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Board of Directors Public Meeting Board Room, Chelsea 21st March 2018, 11:35am – 1pm Agenda

1. Apologies for Absence & Declarations of Interest

None

2. Minutes of the Board Meetings held on the 20th September 2017 (Chairman)

Enclosed

3. Matters Arising

4. Five Year Strategy (Chief Executive)

Enclosed

5. Report from the Chief Nurse and Medical Director 5.1. Quality Accounts January 2018 (Chief Nurse) 5.2. Consultant Appointments 5.3. Quarterly Hospital Mortality Review (Medical Director)

Enclosed

Enclosed Enclosed

6. Quality and Performance 6.1. Key Performance Indicators Q3 6.2. Cancer 62 Day Waiting Times (Chief Operating Officer) 6.3. Financial Performance Report 6.4. Financial Plan 2018/19 (Chief Financial Officer)

Enclosed Enclosed

Enclosed Enclosed

7.

Governance and Assurance 7.1. Board Assurance Framework (Janet Husband and Ian Farmer, Chairs of the Board Sub-Committees) 7.2. Information Governance Assurance Report (Chief Nurse) 7.3. Board Self-Certification (Trust Secretary)

Enclosed

Enclosed

Enclosed

8. Any other business

Date of next meeting: 27th June 2018

Minutes of The Royal Marsden Board of Directors Public Meeting Wednesday 20th September 2017, 3:30pm – 5pm Board Room, Chelsea

Present Charles Alexander Chairman Cally Palmer Chief Executive Mark Aedy Non-Executive Director Ian Farmer Non-Executive Director Professor Dame Janet Husband Non-Executive Director Heather Lawrence Non-Executive Director Richard Turnor Non-Executive Director Professor Paul Workman Non-Executive Director Dr. Liz Bishop Chief Operating Officer Eamonn Sullivan Chief Nurse Dr Nick van As Medical Director Marcus Thorman Chief Financial Officer In Attendance: Syma Dawson (minutes) Trust Secretary

1/17 Apologies for absence None

2/17 Declarations of Interest No declarations of interest were made.

3/17 Minutes of the Public Board held on the 28th June 2017 The minutes were approved as an accurate record.

4/17 Matters Arising 4.1. CQC Update The Chief Nurse reported that following the CQC Quality Summit in April 2017, a ‘must do’ action plan was agreed and is almost complete. The Board were reminded of the action for the Hospital which related to the use of a surgical WHO checklist in Outpatients which is now in place. The other four ‘must-do’ actions related to Community Services, two of which will be completed by the end of quarter 3. The Trust has also devised an ‘internal’ action plan based on all of the CQC’s findings in the inspection report which will be completed by the end of September 2017. The Board discussed the CQC’s agreement at the Quality Summit to re-inspect Outpatients at Sutton and End of Life Care given the additional information given to the CQC about progress and performance in these areas. While the Trust has followed this up with the CQC and is yet to receive a response, it was noted that the CQC will inspect the Trust under the new well-led inspection regime in future which involves quarterly reporting as well as focus group meetings with staff. The Board noted progress on the action plan and the new arrangements for CQC inspections in future.

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5/17 Report from the Chief Nurse and Medical Director 5.1. Quality Accounts June and July 2017 The Chief Nurse reported that the SI’s target in the Quality Accounts is listed as ‘4’ however, this should be ‘9’ and therefore this is an amber rating given that the Trust had 3 SI’s for the year. Following a discussion about Trust performance in this area compared to other NHS organisations, the Trust agreed to consider which peer groups are the most comparable to RM in order provide relevant benchmark data to the Board. The Chief Nurse also highlighted that a Darzi Fellow has been appointed for Tissue Viability as well as a Tissue Viability Nurse which will improve pressure ulcer performance. The nurse vacancy rate was reported at 12.9% as at September 2017 which the Chief Nurse noted is the lowest it has been in years. He added that there are 70 nurses due to start at RM in the next 12 weeks. The Trust is also focussing on nurse retention and is grateful to have received Royal Marsden Cancer Charity funding to enhance efforts in this area. The Board congratulated Pat Cattini, Deputy Director of Infection Prevention and Control, on her appointment as President of the UK Infection Prevention Society. The Board discussed the chemotherapy waiting times which is not a mandatory metric but an area the Trust chooses to closely monitor. Professor Dame Janet Husband queried the Trust’s plans to address the issue of patients waiting for over an hour. The Medical Director explained that following Board approval at the last meeting to expand Pharmacy accommodation, the Chief Pharmacist Jatinder Harchowal is looking into this issue as a key priority however, there are a number of contributory factors to consider including capacity issues. The Board discussed the importance of the RM School in nurse recruitment and retention. The Chief Executive highlighted that the Trust needs consider the future growth strategy of the School to obtain economies of scale and ensure the School is sustainable long term. The Board noted the Quality Accounts for June and July 2017. 5.2. National legal and regulatory changes The Chief Nurse reported on the changes resulting from the NHS Litigation Authority which is now named NHS Resolution (NHSR). The core principles of the NHSR are to deliver fair resolution and learning from harm to improve safety. This means increased transparency nationally and resolution as early as possible. The Board noted the ‘saying sorry’ policy and the importance of timing with this. The Chief Executive explained that the Trust’s approach in responding to complaints is to apologise to the patient for what has happened and identify the lessons learned as a result of the investigation. The Board noted the national legal and regulatory changes report. 5.3. New Medical Appointments The Medical Director noted the medical appointments of Dr. Zaidi, Consultant Clinical Oncologist in Sarcoma, and Dr Nanidis, Cosultant Plastic and Reconstructive Surgeon. He also highlighted the difficulty nationally in recruiting consultant radiologists. The Board noted the appointments of Dr. Zaidi and Dr Nanidis.

6/17 Quality and Performance 6.1. Patient Experience Survey Results The Chief Nurse presented the results from the National Adult Inpatient Survey, Children & Young People’s Inpatient & Day Case Survey 2016, and the National Cancer Patient

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Experience Survey 2016. The Chief Nurse noted that he is consolidating the results from all three surveys to establish one improvement plan. The Board noted the excellent results from the three Patient Experience Surveys as well as the areas for improvement. 6.2. Key Performance Indicators (KPI) Q1 The Chief Operating Officer reported on the additional KPI’s which have been agreed in consultation with the clinical teams. The Board discussed Trust performance against the 62 day urgent GP referral standard. It was noted that while the Trust exceeds the 85% target following reallocation of breaches in performance to the referring Trusts (current performance is at 85.6%), the Trust is currently not meeting this standard before reallocation (current performance is at 76.2%). The Medical Director explained that there are external factors beyond the Trust’s control which are influencing Trust performance in this area as the Trust continues to receive a high number of late referrals. The Chief Executive stressed the importance of the Trust as a system leader working with providers in order to meet this standard and highlighted the reputational risk in failing to do so. She added that a key issue relates to the recording and management of data which the national team is seeking to address by providing a new Cancer waiting times database. NED Richard Turnor queried whether there is a risk to RMP in relation to the 62 day standard performance. The Chief Executive confirmed that the Trust has not had any transformation funding withheld for this reason nor does she expect this will be an issue as RMP moves into its next phase of work regarding early diagnosis. RMP should to help address this issue as providers are working more collaboratively. The Chief Operating Officer reported on the Community Nurse vacancy rate which is reducing. NED Heather Lawrence advised the Trust review the 5% target for this; it was agreed that this would be changed to 15% to better align this with London’s average target rate. The Board noted the KPI’s for Quarter 1. 6.3. Financial Performance Report The Chief Financial Officer reported on the Trust’s financial position as at August 2017. He highlighted the following key headlines:

• Operating surplus in month of £1.9m, a favourable variance of £0.3m • Retained surplus in month of £0.6m, a favourable variance of £0.4m • Agency expenditure of £0.6m, a favourable variance against the cap of £0.2m • Capital expenditure of £0.5m, a favourable variance of £0.3m • Cash in bank of £27.6m, a favourable variance of £10.5m.

He highlighted that agency expenditure decreased in month and for the first time the Trust underspent against the medical staffing cap set by NHSI. Overall the Trust is below the NHSI spend cap by £0.2m in month and is now £0.7m under the cap year-to-date. It was reported that NHS clinical income was adverse to the plan in month by £1.4m. Although most activity areas were broadly on plan in month, there were two particular areas that had significant adverse variances. The first was BMTs due to the planned closure of Bud Flanagan Qard for refurbishment works required for JACIE accreditation, and the second was in critical care due to the revised pricing agreement with CCGs which was implemented this month but included backdating to the beginning of the financial year.

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The Chief Financial Officer also highlighted the position with regard to non-pay expenditure and reported a favourable variance of £0.4m to plan in month. Capital expenditure was noted and the impact of scheduling for donated equipment, which in the original plan was due to be received in June and will now be delivered later in the year. The other key timing difference is in IT schemes resulting in a favourable variance overall. Regarding debt, NHS debt was reduced by £3.2m and non-NHS debt fell by £1.8m. Despite this improvement, ongoing work is required on embassy sponsored private care debt. The Board noted the Financial Performance Report for August 2017.

7/17 Regulatory Issues 7.1. NHSI “Learning from Deaths” The Medical Director presented the report to the Board and noted that it is a national requirement for the Trust Board to receive this report. He highlighted that there were 56 inpatient deaths reported at the Trust and the Trust has been rated green for the period between April and June 2017. The Board agreed that the term ‘standard achieved’ should be amended to ‘standard met’ in the report. The Board noted the “Learning from Deaths” Report and the Trust’s green rating for the period between April and June 2017. 7.2. EPRR Assessment The Chief Nurse presented the results of the Trust’s 2016/17 Annual Emergency Preparedness, Resilience and Response (EPRR) Assurance Review and explained that the report to Board satisfies the requirements of the EPRR Assurance process which state that these results are to be presented to the Board on an annual basis. It was noted that the Trust was fully compliant with the NHS England Core Standards. The Trust will undergo an external assessment in November 2017. The Board discussed the risk of cyber-security and the Board monitoring of this risk. It was noted that the Audit and Finance Committee has reviewed this risk, which is rated green in the EPRR assessment. NED Ian Farmer commented that he recently attended a Deloitte meeting which advised that Boards should ensure they have the relevant cyber-security expertise in order to raise the Board’s knowledge in this area and effectively manage the risk. It was agreed that a report on cyber-security would be brought to the Board in due course. The Board noted the EPRR Assessment Report and agreed that a specific report on cyber-security should come back to the Board in due course.

8/17 Board Assurance Framework Professor Husband presented the Board Assurance Framework (BAF) and explained that this had been amended and simplified, with allocated ownership to Board Sub-Committees and Board as well as inclusion of an effective date to help determine when items should be removed from the BAF i.e. after twelve month period. She noted that QAR was due to review its relevant areas of the BAF at its meeting the following day (21st September). Ian Farmer commented that the Audit and Finance Committee (AFC) items in the Board Assurance Framework are main agenda items for the meetings. The Board noted the Board Assurance Framework.

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9/17 Any other business 9.1. Business Conduct Policy NED Ian Farmer noted that there will be an Audit and Finance Committee following the Board meeting to review and approve the Business Conduct Policy presented by the Trust Secretary. 9.2. Senior Independent Director The Chairman informed the Board following the departure of NED and former Senior Independent Director (SID) Dame Nancy Hallett, he has asked NED Mark Aedy to take this position subject to his agreement and Board approval. The Chairman summarised the key responsibilities of the SID and proposed a resolution to appoint Mark Aedy to this role. The Board unanimously approved the appointment of NED Mark Aedy as Senior Independent Director.

Signed as a true and accurate record Chaired by: Date:

BOARD PAPER SUMMARY SHEET

Date of Meeting:

21st March 2018

Agenda item 4.

Title of Document: Five Year Strategy

To be presented by

Chief Executive

Executive Summary The new Five Year Strategy, covering the period 2018/19 – 2022/23, is due to be published in April 2018. It will look at the general health landscape in the UK and the market context and how the strategic work of The Royal Marsden contributes to national and international developments in cancer research, treatment and care, together with how this can be delivered through healthcare systems, principally our collaborations through RM Partners and other local partnerships. The plan then takes four core themes identifying our key strategic focus and aims: • Research and innovation • Treatment and care • Modernising infrastructure • Financial sustainability and best value

Supporting these four areas of work are four cross cutting themes, namely Workforce, Quality, The Royal Marsden Cancer Charity, and Private Care. Finally, the document covers the future strategic objectives and delivery plans for the coming five years, detailing how we will achieve this and measure success. Recommendations The Board is asked to approve the final draft of the Five Year Strategy. Author: Chief Executive

Contact Number or E-mail: x2101

Date: 13th March 2018


Date of Meeting: 21st March 2018

Agenda item 5.1.

Title of Document: Quality Account for January 2018

To be presented by Chief Nurse

Executive Summary The Board of Directors are asked to note:

1. The achievement of the Flu CQUIN with a compliance level of 73% against a 70% target

2. The overall reduction in level of harm associated with falls for January and on-going falls campaign

3. The sustained reduction in pressure ulcers across the Hospital

4. To note the variation and changes in FFT scores for December

5. The fluctuating vacancy rate for January, offset by the volume of pipeline new starters

6. The summary of the All-Party Health Select Committee on Nursing.

Recommendations The Board is asked to review and comment on this Report. Author: Chief Nurse

Contact Number or E-mail: x 2121


The Royal Marsden NHS Foundation Trust

Monthly Quality Account

January 2018

Trust Board 21st March 2018

A report by the Chief Nurse: Eamonn Sullivan

[email protected]

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mailto:[email protected]

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Monthly Quality Account – Table of Contents

Summary Dashboard P3-4 Infection P5 Falls P6 Medication Incidents P7 Hospital Pressure Ulcers P8 Community Pressure Ulcers P9 Readmissions & VTE P10 Chemotherapy Waits P11 Patient Experience P12-14 Safer Staffing P15-18

Quality Account Dashboard 2017-18 Annual Target Aim Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2017/18

YTD2016/17

Safe care4 Below 1 0 0 1 0 1 2 0 0 1 6 40 Below 0 0 0 0 0 0 0 0 0 0 0 1

No target 5 5 3 5 6 5 5 5 6 3 48 4631 Below 2 31

8 Below 0 1 0 0 0 0 1 1 0 1 4 8No target Above 92.5% 94.7% 92.7% 94.6% 92.0% 91.9% 95.3% 96.5% 96.4% 96.6% 94.3% 94.3%No target Above 95.2% 94.9% 90.7% 92.1% 92.1% 90.4% 95.3% 90.0% 86.3% 92.0% 91.9% 92.0%

95.0% Above 94.8% 96.2% 92.7% 96.0% 95.3% 94.1% 98.4% 97.9% 97.8% 98.0% 96.1% 96.4%95.0% Above 98.6% 98.0% 96.3% 96.7% 97.1% 98.5% 97.6% 96.8% 92.3% 98.9% 97.1% 97.3%

3 Below 2 0 0 0 0 0 0 1 1 0 4 30 Below 0 0 0 0 0 0 0 0 0 0 0 00 Below 0 0 0 0 0 0 0 0 0 0 0 05 Below 0 0 1 0 1 1 1 2 1 2 9 5

20 Below 1 3 2 2 0 0 1 2 0 0 11 200 Below 0 0 0 0 0 0 0 0 0 0 0 0

95% Above 96.2% 96.9% 94.3% 96.7% 96.5% 96.8% 96.6% 96.4% 96.4% 97.1% 96.4% 96.9%** Figures calculated according to the Department of Health methodology revised December 2008. Lapses of care are determined in conjunction w ith Commissioners, and the determination of w hat w arrants a lapse in care can be several months after the diagnosis.Effective Care

Number of patients 136 Below 16 7 14 12 7 9 10 6 2 9 92 136Category 2 No target Below 15 7 12 12 7 9 10 6 2 5 85 127Category 3 No target Below 1 0 1 0 0 0 0 0 0 0 2 9Category 4 0 Below 0 0 1 0 0 0 0 0 0 0 1 0Number of patients 160 Below 11 16 13 19 14 15 12 13 6 21 140 160Category 2 No target Below 8 12 12 13 10 12 12 13 5 16 113 106Category 3 No target Below 1 1 1 0 1 1 0 0 1 2 8 50Category 4 0 Below 0 0 0 0 0 0 0 0 0 0 0 4

Patient Experience95% Above 97.5% 98.0% 95.5% 97.3% 98.5% 97.2% 97.4% 93.7% 98.7% 99.0% 97.2% 97.8%

No target 354 688 421 484 473 457 427 426 229 303 4262 584295% Above 97.8% 95.9% 96.3% 98.3% 96.5% 98.8% 98.1% 97.5% 87.1% 99.4% 96.2% 97.4%

No target 186 363 246 177 115 162 52 201 209 168 1879 2208Target under review Above 76.1% 76.7% 77.7% 79.3% 70.7% 74.9% 72.1% 76.0% 78.6% 67.5% 74.9% 74.2%Target under review Above 89.8% 88.5% 86.4% 90.4% 89.6% 86.0% 85.7% 94.4% 91.8% 90.3% 89.3% 88.6%Target under review Above 81.9% 74.2% 83.6% 80.5% 89.4% 87.3% 84.2% 85.2% 86.6% 83.5% 83.6% 62.2%

No target 444 548 508 593 553 527 561 484 402 493 5,113 5,375107 Below 11 12 11 9 15 6 11 10 8 9 102 107

27 Below 1 4 2 2 1 2 4 1 0 3 20 27Vacancy/Sickness Rates

5% Below 11.2% 11.7% 10.8% 11.7% 10.2% 9.6% 9.0% 8.5% 9.0% 8.9% 10.1% 9.4%3% Below 2.9% 2.5% 2.7% 2.7% 2.6% 2.4% 2.8% 3.2% 3.6% 3.7% 2.9% 3.0%

10% Below 15.1% 14.3% 13.3% 14.1% 12.9% 11.5% 10.4% 10.1% 11.4% 11.3% 12.4% 13.8%3% Below 3.4% 3.5% 3.7% 3.3% 2.9% 2.9% 3.4% 3.5% 4.2% 4.6% 3.6% 3.7%

15% Below 17.3% 17.0% 18.0% 18.3% 17.5% 17.3% 16.5% 16.1% 17.5% 17.6% 17.3% 17.5%

HSMR Quarterly FiguresQuarterly Target Aim Qtr3

16/17Qtr4

16/17Qtr1

17/18Qtr2

17/1875 Below 70.73 69.47 68.1 78.96

Failure to recognise deterioration in a patient leading to deathVTE risk assessment

% New harm free care (RMH)% New harm free care (RMCS)

% Harm free care (RMCS)

Falls: Attributable Moderate Harm Incidents while patient under RMH careFalls: Attributable Major Harm Incidents while patient under RMH care

1 1

Chemotherapy waiting times (Sutton): % waiting an hour or less

Number of patients with attributable pressure ulcers (RMH)

Number of patients with attributable pressure ulcers (RMCS)

0

% Harm free care (RMH)

Falls: Attributable Death IncidentsNumber of attributable medication incidents with moderate harm and aboveNumber of cardiac arrests

Chemotherapy waiting times (Chelsea): % waiting an hour or less

Hospital Standardised Mortality Rate (roll ing 12 months, NHS and PP)

Indicator

Indicator

Complaints: Number of complaints (RMH)Complaints: Number of complaints (RMCS)

Trust vacancy rateTrust sickness rate

RMH Inpatient Friends and Family Test: % RecommendedRMH Inpatient Friends and Family Test: Number of responsesCommunity Friends and Family Test: % RecommendedCommunity Friends and Family Test: Number of responses

SIs: Number of SIs (excluding PU cat 4)Number of diagnoses of Methicil l in-resistant Staphylococcus aureus (MRSA) bacteraemiaNumber of diagnoses of Clostridium difficile (C.Diff) (Attributable)**Number of C-Diff lapses of care (quarterly)**Number of diagnoses of Methicil l in-sensitive Staphylococcus aureus (MSSA) (Attributable)

Nurse vacancy rateNurse sickness rate

Chemotherapy waiting times (Kingston): % waiting an hour or lessNumber of PALS contacts (Trust)

Nurse turnover rate

Community Services dashboard 2017-18

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Annual Target

Aim Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2017/18 YTD

2016/17

Safe care408 Below 24 48 53 50 29 32 43 43 33 38 393 408

1 Below 0 0 0 0 0 0 0 0 1 3 41 Below 0 0 0 0 0 0 0 0 0 0 0 11 Below 0 0 0 0 0 0 0 0 0 0 0 1

Effective CareNumber of patients 160 Below 11 16 13 19 14 15 12 13 6 21 140 160Category 2 No target Below 8 12 12 13 10 12 12 13 5 16 113 106Category 3 No target Below 1 1 1 0 1 1 0 0 1 2 8 50Category 4 0 Below 0 0 0 0 0 0 0 0 0 0 0 4

Patient Experience95% Above 97.8% 95.9% 96.3% 98.3% 96.5% 98.8% 98.1% 97.5% 87.1% 99.4% 96.2% 97.4%

No target 186 363 246 177 115 162 52 201 209 168 1879 2208Total number of PALs contact Concerns No target 2 2 4 5 4 1 4 1 1 2 26

Praise No target 2 0 0 0 5 0 0 0 0 0 727 Below 1 4 2 2 1 2 4 1 0 3 20 27

100% 2 ( )

3 ( )

1 ( )

1 ( )

1 ( )

1 ( )

1 (50%) 1 ( )

1 ( )

0(100%) 12 100%

100% 2 (100%)

2 (100%)

5 (100%)

3 (100%)

3 (100%)

1 (100%)

2 (100%) 3 (100%)

1 (100%)

0(100%) 22 100%

No target 0 2 1 1 0 0 1 (50%) 2 1 0 8 29.6%

Safeguarding Training80% Above 96.1% 96.3% 96.0% 97.4% 97.3% 97.0% 97.0% 95.0% 100.0% 92.1% 96.0%80% Above 93.3% 95.6% 96.0% 96.5% 96.5% 97.0% 96.0% 95.0% 96.0% 89.3% 93.0%80% Above 60.4%80% Above 97.9% 98.2% 98.0% 96.7% 97.9% 98.0% 100.0% 100.0% 97.0% 84.1% 97.0%80% Above 98.5% 98.1% 98.0% 90.1% 97.8% 98.0% 100.0% 95.0% 96.0% 94.2% 98.0%80% Above 87.7% 87.7% 88.0% 95.0% 92.1% 92.0% 84.0% 86.0% 89.0% 95.7% 86.0%

Number of complaints responded to in required timescale

% of due complaints in calendar month responded

% of due complaints in calendar month upheld

Child Safeguarding: % of staff compliant with training – Level 3

Adult Safeguarding: % of staff compliant with training 1Adult Safeguarding: % of staff compliant with training 2Adult Safeguarding: % of staff compliant with training 3Child Safeguarding % of staff compliant with training – Level 1Child Safeguarding: % of staff compliant with training – Level 2

Community Indicators

Number of attributable medication incidents with moderate harm and above

Number of incidents reported on DATIX

Number of SIs (excluding PU cat 4)

Number of complaints

Friends and Family Test: % RecommendedFriends and Family Test: Number of responses

Number of patients with attributable pressure ulcers

Total number of patient safety hard incidents (moderate and above)

5 Healthcare Associated Infections & Hand Hygiene

Data Owner – Pat Cattini – Deputy Director of Infection Prevention and Control. There have been no MRSA cases (last case was July 16) and only two cases of MSSA for January (both IV Line related). There were no hospital acquired infections relating to CPE for this reporting period. To date the Trust has not had any cases of Norovirus. There have been 36 cases of Flu identified this year, which are predominantly type B. The CQUIN target of 70% for staff vaccination has been achieved and an evaluation of this years campaign will take place before the end of March with lessons learned considered as well as sharing good practice from organisation that made significant improvements with CQUIN compliance. Work with the Christie Hospital and NHSi is on-going to develop the EColi care bundle.

CDT cases 2017-18 MRSA /S.aureus BSI 17-18

Gram negative blood stream infection

MRSA and CPE Screening compliance

Patient Fall Incidents Target: <0.7 falls with moderate or above harm

Data Owner: Ann Duncan, Matron, member of the Falls Prevention Committee. From April 2017 to January 2018, 194 incidents out of a total of 3384 attributable patient safety incidents were categorised as patient falls. To date, Trust falls rates are 0.077 (moderate or above falls) per 1000 bed days for the current financial year, exceeding the Quality Account target. The majority of falls occurred on inpatient wards and resulted in no or low harm, however one moderate harm fall did occur in both November and December 2017. Signage for ‘Call don’t fall’ has been put up in bathrooms and side rooms. Placemats with ‘Call don’t fall’ and ‘8 simple steps to keep yourself safe during your stay in hospital’ have been ordered for wards. There are a number of falls initiatives that are being trialed across the trust and will be fed back to the Falls Prevention Committee. The Falls prevention patient information leaflet is do be updated to reflect latest guidance within the next quarter. Matron review of all Falls and dissemination of learning remains an important element of the Falls campaign work.

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Table 3.0

Medication Incidents

Target: Increase the reporting of near misses and decrease incidents that cause harm (low harm <2 per 1000 bed days and moderate <0.17 per 1000 bed days) Data Owner: Suraya Quadir, Associate Chief Pharmacist. The current 12 month reporting period sees the majority of all reported medication incidents resulting in no or low harm within the Trust. The number of moderate or above harm events for the current financial year remains extremely low for a Trust of our complexity (moderate incident n = 10, severe & catastrophic n = 0). In January the number of incidents relating to adverse reactions (20%), delayed and omitted medicines remained constant. As part of intervention audits, we will also be focusing on increasing near miss reporting which has decreased; there were 95 near misses reported in the 12 month period compared to 123 for the same period last year.

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Table 4.0

Hospital Pressure Ulcers* – Category 2,3,4 Target: Zero grade 4 pressure ulcers

Data Owner: Andrew Dimech DND. There have been no Category 3 & 4 pressure ulcers (PU’s) for 6 months. We have seen a reduction in Category 2 PU’s in the Hospital since September. The total hospital acquired PU’s remain stable in single figures. Ongoing category 1 reporting indicates early detection and management. The strategic committee continues to review and guide Tissue Viability in the acute and community services. Our Darzi Fellow (Tissue Viability) is undertaking a quality improvement (QI) project specifically looking at further reducing pressure damage in complex cancer patients. The ‘Pressure Ulcer MDT Collaborative’’ working group is now in its 3rd month and is working towards a cultural shift by using a shared accountability model. We are piloting a new root cause analysis (RCA) tool, which when embedded will allow a deeper thematic analysis of category 2 PU. Teaching sessions continue at ward level in preparation for EPUP guideline implementation in April 18*. Regular Link Nurse meetings, monthly Tissue Viability Committee meetings and 70 staff attended a mock coroners court for pressure ulcers in January 18 are assisting in driving this agenda forward.

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Table 5.0

* Since November 2017 the Trust is reporting in line with the European Pressure Ulcer Advisory Panel (EPUAP) guidance of six categories of pressure ulcers, including Unstageable and Suspected Deep Tissue Injury (DTI). Reporting of this data will commence from May 2018 (April data).

Community Pressure Ulcers* – Category 2,3,4 Target: Zero grade 4 pressure ulcers

Data Owner: Debbie Linton-Taylor Community DND. There have been no category 4 pressure ulcers since Feb 2017. There has been an in increase in both category 2 & 3 pressure ulcers seen in January, this is reflective of casemix acuity, including patients admitted to Sutton Community Services with existing pressure damage from other agencies and organisations. The recent category 3 incidents are under final review by the Nurse Director and TVN team to ascertain if they were avoidable and to share lessons learned. The new pressure damage and wound care bundles are now in place across community services.

9 * Since November 2017 the Trust is trialling reporting in line with the European Pressure Ulcer Advisory Panel (EPUAP) guidance of six categories of pressure ulcers, including Unstageable and Suspected Deep Tissue Injury (DTI). Reporting of this data will commence from May 2018 (April data).

Table 6.0

Hospital Readmissions Performance (Dec Data)

Hospital VTE Screening Performance (Dec Data)

December 2017 Readmissions Summary: There are no anomalies reported in relation to emergency readmissions this period. It is acknowledged that there is no national readmission rate/target for a specialist cancer Trust. Cancer ICD codes are excluded from national readmission figures due to an accepted clinical rationale that cancer patients will re-attend on multiple occasions. The figures in the graph therefore represent a small number of patients who may not have a defined cancer diagnosis. The Chief Nurse and Medical Director are working with the Head of Performance to refine a suitable readmission metric for our Trust.

Table 7.0 Hospital Readmissions Summary

VTE Data Owner: Lara Roskelly January 2018 Data VTE Screening remains stable at greater than 95% across the Trust (Jan). January VTE assessment has seen a slight improvement at 97.1% v December at 96.4%.

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Month

Reported % of Emergency Readmissions

Chemotherapy Waiting Times & Prescribing

Data Owner: Jatinder Harchowal, Chief Pharmacist & Lorraine Hyde, Matron, MDU Sutton. Chelsea MDU in particular has seen a significant increase in activity and associated waiting times this winter. This has been coupled with a large number of new staff into the area, who have required additional training in safe administration of chemotherapy. Chelsea MDU has been supported by Sutton MDU in this period. The introduction of the quality improvement (QI) project in November has shown an improvement particularly in those patients waiting for more than 1 hour for administration of their chemotherapy from their scheduled time. The QI project is continuing to look at ways to improve the waiting times across the whole pathway from prescribing to approval on the day of chemotherapy and from manufacturing to administration. One of the key transformation projects for 2018/19 will be a whole systems review of the chemotherapy clinical pathway, which will build upon the Q1 work, this work will be led by the Trusts new Consultant Pharmacist and Consultant Nurse for Chemotherapy appointed in Q4.

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0%10%20%30%40%50%60%70%80%90%

100%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan

D CLINIC

Sutton Chemotherapy Waiting Times

>1hr

>30mins to 1hr

Within 30mins

0%10%20%30%40%50%60%70%80%90%

100%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan

D CLINIC

Chelsea Chemotherapy Waiting Times

>1hr

>30mins to 1hr

Within 30mins

Our Patient Experience Friends & Family Test (FFT) National Friends & Family Test Data (RM data as of 9 February 2018 – Against December National data)

Inpatient data was collected for 177 Acute NHS trusts and independent sector providers. Nationally, the overall average percentage for those who would recommend the service to friends and family was 96% in December. The Trust is above this with a score of 98%.

Outpatient data was collected for 238 Acute NHS trusts and independent sector providers. Nationally the overall average percentage for those who would recommend outpatients to friends and family was 94% in December. The trust is above this with a score of 95%.

Community Services data was collected from 150 NHS organisations and independent sector providers. Nationally the overall average percentage for those who would recommend community services to friends and family was 96% in December. The trust is below this with a score of 87%.

INPATIENTS FFT Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Oct 2017 Nov 2017 Dec 2017

The Royal Marsden inpatients who would recommend

98% 98% 97% 97% 98% 96% 97% 94% 98%

National average 96% 95% 96% 96% 96% 96% 96% 96% 96%

Response number 1437 1371 1561 1463 1414 1158 427 426 305

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OUTPATIENTS FFT Q2 16/17

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Oct 2017 Nov 2017 Dec 2017

The Royal Marsden outpatients who would recommend

98% 98% 98% 98% 96% 95% 97% 93% 95%

National average 93% 93% 93% 94% 94% 94% 94% 94% 94%

Response number 964 933 1016 1192 1520 1119 403 347 369

sdf

COMMUNITY SERVICES FFT

Q2 16/17

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Oct 2017 Nov 2017 Dec 2017

The Royal Marsden community services clients who would recommend

100% 97% 97% 97% 98% 96% 98% 98% 87%

National average 95% 95% 96% 96% 96% 96% 95% 96% 96% Response number 322 841 781 795 454 454 52 201 209

Our Patient Experience Monthly Survey Results

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Example of Positive Comments this period

My experience was completely positive. The whole team put me at ease as I was a nervous first timer. The nurse who looked after me before and after the procedure was lovely, kind and caring. The doctor explained the procedure and the staff during the colonoscopy were fabulous. Overall a great experience, caring, kind, informative. (Endoscopy) Excellent no other words needed. (CAU) The whole Franklin Unit Team conveyed the perfect mix of professional and competence allied to personable greeting and communication. They are all a credit to themselves, their profession and the Royal Marsden. I hope I don't have to return but if I do I know I'll be in good hands. (Radiotherapy-Chelsea) The care was absolutely wonderful. Very professional, very friendly, very caring and very efficient. (Kennaway) The way what is run should be held up as an example of best practice across the NHS I can't think of any negatives I've only had exemplary service here and other departments at the Royal Marsden. (Oak) My experience with the nurses have been very good. They are very caring and do a remarkable job. I would recommend them every time. (Community nursing- Wallington)

Comments where care can be improved this period

The kindness and efficiency of all the staff is invaluable the only difficulty encountered today was finding my way to the CAU that was probably the result of my anxious state of mind rather than efficiency in signage allowing family members to remain is great and your staff are extremely kind and sympathetic. (CAU-Chelsea) Would have appreciated if procedure carried out here could be made available in Sutton, lack of car parking facilities to be regretted. (BC ward, Chelsea) The catering could be improved by more attention to detail missed or incorrect items. (BFW) Letter notification of forthcoming appointments seems costly and sure method of communication lot to correspondence more via email and text. (McElwain) Was told to be here 7:30 AM nor food after midnight did not have procedure till 5 PM, started to feel faint and had headache through lack of food and drink. (Smithers) My only minor criticism is that one or two of the changing cubicles are a bit cramped or have no hooks or are numbered inside. This is useful to remind you which one you have to return to. (Radiotherapy, Sutton) The service is excellent and everyone involved most pleasant. My only criticism is that I left a message on Friday and received no response what so ever. (Endoscopy) Waited too long for initial appointment as needed a frame to help with my walking. (Community- Neuro-therapy team)

Table 14-18: The patient comments below are captured via our paper comments cards. Ward Sisters and Matrons review the data at minimum monthly, and it is also reviewed at the CBU Performance Review meetings. February – the Trust is reviewing its feedback system with the supplier (Iwantgreatcare) to upgrade the current monthly paper based system to a more ‘live’ electronic system which can feedback contemporaneously.

Patient Feedback – PALs Queries and Complaints Data Owner: Helen Mills, Head of Assurance. PALs and Complaints summary. January 2018 PALS Summary: 212 patient contacts this month - within expected numbers (cross site). Top three contact subjects were Advice and Information (144) Miscellaneous (16) and Referral Information (14). Complaints Summary: 13 new complaints were opened in January 2018, with 29 remaining open in total at the end of January. Attitude of staff, communication, Delays and concerns surrounding diagnosis and treatment has continued to dominant complaints received.

• Changes to appointment scheduling

Table 19.0 Formal Complaints Trend

Table 20.0 Formal Complaints – Detailed information by Division

Table 18.0 Complaints Narrative: Out of the 13 complaints, specific issues/themes raised this month were: - Attitude of staff - Communication - Clinical Care issues - Delays in service being provided

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Complaints Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

Number per month

(aim <12)PHSO - Upheld 0 0 1 0 0 0 0 0 0

PHSO – Not upheld 2 1 1 0 0 1 0 0 0

1313 16 9 15 11 1217 16 11 15 19

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Safer Staffing: Nurse Recruitment Nurse Recruitment. Nurse recruitment remains a Trust priority and the nursing recruitment and retention group meets weekly to ensure focus on our objectives. The Nursing vacancy rate decreased slightly in month 11.4% to 11.3%.The Hospital vacancy rate decreased to 9.6%, whilst the Community vacancy rate increased to 22.3% respectively. There are 104.35 wte nurses in the recruitment pipeline, of which 38.2 wte have a start date confirmed. 214.15 wte registered nurses have been recruited between April 17 and January 18 and we remain on course to meet our 225 target. Summary of February/March 2018 Nurse Recruitment Activity: • Recruitment activity plans for nurse’s remains on track, with Open Days taking place every month across each site. • Private Care recruitment campaign • External recruitment events plans in place targeting universities • First cohort of International nurses arrive from the Philippines in quarter 4 • Increasing awareness of the Nurse transfer scheme. • Entry into healthcare for administrative and catering recruitment open planned in March • International recruitment pack developed for exchange programme in Australia and Canada • Centralised Healthcare support worker recruitment plan being scoped for 2018. • OSCE boot camps

Table 23.0 Nurse Vacancy Rates

sdf

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Safer Staffing: Nurse Retention Turnover/Retention The overall (all staff) turnover rate for the Trust has increased in month to 15.3%. Both the Hospital and Community turnover rates increased to 14.9% and 18.2% respectively. Nursing specific turnover slightly increased to 17.6% however the overall Trust turnover rate is average for London. Retention & Recruitment continues to the key focus of the Chief Nurse and HR Director, working together they now chair weekly Retention & Recruitment Meetings. The focus of the group will over the following months will shift towards retention. The Trust has engaged a firm called April who identified five key priorities from the feedback gathered. An action plan has put together to implement both locally and corporately. Most notably in January 2018 the (all-party) Commons Health Committee released its ‘Nursing Workforce’ paper which details, for the first time, the unique pressure on the profession nationally. RMH is not currently an outlier in staff experience or recruitment, however it is important to note the reports findings, a summary and of which can be found on the next page.

Table 21.0 Nurse ‘Joiners and Leavers’ cumulative position

Table 22.0 Top six ‘reasons for leaving’

1 Relocation 62 Promotion 23 Child Dependents 24 Work Life Balance 1

Nursing Leavers Bands 5 &6

Month Feb-17 Mar-17 Apr-17 May -17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 T otal Starters (fte) 11.1 9.8 14.0 12.0 13.5 8.6 18.6 42.4 33.7 17.8 5.0 13.7 200.1

Leavers (fte) 5.3 13.8 7.0 2.8 9.7 8.7 7.2 8.0 2.3 7.4 16.5 10.0 98.6

Variance 5.8 -4.0 7.0 9.2 3.8 -0.1 0.9 34.4 31.4 10.4 -11.5 3.7 101.5

Nursing Joiners & Leavers - Band 5-6

17 Safer Staffing: Nurse Retention Commons Health Select Committee Infographic: Jan18

In January 2018 (the all-party) Commons Health-Select Committee published its report ‘The Nursing Workforce’ – this report is the first of its kind by this Committee. The report detailed the issues in nursing across England. Although RMH Nursing is currently not an outlier in terms of vacancy rates or staff experience in London, the reports contents are important as they describe in unique detail the workforce challenges that the profession faces. The report states that there are many causes for the shortfall in nursing, including workload pressure, on-going pay restraint, a sense of not feeling valued and most notably a ‘major issue’ of access to continued professional education, as training budgets have been cut significantly across England. The full report can be found here: https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf

https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf



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Safer Staffing: Planned Vs Actual Staffing

January 18 Safer Nurse Staffing Summary: The planned staffing level versus the actual staffing level for January 18 remains greater than 95% for RN. A greater than 100% scores seen for Healthcare Assistants can largely be explained through the use of ‘specials’ (one to one care). Keeping our wards safely staffed – launch of ‘Safe Care’ module – March/April 2017. The Trust launched a daily census and staffing sitrep which Clinical Site Managers & Matrons use as a decision aid to deploy and move staff safely across our wards and departments. In January ‘18 the Trust rolled out the Shelford Acuity tool recommended by NHSI and replacing the AKUKU model previously being used. Care Hours Per Patient Day (CHPPD) CHPPD is the preferred metric recommended by the Lord Carter review. It is calculated by dividing the Nursing hrs. (both RN + HCA) by the number of patients.

Date 2017/2018 RN fill % HCA fill %

Chelsea Sutton Combined Chelsea Sutton combined

October 97.69% 97.40% 97.58% 122.90% 105.02% 115.24%

November 98.69% 98.84% 98.75% 107.97% 105.02% 107.00%

December 98.56% 97.77% 98.25% 105.60% 107.94% 106.54%

January 98.73% 96.83% 97.98% 109.69% 115.52% 111.98%

Table 22.0 January 18 Planned vs Actual RN & HCA fill rate

Quality Account Summary The Board are asked to note and comment on this report. Eamonn Sullivan Chief Nurse March 2018


Date of Meeting:

21st March 2018

Agenda item 5.2.

Title of Document: Consultant Appointments

To be presented by

Medical Director

Executive Summary The enclosed report provides the Board with an update on consultant appointments since September 2017 and the last Board report. Recommendations The Board is asked to note this report. Author: Director of Workforce



Consultant Appointments September 2017 – February 2018

Dr Alicia Okines – Consultant Medical Oncologist – AOS Breast Following an AAC on 12 October 2017, Dr Okines was appointed as Consultant Medical Oncologist, AOS Breast and took up her post in October 2017. Dr Okines qualified as a doctor in 2002 from Sheffield School of Medicine with her MBchB. She received a PhD from the University of London in 2013. Her thesis focussed on Therapeutic Strategies in Oesophagogastric Cancer. She completed her CCT in 2015 and is registered with a licence to practice on the GMC Specialist Medical Oncology register. She has been employed as a Locum Consultant Medical Oncologist within RMH for the last two years. She completed her Medical Oncology SpR Training here at The Royal Marsden with experience gained in Gynaecological Oncology, Lymphoma, Sarcoma, Renal, Melanoma and Thoracic Oncology. She was involved in establishing the Acute Oncology Service at The Royal Marsden and has established herself as a research-active consultant within the Breast unit working closely with Professor Turner to secure funding for Phase II Clinical Trials. She has been involved in authoring a considerable number of research publications, articles and case reports. Dr Nadia Yousef – Consultant Medical Oncologist – AOS Lung Following an AAC on 12 October 2017, Dr Yousef was appointed as Consultant Medical Oncologist, AOS Lung and took up her post in October 2017. Dr Yousef qualified as a doctor in 2002 from Newcastle Upon Tyne School of Medicine. She received her MD from the University of Leicester. She completed her CCT in 2014. She is registered with the GMC and has had a licence to practice on the Specialist Medical Oncology Register since 2014. Dr Yousef completed her Medical Oncology SpR training at the Royal Marsden and at St Georges including rotations in the Acute Oncology, Thoracic Malignancies, Breast, Upper Gastrointestinal and Lymphoma. She has been a Locum Consultant at the Royal Marsden since 2015. She is committed to service development and new models of care and together with Dr Okines led the development and roll out of the Acute Oncology Service. This included the development of both the Ambulatory Acute Oncology Service and the In-patient Service. Furthermore she has embedded a molecular MDT within the Lung Unit at The Royal Marsden whilst increasing the research capacity of the unit and has focussed on enhancing the Core Medical Trainee experience here at The Royal Marsden which significantly influenced the recent GMC trainee survey results. She is currently leading on research to describe the spectrum of endoscopic appearances and patterns of corticosteroid use in immune checkpoint inhibitor related diarrhoea and colitis.

Dr Julia Murray – Consultant Clinical Oncologist/ Urology Dr Murray completed a BSc (First Class Honours) in Medical Scenarios with Endocrinology at Imperial College in 2003. She then went on to complete her MRCP in 2007 and FRCP in 2012. She also previously completed a secondment as Clinical Research Fellow to the Institute for Cancer Research where she completed her MSc in Oncology in 2012 and her PHD in 2017 entitled ‘the evaluation of toxicity modification using image guided radiotherapy delivery in the treatment of prostate cancer.’ She completed her specialist oncology training at Guys and St Thomas’ and before being appointed substantively was employed as Locum Consultant here at The Royal Marsden. She has recently recruited and led clinical trials involving Prostrate IGRT and other urological malignancies and participated in the RMH Paired Learning Programme where she collaborated on the development of a multi-professional workforce for Clinical Oncology. Recently she was awarded the Helen Patterson Award for research at the recent British Uro-Oncology Group Meeting. Following an AAC on 10 November 2017, Dr Murray was appointed substantively as Consultant Clinical Oncologist – Urology. Dr Antonella Savio – Consultant Histopathologist Following an AAC in June 2017 Dr Savio was appointed as Consultant Histopathologist and joined the Royal Marsden on 6 November 2017. Dr Savio completed her medical training at the University of Pavia in Italy and gained entry to the GMC specialist register in October 2006. Before coming to the UK she was employed as lead GI Histopathologist at the Fondazione Poliambulanza Institutio in Brescia, Italy. She has practised widely within pathology including Gastro Pathology since 1994, Hepatic and Pulmonary Pathologies since 2003 and Gynaecological Pathology since 2005. Dr Savio has previously completed locum position at Kings College Hospital, Northwick Park and at The Royal Marsden. She has published extensively including completing a thesis on Hodgkin disease in Bone Marrow. Dr Darina Kohoutova – Consultant Gastroenterologist Following an AAC panel held on 20 October 2017 Dr Kohoutova was appointed as Consultant Gastroenterologist and began her role here as of 1 January 2018. Dr Kohoutova qualified as a doctor at Charles University Faculty of Medicine in Prague, Czech Republic, in 2005. She completed a national qualifying exam in Internal Medicine and a post graduate diploma in Gastroenterology (with distinction). She completed her specialist gastroenterology training in 2013 in Prague and completed a thesis in ‘large intestinal microbiota in inflammatory bowel disease and colorectal neoplasia’. She has worked in the UK since 2013 at UCLH as an honorary consultant and clinical fellow in ECRP and EUS at Imperial College Healthcare.

She has previously secured funding from the Czech Ministry of Health for research into ‘factors affecting apoptosis in colonic mucosa’ and ‘screening in colorectal cancer in Type 2 diabetics/high cardiovascular risk study’. She was awarded first prize for the national Kasafirek Award (Czech 2015) and secured third place in the international Dr Bares Award in 2015. She has published a number of publications and articles in gastroenterology. Dr Kohoutova is registered with a licence to practice with the GMC and is on the Gastroenterology specialist register as of February 2013.


Date of Meeting:

21st March 2018

Agenda item 5.3.

Title of Document: Quarterly Hospital Mortality Review

To be presented by

Medical Director

Executive Summary The Trust is compliant with the requirement by NHS Improvement to collect new data on patient deaths from April 2017; published a policy in September 2017; publish information on deaths quarterly via an agenda item and paper to the trust public board each quarter; publish an annual summary of the data in their annual quality accounts. The quarterly audit of all inpatient deaths has found that no deaths during the period October to December 2017 were avoidable. Recommendations The Board is asked to note that overall from the review of the data the Trust is RAG-rated green for the period between October 2017 and December 2017. Author: Medical Director



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Quarterly Hospital Mortality Review 1 October 2017 to 31 December 2017

1.0. Background 1.1 The Trust has been reviewing all inpatient deaths each quarter since 2015. The aim of this audit is to review all patient deaths occurring in The Royal Marsden in this three month period to determine the reasons for these deaths occurring in the hospital and the patient’s preferred place of death. 1.2 The audit evaluates if the patient’s death was reasonably to be expected given their clinical condition, whether the referral to the Palliative Care team was timely and whether there were any problems in care identified following the full Structured Judgement Review in accordance with guidelines from the Royal College of Physicians. In August 2017 the standards were refreshed and updated as below in 3.0. 1.3 The audit results have been presented in a quarterly report to the Integrated Governance and Risk Management Committee and the Quality, Assurance and Risk Board Sub-Committee each quarter by the Medical Director. 2.0 National Guidance on Learning from Deaths 2.1 The Trust is compliant with the requirements by NHS Improvement to; have a policy in place on learning from deaths (available on the Trust’s website); publish information on deaths quarterly via an agenda item and present a paper to the Trust Public Board. The requirement to publish an annual summary of the data in the Trust’s Annual Quality Account will be completed by end of May 2018 when this document is published. 2.2 The definition of a reasonably expected death was also provided in the policy as follows: A death that is reasonably expected is one which given the overall clinical condition, the patient is unexpected to survive. All attempts at treating reversible conditions will have been attempted and the death is due to irreversible progressive disease. 2.5 Death due to a problem in care: A death that has been clinically assessed using a recognised methodology of case record/note review and determined more likely than not to have resulted from problems in healthcare and therefore to have been potentially avoidable. 2.6 The National Mortality Case Record Review Programme from the Royal College of Physicians (RCP) outlines use of the ‘Structured Judgement Review’ to conduct in depth ‘case record review’ of certain deaths. The consultants undertaking the reviews have attended training on how to conduct a ‘Structured Judgement Review’. 3.0 Audit methodology 3.1 The data was reviewed at a meeting on 11 January 2018 with Dr Grover, Dr Halley, Dr Watkins, Dr Yousaf, Ms Mills, Ms Curtis, Ms Saunders and Mr Ahad to agree the findings as outlined in this report. Dr Halley and Dr Grover submitted comments via email prior to the meeting that were included in the discussion. 4.0 Conclusions Standard 1: 100% of in-hospital deaths should either be expected given the patient’s overall clinical condition, or should have a clear identifiable irreversible reason for death that could not have been prevented by clinical intervention. There were 45 inpatient deaths between 1 October 2017 and 31 December 2017. At the time of writing this Report, there is 1 death from November that is currently being investigated by the Quarterly Mortality Review Panel by asking the consultant who was involved with the patient’s care. Therefore this death will be excluded from the analysis for this standard until

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the outcome of the investigation is known. The remaining 44 eligible patients will be considered for this standard (and therefore also for standard 3 below). Conclusion: 44 inpatient deaths were reasonably expected therefore 44 out of 44 eligible patients met the standard. 100% - standard achieved. Standard 2: 100% of patients who died in hospital with a documented preferred place of death that was not “hospital” should have a clear, identifiable reason outside the control of RM as to why their preferred place of death was not achievable. Conclusion: Of the 45 deaths, 4 patients had indicated a preferred place of death other than “hospital” but were too unwell to be transferred. Therefore 4 out of 4 patients met the standard. 100% - standard achieved. Standard 3: A discussion with the Symptom Control and Palliative Care Team takes place in 80% of the admissions which resulted in patient death in hospital, where the death was reasonably expected as per standard 1. Conclusion: 95% of patients were discussed with the Symptom Control and Palliative Care Team before their death. 95% - standard achieved. The percentage of referrals in Q3 2017-18 has increased since the last quarter (which was 91%). Standard 4: 100% of patients for whom the Structured Judgement Review (SJR) is undertaken have no problems in care identified. Conclusion: There were 6 patients from Q3 for whom the Structured Judgement Review (SJR) was undertaken. There is 1 patient from November whose death is currently being investigated by the Quarterly Mortality Review Panel. Therefore this patient will be excluded from the analysis for this standard until the outcome of the investigation is known. The remaining 5 patients from Q3 will be considered for this standard. The 6 deaths from Q3 were selected for the SJR for the following reasons:

• Deaths in infants or children: 1 death • Concerns raised by the family or carer: 3 deaths • Death due to unexpected cardiac arrest: 1 death (currently being investigated) • Death of a patient who was on DoLS at the time: 1 death

5 patients this quarter for whom the SJR was undertaken had no problems in care identified. Therefore 5 out of 5 patients met the standard. 100% - standard achieved for Q3. There were also 2 deaths from Q2 that were being investigated and for which SJRs were completed this quarter.

• 1 patient referred to coroner – outcome from coroner was that there were no problems in care identified and the death was reasonably expected.

• 1 patient referred to the Serious Incidents review panel – outcome was that patient did have problems in care identified. The actions from this incident have been disseminated via the Serious Incident review action plan.

Therefore in Q2, for Standard 4, of the 7 patients for whom the SJR was undertaken, 6 patients had no problems in care identified. Therefore 6 out of 7 patients met the standard. 86% - standard not achieved for Q2.

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5.0. The Learning Disabilities Mortality Review (LeDeR) Of the 45 inpatient deaths in Q3 2017-18, there were no patients with learning disabilities according to information recorded in the EPR. 6.0 Children’s cases Of the 45 deaths, there was 1 paediatric case which will be reviewed at the Trust’s Paediatric Clinical Quality Forum in January 2018. 7.0 Serious incidents There were no deaths in this quarter that were investigated as Serious Incidents (SIs). 8.0 Complaints There were no complaints received regarding any of the 45 patient deaths. 9.0 Numbers of deaths caused by problems in care There were no deaths identified in this quarter that had been caused by problems in care. 10.0 Themes, trends and learning points There were no themes and trends identified during the review. The review found that of the 45 inpatient deaths, 34 (76%) of the deaths occurred in patients with metastatic disease according to the death certificate and information recorded in the electronic patient records. The other 11 patients died from a range of cancers. At the time of writing this Report, there is 1 death from November that is currently being investigated by the Quarterly Mortality Review Panel by asking the consultant who was involved with the patient’s care. In this quarter, reviews of care in the SJRs provided the following learning points:

• Prolonged admissions should involve regular communication with the patient’s family members regarding the patient’s progress.

• Death within 24 hours of admission should ideally be discussed with a coroner. • The need to act on worsening NEWS score with escalation via the SBAR tool to CCU

Outreach with early involvement of the CCU registrar if Outreach is concerned. 10.0 Summary The Board is asked to note that overall from the review of the data the Trust is RAG-rated green for the period between October 2017 and December 2017. The table below shows the RAG ratings from previous quarters:

Quarter RAG ratingQ4 2016-17 GreenQ1 2017-18 GreenQ2 2017-18 GreenQ3 2017-18 Green


Date of Meeting:

21st March 2018

Agenda item 6.1.

Title of Document: Key Performance Indicators Q3

To be presented by

Chief Operating Officer

Executive Summary This paper provides the Board with an update on the Trust’s performance for quarter 3 2017/18. The scorecard and narrative is also submitted to the Council of Governors. The report includes the balanced scorecard for the Trust and a commentary on the red-rated indicators in the quarter 3 report including actions underway to improve performance. Recommendations The Board is asked to note the Trust balanced scorecard and commentary for quarter 3 2017/18 and is invited to discuss the position. Author: Director of Performance and Information

Contact Number or E-mail: [email protected]

Date: 28th February 2018

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KEY PERFORMANCE INDICATORS

QUARTER 3 2017/18

1. PURPOSE This paper provides the Board with an update on the Trust’s performance for quarter 3 2017/18. The scorecard and narrative is also submitted to the Council of Governors. The report includes the balanced scorecard for the Trust and a commentary on the red-rated indicators in the quarter 3 report including actions underway to improve performance. 2. PERFORMANCE FOR QUARTER 3 65.0% of RAG-rated metrics were green in quarter 3, with 11.3% (9) metrics being red.

Please note there were no figures for the Staff Friends and Family Test for Quarter 3 as this was the national staff survey period. 2.1 Patient Safety, Quality and Experience

Q3 17/18

62 day wait for first treatment – GP referral to treatment (before reallocation)

Actual: 71.7% Target: 85% Forecast: Green on reallocated measure by Q4 2017/18

62 day wait for first treatment – GP referral to treatment (following reallocation)

82.6% 85% Forecast: Green by Q4 2017/18 on reallocation

The Trust did not meet the standard for quarter 3 2017/18 (before reallocation or post reallocation) with performance at 71.7% and 82.6% respectively, against a target of 85%. During quarter 3, there were 59.0 accountable breaches prior to reallocation. Of those accountable breaches 35.0 were received late in the pathway (defined as after day 38). Of those remaining, the breaches occurred for the following reasons:

Of the 9 red-rated metrics, five have been identified as longer-term issues. These include: 62 day standard, Community Nurse Vacancy rate, non-PP debtors, research (accrual to target) and PP aged debt. Appendix A shows the full balanced scorecard report for quarter 3 for 2017/18.

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Administrative delays (2.0)

Late notification of pathway (3.0)

Delay in workup (6.0)

Complex diagnostic pathway (3.5)

Patient choice (3.0)

Patient unfit (0.5)

Delay to enabling treatment / fertility treatment (2.5)

Patient compliance (1.5)

Inappropriately early referral (2.0) On 30th March 2017, the Trust submitted a trajectory to NHSE for compliance with the 62-day standard in 2017/18. This trajectory incorporated plans submitted by referring trusts within SW London to ensure referrals are made to RM by day 38 wherever appropriate.

During quarters 1, 2 and 3, performance has remained below this trajectory. Throughout this time, SW London providers have failed to meet their trajectories for referral by day 38. The Trust has met the 62 day standard based on reallocated performance in 6 of 9 months in 2017/18. The Trust has met its internal trajectory for performance against GP referrals in 7 of 9 months in 2017/18.The Trust Performance Group has developed and is progressing an internal action plan to manage the service improvements needed to meet the 2017/18 trajectory.

Q3 17/18

62 day wait for first treatment – Screening referral to treatment (before reallocation)

Actual: 88.o% Target: 90% Forecast: Meet the standard in Q4 2017/18 on reallocation

62 day wait for first treatment – Screening referral to treatment (post reallocation)

87.8% 90% Forecast: Meet the standard in Q4 2017/18

RMH did not meet the 62 day screening target in quarter 3 2017/18 (before reallocation or post reallocation), with performance at 88.0% and 87.8% respectively, against a target of 90%. This was the result of 4.5 accountable breaching pathways. The reasons were as follows:

Patient choice (1.5)

Complex diagnostic pathway (1.5)

Delay in workup (0.5)

Late referral (0.5)

Late notification (0.5) 2.2 Community measures

Q3 17/18

Community Nurse vacancy rate

Actual: 20.43% Target: <15% Forecast: Red

The Community nurse vacancy rate has reduced by over 3 percentage points in quarter 3, but remains above the newly agreed 15% target. This reduction in the nurse vacancy rate is a

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result of the significant programme of work to attract more nurses to work in Community services. This has involved local, national and international recruitment campaigns. Recruitment incentives including ‘refer a friend’, ‘golden hello’ and an increased online advertising and social media presence is having a positive impact on the recruitment pipeline of staff waiting to start. In quarter 3, deep dive sessions were undertaken with Community services to support them address feedback from the last CQC visit including recruitment and retention challenges.

Q3 17/18

Community Friends and Family Test – Patient satisfaction

Actual: 92.9% Target: <95% Forecast: Green

While not red-rated, the community friends and family test score decreased in quarter 2 to 92.9%, below the 95% target. This was the result of the December figures where there was an increase in the number of people reporting ‘neither likely or unlikely to recommend’. This increase was driven by a cohort of children who were being weighed and measured, all of which selected the ‘neither likely or unlikely to recommend’ category. Following review this cohort will not be included within the FFT going forward as it not an appropriate mechanism to gather patient feedback from children attending this service. 2.3 Finance, Productivity and Efficiency

Q3 17/18

PP Aged Debt at >6months

Actual: 29% Target: <23% Forecast: Amber

The total PP debt over 6 months old at the end of quarter 3 has improved from 31% in Q2 to 29% in Q3 but this is still above the target of 23% at the end of quarter 3. Ageing of Embassy debt remains the challenge. A number of old outstanding invoices have been re-invoiced to the Embassies in the recently agreed new format in an effort to expedite payment. The Private Medical Insurance (PMI) position continues to improve but is masked by the Embassy position.

Q3 17/18

Non-PP Debtors over 90 days (% of total PP-debtors)

Actual: 46% Target: <25% Forecast: Amber

Non-PP debtors over 90 days decreased in quarter 3, however remain above target. Total debt over 90 days has remained constant but total debtors have increased. This is in part due to over-performance invoices outstanding at Q3 which is expected to be paid in Q4 and improvement is anticipated in Q4. 2.4 Clinical and Research Strategy

Q3 17/18 (1 quarter in arrears)

Accrual to target, % of closed commercial trials meeting contracted recruitment target (national definition)

Actual:54.5% Target: 85% Forecast: Red As described in previous reports, the NIHR made changes to its Delivery metric (from quarter 4 2015/16), which now focuses on recruitment to target, by target date recorded in each trial’s contract. The recruitment target is set following discussion between the Principal Investigator and the Sponsor and is a best estimate of recruitment at the site – recruitment to time and target. Recruitment to target is affected by many factors. Recruitment may be more challenging than anticipated; the Sponsor can often choose to close the trial earlier than anticipated and the trial is sometimes withdrawn by the Sponsor. In some instances, the recruitment

4

window may be extended in agreement with the Sponsor, with no change to the date held the trial Contract (and hence the metric does not reflect the agreed extension). The NIHR collects reasons for recruitment targets not having been met but, unlike the NIHR Initiation metric, no adjustment is made to account for these reasons. Of the 20 studies that did not meet their target recruitment, 14 studies were withdrawn by the sponsor, which means the trial was shut earlier than expected, therefore not providing the opportunity to recruit to the agreed target. No adjustment is made by the NIHR for studies that were closed early by the sponsor. In order to improve performance against the NIHR metric, researchers are negotiating recruitment ranges, rather than a single definitive number of patients, and will request amendments to contracts where recruitment is not happening at the anticipated rate. Recruitment data are reviewed regularly at Clinical Research Team meetings, and are reported at quarterly performance meetings held with the teams. 2.5 Efficient Clinical models

Q3 17/18 NHS Average (mean) Elective LoS

Actual: 5.39 Target: <5% Forecast: Amber

The average length of stay increased in Quarter 3 to 5.39 days, up from 5.10 in quarter two. Analysis indicates that Bud Flanagan East and West, Critical Care Unit and the Teenage Cancer Trust Unit had the biggest increases in average length of stay in Q3. It is too early to predict exactly what has caused this and whether it is a trend or the impact of winter. This will be monitored monthly through Performance Review Group 3.0 Conclusion The Board is asked to note the Trust balanced scorecard and commentary for quarter 3 2017/18 and is invited to discuss the position.

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APPENDIX B 62 Day GP Urgent Referrals by Category

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APPENDIX C 62 Day Wait for First Treatment (GP Urgent). Performance by Tumour Type Please note that the RAG ratings below are designed to be used at Trust level rather than tumour level and are only shown below as a guide. The pre-allocated data position is submitted via the National Cancer Waiting Times database, hosted by the national database Open Exeter (OE) and is displayed in the table, along with the post reallocated position as a comparison.

Tumour site Q3 17/18

85% target OE

position Reallocated

position

Breast 94.64% 95.58% Gynaecological 64.00% 72.00% Haematological (excl. Acute Leukaemia) 66.67% 72.73% Head & Neck 31.58% 66.67% Lower GI 83.33% 90.00% Lung 47.83% 83.33% Other/Unknown 77.78% 87.50 Sarcoma 71.01% 73.91% Skin 92.86% 100%

Upper GI 77.78% 83.72%

Urological 40.48% 58.82%

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The Royal Marsden NHS Foundation TrustBalanced Scorecard 2017/18

NHSi denotes NHS Improvement standard

Patient Safety, Quality & Experience Target in 2017/18Q3

(Oct-Dec 17/18)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)

NHSi 1 1 1 1 1 2

MRSA positive cultures (cumulative) 0 0 0 0 1 1

C Diff lapses of care ≤31 per annum 0 1 1 1 1

VTE risk assessment ≥95% 96.5% 96.7% 95.8% 97.3% 96.7%

NHSi G G G G G G

Serious incidents (excl pressure sores) ≤4 per annum, ≤1 per quarter 2 2 1 1 0

Complaints - % upheld < 27% 21.00% 14.28% 16.22% 19.00% 24.00%

MortalityHospital Standardised Mortality Ratio (rolling 12 month - qtr in arrears - NHS & Private patients) ≤75 78.96 68.1 69.47 70.73 72.51Mortality audit (based on qtr data in arrears) G G G G G A30 day mortality post surgery < 0.8% 0.28% 0.57% 0.29% 0.66% 0.36%30 day mortality post chemotherapy < 2.2% 1.57% 1.85% 1.62% 2.09% 2.27%100 day HSCT mortality in previous 6 months (Deaths related to SCT) <5% 2.10% 1.60% 4% 0.00% 5.40%100 day HSCT mortality in previous 6 months (All deaths) <5% 2.10% 1.60% 6% 0.00% 5.40%

Medicines Management% Medicines reconciliation on admission ≥ 90% 88.00% 95% 95% 100% 98%Unintended omitted critical medicines 0 0.5 0.7 0.7 1.7 2.5

Cancer stagingStaging data completeness sent to Thames Cancer Registry (1 qtr in arrears) >70% 73.78% 72.10% 70.90% 72.41% 72.62%

Patient satisfaction Friends and Family Test (inpatient and day care) ≥95% 96.11% 97.67% 97.13% 97.20% 97.90%Friends and Family Test (outpatients) ≥95% 95.08% 95.59% 97.99% 98.30% 98.20%Waiting times for day chemotherapy (over 3 hrs) ≤13% 9.10% 9.47% 12.10% 11.56% 12.69%Mixed sex accommodation breaches 0 0 0 0 0 0PP access to single rooms - Chelsea % ≥95% 100.00% 100.00% 100.00% 99.90% 100.00%PP access to single rooms - Sutton % ≥95% 100.00% 99.74% 100.00% 99.70% 100.00%

National waiting times targetsNHSi 2 wk wait from referral to date first seen: all cancers ≥93% 96.8% 97.0% 97.4% 97.7% 98.7%NHSi symptomatic breast patients ≥93% 96.1% 95.7% 93.6% 95.9% 96.7%

NHSi 31 day wait from diagnosis to first treatment ≥96% 97.0% 98.0% 98.1% 97.4% 98.3%

NHSi 31 day wait for subsequent treatment: surgery ≥94% 95.6% 95.7% 97.0% 95.2% 94.0%NHSi drug treatment ≥98% 98.8% 98.9% 99.0% 98.8% 99.4%NHSi radiotherapy ≥94% 95.8% 95.9% 94.6% 96.6% 98.1%NHSi 62 day wait for first treatment: GP referral to treatment (reallocated) ≥85% 82.6% 86.9% 85.6% 85.3% 87.0%NHSi GP referral to treatment (pre-reallocations) ≥85% 71.7% 75.5% 76.2% 77.9% 77.9%NHSi Screening referral (reallocated) ≥90% 87.8% 89.5% 91.3% 89.6% 93.3%NHSi Screening referral (pre-reallocations) ≥90% 88.0% 93.0% 89.6% 90.8% 92.6%NHSi 18 wks from Referral to Treatment still waiting (incomplete) ≥92% 96.9% 95.9% 95.6% 95.9% 94.7%NHSi 18 wks pathways - patients waiting > 52 wks. (distinct patients across the quarter) ≤ 6 a quarter 1 4 4 2 3

Staff Friends and Family TestTarget in 2017/18

Q3(Oct-Dec

17/18)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)Recommend – Care ≥96% N/A 100% 95.90% 95.40% N/ANot recommend – Care ≤1% N/A 0% 0.60% 0.70% N/A

NHSi Community MeasuresTarget in 2017/18

Q3(Oct-Dec

17/18)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)NHSi Community care data completeness referral to treatment information ≥50% 75.00% 75.00% 75.00% 75.00% 75.00%NHSi referral information ≥50% 75.00% 75.00% 75.00% 75.00% 75.00%NHSi activity information ≥50% 76.20% 76.20% 76.20% 76.20% 76.20%

Patient satisfaction Friends and Family Test ≥95% 92.9% 98.0% 96.7% 97.0% 96.9%

Effective care

Total ≤160 per annum, ≤40 per quarter 31 37 44 New in Q1

Category 4 0 0 0 0 New in Q1

Community staff vacancy rateNurse vacancy rate

≤15% 20.43% 23.87% 26.75% 24.14% 24.69%

Certification against compliance : access to health care for people with a learning disability

3. Community Measures

2. Staff Friends and Family Test - How likely are you to recommend this organisation to friends and family… as a place to receive care or treatment

1. To achieve the highest possible quality standards for our patients, exceeding their expectations, in terms of outcome, safety and experience

Single Oversight Framework: level of support segment

Quality Account indicators

Number of patients with attributable pressure ulcers (RMCS)

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Finance, Productivity & EfficiencyTarget in 2017/18

Q3(Oct-Dec

17/18)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)NHSi NHSi Use of Resources risk rating 1 1 1 1 1 2NHSi %age variance from Agency Spend Cap On/below cap -26% -22% -18% -14% -13%

Cash (£m) Over plan 36.1 30.0 20.0 21.1 13.6

NHS activity Income Variance YTD (£000)Breakeven or ahead of plan 1418 0 714 1610 904

PP activity Income Variance YTD (£000) Q2 ≤23% 4,774 1,788 1,100 2,868 1,862PP Aged debt at >6months <23% 29% 31% 29% New in Q1Non-PP Debtors over 90 days (% of total non PP-debtors) <25% 46% 48% 57% 42% 51%

Achievement of Efficiency Programme YTD (%)Greater than 100%

of plan 98% 84% 81% 102% 99%

Capital Expenditure Variance YTD (£000)Between 85% and

115% of plan -3,028 -3,793 -3,261 -4,579 -5,072

Productivity & Asset UtilisationBed occupancy - Chelsea ≥85% ≤90% 81% 85% 83% 85.10% 82.47%Bed occupancy - Sutton ≥85% ≤ 90% 83% 83% 81.05% 79.40% 79.26%Care Hours per Patient Day total ratio ≥11.3 11.70 11.20 11.50 11.30 11.40Theatre utilisation - Chelsea ≥80% 93.08% 87.87% 87.20% 89.90% 92.35%Theatre utilisation - Sutton ≥80% 71.35% 70.78% 81.20% 82.70% 69.81%MDU Patients per Chair (Adjusted method and chair numbers) ≥1.5 1.53 1.46 1.55 1.58 1.57

Quarter in arrears Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)

Q2(Jul-Sep 16/17)

Contractual Sanctions incurred (£000) 0 0 0 0 0 0CQUIN %age achievement Acute NHSE ≥95% 100% 100% 100% 100% 100%CQUIN %age achievement Acute CCG ≥95% 100% 100% 100% 100% 100%CQUIN %age achievement Sutton Community Services ≥95% 100% 100% 100% 100% 100%

Clinical and Research StrategyTarget in 2017/18

Q3(Oct-Dec

17/18)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)Total NHS referrals ≥4950 5053 4764 4967 5150 4710Total PP referrals ≥988 1150 1094 1093 1221 1033

Meet trajectory 450 420 340 248 184

Efficient clinical modelsNHS Average (mean) Elective LoS ≤5 5.39 5.10 5.26 4.87 5.24NHS Non-Elective Admissions as %age of all NHS Admissions ≤26% 28.58% 27.93% 29.85% 26.97% 25.01%

Research (1 QUARTER IN ARREARS)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)

Q3(Jul-Sep 16/17)

Performance in Initiating Clinical Research (70 day benchmark - all trials)

NIHR Adjusted figure (excl delays attributed to sponsor/neither sponsor or trust) ≥80% 74.30% 85.7% 63.6% 90.5% 94.3%

Accrual to target (1Q arrears) - National definition % of closed commercial interventional trials meeting contracted recruitment target (excluding trials that had no set target)

≥85% 54.50% 52.9% 47.8% 45.7% 42.6%

No. of 1st UK patients 1 12 11 1 New in Q4No. of 1st European patients 1 1 1 1 1 1No. of 1st Global patients 1 5 4 New in Q1

Trials lead by RMH as %age of commerical interventional trials with RMH involvement which opened in the last 12 months

≥20% 41.0% 41.0% New in Q1

WorkforceTarget in 2017/18

Q3(Oct-Dec

17/18)

Q2(Jul-Sep 17/18)

Q1(Apr-Jun 17/18)

Q4(Jan-Mar

16/17)

Q3(Oct-Dec

16/17)Workforce productivityVacancy rate ≤5% 8.80% 10.51% 11.30% 8.80% 8.60%Staff turnover rate ≤12% 14.95% 15.50% 15.10% 15.20% 15.10%Sickness rate ≤3% 3.20% 2.60% 2.70% 3.50% 2.80%

Quality & developmentConsultant appraisal (number with current appraisal) ≥90% 97.30% 97.30% 98.00% 96.00% 94.00%Appraisal & PDP rate ≥90% 82.60% 81.70% 85.70% 86.90% 83.00%Completed induction (new measure) ≥80% 84% 83% 84.20% 80.80% 72.00%Statutory and Mandatory Staff Training ≥90% 89.20% 88.50% 89.00% 87.80% 86.40%

No. of 1st patients recruited in previous 12 months

6. To recruit, retain and develop a high performing workforce to deliver high quality care and the wider strategy of the Trust

RMH Patients recruited to 100K Genome Project

4. To improve the productivity and efficiency of the Trust in a financially sustainable manner, within an effective governance framework

5. To deliver the Trust's clinical and research strategy; to better meet the needs of patients and commissioners


Date of Meeting:

21st March 2018

Agenda item 6.2.

Title of Document: Cancer 62 Day Waiting Times

To be presented by

Chief Operating Officer

Executive Summary This paper updates the board on performance against the Cancer 62-day standard, and includes:

1. RM and RM Partners performance against the 62-day standard and a summary of factors affecting compliance in January.

2. Plans in place to address issues which contribute to delays within the Trust.

3. An update on the implementation of an innovative Sarcoma triage model to manage the increasing demand from urgent referrals.

Recommendations The Board is asked to note January performance against the 62-day standard, and to support both the internal and wider system actions in place to address 62 day compliance. Author: Service Manager for Performance / Managing Director for RMP



1

Cancer 62 Day Waiting Times

1.0. Background The Trust reported non-compliant performance against the 62 day standard in January 2018 which was below the level usually seen, but was an improvement upon the December position. This disappointing performance is congruent with sector wide poor performance, and in line with historical dips in performance in January. A number of actions further to improve performance in February and March are underway. 2.0. Current Performance Update The Trust undertook analysis of its extremely unusual December 2017 62-day position, in which a number of unrelated and unpredictable breaches contributed to a significant underperformance. Since the last board report, the Trust has posted its January position for cancer waits. The January performance was low across the sector. The table below shows both the 62-day standard and reallocated positions for the Trust and for RM Partner Trusts as a whole and the RM Partners performance on a CCG basis*. Month Royal Marsden NHS Trust RM Partners Unadjusted Reallocated Unadjusted Reallocated CCG* Oct 2017 73.2% 81.0% 84.0% 84.1% 85.1% Nov 2017 79.3% 87.2% 87.2% 87.7% 88.9% Dec 2017 64.4% 78.5% 85.5% 86.5% 86.5% Jan 2018 70.2% 82.7% 83.3% 83.4% 83.1% *Nationally published figures for 62 day performance are derived on a CCG basis, not a provider basis. In Q3 2017/18, RM Partners was one of only five cancer alliances nationally to have delivered the 62-day target. RM Partners’ failure to deliver in January was due to poor performance at RMH, St George’s and Epsom and St Helier trusts. This means that the system will be required to provide additional assurance to regulators over the coming month. In addition, any continued underperformance is likely to affect RM Partners’ ability to attract transformation money in the second half of 2018/19. Improving 62 day cancer performance is therefore a key focus for all Trusts in SWL as well as for RM Partners. Historic trends show that January and February performance tends to be depressed, but picks up significantly in March. Our unvalidated figures for February (both for RMH and for RM Partners overall) indicate that performance has improved with actions undertaken by RMH and targeted interventions at St George’s and Epsom and St Helier.

2

3.0. January Breach Analysis The Trust undertakes a comprehensive pathway review and root cause analysis for all 62-day breaches each month. In January the Trust experienced a month with a significant number of unavoidable patient choice, patient fitness, and clinical complexity issues that lead to breached pathways. The breach review process has shown that January’s performance was not due to any systemic issues within the Trust in terms of pathway management or capacity constraints. There were two main components that accounted for the low level of compliance in January.

1. GP pathway breaches (where the GP refers direct to RMH as a TWR) • There were 5 GP breaches for RMH in January. This is a high number within

a single month. • 3 of the 5 breaches were entirely beyond the control of the trust, these were

due to :- 1 patient choosing to delay their pathway over the Christmas period. 1 patient who was not fit for treatment within the 62 day period. 1 patient requiring genetic testing before a treatment plan could be

determined, which added unavoidable delays to the pathway • The remaining 2 breaches contained delays which could have been avoided

through improved admin, improved communication between the clinical team and admin, and improved capacity planning. Although these were both isolated incidents, learning from these is being taken forward in the Trust.

2. Inter-trust pathway breaches (where the patient is referred from another trust to

RMH mid-pathway) • There were 29 inter-trust patients who breached the 62 day standard in

January. Only 2 of the 29 patients who breached were referred by day 38. 93% of these breaches are therefore classified as late referrals in line with national guidance.

• 9 of the inter-trust breaches (31%) were referred to RMH after day 62 and had therefore already breached the 62-day target before they were referred to RMH.

4.0. Actions to address non-compliance Although many 62 day breaches are unavoidable, the breach review process has helped to highlight internal themes which contribute to delays within 62 day pathways. These themes relate to administrative processes, clinical pathway management and escalation. As a result, the Trust has identified the following key areas for focussed work to minimise delays:

• A strengthened escalation policy is now in place, ensuring increased engagement with clinical teams as well as appropriate escalation to the Chief Operating Officer, Medical Director and Chief Nurse.

• A review of administrative processes is currently being undertaken by Clinical Services.

• IT are in the final testing phase to implement a flagging system in ICW to highlight all patients on a 62-day pathway.

3

• The Trust Performance Group has agreed a proposal to develop a communications plan to support improved communication regarding Cancer Waits Targets and performance to all staff groups across the Trust.

• RMP have funded additional patient navigator support to manage inter trust transfer between Epsom Hospital / RMH prostate pathway to improve 62 day performance.

• Continued close working with the South West London Leadership Forum and specific intervention at referring Trusts to support their overall and ITT performance.

Sarcoma Clinical Triage Model

The Trust has instigated an innovative RMP funded project to implement a new pathway in Sarcoma which includes transforming capacity for 2-week rule referrals (which have historically contributed to Trust breaches). In particular, the new pathway encompasses a clinical triage model based on review of ultrasound (with the expectation that GPs will ensure referrals are sent to the Trust with an up to date US in line with NICE guidance). This model was implemented on 23rd February 2018. 5.0. Recommendation The Board is asked to note January performance against the 62-day standard, and to support both the internal and wider system actions in place to address 62 day compliance.


Date of Meeting:

21st March 2018

Agenda item 6.3.

Title of Document: Financial Performance Report

To be presented by

Chief Financial Officer

Executive Summary The paper provides a summary of the financial position for the month of January 2018 in FY 2017/18. The reporting format within this paper provides consistent reporting to all Trust Committees. Recommendations The Board is requested to note the Financial Performance Report. Author: Chief Financial Officer



Summary Financial Performance Report for January 2018

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1. Introduction The paper provides a summary of the financial position for the month of January 2018 in FY 2017/18. The reporting format within this paper provides consistent reporting to all Trust Committees.

2. Summary Financial Position Key headlines

For the month of January the key headlines are as follows:

• Operating surplus in month of £3.5m, a favourable variance of £0.9m • Retained surplus in month of £2.9m, a favourable variance of £1.4m • Agency expenditure of £0.3m, a favourable variance against the cap of £0.4m • Capital expenditure of £1.8m, an adverse variance of £0.2m • Cash in bank of £37.8m, a favourable variance of £19.9m

There was a favourable variance on income in the month of £2.0m spread across all the income categories. Offsetting this was an adverse variance on non pay of £1.2m. This meant an operating surplus in month of £3.5m which is a favourable variance of £0.9m. The revised forecast outturn reported to NHSI at month 10 is a £12.9m surplus which is a favourable variance of £11.3m against the control total (excluding STF). Due to the additional matched STF for overperforming against the control total, the forecast surplus overall is £27.3m a favourable variance of £22.1m. This is an exceptional performance in the latter half of the year, but the majority of the favourable position is non-recurrent and therefore is not repeated into 2018/19. In-Month – January 2017 Year to Date - January 2017

Budget Actual Var Budget Actual Var

£'000 £'000 £'000 £'000 £'000 £'000 Income

(18,125) (18,545) (421) NHS Clinical Income (174,327) (173,428) 899

(8,834) (9,493) (658) Non NHS Clinical Income (81,906) (86,523) (4,617)

(4,109) (4,698) (589) NHS Non Clinical Income (40,498) (49,789) (9,291)

(1,783) (2,165) (382) Non NHS Non Clinical Income (18,130) (18,521) (392)

(32,850) (34,900) (2,050)

(314,861) (328,262) (13,400)

Expenditure 17,964 17,929 (35) Pay 179,272 176,788 (2,484)

12,328 13,514 1,186 Non Pay 119,507 127,044 7,536

30,293 31,443 1,150 298,780 303,832 5,052

(2,558) (3,457) (900) Operating Surplus (16,081) (24,429) (8,348)

341 330 (11) PDC, Interest, JV 3,372 3,337 (35) (2,217) (3,127) (910) Development Reserve for Inv (12,709) (21,093) (8,383)

(589) (926) (337) Donated Asset Income (5,512) (6,685) (1,173) 1,333 1,288 (45) Depreciation 12,840 12,560 (280)

(100) (100) Impairment and loss on disposal 801 801 (1,473) (2,866) (1,393) Retained (Surplus)/Deficit (5,382) (14,417) (9,035)

(1,073) (2,124) (1,051) Control total excl STF (2,420) (10,588) (8,168)

% of NHS income/Total income 68% 68% (0%)


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As shown in the table above, the Trust was ahead of plan in month on a control total basis and as such the full STF year-to-date has been accrued. The operating surplus at month 10 of £24.4m is a favourable variance of £8.3m and £12.3m better than the same period last year. This is predominantly driven by additional income, including the additional STF, which year on year is showing an increase of £31.1m or 10.5%. Under the new Single Oversight Framework, the Trust delivered a Use of Resources rating of 1, against a plan of 1. The Trust reports the percentage of income for the provision of goods and services for the purpose of the health service as set out within the NHS Act 2006 and amended by the Health and Social Care Act 2012. This is completed annually and a statement included within the Annual Report, which the auditors review. However, it is also reported to the Board and Council of Governors in each finance report. The income is split into four overall categories with examples of the types of income included:

• NHS clinical income – income from NHS England and CCGs for clinical activities; • Non-NHS clinical income – private care income for clinical activities; • NHS non clinical income – NHS R&D; salary support for staff in training e.g. junior doctors; • Non-NHS non clinical income – commercial R&D; car-parking; catering income.

As a ratio the Trust is required to have more income as NHS than non-NHS and as at month 10 the position was 68% of income from NHS sources.

3. Income and Expenditure Income – The income position in month 10 was a favourable variance of £2.1m. NHS Clinical Income was favourable to plan in month by £0.4m. The majority of service lines overperformed against the plan in month with a total favourable variance of £0.9m. Inpatients was £0.2m ahead of plan and outpatients and daycases both £0.1m ahead of plan. This was then offset by an adverse variance on the cancer drug fund of £0.5m, which is a pass-through payment so is offset by reduced drug costs.

Private Care income was £0.7m ahead of plan in month due to continued strong underlying activity, although partially offset by the growth areas not delivering as well as planned. Year to date NHS Clinical Income is now 7.2% higher and Private Care is 13.6% higher when comparing the same period with the previous year.

£-

£5.0

£10.0

£15.0

£20.0

£25.0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

NHS Clinical Income

Acutal 15/16 Actual 16/17 Actual 17/18 Plan 17/18 Forecast 17/18


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Pay expenditure – was break even in month and remains £2.5m favourable year to date. The position in quarter 3 had deteriorated and despite significant recruitment there has been broadly the same expenditure on bank and agency, resulting in a number of areas now having supernumerary staff. This showed some signs of improvement in January, however it is not yet clear that this is an improving trend. Review of spend and controls is ongoing for the remainder of this year and for 2018/19 in order to secure an affordable recurring run rate.

Overall the Trust is still below the NHSI agency expenditure cap by £0.4m in month and is now £2.1m under the cap year-to-date. The focus continues on converting from agencies to the bank, as with the IR35 changes and NHSI pressure on agency rates, pay has become more comparable, however the agency premium is saved.

£- £1.0 £2.0 £3.0 £4.0 £5.0 £6.0 £7.0 £8.0 £9.0

£10.0


Private Patient Clinical Income

Acutal 15/16 Actual 16/17 Actual 17/18 Plan 17/18 Forecast 17/18

£13.0

£14.0

£15.0

£16.0

£17.0

£18.0

£19.0

Pay Cost Trend

Substantive Bank Agency Pay Budget


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Non-pay expenditure – was an adverse variance of £1.2m to plan in month and is now an adverse variance year-to-date of £7.5m. The key variance in month was an adverse variance of £0.4m relating to RM Partners expenditure. This is because RM Partners was unbudgeted for at the beginning of the year due to the timing of the award from NHSE, but is fully funded through income. This will continue throughout the year, but as it was a two year allocation it will form part of the budgeted position in 2018/19. The other key variances are drugs £0.4m adverse in month which is offset by income, and overspends in clinical supplies, £0.3m in month, largely due to pathology and theatre consumables.

4. Capital Expenditure Capital expenditure was £1.8m in month an adverse variance of £0.2m. Year-to-date the expenditure is £10.5m with a forecast outturn of £17.1m. The forecast for donated equipment is now an adverse variance due to the additional equipment grant agreed and funded by RMCC in September 2017. This is to purchase the surgical robot and genetic sequencer, which were processed in December and is now forecast to be an adverse variance of £1.5m. IT and estates schemes are the main reasons for the favourable variance. Both are due to delays in projects against the original plan.

5. Cash and Debt Cash – The Trust had £37.7m in cash at the end of January, £19.9m more than planned. The cash position increased in month although the variance reduced compared to December. Debt reduced by £0.5m overall but there were a number of other working capital movements that explain the reduction in favourable variance. Chart 2.3 in Appendix 2 shows the trend of cash balances in the last three months and the forecast and plan for the full year. Cash is continually monitored and despite recent success in clearing historic items NHS organisations are generally paying much slower than in previous years. The other main area supporting the cash position is the underspend in capital, which is a timing issue. Debt – Invoices raised but not yet paid decreased in month by £0.5m to £58.6m at the end of January. NHS debt decreased by £0.8m and is expected to improve further with NHSE catching up on the cancer drug fund invoices and paying the quarter 2 overperformance. Private care debt has improved by £0.4m in month and is the second month this has been below £30m despite increasing revenue. Chart 2.4 in Appendix 2 provides a trend of debtor balances for the last twelve months by age of debt, which shows the increase in debt over 90 days, the majority of which is with embassies and a small number of commissioners.

£-

£0.2

£0.4

£0.6

£0.8

£1.0

£1.2

Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

Bank and Agency Spend Trend

Bank Agency Linear (Bank) Linear (Agency)


5 | P a g e

6. Forecast and Sensitivities Forecast - The Trust has reforecast the outturn based on the month 10 position and following discussions in the business planning meetings with each of the divisions. The revised forecast is for a retained surplus of £27.3m, £22.1m favourable compared to budget and £11.3m favourable compared to the NHSI control total. The significant improvement over the previous forecast is related to the matched increase in surplus by additional STF, now confirmed by NHSI. This additional STF will greatly assist the capital programme in 2018/19. Sensitivities

Risks totalling £2.7m have been identified against the current forecast variance to the NHSI control total. These risks are identified below and if realised in full provide a worst case scenario of which due to the matched funding of STF doubles to a downside of £5.4m. - Private Care Market Volatility – potential £1.2m risk to forecast due to competition. Work

continues to diversify private care income sources to mitigate against this in future. - Junior Doctor Rota gaps – £0.25m to £0.5m risk to forecast. The latest Deanery rotation has left

fewer gaps than previously but the Trust continues to have difficulty filling gaps in Junior Doctor rotas, requiring bank and agency staff. Should these gaps increase again there is potential for up to £0.5m of overspend against the Junior Doctor budget.

- R&D Transition – up to £1.0m downside. Year-to-date the Trust is behind its targeted commercial trials income increase to offset this.

On the upside is clearing of historical debts and therefore the ability to reduce the provision for doubtful debts. Again this increases due to the matched STF funding.

7. Conclusion and Recommendation The month of January was another positive period for the Trust due to sustained growth in clinical income, both NHS and Private Care. Pay controls on expenditure will need to be reviewed in order to ensure an affordable exit run rate from 2017/18 is achieved into 2018/19. Overall the position means the Trust has again delivered the control total set by NHSI in month and is set to deliver a favourable forecast against the control total for which the Trust will receive additional STF income. The Board is requested to note the continued financial performance as at month 10 and the forecast for the year as well as the highlighted downside risks.

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Q1 Q2 Q3 Q4

£'0

00

m

Sensitivity analysis

Downside

Upside

Forecast

6 | P a g e

Budget Actual Var Budget Actual Var Actual Var Budget Forecast Forecast Var 1617 Q4 1718 Q1 1718 Q2 1718 Q3

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Income Actual Actual Actual Actual

NHS Clinical Income (18,125) (18,545) (421) (174,327) (173,428) 899 (161,708) (11,720) (208,554) (207,792) 762 (18,675) (17,084) (16,789) (17,773)

Non NHS Clinical Income (8,834) (9,493) (658) (81,906) (86,523) (4,617) (76,237) (10,286) (97,587) (102,945) (5,359) (8,214) (8,386) (8,404) (8,887)

NHS Non Clinical Income (4,109) (4,698) (589) (40,498) (49,789) (9,291) (36,942) (12,847) (48,718) (72,683) (23,965) (4,447) (4,464) (4,780) (5,767)

Non NHS Non Clinical Income (1,783) (2,165) (382) (18,130) (18,521) (392) (22,271) 3,750 (21,733) (22,081) (348) (1,612) (2,088) (1,485) (1,914)

(32,850) (34,900) (2,050) (314,861) (328,262) (13,400) (297,158) (31,104) (376,591) (405,501) (28,911) (32,947) (32,021) (31,458) (34,341)Expenditure

Pay 17,964 17,929 (35) 179,272 176,788 (2,484) 167,248 9,540 215,238 212,435 (2,803) 17,685 17,437 17,465 18,085

Non Pay 12,328 13,514 1,186 119,507 127,044 7,536 117,809 9,235 143,136 152,018 8,882 11,730 12,550 12,160 13,133

30,293 31,443 1,150 298,780 303,832 5,052 285,057 18,775 358,374 364,452 6,079 29,415 29,987 29,625 31,217

Operating Surplus (2,558) (3,457) (900) (16,081) (24,429) (8,348) (12,100) (12,329) (18,217) (41,049) (22,832) (3,532) (2,034) (1,833) (3,124)

PDC, Interest, JV 341 330 (11) 3,372 3,337 (35) 4,361 (1,024) 4,058 4,106 48 47 333 336 333

Development Reserve for Inv (2,217) (3,127) (910) (12,709) (21,093) (8,383) (7,739) (13,353) (14,159) (36,943) (22,784) (3,485) (1,701) (1,497) (2,791) -

Donated Asset Income (589) (926) (337) (5,512) (6,685) (1,173) (5,289) (1,396) (6,600) (6,685) (85) (237) (66) (360) (1,494)

Depreciation 1,333 1,288 (45) 12,840 12,560 (280) 11,085 1,475 15,508 15,508 - 1,273 1,222 1,253 1,282

Loss Disposal Fixed Assets - (100) (100) - (55) (55) (2) (53) - (55) (55) 55 - 13 1

Impairment - - - - 856 856 29,260 (28,404) - 856 856 9,505 - - 286

Retained Surplus (1,473) (2,866) (1,393) (5,382) (14,417) (9,035) 27,315 (41,732) (5,251) (27,319) (22,068) 7,111 (546) (590) (2,715)

Control Total (excl. STF) (1,073) (2,124) (1,051) (2,420) (10,588) (8,168) 1,257 (11,844) (1,585) (12,886) (11,301) (1,150) (625) (485) (1,710)

Use of Resources Rating Plan Y TD Actual Y TD

Liquidity 1 1 (1) - Liquidity = Cash for l iquidity purposes (net current assets excluding inventories) divided by opex expressed in days

Capital Debt Cover Ratio 1 1I&E Margin 1 1Variance From Plan 1 1 (3) - I&E Margin - degree to which the Trust is operating at a surplus / deficit

Agency Spend 1 1 (4) - Variance between the Trust's planned I&E Margin and its actual I&E Margin year to date

Use of Resources Rating 1 1 (5) - Distance from the Trust's agency spend cap

Appendix 1: Income and ExpenditureIn Month Year to Date Year - 2017/18 Average Monthly Run RatesPrior Year to Date

N.B. In Budget and Actual Columns, Income is shown in brackets, Costs are without brackets. In Variance Columns, Red is an Adverse Variance and Black a Favourable Variance.

(2) - Capital Debt Cover Ratio = revenue available for debt servicing (EBITDA plus interest receivable) divided by annual debt (PDC Dividends, Loan repayments, Loan interest)

-15-10

-505

10152025


1.1 Liquidity Ratio 2017/18 (1)

-1

1

3

5

7


1.2 Capital Debt Cover 2017/18(2 )

-3%

-2%

-1%

1%

2%

3%

4%


1.3 I&E Margin 2017 /18 (3)

-2%

-1%

0%

1%

2%

3%


1.4 Variance from plan (4)

-35%

-15%

5%

25%

45%


1.5 Agency Spend Variance to cap 2017 /18 (5)

4

3

2

1

Actual

7 | P a g e

Appendix 2: CIPs, Agency, Cash and Debt

CIPs: The Trust has delivered £7.7m of savings YTD, £2.1m behind the full list of schemes identified but only £0.1m behind the YTD NHSI plan. The forecast CIP delivery is £8.9m which is £0.4m ahead of the NHSI plan but £1.9m behind the full list of schemes identified. However this performance is largely due to overperformance on income/coding related schemes which is offsetting underpeformance on cost reduction schemes.Agency - The Trust was £446k under the £756k NHSI monthly cap in month and £41k under the medical agency spend cap in month, although the Trust is £132k adverse to the medical agency cap YTD. Total agency spend was lower than December, with reductions across Cancer and Clinical Services. However December did have a small over accrual so it is unclear if this reduction is recurrent. Private Care was over their monthly cap in month due to high nursing costs, particularly in Wiltshaw, outpatients and GH. Cash - Cash was £37.8m at month-end, £20m ahead of plan. Strong performance, working capital, delays in capex and a favourable opening position drove this variance.Debt - Trade receivables have decreased £0.8m in month, largely due to a reduction in NHS receivables as NHSE have paid Q1 overperformance (£2.5m) offset by invoicing for Q4 NMET funding. PP debt reduced by £0.4m in month but has increased £2.6m YTD.

£- £5.0

£10.0 £15.0 £20.0 £25.0 £30.0 £35.0 £40.0 £45.0

2.3 Cash Balance

Actual Forecast Plan

£14

.6

£13

.9

£14

.2

£15

.7

£21

.0

£22

.0

£22

.8

£18

.1

£19

.7

£18

.0

£17

.9

£16

.5

£15

.8

£22

.1

£13

.5

£13

.8

£13

.2

£17

.7

£12

.3

£13

.3

£13

.3

£17

.4

£18

.7

£15

.6

£-

£10.0

£20.0

£30.0

£40.0

£50.0

£60.0

£70.02.4 Debtors - Aging over time

>365 90-365 30-90 0-30

£0.0

£2.0

£4.0

£6.0

£8.0

£10.0

£12.0


£m 2.1 Performance against Efficiency Programme

Planned todeliverYTD Gap tocatch upDelivered

NHSI target £-

£100

£200

£300

£400

£500

£600

£700

£800

£900 £k 2.2 Agency Spend by Division against NHSI CapOther Private PracticeCancer Services Community ServicesClinical Services Cap

8 | P a g e

Appendix 2: CIPs, Agency, Cash and Debt

CIPs: The Trust has delivered £7.1m of savings YTD, £2.3m behind the full list of schemes identified but only £0.5m behind the YTD NHSI plan. The forecast CIP delivery remains £1.1m ahead of the NHSI plan (£1.3m behind the total list of identified schemes). However this performance is largely due to overperformance on income/coding related schemes which is offsetting underpeformance on cost reduction schemes.Agency - the Trust was £231k under the £756k NHSI monthly cap in month but £15k over under the new Medical Agency spend cap in month. Total Agency spend was £36k lower than Nov driven by reduction in spend in clinical services offset by increases in spend in Cancer services and Community, although both were below monthly cap in month. Private care was over their monthly cap in month due to high nursing costs particularly in Wiltshaw, outpatients and GH1 &2. Junior Doctor spend continues to be lower than previously as the new rotas have been filled. Cash - Cash was £36.1m at month-end, £22m ahead of plan. Strong performance, working capital and a favourable opening position drove this variance.Debt - Debtors increase £3.4m to £59.1m in December. NHS debt increased £4.7m in month due to NHS England overperformance and £2m RMP funding due from Sutton CCG. Non-NHS debt decreased £0.1m in December £4.3m YTD as old debts were cleared with Sphere, the ICR and LBS. PP debt decreased in month £1.1m, although has increased YTD. The in month decrease is a reduction in Embassy and UK sponsored debt.

£- £5.0

£10.0 £15.0 £20.0 £25.0 £30.0 £35.0 £40.0

2.3 Cash Balance

Actual Forecast Plan

£19

.3

£14

.6

£13

.9

£14

.2

£15

.7

£21

.0

£22

.0

£22

.8

£18

.1

£19

.7

£18

.0

£17

.9

£19

.9

£15

.8

£22

.1

£13

.5

£13

.8

£13

.2

£17

.7

£12

.3

£13

.3

£13

.3

£17

.4

£18

.7

£-

£10.0

£20.0

£30.0

£40.0

£50.0

£60.0

£70.02.4 Debtors - Aging over time

>365 90-365 30-90 0-30

0

2000000

4000000

6000000

8000000

10000000

12000000


£m 2.1 Performance against Efficiency Programme

Planned to deliver

YTD Gap to catch up

Delivered

NHSI target

£-

£100

£200

£300

£400

£500

£600

£700

£800

£900 £k 2.2 Agency Spend by Division against NHSI CapOther Private Practice Cancer ServicesCommunity Services Clinical Services Cap


Date of Meeting:

21st March 2018

Agenda item 6.4.

Title of Document: Financial Plan 2018/19

To be presented by

Chief Financial Officer

Executive Summary This paper provides an update to the Board on the progress of Business Planning for 2018/19, and the proposed budget for 2018/19. A paper was presented at Audit and Finance Committee (AFC) on 21 February 2018 and this paper sets out changes to the plan since that time. Recommendations The Trust Board is requested to: • Note the progress thus far in the business planning process and the risks identified as well as submission of the plan to NHSI; • Approve the target surplus and delivery of the Control Total; • Approve the draft financial plan for 2018/19 and delegate approval for changes to this plan, as the business planning process completes, to the executive team, subject to delivery of the Control Total; and • Note the capital budgets proposed and delegate approval for the final capital plan to Audit and Finance Committee in April prior to submission to NHSI. Author: Chief Financial Officer



Financial Plan 2018/19

1. Introduction

This paper provides an update to the Board on the progress of Business Planning for 2018/19, and the proposed budget for 2018/19. A paper was presented at Audit and Finance Committee (AFC) on 21 February 2018 and this paper sets out changes to the plan since that time.

A two year plan (2017/19) was submitted to NHS Improvement (NHSI) in March 2017 with 2017/18 in detail and 2018/19 at a high level. The Trust was required to submit a draft plan to NHSI on 8th March and the version submitted to AFC, with known adjustments, was used as a basis for this. The Trust is required to submit a final detailed plan for 2018/19 on 30th April 2018.

The plan submitted in March 2017 delivered the Control Total (CT) issued by NHSI at that time. NHSI have since issued revised guidance on the CT on 6th February 2018; this reduced the surplus requirement for the Trust from £5.1m (incl. STF) to £3.2m (incl. STF).

2. Planning Context

Alongside national planning guidance and other NHS business rules (National Tariff, CQUIN), the Contract was issued to cover the two-year period from April 2017 to March 2019, thus providing a stable environment for longer-term planning within the NHS. The intention behind this was to support organisations as they worked on service quality and transformation.

The Contract was designed to include all the requirements which could, at the time, be foreseen for both 2017/18 and 2018/19 – but, should there be any significant legislative or policy changes, it would be necessary for NHS England to issue a National Variation to the Contract. There have been a number of such changes, and NHS England therefore published a National Variation containing appropriate updates to the Contract. This was signed by the Trust on 8th February 2018 along with a Memorandum of Understanding (MOU) which outlines the mutual understanding, including each parties' requirements and responsibilities, and forms the basis upon which the National Contract Variation has been signed.

The Trust is also required to agree a Local Variation to the Contract which will incorporate revisions to local requirements i.e. indicative activity and finance plans for 2018/19 by Commissioner. The deadline for agreement is 23rd March 2018.

Revised Control Totals have been issued alongside Sustainability and Transformation Fund (STF) allocations. The revision in the 2018/19 CTs

allows some flexibility in 2018/19 if the Trust is meeting or exceeding the 2017/18 CT. The Q3 forecast is for a surplus of £11.9m excluding STF (£12.7m on a CT basis after adjusting for donated asset income/depreciation). The CT has also been adjusted for the change in CNST premiums. A further £650m of STF is now available to the sector in addition to the £1.8bn previously allocated for 2018/19 and this has been allocated across providers. The changes to the control total are shown below:

£’m 2018/19 Control total (incl. £1.8m STF)

5.1

Adjustments to CT incl. CNST, risk reserve and 2017/18 flexibility

(2.64)

Additional STF 0.75 Revised Control Total (incl. STF) 3.2 Revised Control Total (excl. total STF) 0.6

An NHS England and NHSI oversight process provides a unified interface with local organisations to ensure effective alignment of CCG and provider plans.

The planning process has been approach in two ways, “top-down” high level plan based on Q2 and Q3 forecasts alongside a detailed “bottom-up” process using the quarterly Business Planning rounds to develop plans delivering the CT by year-end and informing the final plan for the Board. The Trust needs to deliver a CIP target of c.3% which has been allocated to the clinical and non-clinical divisions. This target is in addition to funding any investments/cost pressures identified through the quarterly meetings.

3. Business Planning Process

The top down plan has been developed from the Q3 forecast. The detail of this process can be found in Section 4 below.

The 2017/18 Q3 forecast shows a £11.3m favourable variance against the CT. This improvement against plan is predominantly due to net over-performance in Private Care (£4.1m) and non-recurrent movement in provisions and deferred income (£6.8m) with over-performance in NHS income largely offset by additional expenditure in the main divisions.

Internally, the quarterly Performance Review Group (PRG) meetings have been continuing throughout the year. At these meetings, each division’s financial position is reviewed in more detail and shared with the Executive Team. These meetings form the basis of a rolling business planning cycle:

• At each quarterly meeting, the underlying (normalised) run rate of expenditure and income will be reviewed with a high level view of efficiency opportunities.

• The forecast for the following four quarters will be reviewed, not just the period until the year end.

• The impact of the transformation board themes will be considered as well as any approved business cases. Any unavoidable cost pressures will also be highlighted in this meeting.

• The financial position will be triangulated alongside workforce and activity.

• The Q3 PRG meetings are extended to two hours and fulfil the first full review of the plans for the following year. Detailed efficiency schemes will need to be in place, preferably ready to go ahead of the new financial year.

• A follow up meeting has been scheduled to finalise the plans for 2018/19. These meetings will all take place ahead of the final plan being submitted to the Board.

The aim of the Q3 and follow up meetings is to develop the detail behind the high level “top-down” plan to inform the final plan for Board review in March.

Outside of the quarterly meetings there should be no changes to budgets unless a business case is approved. All business cases valued >£100k revenue and/or capital investment are now reviewed by Financial Strategy Group (FSG) and therefore major changes to the current budget will be through FSG year round and not in separate Business Planning/Quarterly PRG meetings. Business cases valued <£100k will still require COO and ADF sign off and will be reported to FSG.

The Quarterly Performance Review Panel will also act as the Business Planning Panel, leading the process and reviewing plans developed by Directors for final approval by FSG, AFC and the Board in March. This Panel will include the COO, CFO, Director of Workforce and will consult with the Medical Director and Chief Nurse on all efficiency schemes and proposed changes to service.

Divisions are being encouraged to work collaboratively on efficiency and development schemes as well as with Procurement on supply savings. The Workforce team are also supporting on staffing levels and restructurings.

4. Income & Expenditure

4.1.Plan Presented to Audit and Finance Committee

2017/18 Q3

Forecast*

2018/19 Draft plan AFC 21 Feb 18

AFC Plan vs.

Forecast

£'000 £'000 £'000 NHS acute activity income 187,042 195,645 8,603 Community services income 20,750 20,119 (631) Private patient income 102,945 110,449 7,504 Total income from patient care activities 310,737 326,213 15,476

Research and development 24,892 25,092 200 Education and training 9,127 5,972 (3,155) Donations / grants for the purchase of capital assets 6,685 9,333 2,648

Charitable contributions to expenditure 12,644 10,461 (2,183) Sustainability and Transformation Fund (STF) 13,565 2,597 (10,968)

Other 26,128 25,938 (191) Total other operating income 93,042 79,393 (13,649)

Total Operating Income 403,780 405,606 1,827

Employee expenses 209,639 223,710 14,071 Drugs costs 69,576 73,832 4,255 Clinical and non-clinical supplies and services 36,412 37,113 701

Other 40,418 43,266 2,848

Total Operating Expenditure 356,045 377,920 21,875

Operating Surplus 47,734 27,686 (20,048)

Depreciation/Amortisation 15,508 15,521 13 Net Finance expense 70 35 (35) PDC dividends payable 3,981 4,186 205 SURPLUS FOR THE YEAR (PRE-IMPAIRMENT) 28,175 7,944 (20,232)

Impairment 856 0 (856)

SURPLUS 27,319 7,944 (19,376)

Remove capital donations/grants I&E impact (1,904) (4,552) (2,648)

Adjusted financial performance surplus/(deficit) 26,271 3,392 (22,879)

Control totals for planning years (incl. STF) 3,432 3,174 (258) Performance against control total 22,839 218 (22,621)

Control Total (excl. STF) 12,706 795 (11,912)

*note RM Partners has been excluded from FOT and draft plan

Activity and Income

NHS Acute Income

The income plan is based on Month 6 extrapolated for full year (as per contracting guidance). The two year tariff allowed for a 0.1% uplift in prices which has been applied. Other income changes modelled include:

• Increase in CCU prices for CCGs (removing the in-year transitional impact);

• Limited growth based on trends: o Inpatient admissions (excluding surgery) will be contained

at current volumes, surgical activity is expected to increase by 1%

o Outpatients at 1% o Chemotherapy delivery across all settings at 2.5% o Referrals growth at c.4% o Rehabilitation attendances will increase by 1% o Radiotherapy will not grow as reduced fractionation

treatment offsets prevalence • Income for approved business cases (e.g. Acute Oncology Service,

planning CT, MRI), associated costs are also included; • Indicative values for drug increase in relation to both inflation and

clinical practice. As these are mainly pass-through funded this has a net nil impact on the surplus.

Community Services Income

2017/18 in year contract variations not anticipated at the start of the year included transfer of the SALT & OT services (£0.4m) and reduction in the LBS contract (£0.1m). The other movement from 2017/18 is the loss of podiatric surgery. The Sutton Health and Care project is not expected to significantly impact on Community income in 2018/19. No other significant variations to the contracts are expected in year.

Private Patient Income

Private Patient activity and income is targeted to increase year on year as per the Trust’s strategy. The 2017/18 forecast income is £102.9m which is a 12% increase on 2016/17 and £5.3m ahead of the 2017/18 plan. A c.7% increase has been planned for 2018/19 driven by a number of identified business cases and initiatives (e.g. additional robotic surgery and additional MRI work) as well as price increases.

Other Operating Income

The impact of RM Partners has been excluded from the forecast above and excluded from this draft plan. RM Partners is yet to finalise plans for next year and this will be included in the final plan submission to NHSI in April.

Once the RM Partners position is adjusted slight reductions in other income compared to 2017/18 forecast are due to in-year deferred income releases in research and education reflecting completion of projects and the removal of the Macmillan hotline grant funding which finishes in year.

Donations for purchase of capital assets has been based on projects/equipment currently agreed and approved by RMCC Trustees (e.g. CCRC) only.

Due to the plan meeting the Control Totals, the full Sustainability and Transformation Funding (STF) is planned to be received in 2018/19. The 2017/18 forecast is ahead of plan and therefore £11.1m of incentive STF has been included in the forecast as well as the £0.4m relating to the prior year received post accounts and the planned £1.8m giving a total of £13.6m forecast STF in year.

Expenditure

Employee expenses

Employee expenses are forecast to be £2.8m below plan in 2017/18 but expected to increase in 2018/19. CIPs will be offset with inflationary growth (funded through the National Tariff), roles required for revenue generating efficiency schemes, and approved investments (Private Care and other business cases). Any pay increase above that included in the comprehensive spending review (CSR) are assumed to be fully funded as per the NHSI guidance.

The agency cap for 2018/19 has been reduced by £2.1m and therefore a continued key focus on the pay expenditure in 2018/19 will be to maintain and continue the reduction in temporary staffing by ensuring rostering of staff is maximised; junior doctor rotas are appropriately reviewed; tight contracts for agencies are in place; and, the turnover rate of staff is reduced. The forecast for agency pay in 2017/18 is £6.5m and is below both the current year and revised 2018/19 cap.

Non-Pay expenses

Drug costs are anticipated to rise due to both price inflation but also increased NHS and Private Patient activity. The anticipated approval of a number of immunotherapy drugs by NICE will increase costs but also NHS income.

The revenue impact of the IT strategy for 2018/19 (£2.1m) has been included as a cost pressure within other costs reflecting the additional costs expected to deliver this strategy.

All other costs are expected to increase with inflation and any approved business cases but are then targeted for CIP scheme reductions. Inflation assumptions are driven by national guidance and are split by cost type. CIP schemes vary in the level of their development, from the full year effect of a number of in year schemes being quantifiable, to new schemes being

identified but not yet quantified. Procurement are targeting price savings in year with remaining CIPs being service efficiencies.

Non-operating items

The increase in depreciation compared to the original plan reflects business cases for capital investment approved in year.

Control Total

The Control Total is calculated as the Total Surplus less the impact of Donated Asset Income and Depreciation. This plan shows a reduction in this in 2018/19 reflecting the additional flexibility communicated by NHSI and the investments included in the plan.

4.2. Revised Plan

The business planning process has continued since the last AFC and has focussed on reducing run rates to bring performance in line with early parts of 2017/18 and further developing CIPs. A draft plan was required to be submitted to NHSI on 8th March 2018 and this was based on the plan reviewed at AFC and updated to reflect changes since that time.

2018/19 Draft plan AFC

21 Feb 18*

2018/19 Draft plan March 18*

Movement to AFC plan

£'000 £'000 £'000 NHS acute activity income 195,645 194,233 (1,412) Community services income 20,119 20,950 832 Private patient income 110,449 110,202 (247) Total income from patient care activities 326,213 325,386 (827) Research and development 25,092 25,759 666 Education and training 5,972 6,128 156 Donations / grants for the purchase of capital assets 9,333 9,333 0

Charitable contributions to expenditure 10,461 11,402 941 Sustainability and Transformation Fund (STF) 2,597 2,597 0 Other 25,938 26,586 648 Total other operating income 79,393 81,806 2,412

Total Operating Income 405,606 407,191 1,585

Employee expenses 223,710 222,153 (1,557) Drugs costs 73,832 75,741 1,909 Clinical and non-clinical supplies and services 37,113 40,427 3,314 Other 43,266 40,755 (2,511)

Total Operating Expenditure 377,920 379,075 1,155

Operating Surplus 27,686 28,116 430

Depreciation/Amortisation 15,521 16,680 1,159

Net Finance expense 35 106 71 PDC dividends payable 4,186 4,054 (132)

SURPLUS FOR THE YEAR (PRE-IMPAIRMENT) 7,944 7,276 (667)

Impairment 0 1,250 1,250

SURPLUS 7,944 6,026 (1,917)

Remove capital donations/grants I&E impact (4,552) (3,957) 595 Adjusted financial performance surplus/(deficit) 3,392 3,320 (72)

Control totals for planning years (incl. STF) 3,174 3,174 0 Performance against control total 218 146 (72)

Control Total (excl. STF) 795 723 (72)

*note RM Partners has been excluded- to be included prior to final submission to NHSI

Activity and Income

NHS Acute Income

NHS Acute income has been reduced to reflect the known commissioner QIPP schemes. At the time of AFC commissioners had not provided any project initiation documents (PID) for QIPP projects and the income plan has now been reduced to reflect the value of schemes where commissioners have provided a PID.

Community Services Income

Community services income has increased reflecting full year effect of contract variations in year and any known variations for 2018/19.

Private Patient Income

There have been no material changes to Private Patient income plans since AFC.

Other Operating Income

Research and development increases reflect more detailed planning in the clinical units. Charitable contribution to expenditure have increased by £0.9m due to a number of areas including income for GI late effects not received in 2017/18 as staff not in post, and expected increases in research and development charitable grants which is fully offset by additional pay costs.

Employee Expenses

Employee expenses have reduced by £1.5m which reflects additional staff costs for research and development as set out above offset by reductions elsewhere. The follow up business planning meetings have focussed on reducing pay run rates to bring performance back in line with run rates in the early part of 2017/18 as despite an increase in substantive posts the bank and agency has not reduced to compensate for this. There is c£2m CIP expected to

be delivered via reductions in temporary staffing including bank that will be worked up in full over the coming weeks.

Non pay Expenses

Drug increases reflect the changes in drug use in the later part of the year. At AFC the drugs planning was based on the first six months of the year and this reflects trends in Months 7-10 where the change is expected to be recurrent.

Clinical and non-clinical supplies have increase by £3.3m due to additional in year pressures and growth forecast in both NHS and Private care while other costs have reduced £2.5m as plans have been refined.

There is c£1m of CIP expected to be delivered through a number of non-pay reductions such as reducing internal catering spend and reduction in maintenance contracts reflected in these values which will be worked up in full over the coming weeks. As CIPs have been further developed there has been some movement in non-pay categories between the top-down plan and the current plan.

Non-Operating Items

Increases in depreciation reflect the additional capital spend planned for 2018/19 not fully reflected in the plan at AFC as phasing has been refreshed. PDC forecast has been updated to reflect expected net relevant assets and impairment is forecast reflecting backlog maintenance spend (note impairments are excluded from Control Total).

5. Capital Plan

In line with the refresh of the Trust’s five year strategy a review of capital priorities and equipment replacement requirements for the next five years is underway alongside an assessment of affordability.

The Trust’s source of funds for capital over the next five years are internally generated depreciation and any surplus in excess of plan; STF funding; loans; PDC; any prior year underspends; and, charitable donations.

Funding £’000 2018/19 2019/20 2020/21 2021/22 2022/23

5 year total

Depreciation (net of loan repayments) 8,413 9,600 10,212 10,128 10,350 48,703

Surplus (exc. Donated Asset Income, STF) 577 1,300 0 0 0 1,877

Surplus in excess of 2017/18 plan 11,121 0 0 0 0 11,121

STF (2017/18 & 2018/19) 18,132 0 0 0 0 18,132

B/F Underspends 3,427 0 0 0 0 3,427 PDC 2,531 0 0 0 0 2,531 Loan 4,300 9,700 500 0 0 14,500 Total before Donated 47,301 22,300 10,212 10,128 10,350 100,292 Donated 9,333 16,563 28,609 20,060 2,050 76,615 Total 56,634 38,863 38,821 30,189 12,399 176,906

The following key assumptions have been made: • Surplus: 2018/19 assumes revised CT (excluding STF). Assume the

same CT for 2019/20 but that additional STF is non-recurrent. 2020/21 onwards assume breakeven position requiring an improvement in the underlying position (including through the Private Care diagnostic facility) to absorb the impact of the additional IT revenue costs.

• Depreciation: Assumed annual depreciation of c.£11m plus additional depreciation as a result of the Private Care diagnostic facility, the aseptic unit and from implementation of the IT strategy.

• Assumes pound for pound additional STF in 2017/18 for exceeding the CT in line with national guidance. The above is based on Q3 forecast of surplus in excess of plan by £11m.

• Donated is based on known RMCC commitments only (CCRC and medical equipment grants approved to date).

This initial assessment of funding, results in the Trust being able to deliver £100m investment over the five years to 2022/23.

A full list of capital requirements (excluding those with funding committed by RMCC) has been identified over the five year period and this shows a funding gap of £40.1m. This has then been prioritised to reflect known commitments (currently approved schemes) and priority schemes where a business case is currently in development (e.g. IT strategy) which shows once these priority schemes are funded there is £38.7m to be invested into other Capital projects over the five years.

Internal 2018/19 2019/20 2020/21 2021/22 2022/23 5 year total

Total Committed/prioritised Estates 5,904 4,668 1,250 1,250 1,250 14,322 PP 400 7,220 4,050 0 0 11,670 Medical Equipment 3,803 0 0 0 0 3,803 IT 7,415 15,979 7,800 294 250 31,739 Total committed/prioritised

17,523 27,867 13,100 1,544 1,500 61,534

Balance/(Gap) vs. committed/prioritised

30,979 (7,267) (2,388) 8,584 8,850 38,758

To be prioritised Estates* 5,000 6,000 0 0 0 11,000 PP 1,800 0 0 0 0 1,800 Medical Equipment 9,857 9,989 11,832 24,948 5,784 62,410 IT 655 750 750 750 750 3,655 To be prioritised total* 17,313 16,739 12,582 25,698 6,534 78,865 Total internal 34,835 44,606 25,682 27,242 8,034 140,400 Total Balance/Gap. 13,666 (24,006) (14,970) (17,114) 2,316 (40,108) *Excludes any amount for Bud Flannigan refurbishment, stem cell laboratories or potential Dovehouse Street refurbishment for Private Care.

The majority of the capital schemes to be prioritised relate to equipment with the other key scheme relating to theatres in Chelsea. The medical equipment list is to be reviewed and prioritised by the Executive Team. It is proposed the final list of prioritised schemes is reviewed and discussed at the next AFC in April prior to the final submission of the plan to NHSI.

The above plan is a significant increase on the 2017/18 internally funded programme and is largely driven by the significant investment required in IT.

Key schemes, other than IT, are the pharmacy expansion (£2.4m 2018/19, £3.4m 2019/20) 3rd Linac replacement and associated infrastructure (PDC funded equipment), PET scanner replacement in Chelsea (£1.3m) and the Private Care diagnostic centre (£11.6m 2018/19 to 2020/21).

0

5,000

10,000

15,000

20,000

25,000

30,000

2017/18 2018/19 2019/20 2020/21 2021/22 2022/23

Approved/prioritised schemes (excl. donated)

IT PP Estates Medical Equipment

6. Balance Sheet

The forecast March 2018 balance sheet is shown below. There is a forecast cash balance of £30.7m which is an improvement on March 2017 driven by additional STF; delays in capital spend, largely due to timing; over performance in activity; and, recover of some older debtor balances.

The Balance Sheet for 2018/19 is planned to remain largely similar to the March 2018 forecast. The additional capital spending planned for 2018/19 set out above is reflected in the additional PPE.

The Cash position is expected to remain strong (see section 7 below) due in part to the additional STF expected to be paid in quarter two.

A reclassification is required prior to final submission to NHSI as there should be a reclassification of £6.3m between NHS Trade receivables and accrued

STATEMENT OF FINANCIAL POSITION Actual Forecast Plan

31/03/2017 31/03/2018 31/03/2019

Year Ending Year Ending Year Ending

£'000 £'000 £'000Non-current assets

Intangible assets 1,528 2,706 3,291Property, plant and equipment: other 181,527 181,305 190,846Investments in associates and joint ventures 2,097 2,097 2,097Total non-current assets 185,152 186,108 196,234

Current assetsInventories 4,256 4,843 4,843Trade and other receivables: NHS receivables 21,652 17,785 14,430Trade and other receivables: non-NHS receivables 54,222 65,123 58,511Cash and cash equivalents: GBS/NLF 21,096 30,780 35,035Total current assets 101,226 118,531 112,819

Current liabilitiesTrade and other payables: capital (2,080) (2,080) (2,080)Trade and other payables: non-capital (55,696) (55,474) (49,487)Borrowings (2,477) (2,477) (2,477)Other liabilities: deferred income (28,313) (17,920) (17,921)Total current liabilities (88,566) (77,951) (71,965)Total assets less current liabilities 197,812 226,688 237,088

Non-current liabilitiesBorrowings (13,632) (11,654) (13,477)Provisions (20) (20) (20)Total non-current liabilities (13,652) (11,674) (13,497)Total net assets employed 184,160 215,014 223,591

Financed byPublic dividend capital 101,446 104,981 107,512Revaluation reserve 8,023 8,023 8,023Income and expenditure reserve 74,691 102,010 108,056Total taxpayers' and others' equity 184,160 215,014 223,591

income. Non NHS Debtors are expected to increase as Private patients income increases, however this is offset by expected payment from BUPA which is artificially high in March 18 due to the new BUPA contract resulting in delays in payment.

Non-current borrowings increases as the new loan approved in 2017/18 is drawn down in line with the drawdown profile agreed in the loan application.

7. Cash Flow

STATEMENT OF CASH FLOWS Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan PlanApr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Cash flows from operating activitiesOperating surplus/(deficit) 428 428 428 1,641 2,557 (193) 2,557 1,641 (1,108) 1,641 (193) 378Depreciation and amortisation 1,372 1,372 1,372 1,439 1,505 1,308 1,505 1,439 1,243 1,439 1,308 1,372Impairments and reversals 1,250Movement in working capital(Increase)/decrease in trade and other receivables (255) (258) (807) 11,710 (1,257) 193 (258) (258) 193 387 (257) 837Increase/(decrease) in trade and other payables 12 10 16 (3,016) (42) (11) (35) (19) (2,959) (15) 20 46Increase/(decrease) in other liabilities 4,499 (1,103) (1,609) 4,427 (1,177) (2,040) 3,683 (2,096) (2,299) 3,629 (2,206) (3,707) Net cash flow from operating activities 6,056 449 (600) 16,201 1,586 (743) 7,452 707 (4,930) 7,081 (1,328) 176

Cash flows from investing activitiesInterest received 7 7 7 8 8 7 8 8 7 8 7 7Purchase of PPE (1,540) (924) (1,916) (1,144) (1,600) (2,416) (2,018) (2,474) (2,465) (2,530) (3,136) (5,891) Net cash flow from investing activities (1,533) (917) (1,909) (1,136) (1,592) (2,409) (2,010) (2,466) (2,458) (2,522) (3,129) (5,884)

Cash flows from financing activitiesPublic dividend capital received 2,531Loans Received from Department of Health 1,200 3,100Loans Repaid to Department of Health (1,239) (1,238) Interest paid on Loan (97) (88) PDC dividend Paid (2,003) (2,053) Net cash flow from financing activities 2,531 1,200 (1,336) (2,003) 3,100 (1,326) (2,053)

Increase/(decrease) in cash and cash equivalents 4,523 (468) 22 16,265 (1,342) (5,155) 5,442 (1,759) (7,388) 7,659 (5,783) (7,761) Cash and cash equivalents at start of period 30,780 35,303 34,835 34,857 51,122 49,780 44,625 50,067 48,308 40,920 48,579 42,796Cash and cash equivalents at end of period 35,303 34,835 34,857 51,122 49,780 44,625 50,067 48,308 40,920 48,579 42,796 35,035

The cash position is expected to remain strong throughout the year supported by a good opening position and payment of the STF incentive for 2017/18 expected in July 2018 resulting in a peak cash position of £51m in that month. The STF is planned for use over the next five years to support the capital plan and in particular the IT strategy in the next three years and therefore the cash position should remain reasonably high throughout 2018/19. It is also assumed we use some STF to fund working capital payments to reduce creditors in July and December 2018.

The movements in other liabilities reflects the nature of these balances where payments one quarter in advance (predominantly from RMCC and Health Education England) are accounted for as deferred income which is then unwound over the following quarter.

The loan agreed in 2017/18 for £15m will be drawn down over the next three years with £4.3m in 2018/19 with drawdowns in July 2018 and January 2019 of £1.2m and £3.1m respectively. The drawdown schedule was based on the initial forecast capital flows for loan funded projects and will be reviewed as required to ensure the cash inflows match the capital spend. The loan repayments in August and February reflect the repayments of the £21m loan taken out by the Trust in September 2013.

8. Risks

Short Term Risks £ Risk Rating

Mitigation

2018/19 NHS Commissioner Contracts Risk that developments are not funded by the Commissioners. In addition Commissioners have proposed c£3.4m of QIPP but to date have only supported £1.1m with PIDs, there is a risk that Commissioners will successfully identify further QIPP schemes thereby reducing NHS income.

<£3m 15

The Trust has put forward business cases for both robotic surgery and the Macmillan hotline that both demonstrate savings for the Commissioners. Should additional QIPP be identified the Trust would look to reduce costs aligned with the QIPP schemes.

Private Care Strategy Risk that growth is not delivered Risk to cash flow as growth expected through shift from UK sponsored to embassy activity

<£5m 15

Strategic plan developed and marketing plan agreed. International Patient Manager in place to develop relationships with Embassies to improve payment. Monthly review of debt in Performance Review Group.

Genetics Tender Income & costs in relation to genetics tender is uncertain. Capital requirement not currently known.

<£2.0m 12

Pricing prudently via tender process to mitigate any risk over income for the service. Business case approval required prior to any new expenditure being incurred.

PET tender Risk that costs associated with implementation of new PET service (in particular IT costs) are in excess of those included in the bid. Risk other partners cannot deliver capacity agreed thereby leading to RMH incurring fines as lead contractor. Risk that activity is in excess of the levels modelled in the bid triggering additional activity at the marginal rates.

<£0.5m 15

Clear project governance in place with finance/contract, operational and IT workstreams and clear project lead. Contracts with partners being agreed mirroring the performance framework in place between RMH and NHS England such that fines will be transferred where appropriate. Pricing within the bid ensured the marginal rate was still at a breakeven level and activity was stress tested during the bidding process

Impact of RCF RCF is linked to BRC funding levels and therefore expected to reduce following the reduction in BRC income.

<£1.0m 15

Plans to mitigate this through increased funding from alternative sources as well as cost efficiencies so volume of research does not significantly decline.

Junior Doctor position Impact of the reduction in the core medical trainees due to changes in the national focus of training for junior doctors.

<£0.5m 9

Junior Medical Workforce Plan in development with a contingency set aside to fund this.

Pay Cost Inflation Pay cost inflation has been factored in aligned with national planning assumptions. It is assumed any pay award in excess of that assumed in the CSR would be funded. There is a risk that as c32% of Trust income is not from NHS sources any uplift funded via national tariff would not be sufficient to cover the inflationary impact across all staff.

<£2m 9

Should this scenario arise the Trust would look to mitigate through negotiations in non NHS contract prices and through further controls on pay spend (e.g. vacancy freezes if required).

Temporary Staffing Costs The Trust has been notified of a reduction in the agency cap for 2018/19 to £6.89m. Forecast for 2017/18 is £6.5m. CIPs have been identified to reduce usage and rate reduction. Pressure to maintain this position and remain below cap.

<£0.5m 9

Controls on agency usage continue with close monitoring in both Performance Review Group and the Temporary Staffing Board. Adherence to price caps being enforced with agencies, internally and liaison with London Trusts and NHSI to maintain the wider position.

Undeveloped CIP schemes Not all CIP schemes have been fully developed.

<£3.0m 6

Regular meetings with all divisional heads are occurring to drive the development of these plans. The Exec have agreed additional expenditure controls will be in place for at least quarter 1 in order to reduce the spend in line with the budget. This has been split as £2m for bank spend and

£1m for additional non-pay reductions.

RM Partners Funding for RM Partners is anticipated to be lower in 2018/19 as initial Vanguard funding ceases leaving RM Partners with only CTF and Cancer Alliance funding. The risks are that costs for the Alliance or individual projects may exceed funding and RMH may be responsible for the shortfall.

<£2.0m 6

Detailed business planning underway by RM Partners to ensure running costs do not exceed available funds. Initiative budgets to be reviewed by finance and performance monitored on a monthly basis. Contingency to be built into budgets to support overruns. Initiatives to be agreed on a fixed cost basis so RMH will not accept activity risk.

There are some key medium term financial risks which the Board needs to be aware of too in connection with signing the financial plan for 2017/18.

Medium Term Risks Mitigation

Capital Prioritisation Internally financed capital is insufficient to fund all capital requirements.

Capital requests are collated and measured against a prioritisation matrix to assess selection for funding. Charitable funds are being sought for specific items of Medical Equipment as well as the funding from National Programmes particularly for IT.

IT strategy Risk that the procured solutions cost more than the amount budgeted; and/or that the supplier executes unexpected changes that drive up the cost. £8m of revenue per annum (£4m operating cash flow) required.

Requirements have been specified in detail; and dialogue will ensure that they are well-understood – limiting scope for post-contract change. Dedicated team will need to be in place to deliver a transformation work stream and clear assessment of affordability in advance of the Full Business Case being agreed.

9. Recommendations

The Trust Board is requested to: • Note the progress thus far in the business planning process and the

risks identified as well as submission of the plan to NHSI; • Approve the target surplus and delivery of the Control Total; • Approve the draft financial plan for 2018/19 and delegate approval for

changes to this plan, as the business planning process completes, to the executive team, subject to delivery of the Control Total; and

• Note the capital budgets proposed and delegate approval for the final capital plan to Audit and Finance Committee in April prior to submission to NHSI.


Date of Meeting:

21st March 2018

Agenda item 7.1.

Title of Document: Board Assurance Framework

To be presented by

NEDs Professor Dame Janet Husband and Ian Farmer

Executive Summary The Board Assurance Framework (BAF) sets out the Trust’s strategic objectives and identifies risks in relation to each strategic objective along with controls in place and assurances available on their operation. Recommendations The Board is asked to:

• Review the designated items for Board and note relevant updates from the Board Sub-Committees (where applicable);

• Consider any other objectives and risks not already identified.

Author: Trust Secretary



Assurance Score of objective being delivered (1 – 6) 1-2 (Red) low assurance, 3-4 (Amber) Medium value assurance, 5-6 (Green) high value assurance Grey- not possible to make an assessment

Board Assurance Framework March 2018

1.0. Purpose

The purpose of the Board Assurance Framework (BAF) is to set out the Trust’s strategic objectives and identify risks in relation to each strategic objective along with controls in place and assurances available on their operation.

2.0. RM Board Assurance Framework

Appendix 1 presents the strategic objectives for the Trust, some of which have been identified from the four key themes identified in the Strategic Plan 2014/15–2018/19. Detailed operational and corporate risks can be found in The Royal Marsden Risk Register which is presented to the Quality, Assurance and Risk Committee. 3.0. Review and Approval of the Board Assurance Framework Relevant risks and assurances contained within the Board Assurance Framework are reviewed and monitored by the two Board Sub-Committees, the Audit and Finance Committee (AFC), and the Quality, Assurance and Risk Committee (QAR) as well as the Board of Directors. The Trust Board of Directors receives the Board Assurance Framework at their meetings in March, June, September and November. The Chairs of the Committees are requested to highlight any concerns and / or relevant changes to the Board’s attention. Any decisions and actions arising from the Committee’s review of their assigned objectives / risks are to be noted in the ‘Board level decisions and actions’ column. Those consistently rated green for a period of twelve months from the effective date will be removed from the BAF. Please note that the effective date will reset if the risk against the objective is rated higher than green to restart the twelve month monitoring period. Recent amendments / updates to the Board Assurance Framework are highlighted in yellow for ease of reference.


EXISTING Appendix 1: The Royal Marsden Board Assurance Framework

Strategic objectives Objectives 2017-18 and Lead Director/ Risk owner

Effective date

Assurance score

Key Controls (what controls/systems are in place to assist in securing delivery of the objective)

Risks against achieving the objective

Relevant Assurances Progress against achieving actions.

Owner Board Level decisions and actions

1. Innovation and precision medicine- Clinical sustainability/Value for Money

1.1. Delivery of Biomedical Research Centres research strategy with reduced funding award. Director of Clinical Research/COO

28/06/2017 Amber Joint Research Strategy launched July 2016. BRC awarded £42.5m December 2016 following submission of a revised plan, showing the impact of the reduced funding.

Oversight of progress at weekly Clinical Research Executive (CRE), chaired by Director of Clinical Research and BRC Steering Board. Efficiency plans in place

All themes were allocated a reduced budget in 2017-18. Each theme lead has been instructed to prioritise research and seek alternative sources of funding where possible. Grant manager appointed to facilitate increase in grant submissions R&D business planning for 18-19 underway. Financial performance of the wider clinical research programme will be monitored at quarterly Clinical Research PRG DDU open book financial analysis remains incomplete

Board



Effective date

Assurance score





1.2. Maintaining top quartile research performance. Helping to ensure the UK is globally competitive as a centre for clinical trials. COO

28/06/2017 Green Fortnightly Trial Set Up meeting in place to plan/manage capacity for clinical research delivery Quarterly reviews of all research delivery group financial and operational performance, including accruals and 70 day target. No change.

Oversight of progress at weekly Clinical Research Executive, chaired by Director of Clinical Research Monthly review of research targets at Performance Group, chaired by Director of Performance Reported on Trust Board scorecard. Research performance metrics are included as part of the board scorecard review.

Annual Review of R&D Performance and targets to be scheduled at future Board.

RM has been informed by NIHR that there will be no financial penalty

Maintain current oversight of performance CRE and monthly Performance Group monitoring

Board

1.3. Providing research leadership in cancer for local clinical research networks. COO

28/06/2017 Amber Assistant Dir. of Clinical Research attend at CRN Partnership Board and Finance Group. Professor Stan Kaye continues as Director of Research in the RM Partners Cancer Vanguard

Decreasing CRN financial allocation; control by South London CRN

Network study accrual performance is reviewed at RM Clinical Research Leads meeting and Clinical Research Executive; both chaired by Director of Clinical Research Best time to target

It is important strategically that RM continues to perform well with network studies (currently deliver 51% of South CRN cancer research) but at risk due to decreasing funding

Board



Effective date

Assurance score





performance in South London CRN Flexible workforce model enforced by NIHR/south London CRN. Assistant Director R&D managing CRN staff

over the last 4 years. Funding model agreed for 2018-19 continues on activity based funding and the opportunity to apply for research contingency funds.

1.4. Achieving optimal scale and impact through strengthening academic and research ways of working. RM /ICR CEOs

28/06/2017

Red The Joint Working Agreement aims to cover the following areas:

• Governance • Workforce • Intellectual property &

revenue sharing • Finance and

estates/fundraising • Marketing/communications • Information

This work is now long overdue but business as usual research activity continues. RM continues to make research appointments.

Oversight of progress through the Board. Joint Executive Group consisting of Royal Marsden/ICR, Chief Executive Officer, Chief Operating Officer and Financial Director established June IP Committee established November 2016. Both of these have been paused until formal agreements in place. Joint estates working group established.

JWA (including IPA) principles to be re-drafted and agreed. Next steps to be discussed at Board 21 March Estates re-charging work near completion

Board Agreed at RM / ICR Board to Board meeting that a joint memorandum will be developed.

2. New systems of care - Clinical and operational sustainability

2.1. Systems leadership for acute cancer care. CEO and MD-RMP.

28/06/2017

Amber Further to award of programme funding for 16/17, Managing Director appointed October 2016. Cross vanguard oversight group in place, monthly RMP Exec Board comprising of CEs established for NW & SW London, and Clinical Oversight Group across RM Partners meets monthly. KPMG appointed to deliver some technical planning aspects, with weekly contract monitoring meetings in place.

Oversight of progress through the RM Executive Board up to the RM Board. External oversight by NCM team and National Cancer Team – formal schedule of quarterly review meetings in place. KPMG appointed August 2016 to lead the design,

RM Partners Executive Board meets monthly. Timetable and programme in place to deliver shadow lead provider model during 2017/18. Vanguard risks and governance issues, to be discussed at Board

Board

Agreed at AFC on the 1.11.17 that RMP’s finance lead will provide relevant assurances to the AFC on the issue of Board accountability regarding financial



Effective date

Assurance score





Further bid made to National Cancer Team for Transformation funding for 2017/18 and 2018/19 on behalf of both NWL and SWL STPs. Funding for two years confirmed in June 2017, and transformation programme commenced. RM Partners and Cancer Vanguards/Alliances accountable to New Care Models for Vanguard work, and National Cancer Programme via London NHSE and NHSI regional teams for delivery of the cancer plan. Aligns with STP and pan London plans.

modelling and implementation of the new contracting and financial model with RM. Met with NHSI, NHSE regarding joint assurance process and national governance arrangements for new care models. To work in partnership with the regulator to determine methodology for assurance. Vanguard funding request for £2.3m to continue activities in17/18 confirmed by NHS England in December 2016. Recovery plan under development with STPs to demonstrate recovery of the 62 day target by individual organisations, supported by RM Partners. Delivery dependent on demonstrating improvement in 62 day trajectory in order to continue to release share of cancer transformation fund. 100% of Early Diagnosis funding confirmed by NHS England for Q1/2 of 18/19 on 5/3/18.

Away day Oct ’17. Updates presented to Board and COG in Q4 2016/17.

decisions. Agreed at AFC 21.2.18 to explore whether the Trust’s internal auditors can assist in a review of RMP governance structures.



Effective date

Assurance score





2.2. Pathway redesign: creating efficient clinical pathways to improve quality and value and manage capacity. COO

28/06/2017 Amber Transformation is being managed through the Transformation Board chaired by Director of Transformation. Work plan 17-18 includes: Capacity & Efficiency

• Work programme includes:

• Outpatients • Inpatients • Medicines optimisation • 7 day working

Workforce • Sustainable medical

workforce • Multidisciplinary role

development • Quality improvement

capability Commercial opportunities

• Pharmacy • Nuclear Medicine • Potential genetics tender

Actively monitored monthly at PRG. Chaired by COO Local activity monitored through the CBUs managed by Clinical Directors & DD Cancer Services Audits have been undertaken in second opinion activity and non-elective admissions. Management of portfolio is dependent upon support of commissioners New medical model implemented in Chelsea and pilot extended to Sutton; new AOS locum Consultants appointed Non elective admission criteria has been refined. GMC (2017) indicate significantly improved feedback. Clinical Advisory Group established by MD July 2016

On-going monitoring through PRG and Transformation Board Joint RHM/RMP 62 day CWT action plan in place and being implemented and monitored through RMP and the Systems Leadership Forum.

Board

2.3 Impact of South West London STP plans and Specialised Commissioning planning

1/11/17

Red The London Specialised Commissioning Board is well established and the aim is to consolidate specialised services to improve quality & outcomes and

ESH is key referrer into the Sutton site so any reconfiguration could have an impact on referral patterns.

Renal and Cardiac spec comms workstreams being prioritised before cancer and paediatrics.

RM partners transformation bid was successful as above.

Board

See 3.2 re paediatrics



Effective date

Assurance score





decrease costs. SWL and SEL specialised commissioning board established to review specialised services across SW and SE London including cardiac, renal, paed, neuro workstreams. RM Partners and Cancer Vanguards/Alliances accountable to New Care Models and National Cancer Programme for delivery of the cancer plan and to align with STP and pan London plans

It has been agreed the cancer workstreams are being led by Vanguard/RM Partners SWL STP have refreshed the governance arrangements under the leadership of the SRO Sarah Blow.

2.4. Successful delivery of The Royal Marsden surgical strategy to ensure long term sustainability. Chief of Surgery/COO.

28/06/2017 Green Surgical planning group in place; led by Chief of Surgery. Key work streams:

• Capacity planning through optimal resource utilisation

• Off-site Private Care Diagnostics development

• Portfolio management/patient selection framework

Loss of private surgery due to other private providers and capacity constraints Risk to 62 CWT

Activity and financial monitoring by Clinical Services Division and through PRG Minimum procedures mandated by CRGs and differences in coding and analysis between providers Surgical pathways managed through Patient Tracking List meeting and escalation process in place to avoid surgical breaches.

Private Care Business Case in development to provide additional surgical capacity through Saturday operating. Consultant leave arrangements are now transparent on healthroster. Work underway to ensure maximal list utilisation during holiday periods.

Board Agreed at AFC on 1.11.17 to undertake a review of surgery, including theatre arrangements and utilisation, and report to the Transformation Board and to QAR (LB). On 15.2.18 QAR expressed an interest in undertaking a clinical visit to theatres (ES).

2.5. Development of integrated models of care across acute,

19/06/17 Red Sutton Community Services fully mobilised with refreshed KPIs.

Staff recruitment and retention continues to be a challenge, in particular

Weekly deep dive sessions in place to

Full roll out of mobile working and RiO in place November 2016

QAR QAR requested at their meeting on 15.11.17 that



Effective date

Assurance score





community and home care provision. COO and CN.

Continues challenges with recruitment and managing small teams. Multiple changes to smaller contracts being driven by commissioners. Some integration has taken place (safeguarding, home chemotherapy).

adult nursing.

support improvement with nurse recruitment and retention with involvement from nursing, community and HR . New KPI’s developed.

KPMG completed a mock inspection of Sutton Community Services and some further work on documentation of risk assessments to be completed

following relocation of staff into new sites. New Business Manager appointed to facilitate performance and delivery and management of contract. Weekly staffing level/usage monitoring. At month 4, community vacancies decreased in month. Weekly senior management team meetings in place attended by COO/CN where possible to ensure performance is maintained. Further integration is being proposed through the Sutton Health and Care business case. An alliance model has been proposed with ESH, LBS, SWL mental health trust and RMH. RMH to be a supportive partner and not a formal alliance partner.

Community Services Director Anne Howers reports back in 6 months’ time on progress made in the Division and completing the outstanding actions.



Effective date

Assurance score





3. Modernising infrastructure- Operational sustainability

3.1. Estate and planning investment for Sutton and Chelsea site COO.

1/11/17

Red RM planning contribution to Sutton Hospital campus schemes (London Cancer Hub; new acute hospital-ESH scheme) continues in parallel until Sutton Hospital site plans are defined and agreed and alongside STP planning. ESH propose land sale by Dec 2017. Major capital plans/proposals for each site being managed through the refreshed Capital Programme Board chaired by CFO; this includes the Maggie’s Centre and the Clinical Care & Research Centre at Sutton and pharmacy expansion at Chelsea.

Risk of future schemes being affordable, including Bud Flanagan and stem cell laboratory. There may be a need to increase surgical capacity in the future following completion of Harcourt House.

Seek alternative sources of funding where possible; bid for RMCC is being developed. LCH Development Framework and implications for future planning of the Sutton site. RM re-engaging with LCH and ESH plans.

New radiopharmacy at Sutton complete. Accreditation processes underway, due to be complete April 2018. Pharmacy rebuild approved at Chelsea. Access road at Sutton complete and Maggie’s on site. CCRC 1:100 plans signed off. CCRC Programme Board created to ensure CEO oversight of the whole project including workforce models, car parking and project build LCH Development Framework approved at Sept 2016 Board. ESH land sale complete with the exception of plot 2b. SOC development proceeding for new hospital at Sutton being led by SWL STP and commissioners.

AFC

3.2. To ensure a sustainable paediatric service model at RM.

19/06/2017

Amber Detailed submission to the Specialist Tertiary review 2014 of RM paediatric clinical and research data / quality

Current gap in senior academic leadership; international search panel

Good and improved relationships with current PICU partner (SGH) and

Bi-monthly meetings with clinical team leaders.

QAR No further advice or information from Specialised



Effective date

Assurance score





CN

metrics benchmarked nationally / internationally. Currently national reviews underway in Paediatric Specialised surgery and PICU, due 2017. Paediatric Oncology being led by the national programme. .

being led by Johann de Bono

.

joint governance structures in place. Regular Executive Director led meetings with multi-professional paediatric clinical team leads. Successful RM leadership across the PTC with demonstrable improvement in communication and clinical standards. Paediatric Oncology services are within the remit of the national cancer programme under the direction of National Cancer MD – Chris Harrison CQC inspection gave paediatrics a rating of “Good”. Internal service evaluation of the Paediatric Service commenced in January 2018 with a focus on the quality and safety aspects of the current model. The review has confirmed that the Principal Treatment Centre provides a comprehensive, high-quality, safe service to children.

CQC draft report received; responded to factual inaccuracies Nov 2016. Consultant workload has been reviewed and new posts prioritised, Two new Consultants appointed. Working with St George’s Hospital to optimally manage PTC beds at St George’s jointly. New Divisional Nurse Director for Paediatrics appointed. Three new Consultants to be appointed; interviews planned

Commissioners has been received to date. Board agreed on 6.2.18 that the internal service evaluation should also include resilience and contingency planning as well as the workforce model for weekend and out-of-hours cover. It was also agreed that the final review report should be provided to Specialist Commissioners, with assistance from the AFC in validating the data.



Effective date

Assurance score





3.3 Major equipment

replacement scheme: including diagnostic (CT, MRI) and RT schemes CFO and COO

1/11/17

Green Major equipment schemes prioritised Major capital plans for each site being managed through the refreshed Capital Programme Board chaired by CFO

Funding gaps for replacing aging equipment. Equipment requiring replacement at similar timescales (large volume of equipment was originally funded from grants in 2004)

Equipment list has been merged into a single list of priorities agreed by clinical and management team, through the oversight of the Capital Programme Board. The RMCC Board of Trustees agreed, on 19th September 2017, to make an investment of £14,323,000 to support the following five key areas of investment:

1. Linac Infrastructure 2. Genetic Sequencing 3. Flexible equipment

fund 4. Imaging; and 5. Robotic Surgery – da

Vinci Xi Robotic Suite.

RMCC bid for major equipment and enabling works presented and approved in full at RMCC Board of Trustees meeting held on19 Sep. National programme of replacing Linacs through NHSE will fund the replacement of three machines for the Trust. Programme Board oversight Board reviewed the capital programme priorities February 2017. Capital programme to be submitted to Board March 2018 as part of 2018-19 business plan

AFC Board discussed the capital prioritisation at the Board Away Day and agreed the need to review the longer term options.

3.4 Development of a clear IT strategy and programme of delivery CFO and CCIO

1/11/17-

Amber The IT strategy has been finalised and agreed by the Board. There is a Board approved Joint Venture with Chelsea & Westminster Trust that oversees and runs the technical aspects of the IT infrastructure. The CFO and COO are on the Board of the JV (Sphere).

The strategy is limited by the funding available

The ITSG assesses the risk of the lack of investment and manages this within the resources available. Recruitment of a CIO Cyber risk has been added

The outline business case will be coming to the Board in 2018 for the replacement of the EPR and infrastructure. The Trust has secured support through a framework to assist

AFC/ Board

Agreed at AFC 21.2.18 that an annual report on cyber-security will be presented as well as interim reports as and when required



Effective date

Assurance score





A review of the current EPR and options for replacement is currently being scoped. Oversight of the programme is through the IT Strategy Group (ITSG) Monthly tracking against capital plan at IT Programme Board (ITPB)

to Risk Register and monitored. It was agreed on 21.2.18 that the AFC will receive an annual progress report on the IT Strategy. The Board received a report on Cyber-Security at its meeting in November 2017 and held a Board Seminar on this subject on the 6.2.18.

with the business case. Explore alternative funding sources such as managed service or national capital through the CSR. Exploring joint options on EPR with Imperial or UCLH. IT Strategy reviewed by Audit and Finance Committee (AFC) and approved by Board 1st June 2016. AFC reviewed the draft overarching business case at the meeting 21.2.18.

on the strategy implementation.

3.5 Development of a sustainable Consultant medical model MD, DoW, DME, COO

19/06/2017-

Amber Development of a sustainable and compliant junior medical model to support excellence in training is underway (rota review); ward based medical model; support roles) as part of transformation work plan. Job planning review to be undertaken to ensure clarity of private/NHS planned activity sessions. Succession planning and medical workforce planning processes to be agreed to ensure the Consultant medical workforce is sustainable to maintain national and international

Job planning exercise is resource intensive. Gaps in Academic Paediatrics, Academic Haematology and Pathology. Recruitment challenges in pathology, radiology continue.

Job planning reviewed at Medical Workforce Committee.

Job planning approach is being reviewed by Medical Workforce Committee in light of new national guidance and reviewed. All junior doctor rotas have been reviewed and changes implemented in line with new contract requirements.

QAR



Effective date

Assurance score





impact. GMC survey results (2017) show significant improvement with green outliers increasing from 16 to 25 and red outliers decreasing from 14 to 5 and as a result GMC Enhanced Monitoring in clinicology ceased September 2017. The roles (advance practice and specialist roles) that support junior doctors are being reviewed through Transformation Board. Job planning policy is being reviewed at Medical Workforce Committee in light of new national guidance. Anticipated that Consultant gaps in paediatrics and pathology will be closed in February.

4. Financial sustainability and best value.

4.1. Successful delivery of the Private Care Strategy which requires short and medium term initiatives to enable profitable

1/11/17

Amber Private care KPIs for financial, operational and clinical performance have been created. Reporting of these KPIs happen quarterly to the Private Care Steering

Private Care audits from KPMG and Monmouth Partners identified need for further training and process improvement in billing, debt collection and

Improved stability within Billing and Credit Control teams and improved debt recovery and data quality performance. Risk remains around recruitment and

Audit recommendations on-going.

New outpatient and diagnostic capacity

AFC / Board



Effective date

Assurance score





growth. MD Private Care.

Committee (PCSC). Wider strategic initiatives taken to PCSC for approval to implement. Monthly performance review of Private care delivery as part of the PRG review. Monthly meetings to track income scheme delivery with action plans developed where under performance is identified. Major business cases supported, signed off and post implementation evaluated by FSG. All Private Care risks are monitored and reviewed across all areas and are reported into the monthly Quality and Safety meetings. Debt management position for the Trust is reviewed and monitored at every AFC and Board meeting.

LOG performance. Private Care capacity from shared services needs to be more carefully monitored. Business planning process to ensure PP shared service needs are adequately resourced to support Private Care growth requirements.

Lack of system integration (Compucare vs HIS) has resulted in various manual processes which reduce the efficiency and accuracy of billing information.

Rate of business growth increasing pressure on staffing models resulting in increased turnover and rates of sickness.

retention of key staff and reliance on other departments to deliver benefits of the Profitability and Automation projects. A new diagnostic capacity business case has been approved by the Board and lease negotiations for Cavendish Square have been finalised. A project manager will be starting in January 2018. Performance is reviewed against income/contribution targets. Risks are held on the Trust risk register including action and improvement plans across each team. Staff metrics monitored monthly in partnership with HR Business Partner.

will be provided through the RDAC centre (shared with the NHS).

Theatre Build business cases on hold due to capital investment required.

Capital Programmes to increase capacity are being reviewed at programme board.

Cavendish Square Lease signed following Board approval in July 2017.

Staff engagement plan developed, looking to rollout in Q4 (17/18).

4.2. Ensuring fair prices for activity covered by the NHS tariff. CFO

1/11/17

Amber The Trust applied to Monitor for a Local price Modification in 2014, which was unsuccessful at the first hurdle as the Trust did not have a deficit greater than 4%. As part of the review of tariff structure the Trust has volunteered to be part of the NHS Improvement costing transformation programme to ensure RM’s views are considered.

There is not a clear national process for challenging structure within tariff

The Trust is engaging with both NHSI and NHS England to review the structure of tariff.

The Trust is not in control of the process or timetable and therefore has to use its national influence to be able to move these issues

The Trust has agreed with its Commissioners an uplift on local prices implemented from 1 April 2017 for NHSE and 1 April 2018 for CCGs. RM Partners is potentially the way

AFC



Effective date

Assurance score





The Trust has raised with commissioners the need to be fairly recompensed for the activity it undertakes and continues to raise these issues at the highest levels. RM Partners will potentially deliver a different currency to recompense work completed by the Trust. Work is on-going to identify how this could be implemented in future years

forward. forward in determining a fair price for the work that is completed in the Trust. A key risk that is discussed regularly at the Board and highlighted as a financial risk at both the AFC and Board.

4.3 Control of temporary Staff expenditure

DoW and COO

1/11/17

Amber Temporary staffing control measures in place.

Proactive recruitment plans in place to reduce reliance on temporary staffing in high users of temporary staffing (Theatres, pharmacy, CCU; AHPs and Community Services)

There is a risk of compliance with caps for medical locums with a new target being set for Trusts in 2017/18 here is acknowledgement by NHSI that this a national issues requiring a collaborative response, which will be coordinated via the STPs.

KPIs consistent with Carter metrics are in place and reviewed monthly by PRG and Temporary Staffing Project Board. Deep dives are held with areas that highest expenditure spending or are above their control total and there is a particular focus on medical locum breaches, which remain challenging for all London Trusts. Information from new e-rostering system is shared with Divisions on monthly basis. Performance data (spend and Carter metrics) is reviewed by PRG, Temporary Staffing Project

. At month 9 the cumulative expenditure on agency staff was £5.1m, which is £1.7m below the NHSI cap. The impact of the new rotas as well as the new contract is being reviewed to see if this can further reduce agency usage.

The Trust continues to work with the Pan-London Bank and Agency Group and NWL STP to develop a consistent response to reducing temporary staffing expenditure. In October 2017, the new pan–London

AFC



Effective date

Assurance score





Board and deep dives are held with areas that highest expenditure spending or are above their control total. The latest NHSI shows that the Trust is ranked 3rd best in London for achieving control total and 5th for overall workforce costs. KPI consistent with Carter are in place. Monthly reports show progress towards targets set. . Medical locum breaches (on price caps) are being reviewed

The Trust continues to focus on converting agency staff to the bank.

medical locum rates were implemented as part of this approach.

5.To ensure compliance with GDPR

5.1. GDPR (Chief Nurse)

15.2.18 Red GDPR Working Group formed to review what actions are required to ensure the Trust is complaint with the new legislations. The Group is chaired by the SIRO and Caldicott Guardian.

There is a risk of regulatory action from the ICO who can fine organisations, acting as either data controllers and/or data processors, a maximum of €20m or 4% of total worldwide turnover, in addition to the reputational damage, for serious breaches of confidentiality or

GAP analysis has been carried out between current Data Protection Act and GDPR. GDPR working group met on the 7th February 2018 and agreed a list of actions required.

Review of IG training has been carried out to include cyber security information. Further review to ensure changes required for GDPR. April 2018 Work on updating Information Asset Register which is a

Board QAR agreed on 15.2.18 that a further update on GDPR compliance would come back to the Committee.

The AFC agreed



Effective date

Assurance score





procedure. key part of compliance has begun with the assignment of Information Asset Owners/Administrators (IAO and IAAs) – April 2018 Information Mapping exercise complete but still some flows outstanding. Review of results in progress ad due to be completed end of March 2018.

on the 21.2.18 that a report should also be presented to the Trust Board on GDPR.


Date of Meeting:

21st March 2018

Agenda item 7.2.

Title of Document: Information Governance Assurance Report

To be presented by

Chief Nurse

Executive Summary The purpose of this report is to provide assurance to the Board of Directors with regard to the Trust’s position and performance in Information Governance (IG), particularly our expected submission score in the national IG toolkit submission at the end of March 2018.

This report also notes the changes to the IG Toolkit that take effect from 1 April 2018 as well as those relating to General Data Protection Regulation (GDPR) that take effect from 25 May 2018.

Recommendations

The Trust Board is asked to note and discuss:

• The Trust’s expected IG Toolkit submission score by 31 March 2018; • The changes to the IG Toolkit in 2018/19 as a result of a national focus on cyber-

security and GDPR; • GDPR risks and action plan for The Royal Marsden.

Author: IG Manager / Trust Secretary



1

Information Governance Assurance Report 1.0. Introduction

The purpose of this report is to provide assurance to the Board of Directors with regard to the Trust’s position and performance in Information Governance (IG), particularly our submission score in the national IG toolkit submission at the end of March 2018.

This report also notes the changes to the IG Toolkit that take effect from 1 April 2018 as well as those relating to General Data Protection Regulation (GDPR) that take effect from 25 May 2018.

2.0. Information Governance 2017/18

2.1. IG Toolkit 2017/18

The IG Toolkit is due to be submitted by the 31st March 2018. The current score is 83% however; the Trust is on track to achieve 88% which is the same score as last year. This score will ensure overall compliance with the IG Toolkit requirements and a RAG rating of ‘green’. As was the case last year, this position is expected to place The Royal Marsden in the top 15 IG toolkit scores in the country for acute Trusts and second highest in London.

2.2. Information Governance Incidents

The Information Commissioners Office (ICO) regulates organisations compliance with the Data Protection Act 1998 and can issue monetary penalties of up to £500,000 for breaches of this legislation.

In September 2017, the Trust reported a level 2 incident to the ICO whereby a finance transaction report containing patient information was emailed to an external finance team. The report contained information relating to 4,062 patients and included the patient’s hospital number, full name and drugs dispensed. There was no address, date of birth or diagnosis.

Following their investigation, the ICO took no action as they felt the incident did not meet the criteria for formal enforcement action. They felt that the incident had been contained and that the individuals were unlikely to suffer significant detriment as a result of this incident. To date The Royal Marsden has not been subjected to any enforcement action, including monetary penalties for breaching the Data Protection Act.

3.0. Information Governance changes in 2018/19

The IG Toolkit has been in place for the last 15 years giving organisations a framework to demonstrate compliance with 45 requirements. The framework has seen little change during this time however, with a strong focus now on cyber security, NHS Digital has been working on releasing a completely new version. The Royal Marsden has put itself forward to support the national team in reviewing and testing the new IG Toolkit before its launch in 2018/19.

2

Below is a high level analysis of the changes to the IG Toolkit that affects Trust compliance with GDPR.

Area relating to GDPR

2018 Toolkit requirement Change from last year.

Accountability The Trust Board must be made aware of the top three data security and protection risks and seeks assurance on the action taken to mitigate these risks.

Evidence of the Trust’s actions on these risks.

DPO A Data Protection Officer (DPO) to be appointed and reports directly to the Board. This cannot be anyone who is a Board member or holds responsibility for the Trust’s information assets, the Senior Information Risk Owner (Chief Operating Officer), or Caldicott Guardian (Chief Nurse).

Trust will have to evidence that we have a DPO in place and the independence of the role.

Information Asset registers and processing data

List of all assets which includes the legal basis for holding and processing, including a record of processing activities.

No real change as this is something organisations have always been required to do. There is a new requirement for asset register to identify legal basis for processing personal data.

Transparency More detailed Privacy Notices need to be in plain English and unambiguous detailing what we process, why we process and the legal basis for processing. Notices need to be available in multiple formats i.e. leaflets, information on Trust website, posters etc.

Data Protection Impact Assessment (DPIA) required for high risk processing. This replaces Privacy Impact Assessments which are advisory at the moment but become mandatory under the new act.

The ICO has required organisation to complete Privacy Impact Assessments for a number of years now but there has been no legal requirement to do this. GDPR makes it required by Law to complete a DPIA.

Contracts Contracts with all third parties that handle personal information are compliant with GDPR. Evidence that the Board or equivalent senior management team are assured that suppliers/data processors are prepared for GDPR.

All contracts must contain relevant GDPR complaint clauses. A review of contracts to ensure reference to new laws have been included.

IG Training More detail regarding senior management compliance for data security and awareness training. Subject matter experts must be adequately trained.

Evidence that Board members have completed level 3 training.

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3.1. GDPR risks and compliance at The Royal Marsden

The EU General Data Protection Regulation (GDPR) will become applicable as law in the UK from 25th May 2018. The current Data Protection Bill, which will become the Data Protection Act 2018 (DPA18), will ensure compliance with the GDPR. It is important to note that the GDPR will not be applicable in the UK post Brexit. It is expected that the DPA18 will ensure continuity by putting in place the same data protection regime into UK law.

A comparison of the requirements under GDPR against the Data Protection Act principles has been carried out and presented to the Information Governance Committee which is chaired by the Chief Operating Officer and the Chief Nurse. A GDPR project group has also been formed to closely monitor the Trust’s compliance with the new regulations.

In addition to the points listed in the above table, the key risks for the Trust Board to be aware of are;

• Significantly increased penalties possible for any breach of the regulation – not just data breaches. Current fine is £500,000 but this will rise to a potential €20m or 4% of gross annual turnover.

• Removal of charges in most cases for providing copies of patient and staff records under the Access to Records Policy.

• More stringent rules on consent where this is used as a basis for lawful processing. • The need to identify the personal (sensitive) information the Trust holds to populate

the information asset register and the legal basis for which we process it.

RM action plan for 2018

Following a meeting with KPMG, the Trust has identified the following actions to be completed in 2018;

• Appoint a Data Protection Officer • KPMG to review the Trust’s data flow mapping process prior to this exercise being

completed • A communications plan to be developed for patients and staff • IG mandatory training for staff to be amended and reference GDPR requirements • Board to be kept informed on progress; GDPR to flagged as a red in the Board

Assurance Framework and Corporate Risk Register • Subject access request process to be reviewed and tested to ensure compliance with

GDPR and avoid breaches (the process by which patients request copies of their personal data)

• Note research algorithms will become a ‘medical device’ under GDPR (consider this ahead of MHRA inspection)

• Contracts review • Review Data Protection Privacy Assessments in line with GDPR requirements • EPR business case to take into account GDPR requirements, particularly around

consent and data security.

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4.0. Conclusion

The Trust Board is asked to note and discuss:

• The Trust’s expected IG Toolkit submission score by 31 March 2018; • The changes to the IG Toolkit in 2018/19 as a result of a national focus on cyber-

security and GDPR; • GDPR risks and action plan for The Royal Marsden.


Date of Meeting:

21st March 2018

Agenda item 7.3.

Title of Document: Board Self-Certification

To be presented by

Trust Secretary

Executive Summary The healthcare regulator, NHS Improvement, requires NHS Foundation Trust Boards to self-certify against the Corporate Governance Statement, the training of Governors and the General Condition set out. To give the Board assurance in confirming this, the Board sub-Committees have reviewed evidence provided against the Corporate Governance Statement below and confirm that they are satisfied that the Trust is compliant. Recommendations The Board is asked to confirm the Board self-declarations. Author: Trust Secretary



1

Board Self Certification Report 2017/18

1. Introduction The healthcare regulator, NHS Improvement, requires NHS Foundation Trust Boards to self-certify against the Corporate Governance Statement, the training of Governors and the General Condition set out below. To give the Board assurance in confirming this, the Board sub-Committees have reviewed evidence provided against the Corporate Governance Statement below and have confirmed that they are satisfied the Trust is compliant with the exception of the ‘Training of Governors’ requirement which is a matter reserved for Board approval. 2. Corporate Governance Statement

Corporate Governance Statement Response

1. The Board is satisfied that the Licensee applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.

Confirmed

2. The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement from time to time.

Confirmed

3. The Board is satisfied that the Trust implements:

a) effective Board and Committee structures; b) clear responsibilities for its Board, for Committees reporting to the

Board and for staff reporting to the Board and those Committees; and c) clear reporting lines and accountabilities throughout its organisation.

Confirmed

4. The Board is satisfied that the Licensee has established and effectively implements systems and/or processes:

a) to ensure compliance with the Licence holder’s duty to operate efficiently, economically and effectively;

b) for timely and effective scrutiny and oversight by the Board of the Licence holder’s operations;

c) to ensure compliance with health care standards binding on the Licence holder including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions;

d) for effective financial decision making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licence holder’s ability to continue as a going concern);

e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making;

f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence;

g) to generate and monitor delivery of business plans (including any

Confirmed

2

3. Training of Governors

changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and

h) To ensure compliance with all applicable legal requirements.

5. The Board is satisfied that the systems and/or processes referred to above should include but not be restricted to systems and/or processes to ensure:

a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided;

b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations;

c) The collection of accurate, comprehensive, timely and up to date information on quality of care;

d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;

e) That The Royal Marsden NHS Foundation Trust including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources

f) That there is clear accountability for quality of care throughout The Royal Marsden NHS Foundation Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.

Confirmed

6. The Board is satisfied that there are systems to ensure that the Trust has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.

Confirmed

1. The Board is satisfied that during the financial year most recently ended the Licensee has provided the necessary training to its Governors, as required s151(5) of the Health and Social Care Act, to ensure they are equipped with the skills and the knowledge they need to undertake their role.

To be confirmed

Evidence for the Board: • Governors receive relevant Trust reports and briefings at Council of

Governor meetings and a Governor bulletin in between meetings; • Governor Seminars are also held following some Council of Governors

meetings e.g. A Governor Seminar on Finance was held in June 2017; • All Governors are invited to meet with the Trust Secretary on an annual

basis to discuss individual training and development needs; • Governors are invited to attend external conferences and seminars as and

when the opportunity arises, • Governors are invited to undertake clinical hospital visits following a

training session with the Chief Nurse/Deputy Chief Nurse and are supported by a Matron; and

• Governors Training Day was held on the 6 March 2018 which included a presentation on the Trust’s Five Year Strategy, external lawyers presenting on their statutory duty to represent members, and other mandatory training areas such as risk management and safeguarding.

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4. General Condition 6 (G6) – Systems

5. Conclusion

The Board is asked to confirm the Board self-declarations listed above.

1. Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have regard to the NHS Constitution.

Confirmed

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