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BOARD OF DIRECTORS

14th JULY 2010

BOARD OF DIRECTORS

Agenda for the meeting to be held on Wednesday 14th July 2010 at 2.00pm in the Education Centre, 1st Floor West Wing,

250 Euston Road, London NW1 2PG 1. Apologies for Absence 2. Minutes of the Meeting held on 9th June 2010 Attachment A 3. Matters Arising Report Attachment B 4. Other urgent matters not appearing on the Matters Arising Report 5. Presentation: Research & Development Update Professor Monty Mythen, Director of R & D 6. Chairman’s Report Attachment C 7. Chief Executive’s Report Attachment D Including presentation on Quality, Efficiency & Productivity 8. Executive Board Report Attachment E 9. Performance Report Attachment F 10. Quality & Safety Committee Report Attachment G 11. HR & Communications Committee Report Attachment H 12. Finance & Contracting Committee Report Attachment I 13. Report of the Audit Committee held on 3rd June Attachment J 14. Minutes of Audit Committee held on 20th April Attachment K 15. Any Other Business 16. Date of Next Meeting: The next meeting will be held on Wednesday 11th August at 2.00pm

A

Agenda Item 2

Minutes of the Meeting held on

9th June 2010

UNIVERSITY COLLEGE LONDON HOSPITALS

NHS FOUNDATION TRUST

BOARD OF DIRECTORS

Minutes of the Meeting held on 9th June 2010

Present: Peter Dixon, Chairman Sue Atkinson, Non-Executive Director Nick Monck, Non-Executive Director Richard Murley, Non-Executive Director Jane Ramsey, Non-Executive Director Richard Alexander, Finance Director Geoff Bellingan, Medical Director, Surgery & Cancer Louise Boden, Chief Nurse Mike Foster, Deputy Chief Executive Gill Gaskin, Medical Director, Specialist Hospitals Paul Glynne, Medical Director, Medicine Tony Mundy, Corporate Medical Director Robert Naylor, Chief Executive In attendance: Tonia Ramsden, Director of Corporate Services (Board Secretary) Sarah Johnston, Director of Performance & Partnerships

Julia Whitehouse, Interim Workforce Director Sandra Hallett, Director of Quality & Safety (for item 5) James Thomas, Director of ICT (for item 6) Jocelyn Laws, Trust Administrator (Minutes)

6/1 Apologies for Absence No apologies were received. The Chairman advised that Richard Delbridge had been appointed as a new Non-Executive Director and would take up post on 1st July when Richard Murley took over as Chairman. He was considered to be a very strong candidate. 6/2 Minutes of the Meeting held on 12th May 2010 Minute 5/8.3 - Procurement Sue Atkinson said the minutes did not record the issue she had raised about the importance of sustainability in procurement.

Minute 5/16 – Minutes of the Audit Committee Meeting of 25th March Nick Monck requested that the wording be amended to: “The decision on the Engagement of External Auditors for non-audit work was ratified by the Board”. The minutes were otherwise agreed to be a correct record.

6/3 Matters Arising Report The report was noted. 6/4 Other Urgent Matters There were no other matters arising. 6/5 Presentation: Inpatient Survey Results 2009 Sandra Hallett attended to present the results of the Care Quality Commission (CQC) national inpatient survey which had recently been published on the CQC website. The presentation covered:

• The survey methodology; • How trusts were rated across 65 indicator questions; • The 10 survey sections which covered the patient journey from admission to leaving hospital, and overall views and experiences; • A comparison of the latest UCLH results with those from 2007 and 2008; • A summary of the areas/questions where the Trust had been rated among the best performing and worst performing 20% of trusts; • UCLH ranking against London peers, all London trusts and nationally (produced informally, not by the CQC); • Priorities for 2010 and future improvement plans.

Sandra Hallett explained that the survey was conducted among a cohort of

patients admitted to hospital in August. The national average response rate was 52% and the UCLH response was in line with this figure. Trusts were given scores out of 100 for each of the 65 questions and rated green, amber or red, depending on performance.

In the 2009 results UCLH had been among the 20% best performing trusts for 23

questions and in the 20% worst performers for 4 questions. This represented a significant improvement over the 2008 results and a return to the excellent results achieved in 2007. Areas where the Trust had scored well included questions about doctors and nurses, involvement in discharge decisions and receiving information when leaving hospital, and the overall rating of care received. Low scoring areas included delays in discharge, explanation of anaesthesia and pain control and lack of information given in A&E. A further area which had scored poorly was a new question relating to the visibility of posters and leaflets asking patients and visitors to wash their hands.

Sandra Hallett advised that the CQC had abandoned the publication of league

tables as it was recognised that specialist hospitals generally scored better than general hospitals and because of factors that disadvantaged London hospitals. However we had produced our own informal rankings which showed that UCLH had scored the highest of the London teaching hospitals, was ranked third of all London trusts and was 21st nationally. However, there was little difference between the overall scores of our London peers.

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The priorities for 2010 were to embed the improvements that had been made,

and to address low scoring areas with particular attention to the ‘personal needs’ questions which were part of the Commissioning for Quality and Innovation (CQUIN) framework.

The Chairman invited questions and comments. Sue Atkinson was pleased that

the results indicated a similar position the 2007. She referred to the issue of a combined action plan to address both the inpatient survey and the staff survey results, because of the proven link between staff satisfaction and patient satisfaction. Julia Whitehouse said the Trust was developing joint action plans for inpatient and staff issues where there was cross-over.

The Chairman asked whether any of the interventions following last year’s

survey had not had the desired impact. Tony Mundy said the poor score on the question related to posters and leaflets on hand washing was a surprise, as there were numerous posters displayed in patient areas. Sandra Hallett said the initiative that had worked well was the implementation of a continuous feedback system and it was now planned to re-programme the devices to reflect the areas of the survey where we had performed less well, including the hand hygiene issue.

The Chairman thanked Sandra Hallett for the presentation. It was agreed that

the CQC survey report for UCLH would be circulated to Board members. Action: Director of Quality & Safety

6/6 Presentation: UCLH ICT Strategy – Vision and Implementation Plan James Thomas said the purpose of the presentation was to update the Board on progress with implementation of the ICT Strategy since his previous presentation in November 2008. The presentation addressed:-

• Milestones in the ICT journey since 2005 aimed at developing and implementing the vision; • The key elements of the vision (patient-centred; supports the Trust’s mission statement; four key enterprise flows); • Progress on Year 1 (April 2009 to March 2010) schemes and systems, almost all of which had been successfully implemented; • Progress on Year 2 (April 2010 to March 2011) schemes to date, some of which had been launched while others were in development and testing; • Update on Years 3 to 5 schemes; • A summary of the current position related to infrastructure, preparedness for the future and clinical focus.

James Thomas provided an overview of the current maturity and functionality of ICT systems at Guy’s & St. Thomas’, the Royal Free and Imperial College Hospitals compared with UCLH. It was noted that we were further advanced and had continued along the planned trajectory, working with our IT partners to deliver the strategy.

The Chairman commented that progress appeared to be ahead of plan. James Thomas confirmed this was the case and emphasised that the priorities were

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determined by the clinical boards. In response to a question from Richard Murley about the achievements he would like to see, James Thomas said the move towards a paperless electronic patient record was a key development. The technology existed to also create a single, read-only record for use across UCL Partners.

Geoff Bellingan felt that enormous progress had been made but the interface

with partner organisations was critical. Paul Glynne agreed that more had to be done to share information with general practitioners and increase the speed with which information was provided. IT had a huge role in creating integrated patient pathways but clinicians had to be able to use the systems effectively. Sue Atkinson endorsed the importance of interface with GPs and said this had been reflected in the outcome of a recent GP survey. James Thomas said this was being taken forward and we were able to deliver content to their systems rather than GPs having to access the Trust’s portals.

Gill Gaskin commented that, having come from an organisation linked with

Connecting for Health, she felt that being independent from it was positive. Mike Foster said we believed strongly that we had taken the right approach but we would be revisiting the ICT strategy in the light of new Government priorities, as the importance of IT in communication should not be underestimated. Tony Mundy said progress in the last two years was impressive but training was required to ensure that clinicians were able to keep up with the advancements.

Nick Monck asked whether a read-only facility for UCLP organisations would

restrict use. James Thomas said this would be a first step only and a much larger project would be required to reach a point where other organisations could write-up on the system. However, it was recognised that this would be helpful in the case of patients being treated at more than one hospital in the sector.

The Chief Executive congratulated James Thomas on developing impressive

systems and informed the Board that he was in discussion with the Chief Executive of Logica about opportunities for developing elements of this product that had originated at UCLH. The Chairman thanked James Thomas for his presentation.

6/7 Chairman’s Report The Chairman’s final report expressed his thanks to Board colleagues and all

those he had worked with at the Trust over the previous nine years. 6/8 Chief Executive’s Report 6/8.1 Sir Peter Dixon The Chief Executive’s report paid tribute to the Chairman for his

achievements since joining the Trust in 2001, and for his strong leadership of the Board and Governing Body. In particular, the report highlighted the acquisition of the Heart Hospital, the opening of the new UCH, the achievement of Foundation Trust status and the designation of UCLH as the top performing hospital in the Dr. Foster league tables.

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The Chief Executive’s sentiments were echoed by Board members. 6/8.2 Director of Workforce The report advised that David Wherrett, currently Director of HR and

Organisational Development at Cambridgeshire and Peterborough NHS FT, had accepted the post of Director of Workforce. He would commence during August and in the meantime, Julia Whitehouse would remain as Interim Director.

6/8.3 Barts & The London (BLT) NHS Trust The Chief Executive emphasised that recent media reports concerning a

transfer of Barts Hospital to UCLH were inaccurate. The two trusts had been looking at ways in which they could collaborate to improve patient care and academic output, but this was far short of the implications in media articles that UCLH was taking over Barts to ‘rescue them’ from financial difficulty.

6/8.4 NHS Confederation and the Foundation Trust Network The report advised of changes to the constitution of the NHS

Confederation, the replacement of the Chairman and recent resignation of the Chief Executive. It was possible that these issues could attract publicity at the forthcoming NHS Confederation Annual Conference. The Board would be kept informed of any further developments.

6/9 Executive Board Report 6/9.1 Ward Sisters, Charge Nurses and Senior Midwives Training Needs

Analysis The EB was informed that a training needs analysis had been

commissioned and presented to the Nursing & Midwifery Advisory Board and measures were being put in place to ensure the needs were met. Louise Boden said the development of these staff was crucial to the Trust.

6/9.2 Switchboard and Contact Centre Performance The Chief Executive said the EB had recognised that this was an area of

weakness and had agreed to re-establish the Contact Centre and Switchboard Improvement Group. Performance Monitoring would be developed to encompass all sites and quarterly reporting to the Board would be reinstated as part of the Performance pack.

6/9.3 Capital and Estates Issues The Board noted that the EB had approved a number schemes from the

Capital Programme. The Board also noted that the quarter 4 review of the schedule of protected and unprotected assets had been undertaken and there were no changes.

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6/9.4 ICT Issues The report updated on progress towards delivery of a comprehensive

electronic clinical record. 6/10 Performance Report Sarah Johnston drew attention to key changes in the contents of the

performance report, in particular the addition of CQUIN indicators. Some metrics had been replaced with new ones following a review of priorities for 2010/11. The changes had been agreed by the EB.

Key issues highlighted were:

Performance against the 18 weeks target Clinical Boards and Divisions were working hard to achieve this target but the Board was asked to note a risk for Quarter 1. Cancer targets: The Trust had achieved 100% for 62 day referral to screening and 84.7% against a threshold of 85% for 62 day GP referral to treatment. Infection: There had been one case of MRSA against a threshold of 2. All efforts were being made to ensure we stayed within the threshold of 8 cases for the year. Actual incidence of C.difficile in month was 5 cases against a threshold of 10. Last minute cancellations to elective surgery: The target had been achieved on a Trust-wide basis but performance was rated amber as there was still a risk of failing the target, going forward. CQUIN Indicators The local, regional and national indicators were listed, together with the lead directors for each. Sarah Johnston reminded the Board that achievement of the indicators would attract additional payment and the total value to the Trust was approximately £7.5m. Richard Alexander confirmed that this income had been included in the financial plan but a contingency was also built in. Richard Murley referred to length of stay targets and asked for views on the Secretary of State’s recent announcement concerning readmission of patients. The Chief Executive said that, although our readmission rate was lower than average, the potential cost to us arising from the pronouncement was around £6m. However, Sarah Johnston advised that the percentage of emergency readmissions shown in the Performance Report referred to the total number of readmissions and did not take account of admissions within 28 days for conditions unrelated to the initial treatment. Tony Mundy said he received a list of readmissions on a monthly basis. The figure averaged approximately 250 per month but it appeared that the majority were planned or were unconnected with the initial admission. He felt that scrutiny of the data was required to ascertain

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the true number of emergency readmissions related to the original condition and would discuss this with Paul Glynne to identify an appropriate person to undertake this work.

Action: Corporate Medical Director/Medical Director, Medicine

The Chief Executive said that if acute trusts were to be made responsible for managing patients for the first month following discharge it would call for greater involvement with primary care. This would have to be resolved if we were to avoid losing a significant amount of income in addition to the cost pressures that were already having to be addressed.

On the issue of pre-11.00am discharge, Paul Glynne said that although progress had been poor he felt that improvements could be achieved. Richard Murley proposed that this be considered as part of the discussion on QEP scheduled for the next meeting. Sue Atkinson referred to the performance on complaint responses sent within target time which was 64.4% for the Trust as a whole and 52.2% in Specialist Hospitals. Gill Gaskin said the data for the month was inaccurate and understated actual performance for her Board. However, there had been a number of complaints not responded to in the required timeframe and they were now being escalated to the divisional managers. It was proposed that the Clinical Boards should reinforce the requirement to meet this target. Sue Atkinson also drew attention to the performance on ethnicity coding. She felt this required a focus in relation to improving services for black and minority ethnic patients. It was thought that the underachievement of this target was partly a result of patients choosing to withhold the information; Mike Foster agreed to check whether ethnicity was a mandatory field in the patient administration system.

Action: Deputy Chief Executive

Richard Murley asked about progress on the target reduction in capital scheme value and emphasised the importance of ensuring that any reduction represented actual savings, not slippage. Richard Alexander would look into this.

Action: Finance Director

The Chairman commented that activity in Month 1 was behind plan, particularly in the Surgery and Cancer Board. Sarah Johnston said there was usually some uncertainty about the month 1 position. Geoff Bellingan said that the planned move of HPB services was a significant factor in the underperformance against surgical activity plans. Activity had also been affected by the volcanic ash problem.

6/11 Quality and Safety Committee Report The report was presented by Tony Mundy who advised that the committee was

supporting the MRSA and venous thromboembolism (VTE) initiatives by investigating all instances using the Serious Incident process.

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The report advised of a decision to defer assessment for NHSLA level 3

accreditation until January. Tony Mundy informed the Board that following a mock assessment it was considered sensible to defer the actual assessment to allow sufficient time for actions to address identified areas of weakness to be embedded. These areas related to ‘developing a capable workforce’ – specifically concerning evidence to record attendance at corporate induction and statutory/mandatory training, and to monitor follow-up of non-attenders.

The remaining issues in the report were noted. 6/12 HR & Communications Committee Report The report advised that the number of Employee Relations cases had reduced

substantially and actions to resolve the remaining cases were due to be taken before the end of July. Sue Atkinson said congratulations were due to Julia Whitehouse and the HR team for their efforts.

Sue Atkinson drew attention to the update on the Workforce Efficiency

Programme, in particular the plans for Electronic Staff Record self service which would enable the Trust to track attendance at training sessions more efficiently than the current paper-based system.

The HR&CC had considered the outcome of the GP survey, as referred to in the

IT presentation. The growing importance of GPs as commissioners was recognised and Sam Higginson, Director of Strategic Development, was leading an exercise to develop a strategy for engagement with GPs. Jane Ramsey thought the Board should see the GP survey results; it was agreed that the report would be circulated and comments should be passed to Sarah Johnston.

Action: Director of Performance & Partnerships

The remaining issues were noted.

6/13 Finance & Contracting Committee Report Jane Ramsey presented the report and highlighted the adverse position of the

Surgery & Cancer Board. This issue had been raised under the Performance Report. The overall financial risk rating for Month 1 was 1 against a planned rating of 2.

The FCC had welcomed a discussion paper from the Finance Director on

profitability and Jane Ramsey said the Committee looked forward to greater transparency that would arise from the development of service line management and reporting and the Patient Level Information and Costing System.

The FCC had also received a paper updating on the Cancer Centre Financial

Model and considered a report setting out the rationale for the planned elective growth in 2010/11.

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6/14 Entries in the Seal Register The report was noted. 6/15 Any Other Business There was none. 6/16 Date of Next Meeting The next meeting would be held on Wednesday 14th July. The Board of Directors resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

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B

Agenda Item 3

Matters Arising Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

BOARD OF DIRECTORS

REPORT ON MATTERS ARISING FROM THE MEETING HELD ON 9th JUNE 2010

Minute

no. Issue Outcome

6/5 Inpatient Survey: circulate CQC report to Board members

The report was circulated following the meeting. Action completed

6/10 Performance report: Emergency readmissions data – identify a method for scrutinising readmissions within 28 days

Dr. Daniel Wallis, Divisional Clinical Director for the Emergency Division, has agreed to scrutinise readmissions to determine the proportion that are unplanned and related to the original condition, and whether there are mitigating circumstances. Dr. Wallis will obtain input from the Surgery & Cancer and Specialist Hospitals Clinical boards where necessary. Action completed.

6/10 Performance report: Ethnic coding data quality – check whether ethnicity is a mandatory field on the Patient Administration System

It has been ascertained that ethnicity is a mandatory field but it is possible to enter ‘not known’ or ‘declined to give’. For several reasons it is not considered advisable to make entry of patients’ ethnic group mandatory.

6/10 Performance report: Progress on target reduction in capital scheme value

This issue will be incorporated in the Quarter 2 financial review of the Capital Programme which will be reported to the Board via the Executive Board in August.

6/12 HR & Communications Committee report: circulate GP survey results to Board members.

The report was circulated following the meeting. Action completed.

Items from previous meetings brought forward

Date of Meeting

Minute no.

Issue Action

March 2010 and May 2010

3/7.4 and 5/8.3

Chief Executive’s report: Commercial Developments in Procurement – keep Board informed of progress

This issue is referred to in the EB report to Part 2 of the meeting.

Items from previous meetings carried forward to future meetings

Date of Meeting

Minute ref.no.

Issue Action

April 2010 4/3 Matters Arising report: Homeless Health Project

A progress report will be presented to the Board in October.

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Agenda Item 6

Chairman’s Report


CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS

14 JULY 2010

1. BOARD APPOINTMENTS

I am pleased and privileged to have taken over as Chairman on 1 July. I look forward very much to working with the Governing Body and with Board and other colleagues during my term of office. The July Board will be the first meeting for Richard Delbridge. We look forward very much to benefiting from his experience gained in a wide range of private sector plc Board roles. I am happy also to report that the Governors have agreed to extend Nick Monck’s appointment for a further 12 months from February 2011.

2. VISIT BY HRH PRINCESS ROYAL On 6 July HRH The Princess Royal visited the Occupational Therapy Unit. She met a number of members of staff and was introduced to two patients who talked about the difference which local OT services have made to them. The Princess is Patron of the College of Occupational Therapists and her visit coincided with a conference in the Education Centre ‘Occupational Therapy: At the Frontline of High Quality Care’. The Princess addressed the conference briefly and spoke knowledgably about the importance of the OT role and the need to treat the patient as an individual.

3. OPENING OF BRAIN TUMOUR UNIT AT NHNN

Also on 6 July, Boris Johnson, Mayor of London, visited Queen Square to open the new Molly Lane Fox Unit. This unit consolidates the NHNN’s resources for the treatment of patients with brain tumours. It was made possible by a very generous donation from Molly’s Fund which was established by the family of Molly Lane Fox who tragically died of a brain tumour in 2008 at the age of only five. At the same time, the Mayor visited the stalls which had been created by the staff at the National to commemorate the NHNN’s 150th anniversary. There was a fantastic array of exhibits, illustrating some of the advances that have been made in the treatment of neurological conditions over the last 150 years. The staff of the National had gone to considerable trouble to prepare attractive and informative stalls and all who saw them were interested and impressed by the displays.

4. CHAIRMAN’S MEDAL Peter Dixon’s last function as Chairman was the presentation of the Chairman’s Awards for Education which he inaugurated during his time here. This year, a range of awards went to individuals and teams from various areas in the Trust marking the great contribution made by members of staff in this important field. I was very struck by the quality of the contribution of all those nominated for awards and fully intend to keep up the awards system. The awards are organised and supervised by Jean McEwan and Stephanie Eborall in the Directorate of Undergraduate Education. I am grateful to both of them for all that they do to make the awards happen.

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5. INSTITUTE FOR SPORTS & EXERCISE MEDICINE On 1 July the Institute for Sports and Exercise Medicine was launched at UCL. The morning was attended by an impressive array of senior representatives from UCL, UCLH, UCLP and the London Organising Committee for the Olympic Games. Board members will recall that the Institute is to be led by Fares Haddad, Divisional Clinical Director for surgical specialties and consultant orthopaedic surgeon. At the launch there was an interesting discussion about how the Olympics and Paralympics in 2012 can inspire individuals to take more exercise and thereby improve their level of health and lower the burden on the NHS. This is clearly not an easy task but one which seems ever more important as financial constraints are imposed on us.

6. GOVERNOR MATTERS

An unusually large number of changes to the composition of the Governing Body are in train. We are saying goodbye to Sue Payne, Eileen West, Janet Clarke, Raj Davé, Mark Gaze, Kevin Ryan, Patricia Pank, Roger Freeman and Marcus Carr. Three other Governors are coming to the end of their term of office and are seeking re-election, along with a number of new candidates, for the eleven vacant posts. I would like to thank all the retiring Governors for all that they have done for the Trust during their term of office. On 15 June there was a joint meeting between the Governing Body and the Board of Directors. Discussion ranged across a wide and interesting variety of topics including the role of the Governors and how to improve the Trust’s engagement with the wider Membership.

RICHARD MURLEY CHAIRMAN

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D

Agenda Item 7

Chief Executive’s Report


CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

14 JULY 2010

1. QUALITY, EFFICIENCY AND PRODUCTIVITY PROGRAMME

Directors will be aware of the process we have used to develop the QEP Programme. It started at the back end of last year with an engagement event which included a wide cross section of managers, clinicians and other professionals from across the Trust. More than a hundred ideas were generated which were categorised into the five work streams of workforce efficiency, productive clinical services, back office rationalisation, asset utilisation and procurement. In recent months this work has been led by Tara Donnelly with the engagement of a number of the Executive Directors and Programme Leads. Attached as appendix A is the May Progress report which will be presented by Tara Donnelly at the meeting. The key issues are that plans have been defined to achieve 90% of the saving requirement of £26.5m this year. These savings were originally phased on an equal twelfths basis across the year, but this has now been adjusted by the Finance Director to reflect the fact that more savings are expected later in the year (as projects come to fruition), rather than in the early months. The ongoing debate about whether increased income can count against the QEP target has been largely resolved. At a recent Monitor conference it was stated that 27% of all Foundation Trust’s savings plans were attributed to increased income – this is broadly equivalent to our existing plan. However, there is an increased risk this year of PCTs not being able to pay for over performance, particularly in the light of the Secretary of State’s decision to amend the waiting time targets. These matters were discussed at some length at the Finance and Contracting Committee where it was concluded that a longer term perspective was needed, particularly as we should anticipate a consistently high level of savings required over the next 4/5 years. Following a similar discussion at the Executive Board, I decided to establish a monthly Steering Group meeting, which I shall chair, at which a number of the Executive Director’s will oversee progress with the QEP Programme by receiving reports from Tara Donnelly and the Programme Leads. I envisage that these meetings will continue until such time as both I and the Board have confidence that the QEP targets are being met.

2. TRIPARTITE DISCUSSIONS

Since the general election the Tripartite discussions have progressed to the point where all three Boards have agreed to commission external consultancy to explore the question of whether a merged configuration would produce greater financial and clinical benefits than the existing stand alone organisations. Three consultancy companies have been short listed and a decision is likely to be known in time for the Board Meeting. Independently each Trust will considering their “status quo” position, which in the case of the other two Trusts will be an evaluation as to whether they can achieve Foundation Trust status. Our position is more a case of whether the QEP Programme over the next few years will be sufficient to enable us to maintain financial viability. These separate pieces of work will be brought together with the external consultancy project in the form of a report to each of the three Boards of Directors in due course.

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3. COMMUNICATIONS – TEAM BRIEF

The Board will know that a major focus of activity in recent years has been to improve internal and external communications. Activity has routinely been reported to the Board via the HR and Communications Committee. Historically, communications was seen as weakness at UCLH, with numerous comments complaining about lack of engagement, information and communications generally. In recent years we have developed a range of communication strategies including Inside Story (the monthly in house magazine), Insight (the intranet website), the Internet website, Team Briefing and CEO Road Shows. Most of these initiatives have been successful, but there has been a delay in commissioning the new Trust website for technical reasons. Team briefing was introduced to the Trust nearly 10 years ago and has occurred every month since then. The intention of team briefing is for the Chief Executive and Executive Directors to decide the most important items for communication on a monthly basis and for these to be summarised on one side of A4 paper. This is then to be cascaded throughout the organisations management structure within the shortest possible timescale, normally 48 hours. One of the main benefits of team brief is to enforce the discipline of every manager/supervisor having to sit down with their staff to talk about communications on a monthly basis. The Trust has recently undertaken a major review of the effectiveness of team briefing, from which there were a number of key conclusions. These can be summarised as team briefing being highly regarded by the majority of staff, but that it was too frequently delivered by email rather than “face to face”. It was also suggested that there should be more opportunity for discussion and feedback.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

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Board of Directors Meeting 14th July

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Chief Executive’s Report to the Board Appendix A

QEP – May Progress Report

1. Introduction The purpose of this paper is to update the Board on the progress of the Trust’s plans to achieve significant savings in 2010/11, while retaining the high quality of care we are known for. QEP stands for the Quality, Efficiency and Productivity programme, and all three elements are important. This paper provides:

• Progress on plans in place to deliver the QEP target • The financial assessment at Month 2 • Detail on how we plan to move forward for the remaining part of 2010/11 and • Outline on commencing the development of plans for subsequent years.

At the meeting a presentation will be given and this will provide:

• An analysis of UCLH’s performance against productivity metrics • Including a comparison with the McKinsey work

Productivity measures have been embedded for key change programmes and This document outlines

2. Summary of key indicators of success 22..11 OOvveerraallll QQEEPP ffiinnaanncciiaall ssuummmmaarryy Month two financial data has given an adequate if not perfect view of progress for the clinical and corporate services at the Trust. QEP Plan There are defined plans to achieve savings of £23.7m, which is 90% of the total requirement of £26.5m. The residual gap has reduced from £4.5m to £2.8m since March. Performance to end May The financial performance of QEP Trust-wide at month two is £3m achieved against a year to date target of £3.67m, a variance of £0.67 million. A full breakdown of the performance in month for each clinical board and corporate directorate is provided within the Finance Report. The analysis of QEP performance in-month indicates the following: £600k due to the residual QEP gap referenced above £100k underperformance against plans At Month 2, the variance sits within the Clinical Boards, and within the Workforce and Productive Clinical Services strands. The QEP Procurement strand is ahead of plan in terms of savings realised by almost £100k.


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All Directors are reviewing their performance in detail and taking action to accelerate the implementation of schemes within Divisions and Departments. 22..22 QQuuaalliittyy SSuummmmaarryy The overall measures for quality for the Trust including HSMRs and patient experience are currently delivering excellent results. The inpatient survey results published recently places us as the top non-specialist Trust in London. Specific initiatives such as the productive ward and TCAB are focused on further improving quality indicators such as the number of falls at the Trust, pressure sore reduction and increasing the amount of time nurses spend in direct patient care. 22..33 EEffffiicciieennccyy SSuummmmaarryy The Trust is making progress on crucial areas that will enable us to undertake processes at the organisation in a safer, more effective manner, for example Order Comms (electronic ordering of radiology). However the progress on moving to paperless outpatients has halted due to clinical concerns regarding the current speed of CDR, which is a frustration. The opportunities to advance our efficiency through successful harnessing of technological solutions are major, and as a Trust we need to ensure we maximise these. 22..44 PPrroodduuccttiivviittyy This month we have taken a closer look at comparative productivity metrics and the potential for changes as part of this work. Some of the highlights of this will be included in the presentation to the Board.

3. Key activities of the QEP Programme • Strong focus within the Clinical Boards and Corporate Departments • Clearer deliverables, metrics and project plans now developed across all Project Strands • Greater organisation-wide engagement in the quality, efficiency and productivity agenda

through organisation wide events, small working groups and better communications • Learning from elsewhere and forging links with transformation/efficiency programmes at

other organisations and with the Department of Health – positioning UCLH to be one of a small number of alpha/test sites for QIPP

• A focus on measuring success with new productivity indicators developed and use of SPCs (statistical process control charts) wherever possible

Highlights for this month include the following: Procurement • £1.7 million savings achieved for 2010/11 based on projects delivered with improved

service delivery, including:- A total £270k saving in the Patient Transport contract through contracting with a

single provider across the UCLH hospitals Cardiac implantable devices (ICDs and Pacemakers) savings of £181k on

purchase New consolidated print services being rolled out across the Trust and will make a

c£50k in-year saving, £100k FYE Workforce • Agency spend reduction - the overall Trust trajectory for Agency reduction was achieved in

May. Specialist Hospitals did better than trajectory. Our plan is to spend a very significant £4m less on Agency staff than last year.

• 400 additional staff on the Staff Bank, compared to January. Bank opened in April to staff from all disciplines. 200 further applications being processed following successful campaign

• Revised (markedly reduced) agency rates came into effect on 17th May (UCLH led this work with Barts on behalf of London)


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Productive Clinical Services • A reduction in DNA rate across the Trust by 0.8% which equates to an additional 5,856

slots freed up (outpatient “did not attend” rate) • Month-on-month improvement in outpatient slot utilisation increasing from 61% in March to

76% in May 2010, and indicating that there is still a significant way to go • A reduction in LOS in elderly care from 13 days to 8 days • Bed reductions scheduled for summer months in Medicine • The productive wards have begun at Queen Square and impressive work here • Successful Lean redesign in Women’s Health • The two longer term programmes – around Pathology and Imaging are being further

worked up. Robert Naylor has become the sponsor for these two areas for UCLP which is an excellent fit.

Asset Utilisation • Considerable activity within the asset utilisation stream in month with lease consolidation

and disposals being advanced which will impact positively on revenue position once finalised

Back Office • Setting up the back office workstreams to deliver in the future (years 2-5). Important buy-in

achieved at senior level across UCLP and associated Trusts

Although there has been some excellent progress across the organisation, there needs to be rapid, further improvement in order to correct the year to date variance, as well as to achieve the challenging targets over the next two to five years. 4. Delivering remaining financial reductions for QEP The savings we need to achieve to close the gap, and to plan for next and subsequent years are likely to require a different order of change. To gain the necessary momentum and focus on cost reduction that the Trust requires we need to ensure staff at all levels understand and are committed to delivering large scale initiatives that deliver cost reduction through better use of resources. The QEP Programme has already undertaken good work in communicating with and engaging staff across and organisation. There is still some way to go and it would be worthwhile to consider broader change initiatives that can work across the organisation and achieve the remaining cost reductions that we need to deliver for the future. We believe that it would be productive to target the QEP team resource to supporting fewer schemes that have the potential to deliver larger dividends. We are therefore focusing the QEP team in the immediate period on supporting work in a number of priority areas, including:

i) Achieving the Bed reductions over the summer months ii) Improvements in outpatients – thereby improving slot utilisation or taking out clinical PAs. iii) Improvements in theatres – increasing utilisation from 79% to over 85% with additional

PAs taken out and significant reduction in overtime iv) Infrastructure review and Pay opportunities v) Acceleration of moving to paperless organisation – in particular where we can stop

transferring information by post, this has an excellent fit with our IT Strategy vi) Repatriating any areas where we outsource work, this includes work at the Eastman and

for Imaging vii) Commencing the identification of schemes for 2011 and beyond


4

5. Closing the Gap The residual gap between schemes identified and the total requirement is now £2.7m. The agreed approach to closing this gap is to focus on a number of pay schemes, noting that 1% of the UCLH pay bill is £3.5m. The three main areas are listed below. 5.1 Scrutiny of vacancies It has been agreed by the Executive Board that all senior posts (band 8a and above) will be reviewed by a Director and all jobs band 7 and below by a Divisional Manager or equivalent (Deputy Director) in Corporate areas. Scrutiny and challenge will be provided together with a consideration of whether the post is required at all, and if so at what grade and hours commitment. This was implemented in July. 5.2 Infrastructure Review Julia Whitehouse and David Wherrett are leading a review of infrastructure and grading within the Trust. While the full review will be a long term piece of work, the QEP Programme Board has agreed plans to commence this work on a pilot basis in the two largest support departments, Workforce and Finance in August, and will include benchmarking with peer organisations. While the review is undergoing all vacancies in these areas will be held. 5.3 Pay review In June an Executive Board Seminar was dedicated to Pay at UCLH. A group consisting of the Deputy CEO, Directors of Finance and Workforce and a Medical Director, Gill Gaskin, has been established to drive action in a number of areas 6. Benchmarking and Productivity There are a number of sources of productivity benchmarking available. Historically the CHKS system has been used to provide peer comparison information. Published this month for the first time is comparable Trust level data by the London Health Observatory. The McKinsey report was commissioned by NHS London, completed in March 2009 and published on the DH Website in early June 2010, on the request of the new Government. Copies of the full report were circulated to Board members at the Chairman’s request. The McKinsey work outlines a number of areas where changes can be made and indicates savings that can be made across London. To help us better understand where the Trust is globally on productivity and efficiency metrics and to assist in identifying opportunities for the future we have analysed the areas that benchmarking highlights. The QEP programme office supported by the information team completed an analysis of the most relevant areas for UCLH and the results will be shown in the presentation. It is not possible to completely replicate the McKinsey calculations and we have had to use judgement in completing these assessments. The overall results can be summarised below indicating further work may be needed in these areas:

• Overall productivity of clinical staff (though research and teaching time not counted) • Theatre utilisation • Outpatient utilisation • Asset Utilisation • Delivering more in a day case setting

A number of productivity metrics are also produced on a monthly basis by the Strand lead Directors and the QEP Programme Office. It is planned to incorporate a number of these in the Board pack with effect from next month.


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7. Communications There has been a significant investment in communicating the QEP programme to staff and stakeholders. Through the two QEP events held in January and March we have reached over 400 people, attending in person and through web-streaming of the presentations. All forms of UCLH media are used as part of the QEP Communications Plan, Insight, Inside Story, Team Brief, Posters, UCLH News, Team Brief, CEO Roadshows, Clinical Board Meetings, Management Forum and the QEP Intranet site. To maximise impact we have aimed to achieve a unified communications programme, so have recently undertaken a major campaign relating to Bank staff recruitment, casestudies of agency staff who have moved to the Bank, publicising the fast-track processes etc. Mobilising the Clinical Community - Following discussions with the Chief Nurse and four Medical Directors, the third QEP Event held on 15th July has been specifically targeted at frontline clinical staff and clinical leaders with the aim of increasing their understanding of the programme and their role in it. 8. Moving forward The approach so far to QEP has been to encourage bottom up support and engagement for all staff in the organisation. This has been successful in engaging the organisation and communicating the approach of improving quality and reducing cost. The QEP programme has also supported sharing learning across the organisation and national and international organisations with many examples of innovation that have been implemented across the organisation. There is plenty more to do, and we are not yet achieving the run-rate we require to hit the savings target for the year. We are also not yet seeing the shift we need in many of our key productivity metrics, for example those relating to LOS. In order to remain concise this report records only highlights, and such a summary may not adequately reflect the depth and range of activities being led by the Lead Executive Directors, Paul Glynne, Gill Gaskin, Geoff Bellingan, Mike Foster, Julia Whitehouse and Richard Alexander. The efforts of John Watts and Kieran McDaid should also be noted. It is important that these activities are recognised, and freeing up lead Directors, and Medical Directors in particular, to lead this critical work is fundamental to its future success. In order to do this, we need to take a hard look at our meeting and committee structure, this key piece of work is underway and being led by Tonia Ramsden. Tara Donnelly 7th July 2010

E

Agenda Item 8

Executive Board Report


Executive Board Report to

the Board of Directors, July 2010 1. Depth of Coding

At the beginning of the year the Executive Board considered a report setting out the improvements in clinical coding processes and outcomes and demonstrating the improved depth of clinical coding (complexities and co- morbidities) during the first six months of 2009/10 compared to the first six months of 2008/09. The EB recently received a further report which detailed the depth of coding, by speciality, on a quarterly basis during 2009. This report indicated that continued progress has been made and the depth of coding during this period has firstly equalled and now has slightly surpassed peer trusts. Work is continuing through the Trust’s Clinical Coding Improvement Group, within the clinical coding team and within divisions to build upon progress made on this important agenda. It should be noted that according to the most recent Audit Commission report dated April 2010 UCLH is recognised as now having achieved (on a sample basis) top 10% performance nationally in terms of the quality of its clinical coding. 2. Nursing and Midwifery Issues

Louise Boden informed the EB that the National Patient Safety Agency guidance requires all grade 3 and 4 pressure area ulcers to be considered as serious incidents. Root cause analysis will be undertaken for all such incidents and the results reported to the PCT and Care Quality Commission. The root cause analysis will cover the whole patient journey including time spent in theatres and critical care. Vigilance in pressure sore prevention is key and a number of initiatives have been implemented, including encouraging ward sisters to consider a higher specification of mattresses where necessary and increased education for student nurses.

3. Six Lives: Parliamentary Ombudsman’s Report The EB noted that the Quality and Safety Committee had received a presentation on the recommendations arising from the Ombudsman’s 2009 report into the provision of services to people with learning disabilities. The report from the QSC contained in the Board papers provides further detail on the recommendations. Additionally, the CQC has set out a number of key areas where it expects trusts to improve the quality of care in relation to patients with learning disabilities.

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The EB discussed the need to identify a solution to delivering the requirements and Louise Boden, in conjunction with the Medical Directors, will look at ways to resolve the issue. 4. Emergency Preparedness

The EB received a quarterly report updating on various aspects of the Trust’s emergency preparedness arrangements. These include major incident and business continuity planning and Louise Boden advised that the Trust was due to host an all day ‘Emergo’ exercise on 9th July 2010. The Health Protection Agency would be running the exercise and, along with representatives from across the Trust, the London Ambulance Service, GOSH, Guy’s and St Thomas’ and Police counter terrorism will be taking part in the day to test our emergency plans and capabilities on major incident response.

Preparing for the 2012 Olympics is now a standing agenda item for the Emergency Preparedness Committee as UCLH is one of the designated hospitals. Profile mapping and projections of attendance numbers will be generated with NHS London and informal tabletop exercises with Facilities, A&E and others have been planned.

Flu planning is now officially ‘closed’ for this year but the item remains on the agenda as a watching brief. 5. Capital and Estates Issues

On the recommendation of the Capital Investment Board, the EB approved a number of schemes from the Capital programme. These include further schemes associated with year 2 of the ICT Strategy and essential replacement of plant and air handling units at The Heart Hospital. The Heart Hospital has two air-cooled chillers that produce chilled water to condition ward areas, catheter labs and theatres, and other linked parts of the hospital. The plant is presently subject to frequent breakdown; this affects patient comfort and the ability of the clinical teams to undertake surgery in a satisfactory temperature-controlled environment.

A more detailed quarterly report on the Capital Programme will be considered

by the Executive Board next month and the Board will be advised of key issues.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

F

Agenda Item 9

Performance Report

Month 2, May

This document contains commercially confidential information and must not be released or circulated

UCLH NHS Foundation Trust

Board of Directors Performance ReportJuly 2010

(Month 2 – May)

1. Executive summaries 2. Finance 3. Efficiency/ Productivity 4. Activity 5. Access 6. Patient Safety and Quality metrics 7. Workforce 8. Externally Reported Frameworks

Month 2, May

Contents

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Number of MRSA Bacteraemias post 48 hr

16 2 2 0 1 1 3 0 1 1 Non-admitted closed percentage under 18 weeks

13 95.0% 97.4% 98.1% 98.4% 97.0% 96.9% 97.2% 97.7% 96.5%

Number of clostridium difficile cases post 48 hours*

16 10 10 1 8 1 15 1 10 4 Admitted closed percentage under 18 weeks

13 90.0% 94.6% 100.0% 94.4% 94.4% 94.3% 99.2% 93.3% 94.6%

Percentage Hand Hygiene Compliance

16 85.0% 90.6% 86.2% 87.7% 92.9% 90.1% 83.9% 87.5% 92.5%62-day wait for first treatment from urgent GP referral to treatment: all cancers

14 85.0% 94.9% 100.0% 92.1% 100.0% 90.6% 100.0% 88.6% 100.0%

Percentage MRSA screening for elective admissions

16 100% 100% + 100% + 100% + 100% + 100% + 100% + 100% + 100% +62-day wait for first treatment from consultant screening service referral: all cancers

14 90.0% 100.0% 100.0% 100.0% 100.0%

Patient falls with harm17 1 1 2 1 1 31-day wait for second or subsequent

treatment: surgery14 94.0% 95.5% 93.3% 100.0% 96.2% 94.1% 100.0%

Complaints responded to within target time

18 85.0% 68.4% 94.1% 65.4% 58.1% 69.0% 92.6% 71.7% 55.8% 31-day wait for second or subsequent treatment: drug treatments

14 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Overall, how would you rate the care you have received

18 82.9% 78.1% 77.4% 69.5% 83.4% 77.7% 75.7% 73.3% 82.0% 31-day wait for second or subsequent treatment: Radiotherapy

14 94.0% Available Month 3

Percentage Last Minute Cancellations to Elective Surgery

18 0.8% 1.1% 0% 0.9% 1.3% 0.9% 0% 0.6% 1.3% 31-day wait for second or subsequent treatment: other

14 98.0% Available Month 6

Readmitted in 28 days after cancellation*

19 95.0% 100.0% 100% 100.0% 100.0% 100.0% 100% 100.0% 100.0% 31-day wait from diagnosis to first treatment: all cancers

14 96.0% 98.4% 100.0% 98.0% 100.0% 99.2% 100.0% 99.0% 100.0%

Hospital standardised mortality ratio (1yr rolling data, 2 months in arrears)

19 0.74 0.61 0.59 0.58 0.78 Two week wait from referral to date first seen: all cancers

14 93.0% 92.7% 92.1% 100% 97.7% 93.3% 92.2% 100% 97.1%

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

14 93.0% 96.4% 96.4% 96.3% 96.3%

* The trust threshold is an aggregate of individual clinical board thresholds A&E attendances within 4 hours14 98.0% 98.6% 98.6% 98.8% 98.8%

Month 2, May

This month Year to dateThis month Year to date

Executive summary 1: quality, access

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Direct income (£m) 4-10-0.4 0.5 -0.5 -0.8 0.5 -1.1 0.6 -1.4 -0.6 0.3

% Elective activity variance from plan

12 0.0% -4.5% -28.7% -1.6% -6.2% -7.8% -28.0% -4.4% -10.0%

Direct costs (£m) 4-10-1.3 -0.7 -0.1 -0.6 0.1 -1.9 -1.1 -0.8 -0.5 0.5

% Daycase activity variance from plan

12 0.0% -6.7% -24.0% -3.4% -8.4% -5.3% -20.8% -0.8% -8.8%

EBITDA (£m) 4-10-0.5 -0.2 -0.5 -1.4 1.6 -1.5 -0.5 -2.0 -1.1 2.0

% Non-elective activity variance from plan

12 0.0% -1.4% -12.3% 0.4% 3.9% 2.3% -2.6% 0.3% 5.5%

Net surplus/deficit (£m) 4-10-0.4 -0.2 -0.5 -1.4 1.7 -1.4 -0.5 -2.0 -1.1 2.2

% Outpatient activity variance from plan

12 0.0% 4.0% 11.6% -0.2% 4.1% 3.3% 10.0% 1.8% 2.1%

Finance: Green: variance either positive or less than 5% of budget, Amber: variance between less than 5% and less than 10% of budget, Red: variance less than 10% of budget

Workforce turnover 20 12.4% 14.1% 9.7% 13.4% 10.2%Externally Reported Frameworks

Vacancy rate 20 N/A N/A N/A N/A N/AFRR 4

Monitor compliance 21 (Quarterly position)

Sickness rate 20 3.0% 2.7% 2.9% 2.7% 3.0%

Staff numbers versus plan 20 -3.1% -2.9% -3.0% -4.1% 2.0% -3.1% -2.9% -3.0% -4.1% 2.0%

Agency spend 20 N/A N/A N/A N/A N/A

Appraisal rate 20 67% 61% 64% 73% 66%

Month 2, May

Not yet available

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Executive summary 2: activity, efficiency, finance, workforce

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4. Overall I&E

1. Operational Performance

2. Liquidity

3. Use of Assets

Financial Summary- Overall Rating

Year to date rating

Month 2 Actual

Month 2 Plan

Month 1 Actual

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Area of review Key Highlights

2. Financial performance2.1 Financial Performance Summary

Year to date Monitor Financial Risk Rating (FRR)

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Area of review Key HighlightsMonth 2 actual

Month 2 plan


Against EBITDA, the year-to-date position is £1.5 million behind plan (£8.6m actual versus £10.2m plan) (YTD FRR = 3).At M2, the Trust has made a contribution of £21.9 million before overhead & corporate costs. This is £2.9 million (rounded) behind the planned contribution of £24.9 million.Net year-to-date income from activity (i.e. excluding drugs, devices & other pass-through items) is £1.3 million behind plan.The balance of the adverse variance is largely down to a shortfall on the delivery of the QEP.

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At M2, against EBITDA, the Trust has a 7.4% return on income (YTD FRR = 3). YTD positions are:Medicine £0.5 million behind plan (-£0.2m in-month).Specialist Hospitals £1.1 million behind plan (-£1.4m in-month).Surgery & Cancer £2.0 million behind plan (-£0.5m in-month).The remaining Corporate budgets (including R&D & Education) are £2.0 million ahead of plan.

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2. LiquidityThe liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 29 days of the Trust’s operating expenses (YTD FRR = 4).At 31st May 2010 the Trust’s cash position was £99.0 million against a planned cash position of £99.6 million, an adverse variance of £0.6 million.

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3. Use of AssetsThe Trust made a 1.9% return on net assets (YTD FRR = 2). Of the current capital programme totalling £110.6m, 61% (or £67.9m) is approved & in progress. The plan for capital spend in 2010/11 remains at £72.2m.

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4. Overall I&E The YTD “bottom-line” I&E position is a deficit of £0.3 million, a -0.3% return on income (YTD FRR = 2). This is £1.4 million behind plan, which predicted a £1.0 million surplus. 2 2

Year to date Monitor Financial Risk Rating (FRR)

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Against EBITDA, the year-to-date position is £1.5 million behind plan (£8.6m actual versus £10.2m plan) (YTD FRR = 3).At M2, the Trust has made a contribution of £21.9 million before overhead & corporate costs. This is £2.9 million (rounded) behind the planned contribution of £24.9 million.Net year-to-date income from activity (i.e. excluding drugs, devices & other pass-through items) is £1.3 million behind plan.The balance of the adverse variance is largely down to a shortfall on the delivery of the QEP.

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At M2, against EBITDA, the Trust has a 7.4% return on income (YTD FRR = 3). YTD positions are:Medicine £0.5 million behind plan (-£0.2m in-month).Specialist Hospitals £1.1 million behind plan (-£1.4m in-month).Surgery & Cancer £2.0 million behind plan (-£0.5m in-month).The remaining Corporate budgets (including R&D & Education) are £2.0 million ahead of plan.

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2. LiquidityThe liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 29 days of the Trust’s operating expenses (YTD FRR = 4).At 31st May 2010 the Trust’s cash position was £99.0 million against a planned cash position of £99.6 million, an adverse variance of £0.6 million.

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3. Use of AssetsThe Trust made a 1.9% return on net assets (YTD FRR = 2). Of the current capital programme totalling £110.6m, 61% (or £67.9m) is approved & in progress. The plan for capital spend in 2010/11 remains at £72.2m.

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4. Overall I&E The YTD “bottom-line” I&E position is a deficit of £0.3 million, a -0.3% return on income (YTD FRR = 2). This is £1.4 million behind plan, which predicted a £1.0 million surplus. 2 2

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2. Financial performance2.2 Subjective analysis – financial summary

Direct Income, specifically, includes attributed HIV and other Community SLA income.

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Month 2, May

2. Financial performance2.3 Activity and clinical income variance

NB. Finance activity reported on this slide includes only chargeable activity so will differ to the activity figures reported on page 12 which includes both chargeable and non chargeable activity

Note■ A 30% marginal rate has

been applied at divisional level to all emergency activity above each division's threshold in line with the new PbR rule. As some divisions have underperformed against the threshold, this offset lowers the total Trust threshold adjustment, leading to a central favourable variance (as shown on the “unallocated” line).

■ Due to volatility in divisional monthly activity, this will be higher in the early months of the year & is expected to reduce to close to zero in future months.

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2. Financial performance2.4.1 Subjective analysis - Short Term Cash Flow - Outlook

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Cash Forecast Cash Actuals Cash Plan Actual Prior Year 2009/10

Cash actual at 30th Jun-10 = £95.1m

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2. Financial performance 2.5 Planned Costs Efficiency Performance in Context of the Trust overall

(1.2)

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Release ofBoard

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M2 YTD EBITDA Variance

Negative Variance Positive Variance

Graph shows the impact on overall Trust EBITDA of delivery of efficiencies alongside other key variances.

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2. Financial performance 2.5.1 Delivery of QEP

S&C Board QEP M2

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SpH Board QEP M2

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YTD VAR -£336k YTD VAR -£697k

YTD VAR -£313k

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2. Financial performance 2.5.2 Capital

Table B 10/11 Plan

Value of Approved Schemes

Value of Schemes Remaining

to be Approved

Total Value £m

Total Value £m

Total Value £m

Phase 3 44.1 44.1 0.0

ICT Strategy 3.0 1.4 1.6

Externally Funded - PDC 6.5 4.9 1.6

Externally Funded - Other 8.8 3.8 5.0

Replace & Refresh 20.4 4.6 15.8

Property Fund 9.4 2.4 7.0

Investment in Service Quality 10.5 2.7 7.8

Development & Expansion of Service 10.5 4.1 6.5

Target Reduction in Scheme Value -2.7 0.0 -2.7

Current 10/11 Capital Programme 110.6 67.9 42.7

Planned savings to be identified

All new 10/11 ISQ schemes remain to be approved with the exception of clinical team relocation to 250ER

Proposed 10/11 DES schemes still in the early stages of business case development

Primarily Queens Sq House boilers and LINAC replacement remaining to be approved

All new 10/11 R&R schemes awaiting to be approved apart from some ICT schemes

Rosenheim decanting and cost of sale schemes still in early stages of approval

Notes - Summary of Material Schemes Remaining to be Approved

Fully approved

16 Yr 2 Strategy schemes remaining to be approved

3 BRBH schemes remain to be approved

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OP First To Follow-Up Appointments Ratio

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Inpatient length of stay - All Services

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▪ The Productive Clinical Services component of the Quality and Efficiency Programme is finalising the measures it will use to report on progress against each of its workstreams. We will update this efficiency page with those key measures when they are all available. The QEP programme will set a trajectory for each measure, including upper quartile length of stay performance against peers for selected high volume services and to achieve 50% of discharges pre-11am. We will also be measuring our performance against planned reductions in new to follow up ratios in selected specialties as part of KPIs that will be tracked by commissioners. These will be subject to a system of incentives and penalties. Performance will be monitored as part of the QEP programme. ▪ LOS is lower at a trust level than compared to the same time last year for elective and non electives. Only Medicine in electives and Surgery and Cancer in non electives recorded a higher LOS. ▪ Pre-11am performance increased in May reversing a previously decreasing trend.

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% Elective activity variance from plan

0% -4.5% -28.7% -1.6% -6.2%

% Daycase activity variance from plan

0% -6.7% -24.0% -3.4% -8.4%

% Non-elective activity variance from plan

0% -1.4% -12.3% 0.4% 3.9%

% New outpatient activity variance from plan

0% 6.3% 15.9% -3.4% 7.6%

% Follow up outpatient activity variance from plan

0% 3.2% 10.1% 0.5% 2.8%

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

Month 2, May

This month

4. Activity4.1 Activity summary

Number of daycase and elective inpatients - All Services

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11

DC + elective 10/11 actuals DC + elective 09/10 actuals

DC + elective 10/11 target

Number of non-elective inpatients - All Services

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500


Non-elective 10/11 actuals Non-elective 10/11 targetNon-elective 09/10 actuals

▪ Elective and daycase activity was below plan by -4.5% for the trust and all boards. Non elective activity was under plan at a trust level, driven by underperformance in the Medicine board. The trust was above plan for both new and follow up outpatient attendances. ▪ In Medicine elective underperformance, while high in percentage terms , was from a relatively low volume. Underperformance in daycase activity is due to a profiling issue. Extra dermatology and rheumatology day cases are expected this year (NICE guidelines for drug use), but will commence later in the year. Since this is not profiled, the plan will be artifially high until volumes rise. Non elective underperformance was under plan (-12.3%/ -144), primarily due to underperformance in Medical Specialties (-32%/ -151). ▪ Underperformance in Surgery and Cancer was due to the delay in the HPB move which is limiting theatre capacity for other specialties until the move. This contributed to the underperformance in Trauma and Orthopaedics, Urology and Colorectal activity. ▪ In Specialist Hospitals, underperformance in elective activity was driven by the Heart Hospital (-9%/-24) and Queens Square (-11%/-96). Underperformance against plan was also recorded in daycases, driven by underperformance in EDH (-13%/-64) and Queen Square (-12%/-51). Underperformance was affected by a consultant taking unforeseen charitable leave in EDH, which is anticipated to be recovered in year. Also in EDH, daycase underperformance was driven by a switch to new patients to meet referral growth. This is expected to recover by July. Underperformance in both activity types was partially offset by elective overperformance in Paediatrics (12%/1) and daycase overperformance in Women's Health (33%/26). An action plan is in place on inpatient activity, including additional capacity, fast-tracking Thoracic patients, and review of scheduling of complex patients.

NB. In April, finance activity reported on page 6 includes chargeable activity only so differs from the activity figures reported on this page which includes both chargeable and non chargeable activity.

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% Non-admitted closed pathways under 18 weeks 95% 97.4% 98.1% 98.4% 97.0%

% Non-admitted closed pathways with known clock starts 98% 98.4% 99.0% 98.9% 98.2%

Non-Admitted Open Pathways Number Over 52Weeks* 0 268 9 66 193

% Admitted closed pathways under 18 weeks 90% 94.6% 100.0% 94.4% 94.4%

% Admitted closed pathways with known clock starts 98% 95.6% 96.4% 98.2% 93.5%

Admitted Open Pathways Number Over 52Weeks* 0 53 0 16 37

>6 week diagnostic waits 0 6 0 0 6


Month 2, May

This month

5. Access5.1 Access Targets - 18 Weeks

▪ Despite the government's announcement on 18 weeks targets, they remain a contractual requirement and in the Monitor compliance framework.▪ We continue to be compliant with 18 week admitted (90%) and non-admitted (95%) targets. For 2010/11 we must deliver specialty level compliance for admitted and non-admitted pathways on a quarterly basis. Failing against three or more specialty targets in either admitted or non admitted pathways will attract a score of 0.5 against the Monitor compliance framework. ▪ In May we were below threshold in Urology for admitted pathways and Cardiothoracic Surgery for non admitted pathways, although Cardiothoracic Surgery is likely to be excluded from our performance assessment due to the application of Monitor's low numbers rules ▪ We expect urology to be non-compliant by the end of the quarter, for both admitted and non-admitted pathways. ▪ Divisions are focused on reducing the high number of open pathways greater than 18 weeks, which are fully expected to be data quality issues rather than being actual long waiters▪ In May we reported 6 patients waiting over 6 weeks for a diagnostic test, down from 20 recorded in April. The breaches were at Queen Square and were due to a mixture of sudden bereavement leave for a consultant and handling of patient choice issues.

UCLH Retrospective 18 Week Consultant Specialty Function Performance Tracker

London benchmarks for January and February. UCLH figures are from April 2010/11 Al

l tre

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Gen

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Urol

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Trau

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Card

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Card

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Admitted Pathways

London February 90.0% 89.3% 92.8% 80.2% 86.9% 90.4% 88.0% 85.2% 88.8% 93.9% 97.9% 99.3% 96.4% 95.7% 99.4% 95.8% 100.0% 96.4% 91.9% 92.4%London January 90.3% 90.3% 93.4% 79.7% 86.3% 91.8% 90.4% 87.4% 89.1% 97.6% 98.4% 98.5% 96.8% 97.1% 100.0% 97.5% 100.0% 100.0% 92.1% 91.3%

UCLH May 94.6% 100.0% 89.6% 93.1% 100.0% 95.7% 91.8% 95.4% na 100.0% na 98.2% 100.0% 100.0% 100.0% 93.4% 100.0% na 90.1% 97.6% 3 3UCLH April 94.2% 100.0% 87.5% 90.8% 93.3% 92.3% 91.3% 94.8% na 100.0% na 99.2% 100.0% 100.0% 100.0% 95.5% 100.0% na 91.2% 96.6% 3 3

NonAdmitted Pathways

London February 98.3% 97.5% 97.5% 96.0% 98.6% 98.4% 97.0% 94.0% 98.9% 98.8% 99.2% 97.3% 98.8% 98.7% 98.8% 98.1% 98.3% 99.2% 98.3% 98.7%London January 98.1% 96.8% 97.1% 96.5% 97.6% 98.2% 97.9% 95.9% 98.1% 98.6% 98.4% 97.4% 98.2% 98.3% 98.6% 97.5% 98.1% 99.2% 98.2% 98.8%

UCLH May 97.4% 97.4% 95.3% 97.8% 100.0% 100.0% 95.3% 95.7% na 92.9% 99.6% 97.6% 98.3% 95.0% 98.0% 96.5% 97.6% 100.0% 96.7% 98.0% 3 3UCLH April 96.3% 100.0% 90.9% 95.4% 100.0% 98.6% 93.9% 94.4% na 100.0% 99.0% 100.0% 99.3% 96.6% 95.9% 96.5% 91.6% 100.0% 95.9% 96.5% 3 3

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Cancer 2 week wait from GP referral to appointment 93.0% 92.7% 92.1% 97.7%

Cancer 2 week wait from GP referral to appointment: breast symptoms

93.0% 96.4% 96.4% 2

Cancer 31 days from diagnosis to first treatment 96.0% 98.4% 100.0% 98.0% 100.0%

Cancer 31 Day Subsequent Surgery Treatment 94.0% 95.5% 93.3% 100.0%

Cancer 31 Day Subsequent Drugs Treatment 98.0% 100.0% 100.0% 100.0%

Cancer 31 Day Radiotherapy Available Month 3

Cancer 31 Day other Available Month 6

Cancer 62 Day GP referral to treatment 85.0% 94.9% 100.0% 92.1% 100.0%

Cancer 62 day referral to screening 90.0% 100.0% 100.0%


Month 2, May

This month

5 Access5.2 Access Targets – Cancer

▪ The May Cancer Waiting Times figures are subject to change until the submission to Open Exeter is finalised on the 07/07/10

▪ In May 2010 UCLH successfully met the 14 day breast symptomatic referral target, the three 31 day targets (first treatments, subsequent drug therapies and subsequent surgical treatments) and the two 62 day referral to treatment targets (GP referral to treatment and Screening referral to treatment). ▪ The 2 week wait suspected cancer referral to first OPA was narrowly missed with 92.74% performance against a 93% threshold. This was caused by 30 patients choosing to delay their first appointment past the 14 day target, most likely due to the two bank holidays. We are continuing to review our administrative processes, and have planned to carry out a patient audit to understand better the reasons why patients choose to delay their urgent appointments beyond 2 weeks.

Cancer 62 day referral targets

0%10%20%30%40%50%60%70%80%90%

100%

Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10

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

Cancer 62 day referral to screening Target (screening)

Cancer 2 week referral targets

90%91%92%93%94%95%96%97%98%99%

100%


Cancer GP referral to appointmentCancer 2 week wait from GP referral to appointment: breast symptomsTarget

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A&E attendances within 4 hours 98% 98.6% 98.6%

% Last Minute Cancellations to Elective Surgery 0.8% 1.1% 0% 0.9% 1.3%

% Cancelled Operations Readmitted Within 28 Days 95% 100.0% 100% 100.0% 100.0%


Month 2, May

This month

5. Access5.3 Access Targets - A&E and other

▪ Despite the government's announcement on the A&E 4 hour wait target, it remains a contractual requirement and in the Monitor compliance framework.

▪ We continue to have strong A&E performance compared to the rest of London. Our performance for May was 98.6% against a London rolling 4 week average of 97.7% for type 1 attendances.

▪ We cancelled 1.1% of elective surgery, worse than the CQC's target of 0.8% and a decrease on the 0.81% recorded in April. The main driver of underperformance in Specialist Hospitals board is the Heart Hospital, where actions are planned through 2010 to improve performance, principally increasing capacity and throughput in intensive care and high dependency beds.

A&E 4 hr wait target - All Services

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 107,000

7,500

8,000

8,500

9,000

9,500

A&E Attendances A&E attendances within 4 hours

A&E attendances within 4 hours

Last minute cancellations to elective surgery

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


20

40

60

80

100

120

140

Numbers of Last Minute Cancellations to Elective Surgery% Last Minute Cancellations to Elective Surgery% Last Minute Cancellations to Elective Surgery

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Number of hospital acquired MRSA Bacteraemias* 2 2 0 1 1

Number of clostridium difficile cases post 48 hours* 10 10 1 8 1

Percentage Hand Hygiene Compliance 85% 90.6% 86.2% 87.7% 92.9%

Percentage Hand Hygiene Reporting 100% 84.4% 100.0% 96.8% 80.0%

Percentage MRSA screening for elective admissions 100% 100% + 100% + 100% + 100% +

CVC Line infections Available Month 3


Month 2, May

This month

6. Quality6.1 Infection

MRSA bacteraemia / infections - All Services

01

23

45

67

89

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

Clostridium difficile infections post 48 hrs - All Services

0

20

40

60

80

100

120

140


CDiff actuals monthly CDiff threshold monthly

CDiff actuals YTD CDiff threshold YTD

▪ There were two MRSA post 48 hours cases recorded in May. The Trust's target for the year is 8 cases. Although MRSA is green against threshold, as demonstrated in the graph, thresholds are front loaded in the early part of the year and there still remains a significant risk of not achieving the full year threshold of 8.

▪ One MRSA case was recorded in ICU on T03 and the other in ICU at The Heart Hospital. Root cause analyses are completed. The ICU incidence of MRSA was a community acquired MRSA infection of a surgical wound. The second at THH is thought to have been due to a contaminant in taking the sample, though is still reportable.

▪ The MRSA Strategy Group led by Dr Paul Glynne is supporting clinical boards in improvement work focussed on improved hand hygiene, better management of central venous and peripheral lines and screening of all admissions.

▪ There were 10 cases of Clostridium difficile in May, equal to our threshold of 10. There is practice improvement in antibiotic management, early diagnosis, cleaning and isolation.

▪ The total number of MRSA screens continues to increase each month: Jan - 3306: Feb - 3309; March - 3919; April - 4372; May - 4456. MRSA screening for elective admissions is well over 100% for all the boards - more MRSA screens are performed than the total number of eligible patient admissions - and continues to increase each month. The Performance Team is creating an indicator showing the rate of MRSA screening across all admissions - from month 4.

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Number of Falls with harm* 1 1

Incidents per 100 admissions 4.1 5.9 3.2 4.2

Number of Pulmonary Embolisms and DVTs 39 13 17 9

Percentage of VTE Risk Assessments Completed 90.0% 45.1% 50.3% 44.4% 43.1%


Month 2, May

This month

6. Quality 6.2 Safety

VTE Risk assessment - All Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Percentage of VTE Risk Assessments Completed Target

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

0102030405060708090

100


0.5

1

1.5

2

2.5

3

3.5

4

Patient falls Number of Falls with harm Falls per 1000 beddays

▪ There was 1 patient fall resulting in harm during May. This particular T&O patient fell while staying on T6 South. The fall has been categorised as 'short term harm'.

▪ The third month of venous thromboembolism (VTE) audit data shows the Trust's May position at 45% VTE assessments completed, up from 33% in April. Note that this does not imply that patients are not being treated appropriately for VTE, since the measure is accurate only as a risk assessment, not as a gauge for treatment. VTE Risk Assessment is a National CQUIN indicator priority for 2010/11, with a target of 90% completion rate for Q4 2010/11, and an interim target of 50% by the end of Q2 2010/11. Current performance is monitored through auditing of compliance on a sample basis: the VTE strategy group is reviewing options for meeting the national requirement that this information is collected for all admitted patients. The group is developing a communications campaign that will support any changes in standard processes that are needed to deliver compliance with the measure.

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Complaints responded to within target time 85.0% 68.4% 94.1% 65.4% 58.1%

Overall, how would you rate the care you have received 82.9% 78.1% 77.4% 69.5% 83.4%

Switchboard calls answered in 30 seconds 85.0% 82.8% 82.8%

Month 2, May

This month

6. Quality 6.3 Patient experience

Patient Complaints - All Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


10

20

30

40

50

60

70

80

90

Number of Patient Complaints Complaints responded to within target time Target

Patient rating of care - All Services

50%

60%

70%

80%

90%

100%


Overall, how would you rate the care you have received Target

▪ In May 68.4% of complaints were responded to within timescales agreed with the complainant or, in the absence of an agreed timetable, 25 working days. This is down on April's performance of 69.8% and below performance recorded in the first nine months of the last year, which averaged at over 85%.

▪ This complaints performace includes: 3 complaints not responded to within target time in Surgical Specialties, 5 in Gastrointestinal, 7 in Women's Health, 6 in Queen Square, and smaller numbers in other Divisions. Overall there was an increase in the number of complaints received in both March and April, from approximately 60 per month to 80 per month, and these target case deadlines fell into April and May. Specifically for May, there were 76 targets that needed to be met

▪ Our patient survey indicator was below threshold at a Trust level in April. Divisional and Clinical teams continue to track progress against their individual trajectories. Improvements are tracked at the Inpatient Steering Group.

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Percentage Emergency Readmissions within 28 Days* 6.8% 5.3% 10.7% 7.0% 2.8%

Hospital standardised mortality rate - all services 74.0% 61.1% 59.2% 57.6% 77.7%

Global Trigger Tool -Adverse events

Available Month 3

Deteriorating Patients -Cardiac arrest & PERT Calls

Available Month 4


Month 2, May

This month

6. Quality 6.4 Clinical outcomes

Mortality in Hospital - 56 HSMR Diagnoses1yr rolling data, reported 2 months in arrears

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

Rel

ativ

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isk

(Inde

x 10

0 <

Bet

ter R

isk,

> W

orse

Ris

k)

RR 0.75 0.73 0.73 0.73 0.73 0.72 0.72 0.69 0.66 0.65 0.63 0.61

Low 0.69 0.67 0.67 0.67 0.67 0.66 0.66 0.63 0.60 0.60 0.58 0.56

High 0.82 0.79 0.80 0.80 0.79 0.78 0.78 0.75 0.72 0.71 0.69 0.67


▪ Dr Foster benchmarking data shows that we are not an outlier on emergency readmissions over the past 12 months, with results within the expected range. Additional focus is going to be brought to tracking emergency readmissions for Diabetes, COPD and Heart Failure now that they have been included as Regional CQUIN indicators.▪ Our HSMR data provided by Dr Foster is now significantly better than threshold at a Trust level for May. This data is published 2 months in arrears, and we have acheived the 5% reduction published in last years' Quality Account.▪ Later in the year the HSMR data will be subject to a rebasing exercise, with all trusts' performance set to the new national risk-adjusted average position.▪ GTT and Deteriorating Patient indicators are new Quality Account priorities for 2010/11. A new indicator for GTT will be included in the performance pack from month 3, and deteriorating patient figures from Month 4.

Global Trigger Tool - Adverse events - All Services

0

2

4

6

8

10


Adverse events

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Workforce turnover 12.4% 14.1% 9.7% 13.4% 10.2%

Vacancy rate N/A N/A N/A N/A N/A

Sickness rate 3.0% 2.7% 2.9% 2.7% 3.0%

% temp staffing spend 13.0%

Appraisal rate 85% 67% 61% 64% 73% 66%

Month 2, May

This month

7. Workforce 7.1 Turnover and sickness

▪ The turnover percentage remains at around 12% for May with an average number of 44 monthly leavers during the last 12 month period. Fixed-term or ‘planned’ leavers accounts for 13% of leavers during the last 12 month period and 15% for the month of May.▪ The sickness absence rate remains at 3%. The absence percentage does not include medical staff who are reporting a rate of 0.36%. ▪ The total expenditure on temporary staff in May was just under £2.5m. This is a decrease from just over £2.6m in April. The spend on temps in May represents 13% of the total pay bill compared to 10% in the same period in 2009. Both the N&M and A&C data show a reduction in overall requests for temporary cover.▪ UCLH branded bank adverts in Guardian and Metro in May generated an extremely positive response. CVs were received from more than 300 non-clinical applicants (including Admin’, Clerical, Finance, IT and HR etc) and over 50 applications from clinical workers (including Nurses, Doctors, Midwives and Allied Health Professionals) within the first week.

WTE actual v plan 2010/11

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

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

Actual WTE Temp WTE Plan WTE

Trust % of Workforce Spend that is Temporary Staff

0%

2%

4%

6%

8%

10%

12%

14%

16%

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

2010-11 2009-10

20

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Thresholds WeightingQ1

Performance to date May-10 Comments

Refer to comments 1.0 3 1 MRSA is green in month 2 against a threshold of 2 and green for the quarter to date against a threshold of 4. The full year threshold of 8 is phased in the early part of the year (2 from April to July) with a zero tolerance from August to March. See page 16 for detail.

Refer to comments 1.0 14 10 Clostridium difficile is green in month 2 against a threshold of 10 and the quarter to date against a threhold of 20. Our full year threshold is 119. The monththreshold is 10 for every month except March 11 where it is 9. See page 16 for detail.

90% 1.0 94.3% 94.6%

See page 13 for detail

20.5 for 3 or more

specialties 1 1


95% 1.0 96.9% 97.4%


20.5 for 3 or more

specialties 1 1

See page 13 for detail.

85% 90.6% 94.9%See page 14 for detail




94%

96% 0.5 99.2% 98.4%See page 14 for detail



100% 0.5 100%+ 100%+Performance will be reported against this indicator by month 2. See page 14 for detail.

98% 0.5 98.8% 98.6%See page 15 for detail

N/A 0.5

0.4

Green Green

Note: Thrombolysis is a Monitor indicator but we do not provide this service in the Trust therefore we are not measured on this

Month 2, May

Indicators

Core Standards

Maximum time of 18 weeks from point of referral to treatment in aggregate and by speciality for admitted patients

Maximum time of 18 weeks from point of referral to treatment in aggregate and by speciality for non-admitted patients

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

62 day wait for first treatment from urgent GP referral

62 day wait for first treatment from consultant screening service referral

31 day wait for second or subsequent treatment: Surgery

Overall governance rating

Self-certification against compliance with requirements regarding access to healthcare for people with a learning disability

Incidence of MRSA

Incidence of Clostridium difficile

Screening all elective in-patients for MRSA

31 day wait for second or subsequent treatment: Radiotherapy (from 1 Jan 2011)

Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge

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

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

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

1.0

1.0

0.5

8. Externally Reported Frameworks 8.1 Monitor Indicators – Compliance Framework

21

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Est financial value

(assuming £500m contract income) Director Lead Current month

Year to date performance

Q1Risk of non-payment




N1 £750,000 Sandra Hallett 45%25% payment for baselining

performance and developing action plan

25% payment on achieving 50% inpatients assessed

50% payment for 90% of inpatients assessed

N2 £750,000 Tony Mundy Paid on achievement of agreed level of improvement

R1a £375,000 Tony Mundy 25% on delivery of agreed plan andbaselining 25% on delivery of audit results

50% production of evidence of 6 months implementation with run

charts

R1b £375,000 Geoff Bellingan25% on delivery of agreed plan,

baselining and performance measures agreed

25% on evidence of implementation50% on evidence of system being embedded and delivery of agreed

performance

R2a £300,000 Paul Glynne25% for participation in Q2 baseline

audit and agreeing improvement trajectory

25% at the end of Q3 on achievement of Q2 and 3

performance trajectory

50% at the end of Q4 based on achievement of performance

trajectory for that quarter

R2bi £100,000 Paul Glynne 25% for Q1 on achievement baselining and trajectories agreed




trajectory for that quarter.

R2bii £100,000 Paul Glynne 25% for Q1 on achievement baselining and trajectories agreed





R2biii £100,000 Paul Glynne 25% for Q1 on achievement baselining and trajectories agreed





R2c £300,000 Gill Gaskin25% for participation in Q2 baseline

audit and agreeing improvement trajectory




trajectory for that quarter

R3 £450,000 Paul Glynne 25% for preparation of plan 75% for delivery of plan paid in Q4

R4 £900,000

Paul Glynne(Diabetes & COPD)

Gill Gaskin(Heart Failure)

Payments will be made at the end of quarters 2 and 4 on the basis of achieving the agreed improvement

trajectories.

Payments will be made at the end of quarters 2 and 4 on the basis of achieving the agreed improvement

trajectories.

L1a £600,000 Tony Mundy 68%Q4 based on achievement of

agreed performance improvement for the year

L1b £600,000 Tony MundyQ4 based on achievement of

agreed performance improvement for the year

L1c £650,000 Paul Glynne Evidence of adherence to HPA SSISS protocol

L2 £650,000 Louise Boden 25% for preparation of plan75% paid at the end of Q4 based

on delivery of plan.

L3i Paul Glynne

L3ii Paul Glynne

L3iii Paul Glynne 1

7000000

RedAmberGreen

Reg

iona

lN

atio

nal VTE Assessment

Improving Patient Experience

Implement IHI Global Trigger Tool

Implement Enhanced Recovery Programme in at least 2 recognised specialties (one to be new to Trust)

Improving inpatient discharge information – content and electronic transmission

Improving timeliness of discharge - % weekend discharges

Improving care for LTC patients (diabetes, COPD and Heart failure) - reduction in readmission rates

Choose & Book - 98% slot availability

Choose & Book - 99% of appropriate services available

£500,000

Loca

l

Hospital Standardised Mortality Rates

Surgical site recording and improvement

Reducing deaths in low mortality procedures

25% payment for Q1 based on participation in Choose and Book

project

25% payment in Q3 based on achieving performance target for

this quarter

50% payment for maintaining performance in Q4.

Performance Indicators

Implementation of nutritional assessment and support

Improving timeliness of discharge - % discharged pre-noon

Improving timeliness of discharge - proportion discharged in line with predicted discharge date

Improving outpatient information – timeliness and content

Choose & Book - Directory of service rating of either 0 or 1

Implementation of Dementia Pathway

8. Externally Reported Frameworks 8.2 CQUIN Indicators8. Externally Reported Frameworks 8.2 CQUIN Indicators8. Externally Reported Frameworks 8.2 CQUIN Indicators8. Externally Reported Frameworks 8.2 CQUIN Indicators

22

G

Agenda Item 10

Quality & Safety Report

University College London Hospitals NHS Foundation Trust Quality & Safety Committee Summary to the Board of Directors

June 2010 Patient outcomes & effectiveness 1. Imaging Service QSC received a review of plain film reporting for inpatients, general practitioners and oncology outpatients in response to concerns raised in the external review. Initiatives to improve staffing, extend working hours, weekend working and increase the number of radiographers who can report on films has resulted in improved response times. Imaging division is to report back on progress to improve reporting in three months. 2. Scorecards/quality indicators The divisions of Cancer, Queen Square, Eastman Dental hospital, Imaging, Medical Specialties and Gastrointestinal services (reviewed from May), exception reported against the Trust priority quality indicators. Improvement trajectories were discussed for venous thromboembolism assessment, hand hygiene reporting, MRSA bacteraemias and complaints. QSC was informed that an electronic patient record (EPR) overbooking tool has been introduced in Medical Specialties to improve poor patient experience from overbooked clinic appointments. 3. National Institute for Health and Clinical Excellence (NICE) guidance exception report QSC noted, in compliance with the Trusts NICE implementation procedures, our position in relation to guidance and appraisals published by the Institute. The implementation steering group notified QSC that compliance reporting of cross-Trust guidance will be added to the scorecards of all relevant divisions in addition to that of the clinical lead for the particular guidance eg. CG91 Depression with a chronic physical health problem. 4. Patient Reported Outcome Measures (PROMS) QSC received an update on progress with administering mandatory PROMS. The Clinical Outcomes Co-ordinator is working closely with Day Surgery and Surgical Reception to address lower rates of participation for patients having hernia repair and varicose vein surgery. Pre-operative PROMs data has been published for Apr 09 – Nov 09 which indicate slightly higher rates of participation then in-house data. 4.1 Non-mandatory PROMS Professor Mundy is leading on introduction of the EQ-5D survey, a standardised instrument used to measure health outcome which can be applied to a wide range of health conditions, to Urology initially with a view to rolling it out to other specialities later this year.

5. Six Lives: Parliamentary Ombudsman’s report 2009 For the Board’s information, May QSC received a paper and presentation addressing the recommendations of the Ombudsman’s March 2009 report into the provision of public services to people with learning disabilities, in addition to other relevant national reports. The report recommended that all NHS and social care organisations in England should review urgently: • the effectiveness of the systems they have in place to enable them to understand and plan to meet the full range of needs of people with learning disabilities in their areas; and • the capacity and capability of the services they provide and/or commission for their local populations to meet the additional and often complex needs of people with learning disabilities; and should report accordingly to those responsible for the governance of those organisations within 12 months of the publication of this report. Areas where the Trust is meeting the recommendations were highlighted, for example good communication links with Camden PCT. However, identification of patients with learning disabilities, to enable appropriately adjusted care, remains an issue as does provision of information for patients and their families. A learning disability steering group has been formed to address gaps and actions needed. 6. Reports from sub-committees 6.1 Clinical Effectiveness Steering Group (CESG) May 2010 The CESG informed QSC of the Trust results from the Centre for Maternal and Child Enquiries (CMACE) Perinatal Mortality Report 2008. Based on stillbirths and neonatal deaths notified to CMACE and reported to the Office for National Statistics (ONS) in 2008, it indicated that UCLH had favourable stillbirth and neonatal mortality rates compared to London SHA and the national average. All near-term intrapartum-related perinatal deaths are now investigated as a Serious Incident. Women’s Health division plan to move to a quarterly ‘confidential enquiry style’ review of all stillbirths and neonatal deaths, with themes and learning points fed back. 6.2 Research Governance Committee – December 09, January 10 & March 10 QSC received an update on proposals to develop a UCL Partners biobank. The Information Governance Committee are to review any arrangements for the transfer of patient data to ensure data protection. An updated and revised policy for consent in research has been agreed. Progress is being made to flag research patients on the electronic patient record (EPR). A procedure for the withdrawal of host approval where the conduct of the study is likely to jeopardise the safety of patient or the integrity of the research findings has been agreed. QSC noted that Research policies are reviewed by the policy approval sub-group of the EB and research governance has close liaison with Trust governance on complaints and incident reporting.

General issues 7. Controlled Drugs 7.1 Accountable Officer quarter four 2009 report In compliance with the Safer Management of Controlled Drugs report (2007) the QSC received the Trust controlled drug report for quarter 4 from the Accountable Officer for Controlled Drugs, Louise Boden. The Trust is required to provide this report to the NHS Camden Controlled Drugs Local Intelligence Network on a quarterly basis. There was an increase in the number of incidents in March which was investigated. No particular pattern, or type of error, or area from which errors were reported was identified. Local actions appear appropriate and there were no specific issues of concern. The Accountable Officer is to monitor closely in future months to determine if the increase seen in March was a one off or whether there is a sustained increase. 7.2 Care Quality Commission: Safer Management of Controlled Drug Annual Report – August 2009 UCLH is compliant with the two relevant recommendations made by the Commission. 8. Care Quality Commission: In-patient survey 2009 QSC received the survey results for information. Full discussion of the results is tabled for the July Patient Experience QSC agenda. 9. Care Quality Commission: Health & Social Care Act 2008 regulations update QSC received a report on work in progress following initial registration with the CQC, to complete evidence collation, risk assessment and action planning undertaken alongside consideration of a more systematic, robust and sustainable approach to ongoing review. The report is to be submitted to the EB for consideration and approval. 10. Venous Thromboembolism (VTE) prevention QSC received the results of audits indicating that the overall trust position has improved to 45% in May. The QSC discussed extensively the blocks and actions required to improve patient safety by assessment and prophylaxis of VTE in line with the CQUIN requirement of 50% by end of Quarter 2 and the national requirement of 90% by Quarter 4. 11. Infection QSC discussed extensively the blocks and actions required to improve patient safety by reducing health care acquired infection, in particular, MRSA bacteraemia, in line with the reduction threshold. The medical director for the Medicine Board is leading an MRSA taskforce which will report to the Executive Board. Tony Mundy

Medical Director

H

Agenda Item 11

HR & Communications Committee Report

Board of Directors Report – July 2010

Summary Report from the HR & Communications Committee

1. Workforce Performance Report

There has been significant progress in the development on the UCLH Bank. Branded Bank adverts placed in the Guardian and Metro during May have generated an extremely positive response. Within the first week CVs were received from more than 300 non-clinical applicants and over 50 applications from clinical workers. There have been approximately 400 new bank joiners since January 2010 with a further 200 in progress. Two articles profiling a range of UCLH staff who have joined the bank have featured in Inside Story and on Insight. These have generated a great deal of interest and raised awareness of the bank service.

2. NHS Litigation Authority Update

The NHSLA central team have confirmed that satisfactory progress has been made against all of the following workforce standards; Professional Clinical Registration, Employment Checks, Supporting Staff, Sickness Absence, Moving and Handling, Slips, Trips and Falls, Inoculation Incidents, Bullying and Harassment and Stress. Evidence of compliance was gathered earlier in the year and the next stage will be for each of the standard leads to assess evidence trails, identify gaps and implement any necessary changes.

3. Vetting and Barring Scheme (VBS) CRB Update

The government announced on the 15th June that registration with the Vetting and Barring Scheme (VBS) has been halted to allow them to remodel the scheme back to proportionate, commonsense levels. The full details are still to be finalised however changes made when the Vetting and Barring Scheme was launched in October 2009 are still in place.

4. Managing Statutory & Mandatory Training The committee were informed about the ongoing review of statutory and mandatory training. A proposal for more effective recording and reporting of this training was presented and will be further discussed at the Education Board.

5. Update from the Health and Safety Committee

The committee endorsed the following policies from the Health & Safety Committee; COSHH policy, Latex Policy, Falls, Slips and Trips Prevention, Management of Work-Related Stress and the Manual handling. These will now be sent to the EB Policy Sub-Group for approval. The Committee also received an update on the progress of the organisational overview of risk assessments and key audits and agreed that the recommendations from these audits should be included in the Health and Safety Action Plan for 2010/11.

1

6. Communications

• Positive media for May and June has included coverage about the UCLH-led trial into using single shot radiotherapy for cancer patients and a patient whose life was saved at the Heart Hospital after being flown through the volcanic ash cloud. Maxillofacial surgeon, Tim Lloyd featured in the BBC documentary Facing Africa.

• We have focused on the NHNN as part of the 150th year with a week of stories on Insight and articles in the May and June Inside Story.

• The delivery of the new external website has been delayed because the supplier, Precedent, has had difficulty in putting together the design and structure behind it. The Trust is working closely with Precedent to resolve these issues.

Julia Whitehouse Workforce Director Sue Atkinson NED, Chair HRCC

07 July 2010

2

I

Agenda Item 12

Finance & Contracting Committee Report

University College London Hospitals NHS Foundation Trust Finance and Contracting Committee Report to Board of Directors 8th July 2010 1. INTRODUCTION

This report updates the Board of Directors on the issues considered at the meeting of the Finance and Contracting Committee (FCC) on 7th July 2010. These cover:

Matters Arising - Section 2 Finance Directors Report – Month 2 - Section 3 Contracting Update - Section 4 Cross-Committee Issues - Section 5 Any Other Business - Section 6

2. MATTERS ARISING

There were two matters arising that were not covered within the main agenda, as follows:

• The Finance Director updated the Committee on the work that had been undertaken

to review the timing of delivery of QEP savings in 2010/11. The Finance Director informed the Committee that Clinical Board QEP targets had been phased flat across the year (in equal 12ths) within the plan to ensure full focus from the outset. No central phasing adjustment for this had been budgeted. However, a central phasing adjustment of approximately £0.7m was booked corporately in month 2 to reflect the difference between the flat phasing and the phasing which can now be justified by the QEP project plans.

The Committee noted that for month 3, divisional/Board budgets would be adjusted to reflect the revised QEP phasing.

• The Finance Director observed at the last Committee meeting that in the first draft of

the Cancer Centre planning model, income and contribution from non cancer divisions had been included, and the question had been asked as to whether this distorted a fair comparison with the Final Investment Case (FIC) scenario.

The Finance Director informed the Committee that the impact in the planning model of including other divisions’ activity (namely paediatrics, theatres and other outpatients) is to add £0.4m of contribution in year of opening, rising to £1.2m by 2023/24. This had been based upon the prudent assumption that only 10% contribution is achieved for these services.

The Finance Director also reiterated that in the original FIC the activity was included (for capacity planning purposes) but the income was not specifically included but was instead captured as one of the opportunities within the contingency model. The impact of inclusion as presented to the Committee was to improve the point at which the centre becomes profitable by one year and the time to payback overall by two years.

Page 1 of 5

Following an update received from the Chief Executive, the Committee was pleased to note that the project appeared to be well on track in terms of securing the planned level of charitable contributions towards the costs of the Cancer Centre. The Committee also noted that a further update on activity within the Cancer Centre planning model will be presented to the September FCC, as part of the quarterly reporting cycle on the project.

3. FINANCE DIRECTORS REPORT – MONTH 2

Overall Financial Summary The Finance Director presented the month 2 performance summary and management accounts pack, and summarised the key messages contained within these reports. The financial performance is shown summarised in table 1, below. Ratings in this table are scored from 5 to 1 (5 indicating low risk, 1 indicating high risk).

Month 2 Monitor Financial Risk Rating

Area of Review Year-to-date actual

Year-to-date plan

Financial Summary 3 3

Comprising:

Operational Performance 3 4

Liquidity 4 4

Use of Assets 2 3

Overall Income and Expenditure 2 2 Table 1 – Month 2 financial performance summary

The Committee noted that the month 2 year-to-date EBITDA position, as set out in table 2, below, is £1.5m behind plan, and that most of the shortfall relates to under performance against income arising from the Trust’s activity plan. The Committee also noted that the overall year-to-date income and expenditure position is a deficit of £0.3m, which is £1.4m behind plan.

Page 2 of 5

Month 2 year-to-date Service Line

Budget £m

Actual £m

Variance £m

Medicine Board 0.2 (0.3) (0.5) Specialist Hospitals Board 4.8 3.7 (1.1) Surgery & Cancer Board 2.7 0.7 (2.0) Research & Development (0.0) 0.2 0.2 Education (0.5) (0.4) 0.2 Corporate Budgets 3.0 4.6 1.6 EBITDA 10.2 8.6 (1.5) ITDA (9.1) (8.9) 0.2 Net Surplus/(Deficit) 1.0 (0.3) (1.4)

Table 2 – Month 2 year-to-date financial position (figures shown with rounding)

The Finance Director informed the Committee that some further pricing adjustments, believed to be largely favourable, are still required, although there is also a significant income risk relating to potential non-payment by commissioners. The Finance Director advised the Committee that both of these issues will be addressed in month 3 to ensure the figures reported for Quarter 1 reflect as accurately as possible the income that will be collected. The Finance Director highlighted that aside from this, the income shortfall principally reflects an underperformance in activity levels against plan in electives and day cases. Clinical Boards’ Financial Performance The Finance Director accepted that the fact that the QEP phasing adjustment was made centrally, and that because some potentially favourable income adjustments had not been reflected in the month 2 figures this did mean that individual board positions were probably slightly stronger than those reported. The Committee noted the key issues within the Clinical Board financial positions, as follows:

• Medicine’s reported year-to-date position is £0.5m behind plan. Although QEP delivery is £0.3m behind plan, this is being offset by over performance on income from activity (+£0.3m). The key remaining issue relates to an adverse internal trading variance of £0.4m, which is currently being investigated as part of the ongoing work to refine the methodology used to calculate service level reporting (SLR) based financial positions.

• Specialist Hospitals’ month 2 year-to-date reported financial position of £1.1m behind

plan is principally made up of adverse variances within Queen Square, the Heart Hospital and the Eastman Dental Hospital. This overall shortfall is mainly due to income under-performance which continues to be investigated, although there also remains a shortfall on delivery of QEP savings (-£0.3m).

Page 3 of 5

• The Surgery and Cancer Board’s year-to-date position is now £2.0m behind plan. Within this position, income from activity shows an underperformance of £1.7m, whilst the QEP position is £0.7m behind plan. However, the Board has identified that £1.1m of this adverse variance against plan relates to timing issues (i.e. where the shortfall in QEP delivery and achievement of income is expected to be recovered by year-end). The Board has recognised that of the remaining shortfall there is a recurrent gap of £0.4m that is now being addressed.

Trust Efficiency Progress The Committee noted that the overall year-to-date QEP performance, after the inclusion of central phasing adjustment of £0.7m (as outlined in Matters Arising, above) was £0.7m behind plan, and that this could be analysed as follows:

• QEP gap (i.e. plans not yet in place) £0.6m • Under performance against plans £0.1m

The Committee discussed the processes that the Clinical Boards had put in place to both identify additional schemes to address current gaps and any slippages, as well as to ensure the full delivery of all existing QEP project plans. The Committee also noted that there would be an expected additional benefit going in to 2011/12 of the full-year effect arising from schemes commencing part way through the current financial year. The Chief Executive informed the Committee that following Executive Board discussion he would be leading monthly QEP review meetings to ensure a rigorous monitoring and review of progress in those areas where a shortfall in QEP delivery was currently being reported. The Committee noted that the QEP Project Director would be giving a short presentation to the upcoming Board meeting. The Committee also requested that further consideration should be given as to putting on a more detailed QEP seminar at the August Board meeting.

Cash Position The Committee noted that the Trust’s cash position at 30th June 2010 was £95.1m, which is approximately £0.4m ahead of plan; shortfalls arising from the adverse I&E position and slightly shorter creditor days are being offset by less outlay on capital expenditure. Project Diamond Update The Finance Director also provided the Committee with a brief update on the current position on Project Diamond-based funding, in relation to specialist services, for 2010/11. The Committee noted that in order to potentially secure this additional funding in future years, the Trust would need to be able to specifically highlight, to Commissioners, pricing discrepancies across these range of services. The Committee was advised that this key piece of work would be undertaken via the new Patient Level Information and Costing System (PLICS).

Page 4 of 5

4. CONTRACTING UPDATE

The Deputy Chief Executive presented the Committee with an update on contracting issues, specifically covering 2009/10 outstanding payments and 2010/11 contract negotiations. The Deputy Chief Executive informed the Committee that after taking into account amounts expected to be received in July, a relatively small element of the 2009/10 payments would still be outstanding. The Committee noted that these overdue invoices are actively being chased by the Finance department and the balance outstanding will be reviewed following receipt of July’s payments, with a view to escalate as appropriate. The Deputy Chief Executive was pleased to inform the Committee that an agreement has been reached with the North Central London Acute Commissioning Agency (NCLACA) on the wording of the documentation within the 2010/11 contract, and as a consequence the Chief Executive had signed the contract variation on Friday 2nd July. The Trust was now awaiting a reciprocal final sign-off from the NCLACA. The Committee noted that negotiation of the contract values is ongoing with commissioners outside of North Central London. The Deputy Chief Executive informed the Committee that these commissioners are currently seeking to commission below the proposal value submitted by the Trust. The Deputy Chief Executive mentioned that the risk monitoring in this area is being co-ordinated, and the financial values being proposed by individual commissioners are being reviewed, at executive level, before the Trust will agree to them. The Committee noted that an update on details of the progress with negotiations will be provided at next month’s FCC meeting.

5. CROSS-COMMITTEE ISSUES

No new cross-committee issues were noted. 6. ANY OTHER BUSINESS

The Committee reviewed one further item under any other business:

• The Deputy Chief Executive presented the Committee with a report reviewing issues experienced during 2009/10 in relation to challenges, received from commissioners, in the way the Trust recorded and charged for activity.

The Committee noted that following resolution of all issues, control systems relating to billing have been reviewed. The Committee was able to conclude that the overall billing processes have held up well.

Jane Ramsey Richard Alexander Chair Finance Director 8th July 2010

Page 5 of 5

J

Agenda Item 13

Audit Committee Report

Report to Board of Directors July 2010

MAIN POINTS FROM AUDIT COMMITTEE ON 3rd June 2010

Note by Chair of the Audit Committee We discussed the latest Internal Audit Reports by RSM Tenon and were pleased to note that none had received limited assurance. We were presented with the Annual Report for 2009/10 containing the Head of Internal Audit Opinion, which confirmed that the Trust had retained the Significant Assurance rating. We also discussed and approved the Internal Audit plan for 2010/11. We received the Risk and Assurance Framework report for Q4 2009/10 and heard about the progress made on risk rating movements from red to amber and green. We also discussed the work done by A&E with Camden PCT to help direct flows of patients from A&E to other wards. We noted the improvements made on risk management and reporting over the previous 18 months. We reviewed the detailed draft of the 2009/10 Accounts, consisting of Annual Report, Quality Report, Statement on Internal Controls (SIC) and a supporting commentary. We were satisfied with the accounts and recommended them to the Board for approval. We also reviewed the Management Representation Letter to PwC and recommended it to the Board. We discussed the PwC ISA 260 report presented to Audit Committee. We were concerned about the tone of the report, which we felt was different from previous discussions we had during the year. PwC confirmed to us that the misstatements were not at odds with their opinion that the Accounts gave a true and fair view. PwC agreed to review the text and presentation. It was agreed that Finance would discuss with PwC plans for improvements, mainly on the capital front, before the next accounts. The outcome of the discussion would be reported by Finance to the Committee followed by reports on progress each quarter. We agreed a note of the changes to the accounts would be circulated to the Board, these are attached. Nick Monck Chair of Audit Committee 8th July 2010

Details of changes to 2009/10 Accounts as per published Annual Report and Accounts and as per 3rd April Audit Committee(note re: figures in brackets are figures as per 3rd June version. Figures outside brackets are published version figures)AnnualReport SchedulePage Ref Ref. Details of changes post 3rd June Audit Committee

126 SOCI Note number reference changes due to deleted notes.126 SOCI Revenue from patient care activities £518,061k (£502,861k) - see page 143 changes below126 SOCI Other operating income £182,025k (£197,225k) - see page 143 changes below126 SOCI Total comprehensive income -£23,029 (-£23,027k) - rounding adjustment127 SOFP Note number reference changes due to deleted notes.127 SOFP Property, plant and equipment £565,320k (£565,356k) - see page 150 changes below127 SOFP Property, plant and equipment £565,320k (£565,356k) - see page 154 changes below128 SoCITE (1) Zero value lines removed129 SoCITE (2) Zero value lines removed130 SoCF Zero value lines removed. Note number reference changes due to deleted notes.130 SoCF More detailed analysis of cash movements where previously figures were netted off142 Notes Removal of non-applicable note ' Pooled Budgets' - (formerly Note 2)142 Note 2 Operating Segment note (formerly Note 3) completed.143 Notes Removal of non-applicable note ' Income Generation Activities' - (formerly Note 4)143 Note 3

143 Note 3 Addendum to note re: Private Patient Income143 Note 4

144 Notes Removal of non-applicable note 'Revenue From Rendering of Services' - (formerly note 7)144 Note 5

144 Note 5 Addendum to note giving further details on Audit Fees.145 Note 6 (formerly Note 9) Operating Leases note completed.147 Note 8 (formerly Note 11) Pension Costs - Note amended for changes as per revised NHSPA guidance.149 Notes Removal of non-applicable note ' Better Payment Practice Code' - (formerly Note 13)149 Notes Zero value lines removed150 Note 13

151 Note 13 Prior year figures - Changes made to table layout to aid clarity and understanding.152 -153 Note 13 Narrative to note completed.

154 Note 14

(formerly Note 5) Revenue from patient care activities £518,061k (£502,861k) - changes in analysis by Nhs organisation type and re-analysis of £15,200k previously analysed under 'Other Operating Income'.

(formerly Note 6) Other operating income £182,025k (£197,225k) - changes in analysis by Nhs organisation type and re-analysis of £15,200k moved to Patient Care Activities.

(former Note 8) - changes in 'Services from Nhs Organisations' analysis. Changes in analysis between Executive and Other Staff costs. Also some rounding adjustments

(formerly Note 17) - Changes made to table layout and further narrative added to aid clarity and understanding. £36k re-analysed to Intangible Assets (Note 14).

(formerly Note 18) - Changes made to table layout to aid clarity and understanding. £36k re-analysed from Property, Plant &

AnnualReport SchedulePage Ref Ref. Details of changes post 3rd June Audit Committee

155 Note 14 Prior year figures - Changes made to table layout to aid clarity and understanding. 156 Note 14 Narrative to note completed.156 Note 15 (formerly Note 19) - note completed156 Note 16 Additional note.157 Note 17 (formerly Note 20) - note completed157 Note 18 (formerly Note 21) - note completed

157-158 Note 19 (formerly Note 22) - note completed158 Note 20 (formerly Note 25) - note completed158 Note 21 (formerly Note 26) - note completed160 Note 26 (formerly Note 32) - note completed160 Note 27 (formerly Note 33) - note completed162 Note 28

163 Note 29 (formerly Note 36) - note completed163 Note 30 (formerly Note 37) - note completed165 Notes Removal of non-applicable note ' Events after the reporting period' - (formerly Note 38)165 Note 31 (formerly Note 39) - note completed165 Note 32 (formerly Note 40) - note completed167 Notes 33-35 (formerly Note 41 - 43) - notes completed

(formerly Note 35) - amendment to split between 'Current' and 'Non-Current' provision and completion to note for in year movements and additional narrative to note.

Equipment (Note 13).

K

Agenda Item 14

Audit Committee Minutes

1

AUDIT COMMITTEE

Minutes of the meeting held on Tuesday 20th April 2010 from 2.00pm to 4.00pm in the Chairman & CEO meeting room, 250 Euston Road. Present: Sir Nicholas Monck, Non-Executive Director (Chairman) In Attendance: Professor Sir John Tooke, Non-Executive Director

Richard Alexander, Finance Director Peter Anthony, Deputy Finance Director

Tonia Ramsden, Director of Corporate Services Sandra Hallett, Director of Quality and Safety (for point 8)

Marion Storch, Head of Finance Bertram Green, Interim Chief Accountant 1. Apologies. Apologies were received from Sue Atkinson, Non-Executive Director, Mike Foster, Deputy Chief Executive, Janet Dawson, PwC, Tim Merrit, RSM Tenon, Kevin Lowe, PwC Nick Atkinson, RSM Tenon 2. Minutes of the Meeting held on the 25th March 2010. The minutes of the non quorate March meeting were reviewed and agreed. 3. Matters Arising. The table of the matters arising were noted as having been dealt with, covered within the agenda items of the meeting or where not completed an appropriate update had been provided to the Committee. 4. PFI IFRS Accounting Treatment. RA informed the Committee that the 2009/10 draft accounts were prepared for the first time under IFRS. This resulted in a number of financial changes of which the biggest impact for UCLH was the PFI treatment. There had been discussions with PwC who had previously worked with the Trust and agreed the accounting treatment of the PFI under IFRS, they now indicated the view that accounting guidance had moved on. PwC had proposed the Trust should not capitalise the constructors interest and professional fees both of which were included in the fair value of the building. The effect of not capitalising the interest and fees would increase the net asset position of the balance sheet as a result of a reduced finance lease, but lead to greater interest charges to the future expenditure of the Trust. The Trust has disputed this revised view indicating that a) the guidance had not changed sufficiently to render our position not true & fair, b) other NHS FTs were including these items in the fair value of the asset and c) another accounting firm indicated that they allowed their clients to include such costs in their fair value.

2

RA informed the committee he had taken a call from the engagement partner that morning informing him PwC were prepared to accept the UCLH current treatment. Sir John commented that the FD had adopted a reasonable and fair view. The Chair suggested that the Board will need to be advised on the handling of the issue and documentation should be put together for the benefit of the absent non-executive director. The committee agreed that the unaudited accounts reflect the shared view of the FD and PwC. 5. Segmental Reporting. The Chair asked RA for the FD’s recommendation on the treatment of IFRS 8, Segmental Reporting in the draft annual accounts. RA proposed that the draft accounts will show only one segment and will refer readers to the Trust website where the management information reported to the Board is published. If PwC as part of their audit insist on segmenting then the Trust will accede to that request. The Chair asked that the note to Monitor covering the unaudited accounts should inform them that there may be an additional segmental statement in the final accounts if agreed with PwC. The Committee agreed this proposal. 6.1. Draft Year End Accounts 2009/10 PA provided the Committee with a summary of the Trust’s financial position per the 2009/10 unaudited accounts, which were due to be submitted to Monitor. He informed the Committee the Trust is now reporting under IFRS and the format of the accounts was different to that the Committee would be familiar with. The Income and Expenditure Statement is now the Statement of Comprehensive Income (SOCI) and the Balance Sheet the Statement of Financial Position (SOFP). The Trust will be reporting a deficit of £11m for 2009/10 after the impairment of the Trust’s estate. The £22.5m impairment was almost entirely due to the reduction in value of Phase 1 and 2 of UCH by £21.4m. Excluding the impairment the Trust delivered a total of comprehensive income (retained surplus) of £11.5m. PA reported the EBITDA was £63.3m resulting in an FRR of 4. The Chair queried the significant increase of bad debts. PA explained there had not been a change to the calculation methodology which took percentages of debt by age as a provision, and the significant increase in NHS debt, due to contractual changes and challenges had driven the increase. The Chair suggested a suitable note be included in the accounts. Sir John asked for details in Other Reserves, which PA agreed to provide after the meeting.

3

The Committee agreed, as work was still needed on the draft accounts before submission to Monitor on April 22nd the Finance Director will feed back a summary of any significant changes to the Committee Chair by close of business Wednesday April 21st. Subject to their being no significant adjustments the Committee approved the release of the draft unaudited accounts to Monitor. 6.2. Draft Statement on Internal Control . PA reported the SIC had been previously discussed at Audit Committee, EB had reviewed and commented as had the Risk Coordination Board. The Committee reviewed the draft SIC and discussed whether sufficient had been disclosed on the limited assurance audit reports. It was agreed the issues were acknowledged and that details were not required. 6.3. Draft Head of Internal Audit Opinion Report. The Committee agreed the report. 6.4. Final IFRS Accounting Policies The Committee noted the latest draft setting out the policies. 6.5. Fixed Asset Verification Exercise The Committee noted the report. 7. Draft Annual Report The Committee noted the report. 8. Draft Quality Accounts Sandra Hallett presented the 2009/10 Quality Accounts, which are a summary of the Trust’s priorities for the year. The Committee asked for more clarification on the process of the Quality Accounts production. SH explained that the Trust’s priorities were agreed in consultation with the Governors and the Trust’s Divisions. The first outline of the report was included the April Board papers. It was pointed out that the Quality Accounts were part of the Monitor submission. PwC will only review the report; we await the outcome of consultation as to whether an audit is required. Sir John Tooke said that the report will be considered by the Quality and Safety Committee on Thursday April 21st. RA commented on one of the graphs in the report and suggested to check the data quality. 11. Date of Next Meeting Thursday 3rd June 2010 - 1.30 p.m. to 4.00 p.m. in the Chairman & CEO meeting room, 2nd Floor Central, 250 Euston Road.

UCLH/UCL R and D Update July 2010

Monty MythenDirector R and D

1. New Director appointments 2. Research funding streams 3. Clinical Research Facility 4. MHRA 5. UCL / UCLH estates and NIHR capital funding6. CBRC annual report

R and D Update July ‘10

UCLH/UCL

CLINICAL RESEARCH FACILITY

JOINT R and D UNIT

(R M & G)

UCLP

CLINICAL TRIALS

UNIT

DIRECTOR OF R&D

UCLH/UCLNIHR

CBRC

UCLH

R and D

1) New Director Appointments

• Director UCLH/UCL Comprehensive Biomedical Research Centre (CBRC)

• Director UCLP Clinical Trials Unit (CTU)

15. Pain +

Headache

9. Gastro

-

enterology

+ Hepatology

13. Neuro-Degeneration12. Neuro-

Diagnostics

14. Neuro-

Therapeutics

10.

Imaging

8.

Wom

en +

Neon

ates

16.O

ral H

ealth

2. Car

diov

ascu

lar

Diseas

e

4.Cancer

5. Cellular+ GeneTherapy

6. Infectious

Disease

3.

Anaesthesia +

Critical Care

7.

Long

Ter

m

Con

ditio

ns

1.

Educ

atio

n +

Trai

ningNeu

rology

Institute of

Healthy Ageing

WindeyerInstitute

Eastman

Dental

Hospital

Cancer Sciences

Institute

Rayne

Institute

Institute forWomen’ s Health

Clinical

Research

Facility

Inst

itute

of

Hepat

olog

y

Heart

Hospital

11.Neuro-

Imaging

Eastman Dental

Institute

NHNN

Q

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Phase II IC

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TheatresEducationCentre

Imag

ing

Tech

nolo

gy

Wolfson

Institute

Life

Sci

ence

s

UCLH

UCL

EGA Hospita

l

+ Phase II

London School of

Hygiene & TMedicine

PatientBenefit

ResearchNetworks

Indu

stry

UCLBusiness

NH

S Innovations

of

Inst

itute

HatterInstitute

NIMR

New Director Appointments (i)

• Director UCLH/UCL Comprehensive Biomedical Research Centre from September ‘10:Professor Deenan Pillay

(Program Director Infection Immunity UCL Partners)

• “A Registration Process has been established to recognise CTUs that have the expertise to centrally coordinate high quality multi-centre clinical trials. The aim of this process is to help improve the quality and quantity of available expertise to carry out clinical trials in the UK.”

2) Clinical Trial Units

UCLP Clinical Trials Unit

• Aim to increase the number of NIHR grants• Grant writing support• Focal point for clinical trials collaboration• Fills an area of unmet need in non-cancer trials

• “To gain UKCRC Registration, CTUs must demonstrate a track record of experience in coordinating multi-centre trials, expert staff to develop studies, robust quality assurance systems and evidence of long term viability of capacity for trials coordination.”

Clinical Trial Units

New Director Appointments (ii)

• Director UCL Partners Clinical Trials Unit:Dr Ann Marie Swart(MRC Clinical Trials Unit)

3) Research Funding Streams

• Unprecedented transparency of research funding streams

• Implementation of theme trading accounts • Increased accountability for research finance - job

plans not approved for authorization until reconciliation with agreed research budgets

• Progress reporting - 2nd wave of projects and capacity building assessments underway (see 08/09 NIHR report at end of this presentation)

4) Clinical Research Facility (CRF)

• Wellcome - NIHR / UCLH / UCL Partnership• 20 Beds – South Ground Floor Phase II • Director, Professor William Rosenberg • Deputy Directors: Professors Richard Begent

(Cancer) and Raymond Macallister (WellcomeTrust)

• Running at capacity • Re-modeling started (e.g. new clinical trials

pharmacy)

5) Medicines and Healthcare products Regulatory Agency (MHRA)

An executive agency of the Department of Health.

“We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe. No product is risk free. Underpinning all our work lie robust and fact- based judgements to ensure that the benefits to patients and the public justify the risks.”

• MHRA inspection of UCL March 2010 (follow up to 2007) – put on hold after 48 hour

• Plan to return to assess full effect of the current systems following merger with UCLH and RFH

• In parallel: Regulation and Governance of Clinical Trials under-review by Academy of Medical Sciences (major input from UCLH/UCL)

MHRA Inspection 2010

Academy of Medical Sciences Review of the Regulations and Governance

of Medical Research

Joint UCL/UCLH/Royal Free Biomedical Research Unit

May 2010

UCL / UCLH Estates and NIHR Capital Funding

• NIHR awarded Capital Funding for refurbishment schemes in UCL Estate (e.g. Genetics Institute)

• Presented significant accounting and oversight challenges

• Resolved after many hours of expert input• Lesson for future – joint UCL/UCLH bidding team

6) CBRC Annual Report

UCLH/UCL R and D Update July 2010

Monty MythenDirector R and D

board of directors meeting... · 6/8.4 nhs confederation and the foundation trust network the...

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