BOARD OF DIRECTORS

12th NOVEMBER 2014

Agenda

Meeting Title: Board of Directors

Date: Wednesday 12th November 2014 Time: 2.00pm

Venue: UCLH Charity Board Room, 5th Floor East Wing, 250 Euston Road Agenda item Attachment

1. Apologies for Absence and Declaration of Conflict of Interest

2. Minutes of the Meeting held on 10th September 2014

A

3.

Matters Arising Report B

4. Other urgent matters not appearing on the Matters Arising Report

5. Presentation: Junior Doctors’ Experience - Update Emma Taylor, Director of Postgraduate Medical Education to attend

6. Presentation: After Action Reviews Yogi Amin, Director of Culture Development, to attend

7. Chairman’s Report

C

8. Chief Executive’s Report

D

9. Executive Board Report

E

10. Performance Report

F

11. Quality & Safety Committee Reports – September and October

G.1 & G.2

12. Finance & Contracting Committee Report H

13. Report of the Audit Committee Meeting held on 22nd September

I

14. Minutes of the Audit Committee Meeting held on 24th July J

15. Any Other Urgent Business

16. Date of Next Meeting

Wednesday 10th December 2014 at 2.00pm

A

Agenda Item 2

Minutes of the Meeting held on

10th September 2014

Board of Directors Minutes of the Meeting held on 10th September 2014 at 2.00pm

Present Richard Murley, Chairman Alasdair Breckenridge, Non-Executive Director Harry Bush, Vice-Chairman Rima Makarem, Non-Executive Director Kieran Murphy, Non-Executive Director John Tooke, Non-Executive Director Diana Walford, Non-Executive Director Richard Alexander, Finance Director Geoff Bellingan, Medical Director, Surgery & Cancer Board Katherine Fenton, Chief Nurse Jonathan Fielden, Medical Director, Medicine Board Gill Gaskin, Medical Director, Specialist Hospitals Board Neil Griffiths, Deputy Chief Executive Robert Naylor, Chief Executive

In attendance Simon Knight, Director of Performance & Planning Jeremy Over, Acting Workforce Director Tonia Ramsden, Director of Corporate Services (Board Secretary) Jo Begent, Consultant Paediatrician (for item 9/5) Polly Smith, Lead Nurse for Child Safeguarding (for item 9/5) Eamonn Sullivan, Deputy Chief Nurse, Medicine Board (for item 9/6) Jocelyn Laws, Trust Administrator (Minutes)

Item Matters covered 9/1

Apologies for Absence and Declarations of Conflict of Interest Apologies were received from Tony Mundy. The following new declarations of interest were made: Non-Executive Director, The Airline Group Ltd – Harry Bush Non-Executive Director, NATS Holdings Ltd – Harry Bush Board member, Health Services Laboratories (joint venture between The Doctors Laboratory, UCLH NHS Foundation Trust and the Royal Free London NHS Foundation Trust) – Jonathan Fielden

9/2 Minutes of the Meeting held on 9th July 2014 The minutes were agreed to be a correct record of the meeting.

9/3 Matters Arising Report The report was noted.

9/4 Other Matters Not Appearing on the Matters Arising Report There were no other matters arising.

9/5 Presentation: Child Safeguarding Polly Smith presented the key highlights from the Child Safeguarding Annual Report for 2013/14. She provided some quotes from the CQC inspectors during their inspection in January 2014 which included the fact that all staff they spoke to were well informed about safeguarding and that training records they had viewed showed that all staff had completed level 3 child safeguarding training, or were working towards it. She recapped on the priorities for 2013/14 which were:

• electronic flagging of local children on child protection plans • training compliance rates to reach 90% • embedding child safeguarding supervision within antenatal services and • raising awareness on domestic violence (DV) and sexual exploitation.

The presentation provided progress on each of these issues. Good progress had been made on flagging, supervision and training in DV and sexual exploitation which was included in level 3 training. However there were mixed results for child safeguarding training. There had been a significant increase in level 1 (non-patient facing staff) and level 2, but a reduction in completion rates for level 1 patient-facing and level 3. Polly Smith said there were a number of reasons for this, including data quality issues, which were being addressed. Safeguarding activity had increased in 2013/14; much of the work was related to maternity cases and trying to get help for vulnerable families at an earlier stage. The presentation advised of referrals to social care and children’s centres which had increased to c.700, two serious case reviews, two unexpected child deaths due to natural causes and 37 expected deaths. Polly Smith then outlined the priorities for 2014/15 which included further focus on improving training compliance, the introduction of formal DV level 1 and 2 training, preparing for a proposed CQC inspection of Camden children’s services, implementing the national Child Protection Information System (CPIS) once it became available and monitoring/following-up patients who repeatedly rearranged appointments. Other current issues that the Trust may need to consider were lessons to be learned from the inquiry into child sexual exploitation in Rotherham and the Southampton child abduction (Ashya King) case. Jo Begent said we had looked at the report of the Rotherham independent inquiry and did not feel that we had any particular issues. We had a good working relationship with Camden Children’s service. We would follow developments in the Ashya King case to ensure that similar issues did not occur here.

The Chairman commented that there were two similar scenarios – one where parents wanted a particular treatment for their child but the Trust did not feel it

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appropriate, and the other where parents did not wish for treatment but clinicians felt it should go ahead. Jo Begent said we often had to deal with the former, particularly with regard to blood tests and other diagnostic tests. We had very good multi-disciplinary teams to discuss issues with parents and offered second opinions. With the latter situation we ensured that there was good engagement with parents and worked with families to try to persuade them to agree to treatment. Where necessary we could seek advice about legal action but the child’s best interests were always put at the forefront of decisions.

Rima Makarem asked if the Trust had systems to alert us to issues when families with children at risk moved around. Polly Smith said we did not currently have a system but the CPIS would be a register of children who were on child protection plans anywhere in the country. Jo Begent added that all children attending our A&E department had a clinical check and a review by an experienced paediatric social worker. Level 3 safeguarding training had been introduced across the Trust for all staff coming into contact with children and they were our resource for highlighting areas of concern.

The Chairman thanked Polly Smith and Jo Begent for attending.

9/6 Presentation: Safeguarding Adults and the Mental Capacity Act Annual Report Eamonn Sullivan attended to give the presentation on the Safeguarding Adults Annual Report which had been prepared by Betsey Lau-Robinson, the Trust’s Adult Safeguarding Lead Nurse. The presentation covered key achievements including five positive CQC inspections, revised e-learning using film scenarios, introduction of a revised Restraint Policy and recruitment of a Domestic Violence Officer jointly with Camden. Comparisons of training compliance for 2013/14 and at July 2014 were shown. Eamonn Sullivan advised that we had added a significant number of people to the groups of staff requiring training and had therefore not been able to meet the 90% target. However compliance for levels 1 and 2 had increased although level 3 had fallen from 61% in 2013/14 to 58% in July (14/15). Eamonn Sullivan advised that the 42% of staff who had not completed level 3 equated to only 40 individuals and there were plans to ensure they completed the training by the end of September.

A summary of safeguarding alerts showed that they had risen by 39% compared with the previous year and it was felt that this was largely due to increased awareness. Categories of alerts included neglect, physical and financial abuse. The team had to deal with a number of difficult cases and Trust supported them as necessary.

The next section of the presentation outlined the aims of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS), both of which were legal frameworks to protect people who lacked capacity and to ensure that hospitals and care homes acted in their best interests. The application of DoLS was a lengthy and complicated process which had been the subject of a Supreme Court ruling. We had sought legal advice and their view was that clinical care should always come first. The Trust had drawn up a response to the ruling which included development of a ‘DoLS Easyguide’ for staff and updating of training and policies to reflect changes. The Department of Health’s lead for DoLS had recently met with

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the Chief Executive, Eamonn Sullivan and Betsey Lau-Robinson and had been impressed with the actions we had implemented.

Challenges for the year ahead included meeting the 90% training compliance target by 1st April 2015; implementing NICE guidance on domestic violence, the likely increase in DoLS applications and the need to increase training in ‘Prevent’ counter-terrorism. To meet the challenges we would need to identify a clinical lead to champion medical and dental training compliance, develop a strategy around the domestic violence agenda, review resources to meet the increased MCA and DoLS requirements and develop the next strategy for ‘Prevent’.

The Chairman thanked Eamonn Sullivan for his presentation. Following both presentations the Annual Reports were published on the Trust’s website.

9/7 Chairman’s Report The Chairman drew attention to the opening of the new Neuromuscular Complex Care Centre at the NHNN by Sir Robert Francis which had taken place the previous day. The remaining items in the report were noted.

9/8 9/8.1

Chief Executive’s Report Referral to Treatment (RTT) – Project to Reduce Waiting Times The Chief Executive had attached a report from Neil Griffiths which provided detail on our performance against waiting time standards, the reasons why we were not currently meeting the standards for all patients and the actions we were taking to implement a recovery plan. The Chief Executive explained that patient pathways could involve diagnostics, outpatient appointments and/or inpatient episodes. The rules around reporting the waiting list position had changed a while ago and we were now required to identify where patients were on the pathway rather than just recording numbers of patients on waiting lists. This was complex and there were no ideal IT systems for tracking patients in this way.

As previously reported to the Board, the Trust had seen a very significant increase in the number of referrals received and activity had grown by 9%. This had created difficulties in maintaining the level of activity required to meet the RTT targets. We had been working hard to identify the numbers of patients on pathways and to create additional capacity to deal with the extra workload. Owing to a strong political focus on the issue of long waits across the NHS, the Government had made additional funding available and UCLH had been allocated £3.6m for the purpose of reducing waiting times. However, we were unlikely to meet all the targets for several months. Neil Griffiths outlined the key elements of the work we had been doing to improve the RTT position. This included making changes to the Carecast system to provide additional data and ensure greater accuracy of data to support our activity plans. We had brought in a team of people to undertake validation of the waiting lists to obtain a more accurate position. Additional weekend and evening sessions were being run across all clinical services and an agreement with a private sector

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provider had been reached to outsource up to 3,000 inpatients over the next six months. We had been liaising with Camden CCG and NHS England and had shared our recovery plan with them.

As at the end of August unverified figures showed there were more than 38,000 patients on the RTT waiting list, 4,839 of whom had been waiting more than 18 weeks. These were predominantly in five clinical areas. The report contained appendices setting out the performance issues and detailed actions being taken in each of these areas. Gill Gaskin advised that in the Specialist Hospitals Board the area of most concern was Queen Square and the problems were primarily due to the number of highly specialised services. This made it difficult to outsource patients to other providers and recruiting to vacant consultant posts sometimes required seeking candidates internationally which was time-consuming.

Geoff Bellingan said the two key areas in the Surgery & Cancer Board were urology and gastro-intestinal services. There had been huge commitment from staff to undertake additional evening and weekend clinics and he believed that GI was likely to be back on track to meet RTT targets fairly soon.

The Chairman asked whether the plans would be sufficient to accommodate the level of activity required to meet RTT targets. Gill Gaskin said we had developed trajectories but the validation exercise might reveal additional patients on pathways and therefore even more activity would be required. Geoff Bellingan said there were caveats, for example the impact of winter and the likelihood that more emergency admissions would reduce capacity for waiting list activity. Neil Griffiths confirmed that the external project manager we had brought in to oversee the recovery plan had confirmed that the plan was robust.

The Chairman asked how it was intended to balance the demands of A&E and RTT. Jonathan Fielden replied that there was recognition across the Trust of the need to improve the flow of patients through the hospital. Geoff Bellingan emphasised that a significant proportion of RTT activity was outpatient work which was not affected by emergency admissions.

The Chief Executive said that the three main challenges facing the Trust were the A&E waiting time target, RTT targets and finance. We had to find a balance among all three and determine the best solution to these conflicting issues. Commissioners were threatening to impose financial penalties if we failed to meet targets and, to add further pressure, other trusts were closing A&E departments. While it was essential to maximise activity we may not have sufficient capacity and would possibly need to explore transferring services to other trusts that did have spare capacity. John Tooke applauded the efforts to resolve these difficult problems and asked if we had the optimum sources of data to predict required activity levels and provide confidence that planning in the short term was appropriate. The Chief Executive said he was not aware of any IT system that could do this. He also warned that even if we managed to resolve the issues this year, future years would be even more challenging.

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We would have additional capacity available following the move of cardiac services but needed to determine how many more beds could be created at the Heart Hospital as a proportion of the current four-bed bays would need to become single rooms.

Harry Bush endorsed John Tooke’s comment about the efforts of staff to resolve this situation but was not fully assured and felt there were significant risks to achievement of the recovery plan. Geoff Bellingan advised that further plans were being developed but were not yet finalised. The Chairman asked whether we could

reduce inpatient lengths of stay and improve patient flow. Jonathan Fielden said we had initiated schemes to improve discharge, such as UCLH@Home, but he accepted that we could do more, such as ensuring prescriptions for drugs to be taken home were written up early. The Chief Executive said we needed to identify further actions and positive incentives to encourage wards to discharge patients in a timely manner. Katherine Fenton advised that this issue was being raised with ward sisters.

It was agreed that the Board would receive a progress report on RTT each month and the Chief Executive said a set of metrics should be developed to explain clearly how activity was increasing.

Action: Deputy Chief Executive 9/8.2

Strategic Intent Summary Document The revised Strategic Intent Summary document was attached to the Chief Executive’s report for endorsement. The document was approved for publication on the Trust’s website, subject to a minor alteration required on page 15.

9/8.3

Cardiac and Cancer Strategy – Residual Services at UCLH The report advised that a project group had been established to consider the services required to support emergency and other specialist services across the Trust following the relocation of cardiac services to Barts Health. It was noted that a consultation process had commenced for staff who may wish to transfer. The Chairman requested an update at the next meeting.

Action: Chief Executive 9/8.4

CQC Inspection Progress Update The Board was advised that the CQC had requested a progress report on the four compliance areas identified during their inspection in November 2013. The Chief Executive would be responding to them and a copy of his response would be circulated to Board members.

Action: Chief Executive

9/8.5 Collaboration with CCGs and General Practitioners The report advised that a review of current arrangements for engagement and clinical liaison with principal CCGs and GP practices was being undertaken by Jonathan Fielden and Helen Taylor, Divisional Clinical Director for Integration. A report on relationship management and how the integrated care strategy would be taken forward would be presented to the Board in November.

Action: Medical Director, Medicine Board

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9/8.6 Creutzfeldt-Jakob Disease – Media Coverage of a Case at Queen Square The Chief Executive explained that this issue related to sporadic CJD, not variant CJD as referred to in his report; the Board noted that sCJD was quite different from vCJD. The case concerned a patient at Queen Square who was worried that she was at risk of contracting the infection as instruments used during her surgery six years previously had also been used on a patient who had since been diagnosed with sCJD.

The Chief Executive said we had reviewed our position and we had been compliant with all existing guidance at that time. The patient had been counselled and there was a very low risk that the disease had been transmitted.

9/8.7

Genomics Bid The report advised that UCLH and Great Ormond Street Hospital were collaborating on a proposal to submit a bid to be designated as a genomic medicine centre. The Chief Executive would keep the Board informed if the bid moved through the qualification process.

John Tooke said these relatively new studies of cancer and rare diseases would require integration of clinical data with research and would be dependent on the introduction of electronic health records.

9/8.8

Pathology Joint Venture The report advised that the shadow board of the Pathology Joint Venture had appointed Lord Patrick Carter of Coles as its Chairman. The Board endorsed the appointment. The remaining items in the report were noted.

9/9 9/9.1

Executive Board Report Update on Cancer Services and Waiting Times The EB had received a report containing an analysis of reasons for breaches of the 62 day GP referral pathway. A summary report from the Cancer Clinical Steering Group was appended to the EB report and showed that the majority of breaches were caused by late referrals, patient choice and valid medical reasons. However, around 14% were due to administrative delays or capacity issues. A series of actions for improving performance against the access targets were outlined in the summary. Other key issues from the appendix were also noted.

9/9.2 Investment in Theatre and Bed Capacity at Queen Square The EB had considered a draft business case for the refurbishment of four existing theatres, creation of two additional theatres and provision of between 30 and 40 additional beds at Queen Square to deliver the RTT target and meet growing demand. The report advised that the EB had approved seed funding to work up the design and development of a final business case.

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9/9.3 Capital and Estates Issues This section of the report, including the Q1 Capital Programme review, was noted. Board members noted that the Trust had agreed terms to lease the healthcare

element of Fitzroy Place, the redevelopment of the former Middlesex Hospital. The 25 year lease covered 950 square metres on the ground and lower ground floors, and proposals for the use of the space were under consideration.

9/9.4 Implementation of Trust-wide Wi-Fi The update was noted. Among the planned developments was the introduction of guest wi-fi for patients and visitors; however, consideration would have to be given to how this would be funded as it was expensive to provide.

9/9.5

Education, Learning and Development Update The report advised that the annual review of the Education, Learning and Development strategy had been completed. The three elements of the 2014-17 vision were listed. The Board noted that the Trust was in the process of appointing a successor to Aidan Halligan, the former Director of Education. The Chairman advised that congratulations were due to Jeremy Over, Acting Director of Workforce, who had been appointed as Director of Workforce at Norfolk & Norwich University Hospitals.

9/9.6 Staff Friends and Family Test The first quarterly Staff Friends and Family Test (SFFT) had been conducted. The results had been extremely positive and the Chief Executive said this was an excellent endorsement of the Trust, both as a place to work and to receive treatment.

9/10

Performance Report Simon Knight presented the key issues. Cancer waits and RTT had already been discussed. It was noted that we had missed the 95% A&E target in July and Jonathan Fielden advised that August had also been extremely challenging for us, as it had for many other trusts, partly owing to the new intake of junior doctors. A new Divisional Clinical Director for Emergency Services would be joining the Trust in November; in the meantime Daniel Wallis was continuing to support the team.

The position on pressure ulcers and preventable dose omissions was noted. Alasdair Breckenridge referred to his attendance at the Trust Infection Control Committee to better understand issues relating to infection.

Kieran Murphy noted that theatre utilisation across the trust, particularly at Queen Square, was still below target. Gill Gaskin said that surgical cases at QS tended to be long and one theatre session may only be able to deal with one or two patients. NCEPOD and other requirements stated that we must have a theatre available for emergencies and as there were only four theatres this was difficult. We currently protected theatre time in the morning. Geoff Bellingan reminded the Board that a report on theatre utilisation, comparing performance with benchmarking information, would be presented in November.

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The workforce performance indicators were noted. Katherine Fenton advised that a report on nurse establishments and staff in post would be submitted to the Board in November. Rima Makarem referred to a recent survey by the Health Service Journal of the best places to work in the NHS. She was pleased that UCLH was in the top 100 but noted that the top 10 organisations had staff turnover rates of 11% or less, whereas ours was 12.5%. She felt that we could reduce turnover if we

could further improve as a place to work. However, the Chief Executive said that many trusts in rural areas had low staff turnover because there were few competitor organisations nearby. In London there were many more trusts so staff had more opportunity to move around. In addition, London was becoming increasingly unaffordable as a place to live.

9/11 Quality & Safety Committee Report John Took presented the report and drew attention to the launch of the UCLH@Home service. Jonathan Fielden advised that in the first month of operation we had discharged nine patients to the service against a target of six and so far it was going well. Patient feedback was being captured.

It was noted that Rima Makarem would shortly be taking over as chair of the QSC and the Chairman thanked John Tooke for his contribution.

9/12 Performance Committee Report and Board Assurance Framework Diana Walford presented the report of the first meeting of the Performance Committee and advised that they had discussed the objective-setting process. There was a view that the process should be refreshed. We needed to identify what the top priorities were and it was felt the Board should be involved in the process at an earlier stage. The Chief Executive agreed to give this consideration.

Action: Chief Executive

The Committee’s terms of reference which were attached to the report were approved.

The Board Assurance Framework was noted. Neil Griffiths advised that it had been agreed to review the format next year.

9/13 Finance & Contracting Committee The report was presented by Harry Bush. In Month 4 the Trust had recorded a surplus of £1.6m, bringing the year to date position to a cumulative deficit of £2.3m which was £3.8m behind plan. The FCC had been advised that the Executive was making progress on QEP plans and also looking at other measures for further savings to put the Trust in a better financial position before the new financial year. The Board retrospectively endorsed the Q1 declaration that had been submitted to Monitor that the Trust would retain a continuity of service risk rating of at least 3 over the next 12 month period. The Director of Procurement and Supply Chain had given a presentation and had referred to the work taking place among the Shelford Group trusts on standardising products which was aimed at making savings on procurement.

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The contracting update was noted.

9/14 Report of the Audit Committee Meetings held on 23rd May and 24th July Rima Makarem presented the report. The May meeting had reviewed the Annual Report, Annual Accounts, Quality Report and supporting documents which had subsequently been approved by the Board. The Audit Committee had also

reviewed the Internal Audit Annual Report for 2013/14 and Counter Fraud Annual Report and workplan for 2014/15.

At the July meeting the Committee had discussed the Risk Report and had noted that a number of Trust-wide policies had been reviewed. These included the policy on Engagement of External Auditors for Non-Audit Work, which was attached to the report. The Committee had agreed that no changes were required to the policy and the Board noted the recommendation to extend the policy for a further year.

The Annual Report on the work of the Audit Committee for the year 2013/14 had been circulated to Board members and was endorsed.

Rima Makarem advised that the Audit Committee had also reviewed the performance of the External Auditors, Deloitte, and had agreed that their performance was satisfactory. The Committee had agreed to recommend to Governors that Deloitte should be reappointed for a further year. At a meeting held on 21st July the Governing Body had accepted the recommendation and had reappointed Deloitte.

9/15 Minutes of the Audit Committee Meetings held on 23rd May and 24th July The minutes were noted.

916 Entries in the Seal Register The report was noted. The list included the Supplementary Agreement between Health Management (UCLH) plc and UCLH NHS Foundation Trust in respect of the extension of the facilities provision contract to wider elements of the estate.

9/17 Schedule of Public Board Meetings 2015 The schedule was noted.

9/18 Any Other Urgent Business There was none.

9/19 Date of Next Meeting The next meeting would be held on Wednesday 12th November 2014 in the UCLH Charity Board Room, 5th Floor, 250 Euston Road.

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B

Agenda Item 3

Matters Arising Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

BOARD OF DIRECTORS

REPORT ON MATTERS ARISING FROM THE MEETING HELD ON 10th SEPTEMBER 2014

Minute no.

Issue Action

9/8.1 Chief Executive’s report: Keep Board advised of progress on the RTT project

An update is included in the Chief Executive’s report. Action ongoing

9/8.3 CEO report: Cardiac/Cancer Strategy – update on residual cardiac services

A report is attached to the Executive Board report. Action completed

9/8.5 Collaboration with GPs and CCGs – report on engagement with commissioners and GP relationship management

A report is attached to the Executive Board report. Action completed

9/10 Performance report: Workforce indicators – paper on nurse and midwifery establishments and staffing levels

The biannual report is attached to the Executive Board report. Action completed

9/11 Performance Committee report: Objective-setting process – give consideration to process for next year and how to identify top priorities

This will be discussed with the Board at the appropriate time (RN).

Items from previous meetings brought forward

Date of Meeting

Minute no.

Issue Outcome

25th July Extraord meeting

E7/2 ED Development: implement quarterly updates on progress from November

The first quarterly update is attached to the EB report.

June 2014

6/9 Performance report: Theatre utilisation - undertake comparison of performance against other trusts & benchmarking data

This issue is referred to in the Performance Report. Action completed

Items from previous meetings carried forward to future meetings - None

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Agenda Item 7

Chairman’s Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS

12 NOVEMBER 2014 1. COMPLAINTS PLEDGE

In the spring of this year, and as part of the NHS Change Day, I agreed as a pledge to spend time with the central complaints handling team in 250 Euston Road. On 17 September, I spent the morning with Belinda Crawford, Lesley Creasey and John Mahoney. As Board members know, I read all the complaints and have spent a lot of time talking with the team about individual cases. However it was good to have the opportunity to have an overview of how the team works and the day-to-day process of handling a complaint.

2. LONDON ENDOSCOPY LIVE Each year our gastroenterology team hosts a course, ‘London Endoscopy Live’, for colleagues around the country demonstrating developments in our techniques at UCLH. I attended the dinner which followed the course and was able to have a series of interesting conversations with the team about developments and issues in the service. The course is a fantastic showcase for the very high quality service which our team is able to offer to patients.

3. ANNUAL MEMBERS’ MEETING On 22 September we held our Annual Members’ Meeting. As in previous years, the meeting was very well attended and heard the usual presentations from the Chief Executive, Finance Director and the Lead Governor. There were also clinical presentations from Professor Hugh Montgomery (ICU) and Dr Rowland Illing (Interventional Radiologist). These seem to have been well received and there was an opportunity for members of the public attending to talk informally with Board members, staff and governors after the meeting.

4. CHAIRS BREAKFAST Approximately twice a year a number of Chairs of London Hospitals get together for an informal breakfast. The most recent took place on 24 September with representatives from Barts, Chelsea & Westminster, Royal Free, Homerton and UCLH. These provide a useful opportunity for us to discuss informally topics of common interest.

5. MACMILLAN COFFEE MORNING I attended the annual Macmillan Coffee Morning in the UCH Macmillan Cancer Centre on 26 September. As Board members will know the Macmillan Coffee Morning is an astonishingly successful event which is the envy of many charities. The Cancer Centre provides a real focal point for the occasion and I enjoyed meeting with staff from the hospital and from Macmillan. It was good to hear how the partnership is flourishing and about some of the initiatives which are under way.

6. UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST On 1 October, I went with a team from UCLH, including Neil Griffiths, Deputy Chief Executive and Dr Jonathan Fielden, Medical Director, Medicine Board, to visit University Hospitals Birmingham to learn more about how they use information technology to improve patient care. UHB have over the last 10/15 years developed a very impressive IT system and, more

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particularly, have devoted a lot of energy to making the system work to improve patient care. All of us were very impressed with what we heard and took away a number of lessons which we hope to apply as we seek to upgrade our processes and IT support at UCLH.

7. UCL The Chief Executive and I have a regular meeting with the Provost and Vice-Provost (Health) of UCL. This provides an opportunity to review the critically important relationship between our two organisations, and to make sure that our efforts to develop together remain on track. The most recent meeting took place on 15 October.

8. ASSOCIATION OF UK UNIVERSITY HOSPITALS CHAIRS & CEO MEETING On 17 October I attended a session of the AUKUH Chairs which was addressed by Simon Stevens, Chief Executive of NHS England. The meeting took place shortly before the publication of the Five Year Forward View and we were able to have a useful exchange of views about the role which teaching hospitals play in Simon Stevens’ vision for the NHS, as well as more short-term issues of concern.

9. THE DALTON REVIEW INTO NEW OPTIONS FOR PROVIDERS The Dalton Review continues to make progress. I have attended two meetings as one of the group of Chairs who are acting as a sounding board for the process. At the first meeting we reviewed a draft of the report and discussed a number of the key recommendations. The second meeting, which was hosted by the Nuffield Trust, was an interesting exchange of views with a number of Trusts from around the country which had completed or were contemplating various types of structural change (joint ventures, partnerships, mergers etc).

10. RNTNE HOSPITAL – PRODUCTIVE OUTPATIENTS (POP) On 3 November I was invited to attend a workshop at the RNTNEH where the leadership and clinical teams were reviewing how to improve the ‘on the day’ efficiency of outpatients at the hospital. As is sadly the case in other parts of the Trust, patients at the RNTNEH often encounter lengthy delays in outpatient clinics and the POP process is designed to make changes to mitigate this state of affairs. I was impressed to see the level of engagement and range of ideas which came up during the session to try to improve the planning of the clinics. As ever, the next task is to try to make some of these ideas work on the ground on a clinic-by-clinic basis.

11. BBC REITH LECTURE Also on 3 November I attended the BBC Reith Lecture as a guest of Pauline Phillip, Chief Executive of Luton & Dunstable Hospital. The speaker this year is Dr Atul Gawande, the US-based surgeon, lecturer and author who is perhaps best known in this country as the architect of the WHO Surgical Checklist. Dr Gawande is delivering four lectures around the world, of which this was the second. The lectures are being broadcast on Radio 4 during November.

12. VISIT BY NATIONAL UNIVERSITY OF SINGAPORE On 6 and 7 November a senior delegation from the National University of Singapore will visit UCH/UCL/UCLP. I am due to attend with Neil Griffiths, Deputy CEO.

RICHARD MURLEY CHAIRMAN

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D

Agenda Item 8

Chief Executive’s Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

12 NOVEMBER 2014

PART ONE 1. MONITOR ASSESSMENT OF FOUNDATION TRUSTS PERFORMANCE

There are a number of issues to bring the Board up to date since the last meeting. Firstly, I attach as Appendix ‘A’, Monitor’s rather belated analysis of our Q1 submission in which our continuity of services risk rating is 3 and our governance risk rating green. Monitor’s letter confirms that we failed to meet the RTT and cancer 62-day wait standards, performance issues on which the Board will be very familiar. Also attached as Appendix ‘B’, is a letter from Monitor on the outcome of their assessment of our 5-year strategic plan which has been rated green. Secondly, Monitor has published a report entitled ‘Foundation Trusts Under Pressure From Rising Demand’, which is available on their website. The essence of the report demonstrates that NHS Foundation Trusts are providing more treatment, to more patients with more complex care needs in tough financial times. It particularly refers to an increase in the numbers of Trusts in deficit up by 79% compared to the same quarter last year. It outlines the challenges being faced in meeting the governments RTT targets by the end of this calendar year, the increase in the number of cancer target breaches and the pressures being experienced in A&E departments. Many of these issues have been widely reported in the media, including an article in the HSJ which announced that emergency admissions to A&E departments have hit their highest level since records began, with a more rapid increase in the number of emergency admissions in the past year. It stated that only 89.6% of patients visiting major A&E departments were seen within 4 hours, during the week the article was published in late October. The government has announced a further £280m to be allocated to A&E departments in addition to the £400m announced earlier this year. Thirdly, there have been a number of media reports about escalating financial pressures in Trust’s across the NHS, an issue discussed at a recent meeting of the Shelford Group Chief Executives. The general consensus was that all the Shelford Group Trusts were experiencing greater financial pressures, in line with the NHS as a whole. However, most were still predicting a year-end financial balance, subject to sufficient additional funding for specialist activity, such as Project Diamond in London. The detail of our own financial projections is discussed elsewhere on this agenda.

2. KEY CHALLENGES FOR THE TRUST THIS YEAR

At the last Board meeting I referred to three particular challenges that the Executive were focused on for the remainder of this financial year, namely RTT, emergency access and the financial position. These are not necessarily any more important that the objectives set out in the Trust’s Top 10 priorities, but they are given greater emphasis by politicians and regulators. In the last month I have been invited to attend two performance management meetings on RTT and emergency access by what is now known as the ‘Tripartite Group’. This is a collaboration between NHS England, CCGs and Monitor, who together are acting in a similar performance management approach to that exercised by the Regional Health Authority prior to the

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establishment of Foundation Trusts. This indicates the considerable pressure being placed on commissioners and regulators to meet key targets in the current political cycle. The RTT position has been extensively discussed at previous Board meetings. The Executive has spent considerable time in addressing this issue, largely due to our relatively poor performance caused by the significant increases in referrals to the Trust over recent years. Last year the Trust’s activity grew by 9% overall, with 20% increases in some specialist areas. These increases are several times the rate of the NHS as a whole. Our conclusion is that this is due to choices being exercised by patients and their GPs, particularly in specialties which have the strongest reputation such as neuroscience and cancer. We have now reached a position where we can be more confident about the accuracy of our waiting list data due to the extensive validation processes adopted in recent months. We have agreed specific targets with the ‘Tripartite Group’ which we have substantial confidence in achieving. We have been strongly supported by local commissioners, particularly Camden CCG, both practically and financially. Current performance indicates that we will have treated all 52-week wait patients by the end of October and achieve all the key RTT targets including the key 92% target of patients waiting less than 18 weeks by the end of January. The strategy has been to increase the number of outpatient clinics, increase the number of elective inpatients and outsource some surgical cases to other hospitals and the private sector. Increasing the number of waiting list inpatients within our fixed physical capacity, has had an impact on our ability to deliver the A&E waiting time target. Our performance over the last few months has been slightly better than average for London Trusts, with our current year to date performance at 94.4% (patients being treated within 4 hours of attending the A&E department). We will fail the 95% target for Q3 and possibly Q4 unless we adjust our priorities, which would clearly have a negative impact on our RTT performance. We recently invited the Emergency Care Intensive Support Team (ECIST) to evaluate performance in our emergency pathway. Verbal feedback indicated that we could make some substantial improvements in our own internal management of the emergency pathway. In particular they recommended that we designate one person to have responsibility for the overall management of beds in the UCH Tower, whereas this is currently a distributed responsibility between the three Medical Directors. This recommendation was agreed by the Executive Board. Both of the above issues have an obvious impact on our financial position. We have argued, with some degree of success, that we need additional funding to achieve both the RTT and A&E targets. However, even with additional funding we are experiencing difficulties in recruiting and retaining frontline staff in these areas due to overall shortages and recruitment competition from other Trusts. Subject to a satisfactory resolution on Project Diamond funding, we remain broadly on target to achieve a balanced financial position by the end of 2014/15.

3. FIVE YEAR FORWARD VIEW OF THE NHS

At the end of October, Simon Stevens, the new Chief Executive of NHS England, presented a 5-year forward view for the NHS, supported by other system leaders such as Monitor and Public Health England. The full document is available at http://www.england.nhs.uk/ourwork/futurenhs/ The forward to the report suggests that the NHS may be the proudest achievement of our modern society. It suggests that the NHS needs to adapt to take advantage of the opportunities that science and technologies offer patients, carers and those who serve them. It argues for a more engaged relationship with patients, carers and citizens so that we can promote wellbeing and prevent ill health.

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The executive summary boldly states that the NHS has dramatically improved over the past 15 years and that progress has continued even during global recession thanks to protected funding and the commitment of NHS staff. It states that there is now broad consensus on what a better future should be, with an emphasis on a radical upgrade of prevention and public health. It states that patients should take far greater control of their own care, including the option of shared budgets providing health and social care. The report states that the NHS will need to take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres. It argues against a strategy of ‘one size fits all’, but suggests that local health communities should determine their own way forward. It points to the alternatives of either GPs or hospitals taking the lead in developing integrated care. It states that smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. It backs diverse solutions and local leadership, in place of the distraction of further national structural reorganisation. On the question of the future financial position, it says that action will be needed on all three fronts – demand, efficiency and funding. It sets out alternative funding scenarios to close the £30bn gap by 2020/21. Decisions on these options will be for the next parliament and government and will need to be updated and adjusted over the course of the 5-year period. In practice this passes the funding question to the politicians in advance of the General Election next May.

4. IMPACT OF INDUSTRIAL ACTION

Following action earlier this autumn, NHS trade unions and staff representative bodies have announced further strike action shall take place on Monday, 24 November. Each union and body is taking action in response to the Government’s NHS pay award. Unison, Unite, the Royal College of Midwives, Society of Radiographers and GMB are advising their members to strike for four hours. We are putting plans in place to minimise the impact on patient care. A small number of elective appointments shall be rescheduled. Strike action on 24 November shall be followed by a four-day period of action short of a strike, from Tuesday 25 November to Friday 28 November. Our current expectation is that no patient care or treatment shall need to be cancelled as a result of that action.

5. SENIOR STAFF APPOINTMENTS

In my report to the Board in September, I said that we would be interviewing for the Chief Nurse post later that month. That exercise did not lead to an appointment. We have since re-advertised the role and hope to interview a good selection of candidates early in December. Given the additional time it is taken to recruit her successor, I am grateful that Katherine Fenton has agreed to stay with us until the spring. In early 2015, we will embark on the recruitment process for a new Director of Education and a Director of Informatics. We have also appointed Ashvin Sharma to the post of Director of Organisational Development. Ashvin will join us on 8 December and brings exceptional experience in OD from the commercial sector and he will be working closely with the Deputy Chief Executive and Director of Workforce to establish a Trust-wide focus on OD across UCLH.

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6. PROTON BEAM THERAPHY: APPROVAL OF DRAFT APPOINTMENT BUSINESS CASE

FOR PBT SERVICE PROCUREMENT

At the end of October we received confirmation from the Department of Health that the draft Appointment Business Case (dABC) for the Proton Beam Therapy equipment procurement had been approved. This approval has allowed the Trust to reduce to two the number of potential suppliers against a stringent process of evaluation and move forward to final stage of equipment procurement. The final offers from the two remaining equipment suppliers are due back with both UCLH and the Christie and in the middle of November to begin a rigorous period of assessment ahead of final provider selection.

7. GP ELECTRONIC LINKS

I am pleased to report that the Trust is continuing its implementation of the electronic transmission of inpatient discharge summaries and outpatient clinic letters to GPs in Islington. Camden and Westminster GP practices are already live and receiving letters via the new e-messaging system. All Islington GP practices were switched on to the e-messaging system at the end of October, although for a short period we will also send paper copies until we are confident that the system is operating efficiently. This is a long awaited and welcome development that will improve the timeliness of GPs receiving key information about patients, save money and reduce the administrative burden on our own staff.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

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17 September 2014

Sir Robert Naylor Chief Executive University College London Hospitals NHS Foundation Trust 2nd Floor Central 250 Euston Road London NW1 2PQ

Dear Sir Robert,

Q1 2014/15 monitoring of NHS foundation trusts

Our analysis of your Q1 submissions is now complete. Based on this work, the Trust’s current ratings are:

Continuity of services risk rating - 3

Governance risk rating - Green

These ratings will be published on Monitor’s website later in September.

The Trust has failed to meet the RTT admitted, RTT incomplete pathways, and Cancer 62

day wait (urgent GP referral) for three successive quarters, which has triggered

consideration for further regulatory action. The Trust has also failed to meet the RTT non-

admitted target in Q1 for the second successive quarter.

Monitor uses the above targets (amongst others) as indicators to assess the quality of

governance at foundation trusts. A failure by a foundation trust to achieve the targets

applicable to it could indicate that the Trust is providing health care services in breach of its

licence. Accordingly, in such circumstances, Monitor could consider whether to take any

regulatory action under the 2012 Act, taking into account as appropriate its published

guidance on the licence and enforcement action including its Enforcement Guidance1 and

the Risk Assessment Framework2.

We expect the Trust to address the issues leading to the target failure and achieve

sustainable compliance with the target promptly.

Monitor has decided not to open an investigation to assess whether the Trust could be in breach of its licence at this stage. The Trust’s governance risk rating has been reflected as Green. Should any other relevant circumstances arise, Monitor will consider what, if any, further regulatory action may be appropriate.

1 www.monitor-nhsft.gov.uk/node/2622

2 www.monitor.gov.uk/raf

Wellington House 133-155 Waterloo Road London SE1 8UG

T: 020 3747 0000 E: enquiries@monitor.gov.uk W: www.gov.uk/monitor

Chief Executive's Report to Board of Directors, Appendix A

A report on the FT sector aggregate performance from Q1 2014/15 will shortly be available on our website (in the News, events and publications section) which I hope you will find of interest. For your information, we will shortly be issuing a press release setting out a summary of the key findings across the FT sector from the Q1 monitoring cycle. If you have any queries relating to the above, please contact me by telephone on 0203 747 0371 or by email (Victoria.Woodhatch@Monitor.gov.uk). Yours sincerely,

Victoria Woodhatch Senior Regional Manager cc: Mr Richard Murley, Chairman Mr Richard Alexander, Finance Director

31st October 2014

Robert Naylor University College London Hospitals NHS Foundation Trust 2nd Floor Central 250 Euston Road London NW1 2PQ

Dear Sir Robert,

University College London Hospitals NHS Foundation Trust

Five-year strategic plans

Thank you for the huge efforts of your foundation trust during this planning round to address the major challenges faced by the healthcare sector. Below I have summarised the key findings from our review of the five year plans and next steps.

Background

Our review of last year’s strategic planning concluded that there were significant opportunities for the majority of foundation trusts to improve1. This is important as a clear and well thought-out strategy helps foundation trusts achieve the vision and values of the NHS by sustaining safe, effective care for patients in the medium term. Supporting the sector to improve was therefore a key objective of the 2014/15 planning round and why we added the five-year strategic plan to the process. More recently, we launched the Strategy Development Toolkit with guidance for foundation trust boards and their teams on every stage of the strategy development process.

In our letter of 16 May 2014, we stressed the importance of foundation trusts having a realistic view of the scale of the financial challenge over the next few years. Furthermore, we reassured you that we want to engage with you in a supportive manner if risks to sustainability are identified. Our approach to reviewing this year’s five-year plans has been governed by these principles.

Overview

Our review of the five-year plans has highlighted a number of improvements:

the “optimism bias” identified in previous plans has become less pronounced

there is a higher quality of diagnosis and analysis of the various issues facingfoundation trusts

there is evidence of providers and commissioners working more closely together toidentify and confront emerging pressures

some truly innovative transformational initiatives are being developed andimplemented across local health economies.

However, our analysis shows that there are still some key issues in strategic planning at

1 See Meeting the needs of patients: Improving strategic planning in NHS foundation trusts, available

at https://www.gov.uk/government/publications/nhs-foundation-trusts-improving-strategic-planning

Wellington House 133-155 Waterloo Road London SE1 8UG

T: 020 3747 0000 E: enquiries@monitor.gov.uk W: www.GOV.UK/monitor

Chief Executive's Report to Board of DirectorsAppendix B

many foundation trusts:

overall cost improvement programmes (CIPs) appear insufficient to offset the financial pressures facing the system

transformational changes are not yet widespread enough across the sector

there is evidence of poor alignment between provider and commissioner plans

in aggregate, financial pressures continue to be under-modelled in plans. As a result, there are concerns about the robustness of foundation trusts’ plans to deliver quality care on a sustainable basis.

Our approach to the assessment of your strategic plan

We have not undertaken an in-depth review of foundation trusts’ strategies and plans. Instead, we have tested the robustness of the financial projections which describe those plans. We did this by applying a limited number of sensitivities to foundation trusts’ own financial projections to adjust for parameters generally known to be poorly modelled2.

We have used a RAG rating to categorise our assessment of the level of risk in each case:

Green No undue concerns were raised from review of the strategic plan. We will continue to monitor ongoing delivery as normal.

Amber The sensitisation of the projections identifies that the foundation trust’s sustainability may be marginal. We therefore ask the trust to review its plans in light of our findings, and to consider what improvements in strategic planning may be required.

Red There appears to be a high risk to sustainability. Where appropriate, we will invite foundation trusts in this category to a meeting with Monitor so we can reach a shared understanding of possible gaps and agree what is required to close these in terms of resources, support and milestones.

We recognise that there may be limitations in some cases to using top-down sensitivities and will not base any response on this alone. We are of course happy to discuss the outcome and approach applied for your foundation trust with you.

Outcome of the assessment of your strategic plan and next steps

Your strategic plan has been rated as Green.

Our review of your five-year plan has not highlighted any undue concerns. However, we would encourage you to revisit your strategy on a regular basis - to ensure that its implementation remains on track, the underlying assumptions still hold true, the external environment has not changed, and the goals of the strategy are still appropriate to local health economy needs.

2 The following adjustments to trusts’ assumptions were made:

i. expected CIP delivery was adjusted in light of past performance and delivery against

plan

ii. anticipated pressures to tariff and costs were uplifted in line with Monitor guidance

iii. contingencies in plans were released (this mitigates against the above adjustments)

iv. capital expenditure forecasts were reduced to reflect the historical underspend in the

sector against plan.

Further information

In early November you will receive a letter from Monitor, NHS England and the NHS Trust Development Authority which sets out the timetable and high level principles for the 2015/16 planning round. Monitor’s full guidance will be published in early December.

The summarised version of your strategic plan will be published on our website shortly.

As referred to earlier, we recently published our Strategy Development Toolkit. The toolkit describes a seven-stage framework for boards and their teams, and offers practical guidance at every step of the process together with case studies from other NHS providers. It is a series of frameworks, analyses and ideas intended to provide direction and inspiration, rather than to be prescriptive. Please download the toolkit here3; you can also find a link to the landing page, together with further information, here4. We hope you find it helpful.

If you have any queries, please feel free to contact me.

Yours sincerely

Victoria Woodhatch

Senior Regional Manager

Direct line: 0203 747 0371

Cc: Mr Richard Murley, Chairman

3 Available at

https://drive.google.com/uc?export=download&id=0B8FRBEcO1QyULXYxRWlza0xSRjQ 4 Available at

https://www.gov.uk/government/publications/strategy-development-a-toolkit-for-nhs-providers

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Agenda Item 9

Executive Board Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Executive Board Report to the Board of Directors, November 2014

1. Winter Bed Capacity Planning In September and October the EB reviewed its plans for winter and considered

papers which set out the potential bed requirements at UCH over the coming winter period. During this period the Trust will be required to maintain quality of care and patient experience as well as delivering the 18 week referral to treatment target and the 4 hour A&E waiting time target. In quarter 4 there may well be disruption due to the move of cardiac services from the Heart Hospital and at the same time we could experience increased pressure owing to reconfiguration of London cancer services.

The report advised that bed modelling for UCH Tower suggested that we were up to

69 beds short for the winter period, with February being the month when the biggest potential problem would arise. The report outlined possible options for providing additional beds to meet demand. These options include the reopening of Evergreen Ward and maximising the use of Jubilee Ward at St. Pancras Hospital, increased use of UCLH@Home, and outsourcing to another provider. The September report advised that, even with mitigation arrangements in place to increase bed capacity, there could be a shortfall of 20 beds in February.

In October the EB was advised the activity model indicated a reduction in demand in February which, together with better developed plans to increase capacity, has enabled the gap to be closed. Recent initiatives such as ‘Home for Lunch’ and 7 day working of clinical support services will help to improve flow of patients through the Tower. However, this position does not take account of the risk of a major infection outbreak or incident which would significantly impact on capacity. The plan also assumes 90% occupancy across beds with 100% occupancy of Evergreen.

2. National Cancer Patient Experience Survey 2013/14

The 2013/14 National Cancer Patient Experience Survey (NCPES) results were published on 12 September. The survey provides detailed information on cancer patients’ experiences of services across the whole of their pathway from GP to hospital. 153 acute trusts were involved in the survey, allowing a national focus and comparison. The ability to identify trends is now possible as four consecutive years’ data is available at both a trust and tumour group level. The survey was sent to patients treated by UCLH between September and November 2013, and included those treated as inpatients and day-case patients. The response rate to the survey was 51%, compared with a national response rate of 64%. This represents a very small decrease on last year’s response rate of 52%. Following last year’s survey results, the Cancer Patient Experience Programme has continued to take forward specific issues identified in the survey. This has included bi-monthly meetings chaired by Katherine Fenton. Two specific work streams were developed; these are communications and staff experience. There has also been an

increased focus on individual multi-disciplinary teams, monitoring their action plans in relation to the survey. The latest survey results show a slight improvement on last year’s survey; overall the percentage of respondents rating their care as excellent or very good increased from 87% to 88%. In the 2012/13 survey 40 questions showed improved scores, the 2013/14 survey shows an improvement in 38 questions. The number of questions in which the Trust’s score was within the top 20% of trusts has increased from 3 to 5, while the number of questions in which we were rated in the bottom 20% has fallen from 32 to 26.

A key action point from last year’s survey was to improve information for patients. Scores for patient information around support groups, impact of cancer on work or education, free prescriptions and written information about specific types of cancer have significantly improved this year. Substantial improvements have also been seen in questions regarding ward nurses, with all scores for this section having improved. However, we remain in the bottom 20% of trusts for information regarding operations (pre and post-operative). Disappointingly, questions regarding hospital doctors have not shown any general improvement either. Other areas to note for further consideration and improvements include:

• Access to a Clinical Nurse Specialist • Information regarding discharge and community support • Staff giving information on getting financial help.

UCLH will continue to work with partners such as London Cancer, Macmillan and primary care to find ways to improve the cancer patient experience in the community and in the transition from referring hospitals to UCLH. The Cancer Clinical Steering Group will review this year’s data and work with staff from the multidisciplinary teams to formulate suitable action plans. This will show which actions should continue and identify any new areas that require improvement. The Trust’s Patient Experience Board will review the actions.

The Meridian real-time monitoring system continues to provide us with a snapshot of patient views, both within outpatient and inpatient settings. The data gathered since January 2014 shows a higher score for a number of the questions that scored below the national average in the national survey. This supports the view that improvements continue to be made at UCLH.

The Board is asked to note the key results from the National Cancer Patient Experience Survey, the actions being undertaken and the ongoing commitment to improving the cancer patient experience. The UCLH survey can be found on the Quality Health Website.

3. Biannual Nurse Staffing Report

In December 2013 the Board received a presentation from Katherine Fenton entitled Setting Safe Nurse Staffing Levels. The purpose was to assure the Board that nursing establishments were appropriate to ensure that service quality and patient safety was maintained.

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In June the Board was advised that the NHSE had set out specific requirements in relation to the routine publication of nurse staffing data. One of the requirements was that the Board should receive reports on a six-monthly basis outlining the capacity and capability of the nursing workforce and the level of compliance with national safe staffing guidance. The report was the first of these six monthly reports; the second biannual report was considered by the Executive Board and is attached at appendix A. The Board is requested to note the work currently being undertaken to ensure that there is sufficient nursing and midwifery staffing capacity to comply with the national guidance.

4. Cardiac/Cancer Strategy – Residual Service at UCLH Last month the Board was advised that the Trust had been giving consideration to the

residual cardiology services required following the transfer of the Heart Hospital to Barts Health next spring. It was agreed that the Board should receive a report on the proposals. This was submitted to the EB and is attached at appendix B. It contains an overview of the proposed services to remain in order to provide a local general cardiology service, together with consulting and diagnostic support to UCLH’s acute and specialist services. These UCLH-based services will be provided by a combination of Barts Health staff, through a service level agreement, and a small number of UCLH staff.

5. Ebola Preparedness The EB was updated on the preparations being made within the Trust to respond to

the Ebola outbreak in West Africa and the small chance that affected patients will be admitted to UCLH. The risk of UCLH receiving an Ebola patient is deemed higher than for most other London trusts (with the exception of the Royal Free London), owing to our geographical location and the on-site Hospital for Tropical Diseases.

The work undertaken reflects national guidance and expectations of preparedness

and covers issues of procurement of personal protective equipment (PPE), training in the use of PPE, provision of support services, patient admission processes and risk assessment, and staff communications. As at 3rd November over 400 frontline clinicians, as well as the decontamination team and some Interserve staff, had been trained in the latest equipment and processes. Training is complex, taking at least 20 minutes per person. To augment face to face training a film has been produced which demonstrates the correct donning and removal of PPE. Stock levels of enhanced PPE have been increased to ensure availability in all relevant areas.

With regard to patient admissions, current operating procedures for identifying and

isolating any patient with a suspected infection are considered appropriate. The emphasis to date has been on identifying and preparing isolation facilities in high risk

areas such as the Emergency Department and ITU. A laboratory and diagnostics system has been tested and is in place. Processes for disposing of contaminated waste are also in place.

UCLH is well placed to care for Ebola patients; however we continue to adapt and

adjust our plans according to the guidance from Public Health England and other intelligence.

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6. Emergency Department Development Progress Report Following approval in July of the business case for the expansion of the Emergency

Department, the Board requested quarterly reports on progress, both with the construction work and revised operational procedures to better cope with the growing demand. The first report is attached at appendix C.

7. GP Engagement and Relationship Management At the last meeting the Board was advised that, following a review of liaison arrangements with principal CCGs and GP practices, Jonathan Fielden had agreed to take responsibility for clinical liaison with our three principal CCGs, namely Camden, Islington and Westminster. A review of relationships with significant referring GP practices has been undertaken as a key element of the development of an integrated care strategy across our local communities. It was agreed that details of the arrangements would be presented to the Board.

The attached report from Jonathan Fielden and Helen Taylor, Divisional Clinical Director for Integration (appendix D) provides a comprehensive overview of the GP Liaison Service and the ongoing initiatives aimed at strengthening communication between UCLH and GPs/CCGs.

8. Revised Risk Management Strategy

The Trust’s previous Risk Management Strategy was issued in 2005/6 and has been updated on a regular basis, driven by the review cycle and external requirements (e.g. NHSLA standards). Since then our risk management processes have developed and matured and the main challenge no longer lies in the identification of risk and development of risk management processes, but in the ongoing review and improvement of risk management, particularly with regard to high level escalation and acceptance.

It was concluded that the Trust needed to update its risk management strategy to reflect its current situation. The aim was to develop a strategy which is succinct, accessible and provides a common direction covering the management of all types and sources of risk including clinical safety, business, financial, reputational, health and safety and security. The revised strategy should bring these all together in a manner that allows consistent risk information to be brought to management in an efficient and timely manner that enables good and timely decision making.

Following a process of review involving meetings with key personnel to agree the goals and output for the risk strategy review work, a revised Risk Management Strategy has been produced and was endorsed by the EB. It is attached at appendix E for Board approval. 9. ‘Sign Up to Safety’ Campaign The Sign up to Safety Campaign is a high profile national campaign which commits to halve avoidable harm in the NHS over the next three years, saving 6,000 lives as a result. The Campaign was launched by the Secretary of State earlier this year and is supported by NHS England, Monitor, NHSLA, Care Quality Commission and the

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Department of Health. The campaign invites trusts to Sign up to Safety by setting out what their organisation will do to strengthen patient safety by describing the actions it will take in response to five Safety Pledges. Earlier in the year the Trust declared its intention to subscribe to the Campaign and we began developing our pledges. The pledges comprise: Put safety first – commit to reduce avoidable harm by half and make public our locally developed goals and plans; Continually learn – make our organisation more resilient to risks by acting on feedback from patients, and by constantly measuring and monitoring how safe our services are; Honesty – be transparent about our progress in tackling safety issues and support staff to be candid with patients and their families if something goes wrong; Collaborate – take a leading role in supporting local collaborative learning so that improvements are made across all local services that patients use; Support – help people to understand why things go wrong and how to put them right; give staff the time and support to improve and celebrate progress. The CQC has made it known that they will consider the Safety Pledges as a key source of evidence for trusts to demonstrate how they are meeting the domains of safety and quality. The EB has now formally agreed to commit to the Campaign and its five safety pledges. 10. Capital and Estates Issues

The EB was informed that, under the revised approval process for lower value capital schemes, the Capital Investment Board had approved the creation of two additional side rooms on T11 to reduce the need to transfer paediatric cases to other hospitals. On the recommendation of the CIB, the EB approved the replacement of 19 gastroscopes (out of a total of 29) to support patient activity in Endoscopy. The gastroscopes are used for complex therapeutic work and the poor functioning of the scopes has begun to compromise treatment. The consequence of not replacing them would be that the department would be unable to meet demand and the relevant access targets would not be met.

The EB endorsed a recommendation concerning the grant of a Licence to UCL to install a small hydrogen fire vault on the exterior of their leased area at the Eastman Dental Hospital. The EB also supported the grant of a 12 month licence to its radiopharmacy provider, to regularise their existing occupation of part of T5. The licence forms part of a service level agreement with the provider.

11. Establishment of a Company Limited by Guarantee The EB received a paper seeking approval to establish a social enterprise company

limited by guarantee and wholly owned by the Trust. The purpose is to enable us to attract innovation funding for which UCLH is not eligible as an entity in its own right. This

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is a model that is widely used by UCL and some other NHS trusts and FTs. The proposal is being put forward now to enable us to accept an award that UCL Business has made to UCLH for the development of a listening app for children with cochlear implants. Once established the company will allow the Trust to bid for further social innovation and social enterprise funding.

The EB supported the proposal, subject to legal advice and other due diligence issues.

The Board is requested to delegate authority to the Chairman and Chief Executive to approve the establishment of the company limited by guarantee, should it require Board approval.

SIR ROBERT NAYLOR

CHIEF EXECUTIVE

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Executive Board report to the Board of Directors Appendix A

BIANNUAL NURSE AND MIDWIFERY STAFFING REPORT

1. PURPOSE

1.1. The purpose of this paper is to provide the Board of Directors with an overview of nurse staffing capacity and compliance with National safe staffing guidance. It is a requirement that Boards receive such reports on a six monthly basis (Hard Truths, DH 2014). The Board last received a report in June 2014.

1.2 This paper provides planned versus actual nursing and midwifery staffing since the

June Board report as published on NHS Choices. All trusts have published this data on a monthly basis since May 2014.

1.2 This paper highlights progress with setting the nursing and midwifery establishments, compliance with national staffing guidelines/requirements and updates the Board on issues that impact on availability of staff.

2. NATIONAL NURSE STAFFING CONTEXT

2.1 There has been significant national focus on nurse staffing since the publication of the Francis Report.

2.2 NICE have endorsed The Safer Nursing Care Tool (SNCT) as an appropriate tool for setting nurse establishments and this is used at UCLH.

2.3 Demand has increased for Registered Nurses as a result, however there is insufficient capacity, in the form of pre-registration nursing commissions, to meet the demand see Appendix 1.

3. SETTING NURSING AND MIDWIFERY ESTABLISHMENTS

3.1 The Executive Board have an agreed process for setting nursing and midwifery establishments (EB Establishment Setting Paper, 2012). This includes a number of important components:

• Using the SNCT an assessment of acuity and dependency, on a daily basis for 1 calendar month

• Repeating this exercise three times per year – to ensure validity • External (to the Division) validation to ensure that the data collection is accurate • A multi-professional meeting to agree establishment proposals • Professional judgement from the Head of Nursing and operational, financial and

workforce judgement which triangulates the SNCT data and contributes towards the final proposal

• Sign off by EB before proposals are fed into the annual planning cycle and budgets.

3.2 Although the SNCT has been endorsed by NICE as a tool for setting nurse establishments based on patients’ needs the tool does not currently identify patients in need of 1:1 specialing on wards. The demand for this type of care has increased for a number of reasons, including increases in patients with dementia, mental health issues and risk of falls and an increasing focus on quality which has led to nurses being more risk averse. This element of the tool is being developed by the Shelford Group Chief Nurses.

4. IMPLEMENTATION OF THE ACUITY & DEPENDENCY ASSESSMENT

4.1 The 2013/14 changes in nursing establishment were reported in the paper in June and were implemented in full in April 2014 when budgets were set. As a reminder the breakdown was:

Board Previous Establishment New Establishment Specialist Hospitals 433wte 441wte

Medicine 221wte 233wte Surgery 162wte 162wte

4.2 The Nursing and midwifery board continues to monitor nurse sensitive outcomes in relation to staffing and other factors (such as ward leadership) via the care thermometer. A breakdown of the last 6 months care thermometer data can be found in appendix 2.

4.3 Core principles in determining the nursing and midwifery establishment are maintained as per previous years, namely:

- The ward sister is supernumerary, it is a supervisory role, they use their time to direct care and undertake front line clinical leadership

- The skill mix on the ward will not be below 70:30 for acute wards and 60:40 for sub-acute/rehab wards

- An additional 22% ‘headroom’ resource is included in ward establishments to allow for annual leave, sickness, maternity leave and education. This headroom is not sufficient to meet the training needs and is currently under review.

4.4 The 2014/15 assessment to inform the budget setting for 2015/16 is nearing completion. Acuity and dependency data has been collected and the results will be discussed in November and December.

5. EXTERNAL STAFFING REVIEWS

5.1 Responding to staffing concerns raised within the last 12 months within the cancer and neurosciences divisions, external reviews have been commissioned to provide the organisation with assurance about the staffing within these divisions.

5.2 A cancer review found that the SNCT is a robust tool for assessing staffing requirements; the review has made a number of recommendations which are currently being implemented.

5.3 The neurosciences review will be led by nurses from The Walton Centre in Liverpool and is scheduled to commence in November 2014.

6. COMPLIANCE WITH NICE STAFFING GUIDELINES

6.1 NICE published comprehensive guidance on nurse staffing in July 2014. An analysis has been undertaken of compliance against the guidance which demonstrates only one exception. The exception is “Red Flag” event for example an unplanned omission in providing patient medications. These are deemed to be early indicators of where workforce shortages may have a detrimental impact on care delivery.

6.3 The guidance requires that systems and processes are in place for staff, patients and their families to record red flag incidents so that organisations can monitor and respond to these.

6.4 The UCLH nurse staffing escalation guide includes most of the red flags and asks staff to report their occurrence. A project has been set up to identify an IT solution to support easy reporting by frontline staff and patients/relatives. This will give greater assurance that all red flag incidents are captured.

7. PLANNED VS ACTUAL STAFFING

7.1 All NHS provider trusts are required to publish nursing and midwifery staffing data and show the planned staffing hours (i.e. those that were planned in the roster) vs actual staffing hours (i.e. actual hours worked by substantive and temporary staff). Data is published on NHS choices and on the Trust’s website. A summary of data is contained in graph 1 below.

7.2 Overall staffing levels in June were 9% above the planned staffing numbers. The September data shows that 2% more staff were used than was planned.

7.3 The number of nursing assistant shifts, whilst reducing month-on-month, is the largest contributor towards the 3% over-plan of staff. This is predominantly due to the use of 1-1 specials for patients at risk of falls and/or with dementia/mental health problems.

7.4 The number of Registered Nurse actual hours has fallen month-on-month since June. The August and September position shows that there were fewer Registered Nursing hours worked than was planned. In some areas this has had an impact on activity, with beds being closed or requiring escalation to agency. Heads of Nursing have been involved in the operational management of these situations where they have occurred.

Graph 1. Published Nurse Staffing Data (data is substantive and temporary staff combined)

7.5 The overall monthly position shows a steady decrease in the number of nursing staff used across the Trust since May 2014. For benchmarking purposes graph 2 shows the monthly position as reported by Shelford and UK Teaching Trusts.

June July August SeptemberRN Day 100.16 97.52 94.41 92.2RN Night 103.91 104.11 97.98 98.3NA Day 125.97 121.16 121.65 117.9NA Night 159.25 150.53 141.21 147Combined 109.52 107.16 103.04 102.08

80

90

100

110

120

130

140

150

160

170

% H

ours

Fill

ed

Graph 2: Monthly Staffing Fill Rates for Shelford Trusts (as reported on NHS Choices)

8. MANAGING STAFFING VARIATION FROM PLANNED LEVELS.

8.1 Ward establishments are based on an average acuity and dependency assessment, however on a day by day basis this will vary with some shifts having a higher acuity than establishment and some shifts having a lower.

8.2 It is difficult to achieve the flexibility to staff up and staff down as acuity changes and this often results in the use of temporary staff to support wards.

8.3 A process of staff ‘levelling’ has been introduced recently to try and address this issue. A twice daily assessment is undertaken by the Matrons and site managers of activity and staffing numbers. A new ‘levelling’ tool has been developed and launched trustwide which acts as a decision aid for Matrons, Site Managers and Heads of Nursing to identify wards that may be able to release staff to support another ward.

8.4 The ability to level is closely related to the amount of vacancies a ward has and as such the process has been less successful where wards have a high number of vacancies. It has however contributed towards the reduction in the use of agency staff in ‘amber’ wards as demonstrated in graph 3.

80

90

100

110

120

130

140

July August September

% F

ill o

f Shi

fts UCLH

UHB

NUTH

CMFT

Kings

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

10.08.14 17.08.14 24.08.14 31.08.14 07.09.14 14.09.14 21.09.14 28.09.14 05.10.2014

WTE

Week Ending

Graph 3. Agency reduction for ‘amber’ wards

8.5 The use of temporary nursing and midwifery staff is managed and controlled by the Heads of Nursing for each board. Wards/departments are classified as Amber or Green in relation to staffing as set out in chart 4 below.

Head of Nursing controls include:

• Wards are allocated a ‘bank allowance’. This is the current wte vacancies on the ward converted into hours. The ward is only allowed to book temporary staff up to this bank allowance

• Temporary staff required above the bank allowance requires authorisation of the Head of Nursing. This will only be authorised once all other alternatives have been exhausted and where there is a risk to patient safety of delivery of activity if additional staffing is not provided

• All requests for agency usage in amber wards require Head of Nursing

approval. This is only approved where all other reasonable alternatives have been explored first and levelling of staff across the hospital site has taken place.

Chart 4: Amber/Green ward/departments classification

9. REDUCING THE USE OF 1:1 SPECIALS

9.1 There has been an increasing use of ‘specials’ to provide 1-1 care for patients not only at UCLH but across the NHS in recent years. This is for a number of reasons:

• A significant focus on quality and outcomes such as falls, pressure ulcers, complaints or cardiac arrest numbers which means that individual practitioners are more likely to be cautious about their decisions, and have less appetite for ‘taking risks’.

• Increases in the number of patients with dementia and mental health issues being cared for on general wards.

9.2 The SNCT does not currently identify separately those patients requiring 1:1 nurse specialing (outside of level 3 ICU). This aspect of the tool is undergoing further development by the Shelford Group Chief Nurses.

9.3 A task and finish group has been established to develop an alternative to 1:1 care for patients at risk of harm. An assessment of best practice in relation to 1:1 care has been developed to provide a comprehensive risk assessment for patients requiring increased levels of observation.

9.4 The assessment tool has been through ‘Plan, Do, Study, Act’ cycles and is now part of a wider trial. It is expected that this will demonstrate that care which is at least as safe as 1:1 care can be provided by other means. Outcomes metrics are being used to

Classification/Descriptor Areas included Amber – Head of Nursing must personally approve all agency use. This will only be approved if there are safety concerns and following ‘levelling’ of staffing across hospital sites.

Nursing: all areas - where daily staffing/ acuity tool indicates needs for potential agency use and all other options exhausted

Green – wards are allowed to book agency without additional approval being required. These areas are classed as wards with vacancies which have an operational impact and where recruiting to these vacancies is challenging.

Nursing: • Theatres • A&E • NNU • Critical Care • Haematology (T8) • Paediatric Cancer • Dental • Endoscopy

measure the effectiveness of the tool for the period of the trial, which is expected to run until the end of November 2014.

9.5 The alternatives to 1:1 care described in the new patient assessment are reliant on the availability of monitoring equipment, such as bed/chair/toilet alarms or high/low beds.. A paper will be considered by the EB once the trial completes.

9.6 UCLH has recently committed to working in partnership with Salford Royal Hospital in order to analyse the drivers behind the increasing use of 1:1 care in the NHS and to make recommendations for alternatives. It is expected that this group will produce recommendations late in 2014/early 2015.

10. RECRUITMENT & RETENTION

10.1 The recruitment initiative, commenced in March 2013, has delivered a steady intake with more than 800 staff recruited overall since its launch enabling:

• 654 new starters since Sept 2013 compared 456 leavers (198 more starters than leavers)

• A 47% increase in new recruits (649 appointments compared to 441) in first year;

• A 31% improvement in speed of time to hire (13 weeks compared to 19 weeks) through centralisation of administrative tasks; and

• Recognition of the improvement in the quality of newly appointed staff amongst our ward sisters.

10.2 However despite this there are currently 375.6wte (15.5%) vacancies for Registered

Nurses, 107.1wte (17.9%) for Nursing Assistants with the overall nursing/care staff vacancies standing at 482.7wte (16%). Vacancy data is shown in Appendix 3. These current vacancy rates do not reflect the increases to staff that will be required as a result of opening Evergreen ward and movement of services into the current Heart Hospital site when this transfers to Barts Health. The exact impact of these developments is being analysed currently but is likely to be in the region of c350wte additional posts.

10.3 Approximately 25% of candidates that are booked to attend an assessment centre are

given a conditional offer of employment. A number of actions are being taken to increase the conversion rate including:

• Weekly assessment centres to ensure that candidates are processed rapidly

following application; • Revision of the pre-assessment centre letter to highlight the need for interview

preparation; and • Signposting applicants to pre-assessment centre learning materials such as on-

line practice drug calculations.

10.4 There is a strong pipeline of staff (172 in total as at 17th October 2014 – 50 Nursing Assistants and 122 Qualified Nurses) that have been made a conditional offer and are currently undergoing pre-employment checks or working their notice pending start date with UCLH. Additionally, there are currently 115 shortlisted candidates for a range of specialities (including Queen Square, Emergency Department, Critical Care, Surgical Specialities and Theatres), who will be booked into the assessment centres scheduled in late October and early November.

10.5 Current turnover is 15.2% for Registered Nurses, 16.9% for Nursing Assistants and

15.5% combined. Exit interviews are being conducted with all leavers and the main issues being cited during these are career progression/promotion, relocation and work life balance.

A short-term retention delivery plan is in place to reduce turnover within nursing and midwifery. Monitoring of turnover rates and reasons for leaving is conducted on a quarterly basis at ward level; with intensive support provided to problem areas by

clinical board teams. In addition to this, there are over 20 actions that will be delivered by the end of January 2015. These will ensure nursing and midwifery staff employed at UCLH:

• Receive an excellent onboarding experience • Develop an alumni network • Receive financial assistance to support them in their first months with the Trust • Are offered an informal meeting with the Chief Nurse / Deputy Chief Nurse • Are subject to good management practices • Know how to access personal development opportunities • Understand that there are alternatives to leaving the Trust

10.6 Now is the right to time to close the Recruit 500 campaign and, using the learning derived from this, move forwards with the next stage of accelerated nurse and midwife recruitment at UCLH to meet the strategic priorities set by EB for the end of this financial year. 10.7 A recruitment and retention strategy is being developed and will come into effect in

April 2015. In the short-term, to enable the organisation to get the recruits in the current pipeline into their posts sooner and to increase the number of additional staff being appointed (who are also able to start as quickly as possible), the following steps must be taken:

• Re-energise the advertising and attraction strategy including weekly national

adverts in the nursing press and proactive application of social media; • More rotational posts within and across specialities; • Re-prioritising induction bookings, giving preference to nursing and midwifery

staff. 11. RECOMMENDATIONS

11.1 The Board of Directors is asked to note the work currently being undertaken to ensure that there is sufficient nursing/midwifery staffing capacity in compliance with National safe staffing guidance.

Appendix 1. Nurse Education Commission Projections for NECL Sector

Ward Performance - Rolling six months data April to September 2014

WARD_INT Ward Total Green RAG ratings

Total Amber RAG ratings

Total Red RAG ratings

% Improvements since April

% Declines since April

Nursing & Midwifery %

Staff Sickness

Nursing & Midwifery %

temporary staff usage

Percentage of patients getting

enough help with their meals

Percentage of Complete Vital

Signs Observations

% Hand Hygiene

Compliance

% Harm free care

Inpatient falls with

harm

All Pressure Ulcers

Acquired at UCLH

Preventable dose

omissions

Friends & Family Test (IP survey)

661 Jubilee Ward 8 0 2 33.9% 22.6% 2.4% 21.6% 96.8% 100.00% 100.0% 96.0% 4 0 1.2% 78525 Jules Thorne - Telemetry Unit 7 0 1 20.8% 24.5% 56.0% 94.4% 100.00% 98.2% 100.0% 0 0 78657 RNT C Ward 7 1 2 25.0% 32.7% 10.1% 0.7% 89.0% 96.20% 100.0% 100.0% 0 0 6.0% 79658 RNT B Ward 6 0 4 34.0% 22.6% 1.6% 0.7% 84.5% 94.37% 100.0% 100.0% 2 0 23.9% 77631 T06S - Surgical AAU 6 2 2 23.9% 31.0% 3.2% 17.7% 90.1% 94.52% 90.3% 100.0% 3 0 0.5% 76571 T13N - Haematology 8 1 1 28.1% 29.8% 2.8% 19.4% 95.2% 96.33% 96.4% 98.6% 3 0 0.1% 92659 RNT D Ward 6 0 0 27.3% 9.1% 0.2% 4.8% 96.6% 0 0 -536 MITU 6 0 2 25.0% 28.1% 5.8% 9.9% 97.1% 88.2% 0 0 1.3% -511 HH Floor 4 5 2 3 34.3% 35.8% 1.5% 19.5% 87.5% 88.73% 96.4% 99.1% 3 0 2.3% 87533 Lady Anne Allerton 4 2 4 34.4% 34.4% 1.8% 21.9% 88.5% 86.84% 96.2% 97.9% 3 0 2.2% 52614 EGA Labour Ward 6 1 1 31.6% 15.8% 3.2% 11.2% 98.8% 100.0% 0 0 -553 SITU 6 0 2 37.1% 22.9% 6.0% 9.3% 96.6% 100.0% 0 2 0.3% -617 Neuro-Rehab Unit 5 2 3 25.5% 27.3% 3.7% 16.1% 91.7% 95.83% 100.0% 100.0% 6 0 1.5% 31602 T11S 6 2 1 36.2% 19.1% 3.4% 5.7% 95.79% 93.8% 100.0% 0 0 10.3% -527 John Young 3 2 5 31.9% 34.8% 1.4% 29.5% 84.0% 100.00% 94.6% 98.1% 7 1 1.8% 58644 Molly Lane Fox 3 3 4 33.9% 25.8% 17.7% 27.6% 88.1% 93.94% 92.7% 100.0% 1 0 0.8% 58515 Hughlings Jackson 5 0 5 23.8% 35.7% 1.6% 23.6% 90.0% 89.29% 99.0% 92.2% 1 0 1.5% -531 Chalfont Assessment Epilepsy Unit 4 1 1 34.3% 25.7% 81.3% 97.62% 97.9% 0 0 70611 EGA Birthing Centre 5 0 2 26.7% 16.7% 8.5% 28.3% 98.5% 100.0% 0 0 -601 T11N 6 0 3 29.5% 20.5% 1.6% 20.4% 98.86% 83.7% 100.0% 0 0 3.4% -999769 T13S 3 2 3 30.4% 30.4% 76.9% 100.00% 95.0% 97.8% 3 1 1.0% 67488 David Ferrier 3 2 5 28.2% 26.8% 10.6% 23.6% 90.4% 98.55% 99.8% 95.7% 1 1 5.0% 68604 T12N 4 3 2 24.5% 36.7% 4.2% 15.7% 89.29% 94.4% 100.0% 0 0 3.1% -642 T07 HASU 4 2 4 37.3% 40.7% 3.3% 23.1% 87.4% 96.77% 95.1% 97.8% 5 2 2.9% 80612 EGA MCU 4 2 3 33.3% 30.8% 3.8% 10.6% 88.68% 97.5% 92.2% 0 0 4.2% -490 T02 4 1 0 20.0% 40.0% 0.7% 11.3% 0 0 -999771 T10N 4 2 4 33.3% 34.7% 3.0% 21.8% 88.9% 98.41% 95.3% 95.9% 2 3 2.3% 74606 T12S 4 2 3 32.7% 34.7% 3.0% 11.7% 91.89% 92.4% 100.0% 5 0 3.2% -999761 Albany 3 2 4 33.3% 24.4% 3.3% 23.9% 73.1% 100.00% 93.5% 9 0 0.2% 29508 HH Floor 1 4 1 2 38.7% 25.8% 3.3% 35.9% 97.4% 0 2 1.4% -566 T09 3 2 2 23.8% 38.1% 3.5% 18.6% 84.4% 97.7% 3 0 72633 T14S - WARD 3 0 7 31.9% 45.8% 3.0% 27.1% 82.8% 83.87% 88.2% 100.0% 7 1 2.9% 74507 NQ - HDU 4 0 0 0.0% 0.0% 100.0% 0 0 -637 David Ferrier Stroke 4 0 0 0.0% 0.0% 100.00% 0 0 -495 T03 4 3 3 42.3% 42.3% 4.1% 14.1% 94.5% 100.00% 94.6% 89.4% 2 1 0.6% -674 T9N 5 0 2 48.1% 25.9% 97.33% 97.0% 98.8% 3 0 2.1% -675 T9S 4 0 3 36.4% 31.8% 93.07% 95.8% 98.3% 3 0 1.8% -475 Bernerd Sunley 4 0 6 32.4% 30.9% 6.4% 20.2% 100.0% 96.36% 98.4% 94.2% 4 1 3.2% 85999770 T10S 2 2 6 37.5% 37.5% 5.0% 22.9% 82.2% 95.89% 92.0% 99.4% 3 3 3.8% 68999753 T06N - Adults Inpats 3 3 4 35.6% 34.2% 7.3% 19.4% 86.4% 98.46% 94.4% 99.5% 2 1 2.4% 74999755 T07 3 2 5 41.4% 35.7% 8.4% 17.6% 97.7% 98.65% 93.4% 88.5% 4 3 2.2% 96557 Victor Horsley 2 1 7 32.8% 29.5% 5.5% 24.6% 50.0% 100.00% 100.0% 92.4% 6 2 1.6% 57510 HH Floor 3 1 3 5 39.3% 36.1% 3.4% 23.5% 84.8% 87.50% 93.5% 4 0 3.5% 69577 T16S - Haematology 3 3 4 38.6% 38.6% 5.3% 17.0% 85.7% 96.55% 96.4% 98.1% 4 1 1.5% 61540 NNU 3 2 0 37.5% 25.0% 3.3% 17.3% 0 0 -541 Nuffield 4 2 4 29.8% 33.3% 2.9% 26.0% 85.6% 97.92% 90.7% 100.0% 1 1 8.7% -479 HH ITU North 3 1 4 35.3% 29.4% 4.6% 17.0% 100.00% 89.9% 88.5% 0 1 -496 T08 1 4 5 48.6% 33.3% 6.3% 25.4% 85.9% 98.29% 90.0% 96.0% 13 1 2.4% 67494 AMU 1 2 7 43.8% 42.5% 3.6% 25.9% 74.1% 87.61% 88.7% 95.7% 9 2 3.5% 74632 T14N - Oncology 1 2 7 41.9% 40.5% 8.2% 24.0% 86.2% 94.37% 94.6% 94.0% 5 5 3.4% 78506 Chalfont - Gower 2 0 1 22.2% 33.3% 16 0 -576 T16N - Oncology 1 1 8 33.8% 29.4% 4.7% 22.3% 82.1% 91.38% 90.6% 93.0% 1 2 1.8% 75509 HH Floor 2 2 1 7 45.5% 29.5% 5.4% 21.3% 90.0% 82.26% 90.3% 92.3% 1 1 3.9% -

Appendix 2

Appendix 3. Current Vacancies

Vacant Posts (FTE) Vacant Posts (%)

-

100.0

200.0

300.0

400.0

500.0

600.0

RN/M N/MA ALL

Vacant Posts (FTE)

15.52%

17.89%

15.98%

14.00%

14.50%

15.00%

15.50%

16.00%

16.50%

17.00%

17.50%

18.00%

18.50%

Vacancy Rate

RN/M N/MA ALL

Executive Board Report to the Board of Directors

Appendix B

Proposed Residual Cardiology Services at UCLH 1 Background Specialist cardiac services, currently based at the Heart Hospital, are expected to start to transfer from UCLH to Barts Health NHS Trust at the end of March 2015, completing the move by May. Following the move, there will be a need to continue to provide some cardiology services at UCLH. These “residual” cardiology services will provide the necessary cardiology support to UCLH’s acute and specialist services as well as continuing to provide a “district general” cardiology function for the local population. While an increasing number of cardiological emergencies are taken directly to specialist centres, patients will continue to walk into the Emergency Department with cardiac problems, or have cardiac disease as a co-morbidity when being managed for other pathology. Cancer patients are at particular risk because of toxic chemotherapy regimens. This proposal is in line with local commissioner expectations and feedback from UCLH clinicians. Thoracic surgery is planned to stay at UCLH and is not within the scope of this paper. 2 Development of the proposal The proposal for cardiology services has been developed as follows:

1) Dr Simon Woldman (UCLH lead clinician general cardiology) and Dr Malcolm Walker, Consultant Cardiologist, have agreed the following plan based on their experience and knowledge of the services at UCLH.

2) It is proposed that all clinical activity undertaken at UCLH sites will be owned by UCLH (commissioned from UCLH; governance responsibility with UCLH). Some staff (those already predominantly involved with UCH-based rather than Heart Hospital services) will be employed by UCLH while the team will be supplemented by staff from Barts Health who will work under honorary contracts; in order to retain relevant skills and attract high calibre staff, affiliation or rotation with the specialist centre is considered desirable. The ownership of any future local community heart failure service is yet to be determined.

3) A Cardiology Reconfiguration group has been convened between the Heart Hospital Division and representatives from the Medicine Clinical Board to agree the model and also to provide a implementation group once the model has been agreed. Representatives include Divisional Managers and Divisional Clinical Directors from the Heart Hospital, Medical Specialties and A&E/Critical care, and the Head of Operations for the Medicine Board. The Medical Specialties Division of the Medicine Board will host the residual services.

4) A detailed list of the proposed services has been sent to the Medicine board Finance and Information teams to determine the activity and costs. The activity will need to be included in UCLH’s 2015/16 plan.

5) Further meetings are scheduled with the Cardiology Reconfiguration group to refine and finalise these proposals and agree implementation. Challenge is possible on the balance between (i) affordability (ii) necessity to maintain the relevant services on the UCLH sites and (iii) adequacy of support for other UCLH services.

6) The proposals for local ambulatory services will be discussed with local CCG commissioners.

7) When the proposals have been agreed, the relevant SLAs will be agreed with Barts Health NHS Trust for those staff who will provide services at UCLH.

8) Mechanisms for timely acceptance and information sharing for patients who are referred on to Barts Health for specialist interventions will be agreed as part of the implementation planning.

3 Proposal for cardiology services to be provided for at UCLH

The proposed cardiology services will comprise all current inpatient, outpatient and diagnostics provided at the UCH, NHNN, and Cancer Centre sites and some services currently provided from THH site for UCLH inpatients, outpatients and diagnostics that will be transferred to UCH. There are also some proposed additional services for the UCH site. 3.1 Outpatient clinics

Specialist cardiac outpatient services based at the Heart Hospital (for example Inherited Cardiac Disease, Grown-up Congenital Heart Disease other than in pregnancy, Cardiac Surgery) will move to the Barts site. In contrast, current provision at the UCH, NHNN and MCC sites will continue; some locally-facing Heart Hospital-based outpatient services will transfer to UCH. Specifically: UCH – NO CHANGE 11.5 General Cardiology clinic sessions weekly; 3 Interventional cardiology clinic sessions weekly; 3 Rapid Access Chest Pain clinic sessions weekly; 3 Heart Failure clinic sessions weekly with nurse specialist support; 1 Pregnancy Grown-up Congenital Heart Disease session weekly, with echocardiography support. (Actually an increase from current provision of every two weeks) MACMILLAN CANCER CENTRE - NO CHANGE 2 Thalassaemia (joint with haematology) clinic sessions weekly HATTER INSTITUTE – NO CHANGE 1 Cardiology clinic session weekly; daily nurse and physio-led cardiac rehabilitation clinics PLUS: 1 Electrophysiology clinic weekly and 1 GUCH clinic weekly (a Barts Heart Centre outreach clinic) will transfer to the UCH site. 3.2 Inpatient and specialist support Specialist cardiac inpatient services will move from the Heart Hospital to Barts. Services supporting the acute and specialist non-cardiac services of UCLH will be as follows: UCH – NO CHANGE General Cardiology ward rounds for Admissions, ITU and ward referrals. 5 days a week (registrar led); 3 days a week (consultant led) Heart Failure ward rounds for ward referrals. 5 days a week (nurse specialist led); 1 day a week (consultant led), 1 day a week (registrar led) Transoesophageal echo (TOE) ward rounds for ITU: as needed – approx. 4-5/ month (Consultant led)

2

NHNN - NO CHANGE Cardiology ward rounds for ward referrals. 1/2 day a week (registrar led). 1/2 day every 2 weeks (consultant led) PLUS: Pacemaker interrogation service for inpatients will transfer from the Heart Hospital to UCH. 1/2 day a week (physiologist led)

3.3 Diagnostics UCH – NO CHANGE All current echocardiography and non-invasive diagnostics for inpatients and outpatients will remain the same: echo service for inpatients and outpatients 5 days a week (2 echo machines each for inpatients and outpatients); non-invasive diagnostics (Holters, ECGs, exercise tolerance, BP monitoring) for inpatients and outpatients 5 days a week (physiologist led with cardiographers and clinical assistant practitioner) NHNN – NO CHANGE All current echo and non-invasive diagnostics for inpatients and outpatients will remain the same. Echo service for inpatients 1 day a week (echo cardiographer led); 1/2 day a week (consultant led) and 1/2 day a week (registrar led). Non-invasive diagnostics for outpatients. 3 hours a week (Senior physiologist led) CANCER – NO CHANGE Echo service for oncology inpatients remains the same: Echo service for inpatients1 day a week (echo cardiographer led) PLUS: Ambulatory GP service for outpatients will transfer to UCH. 8 appointment slots/ day x 5 days a week (Clinical Assistant Practitioner led) 3.4 Clinical audit support This is currently provided from THH for UCH, and will be transferred to UCH. 1 day a week (Audit nurse led). 3.5 Future additional support It is proposed that support to UCH inpatients could be improved through additional General Cardiology ward rounds and Heart Failure Ward Rounds and a dedicated monitored AMU bay for patients with cardiological conditions. A proposal for a 7 day consulting service is being developed, together with proposals for an extended Cardio-oncology service. These proposed services (with activity and finance information) will be discussed and agreed by the Cardiology reconfiguration group during November. 4 Staffing of cardiology services to be provided for at UCLH Residual cardiology services will be provided by a combination of Barts Health staff (through an SLA) and directly-employed UCLH staff. All cardiovascular staff will move to the Barts Health NHS Trust other than 1.4 WTE consultants (whose work is more than 50% based at UCH), administrative support, and the cardiac rehabilitation service. Under the current proposal 12.7 wte would remain under UCLH employment with the services of an additional

3

15.4 wte available through an SLA with Barts Health; this may increase by up to 13.5 wte for the additional service developments. Further staffing details are available on request. A detailed schedule of clinical activities has been developed. 5 Issues yet to be addressed 1) The clinical lead for cardiology services at UCLH has yet to be identified. 2) An increment in management for these services has not been included at this stage,

pending further financial analysis, but it may be possible to absorb this within current establishments (a decision for the Medicine board).

3) There is a small requirement for clinical and office space on the UCH site. 4) The cardiology consulting support currently has no identified funding stream. In the past it

did not meet the materiality threshold for internal trading and so was absorbed by the Heart Hospital, but will need to be funded in the future from the income for care of the relevant inpatients. The internal trading mechanism will be developed.

5) There are ongoing discussions about the provision of registrars and their training which have yet to be resolved.

The Board is asked to note the progress to date.

4

Executive Board Report to the Board of Directors Appendix C

Emergency Department Development Progress Report Background The Board agreed the Business Case for expansion of the Emergency Department (ED) in July 2014 and requested quarterly updates on progress. This first update covers our productive ED programme, an update on the building plans and how we are working with the local CCGs. Productive ED Programme – Introducing new ways of working in ED All workstreams are progressing well and they have introduced new ways of working over the last few months. Generally the ‘Plan, Do, Study, Act ‘PDSA’ model of quality improvement has been used to introduce change. Test weeks have been used for each suggested change. Key programmes of work include improving the processes to manage the patient care and experience with the least delay for example Rapid Assessment and Treatment (RAT)

• RAT (early assessment of a ‘majors’ patient). This service is embedded in the ED and the hours for the service have been extended to cover 10:00am -20:00pm. Advantages of this approach include reducing queues for triage, ensuring early senior clinical involvement, and a reduction of unnecessary tests. The main obstacle to its success can be lack of space when all the ‘majors’ cubicles are full. RAT working is now considered business as usual, this workstream will be replaced with a new priority.

• See & Treat (see patient on arrival, assess needs, and provide treatment). Following the review of results of three test weeks this approach now operates 10:00am -20:00pm each day in the Urgent Treatment Centre (UTC). An additional See and Treat stream can be set up to meet patient demand when triggered by the ‘front door’ of the ED.

• Clinical Decision Unit (CDU) (an area for ED patients who require observation, planned investigation or on-going assessment). A project looking at an agreed method for better managing discharge summaries with a nursing group finalising better patient information.

• Escalation – Visual management boards introduced into the UTC and Majors Area in ED to provide information to better manage patients. The information can be reviewed against escalation triggers and prompt action can be taken to avoid long waits developing. Information is updated hourly. This will be rolled out to the Paediatric area during November.

New workstreams:

• Primary Care redirection – The aim of this project is to direct patients to the most appropriate service. Working with CCG colleagues three test weeks are planned for November where GPs will be used to triage/redirect and/or See & Treat patients. Once the most effective model has been determined this service will be expanded and embedded into the ED practice.

• Specialty Review of ED patients – Renewed focus is being given to the specialty response times to attending ED. Manual data is being collected to identify where the main problems are. Algorithms for escalation will be agreed with each specialty – Gynaecology is the test specialty.

Ambulatory Emergency Care Some patients who may previously have been admitted to an inpatient bed can now have their care in an ambulatory setting; these patients can be transferred from ED to the Ambulatory Emergency Care area (AEC) on the AMU. GP direct admissions can also go straight to the AEC. This new way of working is in place and is having a positive impact. The service has been well received by both patients and GPs and is aiding our clinical teams to develop the concept of ambulatory care as a default mode of care.

In order to expand the number of referrals from ED to AEC a test week in August co-located the service in the new area in the EGA Wing which proved to be very positive for both ED and AEC. Further tests are occurring with additional space for AEC on Acute Medical Unit and using the AEC consultant to support the medical take more directly. Urgent Care Transformation Programme This programme covers work with primary care colleagues the aim of which is to avoid emergency admissions and make improvements in the patient pathways through the ED, AEC and Tower wards. Quality Improvement programmes are now running in each area, including the paediatric, care of the elderly, and frailty pathways, and enhancing medical recovery for respiratory and infection patients.

This programme will align with the Trust-wide Transformation Programme and enable more productive ways of working to both improve patient care and the patient and staff experience before and during the further development of the ED. ED Development There is a monthly Project Board, which reports into the Strategic Delivery Board, and numerous workstreams which report into the Project Board each month. Main areas of work to date are:

• Initiation of ED Roadworks (ED Phase 4) – Work is due to commence on site 12th January 2015 until 5th June 2015. First monthly Stakeholder Meeting has been held with those affected by the site works. Key areas to be resolved/completed include disabled parking, extension of the transport pull-in area on Euston Road in front of UCH (known as the Euston slip) by Camden, and gas delivery. No major risks to successful delivery and implementation have been identified.

• ED Phase 5 (Majors) – weekly meetings are taking place to advance the next phase of the design. All risks identified and mitigations in place.

Working with Clinical Commissioning Groups In addition to the strategic and integration work with CCGs, several lines of collaborative working are in place around the ED development:

• An Urgent Care Model Steering Group meets monthly to review current and future models of urgent care ‘front door’ provision. The group has clinical and managerial representation from UCLH, Camden and Islington CCGs. Work is focusing on developing better models of primary care interface with ED through the use of “test weeks” in the UTC.

• Visits to the department - The CEO of Camden CCG (David Cryer) visited the ED and ED also hosted a quality and safety review visit from Camden with CCG Caz Sayer (Chair) and Rosie Price (Quality and Safety Manager).

• Systems Resilience Group - Jonathan Fielden, Medical Director, Medicine Board and Simon Knight, Director of Performance and Planning meet monthly with Camden CCG (plus all Camden health and social care providers) to review and enhance emergency access.

Executive Board report to the Board of Directors Appendix D

GP Engagement and Relationship Management It is important that UCLH continually strengthens strategic relationships with GPs as key stakeholders. To achieve this, UCLH strengthened its GP liaison service in 2013, following a 2012 pilot to ensure more effective GP relationship management. This enhanced the GP liaison work that had been in place since 2007.

The purpose of the GP liaison service is to ensure that UCLH communicates effectively with GPs, involving them in improving services and providing a responsive system to address concerns GPs may have, as well ensuing feedback is provided to GPs on such issues. This “customer engagement” aims to improve relationships, enhance how we jointly care for patients and enhance appropriate referrals from local GPs. The GP liaison programme also supports the development of the GP engagement strategy and the GP relationship management initiative and aims to strengthen relationships between the Trust and primary care, in line with the Trust’s visions and priorities. GP Liaison Programme Initiates

GP Relationship Management Programme A senior management representative manager e.g. a Divisional Manager of Head or Operations fulfils the role of Relationship Manager and is the contact point for the one or more of the top 20 referring GP practices. The manager aims to carry out 1 visit every 6 months and is responsible for identifying areas of good practice, areas requiring improvement and for putting an action plan in place where improvements can be made.

GP Education Programme Throughout the year UCLH hosts evening educational events and seminars for primary care. These are designed to share good practice and ensure that our primary care partners are aware of our services and specialties. They are also an excellent opportunity for discussions and shared learning between our secondary care teams, including consultant and specialist nurses and primary care teams in the development of integrated care. The programme for 2014/15 includes Bone Health, COPD, Dementia & Frailty, Dermatology, Diabetes and Heart Failure. Information is sent to GPs in GP Links (see below) and by email. GP Survey We undertake an annual GP survey in the autumn; this year’s is in progress. The results should be available in the next two months. Last year’s results were presented to the GP Liaison

GP Liaison

GP Web App

Relationship Managers

GP annual survey

GP Links Newsletter

GP Education

eMessaging

Committee. The three main themes for improvement and actions taken by UCLH are shown below. • Discharge summaries needed improving In response to the concerns raised we have reviewed the processes and the quality and timeliness of information provided by our clinical teams to patients’ GPs. As a consequence, we now carry out monthly audits to aid team improvements and have produced a quick reference guide on how to fill in discharge summaries appropriately. This has supported a significant improvement in discharge summaries in all areas, except ED. A separate piece of work is currently underway in ED.

• Difficulty contacting clinical teams to discuss patient referrals We have emphasised the importance of rapid and responsive communications by carrying out quality audits to all our rapid access numbers and secure ‘nhs.net’ addresses and faxes. A rapid access flyer was created with rapid access numbers for GPs to contact our clinical teams with any urgent clinical enquires. The flyer was sent to GPs and is available on our website. Quality audits take place every 3-6 months to ensure our emails, faxes and telephone numbers are updated regularly. GPs are encouraged to send enquiries to nhs.net addresses, which we guarantee to reply to within 48 hours. For urgent admissions we now have our Ambulatory Emergency Care (AEC) unit which has had positive feedback.

• Improve our pathways and work more closely with our community partners Helen Taylor, Divisional Clinical Director for Clinical Integration, is facilitating partnerships around many clinical pathways, particularly for long term conditions in diabetes, heart failure, COPD and elderly care. We are working in collaboration with Camden, Islington and Westminster CCG’s to develop services more effectively. In addition we are listening and responding to concerns raised by GPs and providing timely feedback.

We have also launched UCLH@Home, delivering care in patients’ homes where clinically appropriate, aiding much more rapid discharge for patients. GP Communication GP Links Newsletter - The communications team, supported by the integration team, produces an informative bulletin outlining any pivotal service changes or pertinent information that GPs should be aware of.

GP Portal - The UCLH GP Portal is a web-based clinical solution which allows GPs to access information about patients they have referred to UCLH. It provides GPs with access to UCLH-held patient information, e.g. results, discharge summaries and clinical letters. The portal also provides a comprehensive list of phone numbers for GPs and is updated every 6 months by the GP Liaison Facilitator.

E-messaging - Is the UCLH solution for the electronic transmission of inpatient e-discharge summaries and outpatient clinic letters, from the Trust’s Clinical Data Repository directly into enabled GP practices in Camden, Westminster and, more recently, Islington. The system assists with meeting the following targets: • Inpatient Discharge Summary to be sent to GPs within 24 hours of patient discharge.

• Outpatient clinic letters to be sent to GPs within 5 days after patient has been seen in clinic.

GP Telephone Hotline and Email - The communication team, supported by the integration division, manages the GP non-clinical hotline. This hotline is a central point for GPs with non-clinical queries. For example, a GP may report that they have not received certain letters in a timely fashion or their patient has not received an appointment. The aim is to respond to GP queries within 48 hours. In order to monitor themes and trends, all calls are recorded and information is reported at the GP Liaison Committee.

General Communications - A representative from Camden CCG communication team has attended a UCLH communication team meeting. The communications team also takes part in a teleconference for sector communications. This is managed by Islington CCG and brings together NHS and local government communications leads across the sector.

Clinical Governance Structure The GP liaison work is managed through the GP Liaison Committee, Relationship Management Meeting and Clinical Integration Project Board (CIPB). Ultimate accountability falls to the Medicine Board, which reports to the Executive Board. The CIPB is the key oversight board for integration activities within the Trust. CIPB members include both internal and external parties, including members of the CCG and patient representatives. The CIPB was set up to lead on resolving operational issues, to enhance engagement and strengthen internal governance.

The GP Liaison Committee provides a high level forum where GPs and UCLH staff share information relating to the primary/secondary care interface.

GP Relationship Management Meetings (held every two months) provide a forum for the relationship managers to review GP feedback and address any recurring themes and trends. An action tracker has been established to ensure monitoring and accountability to address areas of improvement GP Relationship Manual In order to support internal stakeholders and improve GP communication, the integration division has produced a GP Liaison Manual for staff. Current GP Engagement Initiatives

• GP Membership on UCLH Clinical Boards - The integration division will work with Clinical Boards and provide support implementing this as required.

• UCLH Local Hospital Strategy – The integration division will be engaging GPs (and commissioners) in the development and co-production of the Local Hospital Strategy.

October 2014

Risk Management Strategy

Version Version 4

Version Date October 2014

Version Approved By Executive Board and Board of Directors

Publication Date November 2014

Author Sandra Hallett, Director of Quality & Safety

Review By Date End of October 2015

Responsible Director AR Mundy, Corporate Medical Director

Monitoring Committee

Executive Board (via the Risk Coordination Board)

Target Audience All Staff

Executive Board Report to the Board of DirectorsAppendix E

1

Table of Context

Page number

Risk Management Strategy

1.0 Introduction

2

1.1 Risk management framework

2

Risk Management Policy

2.0 Policy Statement

3

2.1 Policy scope

3

2.2 Objectives for risk management

3

2.3 The benefits of risk management

4

2.4 Risk tolerance

4

Risk Management Strategy

3.0 Introduction

4

3.1 Accountabilities & responsibilities

5

3.2 Committee Structure

6

3.3 Resources

6

3.4 Implementing risk management

7

3.5

Integrating risk management

8

3.6 Effective risk management

8

3.7 Communication & reporting

8

3.8 Monitor & review

9

3.9 Training

10

3.10 Continual improvement

10

Appendices

1 Committees with responsible for risk 11

2 Quality & Safety Structure 13

2

Risk Management Strategy and Policy

1.0 Introduction

The Trust is committed to ensuring that the management of risk underpins all key strategies, processes and activities that lead to the achievement of Trust main objectives and effective undertakings, therefore safeguarding against the following:

UCLH’s risk management policy and strategy sets out the processes we will use to successfully deliver effective risk management in the Trust. It is supported by procedures to help us take a consistent and standardised approach to risk management across the organisation. 1.1 The Risk Management Framework The risk management framework is as follows;

Damage to the Trust image and reputation Financial

loss

Harm to patients, service users staff, & visitors involved in Trust activities.

Failure to deliver key objectives or

regulatory compliance

The policy states why it is important to manage our risks. It sets out the objectives and benefits to be derived from risk management in UCLH. It also defines the scope for risk management and includes a statement of our commitment to the positive management of risk

The strategy describes how we will deliver the risk policy. It describes the framework and governance arrangements.

The procedures are the documents we have which describe the key processes to help staff with risk management responsibilities to undertake their work

The plan covers the actions and activities we will undertake to ensure the risk management framework is implemented and continuously improving

3

Risk Management Policy 2.0 Policy Statement

The modern healthcare environment is a highly complex environment and one in which there can be significant risk exposure. Things can and do go wrong and the importance of risk management lies in its role in ensuring the identification, evaluation and control of risks so the risks are eliminated where possible or otherwise are reduced to an acceptable level. By managing risk effectively the Trust aims to:

Support achievement of Trust objectives

Protect patients, staff and the public

Protect Trust assets and reputation UCLH adopts a proactive approach to managing risk, this calls for “positive” management of risk in all our activities including: provision of clinical care, education & research, projects, our supporting services and operational and compliance activities. The Trust is committed to an integrated risk management system which incorporates all types of risks including, strategic, clinical, financial, health and safety, operational, external compliance & reputational risks. The overall aim is to make effective risk management an integral part of everyday life within the Trust 2.1 Policy scope This policy and the positive management of risk applies to all areas and activities of the Trust and to all staff employed by the Trust including contractors, locums and agency staff, students volunteers and staff employed on honorary contracts. 2.2 Risk management objectives: The objectives of our risk management policy and strategy are as follows:

To inform policy and operational decisions by identifying risks and their potential impact

Through risk assessments and controls, minimise harm to patients, staff and the public

To ensure risk is managed in an integrated & coordinated way and not in silos

To support innovation by enabling risk to be quantified & controls put in place

To maximise opportunities by adapting to changing risk factors

To raise awareness of the need and value for risk management in the delivery of services and achievement of the Trust objectives

To ensure that learn from experience when things go wrong, to continually improve our processes and the way we work

To make available the appropriate resources and tools people need, to successfully improve risk management at UCLH.

4

To have effective structures in place to enable and provide the leadership support needed for staff to undertake their risk management responsibilities, and to build their risk management capabilities.

To have in place a system of measurement and control 2.3 Risk management benefits: Effective risk management should improve performance by contributing to:

Improved safety for patients and staff Improved outcomes and experience for patients Better service delivery, Reduction in management time spent fire-fighting Increased likelihood of change and transformation initiatives being achieved More focus internally on doing the right things properly Better basis for strategy setting Fewer unpredicted events More efficient use of resources, less risk of wastage or loss including fraud Improved innovation Improved management of estate and contingency planning and response

2.4 Risk Tolerance

‘Risk Appetite’ is the term used to capture an organisation’s unique attitude towards risk and risk taking, which in turn dictates the amount of risk that it considers acceptable. This is often referred to as risk tolerance.

The Board of Directors will judge the tolerable range of exposure for the organisation and identify general boundaries for unacceptable risk (or at least for risks that should always be referred to/escalated up to the Board for discussion and decision when they arise).

The Board will also agree the delegated risk appetite which describes how levels of tolerance are cascaded down the organisation and agreeing risk appetite in different levels of the organisation.

Currently the risk levels are described in the risk procedures which define what risks need to be escalated to the next management level as well as defining the level of risk which must be referred to the Board.

Risk Management Strategy 3.0 Introduction The Risk Management Framework comprises the Risk Policy & Strategy which establishes the mandate and confirms the commitment of the Board of Directors, the Risk Procedures and their implementation, the monitoring & review of risk management practice and finally, continuous improvement to integrate lessons learnt from both internal and external sources.

5

The Risk Management Framework is a continuous cycle to ensure risks are identified, analysed, evaluated and controlled, leading to the management of the risks that threaten the service delivery and achievement of Trust objectives. The Board Assurance Framework (BAF) will be the principle tool used by the Board where risks which threaten the organisational strategic objectives are monitor and evaluated. It will be considered alongside other key management tools, such as the corporate risk register, performance and quality dashboards and financial reports, to give the Board a comprehensive picture of the organisational risk profile. 3.1 Accountabilities & Responsibilities The Board is collectively accountable for the success of the Trust, including the effective management of risk and compliance with relevant legislation and best practice. The Board and Executive Management have overall responsibility for governance of risk management in UCLH. Various committees have delegated responsibilities, see appendices 1 & 2 A summary of the Trust responsibilities is as follows: CEO / Trust Board

Determine strategic approach to risk and set risk appetite

Establish the structure for risk management and provide the high level commitment,

leadership and shared mandate for the management of risk;

Understand the most significant risks

Manage the organisation in a crisis

6

Executive Board

Ensure the strategy is implemented

Manage and assure risk management activities in the Trust

Lead on risk culture

Ensuring the approach to risk management is consistently applied

Ensuring the strategy is implemented

Clinical Boards & Divisional leads Build risk aware culture

Agree risk management performance targets

Ensure implementation of risk improvement recommendations

Identify and report changed circumstances / risks

Trust Risk Manager Develop the risk management policy and keep it up to date Help co-ordinate the risk management activities

Compile risk information and prepare reports for committees

Provides risk training and support

Keep up to date with developments in their specialist area

Individual staff Understand, accept and implement risk management effective procedures

Report inefficient, unnecessary or unworkable controls

Report incidents, near misses and risks

Co-operate with management on incident investigations

Internal Audit Develop a risk-based internal audit programme

Audit the risk processes across the organisation

Receive and provide assurance on the management of risk

Report on the efficiencies of internal controls

3.2 Committee structure

Various committees within the Trust have responsibilities for risk management and these are

attached as Appendix 1 & 2. These will be reviewed as part of the risk plan

3.3 Resources

The Trust accepts the need to make available the appropriate resources people need to put in place measures that help them to successfully manage the risks associated with their job so that we can successfully deliver our plans and our on-going risk management activities. This will include:

People - Making sure people have the skills, knowledge and support they need to do deliver their risk management responsibilities. Training and coaching will be provided to those who need it. Assessing the development needs of staff is integral to the plan.

7

Tools – Making sure that people have the UCLH tools they need to do deliver their risk management responsibilities. This includes:, access to guidance, risk forms, risk register software, incident reporting software, analytical tools, decision support tools (e.g. a risk matrix), etc. Our plan will therefore include development / improvement of tools, support with the use of the tools (including training, see above), roll-out of tools, and provision of access to tools.

Cooperation – Commitment to support each other in managing our risks. To be successful we all need to work together. Something could potentially “go wrong” in one part of our organisation; however the causal factors may originate in another part of our organisation. Our risk management processes will include arrangements to promote work across disciplines and divisions and the means to handle mitigation and management of risk across the organisation (i.e. overcoming internal boundaries).

3.4 Implementing Risk Management We will undertake risk management in accordance with our risk management policy and strategy and following our risk management process in a manner that is proportionate to the magnitude of the risk exposure. Risk management will be embedded in our natural ways of working. The risk management process is how we do risk management in UCLH. Risk management is the responsibility of everyone in the organisation. The risk management process is a continual cycle, systematic approach to all risks throughout the Trust, as illustrated below:

Establish the Context

Identify Risks

Evaluate Risks

Treat Risks

Accept Risks?

Likelihood Consequences

Level of Risk

Analyse Risks

yes

no

Identify Risks

Risk Assess

Risk Register

Treat / Accept Risks

Action Plan

Likelihood Consequences

Level of Risk

Analyse Risks

Likelihood Severity

Risk Grading

Analyse Risks

Mo

nito

r & R

evie

w

yes

no

Com

mu

nic

ate

& C

on

su

lt

8

3.5 Integrating risk into every day practice At UCLH risk management will be a natural part of our normal work activities. Our work procedures and processes (e.g. for annual planning, projects and change management and reporting) will:

Define when we need to identify and assess what can go wrong, and make decisions on measures /control / contingencies to mitigate the risk exposure.

Embed measures / controls actions and requirements to manage the risk posed by the activity. (Note written procedures should highlight and explain their risk measures / controls actions and requirements in the context of “what can go wrong”).

Embed actions to monitor and review the success of our measures, controls and contingencies.

Risk management responsibilities will be an element of people’s job descriptions and performance appraisals. 3.6 Enabling effective risk management The risk management procedures and guidelines will support the above by:

Defining how to identify and assess “what can go wrong” and how to make decisions on measures /control / contingencies to mitigate the risk exposure. This includes when and how to escalate risk for decision / acceptance by more senior management. (Note: escalation does not mean that the responsibility for the management of the risk has been transferred from those undertaking an activity, rather it means that they have gained approval to undertake their activity in an agreed manner.)

Define when and how on-going risk management communication and consultation

activities are to be undertaken across the organisation.

Define when and how on-going risk management monitoring and review activities are to be undertaken. These will inform our continual improvement

3.7 Communicating and reporting The risk management system will support communication and reporting to internal and external stakeholders and will ensure that:

Everyone at UCLH who has risk management responsibilities is aware of the risk management policy and strategy and risk management procedures so that they can undertake their responsibilities successfully.

Engagement and consultation occurs with the right people (internal and external) in

each step in the risk management process. This includes involving the right people in risk identification, and mechanisms for escalating decisions, to appropriate committees,

There is effective reporting of hazards, near misses and incidents of all types (patient

safety, Health and Safety, financial loss, etc.).

9

Reporting on risk management plans, actions and controls, etc occurs in a consistent, effective and timely manner to support decision making, monitoring and review. This includes mechanisms for the consolidation of risk information to enable higher level review

Reporting is achieved in accordance with legal, regulatory and UCLH governance

requirements.

Feedback systems are in place (for example, actions being taken in response to an employee reporting a hazard or following a near miss or incident) to build confidence in the organisation and its risk management system.

There is effective communication with stakeholders in the event of an incident or risk.

Communication and consultation systems are established at all stages of the risk

management process. For example, when undertaking a risk identification and assessment it is important that the right people are involved, and when risk treatments are identified it is important the people implementing actions are informed.

3.8 Monitoring and review Our risk management performance will be monitored and reviewed to ensure that risk management in UCLH is effective and supports us in the successful delivery of our core purpose and objectives. The monitoring and review covers:

Regular reviews of the potential events or uncertainties (what could go wrong) and how they are being managed. On an individual basis this includes consideration of the level of risk, progress with risk mitigation actions and the current effectiveness of risk measures / controls / contingencies. Concerns should be escalated to the appropriate management level for consideration and response.

Investigations of reported near misses and incidents, both clinical and non-clinical to

understand root causes, and to develop risk mitigation actions (specific measures / controls and contingencies)

Gaining assurance that (i) the measures / controls / contingencies are in place and

performing as specified, (ii) risk plans are being progressed and (iii) we are working in accordance with our risk management system and processes. This is achieved in three parts:

1. Self-assessment – Line managers are responsible for self-assessment of the

risks associated with the delivery of trust objectives including operational activities, projects and business developments.

2. Internal audit – The board will set and review the internal audit requirements

which will focus on assessing the measures / controls / contingencies of greatest importance in mitigating the risks to the organisation.

3. External audit and assessment- The Trust will respond positively to

outcomes of external audits, assessments or inspections (e.g. Care Quality Commission) in relation to the management of risk, compliance and best practice

10

All the above will inform our assurance framework which is provided to the Board of Directors so they can make a judgement on how effectively we are managing our organisation’s risk. We will assess how well risk management across UCLH is performing (performance monitoring) in UCLH and if it is delivering the objectives and benefits defined in the Risk Management Policy. This monitoring will cover indicators (e.g. compliance with risk management requirements, progress with risk plans, near miss and incident rates). 3.9 Training We will ensure that adequate training is in place to help equip our staff to understand and apply our systems and processes in the successful management of risk 3.10 Continual Improvement in the effective management of risk Periodic review of our risk management policy, processes and tools will take place. Based on this and a wider understanding of the context in which we operate, decisions will be made on developments and improvements to include in the risk plan. These decisions will be aimed at improving our management of risk and risk culture throughout the organisation to ensure that our risk management system remains effective, efficient and robust.

11

Appendix 1 Relevant Committees with responsibilities for Risk Management

The following describes how responsibilities of different Trust committees for risk management are undertaken. Committees of the Board of Directors and Executive Groups reporting structure is at Appendix 2 Audit Committee The Audit Committee is constituted as a standing committee of the Board of Directors. Its primary role is to ensure the maintenance of an effective system of integrated governance, internal control and risk management, across the whole of the organisation’s activities (both clinical & non clinical) In particular the Committee will review:

The Assurance framework including updates & reports.

The work of the Quality & Safety Committee, Risk Coordination Board and Executive Board

The processes for ensuring compliance with Terms of Authorisation & other regulatory, legal and code of conduct requirements.

Commissions safety improvement projects in response to aggregated trends from Serious Incidents claims & complaints and from national alerts and patient safety priorities

The Risk Co-ordination Board The Risk Co-ordination Board is a subcommittee of the Executive Board. Its purpose is to coordinate risk management activity within the Trust including clinical, financial, organisational, reputational and environmental risks and in particular to:

Monitor & review risk management systems & processes

Consider and coordinate all identified high graded risks and provide an integrated Trust Risk Register for the Executive Board, & Board of Directors.

Review and provide the challenge to risk action plans & risk controls on behalf of the Executive Board

Assess & review the effectiveness of risk management processes and to make recommendations for developments to the Executive Board

The Risk Coordination Board (RCB) provides quarterly reports to the Executive Board & Board of Directors which includes the Trust Risk Register and the Trust Top Risks. These reports are also submitted for information to the Audit Committee.

In addition to formally submitted reports to ensure transference of knowledge and information there is common membership of all the committees by executive and non executive directors to ensure & monitor that appropriate action is taken. Appendix 2 shows the Quality, Safety and Risk reporting structure and links.

12

Quality & Safety Committee The Quality & Safety Committee is also constituted as a standing committee of the Board of Directors. It has a broad membership from clinical divisions and includes non executive directors and governors and has a non executive director chair. It has a number of executive groups reporting to it, all of which have responsibility for a specific aspect of patient safety. It receives reports and reviews the following:

Standard reports from clinical divisions using a Key Performance Indicator (KPI) data set to highlight performance in relation to national guidance (NICE, NSF, NCEPOD) national targets (MRSA, C.Diff.) clinical standards (mortality, re-admissions) and serious untoward incidents, claims, complaints and serious clinical deficiencies.

Reviews progress, compliance and seeks assurance against Standards for Better Health & NHSLA risk management standards.

Receives reports from sub committees including Patient Safety & Risk Steering Group and Quality & Effectiveness Steering Group.

Reviews clinical risks and ensures appropriate action is taken and is effective locally and Trust wide.

The Quality & Safety Committee (QSC) provides monthly reports to the Executive Board and Board of Directors. Through its reporting arrangements the QSC provides assurance to the Board of Directors and submits recommendations to the Executive Board for action through the Executive line. The Quality & Safety Committee submits a quarterly report to the Risk Coordination Board for integration with the risk register and which identifies significant risks arising from SUI's, complaints, claims, national alerts and patient safety priorities. The Executive Board At UCLH the Executive Board is responsible for managing and assuring risk management activities in the Trust. The Chief Executive takes overall leadership responsibility for risk management and is responsible for ensuring that this Strategy is implemented. The Board and Chief Executive are also responsible for ensuring that an open and fair culture is developed and sustained throughout the Trust because this is an essential foundation for effective risk management. The Director of Corporate Services will ensure that papers received to be discussed at Executive Board and Board of Directors address the issue of risk in line with this strategy. Board of Directors Risk Management Role The Board of Directors is ultimately accountable for ensuring that the Trust is complying with its Terms of Authorisation which includes its arrangements for integrated governance and effective risk management.

Appendix 2 13 Quality & Safety Committee Structure

Board of Directors

Quality & Safety Committee

Investment Committee

Audit Committee Finance and Contracting Committee

HR and Comms Committee

Remuneration Committee

Executive Board Policy Sub Group

Risk Coordination Board

Patient Safety and Risk Steering Group Clinical Effectiveness Steering Group Patient Issues Committee Regulatory Standards Steering Group

Reporting Committees:

Health and Safety

Radiation Protection

Blood Transfusion

Medical Devices

Resuscitation

Haemostasis & Thrombosis

Infection

Medicines Safety

Deteriorating Patient

Reporting Committees:

Use of Medicines Committee

Clinical Audit & Improvement

Clinical Guidelines Committee

Critical Care Delivery Group

Clinical Nutrition Advisory Group

NICE Implementation Steering Group

HTA-Human Applications steering group

Antimicrobial Usage Committee

F

Agenda Item 10

Performance Report

Report to board of directors

Report Title Board of directors performance report Report from Simon Knight Prepared by Bindi Shah Previous papers Board of directors performance report Current issues

Action Month first raised

Theatre utilisation

(Page 7)

Raw data has been collected from the participating sites and the performance calculated by the benchmark company. This overcomes the most significant previous concern over data quality - namely the range of different types of utilisation calculation that is in use and the uncertainty about which method different organisations have used. This benchmarking is undertaken annually. The current data refers to data we submitted in 2011/12 and 2012/13. During this time there were data quality issues as the theatre system was only being sporadically used across the Trust. The submitted data for 13/14 is due to be reported in November and it is anticipated this will provide a good comparator for theatre utilisation.

The data from 2012/13 largely shows UCLH as being in line with other organisation with scope for improvement. There has been on-going work within theatres through productive theatres and a specific initiative supported by KM&T. There is scope for improvement within theatres across the trust. For the Tower there is more opportunity for improvement by looking at patient flow out of recovery and into tower wards and this was the catalyst for the successful 'Home by Lunch' project and need for a single point of contact for management of tower beds first.

August 2014

Cancer waits

(Page 9)

The Trust failed to achieve the 14, 31 day diagnosis to treatment and subsequent surgery as well as the 62 day GP referral to treatment standards in September. The final position will be validated after the Open Exeter reporting deadline for September. Breaches were mainly due to patient choice, administrative issues and particularly lack of capacity for the 31 day waits. The majority of 62 day standard breaches were due to late referrals from other Trusts.

July 2013

RTT update

(Page 8)

For September, we reported a non-compliant position for all three RTT measures. We also recorded 39 patients waiting over 52 weeks.

The Trust has agreed with Monitor and CCGs to bring forward recovery from March 2015 to end December 2014 (reporting a compliant position from January). This means increasing activity further in Q3, which is being delivered through increased productivity, increased weekend work and increased outsourcing.

July 2013

A&E

(Page 11)

In September, we missed the standard for 95 per cent of Emergency Department patients to be seen within four hours. This was mainly due to bed capacity (as a result of ongoing increases in non-elective and elective demand on beds) and departmental delays. The Trust has an Urgent Care Transformation Board which is chaired by the Medical Director and is delivering a wide-scale programme to deliver the 4 hour wait. The Trust aims to get back to compliance by November 2014, and does expect to achieve compliance for Q3 overall.

April 2014

VTE assessment (Page 12)

The Trust missed the 95% standard of patients admitted being assessed for VTE in September. We will be asking divisions to validate their cohorted patients to ensure these are still valid and will be meeting with the VTE leads to agree an action plan to bring back performance to the required standard.

Financial penalties incurred to date with our commissioners are estimated at £53k.

September 2014

September 2014

Month 6 - September

Board of Directors Performance Report

Month 6 - September

1. Executive summaries

2. Finance

3. Delivery of QEP

4. Access

5. Patient Safety and Quality metrics

6. Workforce

7. Externally Reported Frameworks

Page Con

Board of Directors Performance ReportContents

Month 6 - September

Board of Directors Performance Report

Data quality score:

√√ high data quality

√ sufficient data quality

x not sufficient data quality

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% Elective variance -5.3% 0% 29.1% -10.5% -1.8% -3.8% 23.5% -4.0% -4.3% √√ Number of MRSA Bacteraemias 0 0 0 0 0 1 0 1 0 √√

% Daycase variance 2.1% 0% -15.7% 3.3% 4.3% 0.0% -14.3% 1.8% 0.1% √√Number of clostridium difficile cases

due to lapses in care 3√√

% Non-elective variance 10.7% 0% 18.1% -6.4% 11.4% 8.9% 5.5% -6.2% 13.5% √√Number of clostridium difficile cases

under review 13 4 5 4 19√√

Outpatient Variance 2.9% 0% 1.1% 2.8% 3.4% 0.9% 2.7% 2.1% 0.0% √√Number of clostridium difficile cases

successfully appealed 0 0 0 0 35√√

% Hand Hygiene Compliance95.5% 100.0% 94.1% 93.7% 96.3% 95.3% 92.4% 95.2% 95.6%

√√

Trust theatre utilisation 73.9% 85% 76.5% 71.9% 74.9% 78.7% 72.0% √√Number of MSSA Bacteraemias

(Trust Attributable) 1 2 0 0 1 11 3 4 4√√

Tower elective theatre utilisation -

total elective time utilised76.5% 85% 76.5% 76.3% 78.4% 78.7% 77.1% √√

Queen Square theatre utilisation 71.1% 85% 71.1% 71.6% 71.6% √√

All Pressure Ulcers Acquired at

UCLH 4 9 0 2 2 39 7 18 14√√

% Non-admitted closed pathways

under 18 weeks91.8% 95.0% 98.1% 92.6% 90.1% 93.0% 96.5% 92.4% 92.3% - Inpatient falls with serious harm

0 0 0 0 0 3 0 0 3√√

% Admitted closed pathways under

18 weeks79.9% 90.0% 94.0% 77.3% 81.2% 83.3% 97.2% 81.8% 82.3% -

Percentage of Completed eVTE Risk

Assessments96.3% 95.0% 96.1% 96.5% 96.2% 96.3% 96.1% 96.5% 96.2% √√

% incomplete pathways < 18 weeks 88.5% 92.0% 98.2% 90.7% 86.4% 87.5% 97.2% 86.9% 86.6% -Complaints responded to within

target time 75.0% 85.0% 87.5% 72.0% 73.3% 75.5% 82.9% 65.5% 78.3%√√

A&E attendances within 4 hours 94.2% 95.0% 94.0% 95.0% 95.0% - Friends & Family Test Score73 70 76 72 72 73 70 71 76

√√

% Diagnostic waiting list within 6

weeks95.6% 99.0% 96.3% 95.6% 88.2% 94.9% 99.3% 95.7% 93.4% -

Sickness absence rate (%)

3.2% 4.0% 2.7% 2.5% 2.5% 3.0%

√√

Cancer 62 Day GP referral to

treatment 65.5% 85.0% 40.0% 57.7% 83.3% 73.9% 80.8% 65.0% 86.5% √√

Average time to recruit (request

pack - start date) 13.7 14.2 13.0 14.1√√

Cancer 62 day referral from

screening to treatment100.0% 90.0% 100.0% 100.0% 100.0% 100.0% √√

% Statutory and mandatory training

compliance 82.0% 83.0% 83.7% 82.2% 80.0%√√

Cancer 31 Day Subsequent Surgery

Treatment80.6% 94.0% 66.7% 100.0% 94.9% 100.0% 90.6% 100.0% √√

Appraisal Tier 3 - All remaining AFC

staff at Band 7 and above including

all DCDs 93.4% 90.0% 96.2% 97.0% 90.2%

√√

Cancer 31 Day Subsequent

Chemotherapy Treatment98.7% 98.0% 98.7% 99.1% 99.1% 100.0% √√ % Vacancy rate

15.2% 8.0% 14.9% 15.9% 13.4%√√

Cancer 31 Day Subsequent:

Radiotherapy95.1% 94.0% 95.1% 97.9% 97.8% 100.0% √√

Cancer 31 Day Subsequent: Other 100.0% 98.0% 100.0% 100.0% 97.3% 100.0% 96.5% 98.0% √√

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Cancer 31 days from diagnosis to

first treatment95.0% 96.0% 100.0% 93.9% 100.0% 97.2% 100.0% 96.9% 97.9% √√

HEADLINE FINANCIAL

PERFORMANCE (Overall Rating) 3

Cancer GP referral to appointment 92.0% 93.0% 92.9% 90.9% 93.3% 93.2% 91.5% 93.1% 96.3% √√1. Operational Performance (Debt

Service Cover) 1

Cancer 14 day wait from referral

(symptomatic breast)87.4% 93.0% 87.4% 95.2% 95.2% √√

2. Cash and Balance Sheet

Performance (Liquidity) 4

QEP

* The trust threshold is an aggregate of individual clinical board thresholds Page 1

1.2 Executive summary: board performance

This month Year to date

Infection

Page 16

Quality and

safety

Pages 17 - 19

Activity

Page 5

This month Year to date

Month 6 - September

Efficiency and

productivity

Page 13

18 weeks and

other access

indicators

Page 14

Cancer

Page 15

Workforce

Pages 20 - 21

Finance

Page 3

Page 2

2. Financial Performance2.1 Financial Performance Summary

Month 6 - September

Area of review Key Highlights

YTD Monitor Continuity of

Service Risk Rating (CoSRR)

Month 6

actual

Month 6

plan

Month 5

actual

HEADLINE

FINANCIAL

PERFORMANCE

(Overall Rating)

The month 6 income & expenditure position, reported before donation adjustments (i.e. income &

depreciation relating to donated assets), is £2.5 million behind plan (-£0.8m actual vs. +£1.7m plan)

(YTD overall rating = 3).

After the inclusion of donation adjustments, the M6 bottom-line position is a deficit of £0.1 million.

NHS clinical income is £6.7 million ahead of the Trust’s M6 YTD plan, & is analysed as follows:

o Income from patient activity £1.9 million ahead of plan (+£1.1m in-month),

o Drugs, devices & pass-through income is £4.8 million ahead of plan (+£0.9m in-month).

At M6 there has been no release from the Trust’s £5m Board contingency (YTD budget is £2.5m).

3 3 3

1. Operational

Performance

(Debt Service

Cover)

At M6, the Trust’s revenue available for debt service is £4.0 million behind plan (£30.1m actual vs.

£34.1m plan). M6 YTD clinical board positions are as follows:

o Medicine is £0.8 million behind plan (balanced against plan in-month),

o Specialist Hospitals is £7.3 million behind plan (-£0.5m in-month),

o Surgery & Cancer is £4.8 million behind plan (-£0.9m in-month),

o The remaining Corporate budgets within EBITDA (including R&D & Education) are £8.8 million

ahead of plan,

o Interest income is balanced against plan.

Revenue of £30.1m is able to cover 1.2 times the Trust’s debt service (YTD rating = 1).

1 2 1

2. Cash &

Balance

Sheet

Performance

(Liquidity)

The liquidity ratio shows that working capital (i.e. cash plus debtors less creditors) is able to cover 25

days of the Trust’s operating expenses (YTD rating = 4).

At 30th September 2014 the Trust’s cash balance was £91.2 million, £20.9 million behind the planned

cash position of £112.1 million.

The current forecast for October month-end is a cash balance of £86m (£17m behind plan).

Of the current capital programme totalling £103.1 million, 68% (or £69.8 million) is approved & in

progress.

M6 capital expenditure of £18.2m is £8.1m less than plan (of £26.3m).

4 4 4

Area of review Key Highlights

YTD Monitor Continuity of

Service Risk Rating (CoSRR)

Month 6

actual

Month 6

plan

Month 5

actual

HEADLINE

FINANCIAL

PERFORMANCE

(Overall Rating)

The month 6 income & expenditure position, reported before donation adjustments (i.e. income &

depreciation relating to donated assets), is £2.5 million behind plan (-£0.8m actual vs. +£1.7m plan)

(YTD overall rating = 3).

After the inclusion of donation adjustments, the M6 bottom-line position is a deficit of £0.1 million.

NHS clinical income is £6.7 million ahead of the Trust’s M6 YTD plan, & is analysed as follows:

o Income from patient activity £1.9 million ahead of plan (+£1.1m in-month),

o Drugs, devices & pass-through income is £4.8 million ahead of plan (+£0.9m in-month).

At M6 there has been no release from the Trust’s £5m Board contingency (YTD budget is £2.5m).

3 3 3

1. Operational

Performance

(Debt Service

Cover)

At M6, the Trust’s revenue available for debt service is £4.0 million behind plan (£30.1m actual vs.

£34.1m plan). M6 YTD clinical board positions are as follows:

o Medicine is £0.8 million behind plan (balanced against plan in-month),

o Specialist Hospitals is £7.3 million behind plan (-£0.5m in-month),

o Surgery & Cancer is £4.8 million behind plan (-£0.9m in-month),

o The remaining Corporate budgets within EBITDA (including R&D & Education) are £8.8 million

ahead of plan,

o Interest income is balanced against plan.

Revenue of £30.1m is able to cover 1.2 times the Trust’s debt service (YTD rating = 1).

1 2 1

2. Cash &

Balance

Sheet

Performance

(Liquidity)

The liquidity ratio shows that working capital (i.e. cash plus debtors less creditors) is able to cover 25

days of the Trust’s operating expenses (YTD rating = 4).

At 30th September 2014 the Trust’s cash balance was £91.2 million, £20.9 million behind the planned

cash position of £112.1 million.

The current forecast for October month-end is a cash balance of £86m (£17m behind plan).

Of the current capital programme totalling £103.1 million, 68% (or £69.8 million) is approved & in

progress.

M6 capital expenditure of £18.2m is £8.1m less than plan (of £26.3m).

4 4 4

Page 3

2. Financial Performance2.2 Service lines summary

Month 6 - September

Page 4

2. Financial Performance2.3 Clinical income summary

Month 6 - September

Page 5

2. Financial Performance2.4 Clinical income summary - commentary

Month 6 - September

Notes - Clinical Income

1. At Trust level all activity types except “other” were ahead of plan in month.

2. All three clinical boards were ahead of plan on activity income overall, but with some large over & under-performances at divisional level. Drugs &

devices usage continues to significantly exceed planned levels.

3. Potential contractual penalties & planned commissioner intentions impact (not devolved to divisions) are accrued corporately. Estimated RTT

penalties for Apr-Sep have been removed for divisions where a delay in application has been negotiated with commissioners leaving only (-£0.2m) in

clinical board positions.

4. C.diff penalties have not been devolved to clinical divisions.

5. (+£0.5m) of ‘freeze’ 13-14 CQUIN income receivable in 14-15 has been reported as part of the clinical boards’ positions having been transferred from

Corporate.

6. Referral-to-treat (RTT) penalties of (-£0.2m) YTD have been devolved to divisions with the assumed reinvestment being accrued corporately

7. CQUINs are being reported based on a forecast of 90% completion.

8. The M6 YTD variance of (-£0.1m) on the corporate line – as shown on p3 – is made up as follows:

o 14-15 commissioning gains (including commissioning intentions) not attributable to divisions (+£2.0m),

o Release of income contingency (+£1.5m),

o Reinvestment of RTT penalty income (+£0.2m),

o Emergency Threshold (+£0.4m),

o 13-14 CQUIN benefit (+£0.2m),

o Additional QEP activity target held Corporately (-£4.4m).

Page 6

Month 6 - September

3. Delivery of QEP

Commentary

■ The M6 QEP position shows that

the Trust is £4.2m adverse against

planned YTD performance. The

14/15 FOT position is savings of

£31.6m (82% of plan) - a gap of

£6.8m against the annual plan.

■ Medicine Board is reporting a

£1.3m adverse YTD position &,

based on identified schemes, is

currently forecasting a £1.6m

adverse variance against plan for

the year. The board has to-date

identified £4.1m worth of schemes

to be delivered in 14/15.

■ Specialist Hospitals Board is

reporting a £3.3m adverse YTD

position &, based on identified

schemes, is currently forecasting a

£6.7m adverse variance against

plan for the year. The board's QEP

shortfall is mainly centred within the

Women's Health, Queen Square &

RNTNE divisions. Against the

board's annual target of £16.6m,

14/15 schemes totalling £9.9m

have been identified.

■ Surgery & Cancer Board is

reporting a £0.4m favourable YTD

position &, based on identified

schemes, is forecasting a £1.5m

favourable variance against plan.

The board’s annual target is

£13.0m, of which schemes totalling

£14.5m have been identified.

■ Corporate areas are reporting a

balanced position against both the

YTD plan & FY QEP target. As the

performance of the PDC scheme is

dependent on maximising cash

balances in the Trust's GBS

account, it is assumed that going

forward the overall cash position

will come into line with plan.

Page 7

3.1 Financial analysis

3. Delivery of QEP

Month 6 - September

Commentary

■ The M5 QEP position shows that the

Trust is £3.6m adverse against

planned YTD performance. The 14/15

forecast outturn position is savings of

£31.8m for the year (83% of plan) - a

gap of £6.6m against the annual plan –

but also an improvement of £1.1m from

the FOT position shown at M4.

■ Medicine Board is reporting a £1.1m

adverse YTD position &, based on

identified schemes, is currently

forecasting a £1.6m adverse variance

against plan for the year. The board

has to-date identified £4.1m worth of

schemes.

■ Specialist Hospitals Board is reporting a

£2.7m adverse YTD position &, based

on identified schemes, is currently

forecasting a £7.3m adverse variance

against plan for the year. The board's

QEP shortfall is mainly centred within

the Women's Health, Queen Square &

RNTNE divisions. Against the board's

annual target of £16.6m, schemes

totalling £9.3m have been identified.

■ Surgery & Cancer Board is reporting a

£0.2m favourable YTD position &,

based on identified schemes, is

forecasting a £2.3m favourable

variance against plan. The annual

target is £13.0m, of which schemes

totalling £15.3m has been identified.

■ Corporate areas are reporting a

balanced position against both the

YTD plan & FY QEP target. As the

performance of the PDC efficiencies

management scheme is dependent on

maximising cash balances in the Trust's

government banking service account, it

is assumed that going forward the

overall cash position will be in line with

plan.

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Trust theatre utilisation85% 73.9% 76.5% 71.9%

Tower elective theatre utilisation - total

elective time utilised85% 76.5% 76.5% 76.3%

Queen Square theatre utilisation 85% 71.1% 71.1%

DNA rate 8% 11.9% 12.8% 12.4% 11.5%

Discharge rate for outpatient

attendance22.8% 20.3% 7.8% 32.2%

Number of ambulatory care cases 131 129 131

Page 8

3. Delivery of QEP3.4 Efficiency and productivity

This month

Month 6 - September

Productive Outpatients - Overall the improvement in Trust discharge rates has been maintained. All 200 clinics at RNTNEH are going though the programme currently. The teams participating have all held their re-design events this month. Each team presented the data they have collected about their service and proposed a wide range of initiatives that will achieve improved patient experience and service compliance to 18 weeks, whilst continuing to deliver a high quality service to patients. Flow - The emergency ambulatory care levels have increased again this month, and are virtually on target, helping free up inpatient beds. Work on flow continues across the Trust and the QEP team has supported the introduction of a new Medical director led weekly Tower Flow Group meeting to address the key issues which cause delays for our patients. As part of the urgent care transformation work rapid assessment for ambulance arrivals has been extended, the see and treat test weeks have commenced in ED and the AMU transformation programme has commenced. In addition, the ‘Home for Lunch’ campaign continues to have a significant impact on pre-midday discharges on the test ward (three-fold increase) and a roll out plan across the Tower has been agreed. Pathways - The QEP team has started working with QS teams on the brain tumour and other neurosurgery pathways, with expected median length of stay of 5.5 days. The filming for the pelvis osteotomy pathway was completed in September and has a planned release date of December 2014. We are also working on the three quality improvement NHS England CQUINs this year that will focus on improving specialist commissioning pathways for multiple sclerosis, brain tumour, pelvis osteotomy and in rheumatology ehlers-danhlos syndrome hypermobility patients. Theatre Utilisation - Our theatre utilisation figures remain low as a result of numerous constraints, including the pressure on beds in the Tower. Plans are being agreed that will help to unblock some of the delays including: creating a capacity and demand model for Echo, agreeing next steps following the acute radiology service review, introducing theatre quality boards and the work on morning discharges.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Percentage trust theatre utilisation - All Services

Tower elective theatre utilisation - total elective time utilised Queen Square theatre utilisation

0%

5%

10%

15%

20%

25%

30%

35%

Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14

Dis

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Discharge rate for outpatient attendances - All Services

Not On Pop discharge rate On Pop discharge rate

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% Non-admitted closed pathways

under 18 weeks95% 91.8% 98.1% 92.6% 90.1%

% Admitted closed pathways under

18 weeks90% 79.9% 94.0% 77.3% 81.2%

% incomplete pathways < 18 weeks 92% 88.5% 98.2% 90.7% 86.4%

18 week pathways >52 weeks (open) 0 39 0 2 37

% Diagnostic waiting list within 6

weeks99% 95.6% 96.3% 95.6% 88.2%

% Last Minute Cancellations to

Elective Surgery0.8% 0.4% 0.0% 0.3% 0.5%

A&E attendances within 4 hours 95% 94.2% 94.2%

Page 9

4. Access4.1 Access Targets - Referral to treatment

This month

Month 6 - September

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

A&E attendances within 4 hours

A&E attendances within 4 hours Target

For September, we reported a non-compliant position for all three measures. We also recorded 39 patients waiting over 52 weeks. The Trust has agreed with Monitor and CCGs to bring forward recovery from March 2015 to end December 2014 (reporting a compliant position from January). This means increasing activity further in Q3, which is being delivered through increased productivity, increased weekend work and increased outsourcing. Progress is tracked closely via a weekly RTT meeting with divisional managers, a weekly steering group with medical directors and a weekly RTT performance pack reported to EB. Generally the Trust is meeting the activity target, however, the backlog is not reducing as quickly as planned. This is due, in part, to the ongoing validation of all elective pathways to ensure that they are correctly reported as RTT. Validation will be complete by 10th November, by which time we will know the full volume of additional activity required to maintain achievement against the trajectory. The Trust continues to miss the target for diagnostic waits within 6 weeks in September. Those departments that are non-compliant have developed recovery trajectories - most expect to achieve compliance by Q3 (endoscopy, MRI, Ultra-sound, ECHO and cystoscopy). This should bring overall Trust compliance by this point. Sleep studies are predicting compliance by Q4 as the service is undergoing a pathway re-design programme. In September, we missed the standard for 95 per cent of Emergency Department patients to be seen within four hours. This was mainly due to bed capacity (as a result of ongoing increases in non-elective and elective demand on beds) and departmental delays. The Trust has an Urgent Care Transformation Board which is chaired by the Medical Director and is delivering a wide-scale programme to deliver the 4 hour wait. The Trust aims to get back to compliance by November 2014, and does expect to achieve compliance for Q3 overall.

70%

75%

80%

85%

90%

95%

100%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Referral to treatment % completed and incomplete pathways under 18 weeks

% incomplete pathways < 18 weeks % Non-admitted closed pathways under 18 weeks

% Admitted closed pathways under 18 weeks

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Two week wait from referral to date first seen93% 92.0% 92.9% 90.9% 93.3%

Two week wait from referral to date first seen: breast symptoms 93% 87.4% 87.4%

31-day wait from diagnosis to first treatment96% 95.0% 100.0% 93.9% 100.0%

31-day wait for second or subsequent treatment: surgery94% 80.6% 66.7% 100.0%

31-day wait for second or subsequent treatment: drug treatments98% 98.7% 98.7%

31-day wait for second or subsequent treatment: Radiotherapy94% 95.1% 95.1%

31-day wait for second or subsequent treatment: other98% 100.0% 100.0% 100.0%

62-day wait for first treatment from urgent GP referral to treatment85% 65.5% 40.0% 57.7% 83.3%

62-day wait for first treatment from consultant screening service referral90% 100.0% 100.0%

* The trust threshold is an aggregate of individual clinical board thresholds

Page 10

This month

4. Access4.2 Access Targets – Cancer

Month 6 - September

The current performance for the 14 Day Cancer Wait is 92.0%, below the target of 93%. 63 patients breached the 14 day standard (including breast symptomatic). Of these, 54 were the result of patients choosing to not be seen within the 14 day target. Seven breaches were caused by capacity issues in Head & Neck, Lung and Upper GI clinics due to unanticipated change to consultant's availability to review patients, and one breach was due to medical reasons. Breach anlaysis is still underway for one patient. The Trust is also below the target for the 31 day diagnosis to first treatment and 31 day subsequent surgery indicators. These were due to surgical capacity issues in urology. The current performance for the 62 Day Cancer Wait is 65.5%, below the target of 85%. This position is subject to change until the national Open Exeter reporting deadline for September. This position will not be improved by reallocations. 14 patients breached the 62 day standard. Of these, five patients were late referrals, from the originating Trust. Three breaches occurred due to patients needing further diagnostics due to the complexity of their condition. One breach was due to capacity issues, and two breaches was due to an administrative error at the booking centre. Three patients chose to delay their treatment. The Trust is implementing a new protocol for conducting breach analysis that will better identify all potential delays in the pathway, as well as the principal reason. This will allow us to better understand breaches and ensure that everything within our remit is being done to prevent delays at any point. We are also setting up a process to review this breach analysis with commissioners to add an additional level of scrutiny and assurance. The Trust is also introducing improved management of cancer waits through a trust-wide patient tracking list (PTL) meeting chaired by one of the Trust’s medical directors to review all patients at risk of breaching the 62 day and 14 day targets. This will supplement tumour site PTL meetings.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Cancer 62 day referral targets

Cancer 62 Day GP referral to treatment Target (GP referral to treatment)

Cancer 62 day referral from screening to treatment Target (screening to treatment)

70%

75%

80%

85%

90%

95%

100%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Cancer 2 week referral targets

Cancer GP referral to appointment Cancer 14 day wait from referral (symptomatic breast) Target

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Number of MRSA Bacteraemias (Trust

Attributable) (Ward)0 0 0 0 0

Number of clostridium difficile cases

(Trust Attributable) excluding

successful appeals

13 4 5 4

Number of clostridium difficile cases

(Trust Attributable) due to lapses in

care

0 0 0

Number of clostridium difficile cases

(Trust Attributable) under review13 4 5 4

Number of clostridium difficile cases

(Trust Attributable) successfully

appealed

0 0 0

Number of MSSA Bacteraemias (Trust

Attributable) (Ward)2 1 0 0 1

% Hand Hygiene Compliance 100.0% 95.5% 94.1% 93.7% 96.3%

* The trust threshold is an aggregate of individual clinical board thresholds

Page 11

5. Quality5.1 Infection

This month

Month 6 - September

The Trust did not have any cases of MRSA this month. The Trust reported 57 C diff cases between April and September. 35 of these cases were successfully appealed as not being lapses in care. 19 cases are still under review and may be appealed. Three cases of C diff have been found to be a lapse in care by the Trust. Therefore, the Trust's position currently is 35 cases against the September year to date threshold of 36. There was one trust acquired MSSA case reported in September which occurred due to a wound infection.

0

1

2

3

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

MRSA bacteraemia / infections - All Services

MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

0

10

20

30

40

50

60

70

80

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Clostridium difficile infections post 48 hrs - All Services

CDiff Actuals Monthly excl. successful appeals CDiff Threshold Monthly

CDiff Actuals YTD excl. successful appeals CDiff Threshold YTD

Tru

st

thre

shold

Tru

st

actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

% Harm free care (National Safety

Thermometer)95.0% 96.9% 90.0% 98.9% 98.8%

% Harm free care (Hospital acquired

only)98.4% 95.6% 98.9% 99.4%

Preventable dose omissions 1.3% 1.2% 0.6% 0.9% 1.6%

Percentage of Completed eVTE Risk

Assessments95.0% 93.3% 93.0% 93.1% 93.5%

The trust threshold is an aggregate of individual clinical board thresholds

Page 12

5. Quality5.2 Safety

This month

Month 6 - September

We were compliant in achieving the target for dose omissions in September at 1.2% against the threshold of 1.3%. Specialist hospitals board failed to meet the target and a number of actions are in place within divisions to ensure compliance. These include dose ommissions training for new nurses as part of their induction, updating junior doctors each month at their medical meetings and sending out emails to staff after every monthly audit highlighting areas of improvement. The Trust achieved the target of 95% for the National Safety Thermometer harm free care indicator, Medicine board failed to achieve compliance and this was mainly due to the number of events such as pressure ulcers and unrinary tract infections that were present on admission. We missed the 95% standard of patients admitted being assessed for VTE in September. We will be asking divisions to validate their cohorted patients to ensure these are still valid and will be meeting with the VTE leads to agree an action plan to bring back performance to the required standard. Financial penalties incurred to date with our commissioners are estimated at £53k.

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Dose Omissions - All Services

Preventable dose omissions Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

VTE Risk assessment - All Services

Percentage of Completed eVTE Risk Assessments Target

Tru

st

thre

sh

old

Tru

st a

ctu

al

Me

dic

ine

Su

rge

ry &

Ca

nce

r

Sp

ecia

list

Ho

sp

ita

ls

Inpatient falls with serious harm 0 0 0 0 0

Inpatient falls with harm 9 41 10 9 20

Falls per 1000 beddays 1.5 3.6 5.8 2.5 3.5

All Pressure Ulcers Acquired at UCLH 9 4 0 2 2

Number of Grade 3 Pressure Ulcers

Acquired at UCLH0 0 0 0 0

Number of Grade 4 Pressure Ulcers

Acquired at UCLH0 0 0 0 0

Timeliness indicators for inpatient

letters to GPs

Timeliness indicators for out-patient

letters to GPs

The trust threshold is an aggregate of individual clinical board thresholds

Page 13

5. Quality5.3 Safety

This month

Month 6 - September

The Trust did not have any inpatient falls with serious harm in September. There were 41 falls with harm reported in September. One patient fall with harm was in the ambulance loading and pick up area, and another one whilst the patient was in transit. We are unable to map these to any boards, but are reflected in the overall Trust figure. The majority of falls reported by the boards were with minimal or moderate harm. In paediatrics, the importance of ensuring falls risk care plans are up to date for all patients and to review them regularly, will be highlighted to all staff at the safety huddle. At Queen Square, all falls are reviewed in a monthly meeting and the division will be carrying out a benchmaring exercise with other neurological sites to compare the rate of falls. The Trust has continued to maintain a low incidence of pressure ulcers since August, reporting four against a threshold of nine in September.

0

0.5

1

1.5

2

2.5

3

3.5

4

0

20

40

60

80

100

120

140

160

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Patient falls per 1,000 bed days and Overall - All Services

Inpatient falls with harm Patient falls Falls per 1000 beddays

0

2

4

6

8

10

12

14

16

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Pressure Ulcers acquired at UCLH split by Grade/Category - All Services

Grade 4 Grade 3 Grade 2

To be developed by end of Oct 14

To be developed by end of Oct 14

Tru

st th

reshold

Tru

st actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Emergency readmissions within 30

days (with PbR exclusions)6.0% 17.8% 5.2% 2.2%

Percentage of Complete Vital Signs

New95.0% 95.3% 100.0% 95.4% 94.5%

Local SHMI - Relative Risk - (1 yr

rolling data)0.53 0.47 0.63 0.52

The trust threshold is an aggregate of individual clinical board thresholds

Page 14

5. Quality5.4 Outcomes

This month

Month 6 - September

Both Surgery and Cancer and the Specialist Hospitals boards were non compliant against the threshold for completed vital signs observations. In surgical specialties, the PERT team have assisted in auditing the ward frequently to ensure observations are being carried out correctly and extra training is being provided where needed. Sisters have also been spot checking NEWS charts daily and providing ‘on the spot’ training as required. Further training has been booked for ward sisters in the paediatrics division. At the heart hospital, the PERT team recommended further staff education across the hospital around the new observation charts. Daily monitoring by the Matron and senior nurse is taking place. The ward sister will also be carrying out the audit with the nursing team to educate and monitor where there are gaps in education.

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Emergency readmissions - All Services

Emergency readmissions within 30 days (with PbR exclusions)

75%

80%

85%

90%

95%

100%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Complete Vital Signs - All Services

Percentage of Complete Vital Signs Target

Tru

st th

resh

old

Tru

st a

ctu

al

Me

dic

ine

Su

rge

ry &

Ca

nce

r

Sp

ecia

list

Ho

sp

ita

ls

Complaints responded to within target

time85.0% 75.0% 87.5% 72.0% 73.3%

Friends & Family Test (IP survey) 70 73 76 72 72

Friends & Family Test (AE survey) 69 69

Response rate -Friends & Family Test

(IP survey)26.8% 36.1% 24.7% 25.8%

Response rate- Friends & Family Test

(AE survey)19.8% 19.8%

Page 15

5. Quality5.5 Patient Experience

This month

Month 6 - September

The Trust was under the threshold for complaints response times in September. Both Specialist Hospitals and Surgery & Cancer boards were below the threshold of 85%. In surgical specialties, recruitment is under way for two assistant general managers, one of which has been appointed already and the other one due to start in December. Return to full establishment in management posts is expected to improve the response rate. At Queen Square, staff have been reminded that where a complaint is complex, a response time can be extended with negotiation with complainant during 5 day follow up call. They are also ensuring that complaint investigations are spread out amongst the whole team rather than one individual. We had a quite a low response rate for the A&E FFT survey this month. The emergency department have made some structural changes to the data collection process not being captured by the discharging clinician. Although the response rate is low, the score now reflects a large casemix of patients. Although performance across the Trust resulted in late responses, in all cases divisions engaged with patients to ensure they were informed of progress.

0

10

20

30

40

50

60

70

80

90

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Patient experience - FFT scores and response rate (IP & AE)

FFT AE score Friends & Family Test (IP survey)

FFT AE response rate % Friends and Family - IP Response Rate

0

10

20

30

40

50

60

70

80

90

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

Patient experience - Complaints received

Number of Patient Complaints Complaints responded to within target time Target

Tru

st

thre

sh

old

Tru

st a

ctu

al

Me

dic

ine

Su

rge

ry &

Ca

nce

r

Sp

ecia

list

Ho

sp

ita

ls

Co

rpo

rate

Fu

nctio

ns

% temporary staffing filled via bank NA 86.8% 86.3% 89.9% 87.0% 79.8%

% Vacancy rate 8% 15.2% 14.9% 15.9% 15.3% 13.4%

% Staff turnover (excluding

honoraries, bank, junior doctors,

executive and non executive posts)

12.0% 14.0% 13.0% 14.0% 13.0% 19.0%

Staff in post WTE NA 7661 1610 1957 3463 630

The trust threshold is an aggregate of individual clinical board thresholds

Page 16

6. Workforce 6.1 Performance indicators

Month 6 - September

This month Temp Staffing: Total temporary staffing usage decreased by 118 wte between months 5 & 6. Agency usage decreased by 90 wte and bank by 33 wte. Agency usage in Corporate directorate will end by January. Vacancy Rates: Workforce teams are currently prioritising the review of Nursing and Midwifery (N&M) establishments and the Workforce Director and Chief Nurse are overseeing accelerated recruitment. A new retention and recruitment strategy should follow to the EB by February. Staff In Post (WTE): there has been a increase of 276 wte during the last 12 months.

6,8

71

6,9

40

6,9

44

6,9

78

7,0

52

7,0

52

7,0

80

7,1

25

7,1

21

7,2

85

7,3

40

7,3

38

7,3

72

7,3

80

7,3

85

7,4

30

7,4

72

7,4

92

7,5

56

7,5

92

7,6

40

7,6

15

7,6

32

7,6

58

7,6

19

7,6

48

7,6

61

5000

5500

6000

6500

7000

7500

8000

Staff in post WTE (ESR) July 2012 - September 2014

Staff in post WTE

832

846

757

902

872

962

870

903

866

941

907

898

953

907

792

920

920

1047

969

984

954

991

990

990

159

198

152 189

174

175

173

169

179

181

148

170

194

187

161 188

193 205

200

195

189

192

165

137

0

200

400

600

800

1000

1200

1400

WTE Temporary Staff Usage (All staff groups) Previous 24 months, Source: Pulse

Agency WTE Bank WTE

Tru

st

thre

shold

Tru

st

actu

al

Me

dic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Corp

ora

te

Fu

nctio

ns

Sickness absence rate (%) 4.0% 3.2% 3.5% 3.1% 3.3% 2.7%

Appraisal Tier 3 - All remaining AFC

staff at Band 7 and above including all

DCDs

90.0% 93.4% 96.2% 97.0% 90.2% 95.5%

% Statutory and mandatory training

compliance83.0% 82.0% 83.7% 82.2% 80.0% 82.8%

Average time to recruit (request pack -

start date)14.6 14.5 14.3 14.5 15.2 12.4

Page 17

6. Workforce 6.2 Performance indicators

This month

Month 6 - September

* The trust threshold is an aggregate of individual clinical board thresholds

Statutory & Mandatory Training: The Statutory and Mandatory Training compliance rate continues to improve, with an increase of 0.6% from the previous month. A total increase of 3.9% since the beginning of 2014/15 has ben achieved, and this months compliance rate of 82% is the highest the Trust has achieved since 2011/12. Given the demands on staff, particularly those in patient facing roles, the challenge to maintain monthly increases will become greater as we enter the winter period. Performance Appraisals: The Trust achieved the 90% target for Tier 3 appraisals (for those staff on AfC Band 7 and above). With the deadline of 31st October approaching for all staff on AfC Bands 6 and below, work is being carried out through Clinical and Corporate Board Workforce teams to ensure managers have plans in place to complete all outstanding appraisals by that date. Time to Recruit: We are continuing to exceed the KPI on time to recruit across the organisation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Trust Appraisal completion rate - All Services

Tier 4 (Overall) Tier 1 Tier 2 Tier 3

The Annual Appraisals Cycle By end of April - Tier 1 - All direct reports to the Chief Executive

By end of June - Tier 2 - All Staff reporting to a Director who has been appraised by the Chief Executive including all DCDs

By end of July - Tier 3 - All remaining AFC staff at Band 8C and above including all DCDs

By end of October - Tier 4 - Remaining of the workforce

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

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

% Sickness Absence Rate Reported 1 month in arrears

2012/13 2013/14 2014/15

Key Workforce Metrics

and Indicators

RN NA ALL RN NA ALL RN NA ALL RM ALL RN/M N/MA ALL

Establishment (FTE) 469.8 162.5 632.3 703.1 207.6 910.7 1,006.8 183.7 1,190.5 239.8 284.9 2,419.5 598.8 3,018.4

Staff in Post (FTE) 397.6 127.5 525.1 579.7 172.6 752.3 849.9 157.5 1,007.4 216.8 250.9 2,043.9 491.7 2,535.7

Vacant Posts (FTE) 72.3 35.0 107.3 123.3 35.0 158.3 157.0 26.1 183.1 23.0 34.0 375.6 107.1 482.7

Starters (FTE) 6.0 2.0 8.0 3.0 8.0 11.0 7.8 12.0 19.8 4.0 9.0 20.8 27.0 47.8

Leavers (FTE) 3.9 1,610.0 1,957.0 10.6 4.0 14.6 11.7 3.0 14.7 1.0 1.0 27.2 1,617.0 1,644.2

Vacancy Rate 15.4% 21.5% 17.0% 17.5% 16.9% 17.4% 15.6% 14.2% 15.4% 9.6% 11.9% 15.5% 17.9% 16.0%

Turnover Rate 17.4% 10.7% 15.9% 15.2% 22.0% 16.6% 15.3% 14.9% 15.3% 10.5% 12.3% 15.2% 16.9% 15.5%

Temp Staffing Usage 14.8% 33.3% 20.2% 15.6% 28.6% 19.0% 14.2% 30.5% 17.2% 9.1% 11.1% 14.2% 30.1% 17.8%

Sickness Absence 5.8% 6.7% 6.0% 5.0% 3.5% 4.6% 4.9% 4.5% 4.9% 3.8% 4.7% 5.0% 5.1% 5.0%

Right staffing level by shift 87.6% 126.5% 98.6% 98.4% 122.6% 101.0% 93.8% 132.1% 103.2% - - 94.9% 129.8% 102.1%

RN - Registered Nurse

NA - Nursing Assistant

RM - Registered Midwife

MA - Midwifery Assistant

All - All Nursing and Midwifery Staff

Page 18

Month 6- September

Nursing and Midwifery Detailed Workforce Dashboard University College London HospitalsNHS Foundation Trust

Medicine Board Surgery and Cancer Board Specialist Hospital Board Maternity Services UCLH Trust

-

MA

45.1

34.1

11.0

5.0

-

24.4%

21.7%

22.0%

10.8%

Total Trust Nursing & Midwifery (Qualified) Starters and Leavers

Nursing and Midwifery Workforce Comments Key

The N&M vacancy rate increased in April 14 as a result of adding 135 WTE posts to nursing establishments budgets. There are currently 178

Nurses and Nursing Assistants who are undergoing pre employment checks and will be starting imminently.

Vacancy Definitions: The Nursing and Midwifery vacancy rates are based on ESR establishment figures. Positions occupied by employees on

planned leave (e.g. maternity leave) and or unplanned leave (e.g. sick leave) are reported as occupied and not vacant.

The majority of N&M budgets have a 22% uplift (to cover leave).

0

20

40

60

80

100

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

Oct

-14

Oct

-14

Oct

-14

Oct

-14

No

v-1

4

No

v-1

4

No

v-1

4

No

v-1

4

No

v-1

4

De

c-1

4

Jan

-15

Feb

-15

Mar

-15

Starters Leavers

0%

5%

10%

15%

20%

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-1

4

Jan

-15

Feb

-15

Mar

-15

Nursing and Midwifery Qualified Vacancy Rate

Incremental Target Vacancy Rate

Estimated riskThresholds Weighting Sep 14 Q2 Comments

36 1.0 13 2219 cases still under review, 3 lapses in care.

90% 1.0 79.9% 82%See page 8 for detail

95% 1.0 91.8% 93%See page 8 for detail

92% 1.0 88.5% 86%See page 8 for detail.

85% 65.5% 67.7%See page 15 for detail.

90% 100.0% 100.0%See page 9 for detail

94% 80.6% 92.0%See page 9 for detail

98% 98.7% 99.5%See page 9 for detail

94% 95.1% 99.6%See page 9 for detail

96% 0.5 95.0% 93.8% See page 9 for detail

93% 92.0% 93.0%See page 9 for detail

93% 87.4% 93.5%See page 9 for detail

95% 1.0 94.2% 94.2%See page 8 for detail

Green Green

Page 19

Month 6 - September

31-day wait from diagnosis to first treatment (all cancers)

Two week wait from referral to date first seen: all cancers

0.5

Two week wait from referral to date first seen: symptomatic breast patients

A&E: Maximum waiting time of four hours from arrival to admission/ transfer/ discharge

Overall governance rating / Monitor RAF assessment

7. Externally Reported Frameworks 7.1 Monitor Indicators – Compliance Framework

Indicators

62 day wait for first treatment from urgent GP referral

1.0

62 day wait for first treatment from consultant screening service referral

31 day wait for second or subsequent treatment: Surgery

1.031 day wait for second or subsequent treatment: anti cancer drug treatments

31 day wait for second or subsequent treatment: Radiotherapy

Incidence of Clostridium difficile year to date

Maximum time of 18 weeks from point of referral to treatment - admitted

Maximum time of 18 weeks from point of referral to treatment - non-admitted

Maximum time of 18 weeks from point of referral to treatment - incomplete pathways

Page 20

7. Externally Reported Frameworks 7.2 CQUIN and financial penalty summary

Month 6 - September

Estimated

Annual value

available

Financial Plan

assumptionsQuarter 1

actual

Quarter 2

risk

Quarter 3

Risk

Quarter 4

Risk Total

£483,661 £ -

£345,472 £ -

£483,661 £ -

£ -

£ -

£ -

£ -

QIPP schemes

£ -

£ -

£ -

Domestic violence

Value based commissioning £829,133

£6,909,440 £0 £0 £0 £0 £0

Financial Plan

assumptions

£0 £10,000 £ 10,000

£1,000,000 £0 £360,000 £ 360,000

£980,750 £1,256,600 £ 2,237,350

£0 £1,150,000 £590,000 £ 1,740,000

Cancer waits £17,500 £34,865 £ 52,365

A&E £0 £49,750 £ 49,750

Diagnostic waits £99,502 £196,388 £ 295,890

£70,400 £41,200 £ 111,600

£0 £52,900 £ 52,900

£2,250 £8,750 £ 11,000

£0 £2,320,402 £2,600,453 £0 £0 £4,920,855

Financial Plan

assumptionsQ1

£2,057,207 £685,735.67 £514,301.75

£3,937,946 £1,072,972 £984,486.50 £0 £0 £ 2,057,458

£3,393,374 £3,584,940 £0 £0 £6,978,313

Emergency readmissions (external)

First / follow up ratios (full year projection)

Total non-reimbursed penalties

Overall penalty / risk / non-reimbursement

Emergency readmissions (internal)£1,880,739 £387,236 £ 470,185

RTT 52+ penalties

LAS 30 & 60 Minute handover breaches

VTE risk assessments

Mixed sex accommodation breach

Total penaties

Non-reimbursed activity - Contract metrics

Total CQUIN Incentive payment risk

Financial Penalties

MRSA

C. Difficile

RTT penalties

Fetal Medicine - tertiary opinion

Dashboards

Alcohol misuse

Smoking cessation

Endocrine out-patient coding

Cardiac surgery

Specialised orthopaedics

Perinatal pathology

Retinopathy of permaturity

Clinical utilisation (Neuro rehab)

£4,767,513

Lo

cal

Risk of forfeited CQUIN income

Nati

on

al

Reducing pressure ulcers

Friends & Family Test

Dementia

NH

SE

Specialised workshops

Financial values not yet agreed with commissioners.

.

Still under discussion with NHS England

Scheme commences in Q3

Scheme commences in Q3Commences in Q3

Still under negotiation with NHS EnglandStill under negotation with NHS EnglandDashboards still not finalised by NHS England

Commences in Q3

RTT penalties have been calculated using the methodology for

2013/14 as 2014/15 penalty calculations are still being determined. The Trust may be exempt from Q1 and Q2 penalties.

The level of LAS breaches remains an estimate at this time as there are many cases being reviewed and challenged by the A&E

department

1. Referrals and activity

2. Access

3. Patient safety and quality metrics

4. Top 10 objectives

5. Externally reported frameworks

6. Data quality report

Page 21

Quarterly review slidesContents

Month 6 - September

Page 22

Month 6 - September

Quarterly Review1. Referrals and activity

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

Number of referrals to UCLH per Quarter (RNTNE included from Apr-12)

GP Refs Non GP Refs Total Refs

190,000

200,000

210,000

220,000

230,000

240,000

250,000

260,000

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

All Outpatient Attendances (RNTNE included from Apr-12)

Total Attendances

23000

24000

25000

26000

27000

28000

29000

30000

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

Daycase and Elective Inpatients (RNTNE included from Apr-12)

Total DC & ELIP

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

Non Elective Inpatients (RNTNE included from Apr-12)

Non Elective

Page 23

Quarterly Review2. Access Targets

Month 6 - September

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

62 day from GP referral target (without reallocations)

Performance Threshold

27000

28000

29000

30000

31000

32000

33000

34000

90%

91%

92%

93%

94%

95%

96%

97%

2012-13 Q22012-13 Q32012-13 Q42013-14 Q12013-14 Q22013-14 Q32013-14 Q42014-15 Q12014-15 Q2

A&E 4 hour wait target

A&E Performance Threshold A & E Attendances

0%

20%

40%

60%

80%

100%

120%

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

62 day screening target

Performance Threshold

76%

78%

80%

82%

84%

86%

88%

90%

92%

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Switchboard performance

Calls answered within 30 secons Threshold

No Data

Page 24

Quarterly Review3.1 Infections

Month 6 - September

0

1

2

3

4

5

6

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

MRSA - All Trust reported cases to HPA (including community acquired)

UCLH All MRSA (incl community acquired) MRSA Peer average

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

MRSA cases per 10000 bed days UCLH Vs London Peers

UCLH MRSA bed rate London peers MRSA bed rate

Linear (UCLH MRSA bed rate) Linear (London peers MRSA bed rate)

0

5

10

15

20

25

30

35

40

45

50

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

C. Difficile - All Trust reported cases to HPA (including community acquired)

UCLH All C-diff (incl community acquired) C diff Peer average

0

1

2

3

4

5

6

7

8

9

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

C. Difficile cases per 10000 bed days UCLH Vs London Peers

UCLH Cdiff bed rate London peers Cdiff bed rate

Linear (UCLH Cdiff bed rate) Linear (London peers Cdiff bed rate)

Page 25

Month 6 - September

Quarterly Review3.2 Other Quality issues

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

Last minute cancellations to elective surgery

Cancellations to Elective Surgery Threshold

0

500

1,000

1,500

2,000

2,500

3,000

3,500

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

Number of Incidents

0

50

100

150

200

250

300

350

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

Inpatient Falls

Falls with no harm Falls with harm (w/o serious harm) Falls with serious harm

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Local SHMI 0.5 0.48 0.48 0.47 0.47 0.48 0.47 0.47 0.48 0.48 0.48 0.47 0.48 0.48 0.52 0.52 0.52 0.52 0.52 0.52 0.53 0.52 0.53 0.53

External SHIMI 0.71 0.68 0.71 0.71 0.74 0.75

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

Rela

tive R

isk (

Index 1

00 <

Better

Ris

k, >

Wors

e

Ris

k)

Mortality - SHMI Relative Risk, 1 year rolling data

Appendix 1

Page 26

Quarterly review3.3 Other Quality issues

Month 6 - September

- The HSMR indicator has been replaced with the new SHMI indicator. The Trust remains

0

10

20

30

40

50

60

70

80

90

2012-13Q2

2012-13Q3

2012-13Q4

2013-14Q1

2013-14Q2

2013-14Q3

2013-14Q4

2014-15Q1

2014-15Q2

Emergency Readmissions with Complications Within 30 Days- All Services

Emergency Readmissions with Complications

3 per. Mov. Avg. (Emergency Readmissions with Complications)

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

0

100

200

300

400

500

600

700

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

30 Day Readmissions following elective admissions - All Services

External readmissions - Elective 30 Day Readmissions - Elective % 30 Day Readmissions - Elective

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

0

100

200

300

400

500

600

700

800

900

1000

2012-13Q2

2012-13Q3

2012-13Q4

2013-14Q1

2013-14Q2

2013-14Q3

2013-14Q4

2014-15Q1

2014-15Q2

30 Day Readmissions following non-elective admissions - All Services

External readmissions Non-Elective 30 Day Readmissions - Non-Elective

% 30 Day Readmissions - Non-Elective

0

50

100

150

200

250

300

350

400

450

2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2

7 Day readmissions - All Services

7 Day readmissions - All Services 3 per. Mov. Avg. (7 Day readmissions - All Services)

Page 27

Quarterly review4.1 Top 10 Objectives (1)

Month 6 - September

Top 10 objective Deliverable

Director responsible for

coordinating deliverable

Delivery of

objective status

at Q1

Progress to

end Q2

Reduce hospital acquired falls Chief nurse- Katherine Fenton AG AG

Reduce number of missed medication Chief nurse- Katherine Fenton AG AG

Reduce number of blood clots Chief nurse- Katherine Fenton G G

Reduce hospital acquired infections (MRSA & C-diff)

Medical director (Medicine

Board)- Jonathan Fielden AR AG

Reduce hospital acquired pressure ulcers Chief nurse- Katherine Fenton AG G

24/7 care

Director of Workforce- Ben

Morrin G G

Improve sharing learning

Director of Quaity and Safety-

Sandra Hallett R A

Improve outcomes against Trust & specialty specific measures

Director of Quaity and Safety-

Sandra Hallett G G

Reduce avoidable admissions

Medical director (Medicine

Board)- Jonathan Fielden G AG

Access standards and right staff across emergency pathways

Medical director (Medicine

Board)- Jonathan Fielden AG AR

Standards for patient experience, as customers Chief nurse- Katherine Fenton AR AR

Making a Difference Together (MaDT) programme improve patient experience Chief nurse- Katherine Fenton AR AR

Make it easy for patients to give us timely feedback and act on it Chief nurse- Katherine Fenton AR AR

Referral to Treatment – Surgery & Cancer

Medical director (Surgery &

Cancer)- Geoff Bellingan,

Deputy CEO- Neil Griffith ,

Medical director (Specialist

Hospitals Board)- Gill Gaskin R R

Meeting cancer waiting times - Surgery & Cancer

Medical director (Surgery &

Cancer)- Geoff Bellingan R R

Reduce time patient to be seen as outpatients

Medical director (Specialist

Hospitals Board)- Gill Gaskin AG AG

Achieve financial targets

Finance Director- Richard

Alexander AR AR

Agree financing strategy for capital developments

Finance Director- Richard

Alexander AG AG

Develop collaborative, robust relationships with commissioners and commercial partners

Director of Commissioning-

Mike Foster G G

1.Improve Patient

Safety

2.Deliver excellent

clinical outcomes

3. Deliver high quality

patient experience and

customer service

4. Reduce waiting

times

5. Achieve sustainable

financial health

Page 28

Quarterly review4.1 Top 10 Objectives (2)

Month 6 - September

Top 10 objective Deliverable

Director responsible for

coordinating deliverable

Delivery of

objective status

at Q1

Progress to

end Q2

Working with stakeholders to develop integrated services

Medical director (Medicine

Board)- Jonathan Fielden G AG

Lean Transformation Deputy CEO- Neil Griffith G G

Standardise patient pathways

QEP Director (in collaboration

with MDs)- Tara Donnelly AR AR

Strategy to improve education

Director of Workforce- Ben

Morrin AG AG

Combine leadership of all research activities

Corporate Medical Director-

Tony Mundy A G

Implement Recruitment Strategy for clinical academic appointments

Director of Workforce- Ben

Morrin AG AG

Staff experience of working at the Trust

Director of Workforce- Ben

Morrin G G

Appraisal & mandatory training

Director of Workforce- Ben

Morrin AG AG

Design & implement development programme

Director of Workforce- Ben

Morrin AG AG

Business case for phase 4 and 5

Director of Strategic

Development- David Probert G G

Implement cardiac strategy

Medical director (Specialist

Hospitals Board)- Gill Gaskin AG AG

Implement cancer strategy

Medical director (Surgery &

Cancer)- Geoff Bellingan AR AR

Expansion of maternity services

Medical director (Specialist

Hospitals Board)- Gill Gaskin AG AG

Expansion of neurosciences services

Medical director (Specialist

Hospitals Board)- Gill Gaskin AG AG

Develop & implement ICT strategy

Acting Director of ICT -David

Hill R A

Deliver improved pathology services with commercial partner

Medical director (Medicine

Board)- Jonathan Fielden R AR

Develop new strategy for procurement & logistics

Director of Procurement and

Supply Chain - Pia Larsen AR AR

7. Develop research

and development and

education

8. Enable staff to

maximise their

potential

9. Progress strategic

developments

10. Other key strategic

developments

6. Develop a

transformational

strategy based on

patient pathways

Page 29

Quarterly review5.1 New CQC Risk Summary July 2014

Month 6 - September

Page 30

Quarterly review5.2 Dr Foster Summary of key indicators supporting the CQC reporting indicators

Month 6 - September

Page 31

Month 6 - September

Quarterly Review6.1 Data quality reporting

70%

72%

74%

76%

78%

80%

82%

84%

86%

88%

90%

Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May14

Jun 14 Jul 14 Aug 14 Sep 14

Ethnic coding completeness

In-patient Out-patient

50%

60%

70%

80%

90%

100%

Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14

NHS Number completeness

In-patient Out-patient A&E

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May14

Jun 14 Jul 14 Aug 14 Sep 14

GP Practice Validity

In-patient Out-patient A&E

3

3.5

4

4.5

5

5.5

6

Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14

Depth of Clinical Coding

Average Diagnosis per Coded Episode

G1

Agenda Item 11

Quality & Safety Committee Report

September

September Quality & Safety Committee Summary Report for the Board of Directors 1. Clinical Audit

1.1 QSC received the results of an audit of Clinical Audit practice in the Trust. The objectives were to review the process by which UCLH produces its clinical audit programmes, review UCLH policy and audit standards, report on what happens in practice, and outline challenges and recommendations. 1.2 Challenges identified include; control of divisional projects and their quality, their congruence with Trust priorities and supervision of juniors, divisional engagement and resource, non-submission of audit programmes and / or reports and support for divisional leads and the cascade of information from Board to Ward. 1.3 The Emergency Department was presented as one area where good practice is evident. Most audits are multidisciplinary and have both Nursing and Medical leadership. Medical staff are ‘hands on’ and so able to inform the audit programme more successfully. Weekly governance meetings focus on the outcomes of audits, which is easier in smaller rather than complex units. 1.4 The conclusion from the audit was that, as in other organisations, clinical audit should be a tool for improvement. It was decided that QSC would discuss possible solutions at its next meeting.

2. Clinical documentation

The Trust is committed to providing name stamps to our staff to improve the legibility of clinical documentation. These are to be available in the divisions and Workforce will be supplying stamps to the October 2014 intake of junior doctors. Stamps will be introduced to the ‘On-Boarding’ process for all staff by February 2015. 3. Improving prescribing

Following the presentation of an audit of quality of prescribing on acute wards within the Trust, the QSC endorsed the recommendation and need for clinical leadership/consultant led review of drug charts. This has been implemented through the use of a quality improvement audit and review of 5 inpatient prescription charts by trainee doctors on a monthly basis. Progress to date is that the Cancer division, the Heart Hospital division, and the respiratory, infectious diseases, rheumatology specialties have agreed to pilot the tool. An electronic version of the take 5 audit tool has been developed and a pilot was underway in August 2014. Two early implementers have already submitted data. The take 5 audit tool will be launched formally at the FY1 practical prescribing teaching sessions scheduled for October 2014. Data will be cascaded to divisions via the divisional pharmacists. The tool will require review and revision once e-prescribing roll-out begins, as some of the issues identified in the original audit e.g. legibility will be eliminated with eprescribing. 4. Water Safety

The Audit Committee requested assurance on patient safety after it received a verbal report on Water Quality issues in the Rosenheim and the Cancer Centre. Microbiology reported that all patient services from the Rosenheim building have been decanted and the taps in the Cancer centre have been changed. There have been no cases of

legionella or pseudomonas. Prof Wilson reported that there were no concerns about water safety for patients across all sites. 5. Infection Prevention and Control

5.1 There was one case of MRSA bacteraemia in July and none in August against a zero target. There were three cases of Trust-attributable MSSA bacteraemia. An increased incidence of MRSA colonisation has been noted on a T13S, which required the creation of two cohort bays to prevent transmission. The infection control team have requested that infection control should be considered when restacking the tower wards. 5.2 There were seven cases of E.coli in August and 9 cases in July although an objective for reduction has not been set. Microbiology have reported that E.coli is on the increase generally. QSC requested that the ‘hot spot’ data received from Public Health England be shared more widely. 5.3 There were 12 cases of C.difficile in July and 11 cases in August bringing the Trust total to 47 against a threshold of 71. Root Cause Analysis (RCA) continues on all cases and no lapses of care have been identified. 5.4 QSC was updated that the EB approved funding for Hydrogen Peroxide Vapour decontamination until November; a further review will be presented to the EB in October. The deep clean programme has commenced. 5.6 Norovirus and Influenza cases are expected to start to rise, as we move into the next season, staff are being reminded to isolate and sample possible Norovirus and Influenza patients. QSC was informed that the plan for implementation of the Public Health England toolkit and guidance for Carbapenemase-producing Enterobacteriaceae (CPE) and organisms had been accepted by the Executive Board.

6. Complaints

6.1 Complaints are remaining steady for this quarter, both in number against the previous quarter and compared to quarter one for last year. Seriousness by grade is also relatively stable on last year but response times require improvement. UCLH compares to the national dataset that has just been released for 2013/14 for most categories but is above national average for complaints linked to staff attitude. 6.2 In response to the Francis report the Complaints Regulations of 2009 are due for review in October 2014 and changes are planned to data collection methodology. These changes have significant potential for impact on the Trust: Data will be required to be reported and published nationally every quarter, times for responses will be published, subject categories will be changed and this affects our plan to provide comparative data between complaints and incidents. 6.3 QSC discussed the merits of having dual signatures for complaints responses to improve clinical involvement and the use of personal apologies, as per the UCLH complaints Standards. Proposals for adjusting the response time and dual signatures will be considered at the next QSC. QSC was informed that the Department of Health has not taken forward the Sir Robert Francis recommendation to publish complaints on provider websites.

7. Claims & Inquests QSC received an annual report for 2013-14 on Claims & Inquests.

8. Patient identification QSC endorsed the revised plan for printable patient identity wristbands to include the NHS number as a core patient identifier, and for allergy status not to be printed on the allergy band itself. 9. Patient feedback QSC received the update on the real-time patient feedback collected on the Meridian platform. As the previous report was submitted in April 2013 this report covered the last 12 months. The report will be produced on a quarterly basis. 10. Patient Experience

QSC received the Patient Experience Committee report. 11. Quality & Safety performance

QSC was informed that there is ongoing discussion underway about the timing of submission of the Quality & Safety Performance Book to QSC and the executive board. QSC requested clarification on the apparent marked increase in incidents with harm in the Infection division from April 2014. This was felt to be due to a change in counting and grading but clarification will be brought back to QSC. 12. Care Quality Commission compliance The QSC was updated on the CQC UCLH Intelligent Monitoring report, published in July 2014 and available on the CQC website: http://www.cqc.org.uk/provider/RRV/reports

Improving care walk rounds to help staff improve care in their preparation for specialist hospital inspections have now commenced. A progress update on compliance actions following the CQC inspection in November 2013 was requested and has been provided to CQC.

Sandra Hallett Director of Quality & Safety October 2014

G2

Agenda Item 11

Quality & Safety Committee Report

October

October Quality & safety Committee Summary Report to the Board of Directors 1. Investigation safety A Safety group has been set up to find a solution which is more effective in ensuring that important tests (i.e. those likely to reveal clinical issues which need urgent follow up) are seen in a timely manner and appropriate action/treatment is initiated. The group includes the four UCLH Medical Directors, the DCDs for the Imaging, Pathology and Emergency divisions and a Consultant Biochemist. Changes to include Clinical Teams, filtering and flagging are judged to be most effective but require prioritisation by ICT. QSC required that these proposals be cross referred to the ICT Strategy Board and reported back to QSC.

2. Clinical Effectiveness

2.1 The Clinical Effectiveness steering group (CESG) provided a progress report on the work underway to meet the recommendations within the Bariatric Surgery National Confidential Enquiry into Patient Outcome & Death study. 2.2 Five applications to introduce new interventional procedures have been received and details of the outcomes of 5 previously approved procedures have been reviewed. The scheduled review of the associated policy has been undertaken. 2.3 QSC were informed that a policy for safe management of non-UCLH staff in theatres and other interventional areas across the Trust has been developed and approved. 2.4 A non-executive director requested an update on ‘Time to Act: severe sepsis’ as another national audit is planned and was informed that the clinical lead from ITU will report back in November. The next Trust ‘Deaths review’ will focus on sepsis. 2.5 CESG raised concern that UCLH has no memorial process in place for organ donors such as in other Trusts. QSC recommended that the UCLH Charity be requested to address. 3. Clinical audit A team is currently undertaking a review of practice in relation to the WHO safe surgery checklist and will report back to November QSC. QSC received assurance that the corporate clinical audit programme 2014-15 program is on track. Practice in relation to consent requires improvement and the Internal Auditors are currently auditing compliance with the Consent policy. 4. National Cancer Patient Experience Survey 2013/2014 The 2013/14 National Cancer Patient Experience Survey (NCPES) results were published on 12 September 2014. A great deal has been achieved and there is an upward trend to most of the responses but there are remaining areas where the Trust will need to undertake considerable work to ensure patients across all tumour groups receive the same excellent experience.

5. Clinical Research update QSC welcomed Research Support Centre’s Quality & Safety Director who will be reporting to QSC on the reviewed structure for research governance in the future.

6. Statutory Duty of Candour 6.1 A Statutory Duty of Candour will be introduced from November 2014 which introduces a legal requirement to be open with patients when they suffer harm. It will be a criminal offence not to notify a service user of a notifiable safety incident or to fail to meet the requirements for such a notification. The Trust has considered what this will mean in practice and actions taken to date. The Trust’s Being open Policy and Procedure describes how to offer acknowledgments, apologies and explanations to patients, their families and/or carers when a patient has been involved in an incident, complaint or claim. There is a new requirement for candour where there is ’prolonged psychological harm’.

6.2 Only parts of the overall Duty attract an immediate potential criminal sanction. These

include the failure to give notification that a notifiable patient safety incident has occurred as soon as reasonably practicable and technical requirements of the notification process (draft Regulations para 20(3)) covering the immediate notification and record keeping

Challenges include improvement in documentation that demonstrates compliance with the Duty, so that poor compliance with documentation does not inaccurately suggest poor compliance with the Duty. 7. Quality Account priorities quarterly report Progress against the priorities contained within the 2013/14 Quality Account was reported to QSC. Thus far most priorities are on track with good progress being made. It is expected that the targeted improvements will become increasingly evident later in the year as improvement projects gain momentum and planned actions (e.g. for pressure ulcers & infection) take effect. Some areas such as patient experience need even more focus than currently planned, and this will be actioned via the respective delivery groups. Specialty specific clinical outcomes measures will be instigated in the next few weeks. 8. iQuasar self assessment report update Progress on this project to address the eight common quality improvement “Challenges” faced by all hospitals was reported. The tool aims to identify how much progress has been made in each challenge with a view to identifying gaps & opportunities which could strengthen our future quality improvement efforts. The intervention consists of four phases over a 12 month period (July 2014 to July 2015) addressing leadership, Culture, Politics/Emotion and physical/technological. The next steps,, are to agree the key areas that need most attention, select one whole Trust quality improvement intervention to pursue within the iQuaser programme and identify one element of an organisational QI strategy that we would be willing to share. It was recommended that the work was congruent with the UCLH Transformation project. 9. Falls Data from the National Safety Thermometer monthly point prevalence audits place UCLH below 5 harms per 1000 bed days. Although the overall prevalence of falls is low at UCLH the Falls steering group is working towards the ambition of zero harm events from falls. The group appreciates that much work is needed before this can be achieved. Although not a prerequisite for success, the deployment of a dedicated team could facilitate the Falls Group moving at greater pace, potentially making the same rapid gains as the Pressure Ulcer Reduction group made in 2013/14. The Falls group are in discussions regarding funding such a pilot team via a UCLH charity bid, through the development of a 2015/16 (local) Falls CQUIN or reconfiguring existing resources. A Falls training day has been organised for 50 Falls Champions in December and focused work is planned on the wards.

10. Nutrition & Hydration QSC received an update on implementation of the Trust Nutrition Strategy. 10.1 Work continues in catering to improve consistency of food service provision across wards, with service delivery training being put in place for catering staff. Management of catering and domestic staff will be handed over to nursing. 10.2 There is a new DoH directive regarding food standards in Hospitals which incorporates new regulations regarding food provided to staff and patients, including guidance on vending machines and hospital restaurants. Work will be undertaken in the following months to understand the impact of this guidance and the changes that need to be made to meet the regulations. 10.3 September’s Meridian results regarding the quality of the food have improved, bringing patient satisfaction with the food at UCH in line with the rest of the Trust. 10.4 The Nutrition Screening tool (NST) has now been in place for more than a year and though compliance is still higher than that of the previous tool (MUST Score) there are still improvements to be made. An electronic app has been implemented to assist the dietetic team to undertake the audits on a monthly basis. Results are now automatically uploaded into the Care Thermometer which will provide greater focus on the management of malnutrition in the ward environment. Following a Nutrition Screening audit in the Cancer Centre, key clinics have been identified to pilot the introduction of Nutrition Screening in Out Patients (as per NICE guidance) 10.5 The N&H strategy group has developed objectives for 2014/15 to include compliance with the Pre-operative Fasting policy, Nurse-led meal times, the Nutrition Screening Tool and development and implementation of an action plan to achieve a 10% improvement on patient’s feedback, by March 15. 11. Quality & Safety QSC received the Quality & Safety performance Book for August 2014. 12. Infection Scorecard 12.1 There were no cases of MRSA bacteraemia in September against a zero target. There was one case of Trust-attributable MSSA bacteraemia. 12.2 There were three cases of E.coli in September although an objective for reduction has not been set. 12.3 There were 13 cases of C.difficile in September the Trust total to 57 against a threshold of 71. Root Cause Analysis (RCA) continues on all cases and no lapses of care were identified. 12.4 Ebola – Viral Haemorrhagic Fever (VHF) Training for key stakeholders who may come into contact with possible Ebola cases from West Africa has been delivered, including the Emergency Department, Intensive Care and areas likely to see returning travellers, such as the Hospital for Tropical Diseases and the private wards. It is planned that any cases with a high probability of Ebola will be diverted to the Royal Free hospital as they have purpose built isolation provision for VHF. In the interim this has been an opportunity to review our VHF policy and ensure we are prepared should a case be admitted to UCLH.

12.5 Prevention of Needle stick and sharps injuries Infection Control, Procurement and Occupational Health continue to work together to reduce the risk of needle-stick and sharps injuries in the Trust including on reducing harm when staff use unfamiliar equipment such as patient’s own insulin pens. Guidance is currently being agreed for use of safety engineered disposable syringes. Professor Mundy Corporate Medical Director October 2014

H

Agenda Item 12

Finance & Contracting Committee Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST FINANCE & CONTRACTING COMMITTEE REPORT TO THE BOARD OF DIRECTORS

1. Introduction 1.1 This report updates the Board of Directors on the issues, considered at the meeting of

the Finance and Contracting Committee (FCC) on 5th November 2014, relating to the financial performance and contracting position of the Trust as at 30th September 2014.

A brief update is also provided on issues discussed at the FCC meeting of 1st October 2014, which have not been previously reported to the Board of Directors.

1.2 The Board of Directors is asked to: • Note the financial performance for the first six months of the 2014/15 financial

year, and associated financial issues, • Note the contracting update, • Note the other updates (Specialist Hospitals Board financial performance,

profitability and consultant productivity) also provided to the Committee, • Endorse the declaration, which was submitted as part of the Quarter 2 financial

return to Monitor, that the Trust will retain a continuity of service risk rating (CoSRR) of at least 3 for the next 12-month period, and

• Note the issues discussed at the previous FCC meeting of 1st October 2014.

2. Finance Director’s Report 2.1 The Trust’s bottom line income and expenditure performance (prior to donations and

donated asset adjustments) for the year to September, as shown in table 1 below, was a deficit of £0.8m, which was £2.5m worse than the planned position.

Additionally, at month 6 the Board contingency of £5m remained available in full and, within the Quarter 2 financial return to Monitor; the Trust reported a continuity of service risk rating (CoSRR) of 3, in line with plan, as part of Monitor’s risk assessment framework.

Table 1 – UCLH 2014/15 month 6 financial position

2.2 The Finance Director informed the Committee that following the normal quarterly review of provisions and central budgets the reported financial position in the month (prior to donations and donated asset adjustments) was £2.5m better than plan. This included an adjustment of £3m that had been made in respect of section 106 obligations, following an in-year review of accounting treatment, which resulted in a decision to capitalise these costs when incurred, and release the provision funded originally through income and expenditure. When this one-off benefit to income and expenditure was

Page 1 of 6

excluded, the financial results showed that the Trust was continuing to face an underlying run-rate problem of c. £1m per month.

The Finance Director pointed out that the main driver of the financial gap remained a shortfall in delivery of QEP, although the level of QEP identification and delivery was improving month on month.

2.3 The Finance Director advised the Committee that although the outlook for the financial year remained uncertain, the latest forecast from clinical boards and corporate directorates for the year anticipated that a significant element of the year-to-date shortfall would be made up over the latter half of the year.

2.4 The Finance Director informed the Committee that the Executive Board remained committed to the Trust maintaining strong budgetary control. The Finance Director pointed out now that the Trust was more accurately budgeting for income growth, there needed to be a focus on re-establishing the expense and establishment budgets as the fundamental authority to spend and hire. Forecasts should be used to help clinical boards proactively address the risks around their financial outturn. The Finance Director noted that this was consistent with the focus of the return to run-rate programme on establishment control.

2.5 The Finance Director mentioned that the Executive Board was also concentrating on addressing the Trust’s run-rate so that it was not only sufficient to deliver this year’s budget, but it also does not create unattainable QEP targets for next year. This was likely to be an immensely challenging task.

The Committee also endorsed a number of recommendations that had been put forward by the Executive Board, which focussed on the 2015/16 financial year. These included:

• 2015/16 activity plan would be based upon demand, with a plan to address physical capacity limitations,

• Zero headcount growth would be built in to budget proposals, and all increases to establishment hiring were subject to separate authorisation,

• Non-recurrent funding would be made available specifically for targeted local initiatives that would reduce costs in 2015/16.

2.6 The Committee noted that the Trust’s October monthly submission of forecast positions to Monitor showed the following year-end outturn values as at 31st March 2015:

• Income & expenditure surplus of £2m, as per plan, and endorsed by the previous FCC meeting,

• Capital expenditure of £36.0m, which was £31.3m less than plan of £67.3m. The Committee noted that as month 6 year-to-date capital expenditure was less than 85% of plan, this had triggered the requirement for the Trust to produce a capital expenditure reforecast as part of the Quarter 2 return to Monitor (see section 5 below). The revised estimate of £36.0m had factored in slippage on capital expenditure that was now forecast to be carried over into 2015/16 as well as a reduction in in-year discretionary capital replace & refresh spend, identified as part of the return to run-rate programme. The Committee also noted that the Chief Executive had formally endorsed the capital expenditure reforecast, on behalf of the Board of Directors

3. Efficiency and QEP 3.1. The month 6 QEP position showed that the Trust had delivered year-to-date savings of

£13.3m, a shortfall of £4.2m (rounded) against the planned target of £17.6m.

The current forecast year-end QEP position, based on schemes identified to-date, was £31.6m savings (82% of the annual target of £38.4m), with full year equivalent savings of £34.4m.

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4. Balance Sheet and Cash 4.1 The Trust's cash balance at 31st October 2014 (month 7) was £83m, which was £20m

behind plan. The most significant element of the adverse performance continued to relate to outstanding debt with commissioners for the last financial year. The Committee noted that the Finance Director had escalated this issue to the commissioner finance directors and, while progress continued to be slower than he would like, further payments had continued to be received in October.

5. Quarter 2 Monitor Narrative and Declarations 5.1. The Committee noted the financial and governance narrative that formed part of the

Trust’s Quarter 2 report to Monitor, as submitted on 31st October 2014, which highlighted three governance (targets and indicators) issues concerning delivery against:

• Referral to treat waiting times, in general, • Cancer waiting times, and • The A&E access standard.

The Committee noted, as a result, that the Trust was unable to confirm that it was satisfied that plans in place were sufficient to ensure on-going compliance with all existing targets (after the application of thresholds), as set out in appendix A of Monitor’s risk assessment framework, and a commitment to comply with all known targets going forwards

5.2 The Committee noted that the finance declaration attached to the Quarter 2 financial return, which stated that “the Trust anticipated retaining a CoSRR of 3 for the next 12 months”, had been previously agreed by FCC in October. The Committee noted that the forecast had been based on the following statement, which had been discussed and agreed at the previous FCC meeting: “In anticipating that the Trust will continue to maintain a CoSRR of at least 3 over the next 12 months, the Board has noted that the Trust has made a slow start to the delivery of QEP this year, which has been the major reason for the adverse income and expenditure position, against plan, to-date. The Executive is in the process of implementing corrective measures to address this, which will be closely monitored for impact. The Board has also noted the assumption that Project Diamond income received in prior years is received by the Trust in full in one form or another in 2014/15. The Board is also aware that the current cash balance held by the Trust generates a favourable liquidity position which creates significant headroom (upwards of £20m) in the calculation of the CoSRR before falling to a rating of 2.”

The Board of Directors is asked to provide their formal endorsement of the finance declaration.

6. Contracting Update 6.1 The Director of Performance and Planning was pleased to inform the Committee that the

2014/15 Camden CCG and associates contract had been signed by the Chief Executive in October. The Director of Performance and Planning also mentioned that the Trust had agreed baseline values with 89 of 92 CCGs, although the three outstanding CCGs were paying monthly cash advances.

6.2 The Director of Performance and Planning also pointed out the Trust had agreed all material financial components with NHS England and was therefore close to finalising the contract documentation.

6.3 The Committee also received updates showing: a) Month 6 performance, based on agreed CCG contract value, against contract

baselines,

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b) The value of challenges received from NEL CCGs and NHS England for months 1-5, and progress in closure, and

c) Progress on the compliance process for UCLH services that were subject to NHS England’s service specification compliance programme.

6.4. The Director of Performance and Planning provided the Committee with a brief update on the 2015/16 commissioner landscape, noting:

• Commissioning intentions, recently received from NHS England and CCGs, would be further assessed and incorporated into the Trust’s contracting strategy for 2015/16,

• The Trust would continue to work closely with commissioners in the development of the prime contractor model of commissioning,

• The Trust had agreed an internal project plan and governance structure for 2015/16, and was in discussions with commissioners to agree joint project plans to guide the process to successful conclusion in a much quicker timeframe for next year.

7. Other Updates 7.1 The Medical Director for the Specialist Hospitals Board presented the Committee with an

overall financial summary for the board, covering the year-to-date financial position and an analysis of the key drivers of financial performance and profitability, as well as a forecast to the year-end.

At the end of month 6 Specialist Hospital Board was £7.3m behind plan. The key drivers of the year to date position were:

• Unachieved QEP across all divisions except Paediatrics (£3.3m), • Clinical income activity behind plan due to both case-mix and volume variances

(c£2.0m), • Private patients net income behind plan largely due to the use of bed capacity

for NHS patients to meet RTT pressures (c£1.0m), • Unfunded RTT premium costs (£0.5m), and • Overspends on medical locums, nurse and therapy bank and agency costs to

cover vacancies and maternity leave (£0.3m). The Medical Director also pointed out that, at divisional level, Queen Square (-£4.8m)

and Women’s Health (-£1.9m) were the main areas of concern within Specialist Hospitals.

7.2 The Medical Director informed the Committee that a series of actions had been taken at divisional level to improve the adverse run-rate, including those under the remit of the return to run-rate programme and, as a result, Specialist Hospitals Board was forecasting a significantly improved run rate in the second half of the year. The Medical Director also outlined a range of other initiatives that the board was exploring to further improve its profitability, including:

1. Review of diagnostics utilisation. 2. Exploring the potential to increase private maternity services. 3. Exploring a range of options around further use of the RNTNEH.

7.3 The Committee received an update from the Finance Director on how strategic trends information and other profitability analysis were being used by clinical boards and divisions to support their business. The Finance Director mentioned that given the current financial position of the Trust and the need to focus on basic, budgetary control monthly Finance Director/ Medical Director review meetings had not yet been able to move away from addressing the monthly performance to, instead, focussing on examining the profitability of specific specialties.

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7.4 The Finance Director mentioned that following a request from the Chief Executive, the Corporate Medical Director was running a pilot looking at consultant profitability and productivity, with the aim of ensuring the resource implications of variation in clinical practice were fully understood with a view to ensuring the Trust was working in a consistently efficient way. The Finance Director provided an outline of the type of information that was currently available from the Trust’s PLICS data and was being examined for the pilot specialty. This information included:

• League tables, • Activity based metrics, • Operational efficiency, and • Cost benchmarking.

8. Summary of issues discussed at the FCC meeting of 1st October 2014

8.1 This section summarises the discussion at the previous FCC meeting, which due to the absence of a formal Board meeting in October has not yet been reported to the Board.

8.2 The Committee noted that the Trust’s recorded financial performance in August was a deficit of £2.0m, bringing the year-to-date position to a cumulative deficit of £4.3m, £5.0m adverse to plan. Whilst the main driver of this adverse variance remained a £3.6m (26%) under-delivery of QEP, the full year QEP forecast had however improved by £1m to 83% achievement which would leave a shortfall of £7m by year end.

As the month 5 financial results continued to reveal an underlying run-rate problem (c£1.5m in month), the Finance Director informed the Committee that the Executive Board had dedicated the majority of its September EB4 meeting to specifically address the challenges represented in the results and likely projection to year-end. The Committee noted that the return to run-rate programme led by the Deputy Chief Executive was currently projecting in year improvements of between £4-£5m but this might not be sufficient to close this year's gap or improve the Trust’s chances of achieving next year's target. Consequently, the Executive Board had hardened its approach to all spend on non-employed staff and to internal financial management and accountability in general. The Finance Director pointed out the seriousness of the financial challenge had been reflected by the prominence of finance as the opening message of the latest Chief Executive briefing to all staff.

8.3 The Chief Executive informed the Committee that further work would need to be undertaken to look at the sustainability of the return to run-rate actions against the Trust’s underlying position, and that the Board would also need to understand the impact against the year-end forecast of some of the key financial risks that had been identified. The Chief Executive reminded the Committee that alongside delivery of financial targets, the Trust needed to be mindful of the importance of being able to deliver its RTT targets as well as ensuring that at least 95% of A&E patients were seen, treated, admitted or discharged in under four hours.

8.4 The Director of Performance and Planning provided an update on 2014/15 commissioning negotiations with:

• North East London CCGs, where good progress had been made in finalising residual elements of the contract with a view to sign-off taking place shortly, and

• NHS England, where an escalation and closure plan to reach contact signature had been drawn up, although it was thought that the outstanding issues were not significant.

8.5 The Committee also discussed the potential financial impact to the Trust resulting from the introduction in 2015/16 of the Better Care Fund, which would shift resources into social care and community services in order to reduce demand and pressures on healthcare services. The Director of Performance and Planning informed the Committee

Page 5 of 6

that the national planning assumption was to reduce emergency admissions by 3.8%, and some ideas/proposals from local commissioners had been received, identifying the volumes of non-elective activity that they believe could be removed from contract baselines. The Chief Executive mentioned that whilst further work needed to be done to fully understand the risks to the Trust of the introduction of the Better Care Fund, there were opportunities available to UCLH in delivering the commissioners' plans for integrated care via the prime contractor commissioner model.

8.6 The Director of Research provided an update to the Committee on research and development (R&D) issues including a summary of the income that the Trust attracted to support its R&D activities and an outline of both the opportunities and threats to the current levels of funding.

The Director of Research also pointed out that the National Institute for Health Research sought regular reassurance that its funds were ring-fenced within NHS trusts, accountable through a dedicated research leadership and being spent on identifiable research.

The Committee noted that robust financial processes that align with UCLH financial instructions were in place to govern all allocations of research funding.

8.7 The Committee also reviewed a set of metrics that were used by the Joint Research Office in describing the Trust’s performance in initiating and delivering research with comparative data from other NHS trusts. The Committee agreed that the metrics provided a valuable indicator of the Trust’s research capacity and capability.

8.8 The Committee discussed the findings from a review of the effectiveness of the FCC, which was based on a survey of performance from members, as well an assessment of the key documents which supported the running of the Committee. The Committee noted that, overall, the FCC was considered to be well chaired with a relevant agenda and membership.

The Committee also reviewed the recommendations from the report and agreed that the terms of reference and frequency of meetings would be the assessed at the December FCC meeting.

Dr Harry Bush Richard Alexander Chair of FCC Finance Director 6th November 2014

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I

Agenda Item 13

Report of the Audit Committee Meeting

Held on 22nd September

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Report to Board of Directors – 12 November 2014 MAIN POINTS FROM THE AUDIT COMMITTEE

The Audit Committee (AC) met on 23 September 2014 to consider the following important matters:

1. Internal Audit (IA) 1.1. Assurance and advisory reports AC received and reviewed three assurance and advisory reports with varied findings. One of the reports (pre-employment checks) had two ratings and one report was red rated; both reports had high priority recommendations. AC noted that management had accepted the recommendations and had in place action plans with dates to deliver the actions to implement the gaps in the controls identified.

The reports and ratings were:

NHS Pre-employment checks – standards amber/green NHS Pre-employment checks – recruitment processes amber/red Medical appraisals and Job planning red Monitor Licensing advisory

Discussion focused on the recruitment and appraisals reports.

1.2. Pre- Employment Checks The report focused on two issues. On standards IA found that controls were generally in place. However, as the Trust’s own in-house audits of its checklist had not always been undertaken on a timely basis IA were unable to issue a green rating.

On recruitment processes IA had reviewed a number of elements of the process including approval to recruit, advert placement and time between interview and offer made. Workforce were disappointed in the rating as there had been improvements in their processes following the previous audit. IA acknowledged the improvement in the overall time to recruit but this had not been consistent. Although this was not a major risk it might increase the use of agency staff. AC noted the improvement and asked the Director of Workforce to consider if additional guidance for managers could further improve the process.

1.3. Medical Appraisals and Job Planning The report focused on whether the Trust met its threshold for completed job plans and how effective the plans were; the audit covered a period in 2013/14. IA found that the majority of job plans were completed during a 12 month period but that the target at stages throughout the year was not met. In addition not all job plans included links to the top 10 objectives or made clear what PAs (programmed activities) had been agreed. IA commented that job planning was difficult in many organisations and was made more difficult where a Trust had to manage its own system and that of its linked University. AC noted the action plan which included a revised sign off process for 2014/15.

AC was also reminded of an IA report on private patient work it had considered at a previous meeting and that the job planning process was being tightened up for 2014/15 to improve recording of private patient sessions and to support the appraisal and annual declaration of interest process; the above job planning action plan included the actions from that audit.

AC noted the status of unimplemented recommendations from past audits.

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2. Counter Fraud

AC reviewed the Local Counter Fraud Specialist’s (LCFS) quarter 2 report. LCFS drew particular attention to the potential external risks they had identified including cybercrime. These will be incorporated into future work.

LCFS also advised that they were undertaking a Fraud and Bribery Assessment to identify any risk areas and help put in place further action to mitigate those risks. Areas being reviewed include those identified in the ‘heat map’, an audit universe for fraud, for example working whilst sick. The report will be presented in quarter 3.

3. External Audit plan and report Deloitte presented their audit plan which set out the key areas of work that would be monitored during the year including delivery of the QEP and RTT targets, and greater focus on the capital programme. Deloitte also planned to review the new finance system in quarter 2 which had recently gone live.

In their quarter 1 report Deloitte confirmed they had completed planned fieldwork and would be introducing a new checklist for management to evidence completion of procedures on a quarterly basis.

4. Project Evaluation

David Probert, Director of Strategic Development presented a report on progress made to improve strategic project management since 2012 following the Cancer Centre opening and the transfer of the RNTNEH. AC noted that a project initiation checklist had been developed which was used to ensure appropriate governance structures and clear documentation records were in place for each project. AC proposed a useful amendment to further strengthen the checklist suggesting it might include a section on expected outcomes. David Probert advised that he planned to produce a how-to guide to ensure a consistent approach was taken across the Trust.

The report also advised that a collaborative forum, a strategic delivery board, was being established which would undertake a review role of projects to ensure regular corporate input to local divisional projects.

5. Risk Report

AC reviewed an early draft of the risk report for quarter 1 (end June 2014) and noted that this was subject to executive review and challenge and may change. The report was presented in a revised format which included the impact of the risk on the Trust be that its services, patients or delivery of objectives. This is work in progress.

AC noted that two new red risks had been added to the register; both of these were financial risks including income recovery and failure to achieve our QEP.

AC focussed its discussion on other red risks those of meeting the Emergency Department waiting times target and on ICT. On ED, AC asked whether plans to expand the department would mitigate the risk and noted that the development of the department would reduce the risk but the new department was some way off. On ICT, Neil Griffiths confirmed that the ICT priorities were being reviewed; this was being undertaken with the Medical Directors.

6. Other assurance matters At a previous meeting AC had asked the QSC for further assurance on the water

sample testing programme. The QSC advised that new national guidelines were being published on this issue.

AC also asked the QSC for assurance on the clinical audit programme and noted that the QSC had received a presentation on the audit programme from Dr Paul Glynne, Clinical Audit Lead for the Trust. It confirmed that there were variations in quality and the aim was to establish more consistency across the Trust and to better

- 2 –

link the programme to risks and outcomes. The AC would return to this issue at a future meeting.

The AC noted that the Trust’s expenses policy had been revised. It reconfirmed the current process of provision of receipts prior to payment. Following a recent payroll audit (amber/green) AC had asked management to consider if the claims checking process could be strengthened. The Finance Director confirmed that he would put in place a targeted approach to provide assurance which would include reviewing, for example, the highest expense areas.

In July, the AC considered a report on Whistleblowing (Raising Concerns) and noted that some concerns were raised outside the Trust system through other routes such as the CQC. AC discussed a separate report on this issue which demonstrated that every episode is investigated and a response on each is provided to the CQC, where the issue raised is a known issue the CQC are also told what action has been taken. AC also noted that some issues raised via the CQC are not considered to be whistleblowing issues and the CQC advise patients to follow the Trust’s internal complaints process.

Rima Makarem Audit Committee Chair

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J

Agenda Item 14

Minutes of the Audit Committee Meeting

Held on 24th July

1

AUDIT COMMITTEE (AC)

Minutes of the meeting held on Thursday, 24th July 2014

Present: Audit Committee Members Rima Makarem Non-Executive Director and Chair (RM) Harry Bush Non-Executive Director (HB) Kieran Murphy Non-Executive Director (KM)

Non-Members Richard Alexander Finance Director (RA) Tonia Ramsden Director of Corporate Services (TR) Nick Atkinson Baker Tilly (NA) Mark Trevallion Baker Tilly (NT) Hannah Wenlock Baker Tilly (HW) Clive Makombera Baker Tilly (CM) Jonathan Gooding Deloitte (JG) Neil Griffiths Deputy Chief Executive – for item 8 (Risk Report) (NG) Pia Larsen Director of Procurement – for item (PL) Jeremy Over - for item 4 (JO) Mairi Bell Minutes & Item (MB)

Item Matters Covered Action

1. Apologies for Absence

Diana Walford (DW)

2. Minutes of the Meeting held on 23rd May 2014

No issues raised. The minutes were agreed.

3. Matters Arising

195 – Evaluation of Audit Effectiveness: This item to be closed. Decision already made to reappoint Deloitte as auditors

223 – QSC and Clinical Governance: Item to be closed and referred to Quality Sub-Committee

226-230 – Agreed to Close these items

2

Item Matters Covered Action

127 – Update SFIs: RA gave an update that while some work had started, it had been difficult to resource. It was also noted that EB discussion on 23rd July had considered the level and direction of centralisation in the organisation, wth a possible impact on this work. RM queried whether an incremental approach could be adopted. TR suggested that key people sit together to do a page-turn review. This was agreed.

NA noted that experience across the Baker Tilly client base was that this was always a difficult exercise.

RM commented that SFIs need to be current.

ACTION: RA to arrange page-turn review of SFIs and SOD

168/205 - Fixed assets. RA provided an update on this item. RM commented that the paper provided was good, although HB noted that the way forward remained unclear.

There was discussion about the F2 medical physics asset database, and its shortcomings. HB queried whether failures in this IT project had implications for the much bigger asset management project under discussion. RM queried why the database had been bought, and also if a majority of issues could be fixed without a new system being required. RA advised that F2 had been purchased via an emergency route to deal with an issue of non-compliance, regarding evidencing of training and maintenance for CQC. RA identified an issue with local departments doing systems projects in isolation, making a Trust wide solution more difficult. HB highlighted the possible savings to be made in high value maintenance contracts, suggesting this could make a big solution more affordable. RA advised that a big solution would only work if driven by users, but co-ordinated centrally. RM queried whether progress could be made with a non-technological solution. RM also asked what could be achieved this year. ACTION: RA to bring update to November meeting outlining next steps

3

Item Matters Covered Action

4. Policy Reviews 4.1 Whistleblowing – Annual Review

JO attended to present the annual update on Whistleblowing and review of the Whistleblowing policy.

JO updated the committee on the definition of whistleblowing, and

grievance, and advised that the policy was due for formal review during the next 12 months. JO noted that the number of whistleblowing cases had increased from 9 in the previous year to 18. Committee discussed some instances in the paper of staff raising concerns directly to CQC. RM asked why this occurred. JO said that staff shouldn’t have to use this route, and a majority of the instances related to members of the public. TR suggested that the timing of the CQC inspection may have increased the likelihood of reporting to CQC. JO advised that there was a key role for HR representatives on Boards, to assess the culture and ensure staff can raise concerns. RM asked about any success stories coming from these to encourage more staff to come forward with concerns. JO responded that policy refers to positive benefits, and will identify a success story for publication, and work with Comms. NA said that Internal Audit would be looking at Bullying and Harrassment policy this year, and there was a possibility of tying into this work. HB referred to ambiguous wording in Section 3, Bullet Point 4, and asked if this could be worded more explicitly. JO replied that this was intended to have a wider more general interpretation, but acknowledged it could be worded better. KM asked what was unveiled in the concerns raised to CQC. JO advised he only sees Workforce related issues so would need to ask for more details.

ACTION: JO to revise wording in Section 3, Bullet Point 4 ACTION: JO to identify a Whistleblowing success story for publication ACTION: Sandra Hallett to bring a paper to September AC on issues raised directly to CQC

4.2 Code of Conduct – Annual Review TR presented the annual review of the Code of Conduct.

TR noted firstly that the report had been drafted originally for September 13, so may be slightly out of date. TR said that the policy looks at compliance with two registers –Declarations of Interest, and Gifts and Hospitality.

4

Item Matters Covered Action

TR said that compliance was not as good as it could be, particularly

regarding Consultants’ annual declarations. It was suggested that compliance requirements be more explicitly stated in the policy review and in letters to new consultants. KM asked what Consultants should declare. TR advised there was an element of judgment required. HB suggested the policy should request disclosure of any activities in healthcare. TR agreed to include this, and RM commented that it was better to overdeclare. RM asked if there was a cap on Gifts & Hospitality. TR replied £50, which was felt reasonable by Audit Committee. TR also noted that in some cases (e.g. Presidential visit) it may be inappropriate to refuse gifts of higher value. TR said that cash should not be accepted, but should be donated to UCLH charities. It was agreed that the code needed to be clearer about this. HB asked about declining gifts. TR replied that refused gifts are often undeclared, but should be declared via an easy online form. RA noted that the process should be as smooth as possible, e.g.form with email attached. NA advised this was likely to be acceptable from a Counter Fraud perspective. MT noted that any solution needed to be practical, and agreed with RA’s proposal. Committee discussed Declarations of Interest in the context of procurement. There was discussion regarding appropriateness of Panel membership for tender evaluation, particularly where there was very specialist knowledge required. TR advised that the policy could allow for someone remaining on a Panel after making declaring an interest, if unavoidable. HB commented that the balance of the Panel was the key to reaching an informed and decision.

5. Review of Financial Reports 5.1 Waivers to SOs and SFIs

PL attended to present a report on waivers to SOs and SFIs in relation to purchase of goods or services.

PL advised that she was awaiting conclusion of SFI updates.

PL also noted that she had good oversight on waivers being signed off, with a generally decreasing trend.

PL acknowledged that the summary table was not as helpful as it could be, as based on calendar rather than financial year.

5

Item Matters Covered Action

6.

Counter Fraud Representatives from Baker Tilly (NA, MT,HW) presented the Counter Fraud report for Quarter 1

MT said that Counter Fraud were working to seek assurance on both proactive and reactive work, and liaising with RA on improvements to reporting. Committee was advised that outstanding Counter Fraud recommendations had been reduced to 2 proactive and 8 reactive, of which 2 were pending closure. RM asked if the log of outstanding recommendations could be an Appendix. NA advised that all the reporting information was now in Baker Tilly’s 4Action system, and the possibility of combining Internal Audit and Counter Fraud reporting was being considered. Both RM and RA thought this would be beneficial. MT highlighted the Fraud Heat map in Appendix 1. RM noted that the Heat Map was bespoke to UCLH, but there were risks at other organisations. NA drew a comparison to the Audit Universe, drawing together local knowledge, history and external knowledge of other organisations. RA expressed concern about what was not being seen. RM noted that working while sick was a big issue which kept coming up, and queried what the Trust was doing about it. NA said sickness could be reviewed to look for themes, as this was the biggest known fraud in the NHS. HB asked if the Trust did this. NA advised that Counter Fraud look at high numbers, while TR suggested that good line managers would pick this up at a local level. RM suggested that the new Director of HR should come to Audit Committee to discuss this in more detail 3-6 months after his expected start date. HB asked what sanctions were imposed. TR replied disciplined, some sacked. MT noted that usually it was not worth pursuing criminally. TR advised she would query the range of outcomes from working while sick with JO.

6

Item Matters Covered Action

ACTION: NA/MT to ensure Counter Fraud progress report picks up external factors. ACTION: TR to confirm range of outcomes from Working While Sick cases

ACTION: New Director of HR to be invited to March Audit Committee meeting to discuss working while sick issue.

7. Internal Audit Representatives from Baker Tilly (NA, CM) presented the Internal Audit report outlining new audit reports, and progress on implementation of outstanding recommendations. NA advised that 4 reports had been finalized, with one rated Amber-Red. NA also advised that an increase in outstanding recommendations had been noted, with increased efforts now underway to reduce these.

RM asked about the Client Briefings update in Section 5, and if there was anything significant to be covered in more detail. It was noted there was a new issue of the HFMA Audit Committee Handbook and TR agreed to get some copies. NA spoke about the final report on the Cancer Division, and noted an issue around non-compliance with procurement processes. NA spoke about the Procure to Pay report and noted that the new system was a significant improvement, although there was a human error issue in setting up approval limits. RM noted that this report had been Amber-Red for three years, and wondered if the new system would help. RA responded that now a better system and substantive procurement director were in place, improvements should follow, but that it could take 1-2 years to get to the right place. An improvement to Amber-Green in a year should be expected. TR commented that the new system was much better as an end-user. The issue of old invoices on the system, and how to cleanse/release these was also discussed briefly. JG advised that under IFRS, there was an increased requirement to prove release from commitment. PL advised that improvements in procurement processes were expected in the current year, with procurement and Accounts Payable working together to achieve this. PL also noted that there was positive feedback from around the Trust on the new procurement system and processes.

7

Item Matters Covered Action

NA introduced the Amber-Green report on Temporary Staffing.

ACTION: TR to get some copies of the HFMA Audit Committee Handbook for Audit Committee members

Risk Management and Assurance Framework

NG attended to present the Risk Report.

NG gave a brief overview and summarised previous discussion on how best to manage Risk, with an expected formal report on this to September Committee.

NG highlighted two new Trust wide risks:

i) Management Capacity

ii) Barts Cardiac/Cancer switch

RM asked if Barts would be physically ready for the switch. NG advised that assurance had been provided from their Chief Executive.

NG noted two red risks in the report:

i) RTT issues

ii) Capacity for ICT projects

On item i) there was discussion about a proposal to outsource some work to HCA to improve capacity.

KM asked if this would be cost neutral to the Trust. NG confirmed that it would be.

TR noted that the Chariman had requested a presentation on this issue at September’s Board meeting.

On item ii) RM referred back to discussion on Asset Management, highlighting the importance of a suitable IT solution, and noting the importance of capacity within the IT team.

HB queried quoted numbers from Page 7, regarding nursing staffing levels. TR responded that although recruitment targets had been met, the number of new recruits leaving after a short time was much higher than anticipated. NG said that EB had discussed possible overestablishment within nursing.

RA noted that no financial risks had been included in the Risk Report, and would expect to see at least 1 or 2 on here, e.g. Project Diamond.

Update from Committees dealing with Risk:

8.

8

Item Matters Covered Action

Performance Committee – All Audit Committee members attended

FCC – HB advised no issues to report

QSC – DW not present. No update provided

9.

9.1

Financial and Accounting Issues

Proposed Bad Debt Write-Offs

RA introduced the Write-Offs paper. RM requested a covering report for future submissions. Committee discussed the nature of write-offs. RA advised mostly from Overseas patients, small amount from Private Patients, and that the written-off items were largely significantly aged. RM asked how to prevent this occurring in future.

RA said that reducing the credit risk from overseas patients was difficult, as the presentation of such patients was usually as Emergency cases. Treatment was down to individual clinicians, with any not to treat becoming a potentially political issue.

For Private Patients, RA noted that the use of credit card payments in advance was being investigated.

KM asked if £770k was being written off now, how much more could there be. RA replied that the new system was now in place, and there was a focus on cleansing the backlog of invoices.

Losses and Special Payments Report

MB introduced the Losses and Special Payments report for 2014-15 Quarter 1. As no significant payments had been made to date, Committee noted the report.

10.

11.

Audit Committee Annual Report

TR advised that the Audit Committee Annual Report had not yet been approved by RM. TR to circulate the report to committee members. To go to next Audit Committee meeting.

ACTION: TR to circulate AC Annual Report to AC members

Audit Committee work programme for 2014/15

AC noted the work programme for 2014/15.

9.2

9

Item Matters Covered Action

RM updated on Deep-Dive work. HB requested that dates should be fixed in line with other meetings. TR confirmed that would be the case, and dates would be arranged by TR.

ACTION: TR to arrange dates for Deep-Dive reviews

12.

13.

Items Requested for Cross Committee Referral

Water Quality report to QSC presented by TR. Committee understood issues raised, but not happy on assurance. Peter Wilson requested to attend the September QSC meeting.

TR also updated on rolling out of national early warning score card. First data was received in June, and expected to be presented to QSC in August.

Any Other Business

RM introduced a late paper on Section 106 liabilities. This concerned risks with Centre for Independent Living proposal and redevelopment of Arthur Stanley House. It was noted that a deadline had passed triggering a potential liability.

RA advised this issue was known at Executive level and to Investment Committee, but not felt to be a significant risk, as there was no sign of it being applied.

RA also advised that such obligations are often lengthy undertakings.

RA advised that discussions will be held with Deloitte regarding the accounting treatment of Section 106 obligations to review how to capitalise such costs.

Audit Committee requested that Robert Bexton attend the next meeting to provide more detailed explanation.

ACTION: Robert Bexton to attend September meeting for more detailed discussion

14. Date of Next Meeting 9am, Tuesday 23rd September, Trustees Boardroom, 5th Floor East 250 Euston Road