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PUBLIC BOARD MEETING OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS

TRUST BOARD ON WEDNESDAY 8 JANUARY 2020 AT 13:00 GREAT NOTLEY AMBULANCE STATION AVENUE EAST, GREAT NOTLEY,

BRAINTREE, ESSEX, CM77 7AH

AGENDA: PUBLIC SESSION (Disclosable)

SUBJECT LEAD PURPOSE TIME

1 Welcome Verbal: Trust Chair - 13:00 -

2 Apologies for Absence Verbal: Head of Governance - 13:01 -

3 Declarations of Interest To receive any new or amended declaration of interests from Board Members

Verbal: Board Members - 13:02 -

4 Patient Story Herewith: Director of Clinical Quality and Improvement

- 13:03 3

5 Report from the Trust Chair Herewith: Trust Chair Update 13:15 Verbal

6 Report from the Chief Executive Herewith: Chief Executive Update 13:25 5

7

Minutes To approve the minutes of the previous meeting held on 13 November 2019

Herewith: Trust Chair Approve 13:35 11

8 Matters Arising Not Addressed Elsewhere on the Agenda To consider the actions checklist from previous minutes

Herewith: Trust Chair

Update 13:40 20

STRATEGY & BUSINESS PLANNING 9 Winter Plan Herewith: Chief Operating Officer Assure 13:50 21

10 Horizon Scanning Herewith: Head of Governance Assure 14:05 24

PERFORMANCE MONITORING

11 Integrated Performance Report Herewith: Chief Operating Officer Inform 14:15 28

12 M8 Finance Report Herewith: Director of Finance

and Commissioning

Inform 14:30 86

13 Revised Forecast Outturn Herewith: Director of Finance

and Commissioning

Approve 14:40 104

14 CQC Quality Improvement Plan and Quality Report

Herewith: Interim Director of

Clinical Quality and Improvement

Assure 14:55 114

15 Director of Clinical Quality and Improvement Briefing

Herewith: Interim Director of


Assure 15:05 120

16 FTSU Quarterly Report Herewith: Medical Director Assure 15:15 132

17 Flu Update Herewith: Interim Director of


Inform 15:25 135

18 Committee Reports to Board: Performance and Finance Committee Workforce Committee Quality Governance Committee Audit Committee

Herewith: Chair of P&FC

Herewith: Chair of WFC

Herewith: Chair of QGC

Herewith: Chair of AC

Assure Assure Assure Assure

15:35 15:40 14:45 15:50

142 148 152 154

GOVERNANCE AND REGULATORY 19 Board Assurance Framework Herewith: Head of Governance Assure 15:55 156

CLOSING ADMINISTRATION

19 Items Referred to/from Other Committees Verbal: Trust Chair - 16:05 -

20 Key Messages and Risks Identified Verbal: Trust Chair - 16:06 -

Trust Board Public Agenda - 08.01.20

1 of 183Public Board Reports - 08.01.2020-08/01/20

East of England Ambulance Service NHS Trust: Public Board Agenda of 2

21 Any Other Business Verbal: Trust Chair - 16:07 -

22 Questions from the Public -

23 Reflection on Meeting Verbal: All - -

24

Agenda Items for Next Meeting:

All standing agenda items

Strategic Objective Setting

Annual Staff Survey Report and Plan

Review of Winter

Risk Management Strategy

SO/SFI/Scheme of Delegation/ Reservation of Powers to the Trust Board

Trust Board Agenda Plan

Annual review of Board Sub-Committees

Board Evaluation

Register of Directors Interests

Register of Seals

- -

Date of Next Meeting: 11 March 2020 Verbal: Trust Chair

MEETING OF THE CORPORATE TRUSTEE

SUBJECT LEAD PURPOSE TIME

1 Minutes from the meeting on: 11.09.19, 13.11.19 and 18.12.2019

Herewith: Trust Chair Approve 16:10 172

2 CFC Terms of Reference Herewith: Head of Governance Approve 16:15 177

3 CFC report to the Corporate Trustee Herewith: Committee chair Inform 16:20 182

4 Any Other Business Herewith: Trust Chair - 16:25

Trust Board Public Agenda - 08.01.20

2 of 183 Public Board Reports - 08.01.2020-08/01/20

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MEETING TITLE

TRUST BOARD - PUBLIC

Date: 08.01.2020

Report Title: Patient / carer story

Agenda Item: 4

Author: Gillian Hooper

Lead Director: Gillian Hooper

Purpose: Assurance Decision

Discussion X Information X

SUMMARY AND BACKGROUND:

The trust board will be shown a short video when a former patient Mr Berrington and his wife share their

experience of recently requiring an emergency response to a life threatening situation.

Mr Berrington had experienced several episodes of atrial fibrillation over a few days, calling 111 and his

GP during this time. During an appointment with his GP, an ECG indicated the need for a 999 call to be

made, with Mr Berrington waiting 10 mins in the reception area for the ambulance to arrive.

Mr Berrington describes the professional , compassionate and respectful care that both he and his wife

received, providing great reassurance at a time when they were both at their most vulnerable. This

‘story’ evidences good collaborative working with primary care, ambulance and hospital services and

also the good clinical skills of general practice, ambulance staff and hospital staff.

The ‘story’ also evidences effective systems and processes of call handling, ambulance dispatching,

hospital handover and timely clinical reassessment and escalation to mitigate risks and optimise clinical

outcomes.

This ‘good news story’ is evidence in the optimal response to a potentially life threatening situation and

the services EEAST are striving to provide and achieve on each and every similar occasion. Routine

performance information considered by the board evidences that the level of achievement of these

standards is currently significantly below that which we are seeking to consistently provide.

RECOMMENDED ACTION: To internally increase the focus of investigation and learning from those events that occur where response

times to calls are not as expected, liaison with primary care is not as effective and / or handover and

access to hospital diagnostics and treatment is not available in a timely manner.

To present to the private board meetings some more challenging patient ‘stories’ where care, services and

treatment has been identified as not meeting desired standards, so that the learning from these influences

corporate priorities and decision making.

KEY ISSUES IDENTIFIED

To consider using patient stories to identify and recognise the improvements required in systems and processes to drive and increase in the consistency and standards of services routinely available to patients.

DECISION OR RESOURCE REQUIRED:

To agree in the use of patient stories as part of private board meetings.

Patient Story


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PREVIOUSLY CONSIDERED BY:

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers]

INDICATE WHICH STRATEGIC RISK THIS REPORT RELATES

SR1: Failure to deliver a timely service to our patients in line with commissioned national standards, to ensure a safe level of service

X

SR2: Failure to achieve continuous quality improvements in the quality of care delivered to our patients

X

SR3: Failure to embed a patient-focussed culture that puts the patient at the heart of everything we do

X

SR4: Failure to deliver an efficient, effective and economic service X

Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE

Provide better care X

Value our people

Value for money

Improve performance X

OTHER:

To ensure effective governance and compliance x

LINK TO CQC:

Caring X

Responsive X

Effective x

Well Led x

Safe X

RELEVANT LEGAL OR STATUTORY ISSUES

Patient Story


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MEETING TITLE

Trust Board (Public Session)

Date: 08.01.2020

Report Title: Chief Executive’s Report

Agenda Item: 6

Author: Dorothy Hosein, Chief Executive

Lead Director: Nicola Scrivings, Chair


Discussion Information

SUMMARY AND BACKGROUND: The purpose of this paper is to update the Board on issues and matters the Chief Executive has been addressing or involved in since the last Trust Board meeting on 13 November 2019.

RECOMMENDED ACTION: None

KEY ISSUES IDENTIFIED Winter, Building Better Rotas and Education and Training

DECISION OR RESOURCE REQUIRED: None


NA




x


x


x

SR4: Failure to deliver an efficient, effective and economic service x



Provide better care x

Value our people x

Value for money x

Improve performance x

Chief Executives Report


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OTHER:

To ensure effective governance and compliance x

LINK TO CQC:

Caring x

Responsive x

Effective x

Well Led x

Safe x


Chief Executive’s Report Christmas At the time of writing this report, just after Christmas I wanted to take the opportunity to thank all our staff for their hard work over the last few weeks. I really appreciate the time you have spent working which has meant you have sacrificed time with your families and friends. Please pass on my thanks to all those who support and respect your vocational role as I know that it is not always easy and can mean changing traditional plans. I would also like to thank our Community First Responders, students, all volunteers and St John Ambulance members who have offered their time to care for our patients during this busy period. Your input has enabled us to offer additional resources for patients to help relieve the pressure in other areas and improve the service we provide to patients. Thanks to all your hard work we have responded to more patients this year than last year. I am also pleased to be able to report that less of our life-threatening patients (C1 Category) waited for an Ambulance this year compared to last year. Importantly as part of the role we play in the wider health environment and relieving system pressure, conveyance of patients to hospital during our busiest period was lower than the average for the year. I am also extremely grateful to my Executive team and all those who have been on call over the last few weeks. I know that much of their time has been spent managing and escalating hospital delays with system leaders. This essential but time-consuming role is reliant on both a commitment to patient safety and the goodwill of senior team members for which I am most grateful. I look forward to working with you all in the New Year to continue this journey of improvement.



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Dame Professor Donna Kinnair I was honoured and delighted that Dame Donna Kinnair accepted an invitation to meet with myself and my senior team before Christmas. As the Chief Executive and General Secretary of the Royal College of Nursing we had a really interesting discussion regarding the challenges of workforce and in particular focused on the following areas:

Roles and opportunities within Paramedicine

Potential models of care

Retention of staff

Flexible working

Multi-disciplinary working

Our role as a system partner

Our next steps will be another visit from Donna in the Spring to explore further joint opportunities. Dragons Den As you will know from previous reports the Trust has commissioned a leadership development course for all our managers. As part of the programme managers were asked to brainstorm and develop new and exciting ideas to improve our service. As the name suggests ideas were pitched to an Executive panel and each manager had ten minutes to convince a sponsor. The ideas successfully sponsored are as follows:

Shaun Cross - Patient & Staff Feedback Service For frontline colleagues to hear how their patients are doing and to ask patients directly about their experience of EEAST and how we can improve the service. Exec Sponsor: Dr Tom Davis, Medical Director Matt Bell and Lou Donno - Mental Health First Aid To provide Mental Health first aid training throughout the Trust. Exec sponsor: Dorothy Hosein, Chief Executive Officer. Carl Friar - Rostered Development Days To put in place regular protected development days that move beyond professional updates (PUs). Exec Sponsor: Marcus Bailey, Chief Operating Officer. Ben Jacobs - Final Hour of Shift Policy An idea which will have a big impact on staff and their ability to finish on time. Executive sponsor: Nicola Ward, Interim Head of Strategy. Mark Haynes - HR: Quality with Pace A strategic approach to achieving world class HR. To establish an advisory group to help build requirements. Exec sponsor: Sudha Pavankumar, Interim Deputy Director for HR



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Laura Spears - Last Wish Bus To allow all EEAST staff to take part in a great initiative to give terminally ill people a chance to fulfil their last wishes. Exec sponsor: Kevin Smith, Director of Finance. Jordan Nicholls and Adrian Penrose - Cafe Paramedique The café is to allow informal discussions and share ideas across departmental boundaries. Exec sponsor: Julie Hollings, Director of Communications

Further update will be provided in the coming months. Police Following a discussion with Essex Police Constable B J Harrington back in August where we explored opportunities to collaborate on estates, demand, sharing of information and wider initiatives we agreed to jointly establish a forum to progress our opportunities. In December, with my seven regional police force colleagues we held our first joint event which was hosted by the Police in Witham. This collaboration identified a number of workstreams for us to progress around our identified key opportunities and we look forward to updating again at our next event in February 2020. Coming up You will have noticed on Need to Know that we have published another list of “Air and Share” events across the region for the next two months. It has been pleasing to see so many of you at these events and to receive such valuable feedback. We are in the process of collating the feedback we have received from these events and on Need to Know and I will issue a full response in the coming weeks. I am also planning to discuss this feedback with Board colleagues so that it can form part of the discussions in the new year to underpin a strategy to progress on work on the culture of the organisation. I look forward to meeting you in the coming months at my “Air and Share” sessions. As you may have noted from Need to Know we have a new Occupational Health provider, Kays Medical. The Kays team are providing a wide range of services to help staff stay healthy along with additional support when required. I would like to take this opportunity to welcome Ben Ludzker, Managing Director and his team to EEAST and I look forward to working with them. Contact details for the team are available on Need to Know https://ntk.eastamb.nhs.uk/news/important-changes-to-our-occupational-health-provider-from-today.htm . I would like to say a huge thank you and well done to our Flu Fighting team and all those who have been protected. We have currently vaccinated 71% of staff which is an 18% increase on last year.



https://ntk.eastamb.nhs.uk/news/important-changes-to-our-occupational-health-provider-from-today.htm

https://ntk.eastamb.nhs.uk/news/important-changes-to-our-occupational-health-provider-from-today.htm

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Plans for the New Year I was delighted recently to be appointed as the substantive Chief Executive and I am full of enthusiasm and commitment to making 2020 a very productive year for EEAST. I am in the process of agreeing my objectives with the Chair however in the meantime, with my Executive colleagues we are very much focused on keeping our patients safe and supporting staff wellbeing during these busy times. Stakeholder Engagement

Stakeholder Location Date

EEAST Staff Engagement Norwich AOC Staff Engagement Ipswich Ambulance Station Staff Engagement Bury Ambulance Station Staff Engagement Chelmsford Ambulance Station Staff Engagement Chelmsford AOC and Headquarters Staff Engagement Watford Ambulance Station Staff Engagement, Cambridge Station Staff Engagement Chelmsford Ambulance Station Staff Engagement Broomfield Hospital Staff Engagement Chelmsford EOC and Headquarters Staff Engagement, Great Notley, HART Staff Engagement – Rideout with crew Chelmsford Air and Share Event Chelmsford Get Real Change – Dragons Den event Air and Share Event Basildon Air and Share Event Southend Staff Engagement, Luton Staff Engagement, Stevenage Staff Engagement, Kempston Air and Share Event Southend Air and Share Event Basildon Staff Engagement, Newmarket Training Centre

14/11/2019 16/11/2019 16/11/2019 16/11/2019 16/11/2019 19/11/2019 25/11/2019 25/11/2019 25/11/2019 25/11/2019 02/12/2019 02/12/201902/12/2019 06/12/2019 09/12/2019 09/12/2019 31/12/2019 31/12/2019 31/12/2019 03/01/2020 03/01/2020 06/01/2020

CCG

NHS Trusts Meeting with Christine Allen, CEO Watford Hospital Meeting with David Wherrett, Addenbrookes Hospital Call with David Wherrett, Addenbrookes Hospital Call with Melanie Craig, Great Yarmouth & Waveney CCG

18/11/2019 19/11/2019 29/11/2019 13/12/2019

HOSC

MPs

CQC

NHSI/E Oversight and Support Meeting NHSI/E NHS East of England Leaders Event, NHSI/E

26/11/2019 10/12/2019



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NHS Leadership Event, NHSI/E Meeting with Elliot Howard Jones, NHSE/I

17/12/2019 07/01/2020

UNISON

GMB Call with Lola McEvoy 15/11/2019

Blue Light Partners

Essex Police Pass Out Parade

Call with BJ Harrington, Essex Chief Constable

Strategic Police Regional Seminar

15/11/2019

02/12/2019

03/12/2019

Healthwatch/

CEG

Media

Health Education England

HEI

RAF

HSE

Dept. of Health

AACE Call with Anna Parry, AACE

AACE Council Meeting and Chief Executives Group

29/11/2019

19/12/2019

Other Stakeholders

Meeting with Dame Donna Kinnair, Chief Executive of Royal College of Nursing Visit to Cambridge Central Mosque Event Shoeburyness Residents' Association Meeting with Angie Crashley, Karl Damian, TASC

05/12/2019 13/12/2019 16/12/2019 02/01/2020

British Heart Foundation

Wellbeing Services



East of England Ambulance Service NHS Trust

Page 1 of 9 Minutes of Trust Board

The UNCONFIRMED (Disclosable)

MINUTES OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST BOARD MEETING (PUBLIC SESSION) WEDNESDAY 13 NOVEMBER 2019 AT 14:00

GROUND FLOOR MEETING ROOM, EEAST HQ, UNIT 3, WHITING WAY, MELBOURN SG8 6NA

Present: Tom Spink Non-Executive Director and Acting Committee Chair Wendy Thomas Non-Executive Director Carolan Davidge Non-Executive Director Ravi Mahendra Non-Executive Director Neville Hounsome Associate Non-Executive Director Tom Davis Medical Director Dorothy Hosein Chief Executive Tracy Nicholls Director of Clinical Quality and Improvement Marcus Bailey Acting Chief Operating Officer Kevin Smith Director of Finance and Commissioning Alison Wigg Associate Non-Executive Director Yasmin Rafiq Interim HR Programme Lead In Attendance: Julie Hollings Director of Communications and Engagement Emma de Carteret Head of Governance Esther Kingsmill Deputy Head of Corporate Governance Members of the Public

PUBLIC SESSION (Disclosable) 1.0 WELCOME 1.1 Tom Spink, Non-Executive Director and Acting Chair (AC) welcomed those present to the

meeting. 2.0 APOLOGIES FOR ABSENCE

2.1 Apologies were received from the Trust Chair, Nigel Beverley (TC), Head of Governance, Emma

De Carteret (HoG) and Non-Executive Director, Lizzy Firmin (NED-LF) 3.0 DECLARATIONS OF INTEREST 3.1 There were no new declarations of interest.

4.0 PATIENT STORY

4.1 The Director of Clinical Quality and Improvement, Tracy Nicholls (DoCQI) presented the video

from a patient’s mother on her experience dealing with EEAST when her son suffered an acute mental health issue. Mental health was an extremely challenging pathway and the story reflected on how the provision helped the mother to support her son throughout the journey. The patient had deteriorated to a position in which he required support from the crisis team after a telephone assessment in the weeks and months previously indicated he was not unwell enough for intermediate intervention.

4.2 Non-Executive Director, Carolan Davidge (NED-CD) enquired how the case would be shared with system partners to support learning. She was advised by the DoCQI that it was recognised

Draft Public Board Minutes - 13.11.19




that mental health services were under severe pressure which exacerbated the ability to take non-urgent referrals. Learning would be shared through the A&E delivery boards and STP to emphasise the reality for patients needing support.

4.3 Non-Executive Director, Wendy Thomas (NED-WT) recognised the concern that as a system, patients were not being adequately supported. She noted some regions had rapid response vehicles for patients in a mental health crisis and enquired how this was captured. She was advised there were a number of models to manage patients throughout their mental health journey – to assess the impact a national thematic review was required on the access and outputs from these interventions. Mental health models were difficult to assess however A&E delivery boards were starting to discuss how acute care could be managed in a provider situation. EEAST had an initiative to employ social workers in safeguarding who would support the mental health agenda alongside capacity and paediatric care. A business case had also been approved to employ 6 mental health professionals in the ambulance service to support crews and identify system working opportunities.

5.0 REPORT FROM THE CHIEF EXECUTIVE

5.1 The Chief Executive Officer, Dorothy Hosein (CEO) presented her report and highlighted the success of the staff awards ceremony, recognising the achievements of EEAST staff who had delivered above their duties in their roles. She also extended her thanks to the EEAST staff who had attended a major incident in Thurrock on the professional care they delivered in extremely challenging circumstances. She had attended a service of condolence with the Prime Minister and other emergency services who recognised the professionalism and partnership working which had taken place. Winter planning had commenced, and it was vital to ensure delivery against the plan agreed. There were also plans underway to progress to a centre of excellence for education and training. Building Better Rotas had commenced rollout following significant consultation with staff. She also updated on the Board developments including the commencement of Nicola Scrivings as Trust Chair on 18.11.2019 and the appointment of Marcus Bailey as substantive Chief Operating Officer (COO). The DoCQI would be leaving the organisation and she extended her thanks to her for the significant legacy and support she had provided.

7.0 MINUTES FROM THE MEETING ON 11.09.2019

7.1 The minutes from the meeting on 11.09.2019 were approved with no amendments.

8.0 MATTERS ARISING AND ACTION LOG

8.1 CFC.15.10.19/9.1: It was confirmed the scheme of delegation would be updated to reflect CFC

delegated responsibility levels in the annual refresh in Q4 and the action was closed.

8.2 11.09.19/13.4: Work remained underway to provide a linked service between EOC and the Samaritans. A further scheme was being pursued to employ mental health workers on site. Proposals would be managed in a business case. The action was closed.

8.3 27.03.19/13.3: An overall performance plan would report into WFC and would be aligned with the Integrated Performance Report. The action was closed.

8.4 27.03.19/16.5: the acceptance of financial loss in pursuit of strategic objectives would be considered in the risk appetite development session on 18.12.19.

8.5 11.09.19/15.3: The item was closed on the basis that the financial status had been RAG rated.





8.6 30.01.19/014/19: The Medical Director, Tom Davis (MD) advised this was tied with a larger piece of work to reconsider and redefine how information was presented in the IPR which would be supported by the CIO when commenced in post. It was proposed the action be closed and a broader action agreed to undertake a complete review of the IPR. ACTION: CIO to undertake complete review and refresh of IPR including associated KPI’s. Lead: CIO

9.0 WINTER PLAN

9.1 The COO presented the winter plan framework which focussed on the demand>capacity for ambulances and response vehicles over the winter period and the actions required to maintain and sustain performance. The Trust Board were asked to approve the plan.

9.21 NED-AW highlighted that the security threat level referenced at section 4.11 had been increased and it was agreed this would be amended.

9.3 NED-WT enquired how the system were working to address handover delays collaboratively. She was advised by the COO that NHSI and NHSE were seeking assurance on winter plans which would be approved through the A&E delivery board. This would provide a risk assessed, RAG rated approach however there was a responsibility to test these. A template had been developed for Heads of Operations to report to the system ambulance service requirements to support in handovers which would be discussed in the regional winter event to identify how the winter plan was risk managed. The return to NHSI and NHSE on system assurance would highlight major concerns for delivery through winter.

9.4 Associate Non-Executive Director, Neville Hounsome (NED-NH) suggested that in periods of pressure there may be opportunity to cohort patients in a single ambulance during handover to enable another vehicle back onto the road. The MD advised there were two initiatives being pursued, the ability of the ambulance service to cohort patients within a prepared space within the hospital where the hospital did not have the capacity to support this, or the cohorting of patients within a limited number of ambulances supported by medical staff to enable vehicles back onto the road. A risk assessment action card was being developed for each of the acute hospitals to provide drop and go ability. This would also be discussed with executive strategic commanders.

9.5 The AC sought assurance on the contingency plans in the event the telephony system collapsed. He was advised that there were several continuity arrangements in place which included primary, secondary and tertiary lines with mobile phone backup and buddying arrangements as a final resort. These had been tested up to the third layer of resilience.

9.6 The Winter Plan was approved subject to amendment of the security threat level.

18.0 COMMITTEE REPORTS TO BOARD – PART 1

18.1 Workforce Committee – 18.09.19: Non-Executive Director, Ravi Mahendra (NED-RM) advised that he had chaired WFC supported by NED-WT in the absence of the substantive committee members. There was partial assurance received on metrics and risks however there remained significant work required to progress to a sustainable position. A lack of assurance was received on the gender pay gap report and sustainable actions were being identified to close the gender pay gap.

18.2 Audit Committee: NED-RM highlighted with particular concern the outstanding internal audit actions from HR and Finance which required completion in advance of the Audit Committee meeting on 20.11.2019. Further work was required to assess sustainability of the tenders and





waivers process including identifying resources to support in the management of tenders and waivers. There had been a significant improvement in risk management although further assurance was requested on corporate and operational risks including how they were managed through relevant operational groups.

9.0 HORIZON SCANNING

9.1 The CEO advised that a corporate strategy was under development and would have implications on workforce and performance as well as addressing system working.

9.2 NED-NH noted there was an FTSU index and enquired how EEAST ranked. He was advised by the MD that support was being received from the national whistleblowing office on FTSU. Access had not yet been granted to the index however once enabled a comparative position would be provided.

9.3 The AC enquired how artificial intelligence would feature in the long-term plan and it was agreed the HoG would provide an overview of Artificial Intelligence in the NHS system and long-term plan. ACTION: Provide an overview of Artificial Intelligence plans within the NHS system and long-term plan. Lead: HoG

10.0 INTEGRATED PERFORMANCE REPORT

10.1 The COO presented the report and advised that work was underway to triangulate the IPR with the Integrated Improvement Plan and Recovery Plan to provide a set of static targets for the financial year. The IPR would also be updated to reflect tracking against the year-end position which would highlight deviation from the plan and ensure a greater level of assurance could be provided. The IPR was beginning to reflect performance targets following a history of non-delivery.

10.2 NED-NH highlighted that the RAG ratings required addressing, as some areas were coded green although they were significantly off target. He also extended his congratulations to the teams following the recruitment of 120 individuals more than the attrition rate in September 2019.

10.3 The CEO suggested the relevant sub-committees scrutinise the IPR to identify the appropriate metrics to provide suitable assurance.

10.4 NED-AW requested a more current overview of C1 performance. She was advised by the COO that the revised trajectory pushed C1 performance above 8 minutes. EEAST were off trajectory by 15 seconds for the month to date which was a recoverable position and actions had been agreed. He advised the committee that achievement of 7 minutes for C1 performance was not possible under existing workforce constraints, a trajectory would be provided in the next iteration of the IPR.

10.5 NED-AW further sought assurance that poor C1 performance was not causing an increase in incidents. She was advised by the COO that variation from C1 performance was calculated in seconds, calculating harm associated with a delay of seconds was difficult. Instead C2 performance provided an improved means of understanding harm associated with delays, and as such the focus in improving performance was to improve C2 response times. The Integrated Improvement Plan provided assurance on the actions underway to address C2 performance.

11.0 PROGRESS AGAINST WELL LED





11.1 The CEO advised that an action plan had been developed to address concerns raised regarding

well led. An independent review would also be undertaken to provide assurance on actions identified and progress against the plan. It was recognised that although significant progress had been made there remained a high level of amber areas which were being actively addressed.

11.2 The AC recognised the positive progress being made and supported the action identified however emphasised the importance of ensuring delivery against actions as a priority.

12.0 GOVERNANCE REVIEW REPORT

12.1 The report was taken as read. NED-NH recognised the progress however noted that the CQC report had reflected on a mixed culture with regards bullying and support for staff in grievances which was not addressed in the report. He was advised by the CEO the Get Real Change Leadership Programme was working to address cultural issues in people managers including bullying and support for staff.

12.2 The DoCQI recognised the positive work which had gone into the development of the review and actions identified. The actions focussed on not only reaching a level of compliance but ensuring there were appropriate systems in place to maintain and further improve this compliance.

13.0 CQC QUALITY IMPROVEMENT PLAN

13.1 The DoCQI presented the CQC quality improvement plan which had been aligned with the Integrated Improvement Plan and Recovery Plan. Work was underway to ensure a strategic focus to tactically drive actions and analyse trends – the plan would be published on the website to ensure accountability. The DoCQI highlighted the potential capacity demand in collating, accuracy checking and submitting the CQC information request. Items which could be uploaded in advance were being included on the portal which was mitigating some pressures however there remained a significant capacity risk and the team would highlight any concerns which may impact the timely submission of information.

13.2 The AC was concerned regarding the accurate evidencing of work undertaken and it was agreed a report would be provided to the meeting in January on how the quality of evidence submitted in the CQC information request would be assessed including the process and resourcing. ACTION: Consider and report to public board how the quality of evidence submitted in the CQC information request would be assessed including the process and resourcing. Lead: DoCQI

13.3 NED-AW requested the communications plan for the CQC improvement plan include metrics for measuring delivery. ACTION: Include metrics for measuring delivery in the engagement plan for the CQC Improvement Plan. Lead: DoCE

14.0 M6 FINANCE REPORT

14.1 The Director of Finance and Commissioning, Kevin Smith (DoFC) advised that following the divergence from plan at M5, M6 had recovered the position and was operating at a small surplus which had enabled achievement of Q2 PSF. The risk remained for the remainder of the financial year with a forecast outturn of £7.7m deficit position, worse than the original planned NET deficit of £1m and underlying deficit of £3.2m. Capital activity remained on plan and additional funding had been received to support in winter preparations.





14.2 The AC was concerned to note the deteriorating financial position however recognised the

significant improvement in planning and forecasting and also delivery of the CIP to reduce the deficit position.

15.0 WORKFORCE UPDATE

15.1 The Interim Director of People and Culture, Yasmin Rafiq (DoPC) presented the report and advised that the HR team, had been re-configured to better support delivery of the key objectives and KPI’s supported by the Operations Team. A deep dive was being undertaken of legacy contract issues which would be reported to ELB with actions to address. There had been progress to move towards a single view of workforce metrics between HR, finance and payroll which would be published on EEAST24 and utilised in workforce reporting. The staff partnership forum had been relaunched with strong engagement received from Unison colleagues, the inaugural meeting had focussed on resetting the concept of partnership working and supporting challenge and debate. A ToR were being agreed and future dates. A report had been submitted to the WFC on overdue HR policies. It was considered there were 4-6 policies which required a complete refresh with a significant number of policies overdue. Work was underway supported by NHSI on initiatives to improve staff retention with a focus on culture, leadership and health and wellbeing. Operational HR colleagues had also been trained in best practice for managing sickness absence, the programme would be rolled out to General Managers and Assistant General Managers.

15.2 NED-AW noted that West Midlands Ambulance Service had halved their sickness rate since April 2013 despite commencing the period at the same level as EEAST, and enquired whether a review had been undertaken to identify the contributing factors in this reduction. She was advised by the DoPC this was being reviewed to identify best practice across other trusts and incorporate within the work programme.

15.3 NED-AW was keen to see staff engagement reflected as a key priority.

15.4 NED-CD noted the positive work underway and enquired when further detail would be received on a staff retention plan – she expressed her interest in supporting in this area. She was advised by the COO that a draft plan for retention would report to NHSI on 29.11.2019 3-5 themes were proposed with staff engagement representing a key enabler. It was agreed he would work with NED-CD to support the retention plan. ACTION: Collaborate with NED-CD on staff retention plan. Lead: COO

15.5 NED-NH was concerned regarding the language used to reference sickness management as used on p158 “tightening the grip on sickness management” and suggested this was not appropriate for supporting unwell employees. The CEO recognised this was not a supportive phrase and would be addressed in future reports.

16.0 LEADERSHIP AND CAPABILITY TRAINING

16.1 The DoPC advised that the Get Real Change Programme had been successful in developing people managers skills as leaders. There was further work underway to upskill people managers to enable them to support staff in managing disputes. HR colleagues would also receive this training to support managers through the process. A further report would come to the private board in December.

17.0 FLU UPDATE





17.1 The DoCQI presented the flu update and advised that vaccinators had been motivated and

engaged at the launch event and were integral to the success of the flu programme. At midway through the programme, 60.3% of frontline staff had been vaccinated against a target of 80%. The DoCQI was confident the target could be achieved however this had been delayed due to a national shortage of flu vaccines. All Board members had received the flu vaccination.

17.2 The AC and team extended their congratulations to the team in their drive to ensure the success of the flu programme and maintain the safety of patients and staff throughout flu season.

18.0 COMMITTEE REPORTS TO BOARD – PART 2

18.3 Performance and Finance Committee: The AC presented the PAF report to Board and advised that following concern raised regarding the telephony network, he was pleased to see a timeframe for replacement of the system. The committee had noted positive progress to develop the CIP scheme for 2019/20 to ensure maximum benefit. The Integrated Improvement Plan was also received positively, and the committee were particularly pleased to note the major impact Building Better Rotas would have on improving C2 performance. There was a lack of assurance on GRS rostering. The COO advised that ELB had discussed GRS and would provide an update to the next committee including oversight of project delivery.

18.4 Workforce Committee – October: NED-NH presented the report and noted positive progress in the development of workforce metrics. The WFC were clear in the aim to progress to a fully established and suitably trained workforce which could be assured with agreed end goals and a trajectory. There were some concerns regarding the completion of mandatory training and he emphasised the expectation that all staff should be fully training compliant. There had been positive work to resolve ER and ET cases and a significant reduction in the number of longstanding cases. The equality networks were not as established as expected however support had been offered for these networks and they were now seeing improvements. Preparations for Ofsted were overseen by the WFC who were reassured the quality of work undertaken to date was positive. A benchmarking and audit had been undertaken and the WFC would continue to receive updates.

18.5 Quality Governance Committee – November: NED-WT advised that following concerns raised regarding sepsis a deep dive had been reported to the preceding committee who were assured on the provision of sepsis bundles however pre-alert documentation was impacting performance – training on this would be included in the CPD cycle. The 10:10 campaign had been relaunched and would support in the identification and timely care of suspected sepsis patients. A deep dive had also been undertaken of stroke – as a C2 call response rates for stroke were likely to reduce in line with building better rotas. Scene turnaround time for stroke patients was a key concern raised and would also be supported by the relaunch of the 10:10 initiative. SI’s had reduced by 43% with themes focussed on culture, professionalism and leadership which was included in the retention plan. NED-WT advised that the rollout of social workers to support safeguarding referrals was a new initiative and was receiving good feedback. The committee were assured on the medicines management work underway including the progression of the programme ahead of schedule. The committee had expressed concerns regarding the CQC action plan however this had been addressed by the Integrated Improvement Plan. They were also concerned that the external providers assurance group had ceased meeting although this had since recommenced.

19.0 QUALITY REPORT

19.1 The DoCQI presented the quality report and advised that there had been an increase in complaints regarding PTS services focussed in the Cambridgeshire sector which was linked to the move of the PTS control room. The CEO was leading plans to address concerns; however it





was anticipated that following the move the issue would resolve but not for some time. The Trust had been unable to meet ACQI targets due to capacity and workforce constraints which would be mitigated as the staffing establishment increased. Assurance could not be gained on statutory and mandatory training compliance, there had been a misunderstanding in some sectors who had restarted compliance from 01.04.2019 however it was a rolling target. EEAST was the first ambulance trust to employ social workers to assist in safeguarding referrals, this had enhanced the referrals to more bespoke organisations with 60 potential points of contact.

19.2 The CEO advised with regards the move of the PTS control room to Bedford, it was anticipated the improvement journey would take six weeks to address the environment and leadership concerns however staff were assured work was underway to improve working conditions.

20.0 BOARD ASSURANCE FRAMEWORK

20.1 The DoCQI presented the BAF and recognised Board concerns regarding how realistic target dates for reductions were. She advised further reviews had been scheduled and a Board development session on risk was scheduled for 18.12.2019. There had been a risk assessment to assess scoring accuracy to ensure there was triangulation between metrics and assessments including the rationale and risk assessments.

20.2 NED-AW noted that there were a number of items requiring implementation in October 2019 and sought assurance that this was realistic. She was advised that the reviews would test the likelihood of delivery within set time frames each month, if there was not assurance the dates would be met, they would have been reconsidered.

20.3 The DoCQI reminded the committee that actions identified in the BAF were intended to reduce the level of risk, where this was not achieved on closure of the action subsequent actions would be required to address concerns.

21.0 KEY MESSAGES AND RISKS IDENTIFIED

21.1 The following points were highlighted:

The board noted the patient story had provided a strong overview of the difficulties in mental health provision and recognised the positive work of ambulance staff to support the patient and family.

The Winter Plan had been approved

There was a projected final outturn of £7.7m deficit however where possible this would be reduced.

The flu campaign had launched successfully with strong uptake from staff and engagement from vaccinators.

There was improved transparency from teams to address key concerns.

Workforce remained a significant risk and it was vital work continued on trajectory to deliver the workforce plan.

22.0 ANY OTHER BUSINESS

22.1 The DoCQI presented her thanks to the Board for their support throughout her role as DoCQI.

The DoCQI would leave the Trust on 20.11.2019 and the Board thanked her for her support, dedication and attitude to the Trust.

23.0 QUESTIONS FROM THE PUBLIC

23.1 What protocol would EEAST have for handling a patient fall and providing reassurance to the patient/carer, including utilising another service to support where there are delays with providing





ambulance response? The MD advised that EEAST was seeking alternative methods of responding to patient falls to improve the experience and outcome for patients. These included work with AOC colleagues on the welfare process to highlight patients at risk. Work was also underway with CFR teams on a falls initiative which would be rolled out imminently. There was a collaborative approach with partner organisations to identify how other services could support in the ability, capacity and skills to respond and support falls patients, linked with clinical assessments and the use of new technology to support. There was the potential that in developing a relationship with other agency’s falls patients could be supported by non-clinical agency’s where there was a lack of capacity within the ambulance service.

23.2 How successful has mental health street triage been, what areas does it cover and how is it funded? The MD advised that mental health street triage had been commissioned as a separate provision within Bedford and there was a general view that this had proven very successful and would support wide discussions on mental health provision. A summary of the service provision and success would be provided to the requestor.

23.3 There was no other business and the meeting closed.



AGENDA ITEM: XX (Disclosable)

Key: red – new items from previous meeting, blue – commentary updates, black – outstanding items, grey – completed items

Meeting Date Reference Action

13.11.19 8.5 MATTERS ARISING AND ACTION LOGCIO to undertake complete review and refresh of IPR CIO 11.03.20 Item not yet due.

13.11.19 9.3HORIZON SCANNINGProvide an overview of Artificial Intelligence plans within the NHS system and long-term plan.

HoG 08.01.20Included within agenda item 10

Proposed for Closure

13.11.19 13.2

CQC QUALITY IMPROVEMENT PLANConsider and report to public board how the quality of evidence submitted in the CQC information request would be assessed including the process and resourcing.

DoCQI 08.01.20

CQC update paper on agenda – close.

Executive Lead reviewing evidence for their specific areas and reporting to ELB.

13.11.19 13.3CQC QUALITY IMPROVEMENT PLANInclude metrics for measuring delivery in the engagement plan for the CQC Improvement Plan.

DoCE 08.01.20 Verbal update to be provided

13.11.19 15.4 WORKFORCE UPDATECollaborate with NED-CD on staff retention plan. COO 08.01.20 Verbal update to be provided

11.09.19 12.3LEADERSHIP AND CAPABILITY WORKSHOPSReport on the long-term plans to embed leadership and capability training.

DoPC 13.11.1908.01.20

Defer to allow interim HR Director to commence in post. Propose date realigns to April and is reported through the Workforce Committee

27.03.19 16.5RISK STRATEGY AND PROCEDURESReconsider acceptance of financial loss in pursuing strategic objectives.

All11.09.1913.11.1908.01.20

Risk management strategy review for tabling at Audit Committee on 6 Feb – to report to Board following this date

27.03.19 16.6 RISK STRATEGY AND PROCEDURESReconsider risk appetite for statutory requirements. All

11.09.1908.01.20

Risk management strategy review for tabling at Audit Committee on 6 Feb – to report to Board following this date

TRUST BOARD PUBLIC: ACTION CHECKLIST ARISING FROM PREVIOUS MINUTES TO BE CONSIDERED BY THE BOARD AT ITS MEETING TO BE HELD ON [DATE]

OUTSTANDING MATTERS FOR FUTURE CONSIDERATION

FOLLOW UP ACTION FROM PREVIOUS MEETINGSACTION BY DEADLINE STATUS

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MEETING TITLE

Trust Board - Public

Date: 08.01.2020

Report Title: Critical Path - Winter Capacity

Agenda Item: 9

Author: Marcus Bailey, Chief Operating Officer

Lead Director: Marcus Bailey, Chief Operating Officer

Purpose: Assurance X Decision


SUMMARY & BACKGROUND This paper for the Trust Board looks to provide assurance related to winter capacity following work by the operations and Executive Leadership team. This has been shared with the regulators through our Oversight and Scrutiny meeting (OSM). It has also been shared with our commissioners. The key actions are focussed on increasing capacity relate to increase resourcing above that of the staff in post or ensuring the staff are workforce effective. Central to increasing PFSH is the planned used of an overtime incentive which has been built into the Trust financial forecast. Along with a reduction in annual leave for staff. It should be noted that the winter capacity, is at times, lower than the production levels of last financial year for which the regulators have requested further mitigating actions. These actions include:

System demand management at STP level

Expansion of falls schemes

Establishment of Urgent Tier

Escalation assessment and use of tools to support rapid handover at hospitals

Increase clinical presence within AOC

Increased welfare support for AOC

Revised SURGE Demand Management Plan At the time of writing this report the Trust had completed week 39, covering Christmas and Boxing Day. The key highlights were:

Respiratory condition and flu like illness have been high and remained constant.

Hospital pressures were experienced across most acutes and STP areas over 15minutes than compared with last year.

Demand in C1 and C2 was up along with our overall face to face responses.

Conveyance to hospital was 63% (average 64%) noting the acuity shift into C1 and C2.

PFSH were 90,483 which were 561below plan but mitigated through actions above. Horizon Scanning

Concern related to hospital patient handover delays continuing and increasing.

Impact of hospital and system capacity related to infectious illness.

System staffing related to illness and absence

Likelihood of needing to increase PFSH further into January and February on this basis, reviewing incentivisation options.

A further reduction is annual leave is not possible in order to ensure staff are able to adequately rest.

Critical Path - Winter Capacity Report


A full report covering the festive period will be provided at the next Board

RECOMMENDED ACTION: The Board are asked to note the content of the report.

KEY ISSUES IDENTIFIED Key risks and issues are highlighted in the paper

DECISION OR RESOURCE REQUIRED: Assurance required


ELT – performance and capacity, financial commitment. PFC – winter plan, critical path and performance trajectory


SR1 and the associated actions IBR – KPI metrics and associated areas for improvement have been highlighted.



X


X


SR4: Failure to deliver an efficient, effective and economic service



Provide better care

Value our people

Value for money


OTHER:

To ensure effective governance and compliance

LINK TO CQC:

Caring X

Responsive X

Effective X

Well Led X

Safe X




N/A



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MEETING TITLE

TRUST BOARD (PUBLIC)

Date: 08.01.2020

Report Title: Horizon Scanning

Agenda Item: 10

Author: E de Carteret, Head of Governance

Lead Director: D Hosein, Chief Executive



SUMMARY AND BACKGROUND: Three briefing highlights have been included in this month’s horizon scanning report, for the Board’s information. ESR will be updated to support improved monitoring of declarations of interest in 2020. This will support strengthened governance and public trust. The third report on cyber security following the WannaCry attack has been published, outlining the work both already completed and planned for 2020. The Parliamentary and Health Service Ombudsman have published their review of NHS complaints for quarter 1 2019/20. At the last public Board meeting, an action was requested pertaining to potential plans pertaining to the use of artificial intelligence (AI) in the Trust’s business. In order to address this, the Chief Information Officer and Head of IM&T have provided a brief synopsis of possibilities for information, which is included within this report. Potential AI advances will be considered within the Digital Strategy and reported through the Performance and Finance Committee.

RECOMMENDED ACTION: The board is invited to note the report.


N/A

DECISION OR RESOURCE REQUIRED: N/A

PREVIOUSLY CONSIDERED BY: N/A. The Horizon Scanning report comes to every public Trust Board meeting

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] N/A








Provide better care

Value our people

Value for money

Improve performance

Horizon Scanning Report


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OTHER:

To ensure effective governance and compliance X

LINK TO CQC:

Caring

Responsive

Effective

Well Led X

Safe

RELEVANT LEGAL OR STATUTORY ISSUES None

Electronic Staff Record (ESR) and Conflicts of Interest (November 2019)

As per national guidance, all staff must declare interests, including gifts and hospitality to the organisation. This is set out in the Trust’s policy. However at present this is a manual ‘paper form’ process whereby declarations are submitted to the Head of Governance.

NHS England through an engagement process with trusts and Company Secretaries have confirmed that there will shortly be an update to the ESR system, which will support electronic capture of declarations. It is currently anticipated that the national update will be completed in March 2020.

The Head of Governance has made contact with the national department to gain further information and will work with IM&T to assess viability for utilisation within the Trust.

Department of Health and Social Care progress on securing cyber resilience (November 2019)

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/844003/Securing_Cyber_Resilience_in_Health_and_Care_progress_update_2019.pdf

This report is the third in the series since the WannaCry Cyber Attack in May 2017. Progress in the

last 12 months includes:

Establishment of NHSX to support digital and cyber advances, through improved national leadership

Trusts now have access to Microsoft Defender Advanced Threat Protection (ATP), which is providing real time detection and protection against potential threats by identifying suspicious behaviour on devices indicative of a cyber-attack. EEAST utilises ATP. Install is automatic on all devices.

Support to NHS organisations to migrate to the Windows 10 Operating System to maintain secure and up to date systems. Windows 10 is more secure and significantly faster than Windows 7, saving NHS staff time in delivering patient care. This programme of work is critical as unsupported and unpatched systems were key risk factors in the WannaCry attack. EEAST’s transfer is almost fully complete – by the end of January 2020 with mop up during February.

The Cyber Security Operations Centre (CSOC) has been implemented which provides the ability to undertake protective monitoring at a scale and level of detail not previously possible. This makes it quicker and easier to predict, detect, prevent and respond to data and cyber security incidents across the NHS.





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Planned steps for 2020:

NHSX to launch the Cyber Security Strategy for Health and Care

Completion of the CIO recommendations following the WannaCry attack

Parliamentary and Health Service Ombudsman: Complaints about the NHS in England: quarter 1 2019-20 (December 2019) https://www.ombudsman.org.uk/sites/default/files/Complaints_about_the_NHS_in_England_Quarter_1_2019-20.pdf The PHSO have published their report on NHS complaints for quarter 1. In total of those investigations concluded, the PHSO upheld or partially upheld 49% of cases. In the quarter, a total of 9 ambulance cases were concluded with two upheld (22%), which is a significantly lower proportion than across the rest of the NHS. None of the nine were EEAST cases.

Artificial Intelligence Update (as per Board action)

NHSX: Artificial Intelligence: How to Get it Right (October 2019)

https://www.nhsx.nhs.uk/assets/NHSX_AI_report.pdf?dm_i=21A8,6KCKC,W9SEF5,Q3SMC,1

The report above builds upon the NHS Long Term Plan in relation to the Health Secretary’s

technology vision, focussing upon the five missions set out:

1. Reduce the burden on clinicians and staff, so they can focus on patients

2. Give people the tools to access information and services directly

3. Ensure clinical information can be safely accessed, wherever it is needed

4. Improve patient safety across the NHS

5. Improve NHS Productivity with digital technology

The report outlines the following opportunities for the use of AI within health and care:

The report also outlines five key areas of challenge in relation to the development and adoption of AI systems within health and care, which are being focussed on via the AI lab within NHSX and must be considered within any local developments;

Leadership and society – and forming positive links between industry, government and academia

Skills and talent, to ensure the best environment for the deployment of AI systems



https://www.ombudsman.org.uk/sites/default/files/Complaints_about_the_NHS_in_England_Quarter_1_2019-20.pdf

https://www.ombudsman.org.uk/sites/default/files/Complaints_about_the_NHS_in_England_Quarter_1_2019-20.pdf

https://www.nhsx.nhs.uk/assets/NHSX_AI_report.pdf?dm_i=21A8,6KCKC,W9SEF5,Q3SMC,1

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Access to data - ensuring data sharing is legal, fair, ethical and safe

Supporting adoption – there must be a clear driving force to support AI adoption

International engagement – partnership working to support delivery Early consideration of the potential for AI systems utilisation within the East of England Ambulance Service has suggested the following potential areas. Our use of data would align with the NHSX area of ‘system and resource efficiency’: Vehicle Failures (out of cycle), sensory data can be aligned with external impacts (weather,

patient predictions, driver data, training)

Weather forecast to service demands, by region, to station

Staff rota, Sickness Predictions (no shows), Overtime costs

NHS A&E service estimates enable us to consider planning delivery of patients to other Hospitals to stop the conveyance holding effect thus releasing our vehicles and crews back onto station quicker

More accurate calls on our services, by days, hour and minute level

Workforce redesign for the future

Control room prediction by call class. It is important to note that the implementation of AI within health and care is a long-term aim, under the ten-year NHS Plan with intelligence suggesting 3-5 years for the majority of AI systems to be ready/viable. Other areas important for the Trust to consider includes Robotic Process Automation (RPA) to create efficiencies within systems – RPA repeats human actions, whereas AI is self-learning and simulates human intelligence. Both are confirmed as planned to feature within the Trust’s Digital Strategy.



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MEETING TITLE


Date: 08.01.2020 Report Title: Integrated Performance Report Agenda Item: 11 Author: E. de Carteret, Head of Governance Lead Director: M Bailey, Chief Operating Officer Purpose: Assurance Decision


SUMMARY AND BACKGROUND: This report provides the IPR for the month, consisting of November 2019 data. Directors will talk to their relevant sections of the IPR in the Board meeting. In addition to the above, in December the Board discussed the IPR and usability. Already agreed is a piece of work via the Chief Information Officer and the Informatics Team to improve the report, however Board recognised the time period this will take. In the interim, Board requested that the Executive team compile a single first slide of the IPR with the top 10-12 metrics the Trust is currently focused on in terms of delivery. This as a first draft has been included within the IPR (page 2 of the pack) for comment and discussion. The 10 metrics were identified from the existing IPR data set, so does not include any new informatics at present. Executives have already through this process began to identify different data sets for the longer term IPR inclusion. This longer-term work will also consider the metrics aligning to the relevant Board strategies for inclusion and monitoring. The Board are asked to consider the metrics outlined on page 2 of the IPR and discuss whether these are consistent with the areas of risk and focus within the Trust. Any suggestions and/or amendments can then be encompassed within the report for the next meeting.

RECOMMENDED ACTION: Discuss the proposed overview metrics

KEY ISSUES IDENTIFIED None noted.

DECISION OR RESOURCE REQUIRED: Due to the short period between meetings, the first version has been established by the Chief Operating Officer and Head of Governance for Board discussion, further input is sought from all Board members. Suggestions provided by the Executive in between paper submission and the meeting will be verbally narrated to the Board for consideration.

PREVIOUSLY CONSIDERED BY: Verbal discussion at ELB 2 January 2020

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] Key metrics identified and proposed were risk based, and based on areas of focus at Board and committee level.

INDICATE WHICH STRATEGIC RISK THIS REPORT RELATES SR1: Failure to deliver a timely service to our patients in line with commissioned national standards, to ensure a safe level of service

X

Integrated Performance Report


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X


X

SR4: Failure to deliver an efficient, effective and economic service X Other: Please Specify X

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X Value our people X Value for money X Improve performance X

OTHER: To ensure effective governance and compliance X

LINK TO CQC: Caring Responsive Effective Well Led X Safe


Integrated Performance Report


Integrated Performance ReportTrust Board – January 2020

November 2019 Data

EEAST: Integrated Performance ReportJanuary 2020, November 19 [email protected]

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Key IndicatorsTrust (November 2019 data)


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Overview Trust (November 2019 data)

• Fields with no RAG rating currently do not have a plan / target• Average YTD % figures are currently all calculated by adding the monthly data and dividing by the number of months.


Trust TrustMonth YTD Month YTD

National Standards R R Safety & Risk Management A A

Category 1 Mean 00:08:25 0:08:01 Serious Incidents 2 38Category 1 90th Percentile 00:15:27 0:14:41 Harms 0 20Category 2 Mean 00:30:20 0:28:06 Near Misses 2 18Category 2 90th Percentile 01:04:07 0:58:09 12wk IPC Service Clean Compliance* 88.00% 85.75%Category 3 90th Percentile 04:56:27 4:10:22 Claims Received 3 28Category 4 90th Percentile 04:53:47 4:12:47

Operational Performance R R People & Culture R R

999 calls abandoned 6.47% 7.24% Whole Trust WTE (Finance Adj. Staff in post) 4915.88 4776.85S,T&C (ED 1&2) 60.25% 60.92% Net variance to Fin Adj staff in post over prev. period 26.79 232.33Average Arrival to Handover Time 0:25:22 0:22:03 Trust Turnover 8.44% 8.83%Average Handover to Clear Time 0:17:34 0:16:58 A&E WTE 2893.13 2854.37Hear & Treat % 6.60% 6.32% Sickness 6.45% 6.56%

EADR Compliance 80.49% 77.40%Mandatory Training Compliance 78.41% 86.92%Professional Update Compliance 85.23% 74.58%New Starters to trust WTE 47.36 62.55

Clinical Performance - - Finance R R

STEMI Care Bundle* (qtrly - most recent data) 87% 88% Financial Surplus/(Deficit) -1195 -1280Stroke Care Bundle* (qtrly - most recent data) 100% 99% Financial Risk Rating - 2Cardiac Arrest ROSC* 27% 28% Capital Plan 6725 50976Cardiac Arrest Utstein* 44% 54%

Patient Experience R R Cost Savings - R

Complaints 76 720 CIP Plan Delivery 413 4754Concerns 42 396 CIP Plans Quality AssessedCompliments 313 2185FOI Compliance 64.71% 73.17%

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OverviewSTP (November 2019 data)


Month YTD Month YTD Month YTD Month YTD Month YTD Month YTD

National Standards Target G G R R R R R R R R R R

Category 1 Mean* 00:07:00 00:07:14 00:06:51 00:08:23 00:08:03 00:08:14 00:07:55 00:08:11 00:07:58 00:08:43 00:08:14 00:09:24 00:08:45Category 1 90th Percentile* 00:15:00 00:12:55 00:12:17 00:15:17 00:14:53 00:14:48 00:14:03 00:14:58 00:14:04 01:16:45 00:15:41 00:17:28 00:16:29Category 2 Mean* 00:18:00 00:26:36 00:24:36 00:28:53 00:25:53 00:33:42 00:29:52 00:36:32 00:31:23 00:28:37 00:24:29 00:32:04 00:30:06Category 2 90th Percentile* 00:40:00 00:55:38 00:51:59 00:58:58 00:53:42 01:07:57 01:01:24 01:13:02 01:03:27 00:59:41 00:50:33 01:04:08 01:01:36Category 3 90th Percentile* 02:00:00 03:00:27 02:50:15 03:47:35 03:22:28 04:47:43 04:00:45 07:51:05 06:07:39 04:05:00 02:58:08 04:53:53 04:47:19Category 4 90th Percentile* 03:00:00 03:33:08 02:45:39 03:55:15 03:30:34 04:18:15 03:47:05 06:52:25 05:53:11 04:00:33 03:07:30 04:55:11 04:35:56

R R R R R R R R R R R R

S,T&C (ED 1&2) 4,693 35,854 6,366 49,729 9,093 70,839 8,320 64,980 8,542 68,457 7,467 60,407Average Arrival to Handover 00:15:00 00:20:34 00:18:22 00:28:23 00:24:50 00:23:31 00:22:09 00:23:04 00:20:45 00:34:26 00:25:30 00:19:47 00:19:03Average Handover to Clear 00:15:00 00:16:58 00:16:34 00:16:10 00:15:37 00:16:13 00:16:14 00:19:09 00:18:04 00:17:20 00:17:09 00:18:20 00:17:24Hear & Treat % 7.48% 7.26% 7.10% 6.32% 6.94% 6.45% 7.69% 6.85% 5.62% 5.24% 6.17% 6.53%

Patient Experience - - - - - - - - - - - -

Complaints 0 9 65 13 121 26 180 4 48 4 45 4 71Concerns 0 4 21 11 60 8 79 4 41 3 27 3 56Compliments 32 123 37 162 56 212 59 237 57 273 71 273

- - - - - - - - - - - -

Serious Incidents 0 0 1 0 4 1 5 0 6 0 11 1 10Harms 0 0 1 0 2 0 3 0 6 0 4 0 6Near Misses 0 0 0 0 1 1 2 0 2 0 6 1 4

People & Culture R R R R R R R R R R R R

Sickness 5.00% 4.18% 4.97% 5.70% 6.84% 6.30% 5.80% 6.21% 6.41% 7.66% 6.48% 8.44% 8.40%Mandatory Training 95% 83.8% 88.6% 76.8% 85.6% 86.3% 93.4% 75.8% 86.8% 66.2% 79.7% 84.1% 91.7%Professional Update 95% 72.1% 60.6% 86.6% 83.5% 85.3% 65.9% 87.4% 79.9% 94.8% 90.1% 88.1% 75.3%

*National Standards

Beds & Luton Cambs & P'Boro Herts & W Essex Mid & S Essex Norfolk & Waveney Suffolk & NE Essex

Safety & Risk Management

Operational Performance

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Performance – Emergency Operations, AOC & EPRRLead Director: Marcus Bailey


Key Indicators for 2019/20

Description This Month Trend YTD

C1 Mean Response 00:08:25 00:08:00

C1 90th Percentile 00:15:27 00:14:39

C2 90th Percentile 01:04:07 00:57:47

C3 90th Percentile 04:56:27 04:09:26

C4 90th Percentile 04:53:47 04:11:10

Average Arrival to Handover 00:25:22 00:22:03

Average Handover to Clear 00:17:34 00:16:58

Hear and Treat Rate 6.60% 6.32%

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Performance – Emergency Operations, AOC & EPRRLead Director: Marcus Bailey

SummaryThe summary will form part of an overall summary please highlight any key successes and/or issues in this section

KPI Key Success / Issue Action Progress

ISR performance targets Lower Patient Facing Staff Hours Agreement of a set of key winter actions to complement previous critical path work. Including finalising the specific overtime incentive.

Incentive released and all actions being monitored ahead of key winter pressure period. Surge (demand management) plan reviewed. ECAT staffing levels improving ahead of winter.

ISR performance targets Modelling on performance with current staffing

To under ORH modelling and results to be discussed with commissioners

Modelled internal trajectory targets identified, agreed and released at STP along with Trust level.

Commissioner and regulatory discussion has occurred.

Hospital Handover Increasing Arrival to Handover times at certain acute hospitals

Engagement with regional handover programmes

Regional workshop attended. Draft changes proposed back to NHSE on divert protocol

ISR performance targets Profiling of resources to match demand Implementation of building better rotas Phase 2 go live in progress


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Performance – Patient Transport ServiceLead Director: Marcus Bailey


KPI Key Success / Issue Action ProgressPerformance Poor operational and financial

performanceReview each contract delivery. Commencing January 2020

West Essex Efficient use of resources Trial use of software auto-planning functions

Task and finish group commenced

NEPTS Lack of co-ordination of all business activity for NEPTS

Role established to facilitateorganisational wide operations

Appointment made

Recruitment Lack of training courses Increase planned in training provision for September and October

Good progress with training placed resulting in decrease vacancies.

Key Indicators for

2019/20(Risk

Identified)

Description This Month Year End

Bedfordshire & Hertfordshire Performance Under development Under development

Bedfordshire & Hertfordshire Mandatory

Training ComplianceUnder development Under development

Recruitment Reporting from February 2020


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People & CultureLead Director:



Description This Month Trend YTD RAG

Short Term Sickness 3.31% 2.83%

Long Term Sickness 3.15% 3.74%

Professional Update (Staff Training) 85.23% 74.58%

Statutory & Mandatory Learning (85% rolling compliance) 78.41% 86.92%

Information Governance Training (95% rolling compliance)

Compassionate Conversations (rolling 95% compliance) 80.49% 77.40%

Employee Relation Cases 81 79

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People & CultureLead Director:


KPI Key Success / Issue Action ProgressSickness Absence Long Term Aim is to decrease staff absence which is

longer termOccupational Health contracthas been awarded to Case Medical.Line by line reviews are taking place with managers and HR for top 20 cases, each with milestones and plans in place

Implemented working groups . Progress is on-going

Sickness Absence Short Term Aim is to decrease staff absence which is short-term

Training has been delivered on sickness policy and management of sickness.A group has been created to focus on 'alternate working duties' and compliancy on Return to Work interviews

Focus and review ongoing.

Recruitment Underlying vacancy gap across service line

Projection plans are in place with gap analysis incorporating staff turnover

Review ongoingAdditional capacity be sourced

Professional Update training Need to ensure PU compliance Revised trajectory required for PU completion from operations

Trajectories in place and monitoring/exception


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Clinical (1)Lead Director: G Hooper



*New Reporting due Q4

Description This Month Trend YTD

Patient Safety - Harmful Incidents(All) 2 38

IPC Compliance - Vehicles A&E -Deep Clean Compliance 96.00% 96.25%

IPC Compliance - Vehicles A&E -Interim Clean Compliance 76.00% 72.25%

IPC Compliance - Vehicles PTS -Deep Clean Compliance* tbc tbc

IPC Compliance - Vehicles PTS -Interim Clean Compliance* tbc tbc

IPC Compliance -Station Cleanliness Compliance 95.00% 96.13%

Outstanding Complaints Against Timeframe 37.17% 37.68%

Outstanding Incidents Against Timeframe 76 747

Medicine Management Compliance -Controlled Drug Audit

Not reported in month (1/4 report) >90%

Medicine Management Compliance -Prescription / Pharmacy Audit

Not reported in month (1/4 report) >90%

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KPI Key Success / Issue Remedial Action ProgressIPC Vehicle & station cleanliness audits

continue to be above the target of 95%.

Uniform compliance, including the updated BBE policy, continues to achieve above the Trust target of 95%

IPC Team continues to support Make Ready Team monitoring/ reporting to push further increase in compliance.

Ongoing training for all MRO staff to ensure clear understanding and consistent application of the procedures.

New method of cleaning being explored through the Product Alignment Group.

Bare below elbows introduced from 1/12/19 that will affect all patient facing staff on duty.

Additional station poster campaign developed to support this change.

A task and finish group is reviewing the Make Ready system and its ability to align with the new fleet. Training to Make Ready Group Leads has been completed.

Flu programme continues to improve, current vaccination rate is 70% with a stretch target of 80%. Highest performing ambulance trust, 10th (out of 27) highest performing trust in region. Likely maximum vaccination rate being 73% on form return.

New OH provider will deliver flu programme in 2020/2021 going forward.

Medicine Management Medicines Centralisation plan nearing completion and on target for early implementation (Jan 2020) to reduce variation and improve compliance.

Updated detailed action plan sought for CQC, to reflect all aspects of medicines management.

Datix analysis being undertaken to identify themes and issues within reported incidents.

Significant number of incidents relating to all aspects of medicines management –storage, availability, stock dates and administration being reported via datix.


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KPI Key Success / Issue Remedial Action ProgressPatient Safety - Harmful Incidents (Moderate or above)

2 new cases reported (2 x near miss/low harm) due to:

One is the staff deaths SI. It’s WEB161927 – staff death & recorded as no harm.

WEB159856 - a patient fell from a wheelchair on the tail lift and fractured her arm & recorded as low harm.

Currently, outstanding incidents has reduced to the lowest for the current quarter at 76 (dropped from 102 last month).

Minor clarifications made to SI policy to promote consistency.

Trialling the removal for the SI Panel to improve the decision making around early recognition via the Safety & Risk Lead along with updating the current SI policy.

Instigated formal lessons learned exercise to inform policy review and training priorities, prior to establishing a comprehensive quarterly performance review to drive improvements going forward.

Aiming to review impact of changes to the internal SI notification process

Currently working with Suffolk ICS to be an early adopter for the new SI Framework – agreed to urgently jointly review SI policy to reflect best practice regarding investigations and reporting.


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KPI Key Success / Issue Remedial Action ProgressPatient Experience -Outstanding Complaints Against Timeframe

Complaints average closure is increasing to 37.17 days against the 25-day target despite the complaints logged within the month is the lowest for the quarter at 75.

No substantive managerial staff in team currently, oversight being provided by compliance manager.

Appointing interim Patient Engagement Lead for up to six months to help manage the capacity gaps within the department to address the quality and quantity of complaints/concerns investigations/outcomes/lessons learned.

Commencing recruitment of complaints manager to cover maternity leave.

Interim Patient Engagement Lead to commence 6th January 2020


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KPI Key Success / Issue Remedial Action Progress

Legal Services – Claims 3 new claims received in November that are progressing:

1. Employer liability – Incident type: Violence against the member of staff – North Beds locality – Claimant called to intoxicated male, who punched the member of staff during attendance.

2. Employer liability – Incident type: Slip, trip, fall – West Suffolk Locality – Claimant slipped on ambulance step

3. Public Liability – Incident type: Inadequate Care/Assistance – Cambs PTS – Claimant fell backwards from wheelchair during transfer to hospital appointment. (this is also reported as in month)

Claims Facilitator collating file for NHS R to determine level of liability against all three cases

Compliance & Standards Lead seeking assurance from Fleet to ensure slip hazard rectified as not first incident reported on new Ambulance

CLIIP reporting to be reviewed by Patient Engagement/Compliance & Standard/Risk & Safety Leads to ensure developing lessons/learned/outcomes from incidents in Q4.


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FinanceLead Director: Kevin Smith

Summary

KPI Key Success / Issue Action ProgressCIP Target Revised CIP Action Plan.

PMO in situ to add structure to programmeM8 decline in achievement. M8 plan £1.0m, M8 achievement £0.4m

CIP Delivery Board Scrutiny, Re-Forecast of likely achievement level has given an improved position. Likely shortfall c£3.8m

Ongoing

Year End Forecast Risks to Financial Plan.Detailed reforecast has been completedTrust at risk of a deficit at the end of the financial year of £(7.7)mThis has been presented to Trust Board and Regulators

Budget monitoring, costing of new initiatives to enable fully informed decision making (eg: incentives)Work continues on CIP achievement and mitigations for shortfallsTrust Recovery plan WIP

Ongoing

Cash Flow Forecast M8 remains ahead of plan Rolling cash flow forecast reviews weekly BAU

Financial Risk Rating Currently at 2 (Rated between 1&4, top rated would be 1)

Budgetary Control and Management, CIP Action plan

Ongoing BAU

Key Indicators for

2019/20

Description This Month YTD

Financial Position – variance to plan £(0.8)m £(1.5)m

Capital Expenditure £(0.2)m £(4.4)m

Cash Balance £(10.6)m

Financial Forecast £(7.7)m


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Data Pack


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Workforce (1)


Baseline Actual Variance Baseline Actual Variance ISR Estab Actual Variance

5.00% 6.45% 1.45% 2.33% 3.31% 0.98% 2.67% 3.15% 0.48%

Previous Month Previous Month Previous Month

6.49% 2.54% 3.95%

Budget Estab Actual Variance Budget Estab Actual Variance Baseline Actual Variance

393.75 348.85 -44.90 703.22 609.58 -93.64 547.27 482.87 -64.40


363.84 615.62 478.41

Baseline Actual Variance Baseline Actual Variance Baseline Actual Variance

5535.73 4915.88 -619.85 3200.34 2893.13 -307.21 - 619.85 -


4835.00 2856.90 670.57

Sickness Sickness - Trust Short Term

% Change from Previous Month % Change from Previous Month % Change from Previous Month

↓0.04% ↑0.77% ↓20.25%

Sickness - Trust Long Term

Total Trust FTE in Post ISR Front Line FTE (B3-B6) Vacancies (WTE)

↑0.93%

PTS FTE


↓4.12% ↓0.98%

Call Handling & Dispatch Staff FTE EOC Total FTE


↑1.67% ↑1.27% ↓7.56%

Target, 5.00%

2.00%

4.00%

6.00%

8.00%

10.00% Monthly Trend from Apr18

Target, 2.33%

0.00%

1.00%

2.00%

3.00%

4.00%


Target, 2.67%

1.00%

2.00%

3.00%

4.00%


Budgeted, 392.75

320

340

360

380

400 Monthly Trend from Apr18 Budgeted, 701.22

0.00

200.00

400.00

600.00

800.00 Monthly Trend from Apr18Budgeted, 550.87

200.00

300.00

400.00

500.00

600.00

700.00

800.00 Monthly Trend from Apr18

Budgeted, 5505.57

3000.00

3500.00

4000.00

4500.00

5000.00

5500.00

6000.00 Monthly Trend from Apr18 Budgeted, 3194.84

1500

2000

2500

3000

3500Monthly Trend from Apr18

500.00

700.00

900.00

1100.00 Monthly Trend from Apr18

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Workforce (2)



95.00% 78.41% -16.59% 95.00% 67.68% -27.32% 95.00% 85.23% -9.77%


83.06% 65.82% 77.78%


- 52.00% - - 48.00% - - 3.45% -


52.45% 47.55% 3.38%


- 3.04% - - 80.49% - - 8.44% -


3.03% 82.53% 8.48%

↑1.86% ↑9.58%

Mandatory Training Mandatory Compliance PU (Rolling 18mth Compliance)

↓4.65%


↑0.45% ↑2.07%

Gender Male Gender Female Disability


↓0.45%

Diversity BAME EADR Turnover


↑0.01% ↓2.04% ↓0.47%

Target, 95%

40.00%

60.00%

80.00%

100.00%Monthly Trend from Apr18 Target, 95%

25.00%

45.00%

65.00%

85.00%

Monthly Trend from Apr18 Target, 95%

50.00%

70.00%

90.00%

Monthly Trend from Apr18

40.00%

45.00%

50.00%

55.00%

60.00%Monthly Trend from Apr18

40.00%

45.00%

50.00%

55.00%


2.90%

3.00%

3.10%

3.20%

3.30%


2.00%

2.50%

3.00%

Monthly Trend from Apr18 Target, 95%

20.00%

40.00%

60.00%

80.00%


6.00%

7.00%

8.00%

9.00%

10.00%


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999 Performance (1)


Local Target Actual Variance Local Target Actual Variance Local Target Actual Variance

105,985 64,018 -41,967 - 42,575 - - 39,764 -


111,345 73,953 69,228


7.00% 6.60% -0.40% - 33.15% - - 60.2% -


6.39% 32.45% 61.2%


- 13,234 - - 0:00:56 - - 334,126 -


21,566 0:00:30 335,894


↓38.63% ↑86.67% ↓0.53%

Total 111 Calls Call Answer 95th (AQI A5) Net PFSH

Total Responses (AQI A56)

↓1.50%

See, Treat & Convey (A53+A54)


↑3.34% ↑2.17%

Hear & Treat (AQI A17) See & Treat (AQI A55)

Total Calls (AQI A0) Total Incidents (AQI A7)


↓42.50% ↓42.43% ↓42.56%

80000

90000

100000

110000

120000 Monthly Trend from Apr18

65000

70000

75000


58000

63000

68000

73000


Target, 7.00%

5.00%

7.00%


29.00%

30.00%

31.00%

32.00%

33.00%


59%

60%

61%

62%

63%

64% Monthly Trend from Apr18

15000

17000

19000

21000


00:00:00

00:00:17

00:00:35

00:00:52

00:01:09

00:01:26 Monthly Trend from Apr18

250,000.00

300,000.00

350,000.00

400,000.00

450,000.00

500,000.00 Monthly Trend from Apr18

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999 Performance (2)


National Actual Variance National Actual Variance Local Target Actual Variance

00:07:00 0:08:25 0:01:25 00:15:00 0:15:27 0:00:27 - 11.3% -


0:08:10 0:15:02 11.3%

National Actual Variance National Actual Variance National Actual Variance

00:18:00 0:30:20 0:12:20 00:40:00 1:04:07 0:24:07 0:15:00 0:25:22 0:10:22


0:29:25 1:00:06 0:23:56

Local Target Actual Variance National Actual Variance National Actual Variance

01:00:00 1:47:14 0:47:14 02:00:00 4:56:27 2:56:27 0:15:00 0:17:34 0:02:34


1:46:29 4:26:42 0:17:27

Local Target Actual Variance National Actual Variance Local Target Actual Variance

01:30:00 1:42:34 0:12:34 03:00:00 4:53:47 1:53:47 - 90 -


1:41:42 4:15:30 158 ↓43.04%

C4 Mean (AQI A37) C4 90th (AQI A38) S136 Incident Count


↑0.86% ↑14.98%

↑0.64%

C3 Mean (AQI A34) C3 90th (AQI A35)


↑0.69% ↑11.15%

↑6.68%↑3.10%

% Change from Previous Month% Change from Previous Month% Change from Previous Month

Hospital Handover to Clear

C2 90th (AQI A32)C2 Mean (AQI A31)

↑5.98%

Hospital Arrival to Handover

C1 Mean (AQI A25) C1 90th (AQI A26) C1 Demand % Proportion


↑3.17% ↑2.77% ↑0.36%

Target, 00:07:0000:06:29

00:07:12

00:07:55

00:08:38

00:09:22


Target, 00:15:000:11:31

0:14:24

0:17:17

0:20:10

0:23:02Monthly Trend from Apr18

7%

8%

9%

10%

11%Monthly Trend from Apr18

Target, 00:18:00

ISR, 00:19:30

00:14:24

00:21:36

00:28:48


Target, 00:40:00

00:28:48

00:36:00

00:43:12

00:50:24

00:57:36

01:04:48


Target, 00:15:00

00:00:00

00:07:12

00:14:24

00:21:36

00:28:48


Target, 01:00:0000:43:12

00:57:36

01:12:00

01:26:24

01:40:48

01:55:12


Target, 02:00:00

00:00:00

01:12:00

02:24:00

03:36:00

04:48:00


Target, 00:15:00

00:13:4100:14:2400:15:0700:15:5000:16:3400:17:1700:18:0000:18:43 Monthly Trend from Apr18

Target, 01:30:00

00:57:36

01:12:00

01:26:24

01:40:48

01:55:12


Target, 03:00:00

00:00:00

01:12:00

02:24:00

03:36:00

04:48:00


50

100

150

200


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PTS Performance (1)


Contracted Delivered Variance Contracted Actual Variance Contracted Actual Variance Target Actual Variance Target Actual Variance

6,067 5,740 -327 - 4,978 - - 762 - 90% 72% -18% 95% 72% -23%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

5,854 5,453 401 74% 78%


3,107 2,635 -472 - 2,341 - - 294 - 90% 79% -11% 95% 78% -17%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

2,793 2,385 408 77% 83%

NHS Bedfordshire CCGJourneys Planned Journeys

% Change from Previous Month



Same Day Journeys

↓1.95% ↓8.71% ↑90.02% ↓2.00% ↓6.00%

Arrivals KPI Collection KPI








↓5.66% ↓1.84% ↓27.94% ↑2.00%

Planned Journeys Same Day Journeys Arrivals KPI Collection KPINHS Luton CCG

Journeys

↓5.00%

Contracted

60676067606760676067606760676067

4000

4500

5000

5500


50%

60%

70%

80%


5%

25%

45%

65%

85%


Contracted

31073107310731073107310731073107


25%35%45%55%65%75%85%


5%

25%

45%

65%

85%


0

2500

5000

7500 Monthly Trend from April 19

EEAST Other0

250500750


EEAST Other

0

1000

2000


EEAST Other0

250

500


EEAST Other

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PTS Performance (2)



6,264 6,790 526 - 5,709 - - 1,081 - 90% 59% -31% 95% 62% -33%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

6,115 4,907 1,208 65% 68%


4,366 4,410 44 - 3,429 - - 981 - 90% 64% -26% 95% 62% -33%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

4,253 2,823 1,430 64% 69%

NHS East & North Herts CCG



NHS Herts Valley CCGJourneys

Journeys Planned Journeys Same Day Journeys Arrivals KPI Collection KPI



↑11.04% ↑16.34% ↓10.51% ↓6.00% ↓6.00%





↑3.69% ↑21.47% ↓31.40% ↑0.00% ↓7.00%

Planned Journeys Same Day Journeys Arrivals KPI Collection KPI



Contracted

62646264626462646264626462646264

4500

5000

5500

6000

6500

7000


30%

40%

50%

60%

70%


5%

25%

45%

65%

85%


Contracted

43664366436643664366436643664366

3000

3500

4000

4500

5000


30%

40%

50%

60%

70%


5%

25%

45%

65%

85%


0

2500

5000


EEAST Other

0

1000

2000

3000Monthly Trend from April 19

EEAST Other

0

500

1000

1500


EEAST Other

0250500750


EEAST Other

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PTS Performance (3)



1,034 1,065 31 - 992 - - 73 - 85% 79% -6% 90% 92% 2%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

990 736 254 76% 89%


1,034 1,710 676 - 1,255 - - 455 - 85% 66% -19% 90% 90% 0%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

1,657 1,415 242 72% 91%

NHS Basildon & Brentwood CCGCollection KPIJourneys Planned Journeys Same Day Journeys Arrivals KPI




Same Day Journeys

↑3.20% ↓11.31% ↑88.02% ↓6.00%



↑7.58% ↑34.78% ↓71.26% ↑3.00% ↑3.00%

↓1.00%

NHS Castlepoint & Rochford CCGJourneys Planned Journeys Arrivals KPI Collection KPI






Contracted

1066

1066106610341034103410341034

500

700

900

1100

1300


50%

60%

70%

80%


50%

60%

70%

80%

90%


Contracted1569

1569156917161716171617161716

1000

1200

1400

1600

1800


50%

60%

70%

80%


50%

60%

70%

80%

90%


0


EEAST Other

0

500

1000

1500


EEAST Other

0

250


EEAST Other

0

100

200

300

400Monthly Trend from April 19

EEAST Other

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PTS Performance (4)



1,509 1,603 94 - 1,118 - - 485 - 85% 77% -8% 90% 91% 1%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

1,663 1,389 274 73% 92%


864 1,042 178 - 999 - - 43 - 85% 83% -2% 90% 88% -2%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

897 605 292 74% 95%

NHS Southend

NHS Thurrock CCG






↓3.61% ↓19.51% ↑77.01% ↑4.00% ↓1.00%

Collection KPIJourneys Planned Journeys Same Day Journeys Arrivals KPI

Collection KPI






Planned Journeys Same Day Journeys Arrivals KPIJourneys

↑16.16% ↑65.12% ↓85.27% ↑9.00% ↓7.00%

Contracted

1534

1534153415091509150915091509

1000

1200

1400

1600

1800

2000


50%

60%

70%

80%


50%

60%

70%

80%

90%


Contracted

899

899899864864864864864

600

700

800

900

1000


50%

60%

70%

80%


80%

85%

90%

95%


0

500

1000

1500


EEAST Other

0

250

500

750

1000


EEAST Other

0

250

500


EEAST Other

0

100

200

300

400


EEAST Other

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PTS Performance (5)



8,125 5,832 -2,293 - 4,915 - - 917 - 85% 92% 7% 90% 90% 0%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

5,939 5,226 713 88% 83%


3,048 3,164 116 - 2,549 - - 615 - 90% 60% -30% 90% 72% -18%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

3,276 2,710 566 64% 80% ↓8.00%

NHS West Essex CCGJourneys Planned Journeys Same Day Journeys Arrivals KPI Collection KPI



↓3.42%






↓1.80% ↓5.95% ↑28.61%

Planned Journeys Same Day JourneysNHS North East Essex CCG

Journeys

↑4.00% ↑7.00%

Arrivals KPI

↓4.00%↓5.94% ↑8.66%

Collection KPI




Contracted

81258125812581258125812581258125


50%

60%

70%

80%


50%

60%

70%

80%

90%


Contracted

3144

3144314430483048304830483048


50%

60%

70%

80%


50%

60%

70%

80%

90%



EEAST Other

0500


EEAST Other

0

250

500

750


EEAST Other

0

250

500

750


EEAST Other

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PTS Performance (6)



11,589 12,287 698 - 10,670 - - 1,617 - 90% 81% -9% 90% 82% -8%Previous Month

Previous Month

Previous Month

Previous Month

Previous Month

11,460 8,912 2,548 81% 83%

Same Day Journeys Arrivals KPI Collection KPI


↑7.22% ↑19.73%

NHS Cambridgeshire & Peterborough CCGJourneys





↑0.00% ↓1.00%↓36.54%

Planned Journeys

Contracted

11966

11966119661158911589115891158911589

9000

10000

11000

12000

13000


50%

60%

70%

80%


50%

60%

70%

80%

90%


0

2500

5000

7500

10000


EEAST Other0

1000

2000

3000


EEAST Other

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EPRR Performance


Baseline Actual Variance Baseline Actual Variance Baseline Actual Variance Baseline Actual Variance

- NA - - NA - - NA - - NA -Previous Month

Previous Month

Previous Month

Previous Month

882 64 539 73

Incidents Attended - HART HART Dropped Shifts

- - -


-




Incidents Attended - Air Ops MFTA Trained Staff

0

500

1000


0102030405060708090


0

200

400

600

800


70

75

80

85

90

95


Note: No update was available for EPRR this month.

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Clinical Performance (1)



- 2 - - 0 - - 2 -


6 2 4


- 76 - - 37.17% - - 42 -


117 34.64% 44


- 313 - - #N/A - - 3 -


289 25 9

% Change from Previous Month % Change from Previous Month

↓35.04% ↑2.53% ↓4.55%

Complaints Complaints - Time to Completion Concerns

Compliments Controlled Drug Incidents (Quarterly from Oct19)

Serious Incidents Harm

% Change from Previous Month Total Year to Date % Change from Previous Month

↓66.67% 24 ↓50.00%

Near Miss


Claims - Number Received


↑8.30% - ↓66.67%

0

5

10


0

5


0

2

4

6

8


020406080


Target, 25.00%0.00%

20.00%

40.00%

60.00%



050



0123456789


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95.00% 95.00% 0.00% 95.00% 96.00% 1.00% - 98.00% -


94.00% 96.00% 99.00%

Baseline Actual Variance Baseline Last Full Qtr Variance

- 88.00% - - 76.00% -

Previous Month Previous Qtr

84.00% 74.00%

Baseline Actual Variance Baseline Last Full Qtr Variance

- 47 - - 64.71% -

Previous Month Previous Qtr

33 61.90%


↑1.00% - ↓1.00%

Station IPC Vehicle IPC Uniform IPC

↑42.42%

IPC Service Clean Compliance IPC Vehicle Interim Clean Compliance

% Change from Previous Month % Change from Previous Qtr

↑4.00% ↑2.00%

FOIs Compliance %FOIs - Number Received

% Change from Previous Month % Change from Previous Qtr

↑2.81%

1

Target, 95%

92.00%

94.00%

96.00%

98.00%


Target, 95%93.00%

95.00%

97.00%


93%94%95%96%97%98%99%


Target, 90.00%

70.00%

80.00%

90.00%

100.00% Monthly Trend from Nov18Target, 85.00%

50%

70%

90%Monthly Trend from Jan19


40.00%

60.00%

80.00%


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56.00% 98.00% 100.00% 2.00% 86.00% 87.20% 1%


99.70% 83.70%

Baseline Actual Variance Baseline Last Full Qtr Variance Baseline Actual Variance

58.00% 43.50% -14.50% 30.00% 26.80% -3.20% 7.00% 9.30% 2.30%

Previous Month Previous Qtr Previous Month

61.40% 27.60% 8.80%

Baseline Actual Variance Baseline Last Full Qtr Variance Baseline Actual Variance

27.00% 23.90% -3.10% - 2646 - - 936 -

Previous Month Previous Qtr Previous Month

42.50% 2588 970

↑0.30% ↑3.50%

Stroke - Care Bundle* STEMI - Care Bundle*


↓3.51%

% Change from Previous Month% Change from Previous Qtr% Change from Previous Month

Safeguarding - ChildSafeguarding - AdultCardiac Arrest - Survival to Discharge - Utstein

Cardiac Arrest - Survival to DischargeCardiac Arrest - ROSC OverallCardiac Arrest - Utstein

No longer reported as of Apr 2019

↑0.50%↓0.80%↓17.90%

% Change from Previous Month% Change from Previous Qtr% Change from Previous Month

Stroke - FAST Patients to HASU < 60 mins

↑2.24%↓18.60%

1

Target, 56%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%Monthly Trend from Apr18 Target, 98%

85.0%

90.0%

95.0%


Target, 86%80.0%

85.0%

90.0%

95.0%


40.0%

50.0%

60.0%

70.0% Monthly Trend from Jan 2019 - updated benchmark as of Apr 2019

15.0%

25.0%

35.0%

Monthly Trend from Jan 2019 - updated benchmark as of Apr 2019

0.0%

5.0%

10.0%

15.0%


10.0%

20.0%

30.0%

40.0%


2000

2500

3000

3500

4000


0

500

1000

1500


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Financial Performance (1)


Forecast Actual Variance Budget Actual Variance Plan Actual Variance

-415 -1,195 -780 0% 49% 49% -952 -7,677 -6,725


-956 51% -7,677

Baseline Actual Variance Plan Actual Variance Cap Funding Actual Variance

- 3,813 - 9,821 10,603 782 668 159 -509


4,174 10,209 199

Plan Actual Variance Baseline Actual Variance Baseline Actual Variance

18,583 18,900 317 7,261 7,373 112 200 744 544


18,521 7,361 780

Trust Surplus / (Deficit)

Change from Previous Month % Change from Previous Month % Change from Previous Month

↑25.00% ↑0.00%↓2.00%

Cash Balance £'m

% Change from Previous Month % Change from Previous Month Change from Previous Month

↓8.65%

Value of Budgets in deficit

% of Cost Centres in deficit Forecast for Year End

Pay Costs Non-Pay Costs Debtors > 90 days £'m

↑3.86% ↓20.10%


↑2.05% ↑0.16% ↓4.62%

Capital Expenditure £'m

-3,000

-2,000

-1,000

0

1,000

2,000 Monthly Trend from Apr18

30.00%

40.00%

50.00%

60.00%


-8,000-7,000-6,000-5,000-4,000-3,000-2,000-1,000

01,0002,0003,0004,0005,000 Monthly Trend from Apr18


0

5,000

10,000

15,000


0250050007500


7,5009,500

11,50013,50015,50017,50019,50021,500 Monthly Trend from Apr18

4,000

5,000

6,000

7,000

8,000


0

500

1,000

1,500

2,000


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Financial Performance (2)


Forecast Actual Variance Budget Actual Variance Plan Actual Variance

1 2 1 - 2 - - 1 -


3 4 10

Baseline Actual Variance CIP Plan Actual Variance Baseline Actual Variance

6725 6725 0 979 413 -566 3.50% 3.50% 0


6725 917 3.50%

Baseline Actual Variance

95.00% 90.00% -5.0%

Previous Month

94.18%

Financial Risk Rating Financial Claims - Number Paid Financial Claims - £ Value Paid

Change from Previous Month % Change from Previous Month % Change from Previous Month

↓33.33% ↓50.00% ↓90.00%

Capital Plan YE Forecast


↑0.00%

CIP £'m Rate of Return % (Asset Utilisation)

BPPC Non-NHS %

% Change from Previous Month % Change from Previous Month


↓54.96% ↑0.00%

↓4.18%

0

1

2

3


05


05


0

5000

10000

15000


0

200

400

600

800


3.45%

3.50%


85.00%

90.00%

95.00%


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National Benchmarking Ambulance Quality Indicatorshttps://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/


EEAS EMAS LAS NEAS NWAS SCAS SECAMB SWAST WMAS YAS

Total Contacts A0 111,664 95,089 176,404 52,466 140,609 72,550 90,098 109,416 122,039 102,003

Calls answered A1 71,643 80,162 142,095 36,353 126,698 43,049 69,437 85,276 88,922 58,572Total call answer time (seconds) A2 675,844 290,631 1,566,562 303,250 1,583,850 285,665 235,548 970,603 382,937 418,932Mean call answer time (seconds) A3 9 4 11 8 13 7 3 11 4 7Median A4 1 2 0 1 1 3 1 3 1 1

All Incidents (= A17+A56) A7 73,865 66,261 107,529 35,866 99,489 51,733 64,620 76,081 93,965 72,412C1 Incidents (number of) A8 7,929 7,502 9,868 3,164 10,787 2,811 4,093 4,772 6,337 5,850C1T Incidents (number of) A9 5,229 5,160 7,209 2,156 7,695 1,756 2,670 2,980 4,021 4,193C2 Incidents A10 44,257 39,538 63,116 21,658 53,795 25,681 35,606 42,831 48,242 41,615C3 Incidents A11 10,386 10,012 20,236 6,025 15,922 15,517 17,830 17,149 29,509 11,182C4 Incidents A12 1,920 672 1,830 357 3,438 890 364 1,386 1,116 425

Hear and Treat % A17 / A7 6.80% 8.40% 7.20% 6.00% 8.10% 7.60% 6.20% 5.50% 3.70% 7.40%See and Treat % A55 / A7 33.00% 25.00% 27.60% 26.60% 27.20% 32.80% 30.70% 36.20% 34.40% 24.70%Convey Elsewhere % A54 / A7 2.90% 4.90% 6.50% 9.50% 5.40% 6.90% 1.00% 4.70% 6.20% 9.00%See and Convey to ED % A53 / A7 57.30% 61.80% 58.80% 58.00% 59.30% 52.70% 62.10% 53.60% 55.80% 58.90%

C1-Mean response time A25 0:08:24 0:08:03 0:06:46 0:07:02 0:07:27 0:07:25 0:07:39 0:07:10 0:07:06 0:07:29C1-90th centile response time A26 0:15:27 0:14:37 0:11:14 0:12:14 0:12:38 0:13:34 0:14:39 0:13:15 0:12:15 0:12:46C1T -Mean response time A28 0:12:38 0:17:08 0:11:11 0:08:14 0:10:36 0:09:18 0:09:26 0:10:07 0:08:06 0:09:03C1T-90th centile response time A29 0:22:39 0:39:05 0:19:19 0:14:18 0:18:19 0:17:51 0:18:09 0:18:52 0:14:07 0:16:23C2-Mean response time A31 0:31:39 0:36:05 0:22:18 0:37:11 00:30:43 0:18:59 0:20:54 0:29:19 0:14:31 0:23:10C2-90th centile response time A32 1:04:07 1:15:25 0:46:30 1:14:39 1:07:14 0:39:50 0:39:48 1:01:29 0:27:06 0:49:00C3-Mean response time A34 1:56:24 01:49:08 1:13:25 2:06:06 1:51:11 0:58:34 1:47:51 1:18:37 0:59:55 0:56:33C3-90th centile response time A35 4:56:27 4:26:12 2:57:45 5:05:03 4:26:17 2:19:27 4:03:22 3:10:44 2:16:52 2:18:59C4-Mean response time A37 1:54:56 1:50:35 1:39:14 1:40:07 1:32:52 1:22:44 2:08:41 1:32:45 1:19:40 1:11:37C4-90th centile response time A38 4:53:47 3:54:58 3:48:51 3:55:32 3:29:38 3:09:31 4:46:20 3:43:59 3:18:23 2:38:08

Mean resources arriving at C1 A40 / A8 1.60 1.40 2.05 1.48 1.70 1.40 1.51 1.73 1.37 1.54Mean resources arriving at C1T A42 / A9 1.61 1.44 2.06 1.46 1.71 1.40 1.51 1.76 1.37 1.51Mean resources arriving at C2 A44 / A10 1.12 1.05 1.13 1.07 1.06 1.08 1.06 1.13 1.05 1.10Mean resources arriving at C3 A46 / A11 1.14 1.08 1.13 1.56 1.07 1.11 1.05 1.08 1.05 1.11Mean resources arriving at C4 A48 / A12 1.07 0.93 1.06 0.94 1.09 1.15 1.04 1.06 1.05 1.15

Resource allocation and arrival

Contacts

Calls

Incident counts

Incidents with no face-to-face response

Response times

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National Benchmarking AQIs C1 Mean (AQI A25)


00:05:46

00:06:29

00:07:12

00:07:55

00:08:38

00:09:22

hr:m

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Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19East Midlands 0:08:36 0:08:07 0:07:14 0:07:42 0:07:34 0:07:26 0:07:37 0:07:52 0:07:45 0:07:40 0:07:39 0:07:29 0:07:18 0:07:24 0:07:35 0:07:41 0:07:23 0:07:34 0:07:45 0:08:03East of England 0:08:06 0:08:35 0:08:42 0:08:37 0:08:10 0:08:02 0:08:09 0:08:11 0:07:31 0:07:42 0:07:53 0:07:35 0:07:51 0:07:42 0:07:58 0:08:19 0:07:45 0:07:55 0:08:09 0:08:24London 0:06:51 0:06:54 0:07:13 0:07:27 0:06:45 0:06:57 0:06:13 0:06:16 0:06:17 0:06:21 0:06:37 0:06:18 0:06:04 0:06:08 0:06:36 0:06:35 0:06:36 0:06:41 0:07:03 0:06:46North East 0:05:53 0:05:50 0:06:04 0:06:20 0:06:09 0:06:14 0:06:14 0:06:13 0:06:29 0:06:18 0:06:12 0:06:08 0:06:15 0:06:12 0:06:46 0:06:32 0:06:33 0:06:39 0:06:40 0:07:02North West 0:07:51 0:08:10 0:08:18 0:08:02 0:07:53 0:07:58 0:08:01 0:07:42 0:07:41 0:07:52 0:08:02 0:07:28 0:07:29 0:07:08 0:07:21 0:07:26 0:07:16 0:07:24 0:07:31 0:07:27South Central 0:06:35 0:06:52 0:06:53 0:07:12 0:07:08 0:07:14 0:06:53 0:06:56 0:06:55 0:06:45 0:07:39 0:07:11 0:06:54 0:07:00 0:07:09 0:07:12 0:06:55 0:07:15 0:07:28 0:07:25South East Coast 0:07:26 0:07:38 0:07:41 0:08:18 0:07:33 0:07:41 0:07:30 0:07:31 0:07:44 0:07:58 0:07:49 0:07:31 0:07:20 0:07:18 0:08:18 0:07:21 0:07:15 0:07:35 0:07:43 0:07:39South Western 0:08:31 0:08:24 0:07:39 0:07:09 0:07:02 0:06:50 0:07:02 0:06:58 0:06:49 0:06:44 0:07:01 0:06:47 0:07:00 0:06:46 0:06:59 0:07:10 0:07:15 0:07:11 0:07:02 0:07:10West Midlands 0:06:50 0:06:51 0:06:59 0:06:47 0:06:40 0:06:46 0:06:51 0:06:53 0:06:48 0:06:44 0:06:46 0:06:46 0:06:43 0:06:44 0:06:48 0:06:52 0:06:44 0:07:00 0:07:02 0:07:06Yorkshire 0:08:02 0:08:15 0:07:38 0:07:19 0:07:03 0:07:18 0:07:10 0:07:02 0:07:03 0:06:59 0:07:03 0:06:44 0:06:58 0:06:49 0:06:49 0:06:54 0:06:50 0:06:58 0:07:19 0:07:29

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National Benchmarking AQIs C1 90th Centile (AQI A26)


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National Benchmarking AQIs C2 Mean (AQI A31)


00:07:12

00:14:24

00:21:36

00:28:48

00:36:00

00:43:12

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00:12:58

00:20:10

00:27:22

00:34:34

00:41:46

00:48:58

00:56:10

01:03:22

01:10:34

01:17:46

01:24:58hr

:min

:sec


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-

01:12:00

02:24:00

03:36:00

04:48:00

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-

01:12:00

02:24:00

03:36:00

04:48:00

06:00:00

07:12:00hr

:min

:sec

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-

19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19

East Midlands 2:01:502:42:502:14:042:29:242:47:182:27:502:16:132:45:582:50:272:21:542:50:322:53:372:25:002:34:372:52:012:54:363:25:452:55:354:06:463:54:58East of England 2:47:283:20:224:02:534:08:243:36:414:07:383:47:124:11:473:06:173:14:453:25:273:28:184:10:503:57:304:07:095:08:233:00:443:38:184:15:304:53:47London 2:05:032:24:502:28:172:41:112:03:532:16:152:35:012:52:132:52:362:51:283:24:432:53:243:14:393:13:503:34:043:39:333:20:573:01:502:56:113:48:51North East 1:52:322:07:182:16:352:29:592:52:473:41:533:06:303:37:553:44:093:45:382:56:313:14:382:57:442:59:133:06:413:05:063:35:323:31:553:16:583:55:32North West 2:56:373:06:363:03:113:15:012:58:103:13:003:19:133:08:593:24:463:39:263:31:503:01:532:55:412:48:122:58:213:17:253:05:043:29:273:23:073:29:38South Central 2:33:042:54:302:51:353:01:162:41:412:47:122:37:462:50:282:56:592:46:454:06:143:17:563:18:252:58:582:33:482:41:572:43:342:46:183:28:183:09:31South East Coast 4:10:574:38:254:57:154:33:223:37:104:06:214:38:294:12:294:40:584:27:245:11:045:06:194:30:424:52:545:29:064:41:024:25:384:34:315:34:124:46:20South Western 4:14:145:52:445:50:156:24:326:05:075:49:395:09:164:17:403:40:213:52:213:40:583:41:543:30:083:16:203:46:293:57:313:28:143:34:503:11:483:43:59West Midlands 1:32:402:02:222:08:262:16:071:42:382:05:382:03:552:22:262:01:162:05:522:03:301:49:441:55:461:45:222:27:543:05:422:07:182:55:442:58:493:18:23Yorkshire 2:44:533:37:092:43:113:12:542:45:482:41:032:47:562:43:412:43:072:47:482:33:032:21:052:23:552:00:561:58:531:41:391:28:021:28:162:40:552:38:08

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National Benchmarking AQIs Hear & Treat % (AQI A17 / A7)


2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-

19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19

East Midlands 6.4% 6.3% 6.3% 7.0% 6.9% 6.8% 7.1% 8.1% 8.4% 7.4% 6.4% 6.0% 6.7% 7.9% 8.5% 8.9% 9.0% 7.9% 8.0% 8.4%East of England 6.3% 7.6% 7.9% 7.6% 6.9% 6.6% 6.3% 6.5% 7.0% 7.4% 6.9% 7.0% 6.4% 6.2% 6.2% 6.4% 6.0% 6.3% 6.4% 6.8%London 7.1% 6.9% 7.3% 7.7% 6.7% 6.8% 6.7% 6.9% 7.2% 7.3% 7.5% 7.0% 7.0% 7.2% 7.4% 7.4% 7.0% 6.7% 6.8% 7.2%North East 5.1% 5.0% 4.9% 5.0% 4.9% 5.2% 4.9% 5.3% 5.4% 5.4% 5.0% 4.7% 4.5% 4.5% 4.4% 4.6% 5.0% 5.4% 5.5% 6.0%North West 4.8% 4.8% 5.1% 5.4% 5.8% 5.7% 6.8% 7.2% 7.5% 7.6% 7.1% 7.4% 8.2% 8.7% 7.7% 7.6% 8.0% 7.1% 7.3% 8.1%South Central 6.2% 5.7% 5.6% 6.1% 5.5% 5.8% 5.7% 5.4% 6.1% 5.9% 7.0% 7.1% 7.9% 7.4% 7.3% 7.4% 7.0% 7.7% 7.9% 7.6%South East Coast 5.7% 6.3% 5.9% 6.6% 5.9% 5.7% 5.6% 5.6% 6.3% 5.8% 6.5% 5.5% 5.7% 5.6% 6.1% 5.7% 6.0% 5.8% 5.8% 6.2%South Western 5.8% 6.6% 6.2% 5.9% 5.2% 5.5% 5.6% 5.8% 5.6% 6.8% 6.9% 6.5% 6.4% 6.5% 6.6% 6.4% 6.0% 5.9% 5.5% 5.5%West Midlands 3.2% 3.4% 3.5% 3.4% 3.0% 3.0% 3.0% 3.0% 3.2% 3.0% 3.2% 3.2% 3.2% 3.2% 3.5% 3.8% 4.0% 3.9% 3.8% 3.7%Yorkshire 6.5% 7.0% 7.4% 7.5% 6.6% 6.3% 6.5% 6.3% 6.8% 6.8% 7.5% 6.5% 6.7% 6.8% 6.8% 6.7% 6.0% 6.1% 6.6% 7.4%

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National Benchmarking AQIs See & Treat % (AQI A55 / A7)


20%

22%

24%

26%

28%

30%

32%

34%

36%

38%

40%

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19East Midlands 26.8% 27.5% 28.0% 28.4% 27.6% 27.7% 27.2% 26.5% 27.1% 26.8% 27.3% 27.2% 26.7% 25.0% 25.0% 25.9% 26.0% 24.8% 24.3% 25.0%East of England 30.6% 30.1% 30.2% 31.3% 31.0% 31.3% 31.3% 31.2% 31.8% 31.7% 32.1% 31.5% 31.9% 32.0% 33.0% 33.2% 33.0% 33.0% 32.5% 33.0%London 25.0% 26.3% 26.4% 27.8% 27.1% 26.2% 27.0% 26.1% 27.4% 26.4% 26.4% 27.0% 27.1% 27.0% 28.0% 28.4% 29.0% 28.5% 28.0% 27.6%North East 24.2% 25.0% 24.8% 25.3% 24.7% 24.1% 25.9% 26.1% 26.7% 25.2% 25.8% 25.5% 25.7% 26.0% 26.0% 26.8% 27.0% 25.9% 25.7% 26.6%North West 23.5% 24.5% 25.0% 24.9% 24.4% 24.7% 24.5% 24.8% 26.2% 25.4% 26.0% 26.2% 26.6% 26.0% 27.0% 27.9% 28.0% 28.1% 27.2% 27.2%South Central 32.5% 32.7% 32.7% 33.7% 33.4% 33.8% 33.0% 33.3% 33.4% 33.1% 33.2% 33.8% 33.1% 33.0% 33.0% 34.0% 34.0% 33.1% 31.9% 32.8%South East Coast 33.2% 32.9% 33.0% 32.8% 32.8% 33.5% 32.4% 32.8% 32.7% 32.1% 31.7% 31.8% 32.2% 32.0% 32.0% 32.6% 32.0% 31.9% 31.3% 30.7%South Western 36.6% 36.2% 36.7% 37.5% 37.2% 35.8% 35.5% 35.6% 36.1% 35.1% 36.0% 35.8% 35.5% 36.0% 36.0% 36.2% 36.0% 35.9% 36.0% 36.2%West Midlands 36.6% 36.6% 36.6% 37.1% 36.3% 36.3% 35.5% 35.2% 35.5% 34.6% 35.3% 35.5% 34.9% 35.0% 35.0% 35.1% 35.0% 34.9% 34.6% 34.4%Yorkshire 23.0% 23.2% 23.5% 23.9% 23.9% 23.4% 22.8% 23.1% 23.6% 23.0% 22.9% 23.5% 23.7% 24.0% 24.0% 26.6% 25.0% 25.0% 24.6% 24.7%

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National Benchmarking Ambulance Clinical Quality Indicators https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/


13%

18%

23%

28%

33%

38%

43%

48%

May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19East Midlands 30.8% 25.0% 29.2% 29.1% 27.6% 28.1% 21.3% 24.6% 24.6% 23.8% 27.7% 30.5% 26.6% 32.4% 26.4%East of England 32.2% 32.1% 31.6% 27.3% 26.0% 31.5% 25.3% 29.8% 30.4% 29.3% 35.0% 27.0% 34.0% 29.9% 28.2%London 38.5% 38.3% 33.6% 37.4% 36.5% 38.4% 30.0% 35.4% 37.4% 31.3% 34.6% 31.0% 36.2% 34.5% 36.4%North East 26.6% 24.4% 32.1% 43.9% 28.7% 31.8% 32.4% 29.3% 29.8% 35.0% 33.9% 34.1% 28.1% 35.9% 30.5%North West 34.5% 37.5% 37.6% 33.7% 30.9% 28.4% 36.5% 30.8% 33.2% 32.6% 33.0% 33.2% 31.5% 33.6% 37.7%South Central 36.6% 27.5% 35.8% 25.2% 27.3% 28.5% 31.6% 33.3% 33.2% 29.6% 26.8% 32.3% 21.2% 30.7% 33.5%South East Coast 25.1% 36.6% 28.8% 31.9% 31.3% 27.9% 19.1% 25.9% 29.5% 27.2% 33.0% 19.2% 23.7% 22.5% 31.0%South Western 29.5% 31.0% 30.2% 27.5% 28.1% 29.7% 28.9% 31.3% 29.6% 33.2% 30.5% 31.4% 38.7% 34.0% 34.7%West Midlands 32.3% 32.7% 37.2% 39.8% 28.8% 33.8% 32.7% 30.7% 32.1% 31.6% 35.0% 32.8% 30.6% 34.4% 35.3%Yorkshire 25.7% 21.7% 19.7% 27.1% 22.5% 24.4% 23.1% 22.1% 17.1% 24.9% 37.1% 27.9% 31.8% 25.9% 25.4%

Cardiac Arrest - All Patients - proportion who had ROSC on arrival at hospital

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National Benchmarking ACQIs Cardiac Arrest – Utstein Comparator Group – Proportion who had ROSC on arrival at hospital


19%

29%

39%

49%

59%

69%

79%

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19East Midlands 61.9% 72.2% 40.0% 57.6% 53.6% 35.7% 48.7% 51.5% 58.6% 53.8% 37.5% 33.3% 45.2% 44.4% 55.6% 40.5%East of England 60.0% 56.3% 61.5% 62.5% 50.9% 51.2% 56.5% 63.4% 51.6% 62.5% 60.0% 60.0% 56.0% 67.3% 46.7% 59.0%London 61.8% 58.9% 70.0% 60.5% 50.0% 69.6% 70.6% 75.0% 70.2% 57.6% 75.0% 54.7% 57.8% 62.1% 55.3% 61.7%North East 75.0% 57.9% 60.0% 61.1% 60.0% 61.5% 50.0% 57.1% 61.9% 76.5% 51.9% 64.0% 52.9% 44.4% 50.0% 58.8%North West 53.7% 54.3% 64.9% 71.4% 58.3% 40.0% 39.6% 57.1% 47.4% 42.0% 47.7% 54.3% 62.7% 56.8% 59.1% 53.7%South Central 50.0% 60.0% 52.9% 72.2% 54.5% 68.8% 47.8% 53.7% 64.0% 60.5% 50.0% 60.9% 55.0% 73.9% 66.7% 62.1%South East Coast 40.9% 50.0% 69.7% 46.7% 71.9% 56.0% 48.6% 50.0% 41.5% 52.9% 46.9% 50.0% 34.6% 58.1% 31.0% 64.0%South Western 58.3% 50.0% 41.9% 45.1% 46.0% 36.8% 54.3% 45.2% 55.3% 48.1% 61.3% 46.4% 55.9% 60.9% 59.0% 57.7%West Midlands 42.9% 66.7% 67.6% 59.5% 71.0% 58.3% 60.0% 43.6% 54.8% 56.6% 40.4% 50.0% 55.6% 55.6% 65.7% 52.1%Yorkshire 50.0% 44.8% 45.7% 28.6% 53.1% 53.8% 63.0% 41.3% 53.1% 24.0% 52.0% 61.4% 62.1% 64.1% 51.7% 55.0%

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National Benchmarking ACQIs Cardiac Arrest – All Patients – Proportion who were discharged alive


0%

5%

10%

15%

20%

25%

30%

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19East Midlands 10.8% 10.8% 8.3% 12.4% 9.1% 8.9% 8.3% 5.8% 5.9% 6.3% 5.6% 6.4% 7.6% 6.8% 10.5% 8.9%East of England 11.6% 11.5% 9.4% 15.7% 12.0% 10.4% 10.3% 8.4% 9.6% 9.0% 13.0% 10.2% 4.7% 13.0% 12.0% 9.6%London 3.4% 8.7% 10.9% 10.6% 9.0% 8.7% 10.5% 6.5% 8.1% 8.1% 8.5% 8.7% 8.5% 9.2% 8.7% 9.3%North East 14.9% 10.1% 10.5% 7.9% 15.8% 10.3% 8.7% 11.9% 8.4% 4.8% 10.4% 10.6% 11.0% 5.3% 9.2% 9.5%North West 7.5% 10.5% 11.5% 9.4% 8.6% 9.3% 7.9% 6.3% 6.3% 3.9% 7.7% 8.1% 7.9% 5.7% 10.6% 9.1%South Central 14.1% 13.0% 25.7% 18.9% 11.0% 16.2% 15.2% 16.1% 9.0% 10.2% 8.7% 10.7% 12.9% 22.9% 14.5% 14.5%South East Coast 8.6% 4.5% 10.2% 8.4% 11.7% 8.2% 9.0% 6.6% 7.2% 9.7% 6.7% 9.8% 6.0% 7.0% 8.5% 11.1%South Western 9.2% 8.4% 11.0% 12.4% 8.2% 5.0% 10.9% 11.0% 8.8% 8.4% 8.9% 10.7% 9.9% 12.3% 9.9% 12.0%West Midlands 14.1% 12.5% 9.9% 15.2% 13.2% 11.5% 11.2% 11.3% 11.0% 10.8% 11.3% 10.4% 11.3% 10.3% 16.5% 14.1%Yorkshire 8.3% 24.4% 6.5% 6.9% 7.9% 8.5% 8.9% 11.5% 8.8% 9.2% 7.8% 9.7% 6.6% 13.8% 8.3% 10.6%

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National Benchmarking ACQIs Cardiac Arrest – Utstein – Proportion who were discharged alive


0%

10%

20%

30%

40%

50%

60%

70%

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19East Midlands 36.8% 35.3% 20.7% 36.4% 32.1% 15.4% 23.1% 24.2% 32.1% 30.4% 16.1% 14.7% 22.2% 21.2% 40.0% 30.0%East of England 43.3% 48.4% 37.5% 41.7% 34.0% 33.3% 35.0% 35.9% 39.3% 34.1% 40.0% 34.1% 20.8% 40.4% 31.0% 37.5%London 20.8% 20.8% 34.4% 40.0% 21.1% 32.4% 39.5% 29.5% 32.4% 31.1% 40.0% 31.3% 32.4% 29.6% 26.7% 20.0%North East 47.6% 35.3% 33.3% 21.4% 58.3% 38.5% 25.0% 28.6% 42.1% 25.0% 40.7% 36.0% 35.3% 17.6% 31.8% 35.3%North West 21.6% 30.2% 43.2% 28.6% 25.0% 24.3% 22.9% 14.9% 25.7% 12.5% 24.4% 43.3% 21.7% 23.5% 33.3% 21.1%South Central 18.2% 35.7% 35.3% 50.0% 18.2% 31.3% 52.2% 37.5% 20.0% 31.6% 11.5% 47.8% 40.0% 42.9% 36.0% 41.4%South East

Coast 21.4% 20.7% 33.3% 28.6% 35.5% 17.4% 38.9% 14.3% 18.4% 21.9% 29.0% 28.1% 8.0% 32.3% 24.1% 33.3%

South Western 26.5% 16.7% 23.0% 26.5% 18.6% 10.7% 20.9% 25.6% 31.6% 26.9% 22.0% 27.3% 28.8% 35.6% 41.0% 34.6%West Midlands 34.1% 35.7% 26.7% 47.2% 35.7% 27.3% 35.9% 23.8% 35.0% 33.3% 25.0% 25.0% 31.6% 35.7% 44.1% 34.9%Yorkshire 9.1% 25.0% 30.4% 15.8% 15.8% 22.7% 37.9% 35.3% 29.0% 22.2% 34.6% 22.2% 35.0% 45.2% 30.8% 28.6%

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National Benchmarking ACQIs Acute STEMI – Proportion of all patients who received STEMI Care Bundle


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-18 Jul-18 Oct-18 Jan-19 Apr-19 Jul-19East Midlands 81.5% 76.8% 83.5% 75.6% 80.0% 76.8%East of England 93.8% 91.0% 89.8% 93.4% 92.3% 83.9%London 74.5% 74.1% 75.9% 76.0% 78.7% 70.2%North East 72.4% 80.0% 82.2% 93.8% 99.1% 90.7%North West 63.9% 78.2% 75.8% 71.3% 65.2% 75.0%South Central 70.0% 73.6% 75.4% 70.5% 74.1% 69.0%South East Coast 69.1% 69.4% 62.7% 53.6% 57.5% 51.4%South Western 82.4% 84.3% 80.7% 84.8% 81.8% 83.1%West Midlands 90.8% 94.2% 95.1% 96.1% 98.0% 98.9%Yorkshire 76.6% 79.7% 58.1% 55.9% 53.1% 40.0%

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National Benchmarking ACQIs Stroke – Proportion of patients who received the Stroke Diagnostic Bundle


May-18 Aug-18 Nov-18 Feb-19 May-19East Midlands 98.2% 98.5% 97.8% 98.6% 98.1%East of England 97.1% 99.1% 100.0% 99.4% 99.0%London 98.5% 98.3% 99.1% 98.8% 98.4%North East 99.1% 99.3% 99.1% 99.6% 100.0%North West 98.2% 98.4% 98.5% 98.3% 98.2%South Central 96.8% 95.2% 96.6% 97.0% 94.2%South East Coast 98.7% 97.9% 97.1% 96.6% 95.8%South Western 98.9% 99.4% 98.5% 98.5% 98.2%West Midlands 99.1% 99.0% 99.6% 99.7% 99.6%Yorkshire 98.5% 98.7% 95.3% 96.1% 93.4%

93%

94%

95%

96%

97%

98%

99%

100%

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AQI Measure Term - Definition Inclusions and Exclusions Data -Calculation1: CONTACTS

A0 - contact count The count of all ambulance control room contacts. INCLUDE all telephone calls to 999 or 112, Include cases transferred from 111, HCPs and fire / police / coastguard, even where an incident is not created. | EXCLUDE - Abandoned calls and interanll calls from crews

Count of all CAD ID's for a particular time period. The only exclusion is TEST CALLs.

2: CALLS

A1 - calls answered The count of all calls answered

INCLUDE calls answered after being presented to switchboard on 999 emergency lines (includes where someone dialled 112). | EXCLUDE, abandoned calls, 111, police, fire, HCP and direct dial numbers (not 999).

Count of call CAD IDs where call source of 111 is null and BT 999 call centre ID is not null. This excludes all 111 calls and only includes calls from a BT 999 call centre to extract 999 calls only.

A2 - Total call answer time The time to answer each call totalled across all calls in the period All A1 calls - the sum of each call times between Time_T0 and Time_T1

A3 - Mean call answer time Across all calls in the period, the mean average time to answer each call (All A1 calls) the sum of each call times between Time_T0 and Time_T1 / total calls in A1

A4 - Median call answer time Across all calls in the period, the median time to answer each call

Median is the 50th percentile - therefore we calculate the 50th percentile time between Time_T0 and Time_T1 across all A1 calls

A5 - 95th Percentile call time Across all calls in the period, the 95th centile time to answer each call. Caculation of the 95th percentile time between Time_T0 and Time_T1 across all A1 calls

A6 - 99th Percentile call time Across all calls in the period, the 99th centile time to answer each call Caculation of the 99th percentile time between Time_T0 and Time_T1 across all A1 calls

3: INCIDENT COUNTS1. Incidents comprise not only calls that receive a face-to-face response from the ambulance service at the scene of the incident, but also calls that are successfully resolved with telephone advice with any appropriate action agreed with the patient. Include incidents resulting from callsto NHS 111. | 2. HCP calls (also referred to as urgents / referrals) that are triaged to one of C1 to C4 should be included in the relevant counts from A8 to A12 and response times from A24 to A38. |3. HCP calls where a response of 1, 2, 3 or 4 hours is agreed should be included in the relevant counts from A53 to A61 and response times from A62 to A73. | 4. Once the category is determined, reporting must remain against the code in the Computer-Aided Dispatch (CAD) recordprior to the arrival on scene of a Trust-dispatched resource. It must not be changed after a resource has arrived at scene. Following triage, either through 999 or 111, prior to the arrival of the responding resource as defined in items i) to iii) in Clock stop; it may be appropriate for somenon-C1 calls to receive additional clinical assessment, which may result in an alternative category for responding and reporting. If the incident is upgraded to a higher category, the clock start will be from the call back made by the clinician, at earliest of the appropriate trigger points inClock start. Otherwise, the clock start from the original call remains.

A7 - all incidents The count of all incidents in the period.

Refer to above text box - Duplicate, Hoax, Cancelled by caller, and Information only incidents are excluded from all.

Calculated when an incident is categorised as a C1, C2, C3, C4, C4H, and URG, Time first unit at scene isnt null (responses A56) + all incidents that provided with a Hear and Treat CAD reference due to receiving a no face to face response (A17).

A8 - C1 incidents The count of incidents coded as C1 that received a response on scene.

Calculated where the CAD = C1 Call Category and where the Time first unit on scene is not null (response).

A9 - C1T incidents The count of C1 incidents where any patients were transported by an Ambulance Service emergency vehicle.

Calculated where the CAD = C1 Call Category and where the Time first unit on scene is not null (response) and where the time at destination is not null to get all C1 incidents that were transported.


Calculated where the CAD = C2 Call Category and where the Time first unit on sceneis not null (response).


Calculated where the CAD = C3 Call Category and where the Time first unit on scene is not null (response).


Calculated where the CAD = C4T Call Category and where the Time first unit on scene is not null (response).

A57 - HCP incident with non-emergency conveyanceThe count of incidents with non-emergency conveyance where a 1, 2, 3, or 4 hour response was agreed, without triage, in response to a call from an HCP.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is greater or equal to 241 minutes. This measure collects all incidents will a call category of urgent however the crew did not make it to scene in 4 hours or less.

A58 - HCP 1 hour response The count of incidents where a 1 hour response was agreed in response to a call from an HCP.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is 60 minutes or less to provide a 1 hour response.

A59 - HCP 2 hour response The count of incidents where a 2 hour response was agreed in response to a call from an HCP. Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And

the response to scene is between 61 and 120 minutes or less to provide a 2 hour response.





Data DictionaryAmbulance Quality Indicators (1)


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4: NOC

A13 - C1 NoC / PTQ incidents The count of C1 incidents, that NoC identified as C1, and received a response on scene.

For A14 to A16, if the call connect time is not recorded, start from the next earliest time, such as T1.

Calculated where the CAD = C1 Call category, and Time first unit on scene is not null and Time of NOC shown is not null. This selects all C1 responses that have been allocated with a NOC.

A14 - Total time to NoC / PTQ C1Aggregated across each call in A13, the time, in seconds, from call connect, until the call was identified as a potential C1 using NoC / PTQ.

Calculated where the CAD = C1 Call category. Then works out the total time between when the first pre triage question was asked 'Time_of_first_prediction_PTQ' and when the NOC code was assigned to the call 'Time_of_first_prediction_NOC'.

A15 -Mean time to NoC / PTQ C1Across all calls in A13, the mean average time, in seconds, from call connect, until a call was identified as a potential C1 using NoC / PTQ.

Definition: A15 = A14 / A13

A16 - 90th centile time to NoC / PTQ C1Across all calls in A13, the 90th centile time, in seconds, from call connect, until a call was identified as a potential C1 using NoC / PTQ.

Calculated where the CAD = C1 Call category. Then works out the 90th percentile time between when the first pre triage question was asked 'Time_of_first_prediction_PTQ' and when the NOC code was assigned to the call 'Time_of_first_prediction_NOC'.

5: INCIDENTS WITH NO FACE-TO-FACE RESPONSE

A17 - incidents with no face-to-face response Count incidents with no face-to-face resource.

INCLUDE - HCP accountable to the Trust providing telephoneadvice, decisions supported by clinical decision support softwareor approved triage tool, referring to another organisationworking with the Trust through an agreed contract or ServiceLevel Agreement, or through the Directory of Services. | EXCLUDE- Duplicate, information, cancelled by caller and hoax calls. Alsoexclude deceased patient with no response on scene, demandmanagement, and calls passed to another ambulance service.

When a incident goes through the Heat and Treat pathway our database assigns it with the Hear and Treat CAD reference as well as a call category. We then do a total of all Inicdents of with a H&T CAD.ID. (A18 + A19 + A21 + A22)

A18 - Incidents closed with advice: Non-C4H Count of incidents with a stop code of self-care Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H.

A19 - Incidents referred to other service: Non-C4H

Count of incidents with a stop code of Refer to GP, Refer to A&E, Refer to Minor Injuries Unit (MIU) / Walk-in Centre, Refer to HCP, Refer to Specific service, or Refer to 111 / out of hours care.

Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H.

A20 - Incidents with call back before response on scene: Non-C4H

Count of incidents where, before any resource arrived on scene, the patient received additional clinical assessment over the telephone, but the patient still received a response on scene.

Caculated where all Inicdents with a H&T CAD.ID and has a Call Category of C2, C3, C4T, and Time first unit on scene is not null, and ECAT lowcode is not null.

A21 - Incidents closed with advice: C4HCount of C4H incidents where the patient was given specific home management advice regarding their condition, and did not require any further onward referral

Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H and ECAT lowcode dispositon is equal to 'Self Care' or 'Triaged by GP in EOC - No ambo required - Self Care'

A22 - Incidents referred to other service: C4H

Count of C4H incidents where an onward treatment path was agreed with the patient; whether the Ambulance Service advised the patient to make their own way

Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H and ECAT lowcode dispositon is not equal to 'Self Care' or 'Triaged by GP in EOC - No ambo required - Self Care'

A23 - Incidents with call back before response on scene: C4H

Count of incidents originally coded as C4H receiving a response on scene.

Calculated where all Incidents with a H&T CAD.ID and has a Call Category of C4H, and Time first unit on scene is not null, and ECAT low code is not null.



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6: RESPONSE TIMES

A24 - Total response time C1 The total response time aggregated across all incidents in A8 in the period.

An ARP Response Time and ARP Transport Response Time measure has been created by EEAST to only take calculate responses for transportable resources.

Calculated when Call Category = C1 and Time first unit on scene is not Null then Sum the ARP Response Time for all incidents across the specified period.

A25 - Mean Response time - C1 Across all incidents in A8 in the period, the mean average response time. A25 = A24 / A8

A26 - 90th centile response time C1 Across all incidents in A8 in the period, the 90th centile response timeCalculated when Call Category = C1 and Time first unit on scene is not Null then calculate the 90th percentile ARP Response Timefor all incidents across the specified period.

A27 - Total response time C1T The total response time aggregated across all incidents in A9 in the period.Calculated when Call Category = C1 and Time first unit on scene is not, and time destination is not null. then Sum the ARP Response Time for all incidents across the specified period.

A28 - Mean response time C1T Across all incidents in A9 in the period, the mean average response time. A28 = A27 / A9

A29 - 90th centile response time C1T Across all C1T incidents in A9 in the period, the 90th centile response time.Calculated when Call Category = C1 and Time first unit on scene is not Null and Time Destination is not null then calculate the 90th percentile ARP Response Time for all incidents across the specified period.

A30 - Total response time C2 The total response time aggregated across all incidents in A10 in the period.Calculated when Call Category = C2 and Time first unit on scene is not Null then Sum the ARP Response Time for all incidents across the specified period.


A32 - 90th centile response time C2 Across all incidents in A10 in the period, the 90th centile response time.Calculated when Call Category = C2 and Time first unit on scene is not Null then calculate the 90th percentile ARP Response Timefor all incidents across the specified period.

A33 - Total response time C3 The total response time aggregated across all incidents in A11 in the period.Calculated when Call Category = C3 and Time first unit on scene is not Null then Sum the ARP Response Time for all incidents across the specified period.


A35 - 90th centile response time C3 Across all incidents in A11 in the period, the 90th centile response time.Calculated when Call Category = C3 and Time first unit on scene is not Null then calculate the 90th percentile ARP Response Timefor all incidents across the specified period.

A36 - Total response time C4 The total response time aggregated across all incidents in A12 in the period.Calculated when Call Category = C4T and Time first unit on scene is not Null then Sum the ARP Response Time for all incidentsacross the specified period.


A38 - 90th centile response time C4 Across all incidents in A12 in the period, the 90th centile response time.Calculated when Call Category = C4T and Time first unit on scene is not Null then calculate the 90th percentile ARP Response Time for all incidents across the specified period.

A62 - Total response time: HCP 1 hour response The total response time aggregated across all incidents in A58 in the period.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is 60 minutes or less to provide a 1 hour response. Then Sum the ARP Response Time for all incidents across the specified period.

A63 - Mean response time: HCP 1 hour response Across all incidents in A58 in the period, the mean average response time. A63 = A62 / A58

A64 - 90th centile response time: HCP 1 hour response Across all incidents in A58 in the period, the 90th centile response time.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is 60 minutes or less to provide a 1 hour response. Calculate the 90th percentile ARP Response Time for all incidents across the specified period.


Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is between 61 and 120 minutes or less to provide a 2 hour response. Then Sum the ARP Response Time for all incidents across the specified period.



Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is between 61 and 120 minutes or less to provide a 2 hour response. Calculate the 90th percentile ARP Response Time for all incidents across the specified period.













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6: RESOURCE ALLOCATION AND ARRIVAL

A39 - Resources allocated to C1 For all incidents in A8, total count of resources allocated.

Excluded Vehicle Types: 'CSD','ECAT','DEF','CFR','RAF','CDF','FIR','FIRE', 'TEST','COR','POL'

Count when CAD ID = C1 Call Category and Time assigned is not null / A8

A40 - Resources arriving to C1 For all incidents in A8, total count of resources that arrived on scene.

Count when CAD ID = C1 Call Category and Time at scene is not null. / A8

A41 - Resources allocated to C1T For all incidents in A9, total count of resources allocated.

Count when CAD ID = C1 Call Category and Time assigned is not null and Time at Destination is not null / A9

A42 - Resources arriving to C1T For all incidents in A9, total count of resources that arrived on scene.

Count when CAD ID = C1 Call Category and Time at scene is not null and Time at Destination is not null / A9

A43 - Resources allocated C2 For all incidents in A10, total count of resources allocated.



Count when CAD ID = C2 Call Category and Time at scene is not null / A10









A53 - Incidents with transport to ED (see and convey)

Count of incidents with any patients transported to an Emergency Department (ED), including incidents where the department transported to is not specified. Include incidents with non-emergency conveyance to ED.

ED includes stroke and Primary Percutaneous Coronary Intervention units.

Count of CAD ID where Time Destination is not null and Hospital Ward Name = 'A&E'.

A54 - Incidents with transport not to ED (see and convey)

Count of incidents with any patients transported to any facility other than an Emergency Department

INCLUDES - MIU, EAU, MAU, SAU, WIC AND transport from hospital to hospice.

Count of CAD ID where Time Destination is not null and Hospital Ward Name not equal to 'A&E'.

A55 -Incidents with no transport (see and treat)

Count of incidents with face-to-face response, but no patients transported.

INCLUDES - patients who refused treatment, deceased or where patient could not be found. Ambulance Service staff arranged an appointment for the patient, or a follow-up home visit or ambulance service staff attended an incident and gave advice.

Count of CAD ID where Time first unit on scene is not null and Time Destination is null.

A56 - Incidents with face to face responsecount of all incidents with a face to face response. Includes all inclusions for A53, A54 and A55.

A56 = A53 + A54 + A55


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Data Dictionary Clinical Quality Indicators

AMBULANCE CLINICAL QUALITY INDICATORS

Measure Term - Definition Data Source

CARDIAC ARREST -ROSC (OVERALL): % of all patients who had resuscitation (Advanced or Basic Life Support), commenced/ continued by EEAST following an out-of-hospital cardiac arrest who had return of spontaneous circulation (ROSC) on arrival at hospital. AuditOnline

CARDIAC ARREST -ROSC (UTSTEIN): % of patients who had resuscitation (Advanced or Basic Life Support) commenced / continued by EEAST following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was Bystander witnessed and the initial rhythm was Ventricular Fibrilliation (VF), or Pulseless Ventricular Tachycardia (VT). AuditOnline

CARDIAC ARREST - Survival to Discharge (OVERALL): % of all patients who had resuscitation (Advanced or Basic Life Support) commenced/continued by EEAST following an out-of-hospital cardiac arrest who were discharged / transferred alive from hospital alive. AuditOnline

CARDIAC ARREST - Survival to Discharge (UTSTEIN):% of patients who had resuscitation (Advanced or Basic Life Support) commenced / continued by EEAST following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was Bystander witnessed and the initial rhythm was Ventricular Fibrillation (VF), or Pulseless Ventricular Tachycardia (VT), who were discharged or transferred alive. Excluding patients for whom survival is not known. AuditOnline

POST ROSC Care Bundle % of patients who had resusciation (Advanced or Basic Life Support) commenced / continued by EEAST following an out-of-hospital cardiac arrest with a ROSC at Scene who received an appropriate care bundle. AuditOnline

STEMI - Care Bundle: % of all patients suffering a ST elevation myocardial infarction (STEMI) who received an appropriate care bundle (aspirin, GTN and analgesia administered and two pain scores recorded). AuditOnline

STEMI Timeliness % of all STEMI patients who received primary percutaneous coronary intervention (PPCI) following direct admission to a PPCI centre. The Mean Average & 90th centile time from call for help until catheter insertion for angiography AuditOnline

STROKE - Care Bundle: % of all of patients with suspected new onset of stroke or transient ischaemic attack (TIA) who received an appropriate care bundle (FAST assessment, blood pressure and blood glucose measurement). AuditOnline

STROKE Timeliness % of all NEW Onset, Face Arm Speech Test (FAST) positive stroke symptom patients potentially eligible for stroke thrombolysis (within local guidelines) who arrived at a Hyperactive Unit.The Mean, Median and 90th centile Clock Start to hospital arrival. AuditOnline

SEPSIS Care Bundle % of all adult patients with a pre-hospital impression of suspected sepsis with a National Early Warning Score (NEWS2) of 7 or above who received the appropriate care bundle - First set of observations (GCS or AVPU, BP, Blood Pressure, Blood, Oxygen Saturation level and Respiratory Rate), Oxygen Administered, Administration of IV Fluids, and Hospital Pre-Alert recorded. AuditOnline


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Data DictionaryGRS

Measure Term - DefinitionRostered Shifts Funded and agreed shifts (approved by staffside and finance) - what we should be puttuing out

Planned Shifts May be funded for X but due to operational demand may put out for Y where Y is higher, lower or at a different time than rostered

Filled Shifts Actual Worked Shifts - terminology after the fact

Abstractions Absence Data - Lost hours due to Sickness or other factors

Alternate Working Dutied For whatever reason - staff not on normal duty - working different hours or different work type - represents lost hours for A&E

Secondments When working outside of their normal role - e.g. DLO doing an acting SLM role - Differing core duties

Short Term Sick Sickness under 28 Days

Long Term Sick Sickness of 28 days or more

Core Training Training staff must undertake to continue role - e.g PARA training

Non Core Training Optional Training e.g. Firearms Training

Annual Leave Statutory or Contractual Leave including TOIL

TOIL Time Off In Lui

Leave Other Special Leave - Maternity and Paternity - Other

Incidental Overtime Over-run in hours at end of shift as opposed to Planned OT

Planned Overtime Planned and agreed overtime

Rota Cycle 12 Week (for example) Rota Plan - Time taken for staff to complete planned Rota Period

GRS Global Rostering System

SEL Software Enterprise Limited (company responsible for GRS)

GRS Web Online Access For all staff

GRS Main Client Restricted access to the system

Skill Mix Balance of Paramedics to other staff types to allow for planned vehicle use


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Data Dictionary ECAT & Hear & Treat

Measure Term - Definition Data SourceData - Definition / Caveat / Calculation

ECAT Calls C1-C4 calls with a LowCode ID ECAT ReportH&T Incidents C1-C4 incident responses + H&T. Duplicate, hoax, cancelled by caller & information only calls are excluded ECAT Report

H&TECAT call closed with valid locus of care disposition and no physical response at scene. (includes valid non algorithm HCP H&T by CCORD and CH H&T). Duplicate, hoax, cancelled by caller & information only calls are excluded. ECAT Report Defined in AQI guidance.

CQUIN H&T

Same as H&T but excludes HCP and 111 calls. Based on pre-ARP AQI guidance. Duplicate, hoax, cancelled by caller & information only calls are excluded

ECAT Report

Based on old AQI definition. Agreed to keep supplying to commissioners as part of CQUIN.

ECAT Saved

Same as H&T but excludes HCP calls. Duplicate, hoax, cancelled by caller & information only calls are excluded

ECAT Report

Part of CQUIN agreement, was originally created in opposition to old AQI definition to show what the figure would be with 111 included. No longer relevant outside of CQUIN.

ECAT H&T Same as H&T but excludes CH and CCORD H&T. Duplicate, hoax, cancelled by caller & information only calls are excluded

ECAT Report

Requested by Ops so they could get an idea of how much of the activity was done specifically by ECAT.

CCORD H&T Total non algorithm HCP H&T by CCORD (either within H&T ECAT or H&T AQI as appropriate). ECAT ReportCall Handler H&T Total calls closed as "Call Handler Hear and Treat" within CH H&T code set. ECAT Report

Call Handler No SendNumber of calls (outside of CH H&T code set) that are implemented via the NO SEND surge process (not counted in any ECAT save activity).

ECAT Report


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Data Dictionary Compliance

Measure Term - Definition Data SourceData - Definition / Caveat / Calculation

Driving Licence Checks

All staff need to have a driving licence check once in a 365 day rolling cycle. The report includes administrators and PTS office colleagues. he driving licence procedure applies to all eligible employees of the Trust. It also applies to bank workers, volunteers or those who are authorised to drive a vehicle belonging to or on behalf of the Trust (including leased and hired). All should comply with driving licence checks including employees who use their private vehicle on Trust business claiming mileage expenses.

GRS - Personnel -Driving Licence -Licence Reports -Licence Checks

All staff with a driving licence check completed <365 days ago are counted as compliant

PU Completion All eligible staff to complete a PU within an 18 month cycle (current cycle ends 30.09.2019) OD Compassionate Conversations 100% compliance in a 12 month cycle (FY 2018-19 cycle ended 31.03.2019) OD

Workbooks 100% compliance in a 12 month cycle (FY 2018-19 cycle ended 31.03.2019) OD DBS Checks TBC TBCPaediatric Harnesses 100% compliance for all eligible staff by 28/11/2018 - OVERDUE OD FFP3 Mask Fitting Operational staff to have an FFP3 mask fitted once in a two year rolling cycle Local Records

DATIX Assigned to an investigator within 5 days, Duty of Candour within 10 days (if applicable), investigation completed within 35 days, finally approved within 5 days of investigation completion DATIX

Report covers awaiting review, being reviewed, awaiting final approval, finally approved and rejected. Also reports on overdue DATIX current week and previous week.

Planning compliance All relief planning for A&E rosters to be completed 12 weeks ahead on a rolling cycle GRSAnnual leave 75% of annual leave allowance to be booked by month 7 of individual leave year GRS

EPCR 85% EPCR usage in all areas by September 2018 - OVERDUE MedusaNumber of EPCR's Created per SLM area/Number of Responses per SLM area (Excluding PAS)

HSDA All blue light drivers to have a high speed driving assessment once in a 5 year rolling cycleDriver

Training/Local records

A new report is being set up by driver training to better capture data for new starters/staff referred following collisions

IG Training 100% compliance by 31.03.2019 - OVERDUE OD Safeguarding Training 100% compliance by 31.03.2019 - OVERDUE OD


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MEETING TITLE

TRUST BOARD – PUBLIC SESSION

Date: 08.01.2020

Report Title: Finance Report Month 8 – November 2019

Agenda Item: 12

Author: Heather Madden, Head of Finance

Lead Director: Kevin Smith, Director of Finance and Commissioning



SUMMARY AND BACKGROUND: The report is to brief the Board on two items: 1. the Financial Position for the Trust as the end of Month 8, November 2019 2. The forecast position for the end of the financial year 2019-2020. FINANCIAL POSITION The accounts for the end of November 2019 show the Trust reporting a deficit of £(0.8)m to the original financial plan having reported a deficit to plan for the month of October of £(1.0)m. This gives an actual position YTD of a deficit of £(1.3)m which gives a cumulative deficit to the original financial plan for the Trust of £(1.5)m, as the plan was set to achieve a surplus at this time of the financial year of £0.2m. The principal items contributing to the deficit are detailed in the report below. FORECAST FOR THE YEAR END 2019/2020 The Trust forecasts a deficit of £(7.7)m for 2019-2020. This is a deterioration of £(6.7)m from the original plan.

Further detail is given in the body of this report.

RECOMMENDED ACTION: To note the position at M8.

KEY ISSUES IDENTIFIED Forecast deficit for the Financial Year 2019/2020


PREVIOUSLY CONSIDERED BY: ELB

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] SR4, SR1


X


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THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care

Value our people

Value for money

Improve performance

OTHER: To ensure effective governance and compliance

LINK TO CQC: Caring

Responsive

Effective

Well Led

Safe

RELEVANT LEGAL OR STATUTORY ISSUES Statutory Duty to Break Even

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Month 8 Headlines of the Financial Position

1. The Trust set the plan for 2019-2020 to deliver a deficit financial position of £(1.0)m. This included £2.2m of PSF (provider sustainability funding), therefore an underlying deficit of £(3.2)m.

2. Achievement of PSF is predicated in the achievement of the Trust’s financial plan across the

financial year. PSF is paid across to the Trust on a quarterly basis and for Quarters 1 and 2 the Trust has achieved its financial targets and has therefore received £0.8m of PSF. However, risks to the achievement of the financial plan emerged earlier in the year giving significant risk to the ability of the Trust to achieve the amounts due for Q3 and Q4. The Trust now forecasts non-achievement of the £1.4m scheduled during Quarters 3 and 4.

3. For Month 8 the Trust reports a deficit of £(1.2)m. This gives an actual position YTD of a deficit of £(1.3)m. This is against the plan for the Trust to achieve a surplus at this time of the financial year of £0.2m so gives the Trust a £(1.5)m adverse variance to plan.

4. The principle items of cost included in the position at Month 8 which were not included in the original financial plan and therefore contribute towards the Trust’s deficit include the following:-

a) £(1.6)m towards the potential liability for the Flowers case concerning holiday pay for

overtime worked.

b) £(1.9)m deficit to plan for PTS Services, mainly the Bedfordshire and Hertfordshire area contract. This contract has further deteriorated in its financial performance during Month 8 with a deficit of £(0.4)m when the deficit had been forecast at £(0.2)m. This additional cost has been for PAS, agency staff and on taxis and is a disappointing position following a more stable position for October.

c) £(1.9)m risk to income from the 4 CCGs who are not signed up to the block contractual

arrangements. d) £(0.7)m expenditure with consultants for the Trusts Recovery plan. e) November saw a shortfall to the planned CIP achievement for the Organisation with

achievement of £0.4m compared to the £1.0m planned amount.

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The summary position for the Trust by directorate is shown below

Detail to the position shown above include - The position for Service Delivery of a deficit to plan of £(3.2) includes the income risk and the PTS position mentioned above plus the additional pay to front line emergency operations staff in overtime, bank and agency to cover vacancies, abstractions and the incentive payments YTD. - The position for Operations Support of a deficit to plan of £(0.6)m includes £(0.4)m additional expenditure in Estates maintenance due to the work taking place to update and refurbish Trust Estate and £(0.2) on fleet issues due to the delays with the fleet replacement programme together with additional vehicles being retained to boost the fleet at this time to assist with the rollout of BBR (Building Better Rotas). - There is a deficit to plan of £(0.2)m is due to expenditure on agreed external interim support. -A new line has been inserted to the report for the expenditure on the agreed support to the Recovery strategy and the £(0.7)m expenditure so far is for consultancy support to the Trust for this matter. - The position for the People and Culture Directorate of a deficit to plan of £(0.1)m is due to costs incurred for specialist support fees together, with agency staff to support delivery in the short term period. - The deficit position show under Depreciation and Provisions of £(1.5)m includes the provision mentioned above for the Flowers legal case. -The year to date underspend for AOCs of £0.8m reflects the recruitment challenges in this area. -The favourable variance for strategy and sustainability of £0.2m is due to vacancies, mainly in the IT and Information Department.

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-The favourable variance for Special Operations of £0.7m is due to vacancies with their associated costs. -The favourable variance on Finance of £0.2m is due to one off non-pay measures. -the favourable CQUIN variance of £0.6m is due to the achievement of income for the CQUIN measures with lower than planned costs -The reserves position of £(1.5)m deficit to plan includes the following:-

a) YTD contingency release of £0.9m (the 0.5% the Trust is obliged to plan and which is released into the position on a monthly basis), b) The release of the reserves held for the additional planned training and PAS expenditure - £2.0m at this stage of the year. c) The PSF due of £1.2m at this stage. £0.8m is achieved for Q1&2, which then give a deficit to plan of £(0.4)m.

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The split between income, pay and non-pay is shown below for information

Summary by Responsibility

Annual

Function Budget Budget Actual Variance Budget Actual Variance

Income

Service Delivery (282,814) (23,556) (23,259) 297 (188,668) (186,393) 2,275

AOCs (1,046) (87) (93) (6) (697) (752) (55)

Strategy & Sustainability 0 0 0 0 0 0 0

Operational Support (2,246) (221) (130) 91 (1,364) (785) 579

Special Operations (10,520) (874) (889) (15) (7,024) (7,153) (130)

Chief Executive 0 0 (16) (16) 0 (52) (52)

Recovery Strategy 0 0 0 0 0 0 0

Clinical Quality (4) (0) (0) 0 (3) (3) 0

Medical Directorate (92) (8) (9) (1) (61) (70) (9)

People & Culture (2,549) (268) (338) (70) (1,522) (2,360) (838)

Finance (736) (60) (61) (1) (497) (483) 14

CQUIN (3,087) (257) (257) (0) (2,058) (1,455) 602

Trust CIP 0 0 0 0 0 0 0

Reserves (2,248) (225) 0 225 (1,236) (787) 449

Depreciation & Provisions (180) (15) (26) (11) (120) (98) 22

Income Total (305,522) (25,571) (25,078) 493 (203,250) (200,392) 2,858

Pay

Service Delivery 161,820 13,632 13,878 245 106,842 106,861 18

AOCs 24,684 2,070 2,027 (43) 16,405 15,603 (801)

Strategy & Sustainability 2,543 211 178 (33) 1,597 1,488 (108)

Operational Support 6,563 609 493 (115) 4,111 3,467 (645)

Special Operations 8,018 684 686 2 5,281 5,198 (83)

Chief Executive 2,475 207 264 57 1,550 1,722 172


Clinical Quality 2,573 186 205 19 1,734 1,778 44

Medical Directorate 844 82 66 (16) 515 473 (42)

People & Culture 6,510 571 648 77 4,359 4,807 448

Finance 2,338 197 211 14 1,503 1,563 61

CQUIN (0) (0) 19 19 (0) 23 24

Trust CIP 0 0 0 0 0 0 0

Reserves 2,773 300 0 (300) 1,648 0 (1,648)

Depreciation & Provisions 0 0 224 224 0 1,651 1,651

Pay Total 221,139 18,750 18,900 150 145,546 144,635 (911)

Non Pay

Service Delivery 20,120 1,638 1,882 244 13,431 14,368 937

AOCs 580 48 92 44 385 451 65

Strategy & Sustainability 5,685 453 381 (72) 3,858 3,755 (102)

Operational Support 34,338 2,983 3,100 116 22,902 23,609 707

Special Operations 2,652 197 118 (79) 1,863 1,331 (532)

Chief Executive 909 35 35 1 771 826 56


Clinical Quality 631 53 46 (7) 417 438 21

Medical Directorate 1,301 104 126 23 860 908 47

People & Culture 4,476 365 369 4 3,084 3,590 506

Finance 1,214 87 79 (7) 774 512 (263)

CQUIN 1,837 153 9 (144) 1,225 25 (1,200)

Trust CIP 0 0 0 0 0 0 0

Reserves 1,648 292 0 (292) 1,322 0 (1,322)

Depreciation & Provisions 9,944 829 880 51 6,630 6,489 (140)

Non Pay Total 85,335 7,236 7,373 136 57,521 57,038 (482)

Grand Total 952 416 1,195 779 (183) 1,281 1,465

EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST - BUDGET STATEMENT

Period 8 - November 2019

Current Month Year to Date

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Key Performance Indicators to 30th November 2019 (Month 8 FY18/19)

Plan Actual Variance

1 Turnover £m 304.4 305.5 203.2 200.3 (2.9) 301.6

2a EBITDA £m 6.5 6.5 5.2 3.5 (1.7) (0.1)

2b EBITDA % 2.1% 2.1% 2.5% 1.8% (0.7%) (0.0%)

3a Surplus / (Deficit) £m (1.0) (1.0) 0.2 (1.3) (1.5) (7.7)

3b Surplus / (Deficit) % (0.3%) (0.3%) 0.1% (0.6%) (0.7%) (2.5%)

4 CIP £m 10.5 10.5 5.8 4.8 (1.0) 7.3

5a Pay £m 219.9 221.1 145.5 144.6 0.9 223.2

5b WTE 5,542 5,542 5,542 4,915 (627) 5,035

5c Non-Pay £m 77.8 77.7 52.5 52.1 0.4 78.4

6 Capital budget £m Delivery of capital plan 6.1 7.9 3.3 4.4 1.1 7.9

7a Cash balance £m 7.9 7.9 9.8 10.6 0.8 8.9

7b Debtors >90 days £m 0.2 0.2 0.2 0.8 0.6 0.2

7b BPPC % Non-NHS 95.0% 95.0% 95.0% 94.4% (0.6%) 0.0%

8 Rate of return % Asset utilisation 3.5% 3.5% 3.5% 3.5% 0.0% 3.5%

9 Finance & use of resources Risk rating 2

Delivery of revenue plan

Management of working capital

KEY PERFORMANCE INDICATORS

KPI Relevance of indicatorOpening

plan

Year to date position YTD RAG

Rating

F/cast

Outturn

Current

Plan

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*The Trust’s forecast at month 6 highlighted a forecast outturn deficit of £7.7m, which remains the current forecast. Please see agenda item 13 for further detail.

Executive Summary - Key Financial Metrics

Plan Actual Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000

Surplus / (Deficit) (416) (1,195) (779) 183 (1,281) (1,465)

Suppliers paid within 30 days - NHS 95% 97% 2% 95% 91% (4%)

Suppliers paid within 30 days - Non NHS 95% 90% (5%) 95% 94% (1%)

2

Supplier Days (No. Invoices paid)

Finance and use of resources risk rating

Month 8 - November 2019Description

Year to Date

(1,500,000)

(1,000,000)

(500,000)

0

500,000

1,000,000

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Operating Surplus

2019-20 Actual 2019-20 Plan

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Cash Balance

2019-20 Actual 2019-20 Plan

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Statement of Comprehensive Income

Plan Actual Variance Plan Actual Variance

Original

Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Income

24,857 24,606 (251) Revenue from patient care activities 199,207 196,653 (2,554) 297,289 296,152 (2,406)

704 456 (248) Other Operating revenue 3,963 3,675 (288) 6,987 5,384 (1,461)

25,561 25,062 (499) 203,170 200,328 (2,842) 304,276 301,536 (3,867)

Operating Expense

(18,750) (18,899) (149) Pay (145,546) (144,635) 911 (219,914) (223,244) (2,122)

(6,602) (6,700) (98) Non Pay (52,466) (52,145) 320 (77,826) (78,427) (683)

(25,352) (25,599) (247) (198,012) (196,780) 1,231 (297,740) (301,671) (2,805)

209 (537) (746) 5,158 3,548 (1,611) 6,536 (135) (6,672)

0.8% (2.1%) 149.5% EBITDA margin 2.5% 1.8% 56.7% 2.1% (0.0%) 172.5%

Depreciation & Financial

(510) (549) (39) Depreciation (4,077) (3,915) 162 (6,115) (6,169) (54)

(122) (122) 0 PDC Dividend (973) (973) 0 (1,460) (1,460) 0

10 16 6 Financing Income 79 64 (15) 119 119 0

(3) (3) 0 Financing Costs (21) (21) 0 (32) (32) 0

0 0 0 Other Gains & (Losses) 17 16 (1) 0 0 0

(625) (658) (33) (4,975) (4,829) 146 (7,488) (7,542) (54)

(416) (1,195) (779) 183 (1,281) (1,465) (952) (7,677) (6,726)Net Surplus/(Deficit)

Month 8 - November 2019

Description

Year End Forecast

Subtotal

Subtotal

EBITDA

Subtotal

Year to Date

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Divisional Expenditure

Plan Actual Variance Plan Actual Variance Current Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Service Delivery

15,271 15,760 (489) Emergency Operations 120,275 121,228 (955) 181,941 184,787 (2,846)

2,117 2,119 (2) AOCs 16,790 16,054 737 25,264 25,102 162

881 804 77 Special Operations 7,143 6,529 614 10,669 10,261 408

18,269 18,683 (414) 144,208 143,811 396 217,874 220,150 (2,276)

Support Services

242 299 (57) Chief Executive 2,321 2,548 (227) 3,384 3,721 (337)

284 290 (6) Finance Directorate 2,277 2,075 202 3,552 3,276 277

3,592 3,593 (1) Operational Support Services 27,012 27,076 (64) 40,900 41,993 (1,093)

665 559 106 Strategy & Sustainability 5,454 5,243 211 8,228 8,122 106

936 1,017 (81) People and Culture 7,443 8,398 (955) 10,986 12,845 (1,859)

239 251 (12) Clinical Quality 2,152 2,216 (64) 3,203 3,407 (204)

829 1,104 (275) Depreciation & Provisions 6,630 8,140 (1,510) 9,944 12,612 (2,668)

153 29 124 CQUIN 1,224 48 1,176 1,836 449 1,387

186 193 (7) Medical Directorate 1,375 1,381 (6) 2,145 2,192 (47)

0 255 (255) Recovery Strategy 0 737 (737) 0 1,024 (1,024)

592 0 592 Trust Reserves 2,970 0 2,970 4,422 (460) 4,882

7,718 7,590 128 58,858 57,862 996 88,600 89,181 (581)

25,987 26,273 (286) 203,066 201,673 1,392 306,474 309,332 (2,858)

25,571 25,078 (493) Income Memorandum 203,249 200,392 (2,857) 305,522 301,655 (3,867)

(416) (1,195) (779) 183 (1,281) (1,465) (952) (7,677) (6,725)


Net Position Memorandum

Full Year

Subtotal

Support Services (inc. Reserves)

TOTAL

Year to Date

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Statement of Position

Mar-19 Sep-19 Oct-19 Nov-19

Actual Actual Actual Actual Plan Variance %

£000 £000 £000 £000 £000 £000

Non Current Assets

Property, Plant & Equip, & Intangibles 56,170 57,320 57,023 56,634 57,066 (432) (0.76%)

Investment Property 980 980 980 980 980 0 0.00%

57,150 58,300 58,003 57,614 58,046 (432) (0.74%)

Current Assets

Inventories 1,371 1,396 1,475 1,516 1,000 516 51.60%

Trade & Other Receivables 17,052 18,769 19,125 18,722 16,950 1,772 10.45%

Cash & Cash Equivalents 16,587 10,747 10,641 10,620 9,821 799 8.14%

35,010 30,912 31,241 30,858 27,771 3,087 11.12%

92,160 89,212 89,244 88,472 85,817 2,655 3.09%

Current Liabilities

Trade & Other Payables (33,832) (28,989) (29,739) (29,938) (29,140) (798) 2.74%

Provisions (3,971) (2,819) (2,819) (2,819) (2,100) (719) 34.24%

(37,803) (31,808) (32,558) (32,757) (31,240) (1,517) 4.86%

54,357 57,404 56,686 55,715 54,577 1,138 2.09%

Non Current Liabilities

Provisions (5,486) (7,661) (7,899) (8,123) (5,614) (2,285) 40.70%

(5,486) (7,661) (7,899) (8,123) (5,614) (2,285) 40.70%

48,871 49,743 48,787 47,592 48,963 (1,371) (2.80%)

Financed by Taxpayers Equity

Public Dividend Capital 71,461 71,461 71,461 71,461 71,331 130 0.18%

Retained Earnings (25,102) (24,230) (25,184) (26,379) (24,881) (1,498) 6.02%

Revaluation Reserve 3,925 3,925 3,923 3,923 3,926 (3) (0.08%)

Other Reserves (1,413) (1,413) (1,413) (1,413) (1,413) 0 0.00%

48,871 49,743 48,787 47,592 48,963 (1,371) (2.80%)

Nov-19

Total Non Current Assets

Total Assets Employed

Total Taxpayers Equity

Total Current Assets

Total Assets

Net Current Liabilities

Non Current Assets plus/less current

assets/Liabilities

Total Non Current Liabilities

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Cashflow Statement

YTD Move YTD Plan Variance

Sep-19 Oct-19 Nov-19 Nov-19 Nov-19 Nov-19

Actual Actual Actual

£000 £000 £000 £000 £000 £000

9,834 10,747 10,641 16,587 9,947 6,640

Operating Surplus 1,027 (834) (1,087) (368) 1,101 (1,469)

(Increase)/decrease in current assets (896) (437) 360 (1,953) 3,557 (5,510)

Increase/(decrease) in current liabilities 1,302 560 106 793 (1,630) 2,423

Increase/(decrease) in provisions 133 239 224 1,485 0 1,485

1,566 (472) (397) (43) 3,028 (3,071)

Returns on investments and servicing

finance 0 (4) 16 62 79 (17)

Depreciation & amortisation 477 475 549 3,915 4,077 (162)

Capital Expenditure (538) (105) (189) (9,327) (6,580) (2,747)

Impairments & revaluation for surplus 0 0 0 0 0 0

Proceeds from disposal of plant,

property and equipment 0 0 0 18 0 18

Dividend paid (592) 0 0 (592) (730) 138

PDC received 0 0 0 0 0 0

(653) 366 376 (5,924) (3,154) (2,770)

Movement 913 (106) (21) (5,967) (126) (5,841)

10,747 10,641 10,620 10,620 9,821 799Closing Cash Balance

In Month Movement

Opening Balance

Cash inflow/outflow from operating

activities

Cash inflow/outflow from financing

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CAPITAL

Items primarily with statement of financial position focus:

Capital Expenditure and Disposals

Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Business as usual Capital Expenditure

316 62 (254) IT Projects and Intangibles 1,283 949 (334) 2,542 2,799 (257)

252 62 (190) Make Ready Projects 1,855 3,208 1,353 2,421 3,699 (1,278)

100 10 (90) Other Building Projects 202 137 (65) 752 620 132

0 0 0 Plant & Equipment Projects 0 0 0 0 0 0

0 0 0 Transport Projects 0 68 68 400 143 257

Additionally funded Capital

0 0 0 ePCR - STP funded 0 0 0 25 25 0

0 25 25 Winter capital centrally funding 0 36 36 0 610 (610)

668 159 (509) 3,340 4,398 1,022 6,140 7,896 (1,756)

Net book value of disposals

0 0 0 Medical devices - defibril lators 0 (20) (20) 0 (20) 20

0 0 0 Atlantic Square (Investment Property) 0 0 0 0 (980) 980

0 0 0 Sudbury 0 0 0 0 (170) 170

0 0 0 0 (20) (20) 0 (1,170) 1,170

Business as usual: CRL 6,115 = Planned Depreciation for the year

Additional CRL disposals 1,170 = Identified disposal sites

Suffolk STP - ePCR funding 25 = Anticipated additional funding

Additional Winter funding 610 = Notified Winter Capital Funding

Planned total CRL: 7,920

Spend 7,896

Under/ (over) spend on CRL 24

Items primarily with statement of financial performance focus:

Depreciation and Amortisation and Gains/Losses on Disposal

Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

132 161 (29) IT 1,061 884 177 1,600 1,600 0

109 109 0 Land & Buildings 872 886 (14) 1,308 1,308 0

2 2 0 Fixtures & Fittings 16 17 (1) 21 21 0

204 205 (1) Plant & Equipment 1,632 1,628 4 2,442 2,442 0

52 52 0 Transport 416 420 (4) 624 624 0

10 10 0 Amortisation of Licenses 80 80 0 120 120 0

509 539 (30) 4,077 3,915 162 6,115 6,115 0

Asset Disposals

0 0 0 Disposals: loss /(gain) 0 (15) 15 0 (15) 15

0 0 0 0 (15) 15 0 (15) 15

Plan and Forecast Variance: Actual depreciation is currently slightly lower than plan due to the timing of the bringing into use of assets from 2018/19. This is expected to

balance out over the year. Minor gains have been achieved on the sale of defibrillators to date.

Year End Forecast

Capital Expenditure


Year to Date

Total

Current month and YTD transactions: Capital expenditure is currently £1m ahead of plan. Development has continued on the Make Ready depots and workshops across

the 10 identified sites which commenced last year. IT expenditure has been on software licenses and the telephone voice recording system, IT spend is currently behind plan

but is expected to ramp up across Q4 which will include significant individual projects like a new telephony system.

£0.61m of Additional Winter funding has been awarded to the Trust to be spent on Estates Transformation work in support of Building Better Rotas and Make Ready.

In furtherance of the estates transformational work commenced in 2018/19, the year to date expenditure on Make Ready reflects the completion of works on 10 depots and

workshops. Two disposal sites have been identified as part of the midyear development of the capital plan instigated by requests from NHSI to review capital spend, such that

utilisation of disposal proceeds on the sale of these properties (Atlantic Square and Sudbury) enable the Trust capital plan to continue at pace.


Year to Date Year End Forecast

STP: The development of ePCR specifications and business cases is expected to be part funded by STP contributions. STP Funding and capital expenditure for the

successful STP bid to transform the estates of the Trust to a make ready service are currently not included in the 2019/20 plan due to administrative and approval requirements

of NHSI and DoHSC.

Total

Capital Disposals

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Divisional WTE

Plan Contract Paid

WTE WTE WTE

Service Delivery

Emergency Operations incl. PTS 4,117 3,656 4,098

AOCs 631 607 695

Special Operations 153 141 153

4,901 4,404 4,946

Support Services

Chief Executive 54 51 50

Finance 60 52 52

Operational Support Services 222 167 183

Strategy & Sustainability 80 44 45

Workforce & OD 141 122 122

Patient Safety 67 59 58

Medical Director 17 14 15

CQUIN 0 2 2

641 511 527

5,542 4,915 5,473TOTAL

Description

Month 8 - November 2019

Subtotal

Support Services

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Trust Cost Improvement Programme The Trust target for the year is £10.5m At the end of Month 8 the Trust has achieved £4.8m savings. Achievement has fallen behind the Trust plan at this point of the year.

2019-20 CIP Schemes - Progress Tracker - Month 8

Scheme

ReferenceCIP Scheme

Responsible

Manager(s)

Recurrent

/ Non-

recurrent

Pay /

Non Pay

NHSI Plan

M8 £000s

Actual

Achieved

M8 £000s

Actual vs.

NHSI Plan

M8 £000s

NHSI Plan

YTD

£000s

Actual

Achieved

YTD

£000s

Actual vs.

NHSI Plan

YTD

£000s

Full Year

NHSI Plan

£000s

Corporate and Operations Support Vacancy Slippage

CP1 Vacancy Sl ippage Al l NR P 90.0 78.3 -11.7 1,425.0 1,237.0 -188.0 1,500.0

Corporate and Operations Support Vacancy Slippage Subtotal 90.0 78.3 -11.7 1,425.0 1,237.0 -188.0 1,500.0

Emergency Operations

EO1 Reduction in Arriva l to Clear Sector Heads R P 105.0 0.0 -105.0 580.0 0.0 -580.0 1,000.0

EO2 Out of Service Reduction Sector Heads R P 60.0 89.3 29.3 360.0 836.8 476.8 600.0

EO3 On Scene Time Reduction Sector Heads R P 100.0 0.0 -100.0 300.0 0.0 -300.0 900.0

EO4Abstraction Reduction (Sickness ,

AWD & 3rd Person)Sector Heads R P 110.0 0.0 -110.0 520.0 0.0 -520.0 1,000.0

EO5Operational Impact of Make Ready

ImplementationR Ashford R P 183.0 0.0 -183.0 664.5 0.0 -664.5 1,500.0

EO6 PAS Uti l i sation & Efficiency Sector Heads NR NP 35.0 51.8 16.8 160.0 466.4 306.4 300.0

EO7 Late finishes / Intel l igent X-ray Sector Heads R P 12.5 0.0 -12.5 75.0 159.0 84.0 125.0

EO8Implementation of Bui lding Better

RotasR Ashford R P 0.0 0.0 0.0 0.0 0.0 0.0 375.0

EO9Suffolk and North Essex Sector -

Loca l SchemesD Al len R NP 0.0 0.0 0.0 0.0 40.1 40.1 0.0

EO10 Beds & Luton - Loca l Schemes S King R NP 0.0 0.0 0.0 0.0 20.9 20.9 0.0

EO11Herts & West Essex - Loca l

SchemesS King R NP 0.0 0.0 0.0 0.0 8.5 8.5 0.0

EO12Cambridge and Peterborough -

Loca l SchemesP Marshal l R NP 0.0 0.0 0.0 0.0 39.8 39.8 0.0

EO13Norfolk and Waveney - Loca l

SchemesT Hicks R NP 0.0 9.5 9.5 0.0 78.3 78.3 0.0

EO14 Mid & South Essex - Loca l Schemes A Whitehead R NP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Emergency Operations Subtotal 605.5 150.6 -454.9 2,659.5 1,649.8 -1,009.7 5,800.0

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2019-20 CIP Schemes - Progress Tracker - Month 8 - Page 2

Scheme

ReferenceCIP Scheme

Responsible

Manager(s)

Recurrent

/ Non-

recurrent

Pay /

Non Pay

NHSI Plan

M8 £000s

Actual

Achieved

M8 £000s

Actual vs.

NHSI Plan

M8 £000s

NHSI Plan

YTD

£000s

Actual

Achieved

YTD

£000s

Actual vs.

NHSI Plan

YTD

£000s

Full Year

NHSI Plan

£000s

AOC

AO1 Staff Streaml ine G Morgan R P 8.0 8.0 -0.0 64.3 64.2 -0.1 96.4

AO2 EOC Vacancy Sl ippage G Morgan NR P 0.0 0.0 0.0 153.6 275.6 122.0 153.6

AOC Subtotal 8.0 8.0 -0.0 217.9 339.8 121.9 250.0

Special Operations

SO1 EPRR Staff Appointment Sl ippage J Moore NR P 0.7 0.7 0.0 172.4 172.5 0.1 175.0

SO3Specia l Operations Vacancy

Sl ippageJ Moore NR P 0.0 0.0 0.0 72.0 132.0 60.0 72.0

Special Operations Subtotal 0.7 0.7 0.0 244.4 304.5 60.1 247.0

Operations Support

OS1 Medica l Device Product Savings P Henry R NP 5.4 5.0 -0.4 35.2 64.0 28.8 56.7

OS2 Fleet - RRV Replacements P Henry R NP 15.7 27.0 11.3 204.0 216.3 12.3 266.7

OS3 Fleet - DSA Replacements P Henry R NP 28.5 29.0 0.5 122.6 122.2 -0.4 254.6

OS4 Fleet - Maintenance Tenders P Henry R NP 3.5 3.5 0.0 25.0 26.0 1.0 39.0

OS5 Fuel Card P Henry R NP 1.7 2.0 0.3 11.2 14.0 2.8 18.0

OS6 Bus iness Travel Pol icy P Henry R NP 13.0 0.0 -13.0 26.0 0.0 -26.0 78.0

Operations Support Sub-Total 67.8 66.5 -1.3 424.1 442.5 18.4 713.0

Estates

E1Maintenance Contract

ManagementC Radestock R NP 30.0 30.0 0.0 130.0 130.0 0.0 250.0

E2Waste & Energy

Management/ReductionC Radestock R NP 14.0 14.0 0.0 34.0 34.0 0.0 90.0

E4 Rate Reduction C Radestock R NP 0.0 0.0 0.0 50.0 0.0 -50.0 50.0

Estates Subtotal 44.0 44.0 0.0 214.0 164.0 -50.0 390.0

Clinical Directorate

CL1 Medica l GasesA Godfrey / C

Radestock R NP 13.4 0.0 -13.4 96.4 34.0 -62.4 150.0

Clinical Directorate Subtotal 13.4 0.0 -13.4 96.4 34.0 -62.4 150.0

Procurement and Finance

PF1 Contract Renewals and Suppl ies S Dubery R NP 120.0 50.1 -69.9 400.0 391.3 -8.7 1,150.0

Procurement and Finance Subtotal 120.0 50.1 -69.9 400.0 391.3 -8.7 1,150.0

Information Technology

IMT1 BT Meridian Leas ing Charges C Chambers R NP 0.0 2.3 2.3 0.0 6.9 6.9 0.0

IMT2 NHS Digi ta l Network Charges C Chambers R NP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

IMT3 Papercut C Chambers R NP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Information Technology Subtotal 0.0 2.3 2.3 0.0 6.9 6.9 0.0

People and Culture

PC1 Tra ining Efficiencies M Stead R NP 30.0 0.0 -30.0 150.0 156.8 6.8 300.0

PC? HR Process Recruitment H Adams R P 0.0 12.5 12.5 0.0 27.8 27.8 0.0

People and Culture Subtotal 30.0 12.5 -17.5 150.0 184.6 34.6 300.0

Grand Total 979.4 413.0 -566.4 5,831.3 4,754.4 -1,076.9 10,500.0

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Trust Forecast The original financial plan set by the Trust was to finish the financial year 2019-2020 with a deficit of £(1.0)m. This included £2.2m of PSF (provider sustainability funding), therefore an underlying deficit of £(3.2)m. However, during the second quarter of 2019-2020 a range of risks to the forecast financial position began to emerge. Detail of those risks include the items listed below. Potential winter activity levels Temporary resource requirements Front line workforce incentive payments The workforce recruitment recovery plan PTS issues, predominately the Beds & Herts contract but also with other contracts Potential worsening of Hospital Delays Potential Patient Safety issues due to the length of waits Temporary resource availability levels – less PAS in the marketplace/less overtime availability from the EEAST workforce Levels of abstraction – especially due to the number of student courses scheduled CIP progress Revenue consequences of the Capital expenditure allocated for make ready The legal case concerning holiday overtime pay Expenditure levels concerning repairs and updates to the Trust Estate Loss of PSF income for Q3 and/or Q4 Expenditure on external resources to support the development of the recovery plan These items, together with the Trust’s response were reviewed as part of the Financial baseline review conducted in August 2019 by PWC, as discussed with the Board. The Trust has therefore calculated the potential financial impact of the risks currently known and now forecasts a deficit of £(7.7)m to be the most likely out-turn. This forecast has been calculated by the Trust’s Finance team in conjunction with support provided by PWC as advisors. Detailed discussions have taken place with NHSI/E concerning the risks that exist to the Trust meeting its planned financial outcome for the year 2019-2020. The Regulators have been provided with the full detail of the risks and calculations made by EEAST and are fully aware of the £(7.7)m deficit prediction. No official forecast amendment has currently been submitted to NHSI at M8 as the window for a forecast change is only available at the end of a quarter. M9, December 2019, will be that end of quarter and therefore Trust Board approval will be sought to officially submit this change to the Trust forecast. The detail for the forecast across Income and expenditure and also across the Directorates is shown in the tables at Pages 9 and 10 of this report – The Statement of Comprehensive Income and the Detailed Expenditure Tables The main expected additional costs over the remaining Months 9-12 of this financial year are shown in the table below:

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FORECAST TABLE - MAJOR ITEMS

M8 Financial Position

Detail Plan Actual Variance

M8 Position -0.2 1.3 1.5

Winter Incentives 1.1 1.1

A&E Income Risk M9-12 1.0 1.0

PTS M9-12 (note B&H re-negotiated income M10-12) 0.2 0.2

Flowers Impact M9-12 0.9 0.9

CIP Shortfall 3.2 3.2

M12 Final Position 1.0 7.7 6.7

Please note - this table shows ONLY the main items contributing to the forecast deficit.

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MEETING TITLE

TRUST BOARD (PUBLIC SESSION)

Date: 08.01.2020 Report Title: PROPOSED REVISION TO 2019-20 FINANCIAL OUT-TURN

FORECAST Agenda Item: 13 Author: Kevin Smith - Director of Finance & Commissioning Lead Director: Kevin Smith - Director of Finance & Commissioning Purpose: Assurance Decision X

Discussion Information SUMMARY AND BACKGROUND: The Trust agreed a Financial Plan for 2019-20 of a deficit of £(1.0)m (net of Provider Sustainability Funding (PSF) of £2.2m). Despite achieving this plan for Quarters 1 and 2 of the financial year, it was clear that a number of financial risks existed that were likely to crystallize in the final half of the year leading to the Trust being unlikely to meet its full year out-turn target. These risks predominately relate to the costs of securing patient facing staff hours over the winter period at levels to ensure patient safety. PWC were engaged to assist the Trust in reviewing its financial baseline which supported the view that there were considerable risks to achievement of the financial plan. This review led to the development of a Recovery Plan (again in conjunction with PWC) that indicated a revised forecast out-turn for 2019-20 of a deficit of £(7.7)m. At the end of Month 8, November 2019, the Trust shows an adverse variance to its financial plan of £(1.5)m which is line with the revised forecast out-turn trajectory. Together with the further adverse variance that is expected to arise in January following continued actions in relation to securing frontline capacity, it is now clear that the Trust will not achieve its original financial plan for 2019-20 and therefore a revision to the forecast out-turn must be agreed. The Trust is required to comply with NHSE&I’s Protocol when considering a change to Plan and the revised forecast must be submitted with Month 9 results. RECOMMENDED ACTION: The Trust submit a revised forecast out-turn of a deficit of £(7.7)m for 2019-20.

KEY ISSUES IDENTIFIED As noted in the Trust’s Recovery Plan previously reviewed at Board and P&F Committee.

DECISION OR RESOURCE REQUIRED: The Board are requested to approve the submission of the revised forecast out-turn of a deficit of £(7.7)m.

PREVIOUSLY CONSIDERED BY: ELB & P&F Committee

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] SR4


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SR4: Failure to deliver an efficient, effective and economic service X Other: Requirement to comply meet financial Control Total for 2019-20. X

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X Value our people X Value for money X Improve performance X

OTHER: To ensure effective governance and compliance X

LINK TO CQC: Caring Responsive Effective Well Led Safe

RELEVANT LEGAL OR STATUTORY ISSUES Requirement to comply with NHSE&I’s “Protocol for Changes to an In-Year Financial Forecast”



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PROPOSED REVISION TO 2019-20 FINANCIAL OUT-TURN FORECAST

INTRODUCTION The Trust agreed a Financial Plan for 2019-20 of a deficit of £(1.0)m (net of Provider Sustainability Funding (PSF) of £2.2m). In agreeing its Plan, the Board recognised there were a number of risks and challenges to achievement, notably the requirement for a £10.5m cost improvement programme and also the costs of securing patient facing staff hours over the winter period at levels to ensure patient safety. At its meeting on 10th June 2019, the Trust Board considered a paper detailing the risks to the financial forecast and the Trust achieving its financial plan for 2019-20. Following the discussions on this paper, the Board concluded that it would be beneficial for further work to be undertaken to more fully understand the risks and the drivers of these. The Regulator also raised concerns on the level of risk being indicated and asked for further clarification of the Trusts baseline position. Therefore, the Executive commissioned an external review by PricewaterhouseCoopers (PWC) to provide an independent view of its financial challenges and particularly of the underlying monthly deficit run rate. This Financial Baseline Review supported the view that there were considerable risks to achievement of the financial plan and therefore the Board agreed a Recovery Plan was necessary. The Board commissioned further work from PWC to assist with developing this Plan. The Board received the initial draft of the Recovery Plan at its September 2019 meeting, with a further iteration presented to the November Board meeting in which a revised forecast out-turn for 2019-20 of a deficit of £(7.7)m was discussed with the Board. The Board agreed to support this forecast position with a challenge to further improve this position if possible. MONTH 8 FINANCIAL POSITION At the end of Month 8, November 2019, the Trust shows an adverse variance to its financial plan of £(1.5)m which is line with the revised forecast out-turn trajectory. Together with the further adverse variance that is expected to arise in the final 4 months of the year following continued actions in relation to securing frontline capacity, it is clear that the Trust will not achieve its original Financial Plan for 2019-20 and therefore a revision to the forecast out-turn must be formally agreed with the Regulator. The Board have been clear that patient safety must be the priority at all times and recognise that this may therefore affect the financial position and recognises that the daily intense focus on performance, safety and finance may require decisive action at times to ensure that safety.



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RECOMMENDATION Therefore, it is recommended that the Board agree the submission to NHSE&I of the revised forecast out-turn of a deficit of £(7.7)m. This would then be submitted to NHSE&I as part of the Trust’s Q3 financial return. PROCESS TO SUBMIT A REVISED FORECAST Where the Board agree to submit a revised forecast, it is important that we adhere to the NHSE&I Protocol, a copy of which is attached to this paper for reference. In order to address the points raised in the Assurance Template, the Board are requested to review and agree the statements below: For finance:

• The board has been fully briefed on the planned adverse change to forecast and has adhered to the NHSE/I protocol for adverse changes to the in-year forecasts prior to requesting the change.

• Confirmed – the Board and its Performance and Finance Committee (P&FC) have discussed

the revision to the Forecast at a number of meetings concluding with agreement to this revision at a Board meeting on 13th November 2019.

• All reporting revisions are accompanied with detailed actions and the commissioner /provider

will continue to explore all options to recover the position and achieve delivery of the original financial plan.

• Confirmed – the Board have agreed that the Trust will seek to improve on the revised forecast

out-turn, noting however that patient safety must always be the priority .

• The board/governing body is fully committed to the delivery of the recovery plan and will actively monitor the recovery plan milestones.

• Confirmed – the Board has agreed actions to deliver the revised forecast outturn and this will

be actively monitored through the Trust’s Performance & Finance Committee.

• In advance of formally reporting a forecast outturn variance from plan the commissioner/provider has discussed the financial deterioration and remedial actions with the NHSE/I regional director and regional director of finance.

• Confirmed – discussions have been held with NHSE&I colleagues on the financial position

and the likely revised forecast. This was also discussed at a meeting on 4th November 2019 including NHSE&I’s Regional Director of Finance with EEAST’s Chief Executive and Director of Finance. The meeting was also attended by the Chief Executive of the Trust’s Lead Commissioner.



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For governance:

• The senior clinical decision making body within the commissioner/provider has been engaged with and are party to the identification and delivery of the recovery actions.

• Confirmed – The Trust’s Medical Director and Director of Clinical Quality and Improvement

have been fully engaged in Executive Team & Board discussions on the actions agreed. In addition, the risk and patient experience team continue to review any increases in serious incidents, complaints, tail breaches and staff concerns. These would be escalated to the Executive Leadership Board and actions taken to mitigate risks that are subsequently identified.

• The executive committee, finance committee and board have considered and agree the

proposed financial forecast revision and recovery actions.

• Confirmed – the Trust has followed its agreed governance processes; the Trust Board has agreed the proposed revised forecast following recommendation from the Executive Team and a detailed review of the financial information by the Performance & Finance Committee.

• System review requirements, confirmation that the position has been discussed and agreed at a sustainability and transformation partnerships (STP) level and that all options for mitigation including systems wide solutions have been explored.

• Confirmed – The Lead Commissioner has been informed of the Trust’s financial forecast. CCGs have indicated that no further funding is available to support the position.



1

Protocol for Changes to an In-Year Financial Forecast 1. Introduction

1.1 NHS providers and commissioners submitted financial plans for

2019/20. These plans were quality impact assessed and signed off by individual boards / governing bodies prior to submission.

1.2 The achievement of financial balance, whilst maintaining the quality of

healthcare provision, is a key objective for all organisations. The future success of the NHS depends on clinical commissioning groups (CCGs), direct commissioners (DCs) which includes specialised commissioning, and providers delivering or over achieving the plans that they have signed up to and boards / governing bodies must take organisational and personal accountability for meeting their financial and performance commitments.

1.3 In exceptional circumstances it may be necessary for an NHS

commissioner or provider board / governing body to reconsider its planned forecast outturn position. In this event, the primary focus must be the identification and delivery of a recovery plan that demonstrates the mitigating actions being implemented that ensure any proposed adverse revision to forecast outturn is minimised, managed and fully recovered at the earliest possible time.

1.4 To demonstrate the highest standards of governance and for purposes

of consistency and transparency, the protocol set out below should be followed by all commissioner and provider boards / governing bodies considering the reporting of a deterioration in the forecast outturn against their planned position for the year. Similar processes will be operated to control directly commissioned services.

1.5 The introduction of this protocol by NHS England and Improvement

(NHSE/I) should not be taken by boards / governing bodies as permission to deteriorate financial positions. All reporting revisions must be accompanied by the actions required to return to planned positions.

1.6 The protocol is required to be followed for all deteriorations in positions,

it does not apply to improvements in positions but these should still be communicated and discussed with regional teams in advance of any changes being formally recorded.



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2. Protocol

2.1 Revisions to forecast outturns can only be made once a commissioner or provider’s plan for the year has been agreed and only at the quarterly reporting points in the year and must be made through the standard quarterly reporting process. Where, in exceptional circumstances, a movement is required on a non-quarter-end month, this should only be undertaken with the express agreement of the NHSE/I regional director of finance. Other important considerations are:

• NHSE/I would not expect to see any changes in the first quarter

given that this follows closely after the planning process. • Changes in the final quarter will be looked on as a sign of very poor

financial control likely to attract further scrutiny. Where such movements are identified and changes required in months 10 and 11, the protocol process must be initiated as soon as the deviation becomes known.

• The protocol should be used to record all adverse movements from plan regardless of whether an organisation is still within its control total.

• If the protocol process has been invoked for an adverse change in position, any subsequent changes from the revised forecast outturn position will require the process to start again. This would be particularly relevant for an organisation that changes its forecast early in the year and then finds that it has worsened later in the year. A further deterioration will be viewed as very poor forecasting and lack of financial control.

2.2 In advance of formally reporting a forecast outturn variance from

plan, commissioners / providers are required to have discussed the financial deterioration with the respective NHSE/I executive regional director and regional director of finance.

2.3 This engagement must be underpinned with a provider / commissioner

prepared detailed report that clearly includes details of:

• The key financial drivers for the deterioration; • An analysis of the underlying causes;

• The actions being taken to address the deterioration and evidenced

confirmation that:

• Relevant partner organisations have been informed of the position and all opportunities for support have been explored and the recovery actions agreed;

• The senior clinical decision making body within the

commissioner / provider has been engaged with and are



3

party to the identification and delivery of the recovery actions;

• Commissioner / provider executive committee, finance

committee and board / governing bodies have considered and agree the proposed financial forecast revision and recovery actions.

2.4 This recovery plan described must explicitly reference:

• Details of the additional measures immediately implemented to improve financial control and where applicable working capital/cash management, including capital programme review. This will include all discretionary spend, agency / locum spend, supplies and consumable spend.

• Details of how the commissioner / provider is reviewing:

• The affordability of planned investments to improve service

quality and performance;

• The acceleration of the delivery of productivity opportunities identified by the Carter review and other efficiency programmes;

• The acceleration or extension of quality innovation

productivity and prevention (QIPP) schemes and areas such as Rightcare.

• The acceleration of proposals for sub-scale service

consolidation or closure;

• The impact on patient safety and experience of recovery actions;

• The demonstration of quarter on quarter improvement in income

and expenditure run-rate from the point the revision is submitted and how QIPP, or cost improvement programmes (CIP) delivery is being maximised.

2.5 System review requirements, system level sign off is required to confirm that

the position has been discussed and agreed at a sustainability and transformation partnership (STP) level and that all options for mitigation including systems wide solutions have been explored. This should involve the following stages:

• Commissioners / providers must demonstrate that discussions have

taken place with partner organisations to resolve any material issues that could affect the partners’ abilities to meet their control



4

totals. There should be an audit trail that shows the partners agreement on the nature and cause of a problem (defined as a deviation from plans) and that the options for mitigation across the system have been properly considered.

• STP partner organisations must have the opportunity to be able to provide peer commentary on the position reached within the organisation. This will ensure there is a system wide understanding of the circumstances leading to a change in planning assumptions.

• Within an integrated care system ICS there may be the added

impact that an organisation that cannot meet its control totals, could impact on the provider sustainability fund (PSF) and commissioner support fund (CSF) of all partners. In these circumstances the ICS will need to decide whether there are any system-wide solutions that could be triggered to provide mitigation for the affected organisation’s financial pressures. This should be brokered and approved by the ICS board.

2.6 When a formal revision to forecast outturn under this protocol is made through

the national reporting process, it must be accompanied by a board assurance statement (BAS) signed by the commissioner / provider chair, accountable officer / chief executive, chief financial officer / director of finance, and audit committee chair in respect of the organisation’s adherence to this protocol and their

commitment to the delivery of the recovery plan. Additionally, for commissioners or providers that are part of an integrated care service, STP sign of is required. This statement will be addressed to the chair and chief executive of NHSI/E and will be formally reported to that organisation’s board.

2.7 The regional team will notify organisations how they wish the BAS to be

submitted. Organisations are required to liaise with regional teams early in the process and well in advance of any monthly or quarterly reporting deadlines. Monitoring arrangements will be determined by the executive regional director to ensure that focus and delivery is maintained.

NHS England and NHS Improvement



Organisation Name

The board are required to respond "confirmed" or "not confirmed" to the following statements (notes below)Board

Response

For finance:

For governance:

Board Declaration

Signed on behalf of the board of directors

Signature Signature

Name Name

Capacity Chief Executive Capacity Chair

Date Date

Signature Signature

Name Name

Capacity Finance Director Capacity Audit Committee Chair

Date Date

Additional sign off for Commissioners / Providers who a part of an integrated care service (ICS)

Signature Signature

Name Name

Capacity STP Board Member Capacity STP Finance lead

Date Date

The senior clinical decision making body within the commissioner / provider has been engaged with and are party to the identification and delivery of the recovery actions

The executive committee, finance committee and board have considered and agree the proposed financial forecast revision and recovery actions

I can confirm that in my capacity as a member of the board, I understand the financial forecast, its key drivers and where there has been a

variance signalled, I can confirm that we will continue to explore all options to recover the position and deliver the original plan that was signed

off by this board and that these actions have been and will be considered in full by clinical decision making groups, the finance committee, and

the board as a minimum.

Adverse Changes to an In-Year Financial Forecast Protocol - Board Assurance Statement

Where a commissioner / provider plans to make an adverse change to an in-year forecast it must be reported through the

national reporting process and accompanied with this board assurance statement which has been signed by the chair, chief

executive, director of finance and the audit committee chair

The board has been fully briefed on the planned adverse change to forecast and has adhered to the NHSE/I protocol for adverse changes to the in-year forecasts prior to requesting the change

All reporting revisions are accompanied with detailed actions and the commissioner /provider will continue to explore all options to recover the position and achieve delivery of the original financial plan.

The board / governing body is fully committed to the delivery of the recovery plan and will actively monitor the recovery plan milestones

In advance of formally reporting a forecast outturn variance from plan the commissioner / provider has discussed the financial deterioration and remedial actions with the NHSE/I regional director and regional director of finance

System review requirements, confirmation that the position has been discussed and agreed at a sustainability and transformation partnerships (STP) level and that all options for mitigation including systems wide solutions have been explored



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MEETING TITLE


Date: 08.01.2020

Report Title: CQC action plan

Agenda Item: 14

Author: Gill Hooper, Interim Director of Clinical Quality and Improvement

Lead Director: Gill Hooper, Interim Director of Clinical Quality and Improvement

Purpose: Assurance x Decision

Discussion x Information x


This paper seeks to provide an update the trust board on the progress in developing a CQC action plan in response to the CQC inspection report published in July 2019. .

RECOMMENDED ACTION:

The board is invited to:

Support the approach and timescales outlined to develop, agree and evaluate the delivery of an explicit CQC action plan.

Approve the publication of a summarised version of the CQC action plan being made available on the trust’s web site.

Endorse the detail of the RAG ratings proposed to evaluate delivery of both actions and outcomes.

Endorse the 4 levels of assurance proposed to be used to summarise monthly evaluations of delivery and progress.

Acknowledge the expectation to receive a CQC action plan approved by the CEO in February 2020, accompanied by an evaluation of delivery as undertaken by the DCQ&I.


The workload and priorities of the CQ&I team have been reviewed to provide focus and capacity to ensure all concerns identified by the CQC are clearly identified, with associated action plans, leadership and oversight arrangements.


See recommendations detailed above.


N/A




X


X

CQC Action Plan Update


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X





Value our people X

Value for money X


OTHER:


LINK TO CQC:

Caring X

Responsive X

Effective X

Well Led X

Safe X




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Summary of Progress – CQC action plan This paper is in response to the board’s request for an update on progress on specific matters relating to quality improvement, namely the development of an impactful action plan to address issues of concern identified by the CQC. Reference to progress reported in November 2019: The last public report to the trust board provided in November 2019 presented an initial draft of an improvement plan seeking to address concerns raised by the CQC. This plan was noted as distinctly separate from an additional plan being developed to address concerns reported on as related to leadership. This plan identified 8 areas for improvement, these being:

1. Achieving a 5% increase in performance 2. Mandatory Training compliance 85% 3. Embedding Medicine Management Systems 4. Governance and Risk Systems 5. Appraisal and Supervision 6. Recruitment and Retention 7. Communication and Engagement 8. Healthcare Legislation

Progress achieved during December 2019:

During December the interim DCQ&I has personally reviewed all aspects of the existing

improvement plan/s, finding there to be a significant number of wide range of aspirational intentions

for improving services, with the need to urgently quantify and strengthen the requirements identified

by the regulator for immediate improvement. The specific section of the IIP focused upon meeting

regulatory standards as summarised above, was found to have some but not all of the reported

requirements placed upon the trust. With the support of both local commissioners and NHSE/I, the

interim DCQ&I has urgently progressed the further development of this plan as a ‘CQC Action Plan’

to address all issues reported on by the regulator in addition to measuring both the delivery of

actions and outcomes.

To develop a comprehensive CQC action plan at pace, the workload and priorities of the wider Q&I

team has required to be reviewed and the Clinical Head of Quality Improvement has needed to

relinquish wider operational and clinical responsibilities to create capacity to ensure explicit action

plans can be agreed for each regulatory recommendation.

The draft CQC action plan currently identifies 13 specific priority areas for improvement. 8 of these

identified in bold represent specific ‘MUST DO’ CQC recommendations, with the remaining 5

representing specific ‘SHOULD DO’ CQC recommendations. These being :

1. Mandatory Training compliance 90%

2. Safeguarding training compliance 90%

3. All aspects of medicine management

4. Response times to E&UC

5. Response times to PTS



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6. Embedding governance and risk processes

7. Appraisal and supervision

8. Recruitment and retention in PTS

9. Recruitment and retention in E&UC

10. Labelling of sharps boxes

11. Reduction in handover delays

12. Timely investigation and resolution of complaints

13. Transformation programme for PTS

In addition to the 13 specific issues identified above the trust board are reminded that the CQC

report also recognised a number of other areas for potential improvement, that could possibly be

described in terms that the trust ‘could do’. These areas are of equal importance to the trust to both

quantify and address in the aim of continually improving services and sustaining these

improvements. It is intended to continue to focus on these areas once this initial version of the CQC

action plan has received the support of the CEO and been shared with stakeholders.

Timescales for finalising and circulating the CQC action plan:

During December the priority areas for improvement have been discussed with delivery and

executive leads, with the aim of developing explicit ‘SMART’ action plans to support consistent

evaluation of progress being made. It is intended that the ELB as a whole consider the action plan in

its entirety on the 2nd January with a view to refining aspects, prior to a further scheduled opportunity

for the ELB to present this finalised plan to the CEO for formal approval.

In parallel this plan is intended to be considered at a meeting of the Clinical Quality and Safety

Group and shared with NHSE/I and commissioners for comment. A meeting to discuss the trusts

approach to addressing the regulatory concerns has also been scheduled with the CQC trust

relationship owner and inspection manager for 28th January 2020.

Commissioners have also indicated their preference for the trust to publish an agreed version of the

CQC action plan on the trust’s public web site.

Proposed approach to evaluating and reporting on delivery:

It has been agreed that once this plan is completed and agreed by the CEO, the interim DCQ&I will

take responsibility for specifically assessing the impact of delivery of the action plans for each

priority area within the CQC action plan, confirming a RAG rating for both delivery of the actions and

delivery of the outcome being sought. To reduce risks of ‘familiarisation, priority areas being led by

the DCQ&I will be evaluated by another executive. The detail of this RAG rating representing a

simplification from that presented to the trust board in November, whilst being applied twice for each

priority area to evaluate both actions taken and outcomes achieved.

The trust board are invited to endorse the use of the RAG rating detailed below:



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RAG Key to RAG Rating for outcomes

The outcome sought is being achieved at both the pace and extent

expected.

The outcome sought is delayed or at a lesser extent than that expected.

The outcome sought is not yet evident (as expected).

Key to RAG Rating for actions

The action will be delivered successfully on time, within budget and to the

level of quality required. There are no major problems or barriers that

threaten delivery.

Successful delivery is feasible, but significant issues and risks exist that

require focussed attention to ensure delivery remains on track and risks do

not materialise.

Successful delivery of the action appears in doubt due to significant risks in

a number of key areas. Urgent action is required to determine if these

issues may be resolved.

Additionally the DCQ&I intends to clarify an overall CQC action plan assurance rating using the

definitions outlined below:

Assurance Description Significant Assurance

The system is well designed and only minor low priority recommendations have been identified in relation to its operation. Weaknesses identified relate to issues of good practice which could improve the efficiency and effectiveness.

Significant Assurance with minor improvement opportunities

The system is generally well designed however minor improvements could be made, indicated by one or more priority two recommendations or a number of priority three recommendations. Weaknesses require improvement but are not vital to the achievement of strategic priorities,

Partial Assurance with improvements required

Both the design of the system and its effective operation need to be addressed by the executive. Indicated by one or more priority one, or a number of priority two recommendations that suggest a weak control environment, presenting a significant risk to the achievement of strategic priorities.

No assurance Means the system has not been designed or is operating effectively, with significant attention needed to address the controls. Might be indicated by one or more priority one recommendations preventing achievement of strategic priorities.

The DCQ&I will provide clear recommendations within each formal update to optimise delivery of

intended outcomes. These recommendations will be priority rated as outlined below:

The board is asked to endorse the proposals for RAG rating progress on delivery of actions and

outcomes; the use of 4 levels of assurance in summarising progress and the intended prioritisation

of any accompanying recommendations that may be made.

High priority (one):

A significant weakness in the system

or process which is putting the Trust

at serious risk of not achieving its

strategic priorities e.g adverse impact

on reputation or non-compliance with

key statutory requirements. Any

recommendations in this category

would require immediate attention.

Medium priority (two):

A potentially significant or medium

level weakness in the system or

process which could put the Trust at

risk of not achieving its strategic

priorities. In particular, having the

potential for adverse impact on the

Trust’s reputation or for raising the

likelihood of the Trust’s strategic risks

occurring, if not addressed.

Low priority (three):

Recommendations which could

improve the efficiency and/or

effectiveness of the system or

process but which are not vital to

achieving the Trust’s strategic aims

and objectives. These are generally

issues of good practice that we

consider would achieve better

outcomes.



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In anticipating formal CEO approval of the CQC action plan in early January, it is intended that

monthly formal evaluations of progress will be presented to the trust board from February 2020 in

addition to being circulated to commissioners, NHSE/I and the CQC .

Gillian Hooper – Interim DCQ&I – 30th December 2020.



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MEETING TITLE


Date: 08.01.2020

Report Title: Director of Clinical Quality and Improvement Briefing Report

Agenda Item: 15

Author: Gill Hooper, Interim Director of Clinical Quality and Improvement

Lead Director: Gill Hooper, Interim Director of Clinical Quality and Improvement

Purpose: Assurance x Decision x

Discussion x Information x

SUMMARY AND BACKGROUND: This paper seeks to provide an update on a wide range of issues pertaining to the portfolio held by the Director of Clinical Quality & Improvement. This including, Serious Incidents and Incident reporting, Infection Prevention and Control activities, Complaints, Clinical Audit, Compliance Software, Safeguarding issues, evaluation of the Quality Improvement strategy, Draft Ambulance Safe Staffing Resource, production of the Annual Quality Account and approach to proactively engaging with CQC inspectors . Appendix A provides a summary of complaint activity. Appendix B provides a summary of the December contract quality report for commissioners.

RECOMMENDED ACTION: The board is invited to:

Recognise and support the initiation of comprehensive lessons learned approaches being taken to support the revision of policy frameworks for Serious Incidents, Infection Prevention and Control, Complaints and Safeguarding.

Note the steps being taken to increase the capacity of the CQ&I team and the priority to design and provide a range of training for operational managers to support improvements and standardisation of practice going forward.

Note the potential being explored to enhance the functionality of existing compliance software.

Confirm who will be the NED safeguarding lead going forward.

Clarify the board’s nomination for the clinician to be responsible for safe staffing.

Indicate any preferences for the production of the Annual Quality Account



See recommendations detailed above.

PREVIOUSLY CONSIDERED BY: Appendix B has been considered by the CCG Quality Leads at the monthly Performance & Quality Review meeting (PQRM)


SR1, 2, 3 & 4


X


X

DoCQI Briefing Report


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X

SR4: Failure to deliver an efficient, effective and economic service X Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X

Value our people X Value for money X Improve performance X

OTHER: To ensure effective governance and compliance x

LINK TO CQC:

Caring X Responsive X Effective X Well Led X

Safe X




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Summary of Progress – Safety & Quality Improvement This paper is in response to the board’s request for an update on progress on specific matters relating to the portfolio held by the Director of Clinical Quality & Improvement; namely:

Serious Incidents:

Two serious incidents (near misses) were reported by the Trust in November 2019, totalling 38 SIs declared in the financial year to date. This is in comparison with 67 in same period of the previous financial year, potentially representing a 43% decrease in such events and reporting. There have been no contractual never events in the year to date, with currently 12 open serious incidents being investigated by the Trust (as at 1 December 2019). An initial update of the existing SI policy has been undertaken to clarify aspects pertaining to the SI

panel and welfare officers in advance of a year to date lessons learned exercise being commenced.

This review to be informed by commissioners for completion in January to inform a comprehensive

policy framework revision to be undertaken collaboratively with commissioners.

Incident Reporting:

Reporting of incidents via datix appears to be well established across the trust, with the need for the

CQ&I team to focus on proactively analysing of trends to inform actions , learning and improvement

going forward.

In the absence of this routine analysis, the DCQ&I currently receives all incidents reported vis datix,

with the emerging clear themes relating to :

Medicine management, storage, administration and out of date medicines

The lack of readiness of vehicles in respect of available equipment

Inconsistencies of control room instructions and communications

Detailed analysis of datix reports will now be undertaken and shared with operational teams to

inform improvement priorities going forward with staff training opportunities being made available to

both interpret and generate bespoke reports. The first of these will focus on medicine management.

Infection Prevention and Control:

Infection prevention and control reports compliance with the vehicle cleaning schedule increased by 4%, with four STP areas achieving an improvement. Additional make ready staff continue to be recruited which should facilitate better compliance, with significant training to over 50 staff, being provided throughout November and December.

Overall vehicle cleaning compliance - STP area Nov

Cambridgeshire and Peterborough STP 76%

Hertfordshire and West Essex STP 67%

Mid and South Essex STP 86%

Milton Keynes, Bedfordshire and Luton STP 85%

Norfolk and Waveney STP 67%

Suffolk and North Essex STP 72%

Overall Trust 74%

The Trust has a comprehensive monthly station cleanliness audit schedule in place, with the average overall compliance of the audits completed locally being 95%. These local audits are



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supported with a schedule of quality assurance audits carried out by the IPC team and other members of the Clinical Quality Directorate to gain assurance in the local audit process and standards. Uniform including ‘bare below the elbows’ audits have been updated to include the change to complete (no watches) ‘bare below the elbows’ policy introduced in December, with compliance consistently above the Trust target. Station cleanliness compliance has also increased this month achieving the Trust target.

A comprehensive year to date lessons learned exercise has also commenced for all aspects of

IP&C; again with the intention that this be completed in January to inform a policy framework

revision and the priorities of the team going forward.

Complaints:

Of the 76 complaints received in November 2019, 37 (49%) were related to the Emergency Services (EUC) and 39 (51%) complaints related to Patient Transport Services including Commercial Services. It is noted that the reduced number of complaints received during November mirrors the trend experienced last year. There have been five re-opened complaints in November 2019. The main complaint themes for EUC continue to relate to delays in attendance, clinical treatment/assessment and attitude of staff. The highest trend for PTS continues to relate to delays. It is noted that whilst all complaints are acknowledged in 3 working days, the number responded to within 25 days remains less than 20%. With no permanent managerial leadership for this team, an experienced interim Head of Patient Engagement has been appointed to commence part time from on 6th January, increasing to full time from February. In parallel with this, the permanent recruitment to this position has also commenced and an interim deputy to be recruited to cover existing maternity leave. Recognising the need to significantly improve our established response to receiving complaints, the

head of compliance has been asked to initiate a comprehensive year to date lessons learned

exercise, to be completed in January by the new interim manager, enabling a robust policy

framework revision to be undertaken to support the radical improvement required. This improvement

not confined to improving timescales for response, but needing to improve the satisfaction of

complainants and equally importantly ensure that the organisation learns from this feedback and

takes sustainable action to improve services for future patients.

Appendix A provides a summary of complaints received to date. Work is actively underway with the trusts Chief Information Officer(CIO), to review the collection and presentation of data to provide a clearer more consistent evaluation of performance for all parties in responding to concerns and complaints received. Clinical Audit: A slight decrease in the majority of indicator outcomes has determined that the Trust has not met the set threshold for any of the audits undertaken and recorded during October. A clinical poster has been cascaded to raise awareness of care bundles and training available and the IT department have also provided a detailed timescale for the completion of software modifications and alternative options for ensuring full engagement in audit programmes with a final end date of 28 February 2020. Snap shot audits based on previous National Clinical Performance Indicators for Asthma, Hypoglycaemia and Falls in the Elderly have also been planned to be completed by mid-February 2020.



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The CQ&I team as a whole is also scoping out some training proposal focused towards Local Operational and General managers, to seek to raise awareness in a range of aspects of performance with the aim of reducing variation and offering greater support and feedback to standardise clinical practice across all STP areas.

Compliance Software The trust currently uses Allocate (HealthAssure) as a software system to monitor internal compliance with the; Health & Social Care Act (CQC Standards), Hygiene Code of Practice, Data Protection Act 2018, Data Security Protection Toolkit and Equality Delivery System (2). It also provides the Trust with a corporate policy management system and an Information Asset Register. The current contract with Allocate (HealthAssure) is due to expire on 12 March 2019. An alternative provider has been identified that potentially could provide existing functionality in addition to also providing performance monitoring enabling a more intelligent view of the Trust’s position and project management. The CIO is working closely with the head of compliance to develop a formal option appraisal to evaluate the potential of the alternative provider, which theoretically would enable the Trust to link disparate data from any source including; Excel, Access, CSV, SQL, Oracle, Web Services, Agresso, Datix etc to facilitate a single reporting tool to significantly improve performance monitoring as well as providing a potential cost saving of £22,813 for a 3-year contract period.

Safeguarding Update:

The establishment during November of an improved approach to structured case management has further reduced the confirmed number of open safeguarding caseload for both children and adults to 22. The arrangements for active weekly caseload review will now be sustained, allowing for appropriate management action to be taken and supervision to be made available to optimise and standardise practice.

A case by case review of all cases held by the Named Professional for Safeguarding has also been undertaken by the MD, resulting in a number of reclassification of cases to reflect the changing health status of individuals and a prioritisation of workload. Two CCG safeguarding leads from Suffolk CCGs will also be assisting in this work in January due to capacity constraints in the team. The DCQI will now be undertaking regular review of the remaining cases with the Named Professional – Safeguarding, to ensure ongoing explicit evaluation of existing and new cases. It is also the intention for the current Named Professional to act as the Head of Safeguarding from the end of January, with Hertfordshire community Trust agreeing to make available their FTSUG to work for 1 day a week from January in this capacity for EEAST, enabling this to take place.

Again, a comprehensive year to date lessons learned exercise is firmly underway to be completed in January to inform a policy framework revision to be undertaken collaboratively with commissioners. This work will be presented to the Clinical Quality & Safety group to triangulate with other sources of information available prior to presenting to the Quality Committee as assurance of appropriate analysis and action to improve performance and mitigate risks associated with this expert field of work. It is intended that this approach will also clearly inform L1,2 & 3 training and improvement priorities going forward. Regarding staff identified as employed before 2014, who have not been entered on the electronic system (Atlantic), a detailed project plan has been agreed with the People and Culture directorate to



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ensure the manual checking of DBS records commences in January. The Adult Safeguarding Lead at Suffolk & North Essex CCG will receive detailed updates of progress until this task has been completed which is expected March 2020.

The trust board is asked to confirm who the NED safeguarding lead will be going forward. The responsibilities of this individual being to ensure:

appropriate scrutiny of the organisation’s safeguarding performance.

assurance is provided to the board of the organisation’s safeguarding performance.

Investigation into the unexpected deaths of staff:

Progress continues to convene a panel of external experts to contribute to actively participate in a

process of considering the findings from an independent investigation due to commence on 13th

January. The purpose of this being:

1. To ensure all appropriate actions have been taken and will continue to be taken to ensure

the welfare of staff is of the highest priority.

2. To consider best practice regarding staff welfare/suicide prevention/risk management.

3. To ensure that learning is identified and translated into improvements by the organisation to

mitigate the reoccurrence of any similar events and the effect upon colleagues of such

events.

Monthly Commissioner Contract Quality Reports:

The summary for the trust’s December contract quality report which purely relates to emergency

services, is provided in appendix B. A joint commissioner/EEAST task and finish group has been

established to streamline and focus quality reports for 2020.

Quality Improvement Strategy:

Professor Rosalynd Jowett is advising on the process of evaluating the impact of the trust’s QI

strategy on completion of year 1. This will be presented to the trust board in due course alongside a

refresh of this strategy to ensure full alignment with developing education and research strategies.

The trust’s strategic advisor to improvement is significantly assisting with this process.

Draft Ambulance Safe Staffing resource:

The trust has received the draft Ambulance Safe Staffing resource, with a request for comments by

31st January 2020. In common with previous safe staffing resources, this has been written by

clinicians and experts from within the Ambulance service and NHS England & Improvement on

behalf of the National Quality Board (NQB). It is intended that the ELB will begin to consider the

detail of this document on 2nd January 2020.

The scope of this document is intended to cover vehicle-based urgent and emergency care services

and ambulance control and dispatch centres and has been developed to help commissioners and

providers of NHS ambulance services create, review and sustain safe and effective ambulance

services. It is based on the National Quality Board’s (NQB) expectations to ensure safe, effective,

caring, responsive and well-led care on a sustainable basis, and to ensure that organisations

employ the right staff with the right skills in the right place and at the right time.



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Meeting NQB’s expectations will help EEAST comply with CQCs fundamental standards on staffing

and related legislation, by ensuring that the three components of safe staffing are used in their

staffing processes, these being:

Evidence-based tools

Professional judgement

Outcomes The resource requires boards to review workforce reports and nominate a Board-level responsible clinician to hold ultimate accountability for safe staffing. The document makes very clear the requirement of Ambulance Trusts Boards to assure themselves that their staffing is safe, sustainable and productive. This assurance arising from an annual review of organisation-level metrics which monitor the impact of staffing levels on the quality of patient care and outcomes, the use of resources and on staff. The board is invited to consider which executive clinician will be nominated to be accountable for safe staffing.

Production of Annual Quality Account:

Previously EEAST has produced a separate Annual Quality Account and Annual Report.

Preparation for the production of both documents will be required to commence this month.

Alternative options are being explored by the ELB on 9th January, to inform further discussion with

the board and subsequent confirmation regarding preferences for production for 2019 - 2020. The

board is invited to offer any existing preferences it may have at this stage.

Liaison with CQC trust relationship owner:

Contact has been re-established with the trusts CQC inspectors, with the intention for regular

meetings to commence on 28th January. These meetings will provide an opportunity to support

regular regulatory monitoring activity, evidence progress against reported regulatory requirements

and proactively offer evidence of wider improvements in place across the trust.



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Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 YTD

Call Volume (999) 100,250 101,637 100,698 110, 152 100,171 99,651 107,157 609,564

Complaints 62 83 87 108 79 108 117 76 720

Concerns 48 50 65 48 47 52 44 42 396

Compliments 160 222 237 362 341 261 289 313 2,185

PALS (lost property, comments, etc) 27 38 35 51 34 35 38 26 284

Re-Opened Complaints 2 4 5 4 8 5 3 5 36

A&E Complaints 22 31 42 32 23 36 36 21 243

Herts & West Essex STP 3 11 9 3 6 7 6 5 50

MK, Beds & Luton STP 4 2 8 4 2 6 2 5 33

Cambridgeshire & Peterborough STP 2 5 4 8 2 7 9 1 38

Mid & South Essex STP 5 6 6 4 5 5 3 3 37

Suffolk & North Essex STP 4 2 10 8 3 3 7 3 40

Norfolk & Waveney STP 4 5 5 5 5 8 9 4 45

PTS Complaints 17 31 21 35 40 51 53 39 287

Bedfordshire PTS 3 2 2 3 7 6 5 4 32

Hertfordshire PTS 5 14 12 12 12 18 19 18 110

Cambridgeshire PTS 4 9 2 7 15 16 18 12 83

North Essex PTS 4 5 2 6 4 4 5 1 31

South Essex PTS 0 1 1 4 0 4 0 1 11

West Essex PTS 1 0 2 3 2 3 6 3 20

AOC Complaints 22 21 24 41 16 21 28 16 189

Other 1 0 0 0 0 0 0 0 1

A&E Concerns 18 18 21 16 15 20 15 13 136

Herts & West Essex STP 2 3 4 3 2 4 1 2 21

MK, Beds & Luton STP 0 1 3 2 1 2 1 1 11

Cambridgeshire & Peterborough STP 4 1 3 3 1 4 1 1 18

Mid & South Essex STP 5 5 2 4 2 1 8 4 31

Suffolk & North Essex STP 4 3 6 1 3 6 3 2 28

Norfolk & Waveney STP 3 5 3 3 6 3 1 3 27

PTS Concerns 18 15 25 21 17 18 14 20 148

Bedfordshire PTS 1 1 1 2 1 0 1 3 10

Hertfordshire PTS 8 5 10 8 3 9 4 5 52

Cambridgeshire PTS 4 7 4 3 6 5 3 10 42

North Essex PTS 4 2 7 3 4 2 5 1 28

South Essex PTS 1 0 1 4 1 2 1 0 10

West Essex PTS 0 0 2 1 2 0 0 1 6

AOC Concerns 12 17 19 11 14 14 15 9 111

Other 0 0 0 0 1 0 0 0 1

Acknowledged <3 days 62 79 87 107 79 108 117 76 715

% Acknowledged in 3 Working Days 100% 95% 100% 99% 100% 100% 100% 100% 99%

Complaints Closed 57 44 58 99 104 48 91 93 594

Closed in 25 working days 17 20 13 19 39 8 14 18 148

% Closed in 25 working days 29.82% 45.45% 22.41% 19.19% 37.50% 16.67% 15.38% 19.35% 25.72%

Patient Experience Report - November 2019

Ack

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/ C

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Appendix A



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Appendix B

Quality Account Summary - December 2019

Please find below a summary of the circulated quality report for EEAST November 2019, to support interpretation and discussion at the forthcoming performance and quality contract meeting and other fora receiving this information. Serious incidents The Trust has declared 38 serious incidents in the financial year to date with 55% causing harm to patients. This suggests a 45% reduction in SIs reported during the same period of the previous financial year. Performance-related incidents and clinical treatment (head injury management and resuscitation) are the two highest theme of incident leading to an SI.

Reporting of all incidents has risen for the second consecutive month with the harm level for these incidents remaining low. Impact – medium risk to delivery of strategic priorities. Actions initiated:

An initial update of the existing policy has been undertaken to clarify aspects pertaining to

the SI panel and welfare officers.

A comprehensive year to date lessons learned exercise has commence, to be completed in

January to inform a policy framework revision to be undertaken collaboratively with

commissioners. This will inform training and improvement priorities going forward.

Infection Prevention and Control Infection prevention and control reports compliance with the vehicle cleaning schedule increased by 4%, with four STP areas achieving an improvement. Uniform including BBE audits have been updated to include the change to BBE and compliance has remained consistent and above the Trust target. Station cleanliness compliance has increased this month and has achieved the Trust target. Impact – Low Risk to delivery of strategic priorities.

Actions taken:

Make Ready Implementation- 45 of the newly recruited MRO staff have been trained in IPC

awareness with a further session scheduled for 20 December.

Waste management compliance- improved communications, incorporation of specific waste

management questions within management and increased alerting to management teams of

non-compliance issues.

Accountability meetings taken place to address performance issues with specific STP areas.


January to inform a policy framework revision to inform training and improvement priorities

going forward.

Appendix B



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Patient Experience Currently the Trust has 51 overdue complaints, 22 of which are related to Emergency and Urgent Care (EUC) and 29 to Patient Transport Services (PTS). The main reason for delays is the ability of operational managers to meet with and interview staff, in all circumstances the complainant is kept fully appraised of progress. However, in four cases for EUC, the Patient Experience department has not received any response from the investigating officer, this increasing the average closure to 37.17 days (from 32) against the 25-day benchmark. However, there has been a decrease of 35% in total complaints across the organisation within November and specifically 42.2% reduction for those relating to the emergency and urgent care service. Of the 37 received for EUC, the main complaint themes continue to relate to delays in attendance (n=14), clinical treatment/assessment (9) and attitude of staff (10). For PTS, despite a reduction in overall complaints, the highest trend relates to delays with 87% (34/39) accounting for these. A comprehensive action plan is in place and being monitored. Impact – Medium Risk to delivery of strategic priorities. Actions taken /proposed:

Sector heads to be formally requested to ensure immediate responses forthcoming

regarding outstanding investigations. Action – Compliance and Standards Lead

Ongoing weekly management review of the quality of all drafted responses to continue.

Action – Compliance and Standards Lead.

The Trust has updated its public website to provide case studies of where a complaint has

been raised and actions and learning have taken place.

Clinical Audit The trust continues to fail in all but one area to achieve the threshold for undertaking the areas identified within the clinical audit programme. Inability to transfer data from EPCR and CAD to auditing software has required a manual process to be followed which in turn has been constrained by vacancies. Within October 2019, a slight decrease in the majority of indicator outcomes has determined that the Trust has not met the set threshold with the exception of Stroke Diagnostic Bundle which continues to perform above the set threshold of 98%. Despite a slight increase in Survival to Discharge (Overall patients) this also failed to meet the threshold for the fourth consecutive month. Impact – Low Risk to delivery of Strategic Priorities. Actions taken /proposed:

Clinical poster cascaded in October to raise awareness of care bundles and training

available.

10:10 posters designed and to be disseminated to provide clinical awareness of care

bundles and the importance of minimum time being spent on scene

The IT department have now provided a detailed timescale for the completion of software

modifications and alternative options for ensuring full engagement in audit programmes with

a final end date of 28 February 2020. Action – Standards and Compliance Lead



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Snap shot audits based on previous National Clinical Performance Indicators for Asthma,

Hypoglycaemia and Falls in the Elderly have been planned to be completed by mid-February

2020.

Workforce Recruitment of our workforce now averages 44/month, with leavers 22/month. The net increase of staff from April being 167WTE. Online mandatory training compliance currently stands at 75.7% and appraisals at 54.5%. Impact – High Risk to delivery of Strategic Priorities. Actions taken /proposed:

An extensive range of development and support has and will continue to be made available

to staff to support best HR practices regarding inducting, managing sickness and absence,

undertaking compassionate conversations. Interim HR Director appointed to commence in

February. Additional HR expertise from Addenbrookes commencing in January.

Detailed action plan to improve performance agreed with Head of E&T.

Safeguarding Current compliance levels of safeguarding training at L1 and 2 has dropped again but this is expected due to all training postponed over the winter period to enable a focus on service delivery. A formal request to CCGs has been made to provide investigation expertise during January to address the 35 open staff allegations, some of which have been open for 1 year. Active case review of open adult and child cases continues with a total closure of 25 old cases to date (now 60 cases). The risk remains around 303 staff who have no DBS certificate reference against their electronic Staff Number which has been escalated to the Executive and an action plan timeline developed to complete the outstanding checks by March 2020. Impact - Remains High Risk to delivering strategic priorities. Actions Underway:

The Named Professional for Safeguarding & Safeguarding Lead are completing the national

and internal gap analysis and blueprint for creating the delivery of L3 training – Action

Named Professional for Safeguarding.

Safeguarding Team continuing weekly review of open cases.

Detailed action plan now commenced to review DBS status of 303 staff who have an

incomplete ESR DBS , to be completed by end March


January to inform a policy framework revision to be undertaken collaboratively with

commissioners. This will inform training and improvement priorities going forward.

Medicines Management The medicine management project to streamline the central storage and processes for medicine management by the Trust has been delayed, due to delays in receiving the new drugs bags. The



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Home Office have now approved the CD Licence for the Letchworth site to enable central CD storage which has enabled the project to gain pace and it is hoped that this will now be enacted from December 2019-January 2020. With the Licence in place this should enable us to obtain a AAH wholesaler contract. A standard drug bag layout in also now being implemented to promote consistency of practice and a monthly process for the ongoing review of the quality and data of the Controlled Drug and Drug bags Audits is in place. Significant numbers of medicine incidents continue to be reported via Datix, warranting a detailed analysis and review of actions taken to date. Impact – Medium Risk to delivery of strategic priorities. Actions initiated:

A comprehensive analysis of all medicine incidents reported this year to date, findings to be

available in early January.

CQC Regulatory Requirements The Trust’s action plan to meet CQC regulatory requirements continues to be reviewed by the interim Director of Clinical Quality and Improvement. This initial plan has proved challenging to finalise and will be circulated asap. The plan will;

Ensure all requirements are clearly reflected

Strengthen the consistency of judgements regarding delivery of identified actions and impact

upon strategic priorities

Clarify leadership and oversight responsibilities

Ensure measurement of both delivery of actions and outcomes sought

Confirm corporate capacity to support delivery of the plan and translation of learning into

improvements

Gillian Hooper – Interim Director of Clinical Quality & Improvement



1 of 3

MEETING TITLE

PUBLIC BOARD

Date: 08.01.2020

Report Title: Freedom to Speak Up Q2 19/20 Update report

Agenda Item: 16

Author: Simon Chase & Anna Price (FTSUG)

Lead Director: Dr Tom Davis


Discussion Information X


This report provides the Trust Board with an update on FTSU activities for the second quarter 2019-2020. This is in line with the national guardian reporting requirements supplied and published by the National Guardians Office.

For the East of England Ambulance Service, the guardians appointed are Simon Chase (Safeguarding Lead) & Anna Price (Named Professional for Safeguarding). Dr Tom Davis provides Executive support. There is currently a gap with the non-executive’s representation due to recent changes, however Mr Neville Hounsome will be supporting the FTSU role from January 2020 whilst a new NED is identified for the role.

Plans were delivered in October to support the national FTSU awareness month. This involved four clinics across Divisional Offices and HQ. Not only was the FTSU profile raised, the opportunity to discuss with staff the planned advertisement to the opportunity for a full time FTSUG becoming available when the current Guardians step down by April 2020.

The CQC report has been published since the last update. Overall the Trust remains at ‘Requires Improvement’ but the Well Led domain was rated ‘Inadequate’. There was no direct mention or action for FTSU, but the report indicates that staff are mixed about raising concerns due to ongoing negative cultural issues.

The recent NGO index (national scorecard) also indicated that the Trust are not the leading ambulance Trust on raising concerns but are neither the worst. The indexing score has been worked on NHS staff survey results predominately around raising patient safety concerns.

Work is continuing to address the Well-Led rating and Dr Tom Davis has commenced chairing the Raising Concerns Forum going forward and has oversight of the current FTSU action plan - which is monitored through the Trust integrated Improvement Plan cycle for next 12 weeks (cycle 4).

RECOMMENDED ACTION:

To receive the information status update and support the continued recommendations in line with the Trust Integrated improvement Plan concerning FTSU within the Trust.


Update for this quarter Q2 (NGO return):

How many new speaking up cases were raised? - 6

Are there any areas of the service that have features more than others? This quarter we have seen many of the cases reported from A & E operations. There is no one area/location that is standing out amongst the rest.

Any actions taken as a result of investigation into these cases? - No

Any themes arising?

FTSU Q2 Report


of 3

The continuing themes are around staff & how they are being made to feel (bullying/pressured/not communicated or consulted).

Data - Numbers and themes Total of 6 cases in Q2 (cumulative total 69). Themes remain constant with behavioural/relationship & bullying & harassment (NGO defined categories)

Engagement events. LGBT meeting (EEAST) National LGBT Conference BAME meeting (EEAST) BAME National Conference EDI meeting (EEAST) Raising concerns Forum NHS I and NGO Executive Engagement


Not required (information only update)


None







X





Value our people X

Value for money

Improve performance

OTHER:


LINK TO CQC:

Caring

Responsive

Effective

Well Led X

Safe

FTSU Q2 Report


of 3


NHS National Contractual Requirement (to appoint and allow staff to access Freedom to Speak Up)

FTSU Q2 Report


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MEETING TITLE


Date: 08.01.2020

Report Title: Flu Update

Agenda Item: 17

Author: Dave Cunningham

Lead Director: Gillian Hooper

Purpose: Assurance x Decision

Discussion Information X


This more detailed report has been provided in response to the trust board’s request. The report evidenced that 71% of staff have now been vaccinated, with 88% of staff confirming their intentions regarding vaccination. This commendable performance reflects an earlier commencement of a vaccination process and a named approach to targeting staff to offer vaccinations. EEAST has achieved the highest level of vaccinations amongst ambulance trusts and has currently the 10th highest level of vaccination out of 27 trusts in the region. With 88% of staff confirming their intentions regarding vaccinations it is deemed unlikely that this level of vaccination will increase significantly further from this position although efforts will continue throughout January.

RECOMMENDED ACTION:

The feedback provided from staff regarding the rationale for them not receiving the vaccination, highlights a range of misinformation regarding the risks to oneself in receiving the vaccination and the risks to others in not receiving the vaccination. A more explicit campaign to inform staff of the facts and risks to others, associated with not having the vaccination will be planned to be undertaken in 2020, effectively bringing the preparation for undertaking the vaccination programme ahead even earlier than undertaken this year.


See the summary and recommended action.


See recommended action.





x





Flu Update Report


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Value our people x

Value for money x

Improve performance x

OTHER:


LINK TO CQC:

Caring

Responsive X

Effective

Well Led x

Safe X


Flu Update Report


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Flu Vaccination Update – December 2019

This report provided the latest figures as of 24th December 2019, for the 2019/20 seasonal flu campaign.

Eligible Staff has been defined as:

All staff who have direct face to face patient contact

All AOC staff

All Make Ready staff

All Training staff

The targets for this seasons flu campaign are for 80% of eligible staff to be vaccinated and for ALL staff to have their vaccination decision recorded.

Therefore, the figures below show the following:

Percentage of eligible staff vaccinated

Quantity of eligible staff vaccinated

Percentage of all staff who have had their decision recorded

1: NHSEI/ PHE Figures

ImmForm-Eligible staff ONLY

Description Total Count

Quantity Vaccinated

Percentage Vaccinated

Patient Facing (all staff with direct patient contact within Service Delivery)

4667 3299 71%

Support (all staff who meet the eligibility criteria outside of Service Delivery)

198 133 67%

Total (Pt Facing and Support groups combined) 4865 3432 71%

2: Overall Trust

Directorate Eligible

Vaccinated All-Forms

Percentage Quantity Percentage Quantity

Executive Team 75% 3 80% 28

Service Delivery 70% 3299 91% 4335

Operations Support Teams 54% 58 52% 78

Clinical Quality 74% 14 87% 58

People & Culture 79% 15 40% 50

Strategy & Sustainability 100% 1 74% 34

Information Management & Technology

N/A N/A 58% 23

Finance N/A N/A 83% 39

Volunteers 100% 42 100% 42

Trust 70% 3432 88% 4645

Flu Update Report


of 7

3: Service Delivery Business Units

Note: PTS Teams have been incorporated within the business units within some areas when the staff lists

were supplied, which is why some of the PTS teams are not listed separately for some Business Units

Business Units Eligible



3.1: Herts & West Essex 68% 438 92% 609

3.2: Bedfordshire 75% 319 100% 439

3.3: Cambs & Peterborough 74% 421 87% 507

3.4: Norfolk & Waveney 73% 590 96% 768

3.5: Suffolk & North Essex 65% 502 87% 675

3.6: Mid & South Essex 75% 473 100% 639

3.7: AOC 68% 482 80% 573

3.8: Special Operations 53% 74 86% 125

Business Unit Total 70% 3299 91% 4335

3.1: Hertfordshire & West Essex

Herts & West Essex Eligible



East & North Hertfordshire 76% 172 100% 230

Mid Hertfordshire 72% 68 99% 101

South Hertfordshire 84% 72 100% 84

PTS West Herts 87% 27 94% 32

West Essex 51% 85 76% 128

PTS West Essex 35% 14 79% 34

AGM Area 68% 438 92% 609

3.2: Bedfordshire

Bedfordshire Eligible



North Beds 75% 92 100% 127

South Beds 72% 119 100% 169

PTS North Beds 81% 108 100% 142

AGM Area 75% 319 100% 439

Flu Update Report


of 7

3.3: Cambridgeshire & Peterborough

Cambridgeshire & Peterborough

Eligible Vaccinated

All-Forms


North Cambridgeshire 73% 187 84% 221

South Cambridgeshire 83% 148 100% 176

PTS North Cambs 60% 29 72% 36

PTS Mid Cambs 58% 23 61% 25

PTS South Cambs 79% 34 94% 49

AGM Area 74% 421 87% 507

3.4: Norfolk & Waveney

Norfolk & Waveney Eligible



West Norfolk 80% 149 98% 183

East Norfolk 67% 265 92% 358

Waveney 78% 176 100% 227

AGM Area 73% 590 96% 768

3.5: Suffolk & North Essex

Suffolk & North Essex Eligible



East Suffolk 67% 145 85% 186

West Suffolk 55% 121 76% 165

North Essex 70% 183 94% 251

PTS North Essex 71% 53 97% 73

AGM Area 65% 502 87% 675

3.6: Mid & South Essex

Mid & South Essex Eligible



South East Essex 65% 132 100% 211

South West Essex 75% 169 100% 227

Mid Essex 86% 172 100% 201

AGM Area 75% 473 100% 639

Flu Update Report


of 7

3.7: AOC Teams

AOC Eligible



AOC Bedford 64% 140 82% 180

AOC Chelmsford 55% 131 63% 150

AOC Norwich 84% 206 96% 238

AOC Regional 56% 5 45% 5

AOC Total 68% 482 80% 573

3.8: Special Operations Teams

Special Operations Eligible



HART 55% 55 90% 94

Resilience 64% 7 100% 11

AirOps 40% 12 69% 20

Special Operations 53% 74 87% 125

4: Flu Uptake Graph

Flu Update Report


of 7

5: Staff reasons for declining vaccination

Below are the main reasons provided by staff for declining the vaccination:

Young, healthy and feels that does not require vaccination to protect them

Has not had the vaccination in the past so does not require it now.

Declined vaccination due to not been unwell with the flu previously therefor does not require the vaccination

Declined due to being extremely unwell, resulting in 3 days in bed, after having the flu vaccination several years ago

Does not believe the flu vaccination works

Afraid of having the flu jab, due to effect on the immune system.

Had previous flu vaccination so does not wish to have it again this year.

Declined due to previous reaction to flu jab and feeling unwell

Does not believe the flu vaccination is necessary as body will protect itself and has a good immune system.

Confirmed previous allergic reaction to the vaccination

END

Flu Update Report


Aviva: Public

Report title: Report from Performance and Finance Committee – 16.11.2019

Report author(s): Tom Spink, Non-Executive Director

Purpose:

Decision Assurance For information Disclosable X

X Non-disclosable

Matters for Escalation:

The Director of Finance and Commissioning presented the M6 finance report showing a break even for the period, a better than expected result for the period. The forecast outturn for the end of year was a deficit to plan of £7.7m. Although this was explained as a worst case scenario and there was a level of confidence this would be achieved, there remained risks to hitting even this number at year end. The COO reported that hospital delays were now extending beyond 60 mins in a number of acute hospitals with significant pressure building at this early stage of winter.

TRUST BOARD (public session)

08.01.2020 AGENDA ITEM 18

Related Trust strategic objective(s):

Provide better care X Value our people Value for money X Improve performance X

Other:


Legal implications None

Regulatory requirements None

Equality and diversity impacts None

Report Title

Committee Reports to Board


Aviva: Public

Other Key Matters Considered:

The BBR implementation was proceeding and would continue into Q4. The likely positive impact on the Trust’s performance towards C2 targets was noted. The Committee had the first CIP Deep Dive involving one of the regions, Cambridge and Peterborough. The Committee was pleased to see local ownership and progress with the CIPS although it was recognised even great focus on delivery of key projects would be needed to deliver this year’s plan and the even more challenging following two years. The DoFC presented the Capital Planning report. Although there was pressure to exceed the Capital Resource Limit of £6.1m, the DoFC was confident it would be achieved as the impending sale of the properties at Atlantic Square and Sudbury Ambulance Station were progressing well. The COO presented the Winter Plan which included a focus on delivering the C1 and C2 targets. This was agreed by the P&FC.

Key Decisions Made and Actions Identified:

Future regional CIP reports to focus on mapping of actions, timeframes and benefits. The Make Ready Programme was one of the more material parts of CIP delivery which had taken considerable investment but was tracking behind in its delivery of benefits. The P&FC therefore requested a report on how the efficiencies from the programme would be delivered The Committee supported the forecast outturn position of a deficit of £7.7m as being realistic taking into account the overall performance of the Trust. It was however stressed, it was vital this number was achieved (or bettered). Concerns were raised around the worsening hospital handover situation and the COO was asked to report to the P&FC what could be done to mitigate the risks to performance. The P&FC was pleased to see such good progress with the development of the Integrated Improvement Plan. Key would now be to ensure effective execution of the Plan. The COO presented the IM&T report which included a recommendation to progress with the Telephony upgrade with BT. This was agreed and recommended to Board for acceptance.

Risks:

The risks relating to the delivery of the financial recovery plan were discussed. This included input from PWC who have been supporting the work. The P&FC were assured the forecast outturn of a deficit of £7.7m could be achieved.

Assurance:

Full Assurance: Finance Report Capital Planning Operational Performance Report including the Critical Path Capacity Plan



Aviva: Public

Partial Assurance: Winter Planning (issue being system stress) Integrated Improvement Plan (the need to demonstrate execution in line with the plan) CIP report at Regional level Lack of Assurance (and next steps): None

Referrals to Other Committees:

None

Meeting Details: Meeting Chair: Tom Spink, Non-Executive Director Lead Director: Kevin Smith, Director of Finance and Commissioning

Yes No Was the Meeting Quorate? X



Aviva: Public

Report title: Report from Performance and Finance Committee– 06.12.2019

Report author(s): Tom Spink, Non-Executive Director

Purpose:


X X Non-disclosable


Although the committee had seen an improvement in the CIP plans, considerable work was needed to land the forecast 2019/20 plan. It was proving more difficult to identify new areas of costs improvement resulting in a further risk to the 2020/21 plans. One of the more material areas of recent and future investment, with consequential CIP benefits was the Make Ready programme. There remained a lack of clarity as to how the return on investment would be achieved. There remained a high level of concern around the deterioration in handover times at a number of hospitals and the knock on affect on the EEAST’s ability to properly respond to patients.




Provide better care X Value our people Value for money X Improve performance X

Other:


Legal implications None

Regulatory requirements None

Equality and diversity impacts None

Report Title



Aviva: Public

Across the Trust, on scene times were still 2 mins off target and Carter benchmarking times. The focus on 10:10 times would need to be monitored for progress against the targets.



Concerns were raised about the number of PTS vehicles waiting at the Lister hospital. The COO agreed to providing a Deep Dive for the PTS in Luton and Beds to understand the root causes and remedial actions needed. The committee was concerned about progress with the Make Ready programme and requested a further review in January to include actions, timelines and planned benefits.

Risks:

The BAF was reviewed and the committee recognised that with the support from PwC in reviewing the CIP planning process, there had been a 4% improvement in the risk profile. It was also encouraging that there had been an improvement in compliance with the Risk register following training in 4 out of the 6 sectors. The majority of the risk profile relates to the operational delivery through the winter period with the potential pressure on the financial plan.

Assurance:

Full Assurance: The recovery plan. Financial forecast Partial Assurance: The CIP plan Operational performance Integrated recovery plan Lack of Assurance (and next steps): PTS contract for Beds and Herts – deep dive in January The Make Ready Programme – detailed report and discussion in January


None

Meeting Details: Meeting Chair: Tom Spink, Non-Executive Director Lead Director: Kevin Smith, Director of Finance and Commissioning



Aviva: Public Aviva: Public




Report title: Report to Board from the Workforce Committee – 20.11.2019

Report author(s): Neville Hounsome, Associate Non-Executive Director

Purpose:


X Non-disclosable


There were no matters for escalation.


The principle area for the Workforce Committee to focus upon was the resourcing pipeline. The Board will recall that the Trust has an ambition to be fully staffed by the end of 2020. To achieve this we need to recruit, train and deploy an additional 600 employees in the 15 month period from October 2019 to December 2020. An extra 40 new staff a month on average. To put this in context, between April and October 2019 we experienced a net gain of 171 employees. An average of 46 starters a month and 22 leavers. Even




Provide better care Value our people X Value for money Improve performance X

Other:


Legal implications The committee overseas compliance with our legal responsivities relating

to safeguarding and employment. Regulatory requirements The committee seeks to provide a good level of governance and

reassurance regarding the recruitment, education, training and general employment of Trust staff.

Equality and diversity impacts The Committee received a general update upon Equality and Diversity. It also considered an update from the Disability Support Network The Committee looked forward to receiving a future paper (update) upon the gender pay gap to include the impact of the national 3 year pay deal.

Report Title



with the one off recruitment of former Private Ambulance Staff, this meant a net gain of only 24 per month. The Workforce Committee were advised that current workforce plans would leave us short of our ambition. However, aware of this, the executive, supported by recently recruited HR and Training colleagues, were working on the art of the possible in terms of recruitment, training, mentoring and deployment plans.


The Executive were provided with a discussion paper on people, communications and engagement measurement. A full report upon the outputs from the Get Real Change Programme is being presented to the Board

Risks:

The committee considered SR3 and elevated risk 526. They were assured that these were reflective of the risks and issues within workforce however further assurance was required to demonstrate improvements.

Assurance:

Full Assurance: Equality and Diversity Update, Get Real Change Programme Update Partial Assurance: BAF, Workforce Metrics and Priorities, PPI and CEG Update, Education and Training Progress Report, ET and ER cases Lack of Assurance (and next steps):


None

Meeting Details: Meeting Chair: Neville Hounsome Lead Director: Marcus Bailey




Report title: Report to Board from the Workforce Committee – 10.12.2019

Report author(s): Neville Hounsome, Associate Non-Executive Director

Purpose:


X Non-disclosable


A full report upon the outputs from the Get Real Change Programme is being presented to the Board


1. The continued principle area for the Workforce Committee to focus upon was the resourcing pipeline. The Committee was advised of plans to increase resources in recruitment (5+) and training (10 people) to facilitate additional staff resourcing. A detailed plan by sector and skill is expected in January. The plan is expected to include recruitment, training, mentoring and deployment projections.




Provide better care Value our people X Value for money Improve performance X

Other:


Legal implications The committee overseas compliance with our legal responsivities relating

to safeguarding and employment. Regulatory requirements The committee seeks to provide a good level of governance and

reassurance regarding the recruitment, education, training and general employment of Trust staff.

Equality and diversity impacts The committee received a general update upon Equality and Diversity. It also considered an update from the LGBT Network. The Executive are realigning sponsors for each network and clarifying time off arrangements. HR are still looking into the impact of the 3 year national pay deal on equal pay gaps.

Report Title



2. Employee relations cases have been manged down from c100 to less than 40. External benchmarking has been requested.

3. A plan to catch up on HR policy reviews was reviewed. Positive relations with staff partners are critical to the rate of progress. HR is recruiting a dedicated role to manage the process and the Committee urged pragmatism.

4. The quarterly report for FTSU highlighted the plan to appoint a full time guardian and NED with defined accountabilities.


The Committee currently meets monthly which can put a strain upon report writers. We have decided to have a more focussed agenda for the next meeting and to make pragmatic use of verbal updates where appropriate.

Risks:

The committee considered SR3 and elevated risk 526. They were assured that these were reflective of the risks and issues within workforce however further assurance was required to demonstrate improvements.

Assurance:

Full Assurance: Equality and Diversity Update, Get Real Change Programme Update Partial Assurance: BAF, Workforce Metrics and Priorities, PPI and CEG Update, Education and Training Progress Report, ET and ER cases Lack of Assurance (and next steps):


None

Meeting Details: Meeting Chair: Neville Hounsome Lead Director: Marcus Bailey




Report title: QGC report to Trust Board – 06.11.2019

Report author(s): Wendy thomas, Non-Executive Director and Committee Chair

Purpose:


X Non-disclosable


CQC action plan – on this agenda – we were concerned that progress not as far forward as expected – we were advised Integrated Improvement plan (had been discussed at P&F committee) gave more assurance – we had not seen at time of the quality meeting. Having seen since, it is comprehensive work and will help focus and priorities PAS update - Some concern that the external providers performance group had not met – ops team oversees this – were assured by those present that these meetings have recommenced


Deep dive on sepsis – pre alert documentation is the issue that reduces our performance – education and MD agreed to pick up in CPD cycle. Check in January




Provide better care X Value our people Value for money Improve performance X

Other:


Legal implications

Regulatory requirements

Equality and diversity impacts

Report Title



Deep dive stroke - C2 call BB Rotas better response times – Scene time turnaround. Transformation programme underway - South & mid were areas requiring most attention – update in January SIs had reduced by 43% but themes remain culture, professionalism and leadership – key areas to address – VERY PLEASED mentioned in Yasmin’s workforce update s part of retention. Appointment of social workers to support safeguarding – innovative 1st to try – will watch progress with interest


Quality report - future summaries of each action point RAG rated and actions to address with evidence. We will see the full report as an appendix. Clinical audit report – again, we wanted to see evidence presented in a different way and Tom and I will meet with team in Dec 19 to discuss alternative presentation – allows focus Flu uptake 56.3% - great achievement and we agreed BBE policy. Update on hygiene code (on this agenda) agreed actions to address gaps

Risks:

BAF – Slowly improving risk profile and want- focus on reducing and addressing risks – score unchanged at 12 after mitigation

Assurance:

Full Assurance: Progress on medicines management – implementation has been B/F from end Jan to early Dec – Home office visit this week. Clinical strategy – assured on progress (previous concern as awaiting overall strategy devt) and team reported clinicians soon to have access to GP records. – Update at next meeting as critical for CQC actions Partial Assurance: Lack of Assurance (and next steps):


None

Meeting Details: Meeting Chair: Wendy Thomas, Non-Executive Director Lead Director: Marcus Bailey, Chief Operating Officer




Report title: Audit Committee Assurance Report to Board

Report author(s): Ravi Mahendra

Purpose:

Decision Assurance For information Disclosable

X Non-disclosable


Decision needs to be made on whether to carry out an independent review of the Quality Account by the External Auditors. This decision was approved by Audit Committee and Board in 2019 and Executive leadership now has some concerns.


• Draft Annual report of Charitable Funds. • Losses and Special Payments • Tenders and Waivers • Risk Deep Dive in to Cambridgeshire and Peterborough


• Approval of the Scheme of Delegation to the Charitable Funds committee

• Approval of Treasury Management Annual Policy


DATE AGENDA ITEM 18


Provide better care Value our people Value for money Improve performance

Other:


Legal implications

Regulatory requirements

Equality and diversity impacts

Report Title



Risks:

• Compliance with Policies and Procedures- As identified by the annual review of policies and procedures

• BAF risk assurance ratings not always backed by appropriate metrics • Insufficient assurances obtained yet from QGC and Workforce

Committees on the BAF ratings and the comfort levels of the committees on these ratings

Assurance:

Full Assurance:

- Finance Committee Assurance to AC - Draft annual reports of Charitable funds

Partial Assurance:

- QGC Assurance to AC - Procurement resourcing and development of sustainable strategy for

consistently lowering Tenders and Waivers Lack of Assurance (and next steps):

- Quality Account External Audit review engagement - Workforce Committee assurance to AC - Closure of Internal Audit open items


Board: Resolve the Open item on Quality Account external audit review if not resolved in the next Audit Committee. QGC and Workforce committees: Improve Assurances to Audit committee and review ratings of BAF scores on whether they are appropriate for the present trajectory of performance.

Meeting Details: Meeting Chair: Lead Director:

Yes No Was the Meeting Quorate?



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MEETING TITLE


Date: 08.01.2020

Report Title: Board Assurance Framework

Agenda Item: 19

Author: E de Carteret, Head of Governance

Lead Director: D Hosein, Chief Executive



SUMMARY AND BACKGROUND: The document provides detail on the four strategic risks agreed by the Board, in line with the current

organisational Strategic Objectives.

The function of the Board is to consider the Strategic Risks in relation to the following:

Consideration of the Strategic risks when receiving information regarding elements of Trust business, to consider the potential impact decisions may have

To seek assurance – or challenge – the mitigating actions identified, based upon information received through other reports and channels, and assurance via the committees

To utilise the Board Assurance Framework to assist in the planning of Board meetings and intended business

To gain assurance that the Board Assurance Framework demonstrates sound risk management principles

Pages 4-6 contain a summary overview of the strategic risk profile, including a progress update against key mitigating actions for each risk as well as a rationale for the current score. Pages 7 to 15 provide more detail as to the risk context and full listing of mitigating actions underway for each of the BAF risks and includes the anticipated date to reach the target score. All strategic risk scores remain the same this month, due to the pressure of winter and the interdependencies across the risks. Key areas of progress:

Operational performance has been stable for much of the Christmas period, demonstrating the effectiveness of the mitigating controls and capacity planning (SR1). This is subject to ongoing pressure and system demand

Infection, prevention and control compliance has improved in this reporting round (SR2) and is likely to continue to improve as AFA recruitment continues

Safeguarding casework reviews has resulted in a significant reduction in cases awaiting conclusion (SR2)

Employee Relations casework has been reviewed extensively which has resulted in a significant reduction in open casework and therefore resolution for individuals. (SR3)

Significant preparatory work for the Recovery plan and 2020/21 CIPs has taken place, with £8m of the provisional £11.5m target already identified in projects that are progressing through the gateway process (SR4)

Key points for escalation and noting:

Lack of assurance from workforce committee in relation to delivery of the workforce trajectory (SR1). Since the committee meeting in December, the workforce projections are available and the training plan up to March 2021 has been drafted – this is for review at Workforce Committee in January and update can be provided by the Chair’s report at the next public meeting.

Medicines Management remains a theme within incidents and whilst the standardisation project is underway, further work is required (SR2). Thematic review of all incidents is taking place to enable

Board Assurance Framework


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operational management to take focussed improvement actions.

HR Policy review and compliance remains low, with a lack of assurance from both Audit and Workforce Committees (SR3). Additional capacity and support have now been sourced and a clear project timeline and trajectory is in place, for completion of the project by March 2020. This is being presented to the Workforce Committee in January.

Freedom to Speak Up improvements are off track from timescales and has been escalated through the Executive Leadership Board (SR3). The business case has now been completed and recruitment commencing in quarter four.

Establishment of a performance management framework has been delayed as a result of the instability in the People and Culture Directorate, resulting in a lack of assurance from the workforce committee in relation to the way in which delivery of strategy is linked to a clear objective setting and cascade process. The action is under review and the timescale has been realigned to be completed in readiness for strategy and objective roll out and cascade at the end of the financial year. It will be followed up and monitored via the Workforce Committee.

RECOMMENDED ACTION: To note the Board Assurance Framework and its contents. To consider areas of focus required, either at Committee or Board level


N/A


N/A

PREVIOUSLY CONSIDERED BY: All Strategic risks are reviewed monthly by the Executive Directors. Each committee also reviews the strategic risks associated with their terms of reference and strategic objectives SR 1 and 4 with the associated corporate risks were reviewed by the Performance and Finance Committee on 6 December 2019 SR2 and the associated corporate risks was reviewed by the Quality Governance Committee on 6 November 2019 SR3 and the escalated recruitment risk will be reviewed by the Workforce committee on 10 December 2019.

LINKS TO THE BAF AND KEY RISK AREAS:

BAF report – all strategic risks and those principal risks escalated to the Board Assurance framework are in included



X

SR2: Failure to achieve continuous quality improvements in the quality of care delivered to our patients X

SR3: Failure to embed a patient-focussed culture that puts the patient at the heart of everything we do X





Value our people X

Value for money X


OTHER:




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LINK TO CQC:

Caring

Responsive

Effective

Well Led X

Safe X

RELEVANT LEGAL OR STATUTORY ISSUES Legal Implications - Health and Social Care Act Equality and Diversity Impacts - None identified



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Board Assurance Framework Summary – January 2020 (Third Line of Defence)

The following table gives an overview of the Trust’s strategic risks, their current status and the anticipated date when the risk will be mitigated to

the required level. It also provides a narrative update on progress in regard to the mitigating actions and rationale for the residual risk score:

Risk Title Owner Committee Inherent Residual Target Risk Review Details

SR1: Failure to deliver a timely response to our patients in line with commissioned national standards, to ensure a safe level of service

Marcus Bailey - Chief Operating Officer

Performance and Finance Committee

I = 5 L = 4

20 (20)

I = 5 L = 4

20 (20)

I = 5 L = 2

10 (10)

Latest Review Date: 31 Dec 2019 Latest Review By: Emma de-Carteret - Head of Governance Last Review Comments: SR1 remains at a residual score of 20 following the Director’s review, considering the pressures faced over the winter period and the system-wide challenges seen in recent days, which has begun to impact upon the positive level of performance seen over Christmas. The key actions are focussed on increasing resourcing above that of the staff in post or ensuring the staff are workforce effective. Central to increasing PFSH is the planned used of an overtime incentive which has been built into the Trust financial forecast, along with a reduction in annual leave for staff. It should be noted that the winter capacity, is at times, lower than the production levels of last financial year for which the regulators have requested further mitigating actions. Key risks over the coming weeks of winter include ongoing system and hospital capacity, potential staff illness and increased sickness absence, and the combination of these requiring increased patient facing staff hours to provide suitable levels of resourcing. These factors are being continuously monitored to ensure that mitigating actions are timely and maximised.

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SR2. Failure to achieve continuous quality improvements and high quality care delivery

Gill Hooper- Interim Director of Clinical Quality and Improvement

Quality Governance Committee

I = 5 L = 4

20 (20)

I = 4 L = 3

12 (12)

I = 3 L = 2

6 (6)

Latest Review Date: 31 Dec 2019 Latest Review By: Emma de-Carteret - Head of Governance SR2 is due for review by the Interim Director of Clinical Quality and Improvement in January ahead of Quality Governance Committee. This month the score remains the same, with IPC compliance increased and a number of additional actions identified to strengthen mitigation and monitoring. has been reviewed and, based upon the current data, the residual risk score remains the same. A number of key metrics have improved or remained static; however several have reduced which requires careful monitoring and review – increased SIs and ACQI intelligence. Review of the CQC action plan in terms of ‘must do’ and ‘should do’ improvements is well under way and this will result in greater detail following the director review in January.

SR3. Failure to establish a culture of engagement and accountability that is patient focussed

Dorothy Hosein – Chief Executive Officer

People and Culture Committee

I = 4 L = 4

16 (16)

I = 4 L = 4

16 (16)

I = 4 L = 2

8 (8)

Latest Review Date: 30 Dec 2019 Latest Review By: Emma de-Carteret - Head of Governance Risk reviewed and score remains the same, in light of the need to continue to progress some longer standing areas of focus. Get Real Change programme first phase has ended with the plan to establish culture action plan in Q4, which will underpin the mitigation of this risk. Significant improvement on ER casework volume has been evidenced in workforce committee giving assurance on progress and correct areas of focus. Score is unlikely to reduce until key actions within the culture plan are identified and delivered.


Kevin Smith, Director of Finance and Commissioning

Performance and Finance Committee

I = 5 L = 5

25 (25)

I = 4 L = 5

20 (20)

I = 4 L = 2

8 (8)

Latest Review Date: 30 Dec 2019 Latest Review By: Emma de-Carteret - Head of Governance Risk reviewed and score stays the same, although significant progression has taken place. There has been good progress on recovery planning, with the 20/21 provisional target of £11.5m set (subject to budget setting and contract negotiations). Of the £11.5m target, £8m has already been identified with schemes now being progressed through the gateway process. The challenge is on the balance between identifying efficiencies versus cash releasing schemes. There has also been regulator recognition of the longevity

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of the recovery plan and the level of support required by the Trust to deliver. EEAST have sent the commissioning intentions letter to commissioners and so are awaiting feedback through the negotiation process. There is good assurance on meeting the in year financial forecast and target, although the risk associated with winter expenditure remains. Score remains high due to the level of ask and the risk associated with non-delivery of recovery.

Ability to recruit the numbers of staff required

Dorothy Hosein, Chief Executive Officer

Workforce Committee

I = 5 L = 5

25 (25)

I = 4 L = 4

16 (16)

I = 4 L = 2

8 (8)

Latest Review Date: 31 Dec 2019 Latest Review By: Emma de-Carteret - Head of Governance Last Review Comments: Risk reviewed, and score remains the same, as the highest risk area impacting upon the strategic objectives. Progression in recent weeks on establishment of the workforce projections which has enabled clarity on the training plan, to achieve a target of full establishment by March 2021. Review of clinical supervision and the pipeline from recruitment through training and out onto the frontline is ongoing, but it is anticipated that greater levels of assurance will be afforded to the recruitment and retention processes in the next two months.

The key for delivery confidence rating of actions in the main section of the BAF (pages 6-13) is as follows. It should be noted that this confidence rating relates to the confidence in completion of the action and establishment of an additional control, as such does not necessarily indicate an improvement in metric as the action is underway, i.e. the control is not yet in place:

Green The action will deliver successfully on time, within budget and the level of quality required. There are no major problems or barriers that threaten delivery

Green/Amber Successful delivery of the action is probable, but constant focus is required to ensure it remains on track and risks do not materialise

Amber Successful delivery is feasible, but significant issues and risks exist that require focussed attention. However, these appear resolvable and can be managed with the action still running to time and within budget.

Amber/Red Successful delivery of the action in doubt due to significant issues and risks in key areas. Urgent action needed to determine whether can be resolved.

Red Successful delivery of the action unachievable. Major issues do not appear to be manageable. The project needs re-basing or its viability re-assessing

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Risk Description Strategic Objective

The Trust has in place a six-year contract to enable delivery of the requirements outlined in the Independent Service review, which includes workforce growth, operational efficiencies and rota conversions, in order to support a timely response to all of our patients. The workforce plan and building better rotas programmes are in situ to reduce the capacity gap and deliver the patient facing staff hours in the long term; however the long-term nature of these programmes and the challenges associated with recruitment and retention result in the need to focus on interim mitigation to ensure a safe staffing level that delivers safe and timely care. Operational efficiencies are also essential to maximise delivery of a timely service to patients, through improved usage of the workforce. The current risks underpinning SR1 include staffing levels, ratio of RRVs to DSAs, abstractions, increased activity acuity, arrival to handover delays, and financial capacity, as well as reputation considering the national context. The high-risk nature of the service includes the pressures within the control rooms, including management of patients waiting, surge and times of peak demand, and the need to balance all of the risks to ensure safe decision making through consistent leadership and behaviours.

Putting into place a new responsive operating model to deliver sustainable performance and improved outcomes for patients

Owner Committee

Chief Operating Officer

Performance and Finance

Risk Score Detail to Date Assurance of controls Target Risk Score Post-Mitigation

Likelihood Impact Score Likelihood Impact Score

Inherent 4 5 20 Moderate

When mitigated 2 4 8

Last month 5 4 20 Mitigated score to be achieved by March 2021

This month 5 4 20

Mitigating Actions Owner Due

Deliver the clinical workforce plan against the trajectory (ISR). Recruitment progression has seen improved course fill rates and the rate of leavers has reduced, but the workforce gap remains significant. Workforce projections now available to enable the build of the proposed training and development plan (complete). The plan supports achievement of the goal of zero workforce vacancies by March 2021, and is due for review at Workforce Committee in January.


March 2021

Implement make ready programmes to maximise efficiencies. Clear programme plan and oversight in situ with 5 sites completed and a further two imminent. Recruitment to AFA posts and capital works progressing well. Currently reviewing rate of efficiencies and savings and when benefits will be realised, through Performance and Finance Committee

Chief Executive Officer

March 2020

Plan and implement rota changes, working with industry experts to support delivery of ISR modelled rosters. BBR will provide a tangible performance benefit, meaning swifter response to patients, particularly in C2, although full effect will not be felt until the capacity gap is lessened. Implementation of rotas is on track with the next phase scheduled for January.


January 2020

Complete Fleet transformation process to provide increased ambulances and a sustainable fleet. Next phase is the total new fleet to 111 by the end of quarter three, with plan on track. This includes a combination of replacement of existing fleet and additional new vehicles. Progress review in Performance and Finance Committee in January


March 2020

Develop and implement a range of alternative response models This includes approaches including the Community Volunteer Strategy and utilisation, external collaboration schemes. CFR strategy launched at the conference in October and CFR lead now in post with improvement plan underway. Joint meeting with Essex police forces undertaken. Date extends through to ensure opportunities continue to be maximised


March 2020

Increase the level of productivity across service delivery, to maximise operating capacity. A core component of the improvement plan, this is being progressed and includes the People and Vehicle Support Hub, make ready site implementation and on scene times and behaviours.


February 2020

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Action ongoing. Review of PVSH undertaken and action plan being produced. AACE peer review of dispatch functions post ARP implementation - action plan to be developed for ELB review

Identify and implement operational efficiencies to deliver required productive patient facing staff hours. Implementation of make ready over coming months will further support greater efficiencies and improved responsiveness. Sectors have established local efficiency plans which are being monitored through Accountability Committee and CIP delivery group to bring recurrent efficiencies and improve unit hour production; schemes in consideration vary but include stock control and out of service work. Activities identified and incorporated within the CIP recovery workstreams. These will be combined with Lightfoot and Carter metrics review in due course along with peer reviews completed.


March 2020

Maximise use of the flexible workforce to minimise delays to patient care. This is an ongoing action through the year to mitigate the risk whilst longer term programmes such as building better rotas and the workforce plan are progressed. It includes utilisation of PAS, managed overtime, and use of agency staff. NHSP reviewed and option appraisal completed. Internal option for bank to be progressed at this current time. Implementation plan to be developed. CIP recovery workstream incorporating effective use of flexible workforce.


March 2020

Implement Lightfoot Performance processes using robust change methodology, focussed upon ways to improve performance across three distinct areas of geographical difference – rural, semi-rural and urban. Delayed due to capacity and current contract ending. New proposal and paper to ELB in January


March 2020

Embed innovation and transformation culture to maximise patient care through efficiencies. Transfer of knowledge is underway to the change agents. Head of PMO recruited to bring capacity to deliver, and further recruitment to the PMO is underway

Head of Strategy and Transformation

March 2020

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Inability to successfully focus upon safety and quality improvements due to pressures financially and operationally would limit the progress made by the organisation in relation to governance, clinical quality and patient safety. This could lead to an inability to provide safe, consistent and high-quality care to patients across the region. This would have regulatory and reputational implications for the organisation. Current risks include the skill mix and relatively inexperienced clinical scope of the workforce, difficulty with clinical supervision, lack of aligned IT systems to support monitoring, repeat incidents, and the ability to be compliant with training requirements are all significant factors to our ability to deliver quality improvements and reduce variation in practice.

Provide Better Care

Owner Committee

Interim Director of Clinical Quality and Improvement

Quality Governance

Risk Score Detail to Date Assurance of controls

Target Risk Score Post-Mitigation




Last month 4 3 12 Mitigated score to be achieved by November 2020

This month 4 3 12


Deliver against ePCR trajectory – targets in situ with compliance with utilisation ranging from 70-90% across General Manager areas. Service Delivery focussed on reducing the variation between areas via the Accountability Committees. There remain interoperability issues and there are limited stock of the current hardware to achieve significant improvements in compliance in the short term. ePCR business case for future solution is progressing and date realigns with the business case and recovery targets.

Chief Operating Officer April 2020

Gain approval of the Clinical Strategy for the Trust, including metrics for measurement of improvement and ensure a robust implementation plan – Report received in July and progressing, as per the agenda and outline of priorities. Clinical strategy being aligned with draft corporate strategy, and consultation continues – date aligns with overarching corporate strategy timeline

Medical Director March 2020

Pilot and then roll out a clinical supervision model for all clinicians, to facilitate both students and the longstanding workforce have appropriate levels of support and supervision for continuous improvement. Clinical supervision proposal being progressed, tabled at Workforce Committee in January for review and assurance

Medical Director & Chief Operating Officer

March 2020

Redesign the Professional Update course to maximise learning and enable successful delivery and compliance with the programme, whilst delivering the core service. Proposal to move from PU to CPD model has been approved and implementation plans are being finalised.

Medical Director April 2020

Embed medicines management procedures, including audit and reporting, into business as usual delivery. Pilot of a centralised medicines stock and supply process is taking place to support consistency and reduce variation – project planning complete, initiating in January for phased roll out.


Review patient safety systems and processes SI policy initial review undertaken, with a collaborative framework review scheduled with commissioners in quarter four. The intention is to provide triangulated informatics reporting and analysis to identify areas for improvement, that will be reported to Quality Governance Committee for assurance


March 2020

Improve time-based clinical targets to deliver sustainable clinical performance, in line with make ready and workforce trajectories. Anticipating a deterioration in time based targets due to the four month-lag in data, but internal indicators such as out


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of service time improvements via the 10:10 scheme and safety huddles are seeking to make sustainable improvements.

Establish Safe Staffing outline proposal. National Quality Board has released the draft Ambulance safe staffing resource which is being reviewed by ELB in January 2020


March 2020

Complete thematic review of Datix incidents for medicines management to ensure informed improvement priorities for operational management teams


February 2020

Undertake lessons learned review of 2019/20 complaints to support a policy framework review. This will support improvements to the complaint process, timeliness, complainant experience and the opportunity for learning


February 2020

Scope training proposal for frontline managers on clinical indicators to raise awareness and support standardisation of clinical practice across all areas


March 2020

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Failure to develop a just culture that focusses upon the patient and our staff has the potential to cause avoidable patient harm, incorrect decisions, low staff morale and issues with retention of our workforce. A lack of just – or safety – culture can lead to inconsistent practice and a lack of confidence in the leadership across the organisation, leading in turn to patient safety and staff welfare issues. Whilst the CQC’s rating of ‘outstanding’ for care demonstrates that staff continue to deliver consistently high standards, the staff survey and well led aspects of the CQC inspection (2018) shows that there are clear cultural issues requiring redress. Current risks include inconsistent practices and management approaches, repeat ER casework and limited preventative work through a lessons learnt or an analysis approach, inconsistent documentation and transparency regarding decision making, lack of collective responsibility towards patients, lack of a performance management framework, backlog in employee relations cases, varied leadership and insufficient staff engagement.

Guarantee we have a patient-focussed and engaged workforce

Owner Committee

Interim Director of People and Culture & Medical Director

Workforce Committee




Inherent 4 5 20 Low


Last month 4 4 16 Mitigated score to be achieved by September 2020

This month 4 4 16


Form professional standards panel Not yet progressed due to focus on clinical staff support actions. To form part of fourth iteration of improvement plan, following finalisation of supervision and new professional update models. Date therefore realigns

Medical Director January 2020

Ensure all staff receive a compassionate conversation and appraisal. The expectation is to meet 90% completion by January and then maintain on a month by month basis – amber confidence rating due to winter but monitoring through Accountability committee


January 2020

Deliver ER process improvement actions to ensure an efficient and effective process. Actions underway include frequent HR lead review of all cases, improved links on police cases and rapid hearing arrangements

Deputy Director of People and Culture

March 2020

Complete structure review focussing on areas of high risk in order to determine the capacity and capability requirements to drive the recovery plan. Forms part of the recovery plan for 2020/21, being scoped via gateway processes


March 2020

Deliver the outputs within the improvement plan: well-led and governance – Moves to cycle four so date now realigns. CQC action plan under final review and therefore subject to amendment. Good progress against Board-identified well led actions. New Chair undertaking review of well led which will establish further actions

Head of Governance

March 2020

Implement the recommendations from the Freedom to Speak Up review – actions delayed to realign with appointment of Freedom to Speak Up Guardian, which slips into quarter four. Business case considered at ELB and now progressing to recruitment. Board self-assessment of FTSU being scheduled for quarter four


Complete HR policy update Clear trajectory and project plan now in place, for tabling at Workforce Committee in January. Intent is to complete project by end of March, additional support in place to achieve this.

Deputy Director of People and Culture

March 2020

Undertake meeting and decisions framework review to reduce avoidable components, improve capacity across the Trust and improve timeliness of decisions. ELB and Board approved, approval of ToR underway. Looking to commence roll out of new meetings in

Head of Governance

January 2019

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January

Establish culture action plan via Board workshop, reviewing the findings from the Get Real Change programme. Board session scheduled for quarter four


February 2020

Refresh and Relaunch the Raising Concerns Forum Group Terms of reference under review, being led by the Medical Director Medical Director February 2020

Complete transfer of remaining staff onto electronic system and manually check DBS records to ensure future oversight of all staff

Deputy Director People and Culture

March 2020

Establish a performance management framework for the organisation. Date realigns due to current focus on recruitment and policy compliance. Work to align with strategy development, to ensure clear objective setting and cascade. To be monitored via the workforce committee

Chief Executive March 2020

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Following agreement of the contract post ISR, 2019/20 was intended to be the first year of full delivery of the ISR targets. However, the workforce challenge and the scale of transformation and risks associated with successful delivery have impacted on the ability to meet the targets within the anticipated timescales. As a result, the Trust anticipates being off-plan financially at the end of the 19/20 year, and so development of a robust and effective Recovery Plan spanning two financial years to bring financial stability and long-term sustainability and efficiency, is underway. The two-year timescale for delivery of the recovery plan take into consideration the significant interdependencies between delivery of the workforce plan, workforce needs, and the transformation required to ensure patient safety during the recovery period. The Trust needs to continue to undertake rapid large-scale change throughout all areas, in order to transform its systems and processes safely; this must be done as efficiently as possible, maximising the value of the public pound. Risks include the cost of transformation and the capacity pressures in situ as a result of a lean support structure under the Carter target, as well as the challenge to seeking viable efficiencies and confidence in overall delivery. A current, mid-term risk relates to the uncertainties surrounding next year’s contract, and the potential to lose block contract and more to an increased proportion of cost and volume. It should also be noted that the recovery plan and mitigation of this risk is also dependent on successful mitigation of SR1 and the escalated recruitment risk.

Delivering innovative solutions to ensure we are an efficient, effective and economic service

Owner Committee

Director of Finance and Commissioning

Performance and Finance







This month 4 5 20

Mitigating Actions Owner Due Establish PMO functionality fully in house to enable long term application of the embedded governance process. New action, Head of PMO recruited, other posts underway. In the interim, PWC are supporting the embedding of the CIPs and recovery plans, with clear focus throughout all management levels. On track


January 2020

Develop Corporate Strategy and five-year plan with interim milestones of September Board for launch of consultation and collaboration with the wider health economy on system plans. Date realigns to March following December Board workshop. February workshop has been scheduled to finalise the strategy proposals and review underpinning strategies. On track to allow strategy implementation in April


March 2020

Develop Commercial Strategy in line with corporate strategy, to establish clear business intent for the Trust. Underpinning strategies are due for drafting in quarter four

Director of Finance & Commissioning

March 2020

Identify and implement operational efficiencies to deliver required productive patient facing staff hours. Implementation of make ready over coming months will further support greater efficiencies and improved responsiveness. Sectors have established local efficiency plans which are being monitored through Accountability Committee and CIP delivery group to bring recurrent efficiencies and improve unit hour production; schemes in consideration vary but include stock control and out of service work. Progress continues with oversight through


March 2020

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performance and finance committee. Mixed results to date, but real focus via CIP delivery group and accountability committees

Implement make ready programmes to maximise efficiencies. Clear programme plan and oversight in situ with 5 sites completed and two further imminent. Good progression of the project, current focus is on quantification of the efficiencies and cost improvements to be released, and when. For review at Performance and Finance committee in January


March 2020

Standardise the Trust’s Procurement Processes to improve financial management and bring efficiencies. Initial focus via the improvement plan on purchase to pay and materials management solutions. Full business case has been reviewed and completion date extends to align with the availability of capital resources – becomes a 2020/21 project. Discussed at Board in December with NED identified to give oversight to actions being taken to strengthen the process.


October 2020

Maximise PTS contract oversight and improvement to maximise budgetary control, balanced with delivery. Contract variation for Beds and Herts has been agreed and is for final authorisation and approval. PTS improvement plan is established and being progressed by the Lead.


January 2020

Re-establish the Sustainability focus within the organisation ToR for the Sustainability Group to ELB in January and the presentation of plans will be at Performance and Finance Committee in February. Date realigns but work well underway


February 2020

Embed Recovery Plan implementation within core business delivery. Recovery plan is for implementation in April, with decision and approval of the final plan scheduled for February 2020. On track with schemes and progression through the gateways, processes embedded in preparation for implementation.


February 2020

Conclude financial negotiations within the current contract for the 2020/21 year. Commissioning intent submitted, awaiting publication of national guidance documents


March 2020

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526: Ability to recruit and retain the numbers of staff required to meet contractual and performance requirements


The recognised shortfall of clinical workforce as evidenced within the Independent Service Review demonstrates the need to recruit a significant number of additional clinicians over and above attrition over the next two-year period. Re-profiling of the workforce plan has demonstrated a re-basing of the second year due to a shortfall in workforce growth by the end of Q4 2018/19. Factors include the national shortage of paramedics, limited resources internally to deliver the training places required, and turnover of existing staff, which includes the desirability of Paramedics in other sectors of healthcare. The risk of non-delivery of the workforce numbers required impacts upon the ability to deliver the patient facing staff hours required to deliver a safe and timely service to patients, in line with performance standards. It also impacts the ability to ensure financial sustainability due to the cost of training combined with using temporary resource to support operational delivery.

Owner Committee


Workforce







This month 4 4 16

Mitigating Actions Owner Due Maximise retention through a suite of schemes including local sector focus upon retention. There has been a slight improvement in retention over the last two months and there is continued focus in operations to reduce leavers, being monitored by the Accountability Committees. Date extends to maintain focus for remainder of the year

Chief Operating Officer October 2019

Recruit to a minimum of 85% utilisation rate of all training courses, to maximise course fill and support delivery against the workforce trajectory. Training pipeline now worked to ensure clarity, next step to ensure flow through from recruitment to operations


September 2020

Complete review of data to enable robust reporting to Board and Committees against trajectory – this action was identified and agreed at Workforce Committee and will result in a clear trajectory and goal to monitor against. Trajectories being established to support oversight and assurance and action can close once complete. 2019/20 workforce plan being modified related to Urgent tier - clear mapping and tracking through recruitment and training near finalisation. Minor amendment to incorporate Urgent tier line

Chief Operating Officer February 2020

Complete Training and Education Improvement Plan to maximise quality of courses and ensure compliance with regulatory requirements. Good progress against actions regarding apprentice training and establishment of the pipeline. Action continues

Chief Operating Officer March 2020

Complete rapid task and finish review of the end to end recruitment to workforce effective staff process, to determine clear trajectory, and improvements to the pipeline process. Phase one: data is complete, now focusing on the end to end pipeline and transactional element between teams. Workforce projections and training plan in situ, joint report to Committee in January

Chief Operating Officer February 2020

Implement new occupational health contract to ensure appropriate levels of support to staff and managers to ensure wellbeing. Transfer commenced to new provider to go live early January.

Medical Director 15/02/2020

Complete sickness absence workshops for managers to support improved management of sickness and better support to staff. Action underway, good levels of attendance

Chief Operating Officer 31/01/2020

Establish Recruitment and Retention Improvement Plan with NHSE/I support as per national improvement collaborative. Underway with four areas – career development, wellbeing and resilience, staff engagement and flexibility in working. Draft plan will


28/02/2020

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526: Ability to recruit and retain the numbers of staff required to meet contractual and performance requirements

be presented to February Workforce Committee

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The CONFIRMED (Disclosable)

MINUTES OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST CORPORATE TRUSTEE MEETING (PUBLIC SESSION) WEDNESDAY 11 SEPTEMBER 2019 AT 12:30


Present: Tom Spink Non-Executive Director and Acting Committee Chair Wendy Thomas Non-Executive Director Carolan Davidge Non-Executive Director Ravi Mahendra Non-Executive Director Neville Hounsome Associate Non-Executive Director Tom Davis Medical Director Lizzy Firmin Non-Executive Director Dorothy Hosein Chief Executive Tracy Nicholls Director of Clinical Quality and Improvement Marcus Bailey Acting Chief Operating Officer Kevin Smith Director of Finance and Commissioning Yasmin Rafiq Interim HR Programme Lead In Attendance: Julie Hollings Director of Communications and Engagement Emma de Carteret Head of Governance Esther Kingsmill Deputy Head of Corporate Governance Members of the Public

PUBLIC SESSION (Disclosable) 1.0 CHARITABLE FUNDS COMMITTEE TERMS OF REFERENCE

1.1 The Head of Governance, Emma De Carteret (HoG) presented the Terms of Reference for the

Charitable Funds Committee. It was recognised greater oversight and assurance was required on charitable funds. A committee had been implemented and would meet quarterly. Their role would be to review movement of funds, approve expenditure and idneitfy ways of maximising charitable income. The ToR had been drafted utilising best practice from other trusts. The Trustee were asked to consider delegated approval levels. The existing scheme of delegation set approval levels at £25,000 however this represented a low number of transactions therefore consideration was required to delegation at a lower level.

1.2 The Director of Finance and Commissioning, Kevin Smith (DoFC) suggested the CFC review transactions within its first meeting and provide a recommendation on delegation levels.

1.3 It was confirmed that all Board members were members of the Corporate Trustee and were responsible for receiving assurance on charitable activity. The Charitable Funds Committee would operate separately to the corporate trustee and would have responsibility for oversight of the charity delegated from the corporate trustee.

1.4 Non-Executive Director, Ravi Mahendra (NED-RM) was concerned that charitable activity was limited and there was the potential to maximise income. He recommended the committee identify how funds could be generated and better utilised to benefit patients and staff. He also suggested a dedicated resource may be appropriate to support in generating funds. The Chief Executive Officer, Dorothy Hosein (CEO) recognised that there had been a lack of clarity on how the charity could be supported and as uch a task and finish group was being developed to identify how income could be maximised and utilised. There was abroad amount of opportunity to increase income.

CONFIRMED Corporate Trustee Minutes - 11.09.19




1.5 The ToR for the Charitable Funds Committee were approved on the basis the committee consider delegated levels for approval of expenditure at its inaugural meeting on 15.10.2019.






The CONFIRMED (Disclosable)

MINUTES OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST CORPORATE TRUSTEE MEETING (PUBLIC SESSION) WEDNESDAY 13 NOVEMBER 2019 AT 15:30



PUBLIC SESSION (Disclosable) 1.0 REPORT TO TRUSTEE FROM CFC

1.1 The Committee Chair, Neville Hounsome, presented the report form the inaugural meeting of the

Charitable Funds Committee. The committee had agreed the ToR and considered levels of delegated responsibility. The EEAST charity had circa £1m in charitable funds, with 100 CFR organisations contributing half of this. Of the remaining funds, approx £250,000 was allocated to specific items and £250,000 was held in a central pot for funding requests. It was the responsibility of the committee to consider requests for funding and ensure it was not exempt based on a set of criteria, which included that items ordinarily funded by the NHS could not be funded through charitable funds. It was recognised there was significant work required to raise the charity profile and communicate best practice on how charitable funds are utilised and supported. Benchmarking would be undertaken of other ambulance trusts to identify investment within charities and communications related to this. The committee had considered and approved a request for funding of batteries for AEDB defibrillators which were community based.

1.2 The Acting Chair, Tom Spink (AC) recognised the charity had been discussed at length and there were two options, to either invest significantly to drive forward income or to continue as a largely passive entity. It was considered that the charity provided a major opportunity to invest in communities. He enquired whether the CFC had considered this future and how it would advance. He was advised by NED-NH this would be considered following benchmarking. It was vital to ensure trust funds were not diverted from emergency services to support the charity when considering investment.

1.3 The CEO recognised the opportunity the charity provided to support patients and staff and emphasised the need to ensure this was aligned with the trust strategic direction.






The UNCONFIRMED (Disclosable)

MINUTES OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST CORPORATE TRUSTEE MEETING (PUBLIC SESSION) WEDNESDAY 13 NOVEMBER 2019 AT 15:30



PUBLIC SESSION (Disclosable) 1.0 MINUTES FROM THE MEETING ON 11.09.19 AND 13.11.19

1.1 The minutes from the meeting on 11.09.19 and 13.11.19 were approved with no amendments. It

was agreed they would be reported for noting at the Public Board meeting on 08.01.19.

2.0 CHARITABLE FUNDS ANNUAL REPORT AND ACCOUNTS

2.1 The annual accounts had been reported to Audit Committee. In 2020/21 it was proposed the annual report section be expanded to incorporate case studies and general charity work undertaken.

2.2 NED-TS suggested £1000 seemed a low level of investment for a bank total of £1m. He was advised that charitable funds were managed in line with the treasury management policy, and there were significant restrictions as an NHS Trust meaning returns were low. There was the potential there may be further opportunities to invest which would eb considered at CFC. ACTION: CFC to consider potential opportunities to invest charitable funds. Lead: DoFC

2.3 The corporate trustee approved the charitable fund annual report and accounts for adoption.


DRAFT Corporate Trustee Minutes - 18.12.19


of 1

MEETING TITLE

Board of the Corporate Trustee

Date: 08.01.2020 Report Title: Charitable Funds Committee Terms of Reference Agenda Item: 2 Author: Emma de Carteret, Head of Governance Lead Director: K Smith, Director of Finance and Commissioning Purpose: Assurance Decision X


SUMMARY AND BACKGROUND: On 10 December 2019, the Charitable Funds Committee reviewed and approved the committee’s terms of reference. Board approval of these is required to formally constitute the committee and enable it to deliver its requirements for the corporate trustee. Audit Committee have approved amendments to the scheme of delegation in recognition of the new Charitable Funds Committee (CFC), which enables the CFC to approve the charitable funds annual report and accounts and charitable funds utilisation. In the absence of the CFC this role was previously undertaken by the Audit Committee. To support amendments to the scheme of delegation, the Board of the Corporate Trustee are asked to formally approve the CFC Terms of Reference. These have been updated to reflect the committee role in overseeing the development and implementation of a charity strategy, expanded attendance at meetings, and reflection of the committee’s role in monitoring of Corporate Trustee-related risks. Given the developing role of the CFC, it is proposed these ToR be reviewed within 6 months to incorporate additional responsibilities of the CFC as they arise.

RECOMMENDED ACTION: It is recommended the Board of the Corporate Trustee agree the ToR for formal adoption.

KEY ISSUES IDENTIFIED There are no issues identified.


PREVIOUSLY CONSIDERED BY: Charitable Funds Committee – 10 December 2020


CFC Terms of Reference


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CHARITABLE FUNDS COMMITTEE – TERMS OF REFERENCE A Constitution The Corporate Trustee hereby resolves to establish a Committee of the trustee to be known as

the Charitable Funds Committee (The Committee). The Committee is a non-executive committee and has no executive powers, other than those specifically delegated in these Terms of Reference. As an assurance committee it may only make recommendations to the Corporate Trustee. The Committee may establish, subject to trustee approval, sub-groups to executive the delegated powers within these Terms of Reference.

B Purpose

The Charitable Funds Committee has been established by the Corporate Trustee to make and monitor arrangements for the control and management of the Trust’s charitable funds and fundraising activities. The committee will gain assurance on the utilisation and generation of funds, the status of funds and will review and approve charitable fund utilisation. The Trust Board is regarded as having responsibility for exercising the functions of the Trustee. The Trust Board delegates these functions to the Committee, within any limits set out in these terms of reference.

C Membership

The Committee shall be appointed by the Corporate Trustee from amongst the Non-Executive Directors and Associate Non-Executive Directors and shall consist of not less than three designated Members. The trustee shall appoint the Chair of the Committee from amongst the independent Non-Executive Directors. In the absence of the Committee Chair, the remaining members present shall elect one of themselves to chair the meeting.

Any non-executive director may deputise for an appointed member of the Committee with the permission of the Chair of the Board. A quorum shall be two members. Members and attendees are expected to attend all meetings. Failure of each individual to attend 75% of meetings will be reviewed by the Committee. The Chair of the Board shall not be a member of the Committee but may attend meetings. The Chair can act as a member if quoracy is dependent.

D Attendance at Meetings

The Director of Finance and Commissioning, Director of Communications and Engagement and Head of Financial Services shall normally attend meetings, in addition to a Service Delivery representative.

By exception, where the members or attendees cannot attend the meeting, deputies may attend

as set out below. The minutes will record whether meetings were attended by the Executive Director or their nominated representative.



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Members unable to attend a particular meeting should appoint a deputy to represent them, provided that the deputy is from the same Directorate and engaged in the management of the Directorate. Deputies need to have an appropriate level of seniority within the Trust and must be approved in advance with the Chair of the Committee.

Other trustee Members, officers and relevant representatives shall have the right of attendance,

subject to invitation by the Committee Chair, particularly when the Committee is discussing areas of relevance.

E Secretary

The Head of Governance will act as the Secretary to the Committee and shall provide

independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders.

The committee administrative function will be provided through the Head of Governance’s office,

which will include; • the agreement of the agenda with the Committee Chair and the collation and circulation of

papers • minuting the proceedings and resolutions of all meetings of the Committee including

recording the names of those present and in attendance; • keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 10 working days from the date of the

meeting. • creating, maintaining and a rolling schedule of business to come before the Committee. It is the responsibility of the Head of Governance to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission.

Trust standing orders and standing financial instructions apply to the operation of the Committee.

F Frequency of Meetings Meetings shall be held as necessary, but not less than four times a year. Extraordinary meetings will be held as necessary for the urgent approval of funds and events. G Authority The Committee is authorised by the trustee to investigate any activity within its Terms of

Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee.

The Committee is authorised by the Corporate Trustee to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions.

The Committee is authorised by the trustee to liaise, as necessary, with other sub-committees

of the Board and Chairs of the formal sub-committees have a responsibility for ensuring that the Charitable Funds Committee and the Corporate Trustee are advised of any risks or potential conflicts.



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H. Duties

The Committee will be responsible for:

• Managing the Trust policies and procedures for charitable funds and ensuring these are compliant with:

o Charity Commissioners Regulations o All Charitable Funds Legislation o The Corporate Trust Deed

• Ensuring a proper and prudent return on investment for fundraising activities • Within the budget, priorities and spending criteria determined by the Trust as trustee and

consistent with the requirements of the Charities Act 1993, Charities Act 2006 (or any modification of these acts) seek assurance that charitable funds have been managed and spent in accordance with their respective governing documents and in line with the Standing Financial Instructions.

• Overseeing the development and implementation of a Charity strategy including governance, major plans and key risks on behalf of the Trustee.

• Ensure that utilisation of charitable funds is in line with the Charity’s strategy and policy, ensuring expenditure is in line with the spirit of the charity principles

• To review and approve the acceptance of restricted funds • Oversee fundraising activities • On behalf of the Corporate trustee, review the accounts of the Charity and receive the

external auditor’s report and commend the accounts to the trustee once considered by the Committee.

• Establish, prioritise and approve major fundraising projects over £25000 and approve major expenditure items over £25000.

• Review and Approve Annual Fundraising Plans I. Telephone Conferencing

Members can participate in meetings by two-way audio link including telephone, video or computer link (excepting email communication) whereby all persons participating in the meeting can hear each other, and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting and count towards the quorum.

J Voting

Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:

Every question put to a vote at a meeting shall be determined by a majority of votes of Members

present and voting on the question. In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) shall have a second, and casting vote.

At the discretion of the Chair all questions put to the vote shall be determined by oral expression

or by a show of hands, unless the Committee Chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. If a Member so requests, their vote shall be recorded by name.

In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote.

For the voting rules relating to Joint Members, Standing Order 2.5 of the Trust will apply. K Reporting Procedures



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The Chair of the Committee will provide a Chair’s report to the next available corporate trustee meeting drawing to their attention any issues or risks that require disclosure to the full Board or require executive action. A copy of the approved minutes from the previous meeting will also eb provided to the corporate trustee for information.

The Chair of the Committee shall draw the attention of the Board to any formal recommendations by the Committee, the requirements for action to implement these, any resource implications and the timescale considered appropriate by the Committee for implementation.

The Trust’s annual report shall include a section describing the work of the Committee in

discharging its responsibilities.

The Committee will undertake an annual review of its performance effectiveness against its duties in order to evaluate its achievements and will report on its findings annually to the Board. Items presented for business should be those provided for assurance or decision and not information items, unless this is supporting assurance.

L Monitoring The Chair of the Board will receive a copy of all meeting papers and will attend at least one

meeting per annum for monitoring and assurance purposes. The Terms of Reference of the Committee shall be reviewed by the Board at least annually. M Relationship to Audit Committee

The Board has determined that the Audit Committee will have responsibility for the oversight of risk management, to gain assurance that appropriate systems of internal control are in place and are operating as intended, and that the Board Committee system is working appropriately. As such the Audit Committee has overall responsibility for the Board Assurance Framework and will delegate any appropriate areas to this Committee as required. For this purpose only, the Committee will report once a year to the Audit Committee on the following areas for assurance: • Any strategic objectives aligned to the Corporate Trustee • The arising risks identified by the Corporate Trustee in relation to Charitable Funds • Annual Plan key objective action plans • Accountability and responsibility of Committee • Effectiveness of the Committee

Approved by: ELB: 29.08.2019 Approved by: Trust Board:



Report title: CFC Report to the Corporate Trustee

Report author(s): Neville Hounsome Sponsoring

director:

Purpose:

Decision Assurance For information Disclosable x

x Non-disclosable


None


a) The fund currently stands at £943k of which £255k sits in general funds of which only £135k is unrestricted. The Finance team are asking all fund holders with funds in excess of £5k to project in year spending.

b) The CGC reviewed in agreed ToR recognising that external benchmarking may result in a more fundamental review later in the year.


The CFC considered a request to extend trials of Raizor Lifting Chairs from 4 to 24 Community Responder Groups at a cost of £52k. The Committee endorsed the principle asking the ELB to confirm that

a) Any roll out would be funded by the Trust (or otherwise) and b) That charitable funds have been used elsewhere in the NHS for this

activity.

Risks:

a) Currently there may be a risk that charitable funds of c£1m are perceived to be being held rather than being effectively deployed.

b) The Committee needs to establish a sensible level of reserves.

Assurance:

Full Assurance: Partial Assurance: Lack of Assurance (and next steps):

CORPORATE TRUSTEE (public session)


Legal implications The Committee has been established in compliance with Charitable Funds legislation.

Regulatory requirements A Charity Committee is commonplace in the NHS and provides additional transparency around decisions to spend monies held in trust.

Equality and diversity impacts Funds may be used to fund equality activities which the NHS would not generally fund from core budgets.

Report Title

CFC Report to the Corporate Trustee



Meeting Details: Meeting Chair: Neville Hounsome

Lead Director:

Yes No

Was the Meeting Quorate? Yes

CFC Report to the Corporate Trustee


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