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GENERAL MEETING OF THE COUNCIL OF GOVERNORS OF BARNSLEY HOSPITAL NHS FOUNDATION TRUST

5.30-7.30PM, WEDNESDAY 17 AUGUST 2016 IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA 1. Apologies & Welcome 2. To invite comments from members of the public 3. To review the Register of Interests and receive ENC 03

any declarations for interest for the meeting 4. To approve Minutes of the General Meeting held on 22nd June 2016 ENC 04 5. To consider any matters arising from the Minutes of the last General Meeting 6. To receive and consider the External Auditor’s report on the ENC 06

Quality Account for 2015-16 & presentation – Ms S Clark, Manager, PricewaterhouseCoopers LLP

7. To receive an update report on Membership ENC 07 – Ms C Wake, Membership and Communications Assistant

8. To approve the latest review of the Constitution ENC 08 – Mr S Wragg, Chairman

9. To consider implications of the Sustainability & Transformation Plan Verbal – Ms D Wake, Chief Executive

10. To receive a report from the Trust’s Chairman, Mr S Wragg ENC 10 11. To receive a report from the Lead Governor, Mr J Unsworth ENC 11 12. To receive an update report from the Trust’s Chief Executive ENC 12

– Ms D Wake, Chief Executive 13. To receive and approve reports from the Nominations Committee:

a) Annual Review of Terms & Conditions for Non Executives & Chairman ENC 13a b) Non Executive appointment process Enc 13b

14. To receive latest update report from the Council of Governors’ sub-groups ENC 14 – Mr D Brannan (Chair, Finance & Performance) and Mr T Smith (Chair, Quality & Governance)

15. To receive and note reports from the Board of Directors ENC 15 – latest Board agenda and Minutes (meetings held in public) – latest monthly integrated performance report – Infection Prevention & Control Strategy 2016-19 – Horizon Scanning report

16. To consider issues raised by Governors – items highlighted in pre-meeting

17. Any other business, including – matters raised by the public – date of Annual General & Public Members Meeting: Tuesday 6th September, 9-11am – date of the next General Meeting: Wednesday 19th October 2016, 5.30-7.30pm

Signed: ………………….. Chairman

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COUNCIL OF GOVERNORS – AUGUST 2016

REF: CG/16/08/03

CoG Aug 2016: Reg of Int

03

REGISTER OF INTERESTS

1. INTRODUCTION In accord with statutory guidance and our Constitution, the Trust is required to maintain and regularly review a Register of Interests for the Council of Governors. In addition, Governors are invited to make a declaration of any interests – which should include any changes to the Register – at each general meeting. Whilst every effort is made to assist Governors’ declarations, it is the responsibility of each individual Governor to ensure that his or her interests are declared in a timely and appropriate manner.

2. REGISTER OF INTERESTS A copy of the Register of Interests for the Council of Governors is attached for reference, reflecting latest known changes. If anyone has any other changes/amendments/additions they should record on the Register, would they please ensure the details are declared at the meeting or advised in writing to the Chairman as soon as possible. The Register, together with the Register of Interest for the Board of Directors, is available to the public on request at any time.

3. RECOMMENDATION Governors are asked to:

• note the Register of Governors’ Interests attached

• advise any amendments, additions or deletions required to ensure that their

personal entries comply with Clause 12 and Annex 7 of the Trust’s Constitution

Carol Dudley SECRETARY TO THE BOARD & GOVERNORS August 2016

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* Entry numbers to run consecutive by date order Signed: ____________________________ Secretary to Board & Governors ** Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chief Executive or Nominated Officer Dated: 10 August 2016

Page 1 of 4

BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF GOVERNORS’ INTERESTS – AUGUST 2016

Entry No*

GOVERNOR (& CONSTITUENCY)

Start date of Term End date of Term INTERESTS Date Interest

registered Date entry reviewed

92

Mr Paul Ardron Constitutency: Partner Org Sheffield Hallam University & University of Sheffield (shared seat)

01 August 2013 to

31 July 2016 None

17 February 2016

109 Ms Kathryn Armitage Constituency: Public Barnsley Public

01 January 2016 to

31 December 2018

Co-opted member, Audit Committee of Barnsley Council 17 February 2016

17 February 2016

110 Ms Joanne Bleasdale Co-opted Governor

01 January 2016 up to

31 December 2016 None

17 February 2016

7

Mr David Brannan Constituency: Partner org Voluntary Action Barnsley (VAB)

01 January 2005 4th term to

31 December 2016

1. Trustee of Voluntary Action Barnsley 2. Member, Independent Remuneration Panel,

Barnsley Council

01 January 2005 03 January 2008

17 February 2016

68 Mrs Pauline Buttling Constituency: Public Barnsley Public

01 January 2010 3rd term to

31 December 2018 Barnsley HealthWatch champion (volunteer) 04 February 2015

17 February 2016

111 Mrs Gillian (Gilly) Cockerline Constituency: Staff Non Clinical Support

01 January 2016 to


17 February 2016

84 Mr Tony Conway Constituency: Staff Volunteers

01 January 2013 2nd term to

31 December 2018 Union representative, GMB 08 October 2014

17 February 2016

93 Mr Antony (Tony) Dobell Constituency: Public Barnsley Public

01 January 2014 to


17 February 2016

94 Mrs Joan Gaines Constituency: Public Barnsley Public

01 January 2014 to

31 December 2016 Non Executive Director, Berneslai Homes 08 January 2014

17 February 2016

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* Entry numbers to run consecutive by date order Signed: ____________________________ Secretary to Board & Governors ** Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chairman or Nominated Officer Dated: 10 August 2016

Page 2 of 4

Entry No*




85 Mr Tony Grierson Constituency: Public Barnsley Public


31 December 2018 Member, Liberal Democrats Party 17 February 2016

17 February 2016

100 Mrs Rachel Hewitt Constituency: Staff Clinical Suppport

01 May 2014 to


17 February 2016

59

Mr Martin Jackson Constituency: Partner Org Joint Trade Unions Committee

January 2008 3rd term to


17 February 2016

112 Mr Stephen Long Constituency: Public Barnsley Public

01 January 2016 to

31 December 2018 Member of Barnsley Magistrate January 2016

17 February 2016

102 Ms Annie Moody Constituency: Public Barnsley Public

01 January 2015 to


17 February 2016

55 Mr Bruce Leabeater Constituency: Public Barnsley Public

01 January 2008 3rd term to


17 February 2016

107 Mr Chris Millington Constituency: Partner org Barnsley CCG

June 2015 to

31 May 2018

a) Chair, CRM: Creating Retail Management b) Lay Member: Governing Body, NHS Barnsley

Clinical Commissioning Group (CCG) c) Deputy Chair, Barnsley CCG d) Chair, Primary Care Co Commissioning Comm. e) Chair, Barnsley Patient Council f) Lead, Patient & Public Engagement,

NHS Barnsley CCG

June 2015 __________

February 2016

17 February 2016

79 Ms Gwyn Morritt Constituency: Staff Nursing & Midwifery



17 February 2016

95 Mrs Jacky O’Brien Constituency: Public Barnsley Public

01 January 2014 to

31 December 2016 None 08 January 2014

17 February 2016

103 Mr Harshad Patel Constituency: Public Barnsley Public

01 January 2015 to


17 February 2016

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Page 3 of 4

Entry No*




67

Councilllor Jenny Platts Constituency: Partner org Barnsley Metropolitan Borough Council (BMBC)

November 2009 3rd term to

31 October 2018

a) Governor, Athersley South Primary School b) Member, Labour Party c) Member, Barnsley Health & WellBeing Board

08 February 2012 08 October 2014

17 February 2016

108 Mr Lee Pryor Constituency: Partner Org Barnsley College

November 2015 to

31 October 2018 None

17 February

2016

74 Mr Ray Raychaudhuri Constituency:Staff Medical & Dental

01 September 2010 3rd term to

31 December 2018

a. Director of Yorkshire Women’s Health 21 March 2011 17 February 2016

b. Member of Yorkshire Clinical Senate 24 Feb 2015

39 Mrs Carol Robb Constituency: Public Barnsley Public



17 February 2016

97 Mrs Lisa Sanderson Constituency: Staff Nursing & Midwifery

01 January 2014 to


17 February 2016

113 Mr Robert Slater Constituency: Public Barnsley Public

01 January 2016 None 17 February

2016

104 Mr Frank Skorrow Constituency: Public Barnsley Public

01 January 2015 to

31 December 2017

Member, Hoyland Medical Practice Patient Reference Group May 2015

17 February 2016

73 Mr Trevor Smith Constituency: Public Barnsley Public

01 September 2010 3rd term to

31 December 2018

a) Member of the Royal British Legion, Branch Chairman & Honorary Poppy Appeal organiser

b) School Governor, Netherwood Advance Learning Centre

c) Magistrate (Supplementary List), Barnsley Bench

d) Member, Friends of Darfield Churchyard Group – Health & Safety

e) Owner, Florida Villas Home Rentals – Est 1998 f) Member, Chartered Institute of Builders g) Member, Association of Building Engineers h) Member, Rotary International

- Rockley Branch i) Member of Barnsley Beekeepers Association j) Member, UKIP

31 January 2015

02 September 2013

____________ 31 January

2015 18 February 2016 03 August 2016

17 February 2016

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Page 4 of 4

Entry No*




98 Mr Luke Steenson Constituency: Public Consituency O (out of area)

01 January 2014 to

31 December 2016

a) Tutor, West Yorkshire RoSPA Advanced Drivers and Riders

b) First Aider, St John Ambulance 08 January 2014

17 February 2016

34 Mr Joseph Unsworth Constituency: Public Barnsley Public


31 December 2016

a) Member, Labour Party b) Member, Penistone Town Council c) Chair, Penistone Grammar School

Foundation Trust d) Councillor, Barnsley MBC

01 January 2005

26 September 2005 May 2014

17 February 2016

e) Director, Berneslai Homes Limited April 2016

66 Mr Stephen Wragg Trust Chairman

01 January 2009) 3rd term to

31 December 2017i

a) Non Executive Director, Barnsley Premier Leisure Trading

b) Sole Director, Wragg Consulting Limited c) Labour Party, Member d) Director, 360 Engagement Ltd e) Governor, Darton College f) Chairman & Trustee, Barnsley Civic

7 January 2009 20 May 2010 29 June 2011

18 October 2011 12 December 2011 15 December 2011

17 February 2016

Next no: 114

i Subject to annual review/renewal

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COUNCIL OF GOVERNORS – AUGUST 2016 REF: CG/16/08/04

04

MINUTES OF A GENERAL MEETING OF THE COUNCIL OF GOVERNORS HELD ON 22ND JUNE 2016, 5.30PM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

Present: Ms K Armitage Public Governor, Barnsley Public Constituency Mrs P Buttling Public Governor, Barnsley Public Constituency Mr A Conway Staff Governor, Volunteers Mr A Dobell Public Governor, Barnsley Public Constituency

Mrs J Gaines Public Governor, Barnsley Public Constituency Mr A Grierson Public Governor, Barnsley Public Constituency

Mr B F Leabeater Public Governor, Barnsley Public Constituency Mr P Lleshi Partner Governor, Barnsley Together

Mr C Millington Partner Governor, Barnsley Clinical Commissioning Group Ms A Moody Public Governor, Barnsley Public Constituency Ms G Morritt Staff Governor, Nursing & Midwifery Mr H Patel Public Governor, Barnsley Public Constituency Cllr J Platts Partner Governor, Barnsley MBC Mr F Skorrow Public Governor, Barnsley Public Constituency Mr R Slater Public Governor, Barnsley Public Constituency Mr J Unsworth Lead & Public Governor, Barnsley Public Constituency Mr S Wragg Trust Chairman

In attendance: Ms J Dean Non Executive Director Ms C Dudley Secretary to the Board & Governors Dr R Jenkins Medical Director (attended to 6.15pm)

Mr R Kirton Director of Strategy & Business Development Mrs H McNair Director of Nursing & Quality Mr F Patton Non Executive Director Ms D Wake Chief Executive Mr M Wright Director of Finance

Apologies: Mr P Ardron Partner Governor, Sheffield Universities Ms J Bleasdale Co-opted Governor

Mr D Brannan Partner Governor, Voluntary Action Barnsley Ms G Cockerline Staff Governor, Non Clinical Support

Ms R Hewitt Staff Governor, Clinical Support Services Mr M Jackson Partner Governor, Joint Trade Unions Committee

Mr S Long Public Governor, Barnsley Public Constituency Mrs J O’Brien Public Governor, Barnsley Public Constituency Mr L Pryor Partner Governor, Barnsley College Mr R Raychaudhuri Staff Governor, Medical & Dental Mrs C Robb Public Governor, Barnsley Public Constituency Mr T Smith Public Governor, Barnsley Public Constituency Mr L Steenson Public Governor, Public Constituency O (out of area)

CG/16 34 APOLOGIES & WELCOME

The Chairman welcomed Governors and Directors to the meeting.

Action

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CoG Aug 16: Mins 05 2016/ page 2 of 8

CG/16 35 COMMENTS FROM THE PUBLIC None.

CG/16 36 DECLARATIONS OF INTEREST For good order the Chairman and Mr Patton declared their interests in the reports from the Nominations Committee (agenda items 10a and 10b respectively).

CG/16 37 MINUTES OF LAST MEETING (Enc 4)

The Minutes of the General Meeting held on 20th April 2016 were reviewed and accepted as a true record.

CG/16 38 MATTERS ARISING No matters were outstanding:

• Appointments to the Nominations Committee and Sub-Groups were detailed in the Chairman’s report.

• Governors’ comments on the Quality Account (per Minute 16/24) had been drafted and submitted to the Trust. In her report to the Committee (agenda item 9), the Chief Executive confirmed that the Quality Account was now complete.

• As agreed under Minute 16/31, the Integrated Performance Report had been revised; it now referred to “recorded medication incidents”.

CG/16 39 ROLE OF THE DIRECTOR OF NURSING & QUALITY Mrs McNair provided an overview of her role. She outlined the wide range covered within her directorate; as well as being the professional lead for nursing and midwifery her responsibilities included patient safety and quality, patient experience and complaints, volunteers and PALS (patient advice and liaison services), legal services and the chaplaincy. She highlighted how the diverse aspects were interlinked and helped to provide a holistic approach to safe, high quality services for patients. Mrs McNair also outlined the key challenges facing her directorate with pressures on staffing levels and recruitment difficulties in some specialties; increasing regulation on staffing, service requirements and increased reporting, and rising expectations nationally, internally and by patients. As a Director of the Board her remit was by no means limited to the specific issues listed above. Working together with the other Directors, she was also responsible for delivering the Trust’s business plan each year and planning for the future. Mrs McNair advised that she had joined the Trust in 2011 and continued to enjoy working in Barnsley, supporting staff and improving patients’ services. Mrs McNair responded to several questions from the Governors and was thanked for providing a helpful insight into her work.

CG/16 40 CHAIRMAN’S REPORT (Enc 9) The Chairman’s report was received and noted. It provided commentary and updates on a range of activities, items of interest and Board discussions since the last General Meeting.

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As requested, the Chairman shared some of the core messages from this year’s NHS Confederation Annual Conference. These included:

• potential risks to the NHS if the UK voted to leave the EU • the importance of managers building effective teams and treating people

– not conditions • the national Sustainability & Transformation Plan (STP); this would be

supported with local plans being developed by 44 regions across the country and would include all health organisations. Barnsley was part of the South Yorkshire & Bassetlaw footprint, the plan for which was required to be submitted by the end of June. Final plans would be subject to approval by the Boards and Governors in every region and were likely to include public consultation too. More information about the local plan would be shared with the Council of Governors as soon as possible. There would undoubtedly include some tough decisions for the Governors as well as the Board.

• information on “Devolution Manchester” • focus on IT developments across the NHS to support digitisation • continuing challenges around funding, with conflicting demands in the

health and social care sector Key note speakers had included the Secretary of State for Health, Chief Executives from NHS England and NHS Improvements, and the Medicaid Director from the State of New York. With a population of six million people and a budget of £60 billion, the State of New York had driven huge improvements in health and social care since 2010, targeting areas with the biggest social need. In response to a question from Mr Millington, the Chairman advised that the approach in New York had been based on an accountable care system, not as an accountable care organisation (ACO); the speaker had emphasised the need for society care and patient focus/ prioritisation although the work had been supported by a much larger budget per capita than was available to the NHS. Referring to other aspects of his report, the Chairman drew attention to the continuing support for the Hospital Charity, including the success of the recent Rainbow Dash. Sincere thanks were reiterated to everyone who had been involved with the event as a runner, sponsor or volunteer on the day. He was also pleased to report that the HEART Awards had also been very successful. It had been well attended and continued to be a valued opportunity to recognise the tremendous work of just a few of the Trust’s superb staff. Ms Sanderson’s resignation from the Council was noted and her reasons for stepping down were fully understood. The Council reiterated its thanks for her contribution and best wishes for the future. It was agreed that, as it was permissible under the Constitution, Ms Sanderson’s seat should be carried forward to the next annual elections. Governors were also pleased to learn that Ms Hewitt and her new baby son were doing well. On behalf of the Council of Governors, Mr Unsworth congratulated the Trust on its recent Award as one of the Top 40 Hospitals, presented from CHKS. As referenced earlier, two expressions of interest had been received for the Chairs of the Council’s sub-groups. Governors endorsed the Chairman’s recommendation to re-appoint Mr David Brannan and Mr Trevor Smith as Chairs of the Finance & Performance Sub-Group (FPSG) and Quality &

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Governance Sub-Group (QGSG) respectively. No applications had been received for the Deputy Chair roles and this would be taken forward by the Chairman and sub-group Chairs. Only one expression of interest had been received for the staff Governors’ seat on the Nominations Committee, from Mr Raychaudhuri. The Council was pleased to ratify the Chairman’s decision to re-appoint Mr Raychaudhuri to the Committee.

SW/

DB/TS

CG/16 41 LEAD GOVERNOR’S REPORT Mr Unsworth reported on:

• The HEART Awards which, as mentioned above, had been a very successful evening. The Governors’ Award had been presented to the team leading the Barnsley Babies Initiative, recognising the work of the specialist midwives and an excellent example of community working.

• The Volunteer Award initiative recently started by NHS Providers; it had been good to see Governors recognised within this.

• The Annual General & Public Members Meeting scheduled for 6th September 2016, at which the Board of Directors would present the Annual Report & Accounts to the Council of Governors. All Governors were asked to note this date in their diaries.

• The Constitution Review meeting – any Governors wishing to attend would be welcomed. Any issues for consideration in this year’s review would also be welcomed and should be submitted via the Secretary to the Board & Governors as soon as possible.

ALL

ALL

CG/16 42 CHIEF EXECUTIVE’S REPORT (Enc 9) Ms Wake expanded on her report, which provided news on a range of operational issues and invited questions and comments from the Council. Mr Millington referred to section 11.2, regarding the performance of the Yorkshire Ambulance Service (YAS). Ms Wake clarified that the data related to turnaround times at the hospital, based on metrics received through the Trust’s Director of Strategy & Business Development, Mr Kirton. Mr Kirton served as a partner Governor on YAS’s shadow Council of Governors. The data could not be validated as YAS performance figures were not easily accessible although Ms Wake was able to access further information during the meeting, which showed 74.1% of red calls responded to in 8 minutes and 95% of all calls in less than 14.5 minutes, reflecting an improvement on historic reports. Councillor Platts advised that the Chair of the Clinical Commissioning Group (CCG) had previously confirmed that the CCG received some statistics and had offered to share them at the Health & Wellbeing Board but this had not yet been actioned. The Chairman and Ms Wake undertook to see if more information could be obtained. Mr Unsworth highlighted the good news in section 14: the HSJ Award to the RightCare Barnsley team (a joint service across the CCG, BHNFT and South West Yorkshire Partnership NHSFT) and shortlisting of the Trust’s Procurement Team for an HSJ Award too. The Chairman advised that the Midwifery Team had also been nominated. The Council agreed that it was encouraging to see increasing recognition of the Trust’s good work. It was noted that, where practicable, Awards were displayed in the winning team’s area or at Trust HQ.

SW/DW

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CG/16 43 NOMINATIONS COMMITTEE (Enc 10a-b – tabled) a) Non Executive Directors’ (NEDs) Year End Review

Mr Patton left the meeting during discussion of this item. On behalf of the Nominations Committee, the Chairman confirmed that the year end performance review of the NEDs had been carried out in line with Monitor’s (NHS Improvements/NHSI) guidance, as stated in the report. Several Governors had contributed to the review and the Chairman had appreciated their input. The internally managed 360 reviews had not been completed due to technical issues but were ongoing; the Nominations Committee had agreed that the overall process had been sufficiently robust without 360s at this stage. The Council of Governors agreed with this approach and also agreed that yearly 360 reviews were not essential and could be unnecessarily onerous; the 360s should be carried out every three years in future. Ms Dean had been excluded from the formal review process as she had only started in January 2016. Nonetheless the Chairman had met with her informally and her good progress to date had been noted. The Nominations Committee had endorsed the Chairman’s view that the NEDs had been working effectively throughout the year, collectively bringing a range of skills to the Board. It was also agreed that each member of the team had made good progress against their objectives. The increased engagement with Governors had been effective with the NEDs providing more support to the Council and making themselves more directly accessible to be held to account by the Governors. The Governors had appreciated the increased engagement with the NEDs and looked forward to continued close working with the team. The Chairman expanded on the strengths and development needs of each NED as noted in the report. The need to increase local knowledge among the NED team had been highlighted; the Chairman was the only locally-based NED and he stressed that this was something the Governors would need to be mindful of for the future. He would continue to ensure local intelligence and relevant data was shared as much as possible. The review was approved and Governors agreed that the NEDs’ objectives for 2016/17 should flow through from the Chairman’s objectives when approved, as in previous years. The Chairman stepped out of the meeting at this juncture. Mr Patton re-joined the meeting and, as Deputy Chair and Senior Independent Director (SID), assumed the Chair.

b) Chairman’s year end review As agreed previously, the Chairman’s review had been led jointly by Mr Patton, as SID, and Mr Unsworth, Lead Governor, with support from the Nominations Committee and in accordance with the Regulator’s guidance. Input had been received from several Governors in addition to those on the Nominations Committee, the NEDs and the Executive Team (ET). The increased input from Governors had been greatly appreciated. The Chairman’s 360 had not yet been completed but would be taken forward, as agreed for the NEDs. In response to an enquiry from Mr Skorrow, Mr Patton provided more information about 360s and the background to the Trust’s use over the past few years.

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Mr Patton expanded on the Directors’ feedback gained against each of the key aspects scrutinised as part of the review. Overall feedback was positive. The Chairman continued to perform well generally; he was hugely committed to the hospital, with a very strong patient focus and strong personal values. His focus on areas for personal development was ongoing and progress was shared regularly with the SID, as noted in the report. Ms Wake added that she enjoyed working with Mr Wragg as Chairman; they worked well together and were able to exchange feedback and comments on one another’s work frankly: this was a valuable tool in their working relationship and leadership of the Trust. Mr Unsworth affirmed that feedback from the Governors largely reflected the NEDs and ET’s views, with two Governors feedback forms rating the Chairman’s performance as exemplary and input received from emails and telephone calls also reflecting high scores. Scope for development had been recognised, as noted by the NEDs and ET. He drew attention to the two dissenting responses received: one feedback form had related largely to process issues rather than the Chairman’s performance. As stated earlier, however, the process was laid down by national guidance; Mr Patton advised that it also reflected common practice in other industries. The other response form had not been fully completed and it was unclear whether the respondent might have misinterpreted the scoring system. The Chairman’s good progress against his objectives for 2015/16 was reviewed and noted. The Governors agreed with the recommendation presented from the Nominations Committee that, to build on progress to date, four should be rolled forward to form the basis of the Chairman’s objectives for 2016/17. Governors were reminded that the Chairman’s current term of office was subject to annual renewal to 31st December 2017, dependent upon his continued satisfactory performance, which had again been endorsed for the year. Whilst conscious that any further reappointment of Mr Wragg beyond his current term of office rested with the Council of Governors, Mr Patton advised that the NEDs would urge Governors to start thinking about succession planning as soon as possible rather than leaving it until 2017. The NEDs also believed it important that the appointment process should be via open competition to avoid any criticism, particularly (i) in view of the lifting of the cap with regard to overall duration of service and (ii) as, for very valid reasons, the last re-appointment of the Chairman after six years’ service had not been open to external candidates. Mr Patton stressed that Mr Wragg would be eligible to apply but open appointment would be the most equitable approach. Ms Wake also supported this approach for transparency and in accord with external reviews. The Council of Governors appreciated their advice and would take it into account. Several aspects of the report and additional information received at the meeting were expanded upon in discussion. In conclusion the Council of Governors:

• received the report and endorsed the overall outcomes for the year end review for the Chairman,

• approved the proposed objectives for the Chairman for 2016/17, and

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• recorded a note of sincere thanks to the increased number of Governors who had contributed to the Chairman’s appraisal; their input was appreciated.

The Chairman re-joined the meeting and resumed the Chair.

CG/16 44 SUB-GROUP REPORTS (Enc 12) The submitted report provided by Mr Brannan, for FPSG, and Mr Smith, for QGSG, was received. Progress from the sub-groups’ meetings held in May and June respectively were noted. In particular it was noted that the QGSG had completed the response to the Trust’s draft Quality Account on behalf of the Council of Governors, as mandated by the Council in April. As requested by the Council of Governors at the last General Meeting, the FPSG had undertaken a review of the sub-groups’ Terms of Reference and the protocols for appointment of the Lead & Deputy Lead Governors. Minor changes had been proposed (per section 4.6) and were approved. Governors were reminded of next meeting dates for FPSG and QGSG, both of which were open to all Governors.

CG/16 45 BOARD OF DIRECTORS (Enc 14) The agenda (June), Minutes (May) and latest Integrated Performance (IPR) and Horizon Scanning reports presented to the Board of Directors meeting held in public in June 2016, were received and noted. Governors were reminded that questions on any of the Board’s papers were welcomed at any time and key issues from the IPR continued to be reviewed regularly at sub-group meetings. Ms Wake also provided a further update on performance of the <4 hours emergency access target. Pressures continued but the Trust was currently one of the best performers in the country. Progress against the phased return to compliance for May and June had been above target albeit the quarter 1 outcome was likely to be just below the 95% overall target. Ms Wake was hopeful that the revised systems and additional recruitment for middle grade doctors in the Emergency Department would help sustain performance throughout the year. Mr Dobell congratulated the teams involved on the good progress to date. With reference to the Horizon Scanner, Mr Patel noted the negative feedback reproduced from the NHS Choices comments. Ms Wake advised that the report’s author, the Director of Marketing & Communications tried to ensure it gave a balanced picture, not just focusing on the positive feedback although that was very much in the majority. She assured Governors that the Trust tried to track and respond to all comments posted on the website and took action to identify and investigate any aspects of concern. Mr Dobell commented that this approach was also reflected in the Patients’ stories reported at Board. Ms Wake stressed the importance of ensuring the Board received a balance of stories – not just the good ones all the time. It was important that the Trust looked at where things had gone wrong, identified and acted upon any learning for the organisation and was able to demonstrate this to the Board. The Chairman advised that the stories were also used to set the tone for the Board’s meetings, reminding Directors to keep patients at the centre of every discussion.

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CG/16 46 ISSUES RAISED BY GOVERNORS Issues raised in the Governors’ pre-meeting had been covered in earlier discussions. Mrs Buttling enquired if any actions had been put in place in anticipation of the impact of the impending EU Referendum. The Chairman advised that this had not been possible in the NHS as the outcome of the referendum could not be prejudged.

CG/16 47 ANY OTHER BUSINESS None. At this juncture IT WAS RESOLVED THAT representatives of the press and other members of the public be excluded from the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with 8.13.2 and 8.13.3 of the Trust’s Constitution.

CG/16 48 EXTERNAL AUDITORS (Presentation) As Director of Finance and on behalf of the Chair of the Audit Committee, Mr Wright presented the recommendations of the Audit Committee to appoint Grant Thornton as the Trust’s External Auditors with effect from August 2016. Subject to the Council’s approval, the contract would be offered on a three years basis, with an option for extension. Mr Wright outlined the work undertaken to ensure a robust procurement process. This had been led by an evaluation panel, which comprised two Audit Committee Members, the Director of Finance and other key personnel from the Trust’s finance team, the interim Head of Procurement and Mr Dobell, Audit Liaison Governor. The Panel had also been supported by a second Public Governor, Ms Moody, to ensure continued Governor input throughout the process. Mr Wright explained the rating system and criteria used to assess both quality and pricing of the bids received, against which Grant Thornton had been identified as the preferred bidder. The proposal to appoint Grant Thornton had been formally reviewed and endorsed by the Audit Committee, before being presented to the Council Mr Dobell and Ms Moody confirmed their full support for the process and the recommendation presented by the Audit Committee. The recommendation to appoint Grant Thornton as the Trust’s external auditors on the basis outlined was unanimously approved. The appointment had been discussed in private session as it would be subject to final contractual arrangements to be concluded in the next 10-15 days. The timings would, however, enable the Minutes to be reported publically.

CG/16 49 CLOSE OF MEETING The date of the next General Meeting was confirmed: Wednesday 17th

August 2016, 5.30-7.30pm There being no further business, the meeting closed at 7.30pm.

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REF: CG/16/08/06

CoG Aug 2016: QA

06

QUALITY REPORT 2015/16

1. INTRODUCTION

1.1. In accordance with Department of Health requirements and Monitor’s (NHS Improvement / NHSI) Foundation Trust Annual Reporting Manual for 2015/16 (the “ARM”), all Trusts are required to provide a report on the quality of care they provide within their annual report.

1.2. NHSI guidance also requires Foundation Trusts (FTs) to include a limited assurance report from the external auditors on the content of the quality report and certain mandated indicators. The limited assurance report gives the auditors’ view on whether anything has come to their attention that leads them to believe that the content of the quality report has not been prepared in line with the guidance or is consistent with other referenced information sources.

2. OUTCOMES

2.1. Barnsley Hospital’s latest quality report and the auditors’ limited assurance report are both included within the Annual Report & Accounts 2015/16, copies of which have been provided to Governors under separate cover. The Annual Report & Accounts will be presented formally to Governors and members at the Trust’s Annual General & Annual Public Members meeting to be held on 6th September 2016 and will be available on the Trust’s website thereafter.

2.2. As usual the external auditors, Pricewaterhouse Coopers (PWC), have also prepared a more detailed report (copies provided separately for Governors). Additionally, senior representation from PWC will be attending our General Meeting to expand on the report, provide further information and welcome any questions or comments from Governors.

3. RECOMMENDATION

The Council of Governors is asked to receive the attached report and further information to be provided by Pricewaterhouse Coopers at the meeting.

Stephen Wragg CHAIRMAN August 2016

Pack pg no 15


07

QUARTERLY MEMBERSHIP UPDATE REPORT

1. OVERVIEW 1.1. This report provides Barnsley Hospital NHS Foundation Trust Council of Governors with

an update on the Trust’s membership and summarises the work underway to secure membership to ensure that it is representative of those eligible to be members. It also highlights what has been happening across the Trust since the last report and forthcoming activities.

1.2. An earlier draft of this report was was reviewed and supported at the Finance & Performance Sub-Group (FPSG) meeting held on 13th July.

1.3. The work outlined is intended to support the Council of Governors with delivery of the Governors’ Strategy, which was also reviewed at the FPSG meeting in July.

2. MEMBERSHIP MANAGEMENT 2.1. The post of Membership Officer ended on 10 February 2015 and a new member of

staff, Chloe Wake, has now been appointed as Communications and membership Assistant. Chloe commenced in post on 20 June 2016 and will play a role in supporting membership communications for the Trust.

2.2. Membership, recruitment of new members and communicating with Trust members will be supported in the following ways in 2016/17:

• Keeping you informed: The reintroduction of quarterly Governor Updates on the area of membership communications with the outcome of building a good relationship with the Governors and engaging them in membership communications.

• New ways of communicating with members: To explore the potential that social media can bring to the membership, including researching other Trust’s social media activities and creation of a member Twitter handle, Facebook page, promotion to members and promotion of key messages as a way to engage our membership.

• E-communications for members: To undertake an analysis of email addresses within the database, to inform a campaign to generate email address collection in order to ensure a more cost-effective, timely and planned method of communicating with our membership, including creation of a regular e-communication about the Trust to members.

• Raising the membership profile: To create promotional material to raise the profile of membership information across the hospital site. To target key areas in the hospital where promotions can be clearly viewed by the public and staff. Increasing the membership awareness and information across the site.

• Engagement of members: To create a calendar of join the conversation style membership events. Encouraging members to engage in service design and other matters, including Governors at such events.

Pack pg no 16

• Creating events: To plan and manage the production of the Trust’s Annual General& Public Members meeting on 6 September 2016, in the form of a summer fete formembers, the formal AGM and the first join the conversation for members.

3. QUARTERLY MEMBERSHIP SUMMARY3.1. Total Members July 2016

The table below shows the total number of members for July 2016

Constituency Members Non-members

Affiliate members

Invalid Non-

members

Total % of Total

Population

Public 8,442 0 0 0 8,442 70 Staff 3,537 0 0 0 3,537 30 Total 11,979 0 0 0 11,979 222,861

3.2. Quarterly (July 2016) Membership Analysis

The table below provides analysis of actual membership, compared against the eligible membership for age, ethnicity, gender and socio-economic groupings.

Public constituency Number of members Population Ages(Years)

0-16 02 8,521

17-21 62 12,184

22+ 8,361 202,156

Ethnicity

White 8,066 218,148

Mixed 15 1,571

Asian 66 1,589

Black 20 1,145

Other 8 408

Socio-economic Groupings

AB - upper/middle class 399 23,741

C1 - lower middle class 3,090 38,724

C2 - skilled working class 1,342 32,287

DE – working/casual class 3,449 72,347

Gender Analysis

Female 3,178 110,761

Male 5,249 112,100

Pack pg no 17

4. RECOMMENDATIONS

The Council of Governors is recommended to receive and note ths report.

Chloe Wake MEMBERSHIP AND COMMUNICATIONS ASSISTANT August 2016

Pack pg no 18

CoG Aug 2016: Constitution


REF: CG/16/08/08

REVIEW OF CONSTITUTION

1. INTRODUCTION 1.1. The Trust’s Constitution is subject to review annually. It was last revised in 2013

and again in 2015: 1.1.1. In 2013 extensive changes were made to reflect new requirements under

the Health & Social Care Act 2012 (amending the National Health Service Act 2006 – the NHS Act), closer alignment with the Model Constitution, changes in the local economy (including abolition of Primary Care Trusts and establishment of Clinical Care Commissioning Groups), the merging of the five ward-based Constituencies across the community into one Barnsley Public Constituency, and reduction in the size of the Council from 35 to 29 Governors.

1.1.2. In 2015 the changes updated our election rules, removed reference to the “initial Chief Executive”, and ensured that the Fit & Proper Person Requirements for Directors were embedded into the Constitution. The latter were also added into the Code of Conduct for Governors.

1.2. Governors are reminded that all proposed changes are subject to approval of more than half of the Governors present and voting at a General Meeting and more than half of the Board of Directors voting, in accordance with the NHS Act (Section 37). If any amendments proposed would affect the powers and duties of the Council of Governors, they would require further approval by the FT’s membership at the next Annual Members Meeting.

1.3. Once approved by the Governors and Board of Directors, any changes will come into immediate effect.

1.4. Approval by NHS Improvements (NHSI), the regulator, is no longer a requirement but FTs are required to provide to NHSI “copies of any document establishing or amending its constitution within 28 days of being adopted” (Condition FT1, under section 6 of the Provider Licence).

2. REVIEW PROCESS

2.1 At the last General Meeting, any issues for review were invited. An open invitation was also extended for any Governors and Directors who wished to be involved with the review working group.

2.2 The review working group comprised the Chairman, Lead Governor, three public Governors - Mr Dobell, Mr Grierson and Mr Smith (Deputy Lead Governor) - and one partner Governor, Mr Brannan. The group was supported by the Secretary to the Board & Governors, Carol Dudley.

2.3 Only one issue was raised for review. 2.4 The working group met on 3rd August.

08

Pack pg no 19


3. PROPOSED CHANGE3.1 Since August 2013, Mr Paul Ardron has served as the Partner Governor for the

Sheffield Universities – ie Sheffield Hallam University (SHU) and The University of Sheffield jointly. This shared seat was a result of changes to the composition of the Council in 2013, when public governors were reduced from 20 to 16 and partner governors from nine to seven. Staff governor numbers were unchanged. Overall the size of the Council was reduced from 35 to 29 Governors to make it more manageable.

3.2 Mr Ardron is employed by SHU. He expressed concerns to me, as Chairman, that he had not been able to represent both Universities equally or provide feedback to the University of Sheffield in the same way as he did for SHU. He asked if it would be possible to revert to the previous position, when both Universities had a seat on the Council.

3.3 Everyone on the review group accepted Mr Ardron’s feedback as a valid and objective comment.

3.4 The individual seats for the two Universities had worked well in the past. Longer serving Governors will remember the valued input from previous postholders from both Universities, including Professor Bax for the University of Sheffield. The Trust works closely with both Universities to support the training and recruitment of high quality medical and nursing staff and values its relationship with both Universities equally.

3.5 SHU and the University of Sheffield were made aware that the Trust planned to revisit this option. They both supported an extension to Mr Ardron’s appointment as joint Partner Governor until 31st December 2016, whilst the review was undertaken.

3.6 In accordance with the NHS Act, elected public Governors must always hold a majority on the Council of Governors. This is reflected in the current Constitution and composition of the Council:

• 16 public governors (15 from Barnsley Constituency and 1 from Out of Area)

• 6 staff governors

• 7 partner organisations3.6 To provide an additional seat to accommodate both Universities, there are two

options: a) remove one of the existing partner organisations, to accommodate a second

seat for the Universities– the review group was reluctant to identify any of the current partner

organisations for removal as all make a valued contributionb) increase the number of partner and public governors by one seat each, to

maintain the ratio, ie 17 public governors (an additional seat in the BarnsleyPublic Constituency), six staff governors and eight partner governors(including two seats for the Sheffield Universities)– this offers a practical solution without making the Council too unwieldy.

3.7 Option b would enable the two Universities to each have a seat as Partner Governors, increasing the Council to 31 but retaining a majority of three elected public Governors (17 public:14 other governors). This is the preferred option proposed by the working group for the Council and Board’s consideration.

Pack pg no 20


3.8 If the option is approved in time the additional seat in the Barnsley Public Constituency will be added to the annual elections, for appointment from 1st January 2017.

4. RECOMMENDATIONS4.1 It is recommended that the Council of Governors considers and endorses

the proposal to: i) offer a seat on the Council of Governors to each of the Sheffield

Universities (Sheffield Hallam University and the University of Sheffield), and

ii) increase the number of elected public Governors from 16 to 17, withan additional seat to be provided in the Barnsley Public Constituency

4.2 Subject to the Council’s approval of 4.1, it is recommended that the same proposal is presented to the Board of Governors at its meeting on 1st September 2016.


Pack pg no 21


CoG June 16: Chairman’s Report (p1)

10

CHAIRMAN’S REPORT

1. INTRODUCTION

1.1 This report is intended to give a brief outline of some of the work and activitiesundertaken as Trust Chairman since the last General Meeting and highlight a number of items of interest.

1.2 The items reported are not shown in any order of priority.

2. TRUST POSITION2.1 Our financial position continues to be an issue that we are addressing, along with

almost every other provider in the NHS, however the early indicators for this year reflect the improvements we have made. There are caveats as 2016/17 brings more challenges and more pressure from the centre to reduce the overall deficit. We must continue to make real progress with our deficit so we can contribute to the overall NHS savings. Our continued record on patient safety will give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and we will continue to turn this current situation around. I will keep reiterating this message as I think it should be constantly in people’s minds. Whilst we are bringing about our return to stability, we will not compromise on quality of care and patient safety.

2.2 We must also continue to give confidence to our staff that the Trust is doing everything it can to improve patient experience and the quality of care our patients receive. In addition we continue to pay tribute to all our staff for their valued work and their efforts to conceive new ideas to deliver better care.

2.3 We must also be conscious of the continuing pressures on the hospital, including activity and cost improvement plans. It has become more difficult to ensure we keep on track to return to financial balance whilst protecting the quality of our services for our patients and meaningful staff engagement.

3. COUNCIL OF GOVERNORS3.1 I am pleased to advise that shortly after the last General Meeting, Mr Tony Dobell,

Public Governor, expressed his interest in standing as Vice-Chair for either or both of the Governors’ sub-groups. The Sub-Group Chairs and I were very pleased to accept and endorse Tony’s application.

3.2 The first 1-to-1 meetings with Governors were fully booked in July and I hope the participants found them useful, I know I did. Looking ahead, the September slots are fully booked but there are still spaces available for the morning of 30th August if anyone would like to book in, and later in the year. I should stress again that these are not intended to be formal review meetings but are an opportunity to discuss your performance and development and to ensure that each of you, as Governors, feels supported and valued. All Governors are encouraged to take up an appointment slot with me at least once a year.

3.3 Dates for this year’s ‘behind the scenes’ visits are still awaited. The Secretary to the Board & Governors, Carol Dudley, will finalise these after the summer holidays.

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CoG Aug 16: Chairman’s Report (p2)

3.4 I was pleased to be shadowed by Public Governor Steve Long, for half a day in July, which I hope he found of interest.

3.5 As agreed at the last General Meeting, a small group of Governors and I met earlier this month to commence the annual review of the Constitution. The outcomes are reported separately, under agenda item 8.

3.6 The Governors’ Strategy has also been subject to review recently; the report from the Sub-groups will provide more information on this (see agenda item 14).

3.7 Looking ahead, please ensure the Annual General & Public Members Meeting (AGPM) is in your diaries for 6th September 2016 – starting at 9am, in the Trust’s Education Centre. The Annual Report & Accounts for 2015/16 will be formally presented to the Governors at this meeting.

3.8 The Trust is planning to build on the AGPM meeting this year to make the most of the day. The AGPM will be followed by a public engagement event at 11.30am and by a summer fete after that. If Governors would like to book a stand at the Fete, please let me know.

3.9 The dates for this year’s elections have been finalised – running from Notice of Election on 6th October to Close of Poll on 8th December 2016. Information workshops are scheduled for 11th October (two sessions: 10.30am and 12.30pm) and 25th October (5.30pm). These have proved very useful in the past for people who would like to know a bit more about the role before putting themselves forward for election. Please share the dates with any friends or colleagues who might be interested in seeking election this year. As usual we will be going to election for up to a third of public seats (involving both public constituencies this year – Barnsley and out of area) and two seats in the staff constituencies (one each in Clinical Support and Nursing & Midwifery). More information will be issued before the process starts.

4. NEWS & EVENTS4.10 On 9th July I took part, with a number of staff and volunteers in the Mayor’s Parade,

promoting both the charity and the Zombie Run. We raised over £200 by collecting on the day.

4.11 On 13th July I attended the Accountable Care Organisation shadow board on behalf of the Trust.

4.12 On 29th July, the CEO and I met with two of our local MPs to keep them informed of the work the Trust is doing and how we are meeting the challenges presented to us.

4.13 On the same day I also joined colleagues to say goodbye to Tracey Helliwell, our Learning & Disability Nurse. Tracey left the Trust after 31 years of valued service; she went with our sincere thanks and best wishes for her continued success in the future.

4.14 31st July saw me attend Higham Methodist Church to receive a cheque donated from the Church activities to our charity.

5. BARNSLEY HOSPITAL CHARITY5.1 The generosity of local people and the support for our Charity continues to grow.

These are the latest figures for this financial year up to the latest balance at the time of writing.

5.2 A point to record here is that the incubator in reception has so far raised a massive £20,000. Please note this figure, these are very difficult times for everyone but this shows that people are very generous when they understand how they can help others less fortunate than themselves.

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CoG Aug 16: Chairman’s Report (p3)

5.3 Donations £83,093.82 Legacies - Other Income - Tiny Hearts £211,086.96

6. RECOMMENDATIONS The Governors are asked to: a) receive and note this report b) endorse the appointment of Mr Tony Dobell as Vice-Chair for the Sub-Groups.


Pack pg no 24


REF: CG/16/08/11

CoG 04 2016 / Lead Gov

11

LEAD GOVERNOR’S REPORT

1. INTRODUCTION & OVERVIEW

This is a brief report highlighting a few matters of interest since the last General Meeting.

2. NON EXECUTIVE DIRECTORS 2.1 I am sure all Governors will join with me in congratulating Mrs Suzy Brain England on

her appointment as Chair of Doncaster and Bassetlaw NHS Foundation Trust (DBH). Suzy has become well known to Governors and we will miss her input to the Board, although we do of course, wish her continuing success in her new role. Suzy’s start date at DBH has not yet been confirmed but will be by 1st January 2017 at the latest.

2.2 The Council of Governors thus has to appoint a Non-Executive Director (NED) to replace Suzy from the start of next year, in addition to the post arising from Francis Patton’s current term as NED finishing at the end of the year.

2.3 The Nominations Committee met on 14th July to consider the NED appointments and a report from the Nominations Committee is on the Council of Governors’ agenda. As advised to Governors before being issued, advertisements for NED posts have been published.

3. MEETINGS ATTENDED BY LEAD GOVERNOR 3.1 The Governors’ training session on 20th July, led by Theresa Rastall, Head of Learning

& Organisational Development, was on effective meetings and questioning skills. There were about a dozen governors present and the presentation stimulated a good deal of discussion.

3.2 A mix of partner and public governors attended the constitution review meeting with the Chairman on 3rd August and the recommendations are a Council of Governors’ agenda item.

3.3 Board of Directors As a result of other commitments it has been some time since I have been able to see a Board of Directors’ meeting held in public, but I was able to get to the Board meeting on 4th August. One other governor, Annie Moody, also came to observe the meeting. The patient story at the start of this meeting was a particularly good one, showing examples of very good care, along with areas where improvements were needed and have since been made. Two other people in the public seats of this meeting were potential NED applicants, which was encouraging. For Governors who have not observed a Board meeting I strongly recommend they try to get to see one. In addition, the Board meeting on 3rd November is our annual joint meeting of the Board with the Council of Governors, so please attend if at all possible.

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CoG Aug 2016 / Lead Gov (p2 of 2)

3.4 I attended the sub-group meetings held in July and August, the first of which included a review of the Governors’ Strategy. Whilst the changes were not significant, it is important that this is reviewed regularly and that we remind ourselves of the aims therein. Further information on this year’s review will be provided in the sub-groups’ report (see separate agenda item).

4. LOOKING AHEAD 4.1 The immediate important date for your diary is, of course, the Annual General

Meeting/Annual Public Members’ Meeting (AGPM) at 9am on 6th September. 4.2 As the full title of the meeting implies, this meeting is a combination of two statutory

meetings. The Trust is required to present the annual report and accounts to an Annual General Meeting of the Council of Governors. The same documents must also be presented to an Annual Members Meeting. The legislation, and our Constitution, permits these two meetings to be combined, and Barnsley Hospital, in common with most Foundation Trusts, sensibly does just that. Both Governors and members of the Trust can ask questions on the annual report and accounts at this meeting.

4.3 You will have seen the email announcing that a summer fete is to be held at the hospital after the AGPM, so we hope for a fine day.

4.4 The next issue of Barnsley Hospital News will be published later this month so that it is out in time for the AGPM. We need Governor input into each issue, As usual I have written a Governor Update feature. If you have any item of governor news for this or any future issue of the hospital newsletter please contact either me, or Erin Brady or Tanya Oates in the Communications team.

5. RECOMMENDATION

The Council of Governors is recommended to receive this report

J Unsworth LEAD GOVERNOR August 2016

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REF: CG/16/08/12

12

CHIEF EXECUTIVE’S REPORT

1. INTRODUCTION 1.1 This report is intended to give a brief outline of some of the key activities undertaken

as Chief Executive since the last report and highlight a number of items of interest. 1.2 The items below are not reported in any order of priority.

2. NHS ANNUAL CONFEDERATION CONFERENCE 2016 – 15-17 JUNE 2.1 This year’s Confederation was attended by Stephen Wragg, Chairman; Diane Wake,

Chief Executive; Karen Kelly, Director of Operations and Bob Kirton, Director of Strategy and Business Development. The conference was held over three days in Manchester and key speakers included, Stephen Dalton, Interim Chief Executive of the NHS Confederation, the Right Honourable Jeremy Hunt MP, Secretary of State for Health and Jim Mackey, Chief Executive of NHS Improvement.

3. CLINICAL TEACHING AWARD

3.1 Dr Abuzeid Eltrafi has been awarded the Clinical Teaching Awards for the third year in succession. He was voted for by the Medical School, University of Sheffield.

3.2 The awards recognises clinical teachers who have provided teaching of the highest quality within a clinical setting over a sustained period, inspire and support students by engaging closely with them and being an excellent role model, enable students to feel part of their clinical team and allow other members of their team to help with their development and create an environment in which students feel empowered to engage with clinical medicine. Dr Eltrafi’s passion for education is evident in all of his hard work.

4. SUSTAINABLE TRANSFORMATION PROGRAMME UPDATES 4.1 The STP for South Yorkshire and Bassetlaw was reviewed in draft prior to the

submission date of 30th June 2016, at the STP meeting held on 27th June 2016 4.2 The draft plan will also be presented to NHS England for South Yorkshire and

Bassetlaw and then to the Chief Executive of NHS Improvement, Jim McKay and the Chief Executive of NHS England, Simon Stevens.

4.3 Feedback from these meetings will be incorporated into the STP plan. Sir Andrew Cash will present the plan at both meetings with the support of a team comprising of provider Chief Executives, Accountable Officers, and Local Authority Chief Executives.

4.4 The Council of Governors will be kept up to date with developments in this key area. 4.5 A number of Directors attended a local STP workshop on 13th June to agree priorities

and actions going forward. 4.6 The current agreed priorities are:

• increasing healthy life expectancy • changing our relationship with communities

Pack pg no 27

CoG August 16: CEO (p2)

• changing our relationship with individuals • improving mental health • improving support for older people, how we work together (cross cutting theme).

4.7 It was agreed that further actions based around these priorities would be developed at a future workshop.

5. ASSOCIATE DIRECTOR OF HUMAN RESOURCES APPOINTMENT 5.1 Interviews for this key post were held on 28th June 2016. No appointment was made. 5.2 The position will be re-advertised in the next seven days with a revised title of Director

of Human Resources and Organisational Development. This will attract a higher calibre field to support the Board and Executive Team.

6. VISIT FROM PROFESSOR ABERCROMBE 6TH JUNE 2016 6.1 As part of the national ‘Get it Right first Time’ initiative, Professor Abercrombie visited

the Trust and met with general surgical consultants supported by Clinical Business Unit (CBU) senior management and members of the Executive Team. Benchmarking data was presented and discussed.

6.2 In many areas the Trust benchmarked well and there were no areas of risk. The discussion identified a range of areas for further development, such as implementation of a laparotomy care bundle, which will be led by Mr Stephen Mitchell as Clinical Director for CBU 2.

7. BOARD TO BOARD WITH MID YORKSHIRE HOSPITALS TRUST 7.1 This was a productive session for the Board where opportunities were explored to

work together further in areas requiring and benefitting from dual collaboration. 7.2 Further meetings have been scheduled throughout the year.

8. QUARTER 1 (Q1) GOVERNANCE REPORT TO NHS IMPROVEMENTS

8.1 As reported to the Board of Directors earlier this month, the Quarter 1 (Q1) governance report was submitted to NHS Improvements. Whilst compliant in most areas, three breaches were recorded:

• Cancer 62 days (below average in May but achieved compliance in June) • Breast symptomatic (not met in Q1 but compliance achieved in Q2 to date) • <4 hours emergency access target, marginally below for the quarter but achieved

phased targets for each month (exceeded for months 2 and 3, ie May and June)

Diane Wake CHIEF EXECUTIVE August 2016

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COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/16/08/13a

13a

REPORT OF THE NOMINATIONS COMMITTEE - ANNUAL REVIEW OF THE TERMS AND CONDITIONS OF SERVICE

FOR THE NON-EXECUTIVE DIRECTORS AND CHAIRMAN

1. INTRODUCTION1.1. In accordance with the Chairman and Non Executive Directors’ (NEDs) service

agreements, the Council of Governors is required to undertake an annual review of their Terms and Conditions of Service to ensure they are remunerated fairly.

1.2. This work is led by the Nominations Committee on behalf of the Governors. 1.3. With reference to national guidance (issued by Monitor, now operating as NHS

Improvements/NHSI), market testing of pay levels needs only to be carried out “at least once every three years” (Your statutory duties: a reference guide for NHS foundation trust governors – Monitor, August 2013, updated).

1.4. The guidance also requires that any considerations must take account of a range of factors beyond comparable rates, for example economic climate, market conditions, changes in roles and responsibilities.

1.5. Market data provided for the Committee’s consideration was sourced from NHS Providers’ Salary survey 2015 and local trusts’ annual reports. The NHS Foundation Trust Board Remuneration Report March 2015 issued by Capita was also taken into account. Additionally the Committee noted the outcome of the NHS Pay Review – Pay circular (AfC) 1/2016, namely a 1% pay uplift effective 1 April 2016

1.6. At the last review in 2015, the Chairman and Non-Executive Directors’ remuneration was uplifted to:

• Non-Executive Directors £12,120 pa• Chairman £40,400 pa

1.7. The Committee received HR support throughout its considerations.

2. 2016 REVIEW2.1. Current remuneration levels are towards the lower end of the average for Chairs of

comparable FTs in the region, with rates ranging from £39,875 (mean) to £42,500 (median).

2.2. NEDs remunerations are similarly placed with FTs across the region paying between £13,250 to £20,000. Non-FT rates range from £5,000 to £10,000.

2.3. Remuneration levels nationally are much more variable, with some NED rates nearer to £20,000 and Chairs over £60,000.

2.4. The Committee also took account of current pressures on the Trust, the local community and the wider NHS, and the growing demands on the role of members of the NED team at Barnsley Hospital (BHNFT). The Committee was conscious too that some FTs offer enhanced payments for specific roles within NED teams, such as Committee Chairs.

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CoG Aug 2016: 13a_NomCom T&C review

2.5. The Committee was also mindful of the impact of a freeze, which could see an unwelcome gap creeping in between BHNFT and peer Trusts as had been the case previously. This could make the Trust less attractive for the calibre of Directors that we require and it took quite a while to redress in the past.

2.6. It was acknowledged that none of the individuals currently appointed to the NED team at BHNFT is motivated to fulfil this important role primarily for monetary gain, rather each has a clear commitment to driving improvements for the Trust’s patients and staff.

2.7. The Committee also reviewed the wider terms and conditions of service for the Chairman and NEDs, currently requiring a time commitment of three days per week for the Chairman and five days per month for the NEDs. These timings seem to be reasonable albeit it is acknowledged that the Chairman and NEDs will – and do – work above their contractual requirement where required.

2.8. No other issues were considered for review.

3. OUTCOMES 3.1. Remuneration

To reflect market forces, recognise the value of our NED team and avoid the risk of a growing disparity in remuneration for our NED team, the Committee agreed that a 1% uplift in line with the NHS Pay review would be reasonable and should be proposed for consideration by the wider Council of Governors. The Committee did not, however, agree that any enhanced payments should be offered for additional duties, as one would expect applicants to anticipate taking on such responsibilities as part of the role of a NED.

3.2. If agreed a 1% uplift would equate to:

• Non-Executive Directors £12,120 pa increased to £12,241.20 • Chairman £40,400 pa increased to £40,804.00

3.3. Time commitment No changes were proposed.

4. RECOMMENDATION The Council of Governors is asked to: a) consider the information provided above b) approve the recommendation to make a 1% uplift for the Non Executive

Directors and Chairman’s remuneration, effective from 1st April 2016 Joe Unsworth LEAD GOVERNOR For and on behalf of the Nominations Committee, August 2106

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REF: CoG/16/08/13b

CoG Aug 2016: NED appointments / p1

NON EXECUTIVE DIRECTOR APPOINTMENTS PROCESS

1. INTRODUCTION AND RECRUITMENT TIMETABLE 1.1. As reported previously, the Nominations Committee commenced work in April to

consider Non Executive Director (NED) appointments due for appointment/ re-appointment in year and the supporting processes.

1.2. This work was revisited by the Nominations Committee at their July meeting, taking account of changes that had arisen in the interim – including Mrs Suzy Brain England’s appointment as Chair of Doncaster & Bassetlaw Hospitals NHSFT (DBH).

1.3. Governors received notice of Mrs Brain England’s appointment and the need to go out to advert early, under an email issued on 15th July 2016. No objections were raised.

1.4. This report asks the Council of Governors to finalise the appointment process and timetable and to take account of changes that have arisen in the intervening period.

2. VACANCIES

2.1. In April, the Committee started to look at the prospect of appointment/re-appointment following the expiry of the latest term of office for Mr Francis Patton at 31st December 2016. In the intervening period, however, two important changes have arisen:

• Mrs Brain England has been appointed as Chair of Doncaster & Bassetlaw NHSFT (DBH) and will take up post from 1st January 2017 (latest).

• The NEDs have been asked to consider the appointment of an additional Executive Director (ED) to the Board, to bring further balance and strength to the Board. This cannot be progressed without agreement for the appointment of an additional (seventh) NED as, under the Constitution, there must always be a majority of Non Executive to Executive Directors (see appendix 1).

2.2. There are currently six NEDs (including the Chairman) and five EDs (including the CEO) appointed to the Board. However, many Governors will recall that steps were taken some time ago to increase the number of NEDs to seven in total, although the seventh appointment was not progressed.

2.3. When the Trust’s Constitution was revised to support this, provision was also made for an increase in EDs (appendix 1 refers).

3. PROCESSES 3.1. As Governors are aware, whilst the Council of Governors is responsible for the

appointment process for NEDs, the NEDs and Chief Executive are responsible for the appointment process for EDs.

3.2. Expansion of the Board would be timely with the demands on both the NED and ED teams growing rapidly in line with the increasing challenges facing the Trust. As a Board of 11 Directors currently, it is one of the smallest FT boards in the region and although it has worked well to date, there would be considerable benefits from the addition of two more Directors, expanding the Board’s collective skills, experience and knowledge.

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CoG Aug 2016: NED appointments/ p2

3.3. The Nominations Committee has also been cognisant of other factors to consider:

• costs: an additional NED’s salary (and on costs) and an uplift to salary (assuming the ED would be appointed from the existing Executive Team) to reflect executive director responsibilities. These would be mitigated by efficiencies made within the Chief Executive’s budget as well as the additional strengths to the Board.

• composition of the Board: to ensure the right mix of skills, experience and knowledge at this critical time

• process requirements: whilst two more Board Directors (one NED and one ED) are already set in the Trust’s Constitution, the recommendation to appoint a seventh NED would need to be approved by the Council of Governors at a General Meeting, before appointment of a further ED could be progressed

• current NEDs: the Committee is conscious that Mr Mapstone and Ms Moore only joined the Board 16 months ago (April 2015), Ms Dean joined in January 2016 and Mr Patton’s term of office expires in December 2016. Mr Patton currently also serves as the Senior Independent Director and Deputy Chairman. Governors are reminded of the year end reviews reported at the last meeting, reflecting continued good performance from everyone on the team.

3.4. The Nominations Committee is supportive of the proposal to increase the Board to seven NEDs and six EDs – and thus looking to recruit to two or three NEDs.

3.5. Equally, however, mindful of the final bullet point under 3.3, the Committee has suggested that Mr Patton be re-appointed for a further term of office – for one year, from 1st January 2016 to 31st December 2017, bringing his collective service to ten years. This would give continuity to the NED team and retain valued corporate knowledge. It is stressed that, if approved, Mr Patton’s extended appointment to December 2017 would not grant an automatic re-appointment for any longer period. As agreed with the Council of Governors previously, every appointment and re-appointment to the Board must remain subject to separate consideration as and when the need arises

4. REVIEW OF NED RECRUITMENT DOCUMENTATION 4.1. The advert, role description for a NED, person specification, application form and

guidance notes to applicants were reviewed in July. These are largely unchanged, other than to give an emphasis to the benefits of a legal or financial background and, as stated in previous adverts, links with the local community. None of these is essential to the role but could be advantageous.

4.2. The focus on legal and financial background is aimed at reinforcing the skills and experience currently brought to the Board by the Non Executives and support to the Audit Committee following Suzy Brain England’s departure.

4.3. Full copies of the person specification and role description are available on the NHSJobs website: http://www.jobs.nhs.uk/xi/vacancy/628cda9f172c8d205c785f762e82121e/?vac_ref=914262075

5. RECRUITMENT TIMELINE & REQUIREMENTS

5.1. The Committee is conscious that whilst Mrs Brain England’s continued commitment to the Trust is unquestioned, her new Trust will doubtless wish her to start working more closely with them sooner rather than later. Accordingly, the appointment timetable has been brought forward to allow at least one appointment to be taken up sooner and others scheduled for 1st January 2017.

5.2. The appointment timeline and process is now proposed as follows:

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http://www.jobs.nhs.uk/xi/vacancy/628cda9f172c8d205c785f762e82121e/?vac_ref=914262075


• out to advert from 22 July 2016 to 18 September 2016 – using NHSJobs, the Barnsley Chronicle (x1 in July and x1 in September) and proven on-line media. The lengthy advertising period should ensure that applicants are not ‘lost’ due to the summer holidays. Informal responses to date have been encouraging;

• shortlisting on 20th September;

• assessment day on 29th September;

• recommendation for appointment(s) to be presented to the Council of Governors’ General Meeting on 19th October 2016.

5.3. As usual, the assessment day will be supported by a stakeholder forum as well as interview. The stakeholder forum will include staff and public governors, and representatives from the Local Authority, the Clinical Commissioning Group and, ideally, local GPs. Expressions of interest from Governors to be involved with the stakeholder forum are welcomed and should be addressed to Carol Dudley before the end of the month.

5.4. For expediency the Committee has had to progress the appointment process on the premise outlined above, based on the approach previously agreed by the Council of Governors. It does not, however, exclude change if the wider Council of Governors would like the Committee to consider any revisions to any aspect of the appointment process.

6. RECOMMENDATIONS

The Council of Governors is asked to: a) note the appointment of Mrs Brain England as Chair of DBH b) note and endorse the proposed appointment timeline and process for 2-3 Non

Executive Directors c) approve the proposal to appoint a seventh Non Executive Director d) approve the proposal to extend Mr Patton’s term of office for a further year

from 1st January to 31st December 2017


Appendices

• Appendix 1 – extract from the Trust’s Constitution (2015)

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Appendix 1

EXTRACTS FROM BHNFT CONSTITUTION (2015)

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CoG Apr 16: 14(i)_Sub-groups report

14

STRATEGIC SUB-GROUPS

1 INTRODUCTION

1.1 This report provides an update on the work and discussions of the Council of Governors’ Finance & Performance sub-group (FPSG) and Quality & Governance sub-group (QGSG) and meetings held in July and August respectively.

2 SUB-GROUP LEADERSHIP & MEMBERSHIP 2.1 David Brannan (for FPSG) and Trevor Smith (for QGSG) chaired the meetings. 2.2 Both Chairs were pleased to receive an expression of interest from Mr Tony Dobell,

public Governor, for the role of Vice Chair in either or both of the sub-groups. With the Trust Chairman’s support, Tony’s appointment has been confirmed.

2.3 Membership of the sub-groups remains informal. Governors are welcome to attend the sub-group meetings regularly or on an ad hoc basis if preferred. If any Governor wishes to raise an item through either of the sub-groups, the Chairs would be pleased to hear from you ahead of the next meeting’s agenda setting.

3 WORK OF THE SUB-GROUPS 3.1 One of the primary objectives of the sub-groups is to support the Governors’ role of

holding the Non Executive Directors (NEDs) – and through them, the Board – to account for the Trust’s performance. As part of this, the sub-groups continue to review progress against the strategic aims and objectives underpinning the Trust’s business plan.

3.2 The sub-group meetings also provide a valuable opportunity for Governors to share feedback from their constituencies (public, partners and staff) and members.

3.3 Minutes from the sub-groups are shared with all Governors by email. Printed copies are available to Governors on request and key points from each meeting are reported at General Meetings (see below).

4 REPORT ON SUB-GROUP MEETINGS Finance & Performance Sub-Group (FPSG) 4.1 The latest FPSG meeting was held on 13th July. The meeting was well attended by

Governors and the Trust’s Chairman and two Non Executive Directors – Mr Nick Mapstone and Ms Ros Moore.

4.2 In addition to regular review of workforce and performance data from the Integrated Performance Report (IPR) - month 2 - and the Finance & Performance Committee (F&P) Chair’s Log, the sub-group received the latest report on membership, reviewed the Governors’ Strategy and received an update on staffing issues from staff’s perspective from Mr Martin Jackson – Partner Governor for the Joint Trade Unions Committee (JTUC).

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CoG Aug 2016: sub-group report (2)

4.3 Subject to some small changes, the membership report was endorsed for presentation to the wider Council of Governors (see separate agenda item). This will also provide a welcome opportunity to meet Chloe Wake, the new lead for membership matters.

4.4 Following review by the sub-group the updated Governors’ Strategy is attached, with proposed revisions tracked for ease. The changes reflect the Trust’s current vision and values, the impact of the Sustainability & Transformation Plan (STP) and a few other minor amendments. The three paragraphs deleted under section 5 referred to several new boards/organisations being established at the time of the last review and can now be removed.

4.5 Martin Jackson’s overview of staffing issues reflected national as well as local matters. Nationally there is a lot of focus on the impact of the new Living Wage on the national pay scheme, Agenda for Change. Within the Trust there are continued pressures in a number of teams, particularly in specialist areas facing national staff shortages. Martin advised that staff are working with managers to identify long term training needs to mitigate against shortages in specialisms and, for the more immediate demands, to support alternative working practices to ensure continued high quality and safe services He also flagged that as the Trust moves towards developing a ‘hot and cold’ site, the plans for change will be unsettling. He confirmed that staff have been assured that any moves would be well managed and disruption kept to a minimum, would not be as intensive as previously mooted and that staff would be kept well informed as plans progress. He said too that staff were more settled with the Trust now on plan financially albeit still in deficit and more work ahead. Co-opted Governor Ms Joanne Bleasdale, also a member of staff and a member of JTUC, highlighted the changes to training in allied health professions and nursing with students having to pay their own fees next year. The full impact of this has not yet been assessed nationally.

4.6 In relation to the IPR and the F&P Chair’s Log, key issues included good progress against the financial plan (as mentioned above); improvements against agency spend due to tight controls; concerns around the Cost Improvement Programme (CIP) with expectations for improvements in the following month; impact of significant debtors (raised with NHS Improvements), and the capital scheme still awaiting approval from the Department of Health (expenditure in the meantime being carefully managed to support progress).

4.7 Activity showed a continued reduction in DNAs (did not attend – below the national average), reduced waiting times in diagnostics, escalation beds closed, and performance on track to return to compliance for the <4 hours emergency access target despite continuing demands on A&E. Non-compliance was noted in some cancer pathways; improvements are expected in breast symptomatic with the new consultant in post and partnership working with another trust, and in shared pathways for lung, head and neck and colorectal patients with continued close working with partners.

4.8 Governors also welcomed the refresh of the Trust’s Workforce Strategy and the continued good performance in sickness absence (best in the region - with a small number of hot spots still to be addressed internally).

Quality & Governance Sub-group (QGSG) 4.9 The latest QGSG meeting took place on 10th August. It too was well attended by

Governors and was also supported by two Executive Directors - Mrs Karen Kelly, Director of Operations, and Mrs Heather McNair, Director of Nursing & Quality. Unfortunately - and unusually - no Non Executive Directors were able to attend.

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4.10 Governors reviewed the latest Chair’s Log from the Board’s Quality & Governance Committee (Q&G) and related issues from the IPR (month 3). Discussions focussed on pressure ulcers (more work needed to ensure these were identified on admission; learning from each reviewed case continues to be shared across the Trust), harm from falls (much lower than national benchmarking but work ongoing to reduce further if possible) and mortality ratios (improvement trends continuing). Governors appreciated the assurance provided by Mrs McNair regarding the ongoing work on each of these matters.

4.11 Governors commended the Trust’s approach to a recent complaint received outside of the mandatory timeframe. This had allowed a second investigation to be carried out, which in turn would enable the Trust to respond to the complainant as fully as possible and identify more learning retrospectively.

4.12 The sub-group received a detailed update on the outpatient review lists reported in 2015, and improvements in outpatient systems and DNAs (did not attends). Mrs Kelly confirmed that no patients remained on the review list and all had been seen without harm arising due to the delays. She also gave assurance that new systems were in place to ensure review lists were not maintained in future and outlined plans going forward to drive further improvements in both outpatients and DNAs. With the advent of new systems such as two-way texting and ‘phone support and more ability to re-use cancelled appointments, DNAs were now below the national average. The sub-group recorded its congratulations to the Trust on the work completed to address the review list and significantly reduce the levels of DNAs.

4.13 Concerns were raised regarding the appointment system and some experiences within Ophthalmology. The Directors could not comment on these, however, as the service is managed by another trust but hosted on site. This may change in future, as the contract is currently out to tender. Mrs Kelly undertook to share the Governors’ comments with the current service provider.

4.14 Concerns were also raised regarding availability of wheelchairs within the hospital. Governors were advised that a review of wheelchairs (type, suitability for differing areas, stock levels etc) was currently ongoing. More information would be shared with the sub-group when the review had been completed.

4.15 Several Governors also shared feedback from their attendance at the latest Quality & Safety visits. These seemed to be working much better than the old system. Whilst it was encouraging to note that feedback was largely very positive from patients and staff, Governors were pleased to note that any queries or concerns were escalated appropriately.

5 CONCLUSION & RECOMMENDATIONS 5.1 As stated previously, sub-group meetings are intended to supplement and support

the work of the wider Council of Governors. Other information will also continue to be available to Governors via formal and informal updates from the Chairman, Governor attendance at Board meetings held in public, the annual joint meeting of the Governors and Board (held in November), briefings received at General Meetings, private briefing sessions for Governors, and the Board’s responses to any questions raised by Governors.

5.2 The notes above are by no means a full reflection of the meetings’ business. Governors are encouraged to come along to hear more and contribute to the sub-groups’ discussions and work.

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5.3 Governors are asked to: • note and support this report, and • approve the proposed changes to the Governors’ Strategy

David Brannan Trevor Smith Finance & Performance Quality & Governance SUB-GROUP CHAIRS August 2016

Appendices - Appendix 1: Governors’ Strategy

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COUNCIL OF GOVERNORS - Governors’ Strategy

2016 1. INTRODUCTION

1.1 The Ggovernors of Barnsley hospital NHS Foundation Trust comprise public

governors, elected by the members of the Trust, staff governors elected by the staff, and partner governors representing partner organisations in Barnsley. The Council of Governors is the voice of the local community.

1.2 The Council of Governors has two broad roles;

• rRepresenting the members of the Trust and the wider community • hHolding the Non-Executive Directors (NEDs) individually and collectively

accountable for the performance of the Board of Directors

1.3 The Council of governors Governors has specific legal responsibilities: • Appointment of the Chairman and the NEDs • Appointment of the Trust’s external auditors • Setting the remuneration and other terms and conditions of the Chairman

and the NEDs • Approving the appointment of the Chief Executive • Approval of mergers, acquisitions and dissolution • Approval of proposed increases in the proportion of total Trust income

attributable to private income of more than 5% in any one year • Approval of significant transactions as defined in the Trust constitution

2. VISION

2.1 The Council of Governors is committed to the Trust’s vision as shown below:

• Our vision o Barnsley Hospital - providing the best healthcare for all.the best

integrated healthcare organisation for our local community and beyond

• Our mission o To improve the health and wellbeing of the people of Barnsley. o To enable people to be in control of their health and wellbeing by

promoting independent living. o To make care more accessible.

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o To reduce the inequalities that exists between Barnsley and the rest of England.

• Our values o To treat people how we would like to be treated ourselves o To work together to provide the best quality care we can o To focus on your individual and diverse needs

3. STRATEGIC OBJECTIVES OF THE COUNCIL OF GOVERNORS

3.1 The Council of Governors will support their Trust’s vision and , mission and values by working towards the following strategic objectives.

• To ensure that the Board puts patient safety and quality of service at the

heart of everything the Trust does • To represent the interests of our members and the wider community • To support the efforts of the Board to make return to financial balance and

the maximum surplus achievable for re-investing in our services • To ensure that the Board provides appropriate information to governors to

enable governors to carry out their role of holding the NEDs to account for the performance of the Board

• To ensure the Board consults the Council of Governors at an early stage in the business planning cycle

• To support the maintenance of a healthy membership base and the organisation of membership engagement events

3.2 The Council of Governors will achieve these objectives through robust

arrangements that enable the Council of Governors to effectively hold the Board to account.

4. HOW WE FURTHER OUR STRATEGIC OBJECTIVES

4.1 The Council of Governors will take a tactical approach to the delivery of their strategic objectives. The following tactics will form a major part of their work through the year.

• Keep our structure of committees, sub-groups, and meeting agendas under

periodic review to ensure effectiveness • Ensure that governors take up the training opportunities that are provided by

the Board • Make full use of the information provided about the Trust performance to

enable us to effectively carry out our statutory responsibility of holding the Board to account

• Take up opportunities to express our views to the Board on Trust forward plans

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• Raise issues of concern about the Trust from governors or the public with the Chairman and/or Trust Secretary to the Board & Governors

• Communicate with our members and the wider community via Barnsley Hospital News, the Trust website, email, social media, and speaking to local organisations

• Give full support to membership engagement events • Take part in periodic inspections to assure themselves of the quality of

develivery of care in the Hospital. • Seek periodic ways to measure our performance as a Council of Governors • Become involved with Trust groups by invitation • Support the Trust’s work with external inspections

5. THE CURRENT SITUATION

5.1 BHNFT has embarked on a challenging transformational programme,five year plan which will challenge traditional ways of delivering healthcare. This will continue to include partnership working both within the local health economy and in the regional health economy.

5.2 BHNFT is one of the founding partners of the Mid Yorkshire, South Yorkshire

and North Derbyshire “Working Together” programme, which over the next three years will continue to seek to take advantage of initiatives to make Healthcare in the region more sustainable and cost effective.

5.3 The NHS is challenged nationally by a rise in demand for services,

particularly urgent care, and by an ageing population. Both of these dimensions have an impact on a service that strives to improve quality with reduced funding. Every health and care system has been charged with working together to to produce a multi-year Sustainability & Transformation Plan (STP), showing how local sevices will evolve and become sustainabile over the next five years, ultimately delivering the NHS Five Year Forward View vision. BHNFT is a key partner within the South Yorkshire & Bassetlaw footprint.

5.4 BHNFT remains in a deficit position. Delivery of the turnaround plan

continues and there are firm foundations in place to return the organisation to financial balance.

5.5 BHNFT remains focused at all times on high quality, safe patient care;

working with partners, and ensuring its staff remain engaged and proud to be part of the organisation.

5.4 In 2013/4 new commissioners, in the form of NHS Barnsley Clinical

Commissioning Group have set out their stall to improve healthcare locally

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and have stated that they will do this in partnership with their contracted providers.

5.5 Again in 2013/4 the Health and Wellbeing Board is formally established and

will have oversight of health provision and commissioning in the Borough. BHNFT will play a role on this board and will need to appraise Governors on how that affects delivery of the strategic ambitions of the Hospital.

5.6 Also formally establised in this year is Healthwatch, which is being marketed

as the consumer champion for health care. Governors will need to keep sight of activities from Healthwatch and help BHNFT play as much a role as possible in its development.

6. STRATEGY DELIVERY

6.1 Governors will deliver this strategy by engaging the tactics at 4.1 but will also hold the Board to account through the following arrangements.

• Receive information from the Board on the delivery of the Commissioning for Quality and Innovation (CQUIN)

• Receive information from the Board on the Trust quality agenda • Receive information from the Board on the Trust performance overall • Receiveing information from the Board on the progress of the

transformation programmeSTP • Receive information from the Board on the financial performance of the

Trust • Monitor and challenge risk ratings • Input into business planning • Bring issues from Board meetings to Council of Governors meetings for

discussion 7. MONITORING THIS STRATEGY

7.1 The delivery of this strategy should will be measured by the Strategy Finance &and Performance sub-group of the Council of Governors.

Presented: June 2013July 2016 (Finance & Performance Sub-group) Approved: June 2013August 2016 (General Meeting) Next review due: annually - 2017

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COUNCIL OF GOVERNORS – AUGUST 2016 REF: COG/16/08/15

CoG August 2016: BoD reports

15

BOARD OF DIRECTORS

1 MEETING PAPERS & AGENDA

1.1 The Agenda for the meeting of the Board of Directors held in public on 4th August 2016, is attached for information. The Minutes of the previous meeting, held in July, are also attached.

1.2 Governors have access to all of the papers from the Board meetings held in public but the following three reports are attached for your attention: 1.2.1 The latest performance report (to end June 2016). These monthly reports

continue to be subject to closer review regularly at Governors’ sub-group meetings. Progress against delivery of the strategic objectives for the Business Plan is monitored through the sub-groups too.

1.2.2 The latest Horizon Scanning report. This is provided each month by our communications lead to add to the Board’s awareness of news items and upcoming national and regional issues.

1.2.3 The Infection Prevention & Control Strategy 2016-19, which was approved by the Board of Directors on 4th August

1.3 Copies of the full reports from all Board meetings held in public are available on the Trust’s website (www.barnsleyhospital.nhs.uk) or on request from the Secretary to the Board & Governors, Carol Dudley.

2 FUTURE MEETINGS 2.1 Governors, staff and members of the public are welcome to come along to observe

any meetings of the Board held in public. Meeting papers will be provided on the Trust’s website and at the meeting.

2.2 The Board of Directors’ regular meetings are usually held on the first Thursday of every month but there are exceptions and Governors are advised to check with the Governors’ Office or on the Trust’s website for further details.

2.3 The next Board of Directors’ meeting to be held in public is scheduled for 1st September 2016, commencing at 9am.

3. RECOMMENDATION Governors are asked to receive and note this report.


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BoD Aug 2016: Agenda (PUM)

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE ON THURSDAY 4TH AUGUST 2016, 9AM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

No Item Sponsor Ref

1. Apologies and Welcome

S Wragg, Chairman

2. To receive any declarations of interest

3. To approve the Minutes of the meeting of the Board of Directors held in public on 7 July 2016 16/08/P-03

4. To approve the Action Log in relation to progress to date and review any outstanding actions 16/08/P-04

Strategic Aim: Patients will experience safe care

5. To receive and review latest Patient’s Story H McNair Dir of Nursing & Quality Presentation

6.

To receive and approve from the Quality & Governance Committee: a) the Chair’s Log and assurance from latest meeting b) the Committee’s Annual Report 2015/16

R Moore, Quality & Governance

Committee Chair

16/08/P-06a 16/08/P-06b

7. To review the Chair’s Log on any escalation issues from the Executive Team

D Wake Chief Executive Verbal

8. To receive and approve from the Audit Committee: a) the Chair’s Log and assurance from latest meeting b) the Committee’s Annual Report 2015/16

S Brain England Committee Chair

16/08/P-08a 16/08/P-08b

9. To endorse quarterly review of the Board Assurance Framework 2016/17 (Q1)

H McNair, Dir of Nursing & Quality

16/08/P-09

10. To endorse the quarterly review of the Corporate Risk Register 2016/17 (Q1) 16/08/P-10

Strategic Aim: People will be proud to work for us Strategic Aim: Performance matters

11.

To receive and approve from the Finance & Performance Committee: a) the Chair’s Log and assurance from latest meeting b) the Committee’s Annual Report 2015/16

F Patton Committee Chair

16/08/P-11a 16/08/P-11b

12. To review the integrated performance report (month 3) Executive Team 16/08/P-12

13. To receive and review the quarterly report on the 2016/17 objectives (Q1)

K Sowden Head of Business

Planning & Programmes 16/08/P-13

Strategic Aim: Partnership will be our strength

14. To note the monthly report from the Chairman S Wragg, Chairman 16/08/P-14

Cont/…

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BoD Aug 2016: Agenda (PUM)

No Item Sponsor Ref

15. To note the monthly report from the Chief Executive D Wake, Chief Executive Verbal

16. To receive intelligence reporting/horizon scanning for the Board

E Parkes Director of Marketing &

Communications 16/08/P-15

17. In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

18. Date of next meeting: 01 September 2016, commencing at 9am Signed: ………..…………………… Chairman

Please see reference section at back of papers for key to business plan and glossary of terms/acronyms

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REF: 16/08/P-03

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

MINUTES OF A MEETING OF THE BOARD OF DIRECTORS HELD ON 07 JULY 2016

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL NHSFT

PRESENT: Mrs S Brain England OBE Non Executive Director Ms J Dean Non Executive Director Dr R Jenkins Medical Director Ms K Kelly Director of Operations Mr N Mapstone Non Executive Director Mrs H McNair Director of Nursing & Quality Ms R Moore Non Executive Director Ms D Wake Chief Executive Mr S Wragg Chairman Mr M Wright Director of Finance

IN ATTENDANCE: Mr J J Bannister Deputy Medical Director Mrs L Christopher Director of Estates & Facilities Mr T Davidson Director of ICT Ms C E Dudley Secretary to the Board & Governors Mr J Fernandez Associate Director of HR&OD Ms J Howarth Service Manager, RightCare Barnsley * Mr R Kirton Director of Strategy & Business Development Mr S Mitchell Clinical Director, CBU2 (Surgery) Ms E Parkes Director of Marketing & Communications Ms K Sadler BMBC Health & Wellbeing Strategy Project Manager** (* attended part of meeting re Minute 16/111) (** attended part of meeting re Minute 16/118)

APOLOGIES: Mr F Patton Non Executive Director

16/107 APOLOGIES & WELCOME

Members and attendees were welcomed. The Chairman also welcomed Mr Mitchell, attending first meeting since taking on the role of Clinical Director, and Ms Howarth, attending to present information on the RightCare Barnsley Service. Apologies were noted from Mr Patton and, as a courtesy, had also been received from Miss Dass and Dr Mitchell, Clinical Directors.

16/108 REGISTER OF INTERESTS (16/07/P-02) & DECLARATION OF INTERESTS The Registers of Interest for the Board of Directors and the Executive Team and Clinical Director, dated July 2016, were received and noted. Mrs Brain England advised the meeting that she would be leaving the Trust to take up a new appointment from 1st January 2017 as Chair of Doncaster & Bassetlaw Hospitals NHS Foundation Trust (FT). Mrs Brain England’s final date at Barnsley had not yet been determined but was not expected to be immediate; in the meantime she assured Members that the Trust would

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BoD Aug 2016: July Minutes PUM (p2 of 12)

continue to have her full commitment and loyalty. It was not envisaged that this would create any conflicts of interest, and indeed could help with some areas of joint interest across the region, but if it was deemed unsuitable at any time for Mrs Brain England to participate in discussions/receive reports on certain topics, she would exclude herself at the Board’s direction. Mrs Brain England was congratulated on her appointment and thanked for her continued support. The Chairman reminded members of the importance of keeping the Registers up to date and requested that any further updates at any time be provided to Ms Dudley.

16/109 MINUTES OF LAST MEETING (16/07/P-03) The Minutes of the meeting of the Board of Directors held in public on 2nd July 2016 were received and approved as a true record.

16/110 ACTION LOG (16/07/P-04) The action log showing progress on matters arising from the last and previous meetings held in public was reviewed and noted. One item (16/104) had been deferred to be discussed in private due to it commercial and confidential nature. The Chairman thanked Ms Christopher and Mr Davidson for progress with the acoustics in the meeting room. The improved microphone system was appreciated and would be useful for the Council of Governors too.

16/111 PATIENT’S STORY Mrs Kelly introduced Ms Howarth, the Service Manager for RightCare Barnsley. The presentation from Ms Howarth (copy attached) aligned with the aim of the ‘patient’s story’ at the start of each meeting to emphasise the focus of the Board’s work: to deliver high quality and safe healthcare services with patients at the centre of every decision. Ms Howarth was pleased to report that the RightCare Barnsley team had recently won a second award, this time from NHS England: the Clinical Commissioning Award for Healthcare Transformation. In her presentation Ms Howarth outlined the improvements delivered by the RightCare service since its inception: it was intended to provide a single point of access and co-ordination for community healthcare professionals referring patients who they believed would need hospital care within the next 24 hours. The service worked closely with teams across the patch, including the Trust’s discharge management team with which it was co-located on the hospital site. It operated seven days a week, with out of hours currently supported by access to the community Rapid Response Service. Ms Howarth explained how referrals were subject to robust clinical assessment to identify the right care, right time, right place for each patient, avoiding unnecessary hospital admissions. Benefits in the first 12 months to March 2016 showed an admission avoidance of c32% (the initial target had been just over 4%), reduced pressure on referring practitioners (many of whom were now ringing the service for information and advice in the first instance rather than simply referring patients for the team’s consideration) and, equally importantly, helping patients and families by effective resolution of their needs. All referrals were reviewed at 24 hours and 30 days to validate the decisions made. The service was about increasing safety too: escalating acutely ill patients quickly where needed.

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Ms Howarth explained that the service was being rolled out in three phases: firstly to avoid unnecessary hospital admissions, secondly to focus on live community bed state (work ongoing) and management of patients in community rehabilitation beds to minimise stays and support timely referrals to social services, and thirdly to support management of discharge from hospital and care home beds, developing management plans for those patients identified at risk of readmission. The fourth phase to follow would be developed alongside case managers, supporting the discharge team working out on the wards and ensuring patients were referred into RightCare as soon as possible. The effectiveness of the service to date was well illustrated in the patient stories provided in the presentation. Its growth and the positive impact of the service had been dependent on building good relationships with other health and social care providers across the community. The Board thanked Ms Howarth for a full and informative presentation. Several aspects were explored in discussion. Ms Brain England enquired if the team had spotted any areas where service offers were not yet being delivered; Ms Howarth acknowledged that the work with the ambulance service was not as fulsome as she would have expected but this was being redressed. In broader terms, the team intended to ensure that referrals operated two-ways across the care providers to ensure patients were able to receive more support in the community (for example: the potential for ECGs to be undertaken in the community, maybe through paramedics, with the results fed in for hospital assessment). In response to a question from Ms Dean, Ms Howarth affirmed that no geographical or other patterns had been identified through the team’s work; referrals had been received from every Practice in the borough and were generally proportional to the scale of each one. Dr Jenkins was pleased to advise that the service had been recognised beyond the immediate community too, having been cited in the ongoing discussions around the Sustainability & Transformation Plan (STP) as a good example of co-regional working. He also appreciated Ms Howarth’s assurance that areas of learning or concern identified by the RightCare team, including some of the issues highlighted in two of the patients’ stories, were fed back to partner organisations. In terms of governance, the Chairman enquired as to how the RightCare Service linked into the Trust’s own reporting systems. Mrs Kelly advised that the Trust sat on the RightCare Service Board so would have an awareness of any issues of concern reported to that board and, if appropriate, through the community-wide Systems Resilient Group too. Additionally assurance was given that cases of concern directly affecting the hospital would be reported as serious incidents in accordance with the Trust’s usual protocols. Ms Kelly reported that the hospital’s consultants appreciated the way that RightCare assessed patients and were considering how that approach could be utilised within the Trust too. Airedale Hospital had a similar system, linked with telehealth to take the system out to patients at home and this would be part of the forward thinking too. It was acknowledged that RightCare was filling a gap in terms of overall co-ordination between the various care providers, which, as pointed out by Ms Wake had been raised previously as a lack by many complainants. Ms Wake would, however, also welcome a focus on management of readmissions. She noted Ms Howarth’s expectation that the RightCare Board would be focussing on a range of identified service gaps, including those in the

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patients’ stories, as the next stage of development now that the pilot service was becoming more established. In response to a query from Mr Mapstone, Ms Howarth also referred to approaches from other providers, including CAMHS (Children & Adolescent Mental Health Services), which would contribute towards building a more holistic approach. She hoped work would also continue on development of virtual wards across the community. Ms Howarth was thanked for making the time to attend the meeting. The Board expressed sincere congratulations on the two well deserved Awards recently won by the RightCare team. Ms Howard left the meeting at 9.35am. The good progress and effectiveness of the service were acknowledged albeit gaps remained, particularly some in relation to some community links – for example, Medworxx, which, contrary to earlier expectations, would not now be rolled out community-wide from the outset although support for closer working would continue to be promoted wherever practicable. It would also be helpful if the RightCare Service would be added to the Health & WellBeing Board’s agenda at some point. Ms Kelly commented on the impact on the hospital: whilst the service clearly had helped to avoid a number of admissions by referring patients to other routes for appropriate care, it seemed to be addressing an unmet need. Hospital admission levels themselves had not yet reduced. The Chief Executive’s comment regarding readmissions was reiterated.

16/112 QUALITY & GOVERNANCE (Q&G) CHAIR’S LOG (16/07/P-06) As Chair of the Q&G Committee, Ms Moore presented the Log from the Committee’s meeting held in June. She highlighted a range of issues including discussions around the reported new risk to Stroke Services, recognition of continued concerns regarding D1s (discharge summaries) and work ongoing for both issues; the annual reports received from each of the Committee’s reporting sub-groups, and the good outcomes from the latest MBRACE national benchmarking data, showing the Trust to be a good performer in terms of the levels of neonatal deaths although work would be continued to reduce these further. Ms Moore also reported briefly on the presentation received from the new team leader for the Advanced Nurse Practitioner (ANP) team, which had been every encouraging and reflected the good progress to date in development of ANPs within the Trust. Several points were expanded upon in discussion: • D1s – Dr Jenkins explained that this had been a long standing issue; he

outlined the background and the concerns raised by some of the local GPs. The Trust had recently revised the form to reduce the number of fields to a more manageable and effective number and was also trying to encourage better use of electronic D1s (compliance had increased from 35% to 80% but more was required). Further actions were planned, including work around nurse led discharges where appropriate and improvements to medication records (to address the differences between GP and hospital records). The Clinical Commissioning Group (CCG) had requested a quality review meeting although it was understood that the Care Quality Commission (CQC) and NHS England believed it should be referred for local resolution. The Trust recognised the validity of the GPs’ concerns around timeliness and quality of the D1s and would continue to work with them and drive forward the improvement works. Dr Jenkins had offered to talk to the CCG’s Governing Body to report on the work in hand although this had not yet been taken up.

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• Stroke Services – Ms Wake assured the Board that all avenues were being considered to identify the best way to address the lack of consultant support in stroke services that would impact from August/September. Options included networked services, recruitment (market testing ongoing) and alternative service models. She also advised that provision of hyper acute services were likely to change as part of the STP and a neighbouring Trust had indicated that they could support Barnsley’s hyper acute patients in advance of this if needed. This would only relate to a very small number of Barnsley patients.

• Annual Fire Statement: This was reviewed and approved for sign off by the Chief Executive.

The Board received and noted the Chair’s Log. The Q&G Committee would continue to monitor the issues highlighted above and keep the Board informed of progress.

CEO

16/113 MEDICAL DIRECTOR’S REPORT (16/07/P-07) Dr Jenkins presented and expanded upon his quarterly report to end of June 2016. He highlighted the Medical Staffing reports and the position with the Junior Doctors’ contract. The contract had recently been rejected by Junior Doctors following a ballot held by the BMA and the Secretary of State had announced that imposition of the contract would go ahead. The first tranche of doctors would be transitioned to the new contract in October, with phased transition for the remainder over the next year. Views were being sought from clinical colleagues to ascertain how this might be received by the Trust’s junior doctors; earlier feedback had indicated a degree of resignation to the situation and little appetite for further industrial action but this could have changed, particularly with the BMA’s lead negotiator having resigned. Dr Jenkins reminded Members that as a Foundation Trust, BHNFT was not obliged to put the contract in place. When options had been considered previously it was acknowledged that any alternative action could attract problems of its own and there had been a consensus that it would be inappropriate to try to avoid the directive. If appropriate, however, this could be reconsidered by the Executive Team. In response to a query from Mrs Brain England, Dr Jenkins briefly outlined the main content of the new contract. Whilst it was not intended to impose extended working hours, junior doctors nationally had raised concerns that some trusts might try to override the guidance put in place to support safe working hours or enforce regular weekend working. Mr Bannister agreed with Dr Jenkins’s view that this was a theoretical rather than a practical risk and advised that junior doctors would be further protected with the right person appointed as a Guardian of Safe Working, to monitor issues such as working hours. The Guardian could be an internal appointment but must be independent of line management arrangements for the staff involved. The Trust was currently out to advert for this appointment. Dr Jenkins responded to several queries from the Non Executive Directors, including: • Safety Huddles: The Board was reminded that initially the Trust had been

part of a multi-centre study, involving two wards (wards 18 and 23). Experience had shown that the huddles had worked well but effectiveness was dependent upon staff engagement and response; it was important to get senior medics involved. Dr Jenkins did not have details regarding timings for the wider roll out to hand but would obtain and circulate the information outside the meeting.

RJ

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• Sepsis compliance: Compliance requirements had changed – previously trusts had been asked to look at (say) five patients per month with actual analysis being lower. Now trusts were being asked to analyse enough notes to find 50 patients, which could entail review of hundreds of notes, putting a significant burden on the system. With the Executive Team and CCG’s support, Dr Jenkins planned to write to NHS England to advise that the Trust would continue to review a smaller number, as a less time consuming but equally effective measurement process.

• Job planning: Dr Jenkins explained that contractually, all consultants were required to have an annual view of their job plans as a minimum (more could be triggered on request). As stated in the report, reviews would be linked to the business cycle based on objectives being developed over the next few weeks in liaison with the Director of Operations and Clinical Business Unit (CBU) leads to capture issues to feed into the plans. Last year’s reviews had been particularly difficult with the dispute around SPAs but this was now nearly fully resolved.

The format of the report was also reviewed. Whilst its qualitative style was appreciated and gave a useful overview of progress, Ms Dean enquired how the Board could best track delivery against the work and plans outlined. On review, it was agreed that the report’s current format was effective and progress of the initiatives and plans should be measurable from the impact on performance evidenced in the integrated performance report (IPR) and other papers presented and could be further tested in Committee and Board discussions. Nevertheless Dr Jenkins would welcome suggestions for change at any time in order to meet the Board’s requirements.

16/114 MORTALITY REPORT (16/07/P-08) The latest report on mortality was received and noted. Dr Jenkins drew attention to the extract from the Dr Foster data, included as an appendix. The report reflected some good progress: the Trust remained below 100 on all measures and had started the new year lower than it had ended the previous year. Pneumonia HSMR (Hospital Standardised Mortality Ratio) had reduced too, which it was anticipated was linked to the growing impact of the pneumonia bundle. There was also evidence of improvements in coding but further work was needed on this important aspect. Dr Jenkins agreed with Mr Mapstone that coding did have a financial impact too, as better coding was expected to provide better payments. Mr Wright advised that an external, retrospective audit of coding recently undertaken at no charge to the Trust had also identified some issues, which had enabled some coding errors and consequent financial gaps to be redressed. Generally there was not an IT solution to the position, although Mr Davidson outlined more work ongoing to support greater accuracy; coding could be improved by more staff awareness, particularly junior doctors (not to detract from the responsibilities of senior doctors), aided by training both internally and through the training schools. Concerns remained around sepsis, which remained high despite improved adherence to the sepsis six guidance. This was being reviewed and findings would be shared with the Board in the next quarterly report.

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16/115 INFECTION PREVENTION & CONTROL (IP&C) (16/07/P-9) - ANNUAL REPORT 2015/16 Mrs McNair presented the annual report, which summarised the Trust’s continued good progress and achievements around IP&C throughout 2015/16. The report had been reviewed and endorsed by the Quality & Governance Committee and the IP&C team’s valued contribution had been acknowledged. It was reviewed and approved by the Board of Directors.

16/116 EXECUTIVE TEAM (ET) CHAIR’S LOG Nil return; relevant issues in the month had been reported via the Finance & Performance and Quality & Governance Committees.

16/117 WORKING TOGETHER PARTNERSHIP (WTP) VANGUARD (16/07/P-12) - ACUTE FEDERATION BOARD The Chairman and Chief Executive jointly introduced the report, which presented the proposed way to formalise decision making across the WTP in certain clinical pathways. Ms Wake emphasised that, contrary to some media reporting, it was neither a transfer of Board powers nor was it intended to undermine the authority of any of the Boards within the WTP. Governance of the programme would fit into the Trust’s existing structure In terms of its budgetary and financial controls, the Chairman reminded members that the WTP already had a shared budget. Ms Wake anticipated that there would be a shared STP Control Target – ie a recovery in totality rather than individual organisational targets – which might impact on the WTP but this was not yet confirmed. Mr Kirton also reported on recent discussions at WTP network sessions which had acknowledged that not every action would be beneficial to every trust but had emphasised the focus on increasing commitment and the ability for partner trusts to hold each other to account, supported by the proposals for the Federation Board. The Chairman was conscious that it would be an executive board and highlighted the need for there to be an accountability to Non Executives and give assurance to Chairs, Mr Kirton confirmed that this point had been well made in the latest WTP discussions and would be taken into consideration in future plans. The Board was also conscious that the intent behind the Federation Board could be misunderstood, as illustrated in the recent media reporting. It was important that, subject to approval, the intent and impact of the Federation Board was explained properly to staff. Ms Parkes advised that work on robust communications was ready to be rolled out if/when required. After considerable discussion of the merits and potential drawbacks to the proposal, it was approved by the Board. Ms Parkes would launch the supporting communications in the next Team Brief.

EP

16/118 HEALTH & WELLBEING (H&WB) STRATEGY (16/07/P-11) Ms Sadler joined the meeting at 11am and was introduced as the HWBB Project Manager leading work on the H&WB Strategy refresh for 2016-2021. Ms Sadler advised that the Strategy refresh had been widely consulted upon as reflected in the latest draft distributed in the Board packs. As a key strategic tool for the local health economy it had been re-presented to the hospital Board for information and any further comments. Ms Sadler highlighted the many challenges facing the region with an ageing population, variable health expectations (very low in some areas of the

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borough) and the consequent demand on healthcare services. The presentation included a snapshot of the many community networks in Barnsley, which contributed to the developments and improvements which needed to be co-ordinated through the H&WB Board and provided enabling strategies supporting an overarching Framework – the H&WB Strategy. The Strategy’s vision was to ensure that “People of Barnsley are enabled to take control of their health & wellbeing and enjoy happy, healthy and longer lives, in safer and stronger communities, regardless of who they are and where they live”. As shown in the presentation, this was underpinned by four guiding principles, four areas of focus and four long term goals. When finalised, key issues in the Framework would include – but not be limited to -

• creating a smoke free generation

• making every contact count to improve health & wellbeing

• reducing health inequalities across the borough

• better integration of health and care services (a national expectation by 2020)

• systems resilience, ensuring Barnsley was well placed to fit with initiatives such as the STP and Sheffield City’s regional plans

• clear measurements to show progress Feedback from was wide ranging:

• Ms Dean queried how the Framework would target geographical issues, mindful that data showed greater uptake of services by the more affluent people in any region. This was particularly pertinent in Barnsley.

• Dr Jenkins suggested it was important to be able to illustrate progress, which could be boosted by focussing on small projects and allocating resources where needed (the number of GPs being a critical issue for the Borough).

• Ms Moore questioned the value of the huge number of underpinning strategies: did the Framework offer an opportunity to reduce/streamline these to make more effective and more manageable?

• Ms Moore also queried the intent of “integration”; discussions to date had referred to integration of services, not full systems.

• Mrs Brain England picked out one heading to illustrate a point: under “integrated health & social care” there was clear intent to put patients at the centre of everything, as was right – but the complexity of the current structure would present barriers. The draft said that the H&WB Board would continue to develop the digital road map (as required by Government) but would it have the power to do so with all organisations having their own IT systems and their own responsibilities?

• Was there too much focus on physical rather than mental health? The Chairman suggested the latter was implicit but should be more explicit.

• Reflecting earlier discussions, it was imperative that the progress was measurable against specific targets, was more “live” and aligned with other drivers regionally and locally, such as PLACE and STP.

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In conclusion it was confirmed that BHNFT very much wanted to be part of the H&WB Strategy for Barnsley. The Board would welcome feedback on the top three things that the Trust could take forward as part of delivering the Strategy. Before leaving the meeting at 11.25am, Ms Sadler was thanked for attending and for a useful presentation, which had led to some interesting discussions.

16/119 CHAIRMAN’S REPORT (16/07/P-13) The Chairman’s report was received and noted, providing an overview on a number of activities undertaken by the Chairman since the last Board meeting and items of interest, including feedback from national and local events and the continuing work of the Council of Governors and Barnsley Hospital Charity. Points highlighted included: - the HEART Awards held in June, which had been another very successful

event; - the Rainbow Dash, which had also been very successful: it had been

thoroughly enjoyed by participants, had raised welcome funds for the Hospital Charity and has also raised the profile of both the Charity and the Hospital across the Region

- the call for volunteers to join the Charity’s team marching in the Mayor’s Parade

- the charitable donations to the end of June, for both the general funds and the Tiny Hearts appeal – including nearly £20,000 raised since November in the incubator collection unit at main reception.

No reports were received from other members of the Non Executive team.

16/120 CHIEF EXECUTIVE’S REPORT (16/07/P-14) The Chief Executive’s report was received and noted, providing information on a number of internal, regional and national matters. Ms Wake highlighted section 10 - a brief update on the STP, which reflected earlier discussions around alignment of the various workstreams and the need to ensure critical initiatives were being progressed.

16/121 COUNCIL OF GOVERNORS (16/07/P-15) The latest agenda and approved Minutes for the Council of Governors’ General Meetings held in June and May respectively were received and noted. A number of Board members had been present at the June General Meeting and had provided feedback to the Chairman and via the governance Committees. The agenda and minutes were noted.

16/122 HORIZON SCANNER (16/07/P-16) The monthly horizon scanner was received and reviewed. Ms Parkes drew attention to the feedback on the Trust’s services included from the NHS Choice Website. Other points of note included the ongoing consultation on the NHS Single Oversight Framework (SOF), which aimed to give an integrated approach for all trusts – any comments on the SOF should be directed to the Chair and CEO as soon as possible for submission as part of the consultation process, and news from the CQC, including reported outcomes from latest inspections carried out in the region. The latter included a “good” rating for Sheffield Teaching Hospitals, despite its breach position on A&E and finance, and “requires improvement” for SWYPFT (the Chairman and CEO had

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received invitations to the quality summit for SWYPFT). The report also referenced the Manchester devolution plans, now endorsed by the Manchester Council.

16/123 FINANCE & PERFORMANCE COMMITTEE (F&P) (16/07/P-17) In Mr Patton’s absence, Mr Wright (Vice Chair of the F&P Committee) presented the Chair’s Log from the Committee’s meeting held in June. Key issues escalated by the Committee included:

• the latest financial position – on plan at the end of month 2 but with areas for scrutiny within the overall outcomes

• improved position in the <4 hours emergency access time

• continued improvement in sickness absence levels, now at 3.7% (best performer regionally)

• two new Strategies received and endorsed on Staff Engagement and ICT (the latter also a separate item on the Board’s agenda) and the updated Workforce Strategy, also endorsed by the Committee

• continued focus on the cost improvement programme (CIP). Mr Mapstone advised that this was currently the area of most concern for the Committee. The Chairman agreed, with costs rising it seemed inequitable that the bottom line was on track but the CIP was considerably off trajectory. As requested by the Committee, Mr Kirton would provide an update for the Board (in private session due to commercial content); Ms Wake advised that this would be a revision to the month end data for May, including some savings not previously captured.

The Log was accepted and the Workforce and Staff Engagement Strategies were approved as recommended by the Committee.

16/124 INTEGRATED PERFORMANCE REPORT (IPR) (16/07/P-18) The month 2 IPR was received and reviewed. Lead Directors highlighted key factors from each section: Quality Mrs McNair reported on the improvements in response times to complaints and the further reduction in harm from falls. She also drew attention to the levels of hospital acquired pressure ulcers, although the numbers were relatively small, there had been an increase and a deep dive had been commissioned to gain more detail. The serious incidents (SIs) had been reviewed by the Q&G Committee, four of which were pressure ulcers (now reportable as SIs). The Chairman advised that, as requested at Q&G, weekly reporting to him on all SIs had been reintroduced and this was appreciated. Workforce Mr Fernandez drew attention to the position on recruitment and highlighted the 41 vacancies recently recruited to nursing subject to qualification; some might give backword but the vacancies had been over-appointed to mitigate this risk. The good performance on sickness absence levels was reiterated, although work still continued around use of the fast track system, which was not yet being adhered to fully. The report reflected the uptake of appraisals at month 2; latest data now included month 3 and showed that the Trust had overachieved target at 91%

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for April-June. Emails had been sent to the CBU triumvirates to ensure all appraisals were completed, so the report next month was expected to reflect 95-96% attainment. Activity As reported earlier, Mrs Kelly was pleased to highlight the continued improvement in the <4 hours emergency access target. This now stood at 94.78% year to date, and she was hopeful that the Trust would reach 95% compliance by the month end, with plans to continue to sustain delivery going forwards. Whilst national benchmarking data was not currently available, the Trust was among the top performers locally. This reflected closure of the escalation beds and very different working practices around management of flows and different working in the bed management team; the Non Executive Directors were encouraged to revisit this team to see the changes. There were still areas of concern around the 62 day cancer targets (largely in lung and colorectal services) and work continued to ensure compliance with the 38 day referral to tertiary services, which would go live in October. The CBUs involved were very aware of the work needed and Mr Wickham, the Cancer Services Lead, would be meeting with key leads to take the work forward. With the new Radiology Consultant now in post, changes were being made in Breast Symptomatic services both at BHNFT and in partnership with Doncaster, the impact of which would be seen in future reporting. Other good news was noted in terms of Referral to Treatment (RTT) pathways, which continued to perform well; DNAs (did not attend), which had continued to reduce (c8% in June - would be seen in the month 3 reporting), and the slot utilisation system now in place for theatres (further embedding work with the CBUs ongoing). Mrs Kelly was also pleased to confirm that the outpatients review list had now been resolved, with only 30 patients outstanding (but all appointed). A more detailed report would be presented to the Audit Committee in July. Finance Most issues had been addressed in the F&P Chair’s Log but Mr Wright highlighted the recovery on income in month 2, which had brought the outcome broadly in line with plan despite some pressures in CBU1. Pay costs were in line with plan due to good controls, particularly around agency spend. Month 3 would be more challenging.

16/125 ICT STRATEGY 2016-2021 Presentation Although Members had seen drafts of the new Strategy in consultation, Mr Davidson presented an overview of the final version. The Strategy document was intended to be a concise summary of the consultation and a move away from traditional ICT strategies, with more focus on outcomes, expected improvements and the real differences to staff and patients. Subject to approval of the Strategy, Mr Davidson planned to issue brochures, posters and screen savers across the Trust to get the core messages embedded quickly. Further workshops would be scheduled on existing technology and how it could be better used to deliver electronic records across the organisation (clinical and non clinical). Key areas of focus in the Strategy included - delivery of electronic records safely by December 2020

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- delivery of missing capabilities in 2016/17 and ensuring all essential technology was in place

- investigation and delivery of patient facing technology (eg quick access to live information on A&E waits etc)

- sharing information with colleagues across boundaries as part of the Digital Roadmap for Barnsley being led by the CCG

- working towards more paperless systems, with a route map outlined (including training and staff support needs) to show how this would be achieved in some teams. A robust template was being developed to roll the programme out to other areas

- continued benefits to patient safety, patient experience, efficiency productivity and interoperability

Ms Dean welcomed the operational focus and the clear articulation in the document and this was echoed by everyone present. The Strategy was approved.

16/126 ANY OTHER BUSINESS & DATE OF NEXT MEETING a) Public Comments

None b) Date of Next meeting

The next meeting of the Board of Directors was scheduled for 4th August 2016, commencing at 9am.

In accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

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HSMR - updated with Dr Foster figures

Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Karen Kelly

June 2016

Integrated Performance Report

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Contents

Executive Summary……………………………… 3

Summary…………………………………………….. 9

Patients will experience Safe Care………. 11

Partnerships will be our Strength………. 25

People will be proud to work for us…… 26

Performance Matters………………………… 30

a) Key Performance Indicators……………… 31

b) Data Quality……………………………………… 40

c) Activity……………………………………………… 44

d) Financial Overview……………………………. 46

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Executive Summary by Exception

Key Messages

1 Patients will experience safe care Committee: Q&G Page: 11-24

Quality & Patient Experience:-

Falls

During June the Trust received 20 new complaints bringing the year to date total to 65, with a primary focus on clinical care and treatment. The complaints were risk assessed as follows: low

risk (5), moderate risk (14) and high risk (1). The majority of complaints were allocated to CBU 1 (13), with CBU 2 having (3), CBU 3 having (3) and Corporate services having (1) new complaints.

The percentage of complaints closed within target increased to 74% which is a further improvement on the previous month. Five complaints were re-opened. CBU 1 continues to have the

highest number of open complaints and staffing changes within CBU 1 have had an impact on investigation timeframes. To mitigate this additional resource has been allocated to CBU 1 to

improve performance and this is being supported by close performance management by the CBU management team.

With effect from 1 July 2016 changes have been made to the complaints process with an emphasis on CBU Investigating Officers (IO) taking responsibility for contacting complainants and

agreeing their areas of concern and how these will be managed. This change in process will allow IOs to build a relationship with the complainant and gain a greater understanding of their

concerns

Complaints

This is the third consecutive month we have seen a significantly reduced number of total falls incidents reported across the organisation. The number of incidents reported were 66 in total, this is

the lowest number reported in the past twelve months. In the main this can be attributed to significant falls incidents reported in AMU and wards 19 and 20. This would support an assumption

that the falls strategies being adopted across the organisation are beginning to deliver a sustained reduction in falls incidents and that we need to maintain our current falls work plan.

In addition we can report in June there were no moderate or above harm from falls. This is another significant improvement in the month and is worthy of particular note.

Patients Partnerships People Performance

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Key Messages

1 Patients will experience safe care cont. Committee: Q&G Page: 11-24

Pressure UlcersGrade 3 pressure ulcers

There were two avoidable grade 3 pressure ulcers in June 2016.

In both incidents, the Waterlow risk assessment score had been inaccurately assessed, so the patients were not identified as being at high risk of pressure damage. Some preventative measures

were utilised, but were not sufficient to prevent pressure damage.

A patient on ward 17 had vulnerable skin due to heavy, oedematous legs, but heel elevation was not high enough to keep the heels offloaded from the bed / footstool. The patient developed

deep tissue damage to both heels.

A patient on ward 19 had no documented evidence of any pressure relieving equipment, until after pressure damage was identified. Poor daily skin assessments were also evident.

Action: The recurrent inaccurate calculation of Waterlow risk assessment and subsequent lack of preventative measures has prompted a review of the BHNFT pressure ulcer risk assessment

process. A fact finding exercise on alternative risk assessment tools / pathways has been completed. A Task and Finish group of senior nursing staff has been set up to develop a new risk

assessment tool and pathway, based on the traffic light model, which has been instrumental in the reduction of hospital acquired pressure ulcers, at Doncaster and Bassetlaw Hospitals NHS

Foundation Trust.

Grade 2 pressure ulcers

There were five avoidable grade 2 pressure ulcers in June 2016 – two of which were caused by devices. A patient on ITU developed a grade 2 pressure ulcer to the clavicle from an Aspen collar,

and a patient on ward 23 developed grade 2 pressure damage to the shoulder from lying on a nurse call buzzer.

Action: There have been a number of pressure ulcers in recent months caused by medical devices / devices. It has been communicated to staff via the Patient Safety Bulletin the importance of

not only checking beneath devices (where possible) but also of documenting any changes to skin integrity, and also that staff must check, when repositioning patients, that the nurse call buzzer is

not trapped beneath the patient. The nurse call buzzers get very hot, increasing the risk of skin damage, and this has been reported to Estates.

Two of the three avoidable grade 2 pressure ulcers developed to the patients sacrum (AMU / ward 19) and one to a patients spine (ward 18). Poor documentation of skin integrity assessments

and preventative measures was evident in all these incidents.

Action: The Task and Finish group will also be reviewing the current pathway, with a focus on ensuring preventative meaures are instigated and documented if the patient is deemed at risk. There

will be a focus in the pathway on expectations around skin assessment.


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Key Messages

1 Patients will experience safe care cont. Committee: Q&G Page: 11-24

Safety

Mortality

DNA Rates

A&E 4 Hour Wait

There have been 7 SIs in total reported in June 2016 only 2 occuared in June 16

• 2016/17629 – missed pulmonary embolism in orthopaedic outpatients; incident occurred in January 2014 (DTX 28895)

• 2016/12027 – avoidable grade 3 pressure ulcer on ward 17; this incident occurred in June 2016 (DTX 28197)

• 2016/16441 – inpatient fall resulting in an intracranial bleed and a fractured wrist on AMU; this incident occurred in May 2016 (DTX 28128)

• 2016/16335 – Retinal screening delays due to delayed referrals from GP practices; this incident occurred in October 2015 (DTX 28558). This SI is shared with NHS England public

health

• 2016/15596 – avoidable grade 3 pressure ulcer on ward 31; this incident occurred in May 2016 (DTX 27858)


• 2016/15337– avoidable grade 3 pressure ulcer on ward 18; this incident occurred in May2016 (DTX 27536)

June 95.5% achieved maintain performance against the agreed trajectory and achievement of the national standard.

Activity continues to be high with a 10% variance against contracted levels.

Serious Incidents

HSMR – We are currently transitioning over to the use of Dr Foster for our HSMR reporting. The rolling 12 months HSMR (to March 2016 ) from Dr Foster is 95.7.

SHIMI - The latest SHMI for Q3 2015/16 is 98.6. SHMI has steadily fallen since Q4 2013/14

2 way text messaging service has been rolled out over all specialties and we anticipate a reduction in DNA rates across the trust.


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Key Messages3 People will be proud to work for us Committee: F&P Page: 26-29

Staff Turnover

Appraisals

Mandatory Training

Sickness Absence

Sickness Absence – has slightly increased from last month’s figure of 3.73% to 3.90%. Weekly monitoring of open ended sickness absence cases will continue to

ensure accurate reporting and timely management of cases. Also an action plan is now in place to improve the take up of the fast track referral service to aid earlier

interventions and return to work for the fast track conditions.

Appraisal – for medical staff is at 98.1% and for non-medical staff is at 97.5%, all CBUs have achieved compliance.

Mandatory Training – overall compliance is just below target at 85.5%. Resuscitation Immediate Life Support and Resuscitation Advanced Life Support continue to be

the worst attended courses with 53.4% and 69.2% compliance respectively.

Staff Turnover – is at 9.30% within the expected range of 7 – 10% and in line with the NHS average turnover of 9%. At the end of quarter 1, we have seen an

improvement in the exit questionnaires return rate from 9% to 26% which should provide useful information to inform future recruitment and retention initiatives.


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Executive Summary by Exception cont.

Key Messages

4 Performance Matters Committee: F&P Page: 30-39

a) Key Performance Indicators

62 Day - Urgent GP Referral to Treatment

Breast symptomatic 2WWThe breast symptomatic target was also non-compliant at the end of Q1 despite some additional capacity and acheivement of the standard in June of 95.2%. Breach reasons remain

predominantly patient choice but lack of capacity to allow booking early in the 14 day window, renders true ‘choice’ limited. However, actions taken to improve local capacity and radiological

support are starting to yield benefit and the Q2 position is stronger and compliant thus far.

The 62 day GP referral to treatment target was non-compliant in both April and May with validated positions of 84.4% and 79.2% respectively. Whilst the June month end position was compliant

at 87.5% - overall, there was failure of the target at quarter end. Final breach validation work has been undertaken but there are no recoverable actions identified. July is showing sustained

compliance and efforts will focus on recovery of the target through Q2.

During May there were 12 breaches in total (9 shared with the tertiary centre and 3 local breaches). Highest breach volumes were seen across the lung (=5) and Lower GI (=4) pathways with

these teams demonstrating performance against the 85% target of 16.7% (Lung) and 25% (Colorectal). Breach analysis revealed delays due to medical reasons, complexity, delays to diagnostics

and inefficient pathways.

Breaches were also seen in UGI (=1), Urology (=1) and Haematology (=1) However, the Haematology patient was originally on a Lung pathway and had breached the target before transfer of care

to the haematology team.


Pack pg no 64

Executive Summary by Exception cont.

Key Messages

4 Performance Matters cont. Committee: F&P Page: 46-49

b) Financial overviewThe Trust has a year to date deficit position of £2.07m that is slightly favourable to plan. CIP delivery for month 3 is adverse to plan year to date, although over performed in month. Clinical income

is ahead of plan, although the activity mix is varied. The Trust is currently on plan to hit its trajectory targets and deficit targets and as such has accrued in expectation of receipt of Sustainability

and Transformation funding.


Pack pg no 65

1 2 3 4 6 7 11 12 13 14 15 16 17 18 19 20

Domain April 16 Summary Target Set By Current QtrFinancial Year

to DateApr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Trend

FFT Positivity Rates - EDG >85%, A >=80%-

85%, R <80% (> )BHNFT 89.3% 89.3% 89.1% 90.5% 88.0%

FFT Positivity Rates - IPG >85%, A >=80%-

85%, R <80% (>)BHNFT 97.6% 97.6% 96.7% 97.4% 98.7%

FFT Positivity Rates - OPG >85%, A >=80%-

85%, R <80% (>)BHNFT 94.8% 94.8% 95.4% 94.4% 94.7%

FFT Positivity Rates - MATG >85%, A >=80%-

85%, R <80% (>)BHNFT 98.7% 98.7% 98.8% 98.0% 99.3%

Complaints closed within target %G >90%, A >=70%-

90%, R <70% (>)BHNFT 58.8% 58.8% 35.7% 66.7% 73.5%

Dementia - Find/Assess 90% (>) National 95.5% 95.5% 97.0% 97.0% 92.5%

Dementia - Investigate 90% (>) National 100.0% 100.0% 100.0% 100.0% 100.0%

Dementia - Refer 90% (>) National 100.0% 100.0% 100.0% 100.0% 100.0%

Falls 785 (<) BHNFT 168 168 58 56 54

Multiple Falls n/a BHNFT 38 38 10 16 12

Falls resulting in moderate harm or above 20 (<) BHNFT 4 4 1 3 0

Hand washing 95% (>) National 99.5% 99.5% 99.7% 99.3% 99.4%

Pressure Ulcers Grade 3 & 4 (Avoidable) 0 (<) BHNFT 8 8 4 2 2

Pressure Ulcers Grade 2 (Avoidable) 0 (<) BHNFT 14 14 3 6 5

Single Sex Breaches 0 (<) National 0 0 0 0 0

Hospital Acquired Clostridium Difficile 13 (<) NHSE 0 0 0 0 0

MRSA Bacteraemia 0 (<) NHSE 0 0 0 0 0

VTE Screening Compliance 95% (>) NHSE 94.3% 94.3% 91.7% 95.5% 95.8%

Recorded Medication Incidents 400 (<) National 132 132 41 56 35

Recorded Medication Errors - Causing harm 10 (<) National 1 1 0 1 0

Never Events - Occurred in Month 0 0 0 0 0

Never Events - Reported in Month 0 0 0 0 0

Serious Incidents n/a NHSE 18 18 3 8 7

Death 0 (<) National 2 2 0 2 0

Severe 0 (<) National 3 3 2 1 0

Percentage of Incidents Causing Harm 28% (<) BHNFT 8.6% 8.6% 8.5% 9.5% 7.0%

Total (All) 7400 (<) National 1785 1785 569 598 618

HSMR (Rolling 12 months) Latest Data is March 2016 100 (<) National 98.8 95.6 96.6

SHMI (Rolling 12 months) Latest Data is December 2015 105 (<) National 97.8 98.6

HSMR (Financial Year to date) - April 15 - February 16 100 (<) 99.3 97.9 99.3 95.7

Summary

Quality & Patient

Experience

Patients will experience safe care

Mortality

Patient Safety

0 (<) NHSE


Pack pg no 66

Domain KPI Target Set By Current QtrFinancial Year

to DateApr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Trend

Staff Turnover (Rolling 12 months)G <=10%, A >10%-11%, R

>11% (<)BHNFT 9.3% 9.3% 9.3% 8.5% 9.3%

Appraisals (Rolling 12 months)G >90%, A >=70%-90%, R

<70% (>)BHNFT 90.9% 90.9% n/a 40.5% 90.9%

Mandatory Training (Rolling 12 months)G >90%, A >=85%-90%, R

<85% (>)BHNFT N/A N/A 86.6% 86.2% 85.5%

Sickness Absence (Rolling 12 months)G <=3.75%, A >3.75%-

4.25%, R >4.25% (<)BHNFT 3.9% 3.9% 4.1% 3.7% 3.9%

RTT Admitted 90% (>) National 0.0% 87.9% 87.2% 88.0% 88.3%

RTT Non-Admitted 95% (>) National 0.0% 98.2% 98.3% 98.4% 97.9%

RTT Incomplete Pathways 92% (>) National 0.0% 94.5% 95.0% 94.3% 94.2%

Diagnostic patients waiting more than 6 weeks 99.88% National 193 197 141 52 4

Cancer 2 Week Waits 93% (>) National 94.1% 93.9% 95.1% 93.2%

Symptomatic Breast 2 Week Waits 93% (>) National 91.0% 85.3% 92.7% 95.2%

31 Day - 1st Definitive Treatment 96% (>) National 99.0% 98.7% 100.0% 98.3%

31 Day - Subsequent Treatment (Surgery) 94% (>) National 100.0% 100.0% 100.0% 100.0%

31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100.0% 100.0% 100.0% 100.0%

62 Day - GP Referral to Treatment 85% (>) National 83.9% 84.4% 79.2% 87.5%

62 Day - Screening Referral to Treatment 90% (>) National 94.1% 100.0% 90.9% 100.0%

62 Day - Consultant Upgrade to Treatment 85% (>) BHNFT 81.0% 80.0% 75.0% 90.0%

Emergency % Patients Waiting <4 Hours 93% (>) National 94.7% 94.7% 93.0% 95.4% 95.5%

Average Length of Stay - ElectiveG <=2.42, A >2.42-2.67, R

>2.67 (<)BHNFT 2.22 2.14 2.33 2.34

Average Length of Stay - Non-ElectiveG <=3.44, A >3.44-3.69, R

>3.69 (<)BHNFT 2.73 2.68 2.83 2.68

Re-admissions % BHNFT 9.7% 9.7% 9.5% 10.0% 9.2%

Cancelled Operations - Breaches of the 28 day rule 0 (<) National 0 0 0 0 0

DNA Outpatient DNA RatesG <=10%, A >10%-

11%, R >11% (<)BHNFT 0.0% 11.0% 11.2% 11.0% 8.5%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets

which will be RED if the target is not achieved)

GREEN Achieved Target

< Less Is Good

> More is good

NOTE: National Indicators such as Cancer, RTT, Cancelled Ops, etc. are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

All other indicators are classed as Achieved or Failed with the exception of all Workforce KPIs, Average Length of Stay & DNA rates which detail the tolerances applied in the Target column.

Elective Access

Cancer

Operational

Efficiency

Performance matters - Key Performance Indicators

People will be proud to work for us

Workforce

Summary


Pack pg no 67

1 2 3 4 5 8 18 19 20 # 22 # 24 25 26 27 39 40 41 42 43

Patients will experience safe care - "At a glance"

Target

16/17

Target

YTDJun-16

Actual

YTDTrend

YTD

Status

Target

16/17

Target

YTDJun-16

Actual

YTDTrend

YTD

Status

Friends & Family Test (Quality Strategy Goal 1) Mortality (Quality Strategy Goal 3)

Friends & Family Test - ED 85% 85% 88.0% 89.3% ↔ 89.3% HSMR Rolling 12 months (Latest data Feb 16) 100 100.0 95.7 95.7 ↓ 95.7

Friends & Family Test - Inpatients 85% 85% 98.7% 97.6% ↔ 97.6% SHMI Rolling 12 months (Latest data Sept 15) 105 105.0 98.6 98.6 ↑ 98.6

Friends & Family Test - Maternity 85% 85% 99.3% 98.7% ↔ 98.7% HSMR Year to date (Latest data Feb 16) 100 100.0 95.7 95.7 ↓ 95.7

Friends & Family Test - Outpatients 85% 85% 94.7% 94.8% ↔ 94.8%

VTE Screening Compliance (Quality Strategy Goal 2) 95% 95% 95.8% 94.3% ↑ 94.3%

Complaints (Quality Strategy Goal 1)

Total no. of complaints N/A N/A 20 65 ↔ Medication Incidents (Quality Strategy Goal 2)

Complaints closed within target 90% 90% 73.5% 58.8% ↔ 58.8% Recorded Medication Incidents 400 133 35 132 ↑ 1

Complaints re-opened N/A N/A 5 11 ↔ Recorded medication errors - Causing harm 10 3 0 1 ↑ 1

Dementia (Quality Strategy Goal 1) Serious Incidents (Quality Strategy Goal 2)

Find/Assess 90% 90% 92.5% 95.5% ↔ 95.5% Never Events Occurring in Month 0 0 0 0 ↔ 1

Investigate 90% 90% 100.0% 100.0% ↔ 100.0% Never Events Reported in Month 0 0 0 0 ↔ 1

Refer 90% 90% 100.0% 100.0% ↔ 100.0% Serious Incidents N/A N/A 7 18 ↑ 1

Falls (Quality Strategy Goal 2) Incident Grading (Quality Strategy Goal 2)

No. of Falls 785 262 54 168 ↔ 1 Death 0 0 0 2 ↑ 0

No. of Multiple Falls N/A N/A 12 38 ↔ 1 Severe 0 0 0 3 ↑ 0

Falls resulting in moderate harm or above 20 7 0 4 ↔ 1 Moderate N/A N/A 10 35 ↑

Low N/A N/A 33 112 ↑

Hand washing (Quality Strategy Goal 2) 95% 95% 99.4% 99.5% ↔ 99.5% No Harm N/A N/A 575 1618 ↓

Percentage of incidents causing harm <28% 28% 7.0% 8.6% ↑ 8.6%

Pressure Ulcers (Quality Strategy Goal 2)

Grades 3 & 4 (Avoidable) 0 0 2 8 ↔ 0

Grade 2 Post (Avoidable) 0 0 5 14 ↔ 0 Patient Safety (Quality Strategy Goal 2)

Total Incidents 7400 2467 618 1785 ↑ 1

Single Sex Breaches (Quality Strategy Goal 1) 0 0 0 0 ↔ 1

Infections (Quality Strategy Goal 2)

Hospital Acquired Clostridium Difficile 13 3 0 0 ↔ 1

MSSA N/A N/A 1 2 ↔

MRSA Bacteraemia 0 0 0 0 ↔ 1

Ecoli - Total hospital N/A N/A 1 4 ↔

Patients will experience safe care - Quality & Experience Patients will experience safe care - Patient Safety


Pack pg no 68

Patients will experience safe care (Safety)

Mortality (Quality Strategy - Goal 3: Delivering Consistently Effective Care)

HSMR rolling 12 month target

HS

MR

HS

MR


Pack pg no 69



SHIMI rolling 12 month target

Comments

HSMR

SHMI

SH

MI

an

d C

rud

e M

ort

ali

tyC

rud

e M

ort

ali

ty

SHIMI - The latest SHMI for Q3 2015/16 is 98.6. SHMI has steadily fallen since Q4 2013/14

HSMR – We are currently transitioning over to the use of Dr Foster for our HSMR

reporting. The rolling 12 months HSMR (to March 2016 ) from Dr Foster is 95.7.

Pack pg no 70



Incidents (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Me

dic

ati

on

In

cid

en

ts -

Ca

usi

ng

ha

rm

Ne

ve

r E

ve

nts

& S

eri

ou

s In

cid

en

ts

Inci

de

nt

Gra

din

g

Pa

tie

nt

Sa

fety

In

cid

en

ts (

All

)

0

10

20

30

40

50

60

0

2

4

6

8

10

12

Total Medication Incidents Causing Harm Cumulative Target

Causing Harm Cumulative Actual

0

1

2

3

4

5

6

7

8

9

Serious Incidents Never Events SI Target Never Event Target

0

100

200

300

400

500

600

700

Actual Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

0

10

20

30

40

50

60

Pe

rce

nta

ge

Ca

usi

ng

Ha

rm

Gra

din

g

Low Moderate Severe Death % Causing Harm

Pack pg no 71

Patients will experience safe care (Quality & Experience)

June 16 Summary

7

9

Fri

en

ds

& F

am

ily

Te

stF

rie

nd

s &

Fa

mil

y T

est


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ED Actual IP Actual OP Actual MAT Actual Target

95.5% 97% 97% 99% 97% 95% 92% 97% 94% 97% 97%

73%

96% 98% 97%

0%

20%

40%

60%

80%

100%

120%

Friends & Family Test - Inpatient Benchmarking(Latest NHS England Published Data - Feb 2016)

Peer Group Local Target

95.9%

100% 99% 99%96%

92%

97%

92%

97% 97% 97% 97% 98%

93%

75%

80%

85%

90%

95%

100%

105%

Friends & Family Test - Maternity Benchmarking(Latest NHS England Published Data - Feb 2016)


86%95%

89% 90% 90% 92% 93%86% 85%

94%85%

90%85%

92%

79%

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

100%

Friends & Family Test - A&E Benchmarking (Latest NHS England Published Data - Feb 2016)


Pack pg no 72



Complaints (Quality Strategy - Goal 1: Delivering Patient Centred Care)

Comments:

Co

mp

lain

tsC

om

pla

ints

Co

mp

lain

ts

During June the Trust received 20 new complaints bringing the year to date total to 65, with a primary focus on clinical care and treatment.

The complaints were risk assessed as follows: low risk (5), moderate risk (14) and high risk (1). The majority of complaints were allocated

to CBU 1 (13), with CBU 2 having (3), CBU 3 having (3) and Corporate services having (1) new complaints. The percentage of complaints

closed within target increased to 74% which is a further improvement on the previous month. Five complaints were re-opened. CBU 1

continues to have the highest number of open complaints and staffing changes within CBU 1 have had an impact on investigation

timeframes. To mitigate this additional resource has been allocated to CBU 1 to improve performance and this is being supported by

close performance management by the CBU management team.

With effect from 1 July 2016 changes have been made to the complaints process with an emphasis on CBU Investigating Officers (IO) taking

responsibility for contacting complainants and agreeing their areas of concern and how these will be managed. This change in process will

allow IOs to build a relationship with the complainant and gain a greater understanding of their concerns

0

5

10

15

20

25

30

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Complaints by Category

Patient Care Access, Appts, etc Communication Medical Records Medication

Falls Infection Control Infrastructure Other

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge

wit

hin

ta

rge

t

Complaints Closed within Target

% closed Target

150

155

160

165

170

175

180

185

190

195

0

5

10

15

20

25

30

Complaints and PALS Enquiries

Complaints Re-opened PALS

Pack pg no 73



Dementia (Quality Strategy - Goal 1: Delivering Patient Centred Care)

Comments:

De

me

nti

aD

em

en

tia

- B

en

chm

ark

ing

De

me

nti

a -

Be

nch

ma

rkin

g

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Find/Assess Actual Investigate Actual Refer Actual Target

95% 95%94%

90%

98%

91% 91%

95%94%

90%

100%98%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Percentage of Cases Identified (Latest NHS England published data December 2015)

Peer Group Target

94%

100% 100% 100% 100% 100% 100%

98%

100% 100% 100% 100%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Percentage of Cases with Diagnostic Assessment (Latest NHS England

Published data December 2015)

Peer Group Target

Pack pg no 74



Falls (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

Fa

lls

resu

ltin

g i

n m

od

era

te h

arm

or

ab

ov

eF

all

s

The number of falls reported in February remains around the same number as prior

months.

Mu

ltip

le F

all

s

This is the third consecutive month we have seen a significantly reduced number of total falls incidents reported across the organisation. The number of

incidents reported were 66 in total, this is the lowest number reported in the past twelve months. In the main this can be attributed to significant falls

incidents reported in AMU and wards 19 and 20. This would support an assumption that the falls strategies being adopted across the organisation are

beginning to deliver a sustained reduction in falls incidents and that we need to maintain our current falls work plan.

In addition we can report in June there were no moderate or above harm from falls. This is another significant improvement in the month and is worthy of

particular note.

0

10

20

30

40

50

60

70

No

. o

f F

all

s

No. of Falls

Actual Target

0

2

4

6

8

10

12

14

16

18


No

. o

f M

ult

iple

Fa

lls

Multiple Falls

Actual Target

0

1

2

3

4

No

. o

f F

all

s

Falls resulting in moderate harm or above

Actual Target

Pack pg no 75



Pressure Ulcers (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

As stated

last

Pre

ssu

re U

lce

rs -

Gra

de

3 &

4P

ress

ure

Ulc

ers

- G

rad

e 2

See Executive Summary

0

1

2

3

4

5

6

7

8

9

10

Grade 2 Unavoidable Grade 2 Avoidable Target

0

1

2

3

4

5

6

7

8

Grade 3&4 Avoidable Grade 3&4 Unavoidable

Pack pg no 76



Infections (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

Eco

li B

act

era

em

ia

Ho

spit

al

Acq

uir

ed

Clo

stri

diu

m D

iffi

cile

To

xin

0

1

2

3

4

5


0

2

4

6

8

10

Hospital Acquired Clostridium Difficile Toxin (cumulative position)

Tolerance Actual

Pack pg no 77



Nursing Staffing Fill Rate (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments:

14 97.8% 81.7% 100.0% 100.0% 2.9 1.5 Registered Nurses

17 84.2% 89.4% 93.4% 140.0% 2.9 2.2 Registered Midwives

18 83.8% 99.7% 92.2% 120.0% 3.4 2.2 Unregistered health care/midwifery care assistants

19/20 68.4% 107.8% 100.8% 155.7% 2.3 3.9 Unregistered nursing/midwifery auxiliaries.

AMU 78.1% 94.6% 91.1% 102.5% 4.9 3.5

Acute

Stroke 79.7% 77.8% 88.9% 116.7% 4.2 2.8

24 102.2% 99.6% 96.7% - 4.7 3.1

28 89.2% 87.0% 100.0% 116.7% 2.2 2.6

31 67.4% 123.4% 100.0% 97.1% 2.7 2.9

32 76.6% 110.7% 100.0% 193.3% 3.1 3.3

34 72.1% 97.7% 84.2% 123.3% 3.2 3.5

ITU 89.1% 99.6% 97.5% - 31.4 2.3

SHDU 100.2% 53.7% 100.0% - 16.1 2.7

CCU 96.9% 93.3% 100.2% - 12.0 1.8

AN/PN 92.0% 90.6% 100.0% 106.7% 6.1 2.1

Birthing

Centre93.0% 115.8% 98.4% 77.6% 27.3 4.8

37 92.5% 83.4% 91.7% - 7.5 1.7

15 93.7% 88.2% 92.0% 73.3% 10.9 2.3

BHNFT is committed to ensuring that levels of nursing staff, match the acuity

and dependency needs of patients in order to provide safe and effective care.

Nurse staffing includes:

Ave fill rate

Care staff

(%)

Night

Registered

Nurses/Midw

ives

Care Staff

Care Hours Per Patient

Nu

rsin

g S

taff

ing

Fil

l R

ate

422- NEONATOLOGY

110 - TRAUMA &

ORTHOPAEDICS192 - CRITICAL CARE

MEDICINE

Day

300 - GENERAL MEDICINE

300 - GENERAL MEDICINE

Ward

name

Ave fill rate

Registered

320 - CARDIOLOGY

340 - RESPIRATORY MEDICINE

430 - GERIATRIC MEDICINE

502 - GYNAECOLOGY

We have started recording and submitting Care Hours Per Patient Day.

This allows for contingency plans to be made where the roster identifies that

the planned staffing falls short of the minimum requirement, for example

where there are vacant nursing posts or staff appointed have not started in

post. These contingency plans can include: moving staff from a shift which is

above the minimum required level, moving staff from another ward/area

which is above the minimum required level, or the use of flexible/temporary

staffing from the Trust’s internal bank or via an external nursing agency.

420 - PAEDIATRICS

192 - CRITICAL CARE

MEDICINE

Specialty

100 - GENERAL SURGERY

Ave fill rate

Registered

320 - CARDIOLOGY

501 - OBSTETRICS

501 - OBSTETRICS

370 - MEDICAL ONCOLOGY

301 - GASTROENTEROLOGY

100 - GENERAL SURGERY

The Trust uses an e-rostering system with duty rosters created eight weeks in

advance to ensure the levels and skill mix of the nursing staff on duty are

appropriate for providing safe and effective care.

Ave fill rate

Care staff (%)

Pack pg no 78

Patients will experience safe careHeatmap Jun-16

MR

SA

Ba

cte

rae

mia

C D

iff

Fall

s -

No

Ad

ve

rse

Ou

tco

me

Falls

-

Advers

e

Outc

om

e

Mu

ltip

le f

all

s -

No

Ad

ve

rse

Ou

tco

me

Mu

ltip

le f

all

s -

Ad

ve

rse

Ou

tco

me

Me

dic

ati

on

Err

ors

- N

o

Ad

ve

rse

Ou

tco

me

Me

dic

ati

on

Err

ors

- N

ea

r

mis

s

Me

dic

ati

on

Err

ors

-

Ca

usi

ng

Ha

rm

Nu

mb

er

of

Seri

ou

s

Inci

de

nts

Nu

mb

er

of

Ne

ve

r E

ve

nts

Pre

ssu

re

Ulc

ers

Gra

de

2

(Avo

ida

ble

)

Pre

ssu

re

Ulc

ers

Gra

de

3

(Avo

ida

ble

)

Pre

ssu

re

Ulc

ers

Gra

de

4

(Avo

ida

ble

)

Inci

de

nts

-

De

ath

Inci

de

nts

-

Seve

re

Inci

de

nts

-

Mo

de

rate

Inci

de

nts

-

Low

Inci

de

nts

- N

o

Ha

rm

Trust 0 0 50 4 11 1 22 13 0 2 0 5 9 0 0 0 2 33 514

AMU 6 4 3 1 1 2 51

ARU 0 0

Cardiology Department 0 0

CCU 0 2

CDU 1 1 8

Chemo Unit 3 2

Dermatology 0 1

Diabetes Centre 0 0

Discharge Unit 1 0 0

ED 3 81

Endoscopy 0 4

Ward 17 1 2 1 1 1 0 5

Ward 18 5 2 1 1 1 1 5 23

Ward 19 5 1 2 2 1 1 3 3 23

Ward 20 9 3 3 1 0 13

Ward 23 5 2 1 1 0 15

Ward 24 2 1 0 8

Ward 28 6 2 4 1 5 19

CBU 2 Management/ Admin Team 0

Day Surgery 0

ENT Outpatients 9

Fracture Clinic 1 3

HDU 1

Hospital at Night 0

ICU 1 1 2 1

Opthalmology OPD 7

Oral Surgery 1

Orthopaedic Outpatients 2

Orthoptics OPD 0

Planned Investigation Unit 1 1

Plaster room 2

Pre Assessment Unit 0

SAU 2

SDA 2

SHDU 11

Theatres 1 1 1 4

Theatres recovery 1

Urology Investigation Unit 24

Ward 29 1 6

Ward 30 0

Ward 31 1 1 1

Ward 32 2 1 0

Ward 33 6 1 1 10

Ward 34 2 6

Antenatal Clinic 1

Antenatal Day Unit

Anticoagulation Clinic

Breast Screening

Childrens Assessment Unit 2

Colposcopy

Community Midwifery 2

Community Paediatrics 1 2

Early Pregnancy Assessment Unit

Gynaecology OPD

Labour Suite 1 80

Medical Imaging 1 1 8

Nuclear Medicine

Obstetric Theatre 2

Paediatric secretaries office 1

Pathology 4

Patient's Home (community) 1

Patient's Home (Maternity) 3

Pharmacy 1 2 3

Phlebotomy Outpatients 1

Physiotherapy 1

Postnatal/Antenatal Ward 11

Ultrasound 1

Ultrasound (maternity)

Urgent Care Therapy Team 2

Ward 14 1 1 1 15

Ward 15 6

Ward 37 2 1 1 13

Carparks 1

Clinical Systems 1

IT Training/ Head of ICT 1

Medical Outpatients 4

Outpatients (Main and reception) 1

Surgical Outpatients 4

CB

U 1

CB

U 2

CB

U 3

Co

rpo

rate


Pack pg no 79

Patients will experience safe careHeatmapThe heatmap below is designed to show the areas of greatest concern.

AMU

ARU

Cardiology Department

CCU

CDU

Chemo Unit

Dermatology

Discharge Unit

ED

Endoscopy

Medical Outpatients

Ward 17

Ward 18

Ward 19

Ward 20

Ward 23

Ward 24

Ward 28

ENT Outpatients

Fracture Clinic

HDU

Hospital at Night

ICU

Opthalmology OPD

Oral Surgery

Orthopaedic Outpatients

Orthoptics OPD

Planned Investigation Unit

Plaster room

Pre Assessment Unit

SAU

SDA

SHDU

Surgical Outpatients

Theatres

Theatres recovery

Urology Investigation Unit

Ward 29

Ward 30

Ward 31

Ward 32

Ward 33

Ward 34

Antenatal Clinic

Antenatal Day Unit

Anticoagulation Clinic

Breast Screening

Childrens Assessment Unit

Colposcopy

Community Midwifery

Community Paediatrics

Early Pregnancy Assessment Unit

Gynaecology OPD

Labour Suite

Medical Imaging

Obstetric Theatre

Paediatric secretaries office

Pathology

Patient's Home (community)

Patient's Home (Maternity)

Pharmacy

Phlebotomy Outpatients

Postnatal/Antenatal Ward

Physiotherapy

Ultrasound

Ultrasound (maternity)

Urgent Care therapy Team

Ward 14

Ward 15

Ward 37

Ward 38

Women's and Children's reception

Care Parks

Clinical Systems

IT Training/ Head of ICT

Medical Outpatients

Outpatients (Main and Reception)

Surgical Outpatients

CB

U 1

CB

U 2

C

BU

3C

orp

ora

te


Pack pg no 80

Patients will experience safe careHeatmap

Reporting Month: Jun-16

Executive lead : Heather McNair

Comments

Serious Incidents

There have been 7 SIs in total reported in June 2016 only 2 occured in June 16.



Indicator Name

Pressure Ulcers


There were two avoidable grade 3 pressure ulcers in June 2016.

In both incidents, the Waterlow risk assessment score had been inaccurately assessed, so the patients were not identified as being at high risk of pressure damage. Some preventative measures were utilised, but were not sufficient to prevent pressure damage.

A patient on ward 17 had vulnerable skin due to heavy, oedematous legs, but heel elevation was not high enough to keep the heels offloaded from the bed / footstool. The patient developed deep tissue damage to both heels.

A patient on ward 19 had no documented evidence of any pressure relieving equipment, until after pressure damage was identified. Poor daily skin assessments were also evident.

Action: The recurrent inaccurate calculation of Waterlow risk assessment and subsequent lack of preventative measures has prompted a review of the BHNFT pressure ulcer risk assessment process. A fact finding exercise on alternative risk assessment tools / pathways has been completed. A

Task and Finish group of senior nursing staff has been set up to develop a new risk assessment tool and pathway, based on the traffic light model, which has been instrumental in the reduction of hospital acquired pressure ulcers, at Doncaster and Bassetlaw Hospitals NHS Foundation Trust.


There were five avoidable grade 2 pressure ulcers in June 2016 – two of which were caused by devices. A patient on ITU developed a grade 2 pressure ulcer to the clavicle from an Aspen collar, and a patient on ward 23 developed grade 2 pressure damage to the shoulder from lying on a nurse

call buzzer.

Action: There have been a number of pressure ulcers in recent months caused by medical devices / devices. It has been communicated to staff via the Patient Safety Bulletin the importance of not only checking beneath devices (where possible) but also of documenting any changes to skin

integrity, and also that staff must check, when repositioning patients, that the nurse call buzzer is not trapped beneath the patient. The nurse call buzzers get very hot, increasing the risk of skin damage, and this has been reported to Estates.

Two of the three avoidable grade 2 pressure ulcers developed to the patients sacrum (AMU / ward 19) and one to a patients spine (ward 18). Poor documentation of skin integrity assessments and preventative measures was evident in all these incidents.

Action: The Task and Finish group will also be reviewing the current pathway, with a focus on ensuring preventative meaures are instigated and documented if the patient is deemed at risk. There will be a focus in the pathway on expectations around skin assessment.


Pack pg no 81

0 1 2 3 4 5 6 18 19 20 # 22

People - "At a glance"

Target Target Actual Month

16/17 YTD Jun-16 YTD Trend Status

Workforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Sickness Absence Rate 3.75% 3.75% 3.90% 3.91% ↓ 3.91%

Staff Turnover 10% 10% 9.3% 9.3% ↓ 9.30%

Mandatory Training 90.0% 90.0% 85.5% N/A ↓ N/A

Appraisal Rates - Medical 90.0% 90.0% 97.5% N/A ↓

Appraisal Rates - Non Medical 90.0% 90.0% 90.4% N/A ↑ N/A

Appraisal Rates - Total 90.0% 90.0% 90.9% 90.9% ↑ 90.86%

People


Pack pg no 82

People will be proud to work for usWorkforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Sta

ff T

urn

ov

er


5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

Pe

rce

nta

ge

Po

siti

vit

yStaff Turnover

Actual

Staff Turnover - is at 9.30% within the expected range of 7 — 10% and in line

with the NHS average turnover of 9%.

Pack pg no 83


Comments

Comments

Ap

pra

isa

lsM

an

da

tory

Tra

inin

g

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge

Po

siti

vit

yMandatory Training

Actual Target


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Appraisals

Total Non-Medical Medical Target

Mandatory Training - Overall compliance is 85.5%,.

The CBU breakdown is ;

Corporate Services 85.8%, CBU1 80.2%, CBU2 84.9%, CBU3 89.8%

Appraisals Medical - Percentage of doctors (eligible for appraisal) in date for appraisal

corrected to 97.5% as an additional appraisal was performed in June but not entered into

ESR due to annual leave, end June.

CBU 1 Medicine = 96.6% CBU 2 Surgery = 98.5%

CBU 3 W&C & Clinical Services = 97.3% corrected to 100%

Appraisals Non Medical - Overall compliance is 90.4% , all CBU’s have achieved

compliance.

Pack pg no 84


Comments

Sic

kn

ess

Ab

sen

ceS

ick

ne

ss A

bse

nce


1%

2%

3%

4%

5%

Pe

rce

nta

ge

Po

siti

vit

ySickness Absence

Actual Target

Sickness - has slightly increased from last month’s figure of 3.73% to 3.90%. Weekly

monitoring of open ended sickness absence cases will continue to ensure accurate reporting

and timely management of cases

3.00

3.50

4.00

4.50

5.00

5.50

6.00

April May June July August September October November December January February March

%

Month

Trust Sickness: Year 'v' Year

Total 12/13

Total 13/14

Total 14/15

Total 15/16

Total 16/17

Target

Pack pg no 85

1 2 3 4 5 6 18 19 20 # 22 # 24 25 26 27 39 40 41 # #

Performance - "At a glance"

Target

16/17

Target

YTDJun-16

Actual

YTDTrend

Current

Qtr

Qtr

Status

YTD

Status

Target

16/17

Target

YTDJun-16 Actual YTD Trend YTD Status

Cancer Reporting Cancelled Operations

All Cancer 2 week waits 93% 93% 93.2% 94.1% ↑ 94.1% 94.1% 94.1% % Cancelled Operations 1% 1% 1.1% 0.9% ↓ 0.9%

2 week wait - Breast Symptomatic 93% 93% 95.2% 91.0% ↓ 91.0% 91.0% 91.0% Urgent operations - cancelled twice 0 0 0 0 ↔ 0

31 day diagnostic to 1st treatment 96% 96% 98.3% 99.0% ↑ 99.0% 99.0% 99.0% Cancelled operations - breaches of 28 day rule 0 0 0 0 ↔ 0

31 day subsequent treatment - Surgery 94% 94% 100.0% 100.0% ↔ 100.0% 100.0% 100.0%

31 day subsequent treatment - Drugs 94% 94% 100.0% 100.0% ↔ 100.0% 100.0% 100.0% Theatre Utilisation

62 day urgent GP referral to treatment 85% 85% 87.5% 83.9% ↓ 83.9% 83.9% Theatre Utilisation - Day 83.2% 81.0% ↑ 81.0%

62 day screening programme 90% 90% 100.0% 94.1% ↑ 94.1% 94.1% 94.1% Theatre Utilisation - Main 95.4% 94.1% ↑ 94.1%

62 day consultant upgrades 85% 85% 90.0% 81.0% ↓ 81.0% 81.0% 81.0% Theatre Utilisation - Trauma 84.9% 91.8% ↓ 91.8%

Breast Screening GP Referrals

Screening to offer of 1st assessment <=3 weeks (May 16) 90% 90% 94.7% 41.8% ↑ 41.8% GP Written Referrals - made 4056 12194 ↓ 12194

Screening to 1st assessment (May 16) 90% 90% 84.2% 81.1% ↑ 81.1% GP Written Referrals - seen 4416 12658 ↓ 12658

Screening to issue of normal results <=2 weeks (May 16) 90% 90% 89.1% 94.3% ↓ 94.3% Other Referrals - Made 1549 5059 ↑ 5059

GP referral rate year on year (2015/16 + 2016/17) -252 -34618 ↑ -34618

Referral to Treatment Total referral rate year on year (2015/16 + 2016/17) -88 -5042 ↓ -5042

RTT Admitted - % treatment within 18 weeks 90% 90% 88.3% 87.9% ↑ 0.0% 0.0% 87.9%

RTT Non Admitted - % treatment within 18 weeks 95% 95% 97.9% 98.2% ↓ 0.0% 0.0% 98.2% DNA Rates

RTT Incomplete Pathways - % still waiting 92% 92% 94.2% 94.5% ↓ 0.0% 0.0% 94.5% New outpatient appointment DNA rate 10% 10% 9.1% 9.5% ↑ 9.5%

Follow-up outpatient appointment DNA rate 10% 10% 8.3% 10.2% ↑ 10.2%

Diagnostics Total outpatient appointment DNA rate 10% 10% 8.5% 11.0% ↑ 11.0%

No. of diagnostic tests waiting over 6 weeks 0 0 4 197 ↑ 197

% of diagnostic tests waiting over 6 weeks 0% 0% 0.1% 2.0% ↑ 2.0% Appointment Slot Issues

No. of appointment slot issues 0 0 n/a 0 ↔ 0

ED % of appointment slot issues 4.0% 4.0% n/a ↔

Percentage of patients treated in less than 4 hours 95% 95% 95.5% 94.7% ↑ 94.7% 94.7% 94.7%

Emergency Department Attendances n/a n/a 7039 21193 ↓ 0 Average Length of stay (Quality Strategy Goal 3)

12 Hours Trolley Waits 0 0 0 0 ↔ 0 0 Average Length of Stay - Elective 2.4 2.4 2.3 2.2 ↓ 2.22

Average Length of Stay - Non-Elective 3.4 3.4 2.7 2.7 ↑ 2.73

Ambulance to ED Handover Time

% under 15 mins 60.0% 62.0% ↓ 62.0% Re-admissions

% between 15 and 30 mins 30.8% 29.1% ↑ 29.1% Percentage of re-admissions N/A N/A 9.2% 9.7% ↔

% between 30 and 60 mins 2.3% 2.1% ↓ 2.1%

% between 60 and 120 mins 0.7% 0.5% ↓ 0.5%

Over 120 mins (SI) 0.0% 0.0% ↔ 0.0%

% Not Recorded 6.3% 6.3% ↑ 6.3%

Total Ambulance Handovers 1973 5896 ↑ 5896

Performance - Key Performance Indicators Performance - Key Performance Indicators cont.


Pack pg no 86

Performance Matters (KPIs)Operational Efficiency

7

9

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Dec-15 Jan-16 Feb-16 Mar-16

Av

era

ge

Le

ng

th o

f S

tay

Bre

ast

Sy

mp

tom

ati

c

Re

-ad

mis

sio

ns

Ca

nce

lle

d O

pe

rati

on

s


0.8% 0.8%

1.1%

0.0%

0.5%

1.0%

1.5%

2.0%

0

1

2

3

28 Day Breaches Target

% Cancelled Ops 2015/16

0.00

1.00

2.00

3.00

4.00

5.00


Average Length of Stay (Quality Strategy - Goal 3: Delivering Consistently Effective Care)

Elective Non-Elective Elective Target Non-Elective Target 2015/2016 Elective 2015/2016 Non Elective

Pack pg no 87

Performance Matters (KPIs)


87.83% 82.94% 83.71% 80.84% 82.40% 82.58% 83.48% 77.24% 84.60% 79.23% 86.09%G

P R

efe

rra

ls

DN

A R

ate

s

Th

ea

tre

Uti

lisa

tio

n

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Theatre Utilisation

Day Main Trauma 2015/2016

0.0%

5.0%

10.0%

15.0%

DNA Rates

New Follow Up

Total Target

2015/2016 Total DNA's

0

1000

2000

3000

4000

5000

6000

GP Referrals Made & Seen

15/16 Made 15/16 Seen 14/15 Made 14/15 Seen

Pack pg no 88



Diagnostics

Comments:

Dia

gn

ost

ic T

est

s o

ve

r 6

we

ek

s (D

M0

1)

2.2%

4.3%

1.5%

0.1%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

0

20

40

60

80

100

120

140

160


Pe

rce

nta

ge

ov

er

6 w

ee

ks

No

. o

ve

r 6

we

ek

s

Target Actual Actual 2015/2016

Pack pg no 89



Regulatory Performance - ED

A&E All Types Benchmarking

A&E benchmarking Quarter % YTD %

93.51%Barnsley

Rotherham

88.18% 87.94%

92.82% 93.26%Doncaster & Bassetlaw

94.51%

88.61% 91.13%

A&

E 4

Ho

ur

Wa

itA

&E

4 H

ou

r W

ait

- B

en

chm

ark

ing

Sheffield Teaching

0

500

1000

1500

2000

2500 No. Ambulance Handover Times (pre-validated YAS)

No. under 15 mins No. between 15 & 30 mins

No. between 30 & 60 mins No. between 60 & 120 mins

No. over 120 mins Not recorded

0

1000

2000

3000

4000

5000

6000

7000

8000

88%

90%

92%

94%

96%

98%

100%

Apr-16 May-16 Jun-16

Within 4 Hours Total Attendances

% Achievement Target

Pack pg no 90



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - June 2016

Final Position

Specialty <18 >18 Total % <18 >18 Total % <18 >18 Total %

General Surgery 143 20 163 87.7% 366 24 390 93.8% 1959 165 2124 92.2%

Urology 33 3 36 91.7% 145 10 155 93.5% 851 69 919 92.6%

Trauma & Orthopaedics 228 19 247 92.3% 269 16 285 94.4% 1365 117 1482 92.1%

ENT 46 34 80 57.5% 561 2 563 99.6% 1136 93 1229 92.4%

Oral Surgery 48 4 52 92.3% 278 4 282 98.6% 810 59 869 93.2%

General Medicine 2 0 2 100.0% 14 0 14 100.0% 73 1 74 98.6%

Gastroenterology 16 0 16 100.0% 153 1 154 99.4% 812 18 830 97.8%

Cardiology 5 0 5 100.0% 297 2 299 99.3% 514 32 546 94.1%

Dermatology 26 1 27 96.3% 407 3 410 99.3% 995 51 1046 95.1%

Respiratory 3 0 3 100.0% 121 5 126 96.0% 225 10 235 95.7%

Rheumatology 0 0 0 - 79 0 79 100.0% 283 8 291 97.3%

Geriatric Medicine 4 1 5 80.0% 45 2 47 95.7% 315 6 320 98.4%

Gynaecology 109 7 116 94.0% 312 1 313 99.7% 682 1 683 99.9%

Other 9 0 9 100.0% 283 2 285 99.3% 929 47 969 95.9%

Total 672 89 761 88.3% 3330 72 3402 97.9% 10949 677 11617 94.2%

Co

nsu

lta

nt

18

We

ek

Re

ferr

al

to

Tre

atm

en

t

Admitted - Target 90% Non-Admitted - Target 95% Incompletes - Target 92%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

Non-Admitted Pathways

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

Incomplete Pathways

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

yAdmitted Pathways

Actual Target

Pack pg no 91



Regulatory Performance - Cancer

Bre

ast

Sy

mp

tom

ati

c

All

Ca

nce

r 2

We

ek

Wa

its

31

Da

y -

Su

bse

qu

en

t T

rea

tme

nt

(Su

rge

ry)

31

Da

y -

Ta

rge

ts

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge

Po

siti

vit

y

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

31 Day Diagnostic to Treatment

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

31 Day Subsequent Treatment (Drugs)

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

31 Day Subsequent Treatment (Surgery)

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge

Po

siti

vit

y

Actual Target

Pack pg no 92




Comments

Ca

nce

r P

erf

orm

an

ce b

y T

um

ou

r S

ite

62

Da

y C

an

cer

Ta

rge

ts

62

Da

y -

Scr

ee

nin

g P

rog

ram

me

The 62 day GP referral to treatment target was non-compliant in both April and May with validated positions of 84.4% and

79.2% respectively. Whilst the June month end position was compliant at 87.5% - overall, there was failure of the target at

quarter end. Final breach validation work has been undertaken but there are no recoverable actions identified. July is

showing sustained compliance and efforts will focus on recovery of the target through Q2.

During May there were 12 breaches in total (9 shared with the tertiary centre and 3 local breaches). Highest breach volumes

were seen across the lung (=5) and Lower GI (=4) pathways with these teams demonstrating performance against the 85%

target of 16.7% (Lung) and 25% (Colorectal). Breach analysis revealed delays due to medical reasons, complexity, delays to

diagnostics and inefficient pathways.

Breaches were also seen in UGI (=1), Urology (=1) and Haematology (=1) However, the Haematology patient was originally

on a Lung pathway and had breached the target before transfer of care to the haematology team.

The breast symptomatic target was also non-compliant at the end of Q1 despite some additional capacity and acheivement

of the standard in June of 95.2%. Breach reasons remain predominantly patient choice but lack of capacity to allow booking

early in the 14 day window, renders true ‘choice’ limited. However, actions taken to improve local capacity and radiological

support are starting to yield benefit and the Q2 position is stronger and compliant thus far.

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y62 Day - Urgent GP Referral to Treatment

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

62 Day - Screening Programme

Actual Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Pe

rce

nta

ge

Po

siti

vit

y

62 Day - Consultant Upgrades

Actual Target

Pack pg no 93




Comments

Ca

nce

r S

ha

red

Pa

thw

ay

Pe

rfo

rma

nce

Shared pathway performance: Validated data from Open Exeter demonstrates a shared pathway performance (accountable pathways) of 43.8% in May for the GP 62 Day Referral to

Treatment target (RFF to RHQ). This demonstrates reduced performance from the previous month. Local performance against this target (RFF to RFF) was 89.3% resulting in an

overall non-compliant position for the month of 79.2%. The June position is reported on Open Exeter at the beginning of August 2016. Latest shared pathway performance for June

showed considerable improvement from the previous month at 91.3% from 61.3%. However, there were no Lung shared pathways referred to the tertiary centre in June and

therefore this result should be regarded as exceptional until further months are achieved.

60.0% 61.3%

91.3%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

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

Shared pathway performance between Barnsley and Sheffield 2016-17

Transferredwithin 38 Days

Pack pg no 94



Regulatory Performance - Breast Cancer Screening

Comments:

Scr

ee

nin

g t

o i

ssu

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The breast symptomatic target was also non-compliant at the end of Q1 despite some additional

capacity and acheivement of the standard in June of 95.2%. Breach reasons remain predominantly

patient choice but lack of capacity to allow booking early in the 14 day window, renders true

‘choice’ limited. However, actions taken to improve local capacity and radiological support are

starting to yield benefit and the Q2 position is stronger and compliant thus far.

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

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Po

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Actual Target

30%

40%

50%

60%

70%

80%

90%

100%

Pe

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Po

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Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

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ge

Po

siti

vit

y

Actual Target

Pack pg no 95

Performance Matters Data Quality

Uncoded Episodes (As at 19th July 2016) Missing Outcomes (Top 10 Specialties)

Treatment Specialty June July Total Specialty Jan Feb Mar Apr Total

ACCIDENT AND EMERGENCY 112 184 296 OBSTETRICS 151 99 251

BREAST SURGERY 2 12 14 ORTHODONTICS 2 90 129 221

CARDIOLOGY 39 71 110 ORAL SURGERY 5 72 142 219

CLINICAL HAEMATOLOGY 2 30 32 OPHTHALMOLOGY 1 34 89 124

CLINICAL HAEMATOLOGY Pre-Assessment 1 1 91 93

CLINICAL ONCOLOGY 15 15 TRAUMA & ORTHOPAEDICS 6 58 64

COLORECTAL SURGERY 11 RHEUMATOLOGY 6 54 60

DERMATOLOGY 33 74 107 NEUROLOGY 1 58 59

DIABETIC MEDICINE 1 1 ANTICOAGULANT SERVICE 53 53

ENDOCRINOLOGY 4 11 15 PAEDIATRICS 9 37 46

ENT 1 8 9

GASTROENTEROLOGY 17 81 98 Comments

GENERAL MEDICINE 132 473 605

GENERAL SURGERY 22 163 185

GERIATRIC MEDICINE 1 7 8

GYNAECOLOGY 1 19 20

NEONATOLOGY 4 47 51

OBSTETRICS 4 145 149

OPHTHALMOLOGY 16 16

ORAL SURGERY 7 7

PAEDIATRIC ENT 3 2 5

PAEDIATRICS 20 66

PAEDIATRIC T&O 2 2

HSMR - updated with Dr Foster figures 0

RESPIRATORY MEDICINE 19 32 51

RHEUMATOLOGY 2 2

Stroke Medicine 1 9 10

TRAUMA AND ORTHOPAEDICS 6 104 110

UROLOGY 2 39 41

VASCULAR SURGERY 0

WELL BABIES 3 71 74

Total 429 1701 0 0 2033

Uncoded Episodes - All episodes for January, February, March, April & May have been

coded.

There are 429 uncoded for June 2016 and 1701 for July 2016.

Overall there are 2033 uncoded episodes for 16/17.


Pack pg no 96

Performance Matters A

dm

itte

d P

ati

en

t C

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CD

S

Barnsley is currently unable to flow the RTT patient pathway data in the APC & OP datasets, hence

the reduced data quality score.

Ad

mit

ted

Pa

tie

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Ca

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DS

Ad

mit

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Pa

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Ca

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DS


98.3% 99.3% 98.3% 97.6%92.9%

76.2%

96.4% 97.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Doncaster &

Bassetlaw

Sheffield

Children's

Sheffield

Teaching

Rotherham Barnsley RDASH St Luke's

Hospice

National

Average

Area Team

Data validity summary average of all fields in SUS Dashboard April-May

2016

99.8%99.7%

99.8% 99.8%99.7%

99.6%

100.0%

99.2%

99.6%

98.8%

99.0%

99.2%

99.4%

99.6%

99.8%

100.0%

NHS Number

99.6%

99.2%

99.7%

99.8%

99.9%

100.0% 100.0%

99.9% 99.9%

99.0%

99.2%

99.4%

99.6%

99.8%

100.0%

Registered GP Practice

99.9%

99.8%

100.0%

99.7%

99.9%

100.0% 100.0%

99.7% 99.7%

99.6%

99.6%

99.7%

99.7%

99.8%

99.8%

99.9%

99.9%

100.0%

100.0%

Postcode

Pack pg no 97

Performance Matters Data Quality - Secondary Uses Service (SUS) Dashboard

Ou

tpa

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Ou

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99.9% 99.9% 99.9% 99.9%

99.8%

99.4%

99.8%

99.0%

99.1%

99.2%

99.3%

99.4%

99.5%

99.6%

99.7%

99.8%

99.9%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching

Rotherham Doncaster &

Bassetlaw

National

Average

Area Team

Average

NHS Number

99.6%

99.5%

99.7%

99.8%

99.9%

99.8%

99.9%

99.0%

99.2%

99.4%

99.6%

99.8%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average


99.9% 99.9%

100.0%

99.9% 99.9%

99.8%

99.9%

99.5%

99.6%

99.7%

99.8%

99.9%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average

Postcode

96.7%

100.0%99.8%

99.5%

99.0%

96.9%

98.9%

95.0%

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average

Attendance Outcome

Pack pg no 98

Performance Matters

Data Quality - Secondary Uses Service (SUS) Dashboard

Acc

ide

nt

& E

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CD

S

Acc

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Acc

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99.2% 99.6%98.9%

86.9%

98.0%

99.5%

98.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average

NHS Number

99.9% 99.9% 99.9%

98.7%

99.7%

99.0%

99.8%

98.0%

98.2%

98.4%

98.6%

98.8%

99.0%

99.2%

99.4%

99.6%

99.8%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average


99.9% 99.9% 100.0%

99.2%

99.8%

98.6%

97.4%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average

Postcode100.0% 100.0% 100.0%

99.6%99.9%

97.8%

95.4%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Barnsley Sheffield

Children's

Sheffield

Teaching


Bassetlaw

National

Average

Area Team

Average

Attendance Disposal

Pack pg no 99

Performance MattersActivity

15/16 16/17 16/17

Actual Plan Actual Variance %

Elective Day cases 5925 6178 6028 -150 -2%

Elective Inpatients 1023 1102 1058 -44 -4%

Elective Total 6948 7279 7086 -193 -3%

Non Elective 9174 8928 8807 -121 -1%

Maternity Pathway 1437 1583 1645 62 4%

A&E Attendances 20287 20763 21190 427 2%

Outpatients 58593 63118 65949 2831 4%

* Please note excess bed days are not included in these figures. 2015/16 Activity Plan

2015/16 Activity Actual

2014/15 Outturn

2015/16 Activity Plan 2015/16 Activity Plan

2015/16 Activity Actual 2015/16 Activity Actual

2014/15 Outturn 2014/15 Outturn

Act

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Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

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In

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Pack pg no 100

Performance MattersActivity

2015/16 Activity Plan 2015/16 Activity Plan

2015/16 Activity Actual 2015/16 Activity Actual

2014/15 Outturn 2014/15 Outturn

Comments:

2015/16 Activity Plan

2015/16 Activity Actual

2014/15 Outturn

Ou

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Ma

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A&

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Main areas of overperformance are Outpatients and A&E. Main area of underperformance is Elective Inpatients.

Outpatients:- areas of underperformance with the highest variances (against aggregated attendances and procedure plans)

in Gynaecology -512, Clinical Heamatology -245, and General Medicine -197. Overperforming are Cardiology 782, Diabetic

Medicine 576 and Gastroenterology 445. Elective Inpatients:- Clinical Haematology,

Oral Surgery, Dermatology & Urology (all Daycases), and Gynaecology, General Surgery and ENT (Electives) are the main

areas of underperformance.


Pack pg no 101

Performance - "At a glance"

Month

Plan

Month

Actual

Variance

%Variance Plan YTD

Actual

YTD

Variance

%Variance

Month

Plan

Month

ActualVariance % Variance Plan YTD

Actual

YTD

Variance

%Variance

ACTIVITY LEVELS (PROVISIONAL) £'000 £'000 £'000 £'000 £'000 £'000

Elective inpatients 385 365 -5.19% -20 1,102 1,033 -6.26% -69 EBITDA 166 196 -18.07% 30 -271 -256 5.54% 15

Day Cases 2,158 2,068 -4.17% -90 6,180 5,935 -3.96% -245 Depreciation -386 -381 1.30% 5 -1154 -1145 0.78% 9

Non-elective inpatients 2,925 2,895 -1.03% -30 8,935 8,838 -1.09% -97 Restructuring & Other -14 0 100.00% 14 -128 -85 33.59% 43

Outpatients 21,838 23,927 9.57% 2,089 62,592 67,920 8.51% 5,328 Financing Costs -189 -205 -8.47% -16 -567 -587 -3.53% -20

A&E 6,918 7,037 1.72% 119 20,763 21,189 2.05% 426 SURPLUS/(DEFICIT) -423 -390 7.80% 33 -2,120 -2,073 2.22% 47

'Clinical' Activity

Other (excludes direct access tests) 11,303 10,239 -9.41% -1,064 32,468 31,090 -4.24% -1,378 SOFP £'000 £'000 £'000 £'000 £'000 £'000

Total activity 45,527 46,531 2.21% 1,004 132,040 136,005 3.00% 3,965 Capital Spend -1,674 -507 -69.71% 1,167 -2,446 -815 -66.68% 1,631

Inventory 2,161 2,070 4.21% 91

CIP £'000 £'000 £'000 £'000 £'000 £'000 Receivables & Prepayments 7,994 12,791 -60.01% -4,797

Income 129 243 88.37% 114 317 347 9.46% 30 Payables -13,786 -15,643 13.47% 1,857

Pay 106 66 -37.74% -40 265 86 -67.55% -179 Accruals -5,312 -4,674 -12.01% -638

Non-Pay 144 158 9.72% 14 373 333 -10.72% -40 Deferred Income -598 -721 20.57% 123

Total CIP 379 467 23.22% 88 955 766 -19.79% -189

Cash & Loan Funding £'000 £'000 £'000 £'000 £'000 £'000

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Cash 2,403 275 -88.56% -2,128

Clinical (Activity) 9,487 9,878 4.12% 391 28,118 28,296 0.63% 178 Loan Funding -40,835 -40,429 0.99% 406

Other Clinical 4,259 4,469 4.93% 210 12,660 13,199 4.26% 539

CQUINS 289 289 0.00% 0 867 867 0.00% 0 KPIs

Risks & Penalties 0 -91 -91 0 -230 -230 EBITDA % 1.06% 1.21% 14.32% -1.06% -0.58% -0.54% 6.30% 0.04%

Non Recurrent Income 141 142 1 425 464 39 Deficit % -2.69% -2.40% 5.62% 0.15% -4.54% -4.40% 3.01% 0.14%

Other 1,558 1,564 0.39% 6 4,613 4,468 -3.14% -145 Receivable Days 15.5 24.8 -60.01% -9.3

Total income 15,734 16,251 3.29% 517 46,683 47,064 0.82% 381 Payable (excluding accruals) Days 67.8 76.9 13.47% 9.1

Payable (including accruals) Days 93.9 99.9 6.38% 6

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000 Continuity Of Service Rating 1 1 0.00% 0

Pay -10,364 -10,504 -1.35% -140 -31,256 -31,243 0.04% 13

Drugs -1,245 -1,226 1.53% 19 -3,737 -3,618 3.18% 119

Non-Pay -3,959 -4,325 -9.24% -366 -11,961 -12,459 -4.16% -498 Consolidated

Total Costs -15,568 -16,055 -3.13% -487 -46,954 -47,320 -0.78% -366 excl charity

Payable days are total op exps, less total pay, add back lead units and agency control total

Performance - Financial Overview Performance - Financial Overview


Page 45 of 48 Pack pg no 102

Performance Matters - Finance

June 2016 Summary

Summary Performance:


CommentaryKey to RAG Rating

The RAG rating applied to Variance % is based on the following criteria:• Green equating to 0% or greater• Amber behind plan by up to 5%• Red greater than 5% behind plan

The key points derived from this table are as follows:

• Total activity is favourable to plan year to date excluding Direct Access. The main driver is overperformance on Outpatient activity. Direct Access tests were excluded from the Other activity because large variances in these figures skew the overall activity variance.

• CIP achievement is adverse to plan by £0.19m. The main driver for this is on pay schemes

• Clinical activity based income is £0.2m favourable to plan before risks and penalties. The main variances are non elective income , £0.3m adverse to plan, and planned same day income is £0.2m adverse to plan. Outpatients income is £0.3m favourable to plan. Other clinical income is £0.5m ahead of plan.

• Other income is £0.15 adverse to plan.

• Operating costs are adverse to plan. Pay is broadly on plan. Agency costs covering vacant posts create a cost pressure, although the costs year to date are significantly lower than at this point last year.

• Non-pay costs total are £0.4 adverse to plan, which links to activity.

• EBITDA is on plan.

• Depreciation, and finance costs are broadly to plan. Restructuring costs are favourable to plan.

• The overall deficit is slightly favourable to plan.

• Capital expenditure is £1.6m favourable to plan.

• Inventory is broadly to plan.

• Total receivables incl. prepayments are £4.8m adverse to plan. Action is being taken to address this position.

• Total payables incl. accruals are £1.9m favourable to plan .

• Deferred income is £0.1m favourable to plan.

• Cash is £2.1m adverse to plan. It should however be noted that actual cash at bank did not breach the minimum holding requirement. There is a timing difference between the payment run being put through the ledger and cash transferring from the account.

• Debtor days are 24.8 year to date, which is 9.3 days adverse to plan.

• Payable days 76.9 year to date which is 9.1 days higher than plan (down from 14.8 days at month 2). Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future payments, the timing of these payments is uncertain.

• The Continuity of Service rating has remained at 1 at month 3.


Performance Matters (Financial Overview)

Comments:

Clinical income per day - this is ahead of plan for June 2016

Act

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Cli

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f In

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Income analysis - this graph analyses the split of income on a monthly basis and

demonstrates the variability of clinical income.

Pay as a % of clinical income is below plan for June 2016


300

320

340

360

380

400

420

440

460

480

500

Ap

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Ma

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£k

Clinical Income Per Day

Clinical/day Plan clinical/day

60%

62%

64%

66%

68%

70%

72%

74%

76%

78%

80%

Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17

%

Pay as a % of Income

Pay as a % of Income Plan Pay as a % Plan Income

CIP Achievement - Cumulative

0

2

4

6

8

10

12

14

16

18

£m

Actual Income Analysis

Clinical Non Recurrent Income Other

Agency Monthly Spend Page 47 of 48 Pack pg no 104

Performance Matters (Financial Overview)


Comments:

CIP is adverse to plan at month 3, although over achieved in month.

Ag

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CIP

Ach

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Agency monthly spend - Total agency spend ytd is £1.17m. Agency expenditure is

reviewed in depth.

Deficit trend analysis - this graph highlights the gap between plan and actual at month 3.

Currently the Trust deficit is on plan.

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17

£k

CIP Achievement - Cumulative

CIP Actual CIP Plan

-9

-8

-7

-6

-5

-4

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-1

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£m

Deficit Trend Analysis

Deficit Plan Deficit

0

200

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1,000

1,200

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£k

Agency Monthly Spend

Year 2017 Year 2016 Year 2015


1

Barnsley Hospital NHS Foundation Trust Infection Prevention and Control Strategy

2016-2019

Pack pg no 106

2

Contents page: Title: Page:

1.0

Introduction 3

2.0

What Infection Prevention and Control means 2.1 What does Infection Prevention and Control mean for our patients 2.2 What does Infection Prevention and control mean for our staff

3

3.0 Why does Barnsley Hospital NHS Foundation Trust have an Infection Prevention and Control Strategy

4

4.0 Infection Prevention and Control’s Vision

4

5.0 Methods of Measurement 5.1 National 5.2 Infection Prevention and Control Annual Programme 5.3 Local Measurement 5.4 Internal Measurement

6

6.0 Our Approach to Infection Prevention and Control 7 7.0 Making the Strategy a Reality

7.1 Communication

7

Appendix:

1. Committee structure – Lines of communication and accountability 10

Pack pg no 107

3

1.0 Introduction

HCAI (Healthcare Associated Infection) impacts upon safety, productivity and our ability to deliver high quality care. This Infection Prevention and Control Strategy builds on previous strategy’s and sets out the approach that will support the Trust to sustain the improvements made in the reduction HCAIs and is key to supporting and underpinning the achievement of broader Trust objectives of sustaining patient safety and ensure compliance with CQC registration requirements.

2.0 What Infection Prevention and Control means The term “Healthcare Associated Infection” (HCAI) encompasses any infection by any infectious agent acquired as a consequence of treatment for a medical condition or acquired by a health care worker in the course of their duties. HCAI impacts on all NHS organisations and their ability to deliver services with an estimated cost to the NHS of around £1 billion per year. It is estimated that approximately 5,000 deaths nationally are directly attributed to infections acquired whilst in the care of a hospital and in addition it is cited in many more as a contributory factor. The last national prevalence survey conducted in 2011 of England, Wales, Northern Ireland and the Republic of Ireland has reported an infection prevalence rate in adult patients in acute hospitals to be 7.6%.(HPA 2012) The England only prevalence rate is 8.2%, Barnsley’s prevalence rate was 8.10%. Infection not only affects an individual, but it can and too frequently does transmit to others who rightly have an expectation that they will be protected from cross infection.

2.1 What does Infection Prevention and Control mean for our patients

If a patient acquires an infection it delays discharge, complicates their underlying condition, increases costs and outbreaks disrupt the normal activity of the Trust; as well as subjecting the patient to anxiety, pain, suffering and sometimes death. This is not how we would wish our patients, their family or friends, to remember their care with this Trust. However the relentless media interest in this arena is increasing the public’s anxiety with the result that patients are more likely to take legal advice and seek compensation for any HCAI. Likewise the public’s perception and their confidence in any Trust’s approach to and delivery of infection prevention and control will increasingly influence patient choice.

2.2 What does Infection Prevention and Control mean for our staff

Infection Prevention and Control is not the sole domain of the Infection Prevention and Control Team (IPCT) it must be everyone’s responsibility underpinned by clear lines of accountability led from a senior level. From Board to the Ward personal commitment to the prevention of infection will be evident and included in personal objectives. Organisational and clinical leaders must take responsibility for efforts to sustain the Infection Prevention and Control change process whilst seeking methods to improve.

“PATIENTS’ WILL EXPERIENCE SAFE CARE.” People have an expectation that they will be protected from infection

Pack pg no 108

4

“TO BE IN THE TOP 10% OF TRUSTS IN COUNTRY FOR INFECTION PREVENTION AND CONTROL

PERFORMANCE”

“PATIENTS’ WILL EXPERIENCE SAFE CARE.” Patient will be identified promptly and managed according to good clinical practice.

3.0 Why does Barnsley Hospital NHS Foundation Trust have a Infection

Prevention and Control Strategy? The Trust aims to be in the top 10% of Trusts in the country for infection prevention and control performance. This will mean continuously meeting and exceeding government targets and running an infection prevention and control programme, which meets the need of our patients, staff and others whilst adhering to current legislative, regulatory and national guidelines/acts. Whilst considerable progress has been made to integrate Infection prevention and control into all management systems this must be sustained and developed. The Health & Social Care Act 2008 (updated 2015) and associated code requires the Trust to address leadership, management arrangements, design and maintenance of the environment and devices, application of evidence based protocols and practices for both users and staff, and education, training, information and communication from boards to ward. Effective prevention and control of HCAI has to be embedded into everyday practise and applied consistently by everyone. This will be led and supported by Board level ownership that includes a Board level agreement outlining its collective responsibility for minimising the risks of infection and the general means by which it prevents and controls such risks. Achieved through the acceptance of this strategy and yearly work programme. Clearly the challenge for successful delivery of a HCAI reduction strategy is to change behaviour at each individual patient contact and to ensure that this change is sustained. However successful delivery of the actions and approaches outlined within this strategy will ensure that the Trust is enabled to change the culture and traditional behaviours, embedding Infection Prevention and Control into the fabric of the organisation and placing it at the forefront of clinical care. The anticipated impact will be a reduction in MRSA, Clostridium Difficile and other healthcare associated infections. The national quality agenda will demand reductions in HCAI and will financially penalise Trusts for not controlling and preventing infections. The benefits to the patients, the public and the Trust are not only significant but a clear statutory duty and thus achievement of this strategy is a key enabler to the Trust’s future service development. The three year objectives will be refreshed yearly to include any significant changes to the national and local infection prevention and control agenda.

4.0 Infection Prevention and Control’s Vision

Patients will experience safe care: • So far as is reasonably practicable, patients’

staff and other persons are protected against identified risks of acquiring HCAI, through

Pack pg no 109

5

“PEOPLE WILL BE PROUD TO WORK FOR US.” Staff will receive instruction, training,

supervision and information on how to be safe practitioners

“PARTNERSHIPS WILL BE OUR Strength. “Patients visitors and relatives are essential to the success of the Infection Prevention and Control Strategy

the provision of appropriate care, in suitable facilities consistent with good clinical practice.

• Patients presenting with an infection or who acquire an infection during treatment are identified promptly and managed according to good clinical practice for the purposes of treatment and to reduce the risk of transmission.

Partnerships will be our strength: The Trust will work together with the CCG, SWYPFT and neighbouring trusts to ensure that there is sharing of information that promotes Infection Prevention and Control. The Trust is an integral part of the District Post Infection Review (PIR) meeting and Health Protection Board. The IP&C team will liaise with appropriate agencies to facilitate the effective discharge and transfer of patients with infection issues. The team will maintain and establish regional and national links by attendance at meetings and maintaining membership of appropriate national bodies. The on-call Consultant Microbiologist/Infection Control Doctor, jointly provided by Barnsley and Rotherham will continue to provide a 24 hour/365 day service.

Healthcare staff will work in partnership with members of the public including patients, visitors and relatives to prevent the transmission of infection and as such they are essential to the success of the Infection Prevention and Control Strategy.

People will be proud to work for us: Each member of staff will be made personally aware of their responsibility for compliance with Infection Prevention and Control policies and procedures and it will be included in the job profile, personal development plans and appraisals, as appropriate to their grade and role including as appropriate non clinical roles e.g. Estates and Facilities. Staff will receive instruction, training, supervision and information on how to be safe practitioners within the Trust. Staff will be offered health surveillance and immunisation where appropriate.

Performance matters: The Infection Prevention and Control programme will be supported by an accredited laboratory service. The lab has acquired the required CPA accreditation and this will be maintained. The Matrons will assist in developing the Trust’s Infection Prevention and Control programme each year and monitor progress locally. The Infection Prevention and Control Team will lead the programme and Matrons will work with and be supported by the team to monitor, enforce and integrate into practice the current and emerging Infection Prevention and Control agenda. The Matrons will complement and play an essential role in the delivery of the strategy under the expert guidance of the Infection Prevention and Control team. They will ensure all staff in their sphere of responsibility are equipped and

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competent to practice the principles of infection prevention and control including education and training against agreed standards. The Trust will instigate a more robust monitoring approach via more frequent clinical and environmental audits. These work streams will be led by Matron’s supported by the Infection Prevention and Control team. All results will be fed back to the CBU’s monitored and action taken to correct deficiencies. The IPCT and Matrons will continue to be actively involved in the cleaning arrangements, PLACE inspections and other environmental audits. The Matron will be the lead in the prevention of sharps injuries monitoring their incidents within their own area and reporting to the Sharps Prevention group via their nominated representative.

5.0 Methods of Measurement 5.1 National

Over recent years the national Infection Prevention and Control agenda has experienced significant change with increasing regulation. The Department of Health (DH) is firmly committed to reducing HCAI and a number of documents have been produced to support and drive this agenda (see references) The most significant was the Health & Social Care Act 2008 (revised 2015) and associated statutory guidance ‘Code of Practice for Health & Adult Social Care on the Prevention and Control of Infections and Related Guidance’ (the Code). The code sets out the minimum requirements by which Trusts can prevent and control HCAIs and is a requirement of registration. Failure to observe the Code may result in an improvement notice being issued to the NHS body by the Care Quality Commission or if significant failings exist being placed on “special measures” or legal procedures including fines. The Code joins and supports other legislative acts that impact on Infection Prevention and Control e.g. Health and Safety at Work etc. Act 1974, COSHH Regulations 2002, Provision of Personal Protective Equipment 1992, The Health and Safety (sharp instrument in health care) regulation 2013 and the Food Safety Act 1995. In addition documents from NHS Estates, Medical Devices Agency, Public Health England, Health and Safety Executive set out a range of guidance and standards.

5.2 Infection Prevention and Control Annual Programme

Each year there is a mandatory requirement for the Trust to produce an annual report and infection control programme of work. The programme of work highlights how the infection control requirements for the Trust for the coming year are to be achieved, in order to meet the requirements in the Health and Social Care Act 2008

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(updated 2015). The annual report demonstrates our performance and achievements over the previous year and is made publically available via the Trust’s internet site.

5.3 Local Measurement

In agreements with our main commissioners, Barnsley Clinical Commissioning Group (CCG), we have a programme for commissioning for quality and innovation (CQUINs). We have worked with our commissioners to agree our CQUIN framework for the year, incorporating national CQUIN targets. The CCG receive the yearly Infection Prevention and Control programme of work.

5.4 Internal Measurement Each CBU is required to report and provide evidence of compliance with the Hygiene code via the Infection Prevention and Control Group and an assurance framework will be introduced and monitored in the form of exception reports. The Infection Prevention and Control Team then review the submissions against local surveillance data and national requirements. Measures to further strengthen local ownership will be identified and implemented.

6.0 Our Approach to Infection Prevention and Control

Whilst every effort and focus will be on managing the infection prevention and control agenda the organisation may need to respond immediately to the threat from emerging diseases as in the most recent Swine flu/Ebola pandemic. Currently the most challenging organisms are MRSA, Clostridium difficile and Extended Spectrum Beta Lactomase (ESBLs) producing micro-organisms. The emergence of ESBLs is a serious concern since early epidemiology revealed that the infection carries a higher mortality rate.

Changes in the microbial population are matched by other social and demographic changes with an increasing percentage of elderly and a decrease in human ability to resist infection. The users of hospital services are increasingly more ill and more vulnerable to infection. The micro-organisms are adapting to conventional treatments becoming more resistant and pathogenic, whilst healthcare is more complex and often accompanied by more invasive techniques. All of this adds up to a highly challenging agenda that requires the Trust’s full commitment. The use of work systems factors, best clinical practise and the built environment as means to maximise and sustain successful HAI reduction efforts.

7.0 Making the Strategy a Reality

HCAI’s are caused by a wide variety of micro-organisms, often bacteria from our own bodies. Thus some degree of HCAI is therefore inevitable. To achieve success in reducing avoidable HCAI the direct responsibility will lie with the clinical team who will be supported in this work stream by the Infection Prevention and Control Team. Accountability and responsibility for the management of infection prevention and control in each CBU will belong to the Clinical

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Our Goals are: • Reducing avoidable Healthcare Associated Infections • Delivering consistently safe care • Delivering consistently effective care • Treating infections with appropriate antibiotics

“PROVIDE COUNSELLING, SUPPORT AND ADVICE TO PATIENTS AND SIGNIFICANT OTHERS”

Director who will be supported in the discharge of this duty by the consultants, Matrons, Lead Nurses and the Head of Nursing. There is a significant remit enshrined within the Matron’s role to work alongside the Infection Prevention and Control Team to support and deliver the agenda within local clinical environments. This will be further enhanced and refined to ensure clinical operational focus of the delivery of this strategy with clear links to patient and public engagement. The Infection Prevention and Control Team will support and advise across the organisation including: • Provide counselling,

support and advice to patients and significant others. • Monitoring, prompt identification and investigation of preventable infection or hazardous

procedures and initiating the response to outbreaks. • To provide specialist Infection Prevention and Control advice to management, clinicians

and practitioners. Advising on appropriate microbiological tests and interpreting results to assist in prevention and control of infection.

• Producing, implementing and monitoring policies, procedures and guidance which reflect relevant legislation, published professional guidance and evidence based practice.

• To undertake targeted audit activities within the Trust, producing reports and identifying areas for action as an integrated part of continuous quality improvement.

• Conducting active surveillance and presenting suitable and sufficient data to inform clinical decisions and the Trust’s overall strategy.

• Ensuring procedures are in place to promote prudent prescribing and antimicrobial stewardship.

• Advice on the purchase, cleaning, decontamination, maintenance and disposal of equipment.

• Assist in the Trust’s waste disposal policy. • To liaise or actively participate with other appropriate

meeting groups and departments. • Being active members of a water safety group and delivery of the water safety plan. • Ensuring that relevant staff, contractors and other persons receive suitable information,

training and supervision in the measures required to prevent and control the risks of infections.

• Providing assurance of IPC to the Trust Board via the Quality and Governance Committee. • Being active members of the organisations Clinical Governance and Patient Safety

systems. • To assist in the identification of risk working with the risk department to maintain the

corporate infection control risk register. • Close working relationships with Estates and Facilities ensuring that their service takes

account and includes Infection Prevention and Control as an integral part of their practices, procedures and strategies.

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“WE WILL WORK WITH PATIENTS AND RELATIVES TO PROMOTE GENERAL INFECTION CONTROL AWARENESS”

• Conducting investigations including assisting clinical teams in route cause analysis (RCAs) and post infection reviews.

Infection Prevention and Control will be integrated into the core business of the Trust and given the same priority as other government targets. Senior clinical staff will be expected to act as role models adhering to and reinforcing excellence in the principles of asepsis and infection prevention and control.

7.1 Communication

The effective communication of our Infection Control Strategy is imperative if as an organisation we are to success in its delivery. Internal communication will support us in delivering the strategy, by ensuring all staff are clear about what our infection control initiatives are and what is expected of them.

We will conduct promotional awareness weeks, targeted training, use information leaflets and display boards in public locations. Opportunities to use other media outlets will be sought. The Trust has an intranet page for Infection Prevention and Control; this will be regularly reviewed and updated. The Trust must not underestimate the importance of the publics perception in this area, with issues such as cleanliness, basic hygiene, cleaning of hands and staff appearance all being issues of significant public concern Communicating to the public in a manner that informs but does not engender fear is challenging and the Infection Prevention and Control Team alongside the Matrons will continue to develop mechanisms to engage with all spheres of the public. This will clearly link with the Improving Patient Experience Strategy. The Trust will consistently provide relevant quality information and advice to patients so that they have sufficient knowledge of the risks when providing consent to the care and treatment being offered to them. Appropriate information will be provided to patients before admission to hospital and during their stay. The methods used to inform them will seek to allay unnecessary anxiety and reassure them that the Trust will take all necessary action to prevent infections occurring but that total elimination of all risk is not possible. Leaflets on key infections are available on the wards from the infection prevention and control team and the infection prevention and control teams strategic aim is that they will see each patient affected by a key pathogen. The team supplements this by being available for advice before during and after their stay to both patient’s relatives and others.

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Appendix 1

Committee Structures Lines of Communications and Accountability

Health Protection Board BHNFT Board of Directors

Quality and Governance Committee

Infection Prevention and Control Group

Decontamination Group

BHNFT Infection Prevention and Control Operational Group

CBUs and Departments

Post Infection Review (PIR) Group

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15(vi)_Horizon Scanner for Board Aug 016

EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: 16/08/P-16 SUBJECT: HORIZON SCANNER DATE: AUGUST 2016

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNCATIONS SPONSORED BY: DIANE WAKE, CHIEF EXECUTIVE PRESENTED BY: DIANE WAKE, CHIEF EXECUTIVE

To provide a brief overview of key developments and initiatives across the national and regional healthcare landscape which may impact or influence the Trust’s strategic direction.

Summary of content for July 2016:

• MY NHS/NHS Choices • NHS England and NHSI announce special measures interventions over finances • CCG efficiency targets increase 50 per cent on last year • 63 trusts have been identified as over recruiting staff since 2014 and face financial

penalties • Theresa May implements a restructure of the Department of Health ministerial team • Manchester aims to create a single provider of out of hospital services by April 2017

and merge two major teaching trusts • Lord Carter: Community and mental health review to start in September • New GP role in STPs

The Board of Directors is asked to receive the contents of this report for information.

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http://www.hsj.co.uk/topics/finance-and-efficiency/ccg-efficiency-target-up-50-per-cent/7009444.article?blocktitle=&contentID=


Subject: INTELLIGENCE MONITORING/HORIZON SCANNING JULY 2016 Ref: 16/08/P-16

*please note that this is not an exhaustive report, submissions welcome to [email protected] Publication Detail Impact/ Action/

Owner / Will Board be involved?

My NHS/NHS Choices

MY NHS: All indicators ‘OK’ - Recommended by staff; Open and honest reporting; Infection control and cleanliness; Mortality rate; Food: Choice and Quality. NHS Choices User Rating – 3.5* (5* is Excellent) Feedback Excellent care and friendly staff We visited the medical outpatient gastroenterologist today. We couldn't navigate the hospital so a lovely volunteer walked with us to sign in. Another colleague then took us to the department. The Dr was so kind and knowledgeable but we needed bloods so attended phlebotomy who again were amazing. Having had recent awful experiences in some other trusts it was so refreshing to go to this hospital where literally all staff were happy and friendly and eager to help from literally the moment we walked in and from the volunteer to the consultant. Excellent service Had an appointment in gastro outpatients today and from start to finish the whole process was kind, thoughtful and positive. From entering and getting lost in the hospital when a wonderful volunteer went out of their way to help us, to the outpatients where the nurses were thoughtful and helpful. And the consultant who actually made me feel like a person not a number or statistic. Would recommend to anyone over Pinderfields and Dewsbury on the care you receive.

Potential impact on reputation / All postings responded to / Board to note for information

National media

NHS England and NHSI announce special measures interventions over finances A new regime has been announced for trusts and CCGs who are not meeting their commitments to ensure NHS financial performance improves. Five trusts and nine CCGs have been put in the intervention regime, which forms part of a package of measures designed to improve NHS’s finances and ED performance. The five trust’s to enter special measures are:

• Barts Health Trust • Croydon Health Services Trust • Maidstone & Tunbridge Wells Trust • Norfolk & Norwich University Hospitals FT • North Bristol Trust

There are a further 13 trusts that have not agreed control totals and are planning for deficits. These may end up in the regime if there is not a resolution. They are:

• Barnet, Enfield and Haringey Mental Health Trust • Imperial College Healthcare Trust • Cambridge University Hospitals Foundation Trust • East Midlands Ambulance Service Trust

Board to note for information

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Publication Detail Impact/ Action/ Owner / Will Board be involved?

• Staffordshire and Stoke on Trent Partnership Trust • Wye Valley Trust • 5 Boroughs Partnership Foundation Trust • Alder Hey Children’s Foundation Trust • University Hospital of South Manchester Foundation Trust • Dorset County Hospital Foundation Trust • Dorset Healthcare University Foundation Trust • Plymouth Hospitals Trust • Poole Hospital Foundation Trust

Trusts will be considered for the regime in the future if they have not agreed a control total and are planning a deficit this year, if they have agreed a control total but are significantly off track, or if there is an “exceptional financial governance failure” such as fraud or irregularity. Once a trust is in special measures, NHS Improvement will arrange a rapid on site process to identify key issues and agree a recovery plan within a month. They will consider whether further regulatory action is needed, including removal of autonomy over key spending decisions or changes in leadership. The DH will also be able to “exchange surplus assets for cash for providers under a programme of financial special measures and does not intend to accept business as usual loan applications from these providers. Providers in special measures will not be able to lead on new care model vanguards or organisational transactions. To exit the regime a provider must have as a minimum a robust recovery plan and evidence of significant improvement within two months.

National media

CCG efficiency targets increase 50 per cent on last year Local NHS organisations are also going to be expected to agree two-year operational plans by the end of December, with NHS England and NHSI set to release joint planning guidance in September. The financial targets set for clinical commissioning groups in 2016-17 assume an average efficiency rate of 3 per cent, which is a 50 per cent increase compared to last year, with a view towards achievement of national financial balance. Targets for individual organisations have not yet been published.


National media

63 trusts have been identified as over recruiting staff since 2014 and face financial penalties Trusts that have been identified as having “excess growth” on their pay bill can expect a proportion of this to be added to their control total targets for this financial year. The figure has been calculated by totalling pay growth between 2014-15 and 2016-17, then subtracting a figure for inflation in each year and halving the result. NHSI has used inflation figures of 1.5 per cent for 15-16 and 3.3 per cent for 2016-17. NHSI will work with providers to determine the final amounts. Work by NHS Improvement to develop new safe staffing guidelines following the suspension of NICE’s work in June last year would be used to support this effort with new metrics that will enable more appropriate benchmarking and assessment of required staffing levels. Trusts where the amount to save was less that £2m have been excluded as have trusts planning a surplus this financial year.


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http://www.hsj.co.uk/topics/finance-and-efficiency/ccg-efficiency-target-up-50-per-cent/7009444.article?blocktitle=&contentID=

http://www.hsj.co.uk/topics/service-design/two-year-operational-plans-to-be-submitted-by-december/7009431.article?blocktitle=&contentID=

http://www.hsj.co.uk/topics/service-design/two-year-operational-plans-to-be-submitted-by-december/7009431.article?blocktitle=&contentID=



National Media

Theresa May implements a restructure of the Department of Health ministerial team Health secretary Jeremy Hunt remains in post with overall charge of all areas of health policy, with a particular focus on financial control and oversight of all NHS delivery and performance. In addition he will now also lead on mental health and championing patient safety. New minister of state for health Philip Dunne, the second ranked minister in the department, will oversee hospital care, NHS performance and operations, NHS workforce, patient safety and maternity care. Mr Dunne was formerly a junior defence minister. Nicola Blackwood has been given the title under secretary of state for public health and innovation. She will lead on public health, health protection, technology, innovation and data. Ms Blackwood was previously chair of the science and technology committee, a role she held since June 2015. David Mowat has been appointed parliamentary under secretary of state for community health and care. He will lead on adult social care, carers community services, cancer, dementia, learning disabilities and all elements of primary care, including dentistry and pharmacy. Junior health ministers Jane Ellison and Ben Gummer have departed, moving to financial secretary to the Treasury and minister for the Cabinet Office respectively. Minister for community and social care Alistair Burt has also left the DH, after announcing his resignation from government. Life sciences minister George Freeman has left the DH to chair the prime minister’s policy board. Mr Freeman’s portfolio included the cancer drugs fund, the NHS digital drive, genomics, life sciences industrial strategy and driving the uptake of new drugs and medical technology.


National media

Manchester aims to create a single provider of out of hospital services by April 2017 and merge two major teaching trusts A local care organisation (LCO) will hold a single contract for all non-acute care, encompassing community services, social care, prescribing and public health services, with a phased approach to transferring services over the next five years. The aim is for primary care to also be provided under the LCO with GPs “contractually linked” to the new provider. However, this will depend on GPs signing up to the government’s new “multispecialty community provider” contract. Under the plans to merge Central Manchester University Hospitals FT and University Hospital of South Manchester FT, the new merged organisation would not take on the community services currently run by the trusts. These would transfer in the LCO, along with those currently run in north Manchester by Pennine Acute Hospitals Trust. The intention is to establish a local care organisation which is capable of holding a single contract with commissioners for out of hospital care from April 2017.


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http://www.hsj.co.uk/primary-care/prime-minister-announces-new-contract-for-large-gp-providers/5090859.article

http://www.hsj.co.uk/primary-care/prime-minister-announces-new-contract-for-large-gp-providers/5090859.article



National Health Executive

Lord Carter: Community and mental health review to start in September Work to review the operational productivity and performance of community and mental health trusts is due to start in September, with a suggested £5bn in efficiency savings to be made. Trusts for review pilot have yet to be identified. Lord Carter said “Where we’ve got integrated providers, a good example would in fact be Sheffield, where the community is part of it, or where people have integrated, will be to look at the service line costing and see where the benefits are, one of the things that seems to have come out is the differing specifications of CCGs. So, interestingly, you can pick out a mental health service in one area and it costs significantly more than another because the specification is different.”


National release

New role to raise role of 'GP voice' in STPs Twenty-nine GPs have been appointed to act as local ambassadors for the General Practice Forward View. The ambassadors, recruited by the Royal College of GPs, will cover the 44 sustainability and transformation plan patches in England and will aim to provide a GP voice within the STP process. They will also be asked to track developments within the GP forward view. Dr Ben Jackson has been appointed as Regional GP Ambassador for the South Yorkshire & Bassetlaw STP area.


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new general meeting of the council of governors of … · 2016. 8. 12. · general meeting of the...

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