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BOARD OF DIRECTORS

10th MARCH 2010

KINDLY NOTE THE CHANGE IN VENUE

BOARD OF DIRECTORS

Agenda for the meeting to be held on 10th March 2010

at 2.00 pm in the ***** CHARITIES MEETING ROOM, 5th Floor East Wing, ****

250 Euston Road, London NW1 2PG

1. Apologies for Absence 2. Minutes of the Meeting held on 10th February 2010 Attachment A 3. Matters Arising Report Attachment B

4. Other urgent matters not appearing on the Matters Arising Report

5. Report and Presentation – Infection Control Attachment C Annette Jeanes, Director of Infection Prevention and Control to attend 6. Chairman’s Report

7. Chief Executive’s Report Attachment D 8. Executive Board Report Attachment E 9. Quality & Safety Committee Report Attachment F 10. Finance & Contracting Committee Report Attachment G 11. Performance Report Attachment H 12. Entries in the Seal Register Attachment I 13. Register of Board Members’ Interests Annual Review Attachment J 14. Any Other Business 15. Date of Next Meeting:

The next meeting will be held on Wednesday, 14th April 2010 at 2.00pm.

A

Agenda Item 2

Minutes of the Meeting held on 10th February 2010

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UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

BOARD OF DIRECTORS

Minutes of the Meeting held on 10th February 2010

Present: Peter Dixon, Chairman Sue Atkinson, Non-Executive Director Nick Monck, Non-Executive Director Richard Murley, Non-Executive Director Jane Ramsey, Non-Executive Director Sir John Tooke, Non-Executive Director Richard Alexander, Finance Director Geoff Bellingan, Medical Director, Surgery & Cancer Louise Boden, Chief Nurse Mike Foster, Deputy Chief Executive Gill Gaskin, Medical Director, Specialist Hospitals Tony Mundy, Corporate Medical Director Robert Naylor, Chief Executive In attendance: Tonia Ramsden, Director of Corporate Services (Board Secretary) Tara Donnelly, QEP Director Sarah Johnston, Director of Performance & Partnerships Julia Whitehouse, Interim Workforce Director Karin Roberts, Head of Staff Services (Minutes) 2/1 Apologies for Absence Apologies for absence were received from Paul Glynne. 2/2 Minutes of the Meeting held on 9th December 2009 The minutes were agreed to be a correct record. 2/3 Matters Arising Report

The Matters Arising Report and timetable for the Electronic Staff Record implementation were noted.

2/4 Other urgent matters arising not appearing on the Matters Arising Report There were none. 2/5 Presentation: Quarterly Research & Development Report

Nick McNally, Director of Research Support, attended to present the quarterly Research and & Development presentation on behalf of Professor Monty Mythen.

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Nick McNally updated the Board on research management and governance issues; advised that the merger of the Royal Free R&D team with UCLH had been completed; that a UCL Consortium had been established, bringing in the Whittington, The Royal National Orthopaedic Hospital and the North Middlesex Hospital; and links with Great Ormond Street Hospital and Moorfields Hospital had been strengthened. He reported that the department had introduced “Project 28” and were working towards a 28 day target from submitting a valid application to approving a study. The department was also helping to support innovation, by providing staff who had an idea for an invention with support and expertise on Intellectual Property. Nick McNally updated the Board on the NIHR Faculty at UCLH/UCL. There were currently 17 Comprehensive Biomedical Research Centre (CBRC) themes, including education and health services research and these had undergone a mid-term review. He outlined a number of measures of success, these included:-

• That the CBRC now had 17 NIHR senior investigators; • The research portfolio had increased to more than 1800 studies; • The number of publications had increased to more than 1200; • There had been a number of innovations including a non-invasive method

for treating patients at risk from heart failure; and • The CBRC open event in September 2009 had been the first such event

in the UK and had been highly successful, attracting 240 attendees. The establishment of a Clinical Trials Unit aimed to increase the number of NIHR grants. The unit was currently piloting initiatives such as grant writing support and was meeting an unmet need for non-cancer trials. Finally Nick McNally talked about the Clinical Research Facility, a 20-bedded unit in the EGA Wing of UCH, which had received funding from Wellcome and the Cancer Research Fund. To date 40 studies had been adopted and the facility was developing links with clinical research facilities at Great Ormond Street Hospital, Moorfields, the Royal Free and the Whittington. Priorities were to finalise the building works required, recruit staff, increase activity and develop an industry standard Phase 1 unit. The Chairman thanked Nick McNally for his comprehensive report.

2/6 Chairman’s Report 2/6.1 Board Appointments

The Chairman welcomed Professor Sir John Tooke to his first meeting. Sir John who had recently taken up the post of Vice Provost (Health) at UCL had been appointed to the Board by the Governing Body following his nomination by UCL. The Board was also delighted to note that the Governing Body had appointed Richard Murley as the Chairman’s successor.

2/6.2 NCL Service Organisation Review The Chairman updated the Board on the positive collaborative discussions with colleagues at the Royal Free and Whittington Hospitals around the more effective delivery of services in the sector.

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2/6.3 Care Quality Commission Feedback

The Board noted the concern of the Governing Body that the CQC did not appear to have a clear understanding of the nature of foundation trusts and their governance arrangements.

2/6.4 UK Centre for Medical Research and Innovation

The Board noted the report of the recent meeting on progress with the UKCMRI at which the adjacency of UCLH’s excellent services had been stressed. It was agreed that it was important that UCLH engaged in this process and Robert Naylor was asked to discuss this with Malcolm Grant. Sir John reported that he was a member of the Steering Group and academic lead for UCL; he would keep the Board updated on progress.

2/7 Chief Executive’s Report 2/7.1 Monitor Quarterly Return The Board noted that a declaration 2 return had been submitted to

Monitor for the period ending 31st December 2009 with a governance risk rating of amber. The two issues on which the Trust was not compliant were the 62 day treatment for cancer referrals and the core standard in respect of staff appraisals.

The Board noted that an action plan was in place to provide satisfactory assurance on the staff appraisal target by the end of February 2010.

There was discussion of the 62 day cancer referral target and the impact of the improved pathway for prostate cancer which adds an additional step to the patient pathway. The Board noted the Chief Executive’s report and the plans to monitor the situation throughout the final quarter of the year. The Chief Executive said all efforts were being made to meet the target in Q4. Following discussion the Board agreed that it would be unacceptable to revert to a lesser quality clinical pathway to achieve the target.

2/7.2 HRH The Prince of Wales’ Visit The Board noted the very successful visit by HRH The Prince of Wales

to meet staff and patients in the photodynamic therapy (PDT) services at UCH in which he had a particular interest. The Killing Cancer Charity had been supportive in raising interest in PDT and was undertaking some high profile fundraising. Sir John advised that this innovation needed to be taken forward on the basis of clinical evidence.

. 2/7.3 Clinical Negligence Scheme for Trusts (CNST) – Maternity Level 3 The Board noted with great pleasure that the Trust had achieved CNST

Level 3 for maternity services. Congratulations were offered to all staff who had been involved in the process.

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12/7.4 Standing Financial Instructions The Board agreed that the current Standing Financial Instructions and

associated documents should be extended until August 2010 by which time a review commissioned by the Finance Director will have been completed.

2/8 Executive Board Report 2/8.1 Capital and Estates Issues The Board noted that the EB had approved a number of schemes from

the Capital Programme. The Board also noted that the quarter 3 review of the schedule of protected and unprotected assets had been undertaken and there were no changes.

2/8.2 Requests under the Freedom of Information Act The Board noted the report from the ICT Strategy Board summarising

the requests received by the Trust under the Freedom of Information Act. The Board asked Mike Foster to thank Annie Lindsey, the Trust Archivist, for her efforts in coordinating the scheme so effectively. The Board questioned the number of late responses and Mike Foster agreed to review the reminder system but pointed out that not all requests were clear and this sometimes delayed responses.

2/8.3 Senior Information Risk Owner Report (SIRO) and Caldicott

Guardian Report The Board noted that the EB had received a report from the SIRO which

set out work being undertaken to meet the requirements of the Information Governance Toolkit Assessment. The report confirmed that in future all ICT governance issues would be considered through the ICT Strategy Board.

The Board noted the positive report from Dr Dominic Heaney, the new Caldicott Guardian. The report outlined his role and reported on activity for the period July – December 2009.

2/8.4 Single Equality Scheme 2010-2012 The Board agreed to adopt the Single Equality Scheme for 2010 to

2012. Jane Ramsey asked how the Board would ensure that the Scheme was implemented. It was noted that the Clinical and Corporate Boards would be responsible for implementation; this would be monitored by the Human Resources & Communications Committee.

2/8.5 Policy Compliance and Policy Approvals

The Board noted the report on policy compliance and noted that four policies had been approved by the EB and that a Maternity Services

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Risk Appendix had been added to Trust Risk Management Purpose and Strategy.

2/8.6 Performance Report

The Board noted that a change control mechanism would be introduced to ensure that changes to the content of the Performance Report were controlled. It was agreed that Mike Foster would chair this small group.

2/9 Quality & Safety Committee Report Richard Murley presented the report and drew attention to the impact which

frequent patient feedback has had on improving the patient experience. He highlighted a new national priority – the prevention of venous thromboembolism (VTE) – which would require a focus equivalent to that for hand hygiene. He also reported that the Trust had registered appropriate locations with the Care Quality Commission by the required deadline of Friday 29th January. Richard Murley was thanked for his sterling work in chairing the Quality and Safety Committee; he in turn thanked Tony Mundy and Sandra Hallett for their help. The Chairmanship would be handed over to Sir John.

Tony Mundy reported that he had invited an assessor to review the Trust’s readiness for the general NHSLA Level 3. Following a request from Richard Murley it was agreed the NHSLA3 project plan would be circulated to Board Members.

Action: Tony Mundy The remaining issues in the report were noted

2/10 HR & Communications Committee Report Sue Atkinson presented the report and highlighted the workforce key indicators,

specifically the reporting rates for sickness absence which continue to be under-reported. It was noted that a revised absence reporting system was being rolled out across the Trust and further benchmarking would be undertaken by HR and internal audit.

She reported that the 2010/11 cycle for consultant job planning had now commenced. More work was being undertaken on the links between job planning, appraisal and CPD and this would need to link into the new GMC revalidation process.

The successful launch of the in-house resourcing service was noted. The Chief Executive was concerned about the high expenditure in November

2009 on temporary staffing (£4.62m). He advised that the programme to move towards a position of reduced to no agency spend from 1 April 2010 formed one of the major deliverables of the efficiency programme and work was being undertaken to meet this objective. The Medical Directors confirmed that they were currently identifying the extent of agency usage within their boards.

The Board agreed the proposed amendment to the HR&CC meeting schedule; from March 2010 meetings would be held bi-monthly.

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The remaining issues in the report were noted.

2/11 Finance & Contracting Committee Report Jane Ramsey presented the report and said that there had been a lengthy and

detailed discussion about the cost of agency staff and the increase in agency expenditure. Julia Whitehouse confirmed that there had been a new nationally negotiated contract for agency staff in which some costs had increased by up to 50%. This issue had been raised with the London SHA and a pan London group had negotiated a 50% reduction to the increase with effect from May 2010.

It was agreed to provide the Board with more information on this on this issue at the next meeting.

Action: Julia Whitehouse/Mike Foster It was noted that month 9 income and expenditure was broadly on plan, although

Richard Alexander highlighted the risk that PCTs might not pay for the full level of over performance.

Jane Ramsey highlighted the need for the FCC to work closely with the HR&CC to deliver better management of workforce costs.

The contracting update and the 2010/11 financial planning update were noted. 2/12 Performance Report

Sarah Johnston presented the key issues from the performance report for December. She drew attention to the fact that achieving the MRSA threshold in 2010/11 will be very challenging as the methodology is changing.

She advised that there had been a significant reduction in patient falls from 57 to 19, although two of these falls had been serious and were being monitored by the Quality and Safety Committee.

She advised that the cancer 62-day screening targets were being excluded from

Monitors compliance framework due to the low numbers involved as they were below the de-minimus level, and that the 14 day breast target would be monitored from Q4. The strong A&E performance was noted and Sarah Johnston confirmed that all specialties had met the 18 week target in Q3 with the exception of trauma & orthopaedics for the admitted pathway.

Richard Murley referred to the financial performance section and requested that the cash figures in the financial performance table were updated, this was agreed.

The performance report contained the quarterly review which was noted. The summary progress against the top 10 objectives showed two red ratings, namely for financial readiness and for staff appraisal rates. In response to a question regarding the process for medical appraisal Medical Directors confirmed that the clinical academic job planning process required that job plans and appraisals were jointly signed off.

Sue Atkinson asked what progress had been made on defining the organisational development programme, considering the high amount of activity in this area. The Chief Executive confirmed that he was still considering a way forward in this area. Sue Atkinson asked if the current baseline activity could be described and it was agreed that Julia Whitehouse should be asked to compile a

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list of current activity in this area which would be sufficient to evidence progress against this objective.

Action: Julia Whitehouse 2/13 Report of the Audit Committee meeting held on 1st February 2010 Nick Monck presented a report of the main points of discussion from the

meeting. The Committee were advised that there was pressure from the external auditors for the Trust to prepare segmented accounts. The Chief Executive reported that most other trusts were not doing this.

There had been substantial assurance from five internal audits and this was welcomed. Outstanding recommendations would be followed up and Internal Audit was asked to review the arrangements for authorising the decision to recruit medical consultants.

Additional information had been requested to support a request from the Finance Department to purchase some non-audit work from a division of PwC.

2/14 Minutes of the Audit Committee meeting held on 26th November 2009

The minutes were noted.

2/15 Entries in the Seal Register

The report was noted.

2/16 Any Other Business

There was none.

2/17 Date of Next Meeting The next meeting would be held on Wednesday 10th March at 2.00pm. The Board of Directors resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

B

Agenda Item 3

Matters Arising Report


BOARD OF DIRECTORS

REPORT ON MATTERS ARISING FROM THE MEETING

HELD ON 10th FEBRUARY 2010

Minute ref.no

Issue Outcome

2/7.1

CEO Report: Monitor Quarterly Return – Provide assurance that staff appraisal objective will be met by the end of March 2010 (see also item below – Oct 2009 minute 10/4: Consultant & non-medical staff appraisal)

The Trust set a target of 85% for the completion of staff appraisal as a top 10 objective for 2009/10. Progress is being made and the target has been achieved for consultant staff. Activity took place during February, with further work planned for March, to ensure the target is met for all other staff groups

2/8.4 EB Report: Single Equality Scheme 2010-2012 – confirm reporting arrangements to provided assurance the SES action plan is being delivered

Revised arrangements for providing assurance on the delivery of the SES action plan have been agreed. The EB and Board will receive twice-yearly reports as part of the HRCC reports. Exceptions will be escalated to the EB The document has been published on the website. Action completed

2/9 QSC Report: Circulate NHSLA level 3 programme and project plan to Board Members

This has been done. Action completed

2/11 FCC Report: PaSA contract increase This issue is referred to in the EB report to Part 2. Action completed

2/12 Performance report: Top 10 Objectives – Objective 6 – to describe current organisational development initiatives in place in the Trust

This issue is addressed in the Chief Executive’s report. Action completed

Issues brought forward from previous meetings

Date of Meeting

Minute ref no.

Issue Action

October 2009

10/4 Education Strategy Update: Consultant and non-medical staff appraisal (see above)

The issue regarding appraisal is addressed above. An update on the Education Strategy will be provided as part of the Education presentation to the May Board meeting

October 2009

10/4 Homeless Health Project – funding from April 2010

This issue is referred to in the EB report. Action completed

December 2009

12/8.2 Ward efficiency projects/Nurse-led Discharge Project

Report back on the evaluation of ward efficiency projects, including nurse-led discharge, prior to roll out across the Trust. (PG). Note: It has been agreed that this will be taken forward as part of the quality & efficiency programme

C

Agenda Item 5

Infection Control Report


Annual Infection Control Report The EB received the 2008/09 Infection Control Annual Report, which had first been considered by the Quality and Safety Committee. The report assured the EB that processes were in place to meet and deliver the annual plan objectives for 2009/10 and summarised that plan. Annette Jeanes, Director of Infection Prevention and Control (DIPC) will present the report to the Board at the meeting. The report is attached for information. Board members will recall that there will be a new national MRSA objective for 2010/11 at the meeting the DIPC will also outline what action is being taken to meet the new threshold. SIR ROBERT NAYLOR CHIEF EXECUTIVE

Infection Control

Annual Report

2008-2009

UCL Hospitals is an NHS Foundation Trust comprising the Eastman Dental Hospital, The Heart Hospital, Hospital for Tropical Diseases, National Hospital for Neurology and Neurosurgery, the Royal London Homoeopathic Hospital and University College Hospital (incorporating the former Middlesex and Elizabeth Garrett Anderson Hospitals).

UCL HOSPITALS NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 2008/2009 ___________________________________________________________________________

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1.0 Contents 2.0 Executive Summary

3

3.0 Background including infection control arrangements

3

4.0 Annual Plan & Objectives 2008-2009

5

5.0

Key aspects of performance

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5.1

Education and training

7

5.2

Hand hygiene compliance

7

5.3

Prevention of occupation exposure to infection

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5.4 Reducing intravenous related infections

9

5.5

Surveillance and infection control information technology

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5.6 Prudent use of antibiotics

12

5.7 MRSA bacteraemia

14

5.8 Clostridium difficile

15

6.0 Outbreaks and incidents

16

7.0 Annual Plan 2009-2010

16

8.0 Recommendation 16 Appendix 1 17 Appendix 2 18


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2.0 Executive Summary 2.1 This report covers the period from 1 April 2008 to 31 March 2009. 2.2 Once again this year there has been strong support from the Board of Directors for

the work to reduce healthcare associated infection in the trust which was a key trust objective. There was considerable investment in molecular MRSA screening, decontamination modernisation at Eastman Dental Hospital and further investment in the infection control team.

2.3 The trust achieved the MRSA bacteraemia and Clostridium difficile (C.difficile)

improvement targets. There were 28 MRSA bacteraemia against a trajectory of 36, whilst there were 61 C.difficile cases against a trajectory of 180.

2.4 The trust implementation of ‘Saving Lives’ continued and included implementation of

evidence based improvements in intravenous line care, isolation utilisation, antibiotic usage and the surgical site infection bundle.

2.5 Increased engagement and ownership of infection control continued and was

enhanced by performance monitoring with feedback including the surveillance of infections, the matrons’ 20 point plan, hand hygiene compliance and the trust wide emphasis of quality and safety.

2.6 The trust achieved the target of >85% hand hygiene compliance during this period.

Training in hand hygiene for all staff and improvements to hand hygiene facilities continued.

2.7 An Antimicrobial Usage committee was established, which reviewed policies,

introduced best practice initiatives, reviewed audits and developed patient information.

2.8 Training in infection control included preparations for flu pandemic, link staff and

housekeeper training, in addition to continuing induction and update sessions. 2.9 There were 16 outbreaks associated with diarrhoea and vomiting during this period.

In one, which was identified as Norovirus, 38 patients were affected and it lasted for 5 weeks.

2.10 The key risks during this period were predominantly associated with maintaining

standards of cleaning and maintenance. These have been identified on risk registers and improvements initiated.

3.0 Background including infection control arrangements 3.1 The Infection Control department provides an infection control service for the

University College London Hospitals NHS Foundation Trust (UCLH). During this period it also provided a service to Camden and Islington Primary Care Trusts and Camden and Islington Mental Health and Social Services Trust (now Camden and Islington NHS Foundation Trust), St Luke’s Hospital & Chalfont through service level agreements. This report relates to infection control at UCLH only.

3.2 The work of the Infection Control department supports the Trust in minimising the

risk of healthcare acquired infection to patients in accordance with and taking into account: Winning ways (DH 2003),


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Towards Cleaner Hospitals and lower rates of infection (DH 2004), A matron’s charter: an action plan for cleaner hospitals (DH 2004), Revised guidance on contracting for cleaning (DH 2004), Saving Lives: A delivery program to reduce healthcare associated infection (HCAI) including MRSA (DH 2005), Going further faster: implementing the Saving Lives delivery program (DH 2006), The Health Act 2006 Code of Practice for the Prevention and Control of Health Care Associated Infections (DH 2006), The national specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes. (NPSA 2007), Essential steps to safe clean care (DH 2007), Clean, safe care: reducing infections and saving lives (DH 2008), Board to ward - how to embed a culture of HCAI prevention in acute trusts (DH

2008), Clostridium difficile infection: How to deal with the problem (HPA& DH 2009).

3.3 The trust is required to meet the duties of the Hygiene Code, NHS Litigation

Authority (NHSLA) and the Healthcare Commission’s Core standards (the HCC changed to the Care Quality Commission in April 2009).

3.4 The infection control service is delivered and facilitated by an Infection Control team (ICT) which includes (for 2008-9) 3.4 WTE infection control nurses (ICN), 2 WTE Clinical practice facilitators (CPF), 1 WTE epidemiologist, 5 WTE wound surveillance staff, 1 WTE antibiotic pharmacist, microbiologists, virologists and includes the staff of infectious diseases, facilities, matrons, infection control liaison, occupational health and sterile services.

3.5 The Director of Infection Prevention and Control (DIPC) is the consultant nurse,

infection control. The DIPC is directly accountable to the Chief Executive and has direct reporting lines to the Chief Nurse and medical directors. The DIPC is responsible for the strategy, policies, implementation and performance relating to infection control and writes the annual report. The DIPC attends the Board of Directors and other meetings as planned or required.

3.6 The core infection control service includes an infection control advisory service, proactive infection prevention work, education and training throughout the organisation. It also undertakes audit, policy formulation and advice, surveillance and epidemiology, outbreak and control management.

3.7 The infection control team meet weekly to formally review infection control issues and performance. A co-ordinated plan of work is agreed and disseminated. Minutes of this meeting are available from the Infection Control administrator.

3.8 Infection control link staff meet monthly and for an annual study day. The programme is facilitated by the Infection control CPF.

3.9 The Trust infection control committee (TICC) is chaired by the DIPC and meets quarterly with representatives from clinical boards and key service areas. The minutes are available on the trust intranet. This committee reports to the Patient Safety and Risk Steering Group (PSRSG), which in turn reports to the Quality and Safety committee (Q&S).

3.10 During this period and in common with many other trusts the requirement for infection control support, advice, interventions and reports of progress and performance increased. The requirement to train all staff in infection control and hand hygiene combined with ad hoc requests was particularly onerous.

3.11 The reporting requirement continued to increase (verbal and written) reflecting

increasing engagement particularly related to demonstration of performance and compliance with guidance, standards, targets or reporting frameworks.


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These included: Quality and safety score card Monitor NHSLA Core standards Hygiene code DH Saving Lives HPA/MESS MRSA and C.difficile reporting SHA/ Commissioning (via Camden PCT) Hand hygiene compliance MRSA and C.difficile Root Cause Analysis (RCA) & Serious Untoward Incident (SUI) work Freedom of Information requests Surgical site infection surveillance Health scrutiny committees (Islington and Camden) Health Care Commission (Unannounced visit) National Audit Office (Audit)

4.0 Annual plan and objectives 2008-9 4.1 The key aims reflected the trust plan:

Achieve Infection Control strategy Achieve the MRSA bacteraemia and Clostridium difficile targets. Achieve >85% hand hygiene compliance of medium to high risk interventions.

4.2 The plan for 2008-9 is included in Appendix 1. 4.3 A proposal for increased funding was developed and two project posts which had

been funded by an external grant were made substantive in March 2009. 4.4 A proposal for ‘ward to board’ implementation was developed and accepted by the

trust and implemented with the support of boards. 4.5 Responsibility for the completion of root cause analysis was transferred to divisions

and clinical staff in an effort to embed learning and improve engagement, in response to guidance from the DH advisors.

4.6 Infection control policies and information for patients and staff were available on the

website and intranet. As these policies were produced by an external expert organisation they did not conform to the trust format and have not been through the revised ratification process. Therefore a complete revision of policies is planned for 2009-10.

4.7 The DH ‘Saving Lives’ programme continued to be used and included central venous line, peripheral intravenous line, C. difficile bundles of evidence based interventions. The trust accepted a recommendation to increase isolation facilities, funding was provided and work commenced. Work to reduce urinary catheter related infections continued with the introduction of an antibiotic impregnated catheter. The surgical site infection prevention bundle was agreed and began rollout at the Heart Hospital. All evidence based care bundles in use are available on the intranet.

4.8 Isolation prioritisation and use was also reviewed and the use of a standard tool was

established for consistent decision making. Further work is required to embed this process.


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4.9 In June 2008 infection control surveillance data was made available on the trust

intranet and further work to ensure users understood the data and could apply the information to practice improvements began.

4.10 Double headed MRSA screening swabs were introduced in July 2008 and molecular

MRSA screening of selected patient groups commenced following the acceptance of a business case in March 2009.

4.11 Information on hand hygiene compliance was collated and made available on the

trust intranet. This was regularly presented and scrutinised by the Q&S committee. 4.12 A new antimicrobial usage committee was established in August 2008, chaired by

Professor Mundy. The purpose of the committee was to improve antibiotic prescribing and reduce the risk of C.difficile infection. (Details of this work are in section 5.6).

4.13 Planning for pandemic flu continued and the trust was successful in bidding for 3

grants. This included delivery of training in safe respirator use across the trust, the purchase of public information banners which outline key public health messages and an increase in supplies of personal protective equipment.

4.14 The Infection Control team in conjunction with Camden PCT trained 50 staff in flu

preparedness which assisted in strengthening the Trust’s business continuity.

4.15 The sterile services department (SSD) is fully operational and accredited. There is an on-going programme to eliminate local decontamination and centralise processing. Where local decontamination is essential, work has been done to ensure compliance with legislation and best practice. A business case was submitted successfully for funding sterilization equipment at the Eastman Dental hospital. A planning process was commenced to develop an onsite reprocessing facility to reduce damage to instruments and improve turnover.

4.16 New patient information leaflets were developed and > 8000 leaflets were distributed

to be placed on infection control notice boards throughout the trust. 4.17 Externally funded research to refine and improve cleaning methods continued in

other NHS facilities including hospitals in Scotland and south London. The Department of Health funded two studies examining the relationship between the cleanliness of the environment, the bio burden in the ward environment and the level of contamination on staff hands. The objective is to improve the efficacy of national cleaning protocols.

4.18 Work to improve the quality and standard of patient equipment and environment at

UCLH continued. This was enhanced by work led by the heads of nursing and matrons to inspect facilities regularly (the matrons’ 20 point checklist) and feedback performance. In addition issues relating to anticipated standards of cleaning and maintenance were highlighted.

4.19 A group focusing on quality improvement in cleaning and maintenance was chaired

by the deputy chief executive Mike Foster and has subsequently worked with Estates and Facilities and Interserve to improve performance. The standard and quality of cleaning delivered and maintenance of the estate are key infection control risks in the trust and feature in risk registers.


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4.20 The development of an infection control course in partnership with external education providers was unsuccessful during this period and opportunities with other organisations are now being explored.

4.21 The IC team provided advice and support for phases 2&3 of UCH and other planning

and developments. This included the commissioning of theatres, sign off of new build prior to occupation and the decommissioning of EGA.

5.0 Key aspects of performance 5.1 Education and training 5.1.1 Infection control training was delivered at all trust inductions and annual health and

safety updates during 2008-2009.

5.1.2 A total of 2854 staff were also given practical hand hygiene training or hand hygiene compliance monitoring training by the infection control team during this period.

5.1.3 A study day in September 2008 focusing on the Saving Lives High Impact Interventions was attended by 47 staff, including 2 staff members from the community.

5.1.4 A study day was delivered to more than 20 Housekeeping staff in April 2008.

5. 1.5 Over 400 Trust staff attended training on the intravenous catheter care bundles.

5. 1.6 Monthly training sessions were held for link practitioners from all sites. 5.2 Hand hygiene compliance. 5.2.1 Participation in the ‘cleanyourhands’ campaign continued.

5.2.2 Improvements in hand hygiene facilities were made in a number of areas including the Heart hospital and The National Hospital for Neurology & Neurosurgery . In some areas where there was a delay in provision temporary portable sinks were purchased and installed.

5.2.3 Alcohol decontaminants are available across the trust although there were instances of theft of alcohol gel from ward entrances which prompted removal from some areas.

5.2.4 The trust target of 85% hand hygiene compliance was achieved and maintained. Monitoring of hand hygiene performance by the Quality and Safety committee began in January 2008. Hand hygiene compliance improved from 78% in April 2008 to 87% in March 2009. (Graph 1).

5.2.5 Further improvement work is in progress and the aim is for consistent and sustained

improvements. This included a social marketing campaign which was awarded innovations funding by the Department of Health and was launched in February 2009 with subsequent positive feedback.


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Graph 1: Hand Hygiene compliance

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All locationsMedicineSurgery & CancerSpecialist Hospitals

5.3 Prevention of occupational exposure to infection 5.3.1 Since the beginning of August 2009 the Occupational Health team have been testing

all new clinical staff for measles IgG if MMR vaccination is declined. 5.3.2 All staff new to the NHS are assessed for TB as part of their pre employment health

screening in accordance with the NICE guidance ‘Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (2006)’and Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers (2007).

5.3.3 The Occupational Health team have given over 1700 vaccinations and requested

over 5000 blood tests (see below) as part of the health clearance and screening processes for new starters.

5.3.4 1030 seasonal flu vaccines were also delivered.


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Table 1: Occupational health screening and immunisation Vaccine Number of staff vaccinated Hepatitis B 909 MMR 719 BCG 36 Chickenpox 44 Test Number of staff tested Mantoux test 158 Measles IgG (since 1st Aug 2009) 128 Chickenpox (VzV) 939 Rubella 904 HBsAb 1069 HBsAg 942 Hepatitis C Antibody 620 HIV antibody 587 Other Number of staff screened TB assessment 1833 5.3.5 During this period, 231 occupational exposures to blood and body fluids were been

reported compared to 195 for the previous year (reporting systems have been strengthened which may explain the increase in reported instances). Seven were from known or strongly suspected HIV positive sources and eight from patients known to be positive to Hepatitis C.

5.3.6 All incidents have been reported via the TICC and measures to reduce the number of

incidents are being addressed by a multi disciplinary sharps prevention group. Measures include additional training at induction and safety engineered medical devices which have been provided and adopted in most areas of UCLH.

5.4 Reducing Intravenous device related infections 5.4.1 Work to reduce intravenous device related infections continued and included:

Use of non ported peripheral catheter where possible to reduce contamination at bung, Audit of practice including the ‘Saving Lives’ audit tools, Use of central line insertion packs to standardise and ensure as much as possible is present in pack and reduce requirement for leaving the patient or prolonging the process, Full scrub and total barrier technique to insertion of central line, 2% chlorhexidine for skin cleaning, Biopatch® for central lines (chlorhexidine patch), Statlock® for intravenous lines to reduce infection risk associated with suturing, 2% chlorhexidine to clean hubs (‘scrub the hub’), Introduction of pigtail patch to secure lines and prevent drag, Visual Infusion Phlebitis Score (VIPS), Monthly IV interest group.

5.5 Surveillance and infection control information technology 5.5.1 The trust-wide infection control surveillance system underwent further development

particularly in the inclusion of antibiotic sensitivities and patient transition data.


10

5.5.2 Surveillance of infection information at ward, division and board level is available on the intranet. Data is revised monthly by the trust epidemiologist and any trends are identified to clinical areas for discussion and possible action.

5.5.3 In collaboration with the information department hand hygiene compliance was included on KPI reporting.

5.5.4 Surgical wound infection surveillance has been undertaken at UCLH for the past 9 years. Orthopaedics and cardiac surgery are monitored continuously and other specialities on a six month rotational basis. Results are fed back to clinicians. High risk and high incidence areas have been identified and improvement plans (formal and informal) have been developed with clinicians. An ASEPSIS score of more than 20 indicates a surgical site infection. Results of surveillance for the last 9 years are summarised in graphs 2 and 3.


11

Graph 2

ASEPSIS>20

02468

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5.6 Prudent use of antibiotics 5.6.1 This section summarises the work of the Antimicrobial Usage Committee (AUC) and

the work undertaken by the antibiotic pharmacist.

5.6.2 Antimicrobial Prescribing and Management Policy The above policy was launched in November 2008. Available to staff on the trust website it defines the principles of good antimicrobial prescribing. In addition, it also lists the roles and responsibilities of all healthcare professionals involved in the prescribing, dispensing and administration of antimicrobials. The policy also includes:

IV to oral switch policy Antibiotic bioavailability Antibiotic review policy Restricted antimicrobial policy

The policy was launched via the Chief Executive’s Brief. As part of the launch of the policy, brief awareness and training sessions for medical staff were organised with divisions as well as presentations at various clinical governance meetings. In addition, it was also presented at the Nursing and Midwifery Board.

Divisional antimicrobial reports

Divisional antimicrobial reports will be produced twice a year, based on results of antimicrobial audits. The reports will highlight compliance to the following indicators of antimicrobial prescribing:

Indication documented in the medical notes Stop/review date documented on the drug chart at the time of prescribing Where duration of therapy is not specified, antibiotic stop sticker applied by ward pharmacist Compliance with trust antimicrobial guidelines

Penicillin Allergy

Administration of penicillin-containing antibiotics to those with known and documented penicillin allergy have led to a number of deaths within the NHS. UCLH incident reports indicate 13 such incidents over the last 2 years, although none to date has had a fatal outcome. Furthermore, a recent trust-wide antibiotic point prevalence audit identified that 4 of 29 patients with a documented penicillin allergy were prescribed a penicillin-containing antibiotic. The AUC have implemented a number of steps to reduce this risk and further work is underway. This includes ensuring existing guidelines are followed, increasing awareness by circulation of posters and bulletins, a ‘traffic light’ warning poster to give staff guidance on which antibiotics are safe to prescribe, improving identification of patients with allergies, which included a pilot of a red drug chart which was launched at the Heart Hospital, and further improvement to IT systems.

Antimicrobial Guidelines Review

The AUC reviews all trust antimicrobial guidelines. Below is a list of those reviewed and ratified by the Antimicrobial Usage Committee since August 2008. This information is available on intranet formulary (Inform) at: http://pharmweb/Inform/Search.aspx?q=antimicrobial

http://pharmweb/Inform/Search.aspx?q=antimicrobial


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Table 2:

Antimicrobial Guideline 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Management of patients with absent or dysfunctional spleen Treatment and prophylaxis of obstetric infections Skin and soft tissue infections – adults Urinary tract infection – adults Amikacin dosing guideline - adults Lower respiratory tract infection – adults Treatment of Clostridium difficile infection ICU antimicrobial treatment guidelines Paediatric antimicrobial guidelines Febrile Neutropenia Tuberculosis Acute bone and joint infections (Adults) Orthopaedic procedures – antibiotic prophylaxis (Adults) Bacterial Endocarditis (Adults) Meningitis (Adults) Sepsis (Adults) Pocket guide for antimicrobial therapy (Adults)

Point Prevalence Audit

A ‘snap shot’ audit of antimicrobial use within the trust was completed. The results of the four main indicators are summarised below: 93.8% of antimicrobial prescriptions have an indication documented in the medical notes. The intended duration of therapy (stop/review date) was documented for only 33% of prescriptions. Where duration of therapy was not stated, an antibiotic stop sticker was applied by ward pharmacists in 61% of cases. 97% of antimicrobial prescriptions were compliant with Trust antimicrobial guidelines.

Surgical Prophylaxis Audit

For 16% of patients there was no record of antibiotic prophylaxis being received. Furthermore, for 50% of MRSA positive patients there was no record of antibiotic prophylaxis being received.

In response to this audit, administration of antibiotic prophylaxis will be included in the pre-operative checklist.

Education and training

An e-learning package for antimicrobial prescribing aimed at junior medical staff will be developed in conjunction with the IT department. Similar packages for other healthcare staff will be considered in the future.

Patient information

Two information leaflets for patients, carers and the public have been produced: General information on use of antibiotics Penicillin allergy

The leaflets are currently available on the intranet and will be made more readily available to patients, carers and the general public.


14

5.7 MRSA bacteraemia 5.7.1 There has been a year on year decrease in the number of MRSA bacteraemia in the

trust (Graph 4)). The reduction target of 36 was achieved and the trust had 28 cases in this period. A number of interventions contributed to this improvement and key changes are identified on the graph.

5.7.2 The root cause analysis of MRSA bacteraemia indicated a significant proportion were related to intravenous lines. Action to improve intravenous line insertion and management is on-going.

5.7.3 Graph 4: MRSA bacteraemia

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Transfer to new hospital building

Renal unit moves to a different trust (the Roral Free Hospital)

MRSA molecular screening of surgical patients begins

IV care bundle starts

Hand hygiene audits begin

Health Care Commission (HCC) inspection

Alcohol-based hand jel for hand hygiene begins

Wound surveillance begins


15

5.8 Clostridium difficile 5.8.1 UCLH had a significant reduction in Clostridium difficile cases during this period.

(Graph 5) 5.8.2 There were 61 cases of C.difficile cases against a trajectory of 180. 5.8.3 The strategy of active C.difficile prevention and management contributed to the reduction and included control and rationalisation of antibiotic use, isolation of cases of diarrhoea, cleaning, hand hygiene and rapid testing for C.difficile. 5.8.4 Graph 5: Clostridium difficile cases and interventions

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Hand hygiene audits begin

Health Care Commission (HCC) inspection

Alcohol-based hand jel for hand hygiene begins

Mandatory reporting begins

ARP

ARP = Antibiotic Review Policy

More sensitive toxin and antigen tests introduced


16

6.0 Outbreaks and incidents 6.1 In the year 1st April 2008 to 31st March 2009, the Occupational Health and Safety

Service worked in conjunction with the Infection control team to manage four instances of TB and three of measles which required contact tracing and follow up. There was no confirmed transmission.

6.2 There were 16 outbreaks associated with diarrhoea and vomiting during this period in the trust. Most involved both patients and staff and led to bed closures for short periods.

6.3 Norovirus 6.3 One outbreak of Norovirus on T10, UCH, involved 38 of the 238 admissions during a

period of 5 weeks and resulted in 83 bed days lost.

6.4 C. difficile

6.4.1 There were no outbreaks of C. difficile during this period.

6.5. MRSA 6.5.1 There were sporadic cases of MRSA but no outbreaks for this period.

6.6 Pseudomonas 6.6.1 The Neonatal intensive care unit at EGA experienced an increase in numbers of

babies colonised with pseudomonas between February and March 2009. An emergency steering group met twice weekly throughout this period to monitor and review actions to ensure safe care was continually delivered.

6.7 Acinetobacter 6.7.1 There have been sporadic cases of acinetobacter at UCLH but no outbreaks for this

period.

7. Plan 2009-2010 - Appendix 2 7.1 The plan was developed by the DIPC, and presented and accepted at the Trust

Infection Prevention and Control Committee, Patient Safety and Risk Committee and Quality and Safety committee.

8. Recommendation 8.1 The Board of Directors are asked to note the annual report and approve the annual

plan.


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Appendix 1 Plan 2008-9 Key aims reflect the trust plan:

Achieve Infection Control strategy Achieve the MRSA bacteraemia and C.difficile targets. Achieve >85% hand hygiene compliance of medium to high risk interventions

The method for achieving, should resources be available, will be:

Continue to deliver infection control advisory service and support to UCLH NHS Trust, pre-empting and reducing risk and minimising the impact of outbreaks or incidents.

Clarify and agree designated leads for infection control in each division, agree how they contribute to and support the infection control strategy

Review current infection control governance processes. Improve quality and access to infection control policies and information for staff and

patients. Continue to introduce and implement the ‘Saving Lives’ care bundles including :

Central venous catheters Peripheral lines (and arterial lines) Blood taking C. difficile Isolation of patients Urinary tract infection (including catheters) Care of ventilated patient Hand hygiene MRSA screening Antibiotic usage Surgical site infection

Audit compliance of the bundles and make any changes required particularly in the light of new evidence and guidance

Continue to feedback surveillance information and infection control performance from wards to board including formal monthly reports.

Increase MRSA screening compliance. Continue work on hand hygiene compliance improvement to achieve a consistent 85%

performance rate for medium to high risk interventions Improve antibiotic management to improve prescribing practice, to optimise patient

outcome and to reflect best practice. Improve isolation facilities and usage Continue to improve pandemic flu planning and improve trust response to seasonal

influenza Develop a medium term solution to decontamination at Eastman Dental Hospital Facilitate engagement by patient groups in the infection control agenda and reflect their

priorities in planning and delivery Continue work to reduce sharps injuries including safe systems and practice Provide infection control advice and support for Phase 2 development and other

renovations or developments Determine methods of cleaning which remove or reduce pathogenic micro organisms Ensure optimal cleaning of patient equipment and environment Develop and support training and education in cleaning. Develop and support courses in infection control to improve infection control knowledge

and competency in the trust


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Appendix 2 Plan 2009-2010 This year the key aims will reflect the overall strategic trust plan and will be to:

Achieve Infection Control strategy, Achieve the MRSA bacteraemia and C.difficile targets, Successfully introduce MRSA screening for elective patients, Achieve compliance with requirements of the Health Act and Care Quality Commission Requirements.

The method of achieving this will be: Action

(A separate plan is available or will be developed for each action)

Time Frame Designated Lead/s

1 Continue to deliver infection control advisory service and support to UCLH NHS Trust, pre-empting and reducing risk and minimising the impact of outbreaks or incidents.

On-going A Jeanes/V Gant

2 Maintain an updated list of all designated infection control leads and liaison staff for each ward, department and division and ensure they have current available infection control information including surveillance and performance. (See also 8, 11, 19).

On-going M Bruce/ A King

3 Clarify and agree infection control key advisors for each area and determine how the service will be delivered and supported.

Complete by 1/8/09 (completed)

V Gant/ M Bruce

4 Review all infection control policies which are more than 2 years old or those affected by recent external changes.

On-going A Jeanes

5 With key stakeholders develop an audit plan for measuring compliance with policies and guidance.

Plan by 1/6/09 (completed)

A Jeanes/V Gant

6 Improve quality and access to infection control information for staff and patients.

On-going M Bruce /A King

7 Continue to introduce and implement the ‘Saving Lives’ care bundles including :

a. Central venous catheters b. Peripheral lines (and arterial lines) c. Blood taking d.C. difficile e. Isolation of patients f. Urinary tract infection (including catheters) g. Care of ventilated patient h. Surgical site infection

Audit compliance of the bundles and make any changes required particularly in the light of new evidence and guidance.

On-going

A Jeanes

8 Develop and implement performance feedback systems and processes including a review of current surveillance.

Complete by 1/9/09

A Jeanes, S Knight

9 Implement MRSA screening for all elective patients (in line with DH guidance).

Continuous process

A Jeanes, B Macrae & APR Wilson


19

10 Measure and report compliance with MRSA screening programme.

As from 1/4/09 (completed)

S Knight

11 Continue work on hand hygiene compliance improvement to maintain >85% performance rate for medium to high risk interventions.

Continuous process

Divisional leads

12 Improve antibiotic management to improve prescribing practice, to optimise patient outcome and to reflect best practice.

Continuous process

Prof Mundy (Replaced by Sally Wilson)

13 Improve isolation facilities and usage. Continuous process

A Jeanes & APR Wilson

14 Continue to improve pandemic flu planning and improve trust response to seasonal influenza.

On-going M Bruce, Virologist, A Bond & L Boden

15 Review compliance with decontamination guidance across the trust and with key stakeholders develop plan to improve performance.

Trust wide review by 1/12/09

A Jeanes & S Martin

16 Facilitate engagement by patient groups in the infection control agenda and reflect their priorities in planning and delivery.

Continuous process

L Boden & M Bruce

17 Continue work to reduce sharps injuries including safe systems and practice.

Continuous process

A Jeanes, D Matthews

18 Provide infection control advice and support for Phase 3 development and other renovations or developments.

Continuous process

A Jeanes/APR Wilson

19 Ensure optimal cleaning of patient equipment and environment (20 point plan).

Continuous process

Divisional leads

20 Continue to provide infection control education and training including annual study day, liaison meetings and ad hoc master classes and seminars.

Continuous process

A Jeanes & M Bruce

21 Continue infection control research including modelling, cleaning, innovations, diagnostics and treatment.

Research A Jeanes & V Gant

22 Optimise opportunities to produce publications and contributions to the infection control evidence base.

Continuous process

A Jeanes & V Gant

23 Undertake audit of practice and on-line questionnaire of wound management across the trust.

Complete by 1/12/09

A Jeanes & S Lewis

24 Deliver study day on basic wound management.

Complete by 1/12/09 (completed)

A Jeanes & S Lewis

D

Agenda Item 7

Chief Executive’s Report


CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

10 MARCH 2010

1. Q3 MONITORING OF NHS FOUNDATION TRUSTS

Monitor’s analysis of the third quarter of 2009/10 is attached as Appendix A, is a letter from the Senior Compliance Manager and a one-page executive summary for UCLH. There is nothing exceptional in the attached letter, except reference to the 62-day cancer target for urgent GP referrals which has been reported and discussed at the Board over the past few months. The Board will note that there is a risk of a failure of the 62-day cancer target at Q4 which would trigger the ‘3 ambers to red’ rule. As at the time of dictating this report we are on track to meet this target for the last quarter, despite the extreme difficulties of access to the specialist MRI scans in view of the significantly improved patient pathway for prostate cancer. The Board will also note that we no longer have to provide monthly reports on A&E waiting time targets due to the fact that we have achieved the 98% target for the past three quarters. There was previously a risk that a failure of the A&E target in the last quarter of this year could trigger a red risk rating as it would have been the third consecutive time that we would have failed the target in the same quarter. I am pleased to report that there is a very high probability that we will achieve the target for this quarter, unless dramatic events occur in the next few weeks. The Board may wish to know that there is a high incidence of norvo virus in the London community – several A&E departments have effectively had to close their doors in order to stabilise the position. This led to a significant number of A&E 4-hour breaches several weeks ago due to patients being redirected by the London Ambulance Service. During the last two weeks, the Trust has experienced a significant outbreak of norvo virus, particularly at UCH and the National Hospital at Queen Square. These have been managed very professionally such that, in order to maintain emergency access, we have only had to cancel a relatively small number of elective admissions. This will undoubtedly have an impact on our elective activity income for this quarter but there are sufficient reserves to cover this eventuality. The Q3 analysis of all Foundation Trusts suggests that income is marginally above plan, driven by an increase in NHS clinical activity and counter balanced by similar increased operating costs. The most significant aspect of the Monitor analysis is that only slightly more than half of Foundation Trusts are rated green for governance, with 16 Trusts red rated and 13 currently in significant breach of their authorisation. In my opinion, this situation is likely to deteriorate during the course of next year due to increasingly challenging targets set by the Care Quality Commission, particularly related to infection control targets and deteriorating financial performance because of the economic recession. These matters are discussed elsewhere on the Board’s agenda.

2. PROGRESS ON DISCUSSIONS WITH THE ROYAL FREE AND WHITTINGTON HOSPITALS

The Board will recollect that there are two separate sets of discussions, one specifically with the Royal Free Hospital and another which includes the Whittington Hospital. The specific discussions with the Royal Free Hospital concern a limited package of service changes involving pancreatic cancer, the hyper acute stroke unit, neurosurgery and ENT. I am pleased to report progress on the first three of these areas, with the report on ENT to be considered by the Royal Free Hospital Board later this month. On the assumption that it agrees the principle of transferring the RNTNE to UCLH, then we can be confident that the package of measures can be implemented. All four services are operating to different timescales. Once the package has been approved then we can proceed to public consultation,

1

if this is considered necessary by the PCT, and to commence the transfer of staff between the two Trusts. Specifically in relation to the RNTNE transfer proposal, we will need to undertake a process of due diligence to ensure that neither Trust is disadvantaged without proper recompense. The tripartite discussions which include the Whittington Hospital, referred to in the Chairman’s report at the last Board meeting, are progressing satisfactorily but on a much slower timescale than those referred to above. These discussions are being led by a project team chaired by Tara Donnelly (who is contractually employed by all three organisations) and overseen by monthly meetings of the Chairmen and Chief Executives. Options and proposals will be submitted to the Board when these are developed.

3. AGENCY COSTS

It is recognised that spend on agency staff is undesirable for a number of reasons, the two main drivers being safety and cost. There is evidence that where high proportions of agency staff are used, care may be less reliable as staff members tend not to be as familiar with trust practices or standards. This can lead to complications such as increased rates of pressure sores or infections, resulting in inefficiencies including longer lengths of stay for patients. Employing agencies charge a commission for their service which is typically in the range of 15-22% of salary; this is spending which adds no value and ought to be reduced to the absolute minimum. Instead we prefer to recruit our own staff substantively, covering any remaining gaps through “bank” staff rather than using commercial agencies. We have therefore committed as an organisation to eliminate the use of agency staff as far as possible. A considerable amount of activity has taken place to review the position within each of the Clinical Boards and Corporate areas to understand current spend on this group of staff and develop plans to reduce spend markedly from April onwards. This work has been led by the Directors in each area. While the bulk of the spend is on clinical agency staff, as a Trust we also spend significant amounts on non-patient facing agency staff. This year we will spend £353m in pay costs, this includes £24m on agency staff and £16m on bank staff, with the remaining £313m being on our own directly employed staff. Our target is to save £2m on our pay costs in 2010/11 and the focus on this is reduction of agency staff spend, and this requires a rate of saving of £170k per month from April. The QEP Workforce project is supporting this work led by Directors by considering both demand; in particular, reducing recruitment delays, and supply; by increasing the numbers and types of staff available to us through the “bank” rather than agency. For example our bank arrangements only cover nurses and admin staff at present; this will be extended to establish a medical staff provision as well as other commonly used staff groups. A report was considered by the Executive in February and each Director has an action plan to reduce agency usage to zero where possible, with performance being reviewed on a monthly basis. In a Trust of our size there will always be some need to access specialist skills urgently, and therefore we recognise that some usage of front-line clinical agency staff will continue, but are making clear statements about the level of ambition.

4. COMMERCIAL DEVELOPMENTS – PROCUREMENT

As part of a package of measures to address the economic downturn, the Department of Health are carrying out work in relation to procurement and the NHS Supply Chain contract. The Board may recollect that the NHS Supply Chain contract was let to DHL and there has been some concern expressed at the cost effectiveness of the new arrangements. In addition to national consideration, a number of the Strategic Health Authorities have initiated work to consider future procurement and supply chain arrangements. Our current arrangements have been secured through the Healthcare Purchasing Consortium (HPC), which is a West Midlands based consortium, for much for the past decade. This consortium is hosted by the University of

2

Coventry & Warwickshire NHS Trust which is currently seeking to divest itself of this responsibility in support of its application to become a Foundation Trust. The Trust considers that the potential liabilities of the Consortium may exceed its asset value and has therefore decided to place an OJEU advert for its disposal. Mike Foster (and the Trust’s Procurement Director, John Watts) will be monitoring this situation as it progresses to ensure that our own arrangements are safeguarded during this process. Once again I should register a potential conflict of interest in that I have been advising HPC on its strategy in an unpaid and non-contracted basis. Should this situation change then I will bring it to the attention of the Board.

5. UPDATE ON ORGANISATIONAL DEVELOPMENT

The Board asked for an update on the Trusts current OD activities, which was part of the objectives set by the Board at the beginning of the year. Although there has been no overall corporate programme of organisational development, each individual clinical board has implemented a series of programmes aimed at improving performance in their own areas of responsibility. On a Trust-wide basis we have implemented a comprehensive ‘After Action Review programme’ which was the subject of a detailed discussion in the Board-to-Board meeting with Cambridge University Hospitals last month. We have also led the way in implementing the WHO Safe Surgery Checklist which has received acclaim from the originators of the programme. Individual clinical boards have developed a range of specific programmes, either across the clinical board as a whole or within individual divisions. Amongst the numerous examples are programmes in cultural change, diversity and equality, service development (COPD and elderly care), board development and divisional awaydays. For the coming year we will seek to develop a more cohesive Trust-wide programme following the appointment of the new HR Director who should come into post within the next 6 months. In the intervening period, Julia Whitehouse will continue as Interim HR Director, focussing on the continual improvement of basic HR practices as previously reported to the Board of Directors.

SIR ROBERT NAYLOR CHIEF EXECUTIVE MARCH 2010

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1 March 2010 Sir Robert Naylor Chief Executive University College London Hospitals NHS Foundation Trust 2nd Floor Central 250 Euston Road London NW1 2PQ

Dear Sir Robert, Q3 2009/10 monitoring of NHS foundation trusts Our analysis of Q3 is now complete. Based on this work, the trust’s current ratings are:

Financial risk rating - 4;

Governance risk rating - AMBER;

Mandatory services risk rating - GREEN. The Trust has been assigned an amber governance risk rating, which reflects that it has failed to meet the 62 day cancer target for urgent GP referral to treatment for all cancers and the national core standard C8b (healthcare organisations support their staff). Compliance with targets and national core standards is a requirement of the Trust's terms of Authorisation. The Compliance Framework sets out the significance that Monitor attaches to a failure to comply. You should by now have prepared and provided Monitor with details of the actions the Trust is taking to address the risk of current and future non-compliance with targets and national core standards. Monitor expects these plans to be successfully executed such that your board will be in a position to submit unqualified self-certifications in future monitoring cycles. The Trust is required to submit information on the 62 day cancer targets on a monthly basis until further notice. Since the Trust has achieved the A&E target for three consecutive quarters, monthly A&E monitoring is no longer required. I have attached a report on the aggregate performance of the NHS foundation trust sector which I hope you will find of interest, together with a one page executive summary of your trust’s Q3 results. For your information, we will shortly be issuing a press release setting out a summary of the key findings across the FT sector from the Q3 monitoring cycle.

4 Matthew Parker Street London SW1H 9NP T: 020 7340 2400 F: 020 7340 2401 W: www.monitor-nhsft.gov.uk

http://www.monitor-nhsft.gov.uk/

If you have any queries relating to the above, please contact me by telephone on 020 7340 2522 or by email ([email protected]). Yours sincerely

Russell Harris Senior Compliance Manager cc: Sir Peter Dixon , Chair Mr Richard Alexander , Finance Director

1

Non financial • Declaration 2 for governance has been signed by the Trust reflecting a breach of the

62 day wait from urgent GP referral to treatment for all cancers (76%) and non

compliance with Core Standard 8b.

• The Trust have achieved the A&E target for all quarters in 2009/10.

• Sir Peter Dixon retires as the Trust Chair on 30 June 2010.

• Professor Sir John Tooke was appointed as Non-Executive Director at the

Governor’s February meeting and takes up post with immediate effect.

• The Trust will commence monthly Cancer monitoring.

• A failure of the 62 day cancer target at Q4 2009/10 will trigger the ‘3 ambers to

red’ rule.

• The Trust will re-commence quarterly monitoring for A&E.

• Richard Murley has been appointed with effect from 1 July 2010. Mr Murley

joined UCLH as a non-executive director in November 2008 and currently

chairs the UCLH Quality and Safety Committee and the Investment

Committee.

FinancialAction /ResolutionKey risks

Long Term Borrowing limit £340.4m

Long Term Borrowing at Q3 was £273.1m

The Trust are rated Amber following a breach of the 62 day cancer target and non compliance with Core Standard 8b.

The Trust is above plan with an FRR of 4 at Q3 09/10.

Continue quarterly Financial

monitoring and re-commence

quarterly A&E monitoring.

Commence monthly Cancer

monitoring.

University College London Hospitals NHS Foundation Trust

Q3 09/10 reporting executive summary

• At Q3 the Trust had a liquidity rating of 4 (26.5 days).

• Cash at £92.9m is £5.2m over plan due to increased EBITDA and

capital slippage partially offset by movements in working capital.

• No working capital facility is in place (maximum per Schedule 5 is

£45m).

Liquidity

Q1 Q2 Q3 Plan

FRR 3 3 4 3

Governance G A A G

Mandatory

servicesG G G G

• EBITDA is £4.9m above plan primarily due to significant additional income from

activity over plan and the associated costs of meeting this.

• NHS Receivables are £29m over plan at Q3. This balance is partially provided for

with a corresponding £18m increase in accruals.

• CIPs over-achieved by £0.9m in the quarter, but cumulative slippage of £0.2m

remains.

• Discussions continue with the PCT in relation to the recoverability of

outstanding amounts. The Trust received correspondence in January 2010

questioning billing in the first 6 months of the year.

FY

Plan Actual Variance Plan Actual Variance Plan

Revenue (Total) 161.8 178.2 16.3 486.6 522.5 35.9 648.5

Employee Expenses (84.0) (90.4) (6.4) (251.8) (264.8) (13.0) (335.9)

Drugs (14.7) (14.1) 0.5 (44.0) (43.2) 0.8 (58.5)

PFI operating expenses (4.5) (4.5) (0.0) (13.4) (12.5) 0.9 (17.8)

Other costs (45.1) (52.9) (7.8) (135.2) (154.9) (19.7) (180.7)

EBITDA 13.6 16.2 2.6 42.2 47.1 4.9 55.6

Depreciation and amortisation (5.3) (4.7) 0.6 (15.8) (13.8) 2.0 (21.2)

Net interest (6.3) (6.4) (0.0) (19.0) (19.0) (0.0) (25.3)

Other (2.3) (2.2) 0.1 (6.7) (6.7) 0.1 (9.0)

Net Surplus / (Deficit) (0.3) 3.0 3.3 0.7 7.7 7.0 0.0

EBITDA % Income % 8.4% 9.1% 0.7% 8.7% 9.0% 0.3% 8.6%

CIPs £m 5.4 6.3 0.9 15.5 15.3 (0.2) 21.0

Net Surplus / (Deficit) (0.3) 3.0 3.3 0.7 7.7 7.0 0.0

Change in working capital 5.6 (10.5) (16.2) 2.4 -10.5 (12.9) (8.2)

Non cash I&E items 12.9 10.2 (2.7) 38.6 32.5 (6.0) 51.6

Cashflow from operations 18.2 2.6 (15.6) 41.7 29.7 (11.9) 43.4

Cashflow from investing activities (13.2) 18.0 31.2 (36.3) (24.7) 11.5 (55.4)

Cashflow before financing 5.0 20.6 15.6 5.4 5.0 (0.4) (12.0)

Cashflow from financing activities (7.8) (0.6) 7.1 (25.2) (19.6) 5.6 (25.8)

Net increase/(decrease) in cash (2.8) 20.0 22.8 (19.8) (14.6) 5.2 (37.8)

Cash at period end 87.8 92.9 5.2 87.8 92.9 5.2 69.8

Financial Summary

£mQuarter YTD

E

Agenda Item 8

Executive Board Report


Executive Board Report to

the Board of Directors, March 2010

1. Capital and Estates Issues On the recommendation of the Capital Investment Board, the EB approved a

number of capital schemes. These include: • An ICT interface scheme to improve the collection of data between

CareCast and the radiotherapy treatment system to remove the need for duplicate data registration – this scheme was part of the year 1 ICT strategy;

• Rotorgene equipment to enable the HTD to better diagnose parasitic infections – funded by Charitable Trustees monies; and

• A research gamma camera to support transitional research in Nuclear – externally funded by UCL Cancer Research Institute.

The Capital Investment Board reviewed the capital programme; this will be presented to the Board in April.

2. Same Sex Accommodation

The EB received a report from Louise Boden, Chief Nurse, which advised that all Trusts are required to self assess their accommodation and make a declaration confirming compliance to the virtual elimination of same sex accommodation. It was noted that the declaration of compliance, which is a national requirement set out in the 2010/11 Operating Plan, must be published on the Trust website by 31st March 2010. The report outlined the action being taken across the Trust to adhere to same sex accommodation guidance and the EB noted that a delivery group had been set up to implement the required action including the production of a same sex delivery plan which will be monitored by commissioners. The declaration statement, which is not considered to be an issue, will be approved by the EB prior to publication at the end March.

3. Homeless Health Service Project The EB received a report from Aidan Halligan, Director of Education, which provided an update on the work of the Homeless Health Service. The report confirmed that the service is now well established and components of the service including the GP led ward round, homeless health practitioners and the sanctuary continue to be developed. There had been an evaluation of the service; this had identified that the duration of unscheduled admissions for homeless patients had reduced by 3.2 days per patient and the proportion of homeless patients discharged with multi-agency care plans had increased ten-fold from 3.5% to 35%. The EB noted that funding had been secured to ensure the service could continue to be provided and that Paul Glynne had received excellent feedback about the project which was regarded as a first rate service.

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4. Policy Compliance and Policy Approvals The EB approved the following new and revised policies:

Disciplinary Policy and Procedure for Medical and Dental Staff This new policy which describes current practice, implements the national policy framework ‘Maintaining High Professional Standards in the Modern NHS’. In implementing this policy framework the Trust is acting in accordance with Directions on Disciplinary Procedures 2005 and the Restriction of Practice and Exclusion from Work Directions 2003.

Complaints Policy - This policy sets out the new approach for resolving a complaint and explains the role of the Parliamentary and Health Service Ombudsman (PHSO) in the complaints process.

Asbestos Management Policy - This policy details how the risk from known or suspected Asbestos Containing Materials within Trust’s buildings is adequately managed. Radiation Safety Policy - This policy describes the framework for protecting employees and other persons from the harmful effects of ionising radiations.

Disciplinary Policy and Procedure - This policy sets out the procedure for investigating and dealing informally and formally with issues of misconduct. Bullying and Harassment Policy and Procedure - This policy sets out the Trust’s commitment to protecting staff from bullying and harassment and includes the procedure that should be followed for raising and resolving complaints. Sickness Absence and Attendance Policy and Procedure - This document sets out the policy and procedures for managing sickness absence.

Copies of the above documents are available to Board Members on request to the Trust Administrator. SIR ROBERT NAYLOR CHIEF EXECUTIVE

F

Agenda Item 9

Quality & Safety Committee Report

University College London Hospitals NHS Foundation Trust Quality & Safety Committee Summary Report to the Board of Directors, February 2010

Patient Safety 1. Serious Untoward Incident (SUI) update

SUI Action and Learning Action plans and learning points arising from the SUIs were reviewed. The Committee signed off and closed a number of action plans developed by Divisions in response to SUIs since the November QSC. 2.0 Patient Identification The QSC received a progress update from the Patient Wristbands Implementation Group. The financial impact of implementation of the National Patient Safety Agency Safer Practice notice to standardise wristbands is to be evaluated. 3.0 Inpatient Survey QSC received the Inpatient Survey Results for 2009 which benchmarked the Trust relative to the Picker average and our London acute teaching hospital peer group. Scores were significantly better than average for 18 of the survey questions, worse than average for one and average for 73. All but one area identified in the lower 20% ranking in 2008 have improved and are no longer ranked as low performance. The score remaining in the lower 20% relates to delayed discharge of > 1 hour, identifying an area for improvement. The Heart Hospital was best performer, with the Queen Square division second best performer and most improved. Overall ranking in the top 20% for Patient Satisfaction is a Trust Quality Account priority with four of the Inpatient survey questions tracked as key performance indicators.

4.0. Care Quality Commission (CQC) Registration The Trust registered compliance with the Health and Social Care Act 2008 regulations on 28th January. The Commission is now considering the declaration and may require additional information prior to registration on 1st April. Action plans for areas of concern identified in the risk assessment for the declaration are being drawn up for: safe restraint, care of patients with learning disability, environmental issues, A&E records, staff appraisal, nutrition team cover and malnutrition screening tool (MUST) scoring. Checking professional registration is not felt to be a problem and clarification is being sought on notification of concern to the Nursing & Midwifery Council. The CQC plan to inspect Trusts by unannounced hospital visits to observe patient care and services and by continuously checking compliance systems. The Trust will be informed of its registration status by the issue of individual Judgement Statements. 5.0. Sub-committee reports 5.1 Risk Coordination Board: The RCB Risk and Assurance Framework report for Q3 2009/10, as previously reported to the Board of Directors, was presented to the QSC. General issues

6.0. Scorecards/quality indicators 6.1 Antibiotic prescribing: Added to the scorecard to highlight importance and encourage divisions to raise the profile with junior doctors. Prescribing guidelines are now in place for 77% of antibiotics and improvements are being seen. The Antibiotic Usage Committee is working with education leads on training for medical staff around prescribing.

7.0 Infection Scorecard (January 2010) MRSA: UCLH is slightly ahead of its threshold. National target to be reduced to eight cases next year. Case mix and complexity are not taken into consideration. It is planned to pre-empt the target by introducing near patient testing and further initiatives. 8.0 NHS Litigation Authority (NHSLA) update Women’s Health division were congratulated for achieving Clinical Negligence Scheme for Trusts (CNST) level 3 accreditation in January. A recent informal inspection by the NHSLA assessor confirmed that the Trust is in a good position to undergo assessment at level 3 for the rest of the organisation, as planned, in June. 9.0 Pressure Ulcer Incident Reporting Divisions were reminded that all grade 2 and above pressure ulcers must be reported using the incident reporting system. Currently 45% are reported and the NPSA are planning to prioritise. Sandra Hallett Director of Quality & Safety February 2010

G

Agenda Item 10

Finance & Contracting Committee Report

University College London Hospitals NHS Foundation Trust Finance and Contracting Committee Report to Board of Directors 4th March 2010 1. INTRODUCTION

This report updates the Board of Directors on the issues considered at the meeting of the Finance and Contracting Committee (FCC) on 3rd March 2010. These cover:

Matters Arising - Section 2 Finance Directors Report – Month 10 - Section 3 Contracting Update - Section 4 Cross-Committee Issues - Section 5 2010/11 Financial Planning Update - Section 6 Any Other Business - Section 7

2. MATTERS ARISING There were a number of matters arising that were not covered within the main agenda, as follows:

• The Deputy Chief Executive updated the Committee on the work that the Director of Procurement is leading upon to implement a new local agency agreement by 1st May 2010. The Committee welcomed this work, but recognised this within the overall context of the Trust aiming to significantly reduce its use of agency staff.

• The Finance Director informed the Committee of the work that was being undertaken

to control pay expenditure as part of the Quality, Efficiency and Productivity (QEP) work streams. The Finance Director mentioned that, as part of the budgetary control process, all pay-related efficiency schemes in future would be clearly monitored on both a financial and headcount basis.

The Finance Director also informed the Committee that Internal Audit would shortly be undertaking an advisory audit on the pay control processes that the Trust had put in place. The Committee also discussed the processes in place for the recruitment of new staff. The Medical Director for the Medicine Clinical Board advised the Committee that the recruitment of new consultants was undertaken in accordance with the recommendations following a previous Internal Audit review of this area in that, outside of the existing establishment, all new appointments had to be in line with the Trust’s business case planning process.

• The Deputy Finance Director (Decision Support) reminded the Committee that some

HIV activity, which had previously been counted as HIV contract-related, was now appearing as part of general PCT contracts. The Deputy Finance Director advised the Committee that appropriate adjustments, to ensure that income recognition was aligned with budgets, would now be made as part of month 11 reporting.

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3. FINANCE DIRECTORS REPORT – MONTH 10

The Finance Director presented the month 10 performance summary and management accounts pack, and summarised the key messages contained within these reports. The financial performance of the Trust is summarised in table 1, below. Ratings in this table are scored from 5 to 1 (5 indicating low risk, 1 indicating high risk).

Financial Risk Rating

Area of Review Year to date actual

Year to date plan

Financial Summary 3 3

Comprising:

Operational Performance 4 4

Liquidity 4 4

Use of Assets 3 2

Overall Income and Expenditure 3 2 Table 1 – Month 10 Financial Performance Summary

The Committee noted that the month 10 year-to-date EBITDA position, as set out in table 2, below, is £4.3m ahead of plan, whilst the overall income and expenditure surplus of £7.6m is £6.8m ahead of plan.

Service Line Month 9 year-to-date Budget

£m Actual

£m Variance

£m Medicine Board 3.1 7.3 4.2Specialist Hospitals Board 9.1 10.4 1.3Surgery & Cancer Board 14.5 8.3 (6.2)Other (Research & Development, Education, Corporate budgets) 20.4 25.4 5.0

EBITDA 47.1 51.4 4.3ITDA (46.2) (43.8) 2.4

Net Surplus/(Deficit) 0.8 7.6 6.8Table 2 – Month 10 year-to-date financial position

The Finance Director informed the Committee that, in relation to plan, January had been a fair month in terms of both activity and overall income. The Committee was pleased to note that the in-month activity for January was slightly better than had been previously anticipated by the Finance Director last month, following such an exceptional December. The Trust’s direct income over performance against plan had now reached £30.2m, an in-month increase of £1.4m. The Finance Director informed the Committee that whilst there remains the risk that PCTs will not pay for the over performance, that the clinical divisions are currently delivering, no

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new issues of concern had arisen in month 10, and therefore he remained confident that the Trust was on course to achieve, as a minimum, the revised income & expenditure target of £7.1m for the full-year. The Finance Director updated the Committee on the financial position of the Clinical Research Facility, noting that income had not been generated as quickly as anticipated because refurbishment delays had meant the facility was not fully operational. The Committee noted the key issues within the Clinical Board financial positions, as follows:

• The Medicine Clinical Board has maintained its over performance into January, and is now £4.2m ahead of plan. The Finance Director remained confident that the Board would reach the EBITDA target of +£5.0m against plan for the year.

• Although the Specialist Hospitals Clinical Board remains ahead of plan by £1.3m year-to-date, in-month the Board is £0.6m behind plan (£0.3m down against its previous forecast). Whilst Paediatrics and Women’s Health have both improved, the latter due to activity increases in maternity and neo-natal services, poor weather had affected performance in other divisions, particularly at Queen Square.

• The overall Surgery and Cancer Clinical Board position has shown an adverse in-month movement of £1.0m, despite continued strong income performance in January. The Committee noted that bariatric cases, including transfers from other hospitals, remained below forecast, and that it was thought this was due to both bed shortfalls as well as adverse weather conditions. The Committee also noted that the Board was not confident of recovering this loss of activity by year-end, and consequently this would have an impact in terms of the Board’s ability to deliver its year-end EBITDA target of -£5.0m.

The Medical Director for Surgery and Cancer updated the Committee on the Board’s progress in improving its operational efficiency. The Medical Director noted that whilst there were still areas that could be further improved; he believed that this was not a major contributor to the Board’s financial position. The Medical Director was also concerned that due to improved efficiency a greater thoroughfare of non-elective admissions in future would result in less income, as a result of changes in the national tariff.

The Deputy Chief Executive updated the Committee on progress with resolving outstanding pass-through payment issues, which included £1.3m relating to the Surgery and Cancer Board. The Committee was advised that of a total potential target of £6.4m, which it had been initially hoped might be settled in the Trust’s favour; £1.3m had been agreed to-date, whilst the remainder is still under discussion.

The Committee noted that some of the Trust’s financial issues related to new business cases, and asked for a further update on the review of the business case planning process, with particular reference to the issues that the Committee had recently discussed, including the Clinical Research Facility, cardiac services, and bariatric services.

The Committee noted the greater transparency that was now being shown in the reporting of the Trust’s cash position. The Committee also noted that whilst the Trust’s cash position at 31st January was £7.7m favourable against plan, this was mainly due to delays in the capital programme.

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The Finance Director updated the Committee on some of the key aspects of the adverse working capital position:

• There was currently a high debtor balance mainly because activity over performance was subject to different invoicing arrangements than PCT baseline income.

• Although creditor payments appear to be slower than planned, the Finance Director

noted that the accounts payable function was currently going through a radical change process. A new accounts payable manager was now in place, and with Procurement input into the process, it was hoped that there would be a significant improvement in performance within six months.

The Committee noted the remaining sections of the management accounts pack.

4. CONTRACTING UPDATE

The Deputy Chief Executive presented the Committee with an update on contracting issues, specifically covering 2009/10 contract negotiations, 2009/10 activity reporting and billing, and an update on 2010/11 issues arising. The Deputy Chief Executive informed the Committee that following progress over the last month the two remaining non-associate commissioners have now confirmed contractual values for 2009/10. The Committee noted that in 2009/10, to-date, the Trust has invoiced PCTs £37m relating to over performance on commissioner contracts, but that off this value, £17m remains outstanding (£12m relating to North Central London commissioners, £5m other). The Deputy Chief Executive provided an update on progress with resolving the element of the North Central London outstanding amount that had been challenged (£4.9m), noting a piece of work demonstrating its validity had now been completed within the Trust. The Committee engaged in a detailed discussion on a range of contracting issues for 2010/11, in particular the element of income that is dependent on meeting national, regional and local Commissioning for Quality and Innovation standards (CQUINs). The Committee noted that as CQUIN funding has now increased by 1.0% to 1.5% of contract values for 2010/11, this could potentially lead to additional requirements involving increased investment costs. The Committee noted that whilst work was being undertaken within the Trust to provide more definitive local guidance to determine whether the Trust had met CQUINs criteria, there were still a number of different interpretations of the guidelines in circulation. The Committee asked that Trust concerns on this issue be raised with the Department of Health (DoH) via the Foundation Trust Network. The Committee also noted its concern on the increase in “low priority” procedures that PCTs were proposing would now require authorisation from a prior approval treatment panel, as part of the referral process. The Deputy Chief Executive advised the Committee that it was thought that up to £6m of Trust income would potentially be affected by this change. The Committee asked the Deputy Chief Executive to update them of progress on this issue.

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5. CROSS-COMMITTEE ISSUES

No new cross-committee issues were noted. 6. 2010/11 FINANCIAL PLANNING UPDATE

The Deputy Finance Director (Decision Support) updated the Committee on current progress with the 2010/11 financial planning process, which included a revised draft 2001/11 financial budget for the Trust, as well as the key assumptions being made. The Committee noted the following key issues:

• There remain two significant contingencies that affect the Executive’s view of the current Trust plan. Firstly, although the gap between the PCTs’ opening position and the Trust’s own has already narrowed significantly, the uncertainties surrounding the ability of the PCTs to pay for the planned income growth is unclear. A provision of £5m has been included to cover this exposure. Secondly, although tariff and R&D discussions with other London Trusts and the DoH are showing considerable promise, the position will not be settled for some time.

• The intention remains to have final budgets in place from 1st April, so that that

divisional budgets can be actively managed from that time on. It is proposed for final Trust board sign-off on 14th April, by which point it is intended that any further issues arising will be handled through board contingencies at the Trust level.

• The updated budget is based on the financial implications assessed as part of

version 4 activity projections for 2010/11, published on 8th February, intended to reflect accurately the purchasing intentions of PCTs. The calculation of income had also been updated to now be based on final tariff just recently released by the DoH.

• The current planning gap remained at £38m, and although it was still intended that

this would reduce, particularly as a result of further management of some issues, e.g. Agenda for Change incremental drift, this continues to be balanced by concerns about the overall capacity of PCTs to pay for growth.

The Finance Director highlighted the following steps that remain to be undertaken:

• Revising the final scale of the QEP and recommending a basis on which this should

be allocated to the relevant boards. • Agreeing the financial management of those clinical boards that are in recurrent

deficit. • Establishing a final basis for the allocation of R&D income, taking account of the work

that is being undertaken to match it with cost. • Refining the SLR based contribution targets which remain in draft, but are still subject

to reconciliation.

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The Committee noted that the plan should also include the assurance from Medical Directors that capacity was in place to deliver the intended 6% increase on clinical income over last year. The Chief Executive informed the Committee that there would be further discussion of the financial plan, including the issue of capacity, at an Executive Board seminar planned for 24th March; the outcomes of this would form the basis for the final Trust budget to be taken to the April Board for approval.

7. ANY OTHER BUSINESS The Deputy Chief Executive presented the Committee with a paper that provided an update on the changes to payment by Results (PbR) for 2010/11 and the related financial and contracting impacts. The Deputy Chief Executive briefly highlighted the following key issues:

• Suspension of PbR – the paper noted that this could only be applied for by SHAs in exceptional circumstances, and would require the full engagement of Monitor, where any such developments affected NHS foundation trusts.

• Threshold of emergency admissions – the Committee was reminded that there was

an adverse financial impact of £5.5m for the Trust as a result of the introduction of a financial threshold for emergency admissions, above which only a marginal rate of 30% would be paid.

• New Standard Acute Contract – the Trust would need to decide whether it should

migrate to the updated version of the Standard Acute Contract. This involves a greater focus on management of contract performance through a series of penalty based measures, as well as the requirement to work more closely with commissioners.

• Beyond 2001/11, it is anticipated that the national tariff is expected to be the

maximum payable for services, rather than the standard tariff.

The Committee thanked the Deputy Chief Executive for his paper, and asked if this could be brought back to the next FCC meeting to allow a fuller discussion on the issues, and their implications for the Trust, to take place. Jane Ramsey Richard Alexander Chair Finance Director 4th March 2010

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H

Agenda Item 11

Performance Report

Month 10, January

This document contains commercially confidential information and must not be released or circulated

UCLH NHS Foundation Trust

Board of Directors Performance ReportMarch 2010

(Month 10 – January)

1. Executive summaries 2. Finance 3. Efficiency/ Productivity 4. Activity 5. Access 6. Patient Safety and Quality metrics 7. Workforce 8. Externally Reported Frameworks

Month 10, January

Contents

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Number of MRSA Bacteraemias*16 4 2 1 0 1 18 3 10 5 Non-admitted closed percentage

under 18 weeks13 95.0% 96.9% 97.1% 98.5% 96.3% 96.8% 98.2% 96.7% 96.4%

Number of clostridium difficile cases post 48 hours*

16 11 6 1 4 1 74 27 32 15 Admitted closed percentage under 18 weeks

13 90.0% 95.0% 100.0% 93.9% 95.3% 93.9% 99.3% 90.8% 95.7%

Percentage Hand Hygiene Compliance

16 85.0% 86.7% 79.7% 84.8% 88.8% 86.6% 85.8% 82.6% 89.4%62-day wait for first treatment from urgent GP referral to treatment: all cancers

14 85.0% 88.5% 100.0% 82.4% 95.7% 79.6% 95.7% 73.5% 92.5%

Percentage MRSA screening for electives

16 100% 100% + 100% + 100% + 100% + 100% + 100% + 100% + 95%62-day wait for first treatment from consultant screening service referral: all cancers

14 90.0% 50.0% 50.0% 61.3% 61.3%

Patient falls*17 41 61 12 18 31 581 125 156 297 31-day wait for second or subsequent

treatment: surgery14 94.0% 95.8% 100.0% 85.7% 97.0% 100.0% 97.6% 94.4%

Serious patient falls17 1 0 0 0 0 3 1 0 2 31-day wait for second or subsequent

treatment: anti cancer drug treatments14 98.0% 99.0% 99.0% 100.0% 99.9% 99.9% 100.0%

Incidents per 100 admissions17 5.0 4.3 3.8 3.5 5.1 5.5 6.3 3.9 6.4 31-day wait from diagnosis to first

treatment: all cancers14 96.0% 97.2% 100.0% 97.0% 97.7% 97.1% 92.1% 97.1% 97.8%

Complaints responded to within target time

18 85.0% 62.0% 62.5% 52.2% 73.7% 81.5% 79.5% 79.3% 84.0% Two week wait from referral to date first seen: all cancers

14 93.0% 93.3% 92.4% 95.9% 93.3% 92.9% 100.0% 94.2%

Overall, how would you rate the care you have received

18 82.5% 78.8% 73.6% 72.3% 88.0% 79.4% 75.8% 79.0% 82.9% Two week wait from referral to date first seen: breast symptoms

14 93.0% 94.0% 94.0%

Percentage Last Minute Cancellations to Elective Surgery

18 0.8% 1.7% 1.4% 2.2% 1.1% 0.0% 0.9% 1.6%A&E attendances within 4 hours

14 98.0% 98.8% 98.8% 99.4% 99.4%

Readmitted in 28 days after cancellation*

19 95.0% 100.0% 100.0% 100.0% 99.1% 100.0% 99.3% 99.0%13 Week Outpatient Wait

15 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Hospital standardised mortality ratio (1yr rolling data, 2 months in arrears)

19 0.74 0.69 0.65 0.64 0.8526 Week Inpatient Wait

15 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Maximum 3 Month Revascularisation Wait

15 99.5% 100.0% 100.0% 100.0% 100.0%

* Thresholds only apply to trust. Clinical Boards have specific targets Choose and book slot issues15 4.0% 1.3% 0.9% 0.3% 1.8% 9.6% 11.2% 7.3% 10.1%

Access to chest clinics in 14 days15 98.0% 100% 100% 100% 100%

Month 10, January

This month Year to dateThis month Year to date

Executive summary 1: quality, access

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Direct income (£m) 4-101.4 0.2 0.6 0.7 -0.2 30.2 7.4 6.1 13.1 3.6

% Elective activity variance from plan

12 0.0% -9.4% -28.6% 6.3% -19.5% -6.0% -14.2% -7.0% -4.6%

Direct costs (£m) 4-10-2.3 0.3 -1.6 -1.2 0.2 -27.1 -2.7 -12.2 -10.1 -2.2

% Daycase activity variance from plan

12 0.0% 0.0% 46.4% -2.6% -1.5% 3.2% 29.8% 0.8% 3.7%

EBITDA (£m) 4-10-0.5 0.5 -1.0 -0.6 0.5 4.3 4.2 -6.2 1.3 5.0

% Non-elective activity variance from plan

12 0.0% 14.5% 25.8% -17.9% 17.8% 14.5% 16.6% 3.2% 16.7%

Net surplus/deficit (£m) 4-10-0.2 0.5 -1.0 -0.6 0.8 6.8 4.2 -6.2 1.3 7.4

% Outpatient activity variance from plan

12 0.0% 2.7% 3.6% 3.6% 1.9% 5.0% 3.3% 3.4% 6.4%

Finance: Green: variance either positive or less than 5% of budget, Amber: variance 5%>10% of budget, - Red: variance >10% of budget

Workforce turnover 20 12% 13% 11% 14% 9%Externally Reported Frameworks

Vacancy rate 20 12% 13% 11% 12% 4%FRR 4

Monitor compliance 21 (Quarterly position)

Sickness rate 20 3% 3% 3% 3% 2%CQC performance (estimated) 22 (YTD position)

Staff numbers versus plan 20 -3% -4% -2% -2% -4% -3% -4% -2% -2% -4%

Agency spend 20 13% 15% 23% 12% 11%

Appraisal rate 20 44% 62% 49% 30% 52% 0% 0% 0% 0% 0%

Month 10, January

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This month Year to date

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Executive summary 2: activity, efficiency, finance, workforce

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Area of review

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2. Liquidity

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4. Overall I&E

Financial Summary- Overall Rating

Year to date rating

Month 10 Actual

Month 10 Plan

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Key Highlights

2. Financial performance2.1 Financial Performance Summary

Year to date rating

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Area of review Key HighlightsMonth 10

actual Month 10

plan


Against EBITDA, the year-to-date position is £4.3 million ahead of plan (£51.4m actual versus £47.1m plan) (YTD FRR = 3).At M10, the Trust has made a contribution of £124.0 million before indirect costs. This is £3.1 million ahead of the planned contribution of £120.9 million.Net year-to-date income from activity (i.e. excluding drugs, devices & other pass-through items) is £27.1 million ahead of plan (£2.0m in-month over performance).

3 3


At M10, against EBITDA, the Trust has a 8.9% return on income (YTD FRR = 4). YTD positions are:Medicine £4.2 million ahead of plan (+£0.5m in-month).Specialist Hospitals £1.3 million ahead of plan (-£0.6m in-month).Surgery & Cancer £6.2 million behind plan (-£1.0m in-month).The remaining Corporate budgets (including Research & Development, & Education) are £4.9 million ahead of plan.

4 4

2. LiquidityThe liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 26 days of the Trust’s operating expenses (YTD FRR = 4).At 31st January 2010 the Trust’s cash position was £83.1 million against a planned cash position of £75.4 million, a favourable variance of £7.7 million.

4 4

3. Use of AssetsThe Trust made a 4.6% return on net assets (YTD FRR = 3). Of the current capital programme totalling £74.8m, 82% (or £61.2m) is approved & in progress. 3 2

4. Overall I&EThe M10 “bottom-line” position is a surplus of £7.6 million, a 1.3% return on income (YTD FRR = 3). The YTD I&E position is £6.8 million ahead of plan, which predicted a £0.8 million surplus. 3 2

Year to date rating

3

3

4

4

4

Month 9 actual

Area of review Key HighlightsMonth 10

actual Month 10

plan


Against EBITDA, the year-to-date position is £4.3 million ahead of plan (£51.4m actual versus £47.1m plan) (YTD FRR = 3).At M10, the Trust has made a contribution of £124.0 million before indirect costs. This is £3.1 million ahead of the planned contribution of £120.9 million.Net year-to-date income from activity (i.e. excluding drugs, devices & other pass-through items) is £27.1 million ahead of plan (£2.0m in-month over performance).

3 3


At M10, against EBITDA, the Trust has a 8.9% return on income (YTD FRR = 4). YTD positions are:Medicine £4.2 million ahead of plan (+£0.5m in-month).Specialist Hospitals £1.3 million ahead of plan (-£0.6m in-month).Surgery & Cancer £6.2 million behind plan (-£1.0m in-month).The remaining Corporate budgets (including Research & Development, & Education) are £4.9 million ahead of plan.

4 4

2. LiquidityThe liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 26 days of the Trust’s operating expenses (YTD FRR = 4).At 31st January 2010 the Trust’s cash position was £83.1 million against a planned cash position of £75.4 million, a favourable variance of £7.7 million.

4 4

3. Use of AssetsThe Trust made a 4.6% return on net assets (YTD FRR = 3). Of the current capital programme totalling £74.8m, 82% (or £61.2m) is approved & in progress. 3 2

4. Overall I&EThe M10 “bottom-line” position is a surplus of £7.6 million, a 1.3% return on income (YTD FRR = 3). The YTD I&E position is £6.8 million ahead of plan, which predicted a £0.8 million surplus. 3 2

4

Month 10, January

2. Financial performance2.2 Subjective analysis – financial summary

Direct Income, specifically, includes attributed HIV and other Community SLA income.

5

Month 10, January

2. Financial performance2.3 Activity and clinical income variance

6

Month 10, January

2. Financial performance2.4.1 Subjective analysis - Short Term Cash Flow - Outlook

60

70

80

90

100

110

120

130

140

March April May June July August Sep Oct Nov Dec Jan Feb Mar

(£m)

Cash Flow Plan 2009/10 Cash Flow Actuals 2009/10 Cash flow forecast Actual Prior Year 2008/09

January actual/Forecast comments:

FC £83.2m (as of 11th Oct 2009)Act £83.1m (as of 31st Jan 2010)

7

Month 10, January

2. Financial performance 2.5 Planned Costs Efficiency Performance in Context of the Trust overall

11.0

0.1

(13.0)

3.3

0.1 1.1

1.8

4.3

-2.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

(£m)

Patient Activity Pass Thru Delivery ofEff iciency

Release ofContingencies

Externaltrading

PrivatePatients

Other ClinicalBoards

Corporate Total

M10 YTD EBITDA Variance

Total Negative Variance Positive Variance

Graph shows the impact on overall Trust EBITDA of delivery of efficiencies alongside other key variances.

8

Month 10, January

2. Financial performance 2.5.1 Delivery of TEP

Medicine Board TEP M10

01,0002,0003,000

4,0005,0006,000

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Month

(£K)

Total Plan Total Actual/Forecast

SpH Board TEP M10

02,0004,0006,000

8,00010,00012,000

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Month

(£K)


S&C Board TEP M10

01,0002,0003,0004,0005,0006,0007,000

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Month

(£k)


Trust-wide TEP M10

0

5,000

10,000

15,000

20,000

25,000

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Month

(£k)


YTD VAR -£101k

YTD VAR -£622k YTD VAR -£588k

YTD VAR £376k

9

Month 10, January

2. Financial performance 2.5.2 Capital

09/10 Plan

Value of Approved Schemes

Value of Schemes Remaining

to be Approved

Total Value £m

Total Value £m

Total Value £m

Phase 3 25.4 25.4 0.0

ICT Strategy 2.0 2.0 0.0

Externally Funded - PDC 13.2 6.9 6.3

Externally Funded - Other 5.8 5.2 0.6

Replace & Refresh 10.8 10.0 0.7

Property Fund 8.2 3.6 4.6

Investment in Service Quality 5.0 3.7 1.3

Development & Expansion of Service 4.5 4.4 0.1

Current 09/10 Capital Programme 74.8 61.2 13.6

Notes - Summary of Material Schemes Remaining to be Approved

Fully approved

Fully approved

Inclusive of BRBH schemes such as Cancer Research Facility, Genome Analysis and part of the recent NIHR grant for £4.682m (7 schemes in total, 1 approved)

Inclusive of the Rebuild of Paed A&E and the balance of the Mandated Changes fund

Inclusive of some small value 08/09 carry forward schemes still to be approved.

Inclusive of 3 QSE 08-09 and the majority of 09/10 QSE schemes

Includes the balance of the Emergency fund and other smaller value schemes

Unapproved S106 schemes, inclusive of Mental Health Resource Centre, Centre for Independent Living and Car Parking schemes

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Elective length of stay* 5.0 4.8 3.4 3.7 6.0

Non-elective length of stay*

4.7 4.7 3.6 8.7 4.3

New to follow up outpatient ratio

2.9 2.8 4.1 2.5

Pre-11am discharges 50.0% 19.3% 28.6% 19.9% 17.5%

* Thresholds only apply to trust. Clinical Boards have specific targets

Month 10, January

This month

▪ The ward efficiency project is concentrating on reducing length of stay, reducing on-the-day cancellations for theatre and improving the number of patients who are discharged before 11 am. The programme is reviewing how costs for inpatient services can be reduced next year. ▪ There has been a reduction in LOS for medicine emergency patients and project work continues to reduce LOS across all pathways. There has been an increase on the number of pre-11 am discharges since last year although the Trust is not meeting the 50% target. Wards are being given further support through the Operations Centre to improve the volume of patients discharged before 11 am.▪ As part of the Trust Efficiency Programme there will be work carried out in outpatients, theatres, diagnostics and clinical support services.

3. Efficiency/productivity3.1 Productivity metrics

Inpatient length of stay - All Services

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Feb-09 Mar-09 Apr-09 May-09

Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10

Episode Average Length of Stay - Electives Episode Average Length of Stay - Non Electives

Percentage of patients discharged pre 11 am - All Services

0%

10%

20%

30%

40%

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Feb-09 Mar-09 Apr-09 May-09

Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10

% of Patients discharged pre 11am Target

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% Elective activity variance from plan

0.0% -9.4% -28.6% 6.3% -19.5%

% Daycase activity variance from plan

0.0% 0.0% 46.4% -2.6% -1.5%

% Non-elective activity variance from plan

0.0% 14.5% 25.8% -17.9% 17.8%

% New outpatient activity variance from plan

0.0% 10.7% 2.5% 10.2% 13.6%

% Follow up outpatient activity variance from plan

0.0% 0.2% 4.1% 2.1% -2.2%


Month 10, January

▪ Elective activity was below plan by 9.4%, mainly driven by underperformance in the Specialist Hospitals Board (-19.5%). Underperformance in the Medicine Board was high, but contained low volumes of activity. Divisions with elective activity significantly under plan included Queen Square (355 actual versus a plan of 483) and Women's Health (103 actual versus a plan of 125)▪ Day case activity was equal to plan at a Trust level, above plan by 46.4% in Medicine but below plan in Specialist Hospitals (-1.5%) and Surgery and Cancer (-2.6%). ▪ Non elective activity remains very high at 14.5% above plan for the month, driven by Medicine (+25.8%) and Specialist Hospital (+17.8%), but partially offset by Surgery and Cancer (-17.9%). Emergency services was the key division driving non elective overperformance (771 actual versus a plan of 480). Other Divisions which overperformed included Women's Health (1,627 actual versus a plan of 1,341) and Queen Square (154 actual versus a plan of 117). Both of these divisions underperformed in their elective activity for the month. ▪ Overall, inpatient (DC, elective and non elective) activity is above plan (9,669 versus 9,347) due to the overperformance in non electives▪ New outpatient attendances were above plan by +10.7% and follow up outpatient attendances were marginally above plan (+0.2%)

This month

4. Activity4.1 Activity summary

Number of daycase and elective inpatients - All Services

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5000

6000

7000

8000

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

DC + elective 09/10 actuals DC + elective 08/09 actuals

DC + elective 09/10 target

Number of non-elective inpatients - All Services

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Non-elective 09/10 actuals Non-elective 09/10 targetNon-elective 08/09 actuals

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Non-admitted closed percentage under 18 weeks 95% 96.9% 97.1% 98.5% 96.3%

Non-admitted pathways with known clock starts 98% 99.6% 99.8% 99.6% 99.5%

Admitted closed percentage under 18 weeks 90% 95.0% 100.0% 93.9% 95.3%

Admitted pathways with known clock starts 98% 97.2% 94.6% 98.6% 96.5%

>6 week diagnostic waits 6 4 2


Month 10, January

▪ We continue to be compliant with 18 week admitted (90%) and non-admitted (95%) targets. ▪ Improvement work to bring all specialties to compliance with the admitted pathway target is focussed on trauma and orthopaedics, with further work on urology to ensure that the current compliant position is a robust one. There were breaches of the admitted pathways standard in January for urology and neurosurgery. The performance of these specialties is being monitored closely to ensure we are compliant for Q4. ▪ For non-admitted pathways there are occasional breaches of the standard by specialties, but these are increasingly one-off issues rather than an indication that the specialty can't sustain 95%+ performance. There were breaches of the non-admitted pathways standard in oral surgery and dermatology in January. ▪ There are six outstanding diagnostic waits over 6 weeks, as at end January. These include two from Specialist Hospitals under Cardiology and four under Specialist Hospitals under Gastrointestinal Services.

This month

5. Access5.1 Access Targets - 18 Weeks

UCLH Retrospective 18 Week Consultant Specialty Function Performance Tracker

All tre

atmen

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code

s

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Gener

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Gastro

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Dermato

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Rheumato

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NonAdmitted Pathways

UCLH Q3 97.0% 98.5% 95.0% 96.5% 100.0% 97.6% 96.7% 96.3% na 100.0% 97.3% 95.0% 99.2% 97.7% 97.8% 96.8% 96.9% 100.0% 96.2% 97.2%UCLH Q2 96.9% 99.6% 95.4% 95.4% 100.0% 97.7% 96.7% 94.6% na 95.5% 97.0% 95.6% 99.8% 98.8% 96.8% 96.3% 97.7% 100.0% 96.1% 97.2%UCLH Q1 96.8% 96.7% 91.5% 95.2% 100.0% 98.5% 99.4% 92.3% na 100.0% 98.3% 93.9% 96.6% 95.9% 97.2% 96.7% 97.9% 100.0% 96.6% 97.2%

UCLH January 96.9% 100.0% 95.6% 99.6% 100.0% 99.1% 94.9% 100.0% na 100.0% 99.8% 95.5% 100.0% 93.0% 98.8% 95.5% 96.1% 100.0% 95.1% 97.2%UCLH December 96.8% 100.0% 96.1% 99.0% 100.0% 94.9% 96.6% 99.0% na 100.0% 96.5% 93.2% 100.0% 97.4% 98.9% 96.1% 96.1% 100.0% 96.2% 96.8%UCLH November 97.2% 96.5% 93.0% 95.2% 100.0% 99.4% 98.6% 94.7% na 100.0% 97.1% 100.0% 99.3% 98.2% 98.5% 97.2% 96.9% 100.0% 96.2% 97.6%Green = > 95%, Red <90%

Admitted Pathways

UCLH Q3 94.7% 94.0% 90.2% 88.4% 100.0% 97.8% 93.1% 92.9% na 99.3% 100.0% 100.0% 100.0% 98.3% 100.0% 96.8% 100.0% 100.0% 97.2% 95.7%UCLH Q2 94.1% 90.3% 90.5% 85.2% 100.0% 94.7% 95.6% 91.7% na 98.9% 100.0% 99.6% 99.8% 99.1% 99.1% 97.5% 100.0% na 94.6% 95.0%UCLH Q1 92.7% 92.4% 80.0% 85.3% 100.0% 100.0% 95.3% 87.2% na 97.5% 100.0% 99.5% 99.1% 100.0% 98.5% 99.0% 100.0% na 89.4% 95.6%

UCLH January 95.0% 100.0% 89.3% 91.4% 100.0% 100.0% 92.8% 86.5% na 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.3% 100.0% na 97.9% 96.7%UCLH December 95.2% 98.9% 90.1% 89.8% 100.0% 96.9% 92.6% 94.2% na 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.6% 100.0% na 96.2% 96.6%UCLH November 95.1% 96.3% 90.3% 90.1% 100.0% 96.8% 94.0% 96.2% na 98.4% 100.0% 100.0% 100.0% 95.0% 100.0% 98.5% 100.0% na 97.6% 94.8%Green = > 90%, Red <85%

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Cancer 2 week wait from GP referral to appointment 93.0% 93.3% 92.4% 95.9%

Cancer 2 week wait from GP referral to appointment: breast symptoms

93.0% 94.0% 94.0%

Cancer 31 days from diagnosis to first treatment 96.0% 97.2% 100.0% 97.0% 97.7%

Cancer 31 Day Subsequent Surgery Treatment 94.0% 95.8% 100.0% 85.7%

Cancer 31 Day Subsequent Chemotherapy Treatment 98.0% 99.0% 99.0% 100.0%

Cancer 62 Day GP referral to treatment 85.0% 88.5% 100.0% 82.4% 95.7%

Cancer 62 day referral to screening 90.0% 50.0% 50.0%

A&E attendances within 4 hours 98.0% 98.8% 98.8%


Indicator Monitor weighting Target Q1 Q2 Q3

14 day 93% 90% 94% 95%

14 day breast (from Q4) 93%

31 day first 0.5 96% 96% 98% 97%

31 day subsequent drug 98% 98% 100% 100%

31 day subsequent surgery 94% 95% 96% 100%

62 day GP 85% 80% 81% 78%

62 day screening 90% 71% 75% 50%

62 day upgrade N/A Not set 100% 99% 97%

Month 10, January

This month

1.0 (if either or both breached)



5 Access5.2 Access Targets – Cancer and A&E

A&E 4 hr wait target - All Services

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 100

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

A&E Attendances A&E attendances within 4 hoursA&E attendances within 4 hours

Note that cancer figures for January are provisional and likely to change▪ 14 day GP referrals: performance now meeting target and trajectory suggests that we will meet the full year target. ▪ Internal figures show that we achieved 94% for January for the new two week waiting time standard for outpatient appointments for breast symptoms▪ 62 day GP pathway: performance meeting target in January, assisted by the opening of the one-stop prostate clinic▪ 62 day screening pathway: capacity is now in place, but performance is below standard. This may be subject to change pending further validations of the data. Based on recording 15.5* cases year to date, we anticipate this target not applying to UCLH after the application of the low numbers rule from Monitor and the CQC (20 annually). However, should we receive a greater than average number of referrals to this service in February and March the low numbers rule will not apply.*Half cases are recorded where breaches are shared with another provider

▪ We continue to have strong A&E performance compared to the rest of London. Our performance for January was 98.8% against a London rolling 4 week average of 98.2%. and our year to date position is 99.4% compared to a London year to date position of 98.3%. ▪ While our performance has been decreasing since October it is significantly stronger than the same time last year.

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13 Weeks Outpatient Waits 99.7% 100% 100% 100% 100%

4 Week Outpatient Waits 47.4% 54.3% 51.1% 44.8%

26 Week Inpatient Waits 99.7% 100% 100% 100% 100.0%

Revascularisation within 13 weeks 99.5% 100% 100%

Access to rapid acess chest clinics in 14 days 98.0% 100% 100%

Choose and book slot issues 4.0% 1.3% 0.9% 0.3% 1.8%

Month 10, January

This month ▪ We were compliant in January with national waiting time targets for maximum inpatient and outpatient waits, access to rapid access chest clinics and for revascularisation treatment

▪ Our performance against the internally set 4 week wait target has increased from 37% in November to 47% in January.

▪ Our rate of issues with booking of slots under the national choose and book system improved from 4.2% in December to 1.3% in January. This is the first month that we achieved target and marks a clear performance improvement trend since July 2009. Our performance compares extremely well to a London-wide average of around 15-20%

5. Access 5.3 Access Targets – national targets, choose and book

% of patients on OP waiting list waiting less than 4 weeks

0%

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30%

40%

50%

60%

70%

Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

CAB slot issues

0%

5%

10%

15%

20%

25%

Apr 09 May09

Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

CAB Slot Issues CAB Target

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Number of MRSA Bacteraemias* 4 2 1 0 1

Number of clostridium difficile cases post 48 hours* 11 6 1 4 1

Percentage Hand Hygiene Compliance 85% 86.7% 79.7% 84.8% 88.8%

Percentage Hand Hygiene Reporting 100% 83.5% 100.0% 89.3% 81.5%

Percentage MRSA screening for electives 100% 100% + 100% + 100% + 100% +


Month 10, January

This month ▪ MRSA bacteraemia cases for the year to date (18) are within the agreed trajectory against the annual threshold of 39. There were two new cases in January (against a threshold of 4). The main focus of practice improvement currently is improving intravenous line insertion and management.▪ There were 6 cases of Clostridium difficile in January which is lower than our threshold of 11. Year to date Clostridium difficile performance is lower than our threshold (full year 127), but higher than the stretch target agreed with the PCT (full year 72). The main focus of practice improvement is in antibiotic management, early diagnosis, cleaning and isolation. ▪ We have seen an increase in hand hygiene reporting from 65% in December to 84% in January. Hand hygiene compliance is stable at 87%.▪ MRSA screening remains high. More MRSA screens are performed than the total number of eligible patients.

6. Quality6.1 Infection

MRSA bacteraemia / infections - All Services

05

1015202530354045


MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

Clostridium difficile infections post 48 hrs - All Services

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140


CDiff actuals monthly CDiff threshold monthly

CDiff actuals YTD CDiff threshold YTD

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Patient falls* 41 61 12 18 31

Number of Serious Falls* 1 0 0 0 0

Incidents per 100 admissions 5.0 4.3 3.8 3.5 5.1

Mortality alerts 0 0


Month 10, January

▪ There were 61 patient falls recorded in January. This was significantly above the threshold of 41 for the month and above threshold in all Boards except Medicine. The highest number of falls were recorded in Queens Square (28) in the Specialist Hospitals Board and Cancer (9) and Surgical Specialties (5) in the Surgery and Cancer Board. Compared to December, the growth in falls is largely due to Queen Square, which recorded an increase of 15 falls in January from December.▪ There were no serious falls this month.▪ We reported 4.3 incidents per 100 admissions year to date, against a peer average of 5.0. The construction of this indicator is in line with how the NPSA reports benchmarked reporting rates and our benchmark figure shows the average value for our peer group, which we have taken as national acute teaching trusts.

This month

6. Quality 6.2 Safety

Total Incidents - All Services

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Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10

Number of incidents

Patient falls per 10,000 bed days and Overall - All Services

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Patient Falls per 10,000 Bed days Patient falls Patient falls (threshold)

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Complaints responded to within target time 85.0% 62.0% 62.5% 52.2% 73.7%

Overall, how would you rate the care you have received 82.5% 78.8% 73.6% 72.3% 88.0%

Percentage Last Minute Cancellations to Elective Surgery 0.8% 1.7% 1.4% 2.2%

Percentage Cancelled Operations Readmitted Within 28 Days 98.0% 100% N/A 100% 100%

Inpatient ethnicity completeness 85.0% 77.4% 84.4% 87.6% 67.2%

Month 10, January

This month ▪ In January 62.0% of complaints were responded to within timescales agreed with the complainant or, in the absence of an agreed timetable, 25 working days. This is below December's performance of 71.9% and well below performance recorded in the first nine months of the year, which averaged at over 85%.▪ Our patient survey indicator was below threshold at a Trust level in January. Divisional and Clinical teams continue to track progress against their individual trajectories.▪ We cancelled 1.7% of our operations at the last minute in January, a slip in performance due to patient flow issues in the Tower and at the Heart Hospital. Year to date our performance is 1.1%, which is in the ‘underachieve’ category for the annual healthcheck. ▪ Levels of inpatient ethnicity recorded are below the annual healthcheck's target of 85% for the month but from April to December, the period covered in the CQC's Annual Health check, our year to date position is 85.5% and therefore in the "achieve" category. Divisions are working with ward administrators to improve data collection since this month's performance is below target.

6. Quality 6.3 Patient experience

Patient Complaints - All Services

0%

10%

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30%

40%

50%

60%

70%

80%

90%

100%


10

20

30

40

50

60

70

80

Number of Patient Complaints Complaints responded to within target time Target

Last Minute Cancellations - All Services

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%

Feb 09 Mar 09 Apr 09 May09

Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09Dec 09 Jan 100

20

40

60

80

100

120

Cancellations % Last minute cancellations Target

18

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Spe

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Percentage Emergency Readmissions within 28 Days* 7.2% 5.8% 12.7% 6.6% 2.8%

Hospital standardised mortality rate - all services 74.1% 69.1% 65.1% 63.6% 85.0%

Hospital standardised mortality rate - non electives 66.4% 64.7% 58.0% 83.5%

Hospital standardised mortality rate - electives 96.7% 89.3% 99.4% 94.0%


Month 10, January

▪ Dr Foster benchmarking data shows that we are not an outlier on emergency readmissions over the past 12 months, with results within the expected range. January figures show we had a 5.8% 28 day emergency readmission rate from those patients discharged in December

▪ Our HSMR data provided by Dr Foster is now significantly better than threshold at a Trust level for January. We are well on track to acheive the 5% reduction published in last years' Quality Account.

▪ Divisions have investigated two recent Dr Foster mortality alerts and have been able to assure the Quality and Safety Committee that they are issues of coding rather than concerns about clinical practice.

This month

6. Quality 6.4 Clinical outcomes

Mortality in Hospital - 56 HSMR Diagnoses - Elective1yr rolling data, reported 2 months in arrears

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

Rel

ativ

e R

isk

(Inde

x 10

0 <

Bet

ter R

isk,

> W

orse

Ris

k)

RR 1.12 1.07 1.03 1.08 1.02 1.00 1.03 0.97

Low 0.90 0.85 0.82 0.86 0.81 0.79 0.82 0.77

High 1.39 1.33 1.29 1.34 1.27 1.24 1.27 1.20


Mortality in Hospital - 56 HSMR Diagnoses - Non Elective1yr rolling data, reported 2 months in arrears

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

Rel

ativ

e R

isk

(Inde

x 10

0 <

Bet

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isk,

> W

orse

Ris

k)

RR 0.70 0.70 0.71 0.71 0.71 0.70 0.69 0.66

Low 0.64 0.64 0.65 0.65 0.65 0.64 0.63 0.61

High 0.77 0.77 0.77 0.77 0.77 0.76 0.75 0.72


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Workforce turnover 12.0% 13.0% 11.0% 14.0% 9.0%

Vacancy rate 12.0% 13.0% 11.0% 12.0% 4.0%

Sickness rate 3.0% 3.0% 3.0% 3.0% 2.0%

Temp staffing spend as a % of total spend -2.6% -4.5% -1.5% -2.0% -4.1%

Appraisal rate 44.0% 62.0% 49.0% 30.0% 52.0%

Month 10, January

This month ▪ The turnover percentage remains at 12% for January with an average number of 43 monthly leavers during the last 12 month period.

▪ The current vacancy rate is 12% and this reduces to 3% if temporary staff are included. Please note that future reporting on establishments will come from ESR, and the finance workstream of the ESR development programme are working well to achieve this objective. This single source of data will ensure that information is accurate, consistent and will be available for managers to access at their desktops.

▪ The sickness absence rate remains at 3% with 934 episodes in January. The absence percentage does not include medical staff who are reporting a rate of 0.38% (9 episodes). Following a pilot in the Corporate areas, the new monthly absence form will be implemented Trust wide in March.

▪ Trust spend on temporary staffing for this month is £3.34m representing 11% of the total workforce salary bill. There has been a 3.7% decrease in new booking requests for Nursing and Midwifery temporary staff (295 less shifts). Significant activities are in progress to reduce usage of agency staff.

▪ There has been a breach to the core standard relating to appraisals. Review of the appraisal not sufficiently robust and that the true figure of appraisals undertaken is unknown. Short term measures will establish monitoring systems to ensure appraisal rates are at a satisfactory level by the end of February 2010, with a longer term plan to introduce a fully automated system in 2011.

7. Workforce 7.1 Turnover and sickness

WTE actual v plan 2009/10

01,0002,0003,0004,0005,0006,0007,0008,000

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

Actual WTE Temp WTE Plan WTE

Trust % of Workforce Spend that is Temporary Staff

0%2%4%6%8%

10%12%14%16%

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Best Range 2008/9 2009-10

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Weighting ThresholdsQ1

PerformanceQ2

PerformanceQ3

Performance Jan-10 Comments

1.0 39 (full year) 7(Threshold 9)

5(Threshold 9)

4(Threshold 10)

2(Threshold 4)

1.0 127 (full year) 14(Threshold 30)

31(Threshold 31)

23 (Threshold 35)

6 (Threshold 11)

1.0 90% 92.6% 94.4% 94.4% 95.0%

1.0 95% 97.0% 96.7% 97.0% 96.9%

85% 80.0% 81.0% 77.8% 88.5%

90% 71.4% 75.0% 50.0% 50.0%Monitor has applied an annual de minimus level of 20 which, based on an estimate of our annual level of activity being under this threshold, will mean that this target does not apply to UCLH. Year to date activity to January is 15.5* *Half cases are recorded where breaches are shared with another provider

94% 95.0% 96.0% 100.0% 95.8%

98% 98.0% 100.0% 100.0% 99.0%

0.5 96% 96.0% 98.0% 97.1% 97.2%

93% 90.0% 94.0% 94.8% 93.3%

93% 94.0%This is a new indicator included in the Compliance Framework from January 2010

0.5 98% 99.5% 99.6% 99.3% 98.8%

0.5 TBC Compliant Compliant Compliant Compliant

0.4 0.4 0.4See Core standard breach relating to appraisals on page 20

Green Amber Amber Green

Note: Thrombolysis is a Monitor indicator but we do not provide this service in the Trust therefore we are not measured on this

NB Cancer figures for November are provisional and likely to change

Month 10, January

1.0 (if either or

both breached)

1.0 (if either or

both breached)

Performance Indicators

Screening all elective in-patients for MRSA

0.5(if either or

both breached)

Core Standards

Overall governance rating

31-day wait for second or subsequent treatment: anti cancer drug treatments

31-day wait from diagnosis to first treatment: all cancers

Two week wait from referral to date first seen: all cancers

A&E Waiting Times

Two week wait from referral to date first seen: breast symptoms

Safe

tyPa

tient

Foc

us &

Acc

ess

Incidence of MRSA

Incidence of clostridium difficile NB. 2008/09 target covered all cases, 09/10 target covers only those acquired 48hrs after admission

18 week maximum wait by Dec 2008 Admitted Patients:

18 week maximum wait by Dec 2008 Non Admitted Patients:

62- day wait for first treatment from urgent GP referral to treatment: all cancers

62-day wait for first treatment from consultant screening service referral: all cancers

31-day wait for second or subsequent treatment: surgery

8. Externally Reported Frameworks 8.1 Monitor Indicators – Compliance Framework

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2009/10 estimated performance for Quality of Services

Outcome YTD predicted score Max possible score

Existing commitmentsFully met

(Fully met, Almost met, Partly met, Not met) 26 27

National prioritiesGood

(Excellent, Good, Fair, Weak) 37 42Core Standards Fully met

Overall Good

Current monthYear to date performance

Year to date threshold Annual threshold

Predicted year end score Comment

Cancelled operations a) % cancelled operations 1.66% 1.14% 0.80% 0.8%

b) readmitted within 28 days 100.0% 99.1% 95.00% 95.0%

Inpatient waits 26 week inpatient wait 100.0% 100.0% 99.70% 99.70% 3

Outpatient waits 13 week inpatient wait 100.0% 100.0% 99.70% 99.70% 3

A&E waiting times % in 4 hours 98.8% 99.4% 98.00% 98.0% 3

Delayed transfers of care Delayed transfers of care 0.21% 0.22% 3.50% 3.5% 3

Reperfusion waiting times Primary angioplasty 3

Rapid chest clinic waiting times Rapid access chest clinics within two weeks 100.0% 100.0% 98.0% 98.0% 3

Revascularisation waiting times Maximum three month revascularisation wait 100.0% 100.0% 99.50% 99.5% 3

Ethnic coding data quality % inpatients with ethnicity recorded 77.4% 85.5% 85.00% 85.0% 3

For each target there is a score of 3 for achieved, 2 for underachieved, 0 for not achieved 26 Fully metIf a target has two or more indicators, the score is based on a comination of the scores

Month 10, January

Data for thresholds and performance to be confirmed

Comments on 2009/10 estimated performance

Since the Care Quality Commission has not finalised its performance assessment for existing commitments or national priorities (due early summer 2009), the 2009/10 table for performance for Quality of Services has been estimated using the performance assessment used in 2008/09.

Existing commitments targets: assumed that >=25 fully met, >=22 almost met, >=19 partly met, <19 not met

2

8. Externally Reported Frameworks8.2 Care Quality Commission targets (Existing commitments)8. Externally Reported Frameworks8.2 Care Quality Commission targets (Existing commitments)

22

National priority targets that apply to UCLH

Healthcare Commission target DescriptionCurrent month performance

Year to date performance

Year to date threshold Annual threshold

Predicted year end score Comment

Incidence of MRSA MRSA cases 2 18 32 39 3Incidence of Clostridium difficile casesNB. 2008/09 target covered all cases, 09/10 target covers only those acquired 48hrs after admission Clostridium difficile cases

6 74 107 127 3

Quality of stroke care

Time spent on stroke unit in hospitalPerformance against clinical process measures on national stroke db 3

Heart disease mortality Participation in heart disease audits 2

18 week waiting times Admitted pathways within 18 weeks 95.0% 95.0% 90.0% 90.0%

Non-admitted pathways within 18 weeks 96.9% 96.8% 95.0% 95.0%

Admitted pathways data quality 97.2% 96.4% 90% - 110% 90% - 110%

Non-admitted pathways data quality 99.6% 98.9% 90% - 110% 90% - 110%

New cancer waitsa) Cancer treated in 62 days from referral 79.3% 79.6% 85.0% 85.0% 0

b) Cancer treated in 62 days from consultant screening service

50.0% 61.3% 90.0% 90.0%N/A

We estimate that a low numbers ruling will be applied based on there being fewer than 20 cases in the year

New cancer waitsCancer treated in 31 days from diagnosis 97.2% 97.1% 96.0% 96.0% 3

New cancer waits

a) Cancer treated in 31 days for second or subsequent treatment: surgery

95.8% 97.0% 94.0% 94.0%

b) Cancer treated in 31 days for second or subsequent treatment: drug treatments

99.0% 99.9% 98.0% 98.0%

New cancer waitsTwo week wait from referral to first treatment 93.3% 93.3% 93.0% 93.0% 3

Patient experiencePatient survey results for defined questions 3

Engagement in clinical audits 3a) Breastfeeding initiation

b) Smoking cessation

Maternity HES data quality indicatorData quality measure on maternity HES data 85.0% 85.0% 2

NHS staff satisfactionStaff survey results for defined questions 3

NB Cancer figures for November are provisional and likely to change 37 GoodFor each target there is a score of 3 for achieved, 2 for underachieved, 0 for not achieved

If a target has two or more indicators, the score is based on a comination of the scores

Month 10, January

Smoking during pregnancy and breastfeeding initiation rates

National priorities: >=39 "Excellent" >=34 "Good", >=30,"Fair" <30 "Weak"




Data for performance to be confirmed

Data for performance to be confirmed 3Performance to be confirmed

3

Data for performance to be confirmed

One element potentially at risk

3

8. Externally Reported Frameworks 8.3 Care Quality Commission targets (National priority targets)

23

I

Agenda Item 12

Seal Report

BOARD OF DIRECTORS MEETING – 10 March 2010

Entries in the Seal Register since the last Report to the Board Number Date of Entry Entry Details

Supporting Information

425 20 January 10 Lease between University College London NHS FT and UCLH Charities

This document relates to the lease of Highwood House, 148 New Cavendish Street


This document relates to the lease of 4 - 14 Cleveland Street


This document relates to the lease of 29 Old Gloucester Street

428 08 February 10 T1 Form – documenting the release of the courtyard in the basement of John Astor House .

The document confirms to the Land Registry the transfer of premises from Paddington Church Housing Association Limited to University College London NHS FT This document includes 2 plans.

429 08 February 10 Supplemented Lease of the Eastman Dental Hospital between University College London NHS FT and The Assisted Conception Unit Limited

This document relates to part basement, part ground floor and part first floor of the Eastman Dental Hospital

430 08 February 10 Lease of the Eastman Dental Hospital between University College London NHS FT and The Assisted Conception Unit Limited

This document relates to part basement, part ground floor and part first floor of the Eastman Dental Hospital

J

Agenda Item 13

Register of Board Members’ Interests


Report to Board of Directors Meeting 10th March 2010

REGISTER OF BOARD MEMBERS’ INTERESTS

Introduction The Code of Accountability requires Board directors to declare interests which are relevant and material to the NHS Board of which they are a director. The Trust’s Standing Orders require that a Register of Interests is established to record formally declarations of directors’ interests. These details are kept up to date by means of an annual review of the Register in which any changes to interests declared during the preceding 12 months, and all newly declared interests, will be incorporated. Annual Review 2010 The annual review of the Register of Board Members’ Interests has recently been conducted and the revised Register is attached herewith for information. Recommendation The Board is requested to note the revised Register of Interests. Tonia Ramsden Director of Corporate Services and Secretary to the Trust

REGISTER OF BOARD MEMBERS’ INTERESTS

March 2010

Interest Declared Board Member Directorships (including non-executive directorships) held in private companies or PLCs:

Director, Sue Atkinson Associates Ltd (Consultancy) Sue Atkinson Co-director, London Intensive Care Ltd Geoff Bellingan Co-director, CPX Ltd (provide cardiopulmonary exercise testing) Geoff Bellingan Non-executive Director, Quintain Estates and Development PLC Peter Dixon Co-director, The Glynne Medical Practice Ltd Paul Glynne Co-director, London Acute Care Ltd Paul Glynne Director, NM Rothschild & Sons (Corporate Finance) Limited Richard Murley Non-executive Director and Chair of the Medical Advisory Panel, BUPA

John Tooke

Ownership or part-ownership of private companies, businesses or consultancies likely to do business with the NHS:

Sue Atkinson Associates Ltd (Consultancy) Sue Atkinson Majority or controlling share holdings in organisations likely or seeking to do business with the NHS:

Position of authority in a charity or voluntary body in the field of health and social care:

Trustee, UCLH Charities Sue Atkinson Member of Research Committee, Intensive Care Society Geoff Bellingan Council member, European Society of Intensive Care Medicine Geoff Bellingan Critical Care Committee member, Royal College of Physicians (RCP) Geoff Bellingan Governor, Chalfont Centre for Epilepsy Louise Boden Member, Acute and General Medicine Committee, RCP Paul Glynne Member, Payment by Results Committee, RCP Paul Glynne Member, Workforce Review Team, RCP Paul Glynne Chairman of Trustees, Oxford Policy Institute Nicholas Monck Member of Council, Royal College of Surgeons of England Tony Mundy Trustee, Covent Garden Cancer Research Trust Tony Mundy Non-executive member, Department of Health Audit Committee Jane Ramsey Connections with a voluntary or other organisation contracting for or commissioning NHS services:

Honorary Visiting Professor, Department of Epidemiology and Public Health, UCL

Sue Atkinson

Chair, Public Health Action Support Team (PHAST) – A social enterprise community interest company

Sue Atkinson

Honorary Visiting Professor, Department of Applied Social Sciences, City University

Louise Boden

Honorary Visiting Professor of Nursing Leadership & Cancer Care, Faculty of Health & Social Care, London South Bank University

Louise Boden

Honorary Consultant, Imperial College Healthcare NHS Trust Gill Gaskin Senior Associate Fellow, University of Warwick Institute of Public Management

Robert Naylor

Member of Board, NHS Innovations London Robert Naylor Unpaid adviser to the Chief Executive of Healthcare Purchasing Consortium

Robert Naylor

Member, Medical Schools Council Executive Committee John Tooke Connections with an organisation or company entering into a financial arrangement with the Trust

Former employee of Oracle Corporation and shareholder Richard Alexander Any other relevant interests; Board Member, Food Standards Agency Sue Atkinson Providing Public Health advice for the North East London Integrated Impact Assessment (Health for N.E. London Consultation)

Sue Atkinson

Member of Editorial Board, ‘Clinical Governance: An International Journal’

Louise Boden

Nurse Advisor to NHS Employers Louise Boden Lay Member, Information Tribunal Peter Dixon Chairman, Office for Public Management Peter Dixon Chairman, Colchester Hospital University NHS Foundation Trust Peter Dixon Member, London Workforce Advisory Forum Gill Gaskin Member, Council of Management of the National Institute of Economic & Social Research

Nicholas Monck

Member of Advisory Council, Transparency International (UK) Nicholas Monck Trustee of BGI (Better Government Initiative) Nicholas Monck Member, Steering Committee of the Alignment Project (led by the Treasury)

Nicholas Monck

Member, Advisory Committee to the Office of National Statistics’ Centre for Measuring Government Activity (including NHS output)

Nicholas Monck

Editorial Board, BJU International Tony Mundy Editorial Board, Current Opinion in Urology Tony Mundy Editorial Board, Urologica Internationalis Tony Mundy Member of the Board, Foundation Trust Network Robert Naylor Chair, UK Health Education Advisory Committee, reporting to HEFCE John Tooke Member, National Institute of Health Research Advisory Committee John Tooke Member, Health Education National Strategic Exchange John Tooke Any of the above interests held by a spouse, partner, close relative or other associated person:

GP Medical Director, Camden Primary Care Trust Dr. J. Dixon

(Lady Judith Dixon) Consultant in Medicine for the Elderly, Barnet & Chase Farm NHS Trust

Dr. Penelope Wiseman (wife of Richard Murley)

Employee, T-Mobile Richard Foster (son of Michael Foster)

Technical Director, WSP Group, Consulting Engineers (undertake work for NHS organisations from time to time)

John Parker (spouse of Gill Gaskin)

Co-director, The Glynne Medical Practice Ltd Dr. S.J. Glynne (wife of Paul Glynne

General Practitioner, Balham Park Practice, Wandsworth Dr. S.J. Glynne Employee, Healthcare Purchasing Consortium James Naylor (son of

Robert Naylor) Employee of Cancer Research Technology Development Laboratory (part of Cancer Research UK)

Dr. Nat Monck (son of Nicholas Monck)

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