Thirty-second Board meeting - Public Health Wales

32 00

1

Thirty-second Board meeting Date of meeting: 26 June 2014

Time of meeting: 10.00 – 16.00

Venue for meeting: Room 1DM2, Pembrokeshire County Council,

County Hall, Haverfordwest SA61 1TP

Version: 1

Time Reference

Preliminary matters

1. 10.00 Welcome and apologies Professor Sir Mansel Aylward

Oral

2. 10.05 Declarations of interest

Professor Sir Mansel Aylward

Oral

3. 10.10 Minutes from thirty-first Board meeting on

29 April 2014 Professor Sir Mansel Aylward

32 01

a) Approval of minutes

b) Action points

c) Matters arising

4. 10.20 Chair report

Professor Sir Mansel Aylward

32 02

(to follow)

5. 10.40 Chief Executive / Interim Chief Executive

report

Dr Tracey Cooper / Mr Huw George

32 03

For decision

6. 11.00 Integrated medium term plan: one year operational plan

Mr Mark Dickinson

32 04 (to follow)

7. 11.45 Policies for approval

a) Statutory and mandatory training

Ms Ruth Davies, Director of Workforce and Organisational Development

32 05

8. 11.55 Governance and accountability module 32 06

32 00

2

Mr Keith Cox

For ratification

9. 12.00 Annual accounts and Annual Governance Statement

Mr Huw George

32 07

10. 12.10 Public Health Wales response to Public

Health Bill white paper Sir Mansel Aylward

32 08

(to follow)

12.20 LUNCH

For scrutiny and discussion

11. 12.50 Performance reports

a) Finance performance report

Mr Huw George

32 09

b) Update from Public Health Wales and Welsh

Government Joint Executive Team meeting Mr Mark Dickinson

32 10

13.

13.20 Governance report

Mr Keith Cox

32 11

a) Plan of Board business 32 12

b) Corporate Risk Register 32 13 (to follow)

14. 13.40 Trusted to Care: assurance to Board

Dr Tracey Cooper

32 14

15. 13.50 Hywel Dda local public health team

Dr Teresa Owens, Executive Director of Public Health, Hywel Dda University Health Board

Oral

16. 14.35 Committee meeting reports

a) Audit Committee

Mr Terence Rose

Oral

b) Information Governance Committee Mr John Spence

Oral

17. 14.45 Audit Committee annual report Mr Terence Rose

32 15

For information

18. 14.55 Non Executive Director reports Oral

19.

15.05 Annual reports

a) Safeguarding annual report 32 16

b) Emergency planning annual report 32 17

20.

Correspondence

a) Dr Tracey Cooper, Accountable Officer

letter

32 18

b) Dr Tracey Cooper, Joint Executive Team

letter

32 19

21. Committee meeting

a) Audit Committee minutes from meeting 32 20

32 00

3

held on 12 March 2014

b) Audit Committee minutes from meeting held on 8 May 2014

32 21

c) Information Governance Committee

minutes from meeting held on 12 March 2014

32 22

22. 15.15 Any other business and meeting close Professor Sir Mansel Aylward

23. Papers for information

a) Executive Team reports presented at the 41st meeting of the Public Health Wales

Executive Team held on 21 May 2014 Planning and Performance report

Board Secretary report Workforce and Organisational Development

report

Public Health Services report Public Health Development report

Nursing report Communications report

b) Public Health Wales and Welsh Government Joint Executive Team meeting presentation

32 23

PRIVATE SESSION

1. 15.20 Remuneration of senior managers Sir Mansel Aylward

32 24

2. 15.25 Proposal for appointing a deputy Chief

Executive Dr Tracey Cooper

Oral

3. 15.35 NATO Dr Quentin Sandifer

Oral

Items containing commercially sensitive information

4. 15.40 Ratification of decision: microbiology total bacteriology automation equipment for

north Wales Dr Quentin Sandifer

32 25

5. 15.45 WEDINOS

Sir Mansel Aylward

Oral

6. 15.50 Managed service contract for serology and

Chlamydia laboratory testing Dr Quentin Sandifer

32 26

7. 15.55 Death Certification and medical examiners

Dr Quentin Sandifer

32 27

16.00 Meeting close

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/9EA47D734DE3B25E80257C160035D22B/$file/35-05bReport%20of%20the%20Director%20of%20Planning%20and%20Performance%20November%202013%20v0c.docx

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/408EAC0A35EDDE9080257C160035EFF0/$file/35-05d%20Report%20of%20the%20Board%20Secretary%20November%20v1.doc

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/27C16CDEA61C580C80257C160035FF05/$file/35-05f%20Report%20of%20the%20Director%20of%20Workforce%20and%20OD%20V1%20November%202013.docx

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/27C16CDEA61C580C80257C160035FF05/$file/35-05f%20Report%20of%20the%20Director%20of%20Workforce%20and%20OD%20V1%20November%202013.docx

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/DB790BDAD3098B0D80257C1600360D08/$file/35-05g%20Report%20of%20the%20Director%20of%20Public%20Health%20Services%20November%202013%20v1.docx

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/5BF1CC0B1C2B018280257C16003617E9/$file/35-05h%20Report%20of%20the%20Director%20of%20Public%20Health%20Development%20November%202013.doc

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/A4A9AB985334492180257C1600362A3B/$file/35-05i%20Director%20of%20nursing%20report%20November.doc

http://nww2.nphs.wales.nhs.uk:8080/PHWExecutiveManWP.nsf/0/D15B815E4AFAADB980257C1900545911/$file/35-05c%20Director%20of%20Communications%20Report%20November13%20v1%20(2).doc

32 01

Date: 16 June 2014 Version: 0a Page: 1 of 16

Minutes from the thirty-first

meeting of the Public Health

Wales Board Date of meeting: 29 April 2014

Venue for meeting: Council Chamber, Temple of Peace and Health, Cardiff

Version: 0a

Present:

Professor Sir Mansel Aylward Chair

Professor Peter Bradley Executive Director of Public Health Development

Dr Carl Clowes Non Executive Director

Mr Mark Dickinson Executive Director of Planning and Performance

Mr Huw George Interim Chief Executive

Ms Tamira Rolls Interim Executive Director of Finance

Mr Terence Rose Non Executive Director

Dr Quentin Sandifer Executive Director of Public Health

Services

Mr John Spence Non Executive Director

Professor Simon Smail Non Executive Director

In attendance:

Ms Rhiannon Beaumont-Wood

Director of Nursing

Professor Mark Bellis Director of Policy, Research and

Development

Mr Hugh Bennett Consultant in Dental Public Health, Team

Leader Dental Public Health and Dental Governance Team

Dr Tracey Cooper Incoming Chief Executive, Public Health

Wales

32 01


Mr Keith Cox Board Secretary

Ms Margaret Foster Chair, NHS Wales Shared Services Partnership

Dr Rosemary Fox Director of Screening Services

Mr Neil Frowe Director, NHS Wales Shared Services Partnership

Ms Eleanor Higgins Corporate Governance Manager

Mr Chris Lines Director of Communications

Mr Chris Orr Business Support Manager

Ms Stephanie Wilkins Unite representative, Public Health Wales

Apologies:

Dr Carl Clowes Non Executive Director

Mrs Ruth Davies Director of Workforce and Organisational

Development

Renata Leonardi-Jones Unison representative, Public Health

Wales

Professor Gareth Williams Non Executive Director

PART A

1. Welcome and apologies for absence

Professor Sir Mansel Aylward all in attendance to the thirty first meeting of the Public Health Wales Board.

Apologies were received from Dr Carl Clowes, Professor Gareth

Williams and Ms Renata Leonardi-Jones.

2. Declarations of interest

No declarations of interest were received.

3. Minutes from Public Health Wales Board meeting held on 27

March 2014


The minutes (paper 31 01) from the last meeting of the Public

Health Wales Board were approved subject to one amendment.

Ms Stephanie Wilkins alerted the Board to an omission in the minutes under section 5 ‘interim Chief Executive’s report’ on page

4. It was agreed to add the following text to this section:

32 01


Ms Stephanie Wilkins mentioned that, while the Statutory and Mandatory training compliance rates had improved, staff

had felt pressure from a number of areas towards the end of the financial year, for example, annual appraisals, the need

to take annual leave, and the request to undertake statutory and mandatory training. It was requested that better

planning take place throughout the year to avoid undue pressure at year-end.

Decision: Minutes from the last meeting of the Public Health Wales

Board were approved.

b) Actions:

Mr Keith Cox provided the Board with an update on actions which

were marked as ‘in progress’. Further information on each action is provided in the action table at the end of the minutes.

c) Matters arising

Dr Quentin Sandifer updated the Board on Diabetic Retinopathy

Screening Services Wales. At the last Board meeting, the Board had approved the recommendation for the Diabetic Retinopathy

Screening Service to transfer to Public Health Wales from Cardiff and Vale University Health Board subject to assurances against

revenue funding, capital funding and a start date of 1 April 2015.

As a result of Public Health Wales’ request for these assurances, the Welsh Government has requested more detailed analysis on

the revenue and capital funding.

4. Introduce new Chief Executive – Dr Tracey Cooper

Professor Sir Mansel Aylward introduced Dr Tracey Cooper to the Board. Dr Cooper would be taking up the appointment of Chief

Executive on 1 June 2014.

Dr Cooper thanked Sir Mansel for the kind words of welcome. Dr

Cooper also thanked everyone she had met from Public Health Wales. She noted the huge opportunity Public Health Wales has in

making a difference to the public health agenda in the Welsh health system.

Dr Cooper offered particular thanks to Sir Mansel, Mr John Spence

and Mr Huw George for facilitating her visit to Public Health Wales.

32 01


5. Chair’s report

Professor Sir Mansel Aylward presented the Chair’s report (paper

31 02).

Sir Mansel informed the Board that he had recently had a meeting with representatives from the BMA (Dr Richard Lewis, Dr Andrew

Cross and Dr Mark Temple), Mr John Spence, Mr Huw George and Mr Keith Cox. The meeting was arranged to discuss whether the

BMA would nominate a member to attend Public Health Wales Board meetings. Both parties agreed that it would be beneficial to

for a representative of the BMA to attend Public Health Wales

Board meetings. It was agreed that Mr Cox and Dr Temple would draft a framework to support the nominated representative.

6. Interim Chief Executive’s report

Mr Huw George presented his Interim Chief Executive’s report

(paper 31.03).

Mr George commented on the considerable improvement in

compliance with statutory and mandatory training. He offered particular thanks to the Microbiology Division which had started

with a very low compliance rate.

The Board recorded its appreciation for all those involved in improving compliance rates. They were pleased to see a

substantial improvement against what had previously been significantly poor rates.

Professor Simon Smail reminded the Board that the Quality and

Safety Committee had shown concern about the low level of compliance. He mentioned that compliance with mandatory

training was still problematic as there was a lack of clarity over what denominators should be used to establish which staff groups

require which training. Mr George suggested that Claire Barley,

Head of Professional and Organisational Development, should report to Quality and Safety Committee and start identifying which

training is not needed by certain members of staff.

Action: invite Claire Barley to attend Quality and Safety Committee and begin identifying which training is not

needed by certain members of staff.

7. Proposal to transfer dental practice advisors from Public Health Wales to Health Boards

32 01


Mr Hugh Bennett presented the Board with a proposal to transfer

dental practice advisors from Public Health Wales to Health Boards (paper 31 04).

The Board accepted the recommendations outlined in the paper.

8. Social media strategy review

Mr Chris Lines introduced the social media strategy review (paper 31 05).

Mr Lines explained that social media has provided a platform to

capture the work of staff selling powerful stories.

Ms Stephanie Wilkins raised some concerns that Unite has about people misusing social media. Mr Lines reassured Ms Wilkins that

he did not want to create unnecessary bureaucracy by restricting use of social media for staff and explained that full training would

be given to staff before accessing social media.

The Board approved the recommendations in the review.

9. Standing orders and standing financial instructions

Mr Keith Cox presented the Board with revised Standing Orders

and Standing Financial Instructions (paper 31 06). The revisions had been made to reflect the requirement for Public Health Wales

to produce an Integrated Medium Term Plan.

The Board approved the amended Standing Orders and Standing Financial Instructions.

10. Nursing and midwifery strategy

Ms Rhiannon Beaumont Wood presented the Board with the nursing and midwifery strategy (paper 31 07).

Ms Beaumont-Wood explained that the strategy had been

developed by a task and finish group comprising nursing and midwifery staff. If approved, the strategy would be launched on 12

May 2014, which was International Nursing Day.

The Board approved the strategy.

11. Policies for approval

a) Home working policy

32 01


Mr Huw George presented the Board with the Home Working policy

in the absence of Ms Ruth Davies (paper 31 08).

Ms Tamira Rolls highlighted an error on page 16. It had previously been agreed to remove the last sentence on that page.

Mr Chris Lines suggested that the definition of ‘occasional home

working’ on page 7 should include a reference to appendix 3.

Ms Stephanie Wilkins requested a review date be added to the policy.

The Board agreed that the implementation of the policy would be crucial and a review should take place to establish whether it was

being implemented in a pragmatic way.

The Board approved the policy subject to the amendments mentioned above.

b) Domestic abuse policy

Mr Huw George presented the Domestic Abuse policy to the Board

(paper 31 09).

Ms Rhiannon Beaumont-Wood confirmed that she was the Executive Lead for the policy. Ms Beaumont-Wood also highlighted

that, under the terms of the policy, the HR team would be the main

source of advice for staff who wanted to use the policy. The team would, therefore, require significant training to undertake this role.

It was suggested that an implementation plan should accompany the policy.

Ms Stephanie Wilkins supported Ms Beaumont-Wood and informed

the Board that Unite members had also raised the issue about whether training would be provided for staff.

The Board approved the policy subject to an implementation plan

being developed to accompany the policy.

Action: ensure an implementation plan is developed to accompany the policy.

12. Quality and Delivery framework performance report

Mr Mark Dickinson presented the Board with the Quality and Delivery framework performance report (paper 31 10). Mr

Dickinson informed the Board that the format of the report had

32 01


been revised to reflect the integrated medium term plan. The aim

was to increase objectivity rather than subjectivity.

He explained that section two would report against specific indicators in a colour coded way and provide data on the previous

four quarters and the latest quarter. Section three would report against the priorities for action from the integrated medium term

plan.

Professor Peter Bradley drew the Board’s attention to the 5 per cent target for the percentage of smokers treated by all smoking

cessation services. He explained that Public Health Wales was

responsible for a proportion of this target, with the Directors of Public Health in Health Boards taking responsibility for the rest of

the target through other methods such as pharmacy services and GP services. He informed the Board that Public Health Wales

would not meet the target in the first quarter of the year, but would deliver more in the second half of the year.

Dr Quentin Sandifer drew the Board’s attention to the uptake rate

for Breast Screening being only 0.5 percent above target. He informed the Board that there was a long term trend of the uptake

rate decreasing over the previous 20 years. He explained that whilst the uptake may be decreasing, the impact of Breast

Screening is increasing with the introduction of higher resolution imaging meaning more cancers are being recognised. The

coverage of Breast Screening was below target and Dr Sandifer

explained that work was underway to address inequalities and access hard to reach groups.

In relation to flu vaccination rates Professor Sir Mansel Aylward

queried what role Public Health Wales has in contributing to the vaccination of NHS staff. Dr Sandifer responded that Public Health

Wales has the following responsibilities through the Vaccine Preventable Disease Programme:

Attendance at national vaccination steering committee

Providing direct advice to the Welsh Government Immunisation lead

A team of staff dedicated to supporting health board local policy and practices and procedures

Running a network of immunisation coordinators

Leading the flu campaign in Wales.

The Board welcomed the revised version of the report.

32 01


13. Finance performance

Ms Tamira Rolls provided an oral update on the year end financial

position. She confirmed that it was likely the final accounts would show a £25,000 - £30,000 underspend.

She also informed the Board that Public Health Wales had not

managed to achieve the target for Public Sector Payment Performance. This had been reported to the Board in July 2013

and the performance against this target had improved following the first quarter of the financial year and consistently achieved the

target.

14. Governance report

Mr Keith Cox presented the governance report (paper 31 11) to the

Board.

Mr Cox reminded the Board that the Chairman is required to sign the annual accounts before they are submitted to the Wales Audit

Office on 6 June 2014. The Chairman will, unfortunately, be out of

the country on this date and will be unable to sign the accounts. Mr Cox confirmed that the Standing Orders state that the Vice

Chair can be given full delegated authority by the Chairman. It has, therefore, been agreed that Mr John Spence will sign the

annual accounts on behalf of Sir Mansel Aylward.

Mr Cox also informed the Board that Dr Tracey Cooper would be taking up post as Chief Executive and therefore will become

Accountable Officer on 1 June 2014 and is required to sign the accounts and Annual Governance Statement on 6 June 2014. Mr

Cox informed the Board that a sentence would be added to the Annual Governance Statement explaining that Dr Cooper was

relying on assurances provided to her by the interim Chief Executive.

a) Plan of Board Business

Mr Keith Cox presented the latest plan of Board business (paper 31 12). Executive Directors have inputted into the plan of Board

business and meetings have been set up with Non-Executive Directors to discuss the plan before it is finalised.

b) Corporate Risk Register

Mr Keith Cox updated the Board on the latest corporate risk

register (paper 31 13).

32 01


14. Medical revalidation

Dr Quentin Sandifer provided the Board with an update on medical revalidation (paper 31 14).

The Committee received the report.

15. Wales Audit Office report into management arrangements in microbiology – update to Board

Dr Quentin Sandifer provided the Board with an update on

progress being made against the recommendations which had been made in the Wales Audit Office report into management

arrangements in microbiology (Paper 31 15).

Mr Huw George asked the Board to nominate a lead Non Executive Director for the microbiology service redesign. It was agreed that

Professor Simon Smail should take up this role as the Quality and Safety Committee had already agreed to take on a monitoring role

for this area. Professor Smail would provide a link between the Board and the project group.

Action: Professor Simon Smail to take up role as lead Non Executive Directors for the microbiology service redesign.

16. Committee Meeting Reports

a) Audit Committee

Mr Terence Rose provided an update on the Audit Committee

meeting which took place on 12 March 2014.

The Committee approved revised terms of reference for the

Committee. A paragraph had been added to clarify the relationship between the Audit Committee and Quality and Safety Committee.

The Committee also approved its work plan for the next 12 – 18 months.

Mr Rose informed the Board that the Committee had discussed a

draft outline of the Annual Governance Statement and noted the timetable for completion of the annual accounts.

b) Information Governance Committee

Mr John Spence provided an update on the Information

32 01


Governance Committee meeting which took place on 12 March

2014.

The Committee received a report about MeetingSphere, which informed the Committee that this was no longer considered a risk

to the organisation. The Committee also received updates on EU data protection legislation, Section 251, and Mail Marshall.

c) Quality and Safety Committee

Professor Simon Smail provided an update on the Quality and

Safety Committee meeting which took place on 22 April 2014.

Professor Smail explained that the agenda for the meeting on 22 April was essentially a double meeting. This was because the

meeting scheduled for 6 February had been cancelled.

The Committee received a number of reports on serious incidents, one of which related to a Bowel Screening Wales colonoscopist who

was currently under surveillance and supervision. The Committee requested further consideration of this case before the

colonoscopist be allowed to return to practice.

The Committee also received an update on a seminar which had been arranged to provide learning from incidents in colposcopy.

The afternoon session of the meeting focused on Microbiology

performance.

17. Non Executive Director Reports

Mr Terence Rose informed the Board that he had attended a

Cervical Screening conference.

Mr John Spence attended the Joint Chairs and Chief Executives of NHS Wales meeting in April. At the meeting the following items

were discussed:

Complaints handling CRB checks of Non Executive Board members

Working together Role of the NHS Wales Chief Executive.

Mr Spence had also attended a meeting of Vice Chairs with the

Minister to discuss mental health.

18. Public Health Bill white paper

Professor Mark Bellis attended the meeting to provide an update on

32 01


what action Public Health Wales was taking in response to the

Public Health Bill white paper.

Professor Bellis advised the Board that a number of engagement events were being organised where people could feed in their

responses to the white paper. He confirmed that Public Health Wales would be consulting with staff and also with key

stakeholders including local authorities and Directors of Public Health.

The Board expressed disappointment that the white paper

appeared to omit some important areas. They referred to Public

Health Wales’ response to the Public Health Bill green paper which had been submitted to the Welsh Government in January 2013. In

particular there was no mention of health impact assessments, or health in all policies.

Professor Bellis informed the Board that the suggestion to place a

minimum price on alcohol was a considerable step forward for public health.

It was agreed that the Public Health Wales response to the Public

Health Bill white paper should be closely aligned to the Public Health Wales response to the Future Generations Bill.

Action: ensure the Public Health Wales response to the

Public Health Bill white paper is closely aligned to the Public

Health Wales response to the Future Generations Bill.

The Board were reminded that there would be a further discussion on Public Health Wales’ response to the white paper at a special

meeting arranged for 5 June 2014.

19. NHS Wales Shared Services Partnership

Mrs Margaret Foster and Mr Neil Frowe from the NHS Wales Shared

Services Partnership attended the Board meeting to provide an update on the Shared Services Partnership.

The presentation provided an opportunity for feedback on what

areas the Shared Services Partnership needed to improve on, and also to discuss any new functions which could be taken on by the

Shared Services Partnership which could benefit all in the NHS in Wales.

It was mentioned that Public Health Wales needs to receive more

up to date performance data from the NHS Wales Shared Services

32 01


Partnership so that any issues can be flagged up as early as

possible. The Board had already discussed that the Public Sector Payment Policy target would not be met for 2013/14. The issues

were experienced at the beginning of the financial year and were rectified as soon as Public Health Wales became aware of the

target not being met. If Public Health Wales had received more timely performance data from Shares Services Partnership then

action could have been taken more promptly and the target may have been met for the financial year.

Mrs Stephanie Wilkins asked for advice on how staff can provide

feedback to the NHS Wales Shared Services Partnership. Mr Keith

Cox informed the Board that he was the Public Health Wales representative on the Shared Services Partnership Committee and

that he could pass on any feedback he received from staff. Mr Neil Frowe requested that feedback include actual examples so that

they can make changes where necessary.

Ms Rhiannon Beaumont-Wood queried whether the Shared Services Partnership would consider taking on the role of providing

Occupational Health Services to NHS Wales. Mrs Margaret Foster agreed that this was an area they could take on.

20. Any other business

No other business was noted.

21. Papers for information

Sir Mansel drew the Board’s attention to the following papers for information:

Audit Committee minutes from meeting held on 18 December 2013

Information Governance Committee minutes from meeting held on 18 December 2013

Board Secretary report; Director of Workforce and Organisational Development

report; Executive Director of Public Health Services report;

Executive Director of Public Health Development report; Executive Director of Planning report;

Director of Nursing report; and Director of Communications report.

PART B – Private Session

32 01


1. C.Difficile investigation in north Wales

Dr Quentin Sandifer updated the Board on the C.Difficile investigation in Betsi Cadwaladr University Health Board.

2. Health Advisory structure review

Dr Quentin Sandifer informed the Board that the Welsh

Government had undertaken a consultation in relation to the structure of committees and groups providing health advice to the

Welsh Government. He explained that the existing structure was large and complex and the intention of the consultation was to

simplify the structure. Dr Sandifer had responded to the consultation in his role as Medical Director.

3. Welsh emerging drugs and identification of novel substances project (WEDINOS)

Professor Sir Mansel Aylward brought the Board’s attention to some recent media interest about WEDINOS which is hosted by

Public Health Wales.

The Board requested further assurance that the evidence base for the public health benefit of WEDINOS was balanced and robust. It

was, therefore, agreed that a rapid review of WEDINOS should take place to provide assurance to the Board.

Action: undertake rapid review of WEDINOS to provide

assurance to the Board that the evidence base is balanced and robust.

4. Bevan Commission

Professor Sir Mansel Aylward provided the Board with a copy of a remit letter he had received from the Minister for Health and Social

Services inviting him to refresh the Bevan Commission with a focus on Prudent Healthcare.

32 01


No Action Who Start

Date

Due Date Status Action taken to

date

Revised

due date

27.09 Share dates of Chair/Chief Executive meetings with teams

and Executive Director of Public Health

Development/Director of Nursing meetings with teams.

EH 19/09/13 30/01/14 In progress Executive team are

reviewing the

visibility and

engagement of

Exec team

members are

having further

discussions about

the best way to

incorporate

visibility and

engagement from

non Executive

Directors

29/07/14

28.02 Sir Mansel Aylward to provide Mr Terence Rose with

further information regarding occupational health provision

in Wales.

MA 21/11/13 30/01/14 In progress Meeting scheduled

for 22 July and

feedback will be

provided after that

meeting

25/09/14

28.06 Include discussion on the revised accountability

arrangements for Public Health Wales at a future Board

meeting.

KC/

EH

21/11/13 30/01/14 In progress Discussions will be

held once draft has

been agreed.

Public Health Wales

is awaiting

comments from

Welsh Government

29/07/14

32 01


No Action Who Start

Date


date

Revised

due date

28.08 Mr Mark Dickinson and Professor Simon Smail to meet to

discuss how the performance reporting process can link

into the Quality and Safety Committee.

MD/

SS

21/11/13 30/01/14 Complete Revised

performance

reporting

arrangements

through the quality

and delivery

framework ensure

that performance

reporting is linked

into Quality and

Safety Committee.

29/04/14

28.09 Professor Bradley present evidence from four nations

review of e-cigarettes when available.

PB 21/11/13 29/04/14 In progress Meeting has been

arranged for June

2014 and further

information will be

provided following

that meeting.

28.16 Provide Board with a report on the Francis review

workshops at formal Board meeting in January 2014.

RBW/

KC

21/11/13 30/01/14 In progress Item will be

deferred to meeting

on 29 July 2014. It

has been agreed

that the

recommendations

from the Trusted to

Care: Andrews

report will further

inform the report

from the Francis

review workshops.

29/07/14

29.02 Consider completing an Equality Impact Assessment for

attendance at Public Health Wales events to ensure a full

representation from across the organisation.

CL 30/01/14 27/03/14 In progress

32 01


No Action Who Start

Date


date

Revised

due date

31.01 Invite Claire Barley to attend Quality and Safety

Committee and begin identifying which training is not

needed by certain members of staff.

KC 29/04/14 29/07/14 In progress Next Quality and

Safety Committee

meeting is

scheduled for 22

July 2014

31.02 Ensure an implementation plan is developed to accompany

the policy.

RBW 29/04/14 26/06/14 In progress

31.03 Professor Simon Smail to take up role as lead Non

Executive Directors for the microbiology service redesign.

SS 29/04/14 26/06/14 Complete Professor Simon

Smail has taken on

the role

31.04 Ensure the Public Health Wales response to the Public

Health Bill white paper is closely aligned to the Public

Health Wales response to the Future Generations Bill.

MB 29/04/14 26/06/14 Complete Discussions have

been held with

Welsh Government

officials and the

Minister for Health

and Social Services

Public Health Wales

will submit a

supplementary

response to the

public health bill

once the Future

Generations Bill has

been published.

31.05 Undertake rapid review of WEDINOS to provide assurance

to the Board that the evidence base is balanced and

robust.

QS 29/04/14 26/06/14 Complete Rapid review has

been completed

and there is an

item on the agenda

on 26 June 2014 to

update the Board.

Date: 17 June 2014 Version: 1 Page: 1 of 7

Chief Executive Report June 2014

Purpose of Document:

The purpose of this paper is to provide the Public Health Wales Board with a report on key issues from the Chief Executive

Board/Committee to- (Please indicate)

To decide- Paper will outline recommendations or issues to

be approved by the Board or Committee.

To discuss- Board or Committee will be asked to discuss

and scrutinise the paper and provide feedback and comments.

X

To inform- Board or Committee will be asked to note the

paper for information only

Other relevant information

The Chief Executive’s Report will be presented to the Board at each formal

meeting.

Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant)

X

X

X

X

Priorities for action All priorities are relevant to this paper.

Author: Tracey Cooper, Chief Executive

Date: 17 June 2014 Version: 1

Who will present: (If appropriate) Tracey Cooper, Chief Executive

Documents attached: (If appropriate)

Report of the Chief Executive Officer

Date of meeting: 26 June 2014

Committee/Groups that have

received or considered this

paper:

N/A

Paper 32 03

http://nww2.nphs.wales.nhs.uk:8080/CorporateServicesDocuments.nsf/65ffc2bb7492efeb80256f2a004a1b2e/3786c77f5e591ba380257c240042db4d/$FILE/Public%20Health%20Wales%20Strategy%20v1%20141113.pdf


Link to standards

for health services

N/A

Link to risk

register

N/A

Equality impact assessment

N/A

Financial implications

N/A

Service user

engagement

N/A

http://www.wales.nhs.uk/sites3/Documents/919/ENGLISH%20WEB%20VERSION.pdf


http://howis.wales.nhs.uk/sitesplus/888/page/45595#ass


http://nww2.nphs.wales.nhs.uk:8080/CommunicationsGroupDocs.nsf/85c50756737f79ac80256f2700534ea3/b53eb69f8e34f1dc80257c60003c130f/$FILE/FINAL%20Public%20and%20Stakeholder%20Engagement%20Strategy.doc



Chief Executive

Report –

June 2014 Author: Tracey Cooper, Chief Executive (from 2 June 2014)


Distribution:

Public Health Wales Executive Team

Public Health Wales Board

Public Health Wales Internet

Purpose and summary of document:

The purpose of this paper is to provide the Public Health Wales Board, Executive Team and Senior Management Forum with a report on key

issues from the Chief Executive.

The Chief Executive’s report will be presented to the Board at each formal

meeting.

Date of Board Meeting: 26 June 2014

Public Health Wales Chief Executive Report – April 2014


1 Welcoming

I would like to thank the Board, the Executive Team, Julie Lake and all of

our staff who I have had the opportunity to meet and work with since I started on 1 June 2014.

I have been made to feel extremely welcome and have been overwhelmed

by the obvious talent and expertise that we have across our various teams.

I very much look forward to working with the Board and our various teams

across the organisation as we continue to drive improvements in the health of our population.

2 Joint Executive Team (JET) meeting with

Welsh Government

The most recent JET meeting took place with Welsh Government on the 4

June 2014. It was a constructive meeting which focused predominantly around a presentation that our Executive Team gave containing a review

of our successes and areas for improvement in our 2013/2014 performance and also priorities for 2014/2015. This presentation is

enclosed in the information papers for the Board for information. It enabled a helpful discussion and challenge around a number of priority

areas that included the following:

Smoking cessation

Screening services Microbiology Health Improvement

Workforce

During the meeting we also discussed areas of challenge for us including

smoking cessation targets and the need for support from Welsh Government in areas that may require escalation where the achievement

of targets is not solely within our control. The establishment of effective ‘service level agreements’ with other stakeholders was also discussed and

identified as a priority for us in the immediate to medium term.

3 Integrated Medium Term Plan and

Operational Plan 2014/2015

As the Board is aware, the Integrated Medium Term Plan has not been approved by the Minister and discussions are ongoing to develop a

2014/2015 Operational Plan which is before the Board. This needs to be submitted by the 4 July 2014.



A substantial amount of work has been done across the organisation in

order to focus on SMART objectives with clear targets where applicable and focused actions to deliver on the targets. We have also expanded the

risks within each section.

Following submission of the Operational Plan, and subject to approval, we

will need to develop a process and timeline to develop a new Integrated Medium Term Plan for submission in January 2015 which will span the

period from 2015 to 2018.

4 Clinical Governance, Trusted to Care Report

and the Francis Report

The Board is familiar with the Trusted to Care Report and may also be

aware that each Health Board and NHS Trust was required to self-assess itself against the recommendations in the report and for the respective

Boards to assure themselves that any gaps in this assessment were being actively managed and met. It was unclear as to whether Public Health

Wales was being asked to do so and therefore a letter was sent to the

Minister outlining our actions taken to date. This letter can be seen in the correspondence section of the Board papers.

The Director of Nursing, Executive Director of Public Health Services/Medical Director and Board Secretary/Director of Corporate

Services have been undertaking an assessment of both the Francis Report and the Trusted to Care report across the organisation and an action plan

is being developed to consolidate the applicable recommendations of both into one plan. This will be presented to the Board in July.

During this process it has been identified that we would benefit from reviewing our clinical governance arrangements – which are taking place

albeit in a somewhat fragmented manner, with the purpose of developing a coherent clinical governance framework for the organisation. The

Director of Nursing and Executive Director of Public Health Services/Medical Director are in the process of developing proposals for

this which will be available to the Board in July.

5 Relationships with Stakeholders

With the increasing requirements for performance and delivery by Welsh Government and expanding roles for Public Health Wales, it has become

increasingly apparent that we need to develop more formalised arrangements with our partners. This is particularly important where there

are shared targets to be achieved by us and other partners which may be compromised by the inability to deliver on the part of either party. An

example of this is the smoking cessation targets and the need for a complementary and collaborative approach by Public Health Wales and



Health Boards through their Directors of Public Health. This collaborative

approach is variable across the country.

As a result of this, and is previously referred to in item 2 above, we will be

progressing the development of agreed service level agreements with key partners over the coming weeks and months that clearly outline the

respective accountabilities, responsibilities and authorities for each party with escalation measures in the case of persistent difficulties in achieving

a combined target. These will be established on the basis of collaboration and combined goals that should be mutually beneficial.

6 Bevan Commission

Progress has been made in relation to securing funding and clarity on the hosting arrangements for the Bevan Commission.

7 Designation as an Accountable Officer

I received the transfer of accountability letter from Andrew Goodall on 12 June 2014 and will respond accordingly. The letter is enclosed in the

correspondence section of the Board papers.

8 Nursing and Midwifery Strategy

The first Public Health Wales Nursing and Midwifery Strategy was launched on the 12 May in the Millennium Centre in Cardiff. The event, which was

planned to coincide with International Nursing Day, was attended by Professor Jean White Chief Nursing Officer for Wales, who confirmed how

pleased she was that Public Health Wales now has a Director of Nursing in post to provide internal and external leadership to represent nursing and

midwifery perspectives at Board level. Raising The Profile: Public Health Wales Nursing and Midwifery Strategy 2014-2017 .

The ten themes of the strategy aim to reflect key approaches to ensure that the nursing and midwifery professionals can respond and adapt to the

changing needs of the NHS in Wales and the aims Public Health Wales.

Huw George, in his role as interim Chief Executive spoke of his new

awareness of the variety of contributions made by nurses and midwives

every day in contributing to the aims of Public Health Wales, which may not always be apparent. He went on to state the profile is now raised,

with this as well as the expectations.

The strategy provides the vision to take forward a number of governance,

developmental and professional requirements such as changes to revalidation which will be expected to come into force during 2015.

http://howis.wales.nhs.uk/sitesplus/888/opendoc/337079

http://howis.wales.nhs.uk/sitesplus/888/opendoc/337079



Recent reports such as Trusted to Care and the Mid Staffordshire enquiry

highlight the need to ensure that nurses and midwives are well supported in adhering to their professional codes, in all working environments.

Nurses involved in co creating the strategy shared their positive experiences in developing the strategy with colleagues attending the

launch. An implementation plan is now being developed led by the Director of Nursing, which the Board will be able to receive updates on.

9 DEMOS

DEMOS, a cross-party think-tank, has published a report, Behind the Screen: Revealing the true cost of cervical cancer…, that contends that

increased screening rates would save the NHS £10m a year, and halve the number of deaths. The report was launched at a Ministerial event on 18

June. Public Health Wales was not approached before the report was written, nor was it asked for data. A few days before the launch we

discovered that the report incorrectly reported that the 2010-11 5-year

coverage rate for women aged 25-64 in Wales was 76.3%, which would suggest that Wales had the lowest coverage in the UK. In fact, the correct

figure for Wales is 79.6% and the best in the UK. DEMOS agreed to take down the online version of the report until it had corrected this error and

made another amendment we requested. They also agreed not to print any copies without correction and to insert an errata sheet in the printed

copies prepared for the launch event. The chief executive will be writing to the chief executive of DEMOS to follow-up on our concerns.

Statutory and Mandatorytraining policy


A new Statutory and Mandatory training policy has been developed and has beenpublished for staff to comment on.

The policy identifies the type and frequency of statutory and mandatory training thatPublic Health Wales will provide in order to help promote safer working practices. Itsets out the roles and responsibilities of staff in relation to attendance of trainingcourses, the arrangements in relation to record keeping and the approach to inrelation to the design and delivery of statutory/mandatory training programmes.

The training is in line with the UK Core Skills Training Framework which has beendeveloped by Skills for Health for use by all health organisations to help guide andstandardise the focus and the key delivery of key statutory and mandatory trainingskills.

All staff are required by law, to undertake the training which is classified asstatutory. Staff must also undertake any mandatory training detailed in the policy asrelevant to their role, as this has been identified as necessary by the NHS and PublicHealth Wales.


To decide- Paper will outline recommendations or issues to beapproved by the Board or Committee.

x

To discuss- Board or Committee will be asked to discuss andscrutinise the paper and provide feedback and comments.

To inform- Board or Committee will be asked to note the paper forinformation only


Next StepsOnce approved this policy will be circulated to all staff within Public HealthWales.

Link to Public Health Wales commitment and priorities for action:(please tick which commitment(s) is/are relevant)

x

Priorities for action include relevant priority for action(s)

Paper 32 05

Public Health Wales Paper Submission Cover Sheet

Date: 13 January 2013 Version:0g Page: 2 of 2

Link to standards forhealth services

Standard 22 - Managing Risk and Health andSafety

Link to risk register

Equality impactassessment

Has an equality impact assessment beencompleted? If so, please indicate here and includeas an appendix to the paper. If not, pleaseindicate here and explain why an equality impactassessment is not required.

Financial implications It may be necessary to engage the services of anexternal company to provide training to staff.

Service userengagement

Have you completed a service user engagementplan? If yes, please attach a copy.

Author:

Date: 16 June 2014 Version: 0a

Sponsoring Executive Director: Ruth Davies, Director of Workforceand Organisational Development

Who will present: (If appropriate) Ruth Davies, Director of Workforceand Organisational Development

Documents attached:(If appropriate)

Statutory and Mandatory trainingpolicy and summary of commentsfrom staff consultation


Committee/Groups that havereceived or considered this paper:

This policy has been circulated inline with the Public Health Walespolicy consultation process

Date: 9 May 2013 Version: v0b Page 1 of 17

Statutory & MandatoryTraining Policy

Policy type: Public Health Wales wide

Policy reference number: PHW04

Policy classification: Human Resources

Author: Professional and Organisational Development Team

Policy lead: Claire Barley, Head of Professional and OrganisationalDevelopment

Executive lead: Ruth Davies, Director of Workforce and OD

Date: 14 May 2014 Version: 0g

Publication/ Distribution:

Public (Internet)

Review Date: TBC

Approval date:

Approving body: Quality and Safety Committee

Purpose and Summary of Document:

This policy covers the training the organisation must provide, and staff mustattend, in order for Public Health Wales to meet and comply with itsstatutory and mandatory requirements.

Intended audience: All staff

Interdependencies with other policies (this is should not be taken as anexhaustive list of relevant and related policies):

Health and Safety Policy Induction Policy (under development)Appraisal and Continuous Development Policy (under development)Welsh Language strategy

Public Health Wales Statutory and Mandatory Training Policy

Date: 14 May 2014 Version: v0d Page 2 of 17

Policy consultation circulation list

Group/Lead policy circulated to Date circulated

Information Government Leads 13/01/14

Partnership Forum/MDLNC 13/01/14 (via e-mail)

H&S Group 13/01/13

Welsh Language Officer 13/01/13

Exec Leads and Divisional Directors 16/01/13

All Staff (six week consultation) 08/01/14-19/02/14

Partnership Forum policy group 08/04/14

Partnership Forum 14/05/14

Public Health Wales Statutory & Mandatory Training Policy


Contents

1 SUMMARY................................................................................4

2 INTRODUCTION ......................................................................4

3 POLICY AIM ............................................................................4

4 SCOPE .....................................................................................5

5 LEGISLATIVE AND NATIONAL INITIATIVES ............................6

6 DEFINITIONS..........................................................................66.1 Statutory Training............................................................66.2 Mandatory Training ..........................................................66.3 Additional Mandatory Training for specific roles....................6

7 ROLES AND RESPONSIBILITIES ..............................................6

8 A SYSTEMATIC APPROACH TO STATUTORY AND MANDATORYTRAINING ...............................................................................88.1 Training Needs Analysis (TNA)...........................................88.2 Training Action Plan(s)......................................................88.3 Training Programme.........................................................98.4 Recording Attendance at Training.......................................98.5 Non-attendance at Training ............................................. 10

9 MONITORING AND AUDITING ...............................................109.1 Quality Assurance .......................................................... 10

10 APPENDICES .........................................................................1210.1 Appendix A References to Legislation............................... 12



1 Summary

Organisations have a moral, economic and legal responsibility to provide a safeand healthy environment for their staff, contractors and visiting members of thepublic and patients. They are required to provide a range of learning anddevelopment that ensures their workforce has the correct level of knowledge andskills to operate safely and that a safe and healthy working environment ismaintained. Although there is legislation that requires statutory training to beidentified, organisations need to establish their own minimum standards for safepractice tailored to the demands and requirements of their business.

2 Introduction

Public Health Wales has staff based across Wales, including sessional and loneworkers in a wide range of locations and environments. The organisation istherefore committed to equipping staff with the knowledge and skills required toundertake their roles competently and confidently. Staff are expected to takeresponsibility for developing and using these skills and participating in thelifelong learning process as they have a contractual responsibility to ensure they,and in turn, the organisation remains compliant with legislation and requiredstandards:

Section 35 of the Public Health Wales NHS Trust Contract of Employmentspecifically notes the employee’s duty to take reasonable care of the health andsafety of yourself and of others who may be affected by your acts or omissionsat work. Sections 6.6 and 6.7 of the Public Health Wales Health and SafetyPolicy specifically set out Managers’ and Employees’ responsibilities with regardto training attendance; subsequent failure to comply with these responsibilitiesmay lead to disciplinary action being taken.

Implied into every employment contract is the common law term of carrying outreasonable instructions given by the employer. Mandatory training is trainingthat the organisation (or wider NHS/Welsh Government) has deemed essentialfor either all staff or specific groups. Attendance at and/or completion ofmandatory training is considered a reasonable instruction; any subsequentfailure to do so may again lead to disciplinary action being taken.

The Disciplinary policy sets out examples of misconduct which include (atvarying levels), failure and/or refusal to carry out reasonable instructions,negligence. Employees would be advised to refer to the policy for full details.

3 Policy aim

The purpose of this policy is to:

Provide information about statutory and mandatory training; Set out the roles and responsibilities in respect of design and delivery of

statutory/mandatory training programmes in these areas;



Identify training requirements in terms of programme and frequency; Set out the arrangements for ensuring all staff are able to attend relevant

training; Set out arrangements for record keeping of attendance and monitoring; Set out arrangements for following up those who fail to attend;

This policy specifies those areas of training that are driven by statute and thosethat have been made mandatory by the NHS and Public Health Wales in line withthe adoption of the UK Core Skills Training Framework, developed by Skills forHealth. The UK Core Skills Training Framework sets out a framework for use byhealth organisations to help guide and standardise the focus and the keydelivery of key statutory and mandatory training skills.

4 Scope

Statutory training is compulsory, by law, for all staff All staff must complete mandatory training appropriate for their post e.g.

a higher level of infection control for some laboratory staff, training in linewith professional standards as appropraite

The requirement to complete statutory and mandatory training is apriority over other forms of learning and development

Temporary staff employed via agencies and contractors must have hadtheir statutory and mandatory training requirements met by theiremployer with the exception of fire safety which should be provided aspart of their induction programme Contractors will be provided withrelevant information to ensure that they meet the requirements of firesafety.

Relating to this policy, the UK Core Skills Training Framework informs staffof the minimum training requirements for all identified statutory andmandatory topics (plus Welsh Language Awareness which is not includedin the framework)

These requirements have been collated on the basis of legislativerequirements (statutory training) and external assurance frameworks thatfeed into Public Health Wales policy documents (mandatory training). Therequirements will be subject to change on the basis of internal andexternal developments and will be reviewed in the event of any significantchange and reissued as necessary

Changes to Public Health Wales’ statutory and mandatory trainingrequirements and subsequently to this policy must be made via thesubject specialist lead, using the Public Health Wales template andsubmitting it to the Learning, Education and Development Group (LEaD)who will quality assure before working with the approving Quality andSafety Committee. No subject can be defined as mandatory unless it hasbeen approved via this process.



5 Legislative and national initiatives

A comprehensive list of legislation, policy and guidance can be found inAppendix A.

6 Definitions

6.1 Statutory Training

Statutory training is training that is required by law and is governed by astatutory instrument. It is part of a package of measures to ensure thehealth, safety and welfare of employees when carrying out their professionalduties. The law applies equally to directly managed staff and employees ofindependent contractors.

6.2 Mandatory Training

Mandatory training is training that the NHS in Wales and Public Health Waleshas identified as essential for all staff to undertake to enable them to work torequired standards and for the organisation to achieve its objectives asdetermined by national, local and professional guidelines. All mandatorytraining requirements will have been agreed at Public Health Wales Board intheir adoption of new organisational policies.It is the responsibility of independent contractors who provide services toPublic Health Wales to identify and provide mandatory training to theiremployees related to the nature of the services they offer.

6.3 Additional Mandatory Training for specific roles

This is mandatory training, as defined above, that Public Health Wales hasidentified as essential for specific groups of staff, relating to their job role.

7 Roles and Responsibilities

Employers

Employers have a duty under the Health & Safety at Work Act 1974 to takereasonable measures to ensure the health, safety and welfare of their employeesat work. They also have a duty towards people who are not their employees butuse their premises.

The implications of failure to comply with the regulations are extremely seriousand can result in premises closure or significant fines being levied against theorganisation. In a serious breach of statutory regulations, responsible individualsmay be personally culpable and this can result in fines or even jail terms beinggiven if the organisation is found guilty.



To ensure that Public Health Wales is, and remains, compliant with all statutoryregulations staff at all levels in the organisation have differing responsibilities asdetailed below.

Chief Executive and Executive Team

The Chief Executive is responsible for ensuring that all Public Health Wales staffhave the opportunity to participate in statutory and mandatory training.

The Director of Workforce and Organisational Development has an overallresponsibility for advising the Executive Team and through this group the Boardon statutory and mandatory training for all staff and for ensuring that systemsare in place to:

Monitor the implementation of the policy; Investigate and report back to Executive Team any issues of non-

compliance with suggested solutions Provide statutory and mandatory training to all staff Ensure that processes are in place to commission, plan and coordinate

statutory and mandatory courses Communicate Public Health Wales statutory and mandatory courses

appropriately Process applications for statutory and mandatory training and ensure staff

maintain their records on the Electronic Staff Record (ESR) system; Notify manager/reviewers should any staff member fail to attend a booked

training event Quality assure training through the monitoring of course evaluations and

as required (i.e. changes in legislation, ensure Public Health Walesmaintains compliance).

Line Managers

It is the responsibility of line managers to ensure that:

All staff undertake statutory and mandatory training and to take anyaction necessary to ensure compliance

All newly appointed staff undertake corporate induction or equivalentalternative within specified timescales

As part of the annual objective setting process line manager/reviewersmust ensure that attendance at relevant statutory and mandatory trainingrequired for their role has taken place and that accurate records aremaintained

Staff are given the opportunity to attend statutory and mandatory training Reviews are undertaken with members of staff where appropriate to

ensure the work environment complies with health and safety regulationsand also with any recommendations made during statutory andmandatory training

When a member of staff is unable to attend a booked statutory andmandatory training session another training date is arranged as soon aspossible



Should a member of staff fail to attend a booked statutory and mandatorytraining course on more than one occasion, other than for reasons of illhealth, a review is undertaken to identify the difficulty

Statutory and mandatory training is up to date or clear plans are in placeto address training needs before considering any further study leaveapplications

Staff

It is the responsibility of staff to:

Review their required statutory and mandatory training and ensure that alltraining is up-to-date and notify their line manager where they have gaps

Plan statutory and mandatory training attendance as part of their annualobjective setting

Maintain an acceptable statutory and mandatory training record e.g. usingthe ESR, Faculty of Public Health tool and portfolios as appropriate

Set a high priority to statutory and mandatory training over other forms oflearning and development and make every effort to attend any trainingevents provided and arranged for this purpose

Advise their manager/reviewer and the course organiser as soon asreasonably possible if they are unable to attend a booked statutory andmandatory training session

Highlight any additional support or needs they may have with regards tounderstanding and benefiting from statutory and mandatory training

Ensure that all statutory training attendance is up to date before applyingfor further protected learning time (including study leave)

8 A Systematic Approach to Statutory andMandatory Training

Where new posts are established the line manager needs to identify statutoryand mandatory requirements for the post when the job description is beingwritten. This should then be reviewed with the post holder during the firstmonth of employment

8.1 Training Needs Analysis (TNA)

Training identified by managers/reviewers should be entered on to the ESR.Reports identifying training needs are gathered from the system and used todevelop a schedule of statutory and mandatory training.

8.2 Training Action Plan(s)

A statutory and mandatory training plan which will inform the structure anddetail of the rolling programme will be developed by the Professional andOrganisational Development team.



8.3 Training Programme

A blended programme of training will be made available to include e-learning,classroom and work-based activities where appropriate. In order to ensurethat all training provided achieves the required outcomes, is of a consistentstandard for all subjects and provides value for money the following critera willbe applied.

Training events will have identified aims and learning outcomes Training will be designed taking into account the range of learning styles

likely to be useful to participants Where possible training should be delivered by someone with knowledge

of adult learning methods Training events will be evaluated by one or more of the following methods

as appropriate:o End of course participant evaluation form (with opportunity for

anonymity)o End of course test of knowledgeo End of course evaluation form completed by the trainer

Follow-up participant evaluation form or interview Other valid evaluation method Evaluations of each training event will be collated into a report Training evaluation reports will be reviewed on a regular basis and will

form part of the quarterly management report.

There will be a blended approach to the delivery of training providing flexibleopportunities for staff to undertake the necessary statutory and mandatorytraining.

Public Health Wales’ Welsh Language Scheme states the following:‘Public Health Wales is committed to assessing the need for vocational trainingthrough the medium of Welsh. Where the need for vocational training throughthe medium of Welsh is identified and suitable training is accessible it will besupported in order to facilitate implementation of the Scheme’.

8.4 Recording Attendance at Training

A guide to statutory and mandatory training relevant to various job roles can befound at Appendix B and C to assist manager/reviewers and staff members inidentifying their individual statutory and mandatory training requirements. Allbookings for training will need to be completed through the ESR system. E-learning programmes are self enrolling and can be undertaken at a time agreedwith the manager/reviewer.

An attendance register will be completed at all classroom based training and willbe signed by the individual delegates. The registers will be retained by thetrainer and a copy forwarded to the training organiser.



Completion of e-learning packages will also be monitored by the Learning,Education and Development (LEaD) Group.

Attendance figures and e-learning package completion data will form part of thequarterly performance monitoring report provided to Executive Team throughthe Professional and Organisational Development Team, including a break downby division of compliance rates.

Individual training records should be maintained through the Electronic StaffRecord (ESR) by the individual and their line manager. Whilst ESR is beingrolled out across the organisation the Professional and OrganisationalDevelopment Team maintain a spreadsheet of current training dates(compliance) which is updated monthly and held in a confidential folder.

8.5 Non-attendance at Training

A copy of the attendance registers are returned to the training organisers at theend of each training programme by the tutor. Should a delegate not be presentat the course the training organiser will inform the delegate’s line manager

Persistent non attendance should be managed through the line manager and willbe recorded in the quarterly report.

Non attendance by division will be reported as part of the quarterly performancemonitoring process to the Executive Team.

Previous Training - Newly appointed staff from across the NHS may transfer anypreviously attended statutory and mandatory training (linked to the UK CoreSkills Frameowrk) attendance provided they are compliant with Public HealthWales requirements as determined by the policy. Details of training undertakenand evidence of attendance must be provided by the new employee and be inline with the requirements of the UK Core Skills Training Framework.

9 Monitoring and Auditing

Adherence to the statutory and mandatory training policy and the effectivenessof the training provided will be reviewed on an annual basis and in line with therequirements of the organisation’s self assessment against the Standards forHealth Services.

9.1 Quality Assurance

The statutory and mandatory training provisions will be evaluated using the annualand mid-year declaration of assurance against Standards for Health Services andany other mechanism felt appropriate by the Director of Workforce andOrganisational Development.

The length and frequency of provision of the various training coursescomprising the statutory and mandatory training programme will be reviewed



against the effectiveness of outcomes and amended as required in line withthe requirements of the UK Core Skills Training Framework.



10 Appendices

10.1 Appendix A References to Legislation

Subject Legislation or Policy

Child Protection The Children Act 2004.Working Together 2006.Laming Report 2003.Children's NSF 2003.'Every Child Matters' 2003.RCP & CH Guidelines HCC CP Performance Indicators 2006-07.

Violence andAggression

Conflict Resolution Training - Implementing the National Syllabus 2004(NHSLA st3)A Professional Approach to Managing Security in the NHS 2003Welsh Violence and Aggression Passport Scheme

CorporateInduction

Standards for Health Services in Wales.Risk Management in the NHS

COSHH Health and Safety at Work Act (1974)Management of Health and Safety at Work Regulations (1999)COSHH Regulations 2004

Display ScreenEquipment

Health and Safety at Work Act (1974)Management of Health and Safety at Work Regulations (1999)DSE Regulations 1992

Equality &Diversity

Race Relations Amendment Act (2000) (NHSLA st3)Code of Practice for Racial Equality P32:3.20

Fire Safety Fire Precautions Act (1971) amended (1999)Management of Health and Safety at Work Regulations (1999)Health and Safety at Work Act 1974Regulatory Reform (Fire Safety) Order 2005Firecode HTM 83 - Fire Safety in Healthcare Premises 1994.

Infection Control Clinical Negligence Scheme for TrustsStandards for Health Services in Wales.MRSA Reduction (Key local and national target) (NHSLA st2 & 4)National Infection Control Training.

InformationGovernance

Caldicott Principles into PracticeData Protection Act 1998Health and Social Care Act 2008Confidentiality: Code of Practice for Health and Social Care in WalesAccess to Health Records Act 1990Freedom of Information Act 2000Human Rights Act 1998Wales Accord for the Sharing of Personal Information (WASPI)Section 251 of the National Health Service Act 2006

Manual Handling Health and Safety at Work Act (1974) (NHSLA st2)Management of Health and Safety at Work Regulations (1999)Manual Handling Operations Regulations (1992).Welsh Manual Handling Passport Scheme

Mental Capacity Mental Capacity Act 2005

RiskManagement

Risk Management in the NHSManagement of Health and Safety at Work Regulations (1999)Health and Safety at Work Act (1974

VulnerableAdults

Patient Safety (NHSLA st3)

Welsh Language Welsh Language Act 2004Welsh Language (Wales)measure 2011

Public Health Wales Statutory & Mandatory Training Policy


Appendix B Statutory and Mandatory Compliance List (shaded are based on UK Core Skills Frameworkguidance)

Course Staff Frequency Additional Notes

RelatedPublicHealthWalesPolicy

Fire Safety ALL STAFF

Induction/ classroominitiallyminimum every 2 yearsrenewal possible throughe learning

For those staff with responsibility forevacuating others e.g. patients, theywill need to receive training on anannual basis and identification of thiswill be based upon local riskassessment.

Fire Marshall/WardenTraining Nominated fire wardens Annually

Only required for staff nominated asfire wardens or first aidersFirst Aid at Work

Certificate Nominated first aiders Every 3 years

Health, Safety &Welfare

ALL STAFF

Initially classroomsession with renewalpossible through elearning - every 3 years

Laboratory staff - induction only anddemonstrated through on goingcompletion of appropriateaccreditation

Moving and Handling(level 1)

ALL STAFF

Induction via classroomor e learning Level 1 is deemed once only unless a

risk assessment deems the individualshould attend more regularly

Level 2 requirements should reviewedthrough a local risk assessmentprocess regularly

Moving and Handling(level 2)

All staff, including unpaid andvoluntary staff, whose role involvespatient handling activities

Organisation todetermine any requiredrefresher periods basedupon local assessment

Resuscitation

Level 1: All staff, including unpaidand voluntary staff involved in directpatient care

Level 1: Once atinduction

Sta

tuto

ry



Level 2: Staff with direct clinical careresponsibilities including all qualifiedhealthcare professionals who deliverpatient services

Level 3: Registered healthcareprofessionals with a responsibility toparticipate as part of the resuscitationteam

Level 2: Every year

Level 3: Every year

Using display screenequipment:

AwarenessDSE Assessment

Staff identified as DSE users

At induction and/orfollowing a change of ITor general officeequipment or move toanother location. Also,identified need followinga risk assessment, returnfrom long term sicknessor pregnancy

When an individual has a DSEassessment undertaken, this countsas training

Radiation ProtectionLevel 1

Radiation ProtectionLevel 2

Screening Services only see separateguidance from screening

Screening Services onlysee separate guidancefrom screening

Screening Services only see separateguidance from screening

Violence andAggression Module A –Induction andAwareness Raising

ALL STAFF

Leaflet issued for all newstaff with offer letters orat inductionLeaflet also available toread on line

Job role risk assessed by linemanager to identify where modules Band C are required

Violence andAggression Modules B –Theory of PersonalSafety and De-escalation

Required staff based upon local riskassessment and training needsanalysis

Induction as identifiedthrough a riskassessment which shouldalso identify requiredrefresher periods for jobroles

Violence andAggression Module CBreakaway

Required staff based upon local riskassessment and training needsanalysis

Mandato

ry



Infection Preventionand Control Level 1

ALL STAFF including contractors,unpaid and voluntary staff

All staff (Level 1) Every 3years

All healthcare staffproviding direct care:every year

Job role risk assessed by linemanager to identify where level 1 and2 are requiredInfection Prevention

and Control Level 2

All healthcare staff groups involved indirect patient care or services

Safeguarding level 1All non-clinical staff working in healthcare settings

At induction and every 3years in classroom or elearning

Job role risk assessed by linemanager to identify where levels 2and 3 are required

Also refer totheSafeguardingTraining Policy

Safeguarding Level 2

Clinical staff who have some degreeof contact with children and youngpeople and/or parents/carers.

Staff that MAY come into contact withchildren, vulnerable adults andfamilies. Staff that supervise otherswho may come into contact withchildren, vulnerable adults and theirfamilies, have recruitmentresponsibilities or deal withcomplaints. Staff who deal withsensitive information relating tochildren and / or vulnerable adults.

Those who have a strategic andmanagerial responsibility forcommission and delivering services,including CEO, directors and boardmembers

Classroom based (2.5hours), every 3 years

Safeguarding Level 3

Health professionals in regularcontact with children, young peopleand/or vulnerable adults or whoprovide direct care. Staff taking alead for children, young people orvulnerable adults

This training should beaccessed on an annualbasis where available.

InformationGovernance (and ITsecurity)

ALL STAFF Every 3 years

InformationGovernancePolicy



Safeguarding adultsAll staff, including unpaid andvoluntary staff

Induction and no longerthan every 3 years

Welsh LanguageAwareness ALL STAFF

At induction / once onlyby DVD or e learning

Equality, Diversity andHuman Rights ALL STAFF Every 3 years

Dignity at WorkALL STAFF Every 3 years

Stress Awareness forManagers All line managers

Once only/every threeyears

Stress Awareness forStaff ALL STAFF

At induction/every threeyears

Course Staff Frequency Additional NotesPHWRelatedpolicy

Man

dato

ry

Improving QualityTogether All staff via e learning Once only

Welsh Government target

Bronze

SilverIdentified individuals via classroomlearning

Once only

GoldIdentified individuals via classroomlearning Once only

Putting Things RightAll staff modules 1, 2 and 5

Managers all 7 modules

Risk Managementtraining Managers and other staff as needed.

Good Clinical Practice(GCP) training forresearch

Individuals undertaking research

AnaphylaxisClinical staff - Screening

LidnocaineClinical staff - Screening



Asbestos awarenessAll staff

Once only

Customer CareScreening

Mental CapacityScreening

Please note that this is not an exhaustive list of mandatory training for all staff groups across the organisation. Therewill be additional requirements in line with different professional bodies and roles and its an individuals and their linemanagers responsibility to ensure that they are aware of their statutory and mandatory training requirements.

1

PUBLIC HEALTH WALES

Statutory and Mandatory Training Policy – Summary of staff consultation comments

Contents Comments received Response

1. Introduction Include patients as they are recipients of PublicHealth Wales services

included

2. Aims andObjectives

3. Scope Recommendation: That the following should be

included in the list of criteria: ‘Training will be

designed to take account of the language needs and

preferences (Welsh or English) of employees’.

PHW has no control over the design ofmuch of the training on line which isdeveloped on a national basis.

An additional line in the policy hasbeen included which has been takenfrom the Welsh Language Scheme.

4. Legislative andNational Initiatives

Need to reference the Welsh Language measure 2011as well as Welsh Language Act

the framework could state that such training is to beprovided only by NHS organisations in Wales.

It is stated that there may (in the future) be arequirement for training in Welsh where required andthis would be a statutory requirement

Welsh language skills for staff

Included in the list

The content of the UK core SkillsFramework is out of the scope ofcontrol of the POD team or PublicHealth Wales.

The policy will have a review periodand flexibility to be updated shouldlegislation change.

The policy should be read inconjunction with relevant others, i.e,.Welsh Language Skills Strategy whendeveloped.

5. Definitions

2

6. Roles andResponsibilities

Include something on the quality of the trainingprovision

Query the tone on the policy and responsibilitiesbeing top down and that “calls to training” are ofteninaccurate.

the policy states that should a member of staff notattend a training course (on more than one occasion)for reasons other than ill health, then the managershould undertake a review. Clarity needs to beprovided on what this review would look like, whowould be involved and how would it be managed.There needs to be a system in place to inform themanager that staff have missed training on morethan one occasion.

This is more to do with theimplementation of the policy andquality of provision will be considered

This is a data management issue

which will be addressed with the

adoption of the Electronic Staff Record

and Self Serve.

Should a manager require support to

carry out their role, this should be

discussed with their line manager,

human resources or the learning and

development.

7. Main body ofpolicy (pleaseinsert appropriatetitle)

Please can you also include Putting Things Right e-learning training on the list and the compliance rateswithin the training report that you submit to the Q&SCommittee as this is mandatory for all staff and weare audited on compliance by the Welsh Risk Pool onan annual basis.

Section 8.5 reference Welsh NHS training – could thisnot be NHS UK?

Putting things right is included in the

list of mandatory training

requirements.

Yes – wording changed

8. Training &communicationwith staff

Add asbestos awareness to mandatory list Resuscitation – is this really needed for all staff?

Added

Added “those involved in direct patient

care”

3

Putting Things right – details on modules to beundertaken by staff and managers

We wondered whether it would be helpful to includesomeone from your team in a silver IQT cohort. Theoutcome measure of compliance rate would be greatfor a run chart and teams could design and test smallchanges to the design of the process.

Additional modular information added

Compliance with statutory and

mandatory training is the

responsibility of the individual and

manager and not the POD team. Their

role is to merely organise required

training and run reports from the

system for management as

appropriate.

9. Monitoring &auditing

10. Informationgovernancestatement

Need to include a statement in the policy on who seesstaff training records. There is a need to include arecords management statement to the policy.

Paragraph now included

Appendices Some suggestions for wording changes Some suggestions for related policies

Queried frequency of information governance trainingand recommended more frequent

All staff should have Datix training not just managers

Level 2 Safeguarding training I would suggest thatyou consider adding staff who sit on Children and

Amended where appropriate Policy leads will need to link

appropriate policies Information Governance lead for

organisation has confirmed that thefrequency will stay at three years forall staff with risk assessment andidentification of roles which requiregreater frequency in place

Referred to lead for comment

The information in the policy is takenfrom the UK Core Skills Framework.

4

Young People’s Partnership groups and HealthySchools Coordinators

Query the amount of statutory and mandatorytraining required and comments that some isduplicated

Additional information is available inthe Public Health Wales Safeguardingpolicy and perhaps these examplescould be picked up in that document?

It has been acknowledged that the listof mandatory training is quiteextensive. Work will be undertaken inthe new financial year to work withthe policy leads to review policyrequirements and consider removingthe requirement for “mandatory”

A process needs to be developed toconsider training requirements in newand amended policies prior tosubmission to the Board / forapproval.


Governance and Accountability module

Purpose of Document: The Governance and Accountability Module is a framework that Boards are required to

self assess against to establish how well the organisation is governed. It is also a requirement of the Welsh Government and forms part of the supporting information

for the Annual Governance Statement. The self assessment covers the period April 2013 – March 2014.


To decide- Paper will outline recommendations or issues to be approved by the Board or Committee.

X

To discuss- Board or Committee will be asked to discuss and scrutinise the

paper and provide feedback and comments.

To inform- Board or Committee will be asked to note the paper for

information only


The Board has approved the Governance and Accountability module ‘out of Committee’ and are being asked to ratify that decision.

Next Steps

The Board are asked to ratify the approval of the Governance and Accountability

module.

Link to Public Health Wales commitment and priorities for action:

(please tick which commitment(s) is/are relevant)

X

Priorities for action Put in place a comprehensive governance framework

Author: Eleanor Higgins, Corporate Governance Manager


Sponsoring Executive Director: Keith Cox, Board Secretary

Who will present: (If appropriate) Keith Cox, Board Secretary

Documents attached:

(If appropriate)

Governance and Accountability module



received or considered this paper:

Executive Team

Board

Paper reference – 32 06


Public Health Wales Governance and accountability module

2

Link to standards

for health services

Standard 1: Governance and accountability

Link to risk

register

N/A


N/A


N/A

Service user

engagement

N/A








3

Governance and

Accountability Module

Self Assessment Author: Eleanor Higgins, Corporate Governance Manager



The Governance and Accountability Module is a framework that Boards are required to self assess against to establish how well the organisation is

governed. It is also a requirement of the Welsh Government and forms part of the supporting information for the Annual Governance Statement. The self

assessment covers the period April 2013 – March 2014.

V1 16/06/14

4

Note: In establishing your level of agreement in relation to each of the statements made, you must be able to

demonstrate through your supporting narrative not only what your organisation or business is doing, but how well it is

working and the resulting impact on organisational performance.

Theme 1 - Setting the Direction

Desired Outcomes:

We place the people who use our services at the heart of our work We make sure our purpose is clear and know to develop and deliver our services to improve overall health and well being We are a value based organisation/business and carry out our work openly, honestly, ethically and with integrity


5

a) We make an effective contribution to the achievement of the strategic vision for health services in Wales

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

ag

ree

Supporting narrative

Public Health Wales plays a pivotal role in improving health in Wales and is committed to setting the

direction in Wales for reducing inequality resulting from the socio-economic determinants of health.

In September 2013, the Minister for Health and Social Services approved the recommendations set out in

the review of health improvement programmes in Wales. The recommendations refocused investment

and future action to improve health and wellbeing and reduce health inequalities. This work is now being

taken forward as ‘transforming health improvement in Wales’.

Public Health Wales continues to play a key role in contributing to the development of a public health bill

for Wales. The organisation is also a member of the reference and advisory groups for the Future

Generations Bill.

Last year we sought to establish clear system leadership on critical public health issues. We have

achieved this in some areas, for example work undertaken by the Public Health Wales Observatory; the

‘Add to Your Life’ over 50s health check; WCISU; vaccination via the measles outbreak; a position

statement on e-cigarettes; public health research and development; and the health improvement review.

An integrated medium term plan has been developed which documents where Public Health Wales plans to

contribute to the overall strategic vision for health services in Wales and how the progress and

achievements will be measured.

Public Health Wales has lead the work on Prudent Healthcare, following a request from the Minister for

Health and Social Services. Through 1000 Lives improvement we will collaborate closely with health

boards.

Discussions are ongoing to develop revised accountability arrangements between Public Health Wales, the

Welsh Government and wider public health system. This work will continue in 2014/15.

√


6

Supporting evidence

Integrated Medium Term Plan

Together for Health

Establishment Order

Our Healthy Future

Fairer Health Outcomes for All

Public Health Wales strategy and priorities for action

Long Term Agreement between Public Health Wales and Welsh Government

Heads of Agreement between Public Health Wales, health boards and local government

Public Health Wales Public Health Strategic Frameworks

Health Board Local Public Health Strategic Frameworks

Public Health Wales Strategic Delivery Plans

Planning and performance framework – quality and delivery framework

Health Improvement Review / Transforming Health Improvement in Wales programme

1000 Lives improvement service

Improving Quality Together

Briefings to Ministers

Chair, Chief Executive, Executive Team and Chair of Committees’ membership of All Wales peer

group meetings

Nursing and midwifery strategy


7

b) We have a clear purpose, vision and overall strategic direction that effectively aligns our local needs with the national strategy for health services in Wales

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

ag

ree


A healthier, happier and fairer Wales: Public Health Wales strategy was refreshed during 2013. It was

launched at the staff conference in October 2013. The strategy sets out the organisation’s aim, purpose,

approach, and commitments and is underpinned by priorities for action. In 2012/13 we identified the need

to refresh the Public Health Wales strategy to reflect the changes which had taken place in the

organisation.

Public Health Wales has a dual role, both locally and nationally in contributing to the national strategy for

health services in Wales.

We have contributed to the reconfiguration of services in Betsi Cadwaladr, Hywel Dda and the South Wales

programme.

The Public Health Wales Board has approved an integrated medium term plan which guides our strategy

and the achievement of a healthier, happier and fairer Wales. It demonstrates financial balance and

covers a three year period from 2014/15 – 2016/17. The plan fits within the NHS Wales planning

framework and supports the aims and policies if the Welsh Government.

There is a particular issue about lack of alignment with health boards, local public health teams and the

wider health improvement sector and we need to improve this area.

Supporting evidence

Public Health Wales documents which contribute to health services in Wales

Integrated medium term plan

Establishment order

Public Health Wales strategy and priorities for action

Public Health Wales Strategic Delivery Plans

√


8

Heads of Agreement between Public Health Wales, health boards and local government

Public Health Wales Public Health Strategic Frameworks

Planning and performance framework

Health Improvement Review

1000 Lives Plus


Briefings to Ministers

Welsh Government documents within which Public Health Wales operates

Long Term Agreement between Public Health Wales and WG

Programme Level Agreements between Public Health Wales and WG

Together for Health

Our Healthy Future

Fairer Health Outcomes for All

c) Our citizens, staff and other stakeholders inform and influence our organisation/ business’s purpose, strategic vision and direction

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Citizens

Public Health Wales has long established links with various groups for engagement. The Screening

Engagement Team works in partnership with a variety of agencies at a local level including local

authorities, health boards, minority groups, community and development teams and third sector agencies.

A Public and Stakeholder Engagement strategy is in place, which seeks to ensure that the ongoing

development of Public Health Wales’ strategic direction is informed and influenced systematically by

citizens and other stakeholders. This was identified as an area for improvement last year and more work

is needed to evaluate whether staff are complying with the strategy.

A Service User Experience and Learning Panel, is in the process of being fully established and embedded.

√


9

The Director of Nursing will provide Executive level leadership on this agenda and will chair the panel.

Welsh Government requests on the organisations progress in implementing the framework for Assuring

Service User Experience (Action 5 of Achieving Excellence, the Quality Delivery Plan), have been provided

as requested at various intervals during this reporting period. A Non Executive Director champion has

been identified together with a Community Health Council representative.

There are plans in place to bring the monitoring of complaints, concerns and incidents together with the

Service user experience and learning panel, in addition to monitoring at local levels within teams and

divisions. It is anticipated that this will provide more clarity over how complaints and analysis from

service users is used to inform our business purpose, strategic vision and direction. We will be looking at

improving this during 2014/15.

We have recognised that there are a number of areas for improvement in relation to citizens informing

and influencing our purpose, strategic direction and vision. We will also develop a performance framework

which will be integrated into the Quality and Delivery performance report. Therefore, we have provided a

lower score than previous years. Once we have embedded learning from service user engagement into

the organisation, we will be able to increase the score.

Staff

The NHS Wales Staff survey results were received in May 2013. Engagement workshops were held to

discuss results of survey with staff and an action plan has been developed and approved by the Board.

The action plan provides details on how staff have informed and influenced the organisation. A number of

staff engagement events have been held across the organisation to consider the Mid Staffordshire inquiry

recommendations, in the context to Public Health Wales. Staff have provided their views on a range of

themes, this will be considered in light of what is already in place to support any required changes and will

highlight gaps which will need further work and focus during 2014-15.

We engage with staff representatives through the partnership forum. We have invited members of trade

unions and BMA to attend Board meetings as full non-voting members to contribute fully to discussions

and decisions at Board level. In 2012/13 we reported that there was no trade union representation at

Board level. We are pleased to report that the partnership forum has nominated two representatives to

attend Board meetings. They will alternate their attendance at each meeting. We are in discussions with

the BMA about securing a representative at Board meetings.

The Board and Executive team are supported by a leadership and delivery group comprising of Divisional

Directors, a national forum of professional and managerial staff and an annual staff conference.


10

Staff have been fully engaged in a review of accommodation. A series of workshops were held where staff

were invited to pass on their views and opinions to inform the future direction of the project.

Stakeholders

We regularly engage with partners and stakeholders. The Health Improvement Review engaged with

stakeholders who contributed to the final report and recommendations for service reconfiguration. The

implementation of the recommendations ‘transforming health improvement in Wales’ will be shaped and

informed by stakeholder groups.

Regular meetings of all Wales peer groups eg Chairs, Chief Executives, Vice Chairs, Directors of Planning,

Directors of Finance, Medical Directors, Directors of Public Health etc.

We also hold the annual Welsh Public Health Conference which has become well regarded amongst

professionals in Wales and the UK.

In 2012/13 we identified the need to improve links with Community Health Councils, third sector and local

government. We have established a link with Community Health Councils and are working with the third

sector and local government. The local government vacancy on our Board is still a risk to the organisation

and we are working with Welsh Government to fulfil the vacancy.

We have poor strategic links with local government and have not paid sufficient attention to stakeholder

and service user experience and feedback in developing our plans and services. This is highlighted as a

weakness in our integrated medium term plan.

Supporting evidence

Public and stakeholder engagement strategy

Content on internet and intranet sites including large number of page views and engagement on

interactive forums

Terms of reference and meetings of the NHS Wales Chief Executives group

Terms of reference and meetings of the Partnership Forum

Social media strategy

Staff engagement sessions

Regular meetings of Director of Public Health Development, Director of Public Health Services with

Chief Medical Officer, Health Board Directors of Public Health

Monthly meetings of the Chairs of the health boards and trusts

Frequent meetings between Executive Team; Board members and Chief Medical Officer

Service user experience reports submitted to Welsh Government


11

Screening services implementation of service user action plan

Stop Smoking Wales focus on improving efficiency of service in response to service user feedback

d) We carry out our work instilled with a strong sense of values, supported by clear standards of ethical behaviour

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


In all our actions, whether with colleagues, stakeholders or partners, Public Health Wales seeks to be

professional, persuasive, open, reflective and responsive.

We have a strongly professionalised workforce who work with a strong sense of values which are

supported by clear standards of ethical behaviour, with a strong commitment to health inequalities. The

Medical Director oversees medical revalidation for the medical workforce and the Director of Nursing

provides a professional lead for nursing and midwifery staff.

Public Health Wales adopted a full set of policies and procedures when it was established on 1 October

2009. These policies and procedures are systematically reviewed in order of priority. Regular policy and

partnership forum meetings have been established to progress and agree policies between management

and trade union representatives. It has recently been noted by the Executive Team that some of these

policies are out of date and action is required to update them.

Board members adhere to the standards of good governance set for the NHS in Wales, which are based on

the Welsh Government’s Citizen Centred Governance Principles.

In the NHS staff survey 510 completed questionnaires were received from Public Health Wales staff, a

response rate of 39%, which was the second highest in Wales. The overall response rate for all LHBs and

Trusts was 27%. In the survey a large proportion of Public Health Wales staff confirmed that they were

prepared to ‘go the extra mile’ and were prepared to report incidences of harm. An action plan has been

approved by the Board to take forward issues identified in the staff survey.

Supporting evidence

Board and Committee Arrangements

√


12

Corporate Policies

Declaration of Interest

Standing Orders

Standing Financial Instructions

Scheme of Delegations

WAO reviews

WAO Structured Assessment

Internal Audit reviews

Appraisals / Performance Reviews

Other external reviews

Public Health Wales vision and values


e) We promote equality and recognise diversity across all our services and activities S

tro

ng

ly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


We have put in place a revised Strategic Equalities Plan (SEP) and a working group to action the plan

which has representation from across Public Health Wales. The SEP considers equality issues affecting all

aspects of our work as well as our workforce. The group aims to facilitate learning across directorates and

divisions to actively engage staff in strategic decisions. The group will investigate embedding the

promotion of equality and diversity across all services and activity. There are equality internet pages

available for staff as a reference tool. An Equality Officer has been recruited on a part time basis to work

on embedding equality and diversity across the organisation.

The NHS Wales Equality Unit transferred into Public Health Wales on 1 April 2013.

All Public Health Wales accommodation has been audited to be compliant with the Disability Discrimination

Act.

Dignity at work and equality and diversity training is mandatory for all Public Health Wales staff.

Compliance of uptake of training needs to improve. We continue to focus efforts on improving compliance

√


13

rates. There is a dignity at work policy in place which is one of the main drivers for managing incidents of

harassment as well as being a management tool.

The recruitment of staff is supported by the two tick system whereby anyone applying for a post who self

declares themselves as disabled can receive automatic shortlisting when applying for jobs within the NHS,

providing they meet the essential criteria for the post, as set out in the person specification. This is

further supported by HR policies and procedures.

A range of equality and diversity data is collected from service users eg Screening. However, this is not

available for analysis of the workforce. The roll out of Electronic Staff Record will allow staff to update

their equality and diversity information directly. This will, in turn, provide more accurate information for

analysis.

We have an approved Welsh language scheme and action plan which demonstrates the organisations

commitment to offering bilingual services to the public of Wales.

We are working to develop a consistent approach for carrying out equality impact assessments (EqIA).

The central message is that EqIA activity should be started at the beginning of planning a new policy or

when substantially revising an existing policy. We are also looking to improve access to our services and

to be more inclusive in the way in which we engage with the wider public.

Supporting evidence

Equality Impact Assessments (EQIA) completed for all Public Health Wales policies

DDA audits

Single Equality Scheme

Welsh Language Scheme

Welsh Language Scheme Annual Monitoring Report

Dignity at Work Policy

Strategic Equality Plan


14

f) We apply and embed professional standards and quality requirements in a way that meets the needs and expectations of patients, service users, citizens and other stakeholders

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


We receive regular scrutiny from internal and external auditors and other regulatory bodies to ensure that,

as a minimum, our services and activities comply with the national standards. We have also adopted and

embedded the Standards for Health Services which set national benchmarks for all our services and

activities. The Executive Team receives quarterly updates on how we are progressing our improvement

programme. This is then reported into the Quality and Safety Committee who have an oversight role.

Throughout the year the Quality and Safety Committee has received updates and presentations from each

division on their approaches to quality and any quality assurance systems in place.

CPA accreditation applies to microbiology and screening for compliance with national standards and

ongoing audit arrangements. The standards for health services have also been mapped to the CPA

standards.

Over a quarter of staff in Public Health Wales have taken up the Improving Quality Together challenge to

develop their quality improvement skills.

2012/13 was the first year that Public Health Wales produced an Annual Quality Statement. The

Statement provides an open and honest assessment of what Public Health Wales is doing to ensure all its

services are meeting the needs of the population of Wales and reaching high standards. It also provides a

summary highlighting how the organisation is striving to continuously improve the quality of the services it

provides and commissions in order to drive both improvements in population health and the quality and

safety of healthcare services. Public Health Wales participated in a peer review of all Annual Quality

Statement’s across NHS Wales. The Director of Nursing led a review team consisting of the Board

Secretary, Corporate Support Manager and Head of Nursing Screening. The team from Public Health

Wales reviewed the Powys Annual Quality Statement. Our statement was reviewed by the Welsh

Ambulance Service Trust. The review included a round table event chaired by the Chair of the Quality and

Safety Committee and contributions from staff who had detailed knowledge of specific areas across the

√


15

organisation. Learning from the peer review process will be used when preparing the statement for

2013/14.

The development of a Nursing and Midwifery strategy for Public Health Wales is underway and will

identify, underpin and support regulatory and fitness to practice requirements. This will be ratified at the

Public Health Wales Board in May 2014.

Further work will be progressed for other regulated health professional groups, Health Care Support

Workers and those in non medical Public Health roles.

2013/14 was the first full year of revalidation for the medical workforce. At the end of March 2014 25

percent of the workforce with a prescribed connection underwent revalidation. All received a positive

recommendation with no deferrals. Revalidation for medical staff will continue in 2014/15.

There is currently no systematic way for talking to the public about health, although it does work well in

some areas. Inroads have been made through the social media strategy where feedback has been sought

via social media channels. The ‘Add to Your Life’ over 50s health check has been developed following

close discussions with the public and service users and provides an example of how this can be taken

forward in others areas of the organisation.

Supporting evidence

Annual Quality Statement

Doctor / Nurse registration

CPA and UKAS accreditation

Screening Quality Standards

HSE Regulations / Regulatory Bodies

Medical revalidation

Annual performance reviews

1000 Lives improvement

Public Health Workforce Development programmes


16

Theme 1- Setting the direction: Your overall assessment

In relation to this particular theme, what is your overall assessment of where and how you:

are governing well

need to strengthen your arrangements

have noteworthy practice which you may wish to share

Governing well

Public Health Wales has an established Board and governance arrangements in place. We have refreshed our strategy to continue to

provide a clear purpose. We continue to develop and deliver our services to improve overall health and wellbeing. This can be evidenced

through the Health Improvement Review, introduction of new screening programmes, modernisation of screening programmes and

microbiology services.

Strengthen arrangements

We need to strengthen our learning from service users and stakeholders to inform service improvement and focus on embedding equality

and diversity within the organisation.

Noteworthy practice for sharing

The Health Improvement Review was a key piece of work where collaboration and engagement led to recommendations for service

improvement.

What maturity level have you demonstrated you have reached for this theme overall: 3

‘We are developing plans and processes and can demonstrate progress with some of our key areas for improvement.’

In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and

when) and how will you measure your success?

Priorities for improvement Action to be taken Timescale Measure of success

Foster learning from service user

experience and complaints

Service user group

Service user engagement

strategy

Patient stories at Board

meetings

To be completed by March

2015

Service user feedback

performance reports will be

embedded into the reporting

system

Board will have opportunities to


17

hear from service users directly.

Strengthen equality and diversity

within organisation

Identify and deliver appropriate

training and development in

relation to equality and

diversity

Implement strategic equality

plan


2015

Equality and diversity will be

embedded within the

organisation

Strengthen the lines of

professional accountability.

Develop nursing and midwifery

strategy

Clarify lines of accountability


2015

Approved nursing and midwifery

strategy

Strengthen engagement with

service users and stakeholders

Review stakeholder

communications and

engagement strategy and

actions

Year 2 of Integrated Medium

Term Plan – 2015/16

Stakeholders, service users and

the public will be engaged in our

planning and all that we do.


18

Theme 2 – Enabling delivery Desired outcomes: We make sure that everyone involved in delivering health services understands each others contribution, and how together we can deliver a better service

We work constructively in partnership with others to improve the quality and safety of services for our patients, service users and the wider community We foster innovation and make the best use of all the resources available to us, including our

people, facilities and finances


19

a) We have the right people, with the right skills, doing the right things, in the right place, and at the right time to meet our responsibilities for the provision of safe, high quality care

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


We have developed an integrated medium term plan, which includes workforce development and has been

approved by the Board.

As a result of engagement sessions with staff and the feedback from the NHS Wales staff survey, we have

developed a leadership and management development programme. This will strengthen the skills set for

many members of staff.

The Wales Audit Office reviewed the management arrangements for the Screening Division, and found

that while management was effective it was not efficient and would not be sustainable with the increased

portfolio of programmes. Management arrangements were amended and an overarching senior

management team was developed for the division. A similar Wales Audit Office review was also completed

for the management arrangements in the Microbiology Division which identified a number of areas for

improvement. An action plan has been put in place to address the issues raised.

A number of divisions are undergoing service redesign / modernisation. There is a risk that the results of

the changes in these service areas may leave people in the wrong place with the wrong skills. The Public

Health Development Directorate was significantly understaffed a consultant level at the beginning of the

year. Plans have been developed to increase the number of consultants in the Directorate and

recruitment processes have started.

All staff are required to undertake statutory and mandatory training. This has previously been identified

as an area which needs to improve. Further resource is needed to enable delivery of training where

necessary and work is being done to encourage line managers to take responsibility for making sure their

staff are up to date with their training requirements. The existing training database does not contain

accurate and up to date training records and further work is needed to establish whether all staff require

all levels of statutory and mandatory training. The Board has agreed to continue to monitor progress in

√


20

this area. Work is in hand to identify which areas of the organisation are falling below the expected level

of activity so attention can be focussed on the highest risk area. The Board feels that the level of marking

in this section reflects the level of improvement needed in this area. A higher marking will only be

achieved once this area has improved.

Supporting evidence

Integrated medium term plan to include finance, workforce and delivery plans

Professional registration

Defined and Practitioner registration

Performance Policies

Concerns and incident reporting policy and process


Annual performance reviews


b) The different services and parts of our organisation/business work well together, and everyone understands who does what and why

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


An organisational development plan has been shaped by the Executive Team which is closely aligned with

a three year delivery plan and financial plan.

Feedback from staff has been received via the staff survey and other engagement events which have

identified that staff feel more work is needed to ensure all parts of the organisation are working well

together. A Director of Health and Healthcare Improvement and Director of Policy, Research and

Development have been recruited which goes some way towards helping to resolve this issue.

Difficulties are experienced from working across multiple sites and this was highlighted in 2012/13 as an

issue. The ‘our space’ programme was launched in 2013 and aims to align flexible working practices, new

technology and the organisation’s accommodation strategy to enable Public Health Wales to move toward

√


21

developing a workplace for the future. An early part of the programme invited staff to attend a series of

workshops where they could feed in their views about how the organisation works together.

A new leadership and delivery group has been established to support the Executive Team and this will be

further supported by an operational group comprising corporate services. This will foster collaborative

working between areas of the organisation.

Supporting evidence

Public Health Wales Board structure

Public Health Wales Executive Team structure, terms of reference and papers

Divisional Director and Assistant Director structures

Executive Director monthly reports to Executive Team

Internal consultation documents

Service Delivery Model project documents

Terms of reference for the leadership and delivery group

Naming and branding strategy

Corporate communications strategy

Public Health Wales Staff e-bulletins

Public Health Wales intranet site

Information exchange process

Terms of reference and documents for the National Forum

Staff Conference feedback reports


22

c) We properly safeguard all those who work in or access our health services (including those who may accompany patients or service users), paying particular attention to the needs of children and vulnerable adults

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Those who work in our services

All Public Health Wales staff are provided with a job description, which contains specific responsibilities

and common responsibilities, relating to risk management, competence, supervision and health & safety

and in addition all staff must attend mandatory training in safeguarding adults and children every 3 years

All relevant staff receive a Disclosure and Barring check prior to taking up employment.

Safeguarding Children and Safeguarding Adults with Vulnerabilities policies have been developed to assist

staff in recognising and acting on abuse and neglect as well as Guidance on working with sexually active

young people and adults with vulnerabilities. Staff can raise concerns in a number of ways, including via

the Whistleblowing Policy, (section 5 page 6 of the policy which details the three steps that staff can follow

to escalate their concern) and if staff have concerns regarding professional abuse there is a policy for

Managing Allegations of Abuse by Staff. Staff are encouraged to raise issues via any mechanism they feel

comfortable with. This can include raising issues with staff representatives, line managers and in local

team meetings. If the issue cannot be dealt with at a local level, they should be escalated up to a

Director, or, to one of the relevant Governance Committees or Corporate Leads.

A Domestic Abuse and Sexual Violence Policy is in place to assist mangers and staff in dealing with

domestic violence in the workplace and an implementation plan is being developed which will include

training.

A Health and Safety Lead was appointed in August 2012. This appointment further strengthens the

safeguarding and protection of all assets, including the staff within the organisation. The individual left

the organisation in November 2013 and an interim arrangement was put in place to ensure there was no

√


23

risk to the organisation. More permanent arrangements will be put in place as soon as possible.

A Named Nurse for Safeguarding provides leadership, expert advice and ensures procedures are in place

to support staff in relation to responsibilities in safeguarding. A safeguarding strategy ‘Safeguarding in

Public Health Wales’ has been developed which includes safeguarding children and vulnerable adults. This

strategy also specifies that training is mandatory for all staff and Board members. This is an area which

required improvement, as compliance rates are below target.

Those who access our services

The Named Nurse Safeguarding ensures that there are safeguards in place to provide assurance that the

services provided by Public Health Wales are safe for children and adults with vulnerabilities. In addition

the Safeguarding Children Service is an independent service of designated professional experts, providing

assistance in keeping children safe to the wider NHS in Wales.

HealthWRAP training to support the Prevent anti-terrorist strategy is delivered to relevant staff.

Complaints and concerns raised by children, young people and vulnerable adults are dealt with under the

Putting Things Right – handling concerns, complaints and claims policy. There has been no significant

increase in the number of complaints received to date compared to last year.

Supporting evidence

Quality and Safety Committee terms of reference

Risk Management Group terms of reference

Safeguarding in Public Health Wales strategy

Safeguarding Children Policy and supporting procedures

Safeguarding Adults with Vulnerabilities Policy

Managing Allegations of Abuse by Staff

Domestic Abuse and Sexual Violence Policy

Guidance for working with sexually active young people and adults with vulnerabilities

Safeguarding Group terms of reference

Named Nurse for Safeguarding

Safeguarding Annual Report submitted to Quality and Safety Committee

Cross ref to Standards 11 – Safeguarding Children and Vulnerable Adults

Reports routinely received by Executive Team and Committees: incident reporting; complaints and

concerns; legal claims; DATIX.

Safeguarding Children Service


24

d) We have the right facilities (equipment and environment) to enable us to consistently deliver safe, high quality services across all the communities we serve

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


A facilities Manager was appointed in early 2013 to ensure that existing facilities are maintained to the

highest standards. An estates database has been created to provide a central reference point for all

information available on the buildings occupied by Public Health Wales. This also includes a list of fire

wardens for each location and, in completing this work, the facilities manager has secured sufficient fire

wardens for each location. An asbestos management plan has also been developed for the organisation

which has assisted in minimising the risk of asbestos to the workforce and users of our facilities. An

internal audit report into asbestos was completed in 2014. It confirmed that work was underway to

address asbestos management arrangements in the organisation, but also identified a number of areas for

improvement. An action plan has been developed and will be implemented during 2014/15.

The organisation does experience some difficulties from working across multiple sites, which was identified

last year. Results from the staff survey and other engagement fora have highlighted that difficulties are

experienced by staff willing to work together. A review of accommodation is underway as part of a wider

project entitled ‘our space’. Workshops have concluded where staff were invited to pass on their views

and opinions to inform the future direction of the project. The project aims to create a modern fit for

purpose working environment that will make better use of space; incorporate new technology and flexible

working practices to support the delivery of organisational priorities and the revised healthier, happier and

fairer Wales strategy. It is hoped the review of accommodation can assist in improving cohesion and

understanding across the organisation of different team’s contributions and priorities.

Microbiology and Screening laboratories are subject to formal standards for health and safety and work to

standing operating procedures and this is assessed via CPA accreditation.

Supporting evidence

Business planning

Capital programme

√


25

Estates SLA

Estates consultation

Estates strategy

Standard 22 – Risk, Health and Safety Management

H&S and Infection Control Policy

Accommodation Strategy

e) We support the development and delivery of high quality, safe and accessible services through strong, effective financial planning and management

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Regular finance reports are forwarded to the Board and monthly financial performance reports are

submitted to the Welsh Government along with monthly Director of Finance commentary. Monthly

financial position / performance reports are also presented to the Public Health Wales Executive Team and

to individual divisional directors.

The Wales Audit Office audits the accounts on an annual basis and provide assurance in the form of an a

structured assessment and annual audit report. For 2013/14 the WAO made some minor

recommendations for improvement but overall concluded that governance arrangements for the

organisation were sound. In addition, the NHS Wales Shared Services Partnership – Audit & Assurance

Services undertake regular audits of financial and associated systems, along with providing assurance on

internal control.

Regular training sessions on budgetary control are provided and all new budget holders are required to

complete this training. The Trust has a budgetary control procedure and a finance guide is available on

the intranet, which includes information on both budgetary and financial control.

An integrated medium term plan has been developed which includes a financial plan.

Supporting evidence

√


26

Board reports;

WAO Structured Assessment

Budget strategy for 2012/13

Annual Governance Statement

Annual accounts letter

Vacancy control process

WAO and Internal Audit Reports

f) Our workforce at all levels in the organisation/business are equipped with the information they need to help them carry out their work effectively, and this information is shared appropriately and securely held

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Staff can access information from a wide variety of sources, including:

Specific information systems used by specific services (eg laboratory information management

systems (LIMS), screening programme call/recall systems)

Internal websites and document databases

Library and knowledge management service and Observatory

External sources facilitated by internet and intranet access

There is a strong informatics function specialising in areas specific to the organisations activity (including

screening, surveillance, microbiology). All staff have access to IT equipment for them to carry out their

work. The Wales Audit Office undertook a review of the organisation’s approach to data quality in

2012/13 and the outcome of this is being used to inform future developments, in particular, the reporting

mechanisms for data quality. During 2013/14 the Wales Audit Office carried out an audit of data backup

arrangements and identified some areas for improvement, but also noted that action was already

underway to address these areas which required improvement.

The Information Governance Committee; Information Governance Working Group; and local Information

Governance contacts all contribute to the effecting sharing of information and secure storage of

√


27

information. The Committee is reassured by the low number of complaints and errors which are reported

in relation to Information Governance.

The ‘Our Space’ programme is also considering ways of working across the organisation and part of this

work will look at accessing and sharing of information for staff. Staff feedback has identified that some

staff experience issues with the IT infrastructure in the organisation. This has prompted the informatics

team to set up a process for staff to use their own devices for work purposes, whilst retaining full security

of data and information, which goes some way to addressing the concerns raised.

Supporting evidence

Intranet

Internet

E-bulletin

Information Governance Committee minutes and Terms of Reference

Information Governance Working Group minutes and Terms of Reference

Policies and Procedures

g) We are an innovative organisation/ business that takes proper account of the risks

(both opportunities and threats) to the achievement of our aims and objectives S

tro

ng

ly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Public Health Wales has a risk management strategy in place which includes a risk management

framework. The strategy involves 5 key areas: developing risk management in Public Health Wales;

embedding key risk management systems and processes; ensuring statutory compliance; ensuring Public

Health Wales is risk aware and staff are appropriately trained and skilled in risk management; ensuring

compliance with regulation and monitoring.

The Audit Committee receives the corporate risk register at each meeting. As part of a self assessment of

the Committee’s effectiveness, it has identified that it must start reviewing the assurances which are in

place for each risk. Internal audit has identified issues surrounding the reporting of risk within

organisational flows and made recommendations for improvement in relation to screening programmes

√


28

and asbestos management in particular. The Information Governance Committee reviews and scrutinises

all information governance risks and the Quality and Safety Committee review all risks relating to quality

and safety.

All incidents are reported to the Quality and Safety Committee. Any risks that are identified as a result of

reported incidents, are discussed in detail and appropriate risk assessments and action plans developed.

The Executive Team has questioned the way risks are managed in the organisation and have sought

independent advice and support on how to improve and embed risk management within the organisation.

Supporting evidence

Corporate Risk Register

Board and Committee structure and terms of reference

Executive Team Terms of Reference

Research & Development Committee terms of reference

Risk Management Group terms of reference

Health & Safety Group terms of reference

Champions for Health


Digital Mammography

Health Protection

Early Years work

Sustainable Communities work

h) We have strong, effective relationships with our workforce, partners, citizens and other stakeholders

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Workforce

√


29

We work closely in partnership with staff and staff representatives through the Partnership Forum and

local negotiating arrangements. Representatives from the partnership forum have been invited to attend

Board meetings as a full, non-voting, Board member.

Staff engagement events have taken place to discuss the organisation’s response to the Francis Review

and to take part in a conversation about what is expected of leaders and managers and through the staff

survey. Action plans and proposals have been developed to address the issues raised by staff.

Partners / stakeholders

Staff within the organisation work closely with health boards and local authorities. The main contact with

local authorities is through the local public health teams. We have a long-standing vacancy on the Board

for a local authority Board member. This poses a considerable risk to our relationship with local

authorities in Wales. Efforts are continuing to recruit to this position and an interim appointment is

currently being sought.

There are well established health protection partnership arrangements with Consultants in Communicable

Disease Control appointed as ‘responsible officers’

Staff representatives are members of all Wales peer groups eg NHS Wales Chairs, Vice Chairs, Chief

Executives, Directors of Finance, Medical Directors, etc. Chairs of Committees also attend meetings with

their respective all Wales Committee Chairs.

A Public and Stakeholder Engagement Strategy is in place but more work is needed to establish whether

staff are following the actions.

Citizens

A Public and Stakeholder Engagement Strategy was developed after working with communications officers

from local health boards, local authorities, the Welsh Government and other public sector organisations to

map public engagement channels and methods with a view to sharing them for collective use.

We regularly use social media to communicate with citizens and stakeholders. We established successful

routes of communication during measles outbreak and this included an effective use of social media. WE

are reviewing our use of social media to ensure we are maximising every opportunity for engagement

through this medium.

It has been identified that the organisation would benefit from a forum/mechanisms for planning,

developing or getting a public mandate for health improvement.


30

Supporting evidence

Partnership Forum terms of reference

Naming and branding strategy

Staff engagement workshops and other fora

Heads of Agreement between Public Health Wales, the Welsh Government, Health Boards and Local

Authorities

Microbiology Service Level Agreements

Terms of reference for the NHS Wales Chief Executives Group

Screening Engagement Annual Report

Public and Stakeholder Engagement Strategy



31

i) Decisions taken throughout our organisation are made by those best placed to do so, are well informed, timely and are effectively communicated

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


All decisions taken by the Board and Committees are made openly and transparently.

The Wales Audit Office produce a structured assessment each year for Public Health Wales. Last year

(2012) they concluded that the governance arrangements and functioning of the Board were sound, but

that there some recommendations which could further strengthen the organisation’s decision making

processes. All recommendations made have now been completed.

The structured assessment for 2013 concluded that in general, the Trust has good arrangements for

governance and board assurance but work remains to strengthen some components of the governance

framework. Improvements were identified for:

Internal controls in relation to statutory and mandatory training need to improve.

The Trust’s draft backup and recovery polices have yet to be formally agreed and some plans and

procedures for individual systems are out of date.

there are gaps in information on service user experience to help improve and shape services.

the Trust’s approach to identifying and recording divisional risks needs to be reviewed and

improved. It is not clear that risk registers are reviewed regularly

Board, Committee and Executive Team paper are published routinely on the Public Health Wales website.

A new leadership and delivery group has been established and will be supported by an operation group.

The National Forum will continue to meet quarterly.

Supporting evidence

Board intranet page

Executive Team terms of reference

Board Committees terms of reference

Executive Team communications process and paper

√


32

National Forum papers

Standing Orders & Standing Financial Instructions

Scheme of Delegation



Theme 2 – Enabling delivery:

Your overall assessment


are governing well



Governing well

We continue to achieve high quality, safe and accessible services through sound financial planning and management. The organisation is

forecast to a balanced position for 2013/14 and has even identified areas of savings to broker some funds back to Welsh Government to

assist the wider NHS Wales financial position.

Our governance arrangements are generally sound.


A number of issues have been identified with staff working across different locations and a project is underway to address these issues

and propose options to improve accommodation and ways of working.

Compliance rates for statutory and mandatory training continue to be a concern and risk to the organisation. Work is continuing to

improve compliance rates and this remains a priority for 2014/15.

The Executive Team has identified the need to review risk management across the organisation and has sought independent advice.


The 1000 Lives improvement service continues to support health boards in national and local improvement work.

The microbiology and screening divisions engage with others in the same business.


33


We are developing plans and processes and can demonstrate progress with some of our key areas for improvement.




Consider ways to improve issues

arising from staff working across

different locations

Our Space programme Phase 1 and 2 to be

completed by March 2015

Reduce number of buildings

occupied by Public Health Wales

and co-locate staff

Improve compliance rates for

statutory and mandatory training

Implementation of statutory

and mandatory training policy

Work with managers to ensure

increase in compliance

March 2015 Compliance rates should either

meet, or exceed, target.

Recruit to local authority Non

Executive Director

Appoint interim position for 12

months, whilst awaiting

amendment to regulations to

allow full appointment

June 2014 Successful interim appointment

to be made.

Review risk management

arrangements

Good Governance Institute to

undertake a review of risk

management arrangements

Refresh approach to risk

management to ensure it is

embedded across the

organisation

Good Governance Institute

report due in June 2014

Refreshed, embedded

approach to be complete by

March 2015

Risk management arrangements

to be embedded across

organisation with divisional risk

registers feeding into corporate

risk register and linked to

integrated medium term plan.


34

Theme 3 – Delivering results, achieving excellence

Desired outcomes: We provide high quality and accessible health services in a manner that ensures equity of access and minimises waste, harm and variation We build on our strengths and take early, decisive action to improve services where we need to. We learn from our own and others experiences to continuously improve the provision of health services We contribute to the overall improvement of health services in Wales by sharing our learning with others


35

a) We have a clear understanding of how well we are performing overall, what services are doing well, and what services need improving (including those services that are carried out by others on our behalf)

We respond quickly and effectively to address areas of concern, including those relating to individuals’ performance S

tro

ng

ly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


We have developed a revised planning and performance framework during the year, which has helped to

inform development of an integrated medium term plan. A Quality and Delivery Framework has been

developed which sets out a mixture of quantitative and qualitative measures to assess performance

internally and externally against strategic objectives. Performance reporting to the Board has improved

greatly throughout the year.

The Quality and Safety Committee places emphasis on identifying, reviewing and assessing quality

performance measures.

The Board has scrutinised performance data and commended areas which are doing well. They have

requested further assurance for areas which need improving and regularly monitor progress against

improvements. For example the Board noted a reduction in performance for breast screening and length

of time to recall women to screening. They requested a full and comprehensive briefing on performance

and what measures were in place to improve matters. The Board have continued to monitor this area

closely.

We collect service user feedback, however we need to improve on how we will use the feedback to

improve services. Patient stories or a mechanism for reviewing outward facing services to give an

overview of how the organisation is performing.

All medical staff are required to comply with medical revalidation. Non medical staff are required to

√


36

undergo regular performance review and personal development.

Engagement sessions with staff have identified a desire for more structured management and leadership

development. A programme has been approved by the Board and implementation will begin in 2014/15.

Supporting evidence

Standards for Health Services and CPA mapping

Quality management systems

Workforce and Organisational Development reports

Quality and Safety Committee reports

Audit Committee reports

Public Health Wales Strategy



b) We operate in accordance with all legal and other requirements placed on us S

tro

ng

ly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


The standing orders, standing financial instructions and scheme of delegation are reviewed periodically by

the Board and are available on the Public Health Wales internet.

The Annual Governance Statement is prepared in line with Welsh Government requirements and takes

account of best practice issued by HM Treasury. The Statement provides an assurance of the governance

arrangements in the organisation. The Audit Committee play a key role in the completion of the

statement and by providing assurance to the Board that the organisation is operating in accordance with

all requirements placed on us.

A Local Counter Fraud specialist is in place and reports regularly to the Audit Committee. They provide

specialist criminal investigation, surveillance capability and financial investigation services.

√


37

A Board Assurance Framework was approved by the Board in September 2013.

A review of the Terms of Reference for the Audit, Information Governance and Quality & Safety Committee

was completed in 2013/14 and has confirmed that there is no overlap in responsibilities between the

Committees. This has also clarified which information needs to be received by which committee.

Workplans for each Committee will be developed together to ensure clarity of roles.

The Wales Audit Office audits our accounts on an annual basis and provides assurance in the form of an

annual audit report and structured assessment. Internal audit arrangements are provided by NHS Wales

Shared Services Partnership – Audit and Assurance Services.

Statutory and mandatory training is required of all staff. However, improvements are needed in this area

because compliance rates are lower than expected.

Public Health Wales policies and procedures highlight any legislation relevant to the policy and efforts are

focused on improving compliance.

Recruitment and selection is undertaken in regard of legal, professional and best practice requirements to

ensure staff are aware and act in accordance with the legislation.

In the last year we have put in place a revised Strategic Equalities Plan (SEP) and a working group to

action the plan which has representation from across Public Health Wales. The SEP considers equality

issues affecting all aspects of our work as well as our workforce.

We also ensure all our facilities comply with the Disability Discrimination Act.

The Welsh Language Board approved our Welsh Language Scheme which demonstrates the commitment

to communicating with the public in the Welsh and English languages on the basis of equality and

championing the Welsh Language.

Supporting evidence

Board and Committee structure

Standing Orders

Standing Financial Instructions

Risk Management structure

Statutory requirements

Policies and procedures

Scheme of Delegations


38

Welsh Audit Office Structured Assessment report

Agreement with NHS Wales Shared Services Partnership

Counter-Fraud SLA

Health & Safety Professional Lead

Radiation advice provided by Velindre NHS Trust

Register of interests

CPA

UKAS (annual review meeting)

Standards for Health Services

Professional registration

Code of Conduct

Support Criminal Record Bureau checks

Welsh Language Scheme monitoring reports


c) We know what our citizens and others (including our workforce) think of us, and this influences what we do and how we do it

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


A Public and Stakeholder Engagement strategy has been approved by the Board. Work is underway to

assess stakeholder and service user satisfaction more systematically and in line with the strategy. A

service user engagement group is being established which will assist with learning from service user

feedback and influence what we do and how we do it.

Currently feed back is received via the following routes:

The screening programmes conduct satisfaction surveys for some of the populations they invite for

screening.

The screening programmes also have a public information group which include user representatives and

which develop public information materials

As part of its quality management system, Public Health Wales microbiology services conduct

√


39

stakeholder satisfaction surveys.

The Public Health Wales Networks evaluate each of their conferences and have themselves been

externally evaluated

Other conferences are also evaluated

Stop Smoking Wales get user feedback from survey sheets

All Public Health Wales websites have a feedback facility

The Equality Group has received ‘patient stories’

In each of the above cases, views are fed into the relevant management groups for consideration and

action. These only represent part of the organisation and work is underway to make this routine across

the entire organisation.

Representatives from the partnership forum have been invited to attend Board meetings as full, non-

voting Board members. We are still establishing representation from professional groups.

As an all Wales organisation we have experienced difficulties in engaging with Community Health Council.

We identified this as an area for improvement last year and engagement has started. We aim to link with

Community Health Councils wherever possible.

The Trust is exploring opportunities to develop staff stories that can be shared with the Board, which

would ensure that geographically dispersed staff can raise concerns with the Board. Although the nature of

the Trust’s business makes it difficult for executives and non-executives to carry out regular planned and

unplanned walkarounds to see first-hand staff experience, the Board has taken positive action to travel

and meet staff deployed in different parts of the Trust and at different locations.

A number of improvements have been identified for how the organisation can learn from citizens and

others. Therefore, the scoring has been reduced from last year.

Supporting evidence

Screening Engagement annual report

Reports on the Screening Services satisfaction surveys

Public Health Wales websites feedback facilities

Web forum

Open blog

Putting things right

Staff survey

Equality Group



40



d) We measure our performance against ‘best practice’ and other standards set for the services we provide and we use the results to drive improvement in the provision of high quality, safe and accessible services

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


Performance is regularly measured against ‘best practice’ from the UK and internationally. Screening

services, for example, regularly compare screening programmes with those taking place in England,

Scotland and Northern Ireland. Each programme is developed and improved using international evidence

and research. The all Wales pathology modernisation work programme has drawn upon international best

practice.

All screening programmes operate a total quality management framework and standards for delivery are

outlined in each programme specific quality manual. There is also an ongoing programme of evaluation

and all reports and statistics are published annually on the Screening website. Programme performance

and individual performance are monitored on an ongoing basis as this enables the service to target re-

training or interventions as required. Screening programmes are being developed further so that they

continue to meet performance standards.

Public Health Wales has strong links with international colleagues and members of staff regularly attend

international meetings and conferences where best practice and innovation is shared. An example is

Public Health Wales membership of Eurohealthnet and staff attendance at the European Public Health

Association (EUPHA) conference. The International Health Coordination Centre strengthens international

links and opportunities.

The 1000 Lives improvement service regularly draws on international work and comparisons when

introducing new service improvement initiatives. The target for smoking cessation is based on an

international benchmark.

Members of the Board, Executive Team and staff within the organisation attend all Wales and international

√


41

meetings where best practice and experience is openly shared.

The Health and Healthcare Improvement Division has undertaken a series of tobacco control workshops

where best practice and other standards can be developed and shared amongst those working on smoking

cessation.

Supporting evidence

Standards for Health Services

Internal and External audit reviews

Reviews and inspections by regulatory bodies

UK and worldwide published data

WG guidance and instructions

Quality Delivery Plan

Internal performance data

NHS Wales Shared Services Partnership Committee

Staff involvement with professional groups

Staff Membership of professional bodies

International conferences and activities

Sharing of best practice within and between professional groups via regular monthly / quarterly

meetings

1000 Lives improvement service quarterly Learning Sessions and Webex meetings


42

e) We learn from our own and others experiences, and in turn share our learning with others

Str

on

gly

dis

ag

ree

Dis

ag

ree

Neith

er

ag

ree n

or

dis

ag

ree

Ag

ree

Str

on

gly

Ag

ree


We foster a sense of learning through engagement with others.

Board meetings are planned to foster learning from others and sharing experiences. Alternate Board

meetings take place in localities across Wales and individuals are invited to present to the Board to share

learning experiences. We hold an annual general meeting which provides an opportunity for staff and

stakeholders to reflect on the work undertaken during the year. A leadership and delivery group has

been established to facilitate learning across divisions and directorates.

We play a full part in the all Wales networks and are engaged in all areas where experiences are shared

and discussed.

We have strong links with the Chief Medical Officer and Chief Nursing Officerin Welsh Government, Public

Health England and public health colleagues in England, Scotland and Northern Ireland. The Director for

Public Health Development attends meetings of the ‘5 nations’ (Wales, England, Scotland, Northern

Ireland, Republic of Ireland) and the Director for Public Health Services attends meetings of the Public

Health England Advisory Board and Director of Nursing is developing stronger links with counterparts

within the four nations.

The Welsh Public Health conference is coorganised by Public Health Wales and provides a forum for

sharing of experiences and learning and is highly regarded amongst professionals in Wales and the UK.

The health protection team take part in formal reviews in relation to health protection and regular debriefs

during and after outbreaks. The measles outbreak has provided an opportunity to share learning with

others and a delegation attended and presented at the American Public Health Conference in Boston.

Supporting evidence

√


43

Welsh Government reviews

Annual General Meeting (AGM)

Stakeholder meetings

Director of Public Health meetings

All Wales Medical Director meetings

All Wales Nurse Director meetings

Board meetings

Committee meetings

Bevan Commission

Advisory committees

Regular meetings of Chief Executives; Executive Directors; Chairs; Board members etc.


44

Theme 3 – Delivering results, achieving excellence: Your overall assessment


are governing well



Governing well

We have developed revised performance and planning arrangements.

We operate within all legal and other requirements placed upon us.


We need to improve learning from service user engagement.


We have applied learning from the measles outbreak and presented findings at conference in Boston


We are developing plans and processes and can demonstrate progress with some of our key areas for improvement.




Learning from service user

experience

Service user group


strategy

Patient stories at Board

meetings


2015

Service user feedback

performance reports will be

embedded into the reporting

system

Board will have opportunities to

hear from service users directly.

Improve compliance with

statutory and mandatory training

Implementation of statutory

and mandatory training policy

Work with managers to ensure

increase in compliance

March 2015 Compliance rates should either

meet, or exceed, target.


45

Standards for Health Services Governance and Accountability Maturity Matrix

1 2 3 4 5

We do not yet have a clear, agreed

understanding of where we are (or how we are

doing) and what / where we need to improve

We are aware of the improvements that

need to be made and have prioritised them,

but are not yet able to demonstrate

meaningful action.

We are developing plans and processes

and can demonstrate progress with some of

our key areas for improvement

We have well developed plans and

processes and can demonstrate

sustainable improvement

throughout the organisation /

business

We can demonstrate sustained good

practice and innovation that is

shared throughout the organisations /

business, and which others can learn from

Public Health Wales Annual accounts and Annual GovernanceStatement 2013/14

Date: 16 June 2014 Version:1 Page: 1 of 2

Annual accounts andAnnual Governance Statement 2013/14

Purpose of Document:The annual accounts and Annual Governance Statement for 2013/14 were approvedby the Public Health Wales Audit Committee on 5 June 2014 and submitted to theWelsh Government on 6 June 2014. The Board are asked to ratify the approval of theaccounts and governance statement.


To decide- Paper will outline recommendations or issues to be approved bythe Board or Committee.

X

To discuss- Board or Committee will be asked to discuss and scrutinise thepaper and provide feedback and comments.



Please include any recommendations/details of decisions Board/Committees are askedto make.Next Steps

The Board are asked to ratify the approval of the annual accounts and AnnualGovernance Statement for 2013/14.


x

Priorities for action Put in place an effective governanceframeworkEnsure financial sustainability

Author: Ms Tamira Rolls, Assistant Director of Finance and Ms Eleanor Higgins,Corporate Governance ManagerDate: 16 June 2014 Version: 1

Sponsoring Executive Director: Mr Huw George, Executive Director ofFinance and Mr Keith Cox, BoardSecretary


Public Health Wales Annual accounts and Annual GovernanceStatement 2013/14


Who will present: (If appropriate) Mr Huw George / Mr Keith CoxDocuments attached:(If appropriate)

Annual accounts 2013/14Annual Governance Statement 2013/14

Date of meeting: 26 June 2014Committee/Groups that havereceived or considered this paper:

Audit Committee

Link to standardsfor health services

Standard 1: Governance and Accountability

Link to risk register Risk ID 87: Failure to meet statutory brake even duty. Failureto full savings targets outstanding WG funding Cost of wageawardsRisk ID 102: Ensuring the Public Health WalesGovernance/assurance and performance managementframework evolves to reflect the changing organisation andchanging external governance environment whilst continuingto meet statutory obligations.


N/A

Financialimplications

N/A


N/A

Public Health Wales NHS Trust Annual Accounts 2013-14

Foreword

Public Health Wales NHS Trust

These accounts for the period ended 31 March 2014 have been prepared to comply with International Financial Reporting Standards (IFRS) adopted by the European Union, in accordance with HM Treasury's I-FReM by the Public Health Wales NHS Trust under schedule 9 section 178 Para 3 (1) of the National Health

Service (Wales) Act 2006 (c.42) in the form in which the Welsh Ministers, with the approval of the Treasury, directed.

The establishment of Public Health Wales in 2009, created for the first time, an

independent NHS body with a clear and specific public health focus, and a remit to act across all the domains of public health practice. The Minister for Health and Social Services confirmed Public Health Wales would provide the national resource for the effective delivery of public health services at national, local and community level. Public Health Wales originally incorporated the functions and services previously provided by the National Public Health Service (NPHS), Wales Centre for Health

(WCfH), Welsh Cancer Intelligence Surveillance Unit (WCISU), Congenital Anomaly Register and Information Service (CARIS) and Screening Services Wales.

Since 2009, we have continued to grow, taking on a range of additional functions

and services from both the Welsh Government and NHS Wales, including the Programme Management Unit, several Health Improvement Programmes, Newborn Bloodspot Screening, Abdominal Aeortic Aneurism Screening and the Wrexham Microbiology Laboratory. One of the outcomes of the review into the former National Leadership and Innovation Agency for Healthcare (NLIAH), was that the improvement functions within NLIAH transferred into Public Health Wale on April 1st 2013, along with the

functions of equality and human rights.

The overall income level for Public Health Wales has increased by over 25 per cent over the last four years, from just over £80m in 2010/11 to £105m in 2013/14.

Furthermore, the National Cancer Service Advisory Group (NCSAG) will be transferring into Public Health Wales from Velindre NHS Trust on April 1st 2014,

with a budget of £240k. The financial target of payment of 95% of all invoices (by number) was not met in 2013/14, with the actual performance at 93.9%; missing the target by just 1.2%. This is a direct result of a several changes to both the reporting requirements and

the operating arrangements for the payment of invoices. Although performance increased during the second half of the financial year, following several

improvements to operational arrangements, the cummulative performance for the year remains below the 95%. The payment of 95% of all invoices by value has

been met. However both statutory targets of acheiving financial balance and remaining within

our EFL have been met again in 2013/14. The accounts that follow present a balanced position, with a small retained surplus of £15k.


STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 March 2014

2013-14 2012-13

Note £000 £000

Revenue from patient care activities 2 83,044 79,098

Other operating revenue 3 22,038 19,299

Operating expenses 6 (105,033) (98,314)

Operating surplus/(deficit) 49 83

Investment revenue 7 16 55

Other gains and losses 8 0 (86)

Finance costs 9 (50) (42)

Retained surplus/(deficit) 33.1 15 10

Other Comprehensive Income

Items that will not be reclassified to net operating costs:

Net gain/(loss) on revaluation of property, plant and equipment 56 0

Net gain/(loss) on revaluation of intangible assets 0 0

Net gain/(loss) on revaluation of financial assets 0 0

Net gain/(loss) on revaluation of PPE and Intangible assets held for sale 0 0

Impairments and reversals 0 (187)

Movements in other reserves 0 0

Transfers between reserves 0 0

Net gain/loss on Other Reserve 0 0

Reclassification adjustment on disposal of available for sale financial assets 0 0

Sub total 56 (187)

Items that may be reclassified subsequently to net operating costs

Net gain/(loss) on revaluation of financial assets held for sale 0 0

Sub total 0 0

Total other comprehensive income for the year 56 (187)

Total comprehensive income for the year 71 (177)

1


Note 31 March 31 March

2014 2013

£000 £000

Non-current assets Property, plant and equipment 14 13,912 15,684

Intangible assets 15 0 0

Trade and other receivables 20 0 0

Other financial assets 21 0 0

Other assets 22 0 0

Total non-current assets 13,912 15,684

Current assets Inventories 19 78 86

Trade and other receivables 20 7,825 7,539

Other financial assets 21 0 0

Other assets 22 0 0

Cash and cash equivalents 23 2,547 2,501

10,450 10,126

Non-current assets held for sale 14.2 0 0

Total current assets 10,450 10,126

Total assets 24,362 25,810

Current liabilities Trade and other payables 24 (5,798) (5,745)

Borrowings 25 0 0

Other financial liabilities 26 0 (623)

Provisions 28 (3,018) (2,365)

Other liabilities 27 0 0

Total current liabilities (8,816) (8,733)

Net current assets/(liabilities) 1,634 1,393

Total assets less current liabilities 15,546 17,077

Non-current liabilities Trade and other payables 24 (1,232) 0

Borrowings 25 0 0

Other financial liabilities 26 0 (1,713)

Provisions 28 (1,115) (1,050)

Other liabilities 27 0 0

Total non-current liabilities (2,347) (2,763)

Total assets employed 13,199 14,314

Financed by Taxpayers' equity:

Public dividend capital 12,660 13,846

Retained earnings 483 468

Revaluation reserve 56 0

Other reserves 0 0

Total taxpayers' equity 13,199 14,314

Chief Executive ........................................................ Date……………………………………..

STATEMENT OF FINANCIAL POSITION AS AT 31 March 2014

The financial statements were approved by the Audit Committee on behalf of the

Board on 5th June 2014 and signed on behalf of the Board by:

2


STATEMENT OF CHANGES IN TAXPAYERS' EQUITY

2013-14

Public

Dividend

Capital

Retained

earnings

Revaluation

reserve

Other

reserves Total

£000 £000 £000 £000 £000

Balance at 1 April 2013 13,846 468 0 0 14,314

Changes in taxpayers' equity for 2013-

14

Retained surplus/(deficit) for the year 15 15Net gain/(loss) on revaluation of property,

plant and equipment 0 56 0 56

Net gain/(loss) on revaluation of intangible

assets 0 0 0 0

Net gain/(loss) on revaluation of financial

assets 0 0 0 0

Net gain/(loss) on revaluation of PPE and

Intangible assets held for sale 0 0 0 0


assets held for sale 0 0 0 0

Impairments and reversals 0 0 0 0

Movements in other reserves 0 0 0 0

Transfers between reserves 0 0 0 0

Net gain/loss on Other Reserve (specify) 0 0 0 0

Reclassification adjustment on disposal of

available for sale financial assets 0 0 0 0

Reserves eliminated on dissolution 0 0

New Public Dividend Capital received 62 62

Public Dividend Capital repaid in year (1,186) (1,186)

Public Dividend Capital

extinguished/written off 0 0

Other movements in PDC in year (62) (62)

Balance at 31 March 2014 12,660 483 56 0 13,199

The notes on pages 6 to 89 form part of these accounts.

3


STATEMENT OF CHANGES IN TAXPAYERS' EQUITY

2012-13

Public

Dividend

Capital

Retained

earnings

Revaluation

reserve

Other

reserves Total

£000 £000 £000 £000 £000

Balance at 1 April 2012 15,596 458 187 0 16,241

Changes in taxpayers' equity for 2012-13

Retained surplus/(deficit) for the year 10 10

Net gain/(loss) on revaluation of property,

plant and equipment 0 0 0 0

Net gain/(loss) on revaluation of intangible

assets 0 0 0 0


assets 0 0 0 0

Net gain/(loss) on revaluation of PPE and

Intangible assets held for sale 0 0 0 0


assets held for sale 0 0 0 0

Impairments and reversals 0 (187) 0 (187)

Movements in other reserves 0 0 0 0

Transfers between reserves 0 0 0 0

Net gain/loss on Other Reserve (specify) 0 0 0 0

Reclassification adjustment on disposal of

available for sale financial assets 0 0 0 0

Reserves eliminated on dissolution 0 0

New Public Dividend Capital received 0 0

Public Dividend Capital repaid in year (1,812) (1,812)

Public Dividend Capital

extinguished/written off 0 0

Other movements in PDC in year 62 62

Balance at 31 March 2013 13,846 468 0 0 14,314

4


2013-14 2012-13

Note £000 £000

Cash flows from operating activities

Operating surplus/(deficit) SOCI 49 83

Depreciation and amortisation 6 2,798 2,438

Impairments and reversals 6 0 1,783

Release of PFI deferred credits 0 0

Donated Assets received credited to revenue but non-cash 3 0 0

Government Granted Assets received credited to revenue but non-cash 3 0 0

Interest paid (50) (42)

(Increase)/decrease in inventories 8 25

(Increase)/decrease in trade and other receivables (348) (1,984)

(Increase)/decrease in other current assets 0 0

Increase/(decrease) in trade and other payables 1,216 418

Increase/(decrease) in other current liabilities (2,336) 223

Increase/(decrease) in provisions 718 20

Net cash inflow/(outflow) from operating activities 2,055 2,964

Cash flows from investing activities

Interest received 17 55

(Payments) for property, plant and equipment (742) (1,924)

Proceeds from disposal of property, plant and equipment 0 0

(Payments) for intangible assets 0 0

Proceeds from disposal of intangible assets 0 0

(Payments) for investments with Welsh Government 0 0

Proceeds from disposal of investments with Welsh Government 0 0

(Payments) for financial assets. (304) (780)

Proceeds from disposal of financial assets. 0 0

Rental proceeds 0 0

Net cash inflow/(outflow) from investing activities (1,029) (2,649)

Net cash inflow/(outflow) before financing 1,026 315

Cash flows from financing activities

Public Dividend Capital received 62 0

Public Dividend Capital repaid (1,186) (1,812)

Loans received from Welsh Government 0 0

Other loans received 0 0

Loans repaid to Welsh Government 0 0

Other loans repaid 0 0

Other capital receipts 0 0

Capital elements of finance leases and on-SOFP PFI 144 30

Cash transferred (to)/from other NHS Wales bodies 0 0

Net cash inflow/(outflow) from financing activities (980) (1,782)

Net increase/(decrease) in cash and cash equivalents 46 (1,467)

Cash [and] cash equivalents [and bank overdrafts] 23 2,501 3,968

at the beginning of the financial year

Cash [and] cash equivalents [and bank overdrafts]

at the end of the financial year 23 2,547 2,501

The notes on pages 6 to 89 form part of these accounts.

STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2014

5

Public Health Wales NHS Trust Annual Accounts 2013-14 13/06/2014

Notes to the Accounts

Accounting policies

1. The Welsh Minister for Health and Social Services has directed that the financial statements of NHS Trusts in Wales shall meet the accounting requirements of the NHS Trust Manual for Accounts. Consequently, the following financial statements have been prepared in accordance with the 2013-14 NHS Trusts Manual for Accounts. The accounting policies contained in that manual follow the European Union version of the International Financial Reporting Standards to the extent that they are meaningful and appropriate to the NHS, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the NHS Trusts Manual for Accounts permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the trust for the purpose of giving a true and fair view has been selected. The particular policies adopted by the trust are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets and inventories. 1.2 Acquisitions and discontinued operations Activities are considered to be ‘acquired’ only if they are taken on from outside the public sector. Activities are considered to be ‘discontinued’ only if they cease entirely. They are not considered to be ‘discontinued’ if they transfer from one public sector body to another. 1.3 Pooled budgets The trust has not entered into any pooled budget arrangements with Local Authorities.

1.4 Revenue

Revenue in respect of services provided is recognised when, and to the extent that,

performance occurs, and is measured at the fair value of the consideration receivable. The

main source of revenue for the trust is from the Welsh Government and the Health Boards.

This revenue is recognised in the period in which services are provided.

Where income is received from Non NHS bodies for a specific activity that is to be delivered

in the following year, that income is deferred.

The Trust receives no income under the NHS Injury Cost Recovery Scheme.

1.5 Employee Benefits

Salaries, wages and employment-related payments are recognised in the period in which the

service is received from employees. The cost of leave earned but not yet taken by

employees at the end of the period is recognised in the financial statements to the extent

that employees are permitted to carry forward leave into the following period.

Retirement benefit costs

Past and present employees are covered by the provisions of the NHS Pensions Scheme.

The scheme is an unfunded, defined benefit scheme that covers NHS employers, General

Practices and other bodies, allowed under the direction of the Secretary of State, in England

and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to

identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is

accounted for as if it were a defined contribution scheme: the cost to the NHS body of

participating in the scheme is taken as equal to the contributions payable to the scheme for

the accounting period.

6


For early retirements other than those due to ill health the additional pension liabilities are

not funded by the scheme. The full amount of the liability for the additional costs is

charged to expenditure at the time the trust commits itself to the retirement, regardless

of the method of payment.

1.6 Other expenses

Other operating expenses for goods or services are recognised when, and to the extent

that, they have been received. They are measured at the fair value of the consideration

payable.

1.7 Property, plant and equipment

Recognition

Property, plant and equipment is capitalised if:

it is held for use in delivering services or for administrative purposes;

it is probable that future economic benefits will flow to, or service potential will be

supplied to, the trust;

it is expected to be used for more than one financial year;

the cost of the item can be measured reliably; and

the item has cost of at least £5,000; or

Collectively, a number of items have a cost of at least £5,000 and individually have a

cost of more than £250, where the assets are functionally interdependent, they had

broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates

and are under single managerial control; or

● Items form part of the initial equipping and setting-up cost of a new building, ward or

unit, irrespective of their individual or collective cost.

Where a large asset, for example a building, includes a number of components with

significantly different asset lives, the components are depreciated over their own useful

economic lives.

Valuation

All property, plant and equipment are measured initially at cost, representing the cost

directly attributable to acquiring or constructing the asset and bringing it to the location

and condition necessary for it to be capable of operating in the manner intended by

management.

Land and buildings used for the trust’s services or for administrative purposes are stated

in the balance sheet at their revalued amounts less any subsequent accumulated

depreciation and impairment losses. Revaluations are performed with sufficient regularity

to ensure that carrying amounts are not materially different from those that would be

determined at the balance sheet date. Fair values are determined as follows:

- Land and non specialised buildings – market value for existing use

- Specialised buildings – depreciated replacement cost

From 1 April 2009 the depreciated replacement cost valuation applies the Modern

Equivalent Asset (MEA) cost basis of estimation to arrive at the cost of replacing the

capacity and utility of a building rather than a like for like replacement cost.

7


Properties in the course of construction for service or administration purposes are carried

at cost, less any impairment loss. Cost includes professional fees but not borrowing costs,

which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair

value. Assets are revalued and depreciation commences when they are brought into use.

For 2012-13 a formal revaluation exercise by the District Valuation Office was applied to

the Land and Properties of NHS Wales Trusts from 1 April 2012. In 2013-14 indexation

has been applied to property plant and equipment based on indices supplied by the District

Valuation Office. The carrying value of existing assets at that date will be written off over

their remaining useful lives and new fixtures and equipment are carried at depreciated

historic cost as this is not considered to be materially different from fair value.

An increase arising on revaluation is taken to the revaluation reserve except when it

reverses an impairment for the same asset previously recognised in expenditure, in which

case it is credited to expenditure to the extent of the decrease previously charged there. A

revaluation decrease that does not result from a loss of economic value or service potential

is recognised as an impairment charged to the revaluation reserve to the extent that there

is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment

losses that arise from a clear consumption of economic benefit should be taken to

expenditure. This is a change in accounting policy from previous years where all

impairments were taken to the revaluation reserve to the extent that a balance was held

for that asset and thereafter to expenditure. However, to ensure that the outcome as

reflected in the reserves figure on the Statement of Financial Position is consistent with the

requirements of IAS 36 had this adaptation not been applied, the balance on any

revaluation reserve (up to the level of the impairment) to which the impairment would

have been charged under IAS 36 should be transferred to Retained earnings.

Subsequent expenditure

Where subsequent expenditure enhances an asset beyond its original specification, the

directly attributable cost is capitalised. Where subsequent expenditure restores the asset

to its original specification, the expenditure is capitalised and any existing carrying value of

the item replaced is written-out and charged to operating expenses.

1.8 Intangible assets

Recognition

Intangible assets are non-monetary assets without physical substance, which are capable

of sale separately from the rest of the trust’s business or which arise from contractual or

other legal rights. They are recognised only when it is probable that future economic

benefits will flow to, or service potential be provided to, the trust; where the cost of the

asset can be measured reliably, and where the cost is at least £5.000.

8


Intangible assets acquired separately are initially recognised at fair value. Software

that is integral to the operating of hardware, for example an operating system, is

capitalised as part of the relevant item of property, plant and equipment. Software

that is not integral to the operation of hardware, for example application software, is

capitalised as an intangible asset. Expenditure on research is not capitalised: it is

recognised as an operating expense in the period in which it is incurred. Internally-

generated assets are recognised if, and only if, all of the following have been

demonstrated:

the technical feasibility of completing the intangible asset so that it will be

available for use

the intention to complete the intangible asset and use it

the ability to sell or use the intangible asset

how the intangible asset will generate probable future economic benefits or

service potential

the availability of adequate technical, financial and other resources to complete

the intangible asset and sell or use it

the ability to measure reliably the expenditure attributable to the intangible asset

during its development

Measurement

The amount initially recognised for internally-generated intangible assets is the sum

of the expenditure incurred from the date when the criteria above are initially met.

Where no internally-generated intangible asset can be recognised, the expenditure

is recognised in the period in which it is incurred.

Following initial recognition, intangible assets are carried at fair value by reference

to an active market, or, where no active market exists, at amortised replacement

cost (modern equivalent assets basis), indexed for relevant price increases, as a

proxy for fair value. Internally-developed software is held at historic cost to reflect

the opposing effects of increases in development costs and technological advances.

1.9 Research and development

Research and development expenditure is charged to operating costs in the year in

which it is incurred, except insofar as it relates to a clearly defined project, which

can be separated from patient care activity and benefits there from can reasonably

be regards as assured. Expenditure so deferred is limited to the value of future

benefits expected and is amortised through the SOCNI on a systematic basis over

the period expected to benefit from the project.

1.10 Depreciation, amortisation and impairments

Freehold land, properties under construction and assets held for sale are not

depreciated.

Otherwise, depreciation and amortisation are charged to write off the costs or

valuation of property, plant and equipment and intangible non-current assets, less

any residual value, over their estimated useful lives, in a manner that reflects the

consumption of economic benefits or service potential of the assets. The estimated

useful life of an asset is the period over which the Trust expects to obtain economic

benefits or service potential from the asset. This is specific to the Trust and may be

shorter than the physical life of the asset itself. Estimated useful lives and residual

values are reviewed each year end, with the effect of any changes recognised on a

prospective basis. Assets held under finance leases are depreciated over the shorter

9


At each reporting period end, the trust checks whether there is any indication that any of

its tangible or intangible non-current assets have suffered an impairment loss. If there is

indication of an impairment loss, the recoverable amount of the asset is estimated to

determine whether there has been a loss and, if so, its amount. Intangible assets not yet

available for use are tested for impairment annually.

Impairment losses that do not result from a loss of economic value or service potential

are taken to the revaluation reserve to the extent that there is a balance on the reserve

for the asset and, thereafter, to the Statement of Comprehensive Net Income.

Impairment losses that arise from a clear consumption of economic benefit are taken to

the Statement of Comprehensive Net Income. The balance on any revaluation reserve (up

to the level of the impairment) to which the impairment would have been charged under

IAS 36 are transferred to retained earnings.

1.11 Borrowing costs

Borrowing costs are recognised as expenses as they are incurred.

1.12 Donated assets

Following the accounting policy change outlined in the Treasury FREM for 2011-12, a

donated asset reserve is no longer maintained. Donated non-current assets are

capitalised at their fair value on receipt, with a matching credit to Income. They are

valued, depreciated and impaired as described above for purchased assets. Gains and

losses on revaluations, impairments and sales are as described above for purchased

assets. Deferred income is recognised only where conditions attached to the donation

preclude immediate recognition of the gain.

1.13 Government grants

Following the accounting policy change outlined in the Treasury FREM for 2011-12, a

government grant reserve is no longer maintained. The value of assets received by

means of a government grant are credited directly to income. Deferred income is

recognised only where conditions attached to the grant preclude immediate recognition of

the gain.

1.14 Non-current assets held for sale

Non-current assets are classified as held for sale if their carrying amount will be recovered

principally through a sale transaction rather than through continuing use. This condition

is regarded as met when the sale is highly probable, the asset is available for immediate

sale in its present condition and management is committed to the sale, which is expected

to qualify for recognition as a completed sale within one year from the date of

classification. Non-current assets held for sale are measured at the lower of their

previous carrying amount and fair value less costs to sell. Fair value is open market value

including alternative uses.

10


The profit or loss arising on disposal of an asset is the difference between the sale proceeds

and the carrying amount and is recognised in the Statement of Comprehensive Net Income.

On disposal, the balance for the asset on the revaluation reserve is transferred to retained

earnings.

Property, plant and equipment that is to be scrapped or demolished does not qualify for

recognition as held for sale. Instead, it is retained as an operational asset and its economic

life is adjusted. The asset is de-recognised when it is scrapped or demolished.

1.15 Leases

Leases are classified as finance leases when substantially all the risks and rewards of

ownership are transferred to the lessee. All other leases are classified as operating leases.

The trust as lessee

Property, plant and equipment held under finance leases are initially recognised, at the

inception of the lease, at fair value or, if lower, at the present value of the minimum lease

payments, with a matching liability for the lease obligation to the lessor. Lease payments

are apportioned between finance charges and reduction of the lease obligation so as to

achieve a constant rate on interest on the remaining balance of the liability. Finance

charges are recognised in calculating the trust’s surplus/deficit.

Operating lease payments are recognised as an expense on a straight-line basis over the

lease term. Lease incentives are recognised initially as a liability and subsequently as a

reduction of rentals on a straight-line basis over the lease term.

Contingent rentals are recognised as an expense in the period in which they are incurred.

Where a lease is for land and buildings, the land and building components are separated

and individually assessed as to whether they are operating or finance leases.

The trust as lessor

Amounts due from lessees under finance leases are recorded as receivables at the amount

of the trust’s net investment in the leases. Finance lease income is allocated to accounting

periods so as to reflect a constant periodic rate of return on the trust’s net investment

outstanding in respect of the leases.

Rental income from operating leases is recognised on a straight-line basis over the term of

the lease. Initial direct costs incurred in negotiating and arranging an operating lease are

added to the carrying amount of the leased asset and recognised on a straight-line basis

over the lease term.

1.16 Private Finance Initiative (PFI) transactions

The Trust has no PFI arrangements.

11

and the carrying amount and is recognised in the Statement of Comprehensive Net Income.

11


1.17 Inventories

Inventories are valued at the lower of cost and net realisable value using the first in

first out cost formula. This is considered to be a reasonable approximation to fair value

due to the high turnover of stocks.

1.18 Cash and cash equivalents

Cash is cash in hand and deposits with any financial institution repayable without

penalty on notice of not more than 24 hours. Cash equivalents are investments that

mature in 3 months or less from the date of acquisition and that are readily convertible

to known amounts of cash with insignificant risk of change in value.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank

overdrafts that are repayable on demand and that form an integral part of the trust’s

cash management.

1.19 Provisions

Provisions are recognised when the trust has a present legal or constructive obligation

as a result of a past event, it is probable that the trust will be required to settle the

obligation, and a reliable estimate can be made of the amount of the obligation. The

amount recognised as a provision is the best estimate of the expenditure required to

settle the obligation at the end of the reporting period, taking into account the risks and

uncertainties. Where a provision is measured using the cash flows estimated to settle

the obligation, its carrying amount is the present value of those cash flows using

discount rates supplied by HM Treasury.

When some or all of the economic benefits required to settle a provision are expected to

be recovered from a third party, the amount receivable is recognised as an asset if it is

virtually certain that reimbursements will be received and the amount of the receivable

can be measured reliably.

Present obligations arising under onerous contracts are recognised and measured as a

provision. An onerous contract is considered to exist where the trust has a contract

under which the unavoidable costs of meeting the obligations under the contract exceed

the economic benefits expected to be received under it.

A restructuring provision is recognised when the trust has developed a detailed formal

plan for the restructuring and has raised a valid expectation in those affected that it will

carry out the restructuring by starting to implement the plan or announcing its main

features to those affected by it. The measurement of a restructuring provision includes

only the direct expenditures arsing from the restructuring, which are those amounts

that are both necessarily entailed by the restructuring and not associated with ongoing

activities of the entity.

1.20 Clinical Negligence Costs

The Welsh Risk Pool (WRP) operates a risk pooling scheme which is currently funded by

the Welsh Government. The WRP is hosted by Velindre NHS Trust.

1.21 Carbon Reduction Commitment Scheme

The trust is not a member of the Carbon Reduction Commitment Scheme.

12


1.22 Contingencies

A contingent liability is a possible obligation that arises from past events and whose

existence will be confirmed only by the occurrence or non-occurrence of one or more

uncertain future events not wholly within the control of the trust, or a present obligation

that is not recognised because it is not probable that a payment will be required to settle

the obligation or the amount of the obligation cannot be measured sufficiently reliably. A

contingent liability is disclosed unless the possibility of a payment is remote.

A contingent asset is a possible asset that arises from past events and whose existence will

be confirmed by the occurrence or non-occurrence of one or more uncertain future events

not wholly within the control of the trust. A contingent asset is disclosed where an inflow

of economic benefits is probable.

Where the time value of money is material, contingencies are disclosed at their present

value.

1.23 Financial assets

Financial assets are recognised when the trust becomes party to the financial instrument

contract or, in the case of trade receivables, when the goods or services have been

delivered. Financial assets are derecognised when the contractual rights have expired or

the asset has been transferred.

Financial assets are initially recognised at fair value.

Financial assets are classified into the following categories: financial assets ‘at fair value

through SoCNI’; ‘held to maturity investments’; ‘available for sale’ financial assets, and

‘loans and receivables’. The classification depends on the nature and purpose of the

financial assets and is determined at the time of initial recognition.

Financial assets at fair value through SoCNI

Embedded derivatives that have different risks and characteristics to their host contracts,

and contracts with embedded derivatives whose separate value cannot be ascertained, are

treated as financial assets at fair value through SoCNI. They are held at fair value, with

any resultant gain or loss recognised in calculating the trust’s surplus or deficit for the

accounting period. The net gain or loss incorporates any interest earned on the financial

asset.

The Trust has no embedded derivatives. (Delete as appropriate).

Held to maturity investments

Held to maturity investments are non-derivative financial assets with fixed or determinable

payments and fixed maturity, and there is a positive intention and ability to hold to

maturity. After initial recognition, they are held at amortised cost using the effective

interest method, less any impairment. Interest is recognised using the effective interest

method.

Available for sale financial assets

The Trust does not have any available for sale financial assets.

13


Loans and receivables

Loans and receivables are non-derivative financial assets with fixed or determinable

payments which are not quoted in an active market. After initial recognition, they are

measured at amortised cost using the effective interest method, less any impairment.

Interest is recognised using the effective interest method.

Fair value is determined by reference to quoted market prices where possible, otherwise

by valuation techniques

The effective interest rate is the rate that exactly discounts estimated future cash receipts

through the expected life of the financial asset, to the initial fair value of the financial

asset.

The Trust has no financial assets, other than those held at ‘fair value through profit and

loss’ that will need to be impaired.

1.24 Financial liabilities

Financial liabilities are recognised on the statement of financial position when the trust

becomes party to the contractual provisions of the financial instrument or, in the case of

trade payables, when the goods or services have been received. Financial liabilities are

de-recognised when the liability has been discharged, that is, the liability has been paid or

has expired.

Loans from the Welsh Government are recognised at historical cost. Otherwise, financial

liabilities are initially recognised at fair value.

Financial guarantee contract liabilities

Financial guarantee contract liabilities are subsequently measured at the higher of:

- the premium received (or imputed) for entering into the guarantee less cumulative

amortisation;

- the amount of the obligation under the contract, as determined in accordance with IAS

37 Provisions, Contingent Liabilities and Contingent Assets.

Financial liabilities at fair value through SoCNI

Embedded derivatives that have different risks and characteristics to their host contracts,

and contracts with embedded derivatives whose separate value cannot be ascertained, are

treated as financial liabilities at fair value through profit and loss. They are held at fair

value, with any resultant gain or loss recognised in the trust’s surplus/deficit. The net

gain or loss incorporates any interest payable on the financial liability.

The Trust does not have any financial guarantee contract liabilities nor any financial

derivatives requiring to be stated at fair value through profit and loss.

Other financial liabilities

After initial recognition, all other financial liabilities are measured at amortised cost using

the effective interest method, except for loans from the Welsh Government, which are

carried at historic cost. The effective interest rate is the rate that exactly discounts

estimated future cash payments through the life of the asset, to the net carrying amount

of the financial liability. Interest is recognised using the effective interest method.

14


1.25 Value Added Tax

Most of the activities of the trust are outside the scope of VAT and, in general, output tax

does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is

charged to the relevant expenditure category or included in the capitalised purchase cost

of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts

are stated net of VAT.

1.26 Foreign currencies

The trust's functional currency and presentational currency is sterling. Transactions

denominated in a foreign currency are translated into sterling at the exchange rate ruling

on the dates of the transactions. At the end of the reporting period, monetary items

denominated in foreign currencies are retranslated at the spot exchange rate on 31

March. Resulting exchange gains and losses for either of these are recognised in the

trust’s surplus/deficit in the period in which they arise.

1.27 Third party assets

Assets belonging to third parties (such as money held on behalf of patients) are not

recognised in the accounts since the trust has no beneficial interest in them.

1.28 Public Dividend Capital (PDC) and PDC dividend

Public Dividend Capital represents taxpayers equity in the NHS Trust. At any time the

Welsh Minister for Health and Social Services with the approval of HM Treasury can issue

new PDC to, and require repayments of, PDC from the NHS Trust. PDC is recorded at the

value received. As PDC is issued under legislation rather than under contract, it is not

treated as an equity financial instrument.

From 1 April 2010 the requirement to pay a public dividend over to the Welsh

Government ceased.

1.29 Losses and Special Payments

Losses and special payments are items that the Welsh Government would not have

contemplated when it agreed funds for the health service or passed legislation. By their

nature they are items that ideally should not arise. They are therefore subject to special

control procedures compared with the generality of payments. They are divided into

different categories, which govern the way each individual case is handled.

Losses and special payments are charged to the relevant functional headings in the

income statement on an accruals basis, including losses which would have been made

good through insurance cover had NHS Trusts not been bearing their own risks (with

insurance premiums then being included as normal revenue expenditure). However, the

note on losses and special payments is compiled directly from the losses and

compensations register which is prepared on a cash basis.

The Trust accounts for all losses and special payments gross (including assistance from

the Welsh Risk Pool). The Trust accrues or provides for the best estimate of its future

payouts for certain or probable liabilities and discloses all other potential payments as

contingent liabilities, unless the probability of the liabilities becoming payable is remote.

All claims for losses and special payments are provided for, where the probability of

settlement of an individual claim is over 50%. Where reliable estimates can be made,

incidents of clinical negligence against which a claim has not, as yet, been received are

provided in the same way. Expected reimbursements from the Welsh Risk Pool are

included in debtors. For those claims where the probability of settlement is below 50%,

the liability is disclosed as a contingent liability.

15


1.30 Critical Accounting Judgements and key sources of estimation uncertainty

In the application of the Trust's accounting policies, management is required to make

judgements, estimates and assumptions about the carrying amounts of assets and liabilities

that are not readily apparent from other sources. The estimates and associated

assumptions are based on historical experience and other factors that are considered to be

relevant. Actual results may differ from those estimates and the estimates and underlying

assumptions are continually reviewed. Revisions to accounting estimates are recognised in

the period in which the estimate is revised if the revision affects only that period, or the

period of the revision and future periods if the revision affects both current and future

periods.

1.31 Critical Judgements in applying accounting policies

There are no critical judgements that management has made in the process of applying the

Trust's accounting policies.

1.32 Key sources of estimation uncertainty

The following are the key assumptions concerning the future, and other key sources of

estimation uncertainty at the end of the reporting period, that have a significant risk of

causing a material adjustment to the carrying amounts of assets and liabilities within the

next financial year

Annual Leave Provision

1.33 Subsidiaries

Material entities over which the trust has the power to exercise control so as to obtain

economic or other benefits are classified as subsidiaries and are consolidated. Their income

and expenses; gains and losses; assets, liabilities and reserves; and cash flows are

consolidated in full into the appropriate financial statement lines. Appropriate adjustments

are made on consolidation where the subsidiary’s accounting policies are not aligned with

the trust’s or where the subsidiary’s accounting date is before 1 January or after 30 June.

Subsidiaries that are classified as ‘held for sale’ are measured at the lower of their carrying

amount or ‘fair value less costs to sell’

For 2013/14 the Trust has not consolidated the NHS charitable funds for which it is the

corporate trustee as the control lies with Velindre NHS Trust; the funds are therefore

subsumed within Velindre NHS Trust's charitable funds.

16

judgements, estimates and assumptions about the carrying amounts of assets and liabilities

16


1.34 Absorption Accounting

Transfers of function are accounted for as either by merger or by absorption accounting, dependent upon the treatment prescribed in the FReM. Absorption accounting requires that entities account for their transactions in the period in which

they took place with no restatement of performance required. For transfers of functions involving NHS Wales Trusts in receipt of PDC the double entry for the fixed asset NBV value and the net movement in assets is PDC or General Reserve as

appropriate. 1.35 Accounting standards that have been issued but have not yet been

adopted The following accounting standards have been issued by the IASB and IFRIC but have not been adopted because they are not yet required to be adopted by the FReM

IFRS 9 Financial Instruments - subject to consultation. IFRS 10 Consolidated Financial Statements - subject to consultation.

IFRS 11 Joint Arrangements - subject to consultation. IFRS 12 Disclosure of Interests in Other Entities - subject to consultation. IFRS 13 Fair Value Measurement - subject to consultation.

IPSAS 32 Service Concession Arrangements - subject to consultation.

1.36 Accounting standards issued that have been adopted early No accounting standards issued have been adopted early

17


2. Revenue from patient care activities 2013-14 2012-13

£000 £000

Welsh Government 83,044 79,098

Welsh Health Specialised Services Committee (WHSSC) 0 0

Local health boards 0 0

Welsh NHS Trusts 0 0

Other NHS trusts 0 0

Strategic health authorities and primary care trusts 0 0

Foundation Trusts 0 0

Welsh Local Authorities 0 0

Local authorities 0 0

Non NHS:

Private patient income 0 0

Overseas patients (non-reciprocal) 0 0

Injury Costs Recovery (ICR) Scheme 0 0

Other revenue from activities 0 0

Total 83,044 79,098

ICR income is subject to a provision for impairment of 15.8% to reflect expected rates of collection.

3. Other operating revenue 2013-14 2012-13

£000 £000

Patient transport services 0 0

Education, training and research 1,750 1,490

Charitable and other contributions to expenditure 0 0

Receipt of donations for capital acquisitions 0 0

Receipt of government grants for capital acquisitions 0 0

Non-patient care services to other bodies 0 0

Income generation 38 43

Rental revenue from finance leases 0 0

Rental revenue from operating leases 0 0

Other revenue:

Provision of pathology services 13,327 12,495

Accommodation and catering charges 0 0

Mortuary fees 0 0

Staff payments for use of cars 0 0

Business unit 0 0

Other 6,923 5,271

Total 22,038 19,299

Other revenue of £6,923k (2012-13 £5,271k) comprises

1 Excellence Awards 284 335

2 Grants - other 529 373

3 Grants - LA 186 254

4 WG - non Core Income 3,622 1,990

5 Staff Recharges 2,149 2,065

6 Other 153 254

Total 6,923 5,271

18


4. Revenue

Revenue is almost totally from the supply of services. Revenue from the sale of goods is immaterial.

5. Income generation activities

2013-14 2012-13

£000 £000

Income 0 0

Full cost 0 0

Surplus/(deficit) 0 0

The Trust does not undertakes income generation activities with an aim of achieving profit, which is then used in patient care.

19


6. Operating expenses 2013-14 2012-13

6.1 Operating expenses £000 £000

Welsh Government 81 49

WHSSC 0 0

Local Health Boards 13,420 13,692

Welsh NHS Trusts 1,377 1,160

Other NHS Trusts 282 382

Goods and services from other NHS bodies 0 0

Purchase of healthcare from non-NHS bodies 0 0

Welsh Local Authorities 4,572 4,912

Other Local Authorities 0 0

Directors' costs 1,252 1,203

Staff costs 59,877 53,302

Supplies and services - clinical 8,061 7,524

Supplies and services - general 231 247

Consultancy Services 415 397

Establishment 6,178 5,388

Transport 530 471

Premises 3,574 3,534

Impairments and Reversals of Receivables 0 0

Depreciation 2,798 2,438

Amortisation 0 0

Impairments and reversals of property, plant and equipment 0 1,783

Impairments and reversals of intangible assets 0 0

Impairments and reversals of financial assets 0 0

Impairments and reversals of non current assets held for sale 0 0

Audit fees 151 155

Other auditors' remuneration 0 0

Losses, special payments and irrecoverable debts 181 149

Research and development 0 0

Other operating expenses 2,053 1,528

Total 105,033 98,314

Both Staff costs and Establishment cost have increased significantly (£6.6m and £800k respectively) as a result of several service transfering into Public Health Wales during 2013/14. 48 staff joined Public Health Wales from the formal NLIAH, and a further 20 staff transferred into Public Health Wales within theWrexham Microbiology Laboratory from Betsi Cadwalidr University LHB. This has resulted in the increased expenditure on both staff costs and establishment costs, and in addition - the increase in expenditure on clinical supplies and services. This increase in expenditure has been covered by an increased level of core income, along with additional microbiology contract income. There have been no impairments of fixed assets during 2013/14

20


6. Operating expenses (continued)

6.2 Losses, special payments and irrecoverable debts:

Charges to operating expenses 2013-14 2012-13

Increase/(decrease) in provision for future payments: £000 £000

Clinical negligence 893 448

Personal injury 36 373

All other losses and special payments 21 20

Defence legal fees and other administrative costs 125 67

Gross increase/(decrease) in provision for future payments 1,075 908

Contribution to Welsh Risk Pool 0 0

Premium for other insurance arrangements 0 0

Irrecoverable debts 8 3

Less: income received/ due from Welsh Risk Pool (902) (762)

Total charge 181 149

Personal injury includes £135k (2012-13 £80k) in respect of permanent injury benefits.

21


7. Investment revenue 2013-14 2012-13

£000 £000

Rental revenue :

PFI finance lease revenue:

Planned 0 0

Contingent 0 0

Other finance lease revenue 0 0

Interest revenue:

Bank accounts 16 55

Other loans and receivables 0 0

Impaired financial assets 0 0

Other financial assets 0 0

Total 16 55

8. Other gains and losses 2013-14 2012-13

£000 £000

Gain/(loss) on disposal of property, plant and equipment 0 (86)

Gain/(loss) on disposal of intangible assets 0 0

Gain/(loss) on disposal of assets held for sale 0 0

Gain/(loss) on disposal of financial assets 0 0

Gains/(loss) on foreign exchange 0 0

Change in fair value of financial assets at fair value through income statement 0 0

Change in fair value of financial liabilities at fair value through income statement 0 0

Recycling of gain/(loss) from equity on disposal of financial assets held for sale 0 0

Total 0 (86)

9. Finance costs 2013-14 2012-13

£000 £000

Interest on loans and overdrafts 0 0

Interest on obligations under finance leases 50 42

Interest on obligations under PFI contracts:

Main finance cost 0 0

Contingent finance cost 0 0

Interest on late payment of commercial debt 0 0

Other interest expense 0 0

Total interest expense 50 42

Provisions unwinding of discount 0 0

Other finance costs 0 0

Total 50 42

22


10. Operating leases

10.1 Trust as lessee

2013-14 2012-13

Payments recognised as an expense £000 £000

Minimum lease payments 883 832

Contingent rents 0 0

Sub-lease payments 0 0

Total 883 832

Total future minimum lease payments 2013-14 2012-13

Payable: £000 £000

Not later than one year 850 735

Between one and five years 1,136 1,293

After 5 years 66 191

Total 2,052 2,219

Total future sublease payments expected to be received 0 0

There are some significant leasing arrangements where the Trust is the lessee; the trust leases a number of buildings where the lease agreement exceeds 5 years.

23


10. Operating leases (continued)

10.2 Trust as lessor

2013-14 2012-13

Receipts recognised as income £000 £000

Rent 0 0

Contingent rent 0 0

Other 0 0

Total rental revenue 0 0

Total future minimum lease payments 2013-14 2012-13

Receivable: £000 £000

Not later than one year 0 0

Between one and five years 0 0

After 5 years 0 0

Total 0 0

There are no leasing arrangement where the Trust is the lessor.

24


11. Employee costs and numbers

2013-14 2012-132008-09

11.1 Employee costs Permanently Agency Staff on £000 £000

employed Staff Inward

staff Secondment

£000 £000 £000 £000 £000

Salaries and wages 46,793 423 4,015 51,231 45,712

Social security costs 3,741 0 0 3,741 3,340

Employer contributions to NHS Pensions Scheme 6,071 0 0 6,071 5,361

Other pension costs 0 0 0 0 0

Other post-employment benefits 0 0 0 0 0

Termination benefits 0 0 0 0 0

Total 56,605 423 4,015 61,043 54,413

Of the total above:

Charged to capital 0 0

Charged to revenue 61,043 54,413

Total 61,043 54,413

11.2 Average number of employees

Permanently Agency Staff on Total Total

Employed Staff Inward

Secondment

Number Number Number Number Number

Medical and dental 95 1 29 125 118

Ambulance staff 0 0 0 0 0

Administrative and estates 720 9 14 743 619

Healthcare assistants and other support staff 0 0 0 0 0

Nursing, midwifery and health visiting staff 49 0 3 52 48

Nursing, midwifery and health visiting learners 0 0 0 0 0

Scientific, therapeutic and technical staff 377 1 2 380 393

Social care staff 0 0 0 0 0

Other 0 0 0 0 3

Total 1,241 11 48 1,300 1,181

11.3 Employee benefits

The Trust operates a lease car policy and 3 salary sacrifice schemes (childcare vouchers, bikes and computer scheme) scheme for employees.

25


11.4 Reporting of other compensation schemes - exit packages

Total number Total number

of exit of exit

packages by packages by

cost band cost band

Number Number

2013-14 2012-13

Exit package cost band

<£10,000 0 1

£10,000 to £25,000 1 1

£25,000 to £50,000 0 2

£50,000 to £100,000 1 1

£100,000 to £150,000 0 0

£150,000 to £200,000 0 0

£200,000+ 0 0

Total number of exit packages by type 2 5

Total resource cost £ 73 102

The above exit packages all relate to the nationally agreed NHS Wales Voluntary Early Release Scheme (VERS) This disclosure reports the number and value of exit packages taken by staff leaving in the year

26


11.5 Remuneration Relationship

Reporting bodies are required to disclose the relationship between the

remuneration of the highest-paid director in their organisation and the median

remuneration of the organisation’s workforce.

The banded remuneration of the highest-paid director in Public Health Wales in the

financial year 2013-14 was £155k-£160k (2012-13, £155k-£160k). This was 5.25

times (2012-13, 5.25) the median remuneration of the workforce, which was

£30,054 (2012-13, £29,464k).

In 2013-14, 0 (2012-13, 1) employees received remuneration in excess of the

highest-paid director. Remuneration ranged from £14,292 to £157,884 (2012-13

£10,029-£155,477).

Total remuneration includes salary, non-consolidated performance-related pay and

benefits-in-kind. It does not include severance payments, employer pension

contributions and the cash equivalent transfer value of pensions.

The figures above are annualised figures

Overtime payments are included for the calculation of both elements of the

relationship.

27


12. Pensions

Pension costs

Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

a) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2014, is based on valuation data as 31 March 2013, updated to 31 March 2014 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office.

b) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes were suspended by HM Treasury on value for money grounds while future scheme terms are developed as part of the reforms to public service pension provision due to be implemented in 2015. The Scheme Regulations allow contribution rates to be set by the Secretary of State for Health, with the consent of HM Treasury, and after consideration of the advice of the Scheme Actuary. A formal valuation for funding purposes as at March 2012 is currently close to completion and will be used to inform the contribution rates applicable from 1 April 2015. c) Scheme provisions The NHS Pension Scheme provides defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained:

28


12.1 Retirement costs due to ill-health

The Scheme is a “defined benefit” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service. With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”.

Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in inflation in the twelve months ending 30 September in the previous calendar year. From 2011-12 the Consumer Price Index (CPI) has been used as the measure of inflation and replaced the Retail Prices Index (RPI).

Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer.

Members can purchase additional pension in the NHS Scheme and contribute to money purchase AVC’s run by the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.

Other Pensions Disclosure National Employment Savings Trust (NEST) NEST is a not-for-profit workplace pension scheme established by law to support the introduction of automatic enrolment providing defined contribution pension schemes. NEST was established by legislation and is treated as a trust-based scheme. The Trustee responsible for running the scheme is NEST Corporation. It’s a non-departmental public body (NDPB) that operates at arm’s length from government and is accountable to Parliament through the Department for Work and Pensions (DWP).

NEST Corporation has agreed a loan with the Department for Work and Pensions (DWP). This has paid for the scheme to be set up and will cover expected shortfalls in scheme costs during the earlier years while membership is growing. Currently, the legal minimum contribution level is 2 per cent of a jobholder’s qualifying earnings for employers whose legal duties have started. Of this the employer needs to pay at least 1 per cent, though they can pay more if they elect to do so. By 2018 the minimum contribution will rise to 8 per cent of qualifying earnings, of which the employer must pay at least 3 per cent. The National Employment Savings Trust has an annual contribution limit. It is reviewed annually and adjusted in line with average earnings. The annual contribution limit is currently up to £4,500 for the 2013/14 tax year.

The annual contribution limit includes member contributions, money from their employer and any tax relief. It also includes any money paid in by someone else on behalf of the member,

such as a member’s partner or spouse .

During 2013-14 there were 2 (2012-13 0)early retirements from the trust agreed on the grounds of ill-health. The estimated additional pension costs of these ill-health retirements will be £81,413 (2012-13 £0). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.

29


13. Public Sector Payment Policy

13.1 Prompt payment code - measure of compliance

2013-14 2013-14 2012-13 2012-13

Number £000 Number £000

NHS

Total bills paid in year 2,147 20,135 1,614 20,079

Total bills paid within target 2,001 19,444 1,501 18,756

Percentage of bills paid within target 93.2% 96.6% 93.0% 93.4%

Non-NHS




Total




13.2 The Late Payment of Commercial Debts (Interest) Act 1998 2013-14 2012-13

£ £

Amounts included within finance costs from claims made under legislation 0 0

Compensation paid to cover debt recovery costs under legislation 0 0

Total 0 0

The Welsh Government requires that trusts pay all their trade creditors in accordance

with the CBI prompt payment code and Government Accounting rules. The Welsh

Government has set as part of the trust financial targets a requirement to pay 95% of

the number of non-NHS creditors within 30 days of delivery or receipt of a valid invoice,

The financial target of payment of 95% of all invoices (by number) has not been

met in 2013/14. This is a direct result of a several changes to both the reporting requirements and the operating arrangements for the payment of invoices. It should be noted that Public Health Wales does not make any contractor

payments which would have the effect of increasing performance substantially.

ALthough performance increased during the second half of the financial year, following several improvements to operational arrangement, the cummulative

performance for the year remains below the 95%. The payment of 95% of all invoices by value has been met.

30


14. Property, plant and equipment :

2013-14

Cost or valuation £000 £000 £000 £000 £000 £000 £000 £000 £000

At 1 April 2013 935 3,745 0 476 10,600 45 6,144 533 22,478

Indexation 0 74 0 0 0 0 0 0 74

Revaluation 0 0 0 0 0 0 0 0 0

Additions - purchased 0 22 0 0 317 12 619 0 970

Additions - donated 0 0 0 0 0 0 0 0 0

Additions - government granted 0 0 0 0 0 0 0 0 0

Transfers from/(into) other NHS bodies 0 0 0 0 0 0 0 0 0

Reclassifications 0 0 0 (476) 476 0 0 0 0

Reclassified as held for sale 0 0 0 0 0 0 0 0 0

Disposals other than by sale 0 0 0 0 (310) 0 (149) (10) (469)

Impairments 0 0 0 0 0 0 0 0 0

Reversal of impairments 0 0 0 0 0 0 0 0 0

At 31 March 2014 935 3,841 0 0 11,083 57 6,614 523 23,053

Depreciation

At 1 April 2013 0 908 0 0 3,213 29 2,276 368 6,794

Indexation 0 18 0 0 0 0 0 0 18

Revaluation 0 0 0 0 0 0 0 0 0


Reclassifications 0 0 0 0 0 0 0 0 0


Disposals other than by sale 0 0 0 0 (310) 0 (149) (10) (469)

Impairments 0 0 0 0 0 0 0 0 0


Charged during the year 0 266 0 0 1,322 3 1,125 82 2,798

At 31 March 2014 0 1,192 0 0 4,225 32 3,252 440 9,141

Net book value

At 1 April 2013 935 2,837 0 476 7,387 16 3,868 165 15,684

Net book value

At 31 March 2014 935 2,649 0 0 6,858 25 3,362 83 13,912

Net book value at 31 March 2014 comprises :

Purchased 935 2,535 0 0 6,858 25 3,362 83 13,798

Donated 0 114 0 0 0 0 0 0 114

Government Granted 0 0 0 0 0 0 0 0 0

At 31 March 2014 935 2,649 0 0 6,858 25 3,362 83 13,912

Asset Financing:

Owned 935 2,649 0 0 6,858 25 1,407 83 11,957

Held on finance lease 0 0 0 0 0 0 1,955 0 1,955

On-SoFP PFI contract 0 0 0 0 0 0 0 0 0

PFI residual interest 0 0 0 0 0 0 0 0 0

At 31 March 2014 935 2,649 0 0 6,858 25 3,362 83 13,912

The net book value of land, buildings and dwellings at 31 March 2014 comprises :

£000

Freehold 2,415

Long Leasehold 292

Short Leasehold 877

Total 3,584

Land

Buildings,

excluding

dwellings

Dwellings

Assets under

construc-tion

and

payments on

account

TotalPlant &

machinery

Transport

Equipment

Information

Technology

Furniture

and fittings

Of the totals at 31 March 2010, £nil related to land valued at open market value and £nil related to buildings, installations and fittings valued at open market


Building have been revalued using indices published by the the District Valuation (DV) Office. The price index for building

for 2013/14 is 102 (ie and increase of 2%) which reflects the increase in market value of buildings during 2013/14.

31


14. Property, plant and equipment :

2012-13

Cost or valuation £000 £000 £000 £000 £000 £000 £000 £000 £000

At 1 April 2012 1,060 5,574 0 1,848 9,763 45 4,907 535 23,732

Indexation 0 0 0 0 0 0 0 0 0

Revaluation 0 (74) 0 0 0 0 0 0 (74)

Additions - purchased 0 374 0 476 369 0 1,314 54 2,587

Additions - donated 0 0 0 0 0 0 0 0 0

Additions - government granted 0 0 0 0 0 0 0 0 0


Reclassifications 0 15 0 (1,848) 1,824 0 9 0 0


Disposals 0 0 0 0 (1,356) 0 (86) (56) (1,498)

Impairments (125) (2,144) 0 0 0 0 0 0 (2,269)


At 31 March 2013 935 3,745 0 476 10,600 45 6,144 533 22,478

Depreciation

At 1 April 2012 0 1,109 0 0 3,259 25 1,399 350 6,142

Indexation 0 0 0 0 0 0 0 0 0

Revaluation 0 (233) 0 0 0 0 0 0 (233)


Reclassifications 0 0 0 0 0 0 0 0 0


Disposals 0 0 0 0 (1,270) 0 (86) (56) (1,412)

Impairments 0 (209) 0 0 68 0 0 0 (141)


Charged during the year 0 241 0 0 1,156 4 963 74 2,438

At 31 March 2013 0 908 0 0 3,213 29 2,276 368 6,794

Net book value

at 1 April 2012 1,060 4,465 0 1,848 6,504 20 3,508 185 17,590

Net book value

at 31 March 2013 935 2,837 0 476 7,387 16 3,868 165 15,684

Net book value at 31 March 2013 comprises :

Purchased 935 2,697 0 476 8,587 16 2,668 165 15,544

Donated 0 140 0 0 0 0 0 0 140

Government Granted 0 0 0 0 0 0 0 0 0

Total 31 March 2013 935 2,837 0 476 8,587 16 2,668 165 15,684

Asset Financing:

Owned 935 2,837 0 476 8,587 16 2,668 165 15,684

Held on finance lease 0 0 0 0 0 0 0 0 0

On-SoFP PFI contract 0 0 0 0 0 0 0 0 0

PFI residual interest 0 0 0 0 0 0 0 0 0

Total 31 March 2013 935 2,837 0 476 8,587 16 2,668 165 15,684

The net book value of land, buildings and dwellings at 31 March 2013 comprises :

£000

Freehold 1,250

Long Leasehold 849

Short Leasehold 1,673

3,772

Land

Buildings,

excluding

dwellings

Dwellings

Assets under

construc-tion

and payments

on account

TotalPlant &

machinery

Transport

Equipment

Information

Technology

Furniture

and fittings



32


Disclosures:

i) Donated Assets

Public Health Wales NHS Trust did not receive any donated assets during the year.

ii) Valuations

The Trusts Land and Buildings were revalued by the District Valuation Service with an

effective date of 1st April 2012. The valuation has been prepared in accordance with the

terms of the Royal Institution of Chartered Surveyors' Valuation Standards, 6th edition.

The Trust is required to apply the revaluation model set out in IAS 16 and value its

capital assets to fair value. Fair value is defined by IAS16 as the amount for which an

asset could be exchanged between knowledgeable, willing parties in an arms length

transaction.

This has been undertaken on the assumption that the property is sold as part of the

continuing enterprise in occupation.

iii) Asset Lives

Land is not depreciated

Buildings as determined by the District Valuation service

Equipment 5-20 years

iv) Compensation

There has been no compensation received from third parties for assets impaired, lost or

given up, that is included in the income statement

v) Write Downs

There have been no write downs

vi) The Trust does not hold any property where the value is materially different from its

open market value.

vii) Assets Held for Sale or sold in the period

There are no assets held for sale or sold in the period

33


14.2 Non-current assets held for sale

£000 £000 £000 £000 £000 £000

Balance b/f 1 April 2013 0 0 0 0 0 0

Plus assets classified as held for

sale in year 0 0 0 0 0 0

Revaluation 0 0 0 0 0 0

Less assets sold in year 0 0 0 0 0 0

Less impairment for assets held for

sale 0 0 0 0 0 0

Plus reversal of impairments 0 0 0 0 0 0

Less assets no longer classified as

held for sale for reasons other than

disposal by sale 0 0 0 0 0 0

Balance c/f 31 March 2014 0 0 0 0 0 0

Balance b/f 1 April 2012 0 0 0 0 0 0

Plus assets classified as held for

sale in year 0 0 0 0 0 0

Revaluation 0 0 0 0 0 0

Less assets sold in year 0 0 0 0 0 0

Less impairment for assets held for

sale 0 0 0 0 0 0

Plus reversal of impairments 0 0 0 0 0 0

Less assets no longer classified as

held for sale for reasons other than

disposal by sale 0 0 0 0 0 0

Balance c/f 31 March 2013 0 0 0 0 0 0

Other assets TotalLand

Buildings,

including

dwellings

Other

property

plant and

equipment

Intangible

assets

34


15. Intangible assets

2013-14

Cost or valuation £000 £000 £000 £000 £000 £000 £000

At 1 April 2013 0 0 0 0 0 0 0

Revaluation 0 0 0 0

Additions

- purchased 0 0 0 0 0 0 0

- internally generated 0 0 0 0 0 0 0

- donated 0 0 0 0 0 0 0

- government granted 0 0 0 0 0 0 0

Transfers from/(into) other NHS bodies 0 0 0 0 0 0 0

Reclassifications 0 0 0 0 0 0 0

Reclassified as held for sale 0 0 0 0 0 0 0

Disposals other than by sale 0 0 0 0 0 0 0

Impairments 0 0 0 0 0 0 0

Reversal of impairments 0 0 0 0 0 0 0

Gross cost at 31 March 2014 0 0 0 0 0 0 0

Amortisation

Accumulated amortisation at

1 April 2013 0 0 0 0 0 0 0

Revaluation 0 0 0 0







Charged during the year 0 0 0 0 0 0 0


31 March 2014 0 0 0 0 0 0 0

Net book value at 1 April 2013 0 0 0 0 0 0 0

Net book value at 31 March 2014 0 0 0 0 0 0 0

Net book value

Purchased 0 0 0 0 0 0 0

Internally Generated 0 0 0 0 0 0 0

Donated 0 0 0 0 0 0 0

Government granted 0 0 0 0 0 0 0

Total at 31 March 2014 0 0 0 0 0 0 0

Develop-ment

expenditure

internally

generated

Total

Computer

software

purchased

Computer

software

internally

developed

Licenses

and trade-

marks

Patents

CRC

Emission

Trading

Scheme

35



2012-13

Cost or valuation £000 £000 £000 £000 £000 £000 £000

At 1 April 2012 0 0 0 0 0 0 0

Revaluation 0 0 0 0

Additions

- purchased 0 0 0 0 0 0 0

- internally generated 0 0 0 0 0 0 0

- donated 0 0 0 0 0 0 0

- government granted 0 0 0 0 0 0 0







Gross cost at 31 March 2013 0 0 0 0 0 0 0

Amortisation


1 April 2012 0 0 0 0 0 0 0

Revaluation 0 0 0 0







Charged during the year 0 0 0 0 0 0 0


31 March 2013 0 0 0 0 0 0 0

Net book value at 1 April 2012 0 0 0 0 0 0 0

Net book value at 31 March 2013 0 0 0 0 0 0 0

Net book value

Purchased 0 0 0 0 0 0 0

Internally Generated 0 0 0 0 0 0 0

Donated 0 0 0 0 0 0 0

Government granted 0 0 0 0 0 0 0

Total at 31 March 2013 0 0 0 0 0 0 0

Develop-

ment

expenditure

internally

generated

Total

Computer

software

purchased

Computer

software

internally

developed

Licenses

and trade-

marks

Patents

CRC

Emission

Trading

Scheme

36



16. Revaluation reserve balance for intangible assets

2013-14 2012-13

£000 £000

At 1 April 0 0

0 0

At 31 March 0 0

Public Health Wales has no intangible assets

37


17. Impairments

Impairments in the period arose from: Property, plant Intangible Property, plant Intangible

& equipment assets & equipment assets

£000 £000 £000 £000

Loss or damage from normal operations 0 0 0 0

Abandonment of assets in the course of construction 0 0 0 0

Over specification of assets (Gold Plating) 0 0 0 0

Loss as a result of a catastrophe 0 0 0 0

Unforeseen obsolescence 0 0 0 0

Changes in market price 0 0 1,676 0

Other (specify) 0 0 107 0

Impairments charged to operating expenses 0 0 1,783 0

Impairments charged in the year to

0 0 1,783 0

0 0 187 0

Total 0 0 1,970 0

18. Capital commitments

Commitments under capital expenditure contracts at the statement of financial position sheet date were:

31 March 31 March

2014 2013

£000 £000

Property, plant and equipment 0 0

Intangible assets 0 0

Total 0 0

Operating expenses in Statement of Comprehensive

Income

Revaluation reserve

2013-14 2012-13

38


19. Inventories

19.1 Inventories

31 March 31 March

2014 2013

£000 £000

Drugs 0 0

Consumables 78 86

Energy 0 0

Work in progress 0 0

Other 0 0

Total 78 86

Of which held at net realisable value: 0 0

19.2 Inventories recognised in expenses 31 March 31 March

2014 2013

£000 £000

Inventories recognised as an expense in the period (8) 25

Write-down of inventories (including losses) 0 0

Reversal of write-downs that reduced the expense 0 0

Total (8) 25

39


20. Trade and other receivables

20.1 Trade and other receivables

31 March 31 March

2014 2013

Current £000 £000


Welsh Health Specialised Services Committee 12 60

Welsh Health Boards 2,165 2,554


Non - Welsh Trusts 22 43

Other NHS 0 0

Welsh Risk Pool 3,105 2,314



Capital debtors 0 0

Other debtors 832 1,112

Provision for impairment of trade receivables (49) (41)

Pension Prepayments

NHS Pensions Agency 0 0

NEST 0 0

Other prepayments and accrued income 923 508

Sub-total 7,825 7,539

Non-current



Welsh Health Boards 0 0


Non - Welsh Trusts 0 0

Other NHS 0 0

Welsh Risk Pool 0 0



Capital debtors 0 0

Other debtors 0 0

Provision for impairment of trade receivables 0 0

Pension Prepayments

NHS Pensions Agency 0 0

NEST 0 0

Other prepayments and accrued income 0 0

Sub-total 0 0

Total trade and other receivables 7,825 7,539

No interest is charged on trade receivables. The value of trade receivables that are past their due payment date but not impaired is £239k. (£550k in 2012-13)

40


20.2 Receivables VAT 31 March 31 March

2014 2013

£000 £000

Trade receivables 172 130

Other 0 0

Total 172 130

20.3 Receivables past their due date but not impaired

31 March 31 March

2014 2013

£000 £000

By up to 3 months 71 279

By 3 to 6 months 17 89

By more than 6 months 102 182

Balance at end of financial year 190 550

20.4 Allowance for bad and doubtful debts

31 March 31 March

2014 2013

£000 £000

Balance at beginning of the year (41) (38)

Transfer to other NHS Wales body 0 0

Provision utilised (Amount written off during the year) 0 0

Provision written back during the year no longer required 0 0

Increase/(decrease) in provision during year (8) (3)

Bad debts recovered during year 0 0

Balance at end of financial year (49) (41)

In determining whether a debt is impaired consideration is given to the age of the debt

and the results of actions taken to recover the debt, including reference to credit

agencies.

41


21. Other financial assets

31 March 31 March

2014 2013

Non-current £000 £000

Finance lease receivables 0 0

Financial assets carried at fair value through income statement 0 0

Held to maturity investments carried at amortised cost 0 0

Available for sale financial assets carried at fair value 0 0

Loans carried at amortised cost 0 0

Total 0 0

Current

Finance lease receivables 0 0

Financial assets carried at fair value through income statement 0 0

Held to maturity investments carried at amortised cost 0 0

Available for sale financial assets carried at fair value 0 0

Loans carried at amortised cost 0 0

Total 0 0

22. Other assets

31 March 31 March

2014 2013


Other assets 0 0

Total 0 0

Current

CRC Emissions trading scheme allowances 0 0

Other assets 0 0

Total 0 0

42


23. Cash and cash equivalents

31 March 31 March

2014 2013

£000 £000

Opening Balance 2,501 3,968

Net change in year 46 (1,467)

Closing Balance 2,547 2,501

Made up of:

Cash with Government Banking Service (GBS) 2,529 2,501

Cash with Commercial banks 0 0

Cash in hand 18 0

Total cash 2,547 2,501

Current investments 0 0

2,547 2,501

Bank overdraft - GBS 0 0

Bank overdraft - Commercial banks 0 0

Cash & cash equivalents as in Statement of Cash Flows 2,547 2,501

Cash and cash equivalents as in SoFP

43


24. Trade and other payables at the SoFP Date 31 March 31 March

2014 2013

Current £000 £000



Welsh Health Boards 1,381 762


Other NHS 77 198



Taxation and social security payable / refunds:

Refunds of taxation by HMRC 0 0

VAT payable to HMRC 0 0

Other taxes payable to HMRC 0 0

National Insurance contributions payable to HMRC 0 0

Non-NHS trade payables - revenue 2,679 3,362

Non-NHS trade payables - capital 95 26

Rentals due under operating leases 53 74

Obligations due under finance leases and HP contracts 640 0

Imputed finance lease element of on SoFP PFI contracts 0 0

Pensions: staff 0 0

Accruals 170 24

Deferred Income:

Deferred income brought forward 67 85

Deferred income additions 0 0

Transfer to/from current/non current deferred income 0 0

Released to the Income Statement 0 0

Other liabilities - all other payables 0 0

Sub-total 5,798 5,745

44


24. Trade and other payables at the SoFP Date (cont)

31 March 31 March

2014 2013




Welsh Health Boards 0 0


Other NHS 0 0



Taxation and social security payable / refunds:

Refunds of taxation by HMRC 0 0

VAT payable to HMRC 0 0

Other taxes payable to HMRC 0 0

National Insurance contributions payable to HMRC 0 0

Non-NHS trade payables - revenue 0 0

Non-NHS trade payables - capital 0 0

Rentals due under operating leases 0 0

Obligations due under finance leases and HP contracts 1,232 0

Imputed finance lease element of on SoFP PFI contracts 0 0

Pensions: staff 0 0

Accruals 0 0

Deferred Income:

Deferred income brought forward 0 0

Deferred income additions 0 0

Transfer to/from current/non current deferred income 0 0

Released to the Income Statement 0 0

Other liabilities - all other payables 0 0

Sub-total 1,232 0

Total 7,030 5,745

It is intended to pay all invoices within the 30 day period directed by the Welsh

Government.

45


25. Borrowings 31 March 31 March

Current 2014 2013

£000 £000

Bank overdraft - GBS 0 0

Bank overdraft - Commercial bank 0 0

Loans from:


Other entities 0 0

PFI liabilities:

Main liability 0 0

Lifecycle replacement received in advance 0 0

Finance lease liabilities 0 0

Other 0 0

Total 0 0

Non-current

Bank overdraft - OPG 0 0

Bank overdraft - Commercial bank 0 0

Loans from:


Other entities 0 0

PFI liabilities:

Main liability 0 0

Lifecycle replacement received in advance 0 0

Finance lease liabilities 0 0

Other 0 0

Total 0 0

25.2 Loan advance/strategic assistance funding

The NHS trust has received no loan advance or strategic funding from the Welsh

Government.

46


26. Other financial liabilities

Current 31 March 31 March

2014 2013

£000 £000

Financial liabilities carried at fair value through income statement. 0 623

Non-current

Financial liabilities carried at fair value through income statement. 0 1,713

27. Other liabilities

Current

31 March 31 March

2014 2013

£000 £000

Lease incentives 0 0

PFI asset - deferred credit 0 0

Other (Please specify) 0 0

Total 0 0

Non-current

Lease incentives 0 0

PFI asset - deferred credit 0 0


Total 0 0

The Trust has no early retirement buy outs.

47


28. Provisions

2013-14

28.1 Public Health Wales NHS Trust including

Welsh Risk Pool

Current

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Clinical negligence 1,922 0 0 0 0 980 (172) (87) 0 2,643

Personal injury 360 0 0 (65) 0 135 (147) (99) 0 184

All other losses and special payments 0 0 0 0 0 21 (21) 0 0 0

Defence legal fees and other administration 83 0 0 0 0 153 (17) (28) 191

Pensions relating to: former directors 0 0 0 0 0 0 0 0 0

Pensions relating to: other staff 0 0 0 0 0 0 0 0 0

Restructurings 0 0 0 0 0 0 0 0

Other 0 0 0 0 0 0 0 0

Total 2,365 0 0 (65) 0 1,289 (357) (214) 0 3,018

Non Current

Clinical negligence 0 0 0 0 0 0 0 0 0 0

Personal injury 1,050 0 0 65 0 0 0 0 0 1,115

All other losses and special payments 0 0 0 0 0 0 0 0 0 0

Defence legal fees and other administration 0 0 0 0 0 0 0 0 0




Other 0 0 0 0 0 0 0 0

Total 1,050 0 0 65 0 0 0 0 0 1,115

TOTAL


Personal injury 1,410 0 0 0 0 135 (147) (99) 0 1,299






Other 0 0 0 0 0 0 0 0

Total 3,415 0 0 0 0 1,289 (357) (214) 0 4,133

Expected timing of cash flows:

Timing period yet to be confirmed In the remainder of spending Between Between Thereafter

review to 31 March 2015 1 April 2015 1 April 2020 Totals

31 March 2020 31 March 2025

£000 £000 £000 £000 £000

Clinical negligence 2,643 0 0 0 2,643

Personal injury 183 314 287 515 1,299

All other losses and special payments 0 0 0 0 0

Defence legal fees and other administration 191 0 0 0 191

Pensions - former directors 0 0 0 0 0

Pensions - other staff 0 0 0 0 0

Restructuring 0 0 0 0 0

Other 0 0 0 0 0

Total 3,017 314 287 515 4,133

At 31 March

2014

Transfers

to creditors

Utilised

during the

year

Transfers

(to)/from

other NHS

body

Unwinding

of discount

At 1 April

2013

Structured

settlement

cases

transferr-ed

to Risk Pool

Arising

during the

year

Reversed

unused

Transfers

between

current and

non current

The expected timing of cashflows are based on best available information; but they could change on the basis of individual ca se changes.

The "Personal Injury" category includes provisions for 3 Permanent Injury Benefit cases.

48


28. Provisions (continued)

2012-13

Current

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000


Personal injury 44 0 0 92 0 374 (149) (1) 0 360






Other 0 0 0 0 0 0 0 0

Total 2,268 0 0 92 0 1,061 (903) (153) 0 2,365

Non Current

Clinical negligence 0 0 0 0 0 0 0 0 0 0

Personal injury 1,127 0 0 (92) 0 0 15 0 0 1,050

All other losses and special payments 0 0 0 0 0 0 0 0 0 0

Defence legal fees and other administration 0 0 0 0 0 0 0 0 0




Other 0 0 0 0 0 0 0 0

Total 1,127 0 0 (92) 0 0 15 0 0 1,050

TOTAL


Personal injury 1,171 0 0 0 0 374 (134) (1) 0 1,410






Other 0 0 0 0 0 0 0 0

Total 3,395 0 0 0 0 1,061 (888) (153) 0 3,415

At 31

March 2012

Structured

settlement

cases

transferr-ed

to Risk Pool

Arising

during the

year

Reversed

unused

Unwinding

of discount

At 31 March

2013

Transfer to

creditors

Utilised

during the

year

Transfers

(to)/from

other NHS

body

Transfer

between

current

and non

current

49


29. Finance leases

29.1 Finance leases obligations (as lessee)

Amounts payable under finance leases:

LAND 31 March 31 March

2014 2013

£000 £000

Minimum lease payments

Within one year 0 0


After five years 0 0

Less finance charges allocated to future periods 0 0


Included in:

Current borrowings 0 0

Non-current borrowings 0 0

Total 0 0

Present value of minimum lease payments

Within one year 0 0



Total present value of minimum lease payments 0 0

Included in:


Non-current borrowings 0 0Total 0 0

The Trust has a finance lease for the Picture Archive Computer System (PACS).

The inherent interest rate has been calculated at 2.77%. This has been used to discount the total future minimum lease payments of £2,016k to their

present value of £1,872k

Maintenance costs are charged directly to SOCI and are not included as part of the lease value.

50


29.1 Finance leases obligations (as lessee) continued

31 March 31 March

Amounts payable under finance leases: 2014 2013

BUILDINGS £000 £000

Minimum lease payments

Within one year 0 0





Included in: Current borrowings 0 0


Total 0 0


Within one year 0 0






Total 0 0

OTHER 31 March 31 March

2014 2013

Minimum lease payments £000 £000

Within one year 690 671




Minimum lease payments 2,016 2,522



Total 0 0


Within one year 640 623



Total present value of minimum lease payments 1,872 2,336


Non-current borrowings 1,232 1,713

Total 1,872 2,336

51


29.2 Finance lease receivables (as lessor)

Amounts receivable under finance leases:

31 March 31 March

2014 2013

£000 £000

Gross investment in leases

Within one year 0 0




Present value of minimum lease payments 0 0

Included in:



Total 0 0


Within one year 0 0




Included in:


Non-current borrowings 0 0Total 0 0

There are no finance lease receivables.

52


29.3 Rental Revenue 31 March 31 March

2014 2013

£000 £000

Contingent rent 0 0

Other 0 0

Total rental revenue 0 0

29.4 Finance Lease Commitment

30. Private finance transactions

Private Finance Initiatives (PFI) / Public Private Partnerships (PPP)

The Trust has no PFI or PPP schemes deemed to be "on or off SoFP."

Public Health Wales NHS Trust has no finance lease commitments for an asset which has not become fully operational during or prior to 2013-14.

53


31. Financial riskCertificate of Chief Financial Officer/Director of Finance

IFRS 7, Derivatives and Other Financial Instruments, requires disclosure of the role that

financial instruments have had during the period in creating or changing the risks an entity

faces in undertaking its activities.

NHS trusts are not exposed to the degree of financial risk faced by business entities.

Financial instruments play a much more limited role in creating or changing risk than would

be typical of the listed companies to which IFRS 7 mainly applies. NHS trusts have limited

powers to borrow or invest surplus funds and financial assets and liabilities are generated

by day to day operational activities rather than being held to change the risks facing NHS

trusts in undertaking its activities.

The NHS trust's treasury management operations are carried out by the finance department

within parameters defined formally within the NHS trust's standing financial instructions and

policies agreed by the board of directors. NHS trust treasury activity is subject to review by

the NHS trust's internal auditors.

Liquidity risk

NHS trust's net operating costs are incurred under annual service agreements with various

Health bodies, which are financed from resources voted annually by parliament. NHS trusts

also largely finance their capital expenditure from funds made available from the Welsh

Government under agreed borrowing limits. NHS trusts are not, therefore, exposed to

significant liquidity risks.

Interest-rate risks

The great majority of NHS trust's financial assets and financial liabilities carry nil or fixed

rates of interest. NHS trusts are not, therefore, exposed to significant interest-rate risk.

Foreign currency risk

NHS trusts have no or negligible foreign currency income or expenditure and therefore are

not exposed to significant foreign currency risk.

Credit Risk

Because the majority of the trust's income comes from contracts with other public sector

bodies, the trust has low exposure to credit risk. The maximum exposures are in

receivables from customers as disclosed in the Trade and other receivables note.

General

The powers of the NHS trust to invest and borrow are limited. The Board has determined

that in order to maximise income from cash balances held, any balance of cash which is not

required will be invested. The trust does not borrow from the private sector. All other

financial instruments are held for the sole purpose of managing the cash flow of the trust on

a day to day basis or arise from the operating activities of the trust. The management of

risks around these financial instruments therefore relates primarily to the trust's overall

arrangements for managing risks to their financial position, rather than the trust's treasury

management procedures.

54


32. Financial Instuments

Financial assets At "fair value" Loans and Available Total

through I&E receivables for sale

£000 £000 £000 £000

Embedded derivatives 0 0 0 0

NHS receivables 5,960 0 0 5,960

Cash at bank and in hand 2,547 0 0 2,547

Other financial assets 1,858 0 0 1,858

Total at 31 March 2014 10,365 0 0 10,365

Financial liabilities At "fair value" Other Total

through I&E

£000 £000 £000

Embedded derivatives 0 0 0

PFI and finance lease obligations 1,872 0 1,872

Other financial liabilities 5,158 0 5,158

Total at 31 March 2014 7,030 0 7,030

Financial assets At "fair value" Loans and Available Total

through I&E receivables for sale

£000 £000 £000 £000

Embedded derivatives 0 0 0 0

NHS receivables 5,829 0 0 5,829

Cash at bank and in hand 2,501 0 0 2,501

Other financial assets 0 0 0 0

Total at 31 March 2013 8,330 0 0 8,330

Financial liabilities At "fair value" Other Total

through I&E

£000 £000 £000

Embedded derivatives 0 0 0

PFI and finance lease obligations 2,336 0 2,336

Other financial liabilities 5,745 0 5,745

Total at 31 March 2013 8,081 0 8,081

Financial instruments play a much more limited role in creating or changing risk than

would be typical of listed companies. The NHS trust has limited powers to borrow or

invest surplus funds and financial assets and liabilities are generated by day-to-day

operational activities rather than being held to change the risks facing the NHS trust in

undertaking its activities.

The directors consider that the carrying amounts of financial assets and financial

liabilities recorded at amortised cost in the financial statements approximate their fair

value.

Only NHS receivables have been included in the financial assets as these have been

formally agreed through the NHS agreement process. The other financial liabilities

figure is the total liabilities from Note 23

55


33. Financial performance targets

The Trust has met 2 out of 3 of its financial targets. Details are given below:

33.1 Breakeven 2013-14

£000

Target retained surplus 0

Actual retained surplus 15

Variance (15)

The Trust has broken even in 2013-14.

33.2 External financing 31 March 31 March

The Trust is given an external financing limit which it is permitted to undershoot 2014 2013

£000 £000 £000

External financing limit set by the Welsh Government (1,809) (1,720)

Cash flow financing (1,026) (1,750)

Finance leases taken out in the year (783) 30

Other capital receipts 0 0

External financing requirement (1,809) (1,720)

Undershoot (overshoot) 0 0

The Trust has achieved its external financing limit.

33.3 Creditor payment

The Trust is required to pay 95% of the number of non-NHS bills within 30 days of receipt of goods or

a valid invoice (whichever is the later). The Trust has achieved the following results: 2013-14

Total number of non-NHS bills paid 2013-14 21,755

Total number of non-NHS bills paid within target 20,416

Percentage of non-NHS bills paid within target 93.8%

The Trust has not met the target.

The in year breakeven target and actual surpluses are £0k and £15k respectively Public Health Wales NHS Trust has also achieved on-going breakeven requirement.

56


34. Contingencies

34.1 Contingent liabilities

Provision has not been made in these accounts for 31 March 31 March

the following amounts: 2014 2013

£000 £000

Legal claims for alleged medical or employer negligence 460 145

Doubtful debts 0 0

Equal pay cases 0 0

Defence costs 0 0


Total value of disputed claims 460 145

Amount recovered under insurance arrangements in the event of

these claims being successful 0 0

Net contingent liability 460 145

34.2 Contingent assets

35. Third party assets

36. Events after reporting period

Other litigation claims could arise in the future due to known incidents. The expenditure which

may arise from such claims cannot be determined and no provision has been made for them.

Liability for Permanent Injury Benefit under the NHS Injury Benefit Scheme lies with the employer.

Individual claims to the NHS Pensions Agency could arise due to known incidents.

The Trust has no Third Party Assets.

The Trust has no contingent assets.

There are no events after the reporting period that need to be disclosed in the financial

statements

57


37. Related Party transactions

Payments to Receipts from Amounts owed Amounts due

related party related party to related party from related party

£000 £000 £000 £000

Payments to Receipts from Amounts owed Amounts due

related party related party to related party from related party

£000 £000 £000 £000

Welsh Government 274 87,864 79 641

FHoT 0 0 0 0

WHSSC 0 337 0 12

ABMU LHB 4,414 3,517 355 313

Aneurin Bevan LHB 3,012 745 314 220

Betsi Cadwaladwr LHB 3,636 3,104 324 256

Cardiff and Vale LHB 3,178 5,208 161 943

Cwm Taf LHB 1,597 217 50 127

Hywel Dda LHB 1,666 1,645 145 300

Powys LHB 217 128 31 6

Velindre NHS Trust 1,615 223 211 15

WAST 49 0 0 0

WRP 0 0 0 0

Cardiff University 809 905 106 212

Merthyr Tydfil CBC 155 1 48 0

Swansea University 464 23 3

Public Health England 271 74 16

21,357 103,991 1,824 3,064

'The Trust is a body corporate established by order of the Welsh Minster for Health and Social Services. 'During the year none of the board members or members of the key management staff or parties 'related to them has undertaken any material transactions with the Trust

The trust is a body corporate established by order of the Welsh Minister for Health and Social

Services. During the year none of the board members or members of the key management

staff or parties related to them has undertaken any material transactions with the trust

The Welsh Government is regarded as a related party. During the year the Trust has had a significant

number of material transactions with the Welsh Government and with other entities for which the Welsh Government is regarded as the parent body.In addition, those organisations which have been identified as related parties to board or executive team members are also listed below.

58


38. Intra Government balances and transactions

38.1 Intra Government Balances Receivables: Receivables: Payables: Payables:

Current Non-current Current Non-current

£000 £000 £000 £000

2013-14:

Welsh Government 641 0 79 0

Welsh Local Health Boards 2,165 0 1,381 0

Welsh NHS Trusts 15 0 264 0

WHSSC 12 0 0 0

All English Health Bodies 22 0 77 0

All N. Ireland Health Bodies 0 0 0 0

All Scottish Health Bodies 0 0 0 0

Miscellaneous 4639 0 3,704 1,232

Credit note provision 0 0 0 0

Sub total 7,494 0 5,505 1,232

Other Central Government Bodies

Other Government Departments 0 0 0 0

Revenue & Customs 172 0 0 0

Local Authorities 159 0 293 0

Balances with Public Corporations and trading funds 0 0 0 0

Balances with bodies external to Government 0 0 0 0

TOTAL 7,825 0 5,798 1,232

Receivables: Receivables: Payables: Payables:

Current Non-current Current Non-current

£000 £000 £000 £000

2012-13:

Welsh Government 848 0 124 0

Welsh Local Health Boards 2,554 0 762 0

Welsh NHS Trusts 10 0 876 0

WHSSC 60 0 0 0

All English Health Bodies 43 0 56 0

All N. Ireland Health Bodies 0 0 0 0

All Scottish Health Bodies 0 0 0 0

Miscellaneous 2,373 0 142 0

Credit note provision 0 0 0 0

Sub total 5,888 0 1,960 0

Other Central Government Bodies

Other Government Departments 52 0 0 0

Revenue & Customs 130 0 0 0

Local Authorities 131 0 214 0

Balances with Public Corporations and trading funds 0 0 0 0

Balances with bodies external to Government 1,338 0 3,571 0

TOTAL 7,539 0 5,745 0

59


39. Losses and special payments

Gross loss to the Exchequer

Number of cases and associated amounts paid out or written-off during the financial year

Number £ Number £

Clinical negligence 9 177,135 9 1,280,491

Personal injury 3 83,955 4 98,973

All other losses and special payments 1 21,000 1 21,000

Total 13 282,090 14 1,400,464

Analysis of cases which exceed £300,000 and all other cases

Amounts Approved to

paid out in Cumulative write-off

year amount in year

Cases exceeding £300,000 £ £ £

Case reference Case type

09RQFMN0005 CN 22,016 788,686 788,686

Sub-total 22,016 788,686 788,686

All other cases 260,074 611,778 611,778

Total cases 282,090 1,400,464 1,400,464

Approved to write-off

to 31 March 2014

Amounts paid out during

year to 31 March 2014

Losses and special payments are charged to the Income statement in accordance with IFRS but are recorded in the losses and special payments register when payment is made. Therefore this note is prepared on a cash basis.

60


40. Pooled budgets

Public Health Wales NHS trust has no pooled budgets.

61


41. Operating segments

[Disclose: [Provide reconciliations of: [Desirable disclosures: Cash flow from:

The Trust’s primary remit is the provision of public health services throughout Wales and this is viewed as the only segment that is recognisable under this legislation. The Chief Operating Decision Maker (CODM) is considered to be the Trust Board. The CODM receives a variety of information dealing with various aspects of the Trust’s performance, however considers the provision of public health services to be ultimately generic, in terms of geography and service. The Trust therefore is deemed to operate as one segment.

62


42. Other

At 1 April the Improvement Functions of the former NLIAH, along with the functions of

equality and human rights, and their associated asset and liabilities were transferred

from ABMU LHB to Public Health Wales NHS Trust.

This resulted in an increase to the annual core funding for Public Health Wales of £4.4m.

48 staff were transferred into Public Health Wales and an opening creditor balance of

£10k, which was paid in year.

The transfer of functions were treated using absorption accounting adapted for the issue

of PDC.

All transactions and balances related to those functions pre 1st April 2013 are included in

the transferor accounts and post 1st April 2013 are included in Public Health Wales NHS

Trust’s financial statements:

63


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

Audit report of the Auditor General to the National Assembly for

Wales

I certify that I have audited the financial statements of Public Health Wales NHS Trust for

the year ended 31 March 2014 under Section 61 of the Public Audit (Wales) Act 2004.

These comprise the Statement of Comprehensive Income, the Statement of Financial

Position, the Cash Flow Statement and the Statement of Changes in Tax Payers Equity and

related notes. The financial reporting framework that has been applied in their preparation

is applicable law and HM Treasury’s Financial Reporting Manual based on International

Financial Reporting Standards (IFRSs). I have also audited the information in the

Remuneration Report that is described as having been audited.

Respective responsibilities of Directors, the Chief Executive and the Auditor

As explained more fully in the Statements of Directors’ and Chief Executive’s

Responsibilities set out on page 66, the Directors and the Chief Executive are responsible

for the preparation of financial statements which give a true and fair view.

My responsibility is to audit the financial statements in accordance with applicable law and

International Standards on Auditing (UK and Ireland). Those standards require me to

comply with the Auditing Practices Board’s Ethical Standards for Auditors.

Scope of the audit of financial statements

An audit involves obtaining evidence about the amounts and disclosures in the financial

statements sufficient to give reasonable assurance that the financial statements are free

from material misstatement, whether caused by fraud or error. This includes an

assessment of: whether the accounting policies are appropriate to Public Health Wales NHS

Trust’s circumstances and have been consistently applied and adequately disclosed; the

reasonableness of significant accounting estimates made by the Directors and Chief

Executive; and the overall presentation of the financial statements.

I am also required to obtain sufficient evidence to give reasonable assurance that the

expenditure and income have been applied to the purposes intended by the National

Assembly for Wales and the financial transactions conform to the authorities which govern

them.

In addition, I read all the financial and non-financial information in the annual report to

identify material inconsistencies with the audited financial statements. If I become aware of

any apparent material misstatements or inconsistencies I consider the implications for my

report.

Opinion on financial statements

In my opinion the financial statements:

- give a true and fair view of the state of affairs of Public Health Wales NHS Trust as at 31

March 2014 and of its surplus, its recognised gains and losses and cash flows for the year

then ended; and

- have been properly prepared in accordance with the National Health Service (Wales) Act

2006 and directions made there under by Welsh Ministers.

64


Opinion on Regularity

In my opinion in all material respects, the expenditure and income have been applied to

the purposes intended by the National Assembly for Wales and the financial transactions

conform to the authorities which govern them.

Opinion on other matters

In my opinion:

- the part of the remuneration report to be audited has been properly prepared in

accordance with the National Health Service (Wales) Act 2006 and directions made there

under by Welsh Ministers; and

- I have been unable to read the other information contained in the Annual Report and

consider whether it is consistent with the audited financial statements as it was not

available at the time of my audit.

Matters on which I report by exception

I have nothing to report in respect of the following matters, which I report to you, if, in my

opinion:

- the Annual Governance Statement does not reflect compliance with HM Treasury’s and

Welsh Ministers’ guidance;

- proper accounting records have not been kept;

- information specified by HM Treasury or Welsh Ministers regarding remuneration and

other transactions is not disclosed; or

- I have not received all the information and explanations I require for my audit.

Report

I have no observations to make on these financial statements.

Huw Vaughan Thomas

Auditor General for

Wales

24 June 2014

Wales Audit Office

24 Cathedral Road

Cardiff

CF11 9LJ

65


STATEMENT OF THE CHIEF EXECUTIVE'S RESPONSIBILITIES

AS ACCOUNTABLE OFFICER OF THE TRUST

The Welsh Ministers have directed that the Chief Executive should be the Accountable Officer to

the Trust. The relevant responsibilities of Accountable Officers, including their responsibility for the

propriety and regularity of the public finances for which they are answerable, and for the keeping of proper

records, are set out in the Accountable Officer's Memorandum issued by the Welsh Government.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in

my letter of appointment as an Accountable Officer.

Date: ........................ 2014 ............................................................Chief Executive

The total value of transactions with Board members and key senior

66


STATEMENT OF DIRECTORS' RESPONSIBILITIES IN RESPECT OF

The directors are required under the National Health Service Act (Wales) 2006 to prepare accounts for

each financial year. The Welsh Ministers, with the approval of the Treasury, direct that these accounts

give a true and fair view of the state of affairs of the NHS trust and of the income and expenditure of the

NHS trust for that period. In preparing those accounts, the directors are required to:

- apply on a consistent basis accounting principles laid down by the Welsh Ministers with the approval

of the Treasury

- make judgements and estimates which are responsible and prudent

- state whether applicable accounting standards have been followed, subject to any material departures

disclosed and explained in the account.

The directors confirm they have complied with the above requirements in preparing the accounts.

The directors are responsible for keeping proper accounting records which disclose with reasonable

accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts

comply with requirements outlined in the above mentioned direction by the Welsh Ministers.

By Order of the Board

Signed:

Date: ............................2014 Chairman: .....................................................

Date: ............................2014 Chief Executive: ............................................

Date: ............................2014 Director of Finance: ........................................

67


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Total

num3

(£25,

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

THE NATIONAL HEALTH SERVICE IN WALES ACCOUNTS DIRECTION GIVEN BY WELSH MINISTERS IN ACCORDANCE WITH SCHEDULE 9 SECTION 178 PARA 3(1) OF THE NATIONAL HEALTH SERVICE (WALES) ACT 2006 (C.42) AND WITH THE APPROVAL OF TREASURY NHS TRUSTS 1. Welsh Ministers direct that an account shall be prepared for the financial year ended 31 March 2010 and subsequent financial years in respect of the NHS Wales Trusts in the form specified in paragraphs [2] to [7] below. BASIS OF PREPARATION 2. The account of the NHS Wales Trusts shall comply with: (a) the accounting guidance of the Government Financial Reporting Manual (FReM), which is in force for the financial year for which the accounts are being prepared, as detailed in the NHS Wales Trust Manual for Accounts; (b) any other specific guidance or disclosures required by the Welsh Government. FORM AND CONTENT 3. The account of the Trust for the year ended 31 March 2010 and subsequent years shall comprise a foreword, an income statement, a statement of financial position, a statement of cash flows and a statement of changes in taxpayers’ equity as long as these statements are required by the FReM and applied to the NHS Wales Manual for Accounts, including such notes as are necessary to ensure a proper understanding of the accounts. 4. For the financial year ended 31 March 2010 and subsequent years, the account of the Trust shall give a true and fair view of the state of affairs as at the end of the financial year and the operating costs, changes in taxpayers’ equity and cash flows during the year. 5. The account shall be signed and dated by the Chief Executive. MISCELLANEOUS 6. The direction shall be reproduced as an appendix to the published accounts. 7. The notes to the accounts shall, inter alia, include details of the accounting policies adopted. Signed by the authority of Welsh Ministers Signed : Chris Hurst Dated : 17.06.2010 1 Please see regulation 3 of the 2009 No 1558(W.153); NATIONAL HEALTH SERVICE, WALES; The National Health Service Trusts (Transfer of Staff, Property Rights and Liabilities) (Wales) Order 2009

68


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

Annual Governance Statement

1 Scope of Responsibility

The Board is accountable for governance, risk management and internal control. As Chief Executive and Accountable Officer of Public Health

Wales, I have responsibility for maintaining appropriate governance structures and procedures as well as a sound system of internal control

that supports the achievement of the organisation’s policies, aims and objectives, whilst safeguarding the public funds and the organisation’s

assets, for which I am personally responsible. These are carried out in

accordance with the responsibilities assigned by the Accounting Officer of NHS Wales.

As Chief Executive and Accountable Officer, I have personal overall

responsibility for the management and staffing of the organisation. I am required to assure myself, and therefore the Board, that the

organisation’s executive management arrangements are fit for purpose and enable effective leadership. I have received assurances from the

Interim Chief Executive as to the controls, which were in place during the year. The following statement demonstrates the mechanisms and

methods used to enable me to gain that assurance.

2 Governance Framework

Public Health Wales has continued to develop a system of governance and

assurance. The Board functions as a corporate decision-making body, with Executive Directors and Non-Executive Directors being full and equal

members and sharing corporate responsibility for all the decisions of the Board.

In particular, the Board has responsibility for the strategic direction,

governance framework, organisational culture and development, developing strong relationships with key stakeholders and partners and

delivery of Public Health Wales’ aims and objectives. In addition,

Executive Directors have Board level responsibility for discharging Public Health Wales’ corporate and public health functions.

The Board is supported by the Board Secretary, who acts as principal

advisor on all aspects of governance within Public Health Wales.

The Board has established a standing Committee structure, which it has determined best meets the needs of the organisation whilst taking

account of any regulatory or Welsh Government requirements.

69


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

Diagram 1.1 below provides an overview of the governance framework

established by Public Health Wales, which operated during 2013/14.

These arrangements have been further strengthened by the introduction of a service user experience and learning panel with clearer senior management

oversight, which will be operational from April 2014 and will report directly to the Quality and Safety Committee. Further information on the development of the

panel appears later in this document.

At an operational level, the Executive Team has a robust governance structure

ensuring monitoring and control of the efficient and effective use of the Trust’s resources. Financial monitoring, service performance, quality and workforce information is scrutinised at meetings of the Trust Board, and at various

operational team meetings.

NHS Trusts in Wales must agree Standing Orders for the regulation of proceedings and business. They are designed to translate the statutory

requirements set out in the Public Health Wales NHS Trust (Membership and Procedures) Regulations 2009 into day-to-day operating practice. Together with the adoption of a scheme of decisions reserved for the Board, a scheme of

delegations to officers and others, and Standing Financial Instructions, they provide the regulatory framework for the business conduct of the Trust. These

documents, together with the range of corporate policies set by the Board and the adoption of the Values and Standards of Behaviour framework, make up the

Governance Framework.

Board

Audit Committee

Quality & Safety

Committee

Information Governance Committee

Remuneration and Terms of

Service Committee

Charitable Funds Committee

(administered by Velindre NHS Trust)

Information Governance

Working Group

Research & Development

Group

Infection Control Group

Health & Safety Group

Safeguarding Group

Executive Team

Senior Management

Forum

Risk Management

Group

Lines of accountability & information flow

Lines of information flow

70


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

During the year, a number of developments have been put in place, which will

further strengthen the governance framework for the organisation and test the robustness of the framework. In response to the Mid-Staffordshire NHS Foundation Trust Public Inquiry (the Francis Report), a Francis review team was

established. The review team has undertaken a series of engagement workshops with staff across the organisation. The workshops considered the

implications for Public Health Wales of the findings from the Mid-Staffordshire Inquiry. The themes identified in the workshops will be considered alongside

work being undertaken by the Workforce and Organisational Development team in response to the staff survey and the Public Health Wales Strategy and delivery planning. The emerging themes focus on organisational culture and ways of

working. More detailed findings are currently being considered by the Executive Team and will be reported to the Board on 26 June 2014.

We have also recognised that information on service user experience can help to improve and shape services in the organisation. This was also identified as an

area for improvement in the Wales Audit Office Structured Assessment for this year. Work has begun to establish a Service User Experience and Learning

Panel, which will bring scrutiny and emphasis on placing service users at the centre of improving, developing and planning services. The panel will also

consider concerns, incidents and complaints in conjunction with Service User Experience. This will provide a more joined up and coherent approach to understanding emerging issues from a citizen centred perspective leading to

service improvements. The panel will have representation from key areas where services are provided across the organisation. A representative from Community

Health Councils has also been identified to sit on the group. The group will report regularly against the Welsh Government’s Service User Experience Framework and the agreed national service user standards. A Non Executive Director has

been appointed as service user experience champion. This will assist quality improvements and service user experience whilst ensuring the user’s voice and

experience are heard and represented at Board level and also further strengthen the assurance arrangements for the organisation.

2.1 Board membership

The Board has been constituted to comply with the Public Health Wales National Health Service Trust (Membership and Procedure) Regulations 2009. In addition

to responsibilities and accountabilities set out in terms and conditions of appointment, Board members also fulfil a number of Champion roles where they act as ambassadors for these matters.

71


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

In addition to the Board members appointed in accordance with the Public Health Wales NHS Trust (Membership and Procedures) Regulations 2009, Public Health Wales has appointed four additional posts, which have an integral role in the

governance of the organisation. These include a Board Secretary, Director of Nursing, Director of Workforce and Organisational Development and Director of

Communications. Individuals appointed to these positions are members of the Executive Team and have a standing invitation to Board meetings where they

can contribute to discussions but do not have voting rights. The Director of Nursing post was a new post created in 2013. The Director of Nursing took up her post in April 2013. This new post provides an improved position for the

organisation in ensuring that appropriate arrangements are in place to ensure the necessary protection for the public, professional leadership and

accountability for registered nurses and midwives employed within the organisation. Professional lines of accountability are made clear and will be reflected in job descriptions for all registered nurses and midwives where

registration with the NMC is a pre requisite for employment within Public Health Wales. Table 1 outlines the membership of the Board for 2013/14 and also

highlights the membership of the Committees and areas of responsibilities that are championed by the members of the Board.

2.1.1 Vacant Board position

The Local Authority Non Executive Director position has remained vacant throughout 2013/14. The Public Health Wales NHS Trust (membership and

procedure) Regulations 2009 prescribe that this position must be filled using a nominee from local authorities in Wales. The Board had recognised that this nomination approach disadvantages people from under-represented groups and

does not promote the organisation’s commitment to openness and transparency. Following discussions with the Minister for Health and Social Services, it has

been agreed to amend the Regulations so that the post can be advertised through fair and open competition, rather than a nomination process. The Welsh

Government has agreed that until the Regulations have been amended, the post can be filled on an interim basis. This vacancy has added pressure to the time already given by existing Non Executive Directors and does not present the

Board with a rounded local government view. We are well into the process of appointing an interim Board member for a 12 month period that can provide a

strong link to local authorities in Wales. Local Government is a key partner in tackling public health issues in Wales and it is therefore a distinct disadvantage for the organisation not to have this link in place.

72


1 4 2

(£10,4 5 1

(£15,

3

(£1

6 (£210,000)

Xxx LHB/NHS Trust

*Nu

mb

er

Number of

other

departures

Num

ber

of

2.1.2 Recruitment of new Chief Executive Mr Bob Hudson left his post as Chief Executive of Public Health Wales in

November 2013. An interim arrangement was put in place whereby Mr Huw George took up the position as interim Chief Executive. There was a seamless

transition between Mr Hudson leaving the organisation and Mr George taking up the role of interim Chief Executive. Mr George’s substantive role as Executive

Director of Finance ensured a continuity of knowledge and did not present any risk to the organisation. Mr Huw George remained in post until I took up the position on 1 June 2014. Mrs Tamira Rolls was appointed as interim Executive

Director of Finance during this period.

2.1.3 Staff representation at Board meetings We have invited members of trade unions and BMA to attend Board meetings as

full non-voting members to contribute fully to discussions and decisions at Board level. In 2012/13 we reported that there was no staff representation at Board

level. We are pleased to report that the partnership forum has nominated two representatives to attend Board meetings. They will alternate their attendance

at each meeting and attendance started in January 2014. We are in discussions with the BMA about securing a representative at Board meetings.

73


74


* Attend Board / Committee meetings, but are not members of the Board / Committee

and therefore do not have voting rights.

The following table outlines dates of Board and Committee meetings held during 2013/14, highlighting any meetings that were inquorate:

Table 1.2 Board and Committee meetings held during 2013/14

Quorate

Inquorate

There were no inquorate meetings held during 2013/14. Where meetings have been inquorate in previous years, escalation arrangements were in place to ensure that any matters of significant concern that could not be brought to the

attention of the Committee could be raised with the Trust Chair.

2.2 Board Committees The Board has established four standing Board Committees, chaired by Non

Executive Directors, that have key roles in relation to the system of governance and assurance, decision making, scrutiny, development discussions, an

assessment of current risks and performance monitoring. Committee papers and minutes for each meeting are published on the Public Health Wales website.

The chairs of the Committees provide verbal reports to the Board meeting following each Committee meeting. Minutes of Committee meetings are also presented to the Board once approved by the relevant Committee. Each

Committee also produces an annual report, which provide a summary of business undertaken during the year. Copies of these reports are available on

the Public Health Wales website. The Committee annual reports provide the Board with assurance that the Committees are working effectively and contribute to the overall assessment of Board effectiveness.

75


There is common membership between the Committees to ensure integration

with each other in relevant areas. The Terms of Reference for the Committees were reviewed in January 2014 to ensure that there were no overlaps or obvious gaps in roles and responsibilities for each of the Committees. This was

undertaken in response to the Audit Committee’s review of its effectiveness. The outcome of the review was that few changes were needed to the Terms of

Reference, although some additional information was included to reinforce the need for Committees to ensure a connection between the business of key

committees and also seek to integrate assurance reporting. In addition, Public Health Wales has established a Charitable Funds Committee.

This Committee has not met, as charitable funds are currently administered by Velindre NHS Trust on Public Health Wales’ behalf. The Board has agreed that in

the interest of cost effectiveness, Velindre NHS Trust will continue to administer charitable funds on behalf of Public Health Wales.

The following paragraphs provide highlights of reports received by Committees throughout the year. These highlights provide evidence of the governance

framework working in practice.

2.2.1 The Audit Committee The Audit Committee met five times during 2013/14 and was quorate on each

occasion. The Audit Committee provides advice and assurance to the Board on the systems of internal control, governance and efficient and effective use of

resources by overseeing and monitoring a programme of internal and external audit. During the year, the Audit Committee received and discussed a number of reports produced by internal audit, which included sustainability reporting;

Annual Quality Statement; implementation of alert notices; Screening services – service modification; Welsh Risk Pool claims management; financial systems

review; and asbestos management. The Committee was pleased to note that, with the exception of the Welsh Risk Pool claims management report and the

asbestos report, each of these reports were rated ‘reasonable assurance’. The Welsh Risk Pool claims management report was rated ‘substantial assurance’. The asbestos management report was rated ‘limited assurance’. In relation to

the asbestos management report the Committee were informed of a number of issues highlighted in the report and noted the recommendations. At the end of

March 2014, a number of the recommendations had been addressed and the Committee agreed that Internal Audit should complete a further review in September 2014.

1. Further information regarding the ratings of assurance from internal audit is

provided at appendix A

76


In July 2013 the Board noted that the organisation was likely to miss the target

for public sector payment compliance. The Audit Committee requested further assurances on what measures were being taken to improve the situation and received a report at their meeting in September 2013. The Committee received

assurance that the issue had occurred early in the financial year and was due to a change over in systems. The organisation had achieved the target for the

majority of the year, however the issues earlier in the year would mean that the target across the year would not be met. The Committee noted that this would

be confirmed in the annual accounts for 2013/14. The Committee also undertook a self assessment exercise where they assured

themselves that the Committee was complying with the requirements set out in the Audit Committee handbook and identified areas for improvement for the

Committee. This self assessment exercise included further development sessions and a renewed focus on roles and responsibilities for the Committee. The Committee also received a presentation on risk assurance in the

organisation and discussed actions, which are currently in place to mitigate the high level corporate risks.

The organisation commissioned an external audit report into the management

arrangements in the Microbiology Division. The final version of that report was received and discussed in December 2013. Consequent to which the Committee requested regular updates on progress being made to address the

recommendations in the report. A similar audit report with recommendations was received by the Committee in March 2013 in relation to management

arrangements in the Screening Division. This was followed by the receipt of regular reports, which provided updates on progress being made against the recommendations in the Screening Division report.

NHS Wales Shared Services Partnership carries out a number of functions on

behalf of Public Health Wales. The Audit Committee receives reports from the internal audit function at NHS Wales Shared Services Partnership which provide

it with assurance that these functions are efficient and cost effective. Public Health Wales also has representation on the NHS Wales Shared Services Partnership Committee where any issues, which have been identified are shared

and fed back to the Committee.

2.2.2 The Quality and Safety Committee The Quality and Safety Committee met three times during 2013/14 and was

quorate on each occasion. However the Committee meeting scheduled for 8 February 2014 did not take place because the meeting did not have a full

quorum.

77


The Committee expressed concern about the low level of compliance of statutory

and mandatory training requirements and requested regular updates on actions to be taken, or already in place, substantially to improve compliance. The Committee has continued to monitor the situation and maintained to exert

pressure on managers across the organisation to soundly address and achieve the necessary improvement in compliance among their colleagues. A focus on

statutory training has been maintained by the Committee. Data subsequently received by the Committee demonstrated a welcome significant improvement in

compliance by end of March 2014. The Committee will maintain its focus on compliance with statutory and mandatory training and expect continuing improvement in 2014/15.

During the year the Committee received a programme of reports from Divisions

within the organisation on their quality assurance arrangements and how they are implemented and monitored. This series of reports also gave the Committee an opportunity to scrutinise thoroughly the performance frameworks within those

divisions and to request further assurance where necessary. The Committee were pleased to note that the microbiology division has robust quality assurance

arrangements in place. They monitored closely the division’s Clinical Pathology Accreditation (CPA), during 2012/13. CPA assesses and declares the competence

of medical laboratories in the UK. Adherence to the CPA standards for medical laboratories ensures a thorough assessment and evaluation of all aspects of an organisation’s operations. A small number of non conformances with the

Standards was identified. These were rectified and full CPA accreditation was received in June 2013. The microbiology laboratory in Wrexham transferred to

Public Health Wales in October 2013 and maintained its CPA accreditation. Public Health Wales is now recognised as the only fully accredited pathology service in Wales. The next scheduled assessment in Public Health Wales

Microbiology is expected in June 2014. This will be subject to the internationally recognised standard ISO15189:2012 medical laboratories – particular

requirements for quality, competence, which was introduced by CPA in October 2013.

During the year, the Committee recognised that further work was needed in the microbiology division to develop performance reporting within the division. The

Committee arranged a half-day session where they requested proposals on how performance reporting will be developed in the division and the link to the

already well-established quality assurance arrangements. This was arranged for February 2014, but was postponed to the meeting on 22 April 2014. The Committee will continue to monitor this closely during 2014/15.

78


The Committee also reviews and considers claims under the NHS Wales redress

scheme. No settlements under this scheme were made during 2013/14. 2.2.3 The Information Governance Committee

The Information Governance Committee met four times during 2013/14 and was

quorate on each occasion. Throughout the year the corporate risk register contained four high level information governance risks (see below). The

Committee received regular updates on each of these risks and discussed the actions being taken to mitigate the risks. The Committee were pleased to note that one risk, relating to all Wales patient consent forms, was removed as a risk

during the year. A second risk relating the removal of section 251 support (which ensured compliance with the data protection act, removing the need to

obtain explicit consent) has significantly reduced following action by, and pressure brought by the Committee. A third risk relating to EU data protection is still listed as a high risk and is being monitored closely by the Committee. The

fourth risk is an overarching one relating to the risk of failure to ensure appropriate governance of information. This is an organisational wide risk which

the Committee has discussed could possibly be reduced due to the robust controls which are now in place. The Committee has agreed to discuss this in

more detail at their meeting in June 2014. The Information Governance Committee receives summaries and reports on all

Information Governance incidents and ‘near misses’ reported through the Trust’s incident management system. All serious incidents are reported fully to the

Committee and Welsh Government and full Root Cause Analysis investigations are undertaken.

2.2.4 The Remuneration and Terms of Service Committee

The Remuneration and Terms of Service Committee met four times during 2013/14 and was quorate on each occasion. As a result of the national pay

freeze which has been observed in Public Health Wales, the Committee mostly considered applications in respect of the voluntary early release scheme. The Committee approved a 1 per cent cost of living pay award for senior managers in

line with that awarded to staff under Agenda for Change and medical and dental staff in April 2013. However, it was subsequently discovered that this payment

was made erroneously. This has now been rectified and reversed.

3 System of Internal Control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risks; it can therefore only provide reasonable and

not absolute assurance of its effectiveness.

79


The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of organisational policies, aims and objectives, to evaluate the likelihood of those risks being realised and

the impact should they be realised, and to manage them efficiently, effectively and economically.

The system of internal control has been in place in the Trust for the year ended 31 March 2014, and up to the date of approval of the Annual Report and

Accounts.

A Board Assurance Framework was approved by the Board in September 2013. The Board Assurance Framework is used to monitor, proactively seek assurance

and ensure shortfalls are addressed through the scrutiny of the Board and its Committees.

Key controls are defined as those controls and systems in place to assist in securing the delivery of the Board’s strategic objectives. Examples of key

controls include:

- Schemes of delegation

- Policies and procedures - Performance data

- Financial management information - Quality and Safety processes

4 Risk Management Public Health Wales has continued to develop and embed its approach to risk management but has identified a need to review the risk management process

to ensure risk is embedded across the organisation and linked to our three year integrated plan.

Public Health Wales has a risk management strategy in place, which includes a risk management framework. The strategy involves 5 key areas:

- developing risk management in Public Health Wales;

- embedding key risk management systems and processes; - ensuring statutory compliance;

- ensuring Public Health Wales is risk aware and staff are appropriately trained and skilled in risk management; - ensuring compliance with regulation and monitoring.

Risks are identified using an online risk management tool, which was launched in

April 2013. All staff have received training and are encouraged to report risks using the online reporting facility. Risks are captured at every level within the organisation, from day to day risks faced by the staff on the ground, to the

strategic risks at Board level.

80


Individual divisions, service areas, teams, programmes and laboratories are responsible for maintaining their own risk registers. These risks can then be prioritised according to a wide range of criteria, enabling principal risks to be fed

upwards to the Board. Divisional Directors review their divisional risks regularly and ensure an action plan is in place and monitor progress against the action

plan. A risk management group has responsibility for reviewing and commenting on the risk register and seeking assurance from those who have identified the

risk that action plans are in place to manage and reduce the risk. These arrangements will be further strengthened in 2014/15. Risks are allocated to Executive leads and are reviewed at each Executive Team meeting.

The Audit Committee receives the corporate risk register regularly and has been

reviewing the assurance in place for each risk. The Information Governance Committee review and scrutinise all information governance risks and the Quality and Safety Committee review all risks relating to quality and safety.

The corporate risk register contains ten high level risks. This is an increase on

the eight high level risks which were in place in at the beginning of 2013/14. The table below provides a breakdown of categories of risk. The risk register is

published on the Public Health Wales website with the Board papers for each Board meeting. The published register provides more details regarding the nature of the risk and the mitigating actions being taken by the organisation

Table 4.1 Category and number of risks

The corporate risk register is supported by an operational risk profile. The risks

on the operational risk profile arise from activities and processes undertaken within Divisions to achieve the organisation’s objectives. The risks are identified

during the normal course of work and are considered as they arise. They are managed at the time that they arise and reported

81


by staff locally. However, if necessary the risk can be escalated as appropriate.

The Wales Audit Office Structured Assessment recommended that ‘the trust’s approach to identifying and recording divisional risks needs to be reviewed and

improved. It is not clear that risk registers are reviewed regularly’. The Board has accepted this recommendation and recognises that more work is needed in

this area. The development of the integrated medium term plan (more detail of which is found later in this document) has linked to a new operational plan with

newly identified corporate risks, which are linked to the organisational priorities. The Board has also commissioned Academi Wales in conjunction with the Good Governance Institute to undertake a rapid review of governance behaviours and

systems in April 2014. This is in response to the recommendation from Wales Audit Office.

All serious incidents are reported fully to the Quality and Safety Committee and Welsh Government and full Root Cause Analysis investigations are undertaken.

The Committee is also responsible for the monitoring progress against actions identified to ensure that they are completed within the timescales set. In

2013/14 a total of seven Serious Incidents were reported to the Welsh Government. All Serious Incidents are reported by the Screening Division and

relate either to misdiagnosis or recognised procedural risks. Each case is reviewed thoroughly and reported to the Quality and Safety Committee through the Putting Things Right highlights report which can be found on the Quality and

Safety Committee website. The Quality and Safety Committee is also responsible for ensuring that lessons are learnt from serious incidents and that

these lessons are embedded in future practices. The NHS Wales Shared Services Partnership, Audit and Assurance Services

provide an internal audit function for Public Health Wales. Their programme of reviews provides an independent and objective opinion on the adequacy of the

systems of risk management, control and governance by measuring and evaluating effectiveness.

5 Doing Well, Doing Better: Standards for Health Services in Wales Public Health Wales uses the Doing Well, Doing Better: Standards for Health Services in Wales as its framework for gaining assurance on its ability to fulfil its

aims and objectives for the delivery of safe, high quality health services. This involves self assessment of performance against the standards across all

activities and at all levels throughout the organisation. An evaluation of this self assessment is undertaken by the Audit and Assurance Service and a plan for improvement is developed, which is further considered by the Quality and Safety

Committee.

82


As part of this process, the organisation has completed the Governance &

Accountability assessment module and has: - openly assessed its performance using the maturity matrix

- responded, where received, to feedback from Healthcare Inspectorate Wales - put plans in place to achieve the improvement actions identified within clearly

defined timescales proportionate to the risk.

For 2013/14 a more streamlined and focused assessment of the Governance and Accountability module has been completed. Areas for improvement have been identified and are reflected in the actions identified from the Standards for

Health Services in Wales self assessment. Progress against these actions will be monitored and reported on a quarterly basis to the Executive Team and the

Quality and Safety Committee and reports are available on the Public Health Wales website. The following improvements were identified and completed during the year:

Standard 1: Governance and Accountability

A Board Assurance Framework was approved by the Board in September 2013. The template for Board papers will be amended to include a requirement

to link any Board discussion to the revised strategic objectives and priorities and the relevant standards for health services

Standard 12: Environment A facilities database has been developed which now acts as the central point for

all estate related documentation and also to track any actions generated from inspections and audits. This database will help the organisation to determine best practice within our premises and also identify any gaps that require

addressing.

Standard 22: Risk, Health and Safety The online risk management system has been implemented across Public Health

Wales and the web based risk assessment form and escalation process has been made available to all staff to enable them to report risks identified. These risks are subject to review and approval prior to being included on the Team, Division

or Corporate risk register.

The organisation considered the following levels of performance for 2013/14. Also included is a comparison with scores achieved in previous years.

83


Table 4.1 Governance and Accountability Module

* 2011/12 ° 2012/13 X 2013/14

This process has been subject to independent internal assurance by the

organisation’s Head of Internal Audit. The Quality and Safety Committee is responsible for the monitoring of progress against the Corporate Standards for Health Services Improvement Plan. Public Health Wales is represented at the

Healthcare Standards Self Assessment Tool User Group.

Public Health Wales embeds the Standards for Health Services within its activities and structures as they develop. Each of the Corporate Standards for Health Services had an Executive Lead and nominated Corporate Lead, along

with a responsible Board Committee. In addition, the revised Healthcare Standards are built into relevant Public Health Policies and Procedures as

appropriate.

Divisional Directors are also required to develop and lead arrangements to cascade and embed the standards that are relevant to their work. To assist with this a protocol has been developed to provide staff with details

84


of their roles and responsibilities in relation to the management of the Standards

for Health Services.

6 UK Corporate Governance Code Public Health Wales Board is required to comply with ‘corporate governance in central government departments: code of good practice 2011’. The information

provided in this Governance Statement provides an assessment of how Public Health Wales Board complies with the main principles of the Code as they relate

to an NHS public sector organisation in Wales. This assessment has been informed by the organisation’s assessment against the Governance and

Accountability Module undertaken by the Board and also evidenced by internal and external audits. Public Health Wales is following the spirit of the Code to good effect and is conducting its business openly and in line with the Code. The

Board recognises that not all reporting elements of the Code are outlined in this Governance Statement but are reported more fully in the Trust’s wider Annual

Report. There have been no reported departures from the Corporate Governance Code.

The main principles of the code, which apply to Public Health Wales Board, include: role of the Board, Board composition, Board effectiveness and risk

management. Public Health Wales complies with the first three of each of the principles in the following ways. More information on how Public Health Wales

Board complies with risk management can be found in section 4. 6.1 Role of Board and Board composition

Public Health Wales is headed by a Board comprising five Executive and seven

Non Executive Board members. There is a clear division of roles and responsibilities. The Board is responsible for shaping strategy and non Executive Directors regularly challenge and scrutinise the work of the executive. The Chair

is accountable to the Minister for Health and Social Services and responsible for ensuring that the Board leads the organisation effectively so that the

organisation delivers against national objectives set by the Welsh Government.

The Chair of the Board is accountable and reports to the Minister for Health and Social Services in regard to the overall performance of the Trust and its strategic direction. The Chief Executive is accountable and reports to the Chair and the

Chief Executive of NHS Wales/Director General, Department for Health, Social Services and Children, Welsh Government. The Board itself is fully accountable

to the Minister for Health and Social Services, the Welsh Government. As a public body, it also has a responsibility to its’ partners and stakeholders, and the

85


general public. The risk management process is described earlier in this

document. Internal control principles are detailed and described in the Board Assurance Framework, which was approved by the Board in September 2013, and the organisation’s annual report and accounts provide an overview of

assurance reporting to the Welsh Government and Welsh Ministers.

6.2 Board Effectiveness

The composition of the Board provides an appropriate balance of skills, experience, independence and knowledge. The board has expressed concern about the gender imbalance of Board members and the lack of people from

under-represented groups. Work is being taken forward to ensure all future recruitment encourages applications from these under-represented groups and is

in line with Welsh Government policy in this area. Agendas and papers are issued ten calendar days before each formal Board

meeting. This provides members and those invited to attend the Board in an observer capacity with sufficient time to consider all relevant information and

papers for decision, discussion, guidance, information and intelligence so that they are aided and informed to discharge their duties and responsibilities

effectively. Inevitably, meetings have very full agendas necessitating a considerable amount of business is completed at each meeting. Nevertheless, the chair of the Board is satisfied that the Board has only very rarely had

insufficient time to fully consider and debate matters. In that rare circumstance less pressing matters are referred to the next meeting, or an agreed balanced

sub-group of board members are assigned to progress the task before the next meeting, report their deliberations to the Chair who ensures that the sub-group’s deliberations and outcomes are reported, discussed and endorsed or otherwise

at the next plenary session of the Board. Board members have also confirmed that they are not pressurised into making decisions without the full and relevant

information being made available to them.

Ongoing training and development for Board members, both Executive and Non Executive, is delivered through informal Board meetings. Non Executive Directors are involved in a variety of other ways which include attending

management meetings through to chairing conferences. The Board has identified the need for a bespoke development programme and has commissioned a

programme of Board development to assist it in evaluating its own performance. The Audit Committee have also undertaken an evaluation exercise which has resulted in a number of actions which will be addressed in Board development

sessions. This is supplemented by regular meetings between the Chair, Board Secretary and Chief Executive to identify areas requiring further development.

Furthermore, the need for specific areas for development of individual Board members and the

86


relevance to general Board development are identified and discussed at regular

performance development reviews of Board members carried out by the Chair and Chief Executive. During 2013/14 these discussions informed a series of informal Board meetings and away days, which provided an opportunity to

address development needs and to reflect on the Board and organisation’s strategic direction and performance since it was established in 2009.

In early 2013 the Board participated in a workshop where they discussed the

recommendations from the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis report). These discussions were used to inform the staff engagement events which are mentioned earlier in this document in section 2.

The Board continued these discussions throughout 2013/14 and reflected on their performance and effectiveness as a group and individually. The Wales Audit

Office and Healthcare Inspectorate Wales report into governance arrangements at Betsi Cadwaladr Health Board was also considered by the Board. The Board reflected on the findings from the report and undertook a piece of work to assure

themselves of the governance arrangements in Public Health Wales. As part of this reflection, the Board concluded that they are confident that Public Health

Wales has indeed been proactive in adopting an enduring review and strengthening of its governance and scrutiny arrangements in response to the

report into Betsi Cadwaladr Health Board. The assessment was submitted to David Sissling, Director General Directorate for Health and Social Services, Welsh Government and Chief Executive NHS Wales. Improvements have been

made to the structure of Board agendas and supporting papers to ensure absolute clarity of why an item is being brought to the Board and whether it is

for decision, scrutiny or information. There was also a renewed focus on Board development, as mentioned earlier in this document. Having undertaken the exercise above, the Board has satisfied itself that the quality of information and

data received at Board meetings is acceptable. An independent consultant from the Good Governance Institute attended the Board meeting on 30 January 2014

to provide feedback on the quality and level of information and data received by the Board. This provided a basis for the rapid review which has been

commissioned.

7 Integrated medium term plan

Public Health Wales has developed an integrated medium term plan, which supports the aims and policies of the Welsh Government and fits within the NHS Wales Planning Framework. The plan guides the delivery of our strategy and the

achievement of a healthier, happier and fairer Wales through our three commitments improve health and wellbeing and reduce health inequalities;

improve the quality, equity and effectiveness of healthcare services; and protect people from infectious and environmental hazards. It demonstrates financial

87


balance and covers a three year period from 2014/15 to 2016/17. The plan was

approved by the Public Health Wales Board in March 2014 and submitted to the Welsh Government for consideration and comment. Following feedback from the Welsh Government a one year, more detailed, plan will be submitted by 30 June

2014.

The plan sets out where we have come from; where we are now; where we want to go; and how we will get there.

This plan is our first under the 2013 NHS Wales Planning Framework. It is also the first under our refreshed strategy.

In early 2013, we started the current planning cycle from first principles, by

reviewing and refreshing the strategy that we had adopted following our establishment in 2009. This was because:

- we had developed as an organisation and had important new perspectives and ideas about our aims, our priorities and the best ways of contributing to them

- the environment in which we operate had changed, with new, more

challenging, expectations of us - we had grown by approximately 25%, by taking on new services and functions

- it was clear that some of the established ways of doing things were not having

a big enough impact on the health of the people of Wales Arising out of the development of our refreshed strategy, we have agreed and

adopted new priorities for action. These were agreed at the end of 2013 and have informed the development of the plan.

We will review our plan annually to ensure that it continues to meet our needs

and those of our partners, stakeholders and the citizens in Wales. Over the next year, we will ensure even greater alignment between our plan and the plans of stakeholders. We will do this by aligning public health priorities and actions to

address and tackle them across NHS Wales and beyond.

A Quality and Delivery Framework has been developed in support of the integrated plan, which sets out a mixture of quantitative and qualitative measures to assess performance internally and externally against the

organisation’s strategic objectives. This has driven an improvement in performance reporting to the Board. This has also assisted a more integrated

approach to finance, workforce and service planning and provides a clearer approach to demonstrating achievement of the organisation’s objectives.

88


8 Additional Assurance Disclosures 8.1 Ministerial Directions

Whilst Ministerial Directions are received by Local Health Boards, these are not

always applicable to Public Health Wales. All Ministerial Directions issued throughout the year are listed on the Welsh Governance website. During 2013/14 nine Non-Statutory Instruments were issued by the Welsh Government.

Public Health Wales was only required to take action on one of these Non-Statutory Instruments ‘establishment of the Emergency Ambulance Services

Committee (Wales). Under this direction the Chief Executive of Public Health Wales is appointed as an associate member of the joint Committee and as such

may not vote in any meetings or proceedings of the joint committee. In addition to the above Non-Statutory Instruments Public Health Wales receives

letters from the Minister where we are required to take action. Any letters which are received are reported at each Board meeting in the Board Secretary’s

Governance report, with further information on what action has been taken in response to the letter.

8.2 1000 Lives Plus

The organisation engages with the 1000 Lives Plus programme, and the Board promotes use of methodologies for improvement, and is aware of improvements

made and barriers to extending it. On 1 April 2013 staff from the National Leadership and Innovation Agency for

Healthcare (NLIAH) service improvement unit transferred into Public Health Wales. These staff, along with the staff working in the 1000 Lives Plus team in

Public Health Wales were brought together to form to 1000 Lives Improvement Service. There were no significant risks identified during the transition process and the staff are now embedded within the organisation.

Improving Quality Together (IQT) was launched by the Chief Medical Officer for

Wales and the Chair of Public Health Wales in March 2013 and is the national quality improvement programme for NHS Wales. It provides a common and

consistent approach to improving the quality of services in NHS organisations across Wales. Public Health Wales made a commitment for 25% of the workforce to be trained in IQT by 31 March 2014. Public Health Wales is pleased

to note that staff have exceeded the target with a current rate of 29% of staff having completed the training. All members of the Board have also completed

the training and were, in fact, the first Board in Wales to gain the bronze level stage of IQT.

89


8.3 Hosted Bodies

During 2013/14, Public Health Wales continued to host the Health and Wellbeing, Best Practice and Innovation Board. Public Health Wales put in place a hosting

agreement which provided details of the responsibilities of Public Health Wales Board and the hosted Board. Consisting of the Chair and two staff members, the

Board of the hosted body has evaluated the potential impact of innovations and developments and facilitated their adoption across the NHS, local government

and the third sector in Wales. The Board of the hosting body concluded their work and published a final report on 31 March 2014.

8.4 Civil Contingencies/Business Continuity

Public Health Wales’ Emergency Response Plan details the organisation’s response to a wide range of incidents and threats. The plan provides an overarching framework for the organisation’s response to incidents and

outbreaks, including the mobilisation of additional resources.

The organisation has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil

contingency requirements as based on UKCIP 2009 weather projections to ensure that the organisation’s obligation under the climate change Act and the Adaptation Reporting requirements are complied with. We monitor our Carbon

footprint using 2013/14 as a baseline figure and we have adopted the Welsh Government initiative of ensuring sustainability is embedded in everything we

do. Public Health Wales has also adopted an Accommodation Strategy that embeds sustainable development as key principles.

Key divisions within Public Health Wales, such as Screening, Health Protection and Microbiology, have established business continuity arrangements in place.

As part of these arrangements, relevant staff are aware of their duties as described within the plans. The Information management and technology

installed infrastructure has been tested to ensure the network is available across multiple sites in the event of local emergencies or one or more buildings suffering unforeseen problems.

8.5 Sustainability

Public Health Wales fully supports proposals detailed in various Welsh Government consultation documents to embed sustainable development as the

central organising principle of public sector bodies in Wales by ensuring a clear focus on outcomes and that strategic decisions are informed by consideration of

the wider determinants of health and wellbeing. Public Health Wales recognises that sustainable development and public health are intrinsically linked and that

complementary and coordinated actions are necessary to address the key challenges facing Wales in relation to both.

90


Public Health Wales is fully engaged in the Welsh Government’s development of

the Future Generations Bill (previously the Sustainable Development Bill). The Bill aims to tackle the generational challenges Wales faces in a more robust, joined up and integrated way. It is expected that the Bill will place a new duty

on public services in Wales to make sustainable development their central organising principle. The Bill will also set out a number of long term economic,

social, and environmental wellbeing goals, many of which will link closely with work undertaken by Public Health Wales. A national conversation has been

launched by the Welsh Government to involve people across Wales in exploring what are for them the most important issues in improving their lives and those of their families and communities. Public Health Wales is fully engaged in the

national conversation and will be playing a key role in the development of the Bill.

8.6 Equality

A Strategic Equality Plan was adopted by the Trust Board in April 2012, with regular progress reports provided to the Board. The plan details the actions we

are taking to address and improve equality related issues in all parts of the organisations. The Strategic Equality Plan also laid out an additional objective to

‘embed Equalities into organisational performance and Executive and Board Decision Making’. As part of the Strategic Equality Plan, all new and revised policies and strategies are subject to an equality impact assessment (EQIA).

An equality group has been established to oversee the strategic equality plan, to

ensure under-represented groups are properly considered and that measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

8.7 Staff

Public Health Wales engages staff systematically in a number of ways which are

part of the checks and balances Public Health Wales undertakes to enable good governance. Formal consultative fora are well established through the Partnership Forum, Joint Medical and Dental Negotiating Group, and the Joint

Negotiating Committee for Agenda for Change staff. These fora provide mechanisms which allow for feedback to senior management on organisational

performance or any other issues that staff wish to raise, which aids transparency. In addition to these formal mechanisms, we have a consultation process open to all staff for all new and revised organisational policies, a staff

conference, a senior management forum and a national forum, all of which are fully exploited and used to engage in conversations with staff at individual and

group levels. These mechanisms are used in parallel with an open blog, a web forum and other virtual ways for staff to share their work and opinions.

91


In 2013/14 we have focussed strongly on improving compliance with Statutory

and Mandatory training as this is a key way of ensuring staff have the appropriate knowledge and skills to enact organisational policies as well ensuring compliance with Health and Safety, Information Governance and other important

legislation. At the beginning of the year compliance against statutory training was considerably low and was identified as an issue by the Quality and Safety

Committee. Compliance figures have improved considerably during the year, for example Health and Safety training compliance has risen from 8 per cent

compliance to 85 per cent, manual handling has risen from 33 per cent to 72 per cent and fire safety has risen from 35 per cent to 70 per cent.

Recruiting the right people is critically important especially where we are providing services directly to members of the public. 2013/14 has seen a

renewed focus on selection methods, with assessment centres being adopted as the preferred method of assessment for all posts at Band 8a and above. This is a more robust method of understanding how job applicants match the competency

requirements and goes beyond asking for information to testing the application of some of the competencies in practice. New procedures to check job

candidates against new Vetting and Barring requirements have been developed and will be implemented in 2014/15.

Public Health Wales, as an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer

obligations contained within the Scheme’s regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and

payments in to the Scheme’s are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Note 12 to the accounts provides details

of the scheme, how it operates and the entitlement of employees.

9 Review of effectiveness

As Accounting Officer, I have responsibility for reviewing the effectiveness of the systems of internal control. My review of the system of internal control is

informed by the work of the internal auditors and the executive officers within the organisation who have responsibility for the development and maintenance

of the internal control framework and comments made by external auditors in their audit letter and other reports. The following text provides examples of the review of effectiveness which has been undertaken throughout the year. In

addition the assessment of compliance with the UK Corporate Governance Code at section 6 contributes to the review of effectiveness.

92


9.1 Internal Audit

Internal Audit provides me as Accounting Officer, and the Board through the Audit Committee, with a flow of assurance on the system of internal control. I

have commissioned a programme of audit work which has been delivered in accordance with public sector internal audit standards by the NHS Wales Shared

Services Partnership. The scope of this work is agreed with the Audit Committee, and is focused on significant risk areas and local improvement

priorities approved by the Board. The overall opinion by the Head of Internal Audit, NHS Wales Shared Services

Partnership on governance, risk management and control is a function of this risk based audit programme and contributes to the picture of assurance available

to the Board in reviewing effectiveness and supporting our drive for continuous improvement.

The Head of Internal Audit has concluded:

“In my opinion the Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas

under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved.”

In reaching this opinion the Head of Internal Audit has identified that the

majority of reviews during the year concluded positively, with the only exceptions being asbestos management and the lack of progress with implementing the recommendations relating to mandatory training.

During the year internal audit issued one report with limited assurance on

asbestos management. Five recommendations were made which have been accepted and an action plan is in place to address the issues raised and improve

the situation across the organisation.

93


9.2 Counter Fraud Cardiff and Vale Counter Fraud Service provides a service to Public Health Wales.

Their work plan for 2013/14 was completed and covered all the requirements under Welsh Government Directions. The counter fraud service provides regular

reports and updates to members of the Executive Team and directly to the Audit Committee. The Audit Committee received the counter fraud and corruption

annual report for 2013/14 and the local counter fraud specialist provided the following declaration:

I declare that the Anti-Fraud, Bribery and Corruption work carried out during the financial year 2013/14, within the Public Health Wales NHS Trust, has been self

reviewed against the NHS Protect Standards for Providers - Fraud, Bribery and Corruption/NHS Standard Contract and the rating as detailed in Appendix 4 (green for all standards) has been achieved.

9.3 External Audit – Wales Audit Office

The Auditor General for Wales is the statutory external auditor for the NHS in

Wales. The Wales Audit Office undertakes the external auditor role for Public Health Wales on behalf of the Auditor General. The Wales Audit Office completed their Structured Assessment for 2013/14 and overall they concluded

that the organisation has good arrangements for governance and board assurance but work remains to strengthen some components of the governance

framework. The Wales Audit Office highlighted the need for internal controls for statutory and mandatory training to improve and to review and improve the approach to identifying and recording divisional risks.

9.4 Information security

During 2013/14, Public Health Wales reported one significant data security

lapse; this incident involved the misdirection of Public Health Wales data by an external data processor. The Information Commissioner found that Public Health Wales and the data processor had taken the appropriate subsequent action and

decided that no further action was needed.

10 Conclusion

As Accounting Officer, I can confirm that no significant governance issues have been identified. Therefore, reasonable assurance can be given that there is a

sound governance framework, designed to meet the organisation’s objectives and that the framework is generally being applied consistently.

Signed: ___________________

Dr Tracey Cooper

94


Appendix A 2012/2013 Audit Assurance Ratings

95

30 09

Date: 16 June 2014 Version:1a Page: 1 of 11

Month 2 2014/15 finance performance report

Purpose of Document: To report on the year to date and projected outturn position of

Public Health Wales as at 31 May 2014

To provide an update on major budget movements, the capitalprogramme and the key financial performance indicators

To provide an update on the financial services function

Board/Committee to- (Please indicate)To decide- Paper will outline recommendations or issues tobe approved by the Board or Committee.

To discuss- Board or Committee will be asked to discussand scrutinise the paper and provide feedback andcomments.

X

To inform- Board or Committee will be asked to note thepaper for information only

Other relevant informationN/A

Next StepsN/A


X

Priorities for action Ensure financial sustainability

Author: Mr Huw George, Executive Director of Finance, Ms Tamira Rolls,Assistant Director of Finance, Ms Margaret Krawiecka, Assistant Director ofFinance

Date: 16 June 2014 Version:1aSponsoring Executive Director: Mr Huw George, Executive Director

of Finance

Who will present: (If appropriate) Mr Huw George, Executive Directorof Finance


Finance performance report


Paper reference 30 09

Public Health Wales Paper Submission Cover Sheet

Date: 15 March 2014 Version:1 Page: 2 of 11

Committee/Groups that havereceived or considered thispaper:

Executive Team



Link to riskregister

Risk 87: Failure to meet statutory brake even duty.


N/A


See information in attached paper


N/A

Public Health Wales Board Arrangements Paper


Month 2 2014/15Finance Performance

ReportAuthors: Huw George , Tamira Rolls and Margaret Krawiecka

Date: 15 June 2014 Version: 1a

Distribution:

Public Health Wales Trust Board

Purpose and summary of document: To report on the month 2 position for Public Health Wales

To provide an update on major budget movements, the capitalprogramme and the key financial performance indicators

Public Health Wales Month 2 Finance Performance Report – May 2014


1 Introduction

The content of this report reflects the Director of Finance commentarywhich was formally submitted to Welsh Government on 12 June 2014 aspart of the full financial monitoring return for month 2 (31 May 2014).

The report will cover the following areas:

Year to Date (YTD) Position and variance report (section 2) Budget movements and reconciliation to 2014/15 budget Strategy

(section 3) Risks and Issues (section 4) Balance Sheet Summary (section 5) Key Financial performance Indicators (Section 6) Capital Programme (Section 7)

2 YTD Position

The table below summarises the month 2 (to 31 May) financial position bydirectorate. A Divisional level summary is provided in the Appendix 1.

The reasons for the individual directorate and divisional variances are givenbelow. Further details are provided in the individual divisional financialreports.

Dir Type

AnnualBudget£000s

YTDBudget£000s

YTDActual£000s

YTDVariance

£000s

PH Services Income -60,766 -9,863 -9,923 -61

Pay 33,741 5,623 5,491 -132

Non Pay 28,247 4,447 4,664 217

PHS Total 1,222 208 232 24

PH Development Income -3,779 -630 -616 14

Pay 22,201 3,700 3,632 -68

Non Pay 10,633 1,772 1,659 -114

PH Dvt Total 29,055 4,842 4,675 -167

Corporate Income -40,187 -6,698 -6,686 12

Pay 7,182 1,189 1,209 20

Non Pay 2,729 459 488 29

Corp Total -30,276 -5,050 -4,989 62

Grand Total 0 0 -82 -82



Summary:

Total Income -104,733 -17,190 -17,225 -35

Total Pay 63,123 10,512 10,332 -180

Total Non Pay 41,609 6,678 6,811 133

TOTAL 0 0 -82 -82

2.1 Public Health Services (£24k YTD overspent)

2.1.1 Microbiology Division (£77K overspent):

Income has over achieved at month 2 by £26k mainly due to ad hocincome.

Pay is under spent £66k mainly due to vacancies at various levels acrossall laboratories of £126k, with an offset of £60k of vacancy factor to date.

Non pay is over spent £168k due to chemicals and kits mainly in Cardifflaboratory. Over activity for the first two months of £46k has beenfactored into the financial statements: both income and non pay budgetshave been increased.

2.1.2 Screening Division (£37k under spent)

Income has over achieved by £32k due to having more trainee assistantradiographers than planned and over achieving course income formammography training.

Pay is £31k under spent due mainly to vacancies of radiography andmedical positions.

Non pay is £25k over spent by small amounts over various expenditureheadings.

2.1.3 Health Protection Division (£6k under spent)

Income is £3k under spent due to an over achievement of tonsillectomysurveillance income.

Pay is £25k under spent due to mainly consultant vacancies and maternityleave.

Non pay is £23k over spent mainly due to a payment for software. Budgetwill now be phased in to cover this payment.

2.1.4 Safeguarding Children (£10k under spent)

Pay budgets are showing an under spend of £11k due to slippage atadministration budget.



Non pay is over budget by £2k mainly due to travel and subsistenceexpenditure.

2.2 Public Health Development (£167k YTD overspent)

Public Health Development has agreed a budget plan with a vacancy factorof £400k which is based on the historical pattern for staff turnover andfilling of vacancies. This target is not currently devolved to divisions andso they would expect to see a local pay underspend which is offset by thecentral vacancy target.

2.2.1 Health and Healthcare Improvement (£86K underspent):

The underspend to date is primarily due to vacant posts within thePharmaceutical and Stop Smoking Wales teams.

2.2.2 Health Intelligence (£30k under spent)

The underspend to date is mainly due to vacant posts within theEvidence Service and the Observatory Analytical teams.

2.2.4 Policy Research and Development (£18k under spent)

This underspend is primarily due to planned lower expenditure atthe beginning of the year within the Research and Developmentand the Public Health Networks teams. Expenditure levels willincrease in line with plans during the remainder of the financialyear.

2.2.5 Local Public Health Teams (£80k under spent)

£52k of the underspend to date is a result of vacant posts withinseveral local PH teams. A further £28k is due to planned lowerexpenditure at the beginning of the year with expenditure levelsplanned to increase during the remainder of the financial year.

2.2.3 PHD Management and 1,000 Lives Improvement Unit (£47kover spent)

This is primarily a result of an overspend against the staffturnover target for Public Health Development as described above.

2.3 Corporate (£61k YTD overspent)

There is a small overspend within the area of corporate budgets as theTrust has set higher targets for the management of vacancies in order toincrease development funds.



3 Budget Changes

The table at appendix 2 reconciles the original Budget strategy figureswith the month 2 figures. The budget currently stands at £105,254m. Thechanges are due to movement of budgets between income andexpenditure lines and because the majority of the investment budget hasnot yet been allocated to the divisions and remain in the corporatedirectorate. There has been some additional noncore income.

4 Risks and Issues

4.1 Savings Plan

The 2014/15 budget strategy includes £2,255 savings, split between pay(£611k) and non pay (£1,644k). As in previous years, the savings will bemonitored on a regular basis with detailed performance reports on each ofthe savings programmes reported to the board on a quarterly basis.

Whilst every effort will be made to ensure the savings plans are achievedin full during 2014/15, there is nevertheless a risk that they are notachieved.

4.2 NHS Agreements and Contracts

All SLAs and contracts with other NHS Wales organisations are currently inthe process of being finalised and signed. We anticipate that all contractswill be agreed and signed by the end of June 2013.

PHW Income:

Public Health Wales has approximately £12.5m in Microbiology contractincome for tests carried out in the Microbiology labs. These contracts arebased on an historic baseline and are updated each year for anyanticipated changes to the activity. The LHBs receive activity reports on aquarterly basis, and are invoiced on a monthly basis.

PHW Expenditure:

The majority of our NHS Wales expenditure relates to Screening ServicesLTAs with other NHS Wales Organisations (approx £11.5m) which aregenerally multi-year LTAs and will therefore have been agreed pre2014/15.

4.3 Re-implementation of Oracle Financial andprocurement system

A new version (R12) of the all Wales Finance and procurement system wasimplemented on 1st April 2014. There were several problems with



migration of data from the old system which caused significant delays withthe implementation. This was the case across NHS Wales and the followingis an excerpt from a recent project status update report:

Although all organisations are operational on the new system.....there is stillconsiderable work to be undertaken to ‘catch up’ and move into steady state.

This catch up will result in a considerable impact on PSPP targets and the catch upprocesses are being agreed by each organisation with Shared Services.

The main issues for the Trust have been: The receipting function was not available until 2nd May; There were no system payment runs during April; Problems with the automated accruals which have been loaded onto

the new system and so no invoices relating to 2013/14 could bepaid.

We have made considerable progress during May and June and haveworked with NWSSP to clear the large backlog of invoices. However, thefact that there was a backlog of invoices in the system will inevitablyaffect our PSPP performance in the short term, as it explained in section 6.

5 Public Health Wales Balance Sheet

All major movements in the balance sheet for month 2 (from the 2014/15opening balance) are shown in the table below, along with an explanationfor the movement.

Mov't£'000 Explanation

Trade and other receivables 1,465 The increase reflects the fact that other NHS organisationhave not able to process payments due to the issues with R12

Cash and cash equivalents 5,256 Movement in working capital

Trade and other payables -6,557 This includes accruals for NHS recharges not received fromother NHS organisations for Screening Services and forinvoices outstanding from Local Authorities. The increase isalso a result of issues with the implementation of R12 andconsequential delays in making system payments.



6 Key Financial Indicators

6.1 Public Sector Payment Policy (PSPP) Compliance

As a result of issues with the R12 implementation, and the consequentialdelays in paying invoices, the PSPP figures are lower than expected.

The table below shows the month 2 (YTD) figures. These are also themonth 2 figures as no payments were made in month 1.

% of NHS Invoices Paid Within 30 Days - By Value 57.9%

% of NHS Invoices Paid Within 30 Days - By Number 53.5%

% of Non NHS Invoices Paid Within 30 Days - By Value 70.1%

% of Non NHS Invoices Paid Within 30 Days - By Number 86.0%

Although we have missed the Non NHS invoices by number at month 2,we had been making significant process during 2013/14 on increasing ourperformance, and we are hopeful that we will be able to achieve the targetof 95% percent by year end.

6.2 Agency Expenditure and WTE movement

The agency costs have reduced significantly during April and May 2014and are 0.4% of the total staff costs for both months 1 and 2.

The table below summarises the movement in all 3 categories betweenApril and May 2014.

Sum of WTE Contracted Sum of WTE Worked Sum of WTE Paid

Job Type April May Mvt April May Mvt April May Mvt

A&C & Board Members 738.10 739.68 1.58 710.96 709.44 -1.52 711.54 710.15 -1.39

Medical & Dental 96.23 95.63 -0.60 93.65 93.29 -0.36 93.65 93.29 -0.36

Registered 51.72 50.92 -0.80 50.16 49.33 -0.83 50.16 49.33 -0.83

Prof Scientific & Tech 12.56 12.81 0.25 12.56 12.81 0.25 12.56 12.81 0.25

Additional Clinical Servs 121.02 123.82 2.80 118.36 121.50 3.14 119.90 123.55 3.65

Allied Health Profs 53.04 52.94 -0.10 54.40 54.10 -0.30 54.57 54.38 -0.19

Healthcare Scientists 195.29 195.29 0.00 192.77 194.77 2.00 196.48 199.74 3.26

Estates & Ancilliary 1.91 1.91 0.00 1.91 1.91 0.00 1.91 1.91 0.00

1,269.87 1,273.00 3.13 1,234.77 1,237.15 2.38 1,240.77 1,245.16 4.39



The table below gives details of the increase of 3.13 WTEs in thecontracted staff category.

New Starters (core) 8.85

Changes in Hours 0.82

Leavers -6.54

Net Change 3.13

7 Capital Programme

The table below shows the Trust’s draft capital programme for 2014/15:

SOURCES OF FUNDS Total2014/15£000’s

HTF - Colposcopy Imaging 1,560

HTF - Bacteriology in Rhyl 1,192

Discretionary Capital 829TOTAL SOURCES OF FUNDs 3,581

APPLICATION OF FUNDS £000’s

HTF - Colposcopy Imaging 1,560.0

HTF - Bacteriology in Rhyl 1,192.0

2014/15 Discretionary Schemes:

IT Screening Microsoft Office Licences required by ELP exercise 45.3

MSC related equipment 30.0

IT Screening Replacement of Screening's Network Switches 20.0

IT Screening Replacement of key clinical printers 8.0

Interfacing of AST/Maldi 17.4

ABI Fast 7500 PCR System Cardiff 35.0

Bionumerics Software Cardiff 20.0

Centrifuge (TB Lab) Cardiff 9.0

1 x class 2 safety cabinet Cardiff 14.0

3 x Class 2 cabinets (molecular) Cardiff 30.0

Safety cabinet Aberystwyth 6.5

Automated DNA extraction - Cryptosporidium Swansea 45.0

Mobile Generators 24.5

Trust IT Replacement Scheme 200.0

Surveillance of Emergency Department Attendance 12.0

Total committed capital funds 3,268.7

Uncommitted 312.3

Total 14/15 Capital Funds 3,581.0



Welsh Government has approved two technology bids: colposcopy andcolonoscopy imaging £1.56m and automation of bacteriology in our Rhyllaboratory £1.192m. The colposcopy imaging equipment was going to bepurchased in 13-14 however due to procurement uncertainties WelshGovernment have authorised the transfer of funding from 13-14 to 14-15to enable the investments to be made during 2014-15. Welsh Governmenthas confirmed the capital charges funding relating to these schemes for14-15.

8 Conclusion

The Trust is forecasting that it will fulfil its statutory break even duty for2014/15.

Work is ongoing to mitigate all risks and also to create opportunities fordevelopment of the organisation.

Appendix 1

2014/15 Financial Performance Report - Month 2 Variance Report by Division

PH DEVELOPMENT: Type Annual Budget YTD Budget YTD Actual YTD Variance

Hlth and HC Improvement Income -1,935,853 -322,644 -373,571 -50,927

Non Pay 7,324,351 1,220,730 1,264,363 43,633

Pay 5,717,103 952,866 873,792 -79,074

Hlth and HC Improvement Total 11,105,601 1,850,952 1,764,585 -86,367

Hlth Intelligence Income -283,740 -47,290 -47,315 -25

Non Pay 531,201 88,534 102,720 14,186

Pay 2,848,357 474,734 430,490 -44,244

Hlth Intelligence Total 3,095,818 515,978 485,895 -30,083

1,000 Lives Improvement Unit Income -591,751 -98,626 -40,500 58,126

Non Pay 1,263,005 210,502 104,133 -106,369

Pay 2,690,625 448,438 388,305 -60,133

Improvement Total 3,361,879 560,314 451,938 -108,376

Local PH Teams Income -717,264 -119,546 -119,746 -200

Non Pay 989,799 164,962 137,707 -27,255

Pay 7,997,013 1,332,840 1,280,574 -52,266

LPHTs Total 8,269,548 1,378,256 1,298,536 -79,720

Policy Research and Development Income -250,865 -41,810 -34,702 7,109

Non Pay 459,830 76,642 37,608 -39,034

Pay 1,179,746 196,628 210,250 13,622

Policy R&D Total 1,388,711 231,460 213,156 -18,304

PHD Management and Admin Non Pay 64,938 10,820 12,042 1,222

*includes staff turnover target* Pay 1,768,105 294,688 448,841 154,153 66,667

PHD Management and Admin Total 1,833,043 305,508 460,883 155,375

PH Dvt Total 29,054,600 4,842,468 4,674,993 -167,475

PH SERVICES: Type Annual Budget YTD Budget YTD Actual YTD Variance

Health Protection Income -4,754,978 -714,316 -717,177 -2,861

Non Pay 795,101 54,337 77,003 22,666

Pay 4,498,232 749,705 724,324 -25,382

Health Protection Total 538,355 89,726 84,149 -5,576

Microbiology Income -20,751,079 -3,532,383 -3,557,922 -25,539

Non Pay 6,427,507 1,149,267 1,317,278 168,011

Pay 14,894,633 2,482,439 2,416,661 -65,778

Microbiology Total 571,060 99,323 176,017 76,694

Safeguarding Children Services Income 0 0 -618 -618

Non Pay 16,316 2,719 4,641 1,921

Pay 987,488 164,581 153,667 -10,915

SCS Total 1,003,804 167,301 157,689 -9,612

Screening Services Income -35,260,429 -5,615,971 -5,647,646 -31,675

Non Pay 21,008,135 3,240,590 3,265,680 25,090

Pay 13,360,584 2,226,764 2,196,079 -30,685

Screening Services Total -891,710 -148,618 -185,888 -37,270

PHS Total 1,221,509 207,732 231,968 24,236

CORPORATE: Type Annual Budget YTD Budget YTD Actual YTD Variance

Board and Corporate (Inc Core Income) Income -38,990,364 -6,498,396 -6,496,122 2,274

Non Pay 1,054,186 171,517 219,125 47,608

*includes staff turnover target* Pay 2,838,795 473,132 544,747 71,615

Board and Corporate Total -35,097,383 -5,853,747 -5,732,250 121,497

Planning IM&T and PMU Income -379,971 -63,328 -63,328 0

Non Pay 325,710 54,287 66,845 12,559

Pay 1,569,576 261,597 253,094 -8,502

Planning IM&T and PMU Total 1,515,315 252,555 256,612 4,056

Estates Income -67,368 -11,228 -11,228 0

Non Pay 917,438 152,906 144,914 -7,992

Pay 34,289 5,714 5,775 61

Estates Total 884,359 147,392 139,461 -7,931

Finance Non Pay 75,000 12,500 9,162 -3,338

Pay 776,406 129,402 132,887 3,485

Finance Total 851,406 141,902 142,049 147

HR / Training and Development Non Pay 395,303 65,884 41,112 -24,772

Pay 761,351 126,892 130,340 3,448

HR / Training and Development Total 1,156,654 192,776 171,452 -21,324

SpRs Income -749,000 -124,834 -115,001 9,833

Non Pay 10,760 1,792 6,472 4,680

Pay 1,151,780 191,964 142,546 -49,418

SpRs Total 413,540 68,922 34,018 -34,904

Corp Total -30,276,109 -5,050,200 -4,988,660 61,540

Grand Total 0 0 -81,699 -81,699

Appendix 2

TOTAL

Investment

Budget Adj

Movement

between

Directorates

Capital

Charges

Adjustment

Other

Changes in

non core

Inc / Exp

Current

Month 2

Budget

Amended

Month 2

Budget

PHS Expenditure 62,328 -210 -130 61,988 61,988

PHS Income -60,896 0 130 -60,766 -60,766

Net PH Services 1,432 -210 0 0 0 1,222 1,222

PHD Expenditure 33,368 -396 -138 0 32,834 32,834

PHD Income -4,081 302 0 -3,779 -3,779

Net PH Development 29,287 -396 164 0 0 29,055 29,055

Corporate

Expenditure 9,305 606 138 -521 383 9,911 10,432

Corporate Income -40,024 -302 521 -383 -40,188 -40,709

Net Corporate -30,719 606 -164 0 0 -30,277 -30,277

Total Expenditure 105,001 0 0 -521 253 104,733 105,254

Total Income

-

105,001 0 0 521 -253 -104,733 -105,254

Date: 16 June 2014 Version: 1p Page: 1 of 2

Update from Public Health Wales and Welsh Government JointExecutive Team meeting


The Public Health Wales and Welsh Government bi-annual Joint Executive Teammeeting took place on 4 June 2014. The attached quality and delivery frameworkperformance report was discussed at the meeting.


To decide - Paper will outline recommendations or issues to beapproved by the Board or Committee.

To discuss - Board or Committee will be asked to discuss andscrutinise the paper and provide feedback and comments.

X

To inform - Board or Committee will be asked to note the paper forinformation only


Next Steps


X

Priorities for action

Author: Mr Mark Dickinson, Executive Director of Planning and PerformanceDate: 16 June 2014 Version: 1p

Sponsoring Executive Director: Mr Mark Dickinson, Executive Director ofPlanning and Performance

Who will present: (If appropriate) Mr Mark Dickinson, Executive Director ofPlanning and Performance


Quality and delivery frameworkperformance report

Date of meeting: 26 June 2014Committee/Groups that havereceived or considered this paper:

Public Health Wales and WelshGovernment Joint Executive Team


Public Health Wales Performance report 2013-14



N/A

Link to risk register N/A


N/A


N/A


N/A

Public Health Wales Quality and Delivery FrameworkPerformance Report – 2013/14

Date: 04/06/14 Version: 1p Page: 1 of 26

Quality and DeliveryFramework

Performance Report2013/14

Author: Public Health Wales

Date: 4 June 2014 Version: 1p(with additional material)

Distribution:

Welsh Government

Public Health Wales Intranet and Internet


The purpose of this performance report is to provide the WelshGovernment with an update on performance, using the Public HealthWales’ Quality and Delivery Framework. This framework, agreed in 2013,consists of performance indicators and updates that Public Health Walesreports against internally and externally. The Performance Report ispresented in two sections:

1. Selected indicators from the latest Welsh Health Survey (outcomes),which illustrate the scale of the challenge faced by TransformingHealth Improvement in Wales

2. Performance indicators for a range of programmes and services andour internal enablers

The Public Health Wales Quality and Delivery Framework continues to bestrengthened and additional performance indicators, including foradditional programmes and services, will be added as they are developed.

Public Health Wales

Date: 04/06/14

1 Selected all-Welsh Health Survey

Smoking

Physically active on five or more days per

0

5

10

15

20

25

30

35

%

0

5

10

15

20

25

30

35

40

%

Quality and Delivery FrameworkPerformance Report

Version: 1p Page:

-Wales indicators from the latestWelsh Health Survey

Physically active on five or more days per week

Men 16+

Women 16+

All

Men 16+

Women 16 +

All

Quality and Delivery FrameworkPerformance Report – 2013/14

Page: 2 of 26

Wales indicators from the latest

week

Men 16+

Women 16+

Men 16+

Women 16 +

All

Public Health Wales

Date: 04/06/14

Overweight or obese

Alcohol consumption above guidelines

0

10

20

30

40

50

60

70

%

-

10

20

30

40

50

60

2008 2009

%


Version: 1p Page:

Overweight or obese

Alcohol consumption above guidelines

Men 16+

Women 16+

All

2009 2010 2011 2012 2013

Men 16+

Women 16+

All


Page: 3 of 26

Men 16+

Women 16+

Men 16+

Women 16+



2 Performance indicators for existingprogrammes and services and our enablers

This section presents numerical performance indicators relating to existingPublic Health Wales programmes and services and to our internal enablers.Most indicators are reported on for the most recent year and the most recentquarter for which data is available, whilst some are only reported for the mostrecent year (where quarterly data is not relevant or available).

Because the indicators are reported on using the most recent data available,and reporting times vary from programme to programme, some indicators arereported for calendar year 2013 and some are reported for financial year2013/14. The periods being reported on are specified for each indicator.

Most indicators are reported against targets. In these cases, the performanceachieved is also colour coded using the following traffic light system:

Green Performance meets target

Amber Performance is within 10% of target value

Red Performance is more that 10% below target

Changes in performance from the previous year are also colour coded:

or Performance has improved

Performance is unchanged (and meets target)

Performance is unchanged (and below target)

or Performance has deteriorated (but meets target)

or Performance has deteriorated (and does not meet target)

Public Health Wales

Date: 04/06/14

2.1 Summary of performance indicators

Overall performance of all NHS Wales smokingcessation services (Tier 1 targets)

Smokers treated by all smoking cessation services

CO validated 4 week quit rate

Stop Smoking Wales performance

Number of smokers completing programme

Self reported 4 week quit rate


52 week success rate

Client satisfaction rate

ASSIST performance

Number of secondary schools targeted

Number of pupils trained


04/06/14 Version: 1p Page: 5 of 26

of performance indicators

Wales smokingcessation services (Tier 1 targets)

Target

for 9m to end Q3 13/14

mokers treated by all smoking cessation services >=5%

>=40%

Target

2013Change

N/A 6,639

>=50% 52.8%

>=40% 37.3%

>=15% 33.7%

>=80% 93.2%

Target

2013/14

50 - 60 51

N/A 1,500

Quality and Delivery Framework2013/14

26

Actual


1.7%

36.5%

Actual

Change from2012

Q3 13/14

1,264

50.1%

34.2%

43.5%

94.9%

Actual

2013/14Change from

2012/13

Public Health Wales

Date: 04/06/14

National Exercise Referral Scheme performance

Number of referrals

Number of consultations

Take up

16 week retention (as a % of take up)

52 week retention (as a % of 16 week retention)

Healthy Working Wales performance

Organisations completing a Corporate Health Standard mock assessment

Private sector organisations completing a mock assessment

Organisations completing a full assessment

Private sector organisations completing a full assessment

Organisations achieving a Small Workplace Health Award

Number of Workboost interventions delivered

Alcohol Brief Intervention training

People trained to deliver alcohol brief interventions

Training sessions delivered

‘Train the trainer’ sessions delivered



National Exercise Referral Scheme performance Target

2013/14Change

2012/13

21,359 29,427

21,359 27,646

16,019 16,345

45% 53%

(as a % of 16 week retention) 50% 37%

Healthy Working Wales performance Target

2013/14

Organisations completing a Corporate Health Standard mock assessment 25 17

Private sector organisations completing a mock assessment 5 8

25 20

Private sector organisations completing a full assessment 5 9

Organisations achieving a Small Workplace Health Award 100 57

600 501

Alcohol Brief Intervention training performance Target

2013/14Change from

2012/13

People trained to deliver alcohol brief interventions 100 3,439

16 223

N/A 2


26

Actual

Change from2012/13

Q4 13/14

8,411

7,626

4,659

49%

35%

Actual

2013/14Change from

2012/13

Actual

Change from2012/13

Q4 13/14

1,271

51

1

Public Health Wales

Date: 04/06/14

Screening programme performance

Breast screening - uptake

Breast screening - coverage

Bowel screening - coverage

Bowel screening - CPA accreditation status

Cervical screening - coverage

Cervical screening - CPA accreditation status

Abdominal Aortic Aneurysm screening - uptake

Newborn hearing screening – percentage offered screening

Newborn hearing screening - uptake

Healthcare associated infections

Clostridium difficile rate (per 100,000 population)

MRSA rate (per 100,000 population)

Microbiology performance

Microbiology - CPA accreditation status

EQA performance – bacteriology

EQA performance – virology



performance Target

2013/14Change from

2012/13

>=70% 70.8%

>=70% 66.1%

>=60% 48.9%

Full Full

>=80% 79.0%

Full Full

>=80% 70.6% New programme

offered screening >=99% 100.0%

>=95% 99.4%

Target

by 09/1512m to March 2014

rate (per 100,000 population) <=31 50.71

<=2.6 5.20

Target

2013/14Change from

2012/13

Full Full

>=95% 98.1% Not

>=95% 98.0%


26

Actual

Change from2012/13

Q4 13/14

71.4%

66.1%

48.9%

Full

79.0%

Full

New programme 69.7%

100.0%

99.4%

Actual

12m to March 2014Change from

2012/13

Actual

Change from2012/13

Q4 13/14

Full

Not previouslyreported

98.1%

98.6%

Public Health Wales

Date: 04/06/14

Turnaround time compliance – bacteriology

Turnaround time compliance – virology

Turnaround time compliance – urgent samples

Non processed samples – bacteriology/virology

Number of samples processed – bacteriology

Number of samples processed – virology

Number of samples processed – reference units

Vaccination rates

Uptake of all scheduled vaccinations at age 4 (2013)

Influenza vaccine uptake among children aged 2

Influenza vaccine uptake among those aged 65 and over

Influenza vaccine uptake among high risk groups

Influenza vaccine uptake among pregnant women

Influenza vaccine uptake among healthcare workers



>=95% 95.0%

>=95% 93.8%

>=95% 95.0%

TBC 1.5%/0.6%

N/A 990,559

N/A 392,715

reference units N/A 37,735

Target

2013/14

2013) >=95% 87.5%

ptake among children aged 2-16 years >=75% Not yet available

65 and over >=75% 68.3%

Influenza vaccine uptake among high risk groups >=75% 51.1%

Influenza vaccine uptake among pregnant women >=75% 70.5%

Influenza vaccine uptake among healthcare workers >=50% 40.6%


26

95.5%

94.2%

Annual

1.9%/0.5%

260,496

102,930

7,549

Actual

2013/14Change from

2012/13

87.5%

ot yet available New programme

68.3%

51.1%

70.5%

40.6%

Public Health Wales

Date: 04/06/14

Enablers

Sickness absence rate

Number of written concerns/complaints received

Written concerns/complaints responded to within target

Number of serious untoward incidents (SUIs) reported

SUI investigations completed within target timescales



Target

2013/14

<=3.25% 3.52%

Number of written concerns/complaints received N/A 92

Written concerns/complaints responded to within target 100% 92.4%

incidents (SUIs) reported N/A 7

SUI investigations completed within target timescales 100% 100%


26

Actual

2013/14Change from

2012/13

3.52%

92.4%

Public Health Wales

Date: 04/06/14

2.2 Health improvement programmes

Overall performance of all NHS Wales smoking cessation services (Tier 1 targets)

Performance Indicator

Smokers treated by all smoking cessation services




Number of smokers completing programme

Self reported 4 week quit rate


52 week success rate

Client satisfaction rate



Health improvement programmes


Target

mokers treated by all smoking cessation services >=5%

>=40%


Target

2013Change from

N/A 6,639

>=50% 52.8%

>=40% 37.3%

>=15% 33.7%

>=80% 93.2%


26


Actual


1.7%

36.5%

Actual

Change from2012

Q3 13/14

1,264

50.1%

34.2%

43.5%

94.9%



Performance trends (actual and planned)

Planned action to improve performance

Development of formal agreement withDsPH outlining set of agreed principlesaimed at improving uptake of smokingcessation services provided by SSW

Development and implementation of jointaction plans with local teams, includingtarget action at vulnerable groups andthose with increased prevalence

Monthly performance meetings with localteams to monitor real time local data

Review and undertake options appraisalon model for service delivery andimplement any recommended changes

Undertake rolling programme of briefinterventions training for health boards

Delivery of locally tailored socialmarketing project across Wales

Delivery of Stoptober campaign

Development of plans for online services,including apps etc

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

13/14Q1

13/14Q2

13/14Q3

13/14Q4

14/15Q1

14/15Q2

14/15Q3

14/15Q4

Number of smokers treated byStop Smoking Wales

Target- Number of smokerstreated by Stop Smoking Walesannually

Cumulative number of smokerstreated by Stop Smoking Wales

Public Health Wales

Date: 04/06/14

ASSIST performance


Number of secondary schools targeted

Number of pupils trained

National Exercise Referral Scheme performance


Number of referrals

Number of consultations

Take up

16 week retention (as a % of take up)

52 week retention (as a % of 16 week retention)



Target

2013/14

50 - 60 51

N/A 1,500

Referral Scheme performance

Target

2013/14Change from

2012/13

21,359 29,427

21,359 27,646

16,019 16,345

45% 53%

(as a % of 16 week retention) 50% 37%


26

Actual

2013/14Change from

2012/13

Actual

Change from2012/13

Q4 13/14

8,411

7,626

4,659

49%

35%

Public Health Wales

Date: 04/06/14

Healthy Working Wales performance


Organisations completing a Corporate Health Standard mock

Private sector organisations completing a mock assessment

Organisations completing a full assessment

Private sector organisations completing a full assessment

Organisations achieving a Small Workplace Health Award

Number of Workboost interventions delivered

Alcohol Brief Intervention training


People trained to deliver alcohol brief interventions

Training sessions delivered

‘Train the trainer’ sessions delivered



performance

Target

2013/14

Organisations completing a Corporate Health Standard mock assessment 25 17

Private sector organisations completing a mock assessment 5 8

25 20

Private sector organisations completing a full assessment 5 9

Organisations achieving a Small Workplace Health Award 100 57

600 501

Alcohol Brief Intervention training performance

Target

2013/14Change from

2012/13

People trained to deliver alcohol brief interventions 100 3,439

16 223

N/A 2


26

Actual

2013/14Change from

2012/13

Actual

Change from2012/13

Q4 13/14

1,271

51

1

Public Health Wales

Date: 04/06/14

2.3 Screening programmes

Screening programme performance


Breast screening - uptake

Breast screening - coverage

Bowel screening - coverage

Bowel screening - CPA accreditation status

Cervical screening - coverage

Cervical screening - CPA accreditation status

Abdominal Aortic Aneurysm screening - uptake

Newborn hearing screening – percentage offered screening

Newborn hearing screening - uptake



performance

Target

2013/14Change from

2012/13

>=70% 70.8%

>=70% 66.1%

>=60% 48.9%

Full Full

>=80% 79.0%

Full Full

>=80% 70.6% New programme

percentage offered screening >=99% 100.0%

>=95% 99.4%


26

Actual

Change from2012/13

Q4 13/14

71.4%

66.1%

48.9%

Full

79.0%

Full

New programme 69.7%

100.0%

99.4%



Performance trends (actual and planned)

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

12/13Q1

12/13Q2

12/13Q3

12/13Q4

13/14Q1

13/14Q2

13/14Q3

13/14Q4

14/15Q1

14/15Q2

14/15Q3

14/15Q4

Breast screening uptake

Target Breast screening uptake

Bowel screening coverage

Target bowel screening coverage

Cervical screening coverage

Target cervical screening coverage

Newborn hearing screening uptake

Target newborn hearing screeninguptake




Action across all programmes to improve uptake and reduce inequalities

Launch ‘key messages’ for all programmes to be disseminated to the public by trusted advisers e.g. primary care, pharmacies, LocalPublic Health Teams, Communities First and secondary care

Ensure screening is incorporated into health board cancer action plans and Local Public Health Team work plans

Deliver Screening for Life month activities

Work with gypsy traveller groups to engage with communities and look at information needs

Develop ‘easy to read’ resources for participants with learning disabilities

Analyse latest annual uptake figures at health board, local authority, GP Practice and GP cluster level and discuss with partnersactions for improvement

Implement programme performance recovery action plans and undertake the following specific actions:

Breast screening

o Increase utilisation of static breast screening units to support improvements in screening round length

o Alter invitation schedule as mobile units come in to standard, to improve equity of round length

o Reduce numbers of cancelled clinics by work with health boards to improve surgical attendance at clinics

Bowel screening

o Work with health boards that have longest waits to improve provision of service to commissioned levels (bowel screeningcolonoscopy wait)

o Consider alternative provision where health boards are unable to provide service

o Support the implementation of the Welsh Government Endoscopy Action Plan, to improve waiting times for colonoscopy

o Trial introductory letters and evaluate impact on uptake and inequalities

o Distribute bowel screening key messages through pharmacies

Cervical screening

o Work with health boards (including primary care) and 1,000 Lives+ to map processes and identify areas where timeliness canbe improved

o Implement 28 day wait for results for cytology samples and undertake local intervention in health boards where performanceis outside standard for colposcopy, cytology or histology

Public Health Wales

Date: 04/06/14

2.4 Healthcare associated infections

Healthcare associated infection


Clostridium difficile rate (per 100,000 population)

MRSA rate (per 100,000 population)

Performance trends

89.24

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Monthly rolling 12 month rates of Clostridium difficile (aged 2and over) diagnosed in Wales per 100,000 population, for the

period Apr 11 to Mar 14





Target

by 09/15 12m to March2014

rate (per 100,000 population) <=31 50.71

<=2.6 5.20

50.71

Monthly rolling 12 month rates of Clostridium difficile (aged 2and over) diagnosed in Wales per 100,000 population, for the

6.92

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Monthly rolling 12 month rates of MRSA bacteraemiadiagnosed in Wales per 100,000 population, for the period

Apr 11 to Mar 14


26

Actual

12m to March2014

Change from2012/13

50.71

5.20

5.20

Monthly rolling 12 month rates of MRSA bacteraemiadiagnosed in Wales per 100,000 population, for the period




Work with health boards to review HCAIaction plans and develop joint work plansto address challenges and barriers

Continued provision of advice andsupport through polices, guidelines andon an ad hoc basis

Provision of data reports and ad hocanalysis to support reductions in HCAI

Revise monthly reports/dashboards tomonitor progress against tier 1 target

Map infection rates alongsideantimicrobial usage for primary andsecondary care

Regularly review routine surveillance dataand notify organisations of any unusualactivity

Provision of educational and trainingtools, including: e-learning packages,forums, leaflets and specialist courses

Hold two HCAI learning events aimed atsharing experience and best practice

Provision of material, such as patientstories, to support local campaigns

Conduct stakeholder engagement eventand agree contributions in relation tocommunity based HCAI prevention andcontrol

Public Health Wales

Date: 04/06/14

2.5 Microbiology

Laboratory Performance Indicators


Microbiology - CPA accreditation status

EQA performance – bacteriology

EQA performance – virology

Turnaround time compliance – bacteriology

Turnaround time compliance – virology

Turnaround time compliance – urgent samples

Non processed samples – bacteriology/virology

Number of samples processed – bacteriology

Number of samples processed – virology

Number of samples processed – reference units



Laboratory Performance Indicators

Target

2013/14Change from

2012/13

Full Full

>=95% 98.1%

Not previously

>=95% 98.0%

>=95% 95.0%

>=95% 93.8%

>=95% 95.0%

TBC 1.5%/0.6%

N/A 990,559

N/A 392,715

reference units N/A 37,735


26

Actual

Change from2012/13

Q4 13/14

Full

Not previouslyreported

98.1%

98.6%

95.5%

94.2%

Reportedannually

1.9%/0.5%

260,496

102,930

7,549

Public Health Wales

Date: 04/06/14

2.6 Teenage pregnancy

Under 18 conceptions

Area

Wales

Abertawe Bro Morgannwg

Aneurin Bevan

Betsi Cadwaladr

Cardiff and Vale

Cwm Taf

Hywel Dda

Powys

Performance trend


Version: 1p Page:

Teenage pregnancy

Under 18 conceptions

2011

Number Rate per100,000

Number

1,885 34.2 1677

292 32.8 279

337 30.1 319

441 36.2 404

295 36.0 267

232 43.2 186

235 34.6 176

53 21.3 46


Page: 20 of 26

2012

Number Rate per100,000

30.8

31.5

28.7

33.5

33.0

34.7

26.9

19.1

Public Health Wales

Date: 04/06/14

2.7 Vaccination and immunisation

Childhood vaccination

Uptake of all scheduled childhood vaccinations at age 4

Area

Wales

Abertawe Bro Morgannwg

Aneurin Bevan

Betsi Cadwaladr

Cardiff and Vale

Cwm Taf

Hywel Dda

Powys

Trend of childhood vaccination uptake (1997


Version: 1p Page:

Vaccination and immunisation

vaccination uptake

Uptake of all scheduled childhood vaccinations at age 4

Target Actual

2013 Change from

>=95%

87.5%

86.7%

86.1%

90.5%

84.3%

89.9%

87.2%

90.2%

vaccination uptake (1997 – 2013)


Page: 21 of 26

Change from2012/13

Public Health Wales

Date: 04/06/14

Uptake of childhood vaccinations by type (as at end 2013)

(Summary of uptake rates for selected immunisations in resident children reaching1st, 2nd, 5th and 16th birthday between 01/10/13 and 31/12/13 and resident on31/12/13)

Planned action to address performance

Support improved uptake of vaccine inpre-school children

Support health boards in the iuniversal flu vaccine for children 2into the routine schedule –secondary schools


Version: 1p Page:

Uptake of childhood vaccinations by type (as at end 2013)

Summary of uptake rates for selected immunisations in resident children reaching1st, 2nd, 5th and 16th birthday between 01/10/13 and 31/12/13 and resident on

Planned action to address performance

Support improved uptake of vaccine in

Support health boards in the inclusion offor children 2-16y

phase 2

Rollout online training resource for allstaff groups responsible for theoperational delivery of immunisationprogrammes in Wales


Page: 22 of 26

Summary of uptake rates for selected immunisations in resident children reaching their1st, 2nd, 5th and 16th birthday between 01/10/13 and 31/12/13 and resident on

out online training resource for allstaff groups responsible for theoperational delivery of immunisation

Public Health Wales

Date: 04/06/14

Influenza vaccination uptake

Health Board/Trust

Target 65y+

Actual2013/14

Wales

>=75%

68.3%

Abertawe BroMorgannwg

65.5%

Aneurin Bevan 70.4%

Betsi Cadwaladr 70.7%

Cardiff and Vale 69.7%

Cwm Taf 66.4%

Hywel Dda 65.7%

Powys 67.1%

Public Health Wales

Velindre

Ambulance Service



uptake

65y+ High risk groups Pregnant women

Changefrom

12/13

Actual2013/14

Changefrom

12/13

Actual2013/14

Changefrom

12/13

Target

51.1% 70.5%

>=50%

45.3% 66.7%

55.3% 65.0%

53.5% 79.6%

52.4% 79.0%

51.7% 68.2%

47.5% 47.3%

49.7% 100.0%

N/A


26

NHS Staff

Target Actual2013/14

Changefrom

12/13

>=50%

40.6%

41.1%

39.4%

41.0%

41.0%

41.1%

41.2%

42.4%

33.9%

No data52.2%

30.2%



Trend of flu vaccination uptake (2007/08 – 2013/14)

Percentage uptake of influenza vaccination in pregnant women by Health Board2013 and 2014


Provision of surveillance, epidemiologicalanalysis and interpretation of vaccinationuptake data by GP practice, cluster, localauthority, health board and all Wales.This will support NHS action, challengeby Welsh Government and public scrutiny

Support health boards and primary carein identifying low uptake and monitor theeffectiveness of interventions to improveuptake and reduce inequalities

Work with partner agencies (WelshGovernment, health boards, third sector)to support meeting targets

Promote uptake of influenza vaccinationto the public and NHS staff via targetedcampaigns

Continue working with WelshGovernment to inform on policy andguidance

0%

10%

20%

30%

40%

50%

60%

70%

80%

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

65y+

High risk groups

Pregnant women

Target

NHS staff

Target (NHS staff)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ABMU AneurinBevan

BetsiCadwaladr

Cardiff &Vale

Cwm Taf Hywel Dda PowysTeaching

All Wales

2013

2014

Public Health Wales

Date: 04/06/14

2.8 Healthy workforce

Sickness absence


Sickness absence rate

Trend of sickness absence during 2013/14

2.9 Concerns and complaints

Written concerns and complaints


Number of writtenconcerns/complaints received

Written concerns/complaintsresponded to within targettimescales


Version: 1p Page:

workforce

Sickness absence

Target Actual

2013/14

<=3.25% 3.52%

rend of sickness absence during 2013/14

Concerns and complaints

Written concerns and complaints

Target Actual

2013/14

N/A 92

100% 92.4%


Page: 25 of 26

Actual

Change from2012/13

Actual

Change from2012/13

Public Health Wales

Date: 04/06/14

2.10 Incidents

Serious untoward incidents (SUIs)


Number of serious untowardincidents (SUIs) reported

SUI investigations completedwithin target timescales


Version: 1p Page:

Serious untoward incidents (SUIs)

Target Actual

2013/14

N/A 7

100% 100%


Page: 26 of 26

Actual

Change from2012/13


Governance Report Purpose of Document: The purpose of this paper is to provide the Board with a report on Public Health

Wales’ key governance issues.

Board/Committee to-

To decide- Paper will outline recommendations or issues to be

approved by the Board or Committee.

To discuss- Board or Committee will be asked to discuss and

scrutinise the paper and provide feedback and comments.

√

To inform- Board or Committee will be asked to note the paper for information only


No further relevant information


√

Priorities for action Put in place a comprehensive governance

framework that addresses the issues raised in the Francis report

Develop and equip staff to work

effectively and in new ways by developing leadership and management skills,

including in support of our system leadership role and making more effective

use of accommodation

Review and update our business continuity arrangements

Author: Mr Keith Cox, Board Secretary


Sponsoring Executive Director: Mr Keith Cox, Board Secretary

Who will present: (If appropriate) Mr Keith Cox, Board Secretary

Documents attached: Governance Report



received or considered this paper:

N/A

PHW 32 11


Public Health Wales Governance Report


Link to standards

for health services

Standard 1 – Governance and Accountability

framework

Link to risk

register

Risk ID 102


An equality impact assessment is not required as the paper is to inform the Board of key governance

issues.

Financial

implications

No financial implications


No









Governance

Report Author: Mr Keith Cox, Board Secretary



The purpose of this paper is to provide the Board with a report on Public

Health Wales’ key governance issues, which includes Board, Committees, and Audit Reports.



Public Health Wales Programme of Board

Business

The latest version of the Public Health Wales Programme of Board

Business is reproduced at Paper 32.12. The document sets out details of planned Board business which has been scheduled for both formal and

informal Board meetings over the next 12-15 months. The programme is reviewed and updated continuously.

List of External Consultations

A list of external consultations for July is attached at Appendix A.

Board Development

Interviews took place between Hilary Merrett from the Good Governance

Institute (GGI) and key Board and Executive Team members as part of the next phase of the Rapid Review being carried out by GGI as part of the

Board Development programme on 7, 8, 9 and 19 May 2014.

Ms Merrett has also carried out a review of key governance documents.

Feedback from the interviews and the document review will be discussed

at a meeting between John Bullivant and Andrew Corbett-Nolan from GGI and Tracey Cooper and Professor Sir Mansel Aylward on 19 June 2014.

Governance and Accountability Module

The Governance and Accountability Module has been completed following comments from Board members. The final version is presented under

Paper 32.07 for approval by the Board.

Risk Register

The Audit Committee expressed some concerns that the Corporate Risk

Register was not fully completed, particularly relating to actions. The Committee asked for the register to be reviewed.

The Executive Team has now reviewed their individual risks and updated the register accordingly. An updated version of the Risk Register is

reproduced at Paper 32.13.

Our Space - Accommodation Programme

Stage one of the Our Space programme has now been completed. A Next Steps paper, detailing the work done to date and what needs to be done

in Stage 2 has been submitted and approved by the Executive Team.



Information is being prepared for communication to managers, trade

unions and staff.

Francis Review

The assessment of the impact of the Francis review on Public Health Wales

is complementary to the work that is also now being undertaken on the Trusted to Care report. As a consequence, an action plan which

consolidates the outcomes from both pieces of work into one plan is now being prepared. This will be presented to the Board in July.

Next Board Meetings Dates for Board meetings throughout 2014 are attached at Appendix B.

The next Board meeting will be partly formal and partly informal and will

be held in the ground floor meeting room, 14 Cathedral Road on 29 July 2014.

Board Committees Meetings

The next Committee meetings are as follows:

Audit Committee: 11 September 2014

Information Governance Committee: 11 September 2014

Quality and Safety Committee: 24 July 2014



Appendix A – List of External Consultations

Title Category Organisation Comments to

Comments from

Public Health

Wales staff to be

received by:

Consultation closing date

The Active Travel

(Wales) Act 2013 – Design Guidance

Physical Activity

Welsh

Government

Malcolm

Ward

03 July

2014

04 August 2014

Guidance for the Delivery of the

Active Travel (Wales) Act 2013

Physical Activity

Welsh Government

Malcolm Ward

03 July 2014

04 August 2014

Active Travel

Action Plan

Physical

Activity

Welsh

Government

Malcolm

Ward

03 July

2014

04 August 2014


Appendix B - Public Health Wales Board Meeting Dates 2014

Date Formal/Informal Venue

30 January 2014 Formal Cwm Taf Health Board Headquarters,

Ynysmeurig House, Unit 3, Navigation

Park, Abercynon

05 March 2014 Informal First floor meeting

room, Unit 1, Charnwood Court,

Nantgarw

27 March 2014 Formal Council Chamber, Temple of Peace

29 April 2014 Formal Council Chamber,

Temple of Peace

22 May 2014 Informal Boardroom, 14

Cathedral Road

26 June 2014 Formal Room 1DM2,

Pembrokeshire County Council

County Hall, Havorfordwest

29 July 2014 Informal Boardroom, 14

Cathedral Road

25 September 2014 + AGM (TBC)

Formal Council Chamber, Temple of Peace

28 October 2014 Informal Boardroom, 14 Cathedral Road

27 November 2014 Formal Aneurin Bevan Health Board

Headquarters, St Cadoc’s Hospital

18 December 2014 Informal Boardroom, 14 Cathedral Road


Plan of Board BusinessPurpose of Document:The Public Health Wales Plan of Board Business sets out details of planned Boardbusiness which has been scheduled for both formal and informal Board meetings overthe next 12-15 months. The programme is reviewed and updated continuously.

Board/Committee to-To decide- Paper will outline recommendations or issues to beapproved by the Board or Committee.

To discuss- Board or Committee will be asked to discuss andscrutinise the paper and provide feedback and comments.

√



No further relevant information


√

Priorities for action Review and update our businesscontinuity arrangements

Author: Mr Keith Cox, Board SecretaryDate: 17 June 2014 Version: 1

Sponsoring Executive Director: Mr Keith Cox, Board Secretary

Who will present: (If appropriate) Mr Keith Cox, Board SecretaryDocuments attached: Plan of Board Business



N/A

PHW 32 12

Public Health Wales Plan of Board Business Cover Sheet



Standard 1 – Governance and Accountability framework

Link to risk register Risk ID 102


An equality impact assessment is not required as the paper isan information tool for the Board.


No financial implications


No

De

cisi

on

Scru

tin

y an

d

Dis

cuss

ion

Info

rmat

ion

January Performance? X Mark Dickinson Mark Dickinson

(Formal) Budget Strategy X Huw George Huw George

Wales Audit Office structured

assessment

X Wales Audit Office Keith Cox / Tami Rolls

Local public health team - Cwm Taf X Nicola John Nicola John

Management learning and

development programme

X Barbara Busby Ruth Davies

Wales Audit Office report -

microbiology (private session)

X Quentin Sandifer Quentin Sandifer

Role of medical examiners and death

certification (private session)


Safeguarding Children Service X Aideen Naughton Quentin Sandifer

February Improving Quality Together - Board

development session

X

(Informal) Board themes and walkabouts X Keith Cox Keith Cox

Shared services X Margaret Foster Sir Mansel Aylward

Communities First X Peter Bradley

Public Health Development capacity to

deliver

X Mark Bellis / Pat Riordan Peter Bradley

Cervical Screening modernisation X Rose Fox Quentin Sandifer Improve cervical screening

through the use of HPV testingBowel Screening complex polypectomy X

Genomics X Quentin Sandifer

Medical Examiner Responsibility (part

formal)


March Integrated Medium Term Plan X Mark Dickinson Mark Dickinson

(Formal) Budget strategy X Huw George Huw George

Timetable for year end governance

documents

X Keith Cox Keith Cox

Welsh Langauge Commisioner's

response to annual monitoring report

X Chris Lines Chris Lines

Recruitment and retention protocol X Ruth Davies Ruth Davies

Employment break policy X Ruth Davies Ruth Davies

Presenter /Author Director Priority for action

Plan of Board Business 2014

Month Items

For

Additional Information

Corporate/Enablers

Protect the public from infectious and environmental hazards

Improve the quality, equity and effectiveness of healthcare services

Improve health and wellbeing and to reduce health in equalities

Healthcare Standard/Risk

Diabetic Retinopathy Screening X Rose Fox Quentin Sandifer Make a proposal for

organisational responsibility for

the diabetic eye screening

programmeApril Year end governance documents X Keith Cox Keith Cox

(Formal) Social Media Strategy review X Chris Lines Chris Lines

Home working policy X Ruth Davies Ruth Davies

Domestic abuse policy X Rhiannon Beaumont-

Wood

Rhiannon Beaumont-

WoodSO and SFI X Keith Cox Keith Cox

Statutory and Mandatory training

update

X Huw George Huw George

Nursing and Midwifery Strategy X Rhiannon Beaumont-

Wood

Rhiannon Beaumont-

WoodTrasfer DPA to Health Boards x Hugh Bennett Peter BradleyPublic Health Bill White Paper x Mark Bellis Peter BradleyMedical revalidation / RO annual report X Quentin Sandifer Quentin Sandifer

Microbiology modernisation X Quentin Sandifer Quentin Sandifer

May Bevan Commission X Mansel Aylward Mansel Aylward

(Informal) Trusted to Care: Andrews report X Rhiannon Beaumont-

Wood

Rhiannon Beaumont-

WoodIMTP response from WG X Mark Dickinson Mark Dickinson

Public Health Wales Observatory

meeting with Minister for Health and

Social Services

X Peter Bradley Peter Bradley

Smoking cessation X Peter Bradley Peter Bradley

Transforming Health Improvement X Peter Bradley Peter Bradley

WEDINOS X Quentin Sandifer Quentin Sandifer

NATO update X Quentin Sandifer Quentin Sandifer

June Strategic Equality plan X Keith Cox Keith Cox

(Formal) Welsh Language monitoring report X Chris Lines Chris Lines

Social enterprise funding X Tami Rolls Tami Rolls

Francis Report update X Rhiannon Beaumont-

Wood

Rhiannon Beaumont-

WoodStatutory and Mandatory training

policy

X Ruth Davies Ruth Davies

Research and development action plan X Mark Bellis Peter Bradley

Infection Control annual report X Rhiannon Beaumont-

Wood

Karen Jones

Safeguarding annual report X Dr Quentin Sandifer Kate MacDonald

Epidemiolgy surveillance X Quentin Sandifer

Liver health plan - consultation x Marion Lyons Quentin Sandifer

July Screening programmes X Rose Fox Quentin Sandifer

(Informal) Update on values and the 'deal' X Ruth Davies Ruth Davies

International work X Peter Bradley To include links with Lesotho and

Betsi Cadwaladr University Health

BoardSudden infant deats X Judith Greenacre Peter Bradley

Child Measurement Programme x Peter Bradley

Working with academia X Mark Bellis Peter Bradley Improve intelligence and

evidence to support action by

strengthening collaboration with

academiaMental Health X Peter Bradley

1000 Lives improvement service and

prudent healthcare

X Alan Willson Peter Bradley

August

No Meeting

September Committee annual reports X Keith Cox Keith Cox

(AGM and

Formal)

Performance? X Mark Dickinson Mark Dickinson

PHW Annual report X Chris Lines Chris Lines

Approval of priorities for action

WCISU update X Judith Greenacre Peter Bradley

Capability- appriasals and performance

management

X Ruth Davies Ruth Davies

CARIS - general overview X Judith Greenacre Peter Bradley

Integrated public health network X Mark Bellis Peter Bradley

Responsible Officer revalidation update X Quentin Sandifer Quentin Sandifer

Public Health training X Brendan Mason Quentin Sandifer

Cervical Screening modernisation and HPV

testingX Rose Fox Rose Fox

Complex Polypectomy X Rose Fox Quentin Sandifer

Service user engagement action plan X TBC Rhiannon Beaumont-

WoodHealth Protection managed outbreaks-

Board brief

X Marion Lyons Quentin Sandifer

Flu Vaccine update report X Quentin Sandifer

Vaccine developments progress report X Richard Roberts Quentin Sandifer

Healthcare associated infections and

antimicrobial resistance

X Marion Lyons Quentin Sandifer

Vaccine developments progress report X Richard Roberts Quentin Sandifer

Liver implementation plan X Marion Lyons Quentin Sandifer

Environmental Health Protection report X Huw Brunt Quentin Sandifer

October Health, Wellbeing and Resilience X Ruth Davies Ruth Davies How the corporate standard

will be achieved, staff survey

work update, team and

individual resilience

(Informal) Medical Survey results X Ruth Davies Ruth Davies

November Declaration of interest X Keith Cox Keith Cox

(Formal) Gifts and hospitality X Keith Cox Keith Cox

Register of Seal X Keith Cox Keith Cox

Attraction and Selection Policy X Ruth Davies Ruth Davies

HCAIs X Marion Lyons Quentin Sandifer

Screening Annual Report X Rose Fox Quentin Sandifer

December Review of internal communications X Chris Lines Chris Lines

(Informal)

Trusted to care: letter to Ministerfor Health and Social Services


On 13 May 2014 the Minister for Health and Social Services published‘Trusted to care’, a report by Professor June Andrews and Mark Butler. Thereport followed the review of the quality of care for older people at thePrincess of Wales and Neath Port Talbot hospitals. In the letter the Ministerrequested that the report be discussed by the Board and gave each Board afour week period to absorb the findings of the report and satisfy themselvesthat departures from basic professional standards highlighted in the reportare not present in their organisation.

The Board discussed the report at their informal Board meeting on 22 May2014. The Chief Executive has since written the attached letter to theMinister providing information on key pieces of work which are well underwaywhich directly correlate to improvements which the Trusted to Care reportalludes to.

An assurance template has been completed which will be shared with theBoard at regular intervals.


To decide- Paper will outline recommendations or issues to beapproved by the Board or Committee.

To discuss- Board or Committee will be asked to discuss and scrutinisethe paper and provide feedback and comments.

x



Next StepsThe Board are asked to scrutinise and discuss the letter.


x

Priorities for action Identify and act on priorities for serviceimprovement, in collaboration with NHS WalesImprove healthcare quality by providingprofessional leadership


Public Health Wales Trusted to Care: response to Minister forHealth and Social Services


Author: Dr Tracey Cooper

Date: 10 June 2014 Version: 1Sponsoring Executive Director: Dr Tracey Cooper, Chief Executive

Who will present: (If appropriate) Dr Tracey Cooper, Chief Executive


Letter to Minister for Health and SocialServices



N/A

Link to standards forhealth services

Standard 7: Safe and clinically effective careStandard 10: Dignity and respectStandard 11: Safeguarding children andsafeguarding vulnerable adultsStandard 15: Medicines managementStandard 14: nutritionStandard 23: Dealing with concerns and managingincidents

Link to risk register N/A


N/A

Financial implications N/A


N/A


Audit Committee Annual report 2013/14

Purpose of Document: The Audit Committee has prepared annual report of its business to present to the

Public Health Wales Board. The report sets out how the Committee has met its terms of reference and what activity has taken place during the year.

Board / Committee to- (Please indicate)

To decide- Paper will outline recommendations or issues to be recommended to the Board for approval.

To discuss- Board / Committee will be asked to discuss and scrutinise the

paper and provide feedback and comments.

√

To inform- Board / Committee will be asked to note the paper for information

only


Next Steps The Board are asked to receive the annual report from the Audit Committee.


√

Priorities for action Put in place a comprehensive governance

framework



Sponsoring Executive Director: Keith Cox, Board Secretary

Who will present: (If appropriate) Keith Cox, Board Secretary


Audit Committee annual report 2013/14


Committee/Groups that have received or considered this paper:

N/A

Paper 32 15


Public Health Wales Audit Committee Annual Report


Link to standards

for health services


Link to risk

register

N/A

Equality impact

assessment

N/A

Financial

implications

N/A


N/A










Audit Committee

Annual report 2013/14




This Report summarises the key areas of business activity undertaken by

the Audit Committee over the past year and highlights some of the key issues which the Committee intend to give further consideration to over

the next 12 months.



Contents Foreword ..................................................................................... 5

1 Introduction ........................................................................... 6

2 Role and Responsibilities .......................................................... 6

3 Committee structure ................................................................ 7

3.1 Membership of Committee ................................................... 7

3.2 Others in attendance ........................................................... 7

3.3 Meeting frequency .............................................................. 8

4 Assurance .............................................................................. 8

4.1 Committee self assessment.................................................. 9

4.2 Risk .................................................................................. 9

4.3 Public sector payments policy ............................................... 9

5 Audit Committee Activity 2013/14 ............................................. 9

5.1 External audit .................................................................. 10

5.2 Internal audit ................................................................... 11

5.3 Financial reporting ............................................................ 13

5.4 Counter-fraud .................................................................. 13

5.5 Other Committee work ...................................................... 13

6 Relationship with other Committees ......................................... 14

7 Actions for next year 2014/15 ................................................. 14

8 Conclusions and Way forward ................................................. 14



Foreword

I am pleased to provide the foreword for the fourth Public Health Wales

Audit Committee annual report.

The report summarises the key areas of business activity undertaken by the Audit Committee over the past year.

Throughout the year the Committee has continued to provide

reassurance to the Board on the governance and systems of assurance of Public Health Wales, with a particular focus on the financial systems

and on management arrangements where change may impact on service provision (eg microbiology and screening).

The Committee has an important role in taking timely action when there are indications that all is not well. Examples during the year

include:

Taking early action and requesting reassurance in relation to the Public Sector Payment Policy and reporting the issue to the

Board. Commissioning the internal audit review of asbestos

management, prompted by the significant number of building locations and the need to ensure risks were being properly

addressed. Actions have been identified for improvement and will continue to be monitored by the Committee.

Audit Committees must never become complacent and satisfied with their own performance and for that reason during the year we have

undertaken a 'self assessment' and will be taking further actions in the

coming year relating to its outcome.

I would like to extend my thanks to all members of Committee and those who contribute to meetings on behalf of Public Health Wales,

internal audit, external audit and counter-fraud.

I am grateful to the support given to me by the Board Secretary, Corporate Governance Manager and Business Support Manager for

ensuring the Committee remains focused on matters relating to governance and assurance. I am particularly grateful to Ms Tamira

Rolls who took on the role of Acting Director of Finance for the second half of the year.

Mr Terence Rose

Audit Committee Chair



1 Introduction

This Report summarises the key areas of business activity undertaken by the Audit Committee over the past year and highlights some of the

key issues which the Committee intend to give further consideration to over the next 12 months.

The Audit Committee’s annual ‘business cycle’ ends on 30 June

following the closure and audit of the Trust’s annual accounts and reflects the Committee’s key role in the development and monitoring of

the Trust’s Governance and Assurance framework, the production of the Trust’s Annual Governance Statement and the relevant Financial

Statements.

2 Role and Responsibilities

The primary purpose of the Audit Committee is to provide advice and assurance to the Trust Board on whether effective arrangements are in

place - through the design and operation of the Trust’s assurance framework - to support the Board in its decision taking and in

discharging its accountability for achieving the Trust’s objectives, in accordance with standards of good governance determined for NHS

Wales.

Where appropriate, the Committee will advise the Board and the Accountable Officer on where, and how, its assurance framework may

be strengthened and developed further.

The core functions of the Audit Committee are as follows;

Consider the effectiveness of risk management arrangements,

the control environment, and the related anti-fraud and anti-corruption arrangements;

Seek assurances that action is being taken on risk related issues

identified by auditors, by regulatory bodies and by the Trust itself;

Be satisfied that the assurance statements properly reflect the

risk environment and any action required to improve it;

Approve the Internal Audit strategy, plan and monitor performance; review Internal Audit reports and the main issues

arising; seek assurance that action has been taken where

necessary; receive and consider the Annual Report from Internal Audit;



Review the reports of External Audit and other Regularity Bodies

and the main issues arising; seek assurance that action has been taken where necessary; receive and consider the Annual External

Audit Report;

Approve the Local Counter-fraud Services (LCS) strategy, plan and monitor performance; review LCS reports and the main

issues arising; seek assurance that action has been taken where necessary; receive and consider the Annual Report from LCS;

Review the financial statements and, acting under delegated

powers, approve the adoption of the accounts;

Consider the results of audit and assurance work specific to the

Trust and the implications of the findings of wider audit and assurance activity relevant to the Trust’s operations to secure the

ongoing development and improvement of the Organisation’s governance arrangements; and

Ensure an effective relationship with the Quality and Safety

Committee and any other Committees or sub-Committees of the Board so that it can understand the system of assurance for the

Board as a whole.

3 Committee structure

A key element of the Committee is that the membership comprises Non

Executive Directors only, this provides a basis for it to operate independently of any decision making process and to apply an objective

approach to the conduct of its business. Executive Directors and other

members of staff are invited to attend meetings to provide assurances and explanations to the Committee on specific issues.

3.1 Membership of Committee

The membership of the Committee during 2013/14 included:

Mr Terence Rose Chair and independent Non Executive Director

Mr John Spence independent Non Executive Director

Dr Carl Clowes third sector Non Executive Director

3.2 Others in attendance During 2013/14 the meetings were also regularly attended by the

following:



Mr Bob Hudson Chief Executive and Accountable Officer (until 30

November 2013)

Mr Huw George Director of Finance (until 30 November 2013)

Interim Chief Executive (from 1 December

2013)

Ms Tamira Rolls Assistant Director of Finance (until 30 November

2013) Interim Director of Finance (from 1 December

2013)

Mr Keith Cox Board Secretary

Mr James Johns Internal audit, NHS Wales Shared Services

Partnership

Ms Jayne Gibbon Internal audit, NHS Wales Shared Services

Partnership

Mr Matthew Coe Wales Audit Office

Mr Jeremy Saunders Wales Audit Office

Ms Gabby Smith Wales Audit Office

Mr Craig Greenstock Local Counter Fraud Service, Cardiff and Vale University Health Board

3.3 Meeting frequency

The terms of reference for the Committee require meetings to be held no less than quarterly and otherwise as the Chair of the Committee

deems necessary – consistent with the Trust’s annual plan of Board Business. During 2013/14 the Committee met five times and was

quorate on each occasion.

4 Assurance The work of the Audit Committee, through scrutiny of external audit,

internal audit, counter-fraud and other pieces of work, enable the Committee to provide reliable assurances to the Board and the

Accountable Officer. The Committee has reviewed the system of assurance and concluded that it is fit for purpose. There are no areas

of significant duplication or omissions in the systems of governance in the organisation that have come to the attention of the Committee or

which have not been adequately resolved.

The Committee has, on occasion, requested further information on particular items to allow further scrutiny of the issues and to enable

them to provide robust assurance to the Board and Accountable Officer.

Examples of this include:



4.1 Committee self assessment During the year the Committee completed a self assessment exercise in

order to assess the effectiveness of the Committee. The Committee used the Audit Committee Handbook as a starting point to establish

how far they complying with the requirements set out in the Handbook

and identified areas for improvement for the committee. The self assessment concluded that the Committee continued to operate

effectively but also identified a need for further development sessions and a renewed focus on roles and responsibilities for the Committee.

Actions arising from the self assessment included reviewing the terms of reference of the Committee and producing a plan of Committee

business.

4.2 Risk

During the year it was agreed that the Committee would received the corporate risk register at each Committee meeting. The Committee

requested further assurance on the system of risk management. In doing so the Committee concluded that the system was adequate in

identifying risks and allowing the Board to understand the appropriate management of those risks. However, there were some areas where

the Committee felt the system could be improved. They requested that further information be provided on what controls and actions are in

place to mitigate the risk. They also recommended that the Board should consider how corporate risks link to divisional risks. In order to

strengthen the system of risk management, the Board has commissioned a rapid review of the system by the Good Governance

Institute. The results will be provided in June 2014.

4.3 Public sector payments policy

The Committee noted that the organisation was likely to miss the target for public sector payment compliance and requested further

assurances on what measures were being taken to improve the situation. The Committee received assurance that the issue had

occurred early in the financial year and was due to a change over in

systems. The organisation had achieved the target for the majority of the year, however the issues earlier in the year would mean that the

target across the year would not be met. The Committee ensured that this was noted in the Annual Governance Statement and that it would

be confirmed in the annual accounts for 2013/14.

5 Audit Committee Activity 2013/14



The Audit Committee fulfilled its work plan for 2013/14 covering a wide

range of activity. This work can be summarised under the following headings:

External audit;

Internal audit; Financial reporting;

Counter-fraud; and Other Committee work.

5.1 External audit External audit services are provided to Public Health Wales by the

Wales Audit Office. The Committee received and agreed the Wales Audit Office annual plan for 2013/14 which set out specific areas to be

covered in relation to both the audit of financial systems and performance audit assignments. The plan of work was developed in

consultation with Executive Directors to ensure it was aligned to the organisational priorities and financial and operational risks facing the

organisation. The Committee received progress reports from WAO at each meeting in relation to this work. These reports also give details of

reviews undertaken at a national level.

The Wales Audit Office final accounts memorandum was received by

the Committee in June 2014 and summarised the findings from the work carried out during 2012/13 as follows:

I have issued an unqualified opinion on the 2013-14 financial statements of the Trust, although in doing so, I have brought several

issues to the attention of officers and the Audit Committee

The Wales Audit Office performance audit work forms the structured assessment for the organisation. The results of the structured

assessment for 2013 were: - The Trust’s financial planning and management work well and

have contributed to the Trust consistently meeting its savings and statutory break even targets

- The Trust continues to improve its arrangements to support good

governance. Work remains to strengthen some components of the governance framework, collect more feedback from service

users and further develop the information in the Annual Quality Statement

- In its approach to managing resources effectively, the Trust has made good progress with workforce planning and organisational

development



The Wales Audit Office concluded the following local audits which were

received by the Audit Committee:

- Data backup arrangements - Microbiology management arrangements

- External review of NHS Wales Shared Services Partnership

The actions agreed by Public Health Wales in response to the recommendations in WAO reports are recorded in an action log and the

Committee continues to monitor progress in addressing them.

5.2 Internal audit

Internal audit services are provided to Public Health Wales by NHS Wales Shared Services Partnership. The Audit Committee approved the

Internal Audit Plan for 2013/14 at the start of the year, ensuring that the plan was robust and specifically targeted to risks identified within

the organisation. The Committee also approved the revised internal audit strategy.

The work completed by internal audit provides assurance that risks are

managed and controls and governance arrangements are in place. The

internal audit plan was developed in consultation with the Executive Directors and reflected the key risks and strategic objectives identified

by the Board.

During the year the Committee received seven assurance reviews. The following levels of assurance were awarded:

Substantial assurance

1. Budgetary control The Board can take substantial

assurance that arrangements to

secure governance, risk

management and internal control,

within those areas under review,

are suitably designed and applied effectively. Few

matters require attention and are compliance or

advisory in nature with low impact on residual

risk exposure.

2. Welsh risk pool claims

3. Standards for Health Services

Reasonable assurance

4. Implementation of alerts

The Board can take reasonable




5. Screening modernisation



6. Financial systems

review

within those areas under review, are suitably

designed and applied effectively. Some matters

require management attention in control design or

compliance with low to moderate impact on

residual risk exposure until resolved.

Limited assurance

7. Asbestos management The Board can take limited




within those areas under review,

are suitably designed and applied effectively. More

significant matters require management attention

with moderate impact on residual risk exposure

until resolved.

The following reports were completed by Internal Audit but did not offer an assurance rating.

Sustainability

Annual Quality Statement

The Head of Internal Audit has concluded:

Reaso

nab

le

assu

ran

ce

- +

Yellow

The Board can take reasonable assurance that

arrangements to secure governance, risk management

and internal control, within those areas under review,

are suitably designed and applied effectively. Some

matters require management attention in control design

or compliance with low to moderate impact on

residual risk exposure until resolved.

In reaching this opinion the Head of Internal Audit has identified that the majority of reviews during the year concluded positively, with the

only exceptions being asbestos management and the lack of progress with implementing the recommendations relating to mandatory

training. The Audit Committee has responded to the exceptions noted by the Head of Internal Audit and has ensured that action has been

taken at Board level to improve the situation and work continues to

monitor the improvements. Significant progress has been made during the year to improve statutory and mandatory training compliance and

this will remain a priority for 2014/15.

The Committee is also scheduled to receive reports during the course of the year on the audits of financial systems operated by NHS Wales

Shared Services partnership, processing transactions on behalf of Public Health Wales. There were no reports of this nature presented to

the Committee during 2013/14.



Any areas identified for improvement by the reviews above are

recorded on the internal audit action log which is received by the Committee at each meeting. It is closely monitored and each action is

allocated to an Executive lead. During the year the committee requested that actions also be allocated an overseeing Committee.

5.3 Financial reporting The Audit Committee considered the annual accounts for 2013/14 in

May 2014, including the organisation’s Annual Governance Statement. The Committee subsequently approved the annual accounts and Annual

Governance Statement in June 2014, on behalf of the Board. In doing so, the Committee confirmed that the Annual Government Statement

was consistent with the Committee’s view on Public Health Wales’ system of internal control. The Committee did not identify any

reasonable limitations to draw to the attention of the Board.

5.4 Counter-fraud

The Committee approved the 2013/14 annual work plan of the Local Counter Fraud Specialist, provided to Public Health Wales by Cardiff

and Vale Counter Fraud Services. Regular reports were received by the Committee to monitor progress against the plan. The reports advised

the Committee about ongoing and concluded fraud investigations, policy and procedure reviews, action being taken to deter and prevent

fraud and to raise fraud awareness throughout the organisation.

5.5 Other Committee work

In addition to the work undertaken by Wales Audit Office, Internal Audit and Counter-fraud, the Committee completed the following pieces

of work:

Received and monitored a report into salary overpayments;

Responded consultation on the Auditor General’s revised Code of Audit Practice and a Statement of Practice for local government

improvement audit, assessment and special inspection work;

Received a report on clinical negligence and personal injury

claims;

Received and reviewed the reporting of single tender contracts and procurement activity at each Committee meeting;



The Audit Committee also received the formal report on the

ongoing work on the register of interest and the register of gifts and hospitality and the register of common seal; and

Reviewed the organisation’s first Annual Quality Statement.

6 Relationship with other Committees

The Audit Committee has worked closely with the Quality and Safety Committee during the year. Two members of the Audit Committee are

also members of the Quality and Safety Committee. This common membership ensures continuity across the two Committees and

provides the Chair of the Audit Committee with assurance that clinical quality and safety is being addressed appropriately by the Quality and

Safety Committee. Performance data has been improved during the

year and information flows relating to performance against Public Health Wales’ strategic objectives are improving.

The Audit Committee and Quality and Safety Committee have reviewed

their terms of reference to ensure that there were no overlaps or obvious gaps in roles and responsibilities for each of the Committees.

The outcome of the review was that few changes were needed, although some additional information was included to reinforce the

need for Committees to ensure a connection between the business of key committees and also seek to integrate assurance reporting.

7 Actions for next year 2014/15

The Committee has identified the following areas to focus on during the forthcoming year:

Continue to ensure that financial controls are operating

effectively;

Ensure continued development and improvement of effective risk

management and governance arrangements;

Continue to monitor progress against recommendations made in internal and external audit reports; and

Ensure continued development and effectiveness of Audit Committee.

8 Conclusions and Way forward



The Audit Committee is now well established and has undertaken all of

its core functions. The results of external reviews are pleasing and all recommendations are forming part of action plans which are actively

monitored. The Committee has concluded that the above programme of work provides a comprehensive and reliable assurance to support

the Board and Accountable Officer in discharging their accountability obligations.

The Audit Committee has established an active process which gives

oversight of all internal and external recommendations and their timely implementation.

Good working relationships continue between the Committee Members

and the colleagues from external and internal audit.

Date: 13 January 2013 Version:1 Page: 1 of 17

Safeguarding Annual Report 2013-2014 Purpose of Document: The purpose of this Annual Report is to provide an overview of safeguarding activity

across Public Health Wales NHS Trust over the last 12 months. In addition this report

will provide assurance to the Board that the Trust meets its statutory responsibilities in relation to safeguarding.


To decide- Paper will outline recommendations or issues to be

approved by the Board or Committee.

To discuss- Board or Committee will be asked to discuss and scrutinise the paper and provide feedback and comments.

To inform- Board or Committee will be asked to note the paper for information only


Next Steps

Link to Public Health Wales commitment and priorities for action:

(please tick which commitment(s) is/are relevant)

Priorities for action include relevant priority for action(s)

Author: Kate McDonald, Named Nurse Safeguarding

Date: 25 March 2014 Version: 1

Sponsoring Executive Director: Dr Quentin Sandifer

Who will present: (If appropriate) Dr Quentin Sandifer


Safeguarding annual report


Committee/Groups that have received or considered this paper:

Public Health Wales Safeguarding Group Quality and Safety Committee

Paper 32 16



Link to standards

for health services

Standard 11: Safeguarding children and

safeguarding vulnerable adults

Link to risk

register

N/A


No, report is for internal purposes only


No

Service user

engagement

No







Public Health Wales Safeguarding Annual Report to Board 2013-2014

Date: 25 March 2014 Version: 1 Page: 3 of 17

ANNUAL REPORT

SAFEGUARDING

2013-2014

Author: Kate McDonald, Named Nurse Safeguarding

Date: 25 March 2014 Version: 1

Publication/ Distribution:

Public Health Wales Board

Sponsor: Dr Quentin Sandifer


The purpose of this Annual Report is to provide an overview of safeguarding activity across Public Health Wales NHS Trust over the last

12 months. In addition this report will provide assurance to the Board that

the Trust meets its statutory responsibilities in relation to safeguarding.


1 INTRODUCTION

1.1 This is the annual safeguarding report to the Public Health Wales NHS Trust board for the period March 2013-2014. The purpose of

this report is to provide the board with an update of the assurance arrangements in place to discharge Public Health Wales’

safeguarding responsibilities. It is imperative for Public Health Wales to safeguard vulnerable persons in accordance with the

legislation framework of the Children Act 1989, Children Act 2004, and key principles and core values arising from ‘In Safe Hands’,

All Wales Interim Adult Protection Policies & Procedures (2013) and the Domestic Abuse Strategic Agenda.

1.2 Safeguarding children and vulnerable adults is a public duty, placed on key agencies across Wales by legislation and guidance.

The duty is a clear one, and to protect the most vulnerable

members of our society requires everyone within Public Health Wales to recognise their important role in helping prevent and

identify abuse and neglect. There were 2.950 children (including unborn children) on child protection registers in Wales at 31 March

2013, a rate of 47 children per 10,000 population aged under 18. The highest number of registrations was shown in categories

involving neglect (43 per cent) (Welsh Government, 2012).

1.3 Wales also has the highest share of over-60s than any other part

of the UK, with nearly one in four aged 60 or over. In 2009/10 there were 3,572 completed referrals alleging abuse of adults in

Wales (WG, 2011) and the number of referrals are increasing year on year. The most commonly reported victim of alleged

abuse was an older woman but it is understood that there is an under reporting of abuse in people who have mental health

problems or learning difficulties.

1.4 The continued high profile court cases relating to sexual abuse and the inquiries currently underway into the abuse perpetrated

by Jimmy Savile inside hospitals and other public institutions serve to underline the importance of ensuring that Public Health

Wales has robust systems in place to ensure that children and vulnerable people may be safeguarded effectively.

2 GOVERNANCE AND ACCOUNTABILITY

2.1 The combining of the safeguarding of children and vulnerable

adults into the remit of one professional has strengthened the governance arrangements and the Named Nurse now takes the



lead for both groups within Public Health Wales in order to ensure

an equal focus. Safeguarding is however a dynamic process which is constantly evolving in line with changing legislation and

guidance as well as recommendations from current investigations and inquiries. Safeguarding is both highly emotive and politically

sensitive and the agenda is expected to increase significantly with the Social Services (Wales) Bill and the Ending Violence Against

Women, Domestic Abuse and Sexual Violence (Wales) Bill expected to reach the statute books in 2014.

2.2 In line with legislation and guidance as well as intercollegiate and professional competency frameworks and the Public Health Wales

Safeguarding in Public Health safeguarding strategy, the role of the Named Nurse Safeguarding for Public Health Wales comprises both

a strategic and operational function. The strategic role includes taking an overview to ensure that children and vulnerable adults

are safeguarded in the planning and development of services and

that there are appropriate policies and procedures in place to ensure their protection. In addition, there are operational duties

including providing advice and support to all levels of staff and training.

2.3 Central to safeguarding in Public Health Wales in 2013-2014 has been the Safeguarding Group which meets on a quarterly basis to

provide a forum and focus for the management of safeguarding in Public Health Wales. In line with the Terms of Reference the

Group is chaired by Dr Quentin Sandifer, lead Executive Director for Safeguarding, attended by Professor Simon Smail, lead Non-

Executive Director for Safeguarding and the Nurse Director and is constituted of representatives from all service areas. Evidence of

the functioning of the group is through the production of relevant minutes, plans, reports and other documentation. Reporting

responsibility is to the Quality and Safety Committee through the

Risk Management Group.

2.4 The Safeguarding Group ensures compliance with section 28,

27(2) (a) (b) and section 25 and section 31 of the Children Act 2004. Although there is no similar legislation for adults the

Human Rights Act 1998 places a positive duty upon ‘public bodies’ to act compatibly with the 1950 European Convention on

Human Rights which includes duties under Article 2: ‘The right to life’; Article 3: ‘Freedom from torture’ (including humiliating

and degrading treatment) and Article 8: ‘Right to family life’. In addition, the Safeguarding Group ensures compliance with safe

recruitment and monitoring arrangements as well as providing leadership, commitment and operational support to

safeguarding across Public Health Wales.



2.5 The attendance at the group has been generally satisfactory in

2012–2013 and it has been a dynamic group with a committed membership which has contributed greatly to safeguarding in

Public Health Wales. The goal for the next year will be to ensure attendance from all service areas.

3 MONITORING AND AUDIT

3.1 The main monitoring and audit system within the NHS in Wales are the Standards for Health Services, and compliance with

Standard 11 is monitored to enable the annual self-assessment submission. Standard 11 is completed by all service areas, and in

considering this year’s submissions it is clear that more work remains to be undertaken with teams to ensure the submissions

are more meaningful going forward. The Safeguarding Group oversees the development, review and implementation of the

Standard 11 Improvement Plan. This will provide the basis for

planning safeguarding priorities in Public Health Wales; additional priorities may also be set by the Safeguarding Group.

3.2 To ensure a robust safeguarding culture it is important to learn from events happening internally or externally, this is achieved

through:

Risk management processes

Membership of the Risk Management Group

DATIX risk reporting system.

Raising concerns and incidents through the Safeguarding Group Recommendations from Serious Case Reviews across Wales are

shared with the Named Nurse Safeguarding Children by the Safeguarding Children Service and for adults via the adult

protection fora. Any risk areas or identified training needs within Public Health Wales would then be addressed.

3.3 The Local Safeguarding Children Boards (LSCBs) in Wales request

an annual audit against section 28 of the Children Act 2004 responsibilities. To avoid duplication across all LSCBs a Public

Health Wales s28 audit setting out Public Health Wales compliance with all statutory legislation and guidance was developed for

LSCBs and distributed in response to requests.

3.4 In his report ‘Safeguarding and Protecting Children in NHS Wales’

(Cardiff University, 2010) Professor Sir Mansel Aylward called for the establishment of an all Wales NHS clinical network for

safeguarding to be established under the leadership of the Safeguarding Children Service. The Named Nurse is a member of



this group the ‘All Wales Safeguarding Children Clinical Network’

and reports back to the Safeguarding Group. He also identified the need for robust monitoring and evaluation in order to improve and

develop services. The acceptance of this recommendation by Welsh Government led to the development of the Quality

Outcomes Framework (QOF) by the Safeguarding Children Service, Public Health Wales. This was completed for the first time

in 2013. The timescales for completion were extremely tight and some of the information proved challenging for all Trusts and

Health Boards including Public Health Wales. A working group has been established to further develop the QOF for the 2013-2014

submission later this year.

4 PROGRESS AGAINST PRIORITIES

4.1 Disclosure and Barring checks

4.11 On the 12 September 2012, the definition of regulated activity for

a check changed and now covers a check against a barred list for children and/or adults.

The key changes that impact on Public Health Wales are:

The term ‘access’ to children or vulnerable adults only concerns

employees having direct, physical, day-to-day contact with patients; it does not include positions where there is no face to

face contact and therefore staff in positions of trust, advising on policies affecting children and vulnerable adults,

Safeguarding Nurses and the Board are not may not have

standard or enhanced checks.

Positions that purely involve having access to records or

sensitive information are not covered under the definition of regulated activity and checks may not be undertaken.

4.12 A Task and Finish Group was established and developed a manager checklist to be used by managers to assess if a position

requires a DBS check and to what level. The group considered the possibility that an audit be completed to ascertain whether a

current post-holder working in a position assessed to require a Disclosure and Barring (DBS) check currently has one. If they do

not have the appropriate DBS check, Public Health Wales would be in a strong position to justify why this has to be completed.

4.13 In order to further clarify the position in relation to performing a check on staff that don’t readily fall into one of the prescribed

categories, the Named Nurse is taking this issue forward with

Welsh Government via the Wales Safeguarding Clinical Network.



4.2 Training

4.21 Safeguarding occurs in a culture that prioritises training and

therefore has a competent and safe workforce, and full engagement of managers and staff is required to increase

knowledge and ultimately reduce the risks to service users, employees and the organisation. A safeguarding training strategy

is currently being developed incorporating the competences

outlined in the RCPCH intercollegiate document ‘‘Safeguarding Children and Young people: roles and competences for health care

staff’ which has been adopted by WG as the safeguarding training standard for Wales. This contains a tool to assist managers to

assess the level of training each staff member requires.

4.22 Training in safeguarding children and vulnerable adults is

mandatory for all staff. A combined children and adult safeguarding training has been developed in line with standards

set in the All Wales Child Protection Procedures 2008, the RCPCH intercollegiate guidance on ‘Safeguarding Children and Young

people: roles and competences for health care staff’ and the ‘Wales Interim Policy and Procedures for the Protection of

Vulnerable Adults from Abuse’ (appendix 1). Safeguarding training is delivered at 3 levels in Public Health Wales. (Appendix 1), all

training is delivered by the Named Nurse Safeguarding.

4.23 Level 1 safeguarding children e learning is now available, but is not suitable for staff to use as there is no POVA element, however

there is an all Wales group currently developing this. Once available this would be useful for those staff new in post and

those whose post outline would only require them to have this level of training. In the interim the development of a POVA

workbook is underway to sit alongside the online training. Not all staff requiring level 1 would have ready access to a computer and

a level 1 training package has been developed which can be delivered by managers and trainers where available. It is hoped

that this will facilitate an increase in the number of staff accessing this training.

4.24 Level 2 training has been delivered to staff across Wales by the Named Nurse Safeguarding. This is face-to-face training delivered

in multidisciplinary sessions as well as to discrete teams. This has

been well-received (appendix 2).

4.25 The only training compliance figures currently reported on are for

level 1 safeguarding children training, which shows compliance across the organisation at 41% (505 staff members) to the end of



January 2014. However, it must be noted that in the absence of

specific and defined training denominators, it is not possible to give accurate compliance figures, for example some staff may not

be required to attend level 1 as they require a higher level training.

The intention going forward is to accurately define and set out in the Safeguarding Training Strategy the staff requiring each level

of training and it would then be possible to report compliance against those denominators.

An additional challenge is that as ESR is not yet rolled out across the organisation a basic Excel database is the only method of

reporting training compliance. In the meantime until there is such accurate central reporting, POD will continue to maintain records

as accurately as possible, however with the implementation of the updated Safeguarding Training Strategy, it may be requested that

training records are maintained locally and fed into POD on a

quarterly basis.

4.26 HealthWRAP training which is part of the PREVENT counter-

terrorism strategy, continues in line with the Implementation Strategy. Another trainer has been trained and is also delivering

HealthWRAP. Four sessions have been delivered in 2013-14 but the attendance has been disappointing with some sessions having

been cancelled.

4.27 Level 3 training is available to staff on topics such as internet and

online abuse, domestic violence, neglect and substance misuse. This has been delivered successfully to discrete teams where

requested e.g. domestic violence, FGM and Sexual Exploitation training to Newborn Hearing Screeners. Three training sessions on

the Mental Capacity Act 2005 are scheduled across Wales in 2014. Training priorities in 2013 will be the roll-out of training on

Domestic Violence to accompany the launch of the Public Health

Wales ‘Domestic violence, violence against women and sexual violence policy, and training on female genital mutilation.

4.3 Policy and Procedures

4.31 The development of safeguarding policy and guidance for Public

Health Wales has been a priority. A ‘Safeguarding adults at risk’ policy’ has been developed and is in the final stages of

consultation prior to adoption by Public Health Wales.

4.32 The ‘Procedure for staff working with sexually active young people and vulnerable adults’ has been developed and is in the final

stages of consultation prior to adoption by Public Health Wales.



This will assist staff in understanding the legislation and guidance

in this area of work. This is particularly timely having regard to the recent high profile cases.

4.33 The proposed legislation to end violence against women, domestic abuse and sexual violence (Wales) will place a duty on all public

sector employers to have a workplace policy for violence against women, domestic abuse and sexual violence. The Welsh

Government has therefore requested that the policy is developed and accompanied by staff training. This has been developed and is

nearing the end of the consultation process prior to adoption by Public Health Wales.

4.34 The all Wales Named Professionals Forum has developed a safeguarding Supervision Strategy which will be considered by the

Safeguarding Group and may be adopted by Public Health Wales.

4.35 National safeguarding policies and procedures, the All Wales Child

Protection Procedures 2008 and the All Wales Interim Adult

Protection Policy and Procedures 2010 are available to all staff on the intranet. In light of the proposed changes under the Social

Services and well-being (Wales) Bill 2012 it is inevitable that these policies may require further amendment to reflect any

changes arising from the final legislation.

4.4 Organisational Support

A key component in safeguarding is to provide advice and support to

Public Health Wales staff to promote good professional practice within Public Health Wales. To ensure that all staff are aware of their

responsibilities and know how to access advice on entry to the organisation safeguarding leaflets are given to staff at induction.

There are safeguarding children and vulnerable adults’ web pages which contain links to all relevant internal and external safeguarding documents

and policies, referral forms and contact details for advice and referrals.

4.41 Children

4.41.1 The Named Nurse is available to all staff to offer advice, however the nature of the work of Public Health Wales means less face-to-

face work with children than in other Health Boards and Trusts. In 2013 – 2014 there were 15 formal requests for advice which

resulted in 12 referrals on to other agencies.

4.41.2 Effective supervision is important in promoting good standards of

practice and supporting individual staff members. Supervision

allows time for reflective practice and is a vital component in the protection of children. A Safeguarding Children Supervision



Procedure is in place which stipulates that direct supervision is

made available to staff dealing with a child protection case. This would also be the case with vulnerable adults and when this

procedure requires updating it will be amended as such.

4.41.3 Safeguarding supervision sessions have continued with all

Newborn Hearing Screeners and are greatly valued by staff and the Named Nurse. An evaluation of the supervision programme

has been completed and a report submitted to the service.

4.41.4 A Public Health Wales Safeguarding Children Handbook has been

developed to assist staff in recognition and the referral process. This is distributed to staff attending training and is available on

the intranet.

4.42 Vulnerable Adults

4.42.1 The Named Nurse Safeguarding is available via telephone or email to all staff to offer advice about any adult protection concern.

Each year there are thousands of adults who come into contact

with Public Health Wales services, however there have been few requests for advice. Due to the workload of the Named Nurse

there has been insufficient time to fully develop this part of the role. This is something which should be a priority for Public Health

Wales in 2014-15. It is envisaged that referrals will increase as awareness of POVA issues increases within Public Health Wales.

4.42.2 A Public Health Wales Safeguarding Vulnerable Adults Handbook has been developed to assist staff in recognition and the referral

process. This is distributed to staff attending training and is available on the intranet.

4.42.3 The Named Nurse Safeguarding is in a position to access the four multiagency adult protection fora in Wales but this is difficult due

to time constraints. This is unfortunate because this would afford the opportunity to keep updated with current legislation,

guidance, recommendations and trends in adult protection as well

as ‘networking’ opportunities. This will be a priority in 2014-15. In addition an all Wales Safeguarding Vulnerable Adults Health

Professionals Group has been established of which the Named Nurse is a member and attends meetings where possible.

5 Social Services and Well-being (Wales) Bill

5.1 The Deputy Minister for Children and Social Services has set out her approach to safeguarding and protecting people in Wales

which included a commitment to carry forward a Social Services and well-being (Wales) Bill in 2012. The bill was introduced on



28/01/13 and is progressing through the Welsh Government for

implementation later this year. The Bill will include a statutory framework for protecting people (adults and children). It will

consolidate arrangements for children and encompass new duties to investigate, co-operate and share information in the field of

adult protection and will include a statutory definition of an adult at risk.

5.2 In addition, there is a rationale for fewer Local Safeguarding Children Boards, currently most of the existing LSCBs are merging

to form Regional Safeguarding Children Boards, some of which are operating in shadow form, and this is also the case for Adult

Protection Boards. The possibility has been mooted of the adult and children boards merging to form Safeguarding and Protection

Boards to reflect the holistic approach required to safeguard and protect people in Wales. If this were to happen it would only be

when ministers believe that these boards are operating effectively

and assessed to provide evidence to support integration.

6 Priorities for 2014 - 2015

6.1 The priorities for Public Health Wales have been identified

following completion of Section 11 of the Healthcare Standards for Wales and the subsequent action plan. These will be included in

the Named Nurse workplan and overseen by the Safeguarding Group.

6.2 The priorities fall under three headings:

1. Policy development:

Update, combine and complete the Training Strategy in

line with the RCPCH and Skills for Health competency

frameworks.

Update the Project and Partnership Risk Assessment Tools

2. Training:

Collaborate with POD to scope training needs and deliver

a training programme across Wales

Further develop training to utilise training-for-trainers and

e learning

3. Governance

Provide a paper for the Board outlining the challenges for

the Named Nurse in delivering adequate safeguards for

children, vulnerable adults and the organisation

Ensure that safeguarding advice is readily available to

staff



Update and further develop the safeguarding web pages

Ensure compliance with Standards for Health 11

Attend meetings of the regional adult protection fora.

6.3 The overarching priority for the next year will be for Public Health Wales to continue to build on the work already in progress and to see substantial progress against issues highlighted in the

Healthcare Standards.

6.4 Personal priorities include increasing my knowledge-base on the

safeguarding of vulnerable adults and updating my job description to take account of my new role.

7 Conclusions

The clear aim of both the child and adult safeguarding functions within

Public Health Wales is to make a fundamental difference to the protection of children and young people, vulnerable adults and those subject to

domestic abuse and violence. There is a requirement to provide a coordinated response to ensure that all staff understand their

safeguarding responsibilities to both children and vulnerable adults and are aware of the nominated point of contact for support and advice when

they have a concern. It should be noted that as Public Health Wales is an all Wales organisation, safeguarding covers the whole of Wales and the

safeguarding of children and vulnerable adults is covered under one post, it is clear that this is a challenging remit for one individual to deliver.

8 References

1. CHILDREN ACT 2004. London: The Stationery Office.

2. HUMAN RIGHTS ACT 1998. London: The Stationery Office.

3. LOCAL SAFEGUARDING CHILDREN BOARDS (2008) All Wales Child

Protection Procedures

4. MENTAL CAPACITY ACT (2005). London: The Stationary Office.

5. ROYAL COLLEGE OF PAEDIATRICS AND CHILD HEALTH (2010)

Safeguarding Children and Young people: roles and competences for

health care staff. London: RCPCH

6. UNITED NATIONS CONVENTION ON THE RIGHTS OF A CHILD (1989)

General Assembly Resolution Document A/RES/44

7. WELSH ADULT PROTECTION FORA (2010). Wales Interim Policy and

Procedures for the Protection of Vulnerable Adults from Abuse. Cardiff:

Welsh Adult Protection Fora

8. WELSH ASSEMBLY GOVERNMENT (2006) Safeguarding Children:

Working Together under the Children Act 2004). Cardiff.



9. WELSH ASSEMBLY GOVERNMENT (2006a) Healthcare Standards for

Wales. Cardiff.



APPENDIX 1

Training Activities March 2013-2014 Public Health Wales

Staff Safeguarding Training

Training Sessions Delivered

Level 1 Training

Date Venue Trainer Region Number

Attended

28/1/2014 Microbiology Lab,

Bronglais Hospital, Aberystwyth

Kate

McDonald

Mid Wales 10

Total Number of Staff Trained to Level 1 10

Level 2 Training

Date Venue Trainer Region Number Attended

15/01/2013 AAA Screening Staff, Llantrisant

Kate McDonald

South Wales 20

19/02/2013 Morning

Newbridge PHT, Anvil Court,

Abertillery

Kate McDonald

South Wales 11

19/02/2013

Afternoon

Newbridge PHT,

Anvil Court, Abertillery

Kate

McDonald

South Wales 7

20/02/2013 Health Improvement Team, Nantgarw

Kate McDonald

South Wales 6

28/02/2013 Screening Staff, BTW Cardiff

Kate McDonald

South Wales 6

25/04/2013 Morning

14 Cathedral Road, Cardiff

Kate McDonald

South Wales 13

25/04/2013 Afternoon


Kate McDonald

South Wales 11

12/06/2013 Preswylfa, Mold

Kate McDonald

North Wales 11

17/06/2013 Stop Smoking Wales

Cardiff

Kate McDonald

South Wales 18

10/07/2013 Orchard Street,

Swansea

Kate

McDonald

South Wales Cancelled

11/07/2013 Public Health

Wales, Carmarthen (TBC)

Kate

McDonald

Mid Wales Cancelled

15/07/2013 Stop Smoking Wales Swansea

Kate McDonald

North Wales 6



Level 2 Training


Attended

16/07/2013 Stop Smoking

Wales Swansea

Kate

McDonald

South Wales 13

17/09/2013 Public Health Wales, Merthyr Tydfil

Gloria Smith South Wales 20

02/10/2013 Preswylfa, Mold Kate McDonald

North Wales 11

08/10/2013 Morning

Programme Managing Unit,

Churchill Way, Cardiff

Kevin Hogan South Wales 14


Programme Managing Unit,

Churchill Way, Cardiff

Kevin Hogan South Wales 5

23/10/2013 Morning

Innovation House, Llanharan

Kate McDonald



Innovation House, Llanharan

Kate McDonald


13/02/2014 Preswylfa Kate McDonald

North Wales

4

19/02/2014 14 Cathedral Rd, Cardiff

Kate McDonald

South Wales

20

04/03/2014 BTW Boardroom Kate

McDonald

South Wales 0 (no

shows)

24/03/2014 BTW Llandudno Kate McDonald

North Wales 13

Total Number of Staff Trained to Level 2 209

Newborn Hearing Screeners POVA & Forced Marriage (Level 2/3)

Date Venue Trainer Region Number Attended

08/07/2013 Velindre HQ, Llantrisant

Kate McDonald

South Wales 24

13/11/2013 Royal Alexandra Hospital, Rhyl

Kate McDonald

North Wales 9

14/11/2013 Singleton Hospital, Swansea

Kate McDonald

South Wales 10

13/02/14 Preswylfa, Mold Kate McDonald

North Wales 6

Total Number of NBHS Staff Trained to Level 2/3 43



Level 3 Training – Mental Capacity Act


Attended

09/10/2013 Temple of Peace,

Cardiff

Nigel

Monaghan


Total Number of Staff Trained to Level 3 (training

cancelled)

0

PREVENT HealthWRAP Training


Attended

11/09/2013 Carmarthen Gloria Smith Mid & West 5

11/11/2013 BSW, Llantrisant Gloria Smith South Wales 8

12/11/2013 BTW, 18 Cathedral Road, Cardiff


02/12/2013


Kate McDonald

South Wales 7

12/12/2013 BTW, 18 Cathedral Road, Cardiff


07/02/2014 Llandudno Hospital Kate McDonald

North Wales 19

Total Number of Staff Trained in PREVENT HealthWRAP 81


Health Emergency Planning Annual Report 2013Purpose of Document:

To present the Health Emergency Planning Annual Report 2013 and the report of theassessment by the Welsh Government.


To decide - Paper will outline recommendations or issues to beapproved by the Board or Committee.

To discuss - Board or Committee will be asked to discuss andscrutinise the paper and provide feedback and comments.

To inform - Board or Committee will be asked to note the paper forinformation only

X


None

Next Steps


X

Priorities for action Health emergency planning is a corefunction of a public health protectionservice.

Author: Dr Quentin Sandifer, Executive Director of Public Health Services

Date: 12 June 2014 Version: 1Sponsoring Executive Director: Dr Quentin Sandifer

Who will present: (If appropriate) Dr Quentin Sandifer


Public Health Wales Health EmergencyPlanning Annual Report for 2013

Health Emergency Planning Annual Reportfor 2013 – Summary Response




Public Health Wales Health Emergency Planning Annual Report 2013



Standard 4 – Civil Contingency and Emergency Planningarrangements

Link to risk register


N/A


None


N/A

Public Health Wales Health Emergency Planning Annual Report 2013


1 Introduction

Health emergency planning is the process by which Public Health Wales responds toincidents and outbreaks where escalation is required to mobilise additional capabilitiesbeyond the norm. It ensures that the organisation is able to fulfil its role as aCategory 1 Responder under the Civil Contingencies Act 2004. This Act places anumber of legal duties on Public Health Wales in respect of:

Risk assessment Maintenance of a risk register Planning arrangements for

o Prevention of emergencieso Response to emergencies

Planning arrangements for business continuity management Warning and informing Sharing information Co-operation with other agencies (planning, response and recovery)

The annual report follows a proforma provided by Welsh Government for self-completion by the Head of Emergency Planning and sign-off by the Chief Executive.The Head of Emergency Planning for Public Health Wales is Dr Gwen Lowe, aConsultant in Communicable Disease Control. The deadline for report submission was31 January 2014.

2 Updates since January 2014

Public Health Wales can report the following changes since submission of the annualreport in January 2014:

An updated Emergency Response Plan was published on 27 February 2014 The evaluation of the measles response centre referred to under Q12 is

complete and available on request Public Health Wales has established a secondary response centre at Magden

Park near Llantrisant An exercise, Exercise Stargate, was arranged to test the secondary centre on

10 June 2014 Public Health Wales, together with Aneurin Bevan and Cardiff and Vale Health

Boards, is working with Welsh Government on the health planningarrangements for the 2014 NATO Summit in September

As part of the planning arrangements for the NATO Summit Public Health Waleshas organised several exercises and training events for June and July 2014.

3 Recommendation

The Board is asked to receive and note the Health Emergency Planning Annual Reportfor 2013.

UUnneedd PPaarrooddrrwwyydddd aamm AArrggyyffyynnggaauu IIeecchhyydd

HHeeaalltthh EEmmeerrggeennccyy PPrreeppaarreeddnneessss UUnniitt

HHEEAALLTTHH EEMMEERRGGEENNCCYY PPLLAANNNNIINNGG AANNNNUUAALL RREEPPOORRTT FFOORR 22001133 Name of NHS

Organisation

Public Health Wales NHS

Trust Date 31/1/14

Signature of Chief

Executive Officer

Planning and Preparation

1. Please provide the name of your nominated Executive level lead for the organisation’s civil

contingency/emergency planning arrangements.

Dr Quentin Sandifer

2. Please provide the name of your nominated Executive level business continuity lead if

different to the above.

Mr Mark Dickinson

3. Please provide the name of your accountable emergency officer(s) with day to day

responsibilities for civil contingencies/emergency planning/business continuity

arrangements.

Health Protection- Dr Gwen Lowe Business Continuity- Mr Nathan Jones

4. Have you identified all posts and services critical to delivery of your Emergency Plans?

YES

As set out in the Emergency Response Plan which identifies the posts and services critical to delivery of a Public Health Wales Emergency Response. The Action Cards identify both the posts and other roles needing to be filled in an emergency and also capture these functions.

5. Does your business continuity planning address the resilience of all posts and services

critical to delivery of your key functions?

YES

The Emergency Response Plan also addresses resilience for key health protection team functions as most of the organisation’s other functions, apart from screening and microbiology, would be redirected to support the emergency response. Screening and microbiology services also have business continuity plans.

6. Have you suitably trained and dedicated staff, resources and facilities available, around the

clock, to effectively manage the organisation’s response to major incident and emergency?

YES

As evidenced by the health protection on call rota, the executive on call rota, the comms and regional epidemiologists on call rotas and the microbiologists hospital on call rotas and the emergency response telephone directory which would the basis of our surge capacity of key personnel.

7. When was your risk assessment of hazards, threats and vulnerabilities last updated?

The quarterly health protection emergency planning meeting considers these on an organisational basis– last meeting was 12/9/13. Risk Assessment of hazards and threats is carried out through LRF multiagency planning arrangements and the community risk register.

Training, Testing & Implementing Arrangements

8. When were your emergency plans for a major incident or emergency last considered and

formally adopted by your Executive Board?

The Public Health Wales Emergency response plan was revised in May 2012 and the Board informed in June 2012 in a report from the Director of Public Health Services that was received and noted.

9. When were your emergency plans last updated to reflect organisational and contact

changes?

Plan amended post measles outbreak evaluation - amendments to be formally adopted at the next Emergency Planning meeting (19/2/14). Emergency telephone directory updated 18/10/13.

10. Please provide the dates when your organisation has met the requirement for testing its

plans through:

a. Carrying out a communications/activation test every six months

20/3/13 and 27/11/13

b. Carrying out a table top training exercise within the last year

Measles Outbreak - as exercised all critical aspects of plan

c. Carrying out a major live or simulated exercise within the last three years

11

th/12

th January 2012

11. Have you implemented any of your emergency plans in response to an incident in 2013?

YES

If yes what was the nature of the incident?

Measles Outbreak

12. Have you undertaken an assessment of staff training needs in relation to your emergency

plans?

YES

Staff training needs are considered formally at quarterly emergency planning meetings as evidenced by meeting minutes. In addition we evaluate post major incident and are finalising collating the questionnaires sent out to staff in the measles response centre - one of the questions formally asks the staff drafted in if they had any further training needs following this.

13. Do you have a training programme relating to your emergency plans?

YES

The on-call training day 7

Feb 2013 and the on call training teleconference timetables and

proformas throughout the past year. In addition we are just finalising an e-learning induction training package on the plan and emergency response for all new starters and for all staff - the package is developed and been electronically tested and we are just negotiating with our OD team about rolling it out.

Communications

14. Have all relevant NHS organisations and partner agencies been consulted about their role in

your emergency plans?

YES

Relevant partners with specified roles in our emergency plan are Health Boards and CRCE. All are members of our emergency planning group that meets quarterly. The emergency plan and proposed amendments are circulated to these members for sign off at the meeting.

15. Is there a mechanism for discussing and co-ordinating health emergency planning

arrangements internally and with other NHS organisations serving the Local Resilience

Forum area?

YES

If yes please provide date of last meeting and health representation. Infectious Disease/pandemic flu Subgroups in all 4 LRF areas - attended by CCDCs and other local health organisations- SWLRF last meeting 12/12/13

16. Who represents your organisation at meetings of the Local Resilience Forum? The local CCDCs

Assessment

17. Are you satisfied with your organisation’s emergency preparedness and business continuity

arrangements?

YES

18. Are you satisfied that your organisation is fulfilling its requirements under the Civil

Contingencies Act 2004?

YES

Completed and signed forms to be returned by 31st January 2014

To: David Goulding, Health Emergency Planning Adviser, Floor 4, Cathays Park, Cardiff

CF10 3NQ or e-mail: [email protected]

Health Emergency Planning Annual Report 2013 - Summary Response

Y% N%

1 Please provide the name of your nominated Executive level lead for the organisation’s civilcontingency/ emergency planning arrangements.

100 0

2 Please provide the name of your nominated Executive level business continuity lead if differentfrom the above.

100 0

3 Please provide the name of your accountable emergency officer(s) with day to dayresponsibilities for civil contingencies/emergency planning/business continuity arrangements

100 0

4 Have you identified all posts and services critical to delivery of your Emergency Plans? 100 0

5 Does your business continuity planning address the resilience of all posts and services criticalto delivery of your key functions?

90 10

6 Have you suitably trained and dedicated staff, resources and facilities available, around theclock to effectively manage the organisation’s response to major incident and emergency?

100 0

7 When was your risk assessment of hazards, threats and vulnerabilities last updated? 100 0

8 When were your emergency plans for a major incident or emergency last considered andformally adopted by your Executive Board?

100 0

9 When were your emergency plans last updated to reflect organisational and contact changes? 100 0

10 Please provide the dates when your organisation has met the requirement for testing its plansthrough:

a. Carrying out a communications/activation test every six months 70 30

b. Carrying out a table top exercise within the last year 80 20

c. Carrying out a major live or simulated exercise within the last three years 90 10

11 Have you implemented any of your emergency plans in response to an incident in 2013? 100 0

12 Have you undertaken an assessment of staff training needs in relation to your emergencyplans?

100 0

13 Do you have a training programme relating to your emergency plans? 100 0

14 Have all relevant NHS Organisations and partner agencies been consulted about their role inyour emergency plans?

100 0

15 Is there a mechanism for discussing and co-ordinating health emergency planningarrangements internally and with other NHS organisations serving the Local Resilience Forumarea?

100 0

16 Who represents your organisation at meetings of the Local Resilience Forum? 100 0

17 Are you satisfied with your organisation’s emergency preparedness and business continuityarrangements?

90 10

18 Are you satisfied that your organisation is fulfilling its requirements under the CivilContingencies Act 2004?

90 10

2013 Nominated Exec level EP lead-AB Mr Richard Bowen HD Mr Paul Hawkins/Stuart MoncurABMU Mr Paul Stauber PHW Dr Quentin SandiferBC Mr Neil Bradshaw Powys Ms Catherine WoodwardC&V Mrs Abigail Harris WAST Mr Mike CollinsCT Mr Robert Williams WBS / V Mr Carl James

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18a b c

AB ABMU x x BC x C& V CT HD P x x x x x xPHW WAST WBS /V

10 10 10 10 9 10 10 10 10 7 8 7 10 10 10 10 10 10 9 9Key : - Yes x - No

1 Please provide the name of your nominated Executive level lead for the organisation’s civil contingency/emergency planning arrangements.

All 10 of the organisations have named nominated Executive level leads

2 Please provide the name of your nominated Executive level business continuity lead if different from theabove.

8 organisations have an Executive lead covering both civil contingency/emergency planning andbusiness continuity. 2 organisations named a different member of staff responsible for each area.

3 Please provide the name of your accountable emergency officer(s) with day to day responsibilities forcivil contingencies/emergency planning/business continuity arrangements

All organisations named an accountable emergency officer with day to day responsibilities.

Public Health Wales named an accountable officer for Health Protection and Business Continuity.

4 Have you identified all posts and services critical to delivery of your Emergency Plans?

All organisations have been able to identify all posts and services that are critical to delivery of theiremergency plans.

5 Does your business continuity planning address the resilience of all posts and services critical todelivery of your key functions?

9 organisations indicated that their business continuity planning addressed the resilience of all posts andservices that are critical to delivery.

6 Have you suitably trained and dedicated staff, resources and facilities available, around the clock toeffectively manage the organisation’s response to major incident and emergency?

All organisations indicated that they have suitable trained and dedicated staff, resources and facilitiesavailable to manage their organisations responses.

Both Public Health Wales and name used the evidence of operating a 24/7 on-call rota

7 When was your risk assessment of hazards, threats and vulnerabilities last updated?

All organisations’ risk assessments of hazards, threats and vulnerabilities were carried out during the last12 months.

name, name, name and Public Health Wales carry out their assessments on a quarterly basis or soonershould any changes occur

8 When were your emergency plans for a major incident or emergency last considered and formallyadopted by your Executive Board?

The requirement is that these plans should be presented to the Board every 3 years and all organisationswere able to provide dates when their emergency plans for a major incident or emergency were formallyadopted by their Executive Boards between 2012 and 2014.

9 When were your emergency plans last updated to reflect organisational and contact changes?

All organisations were able to indicate when their emergency plans were last updated and all wereupdated during the last 12 months.

10 Please provide the dates when your organisation has met the requirement for testing its plans through:

a. Carrying out a communications/activation test every six months

7 organisations indicated that they carry out a communications/activation test every six months

b. Carrying out a table top exercise within the last year

8 organisations were able to demonstrate that they had undertaken at least one table top exercise withinthe last 12 months

c. Carrying out a major live or simulated exercise within the last three years

All organisations were able to indicate that they had carried out a major live or simulated exercise withinthe last three years

11 Have you implemented any of your emergency plans in response to an incident in 2013?

All organisations indicated that they had implemented their emergency plans and were able to give detailsof the various incidents during 2013/14, including flooding, multiple traffic collisions, and chemicalincidents and measles outbreaks

12 Have you undertaken an assessment of staff training needs in relation to your emergency plans?

8 organisations stated that they had undertaken a staff training needs assessment in relation to theiremergency plans with name and name stating that they were currently in progress of carrying outassessments

13 Do you have a training programme relating to your emergency plans?

All organisations stated that they have a training programme relating to their emergency plans.

Public Health Wales are just finalising an e-learning induction training package on the plan andemergency response for all new starters and for all staff. The package is developed and has beenelectronically tested with negotiations currently taking place on rolling it out.

14 Have all relevant NHS Organisations and partner agencies been consulted about their role in youremergency plans?

All organisations have indicated that they have consulted relevant NHS organisations and partneragencies about their role in the emergency plans

15 Is there a mechanism for discussing and co-ordinating health emergency planning arrangementsinternally and with other NHS organisations serving the Local Resilience Forum area?

All organisations stated that they had mechanism for discussing and co-ordinating health emergencyplanning arrangements, internally and with other NHS organisations serving the LRF area, and were ableto indicate necessary dates.

16 Who represents your organisation at meetings of the Local Resilience Forum?

All organisations were able to provide the names of those who represent their organisation at the LRF

For Public Health Wales these are the CCDCs

17 Are you satisfied with your organisation’s emergency preparedness and business continuityarrangements?

9 organisations stated that they were satisfied with their emergency preparedness and businesscontinuity arrangements

18 Are you satisfied that your organisation is fulfilling its requirements under the Civil Contingencies Act2004?

9 organisations have stated that they are satisfied that their organisation is fulfilling its requirements underthe CCA 2004

Yr Adran Iechyd a Gwasanaethau Cymdeithasol Cyfarwyddwr Cyffredinol a Prif Weithredwr, GIG Cymru Department for Health and Social Services Director General and Chief Executive, NHS Wales

Parc Cathays ● Cathays Park Caerdydd ● Cardiff

CF10 3NQ

Ffôn ● Tel 02920 801182/1144

[email protected]

Gwefan ● website: www.wales.gov.uk

Dr Tracey Cooper Chief Executive Public Health Wales NHS Trust 14 Cathedral Road Cardiff CF11 9LJ

Our Ref: AG/ZE/RA

12 June 2014 Dear Tracey DESIGNATION AS AN ACCOUNTABLE OFFICER

It is a condition of your appointment to the role of Chief Executive, Public Health Wales NHS Trust that you must also be formally designated, by me, as an Accountable Officer. This letter formally designates you as the Accountable Officer for Public Health Wales NHS Trust with immediate effect. Full details of your responsibilities as an Accountable Officer are set out in the attached memorandum. Conditions You are directly accountable to me for the conduct of your role as Accountable Officer, and your continuing designation is dependent upon the following conditions, that you:

undertake appropriate training for Accountable Officers;

continue to keep yourself up to date with developments affecting your responsibilities as an Accountable Officer;

demonstrate to me that you meet the full range of your responsibilities set out in

the memorandum, and in a manner that displays a thorough understanding of propriety and accountability issues as they affect public services;

mailto:[email protected]

www.wales.gov.uk

ensure that your Board members and Trust staff are aware of and understand your role and responsibilities as Accountable Officer; and

ensure that your responsibilities as Accountable Officer are reflected within the

Trust’s overall governance and accountability arrangements. Your designation as Accountable Officer may be withdrawn at any time if I consider that you have not met any of the conditions above or if I conclude that you are no longer a fit person to carry out the responsibilities of an Accountable Officer. In considering any such action, I would first consult with your Chair, to whom I am copying this letter. If your position as Chief Executive ceases, your appointment as Accountable Officer will automatically be withdrawn. Next steps You should familiarise yourself with the principles set out in Managing Welsh Public Money, as well as the standards of good governance set for the NHS in Wales - and embodied within the Assembly Government’s Citizen Centred Governance Principles - and the contents of the NHS Wales Governance e-manual www.NHSWalesGovernance.com I would be grateful if you could complete the form enclosed and return it to Zoe Elston within fourteen days to acknowledge receipt of this letter and acceptance of the responsibilities placed upon you as an Accountable Officer. Yours sincerely

Dr Andrew Goodall

cc Sir Mansel Aylward, Chair, Public Health Wales NHS Trust Enc

http://www.nhswalesgovernance.com/

APPOINTMENT AS ACCOUNTABLE OFFICER

I acknowledge receipt of your letter appointing me as the Accountable Officer for: ………………………………………………………….. NHS Trust and confirm I have read the Accountable Officer Memorandum enclosed with your letter and accept the responsibilities placed upon me as an Accountable Officer. Signed: ……………………………………….. Date: ………………….. Please return completed form to: Zoe Elston Workforce and Organisational Development Department for Health and Social Services Welsh Government 2nd Floor Cathays Park CARDIFF CF10 3NQ

Yr Adran Iechyd a Gwasanaethau Cymdeithasol Dirprwy Brif Weithredwr Dros Dro, GIG Cymru Department for Health and Social Services Deputy Chief Executive, NHS Wales

Parc Cathays ● Cathays Park Caerdydd ● Cardiff

CF10 3NQ

Ffôn ● Tel 02920 801182/1144

[email protected]

Gwefan ● website: www.wales.gov.uk

Dr Tracey Cooper Chief Executive Public Health Wales 14 Cathedral Road Cardiff CF11 9LJ

Our Ref: SD/MR/DCL

17 June 2014 Dear Tracey Public Health Wales JET meeting Thank you for attending the JET meeting on 4 June 2014 with your Executive Team to discuss the end of year position against a number of key areas. I recognise this has been a challenging year for your organisation, with both the change in leadership during the year and dealing with the measles outbreak in ABMU. You recognised there were opportunities to strengthen the links between PHW and Welsh Government. You reported that your focus for the coming year was on smoking cessation, screening and building more effective relationships with Health Boards. We started our conversation discussing smoking cessation. You reported that a great deal of work had been done over the last year, including changing the service model which had resulted in waiting times reducing to six days, and that you are looking at ways to improve the data. You recognised there were issues around communication with Health Boards, and it was agreed that a meeting involving all parties would be set up to help resolve them. It was also agreed that further conversations would take place regarding the required increase in episodes of care planned for the coming year to meet the target. We discussed the MAMs smoking cessation project, and I would encourage you to ensure the evaluation of this project is carried out swiftly. You reported on the improvements made in immunisation rates, with the MMR1 figure the highest in the UK, and the MMR2 figure the 2nd highest. This improvement in performance is noted and welcomed. I recognise the improvements made in flu vaccination rates, particularly the improvement in the number of NHS staff receiving the vaccine. It is

mailto:[email protected]

www.wales.gov.uk

important this improvement is continued into the coming year. You reported you have introduced three new vaccine programs this year, and you are committed to deliver further improvements, even though you only have a small team. I note you report you are doing additional work with local partners and communities, as well as working with Flying Start teams. You need to continue this collaborative approach going forward. On screening, you reported that there remain some long standing challenges, particularly with some of the cancer screening programmes, notably around provision of diagnostic assessments such as colonoscopies and cervical histology by Health Boards. You reported you are developing a suite of key messages to be used to support raising awareness, including some of the gender issues around bowel screening. You reported there are issues with working with Health Boards, and it is important that you resolve these issues as a priority. Your priority for the year was around improving efficiency, and are aiming for a 14 day turnaround for cervical screening. You reported that following a survey, 23% of patients were interested in breast screening at “unsocial” hours, and you are now looking at how this may be implemented. On health improvement, you reported that the mechanism to deliver has changed and that the working groups are due to report in July, with implementation then taking place up to the autumn. It is important that you have a representative from the Directors of Public Health on your group, and it was agreed that the CMO would follow this up. You reported a 19% drop in the number of c-difficile cases during the year, but recognise that the target is for zero. There has been a slight rise in the reported number of both MRSA and MSSA cases. You reported that you are in the process of formally establishing a group to develop a plan for antimicrobial resistance. Your main cause for concern going forward is the pace at which you will be able to implement as you only have a small team of people to do this. You reported that you are now carrying out e-coli surveillance after concerns had been raised. On microbiology, you reported that you now have a single service in place across North Wales, and have appointed a new Director of Operations. A new SLA with Health Boards needs to be developed. It is important that you look at prudent healthcare requirements in the number of tests that you are carrying out. I was pleased to hear that your microbiology network service has received CPA accreditation. We discussed user experience and you reported that you have implemented a new framework and have agreed action plans for each program. It is important for equality that you continue to aim to contact those hard to reach groups. It was noted that you are learning from the SUIs reported, and that action plans have been put in place, and that all SUIs are reported to the Quality & Safety Board. You reported that there are issues with autoclaves and estate management. It was agreed that this would be pursued further with relevant Chief Executives and Nursing Directors. You reported that a number of issues had been picked up over the last year in relation to health care quality, including prudent health, unscheduled care and the 1000 lives plus programme. You reported that a paper produced with McMillan had been supplied to the Minister on patient information, and it was agreed that a further discussion would take place outside of the meeting. I noted that you are working on developing your relationship with Health Boards, and are working with Sharon Hopkins, Director of Public Health in Cardiff to develop the SLA. You also reported that you are holding face to face meetings with organisations. It is clear that

this is an area that needs to be developed and improved in the coming year. On planning, you reported that you are working to the end of June to deliver your one year plan, and are learning lessons in preparing your IMTP for next year. You have established a new Policy, Research and Development division and appointed a Director. You recognise there is further work to do, including establishing further links with universities. You reported that you are aligning your workforce to the IMTP, and are developing the skills within the team so as to provide effective leadership. You are tackling staff appraisals and providing training where necessary. You reported that your medical appraisal rate is 100%. This is an important area and needs to be maintained. You reported that you had governance arrangements in place to cover both the vacancy created due to having no substantive Chief Executive, and to cover the absence of the Chair. You are working to get TUS representation on the Board, and there is a development programme on-going. You also reported that you are looking at accommodation issues, as the organisation is currently spread over 50 different locations across Wales. In summary, this has been a year with a number of successes. However, there are areas where further work is required, including the building of effective relationships with Health Boards. I would be grateful if I could have a response to the issues raised in my letter by 27 June 2014. Yours sincerely

Simon Dean

PHW AC 22:01

Date: 06/06/14 Version: 1 Page: 1 of 8

Minutes of the twenty

first meeting of the Public Health Wales Audit

Committee Date of meeting: 12 March 2014

Time of meeting: 13:00 – 15.00

Venue for meeting: Boardroom, 14 Cathedral Road, Cardiff

Version: 1

Present:

Mr Terry Rose (Chair)

Board Member, Public Health Wales

Dr Carl Clowes Board Member, Public Health Wales

Mr John Spence Board Member, Public Health Wales

Mr Huw George Interim Chief Executive Officer, Public Health Wales

Mr Mark Dickinson Director of Planning and Performance, Public Health Wales (in part)

Mrs Tamira Rolls Interim Director of Finance, Public Health Wales


Mr Jeremy Saunders

Wales Audit Office

Mr Ian Virgil NHS Wales Shared Services Partnership – Audit & Assurance Services

Mr James Johns NHS Wales Shared Services Partnership – Audit & Assurance Services

Ms Eleanor Higgins Corporate Governance Manager, Public Health Wales

Mr Christopher Orr Business Support Manager, Public Health Wales

Ms Gay Reynolds Corporate Services Manager

Apologies:



Mr Anthony Ford Wales Audit Office

Mr Keith Cox Board Secretary, Public Health Wales

Mr Craig Greenstock Cardiff and Vale University Health Board – Counter Fraud

Ms Jayne Gibbon NHS Wales Shared Services Partnership – Audit & Assurance Services

1. Welcome and apologies

The Chair welcomed all those in attendance to the twenty

first meeting of the Public Health Wales Audit Committee.

Apologies were received from Matthew Coe, Anthony Ford, Keith Cox, Craig Greenstock and Jayne Gibbon.

Ms Gay Reynolds was also in attendance.


There were no declarations of interest to register.

3. Minutes and matters arising

a) The minutes from the previous meeting were received

by the Committee and agreed as an accurate account subject to one minor amendment.

Action- Ms Gay Reynolds to provide the wording for

inclusion in the minutes to clarify the risk assurance process.

b) Ms Eleanor Higgins provided updates on the actions

currently in the action log

In the absence of Mr Cox no update on the review of library services arrangements could be provided however

it was agreed a short paper would be circulated to the

board members to provide them with an update. It was also agreed that the accountability arrangements with

Welsh Government are a Board and Chief Executive issue rather than solely for the Executive team.

Action-Mr Cox to include a paper regarding library

services arrangements at a future Board meeting.


4. Revised Terms of Reference

a) Audit Committee

Ms Higgins presented the revised terms of reference to the

Committee and highlighted the changes that have been made from the previous terms of reference. Ms Higgins

brought the paragraph regarding the relationship between the Audit Committee and Quality and Safety Committee to

the Committee’s attention. Inclusion of this paragraph was welcomed. It was also agreed that further work was

required to ensure this relationship between Committees

is maintained and how we give the Committees assurance this is happening. Work plans for each Committee should

be agreed annually and the Board Secretary should monitor these plans to ensure there are no omissions. A

column on which Committee is responsible for the action should be added to the internal and external audit action

logs . It was agreed that individuals would also not be named within the terms of reference. The wording relating

to the quorum of a Committee would also be amended.

Action- Names to be removed from the terms of reference and column added to the internal and

external audit action logs detailing which Committee is responsible for the action.

b) Quality and Safety Committee

Ms Higgins informed the Committee that similar changes had been made to the Quality and Safety terms of

reference. These will be reviewed at the next Quality and Safety meeting.

It was agreed that both sets of terms of reference would

be brought to the Board for approval in June 2014.

5. Audit Committee work plan

Ms Higgins introduced the Audit Committee work plan for

2014-2015. This document was welcomed by the Committee and set out the work of the Committee very

clearly. Wales Audit Office requested that local audit work is included within the work plan and the internal and

external audit log would be added as standing items.

Action- Ms Higgins to include additional items into


work plan.

6. Wales Audit Office

a) Audit outline plan

Mr Jeremy Saunders presented the draft audit outline plan

2014/2015. Mr George raised the issue regarding audit fees and the difficulty in setting budgets without knowing

these costs. Mr Saunders informed the Committee that confirmation of these fees was expected in the next couple

of weeks.

The planned audit work on early intervention and public behaviour change was raised as an item of interest for

Public Health Wales and the Committee were keen to ensure Public Health Wales are actively engaged in this

audit work.

The Committee approved the report subject to minor amendments.

7. Internal Audit

a) Internal Audit progress Report

The above report was received and noted by the Committee members for information. The report provided

an update of work against the internal audit plan. Mr Ian Virgil highlighted that the statutory and mandatory audit

had been followed up and there were slippages with regard to the recommendations and actions however these

were being addressed through the internal audit action

log. Mr Virgil also informed the Committee that the planned audit on performance reporting would now be

taking place in 2014/2015.

b) Final audit report for review of Screening

services

This paper was withdrawn from the meeting as response from management had yet to be agreed.

8. Counter Fraud progress report



an update of the key work carried out this year to date by

the Counter Fraud team.

Ms Tami Rolls on behalf of Mr Craig Greenstock informed the Committee that the one case that was open has now

been closed and no further action is to be taken.

9. Internal Audit action log

Ms Eleanor Higgins updated the Committee on the internal

audit action log.

The Committee were pleased to see the progress being made with statutory and mandatory training and were

informed a fuller update on business continuity arrangements will follow at the next meeting.

10. External Audit action log

Ms Tami Rolls updated the Committee on the external audit action log.

Ms Rolls informed the Committee that she had been

unable to get an update for action no.43 and this update will be provided at the next meeting.

11. Procurement report

Ms Tami Rolls presented the Procurement report to the Committee for information. The Committee received the

report.

12. Year end and annual accounts timetable

Ms Tami Rolls presented the year end accounts timetable to the Committee. This outlines the time table for the

production of the annual accounts and when they will be

received by various groups and Committees.

13. Draft Annual Governance Statement

Ms Eleanor Higgins presented a paper outlining the drafting process of the Annual Governance Statement for

2013/14. The annual governance statement will take into account all the recommendations received from the Wales

Audit Office last year and a draft will be circulated .


14. Audit fees letter

This paper was received for information.

15. Clinical Negligence and Personal Injury Claims

update

This paper was received for information.

16. Publication of papers

It was agreed by the Committee that all papers should be

published except the procurement report, year end and accounts timetable and draft annual governance

statement.

11 Any Other Business

There was no other business to be discussed.

12. Dates of next meetings

08 May 2014 05 June 2014

11 September 2014 11 December 2014

PHW AC 22:01


ACTIONS

No. Action Who Start End Status Revised Implementation

date

16.3 Develop an Action Plan to track

progress on implementation of recommendations from report

into management arrangements in Screening

Division.

RF 20.03.13 06.06.13 Complete- Action

plan presented at Board meeting on 29 April 2014.

19.8 Provide Board with more

information on the review of

library services arrangements

KC 18.09.13 18.12.13 Complete- This will

now be picked up as action 21.02

05.06.14

20.01 Audit Committee to take

forward identified actions as outlined in Appendix 1 of paper

20.02.

Audit

Committee

18.12.13 12.03.14 Complete

20.02 Arrange a development session for Audit Committee, internal

audit and external audit to discuss findings of the self

assessment.

CO/EH 18.12.13 12.03.14 This action will be addressed through the wider Board

development work which is currently

ongoing

20.03 Item to be added to agenda of

a future meeting to examine risk in more detail.

CO/EH 18.12.13 12.03.14 To be included

within the Audit Committee work plan

20.05 Board member survey and EH/CO 18.12.13 12.03.14 This action will be


recommendations from Structured Assessment to be

discussed at a future informal

Board meeting.

addressed through the wider Board

development work which is currently

ongoing

20.08 Executive team and Board to

consider the next steps to address the accountability

arrangements with Welsh Government.

Board 18.12.13 12.03.14 In progress

21.01 Provide the wording for inclusion in the minutes to

clarify the risk assurance

process.

GR

12.03.14 05.06.14 Complete

21.02 Include a paper regarding

library services arrangements at a future Board meeting.

KC 12.03.14 05.06.14 In progress

21.03 Names to be removed from the

Audit Committee terms of reference

EH 12.03.14 05.06.14 Complete- Terms of reference included

on Board agenda for June Meeting

21.04 Add column to internal and external action log to reference

which Committee is responsible for the action.

CO 12.03.14 05.06.14 Complete – column added

21.05 Add additional items into Audit

Committee work plan 2014/2015.

EH 12.03.14 05.06.14 Complete – items

added.

PHW AC 23:01


Minutes of the twenty

second meeting of the Public Health Wales Audit

Committee Date of meeting: 08 May 2014

Time of meeting: 13:00 – 15.00

Venue for meeting: Boardroom, 14 Cathedral Road, Cardiff

Version: 1

Present:

Mr Terry Rose (Chair)

Board Member, Public Health Wales

Mr Huw George Interim Chief Executive Officer, Public Health Wales

Mr Keith Cox Board Secretary, Public Health Wales

Mrs Tamira Rolls Interim Director of Finance, Public Health Wales


Mr Jeremy Saunders

Wales Audit Office

Ms Jayne Gibbon NHS Wales Shared Services Partnership – Audit & Assurance Services

Mr James Johns NHS Wales Shared Services Partnership – Audit & Assurance Services

Ms Eleanor Higgins Corporate Governance Manager, Public Health Wales

Mr Christopher Orr Business Support Manager, Public Health Wales

Apologies:

Dr Carl Clowes Board Member, Public Health Wales

Mr John Spence Board Member, Public Health Wales

Mr Anthony Ford Wales Audit Office


Date: 06/06/14 Version:1 Page: 2 of 8

Mr Craig Greenstock Cardiff and Vale University Health Board – Counter

Fraud

1. Welcome and apologies

The Chair welcomed all those in attendance to the twenty second meeting of the Public Health Wales Audit

Committee.

Apologies were received from John Spence, Carl Clowes, Anthony Ford, Craig Greenstock and Gabby Smith.

The Chair informed the Committee that no decisions could

be made at the meeting as the Committee were not quorate.


There were no declarations of interest to register.

3. Minutes and matters arising

As the meeting was not quorate the minutes were not

discussed. These would be approved at the meeting on the 5 June 2014.

4. Draft annual accounts

Ms Rolls provided a short presentation to the Audit

Committee summarising the draft annual accounts that were submitted to the Wales Audit Office on 2 May 2014.

Ms Rolls also informed the Committee that Tracey Cooper, as the Accountable Officer and Huw George, as Director of

Finance, will sign off the accounts on the 6 June 2014.

Dr Clowes had provided comments to the Committee in

advance of the meeting and questioned why Public Health Wales was not a member of the Carbon Reduction

Commitment Scheme. It was agreed that Ms Rolls would look into this and feed back with additional information.

Action- Find out further information on the Carbon

Footprint reduction Scheme and why Public Health Wales is not a member.

Ms Rolls informed the Committee that the Remuneration


paper had not been included in the papers but would be

circulated to Committee members.

Action- Circulate Remuneration Report to Audit Committee members.

Following the discussions, the Chair thanked Ms Rolls and

her team for the work that has been undertaken throughout the year to produce the draft accounts.

5. Annual Governance Statement

Ms Higgins presented the draft Annual Governance Statement to the Committee. The Committee noted a few

minor formatting amendments and were pleased with the content of the statement.

The Chair thanked Ms Higgins for her work on the Annual

Governance Statement to date.

6. Wales Audit Office

a) Audit Position Statement

Mr Saunders presented the Audit Position Statement. Work had commenced to audit the annual accounts and Mr

Coe informed the Committee that there were no further updates on the planned audit work on early intervention

and public behaviour change. He also informed the Committee that Ms Smith, following a conversation with Dr

Sandifer, has agreed that the Wales Audit Office review of Microbiology management arrangements will be published

later this month. Ms Higgins also informed the Committee

that the majority of the comments on the draft Annual Governance Statement had been included in the latest

version and work is underway to incorporate the remaining comments.

b) Outline of Audit work 2014

Mr Coe presented the outline of audit work 2014. The

Committee received the draft outline at the meeting in March 2014. Mr Coe brought the audit fee section to the

attention of the Committee. This outlines the increase in audit fees for 2014-2015 due to the new fee setting

requirements on Wales Audit Office that came into effect from 1 April 2014. The Chair questioned the justification

for the 5.7% increase in fee for next year. Mr Coe


explained that this increase is proportionate and had to be

adjusted to fully comply with their statutory requirements.

Mr Huw George informed the Committee that discussions had taken place with the Wales Audit Office and it had

been agreed that the Wales Audit Office would provide Public Health Wales with a three year plan for the

performance audit work and would highlight added value.

The Committee accepted the increase in audit fees for 2014/2015.

The Committee received both reports.

7. Internal Audit

a) Internal Audit progress Report


an update of work against the internal audit plan. A draft

internal audit plan for 2014/2015 has been issued for comment.

b) Welsh Risk Pool claims management

The above report was received by the Committee. The

audit identified no weaknesses during the review and no areas identified that require management action. The

overall assurance rating for this review was substantial.

c) Financial systems review

The above report was received by the Committee. Internal audit provided reasonable assurance as to the

effectiveness of the system of internal control to manage

the risks associated with the objectives covered in this review. Mr George informed the Committee that the Board

were aware of the likely failure to meet the Public Sector Payment Policy(PSPP) target at an early stage and

appropriate processes were in place. The Committee also requested that this should be reflected in the Annual

Governance Statement. Ms Higgins confirmed that this was referred to in the Annual Governance Statement.

Action- Ensure Annual Governance Statement refers

to Audit Committee and Board’s early involvement in


addressing the issues surrounding meeting the

(PSPP) target.

d) Screening Services – service modification

The above report was received by the Committee.

Reasonable assurance has been provided by Internal Audit as to the effectiveness of the system of internal control in

place to manage the risk associated with the modernisation of Breast Screening Services. The two key

findings were in relation to risk management and that the Implementation Project Board did not include a member of

the trust Board. Following discussions outside the meeting

it has been agreed that a lead Non-Executive Director will be nominated for each major programme however they

will not be required to attend every meeting and will receive updates from the relevant Executive Director. The

nominated Non-Executive Director will then report any issues or concerns at Board meetings.

e) Asbestos Management

The above report was received by the Committee. Internal

audit provided limited assurance to the effectiveness of the systems of internal control to manage the risk

associated with asbestos management. The Committee were informed of the significant improvements that have

been made in this area however at the time of review only

limited assurance could be provided as these systems have not been fully embedded. Internal audit will be

following up this review later in the year which will hopefully provide an improved position.

8. Procurement report

Ms Tami Rolls presented the procurement report to the

Committee for information. The Committee received the

report.

9. Any Other Business

There was no other business to be discussed.

10. Dates of next meetings

05 June 2014

11 September 2014


11 December 2014

PHW AC 23:01


ACTIONS

No. Action Who Start End Status Revised Implementation

date

20.02 Arrange a development session

for Audit Committee, internal audit and external audit to

discuss findings of the self assessment.

CO/EH 18.12.13 12.03.14 This action will be

addressed through the wider Board development work

which is currently ongoing

20.03 Item to be added to agenda of

a future meeting to examine

risk in more detail.

CO/EH 18.12.13 12.03.14 Complete. Item

included on Audit Committee work

plan

20.05 Board member survey and recommendations from

Structured Assessment to be discussed at a future informal

Board meeting.

EH/CO 18.12.13 12.03.14 This action will be addressed through

the wider Board development work which is currently

ongoing

20.08 Executive team and Board to

consider the next steps to address the accountability

arrangements with Welsh Government.

Board 18.12.13 12.03.14 In progress

21.02 Include a paper regarding KC 12.03.14 05.06.14 In progress


library services arrangements at a future Board meeting.

21.04 Add column to internal and

external action log to reference which Committee is responsible

for the action.

CO 12.03.14 05.06.14 Complete. Column

has been added to internal and external action log.

21.05 Add additional items into Audit

Committee work plan

2014/2015.

EH 12.03.14 05.06.14 Complete

22.01 Find out further information on

the Carbon Footprint reduction Scheme and why Public Health

Wales is not a member.

CO 08.05.14 05.06.14 Complete

22.02 Circulate Remuneration Report to Audit Committee members

TR 08.05.14 05.06.14 Complete

22.03 Ensure Annual Governance Statement refers to Audit

Committee and Board’s early involvement in addressing the

issues surrounding meeting the (PSPP) target

EH 08.05.14 05.06.14 Complete

PHW IGC 16:01

Minutes of the fifteenth Meeting of the Public Health Wales Information

Governance Committee Date of meeting: 12 March 2014

Time of meeting: 15.00 – 16.00

Venue for meeting: Boardroom, 14 Cathedral Road

Version: 1

Present:

Mr John Spence Board Member (Chair)

Mr Terry Rose Board Member Dr Carl Clowes Board Member

Mr Huw George Chief Executive

Mr Mark Dickinson Executive Director of Planning and Performance Mr John Morley Information Governance Manager

Mr Christopher Orr Business Support Manager Ms Jane Evans Information Governance Manager

Ms Eleanor Higgins Corporate Governance Manager Dr Quentin Sandifer

Director of Public Health Services

1. Welcome & apologies for absence

The Chair welcomed the Committee to their fifteenth

meeting.

No were no apologies for absence.

2. Declarations of Interest There were no declarations of interest to register.

3. Minutes from Information Governance Committee

meeting held on 18 December 2013


The minutes from the previous meeting were checked for

Public Health Wales Minutes – Information Governance

Committee


accuracy and approved.

b) Actions arising

A verbal update on all actions arising was given by Mr Mark Dickinson.

4. Minutes from Information Governance Working Group meeting held on 4 February 2013

The minutes were noted by the Committee.

5. MeetingSphere

Mr Mark Dickinson informed the Committee that the relevant checks and enquiries had been made and that

MeetingSphere software was no longer considered an information governance risk regarding the use of cloud

services.

6. Information Governance Updates

a) EU Data Protection update

Mr Mark Dickinson informed the Committee that significant

progress had been made with regard to the EU Data

Protection Act. The Committee need to be clear what effect and impact this legislation will have on Public Health

Wales and a report will be provided to the next Committee meeting.

Action- provide a report to the Committee on the

potential impact and risks if the EU Data Protection Act is introduced.

b) Section 251 update

Mr Mark Dickinson informed the Committee that we are

currently awaiting a memorandum of understanding from the Confidentiality and Advisory group and the

Department of Health.

c) Mail Marshall update

The Committee were informed that a paper will be

submitted to the Exec team proposing the switch of Mail Marshall into ‘enforce mode’ with the aim to have this in

place by 1 May 2014.


Committee


7. Information Governance Risk Register

The risk register was discussed by the Committee. It was

agreed that further discussions are required as to what risks are regarded as ‘tolerable’ and the language used

within the risk register needs to be reviewed.

Action: include an item on agenda for next meeting where risk appetite can be reviewed.

8. Freedom of Information Act Report

The above report was presented for information purposes.

The Committee received and discussed the paper.

9. Information Governance incident report

The above paper was presented for discussion.

The Committee were informed that Incident 1522 had now been closed and a letter from the Information

Commissioner’s Office has been received closing the

incident.

The Committee received the papers.

10. Information Governance incident trend report

Mr John Morley presented the incident trend report to the Committee. This will be a standing item on the agenda

every 6 months.

The Committee received the papers.

11. Information Governance training report

The Information Governance training report was presented to the Committee. The Committee were informed that

since the papers had been circulated the compliance rate had increased from 69% to 75%. The Committee were

assured that the target of 80% should be met by the end of March 2014.

There was also discussion with regard to how often the training needed to be completed. At present this is every 3

years however a discussion is needed to establish whether


Committee


this is a suitable frequency or whether it should be

reduced to 1 or 2 years. It was agreed that the frequency of training would be discussed further after the end of this

financial year.

Action: arrange for discussion at next meeting on whether frequency of IG training should be reduced

from 3 years to 1 or 2 years.

12. ICO Closure Letter

This paper was received for information. The letter

confirms that no further action is to be taken with regard to this incident.

13. Care.data

This paper was received for information. The Committee were keen to find out how NWIS are using this

information. There is also the potential that if the EU Data Protection Act is passed, this legislation could override

care.data.

14. Publication of papers

It was agreed that all papers should be published except for the appendix to the information governance incidents

paper.

15. Dates of next meetings 05 June 2014

11 September 2014 11 December 2014

16. AOB

Mark Dickinson updated the Committee on two outstanding information governance incidents which had

been reported in the past week. Once concerned a complaint which had been made directly to the

Information Commissioner and the other concerned a complaint against inappropriate access to data. Further

information would be provided at the next meeting.

PHW IGC 16:01

ACTIONS

No. Action Who Start End Status

15.1 Provide an update on the CPIP-

improvement plan on a 6 monthly basis.

JM/JE 18.12.13 05.06.14 Complete

15.2 Review risk of using MeetingSphere

and report back to the Committee at the next meeting.

MD 18.12.13 12.03.14 Complete- Committee have been

assured that MeetingSphere is not considered as a risk.

15.3 Circulate letter from Mel Evans to

Committee members.

MD 18.12.13 12.03.14 Complete

15.4 Inform Welsh Government when information is released to the media

under FOI

JM 18.12.13 12.03.14 Complete- reported via two routes on a weekly basis. Internally this is done through the Communications team and

externally from the FOI group.

15.5 Prioritise statutory and mandatory

training and hold managers to account for staff attendance at

training

HG 18.12.13 12.03.14 Complete

16.1 Provide a report to the Committee on the potential impact and risks if

the EU Data Protection Act is introduced.

MD 12.03.14 11.09.14 In progress – will be discussed by refreshed Information Governance Working Group and further update

provided at Committee meeting in September.

16.02

Include an item on agenda for next meeting where risk appetite can be

CO 12.03.14 11.09.14 In progress – will be discussed by refreshed Information Governance


Committee


reviewed Working Group and further update provided at Committee meeting in

September.

16.0

3 Arrange for discussion at next

meeting on whether frequency of IG training should be reduced from 3

years to 1 or 2 years.

CO 12.03.14 11.09.14 In progress – will be discussed by

refreshed Information Governance Working Group and further update

provided at Committee meeting in September.

Joint Executive TeamMeeting 2013/14

Insert name of presentation on MasterSlide

Meeting 2013/14

4 June 2014

Introduction• Overview of 2013/14

• Critical Issues in 2013/14 and challenges• Critical Issues in 2013/14 and challengesfor 2014/15

• Integrated Medium Term Plan

• Emerging and developing priorities

• Research Development and Innovation

• Workforce and Organisational Development• Workforce and Organisational Development

• Governance

• Conclusion

Presenter: Tracey Cooper

Overview 2013/14

• Refreshed strategy

• Health Improvement Review conclusion• Health Improvement Review conclusion

• New programmes implementation

• Excellent cancer detection rate

• Measles response

• Observatory reports• Observatory reports

• Health Technology Funding

• Another year balanced financially

Presenter: Huw George

Critical issues 2014/15

• Smoking rates

• Screening uptake• Screening uptake

• Immunisation

• Relationship with health boards and thewider system

• Focus on outcomes• Focus on outcomes



Smoking cessation

Presenter: Peter Bradley

Successes and concerns• Reduced waiting times to 6 days

• Increased appointment availability• Increased appointment availability

• Increased translation of contacts intotreated smokers

• Improved performance management

• New initiatives

• Smoking in pregnancy pilots potential• Smoking in pregnancy pilots potential

• Need to change service delivery model toreach 16% target


Actions for 2014/15

• Formal agreement with DsPH and jointaction plans and performance meetingsaction plans and performance meetings

• Targeted action

• Service delivery model options appraisal

• Brief interventions training programme

• Social marketing campaign• Social marketing campaign

• ‘Stoptober’ campaign

• Online booking, apps etc



Immunisation

Presenter: Quentin Sandifer

• Successful measles outbreak response

Successes and concerns

• Successful measles outbreak response

– 75,000 MMR vaccine doses delivered

• Highest ever MMR uptake for Wales

– 96.5% for MMR1 at 2 years

– 92.6% for MMR2 at 5 years

• Tier 1 target for childhood vaccination at• Tier 1 target for childhood vaccination atage 4: 87.5% (target: 95%)



• Flu vaccination• Flu vaccination

– 2.5% increase in under 65 at risk

– No change in over 65 flu rates

– Only one NHS organisation on target


Actions for 2014/15

• Surveillance of disease, epidemiologicalanalysis and interpretation of vaccination

• Surveillance of disease, epidemiologicalanalysis and interpretation of vaccinationuptake data

• Inform policy and guidance

• Support partner agencies to meettargetstargets

• Inform and educate NHS Wales and thepopulation


Screening


Screening



• Implemented AAA and newborn bloodspotand change in age range for cervical

• Implemented AAA and newborn bloodspotand change in age range for cervicalscreening

• Developed new sickle testing protocol

• First home nation to go fully digital inbreast screeningbreast screening

• Consistently highest cancer detection rateof any UK breast screening programme



• Health board performance (timeliness)against provision of diagnostic

• Health board performance (timeliness)against provision of diagnosticassessment services e.g. colonoscopy(up to 11 weeks) and cervical histology(up to 6 weeks)

• Poor uptake in bowel programme and• Poor uptake in bowel programme andfalling uptake in breast programme


Actions for 2014/15• Targeted support to health boards

• Formal project to address uptake• Formal project to address uptake

• Cervical modernisation programme andHPV ‘test of cure’ in September andplanning for triage in cytology

• 14-day turnaround time cervicalscreening methodologyscreening methodology

• Improving breast and cervical timeliness

• Transfer of diabetic retinopathy service



Transforming healthimprovementPresenter: Peter Bradley


• Completed review: Transforming HealthImprovement in WalesImprovement in Wales

– Not reaching large proportion of thepopulation

– Some had no evidence base

• Established programme to overseeimplementation of recommendationsimplementation of recommendations

• Disinvestment process

• Ongoing delivery of ‘legacy’ programmes


Actions for 2014/15

• Transforming Health Improvementprogramme on scheduleprogramme on schedule

– Infrastructure established

– Ongoing engagement with DsPH/local teams

– Expert groups to report by end July 2014

– Detailed work plans by November 2014

– Implementation of work plans from November– Implementation of work plans from November

• Health Improvement Alliance to promoteinnovation and advocacy


Integrated Medium Term Plan &Budget Setting

Healthcare associatedinfections



• Epidemiological intelligence, direct supportand published outputsand published outputs

• BCUHB Clostridium difficile outbreak

• Review of death certification associatedwith Clostridium difficile

• Health board targets and Code of Practice

• Downward trend in Clostridium difficile (-• Downward trend in Clostridium difficile (-19.2%); increase in MRSA (+2.5%);increase in MSSA (+3.2%)


Actions for 2014/15

• Provide epidemiological analysis andinterpretation of bacterial infections

• Provide epidemiological analysis andinterpretation of bacterial infections

• Continue working with health boardsincluding support to large scale change

• Continue to advise and inform policy onHCAIsHCAIs

• Lead all-Wales action planning onantimicrobial resistance



Clinical microbiology



• Second ever network service to attainfull CPA accreditationfull CPA accreditation

• Single central laboratory established inRhyl, Wrexham service transfer andsingle North Wales microbiology service

• Modernisation programme to achieve asingle, national, managed microbiologysingle, national, managed microbiologyservice network

• Director of Operations


Actions for 2014/15

• Automated technology into bacteriologyservice in North Walesservice in North Wales

• Develop formal commissioner-providermodel for microbiology services

• New performance management framework

• Secure full clinical microbiologistengagement in local HCAI actionengagement in local HCAI action

• ISO 15189 accreditation by June 2016

• Infectious diseases genomics service



Service user experience

Presenter: Rhiannon Beaumont-Wood


• Improved organisational focus

• Service User and Learning Panel established• Service User and Learning Panel established

• User experience, complaints/concernslearning & monitoring now combined

• National core questions do not adequatelycapture requirements

• Planning/evaluating changes to services• Planning/evaluating changes to services

• Creation of agreed PIs

• Better use of existing IT products



• Service example: Stop Smoking Walesclient feedback 1 Jan 2014 – 31 March

• Service example: Stop Smoking Walesclient feedback 1 Jan 2014 – 31 March2014

– 96% + of clients (263 individuals) weresatisfied or very satisfied with the supportthey received


Actions for 2014/15

• Improve data capture• Improve data capture

• Agree approach to reporting

• Dedicated resource

• Improved methods for sharing learning

• Performance framework being developed

• Agree and start Board reporting• Agree and start Board reporting

• Identify methods to inform service users ofimprovements resulting from feedback



Relationship with healthboardsPresenter: Huw George

Relationship with healthboards• Need clarity on roles and responsibilities

• Hold each other to account• Hold each other to account

• Pilot work with Cardiff and Vale

– Including key areas, specification based,agreed action, for implementation inSeptember

• Executive to Executive discussions• Executive to Executive discussions

– Betsi Cadwaladr

– Critical performance issues and ownership



Planning

Presenter: Mark Dickinson


• Refreshed strategy - Summer 2013

• Developed priorities for action - Autumn• Developed priorities for action - Autumn2013

• Developed initial draft IMTP - January 2014

• Refinement and strengthening of plan

• Plan and balanced budget approved byBoard - March 2014Board - March 2014

• Plan not approved and requirement toproduce one year plan by June 2014



• Development of, and reporting against,Quality and Delivery Framework

• Development of, and reporting against,Quality and Delivery Framework

• Contribution to Public Health OutcomesFramework

• Development of further performanceindicatorsindicators


Actions for 2014/15

• Operational Plan 2014/15• Operational Plan 2014/15

– Key areas to be further strengthened anddeveloped

– Updated sections on smoking and screeningperformance submitted

– Divisional Directors leading development ofrelevant sectionsrelevant sections

– To be approved by Board on 26 June


Actions for 2014/15

• Integrated Medium Term Plan

– Formal review of 2013/14 planning process– Formal review of 2013/14 planning process

– Key areas to be improved and specificactions

– Revised plan submitted by January 2015

• Further development of Quality andDelivery FrameworkDelivery Framework

• Complete Public Health OutcomesFramework



Emerging issues


Emerging issues

• Unscheduled care• Unscheduled care

• Prudent healthcare

• Large-scale change in relation tophysical activity

• Primary care vision

• Health inequalities• Health inequalities

• Public Health Bill support and co-ordination



Research and development



• New Policy, Research & DevelopmentDivision and Director

• New Policy, Research & DevelopmentDivision and Director

• Reorganisation including newgovernance structure and new strategy

• Research activity funds increase of£129k£129k

• Co-bidder for research grants



NISCHRUniversity University

InternalUniversity Issues

Pan walesPublic Health

Training &

Wales Government

R&DRequests

Governance

QualityAdministra on

Public HealthWales

Grant IncomeIden fica on

Research, Academic & Surge Requirements of Public Health Wales

Personal,Professional &Developmental

NISCHRUniversityContracts

Universitywork plans

Training &Capacity

Development

Ci zen’s Cohort

RequestsCMO support

Administra on

Ethics

Peer reviewStandards

WalesCapacity

DevelopmentEthos

Iden fica onManagement

Repor ng

New NISCHR Centre(s)for Public Health

Interna onalR&D

ResearchStrategy

Local TeamsNa onal

LeadsSAIL

Individual Staffing, Job Planning, AppraisalBangor - Primary Care 3 staff, Health Economic 3 staff

Cardiff - Public Health 2 staff; Swansea - Public Health 2staff

New and exis ng Joint GrantApplica ons

Personal ResearchOutputs

LeadershipNa onal Lead Violence

and AlcoholDepu sing for Execu ve

DirectorWHO

UKFPHR&D Engagement with other Universi es in Wales

and other Departments - Not progressed

R&D Engagement with other UK Countries -Not progressed

Programme evalua on and data systems development -Not progressed

Wales Health ImpactAssessment Unit

Academic Health Service Collabora on

R&DIntellectual

Property

R&D and Professional Training, Placements MPH, etc

Unscheduled Work / Surge Capacity - Resource

Honorary & New Joint Appointments and Hot Housing Func on to support short term recruitment

Academic Health Service Collabora on



Workforce and OrganisationalDevelopmentPresenter: Ruth Davies


• Work around culture and values• Work around culture and values

• Developing leadership and management

• Improved statutory and mandatorytraining

• Work on staff appraisals

Presenter: Ruth Davies

Actions for 2014/15

• Work on values and culture• Work on values and culture

• Leadership and managementdevelopment

• Learning and development plan

• Further work on mandatory training

• Upward feedback survey on staff• Upward feedback survey on staffappraisals

Presenter: Ruth Davies


Governance

Presenter: Keith Cox


• Interim arrangements to cover vacantChief Executive and absence of ChairChief Executive and absence of Chair

• Vacancy for local authority member

• Trade union/staff representation

• First Annual Quality Statement

• Staff engagement on Francis Review

• Programme to review accommodationneeds and ways in which we work


Actions for 2014/15

• Interim arrangements to cover the localauthority Board vacancy

• Interim arrangements to cover the localauthority Board vacancy

• Work to encourage BMA representation

• Good Governance Institute ‘rapid review’of Board, governance and riskmanagement arrangementsmanagement arrangements

• Work with Academi Wales

• Board Development programme


Actions for 2014/15

• Annual Quality Statement

• Francis Review report to Board in June• Francis Review report to Board in June

• Final decision on accommodation and waysof working options by September


A healthier, happier andfairer Wales

• Continued progress in 2013/14• Continued progress in 2013/14

• Build on our success

• Continue to develop the organisation andBoard

• Focus on delivery

• Focus on outcomes• Focus on outcomes

Presenter: Tracey Cooper

Thirty-second Board meeting - Public Health Wales

Documents

Transcript of Thirty-second Board meeting - Public Health Wales