council of governors meeting · 2017-01-27 · draft. pg/bb . january 2017 . dear colleague . a...

DRAFTCouncil of Governors

Meeting

Thursday, 2 February 2017

Eaglescliffe Golf Club

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PG/BB January 2017 Dear Colleague A meeting of the Council of Governors will be held on Thursday, 2 February 2017 at 10.00am at Eaglescliffe Golf Club, Yarm Road, Eaglescliffe, Stockton on Tees, TS16 0DQ. Refreshments will be served from 9.30am. Free car parking is available. Yours sincerely

Paul Garvin Chairman

Agenda (1) 9.30am Refreshments (2) 10.00am Welcome Chairman (3) 10.00am Apologies for Absence Chairman (4) 10.00am Declaration of Interests (5) 10.05am Minutes of the last meeting held on 24 November 2016 (enclosed) Chairman (6) 10.10am Matters Arising Chairman (7) 10.15am Chairman’s Report and Board Business (BoD agenda 30.03.2017 enclosed) Chairman (8) 10.30am Chief Executive’s Report (enclosed) Alan Foster (9) 10:50am Outcome of Governor Elections 2016 (enclosed) Barbara Bright (10) 11.00am Register of Interests (enclosed) Barbara Bright 11.05am Comfort Break (11) 11.15am Integrated Performance Report (enclosed) Julie Gillon (12) 11.45am Council of Governors Sub-committee Membership Review Barbara Bright (enclosed)

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(13) 11.50am Sub-Committee Minutes (enclosed) (13.1) Membership Strategy Committee Minutes Wendy Gill – 21 November 2016 (13.2) Strategy and Service Development Committee Minutes Steven Yull – 19 December 2016 (14) 12.00noon Any Other Notified Business Chairman Date and Time of Next Meeting The next meeting is scheduled to take place on Thursday, 11 May 2017 at The Centre for Excellence in Teaching and Learning, Brierton Lane, Hartlepool, TS25 4BY

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Governors Roles and Responsibilities Holding the Board of Directors to Account

1. Key Principles

1.1 The overall responsibility for running an NHS Foundation Trust lies with

the Board of Directors. 1.2 The Council of Governors is the collective body through which the

directors explain and justify their actions. 1.3 Governors must act in the interests of the NHS Foundation Trust and

should adhere to its values and Code of Conduct.

2. Standard Methods for Governors to Provide Scrutiny and Assistance

2.1 Receiving the Annual Report and Accounts. 2.2 Receiving the Quality Report and Account. 2.3 Receiving in-year information updates from the Board of Directors. 2.4 Receiving performance appraisal information for the Chair and other Non-

executive Directors. 2.5 Inviting the Chief Executive or other Executive and Non-executive

Directors to attend the Council of Governors meetings as appropriate.

3. Further Methods Available for Governors

3.1 Engagement with the Board of Directors to share concerns. 3.2 Employment of statutory duties. 3.3 Dialogue with Monitor via the lead Governor (if necessary and only in

extreme circumstances)

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Glossary of Terms

Strategic Aims and Objectives

Strategic Aims

Putting Patients First – to create a patient centred organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery.

Integrated Care Pathways – to develop and expand the portfolio of services to provide integrated care pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare.

Service Transformation – to improve and grow our healthcare services to continually review the needs of our healthcare community and transform services. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes.

Manage our Relationships – to ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

Maintain Compliance and Performance – to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

Health and Wellbeing – to embrace the health and well being of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the commissioning of services from the Trust.

Strategic Objectives Maintain Compliance and Performance – assurance around compliance with standards, performance indicators and requirements within the Terms of Authorisation. Requirement to provide Board regulation and self certification on a quarterly and annual basis in accordance with Monitors Terms of Authorisation. Seasonal Pressures – requirement to ensure preparedness for seasonal winter pressures. Reduce Hospital Acquired Infections – supports the Trust’s key strategic theme of; Maintain Compliance and Performance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of the Trust business. Effective Board Governance – corporate oversight and scrutiny will continue to be provided by key management structures; 1. Board of Directors, 2. Executive Team, 3. Trust Directors Group. Training – ensuring the workforce is appropriately trained.

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Workforce – absence management, ensuring we have adequate staffing levels that provide safe and effective care to our patients. Momentum – Pathways to Healthcare – delivery of a new healthcare system for the people of Easington, Hartlepool, Sedgefield and Stockton. Putting Patients First / Patient Safety – to create a patient-centred organisation by engaging and enabling staff to add value to the patient experience, demonstrated through patient safety, service quality and LEAN delivery. Finance – to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

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North Tees and Hartlepool NHS Foundation Trust

Minutes of the Council of Governors’ Meeting

held on Thursday, 24 November 2016 at Eaglescliffe Golf Club

Present: Paul Garvin, Chairman Hartlepool Elected Governors: Easington Elected Governors: Pauline Robson Mary King Alan Smith Maureen Rogers Sedgefield Elected Governor: Wendy Gill Stockton Elected Governors: James Newton Staff Elected Governors: Mary Morgan Carol Alexander Kate Wilson Manuf Kassem Janet Atkins Matt Wynne Tony Horrocks Steven Yull Val Scollen Ann Cains Partnership Governors: Margaret Docherty Angela Warnes, Teesside University Jim Beall, Stockton-on-Tees Borough Council Non-Core Elected Governor: Alison McDonough In attendance: Julie Gillon, Chief Operating Officer/Deputy Chief Executive Caroline Trevena, Director of Finance Deepak Dwarakanath, Medical Director Ann Burrell, Director of Human Resources and Education Julie Lane, Director of Nursing, Patient Safety and Quality Graham Evans, Chief Information and Technology Officer Peter Mitchell, Director of Estates and Facilities Rita Taylor, Non-Executive Director/Senior Independent Director Steve Hall, Non-Executive Director Kevin Robinson, Non-Executive Director Barbara Bright, Company Secretary Raechel George, Freedom of Information Lead

CoG/687 Welcome The Chairman welcomed members to the meeting. CoG/688 Apologies for Absence Apologies for Absence were reported from: Alan Foster, Chief Executive, Brian Dinsdale, Non-Executive Director, Jonathan Erskine, Non-Executive Director, John Edwards, Elected Governor for Stockton, Pat Upton, Elected Governor for Stockton, Mark White, Elected Governor for Stockton, Tom Sant, Elected Governor for Hartlepool, Roger Campbell, Elected Governor for Hartlepool, George Lee, Elected Governor for Hartlepool, Deborah Gardener, Elected Staff Governor, Gary Wright, Elected Staff Governor, Simon Forrest, Appointed Governor for Durham University, Morris Nicholls, Appointed Governor for Durham County Council and Dave Hunter, Appointed Governor for Hartlepool Borough Council.

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CoG/689 Declaration of Interest There were no declarations of interest received on open agenda items. CoG/690 Minutes of the last meeting held on 29 September 2016 The minutes of the last meeting were signed by the Chairman as a true record. CoG/691 Matters arising There were no matters arising. CoG/692 Chairman’s Report and Board Business

a. Consultants Appointments The Chairman reported that an offer of employment had been made to appoint a Consultant Neonatologist and that the Trust were awaiting confirmation of him accepting the post.

b. Annual General Meeting 2016 The Chairman placed on record his thanks to Governors and members of the Board of Directors who attended the Trust’s Annual General Meeting on Wednesday, 5 October 2016. The meeting and presentations provided a comprehensive overview of the work the Trust had done over the past year and its plans for the current year.

c. Meetings The Chairman reported that he had met with Foundation Trust Chairs on 13 October 2016 where most of the discussion was around Sustainability and Transformation Plans (STP). Some of the Chairs felt excluded or unaware of progress but he highlighted that the Trust were fortunate in that Chief Executive and STP Lead for the footprint, Alan Foster kept the Board of Directors and Council of Governors up-to-date.

d. Collaborative Working The Chairman reported that he and the Chief Executive had met with the Chairs and Chief Executives of South Tees Hospitals and County Durham and Darlington NHS Foundation Trusts on 17 October 2016 with a view to establishing a Committee in Common which would fully engage in the STP process and allow the Trusts to make some decisions together. The Committee in Common had no legal basis but would provide a forum for discussion and agreement on key areas which needed to be achieved. The Chairman reported that any decisions taken in respect to the STP would need to be based on robust evidence and be clinically focussed and led. He confirmed that the work that the Chief Executive was leading on was ahead in its thinking and planning, however, delivery would be challenging and difficult. A number of questions were posed by members and discussion ensued in respect to future configuration of hospitals and services; decision making criteria; and public information, engagement and consultation. Jim Beall, Appointed Governor for Stockton-on-Tees Borough Council reported that a network had been established of the five Tees Valley Health and Wellbeing Boards in order to ensure a joined up approach to STP, with an invite to join the group going to North Yorkshire and Durham and also the Chief Executive as the STP lead.

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The Chairman confirmed that a Governor development session would be held on 5 December 2016 where the Chief Executive would present and provide further detail around the STP.

e. PricewaterhouseCoopers event The Chairman reported that he had attended an event hosted by PricewaterhouseCoopers (PwC) on 17 November 2016, which included a number of keynote speakers. A presentation was given by Alan Milburn, former Secretary of State who was undertaking work with PwC on behalf of the Department of Health, on proposals for the development of health and social care.

f. National Institute for Health Research The Chairman reported that the Trust had achieved the criteria for continuous improvement in relation to the return rate on research improving from 39% to 79% in 6 months and as a result, had been recognised for an award by the National Institute for Health Research,

g. Visit of Mayor of Stockton The Chairman reported that he, the Medical Director and Professor Matt Rutter, Consultant Gastroenterologist had accompanied the Mayor of Stockton on a visit to the Bowel Screening department on 23 November 2016. As part of the charitable work of his year in office, the Mayor was supporting this important area of screening by raising funds and public awareness. Jim Beall, Appointed Governor for Stockton-on-Tees Borough Council confirmed that joined up working and public awareness was required in this area of screening and advised that support could be provided through public health and partnership meetings.

h. Board of Directors Meeting

A copy of the agenda for the Board of Directors Meeting on Thursday, 1 December 2016 had been circulated and Governors were welcome to attend.

Resolved: that, the information be noted. CoG/693 Deputy Chief Executive’s Report

a. Sustainability and Transformation Plan (STP) The DCE/COO referred to the information in the report and previous discussions in respect of the development of the STP for the Durham, Darlington, Tees, Hambleton, Richmondshire and Whitby (DDTHRW) footprint.

b. NHS Operational Planning and Contracting Guidance 2017/2019 The Chief Operating Officer/Deputy Chief Executive reported that NHS England and NHS Improvement had jointly published Operational Planning and Contracting Guidance three months earlier than anticipated to assist local organisations to plan more strategically. For the first time, the Planning Guidance covered two financial years, to provide greater stability and to support transformation. This was underpinned by a two-year tariff and two-year NHS Standard Contract with the objective to provide local NHS organisations with an update on the national priorities for 2017/18 and 2018/19, as well as updating on longer term financial challenges for local systems. The nine ‘must-do’ priorities published in 2016/17 remained the priorities for the next two years and the planning process had been built around STPs. The Chief Operating Officer/Deputy Chief Executive reported that an initial draft of the plan required submission on 24 November 2016, with the final submission by 23 December 2016.

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c. NHS Improvement Event 4 November 2016 – Relentless Delivery and Making Change

Happen The Chief Operating Officer/Deputy Chief Executive reported that she, the Chairman and the Chief Executive had attended an event led by NHS Improvement on 4 November 2016. This reflected on quarters 1 and 2 and looked at key deliverables in the forthcoming months. The Chief Operating Officer/Deputy Chief Executive highlighted the challenges around delivery, which centred the discussion at the event.

d. Hartlepool and Stockton Health (HaSH) – GP Federation Business Plan Launch The Chief Operating Officer/Deputy Chief Executive reported that Hartlepool and Stockton Health (HaSH) (GP federation) had launched its business plan, in addition to providing an opportunity to discuss a response to the Hartlepool Matters! Shaping the Future of Health and Social Care in Hartlepool report produced by Professor David Colin-Thomé, Independent Chair. The Hartlepool Matters! report was opened up for public review on the evening of 26 September 2016 and was considered by the Health and Wellbeing Board, the Clinical Commissioning Group (CCG) and the full Hartlepool Borough Council during October 2016. It was agreed that the Council would formulate an action plan in partnership with the CCG and an implementation group would be created to oversee delivery of the plan. The discussion and debate, with regard to the Hartlepool Matters! report, although extensive, would require further consideration as to a response and as to the collective responsibility of the approach in the wider Federation. The Trust continued to work in close collaboration with the Directors of HaSH with positive outcomes around planning for the needs and challenges of the population it served and in keeping with the strategic approach of the Board of Directors, in the wider context of the STP.

Resolved: that, the information be noted. CoG/694 Integrated Performance Report The Chief Operating Officer/Deputy Chief Executive presented the Integrated Performance Report incorporating key compliance, sustainability and transformation planning, quality, workforce and financial information for September 2016 and quarter 2. The A&E 4 hour standard saw an improved position in September and quarter 2, achieving 95.06% and 95.64% respectively, which had continued in October reporting at 96.36%. In respect of the incomplete referral to treatment pathway standard, the Trust remained above the national position at 92.39% for September and 92.59% for quarter 2. The October position showed further improvement reporting at above 93%, which was testament to the progress and improvements with information flows and Trakcare.

All of the cancer standards had been achieved with the exception of the cancer 62 day referral to treatment standard for September and quarter 2, achieving 83.19% and 83.14% respectively. The position for October was greatly improved with the Trust reporting at over 90% and the Chief Operating Officer/Deputy Chief Executive noted that there had been a rise in numbers converting to cancer with 58 in comparison to 48 for the same period last year. The Trust had achieved the 6 week diagnostic standard at 99.57% for quarter 2 and had been successful in a bid for funding that would support improvements in activities such as pre-assessment and endoscopy, waiting times, with additional work on-going to improve access to patient information and GP liaison.

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The latest position indicated that the Trust was performing well within benchmarks against a number of operational efficiency standards, including outpatient new and review ratios, length of stay and pre-op stays. Outpatient did not attend (DNA) were still a challenge to the Trust and were reporting above the internal standard for both new and review appointments, though a downward trend was noted. Bed occupancy rates continued to report above the national recommendation of 82%, indicative of continued pressures within the organisation and across the system. The Safety and Quality Dashboard, was presented as part of the integrated report which is aligned to the Care Quality Commission’s (CQC) five domains: Safe, Caring, Effective, Responsive and Well-Led and brings together all of the key indicators and trend analysis. The Trust had exceeded its annual trajectory of 13 cases for Clostridium Difficile with 19 cases between April and September 2016. One case of MRSA had also been reported. The overall ‘would recommend’ the Trust friends and family responses had increased to 95.47% in September from 94.88% in August. The latest HSMR value was 105.58 (August 2015 to July 2016), which had shown a slight increase from 104.82 (July 2015 to June 2016), though remained within the ‘as expected range’. The SHMI position had continued to reduce from 117.31 to 113.19 (April 2015 to March 2016). The Registered Nursing/Midwife fill rates had decreased to 79.11% from 79.50%, however, it was noted that this remained above the 75% expected fill rate to maintain safe staffing. The highlights from the HR, Workforce and Organisational Development dashboard were presented, including the Trust headcount which reported 81 more staff in September 2016 than in September 2015, however was 27 less when compared to the baseline of 31 March 2016. Sickness absence reported in September was 4.63%, which showed an increase of 0.04% when compared to August; however it was 0.33% higher when compared to the same period the previous year. The long term sickness absence rate in September saw an increase of 0.45% compared to the previous year. The cost of sickness absence had increased again during the months of June and July but then decreased for the following two months of August and September. A high level overview of the financial position across directorate performance, transformation and continuity of services risk rating was provided. Following a member’s query over DNAs, the Chief Operating Officer/Deputy Chief Executive outlined the process in place and work underway to address and improve the position and the need to closely work with the referring GP. It was reported that cancellations were not included as DNAs, however, this position was also under review to ensure that patients were seen in a safe and timely manner. A member raised the issue of DNAs for children and the steps being taken to address this issue. The Chief Operating Officer/Deputy Chief Executive reported that this is an area of concern as the highest number of DNAs could be attributed to children and that the Trust ensured everything was done so that the child was seen appropriately. The process involved staff and key stakeholders across multi-disciplinary teams to ensure a joined up approach. The Director of Nursing, Patient Safety and Quality advised that where the DNAs related to children the casenotes were reviewed by a clinician in order to identify any potential safeguarding issues which would then be addressed through the safeguarding team. In relation to a query on the flu vaccination, the Director of Estates and Facilities reported on the current campaign that the Trust was running to maximise uptake of the vaccine amongst staff,

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which included senior management encouragement, ward vaccinators, daily clinics and a flu video/song. To date, 50% of front line staff had received the vaccination, an increase of 8% on last year and to meet the national target threshold of 60%, a further 500 staff needed to be vaccinated. Following a members query on temporary staffing costs, the Director of Finance reported that year-on-year the agency spend was running at a similar level, however, a number of initiatives had been introduced which would have a positive impact on expenditure. A Temporary Staffing Manager and Senior Rota Maker had recently been appointed, which would have a significant impact on the management of temporary and locum staffing, with a proactive approach being adopted. A specific query was raised in respect to Pathology and the Director of Finance reported that due to vacant posts and some business issues, there had been a reliance on agency and locums to cover gaps and ensure continuity of service. Work was underway to address these concerns with a reduction in spend expected over the coming months. A member raised recent press coverage in relation to staff shortages in Pathology and the Medical Director confirmed that this was a national issue with a shortage of skilled staff especially at Consultant level. The Trust had been actively recruiting and had reviewed staffing establishments and skill mix in order to address shortfalls by developing non-medical staff resources. A member raised the recent press coverage in relation to the Trust position nationally, for the time it takes for stroke patients to get vital brain scans. The Medical Director confirmed the Trust provides a 24/7 CT service for stroke patients and that the Stroke Unit was highly regarded for the services on offer. He expressed concern over the validity and accuracy of the data that had been released and had instigated an investigation and audit to review this. It was confirmed that the Trust complied with NICE guidance criteria and had made changes to referral forms to ensure critical scans were undertaken within timescales. Steve Hall, Non-Executive Director, provided assurance that issues identified were taken seriously and monitored through the Patient Safety and Quality Standards Committee. Kevin Robinson, Non-Executive Director raised a point of clarity with regards to the position on the 62 day cancer standard and the challenges in achieving the target. The Chief Operating Officer/Deputy Chief Executive confirmed that work was undertaken to ensure breaches were the exception, which included involvement with the national Improvement Team, proactively following up DNA’s and achieving the initial 2 week standard. The Trust managed this standard well however, due to the need to refer to Tertiary centres and work closely with GP’s, there were system wide issues in achieving the standard, which required system wide approaches and leadership to address. A service level agreement had been developed to ensure appropriate management of patients through the patient pathway where more than one organisation was involved, and commissioner support had been requested to successfully implement. A query was raised regarding the recent press coverage on the production of passports to ensure eligibility to receive treatment. The Chairman confirmed that the Trust had robust systems in place to manage overseas visitors, which had been communicated to Governors previously via a development session. A key issue was passports and proof of nationally did not necessarily provide the detail required to prove eligibility for healthcare, as residency was also a factor in the decision making process.

Resolved: (i) that, the report be noted; (ii) that, the current position and performance against key standards be

noted; and (iii) that, an update on the Trust position for stroke patients be provided at the

next meeting. CoG/695 Single Oversight Framework

The Chief Operating Officer/Deputy Chief reported on the new Single Oversight Framework, which came into effect on 1 October and replaced Monitor’s Risk Assessment Framework and the Trust

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Development Authority’s Accountability Framework. The Framework required monthly reporting instead of quarterly and sets out the levels of support that provider organisations would receive based upon their level of performance in 5 areas, which were referred to as themes. The Trust had been assessed as segment 2 – emerging concerns/minor issues. It was noted that 45% of Trusts were in segment 2, and 43% in segment 3. The Chief Operating Officer/Deputy Chief reported that as part of the new process the Trust would be happy to accept and engage with support that is offered by NHS Improvement in order to bring about improvements in any of the standards. The new framework suggested an improved relationship between the Care Quality Commission (CQC) and NHS Improvement regulation with more defined areas of monitoring and responsibilities, and aimed to help providers achieve or maintain a CQC rating of ‘good’ or ‘outstanding’.

Resolved: that, the report be noted. CoG/696 Update on Governor Elections 2016 The Company Secretary provided a verbal report on the outcome of the 2016 Governor Elections that had concluded on 18 November 2016. There were nine public and two staff vacancies; following the nomination stage, with Sedgefield being the only Constituency which went out to public ballot. Electoral Reform Services (ERS) had conducted the elections as the Returning Officer, and it was noted that a problem had been encountered with the dispatch of ballot papers to some Stockton members following an incorrect mapping exercise. This was rectified and to ensure a valid process, no ballots from ineligible members were counted in the final return. The vacancies were filled as follows: Stockton Hartlepool Margaret Docherty (re-elected) Tom Sant (re-elected) Val Scollen (re-elected) Pauline Robson (re-elected) Raymond Stephenson Staff Easington 2 vacancies Mary King (re-elected) John Doyle (2 years) Sedgefield 1 vacancy Wendy Gill (re-elected) Resolved: that, the information be noted CoG/697 Sub-Committee Minutes

a. Draft Nominations Committee Minutes The Company Secretary presented the minutes of the Nominations Committee which was held on 15 September 2016 and highlighted the key points.

b. Draft Membership Strategy Committee Minutes

Wendy Gill, Elected Governor for Sedgefield presented the minutes of the Membership Strategy Committee which was held on19 September 2016 and highlighted the key points.

c. Draft Strategy and Service Development Committee Minutes Steven Yull, Elected Staff Governor presented the minutes of the Strategy and Service Development Committee which was held on 19 September 2016 and highlighted the key points.

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Resolved: that, the information be noted.

CoG/698 2017 Council of Governors Schedule of Meetings, including Sub-Committees

and Development Sessions The Company Secretary provided the 2017 Council of Governors Schedule of Meetings for information.

Resolved: that, the information be noted. CoG/699 Any Other Business The Chairman reported that Mary Morgan’s term of office would come to an end on 30 November 2016 and that this was her last Council of Governors meeting. He thanked Mary, who had joined the Trust as a Governor in 2007, for her commitment and contribution to the Trust over the years and wished her well for the future. The Chairman reported that the terms of office for Debbie Gardner and Matt Wynne, Staff Governors, would also end on 30 November 2016, thanking them for their support and contribution and expressing his hope that they may stand again in the future. The Chairman reported that Angela Warnes, Appointed Governor for the University of Teesside, would be retiring in December 2016. Although only a member of the Council of Governors for the last year, he thanked her for her involvement and support during this time and hoped that she would maintain an interest with the Trust as a member for the out of area constituency. The Chairman reported that the Governor Christmas lunch had been organised for Wednesday 7 December 2016 in the Tees Meeting Room at North Tees. CoG/700 Date and Time of Next Meeting The next meeting was due to be held on Thursday, 2 February 2017 at Eaglescliffe Golf Club. The meeting closed at 12.00noon Signed: Date:

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Meeting of the Council of Governors

2 February 2017

Chairman’s Report

Report of the Chairman

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Manage Our Relationships

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Effective Board Governance

1. Introduction 1.1 The Chairman’s Report aims to provide information to the Council of Governors on

key local, regional and national issues.

2. Key Issues and Planned Actions

2.1 Alan and I met with the Chairs and Chief Executives of South Tees Hospitals NHS

Foundation Trust and County Durham and Darlington NHS Foundation Trust.

To progress collaborative working, it was agreed that a Committee in Common be established with Terms of Reference to be agreed by all Trusts. This will provide a form of governance around the STP and decision making forum within the Terms of Reference for the Committee in Common. A proposal was made that Paul Keane, Chair of County Durham and Darlington NHS Foundation Trust, Chair the Committee in Common. I wish to notify the Council of Governors that Deborah Jenkins from South Tees Hospitals NHS Foundation Trust has stood down as Chair and that Amanda Hullick will be fulfilling this role as an interim arrangement.

2.2 I attended the HFMA Chairs conference in London where some really interesting presentations were given as follow up to the Carter Report where they are now looking at unwarranted variations against the model hospital and developing a table of weighted activity units which will allow Trusts to benchmark against each other. STPs are clearly at different stages of development around the country and our STP does appear to have made more progress than many but there were still many concerns over place based regulations.

2.3 The Trust has been assessed against the NHS Standard of Procurement Assessment at level 1 which is ten months ahead of the Carter requirement. We are only the second Trust in the country to achieve this standard, the first being Newcastle Hospitals NHS Foundation Trust. I wish to place on record my thanks to Jane Hawkes, Head of Procurement & Supplies & Scan4Safety Program Lead, her team and Brian Dinsdale, Non-Executive Director.

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2.4 I attended the NHS Providers conference in Birmingham in November. This concentrated on the shortage of money and the degree of financial challenge in the NHS.

It was noted that it was impossible to continue the breadth of the current NHS offer within the money available. The Secretary of State spoke to the conference but was unusually subdued and appeared not to like the message of the impossibility of the challenge.

3. Recommendations 3.1 The Council of Governors is asked to note the content of this report.


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PG/BB February 2017 Dear Colleague A meeting of the Board of Directors will be held on Thursday, 30 March 2017 at 1:00 pm in the Boardroom, University Hospital of North Tees. Yours sincerely


Agenda

Led by

1. (1.00pm) Apologies for absence Chairman 2. (1.00pm) Declaration of Interest Chairman 3. (1.00pm) Minutes of the meeting held on, 26 January 2017 (enclosed) Chairman 4. (1.05pm) Matters Arising Chairman Items for Information 5. (1.10pm) Chairman’s Report (enclosed) Chairman 6. (1.20pm) Chief Executive’s Report (enclosed) A Foster Quality 7. (1.30pm) Safety, Quality and Infection Prevention Report (enclosed) J Lane

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Performance Management 8. (1.40pm) Compliance and Performance Report (enclosed) J Gillon 9. (1.50pm) Finance and Contract Performance Report, C Trevena as at 28 February 2017 (enclosed) 10. (2.00pm) Human Resources and Education Report – Quarter 3: 2016/17 A Burrell (enclosed) Governance 11. (2.10pm) Annual Operational Plan 2017-19 (enclosed) J Gillon/ C Trevena 12. (2.20pm) Any Other Notified Business Chairman 13. Date of Next Meeting (Thursday, 27 April 2017, Boardroom, University Hospital of Hartlepool)

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2 February 2017

Chief Executive’s Report

Report of the Chief Executive Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Manage Our Relationships

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Effective Board Governance

1. Introduction 1.1 The Chief Executive’s Report aims to provide information to the Council of Governors

on key local, regional and national issues.

2. Key Issues & Planned Actions 2.1 Work continues on the development of the Sustainability and Transformation Plan

(STP) which will lead to the development of a business case in order to secure the capital needed to support any proposed service changes. I continue to be invited to various Health and Wellbeing Boards, scrutiny meetings and other stakeholder meetings in order to provide updates and this engagement will continue to gather pace.

All STP leaders have been personally invited to a development session led by Simon

Stevens, Chief Executive of NHS England and Jim Mackey, Chief Executive of NHS Improvement on 30 and 31 January 2017 in London. This will provide an opportunity to take stock nationally and get additional feedback on the next steps in the process.

2.2 As the Council of Governors are aware, the Trust is leading on the Scan4Safety project

along with 6 other Trusts in order to implement this national initiative. I wish to inform the Council of Governors that the Trust has now completed Phase two of the Scan4Safety programme. This has seen the introduction of GS1 identifiers on patient wristbands, within the Trust’s purchasing systems to capture product details, and on all room locations. A point of care technical solution prototype has been built and is currently being tested in order to scan, capture and validate this information. Implementation of the Scan4Safety Programme is being undertaken in four phases.

As I write this report I have been invited to speak at the national Scan4Safety Leadership Conference to give a Chief Executive perspective. I will report back to the Council of Governors on this at the next meeting.

2.3 The NHS continues to be under severe operational pressure and this has been played

out in the national news everyday. We have seen an increase in attendances at Accident and Emergency and an increase in emergency admissions to hospital and as the winter period continues to bite, I anticipate that this pressure will continue to increase during the coming weeks.

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I wish to reassure the Council of Governors that our operational winter plans are

working effectively and that we have opened additional beds in cope with demand and that this is under constant review. Patient safety and dignity remains at the forefront of our thinking and this will not be compromised despite having a very challenging financial target to deliver. Although we have had to cancel some elective/planned surgery, I wish to reassure the Council of Governors that we have not cancelled any cancer surgery as a result of this.

2.4 In early January the Trust achieved accreditation with the Nursing and Midwifery

Council to establish a North Tees and Hartlepool Nursing Academy in collaboration with Sunderland University. Whilst the programme will be delivered by Sunderland University the clinical placements will be within the organisation. Students are being recruited and we will welcome the first cohort of 20 to the organisation in April 2017 with a second cohort to be recruited ready for September 2017.

3. Recommendations The Council of Governors are asked to note the content of this report.

Alan Foster Chief Executive

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2 February 2017

Outcome of Governor Elections 2016

Report of the Company Secretary

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports)

Maintain Compliance and Performance

1. Introduction This report presents the outcome of the Governor Elections that were carried out to fill the vacant seats from December 2016.

2. Background There were nine Public Governor and two Staff Governor vacancies to fill and following the nomination stage, only the vacancy in the Sedgefield constituency went out to public ballot with the other constituencies uncontested. The elections were conducted in accordance with the rules and constitutional arrangements as set out by the Trust’s Constitution using the Single Transferable Vote electoral system. Electoral Reform Services (ERS) were employed to assist the Trust for the purposes of this round of elections and conducted the elections as the Returning Officer. It was noted that a problem had been encountered with the dispatch of ballot papers to some Stockton members following an incorrect mapping exercise. This issue was rectified and ERS confirmed that they are satisfied that the resulting process was in accordance with accepted good electoral practice.

3. Election Results The Election round closed on 18 November 2016 at 5.00pm and the Trust were notified of the results on 21 November 2016. The following candidates were elected with effect from 1 December 2016:- 3.1 Hartlepool Constituency (2 Governor vacancies) Thomas Sant (re-elected) Pauline Robson (re-elected)

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3.2 Stockton Constituency (3 Governor vacancies) Margaret Docherty (re-elected) Val Scollen (re-elected) Raymond Stephenson (declined the seat, now vacant) 3.3 Easington Constituency (3 Governor vacancies) Mary King (re-elected) John Doyle (2 years) One seat remains vacant 3.4 Sedgefield Constituency (1 Governor vacancy Wendy Gill (re-elected) 3.5 Staff (2 Governor vacancies) No nominations, two seats remain vacant 3.6 Terms of Office All Governors were elected to a term of office of 3 years unless otherwise specified.

4. Recommendation The Council of Governors are asked to:

Note the outcome of the 2016 Governor Elections.

Barbara Bright Company Secretary

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1



2 February 2017

Executive Summary

Register of Interests

Report of the Company Secretary Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governor Reports) Maintain Compliance and Performance

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governor Reports) Maintain Compliance and Performance

1. Introduction 1.1 In accordance with Annex 6, of the Trust’s Constitution the Council of Governors are

required to declare interests that may conflict with their position as a Governor of the Trust. Interests are to be recorded in a register which is available for inspection on request.

1.2 The requirement for directors and governors to meet a fit and proper persons test is already included in Monitors provider licence for NHS Foundation Trusts and the Trust’s Constitution, section 12, identifies the criteria as to why Governors may not become or continue as a member of the Council of Governors. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) introduced a new fit and proper person test from 27 November 2014 which broadened the requirements in terms of scope and nature of the test. As good practice the Trust ensures that fit and proper person declarations will be completed on an annual basis for both Governors and Directors, and recorded in the register.

1.3 A copy of the register is attached to this report.

2. Recommendations The Council of Governors is requested to:

note the contents of the appended updated register; and

note that the register will be referred to in the Annual Report and Accounts 2016/17.

Barbara Bright Company Secretary

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1

Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust

Name Directorship including non-executive directorships held in private companies or PLCs (with the exception of dormant companies)

Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS

A position of authority in a charity or voluntary body in a field of social care

Any connection with a voluntary or other body contracting for NHS services

Signed Fit and Proper Person Dec

Thomas Sant Public Governor (Hartlepool constituency)

None None None Director / Trustee Hartlepool Voluntary Development Agency

None

Maureen Rogers Public Governor (Hartlepool constituency)

None None None None None

Pauline Robson (Hartlepool constituency)


Alan Smith (Hartlepool constituency)


George Edward Lee (Hartlepool constituency)

None None None None Member of Executive Committee (Voluntary) Durham Association of Boys and Girls Clubs Chairman of Board (Voluntary) Central Estate Management Organisation, Hartlepool

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A position of authority in a charity or voluntary body in a field of social care



Roger Campbell (Hartlepool constituency)

None None None None Member of Tenants Consultative Council Thirteen Group Ltd Non-voting Director of Housing Hartlepool Ltd

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A position of authority in a charity or voluntary body in a field of health and social care



Janet Atkins Public Governor (Stockton constituency)

None None None None Volunteer Community Health Ambassador – DoH/HaST CCG

Kate Wilson Public Governor (Stockton constituency)


Patricia Upton Public Governor (Stockton constituency)


James Newton Public Governor (Stockton constituency)


Ann Cains Public Governor (Stockton constituency)

None None None None Chair of Patients’ Group, Norton Medical Centre

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Margaret Docherty Public Governor (Stockton constituency)

None None None None Member of patient group, Norton Medical Centre Member of NHS Podiatry patient group, One Life Centre Volunteer Community Health Ambassador – DoH/HaST CCG

John Edwards Public Governor (Stockton constituency)

P&I Design Ltd Joint Owner and Director (Engineering Consultancy business)

P&I Design Ltd Joint Owner and Director (Engineering Consultancy business)

None None None

Tony Horrocks Public Governor (Stockton constituency)

None None None Treasurer Teesside Samaritans

None

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Mark White (Stockton constituency)

Director Association of Colleges and Education and Training Foundation

None None Trustee The Halo Project

Member of Labour Party and Unison Chair of Abingdon Primary School, Middlesbrough Chair Stockton Riverside College Visiting Fellow Teesside University

Val Scollen (Stockton constituency)

None None None None Board Member Billingham Environmental Link Programme Board Chair & Director Billingham Community Newspaper Member of Council Thirteen Housing Group

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Mrs Mary King Public Governor (Easington constituency)


Mr John Doyle Public Governor (Easington constituency)


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Dr Wendy Gill Public Governor (Sedgefield constituency)


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Mrs Alison McDonough Public Governor (Non-core constituency)

Director of Small Business Matters (Northern) Ltd (Consultancy Business) Chief Executive of Sunderland Live Ltd (Events Company)

None None None None

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Mrs Carol Alexander (Staff Governor)


Mr Manuf Kassem (Staff Governor)


Steven Yull (Staff Governor)

None None None None Union Steward Royal College of Nursing

Gary Wright (Staff Governor)


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Cllr Jim Beall (Appointed Governor, Stockton Borough Council)

None None None None

Deputy Leader and Cabinet Member for Adult Services and Health Stockton Borough Council Chair Eastern Ravens Trust Chair, Stockton Health and Wellbeing Board

Cllr Dave Hunter (Appointed Governor, Hartlepool Borough Council


Cllr Morris Nicholls (Appointed Governor, Durham County Council)

None None None None Secretary and Vice Chair Young peoples and Children’s Services, Durham County Durham

Simon Forrest (Appointed Governor, Durham University

None None None None Chair of Board of Trustees AIDS Education and Research Trust

Linda Nelson (Appointed Governor, Teesside University)


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Integrated Performance Report

February 2017

Strategic Aim and Strategic Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Council of Governors Reports)

1. Introduction

1.1 This report highlights performance against standards included in Monitor’s Risk Assessment Framework (Single Oversight Framework) Sustainability and Transformation Plan, NHS Outcomes Framework and Core National and Local Standards for the month of November 2016.

1.2 An overview of performance against key standards covering Compliance and Sustainability

and Transformation Planning, Lord Carter/Model Hospital Operational Efficiency, Human Resources, Workforce and Organisational Development and Quality and Finance is given within the Appendices.

1.3 The Finance section on Appendix 1 provides an overview of the Trust’s position against the key financial metrics across Directorates, Transformation and Continuity of Services.

1.4 Appendix 2 outlines the trend analysis against the key Compliance and STP standards. 1.5 Appendix 3 and 4 provide additional dashboards covering Quality and HR, Workforce and

OD metrics, providing the Council of Governors with a combined overview of operational performance across the organisation.

2. Performance Overview

2.1 Compliance and Sustainability and Transformation Planning (STP)

2.1.1 Performance against the emergency care standard achieved in the month of November reporting at 95.39% against the national requirement of 95%.

2.1.2 The Trust achieved all of the cancer standards in November. 2.1.3 The Trust achieved the Referral to Treatment standard, reporting at 93.27% for November.

A zero tolerance approach to any incomplete RTT non-adjusted pathways over 52 weeks remains a national measure. The Trust reported no over 52 week waits.

1

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2.1.4 The Trust has a strong history of achieving the national standard for the number of patients waiting over 6 weeks for diagnostic procedures however under achieved against this standard for November reporting at 98.33%. Recovery is expected by January 2017.

2.2 Lord Carter/Model Hospital 2.2.1 The latest position indicates the Trust is performing relatively well against a number of the

operational efficiency standards, including outpatient new to review ratios, lengths of stay, day case rates and pre-op stays though acknowledges there is work to be done in these areas to further improve the position.

2.2.2 Outpatient DNAs are reporting above the internal standard for both new and review appointments, however indicating a downward trend.

2.2.3 Bed Occupancy rates continue to report above the national recommendation of 85%, indicative of the continued pressures within the organisation together with delayed transfers of care.

2.2.4 Readmissions for elective and emergency admission are reporting above target with a variable trend.

3. Nursing, Quality and Patient Safety

3.1 The Trust has established a new Safety and Quality Dashboard (Appendix 3) which utilises the CQC domains of Safe, Caring, Effective, Responsive and Well-Led. The dashboard allows users to see month on month positions and the trend from April 2016, together with the benchmark position against data from the same time period the previous year.

3.2 The Trust reported five Trust attributed cases of Clostridium difficile infection for November 2016. Zero cases of Methicilin-Resistant Staphylococcus Aureus (MRSA), two Methicilin-Sensitive Staphylococcus Aureus (MSSA) and six cases of hospital acquired Escherichia Coli (E.coli).

3.3 The Trust has revised the Staff, Patient Experience and Quality Standards (SPEQS)

process for In-patients from August. The revised SPEQS forms have been created to align with the CQC domains. The values for the November SPEQS CQC domains are as follows: Safe increased to 93.75% from 85.57%, Caring decreased to 88.10% from 91.77%, Effective increased to 91.89% from 84.87%, Responsive decreased to 62.50% from 70.36% and Well-Led increased to 77.78% from 75.79%.

3.4 The Trusts overall Harm Free care in November 2016 was 99.39% this has increased from

98.46% in October 2016. The Trust overall New Harm decreased from 1.54% in October 2016 to 0.61% in November 2016.

3.5 The Trust ‘Would Recommend’ for Friends and Family returns decreased to 93.87% for

November 2016 from 93.88% in October 2016. 3.6 The latest HSMR value is 106.45 (November 2015 to October 2016), this has increased

from the previous value of 104.88 (revised – October 2015 to September 2016). The Trust crude mortality rate for HSMR has increased to 3.59% from 3.53%.

3.7 The latest SHMI data has been released for the time period of July 2015 to June 2016 with

the value reducing to 111.84 from 113.19 in the previous period. The new value of 111.84 now places the Trust within the ‘as expected’ range; this is the first time since the 12 month reporting period of April 2012 to March 2013.

3.8 There has been no Never Events in the reporting period.

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3.9 Registered Nurse/Midwife fill rates across inpatient areas for the month of November has increased to 81.82% from 80.53%, which is above the expected 75% expected fill rate to maintain safe staffing.

4. Human Resources, Workforce and Organisational Development

4.1 The Trust headcount as at 31 December 2016 is 67 more than 31 December 2015, and it is 25 higher when compared to the baseline of 31 March 2016.

4.2 The sickness absence rates for quarter 3 2016/17 are for the months of October and November only - further analysis will take place once the information for December 2016 is available.

4.3 The sickness absence rate for the month of November 2016 is 5.05%, an increase of 0.47%, when compared to the previous month (October 2016).

4.4 The sickness absence rate for quarter 3 2016/17 (excluding December 2016) has shown an increase of 0.15%, when compared to quarter 3 2015/16.

4.5 The long term sickness absence rate for quarter 3 2015/16 (excluding December 2016) has shown a decrease of 0.04%, when compared to quarter 3 2015/16.

4.6 The cost of sickness absence increased during the months of October and November 2016. The total cost for quarter 3 2016/17 (excluding December 2016) is £1,117,934, which is £104,160 higher when compared to quarter 3 2015/16.

4.7 Turnover has decreased by 0.62% for quarter 3 2016/17 when compared to quarter 3 2015/16, however it is 0.32% more than the baseline of 31 March 2016.

4.8 The overall compliance for mandatory training is 92%, which is 3% below the target. (Figures are reported up to November 2016 only).

4.9 The Staff Friends and Family Test is carried out as part of the annual NHS Staff Survey and therefore the Trust is not required to carry out this activity for the Q3 period. The Staff Survey Results are expected February 2017.

5. Finance 5.1 A high level overview of the financial position across Directorate performance,

transformation and continuity of services risk rating is provided in Appendix 1.

6. Recommendations

6.1 The Council of Governors is asked to note the detail in the Integrated Performance Dashboard and performance against the key national indicators for November 2016, in the context of the Sustainability and Transformation Plan, the Trusts’ Terms of Licence and the Everyone Counts: Planning for Patients 2014/15 – 2018/19 document.

6.2 In addition the Council of Governors is asked to note the on-going operational performance risks to regulatory key performance indicators and the financial risks together with the work that is being taken forward to mitigate and address going forward to provide a level of assurance and sustainability.

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Julie Gillon, Chief Operating Officer/Deputy Chief Executive Julie Lane, Director of Nursing and Infection Prevention and Control Ann Burrell, Director of Human Resources and Organisational Development Caroline Trevena, Director of Finance

4

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Annual BudgetYTD

PlanYTD Actual YTD Variance

£'000 £'000 £'000 £'000

Income

Accident & Emergency 6 4 4 (0)

Anaesthetics 18 13 7 (6)

Audit North 322 322 340 18

Central Expenditure 0

Central 15,421 12,134 9,847 (2,287)

Contract Income 263,048 171,478 175,134 3,655

EAU & Ambulatory 49 32 29 (3)

Education & Organisation Development 3 2 (2) (4)

Endoscopy 22 15 11 (4)

Estates 4,606 3,309 3,273 (35)

Finance 1,648 1,150 1,217 67

Human Resources 0 0 8 8

ICT 86 59 38 (21)

In Hospital care 240 160 184 24

Medical Director 0 0 0 0

Nursing & Patient Safety 28 27 33 6

Obs and Gynae 101 68 80 12

Orthopaedics 1,455 970 15 (955)

Out of Hospital Care 903 643 739 96

Paediatrics 75 58 58 (0)

Pathology 338 225 261 36

Pharmacy 1,656 1,102 1,206 105

Radiology 211 168 153 (15)

Research & Development 757 537 585 48

Strategy, Operations & Performance 69 47 48 1

Surgery and Urology 107 71 87 15

Total Income 291,170 192,594 193,355 761

Pay Expenditure

Accident & Emergency 6,695 4,587 4,646 (59)

Anaesthetics 16,965 11,394 11,332 62

Audit North 267 267 287 (20)

Central Expenditure (3,021) (789) 48 (837)

Chief Executive 1,462 963 960 3

EAU & Ambulatory 9,793 6,537 7,027 (490)

Education & Organisation Development 1,708 1,157 1,247 (89)

Endoscopy 3,070 2,060 2,106 (46)

Estates 13,293 8,939 8,762 177

Finance 3,319 2,200 2,170 30

Human Resources 1,654 1,215 905 310

ICT 4,141 2,771 2,673 98

In Hospital care 24,111 16,260 17,333 (1,073)

Medical Director 139 90 186 (95)

Nursing & Patient Safety 2,891 1,965 1,805 160

Obs and Gynae 11,870 8,020 7,625 395

Orthopaedics 10,841 7,239 7,413 (174)

Out of Hospital Care 31,017 20,800 20,397 402

Outpatients 1,059 714 723 (9)

Paediatrics 14,696 9,950 9,816 134

Pathology 7,084 4,804 5,215 (411)

Pharmacy 3,953 2,638 2,651 (13)

Radiology 9,150 6,159 6,039 120

Research & Development 572 533 583 (50)

Reserves 1,452 58 0 58

Strategy, Operations & Performance 2,401 1,616 1,582 34

Surgery and Urology 11,574 7,765 8,113 (348)

Total Pay Expenditure 192,158 129,913 131,645 (1,732)

Trust Income & Expenditure

Position Month 8

Appendix 1

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Non Pay Expenditure

Accident & Emergency 720 509 506 3

Anaesthetics 4,958 3,421 3,220 201

Audit North 55 55 54 1

Central Expenditure 8,253 (1,676) (212) (1,464)

Central Income 0 0 0 0

Chief Executive 323 227 198 29

EAU & Ambulatory 1,480 1,079 1,080 (1)

Education & Organisation Development 297 202 273 (72)

Endoscopy 1,778 1,229 1,100 128

Estates 9,912 6,603 6,432 171

Finance 12,196 8,249 8,070 179

Human Resources 572 422 421 1

ICT 1,732 1,154 1,149 5

In Hospital care 12,554 11,236 11,319 (83)

Medical Director 31 30 29 1

Nursing & Patient Safety 255 172 171 2

Obs and Gynae 1,962 1,496 1,481 15

Orthopaedics 6,452 4,465 3,403 1,062

Out of Hospital Care 7,512 5,211 4,716 495

Outpatients 323 222 192 30

Paediatrics 1,624 1,241 1,242 (1)

Pathology 5,558 3,860 3,803 57

Pharmacy 769 523 475 48

Radiology 5,172 3,551 3,577 (27)

Research & Development 30 22 22 1

Strategy, Operations & Performance 97 69 60 8

Surgery and Urology 2,275 1,596 1,386 210

Total Non Pay Expenditure 86,890 55,165 54,167 997

Trust Total 12,122 7,516 7,543 27

Optimus Health Limited 16 2 (69) (71)

Group Total 12,138 7,519 7,475 (44)

CIP

YTD Plan YTD Actual YTD Variance

£'000 £'000 £'000

69 6 (63)

17 17

1,905 664 (1,241)

40 1,647 1,607

64 158 94

8 41 33

760 679 (81)

240 365 125

293 59 (234)

23 23

468 137 (331)

8 326 318

3,559 1,703 (1,856)

296 2,419 2,123

3,855 4,122 267

Recurrent

Revenue Generation

Employee Expenses

Non-Recurrent

Recurrent

Non-Recurrent

Recurrent

Non-Recurrent

Recurrent

Non-Recurrent

Recurrent

Non-Recurrent

Recurrent

Grand Total

Recurrent/Non RecurrentScheme

Non-Recurrent

Total

Recurrent

Non-Recurrent

Drugs

Clinical Supplies

Non-Clinical Supplies

Other

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ID

Ap

r 16

May 1

6

Ju

n 1

6 QTR 1

Ju

l 16

Au

g 1

6

Sep

16 QTR 2

Oct 1

6

No

v 1

6

Dec 1

6 QTR 3

Jan

17

Feb

17

Mar 1

7 QTR 4

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 93.62% 93.40% 92.95% 93.32% 95.30% 96.65% 95.06% 95.64% 96.36% 95.39%

Variance -1.38% -1.60% -2.05% -1.68% 0.30% 1.65% 0.06% 0.64% 1.36% 0.39%

Target 98.00% 98.00% 98.00% 89.95% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%

Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance 2.00% 2.00% 2.00% 10.05% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

Actual 95.00% 90.91% 100.00% 97.83% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance 1.00% -3.09% 6.00% 3.83% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00%

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 100.00% 100.00% 100.00% 75.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance 15.00% 15.00% 15.00% -10.00% 15.00% 15.00% 15.00% 15.00% 15.00% 15.00%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Actual 95.60% 100.00% 97.18% 97.69% 98.30% 93.90% 98.39% 97.04% 100.00% 97.10%

Variance 5.60% 10.00% 7.18% 7.18% 8.30% 3.90% 8.39% 7.04% 10.00% 7.10%

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 86.50% 88.06% 75.00% 83.57% 78.22% 86.92% 82.54% 83.06% 90.10% 92.00%

Variance 1.50% 3.06% -10.00% -1.43% 6.80% -1.70% -2.46% -1.94% 5.10% 7.00%

Target 96.00% 23.34% 30.06% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%

Actual 98.90% 99.17% 99.16% 99.10% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance 2.90% 3.17% 3.16% 3.10% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

Actual 94.00% 97.69% 90.83% 94.13% 92.90% 93.70% 93.04% 93.25% 94.70% 95.40%

Variance 1.00% 4.69% -2.17% 1.13% 0.10% 2.10% 0.04% 0.25% 1.70% 2.40%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

Actual 95.50% 94.40% 96.10% 95.26% 94.80% 98.20% 97.86% 96.84% 99.10% 98.30%

Variance 2.50% 1.40% 3.10% 2.26% 1.80% 5.20% 4.86% 3.84% 6.10% 5.30%

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

Actual 92.01% 92.02% 92.13% 92.05% 92.71% 92.65% 92.39% 92.59% 93.03% 93.27%

Variance 0.01% 0.02% 0.13% 0.05% 0.71% 0.65% 0.39% 0.59% 0.39% 0.39%

Target 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00%

Actual 99.53% 99.30% 99.41% 99.42% 99.45% 99.82% 99.46% 99.57% 99.96% 98.33%

Variance 0.53% 0.30% 0.41% 0.42% 0.45% 0.82% 0.46% 0.57% 0.96% -0.67%

ID

Ap

r 16

May 1

6

Ju

n 1

6 QTR 1

Ju

l 16

Au

g 1

6

Sep

16 QTR 2

Oct 1

6

No

v 1

6

Dec 1

6 QTR 3

Jan

17

Feb

17

Mar 1

7 QTR 4

Target 1.45 1.45 1.45 0.75 1.45 1.45 1.45 1.45 1.45 1.45 1.45 1.45 1.45 1.45 1.45 1.45

Actual 1.21 1.17 1.23 1.20 1.14 1.15 1.19 1.16 1.16 1.27

Variance -0.24 -0.28 -0.22 -0.25 -0.31 -0.30 -0.26 -0.29 -0.29 -0.18

Target 5.40% 5.40% 5.40% 89.95% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40%

Actual 8.31% 9.11% 9.71% 9.09% 8.42% 9.31% 8.62% 8.97% 8.02% 9.02%

Variance 2.91% 3.71% 4.31% -80.86% 3.02% 3.91% 3.22% 3.57% 2.62% 3.62%

Target 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00%

Actual 11.85% 12.60% 11.68% 11.91% 10.61% 10.72% 10.79% 10.75% 11.06% 9.87%

Variance 2.85% 3.60% 2.68% 2.91% 1.61% 1.72% 1.79% 1.75% 2.06% 0.87%

Target 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01 3.01

Actual 4.61 4.74 5.29 5.29 4.98 5.00 4.97 5.19 5.10

Variance 1.60 1.73 2.34 2.28 1.97 1.99 1.96 2.18 2.09

Target 3.22 3.22 3.21 3.21 3.21 3.25 3.25 3.25

Actual 2.61 2.51 2.39 2.39 2.31 2.22 2.16 2.16

Variance -0.61 -0.71 -0.82 -0.82 -0.90 -1.03 -1.09 -1.09

Target 4.38 4.38 4.37 4.37 4.37 4.38 4.38 4.38

Actual 4.09 4.00 4.07 4.07 4.04 4.04 4.03 4.03

Variance -0.29 -0.38 -0.30 -0.30 -0.33 -0.34 -0.35 -0.35

Target 72.72% 23.34% 30.06% 74.59% 74.82% 74.63% 74.92% 74.92%

Actual 72.68% 72.96% 71.55% 71.55% 71.67% 71.26% 70.96% 70.96%

Variance -0.04% 0.20% -3.04% -3.04% -3.15% -3.37% -3.96% -3.96%

Target 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50%

Actual 0.80% 2.16% 0.93% 1.75% 0.88% 1.35% 1.37% 1.50% 1.12% 1.19%

Variance -3.70% -2.34% -3.57% 2.75% -3.62% -3.15% -3.13% -3.00% -3.38% -3.31%

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 86.48% 92.06% 90.14% 89.54% 92.29% 85.09% 91.83% 89.67% 86.06% 87.31%

Variance 1.48% 7.06% 5.14% 7.54% 7.29% 0.09% 6.83% 7.67% 1.06% 2.31%

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 97.19% 97.12% 96.13% 96.80% 95.46% 93.98% 96.61% 95.33% 93.21% 94.88%

Variance 12.19% 12.12% 11.13% 14.80% 10.46% 8.98% 11.61% 13.33% 8.21% 9.88%

Target 147 115 136 398 182 150 144 476 189 198

Actual 217 313 343 873 338 211 631 1180 631 735

Variance 70 198 207 475 156 61 487 704 442 537

Target 1722 1608 2006 5336 1640 1456 1486 4582 919

Actual 1723 1482 1877 5082 1721 1688 1759 5168 1497

Variance 1 -126 -129 -254 81 232 273 586 578

Target 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73%

Actual 9.27% 13.11% 12.37% 12.82% 13.02% 11.99% 11.39% 12.02% 12.21%

Variance -0.46% 3.38% 2.64% 0.00% 3.29% 2.26% 1.66% 2.29% 2.48%

Target 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Actual 4.42% 4.55% 4.00% 4.31% 4.56% 3.76% 3.18% 4.00% 3.80%

Variance 4.42% 4.55% 4.00% 0.00% 4.00% 4.00% 4.00% 4.00% 4.00%

Target 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70%

Actual 9.27% 9.66% 8.68% 9.22% 9.58% 8.51% 7.86% 8.68% 8.73%

Variance 1.57% 1.96% -3.70% 0.00% -3.70% -3.70% -3.70% -3.70% -3.70%

T02

06Excess bed days

T00

25Readmission rate 30 days (Emergency admission)

T00

26Readmission rate 30 days (Elective admission)

T00

62Revised Occupancy Hartlepool

T00

63Revised Occupancy North Tees

T02

05Delayed bed days

T00

61Pre - Op Stays

T01

19Readmission rate 30 days (Total)

T00

09Breast Symptomatic Two week Rule (New Rules)*

T00

12RTT incomplete pathways wait (92%)

T00

58Length of Stay Elective

T00

59Length of Stay Emergency

T00

60Day case Rate

T00

55Outpatient DNA (new)

T00

56Outpatient DNA (review)

T00

57Average depth of coding

T00

54New to Review ratio (cons led)

T01

16

Number of patients waiting over 6 weeks for diagnostic

procedures ****

t00

06New Cancer GP 62 Day (New Rules)*

t00

07New Cancer Current 31 Day (New Rules)*

t00

08New Cancer Two week Rule (New Rules)*

t00

03New Cancer 31 days subsequent Treatment (Surgery)*

t00

04New Cancer 62 days (consultant upgrade)*

t00

05New Cancer 62 days (screening)*

T00

01A&E 4 hr target(excludes walk-in centres)

T00

02

New Cancer 31 days subsequent Treatment (Drug

Therapy)*

Appendix 2 - Compliance & STP Monitoring - Responsive

Lord Carter Model Hospital - Effective

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Appendix 3

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Scorecard Summary Baseline 31/03/2016

Q3

2015/16

Q3

2016/17

Variance from

same qtr prev

year

Trust Headcount 5483 5441 5508 67

Trust WTE 4597.55 4566.20 4612.48 46.28

Sickness Absence Rate 4.73% 4.66% 4.81% 0.15%

Short Term Sickness Rate 0.80% 0.67% 0.75% 0.08%

Medium Term Sickness Rate 1.19% 1.13% 1.24% 0.11%

Long Term Sickness Rate 2.74% 2.86% 2.82% -0.04%

Turnover Rate (inc. Foundations) 11.98% 12.92% 12.30% -0.62%

Turnover Rate (exc. Foundations) 11.11% 11.86% 11.89% 0.03%

Change in Workforce (WTE) Q3

Starters 136.96

Leavers 93.82

Overall variance in workforce 43.14

Mandatory Training Target Q3 Variance

Overall Compliance Rate 95% 92% -3%

Subjects Out of Compliance Q1

Safeguarding Adults Level 1 100% 94% -6%

Appraisal 95% 79% -16%

Information Governance 95% 87% -8%

Safeguarding Children Level 3 100% 94% -6%

Safeguarding Children Level 2 100% 84% -16%

Risk Assessment and Falls 70% 56% -14%

Caring for Parents with Challenging Behaviour 70% 41% -29%

Appendix 4 Council of Governors Report - Workforce Information Dashboard Summary Quarter 3 2016/17

150000

200000

250000

300000

350000

400000

450000

500000

550000

600000

650000

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

Cost of Sickness Absence Comparison

2015/16 2016/17

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

2015/16 4.04% 4.05% 4.06% 4.44% 4.53% 4.30% 4.13% 4.60% 4.91% 4.71% 4.85% 4.67%

2016/17 4.54% 4.66% 5.17% 5.06% 4.59% 4.63% 4.58% 5.05%

Target 16/17 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Sickness Absence Rates

21,238

14,101

6,963

Top 3 Reasons for Sickness October 2015 - November 2016

S10

Anxiety/stress/depression/other

psychiatric illnesses

S12 Other musculoskeletal

problems

S25 Gastrointestinal problems

The Trust headcount as at 31 December 2016 is 67 more than 31 December 2015, and it is 25 higher when compared to the baseline of 31 March 2016.

The sickness absence rates for quarter 3 2016/17 are for the months of October and November only - further analysis will take place once the information for December 2016 is available.

The sickness absence rate for the month of November 2016 is 5.05%, an increase of 0.47%, when compared to the previous month (October 2016).

The sickness absence rate for quarter 3 2016/17 (excluding December 2016) has shown an increase of 0.15%, when compared to quarter 3 2015/16.

The long term sickness absence rate for quarter 3 2015/16 (excluding December 2016) has shown a decrease of 0.04%, when compared to quarter 3 2015/16.

The cost of sickness absence increased during the months of October and November 2016. The total cost for quarter 3 2016/17 (excluding December 2016) is £1,117,934, which is £104,160 higher when compared to quarter 3 2015/16.

Turnover has decreased by 0.62% for quarter 3 2016/17 when compared to quarter 3 2015/16, however it is 0.32% more than the baseline of 31 March 2016.

The overall compliance for mandatory training is 92%, which is 3% below the target. (Figures are reported up to November 2016 only).

The Staff Friends and Family Test is carried out as part of the annual NHS Staff Survey and therefore the Trust is not required to carry out this activity for the Q3 period. The Staff Survey Results are expected February 2017.

Page 1 of 1

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2 February 2017

Council of Governors Sub-Committee Membership Review

Report of the Company Secretary Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governor reports) Maintain Compliance and Performance

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governor reports) Maintain Compliance and Performance

1. Introduction 1.1 This report outlines the work undertaken to review the membership for each of the Trust’s

Governor Sub-Committees.

2. Background 2.1 The Trust has five Governor Sub-Committees, which report to the Council of Governors.

These include:

Strategy and Service Development Committee;

Membership Strategy Committee;

Nominations Committee;

Travel and Transport Group;

External Audit Working Group. 2.2 In line with good practice, terms of reference and membership requirements should be

reviewed regularly, but as a minimum every three years.

3. Terms of Reference 3.1 The terms of reference for each of the Sub-Committees are reviewed on an annual basis,

with a review last undertaken in 2016. It is proposed that in early 2017 each of the Sub-Committees consider and review the terms of reference for their meeting to ensure they continue to be fit for purpose and have fair representation.

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4. Membership 4.1 The membership number for each of the Sub-Committees remains unchanged and as a

result of Governor resignations and changes, expressions of interest were invited to fill any vacancies. A revised list of membership has been compiled and is appended as Appendix 1.

5. Recommendations

5.1 The Council of Governors are asked to note the proposed amendments to the Sub-

Committee membership. Barbara Bright Company Secretary

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Appendix 1

16 January 2017


Governor Representation on Sub-committees

January 2017 Strategy and Service Development Committee Chair: Jonathan Erskine, Non-Executive Director Executive Director: Julie Gillon, Chief Operating Officer /Deputy Chief Executive Janet Atkins, Elected Governor (Stockton) Ann Cains, Elected Governor (Stockton) Roger Campbell, Elected Governor (Hartlepool) Margaret Docherty, Elected Governor (Stockton) John Edwards, Elected Governor (Stockton) Wendy Gill, Elected Governor (Sedgefield) Tony Horrocks, Elected Governor (Stockton) Mary King, Elected Governor (Easington) Alison McDonough, Elected Governor (Non-core public) James Newton, Elected Governor (Stockton) Tom Sant, Elected Governor (Hartlepool) Val Scollen, Elected Governor (Stockton) Alan Smith, Elected Governor (Hartlepool) Patricia Upton, Elected Governor (Stockton) Mark White, Elected Governor (Stockton) Kate Wilson, Elected Governor (Stockton) Gary Wright, Elected Governor (Staff) Steven Yull, Elected Governor (Staff) Membership Strategy Committee Chair: Wendy Gill, Elected Governor (Sedgefield) Executive Director: Barbara Bright Carol Alexander, Elected Governor (Staff) Janet Atkins, Elected Governor (Stockton) Ann Cains, Elected Governor (Stockton) Tony Horrocks, Elected Governor (Stockton) Mary King, Elected Governor (Easington) Maureen Rogers, Elected Governor (Hartlepool) Pauline Robson, Elected Governor (Hartlepool) Val Scollen, Elected Governor (Stockton)

Patricia Upton, Elected Governor (Stockton) (Ex Oficio) Nominations Committee Chair: Paul Garvin, Chairman Carol Alexander, Elected Governor (Staff) Wendy Gill, Elected Governor (Sedgefield) Tony Horrocks, Elected Governor (Stockton) Linda Nelson, Appointed Governor, Teesside University Maureen Rogers, Elected Governor (Hartlepool) Patricia Upton, Elected Governor (Stockton)

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Appendix 1

16 January 2017

Travel and Transport Project Committee Chair: Peter Mitchell, Director of Estates & Facilities Management Ann Cains, Elected Governor (Stockton) George Lee, Elected Governor (Hartlepool) Tom Sant, Elected Governor (Hartlepool) Patricia Upton, Elected Governor (Stockton) (Ex Oficio) External Audit Working Group Chair: Brian Dinsdale Executive Director: Lynne Hodgson Janet Atkins, Elected Governor (Stockton) Roger Campbell, Elected Governor (Hartlepool) Patricia Upton, Elected Governor (Stockton) Mark White, Elected Governor (Stockton) Sub-committees/Informal Groups which DO NOT report to the Council of Governors Healthcare User Group (HUG) Bill Johnson Janet Atkins, Elected Governor (Stockton) Wendy Gill, Elected Governor (Sedgefield) Kate Wilson, Elected Governor (Stockton) Patient Information Evaluation Group (PIEG) (J Blenkinsopp) Janet Atkins, Elected Governor (Stockton) Ann Cains, Elected Governor (Stockton) Margaret Docherty, Elected Governor (Stockton) Wendy Gill, Elected Governor (Sedgefield) Mary King, Elected Governor (Easington) Tom Sant, Elected Governor (Hartlepool) Alan Smith, Elected Governor (Hartlepool) Patricia Upton, Elected Governor (Stockton) *2 Governors per meeting attend on a rota basis Menu Review Group (Catering) (C Chapman) Tony Horrocks, Elected Governor (Stockton) Patricia Upton, Elected Governor (Stockton) Trust Research Awareness and Governance Group (TRAG) Wendy Gill, Elected Governor (Sedgefield) Food and Nutrition Group (FANG) Wendy Gill, Elected Governor (Sedgefield) Governors with no Committee/Group responsibility: John Doyle, Elected Governor (Easington) Manuf Kassem, Elected Governor (Staff) Dave Hunter, Appointed Governor Hartlepool Borough Council Morris Nicholls, Appointed Governor, Durham County Council Jim Beall, Appointed Governor, Stockton Borough Council Simon Forrest, Appointed Governor, Durham University

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Minutes of the Membership Strategy Committee

Held on Monday 21 November 2016

University Hospital of North Tees Present: Wendy Gill, Elected Governor (Sedgefield) (WG) Chair Mary King, Elected Governor (Easington) (MK)

Pauline Robson, Elected Governor (Hartlepool) (PR) Janet Atkins, Elected Governor (

Val Scollen, Elected Governor (Stockton) (VS) Carol Alexander, Staff Elected Governor (CA) In Attendance: Barbara Bright, Company Secretary (BB) Paul Wharton, Volunteer Co-ordinator (PW) Janet Clarke, Note taker (JC) 1. Welcome WG welcomed members to the meeting.

2. Apologies for Absence

Apologies for absence were received from Maureen Rogers, Elected Governor (Hartlepool) (MR) and Sarah Hutt, Assistant Company Secretary (SH) 3. Minutes of the last meeting held Monday 19 September 2016 The minutes of the last meeting were confirmed as an accurate record.

4. Matters Arising Membership Engagement Services (MES) BB reported no formal meeting had been held as yet with MES the new supplier of the Trusts membership services database regarding reporting requirements; however telephone discussions had taken place with them to discuss functionality. BB advised of an issue that had been experienced during the election process whereby a problem had been encountered with the dispatch of ballot papers to some Stockton members following an incorrect mapping exercise. It was agreed a breakdown of the constituency areas would be reviewed and a meeting arranged with MES to enable them to understand the issues.

Action: A meeting to be arranged with MES regarding the Trusts constituencies

Membership Working Group BB advised that due to a number of factors the working group had not met to progress some of the key actions discussed previously. It was agreed, a meeting of the group would be convened in early 2017 to agree a working plan for the year and key actions for the group to take forward.

Action: BB to arrange and facilitate another meeting of the working group

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Member Events BB reported that traditionally member events were held on a Saturday morning, however, this was reliant on staff across the Trust giving up their time in order to facilitate, which at times of pressure and escalation was proving difficult to schedule. Following staff suggestions and discussions with the Chairman agreement was reached to trial the next member event during the week, with the hope of encouraging more public and staff members to attend. The next member event would be held in early 2017 and the topic would be urgent and emergency patient flows and pathways. A date would be circulated in due course. 5. Membership Statistics

5.1 Membership Breakdown Report & Comparison BB gave an overview of the information contained within the reports and highlighted that the Trust had recruited 69 members since the last Membership Strategy Committee held in September 2016. A report on public members was circulated so that the comparison figures could be provided from the previous meetings with very little change in terms of demographic information. 5.2 Eligibility Report & Comparison BB presented the eligibility reports and clarified a couple of points which had emerged in respect to the catchment areas and recording of data, due to the constituencies being wrongly mapped. It was confirmed that this would be addressed with MES. 6. Membership Recruitment

6.1 Membership Data and Recruitment BB gave an overview of the report which provided an update on new members from 1 September 2016 to 15 November 2016. BB reported that the total public membership was 5,807, which included the non-core public members. Once again the committee discussed the difficulties of increasing membership in under-represented groups, for example, in certain age ranges, specifically the 18-50 categories and in the diverse communities that the Trust serves. It was agreed that further work and analysis was required in this area and this aspect of work would be part of the overall plan for recruitment. This would be taken forward for discussions to be held in the next working group. BB advised of the pilot in Endoscopy whereby initial response and return of membership forms being given out to patients was limited, however, the manager of that area had tasked a Healthcare Assistant to actively work on promoting membership, which was starting to see some results. An update would be provided at the next meeting and consideration given to other areas for roll out. It was reported that the overall membership consisted of 11,196 public members. BB explained the importance of maintaining the membership to circa 6,000 members.

Action: Increasing membership in under-represented groups to be part of the overall recruitment plan considered by the working group.

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7. Membership Strategy 2016 – 2018 As discussed at previous meetings, BB gave an overview and confirmed that the membership strategy was still relevant and fit for purpose although some minor adjustments were required. BB reported that to date she had received no feedback or comments from any Committee members; however, in discussion with WG it was suggested that the strategy had some areas of duplication and needed to be streamlined, with an associated action plan and focus on key activities. BB suggested that the strategy is reviewed in some detail at the next meeting of the working group. In advance of and in preparation for this meeting she advised that she would research and review best practice in other Trusts and requested that members also review the document in order to input into discussions at the meeting.

Action: All to review the Strategy in preparation for discussion at the next working group meeting.

8. Volunteer/Membership Engagement/Recruitment PW, Volunteer Co-ordinator briefed the committee on the work that had been undertaken in the period since he had been appointed to the post in May 2016, and how his work with volunteers can support the Trust. PW explained the process and activities that had been developed to recruit volunteers and the synergies and links that could also be developed with the membership. PW reported that he was working closely with further education colleges in recruiting students into volunteer roles and as a result would also encourage membership recruitment. Through all of his volunteer recruitment activities, membership of the Trust would be proactively recommended as part of induction. PW advised of a number of new volunteer roles that had been developed and were being rolled out across the Trust. It was hoped that in some areas such as Outpatients, Accident and Emergency, Access Lounge and Discharge Lounge that the volunteers could support membership recruitment. 9. Any Other Business There was no other notified business reported. Date and Time of the Next Meeting

The next meeting is scheduled to take place on Monday, 6 February 2017 at 11:00am, in the Boardroom, University Hospital of North Tees.

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North Tees and Hartlepool NHS Foundation Trust Minutes of the Governors’ Strategy and Service Development Committee Meeting

held on 19 December 2016 in the Boardroom, University Hospital of North Tees

Present: Jonathan Erskine, Non-Executive Director (Chair) Julie Gillon, Chief Operating Officer/Deputy Chief Executive Alan Smith, Elected Governor, Hartlepool John Edwards, Elected Governor, Stockton Janet Atkins, Elected Governor, Stockton Margaret Docherty, Elected Governor, Stockton Tony Horrocks, Elected Governor, Stockton Mark White, Elected Governor, Stockton Wendy Gill, Elected Governor, Sedgefield Steven Yull, Elected Governor, Staff In attendance: Lynne Taylor, AD, Strategy and Performance Hilton Heslop, Strategy Development Manager Fiona Dinsdale, Clinical Business Change Lead Chris Tulloch, Deputy Medical Director Jennifer Geoghegan, PA Raechel George, FOI Lead

Actions

1. Welcome/Apologies for Absence The chair welcomed members to the meeting. Apologies were received for Kate Wilson, Elected Governor for Stockton, Alison McDonough, Elected Governor for non-core public, James Newton, Elected Governor for Stockton and Patricia Upton, Elected Lead Governor for Stockton.

2. Outpatients Transformation Project Fiona Dinsdale, Clinical Business Change Lead provided an overview of progress with the review of Outpatients Transformation Project and advised that meetings had been held with Health Watch, colleagues, staff and patients to look at:

Pre-appointment

Arrival

Post-appointment

Consultation The top 3 themes had been considered and discussed for each of the above areas. Future plans had also been discussed, including a 10 week trial, to commence in March 2017, introducing kiosks for appointment registering. An outcome from discussions demonstrated no real difference in views between UHNT and UHH sites. A member raised concerns regarding blood tests, suggesting that they should be completed prior to consultant appointments so that results are available to the consultant prior to the appointment. Chris Tulloch responded to the query, agreeing in principle, however identified two potential problems:

- This would involve 2 visits to the hospital for patients. - Patients may not attend their blood test appointment. -

A member queried the communication of updates to patients, in waiting areas, waiting for

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Actions

appointments. It was confirmed that there are posters in waiting areas urging patients to request an update from staff if they have not been called within 20 minutes. Following a query on the x-ray process, Chris Tulloch advised that the process varies depending on whether the patient is new or existing. A member raised concerns regarding data protection of patient information with the proposed electronic check in system. The COO/DCE advised that the personal history of the patient will never be made available via this system. The Chair thanked everyone for their contribution.

3. Corporate Strategy Workshop The Corporate Strategy was introduced and as agreed previously a workshop discussion was held in order to evaluate and refresh the existing strategic direction with the following main outcomes. The Corporate Strategy was last refreshed in 2014. Since then there had been many changes and now there is one overall framework/main overarching strategy. The focus is the next 5 years looking at Strengths, Weaknesses, Opportunities and Threats. The lifespan for these is until 2020/21 however they will be reviewed annually. Strengths In reviewing the strengths, the COO/DCE recommended that the Trusts reputation be publicised in order to strengthen its reputation externally and to convert this into an “opportunity”. Discussion ensued in respect to the strong Board of Directors and a member queried how this can be demonstrated and evidenced. The COO/DCE advised that it is important for management to evidence this by interpreting things that had been commended by the CQC into reality. It was suggested that use of the word “strong” be reviewed with alternative wording such as “committed” or “dedicated” considered. Suggestions were also made by members on ordering and formatting. In terms of Community Services Integration, concern was raised regarding follow up appointments and the serious problems that exist within the system, not least with availability of places and resources through social care. The COO/DCE advised that working collaboratively with social care services should be put into the “opportunity” category and highlighted the importance of cross boundary integration. A member queried why ‘governors and members’ is identified as a strength. The COO/DCE advised that the Governors have a key role to play in supporting the activity of the Trust and their liaison and links with the community. By their involvement they are well informed, independent and offer the ability to have a challenging debate, putting forward member views. The COO/DCE suggested quantifying this by putting a preface to this effect with regards to the Governors. Weaknesses: A review of the list of weaknesses was undertaken with Lynne Taylor, AD Strategy and Performance providing an update as some of the weaknesses originally listed had changed following a recent Business Team Meeting.

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Actions

Opportunities: Following a review of the opportunities, a member suggested that sustainability and transformation plans should certainly be included within the “opportunities” section. A member advised that working across 2 sites could be classed as an “opportunity” for working in a more collaborative way with other organisations. Threats: It was noted that some threats had already been addressed in terms of the political and economic plan. A general comment was suggested in changing the “SWOT” analysis so that statements aren’t inappropriately forced into categories; the COO/DCE agreed and suggested rewording statements and formatting approach. Corporate Strategy: The COO/DCE advised that it is important to ensure that the Trust profile and the way success is measured is right as this is what will be used to monitor progress and assess delivery against objectives. The COO/DCE confirmed that ‘Putting Patients First’ is the top priority for the Trust; it is more than an aim; it is the Trust’s philosophy. The COO/DCE explained that ‘Health and Wellbeing’ had been included not only to ensure the health of the communities served was considered, but also as a reminder for people to take responsibility for their own health and wellbeing. A member suggested that instead of ‘Integrated Care Pathway’ being a separate objective that it was included under the service transformation heading. The COO/DCE advised that sustainability is a major issue for the Trust and needs to be reflected in Sustainability and Transformation Plans (STP). The Chair suggested that the “service transformation” objective be reviewed and phrased differently. A member recommended that a statement be included about how the Trust values staff. A further suggestion was to relook at “Momentum” as an objective and consider review or renaming. Strategic Measures and Metrics: Following discussion, suggested measures that the Governors would like to be included was as follows:

Patient safety

Infection

Weekend mortality

Dementia (recognition and case management) The COO/DCE suggested the focus shifting to a different priority now that HSMR and SHMI are reporting within limits. Following discussion, a member advised that it would be sensible to continue to include HSMR and SHMI to acknowledge that it had shown steady improvement. The Chair noted that following recent advice from Jeremy Hunt “avoidable deaths” data may have to be included. Discussion ensued on the measures for Patient Satisfaction and all agreed that

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Actions

compliance and completion of the Family and Friends Test required improvement. Although it was noted that involvement with the SPEQS panels was an important way of gaining feedback and also provided an opportunity for staff to input into the process and make suggestions/feedback. The COO/DCE reported on clinical sustainability and identified that the three key priorities to be included within the strategic measures was breast, urology and pathology. It was noted from a non-clinical sustainability perspective that the Lord Carter report and resulting recommendations formed the basis and focus for work going forward. The quality of services was discussed and reference made to the CQC ratings from 2015 of ‘requires improvement’. The future direction will ensure not only a move to “good” but aspiration to “outstanding”. The investment of capital in the Trust will be critical to the achievement of the corporate strategy and will be one of the key measures. The Clinical Services Strategy and STP provide details on the clinical outcomes, service redesign, estate and capital required. As previously discussed in the meeting, social integration and system change will enable care to be delivered closer to home and aligns with the STP. It was noted that delayed transfers of care will be a key area of concentration and review from a system wide approach. As a University Hospital it was recognised that research and development plays an important role and all agreed that the profile for R&D needed to be highlighted and consideration given to expansion of the portfolio of studies. The COO/DCE explained that there had been major improvements in the management of breast cancer to ensure achievement of key trajectories; however the same had not been achieved with other cancer specialities. The Chair advised the Committee that there was a lot to do regarding managing the expectations of the population, and as a Governor each had a role to play in working with members and the public. Hilton Heslop, Strategy Development Manager advised that further work is required on the Corporate Strategy and the session had provided some valuable feedback. The Strategy will again be shared with clinicians for final views/comments; the SWOT and PESTL analysis will be reviewed, and the key measures will be re-looked at to agree key targets. The Chair thanked Lynne Taylor and Hilton Heslop for their informative and thought-provoking workshop. 4. Compliance and Performance Position

The COO/DCE provided an overview of the Corporate Dashboard highlighting performance against key access targets. The Trust had performed relatively well against the majority of key operational standards with some recovery evident despite the considerable challenges associated with on-going operational, clinical, financial and system wide pressures The COO/DCE reported that the Trust had performed extremely well against the 62 day cancer standards in October. Some of the key issues in the last few weeks was noted as:

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Actions

Compliance with the 4 hour standard in A&E; there had been acuity and capacity issues in A&E as a result of increasing demand.

The Trust continued to be on track to achieve the diagnostic standard.

An increase in paediatrics occupancy had resulted in diversions to different Trust departments on several occasions.

Delayed transfers – peaked at 44 delayed transfers in October predominantly due to the lack of nursing home care beds. Work is underway in order to improve this position.

The COO/DCE agreed to continue with distribution of the dashboard report monthly prior

to the meeting.

5. Any Other Business Previously Noted A member suggested that meetings could be held in UHH as well as UHNT. The COO/DCE advised that previously when meetings had been held at UHH the attendance had been poor, following which agreement was reached to hold future meetings at UHNT, but to review this periodically. Following a member suggestion, the COO/DCE agreed to arrange a tour of the UHH site for members of the Committee. . Agreed Actions:

A tour of the UHH site to be arranged for Committee members.

COO/DCE

6. Notes of Previous Meeting held 21 July 2016/Action Points The minutes of the previous meeting were accepted as a true and accurate record.

7. Feedback to Council of Governors’ Meeting It was agreed that Steven Yull would present the minutes of this meeting at the next Council of Governors meeting. Agreed Actions:

Steven Yull to present the minutes of this meeting at the next Council of Governors meeting.

SY

8. Date and Time of Next Meeting The next meeting of the Governors’ Strategy & Service Development Committee was scheduled to be held on Monday 20 March 2017 at 1.30pm in the Boardroom, University Hospital of North Tees.

Approved: Date:

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