board room, pah - hsj · these were received from dr claire feehily mrs jan dalrymple and mr chris...

X:\Corporate Services\Trust Board Meetings\2011\FEBRUARY\PART A\AGENDA PART A 240211.doc 1

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

Public Trust Board Meeting (Part A) Thursday 24th February 2011

Time: 1.30pm VENUE

Board Room, PAH

PRELIMINARY MATTERS 1. Health & Safety Briefing Chair Verbal

2. Apologies for absence Chair Verbal

3. To note changes and additions to interests declared by Trust Board Members

Chair Verbal

4. To approve the minutes of Part A of the Board meeting held on 27th January 2011

Minutes Secretary

Paper

5. Action points arising from past meetings Chair 5 mins Paper

QUALITY, GOVERNANCE & RISK 6. Patient Experience Report ED Nursing &

Patient Care 10 mins Verbal

7. First Evaluation of Trust position - NCEPOD report An Age Old Problem

CD Women s & Children s BU

10 mins Paper

8. Maternity and NICU future provision ED Nursing & Patient Care

30 mins Paper

9. SHA Exception Report CEO 5 mins Verbal

FINANCE AND PERFORMANCE 10. Financial Performance Report and Operational

Update CEO/Director of Finance

20 mins Paper (please bring dashboard from B&PC papers 22/2/11)

11. Dashboard Reporting Review Director of Finance

10 mins Paper

STRATEGY 12. FT application and consultation update Director of

Delivery 10 mins Paper

13. Clinical Strategy update ED Nursing & Patient Care/Director of Delivery

5 mins Verbal

INFORMATION 14. Chair s report Chair For noting Paper

15. DATE & TIME OF NEXT MEETING 31st March 2011 1.30 p.m. Board Room Trust HQ

5 mins

X:\Corporate Services\Trust Board Meetings\2011\FEBRUARY\PART A\AGENDA PART A 240211.doc 2

16. Input from Public at Chair s Discretion Chair 5 mins Verbal

Closure of Part A To resolve the representations of the media and other members of the public be excluded from the rest of the meeting, having regard to the confidential nature of the business to be transacted publicity on which would be prejudicial to the public interest: Section 1 (2) Public Bodies (Admissions to Meetings Act) 1960.

Trust Board Meeting 24 February 2011

PART A AGENDA ITEM 4

Minutes of the Meeting held on 27 January 2011

1

The Princess Alexandra Hospital NHS Trust

Minutes of the Public Trust Board Meeting (Part A) Held on Thursday 27th January 2011 in the Board Room, PAH

PART A

Present: Mr Gerald Coteman (GC) Chair Ms Jane Herbert (JH) Chief Executive Officer Mr Tim Escudier (TM) Non-Executive Director Mrs Paula Kerr (PK) Non-Executive Director Mr Richard Stead (RS) Non-Executive Director Mrs Sylvia Thompson (ST) Non-Executive Director Dr Sandra Dimmock (SD) Medical Director Mrs Yvonne Blucher (YB) Executive Director - Nursing Mr Darren Leech (DL) Executive Director - Delivery Mr Chris Oakes (CO) Interim Director - Workforce Mr James Day (JWD) Trust Secretary Mr Andrew Butters (AB) Director of Finance

Members of the Public:

Cathy Gooding Chris Hudson

West Essex LINk West Essex LINk

Also in attendance: Phillipa Bennett West Essex Maternity Services Liaison Committee

Raine Hunt Head of Communications Michelle Penney Minute Secretary

27/01/01 HEALTH AND SAFETY BRIEFING The Board and members of the public received this briefing from JWD.

27/01/02 APOLOGIES FOR ABSENCE These were received from Dr Claire Feehily Mrs Jan Dalrymple and Mr Chris Birbeck.

27/01/03 TO NOTE CHANGES AND ADDITIONS TO INTERESTS DECLARED BY TRUST BOARD MEMBERS There were none.

27/01/04 APPROVAL OF THE MINUTES OF PART A OF THE BOARD MEETING HELD ON THE 23rd DECEMBER 2010 IN THE BOARDROOM TRUST HEADQUARTERS, PRINCESS ALEXANDRA HOSPITAL, HARLOW.

The minutes were approved with the following amendments.

Minute 23/12/05

This should read the East of England Specialist Commissioning Group and not the SHA.

YB informed the Committee that the Maternity and NICU Strategy would now be submitted to the February Board meeting.

Minute 23/12/06

It was agreed that the third paragraph should be reworded to read steps have been taken to prioritise elective work .

Minute 23/12/08

The spelling of Graeme Jones name is incorrect and paragraph 7 should read It was anticipated that a more limited and precise IBP .

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27/01/05 ACTION POINTS FROM LAST MEETING

These were noted. GC explained that Board Champions would be covered by a different approach. The Board were informed that Paula Kerr would now to cover Patient Safety & Quality as a nominated Director.

ACTION

GC and YB to discuss how this arrangement will work.

There is now an increasing level of engagement with GP/consultant leads and these continue to grow.

ACTION

DL to email a brief update on GP/Commissioning leads (completed).

ACTION

SD to check progress of Trust responses to NCEPOD report An Age Old Problem. Report deadline for the Board is February.

ACTION 23/12/08 and 23/12/06 can now be removed from the action log as these are now completed.

27/01/06 PATIENT EXPERIENCE REPORT YB informed the Board that the two letters of complaint reported previously had now been resolved after investigation and final responses sent.

YB then outlined details of a complaint that was made by a sister on behalf of her brother relating to poor communication. The patient had received a poor experience when attending the Oak Unit at St Margaret s Hospital, Epping in relation to the communication of his diagnosis of cancer.

27/01/07 VISIT OF PHILLIPPINES CHARGE D AFFAIRES (19/01/11) The Board were informed of a visit from the Philippine Embassy in London connected to the Trust s recruitment in the Phillipines. A team visited Netteswell Ward and YB gave a presentation in the Social Club followed by a question and answer session. It was reported that everyone was very enthusiastic and a letter of thanks was received back from the Charge D Affaires with the hope of continuing to collaborate with the Trust. The whole experience was very positive, and a good news story for the Trust. The Filipino nurses are settling in well.

27/01/08 MONITORING BOARD AND COMMITTEE PERFORMANCE The need for Board development work was highlighted, and not just for the Trust s FT application. This has been discussed with Chris Oakes, Interim Director, Workforce and a programme would be put together.

GC spoke to the paper he circulated at the January Board meeting seeking feedback. Since then extending the Board evaluation process to commit to self assessment had become the key proposal. Issues will be shared with the Board in due course. GC explained his keenness for 360 degree assessment but had some doubt due to changes in the Board. The Trust needed a contemporary baseline 360 assessment which will form part of the Trust s Board development. This is work in progress.

3

27/01/09 OPERATIONAL UPDATE AND FINANCIAL POSITION

JH explained that the hospital had been very busy after New Year and very close to the highest alert level. Charnley Ward was shut to elective admissions as planned but did open on a couple of occasions to emergency admissions. There was a clear pattern emerging of the hospital getting very busy over the weekend with most of the following Monday and Tuesday spent discharging patients. Volunteer clinicians, GPs and staff have been working over the weekend to see if that makes a difference and the results are currently being evaluated. A small project looking at available medical staff at the weekend and out of hours is currently being undertaken.

Due to these pressures, it was noted that the operational 4 hour target in A&E was not being achieved, but the Trust is trying to meet its target of 95% at year end. JH explained that even at the highest alert level, triage systems are working and satisfaction was expressed that the Trust is delivering proper and safe care.

AB reported that the Trust had moved closer to agreeing the resolution of difficulties with this year s contract with West Essex PCT. The proposed settlement agreed by the PAH Board on 11th January 2011 was being discussed at the PCT Board this afternoon. As part of the settlement, it has been agreed that if Charnley Ward is required to open for emergency admissions, the PCT will pay an additional tariff over the block settlement agreed. AB reported that the figures are based on £7m over and above the original contract value.

As a result, the Trust is reporting breakeven in month with a cumulative deficit of £474,000 to date. Concern was expressed with costs increasing in December. Measures are being put in place to ensure that a downward trend continues. Gateway analysis progress for months 8 and 9 slowed as well. More work is being carried out on cost savings. The Trust was forecasting a breakeven position provided £1m additional income over current forecast was received; we are optimistic about this. To achieve breakeven an additional £1m needs to be found in savings in the next three months. This was recognised as a challenging task.

Discussions have taken place with Hertfordshire PCT to reduce workload by a third. This has been agreed in principle but the year end contract is still to be agreed. DL and AB were working on this at present and were trying to arrange a meeting with Hertfordshire PCT as soon as possible.

The contract with West Essex PCT has been settled and the PCT have released £2m last month for disputed invoices and will be paying £2m for next months payment over and above the base payment. This will free up the cash system and should allow the Trust to achieve its year end cash target without additional funds. The sale of the Derwent Centre had covered current cash demands. The financial risk rating remained at 3.

CO corrected reported inaccuracies with regards to Workforce statistics.

ACTION

AB to make amendments to recorded Workforce data.

With regards to Quality it was reported that the 18 H1N1 cases in December had reduced to just 1, a child on Dolphin Ward. The surge in December was noted as having an impact on critical care services.

4

27/01/10 CHARITABLE FUNDS

These were noted. The accounts and minutes were noted. These will be discussed at the end of the February Audit Committee.

ACTION

DL to discuss with the Marketing Manager on return from maternity leave to look develop a solution to capture marketing and charity funding.

It was reported that the accounts were approved by CF at the Charitable Funds Committee on 23 December 2010 and had been sent to the Charities Commission.

It was recognised that the Trust has a robust Charitable Funds Committee in place which is reporting appropriately. ST highlighted to the whole Board represented the Trust as the sole Corporate trustee that the Charitable Funds Trust is the responsibility of the whole Board.

ACTION

JWD to include the Charitable Funds Committee in the Governance Framework as not currently listed as a sub committee of the Board.

ACTION

DL and AB to discuss how to develop charitable funding and marketing for charitable donations.

27/01/11 FT APPLICATION AND CONSULTATION UPDATE DL reported on events since the Supplementary Board meeting held on 11 January 2011. The SHA had endorsed going out to consultation for a 3 month period. The Trust had also made a written request to the SHA with regard to a variation in the timeline for submission of papers which is being considered and the Trust is awaiting a response.

It had been agreed by JH and Melanie Walker that third party reports on progress would be sought for support in the process and to help benchmark comparatives to give Board assurance.

FT Board sessions have been arranged for Board to Board development and contribution to the IBP. Chapter 3 will be the first chapter to be reviewed on 22nd

February and DL was happy to discuss any aspect of the IBP with the Board.

DL indicated that he was happy with the current process and the detail but looking at some of the issues, the Trust will still be challenged.

PK asked if the draft IBP and LTFM could be circulated as it exists now to work on to help focus on issues.

DL explained the schedule of development meetings should start with a new IBP Chapter 3 because this had been already discussed by the Board. Due to new Board Members, DL was keen to start the process from scratch. A sensitive approach needs to be taken with regard to the Trust s application last year. DL expressed his keenness to get slightly ahead of schedule to gain assurance from the SHA.

AB highlighted that it was a critical time with regard to negotiating and agreeing plans for next year with purchasers, and will determine what happens with the Trust. Timing was important and there was a risk around understanding how risk is shared and what is the responsibility of the Trust or the PCT. The

5

importance of a joint approach needing to be taken was expressed especially around the management of QIPP.

ACTION

FT Strategy to be discussed at the Board workshop scheduled for February DL.

27/01/12 HARLOW CONSULTATION RESPONSE

A paper had been circulated to the Board with a suggested response. DL attended an engagement session and feedback had been received from colleagues. A response has been drafted which was presented for discussion. The Trust would like to engage as Harlow develops to ensure health is considered in the infrastructure and is considered by the Council. DL also reported on cross border issues and the importance of the two Councils, Harlow and Hertfordshire, working together and with the Trust. Any further feedback/comments to be sent to DL.

ACTION

GC to send a response by 28 February 2011 deadline. DL to co-ordinate.

The Board agreed to share the Trust s response with both West Essex and Hertfordshire PCT colleagues - DL.

PK requested that reference be made to the traffic infrastructure and access in and out of Harlow, particularly the A414 and traffic around the River Stort. It was noted that this may be a Highway issue but that the Trust should certainly expand on this access issue.

It was noted that conversations had started with Hertfordshire Council regarding A414 access and patient transport. The Communications Department were also working on this.

27/01/13 CHAIR S REPORT The Board received this report for noting.

GC spoke about a productive meeting with Harlow s MP. Regular meetings will be held with the MP to bring him up to date on emergency issues.

At this meeting JH gave a full briefing recognising the Trust s role and responsibility to his constituents.

DL informed the Board of a link to the MP s office to deal directly with matters connected to patients at the hospital. This process would result in complaints being resolved quickly.

Discussions were held with regards to the Trust s FT process detailing where we are at and the challenges the Trust faces. The Trust s application was supported by the PCT and SHA at present. GC detailed the obstacles faced with Monitor with regard to criteria and the additional challenges now put in place regarding risk. The MP indicated that he would speak to the Secretary of State regarding this matter.

27/01/14 DATE & TIME OF NEXT MEETING

24TH February 2011 1.30 p.m. Board Room Trust HQ

6

It was noted that the March meeting was intended to be held at Bishop s Stortford, but a more suitable venue would need to be found than last year to allow this.

27/01/15 INPUT FROM PUBLIC AT CHAIR S DISCRETION

Cathy Gooding expressed her delight that the Trust was now piloting protected mealtimes. It was recognised that lots of work had been carried out around nutrition and formed a platform for Essence of Care.

Phillipa Bennett, Chair of West Essex Maternity Services Liaison Committee introduced herself to the Board. Phillipa is a lay chair with no medical or NHS background but was a mother of five and a teacher with the National Childbirth Trust (NCT).

The Maternity Services Liaison Committee (MSLC) meets monthly and ST and Chris Hudson are members of the Committee which also consists of community midwives, doctors, consultants and a matron. The main aim is to improve maternity services.

The MSLC is undertaking a project at present looking at information and the Trust s website to see if it is user friendly for women. At present 50 women and partners are taking part in this project.

Phillipa expressed the MSLC s support for the Trust to maintain its Level 2 status.

It was reported that caesarean rates at the Trust are high and lots of work is being carried out to reduce this. The MSLC requested that the Board give priority and support to drive this initiative.

It was reported that the figures for caesarean rates at the Trust were 27% last year but in December 2010 it went to 32%. It was highlighted that natural births are better for the mother with caesarean s being a cost issue for the Trust with 10% of babies requiring special care after a caesarean birth and the mother requiring a longer stay in hospital.

JH recognised that the Trust has a high caesarean section rate and the Board asked why. SD informed the Board that the Trust was in the process of appointing an additional consultant, with an interest in labour ward issues and the Trust is working hard with the PCT on pathway work and how care is delivered in primary care.

It was noted that caesarean targets were included on the Trust dashboard submitted to the Patient Safety and Quality Committee. PK informed the group that she was looking at what was under review. It was recognised that this was a very reasonable challenge and that the Board would pick up on this.

GC reminded the Board that this was TE s last Board meeting. GC thanked Tim for being a loyal and committed member of staff being extremely supportive to the Trust and working extra hard with changes to the NED component. The Board wished him well.

GC also informed the Board that it was also JWD s last Board meeting and that JWD has been successfully appointed as Trust Secretary at Mid Essex Hospital. GC thanked JWD on behalf of the Board for being a loyal and committed servant to the Trust and wished him well in his future position.

7

27/01/16 CLOSURE OF PART A

To resolve the representatives of the media and other members of the public be excluded from the rest of the meeting, having regard to the confidential nature of the business to be transacted prejudicial to the public interest: Section 1 (2) Public Bodies (Admissions to Meetings Act) 1960.



Action points arising from past meetings

Actions as at 08/02/11

84 - Trust Board

Due DateRef Owner Details StatusArea

Plan ID: Target: James DayLocal Contact Responsible:

Actions from the Trust Board Meeting held on 25 November 2010Plan Title:

Priority16/12/201025/11/06 Identify Board Champions and bring to December PS&Q. Trust HQYB/GC IncompleteMedium27/01/201125/11/12 Progress report on GP and Consultant meetings. Trust HQDarren Leech IncompleteMedium24/02/201125/11/11 Return to Board with Trust responses to NCEPOD report 'An Age Old Problem'. Trust HQSandra Dimmock IncompleteMedium

86 - Trust Board



Actions from the Trust Board Meeting held on 23 December 2010Plan Title:

Priority27/01/201123/12/05 NICU Developments - YB to seek confirmation from the PCT with regard to the

affordability of anticipated numbers of cases.Trust HQYvonne Blucher IncompleteHigh

27/01/201123/12/05 NICU Developments - AB to prioritise NICU capital expenditure within the Capital Expenditure Budget for 2011/12.

Trust HQAndrew Butters IncompleteHigh

17/03/201123/12/04 YB quarterly PET report to be brought to the March 2011 Board. Trust HQYvonne Blucher IncompleteMedium

89 - Trust Board



Actions from the Trust Board Meeting held on 27 January 2011Plan Title:

Priority24/02/201127/01/11 Reports to be submitted to the Board in this format at all future Trust Board meetings -

CO.Trust HQChris Oakes IncompleteMedium

24/02/201127/01/01 JWD to circulate notes of the Supplementary Board meeting held on 11 January 2011 prior to February Board meeting.

Trust HQJames Day IncompleteHigh

24/02/201127/01/04 Reflect the Trust s monthly Governance return position in a note to the Board JH. Trust HQJane Herbert IncompleteHigh24/02/201127/01/05 Report on safeguarding issues to be submitted to February Board meeting - YB. Trust HQYvonne Blucher IncompleteHigh24/02/201127/01/10 AB to investigate that the Trust has provision for this and to confirm back to the Board.

Agreed that this should be a standing item for financial reporting.Trust HQAndrew Butters IncompleteHigh

24/02/201127/01/13 Simon Meddick to provide a presentation to a future Trust Board meeting or sub committee regarding overall Strategy. Lead Pathology Consultants to be invited to attend any discussion on Pathology services.

Trust HQDarren Leech IncompleteMedium

24/02/201127/01/05 Board Champions - GC and YB to discuss how this arrangement will work. Trust HQGerald Coteman IncompleteMedium

Generated on 08/02/2011 from the Action Plan Tracking Database Page 1 of 2

24/02/201127/01/05 SD to check progress of Trust responses to NCEPOD report An Age Old Problem. Report deadline for the Board is February.

Trust HQSandra Dimmock IncompleteHigh

24/02/201127/01/09 AB to make amendments to recorded Workforce data. Trust HQAndrew Butters IncompleteHigh24/02/201127/01/10 JWD to include the Charitable Funds Committee in the Governance Framework as not

currently listed as a sub committee of the Board.Trust HQJames Day IncompleteHigh

24/02/201127/01/10 DL and AB to discuss how to develop charitable funding and marketing for charitable donations.

Trust HQDL/AB IncompleteMedium

24/02/201127/01/11 FT Strategy to be discussed at the Board workshop scheduled for February DL. Trust HQDarren Leech IncompleteHigh24/02/201127/01/05 JH to speak with CB to find an alternative external moderator as agreed by the Board. Trust HQJane Herbert IncompleteMedium28/02/201127/01/12 Harlow Consultation Response - The Board agreed to share the Trust s response with

both West Essex and Hertfordshire PCT colleagues - DL.Trust HQDarren Leech IncompleteHigh

28/02/201127/01/12 Harlow Consultation Response - GC to send a response by 28 February 2011 deadline. DL to co-ordinate.

Trust HQGerald Coteman IncompleteHigh

31/03/201127/01/05 YB to report back on scoping exercise of the Business Units March 2011 Board. Trust HQYvonne Blucher IncompleteMedium31/03/201127/01/10 DL to discuss with the Marketing Manager on return from maternity leave to look develop

a solution to capture marketing and charity funding.Trust HQDarren Leech IncompleteMedium

Generated on 08/02/2011 from the Action Plan Tracking Database Page 2 of 2



First Evaluation of Trust position

NCEPOD report An Age Old Problem


Trust Board Meeting

Executive Summary

Thursday 24th February 2011

Part A

Compliance Checklist (to be completed by Trust Secretary)

Governance

Equalities Impact Finance Legal Implications Communications Issues Risk and Health and Safety Issues

Issue:

National Confidential Enquiry into Patient Outcome and Death November 2010

An Age Old Problem

Summary:

This paper describes how NCEPOD works, how trust staff should engage in the Enquiry, and what actions trusts should take when a new NCEPOD report is released. The paper is intended to help trusts:

improve the care of patients by ensuring that clinicians and managers are aware of new NCEPOD reports as they are released

meet the requirements of the Clinical Negligence Scheme for Trusts and the Quality Accounts for 2010/11

Recommendations:

Trust Board is asked to note the level of compliance with the recommendations.

Medical Director to report on progress against outstanding actions to April Trust Board.

Author: Date: Dr. Radha Rajendram 15th February 2011 On behalf of the Medical Director

1

Guidelines for reviewing participation in the National

Confidential Enquiry into Patient Outcome and Death and implementing NCEPOD recommendations

Preamble This tool has been produced to help trusts review their participation in the National Confidential Enquiry into Patient Outcome and Death, (NCEPOD), and their implementation of NCEPOD recommendations.

This paper describes how NCEPOD works, how trust staff should engage in the Enquiry, and what actions trusts should take when a new NCEPOD report is released. The paper is intended to help trusts:

improve the care of patients by ensuring that clinicians and managers are aware of new NCEPOD reports as they are released

meet the requirements of the Central Negligence Scheme for Trusts.

Background The National Confidential Enquiry into Patient Outcome and Death carries out studies into aspects of care in all areas of medicine except obstetrics (covered by the Centre for Maternal and Child Enquiries

CMACE) and mental health (the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness NCISH).

The aims of the Enquiry are to review clinical practice, to identify remediable factors in the care of patients, and to make recommendations for clinicians and managers to implement. The results of the Enquiry have widespread applicability because NCEPOD collects data from all hospitals in England, Wales, Northern Ireland, the Isle of Man, Jersey, Guernsey, the Defence Secondary Care Agency, and from participating private hospitals.

The GMC states that participation by doctors in the Confidential Enquiries is one of the elements of Good Medical Practice. The Department of Health has stated that all doctors will participate in the work of the Confidential Enquiries. The Clinical Negligence Scheme for Trusts expects the Trust Board or Governance Group to review NCEPOD recommendations as part of their risk management activities and participation in the Confidential Enquiries is required as part of the NHS Quality Accounts.

Feeding back data NCEPOD studies are confidential so NCEPOD will not feed back to a trust data that could be traced to an individual clinician. However NCEPOD is keen to help trusts assess their overall performance, so aggregated unidentifiable data are returned to trusts along with comparative data from the whole study database whenever possible.


An Age Old Problem

Page 2 of 5

NCEPOD Self-assessment checklist

Recommendations Is it met?

Y/N/Partially/ Planned

Comments (Examples of good practice or

deficiencies identified)

Action required Timescale Person responsible

Hospital facilities and multidisciplinary care of the elderly

Routine daily input from Medicine for the Care of Older People should be available to elderly patients undergoing surgery and is integral to inpatient care pathways in this population. (Trusts and Clinical Directors)

Yes/partially it is available. High risk pts go through anaesthetic high risk clinic misses some pts e.g. cancer, too weak for treatment. Plans immediate post-op care i.e. HDU/ITU but not ward shared care.

Yes re: #NOF and complex ortho pts

but not general surgical pts. (Consider development of automatic referral to all pts over 80 yrs in surgical wards (ideally pre-op).

Ward based input by physicians to surgical ward pts (as requested post-op)

? little for elective pts.

In Care Pathway it should say is referral to medical for elderly

appropriate?

Check re: individual pathways.

June 2011 Mr Refson Mr Kaldas

All hospitals should address the need for nutrition and mental capacity to be assessed and documented in the elderly on admission as a minimum standard. (Trusts and Clinical Directors)

Yes

On medical proforma. New EAU proforma also includes this.

Patient comorbidities

Comorbidity, disability and frailty need to be clearly recognised and seen as independent markers of risk in the elderly. This requires skill and multidisciplinary input including early involvement of Medicine for the Care of Older People. (Clinical Directors)

Yes Pre-op nurse-lead assessment and referral to clinic as above. (Planned). Anaesthetist assesses prior to emergency surgery. Consultant supervises juniors who assess (anaesth).

Assessment of capacity and appropriate use of the consent process should be clearly understood and documented by all clinicians taking consent in the elderly. (Clinical Directors)

Yes Consent form is very clear and identification of those without m.capacity. Specific consent form for MCA pts.

Medicine reviews need to be a regular daily occurrence in the peri-operative period. Input of both Medicine for the Care of Older People (MCOP) clinicians and an experienced ward pharmacist may greatly assist this process. (Clinical Directors)

Yes Policies and guidelines re: this. Ward-based pharmacist. Care of Elderly physician on a referral basis.

Pre-operative care

Delays in surgery for the elderly are Partially #NOF audit this. To go on audit plan for all


An Age Old Problem

Page 3 of 5

associated with poor outcome. They should be subject to regular and rigorous audit in all surgical specialities, and this should take place alongside identifiable agreed standards. (Clinical Directors)

? not other specialities. surgical specialities for 2011-12. Each speciality to set their own time frame esp. general surgery (e.g. acute abdo).

Senior clinicians in surgery, anaesthesia and medicine need to be involved in the decision to operate on the elderly. Risk assessment must take into account all information strands, including risk factors for acute kidney injury. (Consultants)

Yes Anaesthetists = yes Surgeons = yes Medicine may be referred to (but not always) re: optimisation Medicine for #NOF = yes.

An agreed means of assessing frailty in the peri-operative period should be developed and included in risk assessment. (Clinical Directors)

Yes MUST, skin integrity and bloods done pre-op on planned pts and emergency pts.

Pain must be assessed and managed as a priority before operation. (Consultants)

Yes Acute pain service, especially post op and sometimes pre-op.

All elderly surgical admissions should have a formal nutritional assessment as soon as practicable after their admission so that malnutrition can be identified and managed appropriately. (Trusts, Hospital Nutrition Teams)

Yes Mechanisms in place. Pre-op = yes O/P = yes EAU should be

TBA Alice Dain

Intra-operative care

Temperature monitoring and management of hypothermia should be recorded in a nationally standardised anaesthetic record. This is particularly important in elderly patients. (Clinical Directors)

Yes Done

There should be clear strategies for the management of intra-operative low blood pressure in the elderly to avoid cardiac and renal complications. Non invasive measurement of cardiac output facilitates this during major surgery in the elderly. (Clinical Directors)

Yes Both done

Post operative care

There is an ongoing need for provision of peri-operative level 2 and 3 care to support major surgery in the elderly, particularly for those with comorbidity. For less major surgery extended recovery and high observation facilities in existing wards should be considered. (Commissioning Leads,

Yes = level 2 and 3 No = High observation facilities No = extended recovery

Increased staffing for recovery would enable extended recovery (>24hrs). Pete Bishop would develop a business case re: a high observation facility e.g. Kingsmoor.


An Age Old Problem

Page 4 of 5

Trusts, Clinical Directors) Post operative Acute Kidney Injury (AKI) is avoidable in the elderly and should not occur. There is a need for continuous postgraduate education of physicians, surgeons and anaesthetists around the assessment of risk factors for the development of AKI in the elderly surgical patient. (Postgraduate Deans, Medical Directors)

Yes F1s and F2 both have sessions. Audit of post op AKI to be undertaken in elderly and presented at a variety of audit days.

Fluid management must be clearly documented, and form part of the routine review and handover between theatres and wards. This should continue on at least a daily basis thereafter, alongside monitoring of biochemical function. (Consultants, Nurses)

Partially

#NOF = yes

Fluid balance is part of post-op handover. ? not done everywhere re: daily review and bloods in elderly.

(Check post-op pathway).

Oct 2011

Pain is the 5th vital sign, and requires the same status as heart rate and blood pressure in the assessment and management of all patients. Clear and specific guidance on the recognition and treatment of pain in the elderly should be incorporated into education programmes. (Clinical Directors, Postgraduate Deans, Trusts)

Yes Alert = yes Training programmes = yes

A fully resourced acute pain service (APS) is essential within the context of modern secondary care services. This includes the Independent Sector. (Clinical Directors)

Yes Out of hours by matrons NNPs (but it is not consultant anaesthetist led).

There should be a consultant anaesthetist assigned to acute pain.

Care of the fractured neck of femur

The British Orthopaedic Association and The British Geriatric Society should provide more specific guidance on the ideal levels of seniority and speciality input into the assessment and decision making phase of the care pathway for patients with fractured neck of femur. (British Orthopaedic Association, British Geriatrics Society)

[for T&O and Care of Elderly to do]

? already been done

The Blue Book

The decision about when a patient s physical condition is optimised and when to operate in patients with fractured neck of femur is critical, and requires multi-disciplinary input and expertise. There must be senior surgical, medical and anaesthetic input at this point in the care pathway. (Clinical Directors, Consultants)

Yes


An Age Old Problem

Page 5 of 5

Care of the acute abdomen

Greater vigilance is required when elderly patients with non-specific abdominal symptoms and signs (diarrhoea, vomiting, constipation, urinary tract infection) present to the Emergency Department. Such patients should be assessed by a doctor with sufficient experience and training to exclude significant surgical pathology. (Trusts, Clinical Directors)

Yes Introduced Mr Kaldas as Emergency Surgeon based in Emergency Dept.

The elderly should receive no different level of care from other patients. As NCEPOD has previously recommended10 when admitted to a medical ward consultant review should occur within 12 hours. (Consultants)

Yes Continual PTWR during day (until 9pm) then received again at 8.00 a.m. including weekends.

Clear protocols for the post-operative management of elderly patients undergoing abdominal surgery should be developed which include where appropriate routine review by a MCOP consultant and nutritional assessment. (Clinical Directors)

? unknown check with Dr Vijay. ? auto referral >80 would sort this out. June 2011

A robust method of risk assessment for elderly patients presenting with an acute intra-abdominal catastrophe should be developed.

No ??For Mr Kaldas / surgeons to do? June 2011

Trusts should audit delays in proceeding to surgery in patients requiring emergency or urgent abdominal surgery and implement appropriate mechanisms to reduce these. (Trusts, Clinical Directors)

No See previous action.

Oct 2011



Maternity and NICU future provision


Trust Board Meeting

Executive Summary

24th February 2011 Part A


Governance

Equalities Impact

Finance

Legal Implications Communications Issues Risk and Health and Safety Issues

Issue: Maternity Services investment 2011/12 to 2013/14

Summary: The proposals here set out investment plans for the service which will:

Offer the necessary investment for Maternity and NICU to meet rising demand

Maintain the midwife to birth ratio at an acceptable level, increasing staff numbers in line with birth activity, albeit with no further progress towards EoE and national standards until 2013/14 at the earliest

Enable the Trust to maintain its high market share

Build on the high reputation of maternity services amongst the local community

Move the service to near break even by 2012/13

Move the service into substantial surplus by 2013/14, with the opportunity to improve the midwife to birth ratio from this point

Recommendations:

To expand maternity bed capacity to 18 beds, providing ante and post natal care

Provide a second obstetric theatre in the labour ward

Maintain NICU cot capacity at 16, but with expansion capacity to 20, in order to meet future demand

A phasing of the required capital investment across 2011/12 and 2012/13, totalling £1.7m (£619K in 2011/12)

Support the additional revenue required to support an expanded nurse establishment for NICU, totalling £385K FYE ( £278K in 2011/12)

Endorse the additional revenue required in 2011/12 to support an expanded nurse establishment for Maternity. This comprises the full year effect of decisions made in 2010/11 to move to a 1:38 birth to midwife ratio of £882K

Note the freezing of further improvements to the midwife to birth ratio until 2013/14

Approve in principle the investment in a Maternity Information System during 2012/13

Author: Simon Meddick Date: 16.02.11


MATERNITY SERVICES DEVELOPMENT PLAN 2011/15

1. Executive Summary

The high reputational status of Maternity Services offered by the Trust has been built over the many years of consistently high quality service delivery to the local community. It maintains a very high, and increasing, market share, and is the hospital of choice for a large number of women outside West Essex. The feedback the service receives from its users, both directly and via NHS Choices, is universally positive.

Demand. The service has experienced a near straight line growth in demand, with case complexity increasing, with births expected to exceed 4150 this financial year. Assuming continued growth across its current catchment, and the likely impact of strategic shift across North London and Hertfordshire, the demand is projected to reach 5000 births by 2013/14.

Managing in the interim. To keep up with the increasing number of births, the numbers of babies requiring more intensive care, and at the same time maintaining the quality of the service it offers, the Business Unit has been active in taking steps to positively manage the situation, through;

Limiting activity

Increasing capacity

Better utilisation of space

Improving productivity

Developing systems of community support

Maternity as a core service. The Trust has made a series of informed decisions to defer investment in Maternity Services, including NICU, over a number of years. This, on the basis that a range of measures to mitigate risk and to ensure a continued safe service could be implemented effectively. The Trust now needs to ensure it can maintain the primacy of its position locally in the provision of these services, enable it to keep pace with forecast demand, and to transform the service into a surplus generator.

The service is at a critical stage in its development therefore, as a core service within the Trust, and the proposals here;

Offer the necessary investment to meet rising demand

Maintain the midwife to birth ratio at an acceptable level, increasing staff numbers in line with birth activity, albeit with no further progress towards EoE and national standards until 2013/14 at the earliest

Enable the Trust to maintain its high market share

Build on the high reputation of maternity services amongst the local community

Move the service to near break even by 2012/13

Move the service into substantial surplus by 2013/14, with the opportunity to improve the midwife to birth ratio from this point

The alternative scenario, with limited investment, would result in key national and East of England quality standards not being met, with consequent impact on patient safety and service quality; a risk of loss of Level 2 status for NICU; and the likelihood that a capping of births across all commissioners, including West Essex, would be a necessity during 2011/12.

Many women come into contact with the hospital service for the first time as prospective mothers, and they and their families are potential users of the Trust s full range of services during their lifetimes. A high quality maternity service has important business benefits for the Trust as a whole.

Investment summary. The recommendation here is to approve capital and revenue investment over the two years 2011/13, which will provide the necessary capacity in staffing, infrastructure and physical terms, to manage forecast demand.

The Business Unit has aimed to reduce the financial load as far as possible through slipping capital investment for NICU and Maternity to October 2011, and proposes using bank staff in Maternity to deal with peaks in workload, with no additional midwife recruitment until 2013/14 at the earliest. A much slower pace of delivery of establishment improvements agreed with the SHA therefore, simply maintaining the current 1:38 midwife to birth ratio over the next three years. In summary, the investment comprises;

An additional 18 in patient beds, to be used flexibly for ante and post natal care

Maintain NICU capacity at 16, with the potential to flex to 20 cots according to demand

A second obstetric theatre re-provided in labour ward.

The capital costs for Maternity and NICU, to be phased over 2011/12 and 2012/13 are estimated at;

Maternity - £828K (estimated £307K in 11/12)

NICU - £844K (estimated £312K in 11/12)

Total - £1672K (estimated £619K in 11/12)

It should be noted that this lower cost option for obstetrics is dependant on the planned reduction in general bed requirement by the Trust in 2011/12, and the freeing of ward capacity.

The additional revenue costs, primarily increases in nurse establishment, are estimated at

£278K in 2011/12 for NICU. £385K full year

£882K in 2011/12 for Maternity, as the full year effect of establishment changes agreed in the previous year in order to reach a 1:38 midwife to birth ratio, incorporating an element for temporary staff in order to deal with peaks in workload

The bigger financial picture. An SLR appraisal of the investment needed in both areas shows only a marginal loss consequent on increase in nursing establishment on NICU. However, the case becomes untenable if births were to be restricted, with a resultant loss of income.

For Maternity the position is different. The service currently runs at a loss, and will continue to do so into 2011/12 with the full year impact of changes made in 2010/11 to improve midwife to birth ratios. Tariff income reduces in 2011/12, adding to the problem. In response, the Business Unit has committed to steps towards significant cost reduction, and it is assumed that;

The service implements improved midwife to birth ratios at a much slower pace to that agreed with the SHA in order to limit the investment needed, and would not achieve 1:30 by 13/14. It would maintain a 1:38 ratio until 2013/14 at the earliest, in this proposal

The service achieves an annual CIP of 6% in all areas, with the exception of direct nursing costs

That overhead costs reduce to a greater extent, bringing the Maternity Unit more in line with other Units. Currently, overheads make up a much higher proportion of its costs than is the case in other comparable hospitals

The Business Unit brings nuchal fold scanning in house with resultant cost reduction

With these challenges met, it is estimated the Unit would see a small improvement to out turn in 2011/12 compared to this year, and only a marginal loss in 2012/13. By 2013/14 the service would be making a substantial surplus, such that moves could be made to re-establish a trajectory for improving midwife numbers.

The alternative scenario, with restrictions to the service, limiting activity and income, would worsen the financial picture, with overheads increasing as a proportion of spend, and continued loss.

Information systems. The Business Unit considers it possible to introduce systems to improve data collection in the short term to mitigate income loss and improve QA submissions, and to delay capital investment in the Maternity IT System until 2012/13, to be phased over a two year period. The total cost of the system is £370K (estimated £240K in the first year).

2. Introduction

The next stage development for the Maternity Service and NICU over the next three years is potentially the most significant resource commitment to be made by the Trust during the planning period, and should therefore be one of the key strategic developments set out in the organisation s IBP, 2011/15.

Maternity and NICU services are inextricably linked, and this paper aims to set out the overall strategy for Maternity services as a whole, and at the same time describe the impact of investment decisions within each component service on that strategy.

3. Market assessment

Reputation

The Maternity Service provided by the Trust has an extremely strong reputation across the local community built over many years of consistently high quality service delivery, and is the hospital of choice for a large number of women outside West Essex. The feedback the service receives from its users, both directly and via NHS Choices, is universally positive.

The Trust s reputation is built upon;

The staff team. The Maternity Service at Harlow attracts high quality midwives, many from outside the East of England. Each Midwife has the skills to deliver babies in all situations. They have the experience of working in all areas including the Neonatal Unit and in the Community. Training programmes for newly qualified and experienced Midwives are judged externally to be excellent. All managers within the team are practitioners. The Unit guarantees to recruit all of the students it trains.

The philosophy of care. The team is high visibility, up to date with modern practice and actively promotes a service that puts women at the centre of care, being able to offer choice, promote normality and treat everyone as an individual.

Vulnerable Women

The service actively supports women who fall into this category and plans to extend the reach to these women and offer support and assistance to them and their families during pregnancy, childbirth and the post natal care period.

Neonatal Care in the Community

The specialist team providing continuing transitional neonatal care in the community has been a particularly successful initiative over the past year.

Breastfeeding rates are excellent, with currently a 76% initiation rate - one of best in the East of England. There is clear commitment to the Baby Friendly Initiative with the aim for full accreditation in 2011. To further support breastfeeding many mothers have been trained as breastfeeding support workers and help offer voluntary advice and support to mothers wanting to breastfeed both in the hospital and community.

Normality

Promoting normality is important part of the philosophy of care. Offering women choice and supporting their choices towards a normal birth throughout their pregnancy will help to reduce the caesarean section rate. There is a Birthing Unit and Home Birthing service and plans to increase the number of deliveries in these settings over the coming months.

Demography

There has been substantial population growth each year since 2002 (2800 deliveries) with a predicted 4150 births for 2010/11, This rise has been seen across all commissioners

This increase is predicted to continue into 2011/12. Simple extrapolation to 2013/14 would see births rising to 4500, but the likely impact of Hertfordshire changes in the provision of Maternity services as the QEII service closes in Oct 2010. ( Delivering Quality Healthcare for Hertfordshire ), and strategic shift across North London are predicted to take births to 5000 by this time

The case mix has become more complex and whereas before women with co existing morbidities did not become pregnant or if they did were not able to carry on with a pregnancy and have ended up with a miscarriage, these women now are continuing with their pregnancy and their babies are requiring more support in the form of intensive or special care following birth.

Harlow has the highest number of children on the child protection register and many of these babies require NICU care. Admissions to NICU are over 10% of the total birth population and this is one of the highest in Essex. This is due to the high number women with complex social care needs.

The growth in population size in West Essex area and just outside in East Hertfordshire will continue due to new housing in the area, and East European migration. Despite recent attempts to stop bookings for maternity care from outside the area, growth continues.

Total Number of Births for last 10 years60% increase during this period (2010/11 predicted based on figures at 28/1/11)

3646

39804176

2604 26392844 2873

30613301

3599

2000

2500

3000

3500

4000

4500

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Year

Num

ber

of b

irth

s

predicted

Market share

Its strong reputation has resulted in a particularly high market share across GP surgeries in its core catchment area (primarily GP surgeries within Harlow, Old Harlow, Church Langley and Nazeing) with the Trust securing 98% of obstetric referrals in 2009, increasing to 99% in 2010.

The main competitors for Obstetric referrals are Cambridge University Hospitals NHS Foundation Trust, Mid Essex Hospitals Trust and Whipps Cross University Hospitals Trust. Other providers collectively make-up only 1% of the market share.

Assessment

The Unit has demonstrated its ability to expand its market share over recent years, and to begin to attract women from outside the core catchment area of the Trust. It has been able to absorb a consistent year on year growth in demand through continued improvement in productivity and more effective use of space. However, in the short term, in order to maintain its share of a growing market, the Unit will require investment in order to increase capacity.

It is at an important stage in its development therefore, and the proposals here will offer the necessary investment to meet rising demand, maintain high market share, and move the service into surplus by 2013/14.

4. Operational context

Over a period of consistent increase in demand, the service has maintained a high quality service, able to attract the highest calibre professionals and maintain market share through its excellent reputation. It has only been able to achieve this by increasing staff productivity through skill mix shift and role redesign, developing innovative new services offering enhanced support to women in the community, as well as more effectively using the space available to it on site.

However, the service is at a critical point in its development, in that incrementally it risks falling behind other Units as it tries to deal with the projected increase in numbers of births over the next few years. The day to day context in which the Unit operates can be summarised as follows.

Demand.

Maternity services have expanded to support a growth in births across West Essex and Hertfordshire, from 2800 births in 2004 to 3980 births in 2009/10.

Case complexity has increased over the same period

Births are anticipated to exceed 4150 in 2010/11.

In 2006 the midwifery led Birthing Unit was opened to help provide capacity for low risk women in order to help cope with increased demand on the service. Since opening, this facility accounts for 15% of total births per annum.

As maternity services have grown, admissions to the NICU have also increased with some 10% of maternity admissions needing NICU support.

October, 2010 had the highest number of NICU admissions. Cot numbers increased to 20 from 16 in response. Consequent risk was mitigated by using the community neonatal nursing team (A 9 month pilot supported by the PCT and QUIP agenda) looking after babies that had been discharged home earlier than planned therefore releasing capacity. This has had a significant impact in reducing cot-days (661 days saved to month 8, across West Essex and Hertfordshire) and in securing repatriation of babies from tertiary centres. Commissioners are considering an extension, and potential expansion, of the scheme in 2011/12.

Environment.

The environment within the Maternity Unit is sub optimal. Currently there are 8 high risk delivery rooms and 1 delivery room in the Birthing Unit although a further 1 room can be used to deliver women in an emergency. This is far from ideal due to the size of the room. The shortage of bed capacity has resulted in women giving birth in clinical areas outside the Labour ward.

Delivery room productivity at PAH equates to 345 births per room, with other Units (Homerton, East Sussex and Surrey) ranging between 250 and 275 births per room.

NICU is not compliant with BAPM standards from an environmental and staffing point of view. The limited space around cots, inadequate separation of clean and dirty utility areas, the poor integrity of roof and windows, and poor ventilation are the main areas of concern.

Workforce.

The medical workforce has seen investment over the last two years and when the 8th O & G Consultant is in post, from April 2011, there will be 60 hours of Labour Ward cover, as required by CNST.

The midwife to birth ratio remains static at 1:38 (if temporary staff are included in the calculation; 1.40 if temporary staff are excluded).

Currently the Unit does not achieve the central KPI to achieve 100% 1:1 care in labour. Over the three months to December, performance has averaged 92%

The Business Unit has been active in developing the skills of other professional groups in undertaking non-midwife duties

5. Strategic Context & National and Local expectations: Quality and Patient Safety

Maternity.

Key standards are outlined in national documents such as Safer Childbirth

Minimum Standards for the Organisation and Delivery of Care in the Labour Ward

and Maternity Matters , furthermore CNST requirements are based on these key documents.

The main focus of these documents is staffing and environmental quality. The Trust is compliant with regard to senior medical staff cover, but not so in relation to;

The requirement for 1.15 midwives for each woman in labour and a clinical midwife leader on each shift.

The recommended Midwife to birth ratio of 1:28, although the EoE standard is 1:30

1 WTE Consultant midwife to oversee 900 low risk women

With regard to the standards in relation to staffing, levels are reviewed on a daily basis in order that they meet service demand, with a clear escalation policy in place in order to ensure the appropriate management response.

Units providing neonatal care must meet BAPM standards. This is subject to an action plan agreed by the Trust with the EoE. In relation to environment, the Trust is behind others in meeting these standards. In relation to staffing levels, the Trust is considered to be at a similar stage in working towards them.

A delivery rate above 4000 births requires two operating theatres

NICU.

National organisations and government initiatives such as the DoH Neonatal Toolkit, Poppy Report and BLISS have looked at the most appropriate way of delivering equitable, high quality specialist neonatal care services across England. To achieve this they have stipulated that care should be provided through a managed clinical network, which should consist of 3 types of unit. They are as follows:

Local Special Care Units (Level 1) These units provide special care for babies within their own local population, and also by local agreement with their neonatal network provide some high dependency care. Generally these are babies who are more than 35 weeks gestation.

Local Neonatal Unit (Level 2) This type of unit provide special care, high dependency and a restricted volume of intensive care, and would be expected to transfer babies who require complex or longer term intensive care to a network neonatal intensive care unit. Generally these are babies over 27 week s gestation.

Network Intensive Care Unit (Level 3) These larger neonatal units provide the whole range of medical and or surgical care for their local population as well as for babies referred to them from their local Level 1 and Level 2 units within their network.

The Neonatal Unit at the Princess Alexandra Hospital is currently a Local Neonatal Unit / Level 2 with 2 ITU, 4 HDU and 10 SC cots. All five Essex DGHs are Level 2 Units. In the East of England all maternity units with 4000 births have Level 2 status. Hospitals that have a level 1 SCBU tend on average to have approximately 2800 to 3000 births and are positioned close to a level 3 tertiary unit.

No level 2 Units have been down graded to a level 1 where the birth rate is rising, and the East of England Neonatal Network have stipulated that the PAH Unit;

Should remain a Level 2 Unit with a cot configuration of 2 ITU, 3 HDU and 11 SC cots. This cot configuration was deemed necessary to ensure safe delivery of care and minimal cot blocking across the Network according to a 70% occupancy level.

Should work to achieve Neonatal Service Milestones in order to meet the recommended national and EoE Standards. Critically;

- to improve the clinical environment and facilities available to families - to secure an increase to medical and nursing workforce

establishments.

If these milestones are not achieved by March 2011, the Level 2 status and services will be downgraded to a Local Special Care Unit/ Level 1.

The Specialist Commissioning Group also strongly supports the continued development of NICU services at PAH as a Level 2 Unit.

If the unit were to reduce to level 1 then due consideration will need to be given to the loss of financial income, (£1,200,000) and the risk of adverse media due to:

All babies born under 34 weeks being transferred to other providers a significant distance away (South coast and Liverpool in the last year).

All women with threatened preterm labour requiring to be transferred out

The impact on maternity services due to midwives required to accompany women on transfers.

The increase risk of preterm babies born en route in ambulances.

No local facilities for high risk population high number of women who are socially disadvantaged.

For NICU, the requirement to remain at level 2 is also driven by other national, regional and internal factors.

National and Regional

BAPM standards

East if England Specialist Commissioning Group Milestones, 2008/09

Department of Health Toolkit November 2009

Report for the British Association of Perinatal medicine - Designing a NICU

Internally

NICU risks identified in conjunction with fire, infection control, estates and health and safety officer.

Risk assessments on W&C Business Unit Risk register

7. Mitigating actions to date

The Business Unit has been particularly active in its response to increasing demand, taking steps to proactively manage the situation in order to maintain a safe service, through;

Limits to activity

Maternity growth has been capped to deliver no more than 4000 babies. Any out of area bookings are currently stopped in an attempt to adhere to this figure. Over the last couple of months it has become apparent that the growth in the maternity services is coming from within the local area and despite this action births have now exceeded 4000 with a predicted year end birth rate in excess of 4150. Increasing capacity

The demand has exceeded the capacity in respect of the number of delivery beds and there is also a need for a second obstetric theatre. In order to manage in the immediate term, 1 extra delivery bed has been introduced in the Labour Ward and 2 delivery rooms in the Birthing Unit.

Elective caesarean sections have been undertaken in main theatre. This has been possible due to reduced elective activity freeing theatre time.

Better utilisation of space

For NICU, there are significant environmental problems. The contingency plans put in place to mitigate them is sustainable in the immediate term only. Steps taken so far include the creation of a room provided with oxygen, utilising a former equipment room, to provide additional capacity, in extremis.

Building capacity in the community

A community neonatal service was established in 2010, with the support of NHS West Essex, which has;

Reduced NICU lengths of stay

Repatriated babies more quickly to the local unit from level three units

Resulted in more effective and more efficient discharge planning.

Improved the quality of service to users.

Increased the support to mothers who wish to breast feed and increase the uptake of breast feeding in the West Essex area.

Reduced readmission to hospital

Improving staff productivity

An extensive work programme is in place to ensure maximum flexibility in staff roles is achieved, with nurses and care assistants taking on non-midwife roles, and rotation of staff. All staff are skilled to work in any part of the service, with hourly review of workload to make sure the staff available are matched with demand across the Unit as a whole.

The use of volunteers, and ensuring care is delivered in partnership with women, fostering independence, is an important part of the philosophy of the Unit.

In the community, Care Assistants increasingly take on the role of providing support to women at home.

8. Maternity Unit

Options for service development.

1. Do nothing. No cost , but with major service implications;

- Increased patient and safety issues with women delivering in inappropriate areas.

- Increased number of maternity and NICU closures with nowhere to send the women as surrounding hospital are also experiencing capacity issues. The planned expansion of neighbouring Units will only cope for local population increase

- Increase in clinical incidents, complaints and litigation - NICU will be downgraded to level 1 with a loss of £1.1 million income. - A high number of women will need to have an interutero transfer. - Non compliant with CNST requirements. - Adverse media interest.

2. Phased development of Maternity Services over 2011/12 and 2012/13.

This option enables the Trust to manage the forecast increase in births to 2013/14 through

- An increase in the productivity of the Birthing Unit to achieve 25% of women delivering there (currently 17%)

- Provide a second obstetric theatre re-provided in labour ward. - An additional 18 in patient beds possible through improved

productivity. These beds would provide both ante and post natal care on a flexible basis

- Maintain the midwife to birth ratio at 1:38 by increasing staff numbers in line with birth activity over the period, estimated at an additional 7.5 WTE midwives per annum.

- Plan to further improve the ratio from 2013/14 - Continued investment is being considered by NHS West Essex in the

current community neonatal pilot from 2011/12 in order that the team will have the capacity to reduce length of stay and prevent readmissions on the post natal ward.

This option enables maternity and neonatal services to continue to be provided safely, without the necessity to cap bookings, over the next three year period. It will also mean the Trust can retain a Level 2 NICU service. It is the preferred option.

The Business Unit will action further steps to reduce lengths of stay to upper quartile levels as part of this plan, specifically;

- Continued reduction to C-section rates - Improving the timeliness of baby checks prior to discharge - Extending the philosophy of normalisation of the birth experience

through extension of midwifery led approaches, induction at home and the expansion of the community neonatal team

The Unit will maintain active monitoring of staffing levels on a daily basis to ensure workload is assessed and temporary staff are deployed as necessary to meet peaks in demand.

Resource commitment

A number of alternative capital schemes have been considered. The preferred, lowest cost option, utilises main ward capacity freed over 2011/12 to relocate the Stroke Unit (£44K), re-provides Chamberlen ward (£137K), and creates a second obstetric theatre with delivery suites in the labour ward (£647K), requires a total capital investment of £828,400 inclusive. Assuming a start on site at the end of September, 2011, the costs would be phased over the two years 2011/13, as follows;

2011/12 - £307,243

2012/13 - £521,157

This option is contingent on the plans for bed reduction across the hospital freeing ward capacity during 2011/12.

The Trust had already committed to improving midwife numbers in 2010/11 to achieve a 1:38 midwife to birth ratio. This has a full year effect in 2011/12 of £882K. In order to manage demand the Business Unit will limit additional cost through careful deployment of bank staff to deal with peaks in workload. The SLR analysis is shown below.

Delaying further improvement to midwife numbers until 2013/14, and building capacity to manage the projected increased numbers of births, and therefore income, enables the service to;

Improve its financial position from 2011/12, reducing the loss compared to forecast 2010/11 out turn

Move to near break even in 2012/13

Become a surplus generator from 2013/14

These calculations assume;

6% CIP on all pay and non pay budgets except direct nurse staffing in all 3 years

28% CIP on Direct costs - Appointments & Admissions, Records; and on O/Heads - Senior Nursing Team, Training, Risk management staff,

Achieve Level 3 Maternity CNST in 13/14

Income increasing only by increase in birth rate

A much slower movement towards the agreed milestone of 1:30 from the current 1:38, with further movement stopped until 2013/14.

Overhead costs appear significantly higher than in other Trusts (28% higher than for Maternity Services at the North Middlesex Hospital). This may be due to the relative size of organisations, but the anticipated reduction in overhead costs across the Trust in back office functions and facilities, has been reflected in these calculations.

The Trust pays £2.7m in costs to CNST, reflected in the SLR analysis. Whilst this is a significant element of the costs incurred by the Trust, they are reflected nationally within PbR and covered through tariff income.

10/11 forecast Outturn 11/12 12/13 13/14

SLR Clinical income 14,848,975

15,638,950

16,591,149

17,546,712

Non Clinical income 295,769

438,104

438,104

438,104

Total income 15,144,744

16,077,054

17,029,252

17,984,816

Direct costs 7,719,499

8,278,741

8,446,925

8,746,694

Indirect costs 1,743,292

1,674,470

1,736,692

1,737,075

Overheads 5,706,647

6,098,375

6,209,548

5,935,880

Total operating expenditure 15,169,438

16,051,586

16,393,165

16,419,649

EBIDTA -24,694

25,468

636,088

1,565,167

Interest, Dpn,Amortisation 743,450

768,790

821,790

837,790

Earnings- Profit /( Loss) -768,144

-743,322

-185,702

727,377

Recommendations

The recommendation is to adopt option 3.

9. Neonatal Intensive Care Unit

Options for service development

There are two potential options;

1. Do nothing. Whilst the Trust would retain a SCBU it would necessitate a downgrading of the existing NICU to Level 1, and the loss of 2 ITU and 2 HDU cots. It would have significant financial implications due to loss of income, and service impact;

- A reduction in admissions of 144 ITU/ HDU babies (917 cot days). - A reduction in the number of ITU/ HDU cot days leading to a significant

loss of income. (£908,000) - A reduction in ITU/HDU capacity leading to a significant loss of activity

and income for Maternity Services and for the Trust. (£220,000) - BAPM standards stipulate the levels of staffing required for the

intensity and number of cots situated in NICU. If the specified level of staffing is not reached, the Trust will lose significant income (£1.2M).

- Costs associated with staff redeployment/redundancy

- The existing build will require capital investment to provide an appropriate environment for a SCBU. Estimated capital cost of £550,000

- Increased numbers of patients transferred out, with limited capacity at other Units within the East of England

- Impact on maternity services with midwives required to escort women to other providers and therefore depleting the maternity unit for up to five hours on each occasion.

- Increased liability for potential SIs from both neonatal and maternity services

- Potential loss of nursing, midwifery and medical staff and difficulty in recruitment, and potential loss of medical trainee placements resulting in less cover to other areas in the Trust.

2. Maintaining Level 2 status. This would involve maintaining the current cot numbers at 16 (but with the potential to flex to 20 according to demand), increasing staffing costs to BAPM standards and upgrading the existing environment. It would enable the Trust to meet the increased demand forecast over the next three years and protect income. It is the option given approval in principle by the Trust Board. It has the clear advantages of;

- Being able to continue to provide ITU and HDU care. - Maintaining income for the Business Unit and the Trust. - Limiting the number of patients and pregnant women needing transfer

to other units across the region. - Being able to repatriate our local babies quicker from other hospitals,

increasing quality of care for patients and families and returning costs for care to the local economy.

- Avoiding the separation of mothers and babies and thereby improving and maintaining the quality of care that we deliver.

- Maintaining and improving on our current recruitment and retention status.

- Maintaining our corporate image as a facility that our clients can trust.

Resource commitment

The preferred Option 2, in terms of revenue, is the most advantageous option, despite showing a marginal loss. The SLR forecast is shown below. There may the possibility to renegotiate contracted activity levels next year in order to reduce activity paid at marginal rates to mitigate this loss. These figures do not take into account the loss of £220,000k obstetrics income from mothers who would no longer deliver at the Trust.

Increases to nurse establishment equates to £385,000 full year. Recruitment of these nurses is not anticipated to be a problem as there is a successful recruitment strategy in place. It is anticipated that there will be a phased recruitment, avoiding unnecessary pressure on existing staff to train new starters, with additional investment in 2011/12 (effectively a half year effect) of £278,000.

There is no requirement to increase the medical establishment in this option.

SLR forecast outturn based on M7

Current position

Option 1 - do nothing. Drop to level 1

Option 2 -remain at level 2

Total NICU income 3,194,428

2,285,670

3,194,428

Other income 100,850

100,850

100,850

Total Income 3,295,278

2,386,520

3,295,278

Direct costs 2,102,767

1,798,723

2,487,767

Indirect costs 35,542

35,542

35,542

Overheads 478,982

478,982

512,699

potential reallocation of costs Total Expenditure 2,617,291

2,313,247

3,036,008

EBITDA 677,987

73,272

259,270

Interest, depn, amortisation 224,163

264,344

283,799

Earnings profit (Loss) 453,823

-191,072

-24,529

The capital investment for NICU is estimated to be £843,600 inclusive. The profiling of this spend, assuming an end of September 2011 start on site would be as follows;

2011/12 - £312,132

2012/13 - £531,468

Recommendation

Continue to provide a Level 2 neonatal service by approving option 2.

10. Infrastructure

IT system implementation

The maternity department currently records basic information in the McKesson PAS (maternity module). It has been in place for approximately 20 years and has been outstripped by modern demands. A recent gap analysis of functionality demonstrated that the current system was not fully compliant in 70% of domains hence it no longer meets the requirements of a fit-for-purpose Maternity Information system.

There are three areas of concern;

The last few years has seen a huge increase in the need for maternity units to provide quality assurance data. Both the Royal College of Obstetricians and Gynaecologists (RCOG) and the Kings Fund have published reports containing national benchmarks relating to standards of maternity care. Currently the provision of basic QA data is poor

There are currently gaps in the recording of activity information, with consequent risks to income. This will become even more important with the unbundling of the £2.6m community contract in 2011/12

There are concerns with regard to the current manual recording of procedures such as cardiotocographs (CTG). Central monitoring and remote viewing of results should significantly reduce the number of serious incidents and litigation claims.

Resource commitment

The Business Unit considers it is feasible in the short term to introduce systems to improve the current data collection and recording arrangements to mitigate against lost income, and to improve the data submitted in relation to quality. In doing this, it considers the capital investment in the Maternity Information System could be slipped into 2012/13.

£370K capital over two years (£240K in 2012/13) £70K revenue, part year effect in 2012/13

A conservative estimate indicates that the Trust is losing £260,000 revenue per annum due to a 10% understatement of activity due to poor recording.

The highest value litigation claims for the Maternity Department relate to CTG errors. Currently there are 4 claims outstanding where the legal team could settle for in excess of £4 million each.

Recommendation

To commence procurement in 2012/13

11. Summary

Maternity Services have been able to build a particularly strong reputation for service quality in the locality and with its staff, and at the same time manage year on year growth in the number of births. The service is at a critical point in its development as a core service within the Trust, and the proposals here will offer the necessary investment to meet rising demand, maintain high market share, and move the service into surplus over a two year period, albeit with no improvement to midwife to birth ratios.

The alternative scenario, with limited investment, would result in key national and East of England quality standards not being met, with consequent clinical governance risk; a risk of loss of Level 2 status for NICU; and the likelihood that a capping of births across all commissioners, including West Essex, would be a necessity during 2011/12. Reduced income, combined with proportionately higher overheads would result in continued loss for the service.

12. Recommendations

The Trust Board is asked to note the current situation across Maternity and NICU services, and the positive steps taken so far to maintain a safe, high quality service, and to endorse the recommendations made here. Specifically;

To expand maternity bed capacity to 18 beds, providing ante and post natal care

Provide a second obstetric theatre in the labour ward

Maintain NICU cot capacity at 16, but with expansion capacity to 20, in order to meet future demand

A phasing of the required capital investment across 2011/12 and 2012/13, totalling £1.7m (£619K in 2011/12)

Support the additional revenue required to support an expanded nurse establishment for NICU, totalling £385K FYE ( £278K in 2011/12)

Endorse the additional revenue required in 2011/12 to support an expanded nurse establishment for Maternity. This comprises the full year effect of decisions made in 2010/11 to move to a 1:38 birth to midwife ratio of £882K

Note the freezing of further improvements to the midwife to birth ratio until 2013/14

Approve in principle the investment in a Maternity Information System during 2012/13

15 February 2011 SPM



Financial Performance Report and Operational Update

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST TRUST BOARD, PART A – 24TH FEBRUARY 2011

Issue: MONTH 10 – FINANCE PERFORMANCE REPORT Status: FOR INFORMATION 2010-11 Year to Date The Trust is reporting break even for January 2011 which leaves the year to date deficit unchanged from last month at £474k. The details can be seen in Appendix 1. The Trust is still in the process of finalising an income outturn for the year with its main commissioner, West Essex PCT. The draft agreement has been reflected in the January income figures. The forecast outturn income from its other main purchaser, Hertfordshire PCT, continues to be based on activity performed. This is over-performing by 8.8% year to date. However, income in the month of January only over-performed by 1%, the lowest level this financial year and a reduction in forecast income for the year of c £500k. The steady drop in expenditure (Appendix 2) has resumed in January. Overall pay expenditure decreased by £381k from December to January, primarily due to a reduction in bank & agency spend. The monthly bill is £639k (6.34%), lower than the average monthly pay bill in the first half of the year with the greatest improvement (£271k) in medical staff. Temporary staff needs to remain a focus for reducing costs. The agency pay bill represents 2.6% of the total pay bill in January, a reduction from a high of 8.1% earlier in the year. Non-pay costs also decreased by £655k from December to January, with reductions in medical & surgical consumables and drugs in relation to reduced activity. A delay in capital expenditure has also led to a decrease in the depreciation charge. Clearly there is a need to maintain pressure on costs to ensure the trend continues its downward trajectory. The progress to date in identifying and progressing savings plans is set out in the following table:

Gateway Analysis M10 M9

Idea - not costed in any detail (0) 672 715

Costed plan exists, but not authorised/actioned (1) 1,306 1,306

In progress (2) 457 646

Budgets adjusted (3) 1,863 1,152

Total 4,297 3,821 Of these schemes £1,154,000 has been realised and accounted for to month 10. The reduction in bank and agency spend is not included in the totals above since it is not budgeted for. A more detailed analysis of the schemes by business unit is included in Appendix 3. Appendix 4 lists the individual schemes and provides an assessment on the impact of the scheme on quality of services. A further “on account” payment of £2.5 mn. (over and above the base monthly payment) was received from West Essex PCT in January. This has enabled the monthly payment run to suppliers to be increased. The cash flow to date is shown in Appendix 5 and the balance sheet at the end of January in Appendix 6. Forecast to Year End 2010-11

The forecast to the year end (Appendix 7) has been done in the light of the likely agreement with West Essex PCT. This shows a forecast break even for the year end, however, there are a number of risks to achieving this:

• a further £1 million in cost savings needs to be found in the last 3 months of the year. This pushes to the limit the savings identified through the gateway process and is going to be a challenge to achieve

• the monthly reduction in costs (Appendix 8) has picked up again in January and needs to be sustained and further reduced in the last 2 months of the year. needs to pick up again following the reversal in December

• we are not aware of any material disputes with Hertfordshire PCT on income invoiced and the forecast is based on this continuing

• the Trust planned to close Charnley ward (elective work) from 1st January 2011, but has had to re-open from time to time to take emergency work. The costs savings from the closure have been included in the forecast and the Trust is therefore seeking reimbursement from the West Essex PCT for the cost of re-opening the ward.

Appendix 6 shows the projected balance sheet at the 31st March 2011 and shows, in conjunction with Appendix 5, that provided the forecast outturn is achieved the cash target of £1.3 million in the bank at the year end will be met. The forecast will continue to be kept under close review. Prior Year – 2009-10 Agreement has not yet been reached with West Essex PCT the payment of invoices submitted relating to 2009-10. No provision has been made in the forecast outturn for 2010-11 to write this off. Discussions on this continue. Recommendations: The Board is asked to review and note the Financial Performance Report. Author: Andrew Butters, Interim Director of Finance, Date: 15th February 2011

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUSTMONTH 10 2010-11 Appendix 1

Exp 4 WTE Bud. WTE Cont.WTE

Worked.WTE Paid.

Annual Budget.

Current Month

Budget.

Current Month Actual.

Current Month

Variance.

YTD Budget.

YTD Actual.

YTD Variance.

ADMIN & CLERICAL 536.96 500.90 508.52 507.12 13,390 1,115 1,035 -79 11,147 10,924 -223 ANCILLARY 288.89 261.44 261.83 314.52 6,597 550 493 -57 5,497 5,078 -419 CLINICAL EFFICIENCIES - PAY -49.49 0.00 0.00 0.00 -1,974 -159 0 159 -1,643 0 1,643 INC-TURNOVER-VAC - PAY -19.20 0.00 0.00 0.00 -1,113 -23 0 23 -1,015 0 1,015 MAINTENANCE & WORKS STAFF 31.00 30.34 31.98 32.34 896 75 69 -6 746 762 16 MEDICAL 403.45 376.49 394.40 374.52 36,218 2,969 2,982 13 29,750 31,718 1,968 NURSING 1,143.08 1,071.06 1,106.96 1,167.60 41,508 3,431 3,282 -149 34,286 33,957 -329 QiPP EFFICIENCIES - PAY -36.94 0.00 0.00 0.00 -1,444 -95 0 95 -1,199 0 1,199 SCIENTIFIC, THERAPEUTIC & TECH 364.60 353.54 360.02 360.19 13,945 1,111 1,138 27 11,633 11,717 85 SNR MANAGERS 106.88 99.80 98.14 98.49 6,317 526 442 -84 5,270 4,986 -284 PAY Total 2,769.23 2,693.57 2,761.85 2,854.78 114,340 9,499 9,440 -59 94,471 99,142 4,671 BALANCE SHEET ITEMS 0.00 0.00 0.00 0.00 -1,100 -92 0 92 -917 17 933 BLOOD PRODUCTS 0.00 0.00 0.00 0.00 1,326 111 111 -0 1,118 1,075 -42 CONTINGENCY 0.00 0.00 0.00 0.00 111 0 0 0 83 0 -83 DEPRECIATION 0.00 0.00 0.00 0.00 7,173 598 449 -148 5,977 5,808 -170 DIVIDEND PAYMENT 0.00 0.00 0.00 0.00 3,672 306 306 0 3,060 3,060 0 DRUGS DRESSINGS & GASES 0.00 0.00 0.00 0.00 11,071 944 945 1 9,508 9,712 204 ESTABLISHMENT EXPENSES 0.00 0.00 0.00 0.00 2,802 221 235 14 2,336 2,379 43 GENERAL SUPPLIES & SERVICES 0.00 0.00 0.00 0.00 2,589 215 227 11 2,159 2,416 257 INTEREST PAYABLE 0.00 0.00 0.00 0.00 420 35 35 0 350 350 -0 INTEREST RECEIVABLE 0.00 0.00 0.00 0.00 -31 -3 -2 0 -26 -17 9 INTERNAL RECHARGES 0.00 0.00 0.00 0.00 0 0 0 -0 0 0 -0 LAB EQUIP & CONSUMABLES 0.00 0.00 0.00 0.00 1,779 148 156 7 1,482 1,674 191 MED & SURG EQUIPMENT 0.00 0.00 0.00 0.00 9,336 757 647 -111 7,820 8,425 605 MISCELLANEOUS 0.00 0.00 0.00 0.00 5,512 491 438 -53 4,686 4,408 -278 NON NHS PURCHASE OF HEALTHCARE 0.00 0.00 0.00 0.00 2,795 194 194 -1 2,242 3,167 925 PATIENT APPLIANCES 0.00 0.00 0.00 0.00 680 57 56 -0 567 595 28 PREMISES & FIXED PLANT 0.00 0.00 0.00 0.00 4,644 398 307 -91 3,854 3,621 -233 RESERVES 0.00 0.00 0.00 0.00 -3,280 -247 -45 202 -2,447 -345 2,102 SERVICES FROM OTHER NHS BODIES 0.00 0.00 0.00 0.00 5,044 422 407 -15 4,204 4,148 -56 UTILITIES 0.00 0.00 0.00 0.00 1,217 124 132 9 985 1,063 78 X RAY EQUIP & CONSUMABLES 0.00 0.00 0.00 0.00 567 47 1 -46 472 429 -43 NON PAY Total 0.00 0.00 0.00 0.00 56,328 4,727 4,598 -129 47,514 51,986 4,472 DEPARTMENT OF HEALTH 0.00 0.00 0.00 0.00 -54 -4 0 4 -45 -4 40 DONATION RESERVE 0.00 0.00 0.00 0.00 -133 -11 -8 3 -111 -86 25 EDUCATION, TRAINING & RESEARCH 0.00 0.00 0.00 0.00 -5,234 -429 -450 -21 -4,377 -4,432 -55 INCOME FROM SERVICE AGREEMENTS 0.00 0.00 0.00 0.00 -160,375 -13,158 -13,250 -92 -134,332 -141,620 -7,287 NON NHS OTHER 0.00 0.00 0.00 0.00 -456 -38 -28 10 -380 -398 -18 NON NHS PRIVATE PATIENTS 0.00 0.00 0.00 0.00 -569 -47 -45 2 -474 -449 25 OTHER INCOME 0.00 0.00 0.00 0.00 -3,598 -295 -279 16 -3,077 -2,935 143 RTA INCOME 0.00 0.00 0.00 0.00 -751 -63 21 84 -625 -730 -105 INCOME Total 0.00 0.00 0.00 0.00 -171,168 -14,046 -14,038 7 -143,422 -150,654 -7,233 Grand Total 2,769.23 2,693.57 2,761.85 2,854.78 -500 181 0 -181 -1,437 474 1,911

Month by Month Analysis 2010-11 (£000's) Appendix 2

Exp 4Month 10

Actual.Month 9 Actual.

Month 8 Actual.

Month 7 Actual.

Month 6 Actual.

Month 5 Actual.

Month 4 Actual.

Month 3 Actual.

Month 2 Actual.

Month 1 Actual.

PAY ADMIN & CLERICAL 1,035 1,074 1,081 1,069 1,070 1,091 1,150 1,144 1,129 1,080 ANCILLARY 493 467 497 513 527 524 507 522 520 508 CLINICAL EFFICIENCIES - PAY 0 0 0 0 0 0 0 0 0 0 INC-TURNOVER-VAC - PAY 0 0 0 0 0 0 0 0 0 0 MAINTENANCE & WORKS STAFF 69 79 77 76 77 72 79 74 76 84 MEDICAL 2,982 3,121 3,046 3,049 3,003 3,319 3,304 3,331 3,272 3,292 NURSING 3,282 3,423 3,359 3,328 3,447 3,497 3,472 3,432 3,387 3,331 QiPP EFFICIENCIES - PAY 0 0 0 0 0 0 0 0 0 0 SCIENTIFIC, THERAPEUTIC & TECH 1,138 1,147 1,182 1,133 1,195 1,181 1,172 1,223 1,174 1,172 SNR MANAGERS 442 509 531 468 519 523 505 506 483 499

PAY Total 9,440 9,821 9,774 9,635 9,837 10,207 10,188 10,233 10,041 9,968 NON PAYBALANCE SHEET ITEMS 0 0 0 0 0 0 2 17 1,153 -1,115

BLOOD PRODUCTS 111 99 94 93 124 109 117 102 113 115 CONTINGENCY 0 0 0 0 0 0 0 0 0 0 DEPRECIATION 449 595 595 596 596 596 596 596 593 598 DIVIDEND PAYMENT 306 306 306 306 306 306 306 306 306 306 DRUGS DRESSINGS & GASES 945 1,054 1,036 916 986 939 1,041 951 915 929 ESTABLISHMENT EXPENSES 235 242 241 233 239 242 252 234 209 253 GENERAL SUPPLIES & SERVICES 227 256 234 248 232 236 252 269 238 224 INTEREST PAYABLE 35 35 35 35 35 35 35 22 22 21 INTEREST RECEIVABLE -2 -2 -1 -2 -1 -2 -2 -1 -2 -1 INTERNAL RECHARGES 0 0 0 0 -0 0 0 -0 0 0 LAB EQUIP & CONSUMABLES 156 171 176 178 160 160 184 145 156 187 MED & SURG EQUIPMENT 647 854 847 954 851 794 898 925 801 855 MISCELLANEOUS 438 450 439 441 473 -91 859 453 465 479 NON NHS PURCHASE OF HEALTHCARE 194 253 222 227 329 352 407 533 263 387 PATIENT APPLIANCES 56 50 55 50 57 68 70 67 69 52 PREMISES & FIXED PLANT 307 329 309 352 350 372 426 368 367 442 RESERVES -45 -33 -46 -10 -23 -16 -24 -12 -92 -43 SERVICES FROM OTHER NHS BODIES 407 414 428 412 437 434 407 412 443 355 UTILITIES 132 133 118 100 98 92 98 85 101 107 X RAY EQUIP & CONSUMABLES 1 47 43 47 47 51 43 48 44 57

NON PAY Total 4,598 5,253 5,130 5,177 5,295 4,676 5,965 5,518 6,165 4,206 INCOMEDEPARTMENT OF HEALTH 0 0 0 0 0 0 0 -1 -1 -1

DONATION RESERVE -8 -8 -8 -9 -9 -9 -9 -9 -9 -9 EDUCATION, TRAINING & RESEARCH -450 -423 -447 -437 -373 -459 -446 -443 -534 -419 INCOME FROM SERVICE AGREEMENTS -13,250 -14,187 -13,894 -14,243 -14,464 -13,482 -14,850 -15,061 -14,320 -13,867 NON NHS OTHER -28 -24 -30 -44 -33 -56 -37 -77 -26 -45 NON NHS PRIVATE PATIENTS -45 -46 -49 -42 -46 -41 -49 -43 -43 -44 OTHER INCOME -279 -310 -385 -294 -277 -275 -260 -297 -279 -278 RTA INCOME 21 -75 -91 -40 -80 -115 -114 -100 -104 -33

INCOME Total -14,038 -15,074 -14,904 -15,109 -15,284 -14,438 -15,764 -16,031 -15,316 -14,697 Grand Total 0 0 -0 -297 -152 446 389 -280 889 -523

Appendix 3

Financial Recovery Plans 2010-11 £000's

Business Unit & Trust Iniatives 0 1 2 3 TotalCancer & Core Services 19 109 62 190 Elective 79 95 174 Emergency 14 241 255 Womens & Childrens 139 139 Hotel 288 2 3 293 Estates 58 23 13 173 266 Corporate & Governance 15 379 300 912 1,606

171

894

328

1,530

2,922

Provider Arm Integration reduction - - Admin Review 401 401 Admin - Patient booking 52 52 Admin - Reception Points 50 50 Admin - Secretaries - ESR - Procurement - - 66 333 399 Other schemes to be split by BU 100 311 62 473

672

1,306

457

1,863

4,297

16% 30% 11% 43% 4,297

Gateway

Financial Recovery Plan Schemes Appendix 4

Business UnitTotal £000's

Cancer & Core Services Elective Emergency

Womens & Childrens Hotel Estates

Corporate & Governance Other Total

Quality Risk

Gateway on FRP

Scheme - Estates Energy 173 173 173 3

- -

Procurement 399 399 399 medical gases 0 - standardisation and best price for prostheses 0 - vac pumps procurement 0 - Wound Drainage Pumps 0 - bed hire contract to be reviewed 0 - inco pads 0 - chest drain policy 0 -

Length of Stay 72 72 72 3 1Outpatients 137 137 137 3 1Theatres 55 55 55 2 1FP10 usage 30 30 30 2 1Late TTAs 4 4 4 3 1Use of SEVO 6 6 6 3 1patient wipes - volume 0 0 - 2 1inco pads - volume 0 0 - 2 1Site rationalisation 8 8 8 2 1Cleaning products on non clinical areas 1 1 1 2 3Administration Review 401 401 401 0Removal of vacant admin posts from Emergency BU 110 110 110 1 3review of booking staff 52 52 52 3 1review of reception staff 50 50 50 1 1change in pre-assessment swabbing process 10 10 10 3 1introducing telephone pre-assessment 10 10 10 3 0Approval of all temp. staff, additional sessions etc at Vac. Control 0 0 - 3 0Audit sessions 14 14 14 1 2reduction in staff hours in C&CS 14 14 14 2 3Irish Nurse Recruitment 0 - 1canteen prices 18 18 18 2 1enforcement of transport criteria 10 10 10 1 1In-house provision of training rather than outsourcing manual handling training 5 5 5 1 1patient meals - cost per day review (inc Food Wastage) 10 10 10 1 1pay as you mail 3 3 3 2 1Review of arrangements (PP) 10 10 10 1Review of PMO 24 24 24 2 1Review of staffing of < than 1 year 0 - 0 0review protocol of use of interpreters 5 5 5 2 1reviewing Chronos patient call 33 33 33 3 3Senior Nurse Review 36 36 36 1Tests sent away costs 15 15 15 2 1number of tropins 2 2 2 1 1Printing contract 0 0 - 0 0reduction of desk top printer consumables 10 10 10 2 2Discretionary Spend 100 100 100 0Remove CPD funding 52 52 52 1 2Maintenance budget restriction 58 58 58 1 0Holiday pay accrual 300 300 300 2 2VAT review (Committed) 56 56 56 2 1Asset life review 345 345 345 2 1Depreciation 436 436 436 2 3BU Totals 71

75

124

-

42

239

1,148

1,375

3,073

Financial Recovery Plan Schemes Appendix 4

Business UnitTotal £000's

Cancer & Core Services Elective Emergency

Womens & Childrens Hotel Estates

Corporate & Governance Other Total

Quality Risk

Gateway on FRP

- check#### 4,198

Additional Schemes- 0

Review of Overtime 4 4 4 2 0

In house therapies 43 43 43 3 0

Reduction in Urology Medical Costs 30 30 30 3 0

Reduction in Uroflows 5 5 5 2 0

Reduction on Nursing time in Hand Therapy 2 2 2 0

Withdrawal from HEH from 5 rooms 15 15 15 2 0

Car Parking 15 15 15 2 0

Reduction of CIPS target by Herts contract sign off 0 - 0

Theatre reduction in sessions (inc Anaes) 62 62 62 3 0

Stopping in Mandatory training Outsourcing 216 216 216 1 3

Not recruiting into Chief Exec 8b post 0 - 2

Breast Screening reduction in hours 4 3.8 4 1 3

Recruited lower grade Doctor 21 21 21 3

Essex Pathology Network reduction in costs 23 23 23 1 3

Medical records staff reduction 15 15 15 1 0

Path Managament restructure 9 9 9 2 1

Reduce cash collection/change delivery to once per week 2 1.8 2 1 3

Expenditure Review - Linen Room Staffing 2 2 2 2

NR 8b post Chief Exec 71 71 71 3

Marketing Manager M/L NR Saving 13 13 13 3

Library Posts NR saving 25 25 25 3

Gastro S Bar Contribution 131 131 131 3

Exp review - Domestics 112 112 112 1

Inc review - Restaurant 20 20 20 1

Exp review - Portering 21 21 21 1

Inc review - Hotel Services Managament 30 30 30 1

Exp review - Accomodation 20 20 20 1

Exp review - Telecoms 45 45 45 1

Patient Experience & Risk Mgmt Restructure 0 0 - 0

Streamline Mand training structure 0 0 - 0

Bring first response to drainage problems in-house 8 8 8 2

Bring certain EBME contracted work in-house 5 5 5 2

Eliminate savings on Nutrition Nurse budget AACC 0 0.2 0 3

W&C Budget Reviews - NR 139 138.9 139 3

Corporate Budget Reviews - NR 87 87 87 3

Governance Budget Reviews - NR 30 30 30 3

Total Additional from Star Chamber 119 99 131 139 251 28 458 0 1,224

Grand Total 190 174 255 139 293 266 1,606 1,375 4,297

CASHFLOW Appendix 5

To Forecast31-Jan-11 31-Mar-11

£000 £000

External Financing requirement to be met by:

Retained Surplus/(Deficit) (474) 0

Items not involving use of funds

Dividend Provision (Target Return) 3,086 3,606Depreciation 5,808 6,737Donated Asset Depreciation (86) (99)Net Gain/(Loss) On Disposal 0 0

Funds from other sources

Proceeds From Capital Disposal 3,583 3,583

Application of funds

Capital Expenditure (4,635) (5,909)Dividends Paid (Trust Debt Rem.) (1,850) (3,606)

Movements in working capital

Inventories (Increase)/Decrease 59 0NHS Receivables (Increase)/Decrease (3,294) 1,800Trade & Other Receivables (Increase)/Decrease (5,294) 0Prepayments (Increase)/Decrease (232) 0Creditors - Trade Increase/(Decrease) 2,924 (2,924)Creditors - N.H.S. Increase/(Decrease) (131) (1,500)Creditors - Trust Funds Increase/(Decrease) (1) 0Creditors - N.I.,Tax etc Increase/(Decrease) (17) (0)Creditors - Other Increase/(Decrease) 128 (0)Creditors - Payments on Account Increase/(Decrease) 2,500 0Creditors - Accruals Increase/(Decrease) 4,584 (0)Loans Increase/(Decrease) (1,110) (2,563)Finance Leases Increase/(Decrease) (755) (1,355)Provisions Increase/(Decrease) (70) (69)

NET FINANCIAL CHANGE 4,722 (2,299)

External Financing requirement to be met by:

Repayment of PDC 0 0New PDC 0 0Change in Bank & Interest (Increase)/Decrease (4,722) 2,299

TOTAL EXTERNAL FINANCE (4,722) 2,299

BALANCE SHEET Appendix 6

31-Mar-10 31-Jan-11 31-Mar-11£000 £000 £000

Non-Current Assets

Property, Plant and Equipment 112,596 111,173 111,439Intangible Assets 26 18 16Trade & Other Receivables 5 5 5

Total Non-Current Assets 112,626 111,196 111,460

Current Assets

Inventories 4,210 4,151 4,210NHS Receivables 4,218 7,512 2,418NHS Accrued Income 0 4,377 0Trade & Other Receivables 7,565 4,930 7,565Prepayments 706 939 706Cash & Cash Equivalents 3,604 8,326 1,300

Sub Total 20,303 30,235 16,199

Current Liabilities

N.H.S.E. - Dividends Payable 0 (1,236) 0Creditors - Trade (6,613) (9,569) (6,428)Creditors - N.H.S. (5,106) (4,974) (4,106)Creditors - Trust Funds (1) (0) (1)Creditors - Capital (464) (166) (464)Creditors - N.I.,Tax etc (2,284) (2,268) (2,284)Creditors - Other (1,249) (1,377) (1,249)Creditors - Payments on Account 0 (2,500) 0Creditors - Accruals (560) (5,144) (560)Loans (2,786) (2,906) (2,906)Finance Leases (1,260) (1,150) (924)Provisions (139) (136) (140)

Sub Total (20,463) (31,425) (19,062)

Net Current Assets/Liabilities (160) (1,191) (2,863)

Provisions (542) (475) (472)Finance Leases (1,547) (902) (528)Loans (3,124) (1,894) (441)

Amounts Due After One Year (5,212) (3,271) (1,441)

Total Net Assets 107,254 106,734 107,156

Capital & Reserves

Public Dividend Capital 74,134 74,134 74,133I & E Account (1,277) (1,752) (1,277)Revaluation Reserve 34,052 34,052 34,053Donation Reserve 346 299 247

Total 107,254 106,734 107,156

Appendix 7

Financial Planning - I&E Model£K Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast FRPVersion 1.7 FRP 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 TotalIncomeAccident & Emergency 710 718 691 732 688 720 703 696 661 658 666 666 8,308Critical Care 483 503 717 579 566 490 634 591 597 638 560 560 6,919Direct Access 442 470 459 461 453 464 450 441 415 417 416 416 5,305Elective Income 1,235 1,448 1,505 1,906 1,721 1,601 1,538 1,289 1,196 1,194 1,305 1,305 17,243Elective Income - Charnley Ward closure 0Day Cases 1,738 1,662 1,741 1,838 1,778 1,850 1,817 2,154 1,899 1,817 1,883 1,883 22,060Non Elective Income 5,266 5,028 5,144 4,854 4,987 5,248 5,157 5,070 5,020 4,840 4,841 4,841 60,297Non Elective Income - Hamstel Unit closure 0Diagnostic Imaging 0 0 0 0 0 0 0 0 0 0 0 0 0Outpatient Firsts 1,102 1,263 1,311 1,070 1,507 1,373 1,274 1,279 1,088 1,059 1,160 1,160 14,647Outpatient Follow-ups 1,108 1,052 1,174 1,371 964 1,252 1,170 1,172 1,008 1,068 1,085 1,085 13,510Outpatient Follow-ups - Disqual 0 0 0 0 0 0 0 0 0 0 0 0 0Outpatient Procedures 58 95 97 304 154 123 136 141 121 127 129 129 1,615QiPP3 - income effectCost & Volume converted from Block 0 0 0 0 0 0 0 0 0 0 0 0 0Block - excluding CQUIN 1,362 1,369 1,362 1,366 1,362 1,362 1,267 1,349 1,260 1,260 1,260 1,260 15,841CQUIN 179 179 179 179 179 179 179 179 170 170 169 169 2,110Additional Activity TargetTotal Patient SLA Income 13,685 13,787 14,382 14,660 14,361 14,663 14,324 14,363 13,434 13,246 13,475 13,475 167,855Non Patient SLA Income 169 169 169 169 169 169 168 168 169 169 168 168 2,022Inpatient - 30d EL readmission discount 11/12 0 0 0 0 0 0 0 0 0 0 0 0 0Additional Income (via WEPCT) 250 410 420 420 1,500Additional Income (11/12)Reenablement monies - WEPCT ((£330k, split 1/3 to Trust?))Credit Note - 0910 Herts 0 0 0 (350) (28) 0 56 0 0 (322)Income adjustment provision -0910 Essex 0 0 0 0 0 0 (131) 0 131 0

Income Adjustment provision 1011 Essex 0 0 0 0 (250) (35) (35) 0 320 0 0Income Adjustment Provision 1011 Herts 0 0 0 0 (75) (15) (15) 0 0 5 0 0 (100)

Outpatient F-F-Up target breach 0

CQUIN under-achievement provision 0 0 0 0 0 00

- West Essex (134) (92) (67) (27) (13) (33) (33) (400) - Herts (66) (45) (33) (28) 22 (15) (15) (180) - Other (ONEL) 0

Emergency threshold discount provision 0 0 0 0 0 0 0 0 - West Essex (1,040) (120) (107) (127) (127) (1,521) - Herts (303) (759) (106) (106) (1,275) - Other (18) (43) (6) (6) (73)Total Emergency Threshold provision 0 0 0 0 0 0 0 (1,040) (441) (909) (239) (239) (2,869)

Prior Year - WEPCT Validation liability 0 0Current year validation provision 0Accrued Income - phasing adjustment 0 0 0 0 0 0 0 700 368 303 (620) (751) 0PTS Adjustment 0 0 0 0 0 0 0 0 0 0 0Premium Cost recovery - WEPCT 0 0 700 0 (514) 0 0 (186) 0 0 0 0 0Other SLA Income 0 0 0 0 0 0 0 0 0 40 0 0 40Total Income from SLA 13,853 13,955 15,250 14,479 13,663 14,582 14,230 13,905 14,176 13,273 13,156 13,025 167,545Education, Training & Research 400 534 443 446 459 373 437 500 423 417 456 456 5,344Other income 400 866 357 554 368 377 384 472 475 348 431 431 5,464Total Income 14,653 15,355 16,050 15,479 14,490 15,332 15,051 14,877 15,074 14,038 14,043 13,912 178,354

(10d) Appendix 7 - Forecast Outturn Source: Financial Planning

Financial Planning - I&E Model£K Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast FRPVersion 1.7 FRP 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 Total

ExpenditurePayMedical (3,290) (3,270) (3,331) (3,304) (3,300) (3,003) (3,046) (3,046) (3,121) (2,982) (2,982) (2,982) (37,657)Nursing & Midwifery (3,300) (3,387) (3,400) (3,472) (3,497) (3,447) (3,300) (3,359) (3,423) (3,281) (3,281) (3,281) (40,428)Nursing - Charnley ward cost saving 0Nursing - Hamstel ward closes 1st Mar 2011 130 130Scientific & Technical (1,170) (1,174) (1,223) (1,172) (1,181) (1,195) (1,100) (1,182) (1,147) (1,138) (1,138) (1,138) (13,958)Other Clinical/Ancillary (508) (520) (552) (507) (500) (500) (500) (497) (467) (493) (493) (493) (6,030)Non Clinical (maint & clerical) (1,164) (1,205) (1,214) (1,229) (1,162) (1,128) (1,145) (1,158) (1,154) (1,104) (1,104) (1,104) (13,871)Senior Managers (499) (483) (506) (505) (523) (519) (468) (531) (509) (442) (442) (442) (5,869)QiPP, Turnover & Clinical EfficienciesPay sub-total (9,931) (10,039) (10,226) (10,189) (10,163) (9,792) (9,559) (9,773) (9,821) (9,440) (9,440) (9,310) (117,683)% change in Pay 0.0% 1.1% 1.9% -0.4% -0.3% -3.7% -2.4% 2.2% 0.5% -3.9% 0.0% -1.4% 5.6%Non-PayNon-Pay - excluding Drugs & CS&S (bal item) (900) (3,200) (2,100) (2,250) (1,500) (2,100) (2,000) (1,890) (1,985) (1,866) (1,866) (1,866) (23,523)Non-Pay - Non NHS purchased healthcare (387) (263) (500) (407) (352) (329) (227) (222) (253) (194) (194) (194) (3,522)Non-Pay - Drugs (929) (915) (951) (1,040) (939) (986) (916) (1,036) (1,054) (945) (945) (945) (11,601)Non-Pay - Clinical S&S (1,042) (957) (1,070) (1,082) (974) (1,010) (1,132) (1,023) (1,025) (803) (803) (803) (11,724)Non-Pay sub-total (3,258) (5,335) (4,621) (4,779) (3,765) (4,425) (4,275) (4,171) (4,317) (3,808) (3,808) (3,808) (50,370)QiPP3 - expenditure effect (30% of Inc unless known)Financial Recovery Plan 0 0 0 0 0 0 0 0 453 453

00

Total Expenditure (13,189) (15,374) (14,847) (14,968) (13,928) (14,217) (13,834) (13,944) (14,138) (13,248) (13,248) (12,665) (167,600)Pay as a % Total Expenditure 75% 65% 69% 68% 73% 69% 69% 70% 69% 71% 71% 74% 70%

EBITDA 1,464 (19) 1,203 511 562 1,115 1,217 933 936 790 795 1,247 10,754% EBITDA 10.0% -0.1% 7.5% 3.3% 3.9% 7.3% 8.1% 6.3% 6.2% 5.6% 5.7% 9.0% 6.0%

Profit/Loss on Disposals 0 0 0 0 0 0 0 () 0 0 0 ()Depreciation (600) (600) (600) (600) (600) (600) (600) (600) (595) (449) (449) (449) (6,742)Interest & Finance (22) (31) (24) (42) (38) (40) (30) (33) (35) (35) (35) (35) (400)Public Dividend Capital (300) (300) (300) (300) (300) (300) (300) (300) (306) (306) (300) (300) (3,612)

Retained Surplus/(Deficit) 542 (950) 279 (431) (376) 175 287 () 0 () 11 463 ()Cumulative Surplus/(Deficit) 542 (407) (128) (560) (936) (761) (474) (474) (474) (474) (463) ()

(10d) Appendix 7 - Forecast Outturn Source: Financial Planning

Appendix 8

Monthly I&E 2010-11

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12

Month

£ 00

0

PAY NON PAY INCOME

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST TRUST BOARD, PART A – 24th FEBRUARY 2011

EXECUTIVE SUMMARY

Issue: MONTH 10 – DASHBOARD PERFORMANCE REPORT Status: FOR INFORMATION 1. Introduction: This paper provides Board members with the Trust dashboard performance report at the end of January 2011. 2. Access A&E A/E 4 hour wait - mapped 96.5% and unmapped is 94.8%. Therefore as a Trust we are not meeting the National target of 95% (SLA 98%). The Trust has continued to be under pressure, with emergency demand being higher than planned. Areas of concern are; appropriate medical manpower in the Emergency Department, bed availability at key times of demand, and paediatrics. We continue to work closely with our PCT commissioners and providers to enhance patient flow. The Intensive Support Team visited the Trust on 20 January, awaiting formal report. An internal workshop was held on 3 February to enhance clinical engagement, and having 4 work streams to take forward. 18 Weeks We met our local contracted standards in January for 18 weeks, of 85% Admitted (performance was 85.52%) and 90% Non-Admitted (performance was 96.3%). These local standard are variations on national targets, of 90% Admitted and 95% Non-Admitted. Our Median waits were 8.8 weeks for Admitted and 4.7 weeks for Non-Admitted. Our reduced performance, whilst planned as part of the overall slowing of work agreed with our main commissioner, incorporates a number of routine diagnostic cases that took longer than the expected 6 weeks. This shows that we are slowing activity at each stage of treatment, rather than simply letting people wait at the latter stage of their pathway. Cancer We met all of the waiting time standards for cancer in December 2010 and this also confirms performance for Q3 overall. We expect all of the standards to be met in January 2011 and will be in a position to confirm this once the data has been finalized and closed on the Open Exeter system. 3. Activity Non-Elective activity continues above plan, with us seeing 3,388 more spells than expected. Elective activity continues at reduced levels compared to the first part of the financial year. Outpatient attendances (new) rose in January from December, taking our overall activity year to date 6982 above plan. A&E activity continues at a constant level, of between 6500 and 7000 attendances per month. Year to date, we have seen 4401 than expected 4. Quality Infection Control has remained at historically low levels with zero MRSA bacteraemia

in January and 4 cases of C.difficile, 2 pre 72 hour cases (apportioned to non Acute Trust) and 2 post 72 hour cases (apportioned to Acute Trust – Locke Ward and Saunders Ward). We also now have to provide data on MSSA bacteraemia from 1 January 2011 onto MESS system – Department of Health request which is mandatory. For January we had a total of 2 cases – 1 pre 48 hour case and 1 post 48 hour case. The Trust has also had confirmed cases of Norovirus. As of 15 February there were 2 confirmed positive cases, with a number of patients with clinical symptoms awaiting test results. This is affecting 3 emergency wards at present, which is being managed by the Emergency BU, supported by ICT and the Nursing Directorate with daily outbreak meetings. This has major implications operationally as these wards are closed to admission currently, which equates to 17 beds not being able to be used. H1N1 – confirmed 5 positive cases for January. 5. Workforce The Trust spent £0.6m on temporary staff in December of which £244k was on agency staff. Total agency spend represents 2.6% as a proportion of the pay bill and is lower than last month as a percentage and in terms of financial spend. Vacancies have increased to 6.3% (5.5% last month) which is above the 5% target the Trust aspires to. Nursing numbers are 1072 WTEs in December with 72 WTE vacancies, 63 WTE sickness and 39 WTE maternity and 5WTEs unpaid leave covered by 80.5 temporary staff (1.5 agency 79 bank) net 99 WTEs unfilled nursing gaps. Sickness has increased to 5.1% for December (4.5% in November) and with a rolling 12 month average of 3.90% meeting the Trust target with nursing sickness rates at 5.8% (5.5% previous month). The sickness rate has been increasing which is a trend often experienced in the winter months. This is the highest level in the last 12 months. This will need to be closely monitored. Turnover has increased to 12.5% (12.4% last month) with nursing turnover at 13.3%. PRDP completion has increased to 71% (61% last month) and induction training compliant at 100% (100% last month), refresher training has improved to 73% (69% last month) this was just above the 70% target for January. 6. Governance 6.1 Complaints There were 494 complaints year to date. 54 above the target of 440. 6.2 Financial Risk Rating The financial risk rating has remained at 3. 6.3 Governance Risk Rating This has remained at 1.0 as a result of our A&E and MRSA performance Recommendations: The Board is asked to review and note the Dashboard Performance Report. Author: Andrew Butters, Interim Director of Finance, Date: 16th February 2011



Dashboard Reporting Review

Board Report: Dashboard Reporting Review

Introduction

Following discussions at Business and Performance Committee and Trust Board the dashboard framework has been reviewed. This paper sets out the revised proposals for consideration.

Proposals

It is proposed that the dashboard comprises three elements:

a single high level dashboard which will come from to the Board. This will comprise a small, core set of data plus any reds from the sub committees Attached as appendix 1

more detailed dashboards for the Board sub committees which focus on their particular areas of responsibility

management dashboards for operational management which will go to business unit Performance Management Groups (PMGs)

It is proposed that dashboards are distributed as set out in the tale below:

Audience Dashboards Frequency Board Core data set

Alerts from sub committee Monthly

Business and Performance Activity Access Financial Productivity Workforce

Monthly with quarterly drill down

Patient Safety and Quality Quality Monthly Compliance CQC standards

NHSLA standards Monthly

Business Units (PMGs) Including assistant directors and lead doctors

All the above split by business unit

Monthly

Examples

Examples of the format of the new dashboard will be provided at the meeting.

Recommendations

The Board is asked to: 1. comment on the proposed new format 2. advise on the distribution of the various elements of the dashboard particularly in

relation to which subcommittees receive which elements 3. provide any other comments

Appendix 1

Trust Board: Core Data

Productivity

Length of stay: elective, emergency % daycase EDDs given and achieved A&E Clinics

Quality

Op cancelled more than twice Elective cancelled more than twice HSMR TIAs Section rate Thrombolysis

Workforce

WTEs on payroll Bank and agency

Activity

Emergency & elective by major PCTs Births Op incl A&E (ICU) Referrals, split GP and C2C

Access

Numbers on waiting list - median A&E time to assessment

Revenue

I&E total FRR



FT application and consultation update


Trust Board Meeting

Executive Summary

24th February 2011 Part A


Governance

Equalities Impact Finance Legal Implications Communications Issues Risk and Health and Safety Issues

Issue: Foundation Trust Update

Summary: This paper provides the board with an update on activities relating to the trusts aspiration to achieve Foundation Trust (FT) status.

Recommendations: None

Author: Darren Leech, Executive Director of Delivery

Date: 11th Feb 2011

Trust Board 24th February 2011

Foundation Trust (FT) Update

Introduction This paper provides the board with an update on all activities relating to the Foundation Trust application process.

Consultation We met all deadlines agreed with the SHA in preparing the paperwork and accompanying engagement plan and we began our 12 week consultation on schedule in January.

A copy of the current engagement plan that drives our consultation process is attached, along with a copy of a standard presentation being used at internal and stakeholder events and meetings.

Project plan and deadlines Following Graeme Jones s visit to our board, organised last month, I have now received confirmation of the SHAs agreement to the revised schedule for IBP submission and pre-DH work. I have attached the letter setting this out and it includes the revised timetable and confirmation from the Department of Health that Historic Due Diligence (HDD) will be a single, rather than two stage process.

I have recently received the tender specification used by the SHA for such HDD work, as we may wish to consider commissioning a dry-run HDD exercise in May 2011, in order that we prepare ourselves for the real thing later in the summer.

I have met with a Director at one of the large consultancy firms. They are working with an aspirant FT elsewhere in England who are prepared to trade some of our insight on market analysis work for a copy of their FT Project Plan. I will pursue this, along with information gleaned from our new CEO of similar nature. In addition, I am also meeting with the Managing Director at NHS Elect next week, to discuss how they might provide further assurance on both our project plan and also, our IBP drafting process.

I met with representatives from our internal auditors also, as they are currently looking at some aspects of our FT preparedness.

IBP Development I have communicated to the SHA that we now have early drafts of both Chapter 3 (Strategy) and Chapter 2 (Trust Profile). The SHA have advised that they no longer have the capacity in the Provider Development team to review IBP Chapter drafts as previous. This in part explains my exploration of other expert sources of feedback, as described above. I expect us to be able to review these draft Chapters as a whole board, on our programmed development session on 22nd February.

The drafting process for other chapters is set out in the project plan referred to above. It is intended that draft chapters will be shared with board members for review and comment as we progress.

Supporting activities I attended a Foundation Trust Network (FTN) event on 9th Feb, More on the FT Board , aimed at board members from aspirant FTs. There were a range of interesting presentations

and information from a number of key speakers, including Sue Slipman of the FTN. I have attached the slides from each by way of information for board members.

I also received a set of example board to board questions from colleagues at the SHA and have previously circulated to board members for information and future reference.

Darren Leech Executive Director of Delivery 11th Feb 2011

January - March 2011

Foundation Trusts are NHS Trusts that are given certain freedoms from the control of Government to develop services that suit the needs of their local community.

Introduce new and exciting ways of working.Spend surpluses we generate on our own services and buildings.Offer the care and treatment that local people need.Give our staff and local people the opportunity to help develop services.

Developing patient pathways and processes that sustain and improve the quality and safety of patient care.Creating an organisation that is both clinically and financially sustainable.A commitment to working with GPs and partner organisations to redesign services that deliver where appropriate, care closer to peoples homes.Working to become a Foundation Trust by 2013.

A democratic membership Members elected nominated Governor to sit on a Council of GovernorsGovernors will represent the staff, public and stakeholders.Chairman elected by the Council of Governors.Chairman and the Trust Board Executive Directors work alongside the Council of Governors.Chief Executive remains the Accountable Officer

There will be 38 Governors in total20 Public and Patients 6 Staff12 Nominated Governors

From each of the 6 main geographical constituencies, key stakeholder groups and other interested partiesGovernors are not responsible for the day to day management of the hospital services.

Anyone over 14 years of age can become a member.

Open to staff, public and people from our stakeholder organisations.

It s free to sign up, just complete a membership form, sign up on the website: www.pah.nhs.uk/ft or contact the Foundation Trust office on our free phone number 0800 032 9006.

You can get involved as much or as little as you would like.There will be other opportunities to get involved if I do not want to be a governor as we plan to arrange workshops.Keeping you informed via members newsletters.

We welcome your views on our application for Foundation Trust Status and look forward to working together building a healthy future.

Free phone: 0800 032 9006Email: [email protected]

The Princess Alexandra Hospital NHS Trust s FT Stakeholder Engagement Plan 2011 Month Activity Audience Intended

Nos if known

Comments

Internal Engagement

Internal Meeting: Extraordinary Staff and Consultants All PAH Staff 100 Agenda Item

done

Internal Meeting: Chief Executive Staff Briefing Senior Managers 45 January February 4th

SMH 11th - JWD

Internal Meeting: Trust Board Meeting Board 20 27th January 2011

Internal Meeting: Extended Management Team Executives Associate Directors Clinical Directors

30 1 February 2011

Internal Meeting: Nursing and Midwifery Nurses 20 3 March 2011 Internal Meeting: MAC Doctors 18 11th February Internal Meeting: Patient Council/LINKs Members 8 10th February 2011

Internal Meeting: Business Units Board Meetings BU senior managers 150 Elective 15th March Emergency 3rd March Women s 21 March @ 9:15am RAH Cancer and Core 21 March Facilities

1 March @ 2:00pm Estates 24th Feb @ 9:30am Draman - CB Governance 15 Feb - CB

PR and Comms

PR & Comms: Website and Intranet Staff The Public

90,000 average per month

Front page from Thurs 3 Feb

PR and Comms: FT Consultation Mailout/Email Out Members 8,000 Thurs 27th January & w/c 1 Feb

Currently 31 new members in Jan 4 consultation responses

PR and Comms: Intouch with Corporate Affairs All 3,000 Tues 18 January

PR and Comms: FT roadshow (campaign boards and displays)

PAH Staff, Patient and Visitors Displayed from 24 January

External Engagement

January

External: Patients Patients From 7 February 2011

External: Eoe SHA SHA Board Endorsement via IBP sign off

External: Meeting with Local MPs: Robert Halfon (cons), Bill Rammel (lab), David White (lib dem) & Eddie Butler (BNP).

MPs 4 Sent Monday 14th January (2nd class)

External: NHS West Essex & NHS Hertfordshire Provider and Commissioner arm

PCT Boards 30 Sent Monday 14th January

External Engagement

External: Harlow 2020 Partners 8 Sent Monday 14th January

External: Harlow College College Executives Sent Monday 14th January

External: Harlow League of Friends Volunteers 40 Agenda Item - Feb

External: Harlow Renaissance Board 3 Sent Monday 14th January

External: The Deanery Senior Staff Sent Monday 14th January

External Healthcare Engagement

External Healthcare: Essex & Herts Health Overview and Scrutiny Committee

Board Sent Monday 14th January

External Healthcare: PELC (out of hour s GP) Senior Staff Sent Monday 14th January

External Healthcare: Moorfield s Eye Hospital Senior Staff Sent Monday 14th January

External Healthcare: Herts Urgent Care Centre Senior Staff Sent Monday 14th January

External Healthcare: Ramsey Healthcare, Holly House Practice, Nuffield House, Spire Hartswood, Spire Roding

Senior Staff Sent Monday 14th January

External: Harlow, Essex & Bishops Stortford Chamber of Commerce

Members Sent Monday 14th January

External Healthcare: Runwood Homes Senior Staff Sent Monday 14th January

External Healthcare: St Clares/Isobel Hospice Senior Staff Sent Monday 14th January

External Healthcare: Uttlesford, Harlow and Epping PBC Leads

Partner Sent Monday 14th January

External Healthcare: Addenbrookes, East and North Herts, Mid Essex, Whipps Cross, Barnet and Chase Farm


External Healthcare: Basildon, UCLH and North Mid Board Sent Monday 14th January

External Healthcare: North Essex Partnership NHS Foundation Trust/SEPT


External Healthcare: Dentists, Nursing Homes and Physiotherapists

February

External Healthcare: EoE Ambulance Service NHS Trust Board Sent Monday 14th January

External Charities Engagement

External Charities: Age Concern Members Sent Monday 14th January

External Charities: Alzheimers Society Members Sent Monday 14th January

External Charities: Epping Breatheasy Members Sent Monday 14th January

External Charities: Epping Forest CVS Members Sent Monday 14th January

External Charities: Essex Blind Charity Members Sent Monday 14th January

External Charities: Harlow Centre for Voluntary Support Members Sent Monday 14th January

External Charities: Harlow Sight Support Group Members Sent Monday 14th January

External Charities: Harlow & Loughton Stroke Support Members Sent Monday 14th January

External Charities: Harlow WRVS Members Sent Monday 14th January

External Charities: MS Society East Herts and West Essex Members Sent Monday 14th January

External Charities: Parkinsons Disease Society Harlow Members Sent Monday 14th January

External Charities: West Essex Mind Members Sent Monday 14th January

External Council Engagement

External Council: Hertfordshire and Essex County Council Councillors Sent Monday 14th January

External Council: East Herts District Council Councillors Sent Monday 14th January

External Council: The Bishops Stortford Town Council, Epping Council, Harlow Council, Uttlesford Council

Councillors Sent Monday 14th January

PR and Comms

PR and Comms: Advert in the three local newspapers General Public 258,000 Press Release Sending 16 Feb PR and Comms: Radio Feature via Heart Radio General Public Radio Interview PR and Comms: Monthly Health Column in the Newspaper Local Population Feature - Feb PR and Comms: Hospital Radio Interview Hospital Patients 500 Radio Interview

PR and Comms: FT Consultation Meetings email out Members regarding meeting dates 8,000 17 Feb 2011

PR and Comms: Patients Appointment Letters Meeting Dates w/c 21 Feb

Internal Meetings: Staff Communications PAH 23 Feb HEH 11 March SMH 25 Feb

March PR and Comms

PR and Comms: Roadshows in local libraries General Public Campaign material issued PR and Comms: Correspondence with Local Schools Teachers and Students A letter via Work Experience Lead

PR and Comms: Have your Say Events: BS Harlow Epping

Local People 100 BS 10 March - 1 Harlow 24 March - 2 Epping 15 March - 1

Chief Executive: Sir Neil McKay CB Chair: Sarah Boulton

Tel: 01223 597770 E-mail: [email protected] Website: www.eoe.nhs.uk Our ref: xxx Date: 8 February 2011

East of England Strategic Health Authority Victoria House

Capital Park Fulbourn

Cambridge CB21 5XB

Tel: 01223 597 500 Fax: 01223 597 555

Jane Herbert Interim Chief Executive Princess Alexandra Hospital NHS Trust

Dear Jane

Re: Foundation Trust timeline

I am responding to your email of 19 January 2011 requesting changes within the Foundation Trust timeline agreed in December 2010. The timeline signed off in December 2010 was an extension to that presented by the Trust at the Chair and Chief Executive review meeting in November 2010.

Having agreed a longer timeline in December 2010 it is unfortunate that the Trust is already having to request extensions to submission milestones. A key feedback theme over the last four years has been the inability of the Trust Board to consistently deliver high quality, complete and credible submissions by agreed deadlines.

Your first request is to change the submission of a draft Business Plan and Financial Model from 1 April to the end of May. We are content to receive a full draft of both documents at the end of May (by 5pm on 31 May) but we added in the original milestone to ensure progress is being made. We have held a discussion with Darren Leech and agreed that we will receive the chapters that have been drafted by the end of March (5pm on 31 March) to provide us with some reassurance that progress is being made and enable us to provide some feedback. We will not be able to offer a rolling programme of single chapter reviews. The Trust should be in a position to develop a number of the chapters by the end of March.

The second request is to move both phases of the Due Diligence review by between one and two months. The DH has now confirmed that the Trust will only need to undertake a single stage refresh of the previous Due Diligence. We would expect this to happen in September 2011. The Trust will be charged for the further refresh. The Trust can tender for a mock Due Diligence of their own at an earlier point if the Board thinks that this would be useful.

We will expect to see a further draft version of the Business Plan and Financial Model in early September (5pm on 2 September) to provide further feedback ahead of the final submission at the end of October (5pm on 31 October). These documents will form part of a fuller set of submissions outlined in our regional assurance guide and in the presentation made to the PAH Board by Graeme Jones in January.

We will hold a Board to Board meeting in December 2011 with a view to presenting your case to the DH on 1 January 2012.

http://www.eoe.nhs.uk

Chief Executive: Sir Neil McKay CB Chair: Sarah Boulton

Milestone Due date Submit draft IBP chapters 31 March

Submit first full draft IBP and LTFM (including downside and mitigation) 31 May

Submit second full draft IBP and LTFM (including downside and mitigation) 2 September

Due diligence review and report September

Submit final IBP and LTFM (including downside and mitigation) as part of full set of FT assurance submissions

31 October

Sign off Board to Board meeting December 2011

Planned presentation to the DH 1 January 2012

We will move forward on the basis of this revised timeline and note that any further requests for change should be made in writing by the Trust Chair and Chief Executive. We will then hold a review meeting with you.

When Graeme Jones presented to your Board he was asked what period of performance information would be used by the SHA and DH to review the Trust for FT purposes. I can confirm that the SHA and DH will focus on the most recent full quarter of performance ahead of a decision point which is in line with the approach taken by Monitor. The Board should ensure that it understands the impact of performance and other metrics on the governance risk rating by quarter as well as by month.

The paragraph above is not a sign-off of any plans you have to deal with backlogs and waits in the final quarter of 2010/11. The SHA s position is unchanged. We expect the main commissioner to explain proposed actions to us and the impact they will have. We will then give approval or not.

Graeme also asked you to consider whether you want to hold a mock Board to Board meeting and when that might be most beneficial. Please let us know if and when that would be useful.

Please can you copy this letter to your Board so that they are aware of the changed milestones within the timeline.

Yours sincerely

Dr Stephen Dunn Director of Provider Development

cc. Sarah Boulton (Chair, NHS East of England) Gerald Coteman (Chair, Princess Alexandra Hospital NHS Trust)

Financial Planning - Project Plan

The Princess Alexandra Hospital Trust

Financial Planning - Project PlanVersion 0.816/02/2011 Month

ID Project Name Executive Owner Sub-ordinate Owner Status % Complete Days Start End1.0 Foundation Trust Project In-Progress 608 29-Nov-10 29-Jul-12

1.1 Initiation CEO 50 29-Nov-10 18-Jan-11

1.1.1

Letters to Secretary of State and Department of Health with commitment to proceed CEO 1 29-Nov-10 30-Nov-10

1.1.2 Trust Board session CEO/Darren Leech 1 11-Jan-11 12-Jan-111.1.3 Ian Dalton visit to Trust CEO/Darren Leech 1 17-Jan-11 18-Jan-11

1.2 Consultation Darren Leech 91 3-Jan-11 4-Apr-111.2.1 Prepare consultation document Darren Leech Complete 100% 1 3-Jan-11 4-Jan-111.2.2 Document to SHA for review Darren Leech Complete 100% 4 6-Jan-11 10-Jan-111.2.3 Detailed consultation plan prepared Darren Leech In-Progress 40% 25 6-Jan-11 31-Jan-111.2.4 Start consultation Darren Leech 11 6-Jan-11 17-Jan-111.2.5 PCT Letter of Support Darren Leech 88 6-Jan-11 4-Apr-111.2.6 Close consultation Darren Leech 88 6-Jan-11 4-Apr-11

1.3 Historic Due Diligence Andrew Butters 159 24-Apr-11 30-Sep-111.3.1 Part 1 Andrew Butters 67 24-Apr-11 30-Jun-111.3.2 Part 2 Andrew Butters 92 30-Jun-11 30-Sep-11

1.4 Long Term Financial Model Andrew Butters Not Started 0 160 21-Jan-11 30-Jun-111.4.1 1st cut refreshed LTFM Andrew Butters Not Started 0 59 15-Feb-11 15-Apr-11

1.4.1.1

Remodel TTFM taking account of activity scenarios and the latest guidance and assessment from Monitor, impact of CSR (Comprehensive Spending Review), etc Not Started 0 59 15-Feb-11 15-Apr-11

1.4.1.2

Move forward financial model one year taking 2010/11 as outturn year and modelling forward to 2015/16. Not Started 0 59 15-Feb-11 15-Apr-11

1.4.1.3Agree capital/revenue investment priorities, taking account of 2011/12 budget setting Not Started 0 59 15-Feb-11 15-Apr-11

1.4.2Ensuring QiPP3 latest assumptions are incorporated Not Started 0 38 21-Jan-11 28-Feb-11

1.4.4 Updaing Model for demographic change Not Started 0 68 21-Jan-11 30-Mar-11

1.4.5 Update model for efficiency assumptions Not Started 0 68 21-Jan-11 30-Mar-11

1.4.6 Update model for strategic boundry shifts Not Started 0 68 21-Jan-11 30-Mar-11

1.4.7

Updating the model structure in line with current PBR (eg. Onset of Outpatient Procedures) Not Started 0 38 21-Jan-11 28-Feb-11

1.4.8Testing the out-put of LTFM with executive team, business units & lead clinicians Not Started 0 92 28-Feb-11 31-May-11

1.4.3 Final Draft LTFM Andrew Butters Not Started 0 72 15-Apr-11 26-Jun-111.4.4 LTFM sign off by Trust Board Andrew Butters Not Started 0 76 15-Apr-11 30-Jun-11

Page 1 of 4 Financial Planning




ID Project Name Executive Owner Sub-ordinate Owner Status % Complete Days Start End

1.5 Integrated Business PlanDarren Leech & Andrew Butters Not Started 0 214 31-Jan-11 2-Sep-11

1.5.1Re-write IBP taking account of changes since last revision 15/4/2010 Darren Leech & Exec Team Not Started 0 120 31-Jan-11 31-May-11

1.5.2 NED review of draft Chapters Gerald Coteman Not Started 0 120 31-Jan-11 31-May-11Send Draft Chapters 2,3 & 9 to SHA Darren Leech & Exec Team Not Started 0 1 30-Mar-11 31-Mar-11

1.5.3 IBP Chapters 1,2,3,4,9 complete Darren Leech & Exec Team Not Started 0 74 31-Jan-11 15-Apr-11

1.5.4IBP Chapters 5,6,7,8 & Assurance docs complete Darren Leech & Exec Team Not Started 0 103 31-Jan-11 14-May-11

1.5.5 First Full Draft IBP to SHA including LTFMDarren Leech & Andrew Butters Not Started 0 120 31-Jan-11 31-May-11

1.5.7Second Full Draft IBP to SHA including LTFM

Darren Leech & Andrew Butters Not Started 0 214 31-Jan-11 2-Sep-11

1.5.8 Final Full Draft IBP to SHA including LTFMDarren Leech & Andrew Butters Not Started 0 59 2-Sep-11 31-Oct-11

1.5.9 IBP sign-off by Trust Board Darren Leech Not Started 0 34 31-Oct-11 4-Dec-11

1.6 Business Planning Darren Leech 105 15-Jan-11 30-Apr-11

1.6.1Re issue Business Planning guidance to Business Units Darren Leech In-Progress 40% 16 15-Jan-11 31-Jan-11

1.6.2 Draft Business Unit plans complete Business Units 62 31-Jan-11 3-Apr-111.6.3 EMT overview and agreement Darren Leech and Bus 25 31-Mar-11 25-Apr-11

1.6.4Ensure [read across] with draft IBP and finalise Darren Leech 60 1-Mar-11 30-Apr-11

1.6.5 Finance Budget Setting Finance 30 1-Mar-11 31-Mar-111.6.5.1 - Complete Activity & Income by BU Andrew Horwood 30 1-Mar-11 31-Mar-111.6.5.2 - Complete cost base by BU Finance Managers 30 1-Mar-11 31-Mar-11

1.6.5.2.1 - Ensure Cost Improvement Programe is defined by Business Unit Finance Managers 30 1-Mar-11 31-Mar-11

1.6.5.3 - Present SLR views of profitability by Service/specialty

Andrew Horwood/ Finance Managers 30 1-Mar-11 31-Mar-11

1.6.5.4 - Complete Capital Budget by BU Finance Managers 30 1-Mar-11 31-Mar-111.6.6 Capacity Planning analysis Business Units 30 1-Mar-11 31-Mar-11

1.7 SHA Assurance Darren Leech 332 1-Feb-11 30-Dec-111.7.1 SHA Board observation 316 1-Feb-11 14-Dec-111.7.2 Documentary submission to SHA Darren Leech 59 2-Sep-11 31-Oct-11

1.7.3Action plan to address due diligence issues to Trust Board Andrew Butters 61 30-Sep-11 30-Nov-11

1.7.4 SHA Board to Board CEO 1 10-Dec-11 11-Dec-11

1.7.5SHA to sight 5 months worth of board minutes before Dec Submission CEO 243 1-May-11 30-Dec-11

1.8 DH Assurance CEO 212 30-Dec-11 29-Jul-121.8.1 DH Applications committee 2 30-Dec-11 1-Jan-12

1.8.2SoS (Secretary of State) Submission and decision 90 1-Jan-12 31-Mar-12






1.8.3Monitor authorisation (Foundation Trust status) 120 31-Mar-12 29-Jul-12

2.0 SLA NegotiationDarren Leech / Andrew Butters 48 27-Jan-11 16-Mar-11

2.1First Draft SLA (new contract) made available by Commissioner 1 27-Jan-11 28-Jan-11

2.2Weekly Provider/Commissioner negotiation meetings 46 28-Jan-11 15-Mar-11

2.3Target sign-off of SLA with lead Commissioner 1 15-Mar-11 16-Mar-11

3.0 Qipp3 Planning 122 29-Nov-10 31-Mar-113.1 Planning Darren Leech 35 21-Jan-11 25-Feb-113.1.1 - Update to original submission, to SHA Complete 100% 61 29-Nov-10 29-Jan-11

3.1.2 - Revisit PCT demand reduction (Qipp) assumptions and profile to 13/14 35 21-Jan-11 25-Feb-11

3.1.3 - Reconstruct Trust narrative 35 21-Jan-11 25-Feb-113.1.4 - Confirm any changes to Qipp plan 35 21-Jan-11 25-Feb-113.1.5 - Review meeting with SHA 1 1-Mar-11 2-Mar-113.1.6 - Health system plan submitted to DH 29 2-Mar-11 31-Mar-113.2 Finance Andrew Butters 35 21-Jan-11 25-Feb-11

3.2.1 - Reconfirm challenge & opportunities plan 35 21-Jan-11 25-Feb-113.2.2 - Update the front-end of LTFM 35 21-Jan-11 25-Feb-11

3.2.3 - Confirm the level of Trust Surplus over the planning period 35 21-Jan-11 25-Feb-11

3.2.4 - Confirm CIP contribution by theme/business unit 35 21-Jan-11 25-Feb-11

3.2.5 - Managing the residual gap through further activity or cost reductions 35 21-Jan-11 25-Feb-11

3.3 Information Andrew Butters 35 21-Jan-11 25-Feb-11

3.3.1 - Revisit impact of PCT demand changes on Trust capacity 35 21-Jan-11 25-Feb-11

3.3.2 - Build & incorporate Trust assumptions re: 35 21-Jan-11 25-Feb-113.3.2.1 (a) Length of Stay Reduction 35 21-Jan-11 25-Feb-113.3.2.2 (b) Ambulatory Care plans 35 21-Jan-11 25-Feb-113.3.2.3 (c) Improvements to Day Case Rates 35 21-Jan-11 25-Feb-113.3.2.4 (d) Outpatients Clinic efficiency 35 21-Jan-11 25-Feb-113.3.2.5 (e) Theatre productivity 35 21-Jan-11 25-Feb-11

3.3.3Replay these impacts back into the Financial Model 35 21-Jan-11 25-Feb-11

3.4 Workforce Linda Burton 35 21-Jan-11 25-Feb-11

3.4.1 Reconfirm SIP and establishment baselines 35 21-Jan-11 25-Feb-11

3.4.2Test modelling assumptions re: role redesign and productivity 35 21-Jan-11 25-Feb-11






3.4.3Feed revised productivity assumptions through workforce model 35 21-Jan-11 25-Feb-11

3.4.4Confirm WTE reduction by staff group and specialty 35 21-Jan-11 25-Feb-11

3.4.5

Establish delivery plan for productivity improvement, role shift and headcount reduction 35 21-Jan-11 25-Feb-11

3.5 Presentation / Review meeting with SHA 6 25-Feb-11 3-Mar-113.6 Submission to DH 27 3-Mar-11 30-Mar-11

4.0 Commissioning Transition timetable 306 30-Jun-11 1-May-124.1 PCT clustering arrangements in place 1 30-Jun-11 1-Jul-11

4.2

All GP practices in GP consortia and start of NHS Commissioning Board authorisation of Consortia 1 30-Apr-12 1-May-12

4.3 SHA Abolished 1 30-Apr-12 1-May-12

5.0 Detailed Budget Setting In-Progress 11 25-Jan-11 5-Feb-115.1 Generate First Cut In-Progress 3 25-Jan-11 28-Jan-11

5.1.1Complete First P&L trial balance position by COP Wed In-Progress 1 25-Jan-11 26-Jan-11

5.1.2 Run data through SLR and generate reports In-Progress 1 26-Jan-11 27-Jan-115.2 SLAM upgrade to 11/12 PbR prices Furzana In-Progress 11 25-Jan-11 5-Feb-11

6.0 Annual Accounts In-Progress 3 25-Jan-11 28-Jan-11

6.1Deadline for completion (Thursday 21st April?) In-Progress 3 25-Jan-11 28-Jan-11

7.0 SHA Annual Plan Submission In-Progress 31 28-Feb-11 31-Mar-117.1 Executive Summary In-Progress 3 28-Feb-11 3-Mar-117.2 Annual Plan Commentary In-Progress 3 28-Feb-11 3-Mar-117.3 Strategy In-Progress 3 28-Feb-11 3-Mar-117.4 Finance In-Progress 3 28-Feb-11 3-Mar-117.5 QiPP In-Progress 3 28-Feb-11 3-Mar-117.6 Risk Analysis In-Progress 3 28-Feb-11 3-Mar-117.7 Quality In-Progress 3 28-Feb-11 3-Mar-117.8 Workforce Development In-Progress 3 28-Feb-11 3-Mar-117.9 Sustainability In-Progress 3 28-Feb-11 3-Mar-117.10 NHS Constitution In-Progress 3 28-Feb-11 3-Mar-117.11 Business Continuity In-Progress 3 28-Feb-11 3-Mar-117.12 Declaration & Self Certification In-Progress 3 28-Feb-11 3-Mar-117.13 Board Approval In-Progress 1 21-Mar-11 22-Mar-117.14 Submit Plan to SHA In-Progress 1 30-Mar-11 31-Mar-11


What Makes an FT Board?

John Bruce, ChairmanSouthend University Hospital NHSFT

[email protected]

Board of Governors

• 17 Public Governors• 5 Patient Governors & 1 Carer Governors

• 7 Worker Governors• 12 Partner Governors

Over 13,000 Public & Patient members, 4,000 workers

Board of Directors

• Chairman• 14 Directors 7 NEDs 7 Execs

o Audit Committee (NEDs)o Quality Assurance & Risk Committee

Ownership and Accountability

• The board interprets its owners to be: Legal: Overall -- Governors, on behalf of the

Members, who represent the community of Essex Legal: NHS Franchise -- Parliament, on behalf of the

UK public Moral -- All those who care about our long-term

success

Accountability to GovernorsThe board holds itself to be ultimately accountable to the Southend University Hospital NHS Foundation Trust Governors who operate on behalf of the Trust’s membership who represent the community of Essex. The board commits itself to governing at all times mindful of its moral and constitutional obligations to the Southend University Hospital NHS Foundation Trust Board of Governors. However, the board also recognizes that the Act provides that all the powers of the NHS Foundation Trust are to be exercised by its directors and that the Board of Governors cannot therefore veto its decisions (schedule 1, paragraph 15(2)).

Issues for Directors re Governors

• Loudest may not be wisest• Governors don’t work for Directors• Make time for Governors• Governors are the voice of patients and the community• They are not the only voices• Deciding the level of engagement on different issues• Mutual trust and confidence• Communication

Some observations and commentary

• Be absolutely clear about roles and responsibilities: Owners; Beneficiaries; BoD, BofG, Chair, Governors, Directors; Committees, Members

• Chairs may be nervous of governors• Governors need time as well• Induction is critical as are pre-election expectations• Get skilled at working with governors• (Chairs) What is your ambition in all this?

Some observations and commentary

• Encourage development of BofG• Understand what matters to individual governors – but

‘speaking with one voice’ applies• Work at being accountable to governors (and the wider

ownership)• Engage NEDs and Governors, NEDs need to be

governors’ influence channel• Chair is governors’ lead (not the company secretary or

‘project lead’ or CEO)

Pilot Experience of Monitor’s Pilot Experience of Monitor’s ppQuality Governance Quality Governance Assessment ProcessAssessment ProcessAssessment ProcessAssessment Process

Louise PayneDirector of ComplianceNorthamptonshire NHS

F d ti T tFoundation Trust

Northamptonshire Healthcare NHSNHS

Foundation Trust• FT from May 2009• Approx £100m incomeApprox. £100m income• Provides Mental Health,

S l H lth D &Sexual Health, Drug & Alcohol and Learning Disability Services

• Inpatient community and• Inpatient, community and Prisons

The Assessment ProcessThe Assessment Process

• Meet assessment team• Submit documentationSubmit documentation• Board self-certification• Interviews/Meetings• Further evidence• Further evidence• Draft report• Final report and result

Assessment and Results Structure• Strategy• Capabilities and cultureCapabilities and culture• Structure and processes• Measurement• Scores awarded• Scores awarded• Pass mark – score of less

than four

Our ResultsOur Results

• Ten measures• Two amber/red (two points)Two amber/red (two points)• Remainder amber/green (half

i t h)a point each)• Final score - sixa sco e s

StrategyStrategy

P iti• Positives:• Implementing a quality strategy• Performance is tracked against

plans at Directorate level• Involvement of Patient Experience

Group in developing plans• Service and Clinical input into

CIP’s and service redesign• Reformatting of BAF around

strategic objectives

Strategy continuedStrategy continued

• Actions:• Communicate quality goalsCommunicate quality goals

and new quality strategy to all staffstaff.

• Assess impact of CIPs and establish early warning indicators.indicators.

Capabilities and CultureCapabilities and Culture

• Positives• Involvement of clinicians inInvolvement of clinicians in

quality innovationD l t f• Development of Directorate/Service quality plans

• Meaningful Benchmarking• Meaningful Benchmarking

Capabilities and Culture continued• Actions• Improve triangulation ofImprove triangulation of

service level information to BoardBoard

• Improve training and appraisal rates

• Embed the quality strategy• Embed the quality strategy and goals

Structure and ProcessesStructure and Processes

P iti• Positives• Quality governance challenged at

B d d it b ittBoard and its sub-committees• Involvement of clinicians and

NEDNEDs• Linking staff awards to quality

l d t tgoals and strategy• High incident reporter• Service User and Carer

involvement strategy

Structure and Processes continued• Actions• Clarity on sub-committee roles as y

quality strategy is implemented• NICE guidance implementationNICE guidance implementation

and reasons for departure• Involve governors and carers in• Involve governors and carers in

development of quality goals

MeasurementMeasurement

• Positives• Quarterly Board QualityQuarterly Board Quality

Account reportsR b t t l t• Robust external assessment of systems and processes

• Board sees a variety of quality information at Trustquality information at Trust wide level

Measurement continued/Measurement continued/

A ti• Actions• Centralise monitoring of clinical

audit action plans at Directorateaudit action plans at Directorate level

• Clear plans to achieve goals atClear plans to achieve goals at Directorate level

• Improve staff feedback mechanisms

• Ensure Board information is concise comprehensible andconcise, comprehensible and consistent

Our ExperienceOur Experience

• Challenging and interesting• Lack of clarityy• Sometimes difficult to evidence• Time-consuming• Time-consuming• Helpful in Learning and

DevelopmentDevelopment• Emphasised Board focus on

quality• Monitor Assessment

TipsTips

H i t f li i• Have one point of liaison• Think laterally about evidence• Develop board ‘memo’ early• Reference main documents• Show evidence trail• Brief interviewees and getBrief interviewees and get

feedback• Know what’s submittedKnow what s submitted• Be open and honest

HS

g th

e N

H

Foundation Trust Delivery

bera

ting

ence

: Lib

Matthew Kershaw

Exce

lle

Matthew KershawDirector of Provider Delivery

ity a

nd

Presentation to the Foundation Trust Network 9 February 2011

Equi

Foundation Trust DeliveryH

SFoundation Trust Delivery

g th

e N

H

• Current position – pipeline

A l i f i d d l ti

bera

ting • Analysis of issues and proposed solutions

• Current activity

ence

: Lib

• Key issues

Exce

lle • Timescales

ity a

nd

Equi

Current position - pipelineH

SCurrent position - pipeline

g th

e N

H

• All NHS trusts must become, or be part of a FT by April 2014

118 t t i th i li i l di 16 t ti l CFT

bera

ting • 118 trusts in the pipeline – including 16 potential CFTs

• Applications to be received no later than April 2013

ence

: Lib

• November 2010 returns show 20% of remaining trusts will not apply before April 2013

Exce

lle

April 2013

ity a

nd

Equi

Summary of Application DatesH

SSummary of Application Dates

g th

e N

H

Trust Trajectory November 2010 (98 Trusts)

bera

ting

1614 15

20

of T

rust

s

ence

: Lib

47

10

6 6

Num

ber

Exce

lle

Q1 20

11

Q2 20

11

Q3 20

11

Q4 20

11

Q1 20

12

Q2 20

12

Q3 20

12

Q4 20

12

2013

ity a

nd

The graph represents the 120 NHS Trusts as at 30 November, less the 22 whoi) have already submitted their applications to DH, ii) are being assessed by Monitor,

Q Q Q Q Q Q Q Q

Equi iii) one trust assessed for autonomy (Nottinghamshire Healthcare), or

iv) are part of a franchise, hence 98 are represented on the graph.

Current Activity (1)H

SCurrent Activity (1)

– DH team working with SHAs to develop root cause analysis

g th

e N

H – DH team working with SHAs to develop root cause analysis

– Ian Dalton and Matthew Kershaw visits to each SHA to help collect

bera

ting

intelligence on position and set NHS expectations

Provider Executive Group (PEG) subgroups working in parallel

ence

: Lib – Provider Executive Group (PEG) subgroups working in parallel

workstreams, drawing on Monitor’s expertise and allowing time for implementation

Exce

lle – FT application / assessment process– Quality– Intervention options

ity a

nd Intervention options

– Finance issues – PFI, legacy debt– Leadership and governance

Equi



Tripartite Formal Agreements – Agreed DH, SHA and Trust plans by

g th

e N

H p g g , p y31 March 2011

•Principle means of identifying issues to be resolved to support successful FT application

bera

ting successful FT application

•Finalise format content and process end of February

ence

: Lib •Finalise format, content and process end of February

• Signed by NHS Trust SHA and DH by end March

Exce

lle

• Signed by NHS Trust, SHA and DH by end March

• Focus on bigger risk issues which will require more complex

ity a

nd • Focus on bigger risk issues which will require more complex

solutions

Equi



Provider Development Authority

g th

e N

H Provider Development Authority• Establishment by 1 April 2012 – 31 March 2014

• Fulfil provider side functions currently performed by 10 SHAs

bera

ting Fulfil provider side functions currently performed by 10 SHAs

• Shadow form from Autumn 2011

ence

: Lib

• Three primary functions– Performance management of NHS Trusts

Management of FT pipeline

Exce

lle

– Management of FT pipeline– Management of clinical quality, governance and risk in NHS Trusts

ity a

nd

Equi

Key issuesH

Sey ssues

• Finance • working capital and liquidity issues

g th

e N

H g p q y• onerous loan debt to DH• implications of PFI

bera

ting

• Assessment processSmoothing pathways including quality assessment and board leadership

ence

: Lib

• Organisational form options for NHS Trusts which are not viable in current form

Exce

lle

• Leadership Development

ity a

nd

Equi

TimescalesH

STimescales

g th

e N

H

• Develop menu of support for NHS Trusts – 28 February

Si t i tit f l t 31 M h

bera

ting • Sign tripartite formal agreements – 31 March

• Set up Provider Development Authority – by April 2012

ence

: Lib

• Final deadline for FT applications from NHS Trusts – 1 April 2013

Exce

lle • Monitor authorisation by 1 April 2014

ity a

nd

Equi

Foundation Trust Network:Preparation Programmep g

Miranda CarterAssessment Director

February 2011February 2011

Agenda

1. Context

2. Monitor’s process

3 Fi i l t3. Financial assessment

4. Quality governance framework

5. Lessons from recent assessments

6 Questions and Answers6. Questions and Answers

1

The Coalition Government’s proposalsp p

Monitor to take on role as economic regulator for the

NHS; strengthen the role of CQCQ

Creation of an independent NHS

The NHS

Hand control of budgets and

commissioning to GPs

Commissioning Board to oversee

commissioning and to champion

improvement and patient involvement in health services The NHS

landscape

All NHS trusts will be supported to become

Primary Care Trusts and Strategic Health supported to become

FTs, or form part of an FT, by 2013/14

and Strategic Health Authorities will

disappear

Growth of NHS FTs

History of NHS foundation trusts authorisations

129 132 134140

160Over the last year, we have completed 11 assessments of

92

112 117125 129 132

100

120

completed 11 assessments of which:

• 5 were authorised

5462

8392

60

80

• 6 were postponed/deferred• 0 withdrawn• 0 rejected

1020

31 32 32

20

40Our first time pass rate is 63%84% of trusts we have assessed are now FTs

10

0Reason for postponement split evenly between finance and governance

3

governance

Agenda

1. Context






4

Monitor’s authorisation process

Th f d t l tiThree fundamental questions:

1. Will the applicant be legally constituted?2. Does the applicant have appropriate corporate governance arrangements in place? 3 D id th T t t b fi i ll i bl ?

• Review of Governance aspects:

3. Do we consider the Trust to be financially viable?

• Legally constituted• Effectively governed• Service performance, Quality Governance, CQC

registration

Governance review

g

• Two year working capital review• Review of long term (5 years) strategy and financesBusiness plan review

• Assessors stress-test assumptions and forecasts• Independent accountants involvedRobust challenge • Independent accountants involved• Board-to-Board meetings

gprocess

5

Quality criteria for authorisation

Applicant trusts must demonstrate that:

a) they are registered without compliance conditions; b) they continue to meet the quality threshold set by the Department of Health at the

time of Secretary of State referral; c) the CQC’s current judgment of compliance against registration shows;

• the overall level of concern is no worse than moderate concerns and high confidence in capacity;

• the CQC is not conducting or about to conduct a responsive review into compliance;

• no enforcement/investigation activity is ongoing or planned including preliminary investigations into mortality outliers; and

d) they have a Governance risk rating as detailed in the consultation on the 2010/11 Compliance Framework of no worse than Amber/ Green.

6

3 - 4 month processp

1 2

Initial Review Preparation for the Board to Board pack

Kick off meeting Board to Board meeting Board decision meeting

Post Board to Board follow up

1 2

Month 1 – 2 Month 2 – 3 Month 4

Target authorisation

date

Key submissions (IBP, model)

CQC meeting Independent Accountant’s

opinion

CQC + DH sign off

1 Primary focus for first 2-3 months is to prepare a report for the Monitor Board prior to the Board to Board. The evidence is gathered from a variety of sources:• Review of submissions

M ti /I t i ith NHS T t• Meetings/Interviews with NHS Trusto Board, Board Sub-committees, clinical directorates, PFI project director

• Financial model review meeting with key finance personnelM ti /I t i ith th t l t k h ld• Meetings/Interviews with other external stakeholders

o IA, EA, PCTs, SHAs, CQC• Liaison with and involvement of Independent Accounting Firm

2 Post Board to Board the team will follow-up on key issues raised at the Board to Board, before finalising the report ahead of the Board Decision meeting – usually a few days before the target authorisation date

7

Agenda

1. Context






8

Monitor’s assumptions

Acute Trusts 2010/11 2011/12 2012/13 2013/14 2014/15Assessor case Implied 3 5% 4 0% 4 0% 4 0% 4 0%Assessor case Implied efficiency assumption

3.5% 4.0% 4.0% 4.0% 4.0%

Downside case Implied efficiency assumption

4.5% 5.1% 4.8% 4.6% 4.5%efficiency assumption

Mental Health Trusts 2010/11 2011/12 2012/13 2013/14 2014/15Assessor case Implied efficiency assumption

3.5% 4.0% 4.0% 4.0% 4.0%

D id 1 I li d 4 5% 4 5% 4 5% 4 5% 4 5%Downside case 1 Implied efficiency assumption

4.5% 4.5% 4.5% 4.5% 4.5%

Downside case 2 Implied 5.0% 5.0% 5.0% 5.0% 5.0%

9

efficiency assumption

Currently under review in light of NHS Operating Framework 2011/12

Cost Improvement PlansCost Improvement Plans

• Increase in efficiency will require significant CIPsFinancial

challenge to applicant trustsapplicant trusts

• Robust CIP plans for the first two years of the Business Plan (including detailed implementation plans)

• Key themes for the medium term CIPs• Consideration of impact on quality of service, subject to Board challenge

Monitor’s expectations

• Understand cost base, benchmarking for efficiency improvements• Strong governance over the generation and delivery of CIPs

B d tti t t i di tiRecipe for • Board setting strategic direction • Clinical ownership of schemes• Assessment of impact on quality, quality indicators to track• Regular reporting

Recipe for success

The challenge for trusts is to meet efficiency requirements whilst maintaining quality of care.

10

Agenda

1. Context






11

Recent developments to our process

Monitor commissioned our internal auditors to conduct a lessons learned exercise following

p p

Monitor commissioned our internal auditors to conduct a lessons learned exercise following the failings at Mid Staffordshire.

We’ve acted on recommendations and developed our process to include framework for i lit

Strategy Capabilities and Culture

Processes and Structures

Measurement

assessing quality governance.

▪ Does quality drive the trust’s strategy?

▪ Are there clear roles and accountabilities in relation to quality governance?

▪ Does the Board have the necessary leadership, skills and knowledge to ensure

▪ Is appropriate quality information being analysed and challenged?

Culture Structures1A 2A 3A 4A

▪ Is the Board sufficiently aware of potential risks to quality?

governance?

▪ Are there clearly defined, well understood processes for escalating

knowledge to ensure delivery of the quality agenda?

▪ Does the Board

challenged?

▪ Is the Board assured of the robustness of the quality information?

1B

2B

3B 4B

and resolving issues and managing quality performance?

▪ Does the Board actively

promote a quality-focused culture throughout the Trust?

▪ Is quality information used effectively?

3C

4C

Does the Board actively engage patients, staff and other key stakeholders on quality?

3C

12

How do we assess Quality Governance

Boards self-assess against ten key questions set out in our Quality Governance Framework.

Monitor tests and challenges this evaluation against direct evidenceMonitor tests and challenges this evaluation against direct evidence.

Monitor’s assessment to be supported by external experts providing a challenge function.

E h f th t k th RAG t d t i ll Q litEach of the ten key areas are then RAG rated to give an overall Quality Governance score

13

Scoring

Score Risk rating Definition EvidenceScore Risk rating Definition Evidence0 Green Meets or exceeds

expectationsMany elements of good practice

+ no major omissionsPartially meets expectations Some elements of good practice

0.5 Amber/Green

Partially meets expectations but confident in management’s capacity to deliver green performance

Some elements of good practice

+ no major omissions

+ robust action plans for shortfalls and proven track record of deliverywithin reasonable timeframe track record of delivery

1 Amber/Red

Partially meets expectations but some concerns on capacity to deliver within a

Some elements of good practice

+ no major omissionscapacity to deliver within a reasonable timeframe + action plans for shortfalls in early stages and

limited evidence of delivery in past4 Red Does not meet expectations Major omission in quality governance identified

+ significant volume of action plans required, concerns on management delivery capacity

• Quality Governance score of 4 or worse cannot be authorised • Overriding rule states no category can be rated entirely Amber/Red

Early lessons - General

Assessment bar is tough

Board memoranda assertions not backedby evidenceby e de ce

Unrealistic or lack of self assessment by Trust Boards

Early lessons

Strategy Capabilities and culture

Planning

• SMART goals to support

Lack of awareness/information

• Board not clear on the poor and gstrategy

• Need for improved communication with staff

well performing services (lack of information at board level)

• External perspective

Finance and quality

• CIP evaluation

p p

CIP evaluation early warning indicatorspost implementation review

Early lessons

Processes and structures Measurement

Escalation

• Clarity on how issues are escalated up to the Board

Information Challenged

• Quality dashboard cascaded down through divisionsescalated up to the Board

• Robustness of action plans

Cl i th l

through divisions

• Prioritised KPIs

• Closing the loop

Engagement Robustness of data

• Engaging staffUp-to-date informationTemperature check

• Effective use of internal and clinical audit

Clinical audit linked to quality risksp risksUse to test robustness of data

Agenda

1. Context






18

Lessons learned

1. An effective Trust Board 2. Strategic business planning

3. Quality and clinical governance

4. Financial governanceplanning governance

• Role• Importance of self-

• Contracting and risk• Commissioning

• Quality governance framework

• Accounting policies• Failure to address HDDImportance of self

certification • Transparency of Board

reporting

Commissioning intentions

• CIPs• Downside planning and

mitigations

framework• Failure to address

performance on targets and standards

• Conditions/ responsive i

Failure to address HDD recommendations

• Private Patient

review

Facilitating a smooth processg p

Project lead at applicant to facilitate data requests

Transparent –i.e. contingency reserves notified to the team

Consider impact of Monitor’s efficiency assumptions early

Board challenge on mitigations – what is in Trust’s control and priority for implementation

Availability of working papers to support key LTFMAvailability of working papers to support key LTFM assumptions e.g. marginal costs

Prepare Board Memo on Quality early – careful considerationPrepare Board Memo on Quality early careful consideration of direct evidence

Agenda

1. Context






21

25 January 2011

Update on current issues – Health & Social

Care Bill

Sue Slipman, Director, FTN

Impact of Operating Framework• Flat cash…but take £20bn out of system• In-built inflation – Agenda for Change

– Product and cost inflation

• Transfers risk onto providers• Acute sector: 4% out of tariff, activity cap set at

outturn 2008/09, Marginal pricing 30%• Mental Health no tariff• CIPs average 4.5% but up to 8-9% and beyond in

some FTs

NHS Reforms

• DH Department of Public Health

• Commissioning

• Role of local authority

• Independent provision

• Regulatory framework: Independent economic

regulator (Monitor) and Quality Inspector (CQC)

Department of Health

• Secretary of State accountable for public health and

commissioning line: Promotes

well being

innovation

quality

equal access

autonomy

• Hands annual mandate through commissioning line

National Commissioning Board

• Delivery of mandate

• Contracts: ‘model contracts’

• Incentives

• Oversees GP Consortia

GP Consortia

• Responsible for commissioning pohysical and mental

health services

• Applications to NHS CB

• Must involve patients

• Must not exceed financial allocations

• Regulations to stop conflicts of interest

commissioning and provisiuon

Local authority

• Health and well being boards

• Directors of Public Health

• Promote integration

Economic Regulator

• General Duties• Competition• Designated services• Licensing Fees

Risk pool

Info requirements

Notice to cease providing designated services

• Pricing: methodology, prices and appeal

Foundation trusts

• All public providers FTs by 31 March 2014 or cease

to exist

• New duties for directors

• Members and voting

• New duties for governors

• Constitutional amendments

Foundation trusts: New Freedoms and

Accountabilities• Private patients cap

• Mergers and acquisitions (50% governor vote)

• Significant transactions

• Role of financing facility

• Role of governors

FTN lobbying successes –

so far

• Removal of private patient income cap, with no restrictions

• No compulsion for FTs to hold board meetings in public

• Greater borrowing freedoms • ‘Drop dead’ on the face of the bill – 31 March 2014• Recognition of success of FT model, including

organisational form as a social enterprise • Recognition and addressing Monitor’s conflict of

interest • No reference to establishing employee-owned

organisations

What remains to be done?

• Failure regime

– SoS stand behind assets?

– Off balance sheet?

• Solution to future access to capital and PFI

• Risk pool rules

Conclusions

• Unprecedented productivity and re-configurations required

• Large number of unknowns in system checks and balances

• Risk all on front line • Major funding challenges• Large scale freedom and opportunities New services

Strategic alliances broadening and changing business

models

• Boards, governance and relationships key

On Being an FT ChairOn Being an FT Chair

Vernon HullVernon Hull Chair

Medway NHS Foundation Trust

About Medway FTAbout Medway FT• An FT since April 2008• An FT since April 2008• Serves community of around 350,000 in and

around the Medway Towns in Kent (Chathamaround the Medway Towns in Kent (Chatham, Gillingham, Rochester, etc)

• £220m Turnover • I have been Chair since 2004

What Monitor expects ( C f G )(according to its FT Code of Governance)

‘ A clear division of responsibilities at the head of A clear division of responsibilities at the head of the NHS Foundation Trust between the chairing of the boards of directors and governors and theof the boards of directors and governors and the executive responsibility for the running of the NHS Foundation Trust’s business’NHS Foundation Trust s business .

OrYou run the board and the governing body. The

Chief Executive runs the organisation.

Some Key DifferencesSome Key Differencesbetween chairing a Non FT and an FT

• More is expected of you internally which in turn reflects the fact thatreflects the fact that

• More is expected of you externally – particularly b M iby Monitor

• So you spend more time on the job

What Monitor Expects (2)p ( )Leadership – ‘The chairman is responsible for leadership of the board and

b d f i th i ff ti ll t f th iboard of governors, ensuring their effectiveness on all aspects of their role and setting their agenda’.

Harmony – ‘The chairman is responsible for ensuring that the two boards y p gwork together effectively’.

Information and decision making – ‘ The chairman is responsible for ensuring accurate timely and clear information’ensuring accurate, timely and clear information .

Communication – ‘The chairman should ensure effective communication with patients, members, clients, staff and other stakeholders.

Working Together – ‘ The chairman should ensure constructive relations exist between executive and non executive directors and between the board of directors and governors’.(Monitor Code of Govenance)board of directors and governors .(Monitor Code of Govenance)

What is an Effective BoardAccording to ‘The Healthy NHS Board’ Eff ti NHS B d d t t l d hi bEffective NHS Boards demonstrate leadership by

understanding three key roles. Formulating strategy for organisation– Formulating strategy for organisation

– Ensuring accountability by holding the organisation to account for the delivery of the strategy and through seeking assurance that systems of control are robust and reliable.

– Shaping a positive culture for the board and the organisation. (NLC ‘The Healthy Board 2009’)(NLC The Healthy Board 2009 )

The Challenges

• When things go wrongg g g• When you have to ring the changes

W ki ith G• Working with Governors

Working with your Governorsg y• Managing expectations • Managing engagement• Managing people• Managing people

What of the Future• Monitor is being reborn as a regulator whose first task is

to promote competitionto promote competition. • Cosy relations with commissioners could be a thing of

the past – particularly if challenged as uncompetitive by any other ‘willing provider’.

• Para 5 – 34 of the Health Bill offers ‘the opportunity for providers to offer services at less than the publishedproviders to offer services at less than the published mandatory tariff’.

Instability or (as one conservative MP put it) “creative chaos”.

FTN P li d t D b 2010FTN Policy update December 2010

Sue Slipman, Director FTN

The Comprehensive Spending Review (20 October)

As the 2010 Spending Review sets out, the NHS will receive 0 4 per cent real-terms growth over the next four years – 0 10.4 per cent real-terms growth over the next four years – 0.1 per cent a year. This compares to an average real-terms increase of 5.7 per cent per year from 1997/8 to 2009/10. This is the lowest four-year increase for the NHS since the 1950s. The Spending Review also allocates £1 billion a year from NHS funding to social care: the real-terms change in NHS funding over the next four years, net of the social care support is therefore a reduction of 0 5 per centsupport, is therefore a reduction of 0.5 per cent.

CSR – King’s Fund analysis• An increase of 0.1 per cent a year in real terms will soon be swallowed up by

cost pressures such as incremental pay drift and the increase in VAT. The net lt ill b d ti i th NHS’ h iresult will be a reduction in the NHS’s purchasing power.

• The £1 billion increase in grant funding for social care could provide some respite for hard-pressed local services and buys time while the Dilnotrespite for hard pressed local services and buys time while the Dilnot Commission works on a long-term funding solution. But this money is not ring-fenced so there is no guarantee it will be spent on social care.

U d i l th dditi l £1 billi f th NHS b d t t b k d th• Used wisely, the additional £1 billion from the NHS budget to break down the barriers between health and social care provides a real opportunity to improve service delivery and save money by, for example, reducing the length of time patients spend in hospital. Again though, with the ring fence on local authority p p p g g , g ygrant funding having been removed, and local government funding slashed overall, it remains to be seen whether this translates into increased funding for social care services.

John Appleby

Other pressuresp

NHS faces bed-blocking crisis (22 October)Patients will be denied hospital beds because they will be filled by the elderly and vulnerable who are unable to get council care after Coalition cuts (NHS Confed).

Number of elderly people in hospital surges (28 October)The number of elderly people being treated in hospital has risen by two thirds in a decadeThe number of elderly people being treated in hospital has risen by two thirds in a decade raising fears that cuts in social care will add to pressure on the NHS.

Hospital trusts hit by £90m fall in earnings (28 October)Hospital trusts hit by £90m fall in earnings (28 October)Hospital trusts lost out on income worth approximately £90m during the three months to June as a result of the Department of Health’s policy to restrict funding for emergency admissions.

FTN response to the White PaperFTN response to the White Paper

• The FTN submitted responses to the white paper and associated• The FTN submitted responses to the white paper and associated consultations. These are available on our website.

• Two more consultations were issued on 18 October on choice and information. Public health issued last week. Member consultation taking place

• Further consultations are expected on workforce• Further consultations are expected on workforce

The FTN response and some issuesp

Overall the end vision is the right one - putting patients and carers at theOverall the end vision is the right one putting patients and carers at the centre and giving providers and their clinicians the freedom to innovate and deliver on improved outcomes.

Concerns are many but three of the main ones are:

• arrangements for the accountability, capacity and capability of GP commissioners and the risk to providers of this being lacking;

• Regulatory framework and tariff setting• transiton to the new arrangements, particularly in the

context of the current economic and financial environment;

FTN responseFTN response• Supported removal of the PPIC as a means for supporting innovation

and bringing new cash into the service for NHS patient care

• Asked for certainty on the FT pipeline so that organisations can plan

E l d ibiliti f t d d l i l l d• Explored possibilities for extended governor roles in employee-led models (staff members and governors); approving transactions; providing oversight of board and assets in conjunction with a banking f nctionfunction…

• Agreed with no limits applied on borrowing and being able to secure access to both working and investment capitalaccess to both working and investment capital

• Proposals for extending the role of the Foundation Trust Financing FacilityFacility

FTN response• Sufficient recognition of the provider role driving service reconfiguration

at pace including easier entry to, and exit from, service lines;

• Clarity on the arrangements for investment, managing the state interest in assets and pre-failure regimes

• Transfer of community services to providers (either an FT or future community FT) with their associated assets

• Foundation trusts working with all employers and key stakeholders on the plans for an employer-led workforce and the commissioning of education and training;education and training;

• Stable arrangements for the novation of contracts to GP commissioners and the NHS Commissioning Board (NHSCB)commissioners and the NHS Commissioning Board (NHSCB).

FTN response – system requirementsFTN response system requirements• An even-handed regulator with as few conflicts of interests as possible

able to set a tariff for market sustainability

• A rules-based approach, in transition and beyond, to give system actors clarity and certainty – including implementation of PbR in mental health;health;

• A voice for patients through HealthWatch that has a discrete role from that of FT members and governors – a strategic input into local commissioning strategies?commissioning strategies?

• Provide system balance by setting up provider panels - within the regulator (as is common with other regulated industries) and in the wider system to influence the commissioning functionwider system to influence the commissioning function.

• System tensions in respect of the relative power and accountabilities of system actors need to be worked through.

PbR and tariffPbR and tariff

• Sense check undertaken for 2011-12. Planning to start road testing the tariff around the middle of December with final publication in February 2011

• No change in target dates for Mental Health Currencies/Tariff

• Some arbitrary changes – main ones include extension of best practice t iff d ti f i li d t i di t i d th ditariff; reduction of specialised top-ups in paediatrics and orthopaedics; setting the tariff below average for 30 high volume HRGs

Expanding the scope of tariff HRG4 for A&E; mandate the allocation• Expanding the scope of tariff – HRG4 for A&E; mandate the allocation of service users to mental health care clusters; mandated currencies for critical care;

Significant changes to the tariff are proposed in 2011/122011/12Efficiency Target 2.5%S i li d i tSpecialised service top ups• Top-ups to be introduced for new service areas:– Cancer 21%

S i l 30%– Spinal 30%– Neurosciences 23%– Cardiac and cardiology 13%

Reduce the top up for specialist services for children from 78% to 25%• Reduce the top-up for specialist services for children from 78% to 25%• Reduce the orthopaedic top-up from 30% to 25%

Tariff set below the meanTariff set below the mean• Setting prices for a number of high volume HRGs at a level below the average reported cost. (45th percentile)• 30 HRGs selected based on high volume and stable distribution of costs• 30 HRGs selected based on high volume and stable distribution of costs

Payment by Results in 2011/12 5 New best practice tariffs• Emergency readmissions and reablement

o No payment for emergency readmissions within 30 dayso No payment for emergency readmissions within 30 dayso Tariffs will be inflated to account for a clinically acceptable level of readmissions (but how to calculate?)o From 2012/13 providers to be responsible for post discharge care for 30o From 2012/13 providers to be responsible for post discharge care for 30 days with adjusted tariffso However, in 2011/12, the ‘savings’ will go into a local fund with commissioners that they will be “advised” to spend on reablement servicescommissioners that they will be advised to spend on reablement services in conjunctions with providers and local authoritieso DH’s initial estimate is that the ‘savings’ for the local pots will be around £1bnoRumour of tariff adjustment of A4C increments

30% marginal rate for emergency admissions

HSJ story on £90m losses in the 3 months to June 2010. Demand continues to increase for most :continues to increase for most.:

• 40.1% organisations have seen continued increased rate of growth in emergency admissions from 09/10emergency admissions from 09/10

• 24.5% organisations have seen the rate of growth in

emergency admissions slowed from 09/10 (but stillemergency admissions slowed from 09/10 (but still

growing)

• 35 4% organisations have halted or reversed the growth• 35.4% organisations have halted or reversed the growth

in emergency admissions from 09/10

Time-table for Change

• Command Paper 13.12.10

• Operating Framework 15.12.10

• Draft Bill January 2010

N t f 2012/13• New arrangements from 2012/13



Chair s report


CHAIRMAN S MAIN APPOINTMENTS February 2011

2 February Met with Head of Communications re forthcoming Practice Managers Event Met with Trust Secretary and Sandra Canning, Chair of Harlow Hospital League of Friends Chaired Practice Managers Seminar, Civic Centre

3 February Attended part of Nursing & Midwifery OPD Practice Group meeting Met with Tutors from Harlow College and Church Langley Primary School regarding displaying students work in the hospital

8 February Attended the Trust s Audit Committee meeting Attended the Fracture Clinic MDT meeting Had 1:1 meeting with Trust Secretary Met with Dr Sikdar, Chair of the LNC Met with Louise Barnes, Head of Elderly Care

9 February Attended meeting of NHS Trust Chairs in London, hosted by McKinseys, with senior representatives of Dept of Health and Monitor

10 February Had meeting with the Chief Executive and Interim Director of Workforce Met with Jan Dalrymple, NED for 1:1 Attended the Compliance Committee meeting Met with CEO and Trust Secretary for handover Met with incoming CEO Attended Patient Council meeting

11 February Attended the Harlow 2020 LSP meeting

15 February Attended the Extended Management Team meeting Had meeting with the Head of Training to discuss PRDPs Met with Brian Ng from the Trust s internal auditors Met with representatives of Harlow Pensioners Action Association Had meeting with Dr Rogers and Dr Harchal (ENT consultants)

24 February Attended the Anaesthetic Review meeting Chaired the Trust Board meeting

board room, pah - hsj · these were received from dr claire feehily mrs jan dalrymple and mr chris...

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