board of directors...improvement plan any other business national staff survey education and...

AgendaDeclaration

ofInterest

ApologiesChief

Executive'sReport

Integrated Quality and performance

report

Annual plan, Governance

statement and budget

Advanced Clinical

Practitioner Business Case

MinutesMatters Arising

Chair's Report

Board Committe Reports

Integrated Improvement

Plan

Any Other

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Survey

Education and Training

Proposal

Board of Directors 14 April 2015

9.30amSt Johns Hotel,

Warwick Road, Solihull

Public

Board of Directors April 2015

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April 2015

Agenda

AgendaDeclaration

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Chief Executive's

Report

Delivery Unit Report

Any Other

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Chair's Report


Saftey and Quality Report

Monitor One Year

Operational {Plan

Critical Care at Heartlands

AMU and SAU Safe Staffing

and latest NICE recommenda-

tions

Executive Management

Board

Information Management

and Technology Committee

Workforce Development and Welfare Committee

Citizens Assembly

Board Committee

Membership Proposals

Strategic Risk Register

Update

Council of Governors

Report

Patient Experience

and External Affairs

AGENDA

for a meeting of the Board of Directors of Heart of England NHS Foundation Trust to be held at St Johns Hotel, Warwick Road, Solihull

on 14 April 2015 at 9.30am

9.30am – 11.30AM: Indicative Timings

(Minutes)

1. APOLOGIES

1

2. DECLARATIONS OF INTEREST

1 (Enclosure)

Strategy

3. CHIEF EXECUTIVE’S REPORT (AF)

10 (Enclosure)

Quality & Performance

4. INTEGRATED QUALITY & PERFORMANCE REPORT (JB/DC/AC/SF)

30 (Enclosure)

5. NATIONAL STAFF SURVEY (HG)

10 (Enclosure)

Matters for Approval

6. 2015/16 ANNUAL PLAN, GOVERNANCE STATEMENT & BUDGET (DC)

10 (Enclosure)

7. ADVANCED CLINICAL PRACTITIONER BUSINESS CASE (SF)

10 (Enclosure)

Matters for Report

8. EDUCATION & TRAINING REPRESENTATION PROPOSAL (AC)

2 (Enclosure)

Governance & Administration

9.

MINUTES – 3 February & 18 March 2015

2 (Enclosure)

10.

MATTERS ARISING & DECISIONS/RECOMMENDATIONS TRACKING REPORT

5 (Enclosure)

For Information

11. CHAIR’S REPORT (INCL. CoG) (Chair)

10 (To follow)

12.

BOARD COMMITTEE MINUTES & REPORTS 12.1 Audit Committee (28.01.15 & 25.03.15) (AL) 12.2 Donated Funds Committee (30.01.15) (Chair) 12.3 Finance & Performance Committee (02.02.15, 27.02.15 & 27.03.15) (DL) 12.4 Monitor Standing Committee (02.04.15) (Chair) 12.5 Quality & Risk Committee (23.01.15, 20.02.15 & 13.03.15) (JR) 12.6 Workforce Development & Performance Committee (30.01.15) (LS)

10 (Enclosure & Oral) (Enclosure & Oral) (Enclosure & Oral) (Oral) (Enclosure & Oral) (Enclosure & Oral)

13. INTEGRATED IMPROVEMENT PLAN - DRAFT DASHBOARD (JB)

5 (Enclosure)

14. ANY OTHER BUSINESS

Date and venue of next meeting – 2 June 2015, The Village Hotel, The Green Business Park, Dog Kennel Lane, Shirley, Solihull B90 4GW PRESS AND PUBLIC ARE WELCOME TO ATTEND THIS MEETING AS OBSERVERS ONLY

April 2015

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Welcome

April 2015

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ApologiesApologies

April 2015

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Declaration of Interests


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REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS

VOTING DIRECTORS

NAME DATE OF APPOINTMENT INTEREST (if any) DATE OF

NOTIFICATION DATE OF

TERMINATION OF INTEREST

Mr Jonathan Brotherton

04.03.15 Nothing to declare

Dr Patrick Cadigan

01.07.13 1. Consultant cardiologist at Sandwell and West Birmingham Hospital Trust.

2. Registrar of the Royal College of Physicians of London.

3. Member of the clinical advisory group advising the Trust Special Administrators re the future of Mid Staffs NHS Trust.

4. Member of the clinical advisory group to NHS England on rare diseases.

5. Undertakes paid consultancy work for McKinsey & Co.

Mar 2014

04.07.14

31.12.13

Mar 2014

Mr Darren Cattell 19.01.15 Director & Shareholder - Mill Street Consultancy Limited.

Sept 2005

Dr Andrew Catto 01.03.14 (Interim CEO -

14.11.14 to 16.02.15)

Nothing to declare.

Mr Andrew Edwards

01.10.14 1. Couch Perry & Wilkes. In receipt of annuity following business sale until May 2019.

Mr Andrew Foster 16.02.15 Director of Wrightington Wigan & Leigh NHS Foundation Trust.

Mrs Sam Foster 01.09.13 Nothing to declare.

Ms Hazel Gunter 04.03.15

Nothing to declare.

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

2. Part time judge Social Entitlement Chamber Fitness to Practise

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

BRAP, an equalities think tank.

Mr Les Lawrence 01.04.12 (Chair –

01.06.14)

1. Trustee for the National Institute for Conductive Education.

2. Governor of City of Birmingham School.

3. Director of Lindridge Enterprises Limited.

4. Director (unremunerated) of Bordesley Birmingham Trust Limited (since 7 July 2011).

5. Chairman of the Birmingham Special Educational Needs & Disability Information, Advice and Support Service (SENDIASS).

Mar 2013

Mar 2013

Mar 2014

July 2014

Mar 2015


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Mr David Lock 01.07.13 1. Practising barrister and a member of Landmark chambers. Providing legal advice and representation to a wide range of individuals, NHS organisations, local authorities, charities and commercial organisations mainly on public law issues. These frequently involve issues concerning the rights of patients to NHS treatment as well as structural and management issues involving NHS bodies.

2. Member of Amnesty International. 3. Member of the BMA Ethics

Committee (unremunerated). 4. Member of the Labour Party and

occasional legal advice to Labour Party and elected Members of Parliament on NHS policy issues.

5. Chair of the West Midlands Labour Finance and Industry Group.

6. Mr Lock’s wife, Dr Bernadette Gregory, is a medical doctor employed by Redditch and Bromsgrove Clinical Commissioning Group and is Clinical Lead for the Worcestershire Integrated Care Project.

7. Representing an NHS body in relation to Stafford Hospital.

8. Chairman of Innovation Birmingham Limited.

9. Representing NHS England in relation to specialised services.

10. Receives instructions from the CQC.

Updated Jan 14

10.09.13

05.11.13

06.01.14

04.07.14

Ms Alison Lord 01.05.13 1. CEO and Shareholder of Allegra Ltd.

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

3. In her professional capacity as a 'turnaround executive' Ms Lord has relationships from time to time with major accountancy firms, legal firms, banks and venture capital providers.

4. Company Secretary - Adente Limited (unremunerated).

22.01.14

13.05.14

Dr Jammi Rao 01.07.13 1. Sole director of Gorway Global Ltd. a private company and owning 50% of its share capital. A consulting company offering management support, training and bespoke public health analytical support to public sector organisations involved in health, well-being and health care.

2. Board Director of Welcome CIC - a Community Interest Company supporting minority and disadvantaged communities by working with statutory and other agencies.

3. Shareholder in GlaxoSmithKline plc. 4. Trustee of the Faculty of Public

Health as an elected General Board Member. Term of office from 2010 to July 2013.

05.11.13


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5. Visiting Professorship in Public Health in the School of Health, Staffordshire University.

Prof Laura Serrant

01.04.12 1. Director of Research & Enterprise at University of Wolverhampton

2. Non-executive director National Skills Academy for Health (unremunerated).

01.04.12

23.01.14

Mr Adrian Stokes 01.07.08 1. Director of Heartlands Education Centre Ltd.

2. Pfizer Virtual Customer programme.

01.07.08

20.06.11

Mrs Lisa Thomson

06.11.12 1. Non-executive Director of Multistory 2. Trustee of a charity - Redditch

United Football In the Community

22.12.08 07.11.11

April 2015

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Chief Executive's Report


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Title: Chief Executive’s Report Attachments: 0 From: Andrew Foster To: Board of Directors and

Council of Governors The Report is being provided for: Decision N Discussion Y Assurance Y Endorsement N The Committee is being asked to: Note the contents of the paper Key points/Summary: Update from Chief Executive Recommendation(s):

Assurance Implications: Strategic Risk Register

Y/N Performance KPIs year to date Y/N

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

Y/N Information Exempt from Disclosure

Y/N

1. Introduction

I am just coming up to two months as Interim Chief Executive and would like to first express my appreciation to Andrew Catto, the Executive team and the Trust Board. It is clear to me that the Trust went through a very difficult time in 2014 but the Board took a courageous decision to accept the findings of the Deloitte report without defensiveness or argument and then to take some decisive actions. November marked a watershed and the Resilience Programme was the start of a recovery.

The Board will know that I have spent much of my time listening to staff and external stakeholders and have received a large number of consistent responses. In simple summary, employees are confused, unhappy and angry at the situation HEFT is in. I will leave an assessment of external party views to the report that Deloitte will deliver later this month.

My initial challenge is that we are trying to solve too many problems with too little capacity. Where everything is a priority, nothing can be a priority and the risk is that nothing gets done properly. Hence I drafted the ‘Pyramid of Priorities’ and tested it with the ED team and most NEDs. I negotiated with Monitor that HEFT should give its highest priority, and most of my time to Clarity, Staff Engagement and Quality Improvement. This has now been confirmed by the Trust Board.


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Clarity

The two main areas of uncertainty are about how the Trust is managed and what are its plans for the future?

We have begun a cascade of responsibilities starting with Executive Directors as a group (Appendix A) and then the responsibilities of their direct reports (Appendix B). This process will continue to all management levels. In so doing we have identified a number of gaps, the most important of which is Governance and it would appear both that the Trust has no overall systems and that it has regarded the word Governance as interchangeable with Performance. I am grateful to Sam Foster for taking on the huge task of setting up a Governance department and systems and also to Diane Whittingham who has agreed to Chair a Governance Board to oversee both Clinical and Corporate Governance.

The next major challenge is the confused system where site management, cross-cutting divisional management and individual specialties’ management sit side by side. I do not think the time is right to embark on a major restructuring exercise but would prefer to make the existing structures work better. We plan to agree later this month that site management should be paramount with other levels offering support and advice.

To bring clarity about the future, I have asked Matthew Cooke to oversee a process that will end up with a suite of interlocking strategies to be formally approved by the Trust Board following an extensive process of internal and external consultation. The overall strategy will cover Quality and Clinical Services with supporting strategies for Workforce, Business and Investment, IT and for each Site. I expect an initial skeleton for each strategy to be shared with the Trust Board in April and a more advanced document in June before final sign off by the Board in September. The interlocking strategies will not merely set out our vision for the future, but also how we will get there. It will be refreshed on an annual basis.

Staff Engagement

An extensive programme of events started in March, based on the techniques used in Wigan. There have been three Trust-wide Listening Events (one at each hospital location), four Listening Events specifically about emergency care and a Staff Engagement Summit to highlight existing areas of good practice. At each event, staff are asked what works well, what doesn’t work well and what should be done to improve matters. All ideas are recorded, analysed into themes and then put into categories of what can be done immediately, what can be done in weeks and what can be done in months. By implementing quick actions we begin to build trust in the process and a sense of momentum.

For example in emergency care, we immediately accepted two suggestions: to ring-fence some assessment beds and to increase night time portering staff at Good Hope. By the end of April we will have reopened Discharge Lounges on both sites and later this year



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we will probably make some building changes to increase majors capacity at Heartlands. In the longer term the real solution at Heartlands can only be a brand new build department.

A weekly Staff Engagement communique has just started to both report on “you said we did” actions and to keep staff informed about progress and new events. A baseline opinion survey was carried out in November and will be repeated in June so that we can measure progress.

In April, there will be further Listening Events focusing on the Trust’s strategy and ten teams or departments will be identified to conduct a similar approach in their own areas. In six months’ time a second cohort of 10 teams will follow the same route.

Quality Improvement

We will introduce the system of Quality Champions that won the national patient safety award for WWL. An initial group of around thirty individuals will undergo a 3-day training course in evidence-based improvement techniques. On completion of training, they will select a quality improvement project and be supported by a central infrastructure. New cohorts will be recruited every three months so that before long there will be a large community of Quality Champions. On completion of training they will receive a bronze coloured identity badge and be asked to set a stretching measurable target for their project. Once the target is achieved and sustained for 6 months they will receive a silver badge. If their project is spread regionally or nationally they will receive a gold badge. This scheme of recognition has been found to be highly motivating elsewhere.

There will also be a Quality Summit at the end of April where staff can showcase existing examples of good quality improvement work.

One of the gaps at HEFT is that we do not have reliable mortality data and cannot identify clinical areas or procedures where mortality exceeds normal statistical limits. Dr Foster expect that their own quality data will become reliable by July and in the meantime we will establish a routine Deaths Audit where case notes of deaths will be analysed for ‘triggers’ – indications that mistakes may have been made which could cause harm.

Other Matters

My greatest immediate concern is for patient safety when our A&E departments become over crowded. Temporarily unsupervised patients on trolleys create a risk on both sites and the size and structure of the Heartlands department is seriously inadequate for the numbers of patients seen. In the long run we simply need to build a new emergency floor but we are exploring shorter term measures such as moving Minors to provide extra space for the most seriously sick patients. We plan to bring a paper to the May Board outlining how our cramped and old-fashioned Outpatients department could be taken off site into much better accommodation such as LIFT buildings. This would both ease parking pressures and create space for a new-build tower block to incorporate all



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emergency services, maternity and intensive care. The paper will be accompanied by a long term capital plan to show how it compares to other priorities.

My contention is that we should accord most priority to the challenges described above but there is then a long list of other major issues that need attention:

A&E performance

18 week performance (especially gastroenterology)

Financial trading deficit this year and next

Building and maintaining Monitor’s confidence

The CQC report (when it comes)

The Deloitte Governance and IT reports

The Kennedy report

The Silverman report and excess mortality and harm

Relationships with commissioners and the 15-16 contracts

Staff shortages, especially nursing

Surgical reconfiguration

Solihull Urgent Care Centre

Solihull Integration Plan

Board Development

Quality and capacity of senior and middle management

Andrew Foster 30 March 2015



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Chief Executive Andrew Foster

Associate Medical Directors

Director of Finance Darren Cattell

Deputy Chief Executive

Medical Director Andrew Catto

Director of Nursing Sam Foster

Director of Operations Jonathan

Brotherton

Director of Workforce & OD

Hazel Gunter

Arne Rose, GHH Govindan

Raghuraman, BHH Rex Polson, Solihull Alan Jones, Clinical

Support ? Women & Children’s Phil Bright, Director of

Education

Finance IT

Planning Estates

Strategy Medical Staff

Scientists Therapies

System Performance Medical Quality

Research & Development

Communications

Nursing & Midwifery

System Quality Clinical & Corporate

Governance Patient Experience

Human Resources Organisational Development

Leadership

Line Management Recovery

Programme Office

* Professional accountability

Company Secretary

Kevin Smith

Appendix A



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Associate Medical Directors

Deputy Medical Director

(Strategy and Transformation)

Matthew Cooke

• Communications • Medical

Illustration • Directorate

Policies • Recall

• MD office functions

• Directorate Administration

• Directorate Business Planning

Deputy Director & Chief of Staff

(Medical Director’s Office)

TBC

Deputy Medical

Director (Elderly Care)

TBC

Director of

ICT (interim)

Jonathan Rex

Deputy Medical Director

(Quality and Safety)

TBC

Deputy Chief Executive and Medical Director

Andrew Catto

Deputy Medical

Director (Appraisal,

Performance and Outcomes)

Clive Ryder

• Medical Quality • Quality Improvement • Mortality

• Frail Elderly Strategy

• ICASS • BCF

• Medical Leadership

•Professional standards

•Medical Staffing •Revalidation

Associate Medical Director –

Revalidation and Caldicott Guardian – Adedeji Okubadejo

•Strategy Development

•Strategy Priority Programmes •Primary Care

Integration and Public Health

•Strategy Planning Integration

•Research (via Director of Research

•Innovation (via Innovation Lead)

Appendix B



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Sam Foster Chief Nurse

Deputy Chief Nurse

Sue Hyland

Head of PMO

Nick Varney (interim until end

June ‘15)

Head Nurses

Children’s Head of

Midwifery

Deputy Chief Nurse

Julie Tunney

Deputy Director

of Patient Experience

Richard Brown

Head Nurse Safeguarding

Maria Kilcoyne

Head of Governance

Louise Rudd

Head Nurse Infection

Prevention & Control

Gill Abbott

• Patient

Experience • PALS • Complaints

• Adult &

Children’s Safeguarding

• Health & Safety

• Risk Management

• Audit • Incident

Reporting • Legal

• Infection

Prevention & Control

Head Nurse

Patient Experience

Dr Dawn Chaplin

• Patient

Experience • Bereavement

Services



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Darren Cattell (interim)

Director of Finance (Senior Information Risk

Officer)

Deputy Director of Finance

Aidan Quinn

Head of

Performance

Diane Povey (interim)

• Operational

Finance & Delivery

• Commercial Finance & Planning

• Estates • Facilities • Building

Development

Director of Finance

Operations

Jonathan Gould

Director of Asset

Management

John Sellars

Director of

ICT

Jonathan Rex (interim)

• Performance Reporting

• Informatics

• IT Systems



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Jonathan Brotherton Director of Operations

Line Management Recovery

Programme Office

Birmingham Heartlands Hospital Division

Good Hope Hospital Division

Solihull& Community Services Hospital Division

Clinical Support Services Division

Women’s & Children’s Division

5 x Head of

Operations

Programme Office

Head of PMO Nick Varney

Head

Nur

se

Sara

h Q

uint

on

AMD Govindan

Raghuraman

AMD Arne Rose

Head

of O

ps

Caro

lynn

e Sc

ott

AMD Rex Polson

AMD Alan Jones

Head

of O

ps

Eric

a Lo

ftus

Head

Nur

se

Bhav

na G

okan

i

AMD Vacant

Head

of O

ps

Phil

Lydd

on

Head

of M

idw

ifery

Jo

y Pa

yne

Head

of

Ops

Ca

rl Ho

lland

Head

Nur

se

Julie

Tay

lor

Head

Nur

se

Vane

ssa

Wor

t

Head

of O

ps

Andr

ew C

lem

ents



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Hazel Gunter Director of Workforce

Head of Transactional HR

Ray Reynolds

Deputy Director of Workforce/ Head of

Operational HR

TBC

Head of Faculty

Claire Whittle (interim)

Head of OD

Alex Covey

• Recruitment • Bank • Employee Services • Workforce

Information

• Operational HR • Policy Development • Occupational Health • Service

Transformation • Workforce Planning

• Education • Training

• Culture • Engagement • Leadership


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Integrated Quality and Performance Report


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Integrated Performance Report Reporting period: Month 11 – February 2015


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Contents

Page number Title

3 4 5 6 7 8 9 11 12 13 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 32 33 34

Executive Summary Heat Map Monitor :18 weeks RTT Monitor: Open clocks Activity: Elective operations Monitor: Diagnostics Monitor :Gastroenterology Risks Monitor: Cancer pathways, 2 weeks Monitor: Cancer Pathways 31 and 62 days Monitor: 62 day Pathway-over 100 day waiters Monitor : Urgent and Emergency Care Monitor :Emergency Readmissions Quality and Safety: Infection Prevention update Quality and Safety: Falls Quality and Safety: Pressure Ulcers Quality and Safety: Nursing workforce Quality and Safety: Nursing Vacancies Quality and Safety : Flexed Capacity Quality and Safety: National CQUINs Quality and Safety: CQUINs Quality and Safety: VTE Assessment Workforce: Appraisals Workforce: Mandatory Training Workforce: Sickness Workforce: Voluntary Turnover and Recruitment Internal Reporting: Finance Winter Plan and Flu Patient Experience Metrics Patient Experience: Complaints



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Introduction This report is now named the ‘Integrated Performance Report’ as it continues to incorporate an even broader set of organisational priorities. A monthly cross-division and corporate services meeting is held to discuss performance, to evaluate, develop and document remedial actions. Divisional level meetings are also held with each of the 5 divisions. This report will be developed further to underpin the Performance Assurance and Board Assurance Frameworks that are currently in development. Performance Analysis From 1st March 2015, Solihull Emergency Department was reassigned as a Minor Injury Unit, meaning that Solihull “Lode Lane” Walk-In Centre activity can no longer be included in the Trust A & E reported position. A&E Performance for February was 85.65% (all sites, including Walk-in Centre activity). The position for February without Lode Lane is 82.67% (-2.97% difference when compared against the position including walk-ins). The individual site position in February is as follows: Heartlands ED – 81.95% Good Hope ED – 76.52% Solihull ED (now MIU) – 97.32%. Increased capacity at Good Hope site (Ward 3) has meant that the Vanguard Theatre has increased throughput, and the site A&E performance improved in February by 1.2%. The Trust identified waiting list issues that added 586 patients to the admitted 18 week backlog. This contributed to the organisation not hitting the trajectory of 743 (1,314 on the backlog). The backlog in February is 571 behind target

For February the Admitted RTT performance reduced as expected in part due to the on-going closure of open clocks performance is currently 77.67% and non admitted RTT performance is 92.01% an improvement of 6.10%. A total of 121 patients were treated in the private sector and through the Vanguard theatre in February. Additional private sector capacity was sourced for Orthopaedics and commenced in February. A pro-active programme of independent sector support is planned moving forward to further support capacity. Although there were 121 hospital led cancelled operations on the day during February this is a reduction on the January figure. 51 (42%) of the cancelled operations were at Good Hope, 44 (36%) at Heartlands and 26 (21%) at Solihull. In addition 2 patients had their ‘urgent’ operation cancelled for a second time at Heartlands and 1 patient waited longer than the 28 day elective guarantee date in month. There were a total of 11 52 week breaches in February the majority (7) due to the closure of open clock pathways. Diagnostic performance targets remain below target at 93.81% seen within 6 weeks meaning both the National target and the Monitor trajectory have not been met. The situation is especially acute in Gastroenterology due to an increase in demand and changes the reporting process. There continues to be an improvement in both Two Week Wait Cancer targets, despite continued increases in referrals to these services although 62 days performance fell below the target in February.

Executive Summary|



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Heat Map|

Integrated Quality and Performance ReportIntegrated Quality and Performance Report


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MONITOR| 18 weeks RTT Headlines: The Trust failed to achieve the expected reduction in backlog of patients over 18 weeks in February, 571 behind original trajectory. The Trust has failed both admitted and non admitted targets. Admitted RTT is 77.67% and non admitted RTT is 92.01% for February. It is now expected that the Trust will not achieve 90% admitted RTT compliance as expected in Quarter 1. 4 patients breached 52 weeks in month with a further 7 breaching as a result of the closure of open clock pathways. Key Issues: The revised backlog trajectories for all specialties have been developed with the performance team conducting a quality assurance process on the specialties identified as high risk (Urology and General Surgery). A trajectory and plan for Gastroenterology is in development which will reflect the full complexity of the service and outline additional capacity plans. A Remedial Action Plan (RAP) for the diagnostic element of the service has been submitted in draft form to the CCG as agreed in mid March and a full plan with trajectory will be presented to EMB on the 23rd March. The number of patients waiting over 18 weeks in February was 1,314 against an original trajectory of 743. The causes for this additional backlog over and above target can be identified as follows: • Data Quality: 234 - this includes a significant growth in the

Gastroenterology IPWL resulting from additional outpatient activity. A waiting list reporting issue was also identified and the RTT pathways are now reported as part of the backlog.

• Interventional Radiology: 52 - this is now on PMS2 as opposed to the imaging system, and has added a further 52 patients on to backlog.

• Cancellations due to no bed: 300 – there have been 451 cancellations due to no bed between October 2014 and February 2015. 2/3rds of these will be for patients waiting over 18 weeks and based on Dec14-Jan15 data.

A total of 11 patients breached 52 weeks in month. Two non-admitted patients (General Surgery) and Two admitted patients breached 52 weeks. One of the non-admitted breaches was a delayed consultant to consultant referral within ENT, 7 were legacy patients that waited >=52 weeks. The number of 52 week breaches for clock stops is likely to continue in March and possibly into April as all remaining open clocks are validated and closed. Actions to date: • A total of 121 patients were treated in the private sector and

through the Vanguard theatre in February. • Additional private sector capacity was sourced for Orthopaedics

and commenced in February. The Trust continues to explore transfer of patients in other specialties including Gynaecology, Gastroenterology and General Surgery.

• A plan illustrating return to 2ww/5week diagnostic and 18 week compliance in Gastroenterology will be finalised in March and submitted to Monitor and CCG colleagues.

• Additional analysis is being undertaken to support improvement and visibility of pathways.

Lead: Amanda Markall

Table| HEFT 18 weeks backlog



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MONITOR| 18 weeks – Open clocks Headlines: Currently the Trust cannot report the RTT incomplete pathway due to the number of remaining open clocks. As at 2/3/15 the open clock backlog was 12,320 patients, a reduction of 10,338 in month. The Trust is on trajectory to close the remaining open clocks, outside business as usual, by the 31/3/15. Historically, the Trust has reported between 30,000 and 35,000 open clock pathways prior to the implementation of PMS2 in July 2014. It is likely that, following the closure of the pathways for legacy patients, there is likely to be over 40,000 open pathways representing ‘business as usual’. Key Issues: • The validation of the remaining open clocks will continue to impact

on performance each month. • CRIS data has now been added on to

PMS2 and will increase the number of Open Clocks reported. From 26/03/15, HIV data will also be added in to the Open Clocks dataset.

Actions to date: • The Clinical Consensus Group met in

February and have provided advice and guidance to support closure of Open Clock Pathways.

Lead: Amanda Markall

Graph| Open Clocks profile @12/03/2015

Graph| Reduction in Open Clocks Oct14-Mar15



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Headlines: There were 121 hospital led cancelled operations on the day during February. 51 (42%) of the cancelled operations were at Good Hope, 44 (36%) at Heartlands and 26 (21%) at Solihull. In addition 2 patients had their ‘urgent’ operation cancelled for a second time at Heartlands and 1 patient waited longer than the 28 day elective guarantee date in month. Key issues: • There were capacity issues at Good Hope during early February that led to

operations being cancelled due to no bed, this has now been resolved. • The cancellations as a result of lists overbooked is the highest number this

year. Actions taken: • Additional Theatre capacity (Vanguard Theatre) in place until June. A business

case is being considered to extend until September. • The day case ward at Good Hope is now fully functioning since the 9th

February. • Additional capacity (18 beds) opened at Good Hope on the 11th February on

Ward 3. This will enable Ward 7 (Vanguard) to be fully operational from the 12th February with capacity for 12 patients per day.

• All sites are currently outsourcing procedures to the private sector to mitigate risks and 18 weeks pressures.

• There has been an initiative that commenced in February to improve theatre utilisation by reviewing lists in advance and adding cases to those lists that appear under booked. Most of these lists have finished on time but there is an increased risk of lists overrunning and patients being cancelled which will be monitored as part of the evaluation process.

Further Actions: • There is Zero tolerance to cancellations of elective surgery at Good Hope

unless at level 4 escalation level from February 2014 onwards.

Activity| Elective Operations Graph| Hospital led Operations cancelled on the day

Graph| % Cancelled Operations on the day

Table| Urgent operations cancelled for a second time

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Urgent Operations Cancelled for 2nd Time 1 0 3 1 1 3 4 3 4 3 2

Breaches of 28 day elective guarantee 0 2 1 2 1 1 1 0 0 1 1



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Monitor| Diagnostics

Graph | All Diagnostics seen within 6 weeks (99% target)

Table | February 2015 Position by Test

Headlines: The diagnostics six weeks performance is below target at 93.81% and below the agreed Monitor trajectory in month. February is the sixth consecutive month where performance has been below the 99% target although there has been a slight improvement. The February target is for 43 patients to have waited over 6 weeks, whereas the actual number for February is 685, with the majority (666) in Endoscopy. The Intention is to return performance to 99%, although there is still a significant degree of risk. Key issues: • JAG Accreditation at risk due to inability to achieve the 99% target. • 7 day working. • Increase in referrals compared to last year. Actions taken: • Additional capacity provided by weekend working (extra 14 sessions

per week). This will not be operational until later in the year –this will not be operational until end of quarter 2 at the earliest.

Further Actions: • Meet with JAG to mitigate loss of accreditation while the remedial plan

is being actioned. Support required from Exec Team to provide assurances of recovery plan and future services sustainability.

• Increase to consultant staff by another 2 substantive posts. • Review of clinic templates against demand. • Working with external providers to assess additional capacity available. • Review referral pathways and work with GP practices to ensure

appropriate referrals into the system are made. • Discussion on-going to provide additional capacity for endoscopy with

staffed vanguard unit.



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Graph | Total Gastroenterology Waiting List

MONITOR| Gastroenterology Risks Actions taken: • Increased capacity has been put in place for both OPD clinics (5

clinics per week) and 14 additional weekly Endoscopy sessions. • 2 Locum Consultants are now in place in addition to the base

resource. Further Actions: • Meet with JAG to mitigate loss of accreditation while the remedial

plan is being actioned. Support required from Exec Team to provide assurances of recovery plan and future services sustainability.

• Business case to be completed for an additional 3 consultants. Executive Team support required to implement 3 sessional – 7 day working model.

• In order to ascertain a complete picture of the ‘true’ Gastro IPWL, a validation exercise of 12,000 open clocks will be completed by the end of Mar15.

• An exercise to quantify the demand for Gastro against available capacity is under way.

• Collaborative work with the CCGs to agree and manage a referral protocol has been commenced.

Headlines: The Gastroenterology Directorate are unable to consistently meet KPI targets at present, including: • Cancer waiting times. • Diagnostic waits. • RTT 18 week waits. • Bowel Screening Programme. JAG accreditation is at risk from April 2015 due to the Trust inability to meet the Diagnostic target of 99% of patients seen within 6 weeks (93.81% during Feb-15). Clinical triage of 300 patients waiting for an endoscopy revealed only 12 patients who did not require a scope.

Key issues: • An increase in referrals to the service (>6% during 2014/15 compared

to 2013/14) is impacting upon the capacity required in order to meet the above targets.

• Amendments have been made to the process for managing Gastroenterology inpatient waits as this led to 2 SUIs in December 2014.

• A recent reporting change for patients on the Gastro IPWL has resulted in a significant increase in the numbers reported (shown in the graph).

050100150200250300

0

500

1,000

1,500

2,000

2,500

18+wks

Tota

l IPW

L

01/04/2014 01/05/2014 01/06/2014 01/07/2014 01/10/2014 01/11/2014 01/12/2014 01/01/2015 01/02/2015 01/03/2015Total IPWL 463 554 338 399 543 970 932 1,635 1,711 2,148

18+wks 1 16 5 5 141 174 173 275 176 187

Gastro IPWL 2014/15 Total IPWL18+wks



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MONITOR| Cancer Pathways – 2 Weeks

Headlines: There has been an improvement in two week waits (2WW) from 91.24% in January to 92.66% in February. Breast symptomatic 2WW improved from 76.61% in January to 89.24% in February. All except 4 of the 32 breast symptomatic breaches were due to patient choice. Key Issues: The number of referrals increased since March 2014 and have remained above the average. This can be seen in the SPC chart. The continuing increase in 2WW referrals is a concern and whilst additional capacity is being put into place the rate of growth is exceeding what has been planned. This is likely to be exacerbated by the NICE guidance putting sustained achievement of 2WW performance at risk. Actions taken: • A collaborative approach to addressing breaches has resulted in a

reduction of Patient Choice breaches from earlier this year (239 Aug-14 and 116 in Feb-15, 51% reduction).

• In February there were 138 breaches overall, of which 135 were due to patient choice (98%).

• Currently the median average wait in days for February was 11 days, with specialties being asked to achieve 7 to 8 days. The table shows this is a reduction from 14 days.

• A GP Education event had been arranged for March and is being rearranged for Q1 at GP Lead’s request, in line with publication of NICE guidelines. This will be used to enhance referral management.

• Actions continued on next page

Lead: Amanda Markall Contributor: Elly McFadyen

Table| Two week waits/Breast Symptoms: percentage of patients seen in 2 weeks

Graph| SPC of Two week wait referrals

Table| Median days wait for Two week attendances.



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MONITOR| Cancer Pathways – 2 Weeks Continued

Actions Taken (Continued): • Audit of 2WW patients who breached in Q3 has taken place and

results shared with CCG to cascade to GP practices. The results showed 61% of the patients contacted were informed by their GP that they were being referred via the rapid access/2ww route and 73% of patients were given written information about the 2 week wait appointment and what would happen at the appointment.

• Growth scenarios (for 2WW) to illustrate possible future impact have been modelled. Additional resource requirements have been identified and included in the Business Planning round at the end of January.

• Specialty specific plans and trajectories have been developed, demonstrating a proactive approach to capacity and demand. Performance is monitored and discussed via the weekly Cancer Meeting and scrutinised at monthly Confirm and Challenge.

• New escalation process to improve speed and efficiency in addressing shortfall in 2WW capacity.

• Patient level challenge on 2 week wait has been introduced at the weekly performance meeting, by specialties.

• Lung team has implemented some improvements to their pathway and held a mapping session which identified further areas for improvement. A key action is the development of a revised Lung 2ww referral form, to be designed in conjunction with CCG, GPs and other Providers.

• New skin 2ww referral form has gone live and has been communicated to GPs. Gynaecology due end March.

• Managerial structure – roles designed and job descriptions submitted for banding.

• Cancer strategy brainstorm taken place, next drafting date in March. Lead Cancer Clinician and Manager met with Deputy Medical Director to ensure approach is aligned to Trust plans.

Further Actions : • New date for further GP education event in Q1 to be confirmed. • Patient choice breach audit to be scheduled for Q4 breaches. • Lung and Urology 2ww referral form review and redesign process to

get underway • Urology haematuria pathway to be mapped to identify areas for

streamlining • Continued development of new managerial structure within which

cancer services will be monitored and managed. Roles to be agreed • Cancer Lead Clinician role to be appointed following resignation of

current post holder. • Cancer away day to be planned for Q1 to ensure strategy is developed

by Cancer MDTs, under leadership of new Lead Cancer Clinician. • Further analysis of conversion ratio of 2ww referrals by CCG, GP

practice and speciality to include comparison data. • Performance group plan to review modelling and set trajectories to

reduce median wait to first 2ww appointment, to enable greater flexibility when patients choose to rearrange appointments .

• Continue to challenge and monitor impact of 62 day PTL meetings. • Impact of NICE guidance to be modelled




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MONITOR| Cancer Pathways 31 and 62 Days

Headlines: The 62 Day target was met in Jan-15 with 86.22%, however the provisional position for February is 81.00%. Specialties failing the target in February included Gynaecology (40.00%), Lung (42.86%) and Urology (72.09%). 31 Days Performance continues to achieve the 95% target. There have been two 62 day screening breaches in February (50% compliance). 4 further patients with confirmed cancer have either passed or will breach their target date. Small numbers for this target is likely to result in failure of the 62 day screening target for Quarter 4. This was reported to February F&P and the likelihood of failure was noted. Analysis of the Trust position (against other organisations treating similar numbers of patients - Quarter 3 2014/15), shows HEFTs performance above peers and the English average for the 31 and 62 day target. Actions Taken: • Patient level challenge has been introduced for 62 day patients,

impact is being monitored on a daily basis. • Information on 62 day patients waiting over 100 days is now

highlighted and circulated with the weekly forward look report. • Cancer services lead team have started to review patients weekly. • Initial meeting has taken place with Deputy Chief Nurse with a plan to

establish a short term task and finish group to address quality and safety in this group of patients.

• Urology have agreed to redesign the 62 day prostate pathway and are beginning to test with new clinic set up and imaging process in February.

• Short term task and finish group being established to agree and implement a process for assessing impact on patients treated over 100 days (date to be confirmed).


Table| 31 and 62 day target performance

Table| HEFT 31 Day Performance v Peer Trusts – Quarter 3 2014/15

Table| HEFT 62 Day Performance v Peer Trusts – Quarter 3 2014/15



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Lead: Amanda Markall Contributor: Elly McFadyen Cancer Pathways: 62 Day pathway – over 100 day waiters

Headlines: 7 patients identified on the 62 day cancer pathway who have been on the pathway in excess of 100 days as at 3/3/2015. 3 of these patients have treatment dates planned. Details of these patients and the reason(s) for delay and next steps are shown below. Actions required: Cancer services lead team review patients >100 days weekly and ensure that any issues or concerns are addressed with the relevant MDT, ensuring next steps and treatment dates are in place as clinically appropriate. Next stage is to identify, implement and embed an appropriate process for reviewing quality and safety in this group of patients. Initial meeting has taken place with Deputy Chief Nurse with plan to establish a short term task and finish group to address quality.



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Headlines: The performance in February was 85.65% (all sites, including Walk-in Centre activity). However, from 1st March 2015 Solihull A&E has been reassigned as a Minor Injury Unit (MIU), which means the Trust is no longer able to map Lode Lane Walk-in Centre to its position. The position in February without Lode Lane is 82.67% (-2.97% difference in position when compared against the position including walk-ins). The individual site position in February: • Heartlands ED – 81.95%, • Good Hope ED – 76.52%, • Solihull ED (now MIU) – 97.32%. Key Issues: • Continued increase in the proportion of over 85s attending HEFT ED

departments. In February, 6.2% of attendances were aged over 85, against the average of 4.7% in April 2013 to February 2015 (see SPC).

• Gradual but sustained improvement seen on Good Hope for the past three months, with a March to date position of 84.4%.

• Infection issues reducing available capacity on Solihull site which has now resolved

• A&E department attendances frequently over capacity • All three sites have seen a stepped increase in A&E attendances in the

2014/15 financial year. At Heartlands and Good Hope respectively, the 2013 vs. 2014 calendar years showed a growth of on average 21 and 12 extra attendances per day, highlighting sustained pressure on front door services.

• Actions continue on the next slide.

MONITOR| Urgent and Emergency Care Lead: Andrew Stenton

Table| Key Emergency Indicators YTD

Graph| ED 4 hour performance by site (Jan-14 – 15th March)

Graph| SPC of patients aged >=85 years of age attending HEFT ED:



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Actions Taken: Good Hope: • Ward 3 now open to provide suitable accommodation for medically fit

for discharge patients, to increase flow. • Operational focus on unblocking assessment facilities. • Additional medical staff assigned to front end decision making. Heartlands: • Senior medical and nursing teams focussing, with wards, on unblocking

delays • Maintenance of flow through Minors areas in A&E. • Use of Senior medical decision makers in A&E.

MONITOR| Urgent and Emergency Care

Trust-wide Further Actions:

• Changes in escalation processes to drive Trust wide response:

o To be implemented on Heartlands site initially. o Early warning scoring in A&E to highlight deteriorating

position. o Systematic mobilisation of Multidisciplinary Team across

site to reduce pressure before it peaks. o Site wide communication system.

• Focus on assessment and short stay areas to reduce need to admit to specialist wards and reduce volumes in A&E:

o Strict application of admission criteria and LOS. o Review of staffing model in assessment units. o Review of capacity in assessment areas using ECIST model.

• Enhance staff engagement with improvement process:

o Chief Executive-led breakfast meetings with staff groups. o Cross Directorate improvement teams being put into

place. o Rapid response for investment/resourcing issues.

• A&E physical environment:

o Review of constraints within A&E departments followed by short term reorganisation to improve capacity.

o Development of plans for redesign and expansion on Heartlands site.



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Headlines: • The emergency readmissions figure routinely reported on the

Trust KPIs reflects the Payment by Results (PBR) 30 day readmission definition

• This excludes cancers, under 4’s, maternity and self-discharges, but includes spells that were originally elective or emergency

• The proportion of readmissions has reduced in the past 5 months from a previous level of around 15-16%, to a level of approximately 13-14%

Key issues: • The PMS2 ‘anomaly 8’ issue, whereby patients have been

incorrectly admitted as emergency patients as opposed to electives from a waiting list, will have caused an ‘over-reporting’ of emergency activity. This is likely to have increased the potential for emergency readmissions

Actions taken: • An additional DQ resource has been put in place since February

2015 to ensure that these errors are corrected on PMS2

Further Action: • Further analysis by days between readmission, readmissions to

same specialty/HRG Group, and by patient class

MONITOR| Emergency Readmissions

10%

11%

12%

13%

14%

15%

16%

17%

18%

01,0002,0003,0004,0005,0006,0007,0008,0009,000

10,000

Good Hope Heartlands Solihull % Trust

Graph | Emergency Readmissions within 30 days by Site;

Discharging Specialty Apr14-Feb15 Readmissions

General Medicine 7,927 General Surgery 1,449 Accident & Emergency 822 Urology 589 Gynaecology 554 Trauma & Orthopaedics 373 Paediatrics 260 Elderly Care 221 Rheumatology 197 Thoracic Medicine 196 Grand Total 12,588

Table | Emergency Readmissions by Specialty of Original Spell



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Headlines: • There were no cases of post 48 hour MRSA bacteraemia reported in

February making a YTD total of one case. • There have been three cases of post 48 hour toxin positive Clostridium

Difficile (C.diff) in February making a YTD total of 67 vs. a target of 72 cases. • The policy for recognition and management of patients with

Carbapenemase producing Enterobacteriacae (CPE) was agreed and ratified and full implementation will start Trust wide w/c 16.03.15.

Key issues: • An outbreak of C.diff was declared on BHH ward 4. There were three cases

of post 48 hour C.diff ribotype 027 on the ward within a 28 day period. • Three wards were closed during February due to outbreaks of diarrhoea

and vomiting confirmed as Norovirus. These were BHH ward 6, SHH wards 20A and 19.

• There was one patient admitted to BHH ward 28 with suspected ebola. This was a returning healthcare worker who was subsequently found to be ebola negative.

• MRSA Screening – the data issues are currently being resolved by the additional staff in the Data Quality Team.

Actions taken: • An RCA was carried out for BHH ward 4. The index patient was not

immediately isolated despite being previously positive for Cdiff and presenting with symptoms of diarrhoea.

• Deep cleaning was carried out on all norovirus outbreak wards prior to re-opening.

• The ebola action group continues to meet fortnightly and PPE training is being carried out throughout the Trust.

• A deep clean throughout the entire ward was carried out on BHH ward 4 and education of clinical staff regarding prompt isolation of patients presenting with diarrhoea particularly if known to be previously positive for Cdiff.

Quality and Safety | Infection Prevention Update

NB: The graph above is a YTD cumulative total of cases. This is how the trust is nationally measured, the 3 cases in February have yet to be fully typed and will be retrospectively filled in next month.

Lead Gill Abbott

Graph: Trust wide post 48 hr C. Diff. cases

Table| Trust wide MRSA Bacteraemia Screening results



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Graph| Falls rate per 1,000 occupied bed days (OBD)

Graph| Number of falls resulting in head injury or fracture

Headlines: The falls rate for the Trust has fallen in Feb-15 for the second consecutive month to 6.96 per 1,000 occupied bed days. Safety Thermometer prevalence of falls with harm fell to 0.17 in month, the lowest recorded to date. There were 5 injurious falls in Feb-15; 4 on the Good Hope site (Wards 18 GHH, 24 GHH, and two on Ward 21 GHH); and one in Solihull Outpatients Department. Actions taken : Despite increase in compliance score against falls metrics further work is required by clinical teams to embed falls bundles. • Head Nurse currently reviewing uptake of ‘Vital’ training with

registered nurses / HCA’s • Supervisory Ward Sisters to ensure there are local ward

processes in place to ensure medical / pharmacy review of medication

• Nursing metrics to be revised to capture medication reviews as part of falls bundle by April 2015

• All ward areas to review availability of falls preventative equipment available at all times

• Falls practitioners continue to work with site leads in monitoring multiple fallers

• RCA scrutiny forum continues with Medical Director for Patient Safety / Deputy Chief Nurse / Lead Nurse for Falls.

Further Actions required: • Falls awareness / sharing event (BHH) scheduled for late

October

Quality and Safety | Falls Lead: Sam Foster Contributor: Sue Hyland

Graph| Safety Thermometer: Point prevalence of falls with harm



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Graph | Number of hospital acquired pressure ulcers determined as avoidable

Headlines: Pressure ulcer prevalence from Safety Thermometer remains static at 3.92% for Feb-15. The Trust has remained below the average line for the past 12 consecutive months. The Trust also continues to sit well below the National average figure of 4.31%. Avoidable Grade 3 pressure ulcers increased slightly in month to 8 for Feb-15, however avoidable Grade 2 pressure ulcers fell to just 6, the lowest recorded figure year to date. There remains 18 grade 2 pressure ulcers yet to be confirmed and two grade 3 across Heartlands and Solihull site. None are outstanding for Good Hope. Key Issues: YTD avoidable grade 2 pressure ulcers is 190 against a target of 159. Grade 3 is 55 against a zero tolerance. Although outside of agreed targets, improvements are evident compared to 2013/14 data. The CCG have challenged the outcomes on some of pressure ulcers deemed unavoidable and are requesting further information on the decision process. Actions taken: The Trust is undertaking a corporate quality assurance review on avoidable Grade 3 pressure ulcers from February. This review is to ensure consistency across all three sites and that processes are robust.

Further Action: A trajectory will need to be agreed for 2015/16 for a reduction in avoidable pressure ulcers, along with an action plan. To embed a site Tissue Viability Group which will report monthly to the Tissue Viability Strategy Group.

Graph | Safety Thermometer Point prevalence of all pressure ulcers

Quality and Safety | Pressure Ulcers Lead: Sam Foster Contributor: Maria Mackenzie



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National Staffing Return: Trust Qualified compliance: 99%, HCA compliance: 108% As per the Fill Rate Indicator Return (Nursing, Midwifery and Care Staff) in February, all areas of the Trust were compliant with qualified and HCA staffing. This data includes the resources for one to one care and the addition of the Supervisory Ward Sister hours as per the agreed UNIFY process. NHS England are currently developing safer staffing indicators to support the UNIFY data and these include sickness levels, appraisal uptake, mandatory training and patient satisfaction. HEFT have volunteered to work with NHS England to further develop these indicators.

Headlines: Nursing Staff Sickness: Sickness for February was 5.81% which is the lowest rate since October 2014. Flex areas remain open on all sites and this combined with the vacancy rate continues to put pressure on our teams and is likely to contribute to the sickness rates.

Table| UNIFY Staffing Summary February 2015

Quality and Safety | Nursing Workforce

Graph | % Sickness in Nursing & Midwifery

. Lead: Sam Foster Contributor: Andrea Field

Site Qualified Compliance

HCA Compliance

Heartlands 97% 112%

Good Hope 98% 105%

Solihull 105% 107%

Maternity 99% 99%

TRUST 99% 108%



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Graph | Nursing vacancy position February 2015

Quality and Safety | Nursing Vacancies

• The position includes flex for winter 2014/2015 that will be

removed as funding ceases at the end of March 2015. Flex across the three sites equates to an establishment of 45WTE with 6 WTE in post.

Actions taken: • Good Hope has had an increase of 23WTE in their base ward

funded establishment which has contributed to their vacancy position of 56.5WTE.

• There are 49 new Band 5s due to commence post in March 2015.

• A proposal for recruiting overseas nurses from outside of the EU is currently being developed for consideration.

• A recruitment event held on the 7th March 2015 resulted in 27WTE Band 5 offers being made, however 27 of these are nurses who do not qualify until September 2015. Interest from nurses with post registration experience remains minimal.

Lead: Sam Foster Contributor: Andrea Field

Headlines: Overall vacancy position for Band 5 nurses across all inpatient wards is 198WTE, which is an increase of 16WTE in month.

Key Issues:



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Headlines: Flexed capacity continues to be required due to: • Activity in ED Departments. • Challenges discharging patients into the community No serious or harmful injuries were caused by any falls incidents or pressure ulcers across the flexed capacity areas in Feb-15.

Site/ Division Pressures: • To ensure that staffing is reviewed robustly, weekly

surveillance sheets are completed on the performance intranet site.

• These are then reviewed via teleconference calls with the Chief Nurse or Deputy every two weeks. This looks at the retrospective data from the previous two weeks

• This results in a number of actions the outcome of which are then reviewed at the next meeting

• There are plans, owned by each site team , to close flex areas but these are dependent on activity.

• Site senior nurses will make a professional judgment on a shift by shift basis where there are shortfalls and mitigation is overseen by the site Head Nurses

Quality and Safety | Flexed Capacity Contributor: Andrea Field

Table | Flexed Capacity Wards in Feb-15:

NB: *Opened as medically fit for discharge ward but classed as additional capacity until core team is recruited

Heartlands Site

Ward Prevalence

Feb-15

Site Prevalence

Feb-15Rank

Wardrate per 1,000 OBD Feb-15

Siterate per 1,000 OBD Feb-15

Rank

Ward 7 BHH 17 Throughout Feb-15 122% 0.00 3.59 - 4.20 6.60 16 out of 24

Good Hope Site

Ward Prevalence

Feb-15

Site Prevalence

Feb-15Rank



Rank

Ward 3 GHH* 18 Opened 16th Feb 2015 102% 0.00 - 5.95 13 out of 20

Ward 7 GHH 21As required and mixed with Vanguard activity

101% 0.00 - 3.40 18 out of 20

Ward 22 GHH 6As required throughout

Feb-1595% 0.00 - 5.95 13 out of 20

Solihull Site

Ward Prevalence

Feb-15

Site Prevalence

Feb-15Rank



Rank

Ward 20B SH 26

Throughout Feb-15 with differing numbers of

beds open dependant on demand

127% 3.85 2.69 5 out of 10 2.75 7.26 8 out of 10

9.73

AreaBed

CapacityFrequency opened

Qualified staffing

compliance

Pressure Ulcer Prevalence (%) Falls Rate per 1,000

6.21

AreaBed


Qualified staffing

compliance

Pressure Ulcer Prevalence (%) Falls Rate per 1,000

Pressure Ulcer Prevalence (%)Falls Rate per 1,000Occupied Bed Days

AreaBed


Qualified staffing

compliance



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Quality and Safety | National CQUINs

Friends & Family Test | Headlines: Inpatient – The CQUIN target for January and February has been achieved. The March requirement is 40% and the plan is for a redoubling of efforts on the wards via HoNs and commencement of automated voicemail calls and agent calls facilitated by Performance teams and Healthcare Communications. Emergency Department – Inclusion of automated call responses into February figure and readjust. Automated calls in addition to SMS feedback for all of March 2015.

Dementia | Headlines: Although the fall in percentage for the Refer element of the CQUIN appears substantial the numbers are small (15 patients) Actions: Further investigation is to be undertaken to determine if the Refer figures can be improved, by a change in process.

Table | Dementia FIND element of CQUIN by site

Leads FFT: Richard Brown Contributor: Jamie Emery Dementia: Dr Niall Fergusson

Table | FFT Scores 2014/15 by Month

Safety Thermometer | Headlines See Quality & Safety Pressure Ulcer Slide

INPATIENTS Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 YTD % Responses

Q4 30% 13.59% 14.01% 16.78% 35.74% 36.86% 29.80% 29.51% 37.97% 27.99% 37.34% 31.51% 27.97%

Net Promoters 58.62 56.07 61.54 58.30 68.20 61.82 59.74 56.75 62.67 59.90 63.79 60.98

A&E Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 YTD % Responses

Q4 20% 18.83% 19.02% 17.52% 16.84% 17.36% 17.24% 18.11% 16.75% 16.57% 17.94% 21.63% 17.59%

Net Promoters 32.24 28.18 25.24 27.40 31.46 18.26 24.80 27.72 24.01 33.66 30.86 27.46

Site Q1 Q2 Q3 Q4 (QTD)

BHH 65.5% 75.0% 88.6% 86.3%

GHH 68.4% 75.9% 82.9% 85.5%

SOL 67.0% 82.3% 94.0% 91.9%

HEFT 66.9% 76.6% 87.4% 87.0%

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

Dementia FAIR Assessment

Find - 90% 67.7% 66.7% 66.1% 66.9% 79.3% 84.0% 86.7% 88.1% 87.6% 86.2% 88.0%

Assess - 90% (145 Avg) 89.7% 90.9% 92.8% 91.8% 93.4% 95.3% 90.0% 91.0% 92.9% 92.9% 95.1% Refer - 90% (24 Avg) 80.8% 57.7% 56.0% 73.9% 58.3% 73.1% 56.3% 62.1% 68.6% 90.0% 46.7%



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Quality and Safety | CQUIN schemes at risk Leads FFT: Richard Brown Contributor: Jamie Emery Dementia: Dr Niall Fergusson

Area Number Status

Acute 1.2 Unsure

Acute 1.3 Unsure

Acute 2.1 Not on track

Acute 3.1 Not on track

Acute 3.2 UnsureAcute 3.3 Not on track

Acute 4.1 On track

Acute 4.2 Unsure

Acute 5.1 On track

Acute 5.2 Unsure

Acute 6.1 On track

Acute 6.2 On track

Acute 6.3 On track

Acute 7.1 On track

Acute 7.2 On track

Acute 8.1 On track

Acute 8.2 Unsure

Acute 9 On track

Community 2.1 Not on track

Community 3.1 On track

Community 3.2 Unsure

Community 4 On track



Dementia: Supporting carers of people with

Leadership through harm free care: Improving culture through board level ownership

Cancer survivorship: Wellbeing clinics

Cancer survivorship: Treatment summaries

Maternity

Safeguarding: Learning from safeguarding concerns

Safeguarding: Initiation of CAFs

Improving dignity in elimination: Improving the management of urinary incontinence

Safety Thermometer: Reduce pressure ulcer prevalence grades 2-4

Deteriorating patient: Early identification and escalationDeteriorating patient: Documentation and communication of DNACPRDeteriorating patient: Improvement of sepsis managementLeadership for harm free care: Transparency of care

Leadership for harm free care: Improving culture

Dementia: Dementia Champions

Description

Dementia: Find, assess, investigate, refer

Safeguarding: Learning from safeguarding concernsSafeguarding: Initiation of CAFsImproving dignity in elimination: Improving management of short-term incontinenceImproving dignity in elimination: Prevention of

Friends & Family Test: Increased or maintained response rate

Friends & Family Test: Increased response rate in acute inpatient servicesSafety Thermometer: Reduce pressure ulcer prevalence grades 2-4

Dementia: Clinical leadership

Table | CQUINs Q4 Achievement Status

Comments from Performance: The following CQUIN schemes are at risk for Q4: • 1.3 Friends and family test (FFT) - The in Month target for inpatient responses of

40% is currently not being achieved.

• 2.1 Safety Thermometer (ST) target of 2.1 point prevalence median equalling a 50 % reduction in point prevalence of pressure ulcers, achievement is currently 3.92.

• 3.1 Dementia: The requirements are a CQUIN outline for 2015/16 remains to be written. The numbers of patients assessed, investigated and referred with a target of 90% for each element are not being achieved.

• 3.2 Dementia: A named clinician and a training plan to be written for implementation in 2015/16.

• 3.3 The outcome of carers questionnaires and a date to be arranged for board discussion of survey outcomes.

• 4.2 Safeguarding common assessment framework (CAF’S) number of CAF’s raised is failing the agreed number of 100.

• 5.2 Prevention of constipation: A Rapid improvement plan for oral laxatives usage is being prepared for agreement with the CCG.

• 8 Cancer: Cancer survivor treatment summaries for colorectal cancer. A pilot is to be undertaken with a report and a plan for roll out to other cancers to be provided.

Discussions are being held with the owners of the above CQUINs with regard to remedial planning. Current estimates of achievement is 54.2% of CQUINs with a 60% target.

NB: Specialised CQUINs have not been included



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Headlines: Trust overall performance was on target in February-15 to 95.18%: • Heartlands = 94.62% • Good Hope = 94.79% • Solihull = 97.18%

Wards with the largest number of missed assessments are: Heartlands – Ward 5 = 48 (79.04%), AMU Assessment = 35 (87.41%), Day Surgery Unit = 33 (88.70%), Ward 10 = 28 (80.42%) Good Hope – Ward 2 = 42 (78.01%), AMU = 40 (78.26%), Day Surgery Unit = 34 (92.43%), Ward 7 = 27 (80.15%)

Quality and Safety | VTE Assessment

VTE Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 VTE Assessment 95% 95.0% 95.3% 95.0% 95.2% 95.0% 95.1% 94.5% 95.1% 95.0% 94.4% 95.2%

Actions taken: Improved performance reported for day case units at BHH and GHH in line with changes to practice implemented last month. On plan to achieve target performance of 95% in March 15. Further Actions required: In Day Surgery units: • Drugs and Therapeutic Committee approved the PGD (on 11/03/2015) which enables them to work within this. It will now be for

pharmacy to add onto their list. • The matrons for the areas are aware so they will be sharing this with their teams. Realistically, we should start to see this filtering through

into practice in the next few weeks.

Table | VTE Assessment in 2014/15



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Headlines: The appraisal calculation February's data excludes starters from April 2014 who would not have been due an appraisal. There has been an increase in the last month. Key Issues: The appraisal rate is below the 85% required by the CCG for the end of March. The figures have been recalculated as above which has improved the compliance rate. Actions taken: • HR Business Partners have been working closely with their

Directorates to improve reporting rates. This has resulted in more appraisals being sent through to the appraisal in box so they can be input onto OLM.

• A monthly report is sent out each month by the appraisal team with appraisals which have not been reported.

• To ensure managers know where to report appraisals communications will be asked to highlight the reporting on the intranet.

• Managers will be asked to explain non completions at year end and the information will be summarised.

Further actions: • Message on March payslips requested. • Appraisal pages re-launched on Faculty site. • Reminders on daily communications. HR view: As over previous years has shown that the peak for appraisals is the summer months, to avoid winter pressures. The third quarter audit has just been carried out and an appraisal group set up to review the paperwork.

Workforce| Appraisals

Graph | Appraisals trajectory:

Based on a straight line trajectory at end of month 11 (February 2015) all areas should be at least 70% compliant with appraisals

Table| % Appraisals completed by Division (Feb-15 position): Division BHH GHH SOL CSS WC CORP FAC HEFT

% of Staff Appraisals Completed

49.41% 48.36% 65.15% 75.93% 54.00% 86.28% 86.72% 64.76%

Lead: Hazel Gunter Contributor: Ray Reynolds



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Headlines: As at the end of January, the Trust achievement rate for mandatory training is 85.94% , a drop of nearly 2% this month, but remains ahead of the in month trajectory of 81%. Key Issues: Whilst currently on target, cancellation of Mandatory Training during Gold Command (Dec / Jan) may bring February / March figures down a little. The resuscitation team have current staffing shortages (vacancies and sickness) which is affecting their ability to provide extra training. Areas where achievement is currently quite low include Blood Transfusion (administering blood) 57.83% , Fire Safety 59.09%, and Clinical Resus 58.45% Actions taken: • Additional programmes have been scheduled for March, with the

exception of resuscitation. Focus will be particularly on low completion areas and with support from Corporate Nursing.

• The resuscitation team are exploring use of link worker training in clinical area’s rather than class room teaching by the team.

Further Actions: Attaining target may be dependent on capacity to release staff. HR view: At this stage it is anticipated that the overall target will be met.

Workforce | Mandatory Training

Graph| Mandatory Training (MIA)

Table| Division performance – January 2015 (MIA)

NB: Mandatory training is reported one month in arrears.

Division BHH GHH SOL CSS WC CORP FAC HEFTMandatory Training % Compliance

82.30% 83.91% 84.49% 85.78% 86.49% 79.90% 94.90% 85.93%




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Headlines: The February 2015 figure overall shows 4.70% which is another small increase and is still considerably above trajectory to meet the target of 4% by 31 March 2015. Facilities and Women’s and Children’s Divisions remain highest at 6.07% and 5.40% respectively. Monitor have been informed that we are unlikely to achieve 4% by 31st March 2015. The three significant directorates with the highest sickness levels are: General Medicine at BHH 6.83%, Acute Medicine at GHH 6.83% and Catering 6.77%. Some 79% of sickness absence is due to short term sickness where it is most likely that significant improvements can be made Key issues: Pressures of work and engagement of staff particularly through not feeling valued are still believed to be key issues. It does appear that areas where there is uncertainty due to change management suffer from increased absence levels . (e.g. Sexual Health, ) Actions taken: Continuing as last month. Provision of information identifying hotspot areas. Ensuring management of sickness is taking place. HCA project completed where focus groups have been developed and issues addressed via matrons. Hotspot areas identified, e.g. Delivery Suite at GHH and BHH, Acute Medicine at BHH, Sexual Health and ID in CSS. On going work with managers and escalation as appropriate. Hearings and dismissal where necessary. 11 dismissals since April and 9 staff currently being managed at final stage. Bespoke training in areas where managers are struggling. Referrals to Occupational health as necessary. Review of sickness policy to improve processes - currently ready for consultation with staff side.

Further Actions: Continuing Development of engagement plan as part of overall Trust OD plan. Working group being set up to consider incentives for low sickness. HR view: It is most unlikely that the target of 4% will be achieved but it is anticipated that the focus on staff engagement which has now begun will have a positive impact.

Workforce| Sickness

Graph| Trust sickness as an MAA

Table| February sickness by Division

Division Feb MAA*BHH 3.86% 4.58%GHH 5.83% 4.84%SOL 3.64% 4.10%CSS 4.79% 4.96%WC 4.91% 5.40%

CORP 3.79% 3.60%FAC 8.57% 6.07%

HEFT 4.60% 4.70%




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Headlines: The year end target for voluntary turnover is 8%. Voluntary turnover has been above trajectory over the past four months. The overall figure has stayed at 9.02% for the third month. Corporate and Facilities remain low with GHH and Solihull being the highest at 10.32% and 11.08% respectively although GHH has again shown further improvement. The qualified nursing turnover has reduced further from 11.3% to 11.13% for the rolling year to February 2015. Time to recruit has gone up slightly to 8.9 weeks and although still above the target of 6.25 weeks is well below the peak month of October when it was 10.7 weeks.

Key issues: The main issues is that turnover does appear to have stabilised at around 9% now and hopefully focus on staff engagement will start to have a positive impact.

Actions taken: TURNOVER: • Continued production of reports and identification of hotspot areas. • Deep dive analysis has been completed in main areas (e.g. Pharmacy) and key

issue is engagement. Pharmacy have particular difficulty with retaining bands 6 and 7 and work is being undertaken to see what can be done. Acute Medicine at Heartlands seems to have particularly high Turnover and the pace and volume of work is highlighted. Development of Assistant Practitioner role is taking place to give HCA career progression and support qualified staff workload.

• Recruitment initiatives to replace leavers continue (e.g. Overseas recruitment for Theatres).

• Increased recruitment at GHH to reduce pressures and stabilise turnover. • Local Workforce Committee at Solihull addressing Issues. TIME TO RECRUIT: • Challenge to managers taking excessive time. • Escalation where appropriate • Further Actions| Development of engagement plan. Including events being

held by CEO.

HR view| Whilst turnover has stabilised and actions continue it will not be sufficient to achieve 8% by end of March 2015. The time to recruit has also stabilised over the past few months but is unlikely to achieve the target of 6.25 weeks.

Workforce| Voluntary Turnover and Recruitment

Graph| Voluntary turnover April – Feb-15 (MAA)

Table | Average time to recruit (Feb-15)

Graph| Average time to recruit in weeks (MIA)

BHH GHH SOL CSS WC CORP FAC HEFTAverage Time to

Recruit7.0 7.5 11.6 9.2 9.1 8.7 9.2 8.9




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Headlines: The Trust has an I&E loss of £2.5m in month, and £8.4m year to date. The adverse variance on Medical staffing costs has worsened further this month (£7.5m YTD). The adverse variance on nursing pay has also worsened this month (£4.7m YTD). Efficiency delivery remains challenging (£7.1m shortfall against YTD plan).

Key issues: There are three high level issues requiring in-year focus; 1. Pay bill; 2. Current Service Improvement Efficiency Programme

performance; and 3. Additional costs layered on to support delivering patient care

and performance versus additional income received

Efficiency planning for 2015/16 is the key priority. Progress remains slow and significantly adverse to the Trust’s annual timetable. The Trust is on course to have fully exhausted the agreed envelope for private sector usage by the end of March (£4.2m).

Actions taken: 1. Revised SIEP Steering Group established - weekly meetings

with Divisions from March to ensure conversion of plans to likely delivery & implementation.

2. Review group established to assess additional measures business cases and make recommendation on allocation of recurrent funding / disinvestment.

Further actions: 1. Ensure robust exit plans in place for additional measures

where benefits not demonstrated and funding not agreed recurrently;

2. Medical productivity and job planning; 3. Drive to convert locum and WLI expenditure into substantive

posts where appropriate; 4. Broader recruitment push; and 5. Challenging delivery of the four divisional rectification plans

that themselves would resolve the majority of the Trust’s current underlying position.

Internal Reporting | Finance Lead: Richard Barratt



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Headlines: As we approach March focus needs to be shifted towards exit planning. Taking appropriate action to withdraw from schemes that are due to cease and securing funding for those that are due to continue. External capacity remains the most significant issue in term of scheme delivery with underutilisation on both GHH and SOL .The financial forecast indicates a £400k overspend against the whole plan with a under-spend on external schemes offsetting a large overspend against the Enhanced Bank Rates. An opportunity to extend the most effective scheme from HEFT has come forward from the CCG’s who have received year-round resilience funding increase. HEFT submission is ‘Early Supported Discharge’ and will be reviewed by SRG in March. Other providers also have opportunity to bid for their ‘most effective’ scheme to continue. Key issues: Schemes Delivery – There are 14 external and 13 internal schemes making a total of 27. 21 of these are delivering against the expected outcomes. 2 schemes are the amber zone (delivering within the agreed 25 % tolerance), 2 schemes sit in the red zone (delivering below the target and outside the agreed tolerance) and the KPI’s for 2 schemes need to be adjusted. Schemes in the Red Zone are:

• The Bridging POC for Solihull residents are being under-utilised (to support BHH & SOL discharges.

• Pharmacy Delivery Service at BHH – Implementation of automated equipment within A & E. Scoping is complete, but unlikely to be fully operational in the intermediate future.

Schemes in the Amber Zone are: • St Giles POC at GHH. • SID at Solihull is amber due to Norovirus in Hospital restricting flow. It is

however green year to date.

KPI’s - Data has been received for the is awaited for the Extended CAMHS Service in Paediatrics , but clarity of the baseline measure is required to provide a meaningful measure. Flex Capacity at GHH is showing as Red as only 18 beds against 24 funded are open, however this is not seen as a negative position. An overview of the utilisation of the beds commissioned and managed by Birmingham Cross City CCG has been received. £1m was invested in these schemes at 5 care homes and utilisation varies between 70% and 100%. Bed Modelling – We are awaiting the revised bed model which takes into account increased admissions and bed changes particularly with the GHH capacity. Ward 3 is now open , but this has been offset by the reduced capacity within Cedarwood due to safety concerns and capacity purchased from Healthcare at Home being used to support the unit. These factors need to be reflected in the bed model.

Exit Planning – Each Site has completed an exit template for each of the schemes. Good Hope– The main schemes at GHH are Flex, External Capacity, Frailty, Therapy Support and 7 Day Working. The external capacity at the end of May. Flex on Ward 21 has ceased to provide capacity for a full Frailty Service. Plans are in place to cease Physio and the current level Medic Support on 31.3.15. Business Cases have been submitted to support the continuation of Frailty Service and the relevant support services. HC@H extension may also continue subject to ORCP bid below. Solihull – The main schemes at SOL are Flex, Community Beds, SID and Packages of Care. Plans are in place to reduce flex capacity after the Easter period with a final closing date in May after the early Bank Holiday. Community Beds and most POC will cease after Easter Holiday. SID will continue with re-current funding from ORCP if approved. Heartlands – The main schemes at BHH are Flex, 7 day Working, Frailty , GP Weekend working , Ambulance Support, SID and Servacare. Plans are in place to initially reduce flex capacity and then close by 30.4.15. 7 day working will reduced for Respiratory , Acute Med have submitted a business case and there are no plans for Renal due to safety reasons. A business case has also been submitted for Frailty and Servacare will revert back to baseline activity. There are no plans to exit from the Week – End GP Service or from the Ambulance Support. Extended SID will continue subject to ORCP bid below. The Trust has been asked by CCG to submit its most effective scheme to SRG in March for continued funding post end of April given resilience funding is now year-round and included in CCG baselines. It has been agreed ‘Early Supported Discharge’ extension should go forward c. £1.2m, minimum 41+ placements. This includes SID (BHH and SOL) and HC@H (GHH) with some support from limited POC will go forward for review /approval. Financials - Of the £5.5m investment managed by HEFT. £3.6m has been incurred to date. £1m against the premium Bank Rates to which £500k was budgeted. The current forecast indicates a £470k overspend at the end of April against the whole plan with an underspend on the external schemes subsidising a large forecast overspend of £1m on the enhanced bank rates. The continuation of these payments clearly need to be considered and decision on continuation made.

Winter Plan & Flu | Update

Please note information is based on KPI’s for W/C 23.02.15 The KPI’s are attached for information.



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Recruitment – The position with recruitment remains unchanged. 86% of the posts originally required have commenced (excluding temporary staff) However many of the filled posts particularly within nursing have been absorbed into the base wards leaving a significant reliance on bank and agency staff to resource the additional areas. This is evidenced by the spend on Bank & Agency. Likewise the medic recruitment has been difficult with most posts filled on a locum or agency basis. Deloitte’s Internal Audit Review of Winter gave Moderate Assurance . 15 recommendations were made. 13 have been implemented, one is not yet due and one is outstanding. The recommendations have strengthened our planning ,escalation and reporting procedures . The response and implementation of the recommendations is being overseen by the Audit Committee. Actions taken: Local action is being taken to increase utilisation of the external schemes and schemes within the amber and red zones continue to be reported via the weekly KPI’s . The audit recommendations have been progressed significantly and exit planning has commenced. Recruitment continues to be difficult, posts have been covered by temporary staffing where possible, but this is clearly not ideal. Enhanced Banks Payment Rates have encouraged permanent staff to work additional hours to provide consistency of care, however this comes at a financial cost.

Winter Plan & Flu | Update continued Further actions: • The Urgent Care Improvement Board need to consider and take

appropriate action in relation to the schemes in the Red and Amber Zones.

• A update of the bed modelling is underway. • Sites need to adhere to their Exit Plans . • The financial spend should be noted and a decision needs to be

made regarding the continuation of the Enhanced Bank Rates. • A post implementation review of recruitment is recommended

to inform the on-going planning process. understand the issues



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Table | Trust Inpatient Ward Summary Feb-15

Key Issues: Noise at night still remains an area of lower performance against the other metrics. Significant Improvements have been seen this month in Involved in decision making and informed about going home. February actions: A deep dive into the Disturbed at Noise at Night will be undertaken to identify ‘hot spot’ areas.

Inpatient Feedback | Headlines

Trust Level Patient Opinion| Headlines

Graph | Themes of positive & negative comments from Patient Opinion and NHS Choices websites Feb-15 Key Issues:

Medical Care Received the largest number of negative responses however the positive responses were significantly higher. Nursing care received the highest number of positive comments. February actions: Review of approach to responding to NHS Choices and Patient Opinion to take place in April 2015. Positive comments from Patient Opinion are now being included in regular Trust wide communications emails.

Patient Experience | Metrics Lead: Richard Brown



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Graph| New Complaints

Patient Experience | Complaints

Key Issues: To date 8 Complaints have been upheld by the Ombudsman – 7 partially upheld and 1 fully Reopened complaints themes relate to unanswered questions; unhappy with responses, e.g. defensive tone; and process issues, e.g. time delays in responses. February actions: A review of complaints is underway with planned completion by the end of April 2015. Complaints upheld by the Ombudsman will now be reviewed via SIRIUS meetings. The next meeting is 8th April 2015.

Complaints | Headlines Despite a small rise in complaints in Feb-15, with a small rise in the percentage of complaints, the overall trend is decreasing.

Graph| Quarterly Themes of Complaints

May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Number of re-opened complaints 9 7 8 12 6

Number of referrals to Ombudsman 5 4 2 0 0 3 5 1 3 2 Number of complaints upheld by Ombudsman 3 0 0 1 0 1 0 1 2 0

Complaints | Themes Delays / cancellations is the most common theme at present. Information on delays and cancellations is currently being reported as part of the scheduled care programme. Attitude and behaviour is the second most common reported issue. February actions: Engagement with site / divisional teams to discuss actions is to be improved. A ‘deep dive’ into attitude and behaviour.

Lead: Richard Brown



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Safety SitRep - March

1



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March 2015

Safety Situation Report

Status

Strategic risks (Updated Jan 15) •Regular reports provided to Board to discuss Strategic Risks. There have been 3 new risks added recently

Red (≥ 15) operational risks. •There are ten operational red risks currently open. Seven have been validated in 2014/15 two have now been downgraded and four remain open from 2013/14 • 1 Risk Ultrasound Scanning Risk (Obstetrics) has been downgraded to 12 following review at risk forum but will continue to be monitored. • 1 risk re Sustainability of Endoscopy Service due to loss of JAG accreditation at BHH has been downgraded to 12 a further risk regarding JAG accreditation has been agreed as a serious risk and will be included in the next report.

SUIs and incidents •There have been three new SUI’s declared since the last report. Wrong body release ,Suboptimal care of deteriorating patient, Deteriorating patient. • Following initial investigation one Sui has been downgraded as no evidence of harm identified (Service Failure of Emergency Medicine Pathway)

Mortality •The Trust is still unable to measure mortality reliably using HSMR. •Crude mortality shows a peak and decline in number of inpatient emergency deaths. •The latest Summary Hospital-level Mortality Indicator (SHMI) score for Jul 13 to Jun 14 is 109, this is within the HSCIC ‘as expected’ banding.

IMR (December 2014) •Currently 9 risks and 6 elevated risks highlighted through the December 14 “intelligent monitoring report” (was 11 and 5 in draft version issued in October 14) •Was 9 risks and 7 elevated risks in previous (June IMR)



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Summary risk profile

^Date risk rated as red (≥15) and agreed at Risk Forum *Score with mitigation in place: mitigating action to reduce the risk needs to take place within one month in order to reduce the risk to acceptable level (i.e. Amber).

•W&C – Women's and Children's Services •CSS – Clinical Support Services

3

RED OPERATIONAL RISKS-Monitoring by sites / division.

Risk Summary: Red Site Division Date^ Initial Current*

Staffing the A&E Service at SHH SH BHH Feb 15 16 16

Provision of 24 hour A&E service is dependent on adequate staffing with appropriate skill mix.. Almost all medical shifts at Solihull are now covered by locums. Nursing-wise, received funding for for an additional assessment nurse in response to our last CQC assessment but unable to recruit. ENP-wise the proposed changes to the service at Solihull have created anxiety about job security and many staff are reviewing their options for the future. Our ENPs are a highly desirable group of staff both for other EDs and for primary care. In terms of safety we are unable to guarantee quality standards around assessment. Unable to always ensure locums have up to date training / competencies. This is compounded if the nursing staff / ENPs working with them are bank staff and is set within a hospital site that has little on-site back up for unwell cases. It is becoming increasingly difficult to obtain adequate numbers of staff in all groups of an appropriate calibre to provide a safe quality service.

Implications of Solihull CCG ERG proposals All SH Feb 15 16 16

In June 2014 Solihull CCG published plans developed through their Effectiveness Review Group (ERG). HEFT services affected by the ERG proposals are: (1) Non-renewal: Virtual Wards; Heart Failure; Hospital Liaison Nursing; Nutrition Service; Castle Practice Dietetics and Podiatry; plus Balsall Common Practice ENT; (2) Activity threshold: MSK; Podiatry; (3)Contract renegotiation: Diabetes; SALT (Children); OT (Paediatric). It is important to highlight that there are implications of ERG on wider care pathways utilized by patients cared for by HEFT. HEFT are currently in formal negotiations regarding ERG proposals. As part of these negotiations information regarding the CCG impact assessment of ERG proposals has been requested but not yet received.

Delay in diagnostic Endoscopy tests All BHH Oct 14 15 20

The endoscopy service is not meeting required timescales for diagnostic endoscopy testing of out-patient (2 week wait endoscopy requests, urgent requests) and in-patient requests (especially upper GI bleed which should be completed within 24 hours). GP two week wait cancer proforma requests are being completed within timeframes. Urgent endoscopy requests currently within 4 -6 weeks (should be 2). Update: A further 600 patients have been identified that were not on the waiting list system which has increased the overall waiting list to 1580 patients. The additional backlog now means that the number of patients waiting more than 18 weeks stands at 195 with projected return to 5 week diagnostic time not expected until Q3 2015/16. There have been an increasing number of clinically significant cases with delayed diagnosis.

Emergency Rescue from Lifts at BHH and RSU BHH/GHH Corp Aug 14 16 16

In the event of a lift failing and passengers being trapped, estates staff are trained annually to hand wind the lift to the next floor. This year the trainer deemed it unsafe to undertake this task/provide training for the lifts in the main ward block at BHH and RSU at GHH (due to the loading and effort required to handwind the lift). The lifts in main ward block (BHH) fail approximately 1/month and the lifts in RSU approximately 2/month. Therefore estates staff will have to perform this task, despite their training having expired. A safe system of work for the release of passengers from these lifts is being developed as an interim measure

STRATEGIC RISKS-Monitoring by EMB, QRC & TB (as at March 15)

Summary & score

Future financial risk (↔ 16)

Patient flow (↔ 16)

Ability of the Trust to undertake strategic configuration (↔ 12)

Workforce transformation (↔12) - CLOSED

Staff Morale (↑ 16)

18 Weeks (↔16) 12

Breast Recall (↓12)

Mortality (12)

Enforcement Action (16)

PMS2 (20)



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Remaining Red Risks from 2013/14

Implementation of IT system for Sexual Health – Lillie BHH CSSD Mar14 16 16

Potential loss of vascular service (if unable to provide hybrid theatre and loss of commissioning of these services) Hybrid theatre build now underway – risk remains at 16.

BHH BHH Mar14 16 16

Impact of extended stay in ED. Reviewed Jan 2015 – risk upgraded to 20

GHH BHH

BHH Jan14 15 20

Chemotherapy prescribing / administration in absence of EP BHH BHH Oct13 15 15 4

RED OPERATIONAL RISKS-Monitoring by sites / division.

Risk Summary: Red Site Division Date^ Initial^ Current *

Sexual Health IT system unable to meet statutory reporting requirements

BHH CSS Jul14 6 16

The Telecare system currently used to record attendance and drug treatment is unable to meet mandatory data requirements for Public Health England, HIV and AIDS Reporting System (HARS). As well as the reputational impact this may have on commissioning decisions, organisational non compliance may result in a 10% fine (equates to approximately £400k for 14/15 contract value). The department opted to implement a new (HARS compliant) IT system. Climate–HIV but technical difficulties in the IT systems / interfaces with other Trust systems means that they remain unable to comply with these statutory reporting requirements. Update: Predicted “Go live” date is March 2015. Challenges remain for the timely configuration, training and implementation to be completed.

Impact of unacceptable delay for backlog of cases requiring complex endovascular aneurysm repair (EVAR)

BHH BHH July14 15 16

The death of a patient from a ruptured thoracic aneurysm whilst waiting for a date for treatment at HEFT identified a potential 92 patients on the EVAR pathway without an operation date who were not recorded as part of the HEFT waiting list. Following validation the backlog is 41 patients who are are currently listed for surgery (with another potential 24 patients who may filter into the system as the decision is taken to treat). The oldest case is 38 weeks from decision to admit. 38 additional lists are required to address the backlog. Update: Plan to clear backlog by end of March 15 is on track, some delays in receiving complex grafts but negotiation is ongoing to expedite this.



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Headlines | The Trust is still unable to measure mortality reliably using HSMR. Crude mortality shows a peak and decline in number of inpatient emergency deaths. The latest Summary Hospital-level Mortality Indicator (SHMI) score for Jul 13 to Jun 14 is 109, this is within the HSCIC ‘as expected’ banding. The combined response to the Silverman and internal audit report was provided to the January Trust Board Key issues | Due to issues with PMS2, data from July onwards is not reliable for HSMR mortality measurements. However, HSMR will be published by Dr Foster and this shows a continuing downward trend in Oct 14. The year to date published score is 94.3, this is within the ‘as expected’ banding There was a marked rise in the weekly number of deaths over December which peaked at the end of December/beginning of January. This was associated with increased congestion in patient flow and also mirrors the flu spike – this is in line with the findings of the Public Health England (PHE) report into seasonal flu. There was a decline in crude numbers of deaths throughout January. Actions taken| The Trust Mortality and Morbidity group met to discuss the recommendations from the Silverman report and internal audit report. It was decided that all deaths will be reviewed, an amended proforma was agreed and a consultation document will be circulated.

Quality and Safety| Mortality

Further Actions| Selected case note review to be undertaken by clinicians to review the December weekly spike in crude mortality. A consultation document relating to the review of all in-hospitals deaths will be circulated for comment in February. A meeting is taking place in February to discuss with Dr Foster the impact of PMS2 implementation on HSMR scores and an options appraisal for rectification of data. Table| Trust reported HSMR up to Oct 14

Graph| Crude mortality, weekly adult emergency deaths

Graph| Adult emergency deaths when compared with positive influenza tests*

2012/13 2013/14 2014/15 2008/9 2009/10 2010/11 2011/12 Apr - Jun Jul- Sep Oct- Dec Jan- Mar Apr - Jun Jul- Sep Oct- Dec Jan- Mar Apr - Jun Jul- Sep Oct-14

100 98 98 98 100 104 105 120 119 109 113 96 98 93* 88*

* Data to be used with caution

Lead Dr Ann Keogh



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Summary SUI profile March 2015

6

OPEN SUI INVESTIGATIONS (as at 06/03/15)

Site / Division* Directorate Date (N = Never Event; P = Prevented Never Event) Status

BHH BHH Multiple May14 Salmonella Outbreak (May /June) 2014/18537 Draft report received and QA process commenced

Open

BHH BHH Cardiology Dec14 Delay in Diagnosis of Breast Cancer 2014/41308 Patient diagnosed with metastatic breast cancer in December 14 after having an abnormality noted on CT scan in 2011, whilst under the care of the cardiology team (coincidental finding). A recommendation was made within the CT scan report to refer to Breast Service , which does not appear to have been actioned.

Open

SH SH Ophthalmology

Dec14 Insertion of incorrect lens (Never Event) 2014/41293 Patient underwent cataract surgery in her left eye in January 2014 with successful outcome. Patient then underwent surgery on right eye in July 2014. Both of the lenses chosen for her surgeries were based upon biometry she underwent in November 2013. In December 2014, it was identified than an incorrect lens had been inserted into her right eye and as a result she had poor refractory outcomes and required further surgery. Initial investigation has identified that the wrong biometry was in the patient’s electronic medisoft record that was used to select the lens required.

Open

BHH BHH Gastro Jan 15 Delayed diagnosis 2015/1430 Patient referred to gastroenterology in June 2014, following results of an abnormal abdominal ultrasound scan and CT scan. The referral was marked as urgent. The patient’s first outpatient appointment was in Sept 2014, a delay of approx 3 months from point of referral to first outpatient attendance. Between September and December 2014 the patient underwent further diagnostic investigations and was given a diagnosis of multifocal hepatoma on a background of cirrhosis at the beginning of January 2014. The patient has been given a limited prognosis and is receiving palliative care.

Open

BHH BHH Gastro Jan 15 Delayed Diagnosis 2015/1435 In October 2013, an urgent GP referral was sent to the Trust regarding a patient with a 6 month history of upper abdominal pain and weight loss. Referral was received early November 2013, and marked “for pancreatic clinic soon”. The patient had a complex history of impacted common bile duct stone which required treatment in 2009 (multiple ERCP’s and unsuccessful surgery). This urgent referral is recorded as being received on ICARE in Jan 2014. The Patient was first seen in outpatients in April 2014 and subsequently underwent diagnostic investigations and MDT discussions. In June 2014 the patient was given a diagnosis of metastatic colon cancer and was referred to oncology team for further management. The patient died in October 2014.

Open

BHH BHH Gastro Jan 15 Service Failure 2015/1438 During late December 2014, an increase in the backlog of patients waiting for diagnostic investigations was identified, this position was reviewed and clarified early January 2015, with an additional 600 patients confirmed as not being on the gastroenterology diagnostic waiting list, some dating back to September 2014. In June 2014, a corporate risk was raised relating to a backlog in gastroenterology for diagnostic investigations and a plan was agreed and put into place to manage the backlog.

Open

NB. Linked to “Delay in diagnostic Endoscopy tests” Risk



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Summary SUI profile March 2015

7

OPEN SUI INVESTIGATIONS (as at 06/03/15)

Site / Division* Directorate Date (N = Never Event; P = Prevented Never Event)

GHH GHH Mortuary Feb 15 Wrong body release 2015/6047 Patient A died at GHH and was transferred to an offsite mortuary. Deceased patient B with a similar name was also transferred from a different to the same offsite mortuary. Due to a decision change for patient A to be cremated not buried, it was necessary for patient A to be transferred back to GHH for amendments of required paperwork. In error patient B was transferred to GHH instead of patient A. Patient B was then released for cremation instead of patient A. The error was noted when the pathology laboratory routinely rang the off site mortuary to see if they had any outstanding deceased patients for GHH. Patient A was identified as still being at the offsite mortuary.

NEW

BHH BHH

ED Feb 15 Suboptimal care of deteriorating patient 2015/6003

Patient admitted with a history of chest pain. Whilst being clerked the patient suffered a cardiac arrest. The patient was successfully resuscitated but found to have a potassium of 9.1mmols. Appropriate treatment was given to lower the potassium however: the patient suffered a further two cardiac arrests and despite prolonged resuscitation the patient died. The patient’s potassium at this point was 8.4mmols. It would appear that for a period of six hours the patient did not have a repeat potassium check or receive any treatment for hyperkalaemia.

NEW

BHH BHH ED/AMU Feb 15 Deteriorating patient 2014/36858 A patient was discharged home following a failed endoscopy procedure. The patient presented in ED 2 hours post procedure with difficulty in breathing and marked surgical emphysema . A CT scan confirmed a perforated oesophagus and the patient was transferred to AMU. The following morning the patient suffered a cardiorespiratory arrest and died. Concerns have been raised regarding the management of the patient’s care.

NEW



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Summary SUI profile : Recently closed

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Recently Closed SUI INVESTIGATIONS (as at 06/03/15)

Site / Division* Specialty Date (N = Never Event; P = Prevented Never Event Status

BHH BHH Acute Med

Dec14 Injury following intentional fall through window 2014/38811 Patient admitted to BHH with symptoms of alcohol withdrawal. During the morning patient became increasingly agitated despite attempts to calm him down. The patient broke restrictors on an external window in the ward (which had been in working order) and climbed out of window. The patient was witnessed to jump from the window ledge, landing on his feet (approx 20ft drop). Following assessment in ED it was identified that the patient had sustained bilateral lower limb fractures which have since been treated surgically. NB. Not “Never Event” as window restrictors were in place and in working order

Closed

Raise awareness of the benefit of early referral to the RAID team for all patients admitted with alcohol withdrawal. Acute Med should audit documentation of management plans and that entries are dated, signed and signatures are recognisable. Acute Med should look at the issue of prescribing medication promptly when it is decided to add medication or change medication on the ward round. Acute Med should ensure that diagnosis of acute alcohol withdrawal triggers a discussion on the post take ward round and the level of nursing observation required is documented in the medical notes and reviewed on a daily basis.

NB. Not “Never Event” as window restrictors were in place and in working order



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SUI: August 2013 GHH Care of Elderly Opiate overdose in opiod naive patient – Prevented Never Event Themes: Communication/non adherence to policy

SUI: September 2013 SHH T&O Theatres Retained ribbon gauze following THR – Never Event Themes: Communication/ non adherence to policy/poor awareness of duty of candour

Communication Documentation Medication Safer Surgery Deteriorating Patient

Communication •Vital and iskills resources •Nursing safety manuals •Safety walkarounds and responsive safety review processes •Risky business forum for junior doctors

Documentation •Surgical safety checklist / audit •Nursing Metrics •Annual Trust-wide documentation audit •Safety thermometer •NG tube policy and guideline

SUI Themes (Root causes and contributory factors) and Schedule 5 letters received by HEFT

Common themes from SUIs and associated work-streams

Deteriorating Patient Re-established Deteriorating Patient Recognition Group Vital and iSkills resources Mews audit Nursing metrics Lessons of the month SUI at a glance report Action cards being produced for issue to surgical registrars mandating the circumstances where they must contact their consultant

SUI: September 2013 Gastroenterology BHH Injury during liver biopsy Themes: Communication

SUI: July 2013 SHH ED Unexpected Infant Death Theme: Documentation/Communication

SUI: August 2013 GHH Urology/ED Delay in timely intervention and escalation of the deteriorating patient Themes: Communication/Non escalation of clinical concerns.

Medication •Safe Medication Practice Group •Medication Matters newsletters •Improvement to EP system •New Medicines Group for reviewing all severe harm incidents from medication incidents •New RCA for all severe harm medication incidents •Patient Safety Team developed tool for live information relating to missed dose anti-biotics.

SUI: July 2013 SHH Ophthalmology Wrong lens insertion– Never Event Themes: Theatre checking procedures/communication

SUI: October 2013 Vascular Surgery BHH Unexpected death following surgery Themes: Non adherence to VTE policy/ communication/documentation

SUI: October 2013 General Surgery BHH Wrong Site Surgery – Never Event Themes: Documentation/communication

Safer Surgery •Sharing the learning from theatre related Never Events •Knowing the risk. Perioperative risk assessment / communication tool •Safety walk about in all theatres across sites

SUI: September 2013 Gastroenterology Surgery BHH Delay in escalating deteriorating patient Themes: Delay in escalating patient to consultant level/poor recognition of the deteriorating patient

Serious Untoward Incident Themes /Never Events July 2013 –April 2014

SUI: October 2013 Pathology BHH Delay reporting pathology specimens Themes: Under efficiency, lack of capacity, poor organisation Learning tools

•SUI at a glance reports and cascade system •Mortality digest •Safety lesson of the month •Weekly Quality and Safety Meetings •Developing Dare to Share Meetings



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SUI: May 2014 – ITU BHH Cessation of inotropic drug infusion Themes: Communication/non adherence to standard operating policies

SUI: June 2014 – Paediatrics GHH Delay in recognition and escalation of a sick child. Themes: Communication/ delay in recognition and escalation

Communication Documentation Medication Safer Surgery Deteriorating Patient Patient Handover

Communication •Vital and iskills resources •Nursing safety manuals •Safety walkarounds and responsive safety review processes •Risky business forum for junior doctors •Junior doctor risky business memory bank.

Documentation •Surgical safety checklist / audit •Nursing Metrics •Annual Trust-wide documentation audit •Safety thermometer •Consent Policy

SUI Themes (Root causes and contributory factors) and Schedule 5 letters received by HEFT

Common themes from SUIs and associated work-streams

Deteriorating Patient Re-established Deteriorating Patient Recognition Group Vital and iSkills resources Mews audit Nursing metrics Lessons of the month SUI at a glance report Deteriorating patient campaign Sepsis pilot in AMU on all three sites to improve treatment for sepsis

SUI: August 2014 – Paediatrics BHH Unexpected Death of a child Themes: Ownership of patients by paediatric team regardless of speciality patient is under.

SUI: April 2014 – Surgery BHH Unexpected patient death Themes: Patient Suicide

SUI: May 2014 – Paediatrics BHH Prevented Never Event Opiate overdose in opiod naive patient Themes: Communication/non adherence to policy

Medication •Safe Medication Practice Group •Medication Matters newsletters •Improvement to EP system •New Medicines Group for reviewing all severe harm incidents from medication incidents •Patient Safety Team developed tool for live information relating to missed dose anti-biotics.

SUI: May 2014 – Gastroenterology BHH Delay in escalation of deteriorating patient Themes: Poor recognition of deteriorating patient /delay in escalating patient to consultant level

SUI: August 2014 - Vascular Surgery BHH Death whilst on a waiting list Themes: Lack of aneurysm pathway co-ordinator.

SUI: July 2014 – Cardiology BHH Delay in recognition of sick patient Themes: Communication/recognition and intervention following change in telemetry

Safer Surgery •Sharing the learning from theatre related Never Events •Knowing the risk. Perioperative risk assessment / communication tool •Safety walk about in all theatres across sites •No Mark – No Go Campaign for safer surgery

SUI: August 2014 – Obstetrics BHH Intrapartum Stillbirth Themes:

Serious Untoward Incident Themes /Never Events April 2014 – October 2014

SUI: July 2014 – ED BHH Delay in diagnosis of sub arachnoid haemorrhage Themes: Lack of communication

Learning tools •SUI at a glance reports and cascade system •Mortality digest •Safety lesson of the month •Weekly Quality and Safety Meetings •Patient safety and learning lessons boards piloted in AMU BHH



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Schedule 5 Section 7 (formerly Rule 43) / Coroner’s concerns

Inquest scheduled for 10 February 2015 associated with an incident being investigated through Trust SUI process as “Missed diagnosis of subdural haematoma” STEIS: 2014/36154 Conclusion: Accidental death . Coroner noted unlikely that earlier diagnosis and management would have altered final outcome.

11

Forward look: Potential for adverse inquest conclusion Inquest scheduled for 25 March 2015 associated with delay in recognition of change in telemetry monitoring which was formerly investigated through the Trust’s SUI process STEIS 2014/22609 Inquest scheduled for 16th March 2015 associated with an incident being investigated through the Trust SUI process as “deteriorating patient”. STEIS 2014/36858

SUI profile by management team (as at 06/03/15)

Site/Div 10/11 11 / 12 12/ 13 13/14 14/15

BHH 5 5 3 (1x N) 9 (2xN) 15

GHH 0 2 (2xN) 2 (1xN) 3 (2xN; 1xPN)

0

SHH 1 (1xN) 2(2xN) 1 1 (1xN) 1(1xN)

W&C 5 3(2xN) 5 (1xN) 1 6 (1xPN)

CSS 2(1xN) 5 0 1 2

Never (or PN) Events

2 of 14 6 of 17 3 of 11 6 of 15 2 of 24

Never events in 2012/13 relate to: 1 wrong site surgery (General Surgery) 1 Inappropriate administration of daily oral methotrexate (T&O) 1 retained tampon (O&G) Never events in 2013/14 relate to: 2 wrong implant (T&O / Theatres and Ophthalm / Theatres) 2 retained foreign objects (Gen Surg / Theatres and T&O / theatres) Prevented : Opioid overdose of opioid naive patient (Elderly) 1 wrong site surgery (General Surgery)

Never events in 2014/15 relate to: Prevented: 1 Opioid overdoes of opioid naive patient (Paediatrics) 1x wrong implant (Ophthalmology)

11

SUI profile by location (as at 06/03/15)

Site 10/11 11 / 12 12/ 13 13/14 14/15

BHH 8 11 7 (2x N) 7 (1xN) 17(1xPN)

GHH 5 1 3 (1xN) 4 (2xN; 1xPN)

6

SHH 0 5 1 3 (2xN) 1 (1xN)

Other 1 0

Total 14 17 11 15 24

Summary SUI profile March 2015 and inquest update



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12

CQC IMR December



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EXECUTIVE SUMMARY

We remain under Section 111 Monitor Enforcement.

We continue to see a mixed response to performance issues through the final quarter of 2014/15. Thefinancial loss in month was as expected due to fixed costs and a low income month which is expected to reverse in March, again as planned, if the year end settlement with CCG’s is as expected we will achieve our current forecast.

Additional investment and ongoing support to improve performance, care and quality standards needs to begin to address key areas outlined within this report. As previously stated we will be dependent on our ability to exit additional measures where appropriate as well as having sufficient efficiency plans that commence in a timely manner in order to mitigate financial risk in the first quarter of 2015/16.

It should be noted that there has been a reporting change for March’s A&E 4 hour performance at Solihull will likely worsen performance achievement.

Finance

February’s position was a £2.5m loss, the ongoing pressures continue to drive high pay costs and ashortfall against the efficiency target coupled with additional costs to deliver care has increased the year to date deficit to £8.4m.

Q3 CQUIN performance improved to deliver 75% however Q4 currently stands at 56% therefore continued Executive Director involvement is required to recover this performance to mitigate risk.

Divisions main areas of focus needs to continue to be:

• Manage pressures within approved additional resource envelopes.• Have clear exit strategies in place to mitigate future risk. • Close GAP / implement 2015/16 service improvement efficiency plans.

Performance

The Trust failed to meet the 95% 4 hour A&E target for February with performance at 85.65%, representing a 0.78% reduction in performance in month.

The Trust is currently unable to provide a position against the 18 week incomplete pathway referral to treatment (RTT) target due to problems arising from the implementation of PMS2.

Both the unvalidated Admitted RTT figure of 77.67% and the Non Admitted RTT 92.01% continue to be below target. Performance against the Admitted figure has reduced by 1.67%, however the Non Admitted figure has improved by 6.1% in month.

There has been an improvement in performance of 0.33% against the 6 week diagnostic wait target in month, however performance remains short of the 99% target at 93.81%.

Attachments: 2The Report is being provided for: Trust BoardWhich other Committees has this paper been to? Finance and Performance Committee, March 27th 2015

FINANCE EXECUTIVE SUMMARY & KEY PERFORMANCE INDICATORS

Month 11 to 28th February 2015



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Performance against the 2 week cancer wait target has improved for the second month in a row at 92.66% (unvalidated) against a 93% target, an improvement of 1.42%.

Performance against the Breast symptomatic cancer target has improved significantly by 12.63% at 89.24% (unvalidated) however this still remains below the 93% target.

Performance against the 62 day 1st definitive treatment cancer target has fallen below the target of 85% in February at 81.0%, a reduction of 5.22% and 4% below the target.

In addition Performance against the 62 day 1st definitive treatment when referred from the national screening service has improved by 10%, but remains below the 90% target for the second month in a row.

The percentage of service users waiting more than 62 days for cancer treatment following an upgrade of the priority of their care has fallen below target, reduced by 2.13% to 77.87% against a target of 80%.

The percentage of inpatients undergoing the VTE risk assessment has improved during February to 95.18% against a 95% target which means this target is now being met.

FEBRUARY POSITION

The Trust had an I&E loss in February.

The in-month income for February is £45.6m, with the year to date income of £528.9m, giving an I&E over-performance of £10.2m. This is £0.1m below forecast in month and £0.2m below forecast YTD.

The main areas of year to date over performance continue to be Specialised Services £5.8m (£0.4m in month) with additional income recovered through Cancer Drugs Fund (CDF) of £4.2m. JMRA shadow income is on plan in month and £0.1m above plan year to date.

The in month expenditure position showed a further increase of £0.1m in the pay bill. This was driven by expected winter costs and additional measures to improve care and performance.

The table below summarises our current Finance & Performance position:

Category Feb Headlines

FinanceCosts to delivery performanceUnderlying pay controls Efficiency (SIEP) delivery

Performance

A&E 4 hour18 week admitted RTT / non admitted RTTCancer 2 week wait / breast symptoms/ 62 day waitsDiagnosticsCQUIN’s

Contracting

The Performance & Contracting teams are in dialogue with the CCG regarding the current CQUIN performance. All RAPs remain open but there are no concerns regarding delivery at this stage. Weekly LDP meetings continue in support of the contracting process for 15-16.



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1. FINANCE

The Trust’s income and expenditure position in February was a £2.5m loss and a £8.4m loss year to date. Against operational budget the Trust is overspent year to date by £12.5m.

The table below shows the key issues influencing the financial position:

Category Feb Headlines£m

MedicalStaffing (0.7)

Expenditure remains unaffordableWaiting List Initiatives spend of £0.4mGreatest pressures in BHH, SOL and GHH

Nursing &Midwifery (0.5)

Expenditure remains unaffordableEnhanced bank rates continueGreatest pressures in BHH and GHH

Private Sector (0.5) Additional measures to improve care, of which private sector to achieve 18 weeks the most significant impact

SIEP (0.6) Most significant shortfalls in BHH, SOL and W&C’s

Overall Position

1.1 Medical Staffing – Total medical expenditure remains unaffordable at £10.3m in month compared to a budget of £9.6m. Divisions need to address this as part of their efficiency plans going forwards, where not resolved as part of rebasing capacity.

1.2 Nursing & Midwifery – Nursing expenditure remains unaffordable at £13.9m in month compared to a budget of £13.4m. Divisions need to address this as part of their efficiency plans going forwards, where not resolved as part of rebasing capacity.

1.3 SIEP – Actual delivery in month was £1.4m (71% of target). The current forecast for 2014/15shows expected delivery to be c£16.6m (69%) with the balance of plans being high risk. The focus now must be early implementation of 2015/16 plans.

1.4 Cash Deposits – The cash balance at the end of February 2015 was £101.6m. The Trust has reinvested £75m of funds in the National Loans Fund (within the GBS umbrella) for 6 months which attracts an interest rate of 49bp. A further £9.0m was invested in NLF in tranches on a short term basis attracting a rate of 40bp. Funds remaining in the GBS current accounts earn 25bp interest.

1.5 Monitor Targets – The Trust’s Continuity of Service Rating (COSR) at the end of February was 4. The COSR scale is 1 to 4 with 4 being the highest rating.

1.6 Capital Forecast – The Trust has revised its capital forecast and it now stands at £22.1m, which is a decrease of £5.2m lower than the forecast submitted to Monitor in December. This is due to slippage on investment plans.

1.7 Risk Register – The residual risk currently outside of the position is £1.3m. The main concernbeing re-valuation of rates.



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2. PERFORMANCE

The table below shows the performance targets at most risk:

Indicator MonthTarget Jan Feb Headlines

A&E 95% 86.43% 85.65%Slightly reduced

performance - behind trajectory

Cancer 2 week wait(mia) 93% 91.24% *92.66% Improved performance -

ahead of trajectoryCancer 2 week

breast symptoms(mia)

93% 76.61% *89.24% Improved performance -behind trajectory

18 week admitted RTT (mia) 90% 79.34% *77.67% Slightly decreased

performance

18 week non-admitted RTT (mia) 95% 85.91% *92.01% Improved performance

Diagnostic test within6 weeks 99% 93.48% 93.81%

Slightly improved Performance - behind

trajectoryCancer 62 day 1st

definitive treatment from GP

85% 86.22% *81.0% Decreased performance

Cancer 62 day 1st

definitive treatment from national screening

90% 50.00% *60.00% Improved performance

Cancer 62 day 1st

definitive treatment from upgrade of priority

80% 80.00% *77.87% Decreased performance

*Unvalidated at time of report.

2.1 A&E

The Trust failed to meet the target of >=95% in January with performance at 85.65%, this is areduction in performance of 0.78% against January performance. The reported A & E performancefigure is likely to reduce against the target in March due to a reporting change due to the classification of Solihull A & E from a type 1 to a type 3 unit.

2.2 Cancer

Unvalidated performance against the 2 week cancer wait target has improved for the 2nd Month in a row at 92.66% just below the target of 93%. This exceeds the Monitor plan for March of 91.50%.

February performance against the 2 week Breast symptomatic target has also improved by 12.63% to 89.24% against a target of >=93%. However this remains below the Monitor trajectory for March.

Performance against the 31 day definitive treatment and the 31 day subsequent treatment hasreduced slightly although they remain above target. Performance against both the 62 day 1st definitive treatment targets and the 62 day upgraded target have reduced and are below target.



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2.3 18 Week RTT

Performance for both the 18 week Admitted and Non Admitted RTT performance both remain below target. Admitted performance is currently 77.67% a decrease of 1.67% since January against a >= 90% target. Non admitted performance has improved and is currently 92.01% an improvement of5.1% against a >= 95% target.

2.4 6 week diagnostics

February performance against the 6 week diagnostic wait target has improved by 0.33% with performance at 93.81% against a target of >= 99%. The Trust has also failed to reach the agreed improvement trajectory for February of 99.47%.

2.5 CQUINs

The following CQUIN schemes are at risk for Q4:

• 1.3 Friends & Family Test (FFT) - the in-month target for inpatients of 40% is currently not being achieved.

• 2.1 Safety Thermometer (ST) target of 2.1 point prevalence median equalling a 50% reduction in prevalence of pressure ulcers – achievement is currently 3.92.

• 3.1 Dementia - the requirements are a CQUIN outline for 2015/16 which remains to be written. The number of patients assessed, investigated and referred with a target of 90% for each element are not being achieved.

• 3.2 Dementia – a named clinician and a training plan to be written for implementation in 2015/16

• 3.3 The outcome of Carers questionnaires and a date to be arranged for board discussion of survey outcomes

• 4.2 Safeguarding common assessment framework (CAF’s) – number of CAF’s raised is failing the agreed number of 100

• 5.2 Prevention of constipation – a rapid improvement plan for oral laxatives usage is being prepared for agreement with the CCG

• 8 Cancer – cancer survivor treatment summaries for colorectal cancer. A pilot is to be undertaken with a report and a plan for roll out to other cancers to be provided.

Discussions are being held with the owners of the above CQUINs with regard to remedial planning.Current estimates of achievement are around 56% of CQUIN’s.

3. CONTRACTING

The national timetable for 2015/16 contracting has been extended to the end of March 2015. A decision has now been made regarding the tariff option for 2015/16, the Trust has opted for the Enhanced Tariff Package (ETO). Key to this decision was the level of CQUIN in the Acute contract along with the upside in marginal rate emergency threshold (MRET).

The ETO allows for a reduced deflator of 0.5% for tariff and 1.6% for non tariff, however the specialised services marginal rate still exists, albeit at a reduced rate of 70%.

LDP meetings continue with HEFT service leads and the CCG. Key items for consideration currently are the underlying activity growth assumptions on both the Acute and Community contracts. Discussions are underway at FD level to agree these principles.



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4. ESCALATION PROCESS

5. FORECAST

Following Trust Board approval to invest in additional measures to deliver care the Trust forecast was revised.

The below table shows best, likely and worst forecast:

FORECAST Best Likely WorstOriginal forecast 3.3 0.0 (3.2)

Independent sector (3.5) (3.8) (4.2)Additional measures (1.3) (1.8) (1.8)

Surplus/Deficit (1.5) (5.6) (9.2)

The likely forecast assumes the following;

• Improved performance delivers c£0.6m additional income.• Cost to deliver RTT, winter and additional measures does not exceed approved levels.• Modest delivery on rectification and efficiency.• Pay bill is effectively managed.• Assumes no new additional monies.• Excludes disputed rates charges.• Ignores any potential movement on provisions.



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6. CURRENT ACTIONS

The below are the updated actions:

1. Division’s financial performance to be reported at Delivery Unit meetings.2. Additional action to manage medical pay.3. Executive led improvement in areas of poor performance.4. Implement additional measures to improve performance.5. Exit strategies to be in place for winter/additional measures.6. Close GAP on 2015/16 SIEP and begin early implementation.7. Further review and decision regarding enhanced bank rates.8. Conclude demand and capacity investment decision when linked to 4 & 5 above.

7. CONCLUSION

With investment in ongoing capacity, clear exit strategies from winter and additional measures coupled with early delivery of service improvement efficiency plans will be essential to mitigating financial risk at the start of the new financial year. Additional investment and ongoing support needs to impact positively on performance, care and quality standards in quarter 1 of 2015/16.

8. RECOMMENDATIONS

It is recommended the above actions are implemented.

Darren CattellInterim Director of Finance & PerformanceFebruary 2015Heart of England NHS Foundation Trust



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TRUST WIDE FINANCIAL AND PERFORMANCE RISK REGISTER – 2014/15D

irect

orat

e

Des

crip

tion

ofR

isk

Risk if noaction taken

Action to be taken to

mitigate risk

Lead

Dat

eto

beco

mpe

ted

ResidualRisk

Prog

ress

/C

ompl

etio

n

Ris

kSc

ore

Fina

nci

alVa

lue

(£’0

00)

Ris

kSc

ore

Fina

nci

alVa

lue

TRUST Efficiency non delivery 12 £10.0m Sites to close

gapHead of

OperationsOn

going 12 £7.5m Further work required

TRUSTVolatileenergy market

4 £1.0m

Install CHP Schemeat GHH, Monitor usage, promote awareness andimplement TW

EnergySustainability

J Sellars Ongoing 4 £0.3m

Energy sustainability

project approved

CHP scheme atGHH ongoing

TRUST

Additional coststo deliver

performance /poor paycontrol

12 £16.0m

Divisions tasked with exiting

winter capacity.Manage through

Delivery Unit.Escalation

process to beimplemented.

Finance Ongoing 12 £10.0m Further work

required

TRUST

AcuteContractKPI’s & CQUIN

12 £4.0m

Operational Delivery of CQUIN milestones.Manage KPI issues

jointly with the CCG’sFinancial risk largely

mitigated by agreement of JMRA

in-year.

Finance Ongoing 12 £2.5m

Requiresimplementation

of action plans tomanage residual

penalties. Q3performance

75%, riskassessment andCCG dialogue to

secure Q4.

TRUSTSpecialised

Contract KPI’s &CQUIN

12 £1.9m

OperationalDelivery of

CQUIN milestones,(Specialised)

Finance Ongoing 12 £0.5m

NHSE will mirror fines applied to national CQUIN

targets by NHSE. All local CQUINs are on target for

Q3.

Within Position Sub Total £32.9m £20.8m

TRUSTEducation &

Training-Transition to

Tariff8 £4.0m

Review /mitigate within

funding streamsHR /

Faculty June 4 £0.3mLDA Received.

Review commenced

TRUSTRe-valuation of Rates by Birmingham City Council

12 £1.2mSubmit appeal

to mitigate impact

Facilities/ AssetMg’t

Ongoing

12 £1.0m

External contractors

commissioned to submit appeal

Outside Position Sub Total £5.2m £1.3m

TOTAL £38.1m £22.1m



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ACTIVITY / WAITING LIST PERFORMANCE

1. A&E Activity 2014/15

In-Month Performance

• There were 18,154 A&E attendances in Feb-15, 348 attendances, 2% above plan.

• In February 85.65% of patients were seen within 4 hours including walk ins.

• At Heartlands 81.95% (1,626 breaches) of patients within 4 hours, 76.52% (1,437 breaches) at Good Hope site and 97.32% (81 breaches) at Solihull site.

• A&E activity excludes A&E outpatient attendances.• Form TF2A

2. Emergency Activity 2014/15 excluding Paediatrics, Paediatric Surgery and Obstetrics


• The Emergency activity was above plan by 1% in February, 56 Spells.

• Heartlands 113 Spells, 4% and Solihull, 14 Spells, 3% were above plan.

• Good Hope 39 Spells, 4% and Women & Childrens, 45 Spells, 15% were below plan in month.

• Following the implementation of PMS2 a potential patient classification issue has been identified. This is currently under a detailed review and any necessary retrospective realignment will be actioned.

• Form TF2A

3. Emergency Activity 2014/15, Paediatrics, Paediatric Surgery and Obstetrics


• The activity is above plan by 6%, 55 Spells in Feb-15. • The activity YTD is above plan by 6%, 562. • Following the implementation of PMS2 a potential

patient classification issue has been identified. This is currently under review and any necessary retrospective realignment will be actioned.



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4. AMU, MAU & SAU Activity 2014/15


• There were 1,938 spells during Feb-15, 246 Spells, 15% above plan.

• Good Hope 102 spells, 20%, Heartlands, 87, 15% and Solihull, 58, 9% were above plan in month.

• There were 4,813, 25% additional spells YTD.

5. Maternity Spells Activity 2014/15


• In February 2015, there were 816 Births Trustwide (510 at Heartlands, 294 at Good Hope, and 12 at Solihull). This compares to the plan of 852 (-4%). In February there were 3 planned homebirth (2 at Heartlands and 1 at Good Hope).



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6. Elective & Day Case Activity 2014/15


• The Day case and Elective activity was above plan by 3%, 220 Spells during Feb-15.

• Heartlands, 2%, 75 Spells and Women and Childrens, 32%, 146 Spells were below plan in month.

• Solihull Division, 25%, 318 Spells, Clinical Support, 53 Spells, 46% and Good Hope, 69 Spells, 11% were above plan in month.

• Following the implementation of PMS2 a potential patient classification issue has been identified. This is currently under a detailed review and any necessary retrospective realignment will be actioned.

• There were 186 patients treated by the private sector during February and 1,550 YTD. Ophthalmology (58), General Surgery (56), ENT (32), Orthopaedics (26), Urology (7), Vascular Surgery (4) and Gynaecology (3) had patients treated by the private sector in month.

• 122 patients were treated in the Vanguard Theatre in February and 897 patients since it opened in September.

• There were 24 cancelled sessions during February, 97.22% of the scheduled sessions were utilised. The following specialties cancelled sessions, General Surgery (8), Gynaecology (5), Orthopaedics (4), Thoracic Surgery (2), Urology (2), Vascular Surgery (2) and ENT (1).

• 75% (18) of the Theatre sessions were cancelled due to no surgeon in month.

• In addition 20 sessions were cancelled in the Vanguard Theatre during February.

• 121 operations were cancelled on the day during February, 51 (42%) of the cancelled operations were at Good Hope, 44 (36%) at Heartlands and 26 (21%) at Solihull.

7. Outpatient Activity 2014/15


• There were 64,935 Outpatient attendances during Feb-15, 719 atts, 1% more attendances than planned.

• Good Hope 309 atts, 4%, Clinical Support, 123 atts, 3% and Solihull, 922 atts, 4% were above plan in month.

• Heartlands (303 atts, 1%) and Women & Childrens (331 atts, 8%) were below plan in month.

Total DNA Rates (February-15):

• Good Hope 8.06% (2,166*) • Heartlands 11.95% (3,780*) • Solihull 7.45% (1,783*)

The DNA rate for first attendances was 14.16% (1,361*) at Heartlands site during Feb-15. Good Hope (8.30%) and Solihull (8.12%) achieved the target of less than 11%.*No. of DNAs.



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INCOME AND EXPENDITURE

• The overall I&E deficit was £8.4m at the end of month 11.

• This deficit was £9.4m adverse to the Monitor plan and £2.8m adverse to the recent reforecast.

• Income was £14.9m favourable to plan while operating expenses were £28.5m adverse to the Monitor plan.

• PDC dividend expenditure was £1.2m favourable to plan, depreciation £3.0m favourable to plan.

• Continuity of Service Rating (COSR) was 4 for month 11, the highest rating.

In-month Performance

8. Performance against Monitor Standards 2014/15

NHS Contract Income (Category A)

There was a trustwide over performance of £0.8m in month, £10.2m YTD.

• Specialised Services income was above plan by £0.4m in February, driven by drugs and vascular excluded devices.

• Income relating to the Cancer Drugs Fund was £0.4m in month.


9. Income 2014/15

• The Trust is (£12.5m) over spent at Month 11 of 2014/15.

• Pay is over spent by (£9.2m) • Non Pay is over spent by (£6m) • Other Operating Revenue £3.1m over recovered • Form TF1


10. Income and Expenditure against Operational Budgets



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11. Operational Budgets 2014/15

Corporate Directorates (CD) is under spent by £0.8m

Income under recovery (£0.1m)

Pay under spend £0.8m

Non Pay under spend £0m

Corporate Trust Wide (CTW) is under spent by £16.7m

Income over recovery £0.8m

Pay over spend (£0.2m)

Non Pay under spend £16m

Facilities (FAC) is under spent by £0.4m

Income over recovery £0m


Non Pay over spend (£0.3m)

Bad Debt provision included within the above: £1m

Heartlands Hospital (BHH) is over spent by (£15.1m)

Income under recovery (£0m)



Clinical Support Services (CSS) is under spent by £0.2m




Good Hope Hospital (GHH) is over spent by (£7.2m)

Income over recovery £0m



Solihull Hospital (SOL) is over spent by (£5.4m)


Pay over spend (£1m)


Womens and Childrens (WC) is over spent by (£2.8m)






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Pay Expenditure is over spent by (£9.2m) at Month 112014/15.

Material variances to operational budget relates to:

• Medical Staffing, which is over spent by (£7.5m) , • Nursing & Midwifery overspent by (£4.7m), • Off set by other support staff underspend totalling

£3.1m • Form TF3


12. Pay Expenditure


Non Pay is over spent by (£6m) at Month 11 in 2014/15.

Material overspends against operational budgets are:• 2014/15 SIEP shortfall (£7.1m) • Clinical Supplies overspent (£5.2m)• Drugs over performance benefit £2m• Depreciation, Amortisation benefit £2.3m• Miscellaneous Other Expenses £2m

Form TF4


13. Non pay Expenditure



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• The Trust achieved £1.43m (71.4%) efficiency in Month 11. • These results show a (£0.6m) shortfall against target at Month 11.

Based on Month 11 results the forecast out turn is £16.5m delivery of savings (68.9%).

Analysis of forecast:

• £16m in risk category 5 Delivered • £0.2m in risk category 4 Planned with expected delivery • £0.3m in risk category 3 Suggested plans

Feb - In Month Year To Date Forecast @ Month 11

GROUPS Target ActualRec

ActualNon Rec

Variance Target ActualRec

ActualNon Rec

Variance AnnualTarget

Actual(3,4,5)

Variance(0,1,2)

heartlands hospital 625.0 285.6 43.6 (295.9) 6,875.0 2,475.7 499.2 (3,900.2) 7,500.0 3,301.8 (4,198.2)

good hope hospital 183.3 101.6 2.0 (79.7) 2,016.7 837.4 269.1 (910.2) 2,200.0 1,219.5 (980.5)

solihull 291.7 189.3 7.8 (94.6) 3,208.3 1,554.3 123.8 (1,530.2) 3,500.0 1,894.3 (1,605.7)

clinical support services 433.3 242.6 73.2 (117.5) 4,766.7 2,909.5 622.1 (1,235.1) 5,200.0 4,031.3 (1,168.7)

womens & childrens 225.0 51.0 0.1 (173.9) 2,475.0 540.4 0.7 (1,933.8) 2,700.0 592.3 (2,107.7)

facilities 116.7 102.7 19.3 5.3 1,283.3 1,030.6 201.6 (51.2) 1,400.0 1,355.4 (44.6)

corporate directorates 125.0 136.0 6.8 17.7 1,375.0 1,079.3 117.2 (178.5) 1,500.0 1,353.1 (146.9)

corporate trustwide 0.0 166.7 0.0 166.7 0.0 2,633.3 0.0 2,633.3 0.0 2,800.0 2,800.0

TOTAL 2,000.0 1,275.5 152.6 (571.9) 22,000.0 13,060.5 1,833.6 (7,105.9) 24,000.0 16,547.8 (7,452.2)


14. Service Improvement Efficiency Plan 2014/15



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BALANCE SHEET

YTD Expenditure was £17.8m, 77.0% of the reforecast YTD Monitor Plan (MP) and 42.9% of total Approved Budget (AB) £41.5m. Orders raised were £25.0m, 108.1% of YTD MP & 60.2% of AB.

• Operational was £6.6m, 73.9% of YTD MP, key spends on LAN & other IT projects

• Other was £6.6m, 78.7% of YTD MP; with spend on replacement MRI Scanner, Energy Sustainability, Document Scanning, Negative Pressure rooms.

• Site Strategy Investment expenditure was £4.4m, 79.3% of YTD MP, spend on Hybrid Theatres, Dermatology relocation, AMU refurb at GHH, the Chemotherapy and Rheumatology units

• HPA was £136k, 78.1% of YTD MP

YTD Performance

15. Combined Capital Expenditure YTD 2014/15

M11 In-month expenditure was £2.4m:

• FAC / Site Strategy £2.1m- Hybrid Theatres, Dermatology relocation SOL, AMU refurbishment at GHH, Energy Sustainability, Ward 3 refurbishment at GHH.

• CD £162k- Corporate Community PC Replacement and iPads, Windows 7 compliance, LAN

• CSS £86k- Negative Pressure Isolation Rooms Ward 28 at BHH

• WC £36k- Obstetrics Capacity Risks project at BHH, Bladder Scanner at GHH, 2 Bipad Machines


16. Capital Expenditure in Month 2014/15

• Payment performance in February is about 70%. The volume of invoices paid in February is 13,535 in line with normal volumes.

• The continued poor payment performance is due to backlog clearing and processing delays following the Readsoft upgrades and will also impact on March performance and beyond.

Cumulative Performance

17. Creditors 2014/15



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BALANCE SHEET

• Total debt reduced by £2.423m during February to £19.611m.

• Health Education England paid a training & education invoice for £5.156m during the month

• There was a deterioration in the underpayment of the monthly SLA mandate invoices by £1.387m to a cumulative underpayment of £2.885m, in anticipation of expected contract penalties. Those underpaying include Birmingham Cross City CCG £1.664m and Solihull CCG £1.116m.

• Solihull CCG recalled a £2.000m advance on the February SLA mandate payment, but replaced it with a £0.550m in advance of the March SLA mandate payment.

• A resilience funding invoice for £3.472m to Birmingham Cross City Clinical Commissioning Group remains outstanding and disputed. The invoice will be credited shortly and a replacement invoice for £2.129m will be issued.

• Ante natal maternity pathways activity debt for April 2013 to December 2014 increased to £3.525m , including £1.719m with Burton Hospitals, £0.860m with Sandwell & West Birmingham Hospitals, and £0.490m with Birmingham Womens Hospital.

• Burton Hospitals Foundation Trust have debts of £2.337m, (including £1.719m for ante natal maternity pathways activity), and have recently placed the account on hold until this Trust settle their debt for £0.595m


18. Debtors 2014/15

CASHFLOW

• The cash balance at the end of February 2015 was £101.6m, £18.6m above plan.

• Operating cash flows were £17.0m below plan. This was offset by favourable working capital movements of £18.6m. Capital expenditure in cash terms was £14.9m less than plan.

• The half yearly PDC dividend payment was processed in September and this was £1.7m less than planned including a rebate for the last financial year.

• All Trust funds remain in the GBS umbrella as a change in the rules on calculating PDC dividend means that it is currently financially unviable to invest in other commercial banks.

• £75m of funds have been reinvested in the National Loan Fund (NLF) for 6 months at a rate of 49bp. A further £9.0m was on deposit with NLF at the month end on a short term basis attracting interest rates of around 40bp.

• Funds in GBS attract 25bp.


19. Monthly Closing Cash Balance vs Plan 2014/15



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18 weeks: Reported 1 month in arrears

MONITOR - RISK ASSESSMENT FRAMEWORK KPIs


HEFT have now resumed reported against the Admitted patient pathway (clock stops), and achieved 79.34% against the 90% target for Jan15, with the aim to continue to see

longer waits in order to help clear the backlog

HEFT managed to see 85.91% of non-admitted patients within 18 weeks against the 95% target for Jan15

Admitted Non-admitted

75%

80%

85%

90%

95%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

85%

87%

89%

91%

93%

95%

97%

99%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

No data reported in month

Incomplete Pathways

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Out-turn

Target

Total time in A&E

70%

75%

80%

85%

90%

95%

100%

Apr-

12

May

-…

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct

-12

Nov

-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-…

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-…

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

The 95% target for A&E around 4 hour was not met in February with performance at 85.65%

A&E

N.Atkins PM-P&I 20/03/2015 Z:\Data\PMU\Performance Monitoring\KPI 2014-15\2014-15 Trust KPI.xlsbFC 1



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Cancers: Reported 1 month in arrears

Cancers: (continued)



50%55%60%65%70%75%80%85%90%95%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

2 week GP 2 week Breast Target

The Trust failed the 93% target for the 2 week GP cancer indicator in January at 91.24%, and also failed the 2 week Breast symptom 93% target, achieving 76.61%

The Trust achieved the 96% target for 31 day cancers in January, out-turning at 98.12% in month

2 weeks 31 day GP

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

The Trust met the 31 day anti-cancer drug target of 98% in January, achieving 100%

The Trust met the 31 day surgery modality cancer target of 94% in January, achieving 96.72%

31 day anti-cancer 31 day surgery

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

85%

87%

89%

91%

93%

95%

97%

99%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

The Trust achieved the 62 day cancer 85% target in January, achieving 86.22%

The Trust missed the 62 day national screening cancer 90% target in January, achieving 50%

62 day cancers 62 day screening

75%

80%

85%

90%

95%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target

40%

50%

60%

70%

80%

90%

100%

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Target




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Infection Control


c-diff

The target for incidents of c-diff is no more than 6 in February, and in month the Trust reported 3 cases, with a total of 67 YTD

0

2

4

6

8

10

12

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

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Year to Date

AnnualPlan

Actual

Full Year

VarianceActual to

Plan

AnnualPlan

Forecast

£m £m £m £m £m

VarianceForecast to

Plan

£m

2013/14

£m

516.839 527.059 10.220 NHS Clinical Revenue 563.913 577.912 13.999 560.801

0.715 0.539 (0.177) Clinical Revenue - Private Patients 0.780 0.693 (0.087) 0.628

0.165 0.148 (0.017) Clinical Revenue - Overseas Visitors 0.180 0.168 (0.012) 0.163

3.963 3.861 (0.102) Research and Development revenue 4.323 4.188 (0.135) 4.132

20.662 21.376 0.714 Education and Training revenue 22.540 23.088 0.548 22.885

0.446 0.411 (0.035) PFI Specific Revenue 0.487 0.448 (0.039) 0.448

0.468 0.411 (0.057) Donations and Grants received 0.510 0.313 (0.197) 0.711

4.376 4.370 (0.006) Parking Revenue 4.774 4.829 0.055 4.800

0.848 0.954 0.106 Catering Revenue 0.925 1.029 0.104 0.910

0.246 0.264 0.018 Accommodation Revenue 0.268 0.257 (0.011) 0.306

5.944 9.509 3.565 Revenue from non patient services to other bodies

6.485 10.349 3.864 13.922

21.398 22.100 0.701 Miscellaneous other operating revenue 23.399 24.403 1.004 25.715

576.070 591.002 14.932 Total Operating Revenue 628.584 647.677 19.093 635.422

(350.981) (352.767) (1.786) Employee expenses, permanent staff (382.254) (383.759) (1.505) (376.603)

(0.176) (22.504) (22.328) Employee expenses, agency and contract staff (0.192) (24.702) (24.510) (19.900)

(46.180) (53.434) (7.254) Drugs (50.217) (57.160) (6.943) (51.377)

(58.430) (57.375) 1.056 Clinical Supplies (63.551) (61.202) 2.349 (62.338)

(16.116) (15.365) 0.751 Non Clinical Supplies (17.520) (16.315) 1.205 (17.173)

(2.407) (2.451) (0.044) Research and Development Expense (2.626) (2.701) (0.075) (2.636)

(1.826) (2.007) (0.181) Education and Training Expense (1.992) (2.018) (0.026) (2.229)

(1.049) (1.629) (0.580) Consultancy Expense (1.144) (1.926) (0.782) (2.241)

(66.500) (67.404) (0.903) Miscellaneous other Operating expense (72.853) (75.771) (2.918) (75.593)

(3.749) (1.021) 2.727 (Increase)/decrease in impairment of receivables

(4.090) (1.620) 2.470 (2.291)

(0.096) (0.087) 0.009 PFI unitary payment (0.105) (0.095) 0.010 (0.095)

(547.510) (576.043) (28.532) Total Operating Expenses (596.543) (627.269) (30.726) (612.475)

28.560 14.959 (13.601) EBITDA 32.041 20.408 (11.633) 22.947

(0.110) (0.162) (0.052) Gain / loss on asset disposals (0.120) (0.252) (0.132) (0.031)

(20.900) (17.924) 2.976 Total Depreciation and amortisation (22.800) (20.000) 2.800 (18.039)

(6.545) (5.386) 1.159 PDC Dividend expense (7.145) (5.876) 1.269 (5.574)

0.333 0.404 0.071 Total interest receivable 0.364 0.412 0.048 0.385

0.000 0.000 0.000 Other finance costs 0.000 0.000 0.000 (0.003)

(0.275) (0.249) 0.026 Interest expense (0.301) (0.271) 0.030 (0.282)

1.063 (8.359) (9.422) Surplus/(deficit) before impairments 2.039 (5.579) (7.618) (0.597)

0.000 0.000 0.000 Impairment (Losses) / Reversals 0.000 0.000 0.000 (4.759)

1.063 (8.359) (9.422) Surplus/(deficit) after impairments 2.039 (5.579) (7.618) (5.356)

Key perfomance Indicators (KPIs)Year to Date

AnnualPlan

Actual

Full Year

VarianceActual to

Plan

AnnualPlan

Forecast VarianceForecast to

Plan

2013/14

0.20% (1.39%) (1.59%) Net I&E Margin 0.34% (0.82%) (1.17%) (0.09%)

28.092 14.548 (13.544) EBITDA (£m) adjusted 31.531 20.095 (11.436) 22.236

100.00% 51.79% (48.21%) EBITDA achieved, % of projection 100.00% 63.69% (36.31%) 58.93%

4.88% 2.46% (2.42%) EBITDA margin (%) 5.10% 3.15% (1.95%) 3.50%

28.425 14.952 (13.473) Revenue available for debt service (£m) 31.895 20.507 (11.388) 22.621

Trust Wide Income and Expenditure Form TF1AFebruary 2015



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Year to Date

Last Month Actual

This Month Actual

Full Year

Variance to Plan

Annual Plan Forecast

£m £m £m £m £m

Variance from Plan

£m

31 March 2014

£m

5.100 5.109 (3.486) Intangible Assets, Net 9.238 10.617 1.379 3.051236.009 237.990 (4.397) Property, Plant and Equipment, Net 245.492 239.824 (5.668) 239.867

4.312 4.302 (0.059) On balance sheet PFI assets 4.350 4.250 (0.100) 4.374245.421 247.401 (7.941) Fixed Assets, net 259.080 254.691 (4.389) 247.292

2.756 2.762 1.723 Trade Receivables, non current, gross 1.039 2.700 1.661 2.771

(1.711) (1.711) (1.711) Impairment of receivables for bad and doubtful debts, non current 0.000 (1.711) (1.711) (1.711)

1.046 1.052 0.013 Trade and other receivables, net, non current 1.039 0.989 (0.050) 1.060246.467 248.452 (7.929) ASSETS, NON CURRENT 260.119 255.680 (4.439) 248.352

9.424 9.240 1.362 Inventories 7.878 8.500 0.622 7.99636.691 26.778 (4.199) NHS Trade Receivables, current, gross 31.002 30.000 (1.002) 21.6162.215 4.283 (1.387) Non NHS Trade Receivables, current, gross 5.675 4.100 (1.575) 6.2700.000 0.000 0.000 Other Related Party Receivables 0.000 0.000 0.000 1.0492.159 1.850 0.156 Other Receivables 1.696 1.500 (0.196) 2.775

(9.046) (9.045) 0.665 Impairment of receivables for bad and doubtful debts, current (10.051) (9.735) 0.316 (9.802)

2.884 2.676 (0.048) Accrued Income 2.726 2.000 (0.726) 1.99510.046 8.164 0.029 Prepayments 8.142 6.000 (2.142) 6.17499.671 101.568 18.624 Cash and Cash Equivalants 78.706 83.000 4.294 86.699

154.044 145.513 15.201 CURRENT ASSETS 125.774 125.365 (0.409) 124.771

400.511 393.966 7.273 TOTAL ASSETS 385.893 381.045 (4.848) 373.123

(3.874) (2.716) 0.692 Trade Payables (2.026) (3.000) (0.974) (3.868)(18.101) (17.582) (1.906) Other Payables (19.505) (16.000) 3.505 (2.024)(3.917) (5.472) 1.413 Capital Payables (4.558) (3.654) 0.904 (4.136)

(58.708) (56.344) 13.257 Accruals (42.757) (51.450) (8.693) (47.577)(0.480) (0.480) 0.000 Finance Leases / PFI Leases, Current (0.480) (0.480) 0.000 (0.480)(1.958) (2.448) (0.529) PDC Dividend Payable 0.000 0.000 0.000 0.000

(11.328) (11.154) 3.330 Provisions, current (8.594) (11.100) (2.506) (20.667)(13.004) (11.128) 2.130 Deferred Income (9.006) (6.000) 3.006 (6.605)

(111.370) (107.324) 18.387 CURRENT LIABILITIES (86.925) (91.684) (4.759) (85.356)

42.674 38.189 (3.186) NET CURRENT ASSETS (LIABILITIES) 38.849 33.681 (5.168) 39.415

(7.531) (7.531) 5.181 Provisions, non current (2.580) (7.500) (4.920) 0.000(1.640) (1.629) (0.112) Finance Leases, non current (1.740) (1.620) 0.120 (1.746)(2.410) (2.393) (0.172) PFI Leases, non current (2.564) (2.375) 0.189 (2.574)

(11.580) (11.553) 4.897 LIABILITIES, NON CURRENT (6.884) (11.495) (4.611) (4.320)

277.560 275.088 (16.012) TOTAL ASSETS EMPLOYED 292.084 277.866 (14.218) 283.447

214.169 214.169 0.000 Public Dividend Capital 214.169 214.169 0.000 214.16918.575 16.103 (15.018) Retained Earnings / (Accumulated Losses) 32.691 19.459 (13.232) 22.72844.986 44.986 (0.994) Revaluation Reserve 45.393 44.407 (0.986) 46.719(0.169) (0.169) 0.000 Miscellaneous Other Reserves (0.169) (0.169) 0.000 (0.169)277.560 275.088 (16.012) TOTAL TAXPAYERS EQUITY 292.084 277.866 (14.218) 283.447

(2.57%) (3.31%) Net Return After Financing (0.16%) (3.00%) (2.84%) 0.20 %

Year to Date

Last Month Actual

This Month Actual

Full Year

Variance to Plan

Annual Plan Forecast Variance from Plan

31 March 2014

19.050 16.584 Liquidity 18.690 14.452 (4.239) 18.467

Key perfomance Indicators (KPIs)

Form TF1BTrust Wide Balance SheetFebruary 2015



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Trust Wide Cash flow

Actual Plan Variance to Plan Annual Plan Forecast Variance from Plan 2013/14

(8.359) 1.053 (9.412) Surplus / (Deficit) after tax 2.037 (5.579) (7.616) (5.357) - Non - cash flows in operating surplus / (deficit): - -

(0.155) (0.059) (0.096) Finance income/charges (0.064) (0.141) (0.077) (0.100) (0.411) - (0.411) Donations and grants received of PPE and intangibles - (0.313) (0.313) (0.711)

- - Other operating non-cash movements - - - 17.924 20.900 (2.976) Depreciation and amortisation, total 22.800 20.000 (2.800) 18.039

- - Impairment losses / (reversals) - - 4.759 0.162 0.110 0.052 (Gain) / loss on disposal of non current assets 0.120 0.252 0.132 0.031 5.386 6.550 (1.164) PDC Dividend Expense 7.145 5.876 (1.269) 5.574 1.021 3.989 (2.968) Other 4.353 0.910 (3.443) -

15.568 32.543 (16.975) Operating Cash Flows before movements in WC 36.391 21.005 (15.386) 22.235 Increase / (decrease) in working capital:

(1.244) - (1.244) (Increase)/decrease in inventories - (0.504) (0.504) (0.258) - - (Increase)/decrease in tax receivable - - - -

(5.162) (0.282) (4.880) (Increase)/decrease in NHS Trade Receivables (0.308) (8.384) (8.076) (9.193) 0.232 (0.052) 0.284 (Increase)/decrease in Non NHS Trade Receivables (0.057) 2.170 2.227 3.913

- - (Increase)/decrease in other related party receivables - 1.049 1.049 - 0.925 (0.016) 0.941 (Increase)/decrease in other receivables (0.017) 1.275 1.292 (0.716)

(0.681) (0.025) (0.656) (Increase)/decrease in accrued income (0.027) (0.005) 0.022 0.046 - - (Increase)/decrease in other financial assets - - - -

(1.990) (0.074) (1.916) (Increase)/decrease in prepayments (0.081) 0.174 0.255 (1.208) - - (Increase)/decrease in Other assets (non chartable assets) - - - -

4.523 0.082 4.441 Increase/(decrease) in Deferred Income (excl. Govt Grants.) 0.090 (0.605) (0.695) (3.687) - - Increase/(decrease) in Deferred Income (Govt. Grants) - - - -

(9.513) (0.770) (8.743) Increase/(decrease) in Current provisions - (1.663) (1.663) 7.225 - - Increase/(decrease) in post-employment benefit obligations - - - - - - Increase/(decrease) in tax payable - - - -

(1.152) 0.018 (1.170) Increase/(decrease) in Trade Creditors 0.020 (0.868) (0.888) 0.440 15.558 12.846 2.712 Increase/(decrease) in Other Creditors 12.862 13.975 1.113 0.084

8.767 (12.276) 21.043 Increase/(decrease) in accruals (12.606) 3.873 16.479 5.801 - - Increase/(decrease) in other Financial liabilities - - - - - - Increase/(decrease) in Other liabilities (non charitable assets) - - - -

10.263 (0.549) 10.812 Increase / (decrease) in working capital, Total (0.125) 10.487 10.612 2.447 7.531 (0.230) 7.761 Increase/(Decrease) in Non-current Provisions - (0.404) (0.404) 0.124

33.362 31.764 1.598 Net cash inflow/(outflow) from operating activities 36.266 31.088 (5.178) 24.806 Net cash inflow/(outflow) from investing activities:

(17.797) (15.791) (2.006) Property - new land, buildings or dwellings (18.918) (10.427) 8.491 (12.180) (3.540) 3.540 Property - maintenance expenditure (3.925) (1.759) 2.166 (3.495) (2.987) 2.987 Plant and equipment - Information Technology (3.465) (7.599) (4.134) (3.594) (5.676) 5.676 Plant and equipment - Other (6.675) (6.000) 0.675 (4.149)

- - Property, plant and equipment - other expenditure - - - (2.955) 0.087 (0.087) Proceeds on disposal of property, plant and equipment 0.100 0.114 0.014 -

- - Purchase of investment property - - - - - - Proceeds on disposal of investment property - - - -

(2.942) 2.942 Purchase of intangible assets (3.614) (1.667) 1.947 (1.527) - - Proceeds on disposal of intangible assets - - - - - - Expenditure on capitalised development - - - -

1.336 (0.500) 1.836 Increase/(decrease) in Capital Creditors 0.000 (0.482) (0.482) (1.396) - - Government grants received - - - - - - Purchase of investments & deposits made - - - - - - Proceeds on disposal of investments & withdrawals - - - - - - Other cash flows from investing activities - - - -

(16.461) (31.349) 14.888 Net cash inflow/(outflow() from investing activities, Total (36.497) (27.820) 8.677 (29.296)

16.901 0.415 16.486 Net cash inflow/(outflow) before financing (0.231) 3.268 3.499 (4.490) Net cash inflow/(outflow) from financing activities:

- - Public Dividend Capital received - - - 3.055 - - Public Dividend Capital repaid - - - -

(1.889) (3.572) 1.683 PDC Dividends paid (7.144) (5.876) 1.268 (5.270) - - Finance leases - - - -

(0.128) (0.128) - Interest element of finance lease rental payments - other (0.139) (0.137) 0.002 (0.139) (0.138) (0.138) - Interest element of finance lease rental payments - On-balance sheet PFI (0.151) (0.150) 0.001 (0.151) (0.108) (0.108) - Capital element of finance lease rental payments - other (0.118) (0.120) (0.002) (0.118) (0.181) (0.181) - Capital element of finance lease rental payments - On-balance sheet PFI (0.197) (0.197) - (0.197) 0.404 0.334 0.070 Interest received on cash and cash equivalents 0.364 0.412 0.048 0.385

- - Movement in Other grants/Capital received - - - - - - Donations received in cash - - - -

0.009 - 0.009 (Increase)/decrease in non-current receivables - 0.070 0.070 0.434 - - Increase/(decrease) in non-current payables - - - -

0.001 (0.001) Other cash flows from financing activities 0.001 (0.968) (0.969) (0.476) (2.031) (3.792) 1.761 Net cash inflow/(outflow) from financing activities, Total (7.384) (6.966) 0.418 (2.477)

14.870 (3.377) 18.247 Net increase / (decrease) in cash (7.615) (3.698) 3.917 (6.967)

86.698 86.321 0.377 Opening cash balance 86.321 86.698 0.377 93.665 14.870 (3.377) 18.247 Net increase / (decrease) in cash (7.615) (3.698) 3.917 (6.967)

101.568 82.944 18.624 Closing cash balance 78.706 83.000 4.294 86.698

Form TF1C

Year to Date

February 2015

Full Year



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February 2015

Year to DateMetric Actual Rating Weight 4 3 2 1

Capital Service Cover 2.59 4 50.0% 2.50 1.75 1.25 <1.25Liquidity 16.6 4 50.0% 0 -7.0 -14.0 <-14.0

Weighted Average 4.00 100.0%

Overriding rules 4

FY ReforecastMetric Actual Rating Weight 4 3 2 1



Overriding rules 4

FY PlanMetric Actual Rating Weight 4 3 2 1



Overriding rules 4

Monitor Continuity of Service Ratings (COSR) Form TF1D

COSR:

COSR:

COSR:



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5 March 2015 Mr Andrew Foster Interim Chief Executive Heart of England NHS Foundation Trust Chief Executives Office Birmingham Heartlands Hospital Bordesley Green Birmingham West Midlands B9 5SS

Dear Andrew, Q3 2014/15 monitoring of NHS foundation trusts Our analysis of your Q3 submissions is now complete. Based on this work, the Trust’s current ratings are:

Continuity of services risk rating - 4 Governance risk rating - Red

These ratings will be published on Monitor’s website later in March. The Trust is subject to formal enforcement action in the form of enforcement undertakings and an additional license condition. In accordance with Monitor’s Enforcement Guidance, such actions have also been published on our website. Monitor will raise any concerns arising from our review of the Trust’s Q3 submissions as part of our regular Progress Review Meetings. A report on the FT sector aggregate performance from Q3 2014/15 is now available on our website1 which I hope you will find of interest. We have also issued a press release2 setting out a summary of the key findings across the FT sector from the Q3 monitoring cycle. If you have any queries relating to the above, please contact me by telephone on 020 3747 0617 or by email ([email protected]).

1 https://www.gov.uk/government/publications/nhs-foundation-trusts-quarterly-performance-report-quarter-3-201415 2 https://www.gov.uk/government/news/nhs-foundation-trusts-tackle-rising-patient-demand

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: [email protected] W: www.monitor.gov.uk



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Yours sincerely

Rebecca Farmer Senior Regional Manager cc: Mr Les Lawrence, Chairman Dr Andrew Catto, Deputy Chief Executive Mr Darren Cattell, Interim Director of Finance


April 2015

Board of Directors

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Title: National Staff Survey results and Staff Engagement Action Plan

Attachments: 2

From: Hazel Gunter Director of Workforce

To: Board

The Report is being provided for: Decision N Discussion N Assurance Y Endorsement Y The Committee is being asked to: Endorse the Staff Engagement programme for 2015/16 Key points/Summary:

National Staff Survey results have not changed significantly from 2013, and the Trust remains in the bottom 20% for overall engagement, ranking 128 / 138 Acute Trusts.

Some small improvements seen across key 2014 target areas Action plan to step change staff engagement across all areas of the workforce in

2015/16 is outlined Significant financial and workforce resource investment required to deliver strong

Staff Engagement agenda with pace and at scale

Recommendation(s): The Board accept the findings of the National Staff Survey and this report, and endorse the Staff Engagement programme for 2015 / 16.

Assurance Implications: Strategic Risk Register

Y SR13

Performance KPIs year to date N


Y Information Exempt from Disclosure

N

Which other Committees has this paper been to? (e.g. F & PC, QRC etc) People Development & Welfare Committee

Assurance Implications: Supports focus on Staff Engagement as a top 3 priority (Clarity, Quality, Staff Engagement) Directly supports Deloitte recommendation 13, and indirectly supports Deloitte recommendations 10 – 16. Directly supports Monitor 90 and 210 day Integration Plan – Culture & Engagement work-stream



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1. SUMMARY Latest position on Staff Engagement The National Staff Survey (NSS) ran from Oct – Dec 2014 to a full census, and achieved a 39% response rate (3,850 responses), a positive increase on the 35% of 2013. The results of the survey show that our position across the 28 Key Findings has not changed significantly compared to last year. Our overall engagement score for 2014 is 3.53, and whilst not statistically significant, is a decrease on the 3.60 of 2013. This metric is scored out of 5, with the Acute Trust average being 3.73, and 3.80 being considered a strong score. We remain in the bottom 20% of Acute Trusts nationally (ranked 128th out of 138 Trusts on overall engagement indicator score, compared to 127th out of 141 in 2013). The results for each of the 28 Key Findings of which the National Staff Survey is comprised are shown in Appendix 1, including whether there was any significant change from 2013, and how it ranks against other Acute Trusts. For 2014, we also chose an optional Key Finding on patient experience, which gives 29 Key Findings in total for HEFT. A full report on the NSS findings can be found at www.nhsstaffsurveys.com Across those 29 Key Findings, we have statistically significant changes in three:

A positive increase relating to our focus on Equality & Diversity training A positive increase relating to our focus on Health & Safety Training A negative decrease in the percentage of staff that would recommend Heart of

England as a place to work. In comparison to other Acute Trusts:

11 of our Key Findings rank in the bottom 20%, including key measures of engagement

12 of our Key Findings rank as worse than average 3 Key Findings are average, 2 Better than Average, and 1 in the top 20% (receiving

E&D training in last 12 months)

2. BACKGROUND Reflection on 2014 approach Following the 2013 NSS results, a short term OD plan was developed, which focused on making improvements across key cultural themes identified in numerous contemporary reports, including Francis, Kennedy, Keogh, Berwick and Monitor. We also sought to increase staff willingness to engage by being open & transparent, with our measures of success for 2014 being: - A significant increase in response rates (early indicator of willingness to engage) - Small improvements across NSS questions directly related to the OD plan themes

In this respect, and accepting that our position as a Trust remains very low, the following ‘green shoots’ of improvement are evident;

Our response rate for the NSS increased from 35% to 39% The NHS England defined “Francis Report Key Themes” from the NSS show

improvements across 4 of the 7 themes (Appendix 2) A change from Q1 to Q3 in our key quarterly engagement metric (“how likely are you

to recommend HEFT as a place to work?”). Whilst showing no change in positive recommenders, we did see a significant shift out of the “would not recommend” into the neutral zone. We believe this to be a signal that more staff are moving into the ‘willing to believe and engage’ zone (Chart 1)



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Chart 1 – How likely are you to recommend Heart of England as a place to work?

3. ACTION

Plan for 2015 / 16 In 2015/16 our aim is to step change staff engagement across all areas of the workforce, measurable by a significant positive change in our overall engagement score and a significant improvement in the rankings of a number of the NSS Key Findings, when compared to other Acute Trusts. We will use the ‘staff recommender’ question as a key quarterly measure of progress (“how likely are you to recommend Heart of England as a place to work”). This step change will see us increase the scale and pace of our staff engagement activities, with a key difference being sponsorship and personal leadership by the Senior Executive team, enabling us to reach and have an impact on more of the workforce. The full Culture & Engagement plan has been presented to and is monitored by the People Development & Welfare Committee. The initial staff engagement activities are outlined below. Staff Engagement programme March – September 2015 a) Trust-wide engagement events (senior executive led) Date status 3 x initial large-scale listening events, c.100 attendance March 2015 complete 4 x locally focused listening events (Emergency Dept.) March 2015 complete 2 x large-scale themed engagement events (clarity / strategy) April 28 / 29 scheduled 2 x Recognition events for staff, on Staff Engagement & Quality April 1 / 27 scheduled Establishing a regular meet for senior leadership to review event feedback, action plan ideas to be activated

March 31 first meet

complete

Design and introduce effective communication channels for ensuring staff have easy and regular visibility of the changes and actions being taken, e.g. ‘you said, we did’

March 25 On-track*

*resourcing of effective comms channel may become an issue



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b) Local team engagement plan (introduction of WWL programme)

Date status

Introduction of the WWL 46-item diagnostic as our quarterly Staff FFT

May 2015 scheduled

‘Engaging Teams’ Train the trainer programme, upskilling HEFT to be able to deliver the programme internally

May 19/20 scheduled

First ‘cohort’ of teams for the Engaging Teams programme selected

April On-track

First ‘cohort’ starts Engaging Teams programme June 3 scheduled Second assessment of teams on ‘Engaging Teams’ programme

Nov 2015 On-track

c) Implementation of key initiatives identified from 2014 diagnostics

Date status

Strong Strategic Narrative: Introduction of a refreshed Team Brief, to provide clarity, effectively communicate and cascade key priorities and message to staff

March 19 complete

Senior leaders have implemented a systematic and effective cascade, ensuring all staff regularly hearing news and feedback

March 19 started

Engaging Managers: 4 x Vital conversations pilots: Implement broad programme to improve behavioural skills in difficult situations.

April - May scheduled

Development of a HEFT specific ‘Leadership Mindsets’ programme, focused around attitudes and mindset aligned to new Values. Proposal to come to board for sign off

Not started

Organisational Integrity: Complete development of set of Trust Values, and associated behaviours. Final stage underway via Staff FFT ‘values edition’ – closes March 27th. To come to board for sign off

May Potential 4 week delay

Implementation of Trust Values, including (re)introduction to staff, with focused engagement events to bring Values to life

May – Aug

Incorporation of Values into working practices. Starts with values into Board and EMB appraisals

June 2015

Implementation of zero tolerance to bullying initiative, led by the Staff Engagement Group.

June 2015 On-track

4. RECOMMENDATION(S)

It is recognised that staff engagement levels across the Trust, as measured by the National Staff Survey, are very poor. We would also note the small positive signs of early improvement outlined in Section 2), and the noticeable change in energy over the last few months as a new leadership team comes into place. We believe this, along with the focused, senior exec led engagement plan provides the Trust with a very real opportunity to step change staff engagement over the next 12 months. It is recommended that the board accept the findings of the National Staff Survey and this report, and endorse the Staff Engagement programme for 2015 / 16. 5. NEXT STEPS

Continue implementation and monitoring of the Staff Engagement programme.



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Appendix 1 – National Staff Survey results 2014 across 29 Key Findings



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Appendix 1 cont. Summary of change across Key Findings, 2013 to 2014



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Appendix 1 cont. Comparison of HEFT to all Acute Trusts in 2014



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Appendix 2: Francis Report Key Themes; HEFT Improvements and Deteriorations 2013 to 2014 (scores show % agreeing strongly + agreeing)

Theme NSS Question Acute

Ave. HEFT 2014

HEFT 2013

Improve / deteriorate

Culture Orgs ensure they have a common culture of care

Teams have shared objectives 78 73 69 Improve Discuss team effectiveness 60 55 52 Improve Teams communicate closely 80 75 70 Improve

Staffing Levels set at safe levels Enough staff to do job properly 31 29 26 Improve

Organisational Priorities remain focused on patient care whilst balancing other demands

Know senior manager 82 76 76 No change Senior managers committed to patient care 55 42 42 No change

Care is organisational top priority 70 53 57 Deteriorate

Leadership Line managers supporting staff to provide care

Manager encourages us to work as a team 71 67 59 Improve

Manager can be counted on to help with difficult task 69 66 63 Improve

Manager gives me clear feedback 57 55 52 Improve

Manager asks for opinion before decisions affecting my work 52 49 47 Improve

Supportive in personal crisis 74 71 71 No change

Providing safe care

Encouraged to report errors, near misses, incidents 86 80 78 Improve

Org blames or punishes people involved in errors, near misses, incidents

42 32 35 Improve

Willingness to recommend for standards of care

If friend / relative needed treatment, would be happy with standard of care

67 48 56 Deteriorate

Staff Engagement disengagement can lead to poor care

Overall engagement indicator 3.74 3.53 3.6 Deteriorate

Raising Concerns Feel confident in ability to raise concerns

Would you know how to report unsafe clinical practice 83 79 n/a

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2015/16 Annual Plan, Governance Statement and Budget


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Annual Plan, Governance Statement and Budget

Title: Financial Plan 2015/16 Attachments: 3From: March 2015 To: April 2016The Report is being provided for assurance to: Trust Board, 14th April 2015Decision Y/N Discussion Y/N Assurance Y/N Endorsement Y/NThe Board is asked to:The Board will remember delegating authority to the Monitor Standing Committee (MSC) to sign off the 2015/16 single year draft Operating Plan for Monitor. This was done at the MSC meeting on 2nd April 2016. This summary paper updates the Board on the information and the decisions taken at that meeting. This paper is therefore for assurance.

Key points/Summary:

Overall, average activity is assumed to grow at the same rate as 2014/15.2015/16 Financial plan of £9.9m deficit following a significant investment programme, in both capital and revenue in existing and new capacity.The investment is planned to bring Quality improvement benefits to Patients and to support delivery of care. Continuity of service rating to remain 3 or above.

Recommendation(s):Monitor requires a draft submission of our 15/16 plan on the 7th April. This paper relates to this draft. The Trust has time to review and if necessary revise that plan in line with the final submission expected on the 14th May.

The 15/16 planning narrative and the financial assumptions were first presented to Finance & Performance Committee (F&P) on the 2nd Feb. The planning narrative was presented at Trust Board February 3rd.A workshop was held with the Trust Board Members on the evening of February 24th

introducing assumptions, numbers and constraints. Planning assumptions were further developed by the exec team and presented again to F&P on the 27th Feb alongside budget setting detail for 2015/16, and again at F&P on the 27th March.

As stated above this paper is for assurance as the Board has delegated decision making powers to the MSC for the approval and submission of the draft 2015/16 Operating Plan. Members of MSC will be able to comment and further detail is available upon request.

The Board is asked to note that, the final submission on the 14th May also requires the board to complete the self-certification templates shown in the appendix to this paper.

Assurance Implications:Strategic Risk Register Y/N Performance KPIs year to date Y/N


Y/N Information Exempt from Disclosure

Y/N

Which other Committees has this paper been to? (e.g. F & PC, QRC etc)

Finance and Performance Committee 27th March 2015


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Revenue Financial Plan 2015/16

2014/15 Recurrent Baseline - Our recurrent plan carried forward from last year.

Net Service Investment - Trust Wide re-alignment of reserves, impact of Post Graduate Medical training ‘transition to tariff’ and potential risk associated with HMRC ‘recovery’ of VAT.

Allocations to Divisions - Funded cost pressures submitted from Divisions as part of budget setting.

LDP Adjustment/ Service Changes - 2014/15 full year effect of non JMRA growth, 2015/16 projected JMRA growth, Other growth & Public Health, Specialised Services growth and impact of Sexual Health Tender/ ERG /CAMH’s. Efficiency & Tariff Deflator - National efficiency requirement and resulting net tariff deflator.

Inflation & CNST - Pay awards, employee superannuation contribution increase, Clinical excellence awards and in year incremental drift. General non-pay inflation including known specific non-pay inflation (drugs, bloods, energy) and impact of CNST premiums.

Non Recurrent Investment - R&D Strategy funding ‘Better care through research’, Trust Wide PMO, Urgent and planned care programme delivery and Theatre stock management system.

2015/16 Plan - Planned deficit of £9.9m, our Monitor Submission.

Earmarked reserves - £35m

Contingency– c£6m

Capital - c£49m

Cash - c£50m

COSR - ≥3m



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Reserves

Capital Plan £m

Operational 6.8

Cross Site Strategy 10.0

Other 13.2

Subtotal – new money 30.0

Carry forward– Cross site 10.4

Carry forward– Other 9.0

Total 49.4

Operational -pieces of equipment or smaller schemes that are part of rolling replacement, statutory standards or regulations or are required to ensure the business continues to run in its current format. Cross Site Strategy - larger building projects that are part of the overall development of the Trust. Each scheme has a business case that is sanctioned at Cross Site Programme Board and where appro-priate Executive Management Board (EMB) and Trust Board. Other – schemes that do not fall into the above categories such as investing in new technology, im-provement or expansion of services, required for strategic direction of the Trust. These will normally have a business case that is approved at EMB.

RESERVE– Centrally Held Budget

2015/16

£m

Cost of Growth 6.0 Investment in Improvement/Services 13.0

Winter 4.0 Pay Inflation 5.6 Supervisory Nursing 2.2 Medical Staffing 0.8 NICE Drugs 1.5 Energy Inflation 0.8 Inflation reserve– Specific VAT 1.0 Total Committed Reserves 34.8 General Contingency 6.0 Total Uncommitted Reserves 6.0 Total Recurrent Centrally Held 40.8

Planned Activity

Levels The 14/15 trend continues into 15/16.

A&E 6.6%

Emergency 10.8%

Elective 1.5%

Outpatients 0.9%

Demand and Capacity – detailed scenario modelling on bed and theatre requirements

to support A&E improvement trajectory.

Independent Sector – additional capacity requirements to clear backlog and achieve

RTT improvement trajectory.

Business Case Review Group – a recommendation of further investment

following submission of business cases to deliver improved care.

Further initiatives – a short list of local initiatives to support delivery of compliance.



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Worksheet "Certification G6"

1 & 2 General condition 6 - Systems for compliance with license conditions

1

2

Signed on behalf of the board of directors, and having regard to the views of the governors

Signature Signature

Name Name

Capacity [job title here] Capacity [job title here]

Date Date

A

B

Declarations required by General condition 6 of the NHS provider licence

Further explanatory information should be provided below where the Board has been unable to confirm declarations 1 or 2 above.

The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required.

Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution.

ANDThe board declares that the Licensee continues to meet the criteria for holding a licence.



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Worksheet "Corporate Governance Statement"

Corporate Governance Statement

The Board are required to respond "Confirmed" or "Not confirmed" to the following statements, setting out any risks and mitigating actions planned for each one

4 Corporate Governance Statement Response Risks and mitigating actions

1 [including where the Board is able to respond "Confirmed"]

2

3

4

5

6

Signed on behalf of the board of directors, and having regard to the views of the governors

Signature Signature

Name Name

A

B

C

The board are unable make one of more of the above confirmations and accordingly declare:

The Board is satisfied that there are systems to ensure that the Trust has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.

The Board is satisfied that the Trust applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.

The Board has regard to such guidance on good corporate governance as may be issued by Monitor from time to time

The Board is satisfied that the Trust implements: (a) Effective board and committee structures;(b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and(c) Clear reporting lines and accountabilities throughout its organisation.

The Board is satisfied that the Trust effectively implements systems and/or processes:

(a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively;(b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations; (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions;(d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making;(f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence;(g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and(h) To ensure compliance with all applicable legal requirements.

The Board is satisfied that the systems and/or processes referred to in paragraph 5 should include but not be restricted to systems and/or processes to ensure:

(a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations;(c) The collection of accurate, comprehensive, timely and up to date information on quality of care;(d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;(e) That the Trust, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and(f) That there is clear accountability for quality of care throughout the Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.



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Worksheet "Other declarations"

Certification on AHSCs and governance and training of governors

5 Certification on AHSCs and governance Response

6 Training of Governors

Signed on behalf of the Board of directors, and having regard to the views of the governors

Signature Signature

Name Name

Capacity [job title here] Capacity [job title here]

Date Date

The Board is satisfied it has or continues to:• ensure that the partnership will not inhibit the trust from remaining at all times compliant with the conditions of its licence;• have appropriate governance structures in place to maintain the decision making autonomy of the trust;• conduct an appropriate level of due diligence relating to the partners when required;• consider implications of the partnership on the trust’s financial risk rating having taken full account of any contingent liabilities arising and reasonable downside sensitivities;• consider implications of the partnership on the trust’s governance processes;• conduct appropriate inquiry about the nature of services provided by the partnership, especially clinical, research and education services, and consider reputational risk;• comply with any consultation requirements;• have in place the organisational and management capacity to deliver the benefits of the partnership;• involve senior clinicians at appropriate levels in the decision-making process and receive assurance from them that there are no material concerns in relation to the partnership, including consideration of any re-configuration of clinical, research or education services;• address any relevant legal and regulatory issues (including any relevant to staff, intellectual property and compliance of the partners with their own regulatory and legal framework);• ensure appropriate commercial risks are reviewed;• maintain the register of interests and no residual material conflicts identified; and• engage the governors of the trust in the development of plans and give them an opportunity to express a view on these plans.

The Board is satisfied that during the financial year most recently ended the Trust has provided the necessary training to its Governors, as required in s151(5) of the Health and Social Care Act, to ensure they are equipped with the skills and knowledge they need to undertake their role.

The Board are required to respond "Confirmed" or "Not confirmed" to the following statements. Explanatory information should be provided where required.

For NHS foundation trusts:• that are part of a major Joint Venture or Academic Health Science Centre (AHSC); or• whose Boards are considering entering into either a major Joint Venture or an AHSC.



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A

B

C

Where boards are unable to self-certify, they should make an alternative declaration by amending the self-certification as necessary, and including any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance

The Board are unable make one of more of the confirmations on the preceding page and accordingly declare:


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Advanced Clinical Practitioner Business Case


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INVESTMENT APPROVAL BRIEFING TO: Executive Management Board MTG 17.03.15 Advanced Clinical Practitioners

Project Ref: 14-022-H P.Sponsor: S Foster P. Lead: G Swann

1. EXECUTIVE SUMMARY

This Business Case to support the expansion of the Advanced Clinical Practitioner (ACP) role across Heart of England Foundation Trust (HEFT) forms part of a larger Workforce Strategy that if supported, will: - Reduce Trust system reliance on costly temporary medical staff, locums and trainee doctors Reduce system ‘relearning’ that stifles attmepts to innovate and improve, which coincides with

trainee handover and high locum use Provide more consistent seven day services Provide more consistent out of hours (OOH) cover Provide greater clinician team and trust wide system resilience Address some of the workforce issues related to the availability of senior doctors

The larger workforce strategy will seek to: - CLARIFY - Staff roles and a future vision for the workforce ENGAGE - With staff to ensure they are involved In decision making at every level IMPROVE - Quality of care through improved ‘fit for purpose’ career long training INNOVATE - With the creation of new clinical career pathways with less emphasis on foundation

disciplines MAXIMISE - Our recruitment and retention potential of gifted and talented professionals from all

disciplines The larger Workforce Strategy will consider other potential options including the expansion of the Consultant clinician role, improving and expanding opportunities for SAS grades and other non-medical roles e.g. the Physician Associate role. The success of the ACP role will be integrally linked to the quality of the supervision provided by Consultants and other senior clinicians and by a cadre of senior non-medical clinicians that will be recruited to HEFT at the start of the programme. Therefore, this Business Case should not be viewed in isolation and must be considered in context with other initiatives and key developments within emergency and unscheduled care. The ACP Strategy will form part of a suite of innovative strategies currently being developed by Professor Matthew Cooke for initial presentation to the Board in June 2015 and final presentation in September 2015. It is a significant and conscious financial investment by the Trust Board in a safer and more resilient workforce that will deliver a better experience and future for patients and staff, alike.


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Approvals Timeline

DECISION REQUIRED FULL BUSINESS CASE APPROVAL

INVESTMENT DRIVER(S) PROPOSAL SCOPE Transformation: This ground breaking and innovative workforce model will deliver a new and more permanent integrated workforce consisting of senior clinicians. These new clinicians will be drawn from a number of professional backgrounds that will replace the largely medical workforce model that is heavily reliant on locum and agency staffing. This locum and agency dependency has been shown to impede any attempt to innovate and then sustain improvements over time. Quality: To improve patient quality and safety be removing the need for cyclical ‘system relearning’ that coincides with trainee changeover. This new model will significantly reduce system reliance on locum and agency staff that are of variable quality Cost/VFM: Significant manpower savings will be realised through reduced reliance on locum and agency medical provision at every level of medical practice.

This business case seeks funding up to £44.5m over a 7 year period to support a new approach which will enable the Trust to reduce its system reliance on temporary medical staff, locums and trainee doctors. An empowered and flexible clinician-led workforce will deliver care that is more responsive, more consistent, timely and safer, and one that is driven by quality improvement. Investment will be integrally linked to the adoption of new and more effective ways of working and approaches and the withdrawal of MG posts. At the end of the 7 year period the net investment impact to the Trust is £6.5m. The programme will be externally evaluated and will challenge us to think and act differently.

BENEFITS / FIT TO STRATEGY Enhanced patient care

Greater organisational efficiency and effectiveness

Retained organisational knowledge, skills and competencies

Retention of gifted and talented individuals who are committed

to HEFT values and who will be the leaders and role models of the future

Improved system performance realisation from its increased

reliance on a permanent as opposed to transient workforce

Greater clinician compliance with local guidelines and national Care Quality Indicators

This new model is innovative and is already being replicated in other hospitals. It is based on almost 10 years experience of developing alternative clinicians within the Emergency Directorate at HEFT

Patients are more likely to be seen by the ‘right’ person, with the

‘right’ skills and at the ‘right’ time with this new model

FORECAST FINANCIAL IMPACT £m 15/16 16/17 17/18 18/19 19/20 20/21 21/22 Total

Initial Revenue to Delivery Date Gross Initial Investment 2.06 5.97 9.02 11.80 14.71 16.01 16.60 76.17

Grants/external funding (+ source) Net Initial Investment 2.06 5.97 9.02 11.80 14.71 16.01 16.60 76.17

Marginal costs excl dep’n Marginal savings (0.12) (0.47) (2.80) (4.42) (6.05) (7.68) (10.1

2) (31.66)

Total Cash Flow impact 1.95 5.50 6.22 7.37 8.66 8.33 6.48 44.51

Impact on Trust Surplus 1.95 5.50 6.22 7.37 8.66 8.33 6.48 44.51

Proposed Funding Source Central Reserves Costs to Full Approval

Project Life 7 years Pay £6.3m NPV Not Applicable Drivers Matrix 435

Prior approval

Capital 0 Drugs Not Applicable Payback Not

Applicable Delivery April 2015 Revenue 0

Strategic Case Strategic Delivery Unit

Approval Granted 1 October 2014

Gate 3 Full Business Case Executive Management

Board Approval 17 March 2015

Gate 3 Full Business Case Trust

Board Approval April 2015



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2. BENEFITS REALISATION REVIEW PLAN Title of Business Case: Advanced Clinical Practitioners Investment Review Dates Due Completed Business Case Reference No: 014-014-H Overall Project Lead G Swann First Review: 1st May 2016 Business Unit: Trustwide Executive Director S Foster Second Review: 1st May 2017 Directorate: Trustwide Deputy Medical Director: M Cooke Subsequent Reviews: Annually Business Consultant: Jo-Anne John Project Manager: Estates/ICT

Agreed Actual Variance Reasons for Variance

Initial Investment (£k) Revenue Cost Base Increase (£k) Revenue Savings Impact (£k) Income Impact (£k) Contribution (£k) Implementation Date 1st May 2015

Project outline scope: This project aims to reduce Trust’s reliance on temporary medical staff, locums and trainee doctors over the next 5 years with the introduction of Advanced Clinical Practitioners.

Ref Critical Success Factors & link to KPI. Benefit Type Key Measures (KIM) Base Value Target Value

Target

Date

Review Status

Comments / Actions Agreed

Patient experience should improve in areas supported by ACPs

Clinical Outcomes

Patient Experience / Family & Friends Questionnaires April

2016 Annual

Staff experience should improve in areas supported by ACPs Transformation Staff Survey April

2016 Annual

Patient outcomes should improve in areas supported by ACPs

Clinical Outcomes Agreed metrics 2017 Annually with a formally

evaluated in July 2017

The number of admissions avoided should improve with the introduction of an ACP Led 24/7 integrated care team

Clinical Outcomes Admissions avoided Not currently

measured



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Improvement in admission to clinician assessment should improve in assessment adjacencies

Clinical Outcomes

Admission to Clinician Time (in all assessment

adjacencies) 100 mins 100% within 60 minutes April

2017

The time from admission to initial intervention should improve in assessment adjacencies that are supported by ACPs

Clinical Outcomes

Door to needle Stroke (to CT)

Stroke FAST +ve Stroke FAST –ve Swallow Test STEMI (to PCI) NSTEMI Sepsis (antibiotics <1hr)

50% < 45 mins 60% < 1hour

80 < 30 mins Not measured

65%

100% 80%

100% 100%

100%

Jan 2016

Compliance with agreed PDDs on base wards that are supported by ACPs should improve

Clinical Outcomes

Measure actual discharge and PDD

Not currently measured 80% Jan

2017

The frequency of patient reviews should improve in areas supported by ACPs

Clinical Outcomes MSS Clinician assignment Not currently

measured Twice daily September 2016

The average LOS should improve in assessment adjacencies that are supported by ACPs

Clinical Outcomes

Improve LOS on AMU at BHH

Improve LOS on SAU at BHH

12.8 hours

8.3 hours

<8 hours

<6 hours

April 2017

The average LOS should improve in base wards supported by ACPs

Clinical Outcomes Improvement in LOS

BHH 5.9 GHH 4.3 SH 8.1

Benchmark against NHPA

September 2016

Improvement in TTO turnaround times within ACP areas

Clinical Outcomes TTO turnaround time Not currently

measured

Improvement in discharge rates before midday on wards supported by ACPs Transformation Discharge rates before

midday

BHH 10.1% GHH 10.7%

SH 10% 50% April

2017 10% year on year improvement from 2017

ACP led discharges from assessment adjacencies and acute wards

Clinical Outcomes

Improvement in the % of discharges made by non-medical staff year on year

- 10% 1st

April 2017

10% year on year improvement to a maximum of 50%



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Replacement of middle grade posts with ACPs Transformation No. of withdrawn middle

grade posts -

(Year 1) 0 posts (Year 2) 0 posts (Year 3) 14 posts (Year 4) Further 22 posts (14+22=36) (Year 5) Additional 24 post (36+26=60) (Year 6) Additional 24 posts (60+24=84) (Year 7) Additional 12 posts (84+36=120)

Reduction in locum spend as per predicted model Value for Money

Quarterly locum and agency middle Grade - SHO

expenditure

1st April 2017

Publication of ACP programme development and evaluation within leading periodicals and journals

Clinical Outcomes

No. of publications per year -

1st April 2017

The number of publications would depend upon the number of PDSA cycles

Annual audits of ACP service Clinical Outcomes No. of audits - 1

1st April 2016

Bi-annual whole programme review Clinical Outcomes - 1

Overall Status Comment: Where not green or ‘grey area’ summarise issues which have defined status e.g. ‘Delayed recruitment , risk to LOS’ Lead: Garry Swann

Key Review status Key: Red – Delivery at risk and mitigating actions ineffective. Amber – Delivery at risk, mitigating actions agreed. Green Delivery not at risk. *Benefit Type Key: Clinical Outcomes, Staff Satisfaction, Patient Satisfaction, Transformation, Cost/VFM



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BUSINESS CASE: CONTENT Page

No.

1. Executive Summary 1 2. Project Benefits Realisation Review Plan ‘BRRP’ 2

3. Summary and Recommendations 7 4. The Case for Change 11

5. The Proposed Solution 12

6. Option Choice Rationale and Financial Impact 18

7. Project Delivery and Change History 22

APPENDICES A. ACP Trainer Roles and Responsibilities 25

B. Current Risk Assessment Matrix 26

C. Project Drivers Matrix Score 27

D. Option Generation 30

E. Non-Financial Appraisal by Option 33

F. Project Plan 34



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3. SUMMARY AND RECOMMENDATIONS

Why do we need to change? HEFT, like the rest of the NHS, is facing a significant financial challenge with regard to the resources available to deliver safe, effective and high quality care. Our current locum and trainee dependent service is costly and fails to deliver a consistent and responsive service proportional to patient need. This situation is compounded further by the fact that we know the availability of medical trainees and locums will reduce significantly; so the option of doing nothing may no longer be an alternative in the future. We also know that we are unlikely at any point to have enough medically trained professionals to deliver a consistent service. We must act now and think differently if we are to address this. There is no ideal single solution to the re-organisation of a modern health care workforce but an approach that maximises the significant potential and contribution of other health professionals allied to medicine is one that we believe should be supported.

What are the options? Four options have been considered within this business case to address the crisis within the medical clinician workforce. These relate to: -

Doing nothing The use of ‘Physician Associates’ (PAs) The expansion of the Nurse Specialist role Expansion of the Advanced Clinical Practitioner (ACP) role

Why have we chosen the Advanced Clinical Practitioner role?

An ACP is an experienced senior non-medical clinician who possesses the knowledge, skill and competence to see, treat and manage patients across the age and acuity spectrum; from those attending with minor problems, through to those experiencing major life-threatening injuries and illnesses within a consultant-led team. An ACP is Masters prepared by an expanding MDT of clinicians at HEFT, which enables them to work at a senior clinician level, just like a senior doctor. It is the only potential option that can currently replace doctors and therefore, provides better value for money than our current transient medical workforce consisting of locums and trainees and other non-medical alternatives.

What are we proposing for HEFT? It is our professional view that the ACP model within a MDT Consultant led service is the desired option for HEFT. This is based on more than a decade of experience of developing this role and given its proven track record within the Trust’s Emergency Directorate (ED) and more latterly within Acute Medicine (AM). Repeated local audits have provided the evidence to support our view regarding the efficacy of the role. If this can be achieved in the ED and AM, then it follows that this will be a very safe option in other clinical areas with narrower patient profiles and service remit; and certainly much safer than the current locum and trainee dependent model. The ED would be in a significantly worse situation without its investment in ACPs and we have largely avoided the problems that are common place in other Trusts. This Business Case outlines a new approach, which will enable an empowered and flexible clinician-led workforce (consisting initially of permanent doctors and ACPs) to deliver care that is more responsive, more consistent, timelier and safer, and one that is driven by quality improvement.

How are we going to do it? We will challenge attitudes and behaviours that seek to maintain the ‘status quo’ and break the cycle of poor system resilience. We will introduce the role at scale across speciality areas and help staff to see a better future where patients are seen at the ‘right’ time, in the ‘right’ place, by the ‘right’ professional from our modern multi-disciplinary clinician team. Our aim within 5 years is to largely negate the need for the very high cost cyclical ‘system relearning’ that coincides with trainee changeover and premium rate locum use; which often impedes any



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attempt to sustain improvements or innovations. This Business Case will introduce a complementary career infrastructure that will retain gifted and talented individuals from trainee ACP to ACP Consultant. It will also outline how this model reflects and supports Trust priorities and key regional and national workforce initiatives; providing an exciting and sustainable workforce template for other hospitals and services to follow.

The Trust Board is asked:

To approve this Advanced Clinical Practitioner (ACP) workforce strategy.

To release recurrent funding up to 14.6m to recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of the programme at this stage. Then recruit and train an additional 150 new ACPs in the following 3 years.

To oversee the withdrawal of up to 120 locum and middle grade posts across the Trust by

2021-22 to support the funding of the ACP posts.

Consequences of doing nothing:

Non-medical clinician roles are still likely to proliferate in an uncoordinated manner to address the MG staffing crisis across the Trust, which represents a significant clinical risk for the Trust

The Trust is unlikely to realise the same level of impact or cost savings in terms of staffing or their educational development than if this was coordinated centrally. Roles will remain highly variable in their preparation and scope of practice.

There will be no agreed standard for practice – there will be different standards across disciplines despite the fact that these groups will be treating similar or identical patients

Local solutions and standards are unlikely to be transferable between different directorates

There will be a continued reliance on expensive and variable quality locums and trainees. It is important to note that we have already had 17,026 medical locum and agency shifts for Q1-Q3 this financial year (2014/15)

Governance issues related to standard of practice will be difficult to manage and address

Confusion will continue to grow among patients and staff, alike Performance against nationally mandated Care Quality Indicators and other metrics will

continue to be an issue across the Trust Trust reputation will continue to be tarnished There will continue to be costly duplication of effort across the organisation We will lose gifted and talented individuals Patients will continue to be admitted unnecessarily to hospital because of the lower

clinical decision making thresholds that are now common place within locum and trainee dependent systems



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Optional appraisal of other workforce models: Table 1 – Option Appraisal of the different workforce models Model Effect on

organisational performance

Reliance on locums and trainees

System relearning

Workforce resilience

Cost

Traditional medical model

Performance remains the same. Continuing system and performance variability

Remains unchanged

Will occur cyclically every 4 months and daily in areas of high locum use

Poor High given system reliance on locums

*PA model within a Consultant led service

Unclear what affect this role will have. Performance against a proportion of the KPIs should improve

Significant – PAs will not replace MG clinicians because they work in an associate capacity under the supervision of a Consultant


Improved but the associate role currently has limited scope. There may be the potential to increase pressure in an already pressurised system because of need for long term supervision

High - PAs are unlikely to replace MG clinicians. Likely to increase cost because high locum use is likely to continue

**Nurse Specialist role within a traditional Consultant led service

Performance remains the same. Continuing system and performance variability

Remains unchanged


Poor High given system reliance on locums

ACP model within a MDT Consultant led Service

Evidence from the ED would suggest that performance against KPIs will significantly improve

Significant reduction and will eventually negate the need for locums

Significantly reduced system relearning because of the benefits associated with a constant autonomous workforce

Significantly improved 24/7. Expansive scope and senior decision making capacity will provide a resilience

Significant investment required initially but will eventually avoid the cost associated with premium locum use

The Physician Assistant/Associate role

This group of non-medical clinicians is still relatively new to practice in the United Kingdom (UK), although they are well established in North America and Canada. Generally, PA’s are science graduates or allied health professionals who will have undertaken a nationally approved standard of training within a post graduate course. There are currently only three universities in the UK offering the PA course, which takes one year to complete. There are core competencies to achieve as part of their training, which include;

undertaking medical histories performing examinations



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diagnosing illnesses analysing test results developing management plans referral to other services/professionals

Although PA’s are a growing body of practitioners within the UK they do not currently work in an autonomous capacity. They must work under the direct supervision of a doctor and are only able to practice within set limitations. A current lack of professional regulation prevents them from assuming complete responsibility and accountability for patients with undifferentiated and undiagnosed conditions; nor can they prescribe independently, or request radiological investigations. From the patient’s perspective they can experience an interrupted care pathway, with multiple hand-offs leading to longer consultations and potential safety issues. However, there will be directorates at HEFT where this type of role would address current workforce shortfalls and service need and should therefore, be considered.

The Nurse Specialist role Clinical nurse specialists provide expert advice related to specific conditions or treatment pathways. They focus on improving patient care and developing services. The clinical nurse specialist will:

assess patients, plan, implement and evaluate evidence based care; provide specialist advice to patients, families and carers and the wider multi-

disciplinary team; carry out specialist nursing procedures; contribute to the development of the workforce through developing and delivering

education and training; contribute to the development of services; participate in and lead research activity, and clinical audits in own specialist area; work collaboratively with the multi-disciplinary team to ensure the cohesive

management of patients.

Education, Training and Qualifications

Diploma or degree in nursing Specialist degree, Post Grad Dip or MSc in Specialist Practice Qualification in teaching and learning in clinical practice Leadership skills training Additional qualifications related to specialist area Research training Counselling skills

Although we are fortunate at HEFT to have a significant number of Nurse Specialists, they are unlikely to truly function at full MG level or above. It will be important to consider development opportunities for any Nurse Specialists wishing to become ACP by design. Any bespoke training would need to be agreed by the ACP Education Lead to ensure any skill, knowledge or competency deficits within their specialist area of practice are addressed.



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THE CASE FOR CHANGE HEFT is facing a significant operational challenge with regard to the resources available to deliver safe, effective and high quality care. Patient and public demands and expectations are changing which will affect the way in which activity is commissioned in the future. Our services are being tasked to find new ways of delivering care, which ultimately means our workforce will need to work differently, across specialisms, and in a more flexible manner. An increasing proportion of the locum and agency staffing at HEFT is currently supporting flow dependent initiatives. This is at a time when there is little sustained flow within the organisation. This type of provision is being used to sustain systems and processes that are working reactively within a crisis instead of proactively functioning when we have control. When staff work in a broken system (that is perceived to be out of control), it becomes increasingly difficult to imagine a better, or more effective way, without asking for more of the same. The Trust has to break this cycle of poor system resilience and deliver a better future where patients are seen at the ‘right’ time, in the ‘right’ place, by the ‘right’ professional, making the ‘right’ decision at the very start of their journey. A mismatch now exists between the type of patients attending hospital for treatment and the traditional medical workforce charged with delivering their care. The reasons for this whilst complex and multifaceted include: Reduced number of trainees

The perceived relentless nature of hospital work and the increasing complexity, frailty and acuity of patients has had an effect on the number of doctors choosing hospital medicine as a viable career option. Core training recruitment is to the Acute Care Common Stem (ACCS) programme. The last National Training Survey by the General Medical Council in 2011 showed that recruitment to Acute Medicine and Emergency Medicine remains poor, with only 40% completing their higher level training. In addition, there is currently a planned reduction in junior grade posts by the Deanery (20% reduction in surgery training numbers over the next 3 years, and a 50% reduction in the service contribution for all other specialist trainee grades (ST1-9, including GPVTS).

Cost of non-permanent medical workforce

A reduced cohort of doctors has resulted in most hospitals (through perceived necessity) adopting costly and largely ineffective ‘locum’ dependent systems, including HEFT. The rising cost of locum and agency middle grade staffing over the last 3 years is forecast at £22.4m Table 2 – Locum & Agency Middle Grade Costs

2012-13

£000 2013-14

£000 2014-15

£000 TOTAL £000

AGENCY MEDICAL 2,858 3,720 5,884 12,462

LOCUM MEDICAL 2,746 3,301 3,891 9,938

TOTAL 5,604 7,021 9,775 22,400 Lack of key decision making It has been shown that increased use of non-permanent medical personnel results in lower decision making thresholds and more patients being admitted unnecessarily to hospital. According to the Keogh Review (2013)1, there were 5.2 million patients admitted acutely to hospital nationally in 2012 and it is estimated that 1.2 million of these could have been prevented



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if alternative workforce models were in place. The Oak Audit (2014) confirmed that this national picture related to avoidable admissions is no different at HEFT. This further exacerbates the problems we face resulting in poor system resilience, poor flow, overcrowding within the Emergency Directorate and assessment adjacencies, exit blocks, poor quality care, repeated bed moves, and extended lengths of stay, as well as poorer patient and staff experiences.

Overseas Recruitment Despite many years of experience and extensive recruitment efforts the recruitment of overseas doctors as a long term initiative and solution at HEFT has proved disappointing. Continuing to adopt this approach and expecting a different outcome is problematic and inaction is not a safe or viable option given the projected shortfall in overall doctor numbers and medical trainees over the next few decades. We now need to fundamentally challenge traditional thinking around workforce and maximise the combined potential of professionals allied to medicine.

5. THE PROPOSED SOLUTION

It is now widely acknowledged that solutions to solve performance compliance and patient safety issues cannot be addressed by changing systems and processes in isolation or silo working; the critical issue of having a clinician workforce that is fit for purpose must be addressed. The Centre for Workforce Intelligence predicts that it will be at least 2020 before there are sufficient numbers of medically trained Consultants. However, this projection is based on maintaining the current number of training posts and assuming a 100% uptake from core training and the avoidance of high levels of attrition. Given current and historical trends, we know this will probably not occur and it is likely to be several decades before this is achieved, if ever. In simple terms, we are unlikely at any point in the future to have sufficient numbers of medical clinicians. We therefore, need to look more broadly and develop our own clinician workforce from a number of disciplines. To address local, regional and national workforce issues around Middle Grade (MG) level practice, Health Education West Midlands (HEWM) will introduce guidance related to the standard required for the development of non-medical clinicians in 2015, which will incorporate the Advanced Clinical Practitioner (ACP) role. Work has already started regionally within the West Midlands on developing alternative clinicians to work at this level based on our model at HEFT. A workforce report, commissioned by Health Education West Midlands (HEWM), proposes the development of a standardised, long-term infrastructure to train nurses, paramedics and other professionals in expanded or advanced clinician roles within Emergency and Urgent Care. It is highly likely that NHS England will encourage other regional partners to adopt a similar approach to address the MG staffing crisis within emergency and urgent care, which reiterates the importance of acting now before we start pulling from a contracting workforce pool.

5.1. ADVANCED CLINICAL PRACTITIONERS

As indicated above, an ACP is an experienced senior non-medical clinician who possesses the knowledge, skill and competence to see, treat and manage patients across the age and acuity spectrum; from those attending with minor problems, through to those experiencing major life-threatening injuries and illnesses within a consultant-led team. An ACP will possess a clinical Masters Degree and be a non-medical prescriber. This group of non-medical clinicians tend to come predominantly from the nursing profession; however there are ACPs currently practicing from other AHP groups including; Midwifery, Pharmacy, Physiotherapy, Occupational Therapy, Paramedical and Radiography.



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The ACP role has been in existence since 2006 and HEFT was the first Trust nationally to introduce the role at scale. HEFT is considered by many to have the most advanced programme for developing ACPs in the country at present and 90 hospitals nationally have now visited the Emergency Department (ED) to discuss the role, and potentially introduce similar initiatives within their own organisations. ACPs now make a significant contribution to the ED clinician workforce with just over half of the attending patients (53%) being seen and treated by non-medically trained staff. The success of the ED model (in an area where the majority of patients attend with undiagnosed and undifferentiated problems across the age and acuity spectrum) will provide reassurance that this approach can be safely replicated in other clinical areas and within speciality teams across HEFT. An ongoing large scale research study comparing permanent ED ACPs and ED medical MGs showed that the ED ACPs see approximately one thousand more patients per annum than the average medical ED MG counterpart. Other smaller scale audits that have compared ED medical MGs with ACPs have shown that ACPs are: -

safer, with evidence in prescribing, but also as senior decision-makers interdisciplinary role models and with significant leadership potential more likely to have a understanding of, and adhere to, local policy and procedures and

therefore, less likely to make mistakes less likely to admit patients unnecessarily more likely to see and treat patients across the age and acuity spectrum following the best

pathway for the patient whether that be referral and admission, or referral to another agency, or discharge home

more likely to stay at HEFT than their transient medical MG equivalents Ongoing support from the ED Nurse Consultant, senior ACPs and Medical Consultants has ensured the ACP role has flourished and become the benchmark for other hospitals and systems to follow. The support required by trainee ACPs and junior ACPs is significant and should not be underestimated. Time to undertake effective clinical supervision will be included within this workforce strategy and will form part of the senior clinician’s non clinical commitments. Appendix A outlines the roles and responsibilities of any senior clinician group wanting to support ACPs within their own clinical areas.

5.2. PREFERRED OPTION We believe an ACP model within a MDT Consultant led service is the desired option for HEFT. This is based on more than a decade of experience of developing this role and given its proven track record within ED and more latterly within AM. ACPs will be used in a ‘new ways’ across systems and will replace some locum and permanent medical posts at MG level and above. None of the other options identified within this report currently allow for this to occur. However, simply replacing MGs with ACPs within some specialities will not address ongoing problems with regard to quality, safety, access and flow. This is because many traditional systems and pathways have never been truly designed around patients and will only provide a temporary fix for systems that are unable to systematically deliver against key performance indicators. It is likely that some of the vacancies at MG level will be redundant once new ways of working have been embedded across the emergency and urgent care pathway. ACPs posts will be integrally linked to the adoption of new ways of working and KPIs. Directorates will be able to apply for these new posts but will need to ensure any workforce plans support this new approach. Table 3 outlines how ACP will align to traditional medical staffing roles. The key benefit for selecting ACPs as the desired option is the fact that their developmental programme has been designed to deliver ‘generalists’. They are governed by professional



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regulatory bodies and are therefore, autonomous, accountable and responsible for their commissions and omissions in clinical practice. Experienced ACPs are able to independently prescribe medications (with the current exception of paramedics), request and interpret radiological investigations and independently admit, refer and discharge patients, often without referral to a senior medical consultant. As with all clinicians, there is a spectrum of ability and there will be occasions where an ACP does not meet the required standard. With robust governance, training and line management structures in place, there can be reassurance that any perceived lack of performance will be proactively managed in line with current HR policies.

5.3. CULTURAL CHANGE The introduction of this new and integrated team working will require a significant shift of opinion amongst some senior consultants, nurses and managers who may remain unconvinced that non-medical trained individuals can work at this level. Some may feel professionally threatened or have a viewpoint based on outdated experiences. They may also perceive this to be an unsafe option whilst not appreciating the staffing crisis we are currently facing, or make the link between our fragile clinician workforce and our organisational inability to comply with national performance and quality metrics.



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Table 3 – Comparison between ACPs and medical staffing grades

Grade

4th Year Medical Student

tACP Level

1

5th Year Medical Student

tACP Level 2 & 3

FY1 FY2 GPVTS ACP Level

4

Junior Middle Grade

ACP Level

5

ACP Level

6

ACP Level

7

Senior Middle Grade

ACP Level

8 Consultant

Specialty Training 0 1 0 2-3 1 2 3-5 4 ≥3 5 6 7 >4 8 8

Learning to take patient histories and to clinically examine a patient

Competent at history & examination within own clinical specialty / area Ability to see patients, produce a differential & management plan Work independently the majority of the time & Competent to assess patients within own clinical specialty / area.

Clinical ability to assess all patients and able to supervise others within speciality Competent MG developing to higher levels of practice within speciality Exhibiting mastery level practice and competent in all domains within speciality



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5.4. ACP TRAINING All ACPs will undertake a Masters in Advanced Clinical Practice. The purpose of the Masters in Advanced Clinical Practice at Warwick Medical School is to provide trainee ACPs with a broad range of knowledge skills and competences to enable them to work at an equivalent MG level. On completion of their programme ACPs are able to assess any acutely ill patient and commence resuscitation if necessary. They will be able to diagnose the most likely underlying problem, initiate appropriate investigations, commence appropriate immediate treatment and liaise with other in-patient clinical teams to ensure appropriate definitive care. In simple terms, ACPs will be equipped with identical level of knowledge and will be able to undertake the skills expected of any MG clinician. A clinical portfolio is used to assess clinical ability and to gauge skills progression against a mandated list of clinical presentations. This must show an even spread across the clinical and acuity spectrum in order to achieve stipulated core competencies within any speciality. These have been adapted from the Acute Care Common Stem (ACCS) curriculum for medical trainees. The assessments are grounded in relevant clinical content encountered in the workplace. Identical assessment tools are used for evaluating clinical skills, knowledge, communication and teamwork relating to important clinical problems that are commonly encountered. They are also readily adaptable, in that, they may be applied to different clinical conditions and settings. All assessments within the clinical portfolio must be completed before submission and will be assessed on a pass/fail basis. We will be the first Trust nationally to move to this integrated model across all its services but others will closely follow. Therefore time is of the essence because other services and hospitals are actively recruiting trainee ACPs and ACPs. There will be significant challenges along this journey that will require multi-disciplinary teamwork, tenacity, diplomacy, encouragement, effective leadership and open and transparent communication. It is our view that this is a journey worth taking if we are to achieve, and then sustain excellence across our services. If we fail to act now, we will be trying to attract trainees from a dwindling cohort and competing with other organisations and services who are already considering employing increasing numbers of ACPs or PAs. It is our belief that a controlled expansion of the ACP role across assessment areas and base wards will deliver a more standardised and consistent service 24/7 and reduce the care and quality variance that currently occurs. Why Warwick Medical School? Feedback from a recent West Midlands Emergency Medicine Workforce Summit indicates that almost 80% of key stakeholders (Trust, CCGs, HEIs and HEEs representatives) are in favour of supporting a regional initiative to develop Advanced Clinical Practitioner roles. Despite overwhelming support pertaining to their potential effectiveness across a number of disciplines, there were some concerns raised. These relate to: -

a lack of regionally agreed assessment and competency standards to ensure transferability from one sector to another

an incomplete appreciation of their prospective potential no obvious way of quality assuring clinical and educational supervision to enable the

clinician to flourish poorly developed clinical governance arrangements funding non medical trainee clinician posts that are replacing traditional medical posts



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Health Education West Midlands (HEWM) therefore, commissioned a report to scope the recruitment, development and long term sustainability infrastructure that will be required to train nurses, paramedics and other professionals to undertake these roles across clinical areas and services. An independent pan Birmingham review of all available programmes was undertaken by HEWM and the masters programme run at Warwick Medical School by our Clinical Director for Advanced Practice was selected to scope the report and to pilot a future ACP training programme. It may be beneficial to tender the contract to deliver the ACP programme at other univerisites at some point in the future. Any change in the educational provider would need to be preceded by a market engagement exercise to determine interest from other local HEIs and their suitability against pre-defined criteria.

6. OPTION CHOICE RATIONALE AND FINANCIAL IMPACT In order for the Trust to provide a safe, efficient and stable clinical workforce and support the delivery of national recommendations and standards, an initial assessment of options was undertaken to meet the long term business need. Four options were first identified which included:

Doing Nothing Moving to a Physician Associates workforce model Moving to a Nurse Specialist workforce model Moving to a Advanced Clinical Practitioners workforce model

The first three options were excluded by the Executive Management Board as they were deemed not to meet the long term workforce strategy of the organisation. The option to explore the capability of an ACP model within a MDT Consultant led service was then taken forward and examined. Four further sub-options of how this model could be delivered were then considered. These were:

Option Description

Option 1 Recruit and train 100 new ACPs over a 2 year period

Option 2 Recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of the programme at this point. Then recruit and train an additional 50 new ACPs in the following year.

Option 3 Recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of programme at this point. Then train an additional 100 new ACPs in the following 2 years.

Option 4 Recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of the programme at this point. Then recruit and train an additional 150 new ACPs in the following 2 years.

Each of these were evaluated against set criteria and consideration. Full details of the option appraisal can be found in Appendix D and E. A preferred solution was concluded upon: To recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of the programme at this point. Then recruit and train an additional 150 new ACPs in the following 3 years.



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An over reliance on locum staff is neither safe, nor sustainable, and does not represent value for money. The Trust spent £6.8m on locum and agency medical staff across all junior and middle grades last year (2013/14) and is forecast to spend £9.6m this year at its current run rate. Aligned to the investment in ACPs is the commitment to part fund the programme of expansion through

• The withdrawal of 120 locum and some permanent middle grade posts over 5 years, commencing 2 years following initial implementation. These significant savings over time will be reinvested back into the ACP programme.

• A reduction in locum and agency usage for vacancy cover across junior and middle

grade staffing.



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6.1. WHOLE TIME EQUIVALENT PROFILE The ACP recruitment profile is shown below along with the withdrawal of middle grade posts profile.

Notes Current WTE Year 1 Year 2 Year 3 Year 4

End of Recruitment Programme

Year5

Year 6 Year 7

Net Increase / (Decrease)

Clinical Director (ACP) 0.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

1.00

Administrative Support 0.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00

3.00

ACP Consultants 1 0.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00

4.00

ACP Junior Consultants 1 0.00 0.00 11.00 11.00 11.00 11.00 11.00 11.00

11.00

Lead ACPs 1 2.00 2.00 16.00 16.00 16.00 16.00 16.00 16.00

14.00

ACP Unqualified (Band 7) - Recruitment of trainee ACPs

2 14.00 63.00 79.00 68.00 66.00 66.00 22.00 0.00

(14.00)

ACP Qualified (Band 8a) - Established qualified ACPs

3 7.00 8.00 11.00 19.00 21.00 21.00 21.00 21.00

14.00

ACP Qualified (Band 8a) - Conversion to qualified ACPs

3 0.00 0.00 31.00 84.00 131.00 184.00 228.00 250.00

250.00

Middle Grades - Established 4 143.00 143.00 143.00 138.00 114.00 90.00 66.00 30.00

(113.00)

Middle Grades - Vacancies 5 21.00 20.00 17.00 0.00 0.00 0.00 0.00 0.00

(21.00)

Non-Pay 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00

187.00 244.00 316.00 344.00 367.00 396.00 372.00 336.00

149.00



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6.2. EXPENDITURE PROFILE The revenue costs associated with the preferred option over a 7-year timeframe are shown below.

Notes Current Cost

Year 1 £000

Year2 £000

Year 3 £000

Year 4 £000


Year 5 £000

Year 6 £000

Year 7 £000

Clinical Director (ACP) 0 126 126 126 126 126 126 126

Administrative Support 0 79 79 79 79 79 79 79

ACP Consultants 1 0 334 334 334 334 334 334 334

ACP Junior Consultants 1 0 0 830 830 830 830 830 830

Lead ACPs 1 129 129 947 947 947 947 947 947

ACP Unqualified (Band 7) - Recruitment of trainee ACPs

2 534 1,927 3,073 2,596 2,520 2,520 1,260 0

ACP Qualified (Band 8a) - Established qualified ACPs

3 392 448 616 1,064 1,176 1,176 1,176 1,176

ACP Qualified (Band 8a) - Conversion to qualified ACPs

3 0 0 952 4,004 6,721 9,605 12,153 14,001

Middle Grades - Established 4 9,699 9,699 9,699 9,360 7,732 6,104 4,476 2,035

Middle Grades - Vacancies 5 2,457 2,340 1,989 0 0 0 0 0

Non-Pay 0 76 65 94 121 150 156 162

Total 13,211 15,159 18,710 19,433 20,586 21,870 21,537 19,690

Expenditure Impact 1,948 5,499 6,222 7,375 8,659 8,326 6,479



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Notes 1. ACP infrastructure confirmed by G Swann, CD for Advanced Practice 2. Unqualified ACPs are banded at AFC Band 7. 14 unqualified ACPs already in the system. Band 7 ACPs convert to Band 8a ACP after 18 months of training. For funding purposes a 100% conversion rate is assumed. 3. Qualified ACPs are banded at AFC Band 8a. 7 unqualified ACPs already in the system. Recruitment expectation is that 10% of ACPs from year 2 will already be qualified. 4. Middle grade vacancy position based on average run rate throughout 2014/15. Middle Grades defined as Trust grade doctors. Data provided by Medical Workforce 5. Model assumes that qualifying ACPs will initially replace locum and agency middle grades medics and then the disestablishment of substantive middle grade posts. Any trainee supervision costs are assumed to exist within current consultant job plans.

6.3. IMPACT ON TRUST SURPLUS The total cost to the Trust over the 7 year project period is £44.51m

Year 1 £000

Year2 £000

Year 3 £000

Year 4 £000


Year 5 £000

Year 6 £000

Year 7 £000

Total £000

Expenditure Impact 1,948 5,499 6,222 7,375 8,659 8,326 6,479 44,508

At the end of the 7 year project period the net annual investment impact to the Trust is £6.5m. This is based on the Trust incrementally disestablishing 120 middle grade posts over the 5 to 7 year period to partially fund the expansion of the ACP workforce and reduction in the cost of locum and agency staffing expenditure.



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7. PROJECT DELIVERY AND CHANGE HISTORY

With an investment of the size and complexity of that proposed under this business case, sound project management is recognised as being of paramount importance for its successful delivery.

7.1 PROJECT MANAGEMENT ARRANGEMENTS The major milestones of the project are shown below.

Activity Start Finish

Business Case Approval April -15 April -15

Development of Communication Strategy overseen by Programme Support Group April -15 April -15

Recruitment of leadership team including Clinical Director for Advanced Practice Dec-14 Feb-15

Development of a robust HR Strategy to support the programme April -15 April -15

Agree and resource external evaluation model for the programme and timelines April -15 April -15

Develop Trust wide ACP Faculty May-15 May-15 Quality assure competency framework and ensure current speciality preparation aligns with the new structure Mar-15 Mar-15

Quality assure the teaching of the Masters in Advanced Clinical Practice and the assessment strategies used by Warwick Medical School May-15 May-15

Develop guidance for ACP revalidation, appraisal and annual review of competence (ARC) May-15 May-15

Contribute to the development of a regional quality review mechanism Feb-15 May-15

Link investment to new ways of working Dec-14 Dec-15 Scope the potential demand for ACPs within individual directorates, agree a standard framework, and core and specialist competences for education and training

May-15 May-15

Recruit to first cohort of 25 tACPs April -15

Project Go Live April -15

An outline project plan for this initiative has been developed and is a live document that will constantly be reviewed and updated, throughout the projects’ life, to identify and indicate:

The projects’ objectives and how success in achieving them is to be measured Progress to date and the intended path to completion Reporting and governance arrangements Key project personnel and their roles and responsibilities

High level details of this are set out in outline form in Appendix F.

Timescale The anticipated timescale is as outlined in the attached programme (Appendix F).



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7.2 KEY RISKS The key risks to the project are as follows: - Deterioration in MG recruitment and retention

Long term experience from the ED shows that traditional MGs value the contributions made by ACPs and don’t feel threatened by their complementary knowledge, skills and competences. Having additional senior cover OOHs is reassuring to this group of clinicians who have worked side by side for the last 9 years.

Potential for employee relationships to deteriorate Effective leadership of this strategy is essential along with open and transparent communication. Securing senior clinician (Consultant and MG level) ‘buy-in’ and participation is key. Their support is required to provide clinical supervision and educational supervision. A communication strategy will be developed and staff surveys will accompany this initiative to ensure all staff feel engaged in the change process and reassured by this strategy. It will be important to ensure senior managers are kept abreast of key developments and milestones. The ACP Priority Programme Board will need to engage all levels of staff to ensure their views and opinions are considered, since it is this group that the ACP will work alongside.

Potential to recruit too many people from an already depleted workforce

The recruitment of the first cohort of 25 trainee ACPs with an elderly care focus has resulted in 111 applications to a speciality that has historically experienced difficulty in attracting good quality clinicians. Many gifted and talented individuals have applied for the tACP posts from outside the Trust because it offers exceptional career progression in new roles and ways of working. It can be seen that the ACP programme will help to retain staff and attract new people to the organisation. The ACP Priority Programme Board will work with managers and senior clinicians to ensure wards are not significantly depleted or put at risk.

Insufficient clinical supervision to ensure progression along anticipated milestones

Clinical and education supervision must be funding centrally and embedded in job contracts from the outset to ensure long term sustainability of the model. Some of this (in time) will be undertaken by Lead ACP and Consultant ACPs.

Possible deterioration in care, quality and safety for patients as a consequence of its

introduction Local evidence from the ED and AMU and from other hospitals would suggest that the opposite is likely to occur.

No improvement in Trust performance against KPIs

This may occur if investment is not aligned and integrally linked to the adoption of new and more effective ways of working across teams and directorates, e.g. See and Treat in Assessment adjacencies, greater focus on rapid assessment, admission avoidance, proactive discharge planning and a greater focus on elderly care medicine. This initiative cannot only be used to support existing structures, approaches and workforce models.

Double running costs

The initial financial outlay to support recruitment to the programme will require at least 2-3 years of double funding.

No reduction in locum use over 5 years

Locum use will need to centrally managed to ensure directorates and services cannot continue to fill anticipated shortfalls once ACPs have been developed.



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No reduction in middle grade (MG) vacancies because of a reluctance directorates to replace these with ACPs It will be important that explicit expectations are made related to the use of ACPs at MG level once trained. Directorate workforce plans must stipulate how the ACP workforce will be used to support new ways of working and how they will be linked to the attainment of KPIs. This will be achieved by standardising their preparation and through the development of robust governance structures.

7.3 PROJECT MANAGEMENT ARRANGEMENTS The recruitment process for the Clinical Director and Lead ACP Consultants has already started. This will be a centrally managed process coordinated by members of the ACP Priority Programme Board and Corporate Recruitment. This will be essential if timelines for implementation of the strategy are to be met for 2015-16. Ideally, we would want to see the first cohort of 25 trainees commence their ACP foundation programme at Warwick Medical School by September 2015. An additional cohort would follow this in April of 2016. This would be repeated annually until the appropriate number of ACPs across the Trust has been achieved. This will be dependent upon the delivery of agreed metrics and sustained performance improvements over the next 5 years. The project team will be led by the Clinical Director for Advanced Practice supported by four key senior ACP Consultants who will be responsible for the operational delivery of the programme’s objectives. This will include women and children; acute care (responsible for programme delivery <48 hours); elderly and frailty (responsible for programme delivery >48 hours) and a clinically focussed educational strategy lead between HEFT and WMS. This group (by years 2/3) will be supported by a tier of ACP Consultants that will be appointed across specialities to provide leadership and facilitate greater focus within directorates on the achievement of agreed KPIs. It will be essential to provide tACPs and ACPs with a clear and transparent career escalator through to Consultancy, otherwise retention will become an issue over time. All ACP Consultant will mirror the clinical and non clinical split of their medical counterparts and will support on-call commitments. The Clinical Director will chair an ACP Priority Programme Board and will be responsible for developing the strategy to support this expansion and for overseeing the rollout of this initiative across the organisation. The initial group membership will include a patient representative, the acute pathway transformation Executive Director, Educational Supervisor representatives, a tACP, Lead ACP, ACP Consultant representative, Medical Consultant representation, a corporate senior nursing representative, ACP Educational Lead and co-opted representatives from HEWM and WMS.



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APPENDIX A: ACP TRAINER ROLES AND RESPONSIBILITIES A trainee ACP (tACP) has both a Consultant Educational/Clinical supervisor and an experienced ACP Mentor. Consultant input: A trainee ACP needs the same amount of educational supervision as a junior doctor – 0.25 PA per trainee ACP per week. This covers the following:

Supervision meetings ACATs Shop floor teaching

Extra Consultant time above and beyond this is needed to provide the tACPs with the following:

Shop floor clinical examination teaching Departmental teaching (combined with junior doctor teaching to reduce teaching time

demands) Support other courses that the tACP needs to take e.g. non-medical prescribing course Input to Warwick Clinical skills and examination courses

The experienced ACP mentor provides both pastoral/educational and shop floor support to the trainee. This often involves a tACP being linked to an experienced ACP when they are on the shop floor to review their patients. Every patient seen by a trainee ACP needs to be physically re-clerked and examined by a senior substantive competent clinician – this can either be a senior ACP or a senior doctor or middle grade. This obviously impacts on the time such senior ACPs and clinicians spend seeing their own patients or managing other shop floor issues.



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APPENDIX B: CURRENT RISK ASSESSMENT MATRIX

Table 1 – MEASUREMENT OF LIKELIHOOD

Level Descriptor Description

0 Never The event cannot happen under any circumstances

1 Rare The incident may occur only in exceptional circumstances

2 Unlikely The incident is not expected to happen but may occur in some circumstances

3 Possible The incident may happen occasionally

4 Likely The incident is likely to occur, but is not a persistent issue

5 Almost Certain The incident will probably occur on many occasions and is a persistent issue

Table 2 – MEASUREMENT OF CONSEQUENCE

Level Descriptor Description

0 None No injury or adverse outcome. Low financial loss

1 Insignificant No injury or adverse outcome; First aid treatment; Low financial loss

2 Minor Short term injury/damage (e.g. resolves in a month); a number of people are involved

3 Moderate Semi permanent injury (e.g. takes up to year to resolve)

4 Major Permanent injury; major defects in plant, equipment, drugs or devises; the incident or individual involved may have a high media profile

5 Catastrophic Death

Table 3 - ASSESSMENT MATRIX THE RISK FACTOR = LIKELIHOOD X CONSEQUENCE

CONSEQUENCE

LIKELIHOOD None 0

Insignificant 1

Minor 2

Moderate 3

Major 4

Catastrophic 5

0 Never 0 0 0 0 0 0 1 Rare 0 1 2 3 4 5 2 Unlikely 0 2 4 6 8 10 3 Possible 0 3 6 9 12 15 4 Likely 0 4 8 12 16 20 5 Almost Certain 0 5 10 15 20 25

By using the matrix above the risk score can be calculated to determine risk category. This ranges ranging from 1 (low severity and unlikely to happen) to 25 (just waiting to happen with disastrous and widespread consequences). The risk score can now form a basis upon which to determine the urgency of any actions. *Risks which have a priority score of 9 or more should be reviewed by the Directorate Management Team immediately. Green status denotes low risk. Yellow can denote moderate to significant risk. Red risks which score 15 or more must be notified to the Risk Register Officer.



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APPENDIX C: PROJECT DRIVERS SCORE MATRIX

SCORE RISK AVOIDANCE (i.e. NOT DOING)

(25%)

IMPROVEMENT TO PATIENT CARE

(25%)

FIT WITH MISSION/

STRATEGY (25%)

IMPACT ON MARKET SHARE

(10%)

FINANCIAL VIABILITY

(15%)

5 Very high risk score (> 20) as per Trust’s

Risk Assessment Matrix

Clear evidence that the case delivers a specific & tangible

improvement to patient care

Clear evidence that the case delivers a specific & tangible

element of the Trust’s Strategy

Growth in Market share is real, sustainable,

increases income & is agreed with the Trust’s key stakeholders

Revenue Surplus/

Prevention of Lost Revenue >

£500k &/or Payback

period < 3 years AND NPV +ve

4 High risk score (15

to 19) as per Trust’s Risk Assessment

Matrix

Clear evidence that the case directly

drives a specific & tangible improvement

in patient care


drives a specific & tangible element of the Trust’s Strategy

Case identifies real potential for

future sustainable increases in

income & Market share

Revenue surplus £251k to £500k &/or Pay Back


3 Medium risk score

(9 to 14) as per Trust’s Risk

Assessment Matrix


drives the Strategy on improving patient

care


drives the delivery of the Trust’s

Strategy & Mission

Case directly influences other opportunities for future growth in

income & Market share

Revenue surplus £101k to £250k &/or Pay Back


2 Moderate risk score

(4 to 8) as per Trust’s Risk

Assessment Matrix

Evidence that the case influences a specific part of the

Strategy on improving patient care

Evidence that the case influences a

specific part of supports the wider

delivery of the Trust’s Strategy &

Mission

Case is needed to maintain our

current market share & income

Revenue surplus £0 to £100k &/or Payback period < 5 years AND

NPV +ve

1 Low risk score (1 to

3) as per Trust’s Risk Assessment

Matrix

Evidence that the case influences improvements in

patient care

Evidence that the case influences the

delivery of the Trust’s Strategy &

Mission

No impact on market share &

income

No revenue implications – cost neutral

AND NPV +ve

0 No risk, score 0 No impact on patient care improvements

No impact on delivering the

Trust’s Strategy & Mission

Reduces market share & income

Net revenue loss and/or NPV –ve

SCORE 4 5 5 1 5

WEIGHTING 100 125 125 10 75

WEIGHTED SCORE 435

Further justification is shown below.



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SCORE RISK AVOIDANCE (i.e. NOT DOING) (25%)

IMPROVEMENT TO PATIENT CARE (25%)

FIT WITH MISSION/ STRATEGY (25%)

IMPACT ON MARKET SHARE (10%)

FINANCIAL VIABILITY (15%)

5

Improvement in admission to clinician assessment in areas that support ACPs including, assessment adjacencies *Door to intervention times for patients with stroke, swallow test, STEMI & NSTEMI, Sepsis in areas that support ACPs *Improvement in the frequency of clinical reviews *Improvement in EDD on wards with ACPs *Improvement in TTO turnaround times within ACP areas *Improvement in discharge rates before midday within areas that support ACPs *Improvement in the number of ACP led discharges from assessment adjacencies and acute wards *Improvement in average LOS within ACP areas *Increased number of admission avoided from services that support ACPs *Ability to deploy ACPs in areas of high locum use.

There is clear evidence that the ACP Strategy will deliver specific and tangible elements of the Trust’s Corporate Strategy. The ACP Strategy is innovative and ground breaking in its approach. HEFT will be the first Trust in the UK to adopt such an integrated workforce solution to address its dependency on locum staff and trainees. *Fewer patients are likely to be admitted unnecessarily. This has already been seen both within the ED and more recently within Cardiology *Reduced waits and better flow - ACPs and permanent staff will often see more patients per clinical shift than their non permanent MG equivalents. *Improved compliance with national quality indicators is more likely to be realised.

Although this initiative will require pump priming and ongoing investment to start with, significant cost savings should be realised year 4 or 5. It will be essential to maintain a focus on cost to ensure we have the most cost effective and value for money approach. *It will reduce agency and locum costs over time. It is anticipated that by Year 3 there will be a 20% reduction in temporary staffing and a year on year improvement of 10% thereafter in areas of high locum use. The ACPs by year 3 will be recruited to MG vacancies

4

Trust reputation will be tarnished *Performance against nationally mandated Care Quality Indicators and other metrics will continue to be an issue across the Trust *There will be a continued reliance on expensive and variable quality locums and trainees. It is important to note that we have already had 9,235 medical locum requests in Q1 and Q2 of this 2014 *There will continue to be costly duplication of effort across the organisation *Non-medical clinician roles are still likely to proliferate in an uncoordinated manner to address the MG staffing crisis across the Trust. If this occurs, we are unlikely to realise the same level of impact or cost savings in terms of staffing or their educational development than if this was coordinated centrally *Roles will remain highly variable in their preparation and scope of practice. The MG staffing crisis is unlikely to improve without a coordinated workforce development plan that standardises preparation for practice *There will be no agreed standard for practice – there will be different standards across disciplines despite the fact that these groups will be treating similar or identical patients *Local solutions and standards are unlikely to be transferable between different directorates *Governance issues related to standard of practice will be difficult to manage and *We will continue to lose gifted and talented individuals

3


2

1

There is no real impact on market share or income. However, HEFT will be the first hospital in the UK to introduce such an integrated workforce solution and will therefore be in a position to attract the most gifted applicants before this recruitment stream contracts. The Emergency Directorate receives on average 70 applicants for their annual recruitment drive of 4 posts. This likely to be replicated elsewhere when the role is introduced at scale across the Trust

0


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APPENDIX D: OPTIONS APPRAISAL TO GENERATE SOLUTION 1. OPTION GENERATION Robust assessment of the objectives of the above proposal has been undertaken following best practice. Through discussion with key stakeholders associated with this business case and examination of the investment objectives a range of options were identified that would satisfy the business need.

Option Description

Option 1 Recruit and train 100 new ACPs over a 2 year period




A full non-financial and financial analysis will be undertaken for these options.


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1.1. Set Benefits Criteria

Benefits criteria were established upon which to undertake a non-financial appraisal of the options. The table below shows the key criteria identified and the weighting applied within this business case.

Identified Benefits criteria and weighting

Criteria Reason Selected Weight

Improvement in the quality safety and effectiveness of clinical care trustwide

An ongoing large scale research study comparing permanent ED ACPs and ED medical MGs showed that the ED ACPs see approximately one thousand more patients per annum than the average medical ED MG counterpart. Other small scale audits that have compared ED medical MGs with ACPs have shown that ACPs are: - safer, with evidence in prescribing, but also as senior decision-makers interdisciplinary role models and with significant leadership potential more likely to have a understanding of, and adhere to, local policy and procedures and

therefore, less likely to make mistakes less likely to admit patients unnecessarily more likely to see and treat patients across the age and acuity spectrum following the

best pathway for the patient whether that be referral and admission, or referral to another agency, or discharge home

35

Opportunity to assess effectiveness of the programme

The success of workforce remodelling is dependent on sufficient evidence of benefit being demonstrated by an evaluation programme that has a number of key dimensions. These are: 1. Quality of patient outcome (effectiveness of care) 2. Quality of patient experience 3. Safety of patient care 4. Staff engagement and sense of wellbeing. 5. Economic evaluation In discussion with Dr Ian Bullock at the Royal College of Physicians, the RCP is interested in supporting this innovative programme of change, utilising a range of expertise that they currently have in each of the dimensions above. The primary focus for the evaluation is a test of equivalence, in that changes to the way that care is managed through workforce remodelling, measures against historic baseline data that shows new models of senior clinician care are equivalent. Patient outcome, process, system and experience measures would provide a multifaceted approach to establishing effectiveness of this new and exciting model of service delivery. Expertise offered through the National Clinical Guideline Centre and the Clinical Standards Department over the duration of the programme can link this innovation to other national initiatives, meaning that HEFT would benefit form associated learning with other similar innovations in practice and service delivery modelling. It is anticipated that improvement science measures, combined with prospective observational data, would feature in a time series model that demonstrates change over time, with multiple points of evaluation against the programmes aims and objectives. Subject to Board approval, a detailed evaluation plan can be produced to further illustrate how equivalence will be established, as a baseline aspiration, with potential for improvement in key indicators such as time to patient review, time to transfer of care, quality of patient experience. Economic modelling would support planned change to measure cost benefit to the programme of change.

15

Eliminates reliance on locums and trainee doctors and avoids the cyclical relearning that occurs

This permanent integrated workforce consisting of senior clinicians from a number of professional backgrounds e.g. medicine, nursing, therapies, paramedical etc. will replace the largely medical workforce model that is no longer fit for purpose and the very high cost cyclical ‘system relearning’ that coincides with trainee changeover and premium rate locum use. This has been shown to impede any attempt to sustain improvements or innovations. Increased use of non-permanent medical personnel also results in lower decision making thresholds and more patients being admitted unnecessarily to hospital. According to the Keogh Review (2013)1, there were 5.2 million patients admitted acutely to hospital nationally in 2012 and it is estimated that 1.2 million of these could have been prevented if alternative workforce models were in place. This further exacerbates the problem resulting in poor system resilience, poor flow, overcrowding within the Emergency Directorate and assessment adjacencies, exit blocks, poor quality care, repeated bed moves, and extended lengths of stay, as well as poorer patient and staff experiences. We now need to fundamentally challenge traditional thinking around workforce and maximise the combined potential of professionals allied to medicine. It is more likely to deliver our plans for earlier senior decision making, centralisation of services, seven days services, the surgical reconfiguration programme and supported integrated discharge.

30


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Timeliness to implement solution

The fragility of our current approach to workforce is compounded by the fact that the pool from which available doctors are drawn continues to constrict despite attempts to recruit medical staff nationally and internationally to HEFT. Developing our own ACP workforce is more likely to deliver the number of generalist clinicians required than any other option. The Emergency Directorate continues to attract high number of applicants to their annual recruitment drive (70 applicants for 4 vacancies). Our aim within 5 years is to largely negate the need for any locum use other than to cover short term sickness and absence. It deliver a more standardised and consistent service 24/7 and reduce the care and quality variance that currently occurs.

20

100

Scores were allocated on a range of 0-10 for each option and agreed through discussion with key stakeholders. The summary results from Appendix E are given below. Scores for Non Financial Benefits Option Appraisal

Option Description Raw Score

Weighted Score Ranking

Option 1 Recruit and train 100 new ACPs over a 2 year period 23 545 4


32 760 3


32 830 2


31 845 1

The summary results from Appendix E are given below.


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APPENDIX E: NON-FINANCIAL APPRAISAL BY OPTION

Option 1 Option 2 Option 3 Option 4

Recruit and train 100 new ACPs over a 2 year period

Recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of the programme at this point. Then recruit and train an additional 50 new ACPs in the following year.

Recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of programme at this point. Then train an additional 100 new ACPs in the following 2 years

Recruit and train 100 new ACPs over a 2 year period, with an interim evaluation of the programme at this point. Then recruit and train an additional 150 new ACPs in the following 2 years

Ref Criteria Weight Raw Score

Weighted Score

Raw Score

Weighted Score

Raw Score

Weighted Score

Raw Score

Weighted Score

1 Improvement in the quality safety and effectiveness of clinical care Trustwide 40 5 200 6 240 8 320 10 400

2 Opportunity to assess effectiveness of the programme. 10 5 50 10 100 10 100 10 100

3 Eliminates reliance on locums and trainee doctors and avoids the cyclical relearning that occurs.

35 5 175 9 315 10 350 9 315

4 Timeliness to implement solution 15 8 120 7 105 4 60 2 30

Total 100 23 545 32 760 32 830 31 845

4 3 2 1


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APPENDIX F: PROJECT PLAN

Mar

15 Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Business Case Approval

Development of Communication Strategy overseen by Programme Support Group

Recruitment of leadership team including Clinical Director for Advanced Practice

Elect Programme Support Group

Development of a robust HR Strategy to support the programme

Agree and resource external evaluation model for the programme and timelines

Develop Trust wide ACP Faculty

Quality assure competency framework and ensure current speciality preparation aligns with the new structure

Quality assure the teaching of the Masters in Advanced Clinical Practice and the assessment strategies used by Warwick Medical School

`Develop guidance for ACP revalidation, appraisal and annual review of competence (ARC)

Contribute to the development of a regional and national quality review mechanism

Obtain KPI baseline

Link investment to new ways of working Scope the potential demand for ACPs within individual directorates, agree a standard framework, and core and specialist competences for education and training

Recruit cohort 1 (25 tACPs) Recruit cohort 2 (25 tACPs) Commencement of Clinical Examination Course C1 Commencement of Clinical Diagnostics and Investigations Course Formal evaluation of programme at 12 months (interim)

April 2015

Board of Directors

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Education and Training Representation Proposal


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Education and Training Proposal

Title: Education and Training at the Board of Directors Attachments: 0 From: Dr Phil Bright, Director of Medical Education Presented by: Dr Andrew Catto, Deputy CEO and Executive Medical Director

To: Board of Directors (BoD)

The Report is being provided for: Decision Y Discussion Y Y Assurance N Endorsement Y The Committee is being asked to:

Receive and approve the education governance recommendations.

Key points/Summary: Health Education West Midlands (HEWM) require that both medical and non-medical education and training is represented at the Board and it is a requirement of the training contract that:

Oversight of education and training is provided by a Non-Executive Director; Education and training should be a regular agenda item at appropriate Board

meetings; There should be a clear education governance structure at the Board.

This paper provides the BoD with high level oversight of the considerable breadth of medical and non medical educational activity delivered by HEFT. The contracted values of income for educational activity are reported here. Recommendation(s): It is proposed that:

An experienced Non-Executive Director (Prof Laura Serrant) includes education and training in her portfolio;

An education and training report is presented to the Board via the Workforce Development & Welfare Sub Board Committee;

Education and training is considered by the Board at least every six months; Issues related to patient safety raised by the Director of Medical Education or Head

of Faculty are escalated via sites and directorates through the Quality & Risk Committee as appropriate.

This paper requests that the Board approve these high level governance arrangements, meeting the requirements of HEWM. Assurance Implications: Strategic Risk Register

N Performance KPIs year to date N


N Information Exempt from Disclosure

N


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1. SUMMARY As above.

2. BOARD OVERVIEW OF THE HEALTH EDUCATION AND TRAINING FUNCTIONS

AT HEFT a) Medical Education HEFT has a well established medical education and training department that has the responsibility for undergraduate and postgraduate training. In undergraduate training there are close relationships principally with the University of Birmingham Medical School, hosting students from all three clinical years across the three Trust sites. At any one time we have a maximum of approximately 150 students. Health Education West Midlands (HEWM) makes a payment to the Trust of £7m through the Undergraduate Tariff. The Trust is contracted with HEWM to train approximately 400 doctors at all levels of training. The contract includes the 50% payment of basic salary for some trainees together with a Placement Fee of £12,400 for each partial salary funded trainee; this is paid through the Postgraduate Tariff. The total value of this contract is c. £12m. Medical Education also has responsibility for the training of non-trainee, non-consultant grade staff (approximately 400) and the on-going training of consultant staff. Funding for these groups is provided partly by HEWM and partly by the Trust. The Director of Medical Education (DME), Dr Phil Bright, is responsible for both undergraduate and postgraduate medical education and training and heads a team of Clinical Tutors, Foundation Training Programme Directors, Head of Academy for Undergraduate Training and their deputies. The department is supported by a senior nurse educator and clerical staff. It works closely with the Faculty of Education. The DME is an Associate Medical Director and reports to the Executive Medical Director. HEWM provides external inspection and is responsible to the General Medical Council for ensuring that HEFT delivers effective training and education. A requirement of HEWM is that medical education and training has a presence on the Board by a Non-executive Director who has oversight of the education function. Medical education and training should be regularly considered by the Board; the DME and the Department should be appropriately represented on Trust committees that report to the Board. The Trust is required to demonstrate a clear governance structure for medical education and training with routes for raising patient safety concerns. b) Non-Medical Education HEFT delivers an extensive portfolio of non-medical education.



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There are a number of access routes into health care careers. The Faculty work-streams promoting HEFT as an employer of choice, exposing people to a variety of health careers and aiding recruitment and retention include: Work Experience, Step in Work, Apprenticeships and Year to Care Nuffield Students.

i) Professional Education

BSc(Hons) Healthcare Practice - ‘top up’ degree pathway, MSc Modules – a number of level 7 modules are running at HEFT. Supporting Learning and Assessment in Practice (SLAiP) - a multidisciplinary

module for nurses, midwives, and AHPs Leading at the Frontline - delivered in collaboration with Keele University,

ii) Patient safety and Mandatory Training

Manual Handling Medical Devices

iii) Blended/ e-learning Simulation, clinical skills, digital learning and knowledge management (library

services) Moodle, I-skills and VITAL (Virtual Interactive Teaching and Learning)

iv) Placements - Pre-Registration Non Medical

The Faculty provides student placement, support, monitoring and quality assurance for all nursing and AHP students. HEWM monitors the governance arrangements for all non-medical programmes through the Learning and Development Agreement, Education Commissioning and Quality returns. Capacity is agreed with University partners and placement activity relating to this is reported to HEWM through the quarterly census return. This is a considerable amount of activity relating to placement of students and at any one time HEFT may host between 350 – 650 non-medical students. Non-medical education placements are funded via HEWM through Non Medical Education and Training (NMET) tariff.

v) Non-Medical Post Registration Education NMET NMET Continuing Professional Development (CPD) activity is supported via HEWM through Learning Beyond Registration (LBR) funding. Funding per capita (WTE) can range from £90 - £120 in any given academic year.



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c) Faculty work-streams support workforce transformation The Faculty supports the development of skills in Dementia care, Minor illness/ injury, Neonatal modules-for nurses (adult and sick children’s) and midwives, End of Life Care, Examination of the Newborn-for midwives and neonatal nurses

3. RECOMMENDATION(S)

It is proposed that:

An experienced Non-Executive Director (Prof Laura Serrant) includes education and training in her portfolio;

An education and training report is presented to the Board via the Workforce Development & Welfare Sub Board Committee;

Education and training is considered by the Board at least every six months; Issues related to patient safety raised by the Director of Medical Education or Head of

Faculty are escalated via sites and directorates through the Quality & Risk Committee as appropriate.

This paper requests that the Board approve these high level governance arrangements, meeting the requirements of HEWM.


April 2015

Board of Directors

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Minutes


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Minutes 3rd Feb 2015

Minutes of a meeting of the Board of Directors of Heart of England NHS Foundation Trust

held in the St Johns Hotel, Warwick Road, Solihull on 3 February 2015 at 9.30am

PRESENT: Mr L Lawrence (Chair) Dr P Cadigan Mr A Edwards Mr D Lock Ms A Lord Prof L Serrant

Mr D Cattell Dr A Catto Mrs S Foster Mrs L Thomson

IN ATTENDANCE: Mrs S Bradshaw Mr J Brotherton Prof M Cooke Ms H Gunter Mrs A Hudson Mr P Kennedy (part) Mr J Rex Mr K Smith

Governors and the Public Mr R Hughes (Lead Governor) Mrs J Thompson (Governor) Mr D Treadwell (Governor) Members of the public

15.018 APOLOGIES and WELCOME

The Chair welcomed the directors, staff, governors and members of the public to the meeting and, in particular, Mr Cattell and Mr Rex to their first Board meeting. Apologies were received on behalf of Ms Kneller and Dr Rao.

15.019 DECLARATIONS OF INTEREST

The Declarations of Interest were received. Mr Cattell noted that he needed to declare his interests. Mr Lock asked that his interest as a Trustee of Brook Young People Limited be removed as it was no longer applicable.

15.020 MINUTES OF PREVIOUS MEETINGS

The minutes of the meeting held on 4 November 2014 were approved as a true record.

15.021 MATTERS ARISING / DECISIONS AND RECOMMENDATION TRACKING REPORT

14.117 Circulate letter from JAG regarding endoscopy service - Dr Catto explained that there were further developments and an update would come to the next Board meeting. 14.138 Provide Mr Lock with details of consent training programme - Mrs Thomson reported that this had been done. 14.138 Provide Ms Kneller with copy of Trust Complaints Policy - Mrs Thomson reported that this had been done.


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14.142 & 14.150 (five items in aggregate) All included within the agenda

15.022 NHS IMAS ELECTIVE CARE INTENSIVE SUPPORT TEAM PRESENTATION

Mr Kennedy presented on behalf of the Elective Care Intensive Support Team (‘IST’) on the review of the Trust’s performance against the 12 week referral to treatment (‘RTT’) standard. IST had reviewed the Trust in October 2013, reported to the Trust in December 2013 and an agreed amended report was issued in April 2014, indicating:

73 recommendations, with 9 high priority actions; 140,000 pathways with unknown status/ outcome identified; Quota management system in place within the Trust – actively disadvantaging

long waiting patients; and Significant and growing backlog of patients as a result of inappropriate patient

management processes and focus on achieving targets and not treating patients chronologically and by clinical urgency.

The current status was summarised as:

Action plan developed and being managed on an ongoing basis; Weekly 18 Week RTT review committee; Unknown pathway validation action plan developed and progressing; Clinical Consensus Group established; Patient targeting list (‘PTL’) distribution remains inconsistent and patchy –

however new operational PTL had been developed and will be implemented in April;

Ongoing engagement with CCG’s and Monitor; IST had undertaken an information review for the Trust, and provide

recommendations in a separate paper; IST was monitoring and evaluating Trust validation processes; Progress had been made, although there was still some way to go. IST was

working in collaboration with the Trust and Monitor to support this work. Dr Catto explained that the appointment of Amanda Markall was helping to move this forward and that, at this stage, the clinical risk appeared very small. He thanked IST for their work. Mr Kennedy left the meeting.

15.023 COUNCIL OF GOVERNORS REPORT

The report was taken as read.

15.024 CHIEF EXECUTIVE’S REPORT, INCLUDING FINANCE REPORT

Dr Catto summed up his three month tenure as Interim Chief Executive as seeing intense pressures on the Trust from clinical demand and regulators; this had impacted on patients and staff. The key focus had been on keeping patients safe, although this didn’t always fit well with a good patient experience (e.g. cancellation of elective surgery and increased


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waiting times). Recent exchanges with Monitor had been challenging. The new Interim Chief Executive, Andrew Foster, from Wrightington, Wigan and Leigh NHS Foundation Trust was due to commence with the Trust from 16 February 2015. Mr Foster would bring with him a big focus on staff engagement and quality. Ms Lord questioned the number of individuals on the Board with interim in their job title and suggested that consideration be given to avoiding ‘interim’ titles that might dilute Executive’s authority. Ms Lord and Mr Lock thanked Dr Catto for stepping up to the interim role and the huge effort that he had contributed at a very difficult time for the Trust. Ms Lord also queried the proposed £750k expenditure on a refurbishment of the Heartlands Outpatients department, noting that any expenditure greater than £500k required Board approval. Dr Catto explained that the work would focus on the matters raised by the CQC. Mr Cattell said that he wished to confirm some information around the costs and would also check the governance regarding its approval. (Action: DC) Mr Lock asked for clarification as to when the A&E signage at Solihull would change to reflect its Minor Injuries Unit status. Dr Catto said this would happen before April.

15.025 DELIVERY UNIT REPORT - MONTH 9 (DECEMBER 2014)

Mr Brotherton outlined the key message as being higher level of emergency demand through December (and January) which tracked the national picture. However, the Trust had not deteriorated as much as others. There has been an impact on elective pathways, RTT and recovery plans. The maximum safe flex capacity had been opened. A Gold, Silver and Bronze command methodology had been introduced. The use of the Ward Liaison Officer role - the provision of non-clinical support to wards by corporate colleagues - had a positive impact on the situation. Mr Brotherton said that the discretionary effort made by staff was immense and that he was extremely grateful for it. During the recovery, safety had been maintained. Heartlands and Solihull recovered to a more normal state by the first week in January but Good Hope was still recovering. Lessons had been learned regarding capacity planning, where refinement was required to avoid excessive reactive action. Mr Cattell noted that the organisation had a mindset that there was no money available, which was inaccurate; however, it had to be spent in the right way at the right time. He outlined his view of the priorities:

Recruitment and retention was critical and that it was important to recruit up to the full establishment to reduce agency costs.

Exit strategies were required for the heightened response/ winter pressure initiatives.

Service delivery requirements would mean that costs would increase in the short term due to the ‘cost of quality’ and needed to be considered as part of 2015/16 planning but national efficiency targets (CIP) would still needed to be delivered at around 3-4%.


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A review of financial governance was required. Mr Lock reminded the meeting that the Finance & Performance Committee (‘F&PC’) minutes were in the pack for information. Regarding planning for 2015/16, Mr Lock noted that the Trust had limited levers to control input of patients and that internal efficiency was required, together with the need to discharge patients as soon as was clinically appropriate. Dr Catto noted that there were some opportunities to improve planned care pathways and some work to be done around appropriate access to care. He also noted that patients generally needed care but that it did not necessarily need to be in an acute care setting. Mr Lock explained that work was required to identify where locums were being used instead of substantive staff; this was inefficient both financially and sometimes in terms of quality and patient experience. Ms Lord thanked the team for the new Delivery Unit Report format and the new Finance report but noted that there was some overlap on patient experience that could usefully be eliminated. She questioned escalating under-performance to F&PC which she noted was an assurance committee not an executive committee. She was also concerned about the staffing shortfall which was not being dealt with quickly enough with leavers offsetting the numbers recruited – retention was clearly an issue. Mrs Foster explained that the Trust was currently operating 120 unplanned flex beds, which put an increased demand on nurse staffing, and that it had become clear that a planned increase in beds at Good Hope was necessary; this was being addressed by re-opening Ward 3. A business case for additional staff was going through but this should be viewed against a national picture of recruitment shortages. It was planned to over-recruit; there were a range of initiatives to ensure that this happened. Retention was adversely affected by high use of agency staff, which necessitated moving substantive staff around at short notice to maintain safety, causing staff dissatisfaction. Agency staff were now being inducted like substantive staff to improve their effectiveness. Getting bed planning right would help to create greater stability amongst nursing teams which would engender loyalty and aid retention. Dr Ryder noted there was no guidance for doctor staffing levels, particularly on the acute pathway, and that this had led to a situation where there was over reliance on locum cover. He felt that a step change was required in doctor staffing to improve the working environment. Dr Cadigan supported this view.

15.026 PATIENT EXPERIENCE AND EXTERNAL AFFAIRS REPORT

Mrs Thomson reported that the key headlines were:

93% of inpatients reporting through the FFT during December had something positive to say about their experience with the Trust.

The CQC IMR indicated a risk around patients’ perception regarding the provision of pain control – this wasn’t reflected in the Trust’s own inpatient reporting which gave a consistently positive indicator. Work was ongoing to address this issue.

The National Staff Survey results (subject to embargo) had been received, although the results were un-weighted. The previous poor results in (compliance with Health and Safety and Equality and Diversity training) had seen significant


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improvement on last year. However the overall the rating was unchanged and it was expected that the Trust would remain in the bottom 20% of the NHS league table. The final results were expected in March.

The values work initiated with the Board had been expanded to involve the workforce, which would continue in Q4 with a full staff census.

Mr Edwards was keen to see greater focus on the patients who were not happy, rather than the overall positive data; Mrs Thomson said that this was in hand. Mr Cattell suggested that the top themes for complaints should be shared with the Board; Mrs Thomson said that the team was working with departments to understand the themes and these would then be included in the Delivery Unit Report. Ms Lord commented on recent media coverage elsewhere of ‘tactless’ text backs and asked how the Trust presented its FFT texts. Mrs Thomson undertook to share this with Ms Lord. (Action: LT)

15.027 SAFETY AND QUALITY REPORT

Dr Ryder outlined the key risks:

Ultrasound scanning in Obstetrics - Where demand had outstripped capacity and management had failed to promptly identify the issue. A daily audit was in progress with escalation where necessary and a sonographer post had been advertised.

Delays in diagnostic endoscopy - Where capacity issues were causing problems. A revised trajectory now anticipated full compliance by the end of March 2015.

Unacceptable delay for EVAR patients - Compliance was now anticipated by the end of March 2015.

Mortality - There was an issue on reporting due to PMS2 problems. In the meantime, crude mortality was being used as a measure to ensure that the Trust was not becoming unsafe. The governance around mortality was being reviewed. There were also issues around the impact of coding on mortality data.

SUI profiles and themes - This part of the report showed recurring themes from serious untoward incidents. Dr Ryder reported that there were no robust mechanisms in place to ensure action plans post-SUI drive the learning that is needed. The newly adopted process, called SIRIUS, was designed to address this. The SIRIUS group looks at detailed learning and calls groups to account. Ophthalmology had experienced three SUIs and would be the first department to attend the SIRIUS group session. Mr Lock sought assurance that Associate Medical Directors were seized of the importance of reinforcing the learning; Dr Ryder responded that the commitment of the AMDs wasn’t the issue, the dissemination of information was happening but the uncertainty was around whether lessons were being learned by all relevant staff. Dr Catto explained that following the Deloitte Governance Review there was uncertainty around Ward to Board visibility. He was only partly assured around the Trust’s operational governance arrangements; some areas were clearly robust but there were concerns in relation to others. Mrs Foster reported that Directorate and Site management don’t yet fuel the right conversations at Quality & Safety and Delivery Unit meetings. She hoped that the new


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Quality Governance Framework arrangements would help. The Chair felt that the Quality & Safety Report had improved and that it was almost ready to be integrated into the Delivery Unit Report.

15.028 ANNUAL PLAN 2015/16

The Chair said the Board was not yet in a position to discuss the Annual Plan as a series of considerations would need to be thought through before the submission of the draft plan to Monitor on 27 February 2015; the Secretary was asked to arrange a Board workshop to facilitate this. (Action: KS)

15.029 CRITICAL CARE AT HEARTLANDS - OVERVIEW

Prof Cooke referred to the Justification Case that proposed a new critical care unit for Heartlands, which would increase the number of critical care beds from 23 to 30. Previous work had identified that Heartlands already required a minimum of 24 critical care beds. More beds were likely to be required to support the post-surgical reconfiguration model and to cope with multi system diseases in the elderly. The proposal was to spend up to £300k to develop an options appraisal and move forward to the Outline Business Case stage. The £300k spend was within the delegated authority of the Executive but had been referred to the Board for information because any full proposal would inevitably be for a significant capital project (possibly around £12m) that would require Board approval. Ms Lord commented that the information provided wasn’t particularly useful and questioned how this fit with other projects under consideration. Mr Cattell asked for an opportunity to review the proposed £300k spend, as he thought it seemed high. In addition, he wanted to understand whether it was driven by current pressures or the clinical strategy. (Action: DC)

15.030 AMU & SAU SAFE STAFFING

Mrs Foster presented the report regarding the nursing workforce review in the Acute Medical Units and Surgical Assessment Units across the Trust. The acuity and dependency tool used for the review was developed from the SNCT tool and was recognised by NICE. The review indicated that there were pressures at Solihull AMU that required attention; the Delivery Unit at Solihull was to propose and implement recommendations to ensure that staffing remained safe when there were more than 18 patients in the unit. Staffing levels for the units at Heartlands and Good Hope were shown to be safe. There was a discussion around the staff to patient ratios in the assessment units where, it was noted, patients may be low dependency mitigating risk. It was noted that the SAUs tend to provide flex capacity which impacted the exercise. Dr Cadigan commented on the RAG rating for MEWS recording and escalation; Mrs Foster explained that there was an issue with half-hourly recording but this was often with patients subject to constant care, so was a process error not a care issue.


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Ms Lord noted that the national tool was based on weekday numbers and therefore gave no assurance for weekends. In addition, she was uncomfortable with the suggestion that Heartlands SAU had safe staffing for up to 12 patients but was shown to have more than 12 patients for 26% of the audits. Mrs Foster explained that this didn’t make any allowance for patients sitting in chairs waiting to see doctors and Prof Cooke suggested that it was safer than keeping too many patients in A&E. Mr Cattell suggested there was a language issue in the report and that the narrative element probably needed to be stronger but that the practice of reviewing safe staffing levels three times a day on the wards gave considerable assurance to the Board. Mrs Foster explained that the reporting was only mandated last year but the Trust had been doing this for some time; the next iteration of the report would include an improved narrative.

15.031 EXECUTIVE MANAGEMENT BOARD (EMB) – TERMS OF RERENCE (ToR)

The Secretary referred to the pre-circulated paper. Mr Lock said that in paragraph 8.2 after the word ‘shared’, he would like the word ‘promptly’ inserted. Ms Lord noted that EMB ToR had no defined purpose and referred to the Deputy Chief Nurse(s) rather than their distinct job titles. The Chair asked that the ToR be revised accordingly. Ms Lord questioned the clause which stated that the committee could seek legal advice but did not put a financial limit on this. The Secretary explained that this would be commensurate with the financial authorisation limit of the most senior member of the Committee, being the Chief Executive. The ToR were approved subject to the amendments described above.

15.032 INFORMATION MANAGEMENT AND TECHNOLOGY COMMITTEE – TERMS OF REFERENCE

The Secretary referred to the pre-circulated paper. Ms Lord again questioned the lack of a prescribed purpose in the ToR and was concerned that only two NEDs were included in the Committee membership, noting that this could easily lead to meetings being inquorate. There was a discussion around the role of the Committee in terms of whether it existed to receive assurance or whether it was an executive/ operational committee. Mr Edwards, the Committee chair, explained that in his opinion the main purpose of the Committee was to resolve the recently realised problems with ICT and its membership needed to be an informed group of individuals who could develop a view on the way forward. Dr Cadigan questioned the lack of clinical input. Mr Edwards reported that one of the members was a doctor, also there was already a Clinical IT Committee and a job description for the CD of IT and Informatics was currently being developed.


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The Chair asked that the Committee to proceed to hold its first meeting, considers its ToR, and brings them back to the Board in due course for ratification. On this basis, the ToR were approved pro tem.

15.033 WORKFORCE DEVELOPMENT & WELFARE COMMITTEE – TERMS OF REFERENCE

Mrs Thomson reported that two meetings of the Committee had already taken place and that the ToR would be further refined from feedback received. Ms Lord again questioned the small number of NEDs in the membership (in terms of the risk of meetings being inquorate) and questioned whether this was an example of an operational committee being chaired by a NED rather than an executive. Dr Ryder asked if there was any workforce membership; Mrs Thomson explained that whilst there was not at this stage, it was planned for the future. Mr Cattell suggested that work be done outside of the meeting to clarify the nature of the Board committees (assurance or operational) and their membership.

15.034 CITIZENS ASSEMBLY

Mrs Thomson explained that the paper had been drafted for information and went on to describe the work of the Citizens Assembly (‘CA’) and how it was different from the Council of Governors; though two Governors had been appointed to the CA. Mr Lock asked whether there was a single document which set out arrangements at the Trust for public engagement, as there was a legal duty to document this. Mrs Thomson said that she had an outline of this but that the detail had not yet been completed. Ms Lord questioned whether the CA represented the diversity of the Trust’s patients. Mrs Thomson confirmed that whilst the CA wasn’t fully representative it represented an increase in diversity over and above the Governors. Mrs Thomson confirmed that members of the CA were permitted to claim their travel expenses and were supported by the Patient Experience team. The Chair noted that the original concept of citizens assemblies came from NHS England.

15.035 BOARD COMMITTEE – MEMBERSHIP PROPOSALS

The Chair referred to the pre-circulated paper and noted Ms Lord’s earlier suggestion that a third NED be appointed to the IM&T and Workforce committees. It was noted that Mr Cattell would be a member of the F&PC. It was agreed that the Chair and Secretary would give further consideration to the membership arrangements and the potential conflict between assurance and executive/ operational status. (Action: Chair/ KS)


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15.036 STRATEGIC RISK REGISTER (‘SRR’) UPDATE

The Secretary outlined two main considerations:

The changes to content of the SRR, as described. The developmental work being done to wider Board Assurance Framework and

SRR.

Ms Lord noted that the Audit Committee had reviewed the SRR and agreed to recommend that the Board hold a workshop to critically review the SRR. The Secretary was asked to arrange a facilitated risk management seminar and/ or workshop. (Action: KS)

15.037 CHAIR’S REPORT The pre-circulated report was taken as read.

15.038 BOARD COMMITTEE REPORTS & MINUTES

The pre-circulated minutes of the following committees were noted: Audit Committee Donated Funds Committee Finance & Performance Committee Monitor Standing Committee Quality & Risk Committee

15.039 ANY OTHER BUSINESS

There was none.

15.040 DATE OF NEXT MEETING

18 March 2015 at the Education Centre, Birmingham Heartlands Hospital.

PART TWO

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

....................................... Chairman


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Minutes 18th March 2015

Minutes of a meeting of the Board of Directors of Heart of England NHS Foundation Trust

held in the Education Centre at Heartlands Hospital on 18 March 2015 at 9.30am

PRESENT: Mr L Lawrence (Chair) Dr P Cadigan Mr A Edwards Ms K Kneller Dr J Rao

Mr J Brotherton Mr D Cattell Dr A Catto Mr A Foster Mrs S Foster Ms H Gunter

IN ATTENDANCE: Prof M Cooke Mrs R Paulin Mr K Smith Mr J Bevington (Deloitte) Mrs S Bradshaw (minutes)

Governors and the Public Mrs L Steventon (Governor) Members of the public

15.052 APOLOGIES and WELCOME

The Chair welcomed the directors, staff, governors and members of the public to the meeting. Apologies were received from Mr D Lock, Ms A Lord and Prof L Serrant.

15.053 DECLARATIONS OF INTEREST

The Declarations of Interests were noted. The Chairman declared a new interest; he had been appointed chairman of Special Educational Needs and Disability Information, Advice and Support Service (SENDIASS).

15.054 SURGERY RECONFIGURATION

Prof Cooke referred to the pre-circulated papers and introduced Mrs Paulin, who presented an overview of the activities to date in relation to the project. The case for surgery reconfiguration was clinically led and anticipated improved outcomes for patients. The Trust’s clinical leaders were of the opinion that continuing with the current situation was unsustainable. The main principle behind the proposed changes was consolidation of surgical specialities into centres of excellence rather than the current arrangements where they were spread across two or three of the Trust’s hospitals. This would, however, mean that around 10,000 out of 35,000 patients who undergo a surgical procedure within the Trust would have their surgery at a different hospital that might not be their local hospital. However, all outpatient (both pre-operative and post-operative) appointments would remain at the hospital local to the patient. The findings of the consultation process were that 65% of respondents agreed with the rationale and 81% of respondents supported the creation of centres of excellence with local outpatient attendances. Overall 76% of respondents were supportive as long as their concerns were addressed. Transport was identified as the main concern.


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Mrs Paulin outlined the initial financial appraisal, noting that it had been prepared on a cautious basis (i.e. more rather than less cost savings were ultimately likely) and the savings that would be achieved from a reduction in waiting list initiative spend with the private sector, increased theatre utilisation and reduced length of stay. It was noted that the inclusion of the paediatric theatre was not strictly part of the surgery reconfiguration proposal but was included because it was interlinked to the reconfiguration. Mr Cattell observed that surgery reconfiguration was the right thing to do but ‘how’ was to be determined. He was supportive of the financial proposition and anticipated additional savings to be identified in the coming months potentially leading to a cost neutral outcome. He was also supportive of the proposed expenditure on planning resource, design fees and risk capital. He noted that there was work to do with the CCG and that if the implementation plan and appraisal were worked on in the coming months, by the time a decision was known, a much clearer picture of the financial impact on the Trust would be understood. Prof Cooke explained that the next internal phase of the project would involve the movement of project ownership from a strategic responsibility into an operational responsibility. The next external step would be the CCG consultation exercise, which would begin after the general election. If preparatory work was done ‘at-risk’ and prior to the outcome of that consultation, benefits could be seen before next winter, especially in orthopaedics. Prof Cooke confirmed that a paper would be brought back to the Board following conclusion of the CCG consultation phase. The Chairman thanked Prof Cooke, Mrs Paulin and the surgery reconfiguration team for the work done to date. Dr Cadigan asked about the interdependencies of the services and the effect on deliverable bed occupancy of medical and surgical beds, particularly in the context of ‘winter pressures’. Prof Cooke responded that the interdependencies had been considered and that was built in to the plan; he explained, for example, that gastroenterology and endoscopy would be retained at all sites. It was envisaged that moving orthopaedics to Solihull would reduce the number of medical occupations of surgical beds. Dr Rao was supportive of the proposals but asked what work had been done to address quality and safety; for example, in the case of a patient needing two surgeons across two specialities which are not co-located. Prof Cooke responded that it was proposed to co-locate specialities with common linkages (e.g. gynaecology and urology) but that specialist surgeons would be on call Trust-wide not just for one location. He also assured Dr Rao that data would be accumulated to enable continued analysis of quality and safety performance. In response to questions from the Chair, Prof Cooke confirmed that Birmingham CrossCity CCG and South Staffordshire and Seisdon Peninsular CCG had been involved in the consultation process, also that the CSU was looking at the wider system impact for the CCG consultation.



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Mr Edwards asked about the risk matrix which included loss of key staff as a risk and whether this was a generic risk or one which came from specific discussions. Prof Cooke explained that this was a generic risk and until firm proposals were confirmed, it would remain so. The budget for reconfiguration included an element for re-training for those staff who may choose to switch speciality and remain with the site rather than remain with the speciality and switch site. Ms Gunter confirmed staff had been appreciative of the early consultation and communication. Prof Cooke noted that around 500 staff were likely to be directly affected but that the proposals were anticipated to result in a net increase of staff. The Chair asked the meeting to address the recommendations:

1. To recommend to the CCGs to proceed with public consultation and to include the present HEFT proposals in their options

2. To continue to develop the implementation details and full financial appraisal of the present HEFT preferred option in parallel with development of the CCG Case for Change

3. To work with the CCGs to facilitate the next consultation phase as soon as possible.

4. To continue to develop the implementation plan and full financial appraisal of the present HEFT preferred option in parallel with development of the CCG Case for Change, through spend as described.

5. To present a final business plan to the Board of Directors on completion of the CCG public consultation.

6. To approve the continuation of the planning resource for the period from 1 April to 30 September 2015 up to the value of £350k (or a sooner date to be defined at the point of CCG decision and subsequent HEFT Trust Board approval to proceed to implementation). To approve the ‘at risk’ design fees of £170l and note that approval of risk capital is delegated to the Executive Management Board (as recommended by the Capital Planning Group) up to the value of current sub-Board approval of £500k.

The recommendations were approved.

15.055 SOLIHULL URGENT CARE CENTRE (UCC)

Prof Cooke referred to the pre-circulated papers and explained that he had taken the proposal as outlined to the Health and Wellbeing Scrutiny Board where it had been accepted. The preferred location for the UCC was now block 14 at Solihull Hospital and that decant plans were starting to be formulated. The main departments that would be affected would be Phlebotomy and Community. Options were being explored as to where the various staff could be relocated. Some would need to remain on site, some could be transferred out to the community and the CCG was looking at suitable locations for Phlebotomy. The Estates department was looking at the plans and would present options by the end of month with a more detailed timeline. It was recommended to the Board that the advantages of HEFT being involved in the co-design and therefore not bidding for the service were important for the future of the wider


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healthcare system. Prof Cooke recommended that HEFT did not tender for the service but instead, actively engaged in the co-design of the UCC. It was hoped that a formal agreement on how the CCG and HEFT work together could be formulated by end of month. Mr Cattell tabled copies of a paper that had been circulated electronically the previous evening, setting out the funding arrangements. He explained that regarding capital funding, it had been agreed that whilst HEFT would finance the re-fit and decant, the cost of this would be recovered from the service provider as part of the lease or licence arrangement. In addition, facilities management, diagnostics and other services would be charged to the service provider. The Invitation To Tender would need to include details of this charging mechanism. A transitional arrangement had been agreed whereby the CCG would continue to pay the full A&E tariff for services from Solihull Hospital until November 2016, by which time the UCC should be ready to open. Following the opening of the UCC, the £1.5m p.a. loss of contribution would be made good to the Trust through an, as yet, undefined series of initiatives – this had been agreed with the Accountable Officer and the Financial Director of Solihull CCG. The Chairman explained that Mr Lock, who was unavoidably absent, had sent an e-mail supporting the proposal outlined in the pre-circulated papers (including the funding arrangements paper), subject to the caveats that the service provider would enter into a licence agreement for the property, the CCG would guarantee the financial performance of the service provider and that any agreement not to bid for the services should only apply to the initial tender period. The Chair observed that the involvement of the Overview and Scrutiny Committee had been a positive experience. Dr Cadigan questioned whether co-design of the specification related just to the building or to the service too; Prof Cooke explained that it would apply to both but clarified that it wouldn’t extend to staff training and that patient pathway design would be a wider system issue. In response to a question from Dr Rao, Mr Cattell explained that any diagnostic or other clinical services that the new service provider sought from the Trust would be charged accordingly. The recommendations (a-i) set out in the pre-circulated paper and recorded below were then considered, subject to the amendment to recommendation g, as detailed in bold below: a. The Board accepts the report of the Director of Finance on the proposed financial

model. b. That the preferred location of the Urgent Care Centre for the Solihull Hospital site is

within block 14 (ward 10). c. That decant plans and costs within HEFT to enable block 14 to be vacated for work

are available by 27 March 2015. d. That HEFT enables its operational teams and estates department to commence the

work up of this option to support both decant planning and the build options. e. That HEFT and Solihull CCG jointly map the timeline for design, build and


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procurement by 27 March 2015, including the specific design timeline. HEFT as provider:

f. HEFT takes a wider system perspective and works with Solihull CCG in designing and tendering the Urgent Care Centre on the Solihull Hospital site.

g. That HEFT informs the CCG that it does not plan to tender for the Urgent Care Centre for the life of the current tender (which can run for up to 7 years).

h. That HEFT confirms using the 2014 MoU as a foundation for future working. i. That HEFT commits to agreeing to a formal collaboration agreement building on the

principles of the 2014 MoU and the ICASS compact; that this agreement will be in place by 31 March 2014.

After due consideration the recommendations, as amended, were approved


14 April 2015 at St Johns Hotel, Solihull.


The Chairman reminded the meeting that the Trust was soon to enter purdah and encouraged all Directors to acquaint themselves of the requirements of this.

....................................... Chairman

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Matters Arising

BOARD OF DIRECTORS

Matters Arising & Decisions/Recommendations Tracker

Date raised

Minute No Detail Action Due Status Completed

2 Sep 2014

14.117 Circulate letter from JAG regarding endoscopy service. Update to Apr 15 mtg.

AC Apr 2015

4 Nov 2014

14.138 Provide D Lock with details of consent training programme.

LT Jan 2015

Completed 3 Feb 15

14.138 Provide K Kneller with copy of Trust Complaints Policy

LT Jan 2015

Completed 3 Feb 15

14.142 Bring Staff Development & Welfare Cttee Terms of Reference to Board.

LT Jan 2015

Agenda item 16 3 Feb 15

14.150 Be mindful of the potential value of any predictive algorithm developed from the MSD Collaboration project and the ownership of IP rights.

MC Jan 2015


14.150 Ensure that publication rights relating to MSD Collaboration project are understood.

MC Jan 2015


14.150 Check whether express consent is required from patients in relation to MSD Collaboration project.

MC Jan 2015


14.150 Bring report back to the Board on MSD Collaboration project.

MC Jan 2015


3 Feb 2015

15.024 Outpatients Refurbishment: Confirm costs and approval process.

DC Apr 2015

The BHH outpatients refurbishment scheme has been put on hold until the Estates Strategy supporting the Trust’s Clinical Strategy has been developed by the Trust Board in the Summer of 2015.

15.026 Share examples of FFT text wording with A Lord.

LT Feb 2015

15.028 A Board workshop to be held to formulate the Monitor plan

KS Feb 2015

Complete 24 Feb 15

15.029 Critical Care (Heartlands) Justification Case – review £300k costs and determine whether driven by clinical strategy or current pressures.

DC Apr 2015

The Critical Care redevelopment was originally proposed as part of the Cross Site Strategy. The scheme has received approach to Business Case Stage (£300k). This scheme will not proceed further until the trust develops and agrees the suite of strategies in the Summer of 2015.

15.035 Membership of Board committees to be reviewed and consideration to be given to potential conflict between assurance and executive status.

Chair/ KS

May 2015

15.036 Arrange a facilitated session for consideration of risk management.

KS Apr 2015

Board ‘Away Day’ 16-17 Jul 15

23 Mar 15

April 2015

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Board Committee Reports

12.2 Donated Funds Committee (Enclosure & Oral)

12.4 Monitor Standing Committee (Oral)

(Enclosure & Oral)

12.5 Quality & Risk Committee (Enclosure & Oral)

12.3 Finance & Performance Committee

12.6 Workforce Development Committee (Enclosure & Oral)

12.1 Audit Committee (Enclosure & Oral)


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Audit Committee

AUDIT COMMITTEE

Minutes of a meeting of the Audit Committee held in the Board Room, Devon House, Heartlands Hospital on 28 January 2015 at 10.00am

PRESENT: A Lord (Chair)

J Rao

IN ATTENDANCE:

R Bacon (PwC) R Blackburn (Head of Corporate Risk & Compliance) D Cattell (Interim Director of Finance & Performance) J Howse (PwC) A Jones (Chief Financial Controller) G Miah (Deloitte) M Owen (Deloitte) C Ryder (Interim Medical Director) N Shaw (PwC) K Smith (Company Secretary) S Bradshaw (Minutes)

15.001 APOLOGIES

Apologies were received from L Serrant, D Lock and K Kneller. The Committee Chair noted that attendance from Non-executive Directors in recent months had been patchy and it was hoped that the review of committee members currently being undertaken by the Board Chair would address this.

15.002 MINUTES OF LAST MEETING & MATTERS ARISING

Minutes The minutes of the meeting held on 26 November 2014 were approved as a true record.

Matters Arising 14.070 Add details of remaining KPMG Reviews to tracker once management responses have been received - covered under item 4 in the agenda. 14.071 Review management response to recommendation 1 in Creditors & Payments Review regarding lack of receipts for credit card transactions. A Jones had provided a response to M Owens for the tracker - action closed. 14.071 Review management response to recommendation 2 in Payroll Review regarding lack of awareness of responsibilities amongst budget holders. HR had provided a response to Deloitte - action closed.

15.003 FINANCE UPDATE

A Jones presented the pre-circulated report. Work for the 2014/15 year end had commenced and was progressing well. The month 9 FTCs had been submitted to Monitor by the 21 January deadline. PwC had


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scheduled an interim visit for 9 February. A detailed year end timetable had been developed. No changes were proposed to accounting policies. The Audit Opinion for 2014/15 would include more detail than before due to changes introduced in the 2012 Monitor Code of Governance. The Governors had approved the proposal to extend PwC’s contract for external audit services by one year. The re-tendering exercise would begin around September 2015. Notification had been received from Monitor that a coding and costing audit would be undertaken. Monitor was using CHKS, part of the Capita Group, to carry out the audit in April-May 2015. C Ryder noted that the Trust’s coding was ‘light’ because there wasn’t much clinical buy in; rather there was a perceived bias toward the financial implications of coding. A Jones reported that the review conducted in 2014 on behalf of the DoH only identified an income impact of £15k arising from miss-coding, which was not material to the Trust. J Rao suggested that details of the sample data be requested from CHKS to check the impact of coding on the Trust’s mortality rating. In response to a question from the Chair, J Rao confirmed that Q&RC wasn’t currently looking at any issues around coding. The Chair asked for an update to the next meeting on the mapping of assurance relating to coding. Action: D Cattell/ C Ryder The Chair asked K Smith to look into the Information Governance implications of sharing patient data with CHKS as part of the costing and coding audit pursuant to s.104 of the Health and Social care Act 2012. Action: K Smith

15.004 INTERNAL AUDIT UPDATE (KPMG)

A Jones reported that the three final KPMG reports: Mortality, Quality Impact Assessments (QIA) and Emergency Department – care of patients breaching 4-hour target (ED) went to Q&RC on 23 January. The management response had been received for Mortality but was only covered verbally by the Chief Nurse in the presentations to Q&RC for QIA and ED.

The Chair requested J Rao to report back to the next meeting on the matters being raised by Internal Audit at Q&RC and the level of assurance being received by Q&RC in respect of those matters. Action: J Rao In addition, the Chair asked the Secretary to arrange for all formal board subcommittee chairs to attend Audit Committee once a year to provide a report on the work of their committee over the previous year and their primary focus areas going forward, including any matters being raised by Internal Audit to their committee and the level of assurance being received by in respect of those matters Action: K Smith

15.005 INTERNAL AUDIT (DELOITTE)

Internal Audit Plan – Status Update Field work had been completed for the Workforce Data, CQC and Procurement reviews. More work was required to complete the extended scope of the ED Data Quality review. Field work had commenced on the BAF, IT Controls and ICT Strategy reviews.

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The Terms of Reference (ToRs) for the Information Governance Toolkit review had been circulated to the NEDs for comment. A scoping meeting for the CIP review had been scheduled. Deloitte had been requested to review Maternity Governance by the Chief Nurse. C Ryder explained that this had arisen from concerns over an increased number of SUIs and near misses possibly related to inappropriate governance and clinical practices, particularly at Good Hope, and that it was thought that local management reviews might not be adequate to identify any issues. CQC visits had highlighted some issues around the management of maternity services. It was confirmed that this matter had not been referred to Q&RC. G Miah clarified that the ToRs had gone to the Chief Nurse for review and work could begin imminently. In response to a question from D Cattell, C Ryder explained that the issues had principally been identified by the Chief Nurse and the CQC and that, although they were being addressed, further independent assurance was being sought to ensure a systematic review was undertaken. D Cattell also questioned whether the concerns had been recorded on the Women & Children’s risk register; the answer was not known, so R Blackburn was asked to investigate and report back. Action: R Blackburn A Jones reported that the Maternity Governance review was incremental to the planned internal audit programme. M Owen explained that Deloitte had some flex and could slip the billing of the review into 2015/16. Instead it was agreed to delay the Workforce Retention review if it was agreed that the Maternity Governance review should proceed. It was agreed that the executives should review the requirement for the Maternity Governance review and circulate a note of their decision. Action: D Cattell/ C Ryder The Chair asked that Deloitte confirm that the ToRs for all reviews had been circulated to the NEDs and that columns are added in future reports to show (1) circulated to NEDs (2) approved by NEDs. Action: M Owen Recommendation Tracking M Owen reported that whilst the percentage of overdue outstanding recommendations remained fairly constant at around one third of all outstanding recommendations, work needed to be done to reduce them. The long dated overdue recommendations listed on page 12 of the report were noted. D Cattell questioned the appropriateness of some of the recommendations, particularly noting the maternity scan payment process (Baby TV) items; it was agreed that these should be closed down by the next meeting. The Chair confirmed that the focus should be on the genuine high priority items. Perioperative Services Report The Chair noted that this report was coming to the Committee solely for information as it had already been to the Q&RC. G Miah outlined the background to the review and reported that the results of the review had been fed back to surgery team. The Chair asked how the report was received by staff. G Miah confirmed that it was well received and staff had acknowledged that throughput could be increased.

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C Ryder said that he thought it was a very helpful report and believed the issues were around ownership of surgical services, pathway re-design (which may require external assistance) and establishment staffing resource. He went on to note that the executives needed to decide on how this was to be progressed. The Chair asked for an update to be brought back to the Committee once a proposal had been developed and that this should include an explanation of how progress will be monitored. Action: C Ryder Other Issues The Chair asked for a report from the executives on the Programme Management Office initiative; including staffing, structure and what it will be doing, and associated governance/assurance processes. Action: A Catto

15.006 EXTERNAL AUDITORS – AUDIT PLAN (PwC)

J Howse presented the pre-circulated report and outlined the new areas which would be covered in the 2015/15 External Audit, also drawing attention to the sections on risks, new developments, the PwC approach and fees. He clarified that PwC was required to express an opinion on economy, efficiency and effectiveness. The overall approach would be similar to 2013/14 with a review by PwC’s technical panel in February. R Bacon expressed the view that the process would be more challenging this year because of the Trust’s current regulatory challenges. A&E performance would be a specific risk for this year’s review. N Shaw addressed the accounting risks set out on page 6 of the report and the materiality threshold and trivial reporting de minimus set out on page 7. The Chair asked D Cattell to bring a recommendation to the next meeting regarding PwC’s fee. Action: D Cattell The Chair asked K Smith to arrange for the Annual Whistleblowing Report to be brought to the Committee. Action: K Smith

15.007 BOARD ASSURANCE FRAMEWORK (BAF) & STRATEGIC RISK REGISTER (SRR)

R Blackburn introduced the pre-circulated paper which addressed (1) the current arrangements for the BAF & SRR, (2) an update on the review of the SRR, and (3) aims and objectives to develop the BAF & SRR. The SRR had continued to be reviewed each quarter by the Executive Team and Board, and submitted six-monthly to the Committee. The need to review and improve the BAF and SRR had been acknowledged, including most recently in the Deloitte Governance Review, which included two specific recommendations related to the BAF (as set out on page 2 of the paper). Specific actions had been identified that were being pursued, including a review of local exemplars’ BAFs and a gap analysis. It was noted that there had been a lack of profile, scrutiny and meaningful discussion within the Trust regarding both the BAF and SRR and that this wasn’t helped by the status of the Corporate Strategy that wasn’t well communicated or understood resulting in a disconnect between the

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strategy and the SRR. G Miah observed that Board level ownership and executive buy-in was an issue as were some of the mitigations recorded on the SRR. Deloitte was just finishing its review and felt that it was quite operational rather than strategic and that it was not used as a tool for managing the organisation. He suggested starting the process again was the right approach but that its success depended on Executive Team buy-in and that the resource required shouldn’t be underestimated. R Bacon noted that not everything in the current SRR was bad but there was a missing item regarding managing change. Well led organisations often had champions who questioned colleagues on risk. The Chair asked that a facilitated Board level session be arranged but suggested not using the existing SRR as a starting point. Action: K Smith D Cattell confirmed that he would work with R Blackburn to look at improving the content of the SRR, and bring an update back to the next Committee meeting once the matter had been discussed further with executives and the Board Action: D Cattell

15.008 MEDICAL REVALIDATION PLANS

C Ryder tabled a letter from NHSE dated 5 December 2014 that provided feedback on a review of the Trust’s appraisal and revalidation process. He reported that the Trust’s process was good. C Ryder expressed the view that management had achieved all of the recommendations from the KPMG report, except recommendation 2 that concerned the purchase of a computer software package to measure clinical outcomes data for use in medical appraisals. He stated that measuring clinical outcomes for certain types of surgeon, where national reporting was required, was reasonably straightforward but noted that comparative data could be skewed with the best surgeons dealing with the most difficult cases and consequently experiencing adverse mortality data. The NHSE external scrutineer had indicated that no other NHS organisations had yet managed to achieve the use of clinical outcome data in medical appraisals. In addition, C Ryder noted that doctors were sceptical of the validity of the comparison of clinical outcome data. C Ryder suggested that the way forward was to ask clinical teams to define what factors make them good (or bad), i.e. agreed outcome measures but that the service design needed to be decided as well as the measurement of performance. G Miah encouraged the Trust to identify some suitable benchmarks. C Ryder said that this was possible but that there was no resource available to pursue this currently; D Cattell suggested that it should be possible to address the resource issue. J Rao was sympathetic to the difficulties of identifying clinical outcome data for some specialities but suggested further consideration be given to identifying agreed outcome measures for use in appraisals. It was agree that the outstanding recommendation was no longer relevant to the process and should therefore be removed. Action: M Owen

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It was also agreed that the subject should be considered further by the Q&RC. Action: J Rao


There was no further business. The next meeting was scheduled for 25 March 2015.

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

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Minutes of a meeting of the Donated Funds Committee of Heart of England NHS Foundation Trust

held in the Boardroom, Devon House, Birmingham Heartlands Hospital on 30 January 2015

PRESENT: Mr P Hensel (Chairman) Mr A Jones

Mr L Lawrence Mrs L Thomson

IN ATTENDANCE: Ms A Evans Mrs E Hale Mr K Smith (Secretary) Mrs A Hudson (minutes)

15.001 APOLOGIES

Apologies were received from Mr A Fletcher.

15.002 MINUTES OF PREVIOUS MEETING & MATTERS ARISING

The minutes of the meeting held on 31 October 2014 were approved as a true record. 14.030 Reporting data on website hits – considered at 15.003 below - complete. 14.038 Report on grant income shortfall and strategy – considered at 15.003 below – complete. 14.042 Review and update Investec authorised signatory mandate – it was resolved that Mr D Cattell (Director of Finance, HEFT) and Mr L Lawrence (Chair, HEFT) be added to the mandate, joining Mr P Hensel (Chair, DFC) and Mr Smith (Company Secretary, HEFT), and Mr A Stokes be removed.

15.003 FUNDRAISING & GRANT INCOME REPORT S

Mrs Hale reported that Q3 performance had seen a modest increase over Q2. Donations had fallen by comparison to Q2 but were above Q1. Performance overall remained below Plan. The Fundraising Team had good links with the Friends of Solihull (‘FOSH’) who were leading activities in Solihull because of their local high profile. FOSH raised funds then transfer them to the Charity for causes related to Solihull Hospital. It was understood that FOSH currently held funds of around £100k, including a recent legacy that would be given to the Solihull Infusion Unit (rheumatology and chemotherapy) appeal. Good relationships were being built with staff at Good Hope and links had been facilitated with FOSH to share best practice. In relation to grant income, Mrs Hale explained that grant funders tended to have periodic meetings to review applications but responses to applicants could often be delayed by months. Mrs Jones explained that HEFT capital projects, which were well

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suited to grant funding, go through an approvals process that include Justification Case, Outline Business Case, Detailed Business Case (‘DBC’) with construction work usually beginning immediately after DBC approval. Therefore waiting for DBC is too late for grant applications and appeals but beginning the grant application process too early is also problematic sometimes raising credibility issues for potential funders. Mr Hensel and Mr Lawrence noted that grant applications were an art rather than a science but, in response to a question from Mr Hensel, Mrs Hale confirmed that other FT charities were succeeding in this arena, including UHB and BCH. Mr Lawrence suggested that direct approaches should be made to large local businesses, such as Jaguar Land Rover. Mr Hensel suggested approaching NHS Charities for advice; Mrs Hale said they might be able to review the Fundraising Team’s approach. Mrs Hale explained that a joint NHS Charities event was taking place on 9 May – a Snowden Trek. The Good Hope Charity Ball was taking place the following day, 31 January and would be raising funds toward a bladder scanner for Urology at Good Hope. Mrs Hale was personally planning to do a sky dive and would be seeking sponsorship for the Charity in this respect. A new PR and Marketing colleague with commercial experience had joined the team and was re-building the Charity’s website, based on best practice – this was near completion. Horton estates had selected the Charity as their charity of the year. In response to a question from Mr Hensel, Mrs Hale explained that while donations were down in Q3, they were slightly ahead of the previous year (to date) and that, in part, this reduction may be because the Fundraising Team had been focused on other areas in recent months. Fundraising income was also noted to be slightly ahead of the previous year (to date). Mrs Hale referred to the Grant Income Report and noted the strategy of employing a dedicated team member who was focused on large grant applications (over £30,000) and the number of applications submitted. Although no direct funding had yet been received as a result of these applications, further information had been requested from 15 potential funders and two had pledged an aggregate of £33,000, which would hopefully be received before the financial year end. It was noted that, based on current performance, the costs outweighed the benefits but that it was probably too early to draw a conclusion; however it was also difficult to know when applications were unsuccessful because potential funders seldom advised when applications failed. An alternative strategy of engaging ‘self-funding’ consultants who commit to raise sufficient income to more than cover their costs was noted but the potential for difficulties in contracting and fulfilling HEFT’s obligations in this respect were acknowledged. Mr Hensel suggested that continuing to build the internal resource for the time being seemed more appropriate. Mrs Jones explained that HEFT had just received a £1 million grant from a nursing fund following a joint effort between the Finance and Corporate Nursing teams but questioned how committed other colleagues within HEFT were to grant fundraising. It was suggested that this might be helped by:



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Top down support from the Executive Team that could be led by Mrs Thomson (Action: LT), and

A communications exercise across HEFT that Mrs Hale could co-ordinate with the Head of Communications (Action: EH).

The report on website analytics and digital reach was noted. Social media seemed to be contributing positively; ‘Just Giving’ and text to donate were working well. There was a lack of correlation between written media and donations. It was agreed that this should be reviewed six monthly and further analysis should be done to identify any correlation with donations (Action: EH).

15.004 FINANCE REPORT TO 31 DECEMBER 2014

Mrs Jones outlined the key financial information stating that total income raised to 31 December was £967k with all categories behind Plan; expenditure of £1,192k was £595k behind Plan, resulting in a deficit of £225k. There had been a revaluation gain on investments of £157k, resulting in an overall year to date deficit of £68k. The value of the fund at 31 December was £8,236k. Mrs Jones cited the key points of her report as:

There was £872k on deposit with RBS - the cash position was being carefully monitored and, even if the income position didn’t return to Plan levels but expenditure was in line with Plan there would be no requirement to liquidate investments with Investec.

Large receipts had been received from William Cook Europe (£40k) and in memory of Dean Field (£9k).

Large payments had been made for an ultrasound machine for Breast Care at Solihull (£47k); 18 Hi-lo beds at Heartlands (£58k); and an ophthalmic console and probe (£41k).

There was £78k expected from four outstanding legacies. There had been a 3.1% increase in the value of investments managed by

Investec year to date.

The proposed 2015/16 Budget showing income and expenditure of £1.8m was considered. Mrs Jones explained that this had been scaled back taking into account both current year and previous years’ performance to generate what should be a stretching but achievable target. The Operations Committee would be considering the Fundraising SLA, which included £35-40k of expense related to grant income where none had been received to date in the current year (Action: DFOC). The proposed 2015/16 Budget was approved. The Deloitte Internal Audit Report was considered. There was one low priority, low value, recommendation regarding reconciliation of items on bank reconciliations. Mrs Jones explained that there was a difference in opinion over the current practice in this respect between the internal and external auditors. The risk register was noted.



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15.005 OPERATIONS COMMITTEE

Mr Smith commented on the Operations Committee actions log. The latest design options for the Project Pelican maternity and neonatal unit were subject to an options appraisal. The Solihull Infusion Unit project was on hold, pending clarification of a revenue issue but Mrs Hale confirmed that private discussions were continuing with potential funders. A potential exit from the Baby TV contract was under discussion.

15.006 INVESTMENT REPORT

The Investment Report from Investec at 31 December 2014 was noted.


The proposed dates for future meeting dates in 2015 were noted.


24 April 2015.

....................................... Chairman



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Finance and Performance Committee

Minutes of the Finance & Performance Committee meeting held on 2nd February 2015 at 9.30hrs,

in the Boardroom, Devon House, Heartlands Hospital

Present: Mr Jonathan Brotherton Mr Darren Cattell Mrs Sam Foster Mr Les Lawrence Mr David Lock Dr Clive Ryder

Director of Operations Director of Finance & Performance (Interim) Chief Nurse Chairman Chair Medical Director (Interim)

JB DC

SF LL DL CR

In Attendance:

Mr Andrew Edwards Mr Jonathan Gould Mrs Angeline Jones Mrs Amanda Markall Mr Aidan Quinn Miss Louise Jenkins

Non-Executive Director Finance Operations Director Chief Financial Controller Planned Care Specialist Deputy Finance Director Personal Assistant

AE JG AJ AM AQ

LJ

Partial Attendance:

Dr Richard Brown Mrs Hazel Gunter Dr Arne Rose

Programme Director & Deputy Director – Patient Experience Director of Workforce Associate Medical Director

RB

HG AR

1. APOLOGIES FOR ABSENCE

Apologies were received for: Mr Adrian Stokes 2. MINUTES OF THE MEETING HELD ON 29TH DECEMBER 2014

The minutes of the meeting held on 29th December 2014 were accepted as an accurate record.

3. MATTERS ARISING

All matters arising were identified for action in either this, or a future meeting agenda. The Committee welcomed Mr Cattell to the meeting. Action: Mr Lock and Mr Cattell to liaise together for the structure of future meetings as required.

4. FINANCE POSITION UPDATE 4.1 Finance & Performance Directors Report M9

Mr Quinn opened with December experienced a deficit, in line with expectations, with £1m loss in month, £5.7m loss year to date. We remain under a Monitor enforcement section 111. Divisions need to continue to focus on exiting winter and additional measures. The on-going challenge is the delivery of efficiency.


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The Committee advised it needs greater insight into exit strategies, how far away are we from the agreed plan and how realistic are they. Exit strategy plans need to be in place and discussed at the next meeting. It is most important next year’s projections are aligned. We need to ensure there are robust plans in place which are supported by Finance and Workforce. Mrs Markall advised of a 24% increase of 2 week wait referrals to some specialties in the last 12 months. IST has assisted specialties with demand and capacity planning and recurrent business cases are being developed and reviewed following the release of additional monies agreed at Board of Directors (BoD) in December to fund additional activity in Q4. There is little evidence referral management will impact significantly and it is likely the growth the Trust has seen will continue. The Committee advised it is to be very cautious of the extent the CCG can influence GP’s referral practices. Mr Brotherton continued for demand and capacity, they are symptoms of approach, i.e. RTT, bed base modelling etc. They all fail to be underpinned by capacity planning. We need to understand planning and further work is needed. Dr Ryder added following a conversation with the Accountable Officer at the CCG, the expectation is HEFT will model accordingly, i.e. breast referrals/level of referrals and it’s HEFT’s responsibility to ‘tool up’ appropriately. The Committee stated the CCG should advise HEFT how much work they anticipate to forward. Mr Gould advised we need to go into more detail for the monthly plan, but the annual plan is in target. We need to phase over the year with the different campaigns. Mr Lock provided his personal view, essentially Acute Trusts provide responsible services – not Commissioners. A JMRA contract requires Trusts to take on what they can’t control i.e. demand management. In principle he would favour a Payment by Results (PbR) contract and we will accept that responsibility. A discussion followed on patients referred by other providers, restarting their clocks, breach being shared by referring and receiving providers and the payments received. Dr Ryder added patient choice is down to the Commissioners and we cannot remove a service without negotiations and catchment areas. The Committee provided a message of; 1) Broadly on financial track, 2) Elective and non-elective robust planning required for next year to ensure we have preferably capacity in house, including 7 day working, to deliver against what we expect and 3) The most appropriate contracting method to provide financial stability going forward into next year.

5. CURRENT MATTERS 5.1 Delivery Unit Report

Mr Brotherton advised the principle areas to discuss are; A&E, RTT, Cancer, Diagnostics and Workforce. 4 Hours Correction to statement on page 3 to; ‘Our benchmarking has improved against the national position as we held a reasonable position during December compared to the rest of the country which dipped’.



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When looking at escalation for December, HEFT managed to avoid declarations of internal incidents through a series of interventions and by going above and beyond the winter plans. BHH & SOL recovered from compromised positions, while GHH is still compromised. Additional recovery measures in place for GHH. The underlying solution is in the Urgent Care Improvement Plan (UCIP). The Committee is conscious vast amounts of effort have been made to improve the situation and our thanks to all the staff, managers and clinical staff, but further work is still required. A discussion followed on discharging on Fridays afternoon through to Monday mornings in relation to pharmacy for GHH. Mrs Foster advised pharmacy are now involved in meetings for GHH and attend discharges. We have cross site cover and majority of delays are due to prescribing. Dr Ryder added when junior doctors draft prescriptions, it remains their responsibility which means they are reluctant to draft. The Committee advised this is a management issue and a practice notice needs to be issued. ‘The person clinically responsible for the prescription is the final signature’. A discussion followed on pharmacy capacity & discharges on the day. Mrs Foster advised discharge to assess plans are in progress – the work of the HRP is proving a useful diagnostic with consolidated numbers of work stream improvement plans. The next 30 days will be focussing on KPIs on discharge. We have a better idea of the current situation for the Discharge Hub (DH). BHH has funding to get to a base level similar to GHH. There are no standard practices to review patients medically fit for transfer of care with Partners on a regular basis. We need a standard set of KPIs working in conjunction with our Partners. We also need a better understanding of the Better Care Fund. We have identified significant work around practices including therapies, risk aversion, choice agenda, longer 90 days plan including the DH and Partners. A discussion followed on referrals to the DH, strategic and simple plans and pace of action. Mr Quinn advised the delivery of the plan by 23rd February seems unlikely and questioned when we will have a revised plan. Mr Brotherton advised at the last Monitor PRM meeting they wouldn’t enforce the date, but the CCG is persistent. Mr Lawrence stated staff are key and was concerned with sickness and attrition rates. A discussion followed on workforce, recruiting right staff/right post, data and best practice. 18 Weeks Mrs Markall advised we have not achieved the trajectory in December of 1134, with an actual of 1284. An issue was identified in gastroenterology in late December, where 650 referrals had not been added to the admitted waiting list of which 160 went into immediate 18 week breach. A SUI is currently in progress. The issue was identified at transfer to management from a locally managed to a centrally managed service. Mrs Markall advised generally locally managed areas present a higher risk than centrally managed departments.



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An action plan is in place and a revised trajectory is being created to be submitted to Monitor. Action: AM and an update to the next meeting. Other specialties identified as being of higher risk are vascular and bariatric services. The Heads of Operations have been asked to assure themselves where any specialities are locally managed, good waiting list management practices and processes are in place. In December, 127 operations cancelled on the day due to no bed, circa 50% belonged to orthopaedics and 30-40% belonged to gastro and urology. As of the 22nd January we have cancelled 196 operations on the day or day before surgery. In January we were unable to fully utilise the Vanguard theatre as the ward was being used for the care of patients who had been admitted as medical emergencies Daily review of the following days TCIs is now in place which includes assessing which patients cannot be cancelled and identifying those that could be delayed if deemed to be not clinically The trajectory for January is 974 and Mrs Markall reported due to the high levels of cancellations due to no bed and the increase in gastro backlog, this was unlikely to be achieved. Confirm and challenge meetings were undertaken the previous week and specialty level trajectories are being developed in advance of the Monitor PRM meeting in February We continue to use the private sector, with 223 patients in December and 207 in January, (this number includes Vanguard which was underutilised in January as 29 sessions were not used due to emergency bed pressures). Further independent sector capacity has been sourced, with the Priory being used from mid February for orthopaedic procedures. A modest number of patients are being sent to the ROH 5 patients in December breached 52 weeks. Of this 3 were due to poor pathway management and 2 were due to closure of Open Clock Pathways. Mrs Markall stated further 52 week breaches will occur in the coming months whilst work to close all remaining Open Clock Pathways is completed. A discussion followed on the recent Deloitte theatre review, reasons for cancelling operations, scheduling, lists under/over running, controlling beds and pathway management. A discussion followed on patient choice, patients choosing sites which takes them over 18 weeks and classed as a breach and patients’ rights on outpatients appointments. Mr Cattell advised further work is required on the trajectories and asked Mrs Markall when return to compliance of RTT was expected. Mrs Markall stated this information would be provided following completion of trajectories and ahead of the Monitor PRM. However given the challenges outlined our ability to reduce the backlog to 500 at end of March and 300 at end of April was now highly compromised.



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Action: AM and an update to the next meeting. Open Clocks Mrs Markall advised the Trust has committed a return to compliance for RTT 92% incomplete target by the end of March 2015. Whilst we have reported RTT Admitted and Non Admitted performance since November, it will not be possible to report incomplete until all remaining legacy Open Clock Pathways are closed. There are now circa 17,000 open clocks to be closed by the end of March, the majority of which are being manually validated. This will allow a clean waiting list and provide transparency. Mr Lawrence stated we need to resolve the systemic issues as manual validation is time consuming and provides inappropriate pressures. This is a serious reputational risk and requires a review of our SRR and BAF. Action: RB The committee questioned are the 17,000 purely an accounting issue and how many are still active patients? Mrs Markall responded c6000 patients were defined as being on a 2 week wait pathway, 3000-4000 are referred and awaiting a test or first outpatient appointment. Prioritisation is being given to those patients originally referred on a 2 week/cancer pathway, but stressed that of all patients referred circa 7% receive a positive diagnosis and whilst the Clinical Consensus Group understood that cancer had been excluded they had requested that manual validation of this entire group was required The remaining patients may be those who have DNA’d or on duplicate pathways. Analysis and validation undertaken to date has not suggested any patient has come to harm. Mrs Markall continued we are confident this issue will not be replicated in future. A process is in place which highlights patients who have been sent for a test and are on an open clock pathway with outstanding follow ups. We are confident we are handling patients appropriately. Mrs Markall confirmed numbers are reducing, and no harm to date has been identified. The validation team are closing c2800 clocks per week and it is therefore expected all Open Cloaks Pathways in the live WL system will be validated before the end of March at which point the team will commence validation of the 28,000 open clock pathways that were previously batched closed. Of this group, if a pathway has been closed inappropriately, it will be re-opened. Dr Ryder advised once a diagnosis has been confirmed the open clock closes, clinical pathways means continued treatment. These are 2 different paths. HEFT has invested a lot of time to conclude. A discussion followed on batch closing and the Clinical Consensus Group. The Committee was assured that this group was effectively managing this clinical risk to patients. Cancer Mrs Markall stated all targets were achieved in December with the exception of 2 week waits. Many of the breaches in December were due to patient choice. For breast symptomatic our position deteriorated to 80%, again due to patient choice.



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There are weekly tracking meetings and we are confident February will improve. We have limited ability to influence GPs and despite running a local campaign have not seen a reduction in Patient Choice breaches. In order to affect this, services have commenced proactively contacting of patients to re-emphasise the importance of attending the appointment within 2 weeks of their referral. Dr Ryder stated we have asked the Commissioners where they think referrals will come from and a discussion followed on national campaigns and planning appropriately. Mrs Markall confirmed PALS have called every patient who has chosen not to attend, to confirm they are aware they have been referred on a cancer pathway and so understand the reason why the GP has referred them. Circa 30% of patients did not know they were on a cancer pathway. This information presented by GP practice will be provided to the CCG who have committed to challenging GPs who fail to discuss reason for referral with their patients. As discussed previously, new NICE guidelines will be published in May, which will see a further increase in referrals to 2 week wait pathways. Currently despite increases in referrals the number of patients diagnosed with cancer has not increased. Mr Lawrence stated further down the line, we will need to write to NHSE and NICE and challenge the Patient Choice impact and achievement of the target. The Committee thanked Mrs Markall and her team for their efforts, which she appreciated. Mrs Markall gave a brief overview of the eight 100 day plus patients – the reasons for which were varied and included late referrals and complex pathways. Mrs Markall confirmed if patients are referred late, a letter is sent to the CEO of the referring centre alerting them to this. It is not anticipated this will affect the 62 day target. Mike Foster and the Lead Cancer Manager now complete a weekly clinical review of these patients. We need to decide how the information from Mr Foster is presented to the Trust. Mr Brotherton advised the Committee in January we incurred three 12 hour trolley wait breaches, 1 at GHH and 2 at BHH. SIs and RCAs had started and would report through the Q&S Committee in due course. Action: JB/SF/CR Mr Lawrence questioned the efficiency planning for 2015/16. There is an expectation Trusts will plan a reduction in emergency admissions, circa 3.5% which should be factored into budgetary planning. Mr Lock stated we need to revisit planning as there will be no reduction in emergency admissions. Mr Gould advised we will see the draft capacity plan for next year which will be included in the annual plan and an updated report will be presented at February’s meeting.

5.2 Enhanced Bank Rates Update Mrs Foster advised the report follows a report presented to the Committee in November 2014. The report has been discussed at the Executive Management Board (EMB) and enhanced rates will continue to the end of March. Of the 3 proposed options, we will be backing option 3 – continue business planning and include in capacity planning and then use bank for cover.



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A discussion followed on temporary and bank staff, agency block contracts and staff wishing to take substantive posts (at GHH). A discussion then followed on temporary and substantive posts, business cases and substantive wards.

5.3 Medical Job Planning Update

Dr Ryder advised there have been 3 changes since November/December. 1. Refocus on Trust priorities 2. Changes to job planning process 3. Acute pathways

There is more structure around the process and the overall delivery point has moved. The final sustainable process will take longer and we need support from HR in writing a policy. Most specialities agree with the rules and are working to implement. In December rules were changed to delivering inpatient services. The Committee stated it is fundamental it knows what its doctors are doing and what they should be doing. The timescale needs to quicken up. Dr Ryder advised we can decrease the timescale if we brought in an implementation group. The report from Dr Ryder was deferred till next month. Dr Ryder, Mr Cattell, Mr Brotherton and Mrs Gunter to meet and bring back to the Committee a way forward. The Committee continued we are concerned all are doing what they should be doing in order to achieve the Trust objectives and assurance is needed. We are confident colleagues are working together and we need to realign focus to demand and capacity. Action: CR/Feb 2015 – Provide updated medical job planning report.

5.4 Medical Staffing Update

Dr Rose provided an overview of the report. 6 actions plans are on track. We have started to meet with directorates but we need a project manager either from HR or employed separately. We suggest separate work stream work is on-going but could be quicker. 3 areas of focus

1. Emergency pathways – recruit fully in A&E (5 consultants) 2. Acute medicine – more consultants required 3. Elderly care – more consultants required

Gastro elective - have vacancies and are completing job planning with the Clinical Director. T&O - too many middle grade doctors (c40), more consultants required. The Committee stated its focus is correct in converting locums to substantive posts. What’s not happened is the response from Associate Medical Directors providing information and feeding back.



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Mrs Gunter advised since highlighting the issue, 21 long term locums have converted to substantive post and reports are issued monthly to every area. Action: AR/April 2015 – Provide updated medical staffing report.

5.5 Planning Update & Monitor Self Certification Declaration

Mr Gould advised since the last meeting, planning guidance has been received from Monitor on one year planning. We need to summit the draft annual plan by the end of February with the final plan being submitted by 10th April. Assumptions for the plan are presented and discussed at the weekly Executive meetings, EMB, BoD and Monitor Standing Committee (MSC) The overriding element is, as of Friday tariff has been delayed for a couple of months and we also still need to work out the assumptions. The Committee questioned the process for the Boards approval. Mr Lawrence stated it is a fundamental strategic discussion/decision for the Board and may need to include a special Board meeting. We must include the Governors in the discussion and Governance must be aware of the context/framework. Mr Lawrence continued the Board needs to be aware and make a decision on contract options as to whether we opt for Jointly Managed Risk Agreement or a standard PbR contract. Mr Gould will be presenting at the next available committee an appraisal document for JMRA vs. PbR as requested previously by Mr Edwards, this would be subject to the publication of the 2015/16 Tariff. Mr Lawrence continued we are reaching a critical point and we need to be including the new interim Chief Executive in these discussions. A discussion followed on JMRA & PbR Mr Cattell had previously suggested a Board workshop in late February/early March to discuss and agree a way forward on the 2015/16 Operating Plan Submission. Action: DC to organise Board Workshop(s) with Kevin Smith Mrs Jones presented the Monitor Self Certification declaration which requires approval by the Board before submission by 10th April to Monitor. It has been presented to the MSC and now for discussion at F&PC, and how to obtain Board approval. The Committee stated it requires additional time and would ask Monitor if the submission deadline can be extended to the 15th April due to recent circumstances and the Board meeting being on 14th April. Action: DC to liaise with Monitor.

5.6 Workforce Monthly Update Mrs Gunter provided the context behind the report which is that it provides a snapshot of where we are compared to the previous month only. The RAG ratings provided are different to the Trust RAG ratings and are explained in the attached



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appendix. Mr Brotherton advised Workforce is too important not to be included in the DU report. The DU Triumvirate will agree what workforce information will be included in their report which will replace this monthly update. The Committee expressed concern over staff attrition and continues to pick up staff not feeling valued. Mrs Gunter advised the draft culture and engagement plan was presented to the new Workforce and Development Welfare Committee. Mrs Gunter advised the plan will be shared with Andrew Foster before going to EMB. The Committee questioned do we need a new committee for workforce. Mrs Gunter would like to discuss this further as to where it fits in. Action: HG/ February 2015 - Include appropriate HR statistics in Delivery Unit Report.

5.7 Friends and Family Test Dr Brown presented the report and Q3 remains positive. An overview was provides of the data input method and the delays in December due to Christmas and courier delays. Dr Brown provided an in-depth overview of the response rates and trajectories and if we continue on trajectory we should achieve the Q4 CQUIN target. For the next year, early indicators are that this will no longer be a CQUIN. Future reports should focus more on the feedback rather than the number of cards returned. Action: RB to present the Q4 Update when available in May/June 2015.

5.8 PMS2 Update Agenda item was not discussed. This would be discussed at the IM&T Steering Group chaired by AE. Action: AE/Jonathan Rex

5.9 Bad Debt Write Off Mrs Jones presented the amount of bad debt requesting to be written off which is unrecoverable. It was agreed the SFIs will be amended to agree the Finance Director is authorised to write off individual debts up to £10k and a cumulative value of £250k in one financial year. The Committee approved the write off.

5.10 Bank Mandate Update Mrs Jones presented the changes to the bank mandate following recent change to Finance Director. The Committee approved the changes.



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5.11 Purchase Orders and Contract Awards Mrs Foster understood a review is taking place of third party contracts from a quality perspective parties/out of hospital suppliers. Mr Gould will review the contract to ensure no double counting however the order is in continuation of a previous order. The Purchase order was approved.

6. FOR INFORMATION Mr Quinn provided a high level overview of the Trust Finance KPIs for performance. The theatre efficiency review completed by Deloitte was presented to Audit Committee on 25th January. All items marked for information were noted and no further comments were made.

7. AOB The Committee thanks the attendees for the commitment and more focus was required

8. DATE AND TIME OF THE NEXT MEETING

The next meeting is scheduled to take place on 27th February 2015 at 9:30am in the Board Room, Devon House, Heartlands Hospital.

……………………………

Chairman

Dated .......................................



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Minutes of the Finance & Performance Committee meeting held on 27th February 2015 at 9:30am,

in the Boardroom, Devon House, Heartlands Hospital

Present: Mr Jonathan Brotherton

Mr Darren Cattell Dr Andrew Catto Mr Andrew Edwards Mr Les Lawrence Mr David Lock

Director of Operations Director of Finance & Performance (Interim) Medical Director Non-Executive Director Chairman Chair

JB DC

AC AE LL DL

In Attendance:

Mr Richard Barratt Mr Jonathan Gould Mrs Sue Hyland Mrs Angeline Jones Mrs Amanda Markall Miss Louise Jenkins

Business Consultant Finance Operations Director Deputy Chief Nurse Chief Financial Controller Planned Care Specialist Personal Assistant (Minutes)

RB JG SH AJ AM

LJ

Partial Attendance:

Dr Adedeji Okubadejo Associate Medical Director – Revalidation

AO

1. APOLOGIES FOR ABSENCE

Apologies were received for: Mrs Sam Foster, Mr Aidan Quinn & Mr Adrian Stokes 2. MINUTES OF THE MEETING HELD ON 2nd FEBRUARY 2015

The minutes of the meeting held on 2nd February 2015 were accepted as an accurate record, with amendments to: 4.1 Mr Lock provided his personal view, essentially Acute Trust provide a responsive service (and remove ‘not Commissioners’) 5.6 Mr Brotherton advised Workforce headlines will be included in the Integrated Governance Report but it is too important not to benefit from its own report. The committee agreed the Workforce report will continue to be provided on a monthly basis in addition to the Integrated Governance Report.

3. MATTERS ARISING

Mr Barratt requested item 6.6 be brought forward on the agenda as agreement of the report underpins a submission to Monitor, due by 12.00 noon. All matters arising were identified for action in either this, or a future meeting agenda.

4.0 TERMS OF REFERENCE

4.1 Terms of Reference (Proposed) The committee noted the proposed TOR.


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Mr Edwards asked whether the TOR has addressed the issues raised in the Deloittes Governance review. Mr Barratt advised the TOR had been developed to include responses to the key issues raised. Mr Lock stated section 9 outlines detailed and expanded reporting requirements from the Committee to Board. Mr Edwards asked whether Andrew Foster has yet seen the TOR. Mr Barratt advised this was not the case, and Mr Cattell confirmed the CEO will see the TOR when they are presented to Board of Directors (BoD) in due course. The committee approved the revised TOR, subject to the monthly Workforce update being restored.

5. FINANCE AND PERFORMANCE POSITION UPDATE 5.1 Finance and Performance Directors Report M10

Mr Cattell presented the report and M10 is broadly on track. We expect to achieve a £5.6m year end deficit. Issues still remain regarding exit strategies, clinical staff vacant costs and exiting winter. We achieved the CQUINs for Q3 at 75% across all indicators. A discussion followed on the debtors KPI and the long standing debt with Burton relating to ante natal care. Mr Gould explained the issue is being escalated and may need FD involvement. There is currently no timescale for a resolution. Mr Lawrence queried the variance of 190% on the Schedule of Trust Forms TF1. Mrs Jones and Mr Barratt will liaise and ensure a response is provided to Mr Lawrence outside of the committee. KPIs will be discussed in the Integrated Governance Report (IGR).

6.0 CURRENT MATTERS

6.1 Integrated Governance Report Mr Brotherton presented the report which now requires some additional tuning & development and it includes some information from the safety SITREP. This is the fifth IGR which is now being presented to a wider group including, BoD, F&PC, Quality and Risk Committee(QRC), Council of Governors (CoG), staff briefings and uploaded to the Intranet. We need to agree the sign off procedure for the report. There is a revised Performance Framework which is being developed following the Deloittes Governance Review which will be presented in due course. 4 Hours This is complex, high profile and is under performing, We have not delivered the necessary trajectory set for 23rd February of 95%. Through January there were improved levels of resilience and we delivered a safe service through a period of unprecedented pressures on the health service. For a Type 1 A&E provider we are ranking circa 100 out of 140 and latest reports show us at 95. When benchmarking regionally, our levels of escalation compared reasonably. We de-escalated BHH and SOL in early January from unplanned flex, with GHH compromised until recently when the medically fit for discharge (ward 3) opened. As a



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result we have exited unplanned flex capacity at Good Hope Hospital now. The Urgent Care Plan delivered a series of inputs which has improved elements of pathways which at a granular level includes improving discharge rates through ambulatory care, improved input through acute medical units and reduced Length of Stay (LOS). Focus for the next 6 weeks includes the roll out of LOS reduction work at BHH and GHH. We are building on the work of the assessment unit by ensuring right patients in the right place. We are focusing on the medical staffing compliment i.e. front door initiatives, geriatric assessments and discharges. We believe the plan is still right, we’re confident and we recognise we cannot complete the plan without adapting it where necessary. There was a reduction in attendances for January which is normal as lower in winter months but with greater activity of admissions, conversion rates and LOS. A discussion followed on admissions, January and February’s congestions and assurances for admissions. Dr Catto advised for A&E there are currently 12.5 WTE consultant vacancies and we are currently in the process of a recruitment drive. A high level discussion followed on BHH’s GP service. Dr Catto stated to get emergency care right it is a combination of improvement to system, process, leadership and culture. Mr Lawrence continued we need to undertake a number of initiatives to absorb the increase and stabilise performance before the spike begins. Do we have the physical capacity to deal with the numbers at the front door and are there any environmental constraints. Dr Catto advised the department is undersized and we may need to look at decanting minors. We may need to look at assessment for other areas so they are not assessed in the ED, i.e. gastro. Further work is required with the ED management team to understand potential decanting. There are no shortages of attempts to engage issues and work is needed with the Delivery Unit (DU) on how to engage with A&E staff. Mr Lawrence questioned when we will look at the investment of SID? Mr Brotherton responded currently circa 210 patients are medically fit for discharge and have been so for 24 hour or more, and are on a transfer of care list. These are relying on a discharge which includes partners. Commissioners believe there are enough beds and services but we need to ensure are being used correctly, We are now working on a full discharge to assess model, which will require us and partner to change. Estimated completion will be circa next winter to resolve and deliver. The Commissioners have responded well but significant change is required. Mr Cattell questioned when will we produce the improvement trajectory and how close will we be to the 95%? Mr Brotherton advised no date as of yet as been set. It was discussed at the recent Monitor PRM meeting and we are doing all we can do deliver this trajectory in March. A date has not been agreed with Monitor but we will need to set and agree this at the April PRM. The Committee advised this will need to the presented to them beforehand. An overview was given of what was provided to Monitor.



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A discussion and overview followed of LOS at SOL to increase discharge which was mainly down to interventions, followed by a discussion on discharges. The Committee summarised more focus is required for delivery of discharges. We must support Clinicians to take risks and more details to be provided in next month’s IGR. Action: JB to prepare A&E improvement trajectory in line with the requirement to Monitor for the April PRM. 18 Weeks Mrs Markall provided an overview of the identification of 650 additional patients in gastroenterology in late December and the direct impact this has had on the overall backlog of patients waiting over 18 weeks. In January we cancelled 215 patients on the day or day before due to no beds. 26 cancelled session in the Vanguard theatre, 11 in main theatre and 11 theatre sessions unused due to no surgeon (as many job plans do not allow prospective cover of annual leave). Mrs Markall accepted theatre usage could be improved and the new Theatre Council established following Deliottes recommendations would oversee the work programme to improve efficiencies. Mrs Markall confirmed a weekly theatre scheduling meeting was now in place to focus on list recycling and improve utilisation. In addition, a pilot is commencing to reduce DNA’s on the day of surgery and patient’s surgery being cancelled due to them not being fit. At the beginning of February an additional cohort of 392 patients were identified that had not previously been visible on the In Patient Waiting List following migrating to PMS2. The majority of this patient group presented initially via an emergency route and were discharged pending future elective surgery. Some of the patients were classified as “urgent” or on a 2ww pathway and 1 patient had waited over 52 weeks - Mrs Markall confirmed all of these patients had dates for surgery and were being closely managed. This incident had raised a significant concern regarding data quality and Mrs Markall confirmed Deloittes had been instructed to undertake an audit of Referral to Treatment Time generation of data and reporting which would include interfaces across finance, IT, performance and operations data. Gastro remains a red risk for the Trust and further work will be on going to support the service in coming weeks. The Trust is failing the 5 week diagnostic target, predominantly due to Gastro. Additional sessions have been in place now for several months with 7 day working being standard. Mrs Markall confirmed the Trust is working with the private sector to undertake further scopes, however to date this has not proven to be productive. A mobile endoscopy unit for BHH is now being scoped which will require a business case and associated funding. The Clinical Service Lead is engaged and Mrs Markall and Mr Brotherton have met with the gastro team. Mr Brotherton continued we require a dedicated endoscopy manager which is in progress. Mrs Markall continued a PMO is involved and is putting together a service transformation plan. A discussion followed on quality & safety and performance. Some issues have been reported to the Quality & Safety Committee and are listed on the Trust Risk Register. The Committee stated it is on the performance of the department and patient flow. Next month’s IGR report should include a section on gastro and if the Committee is not satisfied it will request a further detailed report. Mr Brotherton continued all specialities have produced trajectories which the performance



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team will QA before being forwarding to Monitor. Management leads will be accountable for delivery The Vanguard theatre is only taking day cases due to staffing and in-patient bed issues at GHH. Mrs Markall is scoping a move of the facility to either SOL or BHH site to improve usage Action: JB to produce revised trajectories for sign off by EMB prior to 31st March 2015 as requested at the last Monitor PRM. Open Clocks Mrs Markall advised we are confident all clocks will be closed by mid-March. The team is now preparing for validation of the 28,000 previously batched closed group. A letter has been issued to each Consultant to work on patients with open clock pathways under their care. We have received additional funding from Monitor to support validation. Cancer Mr Brotherton advised 31 & 62 days cancers delivered again last month. 2 weeks waits are on trajectory. 2 weeks breast symptomatics are just behind trajectory due to an admin process identified in December and corrected in January. An overview was provided on patient choice breaches i.e. the patient declines to be available to be seen within the 2 week period allowed. Mrs Markall reported an audit had recently been undertaken of all patients who had chosen to not attend within 2 weeks of referral, This showed 39% of patients were not aware they were on a cancer pathway. This is not specific to one GP. The audit will be repeated and work will continue with CCG colleagues to address this with GPs. Mrs Markall advised for the quarter, 62 days is at risk as we anticipate failing and are currently at 81% for February. We have been focussing on patients over 62 and 100 days and ensuring these patients are brought forward and treated. Mrs Markall has asked the lead for cancer and urology, Mike Foster, to provide a statement for the next meeting. Also requested for rectification plans to be put in place. For 62 days screening, we have only received 4 patients month to date of which 2 cancelled, so we achieved 50% which will result in failure of the screening target also in quarter. Action: AM to organise a statement for the next F&PC as assurance over the 62 day Cancer target. Infection Control We experienced 1 case of MRSA Bacteremia, the first case in 18 months which is being investigated. The initial theme is poor screening, For C-Diff we are 1 case below the year to date target. Dr Catto advised the strain found is historically found on major sites and the team did well to contain it.

6.2 Medical Job Planning Update Dr Okubadejo introduced himself to the Committee as the new lead for Medical Job Planning and provided an overview, new approach and history behind the report. Going forward we need to involve the Clinical Directors and Operations Managers in job



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planning. The Committee stated it does not have any assurance on medical job planning as previous reasons for failing will continue. A discussion followed on previous job planning progress, the system platform used, training on using the platform, the right amount of focus and next steps. Mr Cattell questioned how the process will be governed, will it include a steering group? Dr Okubadejo stated HR are becoming involved. If we don’t comply with medical job planning it will ultimately be managed through the performance framework. An overview was provided on medical rostering – which is different to job planning and capacity planning. The Committee stated it is a priority of the Trust to get comprehensive medical job planning established. This should go through the SIEP programme and we want corporate alignment. Action: Dr Okubadejo/March 2015 – Provided updated medical job planning report including clear project progress and number of medics with job plans

6.3 Winter Plan Exit Strategies Mr Barratt provided an overview of the report, explaining that we are broadly on track in terms of expenditure against plan. Each division has been asked to RAG rate their assessment with regard to whether exit plans are both in place and being implemented. At presents two-thirds of schemes present a level of risk with regard to exit plans. With regard to additional measures above and beyond winter plan, a Business Case Review Group is in progress and recommendations will be made to EMB in due course. Decisions are required to fund those measures which are proven to improve patient care and performance, and then exit plans will be required for the remainder. The focus now is to firm up progress of exiting winter schemes and agree which measures are required for a safe transition of exit strategies, with further updates to be provided to Committee over the next three months. The Committee accepted the report and stated we need to assess where high demands are and decide if recurrent funding is required in these areas.

6.4 SIEP Update 2015/16 Mr Barratt provided an overview of the report which is a scheduled financial update and is for assurance by way of response to the residual gap. An overview was provided of targets, carry forward and expected delivery. All Divisions have met with the Director of Operations and Deputy Director of Finance since the last update. Accordingly the Trust currently has just under £24m of plans for 2015/16, for which just under £10m are categorised at likely delivery and the remainder are high risk. Mr Barratt continued that Divisions will be attending further Confirm & Challenge meetings this month, and we are proposing to revise the governance programme from March onwards. We have set up a steering group and included a draft TOR for



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Committee to approve. The key actions for March are implementation of schemes and converting high risk schemes through to likely delivery. Mr Brotherton questioned will the steering group be able to agree a set level of enabling costs. Mr Barratt advised a value can be agreed and included in the TOR accordingly. Mr Lock stated that the challenge is better control and how we manage current expenditure. Unless any transformational items are already in progress it is unlikely they will deliver. We need assurance the plans will deliver in 2015/16. Mr Brotherton stated we need to think about the role of the PMO, which will assist in transformation schemes and provide further rigour. Mr Edwards asked how the targets are set for SIEP and whether these are disincentives for those who consistently deliver. Mr Barratt advised that targets are currently based on 5% of Divisional budgets, but that the Steering Group will review progress from a whole Trust perspective. Gain-sharing agreements can also be agreed to help incentivise delivery where appropriate. Mr Brotherton added that Quality Impacts Assessments (QIAs) will be completed over the coming month and subsequently shared with Medical and Nursing Directors. The Committee accepted the Steering Group Terms of Reference and the actions contained within the paper.

6.5 Planning Update Mr Gould presented the report and advised a 2nd Board workshop would follow in due course. The Committee accepted the report in principle with no commitment to the figures until full Trust Board approval, but should be used as sensible basis for planning.

6.6 Monitor Plan Activity Submission Mr Gould presented the report and advised the submission deadline for financials has been extended by Monitor due to delays in the 2015/16 tariff being released. The new submission date for financials will be early to mid-April, still to be advised by Monitor. Today we will be submitting the activity plans for 2015/16. The activity levels reflect last year’s trends. The report also looks at the annual planning assumptions. The Committee stressed the importance to the Delivery Unit, it is critical we understand activity to deliver and ensure capacity is in place, meaning wards/beds/heads in a baseline ward. Mr Gould provided an overview of the planning process and advised the CCG will be suggesting ways reducing the number of patients treated. A discussion followed on treating patients, affordability issues, capacity, demand and pathway approaches. The Committee confirmed that using the 14/15 activity trends to plan for 15/16 activity is the right approach assuming nothing else changes and secondly to continue to work with CCG to redesign clinical pathways to reduce the foot fall into the front door. The activity sheet submitted to the committee was approved to be submitted to Monitor. Mr Cattell advised a report will be presented to the next meeting on capacity planning.



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The Committee recognized we are planning a deficit this year of £5.6m with a c£10m deficit for next year and capital reserves (cash) will reduce to £50m next year compared to £90m this year. An in-depth discussion followed on deficits, CCG deficits, activity, demand management, Better Care Fund (BCF) and reduction of flow. Mr Cattell advised there is a significant risk with the BCF assumptions and we will work to deliver its plan once we know the impact on activity. In the meantime we must deliver a high quality safe service. Mr Lock advised this time last year, we produced a set of assumptions which were incorrect and the Commissioners should manage demand. The Committee summarised we agree the plan, and advised that the plan needs to be represented to the Committee if there are any changes in planning activity as we need to be assured any assumption in lower activity is supported by robust evidence. Action: DC to present an update on Capacity Planning to the next meeting.

6.7 Contracting Update Mr Gould provided an overview of the report. Mr Lock confirmed that the BoD needs to agree whether we have a Standard or Non Standard contract for 2015/16. This decision would be taken in due course. Mr Cattell advised that a set of contracting parameters will be presented for the BoD approve. This will allow the more detailed contracting negotiations to progress during March/April The Committee advised if we opt for a Non Standard contract we must include discharge target for CCG. A high level discussion followed on discharges and fines.

6.8 Budget Setting 2015/16 Mr Barratt provided a brief overview of the report. A number of points have already been discussed in the meeting and the budget envelope has been set in line with the Budget Setting Policy presented to the Committee in December. As discussed in the Planning Update the envelope provides for a £9.9m loss in 2015/16. The envelope does allow for significant investment in care to meet performance targets and capacity challenges. Key points to note within this are:

1. £13m investment in improvement 2. £6m growth reserve 3. £4m winter reserve – increased from £2.5m this year.

Mr Lock challenged whether it is sensible to plan a £6m contingency reserve and advised he was against general contingencies in principle. A discussion followed on general reserves. The Committee advised that any contingency should be held centrally as a single sum. The Committee accepted the budget setting paper and 2015/16 envelope.



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6.9 PMS2 Update Mr Cattell advised Mr Edwards is the Chair of the Sub Committee so responsibility has now transferred over.

6.10 Purchase Orders and Contracts Awards Mr Lock asked whether the rates revaluation had been resolved. Mrs Jones explained that there was an increase on Birmingham City Council rates for the BHH site as a rates revaluation had taken place in 2014/15 year increasing the charges for 2014/15 and thereafter. The rates review for GHH site has not yet happened. The Estates team is challenging the increase in charges although we still need to make the payments while in dispute. All Purchase Orders were approved.

7.0 FOR INFORMATION All items marked for information were noted and no further comments were made.

8.0 AOB No further business was discussed.

DATE AND TIME OF THE NEXT MEETING The next meeting is scheduled to take place on 27th March 2015 at 9:30am in the Board Room, Devon House, Heartlands Hospital. Chairman …………………………..Dated .......................................................



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Quality and Risk Committee

These minutes are DRAFT until approved at the Quality & Risk Committee meeting of Friday 20th February 2015

DRAFT MINUTES of a meeting of the

QUALITY AND RISK COMMITTEE of Heart of England NHS Foundation Trust

held in the Boardroom, Devon House, Birmingham Heartlands Hospital on Friday 23rd January 2015 at 9.00am

Present RAO, Jammi Non-Executive Director (Chair) JR BLACKBURN, Rachael Head of Corporate Risk and Compliance RAB BRIGHT, Philip Associate Medical Director of Education PB BROWN, Richard Programme Director & Deputy Director of Patient Experience RWB CADIGAN, Patrick Non-Executive Director PC FOSTER, Sam Chief Nurse SF GUNTER, Hazel Director of Workforce HG KEOGH, Ann Director of Medical Safety AK LAWRENCE, Les Non-Executive Director LL OKUBADEJO, Adedeji Associate Medical Director, Revalidation AO RAGHURAMAN, Govindan Associate Medical Director, BHH GR RUDD, Louise Head of Clinical Governance LR RYDER, Clive Interim Executive Medical Director CR STEVENTON, Liz Public Governor LS THOMSON, Lisa Director of Patient Experience and External Affairs LT In Attendance BAHRON, Ali Systems Development Manager AB LEWIS, Sheena Matron, Neonatal Unit SL MARIES-TILLOTT, Caroline Patient Safety Adviser CMT RAYNER, Hugh Consultant, Renal Medicine HR SHARP, Karen Associate Dean KS Minutes HIGGINS, Vickie Executive Assistant VH

ITEM:-

1. Apologies Apologies were received from Patrick Brooke, Andrew Catto, Matthew Cooke, Bhavna Gokani (represented today by Sheena Lewis), Alan Jones, Rex Polson and Lisa Richards-Everton. 2. Draft Minutes

AO requested minor amendments to the wording of section “8. Revalidation”. These amendments have now been made. Therefore, the minutes of the meeting held on Monday 24th November 2014 (Enc 2) are agreed as an accurate record.

3. Actions Arising

The Committee Members reviewed the remainder of the Actions, which have been updated and are at the back of these minutes.

SAFETY:-

4. Chronic Kidney Disease

HR gave an onscreen presentation entitled; “Population Wide Chronic Kidney Disease Management,


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Reducing the Incidence of Kidney Failure” (available if required) and asked if there were any questions. PC felt it was a good presentation and that patient access to results, letters, etc. was a great model for others. HR advised patients could access results from home and this was highly valuable. CMT felt it was QI at its best and HR advised, going forward, they were training nurses. JR advised it was managed care at its best via predictive analytics - using data to produce what the patient wants - and HR advised it was powerful to be able to discharge patients that will not require dialysis anymore. SF asked if this should go to Trust Board to allow them to see the quality work being undertaken and CMT suggested it was also presented to the CCG. HR explained that they were sharing the data and system with other Trusts although, unfortunately, there were some still reluctant to accept the data and adopt the system.

5. Safety SitRep

The report (Enc 5) was taken as read and presented by LR, with the following key points discussed:- JR asked if the SUI in Ophthalmology was a new one and the fourth regarding a wrong implant. AK advised it was a new one but it was not exactly the same as before and was around computer biometry readings. LR advised they were conducting Round Table meetings and looking at missed opportunities and a number of other factors. Concern was raised about leadership ensuring new process and embedded at both GHH and SOL. AO felt the role of the Clinical Director needed to be clarified via a generic Job Description and managing objectives. JR agreed this should be the case. PC asked for clarity around training for incoming Clinical Directors and CR agreed the role of the Clinical Director was confused but the University of Warwick/Matthew Cooke were setting up training programmes for around 60 staff and Clinical Directors will be expected to attend. Future Clinical Directors would also be expected to have been on the course. CR felt they did not always have the tools to do their job and it was for the Clinical Director and Operational Team to work together, with Finance, Quality & Risk, HR, etc. wrapped around them. HG advised we will be developing a HEFT Leaders Programme detailing what was expected from leaders at HEFT, which will include clinical leaders. CR advised the Medical Director and Deputy Medical Director will also be on the Recruitment Panel for new Clinical Directors. SF advised the site team will undertake a self-assessment using the recent Deloitte assessment. JR felt appraisals should be continuous, rather than carried out once a year. For Clinical Directors, this should be an additional part of their appraisal process due to the importance of their role. AO agreed that plans for the year should be reviewed at regular intervals. PC asked for clarity around the Endoscopy red risk affecting some 600 patients and CR advised they had been “lost” in the booking system. An investigation was underway around the booking system - there had been a rise in demand and, whilst lots were doing, there were financial impacts. PC asked about the Endoscopy facilities and JAG accreditation CR advised there were potential funding and screening implications but a Business Case for a rebuild had been submitted some time ago. Action : Louise Rudd to update SitRep.



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6. CQPG

CR advised the CQPG had not met formally since November 2014 due to other pressing issues and it was undergoing redesign. They needed to check where it sat within the assurance and Governance processes and needed a clearer overview and to ensure of any duplications and possible gaps. They were to clarify structures and functions around this Committee and the EAG, with Andrew Catto having overall responsibility. The Terms of Reference will be reviewed and a decision made as to whether it would report here and/or at EMBs. They needed to check where it says within the assurance and governance processes, which are currently being revised. Concern was raised and the clarity of the role of the CQPG and proposed EAG to avoid duplication and minimise any gaps in the assurance processes. It was agreed that EAG was a good idea but they needed to map all committees and functions before finalising the Terms of Reference. There was a further discussion about the impact on Quality & Risk and the introduction of the PMO approach and new committees evolving to support it. Action : RAB and RWB to bring back mapping of committees and Terms of Reference and revised proposal for EAG.

7. Delivery Unit Report

The report (Enc 7) was taken as read, with the following key points discussed:- JR advised this was taken to Trust Board last month and AK advised it came to this Committee two months after being produced as it needed to fit in with Finance & Performance but as Quality & Risk was now monthly, we should receive more timely reports. SF advised it had been a difficult few months, with lots of effort from clinical and non-clinical colleagues around response plans, mandatory training, ambulatory care and flex capacity (specifically at GHH). SF thanked the Faculty, who had made an excellent contribution to key leadership roles during the heightened response. All teams and Directorates had pulled together, with a corporate response to the current pressures.

8. Workforce Compliance

The report (Enc 8) was taken as read and presented by Hazel Gunter, with the following key points discussed:- A current risk was bank usage - running out of people and relying on agency staff more. We are encouraging more staff to do bank work through enhanced bank rates but the financial pressures would need to be reconsidered at the end of March 2015. It was stated that the amount of open flex beds was causing the reliance on bank. JR asked if they monitored the total hours staff were doing, including overtime. HG advised they did. Another risk which would be raised to the Finance Department was regarding a recent national case in which an employer was required to pay annual leave for regular overtime hours worked. We are still awaiting potential developments and legal argument but it remains possible that Trusts may be required to make annual leave payments for additional bank hours paid to substantive staff. If this was agreed, there would be a financial impact. There was a detailed discussion around staffing and over-establishment model. SF agreed to provide a paragraph to inform the minutes. AK asked if sickness levels could be graphically displayed to reflect monthly changes.



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Action : Hazel Gunter to review. AK asked why “long term suspension” figures excluded doctors and HG advised the excluded doctors were included in the report and also reported to Trust Board. CR advised there were “excluded” and “restricted” members of staff, which went to Trust Board last month. There was a discussion around doctor’s hours and monitoring returns. CR felt there should be a better way of reporting (not self-reporting) as to why staff worked to excess when they should manage their own workload. GR advised appraisals remained low and concerns were not being managed. Discussions should be undertaken in appraisals with clearly defined career development. HG advised appraisals had changed and were linked to pay increases nearer to increment dates. Revalidation for nurses would commence April, including corporate objectives around the “Fit and Proper Persons Act”. This would be a huge piece of work that would develop over the next twelve months. GR felt there were some concerns around processes in place, with the feedback that they were a waste of time and a tick-box exercise. It was agreed that both appraise and appraiser need training to overcome this, where this was identified. JR advised appraisals were the job of Managers and Trust Board. If there was a failure, it was a collective failure. SF also felt the working week did not always allow time for appraisals to be completed. HG advised the Workforce Development and Welfare Committee were reviewing proposals of engaging staff but the Staff Engagement Group had not met recently due to site pressures. CR felt certain anxiety was around appraisals being confused with performance management. This needed to be split and must be done properly. HEFT should be developing people and not just “ticking boxes”.

9. Mandatory Health & Training Report

The report (Enc 9) was brought back to the Committee for clarification, with the following key points discussed:- KS advised HEFT was previously a risk as it was not meeting its target of 85% but was now at 85.55% and, therefore, on target. However, it was noted that Mandatory Training had been cancelled for six weeks and, therefore, may become an issue. LR asked how the averages had been calculated and KS explained that following discussion with other organisations, they were not weighted averages. The overall impact of this was a slight increase in calculated compliance. AK asked for clarity around food hygiene and KS advised this was conducted during Corporate Induction. CR asked for clarity around safeguarding children level 3 and KS suggested he speak to Jane Fleming regarding the figure outlining 880 members of staff, which was the entire Women’s and Children’s Directorate. SF felt there were large areas not complying and this required action. HG advised it was closely monitored by the Delivery Unit and agreed to discuss further outside of this meeting. Action : Hazel Gunter to bring back assurance.

10. TeamSTEPPS

The report (Enc 10) was taken as read and presented by Ann Keogh on behalf of Matthew Cooke, with



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the following key points discussed:- AK advised there had been recent changes in the management structure. HG will meet with Matthew Cooke and Alastair Williamson outside of this meeting.

11. Silverman Report - Recommendations

The recommendations (Enc 11) were taken as read and presented by Ann Keogh for information only, with the following key points discussed:- AK advised the report was presented at the last meeting and she was now bringing all of the recommendations together from Silverman and the KPMG internal audit. SF gave an update on electronic observations and advised that Peter Owens was now the Lead on this project as we had received confirmation of £1m to purchase a new system. JR advised he was comfortable with the short-term plans.

12. Urgent Care Improvement Board

The report (Enc 12) was taken as read and presented by Sam Foster, who advised the UCIB also reported through Trust Board and Monitor. It was supported by Band 7 Project Managers and was delivering on most aspects, with some actions now being consolidated. She confirmed it was robust but challenging.

13. Patient Safety Walkabouts

The report (Enc 13) was taken as read and presented by Ann Keogh, with the following key points discussed:- AK advised the system of Walkabouts was well-established and these summary papers were for those members of this Committee that had not attended the Walkabouts. JR advised he had attended most and was happy with how they were running and advised of the CCG’s targets. AK reminded Non-Executives that the CQUIN required all Board members to attend at least one. Action : AK to provide a list of who still had to attend to LL and KS. JR felt the Walkabouts should include junior doctors but AK felt this was often difficult due to clinical pressures and advised they attended Risky Business. CR also suggested the NEDs attend Risky Business. HG advised there had been an issue around obtaining food out of hours for some time. SF advised there was previously a night canteen at GHH past but it was not used. LL advised lots had been done on other sites but they need to look at refreshments at around 10pm/11pm for both staff and visitors. Action : LL to lead and pick up with Finance & Performance. PATIENT EXPERIENCE:-

14. Patient Experience Report

The report (Enc 14) was taken as read and presented by Richard Brown, with the following points discussed:- RWB advised the report covered August to December. Family & Friends results had dropped during Dec14 (Q3 - 32%) but still above their CQUIN target of 30%. They now include percentage of positive



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responders. Nov14 was 88% and Dec14 was 93%, which was interesting to see, in view of the December pressures. A&E was steady at 17%/18%, with a target of 20%, so they were adding further questions. Dec14 was 76% and currently 73%, so not too low and nothing of major concern. There were some elevated risks from the IMR around meeting physical needs - ie. managing pain. However, our own inpatient results do not necessarily reflect this. AO felt figures were consistently poor, maybe as the correct patients were not targeted. Pain patients always engaged, so there may be an issue with those not picked up. SF felt the Delivery Unit needed to understand the figures by working with the Patient Experience Team and JR felt there were Clinical Audit issues around the selected group of patients. RWB advised they were producing more data, reviewing trends and looking how they could work together, looking at the top issues from the patient’s perspective. There was now a more joined up approach, looking at the positive issues and looking at the balance. LS raised an issue around signage - ie. “How Did We Do?” and “You Said, We did”, which were blank and did not set the right impression, particularly at SOL. These should show the patient’s point of view all around the hospital. LT advised they had done an audit of where signs are put up and have a whole new programme in place, so changes should be seen from next month. JR felt it was the responsibility of the Managers to look at this. AK felt there were a further few inaccuracies, which would be picked up outside of this meeting. JR asked about the Patient Opinion website. LT advised patients were using the NHS Choices website, which directed patients to the larger sites. JR had seen a response from LT and MC, which was very good and acknowledged patient opinions. PB asked if staff were aware of the results. JR advised, at a recent Patient Safety Walkabout, staff felt there was not enough time for staff meetings. SF agreed, suggesting short shifts could overlap and this was currently being looked at.

CLINICAL EFFECTIVENESS:-

15. Audit and Effectiveness Update

LR gave an update on the National Audits, COPD position and Colorectal, around where services were going to be. All would be monitored through the Clinical Standards Committee. REGULATORY/CONTRACTUAL:-

16. CQC The report (Enc 16) was taken as read and presented by Rachael Blackburn, with the following key points discussed:- RAB advised updates would come here, as the CQPG was not currently running. Outcome 14 had seen changes to its submission - this will be updated and sent. CQC’s outcomes and regulations were changing from Apr15 and they were conducting an internal review to ensure they will be ready. KS asked if Outcome 14 should be flagged up via the Risk Forum. CR advised risk assessments came to this Committee and RAB advised it was not at the Risk Forum yet but would be discussed there.



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17. Internal Audit : Emergency Department Action : SF left the meeting early. Therefore, SF to send Vickie the wording for this section. 18. Internal Audit : Quality Impact Assessment Action : SF left the meeting early. Therefore, SF to send Vickie the wording for this section. 19. Quality Report RAB advised this was still in progress. They were reviewing assurance, engagement with internal changes, annual report and financial actions. They had commenced external communications with the CCG and will be reporting to Governance and the Council of Governors. They were on track and progressing and more detail will come to this Committee when the first draft has been completed. ASSURANCE FROM SUB COMMITTEES:-

20. Clinical Standards Committee The contents of the report (Enc 20) were noted by the Committee. 21. Infection Control There were no papers submitted today as the previous Infection Control meeting was cancelled. 22. Information Governance The report (Enc 22) was taken as read but there was no representative present. The Committee felt a representative should be present at this Committee if a paper was being presented. LS was present but not Kevin Smith, who is the Chairperson. JR felt this Committee needs a clear route and Kevin Smith should attend to present the report. Action : Kevin Smith to be asked to attend the next meeting where this paper is presented. 23. Safety Committee The contents of the report (Enc 23) were noted by the Committee.

ANY OTHER BUSINESS:-

24. Safeguarding Report (Adult and Child) Action : As there was no representative present at today’s meeting, the report (Enc 24) would be brought back to a future meeting. 25. Executive Assurance Group (EAG) The report (Enc 25) was taken as read and presented by RWB, with the following key points discussed:- RWB advised they were responding to current needs but this was not the final solution. Going forward, they were reviewing what needs to be done. The Delivery Unit had pointed out gaps and Andrew Catto had proposed an EAG as an Executive Group below Quality & Risk giving assurance to the Executives and linking into EMB. This was an interim approach whilst they look at a better way or working. CQPG had not met for a few months, so aspects of assurance and performance were not



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being considered in the necessary detail. It was being sent to Quality & Risk for discussion. JR asked if there were any comments or if it could be approved. SF asked what ran underneath, without the CQPG and CR felt it was a duplication of the Delivery Unit. AK was concerned about the number of Committees. She suggested it required mapping, looking at the gaps and combining the structure. LR felt the concept was correct but it was similar to the CQPG. HG felt it was a great idea, with a Committee below this one and it could alter discussions. However, mapping needed to be done to support both Committees. RWB agreed they must ensure this was done, particularly since the Kennedy Report. SF advised EMB had agreed for RWB and RAB to arrange this and help with the priorities and LL suggested further changes to this Committee - ie. Terms of Reference, existing Sub Committees, with plans of accountability clearer and more focused. CR felt there was an anxiety around the minutes of meetings. Minutes should be fit for purpose, with executive summaries approved by the Chair, so the correct issues can be discussed. JR agreed minutes alone as a record of discussions were not enough. It also requires areas of concern and plans of action, focusing on reassurance and being open. CR agreed, subject to a probationary period - ie. three months - and JR felt mapping could be an ongoing process. AK agreed for the EAG to be set up but felt that the current Terms of Reference needed review. SF suggested RWB, RAB and CR work on the top areas around mapping, training and membership. JR advised the Committee agreed in principal, with the Terms of Reference being subject to review in three months’ time.

26. Future Agendas As some people had left the meeting before it had finished, HG suggested the order of the agenda be reviewed in future, with the more pressing issues discussed first and dealt with earlier. Action: To be discussed at the next meeting. NEXT MEETING:-

27. Next Meeting Friday 20th February at 9.00am in the Boardroom, Devon House, Birmingham Heartlands Hospital. Action : JR gave apologies for the next meeting and will ask LL to Chair.



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Date of Minutes Actions from January 2015 Meeting Target Date Owner

23Jan15 Louise Rudd to update SitRep. 20Feb15 LR

23Jan15 Rachael Blackburn and Richard Brown to bring back mapping of committees, Terms of Reference and revised proposal for EAG. ASAP RAB/RWB

23Jan15 Hazel Gunter to review section in Workforce Compliance around sickness levels. ASAP HG

23Jan15 Hazel Gunter to bring back assurance around the Mandatory Health & Training Report to the next meeting. 20Feb15 HG

23Jan15 Ann Keogh to provide LL and KS with a list of required attendees for the Patient Safety Walkabouts. ASAP AK

23Jan15 Les Lawrence to discuss out of hours refreshments with Finance & Performance. ASAP LL

23Jan15 Sam Foster to send Vickie the wording for Section 17 - Internal Audit : Emergency Department. ASAP SF

23Jan15 Sam Foster to send Vickie the wording for Section 18 - Internal Audit : Quality Impact Assessment. ASAP SF

23Jan15 Kevin Smith to be invited to attend the next meeting presenting the paper on Information Governance. ASAP KS

23Jan15 Safeguarding Report to be brought back when a representative is present. ASAP TBC

23Jan15 The order of the agenda to be discussed at the next meeting. 20Feb15 Chair 23Jan15 Jammi Rao to ask Les Lawrence to Chair the next meeting. 20Feb15 JR Date of Minutes Actions from Previous Meetings Target Date Owner

24Nov14 Hazel Gunter to review Mandatory Training Compliance and bring back to the 23Jan15 meeting. COMPLETE HG

24Nov14 Richard Brown to revise CQC IMR and bring back. COMPLETE RWB 24Nov14 Internal Audit Reports to be brought back. COMPLETE SH/CR/SF 29Sep14 IV Guidelines - SF to check current practice and guidelines. Ongoing SF

29Sep14 Proposal to Create Patient and Staff Experience Sub Committee - Patient safety aspects. LL agreed to own risk. 23Jan15 LL

29Sep14 SUI Action Plan - CR meeting with Arne Rose to discuss T&O job planning. Ongoing CR

29Sep14 Q1 Complaints report - present Q2 report at November meeting. Ongoing RWB 29Sep14 Stakeholder SOL CCU/HDU - update on current position. 20Feb15 MC/RP 29Sep14 Consent Policy - modifications to be brought back to the Committee. 20Feb15 MC 29Sep14 Safety Campaign to be brought back. On Hold SF

28Jul14 It was agreed to invite Philip Bright to the group as a core member - to be included in the ToRs. Ongoing AK

28Jul14 A draft set of ToRs to come to the November meeting. On Hold LR

28Jul14 New site based SitRep as outlined. Bring back to next meeting. Plan to integrate governance report. 24Nov14 LR

28Jul14 ToRs for SIRUS - booked to happen on 9th October - Agenda item. Ongoing AK/LR 28Jul14 T&O Responsive Walkabout - Agenda item. 29Sep14 AK/CR 28Jul14 CQC IMR report to become a standing agenda item. Monthly RAB/AJC

28Jul14 AK to speak to KPMG about raising concerns about risks by September meeting. Take to Deloitte's. COMPLETE AK

02Jun14 LR to bring the revised Clinical Audit strategy and dashboard back to the meeting once they have been through CSC and Q&R. To come to November meeting.

Ongoing LR

31Mar14 LT to bring data on diabetes+ nursing indicator. To come to September meeting. Rib indicators - trying to understand. SF to discuss part of her paper.

Ongoing LT

31Mar14 LR to produce a new report which combines CSC minutes and the audit and effectiveness dashboard and to include highlights of recently published National Audit reports. To come to future meeting.

Ongoing LR



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These minutes were approved at the Quality & Risk Committee meeting of Friday 13th March 2015

MINUTES of a meeting of the QUALITY AND RISK COMMITTEE

of Heart of England NHS Foundation Trust held in the Boardroom, Devon House, Birmingham Heartlands Hospital

on Friday 20th February 2015 at 9.00am

Present LAWRENCE, Les Chairman (Chair) LL BLACKBURN, Rachael Head of Corporate Risk and Compliance RAB BROWN, Richard Programme Director & Deputy Director of Patient

Experience RWB

CATTO, Andrew Executive Medical Director & Interim Deputy Chief Executive

AJC

COOKE, Matthew Deputy Medical Director, Strategy and Transformation MC KEOGH, Ann Director of Medical Safety AK POLSON, Rex Associate Medical Director, SOL RP RAGHURAMAN,

Govindan Associate Medical Director, BHH GR

RUDD, Louise Head of Clinical Governance LR RYDER, Clive Deputy Medical Director, Clinical Performance &

Effectiveness CR

In Attendance

BELL, Kath Public Governor KB

HYLAND, Sue Deputy Chief Nurse SH Minutes HIGGINS, Vickie Executive Assistant VH

ITEM:-

1. Apologies Apologies were received from Philip Bright, Patrick Cadigan, Sam Foster (represented today by Sue Hyland), Hazel Gunter, Angeline Jones, Adedeji Okubadejo, Jammi Rao, Lisa Richards-Everton, Liz Steventon (represented today by Kath Bell) and Lisa Thomson. 2. Draft Minutes

AK apologised for the lateness of the papers this month. A revised version of the Jan15 minutes would be recirculated shortly. In future, the Action Log would be sent out approximately one week after the meeting and the Draft Minutes approximately two weeks after, with the final version agreed at the next meeting.

3. Actions Arising

See point 2. above.

SAFETY:-

4. Safety SitRep

The report (Enc4) was taken as read and presented by Louise Rudd, with the following key points discussed:- LR advised of one new operational risk in relation to the implications of Solihull CCG Effectiveness


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Review Group. Discussion occurred around the length of time some of the red risks had remained on the risk register. SH asked about the Trust’s tolerance to risks and around timescales to close down or respond and LR advised there were no defined timescales. The risks were followed up and for some of these further work was being undertaken to review if any impact on clinical outcomes. SH asked if the Committee just accepted the risks and CR felt processes were not lithe enough and suggested, for example, Radiotherapy and Maternity should come to this Committee to explain why. RAB advised they hold Friday weekly Risk Review Meetings and that CR and SH would be attending in future. RAB felt they could not prescribe how long a risk should be on the Risk Register but it was often too long, possibly due to a lack of governance. They are escalated here but not challenged or scrutinised. There were many issues in the register rather than true risks. She also informed the committee that SIRIUS had not met yet and this was a concern as this was a potential group for scrutiny and looking at governance. First meeting is in March. LL agreed it showed how “broke” the structure was and this was part of operational procedures. CR felt there were issues in the Women’s and Children’s Directorate - ie. identifying the need for ultrasound in pregnancy and Saturday lists. LR advised, at the time of writing the report, there were no new SUIs this month however there had been 3 new SUIs reported since including one in relation to a mortuary incident and wrong identification and AK advised this and two other SUIs would be detailed in the next SITREP. AK advised there were mortality data issues around PMS2 and the inputting of data of incorrect type of admission (elective or emergency) which meant that HSMR was unreliable. There had been a marked spike across the country in congestion within ED departments and a spike in flu in the community. The congestion and flu spike were associated with a marked spike in number of deaths peaking at the end of December. There had been a decline in numbers over January and February. HSMR was still being published by Dr Foster showing HEFT with a good position but need to be interpreted with caution. She had recently met with Dr Foster to discuss the data, look at areas of possible spikes and an option appraisal for rectification of the data. Case note review was currently being undertaken to look at four diagnoses and emergency surgery admissions for improvement using the weekly death data. LL asked about the learning from the recently closed subdural haematoma risk following the inquest of 5th February 2015. LR advised it was closed as the recommendations had been issued and an Action Plan agreed. The issue was not yet remedied and LL felt it should be made clear what “closed” means, as it was not always the end of the issue. 5. Delivery Unit Report

The report (Enc 5) was taken as read and presented by Clive Ryder, with the following key points discussed:- CR advised the report was covering December period and would be circulated to all Sites and Directorates during February. CR advised there had been a scoping of the 18 week rectification plan, which found - (1) The cancellation of operations was around overcrowding. There was a new exit strategy for GHH day case unit with no tolerance of cancellations but there had been no beds at GHH the previous night, so there



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was still some congestion. (2) A number of endoscopy patients should have been on the waiting list but were not due to (a) capacity issues in endoscopy, referral rates despite 14 extra lists plus (b) issues around the booking system. CR discussed cancer pathways, 62-day targets and what they were doing to address the A&E four hour targets. There was a heightened resilience plan involving senior clinical leaderships (Gold) and onsite Silver Commands in place to manage and coordinate flow and capacity. They had looked at the ambulatory care units at BHH and GHH, increased AMU capacity at BHH and increased general medical staff in ED, enhanced consultant presence and an acute medicine pathway, extra shifts in ED, an Elderly Consultant at the front door of both EDs, changes to Trauma at BHH, safe staffing for flex cover and discharge support at all three sites. AJC advised he had met with the CCG yesterday and had plotted our four hour performance. He advised that compared with other Trusts our performance had not deteriorated as much as other Trusts had except for the dip to 70% 4 hours waits. Our figures were now up to the pre-dip figure of 89/90% and, therefore, virtually recovered to pre-crisis levels. CR advised of long-term lessons - ie. bed modelling at all three sites, which was the responsibility of the Finance & Performance Committee and the sites themselves via the UCIB or Site Delivery Unit. There was to be a single strategy for bed modelling, covering both acute and surgical. LL advised the numbers through the front door were now at the heightened norm and we were back to where we were. CR advised bed modelling was required to look at how the surgical activity could be protected during peak medical activity. AJC advised there was a UCIB yesterday, with conversations around a SOL pilot for three wards. Ward 8 had been effective, with nurses and doctors being highly engaged. They were going “back to basics” with support staff at ward level, looking at the ward journey and not just the discharge. This was highly complex and wards needed to be targeted with focused help. There are a lot of wards within the Trust, so this was a huge task but there was a lot of energy and enthusiasm. They were working with existing senior leaderships - ie. Arne Rose and Govindan Raghuraman - to support discharges and sites needed to look at developing Discharge Champions. Rex Polson advised Khaled Elfandi was also helping. AJC felt HEFT was not unusual but was not doing the ward journey well enough and should be focused on supporting ward teams. LL advised of discussions at Board level around surgical and medical beds or an emergency centre at BHH with more capacity at SOL and GHH for planned surgery. CR suggested looking at bed modelling and redesigning pathways. There had been big changes in the last few years, with an increase in the frail and the elderly coming into ED, which was why we were not performing - there were more appropriate pathways. AJC suggested looking at ward pathways - ie. nursing has good ideas around the use of Matrons and SOL were trying to fit a dependency-based model for specialities. Patient movement was huge and it was important that patients get to the right bed. Further discussion led by CR around different sized wards and using dependency rather than specialty forward criteria and would appear the sensible way forward. LL asked if the Trust Board had been asked to make a decision on this and CR advised it had gone to Trust Board and, operationally, could be ready before the next winter. A suite of strategies would be available by the Autumn. LL also raised issues around safe care and corridor nursing as it was recognised that the EDs were not big enough, particularly at BHH. CR felt we were very good at using corridors but need to learn from lessons of the past. In reality, we needed a bigger ED and to use our facilities properly. Patients were here far longer than necessary



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but we see twice as many patients here, so we should redesign our pathways, and we had bigger specialties too.SH recently visited A&E at BHH and asked if it was safe - ie. patients in the A&E corridor for eight hours was not desirable but there were lots of factors. The Committee discussed full-time locums covering all three sites and CR felt it was not enough. They should look at what they were currently doing, what they should be doing and what was missing. RP advised of a similar issue in AMU at SOL - safe but not quality care. CR advised they were targeting and meeting two-week pathways, there were issues with non-suspicious cancers/endoscopies but these were around capacity issues, and falls and pressure ulcers were being picked up by the site teams and of no major concern - GHH was worse but was good for falls, with BHH the other way around. Reminders had been sent to ensure appraisals were done as the target was drifting. Sickness was variable - ie. Women’s and Children’s at GHH and BHH were being addressed. The 3 top concerns for sites and divisions had similar themes around four hour targets, patient flow and surgical cancellations. All needed to be addressed and conflict between site/directorate was causing issues and clarity was required around how teams work to address the issues in current structures. LL advised Andrew Foster was also concerned. SH advised of nurse staffing concerns with an extra 117 beds open across the three sites. The recruitment position was also of concern but was on the Risk Register for each site. Flex was still up at the three sites but was being monitored three or more times a day. Recruitment was not successful and just covering attrition but they would be approaching the universities shortly and asked the Committee to recognise the current demands. There was a discussion on flex areas across the three sites. LL suggested looking at bed modelling, so flex may not be necessary and SH advised of the closure of wards. CR felt bed modelling was wrong a few years ago and SH agreed bed modelling was the key. AK felt the report was now out of date and suggested working with Finance & Performance so it came here before Trust Board but there would be tight deadlines. LL advised it would then go to the Council of Governors and Monitor by the 18th of the month. CR agreed it would be a month in arrears and LL felt the Committee should now be discussing Jan15. CR agreed, describing it as an evolving process. RAB felt there were lots of risks but she was not confident that these were being captured on the Risk Register - ie. the endoscopy bowel cancer screening programme. AK advised this had only just come to light and CR advised of issues with JAG at BHH, where demand out-stripped capacity with an increase in waiting times and thus backlog and we were at risk of a temporary suspension and losing accreditation. This was also in relation to environmental issues. LL asked what was being done and GR advised there had been an increase in capacity but there was not enough space. A Business Case had been put forward and they were recruiting nurses but they needed to control demand. CR advised we were hugely reliant on GPs identifying cancers but screening was not easily available. RAB asked how serious this was and CR advised screening endoscopy meant around £28k per year. There were also issues around the quality of the environment, which affected the JAG accreditation. GR advised there were just 4 Endoscopists at BHH, 4 at GHH and 3 SOL, so the service was stretched. RP advised this was flagged to the Trust many times and was also a national issue, with training issues too.GR advised there were 14 other Trusts in a similar position and CR advised they were speaking with Vanguard. Action : LL suggested an urgent request be sent to AF and AJC that this issue be included in the March 2015 Delivery Unit Report, as well as the Risk Register and Safety SitRep.

6. Incident Report Policy

The papers (Enc6a, 6b and 6c) were taken as read and presented by Louise Rudd.



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LR advised this had taken some time and was to realign to the national framework using the national definitions. The policy had been combined with the SI policy and this was straight forward - the challenge was how to apply it. There had been lots of important feedback from the consultation and they had met with various people - some very clear and vocal - and these were summarised in the attachment. Many issues identified were in relation to awareness, capability and difficulty of the timeliness and resource to deliver the process. A total of eight actions had been put into one strong mandate for example - 24-72 hours to arrange the first Round Table. It was hoped that this would be a Trust-wide mandate. However, it would sometimes be impossible. Completing root cause analysis was another big issue and required a lot of support. For SUIs another problem was independent scrutiny requiring an individual lead with Directorate involvement. They also discussed the complexity of the process around RCAs. There were lots of experts but some people required guidance and as a result they would increase training. There would be an Action Plan from each to look at trends and themes of incidents to learn from incidents. CR supported this approach but advised they should make it as easy as possible for the Clinicians. It would be difficult to get all of the right people together in the same room at the same time - ie. doctors and nurses - and taking two hours out would always be difficult, so good will would be required to provide the local cross cover to enable this to happen. LR advised this had come to this Committee for approval of the policy with an agreement for Executive support for the actions. LL agreed the Committee could ratify the policy but had no further jurisdiction and would refer it to EMB to consider financial implications of proper implementation. Action : LR to present at EMB.

7. Consent Policy and Implementation Plan

The papers (Enc7a, 7b and 7c) were taken as read and presented by Matthew Cooke, who advised this policy came before Christmas but had now been circulated wider. Changes were minor - ie. wording rather than principles- and asked:- 1. To gain approval for the new Consent & Lawful Treatment Policy.

2. To update the Committee on planned dissemination and monitoring. There were now two versions

of the video - a short version and a longer, more legalistic, version plus a leaflet for all staff.

3. To propose, to the Committee, a review of the designated Consent Policy.

4. There would be self-assessment undertaken against the new CQC regulations staring in Apr15.

5. To receive a monitoring plan at future Q&R meeting. LL asked when the five recommendations would be finalised and MC advised around 3 months’ time. AK asked about the video shown during induction and asked who would be supporting the questions and answers.MC advised there were no resources at present, so this would need to be discussed. RP asked if withdrawn consent was included and MC advised it was. LL suggested the financial considerations need to go via EMB and Darren Cattell to be properly resourced as an important policy.MC advised they would also keep an eye on the law around changes so the policy may come to this Committee more often. LL advised the Committee agreed to the above recommendations.

8. DIPC Report

The report (Enc8) was taken as read and presented for assurance by Sue Hyland on behalf of Peter



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Hawkey, with the following key points discussed:- MRSA Bacteraemias : There were 7 pre-48hour bacteraemias - 3 of which were currently being

considered at arbitration. If not allocated to HEFT, MRSA Bacteraemia free days were 352 for BHH, 487for GHH and 1,032 for SOL. Sites were now zero tolerance and there were issues in Ward 12 and Renal at BHH around the insertion of lines. In relation to screening one issue has been noted that busy clinical staff were having difficulty in identifying previously screened positive patients although these alerts were on iCare. ICT to review. Clinicians are to ensure all patients are screened and we are currently at 90%.

C Diff Toxin Results : There were 14 post-48 hour positive cases against a threshold of 19 for Q3.

HEFT had a positive rate of 16/100,000 bed days out of the 10 Midlands Trusts (range 9/ to 24/100,000 bed days). Issues on Ward 4 at BHH with 2 cases which were sporadic and possibly around antibiotic prescribing.

Carbapenemase-Producing Enterobacteriaceae : EMB had approved the screening policy, which will be introduced at the end of January, subject to staffing. The policy includes patients who have received medical treatment overseas and will be placed in a side room. A number of people had come through the system - ie. from Manchester in the North West.

Ebola : The Ebola Action Group met weekly. No confirmed cases had been identified since Dec14. One possible case was a returning Healthcare Worker but tests were negative. A full debrief had been done and will be reported on next Quarter. They will continue to meet and monitor.

Influenza : At the beginning of December, a local spike was noted in the West Midlands. A vaccination programme for unvaccinated staff and long-stay patients was carried out, with good results (to 75%). LL advised the issue of vaccination came up February/March each year against H3N2 and suggested discussions were held now for next winter.

Action : SH will discuss with Gill Abbott and Peter Hawkey. SH advised the Salmonella investigation had been produced by Eric Bolton, which included lessons to be learnt. Action : AK will bring Professor Bolton’s report back to the next meeting.

9. Patient Safety Walkabouts

The papers (Enc9a to 9e), covering the Q3 Patient Safety Walkabouts, were taken as read and presented by Ann Keogh, with the following key points discussed:- AK advised these reports were slightly in arrears due to the follow-up meeting taking place six weeks after a Walkabout. There had been four during Q3 - two were cancelled due to no EDs or NEDs available and one as AK was off sick. At 13 Walkabouts, we were below the CQUIN target of 20 for the year. Therefore, an extra two have been arranged for Q4 to take us to 20. A few of the NEDs have also been asked to attend to fulfil the CQUIN requirement of all Board members undertaking at least one Walkabout during 14/15. AK continues to enjoy these Walkabouts. They listen to staff and look at what works well and what is of concern, as well as the more positive aspects, such as the pride in the care they provide. The Executive Team does not go pre-armed with knowledge of incidents/complaints data. The GHH ED Walkabout, where morale was low before, was now very positive after some recent changes, including using less agency staff. Concerns in Gynaecology’s Ward 2 at GHH were raised at the time in relation to building works and the issues were escalated and actioned upon - ie. fixing the lock to the Treatment Room, decorator’s step ladder was leaned against an open fire door. Staff were now aware of how to facilitate and escalate issues - showing the value of Patient Safety Walkabouts.



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PATIENT EXPERIENCE:-

10. Q3 Complaints Report

The report (Enc10) was taken as read and presented by Richard Brown, with the following key points discussed:- • The overall number of complaints had reduced in quarter from the previous quarter and themes

were the same.

• Delays and cancellations remain the highest reason but there was a decrease in Q3.

• Attitude and behaviours (particularly of Doctors and Nurses) was the second highest reason.

• BHH remains the area with the highest number of complaints but was the largest site. To put it into context, there were just 25 per 1,000 patients which is low. They were revisiting site team reporting.

• Improvements in Governance were required to ensure information was shared and actions addressing key themes.

• The Complaints Review was underway but it had been difficult to get engagement due to increased operational pressures.

• They had established a weekly Complaints Review Meeting. There was a lot of work to be done -

ie. issues around complaints which are also Coroner’s cases not being responded to in a timely manner.

• Complaints were now part of the Integrated Governance Report, meaning better engagement with the Sites. The Patient Experience Committee was mapping all Committees, which should be complete by the end of March/beginning of April, with better reporting in place. Compliance with timeframes was currently around 47% but one case was extremely complex at 200+ days. Some were far quicker and some much longer - one standard was impossible.

LL asked if the review would go to EMB, when complete, for consideration or Trust Board and RWB advised it would go to EMB and would come to this Committee for assurance. LL agreed it was not necessary to go to Trust Board as it was an operational issue - the Integrated Governance Report would be sufficient. GR advised, for a complaints response, a face-to-face interview made a big difference, rather than hiding behind paper and letters. This should be the first thing done - ie. talking to patients. CR agreed there were misunderstandings and staff could become defensive and issues were only escalated when they did not work well. This was often due to poor communication. If handled badly, it was the patient and their family that suffered. They should try the informal approach but it must be owned by the Team as the Consultant was always the clear target. KB asked if they already did face-to-face meetings and RWB confirmed this was patchy. Some Directorates owned their own complaints but this had revealed lots of issues and they cannot always support the Divisions. They need to agree the best way to handle complaints for the whole organisation and set the standards. RAB asked for clearer definition as to what “maladministration” covered as a subcategory of complaint as it was assumed that this was different to the maladministration term used by PHSO. Action : RWB to confirm definition of maladministration. RWB confirmed they now have the policy and it can be circulated. LL suggested it be submitted to



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EMBs and the relevant Governance Committee. It required a framework to be in place across the whole Trust via the individual Directorates.

CLINICAL EFFECTIVENESS:-

11. Audit and Effectiveness Update

The papers (Enc11a to 11d) were tabled and presented by Louise Rudd, with the following key points discussed:- LR advised this was a high level paper submitted for its background. It had been a varied journey, trying to engage people in Clinical Audit and it had been an interesting process. It needed to be done face-to-face and they had recently discussed 4 national audits at the committee meeting during the last few months and it had worked extremely well. There were new HQUIP guidelines “Audit of national Audits” to inform priorities for national audits and also “Clinical Audit: A Guide for NHS Boards and Partners” which places clinical audit within the broader context of quality improvement. CR asked if an audit was not being done, what was happening. It was also felt that although audits were important they were not the “be all and end all” and should lead to overall improvement or assurance of a position at a particular moment in time, not just data collection. Action : LR to bring an update from the next Clinical Standards Committee. REGULATORY/CONTRACTUAL:-

12. Internal Audit Tracker and Update on Quality Governance The papers (Enc12a, 12b and 12c) were taken as read and, as Angelina Jones was not in attendance, presented by Ann Keogh, who advised this would be a regular paper, which came here if there were any quality aspects to look at how they were taken forward. Action : AK to discuss with Jammi Rao and Angeline Jones how this is fed into this Committee and also check the committee Terms of Reference. 13. Update on EAG and Committee Mapping RWB recapped the discussions at the last meeting about whether the EAG was necessary. SF had also asked them to map all Committees within the organisation and they had identified, so far, 86 different Committees, Groups and Sub Committees and were not finished yet. They had looked at Site/Division level and the next layer was Directorate level using Terms of References from the other committees. If all meetings identified so far took place, there would be around 800 meetings per year, which was a significant number. It would appear that there were lots of groups with little or no consistency and some lacked Terms of Reference. This was a huge task and, when finished, will go to EMB or Trust Board. LL asked about timescales and RWB advised most would be done by mid-March as they were now down to Directorate level. GR suggested they look at how they would like it to look, then work backwards from there but RWB felt there were different architectures, flowing from the ward to Board and either way could be right. There were some gaps already identified such as around patient experience agenda. LR felt there were lots of Committees with small functions but some had to exist for some reason and there was merit in capturing what was done and what was important - maybe around 80% needed to



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be realigned and 20% protected and kept. AK felt some could get missed - ie. SMPG was a valuable Committee raising concerns around medicines. ANY OTHER BUSINESS:-

14. Future Agendas AK advised, as this meeting was now monthly, and there had been requests for greater discussion on a number of papers on the agenda. The committee agreed that the volume appeared to be correct today but the Terms of Reference were still on hold due to the mapping and other changes.SH agreed it was a larger agenda before and this was more manageable. The Delivery Unit Report debate had been good but slightly long as there needed to be more discussion around risks, as this was an Assurance Committee. CR agreed the Delivery Unit Report did take some time this time but it had not been reported on before in detail and some of the risks were not always highlighted, so it should be shorter next time. LL advised attendance should be mandatory as this was an Assurance Committee and it should be in the diary. Action : AK agreed to recirculate the current Terms of Reference. AK, CR and JR will then meet outside of this Committee to discuss. AK asked if the meeting should be followed by lunch and LL suggested this was for JR to decide.

NEXT MEETING:-

15. Next Meeting Friday 13th March at 9.00am in the Boardroom, Devon House, Birmingham Heartlands Hospital.



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Date of Minutes Actions from February 2015 Meeting Target Date Owner

20Feb15 Les Lawrence asked for an urgent response to be sent to Andrew Foster and Andrew Catto re. the endoscopy risk being included in the March 2015 Delivery Unit Report, the Risk Register and the Safety SitRep.

ASAP CR

20Feb15 To be presented at EMB. ASAP LR 20Feb15 Sue Hyland to discuss yearly flu outbreak with Gill Abbott and

Peter Hawkey. ASAP SH

20Feb15 Ann Keogh to bring Professor Bolton’s Salmonella report back to the next meeting.

March 15 AK

20Feb 15

RWB to confirm definition of maladministration. March 15 RWB

20Feb15 LR to bring an update from the next Clinical Standards Committee.

March 15 LR

20Feb15 Ann Keogh to discuss Internal Audit Tracker with Jammi Rao and Angeline Jones.

ASAP AK

20Feb15 Ann Keogh to circulate the current Terms of Reference and then meet with Clive Ryder and Jammi Rao to discuss.

ASAP AK

Date of Minutes Actions from January 2015 Meeting Target Date Owner

23Jan15 Louise Rudd to update SitRep. Complete LR 23Jan15 Rachael Blackburn and Richard Brown to bring back mapping

of committees, Terms of Reference and revised proposal for EAG.

New date - April 2015

RAB/RWB

23Jan15 Hazel Gunter to review section in Workforce Compliance around sickness levels.

ASAP HG

23Jan15 Hazel Gunter to bring back assurance around the Mandatory Health & Training Report to the next meeting.

20Feb15 HG

23Jan15 Ann Keogh to provide LL and KS with a list of required attendees for the Patient Safety Walkabouts.

Complete AK

23Jan15 Les Lawrence to discuss out of hours refreshments with Finance & Performance.

ASAP LL

23Jan15 Sam Foster to send Vickie the wording for Section 17 - Internal Audit : Emergency Department.

ASAP SF

23Jan15 Sam Foster to send Vickie the wording for Section 18 - Internal Audit : Quality Impact Assessment.

ASAP SF

23Jan15 Kevin Smith to be invited to attend the next meeting presenting the paper on Information Governance.

ASAP KS

23Jan15 Safeguarding Report to be brought back when a representative is present.

ASAP TBC

23Jan15 The order of the agenda to be discussed at the next meeting. 20Feb15 Chair 23Jan15 Jammi Rao to ask Les Lawrence to Chair the next meeting.

Complete JR

Date of Minutes Actions from Earlier Meetings Target Date Owner

24Nov14 Hazel Gunter to review Mandatory Training Compliance and bring back to the 23Jan15 meeting.

COMPLETE HG

24Nov14 Richard Brown to revise CQC IMR and bring back. COMPLETE RWB 24Nov14 Internal Audit Reports to be brought back. COMPLETE SH/CR/S

F 29Sep14 IV Guidelines - SF to check current practice and guidelines. Ongoing SF 29Sep14 Proposal to Create Patient and Staff Experience Sub

Committee.

23Jan15 RWB



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29Sep14 SUI Action Plan - CR meeting with Arne Rose to discuss T&O job planning.

Ongoing CR

29Sep14 Q1 Complaints report - present Q2 report at November meeting.

COMPLETE RWB

29Sep14 Stakeholder SOL CCU/HDU - update on current position. 20Feb15 MC/RP 29Sep14 Consent Policy - modifications to be brought back to the

Committee. COMPLETE MC

29Sep14 Safety Campaign to be brought back. On Hold SF 28Jul14 It was agreed to invite Philip Bright to the group as a core

member - to be included in the ToRs. COMPLETE AK

28Jul14 A draft set of ToRs to come to the November meeting. On Hold LR Date of Minutes Actions from Earlier Meetings (Continued) Target Date Owner

28Jul14 New site based SitRep as outlined. Bring back to next meeting. Plan to integrate governance report.

24Nov14

LR

28Jul14 ToRs for SIRIUS - booked to happen on 9th October - Agenda item.

COMPLETE AK/LR

28Jul14 T&O Responsive Walkabout - Agenda item. COMPLETE AK/CR 28Jul14 CQC IMR report to become a standing agenda item. COMPLETE

and quarterly as report

comes out

RAB/AJC

28Jul14 AK to speak to KPMG about raising concerns about risks by September meeting. Take to Deloitte's.

COMPLETE AK

02Jun14 LR to bring the revised Clinical Audit strategy and dashboard back to the meeting once they have been through CSC and Q&R. To come to November meeting.

COMPLETE LR

31Mar14 LT to bring data on diabetes+ nursing indicator. To come to September meeting. Rib indicators - trying to understand. SF to discuss part of her paper.

Ongoing LT

31Mar14 LR to produce a new report which combines CSC minutes and the audit and effectiveness dashboard and to include highlights of recently published National Audit reports. To come to future meeting.

Closed LR



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Minutes of the People Development and Welfare Committee

30th January 2015

Attendees Apologies Richard Brown (RB) Bev Baker (BB) Dawn Chaplin (DC) Matthew Cooke (MC) Alex Covey (AC) Sue Hyland (SH) Sam Foster (SF) Claire Whittle (CW) Hazel Gunter (HG) Mike Kelly (MK) Karen Kneller (KK) Jammi Rao (JR) Laura Serrant (LS) Karen Sharp (KS) Lisa Thomson (LT) Bev Bellerby (minutes)

1. Apologies

Apologies were received by those shown above.

2. Working arrangements/rules of engagement and Final Terms of Reference

The name of the committee had changed to ‘Workforce Development and Welfare Committee’ which had been decided at the previous meeting. LS reminded everyone how meetings should be conducted; they should be open and transparent; items were discussed to improve service to patients and staff; everyone should be prepared to challenge and be respectful. The meeting would be focussed on outcomes. Papers would become public documents. LS would maintain the timing of meeting to use everyone’s time in the best way possible. Decisions may be made to change timings, during meetings. BB to add the conduct sheet to each set of minutes; David Locke had made some comments to add to the sheet. The document would be circulated to all members of the committee once David Locke’s comments had been added and all had discussed what they would like to include. HG to email out to all Action 1 The Terms of Reference had been drafted, agreed and sent to Trust Board. HG and LT would meet after the meeting to discuss slight amendments to the wording; they would not dramatically change the ToR. Action 2

Workforce and Development Committee


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SF questioned no. 8 around CQC – should be to receive assurance. No. 3 strategic aims should read ‘strategic and’. No. 9 Revalidation for doctors, to also include nurses and all clinical staff as required. One or two spelling mistakes needed to be updated and the document recirculating. SF asked what was needed to ensure things happened. No. 6 was a good point and was a good opportunity to streamline. HG, SF and LT to meet to discuss outside the meeting re external people to train staff etc. or staff coming in for fixed periods. Action 3 The committee agreed the content of the ToR and accepted them, excepting typographical errors.

3. Minutes of Last Meeting

All agreed that the minutes were an accurate representation of the previous meeting. The last paragraph on page 5 to be amended to remove the word ‘passionate. ’ Action 4

Action no.

Date

Item

Owner

Due Date

Progress/update

1

04.12.14

Share ways of working with other meeting Chairs, to illustrate best practice

HG

Immediate

Action complete. All staff to look at D Locke’s comments and feedback

2

04.12.14

Draft a plan re staff representation at the Welfare Committee meeting

HG and LT

Before Jan 2015 meeting

LT and HG talked about this. Still to meet with SF. Scoping staff councils at present and looking at work done by Staff Engagement Group. Still ongoing. LS asked for suggestions how it could be included in the committee.

3

04.12.14

Send out EDDG paper to all

RB

Before first EDDG meeting

Actioned – first meeting not yet happened.



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4

04.12.14

Send out E&D framework to all

RB

Immediate

Actioned and on agenda

5

04.12.14

Send out EDS2 ToR and framework

RB

Immediate

Actioned and on agenda.

6

04.12.14

Send information on the values and purpose of SEG to HG (work in progress)

LT

Immediate

Actioned. Also on agenda

7

04.12.14

Give LS a briefing note before she sees radiology member of staff

HG and LT

Before radiology meeting

Actioned

4. Cultural-related Deloitte recommendations and additional observations, including 90–day plan and proposal from WWL

LT gave the committee an update on the 90-day plan, being put together for Monitor, of which staff engagement was a large component. She asked the committee to talk about the plan and look at the timeframe. WWL would be starting work on that area, once Andrew Foster was in post. WWL proposal had already been agreed at REM committee. HG added that the 90-day plan had been done for Monitor and she and LT were also working on the Deloitte report. The plan would go to EMB and was created to inform the workforce. There had been much work done to capture everything on one document. LT wanted to be able to give the committee a high level of detail and a thorough overview. A year’s worth of data and feedback had been used to decide which 3 were looked at. The Trust was looking to develop leadership, encourage staff engagement and introduce Wigan’s work. LS asked if Governors were included in the engagement. LT said not in its purest form but the Trust did rely on Governors and CHC to go out and talk to staff to triangulate the work that was already being done. LS was keen for Governors to be more involved. LT to amend. Action 5



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WWL staff were keen to see what HEFT did well. SF suggesting telling them about Governors and LS agreed that it would be beneficial going forward. When the 90-day plan was written Andrew Foster had not been confirmed as the new CEO. Staff Engagement and Staff Councils would continue long after the 90 day period had ended.

JR asked about WWL’s proposal. HG and AC were to meet with WWL on Friday 6th February. When WWL had HEFT’s progress, they may change their plans accordingly as a lot of work had already been done, especially around engagement. The plan would change over time, based on HEFT’s ongoing work and commitment.

LS asked for the progress for the next Welfare meeting to show where everything was aligned. HG/AC/LT Action 5

LS was keen to keep an eye on ‘end dates’. Nick Varney provided some Project Management support but HG had asked for more people to be involved. The culture plan and leadership plans would take a lot of resource to roll out.

LT advised that the Workforce Development Committee was the first one to correlate all of the actions in one place. Culture and engagement needed its own work stream. LS suggested bringing ideas to the committee around what was required, regarding staffing. RB asked what happened around the big action plan as it partially sat inside Governance but not wholly. Everyone needed to know that their work was on track. The right people needed to be at the right meetings. The committee could not keep all of the actions on track and everyone needed to know what sat underneath the committee to support everything adequately. RB and Rachael Blackburn would be looking at the Governance around the work streams to avoid setting up unnecessary committees.

LS wanted to advise the committee that the NHS 5-year forward view points for action had come out. 2 parts related to the ToR of the committee. ‘The forward view into action planning for 2015/16’. Page 6 – paragraph 2.7. Page 8, para 2.15 and 2.18. Identifying and supporting carers, by working with GP surgeries – especially young carers and older carers. NHS employers were to lead the way about the race equality standard and Boards to examine themselves against that standard. LS would send document to BB to send out with the minutes. Action 6

LT would map against the actions to identify gaps and they could also be mapped against the Kennedy work; the information would be ready for the next meeting. Action 7

DC added that the Carers Forum could also feed in.



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LS wanted to ensure that everyone looked at the whole workforce, not just clinical staff.

HG advised that there was much work already ongoing regarding leadership. The plan was to commence developing Board/EMB/Top 200 staff. Elaine Tonks was doing work regarding Board Development. There was a need to capture what was already going on. EMB was a wider group, including senior deputies, etc. The top 200 staff were 8c or above and included senior medics. There would be meetings to find out what was expected regarding behaviours, competencies and skills. AC advised that once it was up and running, other groups would be included.

SF advised that there had been more focus on Band 7 sisters than lots of other staff groups, including very senior staff. Deloitte mentioned issues in senior leadership. LS was keen to be explicit that development covered clinical and non-clinical staff. SF added that there may not be much evidence about what had been done for non-clinical staff. AC advised that the group of staff that had been picked to start with has been focused on, deliberately and were working to an 18-month timescale. There would be a staggered roll out to other staff groups/grades and would go to EMB in February for sign up. A resource gap analysis would be done and would come to the committee for support. There would also be a new appraisal system where staff would be rated on ‘living the values’.

HEFT was a member of NHS Elect who had expert staff drawn from the NHS, such as clinicians, and much work had been done on patient experience. HEFT paid a licence fee but their service was free. SF worked with them previously regarding implementing nursing strategies and were very credible for Trust staff to use. Monitor had asked the Director of Operations if the Trust used NHS Elect, which had not been the case. The triumvirate from each of HEFT’s 3 sites were used to undertake an evaluation. AC was supporting the teams and, since meeting NHS Elect, they put a proposal forward that has been agreed by the EDs. Development of staff in their own teams would be rolled out. The effectiveness of the top teams affected the rest of the Trust’s everyday work.

5. Purpose and Values and National Staff Survey Update Staff gave feedback at recent drop in sessions regarding the Trust values which was fed back to EMB. Since then, AC’s team did some community drop in sessions where they took the Board values out and asked staff to rank the values and give descriptions of those values. 560 members of staff gave feedback at those sessions.



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AC advised that the Trust needed to decide what to do with the feedback. All members of workforce would use Q1 Friends and Family feedback. AC would check that Andrew Foster and his team were happy with that. The next F&F would be done from mid-Feb into March and the values were likely to roll out late in April. AC would feedback to either the next committee meeting or the one after that. An update would be available for the next meeting on 18th March. Action 8

Much thought would be going into those values and how they could be included in appraisals, etc. The most recent sample was very random but covered a wide range of staff. The original work missed out the junior doctors but all other staff groups were covered.

Work was ongoing regarding the national staff survey and the results were due around 11th February. The results are ‘un-weighted’ so could be mainly nurses that replied and very few other staff groups, for example. The overall engagement indicator would go down and remain in bottom 20%. Compared to the previous year, 10 improved, 10 decreased and 10 stayed the same but the data may not be significant and the results were likely to stay around the same, as a benchmark.

Wellbeing feedback identified that many people mentioned workplace stress, bullying, racial discrimination and all were worse than the previous year’s scores. One of AC’s team was working with Health and Wellbeing to see if the needs were being met. LS thought it was good to see what the group thought the next goal was and what activity was being undertaken to achieve that. AC would show the expected scores and what was likely to change. LS was keen to have a sense of how the Trust measured up internally, as well as externally.

SF had been in 4 recent committee meetings where the food provision for staff, patients, and carers had been mentioned. A quick win was needed to help towards wellbeing. HG suggested taking it to EMB or the next ED meeting to raise it with John Sellars. All agreed that it would be a good course of action. Action 9 JR added that the lack of food provision out of hours was always raised. Sometimes a small free item made staff very happy. No decisions were made regarding offering anything free of charge. KS suggested thinking about the right way to do it. LS suggested a trial of something practical and to see what other trusts did well and look what would work on all 3 of the sites at Heart of England. SF would do some preliminary work – Action 10



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6. Equality and Diversity EDS2 Update

RB had been looking at EDS2 for a few months to get an internal benchmark for the delivery system. RB was trying to work out what HEFT did and did not know. More work was required and most trusts would be at the developmental stage. It was hard to develop the evidence that certain groups had had positive outcomes. There were 9 protected groups that ideally would all excel. However, doing something incredibly well in one area, such as learning disability, would still be marked as undeveloped if other areas were not doing well. RB was not asking the committee for approval; he just wanted to note the categories. Some issues were easier to get evidence on than others. The requirement was for further engagement and RB was keen not to undersell the Trust, so was also working with Healthwatch, for confirm and challenge elements. AC advised that she had a product that selected data from the information she had already collected from staff FFT. Patients were not asked to provide certain types of information when they came into the Trust. There was good information on age, gender and ethnicity but not much else. Often the data that was collected was not used anywhere. EDS2 was designed for NHS and had very tight parameters but some trusts did achieve good results. Staff were not obliged to give the information and RB added that the Trust must show that it had made reasonable efforts to get this information. The Trust needed to improve its collection and usage of data, before looking into the sub-categories. LT added that staff said in the E&D section of the staff survey that they felt discriminated against whilst at work. It would be useful to know the background of those staff to see if there was any correlation.

SF commented that the Equality and Diversity Delivery Group may not be appropriate at this stage and that more of task and finish group should be set up to look at the specific actions needed. RB needed the group to be set up and have at least one meeting by the next Welfare Committee, with a basic plan of action. Action 11

7. Review of the Faculty of Education Update HG advised the meeting that it was a Review of Education rather than the Faculty. Lots of interviews have taken place since the review commenced in December 2014 and the review was due to finish in March 2015. Other educators had also been spoken to. Lots of documentation has been made available. The initial findings



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would come back to the committee, maybe as an additional draft. Kay Fawcett could attend the meeting so would be invited to the next one. Action 12

8. Any Other Business SF suggested DC to give an update on where the Trust was, regarding the Schwartz rounds. LS agreed that it could go on the agenda but under one of the regular headings, at the next meeting. Action 13 DC advised that a new interpreting service would be commencing soon, with appropriate communication and training. LS advised that the next CNO BME conference was arranged for 5th March 2015 at Heart of England. The conference would be partially funded and was a national platform. It was still at the planning stage but it would be good to invite staff and updates will be fed back to this committee. LS wanted to have a Governors’ standing item on the agenda which would be an open invitation. LT would help MK to put information together, if required. BB to put on the agenda Action 14

9. Items to roll on to the next meeting

There were no items to be rolled over to the next meeting.

10. Date of next meeting

Wednesday 18th March – 13:00-15:00 – Heartlands



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ACTION LOG Action No. Date Action Owner Date Due 1 30.01.15

Email amended conduct sheet to all attendees, including David Locke’s comments

HG Before next meeting

2 30.01.15 Meet to agree amendments to ToR and circulate to all attendees

HG/LT Before next meeting

3 30.01.15 Meet to discuss staff coming in to the Trust for fixed periods

SF/HG/LT Before next meeting

4 30.01.15 Amend last paragraph on page 5

BB Immediately

5 30.01.15 Add Governors to the 90-day plan and Deloitte engagement. Feedback to the meeting on progress of 90-day plan and Deloitte work

LT AC/HG/LT

Before next meeting At next meeting

6 30.01.15 Send BB document re NHS 5-year forward view points

LS Immediately

7 30.01.15 Map actions to identify gaps and also map against Kennedy work

LT Before next meeting

8 30.01.15 Feedback to meeting on Purpose and Values

AC At next meeting

9 30.01.15 Take issues re food provision to next EMB/ED meeting to raise with John Sellars

HG Before next meeting

10 30.01.15 Do preliminary work re food provision at other trusts

SF Before next meeting

11 30.01.15 Set up task and finish group to look at E&D and have a meeting before the next Workforce Development meeting

RB Before next meeting

12 30.01.15 Invite Kay Fawcett to next Workforce Development meeting

SF Immediately

13 30.01.15 Add item to agenda re Schwartz rounds, under one of the usual agenda headings

BB/LT Before next meeting

14 30.01.15 Add standing item to agenda re Governors’ Feedback

BB/LT Before next meeting


April 2015

Board of Directors

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Integrated Improvement Plan


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Category Number Metric Target Apr-14 May-14 Jun-14 Q1 Jul-14 Aug-14 Sep-14 Q2 Oct-14 Nov-14 Dec-14 Q3 Jan-15 Feb-15 Mar-15 Q4 2014/15 YTD30 31 30 91 31 31 30 92 31 30 31 92 31 28 31 90 365

Volume1 Average Number of A&E Attendances per day 689 689 726 701 667 689 726 694 667 712 703 694 667 763 703 709 676

2 Average Number of Scheduled Operations performed per working day

106 108 105 107 105 100 103 103 102 106 98 105 90 101 95 93

3 Average Number of Outpatients Appointments completed per working day

3834 3852 3836 3841 3644 3474 3653 3595 3656 3828 3489 3655 3805 3733 2453 3385

20 20 21 61 23 20 22 65 23 20 21 64 21 20 22 63 253

Volume

Number & Percentage of Inpatients discharges with a LOS of over 14 days

Emergency

Flow 4

710 738 681 2129 698 647 694 2039 756 689 714 2159 819 713 681 2213 8540

6.25% 6.32% 6.20% 6.26% 5.67% 5.56% 6.16% 5.79% 6.50% 6.29% 6.43% 6.41% 7.46% 7.10% 6.58% 7.05% 6.36%

1157 1551 1838 4546 1734 1228 2671 5633 2764 2094 3920 8778 3261 3126 3407 9794 28751

28.26% 31.40% 31.23% 30.53% 29.99% 29.15% 28.15% 28.94% 28.58% 26.89% 29.90% 28.77% 28.83% 31.38% 33.99% 31.44% 29.99%


Total ED 4 hour breaches & percentage of these that were non-admittedEmerge

ncy Flo

w

Efficiency

4

5

6 Percentage of Theatre Sessions time Used 84.75% 84.48% 85.10% 83.87% 85.62% 85.16% 87.17% 84.95% 82.26% 83.97% 84.86% 84.77%

7 Number of Cancelled Operations on the Day 73 60 78 211 89 108 93 290 89 67 127 283 164 121 285 1069

8 Average Length of Stay 6.62 6.82 6.79 6.75 6.67 6.72 6.84 6.74 7.29 7.16 7.15 7.20 7.68 7.41 7.55 7.01

9 Number of Cancelled Outpatient Appointments TBC

Staffin

g

Efficiency

10 Quarterly Staff Engagement TBC

11 Sickness - in month position, YTD = MAA (mia) 4.08% 4.11% 4.47% 4.62% 4.43% 5.12% 5.12% 5.21% 5.29% 4.98% mia 4.70%

12 Voluntary Staff Turnover 9.47% 9.34% 9.16% 9.16% 9.02% 9.08% 8.80% 8.80% 8.90% 9.34% 9.02% 9.02% 9.02% 9.02% 9.02% 9.02%

13 Number of Vacancies, analysed between Main Categories

TBC

Scheduled Fl

ow

Staffin

g

14 Patients treated within 18 weeks on admitted RTT pathway

>90% 81.44% 86.82% 82.99% 80.93% 82.32% 79.34% 77.62%

15 Number of 2 Week Cancer Waiting list - median waiting times (days)

14 14 14 13 13 13 11 13 12 10 11

16 Number of specialties Failing RTT Admitted Pathway Target

7 5 5 8 6 9 8

Quality

Scheduled Fl

ow

17 Number of Complaints - Open Incidents

18 Number of SUI's

19 A&E from Patient Feedback (Family & Friends) - Positive Promoters

74.60% 73.40% 73.46% 73.82% 74.26% 75.25% 70.01% 73.19% 73.35% 75.67% 72.99% 73.97% 77.25% 76.14% 76.66% 74.20%

258 237 238 733 260 211 241 712 249 237 353 839 382 256 638 3137

2.27% 2.03% 2.17% 2.15% 2.11% 1.81% 2.14% 2.02% 2.14% 2.16% 3.18% 2.49% 3.48% 2.55% 2.03% 2.34%20 Number & Percentage of Total Trust emergency

adult deaths

Quality

Proposed 20 Metrics


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Category Number Metric

Volume

Definitions

The total average daily number of A&E attendances at the Trust (Heartlands, Good Hope and Solihull)1 Average Number of A&E Attendances per day

Volume

The total average daily number of A&E attendances at the Trust (Heartlands, Good Hope and Solihull)

Number of cases in Elective & Day Case Theatres. Shown as an average per working day.2 Average Number of Scheduled Operations performed per working dayVolume

Number of cases in Elective & Day Case Theatres. Shown as an average per working day.

Number of Outpatient attendances. Shown as an average per working day3 Average Number of Outpatients Appointments completed per working day

Volume

Emergency

Flow 4


Number of Outpatient attendances. Shown as an average per working day

Total number of patients discharged after 14 days or more, and the % of these of the total patients discharged (in month, 16 yrs +, all except day cases)

Emergency

Flow 4



Emergency

Flow 4


5Total ED 4 hour breaches & percentage of these that

were non-admitted


Total number of patients who spent 4 Hrs+ in A&E Emerge

ncy Flo

w


were non-admitted

Total number of patients who spent 4 Hrs+ in A&E

The % of A&E 4 hour breaches that are discharged home (as a proportion of the total number of breaches)Emerge

ncy Flo

w


were non-admitted

Efficiency

TBC

The % of A&E 4 hour breaches that are discharged home (as a proportion of the total number of breaches)

6 Percentage of Theatre Sessions time Used

Efficiency Total number of hospital-led operations cancelled on the day

TBC

7 Number of Cancelled Operations on the Day

Efficiency Total number of hospital-led operations cancelled on the day

The average (mean) length of spell (admission to discharge) of all patients discharged from Adult Wards. Excludes Maternity and Paediatrics8 Average Length of StayEfficiency

The average (mean) length of spell (admission to discharge) of all patients discharged from Adult Wards. Excludes Maternity and Paediatrics

9 Number of Cancelled Outpatient Appointments

Efficiency

Staffin

g

10 Quarterly Staff Engagement

Staffin

gIn month sickness reported, YTD position is a Monthly Moving Average (MAA) based on previous months. Sickness data is one month in arrears

(MIA)11 Sickness - in month position, YTD = MAA (mia)

Staffin

gIn month sickness reported, YTD position is a Monthly Moving Average (MAA) based on previous months. Sickness data is one month in arrears

(MIA)

Staff Turnover12 Voluntary Staff Turnover Staffin

g

Staff Turnover

13 Number of Vacancies, analysed between Main Categories

Staffin

g

Scheduled Fl

owPercentage of patients treated in month, seen within 18 weeks on the admitted RTT pathway. 14 Patients treated within 18 weeks on admitted RTT

pathway

Scheduled Fl

owPercentage of patients treated in month, seen within 18 weeks on the admitted RTT pathway.

In month, median waiting time for 2 week cancer patients15 Number of 2 Week Cancer Waiting list - median waiting times (days)

Scheduled Fl

ow

In month, median waiting time for 2 week cancer patients

In month, number of specialties who failed the 90% target of patients on Admitted pathway16 Number of specialties Failing RTT Admitted Pathway Target

Scheduled Fl

ow

Quality

Number of Overdue Complaints received in month

In month, number of specialties who failed the 90% target of patients on Admitted pathway

17 Number of Complaints - Open Incidents

Quality

Number of Overdue Complaints received in month

Number of Serious Untoward Incidents (SUI's) in month18 Number of SUI's

QualityNumber of Serious Untoward Incidents (SUI's) in month

(Number of responses which were positive (i.e. Extremely likely and Likely)/ total number of responses) - based on A&E FFT only19A&E from Patient Feedback (Family & Friends) -

Positive Promoters

Total number of patients who died as a proportion of the total patients discharged (16 yrs +, Emergency and Elective patients only)

Quality

(Number of responses which were positive (i.e. Extremely likely and Likely)/ total number of responses) - based on A&E FFT only

20Number & Percentage of Total Trust emergency adult

deathsTotal number of patients who died as a proportion of the total patients discharged (16 yrs +, Emergency and Elective patients only)

Quality

Metrics - Definitions



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01/04/2015

ProgrammeExecutive Lead

Operational/ Delivery lead

Workstream MetricHighlight Report

Last UpdatedRed Amber Green

KPI Last Updated

Red KPIs

Amber KPIs

Green KPIs

MeasureKPI Last Updated

Red KPIs

Amber KPIs

Green KPIs

GOVERNANCE RECOVERY

Quality Governance Framework

Compliance with QGF metrics 31/03/2015 0 0 1 0 0 0

Self assessment quessionnaire at baseline and at 6 monthly intervals

post implementation

1 2 1

GOVERNANCE RECOVERY

Board Assurance

Assessed level of Board member assurance 31/03/2015 0 1 0 0 0 1

Self assessment quessionnaire at baseline and at 6 monthly intervals

post implementation

0 0 0

GOVERNANCE RECOVERY

Engagement, Culture & Compliance

Attendance at committees 31/03/2015 0 0 1 ######## 0 1 0 Records of attendance 0 0 0 2 31/03/2015Project overdelivering -

additional stretch target to be added

GOVERNANCE RECOVERY


Compliance with BAF reporting standards 31/03/2015 0 0 2 ######## 0 0 0

Audit of reports against BAF standards 0 0 0 31/03/2015

GOVERNANCE RECOVERY


Committee actions closure 31/03/2015 0 0 2 ######## 0 0 0Audit of actions

management and closures

0 0 0 0 31/03/2015Requires further refinement of

KPIs, delivery on course.

GOVERNANCE RECOVERY


Patient complaints relating to Trust values 31/03/2015 0 1 0 ######## 0 0 0 Audit of complaints 0 0 0 4 31/03/2015

Workstream to confirm leading KPIs

GOVERNANCE RECOVERY


Patient experience metrics 31/03/2015 1 0 0 1 0 0 Patient questionnaires 0 0 0Options appraisal in progress to

develop PID

GOVERNANCE RECOVERY


Staff satisfaction 31/03/2015 0 2 0 ######## 2 0 0 Staff survey 0 0 0 1 31/03/2015Awaiting confirmation of

budgets

GOVERNANCE RECOVERY


Governor engagement 31/03/2015 1 0 0 1 0 0 Governor survey 0 0 0 Project not commenced

GOVERNANCE RECOVERY

Risk managemen

t

Align strategic risks with Trust strategic objectives 31/03/2015 0 0 0 0 0 0 Audit of risk register 0 0 0 Project to close

GOVERNANCE RECOVERY

Risk managemen

t

Number and scale of risks registered and mitigated 31/03/2015 1 0 0 0 0 2

Audit of risk registers and management plan

effectiveness 0 0 0 1

GOVERNANCE RECOVERY

Risk managemen

t

Number of CIP's submitted without QIA 13/10/2014 1 0 0 0 0 0 Tracking of CIP approvals 0 0 0 1

GOVERNANCE RECOVERY

Compliance with

complaints policy

Number of complaints closed within target timescales 15/09/2015 1 0 0 0 0 1 Audit of complaints 0 0 0 1 16/07/2014

Project in progress, possible slippage to next financial yr

GOVERNANCE RECOVERY

Compliance with

complaints policy

Number of trended issues converted into remediation

action plans:learning put into practice

10/10/2015 2 0 0 ######## 0 0 0 Audits of remediation 0 0 0 5 13/10/2014

GOVERNANCE RECOVERY

Compliance with

complaints policy

Patient satisfcation 06/10/2015 0 1 0 0 0 0 Patient satisfaction surveys 0 0 0Umbrella reporting, main project reporting directly to Trust Board

GOVERNANCE RECOVERY

Compliance with SUI

management policy

Number of SUI's closed within target timescales 06/10/2014 0 1 0 ######## 0 0 0 Audits of SUI's 0 0 0 09/04/2014

GOVERNANCE RECOVERY

Compliance with SUI

management policy

Number of individual and trended issues converted into remedation plans;learning put

into practice

06/10/2014 0 1 0 ######## 0 0 0 Audits of remediation 0 0 0 1 12/03/2014Expected to delivered via

alternative mitigations

GOVERNANCE RECOVERY

Compliance with SUI

management policy

Number of cases referred to Coroner 06/10/2014 0 0 1 ######## 0 0 1 Audit 0 0 0 2 11/08/2014 Re-scoping of project underway

GOVERNANCE RECOVERY Data Quality

Reliability: Has data been collected using a stable

process in a consistant manner over a period of time?

10/10/2014 0 4 1 ######## 3 0 1 Audit 0 0 0 0 05/02/2014


Accuracy: is data recorded correctly and is it in line with

the methodology for calculation

10/10/2014 0 0 1 ######## 0 0 1 Audit 0 0 0 0


Validity; Has the data been produced in compliance with

relevant requirements10/10/2014 0 1 0 ######## 2 0 0 Audit 0 0 0 1 05/02/2014


Timelines: Is data captured as close to the associated event as possible and available for use within a reasonable time

period?

21/08/2014 1 0 0 ######## 2 0 0 Audit 0 0 0 5 09/04/2014


Relevance: does all data used to generate the indicator meet

eligibility requirements as defined by guidance

21/08/2014 0 1 0 0 0 0 Audit 0 0 0 3 09/04/2014


Completeness: Is all relevant information, as specificed in

the methodology, included in the the calculation

12/08/2014 0 1 0 ######## 2 0 0 Audit 0 0 0 1 05/02/2014

RTT RTT Compliance

Clearance of the Backlog 23/07/2014 1 0 0 0 0 0

100% of capacity and and additional capacity

required to maintain 18 week compliance is

booked against clearance trajectories

0 0 0 0

RTTRTT

Compliance 0 patients waiting >52 weeks 24/07/2014 0 0 1 0 0 0Audit of 52 week

breaches in accordance with RTT pathway clock

0 0 0 0

RTTRTT

CompliancePatients treated within 18

weeks 25/07/2014 1 0 0 0 0 095% of patients are seen

and treated within 18 weeks

0 0 0 0

RTTRTT


weeks 26/07/2014 0 1 0 0 0 095% of patients wait no longer than 12 weeks from referral to DTA

0 0 0 0

RTTRTT


weeks 27/07/2014 0 1 0 0 0 0Less that 8% of patients waiting over 18 weeks 0 0 0 0

RTTRTT


weeks 28/07/2014 0 0 1 0 0 0

100% of non 18 week pathway patients to have an O/P appointment date within four weeks of the

0 0 0 0

RTTRTT


weeks 29/07/2014 0 1 0 0 0 0All patients waiting more than 18 weeks have and

admission date0 0 0 0

A&E4 Hour breach

standard

All patients treated, admitted or discharged within 4 hours 31/07/2014 0 1 0 0 0 0

Time from arrival to initial assessment 0 0 0 0

A&E4 Hour breach

standard

All patients treated,admitted or discharged within 4 hours 01/08/2014 0 1 0 0 0 0

Time from arrival to 1st definitive treatment 0 0 0 0

A&E4 Hour breach

standard

All patients treated, admitted or discharged within 4 hours 02/08/2014 0 1 0 0 0 0 No of A&E attendances 0 0 0 0

A&E4 Hour breach

standard

All patients treated, admitted or discharged within 4 hours 03/08/2014 0 1 0 0 0 0

No of patients admitted, transferred or discharged

via A&E0 0 0 0

A&E4 Hour

standardAll patients treated, admitted or discharged within 4 hours 04/08/2014 0 1 0 0 0 0 0 0 0 0

HR AttendanceSickness and absence is less

that 6% 04/08/2014 1 0 0 0 0 0 No of staff on long term sick 0 0 0 0

HR Attendance Sickness and absence is less that 6%

05/08/2014 0 1 0 0 0 0 No of staff on short term sick 0 0 0 0

HRMinimal use of bank and

agencySafe staffing ratio's 06/08/2014 1 0 0 0 0 0 No of unfilled substantive

vacancies0 0 0 0

HRMinimal use of bank and

agencySafe staffing ratio's 07/08/2014 0 1 0 0 0 0

No of new recruits joining the Trust in this reporting

period0 0 0 0

HR Attendance 08/08/2014 0 1 0 0 0 0 0 0 0 0HR Attendance 09/08/2014 0 1 0 0 0 0 0 0 0 0HR 10/08/2014 0 1 0 0 0 0 0 0 0 0HR 11/08/2014 0 1 0 0 0 0 0 0 0 0

12/08/2014 0 1 0 0 0 0 0 0 0 0

14/08/2014 0 1 0 0 0 0 0 0 0 015/08/2014 0 1 0 0 0 0 0 0 0 016/08/2014 0 1 0 0 0 0 0 0 0 017/08/2014 0 1 0 0 0 0 0 0 0 018/08/2014 0 1 0 0 0 0 0 0 0 019/08/2014 0 1 0 0 0 0 0 0 0 020/08/2014 0 1 0 0 0 0 0 0 0 021/08/2014 0 1 0 0 0 0 0 0 0 022/08/2014 0 1 0 0 0 0 0 0 0 023/08/2014 0 1 0 0 0 0 0 0 0 024/08/2014 0 1 0 0 0 0 0 0 0 025/08/2014 0 1 0 0 0 0 0 0 0 026/08/2014 0 1 0 0 0 0 0 0 0 027/08/2014 0 1 0 0 0 0 0 0 0 028/08/2014 0 1 0 0 0 0 0 0 0 0

HEFT Dashboard - RECOVERY & OPERATIONAL STATUS(Source SharePoint)

Comments

KPIs - LeadingSummary Status# Risks greater than 12

Next Key Decision Due

in workstreamBrief Description of next decision for workstream

QIA and Due Regard Last Reviewed

KPI's Lagging

OPERATIONAL

ACCIDENT AND EMERGENCY

Staff

Friends and Family

Printed: 01/04/2015


.230

AgendaDeclaration

ofInterest

ApologiesChief

Executive'sReport


report



Advanced Clinical



Chair's Report



Plan

Any Other

Business

National Staff

Survey


Proposal

Executive Management Board

Key to BSUH CIP Dashboard

Item Description Attend Last Review Yes/No Did the workstream attend the last 1 hour review they were invited to?# Projects in workstream # How many individual projects are in this workstream. NB a RAG Status, KPIs etc are required for each.Highlight Report Last Updated dd/mm/yy Date the Project Team last updated reported. NB Report is due each fortnight, those overdue highlighted amber and red.

Summary Project Status Red Off track against approved PID and risk of deliveryAmber Off track, slipped some milestones or delivery of finance or fortuitous delivery of original planGreen On track with milestones, plans and a high level of confidence of delivery

Project KPI Last Updated dd/mm/yy Updated over 2 months ago (Source highlight Report)dd/mm/yy Updated within last 42 days (Source highlight Report)dd/mm/yy Updated within last 28 days (Source highlight Report)

Red KPIs Count of Red KPIs in each project according to agreed thresholdAmber KPIs Count of Amber KPIs in each project according to agreed thresholdGreen KPIs Count of Green KPIs in each project according to agreed threshold

# Risk over 12 ## Numbers 12 or over Risks recorded on SharePoint for all projects within workstream

Brief Description of next key decisionDescription

Brief description of the next (date ordered) decision required for workstream to progress. NB there may be multiple decisions due across project, this displays the next for workstream.

Next Key Decision Due dd/mm/yy Date of next Key Decision due - detail held in SharePoint report (indication to EPSG if decisions are required)

QIA and Due Regard Last Review dd/mm/yy QIA Review at Star Chamber in over 120 daysdd/mm/yy QIA Review at Star Chamber in last 90 - 120 daysdd/mm/yy QIA Review at Star Chamber in last 90 days

Finance Annual and Year to Date plan, forecast, variance and risk adjusted delivery for workstream

RAG Status Red Status assigned by PMOAmber Status assigned by PMOGreen Status assigned by PMO

Note: All data for the dashboard will be fed from the PMO SharePoint site, project teams are required to update on a fortnightly basis and data is aggregated to Workstream and Programme Level.

April 2015

Board of Directors

.231

AgendaDeclaration

ofInterest

ApologiesChief

Executive'sReport


report



Advanced Clinical



Chair's Report



Plan

Any Other

Business

National Staff

Survey


Proposal

Any Other Business

April 2015

Board of Directors

.232

AgendaDeclaration

ofInterest

ApologiesChief

Executive'sReport


report



Advanced Clinical



Chair's Report



Plan

Any Other

Business

National Staff

Survey


Proposal

Date and Venue of next meeting2 June 2015, The Village Hotel, The Green Business Park, Dog Kennel Lane, Shirley, Solihull B90 4GW

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