bolton nhs foundation trust – board meeting october 30th 2014 · bolton nhs foundation trust –...

Bolton NHS Foundation Trust – Board Meeting October 30th 2014

Location: Boardroom Time: 0900 – 1230 hrs

Time Topic Lead Process Expected Outcome

0900 1. Patient Story Verbal Patient story and learning points noted

2. Apologies for Absence – Trust Sec. Verbal Apologies noted (G Ashworth, M Harrison, T Armstrong Child, M Wilkinson)

3. Declarations of Interest Chairman Verbal To note any declarations of interest in relation to items on the agenda

4. Minutes of meeting held 25th September 2014 Chairman Minutes To approve the previous minutes

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman Verbal To address any matters arising not covered on the agenda

7 Chairman’s Report Chairman Verbal To receive a report on current issues

7.1 CEO Report including reportable issues CEO Report To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints

Safety Quality and Effectiveness

0930 8 Integrated Performance Report Exec team Report To note and receive the integrated performance report

9. ECIST Actions and System Resilience COO Report To receive the report on ECIST actions and system resilience

10. Mortality report Medical Director

Report To receive the six monthly mortality update

Governance

1045 11. Q2 Compliance declaration Trust Secretary

Report To approve the Q2 compliance declaration to Monitor

12. Request for certification of compliance Trust Secretary

Report To approve the application for certificate of compliance with enforcement undertakings and discretionary requirements

1

Time Topic Lead Process Expected Outcome

Finance and Strategy

1130 13. Healthier Together - update Director Strategic & OD

Verbal To receive an update on healthier together

1145 14 Community Services Director Strategic & OD

Report To receive an update

1200 15 Better Care Fund Director Strategic & OD

Report To receive an update

For Information

Chair reports of the following sub-committees will be noted – if any member of the Board wishes to raise a question regarding one of these items they should indicate this before the start of the meeting.

16. Finance and Investment Committee – Chair Report 16th October 2014

17. Quality Assurance Committee – Chair Report 8th October 2014

18. Health and Wellbeing Board – minutes

18. Audit Committee – No meeting held in the reporting period

19. Charitable Funds – No meeting held in the reporting period

20. Any other business

Questions from Members of the Public

To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting.

Resolution to Exclude the Press and Public

To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

Review of meeting

Trust Secretary

discussion

2

Board of Directors minutes – September 25th 2014 Page 1 of 9

Meeting Board of Directors Meeting

Time 09.30 a.m.

Date 25th September 2014

Venue Bolton One seminar room

Present:- Abbv.

Mr D Wakefield Chair DW

Dr J Bene Chief Executive JB

Dr E Adia Non-Executive Director EA

Mrs T Armstrong Child Director of Nursing TAC

Mrs C Davies Non-Executive Director CD

Mr A Duckworth Non-Executive Director AD

Mr A Ennis Chief Operating Officer AE

Dr M Harrison Non-Executive Director MH

Mr S Hodgson Medical Director SH

Mr A Thornton Non-Executive Director (interim) AT

Mr M Wilkinson Director of Strategic and Organisational Development MW

Mr S Worthington Director of Finance SCW

In attendance:-

Mrs E Steel Trust Secretary ES

Mrs H Edwards Head of Communications HE

Members of the Council of Governors, representatives of the CCG and a representative of

the local media in attendance as observers.

1. Patient Story

“D” a patient with Crohn’s Disease and a learning disability attended the Board to tell of her

experiences of inpatient and other support services.

D first became ill in 2013 and was admitted to hospital for investigations for

Gastrointestinal problems. The following points were made regarding D’s experience and

treatment:

D found that on the whole staff were supportive and calming however she did not

always understand what the doctors and nurses were telling her - simpler

instructions and explanations avoiding the use of jargon and medical terminology

would have helped

Ward rounds when there were several members of a team around the bed made D

feel uncomfortable - it would have helped if there had been fewer people on these

rounds.

D did not always get seen straight away, on one occasion she used the bedside

phone to call her mother to ask her to speak to the nurses on her behalf (this was

whilst being cared for in a side ward as a precaution because of diarrhoea and

vomiting)

D found her second admission much easier to cope with, she knew what to expect


and had a better understanding of the process.

D was initially scared of her stoma however with the support of the learning

disability nurse and the stoma nurse she has adjusted well to managing her stoma.

Board members asked D and her mother questions about the care she had received and

suggestions they had for ensuring others in a similar position get the care and support they

need. The following learning points were noted:

Communication must be clear and easily understood with reasonable adjustments

made and support/safeguarding teams brought in as needed.

Buzzers should always be in reach of patients

The role of carers is important; there must be recognition that patients in D’s

position come with a package of support which must be recognised.

Protocols need to be flexed if necessary to support patients like D

Board members agreed that consideration should be given to videoing the patient stories

to share valuable learning with staff.

Resolved: Board members noted the patient story and agreed that the Exec team should

consider and share the key learning points and agree actions to improve the quality of

communication between clinicians and patients.

FT/14/58 Exec team to consider actions to take to improve communication between clinicians and

patients TAC/SH

2. Apologies

G Ashworth

3. Declarations of Interest

None

The Chairman welcomed attendees to the meeting, new Board members Mark Wilkinson -

Director of Strategic and Organisational Development and Andrew Thornton interim NED

were welcomed to their first Board meeting.

Board members joined in thanking Ebrahim Adia for his time on the Board and wishing him

well in his future career; Ebrahim was presented with a gift as a token of his time on the

Board.

4. Minutes of The Board Of Directors Meeting Held on 31st July 2014

The minutes of the meeting held on 31st July 2014 were approved as an accurate record.

5. Action Sheet

The action sheet was updated to reflect progress on agreed actions.

14/56 The COO provided a verbal update following the request at a previous

meeting for assurance that patients who were not seen within the 31 day

target did not have a lengthy wait. The COO confirmed that a new manager

and clinical lead have been appointed for cancer services; pathways are

reviewed on a weekly basis to check performance and to give


multidisciplinary team overview to the process. - Action closed;

performance will continue to be monitored through the regular performance

reports.

6. Matters Arising

No matters arising not covered by the agenda.

7.1 Chairman’s Report

Trading Conditions - Across the country, Trusts are struggling with performance and

financial targets; for the first time since the inception of Foundation Trusts, the FT sector

delivered a loss in quarter one. As a Trust we have continued to make progress but

continued achievement of savings plans will be a challenge.

Monitor - recent meetings with Monitor have focused on the actions needed to come out of

breach. For the last two months, the Trust has achieved a Continuity of Services Rating

(CSR) of 2 (previously FRR). Achieving a CSR of 2 is a huge achievement and is one of

the significant milestones required in order to come out of breach.

Board members asked that a formal record of their thanks to all who have contributed to

this achievement be formally noted.

Healthier Together - The Chairs and NEDs of the three trusts in the North West sector of

Greater Manchester held a joint meeting which was attended by DW, CD and AD. Those

present at the meeting confirmed their commitment to collaboration in order to find

common ground and do the right thing for the patients and population of the area.

Board members noted the Chairman’s update.

7.2 CEO report

The work to refresh the five year strategy and develop the operational plan for submission

in April 2015 has started with a meeting with divisions to ensure the refresh takes a bottom

up as well as a top down approach.

Stakeholders

Bolton CCG have submitted their second submission to the Better Care Fund,

regular(quarterly) updates will be provided to the Board to show how the allocation of funds

is distributed and spent.

The Chair and CEO will be meeting their CCG counterparts on Friday 26th September;

topics for discussion include the response to Healthier Together and actions to reduce non-

elective admissions.

Monitor have continued their review of the submission for funding for the IT and Estates

Business cases.

Reportable issues

The Trust will submit a joint bid for the 5 - 19 tender, a significant proportion of these

services are already provided by the Trust. (EA declared a non-pecuniary interest in this in

relation to his role on Bolton Council)

There has been one red rated complaint since the last meeting, this is currently being

investigated. Further information on the learning from complaints will be reported to the

QA Committee within the complaints report.


Board Assurance Framework

The BAF was discussed at length in the September Audit Committee with concern

expressed by non-executives that the BAF is not proactively reviewed on a regular and

consistent basis. Board members agreed that the BAF should be a reflection of the “big

ticket items” that really occupy the Board.

Board members agreed the need to spend some Board Development time looking at the

BAF

Industrial Action

A national four hour strike has been called on 13th October 2014 followed by four days of

action. Although consultants and specialists have voted not to strike it is anticipated that

other unions could follow with wider impact. Contingency plans have been agreed but

there is a potential for an impact on flow. There is no plan to reduce services.

Resolved: Board members noted the Chief Executive’s update

FT/14/59 Regular quarterly update on Better Care Fund to be scheduled MW

FT/14/60 Board development session on risk management to include the BAF ES

8 Integrated Performance Report

Quality

Performance to respond to complaints fell to 77% in August and 11 patients did not

receive a response; action has been taken to reduce the number of outstanding responses

to 2 with full recovery by November.

One avoidable pressure sore was reported, this related to a patient in theatre.

C difficile continues to be below the target for the financial year, 10 cases have been

reported in the year to date compared with more than 20 at this stage in 2013.

Medication incidents - remains a concern which the QA Committee do not yet feel

assured is being addressed. PwC have been asked to undertake a review of the

governance of medication management, to include a review of recommendations in

previous internal audit and third party reports. Board members requested medication

incidents to be included on the front page of the performance report.

Operational

The access targets for cancer, A&E and RTT were all achieved in August.

Performance against the A&E target has been challenging in September, the team are

focusing on flow and capacity to ensure patients are seen in a timely manner.

Cancer performance in August was good but will be tight for September and for the

quarter.

RTT - overall performance is good; the target has been achieved in all specialities other

than orthopaedics and plastics.

Diagnostic waits - following the dip in performance as discussed previously, performance

against the target has recovered. The Elective division are dealing with the provider of the

endoscopy washers to seek redress for lost activity and performance.

Board members asked for assurance that the 5% of patients not being seen within the 18


week timeframe were not experiencing excessive waits. The Chief Operating Officer

confirmed that no patient has waited longer than 40 weeks, the total waiting time and the

total volume of the waiting list has reduced, the trust are close to achieving the target for

orthopaedics and are working with UHSM on an SLA to address the wait for plastic

surgery.

Board members asked for assurance that the cancer targets would continue to be

achieved, the Chief Operating Officer confirmed that although September was challenging

he had confidence in the new clinical lead who has already achieved a fantastic level of

engagement from the clinical team.

The biggest operational risk is the achievement of the A&E target; performance is down on

this time last year. However, with continued divisional engagement, although it will be

challenging, there is no reason to believe the target will not be achieved. The recent follow

up report from the intensive support team will be shared with the Board in October

FT/14/62 ECIST actions to be reported to October Board meeting AE

Workforce

Although Sickness absence has fallen and performance has improved compared to

2012/13 it remains above target, Board members requested a graph to provide evidence of

the improving trend.

There is significant variation between the divisions; the family division are significantly

below the target with a rate of 3.38% while the other two divisions are at 5%.

Until recently following TUPE transfers for MiB and TCS, five different policies had been in

use for the management of sickness absence, a new single policy with improved clarity,

early occupational health intervention and earlier thresholds for meetings has now been

approved.

Appraisal rates have reduced and are below the target threshold, divisions are challenged

on all workforce metrics during the performance management meetings, Board members

asked if there were any consequences applied for staff who fail to carry out appraisals the

Divisions are taking the target seriously and are going through lists of staff who have not

had an appraisal to ensure this is addressed.

Using the performance management framework the Elective care division are graded

amber for performance against HR metrics and are red for finance.

FT/14/63 Graph to be provided to show trend in improvement of sickness absence MW

Finance

Board members were reminded of the overall context for finance with a significant number

of Trusts reporting a month 5 position of a deficit against plan.

The month five position is an adverse variance to plan of £0.14m with a year to date deficit

of £0.50m.

The Director of Finance highlighted the following:


The August 2014 in month position shows a small deficit of £0.03m against the planned

deficit of £0.08m.

The August position is made up of:

Income overall is better than plan in month at £23.56m, compared to a plan of

£22.73m, with clinical over achieving by £0.77m.

Pay spend is £16.65m, an under spend of £0.84m.

Non-pay spend is £6.14m, an under spend of £0.05m.

The overall position is slightly better than anticipated and the Trust has used

£0.03m of Risk Reserve in month. Year to date the maximum available has been

utilised.

ICIPs delivered in August total £1.7m. The year to date delivery is £8m, which is in

£0.1m behind plan.

The Trust is still forecasting to deliver the year-end target surplus of £1.6m; however this

will require utilisation of the £6.2m risk reserve, £4.8m being used to mitigate financial risk

and £1.4m being used to finance developments. There is a risk range of delivery from a

deficit of £6.1m to a surplus of £3.6m and this range will narrow as we go through the year.

To manage the risk within the forecast the downside risk management plan has been

enacted, consequently the Corporate division has been tasked with bringing forward

2014/15 ICIP schemes to deliver an additional £1.2m.

The Chair of Audit advised that the auditors had provided a positive report on the financial

transformation and credit should be given to the Executive Team and the Finance Team for

this achievement.

Board members noted the update on quality, financial and operational performance.

9. Update on Revalidation

The Medical Director presented an update on revalidation Medical Revalidation using the

Annual Organisational Audit (AOA) Comparator Report for 2013/14. This was received in

late July and benchmarks Bolton FT self-assessment against others.

Overall the Trust compare well to other organisations however for five indicators the Trust

are not compliant and for two of these performance is worse than peer. Introduction of a

robust appraisal policy and implementation of electronic appraisal will ensure we have the

resources to achieve full compliance with GMC standards for revalidation. The

benchmarking with Salford and Wigan will enable us to examine our current processes in

identifying and responding to concerns, the other key component of the Responsible

Officer role.

Board members challenged the response as being overly modest, although as yet the

Trust has not yet had a QA review it was suggested and agreed that other responses

should be reconsidered in light of Board discussion.

Resolved: The Board noted the update on revalidation and asked the Medical Director to

reconsider the responses to the self-assessment

FT/14/64 Revalidation response to be reconsidered SH


10. Review Standing Orders

The Trust Secretary summarised the proposed changes to the Standing Orders as outlined

in the paper.

Board members were asked to consider the requirement for a quorum and to approve a

change to the quorum to bring into line with the constitution.

Resolved: board members approved the proposed changes to the constitution and agreed

that the quorum for the Board should be a minimum of six Directors with at least three Non-

Executives and at least three Executives.

11 Governance Review

The Trust Secretary presented the proposed programme of Governance reviews to

culminate in a formal governance review in quarter 3 of 2016.

Trusts have always been required to conduct some form of governance review; this

requirement has now been formalised with the publication of the well led governance

framework which requires Trust’s to commission an external governance review at least

once every three years.

Directors were asked to note the governance reviews undertaken since 2012 and to

approve the proposed approach to the well led governance framework.

Resolved: The Board approved the proposed approach to governance reviews and

undertook to complete the survey, the results of which will be discussed in the October

Board meeting (part two)

12 Board Development

The Trust Secretary presented the proposed Board Development plan, Board members

were asked to approve the proposed process.

Resolved: Board members acknowledged the importance of a well led/well developed

Board and agreed to adopt the proposed schedule with the addition of a board awareness

session on infection control.

FT/14/65 Training session on infection control to be added to development programme ES/TAC

13 Fit and Proper persons test/Duty of candour

The Trust Secretary presented a summary of the new requirements for a fit and proper

person test and Duty of Candour.

The proposed process of a declaration and a DBS check to inform the Chairman’s

declaration that Board members are “fit and proper persons” was approved.

Capsticks will be attending a future Board meeting to provide more information on the Duty

of Candour

Resolved: The process of a formal fit and proper declaration on appointment and

thereafter on an annual basis was approved.


14 Revision to Risk Management Strategy

The Director of Nursing asked Board members to consider a proposed change to the Risk

Management Strategy to be more explicit on risk registers when regulatory inspections are

expected/ anticipated.

Board members debated the proposed addition to the strategy; views were mixed with

some Board members feeling that if there are anticipated issues with a regulatory

inspection the issues rather than the inspection should be included on the risk register.

Board members agreed that any issues which could lead to regulatory failure should be on

the risk register or BAF, those in favour of the addition to the strategy felt this would be a

useful prompt as part of the formal preparation for a regulatory visit.

Resolved: board members voted by a show of hands to amend the risk strategy as

proposed in the paper submitted to the Board.

15 Healthier Together Update

Board members considered the proposed organisational response to the Healthier

Together consultation noting that the deadline for response has been extended to 24th

October 2014.

A sector response has also been prepared for discussion during the part two board

meeting.

Board members debated the proposed response, all accepted the case for change but

many felt this could be expressed in a more positive manner making a stronger case for

Bolton to be a specialist hospital

Resolved: Response to be revised to emphasise the capabilities to deliver, the impact on

patients and the interdependencies.

FT/14/66 Healthier Together response to be revised to reflect discussion MW

16. Finance and Investment Committee Chair report (18/09/14)

Board members noted the report from the Finance and Investment Committee

17. Quality Assurance Committee Chair report (13/08/14 and 10/09/14)

Board members noted the report from the Quality Assurance Committee and the actions

taken to seek assurance with regard to medicines management.

18. Audit Committee (18/09/14)

The Chair of the Audit Committee gave a verbal update on matters discussed at the

meeting held on 18/09/14 when the following items were discussed:

The review of committee effectiveness was discussed; this will be used to inform

the committee’s annual report to the Board.

The Committee received a report on non-financial data accuracy; the report

provides assurance that although there are some issues as a result of human

error/manual processes, there are no systematic false reporting issues. These


issues will not be eliminated completely until the Trust has an effective EPR.

Auditors confirmed that they were not concerned about the level of error; it was not

felt to be critical and did not have a significant impact.

A report on Counter Fraud services provided significant assurance that the Trust

takes all reasonable steps for fraud protection.

19. Charitable Funds Chair report

No meeting held during the reporting period

20. Any other business

None

21. Questions From Members of the Public

No questions were submitted.

Date And Time Of Next Meeting

30th October 2014

Resolved: to exclude the press and public from the remainder of the meeting because

publicity would be prejudicial to the public interest by reason of the confidential nature of

the business to be transacted.

22. Review of Meeting

Board members agreed to a proposal to review the meeting using survey monkey

FT/14/67 Survey Monkey to be created and completed for meeting review ES

Sept Board actionsCode Date Context Action Who Due CommentsFT/14/23 24/04/2014 late night transfers Further report back including three months audit report and

comparison with other Trusts

AE Oct-14 verbal update

FT/14/28 24/04/2014 SUI report data loss report back to QA committee on review of compliance with new

standard operating procedures

AE Oct-14 agenda item October QA committee - complete

FT/14/42 29/05/2014 committee reports review of Board and committee effectiveness as part of wider

governance review

ES Oct-14 Part two Board meeting agenda item

FT/14/51 26/06/2014 staffing levels report back to QA Comm to provide assurance that escalation of

unfilled shifts is effective

TAC Oct-14 agenda item October QA committee - complete

FT/14/61 25/09/2014 performance report Medication incidents to be added to front page TAC Oct-14 complete

FT/14/62 25/09/2014 performance report ECIST actions report to October Board AE Oct-14 agenda item

FT/14/63 25/09/2014 performance report graph to be provided to show trend in improvement of sickness

absence

MW Oct-14 attached

FT/14/64 25/09/2014 revalidation report response to be reconsidered in light of Board discussions SH Oct-14 verbal update

FT/14/66 25/09/2014 Healthier Together review of response to reflect discussions MW Oct-14 respnse revised and circulated by email - action

completeFT/14/67 25/09/2014 review of meeting survey monkey to be created for meeting review ES Oct-14 complete- results to be discussed in part two meeting

FT/14/68 25/09/2014 Healthier Together part 2 discuss sector response with commissioners JB/DW Oct-14 complete

FT/14/69 25/09/2014 Healthier Together part 3 further discussion with regard to sector response MW/JB Oct-14 complete

FT/14/59 25/09/2014 CEO report regular quarterly update to be provided on Better Care Fund MW Oct-14 agenda item

FT/14/17 27/03/2014 performance report TAC to provide update to QA Committee on proposals for

volunteers

TAC Nov-14 action deferred

FT/14/53 26/06/2014 reward and recognition reports to be provided on engagement, behaviours and

standards

SW Nov-14 to be incorporated in Workforce Strategy paper - Nov

2014FT/14/57 31/07/2014 performance report Proposal regarding adjustment to the threshold for the appraisal

target to be included when workforce strategy presented

MW Nov-14

FT/14/58 25/09/2014 patient story Exec team to consider actions to take to improve

communication between clinicians and patients

TAC/SH Dec-14 actions to be incorporated into a report on you said

we did in relation to patient stories to be presented FT/14/60 25/09/2014 CEO report Board development session on risk management to include BAF ES Dec-14

FT/14/49 26/06/2014 CEO report Board development session on incident and risk reporting ES Feb-15 incorporated in Board Development programme -

redated to ensure session completed by end of FT/14/65 25/09/2014 Board development Training session on infection control to be added to

development programme

ES/TAC Mar-15 session added to plan - to be scheduled before end of

financial year

All information provided in this written report was correct at the close of play 22/10/2014 a verbal update will be provided during the meeting if required

Agenda Item No

Meeting Board of Directors

Date 30th October 2014

Title Chief Executive Update

Executive Summary

The Chief Executive update includes a summary of key issues since the previous Board meeting, including but not limited to:

Monitor update

Stakeholder update

Reportable issues log

o Coroner communications

o Never events

o SUIs

o Red complaints

Board Assurance Framework summary

Next steps/future actions Clearly identify what will follow i.e. future KPI’s, assurance requirements

The Board are asked to note this update

Discuss Receive

Approve Note

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Esther Steel Trust Secretary

Presented by Dr J Bene Chief Executive

vlomas

Typewritten Text

: 7.1


Chief Executive Update

1. Stakeholders

2.1 Monitor

Members of the Board attended an extended progress review meeting (PRM) with Monitor

on 20th October 2014. In addition to the regular discussions Monitor’s provider assessment

team were in attendance to scrutinise and challenge the case for investment.

Monitor have now requested our formal response to lift the Enforcement undertakings and

Discretionary requirements, this is an important milestone in the process of coming out of

breach. We will submit our application for a compliance certificate as soon as possible and

will expect a response within two - three weeks of submission.

Although this is an important step we will not automatically become green on our

governance rating

2.2 Healthier Together

Following discussions at the September Board meeting the revised organisation and sector

consultation responses were submitted to Healthier Together.

The Trust continues to work closely with partner organisations to ensure the best possible

care is provided to our patients.

At a meeting on Friday 24th October 2014, the Chairs and CEOs of the three trusts and

representatives of the three CCGs and three councils met to agree th MOU around joint

work in the North West Sector.

It is clear that more work is required particularly on achieving the standards set out by

Healthier Together for A&E and Acute Medicine but the work on emergency and high risk

surgery is at a well-developed stage.

It is planned that a proposal from this joint working will be ready to present to the

commissioners by January/February 2015.

2.3 Care Quality Commission

The Trust remains in band 4 of the CQC intelligent reporting. The Trust are not on the

recently announced list of planned inspections between December 2014 and March 2015.

The CQC are still aiming to have completed inspections at all Foundation Trusts and NHS

Trusts by December 2015.

2.4 Ebola

Since December 2013 there has formally been an acknowledged ongoing outbreak of Ebola

Virus Disease. In that period there have been 9,216 cases of EVD, including 4,555 deaths.

There are now three countries where the outbreak persists: Guinea, Liberia and Sierra

Leone. Although the risk of emergent cases in the UK and the Trust is very low, in line with

DH and PHE guidance, the Trust is making plans for resilience in the event of a potential

patient with EVD presenting in the organisation.

This includes planning for:


Patient identification and risk assessment

Management of possible cases

Management of confirmed cases

Isolation of patients

Transfer of patients

Specimen collection

Laboratory procedures

Personal protective equipment

Decontamination

Waste and laundry treatment and disposal

After death care

3. Reportable Issues Log

Issues occurring between 25th September and 20th October 2014

3.1 Serious Untoward Incidents

There have been no SUIs since the last Board meeting.

3.2 Never Events

The Trust have reported one never event, this is currently being investigated; a full report will

be provided to the Quality Assurance Committee.

3.3 Coroner Prevention of future Deaths (PFD) reports

There have been no coroner notices issued since the last report

3.4 Red Complaints

There has been one red rated complaint since the last Board meeting.

3.5 Reputational Issues

None of significance

3.6 Whistleblowing

There have been no concerns raised by whistle-blowers

3.7 Incident reports

There has been a significant increase in the number of incidents reported relating to

overcrowding in A & E. Analysis of current data has shown this to be as a consequence of

increased admissions and slower flow of patients through the hospital. There is already

much work underway to address this. The need for a larger A&E “majors” area to

accommodate times of high admission and reduced flow has been recognised by the Trust

and is part of the bid for capital to fund the Estates Strategy. This issue will be discussed in

greater detail within the Quality Assurance Committee.


4 Board Assurance Framework

4.1. Introduction

The BAF is the framework setting out how the Board are assured that the Trust will achieve

its strategic objectives.

The BAF is used by the Board of Directors to ensure that all significant risks have been

identified; information on control, performance and assurance is timely and relevant; and to

provide leadership on risk management.

The BAF is reviewed on a monthly basis by the Executive team who finalise the list of

strategic risks, confirm actions being taken and check assurances

BAF scores are a composite of impact and likelihood, the impact for the majority of these

scores is major or catastrophic and most are deemed to have likelihood of either 3 or 4 as

defined on the table below:

The full BAF will be reviewed at the November Audit Committee

Level Descriptor Definition % of risk

1 Rare Difficult to believe that this will ever happen /

happen again. <10%

2 Unlikely Do not expect it to happen / happen again,

but it may 10 – 40%

3 Possible It is possible that it may occur / recur 40 – 60%

4 Likely Is likely to occur / recur, but is not a

persistent issue. 60 – 90%

5 Almost certain

Will almost certainly occur / recur, and could be a persistent issue

>90%


3.2. 2014/15 Assurance Framework

lead May June July Sept Oct

1 Failure to control healthcare acquired infections DoN 10 10 10 10 10

2 failure to provide appropriate skill mix for “safe and suitable” staffing DoN 20 20 20 20 20

3 non-compliance with CQC standards DoN 12 16 16 16 16

4 Failure to ensure the safe management, statutory reporting, internal reporting and learning from incidents

DoN 12 12 9 9 9

5 failure to provide an adequate timely response to the deteriorating patient

MD 16 16 16 16 16

6 failure to meet the A&E target COO 12 12 12 12 12

7 failure to meet the RTT target COO 12 12 12 12 12

8 Failure to comply with standards for information governance COO 12 12 12 12 12

9 loss of IT access in community settings COO 12 12 12 12 12

10 failure to provide efficient fit for purpose estate COO 16 16 16 16 16

11 Failure to influence commissioners in shaping future scope of services DSOD 15 15 15 15 15

12 failure to address Monitor concerns and return to green for governance CEO 10 10 10 10 10

13 To fail to achieve planned surplus of £1.6m DoF 20 20 20 20 20

14 Failure to achieve integrated care in Bolton DSOD 15 15 15 15 15

15 Low levels of staff engagement D SOD 16 16 16 16 16

Safe, High Quality Care, Fit for the Future

Quality and Safety

Valued Provider

Financially viable and sustainable

Great place to work

Fit for the future

Well Governed

Subject Integrated Performance Report – October 2014

Prepared By Performance and Information Team

Approved By Executive Management Team

Presented By Chief Executive – Bolton NHS Foundation Trust

Executive Summary

Please see the High level Executive Summary section at the beginning of the report

Key Recommendations

The Board are asked to receive the report and give approval.

Acronyms/Terms used in Report

TRUST BOARD

Trust Objectives

Purpose

This report sets out the Trust’s integrated performance against leading national and local targets and draws attention to key areas for specific review by the Trust Board. Driven by the Trust’s strategic objectives this report is underpinned by a strong platform of integrated governance and assured data quality controls allowing the Trust Board to make effective decisions and demonstrate its commitment to delivering high quality healthcare for the people of Bolton.

Report

Appendix A

Appendix B

Report change log

1 All available data correct as of Wednesday 22nd October 2014


Executive Apex Reports High Level Executive Summary High Level Executive Dashboard High Level Executive Report • Monitor Risk Assessment Framework • Community Heat Map

Section 1 Improving the Quality of Care and Safety of our patients • Quality and Governance Scorecard • Quality and Governance Charts • Quality and Governance Report • Acquired Infection • Falls • Pressure Damage

Section 2 Valued provider of Integrated Services • Operations Scorecard

• Operations Charts • Operations Report

Contents



Section 3 Financially viable and sustainable • Finance Scorecard • Finance Report Section 4 A great place to work • Workforce Scorecard • Workforce Charts • Workforce Report Section 5 Ward to Board Heat Map

Section 6 Fit for the Future Section 7 Well Governed

Appendix A Acronyms/Terms used in Report

Appendix B Dashboard Change log - in month


Complaints responded to within timescale failed in month but are projected to meet the target in October.

There were zero Hospital and Community acquired Category 3 or 4 pressure ulcers in September.

There were no C.Diff or MRSA occurrences in month.

A+E performance failed the 95% target by 0.02% in month, this equates to 2 patients.

Staff Vacancies have shown a significant reduction from 10.1% in April 2014 to 4.9%.

Mandatory training is at 85.5%. The new e-learning system, Moodle is now operational and contributing to the improving position.

Sickness absences remain stable at 4.57%. September usually sees the beginning of the seasonal increase so this is welcomed.

Further improvements in the percentage of appraisals completed, achieving 79% in September. This is due to a management focus in certain areas helping to move towards the target of 80%.

Healthier Together: we have responded to the proposals as a Trust and Sector. The focus is now on the North West sector and how provider collaboration can achieve quality standards in a sustainable way.

Better Care Fund – the Trust has confirmed its support for the latest submission to NHS England.All cancer targets were met in September.

Diagnostic waits longer than 6 weeks met the target in month after August's failure of the endoscopy washer.

The number of Total incidents reported on Safeguard has increased, showing a corresponding increase in Insignificant (No Harm Occurred) incidents.

All CQUIN targets are on plan for Quarter two

Workforce Strategy – a revised strategy will be presented to the November Board

ICIP delivery is £1.4m in month, which is £0.27m worse than plan.

Year to date plan is off track by £0.42m

September's in month deficit is £0.16m and is £0.28m worse than plan

Year end forecast surplus of £1.6m is on plan

Cancelled theatre sessions reduced to meet the target for the first time this quarter.

Executive Summary

This executive summary provides an integrated overview of the Trust Board Performance Report. Supporting the Trust's Strategic Objectives it orientates executives quickly to the areas that have been escalated, are of particular note or political significance. The accompanying High-Level Dashboard and narrative gives further analyses. Compliance levels with the Monitor Risk Assessment Framework and CQC (Care Quality Commission) are also shown.

Improving the Quality of Care and Safety of our patients A great place to work

Valued provider of Integrated Services Fit for the future

Financially viable and sustainable Well GovernedOur Patients

The Trust continues to be licensed to carry out regulated activities with no conditions imposed on

our registration status

Monitor Risk Assessment Framework

CQC

Governance Finance ‐ Level 2

All available data correct as of Wednesday 22nd October 2014

The Trust has been awarded a band 4 weighting by the CQC


Indicator (All measured/reported Quarterly) Threshold WeightingQuarter 1 Actual Jul-14 Aug-14 Sep-14

Quarter 2 Actual

Referral to treatment time, 18 weeks in aggregate, admitted patients 90% 1.0 94.9% 94.7% 93.4% 93.1% 93.7%Referral to treatment time, 18 weeks in aggregate, non-admitted patients 95% 1.0 97.5% 97.2% 96.8% 96.9% 97.0%Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 96.6% 95.5% 95.7% 97.0% 96.1%A&E Clinical Quality- Total Time in A&E under 4 hours 95% 1.0 95.5% 95.4% 96.5% 94.98% 95.6%All cancers: 62-day wait for first treatment from:

(from urgent GP referral) - post local breach re-allocation (Amended) 85% 90.7% 93.3% 96.2% 94.8%(from NHS Cancer Screening Service referral) - post local breach re-allocation (Amended) 90% 100% 100% 100% 100%

(from urgent GP referral) - pre local breach re-allocation (New) 93% 95% 95% 95%(from NHS Cancer Screening Service referral) - pre local breach re-allocation (New) 100% 100% 100% 100%

All cancers: 31-day wait for second or subsequent treatmentSurgery 94% 1.0 100% 100% 100% 100%

Drug treatments 98% 1.0 100% 100% 100% 100%From diagnosis to first treatment 96% 1.0 99% 99% 98% 98%

Cancer: two week wait from referral to date first seen, comprising:Cancer 2 week (all cancers) 93% 97.5% 98.4% 96.7% 97.6%

Cancer 2 week (breast symptoms) 93% 95.6% 97.6% 96.4% 97.0%C.Diff due to lapses in care (Amended) 12 1.0 8 1 1 0 2Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) (New) 8 9 10 10 10C.Diff cases under review (New) 0 0 0 0 0Certification against compliance with requirements regarding access to health care for people with a learning disability 1.0 100% 100% 100% 100% 100%Community care:

Referral to treatment information completeness 50% 99.4% 99.4% 99.4% 99.4% 99.4%Referral information completeness 50% 100.0% 100.0% 100.0% 100.0% 100.0%Activity information completeness 50% 100.0% 100.0% 100.0% 100.0% 100.0%

Risk of, or actual, failure to deliver Commissioner Requested Services No No No No NoCQC compliance action outstanding (as at time of submission) No No No No NoCQC enforcement action within last 12 months (as at time of submission) No No No No NoCQC enforcement action (including notices) currently in effect (as at time of submission) No No No No NoModerate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) No No No No NoMajor CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) No No No No NoTrust unable to declare ongoing compliance with minimum standards of CQC registration No No No No No

Monitor Risk Report 2014-15

1.0

1.0

1.0


Improving The Quality Of Care And Safety Of Our Patients Plan 14/15 Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Financially Viable And Sustainable

Plan 14/15

Plan YTD

Plan Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Well Governed Status

Total number of new SUIs received within the month 0 0 2 1 Forecast year end deficit - FYE 1.6 1.6 1.6 0.0 0.0 0.0

Monitor Risk Assessment Framework On Plan

Total Incidents reported on Safeguard 10786 5393 5055 974 Forecast year end income and cost improvement - FYE 22.2 22.2 22.2 0.0 0.0 0.0 CQC Intelligent Monitoring Report On Plan

Never Event 0 0 2 0 Actual position against plan - YTD 1.6 -0.2 -0.7 -0.2 -0.2 -0.5CQC Essential Healthcare Standards (5) On Plan

All Patient Falls (Safeguard) 982 492 468 78 Actual Income and Cost Improvement -YTD 22.2 9.8 9.4 1.4 -0.3 -0.4CQUINS: National Clinical Quality Indicators On Plan

Acute Inpatients acquiring pressure damage (grades 2+) 27 14 30 3 Capital Expenditure YTD -17.5 -4.2 -0.9 0.0 0.0 3.3 Report to prevent future deaths On Plan

Community patients acquiring pressure damage 76 38 35 5 Cash Position YTD 1.1 0.5 6.0 6.0 -1.1 5.5 Litigation On Plan

VTE Assessment Compliance 95.0% 95.0% 97.0% 97.1% Continuity of services rating 2.0 2.0 2.0 2.0 0.0 0.0 Formal Contract Notices On Plan

Total number of medication incidents 636 318 585 121 Formal Performance Notices On Plan

Same sex accommodation 0 0 4 0 Contract Fines/Penalties Off Plan

C Diff Hospital acquired 48 24 10 0

CHKS RAMI (Rolling 12 months) 100 100 80 80 Staff friends and family test - Recommend treatment (Quarterly) 75.0%

SHMI 1.000 1.000 1.070 1.063Staff friends and family test - Recommend place to work (Quarterly) 59.0%

Surgical WHO Checklist compliance (Elective) 100% 100.0% 97.7% 99.0% Appraisals completed % 80% 80% 79.0% 79.0% Board Assurance Framework On Plan

Surgical WHO Checklist compliance (Emergency) 100.0% 100.0% 98.8% 100.0% Sickness days % of days lost 3.75% 3.75% 4.73% 4.57% Patient Experience Strategy On Plan

Formal complaints from patients 240 120 285 34 Mandatory Training Compliance % 100% 100% 85.4% 85.5% Risk Management Strategy On PlanComplaints responded to within the time period % 95.0% 95.0% 89.3% 75.3%

Cancer Treatment Targets (7) reported 1 month retrospectivelyPlan 14/15

Plan YTD Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan

Valued Provider Of Integrated Services Plan 14/15 Plan YTDActual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Patients 2 week wait (all cancers) % 93.0% 93.0% 93.0% 96.7%

A&E 4 hour target 95.0% 95.0% 95.6% 94.98% Patients 2 week wait (breast symptomatic) % 93.0% 93.0% 93.0% 96.4%

RTT Admitted Clock Stops % 90.0% 90.0% 94.3% 93.1% 31 days to first treatment % 96.0% 96.0% 96.0% 97.9%

RTT Non-Admitted Clock Stops % 95.0% 95.0% 97.2% 96.9% 31 days subsequent treatment (surgery) % 94.0% 94.0% 94.0% 100.0%

RTT: Incomplete pathways within 18 weeks % 92.0% 92.0% 94.3% 97.0% 31 days subsequent treatment (anti cancer drugs) % 98.0% 98.0% 98.0% 100.0%

Diagnostic waits >6 weeks % 1.0% 1.0% 0.7% 0.6% 62 day standard % 85.0% 85.0% 85.0% 96.2%% of patients who spend 90% of their stay on the stroke unit 80.0% 80.0% 82.3% 86.8% 62 day screening % 90.0% 90.0% 90.0% 100.0%

% Readmissions within 30 days of discharge 12.6% 12.6% 14.2% 13.8%

High Level Executive Dashboard

Fit for the Future

Performance improved but off target in month

Performance deteriorated and off target in month

Monthly/ Quarterly Change

On Plan Off PlanDeveloping Our Staff

Plan 14/15

Plan YTD Actual YTD

Monthly/ Quarterly

Actual

The On Plan / Off Plan Columns represent a projected Year End position. The status columns represents the current status of the initiative detailed

Status

Performance improved and on target in month

Performance deteriorated but on target in month


High level Executive Report October 2014

Harm Free Care

• The number of incidents reported in September increased to 974 compared to 841 in August, achieving the target in month. This is due to the continued raising of awareness of the importance of timely and accurate reporting of incidents by the Governance team with the clinical and support teams.

• The number of complaints received in September (34) was significantly over target (20) but lower than the previous month

(54) with a corresponding reduction in the number responded to within timescale. A recovery plan has been developed by the Head of Governance in order to ensure that there are no outstanding complaint responses by the end of October however it is likely that October's performance will be below target due to dealing with the backlog.

• A falls update report was presented to QA committee in October updating on progress against the falls strategy which has now been in place for 12 months. We continue to see a significant number of falls in the intermediate care setting of Darley Court, this is currently under review. However, overall a number of improvements were noted in the Quarter 2 report that was presented to QA committee including a reduction in harm from falls in comparison to last year’s data.

Pressure Damage

• September has seen no category 3 and 4 pressure ulcers. A significant amount of work continues to be undertaken by the nursing teams in both hospital and community to ensure the Pressure Ulcer strategy is fully implemented.


Acquired Infection

• There have been no Trust apportioned MRSA bloodstream infections reported in September. At month’s end it had been 270 days since the last MRSA bloodstream infection apportioned to the Trust.

• There have been 0 MRSA bloodstream infections in the current financial year.

• There have been no Clostridium difficile Toxin cases apportioned to the Trust in September.

• The Trust is 5 cases under trajectory to meet the internal target of no more than 28 cases for 14/15 and 16 cases under trajectory to meet the external target of 48 cases

• The work regarding antibiotic prescribing is on-going and the Trust Antibiotic Stewardship Committee has been taken off hiatus under the direction of the new medical microbiologists

• Flu vaccination for frontline staff started in September with a Department of Health objective of vaccinating 75% of frontline staff. Wards and departments are being encouraged to allocate and support a flu link nurse to support the occupational health and IPC team offering vaccines for staff locally

• The Trust has established a resilience group to ensure that staff are appropriately trained and prepared in the event of a patient a potential Ebola infection being admitted to the Trust. This is being done in view of the on-going Ebola outbreak in western Africa (now related to Sierra Leone, Liberia and Guinea). The resilience group is focussing on Ebola specifically but will be formulating plans that will be easily adaptable to epidemics of other infectious diseases


Valued provider of Integrated Services National Targets

• The A&E 4 hour target was narrowly failed in September with a performance of 94.98% against a target of 95%. The Trust is still on track to deliver the annual target with a year-to-date performance of 95.6%. A new multi-disciplinary group has been set-up by the Chief Operating Officer to investigate organisation flows, including those into and out of A&E.

• Readmissions within 30 days of discharge were over target (12.6%) for the fifth consecutive month with a performance of

13.6% in August. A new weekly readmissions report has been developed and clinicians are being asked to use this to review readmissions within 7 days of discharge, the most likely period for genuine readmissions.

• There are no Ambulance handover figures available for September at the time of writing. This is due to a software problem relating to the NWAS handover screen. NWAS are aware and are liaising with the software company to roll out new software across all the Trusts in the North West.

• Diagnostic waits longer than 6 weeks fell to 0.6% in September, achieving the target of 1%. The year-to-date target is also being achieved with a performance of 0.7%

• Stroke performance data for September was not available at time of writing.

• Cancer targets are reported one month in arrears. All cancer targets were achieved in September and the Trust is on plan to deliver its annual targets.

• All Referral to Treatment targets were achieved in September, for the sixth consecutive month. The Trust has no 52 week

waiters.


1. Executive Dashboard & Commentary


‐1

‐0.5

0

0.5

1

1.5

2

Surplus / (deficit) £m

Cumulative Actual Cumulative Plan

0

0.5

1

1.5

2

2.5

In month ICIP delivery £m

Acute Adult Elective Care

Family Care Trust wide contingency

Non recurrent flexibility release Plan

0

2

4

6

8

10

12

14

16

18

Cumulative Capital expenditure £m

Cumulative Actual Cumulative Plan Financed Capital Plan

0

1

2

3

4

5

6

7

8

Month end cash balance £m

Actual Plan Revised Cash forecast


1. Executive Dashboard & Commentary


Cash & Capital

• There was a cash balance of £6.0m at the end of the month. This is higher than the £0.5m plan and is in line with the Trust cash management strategy.

• The Capital budget for the year is £6.1m plus £1.7m of financed developments. Dependent on additional finance being agreed, there is potential for a further £3.2m in developments related to the Estates & IT strategy. The remaining £6.5m of these proposed developments have now slipped into 2015/16.

• At the end of September the Capital programme has spent £0.9m and is behind the planned expenditure by £3.3m.• The Trust is reviewing the Capital forecast for the year in light of the Estates and IT business cases and steps are also being taken to progress

capital spend for M7.

Income & Expenditure

Overall the Trust has an adverse variance to plan of £0.42m with a year to date deficit of £0.66m. The September 2014 in month position shows a deficit of £0.16m against the planned surplus of £0.12m. The September position is made up of:

• Income overall is better than plan in month at £23.46m, compared to a plan of £23.12m, with clinical over achieving by £0.34m.• Pay spend is £17.06m, an over spend of £1.14m. This is a £0.4m increase in expenditure on last month.• Non pay spend is £5.78m, an under spend of £0.41m.• The overall position is worse than anticipated and the Trust has used £0.11m of Risk Reserve in month. Year to date the maximum available has

been utilised.• The Trust has released, non-recurrently, the following into the position:

- £1.3m redundancy provision no longer required- £0.4m bad debt provision no longer required

and has identified £0.4m of consumable stock that previously had not been counted. This gives a total of £2.1m non-recurrent income and expenditure benefit that is within the position reported as at M6, of which £2.1m is the non-recurrent benefit identified above.

The Trust is forecasting to deliver the year-end target surplus of £1.6m, however there are significant risks within this, particularly in regard of a range of contracting issues with Bolton CCG and the Trust's ability to deliver the planned cost reductions and maintain control on bank and agency costs. Taking these risks into account the Trust's year end position could be a deficit of £3.8m so the risk range is between a surplus of £1.6m and a deficit of £3.8m.


2.1.1 Trust Income & Expenditure position

Trust SummaryAnnual budget £m Budget £m Actual £m Var £m Budget £m Actual £m Var £m

Contract income 254.3 20.9 21.3 0.3 126.3 128.3 2.1Education and Training Income 8.6 0.7 0.7 (0.0) 4.4 4.4 0.0Other income 17.5 1.4 1.5 0.0 8.8 9.3 0.5

Total Income 280.3 23.1 23.5 0.3 139.5 142.1 2.6Direct - Pay (189.3) (15.9) (17.1) (1.1) (95.1) (100.2) (5.0)Direct - Non Pay (74.1) (6.2) (5.8) 0.4 (37.1) (37.7) (0.5)Risk reserve (5.9) (0.1) 0.0 0.1 (2.8) 0.0 2.8

Total Operational Costs (269.3) (22.2) (22.8) (0.6) (135.1) (137.8) (2.8)

EBITDA 11.0 0.9 0.6 (0.3) 4.5 4.2 (0.2)Capital charges (9.4) (0.8) (0.8) (0.0) (4.7) (4.9) (0.2)

Total Costs (278.7) (23.0) (23.6) (0.6) (139.8) (142.8) (3.0)

Surplus / (Deficit) 1.6 0.1 (0.2) (0.3) (0.2) (0.7) (0.4)

In Month Year to Date



2.3.1 Income Summary position

Areas of DeliveryActivity Plan

Activity Actual

Activity Var

Income Plan £m

Income Actual £m

Income Var £m

Activity Plan

Activity Actual

Activity Var

Income Plan £m

Income Actual £m

Income Var £m

Unscheduled Care 14,793 14,641 (152) 6.9 7.2 0.3 90,435 91,983 1,548 41.7 43.0 1.4Scheduled Care 2,730 2,705 (25) 2.7 2.8 0.1 16,729 16,063 (666) 16.6 15.9 (0.7)Outpatient Care 25,025 25,653 629 3.2 3.2 (0.0) 152,057 152,945 888 19.8 19.7 (0.1)Clinical Support Services 758 821 63 0.6 0.6 0.0 4,777 4,527 (250) 3.5 3.4 (0.0)Other & Block 9.7 9.7 (0.0) 58.0 60.0 2.0

Total £m 23.1 23.5 0.3 139.5 142.1 2.6

In Month Movement Year to Date


0

10000

20000

30000

40000

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

Activity Actual (number) Activity Plan (number)

0

5

10

15

20

25

30


Income Actual £m Income Plan £m

Trust Income year to date• Unscheduled Care - in activity terms we have seen an increase again in month with A&E

attendances but not back to the previous highs of 10,000 a month. Non-elective admissions have also increased in month. The financial impact of this movement has been neutral to the run rate due to an increases in the amount of activity that is paid at 30% above the marginal rate threshold, which is calculated on a cumulative basis.

• Scheduled Care - activity and financially we are still behind plan year to date with a slightly improved position in month. All of the underperformance is within the elective point of delivery, as the daycases point of delivery remains on plan year to date.

• Outpatient Care - is mainly on plan in the month, but remains slightly below plan year to date. The two main areas of under performance is still antenatal pathways and outpatient follow-up activity.

• Clinical Support Services - this area is on plan in the month and slightly behind plan year to date. The main area of variation is ECGs which is on plan both in month and slightly behind year to date.

• Block & Other - is above on plan in the month and above plan year to date, the significant movements in month are due to a reduction in the amount of passthrough drugs and devices in month.

• Penalties & CQUINS - there has been some increases in penalties but we still remain lower than last year and significant better than plan.

(more detailed information on income is available at appendix 10.03 to 10.05)


2.4.1 Pay costs position

Pay category

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Senior Managers (5.2) (0.4) (0.5) (0.0) (2.6) (2.5) 0.1Medical and Dental (47.8) (4.0) (4.0) (0.0) (24.1) (23.1) 0.9Nursing, Midwifery And Health Visiting (71.5) (6.0) (6.1) (0.1) (35.8) (36.2) (0.4)Scientific, Therapeutic and Technical (23.6) (2.0) (1.9) 0.1 (11.8) (11.2) 0.7Professional and Technical (4.9) (0.4) (0.4) 0.0 (2.5) (2.4) 0.1Administrative and Clerical (21.8) (1.8) (1.7) 0.1 (10.9) (10.3) 0.6Healthcare Assistants and Other Support Staff (19.5) (1.6) (1.6) 0.1 (9.7) (9.2) 0.6Agency Staff (2.2) (0.2) (0.9) (0.7) (1.2) (4.7) (3.4)Other Pay Budgets 7.3 0.5 0.0 (0.5) 3.5 (0.6) (4.2)

Total (189.3) (15.9) (17.1) (1.1) (95.1) (100.2) (5.0)



Pay

In September pay expenditure was £17.06m. This is £0.4m worse than in August. This variance is caused by the costs of increased permanent staffing not being matched by a reduction in bank and agency costs as expected. This issue is of significant concern and has been reviewed and more effective controls are being put in place. This issue is explored in more detail in the mid-year forecast review which is a separate paper.

The main areas of overspend in September are the use of agency - £0.92m of spend against a budget of £0.18m;

• Medical £271k – Radiology (£68k), Complex Care (£65k), T&O (£51k), Ophthalmology (£15k) and Gastroenterology (£23k)• Nursing £316k – Acute Medicine (£81k), Complex care (£50k), Theatres (£42k), General surgery (£27k), Endoscopy (£26k) & T&O (£24k)• Admin £100k• Other £56k – Blood sciences (£17k), Stroke/ESD (£12k), CAMHS (£11k) and Catering (£9k)

The Other Pay Budgets includes the cost reductions (ICIPs) monies that have all been removed from specific specialty budgets, but not yet allocated to specific staff groups on those statements.


2.5.1 Non Pay costs position

Non Pay category

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Drugs (17.6) (1.5) (1.4) 0.1 (8.8) (9.3) (0.5)Medical & Surgical (10.1) (0.8) (0.5) 0.3 (5.1) (5.0) 0.1Clinical Supplies (9.1) (0.8) (0.9) (0.2) (4.6) (4.9) (0.3)

Activity Dependent (36.8) (3.1) (2.8) 0.3 (18.4) (19.2) (0.7)Establishment (10.6) (0.9) (1.0) (0.1) (5.3) (5.6) (0.3)Estates & Premises (11.7) (1.1) (0.9) 0.2 (5.8) (5.3) 0.5Services from other NHS bodies (3.2) (0.3) (0.2) 0.1 (1.6) (1.8) (0.2)Other Non Pay (11.7) (0.8) (0.9) (0.1) (5.9) (5.8) 0.1

Other Non Pay (37.3) (3.1) (3.0) 0.2 (18.7) (18.5) 0.2

Total Non Pay (74.1) (6.2) (5.8) 0.4 (37.1) (37.7) (0.5)

Total Risk Reserve (5.9) (0.1) 0.0 0.1 (2.8) 0.0 2.8



Non Pay

The total non-pay spend at £5.8m is £0.4m better than plan.

Non pay expenditure against activity dependant items is underspent in month by £0.3m. This is mainly due to counting ward and theatre stock (£0.42m) that were previously not counted. Expenditure is above plan by £0.05m on PbR/FP10 drugs (which has an offsetting income increase).

Again, there has been the release of £0.3m of non-recurrent year end flexibilities into the position and £0.4m of stock so the underlying non-pay position is £0.7m higher than taking these two things into account.

The Trust has utilised £0.11m of the Risk reserve, which takes it to the maximum available year to date.


2.6.1 Capital Charges

Trust Position

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Dividends (3.2) (0.3) (0.3) 0.0 (1.6) (1.6) 0.0Interest Paid (0.9) (0.1) (0.1) 0.0 (0.5) (0.4) 0.1Interest Received 0.0 0.0 0.0 0.0 0.0 0.0 (0.0)Depreciation (5.2) (0.4) (0.5) (0.0) (2.6) (3.0) (0.3)Profit / Loss on disposal 0.0 0.0 (0.0) (0.0) 0.0 (0.0) (0.0)

Total (9.4) (0.8) (0.8) 0.0 (4.7) (4.9) (0.2)

£m Values Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

Dividends (0.3) (0.3) (0.3) (0.2) (0.3) (0.3) (1.6)Interest Paid (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.4)Interest Received 0.0 0.0 (0.0) 0.0 0.0 0.0 0.0Depreciation (0.5) (0.5) (0.5) (0.5) (0.5) (0.5) (3.0)Profit / Loss on disposal 0.0 0.0 0.0 0.0 0.0 (0.0) 0.0

Total (0.8) (0.8) (0.8) (0.8) (0.8) (0.8) (4.9)

Plan (0.8) (0.8) (0.8) (0.8) (0.8) (0.8) (4.7)Variance to Plan (0.0) (0.1) (0.1) (0.0) (0.0) (0.0) (0.2)



Capital charges

Depreciation charges have reduced to £15k above plan in month 6. The Trust is currently looking at re-lifeing its assets, and thus depreciating over a more realistic life. Figures are currently being finalised. Subject to this being confirmed, the depreciation forecast will be circa £5.2m.

A proportion of the risk reserve has been set aside to cover the increased depreciation on Community IT, the budget transfer will be made in due course.

Current year-end forecasts are: net interest of £774k (£140k underspend) and dividends of £3,190k (£54k underspend).


4.1 Statement of Financial Position year to date

£m Values Mar-14SepPlan £m

SepActual

Var to plan £m

Year end Plan £m

Non-current assetsIntangible assets 0.5 0.3 0.4 0.1 0.3Property, plant & equipment 131.4 126.4 129.4 3.0 137.1Trade & other receivables >1 year 0.7 0.9 0.6 (0.3) 0.9

132.6 127.7 130.4 2.7 138.4Current assets

Inventories 1.6 1.6 2.4 0.8 1.6Trade receivables 5.4 3.3 2.5 (0.8) 2.8Other receivables 0.8 0.8 2.4 1.6 0.8Accrued income 1.8 2.8 3.8 1.0 2.8Prepayment 1.3 1.7 1.6 (0.1) 1.5Cash & cash equivalents 0.4 0.5 6.0 5.5 1.0

11.3 10.6 18.7 8.1 10.5Total assets 143.9 138.3 149.1 10.8 148.9

Current liabilitiesLoans due < 1 year (1.4) (2.8) (1.4) 1.4 (2.8)Trade payables (7.3) (9.2) (11.7) (2.5) (8.8)Accruals (4.6) (4.6) (5.4) (0.8) (4.6)Payments on Account (0.4) (0.6) (0.1) 0.5 (0.6)Leases due < 1 year (0.1) (0.1) (0.1) 0.0 (0.1)Other current liabilities (8.1) (8.1) (10.2) (2.1) (7.7)

(21.9) (25.4) (28.9) (3.5) (24.6)Net Current assets / (liabilities) (10.6) (14.8) (10.2) 4.6 (14.1)Non-current liabilities

Loans due > 1 year (18.5) (16.4) (17.8) (1.4) (25.5)Provisions (0.3) (0.3) (0.3) 0.0 (0.3)Leases due > 1 year (0.1) (0.3) 0.3 0.6 (0.7)

(18.9) (17.0) (17.8) (0.8) (26.5)

Total assets employed 103.1 95.9 102.4 6.5 97.7

Taxpayers Equity:Public dividend capital 102.0 102.0 102.0 0.0 102.0Retained earnings (35.3) (35.7) (36.1) (0.4) (33.3)Revaluation reserve 36.4 29.0 36.4 7.4 29.0

103.1 95.4 102.3 6.9 97.7


Summary

• As at month 6 the Trust had net current liabilities of £10.2m an improvement from Month 5 of £0.1m and better than plan by £4.6m.

• The Trust's current assets are £8.1m above plan.

• The Trust's current liabilities of £28.9m compare with a plan of £25.4m. The variance of £3.5m relates to:-

• Tax 0.1• Accruals (0.8)• Provisions (0.8)• Trade payables (2.5)• Loans* 1.4• Other liabilities (0.9)

* Loans current liability variance is offset by the non- current liabilities variance (1.5m). This is due to a change in repayable term since the plan was submitted.

• The plan was submitted prior to a revaluation of the Trust's assets therefore the property, plant and equipment variance is due to the impact of the revaluation.


5.1 Cash flow Source and Application year to date

£m Values Mar-14SepPlan £m

SepActual £m

Var to plan £m

Year end Plan £m

Income 24.4 23.0 24.5 1.5 283.0

PaymentsSalaries / Wages (10.3) (9.5) (9.2) 0.3 (110.2)Tax, NI & Superannuation (4.4) (6.2) (5.9) 0.3 (71.2)Capital (3.3) (0.7) (0.1) 0.6 (15.5)Non Pay (12.2) (6.4) (9.1) (2.7) (90.1)Loan repayment (0.1) (0.1) (0.1) (0.0) (1.4)Loan interest (0.0) 0.0 (0.0) (0.0) (0.7)PDC Dividend (1.6) (1.6) (1.2) 0.4 (3.2)PDC cash support 7.5 0.0 0.0 0.0 9.8

Total payments (24.4) (24.5) (25.7) (1.1) (282.4)

Cashflow (0.0) (1.5) (1.1) 0.4 0.6Opening balance 0.5 2.0 7.2 5.2 0.4

Closing balance 0.4 0.5 6.0 5.6 1.1


Summary

• In month 6 there was a cash outflow of £1.1m with a closing cash balance of £6.0m.

• Cash is above plan by £5.5m at month 6.

• Block payments from Public Health Commissioning of £0.6m relating to month 6 activity were not received in month 6. It has been confirmed that both month 6 and month 7's activity will be paid in month 7. Letters will be issued if there are any further issues.

• The Trusts plan is showing a cash inflow of £0.6m for the year with a planned balance of £1.1m at 31st March 2015 this is based on the approved Budget / Annual plan. The Trust would look to maintain an improved cash balance during the year and improve on the year end position. On the assumption the I&E plan delivers it's surplus, a cash balance of £6.6m should be achievable by the year end.


6. Capital Expenditure position

Capital schemes

Annual budget £'000

Budget £'000

Actual £'000 Var £'000

Budget £'000

Actual £'000

Var £'000

Plant and Equipment 2,037 178 11 (167) 1,098 293 (805)Property - Maintenance 3,350 245 14 (231) 1,480 392 (1,088)Plant and Equipment - Information Technology 713 85 0 (85) 572 23 (549)Sub Total 6,100 508 24 (483) 3,149 708 (2,441)Funded Developments 1,743 176 0 0 1,056 180 0

Schemes plus funded developments 7,843 684 24 (659) 4,205 888 (3,317)

Other Developments 9,693 0 0 0 0 0 0GROSS CAPITAL EXPENDITURE 17,536 684 24 (659) 4,205 888 (3,317)



Capital Expenditure• The Trust Capital plan is £6.1m plus £1.7m of financed developments. The further developments of £9.7m relate to Estates and IT strategy and are

dependent on additional finance being agreed. Part of these strategies has now slipped into 15/16 with £3.2m remaining to be spent in 14/15.• At the end of month 6 Capital Expenditure was £3.3m underspent.• The main areas of underspend are Defibs, main walkway duct, M1 replacement windows, community IT and single sign-on with a total of £2.05m

underspend against plan to month 6.• The Trust has spent 21% of the year to date Capital plan, this is below the 85% Monitor threshold.• Forecast Capital Expenditure is £11.0m with £6.5m now planned for 15/16. The forecast assumes £3.2m of this years developments will be funded via

loans.

(more detailed information on planned capital spend is available at appendix 10.09)


6. Capital Expenditure position

Capital schemes Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

Plant and Equipment 245 (10) 8 23 16 293Property - Maintenance 7 31 60 155 125 392Plant and Equipment - Information Technology 0 0 23 0 0 23

Sub Total 252 21 91 178 141 708Funded Developments 0 0 0 180 0 180

Schemes plus funded developments 252 21 91 358 141 888

Other Developments 0 0 0 0 0 0GROSS CAPITAL EXPENDITURE 252 21 91 358 141 888

Plan 176 568 1,259 805 714 684 2,208 2,138 2,258 2,142 2,292 2,292 4,205Variance to Plan 76 (547) (1,168) (446) (573) (3,317)



7. Income & Cost Improvement Programme

Division Savings typeFull year target £'000

Forecast £'000


Forecast £'000


Adult Acute Pay 3,646 276 139 (137) 1,468 595 (873)Non Pay 700 52 (292) (344) 298 (320) (618)Income 2,822 222 89 (133) 1,495 500 (995)Corporate share 1,394 116 116 0 698 697 (1)Contingency (1,184) (148) 0 148 (962) 0 962Benefit of Risk reserve usage 0 0 66 66 0 838 838

Total Adult Acute 7,378 518 118 (400) 2,997 2,311 (686)

Elective Pay 1,815 149 101 (48) 921 428 (493)Non Pay 1,017 85 (292) (377) 507 (900) (1,407)Income 4,720 394 228 (166) 2,362 1,197 (1,165)Corporate share 1,277 107 106 (1) 640 638 (2)Contingency (1,104) (138) 0 138 (897) 0 897Benefit of Risk reserve usage 0 0 61 61 0 769 769

Total Elective 7,725 597 205 (392) 3,533 2,133 (1,400)

Families Pay 3,468 288 44 (244) 1,735 291 (1,444)Non Pay 618 52 44 (8) 306 672 366Income 2,968 248 98 (150) 1,485 588 (897)Corporate share 955 79 80 1 476 478 2Contingency (912) (114) 0 114 (740) 0 740Benefit of Risk reserve usage 0 0 50 50 0 628 628

Total Families 7,097 553 315 (238) 3,262 2,657 (605)

Trust wide Contingency 0 0 429 429 0 1,275 1,275Trust wide Non Recurrent 0 0 333 333 0 999 999

Total ICIP Delivery 22,200 1,668 1,400 (268) 9,792 9,374 (418)



Cost Improvement Programme• The Trust has released £999k non recurrently year to date, and with the divisions' releasing of risk reserves the overall delivery against ICIP plan is

£419k adverse year to date.• The Corporate and Estates divisions have generated a year to date surplus of £308k which is contributing to the Trust wide contingency of £1275k year

to date.


8. Forecast outturn for year

Trust Summary

Annual budget £m

Forecast£m

Contract income 254.3 261.3Education and Training Income 8.6 8.6Other income 17.5 17.7

Total Income 280.3 287.6Direct - Pay (189.3) (197.9)Direct - Non Pay (74.1) (76.9)Risk reserve (5.9) (1.8)

Total Operational Costs (269.3) (276.6)

EBITDA 11.0 11.0Capital charges (9.4) (9.4)

Total Costs (278.7) (286.0)

Surplus / (Deficit) 1.6 1.6


Forecast outturn for year• The Trust is forecasting that the £1.6m planned surplus for 2014/15 can be delivered• Taking into account the Divisional forecast and allowing for 'optimism bias' within the Divisional Forecasts the Trust is forecasting that the £1.6m

planned surplus for 2014/15 can be delivered by fully utilising the risk reserve of £6.2m• To manage the risk within the forecast the Corporate division has been tasked with bringing forward 2014/15 ICIP schemes to deliver an additional

£1.2m and Estates has been tasked with delivering £0.25m in year.


9. Continuity of Service Risk Rating (CSRR)


Capital Service Cover rating 1 1 1 2 2 2Liquidity rating 1 1 1 1 1 1

Continuity of Service Risk Rating - Actual 1 1 1 2 2 2

Continuity of Service Risk Rating - Plan 1 2 2 2


Continuity of Service Risk Rating• The Capital Service Cover rating is a 2 and the Liquidity rating 1, giving an overall Continuity of Service Risk Rating of 2. • This is as per plan for quarter 2.


Workforce

• As reported last month, the number of completed Consultant job plans dropped significantly due to those completed in September 2013 having now expired. The Medical Director's plan in relation to this year’s job planning round is due to commence in November.

• There have been small improvements in completion of local induction and mandatory training compliance however both

targets have been failed for six consecutive months.

• Sickness absence remains stable at 4.57%. September usually sees the beginning of the seasonal increase so this absence level is welcomed. Our challenge is to ensure that sickness absence does not increase to the same levels as last year during the winter months.

Fit for the Future Healthier Together

• The Healthier Together public consultation process closed on 30 September (questionnaire deadline). The Trust continues to engage with the Healthier Together programme as well as liaising with Salford Royal FT and Wrightington, Wigan and Leigh FT to develop complementary but alternative proposals for future provision of hospital services across GM.


Well Governed

Penalties

• At month 5 we reported we had recognised, following a review process with the CCG, the year to date penalties have been revised slightly. The level of penalty for 18 weeks admitted has been reduced and penalties for breaching the stroke targets have been added.

• In month 6 reporting we are predicting the following penalties changes:

• The validation reduction is where we can't charge for any activities that cannot be coded by the deadline, we have included

an estimate for month 6 which is increasing from previous months actions are being taken to address this. • Re-admission penalty is a set amount based on an audit; this value may change once we've completed a new audit of all

emergency re-admissions within 30 days of original discharge. The audit looks at a sample of patients and determines how many of them could have been avoided if better primary/social care services existed.

• The 18 weeks referral to treatment penalties are estimated to continue for T&O and Plastic Surgery. • There has also been another 28 binding date breach, this is where we have been unable to re-book a cancelled operation

within 28 days of the cancellation. The penalty is non-payment of the patient episode. • 52 week wait is where a patient has been waiting over 52 weeks for treatment; this incurs a set penalty of £5,000 per

instance. • % patients waiting of 6 weeks for a diagnostic test, due to washer failures in the endoscopy unit we breached our target

threshold for diagnostics waits. The penalty is applied at £200 per patient below the threshold. • CQUINS, at month 6 we are reporting 100% achievement of the available CQUINs.


INDICATORS Acute Frailty Unit B2 B4 C1 C2 C3 C4 CCU CDU D1 (MAU1) D2 (MAU2) D3 D4 Darley

CourtH3 (Stroke

Unit) HDU ICU DCU (Daycare)

EU (Daycare) E3 E4 F3

F4/F6 (Combined wards)

G3/G3TSU G4 G5 H2 (daycare)

UU (Daycare)

E5 (Paed HDU and

Obs)

F5 (Short Stay Paed Ass Unit)

M1 and Assessme

ntEPU M2 CDS M3 (Birth

Suite) M4/M5 NICU Total

Number of Beds 22 26 26 25 26 26 27 10 14 27 22 27 27 34 24 10 8 15 15 25 25 24 27 23 25 15 10 4 38 7 16 6 26 18 5 44 38 787

Exception indicator

Friends and Family Net Promoter Score 64.7 63.3 85.7 73.5 60 0 84.6 86.8 63.6 72.2 60 84.6 65.9 94.7 92.9 65.9 80 96.7 76.5 87.8 75 90.5 97.1 78.6

Safety Express Programme Harm Free Care (%) 94.74% 96.15% 100.00% 83.33% 95.83% 100.00% 100.00% 44.44% NA 95.65% 86.36% 90.91% 100.00% NA 90.91% 87.50% 100.00% NA NA 96.00% 100.00% 100.00% 100.00% 100.00% 100.00% NA NA NA 100.00% NA 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 96.55% 95.38%

Weekly KPI Audit % 95.40% 90.10% 95.90% 96.90% 98.60% 96.70% 100.00% 98.00% 76.40% 97.80% 93.10% 97.40% 92.00% 96.60% 99.10% 99.30% 100.00% 100.00% N/A 98.60% 99.10% 98.30% 98.80% 99.50% 97.20% 98.20% N/A N/A 97.50% 97.50% 100.00% 100.00% 100.00% 100.00% 96.97%

Hand Washing Compliance % (Self Assessed) 98.75% 100.00% 100.00% 100.00% 100.00% 95.00% 100.00% 100.00% 100.00% 50.00% 100.00% 100.00% 100.00% 100.00% 95.42% 94.17% 100.00% 85.00% 100.00% 89.17% 93.33% 95.00% 87.22% 95.00% 100.00% 100.00% 100.00% 95.00% 100.00% 100.00% 98.33% 100.00% 100.00% 100.00% 92.50% 87.50% 95.87%

1.60 - Monthly New pressure Ulcers (Grade 2+) 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

1.01 - All Patient Falls (Safeguard) 9 0 10 5 4 2 4 2 0 4 2 5 2 6 6 1 0 0 0 1 1 2 2 3 0 1 0 0 0 0 0 0 0 0 0 0 0 72

1.13 - Infection Control (C. Diff) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1.39 - MRSA HA aquisitions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1.20 - VTE Assessment Compliance (June 14) 100.00% 40.00% 0.00% 100.00% 62.50% 92.59% 100.00% 100.00% 91.48% 93.31% 94.75% 100.00% 100.00% NA 88.33% 100.00% 72.73% 98.34% 98.95% 90.00% 94.12% 98.81% 100.00% 100.00% 100.00% 100.00% 100.00% 95.56% 99.62% 99.57% 100.00% 98.51% 79.31% 97.06%

ESSA Assessment ** ** * *** ** *** * ** ** ** * *** * * ** *** *** N/A N/A *** * *** *** *** N/A N/A ** N/A *** N/A *** *** *** *** ***1.27 - Number of complaints received 0 3 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 4 0 0 0 0 0 1 0 0 1 2 1 1 16

Budgeted Nurse: Bed Ratio (WTE) 1.41 1.16 1.16 1.21 1.16 1.16 1.22 2.72 1.43 1.47 1.59 1.12 1.12 0.94 1.37 4.00 6.57 1.75 1.96 1.18 1.17 1.62 1.40 1.46 1.48 1.28 2.87 4.02 1.73 1.38

Actual/Current Nurse: Bed Ratio (WTE) 1.32 1.09 1.06 1.34 1.25 1.10 1.21 2.48 1.07 1.52 1.69 1.06 1.18 0.94 1.33 3.99 6.28 1.58 2.03 1.29 1.01 1.52 1.22 1.85 1.38 1.24 2.97 3.72 1.56 1.33

% Qualified Staff (Night) 100.0% 95.0% 100.0% 100.0% 100.0% 96.7% 98.8% 100.0% 96.7% 90.0% 90.2% 124.8% 98.5% 100.0% 94.2% 74.9% 95.0% 101.9% 87.5% 84.1% 98.9% 76.5% 100.0% 86.0% 95.1% 100.0% 89.6% 83.3% 98.3% 115.8%95.73%

% un-Qualified Staff (Night) 123.3% 173.3% 201.4% 125.0% 107.0% 165.0% 173.5% 106.7% 114.4% 121.9% 158.1% 124.7% 125.0% 130.0% 100.0% 0.0% 106.7% 152.5% 106.8% 71.5% 124.4% 100.9% 81.8% 100.0% 105.5% 98.6% 115.6% 58.6% 76.5% 76.7%114.18%

% Qualified Staff (Day) 92.3% 94.4% 86.3% 93.8% 98.6% 91.0% 87.3% 96.6% 95.3% 89.1% 91.0% 89.2% 83.2% 100.1% 87.4% 84.7% 94.0% 82.8% 89.4% 70.2% 96.1% 89.2% 84.5% 85.6% 85.9% 91.4% 88.0% 87.5% 86.1% 110.8%90.07%

% un-Qualified Staff (Day) 113.8% 157.6% 151.7% 109.0% 106.2% 136.4% 125.4% 141.9% 96.6% 90.6% 110.0% 116.0% 113.6% 98.9% 100.0% 100.0% 97.3% 128.9% 91.7% 61.9% 103.9% 91.1% 85.1% 61.7% 102.1% 89.1% 70.1% 45.5% 58.7% 97.3%101.74%

AUKUH Acuity/Dependancy (WTE) 1.20 0.40 0.40 2.65 -4.41 -0.81 1.84 N/A 6.82 0.67 -9.05 N/A N/A N/A N/A -2.08 1.05 12.84 16.98 6.69 -1.62 6.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

1.07 - Total Incidents reported on Safeguard 12 3 17 11 13 9 15 5 5 24 17 19 14 20 11 14 20 20 18 5 8 12 12 21 10 5 0 5 17 3 7 2 4 64 6 11 25 484

SUIs in Month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Current Budgeted WTE (From Ledger) 31.02 30.22 30.22 30.22 30.22 30.22 32.87 27.21 19.97 39.64 35.05 30.22 30.22 32.02 32.87 39.96 52.54 26.23 29.42 29.40 29.35 38.77 37.90 33.61 37.07 19.23 28.74 16.08 65.21 27.60 109.34 1,082.64

Actual WTE In-Post (From Ledger) 28.95 28.36 27.56 33.58 32.57 28.52 32.61 24.75 14.92 41.10 37.19 28.56 31.93 32.07 31.87 39.94 50.22 23.77 30.51 32.37 25.36 36.37 33.05 42.47 34.39 18.60 29.66 14.88 62.52 24.98 93.48 1047.11

Actual Worked (From Ledger) 34.11 34.62 31.74 34.02 36.52 34.77 38.42 24.82 16.82 40.99 37.09 29.88 31.91 38.60 34.33 36.66 48.34 25.44 30.51 30.97 29.15 40.81 34.51 43.90 38.76 19.67 29.68 14.97 61.56 25.42 89.49 1098.48

Pending Appointment 3 1 2 3 3 5 2 3 2 4 3.67 2 3 1.92 3.92 1 1 0.8 2 47

Current Budgeted Vacancies (WTE) 2.07 1.86 -0.34 -4.36 -4.35 -1.30 -2.74 2.46 5.05 -6.46 -2.14 -0.34 -4.71 -0.05 1.00 -1.98 -1.68 2.46 -1.09 -6.64 1.99 -0.60 4.85 -10.78 -1.24 -0.37 -1.92 1.20 1.89 0.62 15.86 -11.78

Sickness (%) 15.17 8.00 0.00 0.31 8.00 3.66 10.47 0.94 12.26 5.69 1.44 5.89 7.24 13.37 4.83 2.67 5.03 4.83 5.29 2.45 1.69 7.49 14.40 2.60 3.98 8.81 5.14 2.98 7.46 4.69 0.10 3.96 3.96 3.96 3.96 4.32 5.47

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

6.67% 6.45% 17.65% 3.45% 8.33% 16.13% 12.12% 6.67% 35.29% 7.14% 11.43% 15.63% 12.90% 14.29% 5.88% 4.55% 9.09% 4.17% 16.22% 2.94% 16.67% 7.32% 12.20% 2.44% 20.59% 9.52% 6.06% 12.50% 8.33% 8.33% 13.04% N/A 8.74% 8.74% 8.74% 8.74% 10.53% 10.54%

12 month Appraisal 73.08% 62.96% 46.67% 82.15% 94.12% 79.31% 85.19% 100.00% 33.33% 61.90% 83.87% 96.67% 83.87% 50.00% 57.14% 80.00% 86.00% 100.00% 97.78% 66.67% 66.67% 46.34% 58.82% 68.42% 83.33% 59.09% 51.72% 60.00% 97.14% 97.14% 88.46% N/A 83.82% 83.82% 83.82% 83.82% 90.10% 75.65%

12 month Mandatory Training 87.75% 69.81% 65.99% 92.42% 91.62% 95.72% 68.37% 99.05% 82.22% 69.28% 81.41% 93.06% 82.32% 84.95% 91.76% 84.33% 87.25% 94.27% 85.07% 90.56% 81.35% 84.07% 86.56% 76.40% 81.77% 81.71% 76.32% 95.35% 94.07% 94.07% 85.51% N/A 82.30% 82.30% 82.30% 82.30% 97.89% 85.04%

Friends and Family N/A 4.83 N/A 3.63 N/A 3.19 N/A N/A 4.38 N/A N/A N/A 4.14 3.45 N/A 3.62 3.83 3.83 N/A N/A 4.11 4.03 N/A N/A N/A N/A N/A N/A 3.88 N/A N/A N/A N/A N/A N/A N/A N/A

Board Assurance Heat Map Staffing September 2014


Sample Community Heatmap

INDICATORS

North DN

Teams

Avondale Team 1

Avondale Team 2

Avondale Team 3

Breightmet Team 1

Breightmet Team 2

Crompton Team 1

Crompton Team 2

Crompton Team 3

Egerton & Dunscar Team 1

Egerton & Dunscar Team 2

Waters Meeting Team 1

Waters Meeting Team 2

South &

West DN

Teams

Farnworth Team 1

Farnworth Team 2

Farnworth Team 3

Great Lever

Team 1

Great Lever team 2

Horwich Team 1

Horwich Team 2

Horwich Team 3

Pikes Lane Team 1

Pikes Lane Team 2

Westhougton Team 1

Westhougton Team 2

Evening Service Total

Safety Express Programme Harm Free Care (%) *

96.88% 87.10% n/a 96.97% 94.12% 96.67% 100.00% 94.74% 94.44% 90.48% 96.00% 86.67% 91.30% 100.00% 100.00% 100.00% 90.91% 91.67% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% n/a 96.00%

1.60 - Monthly New pressure Ulcers (Grade 2+) **

0 5

High Dependency Patients (40 Minutes >)

112 163 91 22 121.5 109.5 101 116 43 90 97 73.32 63.32 88.32 210 222 0 2319.96

Medium Dependency Patients (21 Mins >)

293 378 419 340 1028.5 675.5 377 399 772 509 554 305.86 318.86 297.86 729 826 0 10650.58

Low Dependency Patients (< 20 mins)

537 409 367 345 507.5 411.5 351 165 98 445 435 161.86 166.86 130.86 28 60 0 6382.58

Number of Home Visits 242 56 292 904 294 725 94 395 890 950 633 472 179 328 411 493 215 311 449 972 298 701 2422 14999

Current Budgeted WTE 19.95 135.59

Actual WTE In-Post18.97

129.67

Actual WTE Worked19.49

135.31

Pending Appointment6

Current Budgeted Vacancies (WTE)

0.98 -0.08

Sickness (%)4.73 6.3

Substantive Staff Turnover Headcount (rolling average 12

8.6% 8.6%

12 month Appraisal94.3% 74.2%

12 month Mandatory Training

87.9% 74.1%

12 month Staff Survey/ Temp checks

Number of complaints received

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Incidents reported on Safeguard

0 77

* - Harm Free Care is from the Monthly Safety Thermometer showing percentage of patients with no harm recorded within District Nursing Domiciliary. ** - Pressure Ulcers are not broken down by team 1 or 2. For this reason, pressure ulcers have been recorded under the relevant Health Centre Name.

1 0 0 0 2 1 0 0

8.65 10.5011.28 8.71

436

552

968

988

54

888

742

8.65

8.74

69.4% 73.6% 52.7%

4

17.40

11.72

11.72

8.70

5 13 6 0 21 9 7 7 5

17.04

2273

93 68

8.67

9.11 18.11

15.94 10.50

11.32

7.17

7.39

9.99

10.58

15.17

15.29

12.08

12.72

0 1

10.81

10.84

75.0% 64.5% 82.5% 53.6% 80.6%

0.0% 0.0% 14.3% 16.7% 0.0%

14.91

-3.020.00 1.87 0.53 -0.05 0.00

11.34 12.039.99

94.9% 80.6%

77.8%87.5%100.0%66.7%90.0% 25.0%25.0%91.7%83.3%75.0%

18.93 0.00 6.54 0.000.78 4.90 0.00 0.00 18.86

0.00 2.61 1.46 1.54

0.0% 0.0% 0.0% 40.0% 33.3%


Date Indicator Code Indicator Description Requested by Change Authorised by

19/11/2013Monitor Compliance Governance 1013-14

Monitor Compliance Governance 1013-14 Report Esther Steel Remove from Report. No longer used. Esther Steel

27/11/2013

1.07 - Total number of incidents (Clinical and non-clinical)

This metric is everything reported, patient, staff, visitors, contractors, non person. “Clinical & non clinical” infers just patient incidents. Eric Porter

Change to 1.07 - Total Incidents reported on Safeguard Trish Armstrong-Child

04/12/2013

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

Labour turnover of substantive contracted employees Kelly King

This metric previously included turnover relating to contrived reductions in workforce over the course of the year, relating to Turnaround schemes, redundancies (voluntary and compulsory) etc. The data for this metric should be based on “natural” turnover in order to demonstrate a representative picture of the workforce. Retrospective figures have replaced the previously reported figures for the current year (2013/14). The 2012/13 figures have not been adjusted. The target remains at 10%. The metric definition has also been changed. Louise Ludgrove

13/12/2013 1.39 ‐ MRSA HA acquisitions N/A Julie Dziobon This is a duplicate of metric number 1.38 - MRSA Bacteraemia post-48 Hours admission Trish Armstrong-Child

13/12/20131.37 - MRSA Bacteraemia pre-48 Hours admission

No of pts identified as having MRSA presenting complaint 48 hrs before admission Julie Dziobon

All pre cases are now the responsibility of the CCG, for both CDT & MRSA bacteraemia cases, so despite having 4 pre cases of MRSA bacteraemia for the current year– none of them have been attributed to the Foundation Trust. Action: To remove this metric . Trish Armstrong-Child

17/01/2014 1.50 Infection Control Level 1 National Qualification David Wakefield Not Reportable David Wakefield17/01/2014 1.51 Infection Control Level 2 National Qualification David Wakefield Not Reportable David Wakefield

14/02/2014

1.36 Surgical WHO Checklist compliance (Emergency)

Checklist to reduce surgical morbidity and mortality Mike Steele Metric added Jill Patterson

19/02/2014

1.10 - pt incidents that resulted in severe harm or death %

Number of incidents involving pts that resulted in severe harm or death

Trish Armstrong-Child Target changed to 0%

Trish Armstrong-Child

19/02/2014 1.27 - complaints receivedTotal number of complaints received into trust


change target to 10% reduction on last years outturn


11/03/2014

1.25 - NICE Guidelines Adoption of Technology Appraisals

% of Technology appraisals applicable to the Trust that are adopted or adopted with caveat Steve Hodgson

Use the percentages based on total adopted technology appraisals Steve Hodgson

03/04/20144.13 - Qualified Nurse to bed ratio

Compares the number of contracted WTE nurses against in the number of occupied beds in the most recent month Nigel Moloney

Remove from Report. Replaced by ‘Budgeted Nurse: Bed Ratio’ and ‘Actual Nurse: Bed Ratio’ in the Board Staffing Assurance Heat Map Suzanne Woolridge

Report Change log



Report Change log

03/04/2014

1.33 - Compliance of 6 access criteria for learning disability %

to ensure equality of access and equity for all people with learning disabilities Mike Steele

After reviewing the 13-14 and 12-13 data there were incorrect figures in (83%). We were 100% compliant in year 12-13 and also in 13-14. Data changed to reflect this Bev Tabernacle

07/05/2014

2.46 - Readmissions within 30 days of discharge % - National

scorecard to have a line to show the national rate of readmissions along with the Trust’s performance. Esther Steel

Added Line to scorecard and series into 2.40 - Readmissions within 30 days of discharge % Chart Simon Worthington

14/05/20141.01, 1.02, 1.03, 1.04, 1.52, 1.56 (All falls and pressure damage grade 2)


a 5% reduction in year 2013/14 target applied to 2014/15 targets Jill Patterson

14/05/2014

2.40 - Readmissions within 30 days of discharge % Joanna Warburton

Readmission % for Feb14 reported last month has changed from 12.8% to 13.3% due to natural changes in data on LE2.2. The figure has still come within the ranges of previous month’s figures reported. Mike Steele

10/06/20141.13 - Infection Control (C. Diff) Mike Steele Metric duplicated by 1.45 Jill Patterson

13/06/2014

2.40 - Readmissions within 30 days of discharge % Simon Worthington

Target of 8% replaced by average of last years Readmission data = 12.6% Jill Patterson

02/07/2014

Total number of patient incidents (clinical and non-clinical) Total number of patient incidents

Mike Steele/Richard Sachs Number better represented by metric 1.07 Richard Sachs

15/07/2014

4.13 - Substantive Staff Turnover Headcount (Contrived) (rolling average 12 months)

This includes redundancies and MARS but still excludes junior doctors, flexi retirements and TUPE transfers Nigel Moloney New metric Suzanne Woolridge

17/07/20141.34 - No of CQUIN targets achieved in month

CQUINs are reported Quarterly to the CCG. This metric should reflect this position. Mike Steele Revise from monthly reporting to quarterly. Jill Patterson

01/08/2014 N/AAdded new metrics into Monitor Risk Report Mike Steele

New Metrics added to reflect new and amended metrics in the "Monitor Declaration of Risk" return Mike Steele



Report Change log

26/08/20141.07 - Total Incidents reported on Safeguard

Total number of all incidents, patient, staff, visitors, contractors etc


The QA committee has agreed that we need to increase our incident reporting and to get us in the top 20% of reporting nationally. New annual target of 10,786 added inorder to double our incident reporting per 100 admissions ratio from 6.26 per 100 to 12.60 per 100.


27/08/2014

1.09 - Total number of patient incidents reported per 100 admissions

Total number of patient incidents per 100 admissions within the month Richard Sachs as above


11/09/2014

4.05 - Local Induction Attendance (starters in the last 12 months)

Number of local (department) induction packs divided by the number of new starters in the most recent 12 month period Mark Wilkinson

4.05 - Completion of local induction system (starters in the last 12 months) - More accurate metric description. Suzanne Woolridge

07/10/20144.29 - FFT Recommend treatment

Implementation of staff FFT as per guidance, according to the national timetable. Suzanne Woolridge

Added metric 4.29 and 4.30 to the Workforce scorecard, to measure the National CQUIN Friends and Family Test – Implementation of staff FFT Mark Wilkinson

07/10/20144.30 - FFT Recommend place to work

Implementation of staff FFT as per guidance, according to the national timetable. Suzanne Woolridge

Added metric 4.29 and 4.30 to the Workforce scorecard, to measure the National CQUIN Friends and Family Test – Implementation of staff FFT Mark Wilkinson


Agenda Item No



Title Performance in the Emergency Department, the ECIST report and Resilience planning

Executive Summary • The paper proved analysis of the current performance against

the four hour target• It describes the action being taken after the ECIST review and

how the Trust is preparing for winter, to ensure recovery andcontinued compliance with the four hour target

Next steps/future actions

• For the Board to receive the paper• To provide an update on the action plan at the November

Board meeting

Discuss Receive

Approve Note

Assurance to be provided by:

• Four Hour target performance• Reductions in procedures cancelled on the day• Reductions in outliers• Evidence of implantation of action plans




Quality Regulatory


NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Prepared by Andy Ennis – Chief Operating Officer Presented by Andy Ennis –

Chief Operating Officer

9.

Performance in the Emergency Department, the ECIST Report and Resilience planning (formally

Winter planning)

Bolton FT Board meeting October 2014

Andy Ennis

Trends in Bolton ED performance

Looking at the 2 largest bed holding Divisions, Acute and Elective.

Attendance to ED

• At an average of 9500 attendances are similar to last year

• Attendances in Q1 were

high in comparison to previous years but have fallen to seasonal norms in Q2

0

2000

4000

6000

8000

10000

12000

04-Apr

05-May

06-Jun

07-Jul

08-Aug

09-Sep

10-Oct

Ed Performance and Resilience 3

Admission via ED

• There is a year on year rise in admissions through ED

• Admissions are up by

4% on previous years in the first 6 months of year

0

5000

10000

15000

20000

25000

30000

35000

10-Oct

09-Sep

08-Aug

07-Jul

06-Jun

05-May

04-Apr


Admissions v Discharges

-60

-40

-20

0

20

40

60

80

100

13/04/2014 13/07/2014 13/10/2014 13/01/2015

Bolton: Weekly Difference between Emergency Admissions

and Emergency Discharges

Difference (Admissions - Discharges)

• Data from the CSU

suggests the trend is that more emergency patients are admitted than we discharge each week


Timing of Admissions and Discharges

• The Trust has a typical trend whereby admissions peak before discharges.

• This leads to pressure

on bed availability causing flow issues

0

2

4

6

8

10

12

14

16

18

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

10:0

011

:00

12:0

013

:00

14:0

015

:00

16:0

017

:00

18:0

019

:00

20:0

021

:00

22:0

023

:00

Daily Discharges

Daily Admissions


Capacity v demand for beds and ED performance

Beds Required @95% occupancy

Admission method

ED Bed Bureau GP Waiting list Planned Consultant Booked other Total Division Acute 259 32.6 10.5 1 2.1 3.9 2 9.5 320.6 Elective 86 14.7 1.8 5.2 2 7.3 28 5.6 150.6

Beds available Apr May Jun Jul Aug Sep Oct Acute 351 322 322 328 328 323 323 Elective 174 174 174 174 168 168 168

Number admitted compared to previous years Month Apr May Jun Jul Aug Sep Oct Total 2013/4 4662 4634 4350 4752 4644 4702 4876 32620 2014/5 4831 5050 4691 5079 4485 4786 5019 33941 diff 169 416 341 327 -159 84 143 1321

ED 4 hr perf Month Apr May Jun Jul Aug Sep Oct 93.6 97.3 96.6 95.4 96.46 94.98 92.8 QTR 95.7 95.57 Year 95.64

note figures for Oct14 are pro rata for month at 22/10/14

• At current lengths of stay and at 95% occupancy, the Acute Division requires 321 beds and has 323

• Surgical capacity is

more than adequate for inpatient demand. But note Day case patients also use the beds

• Occupancy figures

are based at midnight, daytime occupancy would be higher


No elective length of stay • Length of stay is

falling month on month compared to last year

• Length of stay has

fallen from an average of 6.3 to 5.8 for all admissions

• Efficiency gains in

LOS are lost through increased admissions


0.0

1.0

2.0

3.0

4.0

5.0

6.0

F/Y Week Number

Average LOS - Non-Elective

Last Year Actual This Year Actual This Year Target

Cancelled Operations on the day

• Total numbers cancelled on the day remains low compared to national benchmarks but has risen compared to last year.

• The 2 most common

reasons for cancellations are Trauma/Emergency surgery and lack of beds


0.00%

1.00%

2.00%

3.00%

4.00%

F/Y Week Number

Cancelled Ops on the Day %

Last Year Actual This Year Actual This Year Target

Comment • Performance

– The Acute Divisions bed closure programme has been predicated on reductions in length of stay, which have largely been successful.

– However the efficiency gains have been cancelled out by increasing numbers of

admissions – So far admission avoidance schemes as part of QUIP in the CCG and the Trust have had

little or no obvious effect. – The resultant pressure has led to increased outliers to surgery, and an increase cancelled

on the day for no beds (note: the increase in emergency admissions has also impacted surgery resulting in cancelling elective work and not just because of medical outliers)

– There has been a steady deterioration in 4 hour performance – This is against a regional backdrop of a decline in performance. Only one other Trust is

achieving the year target apart from Bolton in GM


Comment • Staffing

– Feedback from Divisions suggest that although the recruitment of overseas staff and newly qualified students has been successful, this is filling gaps in establishments and does not give us capacity to open immediately extra beds safely.

• Physical capacity

– We have two decant wards (D3 and A4) both are in use and will not be available till December

– B3 is empty but not fit for purpose, Estates will carry out a basic

upgrade of half the ward, this will not be available until mid to late November.

– BCU is empty but is not ideally located for an inpatient area and is

being used as a discharge lounge


Comment • Actions to address flow

– ECIST • Appendix 1 describes the recent ECIST visit findings. • Overall the findings were positive but further improvements can be made • Discussions with teams are progressing to implement findings, but need to be

speeded up

– System resilience • Appendix 2 describes the funding being made available for winter and beyond • The initial tranche of money through the CCG had a community/admission

avoidance bias • Recruitment to these schemes has started • A second tranche of money has been made available through Monitor/DH, just

over £1m has been approved but it is not clear for which schemes as yet.


Comment • General schemes on flow

– There are a large number of schemes in place to look at flow (see appendix 3 for the first high level draft of the schemes)

– The pace of the implementation of these schemes is variable – The capacity for the management teams to progress all the schemes may be

an issue. – A senior divisional group chaired by the COO has been set up to agree

priorities and monitor progress. – The programmes of work will be divided into four schemes

• Pre - attendance –identifying and managing high risk patients • Peri - attendance –offering alternatives to admission • Peri-admission – reducing length of stay • Past admission – keeping patients well


Conclusions • Performance against the 4 hour target is a measure of whole system flow not ED. • Medical bed capacity is too little to cope with the increased admissions despite a

continued reduction in length of stay as a result of increased admissions • The pressure on the system does not allow for assessment areas to function as the

beds are needed for inpatients. • Bed occupancy on the day can often exceed 100% resulting in slow movement out

of ED which causes the 4 hour target to be breached. • “Winter” beds cannot be opened until further recruitment is completed. • Focus on alternatives to admissions and reducing LOS are the short term solutions.


Immediate Actions • All GP practices have been written to inviting them to work with a GP stream in ED. • Senior Clinical staff are carrying out a series of reviews over a number of days, of

all patients on all wards to expedite discharge and assess alternatives to care (the principle behind discharging during a major incident)

• Recruitment being expedited for clinical staff to support schemes • Funded schemes for Resilience being implemented as confirmed • A discharge lounge has been opened on BCU • A senior team from all Divisions overseeing programmes as outlined in appendix 4

to ensure speed of implementation • Full report and action plan to be provided at the November Board


ECIST REPORT Appendix 1


Bolton NHS FT Assurance Visit 14th – 16th July 2014

ECIST Recommendation following

visit December 2012

ECIST Recommendation following visit December 2012

ECIST findings on progress against December 2012 recommendations

New areas of work to develop.

Emergency Department/ Minors/Urgent Care Centre/ Nurse Practitioners in ED

We would also strongly recommend that a full review is carried out to review how and where the GP OOH service is provided from across the Bolton Health economy to exploit more opportunities for integration and cross service provision

Since our visit in 2012, the GP OOH provision has been taken over by a third party provider. We were told that the provider has ongoing issues ensuring that all sessions are covered by OOH GP’s which can impact on the demand within ED. ECIST strongly recommend that as a system, the partners work together to ensure that there is a GP/ Primary Care stream within ED at peak demand times and that the OOH service is co-located within ED to support the demand across the full OOH periods. Deflection of primary care patient within ED has been acknowledged nationally not to be the way forward. Therefore it is recommended that the Trust work with the CCG to ensure that the primary care stream is commissioned in line with national advice and the outputs from the current Keogh review.

Currently the department is using triage at the front door; we would recommend that the work continues to move to the “See & Treat” model.

During our visit we observed that as walk in patients queue to resister, no clinical person is observing the queue. Once the patient is registered if not classed as a major’s patients they are ask to wait again with the ‘red’ seated area. We were told that the if the queue within the ‘red’ seated area increases past 8 patients a second triage nurse is pull to support this area. When ask we were told this happens on a daily basis, we recommend that the current model is reviewed, and suggest that a streaming nurse is placed at the front of house, who continues to ‘eyeball’ the patients in the queue and supports streaming to the appropriate area. We also recommend that the minor unit again move away from the traditional triage model and move to the ‘see & treat delivery of care. While we fully accept the current workforce issues, we strongly recommend that there is a clear plan to ensure that the step change is undertaken from triage to see and treat therefore supporting improved flow and better patient experience. The streaming nurse will support this process. We support the current good practise of using medical staff to support the diagnosis of the more complex cases within the minor’s area.

18




Majors

Consider implementing a RAT model during peak periods led by a senior clinician.

We were told during our visit that (RAT) early senior review was not being undertaken within the department currently due to the current workforce gaps in senior clinicians. We would encourage the team to develop a model to deliver early senior review carried out by a ST4 or above. The model should be used at current peak times within the department. ECIST are happy to share examples where this model has been developed and is being used, where consultant numbers are below base line.

We also recommend that the Trust consider developing within the IPS agreements across the Trust for the ED consultant to have admitting rights when senior clinicians for the specialities are not available for the agreed response time.

Although internal professional standards (IPS), have been developed across the trust to support patient flow into the right areas first time. ECIST recommend that these are reviewed, monitored and reported against to ensure that all areas of the Trust are accountable for delivering what they have signed to deliver to support the flow of the emergency patient within the Trust. We were informed that not all areas or specialities adhered to the current IPS. This would be best discussed at the daily breach meetings where the blocks to a streamline patient pathway are being identified

19




Majors

Ambulance Queue within the Emergency Department.

We were told that a significant number of patients are remaining on Trolleys in the ED corridor awaiting admission on a daily bases as the peak times. These patients we were told are both awaiting ED assessment, and can wait long periods of time due to the lack of exit flow of patients already in the departments. We were concerned that this issue had become normalised as ED had planned staffing in their rota to care of patients in the queue. This clearly was resulting in frustration within the clinical team and indeed for patients and relatives. These delays in the patient’s journey are known to increase the clinical risk for patients in a crowded department. There is an increasing evidence base that crowding in ED leads to increased length of stay and mortality. The College of Emergency Medicine (CEM) also recently published guidance to manage crowding in ED. Their guidance suggests that Trusts should consider moving pre-selected patients to ward areas to wait for beds. International evidence suggests this approach (sometimes called the Full Capacity Protocol) is a more measured way of disseminating the risk associated with crowding in ED. We were also told that the current agreed ED escalation triggers are at 3hours. We recommend that this is pulled back to 2hours on the agreement that the ED have achieved the 20mins ‘time to assessment’ by senior reviewer and the 60min ‘time to treatment’. Therefore by 2hours the referral to speciality should have been made and/or DTA should have been agreed giving the receiving area time to pull the patient through. We therefore strongly recommend that the trust consider developing a corporate approach to address escalation and manage ED crowding. We would be happy to share how others have approached this area. ECIST would be keen to work with the Trust to fully understand the root cause of the queue and support the changes needed to address the daily occurrence.

20




Majors Cont:

Plaster room technician During our visit we were told that currently during peak times and OOH the department has no access to a plaster technician. We recommend this is reviewed and addressed, to reduce the impact on nursing staff and overall flow across the department.

ED clinic’s We were again informed that the ED clinics continue to be delivered 5days a week 2hours a day. We recommend that these are reviewed, and either reduced or removed as they are pulling consultant time away from the floor. This activity should be managed in primary care, a discussion with commissioners may be beneficial to understand how they wish for these patients to be handled.

Emergency Department Co-ordination

Floor Co-ordination/Nurse in charge, is currently the same person. However these are very different roles. We recommend the roles are reviewed and clear accountabilities are put in place for each role. We suggest that the floor co-ordinator role is supernumerary so they do not get pull into clinical work at peak demand time, unlike the nurse in charge.

Paediatric Emergency Department.

Currently the paediatric department have attendances which exceed 26,000 a year, being staff by 3 ANP’s, however it is not providing a service 24/7. We recommend that the department work with the paediatric ward and the GP OOH to develop a model that could support delivery a paediatric ED cover over the 24/7 period. ECIST can provide examples and linkage to other departments who provide such models.

21




Clinical Decision Unit (CDU)

We would recommend further work is done with the elderly care physician to look at the possible development of an Elderly Frail Unit that could possibly be established within the BCU and could be accessed from ED/CDU as well as the Community Services.

The clinical decision units continue to be a well-run unit, with the acute physicians taking responsibility for patients that would normally be covered by ED consultants. There appears to be an excellent working relationships across the trust,

We recommend that the ward manager for the unit is supervisory to enable good co-ordination and flow through the unit at all times. We support the further development of the advanced nurse practitioner (ANP) workforce and would suggest that these posts rotate across the ED, assessment units and the frailty unit, which will ensure that the role are interesting and support the retention of high motivated staff. These roles could also support the middle grade rota to support the 24/7 cover that is required. It was stated currently this can be a challenge to cover with the level of middle grade staffing.

Bolton Acute Frailty Unit

Following our review in 2012 we recommend that the trust look at the development of a frailty unit, combining the learning from the community unit and the then newly opened CDU. We were pleased to observe during our visit and walk through that the newly developed acute frailty unit within the trust had been open and was functioning extremely well. It was good to see that the aim of the unit is to work on a 72hour model in conjunction with community partners in reaching and pulling patients out when appropriate. ECIST where very impressed by the social care navigator role which works across the different authorities and coordinates any social care input to ensure the flow and appropriate discharges are sustain for this client group of patients. ECIST would encourage this role to have a formal review and if seen to be working well, it should be considered to be rolled out across the trust in high demand areas. It was acknowledged by the unit that there remains work to be done to support the direct referrals from ED. This work will improve flow and the patient experience of their journey into the unit. ECIST recommends that the trust ensure as with all assessment areas that support services are available seven days a week. 22




GP assessment unit/Ambulatory Care Unit

We recommend that the local community aims for up to 10% of emergency admissions to be managed as ambulatory care, including pathways for a wider group of high volume conditions

The unit again is seen as a unit of good practice with the consultant taking direct referral from GP colleagues ensuring that referrals are streamed to the most appropriate care for the patient. Referrals appear to be low to the ambulatory stream, and we recommend this is reviewed, to ensure that the ED department is accessing the pathway appropriately. It is worth auditing this as a possible reason for low ED referrals may be due to Consultant streaming for GP referrals

ECIST recommend that the trust rename the unit to what it is which an Ambulatory Acute Assessment Unit. We also recommend that the trust work with the team to extend the hours of operation to be delivered to 10pm and also 7 days a week. Currently we would suggest some patients that could be cared for within the stream are being admitted as the service is not available into the evening and at the weekends.

Medical Assessment Unit (MAU)

Flow into and out of the unit needs to be reviewed and standardised.

During our last visit in 2012 we were told that there was an ongoing issues with access to diagnostics and access to speciality wards once the patients had been accepted, with patient move taken up to 24hours. ECIST supported the units working with the speciality team revise the IPS’s to include a 2hour standard around pull from the unit once accepted by the speciality to the ward. At the 2014 assurance visit ECIST reviewed the output from this IPS as we were told the pull from the units remained poor for support specialities. On investigation it was clear the KPI’s that had been agreed within the IPS were not being monitored, recorded, reported or performance managed against. We recommend that the IPS is review and re- launched and that there is a framework set up to monitor, record, report and manage against to understand the flow blockages so that they can be addressed.

The unit’s average length of stay, despite the lack of speciality pull was reported as 1.1. There however was reported to be a difference in access to diagnostic for the assessment areas than there is for the ED department. We strongly recommend this is addressed as these are all the same patients requiring assessment, diagnostics and referral, and therefore should have the same standardised access to all support services. Well run unit, early morning board rounds with ward rounds following, rostered consultant of the week model. However due to current job planning, the unit cover from 1pm is from the on call consultant. It is evident that continuous reviews cannot take place with these arrangements. ECIST recommend that a full review is undertaken on the current job planning and resources to ensure were possible the assessment unit is meeting the standards set out by the College of Physicians.

23


ECIST findings on progress against December 2012 recommendations New areas of work to develop.

Surgical Assessment Unit

Currently, due to flow issues, the SAU is not being run as an assessment unit with some of the patients having their complete stay on the unit. It has been acknowledged that this is not a good experience for the patient and can cause flow issues and increase patients stay due to inappropriate admission to the surgical ward.

Unfortunately this unit has stood still since we last reviewed in 2012, ECIST recommend that the following areas are addressed with the support of the trust • lack of dedicated registrar cover, to provide early senior review and decision making. The lack of this

post is causing an issue with flow; patients are often not receiving senior review until late afternoon or early evening when the on call registrar comes out of theatre. This impacts on patients being streamed to the SAU.

• As with D1/D2 protocols were developed this agreed to 2 hour pull. However these have not sustained

as access to senior review is limited and there is currently no framework to monitor, record, report or performance manage against.

• Patients attending ED who have not seen a GP are receiving a full assessment and commence treatment in ED before referring to SAU. We are told this is due to not having access to a senior surgical decision maker on the unit. ECIST recommend this pathway is reviewed in line with direct admission from ED and also medical cover on the assessment unit.

Currently the unit have no advanced nurse practitioner (ANP) roles; we would support the development of such roles on the unit. These roles once developed and in place could help to support the gaps within the medical workforce needed to run such as unit. We were informed during our visit that the surgical acute referral clinic (ambulatory care unit) is only provided Mon/Wed/Fri 9-12; this also takes up a great deal of registrar time. It is worth reviewing and combining clinic with an ambulatory care model available 7 days per week – the trust could consider such a model in conjunction with the development of the ANP role. . It was positive to hear that criteria led discharge is working well within the unit and the nursing staff feels confident in using the current framework. This positive implementation of CLD should be rolled out across the trust using staff from SAU to support training less confident staff. We were told that the average length of stay is 1.8days; however stay can be up to a week as electives are taking priority over emergency. We recommend that current theatre lists are reviewed to ensure that emergency patients do not have to wait for treatment when elective demand is high. Radiology access was again highlighted as an issue as it was in 2012. When asked what access the unit had we were told, 3 slots Monday am then 1 slot every day at 8.30 outside these times the unit has to queue. ECIST recommends that a full demand capacity review is undertaken for the assessments units in this trust as access to diagnostics has been raised as an issue.

24




Base Wards

While we observed good practice within the wards we review during this visit we would recommend that the Trust undertaken a length of stay review, this will help understand the trust internal waits. Review the current service provision of support services such as diagnostics, pharmacy, review demand for extended hours and 7 day working within the support services. It will also support the review of the current processes and delay reasons of the commencement of packages of care, and support work with social services partners to enable attendances at the MDT.

Excellent in-patient ward model being delivered, with consultant ward round every morning, 7 days a week. The consultant of the week model in place (weekend on call), with patients then roll over to next consultant with robust a handover. Daily MDT’s has shown the sustained reduction of length of stay and trust mortality rate down. It was reported that social care input to the MDT’s remain inconsistent, which has an impact of discharge planning and flow. It was also reported that fast track does not happen from Friday to Monday. ECIST recommends that this is reviewed and that formal processes are implemented. As with many areas it would appear that the current CHC process undertaken by the commissioners are different in Bolton and Salford, with local policy in place causing several delays. It was reported that the process can take the following time, 7 days for review CHC checklist, 7 days for assessment (DST to be undertaken and panel outcome), 7 days or more to find care. These processes need to be reviewed and replaced by more responsive flexible services in lieu of national guidance. ECIST is happy to facilitate a workshop with the commissioners and service providers to agree a way forward that will provide a faster outcome for the patient.

25

SYSTEM RESILIENCE FUNDING

Appendix 2


Funded System resilience by CCG to date

27

• Volunteer Hospital at home £30K • 7 day discharge coordination £43K • Additional surge bed capacity £340K • IV Therapy team £83K • Enhanced referral and assessment £216k • 7 day working supporting early discharge £150k • 7 day working various schemes £100k • IMC beds £136k Total £1,098,000 Total available to CCG £1,862,000 Residual £764,000

Funded System resilience through Monitor/DH 2nd tranche

• Hospital Deflection/MDT team £450K • Respiratory beds £200k • GP direct/telephone advice £374k • Increasing Medical input £183k Total requested £1,207,000 Total allocated £1,060,000


INITIAL LIST OF ACTIONS TO ADDRESS FLOW

Appendix 3



PROJECT/INITIATIVE SUMMARY IMPACT OR LINKS WITH ACUTE DES FOR Unplanned Admissions Payment to GPs to develop a Crisis Care Plan to avoid a hospital

admission Aims to reduce hospital admissions and A & E attendances

Care Homes Project

Following a pilot involving one LTC Practitioner and four care homes a service specification has been issued by the CCG to roll the service out to all care homes in Bolton.

KPI to reduce NEL by 40 in 14/15 81 in 15/16 121 in 16/17

Care Co-ordination for the Over-75’s

26 practices have commissioned a Care Co-ordination Service from the FT-to assess the needs of the over-75 patients and develop a care plan. 24 practices are delivering this service in-house.

Aims to reduce hospital admissions and A & E attendances

Care Co-ordination Centre Aims to introduce a single point of contact for all integrated Health and Social Care Services in the Community.

Aims to reduce avoidable hospital admissions by facilitating timely access to alternative community pathways

Ambulatory Care CQUIN

GM CQUIN -local agreement is to focus on Diabetes patients Aims to reduce avoidable non-elective admissions by Integration

Intermediate Tier

Hospital admission avoidance scheme funded by BCF Aims to reduce NEL by 219 in q.4.2014/15 Aims to reduce NEL by 526 in 2015/16

Better Care Fund

Non-recurrent fun ding available in 2014/15 and 2015/216 to facilitate transformation of Community Health and Social Care Services

Minimum requirement is to reduce non-elective admissions by a minimum of 3.5 % from the baseline in Q.4 2013/14 and first 3 quarters of 2014/15.

Integrated Neighbourhood Teams Integrated Health and Social Care Teams including DNs, Social Workers, LTC Practitioners, Therapists, mental health professionals and Pharmacists

Being established with funding from the Better Care Fund-see above Aims to reduce NEL by 73 in q.4 2014/15 Aims to reduce NEL by 243 in 2015/16

Staying Well

Proactive Preventative service to keep people well and in their own homes for as long as possible.

Being established with funding from the Better Care Fund-see above Impact on NEL much longer term

Complex Lifestyles

Service for people with drug/alcohol/mental health problems/homelessness resulting in high usage of health and care services.

Being established with funding from the Better Care Fund-see above Aims to reduce NEL by 40 in 2015/16.

PRIMARY AND COMMUNITY CARE INITIATIVES AIMING TO REDUCE ACUTE ACTIVITY


Task Lead(s) Status/Progress Risks/Issues Monitoring/Measure 12 noon medicine bed meeting – LOS delays, today and tomorrow discharges

Janet Hurst All wards attending Visible improvement in information and challenge on delays

DTOC meeting Weekend Discharges Trial of weekend discharge stickers Nurse led discharge

Brian Bradley Harni Bharaj Cheryl Casey

EDD, PDD, LOS – routine audits in each BU

Kate McKenna Tracey Studholme

Routine tracking by BUMs

Ward rounds, Board Round, MDTs – routine audit, point prevalence challenge, use of standard work in each BU

Kate McKenna Tracey Studholme Richard Brownhill

Feasibility review of Discharge Lounge (possibility B1, B3, BCU, Winter Ward, Day Rooms on wards)

Sarah Morton Cheryl Casey Michelle Redgard

Reviewing Pennine Gold Standard discharge Unit

Quality concerns

Monitoring of AMU twice daily short stay vs speciality patients

Janet Hurst Sarah Morton

In place

IMC – in reach for assessment, monitoring of LOS and delays in LOS and DTOC

Anne Greenwood Jill Pinington

In place

TTO’s Ascribe Process Pharmacy Process Visibility at 1pm bed meeting

Brian Bradley

Needs corporate and elective division input to make sustained change

Acute Adult Division Urgent Care Action Plan

32

ED staffing review Nursing skill mix and shift patterns Medical skill mix and shift patterns Triage and RATS model review Earlier Senior Review Model - review GP stream – ANPs, GPs Shift Leader and Charge Nurse role review

Richard Brownhill Sue Beswick

Weekly Breach Meeting Aggregate themes and deep dive for learning and actions

Richard Brownhill

Flow Team Office redesign New structure for bed managers and site coordinators NNP roles and competencies, lie management Discharge team – review of working model and recruitment


Redesign Flow Report capacity and demand management monitoring of bed numbers in medicine at midnight and 7am for assurance for closing beds


Bed Management Policy


Extramed Define standard use/SOP Further training of staff Redesign of functions (outliers, EDDs/PDDs)

33

On Call tier 1 and 2 Training packs Prompt questions Flow Capacity and Demand Template Call logs Handovers

Janet Hurst Sarah Morton Michelle Redgard

Clarification of role actions/tasks Bed managers Site coordinators Shift leaders MOD acute and elective Medical Reg Medical consultant on call Tier 1& 2 Ward Mangers Band 7 at W/E


Redesign of Acute Medicine Bed Base (CDU/D1 and D2) Audit of Ambulatory Care Score of patients from ED to GPAU/CDU/AMU Review of DVT Bleep and referral pathway Review of GP Bleep and referral pathways Review model of care (Ambulatory Care Unit, Planned Investigation/Medical TCIs and GP expected for CDU and Short Stay ward for D1 and D2) Review staffing model Review nurse led discharge Review acute physician job plans and model of working in hours and OOHs, review use of standard work

34

Review Medical Working OOHs Rota’s Responsibilities Model of working OOH handovers Medical management of medical staff OOHs

Richard Brownhill Harni Bharaj

Community In Reach IV therapy Team LTC team

Jill Pinington

CHC Process Monitoring Redesign of Internal Process Daily Incident reporting of process delays Daily report to CCG of delays in process

Janet Hurst Sarah Morton Kate McKenna

Staffing Level Monitoring Acute ward nurse staffing IMC staffing DN staffing Medical staffing ED and acute medicine

Cheryl Casey Michelle Redgard Brian Bradley Harni Bharaj


Internal Professional Standards ED to AMU/AFU/CDU/GPAU AMU to Speciality Ward Pathology Radiology Pharmacy Ward Discharge

Readmissions HODs Clinical Leads

Integration Work streams IMC beds IMC at Home Community Admission avoidance Hospital Admission Avoidance 7 day discharge Integrated Neighbourhood teams Care Coordination centre

Anne Greenwood Jill Pinington Helen Clarke

Winter Resilience Plans Age UK Service Community Admission Avoidance Community Capacity IMC In reach Winter Ward/Discharge Lounge IMC beds Spot Purchase NH beds Front end schemes – ED staffing, GPAU/CDU IV therapy Team enhancement Care Homes Project Respiratory Care Scheme

Sarah Morton Michelle Redgard

AQUA Work Streams Mortality AFU readmissions Safety of hospital at Night

Brian Bradley Kate McKenna Richard Brownhill


Local Authority

RAID Richard Brownhill NWAS Handover/Turnaround action plan

Richard Brownhill

GPOOHs/Bardoc Richard Brownhill CCG Weekly 10am Conference Calls

Jill Pinington Richard Brownhill

ORGANISATIONAL FLOW Appendix 4



Memorandum To: Michelle Redgard, Harni Bharaj, Brian Bradley, Rae Wheatcroft, Jez Wood,

Jo Bolger, Gary Young, Helen Clarke, Steve Tyldsley & Karen Bancroft,

From: Andy Ennis, Chief Operating Officer

Ref: AE/KW/685

Date: 24 October 2014

Re: Performance – Flow and ED

Dear Colleagues, As you know performance this year as measured by the 4 hour target is fragile. We remain one of the better performing Trusts but it is getting difficult. This pressure is not going to decrease as demographics change and pressure grows to close beds. However our recent performance puts us at risk with Monitor, at the point in time that we are applying for removal from breach our performance has dipped considerably. We can continue to fight heroically or we can change how we do things (smarter not harder principle). We have a lot of initiatives which can improve flow but I think there is a gap in how we monitor and manage the programmes. These programmes can roughly be characterised by the following heading:

Pre attendance - Stop them getting sick (better care etc)

Peri attendance - After attending to admission

Peri admission - Admission

Part discharge - Keeping them well

I would like to pull together a steering group to monitor progress and also to manage and agree any bed closures. I think this group needs to be small and focussed and initially setting out the KPI, clarifying or identifying the various schemes, identifying who is the lead and the timescales and finally monitoring the actions. As this is about “flow” in the hospital (of which the 4 hour target is a marker) it is important we have all three Divisions represented and both clinical and management representation. I am asking to set up a meeting before the end of October and because of the short notice this may need to be at an evening or lunchtime although once we have met we can agree an appropriate time. I enclose a draft agenda, suggested KPI’s and a draft Board paper which hopefully gives you an idea on the areas of focus. Yours sincerely Andy Ennis Chief Operating Officer


Terms of Reference – Organisational Flow Purpose: • To oversee the Trusts review of clinical pathways as they relate to flow • To oversee the process of integration of Community and primary services as related

to flow • To assure the executive of the safety of proposed bed closures • To develop KPI’s to monitor flow across the hospital and community • QIA on bed report

Membership: • Chief Operating Officer – Chair • Divisional Director of Operations – Acute/Elective/Families • Head of Division or medical representation - Acute/Elective/Families • PMO Team • Information Analyst

Other staff may be invited where relevant.

Meeting: • Meeting will be monthly for 90 minutes. Administrative Support: • Support will be provided by the Executive Team. Accountability: • The meeting will provide assurance and report any risk to the Executive Team.

Review: • The meeting will review annually the Terms of Reference.

Agenda Item No



Title Mortality Report

Executive Summary

Why is this paper going to the Board

To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Over the last six months the Trust’s performance against the four main mortality measures has remained largely stable. There have been no adverse trends across divisions, departments, diagnostic groups or days of admission.


Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

Discuss Receive

Approve Note

Assurance to be provided by:




Quality Regulatory


NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Steve Hodgson, Medical Director

Presented by Steve Hodgson, Medical Director

10

Mortality Report - October 2014 Through the Trust Mortality Reduction Group we continue to monitor mortality rates across the Trust against the targets in the Quality Improvement Strategy. That is to reach the top 50% of Trusts by the end of 2014 and by the end of 2016 the top 10% of Trusts. Current Performance • Crude mortality = 2.1% (number of deaths/number of admissions excluding day cases) • RAMI = 79 (Risk Adjusted Mortality Index)(April 2013 – May 2014) • SHMI = 105.6 (top 50% = 99.6)(Standardised Hospital Mortality Index)(April 2013 – May 2014) • HSMR = 104.9 (top 50% = 102)(Hospital Standardised Mortality Ratio, Dr Foster)(April 2013 –

May 2014) • Weekend HSMR – 107.6

As the above chart shows, crude mortality has continued to improve. Risk adjusted mortality at 79 remains stable. SHMI at 105.6 (April 2013 – March 2014) has steadily fallen from a peak of 107 six months ago. HSMR of 104.9 remains stable. For crude mortality and RAMI we are in the top 50% of Trusts but not yet there for SHMI and HSMR. The gap of 2.7 between patients admitted at the weekend and overall HSMR places the Trust in the top 25% of Trusts in the North of England for this measure. The Mortality Reduction Group monitors mortality at divisional, departmental, diagnostic group, elective and non-elective cases and days of the week. There have been no significant changes/adverse findings over the last six months. Mortality Reduction Group Key priorities: • Identifying, responding to and rescuing the deteriorating patient • Ensuring timely access to a senior decision-maker • Ensuring safe medical and nursing staffing levels • Increase critical care outreach • Agreement of models for level 1 care in general surgery and medicine • Reliable and timely recognition of patients reaching the end of life • Improving co-morbidity coding.

Agenda Item No



Title Q2 compliance framework declaration

Executive Summary

As a Foundation Trust regular declarations are required with regard to compliance with targets and financial performance.

These declarations are made on a template provided by Monitor which includes worksheets for financial performance, governance declarations and performance against targets.

The governance and target templates will be uploaded with the monthly financial templates by 4.00 pm on October 31st 2014

Although the Trust remain red rated for governance the process to receive a certificate of compliance with enforcement and discretionary actions has been initiated by Monitor.


The Board are asked to approve the Q2 submission to Monitor

Discuss Receive Approve Note For Information Confidential y/n N


Strategy Legal Implications Performance and Quality Regulatory Financial Implications Stakeholder implications Workforce Risk

Prepared by Esther Steel Trust Secretary Presented by Esther Steel

Trust Secretary

Compliance Declaration Q2 2014/15

1. PURPOSE

The purpose of this paper is to inform the Board’s consideration of the quarter two submission to Monitor.

2. BACKGROUND

As a Foundation Trust regular declarations are required with regard to compliance with targets and financial performance.

These declarations are made on a template provided by Monitor which includes worksheets for financial performance, governance declarations and performance against targets.

3. CURRENT POSITION

An update on the current position with regard to operational performance, quality and finance is included on the Board agenda.

4. RECOMMENDATIONS

Board members are asked to agree that the following proposed statements attached to this report are signed for submission to Monitor for the Quarter two return:

• Governance declaration

• Targets and indicators

• Quality Governance declaration.

• Elections

• Cap Ex declaration - (Capital expenditure has been re-profiled due to the delay in securing loan/PDC funding for IT and estates strategy.)

Classified as Restricted per Monitor's Information Security Policy

© Crown copyright 2014

Customised for Acute FT with MARS ID 'BOLTON'. IYR template version 15.6.2.8

This template completed by (and Monitor queries to be directed to): Your relationship management team at Monitor:

Name: Contact Claudia Griffith

email : [email protected]

Job Title: tel : 02037470099

or Susan Docherty

Telephone number: email : [email protected]

tel : 02037470618

Email address:

for : technical queries about this template or MARS

Date: email : [email protected]

Approved on behalf of the Board of Directors by: return by MARS: click for your portal (requires internet access)

Name: David Wakefield guidance: Click for guidance (requires internet access)

Job Title: Chairman

Signature:

Bolton NHS FT

Plan data sourced from your latest submitted plan

In Year Financial Reporting return

Report of Actual performance against Plan to 30 Sep 2014

BOLTON 1415 Q2 in year reporting template (to issue) - Cover

1 of 43 24/10/2014 11:17

mailto:[email protected]

http://www.monitor.gov.uk/information-nhs-foundation-trusts/planning-and-reporting-processes/-year-reporting

In Year Quality Governance Metrics of Bolton

Actual for Actual for

The Risk Assessment Framework (diagram 13) sets out that Monitor will use executive team turnover as one of the

potential indicators of quality governance concerns. Please provide the information requested below and ensure that any

changes are explained in your commentary: units

Quarter ending

30-Jun-14

Quarter ending

30-Sep-14

Executive Directors

Total number of Executive posts on the Board (voting) Posts 6 6

Number of posts currently vacant Posts -

Number of posts currently filled by interim appointments Posts -

Number of resignations in quarter Resignations -

Number of appointments in quarter Appointments 1


List of Governors' elections for Bolton

The Risk Assessment Framework requires a quarterly report of elections held and results as below:

Elections Held in the quarter ending 30 Sep 2014

Constituency Type Full Name of Constituency No. of candidates No. of Votes cast Turnout No. of Eligible voters Date of election

example Public North west ourtown 4 1,345 16.3% 8,230 01/05/2010

Public Little Lever and Darcy Lever 2 58 39.7% 146 12/09/2014

Public Bromley Cross 2 97 39.4% 246 12/09/2014

Public Smithills 3 61 33.7% 181 12/09/2014

Staff AHPs and Scientists 2 145 19.4% 643 12/09/2014

Staff Doctors and Dentists 2 78 22.5% 347 12/09/2014

12/09/2014

BOLTON 1415 Q2 in year reporting template (to issue) - Elections

38 of 43 24/10/2014 11:17


Worksheet "Targets and Indicators"

Declaration of risks against healthcare targets and indicators for 2014-15 by Bolton

These targets and indicators are set out in the Risk Assessment Framework Key: must complete

Definitions can be found in Appendix A of the Risk Assessment Framework may need to complete

NOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines. Quarter 1 Quarter 2

Actual Actual

Target or Indicator (per Risk Assessment Framework)

Threshold or

target YTD

Scoring

under

Risk Assessment

Framework

Risk declared at

Annual Plan

Scoring

under

Risk Assessment

Framework Performance Achieved/Not Met

Scoring

under

Risk Assessment

Framework Performance Achieved/Not Met Any comments or explanations

Scoring

under

Risk Assessment

Framework

Referral to treatment time, 18 weeks in aggregate, admitted patients 90% 1.0 No 94.9% Achieved 0.0%

Referral to treatment time, 18 weeks in aggregate, non-admitted patients 95% 1.0 No 97.5% Achieved 0.0%

Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 No 0 92.0% Achieved 0 0.0% 0

A&E Clinical Quality- Total Time in A&E under 4 hours 95% 1.0 Yes 1 95.5% Achieved 0 0.0% 0

Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation 85% 1.0 No 93.4% Achieved 0.0%

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation 90% 1.0 No 0 100.0% Achieved 0 0.0% 0

Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation 96.0% 0.0%

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation 100.0% 0.0%

Cancer 31 day wait for second or subsequent treatment - surgery 94% 1.0 No 100.0% Achieved 0.0%

Cancer 31 day wait for second or subsequent treatment - drug treatments 98% 1.0 No 100.0% Achieved 0.0%

Cancer 31 day wait for second or subsequent treatment - radiotherapy 94% 1.0 No0

0.0% Not relevant 0

0.0%0

Cancer 31 day wait from diagnosis to first treatment 96% 1.0 No 0 97.7% Achieved 0 0.0% 0

Cancer 2 week (all cancers) 93% 1.0 No 97.6% Achieved 0.0%

Cancer 2 week (breast symptoms) 93% 1.0 No0

95.5% Achieved 0

0.0%0

Care Programme Approach (CPA) follow up within 7 days of discharge 95% 1.0 No 0.0% Not relevant 0.0%

Care Programme Approach (CPA) formal review within 12 months 95% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Admissions had access to crisis resolution / home treatment teams 95% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Meeting commitment to serve new psychosis cases by early intervention teams 95% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Ambulance Category A 8 Minute Response Time - Red 1 Calls 75% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Ambulance Category A 8 Minute Response Time - Red 2 Calls 75% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Ambulance Category A 19 Minute Transportation Time 95% 1.0 No 0 0.0% Not relevant 0 0.0% 0

C.Diff due to lapses in care 24 1.0 No 0 8 Achieved 0 0 0

Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) 8 0

C.Diff cases under review 0 0

Minimising MH delayed transfers of care <=7.5% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Data completeness, MH: identifiers 97% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Data completeness, MH: outcomes 50% 1.0 No 0 0.0% Not relevant 0 0.0% 0

Compliance with requirements regarding access to healthcare for people with a learning disability N/A 1.0 No 0 0.0% Achieved 0 N/A 0

Community care - referral to treatment information completeness 50% 1.0 No 99.4% Achieved 0.0%

Community care - referral information completeness 50% 1.0 No 100.0% Achieved 0.0%

Community care - activity information completeness 50% 1.0 No0

100.0% Achieved 0

0.0%0

Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No

CQC compliance action outstanding (as at time of submission) N/A No No

CQC enforcement action within last 12 months (as at time of submission) N/A No No

CQC enforcement action (including notices) currently in effect (as at time of submission) N/A No No

Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) N/A No No

Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) N/A No No

Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A No No

Results left to complete 0 0 34

Total Score 1 0 0

Report by Exception


In Year Governance Statement from the Board of Bolton

The board are required to respond "Confirmed" or "Not confiirmed" to the following statements (see notes below)

For finance, that: Board Response

4 Not Confirmed

For governance, that:

11 Confirmed

Otherwise:

Confirmed

Consolidated subsidiaries:

0

Signed on behalf of the board of directors

Signature Signature

Name David Wakefield Name Jackie Bene

Capacity Chairman Capacity Chief Executive

Date 30th October 2014 Date 30th October 2014

0

Notes:

A

B

C

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment

Framework page 22, Diagram 6) which have not already been reported.

The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of

thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going

forwards.

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.

Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the

NHS foundation trust.

Monitor will accept either 1) electronic signatures pasted into this worksheet or 2) hand written signatures on a paper printout of this declaration posted

to Monitor to arrive by the submission deadline.

In the event than an NHS foundation trust is unable to confirm these statements it should NOT select 'Confirmed’ in the relevant box. It must provide a

response (using the section below) explaining the reasons for the absence of a full certification and the action it proposes to take to address it.

This may include include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective

quality governance.

BOLTON 1415 Q2 in year reporting template (to issue) - Governance Statement

40 of 43 24/10/2014 11:17

Capital Expenditure Declaration for Bolton

Declaration 1

Signed:

On behalf of the Board of Directors

Acting in Capacity as: Director of Finance

Declaration 2

Signed:

On behalf of the Board of Directors

Acting in Capacity as: [job title here]

Where year-to-date capital expenditure is less than 85% or greater than 115% of levels in the latest annual plan (or any later capital expenditure

reforecast) an NHS foundation trust must submit a capital expenditure reforecast for the remainder of the year. This is set out at the bottom of page 22 of

the Risk Assessment Framework issued by Monitor April 2014.

The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the attached reforecast

plan.

The Board cannot make Declaration 1 and has provided relevant details on documents accompanying this return.

Note: Monitor will accept either an electronic signature or a hand written signature on this declaration

If you have triggered one of these criteria (see worksheet “Capex Reforecast Trigger”) then you must complete the worksheet “Capex Reforecast” and

sign one and only one of the declarations below. If you have not triggered one of these criteria then please do not input into this worksheet and the

worksheet “Capex Reforecast” at all.

Agenda Item No 12



Title Certification of Compliance

Executive Summary

A key part of the process to address our current position in breach of our provider licence is to apply for a compliance certificate in respect of enforcement undertakings and discretionary requirements.

Board members are asked to note the proposed submission in respect of the application for a certificate of compliance. At the time of submitting paper these submissions were being finalised.

A verbal update will be provided at the meeting


Board members are asked to approve the submission to Monitor and to delegate the approval of final sign off of the application for to the Chair and CEO.

Monitor have advised that they will take approximately two weeks to process this application

Discuss Receive Approve Note For Information Confidential y/n


Strategy Legal Implications Performance and Quality Regulatory Financial Implications Stakeholder implications Workforce Risk

Prepared by Esther Steel Trust Secretary Presented by Esther Steel

Trust Secretary

COMPLIANCE CERTIFICATE APPLICATION FORM

TRUST NAME : Bolton NHS FT This is a formal request from the Board of Bolton NHSFTto Monitor for Monitor to issue the Trust with a compliance certificate in respect of all Enforcement Undertakings accepted by Monitor on 25th April 2013 Signed on behalf of Trust Board: Position: Print Name: Date: --------------------------------------------------------------------------------------------------------------------------

To Be Completed By Monitor

Date received: Is the application form complete? Decision deadline date: Amended decision deadline date (if appropriate): Details of any additional information/clarification requested: Date any additional information/clarification is requested: Date any additional information/clarification is received: Decision: Reason(s):

1

Evidence supporting the application form Bolton NHS Foundation Trust Enforcement Undertaking

(insert paragraph number)

Issue

(insert a brief description of the nature of the undertaking)

Evidence of Trust’s Compliance with the Enforcement Undertaking

(explain why the Trust believes it has complied with the undertaking)

1 Target Breaches

1.1 Action plan by 31 May 2013 to reduce C. Difficile to a level that enables the Trust to comply with its contractual obligations with regard to C. Difficile

In March 2013 we worked jointly with our commissioners (Bolton CCG) to commission an external review of Clostridium difficile (C Difficile). We received the results of the review in April 2013 and developed a plan to address the actions required.

1.2/1.3

implementation and delivery of the plan we achieved a reduction in relation to the number of patients acquiring Clostridium Difficile with 38 patients in 2013/14 compared to 65 patients in 2012/13.

The agreed range of actions included:

• Investment in new hand wash basins in areas identified as needing these closer to beds and bays.

• The provision of doors on bays in some of our older wards.

• Hydrogen peroxide “fogging”. This is a procedure where the ward is closed for decontamination.

• Mattresses, pillows and commodes will be reviewed and replaced as necessary.

• Formal root cause analysis will be held for each and every infection.

• Continued close liaison with the commissioners Bolton CCG.

1.4 Submission of data Monthly C. Difficile performance data was submitted as part of the PRM slide packs.

1.5 Any other actions necessary to achieve the required reduction

Plan delivered as above performance data on embedded slide

2

Evidence supporting the application form Bolton NHS Foundation Trust

2. Board effectiveness and governance

2.1 Implement recommendations of Deloitte Quality Governance and Data Quality review

An action plan was developed to implement the recommendations in the Deloitte Quality Governance and Data Quality review

2.2 Programme management of the delivery of the above

An interim information manager was appointed to lead on the delivery of the data quality actions and the development and introduction of a new integrated performance report

2.3 External assurance of implementation of Deloitte Quality Governance and data quality

PwC have provided external assurance of the implementation of the Deloitte reports with an update report providing assurance with regard to actions taken to address previously outstanding recommendations.

Two actions for data quality and x for quality governance are in progress but have yet to be embedded.

2.4 Provide Monitor with the reviewers draft and finalised reports

Draft and final PwC report submitted to Monitor

2.5 Submit Board quality dashboard and narrative to Monitor

Submitted as part of monthly slide packs.

October Board pack embedded

3. Meetings

3.1 Attendance at meetings The requested representatives of the Trust have attended regular PRM meetings with Monitor as requested

3

COMPLIANCE CERTIFICATE APPLICATION FORM

Bolton NHS Foundation Trust This is a formal request from the Board of Bolton NHSFT to Monitor for Monitor to issue the Trust with a compliance certificate in respect of all Discretionary Requirements accepted by Monitor on 25th April 2013 Signed on behalf of Trust Board: Position: Print Name: Date: --------------------------------------------------------------------------------------------------------------------------

To Be Completed By Monitor

Date received: Is the application form complete? Decision deadline date: Amended decision deadline date (if appropriate): Details of any additional information/clarification requested: Date any additional information/clarification is requested: Date any additional information/clarification is received: Decision: Reason(s):

Evidence supporting the application form Bolton NHS FT

Discretionary Requirement

(insert paragraph number)

Issue

(insert a brief description of the nature of the undertaking)

Evidence of Trust’s Compliance with the Discretionary Requirement

(explain why the Trust believes it has complied with the requirement)

1 Target Breaches

1.1 Work with the DoH ECIST to develop an RTT action plan to:

address RTT backlog levels

Improve information reporting

Enable sustainable delivery of RTT compliance

RTT plan developed and delivered

Improved information reporting delivered

Sustained achievement of compliance with the RTT targets

1.2 Development of a monthly RTT Sustainability reporting tool

Monthly sustainability tool developed - demonstrated to Monitor

1.3 Monthly reporting regarding compliance with RTT performance

Monthly reporting provided through PRM meetings

1.4 Any other actions to enable delivery of RTT plan and development and delivery of a monthly RTT sustainability reporting tool

RTT targets delivered

2. Financial Planning

2.1 Implementation of PwC recommendations for financial governance and reporting

PwC recommendations implemented

2.2 External assurance of implementation of PwC recommendations

Assurance provided that all recommendations implemented

2.3 Submission of a realistic and deliverable three year plan, incorporating the turnaround plan

Three year plan submitted Sept 2013

Evidence supporting the application form Bolton NHS FT

and outlining recovery to a sustainable position.

2.4 Programme management and governance arrangements to deliver the financial plan

Initially overseen by Turnaround Director; Programme Management Office now overseen by the Director of Finance

2.5 Delivery of the turnaround plan and three year financial plan

Year one of turnaround plan delivered - updates provided through PRM

2.6 Reporting on the delivery of the turnaround/financial plan

Reporting provided through PRM and additional adhoc reports as requested

2.7 Preparation and submission of quarterly cash flow forecasts

Forecasts submitted as requested

2.8 Following the review by Deloitte deliver review of options and timetable for engagement and strategic decisions with regard to reconfiguration options

Deloitte review completed, continued engagement with Healthier Together and sector working discussed through regular meetings with Monitor.

3. Board effectiveness and governance

3.1 Action plan to implement recommendations in KPMG’s review of Board Governance

Action plan developed

3.2 Implementation of KPMG’s recommendations

3.3 External assurance of implementation of recommendations

3.4 Copied of external reviewers report to be submitted to Monitor

External reviewers report submitted to Monitor

Meetings

3.1 Attendance at meetings The requested representatives of the Trust have attended regular PRM meetings with Monitor as requested

Agenda Item No : 14



Title COMMUNITY SERVICES

Executive Summary

This paper builds on the work described at the July Board, updates on progress made in recent months and outlines the approach to be taken going forward. We face the challenges of realising the potential of becoming a provider of high quality and integrated hospital and community services, valuing all our staff, and ensuring that these services are financially sustainable.


Discuss Receive Approve X Note For Information Confidential y/n


Strategy X Legal Implications Performance and Quality X Regulatory Financial Implications X Stakeholder implications X Workforce Risk

Prepared by

Mark Wilkinson Director of Strategic and Organisational Development

Presented by Simon Worthington Deputy Chief Executive / Director of Finance

1

COMMUNITY SERVICES 1. PURPOSE

The July meeting of the Board of Directors received a paper setting out the work

underway to address key issues faced by the Trust in delivering high quality community services that meet the needs of commissioners and service users.

This paper builds on that work, updates the Board on progress made in recent months and outlines the approach to be taken going forward.

2. BACKGROUND

Since the Trust was created in 2011 bringing together the community services formerly part of the Bolton Primary Care Trust and the hospital services formerly part of Bolton Hospitals NHS Foundation Trust, there have been a series of real and perceived challenges with the Trust’s delivery of community services.

3. CURRENT POSITION

The incorporation of community services into a new and combined integrated care organisation was a strategically significant move although realising the full potential of that move remains work in progress.

In thinking about community services as an essential component of the organisation the following issues can be identified.

a) Internal Integration - integrating the delivery of hospital and community services where that is appropriate and ensuring we have clear lines of accountability internally.

b) Sustainability - working with CCG commissioners so that community services are delivered in a financially sustainable way.

c) Visibility - the NHS is culturally oriented towards hospital services even as it has long been recognised that we should deliver more care in out of hospital settings.

d) Long term visioning - realising the strategic potential of this Trust as a provider of integrated health services across hospital and community settings.

e) Health and care Integration- as well as the need to bring together NHS hospital and community services the bigger challenge facing the NHS and local government is to bring health and care together.

f) Developing Effective partnerships - gaining greater visibility of the Health and Wellbeing Board and the unique role we have in the life of the Borough - its largest employer, with a big economic impact as well as contributing to the health and wellbeing of the people of Bolton.

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4. PROPOSAL

There is considerable work underway in response to these issues which cut across the portfolios of all executive directors and indeed the work of this Board.

Internal Integration – led by Chief Operating Officer

Community services have been located in all three divisions although the majority are found in Acute Adult. Whilst this has been supportive of integration it has made it harder for the CCG to work with us on ‘generic’ community issues. Structural and people changes have also led to some loss of organisational memory which is taking time to build up. The performance focus of the Trust with regards to its divisions can skew effort towards the immediately and easily measurable. A heat map is being developed for district nursing services (Appendix A sets out the proposed format) and departments to mirror the already successful heat map used for hospital wards.

Sustainability – led by Deputy Chief Executive / Director of Finance Since the integrated Trust was created in 2011 there have been concerns that the income received does not match the costs incurred in providing these services. Over the intervening period the Trust has conducted several analyses demonstrating that there is a material deficit on these services. In 2014/15 this translates into a £2m deficit in the first six months and a projection of £3.4m for the year. We have requested support for this analysis or detailed feedback that would allow us to get to an agreed position. More information on this issue is provided in Appendix B.

Ensuring financial sustainability is harder for community services which are typically less measurable and less well specified in contracts. Where our community staff work closely with GPs and their teams there can also be wide variation in terms of who does what.

Visibility / long term visioning / health and care integration – led by Director of Strategic and Organisational Development

The Board has already taken steps to raise its own profile beyond the hospital and these should continue. All staff communication methods are being tested against the need to be demonstrably even handed in our approach. A review and re-launch of team briefing and a new intranet will be in place during the next five months.

The revised five year strategic plan and two year operational plan to be approved by the Board before the end of March 15 will be rebalanced to give appropriate weight to community services. A strategy solely for community services isn’t consistent with the Trust’s desire to be an integrated service provider.

The Better Care Fund is described elsewhere on this agenda. Performance reporting in future months will include Better Care Fund metrics for this and other

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partner organisations. Consistent with the nature of the Better Care Fund it is planned that our performance reporting highlights the contributions made by partner organisations. We have our individual performance metrics to support BCF priorities and these are as set out in Appendix C.

Bolton CCG has recently shared its commissioning intentions for 2015/16. Consistent with their stated strategic objective1 of ‘shifting resources from hospital to community & primary care’ there is a significant focus on care in out of hospital settings. Appendix D sets out these high level intentions. We will be working with the Trust to explore how we can realise these intentions. A key issue is ensuring that existing services are supported by agreed specifications. To this end, the CCG and the Trust are co-producing service specifications for community services - which will help the financial sustainability work. The table below lists those services for which specifications are being produced. Division Service Acute Adult Adult Community Nursing Acute Adult Anticoagulation Service Acute Adult Intermediate Care / Tier Acute Adult Integrated Neighbourhood Teams Elective Musculo-Skeletal Therapy Acute Adult Dietetics Acute Adult Speech and Language Therapy Acute Adult Specialist Weight Management Families Community Paediatric Service Families Children’s’ Community Therapies Acute Adult Care Homes

Developing Effective Partnership – led by Chief Executive

The Health and Wellbeing Board is the principal focus of partnership working in Bolton. The minutes of the last meeting are attached as Appendix E to this report and it is planned that the minutes are regularly reported to Board in future.

The Board in relation to other partnership groups is shown diagrammatically in Appendix F.

The Workforce Strategy at the November board will include commitments to ensuring our workforce reflects the demographic features of the local population Consideration will be given to inclusion of health and wellbeing subjects as part of Board development to inform the development of the Trust’s strategy.

1 http://www.boltonccg.nhs.uk/images/documents/corporate/2014-19%20Commissioning%20Strategy%20final%20%20140718.pdf

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5. CONCLUSION

The prize of delivering joined services across hospital and community is significant.

The Trust currently faces some challenges in realising the potential and this paper has set out our approach to overcoming those changes.

6. RECOMMENDATIONS

It is therefore recommended that the Board: i. Notes the report. ii. Approves the way forward outlined above with regard to:

a. Developing our performance reporting. b. Robust efforts to secure financially sustainable services. c. Board awareness of, and profile with, community services and

the Health and Wellbeing Board.

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Appendix A – Heat Map for District Nursing

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Appendix B – Briefing on Deficit in Community Services Immediately after the Trust took on community services it was integrated into the divisional structure of the Trust. Whilst this made sense for service integration it meant that to some extent the Board lost month by month sight of the financial position of these new services. Since then a number of attempts have been made to establish the financial position of the community services element of the Trust business. Previous attempts are as follows:

• Work undertaken by Deloitte on an “incomplete records” basis, reported to the Finance and Investment Committee in late 2012/13.

• Work based on the Trust’s PLICs database presented to the same committee in August 2013.

• An internal bottom up piece done in March of 2014. All these exercises indicated there was a material deficit on the Trust’s community services. This fourth exercise, reported here, is by far the most robust and will form the basis of monthly reporting going forward. It again demonstrates that there is a material deficit on the Trust’s community services. For the financial year 2013/14 it demonstrated a deficit of £1.9m which is 3.4% of community income. This £1.9m deficit equates to 33% of the Trust’s overall operating deficit of £5.7m in 2013/14. The overall deficit reported was reduced from that identified in previous exercises. This is because it only looked at community services transferred under 'Transforming Community Services' (egg it excluded community midwifery and other community services that the Trust had always run), it took account of the significant cost improvements that were delivered in 2013/14, and is much more robust from a costing perspective. The detailed results of this analysis have been shared with this Trust's Finance and Investment Committee and with the CCG. We believe the work has covered off the following issues:

• Mapping of services to new agreed summarised service lines • Clear statement of the income in the 2013/14 contract and 2014/15 contract for

community services by these service lines • Clear statement of the costs for 2013/14 by these service lines including a

breakdown of pay, non-pay, direct income, indirect costs and overheads • Clear audit trail back to individual budget reports to support these costs with a

note as to what percentage of that cost centre has been allocated to the community contract

• Clear statement of what is in overheads and information to support its reasonableness.

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The overall conclusion of this work was a clear material deficit on the community services commissioned by Bolton CCG which can be summarised as follows (please note this excludes GP out of hours).

The analysis above bridges the 2013/14 deficit to an imputed deficit for 2014/15 on the assumption that the Trust delivers £1.6m of CIP against community services, and also have also included the CCG’s share of revenue costs of the IT infrastructure investments we are making in community. The Trust is planning to proceed with this investment although the CCG has largely rejected it on value for money grounds. Moving into 2014/15, our latest report to Monitor presented the community financial position as follows, with an overall year to date deficit of £3.4m:

The CCG have responded to say that they do not accept this position, citing particular concerns about Trust overheads despite benchmarking information establishing our overheads are relatively low.

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Appendix C – Better Care Fund Metrics The following metrics have been selected by each organisation as indicators of their progress towards the shared Better Care Fund objectives: Performance Indicator Target Current Status Bolton CCG Reduce A&E attendances for Bolton patients

Reduce by 2.7% in 2014/15 compared with 2013/14

Red

Reduce emergency admissions for Bolton patients – NB this is the Fund's payment for performance target

Reduce by 3.5% from 2014 to 2015

Red

Reduce 30 day emergency readmissions for Bolton patients

Reduce by 0.02% in 2014/15 compared with 2013/14

Red

Sustain average non elective stay for Bolton patients

No more than 4.8 days Green

Bolton Council Proportion of over 65s still at home 91 days after discharge from hospital into reablement / rehabilitation services

To be confirmed To be confirmed

Delayed transfers of care from hospital per 100,000 population


Delayed transfers of care from hospital attributable to adult social care per 100,000 population


Improving people's experience of integrated care


Bolton NHS Foundation Trust

Reduce average length of stay


Reduce 30 day emergency readmissions


Reduce A&E attendances To be confirmed To be confirmed

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Reduce hospital admissions


Reduce mortality rates To be confirmed To be confirmed Reduce hospital acquired infections


Improve the Family and Friends Test score for inpatients


Improve the Family and Friends Test score for A&E attendees


Greater Manchester West NHS Foundation Trust

To be confirmed To be confirmed To be confirmed

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Appendix D – NHS Bolton CCG’s Commissioning Intentions for 2015/16 1. Specific areas that we wish to alert the market, our partners and stakeholders for

particular focus during 2015/16 include:

2. A reduction in emergency admissions and readmissions to hospital, through a focus on admission avoidance , including:

a. Redesign of RATS service b. Redesign of Intermediate Care services c. Strengthening community services (24/7) d. Design and implementation of ambulatory pathways for common conditions

including DVT, PE, cellulitis, headaches e. Phased implementation of the children’s acute admission avoidance scheme f. Procurement of a new Out of Hours service and 111.

3. The integration of health and social care to enable the shift from reactive to

proactive care with a specific focus on frail elderly people at the end of their life, those with multiple long term conditions and complex lifestyles in terms of proactive care planning and “staying well” for the over-65 population.

4. A reduction in demand for hospital planned care services, with a shift of healthcare from acute settings to primary and community care. Conclusion of the review (and associated redesign) of community services and implementation of the new Bolton Contract for General Practice.

5. The implementation of “the Bolton Offer” which will ensure only services which add value and are evidence-based are commissioned for the local population. This will include not commissioning Procedures of Limited Clinical Value from any source, ensuring clinically appropriate use of diagnostics and MSK services, and rigid application of the GM Formulary to ensure efficient and effective use of medicines. This will include revising all acute service specifications.

6. A focus on prevention of ill health and the promotion of wellbeing though re-commissioning of IAPT services, redesign of community services and ensuring ill-health prevention and promotion of wellbeing are included in all commissioned services.

7. Ensuring excellent performance against all national targets with a focus on improving cancer pathways, ambulance handovers and response rates, and stroke services.

8. The implementation of the outcomes of “Healthier Together” with a focus on improving quality and outcomes, and ensuring value for money across tertiary, secondary and community care.

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Appendix E– Minutes of Health and Wellbeing Board: 3 September 14 Present Representing Bolton Council Councillor Mrs Thomas (Chairman) Councillor Morris (Vice-Chairman) Councillor Bashir-Ismail Councillor Cunliffe Councillor Peacock Councillor Mrs Fairclough Representing Bolton Clinical Commissioning Group – Dr W. Bhatiani GP Dr C. Mercer GP Dr C. Mackinnon GP Representing Royal Bolton Hospital Foundation Trust Dr J. Bene – Chief Executive Representing Healthwatch Mr J. Firth – Chairman Representing Voluntary Sector Ms K. Minnitt – Bolton CVS Representing NHS England (GM) Mr A. Harrison Also in Attendance Mr S. Harris – Chief Executive, Bolton Council Ms W. Meredith – Director of Public Health, Bolton Council Ms M. Asquith – Director of Children’s and Adult Services, Bolton Council Mr A. Crook – Assistant Director, Children’s and Adult Services, Bolton Council Mr D. Smith – Head of Finance, Bolton Council Dr L. Vallance – Chief Executive, Bolton Hospice Ms M. Laskey – Associate Director, Bolton CCG Ms T. Morris – Bolton CCG Mrs D. Lythgoe – Policy and Performance, Bolton Council Mrs S. Bailey – Democratic Services, Bolton Council Apologies for absence were submitted on behalf of Ms B. Humphrey, Ms S. Long, Mr A. Stephenson and Councillor Dean. Councillor Mrs Thomas in the Chair. 1. MINUTES OF PREVIOUS MEETING

The minutes of the proceedings of the meeting of the Board held on 16th July,

2014 were submitted and signed as a correct record.

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2. FUNDING TRANSFER FROM NHS ENGLAND TO SOCIAL CARE – 2014/15

The Director of Children’s and Adult Services and the Borough Treasurer submitted

a joint report which outlined proposals for the use of NHS England Revenue Funding 2014/15 for the consideration of the Board.

By way of background information, the report advised members that in 2014/15, NHS England had received a revenue allocation of £6.371m for expenditure on social care services. The allocation included £5.213m in relation to uplifted monies previously transferred and a further Integration Payment totalling £1.158m to reflect Bolton’s share of the additional £200m funding which had been incorporated into the Better Care Fund for 2014/15 at a national level. The report went on to outline the criteria for release of the £5.213m element of the funding to local authorities which required expenditure to be on social care services which also had a health benefit. Agreement must also be obtained from this Board as to how the funding would be utilised. The requirement for release of the £1.158m was a satisfactory Better Care Fund submission which had already been satisfied. In this regard, the report put forward various proposals for use of the monies.

Table One to the report outlined various proposed services that the monies could be used to contribute to in their entirety and Table Two outlined services that the funding could be allocated to specifically for the purposes of meeting the NHS England’s national categorisation of spend. In order for the Health England to transfer the funds to the Local Authority, a Section 256 Agreement would need to be in place between Health England and Bolton Council. Annexe B to the report set out an approved Section 256 Agreement totalling £6,371,303m to reflect the total funds to be transferred from NHS England to Bolton Council to be utilised as outlined within the Better Care Fund template and the contents of this report.

Resolved – That the £5.213m of funding held by Health England be used as a contribution to the services outlined in Table One of the report for the 2014/15 financial Year and specifically allocated to the services outlined in Table Two for the purposes of meeting the NHS England’s national categorisation of spend.

3. BETTER CARE FUND - STAGE 3 SUBMISSION

The Director of Children’s and Adult Services submitted a report which provided an update on Stage 3 of the Better Care Fund and highlighted the differences required from previous submissions. The report advised that new guidance and an updated policy framework had been issued which required Health and Wellbeing Boards to revisit their plans in order to demonstrate clearly how they would reduce total emergency admissions as a clear indicator of the effectiveness of local health and care services in working better together to support people’s health and independence in the community.

The report summarised the main policy changes and put forward the areas that would be required to be included in the revised plans, as follows:

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- the local vision for health and care services;

- the case for change; - a plan of action; - strong governance; - protection of social care; and - alignment with acute sector and wider planning

In this regard, the report sought approval for the Chief Executives of the Council and the CCG together with the Chair of the Health and Wellbeing Board to make suitable amendments to the final submission, in line with the new requirements. Resolved – That the Chief Executives of the Council and the CCG together with the Chair of the Health and Wellbeing Board, be given delegated authority to make suitable amendments to the final submission, on the basis outlined in the report now submitted, ahead of the deadline for submission to Government of 19th September, 2014.

4. HEALTH AND SOCIAL CARE INTEGRATION UPDATE

The Director of Children’s and Adult Services submitted a report which outlined the latest progress on health and social care integration in Bolton and Greater Manchester using the new format agreed at the previous meeting of the Board. Following consideration of the report, members felt that it would be useful to include a glossary of terms in future reports together with information on workforce capability. Other comments/observations on the report included the following:

- work was still ongoing to ensure that GP practices were able to fully connect with the integration agenda and to achieve the required objectives;

- there was a need to fully understand and scrutinise the integration objectives and

key performance indicators would be critical in ultimately determining whether integration had been successful in achieving its aims; and - gathering feedback and measuring the views of service users/patients using a

variety of methods would be important for the Board in terms of identifying how successful integration had been.

Resolved – That the report be noted.

5. DIRECTOR OF PUBLIC HEALTH’S ANNUAL REPORT 2013

The Director of Public Health submitted her 2013 Annual Report for the

consideration and comment of members. The Board was reminded that the Director of Public Health was required to report annually on the health of the local population. The report identified and communicated the key health priorities for the Bolton population and approaches to improving health across the Borough.

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Ms Meredith gave a presentation to supplement the report and circulated a copy of

the Annual Report. Resolved – (i) That the report is noted and that updates on delivery of the objectives contained within the Annual Report are submitted to the Board via the Health and Wellbeing Performance Management reports. (ii) That Ms Meredith is thanked for her informative presentation.

6. HEALTH AND WELLBEING STRATEGY – END OF LIFE CHAPTER – PERFORMANCE REPORT – QUARTER 2

The Director of Public Health submitted a report which updated the Board on the performance of the Health and Wellbeing Strategy as it related to the End of Life chapter. The report provided details in relation to each priority with some further commentary on the outcomes and an outline of the actions. Resolved – That the report be noted.

7. BOLTON CCG PROGRESS TOWARDS END OF LIFE PRIORITIES

A report of the Chief Officer, Bolton CCG, was submitted which outlined the progress being made towards the priorities in the End of Life chapter of the Health and Wellbeing Strategy. The report outlined the excellent work ongoing in Bolton regarding End of Life care and good partnership working to deliver general and specialist palliative End of Life Care services to patients and their carers. Good training and education programmes were in place across health and social care which included training for the staff working in care homes across the Borough. Bolton’s Strategy for End of Life care was currently being developed and a number of key areas of work to date had been identified.

These included: - bereavement support; - identification of people with End of Life care needs; - review of the Liverpool Care pathway; - integration; and - the development of an Electronic Patient Care Coordination System. Resolved – That the report be noted.

8. BEREAVEMENT SERVICES – BOLTON HOSPICE

Dr Leigh Vallance, Chief Executive, Bolton Hospice gave a presentation which focused on bereavement and ways in which the impact of bereavement on the health and wellbeing of the local population and the local economy could be minimised.

The presentation highlighted the following issues:

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- reactions to grief;

- how grief impacts on health and wellbeing; - steps to improve support in bereavement; - work ongoing at the Hospice in terms of pre-bereavement and bereavement

support; and training and education for those assisting people who had suffered bereavement.

Various recommendations for future developments were also

identified, as follows:

- map current provision; - identify gaps and plot projected growth; - identify priority areas; - commission services accordingly; - coordinate access and delivery; - reduce the negative impact of bereavement on individuals, services and the

economy; - develop a plan that recognised the significance of bereavement and take action

to reduce its impact by investing in prevention.

Following the presentation, members made a number of comments, as follows:

- it was felt that the area of sudden death needed to be addressed; - the different ways in which individual communities dealt with death; - the links between bereavement and the Children’s Strategy; and - the ongoing work being undertaken by the CCG in developing the End of Life

Care Strategy with the inclusion of bereavement as one of its chapters.

Resolved – That Dr Vallance be thanked for her informative presentation.

9. NHS BOLTON CLINICAL COMMISSIONING GROUP BOARD UPDATE – MINUTES OF MEETINGS

The minutes of the proceedings of the meetings of the Clinical Commissioning Group Board held on 27th June and 25th July, 2014 were submitted for information.

Resolved – That the minutes be noted.

10. GREATER MANCHESTER HEALTH AND WELLBEING BOARD – MINUTES OF MEETING

The minutes of the proceedings of the meeting of the Greater Manchester Health and Wellbeing Board held on 9th May, 2014 were submitted for information.

Resolved – That the minutes be noted.

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11. MONITORING REPORT

The Chief Executive submitted a report which monitored the progress of decisions

taken at previous meetings of the Board. Resolved – That the monitoring report be noted.

12. HEALTH AND WELLBEING BOARD FORWARD PLAN 2014/15

The Chief Executive submitted a draft Forward Plan which had been formulated to guide the work of the Health and Wellbeing Board over the forthcoming year.

Members raised the following item for possible inclusion on the Work Programme, as follows:

- the involvement of the ambulance service in delivery integration. Resolved – That the Forward Plan, as now submitted, be approved. (The meeting started at 2.00pm and finished at 3.10pm)

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Appendix F – Principal Borough Partnership Arrangements

1. The Health and Wellbeing Board is formally a sub-committee of the Council. It

comprises members from the following organisations: Bolton Council, CCG, Foundation Trust, Healthwatch, Council for Voluntary Service, NHS England Area Team, and Greater Manchester West NHS Foundation Trust. Dr Jackie Bene represents this Trust.

2. The Joint Transformation Group comprises the Chief Executives and other Executive Directors from the Council, CCG, Foundation Trust and Greater Manchester West NHS Foundation Trust. It is the ‘delivery arm’ of the Health and Wellbeing Board. Our representatives include the Chief Executive, Deputy Chief Executive and Director of Strategic and Organisational Development.

3. The Health and Social Care Integration Board has a specific focus on integration and

comprises representatives from the Council, CCG, and this Trust – we are represented by a range of Executive Directors, Heads of Division, and Divisional Directors of Operations.

Bolton MBC

Health and Wellbeing Board

Joint Transformation Group

Health and Social Care Integration Board

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Agenda Item No : 15


Date 30 October 2014

Title BETTER CARE FUND

Executive Summary

NHS England announced the launch of the Better Care Fund in 2013 to ensure a transformation in integrated health and social care. The total value of Bolton's fund is £12.1m in 2014/15 rising to £20.7m in 2015/16. The Better Care Fund is set in the context of the Health and Wellbeing Strategy. The following schemes are well underway: Integrated Neighbourhood Teams, Intermediate Step up and step down care, Complex Lifestyles Service, Care Coordination Centre, Staying Well, Information Technology and Primary Care. The establishment of the Fund will challenge the Trust to develop a strategic response to the proposed integration of health and care.


Discuss X Receive Approve Note For Information Confidential y/n N


Strategy X Legal Implications Performance and Quality X Regulatory Financial Implications X Stakeholder implications X Workforce X Risk

Prepared by

Mark Wilkinson Director of Strategic and Organisational Development

Presented by Jackie Bene Chief Executive

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BETTER CARE FUND 1. PURPOSE

The purpose of this paper is to brief the Board on the Better Care Fund and set out some of the strategic implications for the Trust. 2. BACKGROUND

NHS England announced the launch of the Better Care Fund in the 2013 spending round, to ensure a transformation in integrated health and social care. It was described as one of the most ambitious ever programmes across the NHS and Local Government in creating a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their well-being as the focus of health and care services.

Attached to this paper is a summary of Bolton’s Better Care Fund as submitted to NHS England at the end of September 2014. 3. CURRENT POSITION

The total value of Bolton's fund is £12.1m in 2014/15 rising to £20.7m in 2015/16. The Fund is designed to deliver integrated health and social care services for the adult population of Bolton. The Health and Wellbeing Board have recently submitted the latest iteration of the Better Care Fund to NHS England, and this Trust is a signatory to that submission. 4. STRATEGIC CONTEXT FOR THE BETTER CARE FUND

Bolton’s JSNA1 describes the health and wellbeing needs of local people and provides the key evidence for the commissioning of services to address and improve the populations’ health. Bolton’s Health & Wellbeing Strategy 2013-2016, is a three year plan setting out the key priorities to support Bolton people to live longer, healthier lives and address the health inequalities which exist within the Borough with specific focus on the key issues identified by the JNSA. These include; an increasing elderly population (with dementia & frailty), respiratory disease, cardiac disease, alcohol misuse and mental health issues. The approach of the Bolton Health & Wellbeing Strategy2 is to transform the current position of reactive care over time to proactive care to prevent hospital admissions and long term admissions to residential/nursing care through individual person-centred care planning. We aim to achieve this paradigm shift through investing in prevention and earlier intervention, reducing demand for hospitalisation and more complex care, further enabling reinvestment. This is demonstrated in the diagram below:

1 http://www.boltonshealthmatters.org/sites/default/files/JSNA%2020 13%20Executive%20Summary.pdf 2 http://www.boltonshealthmatters.org/sites/default/files/Health%20a

nd%20wellbeing%20strategy%202013-2016.pdf

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The NHS is facing an unprecedented financial challenge and this means that:-

• Bolton CCG has to identify savings of £24m over the next 5 years to ensure that the commissioning plans can be delivered.

• Bolton FT has to find efficiency savings of £73m over the next 5 years. In addition the CCG is planning to reduce the annual amount spent on hospital based care by £11.4m and make reinvestments in community and primary care. This means that the FT needs to downsize its activities on the hospital site.

• Greater Manchester West FT has to find efficiency savings of £27.6m over the next 5 years. The

CCG is planning to make further investments in mental health which may have an impact on GMW.

Local authorities are also facing budget reductions - Bolton council has to make savings of £59m over the next 3 years.

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IMPLICATIONS AND OPPORTUNITIES FOR THE TRUST

The Better Care Fund has been established from a mix of some existing CCG and local authority budgets and additional investment from the CCG’s general budgetary allocation. There has been no new money to create the Fund, so funding now earmarked for the Fund would otherwise have been available to allocate to the other CCG priorities.

As with any pooled budget new and shared priorities will start to emerge for example, and in line with national guidance Bolton’s Better Care Fund earmarks £745k to respond to the financial implications of the Care Bill. National guidance on the Fund requires that it be established at a certain minimum financial value. For Bolton in 2015/16 that figure is £20m. It is at the discretion of the local organisations as to whether they wish to place more of their financial allocations into the Better Care Fund and operate it as a pooled CCG and Council budget. Bolton’s Better Care Fund meets the minimum requirement, and as such is it may almost be seen as a distraction from the big prize of influencing the combined public sector commissioning resource across the town which approaches c £750m. In other parts of the country this joint commissioning has been embraced more enthusiastically; Sheffield, Sunderland, and Salford all plan pooled budgets in excess of £100m3 The Fund, particularly if it grows in financial value over the next few years, will lead to a blurring of health and care and the hitherto relatively strict delineation between the two. Major political parties are keen to see much closer working between health and care organisations. It is therefore important that the Trust responds to this changing climate and considers for example how our services might become more integrated with those of the local authority and how that might improve health and care for Bolton people. There is an opportunity for the Trust will to respond explicitly to the Council’s priorities and therefore position itself well in this changing environment. The Better Care Fund brings with it a new performance management metric with a financial incentive i.e. reduction in non-elective admissions. Part of the investment the CCG is required to make in the Fund (c£1.6m) is conditional upon a reduction in non elective admissions. Should this reduction not be delivered the CCG would retain these funds – this would give them the funds to pay for the activity in providers such as this Trust. The Health and Wellbeing Board was established as part of the 2012 Health and Social Care Act reforms and brings together key local partners to improve health and well being across the Borough. The Trust has the advantage of being a full member of the Board – providers aren’t full members of all Boards - and the opportunity to become an influential partner. 5. CONCLUSION

The Better Care Fund is significant, not in its current monetary value which is modest in overall budgetary terms, but in the signal about the increasing integration of health and care and the opportunities and challenges this presents to the Trust. 6. RECOMMENDATIONS

It is therefore recommended that the Executive Directors:

i. Note the report and consider the implications for the Trust ii. Support the development of a strategic response which sees the Trust becoming a more

actively engaged partner in the Bolton health and care system

3 http://www.hsj.co.uk/news/four-in-10-areas-to-pool-extra-health-and-care-cash/5069815.article 4

SUMMARY OF BOLTON’S BETTER CARE FUND CASE FOR CHANGE The Bolton Programme for Integrated Care is set within the context of a wider review of Health and Social Care in Greater Manchester aimed at improving outcomes, at a lower cost. Specifically this involves Greater Manchester major strategic change programmes as well as locally agreed programmes. A set of consistent community based care standards have been agreed across Greater Manchester to set the expectation for the level of service required to support the overall transformation. The Bolton Vision partnership of private, public, voluntary and faith organisations has a strong track record of working together to improve the quality of life of our Bolton family. For a number of years the partnership has pursued twin aims of promoting prosperity and narrowing the gap around key outcome areas. Some of the successes of this strategy include an increase of 1 year in average life expectancy to 77.8 years, (the highest it has ever been) and a reduction in the life expectancy gap across Bolton from 15.2 years to 11.9 years. The borough has also seen improvement in educational achievement, and a reduction in crime and anti-social behaviour. Recent commitment from private businesses to invest in Bolton town centre will positively impact on regeneration. The Bolton Health and Wellbeing Strategy takes a life-course approach and for each of those life-courses we have set our goals for:

• Helping people to stay well • Identifying and dealing with problems early • Ensuring the best quality care and experience for those with health and/or social

care needs • Making sure we better address the needs of the most vulnerable

The Vision Partnership and the Health and Wellbeing Board see working together to deliver integrated health and social care services as an essential enabler of these aims. Health and Social Care Integration is a standing item on the agenda for the Health and Wellbeing Board, where partners are updated on progress and given the opportunity to discuss developments. As the population of Bolton grows older, the health and social care system in the Borough is under increasing pressure from a combination of reduced resources and increasing demand for services. It is becoming increasingly clear that current models of service provision are rapidly becoming unsustainable. The population of Bolton is expected to grow by 3.8% over the next 5 years (to 2018/19). The number of people aged 65 and over in Bolton is expected to grow by 9.6% over the same period, from 46,000 to 50,000. We have applied population growth projections to 2013/14 secondary care activity (stratifying the activity using 5 year age bands) to calculate the amount of additional activity we expect to see for Bolton patients in a “do nothing” scenario. We have predicted that, due to demographic growth alone, there will be an additional 3,983 A&E attendances, 1,938 non-elective admissions, 2,085 elective and day case admissions, 4,486 first outpatient attendances and 11,555 follow up outpatient attendances over the next 5 years.

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Community services in Bolton are an asset and have the potential to form the building blocks from which a truly integrated system can be developed. General Practitioners and their teams are both providers and commissioners of health care in Bolton. General Practices have a track record in implementing population in health programmes delivered at pace and scale built upon year on year since the Big Bolton Health Check. Outcomes include increases in the diagnosis and evidence-based care of the people with long term conditions such as heart disease and diabetes in primary care. Resulting reductions in admissions to hospital and reductions in mortality have been achieved. Between 2009/10 and 2013/14 there was a 4.7% decrease in the number of heart disease non-elective admissions and a 15% decrease in the number of diabetes non-elective admissions. UK and international evidence suggests that integrating care can deliver better outcomes, improve individual experience and support cost containment, and that significant improvements can be made through a dual focus on redesigning services and supporting people to self-care (building on the assets around them). System level integrated care addresses the fragmentation of care, shifts the focus away from individual organisations and can provide powerful incentives to focus on prevention, self-care and cost reduction at a neighbourhood level.

MODEL OF INTEGRATED CARE To deliver the new system the health & social care partners across Bolton are designing a new model of integrated care which is detailed below. The aims of the Bolton Integrated Care Model are to deliver integrated health and social care services for the adult population of Bolton (230,000 adults registered with a Bolton GP).

• Aim to keep patients well physically and mentally and independent and in their own homes (recognising the importance of family and community in promoting wellbeing).

• Provide a good health and social care experience for patients and their families and result in better outcomes.

• Meet the challenges of rising need for health and social care services within dwindling resources.

• Are centred on the needs of the individual.

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The Bolton model for integrated health and social care is designed around the needs of populations of 20,000 to 30,000 people built from clusters of GP practices. This results in 10 clusters and each population cluster has been “risk stratified”. A multi-disciplinary health and social care team will serve each population cluster. District Nursing teams have already been aligned to the 10 clusters and currently work from 10 health centre bases. Therapists currently work from 3 ‘zones’ across the borough of Bolton, whilst the Social Care Teams work from 2 bases covering the North and South of Bolton. A phased implementation of the service commenced in early 2014 and enabled the Integrated Care model to be tested across a specific area of Bolton. The model is being continually evaluated and any necessary changes made so that the most effective model can be in place across the borough from April 2015. The model is centred on an Integrated Neighbourhood Team MDT and includes: the GP, practice nurse, district nurse, physiotherapist, OT, pharmacist, social worker and community psychiatric nurses.

LIST OF PLANNED BETTER CARE FUND SCHEMES

• Integrated Neighbourhood Teams • Intermediate Step up and step down care • Complex Lifestyles Service • Care Coordination Centre • Staying Well • Information Technology • Primary Care

These are described in detail in Appendix 1 BETTER CARE FUND RISKS The following risks have been identified to our Better Care Fund plans. In priority order:

• Workforce culture - Pressure on teams/ staff who are required to work differently and under new management structures and workforce culture could impact on performance and service delivery

• Contingency Planning - There is risk that non elective admissions will not be reduced and

financial savings from integration not be delivered. This presents a risk to the overall delivery of CCG QIPP savings.

• Financial Context and benefit realisation - Partner organisations are working against financial

constraints and a requirement to make cost savings. Financial allocations are only confirmed for one year ahead. Stakeholders fail to agree benefit apportionment and share of risk.

• Data Sharing - The current legislative framework does not allow certain types of data to be

shared between health and social care organisations. Integrated services rely on the ability to share patient information.

• Workforce – failure to ensure the correct skill mix and development of staff to support new model

of care and service delivery.

• Implementation – Integration programme is based on a number of interrelated work streams for MDT care planning and delivery, service response and supporting infrastructure. Coordination of and timeliness of each component presents risks to implementation.

• Community Services Redesign - The CCG and acute trust are working on a redesign

programme for Community Services. Community Services are a key element for the health and social care integration agenda. The outcome of the service review could affect the integration programme and its ability to access an appropriate level of capacity to deliver MDT planning and service response.

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NATIONAL CONDITIONS NHS England required certain statements in Better Care Fund submissions. These mandatory requirements and our responses to them is set out in the table below:

Condition Our Response Outline your agreed local definition of protecting adult social care services (not spending)

Adult Social Care Services will be protected where they contribute to the desired outcomes, provide good outcomes for service users, and would otherwise be reduced due to budget pressures in local authorities. The Local Authority will maintain its eligibility criteria at substantial until replaced by the level mandated under the Care Act 2014.

Specify the level of resource that will be dedicated to carer-specific support

Submission includes £650,000 for support to Carers. This includes the provision of funding to a number of carer focussed third sector organisations and a contribution to costs incurred in providing respite services.

Describe your agreed local plans for implementing seven day services in health and social care

Bolton already has seven day services in place across health and social care to support people being discharged from hospital and to prevent unnecessary admissions and there has always been a joint commitment in Bolton to ensure seven day access to Intermediate Tier services. These services include, a step up Rapid Response service, Intermediate Care at Home service, Intermediate Care beds and Home Support Reablement.

There are also seven day social work services in place which ensure seven day social work assessment support to A&E and other assessment areas in the acute trust.

There is a recognition locally that although Bolton has good seven day services in place these services are fragmented across health and social care and there is a joint local commitment to integrate what Bolton has in place already in order to reduce duplication and ensure services are seamless but also to enhance what is in place now by increasing the level of community based support to ensure more people are able to have their needs addressed at home preferably by avoiding an admission in the first place or by supporting a timely discharge.

Set out the plans you have in place for using the NHS Number as the primary

Bolton’s partners are using the NHS Number as the primary identifier for

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identifier for correspondence across all health and care services

correspondence across all health and care services to which it delivers an integrated health and social care service. Documents and assessment templates have been changed to reflect this. The NHS number will be collected and used for all new service users. Work has progressed over the past 5 months and there are now approximately 70% of records that contain the NHS number as the unique identifier. The remaining 30% are problematic and not easy to match, however a process is being developed between the Local Authority and the CCG to increase the uptake as much as possible.

Describe how patients, service users and the public have been involved in the development of this plan to date and will be involved in the future.

In April 2014 over 150 patients from across Bolton came together for a one day event structured around ‘Changing our NHS’. One of the main discussion topics was Integrated Care in Bolton. Participants had the opportunity to take part in a number of interactive exercises and discussions. Pre consultation on the Healthier Together programme began in Bolton in January 2013, consisting of public meetings (with over 120 members of the public in attendance), presentations to voluntary sector organisations, and involvement of the local Healthwatch.

Structured interviews and satisfaction surveys were gathered during the pilot phase of the Staying Well project and results have been used to inform service developments. The communications strategy ensures there is a framework to support clear and consistent communication. A quarterly bulletin “Bolton Scene” is sent to every household in Bolton and contains an in depth update on our Integration Plans.

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Appendix 1 – Detailed Scheme Description

Scheme name Integrated Neighbourhood Teams What is the strategic objective of this scheme? The strategic objective is closer Integration of Health and Social Care to provide a focus on prevention, self-care and cost reduction at a neighbourhood level. The main objectives are to:

• Keep people well and independent at home • Provide good experience of care and ensure better outcomes • Meet the twin challenges of rising demand and reducing resource base • Provide care tailored to the needs of the individual.

Overview of the scheme

Existing teams will be redesigned to take on the new and existing work identified from the risk stratified population and the GP practice over 75s register. The borough has been patched into 5 neighbourhoods and the teams will be aligned to GP practices in each neighbourhood. Each practice will have dedicated support from a clinical facilitator who will be a member of the Integrated Neighbourhood Teams and will be the link between the GP and the team. A systematic approach will be used to work through the risk stratified population and the over 75s list to take a proactive approach to case finding and to undertake a comprehensive multidisciplinary assessment, hold MDT meetings where required and develop personalised care plans. There will be a primary focus on self-management and personalised care plans will include specialised admission avoidance plans. The teams will have close links with other integrated services such as intermediate tier, staying well and the complex and challenging lives service. The team will also work with people who have not been risk stratified or defined as elderly who the GP is concerned about. These referrals will be made to the team by the GP. The team do not provide a crisis response service but are closely aligned to a 24/7 admissions avoidance service which forms part of the menu of services offered in the intermediate tier. Existing teams will be redesigned to take on the new work associated with the risk stratified population. Five hubs will be created, based in close proximity to the GP Practice sites identified as being in the first phase. A systematic approach will be used to work through the risk stratified population to undertake comprehensive MDT assessment, MDT meetings where required and the development of personalised care plans.

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Scheme name Intermediate Tier Services What is the strategic objective of this scheme? Bolton will invest in Intermediate Tier Services in order that we promote well-being and prevent, reduce and delay the need for long term health and care services within our population. Our goal is that people should receive adequate rehabilitation and reablement when needed, to prevent permanent disability; greater reliance on care and support, avoidable admission to hospital or care homes and delayed discharge. A key aim is for people to be able to re-engage in the community following a period of intermediate care. All these services will operate 7 days per week in order to meet the 7 day requirement to support discharge. Overview of the scheme

The following services will be commissioned as part of our Better Care Fund Plans: Admission Avoidance Service – Community and Hospital Based, additional home-based Intermediate Care, and 7 day hospital discharge

Bolton will not be investing in Intermediate Care Bed Services or Reablement Services further as we have recently carried out a whole system reconfiguration that saw over £1.5million invested into these services. Admission Avoidance Services When the health or social situation of a person, especially if they are older, rapidly deteriorates they should have rapid access to care including an effective alternative to hospital. Bolton’s Admission Avoidance Service will provide a rapid intervention in response to a health or social care crisis that will allow a person to be supported and treated at home safely and therefore avoid an unnecessary admission to hospital or residential care. It seeks to maintain and/or help the person regain their maximum independence and to support carers, as a crisis can threaten the stability of care and support arrangements. An integrated admission avoidance team of both health and social care professionals ensures that tailored interventions are offered to people to enhance their quality of life and prevent inappropriate, unplanned admissions. Provision of immediate treatment.

• To provide a multidisciplinary assessment in the patients’ own home to determine the level of support required.

• To allow the patient to be supported in the comfort of their own home during an episode of illness

• Provision of urgent equipment • Rapid access to Intermediate Care at home and Reablement Support, personal care, night

services. • To provide rapid access to Intermediate Care beds if required as an alternative to hospital

admission when the patient cannot be maintained in their own home. • The service will support a wide range of acute and chronic conditions in a crisis. • Access to out of Hours GP support • Access to sessional Geriatrician cover

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Additional Intermediate Care at Home The focus is on a shift from bed based to home care where clinically safe to do so. Intermediate care at home will support individuals to regain their optimum independence and mobility following an episode of ill-health, injury or an exacerbation of a long term condition through personalised care planning and care delivery. Benchmarking and comparison of Bolton’s Intermediate Care at home services with other high function services has identified shortfalls in our provision, especially with regard to the management of medicines and access to medication reviews. We are therefore increasing the following elements. The following establishment will be added to our intermediate care/reablement at home services in order that we are able to deliver a more effective service.

• Advanced Nurse Practitioner - 1.0 WTE • Senior Pharmacist - 1.0 WTE • Pharmacy Technician - 1.74 WTE • AHP (OT or PT) - 3.48 WTE • Reablement Support Worker - 3.52 WTE

The additional investment required = £448,000. Prior to these investments Bolton was implementing a whole system review following identification of a significant over use of beds having 29% more than the national average whilst at the same time having 69% less referrals to Intermediate Care at home and 32% less than the Greater Manchester average for Reablement. Reablement is important as it has been evidenced to deliver 62% of people to the point where they no longer need services compared to 5% of a control group. As a result of this benchmarking and prior to BCF submission Bolton had agreed to release £1m of funding used for underutilised respite and intermediate care beds and invest this in reablement. This will see the numbers of people receiving reablement rise from 1200 per year to over 1800 per year or a rise of 600 episodes.

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Scheme name Complex Lifestyles Service What is the strategic objective of this scheme? To reduce inappropriate and/or unplanned (crisis/emergency) presentations and admissions to health and social care provision for people defined as having complex lifestyles. Overview of the scheme

The Complex Lifestyles programme aims:

• To provide a responsive, coordinated, proactive, individual client specific and focused service to improve outcomes for adults with a sub-set of complex needs in Bolton. This sub-set is defined as individuals presenting with a combination of substance misuse, mental health and deprivation needs who do not currently consistently engage with existing service provision.

• To provide a holistic response to some of the most vulnerable individuals in our communities

and to work flexibly and proactively to engage them in service provision, reducing the likelihood of them being at further risk of harm to themselves and, where applicable, to others.

Currently there is no single agency or service with responsibility for co-ordinating care and facilitating access to services for people with complex lifestyles. A new team of Engagement and Support workers is envisaged across the borough to link with the Integrated Neighbourhood Teams. The aim of the Complex Lifestyles programme is to facilitate behaviour change so that clients with complex lifestyles reduce their presentations to inappropriate services. Additionally the programme seeks to provide intensive support to assist clients in navigating health and social care systems with the aim of enabling access to appropriate services. The Complex Lifestyles model will take a holistic approach to understanding and responding to individual client need whilst fostering increased self-care and reduced dependence on services that are currently unable to respond effectively. The proposed model will focus on those clients defined, within the overall complex needs cohort, as having complex lifestyles. These clients are expected to have a combination of issues/conditions, particularly in relation to:

• Active misuse of drugs and/or alcohol • At risk of self-harm or further self-harm • At risk of harming others • Depression and/or anxiety • Social deprivation (e.g. financial problems, worklessness) • Housing/homelessness

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Scheme name Care Coordination Centre What is the objective of this scheme? The scheme aims to deliver Care Co-ordination via one single point of access to Integrated Health and Social care Services in Bolton. Overview of the scheme

Community referrals will be made through a Care Coordination Centre, where an agreed set of information will be collected about the individual and their circumstances. CCC advisors will provide signposting or referral to the appropriate support services. If a clinical service is indicated e.g. Intermediate Tier, the referral will be clinically triaged by a registered health care practitioner (usually a nurse) to determine the level of response required. The patient cohorts being targeted by the scheme are: adults over the age of 18 who have complex care needs requiring an integrated health and social care provider response. This will include patients nearing the end of life, patients with long term conditions requiring active intervention, the frail elderly and patients with dementia.

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Scheme name Staying Well What is the strategic objective of this scheme? The aim of the Staying Well programme is to enable and increase opportunities for individuals to stay healthy, happy, maintain independent, connected to their communities and to reduce dependence on expensive secondary healthcare and social services. Overview of the scheme

The Staying Well service offer will include three elements: 1. Proactive Staying Well (‘Staying Well’): extension of the original pilot approach to all areas of the

Borough, using the care needs index to risk stratify and target through practice lists and utilising the Staying Well Tool.

2. Reactive Staying Well accessed by people who approach Social Care services through Access Bolton, but aren’t eligible for services such as reablement or intermediate care; using the opportunity of this contact and the Staying Well Check Tool to provide preventative support and offer early, time-limited intervention if appropriate. Offer early, brief intervention to Staying Well clients when longer term service support is not required, reducing or delaying future demand on health and social services.

3. Community Capacity Building: Underpinning the individual Staying Well offer, delivered through the Staying Well service, a specific work stream will stimulate and develop community capacity to support older people’s health and wellbeing. This community capacity building work stream is absolutely essential to fully realise the potential of communities, neighbourhoods and their residents to assist in the delivery of prevention and early intervention, and to address the many inequalities in outcomes for older people across the borough.

The service will be targeted at the following customers:- 1. There are over 44,000 people aged 65 and over in Bolton. Using the Potential Care Need Index

(PCNI) 13,064 people are at risk of developing future health and social care needs have been identified as being eligible for a Staying Well Check. Staying Well will undertake a phased roll out aiming for borough wide coverage by April 2015.

2. The Combined Predictive Model (CPM) is a risk stratification tool which aims to predict the likelihood that a patient will be admitted to hospital in an emergency in the next 12 months. The risk score is a probability score between 0 and 100, where 100 is the highest risk score. A further 11,236 people aged 65 and over score over 20, which means there is a 20% likelihood of them being admitted to hospital in the next 12 months, but fall below the threshold of 50 eligibility for an Integrated Neighbourhood Team response.

3. Social services front door. An estimated number of up to 4000 will be eligible for the Staying Well Check who currently despite approaching social services every year are not subsequently provided a service as they fall below Fair Access to Care Criteria.

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Scheme name Information Technology What is the strategic objective of this scheme? Overview of the scheme

There is currently a wide variety of IT systems in use amongst the key organisations. Within organisations, teams use different systems for different purposes, and in the majority of cases, these systems are not joined up nor have the ability to communicate with each other. However, this presents a very real opportunity to identify improvements and start to define a system that meets the emerging needs of the new health and social care system. Discussions to date give confidence that all organisations recognise the need to have interoperable systems that support and underpin clinicians, clinical pathways and patients. The IT will not drive the process, the process will inform the required IT. There are opportunities emerging in the shape of existing procurements that are already in progress, i.e. the acute trust EPR project. The emerging service requirements will be key to informing the way that new systems are implemented; including new ways of working.

Scheme name Primary Care What is the strategic objective of this scheme? To ensure General Practice is at the centre of the integrated care model and can deliver the required shift in emphasis to more proactive care of high risk patients. Overview of the scheme

This work stream provides the capacity to general practice, at the centre of the integration model General Practice is the major initiating point for integrated care working due to them holding the list of registered patients and identifying those most at risk of hospital admission through the following cohorts:

• 2% highest risk of hospital admission (risk stratification) • >75s with application of frailty index (6-7% of Practice population) • vulnerable patients identified by Practices including complex children • Ad hoc support to patients following recent hospital admissions.

Time for care planning is provided through the National 2% DES and additional CCG Investment. The model of care involves identification and Practice based MDT care planning of patients, with options to:

• manage the patient with greater input from Practice • involve the wider integrated neighbourhood team in management of patient • clinical facilitator led referral onto more specialised services depending on need

Having only developed to date the practice involvement in care planning, this scheme will specify a greater involvement of General Practice capacity in

• detailed review of patients (requiring lengthy appointments and or home visits) • intervention from the primary care team with these patients, whether in terms of medication

review or practice nursing support • MDT discussion/ case conferences with the integrated neighbourhood team

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Committee Chair Report

Name of Committee: Finance & Investment Committee Date of Meeting: 16th October 2014 Report to: Board of Directors Chair: Allan Duckworth Key Issues Discussed 2014/15 Financial Plan Delivery mid-year risk review

Month 6 financial performance including Divisional Financial Management

Framework update Healthier Together Impact Review Procurement KPIs Insurance update High Value Routine Contracts 2014/15 update Risks Identified/Further Assurance There is a significant risk to delivery of the planned surplus but the Executive are confident that the continuity of service rating will be maintained at a 2. There is also a significant risk that the Trust’s recurrent financial position at the end of the year will not be consistent with the delivery of the 2015/16 financial plan. Further assurance is required on the following: 1. Cost control in respect of bank and agency staffing 2. Outcome of a range of contracting issues with Bolton CCG 3. Scale of available cost improvements for 2015/16 Apologies received from: Mark Harrison joined the meeting by telephone for the discussion relating to the 2014/15 Financial Plan delivery mid-year risk review. Date of next meeting Tuesday 18th November at 9.30am in the Boardroom

Committee Chair Report

Name of Committee: Quality Assurance Committee

Date of Meeting: 8th October 2014

Report to: Board of Directors

Chair: David Wakefield

Key Issues Discussed

Due to a number of absentees, the meeting was not quorate. In addition to the normal

reports, the Committee took updates on a number of key areas:

• Quality Strategy

• Uniform Policy

• Staffing Report

• Patient Experience Update

• Complaints Report Patient Experience

The Committee noted the improvement in quality as a result of the initiatives taken and were

pleased with the significant gains in patient experience. It was agreed that the Trust should

concentrate on two mortality ratios to avoid confusion. Two ratios were suggested; SHMI

and crude mortality.

A revised uniform policy was endorsed by the committee and is aimed at clarifying what is

deemed to be acceptable throughout the Trust, including the public areas such as the

restaurant. The policy will now go the Executive Director meeting for final approval.

The Committee welcomed an update on how the 12 hour shifts were working following their

introduction last year. Although staff generally prefer these longer shifts the committee

sought assurances that the concerns expressed by several staff in the survey are being

addressed. The committee also asked that patients’ opinions be incorporated to future

surveys.

The committee were updated on the progress made in the delivery of the Patient Experience

Strategy. To date, improvements have been made in the Trust’s monitoring systems and

seven outcomes have been identified to drive a performance framework. In particular, the

committee welcomed the concept of “Always Events”.

The committee reviewed the annual Complaints report for the second time and, whilst

acknowledging the improvements, felt that it still needed further work. The lack of learning

logs is an area of concern as it impacts the Trust’s ability to become a learning organisation.

In addition, the actions from previous year’s recommendations fail to fully address the areas

highlighted.

For Escalation to the Board: no items identified for escalation to the Board

Date of next meeting – 12th November 2014

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HEALTH AND WELLBEING BOARD

MEETING, 3rd SEPTEMBER, 2014

Representing Bolton Council Councillor Mrs Thomas (Chairman) Councillor Morris (Vice-Chairman) Councillor Bashir-Ismail Councillor Cunliffe Councillor Peacock Councillor Mrs Fairclough Representing Bolton Clinical Commissioning Group Dr W. Bhatiani GP Dr C. Mercer GP Dr C. Mackinnon GP Representing Royal Bolton Hospital Foundation Trust Dr J. Bene – Chief Executive Representing Healthwatch Mr J. Firth - Chairman Representing Voluntary Sector Ms K. Minnitt – Bolton CVS Representing NHS England (GM) Mr A. Harrison Also in Attendance Mr S. Harriss – Chief Executive, Bolton Council Ms W. Meredith – Director of Public Health, Bolton Council Ms M. Asquith – Director of Children’s and Adult Services, Bolton Council

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Mr A. Crook – Assistant Director, Children’s and Adult Services, Bolton Council Mr D. Smith – Head of Finance, Bolton Council Dr L. Vallance – Chief Executive, Bolton Hospice Ms M. Laskey – Associate Director, Bolton CCG Ms T. Morris – Bolton CCG Mrs D. Lythgoe – Policy and Performance, Bolton Council Mrs S. Bailey – Democratic Services, Bolton Council Apologies for absence were submitted on behalf of Ms B. Humphrey, Ms S. Long, Mr A. Stephenson and Councillor Dean.

Councillor Mrs Thomas in the Chair. 10. MINUTES OF PREVIOUS MEETING The minutes of the proceedings of the meeting of the Board held on 16th July, 2014 were submitted and signed as a correct record. 11. FUNDING TRANSFER FROM NHS ENGLAND TO

SOCIAL CARE – 2014/15 The Director of Children’s and Adult Services and the Borough Treasurer submitted a joint report which outlined proposals for the use of NHS England Revenue Funding 2014/15 for the consideration of the Board. By way of background information, the report advised members that in 2014/15, NHS England had received a revenue allocation of £6.371m for expenditure on social care services. The allocation included £5.213m in relation to uplifted monies previously transferred and a further Integration Payment totalling £1.158m to reflect Bolton’s share of the additional £200m funding which had been incorporated into the Better Care Fund for 2014/15 at a national level. The report went on to outline the criteria for release of the £5.213m element of the funding to local authorities which required expenditure to be on social care services which also

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had a health benefit. Agreement must also be obtained from this Board as to how the funding would be utilised. The requirement for release of the £1.158m was a satisfactory Better Care Fund submission which had already been satisfied. In this regard, the report put forward various proposals for use of the monies. Table One to the report outlined various proposed services that the monies could be used to contribute to in their entirety and Table Two outlined services that the funding could be allocated to specifically for the purposes of meeting the NHS England’s national categorisation of spend. In order for the Health England to transfer the funds to the Local Authority, a Section 256 Agreement would need to be in place between Health England and Bolton Council. Annexe B to the report set out an approved Section 256 Agreement totalling £6,371,303m to reflect the total funds to be transferred from NHS England to Bolton Council to be utilised as outlined within the Better Care Fund template and the contents of this report. Resolved – That the £5.213m of funding held by Health England be used as a contribution to the services outlined in Table One of the report for the 2014/15 financial Year and specifically allocated to the services outlined in Table Two for the purposes of meeting the NHS England’s national categorisation of spend. 12. BETTER CARE FUND - STAGE 3 SUBMISSION The Director of Children’s and Adult Services submitted a report which provided an update on Stage 3 of the Better Care Fund and highlighted the differences required from previous submissions. The report advised that new guidance and an updated policy framework had been issued which required Health and Wellbeing Boards to revisit their plans in order to demonstrate clearly how they would reduce total emergency admissions as a clear indicator of the effectiveness of local health and care

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services in working better together to support people’s health and independence in the community. The report summarised the main policy changes and put forward the areas that would be required to be included in the revised plans, as follows:

- the local vision for health and care services; - the case for change; - a plan of action; - strong governance; - protection of social care; and - alignment with acute sector and wider planning

In this regard, the report sought approval for the Chief Executives of the Council and the CCG together with the Chair of the Health and Wellbeing Board to make suitable amendments to the final submission, in line with the new requirements. Resolved – That the Chief Executives of the Council and the CCG together with the Chair of the Health and Wellbeing Board, be given delegated authority to make suitable amendments to the final submission, on the basis outlined in the report now submitted, ahead of the deadline for submission to Government of 19th September, 2014. 13. HEALTH AND SOCIAL CARE INTEGRATION UPDATE The Director of Children’s and Adult Services submitted a report which outlined the latest progress on health and social care integration in Bolton and Greater Manchester using the new format agreed at the previous meeting of the Board. Following consideration of the report, members felt that it would be useful to include a glossary of terms in future reports together with information on workforce capability. Other comments/observations on the report included the following:

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- work was still ongoing to ensure that GP practices were able to fully connect with the integration agenda and to achieve the required objectives;

- there was a need to fully understand and scrutinise the integration objectives and key performance indicators would be critical in ultimately determining whether integration had been successful in achieving its aims; and

- gathering feedback and measuring the views of service users/patients using a variety of methods would be important for the Board in terms of identifying how successful integration had been.

Resolved – That the report be noted. 14. DIRECTOR OF PUBLIC HEALTH’S ANNUAL REPORT

2013 The Director of Public Health submitted her 2013 Annual Report for the consideration and comment of members. The Board was reminded that the Director of Public Health was required to report annually on the health of the local population. The report identified and communicated the key health priorities for the Bolton population and approaches to improving health across the Borough. Ms Meredith gave a presentation to supplement the report and circulated a copy of the Annual Report. Resolved – (i) That the report be noted and that updates on delivery of the objectives contained within the Annual Report be submitted to the Board via the Health and Wellbeing Performance Management reports. (ii) That Ms Meredith be thanked for her informative presentation.

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15. HEALTH AND WELLBEING STRATEGY – END OF LIFE CHAPTER – PERFORMANCE REPORT – QUARTER 2

The Director of Public Health submitted a report which updated the Board on the performance of the Health and Wellbeing Strategy as it related to the End of Life chapter. The report provided details in relation to each priority with some further commentary on the outcomes and an outline of the actions. Resolved – That the report be noted. 16. BOLTON CCG PROGRESS TOWARDS END OF LIFE

PRIORITIES A report of the Chief Officer, Bolton CCG, was submitted which outlined the progress being made towards the priorities in the End of Life chapter of the Health and Wellbeing Strategy. The report outlined the excellent work ongoing in Bolton regarding End of Life care and good partnership working to deliver general and specialist palliative End of Life Care services to patients and their carers. Good training and education programmes were in place across health and social care which included training for the staff working in care homes across the Borough. Bolton’s Strategy for End of Life care was currently being developed and a number of key areas of work to date had been identified. These included:

- bereavement support; - identification of people with End of Life care needs; - review of the Liverpool Care pathway; - integration; and - the development of an Electronic Patient Care

Coordination System.

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Resolved – That the report be noted. 17. BEREAVEMENT SERVICES – BOLTON HOSPICE Dr Leigh Vallance, Chief Executive, Bolton Hospice gave a presentation which focused on bereavement and ways in which the impact of bereavement on the health and wellbeing of the local population and the local economy could be minimised. The presentation highlighted the following issues:

- reactions to grief; - how grief impacts on health and wellbeing; - steps to improve support in bereavement; - work ongoing at the Hospice in terms of pre-bereavement

and bereavement support; and - training and education for those assisting people who had

suffered bereavement. Various recommendations for future developments were also identified, as follows:

- map current provision; - identify gaps and plot projected growth; - identify priority areas; - commission services accordingly; - coordinate access and delivery; - reduce the negative impact of bereavement on

individuals, services and the economy; - develop a plan that recognised the significance of

bereavement and take action to reduce its impact by investing in prevention.

Following the presentation, members made a number of comments, as follows:

- it was felt that the area of sudden death needed to be addressed;

- the different ways in which individual communities dealt with death;

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- the links between bereavement and the Children’s Strategy; and

- the ongoing work being undertaken by the CCG in developing the End of Life Care Strategy with the inclusion of bereavement as one of its chapters.

Resolved – That Dr Vallance be thanked for her informative presentation. 14. NHS BOLTON CLINICAL COMMISSIONING GROUP

BOARD UPDATE – MINUTES OF MEETINGS The minutes of the proceedings of the meetings of the Clinical Commissioning Group Board held on 27th June and 25th July, 2014 were submitted for information. Resolved – That the minutes be noted. 15. GREATER MANCHESTER HEALTH AND WELLBEING

BOARD – MINUTES OF MEETING The minutes of the proceedings of the meeting of the Greater Manchester Health and Wellbeing Board held on 9th May, 2014 were submitted for information. Resolved – That the minutes be noted. 16. MONITORING REPORT The Chief Executive submitted a report which monitored the progress of decisions taken at previous meetings of the Board. Resolved – That the monitoring report be noted. 17. HEALTH AND WELLBEING BOARD FORWARD PLAN

2014/15 The Chief Executive submitted a draft Forward Plan which had been formulated to guide the work of the Health and Wellbeing Board over the forthcoming year.

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Members raised the following item for possible inclusion on the Work Programme, as follows: - the involvement of the ambulance service in delivery

integration. Resolved – That the Forward Plan, as now submitted, be approved. (The meeting started at 2.00pm and finished at 3.10pm)

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