board of directors part one · 2016-07-27 · board of directors (part 1) meeting in public tuesday...

Board of Directors Part One

Agenda and papers of a meeting to be held in public 2.00pm–5.00pm Tuesday 26th July 2016 Lecture Theatre, Tavistock Centre, 120 Belsize Lane, London, NW3 5BA

BOARD OF DIRECTORS (PART 1)

Meeting in public Tuesday 28

th July 2016, 14.00 – 17.00

Lecture Theatre, Tavistock Centre, 120 Belsize Lane, London NW3 5BA

AGENDA

PRELIMINARIES

1. Chair’s Opening Remarks Dr Ian McPherson, Trust Vice Chair

Verbal -

2. Apologies for absence and declarations of interest Dr Ian McPherson, Trust Vice Chair

To note Verbal -

3. Minutes of the previous meeting Dr Ian McPherson, Trust Vice Chair

To approve Enc. p.1

3a. Outstanding Actions Dr Ian McPherson, Trust Vice Chair

To note Verbal -

4. Matters arising Dr Ian McPherson, Trust Vice Chair

To note Verbal -

REPORTS & FINANCE

5. Student Story – Adult Complex Needs

To discuss Verbal -

6. Service Line Report – Complex Needs, AFS Dr Michael Mercer, Interim Service Lead

To discuss Enc. p.9

7. Trust Chair’s and NEDs’ Reports Dr Ian McPherson, Vice Chair

To note Verbal -

8. Chief Executive’s Report Mr Paul Jenkins, Chief Executive

To note Enc. p.24

9. Q1 Strategic Objectives Progress Report Mr David Holt, NED

To note Enc. p.27

10. IMT Q1 Report Mr Toby Avery, Director of IMT

To note Enc. p.32

11. Finance and Performance Report Mr Simon Young, Deputy Chief Executive & Director of

Finance

To note Enc. p.38

12. Training and Education Report Mr Brian Rock, Director of Education and Training/Dean

To note Enc. p.48

13. Q1 Dashboards Ms Julia Smith, Commercial Director

To note Enc. p.54

14. Q1 Quality Report Ms Marion Shipman, Associate Director of Quality and

Governance.

To note Enc. p.63

Age

nda

15. Q1 Governance Report

Mr Simon Young, Deputy Chief Executive & Director of

Finance

To approve Enc. p.100

16. Q1 HR Report Mr Craig DeSousa, HR Director

To note Enc. p.105

17. Equalities – WRES Report Ms Louise Lyon, Director of Quality and Patient Experience

To note Enc. p.114

18. Register of Interests Mr Gervase Campbell, Trust Secretary

To approve Enc. p.127

19. Sustainability and Transformation Plan Update Mr Paul Jenkins, Chief Executive

To note Enc. p.132

CLOSE

20. Notice of Future Meetings Tuesday 13th Sept 2016: Directors’ Conference, 12.00-

5.00pm, Lecture Theatre

Thursday 22nd Sept 2016: Council Meeting, 2.00pm –

5.00pm, Lecture Theatre

Tuesday 27th Sept 2016: Board Meeting, 2.00pm – 5.00pm,

Lecture Theatre

Tuesday 4th Oct 2016: Joint Boards Meeting, 12.30pm –

5.30pm

Wednesday 5th Oct 2016: AGM, 4.00pm – 7.00pm, Tavistock

Centre

Verbal -

Board of Directors Meeting Minutes (Part One)

Tuesday 28th June 2016, 2.00 – 4.20pm

Present: Prof. Paul Burstow

Trust Chair

Prof. Dinesh Bhugra

NED

Ms Jane Gizbert

NED

Mr David Holt

NED

Dr Sally Hodges

CYAF Director

Mr Paul Jenkins

Chief Executive

Ms Lis Jones

Nurse Director

Ms Louise Lyon

Director of Q&PE and

A&FS

Dr Ian McPherson

NED & Vice Chair of Trust

Ms Edna Murphy

NED

Mr Brian Rock

Director of E&T/ Dean

Dr Rob Senior

Medical Director

Mr Simon Young

Deputy CEO & Director of

Finance

Attendees: Dr Julian Stern, Director

of Adult and Forensic

Services

Mr Gervase Campbell

Trust Secretary (minutes)

Ms Marilyn Miller,

Governor

Ms Anne Hurley,

Portfolio Lead (items

5,6)

Apologies:

Actions

1. Trust Chair’s Opening Remarks

Prof. Burstow opened the meeting.

2. Apologies for Absence and declarations of interest Apologies as above.

Prof. Burstow noted, in relation to item14, that he was a Trustee for Action on

Smoking and Health (ASH).

AP1

3. Minutes of the Previous Meeting

The minutes were approved subject to minor amendments

4. Matters Arising

Action points from previous meetings:

AP1 – (minutes) – completed

Outstanding Actions:

OAP2 –(Monthly/Quarterly IMT reports) – first update came in May, Quarterly

scheduled for July – completed

OAP3 –(3/5 year financial forward view) – scheduled for Board Away Day.

It was noted that the Visiting Lecturer report would come to the Board in

September.

AP Item Action to be taken Resp By

1 3 Minor amendments to be made to the minutes GC Immd.

2 13 Timescale for MCA work to be given to Board RS July

Min

utes

Page 1 of 146

5. Service User Story – Education and Training, Psychoanalytical Clinical Portfolio

Ms Hurley introduced Ms L, a student finishing her studies this term.

Ms L explained she had come from Greece to study at the Trust 7 years ago,

initially full time on M16, psychoanalytic studies. She had then taken M7, a

psychoanalytic observational course, part time whilst working with children, and

was now on M80, the clinical training in child and adolescent psychotherapy.

Overall her experience had been excellent. Working in a CAMHS team made her

realise how much she had gained from studying at the Trust. She had come from

a continental educational background and found the experience of studying

here very different: instead of large lecture halls there were small groups which

allowed you to find your own voice, which was especially relevant to this

profession.

Mr Holt asked whether the experience of the courses matched what she had

expected in advance. Ms L commented that she had found it very helpful talking

to existing students, it had been that which convinced her to take the courses.

Dr McPherson asked whether the experience of working and studying

simultaneously had been beneficial. Ms L explained that for M7 especially the

essence of the course had been to provide a place to think about the work being

done, through the work discussion groups, and to reflect on their experience and

learn from each other. In addition staff were always very understanding of the

needs to balance study with work commitments.

Ms Lyon asked about what had persuaded her to come here to study initially,

and how the Trust might help those new to the culture or language. Ms L

explained that she had initially come as the course had been recommended by

Tavistock trained staff she met in Greece. Once here she had found some

difficulties in adjusting, but was helped by tutors on the courses who had

experienced the same transition and had a lot of practical advice. She added in

response to a question from Ms Murphy that one of the biggest challenges had

been understanding the system around child care more generally, and she felt

that one helpful change would be to include more context in child development

courses, perhaps as a separate class for those from abroad.

Dr Stern asked what elements it would be important to preserve if the Trust were

to change location. Ms L felt the library was essential, and commented that there

were currently problems with space and finding rooms for supervision.

Mr Rock asked for her view of how the Trust supported students as they finished

courses and moved into employment, and what we should be doing to help

continue the relationship once studies were completed. Ms L commented that

she had received a lot of support from tutors in looking for work. She felt that

there was an issue around how to receive course information once students left

the Trust email system which needed to be addressed, but added that most

important were the personal relationships and keeping in touch with both tutors

and colleagues.

Prof. Burstow thanked Ms L for her time and her helpful ideas on what they did

Page 2 of 146

well and could do better, and wished her well for the future.

6. Service Line Report – Psychoanalytical Clinical Portfolio

Ms Hurley introduced her report, noting that the reorganisation of Education

and Training had provided an exciting opportunity to bring two related adult

and child trainings together under one umbrella.

Prof. Burstow noted the consultation underway on education funding reforms,

and asked if it was having any effect on students. Ms Hurley agreed it was a

concern and a cause of anxiety, but was not having any immediate effect on

recruitment. The team were being active on the issue and in response to a

question raised in Parliament had learnt that there was no plan in place at

present to cut the funding.

Prof. Bhugra noted that M80 was in transition between two university partners,

and asked if that was causing any problems. Ms Hurley explained that there was

some extra work involved in having two sets of course materials , but there were

no major difficulties. She noted that the new M80 course would have more focus

on research, and finding enough doctoral supervisors might be a challenge.

Prof. Bhugra asked about blended learning, and Ms Hurley explained it involved

students watching theoretical lectures online and then coming in for direct

teaching in clinical supervisions, and the combination meant more flexibility and

less travelling for students and also reduced pressure on space. Mr Young asked

whether it was possible in the future that some of the discussion groups could

also be held online. Ms Hurley commented that there was not any real substitute

for direct learning in small groups, as forming relationships was key, and whilst

technologies like Skype were a good option for those who had to travel long

distances, they were not an ideal substitute for physical meetings.

Dr McPherson asked whether the CPD elements were proving attractive, given

that there was a lot of competition in that area. Ms Hurley commented that

recruitment was holding steady, and they were always on the lookout for new

opportunities and adapting to the changing NHS agenda and HEE priorities. They

were also looking at courses that could be marketed as both parts of a core

course but also as CPD. Mr Jenkins noted the potential for packaging up nuggets

of their approach in a way that could reach the wider workforce, and make their

learning available in areas where there was an increasing need.

Mr Holt noted the contributions table on p19, where the D59c course showed a

loss. Ms Hurley explained that it was a couples therapy course, and there was

strong competition in that area from another similarly named organisation,

Tavistock Relationships, and so difficulty in recruiting students. Prof. Burstow

noted that it was an organisation which shared a history with the Trust, and was

in the past based on site. He added that this was an important area given the

impact of couple dynamics on childhood resilience. Mr Rock noted that it was an

area where collaboration across child and adult departments could provide real

opportunities, and Dr Stern confirmed that in was an area Adult Complex Needs

was investing in.

Min

utes

Page 3 of 146

The Board discussed IAPT and the opportunities for training in the broader

modalities beyond CBT.

Prof. Burstow thanked Ms Hurley for her report, which included so many areas of

encouragement.

The Board noted the report.

7. Trust Chair and NEDs’ Reports

Prof. Burstow noted that he had been part of a group of medical directors,

directors of public health and commissioners to visit New York to look at their

city wide approach to mental health, “NYC Thrive” A key part of their approach

was to go beyond traditional delivery methods developing a population

approach, and in some ways they were moving towards elements of our Thrive

model.

Prof. Burstow noted that the NHS Confederation conference had been held last

week, and the presentations had been honest about the scale of the challenges

that were coming.

Prof. Bhugra noted that the World Psychiatric Association was about to publish a

report on laws concerning mental health around the world, and the

discrimination that people with mental health problems experience.

Dr McPherson noted that he had attended the staff Wellbeing Day, and there

had been good attendance, especially from non-clinical staff. He commented

that this event and the recent mental health day were important ways to show

staff that their wellbeing was taken seriously.

Ms Gizbert noted that the new website would be launched soon, and the team

had done excellent work on preparing it. She had recently attended a 5yr

Forward View event hosted by Simon Stevens, where much of the focus had been

on diversity and equal opportunities, and valuing staff.

Ms Murphy reported that she had been involved in the recent recruitment

exercise for the Portman director, which had been well run and had a good

result.

The Board noted the reports.

8. Chief Executive’s Report

Mr Jenkins presented his report, highlighting the CQC report, and stressing that

having a Good rating across all the services was a significant achievement for the

Trust.

He noted that the executive team continued to dedicate a lot of time to the STP

process in North Central London, and that he was now the Senior Responsible

Officer for the Mental Health workstream. The initial submission of the plan

Page 4 of 146

would be made on the 30th June, and would come to the Board in July.

He drew attention to the work Ms Jones had been doing on perinatal mental

health, noting how much transformation was required to ensure women in need

got access to services. He noted that Dr Jessica Yakeley had been appointed as

the director of the Portman clinic, and would take up post on the 1st August. Dr

Yakeley was a longstanding and distinguished member of the Portman team,

and they were very glad she had stepped up to the role of director.

Mr Jenkins noted that the CareNotes update had not been included in the

report, and would instead be circulated after the meeting. Mr Young added that

they had appointed Mr David Wyndham Lewis to the role of interim director of

IMT, and he would be starting in mid-July, initially for a period of nine months.

The Board approved the Quality Report, subject to the amendments discussed.

9. CQC Action Plan

Ms Lyon noted that the CQC had identified three areas that required

improvement, and the action plan presented addressed these three areas. There

was also a longer list of ‘should improve’ areas, and action plans had also been

drafted by the management team to address these.

The Quality Summit would be held on the 7th July. The CQC would present their

report and the Trust would present their response. It would be a relatively small

event, but invited participants included commissioners, service user

representatives and other stakeholders.

Mr Holt suggested it was important not to think addressing the CQC’s points

would be enough to take the Trust to ‘outstanding’, and asked how they were

going to change day to day practice to improve quality, especially given

everyone’s workload. Ms Lyon suggested that aiming for the Trust’s own

definition of ‘outstanding’ was important, and noted that they would start the

process on the 12th July with the leadership event, to which clinical team leaders

had been invited. The aim was to start a bottom up process of improvement

within the Trust, one that clinicians could own, with a focus on making a

difference to their day to day experience, for example in data gathering. Dr

Senior added it was important to put in place a model of quality improvement

that was relevant to our services and our patients.


10. Board and CEO Objectives

Prof. Burstow thanked colleagues for their comments on the circulated draft

version, which had been incorporated.

Mr Holt commented that there were a large number of objectives. Prof. Burstow

agreed, but commented that it had been hard to see any that could be omitted

in the drafting, and added executive directors would each be responsible for only

a few of them. Mr Jenkins commented that they were all important, but there

Min

utes

Page 5 of 146

was a valid question about where to focus the most resources, and that was

something they could follow up on in detail at the Board Away Day.

Ms Gizbert wondered if the dashboards were for strengthening culture, rather

than monitoring performance, and Mr Jenkins explained that this was a

deliberate choice of emphasis, as the dashboards were symbolic of a different use

of data in the culture of the trust. Ms Murphy asked about the purpose of the

governance review, and Prof. Burstow explained that was to ensure that the

current structure was still fit for purpose, and did not contain any overlaps or

inefficiencies in the use of executive directors’ time. The Board discussed the

aspiration to move from ‘good to ‘outstanding’, and agreed that it was

important to do so in the Trust’s own terms, and that it was one priority amongst

many. Prof. Burstow added that they would continue the discussion when they

reviewed the Quality Strategy.

Mr Jenkins suggested that he would include updates on progress against the

objectives within his monthly reports, which would give a more systematic

approach. Prof. Burstow agreed this would be good for accountability.

The Board approved the objectives.

11. Finance and Performance Report

Mr Young presented the report, noting the additional allocation of £500k from

the ‘targeted element’ of the STP had been added to the revised 2016/17 plan,

but was not available for additional expenditure as the control total had been

increased by the same amount.

Mr Young took the board through the reference costs addendum, explaining

that whilst they were more applicable to the acute setting, they were required of

mental health trusts for comparison. He noted some of the difficulties

encountered, here and elsewhere, in working with patient clusters. Mr Holt

asked if he was confident that the reference costs as calculated were a genuine

reflection of the true costs. Mr Young confirmed that he felt they were; that the

quantum of costs was a reasonable estimate, that he was confident unrelated

costs had been removed, and that whilst there would always be some uncertainty

over the number of days in a cluster which might cause distortion, this was not a

major factor.

The Board noted the report and approved the methodology used in calculating

the Trust’s reference costs.

12. Training and Education Report

Mr Rock presented the report, noting that extra granularity on recruitment data

had been provided in appendix 1. He highlighted that the QAA draft report was

positive, and that no significant concerns had been raised. Once the report had

been finalised it would be circulated to the board.

Mr Holt noted that 154 offers had been accepted, and asked if that was where

Page 6 of 146

AP2

the department had hoped to be at this stage in the cycle. Mr Rock explained

that planning was based on number of applications, with forecasts using a

prudent conversion rate, and the expectation that this year’s closer attendance to

applicants should means a higher rate in practice. They were using this to review

over-recruitment and consider operational constraints which might prevent

delivery to the additional students, as well as looking at areas of under-

recruitment to see if further promotion or the reassignment of staff might be

possible.

Mr Holt noted the uncertainty Brexit might be causing foreign students, and

asked if they thought it might have an impact this year. Mr Rock explained that

EU students formed a high proportion on some courses, and it was a critical time,

so communications would be sent out to try and assuage any concerns. Ms

Murphy agreed that communication to students was important, and the message

should include the welcome they could expect and details of student bursaries.

Dr Stern noted that the psychoanalytic clinical portfolio was doing well, and

asked if they could identify any reasons for this. Mr Rock explained that it was

difficult to identify specific causes, especially as the decision to take those

trainings often took years to be made, however they had changed their

marketing approach and messages.


13. Annual Safeguarding Report

Dr Senior highlighted three areas of his report: firstly, the level of activity in the

safeguarding domain had increased, with legislative and CQUIN targets around

domestic abuse and the Prevent Duty. Secondly, there were significant changes

occurring with the structures in local authority children’s services, and a

perception that the new system was more difficult to negotiate, as reflected in

the increased number of consultations staff were requesting on adult

safeguarding issues. Thirdly, there had been issues around reporting due to Care

Notes, and these were being addressed, with the aim of building a more user-

friendly integrated system.

Prof. Burstow asked about a timescale for the work needed on the Mental

Capacity Act, and Dr Senior agreed to check with his colleagues and report back

to the Board with the details via the Patient Safety workstream of the CQSG.

Dr McPherson noted the impact on children of witnessing domestic abuse, and

how having adult clinicians highlighting possible risks to children was an

important development for safeguarding. Dr Senior agreed that witnessing

incidents had direct impacts in addition to the impact made through parenting,

and noted the Trust was rolling out comprehensive training in this area.

The Board noted the report

14. Statement of Support for Tobacco Control

Ms Lyon introduced the paper, explaining the work the Trust had done which

Min

utes

Page 7 of 146

put it in a position to be able to sign up to the statement, and emphasising the

positive effects reducing smoking had on mental health as well as physical

health. She noted that in parallel with the work for patients, the Trust was

looking to review its policy on smoking for staff, and the support it offered to

them, as part of the wellbeing work.

The Board approved the statement.

15. ToR of Management Team and Audit Commitee

Mr Campbell explained the small changes that had been made to the terms of

reference of the two committees.

The Board approved the terms of reference. 16. Scheme of Delegation of Powers

Prof. Burstow explained that most of the changes set out in the report were due

to the changes in director roles over the past year, and the board discussed some

of the details.

The Board approved the scheme of delegation of powers. 17. Second Self-Certification for Monitor

Mr Young introduced the paper, and the board discussed some of the wording

of the paper around how the views of the governors were taken into account

through discussion of the reports presented to them over the year.

The Board approved the self-certification. 18. Any Other Business

The Board noted its future meetings.

Part one of the meeting closed at 4.20pm

Page 8 of 146

1

Board of Directors : July 2016

Item : 6

Title : Service Line Report – Complex Needs, Adult and Forensic Services

Purpose:

The purpose of this report is to update the Board on the current

activities, performance and development of the Service.

This report has been reviewed by the following Committees:

Management Team, July 2016

This report focuses on the following areas:

Quality

Patient / User Experience

Patient / User Safety

Risk

Finance

For : Noting

From : Michael Mercer , Interim Service Lead

SLR

Com

plex

Nee

ds

Page 9 of 146

2

SERVICE LINE REPORT – ADULT COMPLEX NEEDS

Executive Summary

1. Introduction

Adult Complex Needs has undergone changes in its structure since the last report to

the Board in 2014. It no longer provides services to Adolescents and Young People,

and the Directorate now includes a distinct service line for Primary Care. A

relationship with the new Directorate of Education and Training is developing. Two

special projects, Mednet and the Homebase Veteran’s Project have closed at the

end of their contracts. External projects which continue are the Pain Clinic at the

Royal Free Hospital and the work with refugees in the Red Cross. Special outreach

clinics exist in Herts for primary care, alongside a psychotherapy clinic in Watford.

The Tottenham Talking Space Project is newly included in the Service.

Core clinical psychotherapy services for patients with long term and severe mental

health problems continue in the Tavistock Clinic and are organised around 2 generic

units (Lyndhurst and Belsize), the Fitzjohns Unit for personality and severe

disorders, the Trauma Unit, the Couples Unit, and a training Unit (Maresfield) for

the D58/9 Foundation Course.

2. Areas of Risk and/or Concern

The service line is currently under interim management following the

reorganisation. The major concern for the service line is the review of staffing

following the retirement and the departure of significant senior staff in meeting

savings targets. Succession planning is a priority. The current skeleton management

provides little resource for clinical supervision, innovation and development.

3. Proposed Action Plan

Maximise recruitment of new younger staff to permanent positions within budget

and review Unit staffing needs.

Main Report

4. Overview of the Service

4.1 Core identity and purpose. The Complex Needs Service continues to

provide psychoanalytically based psychotherapy to meet a range of needs.

Page 10 of 146

3

It helps patients who otherwise fall between local forms of provision, or

who increasingly fail to reach the higher thresholds for secondary and

tertiary services. The bulk of the service is provided within the block

contracts of CCGs across north and west London and Herts. Camden

remains the largest contract. Individual contract value has fluctuated but

the overall value has been maintained allowing for the savings targets.

Overall vision and strategy. It remains a core vision to offer services and

training opportunities in psychoanalytic psychotherapy not available

elsewhere and to develop new forms of application when contracting

opportunities arise. It is increasingly difficult to maintain a collaborative

stance with local providers, particularly towards service development. It is

also essential to continue to provide some form of professional leadership

in the field whether through research or the promotion of clinical and

service models. Our aim is to maintain the reputation of the Tavistock

Adult Services for high quality attention to the needs of users.

4.2 Clinical contracts seem to have stabilised after much effort. Depending on

the level of savings required over the next period, the effort must be

towards an orientation towards development. However, any further

retrenchment of the core service will be certain to reduce this capacity.

5. Core Clinical Services and Activity Data

Performance against contracts are currently in approximate balance

overall. Camden overperforms and West London, under acute Single Point

of Entry pressure is underperforming.

5.1 Interpretation of performance. On the demand side, referrals are

constrained by rigid Single Point of Entry Systems, controlled by local

providers. Commissioners try to limit the use of our contracts and

maximise local provision. Only Camden allows direct GP referral and a

flexible understanding exists with CIFT psychological therapies. Recently

the impact of TAP in Camden, has reduced GP referrals, but this reduction

has been compensated by direct TAP referrals. Our capacity to exploit

patient choice is so far undeveloped.

On the supply side, we struggle to keep acceptable waiting times for

treatment. This particularly applies to the Fitzjohns Unit which has

increased prospectively to two years for some patients where experienced

staff are most required. The data below reflects the average over the last

SLR

Com

plex

Nee

ds

Page 11 of 146

4

year. Waiting times for the patients seen in the Maresfield training Unit

are less.

5.2 Waiting times.

0

20

40

60

80

100

120

140

160

1-2 3-4 5-6 7-8 9-10 11-12 13-14 14+

Nu

mb

er

of

pat

ien

ts

Weeks

Waiting times for assessment

159

218

270 249

287

0

50

100

150

200

250

300

350

Standard adultonce weekly

psychotherapy

Fitzjohn Unit Individualintensive

Group therapy Couples therapy

Nu

mb

er

of

day

s

Therapy modality

Average waiting times for treatment

Page 12 of 146

5

5.3 DNA rates

5.4 Dormant Case data

5.5 Ethnicity comparison

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Q2 2015-16 Q3 2015-16 Q4 2015-16 Q1 2016-17

% D

NA

rat

e

Quarter

DNA rates for first and subsequent appointments

First appointments

Subsequent appointments

Total DNA

0

2

4

6

8

10

12

14

Nu

mb

er

of

do

rman

t ca

ses

Team

Dormant cases by team SLR

Com

plex

Nee

ds

Page 13 of 146

6

5.6 Supervision. Providing sufficient supervision for the trainee and less

experience staff is a major challenge, but it is still the case that all work is

overseen by senior level staff. In addition the practice of each clinical unit

discussing cases weekly in depth remains central to our model of practice.

6. Tottenham Thinking Space

6.1 Tottenham Thinking Space (HTS) was funded by Haringey Public Health as

a pilot service (2013 -2015). The Service was independently evaluated by

UEL and as a result of the positive evaluation, the service was tendered

and we won the 3 year contract (2015 -2018) to roll out the service across

Haringey as Haringey Thinking Space (HTS).

6.2 TTS was awarded the Bernard Ratigan Award for Psychoanalysis &

Diversity by the British Psychoanalytic Council in 2015.

6.3 The budget for the HTS contract reduces each year with the expectation

that the Project is run by the Community by Year 3, with minimal support

from T&P. The project is receiving increased enquiries and interest e.g. a

request from the Community Links Trust would like to list on their website

HTS as an Early Action case study to support their campaign for early

intervention.

6.4 A German multidisciplinary mental health team from Frankfurt visit our

team as part of a European study of innovative community mental health

27 4%

24 4% 32

5%

141 21%

23 3%

286 43%

134 20%

Ethnicity data: Adult Complex Needs open cases

Asian or Asian British

Black or Black British

Mixed

Not Known/Not Stated

Other Ethnic Groups

White

No data

Page 14 of 146

7

services, and there are discussions about a proposal to run Thinking Space

for adolescents in Camden Schools.

6.5 Islington Council have agreed in principle for us to run a pilot of 9 Thinking

Space events in Adult Social Care & Housing Directorates and if successful

this will be rolled out across the Council and community. We are awaiting

their formal agreement to this work.

6.6 The Thinking Space model is highly adaptive and is being used as a model

of staff support, training and development and as a community mental

health intervention.

7. Pain Clinic at the Royal Free Hospital

7.1 The Complex Needs Services provides two staff, a Consultant Psychologist

and a psychotherapist to the Pain Management Service. As part of the

psychology service in the Pain Management Clinic, they consult to the

team and assess and treat patients with unexplained pain symptoms or

when there are particular stresses associated with their physical pain.

7.2 This successful and highly regarded work applying psychoanalytic

understanding, has a long history of connection with the Tavistock which

has developed into the present consolidated position with a secure

contract. It is closely connected with our concerns about Medically

Unexplained Symptoms, which in spite of considerable efforts has

otherwise not been successful in attracting new funding except in the

Primary Care domain.

8. Financial Situation

Contract title 13/14

Budget 14/15

Budget 15/16

Budget 16/17

Budget

Camden CCG - Adult 442,050 518,775 560,830 667,589

Barnet - Adults 109,500 167,858 168,683 133,869

Enfield CCG - Adults 41,665 67,290 44,649 87,347

Haringey CCG - Adults 58,754 195,939 134,113 102,729

Ealing CCG - Adults 54,480 41,383 38,597 29,110

Central London CCG - Adults 113,046 121,584 109,065 101,390

Islington CCG - Adults 110,675 117,766 115,085 69,119

Hammersmith & Fulham CCG - Adults

23,146 32,986 36,083 42,356

West London CCG - Adults 90,142 88,824 70,057 44,319

SLR

Com

plex

Nee

ds

Page 15 of 146

8

Brent CCG - Adults 16,243 19,146 31,799 19,594

Hertfordshire CCG - Adults 2,894 44,809 59,162 50,826

Hertfordshire Outreach 87,026 88,767 72,313 62,444

Adult Pain Clinic at RFH 89,898 89,898 89,898 92,595

Tottenham Thinking Space

Total CCGs 1,239,519 1,595,025 1,530,334 1,503,287

8.1 The main income for Complex Needs comes from the clinical contracts with

the CCGs. The last 3 years have shown overall that they keep steady, with

a small reduction of 4% and 2% in the last 2 years. Some contracts have

increased substantially, e.g. Camden, whilst other contracts have shrunk,

largely associated with Single Point of Entry pathways designed to favour

local providers. A major loss has been the ending of contracts in East

London CCGs, and the competition from CNWL is threatening to similarly

restrict West London.

9. Clinical Quality and Outcome Data

9.1 Two primary tools are used. The CORE outcome measures which have

been used for more than 10 years. Plus the patient experience

measurement uses the CHI-ESQ. The CORE can potentially be used against

national standards, and although not specifically designed for

psychotherapy as a form of treatment, it has nevertheless been accepted

as a good enough measure. The CHI Experience of Service Questionnaire

is quite good from our point of view.

9.2 It has been difficult to get reliable rates of return. Rates have improved

when we have been able to provide consistent support to staff from a

dedicated psychologist/data officer. It was also complicated by the

adoption of electronic case records which incorporates the CORE system. A

new permanent post has been established to increase returns and

consolidate these processes. Such a post has shown important

improvements in return rates.

9.3 Below is a table of responses as shown by the ESQ over time for one of

the Units (Belsize) which is also representative of the other Units,

indicating a consistency of approach and result across the service over

time.

9.4 Some of the values rise to 100% . Although the work of improving the

data quality is ongoing, and the details of whether there are specific issues

which should be attended to can then be improved, the overall picture

Page 16 of 146

9

remains of a high quality service with a method of listening to and

understanding patients which works well.

JUL-DEC 2013

APR-JUN 2014

JUL-DEC 2014

JAN-JUN 2015

JUL-DEC 2015

JAN-JUN 2016

Listened to 94% 97% 94% 94% 92% 94%

Easy to talk 81% 77% 83% 83% 82% 75%

Treated well 95% 93% 98% 96% 98% 94%

Views and worries 93% 97% 96% 94% 92% 100%

Know how to help 83% 90% 87% 81% 88% 93%

Given enough explanation

82% 79% 76% 60% 86% 71%

Working together 89% 93% 90% 85% 90% 100%

Comfortable facilities 83% 93% 81% 81% 86% 94%

Convenient appointments

77% 89% 88% 83% 79% 81%

Convenient location 74% 97% 79% 72% 75% 75%

Recommend to friend 90% 89% 93% 93% 98% 100%

Options 79% 79% 93% 84% 93% 88%

Involved 79% 81% 91% 86% 89% 75%

Quickly Seen 62% 89% 68% 60% 65% 75%

Good help 93% 89% 98% 95% 98% 94%

10. Serious Untoward Incidents and Safety Issues

10.1 There have been none in the last 2 years.

10.2 There have been a small number of incidents in the last year of confusions

in the room bookings system resulting in sessions being interrupted. We

are hoping to contain this, but the software has been an issue which has

not allowed amendments to be easily made.

10.3 Acquiring experience of using the appointment system on Care Notes has

similarly been a data issue.

10.4 For the first time it was necessary to take out a Harassment Order against

an ex-patient who became paranoid, coming into the building, sending

threatening emails and was deemed below threshold by local mental

health services.

10.5 It remains the case that the Fitzjohns Unit, our personality disorder service

has never experienced a patient suicide.

SLR

Com

plex

Nee

ds

Page 17 of 146

10

11. Clinical Governance, Audit and Research

11.1 Audits are currently being undertaken include.

Herts services: intake profiles, patient pathways, GP survey

Trauma Service: intake profiles

Follow up to Tavistock Adult Depression Study - Impact Study jointly with

Essex University.

Planned events with patients, GPs, focus groups and analysis of data

11.2 A permanent Assistant Psychologist is being appointed to facilitate data

collection, audit and management information. This should provide a much

needed resource to direct this kind of work to improve clinical quality.

10. Education and Training

10.1 The effect of the separation of Training and Clinical Directorates had a

serious impact. Since the primary training within the former Adult

Department was a clinical one, based on close supervision and the

apprenticeship model, the separation of the resources devoted to training

and clinical service was difficult and confusing. As well as such a division

being only approximate, it also inhibited the potential for flexible and

creative movement across activities. This is especially so since much of the

development that has taken place over the years, involved both elements

of training and service provision.

At the same time the value placed on our work was demonstrated by the

steady increase in fee-paying trainee numbers at both the foundation and

advanced levels. As the attention to detailed clinical work of the kind we

practice declines in the mental health field at large, in favour of simplified

case management, so the need for clinicians to study in more depth and

over time to help them understand their clients and to survive the stresses

of the work increases. The satisfaction they experience in the work is

demonstrable. – see staff story below.

As the new structures in the Trust become established and the need to

respond to changes in the Training Contract become pressing, it has been

possible to begin to form a new partnership between DET and Complex

Needs, largely at this point through the psychoanalytic psychotherapy

portfolio. This is becoming a regular review, combining sessions from each

Page 18 of 146

11

Directorate to continue the joint project of clinical trainings. Staff will thus

be able to provide training on an agreed basis within DET priorities,

alongside priority clinical work required by Complex Needs. It is intended

to continue with these developments and work with DET in the future.

11. Staffing.

11.1 This is a most serious issue. The consequences of the savings have led to

the departure of 9 senior experienced clinicians with leadership profiles in

the field over the last 5 years, all of whom had a record of innovation and

publication. Only one was replaced by an equally experienced person. The

present staffing condition of the whole service is on the limit of what is

sustainable, whilst achieving the accepted standards of service and

training. With the interim promotion of Dr Stern to Clinical Director, the

immediate situation of the loss of management capacity within Complex

Needs is critical.

Personally at this point I continue to manage a clinical unit, and I am the

AFS lead on relocation in addition to the Clinical Lead role. The future

management of Complex Needs should be established on a secure basis

for the next period and plans made to attract experienced senior clinicians

from outside the Trust.

Three younger colleagues have been advanced to the role of managing

clinical units and in addition the M1 tutor who also provides clinical time to

the Fitzjohns Unit liaises closely with the management of the service. A

new appointment from outside the service, of a Consultant Psychiatrist

working across Complex Needs, the Family Court Service and Primary Care

is in place for the autumn.

11.2 The pattern of offering only time limited contracts to protect the service

against savings targets has meant that the transitional arrangements

necessary when the contract renewal is uncertain has led to a loss of

service which has built up over time. This applies in particular to the

Fitzjohns Unit which remains in high demand as a specialist service for

complex personality disorder and severe borderline patients and now has a

waiting list of two years. It also applies to the Couples Unit, which

continues to provide an outstanding example of a service not provided

elsewhere in the NHS whilst having a high take up of students for the

training based in the Unit.

SLR

Com

plex

Nee

ds

Page 19 of 146

12

11.3 Financially this has led to underspends which the Service has then lost,

when there are patients waiting for services.

11.4 Our present intention is to try to stabilise and simplify the staffing

arrangements with the modest savings being required for next year.

11.5 This situation has had a deleterious impact on the normal development

work which in the past has led to new initiatives. Management roles have

been concentrated in the Clinical Director/Service Lead posts, at the

expense of the leadership of other Units. This reduces our capacity to

create new opportunities, and we are now more dependent than ever on

the market place for new contract possibilities.

11.6 The Service is now very dependent on two senior staff, Dr Bell and myself,

for continuity and clinical leadership who are within the normal window for

retirement at a time when supervision and management tasks are growing.

New younger and talented clinicians, recently qualified must be recruited

to provide the future.

11.7 Staff Story: Dr Sophie Atwood.

Before medical school I studied Social & Political Sciences at University where I

began to read papers giving a psychoanalytic perspective on people's actions,

motivations and difficulties. I spent my free time acting in and directing plays. It was

the character analysis involved in this that that fascinated me. I decided that I

wanted to understand more about the body as well as the mind, so went to Medical

School, with an aim to eventually work in psychological medicine.

Medical School and house jobs gave me very little chance to explore the

psychological aspects of medicine, and it wasn't until I began as an SHO in

Psychiatry, and started looking for explanations beyond the biological, and I began to

find my way again towards a more psychoanalytic understanding of people and their

difficulties, and things started to make more sense to me than by a psychiatric

explanation alone.

I started attending Medical Psychotherapy conferences, hearing David Bell, Marcus

Evans and Jessica Yakeley talk there, I attended Institute of Psychoanalysis events

and did the Institute of Group Analysis Introductory Course which as available in

Brighton where I then lived and worked.

Page 20 of 146

13

I applied for ST4-6 training in Medical Psychotherapy, putting the Tavistock Centre as

my first choice, and was excited to be allocated to train here. I also enrolled on M1 -

The Interdisciplinary Training in Psychoanalytic Psychotherapy. At my Trust

induction, Matthew Patrick, the then Chief Executive came to speak to the new staff.

As he spoke I became aware of a new and different perspective from anything I had

experienced in previous NHS work. I was hopeful about working in a place of real

thinking and understanding, applied to staff and the organisation as well as to

patients.

My 5 years here have born this out to be true. Many of the ideas and ways of

thinking and working here take quite some time to get used to. The first few months

and even years I felt often out of my depth and in a land with a new culture and

language. Trainees further on in the training reassured those arriving that this feeling

is an ordinary part of the process, to be patient, immerse yourself in the culture and

language, and soon things will start to become clearer. This is a place of such

diversity, which I love, and this brings such wealth to the thought happening here.

Discussions about cases bring perspectives from trainees and staff from all over the

world, and from many different professional backgrounds. The difference is

respected and seen as an enriching and adding to our potential understanding. I

believe people come here to learn about psychoanalytic work, and the department is

open and interested to hear their ideas and to learn from them too.

The work here is fascinating. There is close supervision of all assessments and

therapy sessions, which is challenging as a trainee but also containing for often

difficult work. Senior staff are available if a difficulty or crisis arises, and are open to

think through with the trainee what is really going on, helping the trainee to learn to

think, rather than act before sufficient thought. I believe patients are thought about

as individuals, and their care is considered in such depth. As all senior staff have

been in their own analysis or therapy, and all trainees currently are, there is a clear

understanding of people's difficulties as a being on a continuum, that parts of a

person can be functioning well whilst other parts struggle. There is an understanding

of what it is to be the patient, and this understanding informs the work done as a

clinician with each individual patient.

I have been glad in the last year to be able to apply my combined perspectives of

psychoanalytic psychotherapy and psychiatry to work in general practice through

TAP. This applied work is very interesting, and allows me to use the more in depth

understanding to new services and interactions with professionals working quite

differently with patients.

SLR

Com

plex

Nee

ds

Page 21 of 146

14

As I begin working myself as a member of senior staff and I look forward to

providing new trainees with opportunities that I feel grateful to have gained through

my 5 years here.

(Dr Atwood has now been offered a Consultant Medical Psychotherapist position in

Brighton.)

12. Public and Patient Involvement

Over the last two years the service has contributed to these

developments appointing a staff member to join the PPI team. The take

up by Complex Needs patients has been low, just one or two patients

depending on the activity. It remains difficult to accommodate

therapeutic forms of relating to patients alongside providing social

settings. However, patients participated in the recent CQC visit and gave

excellent accounts of their experience to the inspectors.

Recently a new appointment, Claire Kent who is a social worker by

background, is hoping to take new initiatives forward.

13. Patient Story

A patient who is a current member of Complex Needs psychotherapy

group will present her story at the Trust Board meeting.

14. Future direction

It is clear that the Trust is becoming a more diverse place in many ways.

The former Adult Department is in an important transition, trying to

preserve the years of clinical experience and a model for development

which produces high quality and creative results. The current common

NHS models of quality which are quantifiable have to be fitted in

alongside the less quantifiable experiences of depth and meaning. But

there remains demand for the services provided in Complex Needs and

commissioners have not stopped wanting the Trust to continue to

provide alternatives to the main providers. It requires ongoing work to

maintain this work in the face of the competitive and contradictory

environment of Single Point of Entries.

Potential new areas of work and growth, if they can be contracted,

continue to be in the general field of severe and complex needs – a

Page 22 of 146

15

broad category around personality disorder – and various specialist

services, such as trauma and couples.

The Trauma Unit is about to develop a model of group work for the

survivors of HCSA. The Couples Unit has a plan to use group work for

victims of Domestic Violence. Both projects will be resourced out of our

existing budget, but will lead to new training opportunities.

We have tried for some time to develop services around the physical

health boundary, with Medically Unexplained symptoms and Pain

Management, but so far with limited success. It nevertheless remains a

highly desirable project if it can be realised. An Institute of

Psychosomatic Medicine could be a huge achievement.

The Thinking Space Project is an innovative and very successful model in

providing community based mental health care, especially when

professional services are being cut back or increasing their thresholds.

The Primary Care model in TAP and City and Hackney has equivalents

that could be used around the interface with acute services. Mostly our

style of understanding the interaction between user and professional

carries great advantages and is welcomed by GPs, rather than the simple

provision of low skilled services. We are already in competition, e.g.

Camden for the commissioning of different styles of mental health work

in primary care, and this may be a new opportunity on the boundary of

hospital acute care.

Michael Mercer

Interim Service Lead

July 2016

SLR

Com

plex

Nee

ds

Page 23 of 146

of 3

Board of Directors: July 2016

Item : 8

Title : Chief Executive’s Report (Part 1)

Summary:

This report provides a summary of key issues affecting the

Trust.

For : Discussion

From : Chief Executive

CE

O R

epor

t

Page 24 of 146

of 3

Chief Executive’s Report 1. Deputy Chief Executive and Director of Finance

1.1 We held the interviews for the post of Deputy Chief Executive and Director of

Finance on 5th July. In the light of these we have appointed Terry Noys to the

role. Terry is currently Chief Operating Officer at St Mary’s University,

Twickenham and has extensive experience across a number for sectors. We

have yet to agree a final start date for Terry but are hoping he will be able to

join us before Simon Young retires at the end of September.

2. North Central London STP

2.1 We have continued to be engaged in the development of the mental health

work stream for the North Central London. A paper on the STP is scheduled for

later in the agenda.

3. CQC Quality Summit

3.1 The Quality Summit following our CQC report was held on 7th July. There was a

lot of positive feedback from CQC and others about the clinical work of the

Trust.

3.2 On 12th July we held a Leadership Event which included team managers from

across the Trust. The focus of the event was how we should develop our work

on clinical quality and, in particular, how we should define outstanding and

what strategies what we should follow to get there. This event is part of a

programme of work which will feed into the revised clinical quality strategy

which we will bring back for Board agreement in September or October.

4. National Training Contract

4.1 We have been continuing to work with HEE contracts to agree a new shape to

our National Training Contract. With Brian Rock I am attending on 18th July the

first review meeting for this work with Liz Hughes, the Director of Education

and Quality who has the lead responsibility for the National Contract.

5. Brexit

5.1 The result of the referendum on membership of the EU on 23rd June raises a

number of significant issues for the Trust which has the second highest

percentage in the NHS of staff from other parts of the EU.

5.2 Paul Burstow and I wrote to all members of staff in the aftermath of the

referendum result highlighting our support for those staff affected. We have

Page 25 of 146

of 3

also supported holding a “Thinking Space” event for staff to address the issues

coming out of the Referendum result. 6. Chief Executive Question Time

6.1 Recognising the scale, at present, of both internal and external change I have

decided to establish a regularly month question time to allow staff to raise

questions and concerns. The first session is planned for 19th July.

Paul Jenkins

Chief Executive

17th July 2016

CE

O R

epor

t

Page 26 of 146

of 5

Board of Directors July 2016

Item : 9

Title : Q1 Review of Trust Objectives

Purpose:

A system for reviewing Trust strategic objectives on a quarterly basis is

now fully in place.

The Strategic and Commercial Committee reviewed progress at Q1 on 5

July 2016, the paper outlines key points noted by the committee.

A summary of progress against the objectives is appended.

For : Discussion

From : Paul Jenkins, Chief Executive Officer

S

trat

egic

Obj

ectiv

es Q

1

Page 27 of 146

of 5

1.0 Introduction

A system for reviewing Trust strategic objectives on a quarterly basis is now

fully in place. It consists of

Directors setting milestones for the next quarter and reviewing progress.

Two RAG ratings for each objective. One RAG for achievement of

milestones in the previous quarter. A second RAG for overall progress

towards meeting the objective. A summary sheet contains RAG ratings for

each objective.

The Management Team and Strategic and Commercial Committee then

review the objectives quarterly and select 1-2 objectives to consider in

more detail.

2.0 Quarter 1 Review of Progress

The Strategic and Commercial Committee met on 5 July, reviewed

progress and noted the following points:

Whilst unsurprisingly no objective overall is yet green, good progress has

been made in a number of areas. Several objectives have been rated

green with regard to progress against Q1 milestones. This is a significant

achievement given our ambitious set of objectives and workload

pressures. Progress in Q1 has been green rated for the following areas:

A1 progress on Thrive

B3 To build on the work of FNP

F1 Achieving a good CQC result

F3 To improve information to support quality strategy

G1 Media Coverage and Profile

I1 Finance, growth and losses

All other areas are rated as amber. On the overall progress all areas are

amber apart from Tavistock Consulting (TC), as we do not anticipate TC

being able to meet their income targets for 2016/17. This is part due to

changes in the leadership in TC. As the board is aware, a review of TC is

underway and due to report in September 2016.

3.0 Objective Refresh

The Board of Directors agreed an objective refresh will be finalised in

October 2016. A number of objectives will need to be revised in response to

changes in the external environment including:

Page 28 of 146

of 5

B1 CAMHS namely acquisition of a CAMHS

D2 and 3 DET objectives, so they are aligned more closely to changes

required as part of our contract with HEE.

C2 Primary Care

As we have always recognised there is serious pressure on capacity, which

has been compounded by developments in the external environment,

such as the Strategic & Transformation Plan process. The review of

objectives in the autumn will need to take this into account and

consideration will be given to the further prioritisation of objectives.

Str

ateg

ic O

bjec

tives

Q1

Page 29 of 146

of 5

Summary of Progress against Objectives, July 2016

Objective Rating

Last Q

Rating

Overall

A1 With partners to establish Thrive as the leading model for the provision of

CAMHS services A

A

A2 With partners to develop service models such as One City and Hackney as

demonstrator sites for a psycho-social model of integrated care. A

A

A3 To develop the work of Tavistock Consulting, targeting opportunities

relating to mental health in the workplace, new models of care and the 5

Year Forward View promote increasing income and profitability year on

year.

G

R

B1 To widen our portfolio of CAMHS services A A

B2 To further establish our reputation as experts in the support of vulnerable

children and families A

A

B3 To build on the work of the Family Nurse Partnership National Unit to

provide effective support for vulnerable families G

A

B4 To develop our role as a specialist education provider A A

C1 To maintain and develop our existing portfolio of services for adults with

clear descriptions of interventions, practice- based evidence of clinical

effectiveness and service user support and to promote these options for

patients through the Choice agenda.

A

A

C2 To implement the Camden TAP successfully and to work towards being

commissioned to deliver another similar service. A

A

C3 To maintain our contract for specialist forensic psychotherapy at the

current level and develop further applications of the Portman Clinic’s

approach to support a wider criminal justice workforce nationally through

direct clinical service developments, consultation and training.

G

A

D1 Increase intake of Y1 student numbers to 900 for 2017/8 Academic Year G A

D2 To broaden our portfolio of training interventions to reach a wider section

of the workforce and respond to emerging issues in health and social care G

A

D3 Increase the national reach of our training and education offer through

greater regional presence A

A

E1 To develop a faculty of high calibre researchers both within and outside of

the Trust by establishing working relationships with senior academics

nationally and internationally whose research is linked with the work of

A

A

Page 30 of 146

of 5

the Trust.

E2 To secure further prestigious external grant funding for research,

contributing to raising the Trust’s profile as a leader nationally and

internationally in the clinical and training domains.

A

A

E3 Embed research competences across our training portfolios with particular

emphasis on our clinical trainings A

A

F1 To meet and exceed all our external regulatory requirements, including

external inspections from CQC and QAA. A

G

F2 To set out an aspirational clinical quality strategy for the whole trust,

developed with staff, service users, commissioners and taking into account

the regulatory environment.

A

A

F3 To develop systems for capturing, analysing, reflecting upon and acting

upon qualitative and quantitative data to support the implementation of

the clinical quality strategy with a particular focus on capturing the

experience of people who use our services.

A

G

F4 To develop and implement a new strategy for patient involvement which

makes the involvement of people with lived experience we drive

innovation in the organisation.

A

A

F5 To set out a robust Equality and Diversity Strategy to increase inclusiveness

for staff, service users, students and trainees G

A

G1 To deliver a significant growth in media coverage and wider public profile

for the Trust establishing its position as a thought leader on relevant

issues.

G A

G2 To develop, deliver and maintain an alumni function which creates a

‘community of practice’ and significantly reinforces the lifelong

relationship between the Trust and its alumni.

A

A

H1 Develop our workforce to deliver the Trust’s overall strategy and support

staff health and wellbeing A

A

H2 To develop and implement an IM&T strategy for the Trust G A

H3 To agree a Full Business Case for the best long term accommodation for

the Trust’s businesses A A

I1 Continue steady growth, so as to widen the reach of our influence and

leadership and also contribute to the Trust’s overall financial position.

Minimise reductions in all current income sources.

A

G

I2 Identify and implement productivity improvements, to optimise the use of

resources in all services and departments. A

A

Str

ateg

ic O

bjec

tives

Q1

Page 31 of 146


Item : 10

Title : IM&T Strategy/Programme Update

Summary:

IM&T is currently amber against the plan as we are slightly

behind on some targets and will probably struggle to catch

up.

Having said that some good progress has been made in a

number of areas as shown in the update.

The key to maintaining progress over the next 6 months is

to complete the procurement exercises swiftly and get the

suppliers committed to delivery dates.

This report has been reviewed by the following Committees:

EMT, 19th July

Attached as an appendix is an update on progress with

CareNotes Optimisation.


Quality


Risk

For : Noting

From : Director of IM&T

IMT

Q1

Rep

ort

Page 32 of 146

Restricted - Management

Page 1 of 3 IM&T Programme Update

IM&T Strategy and Programme update

Introduction 1) In February 2016 the Board approved the IM&T Strategy and plan.

2) The Chairman requested that the board keep sight of the IM&T Strategy delivery.

Summary 3) I have suggested that IM&T is currently amber against the plan as we are slightly

behind on some targets and will probably struggle to catch up. 4) Having said that some good progress has been made in a number of areas as

shown below. 5) The key to maintaining progress over the next 6 months is to complete the

procurement exercises swiftly and get the suppliers committed to delivery dates.

IM&T Strategy and Programme Update 6) Telecoms project (phase 1) has been completed with all the back-end systems

being upgraded. This brings the system back into a supported position and delivers capacity for growth which we didn’t have previously.

7) Network refresh requirements are now clear so that a specification for procurement can be defined in Q2. This is behind schedule.

8) Email replacement has been agreed by the IM&T Steering Committee and the Management Team. Procurement is underway and implementation will be in 2 phases:

a) Local upgrade and connection to Office 365 (Office 365 early adopter in place)

b) Migration of staff to Office 365

9) Timescales for delivery of the email element of Office 365 will be available following formal engagement with the supplier, expected to be in early August.

10) Implementing Office 365 also opens up the potential to move data storage to the cloud, using Skype for Business to video conferencing and telemedicine as well as opening up new ways of working for the Trust.

11) IM&T Capability review order will be placed by the end of July with an aim to start in August.

12) CareNotes Optimisation project has been progressing satisfactorily with a target to conclude the agreed scope by the end of September, see full update in separate CareNotes Optimisation Update paper.

13) Evaluation of various risk management systems has been carried out and a recommendation provided to the Management Team.

14) A patch management system has been implemented with software licence management being added to it in July. Processes need to be developed to support patch management going forward.

15) Data Leak Prevention for email has been implemented in monitoring only mode, this is reporting to the IG Manager on likely data leaks through email. Nothing

IMT

Q1

Rep

ort

Page 33 of 146



overly concerning has been reported to date. The next stage will be to switch on active blocking of suspicious messages.

16) All faxes have now been removed from the Tavistock Centre in support of government targets around the paperless agenda. E-fax has replaced fax where services deal with 3rd parties who have not moved away from faxes.

17) N3 network resilience has been assessed and deemed sufficient at this time but should be reviewed when the new HSCN network replaces N3 next year. This project has been closed.

18) ULCC network resilience has been ordered with installation expected by early September. Full resilience is dependent on the internal network refresh as well.

19) Active Directory review has made significant progress with several thousand aged accounts being removed from the system and improved leavers processes being put in place. Further work continues to bring the total number of accounts down to an appropriate working level.

20) Improved power distribution has been implemented in the Computer Room as a temporary measure until a more permanent and robust solution can be implemented. It is expected that a completely new power supply will be delivered during the summer however this will require 3 periods of downtime for all IT systems to run in and further downtime to configure new failsafe devices such as uninterruptable power supplies and improved local cabling.

21) The first batch of replacement devices have been ordered, this is running several months behind schedule.

22) Initial reporting dashboards have been delivered for board and team level, these have been well received, however there is limited resource to deliver further developments in this area. It has also been identified that the current processes are fairly manual. Consideration should be given to the best way to move this project forward.

23) We now have a robust change management process in place for CareNotes and reporting changes which provides a much clearer and safer approach although at times it can appear a little bureaucratic. IT are developing similar process for infrastructure related changes to ensure suitable control is in place this should lead to a more reliable infrastucture.

Other Successes

24) We have successfully recruited to 2 posts that have been proving very difficult to obtain competent staff for at the pay points agreed for the roles: a) Informatics – System Analyst to deliver CareNotes improvements. b) DET Systems Support Team – Business Inteligence Developer

25) These posts should help relieve some of the day to day pressure in both teams and over time lower the DET risk around support capacity/capability.

26) We have responded to a contractual demand for swifter than anticipated implementation of E-referrals and have setup kick off meetings for this project and requested costs from Advanced Health and Care. However we will need to recruit a project manager to support this and other projects ASAP.

27) It should be noted that as part of ‘business as usual’ there are various upgrades of existing systems that have to take place on a regular basis and these are often small projects in their own right. Recent examples include the WIFI solution, IT Helpdesk system and Proofpoint email security solution.

Page 34 of 146



Concerns 28) Following a complete IT outage in June it was identified that the IT Computer

Rooms were pulling more electrical load than was safe. Short term steps have been taken to balance the load better and IT/Estates are working together to deliver a series of upgrades to the infrastructure to improve things in the longer term.

29) The power failure also highlighted a limitation in the resilience of the network design which should be addressed in the network refresh project.

30) An unexpected and unplanned for demand for Informatics resource is creating additional pressure, for example: a) CAMHS transformation, including THRIVE and CYPIAPT changes b) Contracts demanding delivery of E-referrals in this financial year

31) Of immediate concern is training capacity, to deliver business as usual training as well as supporting the various projects that are ongoing, and technical resource to support dashboard development.

32) Connectivity problems being experienced in remote sites where we don’t fully manage the infrastructure are causing issues for the staff in those services and also costing a disproportionate amount of IT staff time to try and resolve.

33) The necessity for the Director of IM&T to spend a significant amount of time on operational issues has been impacting on delivery of strategic plans, this needs to be managed better moving forward.

34) Toby Avery is leaving the Trust at the end of this month, to take up a new role at Surrey and Borders NHS FT. David Wyndham Lewis has been appointed as Interim Director, starting on 25 July. It is envisaged that this appointment will be for nine months.

IMT

Q1

Rep

ort

Page 35 of 146

Carenotes Optimisation Project – July Update 05.07.16

Overview:

A training plan for the new students and trainees starting in September 2016 has been

developed. Approximately 250 to 300 students will need to undergo training. The view of

the COP team is that it is not possible to meet these training needs based on current

resources (1 full time trainer). This is particularly in the context of additional training needs

related to other projects such as the roll out of CYPIAPT and Thrive implementation, and the

expansion of GIDS. A paper requesting additional training resources is being submitted to

the management team meeting.

User feedback has highlighted that the main issues of concern to users are issues with the

speed of the system and connectivity. This is a significant barrier to timely and accurate

recording of clinical data which poses a clinical and financial risk.

We developed and sent out to staff a comprehensive online survey to further understand

these issues, and have drawn several conclusions based on analysis of the results:

o The speed of the system, rather than connection issues, is the #1 problem reported,

both from off-site and on-site respondents. This is not something that had been

reported widely before so may be a new issue

o This suggests the problem is most likely a widespread performance issue in the

CareNotes system, rather than a connectivity issue

o The Director of IM&T, Head of Informatics and Head of IT met with Advanced Health

and Care representatives to escalate this issue w/c 11th July. It was acknowledged

that there have been widespread performance issues affecting many Trusts with the

system however ‘fixes’ have been implemented to address them. It seems that

performance for the Tavi has worsened since the implementation of these ‘fixes’

while it has improved elsewhere.

The Quality team have been continuing to work on addressing issues around the quality of

data already on the system. This includes removing duplicate Outcome monitoring forms

and cleansing migrated data. There is also work underway to increase standardisation of

clinical forms across the trust.

Milestones:

User survey completed

Training plan for September intake developed

Began testing SMS Reminder functionality in the test environment

Car

eNot

es O

ptim

isat

ion

Page 36 of 146

Further tests run on Patient View to determine reasons for varying response times and

whether this is a wifi capacity issue, hardware problem or system issue

Next Steps:

Arrange training with Advanced Health Care for Informatics in order to build Mobile Solution

Informatics to test SMS reminders in live environment and then rollout to pilot team

Informatics to determine how OM Graphs can be delivered; embedded within CN or through

the use of reporting services

IT to investigate the issues affecting the slow performance of the Patient View on iPads

Incorporate new training materials into training package

Paper has been sent to management team requesting further training resources

Risks:

The demand on the training team in the autumn is expected to exceed current capacity

HIGH PRIORITY

o Additional trainer needed ASAP

Network upgrade. While an upgrade has provisionally been approved, the tendering and

implementation process is expected to take a further 6 months.

HIGH PRIORITY

o Clinical Governance and Quality Manager has advised that this timeframe poses a

risk to data quality and both she and the head of IT agree a waiver should be

requested in order to update the system ASAP. One survey respondent stated, ‘Slow

network and connection speeds create significant financial and safety risks as busy

clincians have too little time with a slow system to enter data in a timely way.’

Myooran Canagaratnam and Freddie Peel

Page 37 of 146

of 10


Item : 11

Title : Finance and Performance Report

Summary:

After the third month of the new year, a surplus of £698k is reported after

restructuring costs, £280k above the revised planned surplus of £418k.

We aim to have a surplus of £800k by the end of the year, after the control

total was revised due to additional funding.

Analysis by service line is not provided this month, but will be included in

future reports: Management Accounts are working with colleagues to

finalise the allocation of key elements of income and expenditure.

The cash balance at 30 June was £3,790k, which is £282k less than Plan.

Late payments have been offset by the higher surplus and lower capital

expenditure.

For : Information.

From : Simon Young, Director of Finance

Fin

ance

& P

erfo

rman

ce

Page 38 of 146

of 10

1. External Assessments: NHS Improvement

1.1 A revised 2016/17 Plan has been submitted to NHS Improvement. The Plan

should lead to an FSRR of 4. The two changes from the original plan were:

1.1.1 The Trust will receive an allocation of £500k from the “targeted

element” of the Sustainability and Transformation Fund.

1.1.2 The Trust’s control total – i.e. our required surplus – is increased by

£500k to £800k. There is therefore no funding available for additional

expenditure.

1.2 The return for June will be submitted on 22 July with an FSRR of 4.

1.3 NHS Improvement have announced that the present Risk Assessment

Framework, which includes the FSRR, will be replaced during 2016/17 by a

new Provider Oversight Model which will apply both to Trusts and

Foundation Trusts. Details are not yet available.

2. Finance

2.1 Income and Expenditure 2016/17 (Appendices A and B)

2.1.1 The budget has been revised to reflect the changes outlined in 1.1 above.

The additional £500k income, spread evenly across the year, is shown on line

2 in Appendix B; and is included in Clinical Income on Appendix A.

2.1.2 After June, the Trust is reporting a surplus of £698k after restructuring costs,

£280k above the revised budget. Income is £24k below budget, and

expenditure £345k below budget.

2.1.3 The income shortfall to date of £24k is mainly due to Training and

Consultancy:

2.1.3.1 Training is £51k below plan due to LCPPD income deferred to reflect

activity in a later period.

2.1.3.2 Consultancy Income is £34k below target mainly due to TC Income

£40k below budget. This has been offset by savings.

2.1.3.3 Clinical Income is £43k above budget overall. Adult and Forensic

Services income is £49k under budget due to a shortfall on NPA

income and credit notes relating to last year; which is offset by a GIDU

over-performance payment from 2015/16.

2.1.4 The favourable position of £345k on the expenditure budget was due mainly

to the under spends of £184k in GIDU, £104k in Primary Care and £72k in

Tavistock Consulting due to vacancies and lower than expected non pay

costs.

2.1.5 There are currently 581 Whole Time Equivalent (WTE) funded posts in June,

of which 546 were occupied including 44 WTE bank and agency staff.

Page 39 of 146

of 10

Additional posts will be added as the increased funding for GIDS is phased in

later in the year.

2.1.6 The contingency reserve is a shortfall of £65k; however, cost centres with

significant underspending in the first quarter are expected still to have at

least part of this underspend by the end of the year.

2.1.7 The Executive team is working on proposals for some additional short-term

investment in development work for the future. This will be funded from

the underspending reported above.

2.1.8 Though the surplus is ahead of plan after three months, some of this may be

due to phasing of costs; and income for the remainder of the year is not all

secured.

2.2 Forecast Outturn

2.2.1 The forecast surplus of £819k after restructuring is £19k above budget. This

consists an income surplus to budget of £269k which is offset by an

expenditure overspend of £250k.

2.2.2 At this early stage in the financial year it is difficult for both the Finance

Department and budget holders to make a robust forecast but after

discussions with budget holders we have assumed the following.

2.2.3 Clinical income is currently predicted to be £118k above budget due GIDS

Named Patient Agreements (NPA’s) and the Day Unit over-performing

against targets.

2.2.4 Training income is expected to be £143k above plan due to an additional

£286k funding for Dev. Psychotherapy Unit (the additional expenditure is

also forecast) which is offset by a shortfall on student fee and HEFCE income.

2.2.5 TC Consultancy income is expected to be £63k below target but expenditure

is also forecast to be below budget

2.2.6 Clinical expenditure is expected to be £83k below budget. GIDS is expecting

to maintain their £184k under spend and Primary Care are also £98k under

spent. Both are due to vacancies which are expected to be filled later in the

year. These under spends are offset by additional Day Unit staff due to

increased pupils.

2.2.7 Training expenditure is expected to be £128k over budget due to £286k

additional DPU expenditure mentioned above off set by vacancies in DET.

2.2.8 The Central functions are currently forecasting an overspend of £128k due to

agency staff in addition to unfunded Relocation revenue costs.

2.3 Cash Flow

2.3.1 The actual cash balance at 30 June was £3,790k this is a decrease of £792k on

last month and is £282k below Plan. The decreased balance was mainly due

to the quarterly payment in advance from Health Education England. The

Fin

ance

& P

erfo

rman

ce

Page 40 of 146

of 10

balance is below plan due to the first quarter FNP contract invoice for £707k

not being raised due to Public Health England not passing on relevant

information. There are also old year payments still outstanding of £1m which

have been offset by a larger than planned surplus and capital being below

plan.

Actual Plan Variance

£000 £000 £000

Opening cash balance 3,356 3,356 0

Operational income received

NHS (excl HEE) 4,227 4,794 (567)

NHS England (GIDS) 1,631 1,584 47

PHE (FNP) 748 1,455 (707)

General debtors (incl LAs) 2,602 3,010 (408)

HEE for Training 2,658 2,779 (121)

Students and sponsors 433 625 (192)

Other 118 0 118

12,417 14,247 (1,830)

Operational expenditure payments

Salaries (net) (4,362) (4,566) 204

Tax, NI and Pension (3,591) (3,735) 144

Suppliers (3,652) (4,266) 614

(11,808) (12,711) 903

Capital Expenditure (178) (821) 643

Interest Income 3 1 2

Payments from provisions 0 0 0

PDC Dividend Payments 0 0 0

Closing cash balance 3,790 4,072 (282)

2.4 Better Payment Practice Code

2.4.1 The Trust has a target of 95% of invoices to be paid within the terms. During

June we achieved 91% (by number) for all invoices. The cumulative total for

the year was 92% by number and 93% by value. In line with previous Board

discussions, this is considered satisfactory; Finance will continue to work with

colleagues to avoid delays as far as possible, but no additional action is

planned.

2.5 Statement of Financial Position (aka Balance Sheet)

2.5.1 Appendix E reports the SoFP at 30 June, compared to the Plan figures for the

month.

2.5.2 Property, Plant and Equipment was £609k below plan due to the slower

progress than anticipated on the Relocation and IM&T projects.

2.5.3 Trade and Other Receivables and Other Liabilities are both well above plan

due to the necessary early raising of the second quarter 2016/17 Contract

income in addition to outstanding old year debts and the delayed FNP first

quarter invoice.

2.5.4 As mentioned above in 2.3.1, cash is below plan due to the size of the surplus

plus capital expenditure being below plan.

Page 41 of 146

of 10

2.6 Capital Expenditure

2.6.1 The capital budget for the year is £2,480k in total which includes £1,100k for

the Relocation Project up to Full Business Case.

2.6.2 Up to 30 June, expenditure on capital projects was £178k. This included

£134k on IM&T and £30k on the Relocation project. This is £643k below plan

due to the Relocation Project and the various IM&T projects not making the

expected progress at this stage. The expenditure for the year is forecast to be

on budget.

2.6.3 The Relocation project cumulative capital costs up to 31 March 2016 were

£575k but this was reduced to £112k on the advice of our external auditors

with the balance being charged to revenue. (These figures exclude £76k for

the portacabin extension, which has been capitalised as a separate asset).

Spend to

date

Budget to

date

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Estates General 190 - 190 - 190

Relocation Project up to OBC - - - 50 50 50

Relocation Project up to FBC 1,100 30 1,100 62 92 1,162

DET Works Phase 1 14 14 -

Total Estates 1,290 44 1,290 - 112 156 1,402

IM&T Infrastructure 300 110 300 110 300

IM&T Project Posts 125 - 125 - 125

IM&T Developments 390 - 390 - 390

IDCR 50 (30) 50 389 268 627 707

Student Info. Mgmt System 325 22 325 22 325

Det Intranet 32 16 48 31

Total IT 1,190 134 1,190 389 284 807 1,878

Total Capital Programme 2,480 178 2,480 389 396 963 3,280

Total Project

Capital Projects 2016/17Budget

2016/17

Actual

YTD June

2016

Forecast

2016/17

Spend

2014/15

Spend

2015/16

3. Patient Services

3.1 Activity and Income

3.1.1 All the major contracts have now been agreed. Total contracted income for

the year is expected to be in line with budget. Part of the budgeted income

for the year is dependent on meeting our CQUIN1 targets agreed with

commissioners and achievement is reviewed on a quarterly basis.

3.1.2 After three months the income budget for named patient agreements (NPAs)

is £21k above plan.

3.1.3 Day Unit income budget was increased by £215k to £1,054k in 2016/17 and is

£20k above target after June. 1 Commissioning for Quality and Innovation

Fin

ance

& P

erfo

rman

ce

Page 42 of 146

of 10

4. Consultancy

4.1 TC income was £176k at the end of June, compared to the phased budget of

£216k. Offsetting this shortfall, however, the expenditure budget was under

spent by £72k. Our forecast for the year assumes at present that there will

be a £63k shortfall on income and reduced expenditure will offset this.

4.2 Departmental consultancy is £6k above budget after three months.

5. Training

5.1 Training income is £51k below budget after June, with the shortfall mainly

on LCPPD income due to a deferral and CP Trainees due to lower numbers

than expected. Education and training expenditure was £86k below budget

spread across the service mainly due to vacancies.

5.2 The key area of uncertainty is, as always, fee income from students and

sponsors for the academic year starting in October. Recruitment to date is

reviewed each month by the Training and Education Programme Board

Carl Doherty

Deputy Director of Finance

19 July 2016

Page 43 of 146

pag

e 7

of

10

TH

E T

AV

IST

OC

K A

ND

PO

RT

MA

N N

HS

FO

UN

DA

TIO

N T

RU

ST

AP

PE

ND

IX A

INC

OM

E A

ND

EX

PE

ND

ITU

RE

RE

PO

RT

FO

R T

HE

FIN

AN

CIA

L Y

EA

R 2

01

6-1

7

RE

VIS

ED

OP

EN

ING

FO

RE

CA

ST

BU

DG

ET

AC

TU

AL

VA

RIA

NC

EB

UD

GE

TA

CT

UA

LV

AR

IAN

CE

BU

DG

ET

BU

DG

ET

OU

TT

UR

N

£000'S

£000'S

£000'S

£000'S

£000'S

£000'S

£000

£000

£000

INC

OM

E

1C

LIN

ICA

L2,2

14

2,2

29

15

6,6

58

6,7

02

43

23,6

19

20,5

00

23,7

37

2T

RA

ININ

G1,5

79

1,5

81

1

4,7

38

4,6

87

(51)

20,5

06

20,7

40

20,6

50

3C

ON

SU

LT

AN

CY

90

86

(3)

269

235

(34)

1,0

76

1,1

04

1,0

10

4R

ES

EA

RC

H4

4

0

13

13

0

53

53

53

5O

TH

ER

53

62

9

131

148

17

536

571

608

TO

TA

L IN

CO

ME

3,9

41

3,9

62

22

11,8

10

11,7

85

(24)

45,7

89

42,9

67

46,0

58

OP

ER

AT

ING

EX

PE

ND

ITU

RE

(E

XC

L.

DE

PR

EC

IAT

ION

)

6C

LIN

ICA

L D

IRE

CT

OR

AT

ES

1,8

59

1,7

54

105

5,6

16

5,2

94

322

20,6

64

18,4

54

20,5

81

7O

TH

ER

TR

AIN

ING

CO

ST

S1,0

44

1,0

97

(53)

3,2

19

3,1

33

86

14,0

55

14,2

63

14,1

83

8O

TH

ER

CO

NS

ULT

AN

CY

CO

ST

S57

38

18

177

105

72

687

687

623

9C

EN

TR

AL F

UN

CT

ION

S699

785

(87)

2,0

51

2,1

70

(119)

8,2

61

8,2

33

8,4

04

10

TO

TA

L R

ES

ER

VE

S(2

0)

0

(20)

(16)

0

(16)

(65)

(291)

0

TO

TA

L E

XP

EN

DIT

UR

E3,6

39

3,6

74

(36)

11,0

47

10,7

01

345

43,6

02

41,3

45

43,7

91

EB

ITD

A302

288

(14)

763

1,0

84

321

2,1

87

1,6

22

2,2

67

AD

D:-

11

BA

NK

IN

TE

RE

ST

RE

CE

IVE

D1

1

(1)

2

3

(1)

8

8

8

LE

SS

:-

12

DE

PR

EC

IAT

ION

& A

MO

RT

ISA

TIO

N68

61

7

202

183

19

815

850

815

13

FIN

AN

CE

CO

ST

S0

0

0

0

0

0

0

0

0

14

DIV

IDE

ND

48

48

(0)

145

145

(0)

580

480

580

SU

RP

LU

S B

EF

OR

E R

ES

TR

UC

TU

RIN

G C

OS

TS

186

180

(7)

418

759

341

800

300

880

15

RE

ST

RU

CT

UR

ING

CO

ST

S0

0

0

0

61

(61)

0

0

61

SU

RP

LU

S/(

DE

FIC

IT)

AF

TE

R R

ES

TR

UC

TU

RIN

G

186

180

(7)

418

698

280

800

300

819

EB

ITD

A A

S %

OF

IN

CO

ME

7.7

%7.3

%6.5

%9.2

%4.8

%3.8

%4.9

%

FU

LL

YE

AR

2016-1

7Ju

n-1

6C

UM

UL

AT

IVE

Fin

ance

& P

erfo

rman

ce

Page 44 of 146

of 10

THE TAVISTOCK AND PORTMAN NHS FOUNDATION TRUST APPENDIX B

INCOME AND EXPENDITURE REPORT FOR THE FINANCIAL YEAR 2016-17

All figures £000

BUDGET ACTUAL VARIANCE BUDGET ACTUAL VARIANCE OPENING

BUDGET

REVISED

BUDGET FORECAST

VARIANCE

FROM REV

BUDGET

INCOME

1 CENTRAL CLINICAL INCOME 623 626 3 1,929 1,928 (1) 7,397 7,536 7,536 (0)

2 SUSTAINABILITY AND TRANSFORMATION FUND 42 42 0 125 125 0 0 500 500 0

3 CYAF CLINICAL INCOME 444 458 14 1,418 1,456 39 5,490 5,357 5,429 72

4 AFS CLINICAL INCOME 691 652 (39) 1,942 1,893 (49) 4,127 5,248 5,198 (49)

5 GENDER IDENTITY 415 451 36 1,244 1,299 55 3,487 4,978 5,074 96

6 HEALTH EDUCATION ENGLAND TRAINING CONTRACT 605 605 0 1,814 1,814 0 7,254 7,254 7,254 0

7 CHILD PSYCHOTHERAPY TRAINEES 175 172 (3) 524 512 (12) 2,391 2,318 2,349 32

8 JUNIOR MEDICAL STAFF 70 79 9 209 224 15 838 838 852 14

9 POSTGRADUATE MED & DENT'L EDUC 7 2 (5) 22 6 (16) 88 88 88 0

10 PORTFOLIO FEE INCOME 415 409 (6) 1,243 1,275 32 6,072 5,892 5,624 (268)

11 DET TRAINING FEES & ACADEMIC INCOME 51 55 4 155 82 (73) 823 1,031 1,386 355

12 FAMILY NURSE PARTNERSHIP 257 260 3 772 774 3 3,274 3,086 3,097 10

13 TC INCOME 72 68 (4) 216 176 (40) 863 863 800 (63)

14 CONSULTANCY INCOME CYAF 2 3 1 5 13 8 48 20 37 17

15 CONSULTANCY INCOME AFS 16 16 (0) 48 46 (2) 193 193 173 (20)

16 R&D 4 4 0 13 13 0 53 53 53 0

17 OTHER INCOME 53 62 9 131 148 17 571 536 608 72

TOTAL INCOME 3,941 3,962 22 11,810 11,785 (24) 42,967 45,789 46,058 268

EXPENDITURE

18 COMPLEX NEEDS 135 130 5 404 383 21 1,618 1,618 1,618 0

19 PRIMARY CARE 460 431 30 1,323 1,219 104 1,885 2,936 2,838 98

20 PORTMAN CLINIC 120 126 (7) 359 350 9 1,380 1,378 1,384 (6)

21 GENDER IDENTITY 265 209 55 794 610 184 2,795 4,027 3,843 184

22 NON CAMDEN CAMHS 414 409 5 1,347 1,376 (29) 5,273 5,119 5,281 (162)

23 CAMDEN CAMHS 405 382 23 1,209 1,162 47 4,803 4,866 4,859 7

24 CHILD & FAMILY GENERAL 60 67 (7) 180 194 (14) 699 720 757 (37)

25 FAMILY NURSE PARTNERSHIP 230 228 2 636 615 21 2,893 2,706 2,690 16

26 DEV PSYCHOTHERAPY UNIT 10 10 0 31 29 2 124 124 407 (283)

27 JUNIOR MEDICAL STAFF 83 71 12 248 208 40 993 993 953 40

28 NHS LONDON FUNDED CP TRAINEES 173 185 (12) 519 538 (20) 2,370 2,296 2,356 (60)

29 TAVISTOCK SESSIONAL CP TRAINEES 2 1 0 5 4 1 18 18 18 (0)

30 FLEXIBLE TRAINEE DOCTORS & PGMDE 20 17 3 60 72 (11) 242 242 254 (12)

31 EDUCATION & TRAINING 265 229 36 780 733 47 3,598 3,913 3,956 (43)

32 VISITING LECTURER FEES 127 155 (28) 380 405 (25) 1,229 1,215 1,202 13

33 PORTFOLIOS 135 200 (65) 560 529 31 2,796 2,546 2,345 202

34 TC EDUCATION & TRAINING 0 0 (0) 0 1 (1) 0 0 1 (1)

35 TC 57 38 18 177 105 72 687 687 623 63

36 R&D 23 19 4 49 48 1 155 293 293 (0)

37 ESTATES DEPT 164 225 (60) 493 578 (85) 2,045 1,972 2,057 (85)

38 FINANCE, ICT & INFORMATICS 218 222 (4) 649 644 5 2,562 2,623 2,632 (9)

39 TRUST BOARD, CEO, DIRECTOR, GOVERN'S & PPI 136 139 (3) 382 383 (2) 1,458 1,472 1,476 (4)

40 COMMERCIAL DIRECTORATE 43 44 (1) 120 120 0 464 504 510 (5)

41 HUMAN RESOURCES 52 73 (20) 173 208 (35) 642 642 680 (38)

42 CLINICAL GOVERNANCE 53 54 (0) 156 161 (5) 789 637 638 (1)

43 CEA CONTRIBUTION 10 11 (2) 29 29 (0) 117 117 117 (0)

44 DEPRECIATION & AMORTISATION 68 61 7 202 183 19 850 815 815 0

46 PRODUCTIVITY SAVINGS 0 0 0 0 0 0 (441) 0 0 0

48 CENTRAL RESERVES (20) 0 (20) (16) 0 (16) 150 (65) 0 (65)

TOTAL EXPENDITURE 3,707 3,735 (28) 11,248 10,884 364 42,195 44,417 44,606 (188)

OPERATING SURPLUS/(DEFICIT) 234 227 (7) 561 901 340 772 1,372 1,452 80

49 INTEREST RECEIVABLE 1 1 1 2 3 1 8 8 8 0

50 DIVIDEND ON PDC (48) (48) (0) (145) (145) (0) (480) (580) (580) 0

SURPLUS/(DEFICIT) 186 180 (6) 418 759 341 300 800 880 80

51 RESTRUCTURING COSTS 0 0 0 0 61 (61) 0 0 61 (61)

SURPLUS/(DEFICIT) AFTER RESTRUCTURING 186 180 (6) 418 698 280 300 800 819 19

Jun-16 CUMULATIVE

Page 45 of 146

pag

e 9

of

10

AP

PE

ND

IX D

2016/1

7 P

lan

Ap

ril

Ma

yJu

ne

Ju

lyA

ug

ust

Se

pt

Oct

No

vD

ec

Ja

nF

eb

Ma

rch

To

tal

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

Openin

g c

ash b

ala

nce

3,3

56

4,3

49

4,3

82

4,4

17

4,3

46

4,4

10

4,2

89

4,4

04

4,4

73

4,5

86

4,7

07

4,7

85

3,3

56

Opera

tional in

com

e r

eceiv

ed

NH

S (

ex

cl

HE

E)

1,3

88

1,8

88

1,5

18

1,0

88

1,2

88

1,0

88

1,0

88

1,0

88

1,0

88

1,0

88

1,0

88

1,0

88

14,7

86

NH

S E

ng

lan

d (

GID

S)

528

528

528

528

528

528

528

528

528

528

528

528

6,3

36

PH

E (

FN

P)

984

236

236

236

236

236

236

236

236

236

236

236

3,5

76

Ge

ne

ral

de

bto

rs (

incl

LA

s)1,3

00

1,0

10

700

1,0

00

700

700

700

972

970

773

970

1,0

71

10,8

66

HE

E f

or

Tra

inin

g926

926

926

926

926

926

926

926

926

926

926

926

11,1

16

Stu

de

nts

an

d s

po

nso

rs325

150

150

100

0

200

800

200

200

400

200

100

2,8

25

Oth

er

0

0

0

0

0

0

0

0

0

0

0

0

0

5,4

51

4,7

38

4,0

58

3,8

78

3,6

78

3,6

78

4,2

78

3,9

50

3,9

48

3,9

51

3,9

48

3,9

49

49,5

05

Opera

tional expenditure

paym

ents

Sa

lari

es

(ne

t)(1

,522)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(18,2

64)

Ta

x,

NI

an

d P

en

sio

n(1

,245)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(14,9

40)

Re

stru

ctu

rin

g0

(144)

0

0

(219)

0

0

0

0

0

0

0

(363)

Su

pp

lie

rs(1

,600)

(1,5

59)

(1,1

07)

(929)

(509)

(729)

(1,3

28)

(1,0

00)

(1,0

00)

(1,0

00)

(1,0

00)

(1,0

00)

(12,7

61)

(4,3

67)

(4,4

70)

(3,8

74)

(3,6

96)

(3,4

95)

(3,4

96)

(4,0

95)

(3,7

67)

(3,7

67)

(3,7

67)

(3,7

67)

(3,7

67)

(46,3

28)

Capital E

xpenditure

(206)

(351)

(264)

(269)

(134)

(79)

(218)

(264)

(219)

(213)

(154)

(114)

(2,4

85)

Loan

115

115

115

15

15

15

150

150

150

150

50

60

1,1

00

Inte

rest

Incom

e0

1

0

1

0

1

0

0

1

0

1

0

5

Paym

ents

fro

m p

rovi

sio

ns

0

0

0

0

0

0

0

0

0

0

0

0

0

PD

C D

ivid

end P

aym

ents

0

0

0

0

0

(240)

0

0

0

0

0

(240)

(480)

Clo

sin

g c

ash b

ala

nce

4,3

49

4,3

82

4,4

17

4,3

46

4,4

10

4,2

89

4,4

04

4,4

73

4,5

86

4,7

07

4,7

85

4,6

73

4,6

73

2016/1

7 A

ctu

al/

Fo

reca

st

Ap

ril

Ma

yJu

ne

Ju

lyA

ug

ust

Se

pt

Oct

No

vD

ec

Ja

nF

eb

Ma

rch

Tota

l

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

£000

Openin

g c

ash b

ala

nce

3,3

56

5,0

71

4,5

82

3,7

90

3,7

19

3,7

83

3,6

62

3,7

77

3,8

46

3,9

59

4,0

80

4,1

58

3,3

56

Opera

tional in

com

e r

eceiv

ed

NH

S (

ex

cl

HE

E)

1,2

75

1,8

20

1,1

32

1,0

88

1,2

88

1,0

88

1,0

88

1,0

88

1,0

88

1,0

88

1,0

88

1,0

88

14,2

19

NH

S E

ng

lan

d (

GID

S)

45

661

925

528

528

528

528

528

528

528

528

528

6,3

83

PH

E (

FN

P)

748

0

0

236

236

236

236

236

236

236

236

236

2,8

69

Ge

ne

ral

de

bto

rs (

incl

LA

s)1,1

79

729

694

1,0

00

700

700

700

972

970

773

970

1,0

71

10,4

58

HE

E f

or

Tra

inin

g2,3

91

133

134

926

926

926

926

926

926

926

926

926

10,9

95

Stu

de

nts

an

d s

po

nso

rs306

56

71

100

0

200

800

200

200

400

200

100

2,6

33

Oth

er

25

27

66

0

0

0

0

0

0

0

0

0

118

5,9

69

3,4

26

3,0

22

3,8

78

3,6

78

3,6

78

4,2

78

3,9

50

3,9

48

3,9

51

3,9

48

3,9

49

47,6

75

Opera

tional expenditure

paym

ents

Sa

lari

es

(ne

t)(1

,499)

(1,4

29)

(1,4

34)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(1,5

22)

(18,0

60)

Ta

x,

NI

an

d P

en

sio

n(1

,167)

(1,1

89)

(1,2

35)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(1,2

45)

(14,7

96)

Re

stru

ctu

rin

g(4

)(1

99)

0

(219)

0

0

0

0

0

0

0

(422)

Su

pp

lie

rs(1

,473)

(1,1

19)

(1,0

60)

(929)

(509)

(729)

(1,3

28)

(1,0

00)

(1,0

00)

(1,0

00)

(1,0

00)

(1,0

00)

(12,1

47)

(4,1

43)

(3,9

36)

(3,7

29)

(3,6

96)

(3,4

95)

(3,4

96)

(4,0

95)

(3,7

67)

(3,7

67)

(3,7

67)

(3,7

67)

(3,7

67)

(45,4

25)

Capital E

xpenditure

(112)

20

(86)

(269)

(134)

(79)

(218)

(264)

(219)

(213)

(154)

(114)

(1,8

42)

Loan

0

0

0

15

15

15

150

150

150

150

50

60

755

Inte

rest

Incom

e1

1

1

1

0

1

0

0

1

0

1

0

7

Paym

ents

fro

m p

rovi

sio

ns

0

0

0

0

0

0

0

0

0

0

0

0

0

PD

C D

ivid

end P

aym

ents

0

0

0

0

0

(240)

0

0

0

0

0

(240)

(480)

Clo

sin

g c

ash b

ala

nce

5,0

71

4,5

82

3,7

90

3,7

19

3,7

83

3,6

62

3,7

77

3,8

46

3,9

59

4,0

80

4,1

58

4,0

46

4,0

46

Fin

ance

& P

erfo

rman

ce

Page 46 of 146

pag

e 1

0 o

f 10

Appen

dix

E

ST

AT

EM

EN

T O

F F

INA

NC

IAL

PO

SIT

ION

Pla

n

Actu

al

Vari

an

ce

Actu

al

30 J

un

e 2

016

30 J

un

e 2

016

30 J

un

e 2

016

31 M

arc

h 2

016

£000

£000

£000

£000

No

n-c

urr

en

t assets

Inta

ngib

le a

ssets

110

98

(12)

110

Pro

pert

y,

pla

nt and e

quip

ment

21,3

50

20,7

41

(609)

20,7

33

To

tal n

on

-cu

rren

t assets

21,4

60

20,8

39

(621)

20,8

43

Cu

rren

t assets

Inve

nto

ries

Tra

de a

nd o

ther

receiv

able

s4,2

16

9,8

25

5,6

09

8,4

51

Cash a

nd c

ash e

quiv

ale

nts

4,4

17

3,7

91

(626)

3,3

56

To

tal cu

rren

t assets

8,6

33

13,6

16

4,9

83

11,8

07

Cu

rren

t liab

ilit

ies

Tra

de a

nd o

ther

payable

s(4

,044)

(4,9

75)

(931)

(5,3

81)

Pro

visio

ns

0(6

)(6

)(6

)

Tax

payable

(690)

(688)

2(7

07)

Oth

er

liabili

ties

(3,9

09)

(7,1

87)

(3,2

78)

(5,6

59)

To

tal cu

rren

t liab

ilit

ies

(8,6

43)

(12,8

56)

(4,2

13)

(11,7

53)

To

tal assets

less c

urr

en

t liab

ilit

ies

21,4

50

21,5

99

149

20,8

97

No

n-c

urr

en

t liab

ilit

ies

Lo

an

s(3

45)

0345

0

Pro

visio

ns

(129)

(123)

6(1

23)

To

tal n

on

-cu

rren

t liab

ilit

ies

(474)

(123)

6(1

23)

To

tal assets

em

plo

yed

20,9

76

21,4

76

155

20,7

74

Fin

an

ced

by (

taxp

ayers

' eq

uit

y)

Public

Div

idend C

apital

3,4

74

3,4

74

03,4

74

Reva

luation r

eserv

e14,1

26

14,1

26

014,1

26

Incom

e a

nd e

xpenditure

reserv

e3,3

75

3,8

76

501

3,1

74

To

tal ta

xp

ayers

' eq

uit

y20,9

75

21,4

76

501

20,7

74

Page 47 of 146


Item : 12

Title : Department of Education and Training Board Report

Purpose:

To update on issues in the Education & Training Service Line.

To report on issues considered and decisions taken by the

Training & Education Programme Management Board at its

meeting of 4th July 2016.

This report focuses on the following areas: (delete where not applicable)

Quality

Risk

Finance

Communications

For : Noting

From : Brian Rock, Director of Education and Training/Dean of

Postgraduate Studies

Tra

inin

g &

Edu

catio

n

Page 48 of 146

Department of Education and Training Board Report

1. Introduction

1.1 The Training and Education Programme Management Board met on

4th July 2016 and discussed the issues presented in this report.

2. QAA Review

2.1 The programme board was advised that our response to the QAA

draft report had been submitted and that we were awaiting the

final publication.

2.2 Overall the draft report indicated that the Trust has met all of the

four expectations in relation to the maintenance of academic

standards; the quality of student learning opportunities; the quality

of information around student learning opportunities; and the

enhancement of learning opportunities.

2.3 Our chosen theme was Digital Literacy.

2.4 We are expecting the report to be published in the week

commencing 18 July 2016.

3. Education Funding Reforms

3.1 The Department of Health’s consultation on Education Funding

Reforms ended on 30 June 2016.

3.2 Our Chair Paul Burstow made a submission to the consultation on

behalf of the organisation and the M80 programme.

3.3 It is yet unclear what the likely outcome of the consultation will be

for those professional trainings, such as the IAPT workforce, clinical

psychology, clinical scientists, and most importantly for us, child and

adolescent psychotherapy.

3.4 It has been important for the Trust to make a visible contribution

not least because of the importance of supporting staff who are

concerned about the possible implications.

Page 49 of 146

4. Student Recruitment Update

4.1 The current data since on student recruitment can be found in

Appendix 1. Headlines include;

4.1.1 There have been a further 274 applications since last month’s

board report bringing the total to 1030.

4.1.2 An additional 214 applications have been submitted bringing

the total to 659 with 371 incomplete.

4.1.3 An additional 110 offers have been accepted bringing the

total to 264.

4.2 A Saturday Open Day was held on 9th July 2016 and was well

attended, deploying a new format to these types of events that was

appreciated by the attendees; most of whom had not yet applied for

courses.

4.3 Brian Rock is currently in close discussion with Dominic Micklewright,

Dean of Academic Partnerships, Essex University about the possibility

of offering student loans to our students.

5. National Training Contract

5.1 The programme board discussed the continuing work that was

taking place in relation to the national strategy.

5.2 A task and finish group has been established, which includes

representatives from the Trust and Health Education England. Paul

Jenkins will be meeting with Liz Hughes, Director of Education &

Quality (London and the South East), bi-monthly to provide

oversight for the work of the task & finish group.

5.3 Paul Jenkins now chairs an internal NTC implementation group with

three related workstreams. These have been established to develop

proposals for the transformation of the NTC over the next 2-3 years.

These are:

5.3.1 Portfolio Review working group looking into how our

portfolio aligns with HEE priorities and where changes could

be made.

5.3.2 Educational Consultancy working group looking at how the

Trust could develop an Educational Consultancy to support

HEE.

Tra

inin

g &

Edu

catio

n

Page 50 of 146

5.3.3 Reporting and Outcomes working group looking at how we

monitor and report on the contract.

5.4 The working groups will be taking forward a number of areas

including:

5.4.1 The realignment of our training portfolio to better fit HEE

priorities.

5.4.2 Developing an educational consultancy

5.4.3 Improving mechanisms for performance and financial

monitoring.

5.5 Work continues to develop our national offer with visits taking place

this month to Pen Green and Gloucester Counselling Service.

6. Alumni

6.1 Laure Thomas advised the programme board that now that the new

website was live alumni events would start being added and that

alumni would be contacted through email and social media.

6.2 She confirmed that we do not have details for all those people that

have completed short courses but do have data for most people who

completed our long courses.

6.3 Part of the engagement with alumni at this initial stage will be to

survey what people would wish to see from an alumni function.

7. CEDU Update

7.1 Victoria Buyer presented a paper on the work of the Commercial

Engagement and Development Unit.

7.2 To date 63% or 34 of the new courses taken to the Course Approvals

and Implementation Team (CAIT) have run or are planned for this

summer/autumn term. 17 are in the planning phase or being

reworked following recommendations from the CAIT team.

7.3 CPD work needs to align with what we are doing across the

portfolio and that we need to ensure that we get the balance right

between encouraging creativity of ideas with some of the logistical

requirements of recruiting to and running a successful course.

Page 51 of 146

8. Strategic Objectives

8.1 The strategic objectives continue to be reviewed and have recently

been submitted for this quarter.

8.2 It was noted that the risk rating for student recruitment is currently

green.

Brian Rock Director of Education and Training/Dean of Postgraduate Studies 18

th July 2016

Tra

inin

g &

Edu

catio

n

Page 52 of 146

Appendix 1: Student recruitment as of 18

th July 2016

1030 applications

659 sumbitted

371 incomplete

Page 53 of 146

Board of Directors July 2016

Item : 13

Title : Q1 Dashboards

Purpose: The Trust dashboards were first reviewed at the April Trust Board. The

feedback was very positive and a small number of requests were made to

improve the presentation.

The Board will continue to receive the dashboard once a quarter.

The board is asked to consider

How would you sum up our performance overall?

What are the key points the board should note?

Are there any areas which require further investigation?

For : Discussion

From : Julia Smith, Commercial Director

Das

hboa

rds

Page 54 of 146

1. The Development of the Dashboards

The Dashboard has been developed further

As requested by the Board, the staff survey results in the Well Led and

Quality Safety Dashboards have been re-presented so that they are easier

to read.

We have introduced more data points for a number of items e.g. DNAs,

Experience of Service Questionnaire (ESQ) questions and information on

collection rates for ESQ.

We have introduced a friend and family benchmark for staff recommend

the Trust as a place to work.

It has not yet been possible to ‘band’ the bar chart on referral to first

attendance, by service.

The data is not fully validated. We are in the process of reviewing and finalising

our data validation process and agreeing a programme for systematic validation

of each data item. Therefore the dashboards come with a health warning.

The current informatics workload means that the ability to validate and develop

the dashboard further has been and is limited. Priorities and resources are

therefore being reviewed to ensure that this important work can be taken

forward.

2. Further improvements

Looking back at the Q4 Effective Dashboard, the outcome data between the

two quarters varies significantly. This set of data will be a priority for validation.

We also aim to change the presentation, so that you can see change over time

showing all quarters in a year, rather than just comparing the past quarter with

the same quarter in previous years.

3. Points to Note

Reach: The number of patient attendances YTD does not include services which

are not on CareNotes (i.e. Camden TAP, Mosaic and Early intervention Service).

The number of people we are helping via our patient services continues to

increase year on year, with the most significant increases being in Gender

Identify Development Service and Camden CAMHS.

Quality Well Led: Most indicators suggest the Trust is performing extremely well

in this domain and compares very favourably when benchmarked to other

Trusts. The quality of appraisals and staff training are two areas of concern.

Quality Safety: A drop in safeguarding alerts is noted.

Page 55 of 146

Quality Effective: The outcome data requires full validation. The data tells a

positive story.

Quality Responsive: The large numbers of patients who are waiting more than

11 weeks is primarily due to a significant increase in demand for our Gender

Identity Service. NHS England has increased funding significantly and a key aim

this year is to clear as much of the waiting list as possible.

Education and Training: Around the same number of applications were made

for longer courses, but we accepted a higher number than in previous years and

therefore we have a higher number of students than in previous years. There

was a drop in students who attended CPD and conferences in 2015-16. Student

feedback outlined indicates good outcomes and high levels of satisfaction.

4. What to focus on?

The temptation is focus on what data might be missing and how the data can

be further improved. Whilst these are important considerations, the priority

should be to reflect on what the data tells us. The questions you might

therefore want to ask are

How would you sum up our performance overall?

What are the key points the board should note?

Are there any areas which require further investigation?

Julia Smith

Commercial Director

18th July 2016

Das

hboa

rds

Page 56 of 146

Q1

– 2

016

/17

1

Das

hboa

rds

Page 57 of 146

Q1

– 2

016

/17

2

Page 58 of 146

Q1

– 2

016

/17

3

Das

hboa

rds

Page 59 of 146

Q1

– 2

016

/17

4

Page 60 of 146

Q1

– 2

016

/17

5

Das

hboa

rds

Page 61 of 146

Q1

– 2

016

/17

6

Page 62 of 146


Item : 14

Title : Quarterly Quality Report 2015-16 , Quarter 1

Summary: The report provides an update of the Key Performance Indicators (KPIs),

CQUIN and Quality Indicator targets for Quarter 1, 2016-17. The report

combines performance data reported to the Board and commissioners

(CQRG) for the main Trust contracts.

The Board is asked to note the commentary against a number of metrics

with a RED RAG status. Data has been validated by Director or Service

Leads. The direction in travel in data against Q4 2015/16 is denoted by an

arrow to provide greater understanding of issues.

In respect of Waiting Time data the Trustwide % has increased from 0.6%

in Q4 2015/16 to 10.1% in Q1. However, it should be noted that data

against the 8 week waiting time standard introduced from 1 April 2016

includes a number of cases referred during Q4 when the standard was 11

weeks. Both GIDS and City and Hackney (C&H) services have seen

increases. GIDS has increased from 250 patients waiting in Q4 to 427 in

Q1. C&H from 2.6% patients waiting in Q4 to 4% in Q1.

For Did Not Attend (DNA) rates there is also an increase for Trustwide

data from 7% in Q4 to 9.1% in Q1 and 11% in Q4 to 13.2% for C&H.

Core Scores show a decrease from 76% in Q4 to 64% in Q1 but this is

likely to increase significantly over the year. The recording of smoking

status, whilst not reaching the target of 80% has nevertheless increased

from 33.6% in Q4 to 50.7% in Q1. Additionally, the offer of interventions

to smokers has increased from 4% to 12.5%. The newly appointed

Physical Health Specialist Nurse commenced during Q1 and is taking the

lead on the physical health CQUIN.

This report has been reviewed by the following Committee:

Management Team, July 2016

The Board of Directors is asked to confirm whether this paper is accepted

as adequate assurance, and where not, whether the Board of Directors is

satisfied with the action plans that have been put in place.


Q1

Qua

lity

Rep

ort

Page 63 of 146

Quality


Safety

For : Noting

From : Marion Shipman, Associate Director of Quality and

Governance

Page 64 of 146

Tavis

tock

an

d P

ort

man

NH

S F

ou

nd

ati

on

Tru

st

Qu

art

erl

y Q

ua

lity

Rep

ort

fo

r B

oa

rd o

f D

ire

cto

rs &

CQ

RG

Q

ua

rte

r 1

: A

pri

l, M

ay &

Ju

ne

20

16

1

Q1

Qua

lity

Rep

ort

Page 65 of 146

Qu

ality

Key P

erf

orm

an

ce I

nd

icato

rs –

KPIs

ro

lled

over

fro

m last

fin

an

cial

year

Targ

et

Targ

et%

Pro

gre

ss

% P

rog

ress

for

2016/1

7 R

AG

Wait

ing

Tim

es

Wait

ing

tim

e n

o m

ore

th

an

8/1

1/1

8 w

eeks

(56/7

7/1

26 d

ays)

dep

en

den

t o

n s

erv

ice f

rom

rece

ipt

of

refe

rral)

. IN

TER

NA

L

BR

EA

CH

ES P

RESEN

TED

ON

LY

Q1

Q2

Q3

Q

4

Q1

Q2

Q3

Q4

N/%

Tru

stw

ide

N/%

Lo

nd

on

Co

ntr

act

ing

N/%

Tru

stw

ide

N/%

Lo

nd

on

Co

ntr

act

ing

N/%

Tru

stw

ide

N/%

Lo

nd

on

Co

ntr

act

ing

N/%

Tru

stw

ide

N/%

Lo

nd

on

Co

ntr

act

ing

To

tal w

ait

ers

*

1st

Ap

ril 16=

< 8

weeks-

56 d

ays

(th

resh

old

1-

10%

)

75 / 1

0.1

%

73 / 1

3.0

%

Ad

ole

scen

t Serv

ice**

9 / 1

4.3

%

9 / 1

4.3

%

Cam

den

CA

MH

S**

44 / 1

3.4

%

44 / 1

7.6

%

Oth

er

CA

MH

S**

15 / 8

.4%

15 / 1

3.0

%

Ad

ult

Serv

ice

< 1

1 w

eeks-

77 d

ays

(th

resh

old

1-

5%

5 / 3

.7%

5 / 3

.7%

NH

S E

ng

lan

d P

ort

man

0 / 0

%

NH

S E

ng

lan

d G

IDS

< 1

8 w

eeks-

126 d

ays

(th

resh

old

1-

10%

)

427 / 6

6.2

%

Cit

y &

Hack

ney

13 / 4

.0%

West

min

ster

Serv

ice

< 6

weeks-

42 d

ays

2 / 1

1.1

%

Cam

den

TA

P

<

2 w

eeks-

14 d

ays

n/a

Se

ctio

n O

ne

: K

PIs

fo

r T

PFT

2

*P

lea

se n

ote

To

tal w

ait

ers

da

ta i

ncl

ud

es

Ad

ole

sce

nt,

Ca

md

en

CA

MH

S,

Oth

er

CA

MH

S,

We

stm

inst

er,

Ad

ult

an

d P

ort

ma

n s

erv

ices.

*

*P

lea

se n

ote

th

at

9 p

ati

en

ts in

Ad

ole

sce

nt

serv

ice,

12

in

Ca

md

en

CA

MH

S a

nd

2 i

n O

the

r C

AM

HS w

ere

refe

rre

d b

efo

re t

he

1 A

pri

l a

nd

th

ere

fore

we

re s

ub

ject

to

th

e 1

1 w

ee

k w

ait

tim

e w

ind

ow

. T

he

ca

ses

we

re s

ee

n w

ith

in t

his

tim

efr

am

e. A

s th

ese

ca

ses

we

re s

ee

n a

fte

r th

e 1

Ap

ril,

th

e n

ew

wa

it t

ime

pa

ram

ete

rs h

ave

be

en

im

ple

me

nte

d t

he

refo

re s

ho

win

g t

his

case

as

a b

rea

ch.

Page 66 of 146

Qu

ality

Key P

erf

orm

an

ce I

nd

icato

rs –

KPIs

ro

lled

over

fro

m last

fin

an

cial

year

Targ

et

Targ

et%

Pro

gre

ss

% P

rog

ress

for

2016/1

7 R

AG

DN

A

DN

A r

ate

s: Y

earl

y

avera

ge n

o larg

er

than

10%

.

no

larg

er

than

10%

.

Q1

Q2

Q3

Q4

Q 1

Q 2

Q3

Q 4

% T

rust

wid

e

%

Lo

nd

on

Co

ntr

act

ing

% T

rust

wid

e

%

Lo

nd

on

Co

ntr

act

ing

%

Tru

stw

ide

%

Lo

nd

on

Co

ntr

act

ing

%

Tru

stw

ide

%

Lo

nd

on

Co

ntr

act

ing

9.1

%

9.1

%

To

tal Tru

st D

NA

Ad

ole

sce

nt

Serv

ice

10.7

%

10.6

%

Cam

den

CA

MH

S

10.4

%

11.2

%

Oth

er

CA

MH

S

5.7

%

5.1

%

Ad

ult

Serv

ice

8.5

%

8.4

%

Cit

y &

Hack

ney

13.2

%

West

min

ster

Serv

ice

7.0

%

Cam

den

TA

P

n/a

NH

S E

ng

lan

d P

ort

man

6.8

%

NH

S E

ng

lan

d G

IDS

9.2

%

Se

ctio

n O

ne

: K

PIs

fo

r T

PFT

3

Co

mm

en

tary

fee

db

ack

fro

m S

erv

ice L

ea

ds:

C

ity &

Hack

ne

y S

erv

ice

(T

im K

en

t):

Th

e P

CP

CP

S s

erv

ice i

s co

mm

issi

on

ed

to

wo

rk w

ith

‘h

ard

to

re

ach

pa

tie

nts

’ w

ho

ha

ve

co

mp

lex n

ee

ds

of

co-m

orb

id M

US,

Pe

rso

na

lity

Dis

ord

er

an

d l

on

g t

erm

me

nta

l h

ea

lth

pro

ble

ms.

As

a r

esu

lt D

NA

le

ve

ls h

ave

alw

ays

be

en

ove

r 1

0%

an

d t

he

cu

rren

t le

ve

l in

dic

ate

d is

a r

ed

uct

ion

in

DN

A.

Co

ntr

act

le

ve

l ta

rge

ts d

o n

ot

dif

fere

nti

ate

be

twe

en

typ

es

of

serv

ice a

nd

w

ha

t w

ou

ld b

e a

rea

son

ab

le le

ve

l o

f D

NA

to

exp

ect

as

a b

ase

lin

e. I

n t

his

se

rvic

e 1

3%

co

mp

are

d t

o h

isto

rica

l tr

en

ds

is a

n im

pro

ve

me

nt.

T

ota

l T

rust

DN

A r

ate

of

9.1

% h

as

incr

ea

sed

fro

m 7

% in

Q4 2

01

5/1

6 a

nd

th

e C

ity a

nd

Hack

ne

y r

ate

ha

s in

crea

sed

fro

m 1

1%

in

Q4

20

15

/16

.

Q1

Qua

lity

Rep

ort

Page 67 of 146

Qu

ality

Key P

erf

orm

an

ce I

nd

ica

tors

– K

PIs

ro

lled

ov

er

fro

m l

ast

fin

an

cial

year

Targ

et

Mo

nit

ori

ng

Targ

et%

Pro

gre

ss

% P

rog

ress

for

2016/1

7

Q1

Q2

Q

3

Q4

Q

1

Q2

Q3

Q4

Pati

en

t Sati

sfact

ion

(Q

15 f

rom

ESQ

)

Pati

en

t Sati

sfact

ion

: Targ

et

92%

or

mo

re r

ep

ort

sati

sfie

d w

ith

th

e s

erv

ice

Qu

art

erl

y

92%

N

%

N

%

N

%

N

%

264

93%

Pers

on

al D

evelo

pm

en

t Pla

n

Qu

ality

an

d D

evelo

pm

en

t o

f st

aff

: Targ

et

90%

of

staff

to

have a

PD

P.

Qu

art

erl

y

90%

99%

Sic

kn

ess

an

d A

bse

nce

Sic

kn

ess

an

d a

bse

nce

rate

s.

Targ

et:

<2%

gre

en

(2

-6%

am

ber,

>6%

red

) 6 m

on

thly

<

2%

Sta

ff T

rain

ing

*

% o

f st

aff

wit

h u

p-t

o-d

ate

man

dato

ry t

rain

ing

fo

r in

fect

ion

co

ntr

ol. Targ

et

>95%

gre

en

. 80-9

5%

is

am

ber

< o

r =

80%

red

. A

nn

ua

lly

>9

5%

Tru

st S

erv

ice c

an

cellati

on

rate

s

Targ

et:

<

5%

gre

en

(5

-9%

am

ber,

>10%

red

) Q

uart

erl

y

<5%

2.3

%

Se

ctio

n O

ne

: K

PIs

fo

r T

PFT

4

*P

lea

se n

ote

th

at

the

Tru

st d

eli

ve

rs m

an

da

tory

tra

inin

g v

ia I

NSE

T d

ay i

n Q

1 a

nd

Q3

ea

ch y

ea

r.

Page 68 of 146

Qu

ality

Key P

erf

orm

an

ce I

nd

icato

rs

Targ

et

Mo

nit

ori

ng

Targ

et

%

Pro

gre

ss

% P

rog

ress

for

2016/1

7

Q1

Q

2

Q3

Q

4

Q1

Q

2

Q3

Q

4

Exp

lan

ati

on

of

Serv

ice (

Q6 in

ESQ

)

Nu

mb

er

an

d %

of

child

ren

wh

o a

nsw

er

cert

ain

ly a

gre

e t

hat

they

rece

ived

a c

lear

exp

lan

ati

on

of

serv

ice

Qu

art

erl

y

75%

N

%

N

%

N

%

N

%

11

9

77

%

Care

Pla

ns

A -

% o

f ca

re p

lan

s evid

en

cin

g c

o-p

rod

uct

ion

wit

h s

erv

ice u

sers

6 m

on

thly

80%

B -

%

of

care

pla

ns

wh

ere

th

e p

lan

has

been

sh

are

d w

ith

th

e G

P,

wh

ere

co

nse

nt

has

been

giv

en

.

KP

Is f

or

TP

FT

5

Q1

Qua

lity

Rep

ort

Page 69 of 146

6

Qu

ality

Key P

erf

orm

an

ce I

nd

icato

rs

Targ

et

Mo

nit

ori

ng

Targ

et

%

Pro

gre

ss

% P

rog

ress

for

2016/1

7

Q1

Q

2

Q3

Q

4

Q1

Q

2

Q3

Q

4

Co

mp

lain

ts

% R

esp

on

se t

o C

om

pla

ints

A -

90%

of

com

pla

ints

ack

no

wle

dg

ed

wit

hin

3 w

ork

ing

days.

Qu

art

erl

y

>9

0%

0

B -

80%

of

com

pla

ints

resp

on

ded

to

wit

hin

25 w

ork

ing

days.

>

80%

50%

(3/6

)*

C -

Ach

ieve a

do

wn

ward

tra

ject

ory

of

nu

mb

er

of

com

pla

ints

that

have a

co

nce

rn a

bo

ut

staff

att

itu

de b

y e

nd

of

Qu

art

er

3

n/a

n

/a

D -

100%

of

up

held

co

mp

lain

ts i

den

tify

learn

ing

an

d

imp

rovem

en

ts a

s a r

esu

lt.

100%

100%

E -

Tre

nd

s an

d t

hem

es

of

PA

LS c

on

cern

s an

d c

om

pla

ints

iden

tifi

ed

an

d p

ub

lish

ed

on

a q

uart

erl

y b

asi

s.**

n

/a

Ach

ieved

F -

Im

ple

men

tati

on

of

act

ion

s p

lan

n

/a

A

chie

ved

Co

mp

lain

ts a

nd

Cla

ims

A -

Pro

vid

e q

uart

erl

y c

om

pla

ints

an

d c

laim

s u

pd

ate

to

in

clu

de:

i) n

o. o

f co

mp

lain

ts w

here

resp

on

se is

ou

tsta

nd

ing

at

3 m

on

ths

an

d r

easo

ns

wh

y

Qu

art

erl

y

n/a

0

ii)

Nu

mb

er

of

com

pla

ints

rep

ort

ed

to

CQ

C

0

iii)

Nu

mb

ers

of

com

pla

ints

part

ially a

nd

fu

lly u

ph

eld

by

Parl

iam

en

tary

Om

bu

dsm

an

0

iv)

Nu

mb

er

of

re-o

pen

ed

co

mp

lain

ts.

0

v)

all leg

al cl

aim

s ack

no

wle

dg

ed

wit

hin

14 d

ays

n/a

KP

Is N

CL T

rust

s

*In

Q1

th

ere

we

re 1

2 c

om

pla

ints

rece

ive

d b

y t

he

Tru

st w

ith

six

co

mp

lain

t re

spo

nse

s n

ot

du

e a

t th

e e

nd

of

the

qu

art

er.

Dela

ys

in f

ina

l re

spo

nse

fo

r tw

o c

om

pla

ints

we

re d

ue

to

th

e le

ng

th o

f in

tern

al

inve

stig

ati

on

s. B

oth

co

mp

lain

an

ts w

ere

ke

pt

info

rme

d. In

on

e c

ase

th

ere

wa

s d

ela

y in

ag

ree

ing

ap

pro

pri

ate

in

ve

stig

ato

r a

nd

th

e r

esp

on

se w

as

ove

rdu

e b

y 1

da

y. *

*Se

e C

orp

ora

te G

ove

rna

nce

an

d

Pa

tie

nt

Sa

fety

Ris

k r

ep

ort

fo

r C

om

pla

ints

in

form

ati

on

an

d t

he

PA

LS r

ep

ort

, w

hic

h w

ill

go

to

th

e C

lin

ical Q

ua

lity

an

d P

ati

en

t E

xp

eri

en

ce W

ork

stre

am

in

Ju

ly.

Page 70 of 146

7

Qu

ality

Key P

erf

orm

an

ce I

nd

icato

rs

Targ

et

Mo

nit

ori

ng

Targ

et

%

Pro

gre

ss

% P

rog

ress

fo

r 2016/1

7

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

B -

Pro

vid

e b

i-an

nu

al co

mp

lain

ts a

nd

cla

ims

less

on

s le

arn

t re

po

rt w

ith

: i)

Th

em

es

of

less

on

s le

arn

t in

clu

din

g b

reakd

ow

n o

f cl

inic

al

po

licy

/clin

ical

path

way a

reas

wh

ere

com

pla

ints

are

mad

e

6 M

on

thly

n

/a

ii)

Deta

il o

f act

ion

s u

nd

ert

aken

as

a r

esu

lt o

f co

mp

lain

ts

Seri

ou

s In

cid

en

ts

Imp

rovem

en

t tr

aje

cto

ry a

gre

ed

fo

r th

e f

ollo

win

g:

A-

No

. o

f Seri

ou

s In

cid

en

ts (

SI)

su

bm

itte

d w

ith

in t

he d

esi

gn

ate

d t

imesc

ale

Mo

nth

ly

n/a

Ap

ril

16

M

ay

16

Ju

ne

16

0

0

0

B -

Wh

ere

SI

rep

ort

s are

retu

rned

in

com

ple

te, %

retu

rned

co

mp

lete

wit

hin

10

wo

rkin

g d

ays.

Q

uart

erl

y

0

C -

Evid

en

ce o

f im

ple

men

tati

on

of

act

ion

pla

ns

6 M

on

thly

Au

dit

D -

Org

an

isati

on

al le

arn

ing

id

en

tifi

ed

an

d a

ctio

ns

em

bed

ded

as

a r

esu

lt i

n 1

00%

of

SIs

. Q

4

Safe

gu

ard

ing

Co

mp

leti

on

an

d s

ub

mis

sio

n o

f th

e N

CL S

afe

gu

ard

ing

Ch

ild

ren

an

d A

du

lt M

etr

ics

Retu

rn

Qu

art

erl

y

n/a

T

o b

e r

etu

rne

d b

y

1st A

ug

ust

.

Fem

ale

Gen

ital M

uti

lati

on

*

A -

To

in

clu

de F

GM

as

part

of

man

dato

ry s

afe

gu

ard

ing

tra

inin

g levels

1, 2 &

3, 80%

of

staff

will

be t

rain

ed

in

safe

gu

ard

ing

Qu

art

erl

y

80%

L1

: n

/a

L1

: n

/a

L1

: n

/a

L1

: n

/a

L2

: 9

2%

L2

:

L2

:

L2

:

L3

: 9

3%

L3

: L3

: L3

:

B -

Safe

gu

ard

ing

ale

rts

rais

ed

an

d n

um

ber

cou

nte

d w

ith

in s

erv

ice i

n a

cco

rdan

ce w

ith

NIC

E g

uid

an

ce *

*

n/a

3 A

du

lt S

G A

lert

s

7 C

hil

dre

n S

G

Ale

rts

KP

Is N

CL T

rust

s

*A

t le

vels

2 &

3 o

f sa

feg

ua

rdin

g t

rain

ing

, cl

inic

al st

aff

are

tra

ine

d a

t as

ba

sic

level o

f aw

are

ne

ss f

or

FG

M, as

con

sid

ere

d a

pp

rop

riate

fo

r m

en

tal h

ealt

h s

taff

.

** R

esu

lts

pu

bli

shed

in

Q1 C

orp

ora

te G

overn

an

ce a

nd

Pati

en

t Safe

ty a

nd

Ris

k C

om

pli

an

ce R

ep

ort

Q1

Qua

lity

Rep

ort

Page 71 of 146

8

Qu

ali

ty K

ey

Pe

rfo

rma

nce

In

dic

ato

rs

Ta

rge

t M

on

ito

rin

g

Ta

rge

t %

P

rog

ress

%

Pro

gre

ss f

or

20

16

/17

Q1

Q

2

Q3

Q

4

Q1

Q

2

Q3

Q

4

Co

mp

lia

nce

Co

mp

lia

nce

wit

h r

ele

va

nt

stan

da

rds

of

the

Me

nta

l C

ap

aci

ty

Act

are

co

mp

lete

d a

nd

DO

L a

pp

lica

tio

ns

an

d o

utc

om

es.

*

Q3

50

%

au

dit

ed

case

s b

y Q

3

Au

dit

of

Tru

st C

on

sen

t P

oli

cy s

tan

da

rds

To

pe

rfo

rm a

n a

ud

it o

n 2

0 p

ati

en

t n

ote

s in

Q2.

Q

2 A

ud

it

n/a

Ass

ess

me

nt

Re

po

rts

Pro

vid

e C

CG

s w

ith

a c

op

y o

f a

ll in

tern

al p

roce

ss a

nd

com

pli

an

ce a

sse

ssm

en

t re

po

rts,

act

ion

pla

ns

an

d p

rog

ress

up

da

tes

Qu

art

erl

y

n/a

P

leas

e n

ote

evi

den

ce o

f A

sses

smen

t R

epo

rts

are

sub

mit

ted

to

reg

ula

r C

QR

G M

eeti

ngs

.

Cli

nic

al A

ud

it

A -

Pro

vid

e C

CG

s w

ith

co

py o

f T

rust

wid

e a

ud

it p

rog

ram

me

in

Q2

.

Q2

Au

dit

n/a

B -

Pro

vid

e C

CG

s w

ith

bi-

an

nu

al fi

nd

ing

s a

nd

reco

mm

en

da

tio

ns

of

au

dit

s ca

rrie

d o

ut,

evid

en

ce o

f a

ctio

n

pla

ns

an

d B

oa

rd In

vo

lve

me

nt

6 M

on

thly

Au

dit

C -

Pro

vid

e C

CG

s w

ith

co

pie

s o

f C

lin

ica

l A

ud

it A

nn

ua

l re

po

rt t

o

incl

ud

e le

arn

ing

th

e l

ess

on

s fr

om

au

dit

, d

em

on

stra

tin

g

ach

ieve

me

nt

of

ou

tco

me

s

An

nu

al

Re

po

rtin

g o

n G

uid

eli

ne

s

Re

po

rt o

n c

om

pli

an

ce w

ith

ne

w r

ele

va

nt

NIC

E C

lin

ical

Gu

ide

lin

es,

Qu

ali

ty S

tan

da

rds

an

d T

ech

no

log

y a

pp

rais

als

wit

hin

3 m

on

ths

of

pu

bli

cati

on

da

te.

6 M

on

thly

n

/a

Ma

nd

ato

ry T

rain

ing

**

% o

f e

lig

ible

sta

ff a

re c

urr

en

tly c

om

pli

an

t o

n a

ll o

f th

eir

ma

nd

ato

ry t

rain

ing

Qu

art

erl

y

80

%

94

%

En

ha

nce

d D

BS

ch

eck

s

% o

f st

aff

th

at

req

uir

e a

n E

nh

an

ced

DB

S c

he

ck a

nd

ha

ve

on

e

wit

hin

th

e 3

ye

ar

ren

ew

al p

eri

od

Q

ua

rte

rly

1

00

%

96

%

KP

Is N

CL T

rust

s

*Th

e T

rust

to

pro

vid

e 1

1 M

CA

tra

inin

g d

ate

s to

sta

ff o

ver

the c

ou

rse o

f 2016/1

7

Page 72 of 146

9

Qu

ality

Key P

erf

orm

an

ce I

nd

icato

rs

Targ

et

Mo

nit

ori

ng

Targ

et

%

Pro

gre

ss

% P

rog

ress

fo

r 2016/1

7

Q1

Q

2

Q3

Q

4

Q1

Q

2

Q3

Q

4

Sta

ff F

FT a

nd

An

nu

al

Sta

ff S

urv

ey T

o Im

pro

ve t

raje

cto

ry f

rom

15/1

6 b

ase

lin

e a

nd

pro

vid

e o

rgan

isati

on

al

resp

on

se t

o r

esu

lts

Last

year

resu

lt:

Fu

lly a

chie

ved

fo

r Q

1, Q

2 a

nd

Q4

Qu

art

erl

y

n/a

Incr

ease

d r

esp

on

se

rate

26

.4%

com

par

ed t

o Q

1

20

15

/16

(11

.9%

)

Fri

en

ds

an

d F

am

ily T

est

(Pati

en

t te

st -

fro

m E

xp

eri

en

ce o

f Su

rvey

Qu

est

ion

nair

e)

(Q11 in

ESQ

)

i) %

of

po

siti

ve r

esp

on

ses

on

th

e F

FT

Q

uart

erl

y

80%

1

01

ret

urn

s /

92

%

ii)

Pro

vid

e a

th

em

ati

c an

aly

sis

of

neg

ati

ve f

eed

back

(u

nlikely

an

d

very

un

likely

resp

on

ses)

an

d e

vid

en

ce o

f o

rgan

isati

on

al le

arn

ing

in r

esp

on

se t

o a

dd

ress

ing

neg

ati

ve f

eed

back

n/a

PP

I Rep

ort

to

be

avai

lab

le b

y 2

2n

d

July

20

16

Sta

ff A

pp

rais

als

Nu

mb

er

of

Sta

ff A

pp

rais

als

co

mp

lete

d

Qu

art

erl

y

80%

9

9%

Du

ty o

f C

an

do

ur

A -

100%

of

con

vers

ati

on

s in

form

ing

pati

en

ts a

nd

/or

fam

ily t

hat

a

pati

en

t sa

fety

in

cid

en

t h

ave t

aken

pla

ce w

ith

in 1

0 w

ork

ing

days

of

the in

cid

en

t b

ein

g r

ep

ort

ed

to

lo

cal

risk

man

ag

em

en

t sy

stem

s

for

Med

ium

harm

, Severe

Harm

, D

eath

or

Pro

fou

nd

Psy

cho

log

ical

Harm

cate

go

ries

of

inci

den

ts;

an

d a

n a

po

log

y h

as

been

giv

en

.

Qu

art

erl

y

100%

0 t

o r

epo

rt

B -

100%

of

inci

den

t in

vest

igati

on

rep

ort

s sh

are

d w

ith

in 1

0

wo

rkin

g d

ays

of

bein

g s

ign

ed

off

as

com

ple

te a

nd

th

e in

cid

en

t

clo

sed

by t

he r

ele

van

t au

tho

rity

fo

r M

ed

ium

Harm

, Severe

Harm

,

Death

or

Pro

fou

nd

Psy

cho

log

ical

Harm

cate

go

ries

of

inci

den

ts.

0 t

o r

epo

rt

KPIs

NC

L T

rust

s

Q1

Qua

lity

Rep

ort

Page 73 of 146

10

Qu

ality

Key P

erf

orm

an

ce I

nd

ica

tors

Targ

et

Mo

nit

ori

ng

Targ

et%

Pro

gre

ss

% P

rog

ress

for

2016/1

7

Q1

Q

2

Q3

Q

4

Q1

Q

2

Q3

Q

4

GP s

ati

sfact

ion

wit

h c

om

mu

nic

ati

on

rece

ived

fro

m T

rust

s

> a

bo

ve 6

0%

of

GPs

wh

o r

esp

on

d t

o b

e s

ati

sfie

d w

ith

co

mm

un

icati

on

fro

m M

H T

rust

Serv

ices

An

nu

al

>60%

G

P s

atis

fact

ion

su

rvey

to

be

sen

d o

ut

in S

epte

mb

er.

Lo

cal

part

icip

ati

on

in

Su

icid

e P

reven

tio

n

Tru

st w

ill co

mp

ly w

ith

req

uir

em

en

ts o

n M

en

tal

Healt

h T

rust

s o

utl

ined

in t

he N

ati

on

al Su

icid

e P

reven

tio

n S

trate

gy (

2012)

Qu

art

erl

y

n/a

A

chie

ved

Clin

ical R

isk A

ssess

men

ts

An

nu

al A

ud

it p

rese

nte

d t

o C

QR

G

An

nu

al A

ud

it

n/a

Ad

here

nce

to

Cri

sis

Co

nco

rdat

stan

dard

s

Imp

rovem

en

t fr

om

2015/1

6 b

ase

lin

e

An

nu

al

n/a

Cri

sis

Co

nco

rdat

stan

dard

s -

Cri

sis

pla

n

i) p

erc

en

tag

e o

f p

ati

en

ts w

ho

have b

een

off

ere

d a

cri

sis

pla

n f

or

em

erg

en

cy m

en

tal h

ealt

h s

itu

ati

on

s

6 m

on

thly

n

/a

ii)

resp

on

se t

ime a

nd

% w

ith

in t

arg

et

for

MH

cri

sis

team

iii)

iii)

nu

mb

er

of

CA

ISS a

vo

idab

le a

dm

issi

on

s to

CA

MH

S T

ier

4 s

erv

ices

Eq

uality

an

d D

ivers

ity -

BM

E a

ccess

to

'ta

lkin

g therapies’

Perc

en

tag

e B

ME a

ccess

to

'ta

lkin

g t

hera

pie

s' (

Base

lin

e in

2015/1

6)

Qu

art

erl

y

n/a

Q

1:

42.3

% B

ME

NIC

E g

uid

an

ce -

Bip

ola

r D

iso

rder

(CG

185, Sep

t 2014)

-

CB

T/p

sych

olo

gic

al

treatm

en

t

Base

lin

e in

2015/1

6, P

rop

ort

ion

of

pati

en

ts w

ith

a d

iag

no

sis

of

bip

ola

r

dis

ord

er

off

ere

d C

BT/p

sych

olo

gic

al

treatm

en

t

Qu

art

erl

y

n/a

1

00%

(7 p

ati

en

ts o

ut

of

3151 p

ati

en

ts)

KPIs

Men

tal H

ealt

h T

rust

s

Page 74 of 146

11

Targ

et

Deta

il o

f in

dic

ato

r R

ep

ort

ed

Perf

orm

an

ce

at

Q1

Targ

et

%

Pro

gre

ss

Q1

RA

G

Q2

RA

G

Q3

RA

G

Q4

RA

G

Ch

ild

ren

Yo

un

g A

du

lt

an

d F

am

ilie

s

(CY

AF)

(Ou

tco

me

mo

nit

ori

ng

)

Fo

r 80%

of

pati

en

ts (

att

en

din

g C

AM

HS w

ho

qu

alify

fo

r

the

CQ

UIN

) to

co

mp

lete

th

e

Go

al-

Base

d

Measu

re

(GB

M)

at

Tim

e 1

an

d a

fter

six m

on

ths

or,

if

earl

ier,

at

the e

nd

of

thera

py/t

reatm

en

t (k

no

wn

as

Tim

e 2

).

Q1-Q

4

n/a

th

is

qu

art

er

8

0%

U

nab

le t

o r

ep

ort

in

Q1 b

eca

use

Tim

e 2

data

no

t

availab

le y

et.

Pro

gre

ss c

an

on

ly b

e r

ep

ort

ed

fo

r th

is

ind

icato

r fr

om

Q2.

Ch

ild

ren

Yo

un

g A

du

lt

an

d F

am

ilie

s

(CY

AF)

(Ou

tco

me

mo

nit

ori

ng

)

Fo

r 80%

o

f p

ati

en

ts

wh

o

com

ple

te

the

Go

al-

Base

d

Measu

re (G

BM

) to

a

chie

ve

an

im

pro

vem

en

t in

th

eir

sco

re o

n t

he G

BM

, fr

om

Tim

e 1

to

Tim

e 2

, o

n a

t le

ast

two

targ

ets

(g

oals

).

Q1-Q

4

n/a

th

is

qu

art

er

80%

U

nab

le to

re

po

rt in

Q

1 b

eca

use

Tim

e 2 d

ata

n

ot

availab

le y

et.

Pro

gre

ss c

an

on

ly b

e r

ep

ort

ed

fo

r th

is

ind

icato

r fr

om

Q2.

AD

ULT &

Ad

ole

scen

t

an

d Y

ou

ng

Ad

ult

(Ou

tco

me

Mo

nit

ori

ng

)

70%

to

tal

CO

RE

sco

res

to

ind

icate

an

im

pro

vem

en

t

fro

m

Pre

-ass

ess

men

t (T

ime

1)

to

En

d

of

Tre

atm

en

t

(Tim

e 2

) fo

r 50%

of

pati

en

ts.

Q1-Q

4

64

% c

om

bin

ed

(AYA

=5

6%

,

Ad

ult

=1

00

%)

70%

A

chie

ved

targ

et:

Im

pro

vem

en

t ra

te f

or

peri

od

Ap

ril 1

st 2

016 –

30

th J

un

e 2

016

: A

du

lt a

nd

Ad

ole

scen

t (c

om

bin

ed

) =

64%

Imp

rovem

en

t b

y in

div

idu

al

serv

ices:

Ad

ole

scen

ts =

56%

*

Ad

ult

s =

100%

Ou

tco

me M

on

ito

rin

g K

PI Ta

rgets

*Th

is c

om

pare

s w

ith

76%

fo

r Q

4 2

015/1

6.

Q1

Qua

lity

Rep

ort

Page 75 of 146

12

Ph

ysi

cal H

ea

lth

KP

I Ta

rge

ts

Tru

stw

ide, Pati

en

ts A

ge 1

4+

ass

ess

ed

by a

Ph

ysi

cal H

ealt

h F

orm

– E

xcl

ud

ing

Po

rtm

an

an

d G

IDS

Ta

rge

t D

eta

il o

f in

dic

ato

r R

ep

ort

ed

P

erf

orm

an

ce a

t Q

1

Ta

rge

t

%

Pro

gre

ss

Q1

RA

G

Q2

RA

G

Q3

RA

G

Q4

RA

G

PH

YSIC

AL

HEA

LT

H –

Sm

ok

ing

Ce

ssa

tio

n

80

% o

f p

ati

en

ts h

ave

sm

ok

ing

sta

tus

reco

rde

d

Q1

-Q4

5

0.7

0%

*

80

%

All p

ati

en

ts a

ge

d 1

4+

th

at

att

en

de

d f

irst

ap

po

intm

en

t in

Q1 =

37

5

Of

the

se,

19

0 h

av

e t

he

ir s

tatu

s re

cord

ed

(5

0.7

%)

Of

the

se, 5

9 h

ave

sm

ok

ing

sta

tus

= ‘ye

s’ (

59

/19

0 =

31

%)

18

5 p

ati

en

ts h

ave

no

re

cord

of

smo

kin

g s

tatu

s (4

9.3

%).

50

% o

f sm

ok

ers

ha

ve

be

en

off

ere

d

inte

rve

nti

on

(e

.g. N

RT

, b

rie

f a

dvic

e,

etc

.).

Q1

-Q4

1

2.5

%*

5

0%

O

ut

of

the

48

sm

ok

ers

, 6

we

re g

ive

n b

rie

f a

dvic

e (

12

.5%

). 5

ou

t o

f th

e 4

8 s

mo

ke

rs w

an

ted

he

lp t

o q

uit

(9

.3%

). 4

ou

t o

f th

e 5

wh

o w

an

ted

to

he

lp q

uit

we

re r

efe

rre

d t

o t

he

ph

ysi

cal

he

alt

h n

urs

e (

80

%).

*Th

is c

om

pa

res

wit

h 3

3.6

% r

eco

rdin

g s

mo

kin

g s

tatu

s an

d 4

% o

fferi

ng

bri

ef

ad

vic

e f

or

Q4 2

015/1

6.

Mo

nth

ly T

eam

rep

ort

s o

n p

hysi

cal h

ealt

h f

orm

co

mp

leti

on

are

be

ing

sen

t o

ut

fro

m J

uly

2016 t

o in

crease

aw

are

ne

ss o

f ra

tes

an

d

incr

ease

co

mp

leti

on

.

Page 76 of 146

13

CA

MH

S T

ran

sfo

rma

tio

n K

PI Ta

rge

ts

Ta

rge

t D

eta

il o

f in

dic

ato

r R

ep

ort

ed

P

erf

orm

an

ce a

t Q

1

Ta

rge

t

%

Pro

gre

ss

CA

MH

S

Tra

nsf

orm

ati

on

Ta

rge

ts

80

% C

are

pla

ns

revie

we

d e

ve

ry 6

mo

nth

s

(jo

intl

y d

eve

lop

ed

wit

h y

ou

ng

pe

op

le;

incr

ea

sed

evid

en

ce o

f co

lla

bo

rati

ve

wo

rkin

g)

by M

arc

h 2

01

9.

Q1

-Q4

8

0%

80

% c

om

ple

ted

ca

re p

lan

s (b

y M

arc

h

20

18

)

Q1

-Q4

8

0%

70

% o

f C

YP

on

pa

ed

iatr

ic w

ard

s se

en

by

com

mu

nit

y C

AM

HS w

ith

in 2

4 h

ou

rs o

f

rece

ipt

of

a r

efe

rra

l (M

on

da

y t

o F

rid

ay)

by M

arc

h 2

01

8

Q1

-Q4

70

%

Th

is t

ask

wil

l fa

ll t

o t

he

Ca

md

en

In

ten

sive

Su

pp

ort

Se

rvic

e,

bu

t th

ey a

re n

ot

full

y s

taff

ed

ye

t. R

ecr

uit

me

nt

sho

uld

be

co

mp

lete

by N

ove

mb

er

17

. T

he

n t

his

ta

sk w

ill

be

act

ion

ed

. N

ee

d t

o h

ave

a p

roto

col

wri

tte

n a

nd

rep

ort

ing

me

tho

d a

gre

ed

. T

he

se t

ask

s a

re in

th

e w

ork

p

lan

85

% C

YP

in

re

leva

nt

serv

ices

(CA

MH

S i

n

CSF i

nte

gra

ted

serv

ice)

rep

ort

ing

'cert

ain

ly t

rue

' o

r 'p

art

ly t

rue

' to

CH

I-ESQ

qu

est

ion

7 (

'I f

ee

l th

at

the

pe

op

le w

ho

ha

ve

see

n m

e a

re w

ork

ing

to

ge

the

r to

he

lp m

e')

by M

arc

h 2

01

8

Q1

-Q4

85

%

Re

po

rt h

as

be

en

req

ue

sted

by h

as

no

t b

ee

n d

on

e y

et.

We w

ill

then

ge

t a

ba

seli

ne

. W

e w

ill

alm

ost

ce

rta

inly

fin

d t

ha

t th

ere

are

ve

ry f

ew

ESQ

s d

on

e in

th

e C

SF i

nte

gra

ted

serv

ice,

so

pa

rt o

f th

e w

ork

pla

n is

for

the

serv

ice m

an

ag

ers

, te

am

ma

na

ge

rs a

nd

ad

min

istr

ato

rs t

o

wo

rk t

og

eth

er

to w

ork

ou

t a

wa

y o

f in

cre

asi

ng

th

e n

um

be

r o

f yo

un

g p

eo

ple

an

d f

am

ilie

s w

ho

are

ask

ed

to

do

th

e E

SQ

85

% r

esp

on

din

g p

osi

tive

ly t

o n

ew

Inte

gR

AT

E m

ea

sure

by M

arc

h 2

01

8 (

to b

e

fin

ali

sed

w

ith

th

e c

om

mis

sio

ne

r fo

r in

-

ye

ar

rep

ort

ing

)

Q1

-Q4

85

%

Th

is is

a n

ew

me

asu

re a

nd

wil

l n

ee

d t

o b

e t

ria

lle

d w

ith

in t

he

LA

. P

lan

is

to l

iais

e w

ith

D

art

mo

uth

in

th

e U

SA

an

d d

eve

lop

a v

ali

da

tio

n e

xe

rcis

e. T

he

targ

et

is t

o g

et

this

wo

rk

do

ne

by t

he

en

d o

f M

arc

h 2

01

7

Q1

Qua

lity

Rep

ort

Page 77 of 146

14

CQ

UIN

S -

1. N

HS

Staf

f h

ealt

h a

nd

wel

lbei

ng

CQ

UIN

s

Ta

rge

t D

eta

il o

f in

dic

ato

r R

ep

ort

ed

T

arg

et

Qu

art

er

1 P

erf

orm

an

ce

Q1

RA

G

Intr

od

uct

ion

of

hea

lth

an

d

we

llb

ein

g

init

iati

ve

s

A)

Ph

ysi

cal

act

ivit

y s

che

me

s fo

r st

aff

:

i) U

pd

ate

th

e T

rust

po

licy

on

cycl

e t

o w

ork

sch

em

e,

com

mu

nic

ate

an

d p

rom

ote

th

is t

o s

taff

acr

oss

th

e o

rga

nis

ati

on

.

ii)

Deve

lop

an

d a

gre

e s

taff

ph

ysi

cal

he

alt

h a

ctiv

itie

s/p

lan

wit

h

com

mis

sio

ne

r (i

ncl

ud

ing

; w

alk

ing

me

eti

ng

s).

Q1

ON

LY

n

/a

i) A

chie

ve

d -

Cycl

e t

o W

ork

Sch

em

e P

roce

du

re h

as

be

en

up

da

ted

. H

as

be

en

su

bm

itte

d t

o P

ASC

(Jo

na

tha

n)

for

ap

pro

va

l. Sch

em

e w

as

fea

ture

d a

t th

e H

ea

lth

Eve

nt

(Ju

ne

16

).

ii)

Ach

ieve

d -

a n

um

be

r o

f su

gg

est

ion

s w

ere

rece

ive

d f

rom

th

e H

ea

lth

Eve

nt

wh

ich

wil

l b

e

furt

he

r d

eve

lop

ed

an

d im

ple

me

nte

d Q

ua

rte

r 1

. T

o s

ha

re r

ep

ort

wit

h C

om

mis

sio

ne

rs.

B)

Acc

ess

to

ph

ysi

oth

era

py s

erv

ices

for

sta

ff:

i). B

rie

f re

po

rt t

o c

om

mis

sio

ne

rs o

n t

he

nu

mb

ers

of

sta

ff

acc

ess

ing

OH

fo

r M

SK

re

late

d p

rob

lem

s in

20

15

/16

.

ii).

Est

ab

lish

a f

ast

tra

ck p

hysi

oth

era

py s

erv

ice f

or

sta

ff

suff

eri

ng

fro

m M

SK

iss

ue

s w

ith

Occ

up

ati

on

al

Hea

lth

Pro

vid

er.

iii)

Evid

en

ce o

f c

om

mu

nic

ati

on

pla

n t

o s

taff

aro

un

d M

SK

an

d

ho

w t

o a

cce

ss t

he

se

rvic

e.

iv).

Co

nti

nu

e t

o r

evie

w a

nd

up

da

te p

roce

sses

for

refe

rra

l fo

r

ph

ysi

oth

era

py s

erv

ices

an

d in

form

sta

ff o

f th

e s

erv

ice.

Q1

ON

LY

n

/a

i) A

chie

ve

d. T

he

Ro

ya

l Fre

e L

on

do

n N

HS F

T,

ou

r h

ea

lth

at

wo

rk p

rovid

er,

co

nfi

rme

d t

ha

t 7

refe

rra

ls w

ere

rece

ive

d l

ast

ye

ar

wh

ich

wo

uld

ha

ve

be

ne

fite

d f

rom

a f

ast

tra

ck p

hysi

o s

erv

ice.

ii)

Ach

ieved

- F

ast

Tra

ck P

hysi

oth

era

py is

no

w p

art

of

the

OH

co

ntr

act

.

iii)

Ach

ieve

d.

Th

e c

urr

en

t se

rvic

e i

s p

rovid

ing

on

clin

ical a

sse

ssm

en

t th

rou

gh

ma

na

ge

me

nt

refe

rra

ls. T

he

refo

re, w

he

n a

ma

na

ge

r co

mp

lete

s a

n o

ccu

pa

tio

na

l h

ea

lth

refe

rra

l it

is

de

term

ine

d

wh

eth

er

the

MSK

fa

st t

rack

pa

thw

ay i

s th

e m

ost

ap

pro

pri

ate

. C

om

mu

nic

ati

on

s p

lan

fo

r th

is

CQ

UIN

ha

s b

ee

n d

raft

ed

.

iv)

Ach

ieve

d.

Th

is f

orm

s p

art

of

the

mo

nth

ly p

erf

orm

an

ce in

dic

ato

r m

on

ito

rin

g w

ith

th

e R

oya

l

Fre

e L

on

do

n N

HS F

T.

C)

Me

nta

l H

ea

lth

In

itia

tive

s:

i) D

eli

ve

r m

en

tal h

ea

lth

an

d w

ell

be

ing

aw

are

ne

ss t

rain

ing

eve

nt

in t

he

Tru

st.

ii)

Ide

nti

fy a

ra

ng

e o

f m

en

tal h

ea

lth

in

itia

tive

s o

r tr

ain

ing

ne

ed

s fo

r st

aff

on

str

ess

ma

na

ge

me

nt

cou

rse

s, lin

e

ma

na

ge

me

nt

tra

inin

g, m

ind

fuln

ess

co

urs

es,

co

un

sell

ing

serv

ices

incl

ud

ing

sle

ep

co

un

sell

ing

an

d m

en

tal h

ealt

h f

irst

aid

tra

inin

g

an

d a

gre

e s

taff

acc

ess

arr

an

ge

me

nts

an

d h

ow

use

of

the

init

iati

ve

s w

ill

be

mo

nit

ore

d.

iii)

Pu

bli

cise

in

-ho

use

sta

ff c

on

sult

ati

on

serv

ice a

nd

exte

rna

lly

sou

rce

d c

ou

nse

llin

g r

eso

urc

es

to a

ll s

taff

.

Q1

ON

LY

n/a

i)A

chie

ve

d. M

en

tal H

ea

lth

Fir

st A

id T

rain

ing

de

live

red

ii)

Ach

ieve

d.

Ta

ste

r M

ind

fuln

ess

Tra

inin

g o

ffere

d a

s p

art

of

the

He

alt

h E

ve

nt

he

ld o

n 1

6 J

un

e. A

Sta

ff S

urv

ey h

as

be

en

de

ve

lop

ed

an

d i

ssu

ed

Tru

st-w

ide

to

ga

in f

urt

he

r fe

ed

ba

ck o

n w

ha

t st

aff

me

nta

l h

ea

lth

we

ll b

ein

g g

rou

p s

ess

ion

s th

ey w

an

t to

see

off

ere

d. Lu

nch

tim

e m

ind

fuln

ess

dro

p

in s

ess

ion

s to

co

mm

en

ce in

ea

rly J

uly

. Fu

rth

er

fee

db

ack

wil

l b

e k

no

wn

in

Q2

.

iii)

Ach

ieve

d -

th

e s

erv

ice i

s a

dve

rtis

ed

on

th

e h

om

e p

ag

e o

f th

e i

ntr

an

et

Page 78 of 146

15

CQ

UIN

S -

1. N

HS

Staf

f h

ealt

h a

nd

wel

lbei

ng

CQ

UIN

s

Ta

rge

t D

eta

il o

f in

dic

ato

r R

ep

ort

ed

T

arg

et

%

Pro

gre

ss

Q1

RA

G

Hea

lth

y f

oo

d

for

NH

S s

taff

,

vis

ito

rs a

nd

pa

tie

nts

Qu

art

er

1: T

he

resp

on

ses

to t

he

pro

po

sed

qu

est

ion

s b

elo

w w

ill

form

pa

rt o

f a

na

tio

na

l d

ata

co

lle

ctio

n.

Pro

vid

ers

wil

l su

bm

it t

he

resp

on

ses

via

UN

IFY

fo

llo

win

g lo

call

y

ag

ree

d s

ign

off

pro

cess

by t

he

co

mm

issi

on

er.

1)

Nam

e o

f fr

an

chis

e h

old

er

2)

Nam

e o

f su

pp

lie

r o

r ve

nd

or(

s)

3)

Typ

e o

f sa

les

ou

tle

t (r

est

au

ran

t, c

afé

, ve

nd

ing

, sh

op

/sto

re,

tro

lle

y s

erv

ice)

4)

Sta

rt d

ate

of

exis

tin

g s

up

pli

er

con

tra

ct

5)

En

d d

ate

of

exis

tin

g s

up

pli

er

con

tra

ct

6)

Re

ma

inin

g le

ng

th o

f co

ntr

act

(ti

me

to

exp

irati

on

) w

ith

exte

rna

l su

pp

lie

r(s)

7)

To

tal co

ntr

act

va

lue

8)

Va

lue

of

con

tract

fo

r th

e f

ina

nci

al ye

ar

20

15

/16

9)

Pro

fit

sha

re a

gre

em

en

ts t

ha

t a

re in

ad

dit

ion

to

th

e c

on

tract

va

lue

(p

erc

en

tag

e o

f p

rofi

t th

at

is r

ece

ive

d b

y t

he

NH

S

Pro

vid

er

fro

m t

he

su

pp

lie

r)

10

)Fre

e t

ext

bo

x:

Co

ntr

act

bre

ak

cla

use

s

11

)V

olu

me

of

Su

ga

r Sw

ee

ten

ed

Be

ve

rag

es

sold

Q1

ON

LY

n

/a

Ach

ieve

d.

Re

po

rt in

clu

din

g c

ontr

act in

form

atio

n to

be s

ubm

itte

d to

th

e

Ca

md

en

co

mm

issio

ne

r a

long

with

re

leva

nt co

ntr

act d

eta

ils f

or

sig

n o

ff in

adva

nce

of th

e U

NIF

Y s

ubm

issio

n.

Q1

Qua

lity

Rep

ort

Page 79 of 146

16

CQ

UIN

S -

2. L

ivin

g W

ell P

rogr

amm

e

Ta

rge

t D

eta

il o

f in

dic

ato

r R

ep

ort

e

d

Ta

rge

t %

P

rog

ress

Q

1

RA

G

Hea

lth

y f

oo

d f

or

NH

S s

taff

, vis

ito

rs

an

d p

ati

en

ts

1).

Qu

art

erl

y r

efe

rra

ls t

o P

HSN

fo

r fu

rth

er

inte

rve

nti

on

- s

mo

kin

g, a

lco

ho

l fo

r

all

ne

w p

ati

en

ts a

ge

d 1

4 a

nd

ab

ove

.

Q1

- 4

n

/a

A t

ota

l o

f 2

3 r

efe

rra

ls f

or

smo

kin

g a

nd

alc

oh

ol p

ati

en

t a

ge

14

+.

2).

Qu

art

erl

y r

ep

ort

- n

um

be

rs, is

sue

s a

nd

ou

tco

me

s, (

nu

mb

er

of

1:1

/g

rou

p

sess

ion

s / e

xte

rna

l re

ferr

als

) w

ith

evid

en

ce o

f G

Ps

be

ing

in

form

ed

wit

hin

2

we

ek

s o

f a

tte

nd

ing

ap

po

intm

en

t (i

mp

rove

me

nt

wo

uld

be

mo

nit

ore

d a

ga

inst

Q1

as

ba

seli

ne

).

Ach

ieve

d

3).

Im

pro

ve

use

an

d c

om

ple

tio

n o

f p

hysi

cal

he

alt

h f

orm

de

tail

s (c

urr

en

t

ba

seli

ne

at

en

d o

f 2

01

5/1

6 w

as

27

%).

3

3.9

%

1).

Evid

en

ce o

f co

nsu

ltati

on

wit

h s

erv

ice u

sers

an

d c

are

rs (

min

imu

m o

f 1

00

pa

rtic

ipa

nts

) a

s to

wh

at

form

s o

f in

terv

en

tio

n t

he

y w

ou

ld f

ind

he

lpfu

l -

pro

gra

mm

e s

cop

e a

nd

co

nte

nt.

Q1

ON

LY

A

chie

ved

2).

Re

vie

w N

ICE

gu

ida

nce

on

im

pro

vin

g p

hysi

cal

he

alt

h o

f m

en

tal h

ea

lth

pa

tie

nts

, in

clu

din

g c

hil

dre

n a

nd

pro

vid

e a

rep

ort

sh

ow

ing

ho

w t

he

pro

gra

mm

e is

in l

ine

wit

h N

ICE

gu

ida

nce

.

Ach

ieve

d

3).

Sco

pe

in

form

ati

on

, le

afl

ets

, o

nli

ne

reso

urc

es

etc

ava

ila

ble

to

pro

vid

e a

rep

osi

tory

of

ma

teri

al fo

r th

e L

ivin

g W

ell

Pro

gra

mm

e.

Ach

ieve

d

4).

Im

pro

ve

use

an

d c

om

ple

tio

n o

f p

hysi

cal

he

alt

h f

orm

de

tail

s w

ith

an

au

dit

of

at

lea

st 3

5%

Ph

ysi

cal

Hea

lth

Fo

rm c

om

ple

ted

in

Q1

.

33

.9%

Ph

ysi

cal H

ea

lth

Fo

rms

com

ple

ted

Page 80 of 146

17

CQ

UIN

S -

3. D

om

esti

c V

iole

nce

an

d A

bu

se

Ta

rge

t D

eta

il o

f in

dic

ato

r R

ep

ort

ed

T

arg

et

%

Pe

rfo

rma

nce

Q1

Q

1

RA

G

Hea

lth

y

foo

d f

or

NH

S s

taff

,

vis

ito

rs

an

d

pa

tie

nts

1).

Tra

in t

he

tra

ine

r co

mp

leti

on

of

CA

AD

A-D

ASH

tra

inin

g

cou

rse

(re

fre

she

r) b

y N

am

ed

Pro

fess

ion

al Sa

feg

ua

rdin

g

Ch

ild

ren

.

Q1

ON

LY

n

/a

Tra

ine

r th

e T

rain

er

CA

AD

A-D

ASH

to

ol u

nd

ert

ak

en

on

19

th M

ay b

y t

he

Nam

ed

Pro

fess

ion

al fo

r

Sa

feg

ua

rdin

g C

hil

dre

n;

2).

Id

en

tify

Te

am

ma

na

ge

rs t

o b

e id

en

tifi

ed

fo

r C

AA

DA

-

DA

SH

tra

inin

g a

nd

est

ab

lish

da

tes

for

Q2

-4 w

ith

10

0%

com

ple

tio

n b

y e

nd

of

Q4.

10

0%

3

3 t

ea

m m

an

ag

ers

id

en

tifi

ed

in

clu

din

g t

wo

safe

gu

ard

ing

le

ad

s fr

om

th

e A

du

lt a

nd

Po

rtm

an

serv

ices.

9 t

rain

ing

sess

ion

s (C

AA

DA

-DA

SH

) h

ave

be

en

bo

ok

ed

fro

m S

ep

tem

be

r 2

01

6 t

o M

arc

h 2

01

7

3).

Id

en

tify

Cli

nic

al Sta

ff f

or

Le

ve

l 2

an

d L

eve

l 3

Do

me

stic

Vio

len

ce a

nd

Ab

use

Tra

inin

g a

nd

est

ab

lish

da

tes

for

Q2

-4

wit

h 1

00

% c

om

ple

tio

n b

y e

nd

of

Q4.

10

0%

Cu

rre

ntl

y 1

3 L

eve

l 3

tra

inin

g s

ess

ion

s b

oo

ke

d f

or

A

pri

l 2

01

6 t

o M

arc

h

20

17

. L

eve

l 2

sta

ff w

ill

att

en

d L

eve

l 3

tra

inin

gs

4).

Ba

seli

ne

da

ta o

n n

um

be

rs o

f SA

Fs

wit

h d

om

est

ic

vio

len

ce / a

bu

se p

rese

nta

tio

n; n

um

be

r o

f re

ferr

als

of

vic

tim

s to

sp

eci

ali

st a

ge

nci

es

/ n

um

be

r o

f re

ferr

als

to

MA

RA

C /

nu

mb

er

of

pe

rpe

tra

tors

refe

rre

d t

o s

pe

cia

list

ag

en

cie

s.

n/a

A

) Sa

feg

ua

rdin

g c

hil

dre

n L

eve

l 2

- 2

2 s

taff

ne

ed

tra

inin

g f

or

20

16

– 2

01

7

B)

Sa

feg

ua

rdin

g c

hil

dre

n L

eve

l 3

-

99

sta

ff n

ee

d t

rain

ing

fo

r 2

01

6 –

20

17

. T

he

se f

igu

res

ma

y b

e

sub

ject

to

ad

just

me

nt

acc

ord

ing

to

sta

ff r

ete

nti

on

le

ve

ls;

Ba

seli

ne

20

16

D

om

est

ic A

bu

se D

ata

Qu

art

er

1 2

01

6-2

01

7 t

he

re w

as

on

e c

ase

su

bje

ct t

o a

s.1

7 a

lert

rela

ted

to

re

po

rte

d h

isto

rica

l d

om

est

ic

ab

use

.

Qu

art

er

1 2

01

6-2

01

7 C

are

No

tes;

th

ere

we

re 4

ca

ses

wit

hin

Ch

ild

an

d Y

ou

ng

Pe

op

le’s

serv

ices

wh

ere

do

me

stic

ab

use

wa

s fl

ag

ge

d a

s a

ris

k:

3 c

ase

s lo

w a

nd

1 c

ase

me

diu

m r

isk.

Q1

Qua

lity

Rep

ort

Page 81 of 146

18

Po

rtm

an

CQ

UIN

GID

S C

QU

IN

CQ

UIN

D

eta

il o

f in

dic

ato

r R

ep

ort

ed

Perf

orm

an

ce a

t Q

1

Targ

et

%

Pro

gre

ss

Q1 R

AG

SA

FE

AN

D T

IME

LY

DIS

CH

AR

GE

Au

dit

on

10

% d

isch

arg

e t

o i

de

nti

fy

ba

seli

ne

rate

of

Dis

cha

rge

le

tte

rs

be

ing

iss

ue

d t

o G

Ps

an

d o

rig

ina

tin

g

ag

en

cie

s.

Re

po

rte

d in

Q1

1

0%

T

o b

e c

om

ple

ted

in

Ju

ly 2

01

6 o

n Q

1 d

ata

.

CQ

UIN

Ta

rge

t D

eta

il o

f In

dic

ato

r R

ep

ort

ed

P

erf

orm

an

ce a

t

Q1

Pro

gre

ss

Q1

RA

G

Te

lem

ed

icin

e / V

irtu

al P

ati

en

t Se

ssio

ns

Th

e p

urp

ose

of

this

CQ

UIN

is

to i

nce

nti

vis

e t

he

tru

st t

o

de

ve

lop

a p

latf

orm

wit

hin

wh

ich

th

ese

vir

tua

l se

ssio

ns

can

tak

e p

lace

or

to p

rocu

re e

xis

tin

g p

latf

orm

s th

at

can

be

use

d f

or

the

pu

rpo

ses

of

un

de

rta

kin

g v

irtu

al

pa

tie

nt

sess

ion

s. T

his

wo

uld

cre

ate

an

in

no

va

tive

ne

w

wa

y o

f se

rvic

e d

eli

ve

ry.

Q3

on

wa

rds

n/a

D

ata

to

be

co

lle

cted

an

d r

ep

ort

ed

Q3

on

wa

rds

Tra

nsi

tio

n a

rra

ng

em

en

ts a

cro

ss t

he

Ge

nd

er

Ide

nti

ty

Pa

thw

ay

Th

e C

QU

IN w

ill

focu

s o

n t

hre

e m

ain

th

em

es

tha

t h

ave

be

en

id

en

tifi

ed

wit

h p

rovid

ers

as

de

ve

lop

me

nts

th

at

wil

l su

pp

ort

th

e s

mo

oth

tra

nsi

tio

n o

f p

ati

en

ts

be

twe

en

on

e p

rovid

er

to a

no

the

r;

Q2

on

wa

rds

n/a

D

ata

to

be

co

lle

cted

an

d r

ep

ort

ed

Q2

on

wa

rds

Page 82 of 146

19

Ap

pe

nd

ix: Q

ua

lity

In

dic

ato

r P

erf

orm

an

ce S

up

po

rtin

g E

vid

en

ce

1. W

ait

ing

Tim

es

QU

AR

TER

1 -

TR

USTW

IDE (

8 W

EEK

WA

ITER

S)

<6 W

EEK

WA

IT

11 W

EEK

WA

ITER

S

Ru

n t

ime

A

YA

S

Cam

den

CA

MH

S

Oth

er

CA

MH

S

West

min

ster

Ad

ult

Po

rtm

an

TO

TA

L

Data

ru

n o

n: 4

-7-1

6

Inte

rnal B

reach

9

44

15

2

5

0

75

Exte

rnal

Bre

ach

5

5

10

0

11

2

33

To

tal n

um

ber

of

bre

ach

es

14

49

25

2

16

2

108

Nu

mb

er

of

'bre

ach

es'

sh

ow

n

aft

er

data

valid

ati

on

sh

ow

n t

o

be 'n

o b

reach

'

4

18

19

17

15

0

73

To

tal fi

rst

att

en

ded

ON

LY

46

294

94

11

67

32

544

To

tal W

ait

ing

as

30 J

un

e 2

016

17

34

61

7

69

8

196

To

tal (d

en

om

inato

r)

63

328

155

18

136

40

740

Th

e p

erc

en

tag

e o

f p

ati

en

ts t

hat

are

bre

ach

ed

in

th

e q

uart

er

22.2

%

14.9

%

16.1

%

11.1

%

11.8

%

5.0

%

14.6

%

% In

tern

al

14.3

%

13.4

%

9.7

%

11.1

%

3.7

%

0.0

%

10.1

%

% E

xte

rnal

7.9

%

1.5

%

6.5

%

0.0

%

8.1

%

5.0

%

4.5

%

Q1

Qua

lity

Rep

ort

Page 83 of 146

20

Wa

itin

g T

ime

Bre

ach

es – A

do

lesc

en

t S

erv

ice

(Ta

rge

t <

8 W

ee

ks)

Pa

tie

nt

ID

Te

am

R

efe

rra

l D

ate

C

lock

Re

sta

rt

Ap

po

intm

en

t Fir

st A

tten

de

d

Ap

po

intm

en

t W

ait

We

ek

s

Co

mm

en

tary

fro

m s

erv

ice

In

tern

al/

exte

rna

l

24

68

9

AD

OLE

SC

EN

T N

ort

h a

nd

We

st T

ea

m

15

-Dec-

15

0

9-F

eb

-16

2

6-M

ay-1

6

15

.29

P

ati

en

t d

id n

ot

resp

on

d t

o o

pt

in le

tte

r

sen

t.

Exte

rna

l

17

94

8

AD

OLE

SC

EN

T N

ort

h a

nd

We

st T

ea

m

19

-Jan

-16

2

8-J

an

-16

1

3-A

pr-

16

1

0.8

6

Ca

se h

ad

to

go

to

Ba

rne

t C

CG

fo

r SP

E

ap

pro

va

l fi

rst,

th

ere

fore

d

ela

y i

n

acc

ep

tin

g c

ase

E

xte

rna

l

24

66

7

AD

OLE

SC

EN

T N

ort

h a

nd

We

st T

ea

m

03

-Fe

b-1

6

04

-Fe

b-1

6

18

-Ap

r-1

6

10

.57

La

ck o

f co

rresp

on

de

nce

E

xte

rna

l

23

37

8

AD

OLE

SC

EN

T N

ort

h a

nd

We

st T

ea

m

27

-Oct

-15

2

7-J

an

-16

0

4-A

pr-

16

9

.71

Pa

tie

nt

wa

s o

ffere

d 1

st a

pp

t o

n 1

st F

eb

2

01

6 a

fte

r m

ult

iple

att

em

pts

to

co

nta

ct

he

r, h

ow

eve

r sh

e d

id n

ot

resp

on

d t

o

call

s o

r te

xts

. L

ett

er

wa

s se

nt

wit

h a

pp

t d

ate

s a

nd

tim

es

ho

we

ve

r p

ati

en

t ra

ng

to

ch

an

ge

he

r a

va

ila

bil

ity d

ue

to

wo

rk

pa

tte

rn c

ha

ng

e. T

his

ha

pp

en

ed

a

nu

mb

er

of

tim

es

be

fore

sh

e f

ina

lly

acc

ep

ted

an

d a

tte

nd

ed

he

r a

pp

t in

Ap

ril

20

16

Exte

rna

l

25

34

3

AD

OLE

SC

EN

T Y

PC

S

26

-Fe

b-1

6

26

-Fe

b-1

6

28

-Ap

r-1

6

8.8

6

Bre

ach

ed

be

cau

se o

f n

o r

esp

on

se f

rom

cl

ien

t ,

the

n c

lie

nt

un

ab

le t

o a

tte

nd

as

the

y w

ere

aw

ay

Exte

rna

l

24

84

7

AD

OLE

SC

EN

T C

am

de

n T

ea

m

05

-Fe

b-1

6

18

-Fe

b-1

6

04

-Ma

y-1

6

10

.86

C

lin

ical C

ap

aci

ty

Inte

rna

l

24

45

3

AD

OLESC

EN

T C

en

tral an

d E

ast

Te

am

1

1-J

an

-16

2

2-J

an

-16

0

6-A

pr-

16

10

.71

C

lin

ical C

ap

aci

ty

Inte

rnal

24

57

4

AD

OLE

SC

EN

T C

am

de

n T

ea

m

11

-Jan

-16

2

8-J

an

-16

1

1-A

pr-

16

1

0.5

7

Cli

nic

al C

ap

aci

ty

Inte

rna

l

24

36

5

AD

OLE

SC

EN

T N

ort

h a

nd

We

st T

ea

m

06

-Jan

-16

1

8-J

an

-16

2

2-A

pr-

16

1

3.5

7

Th

is o

ne

is

bre

ach

ed

be

cau

se in

tak

e

tho

ug

ht

the

re

ferr

al w

as

fro

m H

ari

ng

ey

bu

t it

wa

s fr

om

Ba

rne

t, t

he

n i

t h

ad

to

g

o b

ack

to

refe

rra

ls t

o f

un

din

g b

efo

re it

cam

e b

ack

to

us.

Inte

rna

l

24

84

4

AD

OLE

SC

EN

T C

am

de

n T

ea

m

17

-Fe

b-1

6

26

-Ap

r-1

6

30

-Ju

n-1

6

9.2

9

Cli

nic

al C

ap

aci

ty

Inte

rna

l

24

84

4

AD

OLE

SC

EN

T C

am

de

n T

ea

m

17

-Fe

b-1

6

26

-Ap

r-1

6

30

-Ju

n-1

6

9.2

9

Cli

nic

al C

ap

aci

ty

Inte

rna

l

24

12

0

AD

OLE

SC

EN

T C

am

de

n T

ea

m

26

-Fe

b-1

6

26

-Fe

b-1

6

16

-Ma

y-1

6

11

.43

C

lin

ical C

ap

aci

ty

Inte

rna

l

24

68

7

AD

OLE

SC

EN

T C

am

de

n T

ea

m

05

-Fe

b-1

6

05

-Fe

b-1

6

05

-Ap

r-1

6

8.5

7

Cli

nic

al C

ap

aci

ty

Inte

rna

l

24

78

8

AD

OLE

SC

EN

T C

am

de

n T

ea

m

12

-Fe

b-1

6

12

-Fe

b-1

6

11

-Ap

r-1

6

8.4

3

Cli

nic

al C

ap

aci

ty

Inte

rna

l

*P

lea

se n

ote

pa

tie

nts

th

at

in r

ed

we

re r

efe

rre

d b

efo

re t

he

1 A

pri

l a

nd

th

ere

fore

wa

s su

bje

ct t

o t

he

11

we

ek

wa

it t

ime

win

do

w.

Th

e c

ase

s w

ere

see

n w

ith

in t

his

tim

efr

am

e. A

s th

ese

ca

ses

we

re

see

n a

fte

r th

e 1

Ap

ril,

th

e n

ew

wa

it t

ime

pa

ram

ete

rs h

ave

be

en

im

ple

me

nte

d t

he

refo

r sh

ow

ing

th

is c

ase

as

a b

rea

ch.

Page 84 of 146

21

Wa

itin

g T

ime

Bre

ach

es

(Pa

ge

1 o

f 2

) – C

am

den

CA

MH

S (

Targ

et

<8

We

ek

s)

*P

lea

se n

ote

pa

tie

nts

th

at

in r

ed

we

re r

efe

rre

d b

efo

re t

he

1 A

pri

l a

nd

th

ere

fore

wa

s su

bje

ct t

o t

he

11

we

ek

wa

it t

ime

win

do

w.

Th

e c

ase

s w

ere

see

n w

ith

in t

his

tim

efr

am

e. A

s th

ese

ca

ses

we

re

see

n a

fte

r th

e 1

Ap

ril,

th

e n

ew

wa

it t

ime

pa

ram

ete

rs h

ave

be

en

im

ple

me

nte

d t

he

refo

r sh

ow

ing

th

is c

ase

as

a b

rea

ch.

Pa

tie

nt

ID

Te

am

R

efe

rra

l D

ate

C

lock

Re

start

A

pp

oin

tme

nt

Fir

st A

tten

de

d

Ap

po

intm

en

t W

ait

We

ek

s C

om

me

nta

ry f

rom

serv

ice?

Inte

rna

l/E

xte

rna

l

17

16

5

SO

UTH

Se

rvic

e

10

-Ju

n-1

5

12

-Ju

n-1

5

5

4.8

6

Un

ab

le t

o c

on

tact

fam

ily f

or

an

ap

po

intm

en

t -

this

wil

l n

ow

be

clo

sed

. E

xte

rna

l

15

69

1

Re

fug

ee

Se

rvic

e

07

-Ma

y-1

5

29

-Ju

n-1

5

5

2.4

3

On

ly o

ne

ap

po

intm

en

t w

as

off

ere

d a

nd

th

is w

as

can

cell

ed

by t

he

clie

nt.

E

xte

rna

l

18

64

5

Ca

md

en

Ad

ole

sce

nt

Inte

nsi

ve

Su

pp

ort

Se

rvic

e

04

-Ma

r-1

6

04

-Ma

r-1

6

1

6.8

6

Bre

ach

- F

am

ily n

ot

en

ga

gin

g

Exte

rna

l

77

94

SO

UTH

Pri

ma

ry C

are

0

7-M

ar-

16

0

9-M

ar-

16

2

6-M

ay-1

6

11

.14

W

ait

ing

fo

r cl

ien

t to

op

t in

- w

he

n t

he

y d

id t

ha

t w

as

the

ne

xt

ava

ila

ble

a

pp

t th

e c

lin

icia

n h

ad

E

xte

rna

l

25

47

0

NO

RT

H S

erv

ice

0

7-A

pr-

16

0

7-A

pr-

16

0

8-J

un

-16

8

.86

B

rea

ch -

Fa

mil

y n

ot

en

ga

gin

g

Exte

rna

l

25

74

6

Glo

uce

ste

r H

ou

se

24

-No

v-1

5

25

-No

v-1

5

3

1.1

4

Ap

pt

off

ere

d 7

.4.1

6 c

an

cell

ed

by p

ati

en

t In

tern

al

16

80

4

Co

mp

lex N

ee

ds

Ou

trea

ch

27

-No

v-1

5

04

-Dec-

15

29

.86

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

24

47

6

SO

UTH

Se

rvic

e

11

-Jan

-16

1

2-J

an

-16

24

.29

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

65

18

SO

UTH

Se

rvic

e

13

-Jan

-16

1

3-J

an

-16

24

.14

A

pp

t to

be

lo

gg

ed

In

tern

al

24

36

8

SO

UTH

Se

rvic

e

18

-Jan

-16

1

9-J

an

-16

23

.29

A

pp

t to

be

lo

gg

ed

In

tern

al

13

95

3

SO

UTH

Pri

ma

ry S

cho

ol

Se

rvic

e

07

-Dec-

15

0

7-D

ec-

15

1

6-M

ay-1

6

23

A

pro

fess

ion

al m

ee

tin

g w

as

att

en

de

d o

n 7

.3.1

6 w

ith

th

e S

en

co (

this

is

on

C

are

no

tes)

In

tern

al

64

09

SO

UTH

Se

rvic

e

26

-Jan

-16

2

6-J

an

-16

22

.29

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

19

29

1

MA

LT

2

6-J

an

-16

2

6-J

an

-16

22

.29

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

24

60

2

SO

UTH

Pri

ma

ry S

cho

ol

Se

rvic

e

29

-Jan

-16

2

9-J

an

-16

21

.86

A

pp

t to

be

lo

gg

ed

In

tern

al

14

56

6

Glo

uce

ste

r H

ou

se

12

-Fe

b-1

6

14

-Fe

b-1

6

1

9.5

7

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

14

61

8

SO

UTH

Serv

ice

2

5-F

eb

-16

2

5-F

eb

-16

2

4-J

un

-16

17

.14

Lack

of

clin

ical ca

paci

ty

Inte

rnal

18

51

8

Ca

md

en

Ad

ole

sce

nt

Inte

nsi

ve

Su

pp

ort

Se

rvic

e

04

-Ma

r-1

6

04

-Ma

r-1

6

1

6.8

6

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

11

4

NO

RT

H S

erv

ice

0

8-M

ar-

16

0

9-M

ar-

16

16

.14

A

pp

t o

ffe

red

7.4

.16

ca

nce

lle

d b

y p

ati

en

t In

tern

al

25

22

1

Re

fug

ee

Se

rvic

e

11

-Ma

r-1

6

11

-Ma

r-1

6

1

5.8

6

In F

eb

16

we

we

re w

ork

ing

to

11

we

ek

s -

see

n w

ith

in t

his

In

tern

al

24

37

2

NO

RT

H S

erv

ice

0

8-D

ec-

15

2

2-M

ar-

16

14

.29

La

ck o

f cl

inic

al ca

pa

city

= D

aw

n r

esp

on

de

d=

Wil

l co

nta

ct c

lin

icia

n o

n t

his

o

ne

an

d f

ee

db

ack

In

tern

al

23

22

1

Co

mp

lex N

ee

ds

Ou

trea

ch

15

-Jan

-16

1

5-J

an

-16

1

8-A

pr-

16

1

3.4

3

La

ck o

f cl

inci

al ca

pa

city

In

tern

al

25

38

1

Ca

md

en

Ad

ole

sce

nt

Inte

nsi

ve

Su

pp

ort

Se

rvic

e

31

-Ma

r-1

6

31

-Ma

r-1

6

30

-Ju

n-1

6

13

La

ck o

f cl

inci

al ca

pa

city

In

tern

al

Q1

Qua

lity

Rep

ort

Page 85 of 146

22

Wa

itin

g T

ime

Bre

ach

es

(Pa

ge

2 o

f 2

) – C

am

den

CA

MH

S (

Targ

et

<8

We

ek

s)

*P

lea

se n

ote

pa

tie

nts

th

at

in r

ed

we

re r

efe

rre

d b

efo

re t

he

1 A

pri

l a

nd

th

ere

fore

wa

s su

bje

ct t

o t

he

11

we

ek

wa

it t

ime

win

do

w.

Th

e c

ase

s w

ere

see

n w

ith

in t

his

tim

efr

am

e. A

s th

ese

ca

ses

we

re

see

n a

fte

r th

e 1

Ap

ril,

th

e n

ew

wa

it t

ime

pa

ram

ete

rs h

ave

be

en

im

ple

me

nte

d t

he

refo

r sh

ow

ing

th

is c

ase

as

a b

rea

ch.

Pa

tie

nt

ID

Te

am

R

efe

rra

l D

ate

C

lock

Re

sta

rt

Ap

po

intm

en

t Fir

st A

tten

de

d

Ap

po

intm

en

t W

ait

We

ek

s C

om

me

nta

ry f

rom

serv

ice?

Inte

rna

l/E

xte

rna

l

12

88

9

SO

UTH

Se

rvic

e

15

-Jan

-16

1

5-J

an

-16

1

3-A

pr-

16

1

2.7

1

Did

n't

rece

ive r

efe

rral u

nti

l 2

8/1

/16

fro

m J

oin

t In

tak

e. 13

/4 w

as

ou

r n

ext

ava

ila

ble

Ca

R c

lin

ic s

lot

Inte

rna

l

25

39

8

IEY

S

17

-Ma

r-1

6

04

-Ap

r-1

6

1

2.4

3

La

ck o

f cl

inci

al ca

pa

city

In

tern

al

19

73

1

SO

UTH

Pri

ma

ry S

cho

ol

Se

rvic

e

04

-Ap

r-1

6

04

-Ap

r-1

6

1

2.4

3

Ap

pt

to b

e lo

gg

ed

In

tern

al

25

48

3

IEY

S

18

-Ma

r-1

6

06

-Ap

r-1

6

1

2.1

4

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

18

61

1

SO

UTH

Pri

ma

ry S

cho

ol

Se

rvic

e

08

-Ap

r-1

6

08

-Ap

r-1

6

1

1.8

6

Ap

pt

to b

e lo

gg

ed

In

tern

al

86

58

SO

UTH

Serv

ice

1

1-A

pr-

16

1

2-A

pr-

16

11

.29

A

nd

y W

ien

er

ne

ed

s to

lo

g a

pro

fess

ion

al m

eeti

ng

- n

o a

pp

t o

ffere

d a

s o

f ye

t In

tern

al

25

11

5

NO

RT

H S

erv

ice

0

8-M

ar-

16

0

9-M

ar-

16

2

6-M

ay-1

6

11

.14

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

24

59

0

SO

UTH

Se

rvic

e

21

-Jan

-16

2

9-J

an

-16

1

3-A

pr-

16

1

0.7

1

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

10

09

6

SO

UTH

Se

rvic

e

29

-Jan

-16

0

1-F

eb

-16

1

3-A

pr-

16

1

0.2

9

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

26

44

9

IEY

S

20

-Ap

r-1

6

20

-Ap

r-1

6

1

0.1

4

La

ck o

f cl

inci

al ca

pa

city

In

tern

al

25

32

5

SO

UTH

Pri

ma

ry C

are

1

0-F

eb

-16

1

0-F

eb

-16

2

1-A

pr-

16

1

0.1

4

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

52

1

SO

UTH

Pri

ma

ry C

are

1

0-F

eb

-16

1

0-F

eb

-16

2

1-A

pr-

16

1

0.1

4

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

55

4

SO

UTH

Se

rvic

e

30

-Ma

r-1

6

14

-Ap

r-1

6

24

-Ju

n-1

6

10

.14

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

06

8

MA

LT

Co

urt

/PLO

2

6-F

eb

-16

0

3-M

ar-

16

0

9-M

ay-1

6

9.5

7

Th

ere

wa

s a

pro

fess

ion

als

me

eti

ng

on

th

e 1

0/0

3/2

01

6. T

he

fir

st d

irect

a

pp

oin

tme

nt

wit

h t

he

fa

mil

y w

as

off

ere

d o

n t

he

09

/05

/20

16

. T

his

wa

s d

ue

to

te

am

's c

ap

aci

ty.

In

tern

al

11

99

4

Ca

md

en

Ad

ole

sce

nt

Inte

nsi

ve

Su

pp

ort

Se

rvic

e

04

-Ma

r-1

6

04

-Ma

r-1

6

04

-Ma

y-1

6

8.7

1

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

10

60

4

SO

UTH

Se

rvic

e

02

-Fe

b-1

6

05

-Fe

b-1

6

05

-Ap

r-1

6

8.5

7

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

99

66

SO

UTH

Serv

ice

2

8-A

pr-

16

0

3-M

ay-1

6

8.2

9

Wil

l b

e s

ee

n o

n 2

0/7

/16

- p

ut

on

ho

ld a

s cl

inic

ian

did

n't

ha

ve

cap

aci

ty t

o

see

fam

ily.

11

we

ek

ap

pli

es

Inte

rnal

24

93

8

NO

RT

H S

erv

ice

2

5-F

eb

-16

2

1-M

ar-

16

0

6-J

un

-16

1

1

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

68

76

N

OR

TH

Se

rvic

e

02

-Fe

b-1

6

02

-Fe

b-1

6

18

-Ap

r-1

6

10

.86

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

67

2

NO

RT

H S

erv

ice

1

7-D

ec-

15

2

2-A

pr-

16

0

4-J

ul-

16

9

.86

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

07

4

NO

RT

H S

erv

ice

0

3-M

ar-

16

0

4-M

ar-

16

1

0-M

ay-1

6

9.5

7

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

21

9

NO

RT

H P

rim

ary

Ca

re

08

-Fe

b-1

6

08

-Fe

b-1

6

14

-Ap

r-1

6

9.4

3

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

24

97

8

NO

RT

H S

erv

ice

2

9-F

eb

-16

2

9-F

eb

-16

0

5-M

ay-1

6

9.4

3

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

18

82

1

NO

RT

H S

erv

ice

0

3-M

ar-

16

0

4-M

ar-

16

0

9-M

ay-1

6

9.4

3

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

24

97

9

NO

RT

H S

erv

ice

2

5-F

eb

-16

2

9-F

eb

-16

0

3-M

ay-1

6

9.1

4

Lack

of

clin

ical ca

paci

ty

Inte

rnal

25

03

4

NO

RT

H S

erv

ice

2

5-J

an

-16

0

2-M

ar-

16

0

5-M

ay-1

6

9.1

4

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

18

03

0

NO

RT

H S

erv

ice

0

2-F

eb

-16

0

4-F

eb

-16

0

7-A

pr-

16

9

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

25

12

0

NO

RT

H S

erv

ice

0

9-M

ar-

16

1

0-M

ar-

16

1

0-M

ay-1

6

8.7

1

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

83

47

N

OR

TH

Se

rvic

e

03

-Fe

b-1

6

08

-Fe

b-1

6

05

-Ap

r-1

6

8.1

4

La

ck o

f cl

inic

al ca

pa

city

In

tern

al

Page 86 of 146

23

Wa

itin

g T

ime

Bre

ach

es – O

the

r C

AM

HS

(Ta

rge

t <

8 W

ee

ks)

*P

lea

se n

ote

pa

tie

nts

th

at

in r

ed

we

re r

efe

rre

d b

efo

re t

he

1 A

pri

l a

nd

th

ere

fore

wa

s su

bje

ct t

o t

he

11

we

ek

wa

it t

ime

win

do

w.

Th

e c

ase

s w

ere

see

n w

ith

in t

his

tim

efr

am

e. A

s th

ese

ca

ses

we

re

see

n a

fte

r th

e 1

Ap

ril,

th

e n

ew

wa

it t

ime

pa

ram

ete

rs h

ave

be

en

im

ple

me

nte

d t

he

refo

r sh

ow

ing

th

is c

ase

as

a b

rea

ch.

Pa

tie

nt

ID

Te

am

R

efe

rra

l D

ate

C

lock

Re

sta

rt

Ap

po

intm

en

t Fir

st A

tten

de

d

Ap

po

intm

en

t W

ait

We

ek

s C

om

me

nta

ry f

rom

serv

ice?

Inte

rna

l/E

xte

rna

l

22

89

8

Lif

esp

an

2

6-A

ug

-15

2

2-S

ep

-15

1

2-A

pr-

16

2

9

Exte

rna

l -

com

ple

x c

ase

th

at

req

uir

ed

extr

a i

np

ut

fro

m e

xte

rna

l se

rvic

es

Exte

rna

l

24

75

4

Lif

esp

an

0

1-F

eb

-16

1

2-F

eb

-16

19

.86

E

xte

rna

l -

foll

ow

ing

lia

iso

n w

ith

he

rts

serv

ices,

wil

l b

e c

lose

d a

s n

ot

ap

pro

pri

ate

E

xte

rna

l

24

12

2

Fa

mil

y S

erv

ice

1

6-D

ec-

15

2

5-F

eb

-16

18

A

pp

t w

as

off

ere

d w

ith

in a

mo

nth

- d

na

'd Fa

mil

y d

iffi

cult

to

co

nta

ct a

nd

n

ee

de

d t

o b

e s

ee

n a

t B

G -

un

lim

ite

d c

ap

aci

ty a

t B

G c

lin

ic. C

ase

to

be

clo

sed

.

Exte

rna

l b

rea

che

d.

Exte

rna

l

24

85

4

Lif

esp

an

1

2-F

eb

-16

1

9-F

eb

-16

1

3-J

un

-16

1

6.4

3

Exte

rna

l -

cla

rifi

cati

on

ne

ed

ed

fro

m E

nfi

eld

E

xte

rna

l

25

48

0

Lif

esp

an

2

6-F

eb

-16

0

8-A

pr-

16

11

.86

E

xte

rna

l -

mo

re in

form

ati

on

ne

ed

ed

as

un

cle

ar

wh

eth

er

case

wa

s su

ita

ble

E

xte

rna

l

23

49

2

Fo

steri

ng

an

d A

do

pti

on

2

9-O

ct-1

5

28

-Jan

-16

1

9-A

pr-

16

1

1.7

1

(Exte

rna

l -

2 c

an

cell

ed

ap

po

intm

en

ts)

E

xte

rna

l

25

46

3

Fa

mil

y S

erv

ice

2

9-M

ar-

16

0

6-A

pr-

16

1

5-J

un

-16

1

0

Fa

mil

y d

iffi

cult

to

co

nta

ct.

Le

tte

r se

nt

to o

pt

in. P

are

nts

said

ne

ve

r re

ceiv

ed

lett

er.

T

rie

d t

o e

ng

ag

e s

oci

al w

ork

er

into

1st

ap

pt.

E

xte

rnal b

reach

ed

E

xte

rna

l

24

10

4

Lif

esp

an

0

4-D

ec-

15

0

8-F

eb

-16

1

4-A

pr-

16

9.4

3

Re

ferr

al ca

me

in

ju

st b

efo

re C

hri

stm

as,

fu

nd

ing

req

ue

st w

as

ma

de

to

Bre

nt

an

d c

ase

acc

ep

ted

on

ly a

t e

nd

of

Jan

Exte

rnal

22

45

9

Lif

esp

an

0

4-M

ar-

16

0

7-M

ar-

16

1

1-M

ay-1

6

9.2

9

Exte

rna

l d

iffi

cult

ies

wit

h S

W a

nd

pa

tie

nt

en

ga

ge

me

nt

E

xte

rna

l

25

54

7

Lif

esp

an

1

2-A

pr-

16

1

8-A

pr-

16

2

1-J

un

-16

9

.14

E

xte

rna

l -

mo

re in

fo n

ee

de

d f

rom

re

ferr

er

Exte

rna

l

24

49

0

Lif

esp

an

2

2-J

an

-16

2

5-J

an

-16

22

.43

In

tern

al -

case

no

t su

ita

ble

an

d n

ot

see

n. C

losi

ng

pa

pe

rwo

rk o

nly

ju

st

rece

ive

d

Inte

rna

l

24

31

7

Lif

esp

an

0

7-J

an

-16

1

2-J

an

-16

0

1-J

un

-16

2

0.1

4

Inte

rna

l -

La

ck o

f st

aff

In

tern

al

23

77

1

Lif

esp

an

2

2-J

an

-16

2

6-J

an

-16

2

7-M

ay-1

6

17

.43

In

tern

al -

La

ck o

f st

aff

In

tern

al

24

82

3

Lif

esp

an

0

9-F

eb

-16

1

6-F

eb

-16

1

0-J

un

-16

1

6.4

3

Inte

rna

l -

La

ck o

f st

aff

In

tern

al

25

21

7

Lif

esp

an

1

0-M

ar-

16

1

7-M

ar-

16

15

In

tern

al -

lack

of

staff

. n

ot

wa

itin

g,

bu

t w

ait

tim

e a

ccu

rate

In

tern

al

25

03

9

Lif

esp

an

2

6-F

eb

-16

0

1-M

ar-

16

0

8-J

un

-16

1

4.1

4

Inte

rna

l -

lack

of

staff

In

tern

al

11

78

6

Lif

esp

an

0

2-F

eb

-16

1

7-M

ar-

16

0

2-J

un

-16

1

1

Dela

y a

s ca

se w

en

t fi

rst

to a

du

lt d

ep

t b

efo

re b

ein

g p

ass

ed

to

CY

AF i

nta

ke

In

tern

al

13

73

2

Fa

mil

y S

erv

ice

2

9-M

ar-

16

3

0-M

ar-

16

1

5-J

un

-16

1

1

Ca

se c

am

e t

o L

ifesp

an

th

en

to

FM

H t

ea

m, th

en

ba

ck t

o C

AR

. In

tern

al

bre

ach

ed

In

tern

al

25

54

8

Lif

esp

an

1

8-A

pr-

16

1

8-A

pr-

16

10

.43

In

tern

al -

lack

of

staff

In

tern

al

24

89

6

Fa

mil

y S

erv

ice

1

8-F

eb

-16

1

8-F

eb

-16

2

6-A

pr-

16

9

.71

C

ase

wa

s w

ith

Sa

rah

Wyn

ick

try

ing

to

so

rt o

ut

be

st t

rea

tme

nt

for

fam

ily.

Inte

rna

l b

rea

che

d.

Inte

rna

l

19

69

0

Lif

esp

an

1

9-A

pr-

16

2

5-A

pr-

16

9.4

3

Inte

rna

l -

Qu

ery

of

wh

eth

er

suit

ab

le r

efe

rra

l, c

orr

ect

tea

m t

o s

ee

In

tern

al

25

73

8

Fo

steri

ng

an

d A

do

pti

on

1

9-A

pr-

16

2

8-A

pr-

16

9

Inte

rna

l B

rea

ch -

Cli

nic

al ca

pa

city

In

tern

al

24

12

4

Lif

esp

an

1

6-N

ov-1

5

09

-Ma

r-1

6

11

-Ma

y-1

6

9

Sta

ff a

va

ila

bil

ity (

inte

rna

l)

Inte

rna

l

25

76

5

Lif

esp

an

2

6-A

pr-

16

2

9-A

pr-

16

8.8

6

Inte

rna

l -

Se

en

on

28

th J

un

e -

la

ck o

f st

aff

In

tern

al

25

49

8

Lif

esp

an

1

1-A

pr-

16

1

1-A

pr-

16

0

9-J

un

-16

8

.43

In

tern

al -

La

ck o

f st

aff

In

tern

al

Q1

Qua

lity

Rep

ort

Page 87 of 146

24

Wa

itin

g T

ime

Bre

ach

es – W

est

min

ste

r (T

arg

et

<6

We

ek

s)

Pati

en

t ID

Team

R

efe

rral D

ate

C

lock

Rest

art

Ap

po

intm

en

t

Fir

st A

tten

ded

Ap

po

intm

en

t W

ait

Weeks

Exte

rnal/In

tern

al

Su

mm

ary

24963

FA

S F

am

ily A

ssess

men

t 22-F

eb

-16

22

-Feb

-16

04

-May-1

6

10.2

9

Inte

rnal

So

cial

Wo

rker

ho

spit

alise

d o

ff 3

weeks

16480

FA

S F

am

ily A

ssess

men

t 05-F

eb

-16

01-M

ay-1

6

06-J

ul-

16

8.5

7

Inte

rnal

Refe

rral re

ceiv

ed

1st

May d

ela

y r

e: w

ork

er

ab

ove o

ver

run

nin

g w

ith

pre

vio

us

case

Pati

en

t ID

Team

R

efe

rra

l D

ate

C

lock

Rest

art

A

pp

oin

tme

nt

Fir

st A

tte

nd

ed

A

pp

oin

tme

nt

Wa

it

We

ek

s E

xte

rna

l/In

tern

al

Co

mm

en

tary

19743

P

OR

TM

AN

Lim

en

tan

i 06-J

an

-16

15-F

eb

-16

1

9.4

3

Exte

rna

l R

efe

rra

l re

ceiv

ed

6th

Ja

nu

ary

– 1

st a

pp

t 11

th J

an

; 2

nd a

pp

t 28

th J

an

; 3

rd a

pp

t 15

th F

eb

(a

ll D

NA

’d)

21397

P

OR

TM

AN

Gla

sse

r 06-J

an

-16

11-J

an

-16

11-M

ay-1

6

17.2

9

Exte

rna

l

Refe

rra

l (c

hil

d c

ase

) re

ceiv

ed

11

th J

an

: d

ela

y in

1

st a

pp

t o

win

g t

o r

efe

rre

r h

avin

g t

o lia

ise

wit

h

com

mis

sio

ne

r to

se

cure

ag

ree

me

nt

for

risk

a

sse

ssm

en

t to

be u

nd

ert

ake

n.

Wa

itin

g T

ime

Bre

ach

es – P

ort

ma

n (

Targ

et

<1

1 W

ee

ks)

Page 88 of 146

25

Wa

itin

g T

ime

Bre

ach

es – A

du

lt (

Targ

et

<1

1 W

ee

ks)

Pati

en

t ID

Team

R

efe

rral D

ate

C

lock

Rest

art

Ap

po

intm

en

t

Fir

st A

tten

ded

Ap

po

intm

en

t W

ait

Weeks

Co

mm

en

tary

fro

m s

erv

ice

in

tern

al/exte

rnal

21043

AD

ULTS H

em

el Team

04-M

ar-

15

12-J

un

-15

54.8

6

Can

celled

by c

lien

t, t

hen

DN

A

Exte

rnal

10257

AD

ULTS B

els

ize

13-J

an

-15

14-J

ul-

15

50.2

9

Ap

po

intm

en

ts o

ffere

d l

ast

year,

did

no

t att

en

d a

ny –

to

be c

lose

d

Exte

rnal

22789

AD

ULTS L

yn

dh

urs

t 14-S

ep

-15

15-S

ep

-15

41.2

9

Ch

an

ged

min

d in

reg

ard

s to

ap

pt

- p

ati

en

t st

ill

op

en

-

po

ssib

ly t

o b

e c

lose

d.

Exte

rnal

17319

AD

ULTS H

em

el Team

28-A

ug

-15

04-D

ec-

15

29.8

6

Lack

of

corr

esp

on

dan

ce

Exte

rnal

22364

AD

ULTS W

atf

ord

24-A

pr-

15

11-D

ec-

15

28.8

6

Pati

en

t D

NA

tw

ice -

po

ssib

ly t

o

be

clo

sed

Exte

rnal

23663

AD

ULTS L

yn

dh

urs

t 11-N

ov-1

5

14-J

an

-16

24

Du

e t

o h

ealt

h iss

ues,

pati

en

t

had

to

reo

rgan

ise a

pp

t Exte

rnal

23451

AD

ULTS H

em

el Team

16-O

ct-1

5

15-J

an

-16

23.8

6

DN

A n

um

ero

us

tim

es,

to

be

clo

sed

Exte

rnal

24614

AD

ULTS M

are

sfie

ld

27-J

an

-16

02-F

eb

-16

21.2

9

Lack

of

corr

esp

on

dan

ce

Exte

rnal

23985

AD

ULTS H

em

el Team

17-N

ov-1

5

12-F

eb

-16

19.8

6

Lack

of

corr

esp

on

dan

ce

Exte

rnal

24741

AD

ULTS W

atf

ord

02-F

eb

-16

21-M

ar-

16

14.4

3

Pati

en

t ca

nce

lled

nu

mero

us

tim

es

Exte

rnal

25489

AD

ULTS H

em

el Team

26-F

eb

-16

11-A

pr-

16

11.4

3

Pati

en

t ca

nce

lled

nu

mero

us

tim

es

Exte

rnal

24613

AD

ULTS L

yn

dh

urs

t 15-J

an

-16

02-F

eb

-16

21.2

9

Can

celled

by t

rust

-

reo

rgan

isin

g a

pp

t In

tern

al

23944

AD

ULTS T

rau

ma

Un

it

01-D

ec-

15

07-D

ec-

15

03-M

ay-1

6

21.1

4

Lack

of

clin

ical ca

paci

ty

Inte

rna

l

24955

AD

ULTS H

em

el Team

22-F

eb

-16

29-F

eb

-16

17.4

3

Lack

of

clin

ical ca

paci

ty

Inte

rnal

24986

AD

ULTS L

yn

dh

urs

t 01-M

ar-

16

01-M

ar-

16

17.2

9

Lack

of

clin

ical ca

paci

ty

Inte

rnal

10536

AD

ULTS L

yn

dh

urs

t 04-J

an

-16

08-J

an

-16

07-A

pr-

16

12.8

6

Lack

of

clin

ical ca

paci

ty

Inte

rnal

Q1

Qua

lity

Rep

ort

Page 89 of 146

26

Wa

itin

g T

ime

Bre

ach

es – C

ity

an

d H

ack

ne

y (

Targ

et

<1

8 W

ee

ks)

Pati

en

t

ID

Team

R

efe

rral

Date

Clo

ck R

est

art

Ap

po

intm

en

t

Fir

st A

tten

ded

Ap

po

intm

en

t

Wait

Weeks

Co

mm

en

tary

fro

m s

erv

ice

In

tern

al/Exte

rnal

3553

CH

PC

Team

A

15-A

ug

-14

16-S

ep

-14

93.2

9

Did

no

t en

gag

e -

Ad

min

will

no

w p

roce

ss t

o d

isch

arg

e-

DN

A

ap

po

intm

en

t Exte

rnal

2571

CH

PC

Team

A

12-J

un

-15

12-J

un

-15

54.8

6

Did

no

t en

gag

e -

Ad

min

will

no

w p

roce

ss t

o d

isch

arg

e

Exte

rnal

4607

CH

PC

Team

C

15-A

pr-

15

03-J

ul-

15

51.8

6

Did

no

t en

gag

e -

Ad

min

will

no

w p

roce

ss t

o d

isch

arg

e

Exte

rnal

5092

CH

PC

Team

B

15-J

ul-

15

15-J

ul-

15

50.1

4

Did

no

t en

gag

e -

Ad

min

will

no

w p

roce

ss t

o d

isch

arg

e

Exte

rnal

279

CH

PC

Team

B

18-J

un

-15

11-A

ug

-15

46.2

9

Did

no

t en

gag

e -

Ad

min

will

no

w p

roce

ss t

o d

isch

arg

e-

Ass

ess

men

t

ap

po

intm

en

t se

en

2012

Exte

rna

l

4749

CH

PC

Team

C

11-M

ay-1

5

25-S

ep

-15

39.8

6

Did

no

t en

gag

e -

Ad

min

will

no

w p

roce

ss t

o d

isch

arg

e

Exte

rnal

24148

CH

PC

Team

A

23-D

ec-

15

23-D

ec-

15

27.1

4

Did

no

t en

gag

e

Exte

rnal

24099

CH

PC

Team

A

17-D

ec-

15

17-D

ec-

15

22-J

un

-16

26.8

6

Was

wait

ing

fo

r an

ass

ess

men

t ap

pt

neare

r to

ho

me

Exte

rnal

2338

CH

PC

Team

B

02-D

ec-

15

05-F

eb

-16

20.8

6

Un

ab

le t

o c

on

tact

pa

tien

t- G

rou

p T

reatm

en

t 2014

Exte

rna

l

23271

TC

PS C

are

Pla

nn

ing

Team

19-O

ct-1

5

09-F

eb

-16

20.2

9

Did

no

t en

gag

e

Exte

rnal

107

CH

PC

Team

B

06-O

ct-1

5

16-F

eb

-16

19.2

9

Did

no

t en

gag

e-

Ass

ess

men

t 2012

Exte

rnal

1386

CH

PC

Team

A

02-N

ov-1

5

16-F

eb

-16

19.2

9

Did

no

t en

gag

e-

Ass

ess

men

t 2012

Exte

rnal

4284

CH

PC

Team

B

08-F

eb

-15

08-F

eb

-15

72.5

7

No

op

t in

lett

er

sen

t In

tern

al

4333

CH

PC

Team

A

27-F

eb

-15

27-F

eb

-15

69.8

6

No

op

t in

lett

er

sen

t In

tern

al

4399

CH

PC

Team

B

27-F

eb

-15

27-F

eb

-15

69.8

6

No

op

t in

lett

er

sen

t In

tern

al

4411

CH

PC

Team

B

05-M

ar-

15

05-M

ar-

15

69

No

op

t in

lett

er

sen

t In

tern

al

4192

CH

PC

Team

B

13-A

pr-

15

13-A

pr-

15

63.4

3

No

op

t in

lett

er

sen

t In

tern

al

22416

CH

PC

Team

B

23-J

ul-

15

23-J

ul-

15

49

No

op

t in

lett

er

sen

t In

tern

al

22314

CH

PC

Team

C

31-J

ul-

15

31-J

ul-

15

47.8

6

No

op

t in

lett

er

sen

t In

tern

al

23573

CH

PC

Team

B

08-S

ep

-15

08-S

ep

-15

42.2

9

No

op

t in

lett

er

sen

t In

tern

al

22757

CH

PC

Team

A

08-S

ep

-15

08-S

ep

-15

09-J

un

-16

39.2

9

Aw

ait

ing

fo

r tr

eatm

en

t In

tern

al

23645

CH

PC

Team

C

10-N

ov-1

5

10-N

ov-1

5

33.2

9

No

op

t in

lett

er

sen

t In

tern

al

23900

CH

PC

Team

A

01-D

ec-

15

01-D

ec-

15

04-M

ay-1

6

22.1

4

Aw

ait

ing

fo

r tr

eatm

en

t In

tern

al

24805

CH

PC

Team

A

08-F

eb

-16

08-F

eb

-16

20.4

3

No

op

t in

lett

er

sen

t In

tern

al

24053

CH

PC

Team

B

15-D

ec-

15

15-D

ec-

15

21-A

pr-

16

18.2

9

Aw

ait

ing

fo

r tr

eatm

en

t In

tern

al

Page 90 of 146

27

Tru

stw

ide

Wa

itin

g T

ime

s fo

r Q

1 (

Da

ta r

un

15

-7-1

6)

Na

tio

na

l W

ait

ing

Tim

e S

erv

ice

s fo

r Q

1 (

Da

ta r

un

15

-7-1

6)

Wa

itin

g T

ime

s

Se

rvic

e

Tota

l p

ati

en

ts

Me

dia

n (

We

ek

s)

Av

era

ge

(W

ee

ks)

Cit

y a

nd

Ha

ckn

ey

18

we

ek

s 373

6.9

1

0.7

GID

S*

**

*

18

we

ek

s 7

97

(7

86

) 2

0 (

19

.4)

20

.5 (

19

.7)

Se

rvic

e

Targ

et

Tota

l p

ati

en

ts

Me

dia

n (

We

ek

s)

Av

era

ge

(W

ee

ks)

Ad

ole

sce

nt

an

d Y

ou

ng

Ad

ult

*

8 w

ee

ks

63

6.3

7

.2

Ad

ult

s 1

1 w

ee

ks

131

6.1

8

.9

Ca

md

en

CA

MH

S*

*

8 w

ee

ks

349

3.1

4

.6

Oth

er

CA

MH

S*

**

8 w

ee

ks

129

6.0

8

.3

Po

rtm

an

1

1 w

ee

ks

44

5.4

6

.2

We

stm

inst

er

6 w

ee

ks

19

4.0

4

.1

TO

TAL

n/a

735

5.7

6

.5

*A

YA

: N

ote

th

is c

oh

ort

do

es

no

t in

clu

de t

he f

ollo

win

g c

on

tract

: 901 N

PA

Ass

ess

men

t

**C

am

den

CA

MH

S:

No

te t

his

co

ho

rt d

oes

no

t in

clu

de t

he f

ollo

win

g c

on

tract

s: 0

60 F

irst

Ste

p,

025 T

OPS (

Tavis

tock

Ou

treach

Pro

ject

) &

903 G

lou

cest

er

Ho

use

Day U

nit

– a

s th

ese

serv

ices

are

no

t w

ait

ing

lis

t b

ase

d; th

ey a

re a

dir

ect

ass

ess

men

t/tr

eatm

en

t se

rvic

e

***O

the

r C

AM

HS:

No

te t

his

co

ho

rt d

oes

no

t in

clu

de t

he

fo

llo

win

g c

on

tract

s: 0

30 N

ew

Ru

sh S

cho

ol,

060 H

ari

ng

ey F

irst

Ste

p,

123 C

VV

A G

ran

t, 9

00 N

PA

Aw

ait

ing

Fu

nd

ing

, 901

NPA

Ass

ess

men

t, 9

04 A

do

pti

on

Su

pp

ort

ing

Fu

nd

& 9

99 L

eg

acy

.

****G

IDS:

11 d

orm

an

t fi

les

are

du

e t

o b

e c

lose

d. D

ata

in

bra

ckets

refl

ect

s th

e c

han

ge.

Q1

Qua

lity

Rep

ort

Page 91 of 146

28

Lo

nd

on

Co

ntr

act

ing

* W

ait

ing

Tim

es

for

Q1

(D

ata

ru

n 1

5-7

-16)

Wa

itin

g T

ime

s

Serv

ice

Ta

rget

Tota

l p

ati

en

ts

Med

ian

(W

eeks)

A

vera

ge (

Weeks)

Ad

ole

sce

nt

an

d Y

ou

ng

Ad

ult

8

we

ek

s 63

6.3

7

.2

Ad

ult

s 1

1 w

ee

ks

131

6.1

8

.9

Ca

md

en

CA

MH

S

8 w

ee

ks

348

3.1

4

.6

Oth

er

CA

MH

S

8 w

ee

ks

112

5.1

6

.7

TO

TAL

n/a

654

5.6

6

.9

*P

lea

se n

ote

Lo

nd

on

Co

ntr

act

s in

clu

de

co

ntr

act

nu

mb

ers

:

00

1, 0

02

, 0

03

, 0

04

, 0

05

, 0

07

, 0

10

, 0

11

, 0

12

, 0

13

, 0

14

, 0

15

& 0

18

.

Lon

do

n C

on

trac

ts

Cam

den

- A

du

lt

00

1

Cam

den

- C

AM

HS

01

0

Bar

net

0

02

Is

lingt

on

0

11

Enfi

eld

0

03

H

ou

nsl

ow

0

12

Har

inge

y 0

04

H

amm

ersm

ith

& F

ulh

am

01

3

Ealin

g 0

05

W

est

Lon

do

n

01

4

Cen

tral

Lo

nd

on

0

07

B

ren

t 0

15

Her

ts

01

8

Page 92 of 146

29

2. D

NA

Rate

s

*Ple

ase

no

te C

AM

DEN

TA

P S

ervi

ce is

no

t in

clu

ded

in t

his

dat

a se

t. A

sep

arat

e re

po

rt is

pro

du

ced

to

co

mm

issi

on

ers

fro

m t

he

EMIS

sys

tem

.

Tru

stw

ide D

NA

Rate

s*

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

779

817

837

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

117

113

123

To

tal fi

rst

Ca

nce

lled

193

221

247

To

tal fi

rst

ap

po

intm

en

ts

1089

1151

1207

% 1

st a

pp

oin

tmen

ts D

NA

'd

13%

12.2

%

12.8

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

13640

14012

16021

To

tal su

b. ap

po

intm

en

ts D

NA

'd

1219

1258

1562

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

3092

3253

3736

To

tal su

bse

qu

en

t ap

po

intm

en

ts

17951

18523

21319

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

8.2

%

8.2

%

8.9

%

To

tal %

DN

A

8.5

%

8.5

%

9.1

%

Ad

ult

DN

A R

ate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

62

84

67

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

6

7

15

To

tal fi

rst

Ca

nce

lled

22

54

41

To

tal fi

rst

ap

po

intm

en

ts

90

145

12

3

% 1

st a

pp

oin

tmen

ts D

NA

'd

8.8

%

7.7

%

18.3

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

2415

2569

28

26

To

tal su

b. ap

po

intm

en

ts D

NA

'd

179

205

25

4

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

580

607

59

3

To

tal su

bse

qu

en

t ap

po

intm

en

ts

3174

3381

36

73

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

6.9

%

7.4

%

8.3

%

To

tal %

DN

A

7.0

%

7.4

%

8.5

%

Q1

Qua

lity

Rep

ort

Page 93 of 146

30

Ad

ole

scen

t D

NA

Rate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

42

53

46

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

5

9

10

To

tal fi

rst

Can

celled

13

8

15

To

tal fi

rst

ap

po

intm

en

ts

60

70

71

% 1

st a

pp

oin

tmen

ts D

NA

'd

10.6

%

14.5

%

17.9

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

1105

1135

15

15

To

tal su

b. ap

po

intm

en

ts D

NA

'd

235

180

17

6

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

387

453

33

6

To

tal su

bse

qu

en

t ap

po

intm

en

ts

1727

1768

20

27

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

17.5

%

13.7

%

10.4

%

To

tal %

DN

A

17.3

%

13.7

%

10.7

%

DN

A R

ate

s

Cam

den

CA

MH

S D

NA

Rate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

312

235

29

4

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

32

30

40

To

tal fi

rst

Can

celled

45

52

90

To

tal fi

rst

ap

po

intm

en

ts

389

317

42

4

% 1

st a

pp

oin

tmen

ts D

NA

'd

8.8

%

11.3

%

12.0

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

4189

4306

49

97

To

tal su

b. ap

po

intm

en

ts D

NA

'd

329

406

57

1

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

814

884

13

90

To

tal su

bse

qu

en

t ap

po

intm

en

ts

5332

5596

69

58

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

6.9

%

8.6

%

10.3

%

To

tal %

DN

A

7%

8.8

%

10.4

%

Page 94 of 146

31

DN

A R

ate

s C

ity &

Hack

ney D

NA

Rate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

136

165

16

3

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

41

44

34

To

tal fi

rst

Can

celled

39

43

42

To

tal fi

rst

ap

po

intm

en

ts

216

252

23

9

% 1

st a

pp

oin

tmen

ts D

NA

'd

23.1

%

21.1

%

17.3

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

977

1170

10

40

To

tal su

b. ap

po

intm

en

ts D

NA

'd

180

160

14

9

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

305

423

26

8

To

tal su

bse

qu

en

t ap

po

intm

en

ts

1462

1753

14

57

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

15.6

%

12%

12.5

%

To

tal %

DN

A

16.6

%

13.3

%

13.2

%

Gen

der

Iden

tity

Serv

ice D

NA

Rate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

93

131

130

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

20

17

14

To

tal fi

rst

Can

celled

43

35

33

To

tal fi

rst

ap

po

intm

en

ts

156

183

177

% 1

st a

pp

oin

tmen

ts D

NA

'd

17.7

%

11.5

%

9.7

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

1022

1102

1356

To

tal su

b. ap

po

intm

en

ts D

NA

'd

95

134

136

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

201

235

294

To

tal su

bse

qu

en

t ap

po

intm

en

ts

1318

1471

1786

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

8.5

%

10.8

%

9.1

%

To

tal %

DN

A

9.4

%

10.9

%

9.2

%

Q1

Qua

lity

Rep

ort

Page 95 of 146

32

DN

A R

ate

s O

ther

CA

MH

S D

NA

Rate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

86

111

94

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

11

4

6

To

tal fi

rst

Can

celled

21

23

18

To

tal fi

rst

ap

po

intm

en

ts

118

138

11

8

% 1

st a

pp

oin

tmen

ts D

NA

'd

11.3

%

3.5

%

6.0

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

2474

2317

28

77

To

tal su

b. ap

po

intm

en

ts D

NA

'd

101

82

17

4

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

558

392

53

0

To

tal su

bse

qu

en

t ap

po

intm

en

ts

3133

2791

35

81

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

3.9

%

3.4

%

5.7

%

To

tal %

DN

A

4.2

%

3.4

%

5.7

%

Po

rtm

an

DN

A R

ate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

34

23

32

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

0

2

3

To

tal fi

rst

Can

celled

10

5

5

To

tal fi

rst

ap

po

intm

en

ts

44

30

40

% 1

st a

pp

oin

tmen

ts D

NA

'd

0%

8%

8.6

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

1104

1114

1262

To

tal su

b. ap

po

intm

en

ts D

NA

'd

98

88

91

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

237

254

292

To

tal su

bse

qu

en

t ap

po

intm

en

ts

1439

1456

1645

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

8.2

%

7.3

%

6.7

%

To

tal %

DN

A

8%

7.3

%

6.8

%

Page 96 of 146

33

DN

A R

ate

s

West

min

ster

DN

A R

ate

s

QU

AR

TER

1

Targ

et

<10%

2014/1

5

2015/1

6

2016/1

7

To

tal 1st

ap

po

intm

en

ts a

tten

ded

14

15

11

To

tal fi

rst

ap

po

intm

en

ts D

NA

's

2

0

1

To

tal fi

rst

Can

celled

0

1

3

To

tal fi

rst

ap

po

intm

en

ts

16

16

15

% 1

st a

pp

oin

tmen

ts D

NA

'd

12.5

%

0%

8.3

%

To

tal su

bse

qu

en

t ap

po

intm

en

ts a

tten

ded

354

299

148

To

tal su

b. ap

po

intm

en

ts D

NA

'd

2

3

11

To

tal su

bse

qu

en

t ap

po

intm

en

ts C

an

celled

10

5

33

To

tal su

bse

qu

en

t ap

po

intm

en

ts

366

307

192

% D

NA

su

bse

qu

en

t A

pp

oin

tmen

ts

0.6

%

1%

6.9

%

To

tal %

DN

A

1%

1%

7.0

%

Q1

Qua

lity

Rep

ort

Page 97 of 146

34

3. S

afe

ty –

Safe

gu

ard

ing

Tra

inin

g

Level 1 S

afe

gu

ard

ing

Tra

inin

g –

Ad

ult

+ C

hild

ren

Qu

art

er

Q1

Q

2

Q3

Q

4

% o

f st

aff

wh

ose

tra

inin

g

is 'in

da

te'

9

4%

Narr

ati

ve

Q

uart

er

1 r

esu

lts

To

tal n

um

bers

req

uir

ing

tra

inin

g:

5

59

Nu

mb

er

of

staff

tra

ined

:

52

8

Nu

mb

er

of

staff

NO

T t

rain

ed

:

31

Rati

on

ale

(R

easo

n f

or

no

n-a

tten

dan

ce):

12

new

sta

rter

s an

d 1

1 h

ave

bo

oke

d o

nto

Sep

tem

ber

ind

uct

ion

an

d 1

bo

oke

d o

n t

he

Dec

emb

er in

du

ctio

n.

13

sta

ff w

ere

du

e to

att

end

IN

SET

day

an

d h

ave

exem

pti

on

s fr

om

th

eir

Dir

ecto

r, 3

sta

ff h

ave

retu

rned

fro

m M

AT

Leav

e th

is y

ear

and

are

wit

hin

po

licy

com

pli

ance

. 3

are

ove

rdu

e h

ave

com

ple

ted

so

me

on

line

trai

nin

g an

d w

ill a

tten

d t

he

rest

of

the

sess

ion

in N

ove

mb

er 2

01

6.

All

hav

e b

oo

ked

on

th

e N

ove

mb

er d

ate.

3 s

taff

wer

e n

ot

invi

ted

an

d n

ow

bee

n b

oo

ked

.

Level 2 S

afe

gu

ard

ing

Tra

inin

g –

Ch

ild

ren

on

ly

Qu

art

er

Q1

Q

2

Q3

Q

4

% o

f st

aff

wh

ose

tra

inin

g

is 'in

date

'

92

%

Narr

ati

ve

Q

uart

er

1 r

esu

lts

To

tal n

um

bers

req

uir

ing

tra

inin

g: 36

3

6

Nu

mb

er

of

staff

tra

ined

:

33

Nu

mb

er

of

staff

NO

T t

rain

ed

:

3

Rati

on

ale

(R

easo

n f

or

no

n-a

tten

dan

ce):

3

sta

ff d

ue

to a

tten

d a

re d

ue

and

hav

e b

oo

ked

fo

r Ju

ly o

r Se

pt

dat

es.

Level 3 S

afe

gu

ard

ing

Tra

inin

g –

Ch

ild

ren

on

ly

Qu

art

er

Q1

Q

2

Q3

Q

4

% o

f st

aff

wh

ose

tra

inin

g

is 'in

date

'

93

%

Narr

ati

ve

Q

uart

er

1 r

esu

lts

To

tal n

um

bers

req

uir

ing

tra

inin

g:

3

01

Nu

mb

er

of

staff

tra

ined

:

28

2

Nu

mb

er

of

staff

NO

T t

rain

ed

:

19

Rati

on

ale

(R

easo

n f

or

no

n-a

tten

dan

ce):

1

0 s

taff

bo

oke

d f

or

19

th A

pri

l tra

inin

g w

hic

h w

as c

ance

lled

at

the

last

min

ute

an

d t

hey

hav

e al

l res

ched

ule

d.

Thre

e st

aff

ha

ve h

ad M

AT

or

CB

. Fi

ve s

taff

are

new

sta

rter

s an

d a

ll h

ave

dat

es b

oo

ked

. On

e st

aff

du

e h

ad n

ot

bee

n in

vite

d a

nd

has

no

w b

oo

ked

fo

r Ju

ly.

Page 98 of 146

35

4. G

loss

ary

A

YA

(A

YA

S):

Ad

ole

sce

nt

an

d Y

ou

ng

Ad

ult

Se

rvic

e

BM

E:

Bla

ck M

ino

rity

Eth

nic

B

TS

: B

riti

sh T

ho

raci

c So

cie

ty

CA

MH

S:

Ch

ild

ren

, A

do

lesc

en

t, M

en

tal

Hea

lth

Se

rvic

e

Care

Pla

ns:

A d

ocu

me

nte

d p

lan

th

at

desc

rib

es

the

pati

en

t's

con

dit

ion

an

d p

roce

du

re(s

) th

at

wil

l b

e n

ee

ded

, d

eta

ilin

g t

he t

rea

tmen

t to

be

pro

vid

ed

an

d e

xp

ect

ed

ou

tco

me

, a

nd

exp

ect

ed

du

rati

on

of

the

tre

atm

en

t p

resc

rib

ed

by t

he

cli

nic

ian

C

CG

: C

lin

ica

l C

om

mis

sio

nin

g G

rou

p

Clin

ica

l O

utc

om

es

in R

ou

tin

es

Ev

alu

ati

on

(C

OR

E)

Fo

rm:

Th

is is

a c

lie

nt

self

-re

po

rt q

uest

ion

na

ire

desi

gn

ed

to

be a

dm

inis

tere

d b

efo

re a

nd

aft

er

the

rap

y. T

he c

lie

nt

is

ask

ed

to

re

spo

nd

to

34

qu

est

ion

s a

bo

ut

ho

w t

he

y h

ave

bee

n f

ee

lin

g o

ver

the

la

st w

ee

k, u

sin

g a

5-p

oin

t sc

ale

ra

ng

ing

fro

m 'n

ot

at

all

' to

'm

ost

or

all

of

the

tim

e'.

C

QU

IN:

Co

mm

issi

on

ing

fo

r Q

ua

lity

an

d In

no

va

tio

n P

aym

en

t Fra

me

wo

rk

CY

AF:

Ch

ild

ren

, Y

ou

ng

Ad

ult

an

d F

am

ily S

erv

ice

DA

: D

om

est

ic V

iole

nce

D

BS:

Dis

clo

sure

an

d B

arr

ing

Se

rvic

e

DN

A:

Did

no

t a

tte

nd

D

V: D

om

est

ic V

iole

nce

E

SQ

: E

xp

eri

en

ce o

f Se

rvic

e Q

ue

stio

nn

air

e

GB

M:

Go

al

Ba

sed

Me

asu

re

GID

S: G

en

de

r Id

en

tity

Se

rvic

e

KP

I: K

ey P

erf

orm

an

ce In

dic

ato

r M

DT:

Mu

lti-

Dis

cip

lin

ary

Te

am

N

CL:

No

rth

Ce

ntr

al Lo

nd

on

N

ICE

: N

ati

on

al In

stit

ute

fo

r H

ea

lth

an

d C

are

Exce

lle

nce

N

RT:

Nic

oti

ne

Rep

lace

me

nt

Th

era

py

OM

: O

utc

om

e M

on

ito

rin

g

PC

T: P

rim

ary

Care

Tru

st

PD

P: P

ers

on

al D

eve

lop

me

nt

Pla

n

PP

I: P

ati

en

t P

ub

lic

Invo

lve

me

nt

PR

OM

: P

ati

en

t R

ep

ort

ed

Ou

tco

me

Mea

sure

S

WA

P: T

he S

hed

ler-

We

ste

n P

roce

du

re

TP

FT: Ta

vis

tock

an

d P

ort

ma

n F

ou

nd

ati

on

Tru

st

V: V

iole

nce

V

SP

: V

isu

al

Str

aw

Po

ll

Ma

rio

n S

hip

ma

n

Ass

oci

ate

Dir

ect

or

Qu

ali

ty &

Go

ve

rnan

ce

Ap

ril – M

ay

– J

un

e 2

01

6

Q1

Qua

lity

Rep

ort

Page 99 of 146


Item : 15

Title : Quarter 1 Governance statement

Purpose:

The Board of Directors is asked to approve three elements of the

governance statement to be submitted to Monitor for quarter 1:

For Finance

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.

For Governance

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.

Otherwise

The board confirms that there are no matters arising in the quarter

requiring an exception report to Monitor (per the Risk Assessment

Framework page 22, table 3) which have not already been reported.

This paper was reviewed at the Executive Management Team on 19 July.

Members supported all these statements and confirmed that we are not

aware of any risk to compliance with any conditions of our licence.


Risk

Finance

Quality

For : Approval

From : Deputy Chief Executive and Director of Finance

Gov

erna

nce

stat

emen

t

Page 100 of 146

Quarter 1 Governance Statement

1. Introduction

1.1 NHS Improvement oversees NHS foundation trusts through the terms

of our provider licence and through the Risk Assessment Framework.

1.2 A key element of the Risk Assessment Framework is the requirement

to submit a governance statement each quarter.

1.3 This quarter’s statement is to be returned to Monitor by 31 July.

1.4 The Risk Assessment Framework is due to be replaced during this

year. The proposed new Single Oversight Framework has been

issued for consultation; its implementation date is not yet known.

2. Finance declaration

2.1 Based on the Trust’s Operational Plan the results for the four metrics

which comprise the financial sustainability risk rating FSRR are:

Our I&E margin is projected to be 1.75% of income (thanks to

the inclusion of the £500k ST funding), and is therefore be

rated at 4 for all quarters of 2016/17.

Our current rating on “Variance from Plan” is 4, due to

exceeding Plan in 2015/16. To retain this rating at each

quarter through the year, we need to achieve or exceed the

Plan I&E margin. If the margin is less than 1% below Plan, the

Variance from Plan rating will only reduce from 4 to 3.

Our Liquidity rating is projected to be 3 or 4 throughout the

year; though this could fall to 2 with a relatively small

variation in performance.

Our Capital Service Cover rating is projected to be 4 for all

quarters of 2015/16.

2.2 The four elements are each given a 25% weighting; so based on the

ratings predicted, our FSRR will be 3.75 which is rounded to 4, the

highest rating.

2.3 If the Variance from Plan rating reduces to 3 and the Liquidity rating

reduces to 2, then the overall FSRR will be 3.25, which is rounded to 3

and remains satisfactory.

2.4 The liquidity rating is assisted by the securing of the medium-term

loan from ITFF to fund the capital expenditure on continuing

preparatory work for the relocation project.

Page 101 of 146

2.5 The three ratings relating to surplus (the Capital Service Cover and

I&E margin) are all calculated without including certain exceptional

items such as restructuring costs.

2.6 The plan for the first quarter of 2017/18 is to remain at these levels,

though we do not yet have detailed plans to achieve this.

2.7 Based on the above, we are able to affirm that we anticipate that

the trust will continue to maintain a financial sustainability risk

rating of at least 3 over the next 12 months.

2.8 Though capital expenditure is below plan in the first quarter, we are

currently forecasting that it will be in line with plan for the year as a

whole. This will be reviewed after the second quarter.

3. Governance Declaration

3.1 Declaration of risks against healthcare targets and indicators

3.1.1 The Monitor template for our quarterly return sets out a list of

targets and indicators, in line with the Risk Assessment Framework.

The targets and indicators which apply to this Trust are given in the

table below.

3.1.2 All targets and indicators are being met; and plans are sufficient to

ensure that they continue to be met. Further details are given below.

The Trust should therefore continue to receive a green governance

rating.

Target/Indicator Weighting Quarter 1 result

Data completeness: 97%

completeness on all 6 identifiers 1.0

Achieved (see

3.4 below) 0

Compliance with requirements

regarding access to healthcare for

people with a learning disability

1.0 Achieved (see

3.3. below) 0

Risk of, or actual, failure to deliver

Commissioner Requested Services

Report by

exception

No 0

CQC compliance action

outstanding No 0

CQC enforcement action within

the last 12 months No 0

CQC enforcement action

(including notices) currently in

effect

No 0

Moderate CQC concerns or

impacts regarding the safety of

healthcare provision

No 0

Major CQC concerns or impacts

regarding the safety of healthcare

provision

No 0

Gov

erna

nce

stat

emen

t

Page 102 of 146

Target/Indicator Weighting Quarter 1 result

Unable to declare ongoing

compliance with minimum

standards of CQC registration

No 0

Total score 0

Indicative rating

3.2 Care Quality Commission

3.2.1 The Trust was registered by the CQC on 1 April 2010 with no

restrictions. Actions continue to ensure that this status is retained;

assurance is considered at the quarterly meetings of the CQSG

Committee.

3.2.2 The Trust remains compliant with the CQC registration requirements.

3.2.3 Following the CQC inspection in January, their report was published

at the end of May, and has been fully discussed by the Board. The

overall rating was Good; ratings for four of the five domains were

also Good, while the rating for safety was Requires Improvement.

An action plan covering all five domains has been approved and is

being implemented; the CQSG Committee will continue to monitor

the progress and completion of these actions. In management’s

view, the points raised in the report do not amount to ‘moderate

concerns or impacts’ regarding safety, though clearly it is essential

that the agreed actions are completed promptly.

3.3 Self certification against compliance with requirements regarding

access to healthcare for people with a learning disability

3.3.1 The Lifespan team manager carried out the Green Light audit, the

self-assessment tool for our services for people with a learning

disability, in January. This confirmed that the Trust meets the access

requirements for this group. Action is being taken on two points for

further development: (a) continue to develop the gathering and

recording on CareNotes to show how we meet the needs of people

with a Learning Disability via CareNotes; and (b) continue to develop

literature describing our services for patients with a learning

disability.

3.3.2 The Trust has continued to develop its services for LD service users,

and actively involves users to further refine and tailor provision. The

Lifespan team has introduced Photosymbols, a picture based system,

to ensure that where necessary correspondence is written in ways

that fit the communication needs of service users. They are also

continuing to work on a phone App to act as an adjunct to

therapeutic support; though this is initially being tested for people

with autism spectrum conditions, it may later be applicable to a

wider population.

Page 103 of 146

3.4 Data Completeness

3.4.1 The target is 97% completeness on six data identifiers within the

Mental Health Services Data Set (MHSDS). This replaced the MHLDDS

on 1 January, and includes children and young people’s services; so

the number of patients covered for this Trust has almost doubled.

Current statistics confirm that we are still meeting and generally

exceeding the completeness target: see table below.

Month 2,

provisional

Month 1,

final

Valid NHS number 99.24% 99.43%

Valid Postcode 99.68% 99.69%

Valid Date of Birth 100.00% 100.00%

Valid Organisation code of Commissioner 99.55% 99.39%

Valid Organisation code GP Practice 99.70% 99.25%

Valid Gender 100.00% 100.00%

3.4.2 The proposals for the new Single Oversight Framework include a

target of 85% completeness by March 2017 for five additional

“priority” identifiers within the MHSDS. We are currently assessing

the feasibility of achieving this target. Action is already being taken

to improve our collection of Ethnicity, which is one of the five; we

aim to develop action plans for all five. Our response to the

consultation will cover this proposal.

4. Other matters

4.1 The Trust is required to report any “incidents, events or reports which

may reasonably be regarded as raising potential concerns over

compliance with [our] licence.” The Risk Assessment Framework

gives – on page 22 – a non-exhaustive list of examples where such a

report would be required, including unplanned significant reduction

in income or significant increase in costs; discussions with external

auditors which may lead to a qualified audit report; loss of

accreditation of a Commissioner Requested Service; adverse report

from internal auditors; or patient safety issues which may impact

compliance with our licence.

4.2 There are no such matters on which the Trust should make an

exception report.

Simon Young

Deputy Chief Executive and Director of Finance

19 July 2016

Gov

erna

nce

stat

emen

t

Page 104 of 146

Board of Directors: July 2016

Item : 16

Title : Human Resources and Organisational Development 2016/17 – Quarter 1 Report

Purpose: This paper outlines progress made against the strategic HR and organisational development business plan, which overall is progressing as planned. Incorporated within this report are the quarter 1 workforce key performance indicators and metrics.

This report focuses on the following areas: (delete where not applicable)

Quality

Workforce

For : The Board of Directors

From : Craig de Sousa, Director of Human Resources

Hum

an R

esou

rces

Q1

Page 105 of 146

Human Resources and Organisational Development Quarter 1 Report

1. Introduction

This quarterly report details a number of active pieces of work that has been led or

supported by the trust's Human Resources (HR) Directorate during quarter 1 of

2016/17.

This paper sets out progress made against the strategic HR and organisational

development business plan, set in April this year, which details a number of deliverables

that will lead to the creation of an organisational development and people strategy.

Included within this report are a set of key workforce metrics which are monitored by a

number of internal and external stakeholders.

2. Staff Survey Action Plan

The HR business partners have been working with their managers to continue to

implement the corporate and localised action plans. Some of the actions are a little

behind schedule but are progressing with close oversight by the director of HR and

through a range of established groups, like the joint staff consultative committee

(JSCC).

In quarter two the directorate will be starting to prepare for the 2016/17 survey. We

will be working closely with managers to agree the best reporting mechanisms for the

next survey process to allow the granular level of reporting and much more meaningful

action planning.

3. Health and wellbeing

In June 2016 we held a trust wide health and wellbeing event to showcase what we

offer to our staff and also to explore what more we can do as an employer. The event

was well attended with 97 staff visiting the lecture theatre.

Throughout the day we offered the following:

Launched our new physiotherapy service provided by the Royal Free’s

occupational health service;

Provided staff with the change to have a ‘health MOT’;

Promoted the work our physical health nurse is leading on;

Provided information about healthy eating and healthy living; and

Offered some staff a complementary massage.

Twenty two members of staff that attended the event completed an evaluation form.

The feedback was positive and indicates we ought to plan a follow up event post-

Christmas.

Page 106 of 146

4. Strategic HR business plan for 2016/17 – progress update

The table bellows sets out the activities described in the annual business plan and

highlights the current status of each deliverable.

On target / complete

Progressing but behind target

Significantly behind target

Not started

Activity 5 Year Ambition Alignment

Responsible Q1 Q2 Q3 Q4

Organisational development and workforce strategy

Commence the

narrative activities for

the strategy

Reinforce our

reputation as one

of the best places

to work in the NHS

HR Director X X

Draft strategy

consultation process

HR Director X

Final strategy for

board approval

HR Director X

Health and Wellbeing

Finalise the health and

wellbeing strategy

Enhance the

capability of our

organisation

HR Business Partner X

Re-procure the

occupational health

contract

HR Business Partner X X X

Staff engagement

Managers to

implement immediate

actions to the staff

survey and HR report

on progress

Reinforce our

reputation as one

of the best places

to work in the NHS


Plan for launch of

2016 survey and agree

granular reporting

levels


Launch the staff

survey promoting

actions taken to

respond

HR Business Partner

Head of

Communications

X

Report on findings

from 2016 survey and

re-engage with staff


Employee relations

Review key HR policies

– disciplinary,

grievance, capability,

sickness management

and change

management

Reinforce our

reputation as one

of the best places

to work in the NHS

HR Director & HR

Business Partner

X X

Medical Staffing

Hum

an R

esou

rces

Q1

Page 107 of 146



Support the Trust’s

training programme

directors to map

existing rotas against

the proposed revised

rules

Enhance the

capability of our

organisation

Resourcing and

Development

Manager and HR

Business Partner

X

Appoint a rota

guardian to oversee

the safety monitoring

process for the new

contract

Resourcing and

Development

Manager

Medical Director

X X

Work with training

programme directors

to explore the impacts

of the new contract

Resourcing and

Development

Manager

X X

Recruitment and sourcing

Review the trust’s

recruitment and HR

administration

procedures with

involvement from line

managers and

introduce KPI metrics

Reinforce our

reputation as one

of the best places

to work in the NHS

Enhance the

capability of our

organisation

Improve our use of

information and

technology

Resourcing and

Development

Manager

X X

Explore opportunities

for enhancing our e-

recruitment solution

Resourcing and

Development

Manager

X X

Review our branding

and marketing

information for

prospective applicants

Resourcing and

Development

Manager

Head of

Communications

X X

Learning and organisational development

Finalise organisation

learning needs

analysis and

commission

educational

requirements

Reinforce our

reputation as one

of the best places

to work in the NHS

Enhance the

capability of our

organisation

Improve our use of

information and

technology

Resourcing and

Development

Manager

Organisational

Development

Consultant

X

Scope and develop a

trust wide

management

development

programme

harnessing the

resources from the

NHS Leadership

Academy Programmes

Organisational

Development

Consultant

X X

Page 108 of 146



Launch cohorts 1 – 4 Resourcing and

Development

Manager

X X

Transition all training

records on to Oracle

Learning Manager

Resourcing and

Development

Manager

X X

Develop a succession

planning framework

HR Director X

Review and revised

the Trust’s appraisal

process

Organisational

Development

Consultant

X

Reward and recognition

Explore the flexibilities

that existing with

Agenda for Change

and whether we

ought to explore local

terms and conditions

of service

Reinforce our

reputation as one

of the best places

to work in the NHS

HR Director and

Chair of Staff Side

X X

Assess the existing

mechanisms for

recognising and

rewarding staff

Reinforce our

reputation as one

of the best places

to work in the NHS


Develop a recognition

framework and

process


Hum

an R

esou

rces

Q1

Page 109 of 146

5. Key workforce indicators

Period: April 2016 - June 2016

Apr May Jun Q1

Full Time Equivalent Staff in Post (FTE) 495.39 492.97 495.29 494.55

Headcount 594 594 598 595.33

Vacancy Rate 13.56% 14.69% 14.86% 14%

Turnover (Annual) 19.74% 19.69% 19.47% 20%

Stability Index 81.31% 81.42% 81.25% 81%

Sickness Absence Spot Month 2.18% 1.81% 1.48%* 1.82%

Sickness Absence 12 month rolling average 1.42% 1.49% 1.53% 1.48%

Appraisal Compliance (Annual) 98% 99% 99% 99%

Establishment FTE (From Finance ) 573.09 577.89 581.72

*sickness data is entered retrospectively by the payroll team. As a result this figure is likely to increase in the following

month once data entry has been completed.

** data definitions are included in Appendix A of this report.

The trust’s vacancy rate is progressively rising throughout quarter one. This is a result of

new positions being created within the gender identity development service (GIDS)

which are in the final stages of being recruited to. There are other vacancies which the

0

100

200

300

400

500

600

700

Apr May Jun

Full Time EquivalentStaff in Post (FTE)

Headcount

Establishment FTE(From Finance )

Page 110 of 146

HR business partners are working with managers to explore the best way to fill these

posts or review them accordingly.

Whilst there are 86.47FTE vacancies, 7.43 are currently occupied by staff who are

seconded in to the organisation and are not on the payroll and 43.67 are covered by

bank and agency staff.

The HR business partners completed an action arising from the 2015/16 year-end report

which was to explore why the sickness absence rate is increasing. The increase follows

on from work they have been doing to support managers manage absence which is

also resulting in better compliance with submitting the sickness returns to payroll.

The quarter one statistics indicate a decline in absence rates, however, this may change

once retrospective data has been entered by the payroll team.

6. Mandatory and Statutory Training Compliance

Description

Quarter 1 2016/17

Mandatory Training Compliance – INSET Attendance

94%

Description Quarter 1

2016/17

Basic Life Support 99%

Conflict Resolution Training 100%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

Apr May Jun

Sickness Absence SpotMonth

Hum

an R

esou

rces

Q1

Page 111 of 146

Ladder Safety 100%

Manual Handling 100%

Online Safer Recruitment Training 45%

Safeguarding Children – Level 2 92%

Safeguarding Children – Level 3 93%

Statutory and mandatory training compliance is positive with the exception of staff

having completed online safer recruitment training. A review is currently being

undertaken whether the e-learning programme is the best deliver method and whether

an alternative can be designed and implemented to improve compliance.

7. Conclusions and recommendations

Members of the Trust Board are asked to note the contents of this report.

Craig de Sousa Director of Human Resources

July 2016

Page 112 of 146

Appendix A – Workforce KPI Data Definitions

Full Time Equivalent Staff in Post (FTE) The number of staff employed by the Trust relative to the hours that they work each week

Headcount The number of people employed by the Trust

Vacancy Rate The % of FTE staff employed compared to the funded establishment

Turnover (Annual) The % of staff which have left the organisation in the last twelve months

Stability Index A % indicator which demonstrates the retention rate of staff employed with more than twelve months service

Sickness Absence Spot Month The number of FTE days lost as a result of sickness compared to those available for one given month

Sickness Absence 12 month rolling average The number of FTE days lost as a result of sickness compared to those available over the last twelve months

Appraisal Compliance (Annual) The % of staff with a completed appraisal and personal development plan

Hum

an R

esou

rces

Q1

Page 113 of 146

Board of Director : 26 July 2016

Item : 17

Title : Workforce Race Equality Standard - 2016

Summary :

The NHS Equality and Diversity Council announced on July 31

2014 that it had agreed action to ensure employees from black

and ethnic minority (BME) backgrounds have equal access to

career opportunities and receive fair treatment in the

workplace.

Trusts were required to submit a set of baseline data in 2015,

set an action plan and then review progress a year later. This

paper sets out our assessment against a number of assessment

areas, details our current workforce statistics and provides a

follow on action plan.

For : Discussion & Agreement

From : Craig de Sousa, Director of Human Resources & Louise

Lyon, Director of Quality and Patient Experience

W

RE

S

Page 114 of 146

W

ork

forc

e R

ace

Equ

alit

y St

and

ard

Ju

ly 2

01

6

Nam

e o

f P

rovi

der

Org

anis

atio

n

Dat

e o

f R

epo

rt

Tavi

sto

ck a

nd

Po

rtm

an N

HS

Fou

nd

atio

n T

rust

Ju

ly 2

01

6

Nam

e a

nd

tit

le o

f B

oar

d le

ad f

or

the

Wo

rkfo

rce

Rac

e Eq

ual

ity

Stan

dar

d

Lou

ise

Lyo

n, D

irec

tor

of

Qu

alit

y an

d P

atie

nt

Exp

erie

nce

/Dir

ecto

r o

f A

du

lt a

nd

Fo

ren

sic

Serv

ices

/Ch

air

of

the

Equ

alit

ies

Co

mm

itte

e

Nam

e a

nd

co

nta

ct d

etai

ls o

f m

anag

er r

esp

on

sib

le f

or

com

pili

ng

this

rep

ort

C

aro

l Yo

rric

k , H

R B

usi

nes

s P

artn

er

Nam

e o

f C

om

mis

sio

ner

s to

wh

om

th

is r

epo

rt h

as b

een

sen

t N

ame

an

d c

on

tact

det

ails

of

coo

rdin

atio

n C

om

mis

sio

ner

to

wh

om

th

is r

epo

rt h

as b

een

sen

t U

RL

Lin

k to

th

is r

epo

rt

Rep

ort

sig

ned

off

by

(on

beh

alf

of

the

Bo

ard

)

Dat

e

Page 115 of 146

Lou

ise

Lyo

n

Re

po

rt o

n t

he

WR

ES In

dic

ato

rs

1.

Bac

kgro

un

d N

arra

tive

a.

Issu

es

rela

tin

g to

co

mp

lete

nes

s o

f d

ata

The

tru

st h

as b

een

ab

le t

o f

ulf

ill t

he

maj

ori

ty o

f d

ata

req

uir

emen

t to

mee

t th

e W

RES

. Th

e o

ne

area

wh

ere

we

can

no

t, y

et, p

rovi

de

dat

a is

aro

un

d

trai

nin

g an

d t

he

nu

mb

er o

f st

aff

app

lyin

g fo

r n

on

-man

dat

ory

co

nti

nu

ing

pro

fess

ion

al d

evel

op

men

t.

b.

Issu

es r

ela

tin

g to

re

liab

ility

of

com

par

iso

ns

No

ne

to r

epo

rt.

2.

Staf

f N

um

ber

s a.

To

tal n

um

ber

of

staf

f e

mp

loye

d w

ith

in t

he

org

anis

atio

n a

t th

e d

ate

of

the

re

po

rt

612

b.

Pro

po

rtio

n o

f B

ME

staf

f em

plo

yed

wit

hin

th

e o

rgan

isat

ion

at

the

dat

e o

f th

e r

ep

ort

26%

of

ou

r w

ork

forc

e ar

e fr

om

a B

ME

bac

kgro

un

d

WR

ES

Page 116 of 146

R

ep

ort

on

th

e W

RES

Ind

icat

ors

con

tin

ued

3

. Se

lf-r

epo

rtin

g

a.

The

pro

po

rtio

n o

f to

tal s

taff

wh

o h

ave

sel

f-re

po

rted

th

eir

eth

nic

ity

98

.02

% o

f o

ur

per

man

ent

wo

rkfo

rce

hav

e se

lf r

epo

rted

th

eir

eth

nic

ity.

b.

Step

s ta

ken

in t

he

last

re

po

rtin

g p

erio

d t

o im

pro

ve t

he

leve

l of

self

-rep

ort

ing

by

eth

nic

ity

The

curr

ent

leve

l is

very

go

od

an

d w

e fe

el t

hat

ou

r sy

ste

ms

for

cap

turi

ng

eth

nic

det

ails

are

ro

bu

st.

c.

Step

s p

lan

ne

d d

uri

ng

the

cu

rren

t re

po

rtin

g p

erio

d t

o im

pro

ve t

he

leve

l of

self

-re

po

rtin

g b

y et

hn

icit

y

In Q

4 o

f 2

016/

17 w

e a

re li

kely

to

sta

rt im

ple

men

tin

g ES

R s

elf

serv

ice

wh

ich

will

giv

e st

aff

the

op

po

rtu

nit

y to

qu

alit

y ch

eck

thei

r o

wn

rec

ord

an

d m

ake

amen

dm

ents

to

th

eir

div

ers

ity

dat

a.

4.

Wo

rkfo

rce

Dat

a

a.

Pe

rio

d t

o w

hic

h t

he

org

anis

atio

n’s

wo

rkfo

rce

dat

a re

fers

3

1 M

arch

20

16

Page 117 of 146

R

ep

ort

on

th

e W

RES

Ind

icat

ors

co

nti

nu

ed

5.

Wo

rkfo

rce

Rac

e Eq

ual

ity

Ind

icat

ors

Ind

icat

or

Dat

a fo

r th

e re

po

rtin

g ye

ar

201

4-1

5

Dat

a fo

r th

e p

revi

ou

s ye

ar

20

15

-16

Nar

rati

ve: T

he

imp

licat

ion

s o

f th

e d

ata

and

an

y ad

dit

ion

al b

ackg

rou

nd

ex

pla

nat

ory

nar

rati

ve

Act

ion

tak

en

an

d p

lan

ned

, in

clu

din

g e

.g.

do

es t

he

ind

icat

or

link

to E

DS2

evi

den

ce

and

/or

a co

rpo

rate

Eq

ual

ity

ob

ject

ive

For

each

of

thes

e fo

ur

wo

rkfo

rce

ind

icat

ors

, th

e St

and

ard

co

mp

ares

th

e m

etri

cs f

or

Wh

ite

an

d B

ME

staf

f 1

Per

cen

tage

of

staf

f in

eac

h o

f th

e A

fC B

and

s 1

-9 a

nd

VSM

(i

ncl

ud

ing

exe

cuti

ve B

oar

d

mem

ber

s) c

om

par

ed w

ith

th

e p

erce

nta

ge o

f st

aff

in t

he

ove

rall

wo

rkfo

rce.

O

rgan

isat

ion

s sh

ou

ld u

nd

erta

ke

this

cal

cula

tio

n s

ep

arat

ely

fo

r n

on

-clin

ical

an

d f

or

clin

ical

sta

ff.

23%

of

ou

r w

ork

forc

e ar

e fr

om

a B

ME

bac

kgro

un

d

See

app

end

ed

dat

a sh

eet

for

furt

her

det

ails

26

% o

f o

ur

wo

rkfo

rce

are

fro

m a

BM

E b

ackg

rou

nd

Se

e ap

pen

ded

d

ata

shee

t fo

r fu

rth

er d

etai

ls

Ther

e is

a s

mal

l po

siti

ve s

hif

t in

ou

r w

ork

forc

e st

atis

tics

, ho

wev

er, i

t is

ac

kno

wle

dge

d t

hat

th

ere

is m

ore

w

ork

to

do

to

can

ou

r w

ork

forc

e gr

ade

mix

.

The

chan

ge is

like

ly t

o b

e re

flec

tive

fro

m

a ra

nge

of

trai

nin

g in

terv

enti

on

s,

awar

enes

s ra

isin

g an

d a

lso

th

e im

ple

men

tati

on

of

sen

ior

HR

sta

ff

par

tici

pat

ing

on

sel

ecti

on

pro

cess

es f

or

po

sts

grad

ed 8

an

d a

bo

ve.

WR

ES

Page 118 of 146

R

ep

ort

on

th

e W

RES

Ind

icat

ors

co

nti

nu

ed

5.

Wo

rkfo

rce

Rac

e Eq

ual

ity

Ind

icat

ors

Ind

icat

or

Dat

a fo

r th

e re

po

rtin

g ye

ar

201

4-1

5

Dat

a fo

r th

e p

revi

ou

s ye

ar

20

15

-16

Nar

rati

ve: T

he

imp

licat

ion

s o

f th

e d

ata

and

an

y ad

dit

ion

al b

ackg

rou

nd

ex

pla

nat

ory

nar

rati

ve

Act

ion

tak

en

an

d p

lan

ned

, in

clu

din

g e

.g.

do

es t

he

ind

icat

or

link

to E

DS2

evi

den

ce

and

/or

a co

rpo

rate

Eq

ual

ity

ob

ject

ive

2 R

elat

ive

likel

iho

od

of

BM

E st

aff

bei

ng

app

oin

ted

fro

m

sho

rtlis

tin

g co

mp

ared

to

th

at o

f W

hit

e s

taff

bei

ng

app

oin

ted

fr

om

sh

ort

listi

ng

acro

ss a

ll p

ost

s.

Wh

ite

: 70

.1%

B

ME:

27

%

Da

ta r

epo

rted

in

pre

vio

us

WR

ES

Wh

ite

sta

ff a

re

mo

re li

kely

to

b

e ap

po

inte

d

than

BM

E st

aff.

Se

e d

ata

shee

t fo

r fu

rth

er

det

ails

Ther

e re

mai

ns

a ga

p b

etw

een

th

e lik

elih

oo

d o

f B

ME

staf

f b

ein

g ap

po

inte

d c

om

par

ed t

o w

hit

e st

aff.

Sin

ce M

arch

20

16

, sen

ior

HR

p

rofe

ssio

nal

s h

ave

star

ted

par

tici

pat

ing

on

se

lect

ion

pan

els

for

po

sts

grad

ed

Ban

d 8

an

d a

bo

ve. T

hei

r ro

le is

to

p

rovi

de

chal

len

ge b

ias

that

may

em

erge

an

d s

up

po

rt m

anag

ers

to m

ake

rob

ust

an

d w

ell e

vid

ence

d a

pp

oin

tmen

t d

ecis

ion

s.

3 R

elat

ive

likel

iho

od

of

BM

E st

aff

ente

rin

g th

e fo

rmal

dis

cip

linar

y p

roce

ss, c

om

par

ed t

o t

hat

of

Wh

ite

sta

ff e

nte

rin

g th

e fo

rmal

d

isci

plin

ary

pro

cess

, as

mea

sure

d b

y en

try

into

a f

orm

al

dis

cip

linar

y in

vest

igat

ion

*

*No

te:

This

ind

icat

or

will

be

bas

ed o

n d

ata

fro

m a

tw

o y

ear

rolli

ng

aver

age

of

the

curr

ent

year

an

d t

he

pre

vio

us

year

.

No

dat

a to

re

po

rt

Dis

cip

linar

y ac

tio

n h

as

occ

urr

ed in

th

is y

ear,

ag

ain

st w

hit

e st

aff,

no

t B

ME.

Se

e d

ata

shee

t fo

r st

atis

tics

The

Tru

st is

sm

all a

nd

see

s ve

ry li

ttle

em

plo

yee

rel

atio

ns

acti

vity

. Th

at

said

, wh

ere

dis

cip

linar

y ac

tio

n h

as

take

n p

lace

th

e d

ata

sugg

ests

th

at

wh

ite

staf

f ar

e m

ore

like

ly t

o b

e in

volv

ed in

fo

rmal

act

ion

.

The

Tru

st's

dis

cip

linar

y p

olic

y h

as b

een

am

end

ed in

20

16

to

inco

rpo

rate

act

ion

s w

hic

h s

ho

uld

be

take

n if

an

alle

gati

on

is

un

fou

nd

ed. T

he

revi

sed

po

licy

ensu

res

that

if a

mem

ber

of

staf

f is

wro

ngl

y ac

cuse

d t

hen

th

ey r

ecei

ve a

n a

po

logy

an

d a

gree

th

e b

est

way

to

sh

are

a b

road

er m

essa

ge, i

f it

is n

eed

ed.

Page 119 of 146

R

ep

ort

on

th

e W

RES

Ind

icat

ors

co

nti

nu

ed

5.

Wo

rkfo

rce

Rac

e Eq

ual

ity

Ind

icat

ors

Ind

icat

or

Dat

a fo

r th

e re

po

rtin

g ye

ar

201

4-1

5

Dat

a fo

r th

e p

revi

ou

s ye

ar

20

15

-16

Nar

rati

ve: T

he

imp

licat

ion

s o

f th

e d

ata

and

an

y ad

dit

ion

al b

ackg

rou

nd

ex

pla

nat

ory

nar

rati

ve

Act

ion

tak

en

an

d p

lan

ned

, in

clu

din

g e

.g.

do

es t

he

ind

icat

or

link

to E

DS2

evi

den

ce

and

/or

a co

rpo

rate

Eq

ual

ity

ob

ject

ive

4 R

elat

ive

likel

iho

od

of

BM

E st

aff

acce

ssin

g n

on

-man

dat

ory

tr

ain

ing

and

CP

D a

s co

mp

ared

to

Wh

ite

sta

ff

No

dat

a to

re

po

rt

No

dat

a to

re

po

rt

The

tru

st c

urr

entl

y u

ses

a m

anu

al

syst

em f

or

reco

rdin

g tr

ain

ing.

As

a re

sult

it is

no

t p

oss

ible

to

rep

ort

on

C

PD

up

take

by

pro

tect

ed

char

acte

rist

ics.

The

tru

st w

ill b

e im

ple

men

tin

g O

racl

e Le

arn

ing

Man

ager

(O

LM)

in Q

3 a

nd

Q4

w

hic

h w

ill a

dd

ress

th

is r

epo

rtin

g ga

p.

5 K

F 2

5. P

erce

nta

ge o

f st

aff

exp

erie

nci

ng

har

assm

ent,

b

ully

ing

or

abu

se f

rom

pat

ien

ts,

rela

tive

s o

r th

e p

ub

lic in

last

12

m

on

ths.

Wh

ite

16

W

hit

e 1

9

Stat

isti

cally

th

e ch

ange

is s

mal

l, b

ut

a h

igh

er n

um

ber

of

BM

E st

aff

are

still

ex

per

ien

cin

g b

ully

ing

and

h

aras

smen

t w

hen

co

mp

ared

to

w

hit

e st

aff.

Wh

en t

he

late

st s

taff

su

rvey

re

sult

s w

ere

re

leas

ed w

e t

aske

d m

anag

ers

to

use

dir

ecto

rate

leve

l re

sult

s to

exp

lore

th

emes

an

d d

evel

op

ed lo

calis

ed a

ctio

n

pla

ns.

We

will

co

nti

nu

e to

bu

ild o

n t

his

ap

pro

ach

an

d e

nsu

re t

hat

div

ers

ity

and

in

clu

sio

n t

hem

es a

re e

xplo

red

wit

h

sup

po

rt f

rom

se

nio

r H

R s

taff

.

BM

E 1

2

BM

E 1

8

6 K

F 2

6. P

erce

nta

ge o

f st

aff

exp

erie

nci

ng

har

assm

ent,

b

ully

ing

or

abu

se f

rom

sta

ff in

la

st 1

2 m

on

ths.

Wh

ite

1

9

Wh

ite

17

Co

mp

ared

to

pre

vio

us

year

s th

ere

has

bee

n s

om

e p

osi

tive

im

pro

vem

ents

an

d u

nlik

e th

e re

st o

f Lo

nd

on

ou

r B

ME

staf

f ar

e le

ss li

kely

to

exp

erie

nce

bu

llyin

g an

d

har

assm

ent.

We

hav

e b

een

tak

ing

a n

um

ber

of

acti

on

s to

ad

dre

ss t

his

issu

e in

clu

din

g re

visi

ng

the

bu

llyin

g an

d h

aras

smen

t p

olic

y, p

rom

oti

ng

the

ran

ge o

f m

eth

od

s to

rep

ort

co

nce

rns

and

als

o in

tro

du

cin

g a

con

fid

enti

al h

elp

line

for

staf

f to

see

k co

nfi

den

tial

ad

vice

fro

m.

BM

E 1

7

BM

E 1

1

7 K

F 2

1. P

erce

nta

ge b

elie

vin

g th

at

tru

st p

rovi

des

eq

ual

o

pp

ort

un

itie

s fo

r ca

ree

r

Wh

ite

88

W

hit

e 8

9 Th

is a

rea

has

wo

rsen

ed a

nd

we

hav

e b

een

tak

ing

a n

um

ber

of

step

s to

ch

ange

th

is p

osi

tio

n.

We

will

co

nti

nu

e to

ask

sen

ior

HR

p

rofe

ssio

nal

s to

sit

on

inte

rvie

w p

anel

s to

ad

d t

he

app

rop

riat

e le

vel o

f ch

alle

nge

. B

ME

70

B

ME

61

WR

ES

Page 120 of 146

R

ep

ort

on

th

e W

RES

Ind

icat

ors

co

nti

nu

ed

5.

Wo

rkfo

rce

Rac

e Eq

ual

ity

Ind

icat

ors

Ind

icat

or

Dat

a fo

r th

e re

po

rtin

g ye

ar

201

4-1

5

Dat

a fo

r th

e p

revi

ou

s ye

ar

20

15

-16

Nar

rati

ve: T

he

imp

licat

ion

s o

f th

e d

ata

and

an

y ad

dit

ion

al b

ackg

rou

nd

ex

pla

nat

ory

nar

rati

ve

Act

ion

tak

en

an

d p

lan

ned

, in

clu

din

g e

.g.

do

es t

he

ind

icat

or

link

to E

DS2

evi

den

ce

and

/or

a co

rpo

rate

Eq

ual

ity

ob

ject

ive

pro

gres

sio

n o

r p

rom

oti

on

.

We

will

als

o b

e im

ple

men

tin

g co

ach

ing

/ m

ento

rin

g fo

r B

ME

staf

f to

su

pp

ort

th

em in

see

kin

g p

rom

oti

on

al

op

po

rtu

nit

ies.

In

ad

dit

ion

to

th

e ab

ove

we

will

als

o b

e co

mm

issi

on

ing

un

con

scio

us

bia

s tr

ain

ing

for

man

ager

s.

8 Q

17

. In

th

e la

st 1

2 m

on

ths

hav

e yo

u p

erso

nal

ly e

xper

ien

ced

d

iscr

imin

atio

n a

t w

ork

fro

m a

ny

of

the

follo

win

g:

Man

ager

/te

am le

ader

or

oth

er

colle

agu

es

Wh

ite

7

Wh

ite

6

Ther

e h

as b

een

so

me

po

siti

ve s

hif

t ch

ange

s in

th

is in

dic

ato

r.

It is

imp

ort

ant

we

con

tin

ue

to b

uild

on

th

is w

ork

an

d t

hro

ugh

ou

t th

e n

ext

year

w

e w

ill b

e im

ple

men

tin

g a

ran

ge o

f in

itia

tive

s an

d m

anag

emen

t d

evel

op

men

t p

rogr

amm

es t

o e

qu

ip

man

ager

s w

ith

th

e sk

ills

to le

ad t

hei

r se

rvic

es a

nd

dev

elo

p t

hei

r st

aff.

BM

E 1

2

BM

E 5

B

oar

ds

are

exp

ecte

d t

o b

e b

road

ly r

epre

sen

tati

ve o

f th

e p

op

ula

tio

n t

hey

se

rve

9 P

erce

nta

ge d

iffe

ren

ce b

etw

een

th

e o

rgan

isat

ion

s’ B

oar

d v

oti

ng

mem

ber

ship

an

d it

s o

vera

ll w

ork

forc

e.

10

of

ou

r vo

tin

g b

oar

d

mem

ber

s ar

e fr

om

a w

hit

e

10

of

ou

r vo

tin

g b

oar

d

mem

ber

s ar

e fr

om

a w

hit

e

In

20

15

/16

we

hav

e so

ugh

t to

rec

ruit

to

2

exe

cuti

ve p

osi

tio

ns

and

1 n

on

-e

xecu

tive

dir

ecto

r p

osi

tio

n. T

hro

ugh

ou

t th

e se

arch

we

hav

e m

ade

clea

r o

ur

Page 121 of 146

R

ep

ort

on

th

e W

RES

Ind

icat

ors

co

nti

nu

ed

5.

Wo

rkfo

rce

Rac

e Eq

ual

ity

Ind

icat

ors

Ind

icat

or

Dat

a fo

r th

e re

po

rtin

g ye

ar

201

4-1

5

Dat

a fo

r th

e p

revi

ou

s ye

ar

20

15

-16

Nar

rati

ve: T

he

imp

licat

ion

s o

f th

e d

ata

and

an

y ad

dit

ion

al b

ackg

rou

nd

ex

pla

nat

ory

nar

rati

ve

Act

ion

tak

en

an

d p

lan

ned

, in

clu

din

g e

.g.

do

es t

he

ind

icat

or

link

to E

DS2

evi

den

ce

and

/or

a co

rpo

rate

Eq

ual

ity

ob

ject

ive

b

ackg

rou

nd

an

d 1

is f

rom

a

BM

E b

ackg

rou

nd

bac

kgro

un

d

and

1 is

fro

m a

B

ME

bac

kgro

un

d

des

ire

to e

nco

ura

ge a

pp

lican

ts f

rom

B

ME

bac

kgro

un

ds.

Du

rin

g se

lect

ion

p

roce

sses

th

e D

irec

tor

of

HR

sit

s o

n t

he

pan

el a

nd

en

sure

s th

at p

arti

cip

ants

m

ake

con

sid

erat

ion

s o

f an

y b

ias

they

m

ay h

old

ab

ou

t B

ME

can

did

ates

.

6.

Are

th

ere

any

fact

ors

or

dat

a w

hic

h s

ho

uld

be

take

n in

to c

on

sid

erat

ion

in a

sses

sin

g p

rogr

ess?

P

leas

e b

ear

in m

ind

an

y su

ch in

form

atio

n, a

ctio

n t

aken

an

d p

lan

ned

may

be

sub

ject

to

scr

uti

ny

by

the

Co

ord

inat

ing

Co

mm

issi

on

er

or

by

regu

lato

rs w

hen

insp

ecti

ng

agai

nst

th

e ‘W

ell L

ed’ d

om

ain

.

We

hav

e a

wel

l est

ablis

hed

ap

pro

ach

to

man

agin

g d

iver

sity

an

d in

clu

sio

n a

t th

e Ta

vist

ock

an

d P

ort

man

an

d w

hils

t w

e h

ave

a n

um

ber

of

goo

d

fou

nd

atio

ns

we

are

keen

no

t to

be

com

pla

cen

t in

ou

r ap

pro

ach

. In

th

e la

st y

ear

we

hav

e lis

ten

ed v

ery

care

fully

to

sta

ff a

nd

sta

rte

d a

nu

mb

er o

f p

iece

s o

f w

ork

to

imp

rove

acc

ess

of

op

po

rtu

nit

y an

d c

aree

r d

evel

op

men

t.

7.

If t

he

org

anis

atio

n h

as a

mo

re d

etai

led

pla

n a

gree

d b

y it

s B

oar

d f

or

add

ress

ing

thes

e an

d r

ela

ted

issu

es, y

ou

are

ask

ed t

o a

ttac

h it

or

pro

vid

e a

link.

Su

ch a

pla

n w

ou

ld n

orm

ally

ela

bo

rate

on

th

e st

eps

sum

mar

ised

in s

ecti

on

5 a

bo

ve, s

etti

ng

ou

t th

e n

ext

step

s w

ith

m

ilest

on

es f

or

exp

ecte

d p

rogr

ess

agai

nst

met

rics

. It

may

als

o id

enti

fy t

he

links

wit

h o

ther

wo

rk s

trea

ms

agre

ed a

t B

oar

d le

vel,

such

as

EDS2

.

The

acti

on

pla

n is

det

aile

d b

elo

w.

WR

ES

Page 122 of 146

W

ork

forc

e R

ace

Eq

uali

ty S

tan

dard

A

ctio

n P

lan

– 2

016/1

7

Th

em

e

Act

ion

Req

uir

ed

R

esp

on

sib

le

By W

hen

Sta

ff b

elievin

g t

hat

the

org

an

isati

on

pro

vid

es

eq

ual

op

po

rtu

nit

ies

for

pro

mo

tio

n / p

rog

ress

ion

Develo

p a

nd

im

ple

men

t a c

oach

ing

/

men

tori

ng

sch

em

e t

o s

up

po

rt B

ME s

taff

gain

con

fid

en

ce a

nd

skills

to

ap

ply

fo

r in

tern

al

op

po

rtu

nit

ies.

HR

Bu

sin

ess

Part

ner

Oct

ob

er

2016

Evalu

ate

th

e im

pact

of

havin

g s

en

ior

HR

pro

fess

ion

als

on

sele

ctio

n p

an

els

.

HR

Bu

sin

ess

Part

ner

Oct

ob

er

2016

Co

mm

issi

on

un

con

scio

us

bia

s tr

ain

ing

fo

r

man

ag

ers

in

vo

lved

in

recr

uit

men

t an

d

sele

ctio

n.

Dir

ect

or

of

Qu

ality

an

d

Pati

en

t Exp

eri

en

ce

Sep

tem

ber – N

ovem

ber

2016

En

sure

th

at

un

con

scio

us

bia

s tr

ain

ing

featu

res

in o

ur

new

man

ag

em

en

t an

d lead

ers

hip

develo

pm

en

t p

rog

ram

me.

Dir

ect

or

of

Hu

man

Reso

urc

es

Jan

uary

- M

arc

h 2

017

Acc

ess

to

no

n-m

an

dato

ry

con

tin

uin

g p

rofe

ssio

nal

develo

pm

en

t

Un

dert

ake a

revie

w o

f th

e a

pp

rais

al p

roce

ss

incl

ud

ing

th

e e

ffect

iven

ess

of

the t

rain

ing

need

s an

aly

sis

Org

an

isati

on

al

Develo

pm

en

t C

on

sult

an

t

Sep

tem

ber

2016

Imp

lem

en

t th

e O

racl

e L

earn

ing

Man

ag

er

syst

em

fo

r all m

an

dato

ry a

nd

no

n-m

an

dato

ry

train

ing

HR

& S

taff

Develo

pm

en

t

Man

ag

er

Oct

ob

er

2016 –

Marc

h 2

017

Page 123 of 146

RN

KT

avis

tock a

nd

Po

rtm

an

NH

S F

T

Qu

es

tio

n

DA

TA

IT

EM

1a

) N

on

Cli

nic

al

wo

rkfo

rce

(W

hit

e)

1U

nd

er

Ba

nd

1H

ea

dco

un

t0

00

0

2B

an

d 1

He

ad

co

un

t0

10

1

3B

an

d 2

He

ad

co

un

t0

00

0

4B

an

d 3

He

ad

co

un

t7

10

59

5B

an

d 4

He

ad

co

un

t2

12

12

22

2

6B

an

d 5

He

ad

co

un

t4

24

34

54

5

7B

an

d 6

He

ad

co

un

t1

51

51

61

6

8B

an

d 7

He

ad

co

un

t1

01

31

41

6

9B

an

d 8

AH

ea

dco

un

t1

31

41

21

4

10

Ba

nd

8B

He

ad

co

un

t3

44

6

11

Ba

nd

8C

He

ad

co

un

t5

75

7

12

Ba

nd

8D

He

ad

co

un

t2

42

5

13

Ba

nd

9H

ea

dco

un

t0

30

1

14

VS

MH

ea

dco

un

t7

86

8

1b

) N

on

Cli

nic

al

wo

rkfo

rce

(B

ME

)

15

Un

de

r B

an

d 1

He

ad

co

un

t0

00

0

16

Ba

nd

1H

ea

dco

un

t0

50

5

17

Ba

nd

2H

ea

dco

un

t0

00

0

18

Ba

nd

3H

ea

dco

un

t3

31

1

19

Ba

nd

4H

ea

dco

un

t1

21

41

61

9

20

Ba

nd

5H

ea

dco

un

t2

02

02

32

4

21

Ba

nd

6H

ea

dco

un

t3

53

5

22

Ba

nd

7H

ea

dco

un

t6

75

7

23

Ba

nd

8A

He

ad

co

un

t7

78

8

24

Ba

nd

8B

He

ad

co

un

t1

12

2

25

Ba

nd

8C

He

ad

co

un

t1

10

0

26

Ba

nd

8D

He

ad

co

un

t0

00

0

27

Ba

nd

9H

ea

dco

un

t0

00

0

28

VS

MH

ea

dco

un

t0

00

1

1c

) C

lin

ica

l w

ork

forc

e (

Wh

ite

)

of

wh

ich

No

n M

ed

ica

l

29

Un

de

r B

an

d 1

He

ad

co

un

t0

00

0

30

Ba

nd

1H

ea

dco

un

t1

01

0

31

Ba

nd

2H

ea

dco

un

t0

00

0

32

Ba

nd

3H

ea

dco

un

t3

24

2

33

Ba

nd

4H

ea

dco

un

t3

35

5

34

Ba

nd

5H

ea

dco

un

t9

99

8

35

Ba

nd

6H

ea

dco

un

t5

25

44

95

0

36

Ba

nd

7H

ea

dco

un

t5

75

86

97

2

37

Ba

nd

8A

He

ad

co

un

t4

13

65

74

8

38

Ba

nd

8B

He

ad

co

un

t3

52

93

22

7

39

Ba

nd

8C

He

ad

co

un

t6

85

35

34

1

40

Ba

nd

8D

He

ad

co

un

t1

19

77

41

Ba

nd

9H

ea

dco

un

t3

62

3

42

VS

MH

ea

dco

un

t9

01

01

Of

wh

ich

Me

dic

al &

De

nta

l

44

Co

nsu

lta

nts

He

ad

co

un

t3

53

03

23

2

45

o

f w

hic

h S

en

ior

me

dic

al sta

ffH

ea

dco

un

t0

46

No

n-c

on

su

lta

nt

ca

ree

r g

rad

eH

ea

dco

un

t1

11

1

Me

as

ure

31

st

MA

RC

H 2

01

6

Pre

po

pu

late

d f

igu

res

Ve

rifi

ed

fig

ure

s (

lea

ve

bla

nk

if a

cc

ep

tin

g p

re-p

op

ula

ted

da

ta)

No

tes

1

Pe

rce

nta

ge

of

sta

ff in

ea

ch

of

the

AfC

Ba

nd

s 1

-9 a

nd

VS

M

(in

clu

din

g e

xe

cu

tive

Bo

ard

me

mb

ers

) co

mp

are

d w

ith

th

e

pe

rce

nta

ge

of

sta

ff in

th

e

ove

rall

wo

rkfo

rce

Un

ify2

Up

loa

d T

em

pla

te

Wo

rkfo

rce

Ra

ce

Eq

ua

lity

Sta

nd

ard

s a

nn

ua

l co

lle

cti

on

Org

an

isa

tio

n:

31

st

MA

RC

H 2

01

5

Pre

po

pu

late

d f

igu

res

Ve

rifi

ed

fig

ure

s (

lea

ve

bla

nk

if a

cc

ep

tin

g p

re-p

op

ula

ted

da

ta)

WR

ES

Page 124 of 146

47

Tra

ine

e g

rad

es

He

ad

co

un

t1

31

38

8

48

Oth

er

He

ad

co

un

t0

00

0

1d

) C

lin

ica

l w

ork

forc

e (

BM

E)

of

wh

ich

No

n M

ed

ica

l

49

Un

de

r B

an

d 1

He

ad

co

un

t0

00

0

50

Ba

nd

1H

ea

dco

un

t0

03

0

51

Ba

nd

2H

ea

dco

un

t0

00

0

52

Ba

nd

3H

ea

dco

un

t0

00

1

53

Ba

nd

4H

ea

dco

un

t3

24

3

54

Ba

nd

5H

ea

dco

un

t2

21

1

55

Ba

nd

6H

ea

dco

un

t1

11

41

31

4

56

Ba

nd

7H

ea

dco

un

t1

01

21

51

8

57

Ba

nd

8A

He

ad

co

un

t1

51

41

61

5

58

Ba

nd

8B

He

ad

co

un

t7

47

5

59

Ba

nd

8C

He

ad

co

un

t9

91

21

1

60

Ba

nd

8D

He

ad

co

un

t0

00

0

61

Ba

nd

9H

ea

dco

un

t0

00

0

62

VS

MH

ea

dco

un

t1

01

0

Of

wh

ich

Me

dic

al &

De

nta

l

63

Co

nsu

lta

nts

He

ad

co

un

t8

68

6

64

o

f w

hic

h S

en

ior

me

dic

al sta

ffH

ea

dco

un

t

65

No

n-c

on

su

lta

nt

ca

ree

r g

rad

eH

ea

dco

un

t0

00

0

66

Tra

ine

e g

rad

es

He

ad

co

un

t7

79

11

67

Oth

er

He

ad

co

un

t0

00

0

1e

) W

ork

forc

e e

thn

icit

y r

ep

ort

ing

68

Wh

ite

He

ad

co

un

t4

89

44

64

92

45

5

69

BM

EH

ea

dco

un

t1

32

13

31

50

15

7

70

Z N

UL

LH

ea

dco

un

t1

00

12

0

71

Z N

ot

Sta

ted

/No

t G

ive

nH

ea

dco

un

t3

07

0

72

Nu

mb

er

of

sh

ort

liste

d a

pp

lica

nts

(W

hite

):H

ea

dco

un

t4

73

52

2

73

Nu

mb

er

of

sh

ort

liste

d a

pp

lica

nts

(BM

E):

He

ad

co

un

t4

22

34

5

74

Nu

mb

er

ap

po

inte

d f

rom

sh

ort

listin

g

(Wh

ite

):H

ea

dco

un

t8

86

3

75

Nu

mb

er

ap

po

inte

d f

rom

sh

ort

listin

g

(BM

E):

He

ad

co

un

t3

12

2

76

Re

lative

lik

elih

oo

d o

f

sh

ort

listin

g/a

pp

oin

ted

(W

hite

):A

uto

ca

lcu

late

d0

.19

0.1

2

77

Re

lative

lik

elih

oo

d o

f

sh

ort

listin

g/a

pp

oin

ted

(B

ME

):A

uto

ca

lcu

late

d0

.07

0.0

6

78

Re

lative

lik

elih

oo

d o

f W

hite

sta

ff b

ein

g

ap

po

inte

d f

rom

sh

ort

listin

g c

om

pa

red

to

BM

E s

taff

:

Au

to c

alc

ula

ted

2.5

31

.89

79

Nu

mb

er

of

sta

ff in

wo

rkfo

rce

(W

hite

):H

ea

dco

un

t4

46

45

5

80

Nu

mb

er

of

sta

ff in

wo

rkfo

rce

(B

ME

):H

ea

dco

un

t1

33

15

7

81

Nu

mb

er

of

sta

ff e

nte

rin

g t

he

fo

rma

l

dis

cip

lina

ry p

roce

ss (

Wh

ite

):H

ea

dco

un

t0

2

82

Nu

mb

er

of

sta

ff e

nte

rin

g t

he

fo

rma

l

dis

cip

lina

ry p

roce

ss (

BM

E):

He

ad

co

un

t0

0

83

Lik

elih

oo

d o

f W

hite

sta

ff e

nte

rin

g t

he

form

al d

iscip

lina

ry p

roce

ss:

Au

to c

alc

ula

ted

0.0

00

.00

84

Lik

elih

oo

d o

f B

ME

sta

ff e

nte

rin

g t

he

form

al d

iscip

lina

ry p

roce

ss:

Au

to c

alc

ula

ted

0.0

00

.00

85

Re

lative

lik

elih

oo

d o

f B

ME

sta

ff e

nte

rin

g

the

fo

rma

l d

iscip

lina

ry p

roce

ss c

om

pa

red

to W

hite

sta

ff:

Au

to c

alc

ula

ted

#D

IV/0

!0

.00

86

Nu

mb

er

of

sta

ff in

wo

rkfo

rce

(W

hite

):H

ea

dco

un

t4

46

45

5

87

Nu

mb

er

of

sta

ff in

wo

rkfo

rce

(B

ME

):H

ea

dco

un

t1

33

15

7

88

Nu

mb

er

of

sta

ff a

cce

ssin

g n

on

-

ma

nd

ato

ry t

rain

ing

an

d C

PD

(W

hite

):

He

ad

co

un

t0

0

89

Nu

mb

er

of

sta

ff a

cce

ssin

g n

on

-

ma

nd

ato

ry t

rain

ing

an

d C

PD

(B

ME

):

He

ad

co

un

t0

0

90

Lik

elih

oo

d o

f W

hite

sta

ff a

cce

ssin

g n

on

-

ma

nd

ato

ry t

rain

ing

an

d C

PD

:A

uto

ca

lcu

late

d0

.00

0.0

0

91

Lik

elih

oo

d o

f B

ME

sta

ff a

cce

ssin

g n

on

-

ma

nd

ato

ry t

rain

ing

an

d C

PD

:A

uto

ca

lcu

late

d0

.00

0.0

0

92

Re

lative

lik

elih

oo

d o

f W

hite

sta

ff

acce

ssin

g n

on

-ma

nd

ato

ry t

rain

ing

an

d

CP

D c

om

pa

red

to

BM

E s

taff

:

Au

to c

alc

ula

ted

#D

IV/0

!#

DIV

/0!

3

Re

lative

lik

elih

oo

d o

f sta

ff

en

terin

g t

he

fo

rma

l d

iscip

lina

ry

pro

ce

ss,

as m

ea

su

red

by

en

try in

to a

fo

rma

l d

iscip

lina

ry

inve

stig

atio

n

No

te:

Th

is in

dic

ato

r w

ill b

e

ba

se

d o

n d

ata

fro

m a

tw

o

ye

ar

rolli

ng

ave

rag

e o

f th

e

cu

rre

nt

ye

ar

an

d t

he

pre

vio

us

ye

ar

4

Re

lative

lik

elih

oo

d o

f sta

ff

acce

ssin

g n

on

-ma

nd

ato

ry

tra

inin

g a

nd

CP

D

2

Re

lative

lik

elih

oo

d o

f sta

ff

be

ing

ap

po

inte

d f

rom

sh

ort

listin

g a

cro

ss a

ll p

osts

Page 125 of 146

93

% o

f W

hite

sta

ff e

xp

erie

ncin

g

ha

rassm

en

t, b

ully

ing

or

ab

use

fro

m

pa

tie

nts

, re

lative

s

or

the

pu

blic

in

la

st

12

mo

nth

s

Pe

rce

nta

ge

17

.76

%1

9.0

2%

94

% o

f B

ME

sta

ff e

xp

erie

ncin

g h

ara

ssm

en

t,

bu

llyin

g o

r a

bu

se

fro

m p

atie

nts

, re

lative

s

or

the

pu

blic

in

la

st

12

mo

nth

s

Pe

rce

nta

ge

18

.18

%1

8.4

2%

95

% o

f W

hite

sta

ff e

xp

erie

ncin

g

ha

rassm

en

t, b

ully

ing

or

ab

use

fro

m s

taff

in la

st

12

mo

nth

s

Pe

rce

nta

ge

14

.57

%1

6.5

0%

96

% o

f B

ME

sta

ff e

xp

erie

ncin

g h

ara

ssm

en

t,

bu

llyin

g o

r a

bu

se

fro

m s

taff

in

la

st

12

mo

nth

s

Pe

rce

nta

ge

13

.64

%1

0.5

3%

97

% W

hite

sta

ff b

elie

vin

g t

ha

t tr

ust

pro

vid

es

eq

ua

l o

pp

ort

un

itie

s f

or

ca

ree

r

pro

gre

ssio

n o

r p

rom

otio

nP

erc

en

tag

e8

8.7

1%

89

.47

%

98

% B

ME

sta

ff b

elie

vin

g t

ha

t tr

ust

pro

vid

es

eq

ua

l o

pp

ort

un

itie

s f

or

ca

ree

r

pro

gre

ssio

n o

r p

rom

otio

nP

erc

en

tag

e6

9.2

3%

61

.11

%

99

% W

hite

sta

ff p

ers

on

ally

exp

erie

nce

d

dis

crim

ina

tio

n a

t w

ork

fro

m

Ma

na

ge

r/te

am

le

ad

er

or

oth

er

co

llea

gu

eP

erc

en

tag

e6

.45

%5

.74

%

10

0%

BM

E s

taff

pe

rso

na

lly e

xp

erie

nce

d

dis

crim

ina

tio

n a

t w

ork

fro

m

Ma

na

ge

r/te

am

le

ad

er

or

oth

er

co

llea

gu

eP

erc

en

tag

e1

3.6

4%

5.0

0%

10

1V

otin

g B

oa

rd M

em

be

rs -

Wh

ite

He

ad

co

un

t1

01

0

10

2V

otin

g B

oa

rd M

em

be

rs -

BM

EH

ea

dco

un

t1

1

10

3V

otin

g B

oa

rd M

em

be

r -

%B

ME

Au

to c

alc

ula

ted

9.1

%9

.1%

10

4O

ve

rall

wo

rkfo

rce

- %

BM

EA

uto

ca

lcu

late

d2

3.0

%2

5.7

%

10

5T

ota

l D

iffe

ren

ce

Au

to c

alc

ula

ted

-13

.9%

-16

.6%

9

Pe

rce

nta

ge

diffe

ren

ce

be

twe

en

th

e o

rga

nis

atio

ns’

Bo

ard

vo

tin

g m

em

be

rsh

ip a

nd

its o

ve

rall

wo

rkfo

rce

No

te:

On

ly v

otin

g m

em

be

rs o

f

the

Bo

ard

sh

ou

ld b

e in

clu

de

d

wh

en

co

nsid

erin

g t

his

in

dic

ato

r

6

KF

26

. P

erc

en

tag

e o

f sta

ff

exp

erie

ncin

g h

ara

ssm

en

t,

bu

llyin

g o

r a

bu

se

fro

m

sta

ff in

la

st

12

mo

nth

s

7

KF

21

. P

erc

en

tag

e b

elie

vin

g

tha

t tr

ust

pro

vid

es e

qu

al

op

po

rtu

nitie

s f

or

ca

ree

r

pro

gre

ssio

n o

r p

rom

otio

n

8

Q1

7.

In t

he

la

st

12

mo

nth

s

ha

ve

yo

u p

ers

on

ally

exp

erie

nce

d d

iscrim

ina

tio

n a

t

wo

rk f

rom

an

y o

f th

e

follo

win

g?

b)

Ma

na

ge

r/te

am

le

ad

er

or

oth

er

co

llea

gu

es

5

KF

25

. P

erc

en

tag

e o

f sta

ff

exp

erie

ncin

g h

ara

ssm

en

t,

bu

llyin

g o

r a

bu

se

fro

m

pa

tie

nts

, re

lative

s

or

the

pu

blic

in

la

st

12

mo

nth

s

WR

ES

Page 126 of 146

of 1


Item : 18

Title : Register of Interests

Summary:

The Directors’ Register of Interests if presented for approval.


Governance

For : Approval

From : Trust Secretary

R

egis

ter

of In

tere

sts

Page 127 of 146

Reg

iste

r o

f D

irect

ors

’ In

tere

sts

2016/1

7

1.

Intr

od

uct

ion

All

exis

tin

g D

ire

cto

rs s

ha

ll d

ecl

are

re

leva

nt

an

d m

ate

ria

l in

tere

sts

fort

hw

ith

an

d t

he

Tru

st s

ha

ll e

nsu

re t

hat

tho

se i

nte

rest

s

are

no

ted

in

th

e R

eg

iste

r o

f D

ire

cto

rs’

Inte

rest

s. A

ny D

ire

cto

rs a

pp

oin

ted

su

bse

qu

en

tly sh

all

de

clare

th

eir

re

leva

nt

an

d

ma

teri

al

inte

rest

s o

n a

pp

oin

tme

nt.

1 A

t th

e t

ime

th

e i

nte

rest

s a

re d

ecl

are

d t

his

sh

all

be r

eco

rde

d i

n t

he

min

ute

s o

f th

e B

oa

rd

of

Dir

ect

ors

me

eti

ng

as

ap

pro

pri

ate

. A

ny c

ha

ng

es

in i

nte

rest

sh

all

be

off

icia

lly d

ecl

are

d a

t th

e n

ext

me

eti

ng

of

the

Bo

ard

of

Dir

ect

ors

fo

llo

win

g t

he

ch

an

ge

occ

urr

ing

. It

is

the

ob

lig

ati

on

of

the

Dir

ect

or

to i

nfo

rm t

he

Tru

st S

ecr

eta

ry i

n w

riti

ng

wit

hin

seve

n d

ays

of

be

com

ing

aw

are

of

the e

xis

ten

ce o

f a r

ele

va

nt

or

ma

teri

al

inte

rest

an

d t

he

mem

be

rsh

ip.2

If

a D

ire

cto

r h

as

a

do

ub

t a

bo

ut

the

rele

va

nce

or

ma

teri

ali

ty o

f a

ny i

nte

rest

th

is s

ho

uld

be

dis

cuss

ed

wit

h t

he

Tru

st C

ha

ir.3

2.

De

cla

rati

on

Ple

ase

co

mp

lete

th

e t

ab

le b

elo

w,

sta

tin

g a

ll r

ele

va

nt

an

d m

ate

ria

l in

tere

sts.

If

no

ne

are

ap

pli

cab

le,

pu

t “

no

ne

”.

Inte

rest

s

wh

ich

sh

all

be

re

ga

rde

d a

s “

rele

va

nt

an

d m

ate

ria

l” a

nd

wh

ich

fo

r th

e a

vo

ida

nce

of

do

ub

t sh

ou

ld b

e d

ecl

are

d a

nd

sh

ou

ld b

e

incl

ud

ed

in

th

e R

eg

iste

r o

f D

ire

cto

rs’ In

tere

sts

are

:

Dis

clo

sure

Re

qu

ire

me

nt

Dis

clo

sure

4

Dir

ect

ors

hip

s, i

ncl

ud

ing

no

n-e

xe

cuti

ve

dir

ect

ors

hip

s h

eld

in

pri

va

te

com

pa

nie

s o

r P

LC

s (w

ith

th

e e

xce

pti

on

of

tho

se d

ire

cto

rsh

ips

of

do

rma

nt

com

pa

nie

s)

Din

esh

Bh

ug

ra:

Po

rism

Ltd

, Se

cre

tary

Pau

l B

urs

tow

:

Ind

y A

sso

cia

tes

Ltd

., M

an

ag

ing

Dir

ect

or

Jan

e G

izb

ert

: n

on

e

Da

vid

Ho

lt:

no

ne

Sa

lly H

od

ge

s: n

on

e

Pau

l Je

nk

ins:

no

ne

Lis

Jo

ne

s: n

on

e

Lo

uis

e L

yo

n:

no

ne

Ian

McP

he

rso

n:

no

ne

Ed

na

Mu

rph

y:

no

ne

Bri

an

Ro

ck:

no

ne

Ro

b S

en

ior:

no

ne

1 T

avis

tock

& P

ort

ma

n N

HS F

ou

nd

ati

on

Tru

st,

Co

nst

itu

tio

n,

Ele

ctio

n R

ule

s, S

tan

din

g O

rde

rs, 2

01

4,

An

ne

x 5

, P

ara

gra

ph

9.1

2 Ib

id,

Pa

rag

rap

h 9

.4

3 Ib

id,

Pa

rag

rap

h 9

.3

4 A

la

ck o

f d

iscl

osu

re f

rom

an

y D

ire

cto

r in

dic

ate

s a

nil

re

turn

on

th

e D

ecl

ara

tio

n o

f In

tere

st

Reg

iste

r of

Inte

rest

s

Page 128 of 146

Pa

ge

2 o

f 4

Dis

clo

sure

Re

qu

ire

me

nt

Dis

clo

sure

4

Juli

an

Ste

rn:

no

ne

Sim

on

Yo

un

g:

no

ne

Ow

ne

rsh

ip,

pa

rt-o

wn

ers

hip

or

dir

ect

ors

hip

s o

f p

riv

ate

co

mp

an

ies,

b

usi

ne

sse

s o

r co

nsu

lta

nci

es

lik

ely

or

po

ssib

ly s

eek

ing

to

do

bu

sin

ess

w

ith

th

e N

ati

on

al H

ealt

h S

erv

ice

Din

esh

Bh

ug

ra:

dK

b C

on

sult

ing

, D

ire

cto

r

Pau

l B

urs

tow

:

Ind

y A

sso

cia

tes

Ltd

., M

an

ag

ing

Dir

ect

or

Jan

e G

izb

ert

: n

on

e

Da

vid

Ho

lt:

no

ne

Sa

lly H

od

ge

s: n

on

e

Pau

l Je

nk

ins:

no

ne

Lis

Jo

ne

s:

Lis

Jo

ne

s A

sso

cia

tes,

Co

nsu

lta

ncy

Lo

uis

e L

yo

n:

no

ne

Ian

McP

he

rso

n:

no

ne

Ed

na

Mu

rph

y:

no

ne

Bri

an

Ro

ck:

no

ne

Ro

b S

en

ior:

no

ne

Juli

an

Ste

rn:

no

ne

Sim

on

Yo

un

g:

Ma

jori

ty o

r co

ntr

oll

ing

sh

are

ho

ldin

gs

in o

rga

nis

ati

on

s li

kely

or

po

ssib

ly s

ee

kin

g t

o d

o b

usi

ne

ss w

ith

th

e N

ati

on

al

He

alt

h S

erv

ice

Din

esh

Bh

ug

ra:

no

ne

Pau

l B

urs

tow

: n

on

e

Jan

e G

izb

ert

: n

on

e

Da

vid

Ho

lt:

no

ne

Sa

lly H

od

ge

s: n

on

e

Pau

l Je

nk

ins:

no

ne

Lis

Jo

ne

s: n

on

e

Lo

uis

e L

yo

n:

no

ne

Ian

McP

he

rso

n:

no

ne

Ed

na

Mu

rph

y:

no

ne

Bri

an

Ro

ck:

no

ne

Ro

b S

en

ior:

no

ne

Juli

an

Ste

rn:

no

ne

Sim

on

Yo

un

g:

no

ne

A p

osi

tio

n o

f a

uth

ori

ty i

n a

ch

ari

ty o

r v

olu

nta

ry o

rga

nis

ati

on

in

th

e

fie

ld o

f h

ea

lth

an

d s

oci

al

care

Din

esh

Bh

ug

ra:

Wo

rld

Psy

chia

tric

Ass

oci

ati

on

, Pre

sid

en

t

Me

nta

l H

ealt

h F

ou

nd

ati

on

, Pre

sid

en

t

Ca

re-I

F,

Tru

ste

e

Sa

ne

, T

rust

ee

Pau

l B

urs

tow

:

Page 129 of 146

Pa

ge

3 o

f 4

Dis

clo

sure

Re

qu

ire

me

nt

Dis

clo

sure

4

Th

e S

ilve

r Lin

e,

Tru

ste

e

Act

ion

on

Sm

ok

ing

an

d H

ealt

h (

ASH

), T

rust

ee

Jan

e G

izb

ert

: n

on

e

Da

vid

Ho

lt:

Ha

no

ve

r H

ou

sin

g A

sso

cia

tio

n,

No

n-E

xe

cuti

ve

Bo

ard

Me

mb

er

Me

rto

n R

eg

en

era

tio

n B

oa

rd (

Cir

cle

Ho

usi

ng

Ass

oci

ati

on

), C

ha

ir.

Sa

lly H

od

ge

s: n

on

e

Pau

l Je

nk

ins:

no

ne

Me

mb

er

an

d p

revio

us

CE

O o

f R

eth

ink

Me

nta

l Illn

ess

Lis

Jo

ne

s:

No

rth

Lo

nd

on

Ho

spic

e,

Vic

e C

ha

ir

Lo

uis

e L

yo

n:

Ch

air

, T

avis

tock

Cli

nic

Fo

un

da

tio

n

Ian

McP

he

rso

n:

Ce

ntr

e f

or

Me

nta

l H

ea

lth

, T

rust

ee

/Dir

ect

or

Me

nta

l H

ealt

h P

rovid

er

Fo

rum

, T

rust

ee/D

ire

cto

r

Inte

rna

tio

na

l In

itia

tive

in

Me

nta

l H

ealt

h L

ead

ers

hip

, Tru

ste

e/C

ha

ir

Bir

min

gh

am

MIN

D,

Tru

ste

e/D

ire

cto

r

Ed

na

Mu

rph

y:

Un

ive

rsit

y C

oll

eg

e L

on

do

n (

UC

L),

Se

nio

r M

an

ag

er

Bri

an

Ro

ck:

no

ne

Ro

b S

en

ior:

no

ne

Ju

lian

Ste

rn:

no

ne

Sim

on

Yo

un

g:

no

ne

An

y c

on

ne

ctio

n w

ith

a v

olu

nta

ry o

r o

the

r o

rga

nis

ati

on

co

ntr

act

ing

fo

r N

ati

on

al

He

alt

h S

erv

ice

se

rvic

es

or

com

mis

sio

nin

g N

ati

on

al

He

alt

h

Serv

ice

se

rvic

es

Din

esh

Bh

ug

ra:

no

ne

Pau

l B

urs

tow

: n

on

e

Jan

e G

izb

ert

: n

on

e

Da

vid

Ho

lt:

Wh

itti

ng

ton

He

alt

h N

HS T

rust

, C

ha

ir o

f A

ud

it C

om

mit

tee

Sa

lly H

od

ge

s: n

on

e

Pau

l Je

nk

ins:

Me

mb

er

an

d p

revio

us

CE

O o

f R

eth

ink

Me

nta

l Illn

ess

Lis

Jo

ne

s: n

on

e

Lo

uis

e L

yo

n:

no

ne

Ian

McP

he

rso

n:

121

Su

pp

ort

(C

om

mu

nit

y I

nte

rest

Co

mp

an

y),

Dir

ect

or

Ed

na

Mu

rph

y:

Reg

iste

r of

Inte

rest

s

Page 130 of 146

Pa

ge

4 o

f 4

Dis

clo

sure

Re

qu

ire

me

nt

Dis

clo

sure

4

Un

ive

rsit

y C

oll

eg

e L

on

do

n (

UC

L),

Se

nio

r M

an

ag

er

Bri

an

Ro

ck:

no

ne

Ro

b S

en

ior:

no

ne

Sim

on

Yo

un

g:

no

ne

An

y c

on

ne

ctio

n w

ith

an

org

an

isa

tio

n e

nti

ty o

r co

mp

an

y c

on

sid

eri

ng

e

nte

rin

g i

nto

or

ha

vin

g e

nte

red

in

to a

fin

an

cia

l a

rra

ng

em

en

t w

ith

th

e

Tru

st in

clu

din

g b

ut

no

t li

mit

ed

to

len

de

rs o

r b

an

ks

Din

esh

Bh

ug

ra:

no

ne

Pau

l B

urs

tow

: n

on

e

Jan

e G

izb

ert

: n

on

e

Da

vid

Ho

lt:

Eb

bsf

leet

De

ve

lop

me

nt

Co

rpo

rati

on

, D

ep

uty

Ch

air

Pla

nn

ing

In

spe

cto

rate

, N

ED

Sa

lly H

od

ge

s: n

on

e

Pau

l Je

nk

ins:

no

ne

Lis

Jo

ne

s: n

on

e

Lo

uis

e L

yo

n:

no

ne

Ian

McP

he

rso

n:

no

ne

Ed

na

Mu

rph

y:

no

ne

Bri

an

Ro

ck:

no

ne

Ro

b S

en

ior:

Ma

rrie

d t

o C

ha

ir o

f C

ity a

nd

Ha

ckn

ey C

CG

.

Juli

an

Ste

rn:

no

ne

Sim

on

Yo

un

g:

no

ne

Page 131 of 146

of 1


Item : 19

Title : North Central London (NCL) Sustainability and

Transformation Plan (STP) – June Progress Update

Summary:

The NHS Five Year Forward View team set out a challenging vision for the NHS. Its aim is to bring local health and care partners together to set out clear plans to pursue the Forward View’s ‘triple aim’ to improve:

• the health and wellbeing of the population

• the quality of care that is provided

• NHS finance and efficiency of services

The NHS England 2016/17 planning guidance outlines a new approach to help ensure that health and care service are planned by place rather than around individual organisations. There are 44 Sustainability and Transformation Plans (STPs) being developed in local geographical areas or ‘footprints’ across the country that are being submitted to NHS England for approval. Our Trust is part of North Central London (NCL), one of the five London footprints. This paper gives an update on the progress made within our area and the future plans and timescales.


Quality

Finance

For : Noting

From : Chief Executive

NC

L S

TP

Sum

mar

y

Page 132 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

No

rth

Ce

ntr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tra

nsf

orm

atio

n p

lan

Su

mm

ary

of

pro

gre

ss t

o d

ate

Ju

ne

20

16

NC

L S

TP

Sum

mar

y

Page 133 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

2

Bac

kgro

un

d a

nd

ob

ject

ives

Vis

ion

STP

go

vern

ance

fra

mew

ork

Cas

e fo

r ch

ange

Co

nte

nt

Stak

eho

lder

en

gage

men

t

Cu

rren

t p

osi

tio

n

Nex

t st

eps

Wo

rkst

ream

s

STP

pro

gram

me

stru

ctu

re

1

2

3

4

5

6

7

8

9

Page 134 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

1.

The

NH

S Fi

ve Y

ear

Forw

ard

Vie

w t

eam

set

ou

t a

chal

len

gin

g vi

sio

n f

or

the

NH

S. It

s ai

m is

to

bri

ng

loca

l hea

lth

an

d c

are

par

tner

s to

geth

er t

o s

et o

ut

clea

r p

lan

s to

pu

rsu

e th

e Fo

rwar

d V

iew

’s ‘

trip

le a

im’ t

o im

pro

ve:

•

t

he

hea

lth

an

d w

ellb

ein

g o

f th

e p

op

ula

tio

n

•

th

e q

ual

ity

of

care

th

at is

pro

vid

ed

•

NH

S fi

nan

ce a

nd

eff

icie

ncy

of

serv

ices

The

NH

S En

glan

d 2

01

6/1

7 p

lan

nin

g gu

idan

ce o

utl

ines

a n

ew a

pp

roac

h t

o h

elp

en

sure

th

at h

ealt

h a

nd

car

e se

rvic

e ar

e p

lan

ned

by

pla

ce r

ath

er t

han

aro

un

d in

div

idu

al o

rgan

isat

ion

s.

Ther

e ar

e 4

4 S

ust

ain

abili

ty a

nd

Tra

nsf

orm

atio

n P

lan

s (S

TPs)

bei

ng

dev

elo

ped

in lo

cal g

eogr

aph

ical

are

as o

r ‘f

oo

tpri

nts

’ acr

oss

th

e co

un

try

that

are

bei

ng

sub

mit

ted

to

NH

S En

glan

d f

or

app

rova

l. N

ort

h C

entr

al L

on

do

n (

NC

L) is

on

e o

f th

e fi

ve L

on

do

n

foo

tpri

nts

.

3.

The

mo

st c

om

pe

llin

g an

d c

red

ible

STP

s w

ill s

ecu

re f

un

din

g fr

om

Ap

ril 2

01

7 o

nw

ard

s. N

HS

Engl

and

will

co

nsi

der

: •

the

qu

alit

y o

f p

lan

s, p

arti

cula

rly

the

scal

e o

f am

bit

ion

an

d t

rack

re

cord

of

pro

gre

ss a

lre

ady

mad

e. T

he

bes

t p

lan

s w

ill

hav

e a

cle

ar a

nd

po

we

rfu

l vis

ion

. Th

ey w

ill c

reat

e co

he

ren

ce a

cro

ss d

iffe

ren

t e

lem

en

ts, f

or

exam

ple

a p

reve

nti

on

pla

n;

self

-car

e an

d p

atie

nt

emp

ow

erm

ent;

wo

rkfo

rce;

dig

ital

; n

ew c

are

mo

del

s; a

nd

fin

ance

. Th

ey w

ill s

yste

mat

ical

ly b

orr

ow

go

od

pra

ctic

e f

rom

oth

er

geo

grap

hie

s, a

nd

ad

op

t n

atio

nal

fra

mew

ork

s;

•th

e re

ach

an

d q

ual

ity

of

the

loca

l pro

cess

, in

clu

din

g co

mm

un

ity,

vo

lun

tary

sec

tor

and

loca

l au

tho

rity

en

gage

men

t;

•th

e st

ren

gth

an

d u

nit

y o

f lo

cal s

yste

m le

ade

rsh

ip a

nd

par

tne

rsh

ips,

wit

h c

lear

go

vern

ance

str

uct

ure

s to

del

iver

th

em;

and

•

ho

w c

on

fid

en

t ar

e N

HS

Engl

and

th

at a

cle

ar s

eq

ue

nce

of

imp

lem

en

tati

on

act

ion

s w

ill f

ollo

w a

s in

ten

ded

, th

rou

gh

def

ined

go

vern

ance

an

d d

emo

nst

rab

le c

apab

iliti

es.

The

bac

kgro

un

d o

f Su

stai

nab

ility

an

d T

ran

sfo

rmat

ion

Pla

ns

N

C

L

No

rth

Cen

tral

Lo

nd

on

Su

stai

nab

ility

an

d

Tran

sfo

rmat

ion

Pla

n 3

1

NC

L S

TP

Sum

mar

y

Page 135 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

No

rth

Ce

ntr

al L

on

do

n h

as a

co

mp

lex

he

alth

an

d s

oci

al c

are

lan

dsc

ape

2

NC

L C

CG

s ac

tivi

ty s

tats

V

angu

ard

s in

sco

pe

•

Ro

yal F

ree

mu

lti-

pro

vid

er h

osp

ital

m

od

el

•A

cco

un

tab

le

clin

ical

net

wo

rk

for

can

cer

(UC

LH)

Tota

l h

ealt

h

spen

d

£2

.5b

NH

S En

glan

d

•P

rim

ary

care

sp

end

~£

18

0m

•

Spec

. co

mm

. sp

end

~£

73

0m

Tota

l ca

re

spen

d

c.£

0.8

b

A&

E 5

22

,83

8

Elec

tive

1

34

,51

3

No

n-e

lect

ive

1

63

,48

7

Cri

tica

l Car

e

25

,71

8

Mat

ern

ity

45

,52

8

Ou

tpat

ien

ts

1,8

03

,20

2

Wh

itti

ngt

on

Hea

lth

NH

S Tr

ust

(in

cl Is

lingt

on

an

d H

arin

gey

Co

mm

un

ity)

Un

iver

sity

Co

llege

Lo

nd

on

Ho

spit

als

NH

S FT

No

rth

Mid

dle

sex

Un

iver

sity

Ho

spit

al N

HS

Tru

st

The

Ro

yal F

ree

Lon

do

n N

HS

FT

BEH

Men

tal H

ealt

h N

HS

Tru

st (

mai

n s

ites

, in

cl E

nfi

eld

co

mm

un

ity)

Cam

den

an

d Is

lingt

on

NH

S F

T (a

nd

mai

n s

ites

)

Cen

tral

an

d N

ort

h W

est

Lon

do

n N

HS

FT (

Cam

den

Co

mm

un

ity)

Cen

tral

Lo

nd

on

Co

mm

un

ity

Hea

lth

care

NH

S Tr

ust

(B

arn

et C

om

mu

nit

y)

£2

93

m

£9

40

m

£2

49

m

£9

51

m

£1

85

m

£1

36

m

N/A

– n

ot

in s

cop

e fo

r N

CL

STP

fi

na

nce

ba

se c

ase

The

sp

eci

alis

t p

rovi

de

rs a

re o

ut

of

sco

pe

: G

OSH

an

d R

NO

H

Tavi

sto

ck a

nd

Po

rtm

an N

HS

FT is

ou

t o

f sc

op

e f

inan

cial

ly b

ut

wit

hin

sco

pe

fo

r m

en

tal h

eal

th

£0

.7m

-£1

2.4

m

-£8

.3m

-£5

1m

-£3

1m

-£1

4.8

m

15

/16

OT

Ou

r p

op

ula

tio

n

•O

ur

po

pu

lati

on

is d

ive

rse

and

gro

win

g.

•Li

ke m

any

area

s in

Lo

nd

on

, we

exp

erie

nce

sig

nif

ican

t ch

urn

in t

erm

s o

f p

eop

le u

sin

g o

ur

hea

lth

an

d c

are

serv

ices

as

peo

ple

co

me

in a

nd

ou

t o

f th

e ci

ty.

•

Ther

e is

a w

ide

spre

ad o

f d

ep

riva

tio

n a

cro

ss N

CL

– w

e h

ave

a yo

un

ger,

mo

re d

epri

ved

po

pu

lati

on

in t

he

east

an

d s

ou

th a

nd

an

old

er, m

ore

aff

luen

t p

op

ula

tio

n in

th

e w

est

and

no

rth

. •

Ther

e ar

e h

igh

nu

mb

ers

of

ho

use

ho

lds

in t

em

po

rary

ac

com

mo

dat

ion

acr

oss

th

e p

atch

an

d a

rou

nd

a q

uar

ter

of

the

po

pu

lati

on

in N

CL

do

no

t h

ave

En

glis

h a

s th

eir

m

ain

lan

guag

e.

•Lo

ts o

f p

eop

le c

om

e to

set

tle

in N

CL

fro

m a

bro

ad. T

he

larg

est

mig

ran

t co

mm

un

itie

s ar

rivi

ng

du

rin

g 2

01

4/1

5

sett

ling

in B

arn

et, E

nfi

eld

an

d H

arin

gey

wer

e fr

om

R

om

ania

, Bu

lgar

ia a

nd

Po

lan

d. I

n C

amd

en a

nd

Islin

gto

n

in 2

01

4/1

5 t

he

larg

est

mig

ran

t co

mm

un

itie

s w

ere

fro

m

Ital

y, F

ran

ce a

nd

Sp

ain

.

Tota

l GP

re

gist

ere

d p

op

ula

tio

n 1

.5m

Un

ive

rsit

y C

olle

ge H

osp

ital

Bar

ne

t G

en

era

l Ho

spit

al

Ch

ase

Far

m H

osp

ital

No

rth

Mid

dle

sex

Ho

spit

al

Ro

yal F

ree

Ho

spit

al

St A

nn

’s H

osp

ital

The

Wh

itti

ngt

on

Ho

spit

al

Edgw

are

Co

mm

un

ity

Ho

spit

al

Fin

chle

y M

em

ori

al H

osp

ital

St M

ich

ael’s

P

rim

ary

Car

e

Ce

ntr

e

Lon

do

n A

mb

ula

nce

Ser

vice

Ea

st o

f En

glan

d A

mb

ula

nce

Ser

vice

Mo

orf

ield

s Ey

e H

osp

ital

Gre

at O

rmo

nd

Str

ee

t H

osp

ital

Ce

ntr

al M

idd

lese

x H

osp

ital

Hig

hga

te H

osp

ital

St P

ancr

as H

osp

ital

Enfi

eld

CC

G /

En

fie

ld C

ou

nci

l ~3

20

k G

P r

egis

tere

d p

op

, ~3

24

k re

sid

ent

po

p

48

GP

pra

ctic

es

CC

G A

lloca

tio

n:

£3

62

m (-

£1

4.9

m 1

5/1

6 O

T)

LA A

SC, C

SC, P

H s

pen

d:

£1

84

m

Bar

ne

t C

CG

/ B

arn

et

Co

un

cil

~39

6k

GP

reg

iste

red

po

p, ~

37

5k

resi

den

t p

op

6

2 G

P p

ract

ices

C

CG

Allo

cati

on

: £

44

4m

(£2

.0m

15

/16

OT)

LA

ASC

, CSC

, PH

sp

end

: £

15

8m

Cam

de

n C

CG

/ C

amd

en

Co

un

cil

~26

0k

GP

reg

iste

red

po

p, ,

~2

35

k re

sid

ent

po

p

35

GP

pra

ctic

es

CC

G A

lloca

tio

n:

£3

72

m (£

7.2

m 1

5/1

6 O

T)

LA A

SC, C

SC, P

H s

pen

d:

£1

91

m

Har

inge

y C

CG

/ H

arin

gey

Co

un

cil

~29

6k

GP

reg

iste

red

po

p, ,

~2

67

k re

sid

ent

po

p

45

GP

pra

ctic

es

CC

G A

lloca

tio

n:

£3

41

m (-

£2

.8m

15

/16

OT)

LA

ASC

, CSC

, PH

sp

end

: £1

63

m

Islin

gto

n C

CG

/ Is

lingt

on

Co

un

cil

~23

3k

GP

reg

iste

red

po

p, ,

~2

21

k re

sid

ent

po

p

34

GP

pra

ctic

es

CC

G A

lloca

tio

n:

£3

39

m (£

2.7

m 1

5/1

6 O

T)

LA A

SC, C

SC, P

H s

pen

d:

£1

38

m

Stan

mo

re H

osp

ital

Tavi

sto

ck C

linic

, P

ort

man

Clin

ic,

Glo

uce

ste

r H

ou

se D

ay U

nit

No

te: a

ll O

T fi

gure

s ar

e n

orm

alis

ed p

osi

tio

ns

£2

02

m

£2

m

Mo

orf

ield

s Ey

e H

osp

ital

NH

S FT

1

Page 136 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

We

hav

e a

gre

ed

a n

um

be

r o

f o

bje

ctiv

es

for

the

NC

L ST

P

The

goal

s o

f o

ur

STP

are

: •

To im

pro

ve t

he

qu

alit

y o

f ca

re, w

ellb

ein

g an

d o

utc

om

es f

or

the

NC

L p

op

ula

tio

n

•To

del

iver

a s

ust

ain

able

, tra

nsf

orm

ed lo

cal h

ealt

h a

nd

car

e se

rvic

es

•To

su

pp

ort

a m

ove

to

war

ds

pla

ce-b

ased

co

mm

issi

on

ing

•To

gai

n a

cces

s to

a s

har

e o

f th

e n

atio

nal

tra

nsf

orm

atio

n f

un

din

g w

hic

h w

ill e

nsu

re o

ur

ho

spit

als

get

bac

k to

bei

ng

viab

le, t

o s

up

po

rt d

eliv

ery

of

the

Five

Yea

r Fo

rwar

d V

iew

, an

d t

o e

nab

le n

ew in

vest

men

t in

cri

tica

l pri

ori

ties

Go

als

Ou

tpu

ts

Pro

cess

The

STP

nee

ds

to d

eliv

er s

ever

al k

ey o

utp

uts

: •

A c

om

pel

ling

clin

ical

cas

e fo

r ch

ange

th

at p

rovi

des

th

e fo

un

dat

ion

for

the

pro

gram

me

and

is e

mb

edd

ed

acro

ss t

he

wo

rk, a

nd

su

pp

ort

s th

e id

enti

fica

tio

n o

f p

rio

riti

es t

o b

e ad

dre

ssed

th

rou

gh t

he

STP

•

A s

ingl

e ve

rsio

n o

f th

e tr

uth

fin

anci

al ‘d

o n

oth

ing

’ bas

e ca

se w

ith

qu

anti

fied

op

po

rtu

nit

y im

pac

ts b

ased

o

n t

he

pri

ori

ties

iden

tifi

ed

•A

ro

bu

st a

nd

cre

dib

le p

lan

for

imp

lem

enta

tio

n a

nd

del

iver

y o

ver

five

yea

rs

•A

go

vern

ance

fra

mew

ork

th

at s

up

po

rts

par

tner

ship

wo

rkin

g ac

ross

th

e ST

P a

nd

co

llect

ive

dec

isio

n

mak

ing

•Th

e re

sou

rce

in p

lace

to

del

iver

tra

nsf

orm

atio

n a

t sc

ale

and

pac

e in

th

e ke

y ar

eas

iden

tifi

ed

The

pro

cess

to

dev

elo

pin

g o

ur

STP

nee

ds

to:

•B

e co

llab

ora

tive

, an

d o

wn

ed b

y al

l pro

gram

me

par

tner

s in

NC

L •

Be

stru

ctu

red

an

d r

igo

rou

s •

Mo

ve a

t p

ace,

en

suri

ng

qu

ick

win

s ar

e im

ple

men

ted

an

d t

ran

sfo

rmat

ion

is p

rio

riti

sed

•

Invo

lve

all a

reas

of

CC

G, l

oca

l au

tho

rity

an

d N

HS

Engl

and

co

mm

issi

on

ed a

ctiv

ity,

incl

ud

ing

spec

ialis

ed

serv

ices

, pri

mar

y ca

re a

nd

ref

lect

ing

loca

l HW

B s

trat

egie

s 5

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

1

NC

L S

TP

Sum

mar

y

Page 137 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

11

The

NC

L ST

P T

ran

sfo

rmat

ion

Bo

ard

mee

ts m

on

thly

to

ove

rsee

th

e d

evel

op

men

t o

f th

e p

rogr

amm

e an

d in

clu

des

rep

rese

nta

tio

n f

rom

all

pro

gram

me

par

tner

s. It

has

no

fo

rmal

dec

isio

n m

akin

g au

tho

rity

, bu

t m

emb

ers

are

com

mit

ted

to

ste

erin

g d

ecis

ion

s th

rou

gh t

hei

r co

nst

itu

en

t b

oar

ds

and

go

vern

ing

bo

die

s. T

her

e ar

e th

ree

su

bgr

ou

ps

sup

po

rtin

g th

e Tr

ansf

orm

atio

n B

oar

d. T

he

Clin

ical

Cab

inet

pro

vid

es c

linic

al a

nd

pro

fess

ion

al s

teer

an

d in

pu

t w

ith

CC

G

Ch

air,

Med

ical

Dir

ecto

r, n

urs

ing,

pu

blic

hea

lth

an

d a

du

lt s

oci

al s

ervi

ces

and

ch

ildre

n’s

ser

vice

s m

emb

ersh

ip. T

he

Fin

ance

an

d A

ctiv

ity

Mo

de

llin

g G

rou

p is

at

ten

ded

by

Fin

ance

Dir

ecto

rs f

rom

all

par

tner

org

anis

atio

ns.

Th

e Tr

ansf

orm

atio

n G

rou

p is

a s

mal

ler

stee

rin

g gr

ou

p m

ade

up

of

a cr

oss

sec

tio

n o

f re

pre

sen

tati

ves

fro

m o

rgan

isat

ion

s an

d r

ole

s sp

ecif

ical

ly f

acili

tati

ng

dis

cuss

ion

on

pro

gram

me

dir

ecti

on

fo

r p

rese

nta

tio

n a

t th

e T

ran

sfo

rmat

ion

Bo

ard

. Eve

ry

wo

rkst

ream

has

a s

enio

r le

vel n

amed

SR

O t

o s

teer

th

e w

ork

an

d e

nsu

re s

yste

m le

ader

ship

filt

ers

do

wn

acr

oss

th

e p

rogr

amm

e. T

he

Cli

nic

al R

efer

ence

Gro

up

w

ill b

e m

ob

ilise

d o

ver

the

sum

mer

of

20

16

an

d w

ill p

rovi

de

a fo

rum

fo

r in

pu

t, r

evie

w a

nd

co

-des

ign

wit

h a

bro

ader

po

ol o

f cl

inic

ian

s an

d p

ract

itio

ner

s.

We

hav

e d

eve

lop

ed

a r

ob

ust

go

vern

ance

str

uct

ure

th

at e

nab

les

colla

bo

rati

ve in

pu

t an

d s

tee

r fr

om

acr

oss

th

e S

TP p

artn

ers

2

* P

rogr

amm

e G

ove

rnan

ce S

tru

ctu

re t

o b

e re

view

ed

as

pro

gram

me

mo

ves

into

imp

lem

en

tati

on

P r o

g r a

m m

e D

i r e

c t o

r :

D a

v i d

S t o

u t

P r o

g r a

m m

e M

a n

a g e

r :

A l i

c e

H o

p k

i n s o

n

P M

O L

e a

d :

A b

i H

o l l

a n

d

P r o

g r a

m m

e s

u p

p o

r t :

J u l i

e C

h a

n J

o n

e s

S e u

n F

a d

a r e

C

o m

m s

a n d

e n

g a g e

m e

n t

l e a

d :

D e

n i s

e S h

a w

N C

L T r

a n

s f o

r m a

t i o

n B

o a r

d

C h

a i r

: D

a v i

d S

l o m

a n

S R

O s :

D a

v i d

S l o

m a

n (

C o

n v

e n o

r ) , D

o r o

t h y

B l u

n d

e l l

, M i k

e C

o o

k e

M e

m b

e r s

• S R

O s

• N H

S C

C G

r e

p s

• N H

S A

c u t e

p r o

v i d

e r

r e p

s

• N H

S C

o m

m u

n i t

y p

r o v

i d e r

r e

p s

• N H

S M

e n t a

l H e

a l t h

p r o

v i d

e r

r e p

s

• L o

c a l

a u

t h o

r i t y

r e

p s

• L A

S

• H E

N C

E L

N C

L C

C G

s C

O L L

A B

O R

A T I

O N

N H

S P

R O

V I D

E R

S G

R O

U P

H E N

C E L

N H

S E N

G L A

N D

L O

N D

O N

H E A

L T H

Y L O

N D

O N

P

A R

T N E R

S H I P

L A C

E O s

D s P

H

C C

G C

O s

D A

S S s

H W

B s

H A

R I N

G E Y

A N

D

I S L I

N G

T O N

W

E L L B

E I N

G

A L L

I A N

C E

B O

A R

D

N C

L S T

P P

M O

F i n

a n

c e a

n d

A c

t i v

i t y

M o

d e

l l i n

g G

r o u

p

L e a

d : T

i m J

a g g

a r d

C l i

n i c

a l

R e

f e r e

n c e

G r o

u p

T r a n

s f o

r m a

t i o

n G

r o u

p

L e a

d : D

a v i

d S

l o m

a n

C

l i n

i c a

l C a

b i n

e t

L e a

d s :

D r

R i c

h a

r d J

e n

n i n

g s

& D

r J o

S a u

v a g e

• U C

L P

• N H

S s p

e c i

a l i

s e d

c o

m m

i s s i

o n

i n g

• N H

S E n

g l a

n d

• N H

S I m

p r o

v e m

e n

t

• H e

a l t h

w a

t c h

• C l i

n i c

a l l

e a d

• F i n

a n

c e l e

a d

• P r o

g r a

m m

e D

i r e

c t o

r

P r o

g r a

m m

e s

t r u

c t u

r e –

s e

e s

e c t

i o n

6

Page 138 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

Cas

e f

or

Ch

ange

•Th

e C

linic

al C

abin

et h

as m

et f

ive

tim

es, s

ince

its

ince

pti

on

, to

dev

elo

p a

ro

bu

st a

nd

acc

ura

te C

ase

for

Ch

ange

fo

r N

ort

h C

entr

al L

on

do

n’s

hea

lth

an

d s

oci

al c

are

•

On

13

Ju

ne,

th

e C

linic

al C

abin

et a

gree

d t

he

dra

ft C

ase

for

Ch

ange

, pen

din

g so

me

ou

tsta

nd

ing

issu

es;

this

was

th

en

end

ors

ed b

y th

e Tr

ansf

orm

atio

n B

oar

d o

n 2

2 J

un

e

•D

raft

Cas

e fo

r C

han

ge w

as p

art

of

the

sub

mis

sio

n s

ent

to N

HS

Engl

and

on

30

Ju

ne;

th

eir

fee

db

ack

is e

xpec

ted

in J

uly

•

Fro

m n

ow

un

til t

he

end

of

Sep

tem

ber

, th

e C

linic

al C

abin

et w

ill m

ove

th

e C

ase

for

Ch

ange

fro

m d

raft

to

a

com

pre

hen

sive

, fin

al d

ocu

men

t w

hic

h w

ill b

e p

ub

lish

ed in

late

Su

mm

er.

7

Dev

elo

pm

en

t an

d

en

gage

me

nt

pro

cess

to

d

ate

Clin

ical

cab

inet

•

The

NC

L ST

P C

linic

al C

abin

et is

res

po

nsi

ble

fo

r th

e C

ase

for

Ch

ange

. Th

eir

role

is t

o is

lead

th

e fu

rth

er d

evel

op

men

t o

f ST

P w

ork

•

The

Clin

ical

Cab

inet

will

sig

n o

ff t

he

Cas

e fo

r C

han

ge w

ith

ult

imat

e re

spo

nsi

bili

ty fa

llin

g to

th

e N

CL

STP

clin

ical

lead

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

3

•So

me

hig

h le

vel m

essa

ges

fro

m a

nal

ysis

rel

atin

g to

ou

r p

op

ula

tio

n’s

hea

lth

an

d w

ellb

ein

g ar

e:

•P

eop

le a

re li

vin

g lo

nge

r b

ut

in p

oo

r h

ealt

h

•O

ur

dif

fere

nt

eth

nic

gro

up

s h

ave

dif

fere

nt

hea

lth

nee

ds

•Th

ere

is w

ides

pre

ad d

epri

vati

on

an

d h

ealt

h in

equ

alit

ies

•H

igh

leve

ls o

f h

om

eles

snes

s an

d h

ou

seh

old

s in

tem

po

rary

ho

usi

ng

•

Life

styl

e ch

oic

es p

ut

peo

ple

at

risk

of

po

or

hea

lth

an

d e

arly

dea

th

•Th

ere

are

po

or

ind

icat

ors

of

hea

lth

fo

r ch

ildre

n

•H

igh

rat

es

of

men

tal i

llnes

s am

on

g b

oth

ad

ult

s an

d c

hild

ren

•W

hen

an

alys

ing

ou

r ca

re a

nd

qu

alit

y m

etri

cs, w

e id

enti

fy t

he

follo

win

g:

•Th

ere

is n

ot

eno

ugh

fo

cus

on

pre

ven

tio

n a

cro

ss t

he

wh

ole

NC

L sy

ste

m

•D

isea

se c

ou

ld b

e d

etec

ted

an

d m

anag

ed m

uch

ear

lier

•Th

ere

are

chal

len

ges

in p

rovi

sio

n o

f p

rim

ary

care

•

Ther

e is

a la

ck o

f in

tegr

ated

car

e an

d s

up

po

rt f

or

tho

se w

ith

a L

TC

•M

any

peo

ple

are

in h

osp

ital

bed

s w

ho

co

uld

be

care

d f

or

at h

om

e

•Th

ere

are

dif

fere

nce

s in

th

e w

ay p

lan

ned

car

e is

del

iver

ed

•Th

ere

are

chal

len

ges

in m

enta

l hea

lth

pro

visi

on

an

d in

th

e p

rovi

sio

n o

f ca

nce

r ca

re

•So

me

bu

ildin

gs a

re n

ot

fit

for

pu

rpo

se

•In

form

atio

n t

ech

no

logy

nee

ds

to b

ette

r su

pp

ort

inte

grat

ed c

are

. •

Init

ial f

inan

cial

an

alys

is s

ho

w w

e f

ace

a si

gnif

ican

t fi

nan

cial

ch

alle

nge

. If

we

co

nti

nu

e o

n o

ur

curr

ent

spen

din

g p

ath

, th

e d

efic

it

will

ris

e su

bst

anti

ally

ove

r th

e n

ext

five

yea

rs

Init

ial

me

ssag

es

fro

m

the

Cas

e f

or

Ch

ange

NC

L S

TP

Sum

mar

y

Page 139 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

In r

esp

on

se t

o t

he

cas

e f

or

chan

ge, w

e h

ave

co

llect

ive

ly d

eve

lop

ed

an

o

vera

rch

ing

visi

on

fo

r N

CL

wh

ich

will

be

de

live

red

th

rou

gh t

he

STP

7

4 Th

is m

ean

s w

e w

ill:

•h

elp

peo

ple

wh

o a

re w

ell,

to s

tay

hea

lth

y •

wo

rk w

ith

peo

ple

to

mak

e h

ealt

hie

r ch

oic

es

•u

se a

ll o

ur

com

bin

ed in

flu

ence

an

d p

ow

ers

to p

reve

nt

po

or

hea

lth

an

d w

ellb

ein

g •

hel

p p

eop

le t

o li

ve a

s in

dep

end

entl

y as

po

ssib

le in

re

silie

nt

com

mu

nit

ies

•d

eliv

er b

ette

r h

ealt

h a

nd

so

cial

car

e o

utc

om

es,

max

imis

ing

the

effe

ctiv

enes

s o

f th

e h

ealt

h a

nd

so

cial

ca

re s

yste

m

•im

pro

ve p

eop

le’s

exp

erie

nce

s o

f h

ealt

h a

nd

so

cial

car

e,

ensu

rin

g it

is d

eliv

ered

clo

se t

o h

om

e w

her

ever

po

ssib

le

•re

du

ce t

he

cost

s o

f th

e h

ealt

h a

nd

so

cial

car

e sy

stem

, el

imin

atin

g w

aste

an

d d

up

licat

ion

so

th

at it

is a

ffo

rdab

le

for

the

year

s to

co

me

•at

th

e sa

me

tim

e w

e w

ill e

nsu

re s

ervi

ces

rem

ain

saf

e an

d o

f go

od

qu

alit

y •

enab

le N

ort

h L

on

do

ner

s to

do

mo

re t

o lo

ok

afte

r th

emse

lves

•

hav

e a

stro

ng

dig

ital

focu

s, m

axim

isin

g th

e b

enef

its

of

dig

ital

hea

lth

dev

elo

pm

ents

.

Ou

r vi

sio

n is

fo

r N

ort

h C

entr

al L

on

do

n t

o b

e a

pla

ce w

ith

th

e b

est

po

ssib

le h

ealt

h a

nd

wel

lbei

ng

, wh

ere

no

-on

e g

ets

left

b

ehin

d. I

t w

ill b

e su

pp

ort

ed b

y a

wo

rld

cla

ss, i

nte

gra

ted

hea

lth

an

d s

oci

al c

are

sys

tem

des

ign

ed a

rou

nd

ou

r re

sid

ents

.

Ou

r co

re p

rin

cip

les

are

: •

resi

den

ts a

nd

pat

ien

ts w

ill b

e at

th

e h

eart

of

wh

at w

e d

o a

nd

ho

w w

e tr

ansf

orm

NC

L. T

hey

will

par

tici

pat

e in

th

e d

esig

n o

f th

e fu

ture

arr

ange

men

ts.

•w

e w

ill w

ork

to

geth

er a

cro

ss o

rgan

isat

ion

al

bo

un

dar

ies

and

tak

e a

wh

ole

sys

tem

vie

w

•w

e w

ill b

e ra

dic

al in

ou

r ap

pro

ach

an

d n

ot

be

con

stra

ined

by

the

curr

ent

syst

em

•w

e w

ill h

arn

ess

the

wo

rld

cla

ss a

sset

s av

aila

ble

to

us

acro

ss t

he

No

rth

Cen

tral

Lo

nd

on

co

mm

un

itie

s an

d

org

anis

atio

ns

•w

e w

ill b

e gu

ided

by

the

exp

erti

se o

f cl

inic

ian

s an

d

fro

nt

line

staf

f w

ho

are

clo

se t

o r

esid

ents

an

d

pat

ien

ts

•w

e w

ill b

uild

on

th

e go

od

pra

ctic

e th

at a

lrea

dy

exis

ts

in N

ort

h C

entr

al L

on

do

n a

nd

wo

rk t

o im

ple

men

t it

at

scal

e, w

her

e ap

pro

pri

ate

•

we

will

res

pec

t th

e fa

ct t

hat

th

e fi

ve b

oro

ugh

s in

NC

L h

ave

man

y si

mila

riti

es, t

her

e ar

e si

gnif

ican

t d

iffe

ren

ces

wh

ich

will

req

uir

e d

iffe

ren

t re

spo

nse

s in

d

iffe

ren

t lo

calit

ies.

Page 140 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

8

The

vis

ion

will

be

de

live

red

th

rou

gh a

co

nsi

ste

nt

mo

del

of

care

4

S e c o

n d

a r y

c a r

e ( h

o s p

i t a l ) s u p

p o r t

S p e c i

a l i s

t c o

m m

u n i t

y b a s e

d s

u p

p o

r t

C o o

r d i n

a t e

d c

o m

m u n i t

y , p

r i m

a r y a n

d s

o c i

a l c

a r e

L i v i

n g a f u

l l a n

d h

e a l

t h y l i

f e i n t

h e c o m

m u n

i t y

W h e n n

e e d

s c a

n ’ t b

e m

e t i n

t h e c o

m m

u n i t y ,

p e o p l e

h a v e

a c c

e s s

t o a

s s e s s

m e n t f

o r h

o s p

i t a l c a

r e a

n d t r e

a t m

e n t . 2

4 / 7

s u p p o r t

i s a

v a i l a

b l e

t o p

e o p l e

w i t h a

c u t e

o r e m

e r g

e n c y

n e e d s ,

i n c l

u d i n

g a

m b u l a

t o r y

c a r e

a n d d

i a g n o s t

i c s .

T h i s

i n c l

u d e s h o s p

i t a l a d m

i s s i

o n i f r e

q u i r e d .

P e o p l e

w i t h c

o m

p l e

x n e e d s ,

s u c h

a s l o

n g t e r

m c

o n d i t i o

n s ,

r e c e

i v e

o n g o i n

g s

u p p o r t

c l o

s e t

o h

o m

e . H

i g h q

u a l i t

y s p

e c i a

l i s t s e

r v i c

e s a r e

a v a

i l a b l e

w h e n

t h e y

n e e d

t h e m

.

H e a l t h a

n d w

e l l b

e i n

g n

e e d

s a r e

s u p p o r t

e d i n

t h e c o

m m

u n i t y o r c l

o s e

t o h

o m

e . P e o p l e

r e c e

i v e c o

n t i n u i t y o f c a

r e , h a v e

t h e o p p o r t

u n i t y t o

c o - p

r o d u c e

t h e i

r c a

r e w

i t h p

r o f e

s s i o

n a l s

, a n d i n s

o m

e c

a s e

s r e

c e i v

e c a

s e m

a n a g e m

e n t t o

s u p p o r t

m u l t i - d i s

c i p l i n

a r y

i n

p u t a n d r e v i

e w

o f t h

e i r c

a r e

p a c k

a g e s

.

“ I g

e t t h

e c a

r e I n

e e d w

h e n I n

e e d i t ”

I n d i v

i d u a l s

a n d c

o m

m u n i t i e

s i n

N C L a r e

s u p p o r t

e d t

o e

f f e c

t i v e

l y m

a n a g e t h

e i r w

e l l b

e i n g , c

l o s e

t o h

o m

e , w

i t h a

f o c u

s o n p

r e v e

n t i o n a

n d r e s

i l i e n c e

T e r t

i a r y

s p

e c i

a l i s

t s e

r v i c

e s

T h e r e

a r e

c l o

s e l i

n k s t o

c o m

m u n i t y s e

r v i c

e s s o

t h a t

s t a y i n

h o s p

i t a l i

s o n l y

a s

l o n g a

s i t n

e e d

s t o

b e a n d

f o l l o

w i n

g a

s t a

y i n

h o s p

i t a l

p e o

p l e

a r e

s u p p o r t

e d i n

t h e i r r

e c o

v e r y

.

H i g

h l y

s p e c i

a l i s

e d c

a r e

i s a

v a i l a

b l e

t o

p e o p l e

w h o n

e e d i t

.

NC

L S

TP

Sum

mar

y

Page 141 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

We

are

in t

he

pro

cess

of

de

sign

ing

a co

he

sive

pro

gram

me

th

at is

larg

e

scal

e a

nd

tra

nsf

orm

atio

nal

in o

rde

r to

me

et t

he

ch

alle

nge

13

5

Hea

lth

an

d w

ellb

ein

g

•Im

pro

ves

po

pu

lati

on

h

ealt

h o

utc

om

es

•R

edu

ces

dem

and

1.

Pop

ula

tio

n h

ealt

h

incl

ud

ing

pre

ven

tio

n

(Da

vid

Sto

ut,

STP

PD

) 2

.P

rim

ary

care

tr

ansf

orm

atio

n (

Alis

on

B

lair,

ICC

G C

O)

3.

Men

tal h

ealt

h (

Pau

l Je

nki

ns,

TP

FT C

EO)

Car

e an

d q

ual

ity

•In

crea

ses

ind

epen

den

ce

and

imp

rove

s q

ual

ity

•R

edu

ces

len

gth

of

stay

4

.U

rgen

t an

d e

mer

gen

cy

care

(A

liso

n B

lair,

ICC

G

CO

) 5

.O

pti

mis

ing

the

ele

ctiv

e p

ath

way

(R

ich

ard

Jen

nin

gs,

W

hit

tin

gto

n M

D)

6.

Co

nso

lidat

ion

of

spec

ialt

ies

(Ric

ha

rd

Jen

nin

gs,

Wh

itti

ng

ton

M

D)

Pro

du

ctiv

ity

•R

edu

ces

no

n v

alu

e-

add

ing

cost

7.

Org

anis

atio

nal

-lev

el

pro

du

ctiv

ity

incl

ud

ing:

a)

Co

mm

issi

on

er

b)

Pro

vid

er

(FD

s)

8.

Syst

em p

rod

uct

ivit

y in

clu

din

g:

a)C

on

solid

atio

n o

f co

rpo

rate

ser

vice

s b

)R

edu

cin

g tr

ansa

ctio

nal

co

sts

and

co

sts

of

du

plic

ate

inte

rven

tio

ns

(Tim

Ja

gg

ard

, UC

LH F

D)

Enab

lers

•Fa

cilit

ates

th

e d

eliv

ery

of

key

wo

rkst

ream

s

9.

Hea

lth

an

d c

are

wo

rkfo

rce

(Ma

ria

K

an

e, B

EHM

HT

CE)

1

0.

Hea

lth

an

d c

are

esta

tes

(Ca

thy

Gri

tzn

er, B

CC

G C

O

an

d D

aw

n W

ake

ling

, B

arn

et C

ou

nci

l DA

SS)

11

.D

igit

al /

info

rmat

ion

(N

eil G

riff

ith

s, U

CLH

D

CEO

) 1

2.

New

car

e m

od

els

&

new

del

iver

y m

od

els

(Da

vid

Sto

ut,

STP

PD

) 1

3.

Co

mm

issi

on

ing

mo

del

s (D

oro

thy

Blu

nd

ell,

CC

CG

CO

)

Hig

h le

vel

imp

act

Init

iati

ves

A

B

C

D

Page 142 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

11

Wh

at w

e a

im t

o a

chie

ve f

rom

eac

h o

f o

ur

wo

rkst

ream

s 6

Hea

lth

an

d

wel

lbei

ng

Focu

s o

n p

reve

nta

tive

car

e to

ach

ieve

bet

ter

hea

lth

an

d c

are

at a

low

er, c

ost

, wit

h a

red

uct

ion

in

hea

lth

ineq

ual

itie

s P

op

ula

tio

n h

ealt

h

Red

uce

dem

and

by

up

grad

ing

ou

t o

f h

osp

ital

car

e an

d s

up

po

rt, f

or

ind

ivid

ual

s w

ith

dif

fere

nt

typ

es

of

nee

ds

Pri

mar

y ca

re

tran

sfo

rmat

ion

Join

ing

up

of

men

tal a

nd

ph

ysic

al h

ealt

h, a

nal

ysis

of

soci

al d

eter

min

ants

an

d s

up

po

rtin

g p

op

ula

tio

n

to li

ve w

ell

Me

nta

l hea

lth

Car

e an

d

qu

alit

y

Imp

rove

car

e th

rou

gh in

tegr

ated

ap

pro

ach

acr

oss

hea

lth

an

d s

oci

al c

are

U

rgen

t an

d e

me

rgen

cy c

are

Un

der

stan

d t

he

vari

atio

n in

del

iver

y b

etw

een

acu

te p

rovi

der

s to

imp

rove

pat

ien

t sa

fety

, qu

alit

y an

d

ou

tco

mes

Op

tim

isin

g th

e e

lect

ive

pat

hw

ay

Iden

tify

ing

clin

ical

are

as w

hic

h m

igh

t b

enef

it fo

rm c

on

solid

atio

n

Co

nso

lidat

ion

of

spec

ialit

ies

Pro

du

ctiv

ity

Effi

cien

cies

gai

ned

th

rou

gh b

ette

r al

ign

men

t o

f h

ealt

h a

nd

car

e se

rvic

es

Org

anis

atio

nal

-le

vel

pro

du

ctiv

ity

Imp

rove

d d

eliv

ery

op

po

rtu

nit

ies

in a

reas

su

ch a

s: w

ork

forc

e m

anag

emen

t, p

har

mac

y, m

edic

al,

surg

ical

an

d f

oo

d p

rocu

rem

ent

and

dis

trib

uti

on

, po

ole

d d

igit

al in

form

atio

n a

nd

co

rpo

rate

fu

nct

ion

s Sy

ste

m p

rod

uct

ivit

y

Enab

lers

Dev

elo

p n

ew w

ork

forc

e m

od

el, f

ocu

sed

on

pre

ven

tio

n a

nd

sel

f-ca

re, i

ncl

ud

ing

revi

ew o

f ex

isti

ng

role

s an

d r

equ

irem

ents

H

ealt

h a

nd

car

e w

ork

forc

e

Man

agem

ent

of

On

e P

ub

lic E

stat

e to

max

imiz

e th

e as

set

and

imp

rove

fac

iliti

es f

or

del

iver

ing

care

H

ealt

h a

nd

car

e es

tate

s

Dev

elo

p t

he

dig

ital

vis

ion

: in

c. d

igit

ally

act

ivat

ed p

op

ula

tio

n, e

nh

ance

d c

are

del

iver

y m

od

els,

in

tegr

ated

dig

ital

rec

ord

acc

ess

and

man

agem

ent

Dig

ital

/ in

form

atio

n

Wo

rk w

ith

Kin

gs F

un

d t

o d

evel

op

ou

r d

eliv

ery

mo

del

fo

r p

op

ula

tio

n h

ealt

h f

or

NC

L N

ew

car

e m

od

els

& n

ew

d

eliv

ery

mo

del

s

Dev

elo

p s

tro

ng

com

mis

sio

nin

g th

rou

gh p

artn

ersh

ip w

ork

ing

to d

evel

op

wh

ole

po

pu

lati

on

mo

del

s o

f ca

re, i

mp

rove

pat

ien

ts o

utc

om

es a

nd

fin

anci

al a

nd

qu

alit

y ga

ps

Co

mm

issi

on

ing

mo

del

s

A

B

C

D

NC

L S

TP

Sum

mar

y

Page 143 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

Cu

rre

nt

po

siti

on

Un

de

rsta

nd

ing

the

siz

e o

f th

e

chal

len

ge

•W

e h

ave

un

der

take

n a

nal

ysis

to

ide

nti

fy t

he

gap

s in

hea

lth

an

d w

ellb

ein

g, a

nd

car

e an

d q

ual

ity

in N

CL

in o

rder

to

pri

ori

tise

th

e ar

eas

we

nee

d t

o a

dd

ress

•

Ou

r d

raft

Cas

e fo

r C

han

ge p

rovi

des

a n

arra

tive

in s

up

po

rt o

f w

ork

ing

in a

new

way

an

d p

rovi

des

th

e p

latf

orm

fo

r st

rate

gic

chan

ge t

hro

ugh

iden

tify

ing

key

area

s o

f fo

cus

•Fi

nan

ce d

irec

tors

fro

m a

ll o

rgan

isat

ion

s h

ave

bee

n w

ork

ing

to id

enti

fy t

he

pro

ject

ed N

CL

he

alth

an

d

care

po

siti

on

in 2

0/2

1 s

ho

uld

we

do

no

thin

g

De

live

rin

g im

pac

t in

ye

ar

on

e

•Th

ere

is a

lrea

dy

wo

rk in

tra

in t

hat

will

en

sure

del

iver

y o

f im

pac

t b

efo

re n

ext

Ap

ril,

in p

arti

cula

r, C

CG

p

lan

s to

bu

ild c

apac

ity

and

cap

abili

ty in

pri

mar

y ca

re a

nd

del

iver

on

th

e 1

7 s

pec

ific

atio

ns

in t

he

Lon

do

n S

trat

egi

c C

om

mis

sio

nin

g Fr

amew

ork

(SC

F).

•H

ow

ever

, fu

rth

er

wo

rk m

ust

be

do

ne

to b

road

en o

ur

ou

t o

f h

osp

ital

str

ate

gy a

nd

ad

dre

ss i

ssu

es w

ith

re

gard

to

th

e sh

ort

-ter

m s

ust

ain

abili

ty a

nd

via

bili

ty o

f ge

ner

al p

ract

ice

•Th

e im

ple

me

nta

tio

n o

f o

ur

Loca

l Dig

ital

Ro

adm

ap w

ill s

up

po

rt t

he

del

iver

y o

f th

e m

enta

l hea

lth

, p

rim

ary

care

an

d e

stat

es w

ork

, an

d o

ur

two

Van

guar

ds

are

con

tin

uin

g to

pro

gres

s w

ith

th

eir

pla

ns.

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

12

7

Esta

blis

hin

g ef

fect

ive

p

artn

ers

hip

w

ork

ing

•N

CL-

wid

e co

llab

ora

tive

wo

rkin

g is

a r

elat

ivel

y n

ew e

nd

eavo

ur

and

we

con

tin

ue

to b

uild

re

lati

on

ship

s ac

ross

th

e p

rogr

amm

e p

artn

ers

to e

nsu

re t

hat

hea

lth

an

d c

are

com

mis

sio

ner

s an

d p

rovi

der

s ar

e al

ign

ed in

ou

r am

bit

ion

to

tra

nsf

orm

car

e •

We

hav

e es

tab

lish

ed a

go

vern

ance

fra

mew

ork

th

at s

up

po

rts

effe

ctiv

e p

artn

ers

hip

wo

rkin

g an

d w

ill

pro

vid

e th

e fo

un

dat

ion

for

the

pla

nn

ing

and

imp

lem

enta

tio

n o

f o

ur

stra

tegi

c p

rogr

amm

e go

ing

forw

ard

•

The

SRO

s ar

e w

ork

ing

to b

rin

g C

CG

s, p

rovi

der

s an

d lo

cal a

uth

ori

ties

to

geth

er a

cro

ss t

he

5 b

oro

ugh

s to

geth

er r

eco

gnis

ing

the

his

tory

an

d c

on

text

th

at u

nd

erlie

s w

ork

ing

toge

ther

in a

new

way

Page 144 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

•Fo

rwar

d p

lan

nin

g u

nd

erw

ay t

o jo

in u

p a

ll p

artn

ers

and

sta

keh

old

ers

in N

CL

foo

tpri

nt

•D

edic

ated

co

mm

un

icat

ion

s le

ad n

ow

in p

lace

to

u

nd

erta

ke t

his

•

Stak

eho

lder

map

pin

g u

nd

erw

ay f

or

exte

rnal

an

d

inte

rnal

bo

die

s th

rou

gh in

tegr

ated

wo

rk a

pp

roac

hes

w

ith

CC

G c

om

mu

nic

atio

ns

and

en

gage

men

t le

ads

to

incl

ud

e p

artn

ers

such

as

loca

l au

tho

riti

es, N

HS

pro

vid

ers,

GP

pra

ctic

es

and

oth

ers

to b

e d

eter

min

ed

•In

ad

dit

ion

to

par

tner

s an

d s

take

ho

lder

s al

read

y co

nsu

lted

, we

will

iden

tify

op

po

rtu

nit

ies

for

mo

re S

TP

par

tner

s cl

inic

ian

s/st

aff

to h

ave

inp

ut

into

sp

ecif

ic

wo

rk s

trea

ms

asap

, par

ticu

larl

y lo

cal p

olit

ical

en

gage

men

t w

hic

h w

ill b

e ke

y fo

r co

mm

un

ity

lead

ersh

ip o

f ch

ange

•

Pla

n t

o e

nga

ge m

ore

fo

rmal

ly w

ith

bo

ard

s an

d

par

tner

s af

ter

the

July

co

nve

rsat

ion

s •

Effe

ctiv

e co

mm

un

icat

ion

s ch

ann

els

will

be

esta

blis

hed

fo

r al

l sta

keh

old

ers

and

par

tner

s fo

r tr

ansp

aren

t co

ntr

ibu

tio

ns

to o

ngo

ing

pla

ns

and

d

iscu

ssio

ns,

incl

ud

ing

staf

f, c

linic

ian

s, p

atie

nts

, p

olit

icia

ns

etc.

•

A c

ore

nar

rati

ve is

bei

ng

crea

ted

to

co

ver

ou

r h

ealt

h

and

car

e ch

alle

nge

s an

d o

pp

ort

un

itie

s, S

TP p

urp

ose

, d

evel

op

men

t, g

oal

s, s

trat

egic

ap

pro

ach

an

d p

rio

riti

es

– in

per

son

-cen

tred

, acc

essi

ble

lan

guag

e

•R

evie

w r

equ

irem

ents

fo

r co

nsu

ltat

ion

bef

ore

Mar

ch

20

17

We

will

en

sure

all

ou

r st

ake

ho

lde

rs a

nd

wid

er

pro

gram

me

par

tne

rs a

re

app

rop

riat

ely

invo

lve

d in

th

e d

eve

lop

me

nt

of

the

pro

gram

me

30

8

Enga

gem

en

t to

dat

e

Co

mm

un

icat

ion

s &

en

gage

me

nt

ob

ject

ive

s D

eliv

eri

ng

the

ob

ject

ive

s

•To

su

pp

ort

th

e en

gage

men

t an

d in

volv

emen

t o

f ST

P p

artn

ers

acro

ss a

ll o

rgan

isat

ion

s at

all

leve

ls

•To

en

sure

a s

tro

ng

deg

ree

of

org

anis

atio

nal

co

nse

nsu

s o

n t

he

STP

co

nte

nt

and

on

th

e ap

pro

ach

to

fu

rth

er d

evel

op

ing

the

stra

tegi

c p

lan

an

d im

ple

me

nta

tio

n a

pp

roac

h, i

n p

arti

cula

r p

olit

ical

invo

lvem

ent

and

su

pp

ort

•

To s

up

po

rt a

nd

co

-ord

inat

e ST

P p

artn

ers

in

enga

gin

g w

ith

th

eir

stak

eh

old

ers

to r

aise

aw

aren

ess

and

un

der

stan

din

g o

f:

•th

e ch

alle

nge

s an

d o

pp

ort

un

itie

s fo

r h

ealt

h

and

car

e in

NC

L •

ho

w t

he

STP

– s

pec

ific

ally

th

e em

ergi

ng

pri

ori

ties

an

d in

itia

tive

s -

see

ks t

o a

dd

ress

th

e ch

alle

nge

s an

d o

pp

ort

un

itie

s so

th

at

we

can

dev

elo

p t

he

bes

t p

oss

ible

hea

lth

an

d c

are

off

er f

or

ou

r p

op

ula

tio

n

•w

hat

th

e N

CL

stra

tegi

c p

lan

will

mea

n in

p

ract

ice

an

d h

ow

th

ey c

an in

flu

ence

its

furt

her

dev

elo

pm

ent

and

imp

lem

en

tati

on

•

To e

nco

ura

ge a

nd

gat

her

fee

db

ack

fro

m

stak

eh

old

ers

– N

HS,

loca

l go

vern

men

t, lo

cal a

nd

n

atio

nal

po

litic

ian

s, p

atie

nts

an

d t

he

wid

er

com

mu

nit

y –

that

can

: •

infl

uen

ce o

ur

emer

gin

g p

lan

s an

d n

ext

step

s •

hel

p b

uild

su

pp

ort

fo

r th

e ST

P a

pp

roac

h

•To

en

sure

eq

ual

itie

s d

uti

es a

re f

ulf

illed

, in

clu

din

g u

nd

erta

kin

g eq

ual

itie

s im

pac

t as

sess

men

ts

Wo

rkst

ream

s h

ave

bee

n e

nga

gin

g w

ith

re

leva

nt

stak

eh

old

ers

to d

evel

op

th

eir

pla

ns.

•

The

gen

eral

pra

ctic

e t

ran

sfo

rmat

ion

w

ork

stre

am h

as w

ork

ed c

olla

bo

rati

vely

w

ith

th

e Lo

nd

on

CC

Gs

(an

d lo

cal g

rou

ps

of

GP

s) t

o d

evel

op

pan

-Lo

nd

on

fiv

e ye

ar p

lan

•

Men

tal h

ealt

h w

ork

stre

am w

as in

itia

ted

at

stak

eh

old

er w

ork

sho

p in

Jan

uar

y 2

01

6 a

nd

a

furt

her

wo

rksh

op

in M

ay.

Furt

her

ser

vice

u

ser

and

car

er e

nga

gem

ent

is d

on

e vi

a p

rogr

amm

e u

pd

ates

an

d s

pec

ific

atio

n f

or

a ci

tize

ns

pan

el is

bei

ng

dev

elo

ped

•

Sign

ific

ant

enga

gem

ent

was

un

der

take

n

thro

ugh

rep

rocu

rem

ent

of

11

1 p

roce

ss in

u

rgen

t an

d e

mer

gen

cy c

are

wo

rkst

ream

•

The

esta

tes

wo

rkst

ream

has

bee

n

dev

elo

ped

th

rou

gh a

wo

rkin

g gr

ou

p, w

ith

re

pre

sen

tati

ves

fro

m a

ll o

rgan

isat

ion

s in

sc

op

e in

clu

din

g M

oo

rfie

lds,

th

e O

ffic

e o

f th

e Lo

nd

on

CC

Gs,

Co

mm

un

ity

He

alth

P

artn

ersh

ips,

He

alth

y U

rban

Dev

elo

pm

en

t U

nit

(H

UD

U)

and

GLA

•

NC

L D

igit

al R

oad

map

Gro

up

mee

ts t

o

def

ine,

sh

ape

and

co

ntr

ibu

te t

o t

he

inte

rop

erab

ility

pro

gram

me

wit

h

rep

rese

nta

tio

n f

rom

all

key

org

anis

atio

ns

•Ea

rly

enga

gem

ent

wit

h H

eal

th &

Wel

lbei

ng

Bo

ard

s an

d t

he

Join

t O

verv

iew

& S

cru

tin

y C

om

mit

tee

NC

L S

TP

Sum

mar

y

Page 145 of 146

N

C

L N

ort

h C

entr

al L

on

do

n

Sust

ain

abili

ty a

nd

Tr

ansf

orm

atio

n P

lan

Nex

t st

ep

s fo

r d

eve

lop

me

nt

of

the

STP

14

July

/Au

gust

20

16

-

Ref

ine

and

dev

elo

p in

itia

l ap

pro

ach

-

Enga

ge m

ore

bro

adly

wit

h

clin

icia

ns

and

loca

l lea

der

s

Sep

tem

be

r/O

cto

be

r 2

01

6

-

Dev

elo

p a

mo

re

com

pre

hen

sive

pla

n

-C

on

firm

th

e ex

isti

ng

gove

rnan

ce a

rran

gem

ents

su

pp

ort

imp

lem

enta

tio

n

-p

ub

lic e

nga

gem

ent

un

der

way

To J

anu

ary

20

16

-

Dev

elo

p m

ore

det

aile

d

imp

lem

enta

tio

n p

lan

s

9

Page 146 of 146

BO

AR

D O

F D

IRE

CT

OR

S (P

AR

T 1

)

Me

etin

g in

pu

blic

Tu

esd

ay

26

th Jun

e 2

016

, 14

.00

– 1

7.0

0

Le

cture

Th

ea

tre, T

av

istock

Ce

ntre

, 12

0 B

elsiz

e L

an

e, L

on

do

n N

W3

5B

A

AG

EN

DA

P

RE

LIM

INA

RIE

S

1.

Ch

air’s O

pen

ing

Rem

ark

s D

r Ian

McP

herso

n, T

rust V

ice C

hair

V

erb

al

-

2.

Ap

olo

gie

s for a

bse

nce

an

d d

ecla

ratio

ns o

f inte

rest

Dr Ia

n M

cPh

erso

n, T

rust V

ice C

hair

To

no

te

Verb

al

-

3.

Min

ute

s of th

e p

revio

us m

eetin

g

Dr Ia

n M

cPh

erso

n, T

rust V

ice C

hair

To

ap

pro

ve

En

c. p

.1

3a.

Ou

tstan

din

g A

ction

s D

r Ian

McP

herso

n, T

rust V

ice C

hair

To

no

te

Verb

al

-

4.

Ma

tters a

rising

D

r Ian

McP

herso

n, T

rust V

ice C

hair

To

no

te

Verb

al

-

REP

OR

TS

& F

INA

NC

E

5.

Stu

de

nt S

tory

– A

du

lt Co

mp

lex N

eed

s

To

discu

ss V

erb

al

-

6.

Serv

ice L

ine R

ep

ort –

Co

mp

lex N

eed

s, AFS

Dr M

ichael M

erce

r, Inte

rim S

erv

ice L

ead

To

discu

ss En

c. p

.9

7.

Tru

st Ch

air’s a

nd

NED

s’ Rep

orts

Dr Ia

n M

cPh

erso

n, V

ice C

hair

To

no

te

Verb

al

-

8.

Ch

ief E

xecu

tive’s R

ep

ort

Mr P

au

l Jen

kin

s, Ch

ief E

xe

cutiv

e

To

no

te

En

c. p

.24

9.

Q1

Stra

teg

ic Ob

jectiv

es P

rog

ress R

ep

ort

Mr D

avid

Ho

lt, NED

To

no

te

En

c. p

.27

10.

IMT Q

1 R

ep

ort

Mr T

ob

y A

ve

ry, D

irecto

r of IM

T

To

no

te

En

c. p

.32

11.

Fin

an

ce a

nd

Pe

rform

an

ce R

ep

ort

Mr S

imo

n Y

ou

ng

, Dep

uty

Ch

ief E

xecu

tive &

Dire

ctor o

f

Fin

an

ce

To

no

te

En

c. p

.38

12.

Tra

inin

g a

nd

Ed

uca

tion

Rep

ort

Mr B

rian

Ro

ck, D

irecto

r of E

du

catio

n a

nd

Tra

inin

g/D

ean

To

no

te

En

c. p

.48

13.

Q1

Dash

bo

ard

s M

s Julia

Sm

ith, C

om

me

rcial D

irecto

r

To

no

te

En

c. p

.54

14.

Q1

Qu

ality

Rep

ort

Ms M

ario

n S

hip

man

, Asso

ciate

Dire

ctor o

f Qu

ality

an

d

Go

ve

rnan

ce.

To

no

te

En

c. p

.63

15.

Q1

Go

vern

an

ce R

ep

ort

Mr S

imo

n Y

ou

ng

, Dep

uty

Ch

ief E

xecu

tive &

Dire

ctor o

f

Fin

an

ce

To

ap

pro

ve

En

c. p

.100

16.

Q1

HR

Rep

ort

Mr C

raig

DeSo

usa

, HR

Dire

ctor

To

no

te

En

c. p

.105

17.

Eq

ualitie

s – W

RES

Re

po

rt M

s Lo

uise

Lyo

n, D

irecto

r of Q

uality

an

d P

atie

nt E

xp

erie

nce

To

no

te

En

c. p

.114

18.

Reg

ister o

f Inte

rests

Mr G

erv

ase

Cam

pb

ell, T

rust S

ecre

tary

To

ap

pro

ve

En

c. p

.127

19.

Su

stain

ab

ility a

nd

Tra

nsfo

rma

tion

Pla

n U

pd

ate

M

r Pau

l Jen

kin

s, Ch

ief E

xe

cutiv

e

To

no

te

En

c. p

.132

CLO

SE

20.

No

tice o

f Fu

ture

Me

etin

gs

Tu

esd

ay 1

3th S

ep

t 201

6: D

irecto

rs’ Co

nfe

ren

ce, 1

2.0

0-

5.0

0p

m, L

ectu

re T

he

atre

Th

ursd

ay 2

2n

d Sep

t 20

16: C

ou

ncil M

eetin

g, 2

.00p

m –

5.0

0p

m, L

ectu

re T

he

atre

Tu

esd

ay 2

7th S

ep

t 201

6: B

oard

Mee

ting

, 2.0

0p

m –

5.0

0p

m,

Lectu

re T

hea

tre

Tu

esd

ay 4

th Oct 2

016

: Join

t Bo

ard

s Meetin

g, 1

2.3

0p

m –

5.3

0p

m

W

ed

nesd

ay

5th O

ct 201

6: A

GM

, 4.0

0p

m –

7.0

0p

m, T

avisto

ck

Cen

tre

V

erb

al

-

board of directors part one · 2016-07-27 · board of directors (part 1) meeting in public tuesday...

Documents