board of directors meeting draft - north tees and ...€¦ · 3. (1.00pm) minutes of the meeting...

Draft

Board of Directors Meeting

Thursday, 29 October 2015 at 1.00 pm

Boardroom

University Hospital of Hartlepool

Draft

PG/SH

October 2015

Dear Colleague

A meeting of the Board of Directors will be held on Thursday, 29 October 2015 at 1.00pm in the Boardroom, University Hospital of Hartlepool.

Yours sincerely

Paul Garvin Chairman

Agenda

Led by

1. (1.00pm) Apologies for absence Chairman

2. (1.00pm) Declaration of Interest Chairman

3. (1.00pm) Minutes of the meeting held on, 23 July 2015 (enclosed) Chairman

4. (1.05pm) Minutes of the Annual General meeting held on 1 October 2015 Chairman (enclosed)

5. (1.05pm) Matters Arising

Items for Information

6. (1.10pm) Chairman’s Report Chairman

7. (1.15pm) Chief Executive’s Report (enclosed) A Foster

8. (1.25pm) Retrospective Approval of Documents Executed Under Seal A Foster (enclosed)

Draft

Quality

9. (1.25pm) Quality Report (enclosed) J Lane

10. (1.35pm) Infection Prevention and Control Report (enclosed) J Lane

Strategic Management

11. (1.40pm) Transformation Programme Update (enclosed) N Atkinson

12. (1.50pm) Capital Programme Performance 2015/16 (enclosed) L Hodgson

Performance Management

13. (1.55pm) Compliance and Performance Report (enclosed) J Gillon

14. (2.05pm) Finance & Contract Performance Report at 30 September 2015 L Hodgson (enclosed)

15. (2.15pm) Human Resources & Education Report - Quarter 2: 2015/16 A Burrell (enclosed)

16. (2.25pm) Emergency Preparedness, Resilience and Response (EPRR) J Gillon Core Standard Compliance (enclosed)

17. (2.35pm) Patient Level Information & Costing System (PLICS), and Reference Costs Update (enclosed) L Hodgson

18. (2.45pm) Operational Resilience 2015/16 (enclosed) J Gillon

Governance

19. (2.55pm) Board Assurance Framework – Quarter 2: 2015/16 (enclosed) B Bright

20. (3.05pm) Quarter 2 2015/16 Compliance Report to Monitor (enclosed) J Gillon

Operational Issues

21. (3.15pm) Responsible Officer’s Report on Revalidation (enclosed) D Emerton

22. (3.25pm) Any Other Notified Business Chairman

23. Date of Next Meeting(Thursday, 26 November 2015, Boardroom, University Hospital of North Tees)

Draft

1

North Tees and Hartlepool NHS Foundation Trust

Minutes of a meeting of the Board of Directors held on Thursday, 23 July 2015 at 1.00pm

at the University Hospital of Hartlepool Present:

Paul Garvin, Chairman* Chairman Brian Dinsdale, Non-executive Director/Deputy Chairman* Steve Hall, Non-executive Director*

BD SH

Rita Taylor, Non-executive Director/Senior Independent Director* RT Jonathan Erskine, Non-executive Director Designate Kevin Robinson, Non-executive Director Designate Alan Foster, Chief Executive*

JE KR CE

Julie Gillon, Chief Operating Officer / Deputy Chief Executive* Ann Burrell, Director of Human Resources and Education

COO/DCE DoHR&E

David Emerton, Medical Director* MD Cath Siddle, Director of Nursing, Patient Safety and Quality* DoN,PS&Q Lynne Hodgson, Director of Finance, ICT & Support Services Opportunities* DoF,ICT&SS Neil Atkinson, Transformation Change Director Barbara Bright, Company Secretary

TCD CS

In attendance:

Claire Young, Head of Communications Sarah Hutt, Assistant Company Secretary

Marjorie Leckonby, Hospital User Group Representative (HUG) Boleslaw Posmyk, HAST CCG Chair Salvi Patel, HAST CCG GP Member John Edwards, Elected Governor, Stockton Alison McDonough, Elected Governor, Non-core Public Graham Polham, Smith & Nephew Mark Payne, Hartlepool Mail Stella Leighton, Member of the Public

BoD/1986 Apologies for Absence

There were no apologies for absence reported.

BoD/1987 Declaration of Interest

There were no declarations of interest on open agenda items.

BoD/1988 Minutes of the meeting held on Thursday, 28 May 2015

Resolved: that, the minutes of the meeting held on Thursday, 28 May 2015 be confirmed as an accurate record.

BoD/1989 Matters Arising

a. BoD/1949 Deputy Chief Executive’s Report

The CE reported that the Trust was working with the CCGs, South Tees Hospitals NHS

Draft

2

Foundation Trust and County Durham and Darlington NHS Foundation Trust regarding a collaborative bid as part of the Vanguard project, which would be submitted by 31 July 2015.

Resolved: that, the information be noted.

BoD/1990 Chairman’s Report

a. Consultant Appointments

The Chairman reported that Dr Naveen Agrawal, Diabetes Consultant had been appointed since the last meeting.

b. Care Quality Commission inspection

The Chairman thanked the Executive Team and staff as a whole in respect of the amount of preparatory work that had been undertaken regarding the recent Care Quality Commission (CQC) inspection. Initial feedback had been largely positive, and the final report was expected later in the year.

c. General Election outcomes

The Chairman reported that the outcome of the General Election had provided a clearer health focus nationally and that the financial pressures being faced across the NHS were even greater. A deficit of almost £1.5bn was reported for provider organisations at the end of 2014/15, and for 2015/16 a deficit of £2 to 2.5bn was predicted. The Secretary of State had indicated that it would not be acceptable for organisations to have a worse out turn than the previous year, and were required to continue to make savings whilst maintaining quality and safety.

d. Agency staff

The Chairman reported that the Secretary of State for Health, and NHS England would be introducing constraints and greater control in respect of the use of agency staff and external consultants providing cover for positions that have proved difficult to recruit to and remain vacant.

e. New Hospital

The Chairman reported that there was no progress currently regarding funding for a new hospital, however, options in respect of improving the current infrastructure, which required significant investment to ensure it remained fit for purpose, would continue to be considered by the Board.

f. Meetings

The Chairman reported that he and the CE would be meeting with James Wharton, MP and Minister for the Northern Powerhouse to discuss opportunities across the Tees Valley and to replicate in part, the devolved arrangements being set up in Manchester.

g. MRI Scanner

The Chairman reported that Steve Cram had recently officially opened the new MRI Scanner at the University Hospital of North Tees, which was operated by Alliance Medical.


Draft

3

BoD/1991 Chief Executive’s Report

a. General Election

The Chief Executive reported that following the General Election the Five Year Forward View remained the strategic direction regarding the transformation of health and social care, with provider organisations putting into practice its recommendations. The financial pressure on foundation trusts would continue with £22bn of the cost of the Five Year Forward View to be funded from efficiency savings. It had been announced that each trust would be written to in respect of an out turned position for 2015/16, and not to exceed the £1.5bn of last year. Public health budgets had also been cut by £200m nationally for this year.

b. New hospital land site

The Chief Executive reported that the site on which the new hospital was planned to be built at Wynyard had been returned to the developer Wynyard Park Ltd for the original purchase price, c. £4m.

c. Collaborative working

The Chief Executive reported that the Trust continued to work collaboratively with the neighbouring trusts of South Tees Hospitals NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust to ensure services remained clinically sustainable and affordable. This included preparing a bid for the Vanguard Project to improve quality and sustainability of provider trusts, the deadline of which was 31 July. The bid requires a chief executive lead, and AF had been nominated to fill this role.

d. CQC inspection

The Chief Executive reported that following the CQC inspection which had taken place earlier in the month, an unannounced visit was still to take place, which would follow up on any areas identified that required improvement. A final report was anticipated in the autumn.

e. Mortality

The Chief Executive reported that the Trust continued to implement robust action plans to address high mortality rates across the Trust. The Medical Director, Director of Nursing and Patient Safety and the Chief Executive had attended a NHS England Keogh workshop on 14 May in Leeds led by Dr Damian Riley, Medical Director which provided an opportunity to discuss the Trust’s actions in relation to mortality and share best practice.

f. NHS Providers Board

The Chief Executive reported that he had been appointed to the NHS Providers Board for a 3 year term, as a Chief Executive representative for foundation trusts, he had been nominated by other trusts regionally.

g. Urgent & Emergency Care bid

The Chief Executive reported that an urgent and emergency care bid for the North East and Cumbria, as part of the Vanguard project was being put forward by the CCGs and North East Ambulance Service NHS Foundation Trust (NEAS) as the lead provider trust. This would support the work of the Urgent and Emergency Care Network which operates at a strategic level.

Draft

4

Resolved: that, the content of the report be noted.

BoD/1992 Quality Report The DoN,PS&Q presented the Quality Report and drew members’ attention to key points. The highest score from the Staff & Patient Experience and Quality Standards (SPEQS) reviews for June 2015 was 100% by 18 wards/areas, where 42 areas had been assessed. The average scores for May were 94.70% for first impressions; 98.57% for patient experience; 93.18% for nursing evidence, and 97.73% for staff involvement. Areas achieving 100% across all aspects of the inspections continued to be rewarded. The Trust HSMR value had increased to 127.41 (Apr 14 to Mar 15) from 126.40 (Mar 14 to Feb 15) and the Trust’s crude mortality rate had increased from 3.89 to 4.02 since the last reporting period, with both continuing to be out of the ‘as expected’ range. The SHMI value was 118.91 (Oct 13 to Sep 14) with the next data release expected at the end of July 2015, and the crude mortality rate remained at 3.98, which was also outside the ‘as expected range’. The Trust’s End of Life Coordinator who had recently joined the Specialist Palliative Care Team had made an immediate impact on the number of patients seen. The latest CQC Intelligent Monitoring Report had been released in May 2015, and the Trust’s rating had reduced from 3 to 2. There were 3 elevated risks and 6 risks outlined in the report of the 96 indicators reviewed, which were being addressed. The CQC inspection took place at the Trust between 7 and 10 July; the final outcome report was expected later in the year. There had been 300 complaints to date during 2015/16 of which 65.33% were categorised as Stage 1, 6.00% Stage 2, and 28.67% Stage 3. There were currently 85 complaints open. The Safety Thermometer results included: New pressure ulcers decreased from 0.92% in May to 0.76% in June; Falls with harm had increased to 1.52% in June from zero in May; Catheter and New UTI had decreased from 0.61% in May to 0.38% in June; New VTE (venous thromboembolism) had decreased from 0.61% in May to 0.38% in June; Harm free care had increased to 97.34% in June from 93.79% in May. The Friends and Family response rate in May for in-patients were 39.99% and 9.91% for Accident and Emergency (A&E). The number of responses for question 2 - Birth in our Maternity Services was 6.96%, and the number of responses for Outpatient clinics was 1,315. The overall percentages to recommend the Trust’s services were 95.74% for in-patients; 90.17% Accident and Emergency; and 96.10% for Maternity. A new proforma regarding Learning from Incidents would be rolled out across the Trust in an easy to understand format to assist staff. A new Dementia Strategy had been launched outlining the Trust’s five year strategy regarding patients with dementia. The Trust’s Quality Accounts 2014/15 had been finalised and published on the Trust’s website and NHS Choices. An external report has been published regarding the differences in life expectancies in different parts of the borough of Stockton, highlighting reduced life expectancy in more deprived areas. The Kirkup Report was published in March 2015, a report by Dr Bill Kirkup detailing the findings of an independent investigation regarding Maternity and Neonatal Services at the University Hospitals of Morecambe Bay NHS Foundation Trust. The Trust had undertaken a gap analysis, the findings of which would be presented to the Patient Safety and Quality Standards Committee (Ps and Qs).

Draft

5

There had been no Never Events reported to date in 2015/16.

A member sought clarification regarding the effect on mortality data of including patients seen via Ambulatory Care as inpatients which was being back dated to 1 April 2014. It was anticipated that there would be a significant impact, but this would not be seen immediately, with statistics being published that contained data relating to 6 months prior.

The Chairman invited members to be appraised of the work being carried out by the Specialist Palliative Care team whose work was excellent.

Resolved: (i) that, the content of the report be noted; and (ii) that, arrangements be made for board members to see the work of the

Specialist Palliative Care Team.

BoD/1993 Care Quality Commission Inspection

The DoN,PS&Q provided an update in respect of the CQC Inspection, which took place at the Trust between 7 and 10 July 2015, as part of a national programme of inspections. The inspection was based upon the five key domains: safety; effectiveness; caring; responsiveness and well led. The follow-up unannounced visit was yet to take place. The final report was expected to be published later in the year. No major concerns were highlighted during the inspection.

The Chairman placed on record his thanks to the DoN,PS&Q and her team for their work in respect of the inspection.


BoD/1994 Infection Prevention and Control Report

The DoN,PS&Q presented the Infection, Prevention and Control Report to 30 June 2015, and drew members’ attention to key areas:

There had been 0 cases of Clostridium difficile in June; and 8 year to date which exceeded trajectory of 4 cases for the quarter. Full root cause analysis had been undertaken for all the cases. A possible cross infection was identified in one of the Trust attributed cases and a community case who had been on the same ward. One common theme had been poor patient equipment scores which were being addressed. The programme of cleaning and fogging on high risk wards had re-commenced, and Professor Mark Wilcox, Chair of Public Health England’s Rapid Review Panel and Consultant Microbiologist from Leeds Teaching Hospitals NHS Trust had reviewed trust policies, processes and practice to identify any gaps as part of an external review.

. There had been 3 cases of Trust attributed MSSA bacteraemia cases, and 6 year to date against the internal trajectory of 18 cases for the year;

There had been no cases of Trust attributed MRSA bacteraemia;

There had been no cases of Trust attributed E coli bacteraemia, and 7 year to date against the internal trajectory of 27 cases for the year;

Draft

6

Overall compliance for hand hygiene was 92.63%, slightly below the Trust target of 95%. Over 100 hand hygiene champions had been recruited in May to promote good hand hygiene practices to colleagues and patients;

The UK risk to Ebola remains very low, and it was very unlikely the Trust would see a case, however, a programme of staff training on appropriate personal protective equipment continues to be rolled out.

Resolved: (i) that, the current overall IPC position be noted; and (ii) that, the actions undertaken in respect of Clostridium Difficile be

noted; and (iii that, the work across the Trust to improve hand hygiene scores be

noted.

BoD/1995 Strategy Development Progress Report

The COO/DCE provided an update on the progress of the Trust’s Strategy development and next steps in the development of the Clinical Services Strategy (CSS).

The Momentum: Pathways to Healthcare Programme continues to summarise the direction for the Trust’s Strategy and incorporates the way in which, and from what facilities services would be provided in the future. Following the new hospital ‘pause’ decision, the CSS will provide the means to take the Trust’s strategic direction forward, and develop service specific strategies to enable the required clinical and operational changes and financial sustainability. Intense detailed development of the CSS will take place between July and September 2015, consolidating work to date with the final version of strategic options being presented to the Board of Directors in September.

System wide transformational change remains necessary to enable the Trust to continue to develop high quality, safe and affordable services. Implementation of the CSS will see a significant programme of change being delivered within the next ten years, streamlining services and pathways of care across hospital sites and localities. Key to the successful delivery will be collaborative and partnership working between all members of the local health and social care economy. Alongside this external engagement, the Trust was seeking to be included in the national New Care Models Vanguard Programme both in relation to Urgent and Emergency Care, and Acute Care Collaboration.

A committed resource and a directorate focus would be required to evolve through the final stages of strategy options development. The approved costed plan and Project Initiation Document (PID) would now be accelerated to ensure delivery within the timescales.

A member sought assurance regarding deliverability in the relatively short timescale, which the COO/DCE confirmed was achievable given the amount of pre-work already undertaken.

Resolved: (i) that, the progress to date be noted; and (ii) that, the continuing refocus of the strategic objectives be noted; and (iii) that, the development of the Clinical Services Strategy options and

required resource be noted and approved.

BoD/1996 Transformation Programme Update

The TCD provided a progress update of the Transformation Programme, which was split into external and internal transformation. In order to meet current challenges, service delivery would be required to change on an unprecedented scale across the whole health system, and would involve the need to build relationships with partners and stakeholders. Future

Draft

7

models of care would likely include more care out of hospital settings, and early collaboration was vital.

Internally, the Transformation Programme has been organised into three broad levels: Trust wide developments; Continuous improvement; and Commercial/business development, with a number of work streams at each level. A review of individual projects and schemes had been undertaken and current stage of delivery identified. A six stage process had been agreed to support delivery of the work streams, and a new way of managing performance had been undertaken which will improve the rigour and assurance regarding delivery of transformational activity. It will track performance against agreed KPI measures and engage staff to own responsibility for performance. To support the work a transformation team had been established, with 3 key members appointed to date.

Resolved: that, the progress to date be noted, together with the need to increase the pace of delivery.

BoD/1997 Capital Programme Performance 2015/16

The DoF,ICT&SS presented the Capital Programme Performance 2015/16 as at 30 June 2015. The capital funding for 2015/16 was £10.789m, including £2.201m carried forward from 2014/15. A total of £1.29m had been spent to date in quarter 1, with further orders of £2.5m placed. The four work-streams of Medical Equipment, ICT, Service Development and Estates Backlog Maintenance had all performed as anticipated, however payment had been withheld for an element of the EPR implementation as the full scope would not be delivered in phase 1. Monitor now reviews trusts’ expenditure quarterly instead of annually, and the Trust was within the threshold of pending between 85% - 115% of the financial plan.

The implementation of the new EPR system, Trak Care continued and the go-live for stage 1 of the project was anticipated to be September 2015.

Resolved: that, the progress of the programme be noted.

BoD/1998 Finance and Contract Performance Report

The DoF,ICT&SS presented the Finance and Contract Performance Report as at 30 June 2015 and drew members’ attention to the key points.

The Trust was reporting an operational deficit of £4.709m, which was £3.717m behind plan. There was an under-recovery of income of £1,284k against plan, mainly due to a reduction in non-elective admissions. Non-pay budgets were under-spent by £602k, however, pay budgets were overspent against plan by £708K, and this was largely due to recourse to locum and agency staff to cover vacancies hard to recruit to posts and maternity cover. It was hoped that in surgery/orthopaedics the recruitment of nurse practitioners later in the year would relieve some of the pressure.

The Service Improvement and Efficiency Programme (SIEP) target for £2015/16 of £10.901m had been reduced to £8.930m as result of recurrent and non-recurrent schemes actioned during quarter 1. The Trust was phasing in the non-delivery of the SIEP from 2015/16 over the period of the financial year to avoid any adverse movement in the position towards the year end. The Trust had delivered £1.971m of its in-year SIEP, of which £1.242m was recurrent and £0.729m non-recurrent.

An EBITDA of -£2.231m had been generated, which was £3.775m behind plan, resulting in an EBITDA margin of -3.37%. The net cash inflow was £1.031m, resulting in an increase in

Draft

8

cash from £28.133m to £29.598m. Net current assets had decreased by £1.685m to £28.133m. Financial performance was behind plan for quarter 1, and meetings had been held with all directorates to assess their financial requirements for the remainder of the year, resulting in a revised year end out turn of £7.277m being submitted to Monitor against plan of £4.852m. The position was very challenging and although the overall Continuity of Service Risk Rating was a 3, the Capital Servicing Capacity was below plan with a rating of 1, which meant additional scrutiny and reporting could be imposed by Monitor. A discussion regarding contract payments in respect of extended lengths of stay and delayed discharge ensued. In respect of the overall financial position, the Chair of the Finance Committee (BD) reiterated that long term transformation was vital when continued savings were required to be made each year.

Resolved: (i) that, the current financial position be noted; and (ii) that, the analysis of performance against the Continuity of Service Risk

Rating and therefore the risk of Monitor carrying out further scrutiny be noted.

BoD/1999 Compliance and Performance Report The COO/DCE presented the Compliance and Performance Report for June 2015, and drew members’ attention to the key points. Performance against key operational standards and trajectories continued to be a challenge for delivery of both elective and non-elective pathways. Overall non-elective activity indicated a reduction in comparison to the same period last year of 2.25%, A&E attendances also saw a decrease, however, admissions via A&E saw an increase of 4.75%, evidencing the higher level of acuity in patients. Performance against the Emergency Care Target was 96.47%, which surpassed both regional and national averages. The Trust continued to demonstrate positive performance against the original 18 week Referral to Treatment (RTT) pathway standard, with all standards achieved at aggregate level. The Trust had achieved all but one of the 14, 31 and 62 day cancer pathway standards during May, with the exception of the supporting standard of 62 day urgent referral to treatment – consultant upgrade reporting below target at 75%. NHS England had reviewed the future monitoring and reporting for a number of the national access standards in 2015/16. The admitted and non-admitted operational standards had been abolished from June 2015, with the incomplete standard becoming the sole measure of patients’ constitutional rights to start treatment within 18 weeks. With regards to Health Care Associated Infections (HCAI), the Trust has reported outside the cumulative trajectory for C-Difficile, reporting 8 cases against the trajectory of 4 cases. The Trust had in the main performed well against the majority of key operational standards, notwithstanding the on-going operational, economical, and financial pressures. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery. The Chair of the Audit Committee (BD) sought clarification in respect of the Cancer two week wait standard provisionally reporting below the 93% target at 92.87% for quarter 1. The uptake of patient choice causing delay in the diagnosis and treatment stages within the pathway, continued to affect delivery of the standards. The Trust continued to work with

Draft

9

local GPs to ensure patients are encouraged to take up appointments within the required timescales.

Resolved: (i) that, the current position be noted; and (ii) that, the on-going challenges and risks be noted.

BoD/2000 Human Resources and Education Report Quarter 1: 2015/16

The DoHR&E presented the quarter 1 Human Resources and Education Report 2015/16 and drew member’s attention to key points.

The use of NHS Professionals was being reviewed for some staff groups including administrative and clerical staff, alternative solutions and associated costs were being explored. The Stafflow project (electronic booking system for medical and dental locum agency staff) commenced on 13 July 2015, with a 2-3 month implementation. The cost savings of introducing the system would be c.£480k per annum based on current usage. Technical issues had been encountered in the routine two week monitoring round for junior doctors, and a future monitoring exercise may be required once the issues had been resolved.

The Trust remained committed to ensuring that effective leadership was in place to support the delivery of its strategic aims and continues to recognise the importance of developing leaders and managers at all levels of the organisation. The resources of the Organisation Development team were currently being structured to allow them to support the needs of the organisation going forward. The two main work streams were maintaining business as usual and supporting transformation.

The Trust had recently had a visit from the Durham and Tees Valley GP Training Programme to discuss the quality of training and supervision provided to GPStRs (General Practice Speciality training Registrars). Overall the visit was extremely positive.

Some initial planning work had commenced regarding establishing a multidisciplinary training ward in the Trust. The Education and Organisation Development department had commenced work on the Faculty of Inter-professional Education and Staff Training (FINEST) in partnership with Fuse, based at Teesside University. The aim of the project was to review nursing and allied health professionals (AHP) education in the Trust to develop a structured inter-professional training programme from undergraduate to postgraduate working. It was expected that a pilot would take place in the Trust from January 2016.

Clinical Simulation training continued to expand and there were now 9 learning scenarios available. A new member of the Team had been added, Susie a high fidelity mannequin to be used primarily in the community simulation facility.

The Trust’s headcount had decreased by 30 from 5393 at year end to 5363 when compared to the end of quarter 1: 2015/16. The sickness absence rate for quarter 1 to date was 0.8% lower than the baseline figures at the end of March 2015. Short, medium and long term sickness absence rates have decreased in quarter 1 when compared to the base line; however, the quarter end figures were provisional due to June’s data not currently being available. The cost of sickness absence for quarter 1 was £61,197.38. This was due to the cumulative sickness rate for quarter 1 being higher than the same period last year by 0.13%. The main reasons for sickness absence were anxiety/stress; musculoskeletal and other, which was mainly gastro related sickness. The Trust remained below the regional average for sickness.

Draft

10

The turnover rate for quarter 1 was 13.35%, and had been consistently higher throughout the first quarter of 2015/16 when compared to 2014/15. There have been 136 new starters to the Trust in quarter 1, compared to 157 the previous year. This was partly due to the closure of the day nursery with 32 staff, the transfer of the health trainer service with 11 staff and 95 staff flexi retiring. A total of 290 responses were received in quarter 1 2015/16 for the Staff Friends and Family Test, with 81% recommending the Trust to friends and family to receive care and 72% as a place to work.

Resolved: that, the content of the report be noted. BoD/2001 Board assurance framework The DoN,PS&Q and COO/DCE provided a progress report in relation to the Board Assurance Framework and the associated areas of risk. Changes to the design and content of the Board Assurance Framework were undertaken as part of a review of the Trust’s overall Risk Management Strategy. Changes to the Risk Management Strategy underpin the changes made to the Board Assurance Framework to reflect the strategic aims and objectives of the Trust. The progression of the framework will provide leadership in relation to risk management and support embedding of the Trust’s Risk Management Strategy across all areas of the organisation. During quarter 2 Directors and operational leads will review the information provided and assess the gaps in control in order to update the risk reduction plan. The Chair of the Audit Committee (BD) reported that the new framework had been well received with current status of risk and appetite for risk included for each strategic objective; however, overall it was felt the format could be made simpler. It was agreed it would be useful to have a Board Seminar to discuss appetite for risk for each objective once the framework had been amended.

Resolved: (i) that, the new Board Assurance Framework be approved; and (ii) that, the level of risks be approved; and (iii) that, a Board Seminar be arranged to discuss appetite for risk.

BoD/2002 Quarter 1, 2015/16 Compliance Report to Monitor The COO/DCE presented the Quarter 1 Compliance Report to Monitor, highlighting key areas. Monitor’s risk based framework assigns two risk ratings – Continuity of Service and Governance conditions. Monitor was currently consulting on changes to the Risk Assessment Framework (RAF) with proposals to reintroduce two previously used measures. The updated RAF would be published in quarter 2. In respect of governance elements the Trust had under-achieved against two of the key targets during quarter 1: Cancer 2 Week Wait Standard and the Clostridium difficile standard, which would be reported to Monitor along with resulting actions and mitigation plans to manage the position. The under-achievement of the Clostridium difficile objective of 8 cases against a quarter 1 target of 3.5 cases would not impact on the Monitor rating in quarter 1, as the RAF applies a de-minimis of 12 cases before under achievement would be declared. The Trust was committed to constantly achieve against all the cancer targets and a full review of factors causing the drop in performance had been undertaken. A number of national cancer awareness campaigns have been publicised which has impacted the outpatient and diagnostic services. In addition patient choice has significantly impacted the under-achievement of the cancer 2 week standard. A small number of patients were unable to be appointed within 14 days due to capacity issues in Respiratory.

Draft

11

Following the application of Monitor guidelines regarding priority weighting and thresholds for core standard performance, the Trust had achieved an overall aggregate score of 1, which was a green rating with no governance concerns raised at this time. However, there would be an expectation that management and recovery of the under-achieved metrics would take place before the respective triggers were enforced. There were no material concerns to alter the position of the Board with regards to the Corporate Governance Statement certification.

Trust’s had been written to by Simon Stephens on behalf of NHS England, TDA and Monitor outlining the changes to the future monitoring and reporting for a number of the national access standards in 2015/16. The admitted and non-admitted operational standards had been abolished from June 2015, with the incomplete standard becoming the sole measure of patients’ constitutional rights to start treatment within 18 weeks.

In respect of the Continuity of Service Risk Rating the Trust had achieved an overall financial risk rating of 3.

Resolved: (i) that, the quarter end report be noted, and (ii) that, the overall performance, risk, and underachievement of the

cancer 2 week wait standards and Clostridium difficile standard be noted; and

(iii) that, the Board of Directors consider the requirement to declare on-going compliance;

(iv) that, the board of directors delegate responsibility to the Chairman to sign the in-year governance statement contained within Appendix 5.

BoD/2003 Nursing and Midwifery Revalidation

The DoN,PS&Q reported on Nursing and Midwifery Revalidation. A revised professional code regarding standards of practice and behaviour for registered nurses and midwives had been published. It required all registrants of the Nursing and Midwifery Council to revalidate every 3 years in order to be allowed to continue to be registered to practise from April 2016. Registrants were required to evidence that they had completed 450 hours of professional development in order to be eligible. An internal task and finish group had been established to ensure preparation and implementation were carried out and to monitor on-going revalidation. A regional revalidation programme board had also been established to support the initiative regionally.

The Chairman sought clarification regarding the impact to individuals unable to provide sufficient evidence to be revalidated. The DoN,PS&Q explained that it would be necessary to monitor through appraisals when staff were due for revalidation so those not wishing to go through the process could be managed, prompting discussion.

Resolved: that, the changes in process for revalidation and potential risk to the Trust be noted.

BoD/2004 Estates and Facilities Management Annual Report 2014/15

The DoF,ICT&SS presented the Estates and Facilities Management Annual Report 2014/15. During 2014/15 the Directorate had implemented the Department of Health’s Premises Assurance Model, the aim of which was for organisations to demonstrate that robust systems were in place to assure that premises and associated services were safe. The model was scheduled to be audited by Audit North. From 1 August 2015 the Trust would become completely non-smoking on all of its sites.

Draft

12

Resolved: that, the report be noted.

BoD/2005 Research and Development Annual Report

The MD presented the Research and Development Annual Report. Participation in commercially sponsored studies continued to increase, and the Trust was in final stages of discussion with an Israeli Company, Early Sense, to be the first UK site to pilot a contactless patient monitoring system on two wards within the Trust and to run a research project collaboratively with Durham University alongside this. Professor Volker Straub had completed his term of office as Director of R&D and would be replaced by Professor Samir Gupta.

Resolved: (i) that, the report be noted; and (ii) that, the Board place on record thanks to Professor Volker Straub.

BoD/2006 Any Other Notified Business

a. HUG Visits

Marjorie Leckonby, the Hospital User Group (HUG) Representative reported that the HUG had not undertaken any visits in June, however, had visited Urology the previous day which had been positive. As part of a recent patient survey, it was noted that hospital food had been marked as requiring improvement, which was surprising as feedback previously had always been positive.

b. HAST CCG

Posmyk Boleslaw, Chair of Hartlepool and Stockton Clinical Commissioning Group (HAST CCG) introduced a new Non-executive member of the CCG, Salvi Patel who was a GP from Hartlepool. He had noted the assurance in respect of actions around mortality, the acknowledgement of the transformation agenda requiring progression at pace, and that the collaborative bid as part of the Vanguard Project was being finalised.


BoD/2007 Date and Time of Next Meeting

Resolved: that, the next meeting be held on Thursday, 29 October 2015, at 1.00pm in the Boardroom, University Hospital of Hartlepool

BoD/2008 Exclusion of Press and Public

Resolved: that, representatives of the press and other members of the public be excluded for the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1(2), Public Bodies (Admission to Meetings) Act 1960).

Signed: Date:

The meeting closed at 3.20pm.

Draft

- 1 -


Minutes of the Annual General Meeting held on Thursday, 1 October 2015

Eaglescliffe Golf Club Present:

Paul Garvin, Chairman Brian Dinsdale, Non-executive Director Steve Hall, Non-executive Director Kevin Robinson, Non-executive Director Jonathan Erskine, Non-executive Director Rita Taylor, Non-executive Director Alan Foster, Chief Executive Julie Gillon, Chief Operating Officer/Deputy Chief Executive David Emerton, Medical Director Lynne Hodgson, Director of Finance, ICT & Support Services Ann Burrell, Director of HR & Education Neil Atkinson, Transformation Change Director Julie Lane, Deputy Director of Nursing, Clinical Governance and Patient Safety Barbara Bright, Company Secretary Caroline Trevena, Deputy Director of Finance Lindsey Wallace, Acting Assistant Director, Planning & Performance Carol Alexander, Elected Staff Governor Keith Blakey, Elected Governor for Easington John Edwards, Elected Governor for Stockton Deborah Gardener, Elected Staff Governor Wendy Gill, Elected Governor for Sedgefield Tony Horrocks, Elected Governor for Stockton Mary King, Elected Governor for Easington Pauline Robson, Elected Governor for Hartlepool Maureen Rogers, Elected Governor for Hartlepool Thomas Sant, Elected Governor for Hartlepool Pat Upton, Elected Governor for Stockton Kate Wilson, Elected Governor for Stockton Claire Young, Head of Communications Claire Nixon, Private Office Manager / Personal Assistant Heidi Holliday, Private Office Assistant/ Personal Assistant Bill Keene, Member of the Public Jan Armstrong, Member of the Public Jim Armstrong, Member of the Public

Apologies for Absence

Apologies for absence were received from Cath Siddle, Director of Nursing, Patient Safety & Quality, Janet Atkins, Elected Governor for Stockton, Ann Cains, Elected Governor for Stockton, Mary Morgan, Elected Governor for Stockton, Chris Clough, Elected Governor for Stockton, James Newton, Elected Governor for Stockton, Margaret Docherty, Elected Governor for Stockton, Roger Morrow, Elected Governor for Hartlepool, Chander Parkash, Elected Governor for Hartlepool, Alison McDonough, Elected Governor for Non-Core Public, Matt Wynne, Elected Staff Governor, Manuf Kassem, Elected Staff Governor, Jim Beall, Appointed Governor for Stockton-on-Tees Borough Council, Simon Forrest, Appointed Governor for Durham University, Morris Nicholls, Appointed Governor for Durham County Council, Gerrard Hall, Appointed Governor for Hartlepool Borough Council and Tom Lennard, Appointed Governor for Newcastle University.

Draft

- 2 -

1. Welcome

The Chairman opened the meeting and welcomed members to the eighth Annual General Meeting of North Tees and Hartlepool NHS Foundation Trust. He outlined the agenda and explained that the Trust had continued to perform well during the previous 12 months.

2. Minutes of the Last Annual General Meeting (18 September 2014)

The Chairman reported that the minutes of the last Annual General Meeting, which had taken place on 18 September 2014 had been reviewed by the Board of Directors following the meeting. The minutes were agreed by those present.

3. Changes to the Council of Governors

The Company Secretary reported that the Council of Governors membership, as outlined in the Trust’s Constitution, comprised 36 Governors plus the Chairman, which included 22 publicly elected Governors, 6 staff elected Governors, and 8 Governors who were appointed by key stakeholder organisations of Local Authorities, Universities and Clinical Commissioning Groups.

The Company Secretary reported on the results of the Trust’s annual elections that had taken place during the autumn of 2014. The results were as follows:

Pat Upton re-elected to Stockton Constituency (to Dec 2017) Ann Cains re-elected to Stockton Constituency (to Dec 2017) Tony Horrocks elected to Stockton Constituency (to Dec 2017) John Edwards elected to Stockton Constituency (to Dec 2017) Maureen Rogers re-elected to Hartlepool Constituency (to Dec 2017) Beverley Hart elected to Hartlepool Constituency (to Dec 2017) Keith Blakey elected to Easington Constituency (to Dec 2017) Alison McDonough elected to Non-Core Public (to Dec 2017) Carol Alexander re-elected to Staff Constituency (to Dec 2017)

The Company Secretary reported that Governors were elected to a term of office of 3 years, unless they were elected to a vacant post, therefore the Governor would be elected for the remainder of that post.

The Company Secretary reported that during February 2015 Professor Liz Holey had been appointed as Governor for Teesside University and in May 2015 Simon Forrest was appointed as Governor representing Durham University.

With regards to the Trust’s membership, the Company Secretary reported that as expected the Trust had maintained its membership at approximately 6,000, reporting that as of 1 April 2015 membership figures stood at, 5,835 for public members and 5,538 staff members. The Trust would continue to strive to maintain a representation of approximately 6,000 public members. The Trust continued to increase the number of younger members between the ages of 16 to 24 years and had engaged the help of staff and governors to recruit public members. The Company Secretary also reported that the programme of member events held on site had continued to be well received.

4. Notification of Forthcoming Governor Elections and Timetable

The Company Secretary reported that the Trust had commenced its election process for 2015 and outlined that there were 12 vacant seats. The Governors whose current term of office expires in December 2015 are:

Janet Atkins Stockton on Tees Constituency Chris Clough Stockton on Tees Constituency James Newton Stockton on Tees Constituency Kate Wilson Stockton on Tees Constituency Carol Ellis Stockton on Tees Constituency (resignation)

Draft

- 3 -

Roger Morrow Hartlepool Constituency Chander Parkash Hartlepool Constituency Beverly Hart Hartlepool Constituency (resignation) Denise Rowland Easington Constituency (resignation) Manuf Kaseem Staff Nina Bedding Staff (resignation) Vacant Staff

The Company Secretary outlined the proposed Governor Election timetable and reported that the Trust had appointed Electoral Reform Services as the external Returning Officer who would manage the election process on the Trust’s behalf. The Company Secretary reported that the results of the forthcoming election would be reported to the Trust on 23 November 2015. The Company Secretary explained that an induction programme would be arranged in January 2016, following the appointment of new governors. 5. Changes to the Non-Executive Directors The Company Secretary reported on changes to the Non-Executive Directors, following the resignation of Ken Lupton in October 2014 and Michael Bretherick in May 2015. Following a robust recruitment process involving the Council of Governors Kevin Robinson and Jonathan Erskine had been appointed to the position of Non-Executive Director, with commencement in post on 1 August 2015. 6. Presentation of Annual Report/Annual Accounts 2014/15 and the Report of the Auditors The Chief Executive presented the Annual Report for 2014/15, which was a statutory requirement of all Foundation Trusts. The Chief Executive explained that he was the Accounting Officer of the Trust and was required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual. The Chief Executive reported on the Trust performance for 2014/15 and highlighted that the Trust had achieved against the risk assessment indicators including Key Cancer Standards, Referral to Treatment, Emergency Care Access and Clostridium Difficile, he also reported that the Trust had a monitor risk assessment rating of 3 for finance and green for governance. The Trust had also implemented a number of initiatives to support the delivery of service developments including:

A new MRI scanner, benefits including reduced waiting times, significantly improved image quality, high resolution images, scans closer to home and improved patient comfort;

The launch of the Trust commercial venture Optimus, including the Trusts own pharmacy, Panacea; Clinical Simulation including the delivery of simulation education to medical students, foundation

doctors, maternity staff and clinical directorates. The Sim suite also contributes to patient safety through the direct link of all appropriate serious untoward incidents through the use of scenarios;

A state of the art standalone Cardiac Catheter Lab, diagnostic heart services as well as pacemaker services for the local population, increase in activity and improved reputation with GP’s, Commissioners and ambulance crews.

Improvements in hand and wrist services, including the expansion of specialist hand surgeons The Chief Executive reported that the Board of Directors and the Executive Team had enjoyed celebrating the Trust successes in 2014/15, including the Trusts annual recognition event, Shining Stars, covering 12 categories, the Hartlepool Mail Best of Health Awards including winners of the Special Recognition award, nurse of the year, midwife of the year and a long term achievement award. The Director of Finance ICT and Support Services confirmed that the Trust’s Annual Accounts for 2014/15 had been produced in accordance with the NHS Act 2006 and had been audited by Price Waterhouse Cooper, who were the Trust’s external auditors.

Draft

- 4 -

The Director of Finance ICT and Support Services presented the financial accounts for the period 1 April 2014 to 31 March 2015, highlighting the key issues and achievements for the period, emphasising that the accounts had received an unqualified opinion of ‘true and fair view’. The Trust reported that the financial position now included the consolidation of the Trusts Charitable Funds. The Trust had achieved a Continuity of Service (CoS) rating of 3 for 2014/15, and the operational deficit stood at £4.02m before exceptional items of £11.3m which strengthened the Statement of Financial Position (Balance Sheet).

The Director of Finance ICT and Support Services reported that in 2014/15 the Trust had an operating income from commissioners of £285.5m with operating expenses totalling £270m. The Director of Finance ICT and Support Services gave an overview of the financial performance against plan for 2014/15 and the statement of financial position as at 31 March 2015, highlighting immense pressure on pay due to a heavy winter period.

A member of the public queried the Trusts audit rating given the financial deficit of 4m recorded at the end of 2014/15, the Director of Finance ICT and Support Services explained that the Trust had received significant challenge from PricewaterhouseCoopers, and they felt the Trust had made every effort to keep financial sustainability and had all the necessary plans in place. The Director of Finance ICT and Support Services also highlighted that financial pressures were a system wide issue.

There was also a query from a member of the public regarding the Trust planned surplus for the year, the Director of Finance ICT and Support Services explained that a surplus had been the plan however, due to an exceptionally busy winter period the Trust had at times, opened 100 additional unfunded beds, and that financially it had placed the Trust under significant pressure, however it had been the right thing to do for patients.

There was also some discussion regarding monies received from the defunct Strategic Health Authority (SHA) for the new hospital and how this would be spent now the plans were on hold, the Director of Finance ICT and Support Services explained the money was allocated for the Momentum pathway and not just the new hospital, therefore it would continue to be used to support this objective.

7. Quality Accounts 2014/15

The Deputy Director of Nursing, Clinical Governance and Patient Safety presented the Quality Accounts for 2014/15 highlighting the Trusts 3 key priorities, Patient Safety, Effectiveness of Care and Patient Experience.

The Deputy Director of Nursing, Clinical Governance and Patient Safety reported that Dementia, Safeguarding Adults and Mortality were key areas for patient safety, she also gave a brief overview of data including the national mortality measures for Hospital Standard Mortality Ratio (HSMR) and Standard Hospital Mortality Indicator (SHMI). Data was also shared from the nursing and midwifery dashboard, nursing dashboard, care for the dying patient and the friends and family recommendation, with 96.05% of in-patients recommending the Trust as a place to receive care. It was also noted that the Trust had zero cases of hospital acquired MRSA during 2014/15 and had significantly reduced the number of Clostridium-Difficile cases, reporting 20 against a trajectory of 40 for the year.

The Deputy Director of Nursing, Clinical Governance and Patient Safety reported that PricewaterhouseCoopers as the Trusts independent external auditors had given the Trust a clean bill of health and PwC would audit the finalised quality accounts in 2015/16.

8. Annual Plan

The Chief Operating Officer/Deputy Chief Executive presented the Annual Plan, which sets out the Trusts strategic direction and strategic vision, taking into account national and local context.

The Chief Operating Officer/Deputy Chief Executive outlined the Trust’s Annual (strategic) Plan which included finance, quality of service, emphasis on robust planning longer term and the need to understand the risks and challenges the Trust faces. The Chief Operating Officer/Deputy Chief Executive reported on the National context of the NHS and the difficulties in balancing the need for quality with finance and regulation, she detailed how the NHS was facing more regulation than ever before and highlighted the possibility of regulatory intervention for Foundation Trusts.

Draft

- 5 -

The Chief Operating Officer/Deputy Chief Executive emphasised the need to ensure clinical, financial and operational sustainability, including the need to think ‘outside of the box’ including working towards patient centred collaborative or integrated service provision across acute, community, primary and social care.

The Chief Operating Officer/Deputy Chief Executive provided an overview of the Trust’s Clinical Services strategy highlighting that the vast majority of care now takes place within community settings and that infrastructure needs to be in place to support strategic change, including integrated care pathways, community resources and working with social care partners.

The Chief Operating Officer/Deputy Chief Executive presented the Trusts key priorities and timescales including quality and safety of service, patient satisfaction, staff satisfaction, maintaining and improving core services and developing clinical services in line with research and technology. The number 1 priority for the Trust however was highlighted as maintaining patient focus in a difficult and sometimes frustrating system.

9. Any Other Business as Notified to the Company Secretary

There was no other notified business.

10. Date and Time of Next Meeting

The date of the next Annual General Meeting would be held on Thursday, 29 September 2016. Further details would be announced in due course and available on the Trust’s website.

Signed:

Date:

Draft

1


Meeting of the Board of Directors

29 October 2015

Chief Executive’s Report

Report of the Chief Executive

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Manage Our Relationships

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Effective Board Governance

1. Introduction

1.1 The Chief Executive’s Report aims to provide information to the Board of Directors on key local, regional and national issues.

2. Key Issues & Planned Actions

2.1 The Trust went live with its new electronic patient record system (TrakCare) on Monday, 19 October 2015. This project has been funded from £7m allocated from the Department of Health “Safer Hospitals Safer Wards Technology Fund”. This new system replaces a 27 year old patient administration system. Although a significant amount of training and preparation has taken place, it was inevitable that there would be some teething problems as staff get used to working with the new system. Once the system is fully rolled out across the Trust it should enable significant efficiency savings to be delivered.

2.2 Following the independent report on neonatal services by the Royal College of Child Health being presented to the regional Overview and Scrutiny Committee by the Specialist Commissioners the following actions have been agreed:-

a) Specialist Commissioners have agreed to arrange a clinically led meetingbetween the Trust, the clinical network representatives and the Royal Collegeto discuss the concerns raised by the Trust following the publication of thereport.

b) Further discussion will take place with the SeQIHS Board to determinewhether or not neonatal services will form part of this review or be takenforward separately by NHS England.

2.3 Jim Mackey, The Chief Executive of Northumbria Healthcare NHS Foundation Trust has been appointed as the new Chief Executive of NHS Improvement with effect from 1 November 2015. He is keen to encourage Trust collaboration as a means of improving the performance and finances of the provider sector and has asked me to write to South Tees Hospitals and County Durham and Darlington NHS Foundation Trusts to set up a meeting to discuss meaningful collaboration between the three

Draft

2

Trusts. It is likely that a meeting will take place in November 2015 between the Chairs and Chief Executives of the three Trusts.

2.4 Public Health financial allocations for 2016/17 have been announced and these result in a loss of £1m for both Hartlepool and Stockton Local Authorities. Clearly this will have an impact on next year’s contract discussions.

3. Recommendations

3.1 The Board of Directors is asked to note the content of this report.

Alan Foster Chief Executive

Draft



29 October 2015


Retrospective Approval of Documents Executed Under Seal

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports)

Maintain Compliance and Performance

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports)

Maintain Compliance and Performance Effective Board Governance

The following documents have been executed under the Common Seal of the Trust.

Document Date Sealed By

Transfer ’TR1’ relating to land at Wynyard Business Park, Billingham – Title CE207160

From:

North Tees & Hartlepool NHS Foundation Trust

To:

Wynyard Park Limited

13 Aug 2015 Mrs J Gillon Ms L Hodgson

The Board is requested to grant retrospective approval for the sealing of these documents.


Draft



29 October 2015


Retrospective Approval of Documents Executed Under Seal

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports)



Maintain Compliance and Performance Effective Board Governance

The following documents have been executed under the Common Seal of the Trust.

Document Date Sealed By

Lease relating to the former Rainbow Nursery premises at the University Hospital of Hartlepool, Holdforth Road, Hartlepool, TS24 9AH

Between:

1) North Tees & Hartlepool NHS Foundation Trust

and

2) Northern Education Trust

1 Sep 2015 Mr A Foster Mrs A Burrell

The Board is requested to grant retrospective approval for the sealing of these documents.


Draft

1



29 October 2015

Executive Summary

Quality Report

Report of the Acting Director of Nursing, Patient Safety and Quality

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Putting Patients First

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Putting Patients First/Patient Safety

1. Introduction

1.1 Section 2 describes the outcome of the monthly Staff, Patient Experience and Quality Standards (SPEQS) reviews for September 2015 when 40 areas were assessed

The overall score for September 2015 is 95.67%; this has decreased by 2.16% from the August 2015 performance From the September visit, the highest score was 100% by 17 wards/areas The Trust continues to reward and recognise the areas/wards that attain 100% across all aspects of the SPEQS September averages for the four indicators are: First Impressions 98.33% down from 99.17%, Patient Experience 98.43% down from 99.54%, Nursing Evidence 90.56% down from 92.78% and Staff Involvement 89.58% down from 97.08%

1.2 Sections 3 and 4 describe mortality data with Trust HSMR and all-cause mortality data as being out of the ‘as expected’ range. Latest Trust SHMI data is reported as being also out of the ‘as expected’ range. This section provides additional information including benchmark data.

The HSMR value has decreased from 124.54 (Jul14 to Jun15) to 123.86 (Aug14 to July15) The Trust crude mortality rate for HSMR has decreased to 4.08 from 4.09 The latest SHMI value is 118.24 (Jan14 to Dec14).The detailed data for SHMI for the time period of Jan 14 to Dec 14 has been delayed by the Health and Social Care Information Centre (HSCIC).An update will be provided in the next Quality Report The Trust is working with Advancing Quality Alliance (AQuA) to gain a greater understanding and assurance around specific areas of mortality, a plan is being produced with work to commence in the coming months

1.5 Section 5 describes the Trust’s complaints data within the three complaints streams; Stage 1, Stage 2 and Stage 3.

Trust has received 498 complaints between 1 April 2015 and 15 October 2015, of which 123 (25.31%) are Stage 3 There are currently only 71 open complaints, of which 31 (43.66%) are Stage 3 The compliance rate for responding within the 25 day deadline for August 2015 is 92%

Draft

2

1.6 Section 6 provides an overview of the Nursing and Midwifery Workforce Report This paper outlines registered and unregistered care staff fill rates across inpatient areas for the months of June, July and August 2015 (appendices 1, 2 and 3) Appendix 4 represents the first report informing the Board of the progress, implementation and impact of the 1:1 Support Worker role

1.7 Section 7 describes the Safety Thermometer work Following the Trust’s review of the Safety Thermometer data collection process, Senior Clinical Matrons now ensure that all areas returns are checked for accuracy prior to upload The results for Classic Safety Thermometer are as follows: Pressure Ulcers - New has decreased to 0.78% in September from 1.77% in August Falls with Harm has decreased to 0.26% in September from 1.10% in August Catheter and New UTI has increased to 0.78% in September from 0.44 % in August New VTE (venous thromboembolism) has increased to 0.26% in September from 0.22% in August The Trust’s overall Harm free care has increased to 97.92% in September 2015 from 96.47% in August 2015

1.8 Section 8 describes the Trust’s in-patients falls with fracture Since April 2015 the Trust has had 22 in-patients who suffered a fall with a fracture From the 22 falls with fracture, 12 have resulted in a fracture neck of femur

1.9 Sections 9 and 10 describes the Friends and Family Test The % of in-patients who would recommend to their friends and/or family decreased slightly to 96.27% in August 2015 from 96.37% in July 2015 The % of patients who would recommend A&E increased to 91.81% in August 2015 from 90.40% in July 2015 Maternity Friends and Family data was not available at the point of writing this report; an update will be provided in the next Quality Report The number of responses for the out-patients clinics reduced to 746 in August 2015, from the 1,378 in July 2015; the Trust is looking into why this reduction occurred The % of patients who would recommend our Outpatient departments to their family and/or friends increased slightly to 89.68% in August 2015 from 88.61% in July 2015

1.10 Section 11 describes the information on ‘Never Events’ There have been zero Never Events in this reporting year

2. Recommendation

2.1 The Board of Directors is asked to note the content of this report and acknowledge the performance in SPEQS values, the performance from the complaints team, the continued actions being undertaken to understand and improve the position for HSMR and SHMI, the work around the Friends and Family Test and the improved Safety Thermometer data.

Julie Lane Acting Director of Nursing, Patient Safety and Quality

Draft

3



29 October 2015

Quality Report

Report of the Acting Director of Nursing, Patient Safety and Quality

1. Introduction/Background

1.1 This quality report aims to describe progress in relation to the following aspects of patient safety and experience.

Staff, Patient Experience and Quality Standards (SPEQS) Mortality update Hospital Standardised Mortality Ratio (HSMR) Mortality update Summary Hospital-Level Mortality Indicator (SHMI) Complaints update and performance Nursing and Midwifery workforce report NHS Safety Thermometer Friends and Family data Never Events Recommendations

2. Staff & Patient Experience and Quality Standards (SPEQS)

2.1 The Trust continues to embed the combined Acute and Community SPEQS process

2.2 The four sections that are being assessed are:First Impressions Nursing Evidence Patient Experience Staff Involvement

2.3 The following table relates to the 2015/2016 reporting year with the data currently available from April 2015 to September 2015.

SPEQS Visit

Month

First Impressions

2015/2016

Nursing Evidence 2015/2016

Patient Experience 20152016

Staff Involvement 2015/2016

Q1

April 94.81% 96.30% 98.85% 94.81% May 99.35% (G) 93.03% (R) 97.97% (R) 93.46% (R) June 94.70% (R) 93.18% (G) 98.57% (G) 97.73% (G)

Q2

July No Visit due to CQC

August 99.17% (G) 92.78% (R) 99.54% (G) 97.08% (R) September 98.33% (R) 90.56% (R) 98.43% (R) 89.58% (R)

Q3

October

November

December

Q4

January

February

March

Draft

4

2.4 The monthly average value for all clinical areas has decreased slightly to 95.67% in September 2015 from 97.83% in August 2015.

2.5 The ward areas that returned low scores will be re-assessed during an unannounced SPEQS visit. The results from these re-assessed visits will be presented back to the wards/areas with additional actions to be put in place to re-address the issues. Once corrective action has been put in place, the Trust will undertake additional unannounced SPEQS visits on these areas.

2.6 Nursing Evidence completeness has decreased in September to 90.56% from 92.78% in August. The updated adult core assessment documentation is now a fundamental part of the patient assessment process with the individualised care elements which enable holistic planning and delivery.

2.7 The Trust continues with a reward and recognition scheme for all the wards/areas that achieve 100% for the four elements and also meet 100% on the clean toilets and commodes. This includes a letter from Cath Siddle (Director of Nursing, Patient Safety and Quality), signed certificate and a basket of fruit/box of chocolates.

2.8 The following demonstrates the number of wards/areas that have achieved the 100%

Number of areas with 100%

Number of areas visited

% with 100%

Apr-15 25 44 56.82%

May-15 24 49 48.98%

Jun-15 18 42 42.86%

Jul-15 No Visit No Visit No Visit

Aug-15 25 39 64.10%

Sep-15 17 40 42.50%

2.9 The following table demonstrates the Trust’s overall position from the SPEQS visits undertaken during 2015/2016.

First Impressions % 2015/2016

Nursing Evidence % 2015/2016

Patient Experience % 2015/2016

Staff Involvement % 2015/2016

97.72% 93.23% 98.64% 94.55%

2.10 There have been 560 toilets inspected since April 2015 of which 547 (97.68%) were seen to be clean on the day of the visit.

2.11 The following table demonstrates the year on year trends for the four elements included in the SPEQS:

2011/2012 2012/2013 2013/2014 2014/2015 2015/2016

First Impressions 91% 85% 92% 97% 97% Nursing Evidence 90% 87% 90% 91% 93% Patient Experience 98% 96% 97% 98% 99% Staff Involvement N/A N/A N/A 95% 95%

Draft

5

3 Mortality - Hospital Standardised Mortality Ratio (HSMR)

3.1 Data reported in this document is taken from the Healthcare Evaluation Data (HED) tool which provides mortality data for HSMR up to March 2015.

3.2 The HSMR value has reduced to 123.86 (August2014 to July 2015) from 124.54 (July 2014 to June 2015). This value continues to be outside the ‘as expected’ range; the national mean is 100.

3.3 There are three other Trusts within the North East that also fall out of the ‘as expected’ range for HSMR; they are South Tyneside NHS Foundation Trust, South Tees Hospitals NHS Foundation Trust and Northumbria Healthcare NHS Foundation Trust.

3.4 The Trust crude mortality rate has decreased from 4.09 to 4.08 from the previous reporting period. The Crude Mortality Rate continues to decrease from the high values of December 2014 (4.65%), January 2015 (6.73%), February 2015 (4.32%) and March 2015 (5.06%).

3.5 July 2015 crude mortality rate was 2.81%, this has been the lowest value for the Trust since July 2014 when it was 2.99%.

3.6 The following table demonstrates the Crude Mortality Rate (CMR) benchmarked against the other North East Trusts. As the table demonstrates, the Trust has the 4th highest regional CMR value.

Trust Name HSMR Number of palliative

discharges Mortality

Rate

Trust 1 123.72 281 5.22%

Trust 2 109.74 1461 5.09%

Trust 3 107.24 606 4.16%

North Tees and Hartlepool NHS Foundation Trust 123.86 599 4.08%

Trust 5 98.32 857 3.95%

Trust 6 117.24 816 3.69%

Trust 7 101.36 282 3.60%

Trust 8 100.02 1036 2.55%

3.7 For the rolling 12 month period of August 2014 to July 2015, the diagnostic group with the highest difference between expected and actual deaths continues to be Pneumonia with 60.60.

Draft

6

3.8 The Trust has made significant improvements in reducing the number of deaths in the primary diagnosis group of Pneumonia. During January 2013 to December 2013, the Trust had 72.14 more deaths than expected; this has reduced to 60.60 (August 2014 to July 2015).

3.9 It remains more important than ever to accurately record the primary diagnosis, co-morbidities and specialist palliative care input to allow the model to be applied accurately to the Trust’s patients, assigning the appropriate risk to the value.

3.10 The Trust’s End of Life coordinator who joined the Specialist Palliative Care team in May 2015 continues to impact on both the number of contacts made and the number seen.

3.11 The September 2015 value has increased to over 100+ for September 2015, however the Trust is putting additional actions in place to ensure that the patients are referred as soon as possible so that the Specialist Palliative Care team can be involved.

3.12 Other actions such as awareness and Specialist Palliative Care refresher workshops are being held in the next few months to maintain and improve the consultant’s awareness and to ensure that the best processes are followed for the patient.

4 Mortality - Summary Hospital-Level Mortality Indicator (SHMI)

4.1 SHMI provides mortality data relating to deaths within 30-days of discharge from hospital and does not adjust for end of life care. The latest data available nationally

Draft

7

is for the 12 month period ending December 2014 when the Trust SHMI decreased to 118.24 from 118.91 the previous reporting period. This still remains in the ‘higher than expected’ range.

4.2 There has been a delay from the Health and Social Care Information Centre (HSCIC) in releasing the detail for the latest SHMI, therefore our benchmarking provider; Healthcare Evaluation Data (HED) has not been able to update the benchmarking tool.

4.3 The updated detail will be made available in the next Board report.

4.4 The Trust acknowledges that the HSMR and SHMI values are higher than expected and is implementing a number of processes/reviews to gain a greater understanding to the quality of care being given to patients.

4.5 The Trust has ensured that the 7 recommendations for improvement in the North East Quality Observatory System (NEQOS) mortality review have been commenced. This action plan is discussed at the Keogh Delivery Group, ensuring that updates and actions are given and followed through. The Trust also shared the Comprehensive Mortality Action Plan with the Commissioners.

4.6 The Trust has negotiated with the commissioners and it was agreed to include the Trust’s Ambulatory Care patients as inpatients. The change came into effect from the 1 April 2015 and will be seen in the SHMI module in the New Year when April 2015 becomes part of the 12 month rolling period.

4.7 The Trust is working with Advancing Quality Alliance (AQuA) to commence and review the Trusts mortality position. The remit that AQuA will cover is around Sepsis and Acute Kidney Injury (AKI); additional data will be included in future Board papers.

5. Trust complaints breakdown

5.1 Since 1 April 2015, the Trust has received 498 complaints (up to the 15 Oct 2015);68.67% are Stage 1, 7.03% are Stage 2 and 24.30% are stage 3. Currently there are71 open complaints, 33.80% (24) are Stage 1, 22.54% (16) are Stage 2 and 43.66%(31) are Stage 3.

5.2 The Trust also monitors the type of complaints that are being reported. The categoryof complaint with the highest number is communication – Insufficient feedback topatients or relatives.

5.3 The themes are collated and aggregated analysis is considered in the Trust’s quarterly Claims, Litigation and PALS (CLIP) report. The Directorates identify the top themes within their area and provide actions for improvement which is then followed up in the subsequent quarterly CLIP report.

5.4 In response to this the in-hospital care wards (medical and elderly care) are piloting extended visiting hours, however this has raised some issues and challenges for our Doctors to undertake ward rounds, domestics to robustly clean the bed areas and Allied Healthcare Professional (AHP) groups to provide privacy during therapy sessions. A Task and Finish group, led by the Associate Director of Nursing, has been established to ascertain patient, relatives and staff views on appropriate timings for visiting hours.

5.5 Further feedback has been sought by the local patient survey; further detail will be provided in the next Board report.

Draft

8

5.6 All lessons learned from complaints are shared with the clinical teams and managed proactively through the Directorates governance process.

5.7 In August 2015 the Trust’s compliance rate was 92%, with a 12 month rolling average of 93.75% responded to within the 25 day deadline.

5.8 The Trust continues to run the independent complaints review panels established in January 2015. The panel continues to have a good attendance from the Commissioners, HealthWatch, Independent Complaints Advocate, Non-Executive Directors, Director of Nursing, Associate Director of Nursing, Patient Experience Team manager and attendance from the Directorate involved in the complaint. The panel continues to provide a real benefit corporately and at Directorate level to bring further improvement to the process and the outcome for the complainants.

5.9 The Trust is undertaking a written survey questionnaire in September 2015 to complainants for the month of July 2015 who received a response letter from the Chief Executive. This process will help the Trust to ensure that all processes currently in place meet the complainant’s expectations as well as being able to learn from complainant’s experiences to improve the service in the future.

5.10 The questionnaire will be sent out every six months and will cover the complainants for the months of July and January.

6 Nursing and Midwifery Workforce

6.1 The purpose of this section is to provide an overview of registered and unregistered care staff fill rates across inpatient areas for the months of June, July and August 2015 (appendices 1, 2 and 3). In addition this section will provide a rationale for variances within the data where there are high or low percentages for either registered or unregistered care staff.

6.2 The information which is published on the NHS Choices website is an aggregate of the staffing data. Detailed information is published on the Trust website and is accessed via a link to the Trust’s Safer Staffing web page from the NHS Choices website.

6.3 The detailed information is broken down into individual ward and departments with staffing information being expressed both in planned and actual hours and percentage fill rates over the month for both day and night duties.

Draft

9

6.4 Variances in percentage fill rates occur for a number of reasons including staff vacancies, sickness and maternity leave and in some areas higher than planned fill rates due to increased acuity and care needs of the patient group.

6.5 A report will be submitted to each subsequent Board with the previous months staffing data and reasons for variances.

7. NHS Safety Thermometer

7.1 Following the Trust’s review of the Safety Thermometer data collection process,Senior Clinical Matrons now ensure that all areas returns are checked for accuracyprior to upload.

7.2 The Trust will be expecting to see continued improvement in the Safety Thermometermeasures in the coming months.

7.3 The following data has been provided by the information collected via the NHS SafetyThermometer (Data as of August 2015):

Pressure Ulcers - New has decreased for the proportion of patients to 0.78% (this equates to 3 patients from 385 patients inspected) in September from 1.77% (this equates to 8 from 453 patients inspected) in August 2015

Falls with Harm has increased for the proportion of patients to 0.26% (this equates to 1 from 385) in September from 1.10% (this equates to 5 from 453 patients inspected) in August 2015

Catheter and New UTI has increased for the proportion of patients to 0.78% (this equates to 3 from 385 patients inspected) in September from 0.44% (this equates to 2 from 453 patients inspected) in August 2015

New VTE (venous thromboembolism) has increased for the proportion of patients to 0.26% (this equates to 1 from 385 patients inspected) in September from 0.22% (this equates to 1 from 453 patients inspected)

7.4 The Trust’s overall Harm free care has increased to 97.92% in September 2015 from 96.47% in August 2015.

8 Falls with Fracture

8.1 For the past five quarters, there have been 54 falls which resulted in a fracture.

8.2 From the 54 falls which resulted in a fracture, 29 were a fracture of the neck of femur and 25 were attributed to other fractures, such as fractures to a foot, hand etc.

Draft

10

8.3 Since 1 April 2015 there have been 22 patient falls which have resulted in a fracture; the following chart demonstrates the numbers per month.

8.4 The following chart details the locations for the 22 falls with fracture that have occurred since April 2015.

8.5 The average age for the 22 patients who suffered a fracture from a fall within the Trust is 80 years of age.

8.6 When this is split between genders, the average age for females (f) is 84 years of age and males (m) it is 72 years of age.

8.7 The following chart demonstrates the monthly falls by gender.

Draft

11

9 Family and Friends Test (FFT)

9.1 In August 2015 the Trust achieved a return rate of 30.76% (1,032) for in-patients.

9.2 In-patient ‘Would recommend’ – ‘Wouldn’t recommend’ data

Number of forms returned

Would recommend

Wouldn't recommend

Apr-15 844 801 94.90% 6 0.71% May-15 774 741 95.74% 9 1.16% Jun-15 1,103 1,068 96.83% 6 0.54% Jul-15 1,156 1,114 96.37% 11 0.95% Aug-15 1,072 1,032 96.27% 9 0.84%

9.3 Accident & Emergency ‘Would recommend’ – ‘Wouldn’t recommend’ data


Would recommend

Wouldn't recommend

Apr-15 17 15 88.24% 1 0.35% May-15 295 266 90.17% 8 2.71% Jun-15* 176 125 92.05% 10 5.68% Jul-15* 354 320 90.40% 18 5.08% Aug-15* 171 157 91.81 5 2.92%

*From June 2015 Minor Injuries Unit (MIU) data is included into the Accident & Emergency FFT returns.

9.4 Maternity data ‘Would recommend’ – ‘Wouldn’t recommend’ data


Would recommend

Wouldn't recommend

Apr-15 167 162 97.01% 1 0.60% May-15 77 74 96.10% 1 1.30% Jun-15 96 92 95.83% 0 0.00% Jul-15 50 46 92.00% 2 4.00% Aug-15 Not available

9.5 Maternity returns are a challenge across all the services as women are asked on

numerous occasions and are subject to questionnaire overload. The Trust continues to promote returns both within and outwith the hospital setting and recognises that these fluctuate month on month.

9.6 The number of responses for the out-patients clinics was 746 returns in August 2015 compared to 1,378 in July 2015.

Draft

12


Would recommend

Wouldn't recommend

Apr-15 1,660 1,478 89.04% 27 1.63% May-15 1,315 1,171 89.05% 31 2.36% Jun-15 1,360 1,210 88.97% 32 2.35% Jul-15 1,378 1,221 88.61% 33 2.39% Aug-15 746 669 89.68% 13 1.74%

9.7 The Trust is aware of the significant reduction in the numbers for out-patients in August 2015; this is being addressed internally by reminding all Out-patient areas to continue to ensure that each patient is given the opportunity to complete a questionnaire.

10 Family and Friends Test (FFT) – Online

10.1 The Trust has established an online version of the Friends and Family Test on the Trust’s website; this can be found at the following link http://www.nth.nhs.uk/patients-visitors/complaints/friends-family/.

10.2 The online form gives any patient who receives treatment in our organisation the chance to complete a form in the comfort of their own home, or on a mobile device.

10.3 The Trust has launched the website with the help of our communications team; additional posters and other media will help ensure patients and staff members are aware of its availability.

10.4 Unfortunately, even though the Trust continues to advertise and ensure that the online version is available to patients the numbers being returned via this method remains low. Since May 2015 when the service went live, the Trust has received only 19 returns (May 2015 to September 2015).

11 Never Events

11.1 There have been no Never Event’s reported in the period of 2015/2016, the last never event occurred in March 2015.

11.2 Since 2008 the Trust has had 7 Never Events and they are broken down as follows:

Reporting Year Number of Never Events

2008/09 1

2009/10 0

2010/11 2

2011/12 1

2012/13 1

2013/14 1

2014/15 1

2015/16 0

Totals: 7

11.3 The NHS England report can be accessed via: http://www.england.nhs.uk/patientsafety/never-events/ne-data

http://www.nth.nhs.uk/patients-visitors/complaints/friends-family/

http://www.nth.nhs.uk/patients-visitors/complaints/friends-family/

http://www.england.nhs.uk/patientsafety/never-events/ne-data

Draft

13

11.4 The regional position for the number of Never Events in the 2015/16 reporting year (1 April 2015 to 31 August 2015) is as follows:

2015-16 Provider organisation where Never Event (NE) occurred

Sub-total Serious Incident reported as

Never Event

Trust 1 2 Trust 2 1 Trust 3 1 North Tees & Hartlepool NHS Foundation Trust 0 Trust 4 0 Trust 5 0

11.5 The above table indicates a positive position for the Trust across the North East. On a National level there has been 122 Never Events during this time period.

12 Recommendation

12.1 The Board of Directors is asked to note the content of this report and acknowledge performance in SPEQS values, the performance from the complaints team, the continued actions being undertaken to understand and improve the position for HSMR and SHMI, the work around the Friends and Famliy Test and the improved Safety Thermometer data.

Julie Lane Acting Director of Nursing, Patient Safety and Quality

Draft

14

Appendix 1

Safer Staffing

June 2015

North Tees and Hartlepool NHS Foundation Trust prides itself on ensuring that safe staffing levels are maintained at all times in line with the national quality board requirements to have the ‘right staff, with the right skills in the right place at the right time’.

The information below relates to the planned actual staffing levels throughout June 2015. Differences between the planned and actual staffing maybe for a variety of reasons such as sickness or vacancies, whilst areas which appear to be higher than planned may be due to an increased requirement of a specific staff group to meet the needs of the patients at that time. Duty rotas are planned in advance and staffing needs are reassessed on a daily basis by the senior nursing teams for each area to ensure that changing need are met.

The information below shows the planned and actual staffing for the month of June 2015 for inpatient areas.

Ward name Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff

(%)

Acute Cardiology Unit 85.0% 157.5% 95.4% 73.1%

Critical Care 90.2% 75.0% 91.8% 86.7%

Delivery Suite 88.7% 77.8% 88.7% 95.9%

Elective Care Unit 98.1% 95.6% 96.2% 92.5%

Emergency Assessment Unit 77.1% 116.8% 87.2% 121.4%

Neonatal Unit 86.4% 91.2%

Paediatrics 93.1% 82.2% 99.9% 82.0%

Ward 3 76.4% 99.8% 100.0% 99.2%

Ward 22 79.6% 91.0% 93.3% 88.5%

Ward 24 61.5% 137.9% 96.7% 104.1%

Ward 25 75.8% 180.6% 98.9% 132.1%

Ward 26 76.9% 184.4% 100.4% 143.3%

Ward 27 74.7% 160.0% 91.7% 162.6%

Ward 28 81.7% 149.0% 90.4% 180.5%

Ward 30 90.3% 110.2% 100.5% 105.6%

Draft

15

Ward 31 93.5% 106.7% 93.6% 122.3%

Ward 32 73.5% 184.5% 89.2% 170.8%

Ward 33 81.4% 112.9% 98.3% 109.1%

Ward 36 92.0% 101.5% 93.2% 128.6%

Ward 29 78.3% 118.3% 98.3% 99.7%

Ward 37 79.1% 110.2% 90.0% 108.6%

Ward 40 69.6% 158.9% 98.4% 142.4%

Ward 41 85.0% 89.1% 98.9% 105.9%

Ward 42 66.8% 144.4% 89.9% 167.0%

81.4% 118.5% 94.7% 113.4%

.

Draft

17


Safer Staffing Levels briefing

June 2015

Introduction

Publication of the National Quality Board document, ‘How to ensure the right people with the right skills, are in the right place at the right time’ (2013) and the Hard Truths document, (2013) introduce a requirement to publish staffing data on a monthly basis via the NHS Choices website. The data required on the NHS Choices website relates to the number of planned and actual staffing hours for inpatient wards and is presented as a percentage of fill rates. This however does not provide vital information to support the fill rates which will form a part of a briefing to be published on the Trust website which will be hyperlinked to the NHS Choices site. The following information relates to the data upload for June 2015.

Ward Mitigation

Acute Cardiology Unit

Associate Practitioner utilised to support Registered Nurse vacancies Additional Unregistered Care Staff rostered to support Ambulatory across the floor on day duty reducing the Unregistered Care Staff planned for nights Red rules (minimal 2 Registered Nurses at all times) maintained

Critical Care Unregistered Care Staff vacancy resulting in reduced percentage of planned against actual requirements on nights

Delivery Suite

Registered Midwives Maternity leave and sickness resulting in reduced percentage. Department escalation plan utilised, Unregistered Care Staff Long term sickness and sort term sickness resulting in reduced percentage of planned against actual requirements Department escalation plan utilised, Red rules (minimal 2 Registered Nurses at all times) maintained

Elective Care Unit Registered Nurses staff utilised flexibly to cover activity within the directorate – Staff reallocated to North Tees Red rules (minimal 2 Registered Nurses at all times) maintained

Emergency Assessment Unit

Registered Nurses vacancies, and short term sickness Associate Practitioner utilised to support Registered Nurse complement resulting in increased

Draft

18

percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Neonatal Unit Registered Nurses vacancy and secondments resulting in reduced percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Paediatrics Registered Nurses vacancies and maternity leave; Unregistered Care Staff Long Term Sickness Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 3

Registered Nurses vacancies and maternity leave; Unregistered Care Staff Long term sickness and sort term sickness resulting in reduced percentage of planned against actual requirements Assistance from within the directorate and Associate Practitioners utilised to support Registered Nurse complement Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 22

Days/Nights – Registered Midwifes Maternity leave and sickness resulting in reduced percentage. Unregistered Care Staff sickness resulting in reduced percentage of planned against actual requirements Department escalation plan utilised, Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 24

Registered Nurses vacancies; Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 25


Ward 26

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Draft

19

Ward 27


Ward 28


Ward 30

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements

Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 31

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Increase in Unregistered Care Staff requirements due to specialling requirements average x 2 extra staff per shift Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 32

Registered Nurse vacancies – 4 beds closed due to minimal staffing Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Increase in Unregistered Care Staff requirements due to specialling requirements; average x 2 extra staff per shift Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 33

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 36

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Increase in Unregistered Care Staff requirements due to specialling requirements

Draft

20


Ward 29

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 37


Ward 40


Ward 41


Ward 42

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Increase in Unregistered Care Staff requirements due to specialling requirements; average x 2 extra staff per shift Red rules (minimal 2 Registered Nurses at all times) maintained

Draft

21

Appendix 2

Safer Staffing

July 2015

North Tees and Hartlepool NHS Foundation Trust prides itself on ensuring that safe staffing levels are maintained at all times in line with the national quality board requirements to have the ‘right staff, with the right skills in the right place at the right time’. The information below relates to the planned actual staffing levels throughout July 2015. Differences between the planned and actual staffing maybe for a variety of reasons such as sickness or vacancies, whilst areas which appear to be higher than planned may be due to an increased requirement of a specific staff group to meet the needs of the patients at that time. Duty rotas are planned in advance and staffing needs are reassessed on a daily basis by the senior nursing teams for each area to ensure that changing need are met. The information below shows the planned and actual staffing for the month of July 2015 for inpatient areas.


nurses/midwives (%)



nurses/midwives (%)


(%)


Critical Care 89.9% 89.6% 90.5% 79.4%

Delivery Suite 86.4% 83.4% 95.0% 97.6%




Paediatrics 86.4% 80.6% 92.5% 75.7%

Ward 3 86.1% 92.4% 100.0% 112.8%

Ward 22 75.4% 89.3% 94.1% 93.0%

Ward 24 75.1% 153.4% 91.9% 109.5%

Ward 25 75.7% 131.0% 96.2% 122.1%

Ward 26 75.1% 164.1% 97.0% 131.5%

Ward 27 82.5% 170.4% 98.4% 156.0%

Ward 28 83.1% 122.7% 90.6% 124.7%

Ward 30 87.5% 90.8% 85.8% 97.6%

Draft

22

Ward 31 76.9% 119.4% 101.7% 150.3%

Ward 32 74.7% 190.3% 87.9% 159.8%

Ward 33 76.6% 108.4% 93.8% 119.0%

Ward 36 87.4% 93.8% 87.2% 116.4%

Ward 29 77.6% 102.6% 100.0% 108.8%

Ward 37 80.6% 125.8% 95.4% 155.8%

Ward 40 73.7% 127.6% 98.2% 144.5%

Ward 41 80.4% 95.2% 100.2% 129.0%

Ward 42 75.0% 126.4% 88.9% 173.2%

80.8% 112.6% 93.6% 113.5%

.

Draft

23



July 2015

Introduction

Publication of the National Quality Board document, ‘How to ensure the right people with the right skills, are in the right place at the right time’ (2013) and the Hard Truths document, (2013) introduce a requirement to publish staffing data on a monthly basis via the NHS Choices website. The data required on the NHS Choices website relates to the number of planned and actual staffing hours for inpatient wards and is presented as a percentage of fill rates. This however does not provide vital information to support the fill rates which will form a part of a briefing to be published on the Trust website which will be hyperlinked to the NHS Choices site. The following information relates to the data upload for July 2015.

Ward Mitigation



Critical Care Registered Nurses vacancies and maternity leave; Unregistered Care Staff vacancy resulting in reduced percentage of planned against actual requirements on nights

Delivery Suite

Registered Midwives Maternity leave and sickness resulting in reduced percentage. Department escalation plan utilised, Unregistered Care Staff sickness resulting in reduced percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained



Registered Nurses vacancies and maternity leave; Associate Practitioner utilised to support Registered Nurse complement resulting in increased

Draft

24

percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Neonatal Unit Registered Nurses vacancy and secondments resulting in reduced percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained


Ward 3

Registered Nurses vacancies and maternity leave; Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 22


Ward 24


Ward 25


Ward 26


Ward 27 Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements

Draft

25

Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 28


Ward 30 Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 31


Ward 32


Ward 33


Ward 36 Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 29


Ward 37


Draft

26


Ward 40


Ward 41


Ward 42


Draft

27

Appendix 3

Safer Staffing

August 2015

North Tees and Hartlepool NHS Foundation Trust prides itself on ensuring that safe staffing levels are maintained at all times in line with the national quality board requirements to have the ‘right staff, with the right skills in the right place at the right time’.

The information below relates to the planned actual staffing levels throughout August 2015. Differences between the planned and actual staffing maybe for a variety of reasons such as sickness or vacancies, whilst areas which appear to be higher than planned may be due to an increased requirement of a specific staff group to meet the needs of the patients at that time. Duty rotas are planned in advance and staffing needs are reassessed on a daily basis by the senior nursing teams for each area to ensure that changing need are met.

The information below shows the planned and actual staffing for the month of August 2015 for inpatient areas.


nurses/midwives (%)



nurses/midwives (%)


(%)


Critical Care 90.5% 105.1% 94.2% 74.8%

Delivery Suite 83.1% 79.5% 95.9% 76.8%




Paediatrics 84.4% 81.6% 96.1% 80.9%

Ward 3 90.9% 123.9% 100.0% 101.9%

Ward 22 81.9% 87.1% 93.6% 88.9%

Ward 24 81.9% 126.7% 93.5% 103.9%

Ward 25 81.9% 113.6% 108.8% 109.6%

Ward 26 89.3% 137.7% 100.6% 110.8%

Ward 27 78.6% 160.4% 100.0% 140.4%

Ward 28 90.7% 120.2% 90.6% 135.8%

Ward 30 91.0% 92.4% 91.3% 95.3%

Draft

28

Ward 31 87.4% 112.4% 105.2% 121.6%

Ward 32 87.6% 122.0% 95.2% 159.4%

Ward 33 86.4% 111.4% 107.7% 121.6%

Ward 36 93.2% 106.4% 97.5% 113.7%

Ward 29 87.4% 117.2% 103.2% 127.4%

Ward 37 85.8% 124.2% 100.4% 124.3%

Ward 40 80.1% 125.4% 99.3% 125.0%

Ward 41 84.6% 109.6% 101.3% 104.3%

Ward 42 85.4% 140.6% 93.5% 134.6%

89.5% 114.1% 102.4% 109.1%

.

Draft

29



August 2015

Introduction

Publication of the National Quality Board document, ‘How to ensure the right people with the right skills, are in the right place at the right time’ (2013) and the Hard Truths document, (2013) introduce a requirement to publish staffing data on a monthly basis via the NHS Choices website. The data required on the NHS Choices website relates to the number of planned and actual staffing hours for inpatient wards and is presented as a percentage of fill rates. This however does not provide vital information to support the fill rates which will form a part of a briefing to be published on the Trust website which will be hyperlinked to the NHS Choices site. The following information relates to the data upload for August 2015.

Ward Mitigation



Critical Care Unregistered Care Staff allocated to work in Theatres in August resulting in reduced percentage of planned against actual requirements on nights

Delivery Suite

Registered Midwives Maternity leave and sickness resulting in reduced percentage. Department escalation plan utilised, Unregistered Care Staff sickness resulting in reduced percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained



Registered Nurses vacancies and maternity leave; Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Neonatal Unit Red rules (minimal 2 Registered Nurses at all times) maintained

Draft

30


Ward 3

Registered Nurses vacancies and maternity leave; Assistance from within the directorate and Associate Practitioners utilised to support Registered Nurse complement Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 22


Ward 24


Ward 25


Ward 26

Registered Nurse vacancies Associate Practitioner utilised to support Registered Nurse complement resulting in increased percentage of planned against actual requirements

Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 27


Ward 28


Draft

31


Ward 30 Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 31


Ward 32


Ward 33


Ward 36 Increase in Unregistered Care Staff requirements due to specialling requirements Red rules (minimal 2 Registered Nurses at all times) maintained

Ward 29


Ward 37


Ward 40


Draft

32

Ward 41


Ward 42


Draft

1



29 October 2015

Executive Summary

Infection Prevention and Control Report

Report of the Acting Director of Nursing, Patient Safety and Quality/ Director of Infection Prevention and Control (DIPC)

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Board reports) Maintain Compliance and Performance

Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Board reports) Reduce Hospital Acquired Infections

1. Introduction

1.1 The purpose of this report is to inform the Board of Directors of the healthcare associated infection performance position for the period to 30 September 2015. The figures quoted are correct at the time of writing on 8 October 2015.


Clostridium difficile

2.1 The Trust is reporting 3 Trust attributed cases of Clostridium difficile infection for September 2015. This gives a total to date of 18 cases which exceeds the trajectory for the year. All cases have been subject to root cause analysis and the results of genetic typing indicate that cross infection is possible in three sets of patients, some of whom are trust apportioned cases and some who are non-trust cases. The only recurring theme from RCA is poor cleaning scores for patient equipment and this is being addressed by training and monitoring of the cleaning. In the same period 6 community cases were also reported. The programme of cleaning and fogging of high risk wards has restarted, although due to capacity and activity this is being undertaken on occupied wards. An external review of policy, practice and processes by Professor Mark Wilcox took place place on 20 July 2015 and a number of recommendations have been incorporated into the Trust action plan. In addition an NHS England review was very positive about the Trust actions to reduce the risk of infection but made some recommendations about collaborative working with commissioners which are being progressed.

MSSA bacteraemia

2.2 The Trust is reporting zero Trust attributed case of MSSA bacteraemia for September 2015. There is no external trajectory for this infection but the internal trajectory is 18

Draft

2

cases for the year and the Trust is within this trajectory with 14 cases to date. Each case is subject to investigation and no common themes relating to clinical practice have been identified. There were 5 community case reported in September 2015.

MRSA bacteraemia

2.3 The Trust is reporting zero Trust attributed case of MRSA bacteraemia in September 2015 and it is now 293 days since the last case was reported. The Trust continues to compare favourably with other Trusts in the region. No community cases were reported in September.

Ecoli bacteraemia

2.4 The Trust is reporting three Trust attributed cases of E coli bacteraemia in September 2015. There is no external trajectory but an internal objective of no more than 27 cases has been set based on the previous year outturn and the total to date is 17 cases. There were 22 community cases reported in September 2015

Hand hygiene

2.5 The overall Trust compliance score for hand hygiene is 94.88% for September 2015 based on the scores which had been received at the time of writing. This score currently falls slightly short of the Trust target of 95%. Initiatives around improved hand hygiene continue and this will be the focus of the Trust’s activities for International Infection Prevention week in October 2015. Monthly reporting of ward and department scores to General Managers, Clinical Directors and Senior Clinical Matrons is now in place.

Resistant Acinetobacter

2.6 A multi resistant strain of an organism, Acinetobacter, has been isolated in a number of in-patients. This is not an organism that is seen frequently in the Trust. All measures to prevent spread of infection have been implemented and advice taken from Public Health England. At the time of writing two of the patients remain in hospital with isolation precautions in place and it is now almost five weeks since the last new case was identified.

3. Recommendations

3.1 The Board of Directors is requested to note the work underway to improve performance for C difficile, and the work continuing across all clinical services to improve hand hygiene scores.

Julie Lane Acting Director of Nursing, Patient Safety and Quality/ DIPC

Draft

3



29 October 2015

Infection Prevention and Control Report

Report of the Acting Director of Nursing, Patient Safety and Quality/ DIPC


1.1 This report will describe the progress to date relating to:

Clostridium difficile Methicillin Sensitive Staphylococcus aureus (MSSA) bacteraemia MRSA bacteraemia Escherichia coli bacteraemia Hand Hygiene Resistant Acinetobacter Antimicrobial Stewardship

2. Healthcare associated infection progress report

2.1 Infections which are reportable under mandatory surveillance programme

2.1.1 NHS England requires the Trust to enter information monthly into a healthcare associated infection data capture system which is administered by Public Health England. The infections that are reportable under this process are MRSA bacteraemia in all patients, MSSA bacteraemia in all patients, E coli bacteraemia in all patients and Clostridium difficile diarrhoea in all patients aged 2 and over. Trajectories for MRSA and C difficile (CDI) are set centrally and monitored by commissioners.

Clostridium difficile

2.1.2 The table below shows performance against trajectory for the period to 30 September 2015.There were three Trust attributed cases reported for the month and the total of 18 cases to date exceeds the trajectory for the year of 13 cases. This presents a significant risk to the Trust and a formal response to Monitor has been prepared for submission in October 2015.

Year to date C difficile performance against trajectory

Month Trajectory Actual

April 15 2 4 May 15 1 4 June 15 1 0 July 15 1 3

August 15 1 4 September 15 1 3

Total 7 18

2.1.3 Root cause analysis (RCA) has been carried out on each of the cases to date. One continued theme which has emerged from a number of the investigations is poor

Draft

4

scores for cleaning of patient equipment. This may be due to lack of awareness of correct procedures or because of increased activity with cleaning not being seen as a priority. Additional training has been arranged for the wards with cases to update nursing staff on cleaning requirements, using an interactive training programme. Solutions for the problem are being explored with the Trust decontamination team and Trust volunteers. The programme of cleaning and fogging of high risk wards has restarted, although due to capacity and activity this is being undertaken on occupied wards. All high risk medical wards have been completed, with some wards having been fogged twice since the beginning of the year. The cleaning team are now working around the availability of beds within elective care to try and cover as many wards as possible before winter activity makes availability of empty rooms more difficult to facilitate.

2.1.4 The focus on antibiotic stewardship continues and work is underway to explore ways of increasing the number of antibiotic audits carried out to improve compliance. A streamlined process of completion and reporting of audits has been agreed.

2.1.5 To understand any gaps in our policies, practice and processes the Trust arranged for an expert independent review by Professor Mark Wilcox, a Consultant Microbiologist from Leeds Teaching Hospitals, and the main author of the current national guidance on prevention and management of CDI. This review took place on 20 July 2015 and the following recommendations were made and included in the Trust action plan

Optimisation of diarrhoea control – potential to improve the way in which patients with diarrhoea, which may or may not be infectious, are managed

Antimicrobial prescribing – including review of progress against Start Smart Then Focus, streamlining of audit activity, focus on extent of polypharmacy and measurement of the accuracy of stated indication for antibiotic prescriptions

Environmental cleaning/decontamination – including a review of the decant capacity to enable the deep clean programme, review of practices to ensure environmental cleanliness issues are corrected and review of capacity and staffing pressures which may be impacting negatively on performance

C difficile typing – use of enhanced fingerprinting of samples which appear to match on ribotyping

Clinical review of actions from RCA – improving clinical attendance at CDI Assurance panel to ensure shared learning

Whole health economy learning – need for investigation of non-Trust apportioned cases to ensure any learning is identified and shared

2.1.6 Advice has also been sought from Helen Crombie from NHS England who was formerly part of the Department of Health MRSA/ CDI Improvement programme. Ms Crombie visited the Trust on 16 September 2015 and made the following recommendations:

Working with CCGs to achieve appropriate representation at Healthcare Associated Infection (HCAI) meetings

Working with Commissioners to encourage GP involvement in completion of RCAs to achieve joint learning

Review of capacity in the infection prevention and control team to be able to provide advice and support to GP colleagues

2.1.7 The Infection Prevention and Control Team (IPCT) have had an increased presence

on all wards with cases of CDI in the quarter, carrying out hand hygiene observations, environmental audits and informal teaching sessions. Symptomatic patients are reviewed daily.

Draft

5

2.1.8 Genetic typing of all Trust attributed cases continues in 2015-16 and this has shown that there are some linked cases and additional support and intervention is being provided to the wards where this is the case. Further testing results are awaited.

2.1.9 All current measures to reduce infection will be continued and exploration of additional technology such as Ultra Violet light, potential decant facilities and opportunities to increase single room provision are being undertaken. A comprehensive review of performance and actions taken has been produced for Quarter 1.

MSSA bacteraemia

2.1.10 Zero cases of Trust attributed MSSA bacteraemia were reported in September 2015. This is within the internal Trust trajectory of 18 cases and the 14 cases reported to date is a slight improvement on the same period in the previous year when 15 cases had been reported. Root cause analysis has been completed for each and no practice related themes have emerged. Five community cases were reported in September.

MRSA bacteraemia

2.1.11 There have been zero cases of Trust attributed MRSA bacteraemia in September and it is 293 days since the last Trust attributed case at the time of writing. The graph below demonstrates the overall improvements made with this infection since 2006. One non-Trust case was reported in July 2015 and the Trust contributed to the investigation of the case. There were no issues or actions identified for the Trust from the investigation.

Trust attributed MRSA bacteraemia (by quarter) 2006-15

Draft

6

E coli bacteraemia 2.1.12 The Trust has reported three Trust attributed cases of E coli bacteraemia in

September 2015. There is no national trajectory for this infection but the Trust has set an internal trajectory for the year of 27 cases, which is the previous year outturn and the total of 17 cases to date is within that trajectory. The most common source of these infections is the urinary tract, however only a small percentage of the cases have a urinary catheter in situ therefore it is difficult to make any changes to reduce such cases. A significant amount of work around the insertion and care of urinary catheters has been completed and ongoing training is promoted for all relevant clinical staff. Changes have been made to the catheter monitoring document which will make it easier for staff to complete and monthly audits of adherence to documentation requirements continue and are reported to the HCAI Operational Group.

2.2 Hand hygiene 2.2.1 Hand hygiene compliance is assessed by a combination of independent assessment

by the IPCT, self assessment of departments where observation by IPCT is difficult due to the needs of the service/ patient privacy and patient feedback, mostly where staff are lone workers and other methods of assessment are not practical. Directorate and individual ward scores are displayed on the nursing and midwifery dashboard. The scores are split by staff group to allow intervention to be targeted most effectively. The overall Trust score in September 2015 was 91.52% which is below the Trust target of 95%.

2.2.2 34 wards/departments achieved greater than 95% compliance this month with the remainder scoring between 60% and 92%. This is a significant improvement on previous months. Ward matrons of wards with low compliance are now invited to the HCAI Operational Group to provide assurance to the DIPC that action is being taken to improve compliance. Where staff are noted to be non-compliant with policy they are reminded of their responsibility under the hand hygiene policy on the first occasion. If subsequent non-compliance is noted their name is forwarded to the Clinical Director and General Manager of the directorate for action, which may include disciplinary proceedings. Additional monitoring and support is received by wards reporting low compliance. Since July 2015 a RAG rated league table of compliance scores is published to directorate teams and reviewed at the HCAI Operational Group.

2.2.3 Hand hygiene champion events have been held with the focus of activities during International Infection Prevention week at the end of October 2015 being on improved staff and patient hand hygiene. A patient/carer hand hygiene survey will also be available on the Trust website from the end of October and staff will encourage patients to visit the website and provide feedback.

3. Resistant Acinetobacter 3.1 A multi resistant strain of an organism, Acinetobacter, has been isolated in a number

of in patients in the Trust. This is not an organism that is seen frequently in the Trust but is seen more frequently in other countries. All measures to prevent spread of infection have been implemented and advice taken from Public Health England. At the time of writing two of the patients, including the index case, remain in hospital with isolation precautions in place. It is now almost six weeks since the last new

Draft

7

case was identified. Incident meetings have been held regularly, the outbreak has been reported on Datix and via STEIS and an external lead for the investigation has been appointed. It is expected that the investigation will be completed within the timescale agreed with commissioners. The outcome of the investigation will be reported to a future Board meeting.

5. Antimicrobial Stewardship

5.1 Antibiotic audits continue within the Trust with results being fed back to clinical teams and action plans requested where appropriate. Overall results have improved slightly but there are still further improvements to be made. Funding for additional resource to complete audits has been identified and recruitment is underway. Collaborative work with commissioners and GPs is under discussion due to the high prescribing rate in primary care which may have some impact on patients coming into the Trust. The Trust has registered for European Antibiotic Awareness day in November and has a number of volunteer ‘Antibiotic Guardians’ who will assist with promotional activities during a full week

6. Conclusion/Summary

6.1 There has been, and continues to be, much work undertaken to achieve the reductions in healthcare associated infection that is not only required to achieve the Trust targets but is also desirable to achieve the high quality patient experience and outcomes that we want for all of our service users

6.2 Good progress continues to be made generally as even though performance on Clostridium difficile has deteriorated in the first six months of this year, the Trust has still achieved a 91% reduction in cases since 2007. HCAI remains a high priority for the Trust and further work is required to reduce the risk of additional Clostridium difficile infection cases.

7. Recommendations

7.1 The Board of Directors is asked to note the work underway to reduce the incidence of Clostridium difficile for patients in our care and to recognise the contributions made by clinical staff to reduce the risk of infection in the organisation.

7.2 The Board of Directors is asked to note the challenges ahead for 2015-16 given the breach of the Clostridium difficile trajectory.

Julie Lane Acting Director of Nursing, Patient Safety and Quality/ DIPC

Draft



29 October 2015

Executive Summary

Transformation Programme Update

Report of the Transformation Change Director

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Board Reports)

Integrated Care Pathways, Service Transformation

Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Board Reports)

Momentum: Pathways to Healthcare Programme

1. Introduction

1.1 The purpose of this report is to provide the Board of Directors with an update on the progress of the Transformation Programme in general, and an overview of progress in relation to a number of key projects, since the most recent update report in July 2015.

2. Background

2.1 The Trust-wide Transformation programme commenced in April 2015 and the proposed overall purpose of the programme is:

“To create a way of working at North Tees & Hartlepool NHS Foundation Trust which engages staff in continuously improving and sustaining the delivery of safe, high quality and financially sustainable efficient services to patients”

3. Transformation Programme – Progress Update

3.1 The focus of this report is on the short term transitional schemes anticipated to deliver in this financial year. The upcoming 10th December strategic Board session will focus on the medium and longer term Transformational projects.

4. Transformation Programme – Transitional Project Updates

4.1 NHS Professionals and Temporary Staffing (Stage Gate 4)

4.2 A comprehensive temporary staffing review is being performed incorporating NHS Professional bank staff and non medical agency staff. Further controls and initiatives are being considered in a finalised paper to be presented at the Executive Team on 27th October and an update will be provided at the next Board Meeting as the agreed actions are progressed

1

Draft

4.3 Staff Flow – Temporary Medical Staffing (Stage Gate 4)

4.4 STAFFflow is a direct engagement model for employing medical locum staff with the aim of reducing medical locum expenditure and VAT. It was fully implemented on the 28th September.

4.5 Transforming Outpatients (Stage Gate 2)

4.6 A review has been undertaken of the various sub-projects within the Transforming Outpatients project as part of its transfer to the Transformation Programme, and a number of recommendations will be presented at the Transformation Committee.

4.7 Administration Review (Stage Gate 2)

4.8 Following the transfer of the Administration Review to the Transformation Programme, a series of listening events, initially with senior Trust officers, and subsequently with the staff within the affected areas, is underway.

5. Financial Savings

5.1 As at Month 6, circa £712k cash releasing savings have been identified against the £1.55m risk assessed target. This is £52.5k behind the planned position of £765.3k.

6. Establishment of governance and management assurance aroundthe programme

6.1 The Transformation Committee is now established and meeting monthly. Detailed oversight of the projects within the programme will be undertaken via the newly formed Transformation Programme Management Group which is chaired by the Deputy Director of Transformation. This group’s inaugural meeting will take place on Monday 16th November.

7. Conclusion and Recommendation

7.1 The Board of Directors is requested to:

• Note the progress and current status of the Transformation Programmeas presented above;

• Approve that the various specific proposals identified are progressed viathe Transformation Committee

Neil Atkinson Transformation Change Director

2

Draft



29 October 2015

Transformation Programme Update

Report of the Transformation Change Director

1. Introduction

1.1 The purpose of this report is to provide the Board of Directors with an update on the progress of the Transformation Programme in general, and an overview of progress in relation to a number of key projects, since the most recent update report in July 2015.

2. Background

2.1 The Trust-wide Transformation programme commenced in April 2015 and the proposed overall purpose of the programme is:

“To create a way of working at North Tees & Hartlepool NHS Foundation Trust which engages staff in continuously improving and sustaining the delivery of safe, high quality and financially sustainable efficient services to patients”

2.2 In order to agree a direction of travel for the programme for the next 3 to 5 years, the first year is focused on:

• making sure the fundamental project management basics are in place andconsistently applied in order to shape success for the future; and

• ensuring delivery of those shorter term ‘Transitional’ projects allocated to theprogramme.

2.3 The focus of this report is on the short term transitional schemes anticipated to deliver in this financial year. The upcoming 10th December Strategic Board session will focus on the medium and longer term Transformation projects.

3. Programme Overview – current status

3.1 Progress to date in relation to the transitional projects is detailed in section 4 below.

3.2 This section provides a brief overview of general progress across the programme.

3.3 The NHS Professionals flexible worker service went live during November 2013.

3.4 In the last month the Staff Flow project has progressed to Stage 4.

3.5 A review of the Transforming Outpatients project has been undertaken and key actions to progress this have been identified.

1

Draft

3.6 A review of the scope and management arrangements for the Administration Review will be completed by mid-November, and a paper setting out the approach to this project to be presented to the Executive Team in November.

3.7 With regard to the Transformational projects, these continue to be reviewed and scoped as appropriate and an overview will be presented to the Board of Directors at their November meeting and subsequently discussed at the Board Seminar on 10th December.

3.8 Implementation of the Respiratory Integrated Care Pathway enhanced care “Hospital at Home” model continues, with appointment to the Band 3 posts completed and re-advertisement of the registered positions underway following the previous unsuccessful advertisements.

3.9 The overall status of the projects within the programme against the stages is summarised in Appendix 1.

4. Transformation Programme – 2015/16 Transitional Project Updates

4.1 NHS Professionals and Temporary Staffing

4.2 The NHSP flexible worker service went live during November 2013 for all staff groups (except medical staff group). Implementation included booking of the following via NHSP: all bank workers, any additional hours worked by Trust substantive staff and the supply of agency staff.

4.3 A comprehensive temporary staffing review has been performed incorporating NHS Professional bank staff and non-medical agency staff. The most significant proportion of the bank and agency usage and associated cost is registered nursing and non-registered nursing support staff and is the main focus of the review.

4.4 The review is developing a number of work streams to actively reduce and control expenditure on temporary staffing resource and in particular recourse to nurse agency staff.

4.5 These controls and initiatives are being considered in the finalised paper to be presented at the Executive Team on 27th October and an update will be provided at the next Board Meeting as the agreed actions are progressed.

4.6 Staff Flow – Temporary Medical Staffing

4.7 The Department of Health released a paper on improving procurement practice within the NHS: “Better Procurement, Better Value, Better Care: a Procurement Development Programme for the NHS”.

4.8 One of the key components highlighted in the paper related to cutting the £2.4bn annual NHS spend on temporary staff by 25% by the end of 2016. Following work undertaken by the Audit Commission, this represents between 3% and 20% of total medical expenditure for individual NHS organisations. Reducing this spend is a laudable objective, yet historically it has been very difficult to monitor and manage temporary staff costs effectively.

4.9 There are a number of common challenges when attempting to engage and manage cost effective, yet high quality, locums. These include:

• Spending on temporary staff is not always factored into budgets - although theexpenditure makes a substantial impact on the bottom line, there is littlebudgetary ownership of this spend;

2

Draft

• Lack of information for decision making - inadequate or non-existent reportingsystems make it difficult to monitor and control expenditure on medicallocums;

• Lack of information sharing - lack of information at a local level makes itdifficult to draw local conclusions or make regional / national comparisons;

• Lack of transparency - arrangements with agencies can be opaque. Costs arecovered by a multitude of separate invoices and there is often no centralrecord of what is being spent, raising questions around risk, visibility andgovernance.

• Excessive cost – the Trust not only pay commission on each hour worked butare also charged VAT for all non-nursing staff which cannot be recovered.Also, administration involved in processing weekly invoices is often time-consuming and requires considerable resource.

4.10 STAFFflow is a direct engagement model offered by Liaison and Price Waterhouse and Coopers (PwC) to allow NHS Trusts to take control and make a significant reduction in agency spend without reducing the number of staff required to operate efficiently. Following the Executive Team decision on the 3rd March 2015 the Trust implemented STAFFflow and the direct engagement model became effective from 28th September 2015.

4.11 With direct engagement, the Trust engages the temporary worker directly, using a recruitment agency to source candidates and a third party, rather than internal resources, to provide administrative and payroll support.

4.12 The main benefits include:

• Transparency in the organisation’s relationships with agencies;• Centralised and improved management information;• A clearer and stronger supplier sourcing strategy;• Reduced expenditure on temporary staff;• Improved controls in the induction of temporary staff;• Reduced VAT and finance process costs, and;• Protected delivery of frontline services.

4.13 The effect of this alternative model, which broadly involves employing staff on short fixed-term temporary employment contracts, is:

• Improved controls;• Increased transparency in commercial arrangements with agencies;• Potential savings on agency commission charges, and;• Potential savings from more accurate invoicing and reduced invoice

processing.

4.14 The solution involves the Trust recruiting individuals on short fixed-term temporary employment contracts, or directly contracting with those workers who provide their services through a limited company. Agencies will continue to identify candidates on the basis of criteria set by the Trust and introduce the candidate to the Trust but instead of an overall commission rate, the recruitment agent will charge a fee for each introduction.

4.15 Liaison provide the Trust with administrative support covering the lifecycle of each temporary worker assignment and includes:

4.16 For Employees - A website through which:

3

Draft

• The employee will make reward choices and sign the employment contract;• The employee will sign off Trust induction procedures;• The employee will complete his / her timesheets;• Relevant Trust staff will approve timesheets;• The employee will be notified of termination of his / her employment and other

relevant termination documentation, e.g. P45, will be issued, and;• The provision of a payroll service.

4.17 For Limited Companies - A website through which:

• The contractor will complete his/her timesheets;• The contractor will sign off any induction procedures the Trust requires;• Relevant Trust staff will approve timesheets;• The Trust can self-bill the limited company for its charges;

4.18 The basic proposition behind this model is that the Trust continues to attract staff through agencies at pay rates similar to those it pays now. Agency staff are almost always paid more than substantive staff as they do not enjoy the same benefits and the Trust does not want to end up incurring increased employment-related costs on top of these higher pay rates, as this will erode the financial benefits of the model.

4.19 There are a number of distinct advantages of the Direct Engagement Model.

4.20 In the area of cost management, this includes:

• Reduced agency commissions – the aim is to reduce these commissions byup to 15% as the agencies will no longer provide or fund the payroll, take onemployment risk etc;

• The Trust will reduce significantly the number of agency invoices it processesand ensure accuracy of these invoices

• Tax treatment of directly engaged workers:

o VAT is not applicable to the salary of a worker employed by the Trust;o VAT is not chargeable for services provided by a non-VAT registered

personal services company (Ltd company); o VAT on commission charged by a body acting as a recruitment agent

(as opposed to an employment agent) is recoverable under NHS Contracted-out-services guidance.

4.21 As at month 6, the Trust spent £1.9m on temporary medical staffing (2014/15 £3.9m on a full year effect basis). The VAT cost associated with a full year effect of £4.0m locum expenditure is £800,000. The Trust expects to receive net VAT savings of 13%. This would equate to circa £480k per annum based on current usage.

4.22 As at 30th September 2015, the Trust has saved £2,000 in 3 days of full implementation. To date (early October), 274 locum days have been booked via the direct engagement model enabling the Trust to save the VAT element associated with these future bookings. The Trust is continuing to review existing locum arrangements within directorates, to identify where medics are not directly engaged with an aim of migrating them to this model to allow VAT recovery. In some instances this will involve cancelling existing agreements and re-employing them through the new model.

4.23 It is proposed to produce a separate paper documenting the post implementation benefits of ‘staff flow’ in January 2016 which allows additional time to provide a meaningful analysis.

4

Draft

4.24 Transforming Outpatients 4.25 A review has been undertaken of the various sub-projects within the Transforming

Outpatients project as part of its transfer to the Transformation Programme, and the following recommendations will be presented to the Transformation Committee at its meeting on 30th October:

• That a refreshed Outpatients project be incorporated in the Transformation

Programme; • That the Transformation Programme is approved to:

o review the opportunities for transformation of Outpatient Services, to identify an appropriate transformational vision and project proposal, incorporating as appropriate options for the transfer of additional clinics to community settings – complete by December 2015;

o finalise the business case for Bookwise and submit for approval in November, and oversee / support subsequent implementation by the relevant clinical teams if approved;

o finalise the business case for transfer of identified clinics to Eaglescliffe Health centre for approval in November, and oversee / support implementation by the relevant clinical teams if approved;

• That the plans to move identified clinics to One Life Hartlepool are progressed via discussion with the Commissioners, with responsibility for planning and implementation identified when and if agreement to the moves is achieved;

• That any further review of existing pathways be treated as operational LEAN reviews and are managed as business as usual buy the relevant clinical and operational teams;

4.26 The review of the longer term opportunities will create a vision for outpatients

incorporating opportunities to:

• reduce duplication • improve efficiency • review best practice • consider staffing levels • review the use of existing locations • assess the potential benefits of centralisation • introduce technology.

4.27 Administration Review 4.28 Following the transfer of the administration review to the Transformation Programme,

a series of listening events, initially with senior Trust officers, and subsequently with the staff within the affected areas, is underway, and a proposal will be presented to the Executive Team before the end of November setting out the proposed scope, approach and management arrangements for the review. This will provide the necessary clarity and structure for the review to ensure that it can be progressed and delivered within realistic timescales.

4.29 Commercial Developments 4.30 Development of the commercial strategy as an element of the Transformation

Programme is ongoing. This will consider opportunities to broaden the current range of activities in this regard.

4.31 Work continues to progress the development of the commercial aspects of the

Transformation Programme.

5

Draft

4.32 This will incorporate the following specific activities and considerations:

• Supporting the Trust’s response to bid for the Urgent and Emergency CareTender – an initial market engagement event with potential GP partners was heldon 14th October, and will be followed up by one-to-one meetings with each asrequested. The tender process was subject to a national pause, and the nationalguidelines have now been issued, so it is anticipated that the tender will re-commence in the near future, possibly following further discussion between theTrust and the Clinical Commissioning Group as a result of the Trust’s response tothe latest communication from the CCG in relation to the use of Trust premisesshould another bidder win the tender;

• Providing support to the clinical teams in assessing the market share, growthopportunities and utilising the PLICS data to inform consideration of theprofitability and financial viability of current and potential service developments,as part of the development of the Clinical Services Strategy;

• Promoting a culture whereby opportunities for innovations are identified andsupported to implementation where appropriate. This will be presented to theExecutive Team in a paper which will discuss the use of the £25k secured fromthe Academic Health Sciences Network, and the role of innovation championsacross the Trust;

• Working with the Trust’s Communications team to ensure that there is aneffective approach to communicating and marketing the range of services theTrust provides, and planned or potential developments, paying particular regardto establishing effective communication channels with the GP communities.

5. Financial Savings

5.1 Following the 2014/15 budget setting and the Monitor planning exercise the overall funding / efficiency gap identified for 2015/16 was £10.901m. The constituent elements of the 2015/16 savings target approved by the Board of Directors in April 2015 are outlined as follows:

£m

Directorate Savings = £ 6.63m

Corporate Wide = £ 4.27m

Total efficiency required = £ 10.9m

5.2 The corporate savings target of £4.27m (£10.9m - £6.63m) encompassed the unidentified element of the CIP programme and was not predicated on schemes that were developed or in a position to be implemented in year.

5.3 The transformational schemes have been financially evaluated (from both an investment and savings perspective) in order to fully understand the timescales of delivery. This is appended at Appendix 2 and splits the programme into two components: short (0 to 12 months) and longer term (12 to 24 months) programmes.

5.4 The report focuses on actual cash releasing savings i.e. a reduction in expenditure or an increase in income and provides a mechanism for directorate budget release. The Transformation team has been assigned a corporate wide budgeted CIP target of £4.271m but has no immediate ability to release those savings as budgeted adjustments.

5.5 The Transformation team will co-ordinate with finance colleagues to use the report as a basis for identifying and delivering the budgeted savings from the directorate positions. In addition, an element of the financial savings will not result in a budget

6

Draft

adjustment, for example NHS Professionals and Staff-flow. These schemes have no budgeted target and aim to reduce historic spend levels and will remain reported as cash releasing. To date £296 k has been released as a budgeted adjustment to CIP.

5.6 As at Month 6 the Transformation Programme has identified £712 k of cash releasing savings which is marginally behind plan. Appendix 2 provides a full analysis of the savings achieved to date.

5.7 As at Month 6, circa £712k cash releasing savings have been identified against the £1.55m risk assessed target. This is £52.5 k behind the planned position of £765.3k.

5.8 Assuming the part year delivery of the agreed transformational savings (£1.530m) this leaves an in-year shortfall of £2.74m to be delivered corporately in year in order to achieve the Trusts overall £10.9m savings target.

5.9 In order to bridge the anticipated savings gap for 2015/16, the Transformation team presented at the Executive Team strategic session on 18th August 2015 additional savings schemes, for consideration and potential implementation. These schemes are being further evaluated and will become the focus of the Financial Recovery Group.

6. Establishment of governance and management assurance around theprogramme

6.1 The Transformation Committee is now established and meeting monthly.

6.2 Detailed oversight of the projects within the programme will be undertaken via the newly formed Transformation Programme Management Group. This group’s inaugural meeting will take place on Monday 16th November.

6.3 The Sharepoint site is under development and will utilise the potential of the software to provide:

• Access to background information on the Transformation Programme, teamroles etc;

• Guidance to the six-stage gateway process set out in the May report to theBoard of Directors, which will form the basis of planning and management ofthe projects within the programme;

• Easy access to the various templates to be used to support the progress ofthe projects through the gateway process to successful delivery andevaluation;

• An overview of the current status of the projects within the programmeincluding the project sponsors and managers;

• A detailed benefits log for each project;• A Risks, Assumptions, Issues and Dependencies (RAID) log for each project;

and• The facility to capture progress reports to simplify the process of monitoring

and reporting.

6.4 This will be demonstrated to the Transformation Committee at its October meeting, with a view to a formal presentation and launch at the Board of Directors’ Strategic Session in December.

6.5 Appointment to the various roles within the team continues, in accordance with the following timescales:

• Deputy Director of Transformation – in post

7

Draft

• Assistant Director of Finance (Transformation) – in post• (2.00 wte) Clinical Business Change managers – one commenced on

28th September, the second will start on 3rd November • (2.00 wte) Project Managers – one commencing 9th November and the

second to be appointed following interviews on 23rd October • Commercial Manager and assistant – in post• Data Analyst – to commence 13th December• Transformation Project Administrator – in post

7. Conclusion and Recommendations

7.1 The 2016/17 Transformation Programme will be discussed in more detail at the Board of Directors Strategic Seminar on 10th December.

7.2 In the interim the Board of Directors is requested to:

• Note the progress and current status of the Transformation Programme aspresented above;

• Approve that the various specific proposals identified are progressed via theTransformation Committee

Neil Atkinson Transformation Change Director

8

Draft

APPENDIX 1

Draft

Assessment Review Plan 15/16Stage 2 Gateway

2015/16

1 2 3 4 5 S3 S3 S3 S4 S41 2 3 4 5 S3 S3 S3 S4 S4

1 2 3 4 5

S3 S3 S3 S4 S4

TrakCare Phase 2 1 2 3 4 5 Business case developed, awaiting completion of phase 1 due end of Oct 2015. S3 S3 S3 S4 S4

Clinic Utilisation 1 2 3 4 5 S2 S3 S3 S3 S4Community Relocation (Satellite Clinics) Care Closer to Home (12-24 months) 1 2 3 4 5 S2 S2 S2 S2 S3Centralisation of Outpatient Resources (12 -24 months)

1 2 3 4 5 S2 S2 S2 S2 S3

1 2 3 4 5Proposal to Exec Team due 24th November 2015 outlining the vision and scope of the scheme detailing timelines for phased implementation. S2 S3 S4 S4 S5

1 2 3 4 5Finance and ICT areas reviewed services against other Trusts and commercial providers. Business Case to be developed. S2 S2 S3 S3 S3

Income Generation Project

1 2 3 4 5

Proof of concept performed on Month 4 data demonstrated £40.2k of additional income with a further potential increase of £85k. Month 5 identified £57.6k with a further potential of £71.9k. Total additional income identified YTD for M4 & M5 £87.1 k realised. S3 S4 S4 S4 S4

Status Key

1 Complete

2 N/A

3 Pending

4

5

Business Case Approval from C&SD (if applicable)

Business Case approval from TC (if applicable)

Quality Impact Assessment (approved)

High-Level Benefits identified in financial terms

Business Case (scrutiny and challenge process)

Review of Back-Office functions

Outputs from Stage 2

Clinical Income Generation

Transforming Outpatients

Analysis performed on DNA rates. Business cases being finalised for Bookwise (Clinic Utilisation) and Eaglescliffe clinics, to be presented at apporpriate committees etc (CSDG, Exec Team).

Phase 1: Clinical & Directorate Administration

October - 2015

Programmes

EPR Programme

Integrated Care Pathways

External engagement with CCG, GPs, Healthwatch and patient groups is less well developed and requires some acceleration in key areas – particularly where there may be conflicting/complimentary strategies emerging externally that require joining-up. Following a review by Internal Audit all Pathways are currently reviewing their documentation to ensure that all protocols are in place and up to date to ensure continuity of the Pathways.

Frail / Elderly Dementia (12 to 24 months)

Palliative Care (12 to 24 months)

Diabetes (12 to 24 Months)

Q2 Q3 Q4S2 Milestones Proposed project justification

APPENDIX 1

Forecast Gateway Stage

2016/17

Q4 Q1

Draft


2015/16

Respiratory (12 to 18 Months) - as per BC Feb 2015

1 2 3 4 5 6 7 8

The Respiratory ICP is at implementation stage. In line with the business case the Band 3 posts have been appointed and will commence in November, recruitment of the registered staff has been unsuccessful todate and the Trust is readvertising these positions.

S3 S4 S4 S4 S4

TrakCare Phase 1 1 2 3 4 5 6 7 8 S4 S4 S4 S5 S5

SystmOne1 2 3 4 5 6 7 8

S4 S4 S4 S5 S5

EDM 1 2 3 4 5 6 7 8 S4 S4 S4 S5 S5

1

2

3

4

5

6

7

8

Project Initiation Document (PID) approved

Detailed Project Plan

Updated Business Case

Benefits Baselined and Quantified

Documented on Aspyre

Project Team Established Pending

Project Board established with accepted roles, responsibilities & ToR

Outputs from Stage 3 Status Key

Budget established Complete

N/A


EPR Programme

The lastest build of EPR has been released by the software provider and testing now commenced for Phase 1 go live in October 15. Business Continuity Plans being reviewed to ensure fitness for purpose.

October - 2015

Programmes S3 Milestones Next Milestones

APPENDIX 1


2016/17

Q4 Q1 Q2 Q3 Q4

Draft


2015/16

1 2 3 4

Full implementation w/c 28th Sept 2015 £2k released in M6 (three days post full implementation). Post evaluation review to be completed in January 2015. S4 S5 S5 S5 S5

1 2 3 4

Financial analysis of NHS P undertaken to inform future contract negotiations. Paper to be developed for Exec Team to be presented October 2015 S5 S5 S5 S5 S5

1

2

3

4

Staff Flow

Pending

Benefit Review & Handover agreed

Outputs from Stage 4 Status Key

Project Post Evaluation complete Complete

Lessons Learned N/A

Project Closure Report

NHS Professionals

October - 2015

Programmes S4 Milestones Update

APPENDIX 1


2016/17

Q4 Q1 Q2 Q3 Q4

Draft

Assessment Review Plan 15/16Tender Assessment / Commercial Income Gateway

Urgent Care Bid

1 2 3 4 5 6

Prelimary work commenced and will continue whilst specification is finalised. Government announced suspension of all Urgent Care tenders. Awaiting announcement and specification from CCG following Government announcement that all urgent care tenders bids, what ever their stage, was to be suspended. Market engagement event occurred on 15.10.2015, with a number of GP out of hours providers in attendance. Follow up 1:1 meetings to be arranged with intertested parties to develop assurance over suitability of partnering.

Community Wheelchair Service 1 2 3 4 5 6 Awaiting Tender Spec, Directorate engaged.Integrated Health (inc School Nursing, Health Visiting, Family Nurse Partnership & Immunisation. 1 2 3 4 5 6 Awaiting Tender Spec, Directorate engaged.

1 2 3 4 5 6 Income being realised from Advertising, commercial barrow and staff benefits

1 2 3 4 5 6Panacea are VAT recovery commence in Oct 15. Infastructure in place including Ascribe and Ledger.

1 2 3 4 5 6 Income being realised from Smoking Cessation promotions, Physio, and branding for BCF.

1 2 3 4 5 6Application for funding from Innovation North successful and £25,000 secured. Paper to be presented to Executive Team detailing plans for utilisation of funding.

Status Key

1 Complete

2 N/A

3 Pending

4

5

6

S2 Milestones

Income Generation / Commercial Income

October - 2015

Optimus

Outputs from Tender Assessment Review

Tender opportunities

APPENDIX 1

Programmes Proposed project justification

Outline proposal to Commercial Panel

Approval by Commercial Panel / Transformation Committee or CSDG (if applicable)

Benefit / Income Realisation

Marketing Support

Innovation

Formal Tender Announcement by Commissioner

High-Level Benefits identified in financial terms and engagement with Directorate

Analysis performed to ensure compliance with Corporate Strategy / Commercial Strategy

Draft

-Term Projects (Transitional) - 2015/16

Approved Additional Investment (£000) *

Projected Savings 2015/2016Actual Cash Releasing

Month 6

Potential Cash Releasing not

Realised Budget Released as CIP

Non Financial Efficiency Estimates

FYE

£000

TrakCare Phase 1 (as per approved BC)

250 Lynne Hodgson 250 25.0 0.0 0.0 0.0 0.0VAT recovery (technical non-recurrent savings) 300 Mike Kirtley 296 296.0 296.0 0.0 296.0 0.0EDM (as per approved BC)

35 Lynne Hodgson 35 3.5 0.0 0.0 0.0 0.0

Contract negotiation / Financial modelling100 Neil Atkinson 100 66.0 0.0 0.0 0.0 0.0

Forecast demand vs. capacity review100 Neil Atkinson 100 66.0 0.0 0.0 0.0 0.0

Increased bank recruitment to reduce agency usage

50 Ann Burrell 50 33.0 0.0 0.0 0.0 0.0Review of internal trust controls and operational efficiencies

350 Neil Atkinson 350 315.0 225.0 0.0 0.0 0.0

VAT recovery on locum expenditure450 Neil Atkinson 200 180.0 2.0 0.0 0.0 0.0

Management information / intelligence - effective utilisation25 Neil Atkinson 25 16.5 0.0 0.0 0.0 0.0

More effective use of back-office functions (HR, payroll & Accounts payable)0 Neil Atkinson 0 0.0 0.0 0.0 0.0 12.0

Phase 1: Clinical & Directorate Administration

300 Neil Atkinson 75 49.5 0.0 0.0 0.0 0.0

Retail Income / Adverising Income / Salary sacrifice / Marketing55 Neil Atkinson 19 40 57.1 47.4 0.0 0.0 0.0

Optimus - Panacea VAT recovery 150 Lynne Hodgson 63 41.3 0.0 0.0 0.0 0.0

Innovations25 Neil Atkinson 13 12 23.7 12.0 0.0 0.0 0.0

Revised Commercial StrategyTBC Neil Atkinson TBC 0.0 0.0 0.0 0.0

Service re-design & Business Development100 Neil Atkinson 100 66.0 0.0 0.0 0.0 0.0

Clinic Utilisation 50 TBC Neil Atkinson 0.0 0.0 0.0 0.0 TBC

Clincal Income Generation Project - signs & symtoms (test of concept currently)4 800 Neil Atkinson 300 200 100 40 292.0 130.4 157.6 0.0 TBC

TBC Neil Atkinson TBC 0.0 0.0 0.0 TBC

Urgent Care Tender15 TBC Neil Atkinson TBC 0.0 0.0 0.0 TBC

Community Wheelchair ServiceTBC Neil Atkinson TBC 0.0 0.0 0.0 TBC

Integrated 0 -1 9 Health Service (incl. School Nursing , Health Visting, Family Nurse Partnership & Immunisations) TBC Neil Atkinson TBC 0.0 0.0 0.0 TBC

TOTAL 69 3090 585 713 682 388 1530.6 157.6 296.0 12.0

PHASED TARGET TO DATE (£000) 765.3 712.8

AMOUNT OF SAVINGS TARGET DELIVERED TO DATE (£000) 50.0% 46.6%

TRANSITIONAL SAVINGS ARE AHEAD OF TARGET BY (£000): -52.5 MARGINALLY BEHIND PLAN

PROGRAMME OFFICE COSTS 160.1

RATIO OF CASH RELEASING SAVINGS TO COSTS 4.8

* = required investment not currently covered in Transformational expenditure

Notes:

1. Budget Saving target assigned to transformation £4.3m

2. The Report reflects cash releasing ie, a reduction in expenditure or increase in actual income. The Transformation team will work with Finance colleagues to action the savings as budgetary adjustments. The savings identified on the report provides an indication for Directorates to release the savings where a budget target exists.

EPR Implentation delayed from 15 April to Oct 15. The delay has resulted in CIP savings have been reduced from BC £250k to £25k to reflect the delay in switching off the PAS system. The capital expenditure costs associated with the delay YTD £458k.

NR VAT saving over and above Business Case

Revised BC approved by CSDG advised non delivery of further savings 15/16

Contract negotaitions scheduled November 2015

Difficulty in recuitig Oversea Nurses due to VISA restrictions, additional EU nursing recruitment with NHS P in progress

Reduction in Nurse Overtime / Bank / Agency on plan

Scheme Implemented 28/09/2016 - M6



Feasability VFM study

Awaiting Tender Spec

Expressions of Interest released Awaiting formal tender

Expressions of Interest released Awaiting formal tender

Slippage in implementation PID due for completion Oct 2015

Schemes in line with planning assumptions

Ascibe Interface operational due to commence October 15

Schemes in line with planning assumptionsStrategy Paper to be presented at October Transformation Committee

Schemes in line with planning assumptions

Business Case in process of finalisation, implementation EOY 15.

Feasability VFM study

£000 £000

Income Generation


Tender Opportunities

Short Term Transitional Projects (m

aximum

12 months)

EPR Programme

NHS Professionals

Staff Flow

Administration Review

Commercial Developments / Funding opportunities

APPENDIX 2

Current RAG Rating (£000)

Category ProgrammesSavings Target

(£000) FYE

Project Sponsor Red Amber Green Black

£000

Comments

£000Planned

Timescale

Draft

Additional Investment (£000) * Projected Savings 2015/2016

Non Financial Efficiency Estimates

FYE

TrakCare Phase 2 (e-Prescibing) - as per BC 685 Lynne Hodgson 382.0SystmOne TBC Lynne HodgsonEDM - as per BC 90 Lynne Hodgson 90.0

Respiratory (12 to 18 Months) - as per BC Feb 2015540 415 Julie Gillon

Diabetes (12 to 24 Months)TBC David Emerton

Frail / Elderly Dementia (12 to 24 months)TBC Cath Siddle

Palliative Care (12 to 24 months)TBC Julie Gillon

Single Operating ModelTBC TBC

Hartlepool DeliverablesTBC TBC

Phase 2: Booking Office, Waiting List Initaitives teamsTBC Neil Atkinson

Innovations / Research & DevelopmentTBC Neil Atkinson

Innovations in analysing vital signs (Apps)TBC Neil Atkinson

Refer-to-Pharmacy: e-referral from hospital to community pharmacyTBC Neil Atkinson

Respiratory pilot (age group > 65 year LTC)TBC Neil Atkinson

Centralisation of Out-patientsTBC Neil Atkinson

Community Relocation - Care Closer to HomeTBC Neil Atkinson

HRTBC Ann Burell

Finance TBC Lynne Hodgson

Procurement & SuppliesTBC Lynne Hodgson

ITTBC Lynne Hodgson

Community Services BenchmarkingTBC Julie Gillon

Dischage Liaison (in partnership with SBC)TBC Julie Gillon

Falls (in partnership with SBC)TBC Julie Gillon

Multi-Disciplinary Working across Stockton-on-TeesTBC Julie Gillon

7 Day WorkingTBC Julie Gillon

Securing Quality in Health Care (SeQUIS)TBC Alan Foster / David Emerton

Exploration of European Funding OpportunitiesTBC Neil Atkinson

Capital Investment opportunities - Helen McArdle / Tees Valley HousingTBC Neil Atkinson

GP Engagement / Market ShareTBC Neil Atkinson

Partnership WorkingTBC All

Clinical colloboration TBC All

Musculoskeletal Service - Darlington (awarded 2017)TBC Neil Atkinson TBC TBC

TOTAL 540 1190 0.0 0.0 0.0 0.0 0.0 472.0

* = required investment not currently covered in Transformational expenditure

£000

Savings Target (£000)

FYERedProgrammes


Administration Review

Project Sponsor

Long Term Transform

ational Projects (12 to 36 months)

Commercial Developments / Funding opportunities

Personal Health Budgets

Review of Back Office Functions

Service Re-design / Business Development


Category

APPENDIX 2

Current RAG Rating (£000)

Theatres

Technology Developments / New Iniatives

Tender Opportunities

Green BlackAmber

EPR Programme

£000

Assessment of Current Long-Term Projects (Transformational) - 2016/17 onwards

Draft

1



29 October 2015

Executive Summary

Capital Programme Performance 2015/16

Report of the Director of Finance, ICT & Support Services Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports)

Manage our relationships


Finance 1. Introduction 1.1 The 2015/16 capital programme has progressed to plan during the second quarter. A

capital allocation of £10.798m was agreed for the year. At Quarter 2 expenditure was within the annual profile and projections are within the Monitor compliance framework of achieving a minimum expenditure of 85% and less than 115% against the original capital allocation. Monitor are now reviewing expenditure on a monthly basis.


2.1 The capital funding for 2015/16 is £10.798m comprising £2.201m carried forward from 2014/15 EPR programme, £6.447m from internally generated depreciation, £2m loan and £150k donated funds. The 2015/16 capital programme has progressed as anticipated during Quarter 2. A significant number of schemes have been completed during Quarter 2, particularly backlog and patient environment schemes.

2.2 The significant elements of the programme to comment upon are:

Financial expenditure was aligned to the annual programme and capital cash flow projections are in-line with the annual Trust plan, expenditure was 90% of the financial forecast.

The TrakCare project has progressed well during Quarter 2 with a planned ‘go live’ date of mid October.

The upgrade to the Podium corridors has been completed; this scheme included the complete replacement of all flooring in the main corridors, installation of wall protection, decoration and replacement doors.

Potential opportunities to transfer capital funds and defer schemes in order to transfer funding to support revenue position.

3. Recommendation

3.1 The Board is requested to receive this report and note the progress on capital schemes up to 30 September 2015.

Lynne Hodgson Director of Finance, ICT& Support Services

Draft

2



29 October 2015

Capital Programme Performance 2015/16

Report of the Director of Finance, ICT& Support Services


To provide an update as at 30 September 2015 on the progress of delivering the 2015/16 capital programme. The capital funding for 2015/16 is £10.789m comprising £2.201m carried forward from 2014/15, £6.447m from internally generated depreciation, £2m loan and £150K donated funds. The level of activity at the end of Quarter 2 is reflected through invoices and accruals of £4.163m with further orders placed of £1.576m. Monitor requires that between 85% and 115% of the initial capital allocation should be spent by the year end; the quarterly profile of planned expenditure is shown in Appendix 2.

2. Main content of report

2.1 The 2015/16 capital programme has progressed as anticipated during Quarter 2. A number of schemes have completed during Quarter 2.

2.2 The four work-streams of Medical Equipment, ICT, Service Development and Estates Backlog Maintenance have all performed as anticipated in progressing the capital programme to its present position. A detailed summary of each work stream is attached (Appendix 1).

2.3 The OBC to support the upgrade of the primary engineering infrastructure has been submitted to the Department of Health.

2.4 Significant work has been undertaken to develop a procurement framework. This will minimise the time required to progress schemes whilst remaining fully compliant with the recently introduced and more stringent EU procurement rules.

2.5 This report indicates that at the end of Quarter 2, £5.739m of the £10,798 allocation has been committed. There is the possibility that the Department of Health and Monitor will permit Foundation Trusts the flexibility to transfer uncommitted capital funds into revenue to support balance sheet pressures. If this is agreed, it is proposed that £0.25m of the Medical Equipment allocation, £0.25m of the ICT PAS/EPR allocation, £1m of the Reconfiguration allocation, and £1.5m of the Service Development allocation are set aside for this purpose.


3.1 The significant elements of the programme to comment upon are:

Schemes have been completed in a timely manner with good outcomes andpositive feedback.

Financial expenditure has been achieved in-line with the annual programme. Compliance with Monitor expenditure projections for Q1 & Q2 is 133% against

target of 85% - 115%. The variance is due to the Q2 payment for TrakCare.

Draft

3

Projected expenditure in Q3 and Q4 will bring the percentage back in line with the Monitor target range.

3.2 The capital programme has progressed to schedule and the expenditure and cash flow projections were closely aligned with the Trust annual plan.

3.3 The overall financial summary for the period to 30 September 2015 is presented at Appendix 2.

4. Recommendation

4.1 The Board is requested to receive this report and note the progress on capital schemes and delivery of the Monitor financial risk rating at the year end.

Lynne Hodgson Director of Finance, ICT& Support Services

Draft

4

Appendix 1 - Work Stream Reports

1. Medical Equipment

1.1 The business case for the replacement of the existing ECG machines within Cardiology and Angiography departments has been approved and the new machines have been ordered, with delivery and commissioning planned to take place during Quarter 3.

1.2 Approval has been given to purchase a replacement Ultrasound machine for the Emergency Department. This will improve the care given to patients admitted through the department and shall be commissioned during Quarter 3.

1.3 The replacement of monitors in Critical Care has commenced and shall conclude by the end of October. Replacement critical care beds have also been approved and delivery is anticipated before the end of Quarter 3.

1.4 Work is currently underway to replace one of the digital x-ray machines and associated equipment within the Orthopaedic out-patients department.

2. Information Communication & Technology

2.1 The Capital ICT allocation this year has been split into four main streams, all of which support the wider EPR programme.

2.2 A comprehensive wireless survey has been undertaken by a specialist third party that has given us a complete heat map of all areas covered, indicating signal strength and frequency. Based on the outputs from this survey, a plan is to be developed as part of a follow up workshop in November to expand wireless coverage to all clinical areas. This will enable our ability to support mobile working of TrakCare, and options for future electronic asset tagging.

2.3 The Trust’s ICT back-up systems have been replaced with enterprise level disk based back-up solutions. This has reduced the reliance on traditional tape based solutions which are slow, and the need to replace the tapes on an annual basis. The systems were implemented in July and are working extremely well.

2.4 Four physical servers were procured for the Virtual Infrastructure and we are currently going through a process of migrating physical servers. We are concentrating on migrating Microsoft SQL servers across. There are currently 19 physical servers and the opportunity is being taken to upgrade them from an operating system and database version to the latest versions as part of Audit requirements.

2.5 Ten new switches and 150 new wireless access points have been procured to replace end of life network equipment on both main sites. We are currently working through a programme of replacement due to be completed by the end of the year.

2.6 Implementation of the Trust’s new EPR system ‘TrakCare’

This next period of the EPR implementation is going to be challenging. The latest build of the system has been provided to the Trust. The team has validated the different modules and has delivered end user training to all staff that requires access to TrakCare. Smartcards will be used to access TrakCare and the team has started to issue them to those staff that do not currently have a smartcard. This work is on-going and will continue until the system “goes live” in mid-October.

Draft

5

3. Service Developments

3.1 There have been no significant service development schemes approved during Quarter 2 and this is primarily due to the development of the impending Clinical Services strategy.

3.2 UHNT Colposcopy suite - work has been completed to provide recovery facilities. This enables more patients to be treated within the department, without having to attend theatre. The improved facilities allow patients to undergo invasive procedures as an outpatient and on their first ”one-stop” visit.

3.3 During Quarter 2 the development of the outline business case for the replacement and expansion of the aging engineering infrastructure on the UHNT site was developed. There was an unexpected requirement to submit the outline business case to the Department of Health by the 9th October 2015 and this task was achieved.

3.4 A ‘track and trace’ system was installed to extend the monitoring of theatre instrument trays through the re-processing stages of the Central Sterile Services Department and into the main theatre store rooms. The process enhances the availability and retrievability of the 5,000 tray sets within the Trust as well as improving security measures including CCTV and access controls systems.

3.5 A series of procurement framework agreements have been developed during Quarter 2. This will allow for a streamlined procurement process and reduced timescale for theprogression of capital schemes whilst maintaining full compliance with the recently enhanced EU procurement rules.

4 Estates Backlog Schemes

4.1 Updated fire plans have been produced throughout the Trust along with additional fire compartmentation and compliance measures.

4.2 Chapel and Prayer room – both the Chapel and the Muslim prayer room have been refurbished during Quarter 2.

4.3 Podium Corridors- work has been completed to replace the flooring, hand rails, wall protection and general redecoration of the two Podium corridors consistent, with the image and quality of the refurbishment recently completed on the West Wing ground floor corridor.

4.4 PLACE (Patient Lead Assessments of the Care Environment) - a raft of work has been undertaken to improve the aesthetic appearance of patient and visitor areas throughout both hospitals during Quarter 2.

Draft

6

Appendix 2


Capital Programme 2015/2016 - as at 30 September 2015

Capital Report as at September 2015

Category Funding

Allocation £'000

Invoices &

Accruals £'000

Orders Committed & Raised

£'000

Funding Commitments

£'000

Total Committed

£'000

Uncommitted £'000

Medical Equipment

Current Allocation 1,279,896 316,289 163,582 - 479,872 800,024

Prior Year Allocation 296,104 231,274 92,498 - 323,772 - 27,668

Sub Total Medical Equipment 1,576,000 547,563 256,080 0 803,643 772,357

ICT & PAS/EPR

Current Allocation - PAS/EPR 4,063,000 2,152,233 1,036,695 - 3,188,929 874,071

ICT Rolling Programme 521,318 253,291 - - 253,291 268,027

Prior Year Allocation - 1,318 -1,318 - - - 1,318 - 0

Sub Total ICT 4,583,000 2,404,207 1,036,695 0 3,440,902 1,142,098

Service Development

Reconfiguration Plan 1,398,000 - 42,930 - 42,930 1,355,070

Current Allocation 1,824,892 120,210 10,271 - 130,481 1,694,411

Prior Year Allocation 244,108 155,162 48,673 - 203,835 40,273

Sub Total Service Development 3,467,000 275,373 101,874 0 377,246 3,089,754

Estates

Compliance 153,270 54,671 32,045 - 86,715 66,555

Energy 80,000 9,956 - - 9,956 70,044

Infrastructure 237,800 142,594 63,135 - 205,729 32,071

PEAT 260,000 440,450 13,100 - 453,550 - 193,550

Prior Year Allocation 290,930 265,621 73,091 - 338,712 - 47,782

Sub Total Estates 1,022,000 913,291 181,371 0 1,094,662 -72,662

Donated - Funding via Charitable Funds

Allocation 2015/16 150,000 22,805 - - 22,805 127,195

Sub Total Donated 150,000 22,805 0 0 22,805 127,195

Total 2015/16

Capital Programme 10,798,000 4,163,239 1,576,020 0 5,739,259 5,058,741

Draft

7

Original Monitor Plan £8.567m - 85% = £7.3m - 115% £9.8m

Source of Funding £'000

Internally Generated Depreciation 6,447 Loan 2,000 Donated Funds Original Allocation 150 Subtotal: Per Board Report 8,597

Carried Forward from 2014/15 (EPR) 2,201 Additional Charitable Funds (donations during year)

Total Allocation 10,798

Reporting against Monitor Metric 2015/16 achievement of 85%/115% of planned Capital Spend

Q1 £'000

Q2 £'000

Q3 £'000

Q4 £'000

TOTAL

Monitor Plan 1,435 1,686 2,623 2,823 8,567 Actual / Forecast

1,290 2,873 2,623 2,823 9,609

% 90% 170% 100% 100% 112%

Cumulative Position

90% 133% 118% 112% 112%

Draft



29 October 2015

Executive Summary

Compliance and Performance Report

Report of the Chief Operating Officer/Deputy Chief Executive

Strategic Aim and Strategic Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Board of Directors Reports)


1. Introduction

1.1 The Compliance and Performance Report highlights performance against a range of indicators, including Monitor’s Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/15 – 2018/19 indicators, for September and Quarter 2 2015.

2. Key issues and Planned Action

2.1 In September the overall performance against key operational standards and trajectories remains challenging, with pressures in the wider health system impacting on the delivery of both elective and non-elective pathways.

2.2 Non elective activity in September indicated a 4.07% (n=126) increase in comparison to the same period last year. The overall emergency activity included 670 patients (81 greater than the same period last year) who were treated via Ambulatory care, 20.81% of the total emergency admissions.

2.3 September A&E attendances has seen a slight increase in comparison with the same period last year, reporting 0.04% (n=3) higher. Admissions via A&E has increased, reporting 13.49% (n=170) more, evidence of the acuity of the patients coming through the department.

2.4 Performance against the emergency care standard achieved against the national requirement of 95% in September, reporting at 96.80% and for Quarter 2, reporting at 95.74%.

2.5 The Trust continues to demonstrate positive performance against the original 18 week Referral to Treatment (RTT) pathway standards, with all standards achieved at aggregate level.

2.6 The Trust performed well against a number of the cancer standards in August (latest position), however under-achieved against;

• 14 day suspected cancer standard 90.86% against 93% standard

• 14 day breast symptomatic standard 92.31% against 93% standard

• 62 urgent referral to treatment standard 83.33% against 85% standard

1

Draft

The provisional Q2 position indicates the Trust has under-achieved against the 14 day suspected cancer standard and the 62 day urgent referral to treatment standard. Full detail within the main report.

2.7 With regard to Health Care Associated Infections (HCAI), the Trust reported outside the trajectory in September for C-Diff, with the cumulative position of 18 cases now over the 2015/16 objective of 13 cases. No cases of MRSA have been reported in September.

3. Key Challenges

3.1 Continuous achievement of elective and emergency access standards, alongside patient choice, complex pathway management and other complex variables outside of the control of the Trust

3.2 Encompassing quality indicators into directorate ownership with appropriate supportive governance structures is an on-going requirement.

3.3. Continuous strive to minimise the number of C-Diff cases, given the Trust has reported 18 cases to date, against the annual objective which was set at 13 cases (2014/15 outturn 20 cases).


4.1 The Trust has, in the main, performed well against the majority of key operational standards during September, notwithstanding the considerable challenges associated with on-going operational, clinical and financial pressures. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements and principles of Service Line Management.

4.2 The Trust has robust governance processes in place for the monitoring and management of the delivery of all performance standards and will continue to strive to achieve core regulatory requirements. However, there is recognition that current pressures across the whole health economy may ultimately impact on consistent delivery, therefore presents an on-going risk.

4.3 This risk is outlined within the Trust’s Assurance Framework, with supporting mitigation plans, alongside internal and external governance assurance processes.

5. Recommendations

5.1 The Board of Directors is asked to note the detail in the Corporate Dashboard and performance against the Risk Assessment Framework and the key national indicators for September and Quarter 2 2015, in the context of Monitor’s Terms of Licence and the Everyone Counts: Planning for Patients 2014/15 – 2018/19 document.

Julie Gillon Chief Operating Officer/Deputy Chief Executive

2

Draft



29 October 2015

Compliance and Performance Report


1. Introduction

1.1 The Compliance and Service Performance Report highlights performance against a range of indicators, including Monitor’s Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/15 - 2018/19 indicators, for the month of September and Quarter 2 2015.

1.2 The Corporate Dashboard has been reviewed and updated to reflect both the mandatory performance frameworks for 2015/16 and the additional internal reporting requirements.

1.3 Appendix 1 illustrates the monthly and quarterly trend and variance analysis against targets/trajectory profiles; with due consideration given to both positive and negative variances and progress against monthly, annual and in year improvement targets.

1.4 Appendix 2 illustrates a high level view of the Corporate Dashboard and progress against key performance indicators.

1.5 Appendix 3 illustrates the Monitor Risk Assessment Framework – triggers of governance concerns.

1.6 This report must be read in conjunction with the additional information as detailed in the Quality report, Infection Prevention and Control report, the Human Resources (HR) report, the Finance and Contract report and the Quarter 2 compliance report to Monitor.

2. Performance Overview

2.1 In September the overall performance against key operational standards and trajectories remains challenging.

2.2 Non elective activity in September indicated a 4.07% (n=126) increase in comparison to the same period last year with the main increase evident in General Medicine, reporting a 10.75% (n=201) rise and Paediatrics, reporting 27.59% (n=96) higher.

2.3 The overall emergency activity included 670 patients (81 greater than the same period last year) who were treated via Ambulatory care, 20.81% of the total emergency admissions.

2.4 September A&E attendances has seen a slight increase in comparison with the same period last year, reporting a 0.04% (n=3) higher. Admissions via A&E has increased, reporting 13.49% (n=170) higher, evidence of the acuity of the patients coming through the department.

Draft

2.5 Performance against the emergency care standard achieved against the

national requirement of 95% in September, reporting at 96.80% and for Q2, reporting at 95.74%.

2.6 The Trust continues to demonstrate positive performance against the 18

week Referral to Treatment (RTT) pathway standards for admitted, non admitted and incomplete pathways and the supporting median and 95th percentile waits at aggregate level.

2.7 The Trust has achieved against a number of the core cancer standards in

August, however under-achieved against the cancer 2 week rule standard, the 2 week rule breast symptomatic standard and the 62 day referral to treatment standard due to significant pressures within the system and patient choice. However in Quarter 2 the 2 week rule breast symptomatic standard was achieved based on provisional data.

2.8 With regard to Health Care Associated Infections (HCAI), the Trust reported

outside the trajectory in September for C-Diff, with the cumulative position of 18 cases now over the 2015/16 objective of 13 cases. No cases of MRSA have been reported in September, against the target of zero. Shadow monitoring of HCA Infections to include Methicillin Sensitive Staphylococuss Aureus (MSSA) and E Coli continues through 2015/16.

3. Compliance Indicators 3.1 The position against key performance indicators for September 2015 and

quarter 2 is outlined below: 3.2 Referral to Treatment (RTT) Pathways 3.2.1 The National focus for RTT is now one measure of success, the reduction in

‘incomplete pathways’, with the admitted and non admitted pathway standards removed from national monitoring from June 2015. The NHS standard contract will be amended to reflect the changes from October 2015. For the purpose of this report all RTT standards continue to be monitored and reported internally, however as supporting indicators only from October 2015.

3.2.2 The Trust continues to achieve the RTT standards in September, reporting at

98.07% for non-admitted pathways, within the tolerance of 95%, 90.73% for admitted pathways, against the target of 90%, and 96.38% for incomplete pathways against the target of 92%.

3.2.3 The Trust also performed within standards against the supporting RTT

measurement of ‘95th percentile waits’ for non-admitted pathways, reporting at 14.2 weeks against the target of 18.3 weeks, however reported slightly outside of the admitted pathways target, at 23.7 weeks against the target of 23 weeks. The incomplete pathways reported within target at 17.6 weeks against the target of 28 weeks.

3.2.4 The September position against the additional measure of ‘median waits’ was

also within the required standards, reporting at 4.6 weeks for non-admitted pathways, against the target of 6.6 weeks, 9.3 weeks for admitted pathways against the target of 11.1 weeks, and 5.7 weeks for incomplete pathways, against the 7.2 week target.

3.2.5 National RTT data, August position (latest published data) indicates the Trust

is performing above national average for admitted, non-admitted and incomplete pathways measures. Table 1 demonstrates the Trust’s position against the national performance. The national reports are provided at both aggregate and specialty level, with the ability to compare with other individual

Draft

organisations. These are shared monthly with the directorates for monitoring and management purposes.

Table 1: August RTT Benchmarked Position (latest published data)

RTT Measure National Position (August 2015)

Trust Position (August 2015)

Trust v National

Incomplete Pathways waiting < 18 wks 92.6% 96.8% + 4.2%

Half of patients wait less than 6 weeks 6.1 weeks + 0.1

week

Half of Admitted patients waited less

than

9 weeks 8.9 weeks - 0.1 week

19 out of 20 patients wait less than 26 weeks 24.9 weeks -

1.1 week

Half of Non admitted Pathways waited

less than

6 weeks 3.6 weeks -2.4 week

19 out of 20 patients wait less than 19 weeks 13.9 weeks - 5.1week

3.2.6 A zero tolerance approach to any incomplete RTT unadjusted pathways over 52 weeks remains within the Everyone Counts: Planning for Patients 2014/15 – 2018/19 document. This standard has been assigned a £5000 penaltywithin the National Standard Contract. The Trust reported no over 52 week waits in September and continuously monitors this position on a weekly basis via the Patient Tracking List (PTL).

3.2.7 Focus continues around those specialties whereby median waits are rising/outlying to manage process delays, with the aim to reduce waits to support performance management and improve patient experience.

3.2.8 Overall the organisation manages performance against the aggregate standards consistently. The developments to date include the appointment of additional consultants, extended days, additional outpatient, diagnostic and theatre sessions and reviews of individual resources which have supported delivery of the standards. However, with the current limited flexibility in capacity within the system there is significant micro-management on a daily basis to support on-going delivery of the waiting times standards.

3.3 Diagnostic Waiting Times

3.3.1 Diagnostic pathways continue to be monitored closely to ensure maximum contribution to RTT pathway management and to reduce waiting times. In line with the national trend, the Trust is experiencing increased pressures for the provision of MRI and CT scanning services.

3.3.2 The maximum 6 week diagnostic wait indicator remains within the Everyone Counts: Planning for Patients 2014/15 – 2018/19 document. The Trust achieved 99.11% against the target of 99% in September.

3.4 Health Care Associated Infections

3.4.1 MRSA

3.4.2 The Trust reported zero cases of MRSA bacteraemia in September 2015.

Draft

3.4.3 The tolerance for 2015/16 remains at zero cases, in line with the national target of zero tolerance for MRSA.

3.5 Clostridium Difficile (CDI) 3.5.1 There were 3 cases of Clostridium Difficile reported in September, against the

month end target of 1 case, however the cumulative Q2 position has reported above the year end objective at 18 cases against the trajectory of 13 cases. A full detailed report, including current and historical performance, benchmarked position, work to date and next steps, has been developed for submission to Monitor.

3.5.2 A full health economy governance approach to management has been

investigated, according to national directive, and continues to develop in line with local requirements.

3.5.3 Based on the DoH methodology, the Trust’s significant reduction in C-diff

cases has resulted in the 2015/16 objective being set at 13 cases. The Trust has raised its concerns with NHS England and continues to believe that this is an unrealistic aspirational target given that the Trust’s rate per 100,000 bed days has been set at 6.8 against the national average of 12.5. As such, the delivery of the C-diff standard was recognised by the Board of Directors as at risk for 2015/16 against the indicator threshold (Risk Assessment Framework 2015), with a declaration of non-compliance indicated in the Operational Plan submitted to Monitor.

3.6 MSSA and E Coli 3.6.1 The DH introduced the requirement to shadow monitor hospital acquired

MSSA and E Coli cases from 2011 onwards; a reduction in cases is expected. In September the Trust reported no cases of MSSA, against the monthly internal target of one case, and 3 cases of E Coli against the monthly internal trajectory of one case.

3.6.2 Full root cause analysis is carried out of each MSSA and E Coli cases to

identify any emerging themes and trends. 3.7 Cancer Standards (August final position) 3.7.1 The Trust continues to experience significant pressures in achieving the

cancer pathway standards compounded by significant increases in referrals as a result of multiple national cancer awareness schemes. The Trust has achieved against a number of the core cancer standards in August, however under-achieved against the cancer 2 week rule standard, reporting at 90.86% against the 93% target, the 2 week rule breast symptomatic standard, reporting at 92.31% against the 93% target, and the 62 day urgent referral to treatment standard, reporting at 83.33% against the 85% target. Key issues included complex pathway, significant pressures within the system due to increases in referrals and patient choice.

3.7.2 The provisional Q2 position indicates all but two of the reportable cancer

standards have been achieved, with the cancer 2 week wait standard reporting below the 93% target at 91.82% and the 62 day urgent referral to treatment standard reporting below the 85% target at 83.11%. A full detailed report, including current and historical performance, benchmarked position, work to date and next steps, has been developed for submission to Monitor.

3.7.3 The latest national position, August data, indicates a number of Trusts are

experiencing pressures in delivering the cancer standards with the national average for the 62 day urgent referral to treatment standard reporting at

Draft

82.5% against the target of 85%, with seven out of the ten regional organisations breaching the standard.

3.7.4 Table 2 below demonstrates compliance against the 62 day urgent referral to treatment standard by specialty for August’s position, indicating the key areas of pressure within the organisation.

Table 2 – Performance by specialty

Tumour Group August Compliance (85%)

Breast 100% Gynaecology 66.70% Colorectal 100% Upper GI 75% Lung 81% Skin 100% Urology 69.20%

3.7.5 The Trust continues to experience increasing pressures across the cancer services, compounded by significant increases in referrals as a result of multiple national cancer awareness schemes. The increase in referrals has had a substantial impact on the outpatient and diagnostic services, as each 2 week wait referral has to be seen and diagnosed within the required timescales, which can include multiple appointments and diagnostic tests.

3.7.6 The uptake of patient choice, causing delay in the diagnosis and treatment stages within the pathway, continues to affect the delivery of the cancer standards. In response to the patient choice issue, the Trust continues to work with local GPs to ensure continued support to encourage patients to take up appointments offered within the required timescales, to improve patient information and ensure a continued focus. Work has been initiated during 2014/15 to develop an agreed local protocol for the effective management of patient choice; however this is still to be agreed. The Trust continues to pursue this piece of work and remodelling of pathways alongside Commissioners.

3.7.7 The revised NICE guidelines for GP suspected cancer referrals were released in June 2015, which are predicted to result in further increases in 2 week wait referrals. The ‘Be Clear on Cancer Campaign’ for breast cancer in women over 70 took place between July and September 2015, with Quarter 2 seeing an increase in breast referrals of 11.97% (n=116) in comparison to the same period last year.

3.7.8 NHS England, Monitor and the Trust Development Authority (TDA) have initiated a national delivery programme which will focus on improving 62 day performance, working closely with the Cancer Waiting Times Taskforce (CWTT) and Intensive Support Team (IST). The initial workstreams include the implementation of eight key priorities for the delivery of cancer waiting times standards, development of improvement plans for outlying organisations, capacity planning, Local System Resilience Groups to over see delivery, a review of the breach allocation policy and a focus on reducing Endoscopy waits which will be supported by the InHealth Programme Management Office. The Trust has developed a gap analysis against the eight priorities and submitted the required assurance statement at the end of September.

Draft

3.7.9 Aligned with the above, from July 2015, all NHS Providers are required to submit a weekly 62 day Patient Tracking List (PTL) to NHS England, to enable additional monitoring of improvement.

3.7.10 The Trust also received notification that it has been ranked within the ‘concern’ bracket for cancer performance, based on the under-achievement of the 62 day standard in Quarter 4, therefore was required to submit an improvement plan alongside the assurance statement in September. The Trust’s internal recovery plan, supplemented by external review and verification has been submitted within the required deadline.

3.7.11 This risk of underachievement against such standards was anticipated by the Board of Directors and acknowledged in the returns to monitor via the Annual Plan

3.7.12 Work continues to implement all actions outlined within the updated internal cancer recovery plan, however, it is recognised that the consistent delivery of the cancer standards requires a system wide approach, with pathway reviews required across the whole health economy.

3.8 Emergency Care Standards

3.8.1 The Trust achieved 96.80% for the month of September against the 95% emergency care ‘4 hour arrival to discharge or admission’ standard, with the Q2 position reporting at 95.74%.

3.8.2 September reported a 95th percentile wait of 03:58, with the Q2 position reporting at 03:59.

3.8.3 Table 3 indicates the England average against the A&E 4 hour standard has remained below the 95% standard in August 2015 (latest available data).

3.8.4 The North East position overall has shown an improvement, with six out of the eight Trusts achieving the standard. Although the Trust under-achieved in August, the position has been pulled back in September 2015, as outlined in section 3.8.1.

Table 3 - A&E 4 hour standard in August 2015 (latest available data)

3.8.5 For the month of September, the Trust achieved a median wait of 45 minutes against the 60 minutes indicator for ‘waiting time to initial treatment’, with the Q2 position also reporting at 45 minutes.

3.8.6 ‘Time to initial assessment (ambulance arrivals)’ reported at 22 minutes in September, above the standard of 15 minutes, with Q2 position reporting at 19 minutes.

3.8.7 ‘Unplanned returns within 7 days’ reported outside the 5% tolerance in September, at 5.59%, with Q2 position reporting at 5.20%.

Name Q1 2015/16 Jul-15 Aug-15North Tees And Hartlepool NHS Foundation Trust 96.2% 95.6% 94.8%Trust 1 92.5% 95.0% 96.6%Trust 2 95.1% 96.1% 94.9%Trust 3 95.2% 96.6% 95.7%Trust 4 95.0% 95.7% 96.6%Trust 5 97.7% 97.9% 97.5%Trust 6 94.6% 96.4% 97.0%Trust 7 94.1% 96.9% 97.7%North East Average 95.1% 96% 96%England 94.1% 95.0% 94.3%

Draft

3.8.8 Patients who ‘left before being seen’ reported at 2.50% in September against

the standard of 5%, with Q2 position reporting at 2.49%. 3.8.9 These quality outcome indicators are published each month, where

benchmark comparisons can be found. Publication on Trust web sites is a Monitor requirement, mandatory from June 2015. The latest benchmark position for England and the North East will be included in future reports.

3.8.10 Ambulance handovers greater than 30 and 60 minutes are monitored within

the commissioner reports on a monthly basis. In September the Trust reported 1 ambulance handover greater than 30 minutes (due to pressures within the department) and none greater than 60 minutes. In comparison, the North East average handovers greater than 30 minutes reported at 60 (range 0 – 140), with the average over 60 minutes reporting at 9 (range 0 – 21). The Trust’s overall performance in September indicated 98.67% of ambulance handovers (valid) within 15 minutes.

3.8.11 Given the recent national publicity around delays in emergency access, the

delivery of efficient ambulance turnaround times is currently high profile across the health economy. The Trust reported 92.6% ambulance turnaround times within 30 minutes during September, in comparison the North East’s position at 91.7% with performance ranging between 84% and 96.7%. The Ambulance turnaround time is the measurement of the time between the Ambulance arriving at the hospital (electronically captured at base) and the Ambulance leaving the hospital site (electronically captured at base); post the completion of electronic documentation within the A&E department.

3.8.12 Discussions have been held with commissioners and the Area Team to

improve system resilience in the future, with recognition that a review of whole system delivery is required to support emergency care pathway provision, and to ensure financial support for the cost of the impact on Acute Trust resilience provision.

3.8.13 The Trust has taken forward a rapid improvement project across emergency

care in the form of the ‘Perfect Week’ during October 2015, reviewing emergency care pathway delivery with a focus on timely discharge through a structured, Executive led, improvement project, with key milestones and objectives for delivery. Initial feedback reports a very successful week, with excellent support across the organisation. A full evaluation will take place in November.

3.9 Community Information Dataset (CIDS) 3.9.1 Performance indicators for Community Services, with data completeness

used as a measure for the three elements of Referral to Treatment (RTT), referral and activity information, with a target of 50% completeness set for achievement from Q1 2012/13 remain in the 2015/16 Risk Assessment Framework.

3.9.2 August position (latest available data) indicated the Trust had achieved all

three CIDs targets for the period, reporting 93.54% (RTT), 91.90% (Referral) and 94.05% (activity) respectively against the 50% target.

3.9.3 Monitor indicated two further data completeness measures would be

introduced within 2012/13, End of Life Pathway and Patient Identifiable Information, however these were subsequently removed from the Risk Assessment Framework. The Trust continues to monitor these indicators in shadow format with achievement against both.

Draft

4. Human Resource / Productivity Indicators

4.1 Cancelled Operations

4.1.1 In September, non-medical cancelled operations reported at 0.50% (n=19), which is within the Care Quality Commission target of 0.8% (Intelligent Monitoring Report). The Q2 position reported 0.48% (n=52).

4.1.2 The Department of Health Everyone Counts: Planning for Patients 2014/15 – 2018/19 document outlines that no ‘urgent’ operation should be cancelled more than once.

4.1.3 September position reported no ‘urgent’ procedures had been cancelled.

4.2 Outpatient Attendance Indicators

4.2.1 The Trust continues to report progressive positive performance against the national comparative benchmarks for outpatient attendance efficiency indicators. These benchmarks were reviewed in March 2015 to ensure they reflected the current national position. Three year stretch targets have been set for each indicator.

4.2.2 The aggregate New to Review ratios in September are reported at 1.33 below the 2015/16 stretch target of 1.45. Additional individual targets have been agreed with Commissioners for monitoring at specialty level. Further work continues with Clinical Commissioning Groups (CCGs) to develop pathways to support further reduction/exemption, where possible.

4.2.3 The Trust’s performance against New Outpatient DNA rates reported above the agreed 2015/16 stretch target of 5.4%, reporting at 7.11%, with Review DNA rates reporting at 10.54% against the 9% target.

4.2.4 Work is on-going to further reduce DNAs, supported by the automated reminder service and partial booking. In addition, DNA’s are accommodated utilising excess booking to manage potential inefficiency and a patient survey is planned within one sub specialty in an effort to understand key themes around DNAs.

4.3 Choose and Book Appointment Slot Issues (ASIs)

4.3.1 The National reporting system for Choose and Book was migrated to E-Booking in May 2015. Since the introduction of the system there have been a number of issues, most of which have now been resolved with the day to day operating of the system now working as expected. However, the issues with the reporting element of the system has not yet been resolved, therefore at this point in time the monthly ASI position cannot be reported.

4.4 Sickness Absence

4.4.1 The Trust reported an aggregate Sickness Absence rate of 4.80% during September against the set target of 3.5%.

4.4.2 The Trust focus remains on adherence to policy and management support to deliver a reduction in sickness. The Trust has reviewed and updated the Absence Management Policy, with guidance distributed to all managers.

5. High Level Quality Indicators

Draft

5.1 Several new indicators have now been added to the dashboard for continuous monitoring and improvement. This analysis is supported by the Quality Report.

5.2 HSMR and SHMI 5.2.1 The latest HSMR data released from HED for the time period August 2014 to

July 2015 demonstrates the Trust is reporting higher than expected at 123.86 however is demonstrating continued reduction against previous positions of 124.54 (July 2014 to June 2015) and prior to this 125.76 (June 2014 to May 2015). Whilst this is not where the Trust would like to be, it must be noted that every internal effort is being made to sustain this improvement as described in the sections below.

5.2.2 The top 5 HSMR diagnostic groups for this period include;

• Pneumonia • Congestive heart failure; non-hypertensive • Urinary tract infections • Acute and unspecified renal failure • Chronic obstructive pulmonary disease

5.2.3 SHMI is also reporting higher than expected at 118.91 in the most recent

Health and Social Care Information Centre rolling 12 month period (October 2013 to September 2014). The provisional data for the period ending December 2014 indicates a reduction to 118.24; however the final data has not yet been published by the Health and Social Care Information Centre. The updated data will be made available in the next Board report.

Note: SHMI includes deaths outside of hospital, within 30 days of discharge.

5.2.4 The top 4 diagnostic Groups (CCS) SHMI values for this reporting period are

as follows:

• Pneumonia (except that caused by tuberculosis or sexually transmitted disease)

• Urinary tract infections • Chronic obstructive pulmonary disease and bronchiectasis • Acute cerebrovascular disease

5.2.5 Internal work is on-going to review both the HSMR and SHMI position via the Keogh Delivery Group. A number of key areas are being reviewed including accurate documentation, clinical coding and weekly clinical led reviews of all in-hospital mortalities. In addition, to addressing the eight key recommendations in the Professor Keogh report (September 2013).

5.2.6 A comprehensive clinically led Pneumonia Mortality Project is underway to

investigate and improve clinical pathway management, data collection and documentation. This has been supplemented with in-depth work on the Elderly Frail Pathway, Sepsis and Acute Kidney Injury management.

5.2.7 The Trust, while using national mortality measures as a warning sign, is

investigating more broadly and deeply the quality of care and treatment provided.

5.2.8 The internal work is further supported by external peer reviews,

commissioned external audits and collaborative working with other regional organisations.

5.3 Readmissions

Draft

5.3.1 The Trust recognises emergency readmissions as an area requiring further work, in line with national drivers to reduce inappropriate admissions. The Trust is currently reporting emergency readmission rates at 2.21% post elective admission and 12.17% post emergency admission. However the aggregate emergency readmission rate reports at 6.68%, below the revised 2015/16 internal stretch target of 7.70% (based on peer average and year on year improvement).

5.3.3 Work is on-going within the individual directorates to review key issues and recognition of avoidable and unavoidable categorisation. This work is supported by clinical audit and clinical debate to inform discussions and negotiation with the Clinical Commissioning Groups. Appropriate governance structures via the Better Care Fund Working will be put in place to ensure that the responsibility of readmissions is shared across the acute, community, primary and social care providers to tackle the key themes associated with avoidable readmissions.

5.4 Unplanned Hospitalisation and Emergency Admissions

5.4.1 The ‘Everyone Counts: Planning for Patients 2014/15 – 2018/19 Framework’ includes a number of measures aimed at reducing unnecessary hospital admissions for a defined set of acute conditions. These are:

• Unplanned hospitalisation for chronic ambulatory care sensitive conditions(adults)

• Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s• Emergency admissions for acute conditions that should not usually

require hospital admission• Emergency admissions for children with lower respiratory tract infections

5.4.2 Although no set target has been set to date, there is an expectation that acute providers will deliver a year on year reduction against these key areas. The Trust has re-set the baseline against 2014/15 outturn and will monitor delivery on a month on month basis, in addition to continuing joint work with GPs and CCGs to develop pathways to avoid admission where inappropriate.

5.4.3 Two of the four standards reported an improvement on last year’s position, with the remaining two standards reporting an increase in admissions within the defined conditions, including Emergency admissions for acute conditions that should not usually require hospital admission and Emergency admissions for children with lower respiratory tract infections.

5.5 Venous Thromboembolism (VTE)

5.5.1 VTE assessment has now been added to the Corporate Dashboard within the Quality section. This target measures the Trust’s compliance with the assessment for VTE on admission for all appropriate admissions. The Trust reported at 95.08% in September, above the 95% target.

5.6 Grade 3 & Grade 4 Pressure Sores

5.6.1 The monitoring of hospital acquired grade 3 and grade 4 pressures sores has been added to the quality section of the Corporate Dashboard. In September the Trust reported two grade 3 pressure sores and zero grade 4 pressure sores in hospital (hospital acquired).

5.7 In Hospital Falls

Draft

5.7.1 The performance for total ‘in hospital’ falls will be monitored against last year’s position for the comparative period, with an expected improvement. In September the Trust reported 90 falls in hospital, a decrease of 24% (n=29) on the September 2014 position, which reported 119 falls.

5.7.2 In September, one of the ‘in hospital’ patient falls resulted in a fracture which is in comparison to the same period last year. This is further addressed in the Quality Report.

5.8 NHS Choices

5.8.1 The Trust’s current score against the NHS Choices section relating to patient experience and recommendation of provider is reported within Appendix 1 of the Corporate Dashboard. Patient experience and choice is high on the Trust’s quality agenda, therefore this measure is included as a guide to the patient’s perception of the care the two hospital sites are providing.

5.8.2 This is supplemented by the Friends and Family Indicator report in the Quality Report to Board, with September scores for Wards, A&E and Maternity (births element) reported on the quality section of the Corporate Dashboard.

5.8.3 The NHS England review of the patient Friends and Family Test (FFT), published in September 2014, recommended a move away from the Net Promoter Score (NPS) and the introduction of a simpler scoring system in order to increase the relevance of the FFT data for NHS staff, patients and members of the public. Based on the findings of the review, NHS England is now calculating and presenting the FFT results as a percentage of respondents who would be extremely likely or likely to recommend the service to their friends and family. The Corporate Dashboard has reflected these changes from October 2014 onwards.

5.9 Out of Hospital

5.9.1 The Corporate Dashboard has been updated to include a number of Transforming Community Services Indicators, to provide an overview of the progress being made in delivering improvements across community care.

5.9.2 TCS 19 – Community patients with an unplanned admission of 2 days or less is used to monitor the progress being made in reducing avoidable emergency admissions for patients on a community case load, covering a defined set of conditions : Diabetes complications, Nutritional deficiencies, Iron deficiency anaemia, Hypertension, Congestive heart failure, Angina, Chronic obstructive pulmonary disease and Asthma. The latest position (August 2015) reported an admission rate of 17.61% against the internal target of 17%.

5.9.3 TCS 24 - The percentage of patients on a community caseload achieving improvement, as measured using a validated assessment tool appropriate to the scope of the practice, is used by the Community Integrated Assessment Team (CIAT) to monitor progress during/post treatment. The latest position (August 2015) indicates 93.90% of patients measured are showing an improvement post treatment against an internal target of 93.50%.

5.9.4 TCS 35 – Standard wheelchairs to be delivered within 5 working days, is monitored as one of the key standards for home equipment delivery performance. The latest position (August 2015) indicates that 78.57% of standard wheelchairs are delivered within 5 days, against the internal stretch target of 90%. The Trust is working towards the national recommendation of 95% however; performance fluctuates dependent upon whether patients are available to accept delivery of the wheelchair.

Draft

5.9.5 The Trust is progressing well against the chosen TCS indicators, with further work on-going to develop appropriate performance monitoring across community services. The following section gives an overview of work to date within the Out of Hospital directorate.

6. Contract Key Performance Indicators

6.1 The Trust agreed a significant number of key performance measures for 2015/16 within the NHS standard and local contract negotiations. In line with the NHS England Commissioning Board structure, these are reported to multiple commissioning bodies including:

• Clinical Commissioning Groups• Area Team• Local Authority

6.2 The KPIs cover quality requirements across both acute and community services, with financial penalties attached against non compliance. The Trust reports performance to the commissioners on a monthly basis.

6.3 The Trust performed well across the majority of the contract KPIs during the September period. The main areas of pressure are reflective of the Trust’s overall position on Clostridium Difficile and the three cancer standards (14 day, breast symptomatic and 62 day).

6.4 The performance against the contract KPIs for all commissioners are available via a link within the Corporate Dashboard.

7. Changes to National operational standards and reportingschedules

7.1 Sir Bruce Keogh has recently carried out a full review of the mandatory operational standards to assess the measures as ‘fit for purpose’, with the aim to also reduce the burden of data collection on NHS organisations.

7.2 A letter was received from Simon Stevens on the 24th June outlining the resulting changes to future monitoring of Referral to Treatment, A&E and Cancer standards.

7.3 The review has resulted in the abolishment of the admitted and non-admitted RTT operational standards with the incomplete standard becoming the sole measure of patients’ constitutional right to start treatment within 18 weeks.

7.4 NHS England will implement a National Variation to make in-year changes to the 2015/16 Contract to formally remove the financial sanctions for the two completed pathway standards in October 2015. This will also include increasing the value of the sanction which applies where providers are unable to achieve the incomplete pathway standard, in line with the commitment to the incomplete standard as the single new measure of RTT performance.

7.5 The Trust currently performs above the 92% incomplete standard, however further work will commence to reduce the waiting times.

7.6 In addition to the RTT changes, the following statistics are now published monthly on the same date by NHS England: RTT, Cancer, Diagnostics, A&E, Ambulance, NHS 111 and Delayed Transfers of Care. The aim of this is to reduce the weekly reporting and subsequently the additional pressures on NHS organisations.

Draft

8. Monitor 2014/15 Q4 monitoring and 2015/16 Annual Plan Review(APR)

8.1 In August 2015, the Trust received feedback from Monitor on the organisation’s Annual Operating Plan submission and Q4 ratings. The Trust’s current and forecast risk ratings were assigned as follows:

Under the Risk Assessment Framework, the governance rating indicates whether Monitor is currently taking any action; this rating therefore reflects the outcome of both the operational plan review and Q4 monitoring.

8.2 Quarter 4 2014/15 Position: The Trust was assigned a ‘Green’ governance rating, however with recognition from Monitor that the Trust had failed to meet the A&E and Cancer 62 Day (GP referral) targets.

8.3 Monitor outlined the expectation that the Trust is addressing the issues with the aim of achieving sustainable compliance with the targets promptly. Monitor does not intend to take any further action at this stage, however it will consider what, if any, further regulatory action may be appropriate.

8.4 Annual plan review: Monitor identified some specific areas of risk in respect of the Trust’s operational plan for 2015/16:

• The Trust’s operating plan currently assumes minimal additionalinvestment in quality during 2015/16. However, experience shows thatTrusts subject to a full CQC inspection often require some additionalinvestment to address issues identified.

• Whilst the Trust’s 3 year average agency spend is 4.7% of staff costs, the2015/16 plan is for this to reduce to 0.8%. The Trust did however describea number of actions being taken to facilitate this reduction; Monitoroutlined this still appears to be a very challenging target.

Monitor will not take formal regulatory action at this time, but will continue to monitor the Trust’s position as part of their standard quarterly processes.


9.1 The Trust has, in the main, performed well against the majority of key operational standards during September, notwithstanding the considerable challenges associated with on-going operational and financial pressures. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements and principles of Service Line Management.

9.2 The Trust has robust governance processes in place for the monitoring and management of the delivery of all performance standards and will continue to strive to achieve core regulatory requirements. However, there is recognition that current pressures across the whole health economy may ultimately impact on consistent delivery, therefore presents an on-going risk.

Draft

9.3 This risk is outlined within the Trust’s Assurance Framework, with supporting mitigation plans, alongside internal and external governance assurance processes.

10. Recommendations

10.1 The Board of Directors is asked to note the detail in the Corporate Dashboard and performance against the Risk Assessment Framework and the key national indicators, for September 2015, in the context of Monitor’s Terms of Licence and the Everyone Counts: Planning for Patients 2014/15 – 2018/19 document.

10.2 In addition the Board of Directors is asked to note the on-going operational performance risks to regulatory key performance indicators and the work that is being taken forward to address.


Draft

QTR 1 QTR 2 QTR 3 QTR 4

Return to CDB menuProfile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%Actual 91.33% 91.57% 92.96% 92.00% 92.47% 90.64% 90.73% 91.31%Variance 1.33% 1.57% 2.96% 2.00% 2.47% 0.64% 0.73% 1.31%Profile 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%Actual 98.12% 98.05% 98.38% 98.21% 98.12% 98.13% 98.07% 98.15%Variance 3.12% 3.05% 3.38% 3.21% 3.12% 3.13% 3.07% 3.15%Profile 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%Actual 96.36% 96.60% 96.85% 96.69% 96.70% 96.83% 96.38% 96.71%Variance 4.36% 4.60% 4.85% 4.69% 4.70% 4.83% 4.38% 4.71%Profile 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1Actual 9.9 10.1 9.0 9.7 8.7 8.9 9.3 8.9Variance -1.2 -1.0 -2.1 -1.4 -2.4 -2.2 -1.8 -2.2Profile 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6Actual 4.1 3.6 4.0 3.7 3.4 3.6 4.6 3.9Variance -2.5 -3.0 -2.6 -2.9 -3.2 -3.0 -2.0 -2.7Profile 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2Actual 5.4 5.9 4.9 5.6 4.9 6.1 5.7 5.6Variance -1.8 -1.3 -2.3 -1.6 -2.3 -1.1 -1.5 -1.6Profile 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0Actual 24.1 25.2 23.0 24.7 24.1 24.9 23.7 24.1Variance 1.1 2.2 0.0 1.7 1.1 1.9 0.7 1.1Profile 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3Actual 12.9 13.3 13.7 13.1 13.3 13.9 14.2 13.9Variance -5.4 -5.0 -4.6 -5.2 -5.0 -4.4 -4.1 -4.4Profile 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0Actual 16.3 17.3 16.9 17.0 16.6 17.4 17.6 17.1Variance -11.7 -10.7 -11.1 -11.0 -11.4 -10.6 -10.4 -10.9Profile 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0 0 0 0Variance 0 0 0 0 0 0 0 0Profile 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%Variance 5.0% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Profile 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3Actual 6.0 6.0 6.0 6.0 6.0 6.0 7.0 6.3Variance -12.3 -12.3 -12.3 -12.3 -12.3 -12.3 -11.3 -12.0

95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 95.48% 97.27% 96.47% 96.40% 95.56% 94.84% 96.80% 95.74%Variance 0.48% 2.27% 1.47% 1.40% 0.56% -0.16% 1.80% 0.74%Profile 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00Actual 18:00 15:00 16:00 17:00 00:17 00:19 00:22 00:19Variance 03:00 00:00 01:00 02:00 00:02 00:04 00:07 00:04Profile 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00Actual 00:45 00:42 00:48 00:45 00:50 00:40 00:45 00:45Variance 00:15 00:18 00:12 00:15 00:10 00:20 00:15 00:15Profile 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 4.95% 4.54% 4.79% 4.77% 5.06% 5.20% 5.59% 5.20%Variance -0.05% -0.46% -0.21% -0.23% 0.06% 0.20% 0.59% 0.20%Profile 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 2.04% 1.70% 2.59% 2.11% 2.76% 2.20% 2.50% 2.49%Variance -2.96% -3.30% -2.41% -2.89% -2.24% -2.80% -2.50% -2.51%Profile 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00Actual 03:59 03:58 03:59 03:59 03:59 04:13 03:58 03:59Variance 00:01 00:02 00:01 00:01 00:01 00:13 00:02 00:01Profile 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Actual 98.46% 99.14% 98.67% 98.76% 98.90% 98.99% 98.67% 98.89%Variance -1.54% -0.86% -1.33% -1.24% -1.10% -1.01% -1.33% -1.11%

* Data collection, validation and reporting processes prevent these standards from achieving a more timely result

Decem

ber 15

January 16

Appendix 1 - Compliance Monitoring Framework

Trust Performance

(1)

April 15

May 15

June 15

July 15

February 16

March 16

The % of patients whose clock stopped within 18 weeks during the month with an admission (Part1a)

The % of patients whose clock stopped within 18 weeks during the month - non admitted (Part 1b)

The % of patients whose clock is still running waiting less than 18 weeks (Part 2)

RTT admitted wait (Median)

August 15

September 15

October 15

Novem

ber 15

RTT non admitted wait (Median)

RTT incomplete pathways wait (Median)

RTT admitted wait (95th percentile)

RTT non admitted wait (95th percentile)

RTT incomplete pathways wait (95th percentile)

RTT incomplete pathways >52 week wait

A&E left without being seen

A&E Time to departure (95th percentile)

% Ambulance Handover (Valid) within 15 minutes

The % patients treated within 18 weeks of referral to audiology (Hpool site)

Audiology non admitted wait (95th percentile)

A&E 4 hr target (excludes walk-in centres)

A&E Time to Initial Assessment -Ambulance arrivals (95th percentile)

A&E Time to Initial Treatment (Median)

A&E unplanned returns within 7 days

Draft

Appendix 1 - Compliance Monitoring Framework x

Return to CDB menuProfile 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%Variance 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%Profile 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94%Actual 100.00% 100.00% 100.00% 100.00% 90.00% 100.00% 100.00% 96.77%Variance 6.0% 6.00% 6.00% 6.00% -4.00% 6.00% 6.00% 2.77%Profile 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85%Actual 100.00% 75.00% 66.67% 85.00% 100.00% 100.00% 92.86% 94.74%Variance 15.0% -10.00% -18.33% 0.00% 15.00% 15.00% 7.86% 9.74%Profile 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90%Actual 98.51% 100.00% 100.00% 99.50% 97.65% 100.00% 90.48% 96.49%Variance 8.5% 10.00% 10.00% 9.50% 7.65% 10.00% 0.48% 6.49%Profile 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85%Actual 85.84% 88.04% 83.06% 85.59% 85.71% 83.33% 79.55% 83.11%Variance 0.8% 3.04% -1.94% 0.59% 0.71% -1.67% -5.45% -1.89%Profile 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96%Actual 99.16% 99.04% 100.00% 99.12% 100.00% 100.00% 96.36% 98.84%Variance 3.2% 3.04% 4.00% 3.12% 4.00% 4.00% 0.36% 2.84%Profile 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93%Actual 92.88% 94.30% 91.55% 92.87% 90.60% 90.86% 94.12% 91.82%Variance -0.1% 1.30% -1.45% -0.13% -2.40% -2.14% 1.12% -1.18%Profile 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93%Actual 96.03% 94.94% 92.61% 94.43% 91.67% 92.31% 96.10% 93.19%Variance 3.0% 1.94% -0.39% 1.43% -1.33% -0.69% 3.10% 0.19%Profile 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0Actual 0 0 0 0 0 0 0 0Variance 0 0 0 0 0 0 0 0Profile 2 3 4 4 5 6 7 7 8 9 10 10 11 12 13 13Actual 4 8 8 8 11 15 18 18Variance 2 5 4 4 6 9 11 11Profile 4 5 5 5 9 12 13 13 15 15 15 15 17 18 18 18Actual 4 4 7 7 10 14 14 14Variance 0 -1 2 2 1 2 1 1Profile 0 3 5 5 6 7 8 8 14 18 19 19 21 25 27 27Actual 1 7 7 7 11 14 17 17Variance 1 4 2 2 5 7 9 9Profile 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%Actual 90.91% 77.14% 81.08% 81.40% 91.18%Variance 10.91% -2.86% 1.08% 1.40% 11.18%Profile 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%Actual 85.71% 100.00% 83.33% 80.00% 37.50%Variance 10.71% 25.00% 8.33% 194.04% 5.00% -37.50%Profile 4% 4% 4% 4.00% 4% 4% 4% 4.00% 4% 4% 4% 4.00% 4% 4% 4% 4.00%Actual 1.71% 2.61%Variance -2% -1.39%Profile 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0 0 0 0VarianceProfile 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00%Actual 94.91% 95.74% 96.89% 95.76% 95.52% 95.52%Variance 24.91% 25.74% 26.89% 25.76% 25.52% 25.52%Profile 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00%Actual 88.24% 90.17% 95.45% 90.70% 91.81% 93.88%Variance 18.24% 20.17% 25.45% 20.70% 21.81% 23.88%Profile 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00%Actual 100.00% 100.00% 97.29% 80.00% 92.86% 95.00%Variance 30.00% 30.00% 27.29% 10.00% 22.86% 25.00%Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 99.33% 97.96% 96.16% 98.37% 99.79% 96.49% 99.34% 99.45%Variance 4.33% 2.96% 1.16% 3.37% 4.79% 1.49% 4.34% 4.45%

* Data collection, validation and reporting processes prevent these standards from achieving a more timely result** Mandatory from 2013

Trust Performance

(2)

April 15

May 15

June 15

QTR 1 July 15

August 15

Sep 15(C

ancer Provisional)

QTR

2(C

ancer Provisional)

October 15

Novem

ber 15

Decem

ber 15

QTR 3

January 16

February 16

March 16

QTR 4

New Cancer 31 days subsequent Treatment (Drug Therapy) *

New Cancer 31 days subsequent Treatment (Surgery) *

New Cancer 62 days (consultant upgrade) *

New Cancer 62 days (screening) *

New Cancer GP 62 Day (New Rules) *

New Cancer Current 31 Day (New Rules) *

New Cancer Two week Rule (New Rules) *

Breast Symptomatic Two week Rule (New Rules) *

MRSA - Bacteraemia (Cumulative)***

Clostridium Difficile Patients - diagnosed after 72 hours all ages (Cumulative)***

Methicillin Sensitive Staphylococcus Aureus (MSSA) (Cumulative)***

E-Coli (Cumulative)***

Friends & Family - (Birth) **[National Score based on % ‘extremely likely’ to recommend to F&F]

Outcome Compliance

Stroke admissions 90% of time spent on dedicated Stroke unit *

High risk TIAs assessed and treated within 24 hours *

TAL's - (No SLOT analysis) *

Eliminating Mixed Sex Accommodation

Friends & Family - (Ward) [National Score based on % ‘extremely likely’ to recommend to F&F]

Friends & Family - (A&E) [National Score based on % ‘extremely likely’ to recommend to F&F]

Draft

Return to CDB menuProfile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0 0Variance 0 0 0 0 0 0Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0 2Variance 0 0 0 0 0 2Profile 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80%Actual 0.31% 0.74% 0.35% 0.40% 0.55% 0.50%Variance -0.49% -0.06% -0.45% -0.40% -0.25% -0.30%Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 2 0 0 0 0Variance 0 2 0 0 0 0Profile 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00%Actual 99.49% 99.90% 99.76% 99.80% 99.67% 99.11%Variance 0.49% 0.90% 0.76% 0.80% 0.67% 0.11%Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0 0Variance 0 0 0 0 0 0Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0 0Variance 0 0 0 0 0 0Profile 22.63% 23.34% 30.06% 22.67% 26.99% 29.49% 35.84% 33.33% 33.33% 33.13% 33.44% 31.83%Actual 24.55% 25.39% 28.50% 33.14% 33.09% 33.77%Variance 1.92% 2.05% -1.56% 10.47% 6.10% 4.28%Profile 51.46% 53.31% 53.57% 55.28% 51.56% 54.42% 56.94% 51.44% 57.04% 51.81% 54.55% 50.99%Actual 55.39% 49.53% 53.44% 52.96% 52.00% 53.25%Variance 3.93% -3.78% -0.14% -2.32% 0.44% -1.18%Profile 17.88% 15.33% 15.18% 12.42% 16.26% 11.26% 11.85% 17.24% 13.75% 12.95% 10.71% 15.77%Actual 12.57% 14.11% 11.70% 14.20% 15.64% 9.87%Variance -5.31% -1.22% -3.47% 1.78% -0.63% -1.39%Profile 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%Actual 2.10% 1.93% 1.39% 1.54% 2.06% 1.45%Variance -1.40% -1.57% -2.11% -1.96% -1.44% -2.05%Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%Actual 92.76% 92.92% 92.41% 92.65% 93.54%Variance 42.76% 42.92% 42.41% 42.65% 43.54%Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%Actual 92.19% 94.14% 92.51% 93.11% 91.90%Variance 42.19% 44.14% 42.51% 43.11% 41.90%Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%Actual 90.15% 94.44% 91.89% 97.77% 94.05%Variance 40.15% 44.44% 41.89% 47.77% 44.05%Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%Actual 90.15% 94.44% 91.89% 97.77% 94.05%Variance 40.15% 44.44% 41.89% 47.77% 44.05%Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%Actual 96.15% 97.78% 100.00% 98.78% 97.14%Variance 46.15% 47.78% 50.00% 48.78% 47.14%Profile 4.0 4.0 4.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0Actual 5.0 5.0 5.0 5.0 5.0 5.0Variance 1.0 1.0 1.0Profile 4.0 4.0 4.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0Actual 4.0 4.0 4.5 4.5 4.5 4.5Variance 0.0 0.0 0.5ProfileActual Variance


Decem

ber 15

January 16

Appendix 1 - Compliance Monitoring Framework

Trust Performance

(3)

April 15

May 15

June 15

July 15

February 16

March 16

Number of patients waiting over 26 weeks for an inpatient or daycase admission

Number of patients waiting over 13 weeks for an outpatient appointment

Cancelled Operations for non medical reasons

Readmission within 28 days of non medical cancelled operation *

August 15

September 15

October 15

Novem

ber 15

Number of patients waiting under 6 weeks for diagnostic procedures

A & E 12 Hour Trolley waits

Cancelled Urgent Operations for second time

Late Start %

Early Finishes %

Session overuns (>30 minutes)

% Patients recommending University Hospital of Hartlepool

% Patients recommending University Hospital of North Tees

Delayed Transfers of Care

CIDs -Referral to Treatment information *

CIDs - Referral information *

Treatment Activity Information *

Patient Identifier Indicator *

End of Life measure *

Draft

Return to CDB menuProfile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 92.72% 91.89% 92.85% 92.87% 92.67% 92.84%Variance -2.28% -3.11% -2.15% -2.13% -2.33% -2.16%Profile 73.49 73.49 73.49 73.49 73.49 73.49 73.49 73.49 73.49 73.49 73.49 73.49Actual 56.87 63.69 64.27 64.20 61.47 61.69Variance -16.62 -9.80 -9.22 -9.29 -12.02 -11.80Profile 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00%Actual 18.45% 24.43% 18.57% 16.00% 17.61%Variance 1.45% 7.43% 1.57% -1.00% 0.61%Profile 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50%Actual 96.43% 94.94% 98.35% 95.80% 93.90%Variance 2.93% 1.44% 4.85% 2.30% 0.40%Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%Actual 62.32% 100.00% 85.07% 90.70% 78.57%Variance -27.68% 10.00% -4.93% 0.70% -11.43%ProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual VarianceProfileActual Variance


Decem

ber 15

January 16

Appendix 1 - Community Monitoring Framework

Trust Performance

(4)

April 15

May 15

June 15

July 15

February 16

March 16

Diabetic Retinopathy Screening

Health Visitor numbers

TCS 19 - % of Community Patients that have had an unplanned admission LOS <=2 days (Defined set of conditions)

TCS 24 - % of Patients achieving improvement using a EQ5 validated assessment tool

August 15

September 15

October 15

Novem

ber 15

TCS 35 - % of standard wheelchair referrals completed within five days

Draft

Appendix 2Published's Date & Time11/06/2015 09:28

September 2015

September 2015

ID Measure Monthly Target

Monitor Score Act QTR 2 Cum ID Measure Monthly

TargetAnnual Target Act Cum

1 A&E 1 New to Review ratio (cons led) 1.45 1.332 A&E 4 hr target (excludes walk-in centres) 95% 1 96.80% 95.74% 96.07% 2 Outpatient DNA (new) 5.40% 7.11%3 3 Outpatient DNA (review) 9.00% 10.54%4 Cancer Aug 2015 Position 4 Average depth of coding 3.01 4.865 QTR 2 Provisional 5 Length of Stay Elective 3.22 2.946 New Cancer 31 days subsequent Treatment (Drug Therapy) 98% 1 100.00% 100.00% 100.00% 6 Length of Stay Emergency 4.41 4.747 New Cancer 31 days subsequent Treatment (Surgery) 94% 1 100.00% 96.77% 97.98% 7 Day case Rate 68.40% 76.26%8 New Cancer 62 days (consultant upgrade) 85% 1 100.00% 94.74% 89.47% 8 Pre - Op Stays 4.50% 2.63%9 New Cancer 62 days (screening) 90% 1 100.00% 96.49% 97.90% 9

10 New Cancer GP 62 Day (New Rules) 85% 1 83.33% 83.11% 84.31% 10 Bed Occupancy11 New Cancer Current 31 Day (New Rules) 96% 1 100.00% 98.84% 99.12% 11 Revised Occupancy Hartlepool 82.00% 65.90%12 New Cancer Two week Rule (New Rules) 93% 1 90.86% 91.82% 92.35% 12 Revised Occupancy North Tees 82.00% 85.92%13 Breast Symptomatic Two week Rule (New Rules) 93% 1 92.31% 93.19% 93.79% 13

14 1415 RTT Milestones 1516 RTT admitted wait (90%) 90% 1 90.73% 91.31% 91.69% 1617 RTT non admitted wait (95%) 95% 1 98.07% 98.15% 98.18% 17 Theatre Activity18 RTT incomplete pathways wait (92%) 92% 1 96.38% 96.71% 96.70% 18 Operation Time Utilisation 76.25% 74.14%19 19 Run Time Utilisation 94.54% 88.90%20 Community Information Dataset 20 Planned Session Utilisation 92.54% 97.16%21 Referral to Treatment information 50% 93.54% 21 Cancelled on day of operation 5.96% 7.52%22 Referral information 50% 1 91.90% 22 Cancelled (Non medical) 0.80% 0.50%23 Treatment Activity Information 50% 94.05% 2324 24 HR25 HCAI

Cumulative YTD Target 25 Staff in post (wte) 4498.76

26 26 Staff turnover ratio 10.00% 13.07%27 C.Diff (diagnosed after 72 hours) 1 1 3 7 18 27 Sickness absence % 3.50% 4.80%28 28 Mandatory Training 80.00% 95.66%29 Eliminating Mixed Sex Accommodation 0 N/A 0 2930 Access to Healthcare for People with Learning Disabilities 1 0 3031 3132 CQC Registration 2-4 0 3233 3334 3435 35

September 2015

September 2015

ID Measure Monthly Target

Annual Target Act Cum ID Measure Revenue

Position CIP Delivery Strategic CIP Delivery

1 Mortality rate (HSMR) 100.00 123.86 1 ACCIDENT AND EMERGENCY2 Mortality rate (SHIMI) 100.00 118.91 2 ANAESTHETICS3 Mortality rate (SHIMI) - {High relative risk CCS's} TBA 14 3 CHIEF EXECUTIVE4 Readmission rate 30 days (Emergency admission) 9.73% 12.17% 4 EAU & AMBULATORY CARE5 Readmission rate 30 days (Elective admission) 0.00% 2.21% 5 EDUCATION & ORGANISATION DEVELOPMENT6 Readmission rate 30 days (Total) 7.70% 6.68% 6 ENDOSCOPY7 7 ESTATES8 Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) 59.73 54.52 8 FINANCE & ICT9 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s 33.37 15.57 9 HUMAN RESOURCES

10 Emergency admissions for acute conditions that should not usually require hospital admission 119.73 136.99 10 OUT OF HOSPITAL CARE11 Unplanned hospitalisation for respiritory tract infections in under 19s 1.11 2.22 11 IN HOSPITAL CARE12 12 MEDICAL DIRECTOR -13 Patient Safety Incidents (All Grades) {per 100 admissions} 6.80 8.27 13 NURSING AND PATIENT SAFETY14 Patient Safety Incidents that resulted in Serious Harm - {% of total PSIs} 0.60 0.00 14 OBS AND GYNAE15 Complaint response times 79.00% 92.31% 15 ORTHOPAEDICS16 16 OUTPATIENTS17 Corporate & Departmental Risks (Red) 8 17 PAEDIATRICS18 Electronic Discharge Summaries within 24 hours 95.00% 91.00% 18 PATHOLOGY19 Grade 3 Pressure sores (Hospital only) 0 2 19 PHARMACY20 Grade 4 Pressure sores (Hospital only) 0 0 20 RADIOLOGY21 Total Falls (Hospital Only) 119 90 21 RESEARCH AND DEVELOPMENT -22 Falls with Fracture (STEIS Reportable) 1 1 22 STRATEGY, OPERATIONS AND PERFORMANCE23 VTE 95.00% 95.08% 23 SURGERY AND UROLOGY24 Hand washing Compliance 100.00% 91.52% 24 TRANSFORMATION

25Cumulative YTD

Target 25 TOTAL DIRECTORATE26 MRSA - Bacteraemia 0 0 0 0 26 TRANSFORMATION ARRAGEMENTS FOR 15/16 SIEP DELIVERY 27 Methicillin Sensitive Staphylococcus Aureus (MSSA) 1 13 0 14 27 TRANSFORMATION28 E-Coli 1 8 3 17 28 UNALLOCATED CIP 29 29 OVERALL PORTFOLIO TOTAL30 30 CONTINUITY OF SERVICES RISK RATING31 Friends & Family 31 CAPITAL SEVICING CAPACITY (50%) 1

32 Friends & Family - (Ward)-[National Score based on % ‘extremely likely’ to recommend to F&F] 70% -100% 95.52% 32 LIQUIDITY RATIO (50%) 433 Friends & Family - (A&E)-[National Score based on % ‘extremely likely’ to recommend to F&F] 70% -100% 93.88% 33 I&E MARGIN (25%) 134 Friends & Family - (Birth)-[National Score based on % ‘extremely likely’ to recommend to F&F] 70% -100% 95.00% 34 VARIANCE IN I&E MARGIN (25%) 135 35 OVERALL FINANCIAL SUSTAINABILITY RATING 2

Compliance Monitoring HR - Productivity & Process

Quality Process Financial Position

Draft

Appendix 3

Draft

1



29 October 2015

Executive Summary

Finance and Contract Performance Report as at 30 September 2015

Report of the Director of Finance, ICT and Support Services

Strategic Aim (The full set of Trust aims can be found at the beginning of the Board Reports)

Maintain Compliance and Performance.

Strategic Objective (The full set of Trust objectives can be found at the beginning of the Board Reports)

Finance

1. Introduction

1.1 The purpose of this report is to inform the Board of Directors of the financial and contract performance position of the Trust for the period to 30 September 2015.


Financial Risk Rating

2.1 There is a new risk assessment framework in place and the financial performance against the Monitor plan is as follows:

2.2 Summary Financial Position - As at 30 September 2015 the Trust is reporting an operational deficit of £7.229m for the period, which is £3.641m behind the planned deficit for the period of £3.588m.

Draft

2

Income

2.3 There is an under recovery on income against the profiled plan of £176k at the end of September 2015.

The Trust’s income is showing an under recovery of £176k (0.13%)

Expenditure

2.4 To date, pay budgets are over spent against plan by £1,702k. Some spend in relation to locums and agency has continued to cover vacancies and maternity cover, but this has fallen compared to previous months due to corrective action from the Directorate management teams.

2.5 Non pay budgets are £848k under-spent for the period to 30 September 2015, with a worsening trend due to Directorates reducing budget for SIEP.

Service Improvement & Efficiency Programme

2.6 The gross Service Improvement & Efficiency Programme (SIEP) target for 2015/16 of £10.901m has been reduced to £6.648m. The Trust has delivered £4.402m of its in-year SIEP.

The Trust’s expenditure is showing an over-spend of £3,792k (2.9%)

Working Capital

2.7 Net cash outflow for the month was £5.488m, resulting in a decrease in cash from £31.436m to £25.948m as at 30 September 2015. The cash position has been affected by an increase in debtors of £2m, capital spend in month of £1.8m and the balance of £1.68m was due to the deterioration of the financial position (expenditure greater than income).

2.8 Net current assets at 30 September 2015 have decreased by £2.087m to £23.885m in month.

Summary

2.9 Financial performance has continued to be behind plan for the first six months of the financial year 2015/16. As part of the Financial Recovery Group each directorate has been set a control total to bring the financial position back to the level reported to Monitor of £7.3m. The Director of Finance, ICT and Support Services, Deputy Chief Executive and Director of HR are meeting with each budget holder to gain assurance over plans to deliver the reduced spend and to emphasise the importance of strong financial management. If specific directorates fail to achieve their revised control totals, this will be escalated to the Finance Committee.

3. Recommendations

3.1 The Board of Directors is requested to note the financial position as at Month 6, 30 September 2015. In addition, the Board of Directors are requested to note the analysis of performance against the new Financial Sustainability risk ratings, as detailed in Appendix 6 which demonstrates that the Trust is continuing to report a risk rating of 2. This position would have been a 3 had the metrics not changed, the new metrics indicate that the Trust is at material risk and Monitor may instigate a potential investigation.

Lynne Hodgson Director of Finance, ICT and Support Services

Draft

3



29 October 2015

Finance and Contract Performance Report as at 30 September 2015

Report of the Director of Finance, ICT and Support Services


1.1 The purpose of this report is to inform the Board of Directors of the financial and contract performance position of the Trust for the period to 30 September 2015.

2. Main content of report

Financial Risk Rating and Summary

2.1 There is a new risk assessment framework in place and the financial performance against the Monitor plan is as follows:

2.2 The previous metrics only used the first two measures and the Trust performance would have been an overall rating of 3, however, this has fallen to a 2 with the addition of the two new metrics focussing on income and expenditure (degree the organisation is producing a surplus or deficit) and the variance from the Trust plan.

2.3 The table below illustrates that current performance metrics result in a Financial Sustainability Risk Rating of 2 for the period to 30 September 2015, which is the same as the previous month.

Draft

4

Continuity of Services Risk Rating (CSRR)

Area of Review

Month 12 PlanMonth 6

YTD

Month 12

Projection

I&E Margin

(25%)1 1 1

Variance in I&E Margin

(25%)4 1 1

Year to Date Financial Risk Rating (FRR)

2

2

1

4

Capital Service Capacity

(25%)

Overall Financial Risk Rating

2

4Liquidity

(25%)

2 2

4

2.4 A more detailed analysis of the new Financial Sustainability Risk rating is attached at Appendix 6. This appendix includes a rolling forecast of the risk rating over the next 12 months, however, with the two additional metrics that have been added the Trust is not expecting to be higher than a rating of 2 for the reminder of the year. This suggests the Trust is classed as a material risk and is subject to potential investigation from Monitor.

2.5 Summary Financial Position - As at 30 September 2015 the Trust is reporting an

operational deficit of £7.229m for the period, which is £3.641m behind the planned deficit for the period of £3.588m.

2.6 The summarised financial performance is presented as per previous reports in Appendix 1.

Income Performance 2.7 There is an under recovery on income against the profiled plan of £176k at the end of

September 2015. Detailed analysis is provided in Appendix 11. 2.8 The projected income from CCGs as at 30 September 2015 is based on the expected

contract values for the majority of points of delivery for September.

2.9 Income from CCG agreements is under recovered by £1,311k. There is an under performance against the HAST contract of £448k which is due to increased non elective activity in Medicine and Trauma and Orthopaedics, offset by reduced elective work and OP attendances. The DDES contract continues to over perform, by £747k. This is due to increased elective, non elective and day case activity across most specialties.

2.10 The risk income target faced by the Trust for the first six months of the year is £1,895k.

Additional income of £320k has been achieved from the profit realised from dispensing excluded drugs and £250k has been anticipated in achieving full CQUIN. As there is an element of risk associated with this it has not been reflected against the individual commissioners, however, this is still behind plan. An additional £1,000k of income that has not yet materialised has been reflected in the financial position. Indication suggests further allocation to recognise the pressure providers are experiencing is likely to materialise. Bariatric surgery from South Tees FT is also underperforming by £146k.

Draft

5

2.11 A review of Non Contracted Activity has been completed and all income is being recovered.

2.12 Other income from patient care is in line with plan.

2.13 Income from non-patient care (commercial income) is over recovered by £1,135k. There is an under recovery attributable to car parking income mainly attributable to the phasing of the budget as higher income is expected in the winter months, however, this is offset by a larger than expected Injury Cost recovery and £1,400k of the deferred government grant has been factored into the position.

CQUIN and Penalties

2.14 A summary of the measures used to earn additional income to the Trust in the form of CQUIN, and the penalties that the Trust may be required to pay if the elements of the contracts relating to performance targets and information requested are not met, is reflected in Appendix 11 detailing the impact on income. Monitor have advised that Trusts will not be penalised for admitted and non admitted RTT standards and this is to be backdated to the beginning of the financial year. This has removed the risk of penalties totalling £17k for the first six months of the year.

The Trust’s income is showing an under recovery of £176k (0.13%)

Expenditure

Pay:

2.15 To date pay budgets are over spent against plan by £1,702k (after the phased element of the £1.5m non-recurring vacancies factor is taken into account).

2.16 The main area of risk has been recourse to locum staff at premium rates in areas where recruitment is difficult. Where appropriate, and subject to validation, the additional locum costs will be funded in year from the locum contingency reserve approved by the Board in April 2015, however, this is significantly reduced on previous years and any overspends are reflected in the directorate positions. Some spend in relation to locums and agency has continued to cover vacancies and maternity cover, but this has fallen compared to previous months due to corrective action from the directorate management teams.

2.17 The pressure on pay budgets has reduced slightly as a result of the action plans implemented by management teams, with the overspend on pay of £1.7m compared to that of £1.4m at the end of August. The supplementary pay bill was on average £1.4m per month in the first five months of the year, but this has fallen to £1.0m in September. Notably, pharmacy has seen the largest reduction, having made successful appointments to substantive posts. An investigation into some additional training posts seen in four directorates is underway, as “doubling up” of trainees in the changeover month is not usual practice. The vacancy factor of £1.5m for the year has an impact at month 6 of £750k.

2.18 A break down of the employee benefit expense analysis (by value and WTE) is presented in Appendix 9 and highlights expenditure trends on agency, locum, bank, and overtime.

2.19 A graphical presentation of payroll numbers and WTEs for the period to 30 September 2015 and comparison to the previous 12 months is presented at Appendix 10.

2.20 £80k was released from reserves this month to fund locums. The total cost of locum cover was £1,838k and is summarised in Table 2:

Draft

6

Table 2 – Summary of Locum Funding at Month 6

DirectorateAs at

Month 6Vacancies Sickness

Maternity

Other

Released

from

reserves

Premium

Charge for

Locum

£ £ £ £ £

ACCIDENT AND EMERGENCY 117,259 117,259 0 66,447

ANAESTHETICS 57,642 57,642 27,535 50,645

MEDICINE 507,823 407,823 100,000 109,541 378,966

OBS AND GYNAE 104,963 104,963 0 32,748

ORTHOPAEDICS 397,677 397,677 103,460 302,458

PAEDIATRICS 33,720 33,720 0 23,643

PATHOLOGY 171,416 171,416 19,772 145,339

PHARMACY - - 0

RADIOLOGY 41,884 41,884 0 1,327

SURGERY AND UROLOGY 405,257 405,257 207,103 262,935

Total Locum Spend 1,837,641 1,737,641 - 100,000 467,411 1,264,506

Non Pay:

2.21 Non pay budgets are £848k under spent for the period to the end of September 2015. £306k has been removed from non-pay budgets to deliver SIEP and there has been significant additional spend on Clinical Support Services.

2.22 Non pay budgets will continue to be closely monitored throughout 2015/16, however, pressures that materialised in 2014/15 were recognised and funded in budget setting and realistic inflation levels were applied. The favourable variance in the first six months of the year demonstrates the impact of this detailed planning.

2.23 A summary of expenditure by directorate is presented at Appendix 2, positive variances being highlighted in black and adverse movements being highlighted in red.

Service Improvement & Efficiency Programme

2.24 The gross Service Improvement & Efficiency Programme (SIEP) budget for 2015/16 of £10.901m has been reduced to £6.648m as a result of recurrent and non recurrent schemes actioned during the month. The Trust is phasing in the non-delivery of the SIEP over the period of the financial year to avoid any adverse movement in the position towards the year end. The Trust has delivered £4.402m of its in-year SIEP, of which £2.142m (49%) was recurrent and £2.111m (48%) was non recurrent, with the balance of £0.149m (3%) being cash releasing cost avoidance.

2.25 There are two programmes of work: directorate specific programmes and a transformational programme.

2.26 For the directorate specific programmes a target of £6.630m of savings has been set for the year. At month 6, £3.957m of savings has been made (of which, £2.142m (54%) is recurrent and £1.815m (46%) is non-recurrent).

2.27 For the transformational programmes the target is £4.273m of savings to be achieved. At month 6 some cost avoidance schemes have started to deliver and will continue to be monitored by the Transformation Committee. To date £296k has been delivered through

Draft

7

VAT rebates and is shown against Transformation non pay expenditure in the financial position and there has been £149k of cost avoidance schemes.

2.28 The corporate schemes are being led by the Transformation Change Director, including the administration and clerical review, workforce information system, culture and local improvement system (LIS) and Integrated Care Pathways.

2.29 Further work on identifying and delivering recurrent SIEPs continues. The risk adjusted probability of delivery of SIEP totals £6.129m and additional plans need to be identified.

Reserves

2.30 The position reported includes the application of slippage on reserves/contingencies. If performance continues on the current trajectory and the worst case scenario came to fruition the Trust would deliver a deficit of £15m. The most likely case is a deficit of £10.7m and with the planned corrective actions the Trust is expected to report a £7.3m deficit at the year end, assuming the initiatives deliver. This is in line with the position as reported to Monitor in month 3.

The Trust’s expenditure is showing an over spend of £3,7912 (2.9%)

EBITDA (earnings before interest, taxes, depreciation & amortisation)

2.31 The Trust has generated an EBITDA of £(2.450m) at month 6, £3.968m behind plan, resulting in an EBITDA margin of (1.83)%, against a planned margin of 2.0%.

Depreciation, PDC Dividend and Interest Receivable

2.32 Depreciation costs and PDC payable to the DH are £2,885k and £1,890k (respectively). Depreciation costs are slightly less than plan as a result of an in depth review of the valuation of the Trust’s asset base and the independent valuation of the estate by the District Valuer. A full physical verification exercise is currently underway.

2.33 The Trust has generated interest receivable on investments at the end of Month 6 of £57k, which is slightly below plan, however, interest rates remain at a historically low level preventing improved investments being made. This target will be kept under review as the year progresses and will remain the focus of the Investment Committee.

Cash Flow, Working Capital & Balance Sheet

2.34 Cash flow – The cash flow statement with actual figures for September 2015 is presented at Appendix 4. There has been a net cash outflow from the end of the last quarter resulting in a decrease of cash from £29.598m to £25.948m as at 30 September 2015. The Trust has accrued income of c£4.8m which will materialise in future months.

2.35 Current assets – A decrease of £5,437k from the end of the last quarter. Stocks have increased by £10k during the six month period, debtors have decreased by £1,210k and accrued income / prepayments have decreased by £587k. The balance of the change in current assets relates to the decrease in cash of £3,650k.

2.36 Current liabilities – A decrease of £1,189k from the end of the last quarter. Creditors have increased by £1,055k and the PDC dividend creditor decreased by £989k as the 6 month payment was made. Current borrowings and lease commitments have decreased by £22k and accruals have decreased by £1,069k. Deferred income has decreased by £234k and current provisions have increased by £70k.

Draft

8

2.37 Net current assets at 30 September have decreased by £4,248k from the end of the last quarter to £23.885m overall.

2.38 Presented at Appendix 3 is the balance sheet for the year to 30 September 2015, with a comparison to the previous month and Month 12 position for 2014/15.

Capital

2.39 The capital allocation for 2015/16 is £10.798m of which £6.447m is internally generated ‘block capital’ with a carry forward from 2014/15 of £2.201m. The balance reflects £0.15m of donated funds and £2.0m of external financing.

2.40 The Trust has spent £4.163m in the financial year, with further commitments of £1.577m identified. Additions of £1.831m in month include the EPR milestone payment and CCU monitors.

2.41 The capital position is summarised in Appendix 5.

Financial Indicators

2.42 A detailed pack of additional key financial indicators is provided for information at Appendix 7 to 11.

These include:

Performance against Monitor’s Compliance Framework (Appendix 7);

Performance against the Better Practice Payment Code (Appendix 8);

Analysis of the employee benefit expense (Appendix 9);

WTE Comparison graph (Appendix 10); and

Income Statement by Commissioner (Appendix 11).


3.1 Financial performance has continued to be behind plan for the first six months of the financial year 2015/16. As part of the Financial Recovery Group each directorate has been set a control total to bring the financial position back to the level reported to Monitor of £7.3m. The Director of Finance, ICT and Support Services, Deputy Chief Executive and Director of HR are meeting with each budget holder to gain assurance over plans to deliver the reduced spend and to emphasise the importance of strong financial management. If specific directorates fail to achieve their revised control totals, this will be escalated to the Finance Committee.

3.2 Operational pay budgets for the directorates are under pressure, and are behind plan, and this will be one of the main discussion points at the meetings with the Clinical Directorates.

4. Recommendation

4.1 The Board of Directors is requested to note the financial position as at Month 6, 30 September 2015. In addition, the Board of Directors are requested to note the analysis of performance against the new Financial Sustainability risk ratings, as detailed in Appendix 6 which demonstrates that the Trust is continuing to report a risk rating of 2. This position would have been a 3 had the metrics not changed, the new metrics indicates the Trust is at material risk and Monitor may instigate a potential investigation.

Lynne Hodgson Director of Finance, ICT and Support Services

Draft

APPENDIX 1

Original Budget

SettingAnnual Budget Budget to Date Actual to Date Variance

Variance

Previous

Month

Income £000 £000 £000 £000 £000 £000

Commissioning Agreements (230,248) (232,126) (115,025) (113,714) (1,311) (1,355)

Other Income from Patient Care (306) (306) (153) (153) 0 0

Other Income from Non Patient Care (22,732) (21,964) (11,135) (12,270) 1,135 945

Passthrough Reserve (16,461) (16,855) (7,745) (7,745) 0 0

Total Income (269,747) (271,251) (134,058) (133,882) (176) (410)

Expenditure

Pay 185,459 186,885 93,464 95,166 (1,702) (1,393)

Non Pay 63,476 73,817 34,269 33,421 848 1,144

Passthrough Expenditure 16,461 9,110 7,745 7,745 0 0

Reserves 9,958 2,725 0 0

Hosted Services - Audit North (net position) 0 0 0SIEP (10,901) (6,648) (2,939) 0 (2,939) (3,344)

Total Expenditure 264,453 265,889 132,539 136,332 (3,792) (3,593)

EBITDA 5,294 5,362 1,519 (2,450) (3,968) (4,003)

Depreciation 6,324 6,324 3,162 2,885 278 81

Interest Payable Loans & Leases 192 260 130 61 69 57

PDC 3,780 3,780 1,890 1,890 (1) (1)

Interest Receivable (150) (150) (75) (57) (19) (16)

Operational Surplus / (Deficit) (4,852) (4,852) (3,588) (7,229) (3,641) (3,882)

EBITDA 5,294 5,362 1,519 (2,450)

EBITDA Margin % 2.0% 2% 1% -1.83%

EBITDA % Achieved -161.33%

I&E Margin -1.80% -1.79% -2.68% -5.40%

ROA -4.02% -5.94% -10.27%

Operating Expenditure YTD (136,332)

Income & Expenditure Summary as at September 2015

Draft

APPENDIX 2

Directorate Annual Budget Budget to

September

Actual to

SeptemberVariance

Variance Previous

Month

£ £ £ £ £

INCOME

ACCIDENT AND EMERGENCY 0 0 (5,003) 5,003 4,946ANAESTHETICS (14,487) (7,242) (6,694) (548) 524CENTRAL EXPENDITURE 0 0 (1,384) 1,384 0CENTRAL INCOME (15,792,874) (7,800,202) (7,935,501) 135,299 (669,568)CONTRACT INCOME (245,230,205) (120,893,772) (120,764,465) (129,307) 441,879EAU & AMBULATORY CARE 0 0 (750) 750 4,725EDUCATION & ORGANISATION DEVELOPMENT (3,087) (1,542) (36,566) 35,024 35,281ENDOSCOPY (3,600) (1,800) (1,513) (287) 13ESTATES (5,129,852) (2,717,706) (2,454,466) (263,240) (215,088)FINANCE & ICT (574,034) (288,803) (282,992) (5,811) (38,810)HUMAN RESOURCES 0 0 7,530 (7,530) (7,530)IN HOSPITAL CARE (231,977) (115,990) (134,442) 18,452 12,778OUT OF HOSPITAL CARE (3,431) (1,716) (7,604) 5,888 19,323 NURSING AND PATIENT SAFETY (97,134) (48,570) (30,183) (18,387) 4,386OBS AND GYNAE (24,176) (24,176) (45,798) 21,622 (12,662)ORTHOPAEDICS (1,038,025) (464,214) (449,307) (14,907) 16,940OUTPATIENTS 0 0 (437) 437 118PAEDIATRICS (31,451) (31,451) (31,493) 42 0PATHOLOGY (260,240) (150,124) (163,209) 13,085 (5,871)PHARMACY (1,620,684) (810,342) (810,312) (30) (17,381)RADIOLOGY (134,412) (67,212) (49,937) (17,275) (14,429)RESEARCH AND DEVELOPMENT (729,192) (389,565) (425,958) 36,393 21,058SURGERY AND UROLOGY (102,473) (54,473) (54,723) 250 0TRANSFORMATION (231,069) (189,159) (196,452) 7,293 9,449Total Income (271,252,403) (134,058,059) (133,881,659) (176,400) (409,919)

PAY EXPENDITURE 0ACCIDENT AND EMERGENCY 6,566,169 3,288,201 3,395,560 (107,359) (91,367)

= ANAESTHETICS 16,648,373 8,292,718 8,630,544 (337,826) (325,965)CENTRAL EXPENDITURE 848,248 423,822 294,058 129,764 142,417CHIEF EXECUTIVE 713,943 356,279 322,257 34,022 29,083EAU & AMBULATORY CARE 8,799,968 4,408,484 4,742,239 (333,755) (275,024)EDUCATION & ORGANISATION DEVELOPMENT 2,429,216 1,209,703 1,170,743 38,960 12,151ENDOSCOPY 2,843,267 1,401,231 1,326,953 74,278 18,375ESTATES 13,341,536 6,661,492 6,594,487 67,005 47,172FINANCE & ICT 6,706,319 3,337,174 3,238,520 98,654 132,332HUMAN RESOURCES 821,667 407,562 388,743 18,819 15,437IN HOSPITAL CARE 23,491,153 11,705,945 11,972,624 (266,679) (344,706)OUT OF HOSPITAL CARE 34,641,556 17,001,660 16,788,546 213,114 482,834MEDICAL DIRECTOR 99,311 49,266 49,205 61 23NURSING AND PATIENT SAFETY 3,364,507 1,817,083 1,822,281 (5,198) (54,333)OBS AND GYNAE 11,721,425 5,866,017 5,592,642 273,375 221,439ORTHOPAEDICS 10,416,505 5,275,062 5,503,921 (228,859) (344,624)OUTPATIENTS 1,034,796 516,727 500,646 16,081 12,612PAEDIATRICS 9,544,591 4,803,406 4,776,400 27,006 67,778PATHOLOGY 7,017,282 3,514,944 3,819,831 (304,887) (255,522)PHARMACY 3,749,093 1,869,366 1,869,061 305 (30,052)RADIOLOGY 9,036,996 4,494,551 4,675,946 (181,395) (172,173)RESEARCH AND DEVELOPMENT 433,774 407,609 446,495 (38,886) (23,001)STRATEGY, OPERATIONS & PERFORMANCE 2,522,535 1,256,275 1,139,668 116,607 77,608SURGERY AND UROLOGY 11,295,528 5,660,680 5,904,638 (243,958) (109,772)TRANSFORMATION 297,019 189,092 200,144 (11,052) (760)VACANCY FACTOR (1,500,000) (750,000) (750,000) (625,000)Total Pay Exp'd 186,884,777 93,464,349 95,166,152 (1,701,803) (1,393,038)

Directorate Summary Position as at September 2015

Draft

APPENDIX 2

Directorate Annual Budget Budget to

September

Actual to

SeptemberVariance

Variance Previous

Month

Directorate Summary Position as at September 2015

NON PAY EXPENDITURE (INCLUDING PASSTHROUGH EXPENDITURE)

ACCIDENT AND EMERGENCY 708,513 355,350 364,835 (9,485) (3,035)ANAESTHETICS 5,203,939 2,563,549 2,572,937 (9,388) 89,379CENTRAL EXPENDITURE 5,240 202,730 252,241 (49,511) (9,282)CHIEF EXECUTIVE 216,939 108,444 71,270 37,174 9,493EAU & AMBULATORY CARE 1,429,156 783,426 703,667 79,759 33,810EDUCATION & ORGANISATION DEVELOPMENT 537,022 303,300 301,122 2,178 12,750ENDOSCOPY 1,629,506 829,230 752,284 76,946 68,249ESTATES 9,823,580 5,039,008 4,867,161 171,847 244,606FINANCE & ICT 11,697,242 6,813,982 6,740,157 73,825 27,179HUMAN RESOURCES 213,898 106,914 94,237 12,677 6,881IN HOSPITAL CARE 11,025,924 8,857,518 8,858,161 (643) (41,386)OUT OF HOSPITAL CARE 6,872,295 3,556,695 3,458,333 98,362 61,985MEDICAL DIRECTOR 5,300 2,652 89 2,563 2,121NURSING AND PATIENT SAFETY 273,442 148,175 167,102 (18,927) 8,381OBS AND GYNAE 1,785,966 1,017,001 944,760 72,241 (24,524)ORTHOPAEDICS 6,674,881 3,304,239 2,992,742 311,497 333,272OUTPATIENTS 465,629 297,396 286,253 11,143 1,200PAEDIATRICS 1,319,946 783,391 743,330 40,061 13,900PATHOLOGY 5,476,489 2,761,751 2,914,058 (152,307) (116,192)PHARMACY 763,375 381,105 404,219 (23,114) 13,754RADIOLOGY 5,375,714 2,694,512 2,661,730 32,782 41,322RESEARCH AND DEVELOPMENT 27,153 18,060 14,468 3,592 1,943STRATEGY, OPERATIONS & PERFORMANCE 118,605 72,995 69,916 3,079 (23,619)SURGERY AND UROLOGY 2,392,358 1,238,453 1,154,838 83,615 80,378TRANSFORMATION (224,685) (225,976) (223,099) (2,877) 311,503Total Non Pay Exp'd 73,817,427 42,013,900 41,166,811 847,089 1,144,068

Draft

APPENDIX 3

Statement of Financial Position (Balance Sheet)

Previous Month Actual

£000's £000's £000's

Assets, Non-Current

Intangible Assets, Net 177 131 122Property, Plant and Equipment, Net 117,464 117,332 118,850Assets under Construction 518 518 518On balance sheet PFI assets, Non-Current

PFI: Property, Plant and Equipment, Net 376 333 324Trade and Other Receivables, Net, Non-Current

NHS Receivables (Related Party), Non-Current 0Assets, Non-Current, Total 118,535 118,314 119,814

Assets, Current

Inventories 7,935 7,532 7,785Trade and Other Receivables, Net, Current

NHS Trade Receivables (Related Party), Current 6,119 4,890 6,392Non NHS Trade Receivables, Current 1,034 899 1,539Other Receivables, Current 500 391 213

Other Financial Assets, Current

Accrued Income 1,160 5,752 4,804Prepayments, Current

Prepayments, Current, non-PFI related 2,198 4,050 4,019Cash and Cash Equivalents

Cash 37,475 31,436 25,948Assets, Current, Total 56,421 54,950 50,700

ASSETS, TOTAL 174,956 173,264 170,514

Deferred Income, Current (1,861) (1)Provisions, Current (612) (615) (542)Current Tax Payables

Trade and Other Payables, Current

Trade Creditors, Current (8,753) (8,394) (8,803)Other Creditors, Current (3,494) (7,556) (8,198)Capital Creditors, Current (287) (340) (532)

Other Financial Liabilities, Current

Accruals, Current (8,783) (10,268) (8,578)Borrowings, Current (22) (23) 0PFI leases, Current (162) (162) (162)PDC dividend creditor, Current (44) (1,619) 0

Liabilities, Current, Total (24,018) (28,978) (26,815)

NET CURRENT ASSETS (LIABILITIES) 32,403 25,972 23,885

Liabilities, Non-Current

Deferred Income, Non-Current (5,771) (5,953) (6,002)Provisions, Non-Current (1,378) (1,206) (1,206)Trade and Other Payables, Non-Current

Other Creditors, Non-Current

Other Financial Liabilities, Non-CurrentPFI leases, Non-Current (479) (629) (410)Borrowings, Non-Current 0 0 0

Liabilities, Non-Current, Total (7,628) (7,788) (7,618)

TOTAL ASSETS EMPLOYED 143,310 136,498 136,081

Taxpayers Equity

Public dividend capital 130,906 130,906 130,906Retained Earnings (Accumulated Losses) 11,569 4,757 4,340Revaluation Reserve 835 835 835

TAXPAYERS EQUITY, TOTAL 143,310 136,498 136,081

March 2015 September 2015

Commissioning Agreements

Liabilities

Taxpayers' and Others' Equity

Draft

APPENDIX 4

Statement of Cash Flow

Actual£000

Commissioning AgreementsSurplus/(deficit) after tax (3,976) (7,229)

Non-cash flows in operating surplus/(deficit)

Finance income/(charges) (17) 4

Depreciation and amortisation, total 5,303 2,885

PDC dividend expense 3,164 1,890

Other increases/(decreases) to reconcile to profit/(loss) from operations

Non-cash flows in operating surplus/(deficit), Total

Operating Cash flows before movements in working capital 4,474 (2,450)

Increase/(Decrease) in working capital

(Increase)/decrease in inventories (651) 150

(Increase)/decrease in NHS Trade Receivables (342) (273)

(Increase)/decrease in Non NHS Trade Receivables (292) (505)

(Increase)/decrease in other receivables 165 287

(Increase)/decrease in accrued income 113 (3,644)

(Increase)/decrease in prepayments (274) (1,821)

Increase/(decrease) in Deferred Income (excl. Donated Assets) (2,680) (1,630)

Increase/(decrease) in provisions (31) (242)

Increase/(decrease) in PDC Creditor 0 (44)

Increase/(decrease) in Trade Creditors 2,407 50

Increase/(decrease) in Other Creditors & Payments on Account (1,909) 4,704

Increase/(decrease) in accruals 2,710 (205)

Increase/(decrease) in other Other Financial liabilities 0 (22)

Increase/(decrease) in Other liabilities (non charitable assets) 0 0

Increase/(Decrease) in working capital, Total (784) (3,195)

Net cash inflow/(outflow) from operating activities

Net cash inflow/(outflow) from investing activitiesProperty, plant and equipment - maintenance expenditure (11,156) (4,163)

Property, plant and equipment - donated 207 23

Increase/(decrease) in Capital Creditors (113) 245

(7,371) (9,540)

Net cash inflow/(outflow) before financing

Net cash inflow/(outflow) from financing activities

PDC Dividends paid /movement (3,164) (1,934)

Interest element of finance lease rental payments - On-balance sheet PFI (134) (48)

Capital element of finance lease rental payments - On-balance sheet PFI (145) (62)

Interest received on cash and cash equivalents 151 57

Repayment of Commercial Loans (74) 0

(Increase)/decrease in non-current receivables 0 0

PDC Received 7,134 0

Increase/(decrease) in non-current payables 0 0

Other cash flows from financing activities (31) 0

Net cash inflow/(outflow) from financing activities, Total 3,737 (1,987)

Net increase/(decrease) in cash and cash equivalents (3,649) (11,527)

Opening cash 41,109 37,475

Effect of exchange rates 0 0

Closing cash 37,475 25,948

Analysis of Cash Balances

Organisation Amount £000

Lloyds - Commercial bank Commercial bank 79

Lloyds - Fixed Term deposit Fixed Term deposit

Barclays High Interest Deposit Instant

NLF Fixed Term HM Treasury 15,000

Government Banking GBS Bank 10,869

Cash in hand

Petty cash, franking

machines, unpresented

cheques and undeposited

25,948

March 2015 September 2015

£000

Nature of Deposit

Total

Draft

APPENDIX 5

Capital Position as at September 2015

CategoryAllocated

Funding

Budget

£000s

Invoices &

Accruals

£000s

Orders Raised

£000s

Earmarked

£000s

Committed in

2015/16

£000s

Uncommitted

£000s

Medical Equipment

Current Allocation 1,280 316 164 - 480 800

Prior Year Allocation 296 231 93 - 324 (28)

Total Medical Equipment 1,576 547 257 - 804 772

ICT

EPR Allocation 4,063 2,152 1,037 - 3,189 874

ICT Rolling Programme 521 253 - - 253 268

(1) (1) - (1) -

Total ICT 4,583 2,404 1,037 - 3,441 1,142

Service Development /Transformation

Reconfiguration Plan 1,398 - 43 - 43 1,355

Current Allocation 1,825 120 10 - 130 1,695

Prior Year Allocation - Service Development 244 155 49 204 40

Total Service Development 3,467 275 102 - 377 3,090

Estates

Compliance 153 55 32 - 87 66

Energy 80 10 - - 10 70

Infastructure 238 143 63 - 206 32

PEAT 260 440 13 - 453 (193)

Other 291 266 73 - 339 (48)

Total Estates 1,022 914 181 - 1,095 (73)

Donated - Funding via Charitable Funds 150 23 - 23 127

GRAND TOTAL 10,798 4,163 1,577 - 5,740 5,058

Memorandum Item: £'000

Internally Generated Depreciation 6,447

Donated Funds 150

External Financing 2,000

EPR - Funding c/f 2,201

Total Allocation 10,798

Year to Date

Draft

APPENDIX 6


Area of Review


YTD

Month 12

Projection

I&E Margin

(25%)1 1 1

Variance in I&E Margin

(25%)4 1 1

Rolling Forecast of the Continuity of Services Risk Rating (CSRR) for the next 12 months

Q1 Q2 Q3 Q4 Q1

2015/16 2015/16 2015/16 2015/16 2016/17

Capital Servicing

Capital Servicing Capacity 2 1 1 1 1 13 3 3 3 3

Liquidity

Liquidity Days Rating 4 4 4 4 4 4

Underlying Performance

I&E Margin 1 1 1 1 1 1

Variance from Plan

Variance in I&E Margin 4 1 1 1 1 1

Weighted Average Rating 2 2 2 2 2 2

CONTINUITY OF SERVICES RISK RATING 2 2 2 2 2 2


2

2

1

Area of Review

4

Draft Annual Plan

Capital Service Capacity

(25%)


2

4Liquidity

(25%)

2 2

4

Draft

APPENDIX 7

Finance Risk Indicators (Best Practice - no longer mandated by Monitor)

Category Status

Unplanned decrease in quarterly EBITDA margin in two

consecutive quarters

Quarterly self-certification by Trust that CSRR may be less than

3 in the next 12 months

CSRR 2 for any one quarter

Working capital facility (WCF) agreements includes default

clause

Two or more changes in Finance Director in 1 12 month period

Interim Finance Director in place over more than one quarter

end

Quarter end cash balance less than 10 days of operating

expenses

Capital expenditure is less than 85% of plan for the year to

dateRequired by Monitor

Capital expenditure is greater than 115% of plan for year to

dateRequired by Monitor

Debtors > 90 days past due account for more than 5% of total

debtor balances

Creditors > 90 days past due account for more than 5% of total

creditor balances

Summary Points

There have been capital additions of £1.8m in month mainly due to the ramping up of work in preparation for the go live of Electronic Patient Records (EPR) in October.

The Trust plans to achieve the Monitor Metric for Capital and the spend profile for the rest of the year will bring the Trust position back within the target metrics by the year end.

On target

Currently 133% greater than plan for year to date

Description

Commentary on Compliance Framework Indicator

Not applicable

Not applicable

On target

On target

Not applicable

Not applicable

Not applicable

Not applicable

Not applicable

Draft

APPENDIX 8

Month

April 95.0 95.0 94.0May 95.0 99.6 98.4June 95.0 98.7 94.2July 95.0 97.9 96.3August 95.0 96.0 91.1September 95.0 93.7 80.0October 95.0November 95.0December 95.0January 95.0February 95.0March 95.0

Total Cumulative 95.0 97.0 92.0

95.095.0

95.0

95.0

Better Practice Payment Code (BPPC) by Invoice value and count

To pay 95% of all NHS and non-NHS trade creditors within 30 days receipt of the goods or a valid invoice

% Bills Paid Volume % Bills Paid Value

Plan Plan ValueVolume

95.095.095.095.0

95.095.095.095.095.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

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

Pe

rce

nta

ge

(%

)

Better Payment Performance (Volume)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0


Pe

rce

nta

ge

(%

)

Better Payment Performance (Invoice)

Draft

APPENDIX 9

Employee Benefit Expense Analysis (£)

Employee Benefit Expense (£)

Budget

2015/16

£m

Actual

2015/16

£m

Variance

2015/16

£m

Budget

2015/16

£m

Actual

2015/16

£m

Variance

2015/16

£m

Medical 3.74 4.11 (0.36) 22.53 25.96 (3.43)

Nursing & Midwifery 5.82 5.79 0.03 36.33 35.42 0.91

Other clinical staff 1.09 1.08 0.01 6.68 6.64 0.04

Scientific, Therapeutic & Technical 2.34 2.30 0.04 14.91 14.38 0.53

Director & Senior manager 0.51 0.51 0.00 2.93 2.94 0.00

Admin and Clerical 1.76 1.66 0.10 10.83 9.83 1.01

Vacancy factor (0.13) 0.00 (0.13) (0.75) 0.00 (0.75)

Total 15.13 15.45 (0.31) 93.46 95.17 (1.71)

Employee Benefit Expense Analysis (WTE)

Employee Benefit Expense (WTE)

Budget

2015-16

WTE

Actual

2015-16

WTE

Variance 2015-

16

WTE

Current

Month (%)

Cumulative

position (%)

over the last 6

months of the

year

Target (%)

Medical 527 602 (75)

Nursing & Midwifery 2,012 1,918 94 2.26 < 3

Other clinical staff 586 583 3

Scientific, Therapeutic & Technical 833 780 53

Director & Senior manager 82 80 2

Admin and Clerical 878 807 71

Other pay

Total 4,918 4,770 148

Analysis of Overtime, Locum, Bank & Agency

Analysis of Supplementary Pay Bill In-MonthYear to

Date

Monthly

Average

Monthly

AverageActual

2015/16

£m

Actual

2015/16

£m

Actual

2015/16

£m

Actual

2014/15

£m

Agency (not Nursing) 278,003 1,471,287 245,215 166,993

Agency Nursing 131,589 627,023 104,504 106,679

Locum Expenditure 167,411 1,893,636 315,606 310,523

Total over-time (not Nursing) 97,648 525,880 87,647 50,258

Bank expenditure 259,030 1,450,943 241,824 279,251

Nursing over-time 69,197 451,368 75,228 32,683

Total 1,002,878 6,420,137 1,070,024 946,387

In-Month Year to Date

In-Month% of Agency Nursing as total of

Nursing Spend

Additional Monitor Metric

Draft

APPENDIX 10

0

WTE Comparison Graph

Agency, Bank and Locum Spend £'000

4,500.00

4,550.00

4,600.00

4,650.00

4,700.00

4,750.00

4,800.00

4,850.00

4,900.00

4,950.00

5,000.00

5,050.00

5,100.00

WT

E's

Month

September 2013 - September 2015

Total Budgeted Wte'sTotal Contracted Wte'sTotal Actual (Worked) Wte's

0.00

100.00

200.00

300.00

400.00

500.00

600.00

700.00

800.00

£'000

Month

Locum £'000 Bank £'000

Agency £'000

Draft

Appendix 11

Commissioner2015/16

Budget

Annual

Budget

Budget to

date

Actual to

dateVariance

Variance

Previous

Month

Movement

£000 £000 £000 £000 £000 £000 £000

NHS Durham Dales, Easington and Sedgefield CCG 35,003 33,634 16,739 17,486 747 486 261

NHS Hartlepool and Stockton-on-Tees CCG 167,538 161,224 79,924 79,476 (448) 33 (481)

Cumbria, Northumberland, Tyne and Wear, Durham,

Darlington and Tees Area Team 26,760 18,056 9,923 9,279 (644) (53) (591)

Other CCGs (individually less than £5m) 5,645 5,536 2,767 2,658 (109) (78) (31)

Non Contract Activity Income (CCGs)

1,899 2,023 1,023 802 (221) (180) (41)

Other LATs (individually less than £5m) 198 198 99 101 2 2 (0)Other Foundation Trusts 950 950 475 329 (146) (152) 6Public Health England 1,560 1,560 617 459 (158) (125) (33)Risk Income 2,000 3,789 1,895 1,570 (325) (1,223) 898Local Authorities

Hartlepool Council 1,780 1,780 404 445 41 4 37Middlesbrough Council 144 144 72 72 (0) 0 (0)Redcar and Cleveland Council 132 132 66 66 0 0 0Stockton Council 3,100 3,100 1,021 971 (50) (69) 19

232,126 115,025 113,714 (1,311) (1,355) 44

Passthrough drugs and devices and other costs - 16,855 7,745 7,745 0 0 0

Contract income 246,709 248,981 122,770 121,459 (1,311) (1,355) 44

Other

Private Patients 134 134 67 67 0 0 0TEWV Radiology and Pathology 72 72 36 36 0 0 0Depuy 100 100 50 50 0 0 0

Other income from patient care 306 306 153 153 0 0 0

Non Patient care income 22,732 21,964 11,135 12,270 1,135 945 190

Total income 269,747 271,251 134,058 133,882 (176) (410) 234

Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total

£ £ £ £ £

CQUIN - potential attainment (total) 351,922 1,246,951 1,232,102 2,123,995 4,954,970

NHS Durham Dales, Easington and Sedgefield CCG 56,593 208,428 200,990 342,475 808,486

NHS Hartlepool and Stockton-on-Tees CCG 267,634 985,668 950,497 1,619,588 3,823,387

Cumbria, Northumberland, Tyne and Wear, Durham,

Darlington and Tees Area Team 18,317 18,317 47,310 105,182 189,126

Other CCGs (individually less than £5m) 9,378 34,538 33,305 56,750 133,971

Penalties (maximum exposure) £

NHS Durham Dales, Easington and Sedgefield CCG 41,540 NHS Hartlepool and Stockton-on-Tees CCG 251,600

293,140

INCOME STATEMENT BY COMMISSIONER

Draft

1



29 October 2015

Human Resources and Education Report – Quarter 2: 2015/16

Report of the Director of Human Resources and Education

Executive Summary

Strategic Aim: (The full set of Trust Aims can be found at the beginning of the Board of Directors reports) Maintain Compliance and Performance

Strategic Objective: (The full set of Trust Objectives can be found at the beginning of Board of Directors reports) Effective Board Governance

1. Dashboard

The Trust headcount has decreased by 18 from 5393 at year-end 2014/15 to 5375 at the end of quarter 2 2015/16. The sickness absence rate for quarter 2 is 0.37% lower than the baseline figure at the end of March 2015; however at the time of compiling this report, sickness data for the full quarter was not available. Short and long term sickness absence rates have decreased in quarter 2 when compared to the baseline, however, the medium term sickness rate has increased.

2. Change in Workforce

The turnover rate has decreased in quarter 2 when compared to quarter 1, from 13.53% in June to 13.07% in September where the rate includes foundation doctors, and from 12.47% in June to 11.99% in September where the rate excludes foundation doctors. The number of new starters to the Trust in quarter 2 2015/16 has increased by 105 to 242 when compared to quarter 1 2015/16. There were fewer leavers in quarter 2 2015/16 (229) compared to quarter 2 2014/15 (249). End of Fixed Term Contract is the top reason for leaving.

3. Sickness

The top three sickness absence reasons for quarter 2 2015/16 are consistent with the reasons reported in quarter 1. The number of WTE days lost to sickness in quarter 2 has decreased by 3755.46 when compared to quarter 1 however, please note that the sickness absence information for September is not currently available, therefore quarter 2 figures are for July and August 2015 only. Regional sickness absence figures are only available up to quarter 1 2015/16 which shows that North Tees and Hartlepool continues to be below the regional average.

Draft

2

4. Mandatory Training

The Trust has achieved ‘green’ status in a wide range of topics including; Sepsis, Acute Kidney Injury, Fire awareness and Safeguarding Children level 1.

5. Electronic Workforce Solutions

The recruitment process for the Care Support Worker Development Programme began on 4 September. The STAFFFlow system was fully implemented across the Trust on 28 September.

6. Contract Negotiations for Consultants and Junior Doctors

The Department of Health have proposed plans to reform the contractual arrangements for consultants and junior doctors. The Department of Health/NHS Employers and representatives from the BMA are currently negotiating on proposed changes.

7. Recommendation

The Board of Directors are asked to note the content of and accept this report.

Ann Burrell

Director of HR & Education

Draft

3



29 October 2015

Human Resources and Education Report – Quarter 2: 2015/16

Report of the Director of Human Resources and Education

1. Electronic Workforce Solutions

1.1 Temporary Staffing

The Care Support Worker Development Programme, in conjunction with NHSP, provides successful applicants with the opportunity to become a care support worker. The programme went out to advert on 4th September 2015 with interviews scheduled on 15th October 2015. Successful candidates will start their initial training on the 7th December 2015 and are scheduled to start the 3 to 6-month programme week commencing 4th January 2016. Once they have completed the programme they will be eligible to join the bank.

The STAFFFlow system, a booking system for agency locum medical staff, went live in directorates on 21st September for those locums that will be employed on a PSC (Personal Services Company) contract. The system for those who will be employed on a PAYE contract went live week commencing 28th September. A total of £1,611.83 VAT savings have been made so far.

There are several types of locums not able to go through the direct engagement route, such as those on a sponsored visa, self-employed or under an umbrella company who will remain contracted through an agency. The booking can still go through the system for transparency and reporting purposes. The system will also provide a control measure for preventing bookings with non-framework agencies.

2. Leadership and Management Development

The first cohort of Trust staff have successfully completed a two day decision making and problem solving course that was developed in conjunction with the Territorial Army (TA).

The aim of the course was to ensure that the participants:

Develop an understanding of how military decision-making has evolved. Understand the concept of the Estimate Process and how the 7Qs apply in practice. Apply the Estimate Process to address current challenges faced in the NHS.

Initial feedback from the participants was extremely positive. A full evaluation of the programme will be performed and will be reported in a future board report.

The Trust has continued to work collaboratively with the North East Leadership Academy (NELA) to influence and to access regional and national programmes as well

Draft

4

as playing a part in local leadership networks. Leadership programmes offered by NELA are well advertised and accessed by a wide range of staff across the Trust. The national funding framework for the higher level programmes has changed with a significant contribution expected by the Trust. This decision has resulted in a need to ensure a more targeted approach to accessing leadership programmes is in place, therefore helping to ensure that positive outcomes are maximised.

During quarter 2 the seventh cohort of the Practical skills for Managers Programme took place. The programme continues to be a huge success. The programme covers a wide range of practical topics to assist managers in their day to day duties, however, the programme remains under constant review and additional subjects are being added as a result of participant feedback.

3. Organisation Development

The Organisation Development (OD) team using the Local Improvement System (LIS) continue to support the Trust in number of high profile projects including;

6C Conference - This conference ‘Using the 6C’s to support behaviours that enhance the patient’s experience’ was formulated to showcase the achievements that the organisation had made in relation to the introduction of the 6C’s in practice and took place on the 29 July. It was hosted in partnership with Insights Discovery with whom the organisation had collaborated with during the ‘Investing in Behaviours’ programme and also Teesside University who provided the venue for the day. The conference was attended by 190 delegates from various professions across the Northern healthcare region and proved to be a great success as feedback from the attendees was excellent. It showcased the future direction that the Trust is taking with the Education and Organisation Development department taking over the 6C’s and the Care Makers events integrating them into the current work that is taking place. Care Makers event – The OD team held a care makers event in the style of a world café where care makers were asked to discuss topics regarding the role, development and resources needed to continue their care maker role. Although the event was not attended by as many care makers as was hoped for, the feedback was evaluated and will be used to enhance future activity. 6C training and Insights awareness – Following discussion with the Women and Children’s Services training lead and manager, the Local Improvement System (LIS) team continue to deliver mandatory training sessions combining 6C’s and Insight discovery to the midwifery, paediatric and neonate teams. Seven training sessions have been delivered to date with further dates planned in the diary for the next 6 months. Holdforth Unit - Following the CQC inspection, the LIS team were requested to support the staff in the unit. This support includes a member of the OD team to become interim ward manager for the Holdforth Unit to provide leadership and support to the staff. During quarter 2, the OD team worked closely with the Holdforth unit and facilitated staff engagement events to discuss with every staff member the existing culture within the unit and their vision for the unit. Feedback will be evaluated and the team plan to work with the local managers to create a plan of ‘you said- we did’ series of events. Team days – As the Trust continues to experience small and large scale change across all areas of the business, the need to work with individual teams to enhance team building and clarify roles and responsibilities grows. During quarter 2, the OD team have worked with a number of teams from across the Trust including facilitating a development day for finance to clarify roles and responsibilities.

Draft

5

The OD team are also using their expertise and experience to support and develop bespoke training days for Speech and Language Therapy and Women and Children’s Services (Midwifery and Paediatrics).

4. Organisation Culture

Following the presentation at the Executive Team strategic session, it has been agreed that the four priority areas that organisation culture group will focus upon will be:

Ensure all staff know how they do/can make a positive impact on patient care Building productive and effective relationships between individuals/teams and managers Recognise and celebrate good practice Communicate strategic vision and how individuals contribute

The culture group continues to meet regularly and has recently expanded to incorporate the work of the Improving Working Lives group as well as overseeing the distribution and analysis of the National Staff survey 2015.

5. FINEST

Two members of Education and Organisation Development department visited a world renowned interprofessional training ward in Linköping Sweden 23-25 September. The visit gave an insight into the set up and running of such a facility in order to replicate some of the practices in the Trust.

Interprofessional learning at the Clinical Training Ward is led by Johanna Dahlberg, Faculty of Health Sciences, Linköping University. Their approach to interprofessional training and working aims for the following learning goals to be achieved:

To achieve best value for the patient by making the team work effectively Distinguish between different professionals’ knowledge and skills, and realise the significance of this knowledge. To evaluate and develop professional choices and actions for the benefit of the team and patient

Understanding and appreciating each other’s roles in patient care and the importance of communication between professions starts at undergraduate level and now seems embedded as part of the working culture in Linköping. A trial using this model will be rolled out in January 2016.

Initial planning work has commenced regarding establishing a multidisciplinary training ward in the Trust. A task and finish group was launched in September and will enable a group with representation from medicine, nursing and Allied Health Professional’s (AHP’s) to look at how to take this work forward. It is expected a pilot will take place in the Trust from January 2016 in line with the assistantship placement for final year medical students. Nursing, Medical and AHP students will be involved.

FINEST continues to gather information from other Trusts on the above in order to inform an options appraisal for future FINEST projects. One option is the development of the preceptorship programme to be more inclusive of AHP’s. Initial meetings have taken place with preceptorship leads to look at the programme for 2016. Following the development of a paper, options will be considered by the executive team in early 2016.

Draft

6

6. Clinical Simulation

Simulation training at the University Hospital of North Tees continues to improve, with the installation of some new technology as well the development of stronger, broader and more solid links with various specialities within the hospital. As well as members of the simulation team attending nationally recognised courses to enhance their own expertise, the team are hosting an additional ‘Introduction to Simulation’ course to enable members of these clinical teams to gain the skills and knowledge required to develop and deliver sessions. These programmes help ensure the Trust continues to increase our numbers of trained faculty to run simulation scenarios.

Regular simulation is taking place within the simulation suite, for a variety of nursing staff (including midwives preceptorship, endoscopy, general and critical care nurses,) medical staff (particularly in anaesthetics and foundation level doctors) and undergraduate medical students. Strong links have been established with the Orthopaedics team, with simulation sessions now happening on a monthly basis in the simulation suite. We continue to use learning points from various safety panel meetings to develop realistic simulation scenarios based on real events, and have organised teaching sessions incorporating learning from recent SUIs (including intrasseous needle insertion and consent issues.)

Regular simulation in situ is also continuing in A&E and paediatric/neonatal departments. The simulation team are currently working towards the same successful model we have developed with A&E being adopted within medicine (targeting EAU and ambulatory care areas.) This will lead to a regular, weekly simulation training slot in this clinical area. A new development is the initiation of a regular simulation in situ for the surgical staff, with regular sessions being planned to target specific learning needs that have been identified in these areas.

The community simulation suite has been completed, and we have imminent plans to use it to train community staff in a variety of technical skills as well using immersive scenarios. We are currently in the process of developing these training sessions, and will roll them out during quarter 3.

The new SMOTS (Scotia medical observation and training system) camera system has been installed, and members of the simulation team have received training on the use of this. It has been used already on the recent Surgical Laparoscopy day, whereby an operation happening in theatres was viewed on screen in the Simulation suite. The intention is to use the system to enhance our capability of transmitting simulation scenarios to a larger audience, thereby enhancing vicarious learning. The SMOTS system has also been used to link the community simulation suite to the main simulation suite for similar purposes.

The simulation team now have access to the Trust Twitter feed and are using this to increase the profile of clinical simulation using social media and publicise our work within the department with greater effect. The team are also in the process of developing our intranet page for similar purposes. The aim of this is to develop stronger links with our own Trust staff members as well as external or community teams.

Draft

7

7. Contract Negotiations for Consultants and Junior Doctors

The Department of Health have proposed plans to reform the contractual arrangements for consultants and junior doctors. The reforms are based upon recommendations of the NHS Pay Review Body (NHSPRB) and the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) which includes:

Junior Doctors: Enhancing the quality and quantity of training opportunities for junior doctors. A higher basic rate, with a significant increase in basic salary. Proportionate payment for additional hours worked (including when on-call). Unsocial hours paid at a higher rate. Flexible pay premia for hard-to-fill specialties.

Consultants: Expanded seven-day services in the NHS with removal of the current opt-out clause in the consultant contract. The proposals seek to limit the range of hours covered by the out-of-hours premium, to make wider service hours affordable in the long term. The DDRB supports the continuation of national Clinical Excellence Award (CEAs), however the value of national CEAs will need further consideration. Local CEAs are to be reformed as performance pay, or payments for excellence. These would be linked to objective based performance appraisal and the job planning process.

Both contracts: Changes are required to the antiquated approach for time-served, mainly annual incremental progression in both contracts. The ‘night window’ for out-of-hours work should start at 10pm and a common definition should be applied across all staff groups. It is noted that some sectors had also extended plain-time working to include Saturday working.

The current position is that, as of September 2015, the BMA have agreed to re-enter negotiations on the reform of the consultant contract, however there is still a large amount of work needed from both sides in order to deliver the contract reforms required within the given timescales.

In respect of the junior doctor contract, in August 2015, the BMA indicated that they would not be re-entering negotiations and in September 2015, the DoH and NHS Employers issued a statement that they would be pushing ahead with the reforms and a series of open meetings had been scheduled to engage with junior doctors around the proposed new contract. A further update has been issued with effect from 28 September, advising that the Secretary of State has written to the new Chair of the British Medical Association Junior Doctor Committee (BMA JDC), to invite him to a meeting to discuss the proposed changes. In light of this development, all open meetings have now been postponed with immediate effect.

The HR Department is continuing to monitor the situation and further updates will be included in future reports. The government’s implementation timetable remains:

Early implementation of new terms for new consultants from April 2016 (moving existing consultants across by 2017) The introduction of a new juniors’ contract from the August 2016 intake.

Draft

Scorecard Summary Baseline 31/03/2015

Q2

2014/15

Q2

2015/16

Variance

from same

qtr prev year

Trust Headcount 5393 5318 5375 57

Trust WTE 4551.03 4497.33 4520.81 23.48

Sickness Absence Rate* 5.05% 4.40% 4.68% 0.28%

Short Term Sickness Rate* 0.74% 0.51% 0.49% -0.02%

Medium Term Sickness Rate* 0.87% 0.70% 0.98% 0.28%

Long Term Sickness Rate* 3.46% 3.15% 3.23% 0.08%

Turnover Rate (inc. Foundations) 12.69% 11.92% 13.07% 1.15%

Turnover Rate (exc. Foundations) 11.73% 10.80% 11.99% 1.19%

Change in Workforce (WTE) Q2

Starters 200.69

Leavers 196.03

Overall variance in workforce 4.66

Mandatory Training Target Q2 Variance

Overall Compliance Rate 95% 96% 1%

Subjects Out of Compliance

Information Governance 95% 89% -6%

Safeguarding Children Level 3 100% 94% -6%

* Please note that sickness data for September is not currently available therefore the data provided is for July and August only

8. Dashboard Summary Quarter 2 2015/2016

150000

200000

250000

300000

350000

400000

450000

500000


Cost of Sickness Absence Comparison

2014/15 2015/16

19,441.29

12,902.78

6,795.22

Top 3 Reasons for Sickness Sep 2014 to Aug 2015

Anxiety/stress/depression/ot

her psychiatric illnesses

Other musculoskeletal

problems

Other known causes - not

elsewhere classified


2014/15 4.35% 3.82% 4.10% 4.24% 4.40% 4.56% 4.34% 4.74% 5.40% 5.27% 4.87% 5.05%

2015/16 4.11% 4.11% 4.10% 4.57% 4.80%

Target 15/16 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Sickness Absence Rates

8

Draft

Workforce Profile by Staff Group

Staff Group - WTE Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Difference

Add Prof Scientific and Technical 97.07 96.85 97.59 98.39 99.39 96.48 98.19 100.39 99.96 98.17 100.67 99.47 2.41

Additional Clinical Services 829.34 839.21 837.67 845.81 844.09 841.03 830.76 826.61 822.24 819.78 820.34 835.85 6.51

Administrative and Clerical 917.39 935.16 936.93 931.79 933.81 944.22 919.23 920.45 919.79 925.15 928.42 942.04 24.64

Allied Health Professionals 369.69 347.59 370.65 374.96 375.07 375.68 377.39 378.41 380.16 381.27 378.79 376.73 7.03

Estates and Ancillary 435.17 433.45 434.70 432.73 441.60 445.19 441.10 440.83 441.20 441.29 444.60 447.51 12.34

Healthcare Scientists 117.38 114.89 113.90 112.90 115.36 114.74 114.46 112.86 112.86 113.76 111.76 111.76 -5.61

Medical and Dental 366.80 367.80 368.78 368.78 370.78 376.48 371.23 371.98 373.17 415.72 367.02 366.82 0.01

Nursing and Midwifery Registered 1343.20 1347.40 1342.00 1338.22 1346.15 1338.22 1335.77 1340.27 1340.65 1334.97 1330.81 1320.83 -22.37

Students 21.91 21.91 21.91 20.00 20.00 19.00 19.00 18.00 18.00 17.00 17.00 19.80 -2.11

Total 4497.95 4504.28 4524.12 4523.27 4545.95 4551.03 4507.12 4509.80 4508.02 4547.12 4499.41 4520.81 22.86

Staff Group - Headcount Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Difference

Add Prof Scientific and Technical 111 111 112 113 114 111 112 115 116 115 118 117 6

Additional Clinical Services 1020 1032 1032 1037 1037 1038 1031 1028 1026 1024 1023 1039 19

Administrative and Clerical 1067 1086 1088 1077 1080 1088 1063 1065 1066 1069 1072 1086 19

Allied Health Professionals 435 405 442 446 450 452 455 457 459 458 454 455 20

Estates and Ancillary 587 586 586 584 600 605 600 601 599 601 604 606 19

Healthcare Scientists 132 128 128 128 131 130 130 128 128 129 127 127 -5

Medical and Dental 409 409 409 409 412 418 415 416 417 460 409 408 -1

Nursing and Midwifery Registered 1537 1544 1539 1535 1542 1532 1530 1533 1534 1529 1525 1517 -20

Students 22 22 22 20 20 19 19 18 18 17 17 20 -2

Total 5320 5323 5358 5349 5386 5393 5355 5361 5363 5402 5349 5375 55

There has been an overall increase of 22.86 WTE (55 headcount ) between October 2014 and September 2015. The majority of the staff groups have seen a increase in their WTE except Healthcare Scientists (decrease of 5.61 WTE), Nursing and Midwifery Registered (decrease of 22.37 WTE) and Students (decrease of 2.11 WTE).

This is also reflected in the headcount figures, however, the Medical and Dental staff group saw a decrease of 1 headcount but an increase of 0.01 WTE.

9

Draft

Staff Group Headcount Female Male White/British Other Part Time Full Time

Add Prof Scientific and Technical 117 86 31 104 13 48 69

Additional Clinical Services 1039 930 109 953 86 581 458

Administrative and Clerical 1086 900 186 1045 41 425 661

Allied Health Professionals 455 394 61 424 31 224 231

Estates and Ancillary 606 384 222 574 32 385 221

Healthcare Scientists 127 97 30 121 6 41 86

Medical and Dental 408 152 256 195 213 70 338

Nursing and Midwifery Registered 1517 1431 86 1352 165 641 876

Students 20 20 NULL 20 0 1 19

Total 5375 4394 981 4788 587 2416 2959

Workforce Profile by Key Characteristics Quarter 2 2015/16

The headcount at the end of quarter 2 2015/16 has increased by 12 when compared to the end of quarter 1 2015/16, from 5363 to 5375.

There has been an increase in headcount across all key characteristics when comparing quarter 2 2015/16 with quarter 1 2015/16, except for the part time category where there was a decrease of 9.

The largest increase was in the full time category of 21 from 2938 to 2959 This contrasts with last quarter when this characteristic saw the largest decrease.This was followed by the White/British category demonstrating an increase of 11, from 4777 to 4788. The smallest increase was in the Other ethnicity category showing a reduction of 1.

The number of females and males in the Trust have both increased by 6 each.

The 51-55 age category has taken over from the 46-50 age category as the largest group of staff accounting for 16.4% of the total WTE. However the 46-50 is close behind accounting for 16%.

16 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65 66 - 7071 &

above

WTE 38.52 333.15 400.25 487.31 475.51 557.44 724.26 740.30 518.77 187.25 47.63 10.49

0.00

100.00

200.00

300.00

400.00

500.00

600.00

700.00

800.00

Age Profile - WTE

10

Draft

Turnover (% Headcount)

The turnover rate has decreased in quarter 2 2015/16 when compared to quarter 1 2015/16, from 13.53% in June 2015 to 13.07% in September 2015 where the rate includes foundation doctors, and from 12.47% in June 2015 to 11.99% in September 2015 where the rate excludes foundation doctors.

The turnover rate for each of the months so far in 2015/16 has been higher than in 2014/15. This is consistent with the Trust's aim to reduce overall staffing while working towards ourTransformation Plans.

When comparing the turnover rates including and excluding foundation doctors, the rate has increased slightly when the figures include foundation doctors from 13.02% in July to 13.07% in September, however, it has decreased where foundation doctors have been excluded from 12.05% in July to 11.99% to September.

The Medical and Dental staff group continues to show the highest turnover rate both including and excluding the foundation doctors. However the rate is significantly lower when the foundation doctors are excluded at 13.62% compared to 28.19% when they are included.

Additional Clinical Services are the next highest staff groups in quarter 1 at 13.44%, followed by Administrative and Clerical at 12.80%.

The Healthcare Scientists staff group continues to have the lowest turnover rate for the quarter at 7.87%.


2015-16 13.27 13.43 13.53 13.02 13.07 13.07

2014-15 10.93 10.95 10.96 11.54 12.06 11.92 11.81 11.72 11.64 12.41 12.32 12.69

0

2

4

6

8

10

12

14

16Turnover (inc. Foundation Doctors)

2015-16 2014-15

Add Prof

Scientific and

Technical

Additional

Clinical

Services

Administrative

and Clerical

Allied Health

Professionals

Estates and

Ancillary

Healthcare

Scientists

Medical and

Dental

Nursing and

Midwifery

Registered

inc. FD's 11.45 13.44 12.80 12.66 10.74 7.87 28.19 10.82

exc. FD's 13.62

0.00

5.00

10.00

15.00

20.00

25.00

30.00Turnover by Staff Group 2015-16 Q2

inc. FD's exc. FD's


2015-16 12.24 12.11 12.47 12.05 11.97 11.99

2014-15 9.84 9.84 9.87 10.57 10.92 10.80 10.69 10.63 10.61 11.31 11.27 11.73

0

2

4

6

8

10

12

14

16Turnover (exc. Foundation Doctors)

2015-16 2014-15


with 13.27 13.43 13.53 13.02 13.07 13.07

without 12.24 12.11 12.47 12.05 11.97 11.99

0

2

4

6

8

10

12

14

16

Turnover 2015-16 with/without Foundation Doctorswith without

11

Draft

9. Change in Workforce AnalysisNew Starters Headcount WTE

Oct-14 44 28.23

Nov-14 45 27.96 Starters by Staff Group Headcount WTE Headcount WTE

Dec-14 96 63.95 Add Prof Scientific and Technical 6 5.60 3 2.50

Q3 2014/15 185 120.14 Additional Clinical Services 38 30.19 56 40.81

Jan-15 78 60.80 Administrative and Clerical 18 13.86 43 38.57

Feb-15 73 46.19 Allied Health Professionals 10 7.25 15 12.59

Mar-15 63 45.50 Estates and Ancillary 21 11.16 20 11.39

Q4 2014/15 214 152.49 Healthcare Scientists 5 3.63 2 2.00

Apr-15 49 35.05 Medical and Dental 64 59.70 71 67.90

May-15 43 30.08 Nursing and Midwifery Registered 30 24.15 31 23.93

Jun-15 45 32.51 Students 11 12.00 1 1.00

Q1 2015/16 137 97.65 Total 203 167.54 242 200.69

Jul-15 85 72.17

Aug-15 66 53.39

Sep-15 91 75.12

Q2 2015/16 242 200.69

Reasons for Leaving Headcount WTE Leavers by Staff Group Headcount WTE Headcount WTEEnd of Fixed Term Contract 60 59.60 Add Prof Scientific and Technical 6 3.95 4 4.00Voluntary Resignation - Other/Not Known 34 27.24 Additional Clinical Services 33 25.95 35 23.69Flexi Retirement 19 16.13 Administrative and Clerical 30 24.52 26 22.38Voluntary Resignation - Work Life Balance 19 15.22 Allied Health Professionals 19 16.67 21 15.96Voluntary Resignation - Relocation 15 12.20 Estates and Ancillary 12 7.47 14 9.92End of Fixed Term Contract - Completion of Training Scheme 11 11.00 Healthcare Scientists 4 3.80 4 3.60Voluntary Resignation - Promotion 11 9.64 Medical and Dental 82 78.60 81 77.80Retirement Age 11 8.83 Nursing and Midwifery Registered 61 51.21 44 38.68Redundancy - Compulsory 9 6.81 Students 2 2.00 0 0.00Voluntary Resignation - Lack of Opportunities 7 6.13 Total 249 214.18 229 196.03Voluntary Resignation - Better Reward Package 6 4.28

Retirement - Ill Health 5 3.52

End of Fixed Term Contract - External Rotation 5 3.20

Voluntary Resignation - To undertake further education or training

3 2.51

Voluntary Resignation - Health 3 2.47

Voluntary Resignation - Incompatible Working Relationships 2 1.57

End of Fixed Term Contract - Other 2 1.50

Voluntary Resignation - Child Dependants 2 1.33

Dismissal - Some Other Substantial Reason 2 1.07

Has Not Worked 1 1.00

Dismissal - Capability 1 0.79

Bank Staff not fulfilled minimum work requirement 1 0.00

Total 229 196.03

Q2 2015/16

Q2 2014/15 Q2 2015/16

Q2 2014/15 Q2 2015/16

The number of new starters to the Trust in quarter 2 2015/16 has increased to 242 when compared to quarter 1 2015/16 (137). This is an increase of 105.

Medical and Dental had the largest amount of new starters in quarter 2 (71) however this is counter balanced by the number of leavers (81). The increase in starters for the staff group can be attributed to the junior doctor changeover. This is followed by Additional Clinical Services with 56 starters and Administrative and Clerical with 43 starters in quarter 2. This is only partially counterbalanced by the number of leavers in staff groups at 35 for Additional Clinical Services and 26 for Administrative and Clerical. Some of the remainder are likely to be new starters into the Medical Records team for EPR.

Flexi-retirement is no longer the top reason for leaving in quarter 2, it is now End of Fixed Term Contract due to the junior doctors. This is then followed by voluntary resignation - other/not know, and flexi retirement.

12

Draft

Absence Reason

WTE

Days

Lost Episodes

Anxiety/stress/depression/other psychiatric illnesses 4581.24 148

Other musculoskeletal problems 3481.30 143

Gastrointestinal problems 1581.17 220

Total 9643.70 511

0.00

648.33

213.20

31.00

121.50

473.05

281.91

241.27

1352.03

353.08

Anxiety/Stress/Depression/etc - WTE Days Lost - By Dir

0.00

1060.55

18.00

0.00

26.40149.55

596.09

267.55

211.00

Other Musculoskeletal Problems - WTE Days Lost - By Dir

Please note that sickness data for September is not currently available therefore the data provided is for July and August only.

The top three reasons for sickness absence in quarter 2 2015/16 remain the same as in quarter 1 2015/16.

Anxiety/stress/depression/other psychiatric illnesses is the top reason based on WTE days lost, however, gastrointestinal problems account for more episodes of sickness in the quarter. This is consistent with the ranking in quarter 1 2015/16.

The Directorate that has the largest number of WTE days lost for Anxiety/Stress/Depression etc continues to be Out of Hospital Care, as this accounts for 1352.03 WTE days lost. This remains consistent with previous quarters.

The staff group that has the largest number of WTE days lost for Anxiety/Stress/Depression is Nursing and Midwifery Registered, as this accounts for 1293.67 WTE days lost. Again, this remains consistent with previous quarters.

The Finance Directorate accounts for the highest number of WTE days lost for Other Musculoskeletal Problems with 1060.55 WTE days lost. This differs from last quarter when Out of Hospital Care Directorate accounting for the largest proportion.

Nursing and Midwifery Registered is the staff group which has the highest number of WTE days lost (956.28) for Other Musculoskeletal Problems. This is followed by the Additional Clinical Services staff group which accounts with 900.78 WTE days lost.

Out of Hospital Care Directorate is the directorate with the highest number of WTE days lost (278.60) for gastrointestinal problems, closely followed by the Finance Directorate (272.19).

The Nursing and Midwifery Registered staff group continues to account for the largest amount of WTE Days Lost for Gastrointestinal Problems with 501.81.

0.00

1270.24

849.73

598.28

520.3336.00

6.00

1293.67

7.00

Anxiety/Stress/Depression/etc - WTE Days Lost - By SG

0.00

900.78

490.91

132.99

816.88

175.85

956.28

Other Musculoskeletal Problems - WTE Days Lost - By SG

9.640.80

272.19

5.0063.40

13.00

92.00

89.48169.60

219.31

278.60

63.64

Central

Chief Execs Dept

Clinical Support Services

Finance

Human Resources

Nursing, Patient Safety & Quality

Transformation

Operations and Performance Directorate - Corporate Areas

Anaesthetics

Elective Care

Emergency Care Services

In-Hospital Care

Out of Hospital Care

Womens and Childrens

0.80

272.19

63.40

13.00

92.00

89.48169.60

219.31

63.64

Gastrointestinal Problems - WTE Days Lost - By Dir

3.00

376.84

375.75

81.44

196.653.10

501.81

Gastrointestinal Problems - WTE Days Lost - By SGAdd Prof Scientific and Technical Additional Clinical Services

Administrative and Clerical Allied Health Professionals

Estates and Ancillary Healthcare Scientists

Medical and Dental Nursing and Midwifery Registered

Students

3.00

376.84

375.75

81.44

196.6542.57

501.81

Gastrointestinal Problems - WTE Days Lost - By SG

13

10. Sickness

Draft

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000


WTE Days Lost2015/16 2014/15

0

100,000

200,000

300,000

400,000

500,000

Add Prof

Scientific and

Technical

Additional

Clinical

Services

Administrative

and Clerical

Allied Health

Professionals

Estates and

Ancillary

Healthcare

Scientists

Medical and

Dental

Nursing and

Midwifery

Registered

Sickness Cost by Staff Group2015/16 Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4

Please note that sickness data for September is not currently available therefore the data provided is for July and August only.

The number of WTE days lost to sickness in quarter 2 has decreased by 3755.46 when compared to quarter 1 however, the data for quarter 2 is not yet complete.

The WTE days lost in each of the months for quarter 2 2015/16 so far are higher than when compared to the same period last year.

.

As was the case in 2014/15, the Nursing and Midwifery Registered staff group incurs the greatest sickness cost in the Trust for quarter 2 at £313,470.44. This has reduced when compared to quarter 1, by £115,244.54. However the quarter 2 figure is not yet complete.

The staff group with the lowest cost of sickness remains Add Prof, Scientific and Technical with a cost of £7022.37.

14

Draft

Regional Sickness (Quarter 1 2015/16)

The chart above shows the regional sickness absence figures for quarter 1 2015/16. North Tees and Hartlepool Trust continue to have a sickness absence rate that is below the regional average for quarter 1. The average regional sickness absence rate for quarter 1 is 4.48%, whereas the average rate for North Tees and Hartlepool Trust is 4.11%.

Regional sickness absence information for quarter 2 2015/16 is not yet available.

15

Draft

Occupational Health - Reasons for Referral 12. Staff Friends and Family Test

Total

2015-16

Musculoskeletal 64 68 64

Stress/Anxiety 60 48 60

Post Surgery 14 15 14

Bereavement 10 3 10

Frequent STSA 10 13 10

Neurological 8 4 8

Fracture 7 6 7

Respiratory 6 1 6

Cardiac 5 2 5

Infections 5 1 5

Total 189 161 0 0 189

11. Employee Relations Case Summary

Category

Cases

commenced in

Q2

Cases

commenced and

concluded in Q2

(with outcome)

Cases carried

forward from

previous

quarters

Cases carried

forward from

previous

quarters

concluded in Q2

(with outcome)

Total ongoing

cases to carry

forward to Q3

2015/2016

163 - No further

action17

2 No further

action19

1 - Final written

warning2 Verbal warning

2 - Resigned2 First written

warning

1 Final written

warning

1 Dismissal

1 (C) 1 (C) Dismissed 2 (C)1 - No further

action (C)1 (C)

Disclosure of concerns 0 0 1 n/a 1

Absence dismissals 7 n/a n/a n/a n/a

Organisation Change 8 n/a 1 2 9

Employment Tribunal 0 0 0 0 0

Disciplinary & Capability

Grievance 5 1 - Not Upheld 10

1

4

B&H 3 0 3

1 - NFA (appeal

pending), 1

complainant

resigned

4

Mediation 0 0 3

1 - 1 party

resigned, 1 -

partially resolved

2 Grievance

upheld, 2 upheld

in part, 6 not

upheld

Reason for Referral Apr-Jun 2015 Jul-Sep-2015Oct – Dec

2015

Jan – Mar

2016

There were 161 referrals to Occupational Health during quarter 2 2015/16.

The top reason for referral continues to Musculoskeletal with 68 referrals, which is 42% of the total, an increase of 8%. This was followed by Stress/Anxiety with 48 referrals, 30% of the total. This has reduced from 60 referrals in quarter 1.

The remaining reasons for referral amount to 28% of the total.

A total of 307 responses were received for the Staff Friends and Family Test (SFFT) for quarter 1 2015/16.

Overall Scores for Q1 (2015/16)77% of staff would recommend the Trust as a place to receive care of treatment. 6% of staff would not. 16% of staff stated it was neither likely nor unlikely and 1% didn't know.

71% of staff would recommend the Trust as a place to work, 13% of staff would not. 15% of staff stated it was neither likely nor unlikely and 1% didn't know.

* The SSFT was not undertaken for Q3 2014 as this response isobtained via the annual Staff Survey.

Q1 - How likely are you to recommend this organisation to friends and family if they needed care or treatment?

The top three positive themes were:Quality of CareStaff - CommitmentStaff - Hardworking

The three most frequent negative themes were:Quality of care, Staffing levelsLocality

Q2 - How likely are you to recommend this organisation to friends and family as a place to work?

The top three positive themes were:

Quality of CareStaff - Commitment Staff - Hardworking

The three most frequent negative themes were:

Quality of careStaffing levelsLocality

16

Draft

13. Mandatory Training

% Q4 2014/15 % Q1 2015/16

% Q2 2015/16 (Sept

data not yet

available)

Infection Control 95 99 99 99 99

Information Governance 95 90 93 91 89

Medicines Management 80 96 96 97 97

Corporate Induction 100 99 99 99 99

Appraisal 95 91 90 88 86

Patient Handling 80 82 83 75 75

Resuscitation 80 79 76 77 77

Dementia 50* 89 90 90 90

Enhanced infection control 80 N/A*** N/A*** N/A*** N/A***

Safeguarding Children (combined levels) 80 97 97 97 97

Safeguarding Adults (combined levels) 80 94 94 94 95

Human Factors 80 N/A*** N/A*** N/A*** N/A***

Patient falls (Risk Assessment & Falls) 40 64** 78 28 53

Pressure sores (Prevention of Pressure Sores 40 72** 79 38 45

Overall Trust compliance 96 96 96 96

*Patient Falls is now Risk Assessment & Falls and target for May is 10%

*Pressure Sores is now Prevention of Pressure Sores and target for May is 10%

TopicTarget

compliance% Q3 2014/15

The mandatory training results for the first 2 months of Q2 are now available. The Education Delivery Team has made a positive contribution to the overall Trust compliance position and has helped the Trust achieve ‘green’ status in a wide range of topics including; Sepsis, Acute Kidney Injury, Fire awareness and Safeguarding Children level 1.

‘Green’ status was also achieved in five of the six 2015/2016 additional training topics including Sepsis, Risk assessment of falls and palliative care training.

Training compliance on a small number of topics remain a challenge, these include:

- Information Governance – compliance has reduced from 91% to 89%. The concern is that over 400 staff will fall out of compliance in the coming months and without positive action, compliance will reduce further. Education and OD are working with key contacts within the directorates to help promote training, specifically, the use of the e-learning facility- Appraisal – A compliance figure of 86% was achieved, however, this represents a 2% reduction from the previous period. Work is underway to improve compliance levels, although a proactive approach is needed by all line managers to plan time to complete staff appraisals. - Resuscitation – an overall figure of 77% was achieved for combined resuscitation topics, significant work has been undertaken to improve compliance on the topic of Intermediate Life Support (ILS), however, compliance of Basic Life Support (BLS) has fallen in the last quarter. The clinical Educators are working with key trainers across the directorates to improve this position for the quarter 3 results.

Investment continues to be placed in the development of the Trusts e-learning system. During the month of August, the Trust has seen its best ever completion rate for training via the e-learning system. 34% of all training was completed using the system. Feedback on the new system has been extremely positive as we continue to improve the ‘user friendliness’ of the system.

To further enhance the number of packages we offer via e-learning, the following topics are under construction: DNA-CPR, Prevention of Terrorism and Nurse Revalidation.

17

Draft

1 2

3 4

Topic

Appraisal86

Fire 86

Info. Gov89

Safeguarding Children Level 199



Corporate Induction 99

Compliance %

Total Mandatory Training

Completions

2271

2134

2667

1902

1462

0 1000 2000 3000

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Apr-15 May-15 Jun-15 Jul-15 Aug-15

86% 82% 81% 77% 66%

Total Mandatory Training

Completions - e-learning

307

387

517

423

496

0 200 400 600

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Apr-15 May-15 Jun-15 Jul-15 Aug-15

14% 18% 19% 23% 34%

18

Draft

19

14. Recommendation

The Board of Directors are asked to note the content of and accept this report.

Ann Burrell Director of HR & Education

Draft



29 October 2015

Emergency Preparedness, Resilience and Response Core Standard Compliance

Report of the Chief Operating Officer / Deputy Chief Executive

Strategic Aims and Objectives (the full set of Trust Aims can be found at the beginning of the Board of Directors reports)

Maintain Compliance and Performance Putting Patients First Manage our Relationships

1. Introduction

1.1 The NHS needs to be able to plan for and respond to a wide range of emergencies and business continuity incidents that could affect health or patient safety. These could be anything from severe weather to an infectious outbreak or a major accident. Under the Civil Contingencies Act (2004), NHS organisations and providers of NHS funded care must show that they can effectively respond to emergencies and business continuity incidents while maintaining services to patients.

1.2 Minimum standards have been set for emergency preparedness, resilience and response (EPRR) for NHS organisations to undertake a self-assessment to provide assurance to NHS England that they are compliant with core standards of preparedness. Standards have also been set for hazardous materials (HAZMAT), chemical, biological, radiological or nuclear (CBRN) incident and pandemic flu response preparedness.

1.3 EPRR remains a key component of regulatory requirements. The Board of Directors will recall that EPRR compliance was reported at the meeting on 27 November 2014 and that EPRR core standards’ compliance position is an annual requirement.

1.4 This report explains the EPRR requirements and provides details of the Trusts EPRR self-assessment, concentrating on standards whereby the Trust (or healthcare system) is not fully compliant and providing mitigating actions. The self-assessment by variance is included in Appendix 1.

2. EPRR Requirements

2.1 NHS organisations must nominate a director level accountable emergency officer who will be responsible for EPRR and contribute to area planning for EPRR through local health resilience partnerships (LHRPs) and other relevant groups. The Chief Operating Officer/Deputy Chief Executive remains accountable.

3. Conclusion

3.1 The EPRR self-assessment is an annual exercise supported by a robust governance process and whilst the process of assessment is required, the work necessary to

Draft

ensure that the Trust is resilient and in a state of preparedness to respond to emergency incidents, remains intense and on-going throughout the year. The self-assessment and robust action planning, continuous monitoring and the governance process outlined in the report, provides a level of assurance to the Board of Directors and subsequently to NHS England that the Trust is meeting the core standards and, where shortfalls are recognised, mitigation plans are in place to provide future compliance.

4. Recommendations

4.1 The Board of Directors is asked to note the contents of the report and to acknowledge the assessment position, the requirement to continue to work with other emergency care responders to ensure resilience in the care system and where appropriate any mitigating actions that the Trust has put into place to become compliant or to assure delivery to the EPRR core standards.

4.2 In particular, the Board is asked to take a level of assurance in recognising the work undertaken to achieve the current state of resilience and preparedness to respond to emergency incidents. This will be further explored for future planning, at the November Board Seminar.

4.3 Finally, the Board is asked to approve a tentative ‘statement of compliance’ return to the LHRP.


Draft



29 October 2015

Emergency Preparedness, Resilience and Response Core Standard Compliance


1. Introduction

1.1 The NHS needs to be able to plan for and respond to a wide range of emergencies and business continuity incidents that could affect health or patient safety. These could be anything from severe weather to an infectious outbreak or a major accident. Under the Civil Contingencies Act (2004), NHS organisations and providers of NHS funded care must show that they can effectively respond to emergencies and business continuity incidents while maintaining services to patients.

1.2 Minimum standards have been set for emergency preparedness, resilience and response (EPRR) for NHS organisations to undertake a self-assessment to provide assurance to NHS England that they are compliant with core standards of preparedness. Standards have also been set for hazardous materials (HAZMAT), chemical, biological, radiological or nuclear (CBRN) incident and pandemic flu response preparedness.

1.3 EPRR remains a key component of regulatory requirements. The Board of Directors will recall that EPRR compliance was reported at the meeting on 27 November 2014 and that EPRR core standards’ compliance position is an annual requirement.

1.4 Whilst the standards have remained constant from the previous year, four new standards have been added to provide assurance that pandemic flu plans have been updated and exercised.

1.5 This report explains the EPRR requirements and provides details of the Trusts EPRR self-assessment, concentrating on standards whereby the Trust (or healthcare system) is not fully compliant and providing mitigating actions. The self-assessment by variance is included in Appendix 1.

2. EPRR Requirements

2.1 NHS organisations must nominate a director level accountable emergency officer who will be responsible for EPRR and contribute to area planning for EPRR through local health resilience partnerships (LHRPs) and other relevant groups. The Chief Operating Officer/Deputy Chief Executive remains accountable.

2.2 NHS organisations must have up to date plans which set out how they plan to respond to and recover from emergency and business continuity incidents; exercise the plans; have appropriately trained, competent personnel; and share their resources as required.

2.3 NHS organisations must also have up to date plans which set out how they will maintain prioritised activities when faced with disruption from identified local risks.

3. Core Standards

1

Draft

3.1 Each section of the EPRR self-assessment has been RAG rated according to full, substantial, partial and non-compliance. Appendix 1 provides a variance summary.

Table 1 – Levels of Compliance

3.2 There are 37 EPRR core standards comprising of 52 elements of which 46 are relevant to acute health care providers. The standards are categorised into eight sections:

• Governance• Duty to assess risk• Duty to maintain plans – emergency plans and business continuity plans• Command and control• Duty to communicate with the public• Information sharing• Co-operation• Training and exercising

3.3 The Trust is fully compliant (dark green) with 43 of the elements, substantially compliant (pale green) with two and partially compliant (amber) with one, with evidence of progress.

3.4 There are 14 hazardous materials HAZMAT and chemical, biological, radiological and nuclear CBRN core standards, categorised into three sections:

• Preparedness• Decontamination equipment• Training

3.5 The Trust is fully compliant (dark green) with nine of the elements, substantially compliant (pale green) with four and partially compliant (amber) with one, with evidence of progress.

3.6 A check list to ensure that all equipment required to deal with HAZMAT/CBRN incidents is available, categorised into 4 sections:

• Equipment• Personal Protective Equipment (PPE) for chemical and biological incidents• Ancillary• Radiation

3.7 Of the 37 identified requirements, six are not applicable and the Trust is fully compliant (dark green) with the remaining 31.

2

Draft

3.8 As part of the NHS England annual EPRR assurance process for 2015/16 it was agreed that a ‘deep dive’ will be undertaken into pandemic influenza preparedness consisting of four elements.

3.9 Of the four elements the Trust is fully compliant (dark green) with three and substantially compliant (light green) with one.

3.10 Non Fully Compliant EPRR Core Standards

3.10.1 (Standard 8 – partially compliant) Acute Health Care Providers are expected to have effective arrangements in place to evacuate the premises in the event of an incident. The Trust has effective plans to partially evacuate the premises. Last year NHS England accepted that full compliance is unrealistic for hospitals however a planning group has been established which is exploring the local geography to commence communication with external agencies regarding potential evacuation sites.

3.10.2 (Standard 16 – substantially compliant) Managers on Call (MOC) and Directors on Call (DOC) must meet identified competencies and key knowledge and skills. Due to recent changes in the on call rotas, with additional, new members on both, there are now staff members who are non-compliant. All MOC and DOC have been provided with access to online training and are undergoing a period of training.

3.10.3 (Standard 37 – substantially compliant) All incident commanders (MOC and DOC) are expected to maintain a continuous personal development (CPD) portfolio demonstrating training and/or incident/exercise participation. A training record is maintained and is available on the Trust resilience website. Each on call officer is encouraged to maintain a personal development portfolio. There are Trust and regional training and exercise calendars including training and exercises that comply with the occupational standards.

3.11 Non Fully Compliant HAZMAT/CBRN standards

3.11.1 (Standard 38 – substantially compliant) Organisations are required to have an organisation specific HAZMAT/CBRN plan (or dedicated annex). The Trust has a draft standalone plan in place with a dedicated section in the Major Incident Plan. The plan was tested on 16 June 2015 with a live exercise and is being modified with lessons learned and will be ratified at the Trust Resilience Forum (TRF).

3.11.2 (Standard 41 – partially compliant) Rotas are required to ensure adequate and appropriate decontamination capability available 24/7. An on-going training programme is in place to ensure that all A&E health care assistants (HCAs) are competent in decontamination. Other staff members are also participating in the training e.g. porters. A rota is being developed in the MAPS roster system to demonstrate 24/7 capability.

3.11.3 (Standard 49 substantially compliant) internal training is required, based on current good practice, using material that has been supplied as appropriate. The Trust is fully compliant in regards to wet decontamination however standards dictate that all NHS premises require equipment and training for dry decontamination. The acute premises are fully compliant but await guidance from NHS England with regards to community premises.

3.11.4 (Standard 50 substantially compliant) A number of trained decontamination trainers are required to fully support Trust staff HAZMAT/CBRN training programme. Due to staff turnover additional trainers are required and training (provided by North East Ambulance Service) is being accessed.

3

Draft

3.11.5 (Standard 51 substantially compliant) The Trust is to ensure that staff are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant. A programme of awareness has been developed and is being implemented in all community staff settings and health centres.

3.12 Non Fully Compliant with Pandemic Influenza ‘deep dive’

3.12.1 (Standard DD4 – substantially met) Trusts must have taken their plans to their Board for sign off. Following an exercise to test the Pandemic Influenza plan on 24 September 2015, revisions are being made and ratification will take place at the TRF.

4. Conclusion

4.1 The EPRR self-assessment is an annual exercise supported by a robust governance process and whilst the process of assessment is required, the work necessary to ensure that the Trust is resilient and in a state of preparedness to respond to emergency incidents, remains intense and on-going throughout the year. The self-assessment and robust action planning, continuous monitoring and the governance process outlined in the report, provides a level of assurance to the Board of Directors and subsequently to NHS England that the Trust is meeting the core standards and, where shortfalls are recognised, mitigation plans are in place to provide future compliance.

4.2 The Trust is fully compliant (dark green) in 43 of the 56 core standards and all of the associated 31 checklist requirements and plans are in place to address (or work with other emergency services / responders) the remaining elements.

4.3 The Trust is fully compliant (dark green) with three of the four ‘deep dive‘ standards for pandemic influenza preparedness and substantially compliant (pale green) with the fourth.

4.4 EPRR is a standing agenda item at the Trust Resilience Forum and the current position and action plan against the EPRR Core Standards will be discussed and ratified at the meeting on 16 November 2015.

5. Recommendations

5.1 The Board of Directors is asked to note the contents of the report and to acknowledge the assessment position, the requirement to continue to work with other emergency care responders to ensure resilience in the care system and where appropriate any mitigating actions that the Trust has put into place to become compliant or to assure delivery to the EPRR core standards.

5.2 In particular, the Board is asked to take a level of assurance in recognising the work undertaken to achieve the current state of resilience and preparedness to respond to emergency incidents. This will be further explored for future planning, at the November Board Seminar.

5.3 Finally, the Board is asked to approve a tentative ‘statement of compliance’ return to the LHRP.

Julie Gillon Chief Operating Officer / Deputy Chief Executive

4

Draft

Appendix 1

EPRR Core Standards Variance Summary 2015

Reference Core Standard Self-Assessment

Action to be Taken

Core Standard 8 Acute Health Care Providers are expected to have effective arrangements in place to evacuate the premises in the event of an incident. The Trust has effective plans to partially evacuate the premises. Last year NHS England accepted that full compliance is unrealistic for hospitals.

Partial compliance

A planning group has been established which is exploring the local geography to commence communication with external agencies regarding potential evacuation sites.

Core Standard 16 Managers on Call (MOC) and Directors on Call (DOC) must meet identified competencies and key knowledge and skills. Due to recent changes in the on call rotas, with additional, new members on both, there are now staff members who are non-compliant.

Substantial compliance

All MOC and DOC have been provided with access to online training and are undergoing a period of training.

Core Standard 37

All incident commanders (MOC and DOC) are expected to maintain a continuous personal development (CPD) portfolio demonstrating training and/or incident/exercise participation.


Each on call officer is encouraged to maintain a personal development portfolio. There is Trust and regional training and exercise calendar including training and exercises that comply with the occupational standards.

HAZMAT/CBRN Standard 38

Organisations are required to have an organisation specific HAZMAT/CBRN plan (or dedicated annex). Substantial

compliance

The plan was tested on 16 June 2015 with a live exercise and is being modified with lessons learned and will be ratified at the Trust Resilience Forum (TRF).


Rotas are required to ensure adequate and appropriate decontamination capability available 24/7. An on-going training programme is in place to ensure that all A&E health care assistants (HCAs) are competent in decontamination. Other staff members are also participating in the training e.g. porters. A rota is being developed in the MAPS roster system to demonstrate 24/7 capability.

Partial compliance

An on-going training programme is in place to ensure that all A&E health care assistants (HCAs) are competent in decontamination. Other staff members are also participating in the training e.g. porters. A rota is being developed in the MAPS roster system to demonstrate 24/7 capability.


internal training is required, based on current good practice, using material that has been supplied as appropriate. Substantial

compliance

The Trust is fully compliant in regards to wet decontamination however standards dictate that all NHS premises require equipment and training for dry decontamination. The acute premises are fully compliant but await guidance from NHS England with regards to community premises.

5

Draft


A number of trained decontamination trainers are required to fully support Trust staff HAZMAT/CBRN training programme.


Due to staff turnover additional trainers are required and training (provided by North East Ambulance Service) is being accessed.


The Trust needs to ensure that staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant.


A programme of awareness has been developed and is being implemented in all community staff settings and health centres.

DD4 – Pandemic flu deep dive

Trusts must have taken their pandemic flu plans to their Board for sign off.


Following an exercise to test the Pandemic Influenza plan on 24 September 2015, revisions are being made and ratification will take place at the TRF.

6

Draft

1



29 October 2015

Executive Summary

Patient Level Information & Costing System (PLICS) and Reference Costs Update

Report of the Director of Finance, ICT & Support Services

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board

Reports)


Strategic Objective (The full set of Trust Objectives can be found at the beginning of the

Board Reports)

Finance

1. Introduction

1.1 The PLICS system uses electronic patient level data to link events and costs to patient episodes.

1.2 The Trust is represented on the Healthcare Financial Management Association (HFMA) Acute Costing Group, the HFMA Community Costing Group and the Reference Costs Advisory Group.

1.3 In March 2015 the HFMA created the Costing for Value Institute (HC4V). The Head of Costing was invited to be a member of the Institute board.

1.4 Current national tariffs are based on the 2011-12 Reference Costs collection and therefore do not yet reflect improvements in the quality of costing.

1.5 This report updates the Board of Directors on progress made since the last PLICS report, the latest financial position of service lines as at quarter 4 14/15 (Q4), and planned future developments.


2.1 Latest Developments – PbR Assurance audit by Capita and improvements to costing of Radiology and Capital Charges.

2.2 Future Developments – a number of developments are planned as detailed in the report, the majority of which will not impact upon the specialty analysis but are likely to move costs between points of delivery. Costing of therapies is the current priority.

2.3 Q4 2014/15 – The movements between Q4 and Q3 have been analysed. Additionally, a comparison with Q4 2013/14 has been provided.

2.4 Reference Costs 2014/15 – A summary of changes between the 2013/14 and 2014/15 submissions.

Conclusion

2.5 Improvements have been made and work will continue with clinicians to develop the model further.

Draft

2

3. Recommendations

3.1 The Board of Directors are requested to:

Note the content of the report. Support the continued development of PLICS as a tool to assist strategic decision. Support the on-going involvement of the Trust to influence the national costing agenda. Acknowledge the continued potential for the profitability of individual service lines to move

significantly during the expected period of volatility while costing and national tariffs are refined. Note the reference cost submission summary compared to 2013/14.

Lynne Hodgson Director of Finance, ICT & Support Services

Draft

3



29 October 2015

Patient Level Information & Costing System (PLICS) and Reference Costs Update

Report of the Director of Finance, ICT & Support Services


1.1 The PLICS system uses electronic patient level data (where available) to attach events (e.g. tests, drugs, theatre time etc.), and therefore costs, to patient episodes. With the availability of this kind of information, the resources consumed by patients on a daily basis can be identified and used to build and understand the patient profile, the resources consumed and the associated costs.

1.2 The Trust is represented on the HFMA Acute Costing Practitioner Group, the HFMA Community Costing Group and the Reference Costs Advisory Group. These groups are responsible for developing costing standards and Reference Costs guidance.

National Agenda

1.3 In March 2015 the Healthcare Financial Management Association (HFMA) created the Costing for Value Institute (HC4V). The Institute will focus on how cost information is produced and used in organisations, along care pathways and across health economies. A greater understanding in this area will allow for more robust and value-based decision-making around the performance and delivery of services. The Trust’s Head of Costing was invited to be a member of the Institute board. This now means that the Trust is influencing at the highest level in NHS costing.

1.4 Historically the costing standards have been focused on top-down costing. Since 2013/14 there has been a movement driven by Monitor to refine the standards to reflect the PLICS approach to costing. There is still a significant amount of development work to be undertaken. Early indications from pilot studies on key cost categories suggest there will be significant movements in costs between specialties and patient categories. This will have a significant impact on future tariff setting, however it’s important to note that current national tariffs are based on the 2011-12 Reference Costs collection and therefore do not yet reflect improvements in the quality of costing.

1.5 In December 2014, Monitor published it’s costing roadmap document “Improving the costing of NHS services: proposals for 2015-2021” in which it proposed a move to a single national cost collection (replacing Reference Costs, the Monitor PLICS collection and the Education and Training cost collection) informed by PLICS data as defined by an improved, transparent and intuitive costing method, based on agreed standard definitions and rules. There are several work streams that have resulted from this work that the Trust has been asked to participate in.

Change Agent Programme

1.5.1 Monitor’s Pricing Enforcement team invited the Trust to be one of ten pilot sites for this programme. It aims to drive performance improvements through greater engagement with clinicians in performance management. Monitor has advised that the Trust is significantly ahead of almost all of the other Change Agent pilot sites.

Costing Transformation Programme

1.5.2 The Trust has been invited to join an advisory panel to support this programme. This will involve providing ad-hoc advice and contributions to the development of working papers that will underpin the development of the costing standards.

Draft

4

Costing Software Accreditation

1.5.3 The Trust has also been working with Monitor’s costing team on the development of a PLICS software accreditation system. The Trust was recommended to Monitor for this work by Healthcost (the Trust’s PLICS software provider), as one of their strategic business partners.

Purpose of Report

1.6 The purpose of this report is to inform the Board of Directors of the progress made to date, the latest financial position of individual service lines as at Q4, and planned future developments.

2. Main Content Of Report

Latest Developments

2.1 During quarter 4 and for a second year running, the Trust was audited by Capita as part of a national PbR Assurance audit. The Capita audit team were also shadowed by members of Monitor’s Pricing Enforcement Team. The final report was issued in May and found the accuracy of costing to be “good” for inpatients, outpatients and A&E, and “adequate” for community services. The costing of community services has been an area of difficulty for some time now due to the variability of data quality between services and localities. It is expected however that gradual improvements in data quality will materialise with the continued transition of services from manual data capture methods to the use of SystmOne.

2.2 Since the audit, significant resources have been consumed in the collection and production of the 2014/15 Reference Costs return and the PLICS collection, however a number of significant model enhancements (detailed below) have been achieved in this time in order to help drive up the quality of national costing data and internal PLICS reports. The publication of the Reference Costs Index is expected around November, a summary of the outputs from the 2014/15 submissions comparing this year with last year are included at appendix. Further details, comparing the Trust to the national position for 2014/15 will be covered in a future paper.

Radiology

2.2.1 Revised weightings were required to ensure resource allocations associated with specific types of examination are reflective of current practices. The Radiology department have now supplied the costing team with standard times for each examination. In addition to these standard times, rotas have been supplied to enable the accurate allocation of staff costs to specific radiology modalities and sites. As such, the costing of examinations is now significantly more accurate, however next steps will focus on identifying the additional costs associated with delivering a radiology service out-of-hours.

Capital Charges

2.2.2 Prior to quarter 4, capital charges were allocated using out dated allocation statistics based on limited information. The costing team has now carried out a thorough review of the asset register and allocated capital charges to specific services or cohorts of patients based on the type of equipment or location of the building e.g. capital charges relating to the MRI scanner at North Tees are now allocated as an overhead to those patients who have received an MRI scan at North Tees. Given the materiality of the capital charges (over £5m) it was important to ensure these costs are allocated as accurately as possible. The improvement in accuracy has also resulted in a shift in costs from the overhead category to indirect. This is in-line with HFMA costing guidance which states that capital charges which can be allocated to specific cohorts of patients should be classified as an indirect cost. Further improvements are expected in future iterations of the PLICS model due to the pending installation of new asset management software which should significantly improve the quality of the information available to the costing team.

Draft

5

Out of Hours

2.2.3 HealthCost, our costing software provider, has worked with us to develop new out-of-hours mechanisms which will enable us to attach a premium for A&E, Radiology and Pathology out-of-hours activity. A work study is required locally to look at out-of-hours rotas in order to calculate a premium weighting which reflects current staffing levels. This piece of work is on-going and it is hoped will be reflected in the next iteration of the model.

Significant Future Developments

2.3 Below are the most significant future developments required to advance the PLICS model to achieve robustness and assurance in the financial aspects of reported outputs.

Therapieso Currently allocated to specialties, sub specialties and departments based on high level

information. Costs are also currently not weighted.o A deep-dive is required into therapies to understand how higher quality information can be

generated, possibly involving available systems e.g. SystmOne, TrakCare etc.

Implants & Consumableso Currently Orthopaedic Hip, Knee and Spinal implants are allocated to individual patients

based on standard cost. Consumables for most procedures across all specialties areallocated based on standard costs.

o Phase 1 development will be to extend the range of implant standard costs to include allsurgical specialties and procedures.

o Phase 2 development requires implementation of stock management system in theatres. Apilot in Hartlepool elective orthopaedics theatres commenced in March 2015.

Out of Hours Premium Rateso Currently all activity attracts the same hourly rate regardless of date/time it takes place.o Work studies are required in all disciplines to assess cost differentials based on date/time.

Theatre Sessional costingo Issues still to resolve (discussions nationally on costing standards):

Overruns Emergency / Trauma lists Out of Hours theatre activity

Junior Medical Staff Job Planso Currently allocated based on Consultant job plan profiles.o Initial study in General Surgery indicates that £440,000 of cost will be reallocated from

Elective and Outpatients to Non-Elective.

Communityo Quality of activity data is variable between Community services and localities.o Work is underway to more accurately align service costs with commissioner contracts.

Nursing Acuityo Currently nursing costs are allocated using ward minutes on an equal weighting which

ignores the individual acuity of each patient. Healthcost have provided a mechanism toapply weightings which is to be utilised in the next iteration of the model, however the longterm goal remains the acquisition of patient level acuity data.

Pathologyo Revised weightings are required to ensure resource allocations associated with specific

types of test are reflective of current practices. This is a substantial piece of work due to themany thousands of types of test and the lack of national standardisation with regards topath test naming and counting conventions.

Draft

6

Chemo Activity (Cycles etc.)o Chemo cycles not currently recorded in Ascribe but may potentially be derived from EPR /

ePrescribing.

Specialist Nursingo Job plans are required for all specialties to ensure accurate allocation of costs.o Disaggregation of block funding is required to ensure income is matched to those services

and patient cohorts to which it relates.

Draft

7

Quarter 4 2014/15 Model

2.4 The following tables detail the outputs from the 2014/15 Q4 PLICS model, and an analysis of the key movements from the earlier Q3 model, and also the prior year Q4 model.

NB. Values are rounded to the nearest thousand.

PLICS Summary Q4 2014/15, Q3 2014/15 and Q4 2013/14

Model Specialty Group Activity

Income

(A)

Direct Costs

(B)

Indirect

Costs

(C)

Contribution

(A-B-C)

Overhead

(E)

Total Costs

(F=B+C+E)

Surplus /

Deficit

(A-F)

Margin

%

Rank

14/15 Q4 A&E 91,256 £9,827 £8,491 £1,183 £154 £1,765 £11,438 -£1,611 -16% 12

Anaesthetics 16,075 £2,657 £1,511 £246 £901 £420 £2,176 £481 18% 3

Medicine & Elderly 157,863 £85,978 £63,162 £6,856 £15,960 £13,705 £83,723 £2,255 3% 5

Obs & Gynae 44,887 £21,981 £16,809 £5,224 -£52 £4,413 £26,446 -£4,466 -20% 13

Paediatrics 20,835 £12,701 £11,529 £724 £449 £2,141 £14,394 -£1,692 -13% 11

Surgery & Urology 57,622 £29,619 £24,835 £2,046 £2,738 £5,875 £32,756 -£3,137 -11% 10

Trauma & Orthopaedics 62,405 £28,413 £24,258 £1,510 £2,646 £5,247 £31,014 -£2,601 -9% 9

Community Services 7,072 £42,703 £33,595 £732 £8,375 £7,473 £41,800 £902 2% 6

Chemica l Pathology 359 £42 £5 £5 £32 £3 £13 £29 69% 2

Direct Access Pathology 365 £5,653 £4,886 £180 £587 £594 £5,661 -£7 0% 7

Direct Access Radiology 365 £3,813 £2,653 £138 £1,023 £477 £3,268 £545 14% 4

Other Service Lines 17 £12,040 -£4,570 £52 £16,558 £632 -£3,886 £15,926 132% 1

Non-Trust Activi ty 30,575 £3,299 £2,258 £735 £307 £535 £3,527 -£228 -7% 8

14/15 Q4 Total 489,696 £258,728 £189,420 £19,630 £49,678 £43,281 £252,331 £6,397 2%

14/15 Q3 A&E 69,788 £7,492 £6,462 £731 £299 £1,552 £8,746 -£1,253 -17% 11

Anaesthetics 11,824 £1,951 £1,175 £132 £644 £376 £1,682 £268 14% 3


Obs & Gynae 32,968 £16,230 £12,002 £4,040 £188 £3,805 £19,846 -£3,616 -22% 12

Paediatrics 15,005 £9,562 £8,689 £396 £477 £1,772 £10,857 -£1,295 -14% 10

Surgery & Urology 43,561 £22,542 £17,933 £965 £3,644 £5,277 £24,176 -£1,633 -7% 8

Trauma & Orthopaedics 47,232 £21,354 £18,653 £831 £1,870 £4,756 £24,240 -£2,886 -14% 9

Community Services 452 £30,531 £23,461 £476 £6,594 £5,525 £29,462 £1,069 4% 6


Direct Access Pathology 275 £4,308 £5,518 £3 -£1,213 £893 £6,414 -£2,106 -49% 13

Direct Access Radiology 275 £2,820 £2,035 £3 £783 £528 £2,565 £255 9% 5

Other Service Lines 412 £12,143 £4,728 -£220 £7,635 £793 £5,301 £6,842 56% 2

Non-Trust Activi ty 30,009 £6,630 £4,118 £883 £1,629 £936 £5,937 £693 10% 4

14/15 Q3 Total 362,346 £194,737 £148,358 £11,388 £34,991 £37,426 £197,172 -£2,434 -1%

13/14 Q4 A&E 91,316 £11,389 £8,877 £808 £1,704 £2,339 £12,024 -£635 -6% 9

Anaesthetics 14,664 £2,518 £1,423 £166 £930 £591 £2,180 £339 13% 4


Obs & Gynae 45,017 £24,422 £16,746 £3,742 £3,934 £5,797 £26,285 -£1,863 -8% 11

Paediatrics 19,882 £12,650 £10,829 £259 £1,563 £2,557 £13,644 -£994 -8% 12

Surgery & Urology 59,248 £31,128 £22,142 £1,576 £7,410 £7,983 £31,701 -£573 -2% 7

Trauma & Orthopaedics 62,493 £30,793 £24,142 £1,487 £5,164 £6,937 £32,566 -£1,773 -6% 10

Community Services 304 £40,387 £30,898 £497 £8,991 £9,826 £41,222 -£835 -2% 8


Direct Access Pathology 365 £5,898 £4,567 £3 £1,328 £1,276 £5,846 £51 1% 6

Direct Access Radiology 365 £3,777 £2,260 £3 £1,514 £808 £3,071 £706 19% 3

Other Service Lines 616 £16,021 £6,145 £47 £9,829 £1,490 £7,681 £8,339 52% 2

Non-Trust Activi ty 29,692 £1,943 £1,887 £303 -£247 £1,017 £3,207 -£1,264 -65% 13

13/14 Q4 Total 478,535 £267,381 £192,660 £11,024 £63,697 £61,133 £264,817 £2,564 1%

£'000

Draft

8

In-year movement between Q4 and Q3

Movement between Q4 14/15 and prior year Q4 13/14

Highlights

2.4.1 Movement between Q4 and Q3

A&E – Activity, income and cost levels have remained constant resulting in a continued deficit in-line with previous trends.

Medicine – Activity and income levels increased while costs increased to a lesser extent, resulting ina greater than expected surplus.

Obs & Gynae – Activity and income levels increased, while costs remained static resulting in a lowerthan expected deficit.

Surgery & Urology – Activity and income levels decreased slightly while costs increased resulting ina larger than expected deficit. As one of the main users of the Radiology service, the refinedRadiology costing will have impacted Surgery & Urology to a greater extent.

Specialty Group Activity

Income

(A)

Direct Costs

(B)

Indirect

Costs

(C)

Contribution

(A-B-C)

Overhead

(E)

Total Costs

(B+C+E)

Surplus /

Deficit

(A-F)

A&E 21,468 £2,335 £2,028 £452 -£145 £212 £2,693 -£358

Anaesthetics 4,251 £707 £336 £114 £257 £44 £494 £213

Medicine & Elderly 47,572 £26,835 £19,583 £3,710 £3,541 £2,497 £25,790 £1,044

Obs & Gynae 11,919 £5,751 £4,807 £1,184 -£241 £609 £6,600 -£850

Paediatrics 5,830 £3,139 £2,840 £328 -£28 £369 £3,537 -£397

Surgery & Urology 14,061 £7,076 £6,902 £1,081 -£906 £598 £8,580 -£1,504

Trauma & Orthopaedics 15,173 £7,059 £5,605 £679 £776 £490 £6,774 £285

Community Services 6,620 £12,172 £10,134 £256 £1,781 £1,948 £12,338 -£167

Chemical Pathology 105 £12 -£0 £2 £10 -£1 £1 £11

Direct Access Pathology 90 £1,345 -£632 £177 £1,800 -£299 -£753 £2,098

Direct Access Radiology 90 £993 £618 £135 £240 -£50 £703 £291

Other Service Lines -395 -£103 -£9,299 £272 £8,923 -£161 -£9,187 £9,084

Non-Trust Activi ty 566 -£3,331 -£1,861 -£148 -£1,322 -£401 -£2,410 -£921

127,350 £63,990 £41,062 £8,242 £14,686 £5,856 £55,159 £8,831

£'000

Specialty Group Activity

Income

(A)

Direct Costs

(B)

Indirect

Costs

(C)

Contribution

(A-B-C)

Overhead

(E)

Total Costs

(B+C+E)

Surplus /

Deficit

(A-F)

A&E -60 -£1,562 -£386 £375 -£1,550 -£574 -£586 -£976

Anaesthetics 1,411 £139 £88 £80 -£29 -£171 -£4 £143

Medicine & Elderly 3,547 -£439 £423 £4,725 -£5,588 -£6,801 -£1,652 £1,213

Obs & Gynae -130 -£2,441 £63 £1,482 -£3,986 -£1,384 £162 -£2,603

Paediatrics 953 £51 £700 £465 -£1,114 -£416 £750 -£699

Surgery & Urology -1,626 -£1,509 £2,693 £470 -£4,672 -£2,108 £1,055 -£2,564

Trauma & Orthopaedics -88 -£2,380 £116 £23 -£2,518 -£1,690 -£1,551 -£828

Community Services 6,768 £2,316 £2,697 £235 -£616 -£2,353 £579 £1,737

Chemical Pathology 102 £4 -£2 £3 £3 -£3 -£2 £6

Direct Access Pathology 0 -£244 £320 £177 -£741 -£682 -£186 -£59

Direct Access Radiology 0 £36 £393 £134 -£492 -£331 £197 -£161

Other Service Lines -599 -£3,980 -£10,715 £5 £6,729 -£858 -£11,567 £7,587

Non-Trust Activi ty 883 £1,356 £371 £431 £554 -£482 £320 £1,036

11,161 -£8,653 -£3,240 £8,606 -£14,019 -£17,852 -£12,486 £3,833

£'000

Draft

9

Trauma and Orthopaedics – Activity and income levels have remained quite static while costs havesignificantly reduced compared to Q3, resulting in a stabilised deficit. Again, the refined Radiologycosting will have disproportionately impacted upon Orthopaedics.

Community – Income and costs have remained quite static. Note that the large variation in activityis due to activity counting changes in Q4 due to the availability of new data. While the overallincome and quantum of costs will generally remain stable due to mostly block fundingarrangements, activity numbers will continue to be quite volatile as new and more accurate patientlevel datasets become available from SystmOne.

Direct Access Pathology – Income is slightly down, however costs have reduced significantly as aresult of improvements to the data quality. As reported in the last paper, costs in Q3 appeared to beartificially high as a result of anomalies in the data, which have since been corrected.

Other Service Lines – Income has notionally increased to bring the PLICS model (which reportsincome on a PbR basis) in-line with the reported Trust position which reflects the risk-share / blockstatus of the contract, and also an exceptional reversal of impairments in 14/15. This service lineenables the PLICS model to present a more accurate trading position based on true PbR whileensuring the surplus / deficit reconciles to the accounts.

2.4.2 Movement between Q4 2014/15 and Q4 2013/14

While model developments and changes in tariff mean that Q4 2014/15 is not directly comparable with Q4 2013/14, a comparison has been included to provide a more complete overview.

Medicine – Income has reduced slightly while costs have reduced to a greater extent, resulting in afavourable variance when compared to the previous year.

Surgery & Urology – Income has reduced considerably while costs have increased, resulting in anadverse variance when compared to the previous year.

Trauma & Orthopaedics – Income has reduced significantly, while costs have reduced to a lesserextent resulting in an adverse variance compared to the previous year.

Reference Costs 2014/15

2.5 A high level summary of our inpatient, outpatients and A&E Reference Costs data has been included for information in Appendix 1. The national average for the previous year is also shown. It should be noted that the reversal of impairment in 14/15 will have the effect of supressing our cost base and our Reference Cost Index (RCI) score.

2.6 A further paper will be presented to the Board this autumn once the national averages for 2014/15 have been published and we have an understanding of our index score.


3.1 Progress continues to be made in the development of the PLICS data. Improvements have been made and work will continue with clinicians to develop the model further. This goal will be further helped by the recent appointment of a Cost Accountant to support the work of the Systems Accountant.

3.2 The Trust will maintain a strong profile in shaping the National costing agenda, developing costing standards and Reference Costs guidance.

Draft

10

4. Recommendations

4.1 The Board of Directors are requested to:

Note the content of the report. Support the continued development of PLICS as a tool to assist in the strategic decision making

of the Trust. Support the on-going involvement of the Trust to influence the national costing agenda. Acknowledge the continued potential for the profitability of individual service lines to move

significantly during the expected period of volatility whilst costing and subsequently tariffs arerefined.

Note the better than average position for the Trusts reference costs but the deterioration in theposition when compared to the previous year.

Lynne Hodgson Director of Finance, ICT & Support Services

Draft

11

Appendix 1

North Tees & Hartlepool NHS FT - Reference Costs Summary 2014-15

Elective

Year Number of Patients Total Cost Excluded

Drugs Other

Exclusions Total -

Exclusions

Total FCEs -

Exclusions

Cost Per FCE

National Average

2014-15 6,155 £21,489,193 £159,708 £405,829 £20,923,656 6,155 £3,399 2013-14 6,668 £23,429,866 £341,366 £449,488 £22,639,012 6,668 £3,395 £3,375 Movement -513 -£1,940,673 -£181,658 -£43,659 -£1,715,356 -513 £4

Daycase


Drugs Other

Exclusions Total -

Exclusions

Total FCEs -

Exclusions

Cost Per FCE

National Average

2014-15 37,551 £28,391,692 £5,393,812 £10,423 £22,987,456 37,540 £612 2013-14 30,241 £20,188,449 £1,643,609 £41,199 £18,503,641 30,196 £613 £698 Movement 7,310 £8,203,243 £3,750,203 -£30,775 £4,483,814 7,344 £0

Non-Elective Short Stay


Drugs Other

Exclusions Total -

Exclusions

Total FCEs -

Exclusions

Cost Per FCE

National Average

2014-15 38,310 £27,397,408 £205,727 £4,645,452 £22,546,229 38,257 £589 2013-14 39,420 £24,448,791 £274,964 £4,018,939 £20,154,888 39,420 £511 £603 Movement -1,110 £2,948,616 -£69,237 £626,513 £2,391,341 -1,163 £78

Non-Elective Long Stay


Drugs Other

Exclusions Total -

Exclusions

Total FCEs -

Exclusions

Cost Per FCE

National Average

2014-15 22,203 £63,418,222 £644,565 £6,080,769 £56,692,888 21,925 £2,586 2013-14 21,493 £63,712,280 £808,665 £4,685,543 £58,218,072 21,493 £2,709 £2,837 Movement 710 -£294,058 -£164,100 £1,395,225 -£1,525,183 432 -£123

A&E

Year Number of Patients Total Cost Cost Per

Attendance National Average

2014-15 88,319 £10,923,825 £124 2013-14 87,962 £9,806,081 £111 £124 Movement 357 £1,117,744 £12

Outpatients

Year Number of Patients Total Cost Cost Per

Attendance National Average

2014-15 252,081 £36,307,143 £144 2013-14 248,270 £36,598,148 £147 £111 Movement 3,811 -£291,005 -£3

Comments

Significant changes to PLICS model in preparation for Reference Costs collection: 1. Radiology standard exam times and job rotas built in, replacing out-dated and high-level HRG level weightings.2. Capital charges allocation refined based on asset register resulting in charges being matched to specific services (e.g. MRI exams)

Draft



29 October 2015

Executive Summary

Operational Resilience 2015/16


Strategic Aim and Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Board of Directors Reports)

Maintain Compliance and Performance Putting Patients First

1 Introduction

1.1 Significant pressures have been witnessed across the whole health economy both locally and nationally and therefore it is essential that robust plans are in place to not only manage the predicted pressures placed on the Trust through the course of increased all year round surges in activity, particularly during the winter period, but to successfully focus on patient safety, quality and experience.

1.2 To prepare for the winter of 2015/16 and future surges in activity the Trust has reflected on 2014/15 and learnt from the application of plans and responses.

1.3 The Trusts Winter Capacity and Surge Plan 2015/16 has been produced in line with the national context and requirements articulated by NHS England; now merging into an Operational Resilience Plan.

2 Summary

2.1 This report provides an update on the Trusts Winter Capacity, Operational Resilience and Surge Plan 2015/16 and focuses on the required resources, risks, financial impact and challenges to manage the winter months from December 2015 through to March 2016.

2.2 This report describes the arrangements planned by the Trust to maintain effective access to services and strengthen emergency preparedness and resilience specifically for winter 2015/16 but also to ensure on-going resilience during a period of inevitable increase in emergency activity. The paper informs and provides a level of assurance of the scale of planning for 2015/16 which has taken into account the lessons learned from the challenges of previous years.

2.3 Central funding to manage winter pressures is provided as a single funding source for 2015/16 which is also expected to manage surges in activity throughout the year. The allocation is significantly lower than previous years, with no expected second tranche this year. Resilience funding has also been allocated to other organisations within the system to address all areas of health, social and primary care; however it is not anticipated that the system response will be sufficient to support resilience with the impact likely to be felt in the Trust.

1

Draft

2.4 Although work is on-going to support assurance and further refine the plan in readiness for the expected winter surge 2015, a level of assurance with regard to winter resilience has been managed in a number of ways including:

• Planned implementation of winter resources and initiatives• Focused approach to admission avoidance and timely discharge• Provision of appropriate assessment in a timely manner and channelling

patients to an appropriate place of care• Robust management of patient flow and coordination of resources• Strong leadership and engagement at all levels both clinical and non-clinical• Resilient operational, tactical and strategic command and control• Robust governance and assurance.

2.5 The Trust is proactively engaged in the Better Care Fund (BCF) planning with the main Stakeholder Clinical Commissioning Group, Local Authorities and Tees, Esk and Wear Valley Mental Health Trust to improve admission avoidance and timely discharge.

2.6 The Trust continues to engage in the assurance review requirements across the Area Team span of authority and has participated in local Peer Review Programmes. However, despite this and the fact that a number of schemes within the BCF planning (to avoid admission and manage timely discharge) have not come to fruition and reticence remains on system wide readiness for resilience, system resilience is regarded as a risk going forward.

3 Recommendations

3.1 The Board of Directors is requested to note the content of this report and acknowledge the diligence applied to the operational resilience and planning process and proposal for managing surges in activity over the winter months; so to acknowledge the challenges that the Trust will face over the winter months synonymous with resilience management requirements and the potential impact on operational and financial stability.

3.2 The Board of Directors is also asked to consider the risk mitigations that may be taken if planned initiatives are insufficient to meet the demands. To maintain patient safety and effective access, additional funding would be required or resources rationalised, whilst managing the core principle of ‘Putting Patients First’.

3.3 In particular, the Board of Directors is asked to take a level of assurance in recognising the robust work undertaken to achieve the current state of resilience and preparedness to respond to winter whilst noting the risk associated with system resilience.


2

Draft



29 October 2015

Operational Resilience 2015/16


1 Introduction

1.1 Year on year effective winter planning and surge management has been a key priority within both the NHS and the Trust with this year being no exception. Whilst the Trust is well rehearsed in planning for winter and surge, needless to say each year is different bringing with it individual and unexpected challenges from which the Trust reflects and plans for the future, working collaboratively with commissioners and other key stakeholders. There is also a national drive to ensure additional assurance in the system with regard to emergency departments and system resilience.

1.2 System Resilience Groups (SRG) are now established to coordinate capacity planning and operational delivery across the health and social care system. However there has been little additional infrastructure within primary and social care to support surges in emergency activity, reductions in admissions or delayed discharges.

1.3 Last winter presented unprecedented surges in activity and tested the effectiveness and resilience of emergency care provision locally and nationally; this year has seen pressure continue through the spring and summer months and data trends would suggest that despite there not being a significant increase in activity, there has been an increase in the level of patient acuity and complexity.

1.4 Whilst winter is clearly a period of increased pressure, establishing sustainable year-round delivery requires system planning to be on going and robust. The existing challenges are compounded by disease, demographic and economic risks. System partners need to be in a position to move away from what is becoming a reactive approach to managing challenges towards a proactive, year round, system approach to sustainable resilience.

1.5 Central funding to manage winter pressures is provided as a single funding source for 2015/16 which is also expected to manage surges in activity throughout the year. The allocation is significantly lower than previous years, with no expected second tranche this year. Resilience funding has also been allocated to other organisations within the system to address all areas of health, social and primary care; however it is not anticipated that the system response will be sufficient to support resilience with the impact likely to be felt in the Trust.

1.6 The performance of the NHS has continued to be under scrutiny during the summer months of 2015/16, particularly in emergency care, with activity levels being higher than previous years. There continues to be extensive media coverage of A&E performance and under achievement of the 4 hour clinical indicator at national level. Although there has been an increase in the volume of patients attending A&E, the increase in 4 hour breaches has resulted from several pressures in the system. The

1

Draft

waits to see a consultant in A&E is, on occasions, an issue however the acuity of patients on wards, increased length of stay, high occupancy and delayed processes in discharge, in addition to limited impact on admission avoidance, have also contributed to a number of breaches of the 4 hour standard.

1.7 To prepare for the winter of 2015/16 and future surges in activity the Trust has reflected on 2014/15 and learnt from the application of plans and responses. Further work continues to improve patient flow and efficiencies within the system including the ‘Breaking the Cycle’ initiative. Escalation triggers have been amended to be more predictive and responsive within departments. An action plan has been developed to address issues and improve processes and is being governed and monitored by the Internal Emergency Care Collaborative Group.

1.8 As a representative on the SRG and the Northern CCG Forum the Trust has fed back concerns and constructive solutions, with regard to system wide issues and continues to attend to influence options for the future. Not least, payments for diverts and clear protocols to enable immediate enactment of support from agencies other than the acute sector, e.g. spot purchasing of nursing home beds. It is essential that the same robust and transparent escalation and timely response is enacted across the system to support admission avoidance and timely safe discharge.

1.9 Further work is on-going with CCGs and the local authorities to improve the timeliness of social care assessments and the commencement and recommencement of social care packages.

1.10 Risks will continue to be identified to ensure that mitigation can be introduced into the system to minimise any impact on financial and operational efficiency and to support the drive for high quality care to avoid the impact on the Trust.

1.11 The Board of Directors will recall the report presented and discussed on 23 April 2015 summarising the pressures faced in the system during the winter period, a reflection on responses and management tactics and the risks and challenges informing future planning. The Board of Directors will also recall discussions at the Board and Council of Governor’s meetings, throughout the year, on progress and challenges as to the detailed developments and evolvement of the resilience plans.

1.12 This report provides an update on the Trusts Winter Capacity, Operational Resilience and Surge Plan 2015/16 and focuses on the required resources, risks, financial impact and challenges to manage the winter months from December 2015 through to March 2016.

2. Operational and Capacity Resilience Planning 2015/16

2.1 The SRG is required to submit a multi-agency plan to the Area Team, signed off by all membership organisations, including the mandatory elements of good practice, wider considerations, governance and building on existing work.

2.2 Unlike previous years the Trust has been allocated resilience funding in the baseline to address surges in activity all year round, not just for winter. As such, the SRG has requested that all organisations utilise initiatives from last winter as and when required. The funding received is significantly less that previous years and there will be no second tranche to support the expected financial risks, with additional expenditure, associated with the national and local system impact on the Trust.

2

Draft

2.3 In the current economic climate, compounded by the added delay in recruitment of nursing staff in line with the restrictions of immigration policy, albeit recently relaxed, it is anticipated that safe staffing initiatives will err on the worst case scenario of financial outlay. It is also anticipated that other funded schemes across the system will not have the desired impact to reduce attendances, admissions and readmissions to the Trust nor support timely discharge.

2.4 The initial winter plan was produced in line with the national requirements articulated by NHS England and customised following a winter debrief / planning session in July, to review capacity and capability to manage pressures faced last winter, utilising lessons learnt to improve the planning process for this winter.

2.5 With increased political and media interest on the challenges faced nationally within emergency care, in particular accident and emergency units, it is essential that the Trust ensures optimal resilience within financial constraints.

The plan focuses on:

• Planning and support (planning process for 2015/16).• Key pressures that arose from previous winters (key areas of learning from

last year’s experience).• Demand and capacity modelling.• Risks and mitigations to capacity constraints.• Operational response and monitoring.• Governance and assurance.

3 Planned Winter Resources and Initiatives

3.1 Resilience Beds and Emergency Access

3.1.1 On analysis of the past three years activity it is anticipated that an average of 34 medical resilience beds will be required from December 2015 to March 2016. Options of where the beds will be placed are being scoped with a view to being available on 30th November 2015 and staffed through to 4th April 2016, to encompass the week following Easter.

3.1.2 The preferred option, whilst requiring mitigating actions, will create economies of scale with less impact on other specialties.

3.1.3 The risks are the greater expenditure as a result of reliance on agency spend, owing to the delayed recruitment and commencement of nursing staff as a consequence of immigration policy and the ensuing impact on safe staffing. Mitigation plans centre on utilisation of nursing staff in corporate roles as an extended resource and a further European recruitment drive to NHSP to reduce agency spend and manage a consistent and capable resource.

3.1.4 The paediatric resilience requirement, flexing from 20 to 26 beds will be managed within budgeted establishment.

3.2 Day Case Unit and Elective Access

3.2.1 During the winter months, at escalation to NEEP Level 4, a planned initiative is to ‘swing’ surgical beds to accommodate safe emergency patient flow, within existing

3

Draft

resources, whilst opening the Day Case Unit overnight. to ensure minimal disruption to the elective waiting times and cancer programme of work.

3.4 Ancillary support

3.4.1 To support the additional beds and other initiatives across the Trust the increased provision of catering, portering and domestic services is required and planned within the available budget.

3.5 Pharmaceutical support

3.5.1 To service the additional 34 beds and to provide support to the Emergency Assessment Unit (EAU) additional pharmaceutical services are required to ensure that discharge scripts are submitted and dispensed in a timely manner. The opening times of the pharmacy will also be extended to evenings and weekends.

3.6 Front Loading of Elective Activity

3.6.1 With the aim of reducing the impact of seasonal pressures, the Trust will, as far as possible, front load the delivery of elective surgical and orthopaedic activity prior to December. This would reduce the current elective waiting list and therefore lessen the potential pressures during the winter period if emergency activity increases to a point where elective beds and theatre capacity are affected.

4 Admission Avoidance and Timely Discharge

4.1 The Emergency Care Intensive Support Team (ECIST) describe how bed occupancy could be reduced cost and harm events lessened and increased patient satisfaction can be achieved by implementing good practice for complex discharges of frail older people. The good practice includes the development of hospital ‘front-end services, proactively managing patients with a length of stay of over 14 days, using a ‘pull approach’ to acute discharges, improving social services care management, prioritising dementia care and providing care home support.

4.2 Ambulatory care and direct admissions’ pathways have already been established and there is an extended consultant presence in A&E and EAU seven days a week. Daily ‘huddles’ are currently being piloted on medical wards to embed the expected date of discharge (EDD) principles and focus resources to facilitate timely discharges.

4.3 Work is on-going to involve social services within multidisciplinary teams (MDT) and community services will continue to provide education and support to care homes. The Trust embarked on the delivery of ‘A Perfect Week’ from 7 to 14 October, as part of the Breaking the Cycle initiatives. It involved engagement with external organisations, support from non-clinical managers and a visible presence, leadership and support from the Executive team. The week focused on patient flow and discharges and demonstrated an improvement in performance. A report out session will be held in November.

4.4 The Trust continues to strive to comply with the SAFER patient flow bundle through the robust management of projects and piloting different ways of working to monitor their effectiveness. The SAFER patient flow bundle consists of 5 basic principles:

4

Draft

Senior review – all patients have a consultant review before midday All patients have an (EDD) Flow of patients will commence by 10am from EAU to inpatient wards Early discharge with 33% of discharges taking place before midday Review of patients with LOS greater than 14 days weekly.

4.5 Further work is planned to optimise the SAFER principles in practice. In addition, the out of hours management structure has been reviewed to enhance patient flow and discharge with the increase in bed management resource. The team has also been strengthened with investment into critical care outreach with a focus on patient safety. These initiatives have been implemented during the summer months to ensure new practices are embedded pre winter.

5 Admission and Assessment

5.1 On attending the hospital, patients require prompt and comprehensive assessment to ensure the appropriate care and treatment is provided in a timely manner. However many patients attend A&E in the ignorance of other, more appropriate, places of care. Initiatives have been successfully piloted and will be further rolled out this year to ensure supported discharge and redirection of patients to alternative places of care.

5.2 GP in A&E

5.2.1 A pilot to house a GP in A&E from 10am to 10pm on weekends and bank holidays, since the beginning of April, has evaluated extremely well by the A&E staff, GPs and patients. This initiative is continuing and will be rolled out on a permanent basis in line with the urgent care centre tender.

6 Flow and Coordination

6.1 During the winter months of 2015/16, when all available capacity is exhausted, short term, additional capacity will be considered to maintain patient flow, access to emergency services and to sustain elective activity. This can only be achieved within the boundaries of safe staffing, budgetary constraints and whilst maintaining a level of service provision within expected quality standards.

7 Finance

7.1 In the current financial climate and whilst striving to maintain the regulatory requirements of the Terms of Licence and the Risk Assessment Framework the planning associated with operational resilience and specifically the preparation for expected winter surge, has taken due cognisance of allocated budget and financial constraints. Planning has incorporated a financial sensitivity analysis and in doing so, the risks posed by recruitment limitations, the expected insufficiency of system resilience and the impact of triggers for escalation during periods of intense surges in activity.

7.2 The financial outlay, within allocated funding, has been debated, discussed and agreed at Executive team meetings and subsequent discussions have been held with

5

Draft

commissioners and SRGs to alert as to the risks of underfunding the required initiatives as a result of continued surge and the limited assurance around system resilience and therefore the potential impact on the Trust.

7.3 Whilst a number of planned initiatives can be managed within the available funding for winter at £1,462,000, all system eventualities, continuous escalation and associated risks cannot be borne by the Trust, therefore indicating a significant shortfall in funding.

8 Leadership

8.1 Firm leadership arrangements are present to ensure that planning, preparation and proactive resilience is prevalent throughout the organisation.

8.2 The Chief Operating Officer/Deputy Chief Executive is supported by Senior Managers and Clinical Directors who are responsible for communicating key messages, and supporting tactical responses to key challenges.

8.3 All other Directors have a stake hold not only in supervising planning, preparation and response tactics but also in the expertise required for decision making in the event of a sustained surge and process change.

8.4 Clinical leadership and timeliness of senior decision making is vital to, not only to manage successful surge management, but also for overall capacity management. Rotas ensure senior clinical cover at peak times in both EAU and A&E, and improved medical infrastructure on base wards, contributes to timely management and optimises patient flow. The focus on timely decision making and proactive discharge planning continues through senior clinician board and ward rounds.

8.5 The Trust is proactively engaged in the Better Care Fund (BCF) planning with the main Stakeholder Clinical Commissioning Group, Local Authorities and Tees Esk and Wear Valley Mental Health Trust to improve admission avoidance and timely discharge. The schemes being planned have not come to fruition and reticence remains on system wide readiness for resilience. System resilience therefore poses a real risk to the Trust, particularly during the winter period.

8.6 It is imperative that the Trust has identified leaders who have clearly defined roles and responsibilities; therefore, during times of surge, senior decision makers remain at the forefront of operational services to make timely and appropriate decisions. Directors, Senior Managers, Matrons and Senior Nurses provide continuous support to this infrastructure; co-ordinating and controlling the patient flows within the clinical and non-clinical services. This is demonstrated with a senior on call rota, a bed management capacity and patient flow structure and a well embedded electronic bed management system, supported by robust processes. Recent changes to the Manager on Call rota provide a management presence until 2000 hours on weekdays and, at NEEP Level 4, during the day on weekends and bank holidays. This enhancement will ensure the patient flow is managed more appropriately.

8.7 Policies and operational guidelines further support the leadership infrastructure with the expectation of standardised practices and procedures, ensuring quality and patient safety are at the forefront of operational, tactical and strategic decisions..

9 Operational, tactical and strategic command and control

6

Draft

9.1 The successful and tested implementation of the Resilience Command and Control Centre function serves to support escalation during unexpected surges, whereby the operational leads are supported with regard to coordination of advice, guidance and logistics. 9.2 The key to the management of winter and surges in activity is the command and control process. The Clinical Site Coordinator and the patient flow team provide the operational command and management of patient flow. The restructure of bed management and site coordination and the refocus and enhancement of the critical care outreach team will negate additional expense.

9.2 The Manager on Call provides the tactical response and, during times at NEEP Level 4 will provide a presence on site on weekend and bank holiday days to provide visible leadership decision making and support.

9.3 The Director on Call provides the strategic response and takes command at NEEP level 4.

9.4 Escalation

9.4.1 The severity of pressure, due to surges in activity, is continually assessed by the Manager on Call and escalation is activated according to the NEEP levels. At each level of the NEEP there are associated actions ranging from cancellation of training and utilisation of clinical staff in non-clinical roles to declaration of a major incident

9.4.2 In the event of escalation to NEEP Level 4 or above, in parts of the system, system command and control may choose to invoke the Divert Policy and request that ambulances are diverted from one provider A&E to another. In this event there would be a financial penalty of £2,000 per divert and an incentive payment of £1,500, per divert, to the receiving Trust. This proposal has not yet resulted in a variation to contract. The Trust actively participates in resilience command discussions and in the main has always managed escalation control and subsequent resilience.

10 Governance and Assurance

10.1 The Executive Team has agreed the allocation of the winter funding received by the CCGs. The finances are finite and escalation to NEEP Level 3 and above will provide periods of challenge to allocate resources in the most efficient and effective way to optimise patient flow, safety and quality of service provision. Notwithstanding current discussions around funding allocation with the CCGs and SRGs, in the event of extended periods of escalation and system pressure the Trust will place an onus on CCGs to provide continued or additional services beyond and outwith the budgetary allocation / plan.

10.2 All expenditure throughout the period will be monitored by the Executive Team on a weekly basis. Any unforeseen expenditure will be escalated to the Chief Operating Officer / Deputy Chief Executive and Director of Finance for authorisation, with immediate decisions being made by the Director on Call.

11 Summary

11.1 The winter months of 2014/15 proved challenging with unprecedented pressures on the system resulting in unforeseeable expenditure on additional resources to manage patient flow, safe staffing and quality of service provision. Preparation and planning for operational resilience and surge management, this year, has been robust as

7

Draft

always and this paper details the initiatives and allocation of resources to manage surges in activity throughout the winter of 2015/16.

11.2 Whilst resources will be managed to optimise efficiency and safety of service provision in a cost effective manner, it is not anticipated that the system wide approach will have much bearing on the demand on acute services, thus posing a real risk to the Trust.

11.3 The financial outlay for the plan has been agreed at Executive team meetings and subsequent discussions have been held with commissioners and SRGs to alert as to the risks of underfunding the required initiatives as a result of continued surge and the limited assurance around system resilience and therefore the potential impact on the Trust.

11.4 Whilst a number of planned initiatives can be managed within the available funding, all system eventualities, continuous escalation and associated risks cannot be borne by the Trust, therefore indicating a significant shortfall in funding.

11.5 All expenditure will be monitored by the Executive Team, however, the finances are finite and escalation decisions will provide periods of challenge to allocate resources to optimise patient flow, safety and quality of service provision. Notwithstanding current discussions around funding allocation with the CCGs and SRGs, in the event of extended periods of escalation and system pressure the Trust will place an onus on CCGs to provide continued or additional services beyond and outwith the budgetary allocation / plan.

11.6 The Trust will continue to feedback concerns and constructive solutions, with regard to system wide issues and will continue to attend resilience forums to influence options for the future.

12 Recommendations

12.1 The Board of Directors is requested to note the content of this report and acknowledge the diligence applied to the operational resilience and planning process and proposal for managing surges in activity over the winter months; so to acknowledge the challenges that the Trust will face over the winter months synonymous with resilience management requirements and the potential impact on operational and financial stability.

12.2 The Board of Directors is also asked to consider the risk mitigations that may be taken if planned initiatives are insufficient to meet the demands. To maintain patient safety and effective access, additional funding would be required or resources rationalised, whilst managing the core principle of ‘Putting Patients First’.

12.3 In particular, the Board of Directors is asked to take a level of assurance in recognising the robust work undertaken to achieve the current state of resilience and preparedness to respond to winter whilst noting the risk associated with system resilience..


8

Draft

1



29 October 2015

Executive Summary

Board Assurance Framework, Quarter 2, 2015/16

Report of the Company Secretary

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Board Reports)

Putting Patients First Maintain Compliance and Performance Health and Wellbeing

Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Board Reports)

Putting Patients First/Patient Safety Maintain Compliance and Performance Effective Board Governance

1. Introduction

1.1 The purpose of this report is to provide the Board of Directors with the current position in relation to the management of strategic risks on the Board Assurance Framework.

1.2 The change to the design and content of the Board Assurance Framework has been undertaken as part of a review of the Trusts overall Risk Management Strategy. The Board of Directors held a seminar to examine the Trusts Risk Strategy; changes were initiated from this session alongside recommendations from internal audit.

1.3 The changes to the Risk Management Strategy underpin the changes made to the Board Assurance Framework, to reflect the strategic aims and objectives of the Trust. In addition, the framework directly links to the delivery of the strategic aims of the Trust and differentiates the governance surrounding assurance, corporate and operational risk management.

2. Key Issues and Planned Actions

2.1 Each strategic risk on the Board Assurance Framework has been reviewed by the Lead Director in accordance with the agreed process.

2.2 In making their recommendations on proposed assurance levels, the Lead Director considered the notable changes/updates to each risk since the last report and the actions in place to mitigate these risks.

Draft

2

2.3 The Board Assurance Framework has developed in since quarter 1 with further depth provided across each criterion in order to enhance the information provided.

2.4 Further work will be undertaken in respect to some areas within the Framework including risk appetite, assurance and RAG rating, which will be addressed at a Board Seminar being held on 12 November 2015. Following this seminar the outcomes will be used to support further enhancement of the links between the Board Assurance Framework and the corporate risk register.

2.5 The process for review of the Board Assurance Framework will be confirmed at the Board Seminar on 12 November 2015. The proposal will be that each Board Committee will use the Framework to review the assurances on risk controls and consider the proposed assurance levels for each strategic risk which falls under its area of responsibility. The Company Secretary will meet with the Lead Directors no less than 4 times a year in order to review and update progress in preparation for presentation of the Framework to the Audit Committee and for formal approval at the Board of Directors.

2.6 As this is the first review of the new style Board Assurance Framework, changes have been highlighted in blue print within the document to facilitate easy identification. This is provided at Appendix 1 for review and formal acceptance by the Board of Directors. A summary of proposed changes made by Lead Directors are detailed in the main body of the report.

3. Recommendations

3.1 The Board of Directors are asked to approve the levels of risk allocated to each area of risk by the Lead Director. Changes can only be made by the Board following recommendation by the relevant Director, discussion at relevant Board Committees and with the provision of the relevant evidence.

3.2 Lead Directors have provided their assessment of the level of assurance available in relation to the individual areas of risk within the framework; the Trust Board are asked to approve these assessments.

3.3 The Board of Directors are specifically asked to approve the following:

2B – The removal of this criterion from the Board Assurance Framework in view of the „pause‟ that has been initiated by the Trust; 3A - The change in Lead Director from the Chief Operating Officer/Deputy Chief Executive to the Director of Nursing, Patient Safety and Quality‟ 5D - The proposal to reduce the risk level from Amber 9 (3x3) to Amber 6 (2x3).

Barbara Bright Company Secretary

Draft

3



29 October 2015

Board Assurance Framework, Quarter 2, 2015/16

Report of the Company Secretary

1. Introduction

1.1 The purpose of this report is to provide the Board of Directors with the current position in relation to the management of strategic risks on the Board Assurance Framework.

1.2 The change to the design and content of the Board Assurance Framework has been undertaken as part of a review of the Trusts overall Risk Management Strategy. The Board of Directors held a seminar to examine the Trusts Risk Strategy; changes were initiated from this session alongside recommendations from internal audit.

1.3 The changes to the Risk Management Strategy underpin the changes made to the Board Assurance Framework, to reflect the strategic aims and objectives of the Trust. In addition, the framework directly links to the delivery of the strategic aims of the Trust and differentiates the governance surrounding assurance, corporate and operational risk management.

1.4 The Board Assurance Framework for Quarter 1 2015-16 was approved by the Board of Directors in July 2015; this framework contained 18 principal areas of risks across the strategic aims, each of which has an allocated Lead Director.

1.5 During Quarter 2 the Assistant Director of Clinical Governance has met with the identified operational leads for each criterion as well as the Lead Directors. These meetings have been held to ensure that all areas of the framework are reviewed and updated appropriately.

1.6 As this is the first review of the new style Board Assurance Framework there has been further depth provided across each criterion in order to enhance the level of information provided. Some of these changes are relatively minor and as such are not all have been highlighted in this summary report; however all changes are highlighted in blue text in the full document. Clear links between various criterion and relevant actions have been identified.

1.7 The reviewed Board Assurance Framework is provided as appendix 1; details of proposed changes made by Lead Directors are detailed in the following sections of this report.

1.8 Within each criterion Lead Directors have been asked to consider the evidence available regarding assurance and apply a subjective RAG rating in relation to their assessment of the assurance available to the Board of Directors.

Draft

4

2. Key Findings of Review

2.1 Putting Patients First

1A: There is a risk that mortality reporting and monitoring may not be effective in the Trust This criterion has been reviewed and more depth has been added to the cause and consequence sections. The previous actions included the continuing work of the Keogh Delivery Group; this action has been removed as the work of this group is included in the control section relating to this area of risk.

The overall current risk rating remains unchanged at this time. Additional detail has been added to the Assurance section and the overall assessment of the available assurance is identified as AMBER.

Supporting Evidence: Mortality Board Report, Patient Safety & Quality Standards minutes and summaries.

1B: There is a risk that the People Strategy principles are not fully embraced or embedded across the Trust‟. This criterion has been reviewed and more depth has been added to the cause and consequence sections. The Director of Human Resources and Education and the operational leads have reconsidered the wording of the risk identified and have replaced the previous risk “that the Organisational Development Strategy will not be implemented fully” as they felt this did not appropriately reflect the risk to the strategic aim of the Trust.

Previous actions have been completed and are now within the controls applied to manage this area of risk. However, additional actions have been included to enhance involvement in the on-going work of culture; and another to ensure there are systems in place to apply Value based recruitment across the organisation, Board to Ward.

The overall current risk rating remains unchanged at this time; the overall assessment of the available assurance is identified by the Director of Human Resources and Education as GREEN.

Supporting Evidence: HR & Education Board report, inclusive of performance dashboards.

1C: To continuously identify & implement patient safety improvements This criterion has been reviewed and more depth has been added to the cause and consequence sections.

The overall current risk rating remains unchanged at this time; the overall assessment of the available assurance is identified by the Medical Director and Deputy Director of Nursing, Clinical Governance and Patient Safety as GREEN.

Supporting Evidence: Serious Incident Board Report; Patient Safety & Quality Standards minutes and summary.

1D: For patients to consistently have good experiences of our services

Draft

5

This criterion has been reviewed and more depth has been added to the cause, consequence and control sections. Further actions have been included to consider the evaluation of the open and honest culture and also the Trusts ability to obtain feedback from hard to reach groups.

The overall current risk rating remains unchanged at this time; the overall assessment of the available assurance is identified by the Deputy Director of Nursing, Clinical Governance and Patient Safety as GREEN.

Supporting evidence: Quality Report, Patient Safety & Quality Standards minutes and summaries.

2.2 Integrated Care Pathways

2A: To provide appropriate integrated support and care for patients with long term conditions to enable them to maximise their health in the community or avoid the need for hospital admission. During quarter 2 there has been changes in the portfolios of the operational lead involved with this criterion; this has resulted in some changes in process that will support a positive movement against this risk in the coming quarters.

The overall current risk rating remains unchanged at this time; the overall assessment of the available assurance is identified by the Transformation Change Director and Chief Operating Officer/Deputy Chief Executive as AMBER due to the need to enhance assurance with external review. There remain gaps in assurance around stakeholder engagement across pathways; system leadership and system transformation; the Directors will continue to do everything to manage these but they remain an issue for the organisation.

Supporting evidence: North of Tees Partnership Board minutes

2B: The Trust risks placing a disproportionate focus on its longer term solution of a single site hospital and undermines the sustainability of services. The Director of Finance, ICT and Support Services has proposed the removal of this criteria from the Board Assurance Framework in view of the “pause “ that has been initiated by the Trust for the foreseeable future.

The Board is asked to approve the removal of this criterion from the framework.

2.3 Service Transformation

3A: There is a risk that our systems and processes fail to identify when there are problems with clinical practice or outcomes. The content of this criterion has been reviewed in full by the operational leads; this has enabled enhanced detail. There has been a change in the Lead Director with responsibility now shared between the Medical Director and Director of Nursing, Quality and Patient Safety. Previously the Chief Operating Officer/Deputy Chief Executive was identified as jointly responsible with the Medical Director.

The overall current risk rating remains unchanged at this time; the overall assessment of the available assurance is identified by the Medical Director as AMBER as there is a need to gain enhanced detail around the benchmarking from national audit programmes

Draft

6

to give an overall picture across the measurable outcomes. Actions have been added to examine how this can be achieved.

Supporting evidence: Quality Report.

3B: There is a risk that the organisation cannot maintain sustainable service provision. The risk identified in this criterion is covered by the information provided across all other criterion and is non specific in nature. All other aspects of the Board Assurance framework should be considered when examining this risk.

The Transformation Change Director has identified an action to lead into the end of year review of the Board Assurance Framework; this will involve developing specific core criteria in relation to transformation risk.

2.4 Manage Our Relationships

4A: There is a risk that contracted agreements will not be in place for 1 April 2015; and the Trust will then not be able to meet its performance requirements within contract by 31 March 2016. The content of this criterion has been reviewed in full by the operational lead and Lead Director; this has enabled enhanced detail. Additional actions have been included to support provision of enhanced information and assurances in relation to the delivery of CQUIN targets and KPIs within clinical directorates.

The Director of Finance, ICT and Support Services has assessed the level of assurance in relation to this criterion as AMBER.

Supporting evidence: Finance and Contract Performance Report

4B: There is a risk that all stakeholders and partners are not involved in developments relating to the provision of healthcare across the wider health economy and also within the organisation. The risk identified in this criterion is covered by the information provided across all other criterion and is non-specific in nature. All other aspects of the Board Assurance framework should be considered when examining this risk.

2.5 Maintain Compliance and Performance

5A: Risk of failure to meet allocated targets for: MRSA Bacteraemia (zero)

C Difficile (13) This criterion has been reviewed in full by the operational lead; there are few changes made but the additional assurance details have been added in relation to the external reviews completed. This has enhanced the level of assurance but as the operational lead has identified further areas of assurance that can be obtained this has been assessed as AMBER for the end of quarter 2.

Additional actions have been added to include details around the compliance with the recently published patient safety alert and also to review the provision on face to face training across the organisation.

Draft

7

Supporting evidence: Quality Report, Infection Prevention and Control Report, Performance report.

5B: Risk that performance management does not identify and manage risk to compliance in a timely way. The content of this criterion has been reviewed in full by the operational lead and Lead Director; this has enabled enhanced detail. There are gaps in control relating to the need to consider a system wide approach to the cancer pathways and potential inability to provide supplementary activity to support the pathways.

This has resulted in a gap in assurance relating to the system wide approach to management of cancer pathways as it stands currently; therefore the Chief Operating Officer/Deputy Chief Executive has assessed the overall level of assurance as AMBER.

Supporting evidence: Compliance and Performance Board Report. Quarterly/Annual Governance Statements

5C: There is a risk that the Risk Management Strategy will not be understood and implemented across the trust. This criterion has been reviewed with the operational lead and the Deputy Director of Nursing, Clinical Governance and Safety. The Risk Management Strategy was approved at the end of quarter 1 and actions are in place to progress the embedding of this and to also enhance awareness across the organisation. A Board seminar and educational sessions are planned during quarter 3.

Currently the assurance level has been assessed as AMBER until the seminar and training sessions are initiated.

Supporting evidence: Patient Safety & Quality Standards minutes and summaries.

5D: Inability to provide evidence and assurances regarding compliance with the Fundamental Standards and Care Quality Commission (CQC) Regulations. This criterion has been reviewed by the Deputy Director of Nursing, Clinical Governance and Patient Safety. There has been minimal change to the content and the actions have been completed. The Trust is currently awaiting publication of the draft report following the CQC inspection in July 2015.

Following the provision of the necessary evidence to satisfy the requests of the CQC it is proposed that the risk level for the risk reduce from Amber 9 (3 x 3) to Amber 6 (2 x 3). Further assessments and assurance cannot be undertaken until the report has been received. The assurance level has been assessed as AMBER for the same reason.

Supporting evidence: Quality report, Patient Safety & Quality Standards minutes and summaries.

5E: There is a risk that programmes are not in place to meet the full SIEP target of £6.6 million set for 2015/16. This criterion has been reviewed by the operational leads and the Director of Finance, ICT and Support Services. The direct references to transformational nominal targets have been removed and are covered within BAF criterion 2A. However this has identified a minor gap in clarity around the governance of SIEP and transformation that needs to be enhanced.

Draft

8

The assurance level has been assessed by the Director of Finance, ICT and Support Services as being RED due to the Trust not being able to provide assurance that the accountability framework is being fully applied.

Supporting evidence: Delivering the Financial Savings Programme 2015/16

5F: The risk of the trusts ability to turnaround its financial performance and address the operational deficit reported in 2014/15 and the forecasted deficit for 2015/16. This criterion has been reviewed by the operational lead and the Director of Finance, ICT and Support services there have been a few minor changes to the content, however several of the actions have been agreed to be on-going control measures and have been closed as a result.

The assurance level has been assessed by the Director of Finance, ICT and Support Services as being AMBER.

Supporting evidence: Finance and Contract Performance Report

5G: There is a risk that the integrity and robustness of systems, and the use of those systems, will not support the business. This criterion has been reviewed by the operational leads and the Director of Finance, ICT and Support Services; the risks associated with the introduction of Trakcare are currently being assessed in order to identify the major risks from the projects risk register onto the Trusts risk register; clinical directorates have already started to identify internal issues in relation to training and links into current IT systems.

The major concern identified going into quarter 3 is the inability to provide assurance around the ability of the new EPR system to provide the necessary requirements of the organisation until it is “live”. As a result the assurance level has been assessed by the Director of Finance, ICT and Support Services as being AMBER

Supporting evidence: Notes of IM & T Steering Group and the EPR Programme Board Meetings

2.6 Health and Wellbeing

6.A: There is a risk of an inability to provide appropriate health and well-being services andimprove outcomes across the population of Easington, Hartlepool, Sedgefield and Stockton. This criterion has been reviewed by the operational lead and the Chief Operating Officer/Deputy Chief Executive with minor changes to the content, however several of the actions have been agreed to be on-going control measures and have been closed off because of this. The related strategies are currently being reviewed and an update on progress is provided.

The level of assurance available has been considered by the Chief Operating Officer/Deputy Chief Executive who has given a current rating of AMBER.

Supporting evidence: Quality Accounts, Health and Wellbeing Board attendance and minutes

Draft

9


3.1 The Board Assurance Framework, as agreed, will remain in place until the end of quarter 4 2015/16; the framework will then be closed down by the Board of Directors; this will prompt the development of a Board Assurance Framework, aligned to the strategic aims and objectives, to cover 2016/17.

3.2 Over quarter 3 the Lead Directors and the operational leads will again review the information provided and assess the gaps in control in order to update the risk reduction plan. Dependant on this the current risk rating will be considered through relevant committee structures to support Directors in making recommendations to the Board of Directors for any changes to the framework.

3.3 During quarter 3, the Lead Directors and operational leads will also be asked to review what internal and external assurance is available. The level of assurance can directly link to the internal audit plan and to the agenda of the Audit Committee as well as other relevant operational committee structures.

3.4 In line with the Risk Management Strategy there will be continued work to enhance the links between the Board Assurance Framework and the corporate risk register.

4. Recommendations

4.1 The Board of Directors are asked to approve the levels of risk allocated to each area of risk by the Lead Director. Changes can only be made by the Board following recommendation by the relevant Director, discussion at relevant Board Committees and with the provision of the relevant evidence.

4.2 Lead Directors have provided their assessment of the level of assurance available in relation to the individual areas of risk within the framework; the Trust Board are asked to approve these assessments.

4.3 The Board of Directors are asked specifically asked to note and approve the following:

2B – The removal of this criterion from the Board Assurance Framework in view of the „pause‟ that has been initiated by the Trust; 3A - The change in Lead Director from the Chief Operating Officer/Deputy Chief Executive to the Director of Nursing, Patient Safety and Quality‟ 5D - The proposal to reduce the risk level from Amber 9 (3x3) to Amber 6 (2x3).

Barbara Bright Company Secretary

Draft

10

Appendix 1

Board Assurance Framework

1. Strategic Aims

The Trust Board has identified and agreed Strategic Aims within the Corporate Strategy 2013/18. These strategic aims are described in the following table:

Aim What is it

Putting Patients

First

To create a patient centred Organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery.

Integrated Care

Pathways

To develop and expand the portfolio of services to provide integrated pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare.

Service

Transformation

To continually review, improve, transform and grow our healthcare services to respond to the needs of our healthcare community. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes.

Manage our

Relationships

To ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

Maintain

Compliance and

Performance

To maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business

Health and

Wellbeing

To embrace the health and wellbeing of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the provision of services from the Trust.

Many of these Strategic aims are closely interlinked and initiatives in place for one will also cover other areas. There are some aims that have criteria identified that link directly to other sections; these are highlighted and should be considered in conjunction with each other.

2. Board Assurance Framework

The Board Assurance Framework is one of the tools that the Trust uses to track progress against these Strategic Aims. As part of the development of the Board Assurance Framework each financial year, the principal objectives for the year are identified and the potential risks to achieving these assessed for inclusion on the framework. As such, all risks on the Board Assurance Framework are set out under the Strategy Aims.

The Board Assurance Framework is based on seven key elements:

Clearly defined principal objectives with clear lines of responsibility and accountability Clearly defined principal risks together with an assessment of their potential impact and likelihood. Key controls by which these risks can be managed Potential and positive assurances that risks are being reasonably managed Board reports detailing how risks are being managed and objectives met, together with the identification of gaps in assurances and gaps in controls. Risk reduction plans, for each risk, which ensures the delivery of the objectives, control of risk and improvements in assurances.

Draft

11

A target risk rating for the end of the financial year, which is in line with the Board approved risk appetite for each principal risk

The Board will receive a Board Assurance Framework report quarterly summarising any proposals for reduction or increases in risk ratings, along with supporting evidence.

3. Risk Matrix

The table below demonstrates the Trust‟s risk matrix that will be used within the framework.

Consequence/Impact 1 2 3 4 5

Likelihood Negligible Minor Moderate Major Catastrophic 1 – Rare Green

1 Very Low

Green 2

Very Low

Green 3

Very Low

Yellow 4

Low

Yellow 5

Low

2 – Unlikely Green 2

Very Low

Yellow 4

Low

Yellow 6

Low

Amber 8

Moderate

Amber 10

Moderate

3 – Possible Green 3

Very Low

Yellow 6

Low

Amber 9

Moderate

Amber 12

Moderate

Red 15

High

4 – Likely Yellow 4

Low

Amber 8

Moderate

Amber 12

Moderate

Red 16

High

Red 20

High 5 - Almost

Certain Yellow

5 Low

Amber 10

Moderate

Red 15

High

Red 20

High

Red 25

High

Draft

12

4. Risk Appetite

The Trust has decided to adopt the HM Treasury definitions for risk appetite. Recognising that it is not possible to eliminate all risk, the Trust will accept risk on the basis of the Risk appetite. This is the degree of risk, or potential adverse impact from an event, that the Trust is willing to accept within its progress towards achieving overall strategic objectives. The table below provides examples of how this can be applied to risks:

Draft

13

5. Assurance levels

All identified risks will include details of any assurances that have been obtained either through internal or external sources. The level of assurance that this provides needs to be assessed and RAG rated in relation to:

The source of assurance (management or independent) and how robust this is; and the The level of assurance that this provides, i.e. what are the findings/conclusions the source of assurance describes

All Board Committees will be asked to RAG rate the level of assurance for the risks they are managing. This is unlikely to happen until the second quarter of each financial year.

6. Key Findings of reviews

Review meetings will be held with each Executive Director, and operational managers, no less than 4 times per year to assess the progress of the risk reduction plans and whether the target risk rating is likely to be met by the end of the financial year. Sources of assurance will be identified and used to inform both this discussion and any proposals to the Board for a change in risk rating.

All changes to risk ratings must be approved by the Trust Board only. Other Committees in the structure can propose changes and submit evidence via the Board Assurance report to the Trust Board but only the Board can agree any increases or reductions in risk ratings.

7. Monitoring of actions

Each element of risk identified has an associated risk reduction plan. All actions within the plan have a nominated lead and timescale identified. Progress, or lack of, will be reported to the Board via this report.

Draft

14

Board Assurance Framework

Summary Q2, 2015-16

1 Putting Patients First Principal Risks

Lead Director Inherent Rating

Current Rating

Target Rating

A Mortality David Emerton

Cath Siddle Julie Gillon

5 x 5 = 25 4 x 5 = 20 4 x 3 = 12

B Organisational Development Ann Burrell 4 x 4 = 16 3 x 3 = 9 2 x 2 = 4

C Patient Safety Cath Siddle David Emerton 5 x 5 = 25 4 x 3 = 12 4 x 2 = 8

D Patient Experience Cath Siddle 4 x 5 = 20 3 x 2 = 6 2 x 2 = 4

2 Integrated Care Pathways Principal Risks


Current Rating

Target Rating

A Momentum – Pathways to Healthcare

Julie Gillon Neil Atkinson 4 x 5 = 20 4 x 4 = 16 3 x 3 = 9

3 Service Transformation Principal Risks


Current Rating

Target Rating

A Clinical Outcomes David Emerton Julie Gillon 5 x 5 = 25 3 x 3 = 9 1 x 3 = 3

B Maintenance of clinical, operational and financial sustainability.

This principle objective is covered within all objectives within this framework and should be considered within these.

4 Manage our Relationships Principal Risks

Inherent Rating

Current Rating

Target Rating

A Contractual requirements Lynne Hodgson 4 x 4 = 16 3 x 3 = 9 1 x 1 = 1

B Stakeholder engagement and partnership working.

This principle objective is covered within the majority of objectives within this framework and should be considered within these.

5 Maintain Compliance and Performance Principal Risks

Inherent Rating

Current Rating

Target Rating

A Healthcare Acquired Infections Cath Siddle 5 x 5 = 25 4 x 4 = 16 4 x 3 = 12

B Monitor Compliance: Governance Julie Gillon 4 x 5 = 20 3 x 3 = 9 2 x 3 = 6

C Risk Management Cath Siddle 5 x 5 = 25 3 x 4 = 12 3 x 2 = 6

D CQC Registration Cath Siddle 4 x 5 = 20 2 x 3 = 6 2 x 2 = 4

E Monitor compliance: Financial Savings Targets

Lynne Hodgson Neil Atkinson 4 x 5 = 20 4 x 4 = 16 3 x 3 = 9

F Monitor compliance: Financial Stability Lynne Hodgson 5 x 4 = 20 4 x 4 = 16 3 x 3 = 9

G Information Systems Lynne Hodgson 4 x 5 = 20 3 x 4 = 12 3 x 3 = 9

6 Health and Wellbeing Principal Risks


Current Rating

Target Rating

A Protect and improve the health of the population Julie Gillon 3 x 5 = 15 4 x 3 = 12 3 x 3 = 9

Draft

15

1 Strategic Aim: Putting Patients First To create a patient centred Organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery.

A

Principal Objective: Mortality Achieve a sustainable reduction in mortality, as measured by HSMR & SHMI (to within expected levels) The content of this criteria link closely with the following BAF criterion as many aspects are interchangeable:

BAF 3A – Clinical Outcomes

BAF 2A – Pathways to Healthcare

BAF 6A – Health & Wellbeing

Enabling Strategy Associated Committee

Quality & Patient Safety Strategy Clinical Effectiveness Strategy

Patient Safety & Quality Standards Keogh Delivery Group

Risk to Objective: There is a risk that mortality reporting and monitoring may not be effective in the Trust

Lead Director Operational Lead CQC Domain David Emerton Julie Gillon Cath Siddle

Jane Metcalf Janet Alderton Debbie Blackwood Keith Wheldon

Effective

Cause Consequence Inherent Risk

Rating Impact /

Likelihood

Linked risks

Controls Gaps in Control Current Risk

Rating Impact /

Likelihood

Assurance Gaps in Assurance RAG rating

(Assurance)

Target Rating

Impact / Likelihood

Risk Appetite

Lack of consistent application of relevant care pathways across healthcare economy.

Case mix and acuity of patients requiring admission.

Not having a viable alternative to admission.

Failure of clinicians to record co-morbidities fully.

Inaccurate coding.

Patient groups not included appropriately (i.e. ambulatory care)

Sensitivity level in relation to deprivation levels is not integral to the national analysis.

Potential missed opportunities to prevent avoidable deaths.

Possible avoidable deaths from failures in clinical practice.

Increased mortality.

Failure to achieve and maintain mortality levels within acceptable tolerance of 100;

Increased CCG, CQC, Monitor and NHS England scrutiny.

Regulation 28 – preventable death reports from Coroner.

The reputation of the Trust.

Increased, incidents, complaints & claims, increasing NHSLA costs.

25

5 x 5

Keogh Delivery Group established to review ambitions and actions required. Trust Outcome and Performance (TOP) lead in place and TOP team following up actions. Trust Mortality Review process established to undertake case reviews, assess quality and standards of care as evidenced within the records. Details used to provide thematic analysis to use for wider learning and action. Board / PS&QS challenge of variances in outcomes and monitoring. Mortality reviews undertaken in ITU as part of ICNARC data collection. All Cardiac arrest calls reviewed to review issues leading up to the arrest as well as management of the arrest and on-going thematic analysis for shared learning. Consistent application of evidence based clinical care pathways. Utilising information from outliers for service improvements. Collaborative working with primary care and commissioners to examine pathways of care.

Need to continue to further increase clinical involvement in the completion of cases reviews and analysis of care pathways in relation to mortality.

Some causes are out of the control of the Trust as an individual provider in the health economy and national picture.

20

4 x 5

Internal

Results of Mortality case reviews and subsequent thematic analysis. Results of Cardiac arrest case reviews Results of ITU Mortality reviews CAP study data collection and validation Quarterly Mortality Report to the Trust Board Audit and clinical Effectiveness processes.

External

NEQOS Report(s) Regional Peer Mortality Collaboration. CQC IMR and inspection. Clarity Studies NHS England scrutiny.

No absolute independent assurance in relation to activity being undertaken.

12

4 x 3

Averse

Draft

16

Risk Reduction Plan Actions Responsibility When Monitoring Committee Planned Outcome Progress Evaluation

1. Negotiate and agree external independentreview of clinical pathways relevant to mortality.

Mr D Emerton 31/ 08/15 Keogh Delivery Group Patient Safety & Quality Standards

External assurance. 20/08/15 – Initial meeting held with Aqua – Action complete, see action 4.

2. Liaison with organisations, regionally andnationally, that have sustained improvement in this area.

Mr D Emerton D Blackwood

31/12/15 Keogh Delivery Group Alternative views and management of increased mortality statistics.

23/07/15 – Planned visit to N Lincs & Goole – Completed and will be ongoing.October 2015 – Continuing to identify opportunities for external visits; no further confirmed visits as yet.

3. Identify priority relevant clinical care pathways forimprovement work.

Mr D Emerton 31/07/15 Keogh Delivery Group Trust Directors group

Specific programmes of work identified for the key areas.

October 2015 - Clinical priority pathways identified and ongoing actions through Keogh Delivery Group. Completed and will be ongoing

4. Work with AQuA to complete externalindependent review project.

Mr D Emerton D Blackwood

31/12/15 Keogh Delivery Group Patient Safety & Quality Standards

External assurance October 2015 update – further planning underway to focus on key areas identified as AKI and sepsis.

Draft

17


B Principal Objective: Organisational Development – To demonstrate continuous improvement in culture, staff engagement, leadership and staff development. The content of this criteria link closely with the following BAF criterion as some aspects are interchangeable:

BAF 1D – Patient experience


“Our People” Strategy Education and Organisational Development Steering group

Risk to Objective: There is a risk that the People Strategy principles are not fully embraced or embedded across the trust.

Lead Director Operational Lead CQC Domain Ann Burrell Gary Wright

Michelle Taylor Alan Sheppard

Safe Well-led

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood

Linked risks Controls Gaps in control

Current Risk

Rating Impact / Likelihoo

d


(Assurance)

Target Rating Impact

/ Likelih

ood

Risk Appetite

Lack of understanding of Trust direction, vision & values.

Lack of understanding of the implementation plan.

Lack of focus within directorates to sustain organisational culture and engagement.

Poor quality appraisals limiting development opportunities.

Inability to deliver inclusive staff engagement programme

Operational capacity pressures.

Non compliance with policies.

Uncertainty around the trusts 10 year strategy and Clinical Services Strategy.

Current recruitment challenges and use of agencies.

Inability to deliver service improvement plans to benefit patients.

Disaffected staff/poor morale.

Poor retention/recruitment

Staff not equipped to do roles

Reputation of the Trust

Poor staff survey results

Low Family & Friends Test results

Regulatory and commissioning scrutiny.

16

(4 x 4)

6030 4928 3630

Suites of HR and E&OD policies agreed and applied across the organisation.

Improving the clinical outcomes for patients by systematically and regularly reviewing the delivery and outcome of services.

Culture and engagement group measures, develops and influences organisational culture across the Trust.

Use of cultural assessment and output from this.

Use of Communication Strategy to promote staff engagement.

Improving the patient experience and safety of all services through the implementation of a range of initiatives including LEAN through the Trusts Local Improvement System, workforce development, skill mix, Service Line Management and Service Line Reporting.

Use of outcomes of the staff survey, and annual staff engagement events to help improve staff communication.

Internal network of LEAN certified leaders to promote and implement service improvement within their area and continually developing.

Maximum use of technology to support all activities and to support sharing of good practice.

Senior manager performance framework, ongoing implementation and monitoring.

Appraisal and revalidation processes.

Involvement of all stakeholders in the organisational culture and engagement agenda

Analysis of appraisal data and senior performance framework.

Application of Value Based recruitment and retention, from Trust Board to Ward.

9

(3 X 3)

Internal New performance framework will give ability to profile senior managers on performance and behaviours

Investment in OD posts to support transformation agenda.

HR Management Information Reports

Local Cultural Assessment

External Culture toolkit work undertaken by Teesside University.

CQC IMR and inspection

National Staff Survey

Audit North, significant assurance, July 2015.

Deanery visits.

Low staff survey return rate – actions to impact on this on-going within control processes

4

(2 X 2)

Averse

.

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcome Progress Evaluation Development and implementation of local cultural assessment

G Wright 31/03/16 Education and Organisation Development Steering group Health & Wellbeing Group

Overall consistent assessment of culture across the organisation that allows evidence based, targeted interventions

Development and implementation of local cultural assessment. October 2015 – Completed and progress ongoing within controls.

Implementation of Senior Managers Performance Framework

G Wright 31/03/16 Education and Organisation Development Steering group

High quality appraisals that result in staff understanding how the can effectively contribute to the strategic aims of the organisation whilst developing as individuals

Implementation of Senior Managers Performance Framework. October 2015 – Completed and progress ongoing within controls.

Identify methods to increase stakeholder attendance at Culture Group; implementation of these.

G Wright 31/12/15 Culture Group Improved departmental stakeholder involvement in the work of this group.

Draft

18

Examine and agree options available to apply Value Based

Recruitment.

L Pritchard 31/12/15 Culture Group Trust wide application of value based recruitment.

Draft

19


C Principal Objective: Patient Safety To continuously identify & implement patient safety improvements


Quality & Patient Safety Strategy Patient Safety & Quality Standards Patient Safety Committee

Risk to Objective:

There is a risk that the organisation will fail to learn when things go wrong.

Lead Director Operational Lead CQC Domain Cath Siddle David Emerton

Dr Richard Thomas Janet Alderton

Safe Responsive Well led

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood

Linked risks Controls Gaps in Control

Current Risk Rating

Impact/ Likelihood

Assurance Gaps in Assurance

RAG rating

(Assurance)

Target Rating

Impact / Likelihood

Risk Appetite

Poor safety culture and incident reporting.

Inadequate recording of clinical information and documentation.

Poor organisational memory.

Poor Serious Incident Management.

Failure to apply policies, guidelines and protocols.

Not implementing patient safety alerts in a timely manner.

Failing to meet Duty of Candour regulations.

Failure to decrease avoidable harm including pressure ulcers, falls and medication errors.

Failing to take action in response to external publications (e.g. Francis, Kirkup)

Non-delivery of Safe domain in Quality Accounts/Strategy

Sign up to Safety pledges not communicated or understood by staff.

Poor staffing levels and high turn over of staff.

Non acceptance of personal and professional responsibility.

Lack of learning from safety incidents and repeated safety issues.

Lack of available information for clinical decision making.

Lack of involvement or understanding in relation to the safety issues within the organisation.

Avoidable harm to patients.

Occurrence of Never Events.

Poor clinical outcomes.

Increase clinical negligence claims; resulting in higher NHSLA premium. .

Trust reputation.

Insufficient staff to ensure that involvement in safety projects, investigations and the subsequent learning from safety issues can be implemented.

25

5 X 5

3698 5304 5070 5305 5066

Consistent application of the Incident reporting and investigation policies.

Corporate and directorate level feedback mechanisms in relation to incident rends and reporting.

Application of Guidelines/policy led practice. Governance processes around locally developed guidelines.

MDT involvement in safety projects and management of risks associated with clinical care provision.

Application of the HR policies in relation to issues relating to professional and personal responsibility.

Basic education opportunities, in relation to safety and risk, for staff to access, bespoke sessions available at request of the departments.

Awareness and controls in place to prevent Never Events.

Mortality reviews/external scrutiny

Ongoing monitoring of staffing levels, application of the “red rules” and processes of escalation.

Ongoing assessment of culture across the organisation.

Scoping for relevant national reports, gap analysis and improvement planning in relation to any published reports.

SPEQS ward visits and discussion with staff.

Commissioner Assurance visits.

Involvement with regional and local safety collaboratives to examine areas for action to support improvements.

Inconsistent completion and dissemination of action/improvement plans designed to reduce risk of harm events.

Consistency of Patient Safety Walkarounds.

Communication of Patient Safety Strategy and improvement plans.

Lack of opportunity for education in relation to patient safety and risk management.

12

4 x 3

Internal

Monitoring and analysis reports from incidents, CLIPS reports. Staff feedback at SPEQS. Monitoring of compliance with investigation timescales and Duty of candour application, for contractual performance requirements. Performance reports.

External

CCG Assurance visits. NRLS Analysis of Incident reporting covers April – September 2014. CQC IMR and inspection. Audit North report, significant assurance, Sept 2015.

8

4 X 2

Averse

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcome Progress Evaluation Initiate review of internal processes around development and governance of local clinical guidelines.

D Emerton J Alderton E Bainbridge

31/07/15 ACE Committee Patient Safety Committee

Governance processes in place for all locally produced guidelines. Single point of access for all local

RPIW planned for guideline process review (W/C 29 June 2015). Clinical teams asked to provide details of internal processes / guidelines. First meeting planned

Draft

20

guidelines 22/05/15; IT issues already being addressed through CIG. Complete and ongoing – now within controls.

Provide educational opportunities to ensure senior staff acting as leads for investigations are fully equipped to fulfil this role.

J Alderton 30/09/15 Patient Safety Committee To have a cohort of staff with the relevant knowledge and experience to undertake robust investigations and support application of recommendations.

May 2015 - Report writing session held April and July, 2015. October 2015 – Options available for RCA / Incident investigation training from external sources, to investigate funding.

Confirm Quality & Safety Strategy and initiate enhancement of the Sign up to Safety Campaign pledges.

J Alderton / B Carr L Astle Pt Safety Coordinators.

31/03/16 Patient Safety Committee PS&QS

Improved awareness of the need to reduce harm incidents.

July 2015 – Quality and Pt Safety Strategy approved. October 2015 – Planning underway for local launch.

Enhancement of the education and training available to staff in relation to patient safety and risk agendas.

J Alderton L Astle G Wright

31/03/16 Patient safety Committee PS&QS

Improved scores from cultural surveys and staff survey.

19/06/15 - Education session held for Safety teams in relation to risk management. October 2015 - Agreement obtained for support from E&OD; application and process to be agreed and initiated.

Develop a consistent approach towards patient Safety Walkarounds.

J Alderton B Carr

30/06/15 31/12/15

Executive Team Programme of safety Walkarounds to support internal assurance.

October 2015 – Final draft of tool to be presented at Exec team, and then to agree process to be in place and implemented by end of December 2015. .

Draft

21


D

Principal Objective: Patient Experience For patients to consistently have good experiences of our services The content of this criteria link closely with the following BAF criterion as some aspects are interchangeable: BAF 1B – Organisational Development


Patient Safety and Quality Strategy Patient Experience Strategy Carers Strategy Equality & Diversity Strategy

Patient Safety & Quality Standards Quality Standards Steering Group Hospital Users Group

Risk to Objective: There is a risk that patients receive and report poor experience.

Lead Director Operational Lead CQC Domain Cath Siddle

Barbara Carr Michelle Taylor Gary Wright

Caring Responsive

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood

Linked risks Controls

Gaps in Control

Current Risk

Rating Impact/

Likelihood


(Assurance)

Target Rating

Impact / Likelihood

Risk Appetite

Impact of external variables and pressures on the organisation Poor staff attitude. Poor interaction between clinical teams. Poor communication of care pathway and management plan with the involvement of the patient. Excessive waiting times throughout the patient journey (referral – discharge) Ineffective complaints/ PET (PALS) system Failure to meet hospital food standards Failure to deliver the Experience Domain of the Quality Accounts/Strategy. Not responding to patient groups, engagement events, members or surveys. Sub optimal staffing levels. Inconsistent awareness of the Equality & Diversity Strategy.

Patients failing to access healthcare in the Trust. Patient not clear about management plan and the risks associated with this. Increase in complaints Trust reputation diminished and negative media coverage. Reduction in patient involvement/engagement Difficulties with recruitment and retention of staff.

20

(4x5)

3630 5390

Professional Codes of Conduct Compliance with mandatory training and development for all relevant staff groups. Monitoring and progression of Quality and Safety culture, i.e. 6Cs and LIS projects. Consistent application of policies, guidelines, procedures and strategies. Consistent Medical revalidation Consistent Midwifery Supervision Active engagement with third party stakeholders, including healthcare user representatives and hard to reach groups. E&D Operational Group monitoring for issues and also raising awareness. Active recruitment campaign. Application of Duty of Candour Policy. Trust values and objectives. Application of nurse staffing red rules. Monitoring and escalation processes in relation to staffing levels; consistent application of the attendance management policy. Utilisation of NHSP staff and where required specialist agency staff. Appropriate utilisation of skills across staff groups. Family & Friends test results – patients and staff.

Revalidation for nursing not yet in place (Linked to action in BAF 3A) Cannot confirm that all staff groups are aware of open and honest changes following Duty of candour regulations. Values Based Recruitment (link to action in BAF 1B).

6

(3x2)

Internal assurance Friends and family feedback, other patient surveys. Culture survey feedback Board Reports and Board Assurance visits, and SPEQS. Complaints performance and complaints review group Compliance of key performance Indicators. Directorate performance reviews. External assurance NHS Choices CQC IMR and inspection. External stakeholder involvement in complaints review panel. Healthcare user groups / Governors. Commissioner Assurance visits Quality Report and Accounts, Third party narratives from key stakeholders.

Confirmation of sustainability of changes / improvements following 6Cs and LIS work (Link to BAF 1B) Lack of assurance around involvement of hard to reach groups, positive or negative.

4

(2x2)

Averse

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcome Progress Evaluation

Dementia Strategy to be approved. Pauline Townsend 31/07/15 Patient Safety & Quality Standards

Overarching strategy to guide Trust staff.

October 2015 – Completed and

Draft

22

Dementia Steering Group in place.

Identify methods that result in improvements made through LIS become business as usual and sustainable longer term.

Gary Wright 31/10/15 Educational & Organisation Development Steering Group.

Evidence provided to show sustained impact from these projects.

Evaluate application of Duty of Candour and uptake of training opportunities.

J Alderton 31/12/15 Patient Safety & Quality Standards

Assurance of compliance with regulations and understanding of the regulations.

Consider how to enhance assurance levels around the involvement of hard to reach groups.

B Carr 31/12/15 Quality Standards Steering Group Improves assurance around involvement from hard to reach groups.

Draft

23

2 Strategic Aim: Integrated Care Pathways

To develop and expand the portfolio of services to provide integrated pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare.

A

Principal Objective: To provide appropriate integrated support and care for patients with long term conditions to enable them to maximise their health in the community or avoid the need for hospital admission. The content of this criteria link closely with the following BAF criterion as some aspects are interchangeable: BAF 5E – Financial Savings Targets

Enabling Strategy Associated Committee Clinical Services Strategy Corporate Strategy Transformation Strategy

Transformation Committee Capital and Service Development Committee. Trust Board

Risk to Objective: Patients will receive inadequate or poorly co-ordinated care and so suffer deterioration in their condition or be admitted to hospital unnecessarily.

Lead Director Operational Lead CQC Domain Julie Gillon Neil Atkinson

Lynne Taylor Peter Tindall

Responsive

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Gaps in Control

Current Risk

Rating Impact/

Likelihood


(Assurance)

Target Rating

Impact / Likelihood

Risk Appetite

Lack of clarity around funding streams to support integration. Failure to develop robust evidence-based clinical services Lack of engagement across acute, community and social care services and difficulty in maintaining relationships with stakeholders. Insufficient co-ordination with primary care. Lack of robust joint application of Better Care Fund by external stakeholders. Lack of appropriate infrastructure to support community based services.

Insufficient services in place to enable patients to manage their condition at home. Uncertainty of the impact on financial sustainability and overall budgets. Indicative financial savings and possibility that nominal savings will not be achieved. Continued increasing demand and pressures on acute services Fragmented services resulting in poor patient experience. Care not being provided in the correct settings.

20

(4 x 5)

2530 Management of agreed 4 ICPs to be developed via Transformation programme Management Group; reporting to Transformation Committee. Continued involvement in implementation of Better Care Fund Engagement with GPs and external stakeholders. Dedicated resource to support project management. Detailed financial appraisal of the impacts on care pathways. Use of quality impact assessments (QIAs)

No direct control over social and primary care service provision Contingency on capacity and funding for start-up phase while still providing current services.

16

(4 x 4)

Internal : Included in Internal Audit review plan Continue to engender relationships External: Trust membership of North of Tees Partnership Board Involvement in Better Care Fund applications and developments.

No assurance around financial agreements for changes. External assurances around the project; structure, capacity, capability and delivery. Stakeholder engagement across pathways – system leadership and system transformation

9

(3 x 3)

. . Open

Risk Reduction Plan


Identify financial improvement process with North of Tees Partnership Board.

Neil Atkinson 31/12/15 Transformation Committee Transparency for and ownership of associated costs.

October 2015 – Work ongoing.

Business cases for each Integrated Care Pathway including resource allocation.

Neil Atkinson 31/03/16 Transformation Programme Management Group. Capital & Service development Committee.

Approved business cases. October 2015 – Continuing to establishment of an effective governance process for the programme.

External assurance and audit around the project governance and resourcing.

Neil Atkinson 31/12/15 Transformation Committee Positive assurance or recommendations for changes.

Draft

24

3 Strategic Aim: Service Transformation

To continually review, improve, transform and grow our healthcare services to respond to the needs of our healthcare community. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes.

A

Principal Objective: Clinical Outcomes To consistently benchmark in the top 20% of our peers for clinical outcomes.

Enabling Strategy Associated Committee Clinical Effectiveness Strategy Patient Safety & Quality Strategy Research & Development Strategy

Trust Directors group Patient Safety & Quality standards Audit and Clinical Effectiveness Committee Research Advisory Group

Risk to Objective: There is a risk that our systems and processes fail to identify when there are problems with clinical practice or outcomes.

Lead Director Operational Leads CQC Domain David Emerton Cath Siddle

Anil Agarwal Richard Thomas Jane Metcalf Jean Macleod Julie Lane P Raju Jane Greenaway

Effective

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk

Rating Impact/

Likelihood


RAG rating (Assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Poor clinical practice/lack of supervision.

Failure to learn from and review sources of clinical outcome data.

Failure to use best practice evidence and national guidance i.e. NICE, SIGN etc.

Inappropriate resources for application of clinical pathways and care packages.

Turnover of junior medical staff.

Failure to learn from safety incidents, claims and complaints.

Poor participation in National clinical audit programmes and studies

Lack of support to clinical teams to complete the required monitoring.

Recruitment of staff without appropriate values.

Poor participation in national portfolio research studies.

Lack of participation in Local Speciality research group meetings.

Poor supervision through research projects and monitoring through ongoing studies.

Professional staff not able to maintain regulatory body standards.

Increased regulatory scrutiny.

Lack of national analysis, benchmarking and assessment of care pathways.

Inability to instigate actions to improve outcomes.

Recruitment and retention – unable to employ and retain appropriate staff.

Inconsistent or delayed care / management planning and provision.

Increased harm incidents, mortality and morbidity rates.

Inability to achieve the national CQUIN targets.

Poor clinical outcomes and outlier alerts.

Increase clinical negligence claims; resulting in higher NHSLA premium.

Reduced opportunities for pt participation in research studies with consequent impact on pt outcomes.

Trust reputation. Lack of knowledge of local and national research opportunities for pts and staff.

25

5 x 5

1796 Access to clinical support and diagnostic services.

Effective application of the Clinical Effectiveness Strategy, including review of all new procedures introduced.

Clinical teams‟ involvement in ACE Committee; high profile.

All medical staff have work plans agreed with CDs and MD.

Analysis of patient / user feedback and patient related outcome data.

Application of the R&D Strategy, SOPs and other procedures that underpin these.

Full involvement in relevant National Audit Programmes and NCEPOD reviews.

Clinical understanding of, access to and use of overall and individual performance data supplied.

Application of Patient Safety and other safety alerts.

Analysis of incidents, complaints and claims to identify areas of risk.

Case note reviews, morbidity and mortality reviews.

Supervision and education of clinical staff across all professions.

Application of clinical pathways and guidelines.

Increasing R&D involvement across the organisation; increasing the profile of research to enhance the introduction of best practice studies into the organisation.

Inconsistent application of clinical pathways.

Do all staff understand the dashboard and the data presented on this?

Appropriate support for clinical teams to be involved in clinical audit for local and national monitoring.

Need to further enhance the shared learning across relevant directorates from audits etc.

Availability of allocated time / people to undertake and provide clinical and educational supervision.

R&D Strategy requires updating.

9

3 x 3

Internal: Clarity Project data

Internal Audit Programme

Clinical Effectiveness audit programme MDT approach to patient management

Directorate performance reviews

Case reviews and analysis

Research participation evidence through monthly recruitment data.

External: GMC / NMC Reports Royal College Reports / Visits.

NCEPOD Reports.

CQC Intelligent Monitoring

National Audits

Peer Reviews and accreditation.

External sponsor led monitoring visits for research studies.

R&D Performance and initiation data to Department of Health, quarterly.

Difficult to gain consistent assurance that clinicians are following best practices for case management.

Some national audits / studies do not provide benchmarking of data, if they do this is in an inconsistent format so cannot assess and compare status.

Lack of assurance around completion of action plans following audits.

3

3 x 1

Minimalist

Draft

25

Monitoring of attendance at Local Speciality Research groups.

Risk Reduction Plan


Initiation of Nursing Revalidation programme. Julie Lane 31/03/16 IPNMB PS&QS

Full compliance across Nursing staff. October 2015 – Progress ongoing.

Initiation of Sepsis Clarity Study involvement. David Emerton Farooq Brohi

30/06/15 Keogh Delivery Group PS&QS

Consistent application of the Sepsis 6 package. Reduction in harm to patients.

October 2015 – Project initiated and data being collected. COMPLETE

Develop business case for support for CQUIN and Family and friends tests; to free up CEU staff to support audits.

B Carr T Holdcroft

31/07/15 ACE Committee Appropriate support available for national and local audit programmes.

October 2015 – Business case going to Octobers Capital & Service Development meeting.

Raise awareness of this area of the BAF across all clinical directorates. Also to identify how directorates analyse and compare their national audit data.

J Alderton B Bright

31/03/16 ACE Committee Increased awareness of scrutiny applied through BAF.

Identification of national audit benchmarking.

Review contents of directorate dashboards with directorate teams. L Wallace K Wheldon

31/03/16 Performance, planning and compliance Committee

Confirmation that the data on the dashboards reflect the information that the clinical teams need and that this is readily understood.

Draft

26

3

Strategic Aim: Service Transformation

To ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

B

Principal Objective: Maintenance of clinical, operational and financial sustainability.

Enabling Strategy Associated Committee Various Various

Risk to Objective: There is a risk that the organisation cannot maintain sustainable service provision. The information relating to the organisations approach to this risk is covered within the majority of the objectives within this BAF; specifically within:

1A – To achieve a sustainable reduction in mortality; as measured by HSMR & SHMI (to within expected levels.

1B - To demonstrate continuous improvement in culture, staff engagement, leadership and staff development.

1C - To continuously identify & implement patient safety improvements.

1D - For patients to consistently have good experiences of our services.

2A - To provide appropriate integrated support and care for patients with long term conditions to enable them to maximise their health in the community or avoid the need for hospital admission.

2B – New hospital build

3A – To consistently be in the top 20% of our peers for clinical outcomes.

4A – Contractual arrangements.

4B - Stakeholder Engagement

5A – Achievement of HCAI objectives.

5B – Achieve all Healthcare standards outline in Monitor RAF.

5C – Robust risk management systems

5D – Maintain unconditional registration with CQC.

5E – Financial Savings targets

5F – Financial stability

5G – Information systems

6A – Protect and improve the health of the population.

Lead Director Operational Lead CQC Domain As identified within individual BAF references.

As identified within individual BAF references.

Safe Caring Responsive Effective Well led

Risk Reduction Plan


Develop core criteria on BAF for Transformation. N Atkinson / P Tindall 31/03/16 Transformation Committee Specific view of Transformation progress and actions.

.

Draft

27

4 Strategic Aim: Manage our relationships To ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

A Principal Objective: Contractual Requirements


N/A Audit & Finance Committee CQUIN Board Trust Board

Risk to Objective: There is a risk that contractual agreements will not be in place for 1 April and the Trust will not be able to meet its performance requirements within contract by 31/03/16.

Lead Director Operational Lead CQC Domain Lynne Hodgson Pam Gretton Responsive

Effective Well led

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk Rating Impact/

Likelihood


RAG rating

(Assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Poor working relationships with the commissioners of the services the Trust provides

Failure to receive recognition and recompense for achieving performance targets

Non delivery of aspects of CQUIN which is up to 2.5% of the contract value if they are not set for the beginning of the financial year

Whole systems ability to deliver some of the pathway changes required for improved services

Trust pursued service change that could potentially not be aligned to commissioning

Ability to influence the wider health economy and align GP demand management with Trust resources.

Ability of clinical directorates to deliver agreed activity levels and CQUIN targets.

A lack of legal cover for the services provided and a risk that the Trust will not earn quality incentives and avoid penalties if these are not clearly articulated from 1 April 2015

The Trust is working at risk for a proportion of its service delivery

The Trust could provide services in accordance with demand rather than commissioning intentions which could impact on capacity and earnings potential

Reduced quality incentives and increased penalties, both of which result in reduced income will deteriorate if income is not sustained.

Cash flow is monitored and reported upon as part of Finance Committee and Board of Directors reports


16

4 x 4

3637 3635 3634

Formal contract negotiation completed and agreed.

Internal monitoring of performance against contracts and action plans produced by exception

Contract monitoring in place and performance against target reviewed by Commissioners at monthly contract meetings

Monthly review of the SIEP programme and quality impact assessments

Cap and Collar of 1% agreed with main commissioner, to include penalties therefore minimising impact and risk of large variations

Accountability for performance against baseline activity with Directorates and Chief Operating Officer/Deputy Chief Executive and Director of Nursing, Patient Safety & Quality

Formal quarterly assessment against measures

Monitored by CQUIN Board which feeds in to PS&QS and Quarterly report to the Finance Committee.

Review community contract has been agreed

Uncertainty over the impact of the Better Care Fund has been mitigated by agreeing to in year contract variations once the evidence has been validated by all parties

Managing delivery of Service, Delivery, Improvement Programme (SDIP). Quad meetings with each directorate to review performance and activity.

The majority of contracts have been agreed and signed, with commissioners for 2015/16; Local Authority and DDES contracts not signed.

Detailed implementation plans for the Better Care Fund is still being progressed with CCG and Local Authorities but the principle of a joint approach has been agreed (see BAF ref 2A).

Robust action planning and accountability for directorate delivery of CQUIN targets.

Robust action planning from Directorates to bring adverse performance and KPI variances into required levels.

9

3 x 3

Internal: Finance Committee papers on contractual updates

Finance Committee paper on the tariff options

Board of Directors minutes re contract updates and decision on tariff options

External:

Commissioners monitor performance through monthly contract meetings and regular contract negotiation meetings (evidenced through minutes and action plans)

CQUIN Board to monitor through monthly meetings

Impact of Better Care Fund governed through North of Tees Partnership Board

Changes to the Contracts in year evidenced through contract variation notices

CQRG and Star chamber reviews.

Report being developed to present to the Finance Committee focusing on performance against contracts / penalties and CQUIN.

Mitigation of risks which present themselves to the deliver of CQUIN

1

1 x 1

Averse

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned outcome Progress Evaluation Working with Clinical Commissioning Group and Local Authorities to develop alternative pathways of care, both externally and internally with the emphasis on the Better Care Fund

Executive Team 31/03/16 Board of Directors Transformation Committee

To ensure integrated pathways of care which do not negatively impact on patient safety, quality or financial position

Monthly in Finance and Transformation Committees This action is part of the ongoing controls in BAF

Draft

28

2A.

The Trust and HAST CCG are jointly working through the potential impact of the BCF changes. It has been agreed that these will be an in year adjustment to contract once evidenced.

Director of Finance, ICT and Support Services 30/09/15 Executive Team

To ensure integrated pathways of care which do not negatively impact on patient safety, quality or financial position

Review progress quarterly, due 09.15 This action is part of ongoing control and will be removed from risk reduction plan.

Initiatives agreed with the commissioners are recorded in the SDIP and monitored on a monthly basis at contract meetings with all commissioners

Executive Team 31/03/16 Finance Committee To ensure service improvements are achieved

Monthly in Finance Committee This action is part of ongoing control and will be removed from risk reduction plan.

Directorate action plans to be obtained in relation to delivery of CQUIN targets.

J Lane B Carr D Emerton

31/10/15 CQUIN Board To provide assurance around actions being taken to achieve targets.

Directorate action plans to be obtained in relation to adverse performance and KPI variances.

L Wallace R Willis P Gretton

31/10/15 Finance Committee To provide assurances around actions being taken to maintain performance and achieve KPIs.

Draft

29

4 Strategic Aim: Manage our relationships To ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

B Principal Objective: Stakeholder Engagement and partnership working

Enabling Strategy Associated Committee Various Various

Risk to Objective: There is a risk that all stakeholders and partners are not involved in developments relating to the provision of healthcare across the wider health economy and also within the organisation.

The information relating to the organisations approach to this risk is covered within the majority of the objectives within this BAF; specifically within:

1A – To achieve a sustainable reduction in mortality; as measured by HSMR & SHMI (to within expected levels.

1B - To demonstrate continuous improvement in culture, staff engagement, leadership and staff development. 1C - To continuously identify & implement patient safety improvements.

1D - For patients to consistently have good experiences of our services.

2A - To provide appropriate integrated support and care for patients with long term conditions to enable them to maximise their health in the community or avoid the need for hospital admission.

2B – New hospital build

3A – To consistently be in the top 20% of our peers for clinical outcomes.

3B - Maintenance of clinical, operational and financial sustainability.

4A – Contractual arrangements.

5A – Achievement of HCAI objectives.

5B – Achieve all Healthcare standards outline in Monitor RAF.

5D – Maintain unconditional registration with CQC.

5E – Financial Savings targets

5F – Financial stability

6A – Protect and improve the health of the population.

Lead Director Operational Lead CQC Domain As identified within individual BAF references.

As identified within individual BAF references.

Safe Caring Responsive Effective Well led

Draft

30

5 Strategic Aim: Maintain compliance and performance To maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

A

Principal Objective: Achievement of Healthcare Acquired Infections objectives.

Enabling Strategy Associated Committee Not applicable - Suite of policies in place. Patient Safety & Quality Standards

Infection Control Committee Trust Antibiotic Group Trust Board

Risk to Objective: Risk of failure to meet allocated targets for :

MRSA Bacteraemia (zero) C difficile (13)

Lead Director Operational Lead CQC Domain Cath Siddle Lesley Wharton

Dr Chris Dyson Safety Effective Well led

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk

Rating Impact /

Likelihood


RAG rating

(Assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Poor compliance with IPC policies Lack of clinical engagement in IPC processes. Increased activity leading to sub optimal practices Reduced opportunities for deep cleaning due to bed escalation plan

Financial penalties

Increased complaints

Impact on trust reputation

Intervention by regulators (CQC, Monitor, CCG etc)

25

(5x5)

2131 4862

Application of IPC policies including: Hand hygiene Standard precautions Environmental Cleaning Antibiotic policy and guidance.

Audit and feedback around clinical practices and antibiotic stewardship

Robust RCA investigation undertaken for all cases to identify any trends/lessons

Discussion of learning at directorate meetings E-induction.

Competency assessments for prescribing and blood culture sampling

IPC team to provide advice/ support

Enhanced cleaning in clinical areas including HPV, hygienist team and mattress decontamination facility

IPC Action tracker in place to monitor progress effectively.

Collaboration with local GP with regards antibiotics usage.

Applications of recommendations from external reviews.

Poor medical representation on ICC

Lack of action planning and implementation of actions following antibiotic audits

Ability to provide face to face training and provide “live” updates.

Compliance with recent Patient Safety Alert in relation to antibiotic stewardship; completion date March 2016.

16

(4x4)

Internal

C difficile assurance panel

Audit North reviews

External

Commissioner assurance visits

External reviews

CQC IMR and inspection

Prof Wilcox visit and report, July 2015.

Helen Crombie review, September 2015.

Evidence of discussion of IPC issues, audits, learning at directorate level

Evidence of cascade of information to all levels of clinical staff

Audit North reviews of hand hygiene give limited assurance only (2015).

12

(4 x 3)

Averse

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcomes Progress Evaluation ICC Terms of reference to be reviewed to include required medical representation and enhanced directorate feedback.

Nominations for attendees to be confirmed.

L Wharton D Emerton

30/06/2015 Infection Control Committee Audit Committee

Improved attendance at ICC by medical and directorate clinical staff

24/06/15 – terms of reference reviewed. September 2015 – Representation remains low from clinical teams and medical staff.

Commission an external independent review of Infection Control governance, processes and systems.

C Siddle L Wharton


External assurance and learning for the organisation.

24/06/15 – External review planned for 20/07/15 October 2015 – Both external reviews COMPLETED

Explore utilising similar process to IPC action tracker for follow up of antibiotics actions.

R Dube R Keenan


Assurance that action is being taken in response to audit findings.

October 2015 – Audit technician to be recruited.

Patient Safety Alert R Dube 31/03/16 Patient safety committee PD&QS

Compliance with safety alert.

Review provision of face to face training against Code of Practice.

L Wharton G Wright

31/10/15 Infection Control Committee Enhanced opportunities to share live updates with staff of all groups.

Draft

31

5 Strategic Aim: Maintain compliance and performance

To maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business

B

Objective: Achieve all Healthcare Standards outlined in Monitor Risk Assessment Framework The content of this criteria link closely with the following BAF criterion as some aspects are interchangeable: BAF 4B – Stakeholder engagement and partnership working.

Enabling Strategy Associated Committee Performance Improvement framework Audit Committee

Trust Board

Risk to Objective: Performance Management framework does not identify and manage risk to compliance in a timely way

Lead Director Operational Lead CQC Domain Julie Gillon Lynne Taylor Responsive

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Gaps in Control

Current Risk

Rating Impact /

Likelihood


RAG rating (assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Impact of external variables on the performance in the organisation. Patient choice National Campaigns Seasonal pressures Major incidents Ongoing capacity

Non-compliance with multiple standards, inclusive of : RTT Breast Symptomatic Cancer pathways Community indicators A&E targets Hospital Acquired Infections

Compliance declared without supporting validated evidence Inadequate business continuity plans or escalation procedures Unintentional gaps in recording processes.

Access standards - Patients waiting longer than acceptable Impact of / on „Patient choice‟ Invalid data submission internally and externally. Increased monitoring and scrutiny from external stakeholders and regulators. Financial penalties Trust reputation Breaches in targets across all areas.

20

(4 x 5)

3985 5402 5401 5400 5399 3986

Evidence framework presented quarterly to Board.

Internal audit process and monitoring in place.

Focussed delivery groups in place for current standards to monitor and review progress against targets.

Cancer PTL and RTT PTL meetings Executive and directorate leads

identified. Executive led performance reviews

bi-annually. Resilience and Business Continuity

planning continue reflect best practice within policy guidance; including winter planning.

Daily monitoring reports in place for key standards

Ability to initiate supplementary activity within budget (limited).

Escalation processes in place Cancelled elective procedures

process monitoring. Corporate and Specialty dashboards

for performance monitoring Corporate performance team to

monitor and manage delivery SOPS in place for key indicators. Performance Framework in place Cancer recovery plan reviewed

monthly with CCG. Ongoing scoping of new/draft guidance that may impact on services.

Performance framework requires review and update Need to examine the system wide delivery of the cancer pathways. Potential lack of capacity / facility to provide supplementary activity.

9

(3 x 3)

Internal Tailoring of internal audit schedule to ensure the Board can maintain self certification. Performance report Quarterly / Annual Governance Statements Assurance Framework Annual Plan External Audit North significant assurance for RTT in 2015. Audit North significant assurance in Cancer pathways 2013 Intensive support team review of cancer standards, November 2014. Audit North significant assurance for breast sym 2013 62 days standard and RTT incomplete pathways with in Quality Accounts. PWC Audit 2014 Annual Plan EPRR Assurances.

At this time the organisation cannot provide assurances in relation to a system wide approach to cancer pathways.

6

(2 x 3)

Averse

Actions

Actions Recorded Responsibility When Monitoring Committee Planned Outcomes Progress Evaluation 1. Performance Improvement Framework under review to reflect closer Accountability, Scrutiny and Monitoring.

L Taylor 31/8/2015 Executive Team Audit Committee Trust Board

Improved Performance Improvement Framework

October 2015 – Completed - Final ratification required.

2. Further develop emergency care pathways across A&E, EAU and base wards, in line with Commissioning intention.

S Thompson L Johnson

31/08/2015 Emergency Care Collaborative To ensure appropriate response and management within care pathways; and reflected within the Annual Plan.

October 2015 – Completed – reviews ongoing and planned “perfect week” 05/10/15

3. Work with local health economy to prevent avoidable admissions and improve discharge processes. Collaborative use of the Better Care Fund.

N Atkinson J Parkes

31/03/2016 Emergency Care Collaborative Trust Resilience Group Regional System Resilience Group

October 2015 – progressing and will be linked with action 4 below.

4. Continuing development of ECPs ; this will include the “perfect week”

L Johnson 31/11/2015 Emergency Care Collaborative Executive team

Expedited admissions and discharge processes and reduction in length of stay.

Draft

32

5 Strategic Aim: Maintain compliance and performance To maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business

C

Principal Objective: Robust Risk Management Systems.

Enabling Strategy Associated Committee Risk Management Strategy Audit Committee

Executive Team and Trust Board Patient Safety & Quality Standards

Risk to Objective: There is a risk that the Risk Management Strategy will not be understood and implemented across the Trust.

Lead Director Operational Lead CQC Domain Cath Siddle Janet Alderton Safe

Well-led

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk Rating Impact/

Likelihood


(Assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Effective risk management systems not established in all areas.

Lack of risk expertise within the Trust.

Lack of knowledge and understanding in relation to risk.

Ineffective recognition and inconsistent assessment and management of risk across the organisation.

Incorrect assumption of assurance, positive or negative.

Regulatory scrutiny

25

5 x 5

5407 Risk Management Strategy agreed and in place.

Application of robust systems to mitigate against areas of risk identified.

Directorate risk management processes.

Consistent application of the Risk management strategy across the organisation.

Robust challenge from and to Directors in relation to areas of risk and planned actions to mitigate these.

Lack of training and educational opportunities to support management of risk

12

3 x 4

Internal Review of high level clinical risks at PS&QS

Review of Financial risks at Finance Committee.

Review of all Corporate risks at Audit Committee and Trust Board.

External

External Audit reports.

Previous Audit North Report in 2013 provided limited assurance. 2015 follow up report from Q4 2014-15 imminent

6

3 x 2

Averse

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcome Progress Evaluation Review and update Risk Management strategy J Alderton

J Lane 30/06/2015 PS&QS

Audit Committee Trust Board

A clear concise strategy to guide all staff in relation to how the Board expect risk to be managed.

Completed and in place from July 2015.

Review current training and educational requirements across the organisation for the management of risk.

C Siddle J Lane J Alderton

31/08/2015 PS&QS A programme of training to provide compliance with the Risk Management Strategy.

Training session planned for Pt safety coordinators June 2015. October 2015 – Board sessions planned during Q3. Workshops for senior staff arranged. E-workbook drafted and ready for use.

Implementing and embedding of training and education.

J Alderton O Chaplin

31/03/2016 Patient Safety Committee PS&QS

A programme of training to provide compliance with the Risk Management Strategy.

Draft

33


D Principal Objective: Maintain unconditional registration with the CQC

Enabling Strategy Associated Committee Multiple Patient Safety & Quality Standards

Audit Committee Risk to Objective: Inability to provide evidence and assurance regarding compliance with the Fundamental Standards and CQC Regulations.

Lead Director Operational Lead CQC Domain Cath Siddle Julie Lane

Deborah Blackwood Well-led

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk Rating

Impact/ Likelihood


RAG rating

(Assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Lack of knowledge and understanding in relation to CQC Fundamental Standards.

Failure to ensure the application of the Fundamental standards and CQC regulations.

Poor governance arrangements to support compliance.

Failure to apply the Fundamental Standards and CQC Regulations.

Unable to predict what will be identified during inspection process.

Patient care not provided in line with the standards required.

Loss or suspension of specific services.

Diversion of resources to support regulatory measures which can reduce quality service provision.

Inability to provide the level of evidence required at the time of inspection.

Increased levels of scrutiny from regulators and commissioners.

Financial or criminal penalties and regulatory measures.

Poor reputation of the Trust affecting:

Recruitment and retention Staff satisfaction Patient satisfaction Income from referrals into the organisation.

Inability to function as a provider of regulated activities; or as an NHS organisation.

20

5 x 5

All departments provided with details of Fundamental Standards; information provided to staff in CQC update sessions.

Committee structures in place to monitor compliance.

Board visits and SPEQs assurance visits; both announced and unannounced.

An integrated approach between corporate and directorate governance teams.

Commitment to Ward to Board leadership.

Quality Impact Assessments undertaken when service changes are being considered; reviewed by DoN and MD.

Close partnerships with key external stakeholders to support assurance; i.e. Hospital user group, Local Authority.

6

2 x 3

Internal

Escalation through governance structures; resulting in exception reporting to the Trust Board.

Audit North audit programme and reports

Tailoring of internal audit schedule to ensure the Board can maintain self certification.

External

CQC Intelligent Monitoring report.

Quality Assurance visits.

External Stakeholder visits

Commissioner Assurance visits and Clinical Quality Review Group.

PWC and Internal Audit assurance.

CQC inspection report awaited 4

2 x 2

Averse

.

Risk Reduction Plan

Actions Responsibility When Monitoring Committees Planned Outcomes Progress Evaluation Contact chairpersons of responsible committees to obtain update on their analysis of the standards and the actions being initiated to ensure compliance evidenced.

J Alderton 30/06/2015 31/07/2015

PS&QS CQC Board Trust Board

Assurance that relevant standards are being reviewed at relevant committees.

24/06/15 – partially completed, awaiting feedback from those already contacted and identifying further relevant groups / committees. October 2015 – Completed, awaiting inspection report to advice on any gaps in compliance.

Agreed and provide a central repository for evidence for individual standards.

J Lane 30/06/2015 CQC Board Readily available evidence in preparation for unannounced visits.

October 2015 – Completed prior to inspection and utilised effectively during inspection process.

Draft

34


E Principal Objective: Financial Savings Targets of directorates The content of this criteria link closely with the following BAF criterion as some aspects are interchangeable: BAF 2A – Pathways to healthcare

Enabling Strategy Associated Committee Annual Plan, Long Term Financial Management SIEP Board

Finance Committee Trust Board

Risk to Objective: Programmes are not in place to meet the full SIEP target of £6.6m set for 2015/16

Lead Director Operational Lead CQC Domain

Lynne Hodgson Neil Atkinson

Caroline Trevena Well-led

Cause Consequence Inherent Risk

Rating Impact /

Likelihood

Linked risks

Controls Gaps in Control Current Risk Rating

Impact/ Likelihood


(Assurance)

Target Risk Rating

Impact / Likelihood

Risk Appetite

Economic downturn and the wider health and social care system

Demands on services

Lack of new initiatives for savings that do not impact on safety and quality.

Insufficient resources to deliver projects and programmes agreed by the Board

Recourse to Agency and Locum staff to maintain patients safety and quality.

Lack of clarity of the role of Transformational change on savings schemes.

Lack of accountability and responsibility.

A lack of funds to invest in key areas and liquidity problems

A lack of clarity over some schemes impacts on the ability to deliver all of the required savings needed

Failure to meet financial target breaches the terms of the Monitor licence for the Foundation Trust

Insufficient funds to pay staff or creditors

Viability of the organisation as a going concern


CQC negative reporting and Monitor intervention.

20

4 x 5

5418 5419 5420

Accountability framework in place linked to personal objectives

Quality impact assessment and benefits realisation documentation

The Trust monitors compliance with the new Continuity of Services risk ratings

Monthly financial management reports monitored and budget holders held accountable for performance Action plans requested if variances are significant

Performance against Savings Programme is monitored on a monthly basis by Director of Finance, ICT and Support Services to the Executive Team meeting


Ownership of schemes across the Trust

Lack of targeted resources to promote and ensure delivery of the programmes.

Lack of new initiatives that do not impact on quality.

Clarity around governance of SIEP and transformation needs to be enhanced

16

4 x 4

Internal:

Audit Committee reviewed progress on the financial savings programme

Finance Committee held directorates to account for non delivery

Internal Audit review on the process and performance 2014-15

External:

External audit review as part of the Annual Accounts review where unqualified opinion provided

Monthly reporting to Monitor as part of formal assurance process

Application of the accountability framework cannot be clearly evidenced.

9

3 x 3

Cautious

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcomes Progress Evaluation Management across the Trust are in the process of devising further ideas and opportunities to close the SIEP gap

L Hodgson 31/03/2016 Executive team To have a robust plan of projects and schemes that will deliver at least £10.9m of efficiency savings in 2015/16 and into the future

October 2015 – Existing governance process to be reviewed to refocus the requirements for this.

Cash position to be more closely monitored via the Finance Committee

Director of Finance, ICT & Support Services 31/03/2016 Finance Committee To ensure that performance hits planned levels and the Trust has sufficient cash to operate

This action has been moved to BAF 5F and is part of the controls in place for monitoring.

Confirm and clarify the governance process around SIEP and Transformation.

L Hodgson N Atkinson

31/12/2015 Finance Committee Trust Board

Consistent application of the accountability framework.

Draft

35


F Principal Objective: Financial Stability

Enabling Strategy Associated Committee Annual Plan, Long Term Financial Management Finance Committee

Trust Board Risk to Objective: The risk is around the Trust‟s ability to turnaround its financial performance and address the operational deficit reported in 2014/15 and the forecasted deficit in 2015/16

Lead Director Operational Lead CQC Domain Lynne Hodgson Caroline Trevena Well-led

RAG rating (Assurance) Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk

Rating Impact/

Likelihood


RAG rating (assurance)

Target Risk

Rating Impact / Likelihoo

d

Risk Appetite

Potential tendering of services by Clinical Commissioning Groups and Local Authorities

Losing tenders with limited ability to reduce cost base

Financial impact of Agency and locum cover is greater than planned but is required to maintain quality of service and patient safety levels

Focus on the Trust‟s longer term solution of a single site hospital places a risk on the Trust‟s financial performance which could deteriorate further

Inflation greater than planned

Activity and income lower than planned

Demand on services greater than planned and therefore income does not cover the cost of the service

Should services be tendered commissioners may give notice to withdraw services without full impact on health care being considered resulting in the Trust absorbing overhead costs within current services

Potential for increased activity and demand in other services resulting in increased expenditure.

Impact of any AQP, or lost services could result in increased activity in services provided either in areas where capacity to absorb extra work is limited or services under block arrangements leaving the Trust exposed financially.

Clinical governance staffing levels at conflict with financial outcomes if required to staff on premium rate resulting in excess costs

Inability to influence the Junior Doctors assigned to the Trust through Post Graduate Deanery to address the resource requirements resulting in excess costs for locums

Insufficient availability of Consultants for specific specialties resulting in excess costs for locums

The Trust has a forecasted deficit of £7.3m in 2015/16

Additional costs and / or reduced income will result in the Trust going into financial distress

Resilience pressures escalate resulting in excess

20

5 x 4

5418 5419 5420 3500 2908 2119 3637

Marketing analysis and intelligence to inform potential areas to be tendered

Review Clinical Commissioning Group and Local Authority strategic and operational plans for 2015/16 which identify tenders being pursued

Procurement process enables the Trust to be alerted to any potential tender opportunities

External consultancy support to develop bids and increase likelihood of successful tenders

Significant financial implications for all decisions will be reported to the Finance Committee for additional scrutiny

Locum spend is continuously monitored by the Director of Finance, ICT & Support Services and the Medical Director

Internal audit undertook an assessment of consultant work and controls and authorisation of locum, bank and agency, and outcomes reported to the Audit Committee

Implementing Doctor Rostering and this is subject to an internal audit review

Adverse variance in spend reported in Finance and Contracting Performance Report which is submitted to the Trust Board at every meeting

Report monthly on the financial performance of the organisation and agree action plans with the Directorates if adverse variance occurs

Monthly financial reports are provided to all budget holders for strict monitoring of expenditure against plan

Long Term Financial Model, capacity plan and SIEP medium to

Directorates considering alternative workforce model (Extended Nurse Practitioner etc.) to mitigate impact

Ownership of CIP schemes across the Trust

Targeted resources to deliver efficiency programmes

Insufficient schemes to deliver £10.9m savings.

16

4 x 4

Internal:

Medical Director seeking assurance from Directorates that PAs are only approved for clinical activity

Audit Committee considered financial at each meeting with update from the Director of Finance, ICT and Support Services

Finance Committee has reviewed specific details around the financial stability at their meetings holding directorates to account on an exception basis

Board of Directors papers contains a monthly report on the finance position

Internal Audit review provided assurance over financial management processes

External:

Quarterly reporting to Monitor as part of the formal assurance process

External Audit provided unqualified opinion on Annual Accounts and assessment of financial stability

Where services are put out to tender for services, without a full impact assessment, the Trust has little time to react to the situation and protect its resources and there is little or no recourse back to the Commissioner (this has impacted with the Local Authorities)

9

3 x 3

Averse

Draft

36

National tariff income does not cover the cost of services

Insufficient demand for some core services resulting in not achieving economies of scale (e.g. urology and haematology)

Non delivery of Cost Improvement Programme (CIP)

costs

Failure to meet financial target as per FT Annual Plan and deliver the Continuity of Services risk ratings resulting in licence conditions being challenged

Reputation of the Trust.

Inability to deliver financial targets.

Inability to deliver core services and patient safety / quality.

long term review continuing

Portfolio approach developed to ensure strict monitoring of schemes, avoid duplication of resources and prioritising delivery of initiatives with maximum impact

The plan in 2015/16 has set a EBITDA target of 1.9% and this will be closely monitored through the Finance Committee and Board of Directors

The Trust monitors compliance with the new Continuity of Services risk ratings

Transformation Change Director appointed to lead the delivery of whole system change to achieve efficiencies going forward

SIEP performance monitored on a monthly basis by Director of Finance, ICT & Support Services paper to the Executive Team meetings


Potential impacts highlighted through contracting meetings with CCG‟s, at Health and Wellbeing

Boards and North of Tees Partnership Board meetings

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcomes Progress Evaluation Review of prior information notices in tendering website Procurement team 30/09/2015 Executive Team Maximise opportunities for the Trust

to bid for new services and existing ones that go out to tender

This action is ongoing as part of the reported controls and will be removed.

Potential impacts highlighted through contracting meetings with CCG‟s, at Health and Wellbeing Boards and North of Tees Partnership Board meetings.

Executive Team 31/03/2016 Partnership Board Ensure strategies are aligned across the whole health and social care system


Resources have been realigned to compensate for fluctuation in workload – Bed paper

Executive Team 30/09/2015 Executive Team and Board To ensure that resources are aligned to demand


The plan in 2015/16 for the EBITDA has been set a target of 1.9% and this will be closely monitored through the Finance Committee and Board of Directors.

Director of Finance, ICT & Support Services

31/03/2016 Finance Committee and Board of Directors

To ensure that performance hits planned levels

October 2015 – Plan to be reviewed to identify directorate specific financial targets.

Cash position to be more closely monitored via the Finance Committee

Director of Finance, ICT & Support Services

31/03/2016 Finance Committee and Board To ensure that performance hits planned levels and the Trust has sufficient cash to operate


To ensure without risk to delivery of service, locum spend has been curtailed

Divisional Finance Managers 31/03/2016 Executive Team Finance Committee

To ensure the Trust is achieving value for money and can evidence whilst not compromising patient safety staffing requirements

October 2015 - This action has been partially implemented, where completed it is ongoing as part of the controls.

Draft

37


G Principal Objective: To ensure the organisation has robust information systems


IM & T Strategy IM & T Steering Group Healthcare Records Committee

Risk to Objective: There is a risk that the integrity and robustness of systems, and the use of those systems, will not support the business

Lead Director Operational Lead CQC Domain

Lynne Hodgson Pam Gretton Tony Naylor

Well-led

Cause Consequence Inherent

Risk Rating Impact /

Likelihood


Current Risk

Rating Impact/

Likelihood


RAG rating

(Assurance)

Target Risk

Rating Impact /

Likelihood

Risk Appetite

Integrity and robustness of systems can be undermined by IT failure Non-compliance of Health Records Policy & Standards will undermine this objective Supporting and developing existing systems Implementation of EPR and staff knowledge in use of the systems at the start of EPR implementation (Trakcare) Insufficient skilled resources, e.g. within IT; also inadequate general ability to us the IT systems. Insufficient financial resources to develop and replace information systems. Lack of appropriate devices in appropriate locations.

Staff members do not comply with records management standards and responsibilities Lack of readily available information to support clinical decision making.

Patient Safety could be impacted if the system is not understood or operated correctly Performance targets not met and cannot be reported upon Reputation of the Trust negatively impacted (e.g. mortality) Failure of EPR will result in: Contracting information not available for Commissioners Patients records not maintained electronically

20

4 x 5

942 5387

Well established and documented systems, disaster recovery plans and business continuity plans Trust-wide A high level of resilience is built into the Trust locally hosted ICT systems and network, with critical infrastructure physically duplicated across two purpose built machine rooms, one at UHNT the other at UHH. These are also supported by secondary facilities at each site so that single points of failure are removed. Externally hosted solutions adhere to strict quality standards as in the case of Nationally provided solutions such as patient booking via NCRSMS. All major systems have robust support arrangements with the relevant suppliers and clinical systems administrators. Critical systems such as PAS/EPR, A&E, Pathology have full round the clock support from the third party suppliers. EPR implementation strictly monitored through EPR Programme Board

Regular continuous testing audit of EPR Programme

Mandatory training Health records committee addresses issues as they arise

Dissemination of problems via trust wide communications Formal records management policies in place and audited Trakcare supports improvements in record keeping. A high number of systems have Mon-Fri 09:00 – 17:00 support. Local on-site resource supports all systems Mon-Fri 08:00 -17:00, with a highly effective out of hours service fulfilling immediate response outside of core hours

Inadequate follow up of the recording of information to ensure individuals are held to account for non-compliance Ability of External Contractor to deliver EPR specification Not all systems have administration resource to manage all systems across the Trust

A number of systems do not have 24x7 system specific support.

12

3 x 4

Internal: Internal Audit reports on Continuity plans Disaster Recovery Plans, through TRF. Robustness of IT systems for security and control Internal audit of compliance with records management policy Reported through P & Q‟s, IG Team and HCR Committee

EPR Programme Board

External:

Reports to ICO

The lack of knowledge around the ability of the new EPR to support the organisation cannot assess assurance level until the system is live.

9

3 x 3

Averse

Draft

38

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcomes Progress Evaluation Roll out of EDM commenced to Medical Directorate Pam Gretton 30/09/2015 EPR Programme Board Complete archiving of healthcare records onto

accessible electronic records. COMPLETE

Identify lead responsibility for non clinical IT systems. L Hodgson 31/12/2015 IM&T Group Identified person with responsibility of overseeing administration of non-clinical IT systems.

Draft

39

6Strategic Aim: Health and Wellbeing This item should be read in conjunction with BAF reference 2A in relation to the provision of services across the health economy.

To embrace the health and wellbeing of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the provision of services from the Trust.

A Principal Objective: Protect and improve the health of the population

Enabling Strategy Associated Committee Health and Wellbeing Strategy Clinical Services Strategy

Executive Team Trust Board

Risk to Objective: Inability to provide appropriate health and well-being services and improve the outcomes across the population of Easington, Hartlepool, Sedgefield and Stockton.

Lead Director Operational Lead CQC Domain Julie Gillon Peter Tindall

Lynne Taylor Responsive

Cause Consequence

Inherent Risk

Rating Impact /

Likelihood


Current Risk Rating

Impact / Likelihood


RAG rating (Assurance)

Target Risk Rating Impact /

Likelihood

Risk Appetite

No recent comprehensive Joint Strategic Needs Assessment refresh by Directors of Public health– on-line portal not updated for 2 years

No recently updated Health and Wellbeing Strategy for the Trust

Lack of public awareness of screening services

Inordinate increasing demand for cancer services

General increase in demand for services

Deterioration in the overall health of the population requiring increased access to health services.

PH direction may no longer be current

Trust strategic direction unable to respond to changes resulting from population factors.

Services not fit for future service provision.

Uncoordinated approach to public health activity and interventions

Poor uptake of cancer screening programmes by population

Inadequate capacity resulting in patients not receiving best possible care throughout cancer pathway (62 day standard)

15

(5 x 3)

Health & Wellbeing Strategy, 2013-17.

Regular monitoring and reporting under auspices of existing strategies using agreed KPIs.

Identified objectives in relation to cancer screening services, cancer pathways and the overarching clinical services strategy.

Membership of North of Tees Partnership Board

Representation on Health and Wellbeing Committees

Annual planning cycle responding to public health guidance

Regular refresh of SWOT and PESTL analyses

Regular refresh of capacity and demand analysis

Incorporation of/response to updated NICE guidelines

Continuing engagement with/via GPs, Cancer Steering Group, Locality Cancer Group and regional network

Clinical collaboration with tertiary service providers

Collaboration with H&WB Leads in the development of the Clinical Services Strategy.

Require review of H&WB strategy to reassess outcome indicators.

12

(4 x 3)

Internal Included in Internal Audit review plan

External Quality Accounts

IST review

Regular engagement with external stakeholders through existing and new governance frameworks.

9

(3x3)

Open

Risk Reduction Plan

Actions Responsibility When Monitoring Committee Planned Outcome Progress EvaluationUndertake refresh of Health and Wellbeing Strategy as enabling strategy to clinical services and corporate strategies; with supporting action plan.

Peter Tindall 31/10/2015 Executive Team Trust Board

An agreed strategy with clear outcome indicators.

October 2015 – Progressing and development underway planned draft for approval by end of October 2015.

Implement recommendations of the capacity and demand analysis Lynne Taylor 31/07/2015 Executive Team To ensure delivery of the required resources and capacity; to maintain services and achieve standards.


Review and maintain the evidence base to provide assurance. Lynne Taylor 31/07/2015 Executive Team To ensure assurance and evidence available to support requirements.


Development of Clinical Services Strategy Lynne Taylor 31/01/2016 Executive Team Trust Board

Clinical Services Strategy fit for the future that serves the local population.

October 2015 – Work initiated and progressing, phase 1 completed.

Draft



29 October 2015

Quarter 2 2015/16 Compliance Report to Monitor


Strategic Aim and Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Board Reports


1. Introduction

1.1 The attached report provides members of the Board of Directors with the required information with regard to the quarterly submission to Monitor, including:

• a financial summary report, detailing the quarter end (year to date) actualposition against plan (Appendix 1),

• the position against national core standards (Appendix 2),• an update report (Appendix 3) outlining changes that have occurred in

relation to the Licence Conditions and Risk Assessment Framework,since the time of the last formal compliance report (Quarter 1 – July2015) proposed actions, timelines for delivery and next steps,

• Membership and Governor changes – (Appendix 4)• the in year governance statement (Appendix 5)• Quality Governance Metrics – (Appendix 6)• Governance Statement - Supporting Information (Appendix 7a and 7b)• Revised Compliance Requirements (Appendix 8)

1.2 The report focuses predominantly on governance risk ratings in the context of Conditions of Licence.

2. Compliance Requirements

2.1 The Monitor NHS Provider Licence outlines the mandatory set of conditions that all NHS Foundations Trusts must meet.

2.2 Monitor will continue, under the requirements of the Health and Social Care Act 2012, to oversee the governance of NHS Foundation Trusts’ compliance with two sets of conditions of their licence:

• those relating to the continued provision of NHS services (“Continuity ofServices conditions”), which require relevant providers to ensure amongstother matters that they remain a going concern; and

• NHS Foundation Trust condition 4 (governance condition) setting outrequirements relating to governance at NHS Foundation Trusts.

1

Draft

2.3 Monitor carries out this oversight role by requiring all Boards to certify ongoing compliance with their governance condition, via the Corporate Governance Statement (as declared in the Annual Plan submission and contained within Appendix 5), subsequently using performance against governance indicators, financial performance, exception reports and third party information to test that certification.

2.4 Monitor uses a combination of financial information and performance against a selected group of national measures as a primary basis for assessing the risk of Trusts breaching their Continuity of Services and Governance conditions respectively.

2.5 Monitor’s risk-based framework assigns two risk ratings (Continuity of Service and Governance conditions) to each NHS Foundation Trust on the basis of its forward plan and in-year performance against that plan, and consequently the risk of breach of Continuity of Services or Governance conditions of the licence.

2.6 Monitor amended the Risk Assessment Framework (RAF) in August 2015, with the key changes including;

• re-introducing two previously used measures: one tracking FoundationTrust deficits and another the accuracy of planning

• combining a Trust’s rating on these new measures with its existingcontinuity of service ratings (COSRR) to produce a new four-levelfinancial sustainability and performance risk rating, with appropriateregulatory responses to each rating level

• making two further changes to ensure Trusts make sure they delivervalue for money.

See further detail in section 4

3. Current Position

3.1 The Board of Directors has effectively planned for the future, assessed risks to compliance with the Licence, reviewed financial viability, overall governance and quality governance.

3.2 Ongoing and assessment actions continue in monitoring and delivery and compliance with the Licence Conditions. There is no further publication from Monitor on Payment of Fees or the formulation of a Risk Pool Levy on which to make a considered judgement.

3.3 The delivery of the C-diff standard was recognised by the Board of Directors as at risk for 2015/16 against the indicator threshold (Risk Assessment Framework 2015), with a declaration of non-compliance indicated in the Operational Plan submitted to Monitor. In addition, the risk of underachievement against access and cancer standards was anticipated by the Board of Directors and acknowledged in the returns to Monitor via the Annual Plan.

3.4 Taking into account the position going forward, the Board has considered the ability to maintain a financial risk rating of at least 3 in 2015/16 (Finance and Contract Performance Report, 29 October 2015).

3.5 The Trust has under-achieved against three of the key targets during quarter 2 period, Cancer 2 Week Wait Standard, Cancer 62 day Standard and the C-Diff standard. Full analysis with supplementary information are provided in

2

Draft

Appendix 7a and 7b, outlining the current position, historical performance, key issues within the quarter 2 period and the resulting actions and mitigation plans going forward to manage the position against these standards.

3.6 The Monitor Risk Assessment Framework outlines the triggers for concern

against the Access and outcomes metrics, as follows:

• Cancer Two Week Wait Standard: breaches standard for a third consecutive quarter. Q2 is the second quarter reporting an under-achievement against this standard

• Cancer 62 Day Standard: breaches standard for a third consecutive quarter.

• C-Diff: Breaching pre-determined annual C-Diff threshold (either three

quarters’ breach of the year to date threshold or breaching the full year threshold at any time in the year). The Trust has breached the full year threshold during Q2.

A performance score of 4 or greater in a single period will also trigger intervention. (Diagram 13, Risk Assessment Framework 2015/16)

3.7 The Trust has raised concerns with regards the unrealistic C-Diff objective set for 2015/16 with NHS England, and also declared the standard at risk of under-achievement within the Trust’s Annual Plan submission to Monitor.

3.8 Following the application of Monitor guidelines regarding priority weighting

and thresholds for core standard performance, the Trust has achieved an overall aggregate score of 3 (under-achievement against the three standards outlined above).

3.9 However, in line with the Risk Assessment Framework, the breach of the C-

Diff full year objective in quarter 2 is a Monitor ‘trigger’ for concern and may result in further intervention. The Trust has provided a full update of the current position, the work to date and on-going actions to keep C-Diff cases to a minimum. (see Appendix 7a)

3.10 There are no material concerns, at this stage, to alter the position of the

Board with regard to the certification contained with the Annual Plan Corporate Governance Statement and thereby requiring exception reporting in line with the Terms of Provider Licence, however reports providing supporting information, see Appendix 7a and 7b, will be submitted to Monitor alongside the quarter 2 submissions, for the areas reporting outside of the required standards, as outlined within this report.

4. Revised Compliance Requirements 4.1 The revised RAF has seen the re-introduction of measures of Foundation

Trust deficits and variance from plan. Monitor has retained the existing continuity of service measures (liquidity and capital service capacity) and introduced the following additional measures into the Risk Assessment Framework (Appendix 8).

4.2 A Trust’s ratings on these additional measures feeds into its new overall

financial sustainability and performance risk rating. 4.3 Monitor has included a further additional measure within Foundation Trusts’

governance rating linked to value for money. Monitor may consider

3

Draft

investigating if a Foundation Trust demonstrates inefficient or uneconomical spend (actual or forecast) against published benchmarks.

4.4 Changes to the NHS Foundation Trust accounting officer memorandum have also been applied, with the aim to strengthen the requirement to consider value for money.

5. Recommendations

5.1 The Board of Directors is asked to note the quarter end report, outlining current financial position (Appendix 1; full report contained within the Finance and Contract Performance Report, as at 29 October 2015) performance on core national standards (Appendix 2), the update report on the key changes that have taken place in relation to the Licence Conditions and Risk Assessment Framework since the last quarterly submission (Appendix 3), a members and governors update position (Appendix 4) a Quality Governance return outlining the number of current voting members of the Board and any in quarter changes (Appendix 6), and the Governance Statement - Supporting Information (Appendix 7a and 7b) which will be submitted to Monitor as a requirement of the quarterly compliance return.

5.2 In line with the Monitor Risk Assessment Framework 2015/16 the Board of Directors is also asked to consider the quality governance framework and the requirement to declare ongoing compliance with quality and legal requirements. This is supported by Care Quality Commission information (where appropriate) information on serious incidents, patterns of complaints, and further metrics as contained and explored within Board meetings and sub committee meetings. In addition the Board has also pledged to keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

5.3 Monitor has issued guidance on the well-led framework for governance reviews to support NHS Foundation Trusts gain assurance that they remain well led. The framework represents a ‘core’ reference for NHS Foundation Trusts to follow in structuring reviews of their governance, covering strategy and planning, capability and culture, processes and structure and measurement, using a self-assessment approach.

5.4 Due diligence has been paid by the Board of Directors in assessing ongoing compliance and that of new requirements, specifically that illustrated in regular seminar discussion and Compliance and Performance Reports, Quality Reports, Infection Prevention and Control Reports, Finance and Contract Performance Reports and Board Assurance Framework Reports.

5.5 Finally, the Board of Directors is asked to note the under achievement in the context of the Monitor triggers within the Risk Assessment Framework, recognise the work on-going to manage recovery, not withstanding the risks inherent in the health system to financial and operational performance, as discussed at the Board seminar in March 2015 and in each Board meeting since and delegate responsibility to the Chairman to sign the in year governance statement contained within Appendix 5 on behalf of the Board.


4

Draft

Appendix 1


Quarter Two - 2015/16

Financial Summary A commentary on the financial position is submitted separately to Monitor in support of the

detailed quarterly financial proformas.

The key metrics from the financial report are as follows:


Area of Review


YTDMonth 12 Projection

I&E Margin (25%)

1 1 1

Variance in I&E Margin (25%)

4 1 1


2

2

1

4

Capital Service Capacity(25%)


2

4Liquidity

(25%)

2 2

4

Draft

o Overall financial risk rating of 2 (using the new metrics).

o I&E operating deficit of £7.229m – the Trust is under-achieving against its

plan by £3.640m.

o CIP performance = Target at baseline of £10.901m.

o The Trust is phasing in the non-delivery of the SIEP over the period of the

financial year to avoid any adverse movement in the position towards the

year end. The Trust has delivered £4.402m of its in-year SIEP, of which

£2.291m (52%) was recurrent and £2.111m (48%) was non recurrent. This

is £1.049m behind plan for the second quarter.

o Net cash outflow for the second quarter of the financial year 2015/16 is

£3.650m, resulting in a decrease in cash from £29.598m at the start of

quarter 2 to £25.948m as at 30 September 2015.

o Net current assets at 30 September 2015 are £23.885m.

Despite, overall financial performance for the year being behind plan for the first quarter of 2015/16, the Trust achieved a Continuity of Service Risk rating of a 2 using the new metrics.

Financial performance is behind plan for the financial year with operational pay budgets for the Directorates under-pressure because of the reliance on locum and agency staff to meet the unprecedented demand for services. The pressure on pay budgets has reduced slightly as a result of action plans implemented by management teams, resulting in a supplementary pay bill of £1.0m in September, as compared to an average £1.4m per month in the first 5 months of the year. In addition the pressure against medical staff budgets is currently the subject of a detailed review requested by the Director of Finance, ICT and Support Services and will be reported to the Executive Team and Board of Directors at the end of October. SIEP has under delivered for the second quarter and has resulted in the Trust having to report a larger than planned deficit. The Trust is continuing to maintain an appropriate balance between the challenging financial efficiency agenda and the desire to continue to invest in improving quality, patient experience and service performance.

Detailed financial performance meetings have been held with Directorates which has resulted in a revised forecast deficit of c£7.2m by the year end. This remains the current forecast. The actual performance against this position will be monitored monthly to ensure there is no further deterioration in the position.

Draft

Appendix 2Click to go to index

Threshold or

target YTD

Scoring Per Risk

Assessment Framework

Risk declared

Scoring Per Risk


Performance Declaration Comments / explanations

Scoring Per Risk


Performance Declaration Comments / explanations

Scoring Per Risk


must completemay need to completeTarget or Indicator (per Risk Assessment Framework)Referral to treatment time, 18 weeks in aggregate, incomplete pathways % i 92% 1.0 No 0 96.7% Achieved 0 96.7% Achieved 0A&E Clinical Quality - Total Time in A&E under 4 hours % i 95% 1.0 No 0 96.4% Achieved 0 95.7% Achieved 0

Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation % i 85% 1.0 No 85.5% Achieved No Breach reallocation in place 83.1% Not met Exception report submitted

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation % i 90% 1.0 No 99.5% Achieved No Breach reallocation in place 96.5% AchievedCancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation % i 85.5% 83.1%Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation % i 99.5% 96.5%Cancer 31 day wait for second or subsequent treatment - surgery % i 94% 1.0 No 100.0% Achieved 96.8% AchievedCancer 31 day wait for second or subsequent treatment - drug treatments % i 98% 1.0 No 100.0% Achieved 100.0% AchievedCancer 31 day wait for second or subsequent treatment - radiotherapy % i 94% 1.0 N/A 0.0% Not relevant 0.0% Not relevantCancer 31 day wait from diagnosis to first treatment % i 96% 1.0 No 0 99.4% Achieved 0 98.8% Achieved 0

Cancer 2 week (all cancers) % i 93% 1.0 No 92.9% Not met Full supporting information submit 91.8% Not met Exception report submitted

Cancer 2 week (breast symptoms) % i 93% 1.0 No 94.4% Achieved 93.2% AchievedCare Programme Approach (CPA) follow up within 7 days of discharge % i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevantCare Programme Approach (CPA) formal review within 12 months % i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevantAdmissions had access to crisis resolution / home treatment teams % i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Meeting commitment to serve new psychosis cases by early intervention teams OLD measure - use until Q1 2016/17 % i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Ambulance Category A 8 Minute Response Time - Red 1 Calls % i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Ambulance Category A 8 Minute Response Time - Red 2 Calls % i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Ambulance Category A 19 Minute Transportation Time % i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0

C.Diff due to lapses in care (YTD) # i 6.5 1.0 Yes 0 8 Achieved No local process in place to carry 0 18 Not met Exception report submitted 1

Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) # i 8 18C.Diff cases under review # i 0 0Minimising MH delayed transfers of care % i <=7.5% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Meeting commitment to serve new psychosis cases by early intervention teams NEW measure (from Q3 2015/16) % i 50% 0.0% Not relevant 0.0% Not relevantImproving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (from Q4 2015/16) % i 75% 0.0% Not relevant 0.0% Not relevantImproving Access to Psychological Therapies - Patients referred within 18 weeks NEW measure (from Q4 2015/16) % i 95% 0.0% Not relevant 0.0% Not relevantData completeness, MH: identifiers % i 97% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Data completeness, MH: outcomes % i 50% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0Compliance with requirements regarding access to healthcare for people with a learning disability % i N/A 1.0 No 0 N/A Achieved 0 N/A Achieved 0

Community care - referral to treatment information completeness%

i 50% 1.0 No 92.9% Achieved 92.9% Achieved Latest quarterly average (June - August)

Community care - referral information completeness%


Community care - activity information completeness%


Risk of, or actual, failure to deliver Commissioner Requested Services # N/A No No No

Date of last CQC inspection#

i N/A N/A 07/07/2015 No report received at time of submission 07/07/2015Inspected in July, awaiting report at point of submission

CQC compliance action outstanding (as at time of submission) # N/A No No NoCQC enforcement action within last 12 months (as at time of submission) # N/A No No NoCQC enforcement action (including notices) currently in effect (as at time of submission) # N/A No No NoModerate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) # i N/A No No NoMajor CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) # i N/A No No NoOverall rating from CQC inspection (as at time of submission) # i N/A N/A N/A N/ACQC recommendation to place trust into Special Measures (as at time of submission) # N/A N/A No NoTrust unable to declare ongoing compliance with minimum standards of CQC registration # N/A No No NoTrust has not complied with the high secure services Directorate (High Secure MH trusts only) # N/A N/A N/A N/A

0 0Overall Score 3

Declaration of risks against healthcare targets and indicators for 201516 by North Tees and Hartlepool NHS Foundation TrustAnnual Plan Quarter 1 Quarter 2

0 00

Report by Exception

0 N/A1

0 00

Targets and indicators as set out in the Risk Assessment Framework (RAF) - definitions per RAF Appendix ANOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines.

0 0

0

0 01

Draft

Appendix 3

North Tees & Hartlepool NHS Foundation Trust Meeting of Board of Directors

29 October 2015

Quarter 2, 2015/16 (1 July 2015 to 30 September 2015)

Update Report


1. Introduction

The following report provides an update of the key changes that have occurred since the time of the last formal report to Monitor; the report covers the period of quarter 2 (1 July 2015 to 30 September 2015) and reflects the requirements of the Risk Assessment Framework and the Licence Conditions.

2. Update Report

2.1 Continuity of Services Condition 1: Continuing provision of Commissioner Requested Services

This condition prevents licensees from ceasing to provide Commissioner Requested Services, or from changing the way in which they provide Commissioner Requested Services, without the agreement of relevant commissioners.

Update Issue:

2.1.1 Momentum: Pathways to Healthcare

The Momentum: Pathways to Healthcare Programme continues to summarise the direction for the Trust’s Strategy and incorporates the ways in which services will be provided in the future and the facilities from which they will be delivered.

The Clinical Services Strategy will provide the means of taking the Trust’s confirmed strategic direction forward, and developing service specific strategies to enable the achievement of the significant and wide-ranging changes currently demanded.

Considerable work has been undertaken during the quarter, incorporating extensive discussion with the clinical teams to develop a range of locality based options for the next two to five years. A detailed update was provided to the Board of Directors in September, and more detailed scoping and planning is now underway to inform the direction of the Trust’s strategy going forward.

Key to the successful development and delivery of the Clinical Services Strategy will remain the need for partnership working and collaboration between all members of the local health and social care economy.

2.1.1.1 Transformation Programme

The Trust now has an established Transformation Directorate which will oversee the development and implementation of the Transformation Programme.

1

Draft

Appendix 3

The programme is overseen by the Transformation Committee which is now established as a formal sub-committee of the Board of Directors.

The Transformation Team is currently developing training materials, templates and a handbook to support project management across the Trust. This will be presented at the Transformation Committee and disseminated to directorate teams.

The key projects currently allocated to the Transformation Programme are organised into two “tranches” referred to as Transition (1-2 years) and Transformation (longer term). These are:

Transition: • Electronic Patient Record (EPR) Phase 1 (replacement of current

Patient Administration System functionality)• NHS Professionals – review• Staff Flow – to reduce the cost of locum medical staff employment• Administration Review Phase 1 (review of corporate and medical

secretarial services)• Commercial Developments – as identified• Transforming Outpatients – carried forward from the previous

Delivery Programme• DQIP – a review of the coding process and its impact on income and

mortality performance reporting• Tender opportunities – notably the Trust’s response to the Urgent

Care invitation to tender

Transformation: • EPR Phase 2 (including electronic prescribing and order

communications)• Integrated Care Pathways, specifically

o Respiratoryo Diabeteso Frail Elderly and Dementiao End of Life

• Theatres Transformation• Administration Review Phase 2 (impact of EPR implementation)• Technology-led developments• Personal Health Budgets• Back-office functions• Service Redesign

Projects allocated to the programme in future are likely to address developments relating to the following key areas:

• Systems• Technology• Culture

Recruitment to the Transformation Team is underway, and all but one of the posts is expected to be filled by the end of the next quarter. The team is currently reviewing the projects to establish their current status and identify the key next steps for each.

2

Draft

Appendix 3

2.1.1.2 Better Care Fund (BCF)

The Trust continues to be fully involved in this joint programme of work, as agreed between NHS England and the Local Government Association (LGA) that planned, for 2015/16, to re-allocate a number of existing health and social care funding streams to a local, pooled Better Care Fund used to support greater integration between health and social care services.

The on-going Clinical Services Strategy development remains aligned with the planning for the implementation of the Better Care Fund (BCF). The strategic aims are linked to the principles of the Momentum programme, seeking to develop integrated care pathways and expand the portfolio of services to provide integrated care for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible, reducing avoidable admissions by 15%. To affect these changes risk sharing is required and is to be agreed to ensure equitable sustainable outcomes and as such is being discussed at the North of Tees Partnership Board (NoTPB).

2.1.1.3 Primary and Community Care Capital Planning Project

Following the re-configuration of the services and estate at the University Hospital of Hartlepool which consolidated services into the core of the hospital, a significant number of community based administration staff have relocated to the Hartlepool site and local authority partners have now relocated into the hospital during quarter 2 to establish an integrated health and social care base. This has allowed the Trust to reduce external lease costs, avoid additional lease costs and generate income through improved utilisation of the estate. The Trust is continuing to plan for the transfer of further appropriate services from outlying locations in to the hospital to maximize the economic use of the estate going forward.

Actions and Next Steps:

• Proposal to Board for the Trust’s strategic direction and enabling strategies• Continue with and refresh the transformation programme• Prioritisation of Integrated Care pathway work, and identification of pump priming

funding routes via commissioners.• Continued involvement in the development and delivery of implementation plans

as part of the Better Care Fund.• Further development and progress changes relating to the Community Estates

Strategy, linking with key partners to support the future plans for servicesustainability.

2.1.2 Hospital Capital Planning Project – New Hospital

The project will continue on hold until after the outcome of further discussions across political, health and policy stakeholders.

Actions and Next Steps:

The Trust will continue with the new hospital project on hold until after discussions have taken place with the regulators and local community stakeholders.

3

Draft

Appendix 3

2.2 NHS Foundation Trust Condition 4: NHS Foundation Trust Governance Arrangements

This condition enables Monitor to continue oversight of governance of NHS foundation trusts.

NHS foundation trusts should report to Monitor any further information that could reasonably be regarded as having the potential to affect compliance with the organisation’s governance licence condition.

Update Issue:

2.2.1 Board Appointments

Jonathan Erskine and Kevin Robinson were appointed as Non-executive Directors with effect from 1 August 2015 for an initial term of office of 3 years.

The Trust Director of Nursing, Patient Safety and Quality is currently on sick leave, likely to be off for some time due to ill health. Deputy Director of Nursing, Clinical Governance and Patient Safety will be acting Director of Nursing, Patient Safety and Quality during this period of absence. This has been approved at Board level.

2.2.2 Governor Resignations

Denise Rowland, Elected Governor for Easington resigned on 1 July 2015 and Carol Ellis, Elected Governor for Stockton resigned on 26 August 2015. Liz Holey, Appointed Governor for Teesside University retired from post on 30 September 2015.

Update Issue:

Membership

The Trust membership at 30 September 2015 was 11,371 comprising 5,833 public members, (incorporating 199 non-core other area public members), and 5,538 staff members. The Trust’s plan for membership for 2015/16 continues to focus on maintaining current membership levels, improving member engagement, and facilitating governor/member engagement.

The Trust’s Membership Strategy has been refreshed to ensure it remains fit for purpose and reflects the Trust’s overall strategic aims and objectives, and will periodically be updated to reflect the on-going work being undertaken.

The Trust communicates regularly with its members, via email, social network sites, the Trust website and its quarterly magazine, Anthem, to ensure that they are kept up to date on Trust news, plans and developments. This will be expanded to include a programme of governor and member engagement. The programme of quarterly member events continue, including interactive market place events showcasing the work of the Trust, as well as creating other opportunities for members to view the work of the Trust.

Actions and Next Steps: 4

Draft

Appendix 3

The Trust will continue to actively recruit new members to the Trust, maintaining its target membership level of approximately 6,030 members and develop new ideas of engagement.

2.2.4 Quality Governance

2.2.4.1 Standardised Hospital Mortality Indicator (SHMI)

The Trust is indicating a higher than average SHMI. SHMI provides mortality data relating to deaths both in hospital and within 30-days of discharge from hospital, with no adjustment for end of life care. The latest data available nationally is for the 12 month period ending December 2014 which reported at 118.24, which remains in the ‘higher than expected’ range. This has decreased from the previous 12 month reporting period value of 118.91.

2.2.4.2 Hospital Standardised Mortality Ratio (HSMR)

The Trust acknowledges that the HSMR value is higher than expected and is implementing a number of processes/reviews to gain a greater understanding to the quality of care being given to patients and the process, infrastructure and governance to support change.

The HSMR value has decreased from 124.54 (July 2014 to June 2015) to 123.86 (August 2014 to July 2015).This value continues to be outside the ‘as expected’ range; the national mean is 100.

A priority is the end of life pathway and appropriate palliative care coding.

The Trusts End of Life coordinator who has recently joined the Specialist Palliative Care team continues to make an impact on the number of patients seen and co-ordination of care.

Actions and Next Steps for SHMI and HSMR:

A robust governance structure surrounds improvement actions around mortality.

The Trust has ensured that the 7 recommendations for improvement in the North East Quality Observatory (NEQOS) mortality review have been commenced. This action plan is discussed at the monthly Keogh Delivery Group, ensuring that updates and actions are given and followed through.

The Trust has implemented measures for improvement and targets for reducing the Trust’s mortality. The areas included are Frail Elderly, Specialist Palliative Care, Clinical Coding, Community Acquired Pneumonia, Sepsis and working with GPs regarding mortality.

The Trust has also appointed a Trust Outcome Performance Lead (clinical) to take forward the Trusts improvement in mortality and a project manager to be responsible for the Action Plan.

The Trust is in discussions with Advancing Quality Alliance (AQuA) for independent support. The support will be in the form of Sepsis and Acute Kidney Injury (AKI) review

5

Draft

Appendix 3

of pathways and best practice, looking at the Trust’s mortality data, conducting clinical reviews and reviewing the organisation’s safety culture.

The Trust has agreed with commissioners to recognise the Trust’s Ambulatory Care data. This process commenced 01 April 2015. Due to the time-lag in SHMI, the benefit of this change will take until early 2016 to feed through, where it should start to have an effect on reducing the statistical SHMI value and Crude Mortality Rate.

3. Conclusion

Monitor is asked to note the update report, which provides supplementary information within the requirement of the Licence Conditions and Risk Assessment Framework with regard to events having occurred within the Quarter 2 period.

6

Draft


List of Governors' elections for North Tees and Hartlepool NHS Foundation Trust

Constituency Type

Full Name of Constituency

No. of candidates

No. of Votes cast

TurnoutNo. of

Eligible voters

Date of election

Elections held in the quarter ending 30

Sep 2015

NIL RETURNWTE 1WTE 2WTE 3WTE 4WTE 5WTE 6WTE 7WTE 8WTE 9WTE 10WTE 11WTE 12WTE 13WTE 14WTE 15WTE 16WTE 17WTE 18WTE 19WTE 20WTE 21WTE 22WTE 23WTE 24WTE 25WTE 26WTE 27WTE 28WTE 29WTE 30WTE 31WTE 32WTE 33WTE 34WTE 35WTE 36WTE 37WTE 38WTE 39WTE 40

The Risk Assessment Framework requires a quarterly report of elections

held and results as below:

Draft

Appendix 5

Click to go to index

In Year Governance Statement from the Board of North Tees and Hartlepool NHS Foundation Trust

The board are required to respond "Confirmed" or "Not confirmed" to the following statements (see notes below) Board Response

For finance, that:

For governance, that:

Otherwise:

Consolidated subsidiaries:

Signed on behalf of the board of directors

Signature Signature

Name Name

Capacity [job title here] Capacity [job title here]

Date Date

Responses still to complete: 5

A

B

C

Notes:

The board anticipates that the trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months.

The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return.

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Table 3) which have not already been reported.

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

The Trust has under-achieved against three healthcare standards:Cancer 2 Week Rule StandardsCancer 62 Day StandardC-Difficile - breached full year trajectory

Full supporting information, covering current position, key issues and mitigating actions is included within the submissions to Monitor.

As a result of the new metrics introduced by Monitor, the Trust has assed the position in relation to future performance against the revised metrics. The Trust is forecasting a financial risk rating of 2 going forward.

Draft


In Year Organisational Health Indicators for North Tees and Hartlepool NHS Foundation Trust

The Risk Assessment Framework (table 7) sets out that Monitor will use executive team turnover as one of the potential indicators of quality governance concerns. Please provide the information requested below and ensure that any changes are explained in your commentary:

unitsActual For

Quarter ending 30-Jun-15

Actual For Quarter ending

30-Sep-15

Executive DirectorsTotal number of Executive posts on the Board (voting) Posts 5 5 Number of posts currently vacant Posts -Number of posts currently filled by interim appointments Posts -Number of resignations in quarter Resignations -Number of appointments in quarter Appointments -

Draft

Appendix 7b



October 2015

Governance Statement - Supporting Information – Cancer Standards

Quarter 2 – 2015/16 (1 July – 30 September 2015)


The following targets (after application of thresholds) have not been met during the period of monitoring (quarter 2) which has led the Board to review the current position, actions to date and risks to future compliance and assurance before signing the Governance declaration stating on-going compliance.

All targets refer to the Monitor Risk Assessment Framework, around health care and other standards that the Trust shall put in place and comply with, for the purpose of monitoring and improving the quality of health care provided by the Trust. This is in line with Monitor NHS Provider Licencing conditions.

The following supporting information details the current position against the Cancer 2 week Standard and 62 day Urgent Referral to Treatment Standard, the root cause analysis which has taken place to identify issues, the mitigation and proposed actions to reduce future risk against delivery of these standards.

1. Standards

Cancer 2 week wait standard Cancer 62 day referral to treatment standard

2. The Issue

During the quarter 2 period, 1 July to 30 September 2015/16, the Trust has under-achieved against the following standards

• Cancer 2 week wait standard; reporting at 91.82% against the 93% standard• Cancer 62 day referral to treatment Standard; reporting at 83.11% against the 85% standard

(provisional position until final published figures in November 2015)

The Trust is committed to consistent achievement against all cancer targets and has an excellent track record of delivering in line with the national requirements. A full and timely review of the key issues has taken place to identify the reasons/causative factors for under-achievement against the cancer standards, with appropriate mitigation plans implemented to address key issues, with the aim to pull the Trust position back in line with the set targets and provide a level of assurance to the Board of Directors with regard to on-going compliance; notwithstanding the system wide issues described in this report requiring action to enable consistent delivery.

1

Draft

Appendix 7b

3. Current Position

3.1 Referral Increases

North Tees and Hartlepool NHS FT (NT&HFT) has continued to see an increase in Cancer 2 week referrals over the 2015/16 period, with Q2 overall referrals indicating a further 9.19% (n=198) increase in comparison to the Q2 period last year. Chart 1 below provides an overview of the increase in referrals from April 2013 to September 2015 (excluding Breast Symptomatic).

The continued increase in referrals has been influenced by both the NICE revised cancer referral guidelines and Be Clear on Cancer Campaigns, with significant peaks in demand evident during periods when the campaigns are running i.e. Blood in Pee campaign in February 2015.

Chart 1: Cancer 2 Week Referrals (April 2012 –September 2015)

Despite the increase in referrals, historical evidence indicates the conversion rate to confirmed cancers (62 day pathway) have remained at approximately 9% in 2015 (Q1 latest fully treated position), comparable to 2014/15.

However, this continued increase in referrals has had a significant impact on the outpatient and diagnostic services, as each 2 week wait referral has to be seen and diagnosed within the required timescales, which can include multiple appointments and diagnostic tests.

The Trust has managed the increases in demand through additional outpatient and diagnostic clinics, however due to a number of underlying issues, some outside the Trust’s control, there has been pressure points in the system leading to the under performance against two of the key cancer standards.

The following section outlines performance to date against each of the effected standards.

2

Draft

Appendix 7b 3.2 Cancer 2 Week Standard

The Trust has consistently performed well against the Cancer 2 week standard, see chart 2. However, as chart 2 indicates, July and August 2015 saw a decrease in performance, reporting at 90.60% and 90.86 respectively. September reported an improved position, achieving 94.12%, resulting in an overall position of 91.82% for the Q2 period.

The key area of pressure affecting the Cancer 2 week wait standard has been patient choice across all tumour groups.

The Q2 position reported 2360 patients in total seen within the Cancer 2 week wait standard, with 193 of these patients seen outside the 2 week standard, 171 due to patient choice to delay or DNA appointment (88.6% of total delays), 19 due to capacity issues (9.8% of total delays), 3 patients for other reasons (1.6% of total delays).

The capacity delays were associated with significant pressures in Respiratory due to the continued impact of referral increases. Despite additional clinics being provided a small number of patients could not be appointed within 14 days. The Trust has appointed two additional Respiratory consultants to meet the additional demand coming through the service, who took up their position at the end of August. However, if the Trust had not reported any capacity delays (19 patients) the position would still have reported below the 93% standard at 92.6%, indicating the significant impact of patient choice on the delivery of the standard.

In response to the patient choice issue, the Trust is working with local GPs and CCG leads, to ensure continued support to encourage patients to take up appointments offered within the required timescales, to improve patient information and ensure a continued focus on timely pathway management.

This is in addition to the additional measures that the Trust has put in place, i.e. telephone conversations instigated with patients to encourage attendance. Several letters of notification over the course of the six months period (including historical) have been discussed with the CCG to ensure a system wide radical approach to patient management and GP referral behaviour whilst the Trust has been without a GP cancer lead for the last ten months. Further and more robust work with GPs is now underway, with the Trust attending a Hartlepool and Stockton CCG meeting in November to discuss the cancer pathway issues.

3

Draft

Appendix 7b

Chart 2: Cancer 2 Week Standard (April 2012 to September 2015)

Table 1 below gives an overview of the North East performance against the 2 week wait standard during August 2015 (latest comparative period). As the data shows, a number of the North East organisations indicated pressures in delivering the 2 week standard both at aggregate level and across individual tumour groups, with the national average only just achieving the 93% standard, reporting at 93.2%. Evidence of similar pressures across all providers.

4

Draft

Appendix 7b

Table 1: Cancer 2 Week Standard – North East August 2015 Performance (comparative period)

Trust 1 Trust 2 Trust 3 Trust 4 Trust 5 Trust 6 Trust 7 North Tees &

Hartlepool

Trust 8 Trust 9 National

Breast 0 (0/0) 0 (0/0) 93.2 (82/88) 92.9 (329/354)

98.4 (186/189)

92.6 (237/256)

96.6 (197/204)

94.7 (162/171)

95.3 (246/258)

94.7 (1439/1520)

93.0

Lung 94.4 (17/18)

90 (27/30)

100 (19/19) 100 (23/23)

94.7 (36/38)

93.1 (27/29)

98 (49/50) 88.9 (80/90)

95.3 (61/64)

93.9 (339/361)

96.9

Gynae 97.2 (35/36)

98.7 (78/79)

93.9 (77/82) 87.3 (69/79)

94.8 (73/77)

92.2 (95/103)

98.9 (93/94)

95.3 (81/85)

96.2 (128/133)

94.9 (729/768)

93.8

Upper GI 100 (52/52) 75.6 (102/135)

96.7 (89/92) 84.8 (117/138)

90.7 (165/182)

92.7 (164/177)

90.4 (142/157)

91.3 (94/103)

92.8 (154/166)

89.8 (1079/1202)

91.6

Lower GI 97.5 (77/79)

89.9 (98/109)

93.1 (108/116)

95.5 (64/67)

74 (97/131) 90.7 (156/172)

86.2 (162/188)

83.2 (119/143)

86.4 (178/206)

87.4 (1059/1211)

91.7

Urological 0 (0/0) 100 (194/194)

84.8 (134/158)

90.2 (74/82)

100 (133/133)

96.2 (153/159)

98.6 (137/139)

92.9 (91/98)

86.4 (38/44)

94.7 (954/1007)

95.1

Testicular 0 (0/0) 100 (12/12)

85.7 (6/7) 100 (5/5) 100 (8/8) 100 (2/2) 0 (0/0) 0 (0/0) 100 (3/3) 97.3 (36/37) 96.9

Haem 100 (3/3) 100 (7/7) 100 (2/2) 81.8 (9/11)

100 (9/9) 100 (4/4) 100 (3/3) 100 (8/8) 100 (11/11) 96.6 (56/58) 96.2

Leukaemia 0 (0/0) 100 (1/1) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 100 (1/1) 90.5 Head & Neck 92.9

(13/14) 97.5

(118/121) 94.1 (80/85) 92.1

(35/38) 97.7

(212/217) 100 (1/1) 97.3

(177/182) 85.7 (6/7) 95.3

(81/85) 96.4

(723/750) 94.6

Skin 0 (0/0) 0 (0/0) 91.5 (107/117)

0 (0/0) 95.6 (672/703)

93.8 (15/16)

95.9 (282/294)

88 (22/25) 94.5 (446/472)

94.9 (1544/1627)

92.5

Sarcoma 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 95.5 (21/22)

0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 95.5 (21/22) 95.7

Brain/CNS 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 100 (1/1) 0 (0/0) 100 (6/6) 0 (0/0) 0 (0/0) 100 (7/7) 95.6 Children's 0 (0/0) 0 (0/0) 100 (2/2) 100 (1/1) 94.1

(16/17) 0 (0/0) 100 (3/3) 100 (1/1) 100 (10/10) 97.1 (33/34) 93.4

Other 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 100 (2/2) 100 (2/2) 0 (0/0) 100 (4/4) 93.9 All Cancers 97.5

(197/202) 92.6

(637/688) 91.9

(706/768) 91

(726/798) 94.3

(1629/1727)

92.9 (854/919)

94.8 (1253/1322

)

90.9 (666/733)

93.4 (1356/1452

)

93.2 (8024/8609)

93.2

In summary, it is evident that the delivery of the 2 week standard continues to be impacted on by patient choice. The Trust will continue to work with GP/CCG colleagues to address this issue at point of referral, with the aim to fully inform patients of the importance of taking up the first offered appointment to progress timely diagnosis and potentially treatment and a more radical transformational model to deliver on referrals.

3.3 Cancer 62 Day Standard

The Trust has struggled to consistently achieve the 62 day standard during 2015, despite the significant resource that have been applied to review pathway delivery. The Trust initiated a recovery plan in 2014, covering pathway management, governance structures and tracking processes (see section 4), with an independent review from the Department of Health Intensive Support Team also commissioned. The following section provides an overview of the current position and the key issues associated with the under-achievement against the standard.

As outlined in Chart 3, the Trust has seen a dip in performance against the 62 day standard during 2015, under-achieving across a number of individual months, resulting in the Q2 position reporting below the required 85% standard at 83.11%.

5

Draft

Appendix 7b Chart 3: Performance against the Cancer 62 Day Standard (April 2012-September 2015)

The Trust reported a total of 12 full breaches (accountable to NT&HFT) and 13.5 shared breaches (0.5 of each breach accountable to NT&HFT and 0.5 accountable to tertiary trusts). Table 2 shows the overall breakdown by month, with table 3 showing the breakdown of breaches by tumour group.

Table 2: Quarter 2 62 Day Standard Performance

July August September Provisional Q2

Total Number of accountable patients 56 51 44 151 Number of patients who breached 8 8.5 9 25.5 Number of full accountable breaches 4 3 5 12 Number of shared accountable breaches 4 5.5 4 13.5 Performance 85.71% 83.33% 79.55% 83.11%

Table 3: Breaches by Tumour Group

Q2 Tumour Group Full Shared (accountable) Breast 0 0 Colorectal 1 1 (0.5) Gynaecology 1 4 (2) Haematology 1 0 Lung 6 11 (5.5) UGI 0 4 (2) Urology 3 7 (3.5) Total breaches 12 27 (13.5)

6

Draft

Appendix 7b

The Q2 under-achievement against the Cancer 62 Day standard is, in the main, as a result of the September performance, which reported at 79.55%, with only 44 accountable patients treated within the period, however with 9 accountable breaches. In total 151 accountable patients were treated within the Q2 period, with 25.5 accountable breaches reported.

Full root cause analysis of each breach of the 62 day standard is carried out and shared across internal and external stakeholders to enable pathway reviews to be carried out where key themes are identified. Table 4 below shows the preliminary breach analysis by category for the July to September period, however it should be noted that the categories shown are the delays within the pathway which account for the longest period of delay, there can be multiple delays within individual pathways.

The categories indicating the highest proportion of delays are complex pathway (47.1% - 12 accountable pathways), Capacity (25.5% - 6.5 accountable pathways) and Patient Choice (13.7% - 3.5 accountable pathways).

It is recognised that the complexity of some pathways, including multiple diagnostics and sometimes multiple tumour sites may ultimately breach the 62 day pathway. The 85% target assigned to the 62 day cancer standard, allows a 15% tolerance for complex/medical reasons, with patient choice also recognised as a reason for delay. However, as table 4 demonstrates, 68.6% (17.5 breaches) fall into these categories.

The continuous advancement in specialist diagnostics and treatments has seen an increase in the number of capacity delays within the specialist tertiary centers, with extended waiting times across specific treatments i.e. robotic surgery and Stereotactic Body Radiation Therapy (SBRT), which take up additional theatre time/planning to support delivery. From a patient perspective the specialist treatments can provide an improved outcome, however capacity is limited and in itself is creating pressures in achieving the cancer standards.

The Trust is working with tertiary providers to assess the current impact of the specialist diagnostics/treatments on the delivery of the 62 day standards, ensuring any avoidable delays are addressed on a day to day basis, with additional monthly meeting held to discuss on-going issues. Commissioners have been alerted to these issues.

Table 4: Quarter 2 Breach Analysis (Accountable pathways) 62 Day Standard Jul-15 Aug-15 Sep-15 Total % of Total DNA 0 0 0 0 0.0 Patient Choice 0.5 2 1 3.5 13.7 Capacity 2.5 3 1 6.5 25.5 Admin 0 0 0 0 0.0 Medical Reason 2 0 0 2 7.8 Other/Unknown 0 1 0.5 1.5 5.9 Complex Diagnostics 3 2.5 6.5 12 47.1 Late referral to treating trust 0 0 0 0 0.0 Total 8 8.5 9 25.5 100

Table 5 below gives an overview of the regional and national performance against the 62 Day Standard for August (latest published data). It is evident a number of organisations are struggling to

7

Draft

Appendix 7b achieve the standard both at aggregate and across individual tumour groups, with only three out of the ten regional organisations achieving the standard and the national average reporting at 82.5%.

Similar pressures are also evident across Lung, Upper Gastrointestinal and Urology.

Table 5: 62 Day Standard – North East August 2015 Performance (latest available data)

Trust 1 Trust 2 Trust 3 Trust 4 Trust 5 Trust 6 Trust 7 North Tees &

Hartlepool

Trust 8 Trust 9 National

Breast 0 (0/0) 100 (0.5/0.5) 93.3 (7/7.5) 100 (20.5/20.5

)

100 (9/9) 96.3 (13/13.5)

100 (13/13)

100 (5/5) 100 (23/23)

98.9 (91/92) 96.2

Lung 100 (6.5/6.5)

40 (1/2.5) 63.2 (6/9.5) 88.9 (4/4.5)

62.2 (14/22.5)

50 (0.5/1) 75.7 (14/18.5)

81 (8.5/10.5)

68.4 (6.5/9.5)

71.8 (61/85) 76.2

Gynae 0 (0/0) 100 (4/4) 100 (3.5/3.5) 93.8 (7.5/8)

40 (2/5) 94.1 (8/8.5)

89.7 (13/14.5)

66.7 (3/4.5) 100 (7/7) 87.3 (48/55) 78.7

Upper GI 50 (1.5/3) 55.6 (2.5/4.5)

60 (3/5) 75 (1.5/2) 60 (6/10) 70 (3.5/5) 50 (6.5/13) 75 (3/4) 76.5 (6.5/8.5)

61.8 (34/55) 73.1

Lower GI 100 (5/5) 83.3 (5/6) 66.7 (8/12) 87.5 (3.5/4)

46.2 (3/6.5) 83.3 (5/6) 91.3 (10.5/11.5)

100 (8/8) 50 (2/4) 79.4 (50/63) 71.9

Uro (exc testes) 0 (0/1) 72.2 (26/36) 78.6 (22/28) 83.3 (12.5/15)

62 (15.5/25)

88.9 (12/13.5)

84.7 (25/29.5)

69.2 (9/13) 53.3 (4/7.5)

74.8 (126/168.5)

75.1

Testicular 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) #N/A

Haem (exc AL) 100 (1/1) 100 (2/2) 20 (1/5) 100 (2/2) 100 (7/7) 50 (2/4) 55.6 (2.5/4.5)

100 (4/4) 42.9 (1.5/3.5)

69.7 (23/33) 79.4

Head & Neck 0 (0/0) 83.3 (2.5/3) 80 (4/5) 0 (0/1) 75 (4.5/6) 0 (0/0) 41.2 (3.5/8.5)

0 (0/0) 83.3 (2.5/3)

64.2 (17/26.5)

69.3

Skin 0 (0/0) 100 (1.5/1.5) 100 (9.5/9.5) 0 (0/0) 95.8 (69/72)

100 (4.5/4.5)

100 (18.5/18.5)

100 (1.5/1.5)

96.7 (29.5/30.5

)

97.1 (134/138)

96

Sarcoma 0 (0/0.5) 0 (0/0) 0 (0/0) 0 (0/0) 40 (1/2.5) 0 (0/0) 100 (1/1) 0 (0/0) 0 (0/0) 50 (2/4) 73.7

Brain/CNS 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) #N/A

Children's 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) #N/A

Other 0 (0/0) 0 (0/0) 0 (0/1) 0 (0/1.5) 100 (1/1) 0 (0/0) 60 (1.5/2.5)

100 (0.5/0.5)

80 (2/2.5) 55.6 (5/9) 73.4

All 82.4 (14/17)

75 (45/60) 74.4 (64/86) 88 (51.5/58.5

)

79.3 (132/166.5)

86.6 (48.5/56)

80.7 (109/135)

83.3 (42.5/51)

85.4 (84.5/99)

81.1 (591/729)

82.5

In summary, the under-achievement against the 62 day standard for quarter 2 is in the main due to the complexity of pathways and the capacity issues aligned with advanced diagnostics and procedures.

The Trust has dedicated significant resource to the recovery of the cancer standards, however recognizes that there are pressures outside of the organisation’s control that can still impact on delivery, requiring a system wide approach to improving pathway management, including increases in referrals, patient choice to delay diagnosis/treatment and investment in specialist capacity.

The Trust will continue to work with the CCGs and tertiary centers to address the known issues.

Section 4, outlines the current actions to date, section 5 provides an overview of the existing governance structure, with section 6 outlining the system support required to aid recovery.

8

Draft

Appendix 7b

4. Actions to Date

An executive led recovery plan has been implemented to deliver improvements across the following key areas;

• Pathway Management, reviewing previous task and finish action plans to ensure fullimplementation is on-going

• Governance processes, reviewing accountability, escalation processes and waiting listmonitoring procedures

• Management of Patient Tracking, reviewing the current overall tracking procedures and theassociated workload management

The Trust has already delivered on a number of the actions for the recovery of the cancer standards, these include;

• Reviewing pathways to ensure streamlining is introduced wherever possible, this includes

o Initial triage of lung referrals to fast track highly suspicious referrals through thediagnostic and treatment pathway

o Introduction of the clinical vetting of initial GP direct to test chest x-rays to highlighthighly suspicious results to GPs, instigating the 2 week referral process and theordering of CT scans pre first outpatient appointment to reduce the demand ofoutpatient and diagnostic elements of the pathway – implemented from 1st October2014

o Introduction of Urology ‘one stop’ TRUS and Biopsy clinics to reduce time betweenoutpatient appointment and diagnostic test piloted then implemented from 13th October2014

• Reviewed capacity and demand to reduce outpatient and diagnostic waits and addresscapacity gaps in services using Department of Health IMST capacity and demand tools

• Further implemented ‘pooled’ waiting list to ensure equity of service

• Reiterated defined escalation processes across the organisation to support pathwaymanagement

• Reviewed governance processes, including the management of tracking procedures

• Reiterated clinical ownership of breach analysis and management of potential issues, withclinical sign off of each RCA

• Refocused weekly dedicated cancer waiting list meetings

• Reviewed MDT meetings to ensure recommendations from the ‘characteristics of an effectiveMDT’ are being followed. The Breast service is currently utilising ‘MDT Fit’ to review thestructure of their Multidisciplinary Team.

• The Trust invited the NHS Intensive Management Support Team into the organisation toreview the current processes and procedures (the visit took place on the 6th and 7th November2014), with excellent feedback received. The limited recommendations, some of which hadalready been put in place, were integrated into the Trust Cancer Recovery Plan

• Working with tertiary centres to ensure any potential cross pathway issues are addressedeffectively.

9

Draft

Appendix 7b

• Reviewed the NHS ‘Delivering Cancer Waiting times’ guidance, April 2014, to assess theTrust’s position against key recommendations, integrating best practice into the internal cancerdelivery plan.

• Review and update of the Trust’s Waiting List policy to include additional guidance for themanagement of cancer pathways

The Cancer Network is currently working with the Trust to review the Lung cancer pathway, to ensure best practice is applied.

The Trust continues to fully review the root cause analysis of all breaches to ensure all potential pathway issues are addressed in a timely manner, with lessons learnt and shared across the organisation.

The Trust has reviewed the Eight Key Priorities for the delivery of cancer standards, as outlined in the tripartite ‘Improving and sustaining cancer performance’ recommendations, with a gap analysis and associated action plan submitted to NHS England in August 2015. All outstanding actions are expected to be delivered by the end of October 2015.

5. Governance

The delivery of the cancer standards within the Trust is supported and governed by a number of key groups. These include;

• Cancer Strategy Group – Executive led, Chaired by the Chief Operating Officer/Deputy ChiefExecutive and supported by the Lead Cancer Clinician and the Medical Director. Key aims ofthe group included monitoring and management of the delivery of cancer services, coveringpathway management, workforce, national datasets, national guidance and cancerperformance.

• Cancer Steering Group – Chaired by the Lead Cancer Clinician and supported by the clinicalleads for the site specific tumour groups. The group covers all clinical aspects of cancerdelivery across the Trust, and includes external stakeholder representation from the clinicalcommissioning groups and patients groups.

• Patient Tracking List (PTL) Group – Chaired by the Assistant Director of Performance,Planning and Development supported by the Director of Operations. This group monitors theoperational delivery of all elective activity within the organisation, including the delivery of thecancer standards.

Operational day to day delivery of the cancer standards is managed through a dedicated Cancer Team, with defined escalation processes in place to support pathway management.

Cancer standards are included in the key performance indicators reported to Executive Team, the Board of Directors and Council of Governors on a monthly/quarterly basis, including exception reporting for outlying areas, as appropriate. A Performance, Planning and Compliance Committee has been established as a committee of the Board of Directors to oversee regulatory performance.

Detailed breach analysis is shared with key clinical leads and operational managers across the organisation to enable route cause analysis to be carried out and addressed appropriately.

10

Draft

Appendix 7b

6. System Support

As outlined in section 4, the Trust recognises that the delivery of the cancer standards will require the support of the local Clinical Commissioning Groups and GP practices. As such, the Trust has written to the CCG leads with the following proposals for negotiation;

• Financial support for the additional surge in referrals expected as a result of the increasingdemands on capacity during this years’ cancer campaigns, in addition to recognition of theimpact of previous campaigns. Given that financial flows will not be recurring then anintermittent increase in demand will require additional capacity (normally at a premium rate)

• Management of patient choice at referral and during the 62 day pathway• Clinical triage and ‘work up’ prior to referral into the Trust• Potential to manage referrals demand if the above are not supported by commissioners

Some of this will require local agreements to support review of the Trust’s Access Policy and a shared arrangement around performance management and financial impact.

The CCGs and GP representatives have also, once again, been invited to attend the Trust’s internal governance meetings to be involved in the system overview and development.

7. Next Steps

As outlined in the cancer recovery plan, dedicated Cancer Patient Tracking List (PTL) meetings have been introduced to closely monitor the delivery of the cancer pathways, any potential capacity issues and adherence to the accountability and escalation frameworks.

Task and finish groups have been established for the two areas indicating significant pressures, Lung and Urology.

The remaining key actions assigned to the delivery of the Eight Key Priorities will be fully implemented, with delivery monitored through the Cancer Strategy Group.

Review of the key themes behind the shared breaches will be further investigated through joint PTL meetings with South Tees Foundation Trust, to ensure close working to address pathway management.

Further work will be carried out with local commissioners and GPs to address the patient choice issue, to ensure patients are fully informed of the need to take up the both the first appointment offered and any subsequent diagnostics/treatments and to ensure timely pathway management is achieved through capacity in tertiary centres.

8. Conclusion

The Trust continues to strive to deliver against the cancer standards, despite the significant pressures within the system. The main areas where the Trust is struggling to perform consistently is the 2 week wait standard, due to patient choice to delay appointments/tests and the 62 day referral to treatment standard due to a number of issues, including complex pathways, capacity issues both internal and across the tertiary centres and patient choice. The impact of the cancer campaigns on the outpatient and diagnostic services is compounding the issues, with further pressures expected with the revised NICE guidelines.

11

Draft

Appendix 7b However, the Trust also recognises that close working with external stakeholders is a key element to delivery, with a system wide approach to pathway change essential to address the issues.

The Trust continues to work closely with the tertiary cancer centres to review shared pathway management and address any issues at an early stage, with the aim to eliminate avoidable delays.

Cancer performance will continue to be closely monitored through the internal governance processes, with robust escalation frameworks in place to support on-going compliance.


12

Draft

1



29 October 2015

Governance Statement – Supporting Information – Clostridium Difficile standard

Quarter 2 – 2015/16 (1 July – 30 September 2015)


The following targets (after application of thresholds) have not been met during the period of monitoring (quarter 2) which has led the Board to review the current position, actions to date and risks to future compliance and assurance before signing the Governance declaration stating on-going compliance.

All targets refer to the Monitor Risk Assessment Framework, around health care and other standards that the Trust shall put in place and comply with, for the purpose of monitoring and improving the quality of health care provided by the Trust. This is in line with Monitor NHS Provider Licencing conditions.

The following supporting information details the current position against the Clostridium Difficile target, the root cause analysis which has taken place to identify issues, the mitigation and proposed actions to reduce future risk against delivery of these standards.

1. Target or Standard

Clostridium Difficile Infection (CDI)

2. The Issue

During the quarter 2 period, 1 July to 30 September 2015, the Trust has exceeded the Clostridium difficile trajectory as set by the Department of Health (and local contractual commitments) reporting 10 cases against the quarter end trajectory of 3. The annual trajectory of 13 cases has also been exceeded with a total of 18 cases reported to the end of September 2015

The Trust is committed to continuing to reduce the number of Trust attributed CDI cases as it has done in the previous two reporting years, therefore full root cause analysis (RCA) has continued in order to identify the reasons/causative factors for these cases and to ensure appropriate mitigation plans are implemented, to reduce the risk of further cases. This process is consultant led and completed within 3 working days of notification. The report provides a collation of analysis and is supplemented by a comprehensive review.

Draft

2

As chart 1 indicates the Trust has made significant improvements against the CDI target since April 2007, with a more challenging target for this year of 13 cases following a successful year in 2014/15.

Chart 1: CDI performance April 07 – Sept 15

A significant amount of work has been undertaken to reduce the risk of C difficile across the patient pathway, including collaborative work with commissioners and GPs to improve prescribing in primary care, and work with care homes to improve knowledge in staff and provide training and support on cleaning and management of symptomatic patients. The impact of this work can be seen in the reduced number of community cases as shown in Chart 2.

Chart 2: Non Trust attributed cases 2011-16

This report gives actions to date and the agreed mitigation plans.

Draft

3

3. Actions to Date

A comprehensive review of performance, reporting, testing and actions taken has been produced as a formal response to the communication from Monitor on 15 September 2015. This report can be found at Appendix 1

The Healthcare Associated Infection Operational Group continues to meet and review risks, action and performance related to CDI. All actions from root cause analysis are entered on to the action tracker system which is discussed and followed up at the Operational Group. In addition to this group each RCA is discussed and challenged by the CDI Assurance panel comprised of the Head of Pharmacy, a Consultant Microbiologist and Assistant Director of Nursing and Infection Prevention and Control. Representation from the Commissioners has also been requested. A Trust action plan is reviewed at each Operational Group meeting and shared regularly with commissioners. The following areas are covered in detail

Environmental cleanliness – An enhanced cleaning service is maintained to ensure cleaningand fogging of vacated rooms is carried out appropriately, with additional cleaning of high risktouch points on key wards. A proactive programme of cleaning and fogging with hydrogenperoxide vapour has been developed and is underway. The Trust established an in housemattress decontamination service in 2014/15 and this has contributed to improves standards inthe cleanliness of this equipment. A project to improve cleaning of patient equipment bynursing staff is also underway and the Trust is piloting use of ultra violet light decontaminationto enhance the current programme.

Point of Care Practices – new staff and public posters, displays and information cards havebeen developed to further raise awareness of the importance of hand hygiene to all.Unannounced hand hygiene observation has continued and has seen an improvement incompliance across all groups of staff. Over 100 hand hygiene champions, including the chiefexecutive were recruited in May 2015 and a programme of awareness raising has begun,utilising these champions to promote good practice in clinical areas. From 1st July a leaguetable of hand hygiene compliance has been produced and shared with clinical areas monthly.General practices are reviewed daily on wards with confirmed cases of C difficile during thedaily review visit by an infection prevention and control nurse

Isolation facilities – as single rooms are limited and much sought after a flow chart to assistclinical decision making has been developed. Facilities are constantly under review and allpotential projects to increase the number of single rooms discussed at HCAI OperationalGroup.

Antibiotic Prescribing – The Trust antibiotic guideline has been reviewed and made availableto staff. Updated pocket sized guides are being produced for prescribers as a reference tool.Audits of compliance by the antimicrobial pharmacist and junior medical staff continue withtimely feedback on audit results being provided to clinicians. Antibiotic champions have beenidentified in all directorates. These champions have a role description to follow and attend theTrust antibiotic group to discuss actions and learning

C difficile assurance panel – a panel of independent members, who have not been involvedin the RCA process review each case, with clinical teams in attendance to answer any queries.The panel includes a representative from commissioners and reports to the Infection ControlCommittee

4. Governance and Assurance

In order to seek assurance for the Board or gain advice on additional measures the Trust commissioned an external review from Professor Mark Wilcox (Head of Microbiology Leeds Teaching

Draft

4

Hospitals, Professor of Medical Microbiology University of Leeds, Public Health England Lead on C difficile in England). This review took place on 20 July 2015 and a report was received on 10 August 2015. Professor Wilcox writes that ‘the HCAI team encompasses much experience in their field of expertise…overall the Trust has demonstrated good infection prevention performance in recent years; partly given this success, the current CDI objective is very stringent’

The report highlights six main areas where changes could be beneficial and details some actions for each:

Optimisation of diarrhoea control – potential to improve the way in which patients with diarrhoea, which may or may not be infectious, are managed

Antimicrobial prescribing – including review of progress against Start Smart Then Focus, streamlining of audit activity, focus on extent of polypharmacy and measurement of the accuracy of stated indication for antibiotic prescriptions

Environmental cleaning/decontamination – including a review of the decant capacity to enable the deep clean programme, review of practices to ensure environmental cleanliness issues are corrected and review of capacity and staffing pressures which may be impacting negatively on performance

C difficile typing – use of enhanced fingerprinting of samples which appear to match on ribotyping

Clinical review of actions from RCA – improving clinical attendance at CDI Assurance panel to ensure shared learning

Whole health economy learning – need for investigation of non-trust apportioned cases to ensure any learning is identified and shared

Advice has also been sought from Helen Crombie from NHS England who was formerly part of the DH MRSA/ CDI Improvement programme. Ms Crombie visited the Trust on 16 September 2015 and made the following recommendations.

Working with CCGs to achieve appropriate representation at HCAI meetings

Working with Commissioners to encourage GP involvement in completion of RCAs to achieve joint learning

Review of capacity in the infection prevention and control team to be able to provide advice and support to GP colleagues

Use of different groups, such as volunteers, to carry out hand hygiene observations to increase objectivity of assessments and release some IPCT resources to assist with the above

Explore possibility of ward matrons carrying out daily reviews of CDI patients on one weekday and at weekends to provide 7 day reviews and release some IPCT capacity

These recommendations have been discussed within the team, will be presented to the Infection Control Committee on 15 October and discussed with commissioners at the next available opportunity.

Draft

5

5. Current Position and Next Steps The current status sees C diff cases increasing again after a month without cases in June. The Trust action plan has been revised in line with the external reviews by Professor Wilcox in July and Helen Crombie in September and progress against the action plan is monitored via the Operational Meeting and the Infection Control Committee. However with deteriorating performance a task and finish group has been established to ensure that all appropriate actions have been identified and that there are no barriers to implementation 6. Conclusion In summary the Trust has invested a significant amount in terms of finance and time into the measures to reduce the risk of CDI and this has been very successful in the past few years. However it is acknowledged that in this reporting year, although the number of cases remains relatively low, the Trust performance has deteriorated and it has subsequently exceeded the annual trajectory in terms of numbers of cases and rate per 100,000 bed days. The Trust is committed, despite the fact that the trajectory has been exceeded to taking all measures appropriate to reducing the risk of further C diff infections across both acute and community settings. The challenge in reducing the hospital acquired C-diff numbers is not to be underestimated and it is recognised, with a legacy of successful performance that further and continued focus will assist with controlling and managing potential numbers. The Trust sought external expert opinion on additional measures which could be taken. This advice has been taken on board and included in the Trust action plan which is reviewed regularly. Julie Gillon Chief Operating Officer/Deputy Chief Executive October 2015

Draft

Appendix 8

Revised Compliance Requirements 1.1 The revised RAF has seen the re-introduction of measures of Foundation Trust

deficits and variance from plan. Monitor has retained the existing continuity of service measures (liquidity and capital service capacity) and introduced the following additional measures into the Risk Assessment Framework:

• income and expenditure (I&E) margin • two additional measures of variance from plan: variance of I&E margin and

variance of capital expenditure. A Trust’s ratings on these additional measures feeds into its new overall financial sustainability and performance risk rating

1.2 The additional measures for variance from plan include:

• I&E Margin: calculated as I&E operating surplus (deficit)/total operating income • Capital Expenditure: absolute variance as a percentage of planned capital

expenditure. •

The revised rating thresholds are

1.3 The existing continuity of service risk rating highlights the risk of short-term

insolvency and financial risk. Monitor’s inclusion of the additional measures above means they will be monitoring a number of measures that link to financial risk, a combination of the COSRR with the new financial metrics to create a new sustainability and financial performance risk rating.

1.4 The new risk rating has a four-point rating scale. A Trust’s rating will be calculated by

combining the existing COSRR elements (i.e. liquidity, capital service capacity), with the re-introduced I&E margin, and variance from plan measures, with a fixed weighting for each component.

1.5 An overall rating of 2 is likely to lead to investigation. If a Trust’s overall rating is

higher than 2 but it is rated as 1 on any of the individual measures, except variance in capital expenditure (due to its volatility), the Trust’s overall risk rating will be subject to an override and capped at a 2, triggering likely investigation.

1.6 Monitor has included a further additional measure within Foundation Trusts’

governance rating linked to value for money. Monitor may consider investigating if a Foundation Trust demonstrates inefficient or uneconomical spend (actual or forecast) against published benchmarks. Such demonstrations could include examples of inefficient operational performance; for instance, poor control over input costs such as agency and management consultancy spend.

Draft

1.7 Changes to the NHS Foundation Trust accounting officer memorandum have also been applied, with the aim to strengthen the requirement to consider value for money. Monitor will set out that the accounting officer must ensure:

• the Foundation Trust delivers efficient and economical conduct of its businessand safeguards financial propriety and regularity throughout the organisation

• financial considerations are fully taken into account in decisions by the NHSFoundation Trust

Draft

1



29 October 2015

Executive Summary

Responsible Officer’s report on Revalidation

Report of the Medical Director

1. Introduction

This paper provides the Board of Directors with an update of the work that has been undertaken by the Trust in relation to medical revalidation in the past 12 months along with the plans for the forthcoming 12 month period.

2. Summary

Revalidation is the process by which licensed doctors regularly demonstrate to the General Medical Council (GMC) that they are up to date and fit to practise. In doing so it aims to deliver further assurance to patients about the doctors who treat them.

All the practising doctors in the UK are required to relate to a Responsible Officer (RO) nominated or appointed by an appropriate healthcare organisation (designated body). This has been a statutory requirement from 1 January 2011 for England.

The Medical Director is the RO for North Tees and Hartlepool NHS Foundation Trust. This role covers all non-training grade doctors. (The RO for training grade doctors is the post-graduate dean at Health Education North East).

Revalidation began in December 2012 with Responsible Officers being revalidated first. The Trust has now made 184 positive revalidation recommendations to the GMC. The majority of existing doctors will revalidate by 31 March 2016.

The requirements for revalidation of doctors within the Trust have continued to be implemented via the Revalidation Project Team. In addition to the work being carried out by the Trust, two key regional network groups, the Responsible Officer Network group and the Appraisal Lead network have been established. These two groups are working together to share best practice and provide mutual support across the Northern Region.

It is important that the Board of Directors are aware that there may be an increase in clinicians referred to NCAS and the GMC as a consequence of the more focussed scrutiny via the appraisal process, with the potential for an increase in the number of doctors on restricted practice.

It is also important that the Board of Directors are aware that there will be costs in relation to any remedial processes and also in relation to ensuring appraisal recording and quality assurance processes fully meet the requirements for revalidation.

In addition, it is important that the Board of Directors are aware that as an organisation we could be asked to take a consultant requiring remediation from another Trust.

Draft

2

3. Conclusion

The Revalidation Team led by Basant Chaudhury, Deputy Responsible Officer, has continued to make significant progress during 2014/2015.

An Annual Statement of Compliance with the RO Regulations has been completed and endorsed by the Chief Executive of North Tees and Hartlepool NHS Foundation Trust.

An Annual Statement of Compliance has also been completed on behalf of the Butterwick Hospice and Hartlepool Hospice, with endorsement by their relevant Chief Executives.

4. Recommendation

The Board of Directors are asked to confirm their continued support for this activity.

Mr David Emerton Medical Director

Draft

3



29 October 2015

Responsible Officer’s report on Revalidation

Report of the Medical Director

1. Strategic Aim

This report reflects achievement towards the strategic aims of the Trust’s Corporate

Strategy:

a) Putting Patients FirstTo ensure that doctors treat patients to the highest possible clinical standards inorder to create a patient centred organisational culture, adding value to the patientexperience and demonstrated through patient safety, service quality and LEANdelivery.

b) Integrated Care PathwaysTo ensure that the personal development plans of doctors are aligned to thedevelopment and expansion of the portfolio of services to provide integrated carepathways for the people of Easington, Hartlepool, Sedgefield and Stockton providingequal access to acute care and care as close to home as possible in line withMomentum: Pathways to Healthcare.

c) Maintain Compliance and PerformanceTo ensure, via the appraisal process, that doctors maintain performance andcompliance with required standards and continually strive for excellence by goodgovernance and operational effectiveness in all parts of our business

2. Introduction

Revalidation is the process by which licensed doctors regularly demonstrate to the General Medical Council (GMC) that they are up to date and fit to practise. In doing so it aims to deliver further assurance to patients about the doctors who treat them.

Revalidation ensures that individual doctors are able to demonstrate that they are up-to-date and fit to practice. National and international data shows that 3 to 5% of doctors at any one time are outliers in performance.

The professional standards under which all doctors practice are laid out by the GMC in their publication - Good Medical Practice.

The GMC has outlined requirements for doctors in its guidance ‘Supporting Information for Appraisal and Revalidation’. It also recommends that doctors in specialist practice should consult the supporting information guidance provided by their college or faculty. This guidance amplifies the headings provided by the GMC, by providing additional detail about the GMC requirements and what each college or faculty expects relating to this, based on their specialty expertise.

All the practising doctors in the UK are required to relate to a Responsible Officer (RO)

http://www.gmc-uk.org/static/documents/content/Supporting_information__for_appraisal_and_revalidation.pdf

http://www.gmc-uk.org/static/documents/content/Supporting_information__for_appraisal_and_revalidation.pdf

Draft

4

nominated or appointed by an appropriate healthcare organisation (designated body). This has been a statutory requirement from 1 January 2011 for England.

The Medical Director is the RO for North Tees and Hartlepool NHS Foundation Trust. This role covers all non-training grade doctors. (The RO for training grade doctors is the post-graduate dean at Heath Education North East).

The RO makes a recommendation to the GMC on a doctor’s revalidation, based on clear and unambiguous statements from appraisers and reliable information from clinical governance systems. The possible recommendations that an RO can make are:

Revalidate; Defer; Notification of a failure to engage.

Revalidation began in December 2012 with Responsible Officers being revalidated first. The Trust has now made 184 positive revalidation recommendations to the GMC and the majority of existing doctors are expected to revalidate by 31 March 2016.

This paper provides the Board of Directors with an update of the work that has been undertaken by the Trust in relation to revalidation in the past 12 months along with the plans for the forthcoming 12 month period.

3. Progress Report

Robust Medical Appraisal and the Framework for Quality Assurance lies at the centre of revalidation and ensures a consistent approach to revalidation for all doctors, regardless of where they may work.

The GMC has also stipulated that all doctors are required to undertake 360/multi-source feedback as part of the requirements for revalidation and includes patient feedback, where appropriate to the role. The requirement is that this is undertaken once in every 5 year revalidation cycle and no later than year 3.

The GMC Employer Liaison Service promotes closer working relationships between the GMC and Employers and assists Responsible Officers and their teams to gain an understanding of GMC thresholds and procedures. The Medical Director/RO regularly meets with the Trust’s assigned Employer Liaison Advisor on a quarterly basis to support the two way exchange of information about under-performing doctors, therefore improving patient safety and the quality of referrals. Also in attendance at these meetings are representatives from the Human Resources Department and the Department of Education.

The following work has been undertaken in the previous 12 months by the Revalidation Team (overseen by the Responsible Officer).

87.2% of appraisals completed in 2014/2015 (232 doctors), with a further 8.6% (23 doctors) recorded as having an approved incomplete/missed appraisal.

An exception report was completed for the remaining 4.1% (11 doctors) and, following discussions and additional support for these doctors, 100% of appraisals for 2014/2015 are now complete.

Doctors who are due to revalidate by 31 December 2016 are currently undertaking 360 degree appraisal. In 2014, the Trust commissioned a new provider for

Draft

5

undertaking the 360 feedback process. This system is now fully implemented and is proving to be successful.

Update training has been delivered to existing appraisers along with training for new appraisers, which is in line with the Revalidation Support Team’s national training programme.

A review of the current resources allocated to Medical Revalidation has taken place, the purpose being to ensure that they are sufficient and supported going forward. It has therefore been agreed that the management of medical revalidation will transfer to the Quality Team within the Directorate of Education, to sit alongside trainee and nursing revalidation. This transition commenced in July 2015, with full handover to take place during October 2015.

The Medical Practice Information Transfer (MPIT) process is in place to ensure revalidation information is obtained from the previous Responsible Officer (where applicable) for newly appointed doctors. Further enhancements are planned for 2015/16, with a view to incorporating the MPIT Form as part of the pre-employment check process. This will ensure that no doctor will be permitted to commence employment with the Trust until receipt of this information has been confirmed and the document has been reviewed and approved. It should be noted that the MPIT Form is only applicable to doctors who have previously worked within the UK. Any other exceptions to this process must be approved in advance by the Medical Director/RO.

The Trust continues to provide appraisal and Responsible Officer support to the Butterwick Hospice and Hartlepool Hospice, in line with the Service Level Agreements.

A review of the Medical Appraisal Policy has taken place, which formalises the arrangements for doctors returning to practice, ensuring there are appropriate mechanisms in place to support the doctor following a period of extended leave.

Enhanced departmental reports are to be rolled out to all Directorate Appraisal and Administrative Leads commencing October 2015. The new report will take the form of a Dashboard system, covering: appraisal compliance; doctors under notice of revalidation; doctors undertaking multisource feedback; trained appraisers within the directorate and their compliance with update training.

The Trust has made reciprocal arrangements with South Tees NHS Foundation NHS Trust and County Durham & Darlington NHS Foundation Trust, to allow for their Responsible Officer’s to undertake the RO function in respect of any doctors within NT&H, in the event of any perceived concerns regarding conflict of interest or bias.

The Medical Director/Responsible Officer attends the annual RO conference and is an active member of the RO Network (North of England) which meets on a quarterly basis to promote group discussion and the sharing of best practice and current position statements.

A total of 184 positive recommendations for revalidation have been made to the GMC, 106 of which were completed since the last Board Report of October 2014.

Draft

6

A total of 27 requests for deferral of revalidation have been submitted to the GMC, of which 24 were due to a lack of supporting information and 3 were to allow the completion on an on-going investigation/process.

Work planned for the coming 12 months includes:

On-going review of the medical appraisal process, with an emphasis on compliance with the Quality Assurance Framework.

Re-scheduling of appraisal dates, ensuring that there is an annual plan for the delivery of medical appraisal within each directorate and with all appraisals to take place during the period April to December.

Undertake a full review of the current Service Level Agreements which are in place for the Butterwick Hospice and Hartlepool Hospice, to ensure they reflect the time and resource commitments, in the event of there being significant concerns regarding a Hospice doctor which would require the Trust to provide Case Investigator/Case Manager support.

The Deputy Responsible Officer to attend an annual meeting with the Boards for the Butterwick Hospice and Hartlepool Hospice, to present and review the AOA submission for their organisations.

Implementation of structured case investigator training to fulfil the statutory duties of the RO in relation to investigating, monitoring and responding to concerns; ensuring that all medical investigations are conducted by an appropriately trained case investigator. The programme for this training has been confirmed and the first event is scheduled to take place on 22 January 2016.

Continue to monitor the numbers of appraisers and deliver training and update sessions as required.

Develop an Appraiser network within North Tees and Hartlepool NHS Foundation Trust, using the format of the Regional RO/Appraisal Lead networks as a blueprint for implementation within NT&H.

It is important that the Board of Directors are aware that there may be an increase in clinicians referred to NCAS and the GMC as a consequence of the more focussed scrutiny via the appraisal process, with the potential for an increase in the number of doctors on restricted practice.

It is also important that the Board of Directors are aware that there will be costs in relation to any remedial processes and also in relation to ensuring appraisal recording and quality assurance processes fully meet the requirements for revalidation.

In addition, it is important that the Board of Directors are aware that as an organisation we could be asked to take a consultant requiring remediation from another Trust.

4. Annual Organisational Audit (AOA) Comparator Report

North Tees and Hartlepool NHS Foundation Trust has participated in the Annual Organisational Audit for 2014/15, which is one of the elements of the Framework of Quality Assurance.

Draft

7

NHS England uses the AOA information submitted by each designated body, to produce an AOA Comparator Report. Analysis of this report has highlighted the following exceptions for this Trust:

In comparison with other designated bodies, the Trust has not yet commissioned or undertaken an independent review of its processes relating to appraisal and revalidation. This may include peer review, internal audit or an externally commissioned assessment.

National statistics report that a total of 67.3% of designated bodies have commissioned or undertaken an independent review.

The Trust reported that, as at 31 March 2015, there were no arrangements in place to access sufficient numbers of trained case investigators and case managers. This is compared against a total of 81.6% of designated bodies who do have appropriate arrangements in place.

Whilst there are a number of individuals who currently undertake investigations involving medical staff within NT&H, in order to comply with the above requirement, it is necessary for all individuals involved in undertaking investigations for medical staff to be appropriately trained in accordance with the RO regulations.

A bespoke training session has been developed, with the first session scheduled to take place in January 2016. This initial session has been targeted towards Clinical Directors, and Associate Medical Directors, with a view to recruiting additional case investigators during 2016/17. This will ensure that the Trust will be in a position to submit a positive response to this area as part of the 2015/16 AOA submission.

Details of the AOA appraisal performance data is contained at Page 7 of this report, which contains information regarding the Trust’s submission, with comparison against both National and Northern data.

Overall analysis shows that the Trust has a high rate of compliance with 87.2% of doctors having completed an appraisal between 1 April 2014 and 31 March 2015. This figure is above both the national and regional figures of 81.4% and 85% respectively.

Although overall compliance with medical appraisal remains high, the category which includes temporary and short term contract holders is below the national and regional figures at just 59.6% of doctors within this category having completed an appraisal for 2014/15. This does not suggest a significant cause for concern, since a further 31.9% of these doctors had an approved incomplete/missed appraisal which results in only 8.5% of the doctors in this category having an unapproved missed appraisal.

Work is being undertaken to increase compliance within this category of doctors, with a view to undertaking PDP setting for doctors new to the UK within 3 months of their commencement with the Trust, which will be recorded as an interim appraisal. All other short term/temporary doctors will require an appraisal within 12 months of their previous appraisal (as confirmed via the MPIT Form).

Draft

8

Performance Data:

No. of doctors with whom the designated body has a prescribed connection on 31 March 2015 who had a completed annual appraisal between 1 April 2014 – 31 March 2015


National Responses

Responses for the Northern Region.

Completed Appraisals (1a and 1b)

Consultants 162 (93.1%) 85.70% 90%

Staff grade, associate specialist, specialty doctor 42 (93.3%) 83.10% 88%

Temporary or short-term contract holders 28 (59.6%) 60.40% 64%

Total number of doctors who had a completed annual appraisal 232 (87.2%) 81.40% 85%

No. of doctors with whom the designated body has a prescribed connection on 31 March 2015 who had an Approved incomplete or missed appraisal between 1 April 2014 – 31 March 2015


National Responses

Approved incomplete or missed appraisal (2)

Consultants 5 (2.9%) 6.20% 6%

Staff grade, associate specialist, specialty doctor 3 (6.7%) 8.70% 7%


No. of doctors with whom the designated body has a prescribed connection on 31 March 2015 who had an Unapproved incomplete or missed annual appraisal between 1 April 2014 – 31 March 2015


National Responses

Responses for the Northern Region.

Unapproved incomplete or missed appraisal (3)

Consultants 7 (4.0%) 8.10% 5%

Staff grade, associate specialist, specialty doctor 0 (0%) 8.20% 5%


Draft

9

5. Conclusion

The Revalidation Team, led by Dr Basant Chaudhury, Deputy Responsible Officer, has continued to make significant progress during 2014/2015 in ensuring the Trust is meeting the requirements of Revalidation.

An Annual Statement of Compliance with the RO Regulations has been completed and endorsed by the Chief Executive of North Tees and Hartlepool NHS Foundation Trust.

An Annual Statement of Compliance has also been completed on behalf of the Butterwick Hospice and Hartlepool Hospice, with endorsement by their relevant Chief Executives.

6. Recommendation

The Board of Directors are asked to confirm their continued support for this activity.

Mr David Emerton Medical Director