Key: FE: For Endorsement; FA: For Approval; FR: For Report; FI: For Information

AGENDA

Meeting Public Board of Directors

Time of meeting 09:30-12:15

Date of meeting Wednesday, 06 July 2016

Meeting Room Dulwich Room, Hambleden Wing

Site King’s College Hospital, Denmark Hill site

Encl. Lead Time

1. . STANDING ITEMS Chair 09:30

1.1. Apologies

1.2. Declarations of Interest

1.3. Chair’s Action

1.4. Minutes of Previous Meeting – 01/06/2016 FA Enc. 1.4

1.5. Action Tracker & Matters Arising FE Enc. 1.5

2. . BEST QUALITY OF CARE

2.1. Patient Story – Matthew’s Story FR Video H Mothersole E Allan

09:35

2.2. Quarterly Patient Safety Report FR Enc. 2.2 J Wendon 09:55

2.3. Quality & Governance Committee Chair Update FI Enc. 2.3 G Mufti 10:10

2.4. Volunteering Update FR Enc. 2.4 P Storey 10:15

3. . Chief Executive’s Report FR Enc. 3 N Moberly 10:30

4. TOP PRODUCTIVITY

4.1. Performance Report (Month 2) FE Enc. 4.1 J Farrell 10:40

5. . SKILLED, CAN DO TEAMS

5.1. Monthly Nurse Staffing Levels Report FE Enc. 5.1 P Townsend 10:55

6. . FIRM FOUNDATIONS

Sound Finances

6.1. Finance Report (Month 2) FE Enc. 6.1 C Gentile 11:05

6.2. Finance & Performance Committee Chair Update FI Enc. 6.2 C Stooke 11:20

Rigorous Governance

6.3. PwC Governance Review Enc. 6.3 Chair 11:25

6.4. Council of Governors Report FR Verbal C North 11:35

6.5. Board Committee Annual Reports

6.5.1. Audit Committee FA Enc. 6.5.1 A Pryde 11:45

6.5.2. Finance & Performance Committee FA Enc. 6.5.2 C Stooke 11:50

6.5.3. Quality & Governance Committee FA Enc. 6.5.3 G Mufti 11:55

6.6. Chair & Non-Executive Directors’ Activity Report FI Enc. 6.6 Chair 12:05

6.7. Board Committee Minutes FI Chair 12:10

6.7.1. Finance & Performance Committee – 26/05/2016 Enc. 6.7.1

7. . ANY OTHER BUSINESS Chair 12:15

8. DATE OF NEXT MEETING:

Wednesday, 09 September 2016, 09:30 in the Dulwich Room, Hambleden Wing.

Members:

Lord Kerslake (BK) Trust Chair

Sue Slipman (SS) Non-Executive Director, Vice Chair

Christopher Stooke (CS) Non-Executive Director

Faith Boardman (FB) Non-Executive Director

Prof. Ghulam Mufti (GM) Non-Executive Director

Prof. Jonathan Cohen (JC) Non-Executive Director

Dr Alix Pryde (AP) Non-Executive Director

Erik Nordkamp (EN) Non-Executive Director

Nick Moberly (NM) Chief Executive Officer

Dawn Brodrick (DB) Director of Workforce Development

Jane Farrell (JF) Chief Operating Officer

Colin Gentile (CG) Chief Financial Officer

Toby Lambert (TB) – Non-voting Director Interim Director of Strategy

Ahmad Toumadj (AT) – Non-voting Director Interim Director of Capital, Estates and Facilities

Paula Townsend (PT) Acting Director of Nursing & Midwifery

Prof. Julia Wendon (JW) Medical Director

Attendees:

Tamara Cowan (TC) Board Secretary (Minutes)

Chris North (CN) Lead Governor

Helen Mothersole (HM) Speech & Language Therapist

Elizabeth Allan (EA) Speech & Language Therapist

Diedre Rainbow (DR) Head of Speech and Language Therapy

Petula Storey Head of Volunteering

Apologies:

Trudi Kemp (TK) – Non-voting Director Director of Strategy

Circulation List:

Board of Directors & Attendees

Enc. 1.4 Subject to Chair's Approval

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King’s College Hospital NHS Foundation Trust Board of Directors - PUBLIC

Minutes of the Meeting of the Board of Directors held at 09:30 on 01 June 2016 in the Board Room, Princess Royal University Hospital, Farnborough Common, Orpington, Kent, Greater London BR6 8ND

Members: Sue Slipman (SS) Non-Executive Director, Vice Chair – Meeting Chair Faith Boardman (FB) Non-Executive Director Chris Stooke (CS) Non-Executive Director Prof. Ghulam Mufti (GM1) Non-Executive Director Prof. Jonathon Cohen Non-Executive Director Dr Alix Pryde (AP) Non-Executive Director Erik Nordkamp (EN) Non-Executive Director Nick Moberly (NM) Acting Chief Executive Officer Dawn Brodrick (DB) Director of Workforce Development Colin Gentile (CG) Chief Financial Officer Jane Farrell (JF) Chief Operating Officer Toby Lambert (TL) Interim Director of Strategic Development Judith Seddon (JS) – Non-voting Director Acting Director of Corporate Affairs Ahmad Toumadj (AT) – Non-voting Director Interim Director of Capital, Estates & Facilities Geraldine Walters (GW) Director of Nursing & Midwifery Julia Wendon (JW) Medical Director

In attendance: Sally Lingard (SL) Associate Director of Communications Paula Townsend (PT) Deputy Director of Nursing Jessica Bush (JB) Head of Engagement & Patient Experience Tamara Cowan (TC) Board Secretary (Minutes) Andy Simpson (AS) Corporate Governance Officer Chris North (CN) Lead Governor Penny Dale (PD) Public Governor

Fiona Clark (FC) Public Governor Dorothy Marshall (DM) Ward Manager Kay McDowall (KM) Senior Physiotherapist Apologies: Lord Kerslake (BK) Trust Chair Trudi Kemp (TK) – Non-voting Director Director of Strategic Development

Item Subject Action

16/55 Apologies Apologies for absence were noted. It was noted that BK had taken ill and was not able to make the meeting.

Enc. 1.4 Subject to Chair's Approval

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Item Subject Action

16/56 Declarations of Interest EN advised that if there were any extended discussion or decision to be made in relation to off-tariff drugs he would remove himself as he works for Pfizer.

16/57 Chair’s Action

There were no Chair’s actions to report.

16/58 Minutes of Previous Meeting

The minutes of the meeting held on 01 June 2016 were approved as a correct record subject to correcting a few minor typographical errors.

16/59 Matters Arising/Action Tracking The action tracker was noted.

Action Item 25/11/15-15/116 – JF agreed to undertook to follow-up on this action but advised that it was proving more complex to extract. She proposed to pull together quarterly summary by speciality and by division. This will be circulated as soon as available.

16/60 BEST QUALITY OF CARE

16/60.1 Patient Story The Board welcomed Ward Manager Dorothy Marshall (DM) and Senior Physiotherapist Kay McDowall (KD) from the Ontario Ward based at the Orpington Hospital. The Board also heard an audio interview conducted by Jessica Bush (JB). The following key points were reported:

The Ontario Ward is a step down facility for patients at Denmark Hill (DH) and the PRUH sites. Because of the type of service provided staff have more time to spend with patients and providing more one on one care. The patient was admitted on the ward for three months following a 5 week stay at the Princess Royal University Hospital (PRUH);

Reflecting on her experience, the patient said that the staff were kind and caring. The ward area and corridor were spotlessly clean, and she could find no fault with the doctors or the physiotherapy she receive.

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Item Subject Action

This support has helped her to become independent again. There was however one nurse that she did not like since she found her to be uncaring and felt like she was being rushed by her. She also commented that she would often hear other patients in distress or shouting out in pain.

The following points were raised in discussion:

The ward’s success and ability to delivery good patient experience can be attributed the team and excellent leadership;

The average length of time for patients to stay on the ward is 2-3 weeks however, this was extended for this patient because her care plan was modified to meet her goal to be independent when she left hospital.

There were also system challenges, namely the correct equipment and social care infrastructure not being available to repatriate the patient back home.

Lessons learnt from the good patient experience should be encapsulate used in other areas;

The issue with the nurse not being caring was addressed immediately;

When patients attend these ward they are medically fit and the staff can focus on rehabilitating patients;

Some of the frustrations staff experience is the lack of pharmacy services on site which causes delay for discharge and admissions.

Catering is also an issue with patients complaining about limited choices. This is because of a lack of storage; and

It is surprising to learn about the issues with patient complaining about pain given that there is good pain management on the ward with a pain teams providing a 6 day service. This will be unpicked with the patient to find out the root of her comment.

16/60.2 Quarterly Patient Experience Report The Board received the quarterly patient experience report. The following key points were reported by JS and JB:

The Trust is providing excellent patient services in child health and patient experience is improving across the Trust;

Areas for improvement include friends and family especially responses in the emergency department which has dropped well below the national average; and

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Item Subject Action

Complaints is down and response rates has improved. The following key points were raised in discussion:

The improvements made in the quarter is a good step forward but there is a long way to go and the Trust has to find operational ways to drive improvements to patient experience. Increasing capacity will be a key factor;

The new format of the report is very welcomed and good;

Patient experience poor performance in maternity services is being by antenatal, postnatal and caring services;

The Complaints Committee are making headway with information around complaints with more benchmarking information;

More needs to be done to improve outpatient services in particular back-office support. It would be worth looking at what has been done at Birmingham Hospital. There will also be service changes in second wave of transformation programme.

Improvements about waiting times in outpatients areas can be addresses quickly with better communication. The Trust need to look at the outpatient services sooner rather than later as there is a worry if this is not addressed sooner rather than later the patient experience performance will continue to deteriorate;

It would be helpful to have nest steps and action plans captured in future reports. These next steps should be measurable; and

Options to address these issues is to focus work in one area, fix the problem them use the same model across other areas.

16/61 Chief Executive's Report The Board received and noted the report from the Chief Executive Officer (CEO). The following key points were noted in discussion with the Board:

Work has been ongoing to get a better grip on performance, developing the transformation programme ready for launching and tightening governance structures;

The work with KHP Institutes continue and the Board will receive the strategic outline business cases in September.

The following key points were noted:

The joint sustainable transformation plan is in development as part of a framework which includes good engagement with commissioners. The plan is about making sure that there is a better model for service delivery across the sector; and

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Item Subject Action

The Trust needs to do more work to ensure that research and teaching and grant is higher on the agenda.

16/62 TOP PRODUCTIVITY

16/62.1 Trust Performance Report 2016/17 (Month 01) The Board received and discussed the month 1 performance report which was also discussed at the Finance & Performance Committee meeting held on 26 May 2016. The following key points were reported:

The Trust’ emergency department (ED) performance improved from 81% to 83.48% in April;

There were 50 beds closed at the Princess Royal University Hospital (PRUH) because of norovirus;

Referral to treatment is ahead of trajectory by 29%. There are detailed demand and capacity plans to address the capacity issues to ensure that the Trust can meet the trajectories; and

The Trust is working at pace to manage performance trajectories. The following key points were raised in discussion:

The Trust has not got a real grip on the underutilisation of theatres as yet but this is part of the operational plans; and

The vacancy rates is variable but work is being undertaken to develop robust recruitment strategies.

16/63 SKILLED, CAN DO TEAMS

16/63.1 Monthly Nurse Staffing Levels Report The Board received and noted the monthly nurse and midwifery staffing levels report.

16/63.2 Nursing and Midwifery Staffing Levels Report The Board received and discussed the 6 month nursing and midwifery. The following points were raised in discussion:

The Trust conducted lots of analysis and modelling around nurse staffing levels in 2014-15. IT was found then that the staffing levels were too low;

In some areas the Trust needs more nursing staff to deal with complex patient cases;

The Trust has worked hard to make improvements in the use of agency and temporary staff and increase permanent staff in post. The Trust also made

Enc. 1.4 Subject to Chair's Approval

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Item Subject Action

The following key points were noted in discussion:

The Education & Workforce Development Committee is going to do a deep dive into agency spend;

The Trust looks at the quality indicators around red shifts. There has been some increase in red shifts because people feel under pressure which is resulting in more absences;

Stress in the organisation is a big issue for the Trust and there needs to be more management infrastructure to support staff;

The Director of Nursing & Midwifery will continue to monitor the issues around staff pressures in addition to the Education & Workforce Development Committee and Quality and Governance Committee;

The Trust is looking at what it can do to support people in developing career paths and ways to progress internally as opposed to leaving the Trust;

The Trust needs to invest in training and investment to attract and retain staff; and

The workforce redesign will look at how the Trust retain and support staff.

16/63.3 Staff Pay Awards The Board received and noted the staff pay awards report.

16/64 FIRM FOUNDATIONS

Sound Finance

16/64.1 Finance Report (Month 1) The Board received and discussed the month 1 finance report which was also discussed at the Finance & Performance Committee (FPC) meeting held on 26 May 2016. The following key points were reported and raised in discussion:

The Trust is overspent by £10.2 which is £4.7m off plan with the biggest driver being £3.6m underperformance on clinical income;

It should be noted that the data provided has been extrapolated from the first two weeks of activity;

Other drivers for the performance include the closed beds related to norovirus and the junior doctors strike;

The CIPS has slipped;

There has been a £1m variance on consumables;

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Item Subject Action

The main risks in the plan include CIPs, delivering activity levels in contract and the cash position; and

The Trust has applied to draw down extra cash from the fund to use to pay creditors in the region of £19.6m.

The following key points were raised in discussion:

The Board needs to be concerned about the current position until there is more certainty around delivery and the finance and performance committee are monitoring the position;

Extra focus has been given to the debtor position. The Trust is owed almost as much it is owed;

The executive is accountable for the delivery of the savings plan and through the savings Board, executive meeting and FPC delivery is being monitored and challenged;

The Trust’s RTT plan is off trajectory and this is key to attaining its income; and

There are tighter controls around cost lines and management of the CIP programme.

16/64.2 Finance & Performance Committee Chair Update The Board received and noted the report from the Committee Chair.

Rigorous Governance

16/65 Board Assurance Framework The Board received and noted the Board Assurance Framework.

16/66 Council of Governors Report The Board received an update on the activities of the Council of Governors from Lead Governor, Chris North. On behalf of the governors he relayed the following key matters:

The Council want to hear more about the joined-up sustainable transformation programme;

There needs to be long-term strategic thinking around recruitment into specialist areas; and

There is a ground swell of morale issues in the Trust which need to be addressed.

16/66.1 Chair's and Non-Executive Director's (NEDs) Activity Report The Board noted the report on the Chair and NED's activity.

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Item Subject Action

16/66.2 Confirmed Board Committee Minutes The Board noted and received the confirmed minutes of the Finance & Performance Committee held on 26 April 2016.

16/67 ANY OTHER BUSINESS

There were no matters of any other business raised for discussion.

16/68 DATE OF NEXT MEETING

Board Public Session on Wednesday, 06 July 2016 from 09:30am – 12:30pm in the Dulwich Commitee Room, Hambleden Wing

Enc. 1.5

Action Status as at: 06/07/2016 1

BOARD OF DIRECTORS (PUBLIC MEETING) ACTION TRACKER

Date Item Action Who Due Update

COMPLETED

06/04/2016 16/35.1 Performance Report (M11) – It was agreed that the recruitment plan for next year will be presented at the May Board meeting.

DB 06/07/2016 In part 2 of the meeting

04/05/2016 16/49.1 Monthly Nurse Staffing Levels Report - It was agreed that the Board would pick up staff retention issues in the July.

DB 06/07/2016

NOT DUE

06/04/2016 16/34 Chief Executive's Report - It was agreed that the Trust would start to promote its Orthopaedics outcomes and the merits of the Trust hosting one of the centres in the interim.

NM 09/09/2016

06/04/2016 16/34 Chief Executive's Report - It was also agreed that FB, BK and JF would have a side meeting about hitting the 50% response to complaints.

JF/BK/FB 09/09/2016

02/02/2016 16/8.2 Adult Safeguarding Report - It was agreed that the Trust would look at DoLs benchmarking data across the Shelford Group and get some qualitative data about the process being used elsewhere.

GW 05/10/2016

02/02/2016 16/8.3 Children Safeguarding Report - It was agreed that a progress report on the safeguarding training and the implementation of the new system would be presented to the Board in 6 months.

DB/GW 05/10/2016

06/04/2016 16/33.2 Quarterly Patient Safety Report – The following was agreed:

1) The Board noted that whilst it is reassured people are not getting complacent and use to the current level of never events the Trust should test out its current

JW/NM 02/11/2016

2

Date Item Action Who Due Update

position against other hospitals and garner any learning;

2) The Board also noted and endorsed the commitment from management to improve the position by quarter 3/4.

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Report to: Board of Directors, Public Session

Date of meeting: 5th July 2016

Subject: Quarterly Patient Safety Report

Author(s): Dr Jules Wendon (Medical Director) & Richard Hinckley

(Head of Patient Safety)

Presented by: Dr Jules Wendon (Medical Director)

Sponsor: Dr Jules Wendon (Medical Director)

Status: For discussion

1. Summary of Report

The purpose of the report is to present an overview of patient safety issues to the Board of Directors highlighting areas of concern.

2. Action required The Board of Directors is asked to review the report and make any recommendations as required.

3. Key Implications

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1. Executive Summary

3 Never Events occurred in Q4: 1 misplaced NGT, 1 retained swab and 1 retained guidewire. The Never Event total for 2015-16 was 11. To-date one Never Event has occurred in Q1 of 2016-17 (misplaced NGT on PRUH ICU)

All of the 4 direct maternal deaths which occurred at DH in 2015-16 (and referenced in the last Board safety report) have been fully investigated and the reports reviewed at the Trust’s Serious Incident Committee. There do not appear to be any obvious common themes emerging from these deaths. Nevertheless an external review of all 4 cases has been commissioned to provide further external assurance that appropriate action has been taken in response to these incidents (still awaiting report)

Important Patient Safety Issues

2. Safety Quality Priority: Improving Safety in Surgery through use of the Safer Surgery Checklist (SSC)

As noted above 3 Never Events were reported in the Jan-Mar 16 quarter, and a further Never Event reported in the current quarter. Several themes have emerged from recent the Never Events, some of which were commented on in the last report to the Board in April – an update on these safety themes is summarised below. As Never Events relating to invasive procedures continue to occur the Trust has decided to retain this as a safety quality priority for 2016-17. Retained guidewires: As noted in the April safety report there have recently been 3 retained guidewire incidents (2 in December and 1 in January), of which 2 were retained following chest drain insertion and one following central line insertion. As at June 29 there have been no further retained guidewire incidents. A series of actions that have been taken to prevent recurrence were summarised in the last report. An update on these actions is provided below:

Seldinger device insertion checklists have been rolled out to all non-theatre areas where seldinger procedures performed. Seldinger procedures in theatre environments continue to use the WHO checklist which has a guidewire removal prompt at sign out

Communications campaign about the risk of retained guidewires has been launched (internal safety alert, “get a grip” poster, kingsweb news item, CEO brief, fact of the fortnight bulletin)

Standards with respect to seldinger invasive procedures have been drafted and communicated to staff (two person procedure, expectations pre and post procedure etc). These standards will be incorporated into a Standard Operating Procedure for all invasive procedures performed outside a theatre setting, which will mandate that specified invasive procedures (including central lines, arterial lines and chest drains) must be performed in a monitored area (unless it is an emergency situation)

Rationalisation of invasive procedure packs into large and small sizes, both of which will include the seldinger device insertion checklist as a standard item. These packs and equipment will be available in monitored areas

Sign-off of junior doctor competencies (including invasive procedures using seldinger technique such as chest drains and central lines) at specialty level is currently being reviewed

Proposal to amend the x-ray request form to have a prompt for the requester to specify number of drains/lines inserted is currently under discussion with Radiology

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Fluid administration via misplaced naso-gastric tubes: As noted in the last report a series of actions had been taken to reduce this risk. However unfortunately a further incident occurred on 1st June while some of these actions were still being implemented. An update on the current status of the actions to prevent recurrence is provided below:

A communications campaign about the risk of misplaced NG tubes has been launched (internal safety alert, Fact of the Fortnight bulletin, and recent memo to all staff by the Medical Director and Director of Nursing in June)

Separate algorithms for NGT placement for feeding and for free drainage have been developed. These include guidance to avoid feeding overnight (except for critical medications)

An NGT request code for x-rays has been developed and Radiology have committed to reporting all NGT-coded x-rays within 2 hours of the x-ray being performed. Requesters have been reminded to ensure that both the correct image and report are reviewed prior to position confirmation

Sign-off of junior doctor competencies (including NGT insertion and position confirmation) at specialty level is currently being reviewed

Review of the enteral feeding policy underway

Training for existing staff in NGT insertion and ongoing management is being reviewed by NGT Working Group

Retained swabs in Obstetrics: There was one retained swab at DH (Nov 15) and one at PRUH (Feb 16). The following common risk factors have been identified through review of these NEs:

Potential for increased risk of swab retention when there are changes of procedure (for example from instrumental delivery to c-section)

Lack of standardisation in the swab count documentation for different obstetric procedures (normal vaginal delivery, perineal tears, complex perineal tears, instrumental delivery, c-section etc)

Failure to attach metal clips to swab tails to ensure swabs not retained Actions being taken to prevent recurrence:

A safety checklist for vaginal and instrumental births has been developed and is currently being piloted

Training has been updated to reinforce that metal forceps should be applied to the tag of any swab used as a tampon and that a vaginal examination should be carried out at the end of any procedure to ensure swabs not retained

“Swab safe” disposal trays have been introduced to obstetric theatres to add an additional visual prompt for any potential retained swabs

Other actions planned or underway to improve surgical safety: In addition to the actions mentioned above, the following action is also being taken:

Doctor induction has been amended to include surgical safety issues

Addition of ‘Team Brief’ and ‘Debrief’ as a specific time slot on the electronic theatre system (Galaxy) has been agreed and IT are currently scripting this for implementation. This will ensure dedicated time is on the list to perform brief/debrief & that performance can be tracked

Annual externally facilitated surgical safety consultant development morning is being arranged, in addition to in-house simulation training that will be provided to hotspot areas

All specialties carrying out invasive procedures have been tasked with developing local safety standards for invasive procedures (LocSSIPs). LocSSIPs in higher risk areas (ophthalmology, orthopaedics, and obstetrics) have been prioritised

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Implementation of the SSC is monitored by the SSIG (chaired by a Consultant Neurosurgeon) which reports to the Patient Safety Committee chaired by the Medical Director.

3. Safety Quality Priority: Medication Safety In the 2015-16 Quality Account the Trust set itself 4 objectives to demonstrate an improvement in medication safety. The objectives and progress at year-end in achieving them are detailed below. Medication safety has not been selected as a safety quality priority in 2016-17 – however reducing medication omissions has been selected as one of the Trust’s Sign-up to Safety priorities and in future reports progress against this will tracked.

Reduction in incidents involving 10-fold errors: despite launch of the “Rule of One” vial in paediatrics in June 2015 and a recent internal safety alert (about the risk of tenfold errors in babies under 1 kg) there was no reduction in tenfold errors in 2015. A drug calculator has been rolled out in neonatal to help address this problem

Reduction in incidents involving administration of drugs to patients with known allergies: there was a reduction in number from 59 in 2014-15 to 51 in 2015-16. The electronic allergy documentation fields are currently being reviewed as part of the new EPR. In DH ED a prompt has been added to the CAS card to check EPMA for patient allergies prior to the prescription of any drug

Increase in % of nursing staff passing the drug calculation competency assessment at 100%: 6 additional questions were added in-year to the drug calculation competency test to make it more robust. However this means that the results are not comparable between years

Reduction in the number of medication errors involving the wrong patient: 70 incidents were reported in 2015-16 which is the same as was reported in 2014-15. As noted in previous reports the positive patient identification campaign has focussed on selection of the right patient. There have been no serious identification errors in 2016

This work will be lead through the Medication Safety Committee chaired by Professor Arya, and monitored by the Patient Safety Committee.

4. Improving the recognition and management of sepsis

This has been chosen as a safety quality priority for 2016-17 as:

It is a national safety issue which contributes significantly to patient morbidity and mortality;

PRUH highlighted as a mortality outlier for the diagnostic group ‘septicaemia (except in labour), shock’’ in a Nov 15 report by HSCIC;

A significant proportion of deteriorating patient incidents at KCH have a sepsis-related element.

There is also a national CQUIN for sepsis. The nCQUIN performance indicators will be used to track improvement in sepsis recognition and management – these indicators are:

% screened against locally developed screening criteria

% of those screened with severe sepsis/septic shock who: o Received appropriate management (time to abx therapy) o Have received appropriate monitoring for at least 72 hours

The local screening criteria which the Trust will initially use will be those patients who are referred to i-mobile for sepsis. I-mobile will then complete a sepsis screening tool to identify those with severe sepsis/septic shock, and an EPR audit tool to assess those patients with

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severe sepsis/septic shock who receive appropriate initial management (sepsis 6 including IV antibiotics within an hour) and appropriate monitoring for at least 72 hours. Preliminary data is available from the i-mobile team at DH and baseline performance data should be available for the next quarterly patient safety report. Note also that in response to the HSCIC report (referred to above), a review of PRUH sepsis-associated deaths was undertaken in February 2016. The review highlighted the following issues: potential delay in antibiotic administration in some cases; generally poor documentation of fluid monitoring and oxygen administration. However it concluded that these issues did not materially contribute to mortality in any of the cases reviewed. In response to the findings a “frail sepsis” pathway is in development and additional training in sepsis is being scheduled for acute medical and ED staff. Work to improve the recognition and management of sepsis is led by the Medical Director and will be monitored through the Patient Safety Committee.

5. Falls & Pressure Ulcers The incidence of hospital acquired pressure ulcers and patient falls across all sites are monitored closely by the respective Tissue Viability and Falls Teams. All serious falls and pressure ulcers (grade 3 or 4) are reviewed by the Safer Care Fora at DH or PRUH. The Safer Care Fora report to the Patient Safety Committee.

5.1 Falls

Serious falls (those involving major harm/death) increased from 9 to 10 in Q4. Serious falls at DH increased from 4 to 5, while at PRUH there were 5 (same as Q3 - there were none at Orpington). There was no trend with respect to the location of serious falls

At DH overall falls rate was 4.9/1000 bed days in Q4 (similar to Q3). There are some hotspots where the rates are high however – for example some of the health & ageing wards. At a senior nursing meeting in June at DH the TEAM wards were asked to set local targets for falls in an effort to reduce these to below 10 per month

At DH and PRUH themes with respect to falls continue to relate to toileting (falling while attempting to mobilise to the toilet or falling whilst in the toilet). There is a dignity and continence project being led by the Donne ward manager which is reviewing toileting issues in more detail

Current actions to reduce avoidable falls are provided below:

The Specials Team continues to provide 1:1 specials at DH to monitor patients specifically assessed as at risk of falling. This team is being expanded through the use of volunteers

The Falls Team is working jointly with the Dementia Team on the management of patients with cognitive impairment in the prevention of falls. A similar joint project is underway with the Continence Team focusing on the link between incontinence and falls

5.2 Pressure Ulcers

Across the Trust there were 93 Hospital Acquired Pressure Ulcers (HAPUs) graded 2 or above (including unstageable HAPUs) in the period Jan-Mar 16, up slightly from the 83 reported in Q3

At DH there were 59 HAPUs in Q4 (same as Q3), of which there were 2 grade 3s and 2 unstageable ones. The rate of HAPUs per 1000 bed days has remained static when

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compared to last quarter, but is significantly lower than the peak reached in the Jan-Mar 15 quarter (refer to graph below). A comparison of HAPUs between 2014-15 and 2015-16 shows a marked reduction in grade 3 HAPUs (from 40 down to 8)

In April there was a patient with traumatic spinal injuries who acquired a grade 3 pressure ulcer which deteriorated to a grade 4 on David Marsden ward at DH. Issues which have been addressed include improving access to dressings and streamlining the referral process to the learning disability service

The first intensive care grade 3 HAPU since November 2014 occurred in March 2016 on Jack Steinburg ICU – however this was subsequently assessed as being unavoidable

At PRUH HAPUs increased in the last quarter (from 24 to 34) but remain well below the peak in Oct-Dec 2013. The PRUH rate of HAPUs per 1000 bed days (0.7) has increased marginally but is the same rate as at DH

Current actions to reduce avoidable pressure ulcers are provided below:

A drive to reinforce the correct Waterlow Score calculation as this ensures prompt provision of the most appropriate pressure relieving equipment

Continued staff training in HAPU assessment and prevention

6. Hospital Acquired Thromboses (HATs) The incidence of hospital acquired thromboses are monitored closely by the VTE team. All HATs leading to significant harm are reviewed by the Safer Care Fora at DH or PRUH, or by the Serious Incident Committee if serious avoidable harm has occurred. The Safer Care Fora report to the Patient Safety Committee. Note that venous thromboembolism (VTE) risk assessment and treatment (prophylaxis) are the main methods of prevention of HAT. A summary of the current position is as follows:

At DH the number of HATs increased from 51 to 62 in the last quarter. The number of potentially preventable HATs (11) also increased on the 6 reported in Q3 (refer to graphs below) although the proportion of HATs which were potentially preventable remains low compared to other Trusts. The VTE risk assessment rate at DH for the quarter remained well above target at 97% (target is 95%)

At PRUH the number of HATs increased in Q4 to 27 (from 19 in Q3), and the number of potentially preventable HATs increased from 2 to 3. However in the last year at PRUH there has been a reduction in potentially preventable HAT cases from 25% to 12% (2015 compared to 2014). The VTE risk assessment rate averaged 96.6% in Q4

At PRUH a 6 month retrospective audit of VTE standards (655 patients) found that 16% did not have a weight recorded. This was a particular issue on some wards such as AMU. This may connect with the main theme emerging from potentially preventable VTE events being incorrect dose according to weight and renal function. This issue has been raised in governance meetings and the Safer Care Forum

Recommendation The Board of Directors is asked to note the content of this report.

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Report to: Board of Directors

Date of meeting: 06 July 2016

Subject: Summary Record of Quality & Governance Committee Meeting

Presented by: Prof Ghulam Mufti, Non-Executive Director & Committee Chair

Status: For Information

Introduction This report provides the Board of Directors with a summary of all the key issues considered by the Quality & Governance Committee at its meeting on 28 June 2016.

End of Life Care Annual Report The Committee received the Trust’s annual End of Life Care Report. The following key points were noted:

There needs to be a clearer vision within the Trust on the communication, implementation and adherence to the five main priorities related to the care of dying people, namely identity, communication, assess, respect and establish (ICARE);

The Trust needed to make improvements with ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) documentation;

There is consistent evidence of better outcomes for patients following palliative care in acute hospitals, and emerging evidence that it reduces the overall cost of healthcare; and

Future actions for the Trust must include ongoing education and training in palliative care.

Quarterly DIPC Report (Q4) The Committee received and discussed the quarterly DIPC Report for Quarter Four of 2015-16. The following key points were noted:

There have been cases of a new strain of CPE known as the IMP strain at the Denmark Hill site. This is an unusual strain in the UK;

There has been one case of Clostridium difficile (C Diff) on a surgical ward which following investigation has been identified as a ‘lapse in care’;

The Trust is under the trajectory for C Diff so far this year;

There have been two MRSA bacteraemia in this reporting year, one in May 2016 and one in

June 2016;

There have been more cases of Norovirus detected at the PRUH which had continued until May 2016; and

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There have been cases of parainfluenza at the Neonatal Intensive Care Unit (NICU), which the Infection Control Team is investigating. Actions were taken to control the spread. Plans were in place to improve the isolation facility within NICU.

Quarterly Patient Safety Report The Committee received the Quarterly Patient Safety report. The following key points were noted:

In 2015-16 there were a total of eleven ‘Never Events’, three of which occurred within quarter four (1 misplaced naso-gastric tube, 1 retained swab and 1 retained wire). The Royal College of Orthopaedic Surgeons has been invited to conduct an external review at the Denmark and PRUH sites following a number of concerns including a recent ‘Never Event’ (wrong implant). The review was currently underway; and

Standard Operating Procedures for the insertion and maintenance of entry tubes are going to be re-developed and streamlined to be made more accessible.

Quarterly Organisational Safety Report (Q3) The Committee received the Organisational Safety Report for quarter three of 2015-16. The following key points were noted:

There were eleven submissions for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), but this does still amount to a continual reduction in the number of submissions;

One of the concerns in the prevention of RIDDORs is the training of staff, but there is currently only a training team of three people. Another training-related concern is the difficulty of releasing staff for training;

There were six incidents during the quarter which were potentially linked with dermatitis but it

has been shown that five of these were related to poor individual hand hygiene; and

There has been an increase in the number of violence and aggression incidents against staff at King’s College Hospital and nationally. There were 401 in the Trust for 2015-16.

National Survey: Emergency and Elective Inpatients The Committee received the results of the 2015 CQC National Inpatient Survey, in which inpatients at the Trust and others nationally were asked about their experiences. The following key points were reported:

Performance was as expected across the board, but overall performance has improved significantly compared to 2014. It was the Trust’s best score ever on the National Patient Survey.

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Update on CQC Action Plan The Committee received the update on the CQC Action Plan. The following key points were noted:

The CQC Steering Group will be relaunched as the CQC Board and will be chaired by the Chief Operation Officer;

CQC actions would be consolidated under one plan;

Back to Basics Audits were in train to drive up improvement within ward and clinical areas against the CQC Fundamental Standards;

The development of an Accreditation Programme was in progress; and

There will be a more substantial update on the shape of the new action plan at the Committee’s

next meeting on 26 July 2016. Committee Administration The Committee received the Committee Annual Report and the Committee Forward Plan. The following key points were noted:

Following a review by PricewaterhouseCoopers (PwC) the Committee has made a number of changes to the membership in the Terms of Reference (ToR) and the Annual Work Plan. Theseincluding increasing the frequency of the meetings to monthly and introducing deep-dives; and

The Committee felt that there would be an opportunity to revisit the membership once the senior divisional management structure was in place. This would build in ownership and accountability at the Divisional level.

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Report to: Board of Directors

Date of meeting: 6 July 2016

Subject: Volunteer Programme

Author(s): Petula Storey, Head of Volunteering

Jessica Bush, Head of Engagement and Patient Experience

Presented by: Petula Storey, Head of Volunteering

Sponsor: Judith Seddon, Associate Director of Governance

History: N/A

Status: Information

1. Summary of Report This report to the Board provides background about the King's Volunteer Service, its recent achievements and plans and challenges for the future. 2. Action required The Board is asked to note this report and offer comments and recommendations. 3. Key implications

Legal: N/A

Financial: Reputational risk

Assurance: CQC Fundamental Standards – Caring and Responsiveness

Clinical:

Equality & Diversity:

The Equality Delivery System seeks to ensure that all patient groups receive the same quality patient experience

Performance:

Performance against CQC Fundamental Standards Friends and Family Test

Strategy:

Patient Experience is a key deliverable of the King’s Strategy, Quality Strategy and forms a part of the Trust Quality Account

Workforce: Links to Staff Friends and Family

Estates:

Reputation: Poor volunteer and patient experience is a reputational risk

Other:(please specify)

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Executive Summary 1. Background

1.1. King’s Volunteer Service was re-launched in 2011 with a clear focus to support

improvement in patient experience and to align with King’s Value of working more closely

with our local community. We are proud to say that our volunteer base reflects the

communities it serves.

1.2. Our volunteers are present on all Trust sites and, importantly, out in the community

through our Hospital to Home and Home Hamper services which are providing support to

some of our most vulnerable patients.

1.3. The service has been generously funded by the King's Charity and the Trust for the past

five years. However, charitable funding is due to cease next year and the charity is keen to

work with us and fundraising to secure further funding for the programme. There is an

urgent need to secure sustainable funding for the future, for both 'business as usual' and to

further enhance the service in areas of specific need.

1.4. In 2015, as the volunteer service celebrated its fifth birthday and, with a new management

team in place, took the opportunity to reflect on its achievements but also what we wish for

the future. With this in mind we have spent time taking stock, improving our recruitment,

training and administration processes, looking at what we’ve learned and the opportunities

and challenges going forward and the final section of this paper outlines our direction for

the future.

1.5. The King’s volunteer service is in a strong position to support delivery of the King’s Quality

Strategy launching shortly.

2. What do our Volunteers do? Our volunteers support patients in diverse roles across our sites ranging from befrienders on

our wards and in our outpatient clinics, acting as guides for patients and visitors to providing

pastoral care through our chaplaincy programme. Increasingly volunteers are actively

supporting the service by helping us to recruit volunteers in the community and raise

awareness of the service, as well as acting as assessors in our re-vamped recruitment

sessions and even coordinating our Home Hamper programme.

Volunteers are there to improve patient and visitor experience and all roles are designed to

complement rather than be a substitute for the work of staff.

Volunteers go through a comprehensive recruitment and training programme, so that they are

clear what their role is, what their limitations and boundaries are and what our expectations are

of them when they are with us. All volunteers also undergo a DBS and Occupational Health

check.

2.1. In hospital initiatives

2.1.1. Social Club -

The volunteering service has a volunteer-led Saturday club for patients where patients can

take part in a range of activities from film afternoons and bingo sessions, to arts and crafts

and reminiscence activities.

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2.1.2. Peer Support

The volunteering programme supports a mentoring project for adult liver outpatients. This

programme has now expanded to Renal. In these instances, members of staff identify

which patients are suitable to become mentors and then refer them to the volunteering

service so that they can undertake the relevant training and checks to become volunteers.

2.1.3. One-off Opportunities

Volunteers have also been involved micro-volunteering or one-off opportunities, for

example, conducting surveys for pharmacy, our ED department and a food survey on

behalf of the Patients’ Association. Volunteers also help the King's Charity by supporting

their events such as the Carol service and Get Colourful week. Volunteers have provided

tours of the garden at Jennie Lee House run by the Lambeth Food Co-op on NHS

Sustainability Day.

2.2. In the community

2.2.1. Home Hamper Scheme

Patients in need are given a food parcel to take home with them on discharge. The service

is predominantly targeted at long-term inpatients who may not have provisions at home,

patients who are being discharged to a new home environment, and those who face other

hardships. The scheme also takes referrals from the Trust’s homeless team and also helps

families who come from afar when a child is undergoing treatment and staying in the

Ronald McDonald House but need some initial supplies. All food is donated.

2.2.2. Hospital 2 Home Service (H2H)

H2H is a befriending scheme for patients, offering support in the hospital and the

community at the DH site. It helps frail, long-term and vulnerable patients make the

transition from hospital back to their home environment, offering assistance to people who

require additional time and support to ensure that they can return home safely. Volunteers

do not handle money or medication, nor provide personal care.

The H2H service takes referrals hospital wide and has also developed strong links with

Lambeth and Southwark Safe and Independent Living (S.A.I.L) part of Age UK, which

signposts patients to appropriate support organisations. H2H also works closely with the

British Red Cross which has a hub at King's and caters for patients with more complex

needs, In turn, the Red Cross will, refer to H2H. This collaboration ensures we can meet

the needs of most patients

This is an example of typical H2H support provided to one patient:

Patient A

• Patient was escorted home on day of discharge

• 7 visits were made over a period of 6 weeks

• SAIL form completed to ensure longer term befriending as in place

• Patient was also referred to Phoning Friends

• Volunteer helped with setting up meals on wheels

A similar service is provided by Age UK Bromley and Greenwich at PRUH. This service is

currently under review.

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2.3. Under development – short to medium term

Within the hospital we wish to create a more structured volunteer programme in our Emergency

Department, with enhanced training for volunteers enabling them to support particular vulnerable

groups including those with mental health issues.

We will shortly be relaunching our meeters and greeters role, increasing the number of volunteers

who can be a welcoming presence for patients and visitors to the hospital.

In light of the success of the peer support programmes in liver and renal we are looking at

developing programmes in areas of need such opthamology, cancer, haematology and cardiology.

At Denmark Hill, we have started working with various teams within the hospital as we think we can

be more effective by reaching out to people whilst they are in our care. We are in discussions with

the nutrition team and the smoking cessation team to determine what would be the most effective

training and tools for our volunteers.

With the growth of activity at Orpington, we would like to expand H2H at Orpington and wish to

grow the service at Denmark Hill and the PRUH.

3. Key benefits of the service

3.1. Volunteers have a positive impact on patient experience: Patients who have contact with a

volunteer are between 2-4% more likely to recommend King’s as a place to be treated as

an inpatient as measured by the Friends and Family Test. This is evidence that the

service is fulfilling one of its primary aims – to improve the quality of patient experience.

3.2. Volunteer Return on Investment (ROI): The King’s Fund report from 2013 states that for

every £1 invested in volunteers, the trust will get a ROI of £11. So for every pound

invested in the volunteer programme at King’s, the Trust gets around £2 million pounds

worth in return.

3.3. On Friends Stroke Unit, a volunteer calls patients to remind them about their follow up

appointment. Since this initiative started, there has been a 40% reduction in DNAs for

follow up appointment. Given that each DNA costs the trust circa £160.00, this represents

an average saving of £1300 per quarter. If this type of initiative was spread across other

areas this would be a significant cost saving for the Trust.

3.4. King’s volunteers are helping to meet the bigger challenges facing the health and social

care sector and the potential for growth in this area is strong. H2H supports people after

discharge to aid their recovery and help them settle back into their lives after a stay in

hospital and has helped hundreds of our more vulnerable patients and shows that

volunteers can have a positive impact in enabling patients to be discharged safely from

hospital. On the back of H2H, we launched our Home Hamper scheme which provides

patients with a basic food bag to take home.

3.5. Volunteer programmes have a positive impact on people who volunteer and we will be

looking to use a World Health Organisation Quality of Life tool (WHOQOL - BREF) to

conduct research to evidence this.

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3.6. King’s is in a strong position to influence hospital volunteering nationally. Externally, King’s

continues to be asked to sit round the table with key decision makers as we are seen as a

centre of volunteer excellence and innovation. We are currently working alongside key

decision makers: the Greater London Authority, NHS England, NESTA and the Cabinet

Office to shape volunteering for the future.

4. Wider, national context: excellence, influence and recognition

4.1. In 2013, a report on ‘Volunteering in Acute Trusts’ published by the King's Fund, stated

that around three million people volunteer for health, disability and welfare organisations in

England – the same number as the combined NHS and social care workforce.

4.2. In light of the pioneering work done by the King’s volunteer programme in showing the

positive impact of volunteering on patient experience, NESTA have, through their ‘Helping

in Hospitals’ programme, funded a further ten hospital trusts to help them build their

volunteering programmes.

4.3. The Royal Voluntary Service report published in 2015, states that over the last 10 years,

hospital discharges for those over 75 have been rising at a much faster rate than ageing

trends in the population, almost four times faster. The growth in hospital readmissions has

been higher still, up by 86%. If Hospital to Home Services could alter the underlying

causes of inappropriate admissions and were targeted appropriately with full coverage

across England, it might reduce the cost of readmissions by around £40.4m per year.

4.4. King’s Volunteer Service already implements many of the current and forward-looking

recommendations about best practice. For example:

4.5. As part of the governance of the NHS Five Year Forward View, three of the six principles

set out to guide local health systems when developing and their Sustainability and

Transformation Plans resonate particularly strongly with volunteering:

• Voluntary, community and social enterprise and housing sectors are involved as key partners and enablers

• Volunteering and social action are recognised as key enablers • Focus is on equality and narrowing inequalities.

4.6. One of the recommendations from the 'Joint review of partnerships and investment in

voluntary, community and social enterprise organisations in the health and care sector’,

report produced in partnership by representatives of the Voluntary, Community and Social

Enterprise (VCSE) sector and the Department of Health, NHS England, and Public Health

England states that:

“CQC should review its Key Lines of Enquiry and ratings characteristics

across all sectors to include the value of personalisation, social action and

the use of volunteers, based on the evidence of their efficacy in achieving

improved quality of care”

The most recent CQC report acknowledged the national reputation of King's volunteer

service; we believe this is a first in a CQC report.

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4.7. The above report also recommended that Volunteering is valued, improved and promoted

in all NHS settings, with strategic leadership from NHS England through the Active

Communities and Health as a Social Movement programme, should develop more high-

quality, inclusive opportunities for volunteering, particularly for young people and those

from disadvantaged communities.

This is something that is embedded in King’s Volunteer Service

4.8. One of the recommendations in the Lampard report: Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile, published in 2015, states the following: Effective management of volunteers requires board level commitment and leadership. Organisations need to take a strategic approach to planning their volunteer schemes. Managing a scheme properly demands resources and has a cost.

4.9. All NHS settings, not just trusts, should also comply with the second and third

recommendations made by the Lampard Review on volunteer recruitment, training,

management and supervision. This should include consideration of whether to apply for

accreditation under the Investing in Volunteers scheme.

• This is something the service will benefit from and intends, with appropriate

support the Board, to apply for accreditation.

Influence

4.10. King’s continues to be asked to sit round the table with key decision makers. Here are

some examples:

The Head of Volunteering spoke about the King’s Volunteer Programme and its plans for

the future at a Nesta ‘Helping in Hospitals’ workshop which brought together the ten

hospitals NESTA have recently funded. The event included representatives from the

Department of Health, NHS England and Cabinet Office

Head of Volunteering presented at the Harnessing Social Action: Health, Ageing & Care

event, hosted by the Cabinet Office and attended by around 70 key figures from the health

and social care sector, including ministers

The service is represented on the Health Inequalities Strategy Steering Group which has

oversight of the development of the new London health inequalities strategy for the London

mayor

The Head of Volunteering is involved in the Active Communities Programme set up by NHS

England

King's Volunteer Service has created a network of volunteer management peers from

seven hospitals in the Greater London area to network and share good practice

There have been visits from other trusts including the Royal Free, Barts Health and

Cambridge University Hospitals. Our reputation extends beyond the shores of the UK as we

had a team of people from Slovenia visit as well.

Recognition

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4.11. Both King’s volunteers and the programme continue to be recognised, for example:

Lammy Awards: Organised by NHS Lambeth CCG to recognise the contributions of

individuals and teams supporting excellent health and care services in the borough

HSJ Awards: For the second year running our volunteering scheme has been shortlisted for

a Health Service Journal (HSJ) Value in Healthcare award

NCVO Blog: Justin Davis Smith, the Executive Director of Volunteering and Development in

his January blog said that we were a great example of how volunteers can make a

difference when involved in public services

BBC Radio 4: In December 2015, Radio 4 showcased a documentary called Volunteer

Nation, which featured King’s volunteer service. The programme was conceived by Andy

Haldane, Chief Economist at the Bank of England, who explored the hidden engine of the

British economy - it's volunteers. http://www.bbc.co.uk/programmes/b06ryrmz

5. Taking stock

As the service celebrates its fifth birthday, we have spent the last six months taking stock of

where we are, reviewing and improving processes from recruitment and training through to

volunteer support and recognition to ensure the service is fit for purpose to take on the

challenges of the future. We will continue to build our volunteer base but with an emphasis on

quality, whilst making sure staff and volunteers are clear about their role and responsibilities.

We are already seeing a greater commitment from our recent cohort of volunteers and are

confident we will see a positive impact on retention. At 'The Future of People Powered Health

event' in February, Simon Stevens praised King's Volunteer Service as an exemplar of best

practice and we want to ensure that we continue to innovate and are a beacon of best practice

for volunteering in the NHS and beyond.

6. The next five years

With improved processes and systems in place, we are in a stronger

position to provide the best quality of experience for both volunteers

and the patients and staff they support. The following seven work

streams have been developed and will be the focus of our work in the

coming years:

a. Demonstrating Impact and Value

b. Staff Engagement

c. Continued Excellence

d. Development and Innovation

e. Volunteer Experience and Engagement

f. Collaboration and Influencing

g. Sustainability

7. Going forward - the future of the Kings Volunteer Programme

The following seven streams of work will be our focus in the next three to five years.

a) Demonstrating Impact and Value

We will increase our focus on service quality and impact and reaching those most in need

Our new volunteer management system 'Better Impact' will provide us with robust data to

evaluate the service with accurate data on volunteer contacts and interactions The above

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will provide volunteers with a demonstrable measure of their individual impact which is key

to motivation and retention

With the NHS agenda on mobilising communities and creating healthy areas, we plan to

conduct research that demonstrates that volunteering does make a difference to the

wellbeing of the individual.

b) Development and Innovation

Develop and expand volunteering to link with both NHS and local priorities

Develop a structured programme of support for the ED incorporating specific support for

mental health service users and other vulnerable groups in line with the 5 yr forward mental

health strategy

Mental Health - in partnership with other agencies, develop specific volunteer support for

patients with mental health issues

Look at opportunities to promote the public health agenda both internally and externally

Link with primary care to scope volunteer input to promote appropriate use of the ED

Expand our chaplaincy programme to provide support to patients at the end of life

Partner with the local community, particularly local businesses on collaborative work,

donations in kind and fundraising

Become the first trust where all volunteers become ‘Dementia Friends’.

c) Continued excellence

Continue to improve the service to ensure a good experience for all our volunteers and the

staff they support

Continue to positively impact on the quality of patient experience and enhance the role of

volunteers in achieving the targets set out in the King's Quality Strategy

Achieve the Investors in Volunteers Quality in line with recommendation. This is

dependent on securing funding.

d) Staff engagement

Raise the profile of volunteers to ensure that everyone has a better understanding of how

volunteers can contribute to improving patient experience, reducing health inequalities and

support the trust as it transforms services

Develop a peer support network for volunteer placement managers

Develop an e-learning module to provide managers with the unique skills needed to

manage volunteers and maximise their impact - aiming to achieve accreditation via ILM or

another appropriate body, or linking to the King's Academy

Scope the potential for volunteers to support staff well being in line with both local and

national priorities.

e) Volunteer Engagement

Develop tools to manage volunteer expectations

Increase the focus of the service retention of volunteers including support provided via our

placement managers

Continue to develop recruitment opportunities, particularly within the local community

Develop tools to support volunteers in their roles such as activity boxes

Develop a suite of training modules to support ongoing volunteer learning, training will be

on: learning disability, mental health to name a few.

f) Collaboration and Influencing

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Lead on best practice and innovation so that we continue to be seen as the beacon

volunteer programme in the NHS

Lead on the development of a London Hospital Volunteer Network

Continue to engage with NHS England through Active Communities Alliance

Continue to engage with Cab Office, DH, GLA, Kings Fund and NESTA

Work collaboratively with KHP partners

Develop closer links with the King's Charity in areas which are mutually beneficial and

support both services.

g) Sustainability

With charitable funding tailing off in 2017, work with the charity, fundraising team and the

trust to explore sustainable core funding to ensure that the volunteer service can continue

Explore project funding for key areas of work

Explore with the Board and King’s Executive how individual and collective networks could

be used to identify potential support and partnership working for the service both within the

public, not for profit and private sectors

Based on funding the current core service, we will require funding of circa £275,000 per

annum with additional project funding to support new service developments, such as the

ED volunteer programme

Conclusion

Key to succeeding with these workstreams is:

• support from King's Executive, The Trust Board and Council of Governors to 'fly the flag' for

volunteering

• ensuring that volunteers are on the radar as we take the trust's strategy forward and

transform

• securing funding so as to achieve Investing in Volunteers Quality Mark

• securing the sustainability of the service through both trust and charitable funding

• working collaboratively with our partners to innovate and tackle key issues

• success in the above means we are able to influence nationally and continue to be seen as

the leading example of best practice in the health care sector.

Recommendation The Board is asked to note this report and offer any comments.

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Report To: Board of Directors Date of Meeting: 06 July 2016 By: Nick Moberly, Chief Executive Officer Presented By: Nick Moberly, Chief Executive Officer Subject: Chief Executive’s Board Report OVERVIEW As we reach the end of the first quarter of FY 16/17, a huge amount of work is underway within the Trust, focusing on maintaining a tight grip on operational performance, starting to drive longer term transformation of our services, and progressing a number of longer term strategic issues. MISSION Integrated Care In Lambeth and Southwark, King’s have signed up to a Strategic Partnership whose membership includes all the major health and social care organisations operating in the 2 boroughs. Work has now kicked off under the auspices of the Strategic Partnership on developing the pre-existing Local Care Networks as a platform for delivering more joined up and integrated care across the 2 boroughs, focusing initially on people with complex needs In Bromley, work is focusing on the development of 3 Integrated Care Networks. A Memorandum of Understanding has been signed by provider partners to support this work. Given the large elderly population in Bromley, the initial focus will be on developing a model of care for frail older people. The emerging model is likely to include delivering proactive care through risk stratification in primary care, more case management, community holistic assessments, community MDT reviews with more robust care planning, and improving access and navigation to appropriate services. It should be noted that in parallel with this work, Bromley CCG has issued a notice of its intention to tender community services in the borough. King’s Health Partners/Institutes Significant progress has been made over the last month in developing Strategic Outline Cases for the Haematology and Cardiovascular Institutes. Both cases are now being revised in response to feedback from partners and, in the case of cardiovascular, the GSTT charity. It is expected that these will be submitted for Board-level review and approval during Q3. Pathology The transfer of pathology services at the PRUH to our Viapath Joint Venture has now been completed. Meanwhile, work continues to develop a forward strategy and operating model for Viapath. Sustainability and Transformation Plans A Sustainability and Transformation Plan (STP) for South East London has now been developed and submitted. Collaborative work continues to agree the financial plans and level

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of attainable savings and to reconcile assumptions and control totals in the STP and in provider Operational and Strategic plans. The elective orthopaedic centre process has restarted. If appropriate, public consultation would be expected to start in October / November, before implementation in mid to late summer 2017 BEST QUALITY OF CARE Outcomes The Trust continues to perform better than expected, and better than many Shelford peers, against the Summary Hospital Mortality Indicator(SHMI), the key national mortality indicator used by the Care Quality Commission. The most recent data shows that Trust SHMI, which includes palliative care patients and deaths up to 30 days after discharge, is 86.61 (Feb 15 – Jan 16), where a score of 100 is as expected according to casemix and below 100 is better than expected. That places KCH as 10th best performing of 136 hospitals. Shelford Group average performance is 88.86, and KCH is performing 5th best of the 10 Shelford Group trusts. The Trust’s SHMI performance is better than expected for both Denmark Hill and PRUH sites, for both weekday and weekend admissions, for elective and non-elective admissions and across all the high-risk diagnoses – pneumonia, heart failure, sepsis, stroke, acute kidney injury, fractured neck of femur and acute myocardial infarction (identified by Professor Sir Bruce Keogh, National Medical Director of NHS, in his letter to Trusts 17/12/15). Experience and complaints

We continue to focus on customer care and respond to the feedback obtained ensuring the clinical areas are engaged with the process.

Complaint response times remain a challenge and continue to be an area of active focus. In terms of access, the Trust performance against the 4-hour target improved further from 83.5% reported in April to 85.1% in May which is better than the 83.8% target based on our STF trajectory submission. Performance improved at the PRUH from 80.7% to 84.0%, despite a second norovirus outbreak in May where 180 beds were closed early in May. Performance at Denmark Hill also improved slightly from 85.6% to 85.9% in May, despite significant increases in attendances where the daily average number of patients seen exceeded 400. There were 15,910 patients waiting over 18 weeks at the end of May which was an increase compared to April, but our incomplete performance was 80.9%, a slight improvement from the 80.7% reported in April. This position is better than the 80.6% target set in our STF trajectory submission. The number of 52 week breaches increased from 155 in April to 197 in May, so we are 25 cases above our trajectory target of 172 for May. Neuro specialties are 25 cases ahead of their plan but non-neuro specialties are 50 cases above plan. We are still planning to have zero non-neuro 52 week breaches by October. The number of 6-week diagnostic waiting time breaches increased by 297 cases to 978 at the end of May which represents 8.0% of total patients waiting. This is above the 1% national target and above the 4.0% target for May based on our STF trajectory submission. The increase was again largely due to an additional 233 breaches reported in non-obstetric ultrasound mainly on the Denmark Hill site, and an increase of 48 MRI breaches. Plans are in place to reduce the ultrasound backlog by August and secure

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additional capacity to achieve a maximum 5-week waiting time, and discussions are being held with multiple off-site providers to secure additional MRI capacity. Cancer waiting time targets are being achieved at a Trust-level for May with the exception of the 2-week-wait suspected cancer referral target which is not being achieved at 92.6%, but is being achieved for Q1 currently at 93.8%. We have seen an increase specifically in breast, skin and gynae tumour group referrals. Having been achieved for five consecutive months, the 62-day first treatment target has not been achieved at 77.7% in May. This means that Q1 performance against the 85% target is currently at 83.5%, and the position is being reviewed weekly across all tumour groups. Care Quality Commission (CQC)

Following inspection in April 2015, the CQC rated the Trust as “Requires Iimprovement”. We

are committed to achieving an improved rating at the next inspection and therefore the CQC

action plan remains a high priority.

Progress towards a “Good” rating will be monitored closely by the CQC Board which is being

chaired by the Chief Operating Officer. We are currently rolling out a programme of ‘Back to

Basics’ inspections to ensure that we are meeting the fundamental standards of care in all

our wards and clinical areas. This inspection regime will continue until a trust-

wide accreditation scheme has been designed and implemented as part of the Trust’s

transformation programme.

We have invited our internal auditors to carry out a deep dive review of care on the wards later in the year and we will respond swiftly to any findings they may make. EXCELLENT TEACHING & RESEARCH After successfully being shortlisted, the 2 BRC (Biomedical Research Centre) reapplications (led by GST and SLaM, with input from KCH researchers and academics) are now submitted, with interviews pending in July. KCH based staff in cardiology, haematology, child health and liver have been included in the GSTT-led bid, and likewise KCH based staff in neurology, diabetes/obesity, and palliative care have been included in the SLAM-led bid. The KCH Research and Innovation Director and other research related staff have been supporting Professor Peter Goadsby prepare the full application to NIHR for renewal and refreshment of the CRF (Clinical Research Facility, physically located in the centre of KCH) for submission by June 24 2016. Note that this CRF bid was originally submitted to NIHR through SLAM as it supports mental health as well as physical health studies. As the call is to renew and refresh this structure is continuing. A task and finish group of the four KHP partner organisations to reorganise the financial flows and process of the Commercial Trials office (hosted by KCL) has started work; agreement already reached will save KCH £325k pa in contribution fees. KCH is seeking to grow its research impact and profile commensurate with our aim to be an international centre of excellence; between 16 May to 13 June 2016, 59 new articles by authors based at King’s College Hospital were listed on Web of Science, including in top journals such as Thorax, BMC Neurology, and Medicine. The KCH Trust research office has supported grant applications for external funding from investigators across KCH for over £17m. These are now under consideration, several are first phase outline, and some have been shortlisted to second phase, full application.

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SKILLED, “CAN DO” TEAMS Organisation restructures The Phase 1 consultation of the organisational restructure, relating to the new senior operations leadership structure, has now closed. Design of the Tier 2 leadership structures is currently being finalised following input and feedback from across all professional groups during the first part of June. The formal consultation processes for individuals who are likely to be impacted by the Tier 2 proposals is likely to commence in early July. We have also offered confidential 1:1 coaching with an external provider to all those likely to be affected by the organisational changes in Tiers 1 and 2. Talent Management and succession planning A presentation on our proposed approach to managing talent and succession was taken to the Education and Workforce Development Committee at the end of May. We will build on this discussion with a follow-up presentation to KE in the next two months. Objective-setting and appraisals The 2016/17 Trust objectives have been agreed in line with the revised Executive Portfolios, and a performance contract has been developed to monitor delivery of objectives against the Trust framework for both Executives and the management tier below. Formal cascade of Trust objectives will commence once the new organisational structure has been implemented; in the meantime all Executive Directors will be held to account for increasing the uptake of appraisals in each of their areas. Recruitment & Retention A Trust Recruitment Strategy is being prepared for the July Board. Recruitment partners are working to ensure that those candidates who are post selection/ assessment join the Trust at the earliest opportunity. They, together with local managers, are engaged in a wide variety of recruitment initiatives (International, European and National campaigns, attending career fairs, exploring new markets, working with strategic recruitment partner organisations & agencies). There is a specific push on PRUH recruitment including extensive dedicated recruitment advertising. To aid both recruitment and retention, development programmes initially focusing on Nursing Bands 5 & 6 are being worked up, including the introduction of roles at Bands 5.5 & 6.5. Work continues on improving the employment offer. A car leasing scheme was introduced the week commencing 13 June 2016, which has already received considerable interest. A full range (cycle scheme, technology, cars, childcare) benefits roadshow is planned for July. TOP PRODUCTIVITY We launched our Clinical Transformation Programme on the 20th June 2016. This includes 3 “clean sheet redesign” work streams focusing on pre-assessment and theatres, bariatrics and emergency and acute medicine up to 72 hours. The programme is still in its very early stages, but it is encouraging to note the level of clinical engagement and commitment thus far.

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Strong Executive leadership will be required as the programme gathers pace, and it will be important to be sensitive to the considerable operational pressures which front line teams are having to contend with alongside their engagement with this work. FIRM FOUNDATIONS Sound Finances At Month 2, the Trust is reporting a £16.8m deficit. This is a £6.7m adverse year to date

variance against a planned deficit of £10.1m. The current position is an in month deficit of

£6.6m against a planned in month deficit of £4.6m (an adverse in month movement of £2m).

A number of income issues in months 1 and 2 that have contributed towards the adverse

variance as well as a CIP/QIPP gap due to unidentified saving schemes and CIP slippage.

The full details of the Trust’s financial performance can be found under agenda item 6.1. Compelling Communications New and events can be found on the Trust’s website: https://www.kch.nhs.uk/news. Some noteworthy media coverage and events include:

Medium Summary

BBC Online ITV News Channel 4 News ITV News The Daily Telegraph Evening Standard

There was extensive national and international reporting on research carried out by Professor Francesco Rubino, Consultant Metabolic and Bariatric Surgeon at King’s, which shows that metabolic surgery is an effective treatment for some patients with type 2 diabetes.

Evening Standard Southwark News

The Evening Standard and Southwark News reported that Sir Elton John and David Furnish visited King’s to launch a proactive HIV blood testing initiative. The articles explained that the Elton John AIDS Foundation had provided funding to support King’s in setting up the testing programme, which aims to significantly decrease late diagnosis rates in Lambeth and Southwark - areas currently recognised as having the highest HIV prevalence rates in the UK.

The Evening Standard

Mr Duncan Bew, Consultant Trauma Surgeon and Clinical Lead for Trauma and Emergency Surgery at King’s, featured in an article about his appeal for funds for Growing Against Violence. Growing Against Violence is an initiative set up to reduce gang membership and serious youth violence, of which Br Bew is a founder.

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Medium Summary

BBC Online Daily Mail Kent Online

There was coverage of a Parliamentary and Health Service Ombudsman (PHSO) report which detailed the case of a patient who had been diagnosed with pancreatic cancer at another hospital but referred to King’s for treatment. The coverage highlighted that delays at King’s affected his treatment and that the Trust ‘failed to act fast enough’ on advice given from another hospital. The patient sadly died.

Bromley News Shopper

There was coverage of King’s in the Bromley News Shopper after the biggest baby to be delivered naturally at the PRUH’s Oasis Centre was born. The baby was born weighing 12Ib and 8oz.

Bromley News Shopper

The Bromley News Shopper published a story about pathology services at the PRUH transferring to the private company, Viapath. The article acknowledged that Viapath two-thirds NHS owned, with one of the partners being King’s.

Bromley News Shopper

The Bromley News Shopper reported on a woman who is warning people of the effects lithium can have on kidney function.

Helen Wilkinson’s partner was prescribed the drug by another Trust but despite blood tests the hospital did not pick up on the damage it was doing to his body. He was taken to the PRUH after falling ill but sadly died.

Ms Wilkinson raised concerns about the treatment her partner received at the PRUH, which were investigated by the Trust.

Daily Mail There was coverage of pioneering new treatment for heart bypass patients at King’s. The new technology involves surgeons using a special camera so they can see the patient’s blocked artery in 3D. This allows them to see the affected artery more clearly than with a standard keyhole operation. Mr Ranjit Deshpande, a consultant cardiothoracic surgeon at King’s who has used the camera, was quoted in the article.

South London Press The South London Press reported that TV couple, Steph and Dom Parker would be abseiling off the hospital roof to raise money for King’s. The article explained that their son has been a long-term patient at King’s since being diagnosed with epilepsy as a baby.

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Medium Summary

Irish Post Southwark News

There was coverage of an 81-year-old former King’s patient who decided to abseil off the hospital roof to raise money for the King’s charity as she was so impressed with the care she had received.

Robust IT And Information Work continues at pace on the roll out of our new Allscripts Sunrise EPR. We are targeting a “go live” date for Denmark Hill of 5 August.

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Report to: Board of Directors

Date of meeting: 06 July 2016

Subject: Trust Performance Report 2016/17 Month 2

Author(s): Steve Coakley, Acting Assistant Director of Performance &

Contracts

Presented by: Jane Farrell, Chief Operating Officer

Sponsor: Jane Farrell, Chief Operating Officer

History: None

Status: For Information

1. Summary of Report This report provides the details of performance achieved against key national performance and quality indicators, and governance indicators defined in the Monitor Risk Assessment framework for the interim Q1 position in 2016/17. 2. Action required The Board is asked to approve the M2 performance reported against the governance indicators defined in the Monitor Risk Assessment framework for the interim Q1 position in 2016/17. 3. Key implications

Legal:

Statutory reporting to Monitor and the DoH.

Financial:

Trust reports financial performance against published plan.

Assurance:

The summary report provides assurance that the Trust has met the performance targets as defined within the Monitor Risk Assessment framework (RAF) for the interim Q1 position with the exception of the A&E 4-hour target, the 2 week-wait symptomatic breast referral, 62-day GP referral and consultant screening cancer targets, and the RTT incomplete pathway target.

Clinical:

There is no direct impact on clinical issues.

Equality & Diversity:

There is no impact on equality & diversity issues.

Performance:

The summary report demonstrates that the Trust has achieved the performance indicators for the interim Q1 position as defined in the RAF with the exception of the A&E 4-hour target, the 2 week-wait symptomatic breast referral, 62-day GP referral and consultant screening cancer targets, and the RTT Incomplete pathway target at 80.9%.

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Strategy:

Performance against the Trust’s annual plan forecasts and key objectives.

Workforce:

None.

Estates:

There is no direct impact on Estates.

Reputation:

Trust’s quarterly and monthly results will be published by Monitor and the DoH.

Other:(please specify)

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Key Messages of this Report

Trust performance against the 4-hour target improved from 83.48% reported in April to 85.06% in May. Whilst the national 95% target is not being achieved, we have met the 83.8% performance trajectory for May that has been agreed with commissioners and NHSI.

RTT incomplete pathways performance improved further from 80.7% in April to 80.9% in May which is better than the 80.6% performance trajectory. There were 197 patients waiting 52+ weeks at the end of May 2016, which is higher than the 155 patients waiting at the end of April. There were 102 patients on admitted pathways and 95 patients on non-admitted pathways.

Performance against the two week-wait symptomatic breast referral target exceeded the national target in May at 93.5%, and delivered 98.3% in June (to date). Whilst Q1 aggregate recovery remains compromised (currently 88.7%), sustainability and Q2 performance more assured.

62-day GP referral for first treatment underperformed significantly in May at 77.6%, hence whilst June’s current position is above target at 85.3%, Q1 is currently at risk.

All cancer targets are currently exceeding national performance targets for the monthly position in June.

There have been no MRSA cases reported in May 2016. Five c-difficile cases were reported in May – all on the DH site. 10 cases YTD which is below the Trust quota of 12 cases for May YTD position.

Introduction/Background

The performance report for May 2016 includes updates for the Emergency Care 4-hour performance Action plans for PRUH and DH, the Trust-wide RTT programme and HCAI.

Trust Priorities

Emergency 4-hour performance at Princess Royal Hospital (PRUH):

All types attendance performance improved from 80.7% reported in April to 84.0% in May. Type 1 ED attendance performance also improved from 67.9% in April to 71.9% in May. The PRUH had a second norovirus outbreak in May with over 180 beds closed on 9 May and 70 beds still closed on 18 May.

Attendance levels in the ED increased by 1% in May compared to April, but the number of type 1 breaches reduced by 190 cases. Urgent Care Centre (UCC) activity increased by over 8%, and there were still 95 breaches and a further 189 breaches due to delayed UCC handover.

Emergency 4-hour performance at Denmark Hill (DH):

All types performance improved from 85.6% in April to 85.9% in May, and type 1 ED attendance performance improved from 83.0% to 83.4%.

The number of ED attendances increased significantly again in May to over 12,500, similar to the levels reported in March. This equates to over 404 patients seen on average per day.

Referral to Treatment (RTT) Incomplete pathway performance:

The number of 52+ week breach patients increased from 155 patients reported in April to 197 patients reported in May based on the new operational Patient Tracker List (PTL) reports. All 18+ week incomplete pathways have been validated for this position by the central RTT Tracker team. Whilst we are behind our 52-week trajectory of 172 breaches by 25 cases, we are 25 patients ahead of our trajectory for neuro-specialties.

Following the release of the draft report from the DoH Intensive Support Team into the review of our RTT reporting processes, the report has been finalised with our comments at the end of May 2016.

There are 15,910 patients waiting over 18 weeks at the end of May so our incomplete performance is 80.9% which is a further improvement compared to the 80.7% reported for April.

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Key Issues

Clinical Effectiveness:

The national Summary Hospital Mortality Index (SHMI) continues to improve and is better than the expected index of 100 at 82 for the DH site and 88 for the PRUH site, based on the latest 12-months data available from the ‘HED’ benchmarking tool.

The number of diagnostic 6-week waiting time breaches increased by 297 cases reported at the end of May to 978, which represents 8.0% of the total number of patients waiting. This is therefore above the national target of 1% but also above the performance improvement trajectory of 4% for May which was agreed with commissioners. The increase was largely due to an additional 233 breaches reported in non-obstetric ultrasound (non-US), mainly on the DH site, and an increase of 48 MRI breaches, again mainly on the DH site. Revised action plans have now been put in place, in particular to support the reduction of the non-obstetric ultrasound backlog which has a dependency on additional capacity at BMI sites in South East London, as well as on-site solutions.

Safety:

There were no MRSA cases reported in May. There were 5 c-difficile cases reported in May which is below the quota of 6 cases for the month. All of these cases were on the DH site – so there have been 9 cases YTD on the DH site which is consistent with the quota of 9. There has been 1 case YTD on the PRUH site which is better than the quota of 3 cases.

The number of hospital-acquired pressure sores increased from 23 cases in April to 25 cases in May on the DH site, of which 11 cases were on critical care units including Liver ICU, 6 cases on surgical wards and 3 cases on cardiac wards. The number of pressure sores at the PRUH site increased from 2 to 4 cases.

There were 7 inpatient slips, trips and falls cases on the DH site in May compared to 2 cases in April, of which 4 were on cardiovascular wards.

Patient Experience:

The HRWD Inpatient survey overall score improved on both DH and PRUH sites, with scores reported above their targets. The Friends and Family (FFT) scores for Inpatient/Day cases is also achieving target for both sites with DH at 93 and PRUH at 95. FFT scores for ED is achieving target at 80 for DH but us below the 89 target for PRUH at 77.

The number of inpatient cancellations on the day reduced from 70 cases in April to 59 in May – with 31 cancellations at the DH site and 28 cancellations at the PRUH. There were however 13 breaches of the 28-day cancellation standard again for May – with 9 breaches on the DH site for a number of non-medical reasons and 4 at the PRUH site (of which 2 due to the impact of the norovirus outbreak).

The number of patient complaints reduced from 76 in April to 73 in May, of which 8 were rated high/severe. The number of complaints still open or not responded to within 25 working days reduced from 31 to 26 cases.

Finance & Operational Efficiency:

Financial position - please see the Finance report for further details.

The proportion of inpatients discharged at weekends improved slightly from 22.7% in April to 23.0% in April on the DH site, but worsened on the PRUH site from 22.2% to 19.8%; and both indicators remaining below the 28% target.

Utilisation remained below the 80% target across all theatres in May. On the DH site, main theatre utilisation worsened from 76% in April to 73%, but DSU utilisation improved from 73% to 75%. On the PRUH site, main theatre utilisation worsened from 69% to 64%, but DSU utilisation improved from 66% to 71%. Utilisation in Orpington main theatres improved from 60% to 75%. Theatres and pre-op assessment processes are one of the initial areas of focus for the Kings Transformation programme launched on 20 June.

Staffing:

Vacancy rate remains stable at 10.7% for May on the DH site, but improved from 17.3% to and to 16.5% for the PRUH sites, so above the internal 5-8% target.

Compliance against mandatory and statutory training and induction courses improved to 82, above the target of 80 for the DH site. No data available for PRUH.

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Regulatory Performance/Monitor compliance

Monitor – Q1 2016/17 position:

The Trust has achieved the performance indicators in the Monitor Risk Assessment Framework for the interim Q1 position with the exception of the A&E 4-hour performance target, the 2 week-wait symptomatic breast referral and 62-day GP referral and consultant, and the RTT incomplete pathway target.

Our RTT incomplete performance is better than our agreed performance trajectory of 80.6% at 80.9% for May 2016.

We therefore have a notional score of 5.0 based on the latest RAF for our May 2016 reported performance.

Performance against the two week-wait symptomatic breast referral target improved to meet the national 93% target at 93.5% in May, and has improved further to 98.3% in June. However, we will not be able to achieve the target for Q1 due to the high number of breaches reported in April. There were 21 breaches of the 62-day GP referral for first treatment standard in May with performance dropping to the 77.7%, below the national 85% target. We will not achieve this target for May and work continues to assess our performance for Q1, as this target is currently exceeding 85% in June. Planned treatments for June are being reviewed but achievement of this target is at risk for Q1.

We have reported 10 c-difficile cases for May 2016 which is below the quota of 12 cases for the YTD cumulative position.

#### #### #### ####

Metric Units WeightingYTD

ThresholdQtr 1 Qtr 2 Qtr 3 Qtr 4

Acute targets - National requirements

Clostridium difficile year on year reduction YTD Number 1.0 72 10

31 day wait for second or subsequent treatment 1.0

Surgery % 94 95.8 #DIV/0! #DIV/0! #DIV/0!

Anti cancer drug treatments % 98 100.0 #DIV/0! #DIV/0! #DIV/0!

Radiotherapy % 94 100.0 #DIV/0! #DIV/0! #DIV/0!

62 day wait for first treatment 1.0

from urgent GP referral to treatment: all cancers % 85 83.5 #DIV/0! #DIV/0! #DIV/0!

consultant screening service referral: all cancers % 90 88.9 #DIV/0! #DIV/0! #DIV/0!

Acute targets - minimum Standards

31 day wait from diagnosis to first treatment: all cancers % 1.0 96 98.2 #DIV/0! #DIV/0! #DIV/0!

Two week wait from referral to date seen: 1.0

all cancers % 93 93.8 #DIV/0! #DIV/0! #DIV/0!

for symptomatic breast patients (cancer not initially suspected) % 93 88.7 #DIV/0! #DIV/0! #DIV/0!

Maximum time of 18 weeks from point of referral to treatment in

aggregate – patients on an incomplete pathway% 1.0 92 76.2 #DIV/0! #DIV/0! #DIV/0!

A&E:

Maximum waiting time of 4 hours in ED from arrival to admission,

transfer or discharge% 1.0 95 84.30 #DIV/0! #DIV/0! #DIV/0!

Self-certification against compliance with requirements regarding access

to healthcare for people with a learning disability% 1.0 N/A Achieved

Total Score 5

Kings Monitor Scorecard May-16

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Trust Performance Scorecard – DH site

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Trust Performance Scorecard – PRUH sites

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Trust Emergency Care 4-hour performance and ED Recovery Programme

Highlights – May 2016 Trust performance for all types attendances against the 4-hour target improved from 83.48% reported in April to 85.06% in May. This is below the national 95% target and is also below the performance achieved in May last year. However, based on the performance trajectories that we have agreed with commissioners and submitted to NHSI for 2016/17, we are meeting the target of 83.8% set for May. The charts below compare monthly and quarterly Trust performance against the 4-hour target.

89.89%91.84%

89.34%

83.39%84.05%

70%

75%

80%

85%

90%

95%

100%

Qtr 1 Qtr 2 Qtr 3 Qtr 4

KIngs - Quarterly All Types Performance

2015/16 2016/17

70%

75%

80%

85%

90%

95%

100%

Kings- Monthly All Types PerformanceMay 2014 - May 2016

May 2014 - May 2015 May 2015 - May 2016

ED Recovery Programme 2016/17 The Trust’s ED recovery programme for 2016/17 which comprises 3 key work-streams - out of hospital care, in-hospital care and increased bed capacity for both the PRUH and DH sites - has been approved following review at Clinical Summit meetings held with commissioners and NHS England/NHSI. As outlined in last month’s report, the recovery plan includes a planned increase and re-configuration of bed capacity across the DH, PRUH and Orpington Sites. We have received a letter from Southwark CCG in early June which sets out the position of the Trust’s three local commissioners: Southwark, Lambeth and Bromley, in relation to our 2016/17 bed proposals. The letter confirmed that appropriate committees from each of the three CCG governing bodies has considered our proposals, and have secured in principle support from all three CCGs. The proposals are also being shared more widely with south east London CCGs and work is on-going to secure south-east London wide engagement with Overview and Scrutiny Committees (HOSCs). Proposed engagement and consultation arrangements South East London commissioners have agreed a process for further discussing the bed capacity proposals with HOSCs during July 2016. Based on the proposals that have already been shared and discussed, the Trust is required to provide a HOSC trigger template including detail of the recovery plans and covering issues such as patient choice and transport by 24 June 2016. The Kings Way On 20 June 2016, the Trust launched ‘The King’s Way’ which is a new long-term transformation programme. In terms of service re-design, one of the first three areas of focus will be the Emergency Department and the acute medical pathway for patients who stay less than 72 hours. This work will link in with the wider actions that have been agreed as part of our 2016/16 recovery plan for both the DH and PRUH sites.

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Emergency Care 4-hour performance Action Plan Update @PRUH

Highlights – May 2016 All types attendance performance improved from 80.7% reported in April to 84.0% in May. Type 1 ED attendance performance also improved from 67.9% in April to 71.9% in May. Despite the improvement, performance was lower compared to May last year as demonstrated in the charts below.

88.54%

91.50%89.26%

81.27%83.15%

70%

75%

80%

85%

90%

95%

100%

Qtr 1 Qtr 2 Qtr 3 Qtr 4

PRUH Quarterly All Types Performance

2015/16 2016/17

70%

75%

80%

85%

90%

95%

100%

PRUH Monthly All Types PerformanceMay 2014 - May 2016

May 2014 - May 2015 May 2015 - May 2016

In-Hospital Actions: 8-point plan for PRUH An Eight point plan has been finalised to address a number of critical areas including:

Bottom-up re-design of emergency and acute care pathways to address length of stay (LOS) and process issues.

Improved usage of Ambulatory Care, direct access for primary care, extension across multiple-specialties.

Acute Care Hub (ACH) / Acute Medical Unit (AMU) at PRUH silted with patients unable to move to next phase, and needs to be enabled as an ACH/AMU environment

Improvement of intra-ED processes to support flow out of the ED department, capacity constraints of significance, paediatric assessment, sub-acute care, SIFT, RAT, nursing model and recruitment appropriate to manage patients safely during peak times.

Improvement in LOS for frail and elderly patients, improved discharge focus and admissions avoidance, and support for patients on surgical pathways/

Insufficient inpatient capacity at the PRUH site to manage flow across the emergency and acute care pathway due to long staying inpatients

Developed planned site response to norovirus risk Following the achievement of the ED 4-hour trajectory in April and May, a number of senior management changes have been implemented in the middle of June for both the PRUH and DH sites. A new Operations Director has joined the management team at PRUH from 14 June 2016, as well as General Manager for Emergency and Acute Medicine who will take a lead role in urgent care pathway improvement.

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Emergency Care 4-hour performance Action Plan Update @DH

Highlights – May 2016 All types performance improved from 85.6% in April to 85.9% in May, and type 1 ED attendance performance improved from 83.0% to 83.4%. However, performance remains below the levels achieved in May 2015 as shown in the charts below.

90.78%92.51%

89.41%

85.04%84.71%

70%

75%

80%

85%

90%

95%

100%

Qtr 1 Qtr 2 Qtr 3 Qtr 4

DH Quarterly All Types Performance

2015/16 2016/17

70%

75%

80%

85%

90%

95%

100%

DH Monthly All Types PerformanceMay 2014 - May 2016

May 2014 - May 2015 May 2015 - May 2016

In-Hospital Actions: 6-point plan for DH A six-point plan has been finalised to address a number of critical areas including:

Ability to manage flow at peak times - wait for first clinician and cubicle most significant breach reasons at peak.

Separation of minors/UCC from majors/resus to prevent mission creep.

Improve capacity in majors to address safety and quality concerns at times of peak demand.

Flow out of department - in terms of both robust acute care pathways and capacity to flow patients into.

Flow across entire emergency and acute care pathways and discharge focus of pathways and services.

Emergency care physician model for minor injuries/illnesses/single system problems.

Provision of frailty assessment in CDU and not focussed on patient or creating gerontology resource free at the point of delivery.

Following the introduction of new management roles at the PRUH, the senior operational management team has been strengthened at the DH site, with staff on interim roles returning to their permanent post for Head of Clinical Site Management and Emergency Planning, and the post of Head of Nursing for TEAM/Medicine.

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RTT Update

RTT Reporting Suspension update The draft report from the DoH Intensive Support Team (IST) has been shared and reviewed by commissioners and the Trust. Comments have been incorporated and the final report has been published to the Trust for the end of May. The report provides a number of key actions and recommendations which have been incorporated into the Trust’s revised RTT Recovery Programme for 2016/17. Validation Update Incomplete pathways for the end-May 2016 position have been validated below 18 weeks for both admitted pathways and non-admitted pathways. The Trust is continuing its RTT recovery programme in 2016/17 and plans the on-going validation of incomplete pathways down to 10 weeks. The central validation team have validated pathways down to 14 weeks. End-May 2016 Incomplete pathway position There were 15,910 incomplete pathways with a waiting time over 18 weeks, which is an increase of 795 pathways compared to our position at the end of April. The number of admitted incomplete pathways increased by 441, and the number of Non-admitted pathways increased by 354. Our incomplete performance for May 2016 was therefore 80.9% which is a slight improvement of 0.2% compared to April. This is also better than the performance improvement trajectory of 80.6% which was agreed between the Trust, commissioners and NHSI. The waiting time position for May 2016 compared to April 2016 is summarised below:

Patients waiting end-May (April position in brackets)

18-39 weeks 40-51 weeks

52+ weeks

Incomplete -Admitted 4,053 (3,679) 327 (285) 102 (77)

Incomplete – Non-admitted 10,707 (10,310) 626 (686) 95 (78)

Total Incomplete pathways 14,760 (13,989) 953 (971) 197 (155)

52-week Waiting Time position There were 197 patients waiting over 52 weeks that we have reported in our May 2016 month-end position to Unify, of which there were 102 patients waiting on admitted pathways and 95 patients waiting on non-admitted pathways. This is an increase compared to the 155 patients that we reported for the end of April position. We are therefore 25 patients behind our agreed trajectory of 172 for the month. The number of Neuro-specialty breaches increased from 69 to 80 but they remain 25 ahead of trajectory. Non-neuro breaches have increased slightly from 86 to 117 and are now 50 cases behind trajectory. Action plans are being developed in Orthopaedics, General surgery and Ophthalmology which are the key specialties above their 52-week trajectory based on the position for May. We are still planning to have zero 52+ week patients waiting by the end of October this year. An interim RTT project manager has also joined the Trust from week-commencing 20 June to support delivery of our 52+ and 18+ week backlog reduction plans. Demand and Capacity Modelling Demand data has been populated for the phase 1 specialties using the IST models for outpatient and admitted car including T&O, Ophthalmology, Neurology and Neurosurgery. We are working with service leads for these specialty areas to populate the capacity elements of the model. The outpatient models in Ophthalmology have been reviewed the IST lead who is supporting this initial phase of the project. Outputs from the modelling will be used to review our RTT trajectory by specialty, and to inform future activity and capacity planning.

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Cancer – May 2016 Performance Update

The table below summarises the achievement of cancer targets at Trust-level for the May 2016 and latest Q1 position. The two-week wait suspected cancer referral target is not being achieved at 92.55% for May compared to the national 93% target, but is being achieved for the latest Q1 position at 93.79%. Whilst the two week-wait symptomatic breast performance has recovered to 93.5% for May, the high number of breaches that we reported in April means that Q1 performance is 88.7% and we are not therefore going to achieve this target for Q1. The 62 day GP referral target of 85% is not being achieved at 77.66% for May and performance for June is above target at 85.3%, but below target for Q1 at 83.5%.

2WW Symptomatic Breast Following the capacity and process/administration issues that contributed to the deteriorating performance in March and April, a number of actions have been agreed and implemented at pace to try and recover the position for May and June. Performance has exceeded national target at 93.5% in May and 98.4% in June to-date, but this target will not be achieved for Q1. 2WW Suspected Cancer referrals We are seeing an increase in 2WW referrals, in particular in breast, skin and gynae tumour groups. Whilst the 2WW target is not being achieved for the latest position in May, performance is above national target at 94.6% for June to-date. Referrals and associated performance is being reviewed by tumour group at internal performance meetings. 62-day GP Referral This target has not been achieved for the latest position for May at 77.7% as there has been a number of challenging patient pathways and patient choice impacting on this month’s performance. The June position is being closely monitored as the latest position for Q1 is 83.5% which is below the national target of 85%. Tumour groups have been refreshing their action plans, and weekly meetings are being held with the Director of Operations to review plans and the latest performance position. Treatments planned for June are in the process of being reviewed, in order to determine if the target will be achieved for Q1. Inter Trust Transfers (ITT) In April, 41.2% of pathways were referred to GSTT by day 38 which was worse than the average of 62.3% achieved for January – April 2016. The position for May is 65.5%, subject to final validation by GSST, and is better than the trajectory of 51.4% which was shared with commissioners. Key actions for the Trust to implement in 2016/17 include:

Root cause analysis of all late ITTs to enable tumour groups to identify trends and causes of delays

Minimise delays at the start of the pathway

Work with diagnostics to improve access to diagnostic testing and availability of reports.

Enc. 4.1

13 of 13

Healthcare Associated Infection (HCAI) Update (1/1)

MRSA (post 48 hour bacteraemia:

0 cases in May 2016 (Last case reported in February 2016.) C-difficile:

5 new cases reported in May (all 5 cases at DH); 10 cases YTD which is below the quota of 12 cases for May YTD position and better than the 21 cases reported in May last year.

VRE bacteraemia:

8 new cases at DH and 1 new case at PRUH in May; 9 cases YTD which is above the target of 4 cases for the May position and higher than the 4 cases reported in May last year.

E-Coli bacteraemia:

6 new cases reported in May at DH and 2 new cases at PRUH; 21 cases YTD which is above the target of 16 cases and higher than the 15 cases reported in May last year.

C-Difficile (CDI) Action Plan Update:

Reviewing of current practice and integration of policies and practice: Work is on-going to align policies and protocols across sites. This work will be overseen by the HCAI Operations Committee.

Policies approved and published: Infection Prevention and Control, Intravascular Catheters, Waste Management and Trust Decontamination.

Protocols approved and published: Isolation Precautions, Infectious Death Handling, Management of Gastrointestinal Infection, Respiratory Virus and Atypical Bacterial Infections Treatment and Infection Control, Varicella Zoster Virus (VZV), Transmissible Spongiform Encephalopathy, Blood Cultures, Standard Precautions, Hand Hygiene, Linen and Laundry, Guidelines for Animals on Hospital Premises and Aseptic Non Touch Technique.

Protocols under consultation: MRSA, Clostridium difficile, Multiple Resistant Gram Negative, Tuberculosis protocols are under consultation.

Protocols outstanding: Control of Outbreaks of Infection, Pandemic Influenza Protocol, Coronavirus including MERS-CoV & SARS-CoV and Streptococci and Enterococci.

Centralisation of endoscope reprocessing: A project on-going to plan and develop a central reprocessing facility for endoscopies. The unit at DH site is being used as a template for the PRUH unit. This project is still very much in the planning stages, but should allow for a much higher level of decontamination than is currently the case.

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Monthly Unify Staffing Report

(May 2016)

6th July 2016

Board Meeting

Report to: Board Directors

Date of meeting: 6th July 2016

Subject: Monthly Unify Staffing Report (May 2016)

Author(s): Maria Donbavand

Presented by: Paula Townsend

Sponsor: Paula Townsend

History: Monthly Nursing, Midwifery and Care staff numbers to the Board

Status: For Information

Legal:

Patients have a right to be cared for by appropriately qualified and experienced staff in safe

environments. This right is enshrined within the national Health Service (NHS) Constitution, and the

NHS Act 1999 makes explicit the board’s corporate accountability for quality. Nurses’ responsibilities

regarding safe staffing are stipulated by the Nursing and Midwifery council (NMC).

Financial: Nursing is the largest professional group in the Trust and consumes a large amount of resource.

Cost efficiency is therefore paramount

Assurance:

This report provides assurance and evidence on nursing workforce.

Clinical: Nursing is a key component in provision of good patient experience and harm free care

Equality & Diversity: There are no issues or implications relating to equality and diversity within this report

Performance: This report highlights achievements against national and local key performance indicators

Strategy: The contents of this report is directly aligned to the Trust Nursing and Midwifery Objectives

Workforce: This report will inform Trust’s Nursing and Midwifery Workforce Strategy.

Estates:

There are no implications

Reputation: Poor nursing care would have a deleterious effect on the reputation of the Trust

Other:(please specify)

n/a

Key Implications

This report provides assurance to the Board of Directors around the safety of the Nursing and Midwifery staffing levels across the Trust and also

provides details of the actual hours of Nursing, Midwifery and Care Staff time on ward day shifts and night shifts versus planned staffing levels for

May 2016.

In addition to the above please note that as of the May 2016 return the Department of Health issued new guidance on Nursing Hours

per Patient Day (NHPPD) – attached separately for information if required. As this is the first return this report will only reflect the new

layout of the submission and not analysis as we are not yet clear what the benchmark for NHPPD should look like as this is yet to be

provided by the Department of Health.

KEY POINTS

• The number of staff required per shift is calculated using an evidence based tool, which is based on the level of Acuity of the patients. This is

further informed by professional judgement, taking into consideration issues such as ward size and layout, patient dependency, staff

experience, incidence of harm and patient satisfaction, and additional tasks that the ward staff might be required to perform. This method is in

line with NICE guidance. This gives us the optimum planned number of staff per shift.

• For each of the 76 clinical inpatient areas, the actual number of staff as a percentage of the planned number is recorded. The overall figures

are shown below.

Some variance between planned and actual levels is to be expected. The report explores in detail where there was a variance of greater than

15% between actual fill rates and planned staffing levels.

Across the Trust, the (combined) average actual level of registered nursing staff was generally within 15% of the levels planned across all

shifts.

At Denmark Hill, there were 21 clinical areas where the actual number of Healthcare assistants was more than 115% above the planned level,

and 2 areas where the levels were less than 85% of those planned. (numbers are based on combined day and night average)

At PRUH, there were 3 clinical areas where the actual number of Healthcare assistants was more than 115% above the planned level, and 6

areas where the levels were less than 85% of those planned. (numbers are based on combined day and night average)

Summary of Report 1/2

% Average fill rate

RN

% Average Fill rate

HCA

Denmark Hill 94% 132%

PRUH 95% 93%

Safer Staffing Fill rate - May 2016

Site

Day and Night

Summary of Report 2/2

Understaffing

• Although the Trust position shows that staffing levels overall for Registered nursing did not fall below 85% over the month, there were areas

particularly at Denmark Hill where this was the case. (these are identified in slides 8 and slide 11 for the PRUH) . A system of “Red Shift”

reporting is in place which allows staff to flag instances when they believe that the shift is inadequately staffed to look after the current cohort

of patients. In some cases this is due to having fewer Registered Nurses than planned, or when the number of staff planned is correct but the

patients are more acutely sick or dependent than usual. In total there were 125 red shifts declared in May. The majority from Denmark Hill,

many associated with the opening of a temporary ward, and from the emergency medical wards where there are high vacancies. In each case

local managers assess the situation and make a judgement about whether moving staff from better staffed areas is required to maintain

safety.

Where there are instances of hours exceeding those expected the reasons particularly in relation to HCAs are as follows:

o Extra staff required on an ad hoc basis to “special” high risk/vulnerable patients, this number has reduced over the year

o Overseas Nurses awaiting their NMC registration are recorded as unregistered,

o HCA usage is increased to minimise the impact of reduced RN fill rates

o Where the expected staffing level is only one person, an increase of one member of staff on a few occasions generates a large

percentage increase.

In summary the actual number of additional healthcare assistants used is less than the percentage would suggest, usage is

subject to controls and is decreasing.

• ACTION REQUIRED

• The Board is asked to note the report.

0102030405060708090

100110120130140150160170180190200

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

No. of Red Shifts between Dec 15 - May 16 Denmark Hill

Red

Linear (Red)

0102030405060708090

100110120130140150160

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

No. of Red Shifts between Dec 15 - May 16 PRUH

Red

Linear (Red)

6

Trends and patterns, Nursing hours:

Planned Vs. Actual – Denmark Hill

The summary below is based on 46 in-patient wards across the Denmark

Hill site.

RN Day and Night Shift - The overall Planned versus actual RN nursing

hours for May 2016 was 6% below plan. This is an increase of 2% from

the previous month, this is within acceptable limits.

HCA Day and Night Shift - The overall Planned versus actual HCA

nursing hours for May 2016 was 132% above plan.

70%85%

100%115%130%145%160%175%190%205%220%235%250%265%280%295%310%325%

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

AVG - RN Day and Night

AVG HCA Day and Night

Over

Under

Planned vs Actual by month - Denmark Hill

Hospital % Against Planned (RNs) Day/Night

St Thomas Hospital 99%

Imperial (St Mary's) 96%

Kings College Hospital - DH 94%

Safe Staffing levels - taken from NHS choices - 24.06.2016

Trends and patterns, Nursing hours:

Planned Vs. Actual – Denmark Hill

4%24%44%64%84%

104%124%144%164%184%204%224%244%264%284%304%324%344%364%384%404%424%444%464%484%

Avg Combined RN

Avg Combined HCA

Over

Under

Planned Vs Actual by month - Denmark Hill

Key: Reasons for high % of actual v’s planned is due to some areas having no budget for a HCA but then

may require 1 special which can then inflate the numbers.

Exception Report – Denmark Hill

HCA and RN staffing levels – Lower than Planned

Division Ward NameReview by HON/Matron/Ward where 15% or more of nursing hours did not meet agreed staffing levels (Highlighted

in red)

Women's Brunel Low average HCA rate on day shift due to vacancy, now recruited to, care not compromised.

TEAM Byron Ward operating at safe staffing levels (amber / green). Additional HCA staffing to support 1:1 care (day and night shifts)

Surgery Coptcoat WardVacancies currently exist on this ward which we are backfilling with HCAs where possible to ensure that patient care is not

affected.

Haematology Davidson

Used of HCA day & night to cover RN shortfall to support bed side care, regular RN's moved around other area of Haematology

unit to dilute skills. HCA also used to 1:1care to 1Xpt 24/7. High sickness rate over month of May. Matron & ward managers

worked frontline to cover skills shortfall.

Liver and Renal DawsonThere are vacancies within this ward and where Bank staff not available for RN shifts we have downgraded them to HCAs to

support where possbile to ensure patient safety is not affected.

Haematology Derek Mitchell Unit

High rate of sickness over the month of may, shortfall cover by other haematology ward (Elf&Libra, Waddington&Davidson),

Matron and ward manager worked front line to cover skills. Hig used of HCA to support RN shortfall. HCA also used for to 1:1

care to patients X3 24/7 to ensure safety.

Liver and Renal Fisk and Cheere Ward Extra HCAs booked used to cover nursing vacancies, Shifts covered by ward manager/PDN.

Private Patients Guthrie WardWe are currently recruiting to vacancies however ward operating at safe staffing levels with support from Senior Sister and

Matron.

Neuro Kinnier Wilson HDU Not all HCA shifts filled so staff moved around to ensure patient safety not affected.

Surgery ListerHigh RN vacancy factor with HCAs filling some of the vacant shifts and large nos of specialling required with shirts unfilled by

specials team.

Liver and Renal Liver ICU Vacancies on the ward however staff moved around where possible to ensure patient safety is not affected.

TEAM Lonsdale Ward operating at safe staffing levels (amber / green).

TEAM Marjorie Warren Ward operating at safe staffing levels (amber / green). Additional HCA staffing to support 1:1 care (day and night shifts)

TEAM Mary Ray Ward operating at safe staffing levels (amber / green). Additional HCA staffing at night to support 1:1 care

Children's Rays Of Sunshine Patient is being specialled

Children's Thomas Cook CCCCThere are vacancies within this ward along with Mat leave and where Bank staff not available - staff have been moved around

from other wards to ensure patient safety is not affected.

New Return NHPPD – Denmark Hill

Division Ward Name

%

Average

fill rate RN

- Day

%

Average

Fill rate

HCA -

Day

%

Average

fill rate

RN -

Night

% Average

Fill rate

HCA -

Night

Patients at

Midnight

23:59

Registered

midwives/

nurses

Care Staff OverallNo. of

Beds

TEAM Annie Zunz 89% 102% 95% 132% 735 6.3 2.8 9.1 28

Women's Brunel 94% 69% 103% 95% 470 5.4 1.9 7.3 18

TEAM Byron 89% 111% 78% 126% 885 3.7 2.9 6.6 30

CCTD Christine Brown CCU 98% 94% 97% 100% 511 24.5 1.4 25.9 17

Surgery Coptcoat Ward 78% 123% 95% 141% 380 6.0 2.2 8.2 15

Cardiac Coronary Care Unit (Sam Oram) 98% 120% 95% 550% 216 9.5 2.5 12.0 8

Cardiac Cotton 91% 97% 90% 137% 789 3.6 2.0 5.6 26

Neuro David Marsden 96% 139% 93% 159% 956 4.6 4.4 9.0 31

Haematology Davidson 90% 110% 85% 200% 518 5.4 2.9 8.3 17

Liver and Renal Dawson 74% 137% 84% 138% 669 3.7 3.0 6.7 21

Haematology Derek Mitchell Unit 83% 97% 99% 106% 429 6.0 1.8 7.8 14

Children's DH-The Children's Surgical Ward 88% 98% 93% 280% 566 7.3 1.5 8.8 21

TEAM Donne 92% 90% 98% 121% 920 3.6 2.9 6.5 30

Haematology ELF & LIBRA Ward 85% 86% 85% 125% 489 5.7 2.3 8.0 16

Liver and Renal Fisk and Cheere Ward 77% 135% 79% 143% 645 6.0 3.0 9.0 29

CCTD Frank Stansil Critical Care 101% 93% 101% 100% 393 25.6 1.7 27.3 30

Children's Frederick Still (Newborn Unit) 110% 100% 106% 100% 943 12.1 0.0 12.1 34

Private Patients Guthrie Ward 84% 100% 101% 100% 468 6.1 1.5 7.6 21

Liver and Renal Howard Ward 95% 145% 100% 194% 490 4.7 3.1 7.8 16

CCTD Jack Steinberg Critical Care 104% 97% 104% 106% 513 24.6 1.4 26.0 16

Surgery Katherine Monk 91% 110% 95% 136% 653 7.1 4.7 11.8 28

Neuro Kinnier Wilson 98% 111% 86% 160% 599 5.0 3.9 8.9 20

Neuro Kinnier Wilson HDU 100% 77% 100% 100% 330 12.9 0.7 13.6 11

Surgery Lister 85% 127% 91% 167% 892 3.8 2.4 6.2 25

Liver and Renal Liver ICU 112% 29% 103% 21% 440 30.5 0.3 30.8 19

TEAM Lonsdale 89% 98% 79% 92% 682 4.6 2.6 7.2 25

TEAM Marjorie Warren 84% 120% 97% 129% 921 3.7 3.1 6.8 30

TEAM Mary Ray 97% 102% 80% 122% 899 4.0 2.9 6.9 30

TEAM Matthew Whiting 98% 97% 96% 103% 494 4.9 2.9 7.8 26

Neuro Murray Falconer 92% 96% 91% 105% 821 4.9 2.6 7.5 31

TEAM Oliver 104% 103% 119% 118% 921 4.0 2.5 6.5 30

Children's Paediatric Short Stay 103% 97% 100% 94% 127 11.2 5.3 16.5 6

Women's Postnatal William Gilliat 94% 91% 98% 101% 1356 3.8 2.3 6.1 50

TEAM R D Lawrence 94% 96% 91% 105% 744 5.8 2.4 8.2 28

Children's Rays Of Sunshine 100% 138% 108% 58% 493 8.3 1.4 9.7 19

Cardiac Recovery Ward 98% 100% 99% 100% 90 25.6 0.0 25.6 17

Cardiac Sam Oram 94% 130% 91% 190% 527 4.4 2.8 7.2 17

Neuro The Friends Stroke Unit 98% 127% 99% 130% 809 7.2 3.9 11.1 29

Children's Thomas Cook CCCC 89% 100% 92% 71% 392 19.7 1.6 21.3 15

Liver and Renal Todd 98% 100% 97% 131% 628 5.9 3.0 8.9 22

Children's Toni & Guy 87% 121% 90% 425% 370 9.4 1.6 11.0 15

Surgery Trundle 96% 112% 99% 123% 437 5.2 4.7 9.9 16

Surgery Twining 95% 97% 90% 105% 774 3.8 2.9 6.7 26

Cardiac V&A HDU Ward 96% 110% 98% 119% 326 9.1 2.5 11.6 10

Cardiac Victoria & Albert 97% 113% 94% 225% 524 4.7 1.1 5.8 18

Haematology Waddington 89% 158% 90% 833% 279 6.9 3.1 10.0 9

This is calculated by taking the Actual hours of Day and Night combined for each staff type

and dividing by the number of patients on the ward at 23:59

10

The summary below is based on 30 in-patient wards across the

PRUH site.

RN Day and Night Shift - The overall Planned versus actual

RN nursing hours for May 2016 was 5% below plan. This is a

decrease of 1% from the previous month.

HCA Day and Night Shift - The overall Planned versus

actual HCA nursing hours for May 2016 was 7% below plan.

This is a decrease of 17% from the previous month.

Trends and patterns, Nursing hours:

Planned Vs. Actual – PRUH

Hospital % Against Planned (RNs) Day/Night

Croydon University Hospital 97%

University Hospital Lewisham 97%

Kings College Hospital - PRUH 95%

Safe Staffing levels - taken from NHS choices - 24.06.2016

70%

85%

100%

115%

130%

145%

160%

175%

190%

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

% Avg Fill rate RN Day and Night

% Avg Fill rate HCA Day and Night

Over

Under

Planned Vs Actual by month - PRUH

Trends and patterns, Nursing hours:

Planned Vs. Actual – PRUH

Ward Level performance – Planned Vs Actual Day and Night combined - PRUH

4%24%44%64%84%

104%124%144%164%184%204%224%244%264%284%

Avg Combined RN

Avg Combined HCA

Over

Under

Exceptions Report – PRUH

HCA and RN staffing levels – Lower than Planned

Division WardReview by HON/Matron/Ward where 15% or more of nursing hours did not meet

agreed staffing levels (Highlighted in red)

CCTD Intensive Care Unit One HCA vacancy not filled by bank, new starter in for next month.

Children's Children's WardThere are vacancies currently in our HCA establishment which were not filled by Bank,the

ward operated at safe staffing levels for patient numbers and acuity.

Children's Special Care Baby UnitThere are currently vacancies within our HCA establishment which were not filled by Bank,

SCBU operated at safe staffing levels for patient numbers and acuity

LRS Boddington (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is because we

have a lower number of patients on the ward.

LRS Quebec (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is because we

have a lower number of patients on the ward.

Network Acute Stroke Unit (PRUH)There are RN vacancies that exist on this ward so we are topping up with HCAs where

possible to ensure patient care is not affected.

Network HASU - Hyper Acute Stroke UnitThere are vacancies that exist for HCAs however the ward manager and TIA nurse have

supported where possible to ensure patient care is not affected.

Network Ontario (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is because we

have a lower number of patients on the ward.

Neuro Frank Cooksey Ward operating at safe staffing levels within the planned number.

TEAM Medical Ward 7There are currently vacancies within our HCA establishment which were not filled by Bank,

however the ward operated at safe staffing levels for patient numbers and acuity

Women's Maternity Unit (PRU)There are vacancies currently which were not filled by Bank however staff moves ensured

that Patient care was not affected.

New Return NHPPD – PRUH

This is calculated by taking the Actual hours of Day and Night combined for each staff type

and dividing by the number of patients on the ward at 23:59

Division Ward

%

Averag

e fill

rate

RN/RM -

Day

%

Averag

e Fill

rate

HCA -

Day

%

Averag

e fill

rate

RN/RM -

Night

%

Averag

e Fill

rate

HCA -

Night

Patients

at

Midnight

23:59

Registered

midwives/

nurses

Care

StaffOverall

No. of

Beds

Network Acute Stroke Unit (PRUH) 98% 92% 76% 127% 786 3.1 2.6 5.7 20

LRS Boddington (ORP) 84% 64% 78% 78% 435 5.4 2.9 8.3 24

Network Chartwell Unit 97% 113% 100% 159% 355 5.9 4.0 9.9 12

Children's Children's Ward 96% 25% 94% 52% 309 7.6 0.7 8.3 12

Cardiac Coronary Care Unit (CCU) 98% 100% 98% 133% 329 7.2 0.1 7.3 12

TEAM Darwin 1 (S1) 88% 103% 100% 118% 550 4.0 5.5 9.5 20

TEAM Darwin 2 (S2) 98% 97% 100% 102% 611 3.5 4.7 8.2 20

TEAM Emergency Assessment Unit (EAU) 98% 98% 102% 100% 767 5.6 3.6 9.2 28

TEAM Farnborough Ward 103% 140% 101% 163% 771 3.8 3.1 6.9 25

Neuro Frank Cooksey 104% 87% 97% 83% 447 5.2 4.3 9.5 15

Network HASU - Hyper Acute Stroke Unit 97% 79% 95% 75% 387 10.6 2.8 13.4 20

CCTD Intensive Care Unit 94% 106% 96% 68% 247 24.7 2.5 27.2 10

Women's Maternity Unit (PRU) 99% 81% 94% 97% 653 5.2 2.4 7.6 30

TEAM Medical Ward 1 99% 95% 100% 94% 352 6.0 2.9 8.9 12

TEAM Medical Ward 2 103% 93% 112% 102% 577 3.8 2.9 6.7 20

TEAM Medical Ward 3 89% 92% 85% 86% 595 3.9 3.9 7.8 20

TEAM Medical Ward 4 94% 94% 98% 119% 554 4.1 4.3 8.4 20

TEAM Medical Ward 6 99% 98% 103% 103% 579 4.1 3.1 7.2 20

TEAM Medical Ward 7 96% 102% 100% 69% 572 3.9 3.2 7.1 20

Cardiac Medical Ward 8 99% 97% 100% 100% 597 3.6 2.4 6.0 20

TEAM Medical Ward 9 97% 96% 98% 99% 757 5.5 3.7 9.2 28

Network Ontario (ORP) 90% 67% 102% 90% 463 3.6 2.9 6.5 20

LRS Quebec (ORP) 46% 39% 35% 35% 131 7.8 3.2 11.0 19

Children's Special Care Baby Unit 97% 27% 99% 15% 198 10.5 0.6 11.1 12

LRS Surgical Ward 3 99% 98% 99% 100% 507 4.9 2.7 7.6 20

LRS Surgical Ward 4 105% 105% 100% 90% 396 4.5 3.2 7.7 14

LRS Surgical Ward 5 98% 102% 102% 102% 807 3.9 2.3 6.2 28

LRS Surgical Ward 6 100% 106% 100% 110% 574 4.3 2.7 7.0 20

LRS Surgical Ward 7 98% 106% 101% 106% 805 3.9 3.7 7.6 28

Women's Surgical Ward 8 99% 100% 100% 106% 440 5.3 2.5 7.8 16

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Finance Report

Month 02 (May) 2016/17

Finance Committee

27th June 2016

Enc. .

Page 1 of 25

Report to: Finance and Performance Committee

Date of meeting: 27th June 2016

Subject: Finance Committee Report – Month 02 (May 2016)

Author(s): Simon Dixon, Nicola Hoeksema, Rita Ragunath, Iris Lewis

Presented by: Colin Gentile, Chief Financial Officer

Sponsor: Colin Gentile, Chief Financial Officer

History: First submission to Finance and Performance Committee

Status: Decision/Discussion/Information

1. Purpose The Finance Reports includes information on the Trust’s financial performance and position which support the in-year

submissions to Monitor on a quarterly basis.

This report covers the Income & Expenditure position, Cost Improvement Programme, Capital and Working Capital Plans.

2. Action required The Finance Committee is asked to approve the Finance Report

Enc. .

Page 2 of 25

Legal: Reporting to Monitor

Financial:Trust reports financial performance and position against published plan and notifies the committee

of financial risks, cost pressures and action plans to mitigate any material variance from financial

targets.

Assurance:The summary and appendices provide assurance that the Trust is meeting Financial targets

(internal and those set by Monitor) and is compliant with its terms of authorisation.

Clinical: There is no direct impact on clinical issues

Equality & Diversity: There is no direct impact on E&D

Performance: Financial Performance against annual plan, budgets, CIPs and Monitor Risk Ratings and Limits.

Strategy: Performance against the Trust’s Annual Plan including Risk Ratings

Workforce:There are implications for workforce recruitment in respect to service developments and

vacancies.

Estates: There are implication on the Trust’s estates strategy.

Reputation:Finance Committee Report is provided to Monitor and Commercial Bankers as additional

information to support the quarterly Monitor Return.

Other:(please specify) None.

3. Key implications

Enc. .

Page 3 of 25

Page

Key Messages 5

Summary 6

Month 2 Surplus / (Deficit) £k 7

Income 8

Operating Expenditure 9

Run Rate 10

16/17 Annual Plan Budget Phasing 11

Cost Improvement Plans 12

16-17 CIP Programme Delivery Summary (£71M) 13

PMO CIP Green Phasing 14

Cash 15

13 Week Cash Flow Forecast 16

Statement of Financial Position (Balance Sheet) 17

Aged Debtors 18

Debtors Detail 19

Capital 20

Agency 21

Agency Cap 22

Whole Time Equivalents 23

Income Activity Analysis 24

Surplus / (Deficit) (By Division) 25

Contents Enc. .

1

2

Pay - adverse by £637k

2.1

2.2

2.3

3

4 Other key matters:

4.1

4.2

4.3

4.4

The Trust's cumulative operating deficit at Month 2 is £16.8m. This is an adverse variance of £6.7m against the year to date planned deficit plan of £10.1m. The

figures exclude the estimated impairment costs of £1.7m to date.

The income adverse variance is driven by unidentified CIPs (£293k), CIP slippage (£94k), prior year income adjustments (£482k) and Private Patient income (£795k).

There is also an NHS clinical income activity under-performance of (£3.1m) but this is offset by a £3.5m off-tariff drugs and devices over-performance. The activity

under-performance relates to non-block contract income (circa 50%) for CCG's and NHSE specialised services. Contract negotiations are still on-going with NHSE for

Specialised Services. As a consequence the investment for Neo-Natal Transitional Care and Fetal Medicine are not being accrued as well as any MRET income

adjustment. The FYE of these adjustments is £4.6m.

The pay adverse variance is due to unidentified CIPs (£1.9m) and CIP slippage (£263k) which are offset by pay underspends in respect to current vacancies (£1.5m).

The non-pay adverse variance is primarily due to additional expenditure on off-tariff pass through drugs and devices (£3.5m). the other adverse variances relate to

unidentified CIPs (£648k) and CIP slippage (£242k). The remaining balance relates to cost pressures such as bad debt write offs and additional clinical service costs

for services provided by non-NHS bodies.

In summary the key financial issues are unidentified CIPs against the Annual Plan indicative phasing (£2.8m) and CIP slippage (£599k) to date; and the

Commissioner income under-performance for non-block contract income (£3.1m).

The key cumulative variances at Month 2 relate to:

Income - adverse by £807k

Non-pay - adverse by £5,283k

The Sustainability and Transformation Fund income (£30m) has been accrued year to date (£5m) although the 2016/17 control total has not been finalised with

NHSI.

The key income risks will be the NHSE QIPP target for 16/17 (£7.7m) and Bromley CCG activity demand management (£3m). The Trust is still in negotiation with

NHSE regarding the 16/17 QIPP. Although the Trust led CCG QIPP for Lambeth, Southwark and Bromley CCG's (£5.3m) is embedded in the block contract, the Trust

needs to attempt to deliver these QIPPs as they are opportunities to reduce costs.

Therefore the key actions to improve the financial position are to deliver the outstanding CIPs and mitigating actions; as well as implement all the operational plans

to meet the income activity growth and RTT targets. A number of business cases are still work in progress. Resolving the NHSE contract position in the next three

weeks as well as the Bexley CCG MSK contract would also benefit the Trust’s financial position.

Other potential cost pressures are the review of Overseas and Private Patient income and the potential write off of outstanding debts. The Trust operating plan still

continues to have no contingency plan.

The Trust cash position is not helped by the current finance position and NHSE contract/NHSI control total negotiations. Suppliers are regularly chasing payment

which is impacting on operational performance. The Trust has presented NHSI with a mission critical case for distressed finance which would support the Trust cash-

flow issues in-conjunction with the current working capital facility of £89.4m The Trust is making every effort to recover outstanding debts but this is being

hindered by the Trust’s inability to pay authorised invoices on time. Detail on material debtors has been included on the Debtors Detail page.

Key Messages Enc. .

Page 5 of 25

Summary

Surplus / (Deficit) £k R Income £k R Operating Expenditure £k R

Plan Actual Variance Plan Actual Variance Plan Actual Variance

Year to Date £k (10,087) (16,777) (6,690) Year to Date £k 179,321 178,515 (807) Year to Date £k (178,866) (184,785) (5,918)

Run Rate £k R Cost Improvement Plans £k R Capital £k G

M1

Actual

M2

Actual

M3

Actual

M4

Actual 16/17 Total Plan Actual Variance Plan Actual Variance

Income £k 87,280 91,236 178,516 Year to Date £k 5,904 5,306 (598) Year to Date £k 10,964 1,754 9,210

Pay £k (52,173) (52,919) (105,092)

Non-Pay £k (45,297) (44,903) (90,200)

Deficit £k (10,190) (6,586) 0 0 (16,776)

Cash £k R Key Risks R Mitigating Actions R

Plan Actual Variance

Year to Date £k 16,997 15,527 (1,470)

The programme overall achieved 90% of its YTD target with the flow through

element achieving 88% and the new schemes achieving 98%. The CIP

programme as at M2 has had a total scheme slippage of £598k (10%) of which

£100k is slippage against procurement schemes which have failed from the flow

through from 15-16. There are substitute schemes to mitigate this slippage and

is not expected to start until Q2. The reasons for slippages are a

combination of delayed implementations, failed recruitment and ward

escalation beds remaining opened

Finance Report Month 02 2016/2017

1.

Mitigating CIP schemes totaling £9.4m. a couple of the CIP schemes are

dependant on NHSI capital funding approval (Finance Leases and Windsor Walk)

2. Implementing operational plans to acheive growth and RTT activity

The Trust is reporting a £16.8m deficit at the end of M02 against a planned deficit of £10.1m resulting in a £6.7m adverse YTD variance. The current month position is a £6.6m deficit against a planned deficit of £4.6m resulting in a £2m adverse

variance in M02 There were a number of income issues in Month 1 and 2 that have contributed towards the adverse variance as well as a CIP/QIPP gap due to unidentified saving schemes and CIP slippage.

The underlying deficit for 15/16 was £118m which equates to a monthly run rate deficit of circa £10m. The phasing of the CIPs should improve this run rate and reduce the deficit position. The run rate improved in M2 by £3.6m, the majority of the

improvement was in income.

The underlying deficit for 15/16 was £118m which equates to a monthly run rate

deficit of circa £10m. The phasing of the CIPs should improve this run rate and

reduce the deficit position. There was a £3.6m improvement in run rate

compared to M1. Income improved by £3.9m in month mainly in clinical contract

income. Pay run rate increased by £746k mainly in medical pay. Nonpay

improved by £395k.

Based on the 13-week cash forecast, the Trust will need to drawdown a further

£19.951m against its Working Capital Facility in June in order to maintain a

positive cash balance in July 2016. This will bring the total value drawdown

against the Working Capital Facility to £31.521m.

The planned capital expenditure for 2016/17 is £71.189. This is based on the

annual plan submitted to the board for approval and is based on the assumption

that the Trust will be able to secure funding.

1. CIP

achievement £50m new and £21m flow through. £44.5m approved 'greened'

schemes to date.

2. Income targets includes RTT backlog £4.8m and 2.3% growth, £20.7m.

3. The key income risks will be the NHSE QIPP target for 16/17 (£7.7m) and

Bromley CCG activity demand management (£3m). The Trust led CCG QIPP for

Lambeth, Southwark and Bromley CCG's is £5.3m and this is embedded in the

Block contract.

4. Cost control measures re: agency spend

Month 2 is based on Month 1 spell activity and pro-rata for Month 2.

Bromley, Lambeth & Southwark contracts have been agreed and are reflected

within the plan. All other commissioners e.g. NHSE are based on KCH internal

income proposals.

The Trust is reporting a £16.8m deficit at the end of M02 against a planned

deficit of £10.1m resulting in a £6.7m adverse variance YTD.

There are £2.8m of unidentified CIPS YTD. There is £0.6m CIP slippage YTD, the

majority of this relates to 15/16 flow through schemes. This CIP gap is being

offset by pay underspends in Nursing, A&C and PAM/P&T, this will have an

impact in later months once these vacant posts are filled. Commisioner

underperforming YTD by £3.1m, the block contract benefit is included in this

position (the benefit as at M1 was £1.9m, the M2 benefit is still a work in

progress)

Pay is £636k overspent at the end of M02 but there are £1.9m of unidentified

CIPs in the M02 position as well as £262k of CIP slippage (15/16 flow through).

These are being offset by underspends in Nursing, A&C and PAM/P&T (historical

vacancies plus new investment for growth) , this will have an impact in later

months once these vacant posts are filled.

Nonpay is over spent due to off-tariff drugs and devices over performance which

is offset by income. There is also £242k of CIP slippage in M02 (15/16 flow

through)

Enc. .

Page 6 of 25

Finance Report Month 02 2016/2017 Surplus / (Deficit) £k R

Year to Date Plan Actual Variance

£k £k £k

Surplus / (Deficit) (10,087) (16,777) (6,690)

Year to Date Plan Actual Variance

£k £k £k

Income 179,321 178,515 (807)

Pay (104,456) (105,092) (636)

Non-Pay (74,410) (79,693) (5,283)

EBITDA * 455 (6,270) (6,725)

EBITDA % 0.3% -3.5%

Profit/Loss on Disposal of Fixed Assets (17) 0 17

Interest Payable (4,887) (4,876) 11

Interest Receivable 22 26 4

Depreciation (4,436) (4,433) 3

Impairments (1,717) (1,717) 0

Public Dividend Capital (1,224) (1,224) 0

Net surplus/(deficit) (11,804) (18,494) (6,690)

Reverse Impairment 1,717 1,717 0

Performance against Control Total (10,087) (16,777) (6,690)

Total (10,087) (16,777) (6,690)

Surplus/(Deficit) % -5.6% -9.4%

* EBITDA Earnings before Interest, Taxation, Depreciation and Amortisation

The Trust is reporting a £16.8m deficit at the end of M02 against a planned deficit of £10.1m resulting in a £6.7m adverse YTD variance. The current

month position is a £6.6m deficit against a planned deficit of £4.6m resulting in a £2m adverse variance in M02

There are £1.4m of unidentified CIPS/QIPPs in month 2 (£2.8m YTD) and £83k CIP slippage in M02 (£598k ytd = 10% of approved green schemes), the majority of this relates to 15/16 flow through schemes.

The overall YTD CIP gap is £2.5m against the annual plan YTD figure of £7.1m, this is a 35% gap.

This CIP/QIPP pay gap is being offset by pay underspends in A&C and PAM/P&T, this will have an impact in later months once these vacant posts are filled.

The income variance of £807k is made up of a number of issues affecting income, these are detailed on the income page.

Enc. .

(15,000)

(10,000)

(5,000)

-

5,000

10,000

15,000

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

£k

Deficit by Month 2016/17 Net Operating Deficit Actuals Net Operating Deficit Plan

Page 7 of 25

Finance Report Month 02 2016/2017 Income R

Year to Date Plan Actual Variance

£k £k £k

Total Income 179,321 178,515 (807)

Year to Date Plan Actual Variance

£k £k £k

Commissioning Contract Income 125,426 122,311 (3,115)

NHS Acute: Drugs - Non Tariff 16,553 19,191 2,639

NHS Acute: Drugs (IFRs, CDF & Hep C) 2,661 2,939 278

NHS Acute: Devices - Non Tariff 2,363 2,929 566 Partly offsetting clinical supplies overspend of £1.7m

Local Authority Income - GUM Services 751 751 0

Other Clinical Income 280 0 (280)

NHS Clinical Contract Income 148,034 148,122 88

RTA Income 750 1,177 427

Other NHS Clinical Income 873 742 (131)

Private Patient Income 4,245 3,449 (795) Income underperformance, the plan is to be reviewed in M3

Education & Training Income 7,822 7,842 20

Research & Development Income 1,640 2,381 740 Offsetting expenditure overspends

Miscellaneous Other Operating Income 15,957 14,802 (1,156)

Total Trust Income 179,321 178,515 (807)

The YTD income position reflects a number of issues that have occurred in M01 and 2 which have had a negative impact on income. These include:

1 Jr Dr strike in M1

2 Theatre disruption re Critical Care Development/Maintenance (Neuro/transplant theatres)

3 Easter impact - bank holiday in April

4 PRUH loss of efficiency - Norovirus impact

5 Business cases for RTT backlog and growth not implemented in month 1 & 2

6 Sustainability & Transformation income accrued in M1 and 2 (£30m) still tbc with NHSI

7 Potential impact from month 1 : QiPP risk £7.7m NHSE, Bromley CCG risk £3m demand mgt but no robust plans. Also £5.3m LSB CCG trust led QiPP built into block contract

Income improved against plan in M02 by £1.7m. £1.5m relates to off tariff drugs and devices income (offsetting expenditure overspends). Commisioner income improved by £749k in month but is still

underperforming YTD by £3.1m, the block contract benefit is included in this position (the benefit as at M1 was £1.9m, the M2 benefit is still a work in progress). This is offset by £212k of unallocated income CIPs and

private patient underperformnace of £590k.

Elective activity underperformance driven by the issues listed above

Offsetting expenditure overspend of £2.9m

80,000

82,000

84,000

86,000

88,000

90,000

92,000

94,000

96,000

98,000

100,000

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

£k

In Month Income 2016/17 Actual Plan

Enc. .

Page 8 of 25

Finance Report Month 02 2016/2017 Operating Expenditure R

Year to Date Plan Actual Variance

£k £k £k

Pay (104,456) (105,092) (636)

Non-Pay (74,410) (79,693) (5,283)

Operating Expenditure (178,866) (184,785) (5,918)

Year to Date Plan Actual Variance

£k £k £k

Pay

Nursing & Midwifery (41,646) (41,347) 299

Medical & Dental Staff (33,362) (33,789) (427)

Administration & Clerical / Senior Managers (17,457) (16,512) 945

PAMS / Scientific / Professional (13,859) (13,444) 415

Unallocated CIP/QIPP 1,868 0 (1,868)

Total Pay (104,456) (105,092) (636)

Non-Pay

Drugs (incl. Medical Gases) (2,099) (2,348) (249)

Drugs : Non-Tariff (19,214) (22,130) (2,917) Income overpermimg by £2.9m

Supplies & Services - Clinical (16,102) (17,781) (1,679) Off tariff devices income overperforming by £566k

Supplies & Services - General (973) (1,022) (49)

Establishment Expenses (1,023) (833) 190

Transport Expenses (1,561) (1,321) 240

Premises (6,626) (6,615) 11

Purchase of Healthcare from Non-NHS Provider (4,765) (5,006) (241)

Services from other NHS Bodies (9,364) (9,199) 166

Consultancy (1,804) (1,424) 380

Private Finance Initiative (9,361) (9,557) (196)

Other Non-Pay/Reserves (1,518) (2,456) (938) £648k unidentified CIPs

Total Non-Pay (74,410) (79,693) (5,283)

Total Expenditure (178,866) (184,785) (5,918)

Pay is £636k overspent at the end of M02 but there are £1.9m of unidentified CIP/QIPPs in the M02 position as well as £262k of CIP slippage (15/16 flow through). These are being offset by underspends in

Nursing, A&C and PAM/P&T, this will have an impact in later months once these vacant posts are filled.

Nonpay is over spent due to off-tariff drugs and devices over performance which is mostly offset by income. There is £648k of unidentified CIPs plus £242k of CIP slippage in M02 (15/16 flow through)

Pay moved adversely in month by £667k, there were £920k of unallocated CIP/QIPPs in M2. Medical expenditure also increased in M2 due to backdated banding payments and increased locum expenditure

(covering vacancies and on call) mainly in Orthopaedics,Urology and Neuroscience. Nonpay moved

adversly in month by £3m. £1.9m relates to drugs and clinical supplies which is partly off set by income, £327k is unidentified CIPs.

Enc. .

Page 9 of 25

Finance Report Month 02 2016/2017 Run Rate R

Q2 Q3 Q4 Apr-16 May-16

£k £k £k £k £k

Deficit (8,693) (12,602) (18,192) (11,048) (7,445)

Impairment 458 458 5,861 858 858

Operating Deficit (8,234) (12,144) (12,331) (10,190) (6,587)

Q2 Q3 Q4 Apr-16 May-16

£k £k £k £k £k

Income

NHS & Local Authority Clinical Contract Income 66,696 62,737 58,117 58,889 63,423

NHS Acute: Drugs - Non Tariff 7,345 8,264 9,399 9,976 9,215

NHS Acute: Drugs (IFRs, CDF & Hep C) - - - 1,325 1,614

NHS Acute: Devices - Non Tariff - - - 1,428 1,501

Local Authority Income - GUM Services 549 203

Other Clinical Income (P2P, RTA, Overseas Visitors) 1,405 1,653 1,517 622 1,297

Private Patients 1,104 1,149 1,695 1,626 1,824

Other Operating Income (T&E, R&D) 9,890 10,219 9,410 12,866 12,159

Total Income 86,439 84,022 80,139 87,280 91,236

Pay

A&C Staff/Senior Managers Agency (696) (353) (424) (717) (744)

Bank (277) (186) (179) (223) (231)

substantive (7,054) (7,151) (7,099) (7,310) (7,288)

Medical Staff Agency (1,233) (1,207) (958) (869) (1,105)

Bank (365) (310) (363) (384) (486)

substantive (14,993) (15,348) (14,721) (15,326) (15,619)

Nursing Staff Agency (1,510) (1,860) (1,154) (878) (872)

Bank (2,122) (2,175) (2,516) (2,409) (2,294)

substantive (17,048) (17,199) (16,867) (17,557) (17,336)

PAMS/Scientific/Professional Agency (606) (463) (710) (343) (762)

Bank (177) (172) (187) (190) (159)

substantive (5,895) (5,905) (5,860) (5,967) (6,023)

Total Pay (51,975) (52,329) (51,038) (52,173) (52,919)

Non-Pay

Drugs (3,750) (3,283) (2,270) (1,330) (1,019)

Off-tariff Drugs Expenditure (7,345) (8,264) (9,399) (11,301) (10,829)

Clinical Supplies (8,023) (8,667) (8,807) (9,215) (8,566)

Non-Clinical Supplies (4,811) (4,954) (4,387) (4,512) (5,279)

Sub Contracted Healthcare - NHS bodies (4,581) (4,594) (3,760) (4,601) (4,598)

Services Provided by non-NHS bodies (2,114) (2,029) (1,135) (2,355) (2,651)

Private Finance Initiative (4,662) (4,684) (4,606) (4,716) (4,841)

Misc. Other Operating Expenditure (1,621) (1,372) (1,849) (2,014) (1,866)

Total Non-Pay (36,908) (37,847) (36,212) (40,044) (39,649)

Financing

Loan/PFI Interest & PDC Dividends (3,121) (3,333) (4,159) (3,044) (3,030)

Depreciation and Impairment (2,458) (2,464) (6,478) (3,067) (3,082)

Lease Charges (670) (652) (444) - -

Total Financing (6,249) (6,449) (11,081) (6,111) (6,112)

Deficit (8,693) (12,602) (18,192) (11,048) (7,444)

Impairment 458 458 5,861 858 858

Operating Deficit (8,234) (12,144) (12,331) (10,190) (6,586)

The underlying deficit for 15/16 was £118m which equates to a monthly run rate deficit of circa £10m. The phasing of the CIPs should improve this run rate and reduce the deficit position. There was a £3.6m

improvement in run rate compared to M1. Income improved by £3.9m in month mainly in clinical contract income. M1 actual income was understated as only 2 weeks of data (estimated to a full month) was

available at the time of reporting. Pay run rate increased by £746k mainly in medical pay due to backdated banding payments and increased locum expenditure (covering vacancies and on call) mainly in

Orthopaedics,Urology and Neuroscience. Nonpay improved by £395k. Bad debt provision (overseas visitors and RTA) increased in M2, this was offset by an improvement in off tariff drug expenditutre and

clinical supplies.

15/16 Normalised Quarterly Average

Page 10 of 25

Finance Report Month 02 2016/2017 16/17 Annual Plan Budget Phasing

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

£k £k £k £k £k £k £k £k £k £k £k £k £k

Themes

Income 90,067 90,849 95,995 95,672 90,694 94,911 96,474 93,296 86,193 92,033 87,768 95,121 1,109,072

Pay (54,342) (54,641) (54,238) (54,338) (54,338) (54,338) (54,338) (54,865) (54,866) (54,866) (54,857) (54,878) (654,905)

Nonpay (44,575) (44,974) (45,455) (45,544) (45,593) (45,597) (45,649) (45,759) (45,794) (45,085) (45,120) (43,961) (543,106)

Flow Through CIP 2,430 2,299 2,126 2,634 2,288 1,992 1,351 1,327 1,209 1,079 1,016 1,003 20,753

CIP 1,161 1,193 1,486 3,408 3,968 3,961 4,883 5,079 5,519 5,142 5,573 8,630 50,002

Deficit (5,960) (5,844) (483) 927 (3,540) 667 3,099 (520) (7,218) (1,047) (4,906) 6,641 (18,184)

Impairment 858 858 858 858 858 858 858 858 858 858 858 858 10,296

Operating Deficit (5,102) (4,986) 375 1,785 (2,682) 1,525 3,957 338 (6,360) (189) (4,048) 7,499 (7,888)

Source: Extracted from Annual Plan submission which reflects a deficit position for months 1 and 2.

The phasing will be adjusted as the CIP delivery plans are materialised in robust and accountable schemes.

Enc. .

Flow Through CIP

CIP

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

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

£000

Month

CIP Monthly Phasing

Monthly CIP

Cummualtive CIP

0

10000

20000

30000

40000

50000

60000

70000

80000

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

£000

Month

Cummulative Total CIP

Page 11 of 25

Finance Report Month 02 2016/2017 Cost Improvement Plans R

Year to Date Plan Actual Variance

£k £k £k

Cost Improvement Plans 5,904 5,306 598

Annual Plan CIP Target 5,904 5,306 598

Year to Date Plan Actual Variance

£k £k £k

Themes

Income

NHS Commissioner (NHSE) 222 129 (94)

NHS Commissioner (CCG) 0 0 0

NHS Provider to Provider 9 9 0

Private Patient 8 8 0

Other Operating 87 87 (0)

Research And Development 0 0

Training & Education 7 7 0

Total Income CIPs 332 239 (94)

Pay

Administrative and Clerical Staff Reduction 491 483 (8)

Medical Staff Reduction 192 187 (6)

Nursing Staff Reduction 1,096 829 (267)

Prof & Tech/PAMS/Other Reduction 215 211 (4)

Procurement 59 144 85

Recruitment - Agency Reduction 280 224 (56)

VAT 24/7 Payroll Service 275 322 47

Nurse Rotas 129 78 (51)

Vacancy Freeze 68 68 0

Theatre Savings 128 128 0

Reducing Clinical Services 1 1 0

Medical Job Planning 192 172 (20)

Total Pay CIPs 3,125 2,846 (279)

Non-Pay

Capital 0 0 0

Clinical Supplies and Services 617 593 (24)

Contracting Services Out 0 0 0

Drugs 146 146 (0)

Establishment Expenses 49 35 (14)

External Contract staffing and Consultants 134 134 0

General Supplies and Services 37 37 0

Miscellaneous 197 197 0

Non-Clinical Spend Reduction 47 47 0

Premises and Fixed Plant 338 338 (0)

Reserves 0 0 0

Reducing Services 3 3 0

Services Provided by non-NHS bodies 151 151 0

Sub Contracted Healthcare - NHS bodies 113 113 (0)

Transport and Moveable Plant 1 1 0

Procurement 613 426 (187)

Total Non-pay CIPs 2,447 2,221 (225)

Efficiency Plan Total 5,904 5,306 (598)

Divisions YTD Plan Actual Variance

£k £k £k

Ambulatory 794 788 (6)

CCTD 1,104 1,028 (76)

TEAM 812 440 (372)

LRS 392 416 24

NWS 939 739 (201)

W&C 688 685 (3)

Corporate 1,176 1,210 35

Efficiency Plan Total 5,904 5,306 (598)

Income slippage relates to failure to implant additional ICDS at the PRUH (NWS – £63k) & slippage on Paediatric Rehab to achieve the best practise tariff. Both schemes have not delivered additional income and there is no evidence to prove delivery or benefit

realisation. Both schemes are FYE schemes and were failing last year. These will require substitution. Pay slippage relates primarily to recruitment and staffing reductions – Nursing staff reductions to achieve length of stay initiatives in TEAM, B&A reduction Nursing in

TEAM, failure to implement nursing rotas within Renal Dialysis. There is also failed implementation of medical job plan changes within Anaesthetics. These failures are due to wards being open, opening of extra escalation beds and shift patterns not changing. Non pay

slippage relates mainly to failed schemes in procurement from flow through schemes. Mitigation schemes have been put forward but are not expected to start until Q2.

Enc. .

Page 12 of 25

Finance Report Month 01 2016/2017 16-17 Programme Delivery Summary (£71M) R

Plan Actual Variance

£k £k £k % Achievement

In Month 3,019 2,936 (83) 97%

Year To Date 5,904 5,307 (597) 90%

The information on this report includes all schemes sent across to finance as at 01/05/2016.The PMO have converted more schemes since that time so the numbers will not reconcile against the weekly report.

The programme overall is achieving 90% of its target YTD with flow through element achieving 88% and the new schemes achieving 98%. The in month achievement was 97%.

The CIP programme as at M2 has had a total scheme slippage of £598k (10%) of which £100k is slippage against procurement schemes which have failed from the flow through from 15-16. There are substitute schemes to mitigate this

slippage expected to start until Q2.

The reasons for slippages are a combination of delayed implementations, failed recruitment and ward escalation beds remaining opened.

The £598k slippage has come from Income (£94k), Pay (£262k) and Non pay (£242k)

£5.6M has been removed from financial budgets made up of £4.7M of flow through schemes and £0.9M of new schemes identified this year

Enc. .

Page 13 of 25

Finance Report Month 01 2016/2017 PMO Green Phasing R

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Total

Income 46 86 84 241 232 228 196 196 187 152 152 152 1,952

Pay 1,298 1,288 1,164 1,523 1,293 1,070 766 755 662 599 540 529 11,487

Non Pay 1,086 925 878 871 764 694 389 376 359 328 323 322 7,314

Total: 2,430 2,299 2,126 2,634 2,288 1,992 1,351 1,327 1,209 1,079 1,016 1,003 20,753

Income 67 67 194 360 378 379 383 390 391 421 487 2,268 5,785

Pay 470 755 764 827 897 980 1,095 1,118 1,245 1,245 1,256 2,024 12,676

Non Pay 268 262 263 296 302 386 442 465 571 580 572 891 5,298

Total: 805 1,084 1,221 1,483 1,576 1,745 1,920 1,973 2,208 2,246 2,315 5,183 23,759

3,235 3,383 3,346 4,117 3,865 3,737 3,270 3,300 3,416 3,325 3,330 6,186 44,512

A total of £45M has been signed off as ‘PMO Green’ from the programme as at the 17th June made up of both flow through schemes from 15/16 and new schemes from this financial year. The phasing is shown on the

left graph below. There remains approx. £25M in pre-pod and POD received status which continue to be worked up. The graph on the right shows the current phasing against the phasing that was submitted on the

trusts annual plan. Note all the above has not been removed from financial budgets yet as a large proportion was converted during period 2. There is approx. £13.7M to be adjusted.

16/17 PMO Green Phasing

15

-16

FY

E

Sch

em

es

16

-17

Ne

w

Sch

em

es

Grand Total:

Enc. .

0

2000

4000

6000

8000

10000

12000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Combined 16/17 'PMO Green' Phasing

16/17 PMO Green Phasing 16-17 Annual Plan Phasing 16-17 Annual Plan Phasing

0

1000

2000

3000

4000

5000

6000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Phasing Split By Type

15-16 FYE Schemes 16-17 New Schemes

Page 14 of 25

Finance Report Month 02 2016/2017 Cash G

Year to Date Plan Actual Variance

£k £k £k

Cash Balance 16,997 15,527 (1,470)

Year to Date Plan Actual Variance

£k £k £k

EBITDA (2,869) (4,413) (1,544)

Movement in Working Capital (43,618) (10,563) 33,055

Provisions 0 (56) (56)

Cash flow from Operations (46,487) (15,032) 31,455

Capital Expenditure (4,906) (1,267) 3,639

Cash Receipt from Asset Sales 0 0 0

Other Cash Flows from Investing Activities 11 11 0

Cash Flow before Financing (4,895) (1,256) 3,639

PDC Received 0 0 0

PDC Repaid 0 0 0

Dividends Paid 0 0 0

Interest on Loans and Leases (2,559) (2,353) 206

Drawdown of Debt 53,267 4,744 (48,523)

Repayment of Debt (325) (353) (28)

Other Cash Flows from Financing Activities 0 0 0

Cash Flow from Financing 50,383 2,038 (48,345)

Net Cash Inflow/(Outflow) (999) (14,250) (13,251)

Opening Cash Balance 17,996 29,777 11,781

Closing Cash Balance 16,997 15,527 (1,470)

Based on the 13-week cash forecast, the Trust will need to drawdown a further £19.9m against its Working Capital Facility in June in order to maintain a cash balance of £3m. This will bring the total value

drawndown against the Working Capital Facility to £31.521.

At month end the Trust’s cash balance was £1.47m below plan.

The movement in working capital is showing adverse variance as the Trust has not be able to drawdown loan pay creditor and reduce thte balance to forecast. Creditor balances remain high as the Trust

cannot use the facility to un-wind its payables, putting pressure on supplier relationship and price negotiations. Capital expenditure for month 2 was £3.6m below plan due to delay in capital plan approval.

Enc. .

Page 15 of 25

Finance Report Month 02 2016/2017 Rolling Cash Flow (13 Week) G

Week ending 27-May-16 03-Jun-16 10-Jun-16 17-Jun-16 24-Jun-16 01-Jul-16 08-Jul-16 15-Jul-16 22-Jul-16 29-Jul-16 05-Aug-16 12-Aug-16 19-Aug-16

Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast

£k £k £k £k £k £k £k £k £k £k £k £k £k

Balance B/F 55,960 23,402 32,570 30,413 54,105 18,658 9,717 1,810 58,211 12,806 5,281 (3,601) (10,653)

Receipts (inflows)

LSB receipts 2,501 20,690 4,920 0 0 0 0 27,442 0 0 0 0 27,442

SLA receipts 0 299 0 13,038 0 135 0 14,338 0 0 135 0 13,438

Patient SLA Over performance 2014/2015 0 0 0 0 0 0 0 0 0 0 0 0

Patient SLA Overperformance 2015/2016 0 0 0 0 0 0 0 0 0 0 0 0

Private Patients receipts 824 926 350 350 350 350 350 350 350 350 350 350 350

Training & Education receipts 0 0 0 0 0 0 0 10,000 0 0 0 0

NHSE Inflows 0 21 0 29,686 0 0 0 29,483 488 0 0 0 29,833

DoH - National RTT, ED Monies & Project Diamond 0 0 0 0 0 0 0 0 0 0 0 0

VAT reclaims 0 3,656 0 0 0 3,150 0 0 0 0 3,150 0 0

Income Generation CIPs 0 0 0 0 0 0 0 0 0 0 0 0

Other 1,221 1,592 1,139 1,513 480 470 420 1,143 1,190 420 1,804 620 1,143

Total Receipts 4,546 27,184 6,409 44,587 830 4,105 770 72,756 12,028 770 5,439 970 72,206

Payments (outflows)

Pay monthly (incl Pay Awards) 24,609 12 70 24,600 70 24,600 70

PAYE/NIC/SUPER (CHAPS) 0 20,200 20,200 20,200

Agency Spend 1,514 976 1,414 1,425 1,372 1,256 1,375 1,400 1,400 1,400 1,400 1,400 1,400

Agency CIP 0 0 0 0 0 0 0 0 0 0 0 0 0

PFI project 0 4,254 0 4,100 0 4,300 0 0 4,100 0 4,300 0 4,100

Trade Creditors 5,651 5,848 5,426 5,265 5,415 5,265 5,415 5,265 5,415 5,265 5,415 5,265 5,415

Other 4,509 6,220 1,084 9,045 1,100 2,030 1,000 9,444 1,250 1,130 2,000 1,030 9,494

Total Payments 36,283 17,310 7,994 40,035 32,487 12,851 7,860 16,109 56,965 7,795 13,185 7,695 40,609

Cash from operations (31,737) 9,874 (1,585) 4,552 (31,657) (8,746) (7,090) 56,647 (44,937) (7,025) (7,746) (6,725) 31,597

Capital & Financing Items

Capital expenditure (outflow) 821 706 572 558 1,205 195 817 246 468 500 1,136 327 317

Commercial Services (Inflow) 0 0 0 0 0 0 0 0 0 0 0 0 0

PDC Dividends (TDR) (outflow) 0 0 0 0 0 0 0 0 0 0 0 0 0

Revolving Working Capital Facility 0 0 0 (19,951) 0 0 0 0 0 0 0 0 0

Interest Paid on Revolving Credit Facility 0 0 0 0 0 0 0 0 0 0 0 0 0

Loans Repaid (outflow) 0 0 0 225 1,709 0 0 0 0 0 0 0 0

Interest on Loans (outflow) 0 0 0 27 876 0 0 0 0 0 0 0 0

Other (inflow) 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Capital & Financing 821 706 572 (19,141) 3,790 195 817 246 468 500 1,136 327 317

Net Inflow / Outflow (32,558) 9,168 (2,157) 23,693 (35,447) (8,941) (7,907) 56,401 (45,405) (7,525) (8,882) (7,052) 31,280

Forecast Balance C/F 23,402 32,570 30,413 54,105 18,658 9,717 1,810 58,211 12,806 5,281 (3,601) (10,653) 20,627

The rolling cash flow forecasts forward for a 13 week period currently to the 3rd Week of August.

The 13 week cash flow allows the Trust to forecast its requirement for drawdown against the agreed Term Loan facility over the following 2 months.

Enc. .

23,402

32,570 30,413

54,105

18,658

9,717

1,810

58,211

12,806

5,281

(3,601) (10,653)

(20,000)

(10,000)

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

27-May-16 03-Jun-16 10-Jun-16 17-Jun-16 24-Jun-16 01-Jul-16 08-Jul-16 15-Jul-16 22-Jul-16 29-Jul-16 05-Aug-16 12-Aug-16 19-Aug-16

£'k

Forecast Weekly Cash Balance

Page 16 of 25

Finance Report Month 02 2016/2017 Statement of Financial Position (Balance Sheet)

Year to Date 01-Apr-16

Actual Plan Actual Variance Notes

£k £k £k £k

Property, Plant & Equipment 532,001 539,550 527,925 (11,625) 1

Intangible Assets 3,670 2,777 3,372 595

Other Assets 11,145 10,500 10,596 96

Non Current Assets 546,816 552,827 541,893 (10,934)

Inventories 17,748 19,200 17,177 (2,023)

Trade & Other Receivables 118,917 118,608 121,942 3,334 2

Cash and Cash Equivalents 18,982 16,997 15,527 (1,470) 4

Current Assets 155,647 154,805 154,646 (159)

Trade and Other Payables (151,607) (107,601) (154,635) (47,034) 3

Borrowings (7,960) (70,106) (18,855) 51,251 4

Other Financial Liabilities 0 0 0

Provisions (1,473) (1,575) (1,561) 14

Other Liabilities (10,139) (7,000) (8,666) (1,666)

Current Liabilities (171,179) (186,282) (183,717) 2,565

Borrowings (314,651) (312,217) (314,683) (2,466)

Other Financial Liabilities 0 0 0

Provisions (5,455) (5,000) (5,455) (455)

Non Current Liabilities (320,106) (317,217) (320,138) (2,921)

TOTAL ASSETS EMPLOYED 211,178 204,133 192,684 (11,449)

Financed by:

Public Dividend Capital (223,838) (223,838) (223,838) 0

Retained Earnings 109,055 121,243 127,549 6,306

Revaluation Reserve (96,395) (101,538) (96,395) 5,143

TOTAL TAXPAYERS' EQUITY (211,178) (204,133) (192,684) 11,449

The Statement of Financial Position reflects changes in asset values as well as movements in liabilites. The plan figures reconcile to the Annual Plan submitted to Monitor inApril 2016.

Year to Date

1. Capital expenditure is behind plan due to delay in Capital plan approval

2. Trade and Other Receivables are higher than the Plan. Although debtors has decreased by £17m from Month 1 Accrued income has increased by £22m. This is as a result od additional income

accrued for Work In Progress, Clinical Income, Sustaninility Funding and CCG SLA's.

3. Trade and Other Payable are increasing due to restricted cash availability and in-line with the terms of the Working Capital Facility , where the Trust cannot use the facility to un-wind its payables.

4. The differences in Cash and Borrowings are primarily due to the inclusion of the additional available facility agreed with Monitor and DH. According to the Plan the Trust should have drawndown

£66m YTD on the loan but only £11.1m has been drawndown to 31st May 2016.

Enc. .

Page 17 of 25

Finance Report Month 2 2016/2015 Aged Debtors

Invoiced Debtors Within

Terms

1 Month

Overdue

2 Month

Overdue

3 Month

Overdue

Total Current

Month

Prior

Month Notes

Other Receivables Current

Month

Prior

Month

1-30

Days

31-60

Days

61-90

Days

Over 90

Days

Over 30

Days

Over 30

Days £k £k

£k £k £k £k £k £k £k

CCG's 3,063 136 1,229 6,674 11,102 8,039 16,751 1 Accrued Income

Trusts 719 653 2,526 3,726 7,624 6,905 7,936 2 Work in Progress 13,639 9,297

Other NHS 1,031 325 116 383 1,855 824 1,078 3 CCG SLAs 3,968 1,051

Other Debtors 2,626 1,116 4,615 8,883 17,240 14,614 16,449 4 Injury Cost Recovery Fund 2,675 2,206

Private Patients 120 455 827 3,187 4,589 4,469 4,554 5 NHSE Hep C Accrual 5,113 1,532

Overseas Visitors 151 305 544 8,026 9,026 8,875 9,938 Clinical Income accrual 10,192 2,519

Total Invoiced Debtors 10,210 2,990 9,857 28,379 51,436 43,726 56,706 Sustainability funding 5,000 2,500

Other 10,214 9,765

Provision for Bad Debts (Incl. RTA Provision) (8,900) Total Accrued Income 50,801 28,870

Accrued Income 50,801

Prepayments 7,307

Other Debtors 19,920

Total Trade & Other Receivables 120,564

The Trust debtors are mixture of invoiced debtors, accrued income and prepayments. The level of invoiced debtors' balance has decrease by £14.7m and private and

overseas patients balance by £1.9m since the end of April 2016. Overdue debts (those >30 days old) have decreased by £15.4m. This is mainly due to payment from NHSE

and Bexley CCG

1. CCG's - Outstanding debt has decreased £10.3m due to payment from NHSE (£6.5m) and Bexley CCG (£2.8m). This has resulted in decrease in overdue debts

2. Trusts - Outstanding debt from Trusts has decreased by £1.3m. The overdue debt has decreased by £1m, majority of which relates to provider to provider invoice

payment

3. Other NHS - Outstanding debt has decrease by £2.86m due to payments. The overdue debt has remain relatively the same

4. Other debtors has decreased by £2.8m during the month.

5. Private patients and overseas visitor has decreased by £1.9m

Invoiced debtors

35%

Accrued income 42%

Prepayments 6%

Other debtors 17%

Trade and Other Receivables

1-30 Days 20%

31-60 Days 6%

61-90 Days 19%

Over 90 Days 55%

Invoiced Debtors Ageing

Enc. .

Page 18 of 25

Finance Report Month 2 2016/2015 Debtor Detail

Organisation Over 30 days

NHS Organisations

NHS England (Central) £1.4m

CCGs £6.8m

NEL CSU (12 CCGs) £3.7m

West Sussex CSU (7 CCGs) £1.5m

Bromley CCG £736k

Croydon CCG £483k

Cambridge and Peterborough CCG £348k

Slough CCG £336k

Guildford & Waverley CCG £202k

Bedfordshire CCG £211k

NHS Trusts £6.9m

Lewisham and Greenwich NHS Trust £2.3m

Guys & St Thomas NHS Foundation

Trust

£1.4m

Dartford & Gravesham NHS FT £0.528m

Oxleas NHS FT £0.438m

Maidstone & Tunbridge Wells NHS

Trust

£0.405m

South London and Maudsley NHS FT £0.088m

Other NHS Bodies £0.658m

TOTAL NHS ORGANISATIONS £15.768m

Non-NHS Organisation

Viapath LLP £3.9m

KCH Commercial Services Ltd £3.6m

Kings College London £2.9m

Bromley CIC £1m

ISS Mediclean £1m

Sainsburys £0.115m

Councils £0.601m

Other Non-NHS Bodies £1.498m

TOTAL NON-NHS ORGANISATIONS £14.614m

KCH owe L&G £3.39m

KCH owe GSTT £2.8m

Issue

£900k relates to IFRs 15/16 - current dispute on how these are being invoiced.

£480k relates to Overseas Patients 15/16 debts - specific details required by NHSE

Finalising 15/16 FYE of NCAs

Current queries relating to Diagnostics Invoices (percentage of NCA invoices)

Current query on Winter Resilience funding 15/16 invoice

Queries relating to SLHT 13/14 Patient Transport invoice, backing data required.

Overperformance for 14/15 and 15/16 outstanding, no queries or challenges.

Challenges relating to patient identifiable data

Challenges raised against 15/16 NCA invoices

Resolutions and Follow up

Discussing with Contracts Dept. re cancelling and re-issuing invoices in required format

Guthrie to provide detailed data from Compucare system

KCH owe KCS Ltd £46k

KCH owe KCL £5.1m

Rental for Beckenham Beacon as well Community Diabetes Service invoices are outstanding

as previously disputed. Payments not being received as Bromley CIC expecting payment of

their outstanding debt (£0.339m)

Invoice against contract raised in March; invoice still to be approved for payment by ISS

Mediclean.

KCH owe Sainsburys £5.2m

Backing data was provided for Patient Transport invoice, invoice now agreed. No payment

dates agreed. Contracts are currently withholding negotiations on reducing 16/17 SLA contract

until old debt is paid.

Disputes relating to the set tariff rates agreed by South East CSU.

KCH owe Viapath £4.5m

KCH owe D&G £3.1m

KCH owe Oxleas £3.4m

Neurosciences invoices disputed by M&TW, do not agree that these invoices should be paid

as included in contract. KCH disagree.

KCH owe SLAM £271k

Challenges relating to patient identifiable data

CCG unresponsive to chasing debt

NEL have agreed 15/16 balances to be paid by end of June. Transferred to SLAs for 16/17 and

paid on a monthly basis.

Contracts have agreed to provide credits for any Diagnostics queries which will release the

remainder for payment. Credits to be raised in June, payments to be released July and August.

Bromley awaiting confirmation from Peter Fry regarding achievement of the ED performance

criteria linked to the Winter Resilience Funding. Non-achievement would lead to a 5%

discount.

Reciprocal payments agreement in place and payments being made weekly. KCH payments

higher.

Settlement proposed by Contracts of credit for £17k, CCG given to 1 July to respond before

referral to arbitration

Contracts attempting to resolve outstanding challenges, looking to return to SLA contracts for

16/17.

Contracts are negotiating for a full settlement

Contracts making contact with CCG with regards to any valid challenges or will refer to

arbitration on 1 July.

Reciprocal payments agreement in place. KCH payments higher.

Reciprocal payments agreement in place. KCH returning payments to GSTT when received

KCH has agreed weekly payments to D&G to reduce outstanding balance. No payments being

received from D&G.

KCH has agreed weekly payments to Oxleas to reduce outstanding balance. No payments

being received from Oxleas.

Director of Finance has issued a letter confirming withdrawal of Neurosciences services if

invoices are not paid. M&TW have agreed to pay, but receipt of payments has been slow.

To be referred to Business Analyst to follow up with cantract parties.

Periodic reciprocal payments are agreed to reduce this balance.

No payments are being received from KCS Ltd

Reciporal payment agreement in place. KCH pay more to KCL weekly

Disputes have been cleared and invoices released for payment. No payment due to amounts

owed by KCH. To be followed up and referred to Director of Finance for agreement.

Payment not being recieved due to outstanding invoices owed to Sainsburys

Queries have been referred to Contracts to provide proof of agreements in place. With

regards to two councils, we are pursuing urgent resolution and are looking to charge interest

on the outstanding debt.

Enc. .

Page 19 of 25

Finance Report Month 02 2016/2017 Capital G

Year to Date Plan Actual Variance Year End Forecast Plan Forecast Variance

£k £k £k £k £k £k

Major Works 7,823 878 (6,945) Major Works 52,344 52,344 -

Minor Works 430 2 (428) Minor Works 2,580 2,580 -

IT (Incl Intangibles) 1,338 644 (694) IT (Incl Intangibles) 8,025 8,025 -

Medical Equipment 1,373 230 (1,143) Medical Equipment 8,240 8,240 -

Total 10,964 1,754 (9,210) Total 71,189 71,189 -

Year to Date Plan Actual Variance Year End Forecast Plan Forecast Variance

£k £k £k £k £k £k

Major Works Major Works

Critical Care Unit 4,368 827 (3,541) Critical Care Unit 26,205 26,205 -

Cath Lab Developments 118 0 (118) Cath Lab Developments 1,295 1,295 -

Helideck 258 42 (216) Helideck 1,550 1,550 -

Site Wide Infrastructure 250 0 (250) Site Wide Infrastructure 1,500 1,500 -

Ruskin Wing - to increase bed capacity 282 0 (282) Ruskin Wing - to increase bed capacity 3,100 3,100 -

ED Additional Bed Capacity 182 0 (182) ED Additional Bed Capacity 2,000 2,000 -

Portakabin enabling - to increase bed capacity 127 0 (127) Portakabin enabling - to increase bed capacity 1,400 1,400 -

Orpington major works - to increase bed capacity 373 0 (373) Orpington major works - to increase bed capacity 4,100 4,100 -

Other - Denmark Hill 989 0 (989) Other - Denmark Hill 5,932 5,932 -

Other - PRUH 402 9 (393) Other - PRUH 2,410 2,410 -

Other - Orpington 475 0 (475) Other - Orpington 2,852 2,852 -

Minor Works 430 2 (428) Minor Works 2,580 2,580 -

IT (Incl Intangibles) 1,338 644 (694) IT (Incl Intangibles) 8,025 8,025 -

Medical Equipment 1,373 230 (1,143) Medical Equipment 8,240 8,240 -

Total Capital Spend 10,964 1,754 (9,210) Total Capital Spend 71,189 71,189 -

Funded by: Funded by:

External Borrowing 0 0 0 External Borrowing 0 0 0

Donations 0 0 0 Donations (4,203) (4,203) 0

PDC Receipts 0 0 0 PDC Receipts (600) (600) 0

Depreciation (4,432) (4,432) 0 Depreciation (26,100) (26,100) 0

Total Funding (4,432) (4,432) 0 Total Funding (30,903) (30,903) 0

Internal Cash Funding Requirement 6,532 (2,678) (9,210) Internal Cash Funding Requirement 40,286 40,286 0

The capital report shows capital expenditure year to date against plan and full year forecasts as agreed with Monitor.

The year to date plan is based on planned profile. The variance is due to various budget holder

awaiting board approval of the plan. It is expected that actual spend will increase from quarter 2

The planned capital expenditure for 2016/17 is £71.189m as approved by the board.

Funding:

The funding is on the assumption that the Trust will be able to secure additional distressed capital

funding from Monitor. The trust is yet to confirm if the £9.4m 2015/16 Capital to Revenue PDC

repayment will be made available as additional funding for 2016/17 - This has been excluded from the

funding below.

Enc. .

Page 20 of 25

Finance Report Month 02 2016/2017 Agency R

Year to Date Plan Actual Variance

£k £k £k

A&C Staff/Senior Managers (169) (1,460) (1,291)

Medical Staff (300) (1,974) (1,674)

Nursing Staff (888) (1,750) (863)

PAMS/Scientific/Professional (11) (1,105) (1,094)

Total Agency Spend (1,367) (6,289) (4,922)

Enc. .

Page 21 of 25

Finance Report Month 02 2016/2017 Agency Cap R

NHSI Agency Price Cap Monthly Trend Analysis

Staff group Control breached Dec 2015

(5 wks)

Jan 2016

(4 wks)

Feb 2016*

(4 wks)

March 2016

(5 wks)

April 2016*

(4 wks)

May 2016 (4

wks)

Actual Reported Number of breaches each month

Nursing, Midwifery & HV Price cap and framework 317 254 494 692 1,379 1,333

HCA and other support Price cap and framework 71 34 37 65 46 46

Medical and Dental Price cap only 1083 790 1571 1995 1,590 1,747

Sci, Ther & Technical Price cap only 82 78 262 304 518 525

Healthcare science Price cap only 42 36 129 111 339 302

Admin & Estates Price cap only 386 354 397 466 365 325

Total 1981 1546 2890 3633 4237 4278

Breaches as a percentage of bookings

Nursing, Midwifery & HV Price cap and framework 14% 13% 20% 22% 52% 54%

HCA and other support Price cap and framework 57% 41% 44% 52% 37% 29%

Medical and Dental Price cap only 62% 56% 92% 89% 81% 98%

Sci, Ther & Technical Price cap only 5% 4% 19% 19% 35% 36%

Healthcare science Price cap only 6% 7% 20% 16% 59% 52%

Admin & Estates Price cap only 31% 28% 27% 22% 21% 18%

Total 29% 24% 38% 36% 50% 52%

Agency Cap Rules:

(1) Price caps for all staff from 1 April 2016 are calculated at 55%* above the hourly rate.

Key Dates:

01-Apr-16

01-Jul-16

01-Nov-16

*Change in cap

Nov 2016-Jan 2016 Junior Dr cap was 150%, all other staff was 100%

Feb 2016-Marc 2016 Junior Dr cap was 100%, all other staff was 75%

Rules on mandatory use of approved frameworks for trusts take effect

Maximum wage rates take effect

The latest date that approved framework agreements must have pricing structures that fully

reflect NHS Improvement’s conditions for approval, including contractually embedding the

price caps and maximum wage rates

Monthly Totals

(2) The price caps set by NHS Improvement apply to the total amount a trust can pay per hour for an agency worker (exclusive of VAT and including all related costs eg holiday pay

for the worker, employer National Insurance, employer pension contributions, administration fee/agency charge). Trusts must not pay more than the price caps to secure an

agency worker. Trusts can override the price caps in exceptional patient safety circumstances only.

(3) From 1 April 2016, trusts are required to procure all agency staff (nurses, doctors, other clinical and non-clinical staff) via framework agreements that have been approved by

NHS Improvement. Overrides to the rule are permitted on exceptional patient safety grounds only.

(4) NHS Improvement is separately setting the maximum amount an agency worker receives per hour. Trusts are encouraged to comply with the maximum rates from 1 April 2016.

Trusts are required to comply with the maximum wage rates from 1 July 2016. Trust compliance with the maximum wage rates is required in addition to compliance to the price

caps. Trusts can override the maximum wage rates under exceptional patient safety circumstances only.

Enc. .

Page 22 of 25

Finance Report Month 02 2016/2017 WTEs R

Year to Date

Budgeted Substantive

Budgeted

Vacancies Bank Agency

Total Staff in

Post

Gap (Budget -

Actuals)

WTE WTE WTE WTE WTE WTE WTE

Ambulatory Services 1,371.7 1,255.4 116.4 21.1 19.1 1,295.6 76.1

Critical care, Theatres and Diagnostics 2,223.3 1,941.4 281.9 106.2 40.5 2,088.1 135.2

Liver, Renal and Surgery 1,751.8 1,590.1 161.7 138.5 14.5 1,743.1 8.7

Networked Services 1,581.1 1,347.5 233.6 128.6 25.5 1,501.6 79.4

Trauma, Emergency and Medicine 2,069.9 1,759.3 310.6 175.2 77.2 2,011.7 58.2

Women's and Children 1,497.2 1,338.7 158.5 100.1 6.5 1,445.3 51.9

Corporate Directorates

Corporate Services 98.7 92.8 5.9 0.5 1.0 94.3 4.4

Executive Nursing 118.1 118.5 (0.3) 1.7 120.2 (2.1)

Facilities 152.6 121.7 30.9 3.9 5.0 130.6 22.0

Finance, Procurement and Information 346.0 276.9 69.1 3.2 19.7 299.8 46.2

Human Resources 238.1 226.1 12.0 2.3 6.2 234.5 3.6

Medical Director 4.9 2.5 2.4 2.5 2.4

Operations 391.3 324.3 67.1 8.1 27.6 360.0 31.3

PFI 0.0 0.0 0.0

R&D 116.8 158.4 (41.6) 0.8 3.1 162.3 (45.6)

Strategic Development 8.1 8.2 (0.2) 8.2 (0.2)

Turnaround and Transformation 19.0 15.0 4.0 3.9 18.9 0.1

Total Corporate Directorates 1,493.5 1,344.4 149.1 20.6 66.4 1,431.3 62.2

Contract Services 49.7 40.8 8.9 0.8 (0.1) 41.6 8.1

Private Patients and Overseas Visitors 66.1 57.4 8.7 10.9 3.4 71.7 (5.6)

Total WTEs 12,104.1 10,674.9 1,429.3 702.1 252.9 11,629.9 474.2

The Trust is showing a budgeted vacancy level of 1429WTEs, of which 702 are covered by Bank and 253 are covered by Agency. This leaves a vacancy gap of 474 WTEs and explains

the pay underspend at month 02. Details exclude Kings Kewitt ACU department (39.9WTE).

The Finance Department is working closely with Workforce to reconcile the WTE numbers

Enc. .

Page 23 of 25

Finance Report Month 02 2016/2017 Income Activity Analysis

Month 2 Actuals are based on month 1 flex activity extrapolated using straight-line method. Bromley, Lambeth & Southwark contracts have been agreed and are

reflected within the plan. All other commissioners e.g. NHSE are based on KCH proposals.

There is alaways the potential for monthly varaiations between the month estimate and actual aptient data.

Enc. .

Page 24 of 25

Finance Report Month 02 2016/2017 Surplus / (Deficit) (By Division) R

Year to Date Plan Actual Variance

£k £k £k

Surplus / (Deficit) (10,087) (16,777) (6,690)

Year to Date Plan Actual Variance

£k £k £k

Ambulatory Services (3,300) (2,658) (642)

Critical care, Theatres and Diagnostics (1,187) (1,568) 381

Liver, Renal and Surgery (3,834) (6,095) 2,261

Networked Services (5,912) (6,858) 945

Trauma, Emergency and Medicine (5,841) (5,901) 60

Women's and Children (4,436) (5,176) 740

Corporate Income 9,099 7,230 1,869

Corporate Services

Capital charges and reserves (459) (33) (426)

Commercial Services 158 158 0

Corporate Services 28 275 (247)

Executive Nursing 2 (50) 52

Facilities (117) 298 (415)

Finance, Procurement & Information (2) 429 (431)

Human Resources 25 239 (214)

Medical Director 1 2 (1)

Operations 53 155 (102)

PFI 8 (100) 107

R&D (133) (291) 158

Strategic Development (5) (67) 63

Turnaround and Transformation 883 958 (74)

Corporate Services Total 442 1,973 (1,531)

Contract Services (MSK, ACU, Pathology Services) 1,272 (306) 1,577

Private Patients and Overseas Visitors 1,893 864 1,029

Surplus / (Deficit) (11,804) (18,494) 6,690

Impairment 1,717 1,717 0

Operating Surplus / (Deficit) (10,086) (16,777) 6,690

Enc. .

Page 25 of 25

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1 of 2

Report to: Board of Directors

Date of meeting: 6 July 2016

Subject: Summary Record of Finance & Performance Committee Meeting

Presented by: Chris Stooke, Non-Executive Director

Status: For Information

INTRODUCTION

This report provides the Board of Directors with a brief summary of all the key issues considered by the Finance & Performance Committee on 28 June 2016. STRATEGIES: TOP PRODUCTIVITY We were informed that Trust’s emergency department (ED) performance against the 4 hours target improved in May was 85.06%, performance was above improvement trajectories target of 83.8%, which was agreed with commissioners and NHS Improvements (NHSI). However, performance was still behind on national target of 95%; Trust cancer performance was mixed with the 62 day referral target not being achieved in May. This means that there is risk to successful achievement of this target in Quarter 1 (Q1), success will be dependent on June performance. The two week wait symptomatic breast referral target exceeded the national target in May at 93.5%, a significant improvement on this target has been achieved in May and early indicator predict good performance for June, but due to low performance in April this target will not be achieved in Q1; We received a deep dive on diagnostics waits, which highlighted the reason for the poor Trust performance and the corrective measures the Trust has implemented; The NHS constitution states that “patients waiting for a diagnostic test should not wait more than 6 weeks from referral for that test” the target linked to the statement is a maximum of 1% waiting more than six week for a referral test, currently Trust performance is 8.4%; The main reasons for the longer patient waits are low staffing levels due to a national shortage in radiographers and sonographers. An increased numbers of referrals received by the Trust which in some areas are as high as 200 referrals per site per day; To cope with the volume of work and clear the backlog the Trust is increasing staffing levels to key posts and working with the workforce department on the best way to retain staff in the Trust. There are also capital programme business cases due to be submitted for approval which will aim at increasing the number of MRI machines on the Denmark Hill and Orpington sites. The Trust is also looking to further increase capacity by weekend working and contractual reviews and negations with private sector service providers; We were presented with a deep dive and high level summary of the Trust’s emergency pathway recovery programme. We noted that pathway work will form part of the wider transformation programme and is an in depth redesign of the delivery of emergency care to patients in the Trust; The Princess Royal University Hospital (PRUH) was reviewed by an external consultancy McKinsey which produced a report ‘One Version of the Truth’, the report indicated that the

2 of 2

PRUH’s biggest contributing factors are linked to inpatient process, low discharge rates, bed shortage and longer waits for specialist consultation; Last year the Transfer of Care Bureau (TCB) was launched at the PRUH to address discharges and improve linkage between the hospital and community care teams. The TCB initiative is a partnership between the Trust, local social care providers and Bromley Clinical Commissioning Group (CCG). This year the TCB’s operational functionality and impact were reviewed by McKinsey to assess if it has had the desired impact of increased discharge rates and more joined up working between partners; The recommendations in the review will be implemented as part of the pathway redesign; The Denmark Hill (DH) ED experienced a larger than normal over 10% increase in winter pressure patient presenting to the ED. The additional pressure is yet to subside. An in-depth review highlighted that the biggest issue for the DH ED is the wait for a patient to see first clinician, wait for a cubicle to carryout patient reviews and capacity constraints; and The Trust is looking at a detailed redesign of the pathway so it can provide ring fenced medical care in its minors urgent care centres and looking at processing speciality patients and serious trauma cases differently. The work is ongoing. FIRM FOUNDATIONS: SOUND FINANCES We were informed that the Trust has received a revised offer letter from NHSI regarding their proposal of one off financial support to the Trust for 2016/17. The financial support will be granted only if the Trust signs up to deliver an agreed control total. The Finance Directorate have been working through the revised numbers and reviewing them in in line with the Trust’s annual financial plan; While securing any finical contribution at this time would be vital, the Trust must ensure it does not sign up to an unattainable target which is beyond what it can deliver. We discussed this in detail and decided the Trust would only agree to the revised offer subject to a number of caveats that the Trust would be submitting along with its acceptance; We noted that the Trust’s financial position continues to remain challenging and the Trust is under tight spending constraints. As at month 2, the Trust's cumulative operating deficit was £16.8m. This is an adverse variance of £6.7m against the year to date planned deficit plan of £10.1m; We were informed that cash continues to remain extremely tight and that the Finance Directorate have once again applied for an increased draw-down from the Working Capital Facility to help mitigate the Trust’s cash position and pay creditors to ensure there is no disruption to service delivery; and The Trust’s Cost Improvement Programmes (CIP) position has improved but there is still a CIPs gap that is yet to filled with appropriate savings schemes. The Trust continues to work hard at identifying savings schemes as successful delivery of the CIPs programme will be key in achieving Trust financial targets. Committee Chair Chris Stooke, Non-Executive Director

Enc. 6.3

1

Report to: Board of Directors

Date of meeting: 06 July 2016

Subject: PwC Governance Review Update

Author(s):

Lord Kerslake, Trust Chair

Presented by:

Lord Kerslake, Trust Chair

History: Previously considered by Board of Directors

Status: For Information Background For the benefit of the new members of the Board, I commissioned a high-level governance review at the start of my chairmanship and the Trust engaged PwC to conduct this review. The terms of reference for the review that the Chair commissioned was to provide a high-level view of Board governance that was forward looking, and that would help us to ensure that our governance arrangements were fit for purpose to take us forward through this challenging period for the Trust. The Trust has moved on significantly since the report Appendix 1 sets out the actions taken by the Trust in response to each of the recommendations put forward in the report. Recommendation The Board is asked to note progress against each recommendation

Legal/Regulatory:

The governance review will inform the Board’s approach to delivery of the financial turnaround and Monitor undertakings

Financial:

The governance review will inform the Board’s approach to delivery of the financial turnaround and Monitor undertakings

Assurance:

3 yearly Governance Reviews provide the Board with independent assurance of the efficacy of governance processes.

Clinical: Not applicable

Equality & Diversity:

Board succession planning will include full consideration of E&D issues in relation to the composition of the Board

Performance:

Effective governance structures are essential to performance delivery

Strategy:

The governance review will inform the Board’s approach to delivery of the financial turnaround and Monitor undertakings

Workforce:

Board Development and succession planning will form part of the review

Estates: Not applicable

Reputation:

Assurance of the efficacy of governance arrangements is essential to the reputation of the Trust and to the views of external stakeholders

Other:(please specify)

This page has been left blank

ACTION PLANS FOR PwC GOVERNANCE RECOMMENDATION

No. Recommendation

PwC

Priority

Rating

PwC

Timeframe

PwC

Implementation

Risk

Who When Trust Status Update

1

Board skills assessment The Board should undertake a skills and working style

assessment to understand any current gaps and the skills and working style mix it will

need to recruit to Executive and NED posts to ensure there is appropriate capabilities

and capacity in place to deliver the Trust’s objectives. The Board should use the skills

mix and working style assessments as a regular exercise and use this as a tool to scope

Board development sessions and to plan future recruitment.

HighWithin three

monthsMedium

Ch

air/

DC

A/D

ire

cto

r o

f

Wo

rkfo

rce

Sep

-16

Chair, DCA and Director of Workforce to agree action

plan incorporating regular review of skills mix. A

proposal for purchasing an online system which

generates bespoke online surveys for annual completion

by the individual directors on skills and support appraisal

is being developedwith the view of implementing the

sytem and processes in the new year.

11

Board development Once the composition of the Board is stable, the Trust should

consider how it can improve on its Board Induction and Development programme. In

order to do this the Trust should conduct a formal assessment using an appropriate

diagnostic tool to assess Board development needs. In accordance with the NHS Healthy

Board 2013 guidance, the Board development plan should include: a structured process

for induction of new Board members; individual Board member opportunities to refresh

and update skills (and knowledge); opportunities for the Board to learn together;

opportunities to learn good practice from peers; and additional development for those in

challenging roles, for example the Chair and Chief Executive. Our review has highlighted

that Board development should include working as a cohesive team and how to

challenge effectively, particularly in relation to seeking assurance over actions taken to

address any concerns regarding the quality of care.

HighWithin six

monthsMedium

Ch

air/

CEO

/DC

A

Sep

-16

Review of current induction programme for NEDs based

on skills assessment. Programme of ongoing board

development to be instituted when all new Board

appointments have been made. Clear guidelines will be

developed and a training and development register will

be kept by the Foundation Trust Office.

14Governors –assessment of performance The CoG should perform an assessment of

its collective performance and its impact on the Trust every two years.Low

Within six

monthsLow

Ch

air/

DC

A/B

S

Sep

-16

A programme will be developed and agreed with the

Council in March 2016. This programme is likely to fit in

line with the system solution being put in place for the

Board under recommendation 1 above.

7

Decision making The Trust should reiterate the forums where decisions need to made

and by whom and what information is required to make these decisions (including in

relation to capital expenditure).

HighWithin three

monthsLow

CEO

/CFO

/DC

A

Sep

-16

In progress - The Trust has SFIs which detail decision

making forums and authorisation limits. This document

needs updating. The review process is currently

underway to reflect the current financial structure of the

Trust. The draft SFI will be presented to the Audit

Committee in January with the view of the new

document being approved by the Board by March 2016.

INTRAIN OR ON TRACK

1

ACTION PLANS FOR PwC GOVERNANCE RECOMMENDATION

No. Recommendation

PwC

Priority

Rating

PwC

Timeframe

PwC

Implementation

Risk

Who When Trust Status Update

INTRAIN OR ON TRACK

25

Executive leadership for informatics The Trust should consider whether data quality

would be more appropriate as part of another Executive portfolio or whether a dedicated

Executive for informatics and information management to support the Trust in the

ongoing development of management reporting systems (e.g. Chief Information Officer

or equivalent) is required.

MediumWithin six

monthsMedium

CEO

Sep

-16 New programmes and plans in place to give focus to

data quality and new Director of Transformation and ICT

will drive this work with CFO and COO.

26

Divisional and financial governance The Trust should undertake a review of divisional

and financial governance arrangements to assess if these are in line with good practice

and operating effectively.

MediumWithin nine

monthsHigh

CEO

/CO

O

No

v-1

6 This will be embedded as part of the new operational

structure and management processes which are

currently in train.

2

ACTION PLANS FOR PwC GOVERNANCE RECOMMENDATION

No. Recommendation

PwC

Priority

Rating

PwC

Timeframe

PwC

Implementation

Risk

Who When Trust Status Update

INTRAIN OR ON TRACK

4

NED appointment The Trust should seek to recruit an additional NED with financial and

operational turnaround experience. We understand the Trust has recruited a NED with

clinical experience to fill a current vacancy and is considering recruiting a further NED.

HighWithin three

monthsMedium

Ch

air

Sep

-15

Board now has 8 non-executive directors who bring a

wealth of finance, audit, commercial, communications,

public sector, clinical, research and, strategic

experience. The membership of the Board is balanced

and this will be kept under review by the chair and the

Nominations Committee.

5Senior Independent Director The Trust should appoint a Senior Independent Director

once NED appointments have been made.Medium

Within six

monthsLow

CH

AIR

Jul-

15

The Senior Independent Director (SID) is appointed to

service two year terms. Faith Boardman remains the

SID and a new person wil be appointed as and when

required.

6

Level of challenge and debate Chairs of meetings should encourage constructive

challenge and debate of the key issues. NEDs should hold the Executives more strongly

to account and Executives should constructively challenge each other.

HighWithin three

monthsMedium

Ch

air/

NED

s

ASA

P

The steps put in place which included changing the

timings of the Board and revising the membership of

Board Committees has fostered more debate and

challenge. Directors and Governors have commented

on the change in the Board meeting and the level of

challenge. Although this will be under continued review

by the Chair. The Board is comfortable that this action

has been met.

8

Articulation of the Trust’s strategy The Trust should undertake further work to ensure

all members of the Board are appropriately engaged and informed of their priority areas,

the overall strategic direction of the Trust, its quality priorities and short term and longer

term financial priorities.

HighWithin three

monthsLow

Ch

air/

CEO

Oct

-15

Whilst each NED has been assigned to each element of

the strategy.

9

Patient story The Trust should move discussion of the patient story from the Q&GC to

the Public Board as a means of helping to ensure a focus on patients and quality during

this time of significant financial challenge.

MediumWithin three

monthsLow

DC

A

Sep

-15

Completed - Commenced September 2015

12

Appraising the Board The Trust should review the effectiveness of Board relationships,

in order to obtain an assessment of the inter-relationships between members of the

Board and with governors and divisional managers. In addition, the Trust should allocate

sufficient time together as a team outside of formal Board meetings and time to identify

and act on its successes and failures. The Trust should consider holding separate

informal sessions for the NEDs as a group.

MediumWithin six

monthsLow

Ch

air/

CEO

/DW

D

No

v-1

6

The Chair and CEO are giving effect to more

opportunities for the Board to meet outside formal

meetings. In additon two opportunites have been put in

the timetable for 2016 for development and reflective

exercises. The Chair is also putting in place opportunies

to meeting witht he NEDs informally.

COMPLETED & REMOVED FROM TRACKER - NOW BUSINESS AS USUAL

3

ACTION PLANS FOR PwC GOVERNANCE RECOMMENDATION

No. Recommendation

PwC

Priority

Rating

PwC

Timeframe

PwC

Implementation

Risk

Who When Trust Status Update

INTRAIN OR ON TRACK

13

Governors –holding NEDs to account The Board of Directors and governors should

agree on a process for holding the NEDs to account for the performance of the Board.

This should include an agreement on the information and timeline of providing

information; the forums at which governors can question directors; what steps to take

should governors be dissatisfied with responses they receive from one or more of the

NEDs; and when governors should use their power to require directors to attend a

governor’s meeting.

MediumWithin three

monthsLow

Ch

air/

DC

A/B

S

De

c-1

5

Completed. New working arrangements with Governors

and NEDs agreed.Governors attending some Board sub-

committees and additional dates for NED/Governor only

reviews in schedule.

15

NED attendance at committees Review NED attendance at subcommittees of the

Board with a view to having a NED chair and two other NED attendees at each

committee in line with their areas of focus where appropriate.

HighWithin three

monthsLow

Ch

air/

DC

A/B

S

No

v-1

5

Completed - New Committee Strucutre and NED

Membership is in place.

16

Timing of Board and subcommittees The Trust should hold the Public Board in

advance of the Private Board and alter the timing of other committees so that they are

not on the same day as the Board meeting and are therefore able to formally report to the

Board. An integrated performance report should then be considered at the Board

meeting to review Trust wide performance. Additionally, the Trust should consider

ceasing the Strategy Committee, covering this business instead in the Private Board on a

monthly basis.

HighWithin three

monthsMedium

Ch

air/

DC

A/B

S

Sep

-15

Completed - Schedule for 2015 adjusted and 2016

Board shedule fully reflects these recommendations.

18

Risk management at Board The Public and Private Board should be used as the forum

by which the risk register (from the Q&GC) is actively discussed and the BAF (from

King’s Executive) is discussed regularly by the Board to assess the effectiveness of the

management of risks.

HighWithin three

monthsLow

CH

AIR

/CEO

/DC

A

De

c-1

5

The revised BAF was presented to the Board in

December 2015. Board agreed that this would be also

presneted at the public meetings on quarterly basis to

enhance transparency and robust Board discussions.

19

Risk management at subcommittees The Trust should ensure that all committees and

subcommittees consider risks appropriate to them and escalate these to the Q&GC for

consideration before they are escalated to the Board in line with the Trust’s Risk

Management Strategy. Given the additional work of the Q&GC, it may be helpful to

segregate the agenda between quality, governance and risk issues.

MediumWithin six

monthsMedium

Co

mm

iitte

Ch

airs

/DC

A

De

c-1

5

Standing agenda item to be added to all Board sub

committees for the Commiittee to consider risks

appropriate to them. Template to be produced, and

forwarded to QGC for inclusion in risk register. Agenda

of QGC has been divided into quality, governance and

risk headings.

4

ACTION PLANS FOR PwC GOVERNANCE RECOMMENDATION

No. Recommendation

PwC

Priority

Rating

PwC

Timeframe

PwC

Implementation

Risk

Who When Trust Status Update

INTRAIN OR ON TRACK

20

Structure of the risk register The structure of the risk register reported to the Board

should be improved to enable effective discussion. The executive summary included with

risk registers reported to the Board and subcommittees should be refined so it guides the

reader of the report to the key points. A risk score should be included before and after

mitigating actions and comments should be provided on the impact mitigating actions are

having. The Trust should also review the risk register for completeness and add details

as to at which committees risks should be considered.

MediumWithin six

monthsMedium

DC

A/

AD

Go

vern

ance

De

c-1

5

Completed - December 2015

21

Agenda planning The Trust should ensure sufficient time is allocated between agenda

items and ensure there is an appropriate balance between quality, finance and

performance. The Trust should encourage subcommittee chairs to reflect on the intended

purpose of the committee and ensure that both the agenda and conduct of the meeting

are aligned to this, particularly in relation to providing the Board with assurance in respect

of performance, risk and Executive action.

HighWithin three

monthsLow

Co

mm

itte

e E

xecu

tive

Lead

s/C

om

mit

tee

Ch

airs

De

c-1

6

Workplans are developed for each sub-committees in

conjunction with the committee chairs. As a matter of

process the agenda for each meeting is drawn from the

workplan and the chair is asked to approve the final

agenda before papers are sent out to the committee.

This process will be enhanced with each executive lead

inviting each committee chair to meet and discuss the

agenda before each meeting.

Board and committee papers The Trust should refine all Board and subcommittee

papers utilising the same principles as the recently amended Performance report. The

Trust should incorporate benchmarking analysis and report on combined Trust

performance to assess how the Trust is performing across all sites. All Board and

committee reports should set out clearly what the purpose of the report is and what the

key issues, risks and recommendations are so it is clear to the reader what is being

asked of them and why.

HighWithin three

monthsHigh

Ch

air/

DC

A/E

xec

team

Sep

-15

Executive leads should refine reports to the Board as

described, including benchmarking analysis where

appropriate. The Board report template has been

updated to cover key issues, risks and cross reference

to BAF Risks and will be implented from 2016.

Board and committee papers Within the Performance report the Trust should ensure

reporting of RTT subset data reports agreed with commissioners are included and the

impact to patients assessed and reported on during the period of non reporting of RTT

performance.

HighWithin three

monthsHigh

CO

O

Sep

-15

Completed - As of November 2015

23

Board and committee minutes To be in line with best practice the Trust should include

reference to discussion and challenge that have been made within the minutes of the

Board and committees. Currently Board and committee meeting minutes are highly

summarised, meaning it is not possible to assess the level of challenge at the meetings

through reviewing minutes.

LowWithin three

monthsLow

DC

A/B

S

Jul-

15

Completed - Secretariat will sub-divide key actions

points to reflect matters reported and those points of

discussion and challenge raised by board members.

Minutes are not verbatim.

22

5

ACTION PLANS FOR PwC GOVERNANCE RECOMMENDATION

No. Recommendation

PwC

Priority

Rating

PwC

Timeframe

PwC

Implementation

Risk

Who When Trust Status Update

INTRAIN OR ON TRACK

24

Committee updates to the Board The Trust should require Chairs of committees to

submit a written report to highlight key issues and risks to the Board. The Trust will need

to consider the timing of this report in line with the scheduling of meetings to ensure up to

date information is reported to the Board.

MediumWithin three

monthsLow

Ch

air/

Co

mm

itt

ee

Ch

airs

Jan

-16

Secretariat will draft a report for the Committee Chair

before each Board.

2

Executive Director Recruitment The Trust should recruit to ensure there are sufficient

skills and capability at Executive level to effectively drive financial and operational

recovery as well as replace the roles of directors who have served notice of their

retirement.

HighWithin three

monthsLow

CEO

Mar

-16

All substantive NEDS in place

3Succession planning The Board should develop and maintain a future succession plan

including where appropriate external recruitment.Medium

Within nine

monthsLow

CEO

/DW

D

Jun

-16

Executive succession plans received and considered by

the Board and Remuneration & Appointments

Committee. A rolling programme to be developed by

DWD/CEO and considered by RemCo. A robust plan will

be developed by the CEO for review by the RemCo in

June 2016.

10Quality focus During this time of financial pressure the Board should develop a quality

strategy in order to support the delivery of the Trust’s vision and quality priorities.Medium

Within six

monthsMedium

Dir

ect

or

of

Nu

rsin

g

Jul-

16 Completed - first draft went to Board and not being

socialised within the organisation

17

Divisional representation at subcommittees The divisions should formally report into

both the F&PC and the Q&GC. This could be achieved by the two committees doing

deep dives into the divisions on a rotational basis.

HighWithin three

monthsMedium

Co

mm

itte

e

Exe

cuti

ve

Lead

s/C

hai

r

ASA

P

Deep dives alread on QGC and FPC.

6

Enc. 6.5.1

1

Report to: Board of Directors

Date of meeting: 06 July 2016

Subject: Audit Committee Annual Review

Author Tamara Cowan, Board Secretary

Presented by: Alix Pryde, Committee Chair

Status: For Information and Approval

All the Trust’s Board Committees are required to complete an annual review of its activities and its terms of reference. This report details the activities of the Audit Committee during the period 01 April 2015 – 31 March 2016. The purpose of the report is to provide the opportunity for the Board to consider the activities of that the Audit Committee undertook during the period and any revision to its terms of reference. The Committee considered the annual review and agreed to present the report to the Board of Directors for endorsement in addition to proposed changes to its terms of reference.

Action Required The Board is asked to: 1) Consider the contents of the annual report and the Committee’s self-

assessment (Appendix 1); and

2) Consider and approved the proposed changes to the Committees terms of reference (Appendix 2).

Enc. 6.5.1

2

Audit Committee Annual Report

April 2015 – March 2016

1. Introduction

This report covers the period from April 2015 to March 2016 to coincide with the Trust’s financial reporting period. Section C3 of the NHS Foundation Trust Code of Governance states that the Board of Directors is required to establish formal and transparent arrangements for considering how the Trust should apply corporate reporting, risk management and internal control principles in addition to maintaining an appropriate relationship with its auditors. Accordingly, the Board established the Audit Committee. The Audit Committee also monitors the integrity of the externally reported financial performance and overall governance and risk processes and provides independent assurance to the Board of Directors on a range of areas including internal control and risk management, internal audit, external audit and financial reporting.

2. Committee Administration

2.1. Meetings

The Committee’s membership is composed entirely of independent non-executive directors. At least one member of the Committee has recent and relevant financial experience.

Role Term

Committee Members

Alix Pryde Committee Chair January 2016 – March 2016

Member November 2015 – March 2016

Chris Stooke Committee Chair April 2015 – December 2015

Member April 2015 – March 2016

Faith Boardman Member April 2015 – March 2016

Graham Meek Member April 2015 – December 2015

Committee Attendees

Simon Taylor Chief Financial Officer April – August 2015

Alan Goldsman Interim Chief Financial Officer August – December 2015

Colin Gentile Chief Financial Officer January – March 2016

Jane Walters Director of Corporate Affairs April – September 2015

Judith Seddon Acting Director of Corporate Affairs October 2015 – March 2016

Roland Sinker Acting Chief Executive Officer April – October 2015

Nick Moberly Chief Executive Officer November 2015 – March 2016

The Trust Chair has a long-standing invitation to attend Committee meetings and during the period, Lord Kerslake attended all the Audit Committee meetings. The Committee also requires the responsible executive director and/or senior manager to attend the Committee meeting to provide further assurance where a review of an area of risk has been highlighted through the internal or external audit process. Other regular attendees include the Trust’s local Counter Fraud Specialist, internal auditor KPMG and external auditor Deloitte.

Enc. 6.5.1

3

2.2. Meetings

During the period, the Committee met four times. The attendance of the Committee members is detailed below.

Members 19/05/2015 22/05/2015 11/011/2015 26/01/2016

Alix Pryde N/A N/A

Chris Stooke

Faith Boardman ×

Graham Meek × N/A

As a matter of course, the Committee members also held private meetings with internal and external audit representatives and the Trust’s local counter fraud specialist without the executive or senior management present. Some of the issues discussed in these meetings included:

Scale of challenge and pressures facing the Trust

Continual issues with non-adherence with Trust policies and procedures

Granularity of consultant job planning

Issues with NHS facilities being used for private patients

Engagement with external audit process

Reliance on the knowledge and expertise of a consolidated and small senior finance team

The level of grip since the acquisition of former South London Healthcare Trust sites

Increased level of involvement from Monitor and the Department of Health (DH) to achieve outturn positions and the resultant pressures on senior teams and the Trust

The Committee members also meet, in private, with the senior executive team to discuss the key issues identified above and any other matters arising.

2.3. Terms of Reference (ToR)

The Committee’s ToR were due to be reviewed by the Committee in May 2015. This was delayed for the following reasons:

The new Chair commissioned a short-sharp governance review the results of which could potentially affect the Committee’s structure. The review was completed and results finalised in September.

There were a number of changes in the non-executive and executive directors on the Board.

The revised version of the ToR of the Committee can be found in Appendix 1 which reflects the changes from the governance review and the personnel on the Board.

2.4. Committee Self-Assessment

The Committee is required to complete an annual self-assessment of its work which is enclosed in Appendix 2.

Enc. 6.5.1

4

3. Work of the Audit Committee during the year

3.1. Internal Audit

The Audit Committee continues to closely monitor the effectiveness of the Trust’s comprehensive internal control and review mechanism through the work of internal and external auditors, the counter fraud team and setting up a system to monitor progress against performance improvement recommendations.

KPMG continues to provide the Trust’s internal audit service. KPMG has been providing the Trust’s internal audit service for 11 years and following a tender process for internal audit services KPMG was successfully reappointed as the Trust’s internal auditors for a further 3 year term starting 1 July 2016. During the period, reviews were undertaken in line with the 2015-16 internal audit plan designed to cover the key risks facing the Trust. The audit plan also included routine audit work and provided assurances on basic financial systems and reporting structure. The 2015-16 audit plan included a programme of work around the integration of the newly acquired sites and services.

In 2015-16, the following reports were presented to the Committee for review:

The Committee also receives progress reports and technical updates on a regular basis.

Enc. 6.5.1

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3.2. Board Assurance Framework (“BAF”) The Board Assurance Framework (BAF) addresses the key strategic risks faced by the Trust. The Audit Committee uses it as an aid to planning assurances and scrutiny. The Committee will review the BAF in September 2016.

3.3. Risk Management Strategy The Committee will review the Risk Management Strategy in in September 2016. 3.4. Counter Fraud

The Trust’s Counter Fraud and Corruption Team (CFCT) has been established since 2004 and during the period enhanced its team to ensure the new sites and services had sufficient fraud prevention coverage across the enlarged Trust. The CFCT develops annual action plans for and provides progress updates and recommendations at each Audit Committee. 3.5. External Audit Deloitte is the Trust’s external auditor. In addition to auditing the Trust’s annual accounts, Deloitte makes a risk assessment each year and reviews are carried out and presented to the Committee. The Trust conducted a tender process for external audit services and Deloitte was successfully reappointed as the Trust’s external auditors for a further 3 year term starting 1 July 2016. The Committee approved the Audit Plan for 2015-16. 3.6. Performance Improvement & Recommendation Monitoring Symbiant tracks the recommendations generated through reviews carried out by KPMG, Deloitte and the Counter Fraud and Corruption Team. All performance improvement recommendations are recorded on a central computer system. Progress is reported to each Audit Committee. 3.7. Appointment of auditors for KCH Commercial Services Deloitte LLP is the appointed auditors for the Trust’s commercial entities. 3.8. Trust Policies The Committee also considered, endorsed and approved the updated version of the delegated authority for the Trust.

Enc. 6.5.1

6

Appendix 1 – Committee Draft Terms of Reference

Name Audit Committee

Chair Alix Pryde Christopher Stooke, Non-Executive Director

Executive Lead Chief Financial Officer

Secretariat

Support Corporate Governance Officer Board Secretary

Members

Marc Meryon, Non-Executive Director

Graham Meek, Non-Executive Director

Faith Boardman, Non-Executive Director

Chris Stooke, Non-Executive Director

Attendees

Chief Executive

Chief Financial Officer

Director of Corporate Affairs

Counter Fraud Manager

Representatives of Internal Audit (KPMG)

Representatives of External Audit (Deloitte)

The Committee reserves the right to ask any officer of the Trust to attend the Audit Committee. The Committee will wish to meet with the Internal and External Auditors and the Counter Fraud Prevention and Detection Corruption Team without any Board Executive Director present.

Meeting

Frequency

Meetings shall be held not less than quarterly and more frequently as required.

The External Auditor, Head of Internal Audit or Head of the Counter Fraud Prevention

and Detection Corruption Team may request a meeting if they consider one necessary.

Quorum The quorum for this Committee is 2 non-executive directors and the Chief Financial Officer or the Chief Executive.

Purpose & Duties

The main purpose of the Committee is to monitor the integrity of the externally reported

financial performance and overall governance and risk processes of the Trust and to

provide independent assurance to the Board of Directors on a range of areas including

internal control and risk management, internal audit, external audit and financial

reporting.

The core duties of the Committee include:

1) Internal Control, Governance and Risk Management

The Committee shall review and provide assurance to the Board on the establishment and maintenance of effective systems of internal control and risk management. The role of the Board’s Quality and Governance Committee is to monitor the effectiveness of the Trust’s governance and risk management framework. The role of the Audit Committee is to provide independent assurance to the Board on the adequacy of these systems through internal and external audit.

Enc. 6.5.1

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Taking into account the findings and recommendations of the Trust’s internal and

external auditors, the Committee will provide independent assurance to the Board on:

All risks and controls related disclosure statements including the Trust’s Annual

Compliance Statement to Monitor, the Statement of Internal Control and

registration with the Care Quality Commission, prior to endorsement by the Board

of Directors.

The structures, processes and responsibilities for identifying and managing key

risks facing the organisation.

The systems and processes for ensuring that there is compliance with relevant

regulatory, legal and code of conduct requirements.

Adherence to internal controls.

Standing Orders for the Board of Directors and the Trust’s Standing Financial

Instructions and Scheme of Delegation.

In carrying out this work, the Committee will primarily utilise the work of Internal Audit,

External Audit and other assurance functions. It will also seek reports and assurances

from directors and managers as appropriate, concentrating on the overarching

systems of the Trust’s governance framework, risk management and internal control,

together with indicators of their effectiveness. The committee will annually review the

Risk Management Strategy.

2) Internal Audit

To monitor and review the effectiveness of the Trust’s internal audit function.

To appoint, or dismiss, and review the contract of the internal auditors.

To ensure that the Internal Audit function is adequately resourced and has

appropriate standing within the organisation.

To review the internal audit programme and ensure that it is consistent with the

audit needs of the organisation as informed by the Assurance Framework.

Consider the major findings of internal audit investigations (and management’s

response), and ensure co-ordination between the Internal and External Auditors.

3) External Audit

To oversee the Trust’s relations with the External Auditor.

To make recommendations to the Board of Governors on the appointment,

reappointment and removal of the External Auditor and approve the remuneration

and terms of engagement of the External Auditor.

Review and monitor the External Auditor’s qualification, expertise, resources,

independence and objectivity and the effectiveness of the audit process, taking

into consideration relevant UK professional and regulatory requirements.

Develop and implement a protocol on the engagement of the External Auditor to

supply non-audit services, taking into account relevant ethical guidance on the

provision of non-audit services by the external audit firm.

Enc. 6.5.1

8

Report to the Board of Governors, identifying any matters in respect of which it

considers that action or improvement is needed, making recommendations as to

the steps to be taken.

Discuss and agree with the External Auditor, before the audit commences the

nature and scope of the audit.

To review the audit representation letters before consideration by the Board.

Review External Audit reports, including the Annual Governance Report together

with the management response.

To assess, at the end of the audit cycle, the effectiveness of the audit process.

4) Financial Reporting

The Committee shall review the Annual Report and Financial statements and the report of the Trust’s External Auditor before submission to the Board focussing particularly on:

The integrity of the financial statements.

Any formal announcements relating to the Trust’s financial performance reviewing

significant financial reporting judgements contained in them.

Changes in and compliance with Accounting Policies and practices

Significant adjustments resulting from the audit.

The extent to which the financial statements are affected by any unusual

transactions in the year and how they are disclosed

The going concern assumption.

Ensure compliance with the requirements of Monitor’s Financial Reporting Manual

(FReM) in respect of the annual report and financial statements.

5) Fraud, Corruption and Impropriety

The Committee shall review the adequacy of arrangements by which staff may

raise, in confidence, concerns about possible improprieties in financial reporting

and control, clinical quality, patient safety or other matters.

The Committee shall review the adequacy of the provision of the local counter

fraud service.

Review the adequacy of the policies and procedures for all work related to fraud

and corruption as set out in Secretary of State Directions and as required by the

Directorate of Counter Fraud Services.

Review the adequacy of the policies and procedures for all work related to fraud,

corruption and bribery as required under the NHS Standard Contract and the

standards set by NHS Protect. Ensure that the Counter Fraud Detection and

Prevention Corruption Team (FDPTCFCT) is adequately resourced and has

appropriate standing within the organisation

Review the programme of work of FPDT CFCT and consider the findings of their

investigations, including the management response.

Reporting

The Audit Committee shall annually review its terms of reference and its own effectiveness and recommend any necessary changes to the Board. The Audit Committee shall prepare a report on its role and responsibilities and the actions it has taken to discharge those responsibilities for inclusion in the annual report and accounts.

Appendix 2 – Self-Assessment Checklist

1 - must do

2 - should do

3 - could do

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

COMPOSITION, ESTABLISHMENT AND DUTIES

1 Does the Committee have written terms of reference that adequately and realistically define the Committee’s role in accordance with Monitor guidance?

YES

1 Have the terms of reference been adopted by the Board? YES

1 Are the terms of reference reviewed annually to take into account governance developments and the remit of other committees within the organisation?

YES

1 Has the Committee been provided with sufficient membership, authority and resources to perform its role effectively and independently?

YES

2 Are changes to the Committee’s current and future workload discussed and approved at Board level?

YES

1 Are Committee members independent of the management team? YES

1 Does the Committee report regularly to the Board? YES

1 Has the Chair of the Committee have prior understanding of, or received training in finance and internal control or other relevant expertise

YES

2

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

1 Are members, particularly those new to the Committee, provided with training? YES

1 Does the Board ensure that members have sufficient knowledge of the organisation to identify key risk areas and to challenge both line management and the auditors on critical and sensitive matters?

YES

1 Does the committee prepare an annual report on its work and performance in the preceding year for consideration by the Board?

YES

1 Does the Committee assess its effectiveness periodically? YES

MEETINGS

1 Has the Committee established a plan of matters to be dealt with across the year? YES

1 Does the Committee meet sufficiently frequently to deal with planned matters and has enough time allowed for questions and discussion?

YES

1 Does the Committee’s calendar meet the Board’s requirements and financial and governance calendar?

YES

2 Are Committee papers distributed in sufficient time for members to giver due consideration? YES

2 Are Committee meetings scheduled prior to important decisions being made? YES

2 Is the timing of the Committee Meetings discussed with all parties involved? YES

COMPLIANCE WITH THE LAW AND REGULATIONS GOVERNING THE NHS

1 Does the Committee review assurance and regulatory compliance reporting processes? YES

3

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

3 Has the Committee formally assessed whether there is a need for the support of a “Company Secretary” role or equivalent?

YES

2 Does the Committee have a mechanism to keep it aware of topical, legal and regulatory issues?

YES

INTERNAL CONTROL AND RISK MANAGEMENT

1 Has the Committee formally considered how it integrates with other committees that are reviewing risk e.g. risk management and clinical governance?

YES

1 Has the Committee formally considered how its work integrates with wider performance management and standards compliance?

YES

1 Has the Committee reviewed the robustness and effectiveness of the content of the organisation’s Assurance Framework?

NO

The Committee is due to review the Board Assurance Framework and the policy in September 2016.

1 Has the Committee reviewed the robustness and content of the draft Annual Governance Statement (previously known as the Statement of Internal Control) before it is presented to the Board

YES

2 Has the Committee reviewed whether the reports it receives are timely and have the right format and content to ensure its internal control and risk management responsibilities are discharged?

YES

1 Has the Committee reviewed the robustness of the data behind reports and assurances received by itself

YES

1 Is the Committee satisfied that the Board has been advised that assurance reporting is in place to encompass all the organisation’s responsibilities?

YES

1 Is the Committee’s role in reviewing and recommending to the Board the annual report and accounts clearly defined?

YES

4

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

1 Does the Committee consider the External Auditor’s report to those charged with governance including proposed adjustments to the accounts?

YES

1 Does the Committee review management’s letter of representation? YES

1 Is there clarity over the timing and content of the assurance statements received by the Committee from the Head of Internal Audit?

YES

INTERNAL AUDIT

1 Is there a formal ‘charter’ or terms of reference exist, defining internal audit’s objectives, responsibilities and reporting lines?

YES

1 Are the terms of reference approved by the Committee and regularly reviewed YES

2 Are key principles of the terms of reference set out in the Standing Financial Instructions?

1 Does the Committee review and approve the Internal Audit plan at the beginning of the financial year?

YES

1 Does the Committee approve any material change to the plan? YES

2 Are audit plans derived from clear processes based on risk assessment? YES

1 Does the Committee receive periodic reports from the Head of Internal Audit? YES

1 Do these reports inform the Committee about progress or delays in completing the audit plan YES

2 Does the Committee effectively monitor the implementation of management actions arising from audit reports?

YES

5

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

1 Does the Head of Internal Audit have a direct line of reporting to the Committee and its chairman?

YES

2 Is internal audit free of any scope restrictions and, if not, what are they and who establishes them?

YES

2 Is Internal Audit free from any operating responsibilities or conflicts of interest that could impair its objectivity?

YES

2 Has the Committee determined the appropriate level of detail it wishes to receive from Internal Audit?

YES

1 Does the Committee hold periodic private discussions with the Head of Internal Audit? YES

2 Does the Committee review the effectiveness of internal audit and the adequacy of staffing and resources within internal Audit?

YES

2 Has the Committee evaluated whether internal audit complies with the NHS Internal Audit Standards (or Government Internal Audit Standards in an FT)

YES

Head of Internal Audit reflect on their compliance with these standards in each of their reports

3 Has the Committee agreed a range of internal audit performance measures to be reported on a routine basis?

YES

1 Does the Committee receive and review the Head of Internal Audit’s annual Report YES

2 Is there appropriate cooperation with the External Auditors? YES

2 Are there any quality assurance procedures to confirm whether the work of the Internal Auditors is properly planned, completed, supervised and reviewed?

YES

3 Has the Committee established a process whereby it reviews any material objection to the plans and associated assignments that cannot be resolved through negotiation

N/A

6

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

EXTERNAL AUDIT

1 Does the External Auditors present their audit plans and strategy to the Committee for approval?

YES

2 Has the Committee satisfied itself that work not relating to the financial statements is adequate and appropriate?

YES

2 Does the Committee receive and monitor actions taken in respect of prior years’ reviews? YES

1 Does the Committee review the External Auditor’s annual audit letter? YES

1 Does the Committee review the External Auditor’s use of resources? YES

1 Does the Committee hold periodic private discussions with the External Auditor? YES

2 Does the Committee assess the performance of External Audit? YES

3 Does the Committee require assurance from external audit about the policies for ensuring independence and compliance with staff rotation requirements?

YES

3 Does the Committee review the nature and value of non-audit work carried out by the external auditors?

YES

CLINICAL AUDIT

1 Is the Committee clear about where clinical audit assurances are received and monitored?

YES

The Quality & Governance Committee are responsible for the review of clinical audits.

7

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

2

If it is the Audit Committee that receives and monitors clinical audit assurances does it:

Review the clinical audit plan at the beginning of each year?

Confirm that clinical audit plans are derived from clear processes based on risk assessment with clear links to the Assurance Framework?

Receive periodic reports from the person responsible for clinical audit?

Effectively monitor the implementation of management actions arising from clinical audit reports?

Ensure that the person responsible for clinical audit has a direct line of access to the Committee and its Chair?

Hold periodic private discussions with the person responsible for clinical audit?

Review the effectiveness of clinical audit and the adequacy of staffing and resources available for clinical audit?

N/A

2

Evaluate clinical audit against the Healthcare Quality Improvement Partnership’s publication Clinical Audit: A simple guide for NHS Boards?

Confirm that there are quality assurance procedures in place to confirm whether the work of clinical auditors is properly planned, completed, supervised and reviewed?

Confirm that there are terms of reference for clinical audit that define its objectives, responsibilities and reporting lines?

Review clinical audit’s terms of reference regularly?

N/A

COUNTER FRAUD

1 Does the Committee review and approve the counter fraud work plan at the beginning of the financial year?

YES

1 Does the Committee satisfy itself that the work plan adequately covers each of the seven generic areas defined in NHS fraud policy?

YES

8

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

1 Does the Committee approve any material changes to the plan? YES

2 Are counter fraud plans derived from clear processes based on risk assessment? YES

1 Does the Audit Committee receive periodic reports from the Local Counter Fraud Specialist? YES

2 Does the Committee effectively monitor the implementation of the management actions arising from the counter fraud reports?

YES

1 Does the Local Counter Fraud Specialist have a right to direct access to the Committee and its Chair?

YES

1 Does the Committee review the effectiveness of the local counter fraud service and the adequacy of its staffing and resources?

YES

1 Does the Committee receive and review the Local Counter Fraud Specialist’s annual report on counter fraud activity and qualitative assessment?

YES

1 Does the Committee receive and discuss reports arising from quality inspections by CFSMS? YES

ANNUAL ACCOUNTS

1 Is the Committee’s role in the approval of the annual accounts clearly defined? YES

2 Is a Committee meeting scheduled to discuss proposed adjustments to the accounts and issues arising from the audit?

YES

1

Does the Committee specifically review:

Changes in accounting policies?

Changes in accounting practice due to changes in accounting standards?

Changes in estimation techniques?

Significant judgements made?

YES

9

STATUS ISSUE YES, NO, N/A EXCEPTION REPORTING

3 Does the Committee review draft accounts before the start of the audit? YES

1 Does the Committee ensure it receives explanations as to the reasons for any unadjusted errors in the accounts found by the external audit?

YES

1 Does the Committee receive and review a draft of the organisations’ Annual Governance Statement (previously known as Statement on Internal Control)?

YES

2 Does the Committee receive and review evidence required to demonstrate fitness to register with the Care Quality Commission?

NO Remit of Quality & Governance Committee

2 Does the Committee receive and review a draft of the organisation’s annual report? YES

1 Does the Committee have a plan of matters to be dealt with over the coming year? YES

3 Does the Committee meet the appropriate number of times to deal with planned matters?

YES

OTHER ISSUES

3 Has the Committee considered the costs that it incurs: and are the costs appropriate to the perceived risks and the benefits?

YES

2

Has the Committee reviewed its performance in the year for consistence with its:

Terms of reference?

Programme for the year?

YES

3 Does the annual report and accounts of the Authority/Trust include a description of the Committee’s establishment and activities?

YES

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Enc. 6.5.2

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Report to: Board of Directors

Date of meeting: 06 July 2016

Subject: Committee Annual Review

Author(s): Jane Badejoko, Corporate Governance Officer

Presented by: Chris Stooke, Committee Chair

History: Previously considered by the Finance & Performance Committee

Status: For Information and Approval

1. Summary of Report This report includes the Annual Review of the Finance and Performance Committee for 2015/16, amended Terms of Reference (ToR) and updated Work Plan for 2016/17. Amendments to the Non-Executive Director(NED) membership were made in-line with the recommendation from the PwC governance review. The ToR include delegated authority from the Board of Directors to sign off the quarterly Monitor Submission. The Annual Work Plan, includes ‘deep dives’ on both financial and operational performance issue within the Trust and external current influences. The changes to the ToR and annual work plan were approved by the Finance and Performance Committee on Tuesday, 26 April 2016. 2. Action required The Board is asked to:

Note the Committee Annual Review Approve the changes to the ToR and Annual Work Plan

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Finance and Performance Committee Annual Report & Self-Assessment 01 April 2015 – 31 March 2016

1. Introduction

In line with the Trust’s model of distributed governance, the seven sub-committees of the Board are jointly charged with providing assurance that the Trust is compliant with relevant external regulatory bodies and statutory requirements.

The Finance and Performance Committee (FPC) is also responsible for reviewing trends and key risks arising from operational and financial decisions. It also monitors compliance against the Monitor financial and performance framework, NHS Risk Management Standards, National Clinical Audits NHS Improvement Agency guidance. This report is part of monitoring the effectiveness of the Finance and Performance Committee as described in its Terms of Reference. To ensure systematic review of all elements of finance and performance the annual work plan continues to form a major part of the Committee activities with a particular focus on the two domains financial and operational performance against targets, both internal and external. To coincide with the Trust’s financial reporting cycle the Committee’s annual report covers the period from April 2015 to March 2016. During this time the Committee met twelve times and this report summarises those meetings and the work of the Finance and Performance Committee.

2. Terms of Reference The Finance and Performance Committee terms of reference state that it should:

Monitor the Trust’s balanced scorecard and other Trust-wide performance issues, be made aware of the key current performance issues and any indicators there is a downward trend in performance, and receive assurance that actions are being taken to bring performance back on target;

To regularly review the Trust’s performance against the Care Quality Commissions’ Annual Health Check assessment criteria and address any adverse performance;

To receive reports from Divisions on strategy, operational, quality and financial performance against Trust’s KPIs, including plans to address any key performance issues;

T review Trust performance against Monitor governance and finance risk ratings prior to submission to the Board, including the Annual Plan and quarterly submissions to Monitor; and

To approve the quarterly Monitor submissions on behalf of the Board of directors with provision that if there is significant variance/exceptions in the submissions, the submission would be sent by email to the full board for comment and approval.

2

3. Membership

Following the governance review carried out by PricewaterhouseCoopers (PwC) in 2015 NED attendance at Board sub-committees was reviewed and the following recommendations were implemented:

A NED continues to chair the Committee with two other NED attendees in line with their areas of focus. This is a total of three NED members for each Committee to facilitate a more focused discussion;

To bring about closer working relationship between the Council of Governors and the Board of Directors a Governor representative has been appointed to observer NEDs in action; and

A full list of membership can be found in the Committee’s Terms of Reference (ToR) included in Appendix 1 of this report.

4. Remit and Reporting Methodology:

The Committee continues to meet monthly and attendance recorded and maintained;

There continues to be a standing item at every Board of Directors meeting to receive the minutes from Committee meetings;

The Board of Directors also receives a number of the reports discussed in more detail at an earlier Finance and Performance Committee meeting;

The Finance and Performance Committee agenda has been divided between operational productivity items and financial business items;

The Committee received deep dive reviews into areas having operational difficulties which have not improved following implementation of improvement measures;

The Committee receives regular updates on performance of savings schemes, Trust cash levels and key financial risks. The Committee also comments on the performance of mitigating measures and advise on business opportunities;

The internal, external financial climate and the increased demand with limited capacity constraints and possible solutions are regularly discussed;

The adequacy of the Trust’s governance and risk management systems and processes are also subject to the scrutiny of the Audit Committee through internal and external audit, and are informed by other regulatory and accreditation bodies including but not limited to those listed in the terms of reference;

The Chair of Committee submits a written report to the Board to highlight key issues discussed at each Finance and Performance Committee meeting; and

The work plan was adjusted to allow for the approval of the quarterly submission to Monitor and the new ‘deep dive’ items were added based on recommendations from the PwC Governance Review.

3

5. Annual Work Plan 2015 – 2016

The annual work plan was revised and agreed in January 2016;

The ‘deep dives’ will focus on both financial and operational performance of the Trust;

The Committee is now held on a separate day to the Board of Directors meeting;

Updates on Contractual negotiations and review of commercial contracts will also be presented to the Committee. All items on the annual work plan for 2015 were presented to the Committee; and

The Committee regularly reviewed the Trust performance against the Monitors deficit level target which was a key metric for 2015/16 financial performance.

6. Unscheduled Committee Activities:

The Committee has continued to strengthen and broaden its activities to develop the way it leads finance and operational activities and ensures compliance with national guidelines;

As well as the items addressed as part of the work plan, a number of other items were brought to the attention of the Committee. These include:

o Referral to treatment back log issues; o Emergency department performing below national targets; o Increased pressure on Trust services with insufficient capacity to meet demand; o The Trust secures a Working Capital Facility of circa £98m through Monitor; o The Trust received one of financial support from various commission partners: and o Invoices disputes with NHS England regarding payment on some specialist.

7. Feeder Committees

The work of the Committee is supported by five feeder Trust Committees and Groups:

Operations Committee

Performance Improvement Group

Divisional Monthly Performance Meetings

Capital Estates and Facilities Group

Business Continuity Group

8. Attendance at the Finance and Performance Committee

To be quorate the Finance Committee requires three members including at least one non-executive director and two executive directors from amongst the Chief Executive Officer(CEO), Chief Financial Officer (CFO) and Chief Operating Officer (COO). All the Finance and Performance Committee meetings for 2015/16 have been quorate.

4

9. Individual Attendance from April 2015 to March 2016

Finance and Performance Committee

Attendance Rate (out of twelve

scheduled meetings per year )

Membership Status

CURRENT MEMBERSHIP

Chris Stooke Non-Executive Director

9/12 Member, Chair

Lord Bob Kerslake (Non-Executive Director, Trust Chair)

11/12 Member From 01/04/2015

Sue Slipman Non-Executive Director

9/12 Member

Nick Moberly (Chief Executive)

4/4 Member From 02/11/2015

Colin Gentile (Chief Financial Officer)

3/3 Member From 02/01/2016

Jeremy Tozer (Interim Chief Operating Officer)

10/12 Member From 23/03/2015 To 31/03/2016

Prof Julia Wendon (Medical Director)

4/5 Member From 02/11/2015

Dr. Geraldine Walters Director of Nursing & Midwifery

12/12 Member

Judith Seddon (Interim Director of Corporate Affairs)

5/5 Member from 02/11/2015

Alan Goldsman (Interim Chief Financial Officer until 01/02/2016, currently Acting Director of Strategy)

6/8 Member from 15/08/2015

Ahmad Toumadj (Interim Director of Capital, Estates & Facilities)

10/12 Member From 02/03/2015

Dawn Brodrick (Director of Workforce Development)

5/5 Member From 05/10/2015

Simon Dixon (Director of Finance)

9/12 Member

Nanda Ratnavel (Public Governor)

2/3 Observer From 14/01/2016

Trudi Kemp (Director of Strategic Development)

Member on extended medical leave 16/12/2015

FORMER MEMBERS

Graham Meek Non-Executive Director

6/8 Member, Chair until 30/11/2015 (Resigned)

Prof Ghulam Mufti (Non-Executive Director, Committee Chair)

5/9 Member until 14/01/2016 Change of ToR

Faith Boardman (Non-Executive Director)

6/9 until 14/01/2016 Change of ToR

5

Tim Smart Chief Executive

Member until 16/11/2015 Resigned following extended sick leave

Simon Taylor Chief Financial Officer

3/4 Member until 20/08/2015 (Resigned)

Roland Sinker Interim Chief Executive Officer

6/7 Member Until 01/11/2015 (Resigned)

Dr Michael Marrinan Medical Director

4/6 Member until 31/10/2015 (Resigned)

Jane Walters Director of Corporate Affairs

5/6 Member until 31/10/2015 (Resigned)

Angela Huxham Director of Workforce Development

3/3 Member until 20/07/2015 (Resigned)

Steve Leivers (Interim Director of Transformation and Turnaround)

4/9 Member until 31/12/2015

Paul Jones (Interim Director of Workforce Development)

2/2 Member until 30/09/2015

Dr Paul Donohoe (Interim Medical Director)

1/1 Member until 30/10/2015

10. Conclusion

The Finance and Performance Committee continues to function as a Committee to the Board of Directors overseeing the Trust Financial and Operational performance. The revised Terms of Reference and Work Plan for 2016 are presented for approval and ratification.

11. Recommendations The Committee is asked to:

Note the committee annual report;

Make recommendations for any changes to the terms of reference it thinks are necessary; and

Recommend that the Board receive and endorse the annual report and updated Terms of Reference and that all documents are approved.

6

BOARD OF DIRECTORS FINANCE AND PERFORMANCE COMMITTEE

TERMS OF REFERENCE

Name of Committee Finance and Performance Committee

Chair Chris Stooke, Non-Executive Director

Executive Leads Chief Financial Officer & Chief Operating Officer

Secretary Corporate Governance Officer

Membership All Executive Directors, Director of Finance, and three Non-Executive Directors

Quorum Three members including at least one non-executive director and two executive directors from amongst the CEO, CFO and COO.

Frequency of meetings Monthly

Overall Purpose To monitor monthly finance, operational and quality performance of the Trust.

Provide assurance to the Board of compliance against Monitor governance and financial risk ratings.

Terms of Reference 1. Monitor the Trust’s Balanced Scorecard and other Trust-wide performance issues, be made aware of the key current performance issues and any indicators where there is a downward trend in performance, and receive assurance that actions are being taken to bring performance back on target.

2. Regularly review the Trust’s performance against the Care

Quality Commissions’ Annual Health Check assessment criteria and plans to address any adverse performance.

3. Receive reports from Divisions on strategy, operational, quality and financial performance against Trust’s KPIs, including plans to address any key performance issues.

4. Review Trust performance against Monitor governance and finance risk ratings prior to submission to the Board, including the Annual Plan and quarterly submissions to Monitor.

5. 6. Approval of the Quarterly Monitor Submissions on behalf of the

Board of directors with provision that if there is significant variance/exceptions in the submissions, the submission would be sent by email to the full board for comment and approval.

7.

8. To review the following financial areas:

Appendix1

Finance and Performance Committee Terms of Reference

7

- Financial Budgets - Financial Statements - Outline Capital Programme - Delegated limits - Financial Strategy - Working Capital Requirements - Projected and Actual Cash Flow - Use and availability of working capital facilities - Aged debtors and creditors - Capital Programme and major variances - Resource Implications of Risk Assessments from the Quality and Governance Committee - Full year and medium term forecasts - Funding requirements - Borrowing requirements - Income and Expenditure - Balance Sheet position

- CIP Updates including RAG rated proposals 9. To address any other matters arising to do with the Trust’s

Finance and Performance.

Reports to

Board of Directors

Receives reports from

Reports from all Reporting Committees are incorporated into the monthly Performance Report.

Reporting Committees Operations Committee Performance Improvement Group Divisional Monthly Performance Meetings Capital Estates and Facilities Group Business Continuity Group Continuity Planning and Disaster Recovery

8

Appendix 2

Finance and Performance Committee Annual Plan

Finance and Performance Committee Meeting Dates

26

/01

/201

6

23

/02

/216

22

/03

/201

6

26

/04

/201

6

26

/05

/201

6

28

/06

/201

6

26

/07

/201

6

23

/08

/201

6

26

/09

/201

6

25

/10

/201

6

28

/11

/201

6

20

/12

/201

6

Standing Items

Minutes

Action Tracker/Matters Arising

For report /Discussion

Finance Report

Monitoring operational performance (formerly the performance report )

Referral To Treatment backlog

Monitoring Operational performance (ED)

Cancer Targets and Performance

Additional Agenda Items

Performance Trends*

Financial Trends** Revenue Budget & Financial Plan

Update on Contractual negotiations with Commissioners

CIPs Planning 2016/17

Financial Recovery Plan CIP performance Reports from Investment Board

Managed Services update PFI review

Viapath Quarterly Review

Sainsbury’s contractual review

9

CIPs Planning 2017/18

Carbon Reduction update For Approval

Quarterly Monitor submission

Schedule of Assurance 2015 (part of annual plan submission)

Committee Administration

Terms of reference Annual committee Review

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Report to: Board of Directors

Date of meeting: 06 July 2016

Subject: Committee Annual Review

Author(s): Judith Seddon, Interim Director of Corporate Affairs

Prof Ghulam Mufti, Committee Chair

Presented by: Judith Seddon, Interim Director of Corporate Affairs

Prof Ghulam Mufti, Committee Chair

Sponsor: Prof Ghulam Mufti, Committee Chair

History: Previously considered by the Quality & Governance Committee

Status: For Information and Approval

1. Summary of Report This report includes the Annual Review of 2015-16 for the Quality and Governance Committee, as well as the amended Terms of Reference (ToR) and updated Work Plan for 2016-17. Amendments were made to the membership list and the frequency of the meetings within the ToR and there have minor amendments made to the Annual Work Plan, which include the addition of an End of Life Care Annual Report and updates of the implementation of the Trust’s CQC Action Plan. The changes were approved by the Quality and Governance Committee at its meeting on Tuesday, 28 July 2016, but the Committee felt that there would be an opportunity to revisit the membership once the senior divisional management structure was in place. This would build in ownership and accountability at the Divisional level. 2. Action required The Board is asked to:

Note the Committee Annual Review

Approve the changes to the ToR and Annual Work Plan

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Quality & Governance Committee Annual Report & Self-Assessment

01 April 2015 – 31 March 2016

Introduction In line with the Trust’s model of distributed governance, the seven sub-committees of the Board are jointly charged with providing assurance that the Trust is compliant with relevant external regulatory bodies and statutory requirements. The Quality and Governance Committee (QGC) is also responsible for reviewing trends and key risks arising from incidents, claims and complaints and monitoring performance and compliance against the NHS Risk Management Standards, CQC essential standards/outcomes, National Audits and NICE guidance. This report is part of monitoring the effectiveness of the Quality and Governance Committee as described in its Terms of Reference. To ensure systematic review of all elements of quality and governance the annual work plan continues to form a major part of the committee activities with a particular focus on the three quality domains of patient safety, patient outcomes and patient experience together with organisational safety.

To coincide with the Trust’s financial reporting cycle the Committee’s annual report covers the period from April 2015 to March 2016. During this time the Committee met eight times and this report summarises those meetings and the work of the Quality and Governance Committee.

Terms of Reference The Quality and Governance Committee has specific responsibility for monitoring the effectiveness of governance and risk management structures and systems as detailed in the Trust’s Risk Management Strategy and Board Assurance Framework Policy. The Committee have reconsidered the structure, remit and reporting methodology of the Quality and Governance Committee during this reporting period. The revised Terms of Reference with tracked changes is attached in appendix 1.

Following the recommendation from the PwC Governance Review the membership of the Committee was updated, an organisational chart is included and the terms of reference was reviewed to achieve compliance with NHSLA standards. The following key revisions were incorporated in the Terms of Reference: Membership:

An additional NED with clinical experience has been added;

NED attendance at subcommittees of the Board was reviewed. A NED chairs the Committee with two other NED attendees in line with their areas of focus where appropriate;

There is continued representation from the Trust’s commissioners in Southwark and Bromley;

A Governor representative have been added observer NEDs in action;

Enc. 6.5.3

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A full list of membership can be found in the Committee terms of reference (ToR) in Appendix 1 attached to this report.

Remit and Reporting Methodology:

Since January 2016, meetings are now scheduled every month and a record of attendance is maintained;

There continues to be a standing item at every Board of Directors meeting to receive the minutes from Board Committee meetings, including Quality and Governance;

The Board also receives a number of the reports discussed in more detail at an earlier QGC meeting;

In addition, the quarterly Quality and Governance report is circulated to commissioners and it is reviewed at the regular Clinical Quality and Review Group meetings;

The QGC agenda has been divided between standing items, quality, governance and risk headings;

The structure of the risk register has been improved to enable effective discussion;

The executive summary has been refined so it guides the reader of the report to the key points;

A target risk score after mitigating actions and comments on the impact mitigating actions are having are under development;

The Trust will review the risk register for completeness and add details as to at which committees risks should be considered following the divisional restructuring;

There are now ‘deep dive’ sessions at every QGC meeting and divisions are invited to present at these sessions;

The risk register and the Board Assurance Framework (BAF) are actively and regularly discussed by the Board to assess the effectiveness of the management of risks;

The adequacy of the Trust’s governance and risk management systems and processes are also subject to the scrutiny of the Audit Committee through internal and external audit, and are informed by other regulatory and accreditation bodies including but not limited to those listed in the terms of reference; and

The Chair of Committee submits a written report to the Board to highlight key issues and risks discussed at each QGC meeting.

Annual Work Plan 2015 – 2016

The annual work plan was revised and agreed in January 2016;

The work plan was adjusted to allow for monthly meeting of the Committee and new ‘deep dives’ items were added accepting the recommendations of the PwC Governance Review;

Enc. 6.5.3

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The work plan (appendix 2) was further adjusted for 2015/2016 to allow segregation of quality and governance focus areas;

In addition to quality and patient experience, ‘deep dives’ to focus on performance of the quality priorities have also been added to the work plan;

Patient Video Stories item have been removed from the work plan following the recommendation of the PwC Governance Review. The patient video story is now incorporated into the Public Board workplan;

End of Life Care annual report and implementing the Trust’s CQC Action Plan have been added as a new items on the workplan; and

All the items on the Annual Work Plan 2015 have been presented to the Committee with the exception of:

Patient Video Story Removal from Work Plan approved by the Board from September 2015

BAF Policy Review Deferred, work still in progress

Risk Management Strategy Deferred, work still in progress

Unscheduled Committee Activities:

The committee has continued to strengthen and broaden its activities to develop the way it leads quality and governance activities and ensures compliance with national standards.

As well as the items addressed as part of the work plan, a number of other items have been brought to the attention of the committee. This includes:

o Medical Records at the PRUH o Ophthalmology Service Review o Clinical Deep Dive: Managing Challenging Patients o Nurse Revalidation Update

Feeder Committees The work of the Committee is supported by four feeder committees:

Patient Safety Committee, chaired by Medical Director;

Patient Outcomes Committee, chaired by Director of Nursing and Midwifery & DIPC;

Patient Experience Committee, chaired by Director of Corporate Affairs; and

Organisational Safety Committee, chaired by the Chief Operating Officer.

Whether monthly, bi-monthly or quarterly, the minutes of all feeder committee meetings are received by the Quality & Governance Committee for information. Attendance at the Quality & Governance Committee

To be quorate the Quality and Governance Committee needs a minimum of 5 members including at least one non-executive and two executive directors. All the Quality and Governance Committee meetings for 2015/16 have been quorate.

Enc. 6.5.3

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Individuals should attend a minimum of 25% of the scheduled meetings. No current member of the Quality and Governance Committee attended less than 25% of the meetings in 2015/16.

Individual attendance for April 2015 – March 2016 is as follows:

Quality & Governance Committee Members Attendance Rate (out of six scheduled meetings per year )

Membership Status

Prof Ghulam Mufti (Non-Executive Director, Committee Chair)

6/6 Member

Lord Bob Kerslake (Non-Executive Director, Trust Chair)

4/5 Member From 01/04/2015

Faith Boardman (Non-Executive Director)

6/6 Member

Prof Jon Cohen (Non-Executive Director)

3/3 Member From 01/09/2015

Nick Moberly (NM) (Chief Executive)

2/3 Member From 02/11/2015

Jeremy Tozer (Interim Chief Operating Officer)

4/5 Member From 23/03/2015

Prof Julia Wendon (Medical Director)

3/3 Member From 02/11/2015

Dr. Geraldine Walters Director of Nursing & Midwifery

5/6 Member

Judith Seddon (Interim Director of Corporate Affairs)

5/6 Member 02/11/2015

Alans Goldsman (Acting Director of Strategy)

3/3 Member

Ahmad Toumadj (Interim Director of Capital, Estates & Facilities)

4/4 Member From 02/03/2015

Jacquie Foster (Head of Governance and OD at NHS Southwark CCG)

3/6 Member

Sonia Colwill (Director of Quality, Governance & Patient Safety at Bromley, CCG)

3/6 Member

Colin Gentile (Chief Financial Officer)

1/2 Member From 02/01/2016

Dawn Brodrick (Director of Workforce Development)

2/3 Member From 05/10/2015

Trudi Kemp (Director of Strategic Development)

1/5 Member

Tom Duffy (Patient Governor)

1/2 Observer From 14/01/2016

Graham Meek Non-Executive Director

2/3 Member Until 30/11/2015 (Resigned)

Sue Slipman Non-Executive Director

3/3 Member Until 14/01/2016 Change in ToR

Chris Stooke Non-Executive Director

0/3 Member Until 14/01/2016 Change of ToR

Enc. 6.5.3

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Tim Smart Chief Executive

1/1 Member Until 16/11/2015 (Resigned)

Simon Taylor Chief Financial Officer

2/3 Member Until 20/08/2015 (Resigned)

Roland Sinker Chief Operating Officer

3/3 Member Until 01/11/2015 (Resigned)

Dr Michael Marrinan Medical Director

3/3 Member Until 31/10/2015 (Resigned)

Jane Walters Director of Corporate Affairs

3/3 Member Until 31/10/2015 (Resigned)

Angela Huxham Director of Workforce Development

3/3 Member Until 20/07/2015 (Resigned)

Marc Meryon Non-Executive Director

1/1 Member Until 20/07/2015 (Resigned)

Conclusion The Quality and Governance Committee continues to function as a Committee to the Board of Directors overseeing the Trust arrangements for quality and governance. The revised Terms of Reference and Work Plan for 2016 are presented for approval and ratification.

Enc. 6.5.3

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Committee Name

QUALITY AND GOVERNANCE COMMITTEE

Chair Non-Executive Director

Executive Leads Medical Director

Director of Nursing & Midwifery

Director of Corporate Affairs

Secretary Corporate Governance Officer

Membership 4 Non-Executive Directors

All Executives

Associate Director of Governance

NHS Southwark Clinical Commissioning Group representatives

NHS Bromley Clinical Commissioning Group representatives

Frequency of Meetings:

Monthly

Quorum 5 members including at least one Non-executive and two Executive Director.

Members are required to attend a minimum of 6 meetings within a 12 month period.

Main Purpose of Committee

To provide assurance to the Board on all aspects of quality and governance. To review performance against the three dimensions of quality:

Patient Safety Patient Experience Patient Outcomes

And Organisational safety Information governance. Compliance with a range of external regulatory bodies

Through the quality and governance reporting framework, to monitor compliance with and the Care Quality Commission’s Fundamental Standards complementing the role of the Finance & Performance Committee and provide assurance to the Board. To review the Self Certification Statements and Annual Plan and compliance with Corporate Governance Statements prior to consideration by the Board of Directors. To monitor progress against the priorities outlined within the Quality Accounts.

Terms of Reference

1. To provide assurance to the Board by reviewing performance and monitoring compliance with the regulatory requirements and national standards set down by external regulatory bodies including but not limited to the following:

Quality & Governance Committee Terms of Reference Appendix1

Enc. 6.5.3

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Care Quality Commission Fundamental Standard

Health Service Ombudsman investigations

National Patient Safety Agency/ NHS England

Human Tissue Authority

Medicines & Healthcare Products Regulatory Authority

Health & Safety Executive.

2. To ensure the Trust has in place trust-wide integrated risk management processes and systems which enable reactive and proactive risk identification.

3. To act in accordance with the Trust’s Board Assurance Framework Policy by undertaking the systematic review of major risks assessed as red and amber identified via the Trust’s risk register and to consider the adequacy of controls, action plans and sources of assurance. To make recommendations to the Board of Directors on the acceptance or non-acceptance of risks and the escalation of risks onto the corporate risk register.

4. To review the annual Self Certification Statements and Annual Plan including compliance with Monitor’ Quality Governance Framework considering/identifying any associated risks and making recommendations to the Board of Directors as appropriate.

5. Through the Patient Outcomes, Patient Safety, Patient Experience

and Operational Safety committees and the Information Governance Steering Group to monitor and consider: i) Patient Outcomes Reports on patient clinical outcomes including mortality

Delivery of clinical effectiveness objectives

Evidence of the effective implementation of clinical good practice, recommendations arising from national confidential enquiries, NICE guidelines

Participation in national and local audits and other national reports

To monitor progress against patient outcome quality priorities outlined in the Trust’s Quality Accounts

ii) Patient Safety Trends arising from incidents/near misses, claims, complaints

reports on a quarterly basis or more frequently if required.

To receive detailed reports on patient safety and the management of risks within maternity and other services.

The findings of investigations into serious incidents/events making additional recommendations as appropriate.

To receive progress reports against agreed action plans ensuring that the action taken is adequate and timely.

To ensure that findings, recommendations and actions are systematically reported to the Board.

To monitor progress against the patient safety quality priorities

Enc. 6.5.3

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iii) Organisational Safety All aspects of Health and Safety

Safeguarding Children and Vulnerable Adults

Mandatory training

Business Continuity & Emergency Preparedness

iv) Patient Experience Quarterly integrated reports on patient experience including trends

arising from patient surveys, complaints and PALS and the Trust’s patient experience indicators

Evidence of compliance against national requirements for delivering Same Sex Accommodation

Foundation Trust membership strategy and Involvement

Patient & Public Involvement Strategy

Implementation of the End of Life Care project

Across the core components of the framework to ensure that appropriate action is taken to address significant/serious issues in order to mitigate/reduce the risk to patients, staff and the Trust and deliver improvements in patient outcomes, patient safety and experience and operational safety

To monitor progress against the key patient experience quality priorities outlined

6. Information Governance receive reports from the Information Governance Steering Group on: Progress in meeting the requirements of the Information

Governance Toolkit

Compliance with the Records Management NHS Code of Practice

The implementation of Information Lifecycle Management and the underpinning processes, policies, practices and tools to ensure the Trust has in place an appropriate infrastructure for retaining information.

Caldicott Guardian report on key issues

7. Other regular reports: To receive regular quality reports on the following: Nursing Performance Report

Annual Infection Control Report

Quarterly DIPC report

Safeguarding Children’s & Adults Reports

Review of latest CQC Intelligent Monitoring Reports

8. To report to the Board on the effectiveness of the Trust’s Quality and Governance arrangements and make recommendations as necessary. To undertake a Committee Self Assessment of the effectiveness of the committee’s governance arrangements together with an annual report of

Enc. 6.5.3

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the work of the committee to be submitted to the Board of Directors annually. The terms of reference will be reviewed annually.

Reporting Committees

Patient Outcomes Committee Patient Safety Committee Organisational Safety Committee Patient Experience Committee Information Governance Steering Group

Enc. 6.5.3

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Meeting Dates & Times

14

/01

/20

16

23

/02

/20

16

17

/03

/20

16

26

/04

/20

16

11

/05

/20

16

28

/06

/20

16

26

/07

/20

16

16

/09

/20

16

25

/10

/20

16

28

/11

/20

16

08

/12

/20

16

Items

DEEP DIVES:

Quality Priorities Deep Dives:

Maximising King's contribution towards preventing disease e.g. alcohol and smoking/ Preventing Ill Health

√

Improving the care of patients with hip fracture - NoF √

Improving experience and coordination of discharge √

Improving the experience of cancer patients √

Medication Safety/ Medication Error √

Safer Surgery/ Surgical Safety √

Other Deep Dives: CQC Mortality Outlier & SHMI Reports - key findings √

National Emergency Laparotomy Audit √

Deteriorating Patients √ √

Surgical Never Events √

DIPC - CRE Prevalence √

Quality & Governance Committee Work-Plan 2016 Appendix 2

Enc. 6.5.3

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Ophthalmology √

Maternal Deaths - Findings √

National Audit Programme and CQC Use √

Dental √

Patient Outcomes - A Strategic Look √

PATIENT & QUALITY FOCUS

National Survey - Emergency & Elective Inpatients Sep2014-Feb2015/ (the CQC national inpatient survey )

√

National Survey - Children & Young People Daycase and Inpatient Oct2014-Feb2015 (summary report for info. only)

√

National Survey - Maternity Survey Results Apr-Aug 2015 (expected publication Dec 2015)

√

2013/14 National Cancer Survey Results Update & Improvements

√

Patient Falls (frequency of repeat falls & comparison to peer group hospitals)

date to be confirmed

Performance against Francis Report Recommendation √

GOVERNANCE FOCUS

Implementing the Trust's CQC Action Plan √ √ √

Nurses Revalidation Report √ √

Enc. 6.5.3

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Doctors Revalidation Report √ √

Caldicott Guardian √

FOR REPORT/DISCUSSION

Quarterly Patient Safety √ √ √

Quarterly Patient Outcomes √ √ √

Quarterly Patient Experience √ √ √

Quarterly Organisational safety √ √ √

Quarterly BAF Review √ √ √ √

BAF Policy Review - Annual √

Risk Management Strategy √ √

Corporate & Divisional Risk Register - Quarterly, as at xx xx xx

√ √ √ √

Quality Priorities 2016/17 √

Update on Quality Priorities √

Draft Quality Accounts √

DIPC Report - Quarterly √ √ √ √

Nursing Performance Report - Quality Issues √ √ √ √ √

Enc. 6.5.3

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Compliance Certification - Self-Certification against Annual Plan Board Statements

√

Safeguarding Adults Report (interim and annual report) √ √

Safeguarding Children Report (interim and annual report) √ √

Information Governance Report and Strategy √

Infection Control Annual Report √

End of Life Care Annual Report √

Annual Complaints Report 2015/16 √

CQC Intelligent Monitoring Report as and when published

COMMITTEE ADMINISTRATION

Committee Annual Report - Approval √

QGC Self-Assessment √

QGC Terms of Reference √

QGC WorkPlan √

FOR INFORMATION

Sub-Committee Minutes

Enc. 6.5.3

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Patient Safety √ √ √ √ √ √ √ √ √ √ √

Patient Experience Committee √ √ √ √ √ √ √ √ √ √ √

Patient Outcomes Committee √ √ √ √ √ √ √ √ √ √ √

Organisational Safety Committee √ √ √ √ √ √ √ √ √ √ √

Information Governance Steering Group √ √ √ √ √ √ √ √ √ √ √

Enc. 2.1

1

Report to: Board of Directors

Date of report: 16 May 2016 to 24 June 2016

Subject: Chair’s and Non-Executive Directors’ Activity Report

Presented by: Lord Kerslake, Chairman

Status: For information

1. Background/ Purpose This report details the activities undertaken by the Non-Executive Directors of the Board for the period from Monday 16th May to Friday 24th June 2016. 2. Action required The Board of Directors is asked to note the contents of this report.

Lord Kerslake - Chairman

Date Activity

23 May Attended Audit Committee Meeting

26 May

Chaired Finance & Performance Committee Meeting Attended second half of Audit Committee Meeting Chaired Public Board Meeting

3 June Held meeting to discuss Board forward plan

8 June Director of Nursing Shortlisting

15 June

Attended Audit Committee Meeting Hosted dinner for Non-Executive Directors

16 June Undertook Erik Nordkamp’s appraisal

17 June

Chaired Private Board Meeting (FRP/CIP Focus) Attended Private Board Meeting (Strategy Focus)

Enc. 2.1

2

21 June Director of Nursing Interviews

23 June Attended KCH/KHP Joint Governor Event

Jon Cohen – Non-Executive Director, Lead for Improving Quality of Patient Care Date Activity

1 June

Attended Public Board Meeting Go See Visit – PRUH Attended Private Board Meeting

8 June Director of Nursing Shortlisting – via telephone

21 June Director of Nursing Panel Interviews

22 June Tel & email discussions with HR concerning an excluded doctor

Alix Pryde – Non Executive Director, Chair of Audit Committee, Lead for Move to Operational Sustainability

Date Activity

20 May Call with External Auditor, Deloitte

23 May

Chaired Audit Committee Meeting

26 May

Chaired Audit Committee Meeting Attended Public Board Meeting

1 June

Conducted tour of the physical security system at the PRUH with the Interim Director of Capital, Estates and Facilities Attended Public Board Meeting Conducted Go See visit to the PRUH NICU Attended Private Board Meeting Attended longlist meeting for recruitment of Director of Transformation & IT

Enc. 2.1

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3 June Attended Audit Committee pre-meet with Board Secretary

15 June

Chaired Audit Committee Attended shortlist meeting for recruitment of Director of Transformation & IT Attended Chair’s/NEDs’ dinner

17 June

Attended Private Board Meeting (FRP/CIP Focus) Attended Private Board Meeting (Strategy Focus)

22 June Attended longlist meeting for recruitment of Director of Communications

23 June Attended interview panel for recruitment of Director of Transformation & IT

Chris Stooke – Non Executive Director, Chair Finance and Performance Committee, Lead for Delivering Financial Plans

Date Activity

23 May Attended Audit Committee Meeting

1 June Attended Public Board Meeting Go See Visit – Pathology at PRUH Attended Private Board Meeting

3 June KCH Charity Meeting

6 June Attended Efficiency Board Meeting

9 June KCH Charity Meeting

15 June Attended Chair’s/NEDs’ Dinner

17 June Attended Private Board Meeting (FRP/CIP Focus) Attended Private Board Meeting (Strategy Focus)

20 June Attended Efficiency Board Meeting

Enc. 2.1

4

Faith Boardman – Non-Executive Director, Chair of Education Workforce and Development Committee, Lead for Organisational Development

Date Activity

23 May

Attended Audit Committee

26 May

Attended Audit Committee Chaired Education and Workforce Committee

30 May Annual leave

15 June Attended Audit Committee

21 June

Interview panel for Director of Nursing

24 June Interview panel for long-list of architect bids for site master-planning.

28 June Attended Quality and Governance Committee

30 June Attended Remuneration Committee

Sue Slipman – Non Executive Director, Deputy Trust Cahir, Chair of Private Board Strategy Focus, Lead for Trust Strategy

Enc. 2.1

5

Date Activity

26 May

Attended Finance & Performance Committee Meeting Attended Private Board Meeting

1 June

Chaired Public Board Meeting Undertook Go See visit to Radiology Chaired Private Board Meeting

3 June Met with Toby Lambert re. agenda for Strategy Board

15 June Attended Chair’s/NEDs’ Dinner

17 June

Attended Private Board Meeting (FRP/CIP Focus) Chaired Private Board Meeting (Strategy Focus)

Professor Ghulam Mufti – Non Executive Director, Chair of Quality and Governance Committee, Lead of Trust Strategy (KHP)

Date Activity

26 May

Attended Public Board Meeting Attended Educational & Workforce Development Committee Meeting

1 June

Attended Public Board Meeting Go See Visit Attended Private Board Meeting

17 June

Attended Private Board Meeting (FRP/CIP Focus) Attended Private Board Meeting (Strategy Focus)

Erik Nordkamp – Non Executive Director, Cahir of Commercial Services Board , Lead for Commercial Services

Enc. 2.1

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Date Activity

25 May Call with Ali Raza, HR concerning Interviews for Consultant Urology

26 May

Attended Board Public Meeting

Chaired Interview Panel for Consultant, Urology

1 June

Met with Nick Moberly

Attended Public Board Meeting

Attended ‘Go See Visits’

Attended Private Board Meeting

3 June

Call with Toby Lambert

Call with Simon Taylor & Richard Miller

14 June

Attended dinner with Mark Combes, Ashmore and Simon Taylor and Lord

Kerslake

16 June Attended KCH NED Annual Appraisal with Lord Kerslake

17 June

Attended Kings Private Board Meeting (FRP / CIP Focus)

Attended Private Board Meeting (Strategy Focus)

Enc. 6.7.1

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King’s College Hospital NHS Foundation Trust - Finance & Performance Committee Minutes of the meeting of the Finance & Performance Committee held at 09:00-11:00 on Thursday, 26 May 2016 in the Dulwich Committee Room, Denmark Hill.

Present:

Lord Kerslake (BK) Trust Chair/ Committee Chair

Sue Slipman (SS) Non-Executive Director/ Deputy Trust Chair

Nick Moberly (NM) Chief Executive Officer

Colin Gentile (CG) Chief Financial Officer

Jane Farrell (JF) Chief Operating Officer

Geraldine Walters (GW) Director of Nursing and Midwifery

Julia Wendon (JW) Medical Director

Dawn Brodrick (DB) Director of Workforce and Development

Ahmad Toumadj (AT) Interim Director of Capital Estates and Facilities

In attendance:

Simon Dixon (SD) Director of Finance

Jane Badejoko (JB) Corporate Governance Officer (Minutes)

Sue Filed (SF) Head of Capacity and Service Development (Item 2.2 only)

Anne Wood Divisional manager in Ambulatory Care and Local Networks (item 2.3 only)

Phillip Burns (PB) Director of Turnaround ( item 3.1 only)

Nanda Ratnaval (NR) Public Governor Observer

Apologies:

Trudi Kemp (TK) Director of Strategic Development

Chris Stooke (CS) Non-Executive Director

Judith Seddon (JS) Acting Director of Corporate Affairs

Toby lambert (TL) Interim Director of Strategy

Item Subject Action

016/56 Apologies

Apologies for absences were noted.

016/57 Declarations of Interest There were no declarations of interest reported.

016/58 Chair’s Actions/ Updates There were no actions to report.

Enc. 6.7.1

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Item Subject Action

016/59 Minutes of the Previous Meeting The minutes of the meeting held on 26 April 2016 were approved as a correct record.

016/60 Action Tracker/ Matters Arising

The Committee agreed the proposed deferral of some items on the action tracker.

TOP PRODUCTIVITY

016/61 Monitoring Operational Performance – Month 01 The Committee received and discussed the performance report for month 01. The following key points were reported:

Trust emergency department (ED) performance against the 4-hour target improved from 81.11% reported in March to 83.48% in April. This is still short of the 95% national target but, it is above the ED improvement trajectory agreed with commissioners;

Unconfirmed performance metrics indicated there will be further improvement in ED performance in May;

The Princess Royal University Hospital (PRUH) closed all its wards at the end of March leading into April due to Norovirus infection outbreak. The PRUH has since reopened some of its wards to admission, but 6 bays remain closed;

Operational arrangement at the PRUH are strengthened and team leadership and responsibility has refreshed to provide a clear escalation lines;

Bromley Clinical Commissioning Group (CCG) commissioned an extensive review of the operational performance of the transfer of care bureau (TCB). There was evidences that the TCB achieved some positive results in increasing bed capacity and improved discharge process at the PRUH, but the results were short of expectation;

The TCB brought together hospital, community and social care teams at a single geographical location to facility better inter-organisation relationships which was a positive step, however with no pathway redesign the results have disappointing.

The leadership of the TCB has not been as effective as it could be. There is need to review the leadership structure accompanied by clarification on accountability and strategic objectives for all partners;

Dr Angela Bhan, Chief Officer for Bromley CCG is aware of the difficulties and is committed to reforming the pathway and refreshing the functionality of the bureau based on the recommendations in the review;

The presentation of the review results of the TCB will be at an event on 10 June, all partner organisations will be present to receive the results;

The Trust is exploring an alternative way to provide care to elderly patients with proposals to create a ‘Frailty Ward’ which will decrease the amount of time elderly patient spend between presenting at accident and emergency (A&E) and through to receiving appropriate care;

Enc. 6.7.1

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Item Subject

Action

The Trust is preparing a business case with appropriate costing for the project. This project has the potential create additional bed capacity across the 3 major sites of the Trust’s sites;

The Trust achieved the 62-day cancer target treatment for the sixth month in a role. Attaining this target is proving more tasking as the pathway is at capacity. The 2 week-wait symptomatic breast cancer referrals target was not achieved in April, there are measure in place to improve performance; and

The Trust’ referral to treatment (RTT) performance is in line with recovery plan trajectories. Regulators have requested the Trust improve its trajectories but due to ongoing operational pressure the Trust is unable to provide an earlier proposed completion date.

The following key points were discussed:

The proposal to create a frailty ward and an additional 65 bed capacity spread across Denmark Hill (DH), PRUH and Orpington sites is promising. Orpington will have 40 new beds to take on some of the capacity from the DH and the PRUH;

There are frailty networks nationally and the unit will link into the existing networks. The unit will support the discharge and admission process and should relieve pressure from ED and provide specialist care to the elderly. The project is about strengthening services and providing additional capacity which is also in line with Bromley CCG service delivery goals;

The Trust is currently running a detailed demand and capacity review to ascertain the correct picture of capacity pressures in the organisation;

The Trust should explore the actual factors responsible t for the improved ED performance as it was noted that attendance to ED has reduced. As there is likely a direct correlation between improved ED performance and a reduced number of patients; and

The Trust will need to review Orpington staffing levels if the frailty project is approved and funded. Targeted recruitment projects are underway to improve vacancy levels at the PRUH.

The Committee will receive a deep dive into diagnostic screening at its June meeting.

JF

016/62 RTT Deep Dive Update

The Committee received an update report on referral to treatment (RTT). The following key points were reported:

The Trust presented its planned completion trajectories to regulators and commissioning partners. The Trust proposes to get to 92% completion of the backlog by December 2017 for non-neurosurgery patients. NHS London have requested the Trust review trajectories and provide an earlier completion date;

The Trust is unable to sign up to or agree an earlier completion date due to capacity constraints and increased levels of demand;

The Trust is looking to improve and maximise productivity levels. The Trust began outsourcing neurosurgery backlog work in April;

Enc. 6.7.1

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Item Subject

Action

The Trust’s over 52 weeks waits have been divided into neurosurgery and non- neurosurgery cases. To reduce the level of 52 week patients additional capacity is required to address the backlog at each stage of the pathway. However, as the backlog in each stage is addressed it will increase the activity demand in the next stage;

There are currently 155 patients waiting over 52 weeks of which 77 are on an admitted pathway and 78 on non-admitted pathway. This is 30 patients ahead of planned trajectory and a reduction from 165 in March, and 182 in February. The reduction is in neurosurgery which is now ahead of trajectory;

At a recent Tripartite meeting a number of options proposed by the Trust and considered by commissioners, particularly relating to the largest element of the neurosurgery backlog which are: o The Trust started running a Saturday neurosurgery clinic with 60 patient capacity

per day, NHS England provided funding for a project to set up a South London neurosurgery pathway. This is should provide some relief to the high number of patient needing surgery; and

o There is an opportunity to create a catchment area pathway that will refer some

patients to St George hospital via catchment area referral.

The following key points were discussed:

The Trust needs to create capacity for neurosurgery at DH, this may include considering having no elective surgery at Denmark Hill (DH) and transfer of all inpatient elective non-tertiary surgeries from DH to the PRUH;

The outsourcing of service to the private sector funded by the local CCG on a case by case basis;

It was noted that 60% of the neurosurgery referral are form Kent and South East London having temporary catchment area restriction would provide short term relief and reduce the number of patients needing treatment at DH;

The Trust is also exploring the possible of being able to perform 3 procedures per day to provide further capacity; and

The Trust has a five point work stream RTT recovery plan which is in full implementation which includes staff training on the new patient tracking systems and looking at theatre efficiency.

016/63 Breast Symptomatic (M12 Report) Update The Committee received the Breast Symptomatic performance update report. The following key points were reported:

Historically Breast Symptomatic performance has been a consistent high performing services against the 2 week screening target. This target was not achieved in quarter 4 of 2015/16;

The service was affected by low staffing number due to staff long term sickness and a number of vacancies at the same time;

The service has also received a 22% increase in the number of breast referrals received across both sites between January and April with the numbers for January and April being particularly high;

Enc. 6.7.1

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Item Subject

Action

Temporary staff and newly appointed staff whom filled vacant positions in the services were appointed but they had training needs and some lacked deeper understanding of cancer booking sensitivities;

The Trust utilises two systems for patient referrals, tracking and recording, PIMS and PCS. It was identified that there was inadequate reconciliation between the two electronic patient records systems. This issue has now been resolved and the team is receiving support from the Trust’s business information unit;

Capacity in the team was reviewed and short term addition staffing support has been provided. The team have also been granted financial approval to engage an additional locum consultant to reduce waits; and

The Trust is currently processing referrals at 10-12 days, the optimum time frame is 5-7days and the team’s target.

The following key points were discussed:

The Trust needs to provide a better induction and training programme for new staff who will be working with time sensitive referrals that require bookings. Lessons have been learned and a robust training programme will be mandatory for all new staff;

The Trust must become better at forecasting and identifying what could be early signs of underlying issue in the system. There is also need to build resilience in the information available particular anything relating to the comprehensive dashboard; and

The service performance improved in April and early signs indicate that there will be further improvement in May.

SOUND FINANCES

016/64 2016/17 CIP Stock take The Committee received a progress update on the 2016/17 CIPs. The following key points were reported:

The size of the current CIPs gap is circa £15m of the £71m target for 2016/17. The £71m target is made up of £50m CIPs target for this year(2016/17) and £21m full year effect form 2015/16. There is prognosis that there will be a £5m slippage on the £21m target from last;

The CIPs target does not include mitigation measure planned for this year such as re- tender of Soft FM services and the buying back of leases;

The current identified schemes are further explored to ensure that the Trust can obtain full benefit from their implementation. Such as the potential benefit of providing a consolidated ophthalmology service;

The Trust is not exploring schemes related to bed closures due to its capacity constraints and overall bed shortage. The focus is on scheme that can improve productivity or generate a surplus on the tariff;

The following key points were discussed:

The Trust’s focus is on getting the big red ticket item into a green position. The CIPs programme is behind plan as it is almost the end of month 2 and there are still big chunks of schemes in the red and amber category; and

Enc. 6.7.1

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Item Subject

Action

The Trust should identify top 10 savings items for the year and have increased focus on their delivery.

016/65 Update on Budget Setting and Contract Negotiations The Committee received an update on the Trust’s budget setting and contractual negotiations for 2016/17. The following key points were reported:

The Trust has one outstanding contract which it is yet to finalise with NHS England. The points that are yet to be agreed are the Foetal Medicine specialist contact, which requires clarity on the review process. Hepatitis C, which will be national Commissioning for Quality and Innovation (CQUIN) for the year, has some ambiguity around success payment and more importantly the point that NHSE could withhold/clawback payment if this CQUIN is not successfully completed by all participating Trusts nationally; and

The Committee discussed the Trust’s contractual negotiations with NHSE, which have been aimed at clarifying all ambiguities to ensure all parties are agreeable on what is expected and what will be within the remit of the contract. This year clarity has been included on payment for over performance which were not previously.

016/66 Viapath Contractual Negotiations Update The Committee received an update on the ongoing contractual negotiations with Viapath. The following key points were reported:

The Trust has pushed Viapath to provide a larger return on the Trust’s investment and thereby delivering a CIPs schemes for the year;

The transfer of pathology services at the PRUH to Viapath will begin in July; and

Viapath is undergoing an internal review to ensure it can continue to provide a valuable and high quality services under the new leadership of David Bennett.

016/67 Finance Report – M01 The Committee receive month 1 finance report. The following key points were reported:

The Trust’s month 1 deficit was £10.2m, with an adverse variance of £4.7m against planned deficit figure of £5.5m;

Factors responsible for the variance are NHS clinical income variance of £1.9m which represents an activity under-performance of £3.6m and £1.7m off-tariff drugs over-performance. The activity under-performance relates to non-block contract income;

Month 1 position was also affected by the two days junior doctors industrial action and the Norovirus outbreak at the PRUH;

The Trusts cash position is very tight. The Trust has been granted a capital working facility equal in value to last year’s to support ongoing operational needs;

Enc. 6.7.1

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Item Subject Action

The Trust has been experiencing increased pressure from creditors on outstanding invoices. Some supplier had sent notice that they will cease delivery of service supplies if outstanding invoices were not settled; and The Trust has had to draw down £18m from its capital working facility for month 1 as oppose to £7m planned, to settle outstanding invoices. Regulators were informed of the Trust’s pressing needs prior to draw down.

The following key points were discussed:

The Trust must focus on CIPs delivery and performance efficiencies to ensure it can finish the year in line with regulators targets; and

The Trust allocated funding for the deep clean of the PRUH programme which is yet to be completed. This should be finalised at the first opportune moment. The Trust may also explore other alternatives to deep cleaning such as fogging.

The Committee will receive an update on the deep cleaning programme at the PRUH.

PT/GW

016/68 Any Other Business There were no items of any other business raised for discussion.

016/69 Date of Next Meeting Thursday 26 July 2016, 09:00-10:45 in the Dulwich Committee Room.

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