part i (open) meeting of the board of directors …...15.30 15 integrated quality & performance...

The Hillingdon Hospitals NHS Foundation Trust

Part I (Open)

Meeting of the Board of Directors

Wednesday 31 July 2019 at 14.00 – 17.00

Board Room, Mount Vernon Hospital

AGENDA

Item Business Items Lead Format Indicative Timing

Business Matters

1 Welcome and Apologies for Absence Chair Verbal 14.00

2 Declarations of Interest Chair Verbal

3 Minutes of the meeting held on 22 May 2019 Chair Minutes

4 Matters Arising and Action Log Chair Action Log

5 Patient Story CN Verbal 14.20

6 Chair’s Report Chair Report 14.40

7 Chief Executive’s Report CEO Verbal 14.50

Quality

8 Q&S Committee Chair’s Report Committee Chair Verbal 15.10

9 Transformation Report (Cares+) DCEO Report

10 Medical Re-Validation MD Report 11 Safer Nurse Staffing Report CN Report

12 National In-Patient Survey CN Report

13 Mortality Report (Learning from Deaths) MD Report

Finance & Performance

14 F&P Committee Chair’s Report Committee Chair Verbal 15.30

15 Integrated Quality & Performance Report (Month 3, June 2019)

DCEO Report

16 Finance Report (Month 3, June 2019) DoF Report

Item Business Items Lead Page Indicative Timing

Well-Led/Governance

17 A&R Committee Chair’s Report Committee Chair Verbal 16.15

18 Board Assurance Framework Update DCEO Report

19 Communications Strategy DC&E Report

20 Committee Portfolio Appointments, 2019/20 TS Report

21 Use of Seal (see Appendices Pack) TS Verbal

Questions from the Public 16.45

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This item is an opportunity for members of the public to pose questions to the Board on matters that related to the Board agenda. Where possible, questions should be sent in advance to the Trust Secretary by Monday 29 July 2019, in order for the Board to ensure that relevant information is available to answer questions raised

Chair Verbal

Date of Next Meeting: Wednesday 25 September 2019, Hillingdon Hospital

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Present: Professor Lis Paice, Interim Chair Richard Whittington, Deputy Chair/SID Sarah Tedford, Chief Executive Linda Burke (NED) Dr Cathy Cale, Interim Medical Director Professor Soraya Dhillon (NED) Jenny Greenshields, Director of Finance Catherine Jervis (NED) Jason Seez, Deputy CEO Terry Roberts, Director of People & OD Dean Spencer, Interim COO In Attendance: Sarah Pinch, Director of Engagement Vanessa Saunders, Deputy Chief Nurse Mike Sims, Trust Secretary Andy Payne (GGI) Michael Wood (Observer) Members of the Public: D Clarke V Cook J Davis A Moustafa A Khakoo F Wizniaki

THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

MINUTES OF THE BOARD OF DIRECTORS

Part I, Open Meeting

Wednesday 22 May 2019

BOARD ROOM, HILLINGDON HOSPITAL

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1. Welcome and Apologies for Absence 1.1 The Chair welcomed all to the meeting. Apologies for absence

were received from Simon Morris and Professor S Gregory. 2. Declarations of Interest 2.1 There were no Declarations of Interest. 3. Minutes 3.1 The Minutes of the Part I (Open) meeting held on 27 March 2019 were approved as an accurate record of the meeting. The Chair requested that in future Board papers and minutes should not include the name of the patient concerned in the Patient Story. 4. Matters Arising & Action Log 4.1 There were no matters arising from the Minutes. The Action Log was noted, it being requested that in future, Estates risks should be captured in the Log. 5. Patient Story 5.1 The Board received a patient story related to patient discharge, the learning points from which were noted. The Chair thanked the patient and the Deputy Chief Nurse for their attendance at the Board and for providing such an informative story. 6. Chair’s Report

6.1 The Chair warmly welcomed Catherine Jervis (newly-appointed

NED) to her first Board meeting and Linda Burke to her first meeting as a full Non-Executive Director.

6.2 Commenting on her first month as Interim Chair, Professor

Paice stated that the Council of Governors had overwhelmingly supported the appointment of Richard Whittington as the Senior Independent Director (SID), following consultation with the Board.

6.3 With regard to the substantive appointment of Chair, the

Board was informed that recruitment advisers had been engaged to identify strong candidates for the role, with a view to an appointment being made by September 2019.

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6.4 The Chair further commented that a meeting had been held

with Sir David Sloman in order to discuss urgent financial investment in the Trust’s estate which was reaching a critical stage. 6.5 The Board learned that the Trust’s Bed Management team

had recently won a national team of the year award, with the catering team as runners up. All team members were to be congratulated for such a significant achievement.

7. Chief Executive’s Report 7.1 The Chief Executive reported the following matters:

• Jenny Greenshields had been recently appointed as Director of Finance; • the Chief Nurse would be leaving the Trust at the end of June to take up a position at

NHSE/I; • Tahir Ahmed would join the Trust as the new Director of Estates in the near future; • Interviews for the post of Chief Operating Officer (COO) would take place later in

May; • A&E performance had slightly improved in recent times which was welcome; • A Quality Surveillance Meeting had been held with NHSI in early May as part of

Improvement Plan monitoring; • initial ‘Gateway’ work had commented in respect of the strategic review of the Trust’s

estate.

7.2 The Board was pleased to learn that a new artwork had been installed near the main entrance, celebrating organ donation and the gift of life. It was intended to that more artworks should be installed throughout the hospital. 8. Operating Plan, 2018/19 Outcomes 8.1 The Deputy CEO presented an update on outcomes of the

Operating Plan, 2018/19, it being commented that key Learning across the Trust had made the plan live and not simply an exercise for the Regulator.

8.2 In response to a NED query on staff engagement, it was stated that within Directorate plans for 2019/20, greater emphasis had been placed on staff development and engagement which was seen as a major priority. The Board noted the Report. 9. Compliance with Fit and Proper Persons Test (FPPT) Protocol

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9.1 The Trust Secretary reported that no concerns had been raised in respect of the Fit and Proper Persons Test for Board members, all criteria having been met. 10. Financial Performance Report (Month 1) 10.1 The Director of Finance presented a report to the Board for the period ended 30 April 2019 (Month 1), the following key points being noted:

• the Trust had breached its agency cap (£1m) and its rating had increased from 3 to 4 as a consequence, which could result in increased NHSI scrutiny;

• a low level of cost improvement savings had been achieved to date (2%), with a further £6m of savings being required. In this regard, PA Consulting were working with the Trust to identify in-year savings;

• improvements had been made in respect of paying suppliers within a target

of 30 days.

10.2 In response to a NED question related to taking urgent action to reduce agency spend, it was commented that the Trust would be looking closely at each speciality on a line by line basis, and that discussions would be held with the CCG in respect of activity levels. 10.3 The Chief Executive stated that rolling out the HI Practice would impact on staff skills and improved performance. In respect of the Trust’s discharge policy, it was noted that reporting had improved but more work was required in terms of monitoring and assurance. 11. NHSI Undertakings Progress Update 11.1 The Board received the Progress Report for assurance. 12. Integrated Quality & Performance Report 12.1 The Board was informed that for the first time in recent months the Trust had bed capacity as a result of improved A&E performance. 12.2 In terms of the 18 week target, it was noted that Trust was currently validating 41,000 patient records in order to provide robust data (expected at the end of August) for analysis. The Board welcomed the fact that the Cancer

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target for March 2019 had been met. 12.3 The Director of People & OD advised the Board that in respect of PDR that the figures may not fully reflect what has happened, in that not all records had been recorded. Temporary staff who had not taken part in mandatory Training (eg infection control) would not be allowed to work on bank. 12.4 It was noted that the vacancy rate had increased by 2.8%. With regard to sickness rates (4%), there had been a fall in short-term sickness, although two-thirds of all reported sickness was long-term. 12.5 The Medical Director reported that efforts were being made, working with the junior doctors’ forum, to identify ways in which external funding to support their wellbeing could be spent. In addition, the Charity was looking at what extra they could fund and support in terms of updating facilities. 12.6 In summarising discussion, the Chair commented that the Report was now in a better format and contained stronger analysis and metrics. It was noted that more work was still being carried out on overall performance reporting which needed to be aligned to risks and strategic objectives (eg digital). 13. Hillingdon Improvement Plan 13.1 The Board received for assurance an update report on the Hillingdon Improvement Plan. 13.2 Arising out of discussion of the Plan, the Board recognised the need for delivery to be the primary focus on the Plan with an accent on clear governance around safety and being well-led. 13.3 In delivering the plan, the Chief Executive stressed that that there was a large cultural and staff engagement piece of work to be undertaken Trust-wide, which was in process. The new People Committee had a remit to look at the health and well-being all staff. In addition, more engagement with patients needed to be carried out. 14. Serious Incidents Summary Report

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14.1 The Board received a comprehensive report on Serious Incidents, members being encouraged by the tangible focus on learning points arising out of investigations. 15. Estates Update 15.1 The Board received an update report on Estates, it being agreed that a more detailed report on the condition of the Trust’s building and facilities would be considered at the next meeting . 16. Annual PALS and Complaints Report, 2018/19 16.2 The Board noted the Annual PALS and Complaints Report, 2018/19, it being highlighted that compared to 2017/18, the total number of complaints had fallen by 36 to 302. Members learned that Medicine and Surgery now met on a weekly basis with the complaints team in order to resolve issues in a timely fashion.. 17. Guardian of Safe Working Hours Quarterly Report 17.1 The Medical Director presented a report on Safe Working Hours in respect of Quarter 4, 2018/19, which was noted by the Board. 18. Safer Nurse Staffing Update 18.1 The Board received a report on Safer Nurse Staffing, it being reported that the Trust was improving its performance in this regard. In response to a NED question about linking report data more closely with other quality and safety reports, it was agreed that this would be considered as part of a more integrated approach to reporting. 19. Equality, Diversity & Inclusion (EDI) Annual Report, 2018/19 19.1 The Board received for assurance the Annual EDI Report, 2018/19. 20. Raising Concerns/Speaking Update 21.1 The Board received a report from the Freedom to Speak up Guardian. In terms of benchmarking, it was noted that the Trust was performing reasonably well compared to other trusts, but more needed to be done to promote the service

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and to encourage staff to engage with the process. 22. Staff Flu Vaccination 22.1 The Board was pleased to note, following independent assessment, that the Trust’s staff flu vaccination programme had been placed in the top 10 (out of 36) in London. 23. Reports from Committees 23.1 The Board noted reports from Assurance Committees. 24. Use of the Trust Seal 24.1 The Trust Secretary reported on the use of the Trust Seal since the date of the last meeting. 25. Questions from the Members of the Public Q1: Could the Board consider using microphones in meetings? The Chair said the logistics of installing microphones in the Board Room would be looked at in advance of the next meeting. Q2: What were the reasons for the previous Chair’s resignation? The Chair commented that the former Chair had served the Trust for over four and a half years, and as he had reported to the Council of Governors on 30 April, he had not been able to achieve everything he had set out to achieve and so had decided to stand down as the Chairman of the Trust Board. Q3: Why is the signage at the front of the Main Building so poor? The Chief Executive undertook to have the signage at the front of the building reviewed and updated as a priority. Q4: Are staff thanked sufficiently for their work? The Chief Executive accepted that more could be done in terms of meeting with individual staff and teams and thanking them for their work and commitment, stating that a lot of effort was being devoted to this important activity. Q5: Why aren’t Charity funds used more to support staff facilities? The Chair commented that the Charity Director was reviewing all requests from Divisions to see what might be feasible to fund as a priority.

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The Chair thanked everyone for their contribution to the meeting which closed at 4.15pm, the date of the next meeting being confirmed as Wednesday 31 July 2019.

Board of Directors Part I Action Log: Date of Meeting 22nd May 2019

Action No. Meeting Date Item Action Lead Due Date Comments

285 May 2019 Estates Report The Board to consider a detailed report on urgent Estates matters at its July meeting. DOE July 2019

267 March 2019 Sepsis Update Deep Dive on Sepsis to be carried out and reported to Quality & Safety Committee in September 2019, with

exception report to Board if required. MD Sept 2019

273 January 2019 Patient Experience & Engagement Strategy

Ensure Strategy is presented to EDI Committee for comment DPOD May 2019

Update to be provided to the

Board

281 January 2019 Performance Report Review performance issues on Fleming Ward and report back CN May 2019

Update to be provided to the

Board

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Board of Directors: 31 July 2019 Agenda item: 6

Title Chair’s report

Report author Professor Lis Paice, Interim Chair

Report sponsor

Status of Report Public Private Internal x ☐ ☐

Purpose of Report For Decision For Assurance For Information ☐ ☐ x

Summary

The purpose of this report is to provide information and updates on:

- External relationships and budgets - Partners’ Event hosted by Brunel University - Lay Strategic Forum - Board Development - Board Frequency - Recruitment of Substantive Chair

Recommendations The Board is invited to note the Chair’s Report.

Links to Corporate Objectives

Well-led: We will empower our people to deliver

Impact

Quality and Safety X Legal X Financial X Human Resources X Equality and Diversity X

Engagement and Communication x

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Chair’s Report to the Board of Directors External Relationships On 14 June, I attended a ‘London Senior Leaders’ event at which the Chief Executive of NHS England made it clear that London trusts have already received their full funding allocations and there is no special reserve or contingency funding available for trusts experiencing financial difficulty. This message did not come as a surprise, although we have reason to expect some support with our most urgent estate issues. Baroness Dido Harding has introduced the new ‘Interim People Plan’ stressing the importance of looking after the personal development and wellbeing of all those we employ. On 26 June, I attended a meeting of London Chairs. Sir David Sloman, (London Regional Director), laid out his plan for clinical commissioning groups (CCGs) in London to be reduced, from 32 to 5 over the next two years. He expects health and social care providers to work together in integrated care systems in each of the five areas, sharing back office functions. He acknowledged the lack of capital investment over the past decade and said that he had been to see our hospital and we were ‘first on the list’ for capital investment. Update on Partners’ Event hosted by Brunel University On the 10 June 2019, Brunel University hosted a Partners’ Event which included representation from the University, Central and North West London NHS Foundation Trust, Hillingdon Clinical Commissioning Group, Hillingdon Hospitals NHS Foundation Trust and Hillingdon Primary Care Confederation. The event was well attended, with wider representation drawn from Hillingdon 4 All, the local voluntary sector representative group, and patient representatives. In a wide-ranging session, there was a very constructive review of the Trust’s:

• vision for health care delivery in Hillingdon for the next decade, based on an integrated and digitised model;

• known future from the perspective of the partners and key stakeholders;

• capacity to make this happen;

• desired outcomes. All partners supported the Trust’s road map in re-establishing the new hospital programme, the following key next steps being outlined:

• NHSI/E Gateway 0 review of developments to date;

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• development of a Strategic Outline Case (SOC), which would formalise the agreed strategic direction;

• on approval of the SOC, the Outline Business Case (OBC) would be developed which would then seek approval of the preferred option.

The Trust will commence the updating of the Clinical Services and Estate Strategies as key priorities for 2019/20. It is planned to have a follow up Partners’ meeting in December 2019. Lay Strategic Forum This Patients’ Forum has completed its third year and successfully met all its objectives. The plan is now to increase the number and diversity of patients and public supporting our work by expanding from one forum to three or perhaps four (e.g. Patient Safety, Patient Experience, Young People) under the umbrella of the Lay Strategic Forum which will now meet annually. A programme of recruitment is underway. Board Development The Good Governance Institute (GGI) is continuing to support our board development with seminars for the Board, Governors and Non-Executives. The terms of reference for all Board committees have been refreshed. A new Board Assurance Framework has been developed. Board Frequency In view of the many challenges we face, the Board will return to meeting monthly from September. Recruitment of Substantive Chair We have now received a number of promising applications. Shortlisting will be completed by the end of next week and we expect the interviews to take place in the first half of September. We are planning three stakeholder panels followed by an interview panel including Sir David Sloman or his deputy.

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Part I Meeting of the Board of Directors

31st July 2019 Agenda item 9

Title: Transformation Report (CARES +) Reason for item: This is a standard monitoring report for the Transformation Programme Summary: The report covers progress against the Improvement Practice, The Emergency Care Programme, the Outpatient Programme, and the Theatres Programme. Action required: To note the report Report Author: James Ross, Director of Transformation Report Sponsor: Jason Seez, Deputy Chief Executive Links to Trust strategic priorities: The Transformation Programme links to all Trust priorities, and particularly to Quality, Performance and Money. Previous consideration at Board or Committees: This report is considered monthly at TME and Finance and Performance Committee Equality and diversity considerations: The Transformation team will ensure that equality and diversity assessments are completed against all transformation programme changes. Financial implications: The transformation programmes will be working to deliver financial benefits in line with the Trust financial recovery plan.

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1. Improvement Practice

Practice Coach Training

The training programme continues as planned; 50% participants (n:36) have now completed all 4 modules, with CCSS and Corporate divisions leading the way with this.

The first session of Lean Basics has been held this month, with 3 further sessions planned over 24-25 July. To achieve certification, practice coaches will be expected to share this learning with colleagues in their own teams, and therefore attendance for them is mandatory. Attendance at these sessions is encouraged from all teams and individuals who would like to find out more about the improvement methodology and principles.

Uptake of training is reflected in Figures 1 and 2 which show the participant numbers by division, and overall progress to date. The visual management of the graphs has improved to more easily reflect the attendance figures, and now includes Lean Basics attendance, reflected as Module 5.

The team continue to provide additional and 1:1 support with practice coaches to enable them to progress with their improvement projects. Common themes reoccur in relation to technical skill development as well as the challenges of introducing new methodology within business as usual strutures. Those who are working with others also undergoing training are making noticeable progress over those who are adopting the principles on their own within a team, and this learning will be reflected in the selection criteria and approach for Cohort 2. As a result, the majority of practice coaches remain in the early stages of their improvement project, and will require ongoing support to progress through to completion and certification.

Kata

Progress with Kata learning continues in the Trust, and improvements have been made in the recording of key metrics for each kata team. The initial cohorts from Churchill, Hayes and Jersey wards and the improvement practice team are continuing to develop their skills as learners.

The team has been approached by the Medicine Division to provide kata training for their divisional service management teams and planning for this is underway.

Event Planning

Figure 3: Improvement Practice Event Planner

June July August SeptExecutive Wall Establishment A&E 6S & Documentation A&E Specialty Referrals A&E Event tbc

ED Blue Zone RIE Implementation Outpatients clinical leads Model Cell Value streamOutpatient Specialty Value Stream (5 days)

Medical On call rota process

Events

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Progress is now underway in preparing for 2 key events in August and September 2019.

The team are working with the Frailty unit on Lister ward who will become the model cell, and will be the host site for the first week long rapid improvement event from 28/08 - 02/09/2019. A small steering group has been established with the ward leadership, divisional management and the improvement team, and they will lead the planning and preparation.

The second 5-day event will be held in Outpatients from 09/09/2019, and they will use the same structure as above. All events are supported and overseen by the national NHS Improvement team.

Guiding Board

The second improvement practice guiding board was held earlier this month, and joined by Elaine Mead, Executive Sensei via conference call. The Board were provided with an update on current activity and agreements were secured for the routes to manage requests for support from the team by the Trust to ensure alignment with the strategic priorities is maintained.

Communications Plan

A communications plan is being developed to launch the new CARESPlus name and to ensure all staff and stakeholders are aware of the strategic fit of the Improvement Practice and of progress to date. This plan will be launched in late July/early August.

Report Outs

The Report Outs started on the 7th June, and there have been 6 sessions to date and have taken placed on both sites. The team have worked with colleagues and utilised their networks to identify speakers and to date, there have been presentations from Medicine, Corporate and CCSS, with future slots covered by Surgery. Support from Communications Team is in place to develop the awareness, understanding of staff about the sessions, and the identification of potential speakers. Publicity for the Report Out has also come from the Chief Executive’s blog. The team are yet to receive their first request from an individual or team to present.

Partnership working

Clinical leaders and members of the team have attended two open days hosted by trusts who are current participants in the Virginia Mason Institute partnership with NHS Improvement. The Director of Transformation and Strategy and the Emergency Care Specialty lead attended the national annual learning event where the five trusts presented. The Care of the Elderly Specialty Lead and the improvement team also attended the Kaizen Open Day at East Surrey Hospital on the 10th July 2019. This is a quarterly event and the team will be identifying colleagues to take part in future sessions.

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Further collaboration continues with partner Vital Signs trusts and the national NHSI team in the lead up to a structured annual review of the programme next month.

2. Emergency Care Improvement

The Emergency Care improvement programme continues at pace. The current progress against the programme is tracked weekly at the A&E programme board, chaired by the chief executive.

Metrics

Figure 4: Metrics for ED Programme

Quartile Commentary Delivery The organisation met the ED trajectory for June 2019, and is currently on

track for July 2019 Cost The financial value of the programme relates to the bed closure

programme. The current achievement of savings ascribed to bed closures is on track.

Quality The number of patients in hospital for more than 21 days is showing a sustained reduction, but is not yet achieving the target.

People The programme is yet to have a visible impact on patient experience, as measured by the Friends and Family test metric. The friends and family metric is only available one month in arrears.

Progress Highlights

The revised model of care for the blue zone continues to be tested. The new model is providing early evidence of improvement (see SPC Chart at figure 5). The first week of the trial did not improve performance, so there was a revision implemented in week 2, led by the multi-disciplinary team. This showed immediate results, as can be seen at the second change point. The department is maintaining

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a process of continuous improvement, and introducing new amendments to the model as issues become evident. The metrics indicate that the change should be continued, and therefore the programme to deliver and sustain the improvement will now continue to ensure sustained performance.

Figure 5: SPC Chart – ED type 1 performance

This chart shows that the initial implementation of the Rapid Improvement Event (RIE) outcome had no significant impact on type 1 performance. The blue dots to the right of the chart indicate that performance above the average for the year has been sustained since the revised process was introduced.

The assessment floor new model is being progressed. Visits have been undertaken to other sites to provide benchmarking information and potential ideas to inform the new model. The trust is participating in the North West London same day emergency care (SDEC) workshop.

The rollout for criteria led discharge has been agreed, and an additional two wards are now included. The target for inclusion of all wards is September 2019. The stranded patient review process has also been expanded, with a division between the acute and rehabilitation wards to provide increased clarity and focus.

Next steps

Additional focus will be brought to the assessment floor pathways, and there will be continued work on criteria led discharge, clinical engagement with stranded patient review, and a system wide review of discharge to assess pathways.

The focus on organisational development support to the emergency department and the ongoing support to the Blue Zone revised process will continue. An additional rapid improvement event is planned for August, focussed on improving nursing documentation across the ED and AMU.

3. Outpatient Transformation

The first system wide outpatient transformation board was held, and the high-level structure of the programme was agreed. The structure will ensure there is a single, coherent approach to outpatient transformation, incorporating the work at Sector (North-West London), System (Hillingdon Health and

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Care Partners (HHCP)), and Trust levels, and incorporating support from the Improvement Practice as appropriate.

Metrics

Figure 6: Metrics for the Outpatient Transformation Programme

Quartile Commentary Delivery The organisation has an improving new to follow-up trajectory. Target is

top quartile performance. Some specialties have very high rates, however, and will be a focus for improvement

Cost The programme value as assessed by PA Consulting is currently at £0.8m. Further opportunities are being sought. Progress against delivery of this value will be tracked going forwards

Quality The number of clinic cancellations is reduced from last year’s average (14.2%) and is trending toward the target of 8% (top quartile performance)

People The programme is yet to have a visible impact on patient experience, as measured by the Friends and Family test metric. The friends and family metric is only available one month in arrears.

Progress Highlights

The first outpatient transformation board demonstrated a determination to work together as a system to deliver the transformation required. The delivery architecture of the programme is being finalised with support from PA consulting.

The NWL Outpatient Transformation programme began with five specialties in phase one. These specialties are all now live with their new guidelines. A further four specialties (phase 2) are nearing completion, and the programme has agreed four more phase three specialties in the past month. The NWL Outpatient Transformation programme is in the process of finalising Quality, Delivery and Financial KPIs, and these will be reported when confirmed.

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Process mapping of the booking process has been completed for 35/55 specialties and will completed for all by the end of July. An event was held with clinicians from primary and secondary care to map clinical priorities in any improvement of the booking processes.

Next Steps

The next steps are to finalise the delivery architecture and appoint leads to each work stream, and then to develop the detailed plans for each area. Completion of this work is scheduled for July. August will then see the implementation begin for each work plan.

4. Theatres Transformation

The theatres transformation programme continues, focussing on reinvigoration and reinforcement of a 6, 4, 2 booking system, reviewing scheduling to ensure maximum appropriate use of lists, ensuring robust annual leave management and 42 week activity, and considering best use of Mount Vernon site, including moving potential service(s) to that site.

Metrics

n.b – These are interim metrics – the final metric suite will be agreed next month

Quartile Commentary Delivery The utilisation percentage is within normal variation. Target is top quartile

performance. Some specialties have lower rates, however, and will be a focus for improvement

Cost The programme value as assessed by PA Consulting is currently at £0.8m. Further opportunities are being sought. Progress against delivery of this value will be tracked going forwards

Quality The number of cases cancelled on the day is within normal variation. The target is to be agreed, based on national benchmarking.

People The people focus of the programme is on staff experience / morale. The team will be developing a staff morale metric.

Progress Highlights

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The project plan has been agreed, and is being finalised next week. Work has been undertaken to increase theatre team engagement with the improvement programme.

A scheduling meeting has been introduced, focussing on improving utilisation metrics. There has been a significant reduction in waiting list initiatives seen.

Next Steps

• Launching the refreshed project

• Set up the metrics and reporting

• Establish work stream groups

• Implement a project improvement rhythm

• Identify a project facilitator

• A theatres improvement event will be planned for October.

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Title Annual Report and Compliance Statement for Medical Appraisal and Re-Validation

Report author Mr Jas Johal, Medical Appraisal Lead Report sponsor Dr Catherine Cale, Medical Director

Status of Report Public Private Internal

x ☐ ☐

Purpose of Report For Decision For Assurance For Information

x ☐ ☐

Summary

The purpose of this annual report for 2018/2019 is to provide assurance that the statutory functions of the Responsible Officer are being appropriately fulfilled and to report on performance in relation to those functions

For the year 2018/19 of these 283 doctors 273 had under gone an appraisal. All 10 that did not undergo appraisal had agreed exemptions in line with the appraisal policy (8 maternity leave, 1 sabbatical and 1 paused due to an investigation taking place). There were no Drs where the lack of an appraisal was unapproved, this compares to a national rate of 2.2 %.

Recommendations

The Board is asked to discuss and agree the recommendation that the compliance statement is signed by the CEO/Chair.


Impact

Quality and Safety x

Legal x

Financial

Human Resources x

Equality and Diversity x

Engagement and Communication

1. Executive Summary

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The purpose of this annual report is to provide assurance to the Board that The Hillingdon Hospitals NHS Foundation Trust continues to provide systems to enable effective operating to carry out its responsibility as a Designated Body. At the end of the 2018/19 reporting year, the trust was the designated body for 283 doctors and responsible for ensuring all doctors with a connection to us undergo an annual appraisal.

For the year 2018/19 of these 283 doctors 273 had under gone an appraisal. All 10 that did not undergo appraisal had agreed exemptions in line with the appraisal policy (8 maternity leave, 1 sabbatical and 1 paused due to an investigation taking place).

The Responsible Officer (RO) submitted the Annual Organisational Audit to NHS England in May 2019. This annual report to the Board contains all of that submitted information with further assurance to the Board. The Trust is required to return a Statement of Compliance to NHSE after the approval of this report.

NHSE Revalidation Comparator Report demonstrates that we meet or exceed the national levels of medical appraisal.

Dr Abbas Khakoo was the Medical Director and Responsible Officer for the first half of the appraisal year and was replaced by Dr Catherine Cale in February 2019. The Responsible Officer undertakes the duty of ensuring that there are processes and procedures in place to ensure there validation of all medical staff in line with the RO regulations.

Mr Jas Johal was appointed to the role of Director of Medical Professional Development in October 2017 and supports the process around Medical Appraisals and Revalidation.

2. Purpose of the paper

• To provide the Board with assurance that The Hillingdon Hospitals NHS Foundation Trust and the Responsible Officer are executing their duties in respect of Revalidation.

• To allow the Board to approve the Statement of Compliance.

3. Background

Medical Revalidation was launched in 2012 and continues to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system. We have had the Equiniti Revalidation Management System (RMS) in place for the last six years to support the management of medical appraisals and revalidation.

Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations and it is expected that provider boards / executive teams will oversee compliance by:

• monitoring the frequency and quality of medical appraisals in their organisations;

• checking there are effective systems in place for monitoring the conduct and performance of their doctors;

• confirming that feedback from patients and colleagues is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

• Ensuring that appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

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4. Governance arrangements

Our governance arrangements are as follows:

Regulation & Compliance Committee

Exception Reports to

Revalidation Advisory Group

The Trust is responsible for all doctors with a connection to the trust as their designated body including Consultants, Staff and Associate Grade Doctors, Locum Doctors (predominantly long term locums) and Trust Grade Doctors. The revalidation process for trainee doctors is the responsibility of the Health Education England.

The Revalidation Team comprises the MD/RO, Director of Medical Professional Development, Assistant Director of HR Operations and the Revalidation Administrator. The team meets monthly to ensure that the progress of meeting our responsibilities for Medical Revalidation takes place and ensure that doctors are engaging with their responsibilities.

In addition a Revalidation Advisory Group has been established. The Group meets on a bi annual basis and is chaired by a Non-Executive Director. Its purpose is provide assurance that the Responsible Officer and revalidation team are undertaking their duties in line with the requirements for medical revalidation

The Medical Appraisal Policy was ratified on 15th December 2015 and is currently being updated.

Monthly updates are provided to the executive team and Board on the progress of appraisals within each division. We report quarterly to NHS England on appraisals due and completed and on an annual basis via the Annual Organisational Audit.

A record of all doctors for whom the Trust is the designated body is maintained by the GMC and we have access to this via GMC connect. We maintain a database for all doctors connected to us with appraisal history and any communication/contact made with them.

All doctors are allocated an appraisal date, which is fixed year on year. Over the last year we realigned doctors appraisal months in line with a change in the GMC recommendation from an annual appraisal to an appraisal every 9-12 months. The following process is followed if an appraisal becomes overdue:

a) If the appraisal hasn’t taken place within 4 weeks of the allocated appraisal date, a reminder letter is sent from the Director of Medical Professional Development, requesting that the

Monthly Revalidation & Appraisal Meetings (Revalidation Team)

4

appraisal takes place within 4 weeks of the date of the letter. The Clinical Specialty Lead and the Medical Staffing Manager are copied in to the letter.

b) If the appraisal hasn’t taken place within four weeks of the first reminder letter, a letter is sent from the RO, requesting the doctor to organise an appraisal within 2 weeks of the date of the letter, and informing them of potential escalation to the General Medical Council (GMC). The Director of Medical Professional Development, Clinical Specialty Lead and the Medical Staffing Manager are copied in to the letter. Non-compliance is tracked via the monthly Revalidation Team meetings.

The Medical Director has quarterly meetings with our GMC Employment Liaison Advisor, and this involves a minuted discussion around matters of concern with any doctor who has a connection with the Trust.

A 6 monthly newsletter on revalidation and appraisal is published on the Revalidation page of the Trust intranet. (Latest newsletter attached).

5. Medical Appraisal a. Appraisal and revalidation performance data

As at 31st March 2019, there were 283 doctors for whom we are the designated body and currently in post. For the appraisal year 273 out of 283 doctors had completed an appraisal. 8 doctors were exempt due to being on maternity leave. Of the 273 eligible Drs the breakdown by grade is:

Position Percentage of Completed

Appraisals Numbers

Substantive Consultants 100% 179/179 SAS Doctors 98.3% 58/59 Temporary/Short Term Contract Holders

97.2% 36/37

Honorary Doctors N/A N/A

b. Appraisers

The Trust currently has 50 trained appraisers, adequately provided within each Specialty so no appraiser does any more than 8 appraisals per year. We provide refresher training and from July 2019 are also providing in house new appraiser training (previously external).

c. Quality assurance

Formal audit of the quality of appraisals has not been undertaken in the last 12 months. However, improvements are made as needs are identified including:

• strengthened the annual appraisal checklist to include a doctor’s whole scope of practice and this has also been emphasized through appraiser refresher training. This is to ensure that there are no concerns at other organisations where a clinician undertakes any type of practice, including voluntary and paid work.

• when doctors seek patient feedback that they should not be able to view that feedback until it

has been collated and put into an anonymous format. This has been communicated to all doctors and we will monitor this closely.

5

d. Access, security and confidentiality

Appraisal documentation is uploaded on to the Equiniti system and is only available to view by the appraiser, appraisee, any nominees the appraisee has provided to upload information on their behalf, system administrators, Responsible Officer and Director of Medical Professional Development. Doctors receive a reminder from Equiniti (when uploading their documentation) to ensure no patient identifiable information is included. There are no information governance issues to report during 2018/2019.

6. Medical Revalidation Annual Organisational Audit (AOA) Comparator Report The Trust submitted a response to the NHS England’s Annual Organisational Audit (AOA) Comparator Report in May 2019. The figures provided demonstrate that we meet or exceed the national medical appraisal rates

THH 2018-19 Sector (n=96) average

All DBs (n=862) average

Total no Drs 283 451 167

Number of Consultants 187 293 61.7

% all Drs with completed appraisal 96.5 89.3 91.5

% consultants with completed appraisal 95.7 93.5 93.7

% Trust Dr/SAS with completed appraisal

98.3 88.8 88.2

% Drs with unapproved missed appraisal

0 2.1 2.2

7. Revalidation Recommendations

Between 1st April 2018and 31st March 2019, 67 recommendations were made to the GMC. Of these, 58 recommendations were positive recommendations to revalidate and there were 9 requests to defer. The reasons for 5 of these 9 deferrals were not enough appraisals having taken place in the Revalidation cycle, due to doctors having moved Trusts frequently. The other 4 were: ong term sickness (1) and incomplete elements in the revalidation requirements (3). 8. Recruitment and Background employment checks

Pre-employment background checks are routinely carried out by Medical Staffing. All doctors are subject to the NHS Employment Checks Standards which include those checks that are required by law. These include verification of Identity, Right to Work, Professional Registrations and Qualifications, Employment History and References, Occupational Health and Criminal Records.

A minimum of two recent references are obtained for all recruited trust doctors. These require the referee to confirm whether they have any concerns about the doctor’s practise.

6

We also use a RO to RO transfer of information form, the purpose of which is to seek out information around appraisals and if there are any concerns with the doctors practise. This is used for all new substantively appointed consultants and is also used prior to revalidation for doctors who have recently joined the trust or who undertake work elsewhere. A form requesting Medical Revalidation and Appraisal details is sent for completion to all new doctors.

NHS England produced an Expert Group Statement on Locum and Short-Term Doctors in Secondary Care in May 2017. The Trust will ensure that the recommendations in the statement will be adhered to in the employment of locums and doctors on short-term contracts. RO to RO Transfer of Information forms are sent to medical bank and agency locum doctors, in addition to the Medical Revalidation and Appraisal details form.

9. Monitoring performance

This report is confined to the issue of investigation of concerns where these are raised. All concerns are escalated to the RO and managed with advice from NCAS (now PPA) and support from the HR Business Partner Team and relevant Divisions. Ultimately with the aim of ensuring processes are followed in line with Maintaining High Professional Standards guidance within the relevant Conduct, Capability, Ill Health and Appeals Policy and Procedure (for Medical and Dental Practitioners).

In the year 2018/2019, there were 5 formal investigations under MHPS procedures commissioned relating to conduct and capability issues. Two of these matters have been concluded; three are to be concluded in 2019.

9. Responding to concerns and remediation

The Trust has a formal structure, policy and processes for managing remediation, as detailed in The Remediation Policy. The data on the numbers of doctors involved in formal concerns processes is shown in Appendix A.

10. Quality Visits

The Trust’s Higher Level Quality Revalidation Visit took place on 21st August 2017. The report following the Visit was generally positive and included some useful recommendations for consideration. An action plan was drawn up to implement the recommendations and all actions have been completed. 11. Recommendations

The Board is asked to accept this report.

The Board is asked to approve the Statement of Compliance document confirming that the organisation, as a designated body, is in compliance with the regulations, to be signed by the Chief Executive for return to NHS England before 30th September 2019 (Appendix B).

12. Annual Report Template 2018/19 a. Appendix A - Audit of concerns about a doctors practice b. Appendix B - Statement of compliance document requiring sign off from The Board

7

Annual Report Template Appendix A – Audit of concerns about a doctor’s practice

Concerns about a doctor’s practice High level1

Medium level2

Low level2 Total

Number of doctors with concerns about their practice in the last 12 months Explanatory note: Enter the total number of doctors with concerns in the last 12 months. It is recognised that there may be several types of concern but please record the primary concern

1 2 2

Capability concerns (as the primary category) in the last 12 months

1

Conduct concerns (as the primary category) in the last 12 months

1 1 2

Health concerns (as the primary category) in the last 12 months

0 0 0 0

Remediation/Reskilling/Retraining/Rehabilitation Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 2019 who have undergone formal remediation between 1 April 2018 and 31 March 2019. Formal remediation is a planned and managed programme of interventions or a single intervention e.g. coaching, retraining which is implemented as a consequence of a concern about a doctor’s practice A doctor should be included here if they were undergoing remediation at any point during the year

0

Consultants (permanent employed staff including honorary contract holders, NHS and other government /public body staff)

Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS and other government /public body staff)

General practitioner (for NHS England only; doctors on a medical performers list, Armed Forces)

N/A

Trainee: doctor on national postgraduate training scheme (for local education and training boards only; doctors on national training programmes)

N/A

Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade)

N/A

Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc) All Designated Bodies

0

Other (including all responsible officers, and doctors registered with a locum agency, members of faculties/professional bodies, some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) All Designated Bodies

0

TOTALS Other Actions/Interventions

1 http://www.england.nhs.uk/revalidation/wp-

content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

http://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

http://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

8

Local Actions: Number of doctors who were suspended/excluded from practice between 1 April 2018 and 31 March 2019: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included

0

Duration of suspension: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Less than 1 week 1 week to 1 month 1 – 3 months 3 - 6 months 6 - 12 months

N/A

Number of doctors who were suspended/excluded from practice between 1 April 2018 and 31 March 2019:

0

GMC Actions: Number of doctors who:

Were referred by the designated body to the GMC between 1 April and 31 March 0 Underwent or are currently undergoing GMC Fitness to Practice procedures between 1 April and 31 March

1

Had conditions placed on their practice by the GMC or undertakings agreed with the GMC between 1 April and 31 March

1

Had their registration/licence suspended by the GMC between 1 April and 31 March 0 Were erased from the GMC register between 1 April and 31 March 0 National Clinical Assessment Service actions: Number of doctors about whom the National Clinical Advisory Service (NCAS) has been contacted between 1 April and 31 March for advice or for assessment

5

Number of NCAS assessments performed 5

9

Appendix B - Designated Body Statement of Compliance The Board of The Hillingdon Hospitals NHS Foundation Trust can confirm that

• an Annual Organisational Audit (AOA) has been submitted, • the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010

(as amended in 2013) • and can confirm that:

1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer;

Yes

2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained;

Comments: Yes, We maintain a list via GMC Connect of all licenced medical practitioners who have a prescribed connection with the Trust.

3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners;

Comments: Yes, the Trust currently has 50 trained appraisers, distributed across specialties.

4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers2 or equivalent);

Comments: Yes. All new appraisers have formal training and there are quarterly half day internal appraiser refresher sessions. The 6 monthly newsletters also highlight key changes in the appraisal and revalidation process. A feedback form is available for completion by the appraisee and shared with the appraiser.

5. All licensed medical practitioners3 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is a full understanding of the reasons why and suitable action taken;

Comments: Yes, the reasons for non-compliance with annual appraisal are documented, and there is a clear escalation process involving the Director of Medical Professional Development, the Responsible Officer (RO) and the General Medical Council (GMC). In all cases, a new appraisal date is offered, and if revalidation may be compromised, a formal notification to the GMC (initially using a Rev-6 form) is sent by the RO.

6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring that information about these matters is provided for doctors to include at their appraisal;

Comments: Yes, This is discussed during the appraisal meeting between the appraiser and doctor in relation to their conduct and performance to ensure any complaints, incidents and other significant events are reflected upon. The NHSE appraisal checklist is used for appraisals.

7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise;

Comments: Yes, This is discussed during the appraisal meeting between the appraiser and doctor in relation to their conduct and performance to ensure any complaints, significant events etc. are

10

reflected upon, and escalated as per our policy. The regular meetings between the RO and the GMC Employment Liaison Advisor further support this process.

8. There is a process for obtaining and sharing information of note about any licensed medical practitioner’s fitness to practise between this organisation’s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works;4

Comments: Yes, We use the RO to RO Transfer information to share information about any licensed practitioner’s fitness to practise.

9. The appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that all licenced medical practitioners5 have qualifications and experience appropriate to the work performed;

Comments: Yes, We can confirm that these checks are in place.

10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance.

Comments: Yes, We can confirm that this is in place.

Signed on behalf of the designated body

[(Chief executive or chairman]

Official name of designated body: The Hillingdon Hospitals NHS Foundation Trust_

Name: Sarah Tedford Signed:

Role: Chief Executive

Date:

4 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents



Title Safer Staffing - Nursing

Report author Vanessa Saunders, Deputy Chief Nurse

Report sponsor Siobhan Gregory, Interim Chief Nurse


☒ ☐ ☐

Purpose of Report For Decision

For Assurance

For Information

☐ ☒ ☐

Summary

This paper provides assurance that nurse staffing across inpatient areas in May 2019 was sufficient to support safe care and high quality patient experience. The report provides the Board with an overview of the average nurse staffing levels. To provide context, vacancy and turnover data for the areas covered is also provided along with summary financial data; a suite of Nurse Sensitive Outcome Indicators (NSOIs) for each ward is included.

Recommendations The Board is invited to note the progress and assurance provided in the report.

Links to Corporate Objectives Quality - We will deliver good care every day

Impact

Quality and Safety

To ensure safe and effective staffing levels across inpatient areas , delivering high quality patient experience

Legal

Financial To utilise resources effectively and within available budget

Human Resources To have the right staff, with the right skills in the right place at the right time

Equality and Diversity

Engagement and communication

Sustainability

1

1. Overview The purpose of this paper is to provide assurance that nurse staffing across inpatient areas in May 2019 was sufficient to support safe care and high quality patient experience The report provides the Committee with an overview of the average nurse staffing levels (actual levels against planned levels, expressed as a percentage) for May 2019, together with average Care Hours Per Patient Day (CHPPD). CHPPD is calculated by adding the hours of registered nurse/midwives (RN/RM) and the hours of health care assistants (HCA) and dividing by the number of patients at 23.59 hours; it is reported split by RN/RM and HCA, and as a total. To provide context, vacancy and turnover data for the areas covered is also provided; a suite of Nurse Sensitive Outcome Indicators (NSOIs) for each ward is detailed in Appendix 1. Although CHPPD cannot be viewed in isolation, it is a standardised metric that can be used to compare services across similar organisations; the most recent benchmarking data is provided in Appendix 2. Wards assessed by the Assistant Directors of Nursing as requiring increased scrutiny and support were: Ward Concern Risk/s Actions AMU High use of agency

staffing Roster template not in line with funded establishment

• Lack of continuity of care

• Financial pressure

• Inability to fill shifts

• Unwarranted

variation

• Reduced quality

• Poor patient experience

• Robust scrutiny of rota

• Template review

• Increased Matron support

Trinity Roster template above benchmarks for patient acuity and dependency and CHPPD

Hayes Average fill rates below 90% of planned across the four shift/staff groups Friends & Family Test: 71% positive responses

2. Staffing levels against plan

Average fill rates against planned levels of RNs/RMs and HCAs are calculated, for day and night shifts. In May the overall rates (all inpatient areas per site combined) ranged from 89.7% - 103.8%, as detailed in Fig. 1 below. There was minimal change to average fill levels across the four shift/staff group subsets compared to April 2019. The positive impact of the January 2019 establishment review is evidenced by the continued downward trend in over-fill rates for HCAs.

2

The stable fill rates are mirrored by the average CHPPD, although it is noted that these increased slightly for Mount Vernon where they were higher than on the Hillingdon site despite not having any critical care units. When compared to national and peer group benchmarks (Appendix 2) the data is again suggestive that staffing levels at Mount Vernon require review. The Lead Nurse for Workforce Transformation Projects has undertaken detailed analysis of the roster patterns, operational demand and patient acuity and dependency data for Trinity ward, working closely with the Senior Sister and the Assistant Director of Nursing. A revised template is due to be implemented. Fig. 1 Average fill rates and monthly trends – site level data

Fig. 2 Average Care Hours Per Patient Day and monthly trends – site level data

Site Summary Data March 2019

Care hours Per Patient Day Cumulative count of patients @ 23.59

RN/RM hours per patient day

HCA hours per patient day

Overall hours per patient day

THH 12303 5.4 3.3 8.7 MVH 776 4.9 4.1 8.9*rounding

Site Summary Data March 2019

Day Night Average fill rate RN/RM

Average fill rate Care staff

Average fill rate RN/RM

Average fill rate Care Staff

Hillingdon 95.5% 100.3% 98.1% 103.8% Mount Vernon 90.5% 92.1% 89.7% 98.9%

5.4 5.4 5.3 5.2 5.3 5.4

3.4 3.5 3.5 3.5 3.3 3.3

0123456789

10

Dec Jan Feb Mar Apr May

Aver

age

hour

s pe

r pat

ient

day

Hillingdon Care Hours Per Patient Day

HCA

RN/RM

4.5 4.6 4.5 4.7 4.6 4.9

3.7 4.1 3.9 4.0 3.8 4.1

0

2

4

6

8

10

12


Aver

age

hour

s pe

r pat

ient

day

Mount Vernon Care Hours Per Patient Day

HCA

RN/RM

3

The average fill rates for each ward can be viewed in Appendix 1; the wide variation is due to a number of factors including changes in activity (more/fewer beds in use), fluctuations in acuity and dependency, and rota gaps. There were twelve wards which recorded average fill rates for RNs/RMs below 95% of plan for at least one of the shift/staff groups. However it should be noted that the critical care units (ITU, CCU and NNU) and the maternity department vary their staffing according to activity, which is reflected in fill rates, particularly with reference to use of HCAs which are only utilised when additional staffing is required to support the Registered Nurses. Similarly, data is skewed for Pinewood Ward due to its closure in month. In all instances where staffing levels were below plan, available resource was assessed against actual need in real time and mitigating actions taken by the Matrons. There were 3 reported suboptimal staffing incidents in May. One was recorded as no harm as although the shift had one less RN on duty than planned, there were also empty beds. The other two were recorded as low harm; patient care was not compromised but staff felt under pressure. Seventeen areas reported average fill rates above 100% (i.e. above the agreed shift template) for either RNs or HCAs on day or night shifts, a reduction from twenty areas in April. It should be noted that where usual planned numbers are relatively small, such as on night shifts, any increase creates a large increase in terms of percentage. 2.1. Financial impact

The combination of shift fill-rate being above plan and high use of agency staffing creates a financial pressure. It is therefore important to ensure effective use of the available resource. This is managed in real time by the Matrons who, where possible, redeploy staff between different wards to match staffing to demand, utilising the validated SafeCare workforce support tool. From a strategic perspective, the Assistant Directors of Nursing, with support from the Chief Nurse’s team, scrutinise rosters for efficiency and effectiveness, ensure robust controls are in place regarding use of additional duties and temporary staffing, as well as working with colleagues in human resources to plan for future workforce.

In May there was a total overspend of £87,551 on staffing across the medical and surgical inpatient wards. This is an improved position compared to previous months. Review of the overspends reveals 50% of the overspend was used on AMU/SAU, this was partly driven by use of agency but it has also been identified that the unit used 6 more RNs than budgeted, which was partially mitigated through underspend on HCAs.

Churchill Ward also had a high agency spend, due to vacancies, followed by Pinewood. Pinewood Ward closed in May, with staff redistributed across the division; this will have a positive impact of vacancies and therefore agency spends from June.

4

Data from the month 2 financial reports shows:

Use of RNs:

• 9.81 WTE below establishment • Overspend of £30,263, due to use of agency staffing

Use of HCAs

• 7.93 WTE above establishment • There were 6 WTE unbudgeted Band 3s in post in May, due to international

nurses working as HCAs whilst preparing for their OSCE examinations to gain admittance to the NMC register. This cost was mitigated by Band 3 vacancies in other areas.

• Other reasons for additional HCA duties include support for patients requiring enhanced observation or to replace a vacant RN shift when risk-assessed as appropriate.

3. Vacancies and turnover

The tables and graphs below show the number of vacancies (budgeted establishment minus filled posts), new starters and leavers for the inpatient areas covered by this report, over the last six months. The data is provided by Workforce Information and the Head of Resourcing, and is in relation to the clinical areas listed in Appendix 1 and does not represent the vacancy or turnover position for the entire nursing and midwifery staff group. There was a downward in-month trend in vacancies on the Hillingdon site in May, most significantly for HCAs (16.79 WTE less than in April 2019). Mount Vernon saw an increase of 8.45 WTE RN vacancies: a bespoke recruitment event has taken place on the site to attract staff specifically wanting to work there. Fig. 3 Vacancy and turnover trends for inpatient areas

THH 2018/19 Dec Jan Feb Mar Apr May MVH 2018/19 Dec Jan Feb March Apr MayRN/RM Vacancies 116.97 111.15 111.5 112.96 123.79 122.34 RN/RM Vacancies 12.17 11.53 11.53 11.47 5.53 13.98HCA Vacancies 53.4 40.9 40.9 46.46 66.35 49.55 HCA Vacancies 2.31 2.31 2.31 3.51 -0.3 -1.63RN/RM Starters 7 13 11 7 4 7 RN/RM Starters 0 2 0 1 1 0RN/RM Leavers 8 5 7 10 5 8 RN/RM Leavers 1 2 0 0 1 0HCA Starters 8 13 12 10 13 12 HCA Starters 0 0 0 0 0 1HCA Leavers 3 0 3 5 3 0 HCA Leavers 0 1 0 0 0 0

0

20

40

60

80

100

120

140


THH Vacancies

RN/RM Vacancies

HCA Vacancies

-202468

10121416

Dec Jan Feb March Apr May

MVH Vacancies

RN/RM Vacancies

HCA Vacancies

02468

101214

Dec Jan Febdraft Mar Apr May

THH Starters and Leavers

RN/RM Starters

RN/RM Leavers

HCA Starters

HCA Leavers

0

5

10

15

20

Dec Jan Feb March Apr May

MVH Starters and Leavers

RN/RM Starters

RN/RM Leavers

HCA Starters

HCA Leavers

5

4. Conclusion

Spikes in activity and patient acuity on specific wards during May resulted in episodes of staffing above anticipated headcount and/or financial plan. However, the overall averages and the CHPPD were stable. Overspends decreased compared to previous months. Nurse-sensitive outcome indicators were in line with previous months, with a marked reduction in recorded suboptimal staffing incidents.

It is reasonable to conclude that nurse staffing levels across inpatient areas in May 2019 were overall in line with need.

1

Trust Board Date of meeting: Wednesday 31st July 2019

Safer Staffing - Planned and Actual Staffing Levels (nursing) May 2019 Appendix 1

Reported concerns

Average fill rate: RN /Midwives %

Average fill rate: Care Staff %

Average fill rate: RN /Midwives %

Average fill rate: Care Staff %

Ald 19 101.6% 138.8% 111.3% 173.8% 23.36% 8.01% 0 0 3/2 100% 0% 3.4 4.0 7.5B'East 20 96.3% 104.2% 100.0% 100.0% 31.01% 2.40% 0 0 2/0 92% 3.2 3.1 6.3Bevan 24 104.5% 107.5% 101.1% 108.1% 22.06% 3.72% 0 0 1/0 100% 0% 3.6 2.7 6.3CCU 7 109.2% 61.4% 112.8% 21.8% 16.93% 6.98% 0 0 0/0 100% 0% 11.2 1.6 12.7Daniels 16 96.9% 98.3% 100.0% 98.4% 17.22% 1.68% 0 0 1/1 100% 0% 3.9 3.8 7.7Dray 18 94.2% 104.2% 97.6% 106.5% 24.75% 14.69% 0 0 5/1 92% 5.1 2.1 7.2AMU/SAU 39 101.0% 78.4% 91.7% 97.6% 22.56% 29.59% 1 0 5/0 93% 4.5 2.9 7.4Grange 30 99.7% 103.8% 98.5% 103.1% 21.39% 7.71% 0 1 4/4 90% 2.9 4.1 7.0Hayes 30 75.4% 86.2% 82.8% 78.0% 8.77% 3.42% 1 0 1/2 71% 4.3 6.0 10.3Lister 10 98.1% 104.3% 100.3% 103.2% 15.30% 5.51% 0 1 4/0 100% 0% 5.5 3.8 9.2Stroke 20 98.2% 102.3% 98.9% 103.7% 23.57% 9.73% 0 0 7/1 100% 0% 3.6 3.1 6.7Pinewood 85.1% 115.6% 101.9% 113.7% 40.41% 22.35% 0 0 5/1 n/a 3.4 3.6 7.0Fleming 29 87.9% 99.4% 107.7% 100.6% 34.22% 13.09% 1 2 3/0 100% 0% 4.3 3.3 7.6Churchill 20 104.5% 121.8% 106.5% 111.3% 18.50% 21.91% 0 0 4/3 100% 0% 4.5 3.6 8.2Jersey 30 103.6% 96.1% 103.0% 99.8% 24.89% 7.69% 0 1 1/0 89% 3.5 2.8 6.4Kennedy 30 103.3% 107.6% 109.7% 111.3% 19.68% 7.51% 0 1 2/1 100% 0% 3.5 4.0 7.5ITU/HDU 9 89.8% 123.6% 91.9% - 2.71% 0.22% 1 1 0/0 100% 0% 24.4 1.2 25.6Trinity 25 84.9% 86.3% 82.8% 100.0% 23.07% 10.55% 0 0 0/1 97% 6.4 4.4 10.8Pagett 10 102.9% 91.7% 100.0% 100.0% 19.94% 2.77% 0 0 2/0 nr 6.5 2.7 9.2Peter Pan 20 112.5% 115.2% 109.2% - 16.58% 20.28% 0 0 0/1 93% 2% 9.7 1.5 11.2

NNU 20 92.8% 72.6% 83.8% 96.6% 19.38% 0.00% 0 0 0/0 100% 0% 6.5 2.0 8.5

Alex 22 93.8% 102.7% 95.2% 108.1% 19.96% 1.25% 0 0 0/0 100% 0% 9.4 6.1 15.6

Kath 15 86.8% 96.1% 93.8% 100.0% 17.26% 0.42% 0 0 0/0 100% 0% 6.1 3.9 10.0

Kath Mat Led 86.0% - 88.8% - 11.38% 0.93% 0 0 0/0 29.9 0.0 29.9

Labour 13 81.8% 99.2% 96.9% 100.0% 17.83% 1.35% 0 0 0/0 100% 0% 31.1 4.3 35.4

**E-rostering report, workforce report ***Incidents reported via datix**** Proportion of bank and agency nursing information provided by temporary staffing office and workforce information

Registered midwives/

nursesOverallCare Staff

Care Hours Per Patient Day (CHPPD)Nurse Sensitive Outcome Indicators

Beds Hospital Acquired

Pressure Ulcers G2 and

above***

Falls with no harm / Falls resulting in

harm***

FFT % of positive responses

Environment

Proportion Agency hours****

Proportion Bank hours

Temporary Staffing

FFT % of negative responses

Fill Rates**

Suboptimal staffing

Days Nights

Wom

en &

Chi

ldre

n

Division Ward

Med

icin

eSu

rger

y

Trust Board Date of meeting: Wednesday 31st July 2019

Appendix 2

CHPPD: Trust (May 2019) vs Model Hospital peer and national medians (Jan 2019)

Alderbourne Rehab 20 7.50 6.01 6.80AMU - (EAU) Gen Med 300 45 7.40 6.99 7.17Beaconsfield East Geriatric Medicine 430 20 6.30 6.45 6.63

BevanGastro 301 24 6.30 5.95 6.11

Bevan ward all single rooms. Mixed speciality - also haematoogy. Benchamark not comparable

Churchill Gen Med 300 20 8.20 6.99 7.17CCU Cardiology 320 7 12.70 6.51 7.95 L2 patients. Benchamrk is for general cardiologyDaniel Rehab 16 7.70 6.01 6.80

DraytonRespiratory 18 7.20 6.32 6.47

HDU patients staffed 1:2

Fleming Gen Med 300 29 7.60 6.99 7.17Grange Geriatric Medicine 430 30 7.00 6.45 6.63Hayes Geriatric Medicine 430 30 10.30 6.45 6.63 Ward partially closed therefore Trust CHPPD misleadingITU/HDU Critical Care Medicine 192 9 25.60 26.01 25.48Jersey Gen Surgery 100 22* 6.40 6.95 7.14Kennedy Trauma and Orthopaedics 110 30 7.50 7.14 7.11Lister Geriatric Medicine 430 10 9.20 6.45 6.63Pagett Gynae 502 10 9.20 7.71 7.87Peter Pan Paeds 420 24 11.20 13.74 12.31Pinewood Closed mid May19The Stroke Unit Neuro 400 24 6.70 8.20 8.01Trinity Trauma and Orthopaedics 110 25 10.80 7.14 7.11

Model hospital peer Median CHPPD is 7.8 and National median is 7.9

CommentsSpecialtyMay 19 CHPPD

Jan 19 Peer Median CHPPD

Jan 19 National Median CHPPD Model HospitalWard

Funded beds open

1



Title National Inpatient Survey 2018

Report author Catherine Holly, Head of Patient and Public Engagement

Report sponsor Siobhan Gregory, Interim Chief Nurse

Status of Report Public Private Internal ☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information ☐ ☐ ☒

Summary

The National Inpatient survey 2018 looked at the experiences of 76,668 adult inpatients involved in 144 acute NHS Trusts and Foundation Trusts who received overnight care and discharged in July 2018. This report provides an overview of the trust’s performance in the 2018 survey. The report highlights areas where patients reported positive aspects of patient experience and outlines the next steps to address areas for improvement. Main points to note: • 446 patients returned a completed questionnaire,

giving a response rate of 38% • When compared with other organisations, the trust

performed ‘about the same’ as most other trusts that took part in the survey in nine out of 11 sections

• The trust performed ‘worse’ than other trusts in two sections: ‘Emergency/A&E department’ and ‘Nurses’. 79% of patients felt overall, they had a good experience

• The majority of trusts in London ‘scored the same’ in all sections; one London trust scored worse in eight sections and another in five sections

• Model Hospital comparison shows two trusts scored worse in eight sections.

Recommendations

Board Action required:

1. Note the contents of this report 2. Comment on the contents of this report


Quality - We will deliver good care every day

Workforce - We want empowered, committed people with the right skills and attitude

2

Performance - We will deliver the right care at the right time for our patients

Well Led - We will empower our people to deliver

Partnership - We will develop sustainable models of care centered around our patient

Impact

Quality and Safety Legal Financial Human Resources Equality and Diversity Engagement and communication Sustainability

3

1. Introduction NHS trusts are required to participate in the annual National Patient Survey Programme commissioned by the Care Quality Commission (CQC). The trust is required to undertake a survey of adult inpatients once discharged. The methodology and timing is strictly prescribed by the CQC: sample is drawn from people who were inpatients at the Trust during the month of July, the survey being sent to them in the October. Results are received the following spring. As in previous years, the trust appointed Picker to deliver the 2018 national inpatient survey on its behalf. Patients were sent by post a questionnaire, a covering letter from the trust, a multiple language sheet offering help with the survey and a CQC flyer. A Freepost envelope was also supplied in which those who wished could return their completed questionnaire. Non-responders were sent a reminder letter after 2-3 weeks and a further reminder with another copy of the questionnaire after a further 2-3 weeks. Picker ran a Freephone helpline for patients who had queries or concerns about the survey. Access to LanguageLine was also available with interpreters in over 100 languages. The questionnaire was developed by the NHS Patient Survey Co-ordination Centre. A total of 1250 patients from Hillingdon and Mount Vernon Hospitals were sent a postal questionnaire inviting them to take part in the survey. 446 patients returned completed questionnaires. The survey response rate was 38%. 2. Results There are 11 sections in the National Inpatient Survey. These are: • The Emergency / A&E Department • Waiting list and admission • Waiting to get to a bed • Hospital and ward • Doctors • Nurses • Care and Treatment • Operations and procedures • Leaving hospital • Overall views of care and services • Overall

The national inpatient survey asked patients to answer questions about different aspects of their care and treatment. Based on their responses, the CQC awarded a trust a score out of 10 for each question (the higher the score the better). Each trust also received a rating of ‘Better’, ‘About the same’ or ‘Worse’.

• Better: the trust is better for that particular question compared to most other trusts that took part in the survey.

• About the same: the trust is performing about the same for that particular question as most other trusts that took part in the survey.

4

• Worse: the trust did not perform as well for that particular question compared to most other trusts that took part in the survey.

The results show that the trust performed ‘about the same’ as most other trusts that took part in the survey in nine out of the 11 sections and scored ‘worse’ than other trusts in the Emergency/A&E department and nurses sections. Breakdown of results by questions There were a total 62 questions. The trust scored worse than other trusts in nine questions as follows: • While you were in the A&E department, how much information about your

condition or treatment was given to you? • In your opinion, how clean was the hospital room or ward that you were in? • Did doctors talk in front of you as if you weren’t there? • When you had important questions to ask a nurse, did you get answers that you

could understand? • Did you have confidence and trust in the nurses treating you? • Did nurses talk in front of you as if you weren’t there? • Did a member of staff tell you about any danger signals you should watch for

after you went home? • Did hospital staff take your family or home situation into account when planning

your discharge? • Did hospital staff tell you who to contact if you were worried about your condition

or treatment after you left hospital? The trust scored about the same in all remaining 53 questions. The survey highlighted many positive aspects of patient experience. To summarise: • Was your admission date changed by the hospital? (92%) • In your opinion, had the specialist you saw in hospital been given all of the

necessary information about your condition or illness from the person who referred you? (92%)

• While in hospital, did you ever share a sleeping area, for example a room or bay, with patients of the opposite sex? (92%)

• Were you offered a choice of food? (87%) • During your time in hospital, did you get enough to drink? (91%) • Did you feel well looked after by non-clinical hospital staff? (87%) • Did you have confidence and trust in the doctors treating you? (89%) • How much information about your condition or treatment was given to you?

(87%) • Were you given enough privacy when being examined or treated? (93%) • Before your operation, did a member of staff answer your questions about the

operation or procedure in a way you could understand? (89%) • Overall, did you feel you were treated with respect and dignity while you were in

the hospital? (89%)

5

3. Comparison with other trusts in London The majority of trusts in London ‘scored the same’ in all sections. One London trust scored worse in five sections and one trust scored worse in eight sections. Trust Better About the

same Worse

Chelsea & Westminster Hospital NHS FT 0 11 0 Guys and St Thomas’ NHS FT 1 10 0 Homerton University NHS FT 0 11 0 Imperial College Healthcare NHS Trust 0 11 0 Kings College Hospital NHS FT 0 10 1 London North West Healthcare Trust 0 6 5 North Middlesex University Hospital NHS Trust

0 3 8

Royal Free London NHS FT 0 11 0 St George’s University Hospitals NHS FT 0 11 0 The Hillingdon Hospitals NHS FT 0 9 2 4. Comparison with Model Hospital peer trusts The Model Hospital is a digital information service designed to help NHS providers improve their productivity and efficiency. The Trust uses this tool to compare productivity, quality and responsiveness data to identify opportunities to improve. When comparing all trusts within the Model Hospital peer group, the majority of the trusts scored the same in most sections. Three trusts scored better in one or two sections. Two trusts scored worse in eight sections. Four trusts scored worse in one or two sections. Trust Better About the

same Worse

Ashford and St Peter’s Hospitals NHS FT 0 11 0 Barnsley Hospital NHS FT 0 11 0 Burton Hospitals NHS FT 0 11 0 Croydon Health Services NHS Trust 0 3 8 Gateshead Health NHS FT 2 9 0 Harrogate and District NHS FT 1 10 0 James Paget University Hospitals NHS FT 0 10 1 Kingston Hospital NHS FT 0 11 0 Mid Cheshire Hospitals NHS FT 0 11 0 Milton Keynes University Hospitals NHS FT 0 11 0 North Middlesex University Hospital NHS Trust

0 3 8

Northern Devon Healthcare NHS Trust 0 11 0 The Hillingdon Hospitals NHS FT 0 9 2 The Queen Elizabeth Hospital King’s Lynn NHS FT

0 10 1

Salisbury NHS FT 1 10 0 South Tyneside NHS FT 0 11 0

6

Southport and Ormskirk Hospital NHS Trust 0 9 2 5. Conclusion

For each national survey, the trust is provided with two final reports: one from Picker and one from the CQC. The Picker and CQC reports have different purposes. The Picker report is designed for use in action planning by individual trusts, to improve performance. The CQC benchmarking report is a national overview, comparing trusts to one another and identifying the trusts that are performing out of the ‘expected range’. The trust received the Picker report at the beginning of the year and the results have been disseminated to Divisional Management teams. The medical and surgical division also receive the results by specialty where there are sufficient numbers of responses. In previous years divisions developed detailed actions in response to the areas requiring improvement, however in reality they focused on too many areas which resulted in not achieving improved results in all areas. During 2019/20 the Trust is developing a single action plan focusing on specific areas to include communication/attitude, reduction of noise at night and information provided at discharge. The action plan will be monitored via the Experience and Engagement Group which reports directly to the Quality and Safety Committee. The full survey results can be found at: https://www.cqc.org.uk/publications/surveys/adult-inpatient-survey-2018

https://www.cqc.org.uk/publications/surveys/adult-inpatient-survey-2018

Learning from Deaths Q4 2018/19

Part I Meeting of the Board of Directors 31st July 2019

Agenda item 13

Report title: Learning from Deaths (LFD), Q4 2018/19 Report to Public Board Report authors: Barbara North, Learning from Deaths Nurse Report sponsor: Dr Catherine Cale, Medical Director Board Action required: The Board is asked to 1. Note that this quarterly report of learning from deaths is in line with NHSI requirements 2. Note the changes to the LFD process to improve learning Link to the Hillingdon Hospitals Strategic Plan 2017/21: STRATEGIC PRIORITY: f) Improving the present – Implement year 2 of the Quality and Safety Improvement Strategy: Aim 3 - Working towards no preventable deaths


Learning from Deaths (LfD) Report for Q 3 and Q4 2018-2019

As part of the National Mortality Review programme each hospital in England is required to publish quarterly data summarising the outcomes of its reviews of patients who have died. THH uses the Royal College of Physicians structured judgement review methodology for case note reviews. Where a death has triggered an SI investigation, it is not separately reviewed via the SJR process.

Learning from Deaths Audit Figures for Q3 and Q4 18/19

Total No. Deaths

Total identified for SJR

Total sent to reviewers

Total No. of SJR’s returned to date

Score 1

Definitely Avoidable

Score 2 Strong Evidence of Avoidability

Score 3

Probably Avoidable (more than 50:50)

Score 4

Possibly avoidable but not very likely (less than 50:50)

Score 5

Slight evidence of avoidability

Score 6

Definitely not avoidable

LD*

Deaths

Q3 205 26 24 21 0 0 0 1 2 18 3

Q4 226 27 25 17 0 0 0 1 1 15 3

LD* = Learning Disability

Q3: 2 SJRs have not been requested: 1 because it was identified as a SI. 1 and notes were in use by the legal team. There were 3 inpatient deaths in patients with learning disabilities; these were reported to the Head of Safeguarding to refer for investigation via the LeDeR process

Q4: 3 SJRs have not been requested 2 because they were identified as being a SI’s and the third because the notes were being used by the legal team. There were 3 inpatient deaths in patients with learning disabilities; these were reported to the Head of Safeguarding to refer for investigation via the LeDeR process.

The aim is from April 2019 75% all deaths that need a SJR will be reviewed within 30 days and the remainder within 60 days. Currently 10% of all inpatients deaths have a SJR, from April 2019 the aim is for 20% of all inpatient deaths to have an SJR to improve the potential for learning

0

50

100

150

200

250

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Inpatient Deaths

Identified for SJR

SJR's requested

SJR's returned


Sharing Lessons

Of the deaths reviewed in Q3 1 was possibly avoidable (score 4), this patient waited in A&E for 2 hours before being seen, there was no evidence of early Sepsis screening and treatment, was not seen within 14 hours of presentation in A&E, should have been commenced on Heparin when suspicion was raised of DVT but was not commenced until Doppler proved positive. There was a delay in treatment for suspected PE. Of the deaths reviewed in Q4 15 2 had slight evidence of avoidability (Score 5). There were many good comments regarding communication with families, good end of life care was highlighted including a DNAR decision made appropriately despite challenging discussions around this with the family. A number of wards were commended in reviews for the quality of care provided including ITU, AMU and Beaconsfield East. The process enables improvements to be made and lessons learned even where it was not deemed that the death could have been prevented. This included:

• It was unclear what was said to a family by the nurse on ward when the request was made for them to come to the hospital, were they asked to present themselves to nurse on arrival? If they were this may have ensured that they avoided the shock of seeing their deceased relative.

• A patient was not for DNACPR but a crash call was put out. The Learning from Deaths (LfD) lead nurse presents lessons learnt from the outcomes of the SJR’s at The Nursing & Midwifery Council, Care Accounts for the Ward Managers and Matrons to cascade to staff also at the Trust wide mortality surveillance group.

Changes since Q3

• Maintaining a pool of sufficient numbers of trained SJR reviewers remains a challenge. The Trust is reviewing how we can support senior nurses and non-consultant grade Drs to support the SJR work

• The mortality surveillance group (MSG) increased in frequency to monthly from May 2019. • Rather than lessons learned being presented by the LFD nurse, each specialty is asked (on

a rotational basis) to report learning from deaths within their specialty that has been derived from SJRs, local mortality reviews and SIs.

• Learning identified is cascaded via the minutes of the MSG and from July will be part of the

new Patient Safety and Learning Bulletin • It has been recognised that figures previously reported did not include SI investigations of

deceased patients, this is being rectified and will be reflected in figures from Q1 2019/20

Further Improvements to be made

1. A&E deaths had been excluded from reviews due to local interpretation of the guidance, A&E deaths are included in the review process from Q1 2019/20.

2. From April 2019, the percentage of deaths that will be reviewed within the SJR process will increase to 20% of all cases,. This will consist of those that meet the set criteria in the LfD policy (comprises on average 10-12% of deaths), with a “top up” to 20% using specific


themes. The theme for Q1 of 2019-20 will be cases with sepsis. Non Invasive Ventilation has been added to the list of criteria to be reviewed.

3. The medical examiner system is now being rolled out nationally and will be in place in

Hillingdon Hospitals by April 2020. This will further support appropriate identification of patients to be reviewed via the learning from deaths process aswell as providing independent scrutiny and support to families

Part 1 Meeting of the Board of Directors 31st July 2019 Agenda item 15

Integrated Quality and Performance Report

Cover Page

2

Title Integrated Quality and Operational performance

Report author

Vanessa Saunders, Deputy Chief Nurse Rachel Stanfield, Deputy Director of People and Organisational Development Melissa Mellett ,Director of Operational Performance Jay Dungeni, Deputy Chief Nurse

Report sponsor Piers Young, Hospital Director

Status of Report Public Private Internal ☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information ☐ ☒ ☐

Summary This report provides oversight to the Trust Board on progress against the quality and performance standards the Trust seeks to meet as either national or local standards.



To improve the present A&E 4 hour standard; the 18 week Referral to Treatment performance; to meet the Cancer targets; to complete the CQC action plan; to implement year 2 of Quality and Safety Improvement Strategy; to maintain finance and the use of resources score of 3 in meeting the control total.

Impact

Quality and Safety

To continue to provide the best level of patient care and safety in delivering core constitutional standards and implementing year 2 of Quality and Safety Improvement Strategy.

Legal Financial

Human Resources To provide hospital services in the most efficient and effective manner

Equality and Diversity To provide and deliver services taking account of the requirements of diverse groups

Engagement and Communication To deliver nationally and locally set targets in terms of engagement, communication , listening and learning

Contents

3

Item Slides

Executive Summary 4-9

Quality 11-19

Operational Performance • A&E • RTT • Cancer • Diagnostics

31-43

People • Medical Appraisals, STaM and PDR • Sickness • Vacancy, TtR and LTR • Temporary Staffing Usage

45-48

Quality Summary

4

Summary: Key Issues Requiring discussion: • Discharge Summaries not issued performance required further improvement . • Patient Falls – 1x fractured neck of femur in Jun, declared as SI. • Serious Incident performance still requires significant improvement. Ongoing concerns around No.

SIs in relation to the deteriorating patient, 12 month review underway. • Infection Control – No reported MRSA (bacteraemia) cases in May or June. However, there were a

total of 7 C-DIFF cases over May and June. • Medication Safety - Reduction in medicines reconciliation rate and an increase in omitted doses

since Feb 2019. • Friend and Family Test requires improvement in particular A&E and Outpatients response and

performance rates. Action required: 1. Review and discuss the quality and safety performance outlined in the report 2. Note the developing reporting format and recommend any further improvements.

Executive Summary: Operational standards (1/2)

5

Commentary • A&E performance was 0.3% above trajectory

in June, driven by achieving the June Type 1 trajectory. Performance at the end of June was strong, including 2 days of >95% and 3 days of >90%.

• RTT performance was below trajectory in June, with the ongoing validation programme likely to put further pressure on performance across Q2. The unvalidated Total Waiting List grew by 690 (2.6%) in June.

• May 19 cancer performance (uploaded) was non- compliant across the leading 2 targets but both showed improvement on the previous month. The unvalidated June performance across both standards is at risk of non-compliance.

• Diagnostics remained compliant across Q1, following the addressing of the non-obstetric ultrasound backlog in Mar 2019.

Summary of performance against constitutional standards

Note: 1Cancer validation takes c 1 month so current month reported position is unvalidated and likely to improve; Conditional formatting indicates achievement of monthly target/ trajectory Source: I-Reporter; Planning Submission

Standard Target Apr-19 May-19 Jun-19

A&E Performance (All Types)

Target: 95% Trajectory: 83.6% 81.3% 84.6% 83.9%

RTT Performance Target: 92% Trajectory: 88.0% 87.5% 87.1% 85.4%

RTT Total Waiting List 25,052 25,184 26,387 27,077

Cancer 2 Week Wait Performance 93% 91.1% 91.9% 88.7%1

Cancer 62 Day Treatment Performance 85% 79.8% 84.0% 83.3%1

Diagnostics Performance 99% 99.9% 100.0% 100.0%

A&E Performance Executive Summary: Operational standards (2/2)

6

Commentary • 4h performance was above 0.3% above

trajectory in June at 83.9% but below May performance.

• Type 1 performance was 62.5%, 3.7% ahead of trajectory. This was driven by strong non-admitted Type 1 performance against trajectory.

• Type 1 attendances were 3.5% higher than plan in June, a continuation of the YTD trend (4.8%).

• Ambulance attendances reduced by 6.2% in June, with blue light ambulances the main driver.

• Improvements to flow - DTOCs and stranded

patients improved in June although DTA delays remained high and ambulance handover, whilst having improved, delays remain a challenge.

A&E Performance Overview

Note: Conditional formatting indicates achievement of monthly target/ trajectory Source: Informatics

Standard Plan: Jun-19 Apr-19 May-19 Jun-19

A&E Performance (All Types) 83.6% 81.3% 84.6% 83.9%

A&E Performance (Type 1) 58.8% 56.4% 64.5% 62.5%

A&E Attendances (All Types) 14,090 13,788 14,223 13,664

A&E Attendances (Type 1) 5,412 5,772 5,809 5,600

Ambulance Arrivals n/a 2,283 2,272 2,131

A&E Type 1 Admission Rate n/a 35.9% 36.8% 34.9%

A&E Decision To Admit Delays - 4 hrs n/a 370 292 334

Stranded Patients 7+ Days n/a 210 200 176

DTOCs - Days Delayed n/a 295 321 200

Ambulance Handover 60 min Delays n/a 19 3 10

People Summary (1/3)

7 Source: HR Team Analysis

Performance analysis – PDR Compliance Compliance at the end of June was 85.48%, an improvement of almost 2.5% on the same time last year. Key risks and challenges: High impact improvement actions: • Reaching 100% compliance before

the extension deadline of 12 July 2019

• Current delays in uploading paper copies of completed PDRs to iDevelop

• Quality of PDRs and the data within iDevelop

• Continuing support for managers to understand and meet any training needs • Discussion at weekly Divisional meetings with bespoke support as needed from

HR People Solutions Partners • Weekly and daily reports from I-Develop reviewed by service area • Risk log of issues raised, with clear timescales on when resolved • Regular cleansing of reporting lists to remove relevant staff (i.e. on long term

sickness or new starters)

Performance analysis – Mandatory Training Statutory/Mandatory training compliance continues to increase month on month with June attaining a new Trust high at 93.47%. Only Data Security & Protection (DSP) remains under target at 92.37%. Key risks and challenges: High impact improvement actions: • Maintaining upward trend again and

making sure all courses are within target

• Bringing Data Security and Protection to within 95% target.

• User feedback that the Fire Safety Level 1 e-learning is lengthy and repetitive

• Weekly meetings within Division to review key metrics including STAM • Weekly report to triumvirate highlighting course compliance by service level • Regularly reviewing the need for additional sessions • Directly booking staff on to sessions or in house training sessions • Temporary staffing team regular monitoring of temporary staffing STaM

compliance, ensuring no new joiners to the Bank who are non-compliant and suspending from the Bank where workers do not become compliant

• DD advising those non-compliant unable to do bank/agency, review of those continuing to do this not via Patchwork

Contents

10

Item Slides Executive Summary 4-9 Quality 11-19


31-43


45-48

Discharge Summaries

11

Patient falls

12

Hospital Acquired Pressure Ulcers

13

Patient Safety Incidents (1/3)

14


15


16

Serious Incidents and Never Events (1/2)

17

Serious Incidents and Never Events (2/2)

18

Infections (1/3)

19

Infections (2/3)

20

Infections (3/3)

21

Medication Safety (1/2)

22

Medication Safety (2/2)

23

Complaints (1/2)

24

Complaints (2/2)

25

PALS

26

Friends and Family Test (1/2)

27

Friends and Family Test (2/2)

28

Mortality

29

Contents

30



31-43


45-48

A&E Performance (1/7)

31

Commentary • The Trust delivered 83.9% (All type) and

62.5 % (Type 1) performance in May 19 against our submitted all type trajectory of 83.6%.

• Type 1 breaches (and within that non-

admitted Type 1) remain the greatest opportunity to improve performance further ahead of trajectory.

• Key actions underpinning this performance improvement included:

• The rapid improvement project supported by the CARES+ team, which reorganised the blue zone (see and treat at front door)

• 2 hourly ward rounds • Trialling a discharge lounge • Execs walks @7am and matrons

based on wards • The Trust continues to drive the

Emergency Care Improvement plan to maintain compliance with the agreed trajectory.

Source: I-reporter; Planning Submission

Performance – All

Performance – Type 1 Only

81.3% 84.6% 83.9%

70%

75%

80%

85%

90%

95%

100%

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

2019/2020 2018/2019 Trajectory Standard

56.4%

64.5% 62.5%

40%45%50%55%60%65%70%75%80%85%


2019/2020 2018/2019 Trajectory

A&E Performance- Type 1 split (2/7)

32

Commentary • Admitted and non-admitted performance achieved monthly trajectory in June.

• Non-admitted accounts for c 65% of all Type 1 activity so is the major driver of Type 1 performance and

thereby overall A&E performance. The rapid improvement event to reduce the time to see a clinician at the front door (blue zone) in June was key to driving this improvement.

Performance – Type 1 Admitted Performance – Type 1 Non Admitted

Source: ED Trajectory v3; Integrated EC Performance Pack

45.3%

52.0%

48.1%

30%

35%

40%

45%

50%

55%

60%

65%

70%


2019/2020 2018/2019 Trajectory

62.0%

71.4% 70.0%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%


2019/2020 2018/2019 Trajectory

A&E Performance - Daily Type 1 (3/7)

33

Performance – Type 1 Admitted Performance – Type 1 Admitted (Jun)

Performance – Type 1 Non- Admitted (Jun)

Source: Informatics

Commentary • Type 1 admitted

performance was consistently above trajectory, with performance only significantly below trajectory in 3/30 days

• However Type 1 non admitted performance showed more volatility, with 13/30 days significantly below trajectory

• Performance was strong at the end of the month, including , including 2 days of >95% and 3 days of >90%.

• This momentum carried forward into early July.

0102030405060708090100

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

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Atte

ndan

ces

Per

form

ance

Attendances Performance Trajectory

0

20

40

60

80

100

120

140

160

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

100%

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Atte

ndan

ces

Per

form

ance

Attendances Performance Trajectory

A&E Attendances by Type (5/8)

34 Source: Informatics; Plan Submission

Attendances – All Type

Attendances – Type 1

Commentary • In June 19, total

attendances were 3.1% below plan (-2.4% YTD).

• However, Type 1 attendances were 3.5% above plan (4.8% YTD).

• This change in acuity mix compared to plan provides a further ongoing challenge to delivering the A&E trajectory.

• We continue to work with the CCG to review demand management options.

10,00010,50011,00011,50012,00012,50013,00013,50014,00014,50015,000

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

2017/2018 2018/2019 2019/2020

A&E Attendances (All Types) Trajectory

4,000

4,500

5,000

5,500

6,000

6,500

7,000

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

2017/2018 2018/2019 2019/2020

A&E Attendances (Type 1) Trajectory

Ambulances Attendances (6/8)

35

Ambulance Attendances

368 386 304 362 304 294 355 380

399 382 331

383 321 348 288

508 517 451 330

449 338 315 259 256 250 248 238 236 156 103

0

400

800

1,200

1,600

2,000

2,400

Oct Jun

Ambulances

Apr-18 May Sep

2,179

Apr-19 Jul Aug Nov Dec

2,346

Jan Feb Mar May

2,092 2,057 2,016 2,125 2,048 2,004 2,084

2,191 2,301 2,313 2,283 2,272

Jun

2,131

Handover 30 min Delays Arrivals - Blue Light Arrivals - Non-Blue Light Handover 60 min Delays

Source: I-reporter

Commentary • Total ambulance attendances were 5.7% higher in Jun-19 than in

Jun-18, with a mix shift towards non-blue light attendances

• 30 mins ambulance handover delays continued to fall for the 10th consecutive month. We have agreed a revised trajectory that will see the elimination of ambulance handover delays by end of Sept 19.

Actions taken since last meeting. Have they worked or is there a barrier to progress? What further actions are required? • Ongoing focus on front door improvements as part of ED

improvement plan • Development of OD programme • Rapid Improvement Event on “Blue Zone” to decrease

delays to first clinician assessment • Performance & accountability discussions at middle

grade level

Decision to Admit (6/7)

36

Decision to Admit Delays (4-12 hours)

Source: i-Reporter

Commentary • DTA delays have been high over the past 5 months, driven by high levels of bed occupancy in the hospital.

• DTAs delays in June remain high but are down 23.2% from the Feb 19 high point.

138

288

161 188

150

44 26

13

71

193

435 428

370

292

334

0

50

100

150

200

250

300

350

400

450

500

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

2018/2019 2019/2020

Discharge Improvement (7/7)

37

Long and Extended Stay Patients

Commentary • June saw an initial reduction in long and extended stay patients but this improvement plateaued towards the end of the month. • Days lost to DTOC reduced in May from April and were stable across the month.

Weekly Delayed Transfers of Care (DTOCs)

Source: Informatics

50

60

70

80

90

100

110

150160170180190200210220

21+

Day

s

7+ D

ays

Stranded Patients 7+ Days Stranded Patients 21+ Days

024681012141618

0

20

40

60

80

100

120

Spe

lls

Day

s D

elay

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DTOCs - Days Delayed DTOCs - Spells

RTT Performance Overview (1/3)

38

Trust-wide RTT Performance

Commentary • In Mar 2019, the Trust commissioned a review of its elective care position given some

increases in long waiting patients and some unexplained anomalies on its waiting list.

• The review highlighted a number of areas requiring immediate action: Large numbers of data quality errors; Limited operational oversight of planned waiting list; Operational grip around booking practices; Lack of understanding and training for our staff.

*please note there is a timing affect of two weeks between the data pulled for the total waiting list size for June (unvalidated) above compared with the rest of the performance pack. July’s performance is also unvalidated and mid-month.

Actions taken since last meeting. Have they worked or is there a barrier to progress? • The Trust is on-track 8 weeks into a 14 week mass validation

programme and has rolled out an RTT training programme for all relevant staff.

• We have submitted a bid for £1.5m to NWL commissioners for

additional activity funding to support the recovery plan.

Source: Informatics

RTT Performance Overview (2/3)

39

RTT Incomplete and PTL by Service Commentary • Two services account for c. 40% of >18

waiters (T&O, Allergy). • Validation process likely to reveal additional

pressure on Pain and Gastro (endoscopy).

Actions taken since last meeting. Have they worked or is there a barrier to progress?

• Support and resources deployed to improve

capacity, oversight and grip of elective care, diagnostics performance and PTL management.

• Recovery plans for key challenged specialties have been developed (T&O, Gen Surg., Pain, Urology, Endoscopy, Allergy, Derm) and continue to be closely monitored but also revised as the validation programme continues.

• Increased focus on maximising use of capacity for long wait patients.

What further actions are required? What is the trajectory for improvement? • Commissioner and Trust joint working to

deliver demand management initiatives and explore alternative provision options (eg other NHS providers).

• Continued focus on outpatient and theatre productivity.

28%

21%

17%

9% 9% 9%

8%

(110) Trauma & Orthopaedics

(330) Dermatology

(301) Gastroenterology

Other (317) Allergy Service

(100) General Surgery

(191) Pain Management

18+ Week Waiters by Service

Note: Table cut to reflect nationally reported dataset; June data unvalidated Source: Informatics

PTL Last Period

PTL This Period

RTT 52 Weeks

RTT 40 Weeks

RTT 18 Weeks Feb-19 Mar-19 Apr-19 May-19 Jun-19

(110) Trauma & Orthopaedics 4,339 4,347 4 35 815 83.1% 84.4% 83.1% 83.2% 81.3% (130) Ophthalmology 2,656 3,009 0 2 153 93.4% 94.8% 95.6% 95.2% 94.9% (100) General Surgery 2,304 2,279 0 18 357 83.7% 84.8% 85.6% 85.9% 84.3% (301) Gastroenterology 1,731 1,920 0 9 311 86.0% 86.3% 85.4% 86.8% 83.8% Other 1,763 1,734 0 1 123 96.7% 95.1% 93.6% 94.2% 92.9% (120) ENT 1,620 1,689 0 2 79 94.6% 96.3% 97.1% 96.0% 95.3% (317) Allergy Service 1,447 1,532 0 49 661 62.8% 59.7% 57.4% 58.7% 56.9% (502) Gynaecology 1,389 1,382 0 0 119 97.2% 95.5% 94.2% 91.7% 91.4% (191) Pain Management 1,231 1,358 3 33 352 80.3% 80.9% 81.0% 78.0% 74.1% (330) Dermatology 1,392 1,350 0 10 353 88.7% 85.5% 80.3% 77.3% 73.9% (420) Paediatrics 1,193 1,248 0 0 41 98.4% 99.2% 97.5% 97.4% 96.7% (101) Urology 1,090 1,120 0 4 90 91.8% 95.4% 95.9% 94.1% 92.0% (400) Neurology 1,112 1,115 1 1 191 85.8% 86.9% 86.4% 86.3% 82.9% (140) Oral Surgery 1,243 1,099 0 0 47 95.0% 96.6% 94.1% 95.2% 95.7% (410) Rheumatology 614 675 0 0 129 84.7% 86.8% 83.7% 84.7% 80.9% (320) Cardiology 582 550 0 0 43 95.7% 95.1% 93.8% 94.2% 92.2% (340) Respiratory Medicine 395 408 0 0 19 97.9% 98.1% 97.2% 97.5% 95.3% (257) Paediatric Dermatology 286 262 0 2 65 86.6% 87.6% 74.7% 72.4% 75.2% Total 26,387 27,077 8 166 3,948 88.2% 88.8% 87.5% 87.1% 85.4%

Summary of RTT Programme Board (3/3)

40

Constitution

• The purpose of the RTT Programme Board is to; direct the work, to have oversight of the key workstreams, provide assurance and updates on progress, and the delivery of expected outputs against the agreed timelines. When required it is also to escalate issues or risk of harm to patients to the accountable boards or committees. The key improvement workstreams are:

• Administration • Training • Data • Validation • Specialty Operating Plans • Clinical Harm Review

• Each workstream has an identified

SRO.

• The RTT Programme Board has also developed, manages and monitors the associated risk register for the improvement work.

Purpose Constitution Membership

• The RTT Programme Board is the body responsible for the overall delivery of the Elective NHS constitutional standards, improvement work streams and improved performance (RTT and diagnostics) and in doing so safeguarding patients.

• The Membership will include: • Chief Executive (chair) • Chief Operating Officer

(deputy chair) • Divisional

representation • Head of information • Trust Medical Director

representation • Director of Operations • Head of Patient Access

Members on an invited basis:

• NHSI/NHSE • CCG • MBI Health Group

Cancer Performance (1/2)

41

2 Week Wait Performance by Tumour Site1

2 Week Wait Performance (all tumour sites)1

906 809 799

913 937 950 1,002

0

200

400

600

800

1,000

1,200

80

85

90

95

100

Performance, %

802

Aug Sep Dec Jul

Patients

Apr-18

May Jun Oct Nov Jan Apr-19

Feb Mar

845

May Jun

736 810 855 798 915

775

Target Cancer - 2 Week Wait Performance Cancer - 2 Week Wait Total Seen

Commentary • Performance in May improved by 0.8% but

remains 1.1% below target, driven by the continuation of consistently high levels of demand experienced since Mar 19

• The May position was driven by non-compliance across 2 large tumour groups (Lower GI and Urology)

• Urology performance impacted by an unplanned reduction in consultant capacity

• Breast performance in May improved following addressing of workforce issues in radiology

• The June position is unvalidated and currently at risk of being non-compliant. Demand remains high (nb. Breast, Derm) with activity flexed up to the highest it had been in 14 months.

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Ongoing review of colorectal capacity to

understand if further increase in additional clinics required.

• Changes to Radiology staffing to increase short-term capacity improved Breast performance in June.

• Extra endoscopy capacity agreed to meet Cancer and 52 week wait demand.

What further actions are required? What is the trajectory for improvement? • Completion of recruitment of a second

Colorectal specialist nurse • Ongoing monitoring of seasonal Dermatology

referral patterns • Urology expected to remain challenged until

locum starts in Sept with ongoing review of short-term options to increase capacity

Note: 1Validation for Cancer lags 1 month so last reported period is unvalidated Source: NHS Digital Cancer Dataset (via internal Informatics team)

Total Seen Performance

Mar-19 Apr-19 May-19 Jun-19 Mar-19 Apr-19 May-19 Jun-19 Suspected breast cancer 142 139 158 211 95.8% 78.4% 95.6% 87.7% Suspected skin cancers 185 169 186 200 96.8% 98.8% 96.2% 95.0% Suspected lower gastrointestinal cancers 182 207 206 195 95.1% 84.5% 83.5% 81.5% Suspected gynaecological cancers 94 116 94 100 100.0% 98.3% 96.8% 97.0% Suspected urological cancers (excluding testicular) 76 87 70 92 96.1% 92.0% 82.9% 73.9% Suspected head and neck cancers 91 83 93 91 98.9% 97.6% 94.6% 96.7% Suspected upper gastrointestinal cancers 75 62 74 57 89.3% 93.6% 93.2% 82.5% Suspected lung cancer 37 29 33 23 100.0% 96.6% 100.0% 95.7% Suspected haematological malignancies excluding acute leukaemia 8 20 11 11 100.0% 85.0% 100.0% 100.0%

Suspected brain or central nervous system tumours 11 13 9 8 100.0% 100.0% 88.9% 100.0% Suspected children's cancer 11 5 9 8 90.9% 100.0% 100.0% 100.0% Suspected testicular cancer 3 7 6 6 100.0% 100.0% 50.0% 100.0% Suspected sarcomas 0 0 0 0 - - - - Other suspected cancer 0 0 1 0 - - 100.0% - Total 915 937 950 1,002 96.3% 91.1% 91.9% 88.7%

Cancer Performance (2/2)

42

62 Day Performance by Tumour Site1

62 Day Performance (all tumour sites)1 Commentary • The Trust was non-compliant in May,

achieving 84.0% against the 85% target. This was however, a 4.2% improvement in performance against Apr.

• In May, there were 3 internal breaches (1x Colorectal, 2x Urology) and 6 tertiary breaches (1 x Colorectal, 2 x Gynae, 1 X H&N, 1 x Derm., 1 x Urology)

• June data is unvalidated, with risk that the validated position will be non-compliant

Actions taken since last meeting. Have they worked or is there a barrier to progress? • Updated Divisional Cancer Recovery

Plans (inc Urology) • Trust piloting the use of Cancer Trackers

at Cancer Recovery Board to track the first 28 days of pathway.

• Monthly Cancer Meetings with Divisional Leads has been established with an action log to monitor progress

What further actions are required? What is the trajectory for improvement? • Completion of CT staffing recruitment to

staff 2nd CT scanner

• Completion of recruitment of a second Colorectal specialist nurse for straight to test

47 41

52 45

52

32

50 50 57

010203040506070

70

75

80

85

90

95

Jun Dec

Performance, % Patients

May Apr-18

Jul Aug Sep Oct Nov Jan Feb Mar

46

Apr-19

May

60

41 47

34 38

Jun

Target Cancer - 62 Day Treatment Performance Cancer - 62 Day Treatment Total Seen

Total Seen Performance

Mar-19 Apr-19 May-19 Jun-19 Mar-19 Apr-19 May-19 Jun-19 Urological (Excluding Testicular) 15 14 13 15 76.7% 89.3% 84.6% 86.7% Skin 6 11 7.5 14 100.0% 100.0% 93.3% 85.7% Breast 11.5 3 3.5 11 100.0% 100.0% 85.7% 81.8% Lower Gastrointestinal 2.5 5.5 4 8 80.0% 54.6% 25.0% 87.5% Gynaecological 1 0.5 1.5 2.5 100.0% 100.0% 100.0% 80.0% Upper Gastrointestinal 1.5 2 2 2 33.3% 50.0% 100.0% 100.0% Lung 3.5 2 2 1 100.0% 50.0% 100.0% 100.0% Head and Neck 0 2 0 0.5 - 25.0% - 0.0% Sarcoma 1.5 0 0 0.5 66.7% - - 0.0% Haematological (Excluding Acute Leukaemia) 3 5.5 3 0 100.0% 54.6% 100.0% - Brain/Central Nervous System 0 0 0 0 - - - - Testicular 0 1 1 0 - 100.0% 100.0% - Head & Neck 0 0 0 0 - - - - Other 0 1 0 0 - 100.0% - - Total 45.5 49.5 37.5 57 87.9% 79.8% 84.0% 83.3%

Note: 1Validation for Cancer lags 1 month so last reported period is unvalidated Source: NHS Digital Cancer Dataset (via internal Informatics team)

Diagnostics Performance (DMO1 Standards)

43

Diagnostics Performance against DMO1 Standard

99.9 100.0 100.0

82

84

86

88

90

92

94

96

98

100

Oct Apr

> 6 Wks %

Sep Jun Jul May Aug Dec Nov Jan Feb Mar

2019/2020 2018/2019 Target

Commentary • The Trust remained complaint in June, albeit

pressure on ultrasound remains high.

• Ultrasound pressures still evident due to reduction in consultant workforce but currently being managed; 3rd party capacity option previously explored proved incompatible.

• Endoscopy waiting list has grown over the past 4 months and this continues to be closely monitored.

Actions taken since last meeting. Have they worked or is there a barrier to progress?

Specific NOUS actions are in place as follows: • Further additional capacity being secured from

West Herts Trust • Specific MSK ultrasound capacity has been

secured through In-Health. • Additional weekend sessions being run to meet

demand whilst work continues on 7 day staffing model

What further actions are required? What is the trajectory for improvement?

• A demand and capacity model for

sonography has been developed and identified a capacity shortfall.

• Further work is required to identify new clinical/operational models to meet the capacity shortfall within the existing cost base.

Performance by Modality

Note: 1Most recently reported month is non validated Source: Informatics Team

Total Waiting List Performance

Mar-19 Apr-19 May-19 Jun-19 Mar-19 Apr-19 May-19 Jun-19

Audiology - Audiology Assessments 326 320 351 329 100.0% 100.0% 100.0% 100.0%

Barium Enema 0 1 1 0 - 100.0% 100.0% -

Cardiology - echocardiography 8 3 3 3 100.0% 100.0% 100.0% 100.0%

Colonoscopy 202 235 217 248 100.0% 100.0% 100.0% 100.0%

Computed Tomography 368 447 374 315 100.0% 100.0% 100.0% 100.0%

Cystoscopy 52 61 36 61 100.0% 100.0% 94.4% 100.0%

Flexi Sigmoidoscopy 48 47 46 61 100.0% 100.0% 100.0% 100.0%

Gastroscopy 168 249 225 244 100.0% 100.0% 100.0% 100.0%

Magnetic Resonance Imaging 581 670 588 563 100.0% 99.6% 100.0% 100.0%

Non-obstetric ultrasound 2127 2420 2542 2776 100.0% 100.0% 100.0% 100.0%

Total 3880 4453 4383 4600 100.0% 99.9% 100.0% 100.0%

Contents

44



31-43

People • Medical Appraisals, STaM and

PDR • Sickness • Vacancy, TtR and LTR • Temporary Staffing Usage

45-48

Medical Appraisals, STaM and PDR

45

Medical Appraisals - Medical appraisals in the new rolling year measure have seen increases for June to 96.77% (+11.4%). All divisions are now either at or above the Trust target of 90%; Corporate 100%, W&Cs 97.62%, Medicine 97.48%, Surgery 97.39% and CCSS 90%. Only 10 of 310 appraisals remain overdue; CCSS 3, Medicine 3, Surgery 3 and W&Cs 1.Those overdue are receiving regular communications from the Medical staffing team to complete the appraisals in a timely manner. Statutory/Mandatory Training Compliance - STaM compliance is at 93.47% which is the highest level recorded for over a year. Every subject is compliant at Trust level with the exception of Data Security and Protection (DSP) which is at 92.37%, although this is the highest level for this course this year. Fire Safety Level 1 is non-compliant in several Divisional/Directorate areas including Temporary Staffing 75.35%, Medicine 76.02% and Surgery 79.21%. To increase compliance, the e-learning package is being reviewed to improve the user experience. At Divisional level, Nursing and Patient Services are below the 80% compliance rate for Adult Basic Life Support Level 2 at 76.6%. Medicine Division (Admin) are non-compliant in a number of subjects including Moving and Handling Levels 1 and 2, Safeguarding Adults level 2 and Safeguarding Children level 2. Corporate services have reached another record high of 95.27% (+1.52%) this month with only one subject under target; Safeguarding Children Level 3 73.33% (target 90%). Medicine have experienced a slight dip in compliance to 89.68% (-0.04%) with three courses non-compliant; DSP 87.54%, Fire Safety L1 76.02% and Infection Prevention Control (IPC) Level 2 86.69%. Medicine division are reviewing individual STaM compliance on a weekly basis and reviewing where additional actions are required, such as bespoke training sessions in team meetings. Surgery continues to increase compliance further at 92.33% (+0.24%) with only two courses non-compliant; DSP 92.55% and Fire Safety Level 1 79.21%. W&Cs also continue to increase compliance to one of the highest levels at 94.23% (+0.66%) with only DSP under target at 92.27%. CCSS continues to lead with the way with the highest compliance of the clinical divisions and third highest compliance overall at 97.16% (0.17%) and all subjects within target. Low compliance amongst medical staff (87.98%) are preventing CCSS from surpassing the current compliance and there is a review of whether bespoke training is available in this area to increase compliance. PDR Compliance - The report excludes staff on maternity leave and new starters that joined the Trust less than 6 months prior to 1st April 2019. The PDR window was open from 1 April 2019. This year a new electronic system was designed and introduced to capture the whole PDR process on iDevelop, the Learning Management System. More than 800 staff were provided with face to face training, group support or one to one support to complete the PDRs. By the end of June we were able to report 85.48% uptake which puts us in a significantly better position this year than previous despite the introduction of a new process and system. At the end of June last year, we were reporting 83.03%. With 369 outstanding PDRs (June data) to be recorded on iDevelop the reporting window has been extended to Friday 12 July 2019 with the latest figures (11.07.19 PM) showing a completion rate of 91.83%. Two areas reached 100% compliance by the end of June (Education Centre and R&D) with Estates and CCSS both above 95%. However Surgery and Medicine divisions are both under 80% at 79.79% and 74.12% respectively.

0%

20%

40%

60%

80%

100%


PDR compliance %

2018-19 2019-20 Target (95%)

0%

20%

40%

60%

80%

100%

120%


Medical Appraisals compliance %

2018-19 (Cumulative) 2019-20Target (90%)

50%

60%

70%

80%

90%

100%


Statutory/Mandatory Training compliance %

2018-19 2019-20 Target (85%)

Source: Workforce Information Team

Sickness

46 Source: Workforce Information Team

Sickness There has been a negligible change in sickness absence this month at 4.08% (long-term 2.77% and short-term 1.31%), and FTE days lost to sickness continue to exceed £3.5k at 3722.5 days with an estimated salary cost of £374k. Sickness within CCSS has decreased this month to 3.14% with an estimated sickness cost of £43,508. Long term sickness decreased to 1.87%, whilst short term increased slightly to 1.26%. The hotspot areas are Outpatient services THH 5.94% with hotspots in T&O and Elizabeth ward to due long term sickness cases. Other hotspot areas within CCSS include Pathology 5.09%, due to Phlebotomy long term sickness, and Pharmacy 4.12%. Additional cost due to sickness is increasing at £5,445 to cover ST– mainly due to Elizabeth Ward £2,208,T&O £1,434, X-ray Hillingdon £1,04. Individual sickness cases are reviewed on a weekly basis ensuring they are managed in line with the sickness policy, and any trends or concerns discussed in the weekly Divisional Team Meeting. Sickness in Estates has largely decreased to 1.13% and all ST sickness is in Building & Estates. The highest sickness rate is in Estates Admin at 6.1% and this is due to LTS. LTS is currently 0.83% and STS is 0.3.%. Facilities sickness is currently 5.95%. ST sickness is 1.00% and LT is 4.95% . The total cost of sickness in this area is £31,938 with 564.36 FTE days lost. Current hotspot areas are: Cleaning & Catering Management (29.76% - LTS), Retail Services MVH (21.26% - LTS) and Patient Dining (13.81%, LTS 12.03%). High sickness rates in these areas are primarily due to long term sickness. Medicine has seen sickness decrease further to 3.65% (continuing to decrease at its lowest level in over 6 months). Current sickness cost is £86,205. The division has also seen a reduction in long term sickness to 2.19% and short term sickness reduced to 1.46%. Medicine Admin has seen a positive increase to 3.9% (a decrease since 9.11% last month), Emergency Care has seen an overall positive reduction to 4.9%, although hotspot areas remain A&E Paeds (8.86%), AECU (7.89%) and AMU (5.94%). Medical Wards is currently at 4.24% with hotspot wards being Lister Ward (10.24%) and Hayes Ward (6.7%). Additional cost due to sickness is £55,779 (£9,406 agency). The top 3 departments with the highest expenditure are AMU £9,946 (mainly due to STS, and some LTS), Grange £6,025 (ST and LTS) and Beaconsfield East £5,490 (mainly due to LTS). Surgery Division sickness is currently 4.13%. LT is currently 2.77% and ST is 1.36%. Current hotpsot areas are Trinty Unit ( 7.62% , ST 1.14%, LT 6.48%), ITU (6.88% ST 2.84%, LT 4.04%), Pagett Ward (6.47%, ST 2.02%, LT 4.45%) and Orthopaedics (5.75%, LTS). Sickness absence rates for the Division have gone up compared to the previous month primarily due to increase in long term sickness absence. Womens & Children's sickness rate is currently 4.42% (a decrease from last month of -0.32%). ST sickness is currently 1.38% and LT is 3.03%. The main hotspot areas are Katherine Ward (8.33%, ST 0.5%, ST 7.83%), Neonatal (6.60%, ST 3.36%, LT 3.24%), MLU (6.18%, ST 1.09%, LT 5.09%). The total cost of sickness for June is £50,945 with 541.10 FTE days lost. Sickness rate is high primarily due to long term sickness absence cases which include stress, anxiety and depression (not work related) and some long term health conditions. To address sickness across the board, there are monthly review meetings held with Ward Managers and regular meetings with Triumvirates (for oversight) to review all sickness cases to ensure these are progressed in line with policy; we continue to deliver bitesize sickness management sessions for managers and team; and cases are managed to the triggers within the new sickness policy.

4.02% 4.07% 4.08%

0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%5.00%


Trust Sickness Rate %

2018-19 2019-20 Target (3%)

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£250,000.00

£300,000.00

£350,000.00

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Total Sickness Cost

Estimated Cost 2018-19 Estimated Cost 2019-20

Bank spend due to sickness 2019-20 Agency spend due to sickness 2019-20

Vacancy, TtR and LTR

47

0%

5%

10%

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Trust Vacancy Rate %

2018-19 2019-20 Target (11%)

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10

20

30

40

50


Time to Recruit at point of formal offer (Average working days)

2018-19 2019-20 33-Day Target

Trust Vacancy rate The Trust has seen a fall in the vacancy rate to 13.01% (-0.73%) compared to last month. The decrease is largely due to the closure of Pinewood Ward. Medicine (16.82%), Women's & Children's (8.42%) and Corporate Divisions have all seen a reduction in their vacancy rates compared to last month, however CCSS (+0.15%) and Surgery (+1.52%) have both seen an increase in their vacancy rates compared to the previous month. CCSS are developing a bespoke Radiology People Plan to focus on the hard to recruit posts, inc. workstreams of recruitment, retention, workforce planning and wellbeing. There is still a high vacancy rate across Band 5 Nursing Staff 29.15% (-0.12%) compared to last month. The highest number of vacancies are within Medicine Division (89.43), with A&E showing the highest number of vacant FTE posts at 22.68. There are a range of high impact action in place to address our nursing vacancy rate. These include bespoke A&E recruitment days over the last few months, which have been successful and which will now be held monthly moving forwards; building on this model there has also been a dedicated recruitment event for Trinity Ward at Mount Vernon and there will be a Care of the Elderly (COTE) recruitment day in August. There is also a Medicine Division recruitment and retention tracker to monitor progress of Nursing vacancies rates. we are also updating adverts, attending ward managers meetings to provide recruitment/interview training, gathering insight from student nurses to understand how to improve experiences and we are refreshing our plan for international nurse recruitment for 2019/20 to diversify our use of suppliers and hold regular standing panels to conduct Skype interviews. There are also three planned Trust wide upcoming Nursing Recruitment days. Time to Recruit. Average times to recruit have improved considerably to within target at 31 days. June sees this figure at it's lowest since the start of this year at 28.4 days. CCSS, Medicine and Women's and Childrens have all seen a positive reduction in their time to recruit, with Surgery showing the biggest improvement (-8.5) to 21.5 days. In CCSS, Admin & Clerical and Nursing & Midwifery posts took the most time to recruit to (73.5 days combined). Medicine saw a positive reduction in their time to hire, although hotspot areas where timings were higher was Emergency Care - in particular with Nursing and Midwifery staff. There is a weekly review of the recruitment SLAs for all divisions to understand any barriers in time to recruit, for example any delays in shortlisting. Voluntary Turnover rate. Voluntary turnover in June increased to 14.35% (+0.10%). Top leaving reasons in June were ‘Relocation’ (10), ‘Promotion’ (6) and ‘Other Not Known’ (5). Of the directorates, Surgery had the highest number of voluntary leavers at 11. Of these, 5 were Band 5 Nursing & Midwifery employees. In CCSS, Healthcare Scientists have the highest turnover at 18.18% (due to Audiology), however the reduction has sustained at 13% for Nursing staff. There will be some specific actions following staff survey feedback to be communicated to staff across August, following further team focus groups. Turnover in Estates has increased to 19.42%, with specific retention actions to be reviewed following staff feedback. Facilities also sees an increase in turnover rate to 9.01% (+1.06%). The main hotspot areas being Coffee Shop MVH (41.38%), Housekeeping Hillingdon (30.17%) and Cleaning & Catering Management (27.91%). Medicine sees turnover rates decrease slightly to 14.51%. Hotspots continue to be A&E, (23.74%), AMUE (20.9%), Drayton (31.94%) and Churchill (31.37%). Allied Health Professionals (69.9%) and Nursing and Midwifery (16.81%) are the staff groups within this division with the highest turnover rates. To address turnover in Medicine, an Emergency Department People Plan is being developed to focus on recruitment, retention and wellbeing, which includes some bespoke actions to engage staff following focus group feedback. Surgery has seen an slight increase in turnover to 12.79% (+0.57%). Critical Care (129.73%), Elective Admissions (26.67%) and Ophthalmology Medical Staff (25.23%) see the highest figures. Nursing and Midwifery sees 5 employees leaving the Trust: 2 relocation, 1 work life balance, 1 better reward package , 1 child dependant. Women's and Children's turnover rate has seen a reduction to 14.73% (-0.44%). The division saw 8 leavers in total - 3 not known, 2 end of fixed term contracts, 1 relocation, 1 health related and 1 work life balance. Allergy & Respiratory sees the highest turnover rate at 25.53%, followed by Katherine Ward (25.26%), Labour Ward (23.92%) and Alexandra Ward (20.69%). Across the Trust we are refreshing the NHSI Retention Programme work to provide greater emphasis on solutions for problem issues including flexible working, career development and bullying & harassment.

0%

5%

10%

15%

20%

Voluntary Turnover Rate % (12 months rolling position)

2018-19 2019-20 Target (11%)

Source: Workforce Information Team

Temporary Staffing Usage

48

Temporary staffing spend has continued to see a reduction since April and June see its lowest expenditure this year at £1,805,314 (-£61,140). Agency spend has decreased to £821,279 (45.49%), and Bank spend to £984,036 (54.51%). Medicine continues to have the highest agency expenditure (£860k), followed by Corporate, Surgery and CCSS (£1.6m combined). W&Cs sees the lowest spend at £163k across Bank and Agency. Nursing continues to have the highest expenditure at £787k - 47.79% spent on agency and 52.21% spent on bank. A&E Department continued to have the highest spend (£91k agency & £86k bank). This was followed by Theatre Pay (£126k) and X-Ray Department (£56k - largely agency usage). Agency price cap breaches have seen a slight increase since last month to 368 (+24). This figure is considerably higher to where we were this time last year (240). The highest increase is shown in Medical and Dental, more than doubling their breaches from 163 in June 2018 to 324 this year. In terms of actions, there is continued implementation of Patchwork for medical locum bookings, to increase use of Bank vs. agency and extend the size of the Bank; ongoing review of controls in place particularly out of hours; Weekly review of high cost and longest serving agency; HR People Solutions Partners working closely with Temporary Staffing manager to tackle hot spot areas for high agency bank/ spend; and participating in refreshed NWL sector temporary staffing programme to look at consistent approaches, e.g. to rate control.

£0£200,000£400,000£600,000£800,000

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Bank Cost (£)

2018-19 2019-20

£0£200,000£400,000£600,000£800,000

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2018-19 2019-20

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%'s filled with off framework

2018-19 2019-20

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%'s filled with agency

2018-19 2019-20

0.00%20.00%40.00%60.00%80.00%

100.00%

%'s filled with bank

2018-19 2019-20Source: Workforce Information Team


Agenda item 16

Title Finance Report - June 2019 Month 03

Report author Mark Pockett, Interim Deputy Director of Finance

Report sponsor Jenny Greenshields, Director of Finance


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Summary This report provides oversight to the board on progress against the financial targets of the Trust and the actions required to ensure the control total is met.



To improve the present A&E 4 hour standard; the 18 week Referral to Treatment; to meet Cancer target; to complete the CQC action plan; to implement year 2 of Quality and Safety Improvement Strategy; to maintain finance and the use of resources score of 3 in meeting the control total.

Impact

Quality and Safety

Legal

Financial To maintain finance and the use of resources score of 3 in meeting the control total.

Human Resources

Equality and Diversity

Engagement and Communication

FINANCIAL REPORT JUNE 2019 (MONTH 03)

1. EXECUTIVE SUMMARY

Table 1 Key Performance Indicators

Table 2 Trust Financial Position at Month 03

This Month Last MonthSurplus/(Deficit) in month (£2.09m) (£1.11m)Surplus/(Deficit) year-to-date (£7.07m) (£4.98m)Variance from Plan in month £0.30m £0.06mVariance from Plan year-to-date £0.20m (£0.10m)Risk Rating 3 3Agency Expenditure £0.82m £0.94mEfficiency Savings £0.25m £0.11mCash Position at month end £1.0m £0.9mCapital Expenditure £0.3m £0.8m

Annual Plan Actual Variance Plan Actual Variance

Plan to-date to-date to-date In Month In Month In Month

£m £m £m £m £m £m £m

Operating IncomeNHS Clinical Income 208.23 50.15 50.00 (0.15) 16.63 16.53 (0.10)Drugs - PbR Excluded 12.64 3.16 3.13 (0.03) 1.05 1.11 0.05Non-NHS Clinical Income 3.37 0.84 0.56 (0.28) 0.28 0.15 (0.13)Other Operating Income 26.72 6.63 6.47 (0.15) 2.23 2.22 (0.00)

Total Operating Income 250.96 60.78 60.16 (0.61) 20.18 20.01 (0.18)

Operating Expenses

Employee Expenses (178.79) (46.63) (46.46) 0.17 (15.48) (15.38) 0.11

Drugs - PbR Excluded (12.64) (3.16) (3.04) 0.12 (1.05) (1.04) 0.01Drugs - In Tariff (5.32) (1.47) (1.45) 0.03 (0.49) (0.46) 0.03Clinical Supplies and Services (25.10) (6.46) (6.11) 0.35 (2.15) (2.06) 0.09Other Operating Expenses (36.39) (9.51) (9.65) (0.14) (3.13) (3.13) (0.01)Total Non-Pay (79.45) (20.60) (20.24) 0.35 (6.82) (6.69) 0.12

Total Operating Expenses (258.24) (67.23) (66.70) 0.53 (22.30) (22.07) 0.23

EBITDA (7.28) (6.45) (6.54) (0.09) (2.11) (2.06) 0.05

Depreciation (9.42) (2.37) (2.33) 0.04 (0.79) (0.76) 0.03Interest Income/Expense (3.70) (0.90) (0.85) 0.05 (0.30) (0.28) 0.01PDC Dividend Expense (3.53) (0.88) (0.88) - (0.29) (0.29) 0.00

Surplus(Deficit) before Exceptionals (23.93) (10.59) (10.60) (0.00) (3.49) (3.40) 0.09

Financial Recovery Fund 14.81 2.22 2.22 - 0.74 0.74 -Provider Sustainability Funding 4.69 0.70 0.91 0.21 0.24 0.44 0.21Marginal Rate Emergency Tariff 1.58 0.40 0.40 - 0.13 0.13 -Gains/(Loss) on Investment Properties - - - - - - -Profit/(Loss) on the Disposal of Assets - - - - - - -

Surplus(Deficit) after Exceptionals (2.86) (7.27) (7.07) 0.20 (2.39) (2.09) 0.30

Income Income from NWL CCGs is shown in line with the contract agreement for 2019/20. The actual performance was above plan by £0.575m. Allowing for the 1% tolerance and marginal rate of 70%, this has generated an additional over performance payment of £91k. This has been included in the position although over performance payments have yet to be decided at STP level. Additional funding is available from NWL to support 52 week waiting time performance. Funding of £74k for existing 52 week breaches has been included. Income for non-North West London CCGs was down against plan, due to Herts Valley and Thames Valley activity underperformance of £0.3m. Non-NHS income is behind plan on income from Overseas Visitors. This continues the downward trend seen last year, however the new Overseas Manager has started in May and processes are being strengthened. Having met the plan for Quarter 1, the position includes accruals for Provider Sustainability Funding (PSF) Financial Recovery Funding (FRF), both of which are dependent on achieving the financial target in the quarter. In addition the Trust has received an extra £200k PSF from NHSE as an adjustment for 18/19. The Trust’s control total will be adjusted to reflect this. Table 3 Activity and Income

A&E activity continues to perform above plan by 3.1% delivering an additional £330k at full cost. Day case & elective activity remains above planned activity but due to case mix across specialties is under performing on income by £379k. Although emergency activity is below plan by 2.7% case mix of patients has delivered an additional £196k above plan and a reduction in excess bed days with significant over performance on ambulatory care income. Outpatients have continued to underperform on activity and income.

Pont of DeliveryYTD Plan Activity

YTD Actual Activity

YTD Act Variance

YTD Plan Cost

YTD Actual Cost

YTD Variance

£m £m £m % £m £m £m %A&E

Hillingdon A&E 16.88 17.18 0.30 1.8% 2.81 3.11 0.30 10.6%MIU 7.51 7.97 0.46 6.2% 0.56 0.59 0.03 5.7%

A&E Total 24.39 25.15 0.76 3.1% 3.36 3.69 0.33 9.8%Critical Care

Adult CC 1.33 1.02 (0.31) -23.1% 1.48 1.28 (0.19) -13.0%Neonatal 1.66 1.85 0.19 11.4% 0.88 0.98 0.10 11.3%

Critical Care Total 2.99 2.87 (0.12) -4.0% 2.35 2.26 (0.09) -4.0%Inpatients

Births 1.04 1.06 0.03 2.5% 3.40 3.43 0.03 0.8%Chemotherapy 0.32 0.37 0.05 15.7% 0.06 0.08 0.02 40.3%Daycase 5.93 6.02 0.09 1.6% 4.84 4.64 (0.20) -4.2%Elective 0.76 0.71 (0.05) -6.2% 2.92 2.75 (0.18) -6.0%Emergency 7.48 7.28 (0.20) -2.7% 12.69 12.89 0.20 1.5%Excess Beddays 2.53 2.29 (0.23) -9.2% 0.77 0.72 (0.05) -7.0%

Inpatients Total 18.04 17.73 (0.31) -1.7% 24.69 24.50 (0.19) -0.8%Outpatients, AEC & Community

Outpatients 114.39 113.25 (1.14) -1.0% 13.26 13.03 (0.23) -1.7%Ambulatory Care 3.71 3.41 (0.30) -8.1% 0.93 1.33 0.40 43.0%Community 5.13 4.54 (0.59) -11.5% 0.59 0.54 (0.05) -8.8%

Outpatients, AEC & Community Total 123.22 121.19 (2.03) -1.7% 14.78 14.90 0.12 0.8%Other (incl CQUIN)

Other including Rehab & CQUIN 4.70 5.11 0.41 8.7% 8.13 8.26 0.14 1.7%NWL Contract alignment - (0.48) (0.48)

Other (incl CQUIN) 4.70 5.11 0.41 8.7% 8.13 7.78 (0.35) -4.3%Grand Total 173.34 172.05 (1.29) -0.7% 53.31 53.13 (0.18) -0.3%

Ealing CCG has continued to over perform against contract due to higher than expected births and emergency activity. Discussions are taking place with Ealing to understand if this is a rise in demand across the sector or a shift in activity from another provider. ‘Other contracts’ include Herts Valley CCG which has seen a decrease in referrals since February across all specialties but mainly General Surgery, Pain, T&O & Dermatology. The reason for this reduction is due to repatriation to local Hertfordshire Hospitals and it is not know at this stage whether it will continue for the rest of the financial year. Divisional performance Surgical activity remains behind plan at the end of quarter 1 however, the Division is developing a recovery plan to ensure that they deliver activity levels across planned care closer to the year-end plan. Medical activity and income continues to over perform across emergency care with higher than expected levels of A&E attendances. Ambulatory care activity & income is above plan, with emergency activity below plan but higher income. Endoscopy & Cardiology continue to see increases in referrals and their activity levels have increased to cope with this level of demand. Although births in maternity are currently slightly ahead of plan this is not expected to continue as antenatal bookings are down. Paediatric emergency activity is below plan which may be due to the integrated clinics that the hospital delivers in the community. Gynae activity for elective and outpatient remains high in response to increasing levels of GP referrals into the service. Radiology direct access is significantly above plan as referrals for plain film and ultrasound have increased from Hillingdon CCG. Pay

Pay was £0.1m higher than in May, but due to a higher plan has a £0.1m favourable variance. Agency costs reduced by £0.1m compared to May, and at £0.82m is within the NHSI ceiling of £0.9m. Pay costs in the Medicine Division remain a concern. They are now £0.7m over budget with Medical Pay, Qualified Nursing Pay and HCA Pay all significantly overspent. Compared to last month Medical & HCA pay are virtually unchanged, due to the closure of Pinewood Ward for the full month Nursing Pay has shown the anticipated reduction. Overseas recruitment plans are being developed in some areas to mitigate the reliance on agency staff.

TABLE 4 - PERFORMANCE BY COMMISSIONER

COMMISSIONERActual

2018/19Plan

2019/20Actual

2019/20Variance to

Plan% Variance

to Plan£m £m £m £m %

Hill ingdon CCG 35.25 36.67 36.57 (0.10) 0%Ealing CCG 5.07 5.11 5.67 0.56 11%Other NWL CCGs 2.22 2.69 2.80 0.11 4%NWL Marginal Rate adjustment - - (0.48) (0.48)Specialist Commissioning 1.91 2.75 2.81 0.06 2%Other Contracts 3.31 3.56 3.30 (0.26) -7%NCAs 0.75 1.02 0.99 (0.03) -3%Other Non-Contracted Income 4.65 0.98 0.97 (0.01) -1%Sub-total 53.15 52.78 52.63 (0.14) 0%CQUINs 1.13 0.54 0.50 (0.04) -7%Total 54.28 53.31 53.13 (0.18) 0%

Within the pay position there is unmet pay CIP of £0.1m. Table 5 Trust Pay Trend against plan

Table 6 Agency Expenditure against NHSI Agency Ceiling

Non-pay The non-pay underspend increased slightly in June, driven by low expenditure on Clinical Supplies resulting from better stock control within Theatres and lower Orthopaedic activity has resulted in a £156k underspend. Establishment expenditure is favourable due to through lower IT costs including maintenance and licencing. Higher utility costs continue to impact the Trust together with ongoing costs of management support and consultancy across the Trust.

2. DIVISIONAL POSITIONS Table 7 Breakdown of Financial Position by Division

Annual Plan Actual Variance Plan Actual Variance

Plan To-Date To-Date To-Date M3 M3 M3

£m £m £m £m £m £m £m

Surgery Income 66.61 16.35 16.02 (0.32) 5.52 5.46 (0.07)Pay (38.33) (9.86) (9.96) (0.10) (3.24) (3.31) (0.07)Non-Pay (15.87) (4.07) (3.82) 0.25 (1.33) (1.24) 0.10Total 12.40 2.42 2.24 (0.18) 0.95 0.91 (0.04)

Medicine and Income 92.61 22.43 22.34 (0.09) 7.42 7.35 (0.06)Emergency Care Pay (53.85) (13.94) (14.64) (0.70) (4.54) (4.79) (0.25)

Non-Pay, Depn & Interest (20.51) (5.36) (5.35) 0.02 (1.71) (1.75) (0.04)Total 18.25 3.13 2.36 (0.77) 1.17 0.82 (0.35)

Women & Children Income 51.23 12.30 12.26 (0.03) 4.07 4.08 0.01Pay (24.98) (6.47) (6.50) (0.03) (2.14) (2.18) (0.04)Non-Pay, Depn & Interest (4.11) (1.07) (1.01) 0.06 (0.34) (0.31) 0.03Total 22.14 4.76 4.76 (0.00) 1.59 1.59 0.01

Cancer & Clinical Income 12.48 3.05 3.16 0.12 1.00 1.06 0.06Support Services Pay (26.44) (6.84) (6.94) (0.10) (2.25) (2.27) (0.02)

Non-Pay, Depn & Interest (2.25) (0.68) (1.02) (0.33) (0.16) (0.31) (0.15)Total (16.21) (4.48) (4.79) (0.31) (1.41) (1.51) (0.11)

Corporate Income 12.87 3.22 3.29 0.07 1.07 1.13 0.06Pay (31.36) (8.05) (7.98) 0.07 (2.64) (2.68) (0.04)Non-Pay, Depn & Interest (29.64) (7.62) (8.31) (0.69) (2.49) (2.65) (0.16)Total (48.14) (12.45) (13.00) (0.56) (4.06) (4.19) (0.14)

Central Budgets Income 33.01 6.76 6.61 (0.15) 2.21 2.24 0.03Pay (3.44) (1.47) (0.45) 1.02 (0.67) (0.15) 0.52Non-Pay, Depn & Interest (20.88) (5.94) (4.80) 1.15 (2.17) (1.79) 0.39Total 8.69 (0.65) 1.37 2.02 (0.63) 0.30 0.93

(2.86) (7.27) (7.07) 0.20 (2.39) (2.09) 0.30

Variance to Budget

3. TRUST RUN-RATE Table 8 Trust Run-Rate for the last 6 months

The table above looks at the actual monthly income and costs over the previous 6 months. This table enables the Trust to review and identify trends or unusual peaks in expenditure or income, these can be reviewed and where necessary future mitigating action put in place to manage or avoid these variations.

Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19£000s £000s £000s £000s £000s £000s

NHS CLINICAL INCOME MAIN NHS CLINICAL INCOME 16,898 15,803 14,928 15,093 17,432 16,027EXCLUDED DRUGS INCOME 1,040 908 1,277 1,049 976 1,106EXCLUDED DEVICES INCOME 159 179 179 107 144 119OTHER DIVISIONAL NHS CLIN INC 691 766 1,368 332 366 381

NHS CLINICAL INCOME Total 18,788 17,655 17,751 16,581 18,919 17,633

NON-NHS CLINICAL INCOME ICR/RTA 57 77 50 78 124 91OVERSEAS INCOME 45 16 18 93 75 42PRIVATE PATIENT & NCA 25 21 13 19 18 16

NON-NHS CLINICAL INCOME Total 126 114 81 191 217 149

OTHER OPERATING INCOME TRAINING & EDUCATION 815 818 929 720 722 752NON-PAT SERV TO OTHER WGA 705 736 859 618 641 642RENTAL INC FROM OPER LEASES 256 275 456 259 258 262CAR PARKING INCOME 180 170 121 149 159 161CATERING INCOME 131 134 117 139 122 142OTHER INCOME 261 205 526 276 185 265

OTHER OPERATING INCOME Total 2,349 2,337 3,007 2,161 2,087 2,224

PAY NURSES & MIDWIVES PAY (4,787) (4,671) (4,836) (4,867) (4,674) (4,663)MEDICAL PAY (4,415) (4,249) (4,566) (4,409) (4,361) (4,382)HCAS & SUPPORT PAY (1,979) (1,912) (1,927) (1,977) (1,864) (1,913)ADMIN & CLERICAL PAY (1,562) (1,731) (1,712) (1,860) (1,764) (1,774)SCI, THERAPUTIC & TECH PAY (1,459) (1,394) (1,390) (1,480) (1,403) (1,402)MANAGERS PAY (591) (522) (510) (515) (537) (528)ESTATES PAY (324) (307) (318) (321) (298) (316)HEALTHCARE SCIENTISTS PAY (193) (193) (186) (213) (202) (197)DIRECTORS PAY (83) (106) (90) (103) (115) (142)APPRENTICESHIP LEVY (58) (58) (61) (58) (62) (58)

PAY Total (15,451) (15,143) (15,597) (15,803) (15,281) (15,376)

DRUGS DRUGS - PbR EXCLUDED (1,066) (910) (862) (1,014) (990) (1,039)DRUGS - IN-TARIFF (514) (532) (393) (575) (414) (458)

DRUGS Total (1,579) (1,441) (1,255) (1,589) (1,404) (1,497)

SUPPLIES & SERVICES - CLINICAL SUPPLIES & SERVICES - CLINICAL (2,992) (3,028) (4,642) (1,943) (2,101) (2,061)SUPPLIES & SERVICES - CLINICAL Total (2,992) (3,028) (4,642) (1,943) (2,101) (2,061)

OTHER NON-PAY CLINICAL NEGLIGENCE (641) (669) (679) (909) (909) (909)ESTABLISHMENT EXPENSES (392) (427) (313) (516) (498) (425)PREMISES EXPENSES (782) (708) (538) (843) (863) (695)SUPPLIES & SERVICES - GENERAL (359) (355) (321) (329) (349) (306)CONSULTANCY (199) (118) (260) (124) (238) (287)TRANSPORT (147) (164) (172) (132) (177) (168)OTHER NON-PAY (707) (462) (1,034) (353) (272) (345)

OTHER NON-PAY Total (3,227) (2,903) (3,316) (3,206) (3,304) (3,135)

DEPRECIATION (751) (751) (924) (800) (763) (763)INTEREST EXPENSE (338) (268) (235) (283) (295) (290)INTEREST RECEIVABLE 5 6 8 7 5 6DIVIDENDS PAYABLE (308) (308) (87) (294) (294) (293)INVESTMENT PROPERTY REVAL - - 2,769 - - -FINANCIAL RECOVERY FUND - - - 740 740 741PROVIDER SUSTAINABILITY FUND - - 2,062 234 234 442MARGINAL RATE EMERG TARIFF - - - 132 131 132

Grand Total (3,379) (3,731) (377) (3,874) (1,109) (2,088)

4. COST IMPROVEMENT PROGRAMME At month 3 YTD the Trust has achieved £414k of the planned £720k, a shortfall of £306k. Further detail is provided in the separate Cost Improvement Report. 5. RISK RATING The “Finance and use of resources metric” forms part of NHS Improvement’s Single Oversight Framework. It is scored between 1 (best) and 4 (worst). The rating for June is a 3:

Table 9 Finance and Use of Resources

Metric Plan Rating for June Capital Service Capacity 4 4 Liquidity 4 4 I&E margin 4 4 Variance from Plan 1 2 Agency spend 1 2 Weighted Average 2.8 3.2 Overall Rating after Overrides 3 3

The ‘Underlying Financial Performance’ risk on the Corporate Risk Register is rated 20 (extreme).

6. BALANCE SHEET

The month end cash position was £1.01. The Trust has received PSF/FRF of £2.9m YTD in advance of the quarterly confirmation of payment. Cash is still restricted and suppliers are being prioritised to ensure continuation of services. Table 10

Statement of Financial Position

31/03/2019 30/06/2019 Movement MovementActual Actual Actual In Month

£m £m £m £mNon-Current Assets

Intangible Assets 2.30 2.74 0.44 (0.06)Plant, Property and Equipment 141.31 139.87 (1.44) (0.39)Investment Property 45.86 45.86 - -Trade and other receivables 1.01 1.10 0.09 0.03Prepayments 0.81 0.81 - -

Total Non-Current Assets 191.29 - 190.38 - (0.91) - (0.42)

Current AssetsInventories 2.96 3.09 0.13 0.08NHS Trade Receivables 10.36 12.92 2.57 (0.21)Non-NHS Trade Receivables 3.56 3.29 (0.27) 0.30Prepayments and Accrued Income 7.35 15.32 7.97 1.59Cash and Cash Equivalents 1.03 1.01 (0.02) 0.07

Total Current Assets 25.26 - 35.64 - 10.37 - 1.83

Total Assets 216.55 - 226.02 - 9.46 - 1.41

Current LiabilitiesTrade Payables 10.54 13.47 2.93 2.31Capital Payables 2.10 2.55 0.45 (0.06)Other Payables 9.55 14.37 4.82 4.06Accruals and Deferred income 15.25 13.71 (1.53) (3.07)Provisions 0.16 0.16 - (0.01)Other Liabilities 1.25 1.02 (0.23) (0.67)Borrowing 1.34 1.34 - -

Net Current Assets/ (Liabilities) (14.92) - (10.99) - 3.93 - (0.73)

Total Assets Less Current Liabilities 176.37 - 179.39 - 3.02 - (1.15)

Non-Current Liabilities (amounts > 1 year)Provisions 1.81 1.83 0.02 0.02Borrowing 74.50 82.50 8.01 0.92

Total Assets Employed 100.07 - 95.06 - (5.01) - (2.09)

Taxpayers EquityPublic Dividend Capital 74.86 74.86 - -Retained Earnings (23.37) (28.10) (4.73) (1.99)Revaluation Reserve 48.58 48.30 (0.28) (0.09)

Total Taxpayers' Equity 100.07 - 95.06 - (5.01) - (2.09)

Table 11 Analysis of Supplier Payment Performance The following table shows the Trust’s performance against the Better Payment Practice Code against a target of 95%.

The Trust’s Cash position is forecast daily forward for 12 months. The current difficulties experienced by the Trust in meeting our suppliers payments terms will be reviewed with a full forecasting exercise being undertaken in the next few weeks to identify the cash requirements going forward and implications should no further cash support be available from NHSi.

Table 12 Cash flow forecast

Better payment practice code Actual Actual Actual Actual30-Jun-19 30-Jun-19 31-May-19 31-May-19

YTD YTD YTD YTDNumber £'000 Number £'000

No n NHSTotal bills paid in the year 19,885 40,210 3,826 11,371Total bills paid within target 4,971 24,339 962 7,522Percentage of bills paid within target 25.0% 60.5% 25.1% 66.2%

NHSTotal bills paid in the year 204 5,024 63 1,390Total bills paid within target 26 3,261 4 1,137Percentage of bills paid within target 12.7% 64.9% 6.3% 81.8%

T o ta lTotal bills paid in the year 20,089 45,234 3,889 12,761Total bills paid within target 4,997 27,600 966 8,659Percentage of bills paid within target 24.9% 61.0% 24.8% 67.9%

Cash Flow Forecast 19-20Act Act Act Fcast Fcast Fcast Fcast Fcast Fcast Fcast Fcast Fcast

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20INCOME £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Clinical Income 16,667 16,894 16,716 17,494 17,431 17,431 17,431 17,431 17,431 17,431 17,431 17,431

Education and Training 1,964 - - 2,237 - - 2,237 - - 2,237 - -

Other Income 3,034 1,585 3,243 1,697 1,750 2,474 1,685 1,750 1,685 1,750 1,685 2,474

HMRC - 1,008 385 284 284 284 284 284 284 284 284 284

STF 1,369 974 974 1,694 1,299 1,300 2,345 1,950 1,948 2,669 2,274 2,276

Loan ITFF 5,611 - - - - - - - - - - -

Other Receipts 318 613 56 79 129 104 104 129 104 129 104 104

TOTAL RECEIPTS 28,963 21,074 21,374 23,485 20,893 21,593 24,086 21,544 21,452 24,500 21,778 22,569

PAYMENTS

Pay Costs (14,913) (14,769) (14,565) (14,957) (15,487) (15,147) (15,487) (15,147) (15,147) (15,487) (15,147) (15,147)

Creditors (12,722) (3,931) (6,519) (7,105) (4,265) (4,784) (7,308) (4,610) (5,130) (7,737) (6,618) (6,892)

NHSLA (1,139) (1,139) (1,139) (1,127) (1,127) (1,127) (1,127) (1,127) (1,127) (1,127) - -

PDC Dividends - - - - - - - - - - - -

ITFF Loan Interest payments (114) (158) (47) (145) (14) (340) (164) (160) (48) (149) (13) (335)

Loan Repayments - (500) - - - (195) - (500) - - - (195)

Other Payments (3) (16) (15) (1) - - - - - - - -

Total Payments (28,891) (20,513) (22,285) (23,335) (20,893) (21,593) (24,086) (21,544) (21,452) (24,500) (21,778) (22,569)

NET CASH FLOW IN PERIOD 72 561 (911) 150 - - 0 - - - - -

OPENING CASH BALANCE 1,128 1,200 1,761 850 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000

CLOSING CASH BALANCE 1,200 1,761 850 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000

Table 13 Capital Spend year to date

Capital spend was £1.31m as at June 2019.

Below is the analysis of the Estates capital expenditure excluding the A&E Refurbishment.

The emergency capital bid for £8.3m has been resubmitted for to NHSi following feedback on the original bid. The requirement to address the capital priorities contained within the paper has become increasing more urgent given the time that has elapsed since the initial bid, the Trust is awaiting feedback and the next steps. Estates are working and planning to on the basis that the majority of the work will be before winter subject to NHSI approval of the application.

7. KEY MESSAGES • The Trust has made a good start to the year, by achieving its plan in Q1 the organization has

retained the £4.9m non-recurrent FRF/PSF support for the quarter; • Although agency spend has reduced, the continuing overspends on medical pay in the

Division of Medicine are of significant concern and will need to be managed down over the coming months;

• The identification of savings plans has been accelerated with support of PA Consulting, with progress now being monitored by the monthly CIP Board. Every effort must now be made to bring forward savings to ensure achievement of the Q2 financial plan and secure a further £4.9m of FRF/PSF.

2019/20 Actual Plan VarianceCapital Plan To-Date To-Date To-Date

£000s £000s £000s £000s

Information Management Technology 855 188 168 20Estates 2,663 848 642 206Major Medical Equipment 1,300 58 324 (266)Contingency 0 28 0 28A+E Refurbishment 2,530 191 618 (427) Sub-Total Outright Purchase 7,348 1,313 1,752 (439)Donated Assets 188 15 48 (33)Grand Total 7,536 1,328 1,800 (472)

Mth 3£000s

Boilerhouse Works 397Surveys & Project Costs 213MVH Air Handling Unit 68Daycare project 52Plant Electrical Infrastructure Upgrade 28A&E Lockdown project 15Ophthalmology Expansion & Tudor moves 15Other 60

848

Estates Capital Expenditure YTD

1



Title Board Assurance Framework Update (v0.02)

Report author Jason Seez, Deputy CEO

Report sponsor Jason Seez, Deputy CEO


x


x

Summary

The Trust is in the process of updating its Board Assurance Framework (BAF). A review of the Trust Strategic Objectives and Strategic Risks was undertaken as part of workshops with the Trust Board and interviews with the Executive team. Following meetings with all the Executive Director leads for each risk, a revised BAF has been drafted.

Recommendations

The Audit and Risk Committee reviewed the development of the BAF on 18 July 2019, and noted the development of the BAF to date, and the ongoing process to ensure we have established robust risk and assurance processes. The Board is invited to note this report update.

Links to Corporate Objectives All

Impact

Quality and Safety x

Legal x

Financial x

Human Resources x

Equality and Diversity x Engagement and communication x Sustainability x

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Assurance goes to the heart of the work of any NHS board of directors. The provision of healthcare involves risk and being assured is a major factor in successfully controlling risk. • Assurance is the bedrock of evidence that gives confidence that risk is being controlled

effectively, or conversely, highlights that certain controls are ineffective or there are gaps that need to be addressed.

• The board assurance framework (BAF) brings together in one place all of the relevant information on the risks to the board’s strategic objectives.

• It is an essential tool for trust boards, but like all tools it needs to be used with skill and diligence.

The Trust Board in Q1 2019/20 reviewed and updated the Trust’s strategic objectives and risks, and the executive team are establishing a systematic process for the review of the associated controls and assurances. By Q4 2019/20 we will have established a systematic process of review, with the key improvements to the way we govern the Trust being – Process On a quarterly basis the Trust’s key strategic objectives, risks, controls and assurances, will be reviewed at the - • Trust’s principal management forum, the Trust Management Executive; • Trust’s principal assurance forum, the Trust’s Audit and Risk Committee; and • Key updates then presented to the Trust Board for review and approval.

Outcomes by Q4 2019/20 • The Trust Board will have a clear and complete understanding of the risks faced by the Trust in

the delivery of our strategic objectives, the types of assurance currently obtained, and consideration as to whether they are effective and efficient;

• The Trust Board will be sighted on areas where assurance activities are not present, or are insufficient;

Summary

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• Identified areas where existing controls are failing and as a consequence the risks that are more likely to occur;

• Refocused our assurance resources so that the agendas of our assurance committees are focused on the key issues highlighted by the BAF process; and

• Developed an evidence base to support the Trust in the preparation of our annual governance statement.

Strategic objectives

The Trust Board reviewed the Strategic Objectives at two Trust Board seminars in Q1.

The following Strategic Objectives were developed:

Quality

• The care we provide to our patients will be safe, effective and result in a good experience Performance • We will deliver the right care, at the right time, and in the right place for our patients Money • We will use our resources effectively to eliminate waste, achieve financial balance, and support

the system Workforce • We will value our people and equip them with the skills to provide the right care Partnership working and well-led • We will work with all of our partners, including patients and the public, to deliver our strategy,

including a new hospital • We will harness the potential of our people to deliver continuous improvement

Strategic Risks

The Trust Board have reviewed the strategic risks related to our strategic objectives, and these

strategic risks will continue to be reviewed and finalised, and will be presented for approval in the

next iteration of the BAF.

Controls and assurances

The Trust’s executive team have reviewed the associated controls and assurances, and these will continue to be reviewed and finalised in the next iteration of the Trust’s BAF.

April to June 2019 (Q1) progress

The development of the Trust’s strategic objectives used the main domains of a balanced scorecard approach, so as to ensure there is a clear framework running through our planning, performance and risk management processes.

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The 18th July 2019 Audit and Risk Committee noted the progress on the development of the BAF and

agreed the following actions -

• The next Trust Board seminar on the 7th August 2019 would further review and agree the drafted

strategic risks;

• This would inform and update the agendas for the Trust Board assurance committees, with

updated agenda schedules by the end of August 2019 for the Trust’s main assurance committees

o Quality – Quality and Safety Committee

o Performance – Finance and Performance Committee

o Money – Finance and Performance Committee

o Workforce – People Committee

o Partnership working and well – Finance and Performance Committee

• A workshop of the executive directors and clinical directors, would further review the drafted

controls and assurances in August 2019;

• In line with the NHS Long Term Plan, the way be provide healthcare increasingly is undertaken in

partnership and on a network basis, the Deputy Chief Executive in August and September 2019

will review with partners how system wide and network controls and assurances are

incorporated into our BAF process; and

• In September 2019, Trust leads will meet with internal and external audit leads to review

progress, and benchmark our assurance processes against other trusts.

The next iteration of the BAF will be reviewed at

• 16th October 2019 Trust Management Executive

• 17th October 2019 Audit and Risk Committee

• 29th October 2019 Trust Board

The report will highlight -

• The finalised strategic objectives and risks;

• The types of assurance currently obtained, and an overview from the management team on whether they are effective and efficient;

• For strategic objectives where the management team review has identified our assurance processes are insufficient the actions the management team are taking; and

• For strategic objectives where the management team has identified existing controls are failing the actions the management team are taking.

July to September (Q2) progress and actions

October to December (Q3) actions

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Title Communications and Engagement Strategy

Report author Sarah Pinch, Interim Director of Communications Report sponsor Sarah Tedford, CEO

Status of Report Public Private Internal X ☐ ☐

Purpose of Report For Decision For Assurance For Information X ☐ ☐

Summary

This strategy has been developed for the organisation, following external independent research. It outlines a basis for establishing communications and engagement activities to improve staff engagement and enhance patient care.

Recommendations The Board is invited to approve the Strategy

Links to Corporate Objectives All the Trust’s corporate objectives are intrinsically linked to our communications activities

Impact

Quality and Safety Legal Financial Human Resources Equality and Diversity

Engagement and Communication X

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Hillingdon Hospitals NHS Foundation Trust Communications Strategy 25th July 2019

1. Context

Current communications across Hillingdon Hospitals NHS Foundation Trust is fragmented, communications activities are disengaged from the Trust’s overall strategic approach and lacks central coordination. A new leadership team, a focused piece of research into the effectiveness of communications and the restructuring of the communications team into a directorate, affords the Trust the opportunity to develop a communications strategy. This strategy addresses the future strategic aims for communications activity at the Trust, ensuring that all activity is coordinated and reaches key internal and external audiences, through careful market segmentation and alignment of key messages. Communications must support the major projects which make up the Trust’s strategic agenda and the Trust’s vision. Excellent Trustwide, coordinated communication activity (including marketing and public relations) can support the delivery of major organisational change and strategic developments, including improving operational performance, increasing staff engagement and outcomes for patients; as well as supporting the development of the two hospitals sites and the revisit of the CQC and its subsequent report. This strategy looks at utilising the full communications toolkit including harnessing internal communications for employee engagement, market research, online communications and marketing and ensuring the Trust is employing 21st Century communications. Communications is a key business tool, supporting growth and profitability, externally and internally. The King’s Fund, amongst others, has undertaken significant research into how the effective use of communications directly increases staff engagement and outcomes for patients.

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At Hillingdon Hospitals we undertook our own research into the effectiveness of communications, by Pinch Point Communications (PPC) and its specialist market researcher, Janice Guy. The research outlined the need for change.

2. Summary of the research findings conducted by Pinch Point Communications

2.1 Staff engagement Staff engagement and satisfaction levels in both Hillingdon and Mount Vernon hospitals, as measured in this audit, are considerably lower than average findings across other surveys of this nature undertaken by Pinch Point Communications: Admin & Clerical, Nurses & Midwives and Estates & Facilities are the

least engaged and satisfied staff groups While one third of staff report that their strongest feelings about

working within the Trust are either happiness, pride or feeling valued, two thirds feel undervalued, overworked, frustrated, unsupported, bullied, stressed, pressured, underpaid or unheard.

2.2 Communication channels Awareness levels of The Trust’s Vision and the CARES Values, along with all the Trust’s various communication channels are very strong (mostly above 90%) Communications engagement levels with all the communication channels, other than social media, are also strong (ie. they are read/ used/ considered at least occasionally). However, perceived effectiveness levels of all the communication channels are at a much lower level when compared with similar PPC surveys Scores for communications within teams, including being able to

make suggestions for one’s team are at a reasonable level Trust-wide communications are considered less effective, Very few members of staff feel that any suggestions they might

make would be listened to or taken on board by the Trust Admin & Clerical, Nurses & Midwives and Estates & Facilities gave

the lowest scores 2.3 A framework for the future

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Staff praised the new Chief Executive, Sarah Tedford, for showing a genuine interest in engaging with staff. However, there is some feeling that the CE’s blog is not concentrating on the bigger problems that the Trust is facing and that the staff are experiencing Others who look to the CE’s blog for inspiration and reassurance and feel it has the potential to deliver these, they would like a summary version of it and for it to appear on more platforms Significant numbers of staff suggested multi-platform communication methods and an updated look and feel to many channels. It was felt that IT limitations and the firewall may prevent the introduction of some useful general improvements and enhancements to internal comms e.g. infographic style communications; use of social media for internal communications and the ability to access communications from home. Through the research, staff recognised the role communications can play in improving staff morale and would like to see an increase in celebrating success and reflecting the life of the hospitals through case studies. Other suggestions from staff included: Staff would like the opportunity to contribute to the conversation

about savings and income generation, so that ideas and suggestions are heard from staff.

Many staff have asked that the senior team is more visible, approachable and accessible. Particularly by engaging in visits to staff departments and teams.

A monthly ‘out and about’ day; without meetings and emails focused on managers getting out of their offices and into departments.

Visits by directors to departments, in addition to the safety walk abouts

3. Objectives

All communications activity will be underpinned by these five key principles; that all our communications and engagement activities will be:

• Trustworthy • Reliable • Honest • Fair • Truthful, never ‘spinning’ or ‘polishing’ the truth

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The Trust’s communications activity will support the Trust’s overall strategic business objectives and the delivery of excellent patient care by delivering accurate, reliable, honest, consistent communications internally and externally, enabling patients and staff to identify the Trust as their provider or employer of choice. This strategy seeks to provide staff with consistent communications, opportunities to feedback, influence and engage. The Trust will position itself as a strong partner in the wider health community, locally, regionally and nationally by embracing external communication tools including, building strong, trustworthy relationships with the media and investing in key stakeholder relationships; continuing to utilise its online presence; being a fully active community partner, through closer links between the Trust’s corporate communications and the Trust’s charity and volunteers. The Trust’s communications team will develop and deliver against a communications plan that promotes and protects the Trust’s fundraising and corporate strategic objectives for the redevelopment of the Trust’s hospitals, its partnership with Brunel University and its role in the future of NW London’s health services. The communications team will:

• Provide accurate and timely information to internal and external audiences, operating with integrity and honesty.

• Develop strong meaningful relationships with the Divisions by keeping close regular contact; each team member is linked to a Division.

• Develop further professional skills in all areas of professional communications.

• Contribute actively to the Trust’s future ambitions and work plans, ensuring that strategic communications is considered a key partner in delivering success.

• Take an active role in the communications profession, through networking and training opportunities.

• Build strong relationships inside and outside the Trust.

4. Audience Segmentation Figure 1. shows the different audiences with whom the Trust needs to communicate.

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Patients

Patient groups

PIP and other engagement

fora

Public

Local councils

Local residents

DH&SC

Brunel Partners

GPs

Staff side & Unions

FT members & governors

Staff Hospital

volunteers

The hospitals’ charity

The Hillingdon Hospitals

Other NW London NHS

providers

Overview & scrutiny

committees

Local business

NHSI & E

University partners

Key: The health community External stakeholders Internal audiences

Audience Segmentation (Figure 1.)

CCGs

CQC

MPs, incl the PM

Media

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5. Communication Flow The Trust will prioritise its communication with staff and ensure that messages and information are delivered in a targeted, reliable way. The diagram shown as Figure Two shows how the communication of messages is intrinsically interlinked. Each audience can hear messages from any other audience and all methods should be explored. The Trust communications and engagement cannot and should not aim to be the only

Staff

Traditional Media and

Social Media

Patients

Stakeholders

Staff need detailed information, so they can talk honestly and accurately to patients

Direct link as can often be the same people in both segments

Use earned media to give and amplify key messages

Potential for negative comms, especially in times of change

The media can be used to give

messages, but they’ll also reflect bad news

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6. Planning Model The planning model demonstrates clearly the need for the Trust’s overall strategy, strategic and operational objectives to be the key drivers in affecting how the communications function within the Trust can prioritise its work in order to develop this strategy and produce a strategic communications plan. The strategy and plan should be revisited and reviewed at least every year to ensure that the activity is still supporting the priority issues of the Trust.

Figure Three: Professor Anne Gregory, Planning Model.

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7. The Elements of Strategic Communications and Marketing 7.1 Internal Communications and Staff Engagement The Trust’s internal communications activity is almost entirely one way and currently ‘pushes’ information to staff in a ‘one size fits all’ way. There is very little support given to Divisions to enable staff to engage in a meaningful way with the Trust’s vision, values and objectives. Strategic internal communications are no longer seen as a ‘nice to do’ by successful organisations and companies but are viewed as a key tool for culture change, staff morale, operational performance and staff retention and recruitment. The importance of giving middle managers the tools for the job is well documented, be that through targeted training (e.g. how to have open conversations, utilising appraisals as a driver for behaviour change) or through the development of a communications toolkit. Internal communications will support the Trust’s key programmes of delivery, including the CARES + programme. What we will do The key objectives for staff communications are:

• To ensure that staff know they are supported and valued in their roles and engender a feeling of belonging to THHT amongst staff.

• Build the communications and engagement architecture to achieve culture change and facilitate two-way communications

• Engage and empower staff to deliver excellent patient care through meaningful, relevant two-way communications.

• Celebrate the successes of staff in ways that are appropriate and inspiring to patients and to staff.

• Ensure our communications activities foster a sense of a warm, welcoming, patient focused and mutually supportive Trust.

• To work closely with HR to ensure that managers have the right skills to engage in meaningful communication with their staff about the Trust’s vision and values.

How we will do it The Trust recognises the importance of internal communications to achieving cultural change and understands the positive impact this will have on staff engagement, the patient experience and operational performance.

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• The research results will inform the internal communications plan and ensure that all our activity is reaching its target audiences.

• The research should be repeated, and the results will continually inform the Trust’s internal communications activities.

• Monthly key messages will be discussed and decided at the first executive team meeting of the month. These will inform and guide the key themes for the Team Brief, Open Staff Forum etc.

• The Pulse, the Trust’s staff magazine will become monthly and will continue to develop its design to include regular sections on performance, patient stories, fundraising updates, research, team focus, staff news and will have at its heart the celebration of success around the Trust. The magazine’s distribution channels will be improved with the targeted use of volunteers.

• One monthly edition will be shared only with staff; then the following month a ‘FT section’ will be introduced in every other edition that will update staff on the Trust’s strategic objectives and progress against these. This will also include a message from the Trust’s Lead Governor; these editions will be shared with the wider Hillingdon Community as well as our staff.

• The Bulletin will be redesigned into sections, so staff can easily access information, it will include a weekly introduction from an executive director to communicate key Trust news. The Bulletin will become the go to place for staff to key weekly information.

• The Team Briefing sessions will continue monthly on both sites, with key performance indicators discussed under the headings of Performance; Money; People and Strategy. A handout will be developed to give to each attending manager.

• Open Staff Forums will continue monthly at each hospital location and seek to be more discursive and celebratory.

• Other forums for staff e.g. Consultants’ Forum, will continue and be supported by communications, as necessary.

• A rolling campaign of internal posters will be developed, starting with the Trust’s objectives, then moving onto celebrate the CARES Plus work. The posters will feature high quality images of staff, displayed in key areas around the hospitals.

• The Trust’s intranet will be reinvigorated as outlined in the digital communications section.

• The Trust’s staff awards will continue to evolve and develop; following the format of 2019’s awards; we will seek feedback to evaluate the evening.

How we will measure our success Feedback mechanisms will be fed into all our internal communications activity, formally and informally and will be the driver for continuous change and improvement; and the results of the internal research will

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provide KPIs and benchmarking opportunities for all future internal communications activity.

• Staff will speak of improved communications, and will be knowledgeable about the key objectives, vision and values of the Trust and how they impact on their work and patient care.

• Managers will have access to team briefings monthly and will have monthly team meetings to discuss the key issues with their teams.

• Patients will speak of improved staff knowledge and behaviours, measurable through the patient surveys and other mechanisms.

• We will review the HR data on staff turnover, vacancy rates and sickness levels to ensure that improvements made by enhanced internal communications are delivering tangible cost savings and improvements.

• We will also, if necessary, focus on key areas of the Trust, where we know improvement in staff engagement and communications is much needed, taking a base line measurement and seeking to track its improvement.

7.2 Stakeholder Engagement Introduction The Trust currently works with a wide range of partner organisations both at a corporate level and at individual service level, however there is opportunity for greater cohesion and coordination. The Trust has not undertaken an audit or any research with this key group of stakeholders; but by looking at best practice systematic stakeholder engagement can enable an organisation to build strong, supportive relationships with key stakeholders who are able to effect direct impact on the success of an organisation. Stakeholders can be external or internal (see internal communications) – for example, patients, MPs, councillors, Council officers, Brunel University, associated health organisations, GPs, CCGs, NHSI, NHSE, NHS London, NHS Providers, local businesses, interest groups, charities, community organisations, and population served by the Trust’s two hospitals. Effective engagement involves listening to the views, issues and expectations of stakeholders and then using these views to support and influence planned changes and service improvements. Currently, the Trust’s engagement with stakeholders is active, but could be better co-ordinated and feedback more systematically collated and actioned. The communications directorate is currently not responsible for Patient Engagement, but it is responsible for Patient Information. There will be

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ongoing discussions to ensure we are making the right decisions for our patients. What we will do The Trust will adopt a more systematic approach to its stakeholder management activities and we will seek to support colleagues across the organisation who are communicating and engaging with stakeholders (see Figure One for our stakeholder map). To achieve this, key stakeholders will be identified, looking at mapping their influence and interest using a similar model to Mendelow’s Power and Influence model [as shown in figure four]. We will seek to undertake a coordinated programme of stakeholder engagement, communications and listening, with the aim of encouraging them to publicly support and become advocates for the Trust’s strategy.

Figure Four: Mendelow’s Power and Influence Model

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Increasing our stakeholder activity and including public affairs in a systematic approach will enable the board to receive advice on the reputational impact of plans and decisions and external pressures that may affect the organisation’s future. The Council of Governors includes representation from some key stakeholder groups, including Local Authorities, CCGs and Universities. It has potential to be further actively engaged to support the development of new and deeper relationships, as well as the Trust engaging with key influences and decision makers in the North West London region in order to position itself as a key player in its own right. The Board will actively participate in the stakeholder engagement plan. How we will do it The Trust will forge closer stakeholder links by:

• Developing ‘a reason to believe’, or ‘offer’ for key stakeholder, being clear on our ask to them, and our offer for them.

• Identifying key stakeholders, understanding their viewpoints and agendas, differentiating between those who need to be informed, involved or both. As per the Power and Influence Model.

• Maximising the effective involvement of the Council of Governors to support the Trust’s strategic aims.

• Building a cohesive, engaging methodology for members. • Improving direct and indirect communication and information to

stakeholders by producing a regular stakeholder newsletter and writing to key opinion-formers about specific issues. Look for opportunities for third party endorsements and communications.

• Programming a series of targeted meetings and events (see events section) for key MPs/councillors/opinion formers to inform them about key developments, including committing to biannual face-to-face briefings.

• Continuing to involve and welcome key opinion formers in strategic and future plans of the Trust.

• Encouraging and helping board members, senior and junior managers as well as clinicians to get more involved in the ‘life of the NW London’ through meetings and regular contact with CCGs, NHS and other health organisations, and where appropriate influential organisations and individuals.

• Ensure all patient information is up to date, easy to access and meeting the needs of our patients.

Measuring our success The Trust will establish and maintain a stakeholder contact database. Success will be measured through:

14

• Clear third party/stakeholder endorsement of Trust strategies and initiatives

• The establishment of ‘a reservoir of good will’. • The willingness of third parties to speak out in support of the Trust, our

staff and patients. • Consideration to undertake an online survey with stakeholders in six

months’ time to gain further insight and provide benchmarking data for this key group, to develop specific KPIs.

• Stakeholders will receive frequent contact from the Trust – at least four times a year through a quarterly stakeholder newsletter, which will be evaluated.

7.3 Media Relations Introduction The Trust has a challenged media landscape, with very few local media outlets. However, there are many other ways to communicate with the local community, including the changes to our Pulse magazine, utilising digital technologies and exploring events and opportunities for the community to be part of the hospital. However, the communications team should develop stronger relationships with the national media, as a London based Trust. And develop links to the trade press for healthcare. What we will do The communications team will take the limited opportunities available to engage with the media to raise the profile and enhance the reputation of the Trust, nationally, regionally, locally and in the trade press, by increasing the amount of positive or neutral media coverage and minimising negative coverage. How we will do it The Trust will take control of its own public/media image by taking the initiative and communicating our mission more forcefully. The Trust will:

• Establish and maintain strong relationships with regional and local media and form new relationships with key national and trade journalists, based on mutual trust, respect, openness and honesty. This will include more one-to-one contact and networking with national newspaper and broadcast health journalists.

• Work closely with divisions and clinicians to ensure a flow of content that is newsworthy and which promote the Trust’s priorities and

15

strategic objectives and give support and attention to all of the divisions within the Trust.

• Distribute timely, accurate and relevant information to journalists to maximise positive media coverage of the Trust’s work, policies and achievements.

• Ensure that all communications with the media – spoken, written and electronic - are clear, consistent, informative, interesting, honest and well-targeted.

• Work with partners to publicise joint initiatives and endorse our own activities.

• Seek to minimise negative media coverage by ensuring accuracy, fairness and balance.

• Quickly address inaccurate reporting or allegations in the media appropriately, for example, face to face or by telephone with the reporter/Editor; Letter to the Editor.

• Encourage staff to get involved - devise and develop ‘events’ to encourage press interest and coverage and flag up positive and potentially negative stories in advance.

• Maintain a high visibility within the Trust and its divisions and build strong relationships with key clinicians, management and staff.

Measuring our success The Trust will:

• Communicate its key messages effectively and accurately through the media.

• Develop a top-line summary of positive and negative media coverage as part of the monthly communications report to the Trust board and to the Trust Executive Group.

• Seek the opinion of journalists and look for an improvement in their perception of the relationship with the Trust when asked.

• Have a pool of staff able to participate in media activity. • Engage the executive team with the editors and owners of regional

and local media groups. • Ensure that the communications team is linked into local, regional

and national media networks. 7.4 Digital Communications Introduction The Internet and Intranet can provide the Trust with a valuable online communications tool which can complement its offline activity. In addition, there are social media channels which can be developed and used to engage with our local community and our staff.

16

What we will do The main objective of the internet is to provide clear, easy to find and understand information for patients, potential patients, GPs, key stakeholders and the media. The intranet is there to support staff communications, provide access to information and become a trust source of information, collation of ideas from staff and a place to go for more information and updates on all issues affecting staff. The Trust’s intranet is in the process of being redesigned and the internet will move to a different hosting arrangement this year, which will provide a more user friendly way of updating content

17

Our social media channels will continue to be valuable to patients and our community; and we will develop effective engaging content for specific projects e.g. using Linked In for recruitment. We will explore the PESO model of planning this activity.

18

Paid Media. This could be social media advertising, sponsored content and email marketing. Paid has become mainstream, for a small amount of money (often a few hundred pounds) it is a way of attracting more attention to your content and driving focused engagement. Earned Media. Earned media is what is known as publicity or media relations. It’s getting your name in print. It’s having a newspaper or trade publication write about you. It’s appearing on the lunchtime news to talk about your product. Shared Media. Shared media is also known as social media, but it can also include other things, where people share your information and add to (or in some cases take away from) its credibility. This would be the social media channels that are in the name of the Trust, but also the social media channels owned by others that support the Trust’s work e.g. other NHS partner organisations, Brunel University, patients and volunteers Owned Media. Owned media is otherwise known as the Trust’s own content. It is something owned by the Trust and it lives on a website, magazine, social media channels or blog. The Trust control the messaging and tell the story in a way you want it told. How we will do it Clear, easy to understand editorial guidelines and protocols will be developed. The communications team will provide support for and lead regular communications with Divisions and for particular campaigns across the Trust e.g recruitment. Our digital communications will:

• Reflect the key messages, vision and value of the Trust. • Ensure the website features real people, patients and staff, telling

their real stories and experiences. • Ensure our digital content works across all platforms. • Provide a real time feedback mechanism for positive comments

and complaints. • Explore the possibility of holding twitter discussions and exploring the

digital possibilities of building communities and sharing successes. • Link to, and take links from, other relevant sites. • Be able to collate and use analytical information to provide

relevant data and insights to improve the site accordingly to respond to feedback.

• Become a site of choice for health information for our patients, local communities and colleagues across the health sector.

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• Realise its full potential as a tool of engagement and supporting technical features will be developed accordingly.

The intranet will:

• Provide up to date relevant information to staff. • Reflect the vision and values of the Trust. • Be reliable and accurate to develop ‘a reason to believe’ for staff

to revisit • Be easy to update • Be interactive and support staff in their role to deliver patient care. • Reflect the diversity of the staff we employ. • Ensure information is easy to find. • Become a place staff visit for up to date operational information. • Provide a place for staff to share learning, celebrate successes and

find useful information.

How we will measure our success We will employ useful digital monitoring and evaluation tools. The Trust will:

• Monitor the number of views for key communication topics highlighted on the website, in line with the organisation’s overall strategic objectives.

• Track the number of users accessing and using the intranet, enabling understanding of where users are progressing through the site and overlay clicks on pages.

• Adhere to best practice for accessibility • Seek feedback from membership, patient groups and

representatives and staff on our digital communications activities. • Ensure that all web-based tools are evaluated as part of any

internal staff surveys to further identify examples of how the website and our digital platforms is being used.

Conclusion It is recommended that quarterly updates are brought to the board, to ensure there is oversight and assurance that our communications activities are improving staff engagement and delivering against the objectives and plans outlined here. The strategy will be reviewed in 12 months’ time. END

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Agenda item 20

Title Committee Portfolio Appointments, 2019/20

Report author Trust Secretary

Report sponsor Interim Chair, Professor Elisabeth Paice


x ☐ ☐


☐ ☐ x

Summary

The Report provides a summary of which Non-Executive Directors will serve on Board Committees, 2019/20, either in the capacity as chair or a member. For information, details of Governors who have indicated that they wish to attend Committees in an Observer capacity (in accordance with revised Terms of Reference) are also included.

Recommendations The Board is invited to note the Report.


Well Led - We will empower our people to deliver

Impact

Quality and Safety X Legal X

Financial X

Human Resources X

Equality and Diversity X Engagement and communication X Sustainability X

2

Roles of Non-Executive Directors

Non-Executive Director

Lead Executive/DD Support

Member

Linda Burke Chair of People

Committee Terry Roberts Vice-Chair of Finance

& Performance Committee

Lead for Workforce

Terry Roberts

Lead for Women and Children

Nikki Jackson (DD)

Janet Campbell

Chair of Equality, Diversity & Inclusion Forum

Terry Roberts Member of Charitable Funds Committee

Lead for Freedom to Speak Up

Cherma St Clair

Member of the People Committee

Lead for Division of Medicine

Michelle Cruys

Prof Soraya Dhillon

Chair of Quality & Safety Committee

Prof Siobhan Gregory

Vice-Chair of Audit & Risk Committee

Lead for Surgery Victoria Cook (DD)

Lead for Re-validation

Dr Cathy Cale

Lead for ACCEA Dr Cathy Cale

Catherine Jervis

Chair of Finance & Performance

Committee

Jenny Greenshields

Vice-Chair of Quality and Safety Committee

Lead for Cancer and Clinical Support Services

Monica Whittle (DD)

Simon Morris Chair of

Charitable Funds Committee

David Jenkins Vice-Chair of People Committee

Lead for End of Life, Mortality and Learning from Death

Dr Cathy Cale Member of Audit & Risk Committee

Lead for Integrated Care System

Jason Seez

Richard Whittington

Senior Independent Director

Trust Secretary

Member of Quality & Safety Committee

Deputy Chair Trust Secretary

Finance & Performance

3

Committee Chair of Audit &

Risk Committee Jenny Greenshields

Lead for

Estates Tahir Ahmed

4

Governor Membership of Committees or Observer Roles

Finance & Performance Committee

Tony Ellis (O)

Lynn Hill (O)

Audit & Risk Committee and Audit Lead

Tony Ellis (O)

Quality & Safety Committee

Rosemary Jenkins (O )

Ahmet Moustafa (O)

Charitable Funds Committee

Rekha Wadhwani ( O)

People Committee Jack Creagh (O)

Governors’ Nomination and Remuneration Committee

Tony Ellis (M)

Rekha Wadhwani (M)

Rosemary Jenkins (M)

Sheila Kehoe (M)

Lubna Hussain (M)

part i (open) meeting of the board of directors …...15.30 15 integrated quality & performance...

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