board of directors 25 september 2019 - royal berkshire hospital governance... · board of directors...

Board of Directors 25 September 2019

MEETING25 September 2019 09:30

PUBLISHED19 September 2019

Agenda

Location Date Owner Time

Seminar Room, Trust EducationCentre, Royal Berkshire Hospital

25/09/19 09:30

Board Meeting - Part 1

Topic

1. Opening and Apologies for Absence (Verbal) Graham Sims

2. Staff Story/ Health & Safety Story (Verbal) Nicky Lloyd 09:30

3. Patient Story (Verbal) Caroline Ainslie 09:50

4. Minutes of 31 July 2019 and Outstanding Actions Schedule andDeclaration of Interests

Graham Sims 10:00

5. Executive Team Peformance Update

5.1. Chief Executive's Report Steve McManus 10:10

5.2. Integrated Performance Report Mary Sherry 10:20

5.3. Buckinghamshire, Oxfordshire and Berkshire WestIntegrated Care System - Response to the Long-Term Plan

AndrewStatham

11:10

6. Winter Plan Progress Report Mary Sherry 11:20

7. Annual Medical Revalidation Report Janet Lippett 11:30

8. Minutes of Board Committee Meetings and CommitteeUpdates

11:40

8.1. Finance & Investment Committee 22 July 2019, 23 August2019 & 20 September 2019 (Verbal)

Sue Hunt

8.2. Audit & Risk Committee 18 September 2019 (Verbal) John Petitt

8.3. Workforce Committee 10 July 2019 Julian Dixon

Continued on the next page... 2

Agenda

Location Date Owner Time

Seminar Room, Trust EducationCentre, Royal Berkshire Hospital

25/09/19 09:30

9. Board Work Plan Caroline Lynch

10. Date of Next Meeting and Close:Wednesday 27 November 2019, 09.30 - 13:30

Graham Sims

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Agenda Item 4

Board Wednesday 31 July 2019 9.30 – 13.15 Seminar Room, Trust Education Centre, Royal Berkshire Hospital Members Present Mr. Graham Sims (Chair) Mr. Steve McManus (Chief Executive) Ms. Caroline Ainslie (Director of Nursing) Dr. Bal Bahia (Non-Executive Director) Mr. Julian Dixon (Non-Executive Director) Mr. Don Fairley (Director of Workforce) Mr. Brian Hendon (Non-Executive Director) Mrs. Sue Hunt (Non-Executive Director) Dr. Janet Lippett (Medical Director) Mrs. Nicky Lloyd (Chief Finance Officer) Mrs. Helen Mackenzie (Non-Executive Director) Mr. John Petitt (Non-Executive Director) Ms. Mary Sherry (Chief Operating Officer and Deputy Chief Executive) In attendance Mrs. Caroline Lynch (Trust Secretary) Mrs. Victoria Parker (Director of Communications & Engagement) Mr. Andrew Statham (Director of Strategy)

There were four governors, six members of staff and one member of the public present. The Chief Operating Officer introduced two members of staff from the Clinical Admin Team (CAT) 11 for cardiology and respiratory. The Board noted that the team were the first point of contact for patients and worked closely with clinicians. CAT 11 vision statement was to providing an outstanding services to patients, support clinicians and colleagues and positively embrace changes. The Board noted that the number of referrals to the speciality had increased significantly and a review had identified that 70% of referrals were not appropriate. A triaging service was implemented and the CAT team worked with clinicians and the Electronic Patient Record (EPR) team in order to implement this. This transformed the service and improved waiting times and, therefore, a better patient experience was provided. The Chief Operating Officer advised that costs were also removed as a result of the new way of working. The Board thanked the team for their story. The Chair welcomed the Medical Director to her first Board meeting. The Medical Director introduced Sharon Herring, Director of Nursing, Networked Care, who advised that an out of area patient had written a letter to the Trust following his recent admission. A video of the patient’s experience had been made. The patient had been admitted with a broken tibia and fibula. Overall staff introduced themselves, were knowledgeable and good at getting the basics right. The food was good and the hospital was clean and he would recommend the hospital. However, he had found he had to repeat information to a number of non-uniform staff. The Director of Nursing, Networked

Minutes

Minutes of the Board – 31 July 2019

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Care, advised that coloured lanyards had now been introduced and uniform posters in all ward areas had been updated. The Board noted, whilst the Electronic Patient Record (EPR) reduced the need for patients to repeat information, there were some questions that clinical staff would need to have repeated, for example, allergies. The Chief Finance Officer introduced Tricia Pease, Associate Director of Safeguarding and Terry Morris, Security Manager who gave a detailed presentation on mental health patient activity in the Trust. Overall, there had been a 26% increase in the number of mental health detentions to the Trust and a 34% increase in mental health attendances to the Emergency Department in 2018 when compared to 2017. In addition, there had been an increase in the complexity in vulnerable adult patients with multiple co-morbidities and complex psycho-social problems as well as an increase in elderly patients with dementia and an increase in young people awaiting Children & Adolescent Mental Health Service (CAMHS) assessment or Tier 4 specialist beds. As a result there was poor patient and staff experience due to challenging behaviour of these patients. The Security Manager gave an overview of Violence & Aggression incidents highlighting that, nationally; over 75% of these incidents involved the elderly. The Board noted compliance training for Conflict Resolution was currently 85.6% with a target of 90% by year end. All wards were completing risk assessments for Violence & Aggression and actions plans were being worked through. The Security Manager highlighted that all the security team were trained to level 3 in Caring Restraint’ in the recovery position. The Associate Director of Safeguarding provided the details of a recent example of a young person admitted to the Trust and the complex process undertaken. The case had been referred for a Child Safeguarding Practice Review by the Berkshire West Safeguarding Children Partnership. The Board thanked the team for the presentation.

103/19 Minutes: 29 May 2019 and Matters Arising Schedule The minutes of the meeting held on 29 May 2019 were approved as a correct record and

signed by the Chair.

There were no declarations of interest. The matters arising schedule was noted. Minute 71/19 (34/19, 02/19): Minutes 27 March 2019 and Matters Arising Schedule: Minute 30 January 2019 and Matters Arising Schedule: Chief Executive’s Report: The Chief Finance Officer confirmed that transformation monies had not yet been received from NHS Improvement (NHSI) and highlighted the risk to the system if these monies were not received by the end of August 2019. Action: N Lloyd Minute 72/19: Chief Executive’s Report: The Chief Executive confirmed that a future Board seminar with the Vice Chancellor of the University of Reading was being arranged and this would include an update from the Research & Development team. Action: S McManus

104/19 Chief Executive’s Report The Chief Executive introduced the report and advised that, following the Use of Resources

review by NHS Improvement (NHSI) and the three day unannounced visit to the Trust by the Care Quality Commission (CQC); the Well Led inspection was currently on-going. The draft report would be received by the Trust in September 2019 to check for factual accuracy. The Chief Executive advised that CQC inspectors had highlighted that their


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reception into the Trust had been positive and had found teams to be open, transparent and proud.

The Chief Executive advised that the latest cohort of Project SEARCH students had

recently graduated from the current programme during July 2019. Half of the current cohort had secured work placements and one student had secured an apprenticeship in the procurement team. Overall, 27 of the 60 students were now working at the Trust.

The Chief Executive highlighted the local system changes including the Buckinghamshire,

Oxfordshire & Berkshire West Sustainability & Transformation Partnership (BOB STP) becoming one of the three new Integrated Care Systems (ICS). David Clayton had been appointed to the role of Independent Chair of BOB ICS. Berkshire West ICS would also now become the Berkshire West Integrated Care Partnership (ICP). This would formalise the involvement of local authorities as well as Primary Care Networks (PCNs).

The Chief Executive advised that the Trust had implemented Electronic Prescribing and

Inpatient Documentation on Electronic Patient Record (EPR) as part of the NHS England (NHSE) Global Digital Exemplar (GDE) Programme. The Board had recently approved a two year capital investment for the second phase of the Digital Hospital Programme.

The Chief Executive highlighted that the Annual General Meeting (AGM) had been held on

Tuesday 16 July 2019. The event had been successful with the theme of celebrating 180 years of the Royal Berkshire Hospital.

The Chief Executive advised that NHSI had requested revised capital plans with 20% less

spend for 2019/20 at system level. As part of the BOB ICP a 14% reduction had been put forward and this included a contribution from the Trust.

105/19 Integrated Performance Report (IPR) The Chief Finance Officer introduced the IPR and highlighted that, the C. Diff. target

remained a challenge following the change to reporting. There had been 13 cases year to date as a result of the changed measure. Therefore, there has been an increase in the number attributable to the Trust. Patient safety standards were overall satisfactory. However, there had been a Trust acquired Meticillin Sensitive Staphylococcus Aureus (MSSA) bacteraemia reported during June 2019 and a review had not highlighted any lapses in care. Mortality remained as expected. The Chief Finance Officer highlighted that stroke performance remained a challenge due to the demand and capacity challenges. The Medical Director advised that there had been an increase in both activity and acuity. Stroke patients were often moved to other wards to accommodate new patients arriving and this affected the target. However, patients still received on-going stroke care. The Board noted that system work was on-going in relation to increasing capacity and both the A&E Delivery Board and the Long Term Conditions Board were focussed on bed capacity.

The Board noted the improved metrics in relation to Speech & Language Therapy following the services being provided in-house.

There had been two Never Events in June 2019. Investigations were on-going and a report

would be submitted to the Quality Committee. The Director of Nursing advised one Never Event related to a retained sheath from a guidewire. Following the incident, the Trust had reported the equipment to the Medicines & Healthcare Regulatory Authority (MHRA). The second Never Event related to teeth extraction. Consent for the procedure had been accurate. Immediate action was to raise awareness in the department about the importance of sequencing. The Director of Nursing highlighted that the Trust had 60 days


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to complete investigations into Never Events and almost all were completed within the timeframe. All incidents were also reviewed with commissioners.

The Board noted increase demand on the Emergency Department as well as an increase in

Delayed Transfers of Care (DTOCs) and Length of Stay. Cancer performance was as expected although there were some staffing vacancies in radiotherapy. However, an improvement plan had been developed. The Chief Finance Officer highlighted that whilst the IPR stated that the Trust had been non-compliant with the 62 day cancer standard, following validation being undertaken, the Trust was compliant. The Trust remained challenged in relation to DM01 performance.

The Board queried the increase in DTOCs. The Chief Operating Officer advised that some

progress had been made. However, there were workforce capacity issues in the community and the Trust was experiencing a higher level of admissions and acuity that had impacted on discharge. It was agreed that the Chief Operating Officer would circulate information to the Board in relation to the cost of DTOCs to the Trust. Action: M Sherry

The Board noted that one complaint had been upheld by the Ombudsman. It was agreed

that the Director of Nursing would provide more detailed information about this complaint at the next Quality Committee. Action: C Ainslie

The Chief Finance Officer highlighted the Workforce and Health & Safety indicators, and

advised that there had been an increase in vacancies and mandatory training had improved. However, there had been an increase in splash injuries and this was being monitored.

The Chief Finance Officer advised that financial performance was plan and Provider

Sustainability Funds (PSF) had been recognised in the month. However, challenges remained and the current gap to the control total was £5.5m. Liquidity was satisfactory and a credit controller had been engaged to review overseas debt. Actual and committed capital was over plan. The Chief Finance Officer advised that, with support from KPMG, a number of large transformational programmes were being finalised. Commercial opportunities, including additional income and research and development income were being reviewed. The Board sought assurance in relation to the £5.5m gap. The Chief Finance Officer advised that the Restructuring Oversight Committee and Restructuring & Transformation Delivery Group had been established in order to provide a significant focus on QiPP delivery. In addition, the transformation team were also now working differently.

The Chief Finance Officer gave an update in the relation to the detailed review of DM01

performance. Six areas had been reviewed in detail. Overall, the Trust was delivering 99% over 13 modalities. Some areas were challenges in relation to capacity. Emergency and cancer patients were prioritised above routine access. The Chief Operating Officer advised that there would need to be decisions made in relation to investment and discussions would held with commissioners in relation to progress this year and plans for next year. The Board noted that any Quality Impact Assessment would be submitted to the Quality Committee. The Chief Operating Officer advised that a trajectory for diagnostics had been developed and this would require a system discussion. Recovery actions would be submitted to the Executive Management Committee and this would include a trajectory for next year. Action: M Sherry

The Chief Operating Officer gave an update in relation to the detailed review of Emergency

Department performance. There had been increase in activity and acuity as well as the number of ambulance admissions. Work was on-going with system partners and a report had been submitted for discussion. A weekly review of actions that could be taken by the


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Trust was on-going as well as recovery actions for the medium and long term. The Urgent & Emergency Care strategy mirrored that of natural trends. The Board noted that the ED facility had been logged on the risk register. The Board queried whether lack of intervention by Care Homes and GPs were adding the challenges seen by the Trust. The Medical Director advised that the Trust already provided a service to Care Homes and a meeting was being scheduled to review how further support could be provided to private Care Homes.

In response to a query raised in relation to the recent heat wave and the impact on the

Trust the Chief Operating Officer advised that the impact on staff was recognised. There had been an issue in relation to air handling and chillers and the operations team had worked closely with the estates team. The Medical Director highlighted the support from volunteers during this period.

106/19 Integrated Care Partnership (ICP) Performance Update The Director of Strategy introduced the report and advised that Berkshire West ICP had

rated itself as amber on performance and quality and red in relation to financial position. The Director of Strategy advised that the Programme Boards had been asked to review resources for key programmes. The Board raised a concern that finance was not included in the list of key programmes and there was a lack of visibility in relation to financial recovery of the system. It was agreed that the Chief Finance Officer would raise this with ICP partners. Action: N Lloyd

107/19 Changes to the Constitution The Trust Secretary introduced the report and advised that, following a review of the

composition of the Council of Governors based on patient flow and population data, the Membership Committee had submitted a recommendation to the Council of Governors to amend the composition by increasing the number of public governors for Wokingham to 4 and reducing the number of public governors for East Berkshire & Borders to 2. The Council had approved the amendment to the Constitution at its meeting on 29 May 2019.

The Board approved the amendment to the Constitution. 108/19 Minutes of Board Committee Meetings The Board received the minutes of the Finance & Investment Committee held on 20 May,

and 17 June 2019. The Chair of the Committee advised that the July meeting focused on Quarter 1 financial position as well as the Quarter 1 forecast. The budget had been achieved. However, the current QiPP gap presented a significant challenge. The Committee had also reviewed the procurement and commercial strategies and noted that the procurement team had achieved their Level 1 accreditation from NHSI Improvement (NHSI). The Committee had also received a detailed update in relation to the risk assessment process undertaken to respond to the NHS England (NHSE) capital request.

The Board received the minutes of the Quality Committee held on 10 May and 9 July 2019.

The Chair of the Quality Committee advised that the Committee had received the outcome of the Clinical Harm review, reviewed the serious incident themes and the results of the 2018 inpatient survey and corresponding action plan. The Committee had also received an update on the Travel and Transport plan. The Board received the minutes of the Audit & Risk Committee held on 15 May 2019.


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The Board received the minutes of the Charity Committee held on 20 May and 9 July 2019. The Chair of the Workforce Committee advised that, at its July meeting, the Committee received an update in relation to the on-going work nationally in relation to workforce and noted the Trust’s People Strategy was aligned to this. The Committee also received the Workforce Disability Equality Report and recommended that there should be an increased focus on this area by the Executive Management Committee. The Committee also discussed the compliance target for appraisals and had recommended the target should be increased to 100%. The Director of Workforce would confirm the implementation date for this. Action: D Fairley

109/19 Information Item: Board Work Plan The Board received the work plan. It was agreed that the Well Led Assessment update

would be rescheduled for November 2019. The Board also discussed the need to ensure a more balanced distribution of items in relation to each of the strategic objectives.

Action: C Lynch 110/19 Date of Next Meeting

It was agreed that the next meeting would be held on Wednesday 25 September 2019 at 9.30am. Chair Date


Board Schedule of Matters Arising and Outstanding Actions Agenda Item 4

Board Date Board Minute

Subject Decision Owner Expected Submission

Update

31 July 2019 103/19 (71/19 (34/19, 02/19)

Minutes: 29 May 2019 and Matters Arising Schedule: Minutes 27 March 2019 and Matters Arising Schedule: Minute 30 January 2019 and Matters Arising Schedule: Chief Executive’s Report:

The Chief Finance Officer confirmed that transformation monies had not yet been received from NHS Improvement (NHSI) and highlighted the risk to the system if these monies were not received by the end of August 2019.

N Lloyd Transformation monies have not yet been received. The Chief Finance Officer (CFO) of the Trust and the CFO of Berkshire West CCG have flagged this as a confirmed risk in ongoing correspondence with NHSE/I

31 July 2019 103/19 (72/19)

Minutes: 29 May 2019 and Matters Arising Schedule Chief Executive’s Report:

The Chief Executive confirmed that a future Board seminar with the Vice Chancellor of the University of Reading was being arranged and this would include an update from the Research & Development team.

S McManus The University of Reading has been invited to the Board Seminar on 18 December 2019.

31 July 2019 105/19 Integrated Performance Report (IPR)

It was agreed that the Chief Operating Officer would circulate information to the Board in relation to the cost of DTOCs to the Trust. The Board noted that one complaint had been upheld by the Ombudsman. It was agreed that the Director of Nursing would provide more detailed information about this complaint at the next Quality Committee. The Chief Operating Officer advised that a trajectory for diagnostics had been developed and this would require a system discussion. Recovery actions would be submitted to the Executive Management Committee and this would include a trajectory for next year.

M Sherry C Ainslie M Sherry

Not available yet, in progress, will follow when available. Noted. Item included on the Quality Committee Workplan. Trajectories will be developed as part of next years’ Operating Plan

Board Schedule of Matters Arising and Outstanding Actions Agenda Item 4

31 July 2019 106/19 Integrated Care Partnership (ICP) Performance Update

The Board raised a concern that finance was not included in the list of key programmes and there was a lack of visibility in relation to financial recovery of the system. It was agreed that the Chief Finance Officer would raise this with ICP partners.

N Lloyd The Finance Oversight Group, established across BOB ICS is providing financial scrutiny of programmes. CFO’s from the member organisations are represented at the Finance Oversight Group and that meets monthly and advises the CEOs across BOB ICS.

31 July 2019 108/19 Minutes of Board Committee Meetings

The Workforce Committee also discussed the compliance target for appraisals and had recommended the target should be increased to 100%. The Director of Workforce would confirm the implementation date for this.

D Fairley The implementation date of the 100% appraisal target is the 1 October 2019

31 July 2019 109/19 Information Item: Board Work Plan

It was agreed that the Well Led Assessment update would be rescheduled for November 2019. The Board also discussed the need to ensure a more balanced distribution of items in relation to each of the strategic objectives.

C Lynch Item included on the work plan.

Title: Chief Executive’s Report Agenda item no: 5.1 Meeting: Board of Directors Date: 25 September 2019 Presented by: Steve McManus, Chief Executive Prepared by: Caroline Lynch, Trust Secretary Purpose of the Report • To update the Board with an overview of key issues since the

previous Board meeting. • To update the Board with an overview of key national and local

strategic environment and planning developments • This includes items that may impact on policy, quality and financial

risks to the Trust.

Report History None

What action is required?

For information and discussion: the Board is asked to note the report.

Assurance Information Discussion/input Decision/approval

Resource Impact: None Relationship to Risk in BAF:

Strategic objectives This report impacts on (tick all that apply):: Provide the highest quality care Invest in our staff and live out our values Drive the development of integrated services Cultivate innovation and transformation Achieve long-term financial sustainability Well Led Framework applicability: Not applicable

1. Leadership 2. Vision & Strategy 3. Culture 4. Governance

5. Risks, Issues & Performance

6. Information Management

7. Engagement 8. Learning & Innovation

Publication Published on website Confidentiality (FoI): Private Public

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Key Issues 1. Provide the Highest Quality Care

1.1. Continuing with my ‘Back to the Floor’ sessions has included the dietetics team. The team delivers the service at the Trust whilst being employed by Berkshire Healthcare Foundation Trust (BHFT). The team support many clinical areas including oncology. As part of my visit I spent time with the oncology dietitian that supports and advises patients in various stages of cancer treatment. Cancer treatment can have a significant effect on a patients’ ability to maintain their nutritional intake due to difficulties in swallowing, nausea or significant pain in areas that have received radiation.

1.2. The Trust is one of three hospitals that are using alerts to help identify sepsis. Screening rates have increased by 70% with nine in ten patients now consistently screened for sepsis during admission as opposed to two in ten beforehand. We are one of the first UK trusts to implement red flag sepsis screening digitally on our Electronic Patient Record and have developed a more robust system for identifying clinical deterioration due to sepsis on the wards.

2. Invest in our staff and live out our values 2.1. Ian Gallen, endocrinologist at the Trust has been awarded a CBE for his services to public

health. Ian has not only built up a specialist interest and knowledge in community and gestational diabetes but also in the management and treatment of diabetes for athletes.

2.2. Mark Foulkes has also recently been elected to the role of 'President Elect' for the UK Oncology Nursing Society (UKONS). UKONS is the voice of oncology nursing in the UK and has established itself as a dynamic and influential body producing guidance and educational material to guide the care of cancer patients. Mark has been an active board member for two years and is currently responsible for cancer nurse education.

2.3. A significant number of our staff recently attended a ‘staff chill out’ day on Sunday 15 September, organised by the Royal Berks Charity (RBC). The day was well attended by members of staff and their families. Approximately 1400 people enjoyed the afternoon and there has been positive feedback from attendees. Further upcoming fundraising events supported by the RBC include a joint event with the League of Friends which is a concert featuring the Reading Male Voice Choir on Saturday 19 October 2019 as well as the Walk for Wards at Dinton Pastures Country Park on Sunday 23 February.

2.4. Our 3rd cohort of colleagues have recently started the Chartered Manager degree at Henley Business School and over the next 12 months the 1st cohort will also be undertaking a number of projects as part of their dissertation to support transformation and quality improvement at the Trust. It is great to have over 100 colleagues undertaking the degree in partnership with Henley Business School and the University of Reading.

2.5. We hosted our second LGBT+ forum recently that was well attended by staff and included a representative from Stonewall. We are also working with colleagues to identify LGBT+ champions across the Trust and for the first time, we raised the Rainbow flag, ahead of the Reading PRIDE weekend, both in support our LGBT+ community and our wider commitment as an inclusive organisation to all staff and the communities we serve.

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2.6. Our Trust Open Day took place on Saturday 7 September and it was a fantastic event with an

amazing turnout from colleagues across the organisation showcasing the outstanding services we provide. The day was themed around our 180 year anniversary, with key note presentations by our Chief Nurse Caroline Ainslie with her reflections on nursing and Alafiya Sachak from our Speech and Language team who spoke about the role therapy services had played at RBFT over the years. A number of tours took place to Pharmacy, Radiotherapy service and Hospital Radio Reading and the Medical Museum was open with our team of volunteers who help keep our 180 year history alive and relevant for current generations.

3. Drive the Development of Integrated Service

3.1. The first meeting of the Berkshire West Integrated Care Partnership (BWICP) Executive took place in early September and involved colleagues from the Clinical Commissioning Group, Royal Berkshire NHS Foundation Trust, Berkshire Healthcare NHS Foundation Trust, local authorities, South Central Ambulance Service and Primary Care Networks. The meeting highlighted the need to develop a performance report covering progress on the combined work programme of the ICP and building on lessons from previous reports. In addition, the principle challenge for the system was financial sustainability.

3.2. Key areas of focus for the next three months included driving forward the implementation of the urgent and emergency care strategy and the development of a health and well-being programme for our population.

3.3. The meeting highlighted the forthcoming engagement exercise on proposals to integrate NHS commissioning across Buckinghamshire, Oxfordshire and Berkshire (BOB) over the next 18 months. The detail of these proposals is still in development and subject to approval by CCG membership, but is likely to include the appointment of a single Accountable Officer / Integrated Care System lead for BOB, combining management teams and ultimately the merger of the statutory entities into a single commissioner. ICP members noted the importance of maintaining focus on the ICP work programme and the needs and priorities of our patients through the engagement period. We will respond to the engagement process once proposals are developed. It is anticipated that the engagement process will start in early October 2019.

4. Cultivate Innovation and Transformation

4.1. Our Joint Academic Board (JAB) recently announced the third round of the Royal Berkshire NHS Foundation Trust and University of Reading (UoR) collaborative innovation fund. The scheme is open to all colleagues across any grade or area in the Trust and at the UoR and gives colleagues the opportunity to put forward proposals for initiatives including teaching, learning and training and research or knowledge exchange. Since its development in October 2018 over 17 proposals have received funding.

5. Achieve Long-Term Financial Sustainability

5.1. Following a competitive procurement process, where framework suppliers where invited to bid for a Masterplanning contract, we have now decided on the consortium bidder we wish to appoint and are in the process of finalising the appointment.

5.2. The Month five year to date position is adverse to plan and we are currently reforecasting our year end outcome and reviewing what actions we can take both internally and with Commissioners to address this situation.

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Title: Integrated Performance Report Agenda item no: 5.2 Meeting: Board of Directors Date: 25 September 2019 Presented by: Mary Sherry, Chief Operating Officer Prepared by: Performance Team Purpose of the Report The purpose of this paper is to provide the Board of Directors with an

analysis of quality performance to the end of August 2019.

Report History None

What action is required? The Board is asked to note the report.


Resource Impact: None

Relationship to Risk in BAF:







September 2019

Integrated Performance Report

The purpose of this paper is to provide the Board of Directors with an analysis of quality performance to the end of August 2019. The report covers performance against the NHS Improvement (NHSI) Risk Assessment Framework as well as national and local key performance indicators. Contact: Caroline Ainslie, Director of Nursing Janet Lippett, Medical Director Mary Sherry, Chief Operating Officer Don Fairley, Director of Workforce Nicky Lloyd, Chief Finance Officer

Contents


Introduction Page 3

NHSI Compliance Page 4

Summary Page 5

1. Patient Safety Page 6

Harm Free Care / Incidents Reporting Page 7

Safeguarding Page 8

2. Patient Experience Page 9

3. Clinical Effectiveness Page 11

Mortality Page 12

Clinical Outcomes Page 15

4. Access

Emergency Waiting Times Page 18

Outpatient Experience Page 20

Waiting Times Page 22

Admitted Patient Experience Page 24

Theatres Patient Experience Page 25

Outpatient Experience Page 26

5. Workforce Page 28

6. Staffing Data Page 29

7. Health and Safety Indicators Page 30

8. Finance Page 32

The purpose of this report is to provide assurance to the Board of Directors on compliance against the NHS Improvement Risk Assessment Framework, national and local key performance indicators.

It acknowledges significant and notable achievements, and highlights and discusses areas of concern or where performance has a less than favourable forecast.

Introduction


NHSI Compliance (Access)


CQC - Responsive

CARE - Excellent

Accident & Emergency (A&E) o We continue to significantly under perform against this standard and in August performance remains below the 4 hour 95%

standard, reporting 87.3% combined (85.0% Type 1 only).

o Acuity and pressure across the Trust is significant. A strong focus continues on actions to control admissions and improvepatient flow/reduce length of stay , as well as with system partners to address the drivers of demand and reduce onwardpathway blocks. However the pressure on staff ED, through to AMU/SSU and all our critical care and inpatient wards is high.

o This last month has seen a complex and continuing picture of an increasing pattern of incidence of trauma (clinical/accidental,and violence/destructive behaviours / mental health related) presentations in ED. This is adding to the already evidenced andreported pattern of clinical acuity and complexity shown by our ambulance arrival patterns.

o System escalation this month resulted in a deep dive into current complex discharge issues and we have a number of actionsbeing taken forward at director level on these, plus help from NHSI regarding length of stay. However, although our LoSmetrics are extremely positive, our stranded patients and Delayed Transfers of Care (DTOC) are high against a reduced bedbase.

o The Emergency Department (ED) estate and facilities is now presenting an increasing risk given the pattern of attendancesnow being seen. This has long been flagged as a concern and now is becoming even more material.

Cancer Waiting Times (July 19) o Performance against the Two Week Wait (2WW), 31 Day First Definitive Treatment (FDT), 62 Day FDT and subsequent surgery

treatment have been achieved in July.

o Seasonal pressure within the Skin/Dermatology cancer pathway has begun to impact 2WW performance in June/July. Whilstwe are compliant in July we expect performance within the skin tumour site will reduce to a level in August that will makecompliance with the standard impossible. It is not expected to impact the 62 day standard.

o We will continue to work closely with local commissioners, NHS Improvement and the Thames Valley Cancer Network inrelation to the 62 day standard sustainability as well as implementation of the new 28 day diagnosis standard.

18 Weeks Referral To Treatment (RTT) o The Trust remains compliant against the RTT 92% standard for August 2019. Continuing pressure in Ophthalmology and ENT.

Diagnostic Monitoring (DM01) o The Trust remains non compliant against the 99% DM01 standard.

August 2019 Summary


CQC – Well Led

CARE - Excellent

18/09/2019

Provide the highest quality care

• Our patients continue to positively respond to our Patient Surveys.

• The Trust mortality metrics continue to report at as expected levels in SHIMI and CRAB.

• Most Safety and Patient Experience metrics continue to perform well and show a stable trend. However we are significantly over monthly threshold on Clostridium difficile (C.diff)since the national change in counting of C.diff.

• During August the Trust was recognised for the great work undertaken to develop the ‘life saving’ digital sepsis alerts within our EPR and strong performance in patient care for these patients

• In-going concerns are:

o A&E Access: Performance against the 95% standard remains non-compliant as the department remains under pressure through the summer. Performance has deteriorated through August as we continue to see unseasonably high demand and acuity levels in the department. We continue to work to improve this situation, including with support fromNHSI and system partners.

o Diagnostic waiting times remain non-compliant. 75% of those waiting above 6 weeks are awaiting either and endoscopic or neurophysiology assessment. The Trust continues towork to resolve issues in year and prioritise Urgent and Cancer pathways as needed and is reviewing modality specific improvement options

Invest in our staff and live out our values

• New appraisal target being adopted and pursued, job redesign continues as part of transformation work with some interesting new innovations being developed eg new pharmacyassistant roles and occupational therapy roles supporting nursing establishements on wards as part of ‘model ward’

• Work continues on care group review, finance matters and the developments with KPMG on future ways of working

Drive the development of integrated services

• During August the Connected Care ecosystem, a collaboration across Health and Social care in East and West Berkshire which provides record sharing, intelligence and personal record capability commenced migration to a new, advanced platform. Through August and early September the team will be working on operationalization of the intelligence capability and apilot launch of a patient held app designed to help our public record important information they wish to share with health and care professionals.

• The first ICP Unified Executive meeting took place in early September.

Cultivate innovation and transformation

• Work on our text reminder service with DrDr continues and most departments in the Trust have completed the prerequisite requirements and deployment of the solution is inprogress. Together with hybrid mail, this will act as one of a number of catalysts for further digitally enabled transformation. This links directly to the Trust Outpatient Transformation and Modern Administration programmes.

• Work continues with KPMG to drive a programme of transformation focused on efficient use of time and resources across the Trust.

Achieve long-term financial sustainability

• The Trust performance is £(2.18)m behind Control Total for the YTD at £(6.63)m against £(4.42)m target.• The value of our identified schemes in 2019/20 have increased to £14.7m against a target of £16.9m. The current risk adjusted value of these schemes in £12.4m.

1. Safety Summary

Integrated Performance Report 18/09/2019

Infection Control: The C.diff objective upper limit for 2019/20 is 24 cases. Of the 3 reported during August, 1 was reported as Community onset, Healthcare associated (COHA), whilst the remaining case was reported as Hospital onset, Healthcare associated (HOHA). Case reviews are currently in progress to determine whether any lapses in care have occurred.

At the start of the financial year the C.diff reporting definitions were updated. Prior to 2019/20, the Trust C.diff objective (upper limit of 26) was set on cases that were detected 4 or more days after admission. For information, had this prior reporting protocol been continued for 2019/20, 13 cases would have been apportioned to the Trust up until the end of August 2019 (9 cases had been reported up to this point in 2018/19). 4 Lapses in care have been reported to date (though it should be acknowledged that there are still case reviews from July and August 2019 awaiting completion). For comparison, 4 lapses in care had been reported in the corresponding period 2018/19. An exception report will be presented at the next Quality Committee.

3 TA Escherichia coli (E.coli) bacteraemia were reported in August 2019; reviews have been undertaken and no lapses in care or common themes have been identified. 1 TA Klebsiella (no lapse identified )

In August the Trust reported 13 Serious Incidents, a thematic review has not identified any significant trends: an increase in vigilance by staff in reviewing and reporting incidents may have contributed to the increase in reporting. 2 incidents were investigated as local RCA’s and upgraded to SI’s following an Executive sign off.

Pressure Ulcers: Of the 11 confirmed hospital acquired category 2 pressure ulcers reported in August lapses in care were identified in 5 cases. In the remaining 6 cases care delivered was outstanding 3 Category 3 / 4 pressure ulcers (lapses in care identified) were reported in August. 1 was identified in March 19, investigated as a local RCA and subsequently upgraded to a SI. The two remaining Pressure Ulcers occurred in June and July, scoped and declared in August.

The August data has been consistent with July. There continues to be a cohort of very sick / end of life patients who have developed pressure damage in the last stages of life.

Safeguarding: The target for Level One Safeguarding Children Training has dipped below compliance – with the exception of NCG and E&F who both achieved > 95% 2 adult safeguarding concerns raised against the Trust concerned pressure damage. In both cases there was pre-admission pressure damage and no deterioration in our care.

CQC – Safety

CARE - Aspirational

1. Safety – Provide the highest quality care


CQC – Safety & Effective

CARE - Aspirational

Harm Free CareTarget

variance

Infection Control Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

Meeting the C.Diff objective 1 1 1 0 3 2 0 6 3 4 8 3 ▼ N 2 1

C.Diff due to lapses in care 0 0 1 0 0 0 0 1 0 2 1 0 ▼ N 0 0

C.Diff (Cummulative) 10 11 12 12 15 17 17 6 9 13 21 24 - N 24 0

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

MSSA surveillance (trust acquired) 0 3 1 2 7 1 4 2 6 5 1 0 ▼ - - -

Ecoli (trust acquired) infections 7 2 5 4 5 5 5 7 2 11 4 5 ▲ - - -

Target Type: N - National / L - Local / H - Hospital

Incidents ReportingTarget

variance

Falls and Ulcers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

Pressure Ulcer Incidence per 1 000 bed days 0.53 0.76 0.55 0.64 0.87 0.46 0.76 0.31 0.30 0.25 0.59 0.64 ▲ N 1.00 -0.36

Category 2 Pressure Ulcers 10 11 10 11 17 10 11 6 11 4 10 11 ▲ N - -

Category 3 or 4 avoidable pressure ulcers (SI) 0 3 0 2 2 0 3 0 2 1 0 3 ▲ N 0 3

Patient Falls per 1 000 bed days 4.0 4.6 4.3 4.3 4.1 4.1 4.2 3.9 3.8 3.3 3.9 3.4 ▼ N 5.0 -1.6

Patient falls resulting in Harm (SI) Avoidable 0 0 1 0 0 0 0 0 1 1 0 0 ◄► - - -


Incidents ReportingTarget

variance

Other Incidents Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

Patient safety incidents reported (approved) 611 701 682 719 773 653 609 617 701 701 802 701 ▼ - - -

Number of incidents reported (unapproved) 59 65 71 81 95 91 75 0 60 86 89 70 ▼ - - -

Patient Safety Incidents/100 Admissions 8.2% 7.9% 8.0% 9.7% 9.1% 8.6% 7.3% 7.3% 8.1% 9.1% 9.0% 8.6% ▼ N 7.0% 1.6%

All serious incidents (SI) 6 6 7 4 8 3 6 1 7 8 5 13 ▲ - - -

Never Events 1 1 1 1 0 1 0 0 0 2 0 0 ◄► N 0 0


Target

Target

Actual

Actual

Actual Target


1. Safety – Provide the highest quality care

CQC – Safety

CARE - Aspirational

Health and Safety Indicators Target

variance

Health and Safety Indicators

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type Month +/-

Number of detentions under the Mental Health Act to the

RBH 7 8 7 7 5 6 2 8 5 9 8 6 ▼ - - -

Number of DOLS (Deprivation of Liberty) applications

applied for 1 8 11 7 7 7 2 4 9 5 12 9 ▼ - - -

Number of DOLS (Deprivation of Liberty) applications

granted1 0 0 0 0 0 0 1 0 1 0 2 ▲ - - -

Number of Child Safeguarding concerns raised by the

Trust103 71 89 94 108 97 115 80 134 99 80 59 ▼ - - -

Number of Adult Safeguarding concerns raised by the

Trust28 25 29 30 29 26 33 25 36 32 45 32 ▼ - - -

Number of Safeguarding concerns raised against the Trust5 3 4 0 2 1 3 2 1 2 2 2 ◄► - - -


SafeguardingTarget

variance

Safeguarding Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

% of relevant staff who have had Safeguarding Children

Level 1 Training92.6% 93.9% 93.4% 92.6% 92.8% 92.8% 93.5% 94.5% 94.4% 94.5% 95.2% 94.6% ▼ N 95.0% -0.4%


Actual Target

Actual Target

2. Patient Experience Summary


Complaints We have seen an increase in formal complaints this month across the Care Groups ; with a higher proportion for Emergency Care Directorate. Clinical Treatment (15) and Communication (16) were the top two themes. Analysis of the incident dates demonstrates that just over 50% were older than a month . Our historic averages suggest an increase in complaints around August. In addition, three of these complaints were unresolved PALS queries.

Of the complaints closed in August; 2 were well founded, 5 were partially well founded and 6 were unfounded. We are awaiting outcomes for 9 complaints; these are being actively followed up.

Out of the 204 PALS concerns the main themes were administration (84), communication and consultation (62) and clinical treatment (42).

54 compliments were logged by the Patient Relations Team, 4 in Networked Care, 8 in Planned Care, 36 in Urgent Care and 6 in other.

Mixed Sex Accommodation The number of single sex breaches have increased in August as the Trust has been on either 3 or 4 OPEL status for a significant period of time. Capacity has been affected due to a closure of one of our urgent care wards and our DTOC and fit to go numbers have increased. This has impacted on patient flow and has resulted in Acute Medical Unit (AMU) receiving admissions from Emergency Department (ED) late into the evening and night.

CQC – Caring CARE - Aspirational


2. Patient Experience – Provide the highest quality care

CQC – Caring CARE - Aspirational

Target

variance

Patient Complaints Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Number of Complaints 23 19 28 21 23 28 28 14 17 29 25 36 ▲ - - -

Complaints avg response (days) 25 30 27 24 25 27 26 26 23 22 23 19 ▼ L 25 -6

Number of complaints returned for a

second review- - - - - - 0 0 3 3 6 2 ▼ - - -

Number of Patient Advisory Liaison

Service (PALS) concerns185 236 236 147 219 218 284 232 256 244 235 204 ▼ - - -

Number of Complaints to Ombudsman 0 1 0 0 0 0 0 0 0 0 1 0 ▼ - - -

Number of Complaints upheld by

Ombudsman0 0 0 0 0 0 0 0 0 1 0 0 ◄► - - -

Number of compliments recieved to

Patient Relations Department101 12 35 9 71 0 30 20 25 66 86 54 ▼ - - -


Surveys and FeedbackTarget

variance

Trust Patient Survey Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Friends and Family Test (FFT) Response

Inpatients42.4% 52.0% 51.1% 40.3% 50.8% 47.7% 51.1% 48.3% 49.2% 52.4% 50.6% 40.4% ▼ N 30.0% 10.4%

FFT Recommendation Rates Inpatients 99.8% 99.7% 99.3% 99.6% 99.8% 99.4% 99.6% 99.8% 99.8% 99.8% 99.5% 99.7% ▲ N 98.0% 1.7%

FFT Recommendation Rates Maternity 96.6% 96.3% 97.0% 96.8% 96.5% 97.4% 98.2% 96.8% 96.8% 97.3% 97.7% 97.5% ▼ N 95.0% 2.5%

Single sex accommodation - breaches

(Excluding Emergency Department

Observation Bays)

41 62 64 105 138 87 166 37 64 105 56 106 ▲ N 0 106


Actual

Actual Target

Target

3. Clinical Summary


• Trust mortality, as a crude percentage of admissions, remains as expected, as does the national Summary Hospital-level Indicator (SHMI); although itremains higher than we aspire to.

• In surgery, risk adjusted mortality and complications remain better than expected overall. An in-depth analysis of Interventional Cardiology proceduremortality has revealed a number of data issues. General Surgery are flagging for their complication rates around haemorrhage / haematoma and chestinfection and are being reviewed internally. The CRAB review of urinary retention revealed that CRAB was not differentiating between patients coming inwith urinary retention, and patients experiencing urinary retention as a post-op complication. Refinement of the CRAB coding algorithm for post-opurinary retention has improved the accuracy of this data and shows that Urology actually have a very low complication rate.

• In Medicine, the management of the deteriorating patient is to be a key theme for 2019/20, aligned to trust priorities and working with colleagues invarious sub-specialty areas of medicine.

• Specialty specific reports are now being issued directly to clinical teams to increase awareness and focus on the areas with the highest incidence of triggers.A training session for all clinical leads is being provided on the 27th September 2019.

• The caesarean section rate has been raised in the last two months. A review is being completed to identify any themes and actions. There has been adecrease in the number of women birthing in the Midwifery led unit which is being monitored.

• Stroke: The Hyper-Acute Stroke Unit (HASU) service, consistently continues to achieve its national target for Door to needle times and CT scanning. TheStroke Sentinel National Audit Programme (SSNAP) rates the overall Stroke Service at the RBFT as a “B” rated organisation for Q1 2019/20. This is based onthe difficulties it faces with access to the unit; as a result of delays in onward pathways. The stroke team continue to work with community partners andthe ICP to develop improved pathways, and focus on delay hotspots.

• MINAP “door to balloon” (D-B) target 1 breach for C –B <120 mins and this was a very long Call to Door by SCAS. A Datix and time line will be actioned andthe service will meet with SCAS to identify the issues. 4 “Golden Hours” for the month of July with, some excellent practice in prompt activation by SCAS.

CQC – Effective & Responsive CARE - Excellent

Crude mortality percentage has decreased in August 2019 although it is higher than the same time last year. Summary Hospital-level Mortality Indicator (SHMI) remains as expected. Please note NHS Digital have started to publish SHMI monthly - May 2018 to April 2019 will be published late September 2019.

The Mortality Surveillance Group (MSG) continues to monitor possible or probable avoidable harm related to hospital care and shares learning points across the Trust. The new Clinical Outcomes Review System (CORS) reporting is now in use and will support the Medical Examiner process and the structured judgement review (SJR).

3.Clinical – Consistently Delivering Quality Care & Healthcare Outcomes


Trust Mortality

CQC – Effective & Responsive

CARE - Excellent

3. Clinical – Consistently Delivering Quality Care and Healthcare Outcomes


Perioperative Care Mortality Overall Perioperative Risk Adjusted Mortality (30 day & in-hospital)

Overall Perioperative complication rate

Complications

Both perioperative Risk Adjusted mortality and complications for our overall case-mix are better than expected. Interventional cardiology continues to alert for peri-procedure mortality. Clinical review of the cases has not revealed any clinical concerns. Investigations continue into whether CRAB is accurately capturing the acuity of these patients; coding are working with the clinical team to review each case to identify opportunities for improving the data capture of these patients where required. General Surgery have alerted this month for complications which appear to be driven by around haemorrhage / haematoma and chest infection. This is currently being reviewed internally. The CRAB review of urinary retention revealed that CRAB was not differentiating between patients coming in with urinary retention, and patients experiencing urinary retention as a post-op complication. Refinement of the CRAB coding algorithm for post-op urinary retention has improved the accuracy of this data and shows that Urology actually have a very low complication rate (0.65).


CARE - Excellent

3. Clinical – Consistently Delivering Quality Care and Healthcare Outcomes


Medical ward based care

The number of medical inpatients with 4 or more adverse triggers continues to be higher than the UK Norm. The mortality rate for medical inpatients with 4 or more adverse triggers has been consistently below the UK norm

The same 4 triggers (Sepsis, Hospital acquired pneumonia (HAP), Acute kidney injury and Shock or cardiac arrest) are consistently above the UK norm (see below).

An in-depth audit of Sepsis and HAP cases has been undertaken by clinical leads. This has identified areas for improvement including education of doctors around classification of HAP and community acquired pneumonia (CAP), and review of diagnostics and appropriate de-escalation.

% of medical ward admissions

with > 4 triggers

Mortality of medical ward

admissions with > 4 triggers


CARE - Excellent

3. Clinical – Provide the highest quality care


CQC – Effective

CARE - Excellent

Monitoring Clinical OutcomesTarget

variance

Stroke Care Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Proportion of patients spending 90% of

their inpatient stay on a specialist stroke

unit (national target)

89.0% 82.0% 82.0% 72.0% 77.0% 65.0% 74.0% 87.0% 74.0% 85.0% 86.0% 97.0% ▲ N 80.0% 17.0%

Proportion of stroke patients scanned

within 12 hours of hospital arrival95.0% 92.0% 96.0% 94.0% 98.0% 92.0% 93.0% 87.0% 93.0% 96.0% 96.0% 97.0% ▲ N 0.0% 97.0%

Proportion of people with high risk TIA

fully investigated and treated within

24hrs (IPM national target)

94.0% 83.0% 71.0% 82.0% 63.0% 71.0% 81.0% 100.0% 100.0% 94.0% 94.0% 95.0% ▲ N 90.0% 5.0%

Average Length of Stay (LOS) from

admission to discharge (days)15 15 14 17 16 15 19 13 16 15 13 11 ▼ N 14 -3.0

Door to needle time <60mins 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ◄► N 95.0% 5.0%

Proportion of S&LT communication

assessments <72 hrs90.0% 90.0% 86.0% 86.0% 82.0% 79.0% 82.0% 100.0% 70.0% 90.0% 92.0% 93.0% ▲ N 95.0% -2.0%



variance

Cardiac Care Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Myocardial Ischaemia National Audit

Project (MINAP): Call to Balloon target

less of than 150 minutes

100.0% 100.0% 89.0% 100.0% 100.0% 93.0% 100.0% 100.0% 100.0% 100.0% 100.0% ◄► N 82.0% 18.0%


Project (MINAP): Call-to-Balloon target

of less than 120 minutes

93.0% 100.0% 89.0% 82.0% 100.0% 93.0% 90.0% 100.0% 100.0% 78.0% 92.0% ▲ N 86.0% 5.7%


Project (MINAP): Door-to-Balloon target

of less than 90 minutes

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 89.0% 88.0% 89.0% 100.0% ◄► N 97.0% 3.0%


Actual Target

Actual Target

3. Clinical – Provide the highest quality care


CQC – Responsive, Safety & Effective

CARE - Excellent


variance

Maternity Care Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Women giving birth: 1:1 delivery of care 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ◄► N 98.0% 2.0%

Midwife : birth ratio (utilised workforce) 1:28 1:27 1:27 1:27 1:28 1:25 1:26 1:27 1:27 1:27 1:30 1:28 - L 1:30

Caesarean Sections - Elective 12.9% 16.4% 17.6% 13.5% 13.4% 11.7% 12.9% 13.6% 14.8% 13.9% 17.0% 15.1% ▼ N 12.0% 3.1%

Homebirths - No of deliveries

(proportion of total)2.0% 3.0% 3.0% 3.0% 4.3% 4.5% 1.7% 2.8% 4.0% 5.0% 2.0% 3.0% ▲ N 4.0% -1.0%

MLU No of deliveries (proportion of

total) 17.0% 13.0% 15.0% 22.0% 16.0% 19.0% 17.0% 16.0% 16.0% 19.0% 15.0% 12.0% ▼ N 20.0% -8.0%

No of times women diverted 2 4 0 0 0 0 0 0 0 0 1 0 ▼ N 0 0

Percentage of Unexpected NICU

admissions over 37 weeks3.0% 5.1% 7.8% 4.5% 4.8% 6.5% 5.8% 4.5% 5.3% 6.4% 4.3% 4.0% ▼ N 5.0% -1.0%

Number of births 402 448 411 400 415 378 403 426 394 391 441 398 ▼ N - -



variance

Other Clinical Indicators Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

VTE Risk Assessment 95.9% 97.3% 96.5% 97.3% 95.3% 96.9% 96.1% 97.7% 95.8% 95.2% 99.4% 95.5% ▼ N 95.0% 0.3%

VTE Incidence (Hospital & Community

Acquired)44 62 58 32 71 69 76 62 59 55 73 58 ▼ N - -

Datix: Number of VTE Incidence

(Hospital Acquired)0 1 0 0 1 0 0 0 0 0 2 1 ▼ N - -

Datix: % VTE Incidence (Hospital

Acquired)0.0% 1.6% 0.0% 0.0% 1.4% 0.0% 0.0% 0.0% 0.0% 0.0% 2.7% 1.7% ▼ N - -


Target Actual

Actual Target

4. Access Summary


A&E performance Performance against the 4 hour standard remains below the 95% standard, reporting 87.3% for August. The Trust continues to see attendance numbers higher than the same period last year. The Trust, with ICP partners and support from NHSE are continuing to identify opportunities to improve flow and through the A&E Delivery board are preparing the Urgent and Emergency Care Strategy setting out plans aimed at addressing capacity, future demand and patient flows.

DToC – total numbers and bed days lost, are high, to note this is out of a lower bed base (28 beds closed); significant number of very complex pathways, deep dive has been held with system partners, with a set of agreed actions being taken forward. Assistance being provided by NHSi on this and stranded patients also (DTOC are a subset of these).

Cancer Performance - July • 14 day, 31 day FDT and 62 day FDT are all compliant. However seasonal pressure on the 14 day standard beginning to have an impact.• 31 day subsequent chemo (44 ) and 62 day screening (16) are non compliant. These are low volume standards with both reporting 2x breach of the standards.• 31 day subsequent radiotherapy performance has continued to improve. The service remains challenged. • Through July and August the number of patients on the Cancer PTL awaiting pathology actions remains in far better position.

Cancer Performance - August The August position is currently being validated and is therefore not final. We expect to be non-compliant with the 2ww standard in August as a result of seasonal increased demand within Dermatology which is further complicated by known issues with capacity within the service.

Residual Risk • Increasing pressure on both the Endoscopy and Dermatology services with extremely limited capacity.• Pathology remains a key area of focus to ensure improvements continue in a sustainable way.• MRI and CT equipment fragility continues to pose a performance risk.• Impact of substantive staffing vacancies in relation to Radiotherapy.

Cancer 104 days. At the end of August there are 10 pathways on the PTL above 104 days. Of these 10, 2 have confirmed diagnosis with the other 8 continuing to progress through the diagnostic pathways. 3 of the 10 pathways are being managed within tertiary providers. There is no specific theme identified this month.

Referral To Treatment (RTT) • The Trust remains compliant with the 92% standard. However at a specialty level Ophthalmology is now presenting a continuing risk (90.2% in Aug 19). Declined

additional sessions, redirection of clinic time to support eye casualty and growing demand have contributed to an extending waiting time profile. We are assessing corrective action to address the operational and patient experience impact (including extended waiting time risk).

• Underperformance in ENT continues to be significantly contributed to by issues within booking processes. This is actively being reviewed by the service and will link directly to the Modern Administration Programme.

• Work to progress an ICP response to the growing demand on the Ophthalmology service is continuing and investigation into interim solutions is under way.

Diagnostic Monitoring (DM01) • The diagnostic standard remains a significant challenge for the Trust. Performance has deteriorated further in August as a result of the continued growth of the

waiting list in both Endoscopy and Neurophysiology which collectively account for 75% of all patients over 6 weeks. Radiology (CT/MRI) has returned to a compliantposition. Further consideration now needed as to whether any in year improvements can be achieved within current financial constraints together with longer termplanning for the delivery of these modalities.

CQC -Responsive

CARE - Excellent

Cancer

RTT

DM01

A&E

4. Access – Provide the highest quality care.

CQC -Responsive

CARE - Excellent


• The department continues to see a steady increase in patients conveyedover the age of 70yrs. It is the highest change proportion.

• Work is underway to plan to take over the PCU service from 1stSeptember.

• The team are still working with the architects and project manager toascertain whether any more non clinical space can be converted in ED.

• Pressure has increased in ED as follows:• When comparing Aug 2019 to Aug 2018, ED has seen a 5.4% increase in

attendances.• The volume of patients streamed to the GP streaming service has again

reduced totalling 627 (July 19=712), averaging 20 per day. The servicehas been non operational on five occasions in July.

• Ambulance handovers were up in Aug averaging 101 handovers perday.

• Total daily attendance averages 301 patients per day, however we haveseen almost 2.2% growth in volume of attendance. This has beenconsistent for the past 5 months.

• Maximum attendances was 360, with 1 occasion where 350+ patientsattended in one day.

A&E ExperienceTarget

variance

Waiting Times: A&E Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

A&E 4hr Limit (RBH combined) 93.7% 87.9% 88.2% 86.1% 89.4% 89.6% 90.6% 91.3% 92.6% 86.4% 90.1% 87.3% ▼ N 95.0% -7.7%

A&E 4hr Limit (RBH combined) - QTR 95.08% 87.41% 89.92% 90.13% ▲ N 95.0% -

A&E 4hr Limit (Type 1 only) 92.9% 85.60% 86.1% 83.2% 87.1% 87.5% 88.5% 89.0% 90.8% 83.1% 88.2% 85.0% ▼ N 95.0% -10.0%

A&E 4hr Limit (Type 1 only) - QTR 94.4% 0.0% 0.0% 85.0% 0.0% 0.0% 87.7% 0.0% 0.0% 87.6% 0.0% ▲ N 95.0% -

A&E Type 1 (number) 9263 9827 9741 9423 9350 8685 9630 9052 9710 9551 10167 9412 ▼ - - -

A&E Type 1 conversion to admission rate (%) 31.5% 32.0% 31.7% 33.3% 35.1% 34.0% 33.8% 33.0% 32.4% 30.0% 30.0% 31.1% ▲ - - -

A&E Type 1: Majors & Resus (number) 6842 7085 7065 7191 7309 6839 7385 6920 6932 7000 6990 6658 ▼ - - -

A&E Type 3: Streamed (number) 1051 944 680 673 577 830 824 882 1091 963 978 963 ▼ - - -

Trolley Waits: 12 hour decision to admit (DTA) 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

Ambulance Handover : 30 Minutes 38 106 92 125 144 51 73 92 75 77 143 ▲ N 0 75

Ambulance Handover : 60 Minutes 2 4 10 2 20 2 5 7 6 12 14 ▼ N 0 6


Actual Target

Type 1 performance in Aug has seen a reduction from the previous month and was 85%. (July 2019 = 88.23%)

Aug-18 Aug-19 % Difference

Attendances 8924 9412 5.40%

Admissions 2858 2923 2.20%

Breaches 416 1412 239%

CQC -Responsive

CARE - Excellent 4. Access – Provide the highest quality care.


• 2712 handovers were received into ED, similar to Aug 18.• Acuity remained high with pockets of increased demand between

1000-2100 particularly Wednesdays to Fridays• Average 101 ambulances per day.

• The new triage process continues to assist in meeting the15min standard for arrival to assessment.

• Total LOS has also reduced in July averaging 200 mins, 3hrs 3mins.

Ambulance handover time declined in August from the rolling 6 week average from 32 minutes up to 36 minutes whilst number of arrivals remained comparable

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Monday 16 18 13 8 11 10 3 7 13 12 26 27 20 25 23 21 19 23 23 24 18 22 26 23

Tuesday 6 10 13 11 9 11 3 7 9 17 18 24 26 30 21 23 22 20 18 29 21 24 19 24

Wednesday 16 11 12 8 9 13 7 10 16 25 23 22 27 25 22 18 20 27 25 25 26 19 15 11

Thursday 12 8 7 4 6 14 10 12 15 19 27 26 27 31 31 35 31 33 33 28 29 24 23 25

Friday 20 16 14 9 15 10 7 8 18 22 21 20 30 27 20 39 22 29 38 31 27 32 22 23

Saturday 16 18 13 13 13 15 13 9 20 21 35 20 33 18 26 24 18 32 24 20 23 24 16 25

Sunday 28 19 15 9 6 10 6 7 13 13 18 20 24 16 17 19 17 31 22 22 14 19 19 30

Arrival Time - Hourly Analysis

Rule 1 Rule 2 Rule 3 Rule 4 Rule 1 Rule 2 Rule 3 Rule 4

n n n n n n n n

36 32

Ambulance attendances

This week 6 wk avg.

637 659

Ambulance handover (over 30 minutes)

This week 6 wk avg.

CQC -Responsive

CARE - Excellent 4. Access – Provide the highest quality care.


Shadow Reporting - Proposed Standards



CQC -Responsive

CARE - Excellent

28 Day Diagnosis

31 Day - Aggregated

62 Day - Aggregated

May 2019 - 95.8% 87.1%

Outpatient ExperienceTarget

variance

Cancer Pathways Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Cancer 2 week wait: cancer suspected - QTR 94.8% 0.0% 0.0% 96.8% 0.0% 0.0% 96.3% 0.0% 0.0% 96.1% 0.0% 0.0% ▼ N 93.0% -93.0%

Cancer 2 week wait: breast patients - QTR 95.9% 0.0% 0.0% 98.5% 0.0% 0.0% 96.3% 0.0% 0.0% 96.1% 0.0% 0.0% ▼ N 93.0% -93.0%

Cancer 31 day wait: to first treatment - QTR 96.6% 0.0% 0.0% 98.0% 0.0% 0.0% 96.9% 0.0% 0.0% 96.9% 0.0% 0.0% ◄► N 96.0% -96.0%

Cancer 31 day wait: drug treatments - QTR 99.0% 0.0% 0.0% 99.6% 0.0% 0.0% 98.6% 0.0% 0.0% 99.2% 0.0% 0.0% ▼ N 98.0% -98.0%

Cancer 31 day wait: surgery - QTR 96.4% 0.0% 0.0% 98.4% 0.0% 0.0% 95.2% 0.0% 0.0% 91.8% 0.0% ▼ N 94.0% -94.0%

Cancer 31 day wait: radiotherapy - QTR 94.8% 0.0% 0.0% 94.4% 0.0% 0.0% 92.6% 0.0% 0.0% 84.0% 0.0% 0.0% ▼ N 94.0% -94.0%

62 day consultant upgrade: all cancers - QTR 90.0% 0.0% 0.0% 64.0% 0.0% 0.0% 69.7% 0.0% 0.0% 70.0% 0.0% 0.0% ▲ - - -

62 Day GP Ref - QTR 75.1% 0.0% 0.0% 85.1% 0.0% 0.0% 85.1% 0.0% 0.0% 86.1% 0.0% 0.0% ▼ N 85.0% -85.0%

62 Day screen Ref - QTR 94.4% 0.0% 0.0% 86.0% 0.0% 0.0% 92.1% 0.0% 0.0% 84.9% 0.0% 0.0% ▼ N 80.0% -80.0%



variance

Cancer Pathways Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Cancer 2 week wait: cancer suspected 95.1% 95.9% 98.0% 96.6% 93.3% 98.2% 97.3% 96.4% 97.1% 94.8% 94.0% 87.7% ▼ N 93.0% -5.3%

Cancer 2 week wait: breast patients 94.5% 97.4% 99.5% 98.6% 97.8% 98.4% 93.0% 96.6% 94.9% 96.6% 98.9% 98.2% ▼ N 93.0% 5.2%

Cancer 31 day wait: to first treatment 98.7% 97.9% 98.5% 97.5% 98.2% 96.6% 95.8% 96.1% 96.3% 98.3% 98.7% 97.9% ▼ N 96.0% 1.9%

Cancer 31 day wait: drug treatments 100.0% 100.0% 100.0% 98.2% 98.9% 98.4% 98.2% 100.0% 100.0% 98.0% 95.5% 95.5% ◄► N 98.0% -2.5%

Cancer 31 day wait: surgery 96.4% 98.3% 97.7% 100.0% 90.3% 100.0% 97.1% 93.3% 91.7% 89.5% 95.5% 93.3% ▼ N 94.0% -0.7%

Cancer 31 day wait: radiotherapy 94.5% 95.6% 91.8% 96.3% 94.3% 97.1% 85.4% 78.9% 81.6% 92.2% 93.6% 95.5% ▲ N 94.0% 1.5%

62 day consultant upgrade: all cancers 100.0% 50.0% 77.8% 62.5% 75.0% 0.0% 68.0% 66.7% 85.7% 57.1% 71.4% 22.2% ▼ - - -

62 Day GP Ref 83.0% 86.5% 87.0% 80.7% 83.1% 85.3% 87.0% 84.6% 84.9% 89.2% 85.7% 76.7% ▼ N 85.0% -8.3%

62 Day screen Ref 92.3% 81.3% 100.0% 82.6% 95.6% 86.7% 92.3% 89.5% 86.7% 76.5% 87.5% 87.5% ◄► N 80.0% 7.5%

Incomplete 104 day waits 9 8 6 10 11 11 8 7 10 9 15 10 ▼ N 0 9


Actual Unvalidated

Actual Unvalidated

Target

Target



CQC -Responsive

CARE - Excellent

18 weeks RTTTarget

variance

Waiting Times: 18 weeks RTT Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

18 Weeks: incomplete pathways (%) 92.5% 93.2% 92.6% 92.5% 92.2% 92.3% 92.3% 92.5% 92.8% 92.8% 92.4% 92.4% ◄► N 92.0% 0.4%

18 Weeks: incomplete pathways (number) 31408 30994 30105 29974 29916 29253 28843 29850 28979 28615 29680 30562 ▲ N - -

18 weeks complete patients (Admitted clock

stops)2326 2418 2691 2427 3037 2739 2806 2729 2974 2540 2938 2582 ▼ N - -

18 weeks complete patients (Non Admitted clock

stops)5552 5634 6130 5234 6884 5869 6102 5629 6146 6046 6376 5298 ▼ - - -

52 Weeks - Admitted 0 0 0 0 0 0 0 0 0 0 0 0 ◄► - 0 0

52 Weeks - Non-admitted 0 0 0 0 0 0 0 0 0 0 0 0 ◄► - 0 0

52 Weeks - Incomplete 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

Diagnostics Waiting < 6 weeks (DM01) (%) 99.1% 98.8% 98.5% 97.0% 94.8% 98.1% 97.6% 95.7% 95.1% 95.6% 94.8% ▼ N 99.0% -4.2%

Diagnostics in 6 weeks: active (number) 5027 4938 5373 5304 5336 5612 5529 5169 5519 5272 5503 ▼ N - -

Diagnostics in 6 weeks: seen (number) 5641 6866 6228 5438 8232 6576 6402 5904 6127 6596 7447 ▼ N - -


Actual Target


4. Access –Provide the highest quality care.

CQC -Responsive

CARE - Excellent

Admitted Patient ExperienceTarget

variance

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

TypeMonth +/-

Percent of Ambulatory Care of Non elective

Admissions31.0% 28.2% 23.4% 22.4% 23.6% 29.2% 29.6% 25.4% 25.9% 24.7% 23.2% 20.2% ▼ N - -

Number of Delayed Transfers of Care (No. of

patients)70 73 77 100 89 132 115 113 102 116 94 93 ▼ N - -

Number of Delayed Transfers of Care (Lost bed

days)592 600 658 900 719 1153 934 831 851 966 754 730 ▼ N - -

Delayed Transfers of Care (%) 3.8% 3.6% 3.7% 4.2% 2.7% 4.7% 4.7% 5.1% 4.8% 6.0% 4.6% 5.6% ▲ N 3.5% 2.1%

Average non-elective length of stay - excluding 0

day LOS (Length of Stay)5.7 6.0 5.9 6.1 6.1 7.2 6.4 6.3 5.9 5.8 6.3 5.7 ▼ N - -

Target Actual



CQC – Responsive

CARE - Excellent

Placeholder – Graphics and data sources under development

Theatres Patient ExperienceTarget

variance

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

TypeMonth +/-

Hospital Cancelled Ops on day of surgery - non

clinical (Numbers)11 13 34 12 18 17 6 19 23 27 54 10 ▼ - - -

Hospital Cancelled Ops on day of surgery - non

clinical (Percentage)0.3% 0.3% 0.8% 0.4% 0.3% 0.4% 0.2% 0.5% 0.6% 0.7% 1.3% 0.3% ▼ - - -

Cancelled Ops not re-scheduled < 28 days 0.0% 0.0% 2.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ◄► N 5.0% -5.0%

Urgent Operations Cancelled 2nd time 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

In List Theatre Utilisation 86.5% 88.6% 86.9% 85.7% 87.1% 88.2% 88.4% 87.5% 87.3% 88.2% 88.3% 88.5% ▲ L 90.0% -1.5%

Sessional Theatre Utilisation 96.0% 92.0% 93.0% 91.0% 94.0% 93.0% 92.0% 93.0% 92.0% 91.0% 90.0% 91.0% ▲ L 90.0% 1.0%

Daycase (DC) Admissions 3261 3719 3629 2940 3690 3265 3461 3416 3586 3220 3919 3419 ▼ - - -

Elective (EL) Admissions 594 657 645 508 502 535 595 545 596 552 548 508 ▼ - - -

Average elective length of stay - excluding 0 day

LOS2.8 2.8 2.5 2.6 2.9 2.5 2.7 2.9 2.6 2.7 2.7 2.5 ▼ L - -


Target Actual


4. Access – Provide the highest quality care.CQC -Responsive

CARE - Excellent

Placeholder – Graphics and data sources under development


variance

Waiting Times: Outpatient Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target

TypeMonth +/-

Number of New Attendances 16877 19824 19171 15229 19023 17495 18908 17938 18637 18131 19819 16759 ▼ - - -

Number of Follow Up Attendances 33866 37843 36421 38816 37184 32517 34615 34020 35341 33686 36623 31812 ▼ - - -

Appointments cancelled by RBFT (number) 4004 4709 4955 4290 5230 4539 4755 4727 4685 4907 5948 5317 ▼ - - -

Appointments cancelled by patient (number) 3106 3502 3521 2816 3368 3167 3108 2992 3252 3085 3595 3010 ▼ - - -

DNA Trust Level 4380 4958 4751 3992 4876 4275 4118 4142 4628 4408 5038 4158 ▼ - - -

DNA Rate 7.5% 7.9% 7.9% 8.3% 8.0% 7.9% 7.2% 7.4% 8.0% 8.0% 8.3% 7.9% ▼ - - -

New to Follow Up Ratio 2.0 1.9 1.9 1.9 1.9 1.8 1.8 1.9 1.9 1.8 1.9 1.9 ◄► - - -

% Advice and Guidance 89.2% 87.6% 75.2% 83.6% 82.3% 89.6% 87.5% 89.3% 86.4% 86.6% 89.2% 85.9% ▼ - - -

% Appointments at Virtual clinic 3.8% 3.5% 3.5% 3.7% 3.6% 3.6% 3.8% 4.1% 4.7% 4.4% 3.8% 4.6% ▲ - - -


Actual Target

5. Workforce – Invest in our staff and live out our values.

Appraisal Rate – Overall appraisal compliance was flat again – ending the month on 87.6%. Improvements in Planned Care and Urgent Care – which were both over 90% were offset by weaker compliance in Estates and Facilities – due to late notification of appraisal completions from this area.

Completed Mandatory Training – Mandatory and Statutory Training (MAST) compliance continued to edge upwards for the 6th consecutive month, ending the period on an historical high of 89.7%. Health, Safety & Welfare reached 89.3% up from 69% when it was first added to the matrix in April.

Rolling 12-month Sickness Absence – Following a steady decline in overall rolling sickness absence rates during the last year, the rise over the last two months has still resulted in a lower rate than reported in the same period in the two previous years. When compared to Corporate and the Care Groups, Estates and Facilities have the highest sickness absence rate, but this may be indicative of them also having a higher proportion of long term vs. short term absence. The Employee Relations (ER) Team are continuing to work across all areas to support sickness absence management and recent development in the ER function will be further assisting identification of areas requiring additional support and implementation of co-ordinated initiatives and case management plans.

Vacancy Rate – The current vacancy rate in August of 6.6% sits favourably against the Trust target of 7%. Our recruitment campaigns have successfully landed 10 EU nurses in August. Through normal domestic recruiting we had 239.85 FTE starters in August (includes all care groups and staff groups). To help improve direct recruitment we will be launching a new social media recruitment campaign alongside the support of our Indeed account manager, to provide more targeted social media campaigns worldwide, which in return will increase brand exposure. We have unlocked 3 subscriptions (recruiter seats) to Indeed’s CV database to try an alternative way of recruiting hard-to-fill roles and therefore reduce agency cost.

Agency Spend – Agency spend reduced in the month of August, there had been a decline in the number of Doctors hours filled in the previous month which has reduced spend. There had been a reduction in the number of hours filled within Allied health professionals (AHP) in the month of August – 971, the previous month had seen a sharp increase of 1414 from July. Nursing fill has remained stable. The spend within AHP is set to reduce in November/December due to agency moving to permanent roles. Within Admin & Clerical there will be a continued trend of a spend reduction due to the new NHSi agency rules in relation to this category.

Rolling 12-month Turnover – The Trusts turnover figure 14.5%, is steady. Still collaboratively working within the BOB streamline group and will be meeting mid-October to share best practice and ideas. Working closely with Library & Knowledge Services Manager to start focus groups from October to discuss candidate experience and to understand how we can improve our processes. Also, successfully working on alternative house share accommodation with a discounted rates and flexible short term tenancy agreements (this will be on trial basis by the end of October).


CQC –Safety & Effective

CARE - Resourceful / Excellent

Caring CultureTarget

variance

Workforce Indicators Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

Appraisal rate 85.8% 85.1% 85.3% 87.1% 87.3% 88.4% 87.4% 88.6% 87.8% 88.1% 87.7% 87.6% ▼ L 90.0% -2.4%

Completed Mandatory Training 86.7% 87.4% 87.4% 87.9% 88.3% 88.3% 88.4% 87.5% 88.6% 89.1% 89.4% 89.7% ▲ L 85.0% 4.7%

Rolling 12 month Sickness absence 3.3% 3.3% 3.3% 3.3% 3.3% 3.2% 3.2% 3.2% 3.2% 3.2% 3.2% 3.3% ▲ L 3.3% 0.0%

Vacancy rate 8.3% 7.2% 7.1% 7.4% 7.3% 7.3% 7.0% 8.7% 9.2% 10.3% 6.7% 6.6% ▼ L 7.0% -0.4%

Agency spend % of total staff cost 3.7% 3.8% 3.3% 2.4% 3.9% 3.4% 3.3% 2.9% 3.3% 3.0% 3.1% 2.3% ▼ L 3.7% -1.4%

Rolling 12 month Workforce Turnover 14.9% 14.4% 14.2% 14.8% 14.6% 14.3% 14.5% 13.6% 13.9% 14.3% 14.2% 14.5% ▲ L 14.5% 0.0%


Target Actual


6. Staffing Data – Invest in our staff and live out our values.

CQC -Safety

CARE - Resourceful / Excellent

Caring CultureTarget

variance

Staffing Data Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

% Fill rate of Registered Nurse Shifts (RN) 90.7% 92.7% 94.2% 90.5% 92.6% 89.4% 88.8% 91.3% 92.5% 93.2% 95.2% 91.0% ▼ N 90.0% 1.0%

% Fill rate of Care Support Worker Shifts (CSW) 108.1% 107.8% 106.8% 107.3% 109.5% 110.1% 107.8% 113.6% 113.5% 112.6% 113.4% 115.9% ▲ N 90.0% 25.9%


Target Actual

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reportable incidents: Estates Department have been asked to review a door’s self -closing mechanism and conduct a similar review across the organisation due to an injury. Spillage in the corridor resulted in a fracture. Post investigation, a decision was made to increase awareness of staff to reporting of spillages and management of slips/trips hazards via training and Round Up.

Health and Safety inspections/advisory visits: The Manual Handling & Health and Safety Advisors continue with their weekly walk the wards program. The purpose of these visits is to respond to staff safety concerns as quickly and efficiently as possible.


7. Health and Safety IndicatorsCQC – Safety

CARE - Aspirational

Health and Safety IndicatorsTarget

variance

Incidents Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Target Type

Month +/-

RIDDOR reportable Incidents 2 6 4 2 5 2 2 1 2 2 1 2 ▲ - -

Total non clinical incidents reported 39 79 83 69 77 72 49 55 66 79 86 54 ▼ - -

Abuse/V&A (Patient to staff) 10 28 47 38 31 30 20 18 32 33 29 23 ▼ - -

Body fluid exposure/needle stick injury 8 24 15 16 18 17 11 10 13 14 12 12 ◄► - -

Building works 2 15 8 5 11 8 4 7 11 20 30 5 ▼ - -

Slips and Trips 4 2 4 3 1 4 9 7 2 8 7 7 ◄► - -

Musculoskeletal - Inanimate object 4 2 5 2 1 1 3 3 1 4 1 0 ▼ - -

Staff receiving H&S related training Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Month +/-

Manual Handling non patient every 3 years 89.6% 83.4% 90.4% 90.7% 91.9% 92.0% 92.3% 92.2% 91.5% 92.7% 94.1% 93.6% ▼ > 90.0% 3.6%

Conflict Resolution 85.1% 83.4% 83.4% 82.5% 82.8% 81.4% 81.6% 79.9% 80.6% 83.9% 84.7% 86.2% ▲ > 90.0% -3.8%

Fire (Annual) 84.2% 83.4% 85.4% 85.3% 86.8% 86.0% 87.1% 87.0% 87.4% 88.3% 88.0% 87.8% ▼ > 90.0% -2.2%

Nursing and AHP Manual handling training

every 3 years90.1% 90.5% 90.3% 91.1% 90.8% 90.7% 91.1% 90.5% 89.8% 90.7% 91.3% 90.9% ▼ > 90.0% 0.9%

Doctors manual handling training every 3 years 65.5% 68.4% 71.3% 71.3% 70.8% 72.4% 74.7% 75.0% 74.5% 75.7% 73.4% 74.3% ▲ > 90.0% -15.7%

Health and Safety Training - - - - - - - 77.7% 82.3% 86.5% 88.5% 89.5% ▲ - -

Health and Safety inspections/advisory visits - - - - - - - 18 27 6 49 24 ▼ - -

Health and Safety Indicators Target

variance

Civil and Enforcement Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug DoT Month +/-

Personal Injury claims 1 1 0 1 0 0 0 0 0 1 1 0 ▼ - -

Interaction with Regulators 0 1 0 0 0 0 0 0 0 0 0 0 ◄► - -


Actual Target

Actual Target

The Overall RAG rating (Red, Amber, Green) is a subjective risk rating determined by the Head of Engineering. By using a variety of records and information, it is an agreed but subjective view of the key item as an overall risk view.

The Datix risk assessment accounts for entries which highlight a particular risk in that key item category and using the Datix matrix for scoring.


7. Health and Safety IndicatorsCQC – Safety

CARE - Aspirational

8. Finance Summary


CQC- Well Led

CARE - Resourceful

8. Finance Summary


CQC –Well Led

CARE - Resourceful

8. Finance Summary


CQC – Well Led

CARE - Resourceful

Title: August Financial Performance Summary Agenda item no: 5.2 Meeting: Board of Directors Date: 25 September 2019 Presented by: Nicky Lloyd, Chief Finance Officer Prepared by: Michael Clements, Deputy Director of Finance – Central Finance Purpose of the Report To update the Board of Directors on the Financial Performance of the

Trust in August 2019

Report History n/a

What action is required? The Committee is asked to NOTE the report.










1 Summary

1.1 The Trust has reported results £(2.18)m behind revised NHS Improvement (NHSI) Control Total

(a) Performance against year to date budget is £(3.40)m adverse

(i) Income £(1.24)m behind plan driven by reduction in accrual of PSF £(0.94)m. Activity is still ahead of plan and this over performance has been partially offset by reduced drug and Private Patients income

(ii) Pay £(0.69)m over budget driven by Medical, Nursing and AHPs and partially offset by Administration and Management. This overspend also includes non-delivery of QIPP

(iii) Non Pay £(1.55)m over budget driven by drugs and QIPP

1.2 The Trust has de-recognised Provider Sustainability Funding (PSF) for Q2. Marginal Rate Emergency Tariff (MRET) income has been accrued to M05 as this is not dependent upon financial performance.

2 Conclusion and Next Steps

2.1 The committee is asked to NOTE the report

3 Attachments

3.1 The following are attached to this report:

(a) Appendix 1 – Chief Finance Officer Report

Financial Performance Cip Performance

People Cash, Capital and other KPIs

QIPP Performance

8. Finance – Achieving Financial Sustainability

CQC - Excellence / Integrity

CARE - Resourceful

Finance summary dashboard – Month 5 2019/20 Red – diamond Amber – triangle Green - circle

Note: Green circle means actual is within +/-1% of plan, amber triangle is from 1-5%, and red diamond is more than 5% ahead of or adverse to plan

Note: Debt includes £2.09m overseas visitors and £0.66m Oxford University Hospital both of which continue to be addressed under Finance Matters

Data source: Trust Ledger Systems, Transformation Tracker and Finance Team

Actual Plan Plan

Income (incl pass through) £179.25m £180.49m £443.53m

Pay £106.21m £105.53m £253.42m

Non Pay (incl pass through) £72.71m £71.16m £169.62m

Surplus/(Deficit) -£2.93m £0.47m £12.51m

Control Total -£6.60m -£4.42m -£1.50m

RAG

Year to date

Pay cost to activity ratio M12 18/19 M1 19/20 M2 19/20 M3 19/20 M4 19/20 M5 19/20

Pay as % of activity income 68.52% 79.49% 72.23% 68.78% 71.26% 74.21%

Capital Programme

Actual &

Committed

YTD

Plan YTD

Total Trust Funded £13.47m £10.79m

Total Donated £0.15m £0.98m

Grand Total £13.62m £11.77m

RAG

Key Metrics Actual Plan

Cash £41.11m £38.71m

IPP Debtor Days 23 37

Creditor Days 24 23

NHS Debtor Days 1 4

Inventory Days 28 25

RAG

Key Messages from Chief Finance Officer Month 5 2019/20

Income and Expenditure

• Performance against control total

– The Trust performance is £(2.18)m behind Control Total for the YTD at £(6.60)m against £(4.42)m target. The Trust is focusing upon changes to capacity in linewith the 2019/20 QIPP plan. The Trust Use of Resources Rating was 1 at year end. It is currently 3

• Patient care Income

– Patient income is £0.60m favourable to plan. Non-Elective activity is overall above plan, within this Berkshire West activity is significantly above the plan andincome has been recognised on a reduced basis within the cost form of contract that the Trust has with the CCG.

• Other Income

– The M05 YTD position includes £2.15m centrally funded MRET monies and £1.63m PSF monies, included in this is an additional £0 .58m bonus PSF relating to18/19. In M05 the accrual of previously recognised M04 PSF has been reversed due to deteriorating financial performance makin g it less likely the Trust willachieve year end Control Total. At this stage the Trust has not formally re-forecast, but will do so in M06. Education Training , R&D, Grants and Other Fundingincome is £(0.89)m behind plan excluding the centrally funded items above. Work is ongoing with R&D to support the recognition of income

• Pay

– Pay decreased against the prior month, partially driven by the accrual in July of the medical pay award. Nursing overspend i s largely attributable to UrgentCare front door demands, and unachieved QIPP across all areas. Bed Closure plans need to continue to secure savings.

• Non Pay

– Non pay is overspent against plan by £(1.55)m. The Non Pay excluding Drugs variance is £(1.05)m adverse. Drug income below plan by £(0.56)m YTD. There hasbeen a year on year increase in expenditure of £(0.37)m, (1.9)%, linked to activity and further work is ongoing to fully understand this and take appropriate action.Miscellaneous expenditure is above plan by £(0.50)m YTD. £(0.45)m relates to unallocated QIPP.

Balance Sheet

• Cash position

– Cash is ahead of plan. Cash remains strong due to high levels of accruals within the cost base. Typically the Trust operates with c£1m in its day to day bankaccounts following payment of daily/weekly commitments and holds up to £30m in short term investments through the Government Banking Service (GBS).

• Debtors

– NHS and Non NHS Debtor Days are better than plan. High levels of debt are still on the ledger for Overseas Visitors, a Credi t Controller continues on a fixedterm basis to target reduction in this part of the ledger

• Creditors

– Creditor days are within plan. Work continues through Finance Matters to ensure Purchase Order receipting is completed in a t imely manner to enablepayment to terms

• Capital plan

– At Month 5 the Trust has spent £6.61m of its capital programme (including £0.15m of donated capital) . The Trust has committed an additional £7.01m

Trust Cash position M05 2019/20

Key messages

• Closing cash position is £41.11m, a decrease of£1.09m from the opening position

• The maximum cash level in month was £68.43m, andthe minimum was £37.22, therefore no particular in-month concerns around timing of receipts vspayments but this continues to be closely monitoredto determine if there are any intra-month mismatchesbetween receipts and payments

Data source: Trust Finance Team

Patient Income Summary – Trust level M05 2019/20

Data source: Trust Ledger Systems

Red – diamond Amber – triangle Green - circle

Key messages

• YTD Mth 5 Total Patient Income is £0.60m ahead of budget.• The main variances within this are favourable variances of +£3.03m

against Non Elective, +£0.54m against Elective Overnight stays(although this is offset by Elective Daycase shortfall of £(0.71)m)and +£0.34m against Outpatients. These are offset by an adversevariance of £(2.34)m against Other Patient Income, which is largelydue to adjusting income in respect of Berks West CCG back down tothe phased contract plan value, by £(1.36)m, and a shortfall againstCritical Care income of £(0.72)m.

• The actions to be taken include monitoring of Berks West CCGactivity wait times and associated income, as this continues to runconsiderably above the contracted level, as noted above.

Actual Plan Plan

Daycase £13.36m £14.07m £35.34m

Elective £9.88m £9.34m £23.05m

Outpatients £32.84m £32.50m £79.77m

Non-elective £45.13m £42.10m £103.59m

A&E £10.16m £9.86m £23.50m

Drugs & Devices £18.12m £18.68m £44.77m

Other patient income £35.34m £37.68m £92.02m

Total patient income £164.83m £164.23m £402.03m

Year to date

RAG

Patient Activity Summary – Trust level M05 2019/20



Key messages

• By POD (Point Of Delivery), and on a YTD basis, the activityvariances against Plan greater than +/-1% are as follows:

• Daycase is (3.6)% (614 Spells) behind Plan• Non-elective is +2.2% (+417 Spells)• A&E is +6.6% (+3,554 Atts) ahead of Plan• Maternity (OP and IP) is +2.3% ahead of Plan

Actual Plan Plan

Daycase 16,590 17,204 42,580

Elective 2,694 2,717 6,700

Outpatients 228,797 228,038 559,729

Non-elective 19,111 18,694 45,997

A&E 57,812 54,258 129,292

Maternity (OP and IP) 10,408 10,178 25,013

Year to date

RAG

Elective Inpatient Summary – Trust level M05 2019/20


Elective Daycase Summary – Trust level M05 2019/20


Non-Elective Summary – Trust level M05 2019/20


Other Income Summary – Trust level M05 2019/20



Key messages

• YTD M5 Other Income is £(1.84)m behind plan.• The key driver for this is a PSF (Provider

Sustainability Funding) shortfall of £(0.94)m as aresult of expected non-achievement of therequirements to receive this funding relating toQ2. The in month gap reflects the reversal ofM04 and the non-recognition of M05 PSF

• Other drivers are shortfalls in income fromEducation & Training of £(0.52)m and R&D of£(0.35)m.

• Total Other Income includes £1.05m of 19/20PSF monies and £2.15m of YTD NHSE MRETcentral funding monies.

Actual Plan Plan

Education & Training £5.05m £5.57m £13.64m

R&D £0.36m £0.71m £1.70m

Grants £4.71m £5.30m £15.00m

Rental £0.24m £0.25m £0.57m

Sales of Goods & Services £0.48m £0.52m £1.25m

Non patient care to other bodies £2.96m £3.01m £7.16m

Other operating income £0.61m £0.89m £2.18m

Total other income £14.42m £16.26m £41.49m

Year to date

RAG

Pay Summary – Trust level M05 2019/20



Key messages

• Pay is £(0.69)m overspent against budget YTD• The continuing underspend in Admin & Management partially

offsets the overspend in other staff groups• There are particular pressures against plan in medical and nursing• Actions continue to be taken for the development and delivery of

pay QIPP schemes within the Care Groups and Corporate areas

Actual Plan Plan

Substantive £99.43m £98.69m £236.70m

Bank £3.67m £2.69m £7.20m

Agency £3.11m £4.16m £9.52m

Total £106.21m £105.53m £253.42m

Pay Cost

Year to date

RAG

Actual WTE Plan WTE

Permanent 4,833.99 4,949.67

Bank 206.96 138.99

Agency 69.71 111.43

Total 5,110.66 5,200.09

Year to date

RAG

Nursing Pay – Trust level M05 2019/20

Key messages

• Nursing Pay is overspent against budget YTD by £(0.72)m• Urgent Care continue to struggle with reducing costs in front door

medical areas• Planned Care nursing has maintained its underspend in M05• Networked Care nursing has increased in month and is overspent YTD• Actions: Continue to focus on bed capacity-based QIPPs, demand &

capacity planning and workforce QIPPs aimed at reduction in cost oftemporary staffing supported by KPMG



Actual Plan Plan

Substantive £37.18m £36.61m £88.00m

Bank £3.47m £2.69m £7.20m

Agency £0.72m £1.35m £3.08m

Total £41.37m £40.66m £98.28m

Pay Cost

Year to date

RAG

Actual WTE Plan WTE

Permanent 2,173.34 2,252.59

Bank 199.43 138.99

Agency 21.65 42.75

Total 2,394.42 2,434.33

Year to date

RAG

AHP, Scientists and Pharmacists Pay – Trust level M05 2019/20

Key messages

• AHPs, Scientists and Pharmacists continue to be overspent againstbudget £(0.19)m YTD, a deterioration of £(0.11)m in month

• The YTD position is driven by Urgent Care (Radiographers) andNetworked Care (Pharmacists and Therapists)

• Action: Review of opportunities to develop QIPP within this staffgroup, including opportunities to reduce temporary spend

• We will explore further opportunities to convert agency to bank toreduce costs further as part of the temporary workforce PIDdevelopment



Actual Plan Plan


Bank £0.00m £0.00m ## ## £0.00m

Agency £0.80m £0.75m £1.66m

Total £13.80m £13.61m £32.62m

Pay Cost

Year to date

RAG

Actual

Average WTE

Plan Average

WTE

Permanent 677.52 687.03

Bank 0.00 0.00 ### ###

Agency 27.68 25.56

Total 705.20 712.59

Year to date

RAG

Medical Pay – Trust level M05 2019/20



Key messages

• Medical Pay is overspent against budget by £(0.62)m YTD• In Planned Care BCC, Ophthalmology, General Surgery and Orthopaedics

are overspent YTD by £(0.15)m, £(0.20)m, £(0.08)m and £(0.05)mrespectively, in Urgent Care Obstetrics is overspent by £(0.10)m andNetworked Care has cost overruns of £(0.08)m in Elderly Care and£(0.07)m in Endocrinology

• Junior Medic costs in Corporate areas are giving rise to £(0.13)moverspend. Work is being undertaken to understand this

• Action: continue with demand and capacity modelling and pursue furtheropportunities being highlighted in work undertaken with KPMG

Actual Plan Plan


Locum £1.64m £1.83m £4.51m

Agency £1.26m £1.53m £3.53m

Total £31.20m £30.58m £73.18m

Pay Cost

Year to date

RAG

Actual WTE Plan WTE

Permanent 644.12 648.55

Locum 27.50 30.22

Agency 9.41 27.46

Total 681.03 706.23

Year to date

RAG

Administration Pay – Trust level M05 2019/20



Key messages

• Administration is now underspent by £1.12m YTD• Care Group underspend is £0.55m, this includes Clinical Administration

Teams (CATs)• In corporate areas Finance £0.21m (vacancies in Payroll and

Procurement), Workforce £0.07m, CEO £0.05m and CNO £0.05m are thedrivers

• Action: understand the reason for the underspend, the extent to whichvacant posts are still required and the year on year impact of reduction intemporary spend creating a lower operating envelope into 2020/21

• Further work is underway as part of the Modern Administrator PID todevelop opportunities for a reduction in Administration expenditureacross the Trust

Actual Plan Plan


Bank £0.07m £0.00m £0.00m

Agency £0.46m £0.51m £1.24m

Total £14.22m £15.37m £36.50m

Pay Cost

Year to date

RAG

Actual WTE Plan WTE

Permanent 889.42 935.35

Bank 4.55 - ###

Agency 13.95 15.06

Total 907.92 950.41

Year to date

RAG

Pay Summary - Agency – Trust level M05 2019/20 Key messages

• Agency remains within the NHSI agencycap YTD.

• In month we have seen a furtherreduction in Medical agency

• Nursing agency costs are relatively flatmonth on month and lower than lastyear

• Admin and Management Agency spendhas remained below last year and furtherreductions are targeted through theapplication of new NHSI rules on use ofAdmin Agency


Agency

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

+/- on

Prior

Year

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Medical 432 298 347 317 276 294 357 310 322 251 293 277 113 319

Nursing 177 179 135 122 83 208 123 156 145 199 138 118 123 54

Management &

Admin156 123 107 122 21 158 77 (284) 47 123 92 94 104 51

Other Clinical 110 138 177 115 99 154 120 153 120 127 101 179 144 (35)

Other Non

Clinical3 2 3 5 4 3 18 3 4 0 0 0 0 3

Total 877 740 769 681 482 817 695 338 638 700 624 669 484 393

Pay Summary – Additional Sessions – Trust level M05 2019/20

Key messages

• At Trust level additional sessionpayments have risen from the M04position and are similar to levels ofpayment made in August 18

• All Care Groups have incurred increasedexpenditure on the prior month with keyincreases in Anaesthetics, Oncology, A&Eand Paediatrics

• Corporate spend was down• On-going Demand and Capacity reviews

by specialty will continue to minimisethe use of additional sessions whereactivity can be undertaken within plaintime


Non Pay Summary – Trust level M05 2019/20 Key messages

• Non Pay is overspent against budget YTD £(1.55)m• Drug costs continue to be above plan YTD £(0.50)m• Year on year Drugs costs have increased by £(0.37)m,

(1.9)%. This links to increased A&E and Non-Electivedemand (3% and 1.7% respectively as at M04)

• Year to date Drugs Income as % of cost is 82.72% (83.06%in 18/19), this difference is equivalent to c£0.07m

• Work continues in order to understand the drivers ofdrug expenditure

• Miscellaneous expenditure is above plan by £(0.50)mYTD. £(0.45)m relates to unallocated QIPP

• The actions to be taken are to continue to develop QIPPprogrammes, to gain the assurance that the fullprogramme will deliver in year and continue spendingwithin budget where this is the case

• All areas are to ensure that non-pay expenditure alignswith levels of activity undertaken



Actual Plan RAG Plan

Drugs £20.20m £19.70m £47.39m

Clinical Supplies £18.64m £18.14m £42.64m

General Supplies £2.84m £3.05m £7.35m

Establishment Expenses £1.65m £1.55m £3.69m

Other Establishment Expenses£7.88m £7.95m £19.08m

Premises Costs £8.76m £8.89m £21.25m

Depreciation £7.03m £6.74m £16.46m

Leases £1.25m £1.19m £2.83m

Miscellaneous £4.46m £3.95m £8.94m

Total Non Pay £72.71m £71.16m £169.62m

Year to date

QIPP Reporting – M5 Note: Black is the value of the gap between the risk adjusted delivery (£11.35m) and the target delivery (£16.88m)

Current In Year risk adjusted forecast £m

4.49 0.55 1.88 9.96 16.88

Previous In Year risk adjusted forecast £m

4.98 0.61 1.43 9.86 16.88

QIPP Year to date In Year

Column1 Actual Budgeted Plan RAG

F'Cast (4+8) (Risk Adjusted) Identified RAG

Non Recurrent 0.93 - 1.82 2.28

Recurrent 4.49 6.38 10.58 12.49

Sub-total 5.42 6.38 12.39 14.77

Delivery risk 4.48 2.10

Total 16.88 16.88

Progress

• The total QIPP target for the year remains at £16.88m

• As at Month 5, the in-year value of our identified schemes in19/20 is £14.77m against this target. The current riskassessed value of these schemes for 2019/20 is £12.39m,which means the Trust is currently projecting that we willunder-deliver by £4.49m against the CIP target.

• At the end of Month 5, the Trust had delivered £5.42m ofsavings (Year to Date) against a budgeted (planned) costsaving of £6.38m.

• Month 5 delivered £1.23m against a forecast of £1.23m anda budgeted plan of £1.61m.

• The top 10 programs comprise 83% of the total programs

QIPP Reporting – M5

Key Changes since last month

• The in-year identified schemes have increased by £0.57m this month from £14.20m to £14.77m. The current risk assessed value ofthese schemes for 2019/20 is £12.39m.

• The risk adjusted figure includes pay savings totalling £4.47m, non-pay savings of £7.41m (including £1.41m of drug savings), andincome efficiencies totalling £0.51m.

• The current gap between the in-year value of identified schemes (£14.77m) and the budgeted cost improvement programme (£16.88m)for 2019/20 is £(2.11)m. The delivery of CIP is starting to fall behind the plan predominantly because we have a continued unidentifiedCIP value which at the beginning of the year was planned to start delivering cost savings in month 3.

• Some progress has been made this month in identifying further pay schemes with the support of KPMG to partially fill the unallocatedCIP gap, 3 Programme Implementation Documents are in development. 2 of these PIDs have been submitted – medical workforce andtemporary staffing.

• The executive sponsors have agreed to take forward a number of initiatives to reduce the cost of the medical workforce and temporarystaffing. These programmes both have PIDs submitted with some schemes in the scope already signed off and moving intoimplementation. The potential in-year savings from these schemes is £0.74m, which is currently risk adjusted at £0.37m, based oncapacity to deliver these and the relative development of the plans. By next month we would anticipate this risk rating to improvesignificantly as resource is identified to drive these through, plans are fully developed and schemes start to be implemented.

• In addition, there are a number of medical workforce and temporary staffing schemes that are not yet agreed due to their high risknature, which are being reviewed for their quality impact through the Trust’s robust Quality Impact Assessment process. This willbalance the financial impact against potential quality impacts, leading to a decision by the executive as to whether these schemesshould proceed. These schemes are not yet on the tracker but the potential value of these schemes, if they proceed is an additional£0.94m. Over the next month, work will be undertaken to assess whether to proceed with these schemes.

• Potential savings for the modern administrator programme are in development and may mitigate some of the remaining gap in additionto the two workforce programmes above. The PID is in development.

• Patient flow continues to under-deliver against it’s forecast as any empty beds without ward closures do not release cost.

Appendices Chief Finance Officer

Report August 2019

Appendix (i) Statement of Comprehensive Income Appendix (ii) Statement of Financial Position Appendix (iii) Care Group and Corporate Financials Appendix (iv) Use of Resources Risk Rating Appendix (v) Reconciliation of Reported Finances to Control Total Performance

Appendix i: I&E Detail – Trust level M05 2019/20



Actual Plan Plan

Activity Income £145.33m £143.51m £1.82m 1.27% £352.36m

Pass through £18.12m £18.68m -£0.55m -2.97% £44.77m

Other patient income £1.37m £2.04m -£0.67m -32.78% £4.91m

Other income £14.42m £16.26m -£1.83m -11.28% £41.49m

Total Income £179.25m £180.49m -£1.24m -0.69% £443.53m

Permanent £97.79m £96.85m -£0.94m -0.97% £232.18m

Bank/Locum £5.31m £4.52m -£0.79m -17.43% £11.71m

Agency £3.11m £4.16m £1.04m 25.04% £9.52m

Total Pay £106.21m £105.53m -£0.69m -0.65% £253.42m

Drugs £20.20m £19.70m -£0.50m -2.53% £47.39m

Other Clinical Supplies £18.64m £18.14m -£0.50m -2.75% £42.64m

Other operating expenses £26.84m £26.57m -£0.27m -1.01% £63.13m

Total Non Pay £65.68m £64.41m -£1.27m -1.97% £153.16m

EBITDA £7.36m £10.55m -£3.19m -30.25% £36.95m

Depreciation £7.03m £6.74m -£0.29m -4.24% £16.46m

Interest £0.15m £0.22m £0.07m 30.12% £0.49m

PDC £3.02m £3.02m £0.00m 0.06% £7.26m

Surplus/(Deficit) -£2.93m £0.47m -£3.40m 723.77% £12.51m

Control Total -£6.60m -£4.42m -£2.17m 49.16% -£1.50m

RAGVariance

Year to date

Appendix ii: Balance Sheet, Cash & Capital – Trust level M05 2019/20

Data source: Trust Ledger Systems and Finance Team


Actual Plan Variance

End year

forecast

Prior

Month Movement

261.86 Non-current Assets 261.33 264.75 (3.42) 277.35 261.28 0.05

36.61 Current Assets (excl Cash) 27.50 23.22 4.28 22.22 28.51 (1.01)

43.10 Cash & Cash Equivalents 41.11 38.71 2.40 33.61 42.20 (1.09)

(70.09) Current Liabilities (67.49) (56.65) (10.84) (53.23) (67.94) 0.45

(14.66) Non-current Liabilities (13.11) (17.29) 4.18 (15.16) (13.11) 0.00

256.82 Total Assets Employed 249.34 252.74 (3.40) 264.78 250.94 (1.60)

Statement of Financial Position

31 Mar 2019

Audited

Accounts

Year to date

Actual Committed Plan Variance

6.91 Estates - Major Projects 2.35 2.01 2.03 2.34

3.03 Estates - Compliance 0.03 0.23 1.20 (0.94)

10.78 IM&T 2.23 2.61 5.00 (0.16)

8.77 Medical Equipment 1.98 2.16 3.43 0.71

0.17 Other 0.02 0.00 0.11 (0.09)

29.66 Total Capital Expenditure 6.61 7.01 11.77 1.85

31 Mar 2019

Audited

Accounts Capital Expenditure

Year to date

Actual Plan RAG

NHS Debtor Days 1.07 4.11

IPP Debtor Days 22.69 36.63

IPP Overdue Debt £m 4.33 #DIV/0!

Inventory Days 27.64 25.19

Creditor Days 24.45 23.47

BPPC NHS (YTD) number 37.98% 85.00%

BPPC NHS (YTD) £ 74.26% 85.00%

BPPC Non-NHS (YTD) number 93.11% 85.00%

BPPC Non-NHS (YTD) £ 81.29% 85.00%

Working Capital

Appendix iii: Care Group and Corporate Financials M05 2019/20

Data source: Trust Ledger Systems and Finance Team Red – diamond Amber – triangle Green - circle

Actual Plan Plan


Pay £36.33m £35.42m £85.79m


Surplus/(Deficit) -£41.06m -£39.81m -£96.02m

Urgent Care Group

Year to date

RAG Actual Plan Plan


Pay £30.84m £30.89m £73.36m



Planned Care Group

Year to date

RAG

Actual Plan Plan


Pay £23.73m £23.59m £56.80m



Networked Care Group

Year to date



Pay £10.47m £10.65m £25.27m


Surplus/(Deficit) £121.05m £121.74m £302.91m

Corporate

Year to date

RAG

Actual Plan Plan


Pay £4.84m £4.98m £12.21m



Estates and Facilities

Year to date



Pay £2.01m £2.00m £4.79m



IM&T

Year to date

RAG

Appendix iv: Use of Resources Rating M05 2019/20


Use of Resources (Actual) 31 August 2019

Capital Service, total £m (-ve) (4,843)

Revenue Available for Capital Service £m (+/-ve) 7,326

Capital Service Cover metric 0.0x 1.51

Capital Service Cover rating Rating 3

Working capital balance (for use in FSRR rating calculation) from SoFP £m (+/-ve) (5,939)

Operating Expenses within EBITDA, Total from SoCI £m (-ve) (171,892)

Liquidity metric Days 153 (5.29)

Liquidity rating Rating 2

Adjusted financial performance surplus/(deficit) £m (+/-ve) (3,347)

Total Income from SoCI £m (+ve) 179,098

I&E Margin - Actual YTD 30 June 2019 % -1.87%

I&E Margin rating Rating 4

I&E Margin - Actual YTD 30 June 2019 % -2.00%

I&E Margin - NHSI Annual Plan YTD 31 March 2019 % -0.20%

I&E Variance from NHSI Plan % -1.80%

I&E Variance From NHSI Plan rating Rating 3

Agency metric % -17.76%

Agency rating Rating 1

Use Of Resources Rating after overrides Rating 3

(Weighting ratio is 20%)

Appendix v: Reconciliation of Reported Finances to Control Total Performance M05 2019/20


Navigation Key

Legend for tables Definition

Green rating: Unless otherwise specified, green means within 1% of plan/target (either

greater or less than)

- In the case of cash and creditor days, there is no boundary on variances in excess of plan

(e.g. if creditor days target is 30 and actual creditor days are 31, this is will be green rated

and if creditor days are 56, this will also be green rated)

- In the case of debtor days, there is no boundary on variances less than plan (e.g. if debtor

days target is 30 and actual debtor days are 29, this is will be green rated and if debtor days

are 5, this will also be green rated)

Amber rating: Unless otherwise specified, amber means between 1% and 5% of plan/target

(either greater or less than)

Red rating: Unless otherwise specified, red means 5% more than plan/target or 5% less than

plan/target

Better than last month

Worse than last month

No change from last month

Table metrics

1. All figures are in £’M to 2 decimal places unless otherwise specified

2. References to Plan refer to the Control Total as filed in May 2019 with NHS Improvement

3. Forecast is a rolling 2+10, 3+9 forecast and is updated each month to reflect the latest position

Title: Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System – Response to the Long-Term Plan

Agenda item no: 5.3 Meeting: Board of Directors Date: 25 September 2019 Presented by: Andrew Statham, Director of Strategy Prepared by: William Wilkins, Associate Director of Strategy Purpose of the Report The NHS Long Term Plan was published in January 2019, with the

associated implementation framework available at the end of June 2019. The Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (BOB ICS) is currently developing a 5-year response to these documents. A draft return is expected to be submitted on the 27th September 2019 with a final submission due on the 1st November following discussion at October Board. As a precursor to the plan BOB ICS published “Improving Health and Care in Buckinghamshire Oxfordshire and Berkshire” on the 9th September. This publicly available document (see appendix 1) sets out the range of organisations involved in the BOB ICS, how they work together and how they are developing their priorities and plans for the next five years. BOB ICS is seeking the views of the public and organisations on the suggested priorities, opportunities and challenges. It will use responses from this exercise to help shape the final plan.


The Board is asked to comment on Improving Health and Care. Specifically, it is asked to confirm its support for the priorities and comment on whether the opportunities and challenges have been appropriately captured.


Resource Impact: The LTP response will influence the priorities and resources of the Trust over the next 5 years.


1. Leadership

2. Vision & Strategy

3. Culture

4. Governance



7. Engagement

8. Learning & Innovation


Improving health and care in Buckinghamshire, Oxfordshire and Berkshire West

Who we are, how we work together and our developing priorities and

plans for the next five years

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Contents 0

Introduction

Positives

How services are planned for and delivered

Developing our five year plan

Our vision

Challenges

Healthy places to live, great places to work - our people strategy

How are decisions made? Our timeline and next steps

About us

How we work together

Our priorities

We are making progress and change is happening

Page 1

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Page 13

Page 16

Page 5

Page 9

Page 14

Page 18

Page 6

Page 11

Page 15

Page 19

2

The BOB ICS five year, one system plan will set out how all ICS partners will work together locally and together at scale to meet the current and future health and care needs of the communities we serve. It will describe how the BOB ICS will deliver the requirements of NHS Long Term Plan (www.longtermplan.nhs.uk) and address BOB ICS’s specific priorities.

We are fully committed to being open and transparent about how the plan is developing over the coming months - this document is the first step in that process. It will be followed by the publication of our draft “technical” submission to NHS England / NHS Improvement in early October and a final version of this technical document, once reviewed and signed off later in the year. Both documents will be made available on our website www.bobstp.org.uk

Our BOB ICS five year plan will be published towards the end of 2019. It will build on the feedback received about our priorities, opportunities and challenges; describe how we will tackle these important issues and how we will deliver the aims of the NHS Long Term Plan.

Introduction 1

Welcome to the first of a number of public updates about the development of a five year strategy for the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (BOB ICS).

Our aim in this update is to provide you with information on:

How we work together as a Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (BOB ICS)

Our vision and aims

Our thoughts about priorities

Our work to develop a five year plan by the end of November 2019

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We are ambitious for the communities we serve. We want to prevent ill health, improve care for patients, reduce pressure on staff and make the best use of the funding available to us.

Our plan will describe how we will accelerate the design of patient care to:

• Improve out of hospital care

• Reduce the pressure on hospital services

• Give people more control over their health and more personalised care when they need it

• Provide digitally enable primary and outpatient care

• Work in partnership with local councils to improve the health of our communities

Delivering improved health and care across the ICS requires a well-developed system and underpinning infrastructure. We will start to set out, in response to the Long Term Plan and the changing nature of clinical commissioning, how we see the commissioning and provider landscape developing, including the role of Clinical Commissioning Groups.

The development of the BOB ICS five year plan is just the start. We can only achieve our ambitions by working together and continuing to listen to and discuss with the communities we serve what changes to health and care will look and feel like in the future.

We would welcome your thoughts and comments, which will be fully considered as the plan develops – please see page 18 for contact details. We look forward to hearing from you.

David Clayton-SmithIndependent Chair Buckinghamshire Oxfordshire and Berkshire West ICS

Fiona WiseExecutive Lead, Buckinghamshire Oxfordshire and Berkshire West ICS

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Our vision is to create a joined up health and care system where everyone can live their best life, get great treatment, care, and support now and into the future.

As well as working within our individual organisations and our communities, we are working together to bring the best of our skills, expertise and resources to make sure the people we serve receive high quality, safe and joined up health and social care services.

Together we are called the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (BOB ICS).

Our aims are:

• To work together to deliver joined up health and care services based on the needs of individuals and shaped by the circumstances and priorities of local communities

• To support people to live longer, healthier lives and treat avoidable illness early on

• To make the best use of limited public funds and resources so that, together, we can secure the best outcomes

• To make our focus local unless it is more efficient and effective for us to pool our expertise and resources to work together as an integrated health and care system across Buckinghamshire, Oxfordshire and Berkshire West (BOB).

• To reach out, where appropriate, beyond our borders and work in partnership with others – for example, across the wider Thames Valley region on specialist cancer services.

Together, we serve a total of 1.8 million people, stretching from Banbury in the North to Wokingham/Riseley in the South, from Hungerford in the West to Amersham in the East.

Our population is one the fastest growing in the country, predicted to increase by almost 25% by 2033 – and more, as the ambition of what is known as the Oxfordshire-Cambridge ARC to stimulate economic growth, research and business opportunities for the area is realised.

www.gov.uk/government/publications/the-oxford-cambridge-arc-government-ambition-and-joint-declaration-between-government-and-local-partners

By working together, we will be in the best position to maximise this opportunity, while making sure our health and care services are fit for such a promising future.

Our vision 2

Health and care organisations across Buckinghamshire, Oxfordshire and Berkshire West are working together with their local communities to help them to stay healthy, make sure services meet individuals’ needs and are easier to access.

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About us 3

We are not a single organisation but a partnership covering Buckinghamshire, Oxfordshire and Berkshire West that includes:

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6 NHS TrustsProviding hospital care, including community care, mental health and ambulance services:

9 District CouncilsWith housing, waste, and planning responsibilities:

1 Academic Health and Science Network 5 Local AuthoritiesWith social care responsibility, across adults and children’s services:

3 Clinical Commissioning Groups (CCGs)Responsible for the planning and commissioning of health services for their local area:

• Oxford University Hospitals NHS Foundation Trust

• Oxford Health NHS Foundation Trust

• Berkshire Healthcare NHS Foundation Trust

• The Royal Berkshire Hospital NHS Foundation Trust

• Buckinghamshire Healthcare NHS Trust

• South Central Ambulance Service NHS Foundation Trust

• Oxford City Council

• West Oxfordshire District Council

• Cherwell District Council

• Vale of White Horse District Council

• South Oxfordshire District Council

• South Bucks District Council*

• Aylesbury Vale District Council*

• Chiltern District Council*

• Wycombe District Council*

• Oxford AHSN

• Oxfordshire County Council

• Buckinghamshire County Council*

• Reading Borough Council

• West Berkshire Council

• Wokingham Borough Council

• Buckinghamshire CCG

• Oxfordshire CCG

• Berkshire West CCG

We work with our 5 Healthwatch organisations in Buckinghamshire, Oxfordshire, Reading, West Berkshire and Wokingham and engage with voluntary and community sector organisations across our geography to help join up our efforts to provide the best possible services and support to the people we serve.

NHS England, NHS Improvement and Health Education England are important partner organisations.

*There will be one unitary council for Buckinghamshire from April 2020

Positives 4

There are many positives about people, places and services in the BOB ICS area:

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People are generally healthier than in other parts of the country:

• People live longer

• Diabetes cases are far lower across the area

• Lower smoking rates than the national average

• Adult obesity rates are below the national average

• There are lower rates of many major diseases compared to the national average including cancer,dementia and stroke

The quality of care provided is recognised by national regulators and by the people we serve

• Many of our services are rated well by the Care Quality Commission (CQC), providing good overallquality of care

• People have told us that, when they do receive services, staff are compassionate and caring

• People have told us that their experience of specialist teams, such as cancer treatment, heart failureservices or MacMillan staff has been good

We are at the forefront of advances in digital technology

• We are part of the Thames Valley and Surrey Care Records Partnership – connecting local recordsacross the region so that people can benefit from more joined up carewww.thamesvalleysurreycarerecords.net

• We have a number of “Global Digital Exemplars” – Berkshire Healthcare Trust, Oxford Health, SouthCentral Ambulance Service and Oxford University Hospitals Trust. These internationally recognisedNHS Trusts are delivering improvements in the quality of care, through the world-class use of digitaltechnologies

We cover an area with strong infrastructure that is predicted see significant economic growth, and which will bring an increase in the numbers of people living in the BOB ICS area

• We have a number of highly regarded medical schools, universities and biomedical research centres

• There is strong investment in research, development and innovation, including over 500 life sciencesbusinesses with major strengths in medical diagnostics and digital innovation

• The government has committed to significant investment in business and infrastructure (includingtransport links) in our area, over the coming years

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Although, on the whole, people have good health, it is not the case for everyone.

Parts of Oxford, Banbury, Aylesbury and Reading are in the 20% most deprived areas of the UK. In these areas there are higher levels of:

50% of people living in the Buckinghamshire, Oxfordshire and Berkshire West area have one or more long term condition.

There is a higher number of premature deaths of people with serious mental illness compared to the national average.

Challenges 5

We are ambitious for the communities we serve. We want to prevent ill health, improve care for patients and reduce pressure on staff but face a significant challenge to make the best use of the funding available to us to meet current and future health and care needs, particularly given the population growth we expect to see.

Homelessness

Childhood obesity

Diabetes

Falls in elderly people

Smoking rates amongst people with anxiety and depression

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Some services are struggling to meet demand:

• Our hospitals have not met the 95% national target of A&E attendees being seen within 4 hours

• Demand for our services is in some cases exceeding our individual capacity to provide them for severalspecialties and this gap is expected to grow

• People have told us that they continue to find it difficult to get a GP appointment

• People have told us that they are waiting too long from referral to treatment

• People have told us that they or their loved ones are waiting too long to receive a number mentalhealth services, particularly for Child Adolescent Mental Health Services (“CAMHS”)

• The estimated 25% population growth will add new pressures on services

We, along with independent and voluntary sector service providers, have difficulty recruiting and retaining staff across the BOB health and social care system. This is due to the high cost of living and competitive local jobs markets

• The cost of both purchasing and renting accommodation is high across our area

• Nursing staff are likely to have to spend 58% of their monthly salary on housing

• The average price of housing in the BOB ICS area is 70% higher than the national average priceof housing

• Our care workers tell us they would leave sector/area for jobs that enable them to buy family homes

• There is significant house building in some areas of our system but in other locations, building isrestricted - which can limit the availability of rented accommodation and social housing. It also meansthat, if staff can’t find homes closer to where they work, their journey time is increased, adding anadditional cost

• Many of our areas have high employment rates, which is a great success but makes attracting peopleto health and care jobs more challenging

Our buildings and medical equipment are becoming outdated

• We face a challenge to maintain our buildings to keep them fit for purpose

• Our equipment does not always keep up with advances in technology

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Local First

Our Integrated Care System is a partnership covering a large area, but we all understand that the majority of improvements are made by applying our efforts to helping people to live healthy lives and get joined up care in their neighbourhoods, villages and towns wherever possible.

That’s why GP practices are coming together as Primary Care Networks to serve communities of around 30,000 to 50,000 people so that they can offer patients access to a wider range of services. For example, more convenient access to some hospital treatments, mental health, social care services or help and support from local voluntary and community groups.

Broadening the focus to cover a wider local geography (areas covering between 250,000 and 500,000 people) are three Integrated Care Partnerships (one in Buckinghamshire, one in Oxfordshire and one in Berkshire West).

These partnerships include clusters of Primary Care Networks, local hospitals and councils, community, mental health and voluntary sector services. Integrated Care Partnerships work together to make a shared assessment of local need, plan how to use collective resources and to join up what they offer – including beyond traditional health and care services – to make best use of overall public and community resources.

Facing the Big Challenges and Opportunities Together

Although our first priority is local through our Local Authorities, Primary Care Networks and Integrated Care Partnerships, there are times when it makes sense to broaden our focus to the whole of Buckinghamshire, Oxfordshire and Berkshire West as an Integrated Care System.

In coming together as an Integrated Care System, we can seize opportunities to make the best use of our resources, skills and expertise; and we can reduce duplication to maximise the value of every pound spent – particularly where we face similar health and care challenges. There are also some services that willbe safer and more clinically effective if they cover a larger number of patients across a bigger area – for example, some more specialist cancer services.

How we work together 6

Answers to how best meet the needs of our increasing and ageing population can also only be found if we apply our knowledge and resources together. We are facing a number of opportunities and challenges:

• We expect to see an additional 300,000 people living in the area by 2033

• The numbers of people over the age of 85 are expected to more than double

• Significant investment is expected from government and the private sector to supporteconomic growth

• There will be a substantial increase in housebuilding

• Improvements are being made to the rail and road infrastructure

• There will be planned increases in government funding as part of the June 2018 NHS fundingsettlement. We will be expected to use this money to deal with current pressures, increasingdemand and new priorities

We will need to work together to ensure that we have the health and care services to meet the demand from this increased population, while taking advantage of the excellence and innovation that comes from our partnerships with leading universities across the our area and the opportunities that economic growth will bring.

The BOB Integrated Care System is also part of a number of wider partnerships, where we work with other systems in the NHS to join up care for patients and improve our services – for example, we are part of the Thames Valley Cancer Alliance; the Thames Valley and Wessex radiotherapy network; and we work with partners in the Thames Valley and Surrey on our Local Health and Care Records programme.

We understand that patients travel outside of our geographical area – for example, going to Milton Keynes from Buckinghamshire or Basingstoke in some parts of west Berkshire. With this in mind we work closely with other health and care systems.

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How care is planned for and delivered 7

Primary Care Networks (PCNs)GP practices working together with local councils, other NHS, voluntary and communities services to serve communities of around 30,000 to 50,000 people, offering patients access to a wider range of services.

Integrated Care Partnerships (ICPs)Covering towns and counties (areas of between 250,000 and 500,000 people) ICPs include clusters of Primary Care Networks, local hospitals and councils, community, mental health and voluntary sector services.

Integrated Care System (ICS)Covering Buckinghamshire, Oxfordshire and Berkshire West and serving 1.8 million people the BOB ICS includes, NHS organisations, local councils and the Oxford Academic Health Science Network (AHSN) wider services to join up and improve care e.g. the Thames Valley Cancer Alliance, the Thames Valley and Surrey Care Records Partnership

• More support to help you stay fit and well before things become a problem

• More focus on your physical and mental health and wellbeing, recognising that peoplehave different needs

• Better access to the care you need, when you need it with a physiotherapist, nurse, clinicalpharmacist, GP or non-medical service such as help from a voluntary or community group

• Better joined up care between health and social services

• More hospital care provided closer to home

• Helping people access urgent and emergency care in the right place for their needs

• Reducing length of stay in hospital to support people to return home more quickly

• More personalised care

• Working across a larger geography it means we can make the best use of our resources, skillsand expertise

• Reducing long waiting times for our services by working together to best meet theneeds of patients

• Planning to meet future needs created by population and housing growth

• Working together to address the workforce challenges of operating in a high cost area with acompetitive job market; and supporting the best development opportunities for our staff

• Ensuring our buildings and estate are fit for the future

But the key to providing safe, high quality services are our staff and those who volunteer their time to care or provide support. They are all equally important. We are proud of the thousands of the dedicated individuals, teams and groups working hard for the people and communities we serve, often in challenging circumstances. Living in this part of the country is expensive and we are facing a shortage of health and care staff across the board.

Those providing care and support are passionate about what they do. We know from what they have told us that they often struggle with the way things are done, the duplication of effort and very practical problems to providing joined up care such as computer systems which do not talk to each other.

It is important to us that the people who work to provide health and care services are supported, feel valued and can provide these services in ways that are manageable and rewarding.

Together we want to create opportunities to help staff to develop new skills and shape new roles to meet the multiple needs of patients and finding ways to make it worthwhile for people to come to work and live our area.

We are doing this through our Primary Care Networks, Integrated Care Partnerships and through the development of a BOB-wide people strategy that will support us to make our Integrated Care System the best place to work, a place where workforce shortages are addressed, where we have a thriving leadership culture and together are able to deliver care fit for the 21st century.

Together as an ICS we have five joint areas of work:

Healthy places to live, great places to work - our people strategy 8

We have described how we are organising ourselves to work together for our local communities, whether that’s in neighbourhoods, villages, towns, counties or across the Buckinghamshire, Oxfordshire and Berkshire West area.

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Workforce planning

Culture and leadership

Productivity

Recruitment and

resourcing

Supporting our staff

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Our priorities 9

In the same way that we group together and organise ourselves as Primary Care Networks, Integrated Care Partnerships or as an Integrated Care System, we are tackling our opportunities and challenges in different ways. We have described below our thinking and would welcome your views.

In establishing our plan, we have started with current Health and Wellbeing Board strategies and the strategic plans of each organisation in our partnership – identifying common ambitions, challenges and opportunities that we can tackle together.

The BOB ICS Five Year Plan will be published at the end of 2019. It will build on feedback received, describe how we are tackling our health and care priorities and how we will deliver the ambitions set out in the NHS Long Term Plan so that together we can:

• Deliver care that is fit for the 21st century – offering more services closer to where people live,tailoring care so that it better suits individuals’ needs and making the most of technology

• Recruit people into health and care jobs, offer new and exciting roles at all levels to helpdeliver our ambitions and keep our staff through more flexible and supportive employmentopportunities

• Support people to live longer, healthier lives and treat avoidable illness early on

• Help people earlier rather than later, keeping them well and helping them to cope with anyhealth and care needs at home or in the community, wherever possible

• Reduce health inequalities, including for our more deprived communities which see pooreroutcomes and for groups who may be disadvantaged due to their characteristics (such asgender, race or disability) or their needs (such as poor mental health).

• Improve care quality and outcomes for stroke, cancer, mental health services

• Take advantage of the opportunities provided by world class research, technological andmedical advances to provide more innovative, accessible and personalised health and careservices

• Make best use of taxpayers money, including getting value for money by doing some thingssuch as procurement once and on a larger scale.

Delivering improved health and care across the ICS requires a well-developed system and underpinning infrastructure. We will also start to set out, in response to the Long Term Plan and the changing nature of clinical commissioning, how we see the commissioning and provider landscape developing, including the role of Clinical Commissioning Groups.

Our plan is being developed by a range of staff and clinicians who are experienced in planning for and delivering a wide range of services, such as mental health, children’s services, primary and hospital care.

In developing their proposals, they are reflecting on the feedback given by local people, patients and carers through the many Clinical Commissioning Group, Local Authority and Healthwatch engagement activities that have taken place in recent years. These health and care leaders are also giving careful consideration to how their ideas and plans address other important areas such as health inequalities, preventing ill health, improving outcomes and being financially sustainable.

We recognise the importance of continuing to link to each area’s Health & Wellbeing Strategy and, as our plan develops, we will be engaging with local councillors on Health and Wellbeing Boards and Healthwatch, as well as talking to our staff and local communities; and keeping all of our stakeholders informed and involved.

Developing our five year plan 10

We are working together as the BOB Integrated Care System to develop a five year plan. It will describe how all partners within the ICS will work together locally and, when appropriate, together across the Buckinghamshire, Oxfordshire and Berkshire West area, to ensure current and future health and care needs are met.

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Improving out of hospital care

Reducing pressure on hospital services

Giving people more control over their health and more personalised care when they need it

Providing digitally enable primary and outpatient care

Working in partnership with local councils to improve the health of our communities

We will be able to do this by:

How are decisions made?

Our legal and statutory responsibilities are still firmly based in the duties placed upon statutory boards and committees. These Boards are kept fully engaged when key decisions are required

We work collectively as a partnership to make decisions together about strategy and priorities. We have a BOB ICS Systems Leaders Group, made up of Chief Executives of all NHS organisations, Local Authority Chief Executives and clinical representatives. The group works to a set of principles, which have at their heart an agreement that activities and decision making should be kept as local as possible, as this is where the most difference can be made to improving care and outcomes.

The System Leaders Group meets every month. A key role of each member of this group is to ensure their own organisations, local boards, council committees and communities have been engaged on key issues, challenges and decisions and that strategies and plans are aligned at each level of our system. The System Leaders Group will be overseeing the implementation of the BOB ICS five year plan.

We also use other communications to make sure our stakeholders are kept informed – for example, regular updates published following each BOB ICS Systems Leaders meeting: www.bobstp.org.uk/what-is-the-ics/keeping-in-touch/

Our Timeline

Next Steps – we welcome your views

We would welcome your views on our priorities. Please do email them to the following contact addresses by 18 October 2019:

• Oxfordshire queries: [email protected]

• Berkshire West queries: [email protected]

• Buckinghamshire queries: [email protected]

How are decisions made? Our timeline and next steps 11Bu

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Date Activity

9th September We publish this document as the first step in developing the BOB ICS Five Year Plan

Late September We will publish a slide pack summarising the key points from the first draft of our technical submission to NHS England/ NHS Improvement

Early October We will publish the full draft “technical submission” sent to NHS England/NHS Improvement – this will describe the responses to the deliverables required in the Long Term Plan

18 October Deadline to give your thoughts and views

1st November Final technical document submission to NHS England/NHS Improvement

End of November Final plan published, following review by NHS England/ NHS Improvement

On-going Continued engagement with communities and stakeholders

Designing Neighbourhoods in Berkshire West with Health and Wellbeing In MindThe Berkshire West “Design our Neighbourhoods” initiative puts health at the heart of the community in a bid to ease pressures on NHS services. It brings together health and care organisations, local community groups and residents to help create healthy environments across the villages and towns of Berkshire West, in which people can walk and travel safely and access healthy activities, events and support networks. These activities and networks can help to boost physical wellness and mental health and reduce unnecessary GP appointments.

Trailblazer mental health care scheme to benefit children in BuckinghamshireAround 16,000 children and young people in Buckinghamshire are set to benefit from a new ‘Trailblazer’ scheme to transform children’s mental health care and ensure those in need get the right support at the right time. The county is one of 25 areas across the country so far to receive Government funding for this new initiative, equating to £2 million over a two-year period.

Two dedicated ‘Mental Health Support Teams’ will work closely with 40 schools (both primary and secondary) and colleges, to offer timely assessments and interventions for pupils in need, treating those with mild to moderate mental health issues in school. If pupils have more severe need, the teams can link smoothly to specialist NHS services at Buckinghamshire Child and Adolescent Mental Health Services (CAMHS) and ensure they get the right support and treatment as quickly as possible.

Oxford Hospital Scheme Gets Stroke Patients Home SoonerOxford University Hospitals has helped thousands of stroke patients recover in their own homes in the past year. The Oxfordshire Early Supported Discharge (EDS) service for stroke helps patients by continuing their rehabilitation in their home after they leave hospital, providing them with the same level of rehabilitation at home as would be delivered on an inpatient Stroke Unit. The service covers Oxfordshire from three hubs at the John Radcliffe, the Horton General and Cowley. The Trust’s ESD team is made up of stroke consultants, physiotherapists, occupational therapists, speech and language therapists, dietitians, and rehabilitation assistants.

The teams provide a six-day-a-week service helps stroke patients return to normal, daily activities such as walking, shopping, reading, cooking, and driving. In addition, ESD has played a vital role in helping patients avoid an otherwise necessary admission to hospital by delivering the required therapy at home. Overall, 307 patients received therapy in their own homes provided by ESD in its first year.

Good Hydration! – award winning care home residents’ hydration improvement programme Berkshire East CCG and Oxford AHSN Patient Safety Collaborative won a national Patient Safety Award for Quality Improvement Initiative of the Year for the Good Hydration! Initiative in care homes. The scheme has reduced hospital admissions due to urinary tract infections by 36% and is being introduced across the BOB ICS and more widely.

We are making progress and change is happening 12

Each of our Integrated Care Partnerships are improving services and developing innovations to better serve their local communities. For example:

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People are benefiting as innovations in one area are rolled out across all of our Integrated Care System

Atrial fibrillation programme – reducing the number of strokes in the Thames ValleyThe Oxford AHSN has brought together expertise from the NHS in Berkshire, Buckinghamshire and Oxfordshire and industry to reduce morbidity and mortality related to stroke caused by atrial fibrillation (AF). AF is the most common cardiac arrhythmia, affecting around 2.5% of the population (58,000 people in the Oxford AHSN region).

AF is a major cause of stroke, responsible for 20% of all strokes in the UK but the relative risk of stroke for these patients can be reduced by up to 66% with oral anticoagulation therapy.

Through the AF programme:

• Over 1,000 patients received a review by a specialist pharmacist to ensure their anticoagulation wasoptimised and 465 patients received a consultation with a specialist pharmacist. We estimate that upto 13 strokes per year have been prevented

• 4,440 patients across 28 GP practices in had a detailed review, resulting in an additional 266 patientsnow receiving oral anticoagulation, 227 of whom have a high risk of stroke. This equates to up to 17fewer strokes each year.

Educating young people about careers in healthHealth Education England, has worked with the BOB Integrated Care System to help set up an education programme to educate young people on the NHS and inspire them to become part of its future workforce. Healthtec is a unique health simulation centre located in Aylesbury within the Buckinghamshire College group campus.

Young people are given the opportunity to work alongside NHS professionals whilst learning basic first aid skills in an experiential environment where the hospital is recreated and simulated. Within Healthtec young people are able to learn about the variety of healthcare careers within the NHS and the different avenues there are for entering these careers.

Healthtec professionals ensure these important lessons are spread beyond the Aylesbury located facility and travel to primary schools to ensure that children have the opportunity to learn about health care. Healthtec staff also attend careers fairs to talk about the NHS, and its roles. The programme has currently engaged with 7,000 students.

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Copyright © Buckinghamshire, Oxfordshire and Berkshire West Integrated Care SystemPublished September 2019

ContactsOxfordshire queries: [email protected] West queries: [email protected] queries: [email protected]

Title: Winter Plan Progress Report Agenda item no: 6 Meeting: Board of Directors Date: 25 September 2019 Presented by: Mary Sherry, Chief Operating Officer Prepared by: Mary Sherry, Chief Operating Officer & Mandy Claridge, Director of

Operations for Urgent Care Purpose of the Report To Provide the Board with a progress report on the Winter plan.

Report History n/a


The Board is asked to note the report, comment on progress so far and identify any considerations they would ask to be taken account of in the next stage of planning.


Resource Impact: None Relationship to Risk in BAF: N/a






Publication

Published on website Confidentiality (FoI): Private Public

1. Introduction

1.1 The purpose of this paper is to set out for the Board the context for winter planning

2019/2020, the considerations taken account in putting the plan together and a summary of what will be in the plan.

1.2 It sets out how the plan will be completed and highlights areas (as they are clear at

the time of writing) where we may not yet be able to fully set out optimal solutions and either have potential solutions in progress and/or proposals in development should circumstances change over the next few months, for example central winter funding becoming available.

1.3 The purpose of the plan, firstly, is to create the best conditions that we can over the

winter pressure period so that the experience of our patients and staff is optimised in terms of quality and safety. Secondly, to maintain the highest performance we can in respect of the 4 hour quality standard. In doing both of these to consider the financial implications and work within budgetary envelopes as part of delivering the Trust control total, as well being ready to bid for and access any additional funds should they become available.

1.4 The Royal Berkshire Hospital (RBH) plan will sit as part of, and be supported by, the West Berkshire Urgent & Emergency Care (UEC) system wide winter plan with partners across health, social care and voluntary services.

1.5 The Board is asked to note that we are at a critical point in winter planning, typical for this time of year, and whilst good progress is being made there remains a material level of further work to complete, which is actively being progressed.

1.6 There are two further updates to Board currently timetabled, in October and November. Regular updates on the progression of the winter will be provided to the Board through the Integrated Performance Report, with any other reports of an exceptional nature presented if required.

2 Background

2.1 The plan is derived from a) National guidance for the management of winter which sets out some key

imperatives and recommendations from specific reviews b) RBH learning from last year and in year pressures in terms of activity, acuity

and other particular issues of note c) System working through the West Berks UEC Board in the context of the

UEC strategy 2.2 The plan is underpinned by the following key principles

Valuing patients time and supporting staff Right patient right place, right care, right time Stay well at home, reduce conveyance to hospital Ambulatory care where appropriate, reduce inpatient stays Minimise time in bedded care, reduce patients’ wasted time in hospital Home as first choice following bedded care

Earlier discharge – home early settled and safe Safe staffing and appropriate to need

3 National guidance and recommendations from specific reviews

3.1 National guidance sets out the following important key areas of service provision

‘asks’ that need to be taken forward as part of urgent and emergency care planning generally, which include:

a) Same Day Emergency Care (SDEC) b) Frailty Services c) GP Streaming Services d) Weekend Discharges e) Long Length of Stay

3.2 We are part of the Same Day Emergency Care (SDEC) accelerator programme with

NHS Improvement (NHSI), which commences in October, for which we are preparing now; this will help us further develop these services for medicine (surgery is currently doing very well).

3.3 A recent NHSI visit highlighted a number of improvement areas which, whilst not

new, do place an additional focus and provide guidance on how we may be able to go further than we are currently predicting on the national ‘asks’ noted above.

4 RBH Perspective

4.1 Key learning from last year includes:

a) Positives

i) The bed capacity plan played a positive contribution especially in terms of the phased opening of the new capacity at the front door, the planned temporary conversion of Redlands in the immediate post New Year period and a moderate amount of escalation capacity opened on Hurley ward.

ii) Although a concern arose during the winter, which has since been reviewed with improved proposals for this year, the Point of Care (POC) flu testing assisted greatly with the early identification of flu and the appropriate placing of patients and management of bed capacity.

iii) Increased presence for ward into the Emergency Department (ED) by Acute Medicine and Care of the Elderly, together with increased access to the Medical Ambulatory Care Unit greatly assisted the early management of medical patients and some admission avoidance, together with the availability of the GP streaming service; taken together these all contributed to improved patient care in terms of timely access and morale in ED and were seen as a very positive step.

iv) Initiatives by surgical specialties to provide additional support to the emergency pathway (additional Registrar in Orthopaedics, extended working for Surgical Assessment Unit and a new Urology ‘hot’ clinic to provide direct referral to Urology) all contributed to improving the flow to these areas.

v) The continued drive on length of stay, Board rounds on wards, system partnership working on delays generally kept pathways moving to a large degree, although we did experience the usual seasonal challenges regarding acuity and age profile and securing 7 day response from external agency care provision as well as significant staffing challenges in community care provision.

vi) Strong partnership working at director level, including the locally agreed ‘silent winter’ system escalation which was very successful. It avoided protracted system calls and enabled director time across the system to be focussed on supporting our front line staff at such a time of pressure. This has sparked both local and national interest.

b) Challenges

i) Overcrowding in ED was still a concern however ED staff fed back that the situation was much improved compared to previous years and was safely managed with strong support at times of particular pressure.

ii) Despite increased bed capacity we did still have a numbers of patients waiting for beds each morning and for periods of the day; however this was considerably reduced from previous years and in particular the preceding year, and again ED staff fed back that this felt much safer.

iii) Although Length of Stay (LoS) is relatively strong as described above, we did see a seasonal rise as we continued to experience significant Delayed Transfers of Care (DTOC) and a higher than desirable pattern of patients >7 days and >21 days LoS. This should be noted in the context of a continuing downward trend in LoS overall.

iv) Weekend discharges remain a challenging issue. Although we do have excellent consultant cover across our inpatient wards, however there is not all the supporting infrastructure to enable discharges to significantly increase e.g. junior doctors, occupational therapists. Also community services do not easily commence care over the weekend, and our forward planning of discharges could warrant some improvement.

v) The impact of Go Live / Electronic Patient Record (EPR) did remain a pressure through from Q3 into Q4 which continued to cause some frustration for ED staff whilst they continued to get used to working digitally rather than on paper.

vi) Once again we did carry a high level of outliers, although less than the preceding year and it was challenging for medical staff to cover both the surgical wards and also Redlands Ward.

vii) The GP streaming service was not always available due to staffing constraints, or closed early, which was frustrating for ED when the closure was on very busy shifts.

viii) Pressure on the Acute Medicine Unit (AMU) and Short Stay Units (SSU) was considerable as they sit immediately behind the front door pressure and as we move patient more quickly through from ED this increases the pressure on them.

ix) All critical care areas experienced considerable pressure and in particular the Intensive Care Unit which was ‘over bedded’ for significant periods to 16/18

beds at times (substantively staffed to 13) although the spirit and willingness with which these units supported these critical groups of patients was impressive.

x) Pressure on the inpatient wards is not always commented on and this was considerable, particularly on wards that faced significant staffing issues.

4.2 In year pressures: activity, acuity and particular issues of note a) Activity and acuity

i) We have seen considerable pressures across the Trust this year, in terms of the

volume, acuity and complexity of patients being cared for in our critical care units and inpatient wards. ED presentations are an important factor in this and the acuity of the patients in the hospital is reflected in the increasing number of patients arriving by ambulance and treated in a majors pathway.

ii) These pressures were recently reported to the Board and the Deep Dive paper is attached as Appendix 1 for reference. Despite these pressures it is worth noting that the ED team, through the deployment of a zoning method, have consistently reduced the average time to be seen and assessed, which has been impressive and as a result that first ‘eyes on’ does improve the safe management of the department.

iii) LoS continues to be a good news story (see Appendix 2) and we have reduced our beds over the summer in line with the flexible bed plan. However, as a result of driving on reducing the more easily resolvable/simpler discharge issues and the excessively long LoS, we do now have an inpatient population which proportionately have very complex discharge needs both from a clinical / acuity perspective and significant difficulties resolving their onward care needs. This has proved a real challenge over the summer months.

iv) As a result ward based care is now increasingly ‘heavy’ and we have seen stubbornly high levels of stranded patients (> 7 days > 21 days). This is also presenting a problem fully utilising community beds, because as a result of the continuing drive on Home 1st as 1st Choice, our remaining patients who do still require onward care cannot always matched to the ‘right’ community bed for their needs.

b) Other particular issues of note

i) The GP streaming service, which was situated in the Primary Care Unit (PCU) is no longer available, as it had to be repositioned due to cost and staff availability. We are currently transitioning to a new Nurse Led streaming service managed from within ED and aiming to utilise the space available in PCU regularly, once staffing is fully recruited to, as flexible / buffer capacity.

ii) The estates constraints of the ED are now a significant issue given the consistent volume and acuity of patients being seen and all opportunities to ‘adjust’ this accommodation appear to be exhausted, other than to flex across to the PCU area. This is also a material issue for Paediatric ED for which we also do not yet have an appropriate plan and is consistently subject to overcrowding.

iii) The steady pattern of ambulance arrivals late into the evening and the late evening volume of patients in the ED, particularly on days when onward flow

may be slow and attendances are high, is putting additional strain on staffing, which risks outstripping our recent investment plans.

iv) An important subset of the pressures noted in the Deep Dive report are those relating to trauma. These fall into two categories: those that derive from clinical/accidental cause and those that derive from violence/destructive behaviours including mental health related).

v) The ED has seen, and continues to do so, a particularly concerning pattern of patients presenting for our care of the former (including extremely acutely unwell adults and children with potentially fatal consequence including with a number of very young deaths) and an increasing pattern of the latter (including assaults, stabbings).

vi) Whilst on the face of it this is what an ED is for, taken together this increasing pattern is putting an additional level of pressure on our front door staff, as well as presenting challenges for other services which support them, of note, our security staff.

vii) An additional and related issue is the continuing struggle that we face as a Trust accessing some elements of onward care for patients with mental health needs. Whilst our close working with the front line mental health team who directly support us is excellent and they are both proactive and responsive, there continues to be significant challenges accessing inpatient beds at Prospect Park and we carry a high level of 1:1 care provision across the Trust whilst patients wait to access mental health/related services, including for children.

viii) The net result is that the Reading Emergency Department is now functioning akin to an inner city Emergency Department in terms of volume and case mix

4.3 All of these pressures remain ‘live’ and are not abating and it is important to recognise that the underlying circumstances going into this winter are particularly challenging. To note, this does reflect the local and national picture.

5 System working 5.1 Partnership working across West Berks has remains strong and the development of a

UEC Strategy has been helpful in forming a framework to coalesce around. Partners at director level, and their operational teams, are focussed on both winter interventions and the longer term development of services.

5.2 Other than those elements reflected already in this paper there are various actions

that are being taken across the system in support of overall patient flow. These will be reflected in the relevant chapters of the system wide plan, as for last year.

6 Key Components of the plan

6.1 The plan when finalised will set out a range of actions which will cover improving on existing good practise, new initiatives and will also include some actions that can be taken should new funding become available.

6.2 Material elements in the plan will include: a) System wide – to support attendance/admission avoidance

i) Continued improvements in the use of 111 to control referrals to hospital

improvements (incl on line) have been implemented and at the top end of the options.

ii) Continued access to GP enhanced hours to try to reduce presentations to hospital.

iii) Continued focus on non conveyance by the ambulance service including new processes ‘at scene’ to connect to alternative services.

iv) Continued focus on high intensity users and data driven support to GP practices with high referral levels.

v) Increased focus on rapid response and admission avoidance by community services and local authorities

b) Acute Trust front door services i) Revised Streaming service in ED to see minor illness patients more quickly

and separate them from the acutely unwell patients as part of right patient, right professional, right skills.

ii) Continuation of the ‘zoning’ model in ED to identify quicker pathways for non admitted patients.

iii) Continuation of the Frailty Service in ED and consideration of further

improvements to the model as recommended by NHSI including potentially direct referral admission.

iv) Continued forward presence of Acute Physicians and further

developments in access to ambulatory care supported by the SDEC Accelerator programme.

v) Direct access to Surgical Assessment Unit for ambulance presentations

to reduce pressure on ED and take patients directly to their specialty care. vi) Increased medical cover in ED at night to provide extra capacity at peak

times. vii) Increased medical cover in AMU and SSU to support winter pressures

through these beds and supported by strong pathway coordination to drive out blocks in pathways

viii) Adjustment to Matron responsibilities across AMU, SSU and ED, to

allow the Matron for ED to fully concentrate on ED ix) Implementation of additional administrative support to ED to release

doctor time back to patient care from coding and better support EPR /downtime issues

x) Active progression of outstanding EPR issues for ED adjustments to their prescribing power plan and improvements in tap and go/voice recognition functionality, again releasing doctor time back to patient care (both are escalated with EPR team)

c) In hospital patient flow work and discharging patients

i) Patient pathway coordination, a continued daily focus on Board rounds

and unblocking delays, utilising the Pathway Coordinator roles deployed onto the medical wards, working in partnership with increased support to wards from the Integrated Discharge Service (IDS) team, who will provide complementary pathway coordination to other wards, all working to a consistent approach

ii) Extension of the Early Supported Discharge service to cover a wider range of patients and 7 day working

iii) Action plan on 6 deep dive complex discharge issues accelerated for action at Director level including continued weekly scrutiny to help unblock issues in a timely manner.

iv) Action plan on weekend discharges, to consider how to achieve more pre

planning of discharges, deployment of winter resourcing for OTs and additional juniors (dependant on finance), potential to increase Pharmacy provision (dependant on funding) and continued work with system partners.

v) Reset weekend initiative, in October we are doing an in depth review of

weekend flow / discharges through a repeat of our reset fortnight method, across a Wednesday to Wednesday period, to inform actions on weekend discharges.

vi) Targeted LLOS management, adopting NHSI recommended best practice

through the further development of our well established daily and weekly scrutiny of LLOS/stranded patients, including deploying recommended actions from NHSI regarding proactive communications plan with staff regarding LLOS.

vii) Continued focus on improve To Take Home medication covering the

process from prescribing to drugs received on the ward, including a push to finally resolves long standing issues to do with NOMADs.

d) Bed capacity management including community beds

i) The flexible bed capacity plan, which is supporting estates work across in patient wards, keeps 28 beds closed until mid December and is reviewed on a weekly basis. (See appendix 3). The current plan will see a number open before the Christmas period and a number opening on 2nd January (mirroring last year).

ii) Redlands Ward, will transfer to supporting medical admissions for a 3 weeks period from the 2nd January (two weeks admitting, one week to reduce back).

iii) Hurley Ward, will operate as a 22 + 4 bed ward, subject to nursing

recruitment and medical cover. (Requires some Estates work, currently being scoped and planned.

iv) Community beds across West Berkshire will see some adjustments

coming into place across the winter to further increase neuro rehab beds by 4, increase capacity in Community Based Neuro Rehabilitation (CBNRT) and adjust the model for general beds to improve the ‘match’ for onward care from RBH; this plan is in active development at the time of writing and subject to confirmation including the financial resourcing adjustments required to achieve this.

v) Implementation of remote access to EPR for community wards, to

smooth the discharge pathway vi) Further development of the IDS team, to support the navigation of patients

into the right bed, right patient, right time, together with improved processes to support this, to reduce the risk of unused beds across the system.

e) Operational / system wide management and escalation

i) Daily Ops meetings and hospital wide management and full implementation and further development of the RBH Opel trigger tool, to continue to build on the well recognised partnership approach across the trust in support of patient flow.

ii) Review of RBH on call arrangements including training of new on call managers and consideration of adjustment to the on call director rota.

iii) Continuation of RBH and system wide review of LLOS and DTOC,

utilising recommendations form NHSI.

iv) Implementation of system wide bed management tool, to be able to see available and filled beds across all sites, including those closed/not available for various reasons, e.g. infection, estates, staffing.

v) Further development of the IDS team, to support the navigation of patients

into the right bed, right patient, right time across the system, together with improved whole system processes to reduce the risk of unused beds anywhere in the system.

f) Further actions under review and not yet fully addressed

A number of further actions are in progress that either require confirmation of current funding arrangement and / or could be be implemented if or additional funding should it become available (subject to staff availability), these include:

i) Weekend OTs/Physios ii) Medical support for outliers and weekend discharging iii) Alphacare transport to supplement current contracted service iv) Trial new multi skilled HCA role in ED v) Additional medical cover at night vi) Extra clerking doctor vii) Phlebotomy at weekends viii) MSA breaches ix) Point of Care testing

7 Wellbeing initiatives

7.1 These are not fully shaped up yet, however, it is clear that across our front door services, there are considerable stresses and strains over and above ‘the norm’ that are more than ever now affecting our staff’s wellbeing. This is particularly of concern as we go into the winter in the circumstances described. Front door services are not alone in this and these types of pressures are mirrored elsewhere across the Trust to a greater or lesser degree.

7.2 This is being recognised as an important issue, not just for winter planning, but in

respect of preparing for winter it needs to be acknowledged and also work is going to see what additional measures can be taken to support staff over this period, and in the long term.

7.3 This directly links to a range of initiatives already in train and supported by our HR

colleagues, working closing in support of departments and front line teams, including those on recruitment and retention as there is some connection here.

7.4 Examples include, in ED a wellbeing lead and wellbeing champion has been

appointed and being actively supported by the management team; ‘stay’ clinics across a number of services; mentor groups in ICU.

8 Next steps

8.1 Over the next 4 weeks this plan will be further developed including scrutiny of all

funding issues. This will include a further assessment of remaining risks to the winter in terms of quality, safety, staffing and performance.

8.2 The plan will next come back to the Board in October, via EMC and Executive

channels for scrutiny and finalisation.

Purpose of this paper:

• To brief the Board on the drivers behind recent Emergency Department activity and subsequent 4 hour quality standard performance

1. Background

1.1 The Emergency Department at Royal Berkshire Foundation Trust has experienced a deteriorating performance against the 4 hour standard when comparing Quarter 1 2019 to Quarter 1 2018. Achievement of the 4 hour quality standard has significantly deteriorated, in a far higher percentage than the increase in activity.

1.2 The department has seen a 3% increase in activity in quarter 1 moving from 302 attendances per day in quarter 1 in 2018 to 313 in the same period this year. Peak attendances last year were around 360 and this year 381 with this Monday 15th July being the highest at 393.

1.3 The effect of these peaks can lead to the demand on the department outstripping the available staff

1.4 More significantly the Trust has seen 19.47% increases in ambulance arrivals when comparing Q1 2018 to Q1 in 2019, this that equates to 15.7 more ambulances each day.

1.5 The age profile of patients arriving has changed with a very slight reduction in those under 50 and a 14% increase in those over 70 years old.

1.6 Acuity has also increased within the Emergency Department, some of which is due to the ‘minor illness’ patients being streamed over to the Primary Care Unit.

1.7 The Intensive Care Unit has increased occupancy by 15% over plan particularly level 3 care (the most complex) This is in addition to a stepped change in demand for emergency Cardiac Care and Primary Angioplasty.

1.8 Patients with complex mental health needs arriving in the Emergency Department has also meant that on several occasions there has been a requirement to close the Observation Ward.

1. This deep dive review sought support from Public Health England and our Ambulance Providers to ascertain the cause of the increase

Deep Dive Emergency Department Performance

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2. Ambulance Perspective

2.1 Our Ambulance Provider South Central Ambulance Service (SCAS) do not report any significant difference to the Trust compared with any other hospital within their region

2.2 SCAS have experienced a progressive increase in demand, and are currently 7.5% above demand for this time last year. This equates to approximately 800 additional calls across the organisation per week.

2.3 Some the increase can be attributed to NHS Pathways system changes, which is a National model, and not one that can be influenced locally.

2.4 They have also experienced a similar increase in respiratory and cardiac conditions across the region along with an increase in trauma.

2.5 As of the 1st July SCAS rolled out a new HCP and Inter facility transfer policy, whereby GPs and health care providers have the option for a category 1 call. Again this is accounting for some increased Cat 1 activity, but they are monitoring this, as it is still early days for a new process.

2.6 Post code analysis would suggest the growth is all from our local area.

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3 Public Health Perspective

3.1 The RBFT and NHSE/I asked whether Public Health England (PHE) held any information that could elucidate any population demographic characteristics and changes that could explain changes in the experiences felt in the Emergency Department and wider hospital. It was queried whether the population was changing to one that is more like inner city populations.

3.2 Combining Trust catchment estimates with the latest ONS mid-year population estimates shows a marked year on year growth in all the age ranges above 50 years. This is particularly marked in those aged 85 and above, averaging 3% growth per year, which is at the upper end of change seen amongst Trusts in the South East. Given the increased risk of admission as people age, this consistent growth in the population aged 50 and above could have a significant impact.

2013 2014 2015 2016 2017 Avg number growth per year

Avg % growth/year

0-5 40,144 39,830 39,576 39,157 38,571 -393 -1.02%

6-19 82,054 83,190 84,401 85,924 87,650 1399 1.60%

20-34 94,639 93,808 92,142 91,345 91,831 -702 -0.76%

35-49 107,759 107,624 107,413 107,227 107,062 -174 -0.16%

50-64 85,028 86,483 88,222 89,789 91,942 1729 1.88%

65-84 65,167 66,942 68,125 69,337 70,574 1352 1.92%

85+ 9,801 10,158 10,377 10,754 11,147 337 3.02%

3.3 Ethnicity data show that the catchment population of the RBH is closer to the England average than

the South East in general. This can indicate that there will be challenges of higher prevalence of cardiovascular conditions, reduced primary care usage and higher ED usage.

Ethnicity & Language indicators, 2011, %

RBH England South East

Black and Minority Ethnic (BME) Population 13.8 14.6 9.3

Population whose ethnicity is not 'White UK' 20.1 20.2 14.8

Population who cannot speak English well / at all 1 1.7 0.9

Source: ONS Census, 2011

3.4 Rough sleeping; another measure of inner-city status and pressure on NHS services is rough

sleeping. The annual census in November shows a significant increase in rough sleeping in Reading and West Berkshire Councils between 2010 and 2018.

2010 2011 2012 2013 2014 2015 2016 2017 2018 Reading 6 5 4 8 12 16 22 31 25 West Berkshire 5 6 11 8 23 15 14 20 18 Total 11 11 15 16 35 31 36 51 43

3.5 In summary; The RBH catchment has seen marked growth in the numbers of people aged 50 and

above. The output area classification describes a mixed urban and suburban population with pockets of significant deprivation. In parallel, the numbers of rough sleepers have significantly increased. There has been some movement of deprived communities away from inner city London and it is likely that some of these people will have moved to the catchment population of RBF

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4 Primary Care

4.1 The Trust has not seen a significant increase in GP referrals and the CCG have assured us that additional appointments are available within primary care.

4.2 Some GP practices have seen an increase in attendance when comparing Jan 2018 to July 2018 and Jan 2019 to July 2019 2 GP practices have seen the most growth and our CCG partners are currently working with their data to understand the changes

GP Referrals by GP Practice Last Year This Year Variance

GROVELANDS MEDICAL CENTRE 257 351 94

BROOKSIDE PRACTICE 233 335 102

WOKINGHAM MEDICAL CENTRE 278 296 18

UNIVERSITY HEALTH CENTRE 247 292 45

MILMAN ROAD SURGERY- DR MITTAL 279 224 -55

WESTERN ELMS SURGERY 176 217 41

CIRCUIT LANE SURGERY 137 200 63

TILEHURST SURGERY PARTNERSHIP 252 186 -66

TILEHURST VILLAGE SURGERY 236 186 -50

BALMORE PARK SURGERY 150 185 35

LODDON VALE PRACTICE 215 183 -32

WOODLEY PRACTICE 91 150 59 4.3 Further data of the 2 highest growth practices are shown below

Note: Figures tabulated are total attendances from 1st Jan 2019 to 14th Jul 2019 (this year) as compared to 1st Jan 2018 to 14th Jul 2018 (last year)

Attendances by Complaint Last Year This Year Variance Attendances by Age Last Year This Year Variance Attendances by Triage Category Last Year This Year Variance

Unwell 77 97 20 1 month 10 19 9 Immediate Resuscitation 0 1 1

Chest Pain 22 34 12 2months to 5 Years 52 77 25 Very Urgent 20 12 -8

Abdominal Pain 21 30 9 6 years to 10 Years 8 17 9 Urgent 206 286 80

SOB 23 26 3 11 to 16 years 16 22 6 Standard 29 51 22

Pyrexia 12 19 7 17 to 50 Years 90 99 9 Non-Urgent 2 1 -1

Diarrhoea or Vomiting 10 16 6 51 to 75 Years 51 80 29 Unknown 0 0 0

Skin Problem 7 14 7 > 75 Years 30 37 7

Limb Injury 10 11 1 Total 257 351 94

Eye Problem 8 8 0

Head Injury 6 8 2

Injury 3 2 -1

Unknown 58 86 28

Note: Figures tabulated are total attendances from 1st Jan 2019 to 14th Jul 2019 (this year) as compared to 1st Jan 2018 to 14th Jul 2018 (last year) Note: GP Referrals are totals for the two conmparison periods

Attendances by Complaint Last Year This Year Variance Attendances by Age Last Year This Year Variance Attendances by Triage Category Last Year This Year Variance

Unwell 79 95 16 1 month 7 13 6 Immediate Resuscitation 2 0 -2

Abdominal Pain 25 29 4 2months to 5 Years 42 39 -3 Very Urgent 8 18 10

SOB 8 26 18 6 years to 10 Years 19 30 11 Urgent 201 249 48

Chest Pain 18 22 4 11 to 16 years 12 32 20 Standard 21 64 43

Limb Injury 7 22 15 17 to 50 Years 74 101 27 Non-Urgent 1 3 2

Head Injury 9 13 4 51 to 75 Years 59 81 22 Unknown 0 1 1

Pyrexia 11 10 -1 > 75 Years 20 39 19

Diarrhoea or Vomiting 4 7 3 Total 233 335 102

Skin Problem 8 6 -2

Eye Problem 2 5 3

Injury 1 4 3

Unknown 61 96 35

BROOKSIDE PRACTICE

GROVELANDS MEDICAL CENTRE

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5 Impact of the Activity Growth

5.1 Performance against the 4 hour quality standard has deteriorated at a far greater degree than the increase in activity, 3452 breaches in quarter 1 2019 to 1528 in 2018.

5.2 Contributory factors have been examined;

5.2.1 Staffing: ED staffing is profiled against activity demand and is reviewed annually. This year a further investment was made to increase weekend night staffing. However as the below demonstrates there remains a gap between available staff and demand, particularly at weekends and evenings. There are elevated breach numbers in this time period.

5.2.2 Senior support is often challenged with Consultants often occupied in Resus with complex patients (due to acuity/ambulance arrivals) and also increasingly staying throughout the night to meet the late evening acute demand. Royal college guidance suggests a ratio of 1 consultant per 3600/4000 attendances, which for the RBHFT would imply 28 whole time equivalent (WTE) consultants for a department that is classed as large (sees over 110 000 new attendances/annum).

5.2.3 From a model hospital view the ED is currently one of the most efficiently staffed in the country (note ‘efficient’ for model hospital = cost effective = potentially too few staff = staff under pressure of excess demand). Currently the ED team are working with HR to develop a workforce strategy, that will look to new ways of working, developing a multi-professional workforce, plus recruitment and retention strategies.

5.2.4 Mental Health: Although breach numbers are low for Mental Health patients the impact is felt within the observation bay, and increasingly it has been necessary to close the unit when a particularly aggressive patient is being cared for, we currently admit approximately 20 patients per day through this environment for assessment and these patients then either breach or put additional demand on the hospital beds.

5.2.5 Generally numbers of mental health attendees are remaining at 300 per month however high complexity of patients has increased in those brought in by police on a section 136 from 19 in year to 44 in the last 11 months.

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5.2.6 There has also been an increase of young adults who stay in ED to await a CAHMs assessment / tier 4 specialist beds who put additional pressure on staff. Datex reporting of challenging behaviour self-harm and absconding has increased.

5.2.7 Previous comparators would suggest we are an outlier in both 136 and mental health attendees. Berkshire Healthcare Trust (our mental health provider) is acknowledged as being an outlier in their management of cluster 8 patients (Personality disorders with chaotic lifestyles who tend to self-harm)

5.2.8 Acuity: Numbers of patients attending are sicker and requiring majors cubicles for treatment, the average treatments and assessment for an ambulance arrival is 45 minutes of medical time.

Although 2019 is a YTD running total it shows the increase in CAT3 year on year and decrease in CAT 5 (Minor illness) CAT1 = Resus Cat 2 & 3 Majors Cat 4 = Minors Cat 5 = Minor Illness

5.2.9 ICU: in general ICU activity has seen a step change over the last year with the department running at 15% over plan this year. In particular in terms of acuity where we have seen the numbers of level 3 patients increase significantly in comparison with previous years. This correlates with data demonstrating a 20% increase in the number of patients on ventilation over the same period.

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5.2.10 There are potentially a number of reasons for this; patients are more medically complex as the population is getting older and chronic illness are more prevalent, increased intervention such as thrombolysis on more acute patients. In addition, both patients and their relatives’ expectations are increasing

5.2.11 Space: The current Emergency Department was built in 2002 to accommodate 65, 000 patients annually, yet in 2017 the unit had attended to over 125 810 patients (Care Quality Commission, 2018). The Department is therefore categorised as a large ED (expected attendances >110 000). This mismatch in real estate manifests in capacity constraints and frequent departmental overcrowding with an adversely negative impact on length of stay, serious incidents, high quality patient care and staff well-being (ED overcrowding, 2016)

5.2.12 Our current estate within ED is:

Type Number Majors Area 11 beds (+1 bay for MH patients)

STAT (Senior Triage Assessment and Treatment)

8 (+ ambulatory chair area)

Resuscitation Area 4 beds Observation Ward 8 beds (+ ambulatory chair area)

Paediatrics 6 beds (+ ambulatory chair area) Minors area 1 HCA investigation bay (ECG, bloods)

3 cubicles for doctor assessment 3 cubicles for ENPs

1 treatment room, 1 Eye/ENT room, 1 side room

5.2.13 Analysis has shown that once the department has more than 70 patients higher breach numbers occur as there is limited trolley space to provide necessary treatments. Of late that number has increased to up to 100 patients in the department some evenings

ED attendance by Hour BandHeat Map Activity of 70 and over

00Hr 01Hr 02Hr 03Hr 04Hr 05Hr 06Hr 07Hr 08Hr 09Hr 10Hr 11Hr 12Hr 13Hr 14Hr 15Hr 16Hr 17Hr 18Hr 19Hr 20Hr 21Hr 22Hr 23Hr47 39 31 27 20 19 18 23 29 35 53 66 84 92 102 93 82 75 72 80 82 77 71 6354 38 32 28 30 25 24 21 30 44 65 69 71 81 80 87 81 76 76 84 94 92 86 7970 58 49 47 51 45 45 41 43 51 59 68 63 68 70 74 78 71 78 91 82 74 65 5436 25 26 19 21 19 17 17 18 32 42 45 59 65 64 62 58 50 52 68 63 59 54 4542 34 33 31 27 21 16 13 20 35 45 62 64 66 60 61 61 65 65 63 55 53 55 4737 33 34 32 28 26 24 21 30 38 48 66 73 85 90 93 91 83 85 96 90 86 87 7966 61 66 64 54 50 45 39 42 42 45 52 60 76 77 83 84 69 64 61 65 64 60 5339 26 19 17 15 13 13 21 23 37 53 61 66 73 85 79 77 76 80 87 91 89 76 6856 51 47 34 31 26 27 33 39 49 59 59 66 72 76 81 77 72 77 85 81 78 71 7062 63 54 56 55 48 45 45 41 53 54 63 59 41 24 6 0 0 0 0 0 0 0 0

ED Breaches by Hour band (attn Hour)Heat Map Breaches of 3 and over

00Hr 01Hr 02Hr 03Hr 04Hr 05Hr 06Hr 07Hr 08Hr 09Hr 10Hr 11Hr 12Hr 13Hr 14Hr 15Hr 16Hr 17Hr 18Hr 19Hr 20Hr 21Hr 22Hr 23Hr1 1 1 1 1 1 1 2 2 4 6 2 1 3 8 10 9 4 3 2 3

1 1 2 1 1 6 3 2 5 4 6 4 7 8 9 4 3 4 26 3 3 2 1 3 2 2 3 3 5 3 5 7 2 2 5 2 1

3 1 1 1 2 2 2 5 6 2 21 2 1 1 2 1 2 1 2 1 3 1 2 11 2 2 1 1 2 4 3 8 6 4 6 12 7 6 8 10 910 5 5 3 3 3 2 1 2 1 1 1 2

1 1 2 1 1 4 7 2 2 2 3 7 5 5 4 42 2 1 3 1 2 1 1 2 4 3 6 4 3 4 8 3 13 9 65 9 3 5 4 1 1 1

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5.2.14 Bed delays: 18% (617) of the breaches have been due bed delays, compared with 165 same period last year. Flow improves when length of stay is reduced; an accurate marker is the number of patients on the Stranded list i.e. those are patients with a length of stay over 7 days.

5.2.15 Flow improves when the stranded number is 230 or below, this year it has been steady at an average of 260, of which 100 have stayed for 21 days or more. Ideally we are working to target the 230 total (>7 & >21 days) and drive >21 days down towards 70 if we can.

5.2.16 Experience over Q1 is that in the face of an increasingly acute front door and therefore an increase in the proportion of admissions requiring acute (and longer) pathways of care and/or complex discharge pathways there is an increased need to constantly improve how we care for these patients in respect of ensuring each and every action is speedily taken and any wasted time in pathways is reduced

5.2.17 Work is in progress to reorganise our integrated discharge team who work in support of the wards and also to implement ward based roles in support of clinical staff. The consultation that supported this work is now complete and we are now in progress to implement new roles and strengthen these arrangements.

6 Conclusions

6.1 The combined impact of the analysis shown in this paper is that at Reading in our ED our staffing, estate and ED/hospital processes are struggling to cope in this level of pressure; this level of pressure means that all parts of our processes need to continuously be working at the optimum in order to keep our system in balance as any one of them can knock us an generate high breaching ie long waits and poor patient experience.

6.2 The increasing elderly population as shown within our Pubic Health data with both chronic and acute respiratory and cardiac conditions have placed additional demand on both our ambulance provider and ED, given the demographic growth, this pressure is likely to be sustained into the future.

6.3 To note, our findings are broadly in line with national context in terms of activity and performance.

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7 Mitigations

7.1 Our focus is on both immediate/tactical actions and controls to support departments and wards to work as efficiency as they can in the present circumstances together with work strategically across the ICS and with system partners to develop responses to the demand pressures descried in this paper. Examples of some of our actions are shown below.

7.2 A proactive split of ED to ensure minors flow is protected and streamed appropriately supported a safety initiative whereby all patients are seen and assessed within 15 minutes. This has been a positive addition to our existing STAT process for ambulances. We are working with ED team to ensure that this model is always consistently deployed as sometimes this can be variable.

.

7.3 Regular safety huddles within ED with multidisciplinary team to continually monitor the flow situation and ensure all actions are being taken to optimise pathways and use of space

7.4 Change of hours to deliver a senior site team presence until 23.00 hrs to help support flow within the peak periods of demand with a focus on patient movement out of the ED

7.5 Proactive recruitment of Physicians Associates into medical staff gaps and supporting the development of new roles, i.e. an advanced ED paramedic practitioner, who has become one of the first paramedic independent prescribers in the UK. ED coders to support admin roles in releasing clinician time to care.

7.6 Weekly review of performance and staffing with clinical team to plan forthcoming week and proactively learn

7.7 Daily review of all stranded patients by Matrons, with weekly review by Senior Team, engagement with National Programme to reduce long length of stays

7.8 A continued focus on admission avoidance wherever possible to ensure optimum use of beds including a continue look at how pathways can continuously look at how overnight stays are avoided where it is safe to do so (known as Same Day Emergency Care (SDEC) and subject to national recommendations. Surgery is doing extremely well with this with further work needed in medical specialties.

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8 Next Steps

8.1 Continue to develop the workforce transformation plan to look to close the gap between demand and staffing

8.2 Work with the estates team to examine any further opportunities (and they will likely be at the margins) to develop a short term space plan; in addition make STP and national connections to start to identify any other sources of major funding to contribute to a long term development plan for the ED/front door estate

8.3 Further intensify the work on stranded and longer length of stay to improve flow with Matron and Senior review including full implementation of roles on wards to work in support of clinical staff to focus on pathway management

8.4 Continue work with system partners in Local Authorities and Berkshire Healthcare Foundation Trust to unblock complex pathways and DTOC particularly care provision and any remaining high ijpact changes not yet embedded

8.5 Continue work with ICS partners to look at GP practices with increased attendees

8.6 Support the ICS in moving Primary Care Streaming back to the Emergency Department, enabling a greater flexibility of workforce investment

8.7 Development of system wide winter plan through A&E DB and development and the continued development of the IC UEC Strategy to ensure that long term strategic solutions are being sought

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Appendix 2 – Length of Stay

LENGTH OF STAY 17/18 18/19 19/20 Target Variance average length of stay (inc zero los) 4.65 4.32 4.28 4.19 0.09

Length of stay at record low during August (4.28 global) driven by medicine and surgery staying constant. The super stranded remained high and if discharged in September, we may see increase as length of stay is calculated on discharge.

STRANDED PATIENTS 17/18 18/19 19/20 Target Variance Average number of stranded patients 266 252 251 230 21 Average number of super-stranded patients 112 88 92 81 11

Overall stranded performance mirrors last year, but we did not see the drop in June / July we experienced during 2018/19.

WEEKEND DISCHARGES 17/18 18/19 19/20 Target Variance number of weekend discharges (mth) 694 712 679 783 -104

Weekend discharges continue to reduce.

Outliers where at 2017/18 levels, last year we had really good flow during June and July. T&O have contined to be an issue and there ward stay is up up 0.5 days

DELAYED TRANSFERS OF CARE (DTOCs) 17/18 18/19 19/20 Target Change/Var RAG Objective Reduce the percentage of DToC beddays to 3.5% number of 'DToC' patients (ave week) 29 25 30 - 5 5.4 number of 'DToC' beddays (ave month) 846 744 300 612 -312 -311.8

DTOC patients are at very high numbers, but the delays per patient are less. The impact remains roughly stable. This reflects lower DTOC days for patients waiting routine placements/ CRT but a consistent number of complex patients with protracted delays.

ESD has increase the level of bed days saved over past 4 months and now able to offer twilight / weekends.

Linked to ESD, NOF stays are down and below national average

Date Ward movements

19/06/2019 BASELINE

28/09/2019Scope SSU/Portakabin on possibility of work being undertaken sectionally

03/09/2019 SSU Estates works (TBC)21/09/2019 Target completion for Lift repairs Eye Block (CBRE)22/09/2019 HOPKINS moves out of ASU23/09/2019 ASU Estates work commences11/10/2019 ASU Estates work completes12/10/2019 Deep clean ASU13/10/2019 ASU moves back from CASTLE14/10/2019 SSU moves to CASTLE15/10/2019 AMU moves to SSU15/10/2019 AMU 50% Estates works commences24/10/2019 AMU 50% Estates works completes25/10/2019 Deep clean AMU 50%26/10/2019 AMU 50% returns from SSU27/10/2019 AMU other 50% moves to SSU28/10/2019 AMU other 50% Estates works commences08/11/2019 AMU other 50% Estates works completes09/11/2019 Deep clean AMU other 50%10/11/2019 AMU other 50% returns from SSU11/11/2019 SSU unit flooring 7 days TBC18/11/2019 SSU moves from CASTLE back to SSU19/11/2019 CASTLE Estates works commences03/12/2019 CASTLE Estates works completes04/12/2019 Deep clean CASTLE05/12/2019 CASTLE moves back06/12/2019 50% Mortimer move back Burghfield opens staggered06/12/2019 Work commences 50% Mortimer 13/12/2019 Work commences other 50% Mortmer

20/12/209 Mortimer opensAll other deep cleans not depedent on othersBuscott deep clean is not dependent on anything elseDorrell and Hopkins bay by bay ICU internal planWhitley kitchen complete and deep clean

Estates worksWard decant to and fromCritical compeltion date for Lift worksDeep clean

DRAFT Ward Estates and Deep Clean Programme 2019 Rev 4

SEPT

OCT

NOV

Subject to lift repairs complting on schedule

Awaiting confirmation of SSU flooring

Title: Annual Medical Revalidation Report Agenda item no: 7 Meeting: Board of Directors Date: 25 September 2019 Presented by: Dr Janet Lippett, Medical Director/Responsible Officer Prepared by: Dr Carl Waldmann, Revalidation Lead and Sue Townley, Revalidation

and Appraisal Co-ordinator Purpose of the Report

• For the Responsible Officer (RO) to ensure the framework of quality assurance for responsible officers and revalidation provides the required level of assurance and supports future progress within the Trust

• This report describes the progress of the Trust towards the management of medical appraisal and revalidation during 2018/19

• The annual report to the Board is required by NHS England and NHS Improvement in order that a Statement of Compliance from RBFT is signed by the Chief Executive by 27th September 2019

Report History Executive Management Committee – 9 September 2019


The Board of Directors is asked to recommend that the Chief Executive sign the Statement of Compliance.










1 Executive Summary

1.1 There were 419 doctors with a prescribed connection to the Royal Berkshire NHS Foundation Trust as of 31st March 2019.

1.2 91.2% of doctors who required an appraisal in 2018/19, completed an appraisal to a satisfactory standard.

1.3 There were 31 trained medical appraisers and one appraiser who is awaiting training. The previous Appraisal Lead carries out 20 appraisals and is remunerated at 0.5 PA’s and one appraiser is directly employed solely for the purpose of appraisal and carries out 20 appraisals for which he receives 0.5 PA’s.

1.4 The role of Responsible Officer for the period was held by Dr Lindsey Barker. Dr Janet Lippett took over the role on 1st July 2019 following Dr Barker’s retirement. The RO makes the recommendation to the GMC in relation to each doctor with a prescribed connection once every five years.

1.5 There were 124 positive revalidation recommendations submitted and approved by the GMC. There were 20 deferrals. There were no late or unapproved recommendations. One doctor was revalidated once further information was provided to the GMC. There was one deferral to the GMC for a doctor who was subject to an on-going process. The remediation plan is on-going and has been discussed with the GMC Liaison Adviser. Reasons for deferral included doctors on maternity and sick leave and doctors with insufficient numbers of patient feedback as the minimum required number of patient feedback has increased to 30 in the reporting period. The RO and AMD for Professional Standards discuss doctors under GMC proceedings with the GMC Liaison Adviser. Investigation is currently on-going for 2 doctors.

1.6 Appraisers receive feedback from the doctors they appraise and the Appraisal Lead provides a summarised report together with an audit of the appraisal outputs so this can be discussed at the appraisers own appraisal.

2 Recommendations

2.1 The Board is asked to accept this report and acknowledge that it will be shared, as the Annual Organisation Audit has been, with the Higher Level Responsible Officer.

2.2 It is requested that the Board approves the report and the CEO signs the ‘Statement of Compliance’ at the end of the report confirming the Trust is in compliance with the regulations. This will be submitted to the Higher Level RO.

3 Designated Body Annual Board Report - Section 1 - General:

The Board of the Royal Berkshire NHS Foundation Trust can confirm that:

3.1 The Annual Organisational Audit (AOA) for this year has been submitted.

(a) Date of AOA submission: 7th June 2019

(b) Action from last year: All licensed practitioners have an annual appraisal in keeping with GMC requirements using either the MAG form or the e-appraisal form on Allocate. As of 31st March 2019, 419 doctors had a prescribed connection to The Royal Berkshire NHS Foundation Trust. 91.2% of doctors who required an appraisal in 2018/19 completed this to a satisfactory standard.

(c) Comments: The Trust continues to improve systems and processes for managing appraisals.

(d) Action for next year: To continue the successes of the 2018/19 appraisal year and strengthen processes for managing appraisals and facilitating engagement.

3.2 An appropriately trained licensed medical practitioner is nominated or appointed as a

Responsible Officer.

(a) Action from last year: N/A

(b) Comments: Dr Lindsey Barker retired as Responsible Officer on 28th June 2019.

(c) Action for next year: Dr Janet Lippett was appointed as Responsible Officer on 1st July 2019.

3.3 The Designated Body provides sufficient funds, capacity and other resources for the Responsible Officer to carry out the responsibilities of the role.

(a) Action from last year: Appraisers were remunerated at 0.25PAs for 10 appraisals. Two appraisers were remunerated at 0.5 PAs for 20 appraisals. The Appraisal Lead oversees the appraisal process and the Revalidation Lead oversees the Revalidation process. The Revalidation and Appraisal Co-ordinator provides administrative support to the Responsible Officer and both the Appraisal and Revalidation Leads.

(b) Comment: N/A

(c) Action for next year: A new appraiser will undergo training and an additional appraiser undertakes 20 appraisals. The Responsible Officer has reviewed the number of appraisers within each specialty and will request additional appraisers to increase overall numbers and to boost the number of appraisers within the surgical specialties.

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

(a) Action from last year: Information continues to be provided from the Workforce Information Starters and Leavers list and updated on GMC Connect. Permanent and long term locum doctors are added to Allocate to complete their appraisal.

(b) Comments: N/A

(c) Action for next year: Developing and strengthening relationships with individual departments to ensure permanent and long term locum doctors are added and doctors leaving the Trust are removed in a timely manner. Ensure there is consistency within the Trust for Fellows and doctors on short term locum contracts by strengthening communication pathways within individual departments.

3.5 All policies in place to support medical revalidation are actively monitored and regularly reviewed:

(a) Action from last year: The Medical Appraisal Policy was reviewed in October 2018.

(b) Comments: The Medical Appraisal Policy will be reviewed and updated in line with Responsible Officer Regulations.

(c) Action for next year: To review the policy in line with Responsible Officer Regulations.

3.6 A peer review has been undertaken of this organisation’s appraisal and revalidation processes.

(a) Peer review undertaken? This has not been undertaken.

(b) Action from last year: N/A

(c) Comments: A peer review of processes will be considered.

(d) Action for next year: Currently in discussion with 3 other Trusts to take this forward later in 2019.

3.7 A process is in place to ensure locum or short-term placement doctors working in the organisation, including those with a prescribed connection to another organisation,

are supported in their continuing professional development, appraisal, revalidation, and governance.

(a) Action from last year: All doctors working within the Trust have access to the e-learning module for Statutory and Mandatory training. The Revalidation and Appraisal group proactively supports the appraisal and revalidation of all doctors with a prescribed connection to the Royal Berkshire NHS Foundation Trust.

(b) Comments: N/A

(c) Action for next year: The Revalidation and Appraisal Co-ordinator to work with HR and individual departments to strengthen processes for supporting locum or short-term placement doctors within the Trust.

4 Section 2: Effective Appraisal

4.1 All doctors in this organisation have an annual appraisal that covers a doctor’s whole practice, which takes account of all relevant information relating to the doctor’s fitness to practice (for their work carried out in the organisation and for work carried out for any other body in the appraisal period), including information about complaints, significant events and outlying clinical outcomes.

(a) Action from last year: All doctors are required to complete a declaration form countersigned by their Clinical Lead in which they have to declare any complaints, conduct or competence concerns or any concerns identified in clinical governance meetings, by PALS or through Friends and Family or any involvement in disputes involving medical, nursing or other colleagues. They must confirm that their mandatory training is up to date and if not, state what is outstanding and dates for completion. If the doctor works in any other organisation they are also required to complete an external practice form stating whether they have been involved in any disputes, conduct/capability investigations; significant events; complaints or referral to the GMC or NCAS. The transfer of information form is signed by the hospital manager or governance lead at the organisation.

Appraisals are completed on Allocate or the MAG form. Appraisees are responsible for ensuring that sufficient supporting information is provided to initiate an effective appraisal discussion. The Trust supports the doctor to collect the required supporting information though the PALs department. Corporate data is available for inclusion in the doctors e-appraisal or MAG form. The Revalidation and Appraisal Co-ordinator informs the appraisee of their mandatory training compliance status and any outstanding training together with details and dates for completing future training.

At the close of the appraisal period (31st March 2019), there were 419 doctors with a prescribed connection to the Trust. Within this group 382 had completed an annual appraisal, an overall compliance rate of 91.2% compared with the same sector rate of 89.3%. The number of doctors who had an unapproved, incomplete or missed appraisal is 15 (3.6%) against a same sector rate of 2.8%. An annual audit of all missed or incomplete appraisals is included in this report.

RBH Same Sector

All sectors

Number of doctors with whom the designated body has a prescribed connection on 31 March 2019 who had completed annual appraisal between 1 April 2018 – 31 March 2019

Total number of doctors who had a completed annual appraisal

382 (91.2%) 89.3% 91.5%

Consultants 266 (96.7%) 93.5% 93.7%

Staff grade, associate specialist, specialty doctor

60 (90.9%) 88.8% 88.2%

Temporary or short-term contract holders

55 (71.4%) 77.8% 81.8%

(b) Comments: The new Trust appraisal elements relating to Trust values are being incorporated into the current GMC based appraisal process.

(c) Action for next year: To include Trust based values into the medical appraisal process. The declaration form is being updated to include confirmation that the doctor is participating in Trust based values and the Clinical Lead confirms that the doctor is compliant.

4.2 Where in Question 1 this does not occur, there is full understanding of the reasons why and suitable action is taken.

(a) Action from last year: The Revalidation and Appraisal Co-ordinator ensures any late or missed appraisals have a reason recorded and an audit is included in this report. There has been a reduction in the number of unapproved, incomplete or missed appraisals from 5.5% in 2017/18 to 3.6% in 2018/19 however, additional measures have been put in place to reduce this number further.

(b) Comments: The process for ensuring there is further reduction in the number of unapproved, incomplete and missed appraisals has been strengthened.

(c) Action or next year: The Revalidation and Appraisal Co-ordinator will ensure the Responsible Officer is informed of any potential delay to the completion of appraisals at the monthly Revalidation and Appraisal meetings. To ensure there is a reduction in Measure 1b and an increase in Measure 1a.

4.3 There is a medical appraisal policy in place that is compliant with national policy and has received the Board’s approval (or by an equivalent governance or executive group).

(a) Action from last year: The Medical Appraisal Policy was reviewed and agreed by the Policy Approval Group in December 2018.

(b) Comments: The Medical Appraisal Policy was successfully approved and will be due for review in December 2020.

(c) Action for next year: To review the Medical Appraisal Policy in line with the Responsible Officer Regulations.

4.4 The designated body has the necessary number of trained appraisers to carry out timely annual medical appraisals for all its licensed medical practitioners.

(a) Action from last year: There were 31 active appraisers to appraise permanent and long term locum doctors using Allocate software with two appraisers carrying out 20 appraisals per year. One appraiser was trained with MIAD and one appraiser re-joined the appraiser pool. Temporary and short-term contract holders have their appraisal with

their clinical supervisor or another consultant within the department using the MAG form. The Revalidation and Appraisal Co-ordinator allocates doctors with a choice of 3 appraisers and the Appraisal Lead reviews the allocation to ensure a balanced workload across the appraisers which she reports to the Revalidation and Appraisal Group. Appraisers are remunerated at 0.25 PAs for 10 appraisals per annum and two appraisers receive 0.5 PAs for 20 appraisals, with an additional appraiser also undertaking 20 appraisals.

(b) Comments: The Trust is exploring options to boost the number of trained appraisers.

(c) Action for next year: One doctor is awaiting training. The Responsible Officer is reviewing the number of appraisers within each specialty and will encourage potential appraisers to apply in order to increase numbers both in general and specifically in the surgical specialties to increase the overall number and skill mix of appraisers.

4.5 Medical appraisers participate in on-going performance review and training /development activities, to include attendance at appraisal network/development events, peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers or equivalent).

(a) Action from last year: Appraisers are encouraged to participate in development opportunities such as the Oxford University Hospitals and NHS England’s Appraisers conference. Appraisers are supported during the year by the Appraisal Lead and receive an annual performance report containing a summary of their appraisees’ feedback and ASPAT scores of the appraisals they conducted so they can include this information in their own appraisal. An appraiser refresher training course, delivered by Miad Healthcare is provided at the Trust in November each year.

(b) Comments: The Trust provides a development and performance review of appraisers.

(c) Action for next year: To continue to provide the current processes.

4.6 The appraisal system in place for the doctors in your organisation is subject to a quality assurance process and the findings are reported to the Board or equivalent governance group.

(a) Action from last year: Appraisees are required to complete post appraisal feedback to provide a subjective review of the appraisal and supporting systems. Feedback is mandatory on Allocate and completion of the appraisal feedback questionnaire is necessary in order to finalise the appraisal outputs. The findings following the ASPAT review were reported to the Revalidation and Appraisal Group. Feedback information and the themes identified were shared with the Appraisers to support their development as Appraisers.

(b) Comments: There is an effective system of quality assurance

(c) Action for next year: To continue to provide an ASPAT review of appraisal summaries on a yearly basis. To review all feedback questionnaires and discuss any issues or themes at the monthly Revalidation and Appraisal meeting.

5 Section 3 – Recommendations to the GMC

5.1 Timely recommendations are made to the GMC about the fitness to practise of all doctors with a prescribed connection to the designated body, in accordance with the GMC requirements and responsible officer protocol.

(a) Action from last year: The Revalidation and Appraisal Co-ordinator provides a preliminary check of the annual appraisals and supporting information. The Revalidation Lead then reviews the doctors’ annual appraisals for the previous 5 years; colleague and patient feedback reports and any other supporting information. The RO receives the Revalidation Lead’s report and also reviews the appraisals and supporting information before making her recommendation. All recommendations were made prior

to or on the submission date.

(b) Comments: The Trust will continue to make timely recommendations to the GMC.

(c) Action for next year: The above process has been strengthened to notify doctors at an earlier stage of any outstanding information required for revalidation. Recommendations will be make at least 4 weeks before the revalidation date.

5.2 Revalidation recommendations made to the GMC are confirmed promptly to the doctor and the reasons for the recommendations, particularly if the recommendation is one of deferral or non-engagement, are discussed with the doctor before the recommendation is submitted.

(a) Action from last year: The Revalidation and Appraisal Co-ordinator promptly informs the doctor on the behalf of the RO of the decision reached and submitted to the GMC.

(b) Comments: In the case of a deferral, the Revalidation and Appraisal Co-ordinator informs the doctor before the recommendation is submitted and the doctor is made aware in advance of the reasons for deferral.

(c) Action for next year: The Revalidation Lead contacts the doctor stating the reasons for the decision and any remedial actions are also communicated. The importance of engagement is reinforced and the required information to facilitate a positive recommendation at the amended due date is clearly stated. The doctor is made aware of the consequences of disengagement.

6 Section 4 – Medical Governance

6.1 This organisation creates an environment which delivers effective clinical governance for doctors.

(a) Action from last year: The Trust has clear systems for reporting and reviewing significant events and complaints. The appraisal form provides doctors with an opportunity to reflect on any complaints and develop insight and learning for future practice. All specialties have regular governance meetings. The RO is informed about any significant concerns about a doctor and will make a decision whether to make a referral to the GMC.

(b) Comments: The Trust has a satisfactory system to deliver effective governance for doctors

(c) Action for next year: To continue the current system.

6.2 Effective systems are in place for monitoring the conduct and performance of all doctors working in our organisation and all relevant information is provided for doctors to include at their appraisal.

(a) Action from last year: All Consultant and SAS doctors are managed through regular supervision. A doctor’s conduct and performance is monitored under the management of the RO assisted by the three Care Group Directors. The AMD for Professional Standards is responsible for the development of the fitness to practice process and the alignment of behaviour with the values for the Trust. Relevant information on complaints, SI’s and other corporate data is available for doctors to include in their e-appraisal or MAG form.at their appraisal.

(b) Comments: There is a good system for monitoring the conduct and performance of doctors in the Trust.

(c) Action for next year: To explore options to provide all information regarding concerns in one place.

6.3 There is a process established for responding to concerns about any licensed medical

practitioner’s fitness to practise, which is supported by an approved responding to concerns policy that includes arrangements for investigation and intervention for capability, conduct, health and fitness to practise concerns.

(a) Action from last year: All disciplinary issues are dealt with fairly and consistently and the Trust provides a consistent procedure for addressing concerns about the conduct and capability and health and fitness to practice of medical staff. The Revalidation and Appraisal group consisting of the RO, Revalidation Lead, Appraisal Lead, AMD for Professional Standards, Revalidation and Appraisal Co-ordinator and Head of Medical Workforce meet monthly as part of this process. The Maintaining High Professional Standards Policy (MHPS) provides guidance on managing concerns locally. Processes are followed in line with the MHPS policy.

(b) Comments: The MHPS policy has also been updated and approved by the PAG in 2019. The Trust has a good system for responding to fitness to practice concerns.

(c) Action for next year: To continue the above process.

6.4 The system for responding to concerns about a doctor in our organisation is subject to a quality assurance process and the findings are reported to the Board or equivalent governance group. Analysis includes numbers, type and outcome of concerns, as well as aspects such as consideration of protected characteristics of the doctors.

(a) Action from last year: The RO and AMD for Professional Standards have quarterly meetings with the GMC Employer Liaison Advisor. They are also supported by the PPAS team and processes for investigating doctors where concerns have been raised.

(b) Comments: The Revalidation and Appraisal Co-ordinator will also support the RO at future GMC Employer Liaison meetings.

(c) Action for next year: An audit of concerns about a doctor in the Trust will be completed and reported to the Revalidation and Appraisal group and the Board or equivalent governance group.

6.5 There is a process for transferring information and concerns quickly and effectively between the responsible officer in our organisation and other responsible officers (or persons with appropriate governance responsibility about a) doctors connected to your organisation and who also work in other places, and b) doctors connected elsewhere but who also work in our organisation.

(a) Action from last year: The RO responds swiftly to requests for RO-RO information sharing. Doctors who work in other places are expected to complete an external practice form from other organisations as part of their supporting information for appraisal. There is a process in place for obtaining and sharing information, using the MPIT transfer of information form for doctors who join the Trust.

(b) Comments: N/A

(c) Action for next year: To strengthen the current system to ensure a swift response to information sharing for doctors who join the Trust.

6.6 Safeguards are in place to ensure clinical governance arrangements for doctors including processes for responding to concerns about a doctor’s practice are fair and free from bias and discrimination (Ref GMC governance handbook).

(a) Action from last year: The RO has quarterly meetings with the GMC ELA to ensure that any referral to the GMC has reached the correct threshold. If patients contact the GMC directly, the GMC may refer them back for local investigation if the concern does not reach the GMC threshold. The GMC shares information when doctors rotate into the Trust and have undertakings from previous investigations and doctors currently under investigation who may have worked for the Trust previously.

(b) Comments: N/A

(c) Action for next year: To continue. For consideration of training for senior doctors in how to raise concerns and be involved in investigations.

7 Section 5 – Employment Checks

7.1 A system is in place to ensure the appropriate pre-employment background checks are undertaken to confirm all doctors, including locum and short-term doctors, have qualifications and are suitably skilled and knowledgeable to undertake their professional duties.

(a) Action from last year: The HR department performs pre-employment checks to confirm all doctors including locum and short-term doctors, have the qualifications and skills to undertake their professional duties. The doctor completes a revalidation and appraisal form as part of their pre-employment checks.

(b) Comments: There is a good system in place to ensure pre-employment checks are undertaken.

(c) Action for next year: The Revalidation and Appraisal Co-ordinator will work with HR to strengthen the process for providing the doctors’ appraisal and revalidation history prior to employment.

8 Section 6 – Summary of comments, and overall conclusion

8.1 General review of last year’s actions

(a) There will be a focus on improving quality assurance of appraisal, appraisers and engagement during 2018/19:

The Appraisal Lead and Revalidation and Appraisal Coordinator have reviewed individual appraiser performance using NHS England’s Appraisal Summary and PDP Audit Tool (ASPAT). The Appraisal Lead presented the results to the Revalidation and Appraisal group and provided an overview of findings to appraisers. Appraisers were advised to use the ASPAT tool to ensure there is consistency in the completion of appraisal summaries. Each appraiser was also provided with an individual report summarising feedback from appraisees. The Revalidation and Appraisal Co-ordinator raises any concerns regarding lack of engagement with the Appraisal Lead and this is discussed at their bi-monthly meetings.

(b) Appraisal figures are low for doctors on short term contracts and Fellows.

Clinical Fellows and short term locum doctors are provided with the MAG form to complete their appraisal. A training video is available to assist their appraisers with the form. The process is supported by access to Allocate for the completion of multi-source feedback.

(c) There will be greater emphasis on exploring Allocate functionality and the RO dashboard to maximise the potential of the system in relation to quality assurance and the reporting modules:

The Appraisal Lead is exploring the system and the reporting modules. Clinical Fellows and short term locums now have access to Allocate for the completion of multi-source feedback as required.

(d) The new Trust appraisal elements relating to Trust values will need to be incorporated into the current GMC based appraisal process.

The Trust values are being embedded into the appraisal process for doctors.

The declaration form has been updated with a clause to confirm the doctor is participating in Trust based values. This is countersigned by their Clinical Lead/Clinical Director.

8.2 Actions still outstanding

Development of the consultant code of conduct has been initiated, in line with the Trust behavioural framework, with the focus on a Professional Standards framework to support doctors.

The AMD for Professional Standards continues to take this initiative forward.

8.3 Current issues

(a) Recommendations to the GMC – Revalidation recommendations made to the GMC will be brought forward to at least 4 weeks before the submission due date. The increased number of deferrals is being addressed to ensure there is full engagement with the process. The Revalidation Lead communicates directly with the doctor to reinforce the importance of engagement and to agree the timescale for completing any remedial actions.

(b) Pre-employment Checks - The appraisal history and revalidation information process needs to be strengthened to ensure required information is available for all doctors at an earlier stage as part of their pre-employment checks.

(c) Feedback for appraisers - There is a gap in feedback obtained by appraisees using the MAG form which does not include an automated anonymous feedback tool similar to the feedback form which is mandatory on Allocate. This means there is a gap in feedback for appraisers to reflect on for appraisals completed using the MAG form.

8.4 New Actions:

To strengthen the process for making revalidation recommendations to the GMC and to reduce the number of recommendations for deferral.

To strengthen links with the HR department to ensure appraisal history and revalidation, designated body and responsible officer information is provided consistently for all doctors at the pre-employment stage.

To develop a process for ensuring feedback from doctors using the MAG form is collated to monitor the quality of medical appraisals and ensure appraisers are provided with additional feedback for reflection as part of the appraisal process.

To increase the number of appraisers particularly in less represented specialities.

8.5 Overall conclusion:

There has been significant progress in the appraisal system at the Trust during 2018/19. There has been improved quality assurance of appraisals and appraiser performance. Links with the HR Department will be strengthened to facilitate consistent and robust recruitment processes.

Appendix 1 – Audit of all missed or incomplete appraisals

Doctor factors (total) 31

Maternity leave during the majority of the ‘appraisal due window’ 8

Sickness absence during the majority of the ‘appraisal due window’ 1

Prolonged leave during the majority of the ‘appraisal due window’ 1

Suspension during the majority of the ‘appraisal due window’ 0

New starter within 3 month of appraisal due date 9

New starter more than 3 months from appraisal due date 3

Postponed due to incomplete portfolio/insufficient supporting information 0

Appraisal outputs not signed off by doctor within 28 days 0

Lack of time of doctor 1

Lack of engagement of doctor 3

Other doctor factors (describe) 5

First appraisal in UK, bereavement

Appraiser factors (total) 1

Unplanned absence of appraiser 0

Appraisal outputs not signed off by appraiser within 28 days 0

Lack of time of appraiser 1

Other appraiser factors (describe) 0

Organisational factors (total) 5

Administration or management factors 2

Failure of electronic information systems 2

Insufficient numbers of trained appraisers 0

Other organisational factors (describe) – doctor had completed appraisal 1

9 Section 7 – Statement of Compliance: The Board of The Royal Berkshire NHS Foundation Trust has reviewed the content of this report and can confirm the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013).

Signed on behalf of the designated body

Chief Executive

The Royal Berkshire NHS Foundation Trust

Name: Steve McManus _ _ _ _ _ _ _ _ _ _ _ Signed: _ _ _ _ _ _ _ _ _ _

Role: Chief Executive

Date: _ _ _ _ _ _ _ _ _ _

Agenda Item 8.1

Finance and Investment Committee Monday 22 July 2019 10.10 – 13.10 Boardroom, Level 4, Royal Berkshire Hospital Members Mrs. Sue Hunt (Non-Executive Director) (Chair) Mrs. Nicky Lloyd (Chief Finance Officer) Mr. Steve McManus (Chief Executive) Mr. John Petitt (Non-Executive Director) Mr. Graham Sims (Chair of the Trust) Ms. Mary Sherry (Chief Operating Officer) In Attendance Mr. Raghuv Bhasin (Deputy Director, ICS Delivery) (for minute 107/19) Mr. Mike Clements (Deputy Director of Finance, Central Finance) Mr. Richard Jenkins (Deputy Director of Finance, Contracts) Mrs. Caroline Lynch (Trust Secretary) Ms. Clara Purnell (Head of Procurement & Logistics) (from minute104/19 to 108/19) Mrs. Tracey Middleton (Director of Estates & Facilities) (from minute 109/19) Mr. Mike Robinson (Associate Director of Infrastructure from minute106/19 to 108/19) Mr. Andrew Statham (Director of Strategy) (for minute 107/19) Apologies Mr. Brian Hendon (Non-Executive Director) 100/19 Declarations of Interest There were no declarations of interest. 101/19 Minutes: 17 June 2019 & Matters Arising Schedule

The minutes of the meeting held on 17 June 2019 were approved as a correct record and signed by the Chair subject to some minor typographic amendments. The Committee received the matters arising schedule. Minute 86/19 (68/19, 57/19): Minute 20 May 2019 & Matters Arising Schedule: Budget and Control Total 2019/20: The Chief Finance Officer advised that ICS transformation monies had not yet been received. However, it was anticipated that there would be no issue as the Trust had met the requirements requested by NHS Improvement (NHSI) including the establishment of the Restructuring Oversight Committee. Minute 89/19: Acute Contract Update: It was agreed that specific details in relation to East Berkshire CCG QiPPs would be circulated to the Committee. Action: R Jenkins Minute 97/19: CQC Use of Resources: The Committee noted that further information requested as part of the CQC Use of Resources inspection had been submitted. A further query had been received in relation to reference costs and a response was being prepared.

Minutes

1

Finance & Investment Committee July 2019

102/19 June Finance Update The Chief Finance Officer introduced the report and advised that finance performance

against year to date budget was on target. Income, pay and non-pay were also broadly on target. Provider Sustainability Funds (PSF) had also been recognised in the month.

The Committee noted that a credit controller was being appointed to specifically manage

overseas debt. Actual and committed capital spend was over plan. Patient income was favourable to plan and there had been an increase in both elective and non-elective income. Education and Research & Development income were behind plan. Work was on-going to review these areas. Medical staff pay was under budget year to date. The Chief Finance Officer highlighted that the QiPP gap was currently £5.5m. The Committee noted that when the budget for 2019/20 was set the risk was highlighted when the Board approved the budget.

The Chief Finance Officer highlighted Intensive Care Unit (ICU) spend and advised that this

had been constantly above budget. The Committee noted the difference in costs in relation to Level 1 and Level 2 patients. The Chief Executive advised that this would be discussed with commissioners in September 2019 in relation to plans for 2020/21.

The Committee discussed patient activity by speciality, in particular, orthopaedics and

ophthalmology. The Chief Finance Officer advised that costs and income variances were now being included in the monthly finance report.

The Committee noted that drug costs were on plan year to date. However, drug costs were

being reviewed as there had been an 8% increase year on year. A further update would be submitted to the next meeting. Action: N Lloyd

The Committee noted that corporate areas were ahead of plan whilst Care Groups were

behind plan. The Chief Finance Officer advised that Care Groups would be provided with finance reports for their monthly performance meetings that would enable them to review performance at Care Group as well as Trust level. The Committee noted that patient income was not represented in Care Group finance reports but was included in corporate areas. The Chief Finance Officer would review this, as well as other areas of income and how much this could impact on the forecast. Action: N Lloyd

The Committee discussed additional sessions, in particular, the figures for 2019/20 in

comparison to 2018/19, and the increase during the month of August. It was agreed that the Chief Operating Officer would review this with the Medical Director. Action: M Sherry

The Chief Finance Officer confirmed that financial reporting for 2019/20 would be

performance against budget rather than forecast. The Committee discussed budget setting and noted that vacancy factors were not included when budgets were set. The Deputy Director of Finance, Central Finance, advised that vacancies and staffing establishments were being reviewed with the workforce team and an update would be provided at the next meeting. Action: N Lloyd

103/19 Quarterly Budget Forecast The Deputy Director of Finance, Central Finance, introduced the report and advised that

Care Groups and corporate departments had reviewed their positions and projected outturn based on existing run rate and existing actions. In relation to Care Groups, this included a most likely view as well as a best case and worst case scenario. The most likely assessment was £5.25m off control total. The Deputy Director of Finance, Central Finance, advised that the Trust was still working to achieve the control total. Therefore, a re-forecast was not planned.

2


The Committee noted that research and development income was included in the current

most likely assessment. It was agreed that the actions to close the gap from the control total would be included in future reports. Action: N Lloyd

104/19 QiPPs Update The Committee noted that as at 10 July 2019, £2.9m of savings had been delivered year to

date against a budgeted cost saving of £3.1m. The Chief Operating Officer advised that the patient flow programme had been impacted by the increase in demand. It was agreed that the Chief Operating Officer would review reporting on QiPPs as an extension to the finance report and would include a focus on programmes that were under-delivering.

Action: M Sherry 105/19 Acute Contract Update The Deputy Director of Finance, Contracts, introduced the report and advised that

Oxfordshire Clinical Commissioning Group (CCG) were proposed an indicative activity plan contract value [Section exempt under s43].

Confirmation from Oxfordshire CCG was awaited that they would pay in line with the level of actual activity undertaken. The Committee agreed that a recommendation should be submitted to the Board to approve the contract subject to receipt of this confirmation. Otherwise, a further update would be provided at the next meeting. Action: N Lloyd

The Committee noted that the following contracts required approval:-

• Buckingham CCG at [Section exempt under s43]. • North Hampshire CCG at [Section exempt under s43]. • North West Surrey CCG at [Section exempt under s43]. • North East Hampshire CCG at [Section exempt under s43].

It was agreed that a recommendation should be submitted to Board to approve these contracts. Action: N Lloyd

The Deputy Director of Finance, Contracts, gave an update in relation to the on-going

discussions in relation to the NHS England (NHSE Specialist Commissioning contract for 2018/19 and 2019/20. The Committee noted that the Public Health and Secondary Dental elements of the 2019/20 contract would be submitted to the next meeting. Action: N Lloyd

The Deputy Director of Finance, Contracts, advised that the East Berkshire CCG contract

with the Trust was currently [Section exempt under s43] under budget based on Month 2. The Committee noted that there was an elevated level of activity Berkshire West CCG patients as well the proportion of the Trust’s total activity related to Berkshire West CCG patients was also increasing significantly. This was being discussed by Integrated Care System (ICS) finance directors on a weekly basis.

106/19 Procurement Strategy The Committee noted that the Trust’s procurement function had achieved Level 1

accreditation from NHS Improvement (NHSI). The Head of Procurement & Logistics advised that arrangements had already been made for the department to be reviewed for the Level 2 accreditation. The Committee noted that the procurement strategy had been developed with key themes of future operating model, transformation, innovation, financial sustainability and people. The strategy was linked with Vision 2025 and the Trust’s CARE values. The Head of Procurement & Logistics advised that NHSI had reviewed the strategy and further iterations would be made over the next three months. The procurement team would also be able to support other work streams, eg commercial and transformation.

3


The Committee recommended that the strategy should be aligned to the Vision 2025 strategic objectives as well as further narrative being included in relation to corporate social responsibility and how this linked with the travel and transport plan. Action: N Lloyd

The Committee agreed that a recommendation should be submitted to the Board to

approve the procurement strategy. Action: N Lloyd 107/19 Commercial Strategy The Deputy Director, ICS Delivery introduced the report and advised that the strategy had

been updated to include recommendations from the Executive Management Committee. The strategy had been developed on four areas of focus; growing non-NHS income from delivery of clinical services, growing non-NHS income from delivery of other services, maximising opportunities from estates and infrastructure and creating the conditions to support the development and growth of commercial activities. The Committee noted that a commercial lead had been appointed. The Deputy Director, ICS Delivery, advised that the Commercial Steering Group would provide a forum for ideas to be raised. The Chief Executive highlighted the need to ensure future central provisions were developed to support commercial work.

The Deputy Director, ICS Delivery, advised that the final Commercial Strategy would be

submitted to the Board in August 2019 and launched at the Senior Leaders’ Forum in September 2019.

The Committee recommended that the Commercial Strategy should include an ambition

statement, in line with other enabling strategies. The Committee agreed that, subject to this, a recommendation should be submitted to the Board to approve the strategy.

Action: A Statham 108/19 IT Infrastructure Services Management Contract The Committee noted the report that sought approval to extend the current contract with

Ultima for infrastructure services [Section exempt under s43]. 109/19 NHSE Capital Request The Director of Estates & Facilities advised that the Trust had received a request from

NHSE Chief Finance Officer regarding a capital reduction. The Trust was required to work with Berkshire, Oxfordshire and Buckinghamshire Sustainability Transformation Plan (BOB STP) to prioritise and reduce capital expenditure to a level consistent with that set by the Department of Health & Social Care.

[Section exempt under s43]. The Chief Finance Officer advised that the Trust was unable to

propose any further reduction. The Committee supported this position. It was agreed that a recommendation would be submitted to the Board to endorse this approach. Action: N Lloyd

110/19 Estates Development Programme Board The Committee received the minutes of the meetings held on 12 February and 10 June

2019. The Chief Executive advised that estate master planning was the current focus. The Director of Estates & Facilities advised that the tendering process was currently on-going. The process had been extended in order to ensure good representation from bidders. Dependent upon value, the contract would be submitted to the Committee for approval during August 2019. Action: T Middleton

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111/19 Pathology – BSPS Board Decision The Chief Finance Officer introduced the report and advised that, as a member of the

Berkshire Surrey Pathology Services (BSPS), the Trust Board was required to approve the award of a managed service contract [Section exempt under s43].

[Section exempt under s43].

The Chief Finance Officer confirmed that appropriate procurement process and governance had been undertaken. The Committee agreed that a recommendation should be submitted to the Board to approve the contract. Action: N Lloyd

112/19 Work Plan Review It was agreed that the Trust Secretary would review the work plan with the Chief Finance

Officer to ensure that business cases, including the MRI for West Berkshire Community Hospital, were scheduled. Action: C Lynch

113/19 Key Messages for the Board

Key issues to draw to the attention of the Board included:- • June finance performance received • Quarter 1 forecast reviewed

Recommendations to be submitted to the Board to approve the following:

• Acute contract update • Contract extension for IT Infrastructure Services Management • Procurement Strategy • NHSE Capital Request • Pathology - BSPS Board Decisions

114/19 Date of Next Meeting

It was agreed that the next meeting would be held on Monday 19 August 2019 at 10.00am. SIGNED: DATE:

5

Agenda Item 8.1

Finance and Investment Committee Friday 23 August 2019 12.05 – 14.35 Boardroom, Level 4, Royal Berkshire Hospital Members Mrs. Sue Hunt (Non-Executive Director) (Chair) Ms. Caroline Ainslie (Director of Nursing) Mr. Brian Hendon (Non-Executive Director) Mrs. Nicky Lloyd (Chief Finance Officer) Mr. John Petitt (Non-Executive Director) Mr. Graham Sims (Chair of the Trust) Ms. Mary Sherry (Chief Operating Officer) In Attendance Mr. Mike Clements (Deputy Director of Finance, Central Finance) Mrs. Caroline Lynch (Trust Secretary) Mr. Andrew Statham (Director of Strategy) (for minute 121/19) Apologies Mr. Steve McManus (Chief Executive) 115/19 Declarations of Interest There were no declarations of interest. 116/19 Minutes: 22 July 2019 & Matters Arising Schedule

The minutes of the meeting held on 22 July 2019 were approved as a correct record and signed by the Chair. The Committee received the matters arising schedule. Minute 102/19: June Finance Update: The Committee noted that the new Care Group report format was in line with the budgets, in that patient income was not attributed to Care Groups but, held centrally. Discussions within the Finance and Care Group Leadership teams were on-going in relation to the possibility of aligning income to costs and activity. The Deputy Director of Finance confirmed that Whole-time Equivalents (WTEs) in the staffing budgets were now aligned in the Finance and QiPP reports. Minute 108/19: IT Infrastructure Services Management Contract: [Section exempt under s43]. Going forward, all contracts were being collated onto the database held centrally by the Procurement team and thus timely renewals etc. would be managed by the Procurement team and those subject to VEAT notice would be undertaken in a timely manner.

Minute 110/19: Estates Development Programme Board: The Chief Finance Officer advised that the tender for master planning would be awarded the following week. Three bids from consortia led by well-known expert firms had been received. The likely contract

Minutes

1

Finance & Investment Committee August 2019

award value for the master planning tender would not require approval by the Committee. Minute 111/19: Pathology – BSPS Board Decision: The Chief Finance Officer confirmed that feedback on providing advanced notice of the BSPS tender processes, to ensure that all parties were aware in advance of likely bidding activity and hence likely sums of related contracts, would be raised at the next BSPS Board meeting. Action: N Lloyd The Chief Finance Officer gave an update on discussions with NHS Improvement (NHSI) to the Use of Resources inspection. The Committee noted that a report considering the Model Hospital data would be submitted to the next meeting. Action: N Lloyd The Chief Finance Officer confirmed that the value of the replacement camera stacking systems, as discussed and approved at the May meeting (Minute 76/19), did not include VAT. The replacement of the 18 stacking systems was a capital cost of £935k plus VAT and the VAT inclusive purchase cost had been earlier approved as part of the 2019/20 capital budget approval. There was also an associated ten year maintenance contract with a total value of £626k.

117/19 July Finance Update The Deputy Director of Finance, Central Finance, introduced the report and advised that

finance performance was currently £1.46m behind the year to date control total plan. Income was ahead of plan and pay was over budget. Non-pay was also over budget and drug income and costs were being reviewed. The Committee noted that Provider Sustainability Funds (PSF) monies continued to be recognised in the year to date position but the assumption to accrue PSF monies would need to be re-assessed at Month 5. The Committee discussed the increase in medical staff pay in the month. The Deputy Director of Finance advised that this related to the confirmation of the amount of the national pay award for medical staff. It was agreed that Director of Workforce and the Medical Director would be asked to confirm the governance arrangements of approval in relation to this pay award. Action: C Lynch

The Committee noted and expressed concern that the current QiPP gap was £4.9m. The

Chief Finance Officer advised that cash and income variances were being reviewed and demand and capacity work was on-going. There had been good operational engagement at directorate level in relation to the demand and capacity tool. The Chief Operating Officer suggested that this should be reviewed with the Executive. The Committee discussed the need for a timeframe for this work to be completed. The Chief Finance Officer would provide an update on the progress of the demand and capacity project at the next meeting. Action: N Lloyd

The Chief Finance Officer advised that drug income and expenditure were being reviewed

and work to analyse the underlying drivers of the variances was on-going with the pharmacy team, supported by colleagues from the income and contracts teams. [Section exempt under s43]. The Chief Operating Officer requested that the information from the review should be shared with the operations and clinical teams and the Chief Finance Officer confirmed that Operational teams (Pharmacy) were investigating the variances and the outcome of this work would be reported by them to Care Group leadership. Action: N Lloyd

The Committee recommended that an update should be provided at the next meeting. This

would include the actions to be taken to bring spending back in line with the budget and, in particular, information related to the high cost drugs. Action: N Lloyd

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118/19 QiPPs Update The Committee noted that as at 13 August 2019, £4.1m of savings had been delivered year

to date against a budgeted cost saving of £4.7m year to date. The Chair requested that the Finance Report should be updated to identify the value of

unidentified QiPP in relation to the gap to the control total. Action: M Clements The Committee discussed the need to identify significant transformation schemes in order

to achieve the control total as well as related actions that needed to be taken. The Committee were not assured that the QiPP gap could be delivered and therefore, recognised the risk that the year-end control total may not be met. The Chief Operating Officer advised that leads were engaged with KPMG in relation to an analysis and review of existing and potential schemes. However, there remained a challenge in relation to suggested targets for savings as some actions had already been undertaken and therefore could not be counted again. The Committee recommended that the Executive team should ensure that Project Initiation Documents (PIDs) for the workforce schemes were completed to the agreed deadlines. The PIDs would then be available for review at the next meeting to enable discussions as to next actions required Action: M Sherry

119/19 Medical Staff Additional Sessions The Chief Operating Officer introduced the report that set out proposed changes to the

approval process for additional medical sessions and highlighted that further operational input was required. The Committee noted that the new electronic approval process would be aligned with the demand and capacity work currently being undertaken and would also enable forward booking to be included in the forecasting process. The Committee requested that an update be provided at the next meeting to confirm when the process had been approved by the Executive Management Committee. Action: M Sherry/N Lloyd

120/19 Acute Contract Update The Chief Finance Officer introduced the report and advised that approval was sought to

sign the 2019/20 Public Health and Secondary Dental elements of the NHSE Specialised Commissioning contract. [Section exempt under s43].

The Committee agreed that a recommendation should be submitted to the Board to approve the Public Health and Secondary Dental elements of the NHSE Specialised Commissioning contract. Action: N Lloyd

121/19 MSK Update The Director of Strategy introduced the report and advised that Berkshire West Clinical

Commissioning Group (BW CCG) had confirmed their preferred route to procure the new activities identified in the MSK pathway. [Section exempt under s43]. In addition, an MSK Director would be appointed. A full recruitment process would be undertaken. The MSK Director would report to the Trust’s Chief Operating Officer. Additional physiotherapy capacity would be needed [Section exempt under s43]. The Committee discussed the work programme and accountabilities for the MSK Director. The Director of Strategy confirmed that the MSK Director would link directly with the triage service to ensure appropriate referrals were received.

The Director of Strategy confirmed that work was on-going with the Primary Care Networks

(PCNs) in relation to choice of referral that would include an NHS choice.

3


122/19 Renal: Home Haemodialysis Service The Chief Finance Officer introduced the report that sought approval to award a 3+2 year

contract (£489k + £326k) to Nx Stage at a cost of £815k excluding VAT over 5 years. The Contract was effective from 1 August 2019.

The Committee discussed the benefit of this service to patients and noted that patients

would be cared for by Trust clinical staff. The Committee agreed that a recommendation should be submitted to the Board to approve the contract. Action: N Lloyd

123/19 Mobile CT Scanner – Contract Extension The Chief Finance Officer introduced the report that sought approval to extend the current

[Section exempt under s43]. The Chief Finance Officer confirmed that the contract included a 3 month notice period. The Committee agreed that a recommendation should be submitted to the Board to approve the contract extension. Action: N Lloyd

The Committee recommended that future reports did not require the full details of the

contract terms and conditions to be submitted to the Committee. Action: N Lloyd 124/19 Wheelchair Maintenance Contract The Chief Finance Officer introduced the report [Section exempt under s43] for the

provision of wheelchair maintenance and repair services to the Trust. The Chief Finance Officer confirmed that the contract included a 3 month notice period. The Committee agreed that a recommendation should be submitted to the Board to approve the contract extension. Action: N Lloyd

125/19 Business Case Process The Chief Finance Officer introduced the report and advised that Post Project Evaluations

(PPEs) were now included in the proposed business case process. The Chief Finance Officer advised that the revised business case process had been reviewed by the Executive Management Committee on 12th August 2019, with a period for further feedback to be received by 23rd August and it was proposed that the new process would be launched in September 2019. The Committee supported the process.

The Committee discussed the current governance process for business cases requiring

both review by the Committee and then approval by the Board. The Trust Secretary advised that the Board could delegate authority to the Committee. However, this would need to be aligned with the Standing Financial Instructions (SFIs) and formally approved by the Board. It was agreed that the Chief Finance Officer and Trust Secretary would discuss and a proposal would be developed for consideration by the Board.

Action: N Lloyd/C Lynch 126/19 EU Exit [Section exempt under s43]. 127/19 Work Plan Review The Trust Secretary advised that the work plan would be updated for the next meeting. Action: C Lynch

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Key issues to draw to the attention of the Board included:- • The Committee was not assured in relation to closure of the QiPP gap in order

to meet the control total. Urgent actions were required by the Executive team to develop PIDs for the workforce work streams and these would be reviewed at the next meeting.

Recommendations to be submitted to the Board to approve the following: • Public Health and Secondary Dental elements of the NHSE Specialised

Commissioning contract • Renal: Home Dialysis Service Contract • Mobile CT Scanner – Contract Extension • Wheelchair Maintenance Contract

129/19 Date of Next Meeting

It was agreed that the next meeting would be held on Friday 20 September 2019 at 12pm.

The Committee also recommended that meetings for 2020 should be scheduled for morning of the third Thursday of each month to ensure full financial data was available for review. Action: C Lynch

SIGNED: DATE:

5

Agenda Item 8.3

Workforce Committee Wednesday 10 July 2019 13.00 – 15.00 Boardroom, Level 4, Royal Berkshire Hospital Members Mr. Julian Dixon (Non-Executive Director) (Chair) Ms. Caroline Ainslie (Director of Nursing) Mr. Don Fairley (Director of Workforce) Mrs. Sue Hunt (Non-Executive Director) Dr. Janet Lippett (Medical Director) Mr. Steve McManus (Chief Executive Officer) Mr. Graham Sims (Chair of the Trust) In Attendance Mrs. Suzanne Emerson-Dam (Deputy Director of Workforce) (up to minute 43/19) Mrs. Caroline Lynch (Trust Secretary) Mr. Peter Sandham (Employee Engagement & Organisational Development Manager) Mr. Keegan Timmermans (Corporate Governance Officer) Apologies Ms. Mary Sherry (Chief Operating Officer) 37/19 Declarations of Interest

There were no declarations of interest. 38/19 Minutes: 15 April 2019 and Matters Arising Schedule

The minutes of the meeting held on 15 April 2019 were approved as a correct record and signed by the Chair. Minute 28/19: Staff Health & Wellbeing Newsletter and Update: The Director of Workforce informed the committee that he would confirm who the Board Health & Wellbeing Lead would be with the Chief Executive. An update on the Health & Wellbeing strategy would be discussed at a future Executive Management Committee. The Committee recommended that the ‘treating people with respect’ visual would be circulated to the Board. Action: D Fairley

Minutes 29 October 2018 and Matters Arising Schedule: 20/19 (02/19): Workforce Key Performance Indicators (KPIs): The Director of Workforce advised that a meeting had been arranged with the Chief Finance Officer to review budgeted staffing establishments and ensure these were captured on the Electronic staff Record within the week. Action: N Lloyd/ D Fairley Minute 21/19: Director of Workforce Update: The Director of Workforce advised that medical staff pensions would be discussed at a future Nominations & Remuneration Committee.

Minutes

Workforce Committee 10 July 2019

Minute 28/19: Staff Health & Wellbeing Newsletter and Update: The Employee Engagement & Organisational Development Manager advised that in relation to Health & Wellbeing Champions the number had been set following a national initiative. Work was being progressed to map out champions for different initiatives and combine roles where possible. Action: D Fairley

39/19 Director of Workforce Update (Including Interim People Plan)

The Director of Workforce introduced the report and gave an overview of the National Interim People Plan. The Committee noted that, the interim plan had identified five key themes. Eight priority work groups had been established that would inform the final People Plan.

The Interim People plan had been reviewed against the Trust’s People Strategy in order to identify any potential gaps between the national priorities and the Trust’s strategic direction. The Director of Workforce highlighted that the Trust people strategy was closely aligned with the Interim People Plan. The Employee Engagement & Organisational Development Manager advised that the Interim People Plan would enable decision making at an Integrated Care System level. The Committee received feedback on the people strategy that had been presented at the Berkshire West, Oxfordshire and Buckinghamshire Sustainability and Transformation Partnership (BOB STP). The Director of Workforce highlighted that the strategy had been well received. Further work would be required on the content prior to socialising to the wider community. The Director of Workforce highlighted that a number of priorities identified for the BOB STP during 2019/20. These included, talent Management, Equality Diversity and Leadership, Tackling Bullying and Harassment, Workforce Planning and STP Branding for Recruitment.

The Committee noted that a new cohort were due to start the Henley Business School Chartered Degree shortly. In addition, the first cohort that had participated in the Diploma in Management (ILM3) were due to graduate during Summer 2019. Cohort two had started in May 2019 and 19 staff members were currently undertaking this programme.

40/19 Workforce Key Performance Indicators The Director of Workforce introduced the report and highlighted mandatory and statutory training

(MAST) compliance had continued to increase. The Trust had achieved 89.13% at the end of Quarter 4. The Committee noted that appraisal rate compliance had also increased to 88%.

The Committee discussed the current target of 90% for appraisal rates and recommended that

this should be reviewed as all staff should complete an appraisal. The Committee recommended that the target should be increased to 100% compliance going forward. Action: D Fairley

The Director of Workforce highlighted that the Trust vacancy rate had increased to 10.60%. However, 78 appointments had been made for band 5 nursing staff following successful overseas recruitment initiatives. The Committee discussed turnover at the Trust. The Employee Engagement & Organisational Development Manager advised that the main reason for staff turnover included career development, relocation and flexible working.


41/19 Shared Bank Key Performance Indicators The Deputy Director of Workforce introduced the report and highlighted that a review had been

undertaken focussing on the increase in unfilled shifts, agency supply and NHS Professionals service delivery. [Section exempt under s43].

The Deputy Director of Workforce highlighted that trends in relation to unfilled agency shifts

included inflated rates of neighbouring Trusts’, competition from neighbouring Trusts’ and the introduction of the Electronic Patient Record (EPR) system.

The Committee recommended that an update on agency fill and the service delivery of NHSP be

provided at the next meeting. Action: S Emerson-Dam 42/19 Retention and Recruitment Update The Director of Workforce introduced the report and advised that the Trust was performing well in

relation to nurse recruitment. The report highlighted the success of the recent recruitment scheme undertaken in Dubai in July

2019. The Trust had successfully interviewed 50 candidates and made 32 offers.

The Committee noted that the Trust was currently supporting cohort 4 of the NHS Improvement (NHSI) Retention Direct Support Programme. NHSI had fedback that the Trust was performing well in relation to staff retention against the national standard. Feedback had also highlighted the positive work undertaken at the Trust in relation to career development, staff retention framework and the preceptorship programme. The Committee recommended that a further update on cohort 4 of the NHSI Retention Direct Support Programme should be provided at the next meeting. Action: D Fairley

43/19 Guardian of Safe Working Update The Medical Director introduced the report and advised that the Trust had experienced a

significant reduction in exception reports during Q1. 33 exception reports had been submitted in comparison to 63 in the previous quarter.

The report highlighted rota gaps in both Ears, Nose and Throat (ENT) and Geriatric Medicine.

The Medical Director advised the Trust had put an action plan in place to cover any rota gaps during the August period.

The Committee formally thanked the outgoing Guardian of Safe Working, Mr James Briggs for his

work over the last three years and welcomed the new Guardian of Safe Working, Miss Hanna Thomas.

44/19 Workforce Race Equality Report 2018/19 The Director of Workforce introduced the report and provided an overview of the Trust’s

performance in line with the nine indicators identified in the Workforce Race Equality Standard. The Trust had performed better than average in six of the nine indicators with the remaining three

requiring improvement. The three indicators had included less likelihood of BAME applicants being appointed post shortlisting and no BAME board representation at the time the report was


published. In addition, BAME staff views of fairness of equal opportunities and career progression at the Trust was below national average figures.

The Committee approved the recommendation that the data was published in line with national requirements. Action: D Fairley

45/19 Workforce Disability Equality Report 2018/19 The Director of Workforce gave an overview of the Trust’s performance in relation to the

Workforce Disability Equality Standard (WDES).

The report highlighted that staff with a disability reported a negative experience in terms of declaring a disability, recruitment, bullying and harassment, engagement and career progression.

The Employee Engagement & Organisational Development Manager highlighted that analysis of

the WDES had not been previously carried out. However, this had identified a baseline upon which the Trust could use to measure improvement against the WDES.

The Committee recommended that Disability Equality should be an area of focus going forward

and should receive the same level of management focus as race equality. Action: D Fairley

The Committee approved the recommendation that the data was published in line with national requirements. Action: D Fairley

46/19 What Matters Update The Employee Engagement & Organisational Development Manager introduced the report and

highlighted that the Trust had been awarded the Healthcare People Management Association (HPMA) award for excellence in organisational development.

The report provided an update on the ‘What Matters’ phase four priorities that included:

i. Developing Middle Managers ii. Delivering an Inclusive Workplace Culture iii. Transformation and Improvement Matters iv. Finance Matters v. Talent Management vi. Learning Matters

The Committee recommended that an update be provided at the next meeting.

Action: D Fairley 47/19 Workforce Modernisation The Director of Workforce introduced the report and highlighted the key objectives of the

programme included developing a workforce that was the appropriate size and had the right skills to deliver agreed activity levels. The programme also aimed to transform and modernise the Trust’s workforce by creating new or modified roles, embracing technology and creative ways of working, such as home working or community settings. The Committee noted the programme would be using a six-step LEAN model. Key benefits of the programme included improved quality, higher staff retention, reduced spend on pay and an improved control process for temporary staffing spend.


The Director of Workforce highlighted that the Workforce Transformation Group would report to the Restructuring Transformation Delivery Group (RTDG) and Workforce Committee going forward. Action: C Lynch

48/19 Staff Survey 2019 Action Plan

The Director of Workforce provided an overview of improvements achieved in response to the 2018 survey. The action plan highlighted key interventions required at a strategic level and interventions that aligned to the key delivery strands. The report highlighted that the Trust had performed positively in terms of benchmarked performance but still required improvement a number of areas. These included Bullying and Harassment, Health and Wellbeing, Equality, Diversity and Inclusion and Retention.

The Committee noted the action plan priorities during 2019/20.

49/19 Response to People Practices The Committee noted the update in relation to the response to People Practices. 50/19 Board Assurance Framework / Corporate Risk Register: Workforce The Committee noted the update in relation to the Board Assurance Framework and Corporate

Risk Register and agreed that time periods should be allocated to the improvements/actions column on the Board Assurance Framework. Action: C Lynch In addition, the Committee recommended that the Corporate Risk Register should be updated to reflect any updated mitigation actions/controls. Action: C Ainslie

51/19 Work Plan Review

The Committee reviewed the work plan and recommended that the work plan be updated to schedule in meetings up to October 2020. Action: C Lynch


The Committee reviewed the key issues to draw to the attention of the Board, that included:

• People strategies were being developed at national level, for BOB and for Berkshire West. The RBS strategy was well aligned and would be modified as required in the Autumn strategy refresh.

• The Disability Equality standard to be a key area of focus in line with all other equality standards within the Trust Providing a strategic overview on Local, ICS and National workforce changes. The EMC would develop an action plan for leadership.

• The Board would be asked to approve the recommendation that appraisal rates standard be increased to 100%.

53/19 Date of Next Meeting It was agreed that the next meeting would be held on Wednesday 9 October 2019, 13:00.


Chair: Date:

Agenda Item 9

Focus Item Lead Freq May-19 Jul-19 Sep-19 Nov-19Chief Executive Report SM EveryCorporate Risk Register CAi Bi-AnnuallyBoard Assurance Framework CL Bi-AnnuallyWell Led Framework Action Plan Update SM Bi-AnnuallyIntegrated Performance Report Exec EveryIPR Metrics Review MS AnnuallyAnnual Report and Accounts and Quality Account

CL Annually

NHSI Annual Self-Certification NL/CL AnnuallyFreedom to Speak Up Annual Report JP AnnuallyNominations & Remunerations Committee Update CL QuarterlyStanding Orders Review CL AnnuallyFit & Proper Update DF AnnuallyHealth & Safety Annual Report NL AnnuallyReview of the meeting GS EveryBoard Work Plan CL EveryQuality Strategy CAi AnnuallySkill Mix Review CAi AnnuallyWinter Plan MS AnnuallyPathology JL/NL OnceSeven Day Services Self-Assessment JL Bi-AnnuallyHealth & Safety Story NL EveryStaff Story CAI/JL EveryPatient Story CAI/JL EveryCNST Incentive Scheme CAI AnnuallyBalanced Strategy Scorecard AS Bi-AnnuallyStaff Survey Results DF AnnuallyAnnual Revalidation Report JL AnnuallyChief Finance Officer Report NL EveryFinance Strategy NL OnceQuarterly Forecast NL Quarterly2019/20 Contract NL Annually2020/21 Budget NL Annually2019/20 Capital Plan NL AnnuallyOperating Plan AS Annually

Achieve Long-Term Financial

Sustainability

Board Work Plan

Other / Governance

Provide the Highest Quality Care

Invest in our Staff and live out our

Values

Focus Item Lead Freq May-19 Jul-19 Sep-19 Nov-19CQC Use of Resources CAi AnnuallyStanding Financial Instructions Review NL Annually

ICS Update AS Every

ICP/ICS Governance MOU AS OnceTransformation Strategy MS OnceBusiness Planning 2020/21 AS Once

Cultive Innovation and Transformation

Drive the Development of

Integrated Services