30
West Wales Population Assessment Cross Cutting Themes
4. Cross Cutting Themes

4.1. Overview
Whilst each of the thematic reports identifies issues and challenges relevant to that
user group, some of these are common across all parts of the population and require
a generic response from the RPB and its constituent partners. These common issues
and challenges are set out below.
4.2. Delivering Services in the Welsh Language

Being able to access Welsh language services is a desire for some people whilst for
others it is a necessity and can play a key role in securing positive wellbeing
outcomes. Particularly when they find themselves at a vulnerable point in their lives
and potentially in need of care and support services, some people will find expressing
and communicating needs in Welsh more natural than they would in English,
particularly where Welsh is their first language and that through which they think and
live their lives. Therefore, maximising the availability of services in Welsh needs to be
a priority for local authorities, LHBs and other partners across health and social care
and the wider public service. Failure to do so can mean that the basic needs of some
of the population cannot be met.
Under the Welsh Language (Wales) Measure 2011 the language has official status in
Wales and as such should not be treated less favourably than the English language.
The Measure establishes a legal framework placing a duty on organisations providing
services to the public in Wales to meet specified standards in relation to:
 Delivery of services
 Policy making
 Internal operations
 Promotion of the Welsh Language; and
 Record keeping
Each LA in Wales has been issued with a compliance notice by the Welsh Language
Commissioner setting out the Standards introduced by the measure that they are
expected to meet. Councils are required to submit annual progress reports on how
these standards are being met. Regulations creating the Standards for NHS Wales
are likely to be passed by the National Assembly for Wales in late 2016/early 2017.
From that point, the Welsh Language Commissioner will also have the right to serve
compliance notices to NHS agencies.
The Wellbeing of Future Generations (Wales) Act 2015 (WFG) contains seven goals
for the wellbeing of Wales, one of which is to ensure ‘A Wales of vibrant culture and
thriving Welsh language’. The SSWB Act includes in its definition of wellbeing
‘securing rights and entitlements’. For Welsh speakers, this will mean being able to
use their own language to communicate and participate in their care as equal
partners.
31
The WG’s ‘Mwy na geiriau’ or ‘More than Just Words’ initiative was launched in 2012
and provides a strategic framework for Welsh language services in health, social
services and social care (Welsh Government, 2012). Since its inception the
framework has driven a number of important improvements, achieved by optimising
existing skills and resources across social services and the NHS.
A follow-on Strategy was launched in 2016 (Welsh Government, 2016a), reflecting

the developing legislative context and aimed at building momentum in the
development of Welsh language services, in recognition of the importance of care
and support delivered through the medium of Welsh for vulnerable people. Examples
might include those suffering from dementia or stroke, or very young children who
may only speak Welsh. A key principle of the original Framework – that of the ‘active
offer’ remains central in the new strategy. This means providing a service in Welsh
without someone having to ask for it, placing the onus on service commissioners and
providers rather than the individual needing care and support. The new strategy
covers the following areas: National and local leadership; mapping, auditing, data
collection and research; service planning, commissioning, contracting and workforce
planning; promotion and engagement; professional education, Welsh in the
workplace and regulation and inspection.
Effective delivery of statutory requirements and the requirements within ‘More than
Just Words’ is particularly important in West Wales, where a significant proportion of
the population is Welsh speaking. The following table provides a break-down of the
proportion of Welsh speakers by age in each county within the region, compared with
Wales as a whole.
Figure 4:1 Proportion of Welsh speakers in each County
Age Carmarthenshire Ceredigion Pembrokeshire West Wales

group Wales
3-4 46% 58% 22% 40% 23%
5-9 60% 82% 41% 57% 38%
10-14 60% 83% 46% 59% 42%
15-19 53% 45% 35% 46% 29%
20-24 42% 31% 18% 32% 18%
25-29 39% 49% 16% 34% 16%
30-34 36% 47% 13% 31% 15%
35-39 36% 48% 13% 31% 15%
40-44 36% 45% 13% 30% 14%
45-49 35% 44% 13% 29% 13%
50-54 38% 44% 13% 31% 13%

32
Age Carmarthenshire Ceredigion Pembrokeshire West Wales

group Wales
55-59 39% 42% 14% 32% 13%
60-64 40% 39% 14% 31% 13%
65-69 45% 42% 15% 34% 15%
70-74 46% 45% 15% 35% 15%
75-79 50% 49% 15% 38% 16%
80-84 53% 51% 17% 41% 18%
85+ 57% 51% 17% 43% 19%
All aged
3 and
above 44% 47% 19% 37% 19%
Source: Office for National Statistics, 2011
The above table illustrates that the proportion of the population over 3 years of age
who are Welsh speakers in West Wales is significantly higher – at 37% than in Wales
as a whole, for which the corresponding figure is 19%. Also of note is the variation in
the number of Welsh speakers in each county area; whilst Carmarthenshire and
Ceredigion both exceed the proportion across Wales as a whole by a considerable
margin, the proportion in Pembrokeshire is the same, at 19%. There are also
variations within county areas. 55% of people in the Gwendraeth Valley in
Carmarthenshire speak Welsh, compared with just 25% in Llanelli town. There is a
wide variation between the numbers of Welsh speakers in North and South
Pembrokeshire, the proportions being 40% and 12% respectively. In Ceredigion the
variations are less marked, although 52% of the population speak Welsh in the south
of the county, compared with 44% in the north.
These figures highlight the importance of promoting the Welsh language and taking
all available measures to strengthen the breadth of Welsh language services across
the region. All statutory partners are signed up to the ‘More than Just Words’
strategy, and a number of local initiatives are in place across the region.
A particular challenge in meeting needs in relation to the Welsh language will be in

ensuring that a sufficient number of those providing services on the front line are able
to converse with users and carers in Welsh where individuals have expressed this
preference.
4.3. Minority and marginalised groups

The Regional Community Cohesion Steering Group, comprising Carmarthenshire,
Ceredigion, Powys and Pembrokeshire County Councils, is focusing on
mainstreaming the seven outcomes (set out below) of the
33
Community Cohesion National Delivery Plan 2016-17 (Welsh Government, 2016b)

into policies, strategies, partnerships and service delivery.
The seven outcomes are to ensure:
 Departments, organisations and people understand hate crime, victims make

reports and get appropriate support
 Departments, organisations and people understand modern slavery, victims make
reports and get appropriate support
 Increased awareness and engagement across Gypsy and Traveller communities.
 Increased evidence and awareness on immigration and supporting the inclusion
of asylum seekers, refugees and migrants
 Increased understanding regarding the impacts of poverty on people with
Protected Characteristics across key service and policy delivery
 Key policies and programmes are supporting and evidencing delivery against the
national goal on more cohesive communities through the Wellbeing of Future
Generations (Wales) Act 2015
 Policies and services are responsive to community tensions
There are also a range of partnerships in each county that are supporting this work
including:
 Pembrokeshire Voices for Equality

 Pembrokeshire County Council Corporate Equality Strategy Working Group
 Safer Pembrokeshire, Community Safety Partnership
 Ceredigion Voices for Equality
 Ceredigion Corporate Equality Strategy Working Group
 Ceredigion Community Safety Partnership
 Equality Carmarthenshire
 Fair and Safe Communities Thematic Group
However, in order to deliver these outcomes and to fully understand the care and
support needs of minority and marginalised groups there is a need to obtain and
analyse more robust demographic data than that currently available.
For example, 2011 Census data shows that the Black and Minority Ethnic population
in West Wales made up less than 2% of the overall population (compared to 4.4% in
Wales) and that there were 335, 74, and 454 persons in Carmarthenshire, Ceredigion
and Pembrokeshire, respectively described as White Gypsy or Irish Traveler.
However, we also know that since 2011 there has been inward migration of people
from other parts of the EU and of refugees and asylum seekers from other parts of
the world.
The total number of asylum seekers and refugees living in Wales is estimated to be
between 7,500 and 11,500). The top five countries of origin of asylum seekers living
in Wales at the end of March 2013 were People's Republic of China, Pakistan, Iran,
Nigeria and Afghanistan. The most common age group of asylum seekers is 30-34
years. Just under half of all asylum seekers living in Wales are female. More work is
needed to engage with such groups, identify specific needs and ensure that services
are responsive to them.
34
There is also a lack of consistent data to inform our understanding of these groups
and other minority and marginalised groups including:
 Offenders, ex-offenders, and their families

 Homeless
 The lesbian, gay, bisexual and transgender (LGBT) community
 Black and Minority Ethnic (BME) groups
 Military veterans
For example, in relation to homelessness, local authorities collect data on the

numbers of people who present as homeless and who after advice and / or mediation
are assessed as ‘final duty’ homeless. However, there are less consistent
approaches in relation to identifying rough sleepers across the region.
Where possible, we have highlighted specific needs of minority and marginalised

groups into the thematic reports; for example, the carers Report notes that the
proportion of carers in the BME population is less than the proportion in the
population as a whole and the VAWDASV report makes specific reference to the care
and support needs of migrant, refugee and asylum seeking women in the region.
A high level Equalities Impact Assessment (EIA) was undertaken to support this
population assessment and ensure that it reflects the requirements of the Public
Sector Equality Duty and properly considers the needs of protected groups.
Moreover, it will be vitally important to ensure, when planning future services and
addressing the issues and challenges raised in this report, that partners take all
opportunities to engage with minority and marginalised groups and ensure their
needs are properly understood and addressed. This work will need to be supported
as appropriate by further EIAs.
4.4. Prevention
Prevention lies at the heart of the new arrangements for care and support envisaged
within the SSWB Act. Specifically, Section 15 of the Act requires local authorities to
provide or arrange for the provision of preventative services to prevent, delay or
reduce need for care and support. They also have an important role to play in:
 Promoting the upbringing of children by their families, where that is consistent
with the wellbeing of children
 Minimising the effect on disabled people of their disabilities
 Contributing towards preventing people from suffering abuse or neglect
 Reducing the need forproceedings for care or supervision orders under the
Children Act 1989;
 Criminal proceedings against children
 Any family or other proceedings in relation to children which might lead to them
being placed in LA care, or
proceedings under the inherent jurisdiction of the High Court in relation to children
 Encouraging children not to commit criminal offences
 Avoiding the need for children to be placed in secure accommodation; and
35
 Enabling people to live their lives as independently as possible
Not surprisingly, partners across West Wales have for some time been working to
develop and enhance the range of preventative services available to people who
either need care and support or who are likely to in the future. Some of this activity
has been supported through national initiatives such as Families First, Flying Start
and Integrated Family Support Services in relation to children and families. A range
of initiatives are underway in West Wales to build resilience within communities
through local provision of low level support services including Information, Advice and
Assistance and befriending services which help people remain independent without
having to seek formalised care. Programmes targeted at reducing unnecessary
hospital admissions, especially among older people, and accelerating discharge back
home have been funded through the WG’s ICF. These include third sector-led
partnerships such as the Pembrokeshire Intermediate Voluntary Organisations Team
(PIVOT) which provides a home to hospital service for older people and is now being
replicated across all parts of the region.
Meanwhile many new initiatives are being developed across GP clusters to improve
the integration of primary and community services and develop approaches such as
social prescribing, which encourage the referral of people to wellbeing services within
their communities rather than on to specialist health services. Initiatives such as time
banking are being developed to encourage members of the community to contribute
to such services; optimising community assets and driving genuinely user-led
approaches to prevention.
Current achievements in relation to prevention are set out in more detail in the
thematic reports, with a consistent call for further development to ensure the delivery
of efficient and effective wellbeing for the local population. The identification of
prevention as one of its strategic priorities demonstrates the commitment of the RPB
to further improvement in this area.
4.5. Safeguarding
Safeguarding is a central theme in the SSWB Act. In the Act, one of the identified
elements of wellbeing is protection from abuse and neglect. For children and young
people this includes their physical, intellectual, emotional, social and behavioural
development; and their welfare (ensuring they are kept safe from harm).
Part 7 of the Act introduces a new duty on local authorities to make enquiries if they
have reasonable cause to suspect that an adult within their area is at risk, and on all
relevant partners to report an adult at risk. Councils may grant adult protection and
support orders (APSOs) where there is reasonable cause to suspect that a person is
an adult at risk and the order is needed to enable them to be assessed.
Under the Act all relevant partners of a LA also have a duty to report a child at risk.
Local authorities then have a duty to make enquiries (linking into section 47 of the
Children Act 1989) if they are informed that a child may be at risk; and to take steps
to ensure that the child is safe.
36
Regional safeguarding boards for children and adults are required under the Act,
representing a range of partners and with responsibility for identifying and
disseminating effective practice in relation to safeguarding. These are in place in the
Mid and West Wales region, complementing local safeguarding arrangements and
spanning the West Wales and Powys areas. A review of the regional safeguarding
board – CYSUR - was undertaken in late 2015 and informed the structure and
operation of the adult safeguarding board which was established in early 2016. Both
boards come together on a regular basis to share approaches and consider common
issues.
Arrangements are in place in each LA to ensure compliance with the other

safeguarding duties introduced by the Act and outlined above.
4.6. Promoting social enterprises, cooperatives, user led services

and the third sector
The SSWB Act also places a strong emphasis on the role of social enterprises,
cooperatives, user-led services and the third sector in providing care and support
services. This will be key in delivering the WG’s policy for greater diversity in the
delivery of public services and in empowering people and communities through a co-
productive approach.
Once again, a number of the thematic reports identify existing good practice in this
area, citing specific examples of social enterprises that are providing a range of
services across client groups. However, without exception the reports conclude that
these foundations need to be built upon and the development of such new service
models accelerated, both to achieve sustainability of care and support within
communities and to drive a genuinely community-based approach to wellbeing. In
delivering this, expert support will be sought from recognised experts such as the
Wales Cooperative Centre and Social Firms Wales to ensure that new models are
appropriate and sustainable within the region. Regional forums will be established to
support social value based providers to develop a shared understanding of this
agenda, and to share and develop good practice.
37
4.7. References
Children Act 1989, chapter 41. Available at
http://www.legislation.gov.uk/ukpga/1989/41/section/47
Office for National Statistics. (2011). Welsh Language Skills (QS207WA). [online].
Available at: http://www.neighbourhood.statistics.gov.uk/dissemination/Download1.do
Welsh Government (2012). More than just words: Strategic Framework for Welsh
Language Services in Health, Social Services and Social Care. Available at:
http://www.wales.nhs.uk/sites3/Documents/415/WEB%20-
%2016184_Narrative_e_WEB.pdf
Welsh Government (2016a). More than just words: Follow-on Strategic Framework
for Welsh Language Services in Health, Social Services and Social Care 2016 –
2019. Available at:
http://gov.wales/docs/dhss/publications/160317morethanjustwordsen.pdf
Welsh Government (2016b). Community Cohesion National Delivery Plan 2016-17.

Available at: http://gov.wales/docs/dsjlg/publications/equality/160310-community-
cohesion-plan-en.pdf
38
West Wales Population Assessment Recommendations
5. Recommendations
Whilst specific areas for improvement are identified in each of the thematic reports,
there are a number of generic recommendations which need to be considered by the
Regional Partnership Board if it is to drive sustainable change to services on the
ground. These are set out below under the core principles of the Act:
5.1. Voice and control
1. Ensure that maintaining people’s dignity and protecting individuals from neglect
and abuse must lie at the heart of all services.
2. Ensure all services are available in Welsh for those who require them.
5.2. Prevention and early intervention
3. Build on the considerable foundations in place across the service areas covered
in this assessment to ensure appropriate services are available to prevent or
delay the need for ongoing care and support and that the prevention ethos
underpins all levels and types of care. Specifically, opportunities should be taken
to develop consistent preventative frameworks across services, which build on
existing good practice, facilitate transition between children and adult’s services
and demonstrably reduce the need for ongoing care and support.
4. Invest in the development of community-based preventative services, including

social enterprise, cooperatives, user-led and third sector provision thus building
the resilience of communities and, thereby, of people needing care and support.
5. Align the Intermediate Care Fund (ICF) and Cluster Development Change
Programmes to build consistent, whole system change on the ground.
5.3. Wellbeing
6. Prioritise support for carers, enabling them and those they care for to live fulfilled
and independent lives for as long as possible.
7. Further improve transition services to facilitate effective planning across services

and ensure that young people continue to receive appropriate care and support
into early adulthood.
5.4. Co-production
8. Ensure that people needing care and support and carers are involved
meaningfully at all stages in the planning, delivery and review of services. This
needs to happen at strategic level, engaging with citizens over the future shape of
care and support and expectations on individuals to promote their own wellbeing
and operationally, ensuring that assessment and care planning allows people to
39
West Wales Population Assessment Recommendations
express personal outcomes and influence decisions regarding the support needed
to attain them.
5.5. Cooperation, partnership and integration

9. Create an environment which permits radical change and encourages innovation
rather than trying to do more of the same with less.
10. Use the population assessment as the basis for the development of integrated
commissioning across service areas, based on a common understanding of need.
11. Develop consistent delivery models across service areas and the region, based
on a shared strategic vision and the principles within the Act; ensuring common
standards to all residents in West Wales.
12. Use this population assessment as a basis for detailed modelling of future
scenarios to understand the interdependencies and impact on care and support
services of, for example, demographic increases in the older population, and
expected increases in known carers and victims of violence against women,
domestic abuse and sexual abuse. There is a need to understand how future
conditions in the area might impact on social services provision and the extent
and diversity of needs for social services over the next 10 -25 years.
13. Pool funds and other resources where appropriate to optimise their impact and
support seamless delivery.
14. Engage strategically with providers across all sectors to develop services and
build sustainable markets for the future.
15. Work with partners across the public sector and others to embed a preventative
approach, promote wellbeing, optimise resources and address specific challenges
such as accessibility of services in a predominantly rural area.
The process of undertaking this assessment has brought professionals from across
the region together to consider objectives, contemplate solutions and agree on where
change is most needed. This in itself provides another firm foundation across partner
organisations for the Regional Partnership Board in discharging its primary duty – to
drive the strategic change that is still needed through cooperation, partnership and
integration. This will go long way in ensuring that care and support in West Wales
supports the wellbeing and promotes the independence of those in need within our
communities.
40
West Wales Population Assessment West Wales Population Profile
6. West Wales Population Profile

6.1. Overview
The West Wales region covers three LA areas - Carmarthenshire; Ceredigion and
Pembrokeshire - and is coterminous with the Hywel Dda University Health Board
(HDUHB) footprint. Estimated population of the region is 384,000 (Hywel Dda
University health Board, 2016). Covering a quarter of the landmass of Wales, it is the
second most sparsely populated health board area in Wales. 47.9 per cent of the
population in the region live in Carmarthenshire, 20.7 per cent in Ceredigion and 31.4
per cent in Pembrokeshire.
Current population projections suggest that the total population of West Wales will
rise to 425,400 by 2033, with a rise in those aged over 65 years from 88,200 in 2013
to 127,700 by 2033. These estimates are based on assumptions about births, deaths
and migration. The increase in the number of older people is likely to cause a rise in
chronic conditions such as circulatory and respiratory diseases and cancers. Meeting
the needs of these individuals will be a key challenge for the UHB. In the current
economic climate, the relative (and absolute) increase in economically dependent
and in some cases, care-dependent populations will pose particular challenges to
communities.
Figure 6:1 Projected population counts by age group, Hywel Dda UHB, 2013-
2036
Source: Hywel Dda University Health Board
With 12.4% of Wales’ population the area’s age and sex profile is similar to that of
Wales as a whole.
The following Figure provides detail of how the West Wales region compares to the
rest of Wales in relation to the age and sex distribution of its population. It shows how
in West Wales the age composition of the population is higher than in Wales generally
with fewer people aged between 25 and 44 and more people aged 55 and over.
41
Figure 6:2
Percentage of population by age and sex, Hywel Dda UHB and Wales, 2015
Produced by Public Health Wales Observatory, using MYE (ONS)
Hywel Dda UHB Wales
Males Females
90+
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
05-09
00-04
8 6 4 2 0 0 2 4 6 8

Figure 6.3 sets out further key population statistics for West Wales compared with the
rest of Wales. This shows that West Wales has a higher proportion of people aged
75+ than Wales; slightly higher life expectancy for both males and females than
Wales; slightly higher rates of people who are obese or overweight, and lower
proportions of people who smoke and who drink alcohol above guidelines. West
Wales also has a lower take up of MMR immunization and a lower birth rate than
Wales. Emergency admissions per 1000 population are also lower in West Wales.
Figure 6:3 Key Population Statistics
Key Statistics Wales West

Wales
Total population 3,092,000 384,000
Population aged 75 and over (%) 8.9 10.3
Life expectancy at birth – males (years) 78.1 78.9
Life expectancy at birth – females (years) 82.2 82.7
Adults who are overweight or obese (%) 58.1 58.5
Adults who smoke (%) 20.9 19.7
42
Key Statistics Wales West

Wales
Adults who drink above guidelines (%) 41.1 39.1
MMR uptake (%) 95.8 94.9
Live birth per 1,000 women aged 15-44 59.1 56.8
Emergency hospital admissions (European age standardized 112.4 105.3

rate per 1,000 population)

Within the region there are notable differences in the composition of the population as
illustrated below:
Figure 6:4 Population Pyramids
Percentage of population by age and sex, Carmarthenshire and Wales, 2015

Carm arthenshire Wales
Males Females
90+
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
05-09
00-04
8 6 4 2 0 0 2 4 6 8
43
Percentage of population by age and sex, Ceredigion and Wales, 2015

Ceredigion Wales
Males Females
90+
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
05-09
00-04
8 6 4 2 0 0 2 4 6 8
Percentage of population by age and sex, Pembrokeshire and Wales, 2015

Pem brokeshire Wales
Males Females
90+
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
05-09
00-04
8 6 4 2 0 0 2 4 6 8
Ceredigion has a large proportion of young adults aged 20-24 years in its population
due to its large University town compared to Carmarthenshire and Pembrokeshire.
44
6.2. All cause mortality rates

Figure 6.4 shows that in West Wales the under 75 age-standardised mortality rate for
males and females is statistically lower than the Wales rate. However, at LA level
there seems to be no statistical difference between Wales and Carmarthenshire for
males and Pembrokeshire for females.
Figure 6:5 All cause mortality, EASR per 100,000, count and crude rate, under
75, Wales local authorities, health boards, 2012-14.
Males: Females:
6.3. Deprivation and lifestyle factors

Geographically based deprivation measures can be used to show inequalities in
health and suggest areas likely to most need measures to improve health and
manage ill-health. The Welsh Index of Multiple Deprivation 2014 is produced at
Lower Super Output Area (LSOA) level and is derived from a broad range of factors.
The following figure shows that in West Wales there are areas of deprivation
including parts of Llanelli, Pembroke Dock and Cardigan.
45
Figure 6:6 Welsh Index of Multiple Deprivation, Hywel Dda UHB 2014
Figure 6.6 shows that people living in the West Wales region have generally healthier
lifestyles than is typical across Wales. Yet there are still challenges to be addressed.
For example, Ceredigion has a slightly higher rate of adults reporting to drink alcohol
above the guidelines and binge drink, whereas Pembrokeshire and Carmarthenshire
are reporting higher than the Welsh average in rates of obesity. This is despite better
rates than Wales for levels of physical activity and fruit and vegetable consumption.
46
Figure 6:4 Observed percentage of adults who reported key health-related

lifestyles, by LA, Health Board and Wales, 2013/14.
6.4. Further information

More information on the West Wales population is available in the Public Health
Needs Assessment Report (Hywel Dda University Health Board, 2016). This
document provides further details on the demographic profile, prevalence and
incidence of various chronic conditions, lifestyle risk factors and some of the wider
determinants that impact upon health. There is also reference to the local Single
Integrated Plans for Carmarthenshire, Ceredigion and Pembrokeshire.
Further reference is made to lifestyle and environmental factors where appropriate in

each of the thematic reports that follow.
47
West Wales Population Assessment West Wales population profile
6.5. References
Hywel Dda University Health Board (2016). Health Needs Assessment Report 2016.
Available at: http://www.wales.nhs.uk/sitesplus/862/page/85702
48
West Wales Population Assessment Carers
7. Carers
7.1. Overview and Key Messages
All of us will have our lives touched by caring at some point: 3 in 5 of us will be carers
and many of us will also need care in our lifetime (George, 2001). Carers are the
mothers, fathers, sons, daughters, siblings, spouses, friends and neighbours who
provide unpaid care, caring at home, picking up prescriptions, changing dressings,
providing much needed emotional support and much more, and often neglecting their
own health and wellbeing needs. Carers are vital to those they care for and to the
foundation of the health and social care system.
Around 1 in 8 people in West Wales, many of them young people, are providing
unpaid care with a significant proportion providing between 20 to 50+ hours of unpaid
care per week.
The provision of unpaid care is becoming increasingly common as the population
ages, with an expectation that the demand for care provided by spouses and adult
children will more than double over the next thirty years (See for example Pickard,
2008).
Based on a national calculation conducted by carers UK and Sheffield University in
2015 (Buckner and Yeandle, 2015), the cost of replacing unpaid care in West Wales,
can be estimated at £924m. This exceeds the NHS annual budget for the region
which is almost £727m (Hywel Dda University Health Board 2016a).
7.2. Demographics and Trends

Census data suggests that within West Wales there are more than 47,000 unpaid
carers representing 12.5% of residents (ONS, 2011):
 Carmarthenshire has the highest proportion (13.2%) of unpaid carers in West

Wales, the 3rd highest in Wales
 Pembrokeshire has the second highest proportion (12.4%) in West Wales, the
11th highest in Wales
 Ceredigion has the lowest proportion in West Wales (8,603), the 4th lowest in
Wales. In comparison with the other 21 authorities across Wales however, the
percentage change (8.7%) between 2001 and 2011 of carers in Ceredigion was
the second highest across all of Wales (joint second with Powys)
 The age range that provided the greatest share of care were women aged 50-64,
with more than a quarter of all women in this age group providing some level of
unpaid care
 The percentage of people providing over 50 hours of care per week rises with
age, for both males and females
 The Black and Minority Ethnic (BME) population of West Wales is 2.12% of our
total population or 8,105 people, considerably lower than the Welsh average of
4.4%. The rates of caring amongst the BME population are significantly lower
than the population as a whole, around half that of the general population. This is
partly explained by the lower age profile found in BME groups
49
Figures from Carers UK (2013a) indicate that over one third of eligible carers do not
claim the carers Allowance benefit.
The 2011 Census further suggests that:
 7.2% of the population provide 1-19 hours unpaid care per week
 1.7% provide 20-49 hours unpaid care per week
 3.5% provide more than 50 hours of unpaid care per week
 The age range that provided the greatest share of care were women aged 50-64,
with 25.7% of all women in this age group providing some level of unpaid care. A
total of 10% of this age group are providing over 20 hours care p/w
 The total number of people in the area providing over 50 hours of care p/w is
13,373 of whom 5,485 (41%) are male and 7,888 (59%) are female
 The percentage of people providing over 50 hours of care p/w rises with age, for
both males and females
 In the 25-49 years age group, 2.3% (1,215) of all males and 4.1% (2,297) of all
females provide over 50 hours of care p/w
 In the 50-64 years age group, 4.2% (1,629) of all males and 6.3% (2,564) of all
females provide over 50 hours of care p/w
The percentage of carers identified to health and social care organisations in West
Wales increased from 10.2% in June 2013 to 20.6% in June 2016 (Hywel Dda
University Health Board, 2016b).
Census data suggest that there are 3,436 young carers (defined as 5-17 year olds) in
West Wales. Of those:
 48% are male and 52% are female (compared to 43% and 57%, respectively in
the overall carer population)
 858 (25%) of young carers are providing more than 20 hours unpaid care per
week
 385 (11%) are providing more than 50 hours of unpaid care per week
Figures published by the BBC suggest there are four times more young carers in the
UK than are officially recognised (Howard, 2010).
7.3. Current and Future Support Needs

It is worth noting that not all carers want or need support all of the time. For example,
51% of 1,020 carers who were offered a carers assessment by Ceredigion Social
Services in 15/16 declined the offer. Just over a third (35%) of those that declined the
offer reported that they were managing in their caring role so did not require any
additional support.
However, the Carers Trust (2016) estimate that by 2030 the number of unpaid carers
will grow by around 60% as more people live longer but with more complex needs.
50
The role of an unpaid carer can negatively impact a carer’s physical and mental
health and their career and financial security. Carers can also experience social
isolation, a lack of recognition of their caring role and their knowledge of the cared for
person. Life after caring can also bring its own challenges.
Evidence suggests that:
 Providing more than 50 hours of unpaid care can increase the likelihood of self-
reported poor health (Census data)
 The short and long-term impact of carer collapse can be devastating. Carers can
end up in a double admission alongside their ill or disabled loved one ,(Carers UK,
2014)
 Caring for someone with dementia or mental health needs can have an even
greater impact leading to stress and frustration and a detrimental impact on carers’
physical and mental health
 Carers frequently report that their involvement in care is not adequately recognised
and their expert knowledge of the ‘cared for person’ is not taken into account. A
disconnected model of involvement like this can lead to carers being excluded at
important points (Worthington et al, 2013); and this issue contributed to
readmission of the cared for person into hospital in 62% of cases (Carers Trust
Wales, 2016)
 It can be difficult for working-age carers to combine paid work with caring duties
and carers may choose to quit paid work or reduce their work hours (OECD, 2011)
 Around 5% or 1 in 20 people of working age combine paid work with their role as
an unpaid carer (Carers UK, 2013b) and yet across the region the percentage of
working age people claiming Carer’s Allowance is around 2.0%. Whilst this is
comparable to the Wales percentage (2.1%) in Ceredigion the uptake is lower
(1.4%) (Data Unit Wales, 2015). Direct Payments to carers in their own right is
also low which could be linked to the take up of assessment offers. More than a
third of carers miss out on state benefits because they didn’t know they could
claim for them (Carers Trust, 2016)
“A carer confided in the GP surgery receptionist that she was not coping at home
due to the stress of being a carer to her husband who had been diagnosed with
Dementia. She was alone, and nobody understood how her husband could be a
handful as his friends and family knew him as this kind caring man”.
Source: Hywel Dda Regional IiC (2016)
It is important to recognise that carers’ wellbeing can be significantly improved by

addressing low level issues such as not being able to carry out maintenance or DIY,
tidy up the garden or clean the windows.
Carers are not a static population. Every year around a third of carers find their caring
role has come to end as the person they care for recovers, moves into residential
care or passes away (Carers UK, 2015). Life after caring can bring new challenges.
Loss of role and function compound normal grieving and can lead to isolation and
depression. Many carers will have depended on the welfare benefits of those that
they cared for to jointly live on but when the caring role comes to an end welfare
51
benefits can stop too leaving carers having to apply for benefits themselves. As one
carer put it:
‘why doesn't anyone pick up on this and help the carer to be able to move on?
Source: Carers UK
Carers also face a number of other challenges including transport and finding
suitable and affordable housing, and inadequate and inaccessible service provision
for carers and for the cared for person.
 Looking after someone with a disability or illness can make it difficult to get out of
the house. This could be due to mobility, travel and fuel costs or poor transport
links within large rural areas
 Carers and their families often face problems in relation to suitable and affordable
housing. Carers are not being prioritised for housing, can suffer overcrowding or
other types of inappropriate housing, sometimes without a separate bedroom for
the carer or cared for person
 Inadequate service provision for the carer and cared for person is also an issue
across the region. Lack of services can have a knock on effect on carers, for
example a lack of inpatient, day services, clinics, and respite care, and specialist
services for example for older people, people with mental health issues, veterans
and their families and younger adults with physical disability. The north of the
region is particularly poorly served in terms of mental health and dementia
services
Health and care services need to be better tailored to the carer’s individual needs
rather than the organisations providing them. Mixed consistency of support from local
services means that carers are facing barriers to maintaining their health, balancing
work and care, and balancing education and care which is having a markedly
negative impact on their life chances: Carers who are supported by their communities
are more than three times as likely to always be able to maintain a healthy lifestyle
(Carers UK, 2016).
Local carer feedback supports this:
“As a carer attempting to get understanding, advice, support and emergency care
from the ‘community’ – such as GP, public transport, social services, dentist
pharmacies and hospitals – can be very challenging, exhausting and beyond
stressful.”
‘although a commissioned service is “marvellous”, what is needed, is someone to

take the cared for person out so that the carer can have time at home on their own’.
Young Adult Carers (YACs) (18 -25 year olds) face many of the same challenges as
adult carers including having their own physical or mental health problems. In
addition, they are four times more likely to drop out of college or university than a
student without caring responsibilities. Only 36% of YACs feel able to balance their
52
commitments with their caring role compared to 53% without a caring role. Many
YACs in West Wales live in rural and remote communities and financial hardship can
make it difficult to access services because of travel costs and time restraints. YACs
need advice and information about education, health, employment, benefits,
relationships, respite and support around their caring role and transition to an
independent adult life.
Young carers (5 -17 year olds) face additional challenges of problems at school, with
completing homework and in getting qualifications, isolation from other children and
other family members, being stigmatised or bullied, lack of time for play, sport or
leisure activities, feeling that there is nobody there for them, and that professionals
do not listen to them. Young carers can also experience problems moving into
adulthood, including with finding work, their own home and establishing relationships.
One Young carer said:
“I’ve gone from 12 to 30 and it’s hard. I want to live a normal life. I want to be
understood.”
Source: Children’s Society, 2012
7.4. Current Support Provision

Carers’ needs are currently met in the region through a range of services that are
delivered by or commissioned by the local authorities, health, the third sector and
other local community groups. These can be broadly broken down in to services that
support:
 Identification and recognition

 Advice and information
 Assessment of carers needs
 Practical support (for example replacement care, help around the home,
shopping)
 Advocacy
 Condition specific support for the carer and the person they care for
Services that directly support carers include:
 Carers needs assessments and support plans

 Commissioned support services (i.e. services providing practical and emotional
support for the carer)
 Breaks from caring (from a few hours to extended periods depending on
assessed need)
 Comprehensive information in a range of formats including social media
 Direct payments for carers
 Carers Emergency Card schemes
 Programme of events including carers week and carers rights day
 Carers Forums and support groups (engaging, informing, consulting and peer
support)
 Advocacy
53
 Grants
Services that indirectly support carers include:
 Replacement care for cared for person (day opportunities, replacement care and
respite)
 Direct payments for cared for person
 Expanded care plans
 Workforce development and training / eLearning. The value of workforce training
is highlighted by the following feedback
“This course gave me insight into who can be carers, what defines them for being a
carer and their entitlements under law. The course has also provided me with access
to links which can help me direct carers to the support they can get whilst carrying
out their caring role.”
Source: Carer Aware e-Learner Feedback Survey, 15/16 Hywel Dda University
Health Board Carers' Measure Strategy Annual Report, 2016.
Significant progress has been made in the region particularly through the Investors in
Carers (IiC) scheme. IiC is an accredited award initiative for GP practices, secondary
care settings, pharmacies and schools aimed at improving the help and support given
to carers. The scheme delivers a number of cultural changes including;
 Mainstreaming of areas of good practice within the partner organisations
 Increased communication between professionals and voluntary organisations
 Recognition of the caring role and the identification of ‘hidden’ carers 
 Targeted health checks for carers
 Engaging carers in the design, development and delivery of the services they
receive, for example; the new Information Advice and Assistance (IAA) ‘Pre-Front
Door’ operating Model and the development of a digital inclusion project in rural
Tregaron, Ceredigion, to help overcome social isolation
 Partnership working between Mid Wales Healthcare Collaborative, Ceredigion
County Council’s Carers Unit and the IiC Scheme to develop a training programme
to build resilience and improve the wellbeing of carers across the region - the first
time the training programme has been adapted and trialled with carers in the
whole of the UK
 Roll out of the Carer Aware training scheme and Young Carer Aware E-learning
package
 Ensuring that HR policies include support for employees to remain in work, fulfil
their career potential and meet their caring responsibilities
Evidence of improvements include:
 An increase in the percentage of carers identified from 10.2% in 2013 to 20.6% in

2016
 An increase in the number of carers registered with GP surgeries in the region
from 5,871 in 2015 to over 6,138 in June 2016. GP Surgeries also made 635 carer
referrals for further help and support (almost a 40% increase since 2015)
 Positive feedback for example
54
“I realised that I was a carer and could register with my GP after seeing the notices
on the board in my Surgery.”
“Carer and cared for have used some of the information leaflets available in the GP
surgery to access support/advice.”
Social enterprises and voluntary groups also provide a wide range of services to
support carers including:
 Crossroads Care
 Action for Children – supporting Young Carers
 Mind – Mental health services and support for Carers
 Carers Provider Forum
 Carers’ Networks
In addition, there are numerous voluntary and community groups offering services in
the community, such as luncheon clubs, learning circles, exercise classes, shopping
services, book clubs, and so on which can help improve the wellbeing of carers.
Some work has been done to stimulate social enterprise in the region. County
Voluntary Councils (CVCs) have facilitated development workshops alongside local
agencies with respect to social enterprise but there are resource implications to
progressing this further.
CVCs also support a wide range of social enterprises and voluntary and community
groups, which collectively make up the third sector. Experienced staff provide
information and support on setting up new groups (including legal structures and
governing documents); organisational development; good governance; sustainable
funding and fundraising and quality assurance.
Communities offer significant assets and social capital that could be utilised to
improve the physical and mental wellbeing of carers including:
 Carers themselves (experts through experience)

 A network of community buildings offering local access to services, events and
activities
 A vibrant third sector
 Active volunteer network – including formal and informal volunteers
 A beautiful natural environment, including a national coastal path
 Community based groups
 Community connectors/community champions being developed under the
SSWBA implementation
 Arts, educational, cultural, and spiritual resources
7.5. Gaps and Areas for Improvement

There are challenges to improving experience and outcomes for carers including:
55
 Recruitment and retention of staff to many health and social care providers and
lack of capacity to recruit and support volunteers
 Stretched budgets, reductions in grants, or reduced access to grants to third
sector providers, and short term funding
 Lack of market competition in the private sector in rural areas
 National variations in the age ranges used in relation to YACs which has a
bearing on how research data can be compared. For example, Carers Trust
considers YACs to be 14-25. The Census and other research consider the age
range to be 18-25 years
However, the Population Assessment will inform partners’ future plans including:
 Investors in Carers development plan (2017 onwards)
 Regional Carers Strategy
 Hywel Dda Transition Carers Action Plan 2016-2018
 Ceredigion Carers Unit Business Plan
 Carmarthenshire Carers Action Plan
 Pembrokeshire Carers Strategy – Supporting the Health and Wellbeing of Carers
Headline intentions will be overseen through the Regional Partnership Board and
through local governance structures including the Regional Carers Strategy
Implementation Group and Regional Carers Programme Board, Ceredigion Carers
Alliance, Carmarthenshire Strategic Partnership Board for Carers and Pembrokeshire
Joint Carers Strategy Board.
Partners including the third sector will continue to work together to address gaps and
areas for improvement which are set out below against the core principles of the
SSWB Act.
Voice and Control

There are challenges to improving outcomes for carers. Caring responsibilities can
grow over time so that individuals do not immediately recognise they have become a
‘carer’ or that support may be available. There is a need to:
 Further embed good practices around identification, information and consultation.

This includes maintaining Carers Information Services to include information
about health and care services and key stages in the caring journey from being a
new carer, to changes in needs, transitions points in life stages, preparing for the
end of caring, bereavement and when the caring role ends
 Raise the profile and public understanding of caring
 Ensuring carers are involved in decisions about the cared for person including
discharge planning
Prevention and Early Intervention

There is a need to design and develop preventative services and review
commissioned service specifications to meet the prevention model.
56
Wellbeing
There is a need to improve carer assessments and to do more to ensure services
that support the cared for person are accessible and available (for example rapid
response services to support people with night care during acute episodes and
emergencies, respite services, support for people in a crisis and transitional services
for children and young people).
Programmes aimed at maintaining general wellbeing of carers should also be

considered. One such programme was piloted by the Mid Wales Healthcare
Collaborative in partnership with Ceredigion County Council’s Carers Unit and
HDUHB’s IiC Scheme over an eight week period in autumn 2016. A training
programme entitled ‘Caring for the Third Workforce: The Resilience and Wellbeing of
Carers’ was developed aimed at building resilience and improving the wellbeing of
Carers across Ceredigion. This was the first time this exciting and well trusted
training programme has been adapted and trialled with Carers in the whole of the UK;
Ceredigion was specifically chosen as an area with a rural dispersed population.
Carers had the opportunity to be one of the first in the UK to take part. The resilience
pathway considered the effects of isolation, stress and identity. The methodology
enabled the Carers to develop a situational analysis process regarding stress levels,
as a means of always finding a way back to their “best self” as the core resilience
pathway. The outcomes of the robustly evaluated pilot with the participants indicated
significant and sustainable improvements in a positive mind set and self-help,
identified by the carers through their own analysis and that of the researcher as to
their improved resilience. The participants have continued to meet into 2017 since
course completion as a support group with their own identity ’Caring Friends‘. There
is significant ongoing interest and commitment to further trials for the model of
delivery to support further roll out, both from Carers and professionals, it has potential
for Carers in the Workforce and Young Carers. The Report will be shared with the
Mid Wales Collaborative and the West Wales Regional Partnership Board. The
research is to be discussed at the BMJ International Conference in July 2017, and
with the Welsh Government. It is also a training programme under discussion with
Academi Wales as a tool to support the resilience of the workforce and the Carers
within that environment in Spring 2017 for further development.
Co-production
Support the role of user-led services including:
 Create local carer co-operatives that can commission services that best meet their
needs
 Work with carers through Carer Forums on the co-production of services
Co-operation, Partnership and Integration

 Strengthen the role of social enterprises and user-led services including
• Developing commissioning and procurement processes that pro-actively build
social enterprise supply chains
• Promote new models of service delivery by sharing examples of what works
elsewhere and encourage collaboration
• Develop a programme of training courses and workshops for carers delivered
by third sector organisations and social enterprises
57
 Develop a much more joined up approach between partners and other agencies
to ensure the issues facing carers are taken into account when planning
community programmes such as transport, housing, and technology
developments and other community programmes. For example whilst technology
developments have significant potential many carers need paper based and face
to face advice because they cannot access online information or require the
emotional support from personal contacts
 Support carers with housing problems for example through

• Advice services for carers including specialist housing advice services for
carers of older people or people with learning disabilities
• Local authorities and housing associations taking carers’ needs into account in
housing lettings policies
• Support with adaptations; equipment, repairs and improvements, alarms and
telecare technologies
• Support to move home from an inappropriate property (The Princess Royal
Trust for Carers, 2010)
 Address the challenges of transport in the region through for example, integrating
carers impact assessments within transport planning for the community and more
consistent Community Transport Schemes across the region. For example ‘Cars
for Carers’ is no longer resourced in all counties and needs to be considered on a
regional footprint. And address carer transport needs using Direct Payments,
Voucher schemes and other community schemes
 Address the low up take of benefits and increase claims and to ensure:
• Older carers over the age of 65 take up entitlement that could passport them
onto other benefits or carer addition to Pension Credit
• Coordinated local concessions across the regional footprint e.g. free bus
passes for carers, free parking, and other concessions that can make a big
difference to the lives of carers and their families, and help to build a more
carer friendly community
58
7.6. References
Buckner, L. and Yeandle, S. (2015). Valuing Carers 2015: The rising value of carers’
support. London: Carers UK. Available at:
https://www.sheffield.ac.uk/polopoly_fs/1.546409!/file/Valuing-Carers-2015.pdf
Carmarthenshire County Council (2016) Carers population assessment briefing –

Officers summary to Regional Carers Implementation Group citing Depression in
carers of patients with dementia. Available at: http://priory.com/psych/carerdep.htm
Carer Aware e-Learner Feedback Survey, 15/16 Hywel Dda University Health Board
Carers' Measure Strategy Annual Report, 2016. Available at:
http://www.wales.nhs.uk/sitesplus/862/page/71869
Carers Trust (2016). Key fact about carers and the people they care for. [online].
Available at: https://carers.org/key-facts-about-carers-and-people-they-care
Carers Trust Wales (2016). Investing in Carers, Investing to Save: Key Principles for
Health and Social Care Commissioners. Cardiff: Carers Trust Wales. Available at:
https://carers.org/sites/files/carerstrust/media/commissioning_wales_finallo.pdf
Carers UK (2014). Carers UK Forum [Online] Available at:

https://www.carersuk.org/forum/support-and-advice/all-about-caring/life-after-caring-
21451
Carers UK (2013a) Policy Report Estimating the Take up of Carers Allowance

November 2013) Available at: https://www.carersuk.org/for-
professionals/policy/policy-library/carers-allowance-takeup
Carers UK (2013b). Supporting Working Carers: The Benefits to Families, Business

and the Economy. London: Carers UK. Available at: https://www.carersuk.org/for-
professionals/policy/policy-library/supporting-working-carers
Carers UK (2014). Carers at Breaking Point. London: Carers UK. Available at:
https://www.carersuk.org/for-professionals/policy/policy-library/carers-at-breaking-
point-report
Carers UK (2015). Making life better for Carers. Available at:

https://www.carersuk.org/
Carers UK (2016). Building Carer Friendly Communities: Research report for Carers
Week 2016. Available at: https://www.carersuk.org/for-professionals/policy/policy-
library/building-carer-friendly-communities-research-report-for-carers-week-2016
Census 2011 data, reported in Carers UK Policy Briefing Nov 2015. Available at:
https://www.carersuk.org/images/Facts_about_Carers_2015.pdf
59
Data Unit Wales (2015). Percentage uptake of carers allowance. Available at:
http://www.infobasecymru.net/IAS/themes/employmentandbusiness/benefits/view?vie
wId=88
George, M. (2001). It could be you: a report on the chances of becoming a carer.

London: Carers UK.
Howard, D. (2010). “Number of child carers 'four times previous estimate’”. BBC,
[online], 16 November. Available at: http://www.bbc.co.uk/news/education-11757907
Hywel Dda University Health Board (2016a). Annual Report and Accounts 2015-16
Summary [online]. Available at:
http://www.wales.nhs.uk/sitesplus/documents/862/AnnualReportSummary2016WEB.
pdf
Hywel Dda University Health Board (2016b). Carers' Measure Strategy Annual
Report, 2016. Available at: http://www.wales.nhs.uk/sitesplus/862/page/71869
Hywel Dda University Health Board (2016c). Carers' Measure Strategy Annual
Report, Available at:
Hywel Dda Regional IiC (2016). Thematic analysis of Carers in Ceredigion and
Pembrokeshire between 2013 – 2015 for HDUHB Carers Measure Programme
Board, Analysis of Carers’ Stories Gathered by the IiC Team 2013-2015. Report and
presentation to Hywel Dda Regional Partnership Carers Programme Board
OECD (2011). Help Wanted? Providing And Paying For Long-Term Care. [online].
Available at: http://www.oecd.org/els/health-systems/47836116.pdf
Office for National Statistics (2011). Health and Provision of Unpaid Care
(KS301EW). Available at:
http://www.neighbourhood.statistics.gov.uk/dissemination/datasetList.do?JSAllowed=
true&Function=&%24ph=60&CurrentPageId=60&step=1&CurrentTreeIndex=-
1&searchString=&datasetFamilyId=2480&Next.x=29&Next.y=13
Pickard, L. (2008). Informal Care for Older People Provided by Their Adult Children:
Projections of Supply and Demand to 2041 in England. London: Personal Social
Services Research Unit
The Children’s Society (2012). Supporting young carers and their families:
Information for health care professionals. Available at:
http://www.youngcarer.com/sites/default/files/health_care_pros_booklet_2012_low_r
es.pdf
The Princess Royal Trust for Carers (2010). Carers and Housing: Addressing their
needs. Available at: http://static.carers.org/files/2446-carers-and-housing-en-4965.pdf
Thematic analysis of Carers in Ceredigion and Pembrokeshire between 2013 – 2015

for HDUHB Carers Measure Programme Board, Analysis of Carers’ Stories Gathered
by the IiC Team 2013-2015
60
Worthington, A., Rooney, P. and Hannan, R. (2013). Triangle of Care, 2nd edition.
London: Carers Trust. Available at:
https://professionals.carers.org/sites/default/files/triangle_of_care_2016_latest_versio
n_0.pdf
61
West Wales Population Assessment Children and Young People
8. Children and young people

8.1. Overview and key messages
 Children and young people make up approximately 22.2% of the population in the
West Wales region. The number of young people is expected to stay relatively
stable over the next 15 years
 The region has a lower number of looked After Children (LAC) than the national
average
 Care and support needs span a wide range from universal, through early
intervention, multiple needs and remedial intervention
 Partner agencies have adopted a broadly consistent continuum of care and
support for children and families with a focus on prevention
 Areas for improvement include further development of preventative and early
intervention services, building on established programmes such as Family
Information Services, Families First and Team Around the Family; refocusing
managed care and support to promote independence and wellbeing; improving
multi-agency working and improved collaboration across the region to bring
services to a consistent level and standard
 Collaborative action should also be considered to address strategic challenges
such as reducing budgets, workforce development and the establishment of user-
led preventative services
8.2. Demographics and trends

In 2015 there were 85,170 children and young people (aged between 0 and 19) in the
West Wales region, of which 41,920 reside in Carmarthenshire, 15,890 in Ceredigion
and 27,360 in Pembrokeshire. Across the region this represents 22.2% of the total
population.
Projections suggest these figures will remain relatively stable at regional level
between now and 2030, the estimated number of children and young people standing
at 84,430. Slight increases are predicted in Carmarthenshire (projection of 43,220)
and Ceredigion (17,210) to 43,220 with a slight drop to 26,230 predicted in
Pembrokeshire (Daffodil Cymru).
LA data indicates that there are currently 144 children and young people with a
disability (including Autism Spectrum Disorder or ASD) in Carmarthenshire, with
corresponding figures for Ceredigion and Pembrokeshire standing at 184 and 136,
respectively. Available figures for children with ASD and disability project a relatively
stable incidence of these conditions over the period to 2030.
A study undertaken across the region in 2015-16 indicated that the number of
children and young people identified with complex needs stood at 64 (16 in
Carmarthenshire, 21 in Ceredigion and 27 in Pembrokeshire). 23 children and young
people were identified as having complex needs by Hywel Dda University Health
Board (People and Work Unit, 2016). These numbers should be seen as indicative;
definitions of complexity and nature of conditions vary across local authorities, and
62
anonymised records mean that there could be overlap between those children and
young people identified by social services and those identified by the NHS.
The following table shows the percentage of children and young people not in
education, employment or training in 2015 in each county in years 11, 12 and 13.
Whilst the data shows similarities between the counties for year 12, there are some
notable differences between Ceredigion and the other two counties in year 11, and
between all counties in year 13.
Figure 8:1 Percentage of children and young people not in education,

employment or training (NEET) 2015
Not in Education, Employment or Training 2015
Carmarthenshire Ceredigion Pembrokeshire
% known to be NEET in year 11 3.5 1.4 3.8
Source: Careers Wales
8.3. Current and future care and support needs

Children and young people will have a range of care and support needs depending
on their personal circumstances. Broadly speaking, this range will encompass:
 Universal needs, for example information and advice, low level family support,
preventative services such as health visiting, early ante-natal provision, dietetic
support and advice, childcare and careers advice
 Additional needs and early intervention, such as improvement support for
families, youth engagement, supporting young people into education and training,
education inclusion and welfare
 Multiple needs, requiring coordinated multi-agency support to support children
and families to address complex and/ or entrenched needs
 Need for remedial intervention to support children at risk
Effective transition into adult services for children and young people who need
ongoing care and support, and providing the right support for young people leaving
care are also important factors when planning and delivering services.
Regardless of the specific nature of their need, care and support for children and
young people should contribute to the ten aspects of wellbeing set out in Part 2 of the
Social Services and Wellbeing (Wales) Act. In particular, partners share a strategic
commitment to:
 Promote physical and mental health and emotional wellbeing
 Support welfare and development of children and families by working
collaboratively with parents, family networks and community services including
education, training and recreation providers
 Keeping children safe and protecting them from abuse and neglect
All planning for care and support for children and young people is guided by the
63
United Nations Children Rights Convention and we will work together for children to
ensure they are not harmed, are looked after and are kept safe (Article 19) and
achieve their wellbeing outcomes (United Nations, 1989).
Wellbeing Outcomes that are particularly important to this group are:
Physical and mental health and emotional wellbeing

 I am healthy and active and do things to keep myself healthy
 I am happy and do the things that make me happy
 I get the right care and support, as early as possible
Protection from abuse and neglect

 I am safe and protected from abuse and neglect
 I am supported to protect the people that matter to me from abuse and neglect
 I am informed about how to make my concerns known
Education, training and recreation

 I can learn and develop to my full potential
 I do the things that matter to me
Domestic, family and personal relationships

 I belong
 I contribute to and enjoy safe and healthy relationships
Children will want to achieve wellbeing outcomes that are personal to them and they
may need care and support from many different areas in helping them to achieve
these. Children with disability or additional needs will require enhanced or targeted
support to assist them.
Exposure to Adverse Childhood Experiences (ACEs) such as parental separation,

domestic violence or individuals with alcohol or substance misuse problems have a
long term harmful effect. Preventing ACES can improve health across the whole life
course and enhance an individual’s wellbeing while supporting families with parenting
and child development plays a central role by promoting resilience, positive self-
esteem and has a positive impact on wellbeing outcomes (Public Health Wales,
2015).
Workers across health, social services and associated preventative services gather
the views of children, young people and their families through their day to day
practice. In addition to this a range of consultation and engagement activity is
undertaken to ensure that the experience and voice of children, young people and
their families shapes service improvement and planning. For example, in Ceredigion
the views of the wider children and young people population are gathered through the
School Wellbeing Survey.
8.4. Current care and support provision

In response to the needs identified in the previous section, partners across the region
have adopted a service continuum as a basis for planning and delivering care and
support as shown in the following diagram.
64
Figure 8:2 Service continuum
Source: Institute of Public Care
Whilst the continuum is articulated differently in each county area and the precise
categorisation of services varies slightly, there are common core principles which
include:
 A recognition of the importance of physical, mental and emotional wellbeing of

children and the key role of universal services in achieving this
 The importance of partnership working, for example between social services,
youth services, youth prevention services and other organisations to ensure that
young people have access to social activities
 The view that resilience and wellbeing are rooted in families and communities and
therefore that support should be focused wherever possible on promoting family
life and enabling children and young people to remain within their families and/ or
communities so long as it is safe for them to do so
 A multi-agency and individualised approach to supporting children with complex
needs
 Effective transition for children and young people into adult services where
appropriate
Similarly, service provision varies in detail across the region, but they are predicated
on this continuum of services. A summary of services currently in place is provided
below.
 Family Information Services (FIS) are in place in each LA area which provide
members of the public, professionals and other agencies with access to a broad
range of information about local relevant services and support available to
families including those who may have a need for advice with specific issues
 Advocacy services are provided through a newly commissioned regional contract

spanning Mid and West Wales (including Powys)
65
 A range of services are commissioned through the Families First programme,

which has a clear emphasis on early intervention for families, especially those
living in poverty, through a multi-agency approach and coordinated working with
other programmes and services across the region. These include Flying Start,
which provides enhanced services for children age 0-4 living in particular
geographical areas as well as third sector providers which cover the whole region
such as Action for Children, Plant Dewi and Homestart. More information on
Families First can be found at http://gov.wales/topics/people-and-
communities/people/children-and-young-people/parenting-support-
guidance/help/families-first/?lang=en and on Flying Start at
http://gov.wales/topics/people-and-communities/people/children-and-young-
people/parenting-support-guidance/help/flyingstart/?lang=en
 There is an increasing focus on reducing adverse childhood experiences such as

drug use, domestic violence, mental illness alcohol and drug use as well as
continuing to address child maltreatment verbal, physical and sexual abuse. Those
families who may have more complex or entrenched difficulties require
assessment and coordination by a specialist worker to develop and deliver plans
which will incorporate a range of specialist responses from dedicated services
such as the Integrated Family Support Service (IFSS) and Looked After Children
(LAC) teams. More information on IFSS can be found at
http://gov.wales/topics/health/socialcare/working/ifst/?lang=en
 Education welfare services in each area work with partners in education to reduce
persistent non-attenders and ensure educational entitlement
 Specialist provision for children and young people with complex physical and
mental health needs, including residential care (fostering, in-house placements,
children’s homes, care homes and secure accommodation), community care
packages enabling people to live at home and a range of health and education
services such as Speech and Language Therapy, occupational Therapy, sensory,
educational psychology (EP), physiotherapy, child psychology, and children and
adolescent mental health services (CAMHS)
 A range of ‘looked after’ solutions including child protection reviews, adoption,

fostering and residential care. A regional adoption service is in place across Mid
Wales, including Powys, which has enabled a standardisation of approach and
collaborative working in areas such as promotion, recruitment, assessment,
training and ongoing support
 Regional safeguarding arrangements through the CYSUR Children’s

Safeguarding Board, which has the aim of ‘protecting children who are
experiencing, or are at risk of abuse, neglect or other kinds of harm, and prevent
children from becoming at risk of abuse, neglect or other kinds of harm’. The
regional arrangements have facilitated the development of consistent policies and
procedures, including a regional action plan in relation to Child Sexual
Exploitation, and are being aligned closely with arrangements for adult
safeguarding to address cross-over issues such as domestic abuse and violence
66
 Transition services and enhanced ‘leaving care’ provision to meet the

requirements of the Social Services and Wellbeing (Wales) Act
 A comprehensive range of sexual health services including:
 Sexually Transmitted Infections (STI) testing and treatment

 Complex contraception including provision of all LARC methods
 Basic contraception
 Cervical screening
 Community gynaecology
 Psychosexual counselling
 Rapid access for vulnerable groups
 Child Sexual Exploitation (CSE) risk assessment for all patients under 18
 Assessment for domestic abuse
 Post-Exposure Prophylaxis (PEP) and Hepatitis B vaccinations
The sexual health service sees approximately 25,000 patients a year with the highest
levels of attendance falling within the 15-24 age range.
Within each authority there are individual examples of coproducing creative solutions
to support future services such as the Intergenerational Community Centre in
Aberaeron. This is spearheaded by the third sector (Ray Ceredigion & Age Cymru),
and the introduction of the ‘Signs of Safety’ outcome measurement framework when
working with families which is a strengths-based and safety-focused approach to
child protection work grounded in partnership and collaboration.
The following table provides a breakdown of the numbers of children supported

through a range of statutory and non-statutory services across the region.
Figure 8:4 Numbers of children supported through a range of statutory and

non-statutory services
Statutory Children’s Carmarthenshire Ceredigion Pembrokeshire
Services
Referrals to Social Services 1,473 531 1262
(2015/16)
Rate of Looked After Children 58 (n=215) 62 (n=80) 46 (n=126)
(LAC) per10,000 child
population as at 31/3/16
Number of LAC placed by 166 24 59
other LAs as at 31/3/16
Rate on Child Protection 24 (n=88) 46 (n=55) 24 (n=60)
Register (CPR) per 10,000
child population as at 31/3/16
Rate of Children In Need (CIN) 250 (n=930) 360 205 (n=505)
per 10,000 child population as (n=450)
at 31/3/15
(2016 comparative data not
yet available)
Adoption activity 2015/16
67
Number of Adoption Orders 25 4 3

granted
Placed ready for adoption 12 1 6
Number of approved Adopters 8 6 5
Post adoption support 45 26 27
Adoption breakdowns 0 0 0
Foster placements 2015/16
Within LA boundary 163 50 88
Outside LA boundary 12 12 5
Other community placements 2015/16
Independent living 6 0 1
Residential employment 0 0 0
Residential placements 2015/16
Looked after and placed in 0 0 0
secure unit
Placements in homes and 2 1 8
hostels subject to Children’s
Homes Regulations
Placements in other hostels 0 1 0
and supportive residential
settings
Placements in residential care 0 0 0
homes
NHS/ Health Trust or other 0 1 1
medical establishment
providing medical or nursing
care
Family centre or mother and 0 0 0
baby unit
Youth offender institution or 0 0 0
prison
School placements 2015/16
Residential schools, except 1 0 2
where dual registered as a
school and children’s home
Non-statutory/ preventative services
Family Information Service 2015/16
Contacts – Telephone/email 641 600 300
enquiries
FIS Website visits 15,098 54,725 47,787
Flying Start 2015-16
Numbers of children worked 1570 525 1226
with
% assessed as medium and 41% 37% 41%
high need
Families First 2015-16
Individuals accessing FF 8626 1732 2500
funded projects
Numbers of JAFFs completed 1162 399 205
68
TAF requests for support 476 163 463

TAF cases (closed during the 285 122 203
year)
Youth Justice Service – Preventions
Number of NEW prevention 30 148 33
cases
Number of ACTIVE prevention 35 66 22
cases
Elective Home Education
(EHE)
Numbers known to be in EHE 196 123 119
Children with a disability
Children receiving continuing 11 6 12
care funding
Children receiving a service 135 29 105
from Children’s Community
Nursing Service
Source: Various local data

As outlined above, the range and level of care and support currently being provided
aims to address identified need and offers a range of interventions at varying levels
of intensity, with the aim of preventing escalation and delivering positive outcomes to
children and young people. There is room for confidence that the required statutory
services are in place to meet the needs of the most vulnerable children and young
people and to keep them from harm.
The development of fit for purpose services right across the range is, however, an
ongoing journey and there are a number of areas in which further improvement can
be made. These are set out below against the core principles of the Social Services
and Wellbeing (Wales) Act.
Voice and control

 Enhancing assessment and care planning processes to ensure that citizens have
a genuine voice over outcomes and support needed to achieve them
 Ensuring that children, young people and their families are able to access
services through their language of choice and that the ‘active offer’ of services
through the medium of Welsh is always available

 Further development of information, advice and assistance to meet the
requirements of the Social Services and Wellbeing (Wales) act and direct children
and young people to appropriate care and support within communities
 Continuing to strengthen the focus on prevention across the range of services, to
build resilience of children, young people and families, reduce reliance on
statutory services and facilitate de-escalation from intensive support where
appropriate. It will also be important to have robust mechanisms in place to
assess the impact of these new approaches
69
 Improved working with community-based organisations to support children and

young people in the development of life skills
 Refocusing social work practice and resources towards early, direct interventions
that strengthen the resilience and functionality of families
Wellbeing
 Reducing the number of placement moves for LAC and reducing reliance on
residential care
 Improving access to mental health services at an early stage, thus preventing the
need for referral to CAMHS services. There continue to be significant numbers of
young people who require psychological support (intensive or remedial
intervention) although there remains very limited provision. It will also be
important to improve joint planning between CAMHS and learning disability
services to ensure equitable service provision for children with neuro-
developmental conditions. The ‘Together for Children’ programme provides a
mechanism for this
 Enhancing accommodation and meeting accommodation support needs of young
people who are care leavers (including those leaving residential care) and
following custodial sentences. Local initiatives in place to improve arrangements
need to be consolidated moving forward
 Improving the support offered for family relationships, particularly for new parents
or parents who are experiencing stress due to other factors such as imprisonment
or disability. This will be instrumental in reducing the risk of domestic abuse or
other offending behaviours (Welsh Government, 2016)
 Increasing the level of support available for child victims of sexual abuse; a recent
study also suggested gaps in capacity in this area across Wales (Allnock et al,
2015)
 Achieving better integration between children’s services, mental health and
learning disability to address specialist needs of specific children and young
people
 Improving access to child sexual health services
Co-production
 Developing community-based, user-led services
 Developing consistent methodology such as Signs of Safety to underpin care and
support across the region
 Developing a consistent, outcomes-based performance framework for children
and young people’s services across the region
 Developing links between Integrated Family Support Services (IFSS) and other
council services such as adult care and housing as well as community-based
services, to help families back to independence and enable them to function
effectively within their communities
 Reconfiguring commissioning processes for high cost, low volume care and
support packages for children with complex needs are needed to ensure best
outcomes for service users and improve financial efficiency. The possibility of
developing new services on a regional basis should also be explored
70
Opportunities should be taken to take these areas forward in partnership across the
region; thereby ensuring consistency of provision and enabling a ‘once for West
Wales’ approach wherever possible. The regional partnership arrangements provide
a mechanism for this and for sharing of effective practice and approaches as they are
developed. Shared strategic challenges such as improving services while budgets
are being reduced, workforce development and delivering effective services in a
highly rural area will also benefit from a consistent approach across the region.
These should be considered as the regional Area Plan is developed in response to
this assessment.
Existing strategies such as the ‘Together for Children and Young People’ strategy for
child and adolescent mental health in Wales and Child Poverty Strategy for Wales
(Welsh Government, 2015) will be reviewed and refocused as appropriate to ensure
delivery of the identified areas for improvement.
71
8.6. References
Allnock, D., Sneddon, H. and Ackerley, E. (2015). Mapping therapeutic services for
sexual abuse in the UK in 2015. Luton: The International Centre: Researching Child
Sexual Exploitation, Trafficking and Violence, the University of Bedfordshire
Careers Wales. (2015). Destinations – by Local Authority [online]. Available at:

http://www.careerswales.com/prof/server.php?show=nav.3850
Daffodil Cymru (2014). Population by age: population aged 0-25, by age, projected to
2035 [online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1002&PHPSESSID=2b7me5n71
4paqi0683jjuup840&at=y&sc=1&loc=1
Institute of Public Care (n.d) Children’s Services, Shaping the whole continuum of
need [Online]. Available at: http://ipc.brookes.ac.uk/what-we-do/childrens-
services.html
People and Work Unit (2016). Complex Needs, Transition and Vulnerable Persons
Project – Market Position Statement. Available at:
Public Health Wales (2015). Adverse Childhood Experiences and their impact on
health-harming behaviours in the Welsh adult population. Available at:
http://www.cph.org.uk/wp-content/uploads/2016/01/ACE-Report-FINAL-E.pdf
United Nations (1989). Convention on the Rights of the Child. Treaty Series, 1577, 3.
Available at: https://www.unicef.org.uk/what-we-do/un-convention-child-rights/
Welsh Government (2015). Child Poverty Strategy for Wales. Available at:
http://gov.wales/docs/dsjlg/publications/150327-child-poverty-strategy-walesv2-en.pdf
Welsh Government (2015). Together for Children and Young People: Framework for
Action. Available at:
http://www.wales.nhs.uk/documents/Framework%20For%20Action.pdf
72
West Wales Population Assessment Health and Physical Disabilities
9. Health and Physical Disabilities

This report considers the needs of the population aged between 18 and 64 who live
in West Wales. A significant proportion of people in this age group will not be
accessing care and support directly to address specific needs. However, they will
benefit from general public health information and programmes aimed at encouraging
healthy lifestyles and reducing risks to their health brought about by factors such as
smoking and obesity. More generally, adults in Wales will also benefit from combined
approaches across sectors and within communities to improve the social, economic
and cultural wellbeing of Wales in response to the Wellbeing of Future Generations
(Wales) Act 2016.
Where people within this age range have specific needs because of physical
disability or chronic health conditions, proportionate, person-centred and responsive
care and support may be required to help them achieve positive personal outcomes
and live as independently as possible.
The report identifies a range of ‘accelerating factors’ within people’s environments

that might increase the likelihood of them developing an ongoing health condition, or
aggravate the effects of existing conditions, and against which mitigating action
should be taken. These include unemployment, low wages and poor housing
conditions.
Effective promotion of public health, targeted care and support for those with specific
needs and more general support for people particularly at risk should combine to
optimise the quality of people’s lives and their participation within their communities.
Supporting people to live active and healthy lives will reduce their needs for care and
support and lead to improved outcomes at an individual and community level. The
contribution of care and support services must be complemented by a range of
collaborative approaches to improve people’s social, economic, environmental and
cultural wellbeing.
Public Health has an important role in providing the population with general
information and advice on healthy life choices and support in areas such as diet and
smoking cessation. This needs to start in the early years but should be sustained
where possible across the range of age groups.

There are currently 219,606 people aged between 18 and 64 in West Wales. This
equates to around 70% of the adult population across the region, with the proportion
being slightly lower in Pembrokeshire at 68% and that in Carmarthenshire and
Ceredigion standing at 70% and 71%, respectively.
Of those adults aged between 18 and 64, 1,679 people are registered with a physical
disability and a further 1,744 are registered as having physical and sensory
73
disabilities. Together this represents around 1.1% of the total 18-64 population, which
is in keeping broadly with the Welsh average of 1.02.
Proxy figures suggest that significant numbers of people within this cohort of the
West Wales population experience one or more ‘accelerating’ factors which could
result in increased need for care and support. For example:
 1,010 adults are in receipt of Incapacity Benefit or Severe Disability Allowance,

10.3% of the Wales total
 16,740 adults are entitled to Disability Living Allowance or PIP (personal
independence payment), representing 12% of the all-Wales figure
 3.14% of people between 18 and 64 do not have central heating (1.97% in
Carmarthenshire, 3.47% in Pembrokeshire and 5.5% in Ceredigion), compared
with a Welsh average of 1.84%; and
 Among people living with severe health conditions 9,480 are in receipt of
Employment Support Allowance (which is 0.4% of the Wales 18+ population) .
(Daffodil Cymru).
Neurological conditions are the most common cause of serious disability and have a
major, but often unrecognised, impact on health, social services and on people’s lives
(Hywel Dda University Health Board, 2015).
 25% of people aged between 16 and 64 with chronic disability have a neurological
condition
 33% of disabled people living in residential care have a neurological condition
 10% of visits to Accident and Emergency Departments and 19% of hospital
admissions are for a neurological problem
 7% of GP consultations are for neurological symptoms
 In West Wales there are:
 727 people living with Muscular Sclerosis
 723 living with Parkinson’s disease. 80% of people with Parkinson’s disease
will develop dementia or experience cognitive decline
 2,934 adults with Epilepsy on GP registers
 223 admissions for headaches for people under 65
 31 people known to have Motor Neurone Disease
 247 people attended Rookwood Welsh Spinal Cord Injury Rehabilitation
Centre in Cardiff with spinal injury in the last 10yrs
 Approximately 130 people admitted to hospital with head injury every year. Of
these on average, 30 people per year require admission to a regional centre
due to the significance of the presentation. In addition 10 people have anoxic
brain damage every year in HD
 Approximately 710 people living with cerebral palsy. For many this includes
not only physical disability but also a learning disability and may result in
significant care needs
Of those adults in West Wales living with a limiting long term illness, only 7.5% fall
within the 18-64 age range. The total figure of those with a life limiting illness in West
Wales is 23,656 and is predicted to decrease by 4% by 2030, with the most
significant drop of 9.9% predicted in Ceredigion. This is reflective of general
population trends, which predict a fall in the numbers of adults aged between 18 and
74
64 in general. However, the expected decrease in West Wales is significantly greater

than in Wales as a whole, which stands at 0.7% (Daffodil Cymru).
The following tables provide further details of health related lifestyle factors in the 18+
population.
Figure 9:1 Adults who reported health related lifestyles
Observed percentage of adults who reported being overweight or obese, persons aged 16-
44 and 45-64, Hywel Dda UHB and local authorities, 2013-2015
Aged 16-44 Aged 45-64

Percentage Estimated count* Percentage Estimated count*
Wales 49.2 544,900 67.7 550,200
Hywel Dda UHB 48.1 60,200 68.9 72,400
Ceredigion 42.5 11,900 63.3 12,200

Pembrokeshire 49.2 18,700 67.9 23,300
Carmarthenshire 50.1 29,800 71.5 36,800
Produced by Public Health Wales Observatory, using MYE (ONS) & WHS (WG)
*Rounded to nearest 100
Observed percentage of adults who reported smoking, persons aged 16-44 and 45-64,
Hywel Dda UHB and local authorities, 2013-2015
Aged 16-44 Aged 45-64
Wales 25.1 279,000 21.0 170,800
Hywel Dda UHB 23.3 29,200 18.5 19,500
Ceredigion 22.6 6,300 17.3 3,300

Pembrokeshire 21.3 8,100 19.1 6,600
Observed percentage of adults who reported not meeting guidelines for fruit and
vegetable consumption, persons aged 16-44 and 45-64, Hywel Dda UHB and local
authorities, 2013-2015
Aged 16-44 Aged 45-64

Wales 69.1 766,300 66.9 544,000
Hywel Dda UHB 65.4 81,900 63.1 66,300
Ceredigion 60.8 17,000 64.0 12,400

Pembrokeshire 66.6 25,300 61.2 21,100
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9.3. Current and Future Care and Support Needs

Supporting people to live active and healthy lives will reduce their needs for care and
support and lead to improved outcomes at an individual and community level. The
following chart sets out a range of factors which can affect an individual’s wellbeing,
of which formalised care and support represents a small proportion.
Figure 9:2 The Determinants of Health.
Source: Dahlgren and Whitehead, 1992
The contribution of care and support services must be complemented by a range of

collaborative approaches to improve people’s social, economic, environmental and
cultural wellbeing as required by the Wellbeing of Future Generations (Wales) Act
2016.
Public Health has an important role in providing the population with general
information and advice on healthy life choices and support in areas such as diet and
smoking cessation. This needs to start in the early years but should be sustained
where possible across the range of age groups.
More generally, a range of preventative measures within communities will help

ensure that individuals can take care of themselves, access low level support when
needed and remain independent for as long as possible. Examples of this include:
 Information, advice and assistance about universal and prevention services,

including how to access these services, must be available in formats and venues
that are appropriate to this cohort’s communication needs and preferences
 Effective information, advice and assistance to maximise income and access
employment opportunities and benefits
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 Training and further education to improve probablility of successfully entering

employment
 Access to a range of sport and exercise facilities/programmes that are tailored to
meet specific needs to support good health and wellbeing
 Support to access activities and services within communities that counteract
socio-economic deprivation and maximise engagement (including volunteering);
 Appropriate transport provision, especially in rural areas
 Where appropriate, access to mental health services to improve wellbeing
through diagnosis, assessment and care planning
People with chronic, long term health conditions and physical disabilities will have
specific care and support needs. Given the greater preponderance of these
conditions in older age groups, it is important that services are available to younger
adults and responsive to meet their particular needs. In keeping with the
requirements of the Social Services and Wellbeing (Wales) Act and the expressed
need of individuals, these services need to retain a preventative approach, helping
people to support themselves without the need for long term care and support.
Sometimes this will be about signposting people to ‘low level’ services run within their
communities, others may need an intensive intervention in the short term to prevent
escalation and the need for longer term care. In all instances it is vital that people are
supported in achieving their desired personal outcomes in a proportionate and
dignified way. Early identification of conditions and anticipatory care is vital to
improve people’s health and wellbeing.
Examples of support needs for this section of the population include:
 Support at home to maintain independence, including assistive technology such

as telecare and telehealth (including those that link individuals with clinicians),
adaptations, equipment and aids and assistance with personal care
 Links to groups within the community providing support for people with particular
conditions; and
 Step up and down beds and other intermediate care options such as occupational
therapy and reablement, to avoid admission and support safe discharge from
hospital to provide support when needed
In many cases of complicated health conditions or physical disabilities, specialist

acute provision will be required, although again where possible short-term care and
support should be provided to help people optimise their self care. For others,
residential support in independent/ supported living environments (including extra
care) might be appropriate. In all such cases health, social care and other
professionals should work together and with individuals to ensure service users have
a genuine voice in relation to both their desired outcomes and their choice of service
provision.
9.4. Current Care and Support Provision

There are a range of services and support available to the adult population to help
them lead healthy and fulfilled lives; although a significant degree of responsibility for
this falls on the individual and responsibility for services and support extends well
beyond health and social care.
77
The following table gives an indication of the numbers of people aged 18-64 in
receipt of care and support services.
Figure 9:3 Numbers of people aged 18-64 in receipt of care and support
services
18-64 18-64
18-64 In Receipt Of 18-64 18-64 18-64
Supported Receiving 18-64 18-64
Support Receiving Direct Home
in the residential Equipment Adaptations
2014-15 Services payments care
community services
Wales 8509 8139 370 4742 2031 1471 2275

West Wales Region 959 925 34 493 133 287 219
Carmarthenshire 454 437 17 295 .. 135 112
Ceredigion 134 128 6 19 20 49 21
Pembrokeshire 371 360 11 179 113 103 86
18-64 In Receipt of
Supported Receiving
Support as a % of Receiving Direct Home
in the residential Equipment Adaptations
18+ In Receipt of Services payments care
community services
Support
Wales 17% 19% 5% 21% 29% 55% 13%
West Wales Region 14% 17% 3% 17% 30% 64% 10%
Carmarthenshire 12% 15% 2% 17% .. 71% 9%
Ceredigion 24% 29% 6% 26% 34% 72% 14%
Pembrokeshire 15% 17% 3% 16% 29% 54% 10%
Source: Stats Wales
General services available to promote self-care and wellbeing include:
 Universal services and amenities within the community

 Prevention and early intervention services including information, advice and
assistance
 Third sector provision including a wide range of facilities including transport, social
activities, help at home with domestic tasks such as finance management
gardening and cleaning and various targeted support groups such as carers’
support; and
 Leisure services, which can where appropriate be accessed via the National
Exercise Referral Scheme (NERS) which is in place across the region
For those with chronic and long term conditions and physical disability, a range of
services are provided:
 Chronic conditions management through district and specialist nurses

 Social services support in residential settings and in the community
 Community-based support to reduce risk of deterioration and promote
independence
 High level support through the provision of assistive technology, equipment,
adaptations, direct payments and home care; and
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 Advocacy services to help people make informed decisions about how their needs
can be met and to support or improve independence
People with neurological conditions can receive a range of specialist neurological

services within community settings or hospital. Acute medical inpatient care and
generic rehabilitation services are provided from four District General Hospitals with
support of community hospitals, with a neurological service provided by Abertawe
Bro Morgannwg University Health Board.
Health and LA Leisure services work together to provide targeted intervention for
those who are referred by GPs onto the National Exercise referral scheme. This
produces good outcomes and many of these participants go on to regular exercise
programmes. For example, Ceredigion had 386 referrals in 15/16 of which 65% were
aged 17-65, and in Pembrokeshire there were 608 referrals of which 66% were aged
17-65. Leisure centres also provided support to those with: Stroke, Cardiac, Falls,
Back Care, Pulmonary, Cancer, Weight management, Mental Health and Antenatal
Care.
People with health and physical disabilities are provided with a range of services to
improve or help maintain their independence levels and quality of life.This support
includes: occupational therapy support with assessments, equipment and aids and
referrals for disabled facilities grants and adaptations. Leisure services also provide
exercise and sports programs designed to benefit those with health and physical
disabilities through provision at leisure and sports centres.
General and universal services such as information, advice and assistance and
advocacy, third sector support groups, supported employment, education and training
opportunities are also on offer. Day care provision at day centres and where required
in other settings provide opportunities for this cohort and support carers so they can
benefit from a break from caring duties.
The range of services available include:

 Stop Smoking Wales
 NERS
 Provision of equipment from the Joint Equipment Store
 Disabled Facility Grants
 Reablement including Occupational Therapy and Physiotherapy Services
 Telecare
 Meals on wheels
 Daycare
 Respite care
 Minor adaptation provision
 Falls prevention/fall clinic
 Disabilities sport wales development officer
 50+ Network
 Blue Badge Scheme
 Disability Forum
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 Rally Round App which is being piloted and is a free online service which makes
it easy for friends and family to come together and help a loved one stay safe and
well at home

Although a drop in the number of people falling within this thematic group is predicted
in the medium term, and the current number of people with specific care and support
needs is small, it is vital that appropriate provision is in place to promote wellbeing
and independence and prevent escalation of need. The following gaps and areas for
improvement have been identified and are set out below against the core principles
of the Social Services and Wellbeing (Wales) Act.
Voice and Control

Areas for improvement include information, advice and assistance to ensure that
people are signposted to relevant support within their community, advocacy, and
improved choice in the format and range of services available.

Enhancing community based support to prevent isolation and promote independence
is common to all themes including this one. In addition,
HDUHB has identified a number of areas for improvement to help people adopt
healthy lifestyles and prevent ill health:
 High population awareness of the health harms of smoking and alcohol

consumption above recommended guidelines, the benefits of physical activity
and healthy eating and of sources of help for lifestyle change
 Increased numbers of people who stop smoking
 Increased numbers of people who achieve a healthy weight or, by losing a
clinically significant amount of weight (5-10% body weight), move in that direction
 Increased numbers of people undertaking sufficient physical activity to benefit
their health
 Reduction in alcohol consumption above recommended guidelines; and
 Effective identification and treatment of risk factors associated with health
inequality and heart disease
To achieve this, resources are being targeted at the following priorities:
Reducing smoking prevalence and inequality can be achieved through:

 Developing a clear understanding of the social and economic pressures in
communities, e.g. deprived communities and age groups where smoking rates
are highest
 Supporting intensive targeted interventions to specifically address smoking
cessation uptake with target groups
 Advocating increased action at the population level including plain packaging and
reducing second-hand smoke exposure in children; and
 Ensuring that every contact with health services is used to both prevent smoking
uptake and encourage cessation
80
Reducing the proportion of the population who are overweight and obese
through:
 A better understanding of why individuals are likely to become overweight or
obese in early adulthood and how this can be prevented
 Ensuring effective interventions and pathways for prevention, treatment and
management of childhood obesity are routinely available and systematically
implemented
 Supporting intensive targeted interventions to specifically address weight and diet
issues within the deprived communities; and
 Advocating increased action at the population level to ensure healthy food is
available to all
Increasing physical activity levels especially in older population groups

through:
 Better understanding of why individuals stop exercising as they get older and
how this can be prevented
 Supporting interventions within targeted age groups to increase participation in
physical activity
 Better understanding the motivations and barriers for undertaking physical
activity; and
 Considering interventions within a settings approach
Reducing alcohol consumption and binge drinking through:

 Better understanding the social changes that cause a demographic shift in
alcohol prevalence
 Advocating increased action to reduce the marketing and promotion of alcohol for
home consumption, e.g. multi-buy deals, minimum unit price of alcohol; and
 Increasing awareness of harmful alcohol consumption in less deprived areas
Further health related objectives are;

 To increase survival rates for cancer through prevention, screening, earlier
diagnosis, faster access to treatment and improved survivorship programmes
 To improve the early identification and management of patients with diabetes,
improve long term wellbeing and reduce complications
 To improve the support for people with established respiratory illness, reduce
acute exacerbations and the need for hospital based care
 To improve the mental health and wellbeing of our local population through
improved promotion, prevention and timely access to appropriate interventions
 The measurement of risk factors for the development of cardiovascular disease
and lifestyle improvement programmes are also critical to improve the prevention,
detection and management of the disease
 Establishing structured community Neuro Rehabilitation in Hywel Dda to
compliment commissioned neurological as well as local generic services
Wellbeing
 Raising awareness of the wellbeing impact of leisure and cultural activities and
what’s available especially from the third sector by having a directory or database
of services and support
81
 Domiciliary care and supported living services will have to evolve to support
increased use of assistive technology, such as telecare
 Day opportunities that support people with specific health and physical needs
 Greater flexibility to deliver step up and down provision to respond to changing
needs and a greater focus on mental health provision
 Building community resilience by encouraging a culture of ownership and
responsibility for individuals’ and the community’s own health and wellbeing and
support for example through local support groups for people with chronic
conditions
 Support for and improved awareness of those with mental health conditions
 Improved internet/ broadband access and public and community transport
 Help with low level tasks around the house
To promote a culture of care for patients, carers and the public and a culture of care
for all staff, NHS Wales developed and adopted a Health and Wellbeing Charter in
May 2013. The charter encourages the health and wellbeing of all its staff and
recognises that staff act as role models to the community they serve in promoting
and preventing ill health.
Co-production
A number of the services that people between 18 and 64 with specific needs require
tend to be available to, and shaped around the needs of, older people. It is vital that
they are co-developed further to ensure that younger adults have access to the care
and support needed for them to lead fulfilled lives and have a greater say in the
development of services.
The HDUHB Together for Health Neurological Delivery Plan 2013 – 2017 priorities for
2014 – 17 include reviewing and revising clinical/care pathways in order to deliver
well co-ordinated care that feels integrated from a user perspective (Hwyel Dda
University Health Board, 2015).
Co-operation, partnership and integration

 Strengthening partnership working for Neurological services between Regional
and local services, Statutory and third sector organisations, and Clinical and user
groups
 Strengthening transition arrangements between children and young people’s
services and adult services
82
9.6. References
Daffodil Cymru (2014a). Population aged 18 and over, receiving ESA, Incapacity
Benefit, or Severe Disablement Allowance, as at May 2015. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1098&PHPSESSID=tkcbe3j5tj20
n9hp3b6v3qt8c2&at=a&sc=1&loc=1&np=1
Daffodil Cymru (2014b). Population aged 18 and over predicted to have a limiting
long-term illness, by age and gender, projected to 2035. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1046&PHPSESSID=86j1afe7vb
mmhmuud06laf7u91&at=a&sc=1&loc=1&np=1
Dahlgren, G. and Whitehead, M. (1992). Policies and strategies to promote equity in

health. Copenhagen: World Health Organisation
Hywel Dda University Health Board (2015). Together for Health Neurological Delivery
Plan 2013 – 2017. Version 2. Available at:
http://www.wales.nhs.uk/sitesplus/862/document/266052
Stats Wales. (2016). Adults receiving services by local authority, client category and
age group. [Online]. Available at: https://statswales.gov.wales/Catalogue/Health-and-
Social-Care/Social-Services/Adult-Services/Service-
Provision/adultsreceivingservices-by-localauthority-clientcategory-age
83
West Wales Population Assessment Learning Disability and Autism
10. Learning Disability and Autism

There are several ways in which the term ‘learning disability’ can be defined, however
for the purposes of this assessment, Learning Disability is defined as:
 A significantly reduced ability to understand new or complex information and to

learn new skills (impaired intelligence)
 A reduced ability to cope independently (impaired social functioning); or
 These are in evidence before adulthood and have a lasting effect on
development
The way in which the needs of people with a Learning Disability are met has changed
over the last twenty years. People who would historically have been placed in
institutional care are increasingly being supported to live in their communities. Health
and social care services along with the third sector collaborate to maximise the
independence and potential of those who use our services.
Although Autism is not a learning disability it has been included in this section as
services for people on the spectrum are generally provided from within learning
disability teams or community mental health teams and NICE guidance (2008, 2012)
provides standards for provision of services.

In 2015 there were an estimated 1,483 people over the age of 18 with a moderate or
severe learning disability in the West Wales region. This represents just under 0.5%
of the total adult population, which is comparable with the picture across Wales.
The breakdown across the constituent parts of the region is as follows:
Carmarthenshire: 713
Ceredigion: 305
Pembrokeshire: 465
The rate of incidence within the adult population stands at approximately 0.5% in
each of the county areas, in line with the regional average.
This regional total is predicted to rise to 1,571 by 2030, although as a percentage of

the total population the position is expected to remain largely the same.
An increase of 35 in the total number of adults with a moderate or severe learning

disability in Carmarthenshire is predicted over the same period, whilst in
Pembrokeshire and Ceredigion numbers are expected to remain the same. This
means the proportion of adults with a learning disability will decline slightly in those 2
areas (although the change will be negligible), whilst in Carmarthenshire it will remain
about the same.
84
Of note is the expected significant rise in the numbers of people aged 75 and over
with a moderate or severe learning disability, estimated to increase by 33% by 2030.
Current numbers and projections for each part of the region are as follows:
Figure 10:1 Numbers (current and predicted) of people aged 75 and over with a
moderate or severe learning disability
2015 2030
Carmarthenshire 38 57
Ceredigion 16 23
Pembrokeshire 27 40
Region 81 122
Source: Daffodil Cymru
Whilst the predicted rise is less than that for Wales as a whole over this period, there
are clear implications for care and support services as older people with learning
disabilities encounter other age-related conditions, are less likely to receive support
from family and friends and are therefore more likely to present with more complex
needs than they would at a younger age.
Autism is a pervasive developmental disorder that is thought to affect 1 in 100 people

in the population (Baird et al, 2006). The research shows that there is a high rate of
co morbidity between Neuro-developmental disorders (ND) e.g. Autistic Spectrum
Disorders (ASD)/Attention Deficit Hyperactivity Disorder (ADHD), and also of other
mental health disorders. Research suggests that based on the population of Hywel
Dda UHB:
 1% ASD, 2-4 % ADHD

 70% ADHD/ASD co-morbidity
 40% ASD anxiety disorder
 90 % prisoners mental disorder including ND
 30% IP eating disorders have ASD
 40% specialist substance misuse ND
The current demand for the ASD diagnostic service is based on a pattern of referral
which is likely to be an underestimation of the actual population’s need. Local data
on referrals for ASD diagnostic services shows that for the period January 2013 –
end of November 2015 there were 265 referrals. However, since April 2016, the
service has received 99 referrals.
Data relating to the incidence of autism is not collected routinely by all local
authorities. However, open cases for people with autism in Ceredigion and
Pembrokeshire in November 2016 are as follows:
85
Figure 10:2 Open cases for people with autism in Ceredigion and
Pembrokeshire 2016
Caseload numbers Caseload numbers
(18 years +) (open to transition)
Ceredigion County Council 22 18
Pembrokeshire County Council 91 22
Source: Local data
Data is not available for Carmarthenshire.

People with learning disabilities are likely to require a range of care and support,
depending on the nature and complexity of their individual needs. Depending on
individual circumstances, needs will include support to help people participate fully in
their local communities (for example through education, training, volunteering and
access to employment), day opportunities, (for example access to social activity
centres and programmes), general health care, residential care and supported
accommodation to enable people to remain living independently within their
communities.
There is a growing recognition that, in common with other groups needing care and
support, delivery models for learning disability need to move away from traditional,
risk-averse approaches which result in an over-reliance on options such as
residential care. Such approaches tend to ‘lock’ people into expensive, passive forms
of care which do little to promote independence and are not suited to helping them
build skills and capacity for more active participation in society and, thereby, achieve
more positive personal outcomes. The concept of the ‘progression model’ of care and
support for people with learning disabilities has emerged, described by the Social
Services Improvement Agency (SSIA) (2014) as
‘the ability to promote independence through strength-based assessment, clear

development plans, positive risk taking and outcome based review to transform
services.’
Across the region, numerous mechanisms are in place for engagement with users
and carers to obtain their perspective on the care and support they would like to
receive. Examples include:
 Engagement events facilitated by Carmarthenshire People First in October 2015

to inform the development of Carmarthenshire County Council and Ceredigion
County Council’s Equality Strategies, focusing specifically on the needs of people
with a learning disability
 Consultation in support of the development of Pembrokeshire County Council’s
Strategy for People with Learning Disabilities in May 2016
 Ongoing dialogue between service commissioners, providers and users and
carers through local stakeholder groups in each county area
86
A clear message is coming from service users and carers; they want support to help
them optimise their independence, access employment and benefit from volunteering
opportunities. People also say they want greater opportunities for training and
development and to be able to make new friends and participate in social activities.
These clearly reflect the principles underpinning the progression model of care and
support.
In Pembrokeshire a set of wellbeing outcomes has been co-produced with users and
carers. These send clear messages in terms of the kinds of care and support which
should be provided now and in the future and are set out below:
 Improved Health – ‘I am as healthy as I can be and can easily visit doctors,

dentists, hospitals and other health services’
 Productive and independent lives - ‘I am able to live a fulfilled life’
 Freedom from discrimination and harassment - ‘I have an equal right to live free
from fear, discrimination and prejudice’
 Personal Dignity – ‘I feel valued by others’
 Exercise choice and control – ‘I have the same life chances as other adults.’
 Part of the Community – ‘I can participate as a full and equal member of my
community.’ ‘I can live in a home of my choice by having the right support in
place’
 Maintain and develop social and family ties – ‘I have the same opportunities to
maintain relationships as other adults’
These outcomes are forming the basis of a Learning Disability Charter, which is
currently in draft. Pembrokeshire County Council’s Learning Disabilities Strategy
(2016) is based on a ‘Circle of Support’ shown below, which articulates the types of
support which are needed, and which should equally apply across other parts of the
region:
Figure 10:3 Circle of support for learning disability
Source: Pembrokeshire County Council, 2016
Broad aims under each of the segments in the Circle of Support are as follows:
Community connections/ Creative solutions: Growth of local community solutions

such as social enterprises, cooperatives, user-led and third sector services to provide
87
opportunities for people with a learning disability to contribute to society and develop
skills.
Communication and information: Provision of Information, Advice and Assistance

as required under the Social Services and Wellbeing (Wales) Act, with particular
regard to the specific communication needs of this service user group.
Social care and support: Acknowledging the need for ongoing support for some
people with a learning disability, provision of supported living models which enable as
many of them as possible to live within and contribute to their local communities.
General health care and treatment: Improved access for people with a learning
disability to generic health care services, acknowledging that there is an above-
average incidence among this service user group of conditions such as epilepsy,
diabetes and cardiac disease. Encouraging take-up of annual health checks.
Transitions and family support: Ensuring that children and young people who have
received care and support, and those that have not, are known to social services and
that appropriate measures are in place to arrange appropriate support once they
reach adulthood.
Support for Carers: Ensuring that those caring for people with a learning disability
receive appropriate information, advice and support on options available and
entitlements, etc.
Voice, choice and advocacy: Ensuring people with a learning disability have access
to high quality advocacy services so that they can make informed choices and be
supported appropriately in achieving personal outcomes.
Personal growth, including education, training, employment and volunteering:

Providing equitable access to further education and appropriate support in accessing
training and volunteering opportunities.
Environment, including transport and housing: Availability of transport links to

enable access to care, support and other services and appropriate housing to
facilitate independent and supported living.
Autistic Spectrum Disorder Diagnostic and Pre/post Counselling Service:

Improved recognition and diagnosis of people with Autistic Spectrum Disorder (ASD).
Housing: there are still significant numbers of people particularly in Carmarthenshire

under the age of 65 in residential care. A priority for the LA and Health Board is to
reverse this trend and develop housing options to prevent admission to hospital and
residential settings, facilitate discharge from hospital. There is need to jointly
commission a range of community accommodation options and services that offers
more choice and control for individuals using learning disability services.
88

A range of care and support services are in place across the region to support adults
with a learning disability to live fulfilled lives within the community. Whilst specific
care and support options vary across counties, current provision includes:
 Universal services: For example leisure centres, community centres, libraries,

adult education opportunities although it is recognised that these services do not
yet provide consistent equal access to people with LD
 Preventative services: Council grant funding supports the growth of alternative
community services that are co-produced with members of communities enabling
people to build upon their own individual strengths and resources. These include
good neighbour schemes, luncheon clubs, community enterprises,
community/voluntary services
 Specialist Health interventions : Consultant psychiatry, psychology, community
nursing, Speech and Language Therapy, Occupational Therapy and
Physiotherapy provide specialist interventions to adults with a diagnosed learning
disability both within in-patient and community setting
 Specialist Health Autistic Spectrum Disorder Diagnostic and Pre/post
Counselling Service: The current service consists of allocated sessions from a
locum consultant and a specialist practitioner
 Day Opportunities: Providing social contact and stimulation, reducing isolation
and loneliness, maintaining and / or restoring independence, offering activities
which provide mental and physical stimulation, providing care services, offering
low-level support for people at risk
 Pathways to employment: A range of local initiatives including FRAME,
Workways Plus, Stackpole Estate and ESTEAM in Pembrokeshire and
Opportunities Team and ‘Steps’ in Carmarthenshire. In addition national
programmes such as ‘Work choice’, run by the Department for Work and
Pensions, support those with lower level LD
 Respite provision: Short breaks/respites is a key commitment in recognition that
planned breaks are an essential part of supporting families
 Commissioned Services: Individually commissioned supported living
arrangements which enable people with learning disabilities to live in their own
tenancies with support at varying levels, and residential services which include
both the provision of accommodation and care on site, with care being available
24 hours per day. These include a regional Shared Lives service, managed for
the region by Carmarthenshire County Council and providing a route for people to
return to their communities and is an example of an alternative to traditional
residential services. Advocacy services are commissioned across the region; and
 Direct Payments: These provide another way for individuals to access a range of
opportunities by being able to choose who provides the services they need
Assessment and care planning for people with a learning disability is managed
through multi-disciplinary Community Teams for Learning Disability (CTLDs), in place
across the region and staffed by health and social care professionals. The teams also
work jointly with Disabled Children’s Teams and Transition Teams with occasional
involvement from age 14 upwards and undertaking assessment when a young
person in receipt of services reaches 17. Transition teams play a key role in
89
supporting the transfer of care needs between one service and another, and typically
between adult and children’s services.
The following table indicates the number of people currently being supported through
the CTLDs, and the type of support that is being provided (November 2016).
Figure 10:4 Numbers of people currently being supported through the CTLDs
People supported by the 505 306 422
Teams
People in residential care 98 76 88
People supported in the 407 230 334
community
Transition Team *
People in residential 10 9 16
Colleges
Transition team* in the
community
* Age based eligibility for transition varies across the counties.
Source: Local data
Data held by the Welsh Data Unit indicates that the reliance on residential care in
each of the three counties is above the Welsh average. Pembrokeshire currently
ranks third, Ceredigion sixth and Carmarthenshire eighth in Wales in relation to the
proportion of people with a learning disability receiving care and support that are
supported in this way.
The following figure identifies the wider position in relation to accommodation.

Although most people with a learning disability live at home with their families, 36%
live in homes of their own with a tenancy and receive domiciliary support (supported
accommodation). These arrangements are usually referred to as supported living or
supported accommodation. A further 1,000 people (11%) live in care homes that are
registered and inspected by the Council.
Figure 10:5 Where people with Learning Disability live
Source:
90

As evidenced by the summary of current provision in the preceding section, whilst
there is a clear direction of travel towards a range of care and support for people with
learning disabilities based on progression principles, there is more to do in
rebalancing the current emphasis on traditional solutions such as residential care.
A number of foundations are in place to drive further change. Key among these is a
regional Statement of Intent for Learning Disability Services (Mid & West Wales
Health and Social Care Collaborative, 2014) and Model of Care and Support (Mid &
West Wales Health and Social Care Collaborative, 2015), which have subsequently
been endorsed by all statutory partners in the region. The purpose of the Statement
of Intent is to provide a clear, shared strategic vision for learning disability services
and to articulate an integrated, regional approach to the transformation of services.
Predicated on the ‘progression model’, it identifies four regional aims as follows:
 To improve community resilience and enablement through choice, self- direction

and control for people with learning disabilities over decisions affecting their lives
 To commission services that strengthen quality and value for money across the
range of services provided for people with a learning disability
 To reduce health inequalities by increasing access to and uptake of universal
health, social care and wellbeing services for people with learning disabilities
 To build community resilience and capacity across a range of services that
support people with a learning disability
The development of fit for purpose services is, however, an ongoing journey and
there are a number of areas in which further improvement can be made. These are
set out below against the core principles of the Social Services and Wellbeing Act.
Voice and control

 Empowering people with a learning disability to decide who provides their support
and what form that support takes
 Development of an identifiable framework for service delivery that reflects
individual personalised care and local need

 Giving people access to low level support which they require to remain
independent for as long as possible, which may delay or reduce any further
support requirements
 Improving the recognition, diagnosis and the treatment and management of
people with Neurodevelopmental disorders including Autistic Spectrum Disorder
(ASD) and Attention Deficit Hyperactivity Disorder (ADHD)
Wellbeing
 Improve services for Adults with Neurodevelopmental disorders in order to
provide a high quality integrated model which includes availability of input from
highly specialist expertise and an ability to contribute to the evidence base for
service delivery
91
 Development of a defined model of care and support based on the principles of

the progression model
 Reduction in the number of children and young adults transitioning into residential
care
 Reducing health inequalities across a continuum of care (from accessing
mainstream health and social care services to specialist care, and prevention of
crisis and ill health)
 Reducing reliance on residential care and promoting opportunities for
independent living
 A continued shift from traditional day services to a model that offers choice and
variety, that is outcome and community based, supports access to employment
and volunteering, helps people realise individual aspirations and promotes social
inclusion
Co-production
 Increased access and availability of local housing and accommodation to enable
people with a learning disability to live as independently as possible, in a place of
their choice
 Strengthening pathways back to local communities following education, and
developing local education and work opportunities in communities and making the
necessary adjustments for people with a learning disability
 Placing an emphasis on building strong communities, in which people with a
learning disability have a sense of belonging and can contribute to the wellbeing
of fellow citizens. The development of social enterprise, cooperatives, user-led
and third sector services will be a key factor in this

 ‘Right-sizing’ existing packages of care to ensure they meet current needs and
facilitate personal development and increased independence, and that they are
cost-effective
 Maximising opportunities from regional collaboration, partnership and integrated
working to deliver high quality, cost effective services
 Regional collection and use of data to support future planning and commissioning
Strategic leadership from the Regional Partnership Board will be instrumental in

building on existing foundations and taking this agenda forward. Mechanisms such as
the Learning Disability Service Redesign programme recently launched by Hywel
Dda University Health Board will be key drivers in achieving the change required.
“Together we are committed to support people with individual needs live the
life they choose. By providing a range of flexible care and support services we
will ensure people with learning disabilities are as independent as possible and
connected with their local communities”
From Model of Care and Support, Mid and West Wales Health and Social Care
Collaborative (2015)
92
10.6. References
Baird, G., Simonoff, E., Pickles, A., Chandler, S., Loucas, T., Meldrum, D. and
Charman, T. (2006). “Prevalence of disorders of the autism spectrum in a population
cohort of children in South Thames: the Special Needs and Autism Project (SNAP)”.
The Lancet, 368 (9531), pp. 210-215.
Daffodil Cymru, 2014. People aged 18-64 estimated to have a moderate or severe
learning disability, projected to 2035. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1065&areaID=18&loc=18
Mid & West Wales Health and Social Care Collaborative (2014). Statement of Intent
for Learning Disability Services. Available at: http://www.wwcp.org.uk/documents/
Mid and West Wales Health and Social Care Collaborative (2015). Model of Care and
Support. Available at: http://www.wwcp.org.uk/documents/
NICE (2008). Attention deficit hyperactivity disorder: diagnosis and management,

clinical guidance 72. Available at: https://www.nice.org.uk/guidance/cg72
NICE (2012). Autism spectrum disorder in adults: diagnosis and management,

clinical guidance 142. Available at: https://www.nice.org.uk/guidance/cg142
Pembrokeshire County Council (2016). Learning Disability Strategy 2016-2021.

Available at:
http://www.pembrokeshire.gov.uk/objview.asp?object_id=13659&language=
Social Services Improvement Agency (2014). Transforming Learning Disability

Services in Wales [online]. Available at:
http://www.ssiacymru.org.uk/home.php?page_id=7049
93
West Wales Population Assessment Mental Health
11. Mental Health

This chapter considers the care and support needs of Adults aged 16 + with mental
health needs. The care and support needs of older people (aged 65+) with dementia
are addressed in the Older People’s thematic report.
According to the Mental Health Foundation (2015) in any year one in four of us
experience a mental health problem, yet three quarters of people with mental health
problems receive no treatment.
Many of us will require support with respect to our mental health throughout our lives
whether this is low intensity support for difficulties such as low level anxiety /
depression or longer term support.
Mental illness can develop from a number of factors including social traumas, illegal
drug use and genetic predisposition. Mental health does not discriminate and can
affect anyone often leading to debilitating conditions.
Early intervention is crucial and this can take the form of providing information or
referral to community or third sector services. Admissions to inpatient services may
occur in extreme situations, where the individual cannot be treated in the community
and presents a risk to themselves and / or others.
It has been estimated that the economic and social costs of mental health problems
in Wales is estimated to be £7billion a year (Cyhlarova, 2010).
In 2015-16, the WG ring-fenced £587m for mental health services across Wales – up
from £389m in 2009-10. Earlier this year, Government announced an additional
£15m of new funding is being made available for mental health services in Wales
every year.

In Wales, according to the Welsh Government Mental Health Strategy (Welsh
Government, 2012):

 1 in 4 adults experiences mental health problems or illness at some point
during their lifetime
 1 in 6 of us will be experiencing symptoms at any one time
 2 in 100 people will have a severe mental illness such as schizophrenia or
bipolar disorder at any one time
 Approximately 50% of people with enduring mental health problems will have
symptoms by the time they are 14 and many at a much younger age
 Between 1 in 10 and 1 in 15 new mothers experience post-natal depression
 9 in 10 prisoners have a diagnosable mental health and / or substance misuse
problem
94
 In Wales the number of people detained in police custody as a place of safety

under section 136 of the Mental Health Act 1983 decreased from 8,667 in
2011-12 to 6,028 6,028 2013-14. 2014-15 saw this figure decrease further
(Mental Health Foundation, 2016)
According to Rethink Mental Illness (2016) individuals with a severe mental illness
die on average 20 years younger than the rest of the population, predominatly due to
health related issues such as coronary heart disease, diabetes and some cancers.
This in part may be due to a poor diet, side effects of medication, poor monitoring of
physical health and life style factors. People with mental health needs are more at
risk of social exclusion and poverty and have poorer employment / education
prospects.
The following graph shows the percentage of people in the 3 counties aged 16 + who
are free from experiencing a common mental health disorder (2013-14) when
compared to West Wales and Wales. There are some small variations when
compared to the Wales percentage (74%).
Figure 11:0
Source: Welsh Government
Around 75% of people with a mental health issue have a common mental disorder
(which include depression, anxiety disorder, panic disorder, obsessive-compulsive
disorder and post‑traumatic stress disorder). The following chart shows the predicted
percentage change between 2015 and 2030 of people with a mental health disorder
in each of the counties. Carmarthenshire is expected to see the biggest percentage
changes across all disorders shown when compared to Ceredigion, Pembrokeshire
and Wales.
95
Figure 11:1 Predicted percentage change between 2015 and 2030 of people
with a mental health disorder
16+ With a Mental Disorder - % change 2015-2030

Pembrokeshire: two or more psychiatric… 3%
Pembrokeshire: psychotic disorder 3%
Pembrokeshire: antisocial personality… 4%
Pembrokeshire: borderline personality… 3%
Pembrokeshire: common mental disorder 3%
Ceredigion: two or more psychiatric… 3%
Ceredigion: psychotic disorder 3%
Ceredigion: antisocial personality disorder 3%
Ceredigion: borderline personality disorder 2%
Ceredigion: common mental disorder 3%
Carmarthenshire: two or more psychiatric… 8%
Carmarthenshire: psychotic disorder 8%
Carmarthenshire: antisocial personality… 9%
Carmarthenshire: borderline personality… 8%
Carmarthenshire: common mental disorder 8%
Wales: two or more psychiatric disorders 6%
Wales: psychotic disorder 6%
Wales: antisocial personality disorder 7%
Wales: borderline personality disorder 6%
Wales: common mental disorder 6%
Dementia in people aged less than 65 is described as early onset dementia, young
onset dementia or working age dementia. It is estimated that 1 in 1000 people in
Wales have early onset dementia. This figure is slightly higher in Carmarthenshire
and Pembrokeshire, and slightly higher still Ceredigion.
Figure 11:2 Percentage of people aged 30-64 with early onset dementia
% of 30-64 population with early onset

dementia
Pembrokeshire 0.064%
Ceredigion 0.069%
Carmarthenshire 0.064%
Wales 0.060%
0.050% 0.055% 0.060% 0.065% 0.070%
96
Source:Daffodil Cymru
The symptoms of dementia may be similar regardless of a person's age, but younger
people often have different needs, and therefore require some different support.
There is a wider range of diseases that cause early onset dementia and a younger
person is much more likely to have a rarer form of dementia. However, people under
65 do not generally have the co-existing long-term medical conditions of older people
– for example diseases of the heart and circulation. They are usually physically fitter
and dementia may be the only serious condition that a younger person is living with
(Alzheimers Society, 2015). The following chart shows the numbers of people with
early onset dementia in Pembrokeshire, Ceredigion, Carmarthenshire and Wales.
The Alzheimers Society predict a small decrease in the numbers of people aged 30-
64 with early onset dementia by 2035 NEED REF. The following graph shows how this
trend will affect the population in West Wales.
Figure 11:3 Predicted number of people aged 30-64 with early onset dementia
Suicide in people aged 15 + is also relatively rare however the following graph
suggests there is predicted to be a small increase in the numbers by 2035. Suicide
reaches its peak among males between the ages of 20-39 and for females between
the ages of 40-54 (Welsh Assembly Government, 2008)..
Figure 11:4 Predicted number of mortalities of people aged 15+ from suicide
97

A 2013 survey of attitudes towards mental health showed there is a need for a better
understanding of mental health issues (Opinion Research Services, 2014). The
survey suggests:
 1 in 7 believe that people with a mental illness can never recover

 1in 7 believe that as soon as a person shows signs of mental illness they
should be hospitalized
 1 in 4 people believe said that being around someone with a mental illness
can make them feel uncomfortable
 Nearly 1 in 10 believe that people with mental health issues should not be
given any responsibility
Organisations in West Wales are working in partnership to improve the health and
wellbeing gains for people who are, or have potential to experience, mental health
problems. This work is being driven through the Transforming Mental Health Services
Programme (TMHSP).
Consultation activities to inform the TMHSP have identified the following key care
and support needs for individuals with mental health problems:
 Improve access to care and support services with clear pathways into and
through services, including evenings and weekends
 Improve services and support for young people in transition;
Improve collaboration between statutory organisations,
including primary care, to respond to unscheduled
care needs
 Improve bed availability and management, and
develop community alternatives to hospital in a crisis
 Improve transport and conveyancing in relation to
the Mental Health Act;
 Improve services and support for people with
Autism and Autistic Spectrum Disorders (ASD)
 Develop a collaborative approach with the third sector to facilitate information,
advice and assistance that supports the development of population resilience
98
 Build upon awareness raising initiatives that help tackle the stigma and
discrimination faced by those who have mental health issues
 Improve response for individuals with low-levels of anxiety / depression;
 Improve access to counselling services
 Improve support for carers
 Access to a range of accommodation options and accommodation support
 Improve availability of meaningful day time
employment opportunities
 Access to age-appropriate environments
should be provided for children and young
people; and
 Service users must continue to be at the heart
of service design and provision
Alongside the engagement events the Mental Health Programme Group (MHPG)
have been working closely with West Wales Action for Mental Health (WWAMH) to
produce a report on independent service user and carer perspectives on alternative
models of care (Wright et al, 2016).

The mental health needs of society have changed significantly over the past decade.
Treatment advances have also changed with delivery of services moving away from
a reliance on hospital care and instead providing services in community settings
where people can remain supported primarily by families and friends or, when
required, by services delivered by health, social care and the third sector.
Since 2012 and the introduction of the Mental Health (Wales) Measure 2010 (the
Measure), the vast majority of people with mental health problems are treated at a
primary care level, either through their GP or Primary Care Mental Health Services.
This promotes early intervention for people experiencing mental health difficulties, the
aim being to reduce the likelihood of their condition deteriorating and the need for
secondary mental health services.
The introduction of the Local Primary Mental Health Support service (LPMHSS) has
enabled closer integration of mental health services with primary care and GP
services to provide short term psychological interventions, both individual and group,
to individuals with a mild to moderate mental health problem. In addition, the
LPMHSS also provide support and training to professionals working within primary
care teams in relation to their management of individuals on their caseloads with
mental health issues.
The significant numbers of people accessing Primary Mental Health Support Services
in West Wales during 2015/16 are summarised below, and reflect the priority given to
early intervention support.
Figure 11:5 Number of individuals referred to Primary Mental Health Support

Services in 2015-16
Carmarthenshire 1727
Ceredigion 1130
99
Pembrokeshire 1822
Hywel Dda Total 4679
Source: Local data
In West Wales, Community Mental Health Teams (CMHTs) are a partnership

between Social Services and Hywel Dda University Health Board and are the central
point of referral for those requiring access to secondary mental health services. Part
2 of the Measure specifies that any individual receiving secondary mental health
services must also have an up-to-date care and treatment plan. CMHTs have a duty
to assess anyone who appears to be experiencing mental health difficulties which are
affecting their ability to lead their usual life.
The figure below shows how many individuals were accepted into secondary services
during 2015/16, and also how many have been discharged. Mental health services
focus on a recovery model; this means that many individuals do not need to remain
under the care of secondary mental health services throughout their lives.
Figure 11:6 CMHT Care Treatment Plans 15/16
Community Mental Health Team - Care

100
Treatment Plan 2015/16
90
80
70
60
50
40
30
20 Accepted to CTP
10 Discharged from CTP
0
Most individuals experiencing mental health crisis or more severe problems prefer
not to be treated in hospital. HDUHB established Crisis Resolution Home Treatment
(CRHT) Teams in December 2012 that are able to work flexibly and intensively,
outside normal working hours, to treat people at home and to help them avoid
admission to hospital.
The CRHT Teams also work closely with in-patient units to ensure that people are
able to be discharged as early as possible. The numbers of people referred to CRHT
services in 2015/16 are summarised in the table below.
100
Figure 11:7 Referrals to Crisis Resolution Home Treatment Teams 2015/16
Carmarthen CRHT 840

Ceredigion CRHT 520
Llanelli CRHT 1, 010
Pembrokeshire CRHT 775
Total 3, 145
Specialist Services such as psychological and occupational therapies and psychiatric

interventions deliver services in a range of community and in-patient settings,
including forensic mental health provision. Inpatient mental health services are
provided by the Health Board, or commissioned from the independent sector. The
numbers of admissions to hospital have fallen since 2009 as shown below.
Figure 11:8 Admissions to Psychiatric Inpatient services
Year 2009 2010 2011 2012 2013 2014 2015 2016

Hywel Dda UHB
Psychiatric Inpatient 165 156 164 133 132 119 114 123
Admissions
Source: NHS Informatics Service, 2016
The number of individuals detained under Section 2 of the Mental Health Act has
risen from 217 in 2013/14 to 303 in 2015/16 and based on in-year activity. A further
increase is expected to be reported at the end of 2016/17.
There are still significant numbers of people receiving residential care services and
as illustrated below this is set to continue to rise by 2030.
A priority for the local authorities is to reverse this trend and develop housing options
to prevent admission to hospital and residential settings, and facilitate discharge from
hospital. There is need to jointly commission a range of community accommodation
options and services that offers more choice and control for individuals using mental
health services. 97% of those in residential placements are in independent sector
care homes under contract, with 17% of these receiving nursing care in those
settings.
101
Figure 11:9 Percentage change for 18+ receiving residential services 2015-2030
% Change 2015-2030
For 18+ Receiving residential services
Wales
47% Carmarthenshire Ceredigion Pembrokeshire
46%
45%
43%
Source:Daffodil Cymru
Deprivation of Liberty Safeguards
Any one of us at some point in our lives may lose our mental capacity. This is more
likely as we get older and for many mean receiving care and support in an
environment where there are restrictions or deprivations of liberty. The Mental
Capacity Act (MCA) Deprivation of Liberty Safeguards (Dols) provides a legal
framework to protect vulnerable adults, who may become, or are being deprived of
their liberty in a care home or hospital setting.
These safeguards are for people who lack capacity to decide where they need to
reside to receive treatment and / or care and need to be deprived of their liberty, in
their best interests, otherwise than under the Mental Health Act 1983 (MCA Code of
Practice). The safeguards came into force in Wales and England on the 1st April
2009. Following the Supreme Court judgement on the Cheshire West case of March
2014, the number of people who should be considered under the Safeguards has
increased dramatically. This has placed increasing burdens on local authorities and
health and social care practitioners administering the Dols. For example prior to the
Cheshire West judgement Ceredigion received approximately 10 Dols requests a
year. In 2015/16 requests increased to 421.
The following table shows the number of DOLS requests and the waiting list for
DOLS in each county.
Figure 11:10

DOLS referrals – 2015/16 629 421 623
Dols waiting list - current 685 305 277
Source: Local data
The Health Board and Local Authorities commission a range of third sector
organisations to support people with mental health needs including advocacy
services, information and advice, activities, healthy lifestyles and a range of
102
supported accommodation and tenancy related support services. There are many
voluntary and community organisations and social enterprises working with people
with mental illness including Pembrokeshire Mind, Carmarthenshire Mind, Mind
Aberystwyth, Hafal, and FRAME.
West Wales Action for Mental Health (WWAMH) supports voluntary organisations
with an interest in mental health and seeks to improve the services and opportunities
available to people with mental health problems, their families and carers. WWAMH
has an active presence across the West Wales area, and a number of service users
have been involved or contributed towards future service developments.
Direct payments provide another way for individuals to access a range of

opportunities and services, by being able to choose who provides the services they
need. The numbers of adult social services clients with mental health needs who are
receiving direct payments are shown in the following graph. Although numbers are
low there has been a small upward trend in Ceredigion and Pembrokeshire since
2011.
Figure 11:11 Number of social services clients aged 18-64 with Mental Health
problems receiving direct payments 31 March
11.5. Gaps and Areas for Development

The TMHSP programme have developed a shared vision for a modern mental health
service (Hywel Dda University Health Board, 2015) which should:
• be accessible 24 hours a day so that the person who needs help or their
supporters can walk into a mental health centre at any time and establish a safe
relationship to discuss their needs and agree immediate support
• have no waiting lists so that the first appointment can take place within 24 hours,
with planned meetings to follow that agree the support and treatment needed
• move away from hospital admission and treatment to hospitality and ‘time
out’ so that the mental health centres can provide night hospitality from one night
to several weeks in order to address crisis periods when there is a higher need for
protection and/or to support the needs of the family, when hospital admission is
not the best option; and
103
• day time out and opportunities to provide therapeutic day service options for the
individual to access the care and support that is needed, for a few hours or a
whole day
As part of TMHSP work is underway to consider the implementation of the Trieste

Model in Italy which places a major focus on community based resources that look at
the whole person, break down barriers to accessing services by operating an open
door policy, and are more service user led. The model works on a network of
Community Mental Health Centres that are active 24 hours a day, 7 days a week
(24/7 CMHCs), with a few hospitality / crisis beds, supported housing facilities and
several social enterprises.
In the Trieste model, 80% of the budget is spent on community based support with
20% on in-patient services; this is the direct opposite of the current West Wales area
expenditure profile. The TMHSP are exploring the possibility of developing a joint
funding bid with Trieste in order to access funding to support the transformation of
mental health services in the West Wales area, and to share this learning more
widely across Wales and Europe.
The development of fit for purpose services right across the range is an on-going
journey and there are a number of areas in which further improvements can be
made. These are set out below against the core principles of the Social Services and
Wellbeing (Wales) Act.
Voice and Control

 Develop an outcome focused and “risk-enablement” approach to service provision
to support a flexible approach
 Although fewer individuals with mental health needs are being detained in police
custody, further work is required to improve service user experience and
conveyancing in relation to S136 of the Mental Health Act

 Improve prevention and early intervention services, alternatives to hospital
services such as a safe haven, respite and transfer of care liaison services, and
access to services, especially for those in crisis
 Improve direct access services as many people are not reaching the high
threshold for secondary mental health services, and so problems are escalating
 Wellbeing centres and befriending schemes could be used to support people while
waiting for a diagnosis or access to more specific care
Wellbeing
 Address the lack of Tier 4 specialist services and forensic services within the
region
 Improve the availability of alternatives to hospital assessment and crisis
intervention to manage placement breakdown
 Improve access to specific mental health welfare rights support and increased
support for carers and carers need to be involved in Care and Treatment planning
 Work as therapy could be better supported, and this could include “time credits” to
engage more difficult clients with peer support and/or mentoring
104
Co-production
 Ensure unmet need data is recorded as part of individual assessment processes
and is effectively aggregated to inform future planning
 Increase outreach community based activity which builds social networks,
confidence and supports integration

 Development of a flexible and responsive workforce across health and social care
to successfully deliver new models of mental health service
 Lack of good transport links within very rural regions adds to the difficulty of
accessible service delivery and recruitment challenges
 Increase the range of community based activity such as the golfing projects
recently run by the CMHT in partnership with West Wales Action for Mental Health;
 There are opportunities to base mental health workers at police stations
 Benefit services should be better linked with mental health services because
livelihood fears exacerbate mental health issues
105
11.6. References
Alzheimer’s Society (2015). What is young-onset dementia? [online]. Available at:
https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=164
Cyhlarova E. (2010). Economic burden of mental illness cannot be tackled without

research investment. London: Mental Health Foundation. Available at:
http://www.bmj.com/rapid-response/2011/11/03/economic-burden-mental-illness-
cannot-be-tackled-without-research-investme
Daffodil Cymru (2014a). People aged 16 and over predicted to have a mental health
problem, by gender, projected to 2035. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1071&PHPSESSID=cs35hl8ciis
91rom8k1la1gnv6&at=a&sc=1&loc=1&np=1
Daffodil Cymru (2014b). People aged 30-64 predicted to have early onset dementia,
and people aged 65 and over predicted to have dementia, by age and gender,
projected to 2035. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1076&PHPSESSID=ki572ehkefs
dj86be6qu72n055&at=a&sc=1&loc=1&np=1
Daffodil Cymru (2014c). People aged 18 and over receiving residential services, by
age, projected to 2035. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1079&PHPSESSID=uogbmcgq0
6au4l6kta41qoouf6&at=a&sc=1&loc=1&np=1
Hywel Dda University Health Board (2015) Transforming Mental Health Services.
Mental Health Foundation (2015). Fundamental Facts about Mental Health. London:
Mental Health Foundation. Available at:
https://www.mentalhealth.org.uk/sites/default/files/fundamental-facts-15.pdf
Mental Health Foundation (2016). Mental Health in Wales: Fundamental Facts 2016.
Available at: https://www.mentalhealth.org.uk/sites/default/files/FF16%20Wales.pdf
NHS Informatics Service (2016).
Opinion Research Services (2014). Attitudes to mental illness research report.

Available at:
http://www.mind.org.uk/media/1514683/121168_attitudes_to_mental_illness_2013_re
port.docx
Rethink Mental Illness (2016). 20 years too soon. Physical health: the experiences
of people affected by mental illness. Available at:
https://www.rethink.org/media/511826/20_Years_Too_Soon_FINAL.pdf
Welsh Assembly Government (2008). Talk to Me, Suicide and Self Harm reduction
strategy for Wales. Cardiff: Welsh Assembly Government. Available at:
http://www.wales.nhs.uk/documents/talktomee%5B1%5D.pdf
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Welsh Government (2012). Together for Mental Health: A Strategy for Mental Health
and Wellbeing in Wales. Available at:
http://gov.wales/docs/dhss/publications/121031tmhfinalen.pdf
Wright, S., Forde, E. and Attala, L. (2016). Co-producing Mental Health Services in
Hywel Dda University Health Board: A report of engagement with public, staff and
stakeholders. Available at: http://www.cavo.org.uk/wp-
content/uploads/2016/05/Engagement-Evaluation-Report-June2016FINALno-
appendices.pdf
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West Wales Population Assessment Older People
12. Older People

The population of West Wales has a higher proportion of older people than the Welsh
average, and that already high proportion is predicted to increase significantly in the
coming years, as average life expectancy in the region follows the national upwards
trend (Office for National Statistics, 2011).
The change in the profile of the population will undoubtedly have an impact on health,
as older people are statistically more likely to have a life limiting health condition
(Office for National Statistics, 2011) These changes will significantly impact on the
health and social care services provided, as demand for hospital and community
services by those aged 75 and over is in general more than three times that from
those aged between 30 and 40 (Parliamentary Select Committee on Public Service
and Demographic Change, 2013) .
A number of ‘accelerating factors’ add to the challenge of providing effective services

to older people in West Wales, from pockets of significant deprivation to large areas
of rurality and high levels of migration of older people to certain areas (Henry, 2012)
In 2013-14 an estimated £91 million was spent in West Wales on services specifically
for older people including Tier 1 – Community, Universal and Prevention Services,
Tier 2 - Early Intervention and Reablement and Tier 3 - Specialist and Long Term
Services. Across the UK public expenditure related to older people is expected to rise
from 20.1% of GDP in 2007-08 to 26.7% in 2057 (Mid and West Wales Health and
Social Care Collaborative, 2015). The Office for Budget Responsibility (2011) has
noted that;
‘public finances are likely to come under pressure, primarily as a result of an ageing
population.’

Demographic data suggests three key factors in relation to older people in West
Wales:
1) There are increasing numbers of older people across Carmarthenshire,

Ceredigion and Pembrokeshire:
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Figure 12:1 Population by age and sex and aged over 65 by LA
Current projections on Daffodil Cymru (2014a) suggest that the total population of
people aged over 65 living in West Wales will rise from 89,780 in 2015 to 119,510 by
2035. This represents an approximate 60% increase.
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In addition there has been, and will continue to be, a significant increase in the
people aged over 85 in this area with the greatest predicted increase in population
growth represented in the over 85 age group. An increase of 122% in West Wales
overall by 2035, with a 116% increase predicted in Carmarthenshire, 125% in
Ceredigion and 129% in Pembrokeshire.
Figure 12:2 Projected number of people aged 65+
Figure 12:3 Population projections by age

Population projections by age group, percentage change since 2011, Hywel Dda UHB,
2011-2036
Produced by Public Health Wales Observatory, using 2011
-based population projections (WG)
<16 16 -64 65 -84 85+
160
140
120
100
80
60
40
20
-20
2011 2016 2021 2026 2031 2036
Over the same period there is expected to be a marked decline in the working age
population. By 2033 the proportion of the population between 0-14 years in West
Wales will reduce to 15% and 15 –24 year olds will also reduce to 11%. Older people
in this region currently represent a higher percentage of the population with 21.3% of
the area being 65 or over compared with 18.6% in Wales a whole. This raises into
question capacity and resources to care and support the older age group.
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With large parts of Carmarthenshire, Ceredigion and Pembrokeshire being both rural
and coastal, the region attracts high levels of inward migration of people over 65.
People from elsewhere in the UK already account for almost 22% of the population of
Wales, with the vast majority of the new arrivals retiring from England (Bingham,
2014) The highest levels are found in Pembrokeshire with a 31% migration rate with
87% of these being over 65. Ceredigion has the largest percentage of residents with
a second home in the whole of the UK. Whilst this may be explained in part by the
large student population, census data shows that 325 people over 65 in Ceredigion
have second addresses outside the county. Of equal importance; data indicates that
1,182 pensioners have second homes in Ceredigion; these individuals have not
moved permanently into the area but still spend a significant amount of time there,
during which periods they might access health and social care services.
2) Older adults in the West Wales area have increasingly complex needs:
Healthy and disability-free life expectancy is rising more slowly than life expectancy.
People are living longer but with increased levels of illness and disability. Males in
West Wales have a life expectancy of 77.4, with disability free life estimated at 59.4
and healthy life at 64. The equivalent figures for females are 82, 61.2 and 65.7
respectively (Public Health Wales, 2016).
Limiting long-term conditions and disability are generally more prevalent amongst the
older age group, with 55% of the over 65 population in the three LA areas reporting
having a long-term illness or disability (Hywel Dda University Health Board, 2016a).
The number of people over 65 with limiting long term illness has been steadily
increasing and predictions suggest that this will continue to varying degrees across
all LA areas, with the highest increase predicted in Carmarthenshire.
Frailty is a complex concept as it not an illness but a distinctive state of health,

related to the ageing process, in which multiple body systems gradually lose their in-
built reserves. We have no specific data on the prevalence of frailty in the West
Wales region but national research shows that around 10% of people aged over 65
years have frailty (Clegg, 2013). It is estimated that one in four people aged 85 and
over is living with frailty. This typically means that a person is at a higher risk of a
sudden deterioration in their physical and mental health, can be expected to have
longer stays in hospital, experience increased rates of re-admission and is more
likely to be discharged to residential care (British Geriatrics Society, 2014).
The risk of being admitted to hospital also increases with age; whilst 21% of the
current West Wales population is over 65, 55% of all emergency admissions are of
those who are over 65, with 78% of emergency admission beds taken up by people
who are over 65, which equates to 57% of all bed days (Hywel Dda University Health
Board, 2016a). There is an also a significantly increased likelihood of a person over
65 with a chronic condition receiving inpatient care (Nuffield Trust, 2014).
As people age they are more likely to need help with self-care, domestic tasks and
have reduced mobility. Evidence in the three LA areas supports this, with data trends
predicting an increasing need to support older people with the activities of daily living.
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The prevalence of dementia is also associated with aging and the condition is one of
the major causes of disability in later life. Above the age of 65 the risk of developing
dementia doubles roughly every 5 years, with estimates that dementia affects 1 in 14
people over 65 and 1 in 6 over 80 (Alzheimer’s Society) Recent projections show a
rapid increase in dementia across all LA areas with some of the more rural areas,
including North Carmarthenshire and Pembrokeshire, seeing the highest rises of up
to 44% by 2035 (Roberts and Charlesworth, 2014; Public Health Wales Observatory,
2013). People with dementia stay far longer in hospital than other people who come
in for the same procedure; at least 40–50% of bed days relating to emergency
admission in West Wales will relate to people who have dementia as part of their
multi-morbidity (Hywel Dda University Health Board, 2016). It has been estimated
that Hywel Dda has the lowest rates of dementia diagnosis in Wales at 37.2%
(Alzheimer’s Society, 2015).
It appears that residents in West Wales have increasingly complex needs associated
with dementia and associated lack of capacity; Hywel Dda University Health Board
made the greatest number of applications for Deprivation of Liberty Safeguards in
2013-14, with Carmarthenshire LA having the highest number of applications in
Wales (Care and Social Services Inspectorate Wales, 2015) Whilst this may reflect
improved processes and systems, it may also suggest a heightened level of need
particular to this area, with dementia not being diagnosed but still recognised in a
residential setting.
Falls are a common and serious problem for older adults and it has been reported
that more than 50% of people over the age of 85 fall at least once a year (Age UK,
DATE) Daffodil Cymru data suggests that the number of hospital admissions
because of a fall predicted to increase in the area by almost 70% by 2035.
A significant percentage of older people in West Wales provide unpaid care to
support family or friends with the greatest predicted increase in those over 85
providing more than 50 hours of unpaid care of 122% by 2035. (Daffodil Cymru,
2014b).
3) A range of ‘accelerating factors’ are likely to exacerbate the needs of some

older adults
The West Wales region is the second most sparsely populated in Wales. Research
into ageing in rural communities has described a set of compounding factors which
result in ‘multiple disadvantage’ (Hartwell et al, 2007) as rurality impacts on many
factors including housing, deprivation, access to services and, vitally, levels of
physical and social isolation. Evidence indicates that rural areas are also ageing
faster, the projected increase of the 65+ age group by 2021 in rural areas is 29%
compared to 20% in urban ones (International Longevity Centre, DATE)
In nearly all instances, people living in the more deprived areas experience worse
health than those in more affluent ones. Deprivation has an impact on older adults
especially in relation to healthy and disability free life expectancy. There are a
number of areas of high deprivation in the region, with the largest concentration
around Llanelli in the east of Carmarthenshire. Data shows that people living in the
least deprived areas of Carmarthenshire can expect to live healthily for nearly 14
years longer than those in the most deprived ones (Public Health Wales, 2011).
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The West Wales region reports the second largest instance of excess winter deaths
in the over 65s in Wales (Hywel Dda University Health Board, 2016a). There is a
strong relationship between poor insulation and heating of houses, low indoor
temperature and excess winter deaths of older people (Marmot Review Team, 2013).
With respiratory disease being the major cause of seasonal mortality (Office of
National Statistics, 2015) and the proved causality between damp housing and
asthma (Basham, 2002), levels of fuel poverty and heating may be adversely
impacting on this group. Census data suggest that the older the occupant, the less
likely they are to have central heating. Data on Daffodil Cymru suggests that 3.3% of
households in the area do not have central heating with Ceredigion being the highest
at 5.4%; this is in stark comparison to the Welsh average of 1.9%. Large parts of the
region are also in Fuel Poverty, with some areas having a rate of 17% or higher of
fuel poverty compared to the 14% Welsh average.
Evidence suggests that older people are particularly vulnerable to loneliness and
social isolation (NHS, 2015). Whilst living alone in itself does not equate to
loneliness, research shows that those who do live alone are more likely to be lonely
(De Jong et al, 2011). In West Wales there are currently 40,496 people 65+ living
alone, which represents 45% of this group, with the likelihood of living alone
increasing with age (Daffodil, 2014c). It is predicted that between 2008 and 2033
there will be a 44% increase in the number of 65–74-year-olds living alone, a 38%
increase in those aged 75–85 and a 145% increase in those aged 84+ (Department
for Communities and Local Government, 2010). Levels of loneliness and isolation
could be further compounded by other factors, such as high levels of rurality and lack
of access to transport. The most recent evidence in this area indicates that 14% of
people aged 65 and over felt they were unable to manage walking down the road
without assistance (The Young Foundation, 2006).
The Quality of Life Indicators for Older People (Public Health Wales Observatory,
2012) published by Public Health Wales show that accelerating factors for this group
vary across the different LA areas; with those in Carmarthenshire presenting higher
instances of poor health and disability, with Pembrokeshire having higher levels of
obesity compared with the Welsh average.

Whilst it is not possible to equate population changes precisely with need for
increased care and support (Bolton, 2016), the predicted care and support needs of
older people are summarised below. A holistic approach which supports resilience
and independence needs to underpin all levels of care and support. This will provide
integrated, coordinated and person-centred care, appropriate rapid and effective
support at times of crisis, high quality acute care and choice, and control and support
towards the end of life. In identifying care and support needs, reference has been
made to relevant data and research as well as expressed views of older people. A
range of quantitative data has been obtained from the wellbeing survey undertaken
on behalf of the three Public Service Boards in the summer of 2016, early responses
to the initial wellbeing questionnaires distributed to service users by local authorities
and from ‘what matters to you?’ conversations which form an integral part of
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individual integrated assessments. Local ‘Ageing Well’ consultation data and material
emerging from engagement with fora such as 50 + groups in each LA area and the
Carmarthenshire Dementia Action Board, have also been taken into account.
Care and support needs of older people generally will include:
Support to maintain health and wellbeing: The World Health Organization (WHO)
estimates that more than half of the burden of disease among people over 60 is
potentially avoidable through changes to lifestyle (Oliver, Foot and Humphries, 2014).
These can be broadly defined as preventative community services which promote
engagement, healthy behaviours/eating and physical activity. Evidence shows that
many age-related conditions, including frailty, can be prevented or delayed by helping
maintain individuals’ resilience (Pacala, 2013). Work commissioned by the Social
Services Improvement Agency (SSIA) suggests that targeted support in the areas of
information, relationships, psychological resources, finance, physical health, home,
community and work and learning is most effective in achieving this (Blood et al,
2015).
Effective information, advice and assistance services: This is a key theme within
the Social Services and Wellbeing (Wales) Act 2014 and services, including
advocacy, are of particular value for older people in helping them access services,
make informed decisions, exercise choice and participate in their community.
Research by Age UK suggested that generic information, advice and assistance
services need to be tailored to fit older people’s needs which are likely to include
social contact and care, finance and housing, health and practical support. (Age UK,
n.d). Targeted IAA services might be appropriate for those people aged 65 and over
that retire to the region. In a recent poll the single most important thing to people over
60 planning to move was access to the countryside. More than 80% of those polled
put the countryside ahead of social life or access to healthcare. It also suggested that
people do not consider their potential care needs as most people indicated "don't
know" when asked about the provision of care and support in the area they were
planning to retire to (McVeigh, 2009).
Suitability of living accommodation: It has been estimated that older people spend
70-90 % of their time at home, which means that an environment that is conducive to
supporting wellbeing is crucial (ODMP, 2006 cited in Careter and Hillcoat-
Nallétamby, 2015: 3). The housing environments in which we age plays a
determining role in ensuring that people maintain autonomy and independence and
remain engaged in their local communities (Institute of Public Care, 2012).
Age-friendly communities: An age-friendly community can be simply defined as

one where local people have decided their priorities to better support people as they
age51. This can include physical design, promoting better access and mobility,
promoting people’s social engagement and developing support and relationships
between the generations. The most important aspect is that it is an integrated
approach to thinking about the places where people live and how best to promote
older people’s wellbeing and engagement with their physical and social
environments.
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Maintaining connection and community contribution: Ageing Well in Wales

defines loneliness and isolation as cross-cutting issues that seriously impact on the
health and wellbeing of older people in Wales (Ageing Well in Wales, 2015: no
pagination). Research shows that loneliness and social isolation are harmful to
health: lacking social connections is a comparable risk factor for early death as
smoking 15 cigarettes a day, and is more detrimental to health outcomes than well-
known risk factors such as obesity and physical inactivity.
Effective access to treatment for ‘minor’ needs that may compromise

independence: Many older people experience needs that tend to be characterised
as ‘minor’, but which can significantly affect their independence and wellbeing if not
supported effectively. These can include mobility problems, foot health, chronic pain,
sensory impairment, incontinence, malnutrition and oral health. Proactive, early
identification of such problems, using structured assessment tools coupled with
tailored interventions, can have significant benefits for older people’s wellbeing and
independence. (Melis et al, 2008)
Older people with more complex needs are likely to require a range of care and
support, which will include:
Effective management of frailty, based on a population-led approach that prevents

or delays the onset of the condition through early identification and anticipatory care
management across the primary and community sectors, integrated assessment and
care planning, measures to avoid inappropriate hospital admission and targeted falls
prevention programmes. Evidence shows these can reduce the incidence of falls by
between 15 and 30%.
Holistic support for dementia and cognitive impairment, including improved rates
of diagnosis, quality support in a range of settings and the development of dementia-
friendly communities.
Appropriate and efficient intermediate care services, including rapid response

care and support, therapeutic rehabilitation, reablement, step-up/ step-down
placements and supported discharge schemes, in which the third sector can play a
major role.
Person-centred, dignified long-term care which optimises independence, which

requires outcomes-focused assessment and care management and domiciliary care,
appropriate residential provision based on an enablement approach, effective
assistive technology, telecare and telehealth, effective adaptations and effective
advanced planning which includes choice and control for end of life care.
Effective support structures for older Carers, to ensure that they maintain
wellbeing and are able to continue their support for the relative for whom they are
caring for as long as possible.
Integrated mental health services Evidence suggests that in the UK depression

affects 22% of men and 28% of women aged 65 and over, with another study
estimating that depression affects 40% of older people in care homes (Age UK,
2016).
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For those older people experiencing any or all of the ‘accelerating’ factors identified in
the previous section, support needs will include:
Measures to reduce isolation through effective public transport and generally

improved access to health and social care provided on a locality basis. Evidently the
appropriate model of support for older adults in a deprived urban ward of Llanelli will
be different from those of a coastal area such as Aberporth or rural hamlet such as St
Dogmaels. The Kings Fund recommends the establishment of place-based ‘systems
of care’ in which health and social care collaborate to address the challenges and
improve the health of the populations they serve (Ham and Aldewick, 2015).
Availability of broadband can also play a role in reducing the effects of social
exclusion in later life (Age UK, 2013).
Support that addresses specific needs of older people living in areas of

deprivation through benefit and income maximisation, employment opportunities for
those wanting to work and increased public health activity to reduce limiting factors
such as smoking and obesity.
Prevention activity targeting excess winter deaths, through anticipatory care,

public awareness and tackling fuel poverty.

All partners in the region are moving towards a consistent model of care for older
people based on the principles of wellbeing and prevention encapsulated in the
Social Services and Wellbeing (Wales) Act and informed locally by a range of plans
and strategies including Ageing Well plans, the Health Board’s Integrated Medium
Term Plan, Carmarthenshire County Council’s ‘Vision for Sustainable Social Services
for Older People 2015-25 and the regional Statement of Intent for the Integration of
Services for Older People with Complex Needs in West Wales (2014).
Delivery across the region varies in detail but in each county area it is based around
three levels of service each of which aim to meet person-centred outcomes, as
shown in the following figure. These three levels can be described as ‘offers’ to
individuals according to their need and circumstance and are as follows:
Figure 12:4 Three Levels Of Service
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Source: Carmarthenshire County Council
More detail of each offer is provided below:
Offer 1: Help to help yourself
These are services which build resilience of individuals and communities, aimed at
helping people help themselves and prevent the need for ongoing care. Roles such
as community connectors and community resilience development officers have been
introduced to build third sector capacity and improve sign-posting of individuals.
Locally funded community-based projects such as Solva in Pembrokeshire and
Llandysul in Ceredigion aim to provide holistic, community-based support that
promote and sustain independence.
Provision includes:
 Information, Advice and Assistance which help people achieve their outcomes by
directing them to support available within the community. This should be targeted
when appropriate to support people experiencing one or more ‘accelerating
factors’ as described earlier in the report
 Advocacy to help people articulate needs and access appropriate care and
support
 Community-based home to hospital provision which facilitates effective hospital
discharge, prevents readmission and inappropriate admission
 Third sector services promoting independence, social engagement and inclusion
 Time banking, social prescription and volunteering
 Primary and community care initiatives funded through the cluster development
programme
Data from the regional Market Position Statement for older people’s services in West
Wales (Mid and West Wales Health and Social Care Collaborative, 2015) suggests
that spend on these services represents between 3% and 11% of total older people’s
budgets.
Case Study – Remodelling and Co-designing Services in Llandysul, Ceredigion
Ceredigion has taken an innovative approach to developing services for older adults
and working with communities to remodel services. A small cross organisational
group made up of representation from HDUHB, Ceredigion County Council and
Ceredigion Association of Voluntary Organisations has been established to deliver a
place based system of care within a town in Ceredigion and scope opportunities for
Alternative Delivery Models for public services. The project aims to understand the
opportunities and challenges associated with alternative delivery models and
explores various forms of service delivery such as social enterprises, cooperatives
and user led services. The dialogue includes:
 Sessions for officers from LA, UHB, CAVO with the aim of raising awareness of
the principles of Alternative Delivery Models, including Community Asset Transfer,
social enterprise, cooperatives
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 Sessions for elected members to understand Alternative Delivery Models and the
opportunities for the key partners
 Sessions with community groups and individuals to discuss the support and
options available
Case study – Pembrokeshire Intermediate Voluntary Organisations Team

(PIVOT)
The PIVOT Project was established as a third sector collaborative in Pembrokeshire
to facilitate hospital discharge, support those who are at risk of admission to hospital
for non-medical reasons and reduce support required from statutory agencies. The
project is coordinated by Pembrokeshire Association of Voluntary Services and
includes, British Red Cross, Pembrokeshire Care & Repair and Pembrokeshire
Association of Community Transport Organisations. The PIVOT partners have many
years of experience providing support that builds confidence and self-esteem to
enable people to live independently within their own homes. PIVOT provides home-
based low level support for up to six weeks for people who would benefit from low
level prevention and reablement support in the community.
Offer 2: Help when you need it
Here care and support is designed to support people to regain their previous level of
independence after an illness or injury, which include reablement and rehabilitation at
home. Examples include:
 Rapid access domiciliary care provision
 Acute response teams to facilitate rapid nursing needs in the community
 Equipment provision, telecare and telehealth and home adaptations
 Housing related support to maintain independence at home
 Support for carers
 Residential reablement placement in care homes and rehabilitation facilities in
community hospitals
 Anticipatory care processes such as multi-disciplinary meetings and proactive
care- planning
 Targeted projects funded by the Intermediate Care Fund to build effectiveness in
intermediate care, such as TOCALS – a frailty discharge service aimed at
facilitating effective and appropriate discharge from hospital
The WG’s Intermediate Care Fund has provided resources to develop new,
integrated approaches to care and ensure a level of consistency across the region in
relation to key aspects of care and support.
Analysis shows that this tier accounts for the second largest proportion of the overall
budget in the region at between 4 to 13% (Fig 32). This however does not consider
the significant investment of ICF funds which amounted to £8.4 million in 2014-15,
some of which supported projects aimed at improving intermediate care and reducing
reliance on acute services.
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Case study – Multi-disciplinary Teams (MDTs) and Stay Well Plans in

Carmarthenshire
Effective anticipatory care of frail older adults was identified as a priority in the 2Ts
GP cluster of Carmarthenshire. In partnership with integrated health and social care
teams an MDT approach was embedded to manage frail patients more effectively
and pro-actively in their own home will enhance their experience of care, improve
their outcomes and reduce acute care costs and bed days. As part of the project,
practices nominated a clinical frailty lead and to identify frail patients utilising a
practice based IT Risk Stratification System. The MSDi (software) tool is then used to
risk stratify patients. Patients identified receive a written Stay Well Plan which
includes details of a carer, health and social care summary, optimisation and
maintenance plan, and escalation and urgent care plan. The project also identifies
optimising Multi-disciplinary Teams (MDT) working through the adoption of the MDT
best practice guidance and the appointment of a generic Occupational
Therapy/Physiotherapy (OT/PT) technician who attends all MDT meetings and
accepts referrals to undertake low levels assessments.
Offer 3 – Ongoing support
The third level of support includes services for people whose conditions or
circumstances mean that they need longer-term specialist or substitute care or
support. The route into this level of care and support is usually through an integrated
assessment and multi-disciplinary professional support; a care and support plan is
based on the question ‘what matters to you’ and an outcome plan delivered
accordingly.
Services include:
 Domiciliary care support, direct payments and residential placements in care

homes for assessment, respite or on long-term basis
 Social support and day opportunities are provided through accessing community
based services, direct payments or day centre provision
 Health led services include community nursing and hospital services, continuing
healthcare and end-of life care. Over 60% of the £37,602,320 spent in 2014-2015
on continuing healthcare in HDUHB was spent on older adults, which included
both domiciliary and residential nursing care (Hywel Dda University Health Board,
2016b)
 Residential and nursing care. Across the region, several residential options are
available which range from extra care to EMI nursing. Approximately 668
residential care beds are registered for older people with dementia and 645 EMI
nursing home beds, with 1,257 residential placements and 673 nursing ones; as
well as currently having 254 units of extra care accommodation across the region
 A significant proportion of older people who live in a residential setting in West
Wales currently fund their own placement but may need financial support at a
later date. The Local Government Information Unit (LGiU) estimated that an
average of 41% of people entering residential care each year self-fund, and of
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those, 25% will run out of money during their stay. Estimating the precise
numbers of self-funders in the area is difficult, however a market survey of care
home providers in each county suggests that Carmarthenshire and
Pembrokeshire have a similar rate of self- funders (34% and 33%) while
Ceredigion has a lower number (23%). Another calculation which estimates
numbers of self-funders, and considers the number of beds funded by NHS
continuing health care provided similar results for Ceredigion at 21.5%, but higher
for Carmarthenshire (43%) and Pembrokeshire (41%). (Mid and West Wales
Health and Social Care Collaborative, 2015)
 Safeguarding services to protect against abuse and neglect.
 Comprehensive telecare support
 Management of specific conditions through community nursing which includes;
clinics and district nursing services
Providing services to those with ongoing need overwhelmingly represents the largest
part of the budget in region.

Current provision as set out in the previous section provides a valuable foundation for
further development to ensure that rising levels of need across the region are
effectively met. A number of areas need further development if the requirements of
the Act, including wellbeing outcomes for older people and the aspirations of existing
strategies are to be fully addressed. These are set out below against the core
principles of the Social Services and Wellbeing (Wales) Act.
Voice and control
 Ensuring effective community based advocacy services for older adults is

available and accessible across the region
 Improving the level of services available through the medium of Welsh
 Reducing the reliance on residential and nursing care in favour of lower level,
preventative and wellbeing services
 Mainstreaming integrated approaches across primary, community and social care,
adopting local successful practice across the region where positive impact is
evidenced and further aligning ICF and cluster development programmes
 Increasing the level and range of low level support services such as befriending,
shopping and lunch clubs are not able to recruit volunteers in some areas – where
there are specific befriending services demand greatly outweighs capacity
 Building good-neighbour schemes to promote community connection and
resilience
 Improving availability of rapid response services for older people who have short
term need
 Improving the level and quality of rehabilitation across the region
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 Attaining improved and standardised levels of telehealth and telecare across the
region
 Achieving a consistent approach to frailty; the recent adoption by Hywel Dda
University Health Board of a frailty strategy (Hywel Dda University Health Board,
2016c) is an important first step; the objectives within the strategy need to be
taken forward in an integrated way with all partners working in collaboration
Wellbeing
 Improving community transport to enable older people to access care and support
at the appropriate level; feedback from communities consistently cite effective
transport as a barrier accessing services and provision
 Joined up service provision to support mental wellbeing and address depression
 Ensuring services (including primary care, domiciliary care, residential care and
reablement) and communities are ‘dementia friendly’
 Improving dementia diagnosis rates
 Ensuring appropriate levels of residential and nursing care are available in all
parts of the region
Co-production
 Involving older people more in the design and delivery of services that affect them
 Maintaining a dialogue with older people in relation to personal responsibility for
maintaining wellbeing and care and support available
 Working in partnership across commissioners and providers to articulate and

promote a consistent service model
 Improving anticipatory care across the health, social care and other sectors to
avoid escalation of need
 Building on local pilots for integration of health and social care roles, in keeping
with national guidance on third party delegation, to ensure responsiveness of
services and sustain independence for older people
 Developing integrated commissioning to achieve market sustainability across the
region in residential and domiciliary care
 Growing an integrated approach to quality assurance and contract monitoring of
care homes to identify and address emerging concerns and prevent placement
breakdown
The role of the Regional Partnership Board will be vital in sustaining this drive for
improvement, using the Area Plan and funding such as the Integrated Care Fund to
achieve the paradigm shift still needed. A partnership approach will be needed in
tackling key challenges such as development of new services in an environment of
financial austerity, setting clear and shared outcome targets to measure progress and
impact of transformation, achieving market sustainability across levels of care and
support, and ensuring an appropriately qualified and skilled workforce is in place to
deliver the changes still needed.
121
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126
West Wales Population Assessment Sensory Impairment
13. Sensory Impairment

 Sensory impairment can be a significant life limiting condition and its incidence
increases with age. This means the challenges associated with the condition are
likely to grow over coming decades
 The condition includes sight loss, hearing loss, and dual sensory loss (deafblind).
 Accelerating factors in relation to sight loss include diabetes and obesity
 People with sensory impairment have a range of care and support needs. Early
identification is vital, as is prevention, support to reduce loneliness, isolation and
promote mental health and wellbeing and measures to support access to
employment
 Effective care and support is likely to reduce other risks associated with age and
frailty, such as falls
 A range of services are available across West Wales. These provide a foundation
for improvement in the future
 Improvements need to focus on further development of generic and specialist
services and improving access to other services for people with a sensory
impairment. This will require collaborative approaches to ensure consistency and
that common challenges are addressed

Sensory impairment includes sight loss, hearing loss and dual sensory loss (a
condition also referred to as ‘deaf blind’). Incidence of sensory impairment across
these categories primarily affects older age groups, although there are other
significant groups within the population that are susceptible particularly to sight loss
and genetic conditions and injury can also give rise to a range of sensory impairment.
The prevalence in West Wales of each of these three conditions is examined below.
Sight Loss
The charts below provide numbers of adults predicted to have visual impairment in
each part of the region, in 2015 and 2030. These are based on generic forecasting
and demonstrate that, whilst the proportion of younger people affected is very small,
people are more likely to suffer sight-related conditions as they grow older.
Forecasting predicts that:
 Approximately 0.06% of adults between the ages of 18 and 64 will have a severe
visual impairment
 Moderate or severe visual impairment will be experienced by around 5.6% of
older adults aged between 65 and 74
 Around 12% of people aged 75 and over will have a moderate or severe visual
impairment
 Approximately 6.4% of people aged 75 and over will have registerable eye
conditions
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The most common sight-threatening conditions are age-related macular

degeneration, cataract, glaucoma and diabetic retinopathy. This will become
significant as the population of the region ages over the next 2 decades.
Other conditions such as diabetes and obesity are underlying causes of sight loss
and as the incidence of these increases this will also impact on the preponderance of
vision-related problems within the population (Action for Blind People, n.d).
Figure 13:1 Predicted levels of visual impairment, Carmarthenshire
2015 2030
People aged 18-64 predicted to have a 70 70

severe visual impairment
People aged 65-74 predicted to have a 1,308 1,437

moderate or severe visual impairment
People aged 75 and over predicted to have a 2,382 3,631

People aged 75 and over predicted to have 1,220 1,859

registerable eye conditions
Figure 13:2 Predicted levels of visual impairment, Ceredigion
2015 2030
People aged 18-64 predicted to have a severe visual 30 28

impairment
People aged 65-74 predicted to have a moderate or 540 532

People aged 75 and over predicted to have a moderate 988 1,498

or severe visual impairment
People aged 75 and over predicted to have registerable 506 767

eye conditions
128
Figure 13:3 Predicted levels of visual impairment, Pembrokeshire
2015 2030
People aged 18-64 predicted to have a severe visual 45 43

impairment
People aged 65-74 predicted to have a moderate or 917 948

People aged 75 and over predicted to have a 1,692 2,551

People aged 75 and over predicted to have 866 1,306

registerable eye conditions
The following table provides the latest figures on the numbers of people registered as
partially sighted or blind in each county.
Figure 13:4 Numbers of people registered as partially sighted or blind

Numbers of people registered 1,029 365 663
as partially sighted or blind
(2013/14)
Source: Stats Wales
Other statistics (RNIB, 2016) relating to sight loss include:
• Nearly two-thirds of people living with sight loss are women

• Adults with learning disabilities are 10 times more likely to be blind or partially
sighted than the general population
• People from non-white ethnic groups are at a higher risk of certain sight
conditions
NHS Wales spends around £113 million (Welsh Assembly Government, 2011) on
eye health including costs associated with inpatient treatments and outpatient
attendances, and also the cost of NHS funded eye tests and yet over 50 per cent of
sight loss can be avoided (Public Health Wales, 2013). In published NHS programme
budgets Hywel Dda Health Board combined spend on problems of vision is £15.6
million (2.2% of the overall budget). Indirect costs of sight loss are significant and
include the provision of unpaid care by family and friends, lower employment,
absenteeism and the cost of specialist equipment and modifications.
Hearing loss
Hearing loss has been identified as a major public health issue. The vast majority of
people with hearing loss and profound hearing loss are older people aged 65+, so
129
once again as the population profile of the region ages the number of people with
hearing loss is set to grow (Action on Hearing Loss, 2015)
The following table shows how the estimated numbers of people aged 18+ with a
hearing impairment is set to grow in the West Wales region by 2030.
Figure 13:5 Estimated numbers of people aged 18+ with a hearing impairment
2015-2030
Those aged 18+ with hearing impairment 2015 2030
% Change
Moderate or severe hearing impairment 46,973 61,907 32%
Profound hearing impairment 1,075 1,529 42%
Hearing loss affects us and is more likely to be experienced alongside other

conditions, as we age:
 From the age of 40 onwards, a higher proportion of men than women develop
hearing loss. This may be because more men have been exposed to high levels
of industrial noise (Action on Hearing Loss, 2015)
 71.1% of over-70-year-olds have some kind of hearing loss (Action on Hearing
Loss, 2016)
 Among people over the age of 80, more women than men have hearing loss,
which is due to women living longer than men on average, not because women
are more likely to become deaf (Action on Hearing Loss, 2016)
Dual Sensory Loss (Deafblind)
Deafblindness is when a combination of both sight and hearing loss cause difficulties
in communication, mobility and access to information. People can be born deafblind,
or become deafblind through illness, accident or in older age. Deafblindness is a
growing issue in the UK (SENSE, 2010). Dual sensory loss can be found in all age
groups, including children, but the incidence is greatest in older adults. Once again,
this number is set to grow substantially over the next two decades as the population
ages.
The following table sets out the estimated numbers of people of all ages with some
degree of and more severe dual sensory loss (RNIB, n.d).
Figure 13:6 Estimated numbers of people with some degree of and more severe
dual sensory loss
Estimated number of people
living with some degree of 1,345 931 546
dual sensory loss
Estimated number of people
living with more severe dual 455 320 191
sensory loss
Source: RNIB, n.d.
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The positive impact of prevention, early identification, practical and emotional support
and accessibility of services is common across all categories of sensory loss. Whilst
many people with sensory impairment will not need direct care and support for their
condition, they are more likely to suffer with depression, anxiety, loneliness, loss of
independence and isolation, along with poorer employment prospects and the
financial impact that can bring, than the general population. Appropriate low level
support can play a key role in mitigating the effect of these and in improving the
general wellbeing of people with these conditions.
Since, as outlined above, sight loss can often be accompanied by other chronic
conditions, people may often be receiving other care and support relating, for
example, to stroke, diabetes and dementia.
Care and support needs are explored in further detail below.
Prevention and early identification
Research by the RNIB suggests that 50% of blindness and serious sight loss could
be prevented if detected and treated in time (RNIB, 2016).
It is much easier for people to maintain their independence as their sight deteriorates
if they can learn coping techniques early in the process rather than trying to re-
incorporate activities into their routine that they have previously decided are off-limits.
Adaptations in the home such as better lighting can be of significant benefit
(Rotheroe et al, 2013). Early diagnosis of hearing loss and dual sensory loss can also
facilitate better adjustment to these conditions and better levels of independence and
wellbeing. Diagnosis of hearing loss can currently can take on average 10 years to
obtain. Evidence suggests that GPs fail to refer up to 45% of people reporting
hearing loss for an intervention such as a referral for a hearing test or hearing aids
(Action on Hearing Loss, 2009).
Appropriate services, accessed with the help of communication aids, is the single
biggest need for dual sensory impairment. An example of need is the availability of
guides/communicators to facilitate social interaction and ensure equality of
opportunity in accessing services (Orr et al, 2006). Early intervention is, again,
crucial. People with dual sensory impairment rely on tactile communication and this is
easier to teach whilst individuals are still able to receive audio and visual information.
Once people have lost almost all their sight and hearing, highly-skilled practitioners
are needed to support people in learning tactile communication skills (RNIB, 2013).
Coping strategies for single sensory loss often rely on the other senses working
harder to compensate; audio readers can support those who are unable to read
printed materials and those with hearing loss may rely on lip reading. Where both
senses are impaired, implications for the individual are profound; the impact of losing
both senses is ‘more than the sum of its parts’ (Rotheroe et al, 2013).
Mental health and wellbeing
131
People with vision impairment have an increased risk of depression (Thomas

Pocklington Trust, 2016) and over one-third of older people with sight loss are
estimated to be living with this condition (Hodge et al, 2010 cited in Action for Blind
People, n.d). The provision of emotional and practical support at the right time can
help people who are experiencing sight loss to come to terms with the situation,
retain their independence and access the support they need, thus reducing possible
triggers for depression (RNIB, 2013).
Research findings suggest that deaf people are more likely than their hearing
counterparts to suffer from mental health problems (McClelland et al, 2001). 40% of
the deaf and hard of hearing people in the UK are likely to experience a mental
health problem at some time in their lives. The culturally deaf (that is, those using
British Sign Language (BSL)) have a 50% chance of a mental health crisis (Orr et al,
2006).
Social isolation and loneliness
Research by the Thomas Pocklington Trust identified a significant need among

people with a visual impairment for greater social contact (Percival, 2003).
RNID research undertaken in 2000 found that 66% of deaf and hard of hearing
people feel isolated due to the fact that their condition excludes them from everyday
activities. Research conducted by FMR (a social research consultancy) in 2002,
suggests that deaf people experience social exclusion, discrimination, and barriers in
access services and facilities because of difficulties in communication (Orr et al,
2006).
People of different ages face distinct and particular issues when sensory loss is not
diagnosed. Older people are likely to become more vulnerable, isolated and less
independent if visual loss is not diagnosed and addressed. This concern is
highlighted in an in-depth interview with a service user who said:
‘I feel I want to scream just for human conversation... I feel that I’m deteriorating so
much because I have no stimulant, I suppose. I hardly sleep at all.’
(Bristol City Council, 2014)
For young people, life chances are affected as they may struggle to build the
necessary resilience to cope with transition periods, for example when moving from
education to employment. Social isolation within mainstream schools and the
workplace can also be a problem for people with sight loss (Rotheroe et al, 2013).
Falls reduction
A 2012 study found that between 40% to 50% of older adults with visually impairing
eye disease limited their activities due to a fear of falling. This puts people at further
potential risk for social isolation and disability (Wang et al, 2012)
Every year in Wales half of those over 80 will have a fall in their home. Resulting
injuries such as hip fractures have a hugely detrimental effect on individual wellbeing
and require costly health interventions. Across Wales, falls have been estimated to
directly cost the NHS £67 million per year (Davidson et al, 2011) and evidence
132
suggests around 10% of all falls can be attributed to sight loss (Boyce, 2011).
Appropriate adaptations and aids in the home can play a vital role in reducing risk in
this area.
Access to education and employment
Across the UK it is estimated that two-thirds of registered blind and partially sighted
people of working age are not in paid employment (Douglas et al, 2006 cited in
Action for Blind People, n.d). Over two-fifths of people living with sight loss say that
they have some or great difficulty in making ends meet (RNIB, 2013).
Figures from the Office of National Statistics show that people with hearing loss are
less likely to be employed (65% are in employment) compared with 79% of people
with no long term health issue or disability (Action for hearing loss, 2016).

A range of care and support is available for people with sensory loss in West Wales.
Whilst the precise nature of provision varies in each county area, generally these
include:
 Specialist assessments undertaken for people with sensory loss, which

identify level and type of need
 Rehabilitation Officers for the Visually Impaired (ROVIs) located within social
care who provide rehabilitation service for people of all ages who are certified
blind, partially sighted or are registerable under these categories of reduced
vision. A ROVI’s role is to help build confidence, provide emotional support,
regain lost life-skills and teach new skills, maintain and promote independence
and choice and assess people’s need for specialist equipment and adaptations.
The ROVIs work closely with partner agencies such as the Low Vision Service
Wales (LVSW) and the third sector to ensure clients’ needs can be fully
recognised, supported and progressed. They also build links with other services
to ensure the needs of visually impaired people are taken into account. A recent
example is engagement with Aberystwyth University in Ceredigion which resulted
in the opening of an art gallery with audible provision. Finally, ROVIs work within
communities to provide visual awareness training and look to set up local support
groups for people with vision impairment
 Low Vision service Wales (LVSW)-accredited practitioners located within

primary care, who provide advice and guidance to those who have had diagnosis
of a specific eye condition. People can access LVSW practitioners from the
community or when in secondary care. Practitioners currently operate in 32
community optometric (optician) practices and a further 11 offering a domiciliary
service
 Eye Care Liaison Officers (ECLOs) operating from opthalmology departments

across the region and provide support and advice to patients with vision
impairment; this service is limited and is provided by RNIB in Carmarthenshire
and Pembrokeshire and by Sight Cymru in Ceredigion
133
 Specialist equipment available to facilitate daily activities, such as mobility and

communication equipment (including Braille and hearing loop systems) and lip-
reading services (in Carmarthenshire), where appropriate
 General awareness raising and engagement activities, for example with 50 +

forums which takes place across the region and interaction with other services
such as education, highways and the third sector (in Pembrokeshire) to improve
provision for people with sensory loss. Local engagement activities include work
conducted through the West Wales Audiology Group, facilitated by Hywel Dda
University Health Board and bringing together professionals and service users to
consider and address relevant service issues and the publication in
Pembrokeshire of a monthly audio magazine for the visually impaired which
encourages feedback from citizens on the type and level of services they would
like to receive. Wales Council for the Blind convenes a quarterly ‘Your Voice
Shared Vision’ meeting across Mid and West Wales (including Powys) to discuss
service-related issues and obtain the views of users and carers
 Support for Carers of people with sensory loss, including information,

signposting to appropriate support and advice on carers’ assessments
 Partnership working between the statutory and third sectors at national level
with organisations such as British Wireless for the Blind, Blind Veterans UK,
RNIB, SENSE Cymru, Deaf Children’s Society, Welsh Interpreting and
Translation Services, Wales Council for Deaf People and locally with groups such
as Pembrokeshire Association of Voluntary Services and the Llanelli Blind
Society, to deliver a range of support services. These include social interaction
and activities and specific facilities such as wireless for the blind, talking
newspapers
Regional initiatives to improve provision for people with sensory loss include the
Sensory Friendly Awareness Awards programme, the first to be piloted an rolled out
in Wales and led by Hywel Dda University Health Board. The programme aims to
raise awareness and understanding among health care providers of the needs of
people with sensory loss and their carers and to respond to these appropriately. Its
initial focus is on secondary wards.
Along with other LHBs across Wales, Hywel Dda University Health Board has
recently introduced a sensory e-learning course, in conjunction with SENSE Cymru,
to raise awareness of sensory impairment issues among staff. Service user feedback
has been positive. One user commented:
“I was dreading going into hospital due to being virtually blind and I feared I would not
be helped, however I could not have asked for any more help. They guided me, gave
excellent verbal instruction and even told me when my meal had been placed in front
of me, which has never happened to me before”.
134

The biggest single challenge in relation to people with sensory loss is lack of
diagnosis. This is also an issue where individuals are receiving other services such
as residential and nursing care. Research undertaken in 2012 (Watson and Bamford,
2012) revealed that eye care and sight testing are both neglected in care homes for
older people. A similar situation prevails for hearing loss (Echalier, 2012). Ensuring
people are diagnosed with sensory loss as soon as possible can help them to remain
independent for as long as possible and avoid other risks such as falls.
The following gaps and areas for further improvement are set out below against the
core principles of the SSWB Act. These show that ensuring people with sensory loss
have a voice and are in control of their disability is paramount.
Voice and Control

 There is a need for greater awareness of sensory loss and its impact so that
service providers take specific needs into account and make their services more
accessible. This is particularly important given that sensory loss often exists
alongside other age-related conditions such as dementia and frailty. Information
and advice needs to be provided in accessible formats. Wider services need to be
made accessible so that people are not turned away inappropriately, or give up
because, for example, they are unable to navigate the health and social care
system. Thought also needs to be given to how people receive information, for
example about hospital appointments. Difficulties in reading these can mean
people with visual impairment missing out on other vital health care
 Awareness of the NHS Low Vision Service in West Wales needs to be raised,
thus increasing the number of referrals to the service and enabling appropriate
support to be provided
 Specific support services such as interpretation, translation, lip reading and
talking therapies need to be enhanced to ensure they are available and
accessible across the region
 Take-up of Direct Payments should be encouraged to ensure that people can
exercise genuine choice and control over the care and support they receive
Figure 13:7 Numbers of social services clients aged 18-64 with physical or
sensory disability or frailty receiving direct payments.
135
Figure 13:8 Numbers of social services clients aged 65+ with physical or
sensory disability or frailty receiving direct payments.
 Social care assessment processes should be reviewed to ensure that sensory

loss is identified and steps taken to put appropriate care and support in place

Wales leads the UK in many areas of eye care, including clinical and research
arenas. But where sight cannot be saved, there must be provision for preventing
further functional deterioration and providing mitigating strategies that enable
independent living. Rehabilitation for the Vision Impaired meets the Article 26 UN
Convention on the Rights of Disabled People. Specialist services such as
ophthalmology and glaucoma clinics need to be sufficiently resourced to ensure
timely intervention and to guard against further deterioration in conditions.
Although as stated earlier there is evidence that GPs fail to refer 45% of those
reporting hearing loss (Action on Hearing Loss, 2009) in 2013 Wales became the first
country in the UK to develop guidance on dealing with people with sensory loss for
distribution in GP surgeries and hospitals.
Wellbeing
 There is a need to ‘grow’ low level care and support within communities, such as
facilities to reduce isolation and loneliness and assist people in retaining
independence and wellbeing
 There is a need for improved levels of rehabilitation for people experiencing vision
impairment; this can be highly effective in helping people regain independence,
avoid associated decline in physical and mental health, reduce the risk of
accidents and support carers in understanding and adapting to the needs of the
person they are caring for

There is a need for a collaborative approach across the region in building on current
success and ensuring fit for purpose services that enable people with a sensory
impairment to live fulfilled lives and optimise their wellbeing. Existing commitments
such as those contained in a Strategic Statement of Intent recently developed by the
136
West Wales Sensory Loss Standards Group (2015) provide useful mechanisms for
taking this work forward. The Regional Partnership Board provides a further
opportunity for addressing identified challenges in a focused and joined-up way:
 There is a need for closer working between sensory impairment services and
other services, such as residential, nursing and domiciliary care to raise
awareness and increase referral rates
 Further links between sensory impairment and learning disability and mental
health teams is needed to ensure appropriate support is available to people with
sensory loss
 Similarly, further work is needed with other partners such as employers, to ensure
that the needs of people with sensory impairment are recognised and addressed
 Greater recognition is needed of accessibility issues when designing the built
environment
 Insufficient resources in a time of financial constraint
 Rurality of the region and poor public transport which can hinder access to
services
 Workforce issues relating to difficulties in recruiting appropriately qualified staff
and ensuring their skills develop in line with changing needs and advances in
technology
 The need to develop capacity within the third sector to improve community-based
support
 Ensuring consistency of provision across the region and appropriate levels of
specialist services in all areas
 Developing self-reliant individuals and resilient communities to support people to
remain independent in their own communities
137
13.6. References
Action for Blind People (n.d.). Key statistics. Available at:
https://actionforblindpeople.org.uk/about-us/media-centre/key-statistics/
Action on Hearing Loss (2009). Hearing Matters.
Action on Hearing Loss (2015). Hearing Matters: Why urgent action is needed on
deafness, tinnitus and hearing loss across the UK. Available at:
https://www.actiononhearingloss.org.uk/~/media/Documents/Policy%20research%20
and%20influencing/Research/Hearing_Matters_2015/Hearing%20Matters%20Report
.ashx
Action on Hearing Loss (2016). Facts and figures on hearing loss, deafness and
tinnitus. Available at: http://www.actiononhearingloss.org.uk/your-hearing/about-
deafness-and-hearing-
loss/statistics/~/media/56697A2C7BE349618D336B41A12B85E3.ashx
Boyce, T. (2011). Falls - costs, numbers and links with visual impairment. London:
RNIB
Bristol City Council (2014). Social Isolation and Physical and Sensory Impairment:
Research Findings Report. Available at:
https://www.bristol.gov.uk/documents/20182/34732/Social%20isolation%20and%20p
hysical%20and%20sensory%20deprivation_0_0_0.pdf/393c572d-5eeb-4b01-b013-
b7139843af8e
Daffodil Cymru (2014a). People aged 18 and over predicted to have a moderate or
severe visual impairment by age, and people aged 75 and over predicted to have
registerable eye conditions, projected to 2035. [Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1056&PHPSESSID=r5gr5unq74
u6t4i8jsp0qjjnq6&at=a&sc=1&loc=1&np=1
Daffodil Cymru (2014b) People aged 18 and over predicted to have a moderate or
severe, or profound, hearing impairment, by age and gender, projected to 2035.
[Online]. Available at:
http://www.daffodilcymru.org.uk/index.php?pageNo=1052&PHPSESSID=k4nchq6qm
mbf6qknd4p1tnaqk7&at=a&sc=1&loc=1&np=1
Davidson, M., Nicol, S., Roys, M. and Beaumont, A. (2011). The Cost of Poor
Housing in Wales. Bracknell: HIS BRE Press.
Echalier, M. (2012). A World of Silence: The case for tackling hearing loss in care
homes. Action on Hearing Loss. Available at:
https://www.actiononhearingloss.org.uk/aworldofsilence.aspx
McClelland, R., Chisholm, D. and Powell, S. (2001). “Mental Health and Deafness: an
investigation of current residential services and service users throughout the UK”.
Journal of Mental Health, 10 (6), pp. 627-636
138
Orr, K., Leven, T., Bryan, R. and Wilson, E. (2006). Community Care And Mental
Health Services For Adults With Sensory Impairment In Scotland. Scottish Executive
Social Research. Available at:
http://www.gov.scot/resource/doc/129826/0030944.pdf
Percival, J. (2003). Meeting the needs of older people with visual impairment: social
care or social exclusion. London: Thomas Pocklington Trust. Available at:
http://discovery.ucl.ac.uk/3322/1/3322.pdf
Public Health Wales (2013). ‘Look after your eyes’ at your local pharmacy this July
[press release]. Available at: http://www.wales.nhs.uk/sitesplus/888/news/27804
Rotheroe, A., Joy, I. and Bagwell, S. (2013). In Sight: A Review Of The Visual
Impairment Sector. London: New Philanthropy Capital. Available at:
http://www.thinknpc.org/publications/in-sight-a-review-of-the-visual-impairment-
sector/
RNIB (n.d.). RNIB Sight Loss Data Tool v 3.2 [online]. Available at:
http://www.rnib.org.uk/knowledge-and-research-hub-key-information-and-
statistics/sight-loss-data-tool
RNIB (2013). Sight loss UK 2013: The latest evidence. Available at:
https://www.rnib.org.uk/sites/default/files/Sight_loss_UK_2013.pdf
RNIB (2016). Key information and statistics. http://www.rnib.org.uk/knowledge-and-

research-hub/key-information-and-statistics
SENSE (2010). A sense of urgency. Available at:

https://www.sense.org.uk/sites/default/files/A_Sense_of_Urgency_Summary_report_
CEDR_Research.pdf
 Stats Wales (2016). Physically/sensory disabled persons by local authority, disability

and age range. [Online]. Available at: https://statswales.gov.wales/Catalogue/Health-
and-Social-Care/Social-Services/Disability-
Registers/physicallysensorydisabledpersons-by-localauthority-disability-agerange
Tomas Pocklington Trust (2016). Access to psychological therapies for people with
sight loss and depression: what is the evidence? Available at: http://pocklington-
trust.org.uk/wp-content/uploads/2016/06/Access-to-psychological-therapies-for-
people-with-sight-loss-and-depression.pdf
Wang, M. Y., Rousseau, J., Boisjoly, H., Schmaltz, H., Kergoat, M. J.,
Moghadaszadeh, S., Djafari, F. and Freeman, E. E. (2012). “Activity limitation due to
a fear of falling in older adults with eye disease”. Investigative Ophthalmology &
Visual Science, 53 (13), pp. 7967 – 7972.
Watson, J. and Bamford, S. M. (2012). Undetected sight loss in care homes: an

evidence review. London: International Longevity Centre. Available at:
http://www.ilcuk.org.uk/files/Undetected_sight_loss_in_care_homes.pdf
139
West Wales Sensory Loss Standards Group (2015). Statement Of Intent For Services
For Physically Disabled And/Or Sensory Impaired Adults In South West Wales.
Available at:
140
West Wales Population Assessment Substance Misuse
14. Substance Misuse

This report considers the care and support needs of those affected by alcohol and
drug misuse, the effects of which are far reaching; impacting on children, young
people, adults, whole families and communities. Partnership work to address this
agenda is taken forward through the Dyfed Area Planning Board for Substance
Misuse who are developing their own comprehensive needs assessment to inform
their new strategy and action plan. This thematic report therefore provides a brief
summary only.
The WGs 10 year strategy (Welsh Government, 2008) provides the framework for
partner organisations in West Wales to tackle the harms associated with drug and
alcohol misuse across four key themes;
 Preventing harm
 Support for those that misuse drugs and alcohol in order to improve their health
and aid and maintain recovery
 Supporting and protecting families
 Tackling availability and protecting individuals and communities via enforcement
activity
Those at risk of harm from alcohol misuse come from across the spectrum of society.
They include chronic heavy drinkers, adults at home drinking hazardous or harmful
levels and children and young adults who suffer from the consequences of parental
alcohol misuse. The health impact of misuse of alcohol is considerable; more people
die from alcohol related causes than from breast cancer, cervical cancer and MRSA
infection combined. Foetal alcohol syndrome is also a risk to the babies of mothers
who use alcohol. Most recent data on hospital admissions for Hywel Dda University
Health Board show that over 5,000 bed days were taken up by patients with alcohol
related conditions at a cost to the Health Board of over £5.2million per year in in-
patient treatment alone.
Misuse of drugs, both legal and illegal, and other mind-altering substances such as
solvents, can damage health in a variety of ways. These include fatal overdoses,
addition, mental health problems, infections caused by injecting and the toxic effects
of the many substances that dealers mix with the active substance. Although the
greatest harms are associated with the use of illicit drugs, the misuse of prescription
only medicines and over the counter medicines continues to be a problem.

Within the West Wales region the percentage of adults drinking above the
recommended guidelines has reduced by 5% since 2010/11 and from 40% to 37% in
2014/15 (Welsh Government, 2016). Similarly, the percentage of adults binge
drinking has reduced by 4% over the same time period from 24% to 20%. Hywel Dda
UHB is below the Welsh average for both indicators.
141
Whilst there has been some decreases for Ceredigion and Pembrokeshire in alcohol
related hospital admissions, in Carmarthenshire there has been an overall increase
of 6.7% between 2014/15 and 2015/16. Similarly, for alcohol attributable hospital
admissions both Pembrokeshire and Carmarthenshire have seen rises of 1.3% and
1.7% respectively since 2014/15. (Public Health Wales, 2016)
In 2015/16 there were 1137 referrals for alcohol treatment with 82% successfully
completing treatment. In the same year there were 713 referrals for drug treatment
with 79% completing treatment. The figures for those successfully completing
treatment are above the Welsh baseline. Of those accessing drug treatment 65%
were male and the largest number of referrals were in the 30-39 years age group
(27%), followed by 24% in the 40-49 year age group and 13% in the 50-59 year age
group.
There are considerable variations between local authorities in the proportion of

Children in Need cases where parental substance misuse is a factor. The figures for
the West Wales region are below the Welsh average and Ceredigion and
Pembrokeshire have the lowest proportions in Wales. These areas have dedicated
Hidden Harm services and Integrated Family Support Services (IFSS) which may
account for the lower figures.
West Wales area data for school exclusions due to substance misuse are not
available, but Welsh data (Public Health Wales, 2016) indicates that permenent
exclusions as a result of drug or alcohol related incidents across Wales was 20.2% in
2015/16. Exclusion from school is a key vulnerability for young people and can result
in lack of meaningful daily learning and activities.
There has been an increase in drug related deaths during 2016 compared to 2015/16
and a similar increase is being experienced elsewhere in Wales and in England.

The Dyfed Area Planning Board for Substance Misuse are developing their
commissioning strategy in order to address the following population outcomes:
 To stop people from starting to take drugs, and to reduce harm from alcohol
through ensuring the whole population is informed of the risk and side effects of
drug and alcohol misuse
 To minimize the impact of drug and alcohol use on the health and wellbeing and
safety of children, young people and families
 To support people with substance misuse issues to achieve a good quality,
meaningful life and to make a positive contribution to the community
 To reduce health related harm as a result of drug and alcohol misuse and make
communities safer through tackling issues created by drug and alcohol misuse
within communities
142

In April 2015 a new Dyfed wide drug and alcohol service (DDAS) was commissioned
by the Dyfed Area Planning Board for Substance Misuse in partnership with the
Police and Crime Commissioner, National Probation Service, Hywel Dda University
Health Board and two of the three local authorities. The service provides a single
point of contact for access to all adult drug and alcohol treatment services, including
for criminal justice clients, and is delivered by a consortium of third sector partners.
The region adopts a partnership approach and in each LA area weekly meetings are
held between DDAS, HDUHB and LA Substance Misuse teams to manage risk,
where appropriate share information and oversee the transfer of care between
teams. Teams are co-located in dedicated bases throughout the region and have
established systems and protocols to reduce the barriers to effective partnership
working.
Referrals into Tier 4 treatment – Inpatient Detoxification or Residential Rehabilitation

– are also managed by the Tier 3 community teams. Social Care teams also access
other types of specialist accommodation such as that commissioned through the
Supporting People Programme for example ‘dry house’ or supported
accommodation provision, as well as Floating Support for individuals with substance
misuse needs within their own homes in the community.
The UHB and LAs commission a range of third sector organisations to support
people with substance misuse needs including information and advice, counselling
services as well as treatment and support services. There are many voluntary and
community organisations and social enterprises working with people with substance
misuse needs including Drugaid, Chooselife and Cais.
A specialist children and young people’s service is provided by Drugaid Choices

West, a third sector organisation who link closely with a range of other partners
including the Police School Liaison Officers, Specialist Child and Adolescent Mental
Health Services (Sp CAMHS), Children’s Services, Youth Services, HDUHB Youth
Health Team and Youth Offending Services. The Dyfed Area Planning Board also
commission a dual-diagnosis service for young people who have co-occurring mental
health and substance misuse needs and this is provided by Hywel Dda UHB
Specialist CAMHS.
14.5. Gaps and Areas for Development

The Dyfed Area Planning Board for Substance Misuse is in the process of developing
its third Commissioning Strategy for Drug and Alcohol Misuse. This will involve the
development of a full needs assessment, market and service mapping, gap analysis
and the development of future commissioning intentions. The development of fit for
purpose services right across the range is and on-going journey but a number of
areas in which further improvements can be made have been set out below against
the core principles of the Social Services and Wellbeing (Wales) Act. The further
development of services will be in the context of strategic priorities within the national
‘Working Together to Reduce Harm – Substance Misuse Delivery Plan 2016-18’
(Welsh Government, 2016).
143
Voice, Choice and Control

 Ensuring that children, young people and families are able to access services
through their language of choice and that the ‘active offer’ of services through the
medium of Welsh is always available
 Use of direct payments so that individuals can choose who provides the services
they need

 Establishing a more co-ordinated and coherent approach to drug and alcohol
misuse education and awareness raising for young people across schools and
for those who are not in education, employment and training (NEET)
 Provide support for the further development and roll out of the Alcohol Liaise
Nurse scheme in secondary care settings across the West Wales area
 Establish clear and coherent treatment options for young people and their
families with drug and alcohol problems to provide a more holistic approach to
prevention and early intervention ensuring that there is a clear link to the Adverse
Childhood Experiences (ACE) agenda
Wellbeing
 Re-evaluation of treatment options for young people aged between 18-25 years
old
 Re-evaluation of treatment options for older people with alcohol issues.
 Lack of clear funding and treatment options for patients with Alcohol Related
Brain Damage
Co-production
 Increasing service user involvement, including carers, young carers, parents or
significant others, in service delivery and service planning

 Development of housing options and reintegration opportunities within the
community for recovering service users
 Establish, develop, implement and manage a robust process for the review of
both fatal and non-fatal overdoses including the rollout of the distribution of
Naloxone across hospital sites
 Support the development and implementation of the alcohol and assault data
project between the University Health Board, Welsh Ambulance Services NHS
Trust, Dyfed Powys Police and Public Health Wales in order to improve
information sharing arrangements between partners involved in reducing harm in
the night time economy
 Ensure clear pathways between services for service users with co-occurring
substance misuse and mental health
144
14.6. References
Public Health Wales (2016). Piecing the Puzzle - Profile of Substance Misuse in
Wales 2015-16. Available at:
http://www.wales.nhs.uk/sitesplus/documents/888/Piecing%20the%20Puzzle%20FIN
AL%202016%2C%20v2%2C%2025%20Oct%202016.pdf
Welsh Government (2008). Working Together to Reduce Harm – The Substance

misuse Strategy for Wales 2008-2018. Available at:
http://gov.wales/dsjlg/publications/commmunitysafety/strategy/strategyen.pdf?lang=e
n
Welsh Government (2016a). Working Together to Reduce Harm – Substance Misuse

Delivery Plan 2016-18. Available at:
http://gov.wales/dsjlg/publications/commmunitysafety/strategy/strategyen.pdf?lang=e
n
Welsh Government (2016b). Welsh Health Survey 2015-16. Available at:

http://gov.wales/statistics-and-research/welsh-health-survey/?lang=en
145
West Wales Population Assessment VAWDASV
15. Violence Against Women, Domestic Abuse and Sexual

Violence
 Violence against women, domestic abuse and sexual violence is a fundamental
violation of human rights, a cause and consequence of inequality and has far
reaching consequences for families, children and society as a whole (Welsh
Government, 2016)
 Domestic Abuse costs Wales £303.5m annually. This includes £202.6m in service
costs and £100.9m to lost economic output. If the emotional and human cost is
factored in there are added costs of £522.9m (Walby, 2009 cited in Welsh
Women’s Aid, n.d)
 The cost, in both human and economic terms, is so significant that marginally
effective interventions are cost effective (Welsh Government, 2016)
 New requirements under the Wellbeing of Future Generations (Wales) Act 2015,
Social Services and Wellbeing (Wales) Act 2014, and Violence Against Women,
Domestic Abuse and Sexual Violence Act, 2015 impact this area and are likely to
increase the number of cases of domestic abuse identified
 Improving partnership responses to survivors could reduce the levels of need for
specialist services
Violence against women, domestic abuse and sexual violence includes domestic
abuse, sexual violence, forced marriage, female genital mutilation (FGM), ‘honour-
based violence’, sexual exploitation, trafficking and child sexual abuse. This can
happen in any relationship regardless of age, ethnicity, gender, sexuality, disability,
income, geography or lifestyle (Welsh Government, 2016).
 1.4 million women and 700,000 men aged 16-59 report experiencing incidents of
domestic abuse in England and Wales. Younger women aged 16-24 are most at
risk and a woman is killed every 2.4 days in the UK, with 148 UK women killed by
men in 2014
 Extrapolating this data to Wales shows that 11% women and 5% men a year
experience ‘any domestic abuse’, while rates of ‘any sexual assault’ in the last
year were also higher for women (3.2%) than men (0.7%)
 Approximately 124,000 women, men, boys and girls over the age of 16 in Wales,
have been the victim of a sexual offence
 There has been a 26% increase in the number of recorded sexual offences
involving children under 16 in Wales in the past year. Figures have more than
doubled in the last decade (Bentley et al, 2016). Last year the rate of recorded
sexual offences against children under 16 in Wales was 3.3 per 1000 children
 In 2011 an estimated 137,000 girls and women were living with consequences of
FGM in the UK and in 2011 an estimated 60,000 girls under the age of 15 were
living in the UK who were born to mothers from FGM practising countries and
therefore could be at risk of FGM. It is estimated there are 140 victims of FGM a
year in Wales
146
 80% of cases dealt with by the Forced Marriage Unit involved female victims; 20%
involved male victims. It is estimated there are up to 100 victims of forced
marriage a year in Wales
 750,000 children and young people, across the UK witness or experience
domestic abuse every year and a significant proportion experience abuse in their
own relationships
 In a study of young people in intimate relationships by the NSPCC (Barter et al,
2009), 25 % of the girls and 18% of the boys experienced physical abuse; 75% of
girls and 14% of boys experienced emotional abuse, and 33% of the girls and
16% of the boys experienced sexual abuse. It found that not only do girls
experience more abuse, but they also experience more severe abuse more
frequently, and suffer more negative impacts on their welfare, compared with boys
 People with additional vulnerabilities including mental health needs, substance
misuse issues, disabilities and older people with support needs are more likely to
be affected by Domestic Abuse (Local Government Association, 2015)
The number of high risk and very high risk cases of domestic abuse discussed
via the Multi Agency Risk Assessment Conference process (MARAC) has increased
year on year since the process began over ten years ago.
Figure 15:1 MARAC referrals
MARAC Referrals
35
30
25
Axis Title
20 2013/14
15
2014/15
10
5 2015/16
0 2016/17
Source: Carmarthenshire, Ceredigion and Pembrokeshire IDVA Services, 2016
Note: MARAC data from October 2016 was not available at the time of writing.
The graph shows increases in MARAC referrals from the Dyfed counties
(Carmarthenshire, Ceredigion, Pembrokeshire and Powys) and indicates a year on
year upward trend in referrals over the last three full financial years. Data for 2016/17
are included up to and including August 2016 and suggest the upward trend
continues. The new requirements of the Social Services and Wellbeing Act and
changes in the way that Police record crime and incidents are thought to be
contributing factors to the upward trend. National figures from Her Majesty’s
Inspectorate of Constabulary show the number of domestic abuse cases reported to
the police in England and Wales rose by 31% between 2013 and 2015 (BBC, 2015).
147
There are peaks and troughs in referrals. There is a peak around the Christmas
period when additional pressures can impact on families already experiencing abuse
and there is a trough around August where fewer people are in work and children are
not in school so identification leading to a referral can be lower.
Cases are only heard at MARAC when they become high or very high risk cases and
therefore only represent a small proportion of the total number of actual cases.
Research suggests only around 2% of domestic assaults are reported to the police
and that on average, a woman will be assaulted 35 times before she contacts the
police (Yearnshire, 1997).
Figure 15:2 MARAC cases

MARAC data 2015/16 Carmarthenshire Ceredigion Pembrokeshire Total
Number of cases heard at
MARAC 454 189 341 984
Safe Lives recommended
number of cases 310 130 210 650
Number of children in
MARAC households 448 257 402 1462
79 31 44
Number of repeats
(17%) (16%) (12%) 154 (15%)
BME referrals 21 6 7 34
Alleged victim has a
10 or
disability (physical, mental 5 or under 5 or under 5 or under
greater
etc.)
Referrals where there is
an alleged male victim 28 15 32 75
Fewer
LGBT cases discussed
Under 5 Under 5 Under 5 than 5
Cases where the person
causing harm is aged 17 Fewer
and below Under 5 Under 5 Under 5 than 5
 The number of male victims discussed varies across counties and the numbers
are confounded by a number of factors. Perpetrators of abuse often make
counter allegations of abuse against the actual victim. However, research (ONS,
2015) also suggests
 1/3 of victims of abuse in Wales are male
 male victims are more than twice as likely as women not to tell anyone about
the partner abuse they are suffering (29% and 12%, respectively)
 Levels of reporting for those with a disability appear to be low when it is taken
into account that their additional vulnerability is a known area for increased
susceptibility to being abused; research (Bennett et al, 2013) suggests
 people with a learning disability are not always listened to or believed when
reporting abuse
 disabled children and adults are at greater risk of experiencing abuse and
violence than their non- disabled peers
 people with a learning disability are more likely to be subjected to abuse than
non-disabled people and possibly at greater risk than other disabled people
148
 Very few younger victims are discussed at MARAC. Safeguarding processes are
in place in each county’s children’s services department where high risk cases
are also managed
Cases of abuse in older people appear to be an area where there is underreporting.

The National Strategy (Welsh Government, 2016) suggests:
‘There is sometimes confusion between the experience of domestic abuse in later life
and “elder abuse” (a term which encompasses all forms of violence, abuse and
neglect experienced by older people). Such confusion can result in victims of abuse
falling between the systems which are designed to offer them protection and as a
consequence do not receive appropriate support to help them to stop the abuse or
make them safe.’
Work is ongoing through a pilot in Carmarthenshire and Cardiff led by Aberystwyth

University to improve responses and so improve outcomes for older people.

The Violence Against Women, Domestic Violence and Sexual Abuse Act, 2015
makes it clear that partners including Local Authorities, Local Health Boards, NHS
Trusts, Fire and Rescue Authorities, Police, Police and Crime Commissioners,
education services, housing organisations, the third sector, specialist services,
survivors, crime and justice agencies, and probation services need to work together
to:
 Prevent violence against women, domestic abuse and sexual violence 
 Protect victims of violence against women, domestic abuse and sexual violence 
 Support people affected by violence against women, domestic abuse and sexual
violence 
The National Strategy (Welsh Government, 2016) makes it clear that this requires;
‘targeted action and support to overcome barriers to accessing safety and support.
Women who are known to be especially vulnerable to violence and/or who are
marginalised, such as women in prostitution, women from BME communities,
disabled women, women with mental health or substance abuse problems, young
women in care, will require specialised approaches.’
Feedback suggests survivors of domestic abuse have a range of support needs

including better awareness and understanding, help with feelings of isolation, non-
time limited support, and support for children within the abusive relationship;
“I think we need more awareness of what is available […] a lot of people are afraid of
going into a refuge.”
“I think we need more awareness earlier – in early teens.”
“Being understood by support workers is really important.”
“The group was the most helpful thing as it made me feel less isolated. I had contact
with other women and realised for the first time in years that I wasn’t the only one
living with this.”
149
“We need more support for us so we’re not seen as a case to be closed or passed on
to someone else, we have needs in our own right, and support should be available
for as long as we need it, not time limited.”
“The worse thing was the children didn’t have the option of speaking to someone.
They wouldn’t say anything to a teacher or a police officer… but if there was a
support worker there for children they’d have spoken to them.”
“For a long time I felt confused...Was I just as bad as (dad)? How could I love
someone who hits my mum?”
Source: Welsh Women’s Aid, 2016.
There is also a need to deal with the effects of coercive control that prevents many
victims from getting in touch with any services and some people may not recognise
that they are in an abusive relationship. To help address this issue controlling or
coercive behaviour has been made a crime under section 76 of the Serious Crime
Act 2015 (CPS, 2015)

WG contracted with Hafan Cymru in 2015 to provide awareness-raising in primary
and secondary schools across all schools in Wales through the SPECTRUM Project.
This aims to assist with children having access to dedicated sessions around healthy
relationships. Discussions are ongoing regarding how this contract can be enhanced
to further support the guidance. In addition to this each county’s specialist support
providers provide awareness raising sessions in schools and youth settings.
Community campaigns are coordinated during the year to improve the community’s
understanding of abuse and the support that is available. Domestic Abuse
Coordinators, specialist services and partners also utilise opportunities to raise
awareness in community settings.
A mandatory National Training Framework is in place with training modules currently

under development to ensure that staff are training appropriately for their level of
involvement and are able to target enquiry and act appropriately where abuse or
violence is disclosed. Training has also been arranged for Health Board staff in
Domestic Abuse, Risk Assessment and MARAC training and Domestic Abuse and
the Older Person. Domestic Abuse Routine Enquiry is ongoing in both Midwifery and
Health Visiting. Accident and Emergency staff complete questions with patients to
assist in determining if the patient is experiencing abuse.
The following table shows the range of services from universal services through to
those for acute needs and approximate stages for services to become involved or
hand over to other services. Some services may become involved earlier and remain
involved. Others may only be involved once, or for specific support at different times
when needed. New legislation may impact these areas of support so this represents
current service configuration.
150
Universal Protection /
Additional support More complex needs
services Safeguarding needs
GPs Flying start services
Specialist Safeguarding Team
Midwifery
within Health
Community
Looked After Children
nursing Specialist Safeguarding Midwife
Service
team
Specialist Safeguarding
Child and Adolescent Mental
Hospitals Health Visitor Flying
Health Services
Start
Community Psychiatric Team
attached to Mental Health
Services
Social Care tier 3
Substance misuse services services for substance
misuse
Multi agency Child
Social Care Child and
protection
Childcare Children and family services adult safeguarding and
Multi agency Adult
protection teams
protection
Family
Families first services
centres
Team around the family
Generic community support
services
Disability services
Older people’s services
Victim support Counselling services
Independent Domestic Abuse Refuge/safe
Adviser (IDVA) accommodation
Courts & legal services
New Pathways
(civil, family & criminal)
Police Protecting
Police Probation
Vulnerable People Units
Community Rehabilitation
Company
Citizens
advice
Benefits,
Financial
services
Housing Homelessness options
Safeguarding Leads in
Education
school
Figure 15:3 Range of services
Source: Local data
Peer support can assist survivors with early recovery and specialist services offer
group support work such as the Freedom Programmes, which benefit survivors in
understanding healthy relationships and so reduce the likelihood of abuse in future
relationships.
The MARAC process is led by Dyfed Powys Police and the process allows all
relevant partner agencies to come together to increase safety options for victims of
151
domestic abuse. Each county has an Independent Domestic Abuse Adviser (IDVA)
service that provides short to medium term support to those at high or very high risk.
Target hardening (strengthening of the security of a building or installation in order to

protect it in the event of attack) which allows survivors to stay in their own homes
when it is safe to do so rather than flee to refuge is a preferred option and can reduce
dependency on specialist services.
Each county has specialist services that provide refuge accommodation, move on
accommodation and community support. In addition to this, Carmarthenshire have a
dedicated Domestic Abuse Social worker in their children’s team and Ceredigion
have plans to provide specialists within Flying Start services.
Each LA has dedicated safeguarding teams that provide support and protection to
vulnerable people. Hywel Dda University Health Board have a safeguarding team
that works with other agencies to address risk and support needs.

There are a range of gaps and areas for improvement that need to be addressed in
the context of the new requirements under recent legislation. These are set out below
against the core principles of the Social Services and Wellbeing (Wales) Act.
Voice and Control
Despite a significant amount of work in Wales including many awareness raising

campaigns there remains a public perception that domestic abuse is ‘something that
doesn’t happen around here’ and so signs of abuse in friends and family can be
missed in the community. There are also enduring social problems of violence
against women, domestic abuse and sexual violence and many men, women and
children are still at risk of, or experiencing violence or abuse. More work across
agencies is required to challenge perceptions and provide earlier interventions for
survivors of abuse.
There is no benchmark for the number of children and young people reached through
awareness raising sessions in schools and youth settings although each county
reports increased concerns in teenagers and young adults’ understanding of what
constitutes a healthy relationship. It would be helpful to have a better understanding
of the numbers of children and young people reached through these sessions and to
have the involvement of specialist services during campaigns to support disclosure.
Awareness raising sessions for adults also need to be expanded with improved
effectiveness and resources.
A more robust awareness raising strategy also needs to be developed to raise

awareness of elder abuse building on the pilot in Carmarthenshire and Cardiff.
There is a gap in services for those that are not able to engage with services which
could be because of fear of repercussions or the effects of coercive control.
Historically Domestic Abuse services provided an outreach service which allowed
victims to maintain a level of contact with services and the time to be able to accept
152
support. There is no dedicated outreach service in the region and although specialist
charities make efforts to offer outreach via volunteers, they are often hampered by a
lack of resourcing to recruit volunteers and manage the service effectively. Where
gaps exist survivors could benefit from improved support from universal services
which are able to keep in touch with the survivor and offer additional support via
specialists at the right time. There is also a need to deal with the effects of coercive
control that prevents many victims from getting in touch with any services.
The introduction of targeted enquiry through the Ask and Act process that targets
enquiry through services that are likely to come into contact with those experiencing
abuse is likely to lead to an increase in demand for support and therefore waiting
lists. In Ceredigion some targeted work in training staff in education has resulted in a
large increase in direct support for children, which resulted in increases in waiting
lists for support. Clearly this is problematic as it delays intervention, support and
ultimately recovery. Early intervention can prevent inappropriate development
becoming embedded longer term and can break the cycle of abuse so that it does not
carry on into the next generation.
When teenagers exhibit violent and abusive behavior there is a gap in services to
address violence. This requires a partnership response to combat abusive behaviour
in teenagers and reduce escalation.
Perpetrator programmes which aim to reducing abusive and violent behaviour vary
across the region:
 Ceredigion lacks any perpetrator programme except where there is a court

conviction and relies on being able to refer onto programmes in neighbouring
counties
 Carmarthenshire have a pilot charity-funded project to provide support to whole
families including perpetrators of abuse
 Pembrokeshire run a non-RESPECT accredited programme that is suitable for
some perpetrators and not others
There is a need to consider what model of support is effective and how such work
can be resourced.
The IDVA is a key part of the pathway for survivors of high and very high risk cases.
These services are currently part funded from WG Grants and part funded from
Home Office Grants. Current IDVA provision and pathways vary greatly across the
region and each county lacks the levels required for the number of MARAC cases
heard. The following table shows the number of FTE IDVAs in each county, the
number recommended by Safe Lives, and the number required to service current
case numbers. In Carmarthenshire and Ceredigion the number of FTE IDVAs is less
than the Safe Lives recommended levels and the numbers required to service current
case loads. In Ceredigion the number of FTEs is between these benchmarks. The
aggregated figures for the region also fall short of both benchmarks.
153
Figure 15:4 MARAC cases and IDVA support

MARAC data Carmarthenshire Ceredigion Pembrokeshire Total
Number of cases heard at
MARAC 454 189 341 984
Safe Lives recommended
number of cases 310 130 210 650
Number of Full Time
Equivalent (FTE) IDVAs
recommended by Safe Lives 4 1.5 3 8.5
Number of FTE IDVAs to
serve current volume of
cases 5.8 2.2 4.5 12.5
Current IDVA FTE 2.56 1.8 2.45 6.9
In addition, targeted enquiry is likely to lead to increased demand on services. It is

anticipated that from April 2017 WG will move to a regional funding model for IDVAs.
If this happens there will be an opportunity to ensure that services in each county are
appropriate to the identified level of need and that there is a consistent IDVA pathway
across the region. In order to support the targeted enquiry process it would also be
helpful for staff working across public services to be able to signpost appropriately
through having a directory of services.
Specialist support and protection services include refuge and move on

accommodation which are funded by Supporting People Programme Grant which
provides housing related support to vulnerable people. However, capacity levels are
low and services across the region advise that they are operating at maximum
capacity. The following table shows the numbers supported by specialist services
across the three counties.
Figure 15:5 Refuge and Move on services

Refuge number supported 99 29
Number supported in move on 24 79 9
units
Total 123 79 38
Floating (community) support 227 78 68
Refuges are managed by specialist services, with the refuges being owned by LA or
Social Housing Landlords. Funding for support in refuges comes from Supporting
People. Rents are covered through housing benefits, providing that the survivor is
able to access the benefits system. Housing are a vital partner in addressing
accommodation issues for survivors of domestic abuse.
One Stop Shops have been funded through capital grants from WG, where specialist
services either purchased buildings or leased them utilising the grant. Specialist
services welcome partners utilising these buildings to assist with partnership working.
154
Currently target hardening options are limited in the three counties. Police utilise
locksmith services for emergencies for the most acute needs but options are lacking
further down the scale. Target hardening can improve feelings of safety and can
contribute to a reduction in demand for refuge services. There is a need to identify
cost effective target hardening solutions with a partnership approach.
There is also a need to consider how to assist migrant, refugee and asylum seeking
women who have no recourse to public funds but who may be subject to FGM,
‘honour’ based violence, forced marriage, domestic abuse and sexual violence.
Although the numbers are difficult to estimate accurately (for example the total
number of asylum seekers and refugees living in Wales is estimated to be between
7,500 and 11,500) (Crawley, 2013), there is a need to consider appropriate pathways
for these women who may be suffering abuse and to identify and access funding that
may exist for example from the Home Office for non EU women on spousal visas.
Data collection from specialist services other than IDVA services is lacking. Specialist
providers across all three counties accept referrals from marginalised groups. Each
LA considers equality impact in any decision-making around the commissioning of
services.
Black and Minority Ethnic (BME) communities are able to access domestic abuse
services although specialist support for BME communities and Gypsy and Traveller
communities is required as there are particular risks associated with some
communities. Also the BAWSO service across Wales which provided generic and
specialist services for BME communities ended in 2015/16.
There is evidence that individuals who attend the Sexual Abuse Referrals Centres
(SARC) may also have been victims of domestic abuse, although further work is
required to identify the actual numbers. Support is given by third sector organisations
such as New Pathways. Victims attending the SARC will often require sexual health
services and as such there are robust pathways in place to support this service and
allow easy access for victims. Pathways are also in place for easy access to the
Emergency Departments, should victims require urgent treatment. The follow up of
such victims will be an important element of their physical and mental Health care. It
is these follow up services that may require further in-depth analysis as to what
currently exists.
Wellbeing
There is a high correlation between escalation in abuse with mental health issues
and drug and alcohol use. HDUHB have undertaken some work within Mental Health
Services and some of the specialist teams do work closely with partner organisations.
Public Health and Health Visiting Flying Start/Specialist mental health services will
support some areas, however, it is recognised that more investment and a more
consistent approach across all counties would be helpful.
There is also a lack of supply of suitable, affordable, good quality single person and 2
bedroomed accommodation in Carmarthenshire that cannot be met through social
housing leading to a reliance on the private sector. However, private sector landlords
155
are reluctant to let to people who are benefit dependent. This lack of supply is having
a detrimental impact on the capacity and capability of both supported and
unsupported temporary accommodation to meet the needs of service users. There is
a need to improve working relationships with landlords and providers of housing
related support.
Co-production
There is published research following engagement with survivors of VAMDASV (both

nationally) for example; ‘Are you Listening’ and ‘Am I Being Heard’ (Welsh Women’s
Aid, 2016 ) that sets out the care and support needs of this group in their own words
but more work is needed locally to engage people with lived experience in this area
to co-design and deliver support.
Under requirements of the VAWDASV Act a regional strategic board comprising all
partners (Dyfed Powys Police, Mid Wales Fire and Rescue Service, Welsh
Ambulance Trust, Health Boards, Local Authorities, Education, Probation, Specialist
Third Sector) needs to be established which will report to WG. The Board will be
based around the Dyfed Powys Police footprint so will include Powys organisations.
Consideration should be given to adapting the existing Regional Domestic Abuse
Forum for this purpose. The Board could consider and co-ordinate a regional
response to the new requirements placed upon public services and the gaps and
areas for development highlighted in this report and to support delivery of the 6
objectives set out in the National Strategy:
 Increase awareness of violence against women, domestic abuse and sexual
violence
 Enhance education about healthy relationships and gender equality
 Challenge perpetrators, hold them accountable for their actions and provide
interventions and support to change their behaviour
 Ensure professionals are trained to provide effective, timely and appropriate
responses to victims and survivors  
 Provide victims with equal access to appropriately resourced high quality, needs
led, strength based, gender responsive services
 Work together to understand and meet the needs of communities
156
15.6. References
BBC (2015). Domestic abuse: Police 'nearly overwhelmed' by increase. Available at:
http://www.bbc.co.uk/news/uk-35093837
Barter, C., McCarry, M., Berridge, D. and Evans, K. (2009). Partner exploitation and
violence in teenage intimate relationships. NSPCC. Available at:
https://www.nspcc.org.uk/globalassets/documents/research-reports/partner-
exploitation-violence-teenage-intimate-relationships-report.pdf
Bennett, D., Flood, S., Howarth, J., Melsome, M. and Northway, R. (2013). Looking
into Abuse: Research by People with Learning Disabilities. University of Glamorgan.
Available at: http://udid.research.southwales.ac.uk/media/files/documents/2013-03-
05/Final_report.pdf
Bentley, H., O’Hagan, O., Raff, A. and Bhatti, I. (2016). How safe are our children?
2016. London: NSPCC. Available at: https://www.nspcc.org.uk/services-and-
resources/research-and-resources/2016/how-safe-are-our-children-2016/
Crawley, H. (2013). Asylum seekers and refugees in Wales. Wales Migration

Partnership. Available at:
http://www.wmp.org.uk/documents/wsmp/News%20and%20Events/Migration%20Bri
efings/Asylum%20Seekers%20and%20Refugees%20in%20Wales.pdf
CPS (2015). Controlling and coercive behaviour can "limit victims' basic human
rights" as new domestic abuse law introduced [online]. Available at:
http://www.cps.gov.uk/news/latest_news/new_domestic_abuse_law_introduced/
Local Government Association (2015). Adult safeguarding and domestic abuse, A

guide to support practitioners and managers, 2nd edition. Available at:
http://www.local.gov.uk/c/document_library/get_file?uuid=5928377b-8eb3-4518-
84ac-61ea6e19a026&
ONS (2016). Focus on Violent Crime and Sexual Offences: Year ending March 2015.
Available at:
https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/compendiu
m/focusonviolentcrimeandsexualoffences/yearendingmarch2015
Welsh Government (2016). National Strategy on Violence Against Women, Domestic

Abuse and Sexual Violence, 2016 – 2021. Available at:
http://gov.wales/docs/dsjlg/publications/commsafety/161104-national-strategy-en.pdf
Welsh Women’s Aid (n.d.). Statistics & Research [online]. Available at:
http://www.welshwomensaid.org.uk/index.php?option=com_content&view=article&id=
49&Itemid=55
157
Welsh Women’s Aid (2016). Are you listening and am I being heard? Available at:
http://www.rhianbowendavies.com/wp-content/uploads/2016/09/Are-you-listening-
and-am-I-being-heard-FINAL-July-2016.pdf
Yearnshire, S. (1997). “Analysis of cohort”. In: Bewley S, Friend J and Mezey G. (e d

s.) Violence against women. London: RCOG Press, pp. 45
158
16. Appendices
16.1. Appendix 1 List of figures and tables
To be completed
159
16.2. Appendix 2 Group membership and acknowledgements

A wide range of colleagues from across partner organisations contributed to the
Assessment, through thematic working groups and an editorial group. Thanks are
recorded to the following colleagues who contributed in this way:
Carers
Liz Blazey, Pembrokeshire County Council

Dr Gareth Morgan, Hywel Dda University Health Board
Pennie Muir, Hywel Dda University Health Board
Catherine Moyle, Ceredigion County Council
Jonathan Rees, Carmarthenshire County Council
Heather West, Ceredigion County Council
Children and Young People

Heulwen Davies, Ceredigion County Council
Margaret Devonald Morris, Hywel Dda University Health Board
Joy Fereday, Ceredigion county Council
Billy Goodfellow, Ceredigion County Council
Isobel Hall, Hywel Dda University Health Board
Joff Lee, Ceredigion County Council
Stefan Smith, Carmarthenshire County Council
Dr Michael Thomas, Hywel Dda University Health Board
Noeline Thomas, Carmarthenshire County Council
Health and Physical Disability
Jean Davies, Pembrokeshire County Council

Corinne Wreford, Ceredigion County Council
Gareth A Miller, Carmarthenshire County Council
Sandra Morgan, Hywel Dda University Health Board
Martyn Palfreman, West Wales Care Partnership
Judi O’Rourke, Ceredigion County Council
Julia Wilkinson, Carmarthenshire County Council
Learning Disability and Autism
Anna Bird, Hywel Dda University Health Board

Kelvin Barlow, Carmarthenshire County Council
Avril Bracey, Carmarthenshire County Council
Kim Conroy, Ceredigion County Council
Julie Denley, Hywel Dda University Health Board
Neil Edwards, Carmarthenshire County Council
Melanie Evans, Hywel Dda University Health Board
160

Joel Sven Martin, Carmarthenshire County Council
Silvana Sauro, Carmarthenshire County Council
Nigel Miller, Hywel Dda University Health Board
Donna Pritchard, Ceredigion County Council
Mary Rendell, Ceredigion County Council
Mental Health and Substance Misuse

Avril Bracey, Carmarthenshire County Council
Julie Denley, Hywel Dda University Health Board
Mark Evans, Carmarthenshire County Council
John Forbes-Jones, Ceredigion County Council
Carys James, Ceredigion County Council
Richard Jones, Hywel Dda University health Board
Donna Pritchard, Ceredigion County Council
Dr Boika Rechel, Hywel Dda University Health Board
Joel Sven Martin, Carmarthenshire County Council
Silvana Sauro, Carmarthenshire County Council
Older People

Sandra Morgan, Hywel Dda University Health Board
Sensory Impairment

Mellony Richards, Ceredigion County Council
Violence Against Women, Domestic Abuse and Sexual Violence

Alun Davies, Ceredigion County Council
Nicola Edwards, Hywel Dda University Health Board
161
Sinead Henehan, Pembrokeshire County Council

Alun Jones, Carmarthenshire County Council
Mandy Nichols-Davies, Hywel Dda University Health Board
Sian Passey, Hywel Dda University Health Board
Lowrie Proctor, Dyfed Powys Police
Matthew Richards, Ceredigion County Council
Helen Twidle, Ceredigion County Council
Editorial Group

Mary Palmer, Project Manager
162

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Hywel Dda University Health Board

Annual Plan 2017/18

SUBMISSION TO WELSH GOVERNMENT

THE HYWEL DDA

Action Plan Page

What we planned to do in 2016/17 What we did What we are going to do in

What we said we would do in What we have done. What we will do in 2017/18.

Lead on commissioning, partnership • Provided programme and Continue to provide commissioning,

What we said we would What we have done What we will do in 2017/18

What we said we would What we have done What we will do in 2017/18.

Implement new ‘short term assessment & acute response’ √

Service specification for ‘111’ in Carmarthenshire is being √

• Frail adults ‘off their legs’ due to acute episode, √

Consolidate implementation of pathways to ensure √

Monthly ‘highlight’ meetings with WAST and ‘111’ to √ √ √

To ensure recruitment completed against agreed proposals

Regional Project Manager Appointed and Regional Project √

Pilot of the Implement Pilot - To strengthen service in relation to hospice

Advance Specialist Wider community nursing to access specific training – to √

50% wider community nursing and CDM nurses attended √

75% wider community nursing and CDM nurses attended

100% wider community nursing and CDM nurses attended

To evaluate existing service at year end and consider

IAA Single point of access Follow agreed development plan √

Investors in carers Increase the number of GPs obtaining Silver award √ √ √ √

Objective 2: Intermediate Care (Living with an ongoing condition)

Reablement Improvement in KPIs √ √ √ √

Joint stores Continued good performance of Section 33 agreement √ √ √ √

Cross Hands development discussions commence √

Building Coaching Network Coaching cohort 4 √

Integrated Education Development of integrated education plan for the √

Access Sustainable GMS 7 pillars model to be refreshed √ √ √ √

Develop further common ailment pharmacies √ √ √ √

Summer Social Media Campaign x 3 √

Attendance at a minimum of 3 freshers fairs to √

Involvement in Winter wise campaign √

Winter Wise social media campaign √

Welsh language Develop plan with Welsh Language Team √

Objective 2: Intermediate Care (Living with an ongoing condition)

Long term Special Care Dental Finalise pathway OCP √

As per the ARCH Portfolio Development Plan (Annex Document)

Develop the Community Resilience

Service Task Action Q1 Q2 Q3 Q4

Service area Task Action Q1 Q2 Q3 Q4

What we What we have done What we will do in 2017/18

Identify resource requirements for required services

Service area Task Action Q1 Q2 Q3 Q4

Deliver Business Case to Board for frailty pathway √

Pathway Implementation - Maintain Align with delivery of SSWBA requirements √ √ √ √

Agreement with primary care re roll out √ √

Consolidate community case management √ √ √ √

Review of reablement services and capacity

Rapid response domiciliary care √ √

Model intermediate care bed requirements (incl √

A&E triage to ambulatory care (Link to USC

Agree 7 day cover (within current resource √

Roll out CGA assessment to patients screened as √ √ √

into Ward Rounds, Board Rounds & explicit √ √ √ √

Undertake establishment reviews within √ √ √

Manage overseas recruitment √ √ √ √ √ √

Reduce nurse agency √

Review all agency staff with each √

Targeted recruitment plans linked to