the education centre, birmingham heartlands hospital · 2017-01-19 · council of governors meeting...

Council of Governors Meeting

4.00 – 6.00pm on 23 January 2017

The Education Centre, Birmingham Heartlands Hospital

A G E N D A

Indicative Timings

(minutes) Presenter

1. Apologies

1 Jacqui Smith

2. Declarations of Interest - Governors - Directors

1 Jacqui Smith (Enclosure)

3. Minutes of previous meetings – 3.1 28 September 2016 3.2 24 October 2016

2 Jacqui Smith (Enclosure) (Enclosure)

4. Matters arising

5 David Burbridge (Enclosure)

5. Chair’s Update

5 Jacqui Smith (Enclosure)

6. Chief Executive’s Update

5 Julie Moore

(Oral)

7. Performance Report

15 Kevin Bolger (Enclosure)

8. Clinical Quality Report Q3

10 David Rosser (To Follow)

9. Care Quality Report Q3 inc Infection Prevention & Control Report 9.1 Patient Experience Report Q2 (SF)

10 Sam Foster (Enclosure)

10. Finance Report Q3 inc Capital Programme Update

15 Julian Miller (Enclosure)

11. Quality Account 2016/17/ Audit of Indicators 10 David Burbridge (Enclosure)

12. Compliance and Assurance Report 10 David Burbridge (Enclosure)

13. Any Other Business Previously Advised to the Chair

14. Date of Next Meeting – (CoG Focus Meeting) Monday 27 February 2017, Rooms 2 & 3, Education Centre, Heartlands Hospital

EXCLUSION OF THE PRESS AND PUBLIC

The Council of Governors will be asked to resolve “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”.

Private Session – 6.00pm

Light refreshments will be available from 3.30pm

David Burbridge Interim Director of Corporate Affairs 05 January 2017

PUBLIC

COUNCIL OF GOVERNORS

REGISTER OF INTERESTS

NAME INTEREST DECLARED DATE DECLARED

DATE CEASED

Cllr Mohammed Aikhlaq

Member of Overview & Scrutiny Committee : Health & Social Care

May 2015

Stan Baldwin

1. Joint Vice Chair – Solihull College & University Centre

2. Member of the Institute of Sport and Physical Activity

3. Fellow of The Chartered Management Institute

17 Aug 2016

Kath Bell Company Secretary – Succeed Services Ltd 21 Nov 2011

Nicola Burgess Assistant Professor of Operations Management, Warwick Business School, Warwick University and honorary contract with HEFT to conduct research.

2 Jun 2015

Tony Cannon No relevant of material interests 7 Sep 2016

Carol Doyle Awaiting information

Sarah Edwards Awaiting information

Keith Fielding Awaiting information

Albert Fletcher Director – Aquarius (unpaid). A charity that specialises in helping and treating those with drink and/or drug issues.

28 May 2013

Derek Hoey 1. Member of Advisory Board / Volunteer - Healthwatch, Staffordshire

2. Committee Member – Tamworth and District Civic Society

3. Magistrate – South East Staffordshire Magistrates Bench

4. District Patient Group Member – South East Staffs and Seisdon Peninsula CCG

5. Partner – Specialist Healthcare Partnership

22 Aug 2016 15 Dec 2016

Sue Hutchings Shareholder in Lloyds TSB 19 Sept 2013

Phillip Johnson Nothing to declare 21 Nov 2011

Attiqa Khan Nothing to declare 16 Aug 2013

Anne McGeever 1. Registered with Therapy Bank in Worcestershire to provide services to BMI Droitwich Spa Hospital.

2. Unite Professionals Limited (Occupational Therapists) – ad hoc employment.

12 Sep 2014

14 Apr 2015

Veronica Morgan 1. Magistrate in criminal and family courts 2. Shareholder in Halifax, Millwall FC and Lloyds

TSB 3. Member (patient rep) of West Midlands Breast

Expert Advisory Committee 4. Member of West Midlands Cancer patient

&public engagement expert advisory group 5. Expert member on Solihull Research Ethics

Committee 6. HEFT Employee

07 Jan 2016 07 Jan 2016 07 Jan 2016 07 Jan 2016 07 Jan 2016 07 Jan 2016

Derek Moynihan Awaiting information

Catherine Needham

Nothing to declare 13 May 2014

Barry Orriss Member of Project Management Team, Warwick Medical School, University of Warwick

7 Apr 2016

Louise Passey Conservative Town Councillor – Royal Sutton Coldfield Town Council

16 Aug 2016

Jane Teall Awaiting information

Jean Thomas Nothing to declare 30 Sep 2014

David Treadwell 1. Shareholder – Lloyds TSB 2. Shareholder – STW 3. Shareholder – National Grid

21 Nov 2011

Matthew Trotter

1. HEFT Employee 2. Director – Specialist Health Partnership 3. Clinical Director – Specialist ENT Care Ltd

12 Sep 13 15 Dec 14

David Wallis 1. Knowle, Dorridge & Bentley Heath Neighbourhood Plan Ltd – Director

2. Prospect (Trade Union) – Member

16 Sept 2015 16 Sept 2015

Tom Webster

Awaiting information

Lee Williams

Awaiting information

REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS

VOTING DIRECTORS

NAME DATE OF

APPOINTMENT INTEREST (if any)

DATE OF NOTIFICATION

DATE OF TERMINATION OF INTEREST

Mr Jonathan Brotherton 04.03.15 Nothing to declare 04.03.15

Mr Andrew Edwards 01.10.14 1. Couch Perry & Wilkes - in receipt of annuity following business sale until May 2019.

2. Voluntary role as a business mentor for the Prince's Trust.

01.10.14

26.04.16

Mrs Sam Foster 01.09.13 Nothing to declare. 01.09.13

Prof Jon Glasby 01.10.15 1. Professor / Head of School, University of Birmingham

2. Senior Fellow, NIHR School for Social Care Research

3. Member of Birmingham Health Partners Executive Group

4. Works with Birmingham Safeguarding Children’s Board from time to time.

01.10.15

01.10.15

01.10.15

06.01.16

Ms Hazel Gunter 04.03.15

Nothing to declare. 04.03.15

Mrs Jackie Hendley 13.06.16 1. Director - SC Advisory Services Ltd

2. Director - Smith Cooper - IT Services

Ltd

3. Director – Smith Cooper Ltd

4. Partner/Member – SHH 101 LLP

13.05.13

13.05.13

13.05.13

01.04.14

Dr Michael Kinski 13.06.16 1. NED - Infinis Capital Limited (UK)

2. NED - Trireme Holdings Ltd (USA)

3. Senior Independent Director - AWAS

Aviation Capital Ltd (Dublin)

4. NED - Lake Woods Holding Pty

(Australia)

5. Prof of Business Change – Middlesex

University.

6. NED – Bristol City Council Holding

Company

Jan 2016

01.08.15

01.08.15

01.08.15

01.09.15

06.06.16

Mrs Karen Kneller 01.10.14 1. CEO of Criminal Cases Review Commission

2. Part time judge Social Entitlement Chamber Fitness to Practise

3. Member for General Dental Council 4. Director (unremunerated) of BRAP, an

equalities think tank.

01.10.14

01.10.14

01.10.14 01.10.14

Mr Julian Miller 03.02.16 Director of Finance (non-voting) – University Hospitals Birmingham NHS Foundation Trust

03.02.16

Dame Julie Moore 26.10.2015 1. Birmingham Systems Ltd 2. Director of Innovating Global Health

China Ltd (registered in Hong Kong) 3. Member of Birmingham Business

School Advisory Board 4. Court of the University of Birmingham 5. Governor – Birmingham City University 6. Non-Executive Director – Precision

Medicine Catapult (PMC) 7. CEO – University Hospitals

Birmingham NHS Foundation Trust

26.10.15 26.10.15 26.10.15

26.10.15 26.10.15 26.10.15

26.10.15

Dr David Rosser 01.03.15 Medical Director – University Hospitals 01.03.16

Birmingham NHS Foundation Trust

Prof Michael Sheppard 13.06.16 1. Chair – West Midlands Academic Health Sciences Network

2. NED – University Hospital Birmingham NHS FT

Octr 2013

Dec 2010

Rt Hon Jacqui Smith 01.12.15 1. Chair – The Precious Trust

2. Chair – Public Affairs Practice for Westbourne Communications

3. Associate – Cumberledge Eden & Partners

4. Associate – Global Partners Governance

5. Chair – University Hospitals Birmingham NHS Foundation Trust

01.12.15 01.12.15

01.12.15

01.12.15

01.12.15

Council of Governors

Minutes of a meeting of the Council of Governors of Heart of England NHS Foundation Trust held

in the Partnership Learning Centre, Good Hope Hospital on 28 September 2016

PRESENT: Rt Hon. J Smith (Chair) Dr N Burgess Mr A Cannon Mr K Fielding Mr A Fletcher Mrs S Hutchings Mr P Johnson Mr M Kelly Mrs A McGeever Mrs V Morgan

Mr G Moynihan Mrs S Nicholl Mr B Orriss Mrs L Passey Mrs J Teall Mrs J Thomas Mr D Treadwell Dr M Trotter Mr T Webster

IN ATTENDANCE: Mr K Bolger Mr D Burbridge Mr A Edwards Mrs S Foster Ms H Gunter Mrs A Hudson (Minutes)

Mr J Miller Dame J Moore Dr D Rosser

and members of the public.

16.093 WELCOME and APOLOGIES for ABSENCE

The Chair welcomed everybody to the meeting and introduced Mr Gavin Ralston, Chair,

Birmingham Cross City CCG, who was shadowing the Chair with particular interest in the

chairing of large complex meetings. Apologies for governors had been received from Mrs Bell, Mr Baldwin, Mr Hoey and Dr Needham

Apologies for Directors had been received from Mr Brotherton, Dr M Kinski and Prof Sheppard

16.094 LEAD AND DEPUTY LEAD GOVERNOR ELECTIONS

The Chair reported that, following the recent election to appoint Lead and Deputy Governor, Mrs Jean Thomas had been elected as Lead Governor and Mr Albert Fletcher to the post of Deputy Lead Governor. She congratulated both governors on their appointments. Governor sub-committee membership was to be updated to reflect the recent governor elections and an email would be distributed asking governors to indicate their preferences; following receipt, the Chair and Lead Governor would meet to confirm and agree membership of the sub-committees. The Deputy Lead Governor congratulated Mrs Thomas

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on her appointment and cautioned her not to underestimate the task in hand and said that he and the other governors were there should any assistance be required. The Lead Governor thanked Mr Fletcher for his comments. Mrs Kneller updated the meeting on her role as non-executive representative for the HEFT Board during the process for the Case for Change Project. She, along with Mr Brotherton, had met with four independent legal firms week commencing the 19 September, written proposals were due to be received within the next 10 days. The meeting was reassured that her role was to ensure that the process was as transparent as possible and that HEFT was represented fairly and governors would be kept up to date with progress.

16.095 PERFORMANCE & FINANCIAL POSITION REPORT

16.095.1

Performance The Council of Governors considered the update given by Mr K Bolger, interim Deputy Chief Executive - Improvement on the Trust’s performance that focussed on Monitor, national and local contract indicators rather than internal indicators. Exception summaries had been provided where there was non-compliance with performance for targets and indicators included in Monitor’s Risk Assessment Framework, national and contractual targets. The report only indicated where there were issues against indicators. It was reported that the Monitor Risk Assessment Framework A&E 4 hour wait, 62 day cancer from a National Screening Programme to treatment, 2 week breast symptomatic cancer and C.difficile targets had not been met. The Trust had achieved 92% against the A&E 4 hour target in August, however performance had dipped in September due to a number of factors and the Trust was running at 86.35% and 89% against the quarter. Activity had increased and there had been pressures including DTOC that had caused a detrimental impact on performance; the trust was working to produce action plans to deal with winter pressures. The 2 week urgent cancer target had been breached following the cancellation of a clinic due to equipment failure, the equipment had now been replaced. The number of cancer referrals continued to increase. There had been two breaches of the 62 day cancer target and specialities were working to improve the pathway. Lower GI was an issue across the Birmingham as a whole and the cancer teams were working together to reduce delays. The meeting discussed the work being done with specialities to understand the issues and put in place action plans to address them. Improvements had been seen in the local indicators for workforce including the time to hire indicator improved. In response to a question from a NED, the CEO advised that, following the Brexit result there had been some uneasiness in the workforce and some individual doctors had been offered work back in their own countries. An update against the STF trajectories was provided and it was noted that all targets are currently being met, although A&E for September would be at risk. Following a discussion the Deputy CEO – Improvement advised that the whole of outpatients was being reviewed; and in some cases patients were being recalled who did not require an appointment. The Board Quality Committee had discussed delays experienced by ophthalmology patients at its meeting earlier that day and had been advised that there had been an issue around the leadership of the directorate, but that had now been resolved and improvements to the service had been made. The subject of whether

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the system for DTOCs was as joined up and efficient as it could be was discussed and the Chair advised that this had also been discussed at the Quality Committee earlier that day and that a key issue was the number of beds that had been closed across the Birmingham and Solihull regions. The Trust was working to improve DTOCs, with clinicians undertaking assessments on whether patients were ready for discharge, rather than the conventional system of waiting for the social worker to confirm that the patient could be discharged. The improvement in staff absenteeism was discussed and whether this had been due to the reduction in the number of staff at Trust. The Chair and CEO believed that it was due to increased stability at the Trust that had been felt by staff and that staff were content to wait to see how the case for change would develop in terms of staff opportunities.

16.095.2

Finance The Director of Finance gave an update on the Trust’s financial position and it was noted that the Trust has agreed a plan deficit of (£13.6m) for the 2016/17 financial year, in line with the control total set by NHSI. However, since the plan was submitted, it had been confirmed that emergency readmission penalties were not included within the wider suspension of fines and penalties, as had originally been understood. The latest forecast was a deficit of (£24.8m) based on the guidance that the last quarter of STF would not be received if the (£13.6m) control total was missed. The Trust had reported an actual I&E deficit of (£1.6m) in month 5 (August 2016), which was in line with the plan of (£1.6m) and a £0.4m favourable variance against the forecast trajectory of (£2.0m) including the readmissions penalty. The year to date I&E deficit was (£10.0m) at month 5, an adverse variance of (£0.2m) against the plan of (£9.8m) and a £2.1m favourable variance against the forecast trajectory of (£12.1m). It was highlighted that at the equivalent point last year the YTD deficit was (£29.5m) and going out at (£7m) per month. There was YTD slippage of (£181k) against the CIP delivery however for the first time the Trust was forecasting full delivery of the year end target (101%). This represented excellent progress and reflected a lot of hard work across Divisions and Corporate departments. The cash balance at the end of August was £33.4m, which was £11.6m above plan due to slippage on capital expenditure and favourable working capital movements (creditors above plan). As a consequence it was forecasted that interim revenue support via the distress finance regime would not be required until December. The planning guidance for 2017/18 had been released in September 2016. A draft plan was required by 24 November with submission of the final plan by 23 December 2016. Operational plans were required to be consistent with STP footprint plan. The STF would remain a direct allocation and was based on this year’s controls total rather than outturn. Organisations would also have a shared controlled total, with part of the CQUIN held back and only accessible if other others delivered their plan. Tariff was +0.1% (cost +2.1% and efficiency – 2.0% for both years. There was a discussion, following which, the Director of Finance advised that the tariff had changed and it was no longer the case that the more work you did the more income was received. Commissioners had challenged the Trust on the number of follow up outpatient appointments.

16.095.3

CQC Visit. The Chief Nurse reported that the Trust had been subject to an unannounced visit on the 6 September from the CQC when a 20 strong delegation had visited all three sites. A further 3 day visit with approximately 50 inspectors was planned for 18, 19 and 20 October. The CQC had, ahead of that visit, requested a large quantity of information as well as completion of a self-assessment exercise, all of which had been completed and returned.

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There had been a lot of positive changes made since the last visit undertaken in 2014. Planning for the visit included a targeted staff communication plan, board packs, governor briefing, staff briefing and focus groups. Mock CQC visits would be held in the first week of October against the CQC revised framework. The CQC had also requested meetings with each of the Chair, CEO, Non-executive and Executive Directors as well was holding staff and governor focus meetings. The reports were received.

16.096 DEEP FOCUSES ON ISSUES

16.096.1

Operational Structure The interim Deputy CEO – Improvement delivered a presentation setting out the operational structure at the Trust. The new structure was a site based focused structure. The previous structure had led to lack of clarity for staff. Jonathan Brotherton was the Executive Director of Operations and had responsibility for operational running of the Trust. The structure was split into five Divisions, with directorates being grouped by site into each of the divisions. Each of the divisions would be reviewed over the next few months after which any fine tuning would be undertaken. There was now consistency across the divisions with clear lines of accountability and responsibility. A discussion on the new structure was held and the interim Deputy CEO – Improvement reported that the new structure had been implemented quickly This had been followed by consultation with staff regarding re-banding and realignment of roles and staff opting to apply for MARS (Mutually Agreed Resignation Scheme) there had been savings made across each of the divisions made. The success of the new structure would be measurable by performance as well as feedback from staff; the CQC had already given some positive feedback on the new operational arrangements. In order to ensure that all employees were aware of the new divisional structure it was agreed to ensure that hard copies of the structure were distributed for display in staff rooms. It was agreed to circulate a copy of the structure to governors.

16.096.2 Strategic Risk Register The interim Director of Corporate Affairs delivered a presentation, explaining the role and function of the Strategic Risk Register and the Board Assurance Framework (BAF). The BAF was used to highlight the key risks that affected the Trust achieving its strategic objectives. The Trust was required to have a BAF and it was audited annually by the Trust’s internal auditors to ensure that it functioned effectively. The definition of what constituted a risk was explained i.e. anything that may happen at some point in the future and required positive management to reduced their likelihood of happening. The Board’s role in relation to risk focussed on the external risks such as political and regulatory change that might affect the Trust, which, once identified, were rated for risk and significance. The BAF set out a description of the risk, summarised the magnitude of risk, risk appetite, controls (processes put in place to stop risk happening or controls to mitigate the impact of risk), assurance (how the board were assured that controls were functioning by means of audit, external visits and evaluation). It was noted that there would always be an element of

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residual risk, but where that was higher than the tolerances put in place by the Board, then further action would be undertaken to reduce that risk. The Strategic Risk Register was reviewed on a monthly basis and had a uniform scale of risk. Within the organisation there was a hierarchy of reporting for the risk register that included: Directorate risk register - reviewed monthly at directorate level Divisions risks escalated from directorate Director of ops risk register – cover whole of divisions Each member of the executive team also had a risk register and this was used to form the corporate risk register. The Board needed to be sure that the right risks were on the register and these were reflected in the business the Board considered. The role of the Audit Committee included looking at the effectiveness of controls in place against those risks. The process for considering the risk register comprised of quarterly meetings; the Head of risk and compliance meeting with each of the head of divisions; in order to discuss proposals update existing, close risks or add new risks which are then in turn discusses with the executive team prior to presentation to the Board. The existing strategic risk register (SRR) had been reviewed in light of the organisational changes, and the proposed SRR had been considered by the senior executive team. Those considerations had been made against the following criteria: Workforce Activity Infrastructure Finance Governance Other The floor was opened to questions from the governors. What extent did the Board have control and ownership of the SRR? Patients were dependant on people for timely treatment, equipment and, finances. It needed to be ensured that the same mistakes were not repeated, the principle value of the NHS was important and it needed to work smoothly in order to fulfil those values. The interim Director of Corporate Affairs responded that the Trust was required to have an SRR and it was used to ensure that patients were the priority. The importance and usefulness of the risk register was noted and following a question on how risks were escalated to the Board, the interim Director of Corporate Affairs reported that there was a management structure for escalation, as well as the reports on performance, finance, clinical quality and care quality. The Board also undertook unannounced board governance visits to wards and departments. It was also noted that incident reporting was improving. It was noted that the CoG would not get specific updates on the SRR. The Board were responsible for decision making. It was the role of the Governors to challenge the NEDs on items of assurance. The risk register formed part of the public board papers on a quarterly basis to which governors had access.

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The Chair, in response to an observation, advised that, following the recent change in Board membership and leadership, reporting had improved and assurances had been given that historic failings would not be repeated. The interim Director of Corporate advised that, as part of the changes undertaken around governance including the operational structure, financial controls and papers it received, the Board was assured that the information had gone through a rigorous process of meetings, challenge and assurance. A further external review of Governance would be undertaken at a future time. Had the proposed merger or acquisition had been considered as a risk? The Chair advised that it was too early in the process for it to be on the SRR as the case for change would highlight any risks to be considered as part of that process. Had the Trust conferred with other local trusts when it had identified risks? The interim Director of Corporate Affairs reported that it had not. However, its internal and external auditors did consider external risks as part of their remit. The chair of Audit Committee also met with other audit committee chairs. Governors were keen to receive assurance that that escalation of reporting incidents was undertaken as it could have a reputational risk for the Trust. It was reported that the quality control processes developed for incident reporting, investigation and escalation would identify any occurrences. The Chair reported that she had recently attended the junior doctors’ induction and had been clear in the messaging that the Board encouraged the reporting of incidents.

16.097 ANY OTHER BUSINESS

The Chair advised that a governor had, prior to the meeting, requested an update on the NED appointments process for a fourth NED. The Chair reminded the meeting that, as per her update at the last meeting, the Trust had appointed three 3 new NEDs which was in line with the constitution. In order that the Board was represented by a diverse group of individuals that included a strong representation of the community it served, the Trust had asked Odgers Berndtson to undertake a further search for a fourth NED with a view to encouraging applications from under-represented sectors of the community.

Following a robust discussion, the Chair reminded the meeting that she had overall

responsibility for ensuring that the Board was diverse and that it comprised members with a

mix of skills that enabled the Board to have meaningful discussions in the best interest of

the patients the Trust served. There was a considerable risk for the Trust to have an

unrepresentative board. Governors were reassured that the ultimate decision to

appointment to the Board of Directors would be fully in accordance with the law and the

Foundation Trust Code of Governance. The question on the attendance of NEDs at CoG meetings was raised and the Chair advised that she would be undertaking NED appraisals over the next month or so and this would be covered as part of that process. Following all the appraisals, the Chair would formally report back to CoG to review and set the priorities for the coming year. Another Governor had, prior to the meeting, enquired about a concern raised at a recent meeting the Breast Cancer Support Group regarding the number of patients who had come forward as part of the recall exercise and had questioned whether this was due to the

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wording of letters sent. The Chair advised that the wording of the letter, following feedback, had been changed right at the start of the recall process, so that it was as personalised as possible to the individual's circumstances. The letter referred to was not in respect of the recall as that had already happened, but another letter to give women the opportunity to hear the results of the independent review carried out by the virtual multi-disciplinary team. The interim Deputy CEO – Improvement advised that 299 cases had been independently reviewed, of which 95 had responded. It should be remembered that the Trust could not force people to come back, but Governors could be reassured that all had been communicated with. The interim Deputy CEO – Improvement was due to meet with the chair of the Breast Cancer Support Group and would brief her fully at that meeting. Following a question raised about the Urology review underway, it was reported that the Trust had been active in corresponding with patients affected. The interim Director of Communications reported that the Trust would feature in 3 upcoming television programmes over the next few weeks.

The first was on the BBC Panorama programme which was that was looking at the cost of type 2 diabetes on the NHS; the BBC had been filming at the Trust over the last 6 months as well as at the Birmingham Children’s Hospital and Cross City CCG. The Trust had secured a preview the following day. .

The second was a BBC 2 commissioned series called My Big Week and followed Beth, a recently qualified ED nurse, over 4 days. The ED department had been very positive about being included in the programme.

The third programme was the ITV Tonight Programme with Tom Bradbury that was showcasing the work Mary Ring had undertaken at Good Hope around DTOCs and the interconnecting work with other stakeholders.

It was agreed to email out the dates the programmes would be aired. The Chair reported that, where the Trust was aware of upcoming media events Governors would receive notification. It was agreed that a monthly retrospective update would be produced and circulated. All governors were invited to attend the Building Healthier Lives Awards being held on 3 November 2016, details would be emailed.

16.098 DATE OF NEXT MEETING

The next meeting was scheduled for 24 October 2016, to be held in in the Education Centre, Heartlands Hospital.

There being no further business the meeting closed.

..................................... Chair

Council of Governors

Minutes of a meeting of the Council of Governors of Heart of England NHS Foundation Trust held in Rooms 2 & 3, Education Centre, Birmingham Heartlands Hospital

on 24 October 2016

PRESENT: Rt Hon. J Smith (Chair) Mrs K Bell Mr A Cannon Mr K Fielding Mr A Fletcher Mrs S Hutchings Mr P Johnson Mr M Kelly

Mrs V Morgan Mr G Moynihan Mr B Orriss Mrs L Passey Mrs J Thomas Mr D Treadwell Mr T Webster

IN ATTENDANCE: Mr K Bolger Mr J Brotherton Mr D Burbridge Mr A Edwards Mrs S Foster Ms H Gunter Mrs A Hudson (Minutes)

Dr M Kinski Mr J Miller Dame J Moore Dr D Rosser Prof M Sheppard

and members of the public.

16.099 WELCOME and APOLOGIES for ABSENCE

The Chair welcomed everybody to the meeting. Apologies for governors had been received from Dr N Burgess, Mrs McGeever, Dr Needham, Mrs S Nicholl, Mrs J Teall and Dr Trotter. Apologies for directors had been received from Mrs Alexander and Prof Glasby.

16.100 DECLARATIONS OF INTEREST

There were no new declarations were noted from Governors or Directors

16.101 MINUTES OF PREVIOUS MEETINGS

6 July 2016 The minutes of the meeting were approved as a true record.

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25 July 2016 The minutes of the meeting were approved as a true record.

7 September 2016 (AGM) The minutes of the meeting were approved as a true record. There was a discussion on the current style of recording discussions held at meetings and it was recorded that it was good practice that minutes reflected an overview of the general discussion and the decision taken.

16.102 MATTERS ARISING

16.071.1. Update on progress of STP to a future meeting – An update report would be

presented to a future meeting.

16.077. Check and update Governor email distribution – Completed.

16.080. Update on out-patient cancer appointments. The Deputy CEO –improvement had

given an update at the last meeting. Two areas within Division 5 had been identified for

further review, glycoma and retinal screening. It was agreed that a review of each of the

cancer sites would be undertaken and a report would be presented to the next meeting.

6.082. Provide progress report on Grade 3 pressure ulcers – included in the Care Quality

Report

16.082. Provide report on Calm Care Nursing – The Chief nurse would bring an update to

the next meeting.

16.082 Chair/Governor Breakfast meeting on role of ACP. A date would be agreed and

circulated.

16.103 CHAIRS UPDATE

The Chair and CEO had spent considerable time developing the Sustainability and Transformation Plan prior to its submission on 21 October. Contrary to NHS England wishes, the draft plan had been published on the Birmingham City Council website. The Chair and CEO had met with the leaders from Birmingham City Council, Solihull Metropolitan Borough Council to discuss how the Trust could work more effectively with the council in relation to social care. The Chair and CEO had also recently attended the joint Overview and Scrutiny Committee of Birmingham City Council and Solihull Metropolitan Council to update them on progress at the Trust and to talk about future plans. The Chair had attended the Carers Conference in October which bought together Trust staff, members of the Carers Forum and organisations who provided support for Carers.

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Dame Caroline Spelman, MP and Jack Dromey MP had also attended. Feedback from the event had been very positive. The Chair reported that as formal feedback from the CQC was still to be received and invited the Chief Nurse to give a brief report on initial feedback following the visit on 18, 19 and 20 October. Overall the assessment had been an encouraging one. They said they had seen some significant progress in a number of areas, with a significant change across the Trust in staff attitude, culture and morale since their last inspection in 2014. They highlighted some themes and issues which needed to focus on e.g. information governance, infection prevention and control and medicines management. They also highlighted some areas of excellent practise. Any immediate actions would be implemented through the divisional structure. No items of immediate concern had been highlighted. Since the visit the CQC had requested a further 60 piece of additional information and they had reported that they would come back within two weeks to undertake another unannounced visit. The requested information had not indicated whether the CQC were specifically looking at areas for the next unannounced visit.

The Trust had, through mock CQC inspections, highlighted 3 key areas that required focus:

infection and prevention, uniform policy, information governance including the security of

patient notes. There had also been some incidents of out of date drugs stock and fridges

that were not at right temperature. Following a discussion it was reported that guidance had

been issued to the ward based pharmacists to check ward stocks.

The CEO had sent a message of thanks to staff and had highlighted that the overall

conclusion of the visit had been one of good progress but with more to do, which was

considered a fair assessment.

There was a discussion on patient records and whether there were plans for electronic

patient records at the bedside and it was noted that currently the Trust did not have the

infrastructure to implement trust wide patient records on such a scale at the present time.

There was a discussion on the pros and cons of electronic records and it was reported that

the maternity service had been invited to lead work for a paperless system. There was a further discussion on the visits to the A&E departments at Good Hope and Heartlands and whether the CQC had taken into account how busy it had been. The Chief Nurse reported that it was recognised but not taken into account. The CEO reported that, due to the increase in A&E attendance across the Birmingham area, NHSI would look in to attendance. It was also recognised that A&E were working really hard, and CQC has been asked to take this into account when writing their formal report.

Resolved: to accept the report.

16.104 CHIEF EXECUTIVE’S UPDATE

The Chief Executive reported she had nothing further to add to the Chair’s update.

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16.105 PERFORMANCE

The Council of Governors considered the update given by the interim Deputy Chief Executive – Improvement. Following the NHS Improvement consultation that ended in August 2016, the new final framework had been introduced from 1 October 2016. The key principles of the new framework remained. Providers would be assessed against five domains (Quality of Care, Finance and Use of Resources, Operational Performance, Strategic Change and Leadership and Improvement Capability (Well-Led). A more detailed update would be provided to the next meeting. It was reported that two of the Monitor Risk Assessment Framework targets had been missed: the A&E 4 hour and C.Diff target. The A&E target continued to be a challenge into October with performance at 86.79%. There was a discussion on the A&E 4 hour target and it was reported that although some trusts were achieving the target, over 80% of trusts were not. The winter plan would come to the next meeting. All cancer targets had been met in month and the Governors recognised the performance achieved. There was a discussion on the achievement of performance within the cancer team and whether the learning could be applied to other services at the Trust it was reported that the learning had been rolled out and teams such as in A&E had made tremendous improvement but because of pressures the results had not been realised. The Trust had achieved 11 of the 13 national targets monitored locally through CCG Contract missing the ambulance handover and sleeping accommodation targets. Ambulance handover performance for 30 minute waits had been 94.99%, the worst performance year to date. Following a discussion on how ambulances decided which hospital to take a patient to it was reported that in many instances it was down to the driver, although the decision should be down to the ambulance dispatcher. Patients could express a preference but it was not always honoured. The Trust and West Midlands Ambulance Service jointly funded an ambulance officer on the Heartlands site and was looking to put a similar role at Good Hope. Ambulance control had the technology to manage flow and was able to see track ambulances across the patch however they were reluctant to give dispatchers responsibility for managing that flow. There had been two sleeping accommodations breaches in September affecting 5 patients. HDU and CCU at Heartlands had one breach each, RCAs were being undertaken, It was explained what constituted a sleeping breach. The Trust had failed to meet the breast feeding target in September achieving 71.6% against a target of 72%. The DTOC target had been missed in month achieving 2.06% against a target of 1.4%; despite the amount of work undertaken by the Trust to reduce internal delays. It was reported that the number of beds available in the community had reduced including the closure of private care homes and local health authority beds. There was a discussion around the lack of community beds and what impact the STP had it was reported that there had been an increase in the number of beds in the community and in reality more beds were required. Following the launch of the flu programme 32% of front line staff against a target of 75% had received flu jabs. Staff sickness rates had increased to 4.18%. Staff turnover had increased slightly in month to 9.48% against 9.29% in the previous month. There was a

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discussion on how the Trust managed long term sickness and it was reported that staff dependent upon their individual needs had access to occupational health and well-being services such as mandatory training and physiotherapy as well as graduated return to- work. Sickness for agency staff was not recorded or monitored by the Trust but by the agency used. Resolved: to accept the report

16.106 CLINICAL QUALITY MONITORING REPORT

The Council of Governors considered the Clinical Quality Monitoring (CQM) Report. The report provided assurance on clinical quality and detailed action being taken following the CQM Group held on 27 September 2016. There were four investigations underway into doctors’ performance. The clinical classification system of CUSUM (cumulative summation) and Hospital Standardised Mortality Ratio (HSMR) methodology used by the CCQ was explained, including how systematic problems were tracked; all cases that flagged were subject to a deep dive audit and discussed at an Executive RCA forum. One group, Acute Bronchitis breached the mortality threshold in June 2016 and had been subject to review, which had demonstrated no cause for concern. Fluid and electrolyte disorders, flagged at the meeting in July, had been investigated and had shown no cause for concern, it was noted that there had been some issues around coding. The Trust SHMI (summary Hospital – Level Mortality Indicator) and HSMR (Hospital Standardised Mortality Ratio (HSMR) performance were within acceptable limits. For September the Trust had achieved 80% compliance with the one hour target from prescription to administration for Antibiotic Stat (one-off) does. There was a discussion on why 20% of patients did not receive the dose and it was reported the process was not always straight forward from prescribing to administration of drugs. However compliance had improved following implementation of the first responder bleep holder role on all wards across the divisions and compliance would continue to be monitored.

Resolved: to accept the report

16.107 CARE QUALITY REPORT

The Council of Governors considered the Care Quality Report presented by the Chief Nurse. There had been a regional spike in the number of cases of post 48 hour toxin positive Clostridium difficile (C.Diff), and had twelve reported cases. A post infection review carried out in conjunction with the CCG established that seven of the cases were unavoidable. Of the five avoidable, three were due to inappropriate antibiotic prescribing and two were inconclusive. There had been one new case of CPE identified and an action plan had been put in place There had been a focus on adherence to the uniform policy and hand-washing. It was reported that all patients were screened for MRSA, and stool samples taken to test for C.Diff. There had been a decrease in the number of avoidable hospital acquired Grade 2 pressures ulcers. There had been one avoidable Grade 3 pressure ulcer that, following a full RCA review, had been attributed to poor documentation. The Trust was introducing a

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pilot to increase the number of healthcare assistants to help with repositioning compliance. The number of patients that suffered recurrent falls had increased from 23 in July to 36 in August. Compliance against the 80% Trust target for antibiotic STAT doses administered within one hour was 79% in August. Compliance had improved following the implementation of the first responder bleep holder role on all wards across the divisions, where there was low compliance wards would be called to account. Qualified nursing vacancies across all clinical areas had increased by 24 in month across the divisions and compliance against e-rostering continued to be monitored. There was a discussion on the requirement for 1-1 nursing for some patients and it was reported that the Trust had an enhanced observation policy and a range of options available such as calm care nursing where patients with similar needs were cohorted. The Chief Nurse was confident the policies and compliance was robust an escalation to 1-1 nursing was based on patient needs. Work continued to improve the patient experience and complaints process. There was a discussion on the number of complaint opened versus closed complaints and it was reported that all complaints were tracked with clear escalation processes in place. Divisions now worked with the patient services and had dedicated days to clear complaint backlogs. Divisions received reports of common themes, the most common of which was staff attitude. Resolved: to accept the report

16.108 FINANCE REPORT

The Council of Governors considered and discussed the reported presented by the Director of Finance and it was noted that the Trust has agreed a planned deficit of (£13.6m) for the 2016/17 financial year, in line with the control total set by NHSI. However, after the plan had been submitted it was confirmed that emergency readmission penalties had not been included within the wider suspension of fines and penalties, as had originally been understood. This had worsened the Trust’s financial position by £5.4m and the latest forecast was a deficit of (£19.0m), this assumed full delivery of planned efficiency savings. The current forecast deficit was (£24.8m) and NHSI had confirmed that organisations which did not achieve their original control totals would forgo at least one quarter of STF funding (£5.8m). The Trust had reported an overall I&E deficit of (£1.1m). This was £0.7m better than the plan for September. The reported position included £0.4m of donated asset income which was excluded from the performance for the purposes of accessing STF. Despite the strong performance at Q2, the Trust was still forecast to miss the control total at Q4 due to the scale of improvement required in the second half of the year and risk around winter pressures. The Trust’s cash balance at the end of September had fallen to £23.2m, £23.3m above plan due to slippage on capex and favourable working capital movements. As a consequence it was now forecast that interim revenue support would not be required until January. The financial risk rating remained at 2. As of next month this would be replaced by a new ‘Use of Resources’ (UoR) metric as part of the introduction of the Single Oversight

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Framework (to replace RAF). The Trust was expected to be rated 3 out of 4 for UoR with 1 being best. The meeting held a lengthy debate and it was reported: that the Genesis stock system had been implemented at the start of October and benefits should be seen going forward. The worst possible prognosis would be a deficit of (£24m) based on missing one quarter of activity, an improvement had been seen in the quarter as well as a steady increase month on month and it was predicted that the year-end position would be between (£15m) and (£16m) but further discussion with NHSI and the STP would be held nearer the time. The Board had at its meeting earlier in the day had approved the request to apply for distressed funding, it was advised this was the route that the DH encouraged Trusts to use. The Board had earlier in the day also approved the loan document to fund the ACAD work to access £3m funding in order to commence the enabling works. Despite the cash position the Trust would not put a hold on capital spend for equipment replacement approved by the Board. In response to the worsening national position, NHSI had tightened their grip and control over provider finances with additional requirements for providers in terms of explaining prior year pay bill growth, controlling agency expenditure in terms of publishing details of the top 20 high earners and sign off of all shifts above a certain threshold by the CEO resulting the need for much of the day’s workload taken up by with micro management. There was also a new protocol for changing forecasts adversely in year. The interim Director of Finance agreed to circulate further details of the purchase of community defibrillators following a request from the Governor for Sutton Coldfield referred to under the Division 4 expenditure section. Specifically relating to how many had been purchased, whether they had been delivery and the locations. Resolved: to accept the report

16.109 COMPLIANCE AND ASSURANCE

The Council of Governors considered the paper presented by the interim Director of Corporate Affairs. As Governors were aware that the Trust had received an unannounced visit from CQC in September as the prelude to the formal inspection that had taken place between 18 and 20 October. A review of compliance against the 2014 formal CQC inspection enforcement actions had been completed by the Director of Corporate Affairs and the Chief Nurse and revealed that the Trust had completed 82% of required actions with midwifery staffing and recovery waiting times remained a challenge despite a number of actions having been put in place. There was a discussion on the scoring of the self-assessment exercise that had taken place and it was reported that it had been based on an average across all sites and specialities and improvements seen since the 2014 CCQ inspection. A review of the current position against all NICE guidance had been undertaken with 89% full compliance with published guidance. For 2016/2017, there were 62 active national audits and CORPs Clinical Outcomes Publications (formerly known as Consultant Outcomes publications), that HEFT was eligible to participate in with HEFT currently participating in 60. 36.7% of Clinical Guidelines housed on the Intranet were out of date. This was an improvement from the 50% reported last quarter. For 2016/2017, there were 62 active national audits and Clinical Outcome Review

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Programmes (CORP) that HEFT was eligible to participate in, with HEFT participating in 60. The two audits not participated in were the National Ophthalmology Audit and the National Diabetes Core Audit, reasons for non-participation were clinician and resource led respectively. The close down of all 2014 audits was under review and each directorate had an audit lead. 36.7% of Clinical Guidelines housed on the Intranet were out of date. This was an improvement from the 50% reported last quarter and mirrors work underway with policy work. National Safety Standards for Invasive Procedures (NatSSIPs) was a new NHS England project designed to improve patient safety and reduce never events. Each trust was expected to develop its own set of standards; HEFT was working with colleagues at UHB to produce unified standards. Resolved: to accept the report

16.110 ANY OTHER BUSINESS

There was a discussion on the gap between that days CoG meeting and the next planned meeting of the CoG on 23 January 2017. The Board were due to meet in November to hold a meeting in private. Following a discussion the Chair reported that the gap had been due to moving the meeting forward by one week to 24 October rather than the first week in November and noted that the CoG did not normally meet in December in any event. In recognition of the gap the Chair agreed to keep Governors informed of Trust progress against performance at the scheduled breakfast meetings on 25 November, 16 December and 17 January 2017 as well as by email. The Case for Change Project progress reports from the two Review Group meetings would be made available to all Governors. It was agreed to circulate the new membership for CoG groups by email later that week. It was also reported that the G4S contract was due for renewal in 2017.

16.111 DATE OF NEXT MEETING

The next meeting was scheduled for 23 January 2016, to be held in the Education Centre, Heartlands Hospital.

There being no further business the meeting closed.

...................................... Chair


Matters Arising & Decisions/Recommendations Tracker

Da

te r

ais

ed

Min

ute

No

Detail

Ac

tio

n b

y

Due Status

Co

mp

lete

d

11 May 16 16.050 Report on how local 2015/16 Better Care Fund was utilised.

KB Jul 16 Provided update – closed

25 Jul 16

16.052 Revise format or data on A&E attendance table (3.1.1) to improve clarity.

KB Jul 16 Included in Performance report – closed

25 Jul 16

6 Jul 16 16.071.1 Update on progress of STP to a future meeting

JB TBC

16.077 Meeting of CoG Appointment Committee to be convened post-holiday season

AH Sept 16 Completed Nov 16

25 Jul 16 16.077 Check and update Governor email distribution list if required.

AH Sept 16 Completed 26 Jul 16

16.080 Update on out-patient cancer appointments

KB Sept 16 Included in Performance report – closed

25 Sept 16

16.082 Provide progress report on Grade 3 pressure ulcers

SF Sept 16 Included in Care Quality report – closed

23 Jan 17

Provide report on Calm Care Nursing

SF Sept 16

Chair/Governor Breakfast meeting on role of ACP

AH TBC

HEART OF ENGLAND NHS FOUNDATION TRUST


23 January 2017

As well as other committees and breakfast meetings, governors have met twice in the

Project Review Group and in the joint Working Group with UHB governors. In this work, we

have been supported by the Good Governance Institute to think about how a new Council of

Governors could be the ‘best in the country’!

The work of the Sustainability and Transformation Plan continues. There is a new Board to

direct the work. I am the Vice Chair and have been responsible for proposing new

governance for the ongoing work. The Board is now focussed on pushing forward the work

on new models of care; better integration with adult social care and a new focus on

prevention and working with other bodies to improve the overall health of the Birmingham

and Solihull population. There will also be a new push to engage more widely on the work.

I addressed the NHS Providers conference on the governance lessons from Chairing two

NHS Trusts. I met with Ed Smith, the Chair of NHS Improvement to talk about our STP and

about the progress here at HEFT. Julie Moore and I met with Simon Stevens from NHSE to

talk about local progress and challenges. In all these meetings, we also made clear our view

that national organisations need to do more to support our work and less to interfere and

demand meetings and paperwork.

I opened the first NHS Litigation Authority conference held in Birmingham to ensure that the

Authority is better able to share the learning from the cases it deals with and that Trusts

develop their approach to dealing with incidents and complaints. I also made a video for the

UK Improvement Alliance on how Boards can support improvement in the NHS.

I attended the excellent HEFT Staff Awards and presented the Chairs’ Award and a special

award to our former Lead Governor, Richard Hughes. I thought this was an inspiring

evening and I know that governors and Board members who also attended enjoyed it

immensely too.

I convened a meeting with the Police, clinicians and voluntary sector organisations to

consider how we can better support the victims of violence who present at our Emergency

Departments. There is real scope for intervening and signposting people at this critical

moment for them, but with the departments under so much pressure, we need to find

external support for this to work alongside our staff.

Governor Louise Passey met with me and Sam Foster to talk about her excellent work on

Autism awareness and action. We are thinking about how this can be incorporated into our

work at the Trust.

I attended the Solihull PCP to talk about the Case for Change.

I visited the Coroners’ Office with Liam Byrne MP as part of my continued interest in how we

can support the families of the bereaved. I met with Dawn Chaplin who has done a lot of

work on this and will be presenting our approach to councillors next month.

I have met all the NEDs individually to carry out the new style appraisals. These will be

reported to the CoG via the CoG Appointments committee who will consider and agree the

detail of the appraisals and objectives.

I continue to meet fellow Chairs and have recently discussed local and national issues with

Caragh Merrick, the newly appointed Chair of Worcestershire Acute NHS Trust, Danielle

Oum from Walsall Acute Trust and Jeremy Vanes from the Wolverhampton NHS Trust.

In the run up to the Metro Mayor elections in May, I have met Beverley Nielsen, Lib Dem

Candidate and Sion Simon, Labour Candidate. Invitations are open to all candidates.

Jacqui Smith

January 2017

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MONDAY 23 JANUARY 2017

Title: Performance Indicators Report

Responsible

Director :

Kevin Bolger, Interim Deputy CEO - Improvement

Contact Kevin Bolger, Interim Deputy CEO - Improvement

Purpose To update the Council of Governors on the Trust’s performance against targets and indicators in the Single Oversight Framework, contractual targets and internal targets

Confidentiality Level & Reason

Annual Plan Ref

Not applicable

Key Issues Summary:

Exception reports have been provided where there are current or future risks to performance for targets and indicators included in the Single Oversight, national and contractual targets and internal indicators. A&E 4 hour performance remains a risk for the Trust; all other STF trajectories are being met.

Recommendations The Council of Governors is requested to: Accept the report on progress made towards achieving performance targets and associated actions and risks.

Approved by:

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PERFORMANCE INDICATORS REPORT PRESENTED BY THE INTERIM DEPUTY CEO - IMPROVEMENT

1. Purpose

This paper summarises the Trust’s performance against national indicators and targets, including those in the new Single Oversight Framework which commenced on 1st October 2016, as well as local priorities. Material risks to the Trust’s Provider Licence, finances, reputation or clinical quality resulting from performance against indicators are detailed below.

2. HEFT Performance Framework

The Trust has a suite of Key Performance Indicators that includes national targets set by NHS Improvement and the Department of Health (DH) and local indicators selected by the Trust as priority areas, some of which are jointly agreed with the Trust’s commissioners. This report is intended to give a view of overall performance of the organisation in a concise format and highlight key risks particularly around national and contractual targets.

3. Material Risks The DH sets out a number of national targets for the NHS each year which are priorities to improve quality and access to healthcare. NHS Improvement (NHSI) tracks the Trust’s performance against a subset of these targets, enabling Trusts to access the Sustainability and Transformation Fund as long as agreed trajectories are achieved. Table 1: Performance against key national targets

Indicator ThresholdCurrent Data

Period

Period

actual

18 week RTT - incomplete 92% Dec 92.40%

A&E 4 hour access 95%Dec

(unvalidated)81.54%

Cancer 62 day - GP urgent referral 85% Nov 91.17%

Cancer 62 day - national screening 90% Nov 100%

6 weeks diagnostic test 99% Dec 99.69%

Single Oversight Framework

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3.1 Single Oversight Framework

Of the 5 Operational Performance Indicators in the Single Oversight Framework, 4 were on target in the most recent month. The A&E 4 hour wait target was not met a remedial action plans are in place.

3.2 NHS Improvement – Sustainability and Transformation Fund

Appendix 1 shows latest performance against the Sustainability and Transformation Fund (STF) trajectories. Of the 4 STF trajectories, 3 were on target in the most recent month. The A&E 4 hour wait trajectory was not met. 3.2.1 A&E 4 Hour Waits

There were 22,125 attendances in December, compared to 21,986 in November and an STF projected activity of 21,510. An increase of 0.63% Unvalidated performance shows that the A&E 4 hour wait target position deteriorated in December to 81.54% from 85.45% in November. Validation is unlikely to significantly impact on final performance. Table 2: A&E Performance by Site (unvalidated)

Site Performance

Heartlands 79.4%

Good Hope 77.1%

Solihull 98.8%

Trust 81.54%

Indicator ThresholdCurrent Data

Period

Period

actual

Cancer 2 week 93% Nov 96.40%

Cancer breast - 2 week 93% Nov 96.50%

Cancer 31 days- first treatment 96% Nov 99.31%

Cancer 31 days- subsequent treatment -surgery 94% Nov 96.83%

Cancer 31 days - subsequent treatment - drugs 98% Nov 100.00%

Ambulance Handover > 30 minutes >0 Dec 379

Ambulance Handover > 60 minutes >0Dec

(unvalidated)31

12 hour Trolley waits A&E 0 Dec 0

52 week waits 0 Dec 0

Cancelled Ops rearranged 28 days 0 Dec 0

Urgent operation cancelled x 2 0 Dec 3

Sleeping Accommodation Breach 0 Dec 3

MRSA 0 Dec 1

C.difficile - (all cases) 5 Dec 6

C.difficile - (avoidable cases) 0 14

VTE risk assessment 95% Dec 96.69%

Duty of Candour (2 months in arrears) 0 Oct 0

NHS Number acute 99% Dec 99.64%

NHS Number A&E 95% Dec 98.06%

Other National Targets

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The Trust failed to meet the STF trajectory for quarter 3 and the funding associated with this is now at risk. The Trust is developing an appeal to submit to NHSI. When the trajectories were developed a number of caveats for delivery were stated such as demand staying in line with LDP plans and that DTOC rates were reduced. It is therefore possible that the Trust can provide mitigation to avoid any financial loss.

3.2.2 18 Week Referral to Treatment (Incomplete Pathways)

The Trust met the incomplete pathway target for December achieving 92.4%. There were 3 specialties that failed to meet the target T&O (87.52%, would have needed to see an additional 231 patients in 18 weeks to meet the target), Gynaecology (90.71%, 37 additional patients needed to be seen within 18 weeks) and Rheumatology (91.38%, breaching the target by 4 patients) Gynaecology has been delivering the 18 weeks incomplete target through the validation of the non-admitted pathway. However from December over 50% of the breaches are now on the admitted pathway and a number of these have breached due to a lack of operating time. The Access Booking and Choice team are exploring options in the private sector, under the NHS contract, but have had limited success. Division 2 are also exploring options around extending theatre operating times and are pooling sub-specialty patients.

3.2.3 62 day cancers

The Trust met both the 62 day cancer targets (referral from GP and referral from screening service) achieving 91.2% and 100%, respectively, in November and unvalidated data for December indicates that both targets will continue to be met.

3.2.4 % patients waiting <6 weeks for 15 key diagnostic tests

The Trust has met the target in December achieving 99.69% against the 99% target. (Validation on three patients awaited – which is likely to improve final performance).

3.3 National Targets Monitored Locally Through CCG Contract

There are 19 national targets that are not included as Operational Performance Metrics in the new Single Oversight Framework but are included in the CCG contract.

3.3.1 MRSA

There was one case of MRSA in December, bring the year to date total to 4. This occurred on Ward 3 at BHH an RCA is being undertaken.

3.3.2 C.difficile

The Trust had 6 cases of c.diff in month, against a target of 6, however remains ahead of the year to date target of 46, having had 56 cases in total.

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Only one of these cases has been identified as avoidable, bringing the total number of cases deemed as avoidable to 14 at the end of December.

3.3.3 Urgent Operations cancelled for the second time

There were three urgent operations cancelled twice in December. The reasons related to running out of time due to previous cases overrunning, lists being overbooked and lack of availability of a critical care bed. Further scrutiny of this target will be undertaken at the next Divisional Review Meetings in February.

3.3.4 Ambulance Handover

There were 7433 ambulance arrivals across the Trust in December, the largest number since April 2014. The December 30 minute ambulance handover performance is shown in the table below.

Table 3: Ambulance handover 30 minute breaches by site

Site Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

BHH 134 103 163 128 139 141

GHH 181 147 172 175 169 223

SH 4 7 6 5 6 15

Trust 319 257 341 308 314 379

The unvalidated 60 minute handover performance currently shows that 31 patients waited over 60 minutes in ambulances. The Trust is working with the ambulance service to verify these and it is likely that performance will improve.

3.3.5 Mixed Sex Accommodation Breaches

There was one occasion of the mixed sex breach target affecting three patients in the AMU at Good Hope.

4. Local Indicators – acute contract

There are 45 local contractual indicators that the Trust’s performance is measured against (24 are reported monthly, 18 of these are reported quarterly and three bi-annually).

4.1 Delayed Transfers of Care (DTOC) for health and joint delays

The Trust has failed to meet this target in month, achieving 1.6% against a target of 1.4%, performance by site is shown in the table below.

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Table 4: DTOC HEFT and external NHS joint health delays

The table below shows performance for all delayed transfers of care i.e. those that are health and social delays. Table 5: All DTOC delays

4.2 Maternity Quarterly indicators

For those metrics for which quarterly data is available there are 2 that are currently non-compliant.

Proportion of babies requiring repeat blood sample due to an avoidable failure in the sampling process performance is 2.8% against a 2% target.

Proportion of babies eligible for the newborn physical examination tested within 72 hours of birth achieving 92.5% against a 95% target

This performance will be reviewed at the Division 2 review meeting in February.

5. Local Indicators – community contract

The Trust has a number of community contracts, many of the indicators against these contracts are reported quarterly:

5.1 Solihull CCG contract

Of the 18 KPIs reported through this contract the Trust is compliant with all but one.

This failure relates to the percentage of Designated Doctor sessions delivered by the community paediatrician. Performance for Q3 was 81.6% against a target of 85%. This KPI is primarily used as a tool for monitoring delivery of sessions over the year, and any lost time this quarter will be made up in future quarters.

5.2 Health Visiting KPIs

Following review at the Divisional Review Meeting it was agreed that performance against the Health Visiting KPIs would be undertaken on a monthly basis (with quarterly reporting to the CCG). In November of the 12

Site Jul-16 Aug-16 Sept-16 Oct-16 Nov-16 Dec-16

BHH 2.1% 1.7% 2.2% 1.6% 1.4% 2.2%

GHH 1.3% 0.5% 1.0% 0.6% 1.0% 0.4%

SH 4.9% 4.2% 3.7% 1.85% 1.78% 3.38%

Trust 2.2% 1.6% 2.0% 1.3% 1.3% 1.6%

Site Jul-16 Aug-16 Sept-16 Oct-16 Nov-16 Dec-16

BHH 4.1% 3.5% 4.9% 3.6% 3.1% 4.7%

GHH 2.8% 1.8% 3.1% 1.4% 2.6% 1.7%

SH 7.4% 8.0% 7.7% 4.4% 4.4% 4.6%

Trust 4.1% 3.6% 4.7% 3.0% 3.1% 3.6%

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KPIs that are monitored monthly the division met 5, in December this has improved to 7.

From a quarterly perspective, for the same indicators, the Trust has met 5 of the indicators, an improvement on the two it met in Q2.

A detailed review of performance will be undertaken at the next Divisional Review Meeting in February.

6 Local Internal Indicators . 6.1 Information Governance Training

The Trust has a requirement as part of its mandatory training for 85% of staff to be trained in Information Governance, about 12 months ago the Trust issued a leaflet with payslips to staff, that was deemed adequate to meet the requirements. However this is shortly to expire and staff are now required to undertake training either through a Moodle training programme or through classroom based training. Table 6: Information Governance Training Compliance

Division Aug Sept Oct Nov Dec

Corporate 12.99% 14.97% 26.71% 40.22% 50.95%

Facilities 16.29% 12.42% 19.03% 21.04% 26.99%

Division 1 17.16% 17.70% 27.02% 37.10% 51.42%

Division 2 18.99% 24.17% 31.42% 51.22% 57.02%

Division 3 21.82% 23.25% 24.61% 34.76% 41.97%

Division 4 20.07% 22.25% 25.77% 34.44% 45.53%

Division 5 20.42% 21.96% 25.78% 34.46% 41.87%

Trustwide 18.60% 20.19% 26.32% 37.18% 46.71%

7. Local Indicators - Workforce

7.1 Mandatory Training and Appraisal

Mandatory training performance remains above target at just under 90% with a year to date figure of 92.69. Appraisal completion rates continue to improve and remain above target at just over 88%. The year to date figure is 87.15%.

7.2 Recruitment

Time to hire (recruitment) performance has continued to improve over the past three months and remains within target.

Turnover has increased slightly to 9.55% from 9.44% last month, continuing a recent trend. The launch of a revised exit monitoring process should improve intelligence on reasons for leaving, and target retention effort.

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7.3 Other workforce Indicators

Sickness absence rates have increased slightly to 4.25% from 4.20% last month and remain above the 4% target. Sickness absence has continued to rise over the last few months indicative of cyclical peaks and matches the position last year. Continued efforts to manage long term sickness remain a priority. Short term rates should be checked as a result of the Trust Flu programme which exceeded the 75% vaccination target.

8. Recommendations

The Council of Governors is requested to:

Receive the report on progress made towards achieving performance targets and associated actions and risks.

Kevin Bolger

Interim Deputy Chief Executive - Improvement

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Appendix 2

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

HEFT Performance 89.97% 87.87% 82.20% 91.60% 89.84% 89.84% 88.24% 91.17%

Trajectory 82.80% 84.90% 85.20% 85.40% 85.50% 85.50% 85.30% 85.50% 85.70% 86.10% 86.20% 86.50%


HEFT Performance 92.27% 92.45% 92.13% 92.06% 92.04% 92.72% 93.03% 93.30% 92.40%

Trajectory 91.20% 91.36% 91.52% 91.68% 91.84% 92.00% 92% 92% 92% 92% 92% 92%

2016/17 STF Trajectories at HEFT - December

validated unvalidated

62 Day Cancer Trajectory - month in arrears

RTT Incomplete pathways Trajectory

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


Pe

rfo

rman

ce

Month

HEFT Performance Trajectory

91.00%

91.50%

92.00%

92.50%

93.00%

93.50%

94.00%

94.50%

95.00%


Pe

rfo

rman

ce

Month


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Trajectory 97.34% 97.68% 98.03% 98.37% 98.71% 99.00% 99% 99% 99% 99% 99% 99%



Trajectory 84.0% 85.5% 87.0% 88.0% 90.0% 91.0% 91.0% 92.0% 91.0% 91.0% 91.5% 92.0%

A&E Trajectory

Diagnostics National Target Trajectory

90.00%

91.00%

92.00%

93.00%

94.00%

95.00%

96.00%

97.00%

98.00%

99.00%

100.00%


Pe

rfo

rman

ce

MonthHEFT Performance Trajectory

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


Pe

rfo

rman

ce

Month




MONDAY 23rd JANUARY 2017

Title: Clinical Quality Monitoring Report

Responsible

Director :

Dr David Rosser, Interim Executive Medical Director

Contact Imogen Gray, Interim Head of Quality Development

Amy Fowlie, Interim Project Assistant (Quality Development)

Purpose To provide assurance on clinical quality to the Council of Governors and detail the actions being taken following the Clinical Quality Monitoring Group (CQMG) meeting 20th December 2016.

Confidentiality

Level & Reason

N/a

Annual Plan Ref

N/a

Key Issues

Summary:

The Council of Governors will consider:

Investigations into Doctors’ performance currently underway

Mortality indicators: CUSUM, SHMI, CRAB and HSMR

Board of Directors’ Unannounced Governance Visits

Performance for timely delivery of antibiotic stat (one off) doses

Recommendations The Council of Governors is asked to receive the information set out in this report and accept the actions identified.

Approved by: Dr David Rosser, Interim Executive Medical

Director

16th January 2017

1. Introduction

1.1 The aim of this paper is to provide assurance on clinical quality to the Council of Governors detailing the actions being taken following the December 2016 Clinical Quality Monitoring Group (CQMG) meeting. The Council of Governors is requested to discuss the contents of this report and approve the actions identified.

2. Update On Medical Staff Within The Remit Of Maintaining High Professional

Standards (MHPS) 2.1 There are currently six investigations in progress into Doctors’ performance. The

investigations relate to four Consultant Grade Doctors and two Specialty doctors.

Three of these Doctors have restrictions placed on their practice.

3. Mortality – CUSUM

3.1 Mortality is reviewed in a number of ways including the ‘CUSUM’ (cumulative sum) Hospital Standardised Mortality Ratio (HSMR) methodology which is used by the Care Quality Commission (CQC).

3.2 One CCS (Clinical Classification System) had higher than expected mortalities and

was a potential mortality threshold trigger in September 2016: ‘Peritonitis and intestinal abscess (148)’.

3.3 The case list for the CCS group was reviewed at the CQMG meeting on 20th December 2016. It was agreed that a review of the patient case list for the CCS group ‘Peritonitis and intestinal abscess (148)’ will be reviewed by a Consultant General Surgeon. Once this review has taken place the Trust will write to inform the Care Quality Commission (CQC) of the outcome.

Figure 1: HEFT CUSUM in September 2016 for HSMR CCS Groups

3.4 The Trust’s overall mortality rate as measured by the CUSUM for September 2016 is within acceptable limits.

Figure 2: HEFT CUSUM in September 2016 at Trust level

4. Mortality – SHMI (Summary Hospital-Level Mortality Indicator)

4.1 The Trust’s SHMI performance for April 2016 to August 2016 was 90. The Trust has had 1,733 deaths compared with 1,917 expected. The Trust is within the acceptable limits as shown in Figure 3 below.

Figure 3: HEFT SHMI April to August 2016

5. Mortality – HSMR (Hospital Standardised Mortality Radio)

5.1 The Trust’s HSMR for the period April-September 2016 was 97.37 which is within

acceptable limits. The Trust had 1,243 deaths compared with 1,276 expected (see Figure 4 below).

Figure 4: HEFT HSMR April to September 2016

6. CRAB (Copeland Risk Adjusted Barometer) surgical 30 day risk adjusted mortality ratio to October 2016. 6.1 The Trust’s CRAB 30 day surgical mortality O/E (outcome versus expected) ratio is

within the normal range and either below or equal to the average of 1 (see Figure 5 below). There are no specialty or individual Consultant outliers.

Figure 5: CRAB 30 day surgical mortality O/E ratio October 2016

7. Board of Directors’ Unannounced Governance Visits

7.1The Children’s Assessment Unit (CAU) at Good Hope Hospital (GHH) was visited

16th December 2016. The visit was positive from a patient perspective. The staff on

the ward are engaged and well familiarised with the new length of stay procedures

for CAU. To optimise medical skill mix for Paediatrics across the Trust, the potential

for rotating medical staff will be reviewed and implemented as appropriate. There

are challenges presented by the environment on CAU and a full Estates review will

be undertaken in conjunction with a programme of rationalising equipment and

optimising storage space. The action plan has been sent to the Divisional

Management Team for completion.

8. Recommendations

The Council of Governors is asked to:

receive the information set out in this report and accept the actions identified.

Dr David Rosser Interim Executive Medical Director 16th January 2017

1



Monday 23rd January 2017

Title: Care Quality Board Report

Responsible Director : Sam Foster, Chief Nurse

Contact 4-1323

Purpose The purpose of this report is to provide an overview of performance against targets and indicators in the Single Oversight Framework, contractual and internal targets for October 2016.


Confidential

Annual Plan Ref

Key Issues Summary: Exception reports have been provided where there are current or future risks to performance against targets and indicators included in the Single Oversight Framework, national and contractual indicators and internal targets. Infection Control - There was one MRSA bacteraemia reported for October 2016 in division five. A post infection review has been carried out with the clinical teams and there were no breaches in policy and no lapses of practice identified although it was not possible to determine the focus of infection. Compliance against MRSA screening was below the required 90% and was at 85.99% in October 2016. An increased number of MRSA screening swabs were rejected during October as specimens were sent with two swabs in the sample bottle. In response to this there is an on-going education programme to inform clinical staff of the correct method for obtaining MRSA swabs. Tissue Viability - The number of avoidable grade 2 pressure ulcers reduced in month by 50% from a total of 10 in September 2016 to a total of 5 in October 2016. There were two avoidable grade 3 pressure ulcers in October 2016, both in division five, on two different wards. The number of avoidable grade 2 and 3 pressure ulcers is on trajectory for the month of October 2016. Tissue viability metrics were compliant at 95% in October 2016 with repositioning frequency adhered to at 85% for the third month in a row. VTE - The number of patients not screened for VTE in October 2016 was 595 which is the highest number not screened in the previous 12 months and has risen by 85 missed screens since the previous month (September 2016).

2

Sepsis - Part 2A of the Sepsis CQUIN requires 90% screening compliance for all emergency and inpatients who are eligible to be screened for sepsis. Part 2B requires 90% compliance against all emergency and inpatients that receive antibiotics within one hour to have an empiric review within three days. In October 2016, compliance for Part 2A was at 42.99% (Emergency Department) and 46.97% (Inpatients). For Part 2B, compliance was 10% (Emergency Department) and 37.38% (Inpatients). Dementia Screening - It is an expectation of the Trust that all patients over the age of 75 are screened for dementia. The Trust target for this indicator is 90% and performance for October 2016 is at 84.79%. Community - There are no exceptions for care quality indicators for community services. Nurse Staffing - Compliance for staffing in October 2016 was at 100% with the exception of division two who were at 94% for qualified staffing in both Neonatal and Paediatric High Dependency. Qualified vacancies in October were 295 WTE, which is an increase from September (275 WTE). Qualified predicted starters for December 2016 is 49, and 132 in January 2017. Patient Experience - During October, the percentage of positive responders was 94% for inpatient and 82% for the Emergency Department. This was an increase on 1% in both areas. Response rates remain at a representative level (36% in patient, 20% ED). Complaints - Compliance with the 30 working day standard for October 2016 is at 21% compliant. Health Visiting KPIs- Of the 14 Health Visiting KPIs there are a total of 6 exceptions in October 2016. Non Cubicle Nursing Emergency Department (ED)- The results of the November 2016 audit outline good compliance against the revised Intentional Care Plan within ED.

Recommendations The Council of Governors is asked to consider the information set out in this report.

Approved by: CEG Board of Directors

3




1. Purpose

This paper summarises the Trust’s performance against national indicators and targets, including those in the new Single Oversight Framework which commenced on 1st October 2016 as well as local priorities.

2. Single Oversight Framework

NHS Improvement (NHSI) has introduced a new Single Oversight Framework (SOF) for both NHS Trusts and Foundation Trusts which replaced Monitor’s Risk Assessment Framework (RAF) for Foundation Trusts on 1st October 2016. There are five themes within the framework as follows:

Quality of Care: The CQCs rating for the Safe, Caring, Effective and Responsive domains, delivery of the four priority 7-day standards and in-year information.

Finance and use of Resources: Financial efficiency and progress in meeting the financial control total.

Operational Performance: Progress with improving and sustaining performance against NHS Constitution and other standards.

Strategic Change: How well providers are delivering the strategic changes set out in the Five Year Forward View.

Leadership and Improvement Capability: A shares system view with CQC on what good governance and leadership looks like, including organisations’ ability to learn and improve, building on the joint CQC and NHSI well-led framework.

NHSI will use the information they collect on provider performance to identify where providers need support across these five themes. NHSI have identified an initial set of measures and triggers which will assist them to determine the level of support required and this report will focus on one of the five themes that is Quality of Care. Specifically NHSI will use the quality indicators outlined in table 1 to supplement CQC information in order to identify where providers may need support under the theme of quality:

4

Table 1 Quality Performance Metrics

Measure Frequency Target

Mixed sex accommodation breaches

Monthly 0

Inpatient scores from Friends & Family Test - % positive

Monthly ≥95%

A&E scores from Friends and Family Test - % positive

Monthly ≥95%

Emergency C-Section Rate Monthly

Maternity scores from Friends & Family Test - % positive

Monthly ≥95%

VTE Risk Assessment Quarterly ≥95%

Clostridium difficile - variance from plan

Monthly ≤5

Clostridium difficile - infection rate

Monthly

MRSA bacteraemia Monthly 0

There is now an NHSI requirement to provide an update on the delivery against an agreed trajectory for the four priority standards for 7-day hospital services. This information will be provided in the November 2016 Care Quality Report. Quality of Care

3. Infection Control

3.1 MRSA Bacteraemia

There was one MRSA bacteraemia reported for October 2016. A post infection review has been carried out with the clinical teams from Ward 2 BHH, Radiology BHH, and Renal Dialysis Unit BHH, Infection Prevention Control Team and CCG. There were no breaches in policy and no lapses of practice identified although it was not possible to determine the focus of infection. The infection was attributed to the Trust and an action plan was developed for Ward 2 BHH. The patient was very unwell and subsequently died of causes other than MRSA.

3.2 MRSA Screening

Compliance against MRSA was below the required 90% and was at 85.99% in October 2016. An increased number of MRSA screening swabs were rejected during October as specimens were sent with two swabs in the sample bottle. In response to this, there is an on-going education programme to inform clinical staff of the correct method for obtaining MRSA swabs.

4. Tissue Viability

4.1 Avoidable Grade 2 Pressure Ulcers

The number of avoidable grade 2 pressure ulcers reduced in month by 50% from a total of 10 in September 2016 to a total of 5 in October 2016 and

5

overall numbers remain on trajectory for year end. The embedding of the trust wide grade 2 avoidability checklists has contributed to this reduction of harm for patients.

4.2 Avoidable Grade 3 Pressure Ulcers

There were two avoidable grade 3 pressure ulcers in October 2016, both in division five on two different wards. The division have issued individual staff members on both wards with poor practice / reflection notices for action as per trust protocol. The number of avoidable grade 3 pressure ulcers is on trajectory for the month of October 2016. See Appendix 1 for Trust Wide Tissue Viability Grading Matrix.

4.3 Care Quality Metrics - Tissue Viability Assessment

Tissue viability metrics were compliant at 95% in October 2016 with repositioning frequency adhered to at 85% for the third month in a row. The areas of concern with repositioning are within divisions three and five. Division three reported a total of 12 wards scoring below 80% compliance in month, and division five reported a total of four wards. Each of these wards have presented reason for non-compliance at divisional quality meetings and have been tasked with performing daily metrics to ensure improvement. The introduction of Matrons undertaking additional monthly tissue viability metrics early in 2016 was intended as a second check of performance at the beginning of every month, in particular for repositioning frequency adhered to. However, progress against the additional metrics has highlighted differences in scores and has revealed a difference in the clinical metrics measured. As a result of this, from October 2016 both sets of metrics have been aligned to measure the same indicators to ensure a second check of performance.

4.4 Shared Learning Event

A planned shared tissue viability learning event took place in partnership with the University Hospitals Birmingham Tissue Viability Team in September 2016. The event consisted of a review of performance, teamwork, systems and education and prevention in clinical practice. Shared learning took place across all four hospitals and HEFT have agreed the following actions:

Review the size and capacity of the Tissue Viability Team to ensure capacity for wider education and training;

Introduce a different grading system by April 2017;

Review numbers of patients versus numbers of pressure ulcers;

Split data into harm by medical devices and non-medical devices;

Introduce an electronic referral system.

5. Venousthromboembolism (VTE) Screening

The number of patients not screened for VTE in October 2016 was 595 which is the highest number not screened in the previous 12 months and has risen by 85 missed screens since the previous month (September 2016). There are two divisions that are non-compliant and are division two (gynaecology) and division five (elective surgery areas).

6

Actions undertaken include discussion at speciality directorate meetings where exceptions exist and re-issuing of the VTE policy to all Clinical Directors for discussion with wider teams.

6. Sepsis CQUIN

Part 2A of the Sepsis CQUIN requires 90% screening compliance for all emergency and inpatients who are eligible to be screened for sepsis. Part 2B requires 90% compliance against all emergency and inpatients receiving antibiotics to have received these within one hour and to have had an empiric review within three days. Compliance for October 2016 is as follows:

Part 2A - Emergency Department 42.99% - Inpatient areas 46.97%

Part 2B - Emergency Department 10.00% - Inpatient areas 37.38%

The actions taken to improve compliance in all areas include education and training for all matrons to undertake the audits and re-issuing of the sepsis video highlighted the importance of screening. Further work is to be undertaken by the Clinical Directors in each specialty to review the audit process and improve compliance. More specifically, division three is revising its current process within the Emergency Department.

7. Dementia Screening

It is an expectation of the Trust that all patients over the age of 75 are screened for dementia. The Trust target for this indicator is 90% and performance for October 2016 is at 84.79%. The lowest scoring divisions are division three (Emergency Department, and Cardiology) and division five (Cardiothoracic, ENT, Gastroenterology, Trauma & Orthopaedics, Urology, and Vascular Surgery). Divisional Directors have reminded all medical staff to ensure that Junior Doctors are completing the screening tool.

8. Community Services

There are no exceptions for the care quality indicators for community for October 2016. There was one Pals concern raised that was resolved locally. Performance against the care quality indicators can be viewed in Appendix 2.

9. Nurse Staffing

Compliance against safer staffing levels in October 2016 was at 100% with the exception of division two who were at 94% for qualified staffing in both Neonatal and Paediatric High Dependency. The Head Nurse scoped all areas and led mitigation plans to ensure patient safety during this time.

7

Division Qualified Compliance %

HCA Compliance %

1 (wards only) 100% 99%

2 94% 99%

3 98% 107%

4 99% 108%

5 97% 101%

Trust 98% 103%

Qualified vacancies in October were 295 WTE which is an increase from September 2016 (275 WTE). The main reason for the increase is the addition of Ward 7 BHH and Ward 3 GHH as funded wards, which were previously classed as flex with no substantive establishment. Qualified predictive starters for December 2016 is 49 and January 2017 is 132.

10. Patient Experience

During October, the percentage of positive responders was 94% for inpatient and 82% for the Emergency Department. This was an increase on 1% in both areas. Response rates remain at a representative level (36% in patient, 20% ED). Patient comments received via FFT are shared with Divisions and the themes evident for improvement are analysed. Feedback from Patient Community Panel member’s ‘mystery shopper’ programme has been provided. Findings from this work were largely positive

11. Complaints

Compliance with the 30 working day standard for October 2016 is at 21% compliant. Each week divisions are provided with a summary of all complaints within the 30 working days and their older complaints. This detail is also provided by speciality. The stage each complaint is at in the process is also provided. In addition each Division is provided with a weekly position of the numbers of live complaints they have within the 30 working day period and how many more they need to resolve to achieve the 85% standard. If this 85% standard cannot be achieved, the highest possible response rate which can be achieved within month is communicated.

A complaints session was provided to new Group Support Managers, further more detailed sessions are scheduled across the organisation. This will include a Snakes and Ladders board game based on the NHS Complaints procedure to demonstrate to staff requirements, pitfalls involved in the process and likely occurrences along the way in resolving complaints. During October 136 formal complaints were registered which is a significant increase, when 113 complaints in total were closed. A review of action plans is currently being undertaken. Divisional action logs are planned which highlight actions pledged, mapping these to physical areas, clinical

8

specialties and theme of complaint. Divisions will be asked to provide assurance of actions completed, once the action log template is established. Complaints teams are currently working with Governance colleagues to create the required report to allow this.

12. Health Visiting (HV) KPIs

Of the 14 Health Visiting KPIs there are a total of 6 exceptions in October 2016. These are compliance against

Health Visit by day 14 for all new births

6-8 week breast feeding status

Child 12 month review

Child 2-2.5 year review

Babies under 1year moving into area checked by HV within 14 days

Blood spot status recorded 8-8 weeks In response to this division two are leading a series of work streams to ensure improvements against performance against the KPI exceptions.

13. Non Cubicle Nursing - Emergency Department (ED)

Due to increased activity and reduced capacity within the Emergency Department at Heartlands Hospital, when require, patients are allocated to a designated corridor space prior to being assessed in a cubicle. As a result of this, in September 2016, the Intentional Rounding care plan was re-designed and implemented. This document provided a prompt to nursing staff to ensure that care needs were met when a patient is allocated to the corridor ahead of assessment. The document focuses of the following fundamentals of care:

Is the patient safe to be allocated to the corridor?

Clinical observations/vital signs and MEWS complete.

Pain score complete.

Privacy and dignity maintained.

Nutritional needs assessed.

Mobility needs assessed.

Tissue viability/repositioning considered. In addition the care plan aims to ensure that all patients are provided with a wrist band for identification and allergy status is recorded.

To provide assurance of clinical practice regular audits take place. An audit was undertaken in November 2016 to assess the use and compliance with the care plan/document and the results are displayed in the table below

9

Date

o

f

Att

en

da

nce

Assessm

en

t

Tim

e

Is

pa

tien

t S

afe

?

Me

ws

reco

rde

d

Nam

ed

Nu

rse

All

erg

ies

reco

rde

d

ID B

an

d

Pri

vacy

an

d

Dig

nit

y

Nu

trit

ion

al

Need

s

Mo

bilit

y

Need

s

28/11/2016 17:40 Yes Yes Yes Yes Yes Not Recorded Not Recorded Not Recorded

28/11/2016 20:58 Yes Yes Yes Yes Yes Yes Yes Yes

29/11/2016 01:16 No Yes Yes Yes Yes Not Recorded Not Recorded Not Recorded







29/11/2016 12:55 Yes Yes Yes Yes Yes Not Recorded Not Recorded Not Recorded

The results of the audit indicated the following findings-

90% of patients were safe to be allocated to the corridor

100% of patients had a MEWS score recorded

100% of patients had an allocated named nurse

100% of patients had allergy status recorded and were identifiable by wearing a wristband

There was no evidence of privacy and dignity being assessed for 30% of patients audited

There was no evidence of nutritional needs being assessed for 30% of patients audited

There was no evidence of mobility needs being assessed for 30% of patients audited

Each shift the Emergency Department Team identifies a nurse who is responsible for the care of patients who are allocated to the corridor. For the period audited on day 1 there were15 Registered Nurses on duty against an establishment of 17 for this shift. On day 2 there were 16 Registered Nurses on duty against an establishment of 17 An additional two registered nurses are requested to support Intentional Rounding. These nurses are booked to Ambulatory Emergency Care (AEC). The Intentional Rounding document has been incorporated within the ED Nursing Assessment document making it available to all nursing staff immediately. The Directorate are continuing to work with IT to build a virtual space within MSS to ensure that all patients who are allocated to the corridor are recorded on MSS. This will allow accurate monitoring and audit.

Regular audits will be undertaken and will be included in future reports to provide assurance of safe and effective care to the Council of Governors.

10

Appendix One

11

Appendix Two

1




Title: Patient Experience Complaints Analysis Q2 2016

Responsible

Director :

Sam Foster - Chief Nurse

Contact 4-1323

Purpose Information and assurance


Confidential

Annual Plan Ref

Key Issues Summary:

This Paper aims to:

Present the current Trust performance against the Trust Complaints Handling policy and contractual requirements

Provide the Governors with a thematic review of Complaints and the Friends and Family (FFT) data received in Quarter 2.

Identify current themes and provide examples of actions taken as a result to improve patient experience and reduce formal complaints.

Recommendations Endorse specific projects to enhance patient experience

Approved by: CEG Board of Directors

2

Patient Experience Report

Quarter 2 2016 / 17

3

Introduction The Quarter 2 Patient Experience report provides an overview of complaint and Friends and Family test data and themes. It also highlights service improvements and anticipated outcomes for patient experience. Process Developments A suite of revised KPI’s have been agreed to monitor complaint performance for the Divisions and Complaint team. The KPI’s include monitoring: Divisions

Complaint ‘backlog’ (complaints older that 31st July 2016)

Open Complaints (after 31st July 2016)

New Complaints (received in month)

Response rate within 30 working days

Complaints team

Percentage of complaint front sheets correctly completed

Percentage of complaints acknowledged in 3 working days A further afternoon has been identified in October for Division 3 and 5 to address and reduce the number of older complaints in these Divisions. Training sessions have been arranged for ward sisters; matrons, operational managers and operational support managers. Refresher training sessions have also been organised for the complaints team. The training provides an overview of the complaint process and clear roles and responsibilities for all involved in responding to a complaint. A ‘snakes and ladders’ board game has been created to demonstrate the complexities and pressures of responding to complaints within 30 working days. This will be piloted as part of the training sessions.

4

New Complaints in Quarter 2 Formal complaints - Acute

Indicator

Apr May Jun Q1 Jul Aug Sep Q2 Ytd

Total

No of new complaints 69 81 100 250 66 105 91 264 512

No of on-going complaints - includes re-opened 323 269 355 NA 328 345 327 NA NA

No of complaints closed in month 107 92 88 287 98 93 130 321 608

No closed within 30 days 18 10 13 41 13 16 20 49 90

No of re-opened complaints 2 2 7 11 9 7 11 27 38

No of referrals to ombudsman 1 2 0 3 1 0 0 1 4

No of complaints upheld by Ombudsman 0 0 0 0 1 0 0 1 1

No of complaints partially upheld by Ombudsman 0 1 0 1 0 1 0 1 2

No of complaints NOT upheld by Ombudsman 3 0 0 3 1 0 0 1 4

Total No of active complaints at month end 392 350 455 NA 394 450 418 NA NA

Grading of complaints - green 31 36 57 124 33 67 54 154 278

Yellow 18 18 26 62 21 24 28 73 135

Orange 18 19 16 53 10 9 8 27 80

Red 1 4 1 6 1 4 1 6 12

Formal complaints - community

Indicator Apr May Jun Q1 Jul Aug Sep Q2

Ytd Total

No of new complaints 0 0 3 3 1 0 0 1 4

No of on-going complaints 3 5 2 NA 0 1 1 NA NA

No of complaints closed in month 0 0 0 0 1 2 3 6 6

No closed within 30 days 0 0 0 0 0 1 0 1 1

No of re-opened complaints 0 0 0 0 0 0 0 0 0

No of referrals to ombudsman 0 0 0 0 0 0 0 0 0



No of complaints partially upheld by Ombudsman 0 0 0 0 0 0 0 0 0

No of complaints NOT upheld by Ombudsman 0 0 0 0 0 0 0 0 0

Total No of active complaints at month end 3 2 0 NA 1 1 0 NA NA

Grading of complaints - green 0 2 2 4 1 0 0 0 4

Yellow 0 2 0 2 0 0 0 0 2

Orange 0 1 1 2 0 0 0 0 3

Red 0 0 0 0 0 0 0 0 0

5

Proportion of complaints closed within 30 working days

In line with the new KPI’S each division is now monitored around the number of complaints closed within 30 working days. September saw a dip in numbers closed within 30 working days. It is acknowledged that delays were incurred due to availability of staff over the holiday period. The new Divisional triaging process has assisted in identifying the appropriate person to supply statements to avoid delays in the future.

Distribution of Complaints by Division Divisions 3 and 5 continue to receive the highest numbers of complaints due, in part to the nature and complexity of the services and volume of patients each division treats. The complaint team has restructured to provide more support to these Divisions. The overall number of complaints received is similar to that in Quarter 1 (Q1 250 vs Q2 266)

6

Trust-wide Complaints Themes As the table below highlights, clinical care continues as the dominant theme of complaints, followed by communications. Quarter 2 has seen a significant increase in the number of complaints relating to communications from Quarter 1 (38 Q1 vs 65 Q2).

7

Complaints with themes relating to patient falls; pressure sores; and/or infection accounted for a very small number of complaints in clinical care. This may be a reflection of the focus on these important aspects of care, and the duty of candour applied to these harms. Complaints relating to ‘decision regarding treatment’ include concerns that diagnostic tests, perceived by the patient as necessary, were not carried out; refusal or withdrawal of medical intervention and refusal of surgery. This links in with themes about communication and management of patient expectation. The complaints received regarding all aspects of clinical care were varied in nature with 11 rated complex, 11 green, 8 orange and 2 out of time. These complaints featured dissatisfaction with general care, comments regarding potentially neglectful treatment, continuous failure in care provided, poor follow up care and poor nursing care (as opposed to treatment.

8

Many complaints relating to communication also have an element relating to the attitude of a member of staff contained within them. Further analysis of these complaints demonstrates that verbal communication is the most cause for concern. Complaints in this area are predominately related to what information has, or has not, been provided and the manner in which that information was conveyed. A number of complaints cited inappropriate comments made to or about patients within their earshot. Divisional Complaints Themes

Division 1 has the largest percentage of complaints regarding communication. However as the Division with the smallest number of complaints (16) this is not seen as statistically significant.

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Division 2 received a higher proportion of complaints relating to clinical care and nursing care compared to the Trust average. However, in context the overall number of complaints is low and of the 12 complaints received relating to clinical care only 2 were rated orange.

Division 3 received a higher proportion of complaints relating to admission and discharge, which is anticipated in relation to A and E, but interestingly receive significantly less complaints relating to communication than the Trust average. Of the 45 complaints relating to clinical care, 27 were categorised as complex and each included a number of concerns including inappropriate discharge, missed and mis-diagnosis and perceived lack of care.

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Complaints received relating to communications in Division 4 are 21% higher than the Trust average and account for the increase in overall complaints this quarter relating to communication. However, complaints relating to clinical care can be seen to be almost 10% lower than quarter 1. A review of the Divisional position has identified that 8 (44%) of the communication complaints were related to Haematology / Oncology, which received no complaints in Quarter 1.

Division 5 complaints relating to appointment delay were slightly higher than Trust average for Quarter 2, the majority of which related to outpatient appointments. 38 complaints were received relating to clinical care of which 15 were green, 7 orange, 1 red and 13 yellow. On analysis, only 3 complaints related to unexpected outcomes of surgery, 12 related to decisions regarding treatment and 15 complained were in relation to all aspects of their clinical care.

11

Classification of Complaints

Whilst the majority of complaints were not as a result of perceived patient harm, 12% of complaints were categorised as orange or red. 54% of the most seriously rated complaints were regarding aspects of clinical care and a further 18% related to communication. A divisional analysis of the classification of complaints shows that a higher number of complaints within division does not result in a higher number of red complaints but does increase the proportion of orange (complex) complaints. Divisions 3 and 5 continue to receive the highest number of complaints and the largest proportion of complex and emotive cases which require a significant amount of resource to respond to and resolve.

12

Closed Complaints in Quarter The Complaints department continues to focus on working with clinical colleagues to close outstanding complaints and has seen a net reduction of 49 in the quarter.

315 complaints were closed in total in the Quarter, almost 70% of which related to Divisions 3 and 5.

Over 80% of complaints closed in the quarter were either upheld or partly upheld in favour of the complainant. It should be noted that all complaints are subjective and about the patient’s perspective of the care they received. If this fell short of their expectation and there were issues relating to the main themes then the complaint will be partially upheld and actions taken presented in the action plan.

13

As previously discussed the majority of upheld or partly upheld complaints related to clinical care followed by a perceived breakdown in communication.

14

Friends and Family Test Trust-wide Theme Analysis The chart below shows the monthly average Trust-wide returns for the Friends and Family Test. The positive returns and comments greatly outweigh the negative comments with staff attitude remaining most likely to generate a comment, positive or negative.

The top 10 themes across the Trust for the whole quarter are as follows:

15

The following charts highlight the FFT feedback per division and clearly highlight the predominantly positive patient experience across the Trust:-

1 2 3 4 5

6 - Don't Know 594 1.46%

6

4 - Unlikely 878 2.16%

5 - Extremely Unlikely 1,163 2.86%

2 - Likely 9,142 22.50%

3 - Neither Likely nor Unlikely 1,715 4.22%

Overall Scores

Response Option Response Percentag

1 - Extremely Likely 27,145 66.80%

Service Recommended Not

All Departments89% 5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Divisional Performance


Clinical Support Services89% 5%

Overall Scores

Response Option Responses Percentag


2 - Likely 419 23.86%

3 - Neither Likely nor Unlikely 71 4.04%

4 - Unlikely 47 2.68%

5 - Extremely Unlikely 48 2.73%

6 - Don't Know 26 1.48%1 2 3 4 5 6

16


Women's & Children86% 8%

Overall Scores



2 - Likely 380 20.95%


4 - Unlikely 71 3.91%


6 - Don't Know 18 0.99%1 2 3 4 5 6


Emergency Care84% 9%

Overall Scores



2 - Likely 2,715 22.07%


4 - Unlikely 448 3.64%


6 - Don't Know 201 1.63%1 2 3 4 5 6

17


Medicine92% 3%

Overall Scores



2 - Likely 1,594 23.96%


4 - Unlikely 82 1.23%


6 - Don't Know 96 1.44%1 2 3 4 5 6


Surgery90% 4%

Overall Scores



2 - Likely 2,331 24.17%


4 - Unlikely 176 1.82%


6 - Don't Know 161 1.67%1 2 3 4 5 6

18

The following table demonstrates some of the actions required following complaints and the outcomes for patients. An audit of action plans has been undertaken by the complaints team and Divisions have the responsibility for ensuring action plans are completed, accurate changes are made when required and to provide assurance of lessons learnt:-

ID Failing(s) Identified

Service Improvements Anticipated outcomes for Patient Experience

22046 Inability to offer patient review appointment within recommended time frame.

Increase clinic capacity: Waiting List initiative Clinics. Business Case to increase clinicians in Neurology.

Patients receive review appointment and information about their treatment in a timely manner.

21864 Poor communication with care providers.

Ensure nursing team establish the care needs they are happy to provide.

Improved communication and compliance.

21579 Documenting interventions before they have been carried out.

Reinforcement that this practice is not acceptable and can only be recorded once intervention has been completed.

Assurance of care provided.

21872 Unable to prioritise patient in the phlebotomy clinic.

Phlebotomy manager to feedback complaint to phlebotomy staff and remind all phlebotomy site leads of the need to consider patient circumstances and address these appropriately.

Individual patient needs acknowledged and respected.

21517 Wrong site of surgery anaesthetised.

‘Stop before you block’ process has been implemented. Surgery site is marked with a ‘block’ sticker while patient is awake for confirmation.

Assurance that appropriate care is provided.

21529 Unclear information about choice of medication.

Remind pharmacists to be clear with explanations regarding medicines and check patients understanding when they are providing information to patients.

Assurance that correct and appropriate medication is prescribed and dispensed.

21448 Learning identified for both consultants to reflect on their lack of diagnosis. Share learning with medical team.

Update regarding SAH - delivered to department through Grand Round discussion on two occasions.

Performance of staff monitored. Appropriate actions taken when required to prevent situation reoccurring.

19

ID Failing(s) Identified

Service Improvements Anticipated outcomes for Patient Experience

22052 Patient felt consultant was patronising.

CD to discuss case with consultant to make him aware of how he may be coming across to patients.

All patients to be treated with dignity and respect.

21645 Poor communication re treatment and discharge plans.

Senior Sister has reiterated to the nursing staff on SAU the importance of keeping all patients and their relatives updated with care and discharge plans.

Good communication with all patients and carers.

Lack of food and drink offered.

Senior Sister reminded all nursing staff on SAU to check with Doctors following their review of patients to ensure refreshments are offered.

Patients’ nutrition and hydration needs met.

Process for sharps handling not correctly followed.

Matron reiterated that the correct process must be followed at all times when handling sharps/needles. This is to ensure safety for both patients and staff.

Patient and staff safety maintained.

21801 Transport not able to take pt. with orthopaedic brace.

To ensure in future staff discuss transport options and requirements with the Ambulance Service.

All patients’ requirements noted and appropriate actions identified and undertaken.

Staff did not respond to call bell.

Issue discussed with staff and reiterated to them the need for timeliness and sensitivity and to ensure they acknowledge the request for help.

Patient comfort and dignity maintained at all times.

Delay in receiving indigestion medication.

Reminded staff to ensure they respond to these requests in a timely manner.

Adherence to medication policy and assurance for patients and their carers.

Left in toilet. Staff reminded to inform patients to press the call bell in the toilet when they are ready.

Patient privacy and dignity maintained.




Title: Finance Report to 31 December 2016

Responsible

Director :

Julian Miller, Interim Director of Finance

Contact Ext. 40411

Purpose To provide an update on the Trust’s finances for the period ending 31 December 2016 (Month 9 2016/17).


Confidential

Annual Plan Ref

Key Issues Summary:

The Trust has submitted a planned deficit of (£13.6m) for the 2016/17 financial year, in line with the control total issued by NHSI.

In month 8, the Trust revised the year end forecast from (£24.8m) deficit to (£13.6m) deficit as agreed at the Board of Directors meeting on 7 December 2016.

The Trust has reported an actual I&E deficit of (£0.7m) in month 9 (December 2016), which is a (£0.3m) adverse variance against the plan of (£0.4m).

The year to date I&E deficit is (£13.2m) at month 9, which is a (£0.3m) adverse variance against the plan of (£12.9m).

The in month position includes the loss of (£0.7m) STF relating to the A&E performance trajectory which is expected to be recouped following an appeals process. Under the double jeopardy principle, this is excluded by NHSI for the purposes of accessing the remaining STF.

The year to date position also includes a £0.3m favourable variance related to asset donations, which is excluded from the evaluation of delivery against plan for the purposes of accessing STF.

The cash balance is £23.0m at 31 December 2016.

The Use of Resources Metric (UoR) is a 3.

Recommendations The Council of Governors is requested to:

Receive the contents of this report.

Approved by: Julian Miller 16 January 2017




FINANCE REPORT FOR THE PERIOD ENDING 31 DECEMBER 2016

PRESENTED BY THE INTERIM DIRECTOR OF FINANCE

1. Introduction

This report covers the first nine months of 2016/17 financial year, from April to December 2016. The report summarises the Trust’s financial performance and includes information on healthcare activity, expenditure variances and Cost Improvement Programme (CIP) delivery.

The Financial Plan agreed at Board of Directors on 4 April 2016 included a forecast deficit of (£13.6m) for 2016/17, in line with the control total mandated by NHS Improvement as a condition of accessing the Sustainability and Transformation Fund (STF) allocation. Subsequently, following confirmation that emergency readmissions penalties (£5.4m) would still be levied by commissioners, the forecast was increased to a deficit of (£19.0m) for 2016/17, subject to full achievement of planned efficiency savings and full receipt of STF.

As agreed at the Board of Directors meeting on 7 December 2016, the Trust has now revised the year end forecast to (£13.6m) deficit, in line with the required control total, as a result of the better than expected run rate and identification of some non-recurrent flexibility. This should ensure maximum access to the 2016/17 STF, enable greater opportunities for CQUIN funding in 2017/18 and increase the Trust’s ability to negotiate its control total for 2018/19.

The Trust has reported a deficit of (£0.7m) for December 2016 (month 9). This is an adverse variance of (£0.3m) against the planned deficit of (£0.4m). This moves the year to date deficit to (£13.2m) which is an adverse variance of (£0.3m) against the plan trajectory.

It should be noted that the reported position includes a £0.3m favourable variance related to asset donations, which is excluded by NHSI from their evaluation of delivery against plan for the purposes of accessing STF. Within the position, (£0.7m) of STF has been removed for the under-performance against the A&E target trajectory in quarter 3. Under the double jeopardy principle, this is discounted for the purposes of accessing the remaining STF for the quarter. It is currently expected that the A&E deduction will be recouped in February following an appeals process and therefore the forecast of (£13.6m) is predicated on the Trust obtaining full STF of £23.3m for 2016/17.

The December deficit includes an adverse variance of (£2.7m) on NHS clinical income in addition to the loss of STF described above. The seasonal decrease in elective and outpatient income has been greater than in recent years and has not been mitigated to the expected level by increases in non-elective income. Further work is underway to validate this position in particular around work in progress at the end of the month. Further details can be found within the body of the report.

The cash balance at the end of December is £23.0m against a planned overdraft of (£0.9m) at this point, a favourable movement of £23.8m. The previously introduced cash management initiatives are continuing and it continues to be likely that the need for interim revenue support may be pushed back past the year end.

2. Income & Expenditure

2.1 Summary Position

The Trust’s income and expenditure position as at the end of December is a (£13.2m) deficit against the plan of (£12.9m) deficit. However this includes the removal of £0.7m of STF relating to the quarter 3 A&E trajectory performance. If this were to be recouped following the appeals process, the underlying position is a (£12.5m) deficit against the plan of (£12.9m).

Table 1 below details the actual income and expenditure deficit compared to the planned trajectory submitted to NHS Improvement.

Table 1: I&E – Normalised Actual vs Plan

(14.00)

(12.00)

(10.00)

(8.00)

(6.00)

(4.00)

(2.00)

0.00

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

£m

's

2016/17 I&E - Cumulative Actual vs Plan

Cumulative Actual Cumulative Actual Excl STF Loss Original NHSI Plan/Control Total

Table 2 below summarises the Trust’s income and expenditure position at the end of December with analysis of operating expenditure from section 2.2 and operating revenue from section 2.6 below.

Table 2: Income and Expenditure Plan vs Actual

In Month In Month In Month YTD Plan YTD Actual Variance

Plan August Actual August Variance December December

£m £m £m £m £m £m

Operating Revenue 59.4 55.6 (3.8) 533.3 532.0 (1.3)

Operating Expenses (57.8) (54.3) 3.5 (528.0) (527.4) 0.6

EBITDA 1.6 1.3 (0.3) 5.2 4.6 (0.7)

Depreciation (1.4) (1.4) (0.0) (12.8) (12.8) (0.0)

Interest Receivable 0.0 0.0 0.0 0.0 0.1 0.1

Interest Payable (0.1) (0.0) 0.0 (0.5) (0.2) 0.4

PDC Dividend (0.5) (0.5) (0.0) (4.7) (4.7) (0.0)

Other Finance Costs 0.0 0.0 0.0 0.0 0.0 0.0

Surplus/(Deficit) (0.4) (0.7) (0.2) (12.8) (13.1) (0.3)

Gain/(Loss) on Asset Disposal (0.0) 0.0 0.0 (0.1) (0.1) 0.0

Total Surplus/(Deficit) Before Impairments (0.5) (0.7) (0.2) (12.9) (13.2) (0.3)

Impairment (Losses) / Reversals 0.0 0.0 0.0 0.0 0.0 0.0

Surplus / (Deficit) After Impairments (0.5) (0.7) (0.2) (12.9) (13.2) (0.3)

2.2 Operating Expenditure Analysis

The favourable operating expenditure variance of £3.5m in month and variance of £0.6m year to date can be broken down as detailed in table 3 below.

Table 3: Breakdown of Variance against Plan

In Mth Plan In Mth Actual Variance YTD Plan YTD Actual Variance

December December December December

£m £m £m £m £m £m

PAY

Medical Staff 10.2 10.8 (0.6) 90.5 94.7 (4.2)

Nursing 14.5 14.9 (0.4) 128.3 134.7 (6.4)

Scientific & Technical 5.1 5.1 (0.0) 45.8 45.5 0.2

Other 7.3 5.8 1.5 70.8 59.2 11.6

Total Pay 37.1 36.6 0.5 335.3 334.1 1.2

NON PAY

Drugs 5.7 5.6 0.2 52.5 54.0 (1.5)

Clinical Supplies & Services 4.9 5.6 (0.7) 49.0 52.2 (3.2)

Other 10.1 6.5 3.6 91.2 87.1 4.1

Total Non Pay 20.7 17.7 3.0 192.7 193.3 (0.6)

GRAND TOTAL 57.8 54.3 3.5 528.0 527.4 0.6

The main areas of pay and non-pay variance are explored further in sections 2.3 to 2.5 below.

2.3 Pay Analysis

The main areas of pay variance relate to Medical and Nurse staffing.

2.3.1 Medical Staffing

Tables 4.1 and 4.2 below detail the monthly expenditure for medical staff split between consultant and non-consultant posts respectively.

Total medical expenditure was £10.8m in December, which is a reduction of £0.1m on the expenditure in November and (£0.3m) higher than the average monthly expenditure in months 1 to 8.

The month 9 expenditure on consultant medical staff was £6.1m which is in line with both months 7 and 8 and represents an over spend of (£0.4m) against the budget during the month. Month 9 expenditure on non-consultant staff was £4.7m which is £0.1m lower than the expenditure in month 8 and represents an over spend of (£0.3m) against the monthly budget.

Table 4.1: Senior Medical Expenditure per Month

4,000.0

4,500.0

5,000.0

5,500.0

6,000.0

6,500.0

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

£0

00

's

Month

Senior Medical Expenditure per Month against Budget

Substantive WLIs Agency Locum Budget

Table 4.2: Non-Consultant Medical Expenditure per Month

3,000.0

3,500.0

4,000.0

4,500.0

5,000.0

5,500.0


£0

00

's

Month

Non Consultant Expenditure per Month against Budget

Substantive Agency Locum Budget

2.3.2 Nursing

Table 5 below details the monthly expenditure on nursing compared to the budget.

Table 5: Monthly Nursing Expenditure

11,000.0

11,500.0

12,000.0

12,500.0

13,000.0

13,500.0

14,000.0

14,500.0

15,000.0

15,500.0

16,000.0


£0

00

's

Month

Nursing Expenditure per Month against Budget

Substantive Expenditure Normalised Bank Expenditure Agency Expenditure Budget

Total nursing expenditure in December was £15.0m which is broadly in line with the expenditure in November and is (£0.5m) above budget. The main pressures in nursing expenditure remain in Division 3 (Emergency Care) and Division 4 (Medicine) as a result of acuity pressures across the wards and use of specials, in particular for mental health patients.

Expenditure is expected to increase in January as a result of the significant operational pressures experienced together with the need to use Tier 3 agencies above the NHSI agency capped rates.

2.4 Non Pay Expenditure

2.4.1 Drugs and Clinical Supplies and Services

The expenditure on drugs and clinical supplies is (£4.7m) above plan for the year to date, with an adverse variance of (£0.5m) during December. The in month expenditure on both areas of expenditure has reduced by a total of around £1.8m compared to November. Expenditure on excluded drugs and devices has reduced by £1.1m with the remaining reduction being due to a reduction in elective/daycase activity as described in section 2.6 below.

2.4.2 Other Non-Pay

There has been a favourable variance of £3.6m during December in other non-pay bringing the year to date position to a favourable variance of £4.1m. The main movements in month are due to a reduction in the bad debt provision of circa £1.9m due to the 2015/16 settlements being finalised.

2.5 Divisional Performance

Table 6 below details the budgetary variance by Division split by expense type. The “Income” expense type refers to Category C income such as SLA income from other organisations; it does not refer to NHS Clinical Income, which is detailed in section 2.6 below.

Table 6: Variance Breakdown by Division

Division ExpenseGroupDesc In Month

Budget -

£000's

In Month

Actual - £000's

In Month

Variance -

£000's

YTD Budget -

£000's

YTD Actual -

£000's

YTD Variance -

£000's

D1 INCOME (370.4) (374.9) 4.5 (3,989.6) (4,134.0) 144.3

NON PAY EXPENDITURE 2,344.7 2,034.6 310.0 22,942.4 23,322.4 (380.1)

PAY EXPENDITURE 6,790.2 6,940.1 (149.9) 61,599.9 62,425.0 (825.1)

D1 Total 8,764.4 8,599.9 164.6 80,552.6 81,613.5 (1,060.9)

D2 INCOME (462.3) (396.2) (66.1) (3,918.9) (3,848.9) (70.0)


PAY EXPENDITURE 4,762.3 4,774.8 (12.5) 43,177.5 43,183.8 (6.3)

D2 Total 5,520.0 5,440.9 79.1 48,965.3 49,523.7 (558.4)

D3 INCOME (326.6) (267.0) (59.5) (2,850.7) (2,770.1) (80.5)


PAY EXPENDITURE 7,365.8 7,441.1 (75.4) 63,013.6 66,780.1 (3,766.5)

D3 Total 10,125.1 10,139.6 (14.5) 84,780.3 89,396.2 (4,615.9)

D4 INCOME (240.4) (137.0) (103.4) (2,178.1) (2,174.6) (3.5)

NON PAY EXPENDITURE 4,350.1 4,606.2 (256.1) 40,602.2 42,288.8 (1,686.6)

PAY EXPENDITURE 6,405.2 6,468.1 (63.0) 56,863.1 58,530.8 (1,667.8)

D4 Total 10,514.9 10,937.4 (422.5) 95,287.2 98,645.0 (3,357.8)

D5 INCOME (144.9) (131.3) (13.6) (1,280.2) (1,710.9) 430.7

NON PAY EXPENDITURE 3,504.6 3,093.5 411.1 32,081.7 29,819.6 2,262.1

PAY EXPENDITURE 5,297.3 5,705.7 (408.4) 47,786.0 50,285.1 (2,499.1)

D5 Total 8,657.0 8,668.0 (10.9) 78,587.4 78,393.8 193.7

Grand Total 43,581.5 43,785.8 (204.3) 388,172.8 397,572.2 (9,399.3)

The main monthly issues across the Divisions as detailed below:

Division 1 (CSS) - The contract for 2016/17 with PHE has now been agreed and the annual value is circa £443k lower than previously anticipated, a year to date benefit of £332k. The pressures within the Division relating to temporary staffing within both Theatres and Radiology continue.

Division 2 (W&C) - Some prior year accruals have been removed following a review but the main challenge for the Division continues to be the identification of CIP programmes to address the recurrent gaps for both 2015/16 and 2016/17.

Division 3 (Emergency) - Nursing pressures including agency premium rates and costs of specialling continue to be the main pressure for this Division, with a year to date adverse variance of £2,140k year to date, potential £2,899k for the year. Previously unfunded capacity has now been funded resolving circa £1,254k of this year to date variance going forwards.

Division 4 (Medicine) - Nursing pressures in this division have increased in month primarily relating to additional winter capacity (circa £22k). The main on-going pressure comes from the increased clinical supplies relating to Renal Dialysis programme.

Division 5 (Surgery) - A reduced expenditure in clinical supplies due to reduced activity has produced a significant favourable variance in non-pay in month. Medical pressures continue within the Division for both unfunded rotas and use of waiting list initiatives, a total pressure of £1,961k year to date, potential £2,993k for the year. Ongoing progress against planned reductions in waiting list initiatives will continue to be monitored against whilst a new electronic authorisation and payment system has begun in January 2017 for an initial pilot before roll out across the organisation.

2.6 Income Analysis

2.6.1 Total Operating Income

Total operating income is (£1.3m) below plan year to date which represents a (£3.8m) adverse movement in December as shown in table 7 below.

Table 7 – Income against Plan

In Mth Plan In Mth Actual Variance YTD Plan YTD Actual Variance

December December December December

£m £m £m £m £m £m

Clinical - NHS (53.9) (50.5) (3.4) (485.2) (485.1) (0.2)

Clinical - Non NHS (0.8) (0.7) (0.1) (6.9) (6.9) 0.1

Other (4.7) (4.3) (0.4) (41.2) (40.0) (1.2)

TOTAL (59.4) (55.6) (3.8) (533.3) (532.0) (1.3)

NHS Clinical Income is (£3.4m) below plan in December taking the year to date position to a (£0.2m) under performance against plan. The loss of (£0.7m) of STF associated with the A&E performance trajectory is within this position with the remaining (£2.7m) relating to NHS activity. The year to date position on Excluded Drugs and Devices is £3.7m above plan.

Main areas of under-performance in month include:

Elective/Daycase - (£1.0m)

Maternity Pathways - (£0.5m)

Outpatients/Treatments - (£0.2m)

Direct Referrals - (£0.2m)

Readmissions Penalties - (£0.5m)

This largely reflects seasonal trends, although the impact is greater than seen in recent years, and has not been offset to the extent that would be expected by additional non elective income. Work is underway to validate the income position in particular in relation to work in progress at the end of the month.

2.6.2 NHS Clinical Income/Activity - Inpatients

Table 8.1 below details the monthly admitted patient care (APC) spells against both the evenly phased and seasonally phased targets in December.

Table 8.1: Trust Inpatient Activity

5,000

5,500

6,000

6,500

7,000

7,500

8,000

8,500

9,000

9,500

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

Sp

ell

s

Month

Admitted Patient Care 2016/17 - Actual vs Target (PbR)

Emergency Spells - Actual Emergency Spells - Target Emergency Spells - Phased Target

Daycase & Elective Spells - Actual Daycase & Elective Spells - Target Daycase & Elective Spells - Phased Target

The December in-month activity position reflects an 8.7% over-performance in emergency pathways (733 spells) taking the year to date position to 6.4% over-performance (4,891 spells) against the evenly phased plan. A&E activity has shown 2.1% over-performance in December (457 attendances) taking the year to date position to 3.6% over-performance (7,099 attendances).

The in-month planned elective and daycase activity was (11.8%) below plan (897 cases) increasing the year to date under-performance further to (3.1%) below plan (2,151 cases) predominantly across surgical specialities.

2.6.3 NHS Clinical Income/Activity – Outpatients

Table 8.2 below details the monthly outpatient attendances compared to both the evenly phased and seasonally phased targets in December.

Table 8.2: Trust Outpatient Activity

60,000

65,000

70,000

75,000

80,000

85,000

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

Att

en

da

nc

es

Month

Outpatients 2016/17 - Actual vs Target

Outpatient Attendances - Actual Outpatient Attendances - Target Outpatient Attendances - Phased Target

Outpatient activity in month has under-performed by (7.1%) (5,144 attendances) reducing the year to date delivery to 1.3% above plan (8,635 attendances). There are not any areas of significant over-performance in month however main areas of under-performance in month are Therapies (1,605 attendances, 19.2%), Trauma and Orthopaedics (1,136 attendances, 14.7%) and Paediatrics (563 attendances, 26.9%).

2.6.4 Divisional Performance

Table 9 below details the variance against the evenly phased plan, split by Division and point of delivery but excluding performance on Excluded Drugs and Devices.

Table 9: Healthcare Income Variance vs Evenly Phased Plan

Division IP - £000's OP - £000's Other - £000's Total - £000's

1 - CSS 140 169 (2,567) (2,258)

2 - W&C 361 77 3,527 3,966

3 - Emergency 3,960 2,245 (1,860) 4,345

4 - Medicine (586) 1,509 1,116 2,040

5 - Surgery (4,244) (108) (2,042) (6,394)

Central Risks 0 0 (4,802) (4,802)

Total (368) 3,892 (6,628) (3,104)

Point of Delivery

3. Cost Improvement Programmes

3.1 Current Year CIP Programme

The current year CIP performance by Division is detailed in table 10 below.

Table 10: CIP Delivery by Division

Division Phased YTD

Target - £000's

YTD Actual -

£000's

YTD Var -

£000's

Yr End Target -

£000's

Yr End

Forecast -

£000's

Yr End

Forecast Var -

£000's

CORPORATE 842 661 (181) 970 1,006 36

FACILITIES 800 800 0 940 1,066 126

CSS 1,538 1,443 (95) 1,478 2,006 528

WOMENS & CHILDRENS 859 808 (51) 1,290 1,327 37

EMERGENCY CARE 1,474 1,425 (48) 2,460 2,208 (252)

MEDICINE 1,944 1,848 (96) 2,598 2,580 (17)

SURGERY 1,539 1,406 (133) 2,264 1,951 (314)

Total 8,997 8,392 (605) 12,000 12,144 144

The 2016/17 target for CIPs is £12.0m with a month 9 year to date phased target of £9.0m. Delivery year to date is £8.4m, or 93.3% of target, a (£0.6m) under-performance. Forecast delivery at the year-end is £12.1m, albeit £1.8m of this forecast delivery is non-recurrent in year.

3.2 Financial Recovery Plan

Year 1 of the Trust’s Financial Recovery Plan included agreed cross cutting schemes with saving opportunities of £6.3m, the delivery of which is detailed in table 11 below.

Table 11: Year 1 Cross Cutting Schemes

Workstream / Project Scheme StartIn Year Benefit

2016/17 - £000's

In Mth Target -

£000's

In Mth Actual -

£000's

YTD Target -

£000's

YTD Actual -

£000's

Finance: OBS Restructure Apr-16 236 20 20 177 177

Diagnostics: Radiology Apr-16 332 29 22 246 166

Diagnostics: Pharmacy Apr-16 194 16 16 145 145

A&C: Agency May-16 665 60 50 484 397

A&C: Senior Structure

ReviewJun-16

130 13 31 91 145

Theatres: Trustwide Jun-16 1,004 107 107 631 631

Non Pay: Genesis Jul-16 923 103 615

A&C: Band 2-5 Review Aug-16 168 21 8 105 38

MARS Sep-16 77 255

A&C: Transfer of back

office functions - payrollSep-16

10 38

Non Pay: Standardisation

of spendOct-16

1,168 195 584

Nursing: Nursing Associate

PilotOct-16

265 45 131

Nursing: ACP to replace

locumsOct-16

735 136 327

Length of Stay Oct-16 521 87 0 260 174

Grand Total 6,341 831 340 3,797 2,168

Offset by Tactical CIP (896) (81) (81) (635) (635)

Plan Total 5,445 750 260 3,161 1,532

The main slippage in month continues to relate to the non-pay savings associated with the Genesis stock system, where the roll out has been slower than anticipated,

and the standardisation of spend initiative which has experienced delays at a national level. This month has some further delivery against the MARS scheme which has offset some slippage in other areas in addition to the recognising of the length of stay savings associated with delivering growth activity in the existing bed base. Further contingency plans are being identified in order to mitigate the savings lost during 2016/17 financial year.

4. Statement of Financial Position

The Statement of Financial Position (Balance Sheet) shows the value of the Trust’s assets and liabilities. The upper part of the statement shows the net assets after deducting short and long term liabilities with the lower part identifying sources of finance. Table 12 below summarises the Trust’s Statement of Financial Position as at 31 December 2016.

Table 12: Statement of Financial Position

Actual Actual Plan Annual Plan

Mar-16 Dec-16 Dec-16 Mar-17

£m £m £m £m

Non Current Assets:

Property, Plant and Equipment 260.1 246.9 239.9 246.0

Intangible Assets 2.8 9.9 12.3 12.1

Trade and Other Receivables 1.3 1.5 1.5 1.5

Other Assets 4.0 3.8 4.0 3.9

Total Non Current Assets 268.2 262.2 257.7 263.6

Current Assets:

Inventories 9.1 12.1 10.0 10.0

Trade and Other Receivables 20.8 38.2 41.0 35.0

Other Financial Assets 0.0 0.0 0.0 0.0

Other Current Assets 8.1 16.3 11.0 11.0

Cash 31.5 23.0 (0.9) 21.2

Total Current Assets 69.5 89.5 61.1 77.2

Current Liabilities:

Trade and Other Payables (86.6) (111.0) (93.7) (92.1)

Borrowings (0.5) (0.5) (0.5) (0.5)

Provisions (6.0) (5.3) (5.0) (4.4)

Tax Payable 0.0 0.0 0.0 0.0

Other Liabilities (7.0) (10.9) (6.5) (6.5)

Total Current Liabilities (100.1) (127.8) (105.6) (103.5)

Non Current Liabilities:

Borrowings (3.7) (3.4) (3.2) (3.0)

Provisions (5.9) (5.7) (6.5) (6.5)

Other Liabilities 0.0 0.0 0.0 0.0

Total Non Current Liabilities (9.6) (9.1) (9.7) (9.6)

TOTAL ASSETS EMPLOYED 228.1 214.9 203.5 227.8

Financed by:

Public Dividend Capital 196.7 196.7 196.7 221.7

Income and Expenditure Reserve (24.4) (36.7) (36.8) (36.9)

Donated Asset Reserve (0.2) (0.2) (0.2) (0.2)

Revaluation Reserve 56.0 55.0 43.7 43.1

Merger Reserve 0.0 0.0 0.0 0.0

TOTAL TAXPAYERS EQUITY 228.1 214.9 203.5 227.8

5. Capital Expenditure (Non-Current Assets)

The Trust’s capital programme for 2016/17 totals £23.2m. This reflects £17.1m of internally funded capital, together with £6.1m of capital associated with year 1 of the wider estates programme under discussion with DH and the Treasury.

The planned phasing of this expenditure during 2016/17 together with the actual spend to date is detailed in table 13 below.

Table 13: Capital Programme Trajectory vs Actuals

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

22.0

24.0

26.0


£m

's

Capital Programme versus Actual Expenditure

Cumulative Capex Plan Cumulative Actual

The expenditure to the end of December 2016 was £6.1m against a plan of £13.1m. The team have worked with operational and corporate colleagues and current year end forecast spend is likely to be around £17.8m. This currently includes some contingency funding which is yet to be allocated pending confirmation of a revised forecast outturn for the IT upgrade programme. The main reduction in the capital forecast is a result of the reduced costs of ACAD and the Tower Block.

The quarterly update on the capital expenditure year to date can be found in appendix 1.

6. Current Assets

The Trust’s total current assets (excluding cash and inventories) amount to £54.4m at 31 December 2016, £2.4m higher than plan.

Table 14: Analysis of Current Assets (excluding Inventories and Cash)

YTD Actual YTD Forecast

December 2016 December 2016

£m £m

Trade Receivables 47.5 53.6

Bad Debt Provision (10.1) (14.9)

Other Receivables 0.7 2.3

Trade and Other Receivables 38.2 41.0

Accrued Income 3.0 3.5

Other Financial Assets 3.0 3.5

Prepayments 13.3 7.5

Other Current Assets 13.3 7.5

TOTAL 54.4 52.0

Analysis of the age profile of Trade Receivables (unpaid invoices issued by the Trust) is summarised in table 15 below.

Table 15: Aged Debt Analysis

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0-30 30-60 60-365 1 Year+

% o

f D

eb

t

Aged Trade and Other Receivables for December 2016

Overdue debt now stands at £11.8m an increase of (£0.1m) on November 2016. The top 3 balances (outside of CCG Healthcare Income contracts) are:

Burton Hospitals Foundation Trust (£2.5m > 30 days, £2.8m total) – this is a decrease of £0.2m in the month in both the greater than 30 days and overall debt. These balances relate to maternity charges and remain under discussion. A final offer has been sent to Burton in order to resolve and the Trust are awaiting a response.

Sandwell and West Birmingham Trust (SWBH) (£1.0m > 30 days, £1.3m total) – this is an increase of (£0.1m) in month on both the overall and greater than 30 days debt. The majority of the debt (circa 79%) relates to maternity pathways which remain under discussion. The risk share proposal received from SWBH has been rejected and a counter offer has been made. The Trust has requested a meeting in order to resolve.

University Hospitals Birmingham (£1.1m > 30 days, £1.3m total) – this is an increase of (£0.1m) in month both on overall and overdue debt with a number of other items in dispute in addition to the previous Maxillofacial services debt. The majority of this debt is offset by credit owed to UHB and so resolution will have no impact on cash balances.

7. Cash Flow

7.1 Current Position

The cash balance at the end of December 2016 was £23.0m, a decrease of (£4.9m) in month but a positive variance against plan of £23.8m.

Table 16 below shows that the Trust should be able to avoid a requirement for interim revenue support during 2016/17 subject to a continuation of careful cash management.

NHS Improvement has indicated that the Trust should not submit the Distressed Finance application until the facility is imminently required. As such, the application previously approved by the Board of Directors has not yet been made.

Table 16: Daily Cashflow Forecasting as at 7 January

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

01

/04

/201

6

15

/04

/201

6

29

/04

/201

6

13

/05

/201

6

27

/05

/201

6

10

/06

/201

6

24

/06

/201

6

08

/07

/201

6

22

/07

/201

6

05

/08

/201

6

19

/08

/201

6

02

/09

/201

6

16

/09

/201

6

30

/09

/201

6

14

/10

/201

6

28

/10

/201

6

11

/11

/201

6

25

/11

/201

6

09

/12

/201

6

23

/12

/201

6

06

/01

/201

7

20

/01

/201

7

03

/02

/201

7

17

/02

/201

7

03

/03

/201

7

17

/03

/201

7

31

/03

/201

7

£m

Date

Daily Cashflow to 2016/17 Year End - as at 7 January 2017

Actual Closing Balance - £m Forecast Closing Balance - £m Drawdown of Borrowing Point - £m

8. NHS Improvement Finance and Use of Resources Metric

8.1 Finance and Use of Resource Metrics

The Finance and Use of Resource (UoR) metric replaces the previous Financial Sustainability Risk rating (FSRR). Each metric is scored between 1 (best) and 4 (worst) and then an average is calculated to derive the overall

UoR score for the provider. Where providers have an overall score of 3 or 4 for finance and use of resources, this will identify a potential support need under this theme, as will providers scoring a 4 against any of the individual metrics. Providers in financial special measures will default to a score of 4 on this theme.

The individual metrics scored against are detailed in table 17 below.

Table 17: Scoring Mechanism for Finance and Use of Resources Metric

Area Metric Weight Definition 1 2 3 4

Capital Service

Capacity

20% Degree to which the provider's

generated income cover its

financial obligations

>2.5x 1.75-2.5 1.25-1.75 <1.25

Liquidity (days) 20% Days of operating costs held in

cash or cash-equivalent forms,

including wholly committed lines

of credit available for drawdown

>0 (7)-0 (14)-(7) <(14)

Financial EfficiencyI&E Margin 20% I&E surplus or deficit / total

revenue

>1% 1%-0% 0%-(1%) <(1%)

Distance from Finance

Plan

20% Year-to-date actual I&E

surplus/deficit in comparison to

year-to-date plan I&E

surplus/deficit

≥0% (1%)-0% (2%)-(1%) ≤(2%)

Agency Spend 20% Distance from provider's cap ≤0% 0%-25% 25%-50% ≥50%

Use of Resource Metrics

Financial Sustainability

Financial Controls

8.2 Trust Performance

The Trust has been put into segment 3 as was anticipated. This means mandated support must be complied with to address specific issues and help move the Trust into segment 2.

With regards the Finance and Use of Resource Metric, the December year to date metric scoring is detailed in table 18 below and results in an overall UoR of 3.

Table 18: Trust Scoring Year to Date

Area Metric Weight Actual Score

Capital Service

Capacity

20% 0.76 4

Liquidity (days) 20% (25.79) 4

Financial Efficiency I&E Margin 20% (2.53%) 4

Distance from Finance

Plan

20% (0.13%) 2

Agency Spend 20% (19.47%) 1

Use of Resource Metrics

Financial Sustainability

Financial Controls

This rating is anticipated to continue to the end of the financial year.

9. Conclusion

The annual Financial Plan provides for a year end deficit of (£13.6m). At the end of month 9 the Trust has delivered a cumulative deficit of (£13.2m) which is an adverse variance of (£0.3m) against the plan trajectory but includes the removal of £0.7m of STF relating to the quarter 3 A&E performance trajectory target , which is not included within NHSI’s evaluation of delivery against plan for the purposes of accessing the remaining STF.

Whilst the year to date performance is adverse to the plan, the Trust continues to forecast a year end deficit of (£13.6m) in line with the control total as it is expected that lost STF will be recouped following an appeals process.

The Trust’s cash balance as at 31 December 2016 was £23.0m which is £23.9m above the planned overdraft requirement of (£0.9m) at this point in the year. The latest cash forecast indicates that maintaining tight cash management controls may enable the Trust’s need for interim cash support to be avoided for the 2016/17 financial year. The Distressed Finance application has not been submitted, on advice from NHS Improvement, but close cash management will continue and the application will be made if needed.

10. Recommendations

The Council of Governors is requested to:

Receive the contents of this report

Julian Miller Interim Director of Finance 16 January 2017

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Appendix 1 – 2016/17 Capital Expenditure Update

1. Purpose

This appendix provides a summary of capital expenditure in the 2016/17 financial year along with a short progress update on the major capital projects. An overview of the 2016/17 total capital investment, sources of financing and the impact of the Trust’s cash balance is provided at the end of this document.

2. 2016/17 Capital Expenditure Summary

Actual capital expenditure at the end of quarter 3 was £6.1m as shown below compared to the approved £23.2m capital budget for the year. The Trust has recently reforecast the capital expenditure for the year to £17.4m. At month 9, £9.9m has been committed to date:

Table 1: Summary 2016/17 Capital Programme

Capital Allocation 2016/17 Budget

£m

2016/17 Reforecast

Total £m

2016/17 Orders Raised

£m

2016/17 Actual

Expenditure £m

Division 1 Clinical Support Services 3.6 4.4 3.6 1.1

Division 2 Women’s and Children’s 0.3 0.5 0.3 0.3

Division 3 Emergency Care 0.5 0.6 0.5 0.5

Division 4 Medical Specialties 0.4 0.3 0.2 0.2

Division 5 Surgery 0.7 0.8 0.5 0.5

Radiology 1.3 0.1 0.0 0.0

Corporate Directorates 6.0 6.1 2.8 1.6

Facilities 2.6 2.5 1.9 1.8

Contingency 1.7 1.1 0.0 0.0

ACAD 6.1 1.0 0.1 0.1

TOTAL 23.2 17.4 9.9 6.1

3. Capital Programme Update

Division 1 Clinical Support Services: £0.4m has been incurred in 2016/17 on Anaesthetic machines at Solihull. £0.1m has been spent on replacement Patient Ventilators in Critical Care and an Ultrasound Machine at Good Hope. A replacement Stainer has been received by Pathology at Heartlands. Work is near completion on the mortuary expansion at Good Hope. Orders totalling £0.7m have been raised for the Interventional Room at Heartlands and £0.3m for X-Ray Room 1 at Good Hope. Potential savings of £0.3m are expected for the year.

Division 2 Women’s and Children’s: All orders have been raised for the planned projects in Division 2 with £0.3m expenditure incurred to date on neonatal ventilators, resuscitaires and a baby tagging system. Two further projects have been allocated from Contingency totalling £0.2m and are expected to be completed in quarter 4.

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Division 3 Emergency Care: £0.4m has been incurred for Solihull Urgent Care Centre, replacement of ECG machines at Solihull and Heartlands and Cardiology Holter monitors trust wide.

Division 4 Medical Specialties: Expenditure to date of £0.1m includes hip scanning equipment and HEFT Community Defibrillators. A further £0.2m has been incurred for the Renal Water Treatment Plant and Acid Systems. Orders relating to the Renal Water Treatment Plant and central acid systems are to be fulfilled in quarter 4.

Division 5 Surgery: Expenditure to date of £0.5m includes payments for a laser machine, 6 bladder scanners, 3 ultrasound machines, a mini C Arm, mobility equipment and nasal endoscopes. The delay relating to resolving some IT issues surrounding Optical Coherence Tomographers has now been resolved with installation due early in quarter 4.

Radiology: The Trust will be leasing two CT Scanners (Heartlands & Good Hope) and two MRI Scanners (Heartlands & Good Hope), £1.1m will be used to fund the associated turnkey works. A detailed plan for these works has identified slippage in the 2016/17 year due to the complex order in which project components must take place. This slippage is being offset by schemes already prioritised for 2017/18 capital expenditure.

Corporate Directorates: £1.7m has been spent on LAN (Local Area Network), Voice Platform, Core Room Commissioning and on modernisation items. There is £3.0m of the original budget that the ICT director has committed to spending by March 2017 in order for the Trust to meet its forecast.

Facilities: £1.8m on estates projects include the replacement of the LV switch panel in Rectory Road, essential safety measures, medical equipment purchased for the library, fire damper works and replacement of winding gear for lifts. The remaining projects are expected to be completed within the financial year.

Contingency: £1.1m remains unallocated, although there are a number of calls on this including a replacement X-ray tube at Heartlands in mid-January, neonatal minor works, and re-designation of Heartlands medical day hospital space for A&E/ AMU expansion.

ACAD: Of the £6.1m original budget, £3.1m has been approved by DoH for the ACAD project. £0.1m has been incurred to date of the £1.0m that is expected to be spent in 2016/17.

4. Sources of Funding

This capital investment has been funded from the following sources:

£17.1m Trust depreciation;

£0.0m External funding (Badger Clinic); and

£1.0m DoH funding for ACAD.

To maintain the Trust’s overall cash balances, capital investment should be broadly balanced by the sources of funding. In 2016/17 the sources of funding total £18.1m.

There is the potential that a new scheme to support ICT will be announced by NHS Digital in the next few months and the Trust will be putting forward a bid to secure funding in collaboration with UHB to improve the ICT infrastructure.

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5. Slippage in 2016/17

There is potential slippage in 2016/17 schemes in ICT, radiology and contingency that would result in an under spend against the 2016/17 allocation. The capital regime does not allow carry forwards into future years. This slippage will be mitigated by bringing schemes approved by the Capital Prioritisation Group for 2017/18 into 2016/17 where possible. The Board is requested to delegate the approval of these schemes to the interim Director of Finance.



23rd January 2017

Title: Quality Accounts

From: David Burbridge To: Council of Governors

The Report is being provided for:

Decision Y/N Discussion Y Assurance Y Endorsement Y/N

Purpose: To provide the Council of Governors with an update and timetable for the production of the Quality Accounts 2016/17

Key points/Summary:

The format will be similar to last year. In addition NHS England and NHS Improvement have asked for information on :

How you are implementing the Duty of Candour

The patient safety improvement plan as part of Sign up to Safety campaign

Most recent NHS Staff survey results for indicators:

o KF26 – percentage of staff experiencing harassment, bullying or abuse form staff in the last 12 months

o KF21 percentage of staff believing that the Trust provides equal opportunities for career progression or promotion for the workforce Race Equality Standard

CQC ratings and action plans to address any areas that require improvement or are inadequate,

Recommendation(s):

The Council of Governors is asked to consider the information set out in this report

Assurance Implications:

Board Assurance Framework

N BAF Risk Reference No. N/A

Performance KPIs year to date

N Resource/Assurance Implications (e.g. Financial/HR)

N

Information Exempt from Disclosure

N If yes, reason why.

Identify any Equality & Diversity issues

Which Committees has this paper been to? (e.g. AC, QC, etc.)

Audit Committee and Trust Board

1) SUMMARY

This paper is to provide the Council of Governors with a brief update on the plan for the production of HEFT’s Quality Accounts for 2016/17

2) REPORTING ARRANGEMENTS FOR 2016/17 QUALITY ACCOUNTS

Guidance has just been received from NHS England and NHS Improvement advising that there will be no change to reporting requirements and the recommended audits arrangements for the Quality Accounts for 2016/17. The required core set of quality indictors to be included have been provided

They have asked that the Trust should consider including the following information

How you are implementing the Duty of Candour

(where applicable) your patient safety improvement plan as part of Sign up to Safety campaign

Most recent NHS Staff survey results for indicators:

o KF26 – percentage of staff experiencing harassment, bullying or abuse form staff in the last 12 months

o KF21 percentage of staff believing that the Trust provides equal opportunities for career progression or promotion for the workforce Race Equality Standard

CQC ratings and action plans to address any areas that require improvement or are inadequate,

They have also provided early warning that for next year’s Quality Accounts providers will be expected to report their progress in using learning from deaths to inform their quality improvement plans. (This would be an annual summary of the monthly/quarterly Trust Board report in reviewing and learning from deaths)

The Trust is:

expected to gain external audit assurance as in previous years

to share with and include comments in the final account from :

Commissioners – Birmingham Cross City and Solihull CCGs

Local scrutineers – share the draft Quality Account with local Healthwatch and Overview and Scrutiny Committee

Upload onto NHS Choices by 30th June

3) PLAN

HEFT’s Quality Account Report will follow a similar format to 15/16

Part 1: Chief Executive’s Statement on Quality Part 2: Priorities for Improvement for 2016/17 and progress Priorities for Improvement for 2017/18 Statements of Assurance

Service Income

Clinical Audit

Research

CQUINs

CQC

Information Governance Toolkit

Data Quality

Clinical Coding Error Rate Part 3: Further information

Patient Safety Indicators

Clinical Effectiveness Indicators

Patient Experience Indicators

Sign up to Safety Part 4: Statements from Stakeholders

Commissioners

Local Healthwatch and Overview and Scrutiny Committee

Independent Auditors Assurance Report

The timetable for preparation, external discussions, and committee review is shown in Appendix 1

4) RECOMMENDATIONS

The Council of Governors is asked to note this report.

David Burbridge January 2017 Interim Director of Corporate Affairs

Task Date

Project group meeting – Comms/Governance/Finance/Performance 20th December 2016

Review NHS I and NHS E Annual Reporting requirements when received

January 2017

Meet with KPMG for early discussions regarding audit plan 16 January 2017

Issue information requests to leads for mandatory & Part 3 information

By end of January 2017

Discussion with Council of Governors on the audit to be undertaken 24 January 2017

To write to Birmingham Cross City and Solihull CCG, Bham & Solihull Healthwatch, Bham & Solihull OSC advising of timetable for review, offer a meeting and provide date that we intend to send the draft report to them

31 January 2017

Commencement of Audit Work Early Feb 2017

Deadline for information from individual leads 21 February 2017

Paper to Quality Committee re: new priorities 27 February 2017

Update to Council of Governors re: new priorities 27 February 2017

NHS Digital refresh the links to the most current data March 2017

Update to Audit Committee 27 March 2017

Update to Council of Governors 24 April 2017

Send draft QA to CEG and non Execs 25 April 2017

Conclusion of audit of indicators 25 April 2017

Audit Committee consider Final Draft and outcome of audit results Late April 2017

Draft Report to be sent to external groups for comments 30 April 2017

Issue ‘final’ draft to auditors – to review for inclusiveness April 2017

Audit Committee papers due (Final Copy of Account) 19 May 2016

Board and Audit Committee to approve Quality Report and Accounts 24 May 2017

Sign off by CEO & Chair 24 May 2017

Send completed report to NHS Improvement Noon 31 May 2017

Publication on NHS Choices Website 30 June 2017

Appendix 1



23rd JANUARY 2017

Title: QUARTER 3 COMPLIANCE AND ASSURANCE REPORT

Responsible Director: David Burbridge, Interim Director of Corporate Affairs

Contact:

Ann Keogh, Head of Clinical Safety and Governance

Purpose: To present an update to the Council of Governors of the internal and external assurance processes.

Confidentiality Level & Reason:

None

Annual Plan Ref: Affects all strategic aims.

Key Issues

Summary:

In September and October the CQC carried out an

unannounced inspection. This included medical and

surgical wards, critical care, the Chest Clinic and

Community services. Paediatrics and Maternity services

were not included.

A planned external review of Obstetric services had been

commissioned by HEFT to take place during October which

coincided with the main CQC visit

The draft report for both reviews is awaited.

For 2016/2017, HEFT is currently participating in all 60

active national audits and CORPs that HEFT is eligible to

participate in

37% of Clinical Guidelines housed on the Intranet are out

of date. This is stable but an improvement from the 50%

reported for quarter 1.

Recommendations: The Council of Governors is asked to receive the report.

Approved by: D Burbridge Date: 16th January 2017



23rd JANUARY 2017

Page 2 of 10

COMPLIANCE AND ASSURANCE REPORT

PRESENTED BY THE INTERIM DIRECTOR OF CORPORATE AFFAIRS

1. Purpose

The purpose of this paper is to provide the Council of Governors with information regarding internal and external compliance.

2. Trust Compliance with Regulatory Requirements

2.1 Care Quality Commission (CQC)

In September the CQC carried out an initial unannounced inspection of specific services within the Trust across all 3 sites followed, in October, by a 3 day visit and a further follow up unannounced visit to ED

The first one day unannounced visit covered medical and surgical wards and critical care. The CQC then confirmed that, during the announced inspection, it would not inspect Children’s and Maternity Services, Critical Care Services or End of Life Care. They would review all the other services including the Chest Clinic and Community Services

CQC advised that Maternity Services would not be reviewed at this time as the Trust had commissioned its own external review which took place at the same time.

Following each visit a large amount of requests for data and information was requested and provided. Over a two month period the Trust received a total of approximately 720 requests for lines of information, many of which required submission of more than one document (it is estimated that this equates to in excess of a 1000 individual pieces of information).The requests ranged from minutes of Trust Board meetings, performance and activity information, service specifications, complaints and incidents information through to mandatory training and appraisal down to staff group and copies of drug fridge checking records.

Following the visit and verbal high level preliminary feedback we have focussed on improving the following areas whilst we await the formal feedback

ED safety and overcrowding in corridors- pain relief

Out of date medicines/CDs/ IV fluids/Fridge temperatures

Infection control- Uniform (adherence at GHH in surgery) and handwashing

VTE and sepsis compliance

IG issues- safety/ confidentiality of notes on wards and transportation between sites

The Trust is awaiting the CQC draft report for accuracy checks following the final request and provision of data just towards Christmas.

The Maternity Review draft report is awaited.



23rd JANUARY 2017

Page 3 of 10

2.2 NICE GUIDANCE

Overall Position A review of total NICE guidance to-date has been undertaken with 961 published NICE guidelines reviewed.

Guidance Fully Implemented = 396 (41.2%)

Guidance Fully Implemented (Where Applicable) = 81 (8.4%)

Guidance Not Applicable = 374 (38.9%)

Guidance Not Implemented = 65 (6.8%)

Guidance Partially Implemented (Action Required) = 21 (2.2%)

New guidance awaiting a response from directorates = 24 (2.5%)

The Trust is fully compliant with 81% of applicable guidelines NB. This compliance is across all five Divisions. It should be noted that previously this report, in Q2, identified that a review of total NICE guidance to date had been undertaken with 1,118 guidelines reviewed. This was because if guidance was applicable to more than one directorate each directorate response was counted as opposed to combining the responses for the one guidance. In future, as duplicate statuses have been removed, a piece of guidance will only be counted once and the implementation status will apply to the whole guidance. For example a guidance may be fully implemented in one directorate but partially implemented with action required in another directorate (PI(AR)) therefore this guidance is recorded as PI(AR). Guidance types reviewed include, Clinical Guidelines, Interventional Procedures Guidance and Technology Appraisal guidance. Other types of NICE guidance such as Quality Standards, Public Health guidance, Diagnostics guidance etc. have not been included, as the Trust does not record a compliance status for these.

Status NICE Guidance (CGs and NGs)

Technology Appraisals (TAs)

Interventional Procedures Guidance (IPGs)

Published by NICE 6 14 7

Fully Implemented -(compliant)

0 8 0

Partially Implemented where applicable

1 0 0

Partially Implemented (Action required)

0 1 0

Not Applicable 0 1 1

Not Implemented 0 0 1

Under Review by Directorates

5 4 5



23rd JANUARY 2017

Page 4 of 10

There are a total of 21 guidelines across the 5 divisions with actions outstanding to achieve full implementation. The actions are directorate lead and up-dates are requested on a quarterly basis. This information is shared at the Clinical Guideline Group and Clinical Standards Group. Moving forward, the Divisions will be asked to complete a risk assessment for each outstanding action, which will be supported by the Governance Facilitation Team to oversee the risk status within the Trust. Review and risk assessment of NICE Guidance “not implemented” will also be undertaken.

In addition, each speciality will be expected to provide assurance to the Divisions that their NICE status is valid, particularly when listing compliance as Fully Implemented.

3. Trust Compliance with External Visits/Peer Reviews As identified in the previous compliance report, the Trust is reviewing and developing a more robust process to ensure the appropriate coordination, monitoring and delivery of external recommendations arising from external agency visits, inspections, accreditations and peer review/assessment. Work is on-going, with our Governance Facilitation Teams requested to liaise with their respective Divisional Leads, to capture any external visits inclusive of any resultant action plans. A comprehensive schedule of visits and their associated requirements will then be collated centrally. Progress on actions will be monitored through local clinical governance forums with overview from Divisional Governance Facilitation Managers. A full summary portion will be provided at the end of Q4.

4. Outcome of Clinical Audits Current position:

Although there are no known exceptions currently with the National Audits, this may not be an accurate picture. Due to resource issues within the Clinical Audit Team follow up of all Forward Audit Programme (FAP) completion by all Directorates and their quarterly returns have not yet been requested so overall progress with the National Audits and any exceptions is currently unknown. A more detailed position with National Audits will be available by the end of Q4 as part of the preparation for the Quality Accounts 16/17.

Forward Audit Programme submission compliance for 2016/17

Div Directorate FAP received

RAG rating

Division Compliance

1 100%

2 100%*

3 100%**

4 Neurology No 89%

5

Thoracic Surgery No

75% Trauma & Orthopaedics No

* Community services have not yet been asked to formulate Forward Audit Programmes, But will be for 2017/2018 ** Awaiting addition of Stroke directorate to the audit database, therefore no FAP yet requested. This will be asked for a 2017/2018 FAP



23rd JANUARY 2017

Page 5 of 10

For the 2017/2018 Forward Audit Programme a larger clinical audit team should be in place and quarterly progress will be requested to support identification of issues and concerns, which will also aid completion of the annual Quality Account.

The following work streams are currently underway:

The trust-wide consent and documentation audits are on-going. Data collection closed December 5th but some directorates are yet to submit their data. These directorates are currently being followed up. The final report will be presented to CSG in March.

Work to populate the 2017/2018 Forward Audit Programmes (FAP) will begin at the end of January. Directorates will be requested to agree 17/18 FAPs in February and March and provide updates for their 16/17 FAP.

It is anticipated that all out dated audits (pre 2014) will be formally closed and archived following discussion with the divisional leads. This action was previously reviewed and approved by the former Deputy Director of Safety and Governance, as well as approved through CSG. Increased resource in the team will facilitate the closing of these audits.

Work is on-going on the Clinical Audit Strategy; progression with the strategy should increase once extra resource is in place within the Clinical Audit Team.

It is expected that progress with clinical audits will be reviewed formally through the divisional structure and exceptions highlighted to the Clinical Standards Group with further escalation through Clinical Quality Monitoring Group (CQMG) and the Audit and Quality Committee, if required

4.1 National Audits:

The 2016/2017 national audit programme remains large with several audits still collecting data due to the prescribed annual collection periods and some audits due to start collecting data in the final quarter. The table below presents a breakdown of the national audit programme at HEFT:

Clinical Audit Programme Status

Total Comments

New Reports Published in Q3 16/17 10

No. of applicable National Audits and CORP’s active for 16/17

60 Number of audits actively collecting data in the financial year

No. of audits and CORP’s not applicable

26 Service not available at HEFT

No. of Quality Accounts audits not participating in

0

Any exceptions identified in Q3 0 Progr



23rd JANUARY 2017

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For 2016/2017 there are 60 active national audits and CORPs that HEFT is eligible to participate in with HEFT currently participating in all 60. The difference in figures between Quarter 2 report and Quarter 3 are:

In quarter 2 it was reported that HEFT were not participating in two national audits ie 60 out of 62 (the National Ophthalmology Audit and the National Diabetes Core audit). The Trust are now participating in the Ophthalmology audit, having recently had Caldicott Guardian approval, although confirmation from the directorate is still outstanding. The data collection for the National Diabetes Core audit closed in August 2016 and this was applicable to primary care only.

National audit of Intermediate care did not run for 2016/2017 and is unlikely to run again in the future.

National Complicated Diverticulitis audit was thought to be not running for 2016/2017 but has collected data.

The Learning Disability Mortality review Programme was previously thought not applicable as is a pilot, however data will be collected in Quarter 4

The Falls and Fragility Fractures Audit – Inpatient falls workstream and the National Comparative Audit of Blood Transfusion – Use of Blood in Haematology workstream are not collecting data until May 2017 and thus are audits to be included in the 2017/2018 Audit programme

4.2 Local Audits:

For the third quarter of 2016/2017 there have been 152 new audits registered in addition to the 1,349 existing audits on the database, which are at various stages of the audit cycle.

The total number of “on-going audits” are audits which have been registered prior to this quarter and are yet to be signed off. For the third quarter of 2016/2017 there was a total of 11 audits signed off but some of these may have been performed in previous years. A summary of the divisional audit data is highlighted below:

Quarter 3 Division

No. of audits proposed

No. of audits abandoned

No. of on-going audits

No. of audits Signed -Off

Div 1 - Clinical Support Services 26 13 218 1

Div 2 - Women’s & Children’s 19 15 193 5

Div 3 - Emergency Care 29 0 247 0

Div 4 - Medical Specialties 24 7 222 4

Div 5 - Surgery 54 11 469 1

Total 152 46 1349 11

5. National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

An information sharing agreement is now in place between the Trust and NCEPOD for participating in NCEPOD studies from January 2017. The information sharing



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agreement defines arrangements between the two organisations to facilitate and govern the efficient, effective and secure sharing of good quality information. The Trust is one of the few trusts in the country to have an agreed sharing agreement in place.

Current position

The NCEPOD Young People Mental Health Study commenced in November 2016 and all clinical questionnaires have been sent for completion for return by 1st February 2017. Pre-survey information on the Heart Failure Study and Peri-operative Diabetes Management study has been sent to NCEPOD. Survey information on Cancer in Children study has been sent to NCEPOD. The NCEPOD report on Mental Health Care in General Hospitals is due to be launched on 26th January 2017. The report identifies and explores remediable factors in the overall quality of mental health and physical health care provided to patients with significant mental health conditions who were admitted to a general hospital. Areas of non-compliance with the recommendations for the Elective and Emergency Surgery in the Elderly (November 2010) and Peri-operative care (December 2011) reports have been reviewed and risk assessed. They are due to be signed off as these are now old and outdated. The NCEPOD report Surgery in Children (October 2011) has now been signed off and noncompliant recommendations are on the Risk Register actions. A review of the outstanding recommendations for the NCEPOD Reports, outlined in the table below, is on-going and action plans developed where applicable following the review. The key aspect of change is to gain local ownership with reports managed at a directorate or division level (where applicable). An SOP has been drafted to formalise this process and will go to all Divisional Directors in February 2017 for signing Status of current NCEPOD Reports as at 13/1/2017

NCEPOD Report

Specialty Lead

Date published

Current Status

Cardiac Arrest procedures

Resuscitation

June 2012

Assurance received on completed actions. Follow up meeting to be arranged in February 17 to review outstanding actions.

Alcohol Related liver disease

Acute Medicine

June 2013

Report reviewed and action plan to be developed. The action plan will be followed up by the Alcohol Steering group

Tracheostomy Care

Anaesthetics June 2014 Ongoing action plan



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Gastrointestinal Hemorrhage

Gastroenterology July 2015 Signed off

Sepsis TBC November 2015

n/a as no lead identified currently

Acute Pancreatitis

To be determined

July 2016

E-mail has been sent to all identified leads to review. Follow up meeting to be arranged in February 17

A report is only signed off once the report’s recommendations are reviewed, formally risk assessed and all identified actions from the review are completed. Any non-compliant areas logged on the risk register will be monitored via the risk management process.

6. Novel Techniques and Interventional Procedures (NTIPs)

Since December 2004, the NTIP Group have received 56 NTIP applications, of which 48 have been approved.

Prior to Q3 48 had been approved

3 were not approved

2 have been disbanded,

1 NTIP approved subject to Theatre Governance Council approval.

In Q3 there were 2 new submissions:

1 from haematology which has gone back to the Directorate for more evidence

1 from colorectal surgery: Introduction of rectus sheath blocks with local anaesthetic infusion which is currently being reviewed by the NTIP group.

7. Clinical Guideline Compliance

Currently the Trust’s guidelines intranet site houses 251 guidelines (or alternative guidance) covering all 5 divisions. Out of the 251 guidelines listed, 94 are currently out of date or have no Meta data on them to ascertain date of ratification equating to 37% of guidelines out of date. This is a stable position from last quarter but an improvement from Q1 54%. An additional two guidelines are on the guidelines site as links to a number of nutrition and stroke guidelines held on Sharepoint.

The tables below indicate the current position for guidelines listed on the trust intranet site for each division.

Divisional compliance table(s)

Division Total number of guidelines

Out of date

Division 1 22 5 (23%)

Division 2 104 31 (30%)

Division 3 50 20 (40%)

Division 4 59 24 (41%)

Division 5 16 14 (81%)

Total no. of guidelines 251 94 (37%)



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Overall:

Multiple groups exist within the Trust with different groups responsible for ratifying different guidelines. This has led to a lack of a standardised process and an absence of a cohesive mechanism for ensuring guidelines meets an adequate trust standard.

Secular working within Divisions creating websites where individual clinical guidelines are housed. Apart from the Obstetric and Gynaecology directorate, there is currently no assurance of peer review or the ratification processes that these guidelines have been through, as they have not been formally reviewed through the Trust Clinical Guideline Group (CGG) unless they are new guidance.

It has been identified that clinical guidelines exist within Directorates that are not housed on the clinical intranet but in electronic folders within departmental files. Again, there is no assurance of the ratification processes around these guidelines or evidence of update and review in line with best practice.

A number of “guidelines” housed on the intranet are in fact SOP’s or standards, policies or flowcharts/pathways but badged as guidelines. Recent work within the Safety and Governance Directorate has led to a formal framework for these documents being developed; however further work is required to adjust these documents into the correct format and place into the most appropriate area within the Trust intranet to act as an easily accessible and effective information tool for all staff.

The use of apps within the trust to house guidelines (eMapp) with no IT solution secured to ensure guidelines are routinely updated, resulting in clinicians using apps that contain high numbers of outdated guidelines.

The systems previously in place for the trust guidelines, NICE implementation and compliance have been redeveloped and reviewed at the CGG led by the Trust Guideline Lead and the CGG chair.

Agreed goals have been set with the aim of achieving greater compliance within the Divisions. This work includes:

the revision of the trust policy for generating guidelines,

the development of a policy to assist with NICE recognition, development and compliance,

the generation of compliance and assessment proformas to ensure guidelines have a robust developmental process and include any relevant NICE guidance, where applicable.

identifying the relevant contacts for guidelines in each Division who have then been asked to review all clinical guidelines within their speciality/division and identify whether they are current and include the most up-to-date best practice; are still required; or if they are correctly listed according to the definition of a guideline.

All new guidelines will be overseen by the CGG and uploaded onto the trust intranet site once ratified. All responses and updates are actioned immediately by the workforce team overseeing the guidelines and all necessary information stored in a central repository. All working/minor updated guidelines are currently not taken to



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CGG for ratification, this action sits within the divisions and specialities with an expectance that they are peer reviewed (with a local terms of reference – TOR) and disseminated as appropriate, this is stated in the policy for the generating and updating of trust guidelines.

8. Recommendation

The Council of Governor is asked to receive this report.

David Burbridge Interim Director of Corporate Affairs January 2017

the education centre, birmingham heartlands hospital · 2017-01-19 · council of governors meeting...

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