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Board of Directors’ Meeting Board Room, The Royal Marsden, Chelsea

Wednesday 18th March 2015, 10am – 12pm

Agenda 1. Apologies for Absence:

Professor Dame Janet Husband TIME ALLOCATION

2. Minutes of the Board Meeting held on 24th September 2014

(Chairman)

Enclosed 3 minutes

3. Report from the Chief Nurse and Medical Director 3.1. Duty Of Candour 3.2. Revalidation Report (Chief Nurse / Medical Director)

Enclosed Enclosed

10 minutes 10 minutes

For Decision

4. Draft Financial Plan 2015/16 (Chief Executive/Chief Financial Officer)

Enclosed 20 minutes

5. Corporate Governance 5.1. Monitor’s “Well-Led Framework” 5.2. Trust Constitution (Chairman)

Verbal

Enclosed

5 minutes 5 minutes

For Discussion

6. New Models of Care (Chief Executive / Chief Nurse)

Enclosed 10 minutes

7. Performance 7.1. Finance Report for month 10 (Chief Financial Officer) 7.2. Performance and Quality Report (Chief Operating Officer) 7.3. Quality Account for February 2015 (Chief Nurse)

Enclosed

Enclosed

Enclosed

10 minutes

10 minutes

10 minutes

8.

Board Sub-Committees 8.1. Quality, Assurance and Risk Committee highlight report from meeting held on the 11th February 2015 (Nancy Hallett, Chair of the Quality, Assurance and Risk Committee) 8.2. Audit and Finance Committee highlight report from the meeting held on 28th January 2015 (Ian Farmer, Chair of the Audit and Finance Committee)

Enclosed

Enclosed

10 minutes

10 minutes

9. Any other business

Date of next meeting: 22nd September 2015, 2.30pm – 4.30pm, Board room, Chelsea

Minutes of The Royal Marsden Board of Directors Meeting Wednesday 24th September 2014

Board Room, Chelsea.

Present: R. Ian Molson Chairman Cally Palmer Chief Executive Ian Farmer Non-Executive Director Sir John Craven Non-Executive Director Dame Nancy Hallett Non-Executive Director Richard Turnor Non-Executive Director Professor Dame Janet Husband Non-Executive Director Professor Paul Workman Non-Executive Director Dr. Shelley Dolan Chief Nurse Dr. Liz Bishop Chief Operating Officer Professor Martin Gore Medical Director

In Attendance: Syma Dawson (minutes) Head of Corporate Governance Janice Stephens Associate Director of Finance The meeting was quorate.

1/14 Apologies for Absence Alan Goldsman, Director of Finance.

2/14

Minutes of the Board meeting held on 26th March 2014 The minutes were approved as an accurate record.

3/14

Report from the Chief Nurse and Medical Director The Medical Director was pleased to inform the Board that Dr. Liam Welsh was recently appointed to the Neuro-oncology Department. The Chief Nurse gave an update on the external review of Paediatric Services and confirmed that she would come back to the Board once the specification and timeframe had been confirmed. She added that while Trust outcomes in this area are excellent, all specialist children’s services in London rely on pathways and partnerships between providers and the risk and benefit of different models will be assessed by the Review Panel.

SD

4/14 Development of a shared clinical vision with The Royal Brompton The Chief Executive described the work with The Royal Brompton on the development of a shared clinical vision for cancer and cardiothoracic services in Chelsea. The Chief Executive informed the Board that the review of service and estate issues by NHS England was due to be completed on 12th December and this has led to a pause in the Council’s planning process. The Trust will need to decide how to proceed with its planning application for the Fulham Wing. The Chairman requested that full Board endorsement is achieved prior to the Trust submitting its planning application.

5/14

Board Assurance Framework Non-Executive Director and Chair of the Quality, Assurance and Risk Committee (QAR)

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Nancy Hallett presented the Board Assurance Framework and explained that this sets out the Trust’s position against its strategic objectives. She highlighted that the report states ‘13/14 objectives’ but should read as ‘14/15 objectives’. The Chief Operating Officer added that the community service contract negotiations are likely to be the end of October 2014 as opposed to September 2014 which is noted in the report. The Chairman asked how significant the change will be for the Trust in the event it does not re-tender for SMCS due to complexities and risk. The Chief Executive responded that this will be very significant for the following reasons:

• The Trust has invested a large amount of time and effort in the integration and management of SMCS and has made good progress as a result. Furthermore, she commented that SMCS staff want the Trust to retain the Service and noted that the Trust has a duty to those staff as well as patients;

• Strategically it is wise to retain the Service as the Trust is trying to ‘scale up’ and integrate with other services alongside other NHS Trusts in a wider NHS context. The new emphasis in the NHS is on out of hospital care and integration of patient pathways so SMCS aligns well with this.

The Board noted and approved the Board Assurance Framework.

6/14 Finance Report The Associate Director of Finance highlighted the following:

• At month 4, the Trust had delivered a surplus for development of £2.5m, £0.9m adverse to plan. This adverse variance had arisen in April and May, whilst in June and July performance had been on plan in month so the position had not deteriorated further;

• The variance in the year so far is largely due to Private Care not meeting income growth plans due to capacity constraints;

• The Trust is working hard on its controls for temporary staffing • At the end of month 4, the Trust’s cash position was £8.9m which is below the

target of £10m; • At month 3 the Trust was behind on its capital programme and was therefore

required to submit a revised capital plan to Monitor. The Trust expects to meet this plan which includes a reduction in internally financed capital of £1.5m. This includes an improved position on Private Care income as performance has improved on billing patients from a significant delay of 60 days to an on target position in September. Income had to be estimated whilst there had been a delay in billing patients, and assumptions had been prudent. Cash position is £10.2m against an aim of £10m.

The Associate Director of Finance assured that Board that she was confident the Trust could achieve its overall financial plan for the year, based on the plans the Divisions had in place. In response to a query raised by the Chairman with regard to whose responsibility it is for private billing, the Associate Director of Finance confirmed that the Private Care Division raises the invoice and the Finance Department monitors performance each month against target billing time.

7/14 Performance and Quality 7.1. Key Performance Indicators Q1 The Chief Operating Officer presented the Key Performance Indicators for Q1 and highlighted the following:

• 62 day target: a key issue which affects performance in this area is late referrals.

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The Trust has raised this matter with Commissioners and also plans to discuss this with other NHS Trusts in order to see how they are managing this issue.

• 70 day target in Research: performance in this area has been affected due to a change in NIHR’s definition on 1st eligible patient. However, the Trust remains the top performer against this target in England.

• Workforce targets: it was reported that the Trust has put measures in place to drive recruitment in an attempt to reduce the reliance on temporary workers. The Chairman asked whether there were any findings with regard to the turnover of more senior staff. The Chief Nurse confirmed that this would come back to the Board in November once the Trust had acquired two months’ worth of data. The Board discussed the reasons for a high turnover of staff in some areas, which the Chief Nurse pointed out was an issue for all central London Trusts due to the cost of living.

7.2. Quality Accounts – June / July 2014 The Chief Nurse introduced the Quality Accounts to the Board for June and July 2014 and noted the following:

• Healthcare Associated Infections: the Trust is updated fortnightly by Public Health England on how to manage concerns particularly in reference to the Ebola outbreak.

• Patient waiting times: this matter has been discussed with the new Chief Pharmacist who is confident that he can reduce these. The Board was informed that the Chief Pharmacist is due to present to their Seminar meeting in November 2014.

• The Friends and Family Test: the Trust has received many positive comments and is acting on any concerns raised via IGRM and QAR. The Trust is in the top 5% of Trusts in England for its results on patient experience.

• Safer Staffing: the Chief Nurse reminded the Board of the mandatory requirement for the Board to have sight of this data. She noted that an area of difficulty was short term sickness absence and ensuring quick access to a nurse which can subsequently affect the work experience of the nurse on that shift. However, she reported that overall the Trust is managing its staffing levels well.

SD

8/14 Board Committee Reports 8.1. Quality, Assurance and Risk Committee Nancy Hallett, Chair of the Quality Assurance and Risk (QAR) Committee raised the following points in reference to the QAR meeting held on the 2nd July 2014:

• Patient safety is at the forefront of the Committee’s agenda. • The Trust received positive feedback on the interim steps being taken in the

external accreditation in diagnostic radiology. • There have been some claims of bullying and harassment which the Committee

feels are being managed appropriately in the organisation. • BRC renewal and funding has been carefully considered. The Chief Executive gave

an update on this and highlighted the risk of not achieving the Athena Swan Award, which is key to achieving BRC renewal. Non-Executive Director Professor Paul Workman assured the Board that this was a high priority for the Institute. The Chief Executive offered the Trust’s support which is available for the Institute should they need it.

The Chairman highlighted the issue of public engagement and the Chief Executive confirmed that the PPI reviewer on the BRC Review Panel has made particular recommendations to ensure patient and public engagement is meaningful in achieving value in research which will be followed up accordingly. The Chairman asked that the Board is kept informed on BRC renewal issues in

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advance of the submission in 2016.

9/14

Risk Management Policy The Chief Nurse explained that the Policy has been updated to includes changes introduced by the Health and Social Care Act 2012 and has come to Board for their information. She added that having frontline staff attend the Board sub-Committee, Quality Assurance and Risk Committee, has increased transparency and understanding. In response to a query raised by Non-Executive Director Ian Farmer, the Chief Nurse confirmed that the Policy will go to internal auditors KPMG.

10/14 Equality and Diversity Annual Report The Chief Operating Officer explained that the main purpose of the enclosed report is to demonstrate compliance against the Equalities Act 2010. She highlighted that the Trust has an Equality and Diversity Steering Group to monitor compliance and the Trust’s lead in this area, Lisa Neden, regularly carries out equality impact assessments. Training for staff in this area has also increased and particular attention is paid to equality and diversity during site visits.

11/14 Any other business No other business was raised.

BOARD PAPER SUMMARY SHEET

Date of Meeting: 18th March 2015

Agenda item 3.1.

Title of Document: Report from the Chief Nurse and Medical Director: 3.1. Duty Of Candour

To be presented by

Chief Nurse

Executive Summary The Duty of Candour aims to help patients receive accurate, truthful information from health providers. It is a legal duty on hospital, community and mental health Trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm. Following the publication of the Francis report in 2013 there were many recommendations made for change throughout the NHS. One of the recommendations was for a statutory Duty of Candour, which came into force on the 27th November 2014. All NHS provider bodies registered with the Care Quality Commission (CQC) have to comply with the new Statutory Duty of Candour. If an NHS trust does not comply with the Duty of Candour they can be fined and the CQC has the power to prosecute the trust. Recommendations Board members are invited to discuss the new Duty of Candour legal framework and the actions that The Royal Marsden has taken to ensure that it is compliant with the Duty. Author: Dr Shelley Dolan, Chief Nurse

Contact Number or E-mail: x2121 PA

Date: 9th March 2015

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The Duty of Candour

1.0. Introduction In 2013, Sir Robert Francis QC published his report into failings at Mid-Staffordshire NHS Foundation Trust. He made many recommendations for change throughout the NHS. One of his recommendations was for a statutory Duty of Candour. The aim of the Duty of Candour is to toughen transparency and to ensure that providers of healthcare, like hospitals, are open and honest with patients when things go wrong with their care and treatment. Candour means frankness, openness and honesty. The Duty of Candour aims to help patients receive accurate, truthful information from health providers. It is a legal duty on hospital, community and mental health Trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm. 2.0. Background Previously, there was a contractual Duty of Candour on NHS organisations. This meant that NHS trusts signed up to an NHS contract and had to be open and honest with patients in order to meet the requirements of the contract. Following the publication of the Francis report in 2013 into failings at Mid-Staffordshire NHS Foundation Trust there were many recommendations made for change throughout the NHS. One of the recommendations was for a statutory Duty of Candour, which came into force on the 27th November 2014. All NHS provider bodies registered with the Care Quality Commission (CQC) have to comply with the new Statutory Duty of Candour. If an NHS trust does not comply with the Duty of Candour they can be fined and the CQC has the power to prosecute the trust. 3.0. Requirements of The Duty of Candour To meet the requirements of the regulation, a provider has to:

• Make sure it has an open and honest culture across and at all levels within its organisation.

• Tell patients in a timely manner when particular incidents have occurred.

• Provide in writing a truthful account of the incident and an explanation about the enquiries and investigations that the organisation will undertake.

• Offer an apology in writing.

• Provide reasonable support to the person after the incident.

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4.0. Duty of Candour at The Royal Marsden Open and effective communication with patients begins at the start of their care and continues throughout their time with the RM. This should be no different when a patient safety incident occurs. Being open when things go wrong is vital to the partnership between patients and their hospital. Openness about what happened and discussing patient safety incidents promptly, fully and compassionately can help patients and staff cope better with the sequelae of an incident. The Royal Marsden NHS Foundation Trust has always been committed to improving the safety and quality of services and providing an open and honest approach when things go wrong under the RM “Being Open and Duty of Candour Policy”. Being Open is a set of principles that healthcare staff should use in communication with patients, their families and carers following a patient safety incident in which the patient was harmed (National Patient Safety Agency 2009). The behaviours enshrined in the new legal and contractual duty have been followed by the RM since 2009, however the timeframe and content of written apologies is now mandated. The RM has therefore informed all of its clinical teams through their mandatory training and professional meetings and the risk management team monitor robust reporting. 4.1. Implementation of the new procedures at The RM The patient or their family /carer must be informed that a suspected or actual patient safety incident has occurred within at most 10 working days of the incident being reported on local systems (Datix). (Please see appendix 1 for definitions of harm and patient safety incidents)

The initial notification must be verbal (face to face where possible). The verbal notification must be accompanied by an offer of written notification. The notification must be recorded in the Electronic Patient Record for clinical and audit purposes. An apology must be provided – a sincere expression of sorrow or regret for the harm caused both verbally and in writing.

A step by step explanation of what happened, in plain English, based on fact must be offered as soon as is practicable. This may constitute an initial view pending an investigation, but patients and families must be kept informed of the process. Any incident investigation reports must be shared with the patient/family within 10 working days of being signed off as complete and the incident closed by the relevant authority.

If the requirements of the contractual Duty of Candour are not met the Commissioners can withhold the cost of an episode of care or implement a fine of £10,000 if the cost is not known. The Risk Management and Complaints teams are supporting staff with this process which is detailed in the Being Open / Duty of Candour Policy.

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Training in the principles of Being Open and the Duty of candour form part of the Trust’s mandatory training programme. The principles and concept of Being Open and Duty of candour is in mandatory training for all clinical staff. 5.0. Conclusion Board members are invited to discuss the new Duty of Candour legal framework and the actions that the RM has taken to ensure that it is compliant with the Duty and does the utmost to be open and transparent in a timely way with patients and families. Appendix 1 Recognising a patient safety incident resulting in potential or actual harm The Being Open and Duty of candour process begins with the recognition that a patient has suffered harm or has died as a result of a patient safety incident. The RM has appropriate mechanisms in place to identify patient safety incidents through the process for reporting and investigating incidents and near misses. (Accident/Incident and Patient Safety Incident Reporting Policy Including Serious Incidents (policy 482) and Investigation of Incidents, Complaints and Claims Policy (policy 1630)). A patient safety incident may be identified by:

• A member of staff at the time of the incident

• A member of staff retrospectively when an unexpected outcome is detected • A patient, their family or carers who express concern or dissatisfaction, as

part of the complaints process, with the patient’s healthcare either at the time of the incident or retrospectively

• Incident detection systems such as incident reporting or medical records review

• Other sources such as detection by other patients, visitors or non-clinical staff (for example, researchers observing healthcare staff as part of ethnographic studies)

Levels of harm No harm Incident prevented – any patient safety incident that had the potential to cause harm but was prevented, and no harm was caused to patients. Incident not prevented – any patient safety incident that occurred but no harm was caused to patients. Low harm Any patient safety incident that required extra observation or minor treatment and caused minimal harm to one or more patients. Moderate harm Any patient safety incident that resulted in a moderate increase in treatment and that caused significant but not permanent harm to one or more patients. Severe harm Any patient safety incident that appears to have resulted in permanent harm to one or more patients. Death Any patient safety incident that directly resulted in the death of one or more patients.

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The principles of Being Open should be used to inform patients of incidents that have caused low harm. Being Open Process should be applied to incidents that fall into the moderate/severe and death category. This category of incident is also covered by the contractual requirements of the Duty of Candour. It is important that the results of investigations are communicated appropriately to patients and their relatives. The method of communication will depend on the circumstances of the incident and the patient’s needs. The Being Open Principles There are 10 principles of Being Open: 1. Principle of acknowledgement 2. Principle of truthfulness, timeliness and clarity of communication 3. Principle of apology 4. Principle of recognising patient and carer expectation 5. Principle of professional support 6. Principle of risk management and systems improvement 7. Principle of multidisciplinary responsibility 8. Principle of Clinical Governance 9. Principle of confidentiality 10. Principle of continuity of care Sarah Rushbrooke, Deputy Chief Nurse Shelley Dolan, Chief Nurse



Agenda item 3.2.

Title of Document: Report from the Chief Nurse and Medical Director: 3.2. Revalidation Report

To be presented by

Medical Director

Executive Summary In order to continue to strengthen existing processes and controls and to ensure our appraisal and revalidation systems are robust; it is vital that we continually improve and make necessary changes to ensure that RMH maintains the highest standards for clinical governance, quality assurance and appraisal arrangements. The recommendations are in line with reviews conducted at other Trusts and cited as best practice by the Higher Revalidation Office. Recommendations To approve 3 items on the Trusts forward direction on revalidation: 1) To devolve the Responsible Officer Role and appoint a new Supporting Responsible Officer Role. Both roles to the Associate Medical Directors; 2) Governance of appraisal process and revalidation through the IGRM and half yearly reports to the QAR; 3) Annual board report to be submitted for the first meeting of each financial year. Author: Kelly Abel, Senior HR Business Partner

Contact Number or E-mail: [email protected]


1

Revalidation Report

1. Executive summary Revalidation involves doctors having regular and good quality appraisals provided by their ‘designated body’ and the Responsible Officer for that designated body (at RMH this is the Medical Director) making a recommendation to the GMC of their suitability for revalidation. Currently the Trust is the designated body for 242 doctors. In addition, we have a duty to nominate or appoint additional Responsible Officers in cases of conflict of interest or appearance of bias.

The Responsible Officer is dependent on the quality of the Appraisers. An effective organisational appraisal policy and recognition of the medical appraiser as an important professional role are the cornerstones of the appraisal system. Quality assurance of the medical appraisers is essential.

2. Purpose In order to continue to strengthen existing processes and controls and to ensure our systems are robust; it is vital that we continually improve so that we have the necessary clinical governance, quality assurance and appraisal arrangements in place. 3. Recommendation

3.1 It is recommended that the Board considers that under the Medical Profession (Responsible Officers) Regulations 2010; the current Associate Medical Directors should be appointed as Responsible Officer and Supporting Responsible Officer. This is to avoid conflict of interest and appearance of bias. This is line with reviews conducted at other Trusts and cited as best practice by the Higher Revalidation Office. The Trust will adhere to the rules set out in legislation for the appointment of Responsible Officer (s) and to remain Responsible Officer (s) as laid own in the regulations. A supporting business case will be developed;

3.2 The governance of appraisal processes for revalidation will be through the

Integrated and Governance Risk Management Committee Group (IGRM) and half yearly reports to the Quality Assurance and Risk Management Committee (QAR).

3.3 Under the Framework for Quality Assurance for Responsible Officers and Revalidation an Annual Board Report will be submitted for first meeting of each financial year.

The Board is asked to approve the Trust’s forward direction on Revalidation.



Agenda item 4.

Title of Document: Draft Financial Plan 2015/16

To be presented by

Chief Financial Officer

Executive Summary The first full draft financial plan for 2015/16 is presented to the Trust Board for consideration. The draft will need to be submitted to Monitor in April and the final plan in May after the next Trust Board. Recommendations The Board is asked to discuss the issues within the draft financial plan and to delegate to the Audit and Finance Committee approval for submitting a final draft to Monitor in April. Author: Marcus Thorman, Chief Financial Officer



Trust Board – 18th March 2015

Financial Plan 2015/16

1 Introduction and Background

The Board approved a five-year strategic plan in June 2014, which was submitted to Monitor. The second year of this plan forms the basis of the detailed financial planning and budgeting work for 2015/16. The draft plan for 2015/16, along with the underlying assumptions were presented to and approved by the Board in November 2014. A status update was provided to the Board in February 2015.

This paper provides the Board with the first full draft financial plan for 2015/16 since all the external factors, such as changes to the tariff have been reviewed, and the expected outcome of the Trust’s internal business planning process. It presents the key changes in planning assumptions since the February Board paper, sets out a number of efficiency initiatives, and provides an analysis of the key financial risks and mitigating actions in relation to those risks.

The paper also provides the key sensitivities to be applied and therefore gives the Board a range of the potential scenarios it is facing in 2015/16. This additional analysis is provided because external discussions continue with NHS England and commissioners, and internally with Trust Divisions; it therefore provides a best, expected and worst case for the financial plan for 2015/16.

The Trust is required to submit its draft financial plan to Monitor on 7th April. The Board is requested to approve the draft financial plan for 2015/16, and delegate responsibility to the Audit and Finance Committee to approve the plan for submission to Monitor providing it falls within the range provided in this paper. It is requested to note and comment on the risk mitigation plan.

2 Business Planning Process and Timetable

Monitor issued a planning timetable in December 2014. This required that the Trust submit a financial plan for 2015/16 in two stages: a high level draft plan and short assumptions paper, and a final plan with 20 page operational plan. The results of the revised national tariff were published in January; a majority of Trusts rejected the tariff proposals and therefore an updated planning timetable was issued by Monitor to take account of the delay. The table below sets out the revised timetable and proposed approval process for the Trust.

Original Submission

Date

Revised Submission

Date

Trust Board Sign off

Draft financial plan and short assumptions paper

28th Feb 7th April March Board – approve range

April AFC – approve final draft plan

NHS Contracts agreed 11th Mar 31st Mar

Final plan and 20 page operational plan

10th Apr 14th May May Board

The Trust’s business planning process has continued and divisions have met with the Business Planning Panel to review their plans. The Panel includes the Chief Operating Officer, Chief Financial Officer, Director of Workforce, Medical Director and Chief Nurse to ensure all financial, workforce, quality and safety issues are considered. All plans have been reviewed before presentation to the Board.

3 Summary Financial Plan

Throughout this report reference is made to the ‘development reserve for investment’ which is the surplus before depreciation and capital donations, required to fund the Trust’s capital programme and loan repayments. In this paper the total surplus/deficit is presented, as well as the underlying surplus/deficit which takes account of the one-off impact of charitable donations for capital expenditure which are reported in the income position. The table below shows the assumptions presented to the Board in November, February and in this paper:

2015/16 Financial Plan

At Nov 14 At Jan 15 At Mar 15 Notes

Development Reserve1 £15.0m £15.0m £9.6m

Surplus / (Deficit)2 £5.5m £9.5m £5.1m

Efficiency Programme £13.1m3 £16.3m £10.8m See Section 4.3

Capital programme

NHS - Internally Financed £14.8m £9.2m £9.2m Reduction relates to the

reduced ‘Development Reserve’ NHS Loan Financed (existing

loan) £1.5m £3.6m £4.5m Re-phasing of spend on

equipment

NHS Loan Financed (new loans)

£15m £14m £4m The Board need to confirm its

agreement to draw down additional loans

Donated Capital £4.8m £9.8m £10.0m Inclusion of MR Linac funding

Total Capital £36.1m £36.6m £28.0m

Monitor Risk Rating

Capital Service Cover Metric 4 4 3 Reduction in rating due to reduction in surplus

Liquidity Metric 3 4 3 Liquidity reduces due to

reduction in surplus lot linked to capex reductions

Continuity of Services Metric 4 4 3 Overall rating is a 3 on the base

case

1 The Development Reserve for Investment is the surplus before charges for depreciation, and charitable income for capital schemes. 2 Surplus/(Deficit) is the overall financial position after charges for depreciation and charitable income for capital schemes. This plan relies on continued receipt of donated asset income without which the Trust would be recording a deficit. 3 Efficiency Programme - This assumes the Trust meets its current forecast surplus for development of £11.1m in 2014/15.

4 Key Assumptions

Waterfall chart bridging forecast outturn to 2015/16 financial plan

4.1 Activity and Income

The Statement of Comprehensive Income (SOCI) is in Appendix A and shows a growth in income overall for the 2015/16 plan compared with the 2014/15 plan and forecast outturn. The key drivers of this increase relate to private patient income and donated asset income. The assumptions underpinning the changes in the income position are detailed below:

NHS Clinical Income

The national tariff for 2015/16 was consulted upon by Monitor in December 2014. The Trust responded to the consultation and rejected the proposed changes that were put forward. A majority of trusts likewise rejected the proposals, which means that Monitor are either required to re-consult on some new proposals or refer the decision on to the Competition and Markets Authority (CMA).

In February NHS England wrote to providers with regards to an Enhanced Tariff Option (ETO). If a provider does not accept the ETO, the proposal suggested the 2014/15 tariff will continue until they are formally superseded (Default Tariff Rollover ‘DTR’). NHS England’s position was that CQUIN would not be applied to the DTR. The main changes to the draft 2015/16 national tariff that were proposed under the ETO were as follows:

• Marginal cost reimbursement for emergency hospital admissions is increased from its current 30% to 70%;

• Marginal cost reimbursement for specialised services is raised from the proposed 50% to 70%;

• Efficiency requirement is reduced from 3.8% to 3.5%; • Providers will continue to have access to up to 2.5% of CQUIN, while those on the

DTR will not;

• Providers will benefit from prices that incorporate additional funding for CNST premium increases;

• Required to join sector wide ‘cost data sharing and efficiency initiative’ to improve provider efficiency and reduce inappropriate cost variation.

The Trust responded to Monitor, ahead of the deadline, to confirm that we do not accept either of the tariff options (ETO or DTR) on the basis that both exacerbate an already unsustainable position for the Trust and our patients; accepting either option would threaten the sustainability of the Trust and the quality of the services we provide.

The Trust does not accept, however, there is any legal basis for the DTR being imposed as the ‘default position’ and will therefore be moving forward with contract negotiations on the basis of a roll-over of the 2014/15 contract – with service developments, QIPP and CQUINs to be agreed.

On this basis the Trust has assumed a broadly ‘flat cash’ position into 2015/16 for NHS Clinical Income compared with the 2014/15 forecast outturn.

Private Patients

In line with the strategy for private patients an increase of seven percent has been applied to the income for 2015/16. The target will be met mainly through an increase in activity and there are a number of programmes in place that will secure this additional income.

Donated Income

The key increase in income for donated assets relates to the MR Linac at Sutton which is funded via an MRC grant.

4.2 Expenditure

In Appendix A the main changes on expenditure from the 2014/15 forecast outturn to the 2015/16 plan is the increase in private patients’ expenditure, which is related to the increase in activity and income as per the previous section. The main change from 2014/15 plan to 2015/16 plan relates to the other divisions and includes the Cancer Drug Fund. This has a forecast £7m over-performance in 2014/15, however this is a pass-through cost and therefore any variance will also change income to have a net zero impact upon the bottom-line.

Pay costs

The expenditure position is in the main driven by pay, which once the pass-through drugs and devices are removed from both income and expenditure, pay accounts for about two-thirds of the overall expenditure.

A reserve has been set aside for the expected pay inflation, which incorporates pay awards, net incremental drift and the increase in the NHS employer pension contributions, which rises in April 2015.

A key focus of the pay expenditure in 2015/16 will be the reduction in temporary staffing by ensuring rostering of staff is maximised, junior doctor rotas are appropriately reviewed, contracts for agencies are in place and the turnover rate of staff is reduced.

Non pay costs

Non pay inflation is split by cost type and is based on a combination of historic trends and national guidance. Where these costs have been specifically identified by divisions the cost pressures have been funded, otherwise a reserve has been created to cover the cost of this inflation.

There is an increase in depreciation which is linked to the investment in the medical equipment bought through the loan and based on the draft programme for 2015/16 being primarily focused on IT and medical equipment.

Interest payable increases in 2015/16 due to the loan drawn down in 2014/15.

4.3 Efficiency Programme

There has been an underperformance on delivery of key schemes in 2014/15, some of which were outside the control of the Trust, for example the pharmacy outsourcing. However, about two-thirds of the programme has been achieved and this means a number of the themes that have not delivered will be fundamental targets for 2015/16.

A different approach has been considered for 2015/16 and a new committee has been established which will oversee the Efficiency Programme. This will be the Transformation Board (TB), chaired by the Chief Operating Officer with the Chief Nurse and Chief Financial Officer as central members of the group. The purpose of the TB is to facilitate the following:

• Support teams to prioritise, consolidate and coordinate these Transformation projects and prioritise the input of key people and dependents;

• Monitor delivery of key transformation projects; • Promote and share a consistent, pragmatic approach to managing and running

projects; • Sign-off operational transformations; • Enable the development of service managers and clinical leaders.

There has already been discussion about a number of themes that TB will consider, standardise and oversee. The key efficiencies that are being considered in 2015/16 are as follows:

• Private care strategy • Theatre efficiency • Outpatient review • Access policy • Temporary staffing strategy • Procurement • Pharmacy outsourcing • Asset utilisation • Admin review • Facility service review

In addition to the themes within TB, as part of the business planning round non-clinical areas were required to find seven percent savings. A great deal of this was reviewing posts and not replacing like-for-like upon posts becoming vacant, plus identifying alternative funding streams for areas that were counted as critical but not funded through the normal NHS route. The detailed plan on the savings programme will be summarised and presented to the Audit and Finance Committee and submitted to Monitor as part of the Annual Plan.

4.4 Capital Expenditure Programme

The proposed capital programme for 2015/16 and 2016/17 is set out in Appendix B. The plan shows £28m funds available, providing surpluses are delivered in line with plan. This has been approved by the Capital Review Group. The plan incorporates the final drawdown of £4.5m from the original £21m loan.

Capital assumptions presented in November 2014 and February 2015 included assumptions that the Trust would secure loan financing from the Independent Trust Financing Facility (ITFF) for replacement of medical equipment, and for upgrading clinical IT systems. In light of the challenging position for NHS income, the planned development reserve for investment has been reduced from £15m to £9.6m. Additionally previous plans had included the assumption that the Trust would be able to grow its development reserve for investment to £20m over 4 years.

This plan covers a year of transition due to the uncertainty of the position in relation to the NHS tariff and therefore a reduced development reserve from previous years. On this basis the Trust has had to defer its capital programme until the position improves and there is greater certainty over future cash flows. The plan does include the assumption that the Trust will borrow £6m over 2 years to finance its urgent medical equipment replacement programme. The deferral of the capital programme, in particular for the medical equipment programme and clinical IT systems has been highlighted as a risk in section 6.

4.5 Cash Plan, Monitor Financial Metrics and Balance Sheet

The cash flow and balance sheet plan is presented in Appendix C. The Trust is forecasting to end the year with cash of £20m. The plan for 2015/16 shows £24.4m cash flow from operations, which combined with net inflow from financing of £1.4m will finance the capital programme and maintain a liquidity metric of 3. Alongside this the Trust has a committed working capital facility of £9m in place with Lloyds Bank.

As has been highlighted above, with the reduction in the forecast surplus, the capital service cover ratio is forecast to reduce to 1.96x giving a metric of 3. Overall the plan presents a Continuity of Services Risk Rating of 3.

5 Sensitivity Analysis

In light of the risks within the financial plan for 2015/16, in particular uncertainty in relation to NHS income, three scenarios have been modelled to set out the expected outturn, as well as the best and worst case scenarios. These are set out in Appendix D but are summarised below.

The expected case includes the assumptions set out in section 4.

The best case assumes activity growth with associated marginal costs, and receipt of Project Diamond funding. It assumes that some of the cost pressures highlighted in business planning are mitigated, and that the Trust is successful in achieving its cost improvement programme and achieves the original private care growth plan included within the five-year plan. This will enable the Trust to finance a capital programme of

2015/16 2015/16 2015/16Sensitivity Analysis Best Case Expected Worst

£000s £000s £000s

Development Reserve for Investment £16,750 £9,570 £127Operating Surplus (EBITDA) £31,750 £24,557 £15,098Surplus / (Deficit) for the year £12,260 £5,134 (£3,809)

Total Capital Programme £39,821 £27,972 £14,821

Continuity of Services Risk Rating 4 3 2

£39.8m including new loans and increased internal finance, and have a Continuity of Services Risk Rating of 4.

The worst case assumes a reduction in activity, with an associated reduction in costs, and loss of CQUIN funding. On the cost side it assumed that divisions are not able to contain costs in line with budgets and that the efficiency programme is not fully delivered.

Appendix E sets out the impact on the next five years of the Trust’s financial performance and Monitor metrics. In each case it assumes the development reserve remains at the 2015/16 planned level, with adjustments made to arrive at the surplus/deficit, position for financing, depreciation and donated income. The charts demonstrate that the proposed plan for 2015/16 is not sufficient for the Trust to finance its planned medical equipment programme or to upgrade its clinical IT systems.

The best case scenario would allow the Trust to finance a loan of £25m over 24 months, and afford internally financed capital of £72m over 5 years, compared to loans of £6m and internally financed capital of £41m in the expected case over 5 years.

In the worst case scenario the Trust cannot afford to take out new loans, and will have no surpluses to invest in capital equipment. With no real change in the underlying position, the Trust will not be able to meet its capital requirements and this represents a risk to its ongoing activities.

6 Key Financial Risks

The table below sets out the key financial risks and mitigating actions. The scores have been created using the Trust’s risk framework. The first version of this risk matrix was discussed and reviewed at the Audit and Finance Committee in January and is continually refined as the risks evolve. It is expected that throughout the year the Audit and Finance Committee will constantly review the risks and ensure the Board are assured that progress is being made in each area.

Risk Score before Mitigation

Mitigation Score after Mitigation

Likel- ihood

Impact Overall

Likel-ihood

Impact Overall

NHS Tariff – impact of marginal rate

5 4 20 The Trust has rejected the two proposals from NHS England and will be working to a 14/15 rollover contract.

4 3 12

Private Care Strategy: • Risk that growth is not

delivered 3 4 12 Strategic plan developed and

marketing plan agreed. 2 4 8

• Risk to cash flow – growth expected through shift from UK sponsored to embassy activity; embassies are slower to pay

4 3 12 International Patient Manager in place to develop relationships with Embassies to improve payment. Monthly review of debt reported to PRG.

3 2 6

Divisional expenditure controls and CIPs:

• Temporary staffing costs 4 4 16 Controls on agency usage to continue and be strengthened assisted by the business case for temporary staffing programme and controls.

2 3 6

• Lack of project management for CIP

4 4 16 Transformation lead appointed Jan 15 and Transformation Board in place to oversee the programme.

2 4 8

• Risk that procurement strategy does not deliver expected savings

4 3 12 Procurement savings plan signed off at Financial Strategy Group (Feb 15) and performance monitored through Performance Review

3 2 6

Risk Score before Mitigation

Mitigation Score after Mitigation

Likel- ihood

Impact Overall

Likel-ihood

Impact Overall

Group • Risk the access policy is

not fully implemented 4 5 20 Ongoing monitoring of

admissions against policy criteria through PRG. Specialist group to review key changes.

3 3 9

IT Shared Services 4 4 16 Ensure effective management of the service and joint venture through Directors sitting on Sphere Board and at PRG

3 3 9

Equipment replacement programme – the Trust is heavily reliant on major diagnostic equipment a number of which require replacement in the next 5 years.

4 5 20 Equipment replacement programme has been developed but requires funding. Internally financed capital is not sufficient to deliver requirements.

4 4 16

Clinical IT capital requirements – implementation of the EPR.

4 5 20 An agreed incremental strategy has been agreed by the Board. Internally financed capital is not sufficient to deliver requirements

4 4 16

Community Services – risk of stranded costs if the service is not retained.

4 4 16 Plans are being developed to identify overhead reductions.

4 2 8

These risks will also be regularly reviewed at the Finance Strategy Group and Performance Review Group to minimise the impact on the financial plan.

7 Conclusion and Recommendations This is a year of transition, which has caused a great deal of uncertainty in being able to set the financial plan. Internal progress has been assisted by all areas engaging in delivering upon what is required, however the external environment has created a large amount of flux meaning there are a number of risks that the Trust is managing, over and above the usual issues at this time of year. The key issue that impacts upon the financial plan is the size of surplus that enables replacement of equipment and clinical IT systems. This is driven by the unsatisfactory national tariff position, hence the need to review a range of sensitivities.

The Board are therefore asked to note and approve the following:

• Approve the draft financial plan for 2015/16 and delegate to the Audit and Finance Committee to review and approve the draft plan to Monitor. The key elements of the plan are as follows:

o Surplus of £5.1m o Continuity of Service Risk Rating of 3 o Capital investment of £28.0m

• Note and comment on the risk mitigation plan; • Note and comment on the capital investment requirements and the priorities set out

in the current plan.

Appendix A – Income and Expenditure Account

2014/15 2014/15 2015/16Income and Expenditure Plan Forecast Plan

£000s £000s £000sIncome

NHS Clinical Income 191,467 203,164 202,934Private Income 81,029 77,697 83,541Other Income 71,584 65,853 63,957Donated asset income 3,113 3,506 10,025

347,193 350,219 360,457Expenditure

Private Patients 28,239 25,053 27,445Cancer Services 82,913 85,789 84,750Clinical Services 77,750 80,300 79,800Community Services 34,713 34,452 34,452Other Divisions, other Expenditure and Reserves 56,735 61,383 65,740Divisional Income 47,216 43,786 43,713

327,565 330,763 335,900

Operating Surplus - EBITDA 19,628 19,456 24,557EBITDA Margin 5.7% 5.6% 6.8%

Other Operating and Non-Operating ItemsDepreciation (13,355) (13,043) (14,460)PDC Dividend (4,714) (4,735) (4,714)Interest Payable (232) (165) (289)Interest Receivable 33 41 41

Surplus /(Deficit) for year 1,360 1,554 5,135

Depreciation 13,355 13,043 14,460Donated Asset Income (3,113) (3,506) (10,025)

Development Reserve for Investment 11,602 11,091 9,570

Appendix B – Capital Programme

2014/15 2015/16 2016/17Capital Programme Forecast Expected Plan

£000s £000s £000s

Internally FinancedMedical Equipment & Infrastructure 438 500 500IT Schemes 4,988 1,000 1,000Backlog & Minor Works 1,537 1,790 1,700Private Patients Chelsea & Sutton 163 3,870 3,001Other identified schemes 1,123 1,498 - Other (from development reserve for investment) - 493 2,799

Total Internally Financed 8,249 9,151 9,000

Loan Financed CapitalMedical Equipment (Existing Loan) 11,728 4,498 - Medical Equipment (New Loan) - 4,000 2,000

Total Loan Financed Capital 11,728 8,498 2,000

Public Dividend Capital Funded CapitalBlood Tracking System 672 - - Electronic Document Mgmt/ Archiving 740 298 - Co-ordinate my Care 1,350 - -

Total PDC Funded Capital 2,762 298 -

Donated Capital ExpenditureRobot 1,900 - - MR Linac - Infrastructure 450 4,833 458MR Linac - Equipment (2017/18) - - - RL Breast Cancer Research Centre 101 2,862 38Maggie's Centre - 500 - Other Schemes 1,042 1,830 500Potential schemes:

Haemato-oncology at Sutton - - 10,000Total Donated Capital 3,493 10,025 10,996

Total Capital Programme 26,232 27,972 21,996

Appendix C – Cash Flow, Monitor Metrics and Balance Sheet

2014/15 2014/15 2015/16Cash Flow Statement Plan Forecast Plan

£000s £000s £000s

EBITDA 19,627 19,455 24,557Movement in working Capital (5,511) (113) (204)Cash flow from Operations 14,116 19,342 24,353

Investment Cash FlowsCapital expenditure (30,205) (24,296) (27,972)

Financing Cash FlowsPublic Dividend Capital Received - 2,762 298Dividends Paid (5,014) (5,075) (4,714)Loan drawdown 14,080 9,582 8,498Loan repayment (1,144) - (2,421)Interest Received 33 41 41Loan interest paid (217) (150) (282)

Net Cash Inflow/Outflow (8,351) 2,207 (2,199)

Opening Cash 19,954 19,952 22,160Closing Cash 11,603 22,160 19,961

2014/15 2014/15 2015/16Monitor Metrics Plan Forecast Plan

£000s £000s £000s

Capital Service Cover Metric 4 4 3Liquidity Metric 4 4 3

Overall Continuity of Services Metric 4 4 3

2014/15 2014/15 2015/16Statement of Financial Position Plan Forecast Plan

£000s £000s £000s

Fixed Assets 248,388 241,201 254,713

Current AssetsStock 4,248 5,783 4,883Debtors & Prepayments 43,924 56,091 56,091Cash 11,602 22,160 19,961

Total Current Assets 59,774 84,034 80,935

Current LiabilitiesCreditors (55,789) (75,755) (74,658)Loan Principal due in 1 year (2,288) (2,421) (2,421)

Total Current Liabilities (58,077) (78,176) (77,079)

Loan Principal due after 1 year (17,147) (13,661) (19,738)

Total Assets Employed 232,938 233,398 238,830

Taxpayers EquityPublic dividend capital 101,508 104,280 104,578Income and expenditure reserve 106,671 106,734 111,869Revaluation reserve 24,749 22,384 22,384

Total Taxpayers Equity 232,928 233,398 238,830

Appendix D – Sensitivity Analysis

2015/16 2015/16 2015/16Sensitivity Analysis Best Case Expected Worst

£000s £000s £000s

IncomeNHS Clinical Income 210,150 202,934 197,493Private Income 85,212 83,541 82,192Other Income 63,956 63,956 63,956Donated asset income 10,025 10,025 10,025

369,343 360,457 353,666Expenditure

Operating Expenditure 337,594 335,900 338,568337,594 335,900 338,568

Operating Surplus- EBITDA 31,750 24,557 15,098EBITDA Margin 8.6% 6.8% 4.3%

Other Operating and Non-Operating ItemsDepreciation & Financing (19,490) (19,423) (18,907)

Surplus /(Deficit) for year 12,260 5,134 (3,809)

Depreciation 14,515 14,461 13,961Donated Asset Income (10,025) (10,025) (10,025)

Development Reserve for Investment 16,750 9,570 127

Capital ProgrammeNHS - Internally Financed 18,000 9,151 - NHS - Loan Finance - Existing 4,498 4,498 4,498NHS - Loan Finance - New 7,000 4,000 - NHS Public Dividend Capital Funding 298 298 298Donated Capital 10,025 10,025 10,025

Total Capital Programme 39,821 27,972 14,821

Internally Financed Capital over 5 years 72,000 40,651 - Total Capital Programme over 5 Years 169,323 118,974 72,323

Cash Balance 18,295 19,961 19,664

Loan Finance Liability 25,159 22,159 18,159

Debt Financing Payments (Loan and PDC) 7,426 7,417 7,405

Monitor Risk RatingCapital Service Cover Metric 4 3 1Liquidity Metric 3 3 3

Overall Risk Rating 4 3 2

Appendix D – Sensitivity Analysis (continued)

Bridge Analysis from 2014/15 Forecast 2015/16 2015/16 2015/16Outturn to Planned Surplus / (Deficit) Best Case Expected Worst

£000s £000s £000s

Prior Year Surplus / (Deficit) 1,554 1,554 1,554

NHS Income and Activity Changes 4,934 - (4,441)

Changes to other income / Cost Pressures (7,445) (7,995) (9,887)

Inflationary Pressures (4,192) (4,192) (4,192)

Changes to Deprecation and financing costs (1,587) (1,520) (1,004)

Baseline before Efficiency Programme (6,736) (12,153) (17,970)

Efficiency Programme 12,478 10,770 7,643

Surplus / (Deficit) before Donated Income 5,742 (1,384) (10,327)

Change in Donated Asset Income 6,519 6,519 6,519Planned Surplus / (Deficit) 2015/16 12,261 5,135 (3,808)

Appendix E – Sensitivity Analysis (continued)

Sensitivity Analysis Best Case Expected Case Worst Case2015/16 2016/17 2017/18 2018/19 2019/20 2015/16 2016/17 2017/18 2018/19 2019/20 2015/16 2016/17 2017/18 2018/19 2019/20

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000sDevelopment Reserve for Investment 16,750 16,750 16,750 16,750 16,750 9,570 9,570 9,570 9,570 9,570 127 127 127 127 127 Surplus / (Deficit) 12,260 11,067 14,887 15,541 15,716 5,135 4,418 8,690 9,523 9,877 (3,809) (4,463) 226 1,208 1,710

Capital Programme

NHS - Internally Financed 18,000 14,500 11,500 11,500 16,500 9,151 9,000 6,500 6,500 9,500 - - - - - NHS - Loan Finance - Existing 4,498 - - - - 4,498 - - - - 4,498 - - - - NHS - Loan Finance - New 7,000 12,000 6,000 - - 4,000 2,000 - - - - - - - - NHS Public Dividend Capital Funding 298 - - - - 298 - - - - 298 - - - - Donated Capital 10,025 10,996 15,506 15,500 15,500 10,025 10,996 15,506 15,500 15,500 10,025 10,996 15,506 15,500 15,500

39,821 37,496 33,006 27,000 32,000 27,972 21,996 22,006 22,000 25,000 14,821 10,996 15,506 15,500 15,500

Cash Balance 18,295 18,136 20,969 20,665 15,362 19,961 18,109 18,380 18,275 15,170 19,664 17,366 15,069 12,771 10,474 Loan Finance Liability 25,159 34,738 38,316 32,770 27,224 22,159 21,738 18,941 15,770 12,599 18,159 15,738 13,316 10,895 8,474 Debt Financing Pay ments (Loan and PDC) 7,426 7,609 7,788 10,942 10,965 7,417 7,499 7,912 8,297 8,354 7,405 7,428 7,450 7,469 7,537

Monitor Risk Rating

Capital Service Cover Metric 4 4 4 3 3 3 3 3 3 3 1 1 1 1 1 Liquidity Metric 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2

Overall Risk Rating 4 4 4 3 3 3 3 3 3 3 2 2 2 2 2

Metric Chart T rends

The charts set out the trend of the Monitor metrics over 5 years, based on different scenarios, compared to the metrics for risk rating outcomes.

In the best and expected scenarios, loan and internally financed capital expenditure has been balanced to achieve target performance between a 3 and 4 on each metric. In the worse case revenue for capital servicing will deliver a 1 based on current PDC dividend and loan financing commitments.

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Agenda item 5.

Title of Document: Corporate Governance

To be presented by Chairman

Executive Summary 5.1. Monitor’s “well-led framework” At their last meeting, the Board discussed Monitor’s “well-led framework” which suggests NHS Trust’s to carry out an external review of their Corporate Governance standards every three years. Following this and as requested by the Board, the Trust has reviewed the guidance and discussed the position with its internal auditors. The Chairman will update the Board on the outcome of that discussion and discuss with Board members what the next steps should be. 5.2. Trust Constitution Section 2 of the enclosed report highlights the proposed updates the Trust would like to make to the Trust Constitution and the reasons why. No major policy changes are being put forward at this stage; the Board is asked to note and approve accordingly. Recommendations

• The Board is asked to discuss and agree the next steps with regard to Monitor’s “well-led framework” and;

• Note and approve the proposed updates to the Trust Constitution which are outlined in the enclosed report and have been approved by the Council of Governors.

Author: Syma Dawson, Head of Corporate Governance

Contact Number or E-mail: x2826


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Trust Constitution 1. Introduction and Purpose 1.1. The Board may recall that there have been several commencement orders under the

Health and Social Care Act (HSCA) since the 1st October 2012 resulting in incremental updates to the Trust’s Constitution. However it is recognised that good governance practice ensures the Trust’s Constitution not only remains consistent with legislation but also regulatory requirements, Corporate Governance standards as well as being ‘fit for purpose’.

1.2. The Trust has therefore reviewed the current Constitution and subject to Board approval,

would like to regularise its provisions in line with NHS Constitutional requirements and Trust practice. Please note that the proposed additions do not constitute a major revision of the Constitution as no policy changes have been made at this stage.

2. Proposed updates to the Trust Constitution 2.1. Following the constitutional changes introduced by HSCA, new regulations setting out

fundamental standards of care have come into force for all healthcare providers which includes the ‘Fit and Proper Person Test’ (FPPT) for Directors and Governors. This ‘test’ plays an important part in ensuring the accountability of governors and directors of NHS bodies to encourage a culture of openness and to hold providers to account. As a result, sections 28.1 and 28.2 for Directors have been added to the Constitution to reflect this new requirement.

2.2. Restriction on membership (section 11): additional clauses have been added to this section following a careful review of other NHS Constitutions which clarify the process to be followed in the event a member is found to be ineligible.

2.3. The Council of Governors made the decision to remove the Paediatric and Young Adult Constituency at its meeting on the 3rd December 2013 which has also been incorporated into the revised Constitution (Annex 1).

2.4. New model election rules were published by NHS Providers (formerly known as Foundation Trust Network) in August 2014 and have therefore been included (Annex 2).

2.5. The Council of Governors Code of Conduct has been made more concise in light of other NHS Trust’s Code of Conduct (see Annex 3).

2.6. The Internal Dispute Resolution can be found in Annex 4 of the enclosed Constitution and has been taken from the Council of Governor / Board Standing Orders which were approved at their meetings in November / December 2013.

3. Recommendation The Board is asked to:

• Review and approve the proposed updates to the Trust Constitution which will regularise its provisions in line with regulatory requirements and Trust practice;

• Note that Council have approved the proposed updates at their meeting on the 4th March 2015.



Agenda item 6.

Title of Document: New Models of Care

To be presented by

Chief Executive / Chief Nurse

Background NHS England and its national partners have announced a new programme to focus on the acceleration of the design and implementation of new models of care in the NHS. As set out in the Five Year Forward View, rapid progress is needed to speed up the development of new care models for promoting health and wellbeing and providing care that can then be replicated more easily in other parts of the system. Through the New Care Models Programme, individual organisations and partnerships, including those with the voluntary sector, are invited to apply to be ‘vanguard’ sites. These organisations will have the opportunity to work with national partners to co-design and establish new care models, tackling national challenges in the process. Expressions of interest in becoming a New Care Model partner were invited in February 2015 and the RM application was accepted through to the second round. The RM was then invited to present on its model to NHS England, Monitor, the Trust Development Authority and the Kings Fund on the 2nd March. The RM heard on 10th March that its application was welcomed by the New Care Models programme and that the NHSE team were “extremely impressed” with the RM proposal. RM will be invited to meet with the Programme team in the near future. The document enclosed is the Trust’s application to become a New Care Model site. Executive Summary The world of cancer research and treatment is changing at an astonishing rate, as new developments in science and technology combine with new models of discovery and delivery vehicles. Working in partnership with patients and families, The Royal Marsden (RM) is to progress co-design work to enable a greater number of patients to benefit from RM specialist cancer expertise closer to their home. The Royal Marsden has already developed an integrated pathway between the centre and unit to allow patients to receive care locally wherever possible, with fast referral to the Centre when necessary, delivered by an integrated clinical team. Please note that the current model is for chemotherapy and further models are being developed for radiotherapy across London (south and north west).

http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

Recommendations The Board is asked to note and discuss the Trust’s application to join the new models of care programme. Author: Dr Shelley Dolan, Chief Nurse



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New Models of Care Forward View into Action Registering interest to join the new models of care programme Q1. Who is making the application? (What is the entity or partnership that is applying? Interested areas may want to list wider partnerships in place, e.g. with the voluntary sector. Please include the name and contact details of a single senior person best able to field queries about the application.) The Royal Marsden NHS Foundation Trust in partnership with acute care providers in South and North West London. Cally Palmer, Chief Executive Executive Assistant, Diane Forzani 0207 808 2101 [email protected] Q2. What are you trying to do? (Please outline your main objectives, and the principal changes you are planning to make to change the delivery of care. What will it look like for your local community and for your staff?) The world of cancer research and treatment is changing at an astonishing rate, as new developments in science and technology combine with new models of discovery and delivery vehicles. Working in partnership with patients and families, the Royal Marsden (RM) is to progress co-design work to enable a greater number of patients to benefit from RM specialist cancer expertise closer to their home. The Royal Marsden has already developed an integrated pathway between the centre and unit to allow patients to receive care locally wherever possible, with fast referral to the Centre when necessary, delivered by an integrated clinical team. The current model is for chemotherapy and further models are being developed for radiotherapy across London (south and north west). This would enable benefits to the patient and health economy through: Improved Health and Wellbeing:

• Every contact matters: Specialist multi-professional teams including expert cancer nurses from the cancer centre will run wellbeing and preventative events at the units. These patient / family focused sessions are supported by the cancer charities and provide a network of supportive care.

• Straight to test model: Improved diagnostics with integrated pathways through primary care to cancer centre and units.

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• Risk stratified follow up: The RM has led this model in South West London successfully transferring over 3,000 women with breast cancer onto an Open Access Follow Up pathway to improve patient experience and efficiency.

Improved Quality: Delivery of cancer care closer to home by expert RM multi-professional teams Seamless integrated pathways of care underpinned by international research and

multi-professional expertise. Improved access to molecular diagnostics, precision medicine, novel therapies and

clinical trials. Eliminate unnecessary hospital attendances and travel to RM central site. Improve the acute oncology at the cancer unit by effective partnership with the cancer

centre. Improved efficiency:

• Trial new staffing models, with the ultimate aim of providing the highest quality of care for the best value

• Prevention and avoidance of emergency cancer admissions through Emergency Departments by strengthened multi-professional AOS services.

• Implementation of risk stratified pathways for all the common cancers integrated between cancer unit and centre.

The RM is uniquely placed to lead this innovation across a population of approximately 5.9 million people because of three key factors: 1. The RM track record in the co-design and successful implementation of a specialist cancer franchise providing chemotherapy closer to home with an acute provider. The RM has led this model at Kingston NHS FT for the last seven years delivering a safe and effective service closer to home with excellent patient feedback to approximately 2,000 patients (51, 963 attendances). The evidence on patient waiting times metrics as a proxy for performance is provided in Appendix 1.

RM intends to work with partner providers across London who would not, by themselves, have the expertise or scale required to deliver sustainable, high quality cancer treatment services. Initial partners have been identified to further prove the model and if this is successful then the model would be extended further focussing on extending the model throughout South West and North West London working with acute and appropriate community and primary care providers. The initial focus of the model would be on improving access to specialist expert chemotherapy services and radiotherapy services. The RM has successfully implemented and embedded a chemotherapy franchise seven years ago and has identified at least two further sites in South West London and one in North West London. The RM currently provides all the radiotherapy services for South West London on an international research platform. The plan is to extend this successful model to all radiotherapy services for North West London through the agreed plan for RM@Imperial College HealthCare Trust. The RM also has a research relationship with Mount Vernon Cancer Centre and subject to further discussion would be keen to extend the franchise further to patients receiving their radiotherapy at MVCC. 2) The RM recognised track record in leadership both internally of an internationally renowned comprehensive cancer centre, and externally with partners for example setting up and hosting the London Cancer Alliance and hosting community services

3

for the last four years. The London Cancer Alliance has over the last three years succeeded in leveraging the expertise of over 3000 clinicians across South and West London; agreed and implemented a common data set and quality accreditation system; and commenced on service reconfiguration to improve quality, reduce variation and avoid duplication. The RM began hosting Sutton and Merton community Services in April 2011 and has through robust clinical engagement and leadership improved all patient safety, quality and patient experience metrics and delivered 100% CQUIN targets (Appendix 1). 3) Excellence in translational research: The RM would utilise its successful partnership with the Institute of Cancer Research (ICR) and the joint research programme in molecular diagnostics and molecular monitoring, for example the molecular diagnosis and targeting of women with breast cancer to ensure that only those women who are ICH4 positive receive chemotherapy, thus avoiding the toxicity of treatment for the women and the cost to the NHS. The RM/ICR have equally led international work in precision radiotherapy using the latest innovative techniques to ensure patients have the best curative treatment whilst minimising the damage to their healthy tissue, thus improving cancer survival and minimising and long term consequences of cancer treatment. Q3. Which model(s) are you pursuing? (of the four described) Additional models for smaller viable hospitals: 17. ii “Focusing on delivering specialist tertiary services across multiple sites- for example, cancer services – using an NHS franchise model”. Q4. Where have you got to? (Please summarise the main concrete steps or achievements you have already made towards developing the new care model locally, e.g. progress made in 2014.)

1. Proof of Concept the RM@Kingston NHS Foundation Trust 2008 – current Successful co-design and implementation now embedded for seven years. Research–led chemotherapy services closer to home. Treated in excess of 2000 patients safely and effectively and with excellent experience reported by patients.

2. RM@Croydon University NHS Trust (CUH) for patients receiving chemotherapy who live close to Croydon but currently receive their chemotherapy in RM Sutton. A model has been identified and a pathway developed (see Appendix 2). The design includes a strengthening of the current Acute Oncology Services model provided by RM@Croydon and an Outpatient model seeing patients under a risk stratified follow up model where appropriate.

3. RM@Imperial College Healthcare NHS Trust (ICHT) – RM formally asked to lead chemotherapy and radiotherapy services across ICHT. Both boards have approved a Heads of Terms.

4. RM/ICR together with Imperial College and ICHT have agreed a joint cancer clinical and translational research programme.

Q5. Where do you think you could get to by April 2016? (Please describe the changes, realistically, that could be achieved by then.) Initial site, RM@Croydon could be fully implemented by April 2016. The model has been designed and Pathways developed (see Appendix 1). Patients that will benefit through treatment closer to their homes have been identified. The intention is to initially use existing RM staff. With funding, a chemotherapy suite can be set up and this model tested.

4

RM@ICHT this programme will commence with the RM leading radiotherapy with a start date in July of 2015 and delivering the complete service by April 2016. RM@ICHT chemotherapy could follow the same timescale if agreed by all parties or phased to commence in the Autumn of 2015 and would have been partially implemented by April 2016. The RM/ICR/IC/ICHT translational research programme will commence by April 2015 and is important as it underpins and promotes the clinical engagement of the RM@ICHT. Q6. What do you want from a structured national programme? (Aside from potential investment and recognition: i.e. what other specific support is sought?) Financially it is currently envisaged that the model will be self-sustaining (subject to achieving the necessary volumes). However there are likely to be up front transitional costs for which support will be sought (e.g. capital for equipment and refurbishment of sites and revenue for project team and initial double running costs). RM recognises the need to develop an appropriate clinical and service model and then develop the legal form appropriately and anticipate that this model could follow either a collaborative or a contractual partnership. Support may be required in relation to these structures and any relevant implications that it has under competition laws. Once the models are tested the RM would make the relevant due diligence, contractual and legal documents available so that they could be used as a model for any other centres in the NHS. The models described can be scaled according to available capital and revenue and this can be modelled in the next stage of the process if required. Our track record in establishing a specialist franchise demonstrates very significant impact in patient experience, quality and efficiency for relatively low investment. The RM would utilise any available resource to accelerate delivery of new integrated pathways under the franchise model.

5

Appendix 1 Performance Metrics Franchise model at Kingston Volume of Patients in Franchise Chemotherapy Service

4000

6000

8000

10000

12000

14000

The Royal Marsden at Kingston (Sir William Rous Unit)All Patient Attendances, April 2008 - December 2014 (projected to March 2015)

Patient Feedback on Service Quality Q 32. Overall, how would you rate the care you receive at this day unit? Excellent * 80% Very good * 20% Good 0% Fair 0% Poor 0%

6

RM leadership of Sutton and Merton Community Services The SMCS community nursing service has, over the past three years, markedly improved its KPI performance: 2012/13 reported KPI’s 41% rated Green (≥ target) 2013/14 reported KPI’s 64% rated Green (≥ target) 2014/15 (to Q3) reported KPI’s 96% Green (≥ target)

2012/13

41%

8%

51%

2013/14

64%4%

32%

2014/15 (to Q3)

96%

2% 2%

7

Appendix 2: Pathway for RM@Croydon



Agenda item 7.1.

Title of Document: Performance 7.1. Finance Report for month 10

To be presented by

Chief Financial Officer

Executive Summary The Trust has delivered an improved financial performance in the month driven by the income over-performance and is therefore expected to achieve the financial plan for the year. Recommendations The Board are requested to note the position to date and the continued focus on securing the future financial sustainability of the Trust. Author: Marcus Thorman, Chief Financial Officer



FINANCE REPORT – 10 MONTHS ENDED 31st January 2015 1) Introduction This report provides a brief summary of the Trust’s financial results for the 10 months ended 31st January 2015. 2) Summary After ten months the Trust is reporting a surplus for development of £9.7m against a plan of £10.0m, an adverse variance of £0.3m. In January, the Trust achieved a surplus for development of £0.9m. The position in month was driven by additional income, both the cancer drug fund, but also additional NHS clinical income. It is expected that with continued cost control for the following two months the Trust will achieve its financial plan for the year.

All areas, except two, have demonstrated an improvement in their forecast outturn positions in month. The two that did not show an improvement are subject to further review with an expectation that the forecast at month 10 will be improved for year end. The focus continues to be on the efficiency programme; in particular for completing the transaction for out-patient pharmacy now that the Board have approved the contract; on continuing reductions in use of agency staff, which will be greatly assisted following approval of an update to the rostering system and implementing a set of new measures over the next few months; and on continued strengthened controls on discretionary expenditure. The Business Planning process for 2015/16 is in its final stages internally and all areas are expected to deliver upon the jointly agreed financial plan.

£0.5

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£m

Surplus for Development Reserve

Actual Plan

The Trust has maintained its low risk Continuity of Service Risk Rating of 4 (out of 4) using the Monitor metrics. 3) Cash

The chart below shows the cash balance at the end of January (£20.3m) using the scale on the left hand axis and the liquidity days for the Trust, using the scale on the right. The balances over the last 12 months are shown for reference:

The cash position continues to improve as a result of improvements to the private care billing cycle. At the end of January NHS England had not paid £4.6m of over performance debt, but the first six months over-performance of £3.6m has subsequently been received in February and it is hoped that further payments will be made before the end of the financial year. Further discussions are being held with NHS England with regards to Project Diamond invoices and it is expected progress will be made on this issue in the next few weeks.

4) Revenue The waterfall graph below shows the key variances from the financial surplus plan.

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

Cash £18.3 £20.0 £14.1 £11.7 £9.8 £8.9 £10.2 £12.4 £16.9 £18.1 £17.9 £20.3

Liquidity 27 27 28 24 26 25 26 28 32 33 26 25

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4.1) Income NHS Clinical income is showing a favourable variance of £2.3m in month and £7.3m to date. The key variance is the cancer drug fund which is £5.5m above the plan, however, this is offset by expenditure. NHS acute services income was significantly above plan in month, partly due to catching up on activity from December, but also due to several inpatients being discharged from the hospital with high levels of CCU days included, hence the over-performance. Other key variances to date are private patients, which has a £2.9m adverse variance to plan and clinical research which has a £3.2m adverse variance to plan. Both of these areas are broadly offset by expenditure underspends and are therefore not considered to be at risk for year end. 4.2) Expenditure Operating expenditure is £2.2m adverse variance after ten months. Key adverse variances are as follows: Cancer services division (£2.3m adverse) – staffing cost variances in nursing and junior

doctor driven by temporary staffing usage (£1.2m) due to vacancies, sickness and maternity cover. There are adverse expenditure variances for non-pay which relate to income over performance.

Clinical services division (£2.3m adverse) – staffing cost variances in pharmacy and pathology due to increased costs ahead of reconfiguration, and in critical care nursing due to recruitment difficulties. The division actually achieved a break-even position in month, the first time this year, and have significantly improved their forecast as a result.

Divisional overspends are being managed by management of reserves, where developments have been delayed without detriment to performance for the year to date. 4.3) Efficiency The efficiency programme is behind plan as at month 10 by £4.2m and little progress has been made on new schemes in the past few months. This has to be addressed and therefore a new approach has been developed for 2015/16, which will be based on some key themes and will be overseen by a new committee, the Transformation Board.

5) Capital

The table below shows capital expenditure against the plan, covering both NHS and Charity funded schemes.

Capital Performance (figures in £000)

Original

Plan Revised

Plan YTD Plan

YTD Actual

YTD Variance

Forecast variance

NHS Internally Financed 11,176 9,738 7,844 6,161 1,683 1,136

Loan Financed 15,916 13,869 8,458 7,528 930 1,915

Donated 3,113 3,957 1,544 2,993 (1,449) 464

Total 30,205 27,564 17,846 16,682 1,164 3,515

Favourable /(Adverse)

Where possible and safe to do so, schemes financed from internal resources will continue to be deferred or re-prioritised depending on the revenue and cash position throughout the year.

6) Conclusion The Trust has delivered an improved financial performance in the month driven by the income over-performance and is therefore expected to achieve the financial plan for the year. The key risks looking forward continue to relate to external issues on tariff and its structure for income, whereas for expenditure they are associated with cost control and margin improvement. Recent external focus has seen collaboration with other specialist Trusts in London on Project Diamond and tariff issues, these are expected to continue. Internally the focus has been on reducing expenditure run rates in line with the financial plan and in developing an affordable plan for 2015/16. The Board is requested to note the position to date and the continued focus on securing the future financial sustainability of the Trust.

APPENDIX

FINANCE REPORT – 10 MONTHS ENDED 31st January 2015

Annual

Budget Year to Date

Budget Actual Variance £'000 £'000 £'000 £'000 Operating Income

156,824 NHS Clinical Income 130,736 138,106 7,370

37,871 NHS Community Services 31,559 31,466 (93)

81,664 Private Patient Income 67,863 64,934 (2,929) 13,661 Research and Development 11,487 11,573 86 54,150 Other Operational Income 45,054 42,514 (2,541) _________ _________ _________ _________ 344,170 Total Operating Income 286,700 288,593 1,894 Operating Expenditure 82,913 Cancer Services 69,064 71,398 (2,335) 77,750 Clinical Services 64,638 66,982 (2,344) 34,963 Community Services 29,172 28,630 543 28,187 Private Patients 23,608 20,987 2,621 45,579 Other Divisions 37,827 36,858 969 58,263 Other Operating Expenditure 48,258 49,914 (1,656) _________ _________ _________ _________ 327,655 Total Operating Expenditure 272,567 274,769 (2,202) _________ _________ _________ _________ 16,515 EBITDA 14,132 13,825 (308) _________ _________ _________ _________ 4,913 Dividend Payable / Interest 4,087 4,108 (21) _________ _________ _________ _________ 11,602 Development Reserve 10,046 9,717 (329) _________ _________ _________ _________ 10,242 Depreciation / Donated Capital Income 7,769 7,840 (71) _________ _________ _________ _________ 1,360 Retained (Surplus)/Deficit 2,276 1,877 (400) _________ _________ _________ _________ _________ _________ _________ _________



Agenda item 7.2.

Title of Document: Performance 7.2. Performance and Quality Report

To be presented by

Chief Operating Officer

Executive Summary This paper provides a report on the Trust’s performance for quarter 3 2014/15 including the balanced scorecard for the Trust and a commentary on the red rated indicators and actions underway to improve performance. Recommendations The Board is asked to discuss and note the Trust’s performance against the balanced scorecard indicators for quarter 3 2014-15. Author: Nicky Browne, Director of Performance & Strategy Implementation



1

Key Performance Indicators

Quarter 3 2014/15 1. PURPOSE This paper is intended to provide the Board with an update on the Trust’s performance for quarter 3 2014/15. The scorecard and narrative is also submitted to the Council of Governors. The report includes the balanced scorecard for the Trust and a commentary on the red-rated indicators in the quarter 3 report and actions underway to improve performance. The data included for RMH market share is the most up to date available and more recent data has been requested and will be included once received. The Staff Friends and Family Test does not take place in quarter 3 as the annual staff survey is undertaken during this time period. The results of the annual staff survey are now available and the Board will be provided with this detail separately. 2. KPI REVIEW

The scorecard, including its KPIs and definitions and thresholds, will continue to be reviewed during quarter 4 2014/15 to ensure the indicators remain relevant. The measure pertaining to complaints has been revised and included in the quarter 3 scorecard. The new measure shows the number of complaints fully upheld in the quarter as a proportion of the number of complaints closed within the quarter. The thresholds have been based on the outturn for 2013/14. The rationale for this change is that it is line with the national returns and more accurately measures both the levels of service provided to patients and the transparency and effectiveness of the complaints process. The measure relating to Hospital Standardised Mortality Ratio is currently being validated and has therefore not been included in the quarter 3 scorecard. 3. PERFORMANCE FOR QUARTER 3 The Trust met all of the Monitor indicators and targets for quarter 3. Attachment 1 shows the balanced scorecard report for quarter 3 for 2014/15. As agreed a commentary is only provided for indicators where performance is ‘red’ rated. (NB ▲ shows improvement from the previous quarter, ►◄ shows no change and ▼ shows deterioration). 3.1 Quality Account Indicators The quality account indicator is rated amber in quarter 3 due to one case of MRSA for the year to date against a national standard of zero tolerance. The number of cases of MRSA is no longer a Monitor indicator

2

3.2 62 day wait for first treatment – GP referral to treatment (before reallocation) Q3: 79.4% Target: 85%

The Trust met all cancer waiting times targets, with the exception of the 62 day wait for treatment GP referral to treatment before reallocation. The Trust met the standard after reallocation. A detailed analysis of reasons for underperformance has been undertaken and the key issues are detailed below. During quarter 3 there were 82 patient breaches of which 59 (72%) were due to late referrals. In the remaining 23 cases, the patient was referred on day 42 or sooner. Of these, 16 cases were out of the control of the Trust and were due to: Complex diagnostic (9) Patient fitness (3) Patient choice (4) In only seven cases the breaches were within the control of the Trust and were due to: Capacity (2) Administration (3) – date offered after breach date however patient offered an earlier date which was subsequently declined Delayed pathway (2) The Trust has experienced a deterioration in performance against the 85% standard since quarter 2 2013/14, at the same time as the Trust has experienced an increase in late referrals. Quarter 3 is however an improvement on quarter 2. Given this deterioration, an action plan has been put together to address the issues identified, which has been shared with Monitor, NHS England and local commissioners. The Trust was asked to attend a Tripartite Taskforce Escalation Meeting in February to discuss the issues facing the Trust. RMH has modeled an improvement trajectory based on working with referring Trusts to reduce the number of late referrals, which shows the Trust as meeting the standard from October 2015 and NHS England will provide specific support to ensure numbers of late referrals are significantly reduced.

3

Forecast: The Trust has submitted a trajectory to NHS England showing compliance in Quarter 3 2015/16. The Trust expects to continue to meet the standard post reallocation.

3.3 No. of patients waiting >52 weeks at quarter end Q3: 2 Target: 0 There are two patients waiting >52 weeks at quarter end. Both patients are confirmed benign and have opted for delayed reconstruction. The delays are due to patient choice as both have chosen to wait this amount of time for surgery. Once both patients have completed treatment, these will no longer by 52 week waiters due to the application of patient choice adjustments. The Trust has discussed this with NHS England and has provided the necessary assurance. Forecast: 0 3.4 PP Income Variance

Q3: -£2,622k Target: Break even The PP income position has improved since quarter 2 and is 14% ahead of last year. Despite this improvement the position remains red due to planned capacity in Horder being unavailable for PP use and a delay in the business case for revising the tariff structure for diagnostic tests. The PP adverse income variance is likely to continue into quarter 4 although cost savings and unspent reserves will reduce the overall gap to the planned surplus. The below chart indicates the position over the last year. Forecast: Red Q4

3.5 Achievement of Efficiency Programme

Q3: 66% Target: 100%

The efficiency programme improved in quarter 3 to achievement of 66%. The majority of the remaining shortfall relates to the PP revenue programme as discussed above as well as the unfunded services review cost improvement programme which is still being developed. Whilst the specific CIPs identified in business planning have not been fully delivered, the Trust expects to meet its financial plan through a combination of NHS income performance and management of its costs without detriment to patient care. The chart below shows quarterly performance throughout the year. Forecast: Amber Q4

4

3.6 No. of inpatients discharged whose LOS >15 days Q3: 265 Target: <200

Although the number of patients with a length of stay of fifteen days or more was greater than normal, the Trust has robust procedures in place to monitor all patients with a length of stay greater than 10 days. All patients are reviewed to ensure there is a clear treatment or care plan in place, discharge planning is underway and any delayed discharges are escalated to senior managers to ensure all appropriate actions are taken to facilitate the patient discharge. In view of continued red for this measure, a review of the data across elective and non-elective patients is being undertaken to establish what is driving the length of stay to determine a meaningful measure and threshold. This should be in place for quarter 4 reporting. No forecast has therefore been included in this report. In the meantime, the division will undertake an analysis of the number of patients whose length of stay exceeded 15 days and explore linking in with community services in order to reduce length of stay.

3.7 Percentage of closed commercial interventional trials meeting contracted recruitment target Q2: 59% (1 Q in arrears) Target: >85%

This measure includes trials that the Trust has hosted over the past 12 months and includes clinical trials with a status of either ‘open to recruitment’, ‘closed to recruitment – in follow up’, or ‘closed to recruitment – follow up complete’. For many trials, there is an extremely long follow-up period which can, in some cases, be up to ten years meaning that some trials can remain part of this measure for up to 11 years. Many of the older trials were set up when the principal investigators were much less realistic with recruitment targets and subsequently failed them. These trials however cannot be removed from this measure until their status has been closed to recruitment i.e. follow up is complete for 12 months. The chart below shows quarterly performance throughout the year.

5

3.8 Appraisal and PDP rates

Q3: 68% Target: >85%

The rate has reduced from the previous quarter following a dip in October 2014. However, at the end of January 2015 the figure had increased to 73% compliance. Further action is now being taken to increase reporting to enable closer performance management against this requirement. At the same time audits of data are being conducted to improve accuracy where necessary. These improvements in the frequency and quality of reporting to managers will enable them to closer manage the completion of appraisals achieve agreed performance standard. The chart below shows quarterly performance throughout the year. Forecast: Green by end of Q4

ATTACHMENT 1 - Balanced Scorecard Report for Quarter 3 2014/15

BALANCED SCORECARD end Q3

Patient Safety, Quality & ExperienceQ3 Actual

Trend from Q2 Q2 Actual

Monitor governance risk rating ►◄

Quality Account indicators ▼

Certification against compliance with requirements regarding access to health care for people with a learning disability ►◄

Serious incidents (excl pressure sores) 1 ▲ 2Complaints - % upheld 25.6% ▲ 32.3%

MortalityHospital Standardised Mortality Ratio ( qtr in arrears) TBC ▼ 88.630 day mortality post surgery 0.6% ▲ 1%30 day mortality post chemotherapy 0.3% ►◄ 0.3%100 day HSCT mortality in previous 6 months (Deaths related to SCT) 5.0% ▲ 8.6%100 day HSCT mortality in previous 6 months (All deaths) 5.0% ▲ 8.6%

Cancer stagingStaging data completeness sent to Thames Cancer Registry (1 qtr in arrears) 68.0% ▼ 70%

Patient satisfaction Inpatient 90.3% ▲ 88.5%Outpatient 82.8% ▲ 82.4%Day Unit 87.3% ▲ 87.0%Waiting times for day chemotherapy (over 3 hrs) 11% ►◄ 11%% of formal complaints reopened (indicator under review)Mixed sex accommodation breaches 0 ►◄ 0PP access to single rooms - Chelsea % 99.9% ►◄ 99.9%PP access to single rooms - Sutton % 99.0% ▲ 98.1%

Cancer waiting times targets2 wk wait from referral to date first seen: all cancers 96.8% ▼ 97.0% symptomatic breast patients 96.4% ▲ 93.3%31 day wait from diagnosis to first treatment 99.4% ▼ 99.7%31 day wait for subsequent treatment: surgery 99.2% ▲ 97.5% drug treatment 100.0% ▲ 99.8% radiotherapy 99.0% ▲ 96.7%62 day wait for first treatment: GP referral to treatment (reallocated) 86.9% ▲ 84.2% GP referral to treatment (before reallocations) 79.4% ▲ 71.8% Screening service referral (reallocated) 91.6% ▼ 95.5% Screening service referral (before reallocations) 93.8% ▲ 92.8%

Referral to treatment waiting timesMaximum time of 18 wks from referral to treatment - admitted 95.4% ▲ 95.1%Maximum time of 18 wks from referral to treatment - nonadmitted 98.2% ▲ 97.8%Maximum time of 18 wks from referral to treatment - still waiting 95.1% ▼ 96.5%No of patients waiting > 52 wks at quarter end. 2 ▼ 0

1. To achieve the highest possible quality standards for our patients, exceeding their expectations, in terms of outcome, safety and experience

Finance & Efficiency Q3 ActualTrend

from Q2 Q2 ActualMonitor financial risk rating 4 ►◄ 4Capital Servicing Capacity (times) 3.3 ▲ 3.1EBITDA Margin (%) 4.8% ▲ 4.5%Achievement of planned year to date operating surplus (%) 99% ►◄ 99%NHS activity Income Variance (£000) 290 ▼ 877PP activity Income Variance (£000) -2,622 ▼ -2,472Liquidity (days) 24.9 ▼ 27.7Achievement of Efficiency Programme (%) 66% ▲ 44%

CQUINS % achievement - Acute TBC 100%CQUINS % achievement - Sutton and Community Services 100% 100%

Asset utilisationBed occupancy - Chelsea 88% ▲ 84%Bed occupancy - Sutton 81% ►◄ 81%Theatre utilisation - Chelsea 89% ▲ 86%Theatre utilisation - Sutton 76% ▲ 69%Utilisation of diagnostic radiology (target under review) 29387 ▼ 29407

3. To deliver the Trust's clinical and research strategy; redefining our market position to better meet the needs of patients and commissioners, and increasing market penetration

Clinical and Research Strategy Q3 ActualTrend

from Q2 Q2 ActualNew referralsTotal new referrals 5595 ▲ 5538Total GP referrals 2456 ▲ 2414GP referrals - urgent suspected cancers for diagnosis 1484 ▼ 1506Referrals from Surrey 950 ▲ 932

RMH market share2012/13 2011/12

RMH market share - England (planned cancer admissions) TBC 2.30%RMH market share - London (planned cancer admissions) TBC 14.10%

Personalised care - building molecular diagnosticsInternal referrals 915 ▲ 866External referrals 994 ▲ 917CRUK Stratified Medicine Programme 42 ▼ 96

Private carePP inpatient beddays and regular day attenders - Chelsea 4212 ▼ 4251PP inpatient beddays and regular day attenders - Sutton 1783 ▲ 1685

Efficient clinical modelsNo of inpatients discharged whose LOS > 15 days 265 ▲ 270

Research 70 day target (for externally sponsored trials only)

NIHR Adjusted figure (excluding delays attributed to sponsor/neither sponsor or trust) 94% ▼ 97%

Accrual to target (excluding trials that had no set target) (1 qtr in arrears) 59% ▼ 60%

2. To improve the productivity and efficiency of the Trust in a financially sustainable manner, within an effective f k

annually measured

4. To recruit, retain and develop a high performing workforce to deliver high quality care and the wider strategy of the Trust

WorkforceQ3 Actual

Trend from Q2 Q2 Actual

Human Capital - workforce establishmentBank & agency as % of total FTE 11% ▲ 11.1%Bank and agency spend as % of total pay expenditure 9.2% ▲ 9.4%Agency as % of total pay bill 4.8% ▲ 5.1%

Workforce productivityVacancy rate 6.6% ▲ 7.5%Staff turnover rate 12.8% ►◄ 12.8%Consultants job plans 94% ►◄ 94%Junior doctor rota compliance 100% ►◄ 100%

Quality & developmentConsultant appraisal (number with current appraisal) 84% ▲ 82%Appraisal & PDP rate 68% ▼ 71%Statutory and Mandatory Staff Training 81% ▼ 83%

5. Monitor Community Measures

Q3 ActualTrend

from Q2 Q2 ActualCommunity care - referral to treatment information completeness 75.0% ►◄ 75.0%Community care - referral information completeness 78.6% ▼ 91.7%Community care - activity information completeness 76.2% ▼ 84.2%

Q3 ActualTrend

from Q2 Q2 ActualRecommend – Care N/A N/A 96%Not recommend – Care N/A N/A 1%Recommend - Work N/A N/A 73%Not recommend - Work N/A N/A 10%

Delivering or exceeding Target ▲Underachieving Target ►◄

Failing Target ▼MONITOR TARGET

6. Staff Friends and Family Test - How likely are you to recommend this organisation to friends and family… as a place to receive care or treatment ('care')… as a place to work ('work')

Deterioration

Improvement

No change



Agenda item 7.3.

Title of Document: Performance 7.3. Quality Account for February 2015

To be presented by

Chief Nurse

Executive Summary The monthly Quality Account reports the current Trust performance against the targets for 2014/15 described in the Annual Quality Account (2013/14) under the following three nationally agreed categories:

• Safe care • Effective care • Patient experience

Recommendations The Board is invited to note the performance of the Trust against the agreed national and local quality targets for February2015 and the actions being taken. Author: Dr Shelley Dolan, Chief Nurse



1

The Royal Marsden NHS Foundation Trust Quality Account for February 2015

1.0. Introduction

The monthly Quality Account reports the current Trust performance against the targets for 2014/15 described in the Annual Quality Account (2013/14) under the following three nationally agreed categories:

• Safe care • Effective care • Improved Patient experience.

1.1. Data Quality Information and data at the Royal Marsden is produced by a centralised dedicated expert team that are completely separate from the clinical and operational teams. This separation and expertise is critical to ensure that the data is accurate and appropriate and that it is not affected by the operational teams who are trying to comply with local and national improvement targets. All healthcare associated incidents, falls, medication incidents and pressure ulcers are reported locally onto the central Datix incident reporting system. The Datix analyst from the risk management team who is completely separate to the clinical care team compiles the reports for the quality account. All falls and medication incidents are also reviewed by subject matter experts to ensure accuracy and learning from themes. Every month a report is generated for each clinical area and if there is a reduction in reporting there is a central and local alert and action is taken.

2.0. Safe Care

2.1. Reduction in Healthcare Associated Infections (MRSA bactereamia and C Difficile infections)

Target: <16 C Difficile infections and <1 MRSA bactereamia

• Performance: Table 2.1 shows that the Trust had two attributable C Difficile (CDI) cases in February. As shown in the table below the target this year for the Trust is 16 cases of CDI.

From April 2014 there is new guidance from NHS England which mandates that all CDI positive patients are reported. However in recognition of the concern across England with this particular target and monetary penalties imposed on Trusts where the CDI has been unavoidable, there is a new system whereby each CDI will be discussed with the relevant commissioners who will then confirm whether it was avoidable or unavoidable (lapse in care) and therefore whether the case should be counted against the trajectory. For the RM the Lead Nurse for Infection Prevention and

2

Control met with the Lead Commissioner in the second quarter, at the end of November, and on the 5th March thus far there are three cases counted against the trajectory and query another two depending on the typing.

Table 2.1

No. Organism RM attributable February 15

Attributable to RM YTD

Commissioner judged as avoidable (lapse in care) YTD

RM Annual Trajectory

1. MRSA bactereamia

0 1 1

2. C.Difficile

2 33 3 +2 dependent on CDI typing results.

16

*MRSA has a target of zero but Monitor has a de minimus of six cases.

2.2. Rate of patient safety incidents and percentage resulting in severe harm or death

To include: • Reduction of severe/moderate risk medication errors • Reduction of harm from falls

Target: Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death

Performance: 2.2. (1) Reduction in Falls Target: < 0.7 moderate and above (resulting in harm) falls per 1000 bed days Year to date - to the end of February 2015 the Trust has met the target.

3

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Analysis of data between years reviewed at Falls Steering Group, conclusions may differ from data below

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02

Near Miss No Harm All other incidents

Analysis of data between years reviewed at Falls Steering Group, conclusions may differ from data below

5

Severity of Patient Fall incidents:

3 - Severity - Current Period

2014 03

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

Total

None / Insignificant 10 18 12 21 23 20 20 26 14 16 21 11 212 Low / Minor (Minimal harm) 8 5 11 7 6 4 7 6 4 3 6 9 76 Moderate (Short term harm) 0 1 1 0 0 0 0 0 1 0 1 0 4 Severe / Major (Permanent or long term harm) 0 0 0 0 0 0 0 0 0 0 0 0 0

Death / Catastrophic (Caused by the incident) 0 0 0 0 0 0 0 0 0 0 0 0 0

Totals: 18 24 24 28 29 24 27 32 19 19 28 20 292 % Harm Patient Fall 44% 25% 50% 25% 21% 17% 26% 19% 26% 16% 25% 45% 27%

2.2. (2) Reduction in medication errors Target: To increase the reporting of near misses and decrease the incidents that cause actual harm (low<2 per 1000 bed days and moderate <0.17 per 1000 bed days). N.B. To place medication errors in perspective, annually 0.05% of all medicines administered result in a medication error. For February 2015, the figure is 0.05% There has been a 25% reduction in incidents categorised as near miss in comparison to the same period in 2013/2014. A streamlined near miss reporting method utilising the current IT system will be available from March 2015 for all Trust staff in order to encourage/facilitate an increase in the reporting of near miss incidents. In comparison to the same period in 2013/2014 there has been a reduction in low and moderate incidents per 1000 bed days, therefore the trust has met the target in decreasing incidents that cause actual harm. In the current financial year, 710 attributable medication incidents have been reported using the IT system Datix, of which 81% caused no harm. 125 incidents have been categorised as low severity and 8 incidents as moderate severity (resulting in harm), this represents 2.36 and 0.15 medication incidents per 1000 bed days respectively. As such, the Trust has marginally missed the target relating to low severity medication incidents, however the target relating to moderate severity incidents has been met.

6

Attributable Medication Incidents

1

11 11

64

610

62 2

7 710

8 8

1311

6

118

63

10

57 7 7

58

58

36 5

3

12

42

5047

49 49

6561

64

84

46

54

69 69 70

97

7268

86

59

47

62

57

49

5753

75

55

61 61

6967

88

70 71

0

20

40

60

80

100

120

2012

04

2012

05

2012

06

2012

07

2012

08

2012

09

2012

10

2012

11

2012

12

2013

01

2013

02

2013

03

2013

04

2013

05

2013

06

2013

07

2013

08

2013

09

2013

10

2013

11

2013

12

2014

01

2014

02

2014

03

2014

04

2014

05

2014

06

2014

07

2014

08

2014

09

2014

10

2014

11

2014

12

2015

01

2015

02

Num

ber o

f Inc

iden

ts

Near Miss All Other Medication Incidents

Analysis of data between years reviewed at Executive Medications Safety Group, conclusions may differ from data below

7

Result of Attributable Medication Incidents

0

10

20

30

40

50

60

70

8020

12 0

4

2012

05

2012

06

2012

07

2012

08

2012

09

2012

10

2012

11

2012

12

2013

01

2013

02

2013

03

2013

04

2013

05

2013

06

2013

07

2013

08

2013

09

2013

10

2013

11

2013

12

2014

01

2014

02

2014

03

2014

04

2014

05

2014

06

2014

07

2014

08

2014

09

2014

10

2014

11

2014

12

2015

01

2015

02

Near Miss No Harm All other incidents

Analysis of data between years reviewed at Executive Medications Safety Group, conclusions may differ from data below

8

Severity of medication incidents:

3 - Severity - Current Period

2014 03

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

Total

None / Insignificant 46 50 52 66 49 58 54 62 54 81 58 64 694 Low / Minor (Minimal harm) 8 14 8 16 11 10 11 15 13 13 14 10 143 Moderate (Short term harm) 0 0 0 0 0 1 1 0 3 0 3 0 8 Severe / Major (Permanent or long term harm) 0 0 0 0 0 0 0 0 0 0 0 0 0

Death / Catastrophic (Caused by the incident) 0 0 0 0 0 0 0 0 0 0 0 0 0

Totals: 54 64 60 82 60 69 66 77 70 94 75 74 845 % Harm Medication Incidents 15% 22% 13% 20% 18% 16% 18% 19% 23% 14% 23% 14% 18%

Medication errors notes and actions:

• Further work has been completed to improve the Controlled Drug section of the Medication chart to aid safe prescribing. The new improved medication chart is being rolled out across the Trust in February 2015.

2.3 Percentage of admitted patients risk assessed for Venous Thrombo-embolism (VTE)

Target: 95% have completed VTE risk assessments Performance: The Trust consistently achieves >90% compliance with risk assessment (CQUIN target is 90%). All patients with confirmed VTE as reported by radiology undergo a Root Cause Analysis (RCAs). The VTE steering board monitor all confirmed VTE and scrutinise the RCAs.

9

Percentage of admissions assessed for VTE ((number assessed + low risk admissions)/all admissions)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Dec

-10

Jan-

11Fe

b-11

Mar

-11

Apr

-11

(Res

ubm

itted

)M

ay-1

1Ju

n-11

(Res

ubm

itted

)Ju

l-11

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12Fe

b-12

Mar

-12

Apr

-12

May

-12

Jun-

12Ju

l-12

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13Fe

b-13

Mar

-13

Apr

-13

May

-13

Jun-

13Ju

l-13

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14Fe

b-14

Mar

-14

Apr

-14

May

-14

Jun-

14Ju

l-14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15Fe

b-15

- D

raft

3.0 Effective Care

3.2 Incidence of Trust acquired pressure ulcers

3.2.1 The number and severity of healthcare acquired pressure ulcers are used internationally as a proxy for the effectiveness of care provision. Many people with cancer and or co-morbidity are more vulnerable to tissue damage for the following reasons; multiple hospital admissions, frailty, multiple drugs including high dose steroids (decreases skin elasticity), immobility, malnutrition or susceptibility to infection.

3.2.2 Data for this report was taken on 2nd March (hospital) and on 5th March (SMCS) 2015 from DATIX. Data may have been updated since. 3.2.3 Total number of patients with Trust (hospital/community services) attributable pressure ulcers for the month of

February 2015: 55 [Hosp= 23, Community services= 21]

10

3.2.4 For serious incident reporting to Steis [Strategic Executive Information System] as Hospital/Community Services. Number of patients with Trust attributable pressure ulcers at categories 3 and 4 for the month of February 2015: 4 [Hosp=1, Community services= 3]

3.2.5 Number of patients with Trust attributable category 3 and 4 pressure ulcers

Number of patients with Trust attributable category 3 and 4 pressure ulcers,

April - February 2015

0

1

2

34

5

6

7

8

Apr May June July Aug Sep Oct Nov Dec Jan Feb

hospital

communityserv ices

11

3.2.6 Number of patients with Trust attributable pressure ulcers, all categories

Patients with trust attributable pressure ulcers, all categories April 2014- February 2015

0

5

10

15

20

25

30

35

40

Apr'14 May Jun Jul Aug Sept Oct Nov Dec Jan Feb

acute

smcs

Description of European Pressure Ulcer Advisory Panel (EPUAP) pressure ulcer classification system.

EPUAP Description of Stage 1 Non blanching redness of intact skin 2 Partial thickness skin loss or blister 3 Full thickness skin loss (fat visible) 4 Full thickness tissue loss (muscle/bone visible)

12

3.3. Emergency re-admissions to hospital within 28 days of discharge Target: Reduction in the number of avoidable re-admissions to hospital within 28 days of discharge Some emergency re-admissions following discharge from hospital are an unavoidable consequence of the original treatment, however some can be potentially avoided through ensuring the delivery of optimal treatment according to each patient’s needs, careful planning and support for self care. It is important to note that some readmissions will inevitably include patients who are admitted with side effects of treatment therefore it may be difficult to explain any differences between RMH with other acute Trusts. Performance: Within 28 days of original admission there were the following emergency admissions:

Reported % of Emergency Readmissions

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Month

% o

f elig

ible

adm

issi

ons

resu

lting

in a

n el

igib

le re

-adm

issi

on

13

3.4. New RM ward evaluation system From September 2014 following consultation with all Sisters and Matrons the ward evaluation system has been refreshed to ensure that there is more visible data available to all ward staff and visitors and in an aggregated form to Matrons, Operational leads, Divisional Directors, Chief Operating Officer and Chief Nurse. The methodology for collecting the data has been validated and where possible national indicators have been automated to reduce the amount of nursing time spent collecting data. The project to create the ward dashboards has been led by Sisters and Matrons and supported by Risk Management. This data is then reviewed on the wards by the Chief Nurse and senior nursing teams on their “Clinical Tuesdays”. The data is used to evaluate and to ensure continuous improvement.

15

Wilson Ward

16

4.0 Patient Experience 4.1 Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times

Target: Reduction in chemotherapy waiting times at Sutton/Chelsea and improvement in the patient experience related to waiting times Performance: Data in the following graphs are for all chemotherapy attendances, for NHS and Private Patients. Table 1: Chelsea chemotherapy waiting times

17

Table 2: Sutton chemotherapy waiting times

18

Table 3: Kingston chemotherapy waiting times

The Trust has established a project group to introduce e-prescribing for chemotherapy. The existing paper based proforma printing system for chemotherapy requires transfer of paper prescriptions and orders which can be timely in peak times and slow down the chemotherapy pathway. E-prescribing of chemotherapy allows decisions to be communicated in real time to all relevant departments so that work can commence in preparing a patient’s chemotherapy as soon as a doctor has assessed them as fit to receive it. This reduces process inefficiencies, lost drug charts as well as allowing each step of the pathway to be electronically auditable to facilitate future quality initiatives. The e-prescribing system also aids medical staff in prescribing subsequent cycles of treatment for patients through use of a re-prescribe function, supporting pre-ordering of chemotherapy which has continued to be a challenge in 2014-15. The Trust went live with a pilot with the Lung cancer unit in October 2014 across all sites and was on schedule to introduce e-prescribing to the breast unit in January 2015.

19

4.2 Ensure that we are responding to inpatient’s personal needs The Friends and Family Test

The NHS “Friends and Family Test” was announced by the Prime Minister on 25 May 2012. All Trusts were expected to be “live” by the 1st April 2013. Nationally all patients are asked a simple question to identify if they would recommend a particular A&E department or ward to their friends and family. The results of the test are used to improve the experience of patients by providing timely feedback alongside other sources of patient feedback.

The Royal Marsden elected to be an early implementer site and therefore started collecting the data in February 2013. Outside all wards across the Trust is a Poster and Collection Box. All adult patients who have been an inpatient for more then one night are asked to complete the Friends and Family Test form and then to put it straight into the collecting box. Once a week the forms are collected and an external company collates and presents the data. From September 2014 some outpatient and day case areas have also implemented the FFT.

The national mandated question asked is:

“How likely are you to recommend our ward to friends and family if they need similar care or treatment?”

The patients then select their answer from the following Likert Scale:

Extremely likely; Likely; Neither likely nor Unlikely; Unlikely; Extremely unlikely; Don’t know.

The Royal Marsden has then chosen to add a second question:

What was good about your care and what could be improved?

Patients answer this question with free text comments.

February (470) responses

Inpatient comments (233)

Alongside 220 positive comments 13 patients made suggestions for improvement. These were around the following areas:-

http://www.dh.gov.uk/health/2012/05/friends-test/

20

“ask the patient before giving telephone number out.”

“The catering service could be improved. Didn’t always provide what was asked for and it would be nice to be offered drinks (tea etc) mid morning”

“yesterday I had a 2.30m appt for treatment (usually lasting 2 1/2hrs) but eventually left at 8pm after pharmacy treatment delay combination.”

“Was not washed when confined to bed, cupboards etc, in nurses area need ‘Soft closure’ attachments to reduce noise, which is annoying at night.”

Day case (52) and outpatient (185) comments

Alongside 218 positive comments 19 patients made suggestions for improvement. These were around the following:-

Day case

“Due to problem with blood test department computer I was delayed by four hours in getting my drugs which meant due to blood tests in protocol after drugs I was not allowed to leave until 8.30 which resulted in a 12 hours stay at hospital”

“Can I please suggest more comfortable chairs for friends/family who accompany patients when they have their chemo. The guest chairs are not very comfortable. Thank you”

“Main reception staff also need to remember why carers are here rather than integrate them when they ask for a parking bay permit, there is no please no thank you just “Are you sure you don’t have a blue badge”.

Outpatient

“I would like a written reminder (or text/email) of my annual appointment. I forgot mine help to remember a year on!”

“I think what may be better, is free wifi while waiting.”

“My only moan is had to go to local postal building, to pick up letter that had no stamp on the letter. Cost £3. missed my appointment for MRI can. When I tried to get money back, no one was interested”

21

National FFT inpatient results reporting:

From November 2014 NHS England l no longer report against a ‘net promoter score’ and instead report a percentage of those who would recommend the Trust to friends and family. The table below has been updated to reflect this.

Inpatient data was collected for 170 Acute NHS trusts and independent sector providers. Nationally, the overall average inpatient percentage for those who would recommend the service to friends and family was 95% in December.

The table below shows the results for the Trust over each quarter to date. At the time of reporting (2nd March 2015) national figures were available up to December 2014.

Q1

‘13-‘14

Q2

‘13-‘14

Q3

‘13-‘14

Q4

‘13-‘14

Q1

’14-‘15

Q2

’14-‘15

Q3 ’14-‘15

The Royal Marsden percentage of inpatients who would recommend

-- -- -- -- -- 94% 97%

National average

-- -- -- -- -- 94% 95%

Response number

585 635 450 711 633 738 425

22

I Want Great Care: Examples of FFT comments (verbatim) from February 2015

SUTTON

Bud Flanagan East Ward

All staff, doctors, nurses, health care assistants, kitchen staff and cleaners are so caring and positive and friendly. It makes what a doubting experiencing so much better. I don't think anything needs improving.

Bud Flanagan West Ward

My treatment plan was discussed with me at all times. I felt I was consulted about my treatment and felt I was involved with any decisions.

Kennaway Ward

The staff are everything - they are all amazing people. Sleeping is very hard - makes it harder theme timing - takes a long time to start.

Children & Young People Services

Everyone has been fantastic and very friendly. I can't find anything to complain about.

Medical Day Unit Staff are all lovely, but there is not enough room it no chairs for visitors.

Oak Ward

The staff are excellent, best ward in the country, exceptional levels of care, compassion and nursing knowledge this is a great team that work so well together.

Outpatients

The very high quality of staff and their interest in providing a first class environment for patients.

Robert Tiffany Day Unit Personally given excellent quality of care by expert staff who have time to talk, answer questions etc on a one to one basis . Smithers Ward

The care was professional, considerate and meticulous. A bit more information about the next stage of which was coming up during care could have been useful.

23

CHELSEA Burdett Coutts

The level of care I received was second to none, great atmosphere very friendly staff. Im struggling to think how you could improve.

Day Surgery

The care in the hospital was totally brilliant, I wouldn't worry about coming back again. However the admin was rather stressful - letters contradicting other instructions, etc and not being able to get through to anybody when there was a query/ problem.

Ellis Ward

Nurses treated you with respect. Spoke to you like an adult and if you didn't understand information 1st time round they would explain to you again but they never pressure you into doing something you didn't want to do.

Private Patients MDU

Can I please suggest more comfortable chairs for friends/family who accompany patients when they have their chemo. The guest chairs are not very comfortable

Private Patients Outpatients

Extreme kindness and care from all at the Marsden..

Horder Ward

It is impossible to imagine any improvement. The marvelous dedication patience and sensitivity of everybody has been an inspiration, especially when the work load is so enormous. I can't thank you all enough for all the love I have received.

Markus Ward Everything fine, great care to be fully informed at every stage of the care. Inspired confidence.

MDU

1 st class professional service provided by caring, pleasant individuals. No improvement required.

Outpatients The care in the clinic is wonderful! The attitude of everybody is so caring and helpful. The team is superb. Well done.

Wilson Ward

All staff were respectful and totally professional in their care of me. Nothing was too much trouble, form a cup of tea, to a painkiller to ease my discomfort, to a friendly chat. From my own observation/experience it would be of benefit to a minority to listen to a patient with regard to their own medication and treatment prescribed meds.

24

5.0. Safer staffing From June 2014 all Trusts are required by the Department of Health, Monitor and Care Quality Commission to be able to assure their Boards around the provision of nursing care on its wards and units. This new requirement follows the national failings in care at Mid Staffordshire NHS Foundation Trust and other Trusts since put on “special measures”. The final Francis report recommended that Boards regularly check that levels of nurse staffing are appropriate for good quality care. Therefore from June 2014 the RM Board will receive a monthly summary of planned numbers of nurses and Health Care Assistants (HCA) during the day and at night, versus the actual numbers. It is also mandated that the Board will receive a six monthly report from the Chief Nurse regarding all issues regarding Safe Nurse staffing across the Trust. Such a report has been presented to the June 2014 and January 2015 Board. The following data is the planned and actual nurse staffing for February 2015. Overall the percentages are as follows: Average fill rate for night staff 106.6% Average fill rate for day staff 99.3% Average fill rate for Registered staff 100.1% Average fill rate for Care staff 113.6% Average Trust wide fill rate (All staff, night and day) 102.2% 5.1. Nursing Leavers and Starters Report The tables below show the number of nurse starters and leavers over a two year period. In the financial year 2013 the number of nurse leavers equated to 12 nurses per month on average. For the current financial year more nurses have been recruited at this point than in the last financial year however the Trust still continues to lose more nurses than recruited. In November the Chief Nurse began a monthly recruitment meeting to address the issues around recruitment and retention of nurses. For the first time in February the meeting was able to review the results of a small exit questionnaire, questionnaires were sent retrospectively to 35 nurses who had left and nine were returned. In all but one case the nurses left for personal or financial reasons. In one case the nurse was keen to stay if she could have attained promotion at the Trust – this case is currently being investigated. The RM is keen to improve recruitment and retention of nurses particularly at bands 5 and 6 (junior and senior Staff Nurses). The new recruitment group is facilitating HR, senior nursing, marketing and communications to work together and look at innovative solutions. The Board will be kept updated on this important issue through regular reports at QAR.

25

Apr May Jun July Aug Sep Oct Nov Dec Jan Average TotalStarters 9 7 9 11 14 20 6 24 9 13 12.2 122Leavers 14 11 12 8 15 17 11 16 12 12 12.8 128Balance -5 -4 -3 +3 -1 +3 -5 +8 -3 +1 +2.7 -6

Band 5-7 Nurses April 2014 - To Date

Apr May Jun July Aug Sep Oct Nov Dec Jan Feb March Average TotalStarters 16 8 8 5 4 13 20 8 8 10 4 16 10 120Leavers 9 8 14 13 17 18 11 13 13 14 6 6 12 154Balance +7 0 -6 -8 -13 -5 +9 -5 -5 -4 -2 +10 -2 -34

Band 5-7 Nurses April 2013/ March 2014

6.0. Board Members are invited to note the performance of the Trust against the agreed national and local quality targets for February 2015 and the actions being taken. Dr. Shelley Dolan, Chief Nurse



Agenda item 8.1.

Title of Document: Board Sub-Committees 8.1. Quality, Assurance and Risk Committee highlight report from meeting held on the 11th February 2015

To be presented by

Nancy Hallett, Chair of the Quality, Assurance and Risk Committee

Executive Summary The Chair of the Quality, Assurance and Risk Committee (QAR) will provide the Board an update on the QAR meeting held on the 11th February 2015. Recommendations The Board is asked to discuss and note the highlight report.

Quality, Assurance & Risk Committee (QAR) highlight report from meeting held on Wednesday 11 February 2015

Issue

Actions/assurances in place

Key points

1. Annual national staff survey. The Trust rates well for the raising of concerns and incident reporting and average for bullying and harassment in the survey. A focus on staff wellbeing and stress is needed as well as improving appraisals (9/15)

Local surveys will monitor aspects of the survey on an ongoing basis. The action plan addressing the findings of the survey is to be presented to the next meeting of QAR.

This is an annual national survey in which the Trust does well compared to other organisations. It is however always important not to be complacent and to understand the issues that staff report. It is also important to understand the survey per staff group and area of the Trust.

2. Junior doctor feedback. Junior doctors shared their experience of working at the Trust. The doctors are impressed with the quality of the care provided by the Trust and calibre of colleagues. The doctors suggested that electronic systems be introduced to automate radiology and blood test requests. An improved balance between education and service provision would increase morale and reduce strain (10/15)

Actions are already underway to improve the experience of junior doctors at the Trust. The Trust will work to influence the national training programme for doctors, so that it meets the needs of both the trainees and the Trust. The meeting agreed that an interim improvement in processing blood tests and radiology requests be identified whilst the electronic test ordering system is awaited.

A new medical model and systemisation of education will be required to adapt to the changing role of junior doctors.

3. Emerging financial risks. Specific risks identified include financing of the capital programme and the level of national tariffs (11 & 12/15)

A series of actions is underway including submitting a robust formal response to national tariff proposals about reduced payment for over performance. The Trust is also rigorously determining the baseline contract level to minimize over performance. The Trust is formally challenging the cancer care tariff and developing a lobbying strategy. The Independent Trust Financing Facility has been approached for loans for the capital programme.

The increasing gap between income and spending requires pro-active management to ensure that the Trust continues to provide excellent levels of care.

2

4. Community Services Division contract. Uncertainties about the future of the community services contract, due in significant part to changes in commissioning arrangements (12/15).

2015/16 contract negotiation continues. Ongoing review of overhead related to Community Services Division.

Uncertainties about the contract are making planning and investment decisions difficult for Sutton and Merton Community Services.



Agenda item 8.2.

Title of Document: Board Sub-Committees 8.2. Audit and Finance Committee highlight report from the meeting held on 28th January 2015

To be presented by

Ian Farmer, Chair of the Audit and Finance Committee

Executive Summary The Chair of the Audit and Finance Committee will provide the Board an update on the meeting held on the 28th January 2015. Recommendations The Board is asked to discuss and note the highlight report.

Audit & Finance Committee highlight report from meeting held on Wednesday 28th January 2015

Key issues/papers/ presentations received and discussed

Key decisions and actions agreed

Key points

1.

External audit:

• Routine matters

• Sector developments

• Interim audit commenced 09/02/15

• Work in progress

• Quality accounts – no guidance yet from Monitor re indicators

• Increasing focus on

data integrity

• State of the State and post-Election considerations

2.

Internal audit:

• Assignments Completed

• Follow up of Recommendations

• Cyber security presentation

• Core financial systems

• Divisional Risk Management

• 18 follow up points removed

• For consideration at next Information Governance meeting

• Significant assurance

• Significant assurance with minor improvement potential

• Good progress from

previous report. Now reporting lowest number of overdue recommendations. All medium risk outstanding items individually discussed

• Increasing risk to

sensitive information. Protection levels to be considered

3.

Anti-Fraud

• KPMG now in role

• Nothing material to

report

4.

Key financial matters – 9m

report

• Board to note

• Broadly on plan and

cash position

satisfactory.

• Efficiency Programme behind plan

5. Financial plan 2015/16

• AFC to be kept appraised of

developments

• NHSE tariff

unresolved. Caution required re capital planning & any associated debt.

6. Pharmacy contract

• Recommendation to board

that contract be finalised on revised NHSE terms

• Considered best

outcome available. Ability to exit if required.

7. Community Services Strategy

• Board to note

• Tender process

fragmented threatening economics. Discussions continue

8.

Private Care business case

• AFC recommend that this be

discussed at Board meeting scheduled for 04/02/15

• Project and funding

thereof to be considered in context of pressure on tariffs.

9. IT Shared Services (Sphere)

• Board to note

• Further detail

requested by AFC.

Ian Farmer Chair Audit & Finance Committee

board of directors’ meeting board room, the royal … · board of directors’ meeting board...

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