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Governance and Accountability Module action planAuthor:Eleanor Higgins, Corporate Governance Manager and Keith Cox, Board Secretary
Date:8 February 2013 / Version:1
Purpose and Summary of Document:
The Public Health Wales Board are required to complete a self assessment to establish how well the organisation is being governed. The Governance and Accountability Module provides the framework for the self assessment. It is also a requirement of the Welsh Government and forms part of the supporting information for the Annual Governance Statement.
The Board requested than an action plan be developed against the self assessment to highlight areas for improvement. The action plan was presented to the Board in June 2013. This document provides a progress report against each action and will help inform the self assessment for 2013/14.
The Board are asked to receive the update to the action plan.
Sponsoring Executive Director: Keith Cox, Board Secretary
Who will present: Keith Cox, Board Secretary
Documents attached: Governance and Accountability Module action plan
Date of Board meeting: 21 February 2013
Committee/Groups that have received this paper: Executive Team
Please state of the paper is for:
Discussion / X
Decision
Information / X
Date: 29 January 2013 / Version:1 / Page: 1 of 15
Public Health Wales / Governance and Accountability Module Action Plan
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Governance and Accountability Module Action Plan
Theme 1 – Setting the Direction
Question / Paragraph / Action / CommentsWe make an effective contribution to the achievement of the strategic vision for health services in Wales / During 2012/13, Public Health Wales will lead a major review of health improvement activity in Wales, aimed at focusing increased resources on a limited number of key priorities in ways which will achieve the maximum impact on public health. (pg4) / Need to take this forward as part of the Health Improvement Review / Health Improvement review is due for completion March 2013.
The Public Health Development Division is also undergoing a re-structure which will help achieve this.
The ongoing development of the Public Health Wales Institute is aimed at improving the relationship between academia and service delivery in a way that will improve service effectiveness / Need to review progress being made. / The Institute is part of Public Health Wales and the functions are being taken forward under the title Academic/Service Collaboration. The Public Health Wales Board approved a way forward for this in October 2012 and work is developing in this area.
Our citizens, staff and other stakeholders inform and influence our organisation/business’s purpose, strategic vision and direction / Groups that we engage with have become more established than last year although our engagement with local government should be strengthened / Review engagement with local government. / There is currently a vacancy on the Public Health Wales Board for the Local Authority representative. This has hindered our work with local government slightly. Further work needs to be done on this.
A Public and Stakeholder Engagement Strategy has been drafted and consulted upon, for presentation to the Board in April 2012. The strategy seeks to ensure that the ongoing development of Public Health Wales’ strategic direction is informed and influenced systematically by citizens and other stakeholders. (pg8) / Carry out review on progress of Public and Stakeholder Engagement Strategy / The Board approved the strategy and it was implemented across the organisation in April 2012. The Communications team will develop an action plan and evaluation to ensure staff are compliant. This work is planned for May / June 2013.
The Board has also recently agreed a new Social Media Strategy. (pg8) / Carry out review on progress of Social Media Strategy / Since the approval of the Social Media Strategy it has become clear that further work is needed in this area. Further guidance is being developed for those members of staff who use social media in a personal capacity as well as a professional capacity.
We carry out our work instilled with a strong sense of values, supported by clear standards of ethical behaviour / The Board Secretary has a responsibility for leading the design and ongoing development of governance and assurance framework for the Trust to ensure that it meets the standards of good governance set for the NHS in Wales. (pg11) / Carry out review on governance and assurance framework, ensuring that this has been strengthened further / A Corporate Governance Manager has recently been appointed. Part of this role will be to review the governance and assurance framework for the organisation. The Wales Audit Office have recently completed their Structured Assessment and recommendations within that have been made to improve governance within the organisation. These recommendations will be taken forward in early 2013.
The Board Committees have been established, each with an agreed terms of reference. Each committee is chaired by an independent member and meets quarterly. Mechanisms are in place, through the committee structure, to ensure compliance with key legislation. (pg11) / During 2012/13 Committee papers were published after each meeting. / With the departure of the Local Authority NED the membership of the Audit and Information Governance Committees has been refreshed. There is a new chair of the Audit Committee and a new chair of the Information Governance Committee.
A further review of the Committees and their membership will be carried out in May / June 2013 which will be 12 months after the Committee membership was refreshed.
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. The Board had noted that the policies were being held-up due to the lack of Partnership Forum meetings but that this has now largely been resolved. (pg11) / Check that all policies are up to date – ascertain if and why there have been any delays inapproval / Policies are being reviewed and updated according to priority.
Regular policy and Partnership Forum meetings have been established to progress and agree policies between management and trade union representatives. This has resulted in an improvement in the time it takes approve policies.
We promote equality and recognise diversity across all our services and activities / For example, Public Health Wales is taking forward a major programme of work looking at health literacy in Wales. This explores new and innovative ways of communicating and engaging with severely disadvantaged people who have difficulty in reading, understanding or interpreting health related literature. (pg12) / Review progress made in developing the Health Literacy Programme / A report has been compiled and submitted to the Health Improvement Division in Welsh Government and we are awaiting a response from them to inform the next steps.
Public Health Wales has developed its own Strategic Equality Plan which will be presented to the Board in April 2012 for approval. Further work nevertheless needs to be done on this plan. (pg12) / More work required on Strategic Equality Plan / The Strategic Equality Plan was finalised and approved in October 2012. An Equality Group has been established and equalities intranet pages have been set up for the organisation. The Board Secretary is the interim strategic lead for equality and diversity.
There is no mention of the Disability Discrimination Act in relation to access to buildings. The Accommodation Review will address this issue, so should re-visit it next year to assess progress. / The accommodation review is due to start early 2013 and will take this into account. The organisation has also recently recruited an accommodation manager who will be able to address this issue.
The Public Health Welsh Language Scheme and actionplan demonstrates the organisations commitment to offering bilingual services to the public of Wales. The 2011 Annual Monitoring Report demonstrates progress against the action plan. (pg13) /
- Review progress of 2011 Annual Monitoring Report against Welsh Language Commissioner’s Action Plan
- Ensure successful recruitment of a Welsh Language Officer
The Welsh Language Monitoring report was completed and presented to the Board in June 2012.
The Board also received a presentation from the Welsh Language Commissioner, Meri Huws, at their Board meeting in December 2012. Public Health Wales will be contributing to the Commissioner’s inquiry into the Welsh language in healthcare.
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 / The Quality and Safety Committee are reviewing the way it receives and reviews information with the view to being more proactive on Quality Performance measures. (pg15) / Review whether this is working and if Quality and Safety Committeehave been monitoring Quality Performance on timely basis. / The Chair of the Quality and Safety Committee ,Director of Planning and Performance, Director of Public Health Services and Board Secretary are reviewing the work the Committee receives. This is linked to the planning and performance framework which is being developed.
Revalidation is the process by which licensed doctors will demonstrate to the GMC that they remain up to date and fit to practise. Revalidation is expected to start from late 2012. (pg17) / Review if the revalidation system is operational and effective / The Director for Public Health Services is the organisation’s Revalidation Officer. The first round of revalidation will take place in April 2013.
Non medical staff take part in the KSF review process which defines and describes the knowledge and skills required for their post in order to deliver a quality service. (pg17) / KSF system ceased to exist on 30 March 2012. Check if appraisal process has been put in place for non-medical staff / A new appraisal process has been put in place by the Professional and Organisational Development Team. This has been publicised within the organisation and line managers are encouraged to use it.
Screening Services quality manuals contain QA standards for each aspect of work undertaken. Microbiology Services are monitored via CPA accreditation compliance with national standards. The Trust is also required to under self assessments against the Standards for Health Services in Wales. (pg17) /
- Review if we are showing improvement in carrying out self assessments
- Review if divisional staff are co-operating with properly filling in the self assessments
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? / At present, we are managing considerable legacy activity from previous organisations which were assimilated into Public Health Wales NHS Trust. Work is already well advanced in establishing a review to realign the many health improvement programmes. Whilst we have developed a strategy for the future we face challenges in developing an operational plan linked to our strategy because so much of our activity is governed by Programme Level Agreements (PLAs) which, in some cases, entail undertaking activities which are not clearly linked to our overall strategic goals (pg18). /
- The development and implementation of the organisations Strategic Delivery Plans will take much of this forward. We will need to review progress throughout the year.
- Review whether actions have been achieved
Strategic delivery plans have been put in place.
Theme 2 – Enabling delivery
Question / Paragraph / Action / CommentsWe 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 provisions of safe, high quality care / The Trust’s Workforce Plan, which is a rolling programme, is developed in conjunction with the services, workforce and financial framework and take due account of targets, such as, AOF and local delivery planning. The plan, which was endorsed by NLIAH, identifies potential work areas for the coming year and addresses the organisation’s remit to increase capacity across the public health system. Workforce and OD reports are submitted to the Board. (pg21) / Ensure an up to date workforce plan is in place and is being implemented to ensure we are a professional organisation. / Workforce plan is being developed. Workshops have taken place with staff around the organisation to help develop the workforce plan.
The Business Case Process scrutinises all clinical and non clinical posts to utilise opportunities to reshape the workforce and to review skill mix to increase efficiency and effectiveness. It also makes informed decisions based on the Trust’s workforce direction linked to its workforce planning predictions, configuration of the new Trust and its workforce development/modernisation and reorganisations initiatives. (pg22) / The Business Case Process has been replaced by a vacancy control process. Review whether the new process is an improvement for the organisation / The new vacancy control process ensures that all vacancies are scrutinised by the relevant Executive Director. A business case is required for all new posts.
Issues of personal performance, whether of an executive or independent member are addressed via the appraisal/KSF review process.(pg22) / Review progress against new processes. / All Board members undergo an annual performance review with the Chairman. The Chairman has a similar review with the Minister for Health and Social Services. The Chief Executive undergoes a joint performance review with the Chair and the Chief Executive of NHS Wales. The Exec Team also have individual performance reviews with the Chief Executive.
The different services and parts of our organisation/business work well together, and everyone understands who does what and why / There is no mention of the difficulties the organisation has with working across multiple sites. The Accommodation Review will address some of the issues which are currently experienced. Review progress against Accommodation Strategy / The accommodation review will begin in 2013 and will address some of these issues. The teams based within Local Health Board areas have been brought together under one site by their respective Directors of Public Health.
The staff engagement workshops run by the workforce and organisational development team in autumn 2012 also highlighted this issue and plans will be developed with Communications Team during 2013 to improve cohesion and understanding across the organisation of different team’s contributions and priorities.
The Public Health Development Directorate work which is aligning with Local Public Health teams around national lead roles is contributing to greater understanding across this Directorate.
There are some teams which have clear accountabilities through the Board directors but which do not yet sit within the divisional structures. (pg24) / Ensure that all divisional and accountability structures are clear / Workforce and OD are supporting the Director of Public Health Development in the re-structure and will ensure a development programme supports the structural changes.
Nevertheless, plans for an organisational development programme are being developed which will help ensure everyone in the organisation is aware of what we do and how we do it. (pg24) / Review progress of development of organisational development programme / An Organisational Development plan is being shaped by the Exec Team which will be closely aligned to a refocused 3 year plan for Public Health Wales. This should be drafted by end of March 2013. In the meantime staff engagement activity has begun and will continueto be a strong feature of the ongoing Organisational Development plan.
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 / The Board nevertheless recognise that arrangements for mandatory and statutory training have not been as robust as they should. Action plan for improvement should benchmark and monitor the number of staff who have received the appropriate training. (pg27) / Improve the numbers of staff that are partaking in training courses / Numbers of staff who have received statutory and mandatory training are increasing steadily. Records are being maintained and audited by the Professional and Organisational Development Team.
A recent report completed by the internal auditors recognises the improvement in numbers of trained staff, but highlights gaps where staff have not been trained.