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The Hillingdon Hospitals NHS Foundation Trust

Part I (Open) Meeting of the Board of Directors

Wednesday 30th January 2019, 2pm Board Room, Hillingdon Hospital

Item Status Presenter Page Introductory

1 Welcome and apologies for absence information Chair Verbal

2 Declaration of hospitality, Declaration of amendments to the Register of Interests, Declarations of Interest on items on the Agenda

decision Chair Verbal

3 Minutes of the Part I (Open) meeting 28th November 2018 decision Chair

4 Action Log decision Chair

5 Declaration of Any Other Business information Chair Verbal

6 Patient Story information J Walker Verbal

7 Chair’s Report information Chair Verbal

8 Chief Executive’s Report information S Tedford

Strategy & Governance 9 Review of Executive Structure decision S Tedford 10 Patient & Public Engagement Strategy decision J Walker

11 Quality Account Priorities 2019-20 decision J Walker

12 Nursing Establishment Review decision J Walker

13 The NHS Long Term Plan discussion J Ross

14 Impact of Brexit: implications and actions discussion T Roberts

Performance & Assurance 15 Winter Planning monitor J Smyth

16 Integrated Quality & Operational Performance – December 2018

monitor J Smyth / J Walker / T Roberts

17 Financial Performance Report – December Month 09 monitor M Tattersall 18 NHS Improvement Undertakings: progress update and

assurance monitor J Smyth / M

Tattersall 19 Thematic Care Quality Commission Action Plan monitor J Walker 20 Corporate Risk Register – High Risks monitor J Walker

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21 Board Assurance Framework monitor J Walker

22 Estates Update monitor J Philpot Verbal or report to follow

23 Learning from Deaths Quarter 2 - 2018/19 Update monitor A Khakoo

24 Guardian of Safeworking – Annual Report 2017/18 decision A Khakoo

25 Safer Nurse Staffing Update monitor J Walker

26 Safer Medical Staffing Update monitor A Khakoo

Information 27 Reports back from Committees – Finance & Performance,

Quality & Safety, Audit & Risk, Charitable Funds, Nominations, Remuneration

information Committee Chairs

28 Minutes of Committee meetings information Committee Chairs

29 Use of Trust Seal - none to report information M Sims Verbal

Questions from the Public 30 Questions from the Public

This item is an opportunity for members of the public to ask questions to the Board on matters that relate to the Board agenda. Where possible, questions should be sent to the Trust Secretary, by Monday 27th January 2019 in order that the Board can ensure the information is available to answer the question raised.

discussion Chair Verbal

Date of next Meeting

Date of next meeting - Wednesday 27th March 2019 at Hillingdon Hospital

information Chair

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THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

MINUTES OF THE PART I (OPEN) MEETING OF THE BOARD OF DIRECTORS HELD ON WEDNESDAY 28h NOVEMBER 2018 AT 2PM

MOUNT VERNON HOSPITAL IN THE BOARD ROOM

MEETING HELD IN PUBLIC

Present: Richard Sumray Chair Soraya Dhillon Deputy Chair and Non-Executive Director Lis Paice Non-Executive Director Richard Whittington Non-Executive Director Cheryl Coppell Non-Executive Director Keith Edelman Non-Executive Director Linda Burke Associate Non-Executive Director Sarah Tedford Chief Executive Abbas Khakoo Medical Director Terry Roberts Director of People and Organisational Development Joe Smyth Chief Operating Officer Matt Tattersall Finance Director Jacqueline Walker Director of Patient Experience and Nursing

In Attendance: Chris Navaroe Midwife Specialist Safeguarding Team J Philpot Director of Strategic Estate Development and Asset

Management James Ross Director of Strategy and Transformation Mike Sims Trust Secretary

Members of the Public: N Hadithy

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Action Introductory 1 Welcome and Apologies for Absence

The Chair welcomed all to the meeting, in particular S Tedman who was attending her first Board. He also passed on thanks to D Smith as Interim Chief Executive for the work he had undertaken which was of excellent quality in his short time at the Trust.

He went on to report that this would be the last meeting for C Coppell who would be leaving the Trust at the end of November to focus on a Sustainability and Transformation Programme (STP) role elsewhere in London. On behalf of the Board he passed on his thanks for all her contributions. He added that three Executive Members of the Board, M Tattersall, J Smyth and A Khakoo would also be leaving the Board at the end of January 2019, although they would be attending the Board meeting on 30th January 2019.

2. Declaration of hospitality, Declaration of amendments to the Register of Interests, Declarations of Interest on items on the Agenda

None

3 Minutes of the Part I (Open) meetings of 26th September 2018

Page 9 – Structure of the A&E Delivery programme – the Chair said the reference to the Winter Planning Report to Board should have been identified as an action.

Page 16 – Medical Education –delete “although this could backfire should a residual skill level exist” and rephrase next clause to read “A Khakoo agreed, although expressing some concern on the skills mix”.

Page 17 – People Strategy – replace “Developing commitment” with “Nurturing our people”

Page 17 – People Strategy – delete “L Burke replied by saying she felt she could assist in reducing the unit cost of introducing these roles and told the Board again this was a critical issue that kept returning time after time” and replace with “L Burke suggested that she could identify another Trust / University that had had some success in reducing costs if that would be helpful”.

Page 18 – People Strategy – replace “A Khakoo said he was currently unconvinced by a strategy” with “A Khakoo said he was convinced of the need for a strategy”.

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With these amendments the minutes were approved as an accurate record of the meeting

4 Action Log

The following actions were accepted as completed; 216, 230, 240, 241, 244, 247, 249, 250, 251, 252, 253,254,255,256 and257

• 198 - Feedback on progress with ensuring continued awarenesson End of Life (EoL) February Board Seminar – Noted this was nowbeing considered now for the December 2018 Board Seminar

5 Declaration of Any Other Business

None

6 Patient Story

J Walker introduced C Navaroe who presented a patient story concerning an 18 year old female who had presented as pregnant with mental health issues, highlighting the involvement of the Trust’s Topaz Team which had assisted through continuity of care in encouraging her to place her Trust in hospital staff resulting in a successful birth and the delivery of a child care plan.

She explained that the issues when the patient presented were; • Ongoing mental health issues• Substance and alcohol misuse• Isolation - she was estranged from family• Living in semi- supported accommodation• Experience of abuse• The father of the baby was unknown• That she described her family as “difficult and dysfunctional”• She had indicated at booking that she was no longer in contact with the

people she used to associate with

C Navaroe pointed out there were multiple agencies involved in her care; • Community Mental Health Team• P3 Navigator• Children’s Social Care• Topaz Team

In terms of support there was; • Continuity of care given by the Topaz Team due to a complex social

history• A referral for the unborn child to social care

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• Liaison and joint working with partner agencies, mental health, P3Navigator , social care and health visiting service

For the pregnancy, birth and postnatal care there was; • 1: 1 Parenting facilitated by Topaz team, completed her own birth plan• Continuity of care to improve outcomes• Attendance at Bump and Beyond parenting classes at a Children’s

Centre• The baby being placed on a Child Protection Plan under the category of

Emotional Abuse• Support with items for the baby by Topaz team• The birth of a healthy child• Breastfeeding• Support by professionals through Multi-disciplinary working

Overall the positives outcomes had been; • The recognition of the value of continuity of care from the Topaz Team

and the fact that she had volunteered to speak at the Young mum’sparenting class facilitated by Topaz to share her story

• That she had engaged with professionals and worked towards her goalsset in the Child Protection Plan to address the concerns raised byprofessionals around her chaotic lifestyle and impact on her parenting

• The fact that all case conferences and core groups had been attendedby Topaz Team

The Chair asked if there had been any complications at birth. C Navaroe confirmed there had been none.

He asked how the relationship of the team with Children’s Social Services had worked. C Navaroe explained that she did have a very good relationship with a particular social worker but that the allocated caseworker changed several times and thus the patient had developed more of a relationship with the Topaz Team.

L Paice asked if there was now a transition plan in place. C Navaroe confirmed the patient was now 19 but the Topaz Team would still continue to see her, and the aspiration was the child could come off a child protection plan to be classified only as a child in need.

C Coppell asked whether there was any model in terms of the continuity of care the team could share with others in the Trust. L Burke also pointed out that any learning relating to the relationship with the Local Authority around discharges would be beneficial for other Teams in the Trust. The Chair added that there were cost savings to be gained in ensuring co-ordinated discharges giving the example of not having to place children in care as an example.

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J Walker confirmed there were lessons that could be shared and that this would be undertaken.

The Chair said that the collaborative approach of the Topaz Team helped fill a gap that often existed in terms of the transition of care and asked that thanks be passed on to the team and the patient for sharing the story.

The Patient Story was noted

J Walker

7 Chair’s Report

The Chair reported to the Board on the visit of Lord O’Shaughnessy, Under Secretary of State for the Department of Health, and Sir Robert Naylor, National Estates Advisor to the NHS, to look at and discuss the Trust’s estate. He reported that Sir Robert Naylor had said that the estate redevelopment projects that would receive central government support would be those where there was evidence of the close involvement and support of the Local Authority. He also reported that he could confirm that the Health Secretary, Matt Hancock, had said he would visit the Trust at a date yet to be confirmed.

He explained that the Trust awaited news from NHSI on the announcement of whether £43m Shaping a Healthier Future (SaHF) funding would be received or not and that, in the meantime, progress on the development of the strategic outline case for the healthcare site at Brunel that needed to be considered by the London Estates Board was a priority, as well as continuing to develop a plan for keeping the estate both at Hillingdon and Mount Vernon running in the short-term.

The Report was noted

8 Chief Executive Report

S Tedford introduced a report for information which updated the Board on; • Winter Planning• Improvements• New Medical Models• Hillingdon Improvement Practice (HIP)• Public car parking tariff increase

She reported that the Board would receive a full report on Winter Planning at the January Board and that, in summary, whilst winter funding was being received there was still likely to be pressure on the capacity to deliver services over this period.

J Smyth added that the modelling completed in March 2018 suggested the Trust would be 40 beds short in the winter period but through a

J Smyth

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combination of being able to reduce the number of beds for stranded patients as well as the closure of other beds in Pinewood and Kennedy Wards the Trust would be able to cope.. He added that the Trust was in negotiation with the Clinical Commissioning Group (CCG) on some elements of funding.

S Dhillon said the closure of beds was to be commended and asked what was expected from the primary care sector and Urgent Care Centre (UCC) in helping to deliver winter planning objectives through making less inappropriate referrals. J Smyth said that in terms of primary care the issue was that, whilst the CCG had invested in hub sites for more GP appointments, the public still tended to visit the hospital as they wanted a “one stop” service as opposed to a series of referrals to specialist services through a GP. In terms of UCC the Trust held weekly liaison meetings which included the appropriateness of referrals and that there were plans for them to offer taking blood samples as well to reduce referrals into the hospital. S Dhillon asked whether patients could be triaged to hubs for GP appointments. J Smyth said this was technically possible but in practice proved difficult once already booked into hospital’s triage system. L Burke asked if the Trust was able to track referrals by Practice. J Smyth said the Trust did not do this although the CCG held this data.

L Paice commented that she was concerned about the uptake of hub appointments and asked what the Trust did to promote this. J Smyth said the Trust promoted their availability at the stage of triage and there were other area systems that used direct online booking. S Tedford added that models existed where primary care appointments were made available within 24 hours were handed out at hospitals at the point of triage.

The Chair concluded by saying it would appear the primary care sector was not fulfilling its role in terms of winter pressures as had been proposed. J Smyth said the Trust had documented its concerns on demand management performance to the CCG.

The Chair asked whether there were any early indications that performance was improving with the recent opening of the new A&E facilities. J Smyth reported that given the new facility had only opened in the last three days it was too early to tell.


Strategy and Governance 9 Delivery of the Strategic Plan 2017-21 Update

J Smyth introduced a monitoring report asking the Board to note the update on progress against strategic objectives 2018/19.

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The Chair pointed out the objective on flu vaccinations should be 90%, not 75% and that this should be changed as reported in the Strategic Plan 2017-21.

T Roberts reported that currently the staff vaccination rate stood at 55% and that whilst the Trust was not on target to reach 90% it was still in the top three performing Trusts in London for this indicator.

The Chair challenged the accuracy of the data in the report in relation to the figure used for financial deterioration, the implication that the Financial Improvement Plan was owned by PA Consulting as opposed to the Trust itself and the start date of turn-around specialist, Kingsgate. J Smyth agreed that the first two were incorrect. M Tattersall said that Kingsgate had been appointed in November as reported.

The Chair added that he agreed that the transfer of elective orthopaedic activity to Mount Vernon Hospital was proving a success but that he believed even more elective work could still be undertaken at the site.

L Paice said that she would like to see the metrics for the indicator on patient activation measures in terms of self-management being used as a measure of progress.

The Chair summarised by saying that there were a significant number of indicators under “what needs to be done” that still required completion and that the Board would review the final achievement of objectives at its May 2019 meeting.


J Smyth

J Smyth

10 Trust Charity – Annual report and Accounts 2017-18

M Tattersall introduced a report for decision asking the Board to approve the Charity Report and Accounts for 2017/18.

M Tattersall advised that the Independent Examiner’s Statement confirmed no matter came to their attention that was of material concern.

M Tattersall advised that the Independent Examiner’s Statement confirmed no matter came to their attention that was of material concern. He added that the Annual Report covered; • The Charity’s objectives• A review of the Years Activities• A financial review• The reserves policy• A statement of risk management• A going concern statement

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• The Grant Distribution Policy

L Paice commented that the amount spent on staff support seemed very little. The Chair said that T Roberts was undertaking an assessment of staff facilities which the Charitable Funds Committee could then review so that the Charity could make effective interventions in this respect.

J Smyth added that as and when any schedule of possible improvements was able to be confirmed it would prove to be very popular with staff.

The Chair asked the Board to note that a volunteer manager was now in post.

The Board agreed; Charity Report and Accounts for 2017/18

11 Terms of Reference of the Finance & Performance Committee and its membership

The Chair introduced a report for decision asking the Board to; • Approve the proposed amendments to the Terms of Reference• Approve the addition to the membership of the Committee of T Roberts,

Director of People and Organisational Development

M Sims explained that, in addition to including the detailed monitoring of performance, it was proposed that the function of recommending to Board the proposals for of Strategic and Operational Planning were also included within the terms of reference of the Committee.

The Board agreed; To approve the proposed amendments to the Terms of Reference To approve the addition to the membership of the Committee of T Roberts, Director of People and Organisational Development

12 Charitable Funds Committee self-assessment

The Chair introduced a report for information asking the Board to note that all other Committees had completed their self-assessments at the beginning of the financial year apart from the Charitable Funds Committee; hence the report was being presented now.

He reported that the that the strategy was relatively new and Committee agreed they had actively helped in its development, and that members believed the current terms of reference were fit for purpose.


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Performance and Assurance 13 Integrated Quality & Operational Performance October 2018

J Smyth introduced a report for monitoring asking the Board to review the analysis of quality, experience and operational performance for October 2018 in relation to the Care Quality Commission’s (CQC) intelligent Monitoring systems domains, safe, caring, effective, responsive and well-led. He said that in relation to A&E performance the biggest single factor in the reporting period had been the number of those over 80 years old presenting who then had to be admitted. He stressed that care home admissions had increased significantly and that, going forward, this was a key area for discussion with the CCG in terms of the concern that there was insufficient primary care support contracted for care homes, inevitably resulting in more hospital admissions. He added that whilst it was acknowledged that there were an additional 50 care home beds expected to be provided by the Local Authority in Hillingdon over the next 18 months the position would only improve with the CCG working with GPs to refer more patients back into the primary care system as opposed to the acute sector. Both the Chair and C Coppell referred to the expected role of the Hillingdon Healthcare Partnership (HHCP) in terms of reducing the number of care home referrals. J Smyth agreed, stating that demand management in general required a continued dialogue with the CCG. The Chair reminded J Smyth that at the September meeting he had reported that he believed that the 4-hour A&E standard would have achieved the 90% target by November and asked him why this had not been the case. In response J Smyth said that; • Issues in terms of operational grip and control remained • Delay codes were not being used appropriately • The numbers of discharges each day had not improved The Chair requested that an update on these barriers to delivery should be provided at the January meeting. S Dhillon said that in terms of her experience of Serious Incident (SI) management as Chair of the SI Committee the Trust needed to provide more clinical governance administrative support to clinicians. J Walker said she had carried out a reorganisation of clinical and corporate governance within her Division and expected to see an improvement in the ability to provide better support as a result. She added that the Trust had received a Contract Performance Notice from the CCG in respect of SI reporting and that the Quality and Safety Committee had reviewed and changed the reporting methodology for SI reporting which would assist in mitigating the

J Smyth

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risk of failing to report to agreed deadlines.

A Khakoo said; • He had concerns about the data he had requested from Hunter on

clinical efficiency which had not as yet been provided• He wanted to see better Sepsis performance management reporting

KPIs and that he hoped that this would be agreed under the item on theagenda on Sepsis Policy

• That a deep dive of medicines indicators would take place at Qualityand Safety Committee in February 2019

The Chair questioned whether the Infection Prevention Control data in relation to the time period for Model Hospital peers was correct. J Walker agreed to review this.

He then asked whether there was any explanation for the rise in C-Sections. A Khakoo said that whilst he recognised the increase, he saw no clinical reason that suggested the C-section rate to date was unjustified. J Walker added that the CCG had raised the same initial concern, but following investigation in conjunction with the Trust had found no cause for further review.

The Chair suggested that mixed sex accommodation had not been an issue in the past but the report indicated it was, and he questioned why this was the case. J Smyth said that the issue of mixed sex accommodation may arise when a patient in ITU was not moved after six hours and the Trust usually performed well on this but for this reporting period had not.

T Roberts reported that only two of the key indicators – PDRs and Statutory Training – were trending in the right direction with vacancy rates, staff turnover and sickness increasing. He reported that he had tasked the HR Team to focus on Divisional “hotspots” in terms of poor performance in these three areas, explaining that the January performance report should include a commentary on actions to address concerns in these specific areas.


J Walker

T Roberts

14 NHSI Improvement Undertakings: progress update and assurance

J Smyth introduced a report for monitoring asking the Board to note progress and assurance provided in the report to be presented to NHSI on Undertakings relating to A&E, finance and governance as agreed in June 2018.

He said that the report format agreed with NHSI for undertakings was to provide a Red / Amber /Green (RAG) rating and that for October the ratings

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for Emergency Care were; • Green – 18• Amber – 3• Red - 3

M Tattersall reported on finance and governance undertakings stating that all areas of reporting compliance had been met.

J Smyth added that the contract for Hunter Consulting who had been providing support in A&E was finishing at the end of November and that a report evaluating their impact on performance would be reported to Finance and Performance Committee in December.


/15 Financial Report – Month 7

M Tattersall introduced a report for monitoring stating that the month 7 financial position showed; • A M6 deficit of £1.6m, £1.9m behind plan, but achievement of

forecast.• A year to date deficit of £14.5m, £9.9m adverse to plan.• Agency expenditure of £0.8m in month, an increase on previous

month.• Pay was overspent by £0.9m in month but better than forecast.• A Finance and Use of Resources score of 3.• Efficiency savings of £0.7m in month.• Capital expenditure of £0.9m in month.• A cash position of £1.1m at month end.

He added that; • NHSI’s official position was that they had not updated the forecast that

the Board had approved in October of a £7.2m overspend on theexisting forecast position

• He would report back to the December Finance and PerformanceCommittee in December his view on the robustness of Kingsgate’sforecast on further 2018-19 efficiency savings

The Chair reassured the Board that the Finance and Performance Committee had, at its November meeting, been through the financial report in great detail and overall he was pleased to report that the data evidenced that there was stability returning to forecast and actual spend patterns.


16 Thematic Care Quality Commission improvement plan

J Walker introduced a report for decision asking the Board to;

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• Review and approve the thematic Care Quality Commission improvement plan

• Agree the proposed governance and reporting arrangements in the report

The Chair said it would be the case that there would be items relating to how well led the Trust was that may need adding to the actions in the report that would require ownership directly through the Board or the Audit and Risk Committee. S Dhillon sought clarification on how Divisional ownership and accountability was being achieved with the Action Plan. J Walker replied stating that the Regulation and Compliance Committee (RCC) reviewed whether ownership was taking place as well as progress on completing objectives which was then reported in the same format as Board received to the Quality and Safety Committee. S Dhillon also sought assurance that the report was being reviewed at clinical governance meetings. J Walker confirmed that this was the case. The Board agreed; To approve the thematic Care Quality Commission improvement plan The proposed governance and reporting arrangements in the report

17 Guardian of Safeworking Report A Khakoo introduced a report for monitoring updating the Board on progress on the implementation of the 2016 contract for junior doctors for the period September 2017 to April 2018, adding that the report for the period May to July 2018 had been delayed due to issues relating to data access. He reported that all Junior Doctors were now on the 2016 contract. L Burke said the data on the understanding of exception reporting and reportable events was not that clear and open to interpretation, asking that the next report clarified more clearly the difference between the level of understanding of exception reporting as opposed to the actual level of exception reporting. The Chair said that in particular he saw the Junior Doctor Forum as a critical means of staying in touch with issues on conditions of service as had been highlighted by the report. The Report was noted

A Khakoo

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18 Learning from Deaths Update

A Khakoo introduced a report for monitoring asking the Board to note that quarterly reporting of deaths falling within certain criteria to the Trust Board was a requirement from NHS Improvement.

The Chair asked how learning from deaths was disseminated to relevant staff. A Khakoo said that this took place through; • Circulation to all consultants and junior doctors and discussion at their

meetings• Quarterly reports to the relevant clinical committees• Review at the Mortality Surveillance Group

The Chair said the next report should focus more clearly on the themes emanating from deaths, stating specifically what the learning was from these themes and what the proposals were, if any, on doing things differently.


A Khakoo

19 Safer Nurse Staffing - update

J Walker introduced a report for monitoring asking the Board to note that; • Shift fill rates and Care hours Per Patient Day (CHPPD) averaged

across the month were sufficient to support safe care• At the Hillingdon site the Health Care Assistant (HCA) fill rate continued

to be above plan at night but improved significantly due to right-sizing ofestablishments and improved rigour when assessing staffing demandand capacity for each shift

• At the Mount Vernon site average fill rates and CHPPD were stable.Where these were showing below plan because of flexing staff in linewith varying activity on Trinity Ward

• There was a slight drop in Registered Nurse (RN) vacancies at theHillingdon site in October following the September increase

• Implementing supervisory status for Ward Managers increased RNvacancies by one whole time equivalent across each ward within thescheme and to prevent increased use of temporary staffing, a phasedapproach had been adopted with a gradual increase in the number ofsupervisory shifts undertaken

• A review of the reasons for an increase in pressure ulcers on KennedyWard would be taking place


20 Serious Incidents Summary Report

A Khakoo introduced a monitoring report which provided an overview of Serious Incidents (SIs) including never events reported by the Trust for the period 1st April 2018 – 31st October 2018 asking the Board to; • Discuss the report

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• Note the Contract Performance Notice (CPN) received with regard toSerious Incident Reporting and investigation timelines from the CCG

The Chair said that a number of key issues on SIs had been covered in the discussion on the Integrated Performance Report.


21 Sepsis Policy

A Khakoo introduced a report for decision asking the Board to approve a Sepsis Policy. He explained that; • This was a new policy given sepsis management had been governed by

the appendix on sepsis management previously contained within theManagement of the Deteriorating Adult Patient Policy

• Approval of this policy at Board was a requirement as part of theHillingdon Quality Undertakings Action Plan agreed with NHSImprovement (NHSI)

C Coppell suggested the report would have benefited from having an action plan that accompanied it since it had been a major focus of the group reviewing patient deterioration. A Khakoo said that action points to improve Sepsis management existed in other plans and therefore were not included with the report, the main purpose of bringing the report having been to provide assurance on quality undertakings to NHSI that the Board was sighted on the new policy.

The Board agreed that there would need to be KPIs on Sepsis. A Khakoo replied that the two indicators to be reported would be screening and time to treatment.

The Board agreed; To approve the Sepsis Policy

A Khakoo

22 Staff Survey – Action Plan Update

T Roberts introduced a monitoring report updating the Board on the key actions taken at a corporate level which have helped to address the 2017 survey findings as well as updating on the survey response rate to date for 2018.

He reported that the key corporate actions completed were; • The introduction of supervisory status for Band 7 ward managers• Training managers in coaching to provide more support to their staff• Developing a policy to ensure all staff have 1-1 meetings with their

manager• Launching the iDevelop learning management system to make

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Statutory and Mandatory Training (STAM) easier to access. • Launching Black and Minority Ethnic (BAME) Development Centres and

the Ethnic Diversity Network to increase equity • Rolling out the VIVUP staff benefits platform • Piloting GREATix, a system that recognises staff for innovation and

displaying our values. • More overseas nurse recruitment • Routinely reviewing the Datix information system to provide HR support

directly to those reporting bullying and harassment He reported that as of 19th November, the Trust had achieved a 37.2% staff survey completion rate for 2018 and a concerted effort to build the response rate up to meet the 55% target for this year was being pursued. The Chair said that in terms of the 2018 survey results he expected that as soon as data was received giving a broad indication of outcomes, an early action plan could be formulated. L Burke suggested it may be useful to look at “hotspots” in relation to poor survey results across a number of indicators where HR resources could then be focused. The Report was noted

23 Healthy January T Roberts introduced a monitoring report updating the Board on activities to be undertaken as part of the Healthy January launch of the 2019 health and wellbeing campaign. The Board agreed that a “dry January” campaign should be added to the list of initiatives being undertaken. The Report was noted

T Roberts

Information 24 Report back from Committees – Finance & Transformation, Quality

and Safety, Audit & Risk, Charitable Funds, Nominations, Remuneration. The Quality and Safety Committee had escalated for decision the issue of the provision of funding for using texting services to improve FFT response rates in A&E. The Board agreed a business case should be prepared with a view to possible implementation in 2019-20. S Dhillon requested that the Board receive a compliance report on

J Walker

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consultant job planning at some point after December 2018. The Report was noted

A Khakoo

25 Minutes of Committee Meetings The Report was noted

26 Use of Trust Seal The Report was noted

Questions from the Public 27 Questions from the Public

Question: Why did you use an external interim Chief Executive? Response: The new permanent Chief Executive, Sarah Tedford, had been appointed but could not start at the end of August and so the Trust appointed an interim until the commencement of her contract in November. Question: A person had a meeting with an employee of the Trust and was told on the day the appointment had been cancelled. Response: Please provide the details of the person and the appointment to the CE’s Executive Assistant and we will contact the person to discuss the appointment with them. Question: Can you give an assurance that the gulley at Appletree Avenue will be cleared by the Trust as the area becomes flooded by the river when it is blocked Response: The Trust is working with the Council to ensure the gulley is cleared on a regular basis. Question: Do you think it’s strange Mr Sumray that every Executive Director has left since you have been the Chair. Response: You would need to ask each Executive Director that question.

J Philpot

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Trust Board Part I Action Log

January 2019

Action No.

Meeting Date

Item Action Lead Due Date Comments

198 Nov 17 Patient Story Ensure continued awareness about EoLC to all Wards not just the two wards which experienced the most deaths

JW Oct 18 ( to Board) Presented at December Board Seminar - completed

258 Nov 18 Patient Story Topaz Team to share learning with other Teams on co-ordinating discharges with Local Authority

JW February 19 (to Board)

Not yet due

259 Nov 18 Chief Executive Report Provide Winter Planning Report to January Board

JS January 19 (to Board)

On Agenda - completed

260 Nov 18 Strategic Plan 2017-21 flu vaccinations target should be 90%, not 75%


Amended in Strategic Plan - completed

261 Nov 18 Strategic Plan 2017-21 Revise figure quoted in terms of financial deterioration and note PA Consulting do not own the FIP


Director of Strategy informed for future reporting - completed

262 Nov 18 Performance October 2018

COO to provide verbal update at January Board on the following in relation to A&E performance; operational grip and control delay codes and usage, daily discharges


COO will provide this update at the meeting when presenting Performance Report


Review IPC data in relation to the time period for Model Hospital peers

MS January 19 (to Board)

Reviewed and data did relate to 2016-17, however now updated to reflect 2017-18 - completed

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T Roberts said his January 19 performance report would include a summary of service “hotspots” in relation to vacancy rates, staff turnover and sickness

TR January 19 (to Board)

DPOD will provide this update at the meeting when presenting Performance Report although there are references to hot spots in the Performance Appendix

265 Nov 18 Guardian of Safeworking

Future reports to clarify difference between level of understanding of exception reporting as opposed to actual level of exception reporting.

AK January 19 (to Board)

Guardian of Safeworking informed for future reporting - completed

266 Nov 18 Learning from Deaths Next report to focus on the themes emanating from deaths, stating specifically what the learning was from these themes and what the proposals were , if any, on doing things differently.

AK January 19 (to Board)

Learning from Deaths Nurse informed for future reporting - completed

267 Nov 18 Sepsis Policy The Board agreed that there would need to be a form of KPI on Sepsis. A Khakoo agreed saying the two indicators to be reported would be screening and time to treatment.

AK March19 (to Board)

KPI not yet included in Performance Report – aiming to include for March 2019

268 Nov 18 Healthy January Include dry January in campaign TR January 19 (to Board)

There was no volunteer forthcoming to take forward a dry January campaign by 1st January. However details on alcohol related issues have gone out to staff in January newsletter - completed

269 Nov 18 Submit an FFT Texting business case

Submit an FFT Texting business case before 2019-290 financial year

JW March 19 (to QSC)

Proposed monitoring of this action transfers back to QSC action log as was escalated to board from that Committee - completed

270 Nov 18 Escalations Board to receive a compliance report on consultant job planning at some point after December 2018.

AK March 19 (to Remuneration Committee)

Already picked up at Remuneration Committee where a report is due back in March - completed

271 Nov 18 Questions Report back on action being taken in respect of flooding at Appletree Avenue

JP January 19 (Board)

Relates to the river at the end of the road. Trust is monitoring and when the levels get high Trust is clearing the grates where debris settles. Liaising with going forward on who is liable for ongoing clearance - completed

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Meeting of the Board of Directors – Public Part I session

Date of meeting: 30th January 2019 Agenda item 8

Report title: Chief Executive Report

Report author: Sarah Tedford Chief Executive

Report sponsor: Sarah Tedford Chief Executive

Board Action required:

The Board are asked to:

Note updates from the Chief Executive.

Link to the Hillingdon Hospitals Strategic Plan 2017/21:

STRATEGIC PRIORITY:

None

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Chief Exec Board Report – Jan 19

This paper provides the Board with an overview of matters to bring to the Boards attention which are not covered elsewhere on the agenda for this meeting. The Board is asked to note the content of this report.

Internal Matters

Executive Appointments

Joe Smyth will be leaving the Trust after 7 years as Chief Operating Officer. Joe will be staying in the area and working with us through the STP.

Matt Tattersall is also leaving at the end of January; he joined the Trust in 2016. Matt will be joining the Methodist Church of Great Britain as Director of Finance and Resources. This move will provide Matt with more time to enjoy family life.

Abbas Khakoo, our Medical Director is changing role, whilst continuing his clinical work as a paediatrician he will be working closely with Brunel University as well as supporting us within the Trust in the development of our clinical strategy.

I would like to take this opportunity to wish all of them well in their future endeavours, and look forward to hearing about their successes as they move forward.

I would like to welcome Jason Seez, who will be joining us as Deputy CEO and Director of Strategy on an interim basis from the 11th February, as well as Cathy Cale our interim Medical Director who also starts on the 11th February. They both bring with them wealth of experience which we will benefit from.

Interview processes are ongoing as we look to fill these posts substantively. We are also currently out to advert for a Director of Estates as Jeremy Philpot has secured a new post closer to home and will be leaving at the end of February 19.

Christmas Period I would like to start with a huge thankyou to all our staff for the hard work over the Christmas period. This is always a challenging time, but teams coped very well. Discharge Planning Good planning in the run up to Christmas identified that Social Services and Community Health would not take referrals from Friday the 21st. Appropriate escalation was taken and, as a result, it was agreed that both services would continue to take patients up to 17.00 on Christmas Eve.

During week commencing the 17th, there was intensive support for wards and medical teams to encourage discharging. An effective Command and Control centre was established and non-urgent meetings were cancelled. Additional support was provided to wards to fast track referrals to diagnostics and additional transport was

22

arranged. Pharmacy prioritised all prescriptions coming from the wards to ensure timely discharging from the wards.

The Occupational and physiotherapy services linked closely with the discharge to assess team to facilitate early discharge.

This effective team work and planning resulted that on Christmas Eve there were 65 empty beds in the hospital.

A&E Attendance

A&E attendances were below average over the Christmas Period, however admissions were above average indicating either higher acuity or lack of services on the bank holidays and over the weekend.

Admissions

Description Mon 24 Dec Tue 25 Dec Wed 26 Dec Thu 27 Dec Fri 28 Dec Sat 29 Dec Sun 30 DecTotal 59 68 64 66 87 66 63

Admissions remained high during the run up to Christmas (average admissions were 58) and were particularly high on Friday 28th and over the weekend (averageadmission for Saturday and Sunday is in the region of 45).

Discharges

There were significant discharges on Christmas Eve and Boxing Day and, indeed, across the rest of the week and into the weekend. This meant that on Monday 31 December the Trust still had escalation capacity on Pinewood with 20 Beds.

Mon 24 Dec Tue 25 Dec Wed 26 Dec Thu 27 Dec Fri 28 Dec Sat 29 Dec Sun 30 Dec70 15 35 59 80 55 50

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Staffing The Trust had additional medical staff on over the weekend before Christmas and during the weekend in the run up to the New Year. This allowed a flow of patients through the hospital which also prevented bed blocking. So, an improved, successful Christmas period. However, short notice and staff sickness was a problem that needs review and forward planning for 2019. Flu We have achieved 75% of all our staff being vaccinated against flu. This is a similar figure to last year External Matters Long term Plan The Long Term Plan has now been published. The focus being on :-

• Substantial investment in primary medical and community services

• Sustained commitment to mental health ( both children and adults)

• Creation of a digital front door for remote access to NHS services

• Preventative focus on tackling the causes of early mortality

• Improved outcomes for patients with key Long Term Conditions – cancer , Diabetes, cardiovascular, Respiratory, Stroke , Adult Mental Health

• Explicit ambition to improve child health

• Growing the workforce and tackling the implications of Brexit and immigration policy.

The plan will be delivered through Integrated Care systems- which will be rolled out by 2021.

• Primary care will host integrated teams of GPs, Community health and social care staff, typically serving 30-50,000 people.

• Contracted GP networks will manage population health and deliver integrated, risk stratified services from 2020/21.

• Digital GP consultations offered to all patients by 2024, and redesigned hospital support to avoid up to a third of outpatient appointments

• Personal care model for >2.5 million people by 2023/4; including personal health budgets, social prescribing, and support with self-management.

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As a Trust we are already participating in the local ICS, as well as taking forward work through the STP.

Things to Celebrate

Our programme of ward accreditation has begun. This is an exciting opportunity for our wards to demonstrate the high standards of care they wish to deliver as well as ensuring they are providing the right environment to promote wellbeing for their patients. The first two wards to be accredited are the stroke ward and Jersey ward. Both wards were accredited at Silver. This is an excellent start , all areas will be accredited form March 2019.

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Meeting of the Board of Directors Public Part I Session


Report title: Review of Executive Structure

Report author(s): S Tedford CEO

Report sponsor(s): R Sumray Chair

Committee Action required:

The Committee are asked to:

• Approve the proposal to establish the post of Deputy CEO of Strategy as a votingmember of the Board

• Approve the Proposal to create the post of Director of Estates as a non-votingmember of the Board

• Approve the reallocation of portfolios as detailed in the report


STRATEGIC PRIORITY:

None

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Introduction

At the end of January there will be movement in relation to Executive posts. This provides an opportunity to review the current structure of the Executive team, ensuring that there are the necessary skills within the organisation to address the challenges the Trust faces. This paper provides the nominations committee with the proposed changes to this structure and the rationale underpinning the changes.

Context

The Trust is currently facing a number of significant challenges:- CQC - The CQC report requires an improvement plan ensuring all areas of concern are addressed, embedded and audited. We can expect a re-inspection in 2019 (no date agreed yet). The current plan does not address the problems identified by the CQC; it is high level, does not tackle system issues and does not ensure the ongoing monitoring of the changes made.

Financial position – The significant variation against the originally agreed control total and the need to reduce the current run rate will require clear financial leadership as well as strong operational grip. The financial management across the Divisional teams is neither robust nor consistent.

Constitutional Standards – The continued underperformance against the constitutional standards must be addressed, the daily business rhythm must be brought back into the organisation to ensure this happens in a systematic way.

Estates – The condition of the estate is a significant risk for the Trust today. A clinical strategy needs to be developed to ensure a short and long term estates strategy can be developed and implemented, whilst in the interim keeping staff and patients safe.

Organisational Development (OD) – A programme of OD is required to develop our staff to ensure the Trust has the skills and capability to deliver 21st century health care.

Current Executive Structure

With the disestablishment of the previous Director of Strategy role, the responsibilities under this post were shared amongst the remaining executive team. This increase in portfolio has diluted the effectiveness of the Executive team.

CEO

Chief Operating Officer

Director of Nursing

Director Of Finance

Director of People and OD

Medical Director

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Post Portfolio

Chief Operating Officer Day to day operational management of sites (Division) Performance governance, constitutional standards, site management, EPRR, business continuity, strategy, Integration, Joint venture (Path), SaHF, Brunel Development, Business Development

Director of Nursing Nursing workforce and standards of nursing practice and care Infection Prevention and Control (DIPC) Safeguarding Children and Adults (includes Tissue viability service, Learning Disabilities and Mental health/dementia care) Patient experience and engagement (Pastoral and Spiritual Care, PALS, Complaints, patient surveying, FT member engagement) Clinical Governance (Clinical incident incl. SI management and clinical risk management, Clinical Audit, Legal Services) Corporate Governance (Governance systems (Datix/AVIA etc., regulatory compliance/CQC, BAF, CRR, CGS/AGS, Quality Account etc.) Business Continuity administration Soft Facilities Management (Security, Portering, Cleaning, Catering, Retail Management, Transport, Waste management, Car parking)

Director of Finance Contract Management Procurement Programme Management Office ICT, including Information Senior Information Risk Owner (N.B. Information Governance falling under the Trust Secretary) Health & Safety, including being the nominated "Fire Director"

Director of People and OD Recruitment, temporary staffing, medical staffing, people solutions partners, OH, Charity, Nurse and band 1-4 education, Learning and OD, communications, workforce information.

Medical Director Medical Revalidation Medical Education Clinical Strategy Patient Safety Clinical Leadership R&D

PROPOSAL Moving forward the revised executive portfolios will provide the opportunity to focus on addressing the significant challenges the organisation faces, ensuring the Trust has the appropriate skills and capability to move the organisation towards a CQC rating of Good and onward to Outstanding.

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Deputy Chief Exec and Director of Strategy – This post will provide support to the CEO, managing corporate governance and specifically will lead the development of the clinical strategy. The Dep CEO will provide support to the director of estates, aligning the clinical and the estates strategies. To ensure cohesion across the Trust the post holder will also manage the transformation team. Further, this post will oversee the implementation of the trust improvement plan.

Chief Operating Officer - This post will focus on the day to day operational running of the Hospital, embedding sound operating practices across the organisation. This will include a robust performance framework, to ensure delivery of both constitutional standards and the financial control total through the operational teams. Business continuity, Emergency planning and Health and Safety will be managed by the COO.

Chief Nurse – The job title of this post should be revised to reflect the responsibility of the role. The Chief Nurse must focus on driving up nursing standards across the organisation, rolling out the ward accreditation programme whilst ensuring improved patient experience. Nursing recruitment and retention is also key to this role.

Director of Finance – An experienced Director of Finance is required to develop the Trust finance team again ensuring the necessary skills to support the operational divisional teams are in place. Key to this post is the delivery of the control total. This will involve working with the financial and operational teams to reduce the monthly run rate.

Director of People and OD – The culture across the organisation is of concern. There is a high tolerance of poor practice and an acceptance of below average standards. Staff are not able/ do not feel supported to take decisions and move their services forward. We need to equip our staff with those skills. The Director of People and OD will focus on the range of HR functions across the Trust as well as overseeing a programme of organisational development.

Medical Director – Engagement of the consultant body is essential in delivering a clinical strategy. This will require a complete review of what services we provide at THHT and the

CEO

Chief Operating Officer Chief Nurse Director Of Finance Director of People

and OD Medical Director Director of Estates

Deputy CEO / Director of Strategy

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medical director will support this work. This will also involve the Getting it Right First time work (GIRFT) and the transformational work that will fall out of this work, as well as ensuring clinical standards are maintained.

Director of Estates – The Trust estate is one of the biggest risks the Trust faces, and a Director with the appropriate experience is required to take forward the development of plans for a new build, whilst managing the sites in their current condition. This will require strong networking with the national estates team, as well as sound estates experience managing the complexities of aging estates and large back log volumes.

Revised responsibilities

Post Portfolio

Deputy Chief Exec / Director of Strategy Strategy, Estates, Transformation, Corporate Governance (Governance systems (regulatory compliance/CQC, BAF, CRR, CGS/AGS, Quality Account etc.) Business Development, Integration, ICS, Joint Venture, SaHF

Chief Operating Officer 4 clinical divisions EPRR Business Continuity administration Health & Safety, including being the nominated "Fire Director" Constitutional standards, Site management

Chief nurse Nursing workforce and standards of nursing practice and care Infection Prevention and Control (DIPC) Safeguarding Children and Adults (includes Tissue viability service, Learning Disabilities and Mental health/dementia care) Patient experience and engagement (Pastoral and Spiritual Care, PALS, Complaints, patient surveying, FT member engagement) Clinical Governance (Clinical incident incl. SI management and clinical risk management, Clinical Audit, Legal Services, Datix/AVIA etc.,)

Director of Finance Contract Management Procurement Programme Management Office ICT, including Information Senior Information Risk Owner (N.B. Information Governance falling under the Trust Secretary)

Director of People and OD Recruitment, temporary staffing, medical staffing, people solutions partners, Occupational Health Charity, Nurse and band 1-4 education, Communications, workforce information. Human resource Function Organisational development

Medical Director Medical Revalidation Medical Education Clinical Strategy

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Patient Safety Clinical Leadership R&D

Estates Director Estates Soft Facilities Management (Security, Portering, Cleaning, Catering, Retail Management, Transport, Waste management, Car parking) Hard Facilities Management

Governance The Board’s Nomination Committee is responsible for reviewing the structure, size and composition of the Board of Directors, and in light of the challenges and opportunities facing the Trust, and make recommendations for any required changes to the full Board. The Committee is comprised of the Non-Executive Directors and the CEO. The Nominations Committee met on 9th January to consider its recommendations to the Board in respect of this report. Their recommendations were; • To appoint a Deputy CEO/Director of Strategy - it was agreed that the new role of

Deputy CEO/Director of Strategy would provide experienced support for the CEO in pulling the Executive team together, especially important during this period of churn with new executives joining the team. Adding this role would allow for review and change of other executive roles and would remove some tasks from other executives.

• To appoint the Director of Estates as a non-voting member of the Board – it was agreed that the role was so important to the hospital strategy that the incumbent should be a member of the Board, albeit non-voting. The Director of Estates would be accountable to the Deputy CEO.

• To reorganise the portfolio of the Director of Patient Experience and Nursing – it was agreed this post should lose some responsibilities, including soft facilities management, and should be titled Chief Nurse. It was noted that the separation of quality and patient safety was problematic and both should be a joint responsibility of the Chief Nurse and the Medical Director.

The Constitution requires that at all times the number of non-executive Directors, not to include the Chairman, must be greater than or equal to the number of Executive Directors and that there is a maximum of 7 other non-Executive Directors and a maximum of 7 Executive Directors (including the CEO) who are voting members of the Board. The Board currently comprises 6 Executive and 6 Non-Executive voting members, excluding the Chair, and so this requirement is complied with. The proposal to increase the Board to 7 voting Executives means the number of Non-Executives would need to be increased from 6 to 7 as well. With 2 current vacancies, this would mean the number of NEDs the Trust currently needs to recruit is 3. Finance The Director of People and Organisational Development and the Director of Finance will provide financial implications of this reorganisation at the Board at the meeting.

RECOMMENDATION

The Board is asked to support the proposed changes to the executive structure. Whilst THHT is seen as a medium sized DGH the challenges it faces are significant. To address them, it is essential that the right leadership team is appointed. This will involve Directors with experience of having worked in challenged organisations, who have the drive and enthusiasm to move the Trust forward.

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Meeting of the Board of Directors – Public Part 1 session


Title of Report: Patient Experience and Engagement Strategy 2019-2022

Reason for item: In May 2012 the Trust launched an ambitious three-year Experience and Engagement Strategy titled “Putting Patients First”. This strategy is now out of date and is to be replaced with a new Patient Experience and Engagement Strategy.

Summary: The new Patient Experience and Engagement Strategy sets out the Trust’s intention to ensure the best possible experience for patients, carers, their relatives and the community. This includes involving patients in decisions about their care, seeking feedback about their experience, having patient representatives on boards and committees making decisions about services, and involving the Trust membership and the public in planning future services. The Strategy is based on what patients have told us through stories, complaints and concerns, compliments, national and local surveys, patient and public forums, social media and feedback from Healthwatch Hillingdon. The Strategy sets out our commitment to working in partnership with our patients and involve them in decisions about their care, to listen to our patients about what ‘best care’ means to them and where they wish to receive it, to involve patients and public in decisions about the ways services will change and develop in the future and to support our patients in managing their own health and maximising their well-being. The Strategy embodies our CARES values which continue to be embedded in the way we work with each other, our patients and our partners. The strategy identifies key initiatives to improve patient experience and engagement and includes a governance framework for reporting and evaluating. The Trust will evidence improvement through the triangulation of themes across patient experience measures, patient safety, Friends and Family Test, complaints and PALS data and patient and public engagement activity. Consultation on the Strategy has been undertaken with the Lay Strategic Forum, the Experience and Engagement Group, the Quality and Safety Committee and with staff via the Trust’s intranet. Action required: 1. Provide any comments on the strategy2. Approve the Strategy

Report from: Catherine Holly, Head of Patient and Public Involvement Report sponsor: Jacqueline Walker, Director of the Patient Experience & Nursing

Links to Trust strategic priorities: Ensuring we have safe, high quality sustainable acute services.

Equality and diversity considerations: When we engage with patients and their families to make improvements to the patient experience we need to engage widely to hear the voice of those with protected characteristic

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Meeting of the Board of Directors – public session

Wednesday 30th January 2019 Agenda item 11

Report Title: Consultation on Quality Report Priorities for 2019/20

Report author: Jay Dungeni, Deputy Director of Nursing & Integrated Governance

Report sponsors: Jacqueline Walker, Director of the Patient Experience & Nursing and Abbas Khakoo, Medical Director


The Board is asked to:

1. Note the outcome of the consultation event with key stakeholders;2. Agree the proposed priorities that have been put forward as quality priorities for the

Quality Report; as recommended by the Quality and Safety Committee;3. Agree the key quality indicators to be included taking into consideration the Single

Oversight Framework metrics.


STRATEGIC PRIORITY:

e) Delivery Area 5: Ensure we have safe, high quality sustainable acute services

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1. Introduction

Every year, the Trust is required to publish a Quality Report (as a Foundation Trust ours is also published in our Trust Annual Report), illustrating what healthcare improvement priorities it identified in the previous year; report the progress it made over that period of time, and identify priorities for the following year. It is required to be published on the NHS Choices website by 30th June 2019. Its aim is to help the public choose which healthcare provider they want for their particular intervention. During the year that leads up to the publication of the Report, the Trust works with its stakeholders to reflect on progress and identify priorities for the following year.

2. Progress on Quality Priorities for 2018/19

Good progress has been made on the quality priorities and their key aims outlined in our Quality Report for the current year, some of which has been outlined below. The aims are monitored by clinical and management teams through divisional performance reviews and via the Trust Management Executive with review of the Quality and Safety Improvement Strategy action plan. For some of the priorities, especially priority 2, the Hillingdon Improvement Practice (HIP - Quality Improvement) programme is key to driving the culture of continuous improvement. The year-end results will be reported in the 2018/19 Trust Annual Report:

I. Improving the use of digital systems to enhance patient safety and ensuring timelyaccess to information

The majority of a patient’s summary care record has now been digitised and shared through the Health Information Exchange (HIE) with other partners in HHCP, our Accountable Care Partnership. This has been as a result of strong collaborative working across North West London. The Trust met its requirement of 100% electronic referrals for 1st consultant outpatient appointments through the national Electronic Referral System (eRS), and in addition, an electronic referral vetting system was developed and piloted. The Trust Patient Administration System (PAS) was upgraded to incorporate patient preferences for receiving electronic communications and integrated with the national system to collate patient email addresses automatically at the point of care. In December 2018, the Electronic Observations app - Hillingdon Observations (hOBS) was successfully rolled out across all adult Inpatient areas across both sites, enhancing safety of care, incorporating the National Early Warning Score 2 (NEWS2) and electronic Sepsis screening. In addition, the implementation of clinical handover for nursing was also completed. These initiatives have improved care quality and facilitated better discharge planning and efficiency for Trust staff.

II. Ensuring care and treatment is patient-centred through streamlining patient carepathways and improving discharge management

The integrated discharge improvement plan has progressed throughout the year. It has driven forward implementation of the single referral form, which is now live and available electronically. The strengthened Integrated Discharge Team encompasses the hospital’s Discharge Co-ordinators and the Rapid Response and community HomeSafe services hosted by CNWL; it links closely with the local authority Hospital Discharge Service. The integration provides a single point of access which ensures care is provided in line with need. Historically there were multiple discharge pathways; these have been reduced to three:

• Pathway 0 for people whose needs can be met at home with minimal support or where anexisting package of care is in place and remains sufficient.

• Pathway 1 for people whose needs can be met at home with a rehabilitation or re-ablement programme

• Pathway 2 for people who cannot return home as their needs are too complex, but do notneed to be met in a hospital setting.

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Understanding the patient experience has been progressed via a variety of means. Matrons have undertaken spot audits, contacting patients at home following discharge. Learning has been shared following complaints and incidents. The Hillingdon Improvement Practice Programme undertook a week-long engagement exercise, which included patient representatives, to review specific pathways, including experience of discharge. This information is being used to design better, more effective services.

III. Enhancing patient experience through improving communication and staff attitude,further embedding CARES values

The implementation of our Always Events programme is underway, guided by an NHS England collaborative. An oversight team, including patient representatives has been established to strategically drive this model of patient improvement. A Point of Care Team is implementing a patient co-designed “Always Event” improvement on The Stroke Unit, focused on communication. A second Point of Care team is being scoped.

Patient experience data, including feedback from complaints, PALS contacts and patient surveys, is now being presented as triangulated data at the Experience and Engagement Group. This is used to identify areas for improvement. Funding was awarded by the NHSE’s “Better Care Small Grants” budget in Q4 2017/18 to fund the production of the revised Working Together leaflet; this has now been distributed across all wards.

Customer Care training has been delivered to 487 staff in 2018/19 so far (243 via eLearning and 244 through face to face training). Coaching for managers is an intensive two-day in-house course which has now been delivered to 28 staff through a pilot programme. Six courses are now available for staff to book onto starting from March 2019. We are also training two further in-house trainers to expand our capacity and capability in this area.

We now have 1028 recorded CARES Ambassadors, more than a third of staff. These are supported by 33 CARES Champions, who provide more intensive support to staff. We continue to develop our Champions through monthly meetings, communications and training and development.

IV. Improving the administration of the patient appointment systems and associatedcommunications

We have upgraded PAS to collate patient preferences and integrated with the spine to pull down patient emails (30’000 stored to date). The tasks left to do are:

• Change business processes to collate patient consent / preferences to use their email forpaperless communications.

• Build a model for validating patient email addresses before using them to send patientdocuments.

We are also upgrading the Outpatient Kiosks at MVH to facilitate patients activating online Patient Knows Best accounts; this would be the preferred method for patients accessing their documents securely.This project will continue into 2019/20. The eReferral service has been fully implemented for all Consultant-led services as outlined above as well as for many non-consultant led services like Physiotherapy, Dietetics, and Audiology. The Trust implemented an electronic vetting system for clinical triage with an aim to have a single system that will allow safe and secure vetting platform for both electronic and non-electronic referrals. The in-house eVetting system is currently being trialled with the Ophthalmology service, and it will soon be rolled out other services.

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The Advice and Guidance (A&G) service is being used very well by the GP practices. Most areas within the Trust are very good with the response turn-around times, with the majority responding well within two working days. With the help of Imperial College Health Partners (ICHP), the Trust has developed a dashboard that gives information and report on the A&G service. Being the 1st Trust in the NWL sector to use eRS for A&G, we are now the 1st in London to have developed such a dashboard. The A&G dashboard, developed by a 3rd party provider, is scheduled to go live in February 2019, and will be rolled out to other trusts in the coming months. The Trust continues to use the appointment reminder service, and regularly updates the system with new clinic codes. The Trust’s DNA rate is currently at 8.3%.

3. Consultation for Priorities for 2019/20

The Trust held an engagement exercise with key stakeholders (FT members, HealthWatch, Governors, local voluntary organisations and Trust staff) on 10th January 2019; this event included a review of progress against this year’s priorities and a discussion on the quality priorities for the forthcoming year. Some of the key areas they raised for improvement are listed below: • Improving communication throughout the patient pathway to include digital and paper light

options • Improving the communication and engagement with patients and those nearest to them. • Improving communication to and engagement with staff at grass roots level • Improving engagement with children and young people to better prepare them for transition

into adult services • Improving access to ‘on the job’ training given the financial challenges in accessing

traditional taught courses • Improve the offering of staff development to keep up with the changes in the way that

services are commissioned and provided • Improving specific patient pathways by streamlining the process by which patients engage

with services • Improving the way in which we sign post patients to where services are provided both on site

(signage) and on the letters we send out to patients • Improve the systems we have in place for sharing learning from incidents so that this is

shared across traditional provider boundaries • Improve the Trust participation in clinical research so that opportunities for improved

outcomes are available more locally.

On reviewing the results of the feedback from key stakeholders it must be noted that some of the areas of concern are already being addressed via the current year work streams and work being taken forward as part of our Trust strategy. The Trust will want to ensure that the quality priorities identified for 2019/20 are aligned with the objectives outlined in the Trust’s Quality and Safety Improvement (QSI) Strategy (2016-21) and the North West London Sustainability and Transformation Plan (STP). It will also need to ensure that the Annual Quality Report clearly outlines the Trust’s progress against Care Quality Commission (CQC) standards and improvement plan and that the 2019/20 quality priorities are aligned with this work. The Quality Priorities need to be patient and outcome-focussed taking into consideration progress against this year’s quality priorities and where focused work still needs to continue to realise further improvement. With this in mind it is recommended that the Quality Priorities for 2019/20 include: • Building on work taken forward this year continue to improve communication by - offering

digital solutions in the types of communication to our patients and decision making as they navigate their pathway of care; ensuring carers and those closest to the patient are kept

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informed and engaging directly with front-line staff to ensure their voice is heard and that they receive information in a timely way

• Increase the engagement programmes to focus on children and young people so that thereis an improved contribution to the way services are commissioned and provided fortransitioning

• Improve the way in which we offer training to staff providing care across the whole system toreduce the variation in approach and standardise the required improvement in knowledgeand skills

• Improve the way in which we engage with patient groups and support groups of patients withincreased needs such as those with Autism, Learning Disabilities and Dementia.

Specific indicators under these key areas of care will be determined with the relevant clinical and management leads and will be detailed in the Quality Report. A key part of the HIP and the various Trust committees will be to ensure there is enough time dedicated to the analysis and presentation of data and the progress using mixed methods that support robust data for improvement such as statistical process charts (SPC) and trend charts.

4. Clinical Indicators

It is a requirement for the Board to select and approve a range of clinical indicators to be included in the Quality Report to provide an overview of the quality of care based on performance in the previous year, in consultation with key stakeholders with an explanation of the underlying reason(s) for selection. The indicator set has to include at least three indicators for patient safety; clinical effectiveness and patient experience.

The proposal for this year’s report is to continue with the indicators presented in last year’s report and outlined in NHSI’s Single Oversight Framework (Appendix 1). NHS Improvement published the detailed requirements for the Quality Report in December 2018 and there is no significant change from last year on the requirements. The Trust is required to report against a ‘core’ set of indicators, previously stipulated within Monitor’s Risk Assessment Framework, for at least two reporting periods, using a standardised statement set out in the NHS Quality Accounts Amendment Regulations 2012. This includes an explanation from the Trust on the reasons for the Trust’s reported performance on these indicators.

5. External audit review of the Quality Report

As the Board will recall the Trust’s external auditors are required to undertake testing on several aspects of the Quality Report and this is to be included as a limited assurance report in the Trust’s annual report. This external audit work includes reviewing the content of the Quality Report against the requirements of NHS Improvement’s guidance, and reviewing the content of the Quality Report for consistency with other sources of information such as Board minutes, feedback from sources such as Healthwatch and the Governors, patient and staff surveys, and Care Quality Commission findings.

In addition, external audit are required to undertake testing on several indicators in the Quality Report. Last year, the Trust was required to choose two national priority indicators for data testing as mandated by NHSI, which were the Accident and Emergency four-hour waiting time target and referral to treatment time waiting times – 18 week pathway. There are two key changes in the guidance for this year’s Quality Report that the Board need to consider as part of the selection:

• 62 day cancer waits has moved up in priority in the listing of mandated indicators. A&E4hr waits is still the first item on the list with 62 day cancer waits switching with 18 weekRTT to be second in priority. Prior year recommendations on 18 week RTT should still beimplemented.

• NHSI have made a strong recommendation that the local indicator for substantive sampletesting is the Summary Hospital-level Mortality Indicator (“SHMI”). The governors still

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have the power to determine this indicator. A recommendation will be submitted to the Council of Governors at its February meeting with regard to the NHSI guidance on the indicators for testing, and specifically selection of the local indicator.

6. Conclusion

The Quality and Safety Committee has received and commented on the content of this report at its January meeting and it was in agreement with the suggested priorities with a recommendation to a change in the communication priority which has been incorporated. There have been a number of suggestions put forward from different sources on the quality priorities for 2019/20, these need to be considered alongside priorities within the Trust’s Quality and Safety Improvement Strategy, progress against CQC standards and the aim to improve all dimensions of the quality of care. It is important that the Trust listens to its key stakeholders and particularly its patients and the public to ensure that the quality priorities it agrees accurately reflect what has been communicated through the consultation. In addition, the key clinical indicators for the Quality Report need to be agreed taking into consideration the Single Oversight Framework and associated quality and performance metrics.

Appendix 1 - Consultation on Quality Report Priorities for 2019/20

Quality of Care (safe, effective, caring, responsive) monitoring metrics (NHSI, 2016) as outlined in the Single Oversight Framework

Quality Indicators Organisational health indicators – acute providers

1 Staff sickness

2 Staff turnover

3 Executive team turnover

4 NHS Staff Survey

5 Proportion of temporary staff

6 Aggressive cost reduction plans

7 Written complaints - rate

8 Staff Friends and family test % recommended care

9 Occurrence of any Never Event

10 NHSE/NHSI Patient Safety Alerts outstanding

11 Mixed sex accommodation breaches

12 Inpatient scores from Friends and Family Test - % positive

13 A&E scores from Friends and Family Test - % positive

14 Emergency C-section rate

15 CQC Inpatient Survey

16 Maternity scores from Friends and Family Test - % positive

17 VTE Risk Assessment

18 Clostridium Difficile – variance from plan

19 Clostridium Difficile – infection rate

20 MRSA bacteraemia

21 Hospital Standardised Mortality Ratio (DFI)

22 Hospital Standardised Mortality Ratio – Weekend (DFI)

23 Summary Hospital Mortality Indicator

24 Potential under-reporting of patient safety incidents

25 Emergency re-admissions within 30 days following an elective or emergency spell at the provider

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Operational performance metrics – acute providers

26 A&E maximum waiting time of 4 hours from arrival to admission/transfer/discharge

27 Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate – patients on an incomplete pathway

28 All cancers – maximum 62-day wait for first treatment from: - Urgent GP referral for suspected cancer- NHS cancer screening service referral

29 Maximum 6-week wait for diagnostic procedures

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Wednesday 30 January 2019 Agenda item12

Title of Report: Nursing Workforce Safe Staffing Establishment Review

Summary: An establishment review of inpatient medical and surgical wards has been undertaken, triangulating acuity and dependency data, Care Hours per Patient Day, assessment of skill mix and findings from a deep dive review of establishments with NHS Improvement. Evidence-based tools, best practice guidance and professional judgment were used to identify recommended changes.

This paper outlines the resulting proposal to refine establishments as follows: • Increase the ratio of RNs at night on the 20-bed wards• Reduce Fleming Ward roster by one RN daily.

Board Action required: 1. Review and discuss the information provided in this report2. Approve the proposal to apply the revision to establishments for the new financial year

2019/20.

Report from: Mel Lowe, Lead Nurse for Workforce Vanessa Saunders, Deputy Director of Nursing: Safeguarding, Workforce

and Clinical Standards

Report sponsor: Jacqueline Walker, Director of Patient Experience Nursing


STRATEGIC PRIORITY: Delivery Area 5: Ensure we have safe, high quality sustainable acute services Previous consideration at Board or Committees: Monthly Safer Nurse Staffing (Planned /Actual Staffing levels) to Trust Board; previous Establishment Review – January 2018.

Financial impact: The proposed changes can be funded within existing resources.

Reason for item: The purpose of the paper is to present to the Board of Directors the nursing establishment review of the medical and surgical inpatient wards and outline the resulting recommended changes to establishments. The establishment review was undertaken to:-

• Provide assurance, both internally and externally, that ward establishmentsare appropriate to provide safe care to patients

• Recommend changes to the establishments in line with the review and NHSIguidance.

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Nursing Workforce Safe Staffing Establishment Review

1. Introduction

In 2016 the National Quality Board (NQB) published revised guidance for providers regarding safe and sustainable staffing1. Expectation 1 of this guidance relates to workforce planning and directs that there should be an annual strategic staffing review developed through a triangulated approach including use of evidence based tools.

The nursing establishment for medical and surgical inpatient areas was formally reviewed in October 2017, with findings presented to the Trust Board in January 2018. The resultant business case to right-size establishments where skill mix was found to be misaligned and to facilitate supervisory status for ward managers was supported and approved in June 2018. A separate business case to uplift the Accident and Emergency department (A&E) nursing establishment was approved in July 2018.

In line with the NQB requirements referenced above, the nursing establishments across the medical and surgical inpatient wards at The Hillingdon Hospitals NHS Foundation Trust were further reviewed in October 2018. The maternity department will be undergoing its scheduled Birthrate Plus staffing review in the autumn of this year; the other specialist areas (Paediatrics, A&E, Theatres and Outpatient services) will be reviewed during the course of 2019.

This paper details the findings of the review and recommendations for change with respect to the medical and surgical inpatient areas. The paediatric review is ongoing and will be presented at a later date.

2. Methodology

The Assistant Directors of Nursing, supported by the Lead Nurse for Workforce Transformation Projects, triangulated data regarding patient factors, staff factors and financial efficiency, considered alongside best practice guidance from the Royal College of Nursing (RCN; 2011) and NICE (2015). In addition, recommendations from NHS Improvement colleagues following their “deep dive” into nurse staffing levels across inpatient areas at the Trust in November 2018 were also referenced. Professional judgement was then exercised in light of all of the above to develop the establishment proposals for 2019/20.

2.1 Acuity and dependency

Patient acuity and dependency is recorded three times a day, on every ward, via the electronic system, SafeCare. The acuity and dependency scoring levels are as per the definitions developed by the NICE endorsed Safer Nursing Care Tool (SNCT).

1 https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf

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https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf

The acuity and dependency data recorded for October 2018 was extracted from SafeCare and the SNCT multipliers applied to calculate the recommended number of Whole Time Equivalents required per ward establishment to meet the identified patient care needs. These can be seen in Appendix 1.

Findings: • Current funded establishments were found to be in the main well aligned with

patient need• As a result of the 2017/18 establishment review some wards had their Health

Care Assistant numbers increased, acting as “home” wards for staff that workflexibly across wards to provide enhanced care for patients at increased riskof harm (“specialling”). This remains appropriate.

2.2 Nurse to Patient ratios

Nurse staffing levels are not mandated in England. Studies have suggested varying levels, RCN guidance (2011) recommends nurse: patient ratios of 1:6 in acute hospital settings, and the Safe Staffing Alliance (2013) found that a ratio of more than eight patients per Registered Nurse increases the risk of patient harm.

The review has found ratios of 1:6 across most wards during the day, with the exception of Critical Care areas where there are, appropriately fewer patients per nurse. A number of wards have a lower ratio due to the bed configuration. The RCN guidance references day shifts, there are no specific recommendations for ratios at night; night time nurse: patient ratios at the Trust do not exceed 1:10. Four wards have 20 or fewer beds and are therefore currently staffed with two Registered Nurses (RN) at night, supported by Health Care Assistants.

Findings:

• Following their review of nurse staffing levels at the Trust, NHSIrecommended consideration be given to increasing staffing to achieve nighttime ratios of 1:8 and where there are two nurses on duty, consider riskmitigation through either increasing RN numbers or a robust documentedarrangement to cover breaks/escort duty on the smaller wards at night.

• NHSI also noted that on Drayton Ward whilst staffing was increased withincreasing acuity, the lack of dedicated area/s for High Dependency (HDU)patients within the ward meant staff were not always deployed on a 1:2 basisfor these patients.

• NHSI found staffing ratios in paediatrics were not in line with nationalguidance and recommended using the paediatric SNCT to informestablishment setting to ensure sufficient resource to support a ratio of 1:3 RNfor children under 2 years of age and 1:2 or 1:1 as appropriate for HighDependency patients.

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2.3 Care Hours Per patient Day (CHPPD)

The Carter report (2016) recommended this comparator was adopted by Trusts as a common consistent metric of staff utilisation. This metric calculates the monthly staff hours planned and actual in relation to the activity. It is calculated by adding the total hours of registered nurses and healthcare support workers and dividing the monthly aggregated daily count of patients on the ward at midnight. All Trusts submit monthly data detailing the CHPPD utilised per ward, this is analysed by the national Model Hospital team to produce benchmark data. The data is intended to enable Trusts to compare their staffing with peers so that any variation can be examined to ensure it is warranted.

Findings:

• A number of wards have CHPPD higher than peers / national median; thesewards include the smaller wards noted above

• CCU and Drayton also support HDU patients who require a higher number ofCHPPD.

2.4 Additional shift usage – Enhanced patient observation (EPO)

It is clinically necessary at times for ward rotas to have additional duties booked to support increased care for high risk patients. All requests for additional duties are authorised by the Assistant Director of Nursing for the division with daily risk assessment reviews undertaken. Ward staff record the requirement for “1:1 specials” in SafeCare alongside the acuity and dependency of patients. The WTE associated with these patients during the audit is documented in the table of data.

2.5 Skill mix

The RCN has historically recommended a Registered Nurse (RN): Health Care Assistant (HCA) ratio of 65:35. In practice though there is an increased demand in some areas for additional health care assistants to provide enhanced support to frail and vulnerable patients which, whilst increasing the number of staff available, lowers the RN:HCA ratio. In addition wards including Beaconsfield East provide care for patients who no longer require acute care.

However, as discussed above, total numbers of RNs available at night on some wards has been found to be inadequate.

Findings:

• Skill mix requires adjustment on four wards to increase number of RNs onduty at night.

2.6 SafeCare: staff utilisation

The SafeCare tool enables staffing efficiency to be reviewed through reporting on staff utilisation. The staff utilisation value relates to how well the staff time demand

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derived from the acuity and dependency of patients and any other tasks applied to the shift, such as escort duty, matches with staff time available. If available staff matches the time demand, staff utilisation is 100%. Utilisation under 90% suggests there is an opportunity to reduce or redeploy staff; over 115% indicates shortage of staff.

The majority of wards completed more than 85% of their acuity and dependency census’, which provides high confidence in the overall accuracy of the utilisation data. Staffing utilisation averaged close to 90-115% for the majority of wards in October. Validation of the data however has highlighted that the Stroke Unit has under reported patient dependency which in turn renders their utilisation figure inaccurate.

Findings:

• Staff utilisation in October 2018 indicates overall staffing effectively utilised.

3. Emerging Issues

At the time the acuity-dependency audit was undertaken, CCU was temporarily located on the Acute Medical Unit (AMU). Although CCU has since returned to its own location, further changes have been implemented on AMU. One has been to reduce the Adult Assessment Unit (AAU previously the AMU and SAU) from 45 to 39 inpatient beds with the conversion of one inpatient bay to a Rapid Assessment Medical Unit (RAMU). In line with the reduction of beds the number of RNs required to support 39 patients reduces and an RN is transferred to support the RAMU. The resultant alteration in RN:patient ratio is negligible (from 1:6.43 to 1:6.5).

Findings:

• No change to resourcing of the AAU is recommended.

4. Outcome of NHS Improvement safer nurse staffing deep dive

• The Trust had completed the required template to a high level - an exemplar which evidenced a good understanding of the data and the impact of analysis

• The workforce data is being led by knowledgeable and committed senior team with evidence of shared learning across the senior nurses

• The Trust and senior nursing team have established a robust process for identifying safe establishments and the prudent use of temporary staff to support clinical rosters

• The Trust have just implemented Band 7 supervisory role which is being rolled out across the Trust

• The staffing ratios on specific wards needs to be reviewed - a general discussion during the visit with the senior nursing team identified key wards

• The Trust should consider reviewing nursing levels at night which did not meet safer staffing levels on several wards

• The day nursing ratios met safer staffing recommendations and should not be diluted

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• The NHSI team had a useful discussion on ways in which the night nursinglevels could be improved within budget and a number of recommendationsand offers of support were made

• At the time of the visit the review team did not identify any breaches in saferstaffing requirements during the day and found that senior clinicians and wardstaff appeared aware of the safer staffing requirements, understood their wardestablishments and had good relationships with the senior nursingmanagement teams.

5. Proposal

To resolve the issues highlighted above it is proposed that:

I. The 20-bedded wards (Alderbourne, Beaconsfield East, Daniels andPinewood) alter their skill mix at night. Instead of managing these wardswith 2 RNs and 2 HCAs at night the skill mix will change to 3 RNs and 1HCA.

II. A formalised procedure will be published whereby Fleming Ward providebreak cover for Lister ward at night.

III. A formalised procedure will be published whereby Kennedy and Jerseywill each provide break cover for Pagett ward during RN rest breaks atnight and during weekend and bank holidays.

Options considered to fund (I) are outlined in Appendix 2. It is proposed that Option 4 is progressed, the rationale being:

• There is no evidence base to support reducing HCA staffing on Churchill ward atnight. The CHPPD for current establishment is in line with Model Hospital median CHPPD.

• Current CHPPD for Fleming is above both national and peer group median for acardiology ward. Reducing RN staffing during the day on Fleming ward brings the CHPPD in line with the published median.

6. Financial Impact

The preferred option regarding staffing reconfiguration can be managed within existing resource.

7. Summary and Conclusion

The review has demonstrated that current nursing establishments across medicine and surgery inpatient wards are adequately resourced. However, the skill mix requires minor reconfiguration to ensure safe staffing levels are maintained during the night. Options to create dedicated HDU area/s within Drayton need to be scoped to ensure appropriate and effective use of staffing resource aligned to HDU.

8. Recommendations

The Board is asked to support progression of this proposal.

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Item 13 THE NHS Long Term Plan Briefing

January 2019 James Ross

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Contents 1. NHS Long Term Plan – Overview2. Delivering the Plan3. Priorities

– Emergency Care– Older People– Children and Young People– Prevention– Long Term Conditions– Finance

4. Enablers– Digital– Workforce

5. London and NWL Specific Plans47

NHS Long Term Plan – Overview: Main Areas of Focus: • Substantial investment in primary medical and community services• Sustained commitment to mental health (both children’s and adults)• Will create a “digital front door” for remote access to NHS services• Preventative focus on tackling the causes of early mortality• Seeks improved outcomes for key Long Term Conditions – Cancer, Diabetes,

Cardiovascular, Respiratory, Stroke, Adult Mental Health• Declares an explicit ambition to improve child health• Growing the workforce and tackling the implications of Brexit and immigration policy

Quantified Objectives: • save almost half a million lives• stop 85,000 premature deaths each year• prevent 150,000 heart attacks, strokes and dementia cases• give mental health help to 345,000 more children and young people• Balance the NHS Books including for providers• 50% reduction in still births, maternal mortality, neonatal mortality and serious brain

injury by 2015

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Delivering The Plan

Integrated Care Systems will be the principle delivery vehicle - Roll out by 2021

• Primary care will host integrated teams of GPs, community health and social care staff, typically serving 30-50,000 people.

• Contracted GP Networks will mange population health and deliver integrated, risk-stratified, services from 2020/21.

• Digital GP consultations offered to all patients by 2024, and redesigned hospital support to avoid up to a third of outpatient appointments.

• Personal Care Model for >2.5 million people by 2023/4; including personal health budgets, social prescribing, and support with self-management.

Investment in primary medical and community services will grow faster than the overall NHS budget, with a ring-fenced local fund worth at least an extra £4.5 billion a year in real terms by 2023/24. 49

Priorities – Emergency Care The Plan aims to improve emergency care pathways by providing:

• Multi disciplinary clinical advisory service embedded within 111, ambulance and GP out of hours by 2019/20

• Community health crisis response services within two hours of referral,

• Reablement care within two days of referral for those that need it.

• Same day emergency care’ across all acute hospitals. Increasing the proportion of acute admissions discharged on day of attendance from 20% to 33%, by avoiding the need for an overnight stay.

• Reduction in delays to discharge – enhanced primary care system and agreed clinical care plan within 14 hours of admission

It recognises a need for more effective working with local authorities to cut delayed hospital discharges and free-up pressure on hospital beds.

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Priorities – Older People The Plan seeks to improve aging well by:

• Supporting more people to live independently at home for longer.

• Providing more rapid community response teams to prevent unnecessary hospital spells, and speed up discharges home.

• Rolling-out model of ‘enhanced care in care homes’ to all areas. • Embedding the NHS Comprehensive Model of Care with enhanced

community MDT to improve support for people with Dementia. • Giving people greater say about the care they receive and where they

receive it, particularly towards the end of their lives.

The Plan aims to improve the recognition of carers and support they receive

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Priorities – Children and Young People The Plan seeks to improve care for children by ensuring: • By March 2021, most women receive continuity of the person caring for them during

pregnancy, during birth and postnatally, following the launch of continuity of carer teams.

• The Saving Babies Lives Care Bundle (SBLCB) is rolled out across every maternity unit in England, including a focus on preventing pre-term birth and the development of specialist pre-term birth clinics.

• Improved outcomes for children and young people with cancer, simplifying pathways and transitions between services and ensuring every patient has access to specialist expertise.

• More comprehensive and precise diagnosis for children with cancer and access to more personalised treatments by 2019

• Match-funding of clinical commissioning groups (CCGs) who commit to increase their investment in local children’s palliative and end of life care services.

• A children and young people’s transformation programme will be created to oversee the delivery of the children and young people’s commitments in the plan. .

By 2028 the NHS will move towards service models for young people that offer person-centred and age appropriate care for mental and physical health needs, rather than an arbitrary transition to adult services based on age not need.

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Priorities – Preventing ill health The Plan aims to prevent demand for health and care services by providing:

• Physical health checks to an additional 110,000 people a year by 2023/24; and by improving uptake of screening and early cancer diagnosis

• Reducing air pollution; cutting smoking in pregnancy; and by limiting alcohol-related A&E admissions.

• Supporting people with severe mental illness find and keep a job; and by providing outreach services to people experiencing homelessness.

• Targeting obesity support to those with a BMI over 30; and by doubling enrolment in the Type 2 NHS Diabetes Prevention Programme

Funding allocations will be informed by assessment of health inequalities and unmet need. English local authorities are required to set measurable goals and state mechanisms for narrowing health inequalities.

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Priorities – Long Term Conditions (1) The Plan focuses on tackling the top five causes of early death for the people of England: heart disease and stroke, cancer, respiratory conditions, dementias, and self-harm.

Cancer • By 2028, the proportion of cancers diagnosed at stages 1 and 2 will rise from around half now

to three-quarters of cancer patients.• Review the current cancer screening programmes and diagnostic capacity.• Negotiate a capital settlement in the 2019 Spending Review, in part to invest in new

equipment, including CT and MRI scanners, which can deliver faster and safer tests.• Safer and more precise treatments including advanced radiotherapy techniques and

immunotherapies will continue to support improvements in survival rates.• Extend the use of molecular diagnostics and, over the next ten years, routinely offer genomic

testing to cancer patients where clinically appropriate.Cardiovascular disease • The Plan proposes improvement in early detection, the NHS Health Check, treatment,

support of primary care multidisciplinary teams to help prevent up to 150,000 heart attacks,strokes and dementia cases over the next 10 years.

• By 2028 the proportion of patients accessing cardiac rehabilitation will be amongst the bestin Europe, with up to 85% of those eligible accessing care.

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Priorities – Long Term Conditions (2) The Plan focuses on tackling the top five causes of early death for the people of England: heart disease and stroke, cancer, respiratory conditions, dementias, and self-harm.

Stroke care • A specific aim of the plan is to modernise the stroke workforce with a focus on cross-specialty

and in some cases cross-profession accreditation of particular competencies. Further implementation and development of higher intensity care models for stroke rehabilitation are expected to show significant savings. The existing national stroke audit (SSNAP) will be updated to provide a comprehensive dataset.

Diabetes • The NHS will: Provide structured education and digital self-management support tools, and

improve access to technological support for diabetes management. Respiratory disease • The Plan proposes to do more to detect and diagnose respiratory problems earlier, support

the right use of medication, expand pulmonary rehabilitation and improve the response to pneumonia, particularly over winter. And from 2019, the existing NHS RightCare programme will be extended to reduce variation in the quality of spirometry testing across the country.

Adult mental health services • The long term plan builds on the Mental health five year forward view. The Plan proposes to

increase the budget for mental health, in real terms, by a further £2.3 billion a year by 2023/24. Specific waiting times targets for emergency mental health services will take effect from 2020. 55

Priorities – Finance Returning to financial balance: • Provider sector to be balanced by 2020/21 • All NHS orgs to be in balance by 2023/24 • NHSI to introduce “accelerated turnaround process” for 30 trusts Reducing waste: • “Strengthened efficiency and programme” with ten (familiar) priority areas. Capital: • Acknowledged NHS has invested less in recent years. Reconfirmed capital settlement and

reforms will be set out in SR Other items of note: • More money for providers taken from national risk reserve • Provider Sustainability Fund and CQUIN values reduced • MRET Scrapped • New £1bn “Financial Recovery Fund” for trusts with deficits • FRF subject to higher efficiency target and turnaround plan • 1.1% efficiency factor • More pressure to agree and hit control totals – “Full regulatory powers” for those who don’t deliver • 2019/20: the final year of control totals • Focus on system planning/ control totals • Shared Provider/Commissioner sustainability fund incentives for ICSs • 5 year system plans by autumn 2019 • CCGs and trusts to share 52 week fines

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Enablers – Digital Technology-enabled service provision is at the heart of the Plan:

• Patients will have “a new right” to switch from their existing GP to a “digital first” provider. All patients in England will have access to a “digital first primary care offer”, such as online or video consultations, by 2022-23

• Population health management solutions to be deployed in 2019, with CCIO and CIO on every local NHS organisation board

• By 2020, five STPs will deliver longitudinal health and care records – linking NHS and local authorities, three more in 2021

• By 2020/21, people will access care plans via the NHS app, then via LHCR

The target for all secondary care providers to move to digital records has been pushed back to 2024.

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Enablers – Workforce Pending publication of the 2019 National Workforce Implementation Plan: • Funding is guaranteed for an expansion of clinical placements of up to 25%

from 2019/20 and up to 50% from 2020/21. • International recruitment will be expanded over the next three years, with

incentives for shortage specialties and hard-to-recruit to geographies. • More flexible rostering, increased funding for professional development, with

support for diversity and a culture of respect and fair treatment. • New routes into nursing and other disciplines, including apprenticeships,

nursing associates, online qualification, and ‘earn and learn’ support. • More doctors trained as generalists to shift away from “highly specialised”

medicine and provide better care to patients with long-term conditions. • Formal regulation of senior NHS managers to improve their standing and help

fill the most difficult jobs, with a professional registration scheme. The workforce implementation plan will be overseen by NHS Improvement (NHSI), with a national workforce group established by NHSI, NHSE and Health Education England (HEE) to ensure the delivery of its actions. The aim of the plan “is to ensure a sustainable overall balance between supply and demand across all staff groups” 58

A renewed health and care vision for London • At the same time that we are developing our plans as a system for integrated care, The

London Health and Care Strategic Partnership Board commissioned a renewed health and care vision

• There are certain elements of clinical transformation that have been successful when London came together to realise benefits, such as with stroke and cardiac – the new London strategy aims to identify where it would be useful for us to work together pan London

• The primary purpose of this work is to create a compelling 10-year vision for London and the enablers which will allow us to move “further and faster” if the collaboration between partners at a regional level works effectively

• The vision for London focuses clinical care within a framework of three life-course area:, start well, live well and age well

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Report title: Impact of Brexit: implications and actions Report from: R Stanfield Deputy Director of People & OD Report sponsor: Terry Roberts, Director of People & OD Reason for item: The purpose of this paper is to summarise the actions and planning underway in the Trust to manage the impact of Brexit, including in the event of a ‘no deal’ scenario. Board Action required: Discuss and note the report Links to Trust strategic priorities: f) Improving the present – A&E 4 hour standard – 18 week Referral to Treatment – Meet cancer targets – Complete CQC action plan – Implement year 2 of Quality and Safety Improvement Strategy – Maintain finance and use of resources score of 3 – Meet control total Enabler - workforce

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1. Introduction

The Department of Health & Social Care (DHSC) has issued guidance to the NHS regarding European Union (EU) Exit Operational Readiness1. All organisations receiving this guidance are advised to undertake local EU Exit readiness planning, local risk assessments and plan for wider potential impacts. Specifically, the actions in the guidance cover seven areas of activity in the health and care system that the DHSC is focussing on in its ‘no deal’ exit contingency planning:

• supply of medicines and vaccines; • supply of medical devices and clinical consumables; • supply of non-clinical consumables, goods and services; • workforce; • reciprocal healthcare; • research and clinical trials; and • data sharing, processing and access.

This paper summarises for the Trust Board the work underway in each of these areas and the next steps. The paper also sets out the local governance in place to support EU Exit planning, and the context across the NWL STP.

2. Governance structures and support

National and regional support system

National structures are being established by the DHSC, including a national Operational Response Centre, supported by an Operational Support Structure for EU Exit, coordinated by NHS England and NHS Improvement. This will:

• deal with any disruption to the population’s health and care, and the delivery of health and care services in England, that may be caused or affected by EU Exit; and

• co-ordinate EU Exit-related information flows and reporting across the health and care system.

The Trust will work closely with system partners and in particular the NWL STP to ensure there is a co-ordinated approach across the sector. The STP are currently working to establish an operational support structure which will link with all providers across Northwest London.

Trust systems

The Trust has set up a Local EU Exit Group, to complete an assessment of any risks, covering the following:

• The seven key areas identified nationally. • Potential increases in demand associated with wider impacts of a ‘no deal’ exit. • Locally specific risks resulting from EU Exit.

1 https://www.gov.uk/government/publications/brexit-operational-readiness-guidance-for-the-health-and-social-care-system-in-england

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https://www.gov.uk/government/publications/brexit-operational-readiness-guidance-for-the-health-and-social-care-system-in-england

https://www.gov.uk/government/publications/brexit-operational-readiness-guidance-for-the-health-and-social-care-system-in-england

Governance and systems action to date and next steps:

Action required Current status Next step

Confirm escalation routes for different types of issues potentially arising from or affected by EU Exit into the regional NHS EU Exit teams

Complete – as per operational guidance

N/A

Note the Trust’s nominated regional NHS lead for EU Exit and their contact details

Complete N/A

Escalate any issues identified locally as having a potentially widespread impact immediately to the regional EU Exit team

Ongoing Continue to monitor and escalate as identified through the Trust Local EU Exit Group

Confirm the Trust’s Senior Responsible Officer for EU Exit preparation and notify the regional EU Exit team of these details

SRO has been identified – Terry Roberts, Director of People & Organisational Development

Notify regional team

Identify named staff to work in a team with the Senior Responsible Officer to support EU Exit preparation, implementation and incident response.

Complete – named staff from: all clinical divisions (Triumvirates); Chief Pharmacist; Deputy Directors of Finance and People & OD; Assistant Director of Facilities; Director of Estates; Head of Procurement; Deputy Chief Information Officer; Head of Therapies; Head of Communications

Finalise initial risk assessment and agree frequency of future meetings

3. High level assessment of the seven areas of activity

3.1 Supply of medicines and vaccines

In a no-deal scenario, the default position will be for member states to impose full third country controls on people and goods entering the EU from the UK, meaning that we could see delays to the movement of goods between the UK and EU. In light of this, the planning assumption has been revised and it is anticipated that the flow of goods between the UK and EU could be reduced for a period of up to six months.

Officials at Public Health England are leading a separate programme to ensure the continuity of supply for centrally-procured vaccines and other products that are distributed to the NHS for the UK National Immunisation Programme or used for urgent public health use.

Action to date and next steps:


Chief and Responsible Pharmacists to ensure the Trust does not stockpile medicines unnecessarily and to personally

Ongoing – the Trust’s Chief/Responsible Pharmacist is fully aware of the need to avoid stockpiling and is actively

Continue to monitor and comply with national/ regional directives regarding stockpiling

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investigate any incidences involving the over-ordering of medicines

monitoring – there is no issue to date

Meet at a local level to discuss and agree local contingency and collaboration arrangements. The Chief Pharmaceutical Officer will hold a meeting with the chairs of regional hospital and CCG Chief Pharmacist networks in January 2019 to help inform local plans

Awaiting Chief Pharmaceutical Officer instruction

Respond to Chief Pharmaceutical Officer instruction when received

3.2 Supply of medical devices and clinical consumables

The DHSC is developing national plans to ensure the continued movement of medical devices and clinical consumables supplied from the EU. Work is being undertaken at local and national levels to identify suppliers who source products from EU countries and to review their supply chains to determine what measures they need to take to ensure that healthcare providers have access to the products they need.



Note that there is no need for health and social care providers to stockpile additional medical devices and clinical consumables beyond business as usual stock levels.

Noted by the Head of Procurement

N/A

Be aware that the contingency plan is kept under review, and the Department will communicate further guidance by the end of January 2019

Noted by the Head of Procurement

Head of Procurement to respond as appropriate and feed back to the Local EU Exit Group

3.3 Supply of non-clinical consumables, goods and services

NHS trusts’ procurement leads have been asked to undertake internal reviews of purchased goods and services to understand any risks to operations if there is disruption in supply. This excludes goods and services that are being reviewed centrally, such as food, on which the Department has written to procurement leads previously.



Be aware that NHS Trust and Foundation Trust procurement leads have been asked to undertake internal reviews of purchased goods and services

Self-assessment undertaken in procurement – 95% of our suppliers are covered by the national work to prepare for Brexit and there are no other

Local EU Exit Group to review

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to understand any risks to operations if there is disruption in supply. This excludes goods and services that are being reviewed centrally, such as food, on which the Department has written to procurement leads previously

significant issues at this stage

Continue commercial preparation for EU Exit as part of your usual resilience planning, addressing any risks and issues identified through your own risk assessments that need to be managed locally

On-going in line with our local risk assessment

Local EU Exit Group to review

Continue to update local business continuity plans to ensure continuity of supply in a ‘no deal’ scenario

Ongoing Local EU Exit Group to review

Be aware that the Department is conducting supply chain reviews across the health and care system, and work is in progress to identify risk areas specific to primary care

Noted

3.4 Workforce

EU nationals working in the health and care system have been able to register for EU settled status2 under the pilot scheme that was open 3-21 December. People who did not register under the pilot scheme do not need to worry as the scheme will open by March 2019 and remain open until at least the end of 2020, so there will be plenty of time for EU staff to register.



Assess whether the organisation has incurred a reduction in the number of EU nationals in the workforce before the UK leaves the EU

The Trust had 331 EU staff in January 2019; our trend data actually shows increasing (rather than decreasing) numbers of EU staff over the last 12 months

Continue to monitor through to Brexit

Publicise the EU Settlement Scheme to staff who are EU citizens

The People & OD team advertised the pilot scheme to our staff via a central communication in December 2018 and offered support through drop-in sessions to assist staff with registration for the pilot. A minority (around 25) EU staff attended.

The Trust will ensure strong and proactive communications to support our EU staff, to keep them informed and provide practical support

2 Irish citizens will not need to apply

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Monitor the impact of EU Exit on your workforce regularly and develop contingency plans to mitigate a shortfall of EU nationals in your organisation, in addition to existing plans to mitigate workforce shortages

Ongoing – no significant issue to date with EU workforce numbers

Report regularly to the Local EU Exit Group

Consider the implications of further staff shortages caused by EU Exit across the health and care system, such as in adult social care, and the impact that would have on your organisation.

Ongoing Local EU Exit Group to discuss and take forward

Inform staff about national processes and deadlines relating to the recognition of overseas qualifications

Messages being drafted as part of wider comms plan

Finalise comms and circulate

3.5 Reciprocal healthcare

The Government is seeking to put in place transitional bilateral agreements with EU, EEA member states and Switzerland to continue reciprocal healthcare arrangements, broadly, on the same terms as today. However, this will depend on decisions made by other EU and EEA member states.



Note that, in a no deal scenario, the current arrangements for reciprocal healthcare and for overseas visitors and migrant cost recovery will continue to operate until 29 March 2019, depending on the reciprocal agreements that are concluded

Noted

Continue to support individuals who apply for NHS authorised treatment or maternity care in another member state (the S2 and cross-border healthcare processes)

Noted Communications in the organisation to ensure this is understood

Maintain a strong focus on correctly charging those who should be charged directly for NHS care

Noted Local EU Exit Group to consider required actions

Ensure there is capacity available for any further training that may be required if there are changes to the reciprocal healthcare arrangements. This should be undertaken by the Overseas Visitor Management

Noted Local EU Exit Group to consider required actions

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team, and guidance and support materials will be made available to support this training.

Note that the Department will provide updates and further information in due course. This information will cover migrant cost recovery charging after 29 March 2019 to enable NHS Trusts and Foundation Trusts to amend processes and train staff if reciprocal healthcare arrangements change.

Noted

3.6 Research and clinical networks

Funding: The Government has guaranteed funding committed to UK organisations for certain EU funded projects in the event of a ‘no deal’ scenario. This includes the payment of awards where UK organisations successfully bid directly to the EU while we remain in the EU, and the payment of awards where UK organisations are able to successfully bid to participate as a third country after Exit, until the end of 2020.

Clinical trials: Organisations running investigator-initiated trials, other industry collaborative trials or non-commercially funded trials of investigational medicinal products (IMPs), or clinical trials or investigations using medical devices in the UK, should liaise with trial and study sponsors to understand their arrangements for ensuring continuity of supply of IMPs and medical devices which come from or via the EU or EEA.

European Reference Networks: In a ‘no deal’ scenario, UK clinicians would be required to leave European Reference Networks (ERNs) on 29 March 2019. However, the UK will seek to strengthen and build new bilateral and multilateral relationships – including with the EU – to ensure clinical expertise is maintained in the UK.

3.7 Data sharing, processing and access

The Trust has investigated and confirms that there is no reliance on transfers of personal data from the EU/EEA to the UK that are critical to patient care and/or would have a serious impact upon the system if they were disrupted. The Deputy Chief Information Officer will continue to update the Local EU Exit Group, and will await further guidance due to be issued early in 2019.

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Report title: Winter Plan 2018/19 review – progress report

Report authors: Imran Devji – Director of Operational Performance

Report sponsor: Joe Smyth Chief Operating Officer



Note the progress to date against the winter plan 2018/19


STRATEGIC PRIORITY: b) Delivery Area 2: Eliminate unwarranted variation & improve LTC managemente) Delivery Area 5: Ensure we have safe, high quality sustainable acute services

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1. PurposeThe purpose of this paper is to provide the board with an update on the progress made onthe schemes designed to improve flow and provide capacity for winter 2018/19. The paperalso provides an update on the progress being made on new schemes that were identifiedand added to the Winter Plan 2018/19.

2. The Winter PlanThe Trust plan was based on a strong commitment for delivering a consistently safe andtimely care during the winter for our patients. The focus of the plan was to reduce lengths ofstay, prevent admissions ensuring there was sufficient inpatient capacity to meet demandover the winter period, preventing the opening of Edmunds. The plan also focused onimproving processes in A&E to ensure a safer department and delivery of the A&E trajectoryto achieve 90% by the end of December 2018.

3. Progress3.1 Hunter HealthcareIn line with early plans developed during the summer the Trust commissioned Hunterhealthcare to support delivery of the A&E target. The aim of this programme was toempower the band 7 nurse co-ordinator roles to establish operational performance within thedepartment.

3.1.1 Impact of Scheme Initially good progress was made and the Trust delivered a 7 – 9% improvement in performance. Unfortunately this was not sustained and performance slipped from 86% back to 83%, and has remained static past two months. However type 1 performance in 18/19 (November to January) was better than last year by approximately 4% against increased attendances of approximately 7%. The Trust did not deliver the expected performance from December 2018 of 90% against the 4 hour Emergency Care standard.

3.2 A&E Capacity The aim of this programme was to increase physical capacity within the department creating additional cubicles to improve flows through the department and improve ambulance handover.

3.2.1 Impact of Scheme The new department was successfully completed on time and opened in October 2019 creating 6 additional cubicles, a new mental health room and 2 en-suite side rooms which can be used to isolate patients with infectious diseases if required.

Effect of re-organising the department has resulted in a significant improvement of ambulance handover within 30 minutes. In March 2018 64% of patients were transferred from ambulance to the hospital within 30 minutes. This figure improved to 87.6% in December 2018.

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3.3 Admission Avoidance The aim of this programme was to improve the use of rapid response and ambulatory care to prevent admissions to the hospital.

3.3.1 Impact of Scheme Emergency admissions have decreased YTD by 3.9%. As part of the Urgent and Emergency Care (U&EC) Improvement Programme, the focus on demand management including admission avoidance remains a key feature of this year's plan.

Emergency Admissions Via Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD2018/2019 13.5% 13.2% 14.4% 14.4% 14.9% 15.7% 15.3% 14.0% 12.7% 14.2%2017/2018 13.9% 14.6% 14.0% 14.3% 15.9% 15.7% 14.7% 14.91% 15.2% 14.8%Variance -0.5% -1.3% 0.5% 0.2% -0.9% -0.1% 0.6% -1.0% -2.6% -0.6%% Change -3.4% -9.2% 3.3% 1.3% -6.0% -0.3% 4.1% -6.4% -16.8% -3.9%

3.4 Ambulatory Care The aim of this programme was to reduce follow up appointments and extend opening hours to create capacity for new patients.

3.4.1 Impact of Scheme Follow up appointments have been reduced by 30% and the ambulatory clinics are now open seven days per week. In December the Trust recorded 418 new ambulatory appointments the highest recorded in over two years.

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Ambulatory Care New OP Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD2018/2019 329 279 233 271 275 241 289 336 418 26712017/2018 321 395 339 364 325 303 325 331 280 2983Variance 8 -116 -106 -93 -50 -62 -36 5 138 -312% Change 2.5% -29.4% -31.3% -25.5% -15.4% -20.5% -11.1% 1.5% 49.3% -10.5%

3.5 Stranded Patients The aim of this programme was to reduce the number of patients in the hospital with lengths of stay greater than 7 and 21 days.

3.5.1 Impact of Scheme The number of patients with extended lengths of stay has decreased considerably and is now below the NHS I target.

Category April December Stranded (7 days +) 225 185 Extended (21 days +) 103 65

3.6 Discharge to Assess The aim of this programme was to increase the number of patients being discharged by the D2A team from 40 per week to 65. This has been achieved.

3.7 Beds – Reduce Emergency Admissions The aim was to combine the impact of a number of the schemes outlined above to reduce the number of emergency admissions to the Trust and close beds / not open additional winter capacity.

3.7.1 Impact of Scheme Emergency admissions are down by 3% (YTD) most notable reduction in November and December. As a consequence the Trust was able to close Pinewood for a sustained period and has not opened Edmunds ward.

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Emergency Admissions - A Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD2018/2019 1992 2026 2094 2084 2056 2163 2220 2086 2064 187852017/2018 2020 2285 2054 2117 2160 2200 2166 2179 2179 19360Variance -28 -259 40 -33 -104 -37 54 -93 -115 -575% Change -1.4% -11.3% 1.9% -1.6% -4.8% -1.7% 2.5% -4.3% -5.3% -3.0%

3.8 Other Improvements There are a number of other schemes which the Trust is progressing and these are listed at appendix 1.

4. Winter / Operational Plans – Next Phase

4.1 Leadership and Engagement Good progress has been made in developing the right medical models to support emergency care. The roll out of the board round principles and the use of the nerve centre are some good examples of enablers to support flows.

Further work around criteria led discharge is in progress. Clinical/Medical leadership and engagement with Full Hospital Protocol and patient flow principles such as consistently identifying definite discharges for the following day needs to be improved with urgency.

The Trust supported by the CEO has facilitated sessions at the TME to focus on improving emergency care flows. This remains a key area of focus.

4.2 Rapid Assessment Medical Unit (RAMU) Building work is completed and the RAMU opened in mid-January. It is intended by early February the unit will be fully functional and will facilitate direct referrals from the UCC. This means that speciality referrals from UCC (approximately 10 – 12 per day) will go directly to RAMU. All referrals to speciality from the UCC breach so this development should significantly improve performance.

4.2 Operational Performance The Director of Operations is on secondment for two weeks to Kingston Hospital (high performer) to participate in a share learning opportunity. Once complete the DOO will adapt appropriate policies and procedures with the Teams at Hillingdon. This will include embedding roles, responsibilities and accountabilities.

5. Board ActionThe winter plan will remain under constant review across the system through the weeklyCCG/Trust checkpoints and the monthly A&E Delivery board to ensure its effectiveness aswell as relevance to the system challenges as a collective. The latest winter plan is availableon the V drive/resilience.

The board is asked to note the improvements delivered through the winter / A&E recovery programme and actions that remain under implementation.

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Dater of meeting: 30th January 2019 Agenda item 16

Report title: Integrated Quality & Performance Report Report author(s) Imran Devji (Director of Operational Performance - Emergency) Vanessa Saunders (Deputy Director of Nursing and Patient Experience) Rachel Stanfield (Deputy Director of People and Organisational Development) Melissa Mellet (Director of Operational Performance - Planned) Jay Dungeni (Interim Deputy Director of Nursing and Integrated Governance) Report sponsor(s): Joe Smyth (Chief Operating Officer) Dr Abbas Khakoo (Medical Director) Jacqueline Walker (Director of the Patient Experience and Nursing) Terry Roberts (Director of People and Organisational Development) Board Action required: The Board are asked to: 1. Note the report and monitor the performance of the Trust for assurance Link to the Hillingdon Hospitals Strategic Plan 2017/21: STRATEGIC PRIORITY: f) Improving the present - A&E 4 hour standard - 18 week Referral to Treatment - Meet cancer targets - Complete CQC action plan - Implement year 2 of Quality and Safety Improvement Strategy - Maintain finance and use of resources score of 3 - Meet control total

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Month YTD Model Hospital Peers Source Period

Clostridium Difficile Infection: Trust Attributable

n/a19 Cases (11.1 Cases per 100,000 Beddays)

0 Cases (0 Cases per 100,000

Beddays)

14 Cases (11.1 Cases per

100,000 Beddays)

13.1 Cases per 100,000 Beddays

PHE Apr-2017 to Mar-2018

MRSA: Trust Attributable 01 Cases (0.6 Cases per

100,000 Beddays)

0 Cases (0 Cases per 100,000

Beddays)

1 Cases (0.8 Cases per

100,000 Beddays)

0.9 Cases per 100,000 Beddays

PHE Apr-2017 to Mar-2018

Maintain two week cancer waits (all cancers)

93% 95.3% 96.1% 94.2% 94.9% NHSE Apr-2018 to Nov-2018

Maintain two week cancer waits (breast symptoms except suspected cancer)

93% 95.3% 95.4% 91.6% 94.9% NHSE Apr-2018 to Nov-2018

31 days diagnosis to treatment for cancer (1st Treatment)

96% 98.8% 100.0% 99.5% 98.8% NHSE Apr-2018 to Nov-2018

31 days diagnosis to treatment for cancer (2nd or Subsequent Treatment - Surgery)

94% 100.0% 100.0% 98.4% 98.7% NHSE Apr-2018 to Nov-2018

31 days diagnosis to treatment for cancer (2nd or Subsequent Treatment - anti cancer drug treatments)

98% 100.0% 100.0% 100.0% 99.7% NHSE Apr-2018 to Nov-2018

62 days urgent GP referral to treatment for cancer

85% 85.5% 86.0% 84.1% 85.4% NHSE Apr-2018 to Nov-2018

62 days urgent referral to treatment for cancer (Screening)

90% 96.4% 100.0% 91.3% 93.7% NHSE Apr-2018 to Nov-2018

Referral ToTreatment

**Incomplete Pathways within 18 weeks 92% 91.1% 84.3% 86.0% 90.5% NHSE Apr-2018 to Nov-2018

Accident &Emergency

Percentage of Patients Meeting 4 Hour Standard (All A&E Types)

95% 84.6% 81.9% 82.7% 89.1% NHSE Apr-2018 to Dec-2018

InfectionControl

Cancer*

Target 2017/20182018/2019

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1.014.14.24.34.4

1.021.031.043.13.23.33.43.53.71.13

1.051.061.071.081.091.091.101.111.122.12.22.35.15.2 Sickness5.3 LTR, Vacancy & TtR5.4

[3] Caring[3] Caring

[4] Responsive[4] Responsive[4] Responsive[4] Responsive

[5] Well Led[5] Well Led[5] Well Led

[2] Effective

[1] Safe[1] Safe

[1] Safe

[2] Effective[2] Effective

[3] Caring[3] Caring

[1] Safe

[1] Safe

[1] Safe

[5] Well Led

Minor Significant

[1] Safe Minor Moderate Improving

[3] Caring

Report

[1] Safe

[1] Safe[1] Safe[1] Safe

[1] Safe[1] Safe[1] Safe

[3] Caring

Readmissions Minor Minor Stable

Contractual

National

Local

ExcellentFalls

Never Events

Minor Moderate At RiskModerate Moderate At Risk

PDR, Medical Appraisal & STAM On Track On Track Improving

Temporary Staffing Usage On Track On Track Stable

At RiskDNAs Minor

At Risk

At RiskCancer ModerateMixed Sex Accommodation Minor Minor Stable

ASIs Significant Significant

StableStable

Pressure Ulcers Excellent Minor StableSafety Thermometer Minor On Track Stable

Serious Incidents On Track

Stroke & TIAFNOF

Minor

Maternity

Excellent ExcellentModerate Moderate

Minor Minor

Minor Stable

FFT (A&E Care)

StableOn Track

Moderate Significant At RiskFFT (Maternity Care) On Track On Track Stable

On Track

Maternity Safety ThermometerModerate At Risk

Stable

Patient Safety On Track Minor Stable

Stable

Complaints Moderate

Trust Overview

Domain Ref

Accident & Emergency Significant Significant At RiskRTT Moderate Moderate At Risk

Forecast StatusManagement Priority

Last Month This Month

December-2018

On Track Minor Stable

Theme

HCAI

FFT (Admitted Care) On Track Minor Improving

At Risk

VTE Minor

Mortality On Track On TrackDementia On Track On Track Stable

Minor ImprovingPALS Minor On Track Stable

Medication Minor Minor Stable

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1. Summary

The format of the performance dashboard reflects the core principles of the fiveDomains set out in the Care Quality Commission's Intelligent Monitoring System(Caring, Well-led, Effective, Safe and Responsive). This is an exception report with fullanalysis of the data contained within the appendices that are in the appendixsupplement. The Model Hospital group comparators for performance are: Ashford & StPeters Hospitals NHS Foundation Trust, Barnsley Hospital NHS Foundation Trust,Burton Hospitals NHS Foundation Trust, Croydon Health Services NHS Trust,Gateshead Health NHS Foundation Trust, Harrogate and District NHS Foundation Trust,James Paget University Hospitals NHS Foundation Trust, Kingston Hospital NHSFoundation Trust, Mid Cheshire Hospitals NHS Foundation Trust, Milton KeynesUniversity Hospital NHS Foundation Trust, North Middlesex University Hospital NHSFoundation Trust, Northern Devon Healthcare NHS Trust, Queen Elizabeth HospitalKing's Lynn NHS Foundation Trust, Salisbury NHS Foundation Trust, South TynesideNHS Foundation Trust and Southport and Ormskirk Hospital NHS Trust.

2. Key Highlights

2.1 Safe

Fractured neck of femur patient in theatres within 36 hours: Performance analysis

November performance was at 84.2% against 90% target (3 patients of 19 did not receive treatment within the national standard of going to Theatre within 36 hours). Two of these three patients were appropriately delayed for medical stabilisation. The other patient was delayed due to operational capacity within theatres. YTD performance is 79.1%.

HCAI Performance analysis

There have been no MRSA bacteraemia in November and December following the contaminant declared in December. Key risks and challenges: High impact improvement actions: • MRSA tolerance is zero and this constitutes

a breach should it be found not to be acontaminant. This could trigger a review bythe commissioners. Investigation isunderway.

• Sampling guidance already circulated andcommunicated with key staff and at keycommittees.

• ANTT training to be reviewed across allinvasive procedures.

• NHSI IPC review to be completed in January2019.

Serious Incidents / Never Events Performance analysis

There has been an increase in the number of SIs declared in the first three quarters compared to the same period last year. Whilst this is a good indicator that incidents are investigated in line with the StEIS standards there is a risk that the Trust may not be able to sustain the volume in terms of timely investigation and closure of Serious Incidents. In December there was 1 Never Event and another 1 has been declared in January. Key risks and challenges: High impact improvement actions: • Increase in number of SIs reported

compared to the same period last year. Thecapacity to investigate SIs may beinsufficient to meet the number declared

• Revised process for declaring andinvestigating SIs following consultation withNHSI and CCG

• Reshuffled resource allocation within Patient

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• The CCG have issued a ContractPerformance Notice due to the Trust notmeeting the key standards for investigationtimelines. A remedial action plan will beagreed and tracked to improve performance.

• Learning may not be disseminated in time toreduce the likelihood of similar incidentsoccurring.

Safety Team to support improved performance as part of scheduled restructure.

• Revising reporting to QSC to provideimproved visibility on performance andtherefore assurance.

• Engaged with a consultancy through NHSI toreview processes for quality of investigationsand dissemination of learning

• A review of LocSSIPs in the Trust isunderway to identify and address any gapsagainst national guidance.

Caesarean section rate Performance analysis

C-Section performance was at 35.1% against a target of 29%- an improvement on the previousmonth. The emergency caesarean section rate dropped to 17.43% for December and 19.58% yearto date. A further deep dive review is being undertaken by the multidisciplinary team with findings,recommendations and associated actions to be presented at the Clinical Quality Group in February2019. Elective Caesarean sections consistently remain under the 13% limit.

Mortality (HSMR) Performance analysis

The 12 month rolling HSMR data is to September 2018. The analysis of the data does not highlight any concerns. For all admissions, HSMR continues to improve and remains below expected, this is now 94.5 (range 87.9-101.6). Weekend only admissions remains within the expected range and has seen an improvement from last month, this is now 90.4 (range 77.5-104.9). The Palliative Care coding analysis shows an increase. The Trust is one of the highest for palliative care coding (highest is 4.1). Latest data for the Trust, to September 2018, is 3.8 (range 3.5-4.1). National figures of other acute non-specialist Trusts remains at 2.4 (2.4-2.4). Whilst palliative care coding is higher than other Trusts THH coding is cross checked against the patient list held by Palliative Care Team. Furthermore, the percentage of patients dying in hospital in the London Borough of Hillingdon is 54% versus a National average of 47%, which would contribute to a higher palliative care coding percentage. There is no further published SHMI data.

Medicines Safety Thermometer Performance analysis

Medicines Reconciliation within 24 hours The National average is 77% (October 2018). The Trust target is 70% at end of year based on an average as at October 2018, of 51%. There is a reduction in Medicines Reconciliation rate in December which is attributable to the reduced clinical ward pharmacy service over public holidays. The business case for seven day working has been approved and the consultation period will begin on 14th January 2019 and recruitment is in progress. A 7 day working service is expected to commence at the end of February/ beginning of March 2019. This will improve the number of patients having their medicines reconciled within 24 hours of admission and achievement of this KPI is on track.

Omitted doses The National average is 12% (October 2018). The Trust target is 18% at end of year based on an average as at October 2018, of 26%. There is ongoing effort by the pharmacy team to reduce omitted doses; any identified missed doses of medicines are highlighted to the nurse in charge. Pharmacy bulletin on how to access medication out of hours was re-launched and distributed to all

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wards in December 2018 and also sent to CSPs. There is a drug stock holding list available on the intranet so there is easy access to check availability of medication across the hospital. Nurses are encouraged to review drug charts during every handover to ensure there are no missed doses before they commence their shift and ward managers/matrons are asked to do spot checks on the ward to identify any missed doses. The Chief Pharmacist and Medication Safety Officer carry out weekly walkabouts on wards and will spot check knowledge of staff regarding missed doses. This KPI is on track.

Allergy Status The National average is 98% (October 2018). The Trust target is 98% at end of year based on an average as at October 2018, of 94%. Expect to see reduced variation with allergy status documentation once Electronic Prescribing and Medicines Administration (EPMA) is implemented. This KPI is on track.

Maternity Safety Thermometer Performance analysis

The Trust failed to deliver the 95% harm-free care target in December, achieving 85.7%. Year to date position is currently not available. Key risks and challenges: High impact improvement actions: • The Maternity Safety Thermometer is

collected and administered by the maternityteam.

• Data is submitted at point of collection, notvia the Information team

• Senior midwifery team and Information teamhave worked together to ensure data issubmitted and retrieved in timely manner.This embedded successfully in Quarter 3.

• The Maternity Matron personally overseesdata collection and sharing of results acrossthe maternity unit to facilitate learning andimprovement

2.2 Caring

Friends and Family Test Performance analysis

Three areas failed to achieve response targets:

Admitted Care: Response rate 26.3% (target 30%). There were a total1083 responses received. This was an uncharacteristic drop in performance, year-to-date continues to achieve target (32.3%).

A&E Care (A&E and MIU combined): Response Rate 3.7% (target 20%). This is further deterioration compared to previous months. When broken down to specific areas within the department, the response rate for Minor Injuries was 8.7% (179 responses); Adult and Paediatric A&E combined achieved 1.5% (68 responses) Target has consistently been missed, year to date position currently 5.7%. . Outpatient Care: Response Rate 4.26% (target 6%). There were 905 responses received. Year to date position remains slightly behind target at 5.13%

Maternity (all touch points combined) continued to achieve response target.

All areas achieved over 94% satisfaction

Key risks and challenges: High impact improvement actions: • The required response target for A&E

Care has been significantly missed over• A new matron has been employed in A&E

who will be asked to focus on improving

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sustained period of time • Trial of IPads to collect responses

proved unsuccessful in both adult andchildren’s’ emergency departments

• Highly visible banners have failed togenerate requests for survey formpatients/carers

• Risk of Contract Performance Notice• Outpatient clinics are not the sole

responsibility of the Cancer and ClinicalSupport Services division as some clinicsfall within the Medical, Surgical andWomen and Children’s division

• Maternity results have historically beenreported as a combined total for all touchpoints. This has the potential to maskunderperformance in individual services

response rates • Deputy Director of Nursing has called a

meeting with the Assistant Director ofNursing, Emergency Care, A&E Matron andHead of PPE to review actions to date and toidentify future opportunities for improvingresponse rates.

• Analysis of response rate per outpatientclinic setting has identified:- community clinics generally have a lowerresponse rate- Some clinics have only been giving outsurveys to patients on their first visit ratherthan at every visit.

• The ADoN and Matrons are driving acampaign to increase the frequency ofissuing surveys.

• Maternity results have been analysed bycomponent service. This revealedsignificantly lower response rates incommunity services.

• For postnatal and antenatal communityclients the maternity division has a stagedplan, focusing on driving up response ratesin clinic setting first. Community clinics areheld at multiple locations (excess of 15) so itis scoping options to manage this.

• The maternity division to speak to DigitalServices to identify whether there is analternative online solution to this problem.

Complaints

Acknowledged within 3 working days: Narrowly missed target (achieved 95.8% against 100% target). This was due to one new complaint out of 24 received being formally acknowledged four days after receipt.

Reply Performance: failed to achieve (69.6% responses completed within agreed timeframe against 90% target). There were 23 responses due, seven of which breached. Three divisions (medicine, women & children, patient services & nursing) achieved 100% reply performance against target; CCSS had three complaints during December, only one of which has so far closed, the others requiring further work. Surgery had seven complaints due for response and breached on four, due to late and inadequate investigations. All responses due in December have now been completed.

Despite reduced performance in December, an upward trajectory has been maintained on a quarterly basis: Quarter 1 achieved 55%; Quarter 2 achieved 78%; Quarter 3 achieved 83%.

January performance is currently on track to deliver 90% target. Key risks and challenges: High impact improvement actions: • Continued high operational demands impact

on ability for divisional teams to completeinvestigations

• Dependency on specific individuals withindivisions to complete investigations

• Complaints Summit held with division ofsurgery on 20 December, attended byConsultants and junior doctors. Theimportance of responding promptly andopenly to complaints was emphasised, and

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• Risk of contractual performance notice ifimprovement trajectory does not maintain

supported by a solicitor presenting as well. • The Complaints team meets with divisional

leads in Medicine and Surgery on a weeklybasis to discuss all open complaints andidentify priorities and bottlenecks

• Weekly meeting to be implemented inCCSS in January

• Current status of investigations (“hotlists”)for all open complaints circulated to Directorof Nursing and divisional leads on a weeklybasis

2.3 Responsive

18 weeks Referral to Treatment (RTT) – Incomplete standard Performance analysis

The Trust did not achieve the incomplete pathways constitutional standard (84.3% against the 92% target) in December. This is 0.5% reduction from November.

2018/19 contractual target is to maintain last year’s waiting list size. The total waiting list size was 23518 in December against the target of 22773 (2017/18). The Trust is 745 patients above waiting list target (an improvement of 392 patients from the previous month).

The Focus Performance SPC Charts (attached) demonstrate the waiting list positon broken down by admitted and non-admitted patients. In March the Trust had 4775 patients on the admitted waiting list, currently the list stands at 3750. In March there 17998 patients on the non-admitted PTL. This rose to 20586 and has now begun to decrease. In December there are 19237 patients on the non-admitted waiting list.

There were zero 52 breaches in December. Key risks and challenges: High impact improvement actions: • Validation of the waiting list has highlighted

some areas of risk that are being addressed.• The ability to recruit the staff in Dermatology

to provide the required capacity.• Winter pressures may impact on the activity

plan that has been successfullyimplemented.

• Data quality within the patient tracking list(PTL) – a validation processes is in place.

• Reduction of patients waiting over 40 weeksthis has reduced from 186 to currently 56.

• Reduction of patients waiting over 45 weekshas reduced from 56 to 15.

• Reduction the admitted waiting list – this hasreduced from 4775 patients waiting (March2017/18) to 3774 in December.

• Intensive support Team (IST) start within theTrust to help build a sustainable trajectory,test and challenge our recovery plan andassist in the Data quality improvementsrequired.

Cancer performance Performance analysis

In November the Trust achieved the 62-day standard performance 86% (against the 85% target). Quarter performance is still at risk due to October’s performance (79.4%).

The Trust is monitoring the recovery plan to achieve a sustainable recovery trajectory. National Standards were achieved in 31 day decision to treat to treatment, subsequent treatment, and consultant upgrade. Key risks and challenges: High impact improvement actions:

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• Quarter 3 - 62 performance at risk.• Colorectal pathway is a risk due to increased

2ww waits (42% increase), pressure onendoscopy capacity, and unavailability ofHDU beds due to winter pressures.

• 2nd CT open 3 days per week for Cancerpathway

• Cancer Trackers now in place tracking fromday 0.

• New Gastroenterologists in post – increasedcapacity in Endoscopy (the impact will beseen in January).

• Backlog on 62 day pathway has beenreduced from 39 to 11.

Four Hour Emergency Care Transit Time Standard Performance analysis

The Trust delivered 81.9% (All type) and 60.6% (Type 1) performance in December 18. The average Type 1 attendance from April to November was 5,323 and All Types at 13,599. December saw 6,264 Type 1 and 14,141 All types. This was an increase of 17.6% and 4% higher than the average respectively. The SPC charts on attendances demonstrate higher adult non admitted attendances generally compared to the admitted patients particularly out of hours. This pattern further supports the current performance focus around the improvement of non-admitted stream consistently especially during out of hours to enable improved care for patients by the ED and specialty teams. The LAS handover times continue to improve in the face of increased attendances and this level of sustained performance has been commended across the system. Key risks and challenges: High impact improvement actions: • Non-admitted breaches remain a risk

particularly during out of hours. InDecember, the average non-admittedbreaches were 43 a day (55% of total). Thisis further exacerbated on the days when EDhas over 50 patients in the departmentcausing limited spaces for assessment andtreatment

• Specialty delays in assessing and thentreating patients in ED also result in furthernon-admitted breaches. This amounts toabout 5 to 10 a day

• Inconsistent use of CDU by the ED team ona 24/7 basis is also an issue that is causingbreaches to occur during out of hours

• ED escalation triggers and actions for thenurse and doctor in charge to be re-enforcedfor 24/7 use. This includes Board rounds toensure situational awareness of both theroles and ensuring patient safety throughtimely care

• Dedicated blue zone with 2 cubicles forassessment and treatment of ambulantpatients under ED team

• Specialty teams to attend the breachperformance meetings on Tuesdays to gothrough their delays and improvementactions

• Re-inforce the Pathway Appropriate Careand Treatment (PACT) interventionsincluding the use of CDU trolleys ad chairs

• ED improvement week focusing on reducingthe non-admitted time delays in ED duringthe Multi-Agency Accelerated Dischargeevent (MADE) in January, February andMarch 19

• ECIST to work with the Trust in Q4 to focuson the non-admitted interventions as part ofthe national expert team in this area

Emergency admissions and Length of Stay (LoS) Performance analysis

The stranded patient cohort continues to be case managed by the system through the weekly MADE led by the Director Of Operations. The SPC charts demonstrate a clear reduction in both the stranded (LoS > 6 days) and the Extended LoS (>20 days) since April 18. There was a reduction

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post MADE (10th to 16th December) in both the cohorts followed by a transient increase. The delay codes during this time were mainly around not fit as all the medically optimised patients had clear plans in place. A high number of complex patients were case managed pre-Christmas increasing daily discharges of stranded patients from 14 a day to up to 23 a day (during the full week of MADE). The average LoS was maintained at 4.56 days. Key risks and challenges: High impact improvement actions: • Housing related issues remain a risk as do

patients with challenging behaviours• Out of borough patients result in delays

especially as local trusts get prioritised andassessments are limited due to travelrequirements

• Further internal focus on clinical delays isneeded through clinical peer reviews bymedical colleagues and matrons ensuringrobust plans for every patient as an outputfrom ward board rounds

• Meeting with the housing team took place inNovember focusing on close working. Thiswill be reviewed in February (MADE week)

• The Local Authority has a grant scheme inplace for equipment and home adaptationwhich includes decluttering, repairs and clearout service for patients who may be delayedfor discharge home otherwise

• Full week of MADE planned in January,February and March. Weekly MADEcontinued business as usual with systempartners

• Further improvements to the Trust IP PTL toinclude escalation from ward to theIntegrated discharge team and Silver (toresolve blockages daily)

• Clear out of borough escalation contactsbeing sought from the NWL surge hub tosupport the Trust

• Discharge improvement Lead workingsuccessfully with the ward teams to promoteand embed discharge work streamprocesses

2.4 Well Led

PDR Compliance Performance analysis

PDR compliance increased for December to 98.6%, how higher than the same period last year (98.34%). Key risks and challenges: High impact improvement actions: • Achieving 100% PDR completion across

all directorates/divisions.• Support those outstanding staff to

complete/report PDRs.• Identify reasons for non-completion to

tailor support provided from L&OD team.

Mandatory Training Performance analysis

Compliance has increased further to the highest level of the year 91.87%. Key risks and challenges: High impact improvement actions: • Maintaining the upward trend and

ensuring all courses are within target.• Continued effort to reach target for Data

Protection & Security

• Input from People Solutions Partners indeveloping visual forward planner withnames of staff and dates of training formgrs/matrons to complete and monitor.

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• Increased promotion/uptake of auto-generated compliance reports fromiDevelop to managers.

• Input from People & OD team to supportareas where compliance is at risk bysubject – regular information beingprovided to triumvirate with non-compliant names.

• Maintaining daily monitoring of temporarystaffing STaM compliance, ensuring nonew joiners to the Bank who are non-compliant and suspending from the Bankwhere workers do not become compliant.

• Reviewing training capacity againstdemand for subjects at risk andarranging additional sessions whererequired.

Vacancy and Voluntary Turnover Rates Performance analysis

Both vacancy and voluntary turnover rates have increased in December to 12.48% and 13.25% respectively. Key risks and challenges: High impact improvement actions: • Preventing turnover from increasing

further.• Returning time to hire to within target and

reducing voluntary leavers to help reducevacancy rates.

• Continued work to support NHSI R&Rplan (e.g. focus group with AMU/SAUmerger to aid integration andengagement).

• Bespoke retention campaigns (e.g.emergency department review of middlegrade rotas & rotational programmes formiddle grade/SHO and developmentalroles band 2 to 3 HCAs).

• Review recruitment blockages withrecruitment team with a particular focuson Band 5 nurses.

• Continued review of data from staffsurvey, student nurse retention and exitinterview to improve staff engagementand experience.

Sickness Absence Performance analysis

Sickness has increased further to 4.56%, the highest level of the year. Key risks and challenges: High impact improvement actions: • Prevent potential increases in sickness

absence as we progress further intowinter.

• Increasing manager appetite, capacityand capability to progress long-term

• Weekly performance & review (PAR)meetings with Execs to review sicknessdata from the roster and ensure divisionsprogressing with their cases in a timelymanner.

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sickness cases. • Negotiating with staff-side to tighten theSickness Absence Policy.

• Ongoing management of cases viaregular one to one meetings withmanagers.

• Monthly case conferences with OH todiscuss and resolve difficult and long-term sickness cases.

• Coaching for managers from the HRConsultants on how to manage sicknessabsence and training and support fromP&OD for the supervisory Band 7 nursesin relation to sickness absencemanagement, early interventions andother HR-related policies.

Temporary Staffing Usage and Price Caps Performance analysis

Reduction in overall temporary staffing spend by over -£100k to £1,680,656 following decreases on agency to £811,075 and bank spend to £869,581. Increased overall bank fill rate to 73.4% (including medics). Key risks and challenges: High impact improvement actions: • Further NHSI price cap breaches

particularly for medical locums and off-framework bookings for nurses.

• Continue the reduction in temporarystaffing spend particularly for agencybookings.

• Temporary staffing usage and spenddata reviewed by Execs at weeklyPerformance & Review meetings.

• People Solutions Partners to attend saferstaffing meeting and monitor 6-weekroster publication to ensure coverthrough bank over agency.

• Greater promotion and utilization ofPatchwork to maximize reduction inmedical agency staff and increase thepool of medical bank.

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Report title: Financial Performance Report

Report author(s) Mel Hughes, Deputy Director of Finance Report sponsor(s): Matt Tattersall, Director of Finance



Note the report


STRATEGIC PRIORITY: f) Improving the present - A&E 4 hour standard - 18 week Referral to Treatment - Meet cancertargets - Complete CQC action plan - Implement year 2 of Quality and Safety ImprovementStrategy - Maintain finance and use of resources score of 3 - Meet control total

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FINANCIAL REPORT DECEMBER 2018 (MONTH 09)

1. EXECUTIVE SUMMARY

Key Points to note at Month 09: • M9 deficit of £2.4m, £1.3m behind plan, and £0.2m adverse to forecast for month.• Year to date deficit of £18.4m, £12.3m adverse to plan.• Agency expenditure of £0.8m in month, a small decrease on previous month.• Pay overspend reduced to £0.6m in month and £0.1m better than forecast.• Finance and Use of Resources score of 3.• Efficiency savings of £1.1m in month.• Capital expenditure of £0.6m in month.• Cash position of £1.0m at month end.

The actual position for December was £231k adverse to the forecast deficit of £2,360k.

Clinical Income in December was ahead of plan in total by £541k but behind forecast by £326k.

The Daycase activity was well above forecast in both numbers and value, helping the Trust recover some of the loss incurred in previous months. The Elective in patient activity met forecast in value terms and was only marginally behind in activity. However, Outpatient activity was again down both on numbers and value against the forecast. The Christmas break has meant that some clinics have been cancelled, and whilst this was planned for, activity was still down.

Annual Plan Actual Variance Plan Actual VariancePlan to-date to-date to-date In Month In Month In Month

£000s £000s £000s £000s £000s £000s £000s

Operating IncomeNHS Clinical Income 220,643 165,119 165,977 858 17,599 18,140 541Non-NHS Clinical Income 2,763 2,069 2,476 407 231 284 53Other Operating Income 28,820 21,603 21,047 (556) 2,428 2,212 (216)

Total Operating Income 252,226 188,791 189,500 709 20,258 20,636 378

Operating ExpensesEmployee Expenses (168,103) (125,608) (132,341) (6,733) (14,056) (14,679) (623)Drugs (18,452) (13,816) (13,939) (123) (1,347) (1,422) (75)Clinical Supplies and Services (29,070) (21,707) (24,227) (2,520) (2,332) (2,783) (451)Other Operating Expenses (33,622) (25,104) (25,370) (266) (2,764) (2,753) 11

Total Operating Expenses (249,247) (186,235) (195,877) (9,642) (20,499) (21,637) (1,138)

EBITDA 2,979 2,556 (6,377) (8,933) (241) (1,001) (760)

Depreciation (9,722) (7,287) (6,910) 377 (828) (774) 54Interest Income/Expense (3,448) (2,546) (2,295) 251 (295) (277) 18PDC Dividend Expense (3,749) (2,825) (2,825) 0 (308) (308) 0

Surplus(Deficit) before Exceptionals (13,940) (10,102) (18,407) (8,305) (1,672) (2,360) (688)

Provider Sustainability Funding 6,181 4,017 0 (4,017) 618 0 (618)Gains/(Loss) on Investment Properties 0 0 0 0 0 0 0Profit/(Loss) on the Disposal of Assets 0 0 0 0 0 0 0

Surplus(Deficit) after Exceptionals (7,759) (6,085) (18,407) (12,322) (1,054) (2,360) (1,306)

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Activity Based Clinical Income for the year to date the Trust is ahead of plan by £858k, but within this there is the £2.1m funding relating to the pay award. Therefore, the actual underlying position is £1.2m behind plan. The summary can be found at Appendix I.

Pay was lower than forecast in month by £143k continuing last month’s trend. Agency costs were down compared to November by £53k, medical locums were down by £40k and other areas remained stable.

Drugs were below forecast levels by £98k, and below the year average, in part due to lower activity levels.

Clinical supplies were above both planned and forecast levels this month, this is due to NWL Pathology where an additional £138k expenditure to cover prior year deficit was incurred. Activity based costs were generally down in month in Surgery however outsourcing of MRI and CT reporting was overspent by £45k.

Key Performance Indicators

Surplus/(Deficit) (£2,360k) ↑ Risk Rating 3 ↔ Agency expenditure £811k ↓ Efficiency Savings £1,125k ↓ Pay Variance £623k ↓

2. DIVISIONAL POSITIONS

Surgery have over performed in month on Income due to catch up on elective activity, however costs of delivery have increased due to WLI payments and theatre staff costs meaning that the

Annual Plan Actual Variance Variance Variance WTE WTE WTEPlan To-Date To-Date To-Date Last Month Plan M9Actual M9Variance

£000's £000's £000's £000's % £000'sSurgery Income 48,012 35,976 34,825 (1,150) (3.2%) (1,153)

Pay (38,280) (28,731) (29,370) (638) (2.2%) (496) 663.10 669.60 6.50Non-Pay, Depn & Interest (19,000) (14,257) (14,407) (150) (1.1%) (275)Unallocated CIP 983 745 0 (745) (100.0%) (665)Total (8,285) (6,268) (8,951) (2,683) (42.8%) (2,590)

Medicine and Income 66,334 49,547 48,976 (571) (1.2%) (350)Emergency Care Pay (52,157) (39,097) (41,290) (2,193) (5.6%) (1,906) 1070.14 1032.94 -37.20

Non-Pay, Depn & Interest (21,327) (16,010) (16,839) (829) (5.2%) (810)Unallocated CIP 1,557 1,115 0 (1,115) 100.0% (1,048)Total (5,593) (4,445) (9,153) (4,708) (105.9%) (4,114)

Women & Children Income 36,813 27,528 27,128 (401) (1.5%) (510)Pay (24,770) (18,575) (18,591) (17) (0.1%) (3) 447.40 442.10 -5.30Non-Pay, Depn & Interest (4,346) (3,370) (3,315) 56 1.7% 56Unallocated CIP 576 469 0 (469) 100.0% (433)Total 8,273 6,052 5,222 (831) 13.7% (890)

Cancer & Clinical Income 31,240 23,421 23,474 53 0.2% 111Support Services Pay (25,768) (19,339) (19,510) (171) (0.9%) (171) 599.80 555.20 -44.60

Non-Pay, Depn & Interest (8,579) (6,656) (8,388) (1,732) (26.0%) (1,362)Unallocated CIP 1,312 953 (953) (100.0%) (834)Total (1,795) (1,621) (4,424) (2,803) (172.9%) (2,256)

Corporate Income 18,742 14,044 14,854 810 5.8% 916Pay (30,294) (22,752) (22,386) 366 1.6% 224 764.30 717.40 -46.90Non-Pay, Depn & Interest (26,532) (19,940) (21,783) (1,842) (9.2%) (1,660)Unallocated CIP 917 728 0 (728) 100.0% (650)Total (37,167) (27,921) (29,315) (1,394) (5.0%) (1,170)

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total overspend has increased by £93k

Medicine under delivery of income in Emergency admissions, and overspends on additional sessions in A&E and AMU mean that the overspend has increased by £594

Women’s & Children have exceeded forecast on income due to emergency admissions and Outpatient activity and have only small overspends on pay and non-pay, thus their position has improved by £80k.

CCSS position has worsened by £547k this month £250k is due to NWL Pathology provision for increased costs for prior year deficits, Income was underperformed on Direct access and the remainder is due to unmet CIP.

Corporate areas have seen costs for a compensation claim for carparking of £98k and Kingsgate fees of £80k this month, unmet CIP of £78k accounts for the remainder.

3. FINANCE IMPROVEMENT PROGRAMME

M9 Performance

Divisions In Month £ Year To Date £

Plan Actual Var. Plan Actual Var. Clinical Support Services 94,271 92,787 (1,484) 386,264 423,579 37,315

Corporate 213,119 159,142 (53,976) 1,771,521 1,704,683 (66,838)

Medical Division 692,059 536,849 (155,210) 2,058,479 1,839,963 (218,515)

Surgical Division 220,392 189,845 (30,547) 1,440,735 1,329,097 (111,638)

Women & Children's Division 175,132 138,269 (36,863) 609,774 608,230 (1,544)

Trust-wide 157,355 7,646 (149,709) 650,986 81,536 (569,450)

Totals 1,552,328 1,124,538 (427,790) 6,917,758 5,987,088 (930,670)

M9 delivered £1.12m against a planned target £1.55m (achieved 72%) areas of under-performance are Medical Productivity, Non-Pay & Nursing. Non-pay is still at risk of delivery whilst saving opportunities are identified and agreed by the NW London Procurement Cluster. Medical Productivity is expected to recover a significant proportion of undelivered savings YTD from the roll-out of the Patchwork app which significantly improves the booking process for locum doctors reducing the need for agency doctors. Nursing Productivity delivery against plan was heavily impacted by the reduction in available bank staff over the holiday period. This meant that off-framework agencies were used to fill over 100 shifts in December as opposed to 25 shifts in November.

4. FORECAST

The Trust has met with NHSI to agree a revised forecast. The reforecast was discussed with NHSI in line with their protocol. The revised deficit of £20.5m was accepted, however, we were advised to increase the forecast to reflect the risk of not receiving the £2.2m support funding from the NWL CCGs. Consequently, the revised forecast submitted at quarter 3 was £22.7m deficit (see Appendix II for the summary).

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Risks not included in the forecast

• NWL Pathology has indicated that Hillingdon has not made sufficient contribution to theJV. Whilst the value concerned has reduced, the move to the Customer Contract wherethe Trust pays a price per test, could put pressure on the forecast. Nevertheless, there isan agreement between the shareholders that no Trust will be disadvantaged in year. TheJV has not achieved the savings envisaged and will be in deficit this year; we are workingwith the finance team to calculate the Trust’s share of this.

• A bad winter could cause pay and non-pay costs to escalate.• Given the fragile nature of the Trust’s Estate, there is always a risk of emergency

expenditure being required above the current rate of expenditure.• The forecast contains no contingency for unforeseen issues.

NWL CCG Support

As part of the financial plan, the NWL CCGs agreed to cover the £2.2m gap between our budget and the control total issued by NHSI. The context to this was that achieving the Control Total (CT) would unlock Provider Sustainability Funding (PSF). As we are not achieving our CT the CCGs are not prepared to provide the £2.2m funding and this will worsen our financial position. The Trust’s position is that the only condition placed on this funding was that we did not charge the CCG any over performance on the contract. As we have kept to this agreement, we believe we would be successful at arbitration. However, NHSI advised that if they were asked to arbitrate, they would find it very difficult to find in our favour. They were involved in the negotiations to secure the funding, and the conditionality with respect to PSF was key to securing the funding, even if this was not subsequently written down. It is proposed that the Trust does not take the issue to arbitration due to the damage this would make to relationships with the CCG and NHSI at a time when building relationships is key to our financial recovery moving forward.

5. RISK RATINGThe “Finance and use of resources metric” forms part of NHS Improvement’s Single OversightFramework. It is scored between 1 (best) and 4 (worst). The rating for December is a 3:

Metric Plan Rating for November Capital Service Capacity 4 4 Liquidity 1 3 I&E margin 4 4 Variance from Plan 1 4 Agency spend 2 1 Weighted Average 2.4 3.2 Overall Rating after Overrides 3 3

The ‘Underlying Financial Performance’ risk on the Corporate Risk Register is rated 20 (extreme). Given that we have now reforecast the finajcial outturn, the risk is assessed as assured rather than unassured.

6. BALANCE SHEET AND CASH

The month end cash position was £1.6m, having received £3m deficit support in December. The Trust has arranged deficit support of £2m for each of January and February. Cash remains under pressure with suppliers chasing outstanding invoices being prioritised for payment from Deficit support funding.

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Meeting of the Trust Board Public Part I Session

Date of meeting:30th January 2019 Agenda item: 18

Report title: NHS Improvement Undertakings - progress update and assurance

Report author(s): Imran Devji (Director of Operations) and Matt Tattersall (Director of Finance)

Report sponsor(s): Joe Smyth (Chief Operating Officer) and Matt Tattersall (Director of Finance)



Note the progress and assurance provided in the report


STRATEGIC PRIORITY: f) Improving the present - A&E 4 hour standard - 18 week Referral to Treatment -Meet cancer targets - Complete CQC action plan - Implement year 2 of Quality andSafety Improvement Strategy - Maintain finance and use of resources score of 3 -Meet control total

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UNDERTAKINGS

This report provides oversight to the Trust Board (through the Finance and Transformation Committee on alternative months) on progress against the undertakings made by the Trust to NHS Improvement. These undertakings relate to A&E; Finance; Governance and Programme Management. The report includes detail in relation to the Hillingdon Emergency Care improvement Programme.

A&E

1. The Trust has provided to NHS Improvement a Board-approved plan for A&Eperformance recovery (“the A&E Plan”) as agreed with NHS Improvement. Thisincluded:A. the key milestones and how they will be achieved;B. what resources the Trust has in place to deliver the A&E Plan;C. the key risks to delivery, monitoring and mitigations;D. the key performance indicators (KPIs) to monitor the A&E Plan; andE. how the Board will have oversight and overall governance over the A&E Plan.

A. The current Urgent and Emergency care Improvement Plan for the Hillingdonsystem sets out the key milestones and how they will be achieved (attachedas appendix 1). The plan has been refreshed to incorporate furthermilestones for improving the Emergency Care performance.

B. The Trust has invested additional managerial staff within the A&E, provided asenior programme manager and commissioned Hunter Consulting to resourcedelivery of the A&E action plan. The Trust is also continuing to work withECIST to focus on improving ambulance handover, reducing non-admittedbreaches and strengthening the progress on reducing the stranded patientcohort. The Trust will increase support for the department out of hours byinvesting in additional twilight registrar to facilitate more timely admissions tothe hospital.

C. Risks and mitigations are outlined below.

D. The critical success factors which details the key performance indicators isattached as appendix 2. This includes the stranded patients.

E. The Board receives reports either at the Board meeting (every other month) orthrough the Trust Finance and Performance Committee, which meetsmonthly.

2. The Trust will provide to NHS Improvement a monthly Board approved report onprogress against the A&E Plan, which includes the following:

• progress being made against the key milestones;• if there are any areas of slippage against milestones, how performance will

be recovered and monitored; and,• Any key risks to delivery of the Plan, and the related mitigations.

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The table below provides an update on the milestones for December 2018 and actions taken where these were not achieved. Please note the RAG rating in this report is refreshed and there may be some variation from appendix 1.

Milestones (Improve Flows in ED and Site) RAG Assurance for variation Ensure dedicated use of side-rooms in blue zone for the management of non-admitted stream to reduce delays

On track - 30/60/90 days sustainability checks in place. The ED improvement week (from 14-18.01.19) will focus on the non-admitted improvements in flow with ECIST support.

Site to ensure 12 definite patients for discharge sat out on wards by 08.30 to create assessment capacity upstream

Daily process in place. Further work is required through the Discharge Task and Finish Group to ensure day before identification of definite discharges. Divisional leads also providing daily support to clinical teams through the use of Nerve Centre for discharges. Further support from clinical teams around boarding patients safely on wards with definite discharges.

Patient flow data available real time to support the management of flow

Real time data successfully in place on ireporter. The next phase is to focus on the consistent use of data and improving it. 30/60/90 days review and reinforcing use of data during ED improvement week to support the prospective management of flows.

Use of agreed shared escalation triggers between Site & ED to support patient flow both in and out of hours

ED Improvement week during the 14th -18th January 19 to support and embed the use of trigger points and escalation.

Strengthen daily emergency care performance meetings to include specialty engagement through divisional escalation leads.

Plan in place and speciality level attendance will be every Tuesday. UCC in attendance on a daily basis with ED.

Embed and sustain agreed roles & responsibilities for ED & Site - sustainability check 30 days

Progress is being made in this area, but there needs to be greater focus on the importance of the band 7 role. Operational management of the department continues to be challenging and this will be addressed by the new Clinical Lead and Deputy Divisional Director, who have outlined a six point plan for recovery.

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Monitoring ED IPS and sustainability check 30 days

Escalating from the department is still happening too late to allow appropriate action to be taken to resolve the issues. Additional actions are required which will be tracked in the new plan currently under development.

ED SOP 30 day sustainability check On track awaiting review. Implementation of the Manchester triage during ED Improvement week

ED improvement week taking place 14-18th January 19.

Audit compliance rate with external IPS during ED Improvement week

ED improvement week taking place 14-18th January 19. If successfulthis action will go green.

Ambulance handover sustainability at 90 days 60 day review showed progress since 30 day review. Positive progress seen around time taken to do handover with improving patient experience.

Milestones (Improving Discharges) RAG Assurance for variation MADE week (14th – 18th January 19) to support working with system partners to target delay themes and reduce delays

Delays reporting to include daily/weekly numbers. Major current themes are awaiting CHC bed/DST/POC/ Housing/rehab. MADE week 14th -19th Jan to continue to work through this.

Refresh & relaunch Choice & Discharge policies In progress. Choice letters developed and signed off for use. Coaching session to be held with ward managers to cover: Self funder management, palliative fast track process, management of homeless patients, use of Take Home and Settle, booking transport. A number of patients have been discharged during the MADE weak using this policy.

Further refinement of Stranded Patients process Completed. Testing out changes in MADE week to help also identify themes. Next action will be to improve the IP PTL – April 225 and December 185

Go live with Criteria Led Discharge Progressing well. 3 wards expected to go live by mid-Jan as Phase 1, Phase 2 and 3 launches are anticipated for Feb and March respectively.

Commence work stream to flush out delays Pilot of transcribing TTAs to start.

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caused by TTAs, commence PDSAs to identify solutions

Plan in development to identify the biggest impact areas.

Improve identification of weekend discharges between ward managers and medical teams. Increase by 10% patients identified for discharge that actually go home

Progressing - CARES week drive to improve accuracy of Nerve centre information with nursing & medical input.

Milestones (New Medical Model) RAG Assurance for variation Commence hybrid model of Single Point of Access (SPA) and out of hours (phased development)

Interim hybrid model now in place. IT working group to be set up and review options to facilitate the required model

Estates to hand back new AECU area to division Progress for handover, expected for Wednesday 16 Jan

Decant temporary AECU area on AMU, replace with trolleys as an assessment bay

On track and progressing

Open new AECU area AECU area expected to open on Monday 14th Jan (during MADE/CARES week)

Open RAMU as a trollied bay on AMU (4 trolleys initially) with a LoS of 4-8hrs

RAMU area expected to open Wednesday 16th Jan 9during MADE/CARES week)

Sign off SOP for AMU, AECU, RAMU Sign off is progressing and expected by 18th January

These milestones are tracked at a weekly Emergency Care Recovery Group where all three work streams are reviewed. Appendix 1contains the latest reports produced at the last weekly meeting.

The Trust is now undertaking a complete review of all of the action plans designed to improve flow (Patient Flow, Improve Discharge and New Medical Model). This will result in a new combined action plan focused on improving operational management in the department by driving roles, responsibilities and accountabilities.

Key risks with mitigations

Risks Mitigations Data quality and completeness against time standards does not back up what we are trying

Active ECDS workgroup in place to monitor & drive improvement. ED hourly daily sitrep

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to deliver introduced. Colleagues not conforming to the ED & Trust wide IPS

Interim manual data capturing process to monitor adherence until electronic update of requirements are in place. Trust wide IPS - AECU/RAMU will enable compliance through improved pathways as a default “pull”

Leadership cover into the evening reduced, but is a key part of the resilience and grip in the department

Formalised checkout huddle started from 3rd December 18 with ED nurse in charge for plan going into the evening; to be sent to DOP and the on call manager. Senior Manager and Director rota produced over winter months.

Lack of Electronic Bed Management system to effectively manage flow and bed utilisation in "REALTIME" from admission through to discharge

Capital to purchase a system (subject to specification and "fit for purpose" could be provided by ICT. PAS to be demonstrated by Silverlink)

ED and Ops teams not consistently following OPEL Triggers and RAG status of organisation to initiated escalation procedures effectively and appropriately

Training and Communication plans in place with revised Escalation Pack. Monitoring of SITREPS to challenge OPEL status of organisation at any given time.

ADT (Admissions, Discharge and Transfers) not recorded in real time which impacts on data quality - there is no standard for an accurate bed state.

Refresher programme to all wards

No common list of patients identified for discharge.

Ward managers to ensure patients identified by medical teams are reflected on NC & vice-versa: emphasis during CARES week

Buy in across the organisation to SPA / co-working and response to escalation.

SPA trial in place twice before go-live to ensure learning

Lack of Downstream flow preventing onward flow from RAMU

Work in place through FLOW workstream.

Clinical Leadership and engagement to affect change in processes within A&E.

There is much greater clinical ownership of processes and procedures within the department. Further work is required and this will be an ongoing risk.

Clinical leadership of the SAFER/SORT best practice team is currently at risk due to clinical commitments.

The CEO now holds regular meetings with the Clinical Leads, Divisional Directors, Director of Nursing, Medical Director and COO.

Table 1: Trajectory

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The performance position in December 18 was 81.9% against the trajectory of 92%. The month also saw an increase of 7.4% in Type 1 attendances compared to 17/18 with just over 1% improvement in performance (December 17 was 80.6%). Please refer to appendix 2 (Critical Success Factors) for further details. The Trust is also improving its discharge management with a specific focus on both internal and external improvement schemes.

The undertakings relating to Finance, Governance and Programme Management are as follows:

The undertakings relating to Finance, Governance and Programme Management are as follows:

Undertaking Status Finance

1. The Trust will develop a financialplan to March 2020 (“the FinancialPlan”) which includes:

• an understanding of theunderlying financial positionand a detailed analysis of thecauses of the underlyingposition;

• a well-developed CIP planwhich takes into account allrelevant operationalproductivity opportunities;

• A drivers of deficit paper hasbeen provided to NHSI

• The Trust’s Long TermFinancial Model is beingupdated

• The existing FIP plan takesaccount of opportunities asidentified in the Model Hospital.The plan to March 2020 willfurther explore theseopportunities

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and • a link to workforce

optimisation.

• The Trust’s People Strategy willbe embedded within thefinancial plan

2. The Trust will keep both theFinancial Plan under review andprovide regular highlight reportsincluding key performanceindicators and attend regular updatemeetings, the content and timing ofwhich will be agreed with NHSImprovement.

• The Trust continues to engagewith NHSI through: an openinvite to the new weekly “checkand challenge” divisionalreviews; monthly returns;monthly oversight meetings;and at other times as required.

Governance

3. The Trust will undertake anexternally commissionedgovernance review to inform thestrengthening of governancearrangements to be completed by adate to be agreed with NHSImprovement. The scope andsupplier will be agreed with NHSImprovement

4. The Trust will address the findingsof the governance review. Thetiming of delivery of therecommendations will be agreed byNHSI and the Trust will provideassurance to NHS Improvement ifrequested on progress with delivery.

• Deloitte have undertaken thegovernance review to a scopeagreed with NHSI.

• Deloitte have not yet releasedthe report and the Board willconsider its findings oncereceived

5. The Trust will work with a SeniorBoard Advisor who may beappointed by NHS Improvement toassist the trust’s executive teamwith the delivery of the Plansidentified within these undertakings.

• NHS Improvement has not asyet made any suchappointment.

6. The Trust will co-operate and workwith such partner organisations (thismay include one or more ‘buddytrusts’) which may be appointed byNHS Improvement to support andprovide expertise to the Trust and to

• NHS Improvement has not asyet made any suchappointment.

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assist the Trust with the delivery of one or more of the Plans identified within these undertakings and the quality of care the Trust provides. The scope and scale of any such support will be directed by NHS Improvement.

Programme management

7. The Trust will ensure adequatesenior management (PMOresource) to support the executiveteam to deliver the undertakingsabove.

• The Trust has alreadyappointed to the AssociateDirector of PMO role thatsupports the FinancialImprovement Programme

• The Trust has appointedKingsgate to support delivery offinancial recovery

8. The Trust will implement sufficientprogramme management andgovernance arrangements to enabledelivery of these undertakings.

The programme management andgovernance arrangements mustenable the Board to:

• obtain clear oversight overthe process in deliveringthese undertakings;

• obtain an understanding ofthe risks to the successfulachievement of theundertakings and ensureappropriate mitigation; and

• hold individuals to account forthe delivery of theundertakings.

• The undertakings will bemonitored by the Finance &Performance Committee andthe Trust Board

9. The Trust will attend meetings or, ifNHS Improvement stipulates,conference calls, at such times andplaces, and with such attendees, asmay be required by NHSImprovement.

• Agreed

10. The Trust will provide such reportsand access to any of the trust’s

• Agreed

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advisors in relation to the matters covered by these undertakings as NHS Improvement may require.

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Report title: Care Quality Commission Thematic Improvement Plan

Report author: Sue Manthorpe, Assistant Director of Regulatory Compliance

Report sponsor: Jacqueline Walker, Executive Director of Patient Experience and Nursing

Executive Summary:

The purpose of this report is to provide monthly assurance control monitoring specifically relating to areas of improvement arising from the requirement notice received from the Care Quality Commission (CQC) inspection.

Key highlights from this report:

- 17 of the 18 actions relating to the CQC Requirement Notice have been met;- 13 of the 14 ‘must do’ and 64 of the 70 ‘should do’ actions outlined in the inspection report

have been completed.- The Themed Clinical Fridays’ process has been developed to provide a consistentapproach to continuous quality improvement which is having a positive impact on staffbehaviours and providing evidence of improved standards and compliance.


The Board is asked to:

- Note and comment on the information provided in the report;- Review and comment on the Care Quality Commission (CQC) thematic improvement planwhich was reviewed in detail by the Quality and Safety Committee in January.

Appendices:

1. CQC Thematic Improvement Plan


STRATEGIC PRIORITY:

Aim 5 - Delivery Area 5: Ensure we have safe, high quality sustainable acute services

103

1. Introduction

This report provides the regular update for the Trust Board against the progress of the CQC Thematic Improvement Plan (TIP) and the Trust’s CQC assurance framework. The report provides an overview of how the areas of concern identified in the CQC inspection report and the Quality Summit in September 2018 are progressing.

The attached plan (Appendix 1) has been reviewed at the Executive Directors’ meeting and was presented for discussion at the January Quality and Safety Committee (QSC).

The TIP does not replace the detailed action plan that has been addressing the ‘must’ and ‘should’ do’s identified for the core services inspected, and that addresses the Trust’s requirement notice with the CQC as outlined below.

2. Progress of improvement actions (Thematic Improvement Plan and must /should do action plan)

The TIP has been developed as a result of engagement with key stakeholders at the Trust’s Quality Summit and was approved by the Trust Board in November 2018. It is now presented to each QSC monthly meeting to ensure there is regular and high level scrutiny of the detail by a Board Committee, with presentation of the action plan by the Director of Patient Experience and Nursing to the bi-monthly Trust Board meeting with exception reporting and escalation, supported by the Chair of QSC. The areas of concern, highlighted in red are the aged estate and the Estates strategy, which is under development and in need of further consideration in light of the loss of the Shaping a Healthier Future investment. The TIP is provided as Appendix 1 in the Appendices document to the Board for review.

The QSC carried out a detailed review of the Thematic Improvement Plan at the meeting held on 21st January. The Committee recognised there had been some delays in updates received from People and Organisational Development services and Site Operations. Key leads for these areas have been invited to attend the next QSC to provide further updates.

The Trust received 18 actions relating to the Requirement Notice on Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance. All of these actions as part of the Must/Should do action plan have now been completed and have received external assurance from the monthly evidence meetings with the CCG and NHSI, with the exception of the one action regarding the WHO Theatre Checklist. The CCG and NHSI have requested an observational audit of the checklist is completed to support the administrative audits conducted every month before reasonable or substantial assurance can be given.

Of the 14 ‘Must Do’ actions from the CQC Inspection Report, all of these have been completed and received external assurance from the monthly evidence meetings with the CCG and NHSI, with the exception of the one action relating to medicines storage and the replacement of broken locks. This could not be given reasonable or substantial assurance. The medicine cupboard locks breaking is a persistent challenge and the Estates department have been tasked with finding a suitable, robust alternative.

104

A large number, 64, of the 70 ‘Should Do’ actions for the core services have also been closed. The actions remaining open are those causing areas of challenge across the Trust. Two actions relating to staff understanding and level of training for the Mental Capacity Act (MCA), Learning Disabilities and Dementia have slipped in meeting their targets with regard to developing a more robust training programme that meets new national training competencies. The Trust requested that NHS England undertake a deep dive review of the MCA and Deprivation of Liberty Safeguards (DoLS) arrangements at the Trust and the outcome of this is to be discussed at the next Safeguarding Adults Committee. This area for improvement has been outlined in the TIP alongside other key subjects for review as part of Statutory and Mandatory training requirements with a deadline for completion of 31st March 2019. Another two challenging open actions relate to the documentation audit in the Medicine Division. Increased support is being offered to improve engagement with these actions. The final two open actions are on target and are concerned with patient flow and timely discharge from hospital, including reflection of the impact of recent projects led by Hunter Healthcare.

To ensure the TIP continues to receive robust focus, two weekly CQC governance meetings with key leads will commence in February 2019.

3. Themed Clinical Fridays and the ward and department accreditationprogramme

The Themed Clinical Fridays continue to take place every week with a different theme presented by a Subject Matter Expert. These sessions continue to provide essential support to wards and departments through the provision of information and guidance on best practice and regulatory compliance. Themes in January 2019 are covering, Health and Safety and fire compliance; Resuscitation Trolleys and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) completion; Infection Prevention and Control and Hand Hygiene compliance. The outcomes from these sessions in relation to improved standards and compliance are to be reported from February 2019 at the QSC meetings with regard to Ward to Board reporting. The process has been enthusiastically received by staff who utilise the opportunity to benchmark themselves against others and learn from their peers. Feedback from staff has indicated positive changes in staff behaviours with many stating they feel valued and see their contribution making a difference to patient care.

The ward and department accreditation programme was piloted in November 2018 and is due for roll-out across the Trust in March 2019. The pilot revealed key themes across the two areas piloted and key areas for improvement. Preparations are underway with management colleagues to progress this work to ensure a successful assessment process in March. The roll-out Trust-wide will build on the information from the pilot assessment to demonstrate a cycle of continuous improvement across the organisation.

4. Stakeholder Visits and Outcomes and NHSI/CCG Evidence meetingNHSI, the CCG and key members of the Trust’s CQC improvement team continue to hold regular monthly CQC evidence review meetings. The meeting held on 10th January 2019 specifically reviewed the progress, robustness, and quality of the evidence in relation to some of the key areas in the Surgical Division’s improvement requirements referenced in

105

the CQC Inspection Report. This meeting’s focus was to confirm the level of assurance provided by the Trust in meeting the requirements expected by NHSI and the CCG. At the meeting evidence was provided and discussed in detail on a range of areas that are part of the Trust’s improvement plan. Following discussion, substantial assurance was given for the Preoperative fasting audit. Reasonable assurance was given for the development of the Full Hospital Protocol Escalation Policy and Sepsis Training at Level 1. Sepsis training Level 2 TNA will need to be produced before substantial assurance can be provided. Reasonable assurance was also given for the Critical Care Outreach action and the coordination with the Hospital at Night team. This will move to substantial assurance once the vacant critical care outreach posts have been filled. The work on the training content for Dementia, Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Assessment (MCA) was acknowledged and discussed. However this will remain with limited assurance until the plan from the recent NHS England deep dive report has been presented and discussed at the next meeting. As part of the assurance process NHSI, the CCG and members of the CQC implementation team visited one of the surgical wards, Jersey Ward to review the relevant evidence referenced in the improvement plan. Throughout the visit on Jersey ward the ward team was able to demonstrate systems and processes in place to assure patient safety and meet the improvement plan requirements. The ward staff confirmed the use of NEWS and its use every time a patient has observations taken as well as the use of the electronic screening tool to assist with the identification of Sepsis. A recently recruited and newly qualified staff nurse was able to clearly describe the Sepsis process in detail. The staff nurse was also able to describe the process for implementing the DoLS and how she would escalate concerns to her manager. She went on to confirm she was currently on the preceptorship programme and felt fully supported by her mentor, manager and colleagues. The Nurse in Charge of the ward, when questioned, was able to provide information on staffing levels, vacancy rates and Statutory and Mandatory training levels for ward staff. The visitors complimented the ward team on the clean, uncluttered environment and positive atmosphere on the ward. Verbal assurance ranged from reasonable to substantial during the visit. This will be reflected in the implementation action plan, allowing many of the actions to be closed as approved by the CCG. The next evidence review meeting will be held 14th February 2019.

5. Conclusion and summaryIt is essential that the Trust adopts a more transformational approach to improvement and learning identified from the lack of progress in some areas following the 2015 CQC inspection. The TIP will ensure the Trust-wide themes identified are addressed and have Board oversight, alongside the Trust progressing the improvements associated with the CQC Requirement Notice. A key element to support a revised approach will be to ensure that quality improvement is included in business as usual activities. Furthermore, this will ensure the Trust adopts a culture of quality assurance via strong evidence and the Board is well-sighted on performance from the shop floor to the Board. It must be noted the improvement plan will need further review once the externally facilitated governance and well led review undertaken by Deloitte has been published.

106



Report title: Corporate Risk Register (Extreme Level Risk)

Report author(s): Vikas Sharma – Assistant Director of Integrated Governance

Report sponsor(s): Jacqueline Walker – Director of the Patient Experience and Nursing



1. Discuss the report2. Review and challenge the Extreme level Corporate Risks and progression of risk mitigation.3. Mote the Audit and Risk Committee reviewed all High and Extreme risks at its meeting on

14th January. The Committee agreed an escalation of all High and Extreme Corporate Risksthat were not assured. In response to this escalation The Executives management team willbe undertaking a review of all Corporate Risks that are Not Assured.


STRATEGIC PRIORITY:

This paper has links across all of the Trust strategic priorities

107

Corporate Risk Register (Extreme)

New Risks

• Risk 847 Extreme (20) Annexe Wards: Verified - 24/12/2018.

Risks Not Assured

• Risk 41 Extreme (20) The Management of Legionella and Pseudomonas at the HillingdonHospital:Not Assured - Level of risk remains due to lack of knowledge of the scope of the work needed tothe water system.

• Risk 445 Extreme (20) The Management of Legionella and Pseudomonas at the MVH site:Not Assured - Risk is not assured due to not knowing the scale of pipework that requiresreplacement as well as the resource required for the programme of replacement.

• Risk 665 Extreme (16) Lack of capacity:Not Assured - Current processes still being embedded, such as SAFER and Criteria ledDischarge. There is also further work in progress to strengthen the management of strandedpatients.

• Risk 815 Extreme (16) Increasing workload and Higher acuity requiring additional medicalcover:Not Assured - Difficulty in filling the agreed additional locum shifts to support the on call teams.Delay in recruiting to additional middle grade posts. Currently looking at agencies to recruit fromoverseas.

• Risk 773 Extreme(15) Life expired single steam main pipe running from Estates complex toHillingdon Hospital main site :Not Assured - Radiology test of joints is required which will require a full steam shutdown which

requires planning outside of the winter period.

108

Consequence →

Likelihood ↓ 1. Negligible 2. Minor 3. Moderate 4. Major 5. Catastrophic

1. Rare 332A, 400A, 457A 116A, 176A, 475A 141A, 624A, 784A 651A

2. Unlikely 343A, 377A 140A, 143A, 165A, 239A, 335A, 342, 452, 490, 786, 805, 807, 810, 812, 844

544, 790, 804, 148A 551, 753, 846

3. Possible 819A 144A, 194A, 197, 496, 502, 652, 725, 809, 811

188, 350, 399, 464, 638, 842 149, 450, 569, 639A, 672, 695, 736

773, 785

4. Likely 151, 818 527, 655, 665, 751, 815 41, 190, 445, 822, 847

5. Almost certain 532

** A = Accepted Risk

Corporate Risk Register (Extreme) (FT= Forecast/Target in year only)

Total Records: 13

Ref Subject Exec Residual Duration at level

Q1 Q2 Q3 Q4 Target Target date

Assured (Y/N)

41 The Management of Legionella and Pseudomonas at the Hillingdon Hospital

Jeremy Philpot

20 (C5xL4) Prev: (20) - 29/11/2017

420 days 10 (C5xL2)

30/04/2020 No Level of risk remains due to lack of knowledge of the scope of the work needed to the water system

190 Tower & Podium Mains Electrical Distribution Panel, Sections A, B & C

Jeremy Philpot

20 (C5xL4) Prev: (9) - 24/02/2016

1064 days FT 10 (C5xL2)

31/01/2019 Yes

445 The Management of Legionella and Pseudomonas at the MVH site

Jeremy Philpot

20 (C5xL4) Prev: (15) - 27/03/2018

302 days 10 (C5xL2)

30/04/2020 No Risk is not assured due to not knowing the scale of pipework that requires replacement as well as the resource required for the programme of replacement

532 Non-compliance and single points of failure (resilience) with piped medical air systems at Hillingdon (ITU, Theatres, Tower and A&E).

Jeremy Philpot

20 (C4xL5) 301 days FT 4 (C4xL1)

31/03/2019 Yes

822 Underlying Financial Performance 2018/19 Matt Tattersall

20 (C5xL4) Prev: (15) - 22/05/2018

246 days FT 15 (C5xL3)

31/03/2019 Yes

847 Annexe Wards Jeremy Philpot

20 (C5xL4) Prev: (16) - 24/12/2018

30 days 4 (C4xL1)

30/11/2022

109

http://cgov2/RISKTHH/RiskPrintReadOnly.php?risk_id=332&HP=hp







































































Corporate Risk Register (Extreme) (FT= Forecast/Target in year only)

Total Records: 13

Ref Subject Exec Residual Duration at level

Q1 Q2 Q3 Q4 Target Target date

Assured (Y/N)

815 Increasing workload and Higher acuity requiring additional medical cover.

Abbas Khakoo

16 (C4xL4) 118 days FT 4 (C4xL1)

30/03/2019 No Difficulty in filling the agreed additional locum shifts to support the on call teams. Delay in recruiting to additional middle grade posts. Currently looking at agencies to recruit from overseas.

655 Inefficient and life expired Heating Ventilation AC (HVAC) plant on Hillingdon Hospital requires urgent renewal.

Jeremy Philpot

16 (C4xL4) 419 days 4 (C4xL1)

31/03/2022 Yes

665 Lack of capacity Joe Smyth 16 (C4xL4) Prev: (20) - 18/04/2017

645 days FT 12 (C4xL3)

30/11/2018 No Current processes still being embedded, such as SAFER and Criteria led Discharge. There is also further work in progress to strengthen the management of stranded patients.

751 Gaps on Junior doctors rotas Abbas Khakoo

16 (C4xL4) 118 days 4 (C2xL2)

30/06/2020

527 5-yearly Test & Inspection (Periodic Inspection)of Electrical Distribution system

Jeremy Philpot

16 (C4xL4) 105 days 4 (C4xL1)

31/01/2021 Yes

773 Life expired single steam main pipe running from Estates complex to Hillingdon Hospital main site.

Jeremy Philpot

15 (C5xL3) 419 days FT 10 (C5xL2)

31/03/2019 No Radiology test of oints is required which will require a full steam shutdown which requires planning outside of the winter period.

785 Provision of heat/hot steam to the entire hospital Jeremy Philpot

15 (C5xL3) 419 days 10 (C5xL2)

31/08/2019 Yes

22/01/2019 12:26

110


Date of meeting: 30th January 2019

Agenda item 21

Report title: Board Assurance Framework Q3 2018/19

Report author(s): Vikas Sharma – Assistant Director of Integrated Governance

Report sponsor(s): Jacqueline Walker – Executive Director of the Patient Experience and Nursing

Action required:


1. Discuss the report2. Review and challenge the Board Assurance Framework and progress of risk mitigation.


STRATEGIC PRIORITY:

This paper has links across all of the Trust strategic priorities

111

Reason for item:

The Board Assurance Framework (BAF) seeks to provide assurance that management and the Board in its oversight role are made aware in a timely manner of the extent to which the Trust is managing the key risks to achieving its strategic objectives. The BAF provides information and assurance, as well as highlighting where the Board may need to intervene or make decisions.

Summary:

The BAF is a record of the key risks relating to the achievement of the Trusts strategic objectives as identified by the Executive Team.

The Audit and Risk Committee reviewed the full BAF at its January meeting which includes more detailed information relating to the controls, assurance and mitigating actions for each risk.

An evaluation to assess overall whether there are sufficient controls, assurance and action plans in place or not to ensure effective management of the risk, has been made by the Executive risk lead (Assured column).

Assessment at Q3 suggests a sufficient level of assurance is evident for each risk with the exception of the following risks:

2.1.2 Progress could be limited unless there is greater involvement from London Borough of Hillingdon – Not assured. Limited assurance of certainty that LBH will be fully involved. Working to achieve an Integrated care system continues

2.4.1 On-going insufficient clinic capacity could hinder improvement in percentage of 2-week referrals – Not assured. No assurance currently to meet the increase in 2WW refs. Additional capacity has been added as ad hoc rather than through appropriate D & C planning which has been requested.

4.1.1 Inability to discharge Mental Health patients from A&E in a timely manner – Not Assured. There remains a high risk around Mental Health Capacity (Beds and assessment)

5.2.2 Demand management schemes fail to reduce flows into hospital which will overwhelm physical capacity within A&E – Not assured. Continued emphasis across the system to strengthen Demand Management schemes for emergency care. However, this remains work in progress including LAS use of the Alternative care Pathways.

5.2.3 Insufficient capacity in the community to accommodate medical fit patients – this will result in bed blocking – Not Assured. Continued focus on the external delays for stranded especially the Nursing, residential and dementia bed constraints.

EE1.1 Full list of assets may not be known; therefore, assets requiring statutory inspection may be missed, therefore reducing effectiveness of ppm and capital investment planning – Not Assured. Lack of resources in terms of unsuccessful recruitment to vacant post of Compliance and Asset Management Estates Officer to deliver required actions to mitigate identified risk.

112

EE1.2 Financial restraints may restrict investment and reduce rate at which remedial works can be completed – Not assured. Remedial works exceed the Trust’s capacity to deliver

EE1.3 Items identified that are not on the existing Asset Register will require a maintenance and inspection regime which may require additional finance and labour resource – Not assured. Funding not allocated. Business cases requires re-submission

EE2.1 Not knowing the long-term strategy may impact in formulating the short to medium strategies – Not assured. Funding not yet identified.

EE2.2 Due to the condition of the plant and estate, there is a significant risk of sudden failure (including known and unknown risks) that would require reprioritising of the five-year plan to meet business objectives – Not assured Insufficient Resources identified as a result of Wave 4 & Emergency Backlog not yet agreed

IP6.1 Failure to fulfil financial objectives – Not assured. Current forecast does not fulfil financial objectives

New Risks

None.

Closed Risks

EE3.1 Delay to the production of the Strategic Outline Case for a reconfigured estate will lead to a delay in implementing the Trust masterplan and strategic redevelopment option and therefore a delay in the provision of a suitable for purpose (CQC Regulation 15 premises and equipment) and a financially sustainable estate.

EE3.2 Risk that there is no funding strategy identified to implement the chosen strategic redevelopment option.

EE3.3 Risk that resource is concentrated on the concept case for the academic health campus resulting in no development of a contingency plan if the academic health campus plans do not materialise.

113

Board Assurance Framework 2018/19

Assured: High level assessment Yes or No to assess overall whether there are sufficient controls, assurance and action plans in place or not to ensure effective management of the risk

Delivery Area 2: Eliminate unwarranted variation & improve LTC management Ref Risk Exec Objective Risk

Score Q1 Q2 Q3 Q4 Target Assured

2.1.2 Progress could be limited unless there is greater involvement from London Borough of Hillingdon

COO 2.1 Increase number of community based integrated services

12 12 12 12 9 No

2.4.1 On-going insufficient clinic capacity could hinder improvement in percentage of 2-week referrals

MD 2.4 Improve diagnosis times IP3 Meet cancer targets

9 9 9 9 6 No

Delivery Area 3: Achieve better outcomes and experiences for older people 3.1.1 Inability to obtain agreement from all partners

Revised models of care will be difficult to deliver and require new ways of working – significant resource will be required to delivery this transformation. There is therefore a risk that the operational changes won’t be delivered within the required time scale.

COO 3.1 Implement ACP and Associated New Models of Care

12 12 12 12 9 Yes

Delivery Area 4: Improve outcomes for children and adults with mental health needs 4.1.1 Inability to discharge Mental Health patients from A&E in a timely manner. COO 4.1 Improve the journey for patients requiring

mental health support who attend our services 15 15 15 15 8 No

Delivery Area 5: Ensure we have safe, high quality sustainable acute services 5.2.1 Staff may have insufficient capacity to fully engage with transformation

programme COO 5.2 Implement best practice emergency pathways

IP1 A&E 4-hour standard 12 12 12 12 6 Yes

5.2.2 Demand management schemes fail to reduce flows into hospital which will overwhelm physical capacity within A&E.

COO 5.2 Implement best practice emergency pathways IP1 A&E 4-hour standard

20 20 20 20 10 No

5.2.3 Insufficient capacity in the community to accommodate medical fit patients – this will result in bed blocking.

COO 5.2 Implement best practice emergency pathways IP1 A&E 4-hour standard

20 20 20 20 12 No

5.4.1 Inability of clinical staff to adapt to change and use the technology (and continue to use paper or phone/fax).

MD 5.4 Deliver Health In-reach providing specialist Advice

12 12 12 12 6 Yes

5.5.1 Inability to implement early consultant review for all admitted patients and ongoing medical reviews thereafter

MD 5.5 Implement the core 7-day service standards 10 10 10 10 6 Yes

5.8.1 Insufficient space and specialist facilities to co-locate dermatology services and dermatology tertiary care. This may lead to a service that is not financially viable. Inability to deliver the long awaited skin centre may impact on staff morale and loss of consultant and other staff.

COO 5.8 Improve clinical productivity 20 20 20 12 No

5.9.1 Failure to maintain high impact support from the PMO when the PA contract ends.

DoF 5.9 Improve non clinical productivity 9 9 9 9 6 Yes

5.9.2 Lack of engagement from partner organisations to realise system wide benefits DoF 5.9 Improve non clinical productivity 16 16 16 16 12 Yes

114

5.9.3 Robustness of FIP delivery schemes DoF 5.9 Improve non clinical productivity 12 12 12 12 9 Yes 5.10.1 Financial implications and structural capacity may not be adequate to develop

new services DPEN 5.10 Implement key recommendations for year 2

of the Better Birth Reviews 16 16 16 16 6 Yes

Enablers – Estates EE1.1 Full list of assets may not be known; therefore, assets requiring statutory

inspection may be missed, therefore reducing effectiveness of ppm and capital investment planning.

DSEDAM EE1 Ensure safety and regulatory compliance 12 12 12 12 6 No

EE1.2 Financial restraints may restrict investment and reduce rate at which remedial works can be completed.

DoF EE1 Ensure safety and regulatory compliance 12 12 12 12 12 No

EE1.3 Items identified that are not on the existing Asset Register will require a maintenance and inspection regime which may require additional finance and labour resource.

DSEDAM EE1 Ensure safety and regulatory compliance 12 12 12 12 12 No

EE2.1 Not knowing the long term strategy may impact in formulating the short to medium strategies.

DSEDAM EE2 Develop short to medium term estate plan 12 12 12 12 6 No

EE2.2 Due to the condition of the plant and estate, there is a significant risk of sudden failure (including known and unknown risks) that would require reprioritising of the five-year plan to meet business objectives.

DSEDAM EE2 Develop short to medium term estate plan 20 20 20 20 20 No

EE2.3 Failure to agree the contract extension for incinerator operation Loss of primary source of heat/hot water supply.

DSEDAM EE2 Develop short to medium term estate plan 15 15 15 15 1 Yes

Enabler - Workforce EW1.1 Insufficient Nursing supply DPD EW1 Improve recruitment 12 12 12 12 6 Yes

EW3.1 Lack of capacity and capability to deliver Trust culture of improvement DPEN EW1 Improve recruitment 9 9 9 9 6 Yes

EW4.1 Lack of sufficient talent management and succession planning to ensure robust clinical leadership into the future

MD / DPEN

EW4 Develop Trust Clinical Leadership 9 9 9 9 4 Yes

Enabler – Digital

ED1.1 Staff fail to engage in moving to digital working DoF ED1.1 Implement Digital Roadmap ED1.2 Implement ICT Strategy

9 9 9 9 6 Yes

ED1.2 Insufficient transformation funds made available by Government for key ICT projects and labour resource

DoF ED1.1 Implement Digital Roadmap ED1.2 Implement ICT Strategy

12 12 12 12 6 Yes

Improving the present IP2.1 Referral activity will continue to exceed available capacity and breach the 18-

week standard - Financial position will limit number of WLI’s available to service demand

COO IP2.1 18-week Referral to Treatment 16 16 16 16 12 Yes

IP4.4 Competing priorities for quality and safety improvement with limited financial and physical resources e.g. water quality, ventilation, staffing, resource for implementing and embedding agreed methodology, resources for implementing the new Learning from Deaths Framework for Mortality review.

DPEN IP 4 Complete CQC action plan IP5 Implement year 2 of the QSI strategy

16 16 16 16 12 Yes

115

IP6.1 Failure to fulfil financial objectives DoF IP 6 Maintain finance and use of resources score of 3 IP7 Meet control total

16 16 16 16 12 No

IP6.2 Regulator fails to acknowledge analysis of underlying financial position DoF IP 6 Maintain finance and use of resources score of 3 IP7 Meet control total

12 12 12 12 9 Yes

IP6.3 Failure to carry on as a going concern DoF IP 6 Maintain finance and use of resources score of 3 IP7 Meet control total

5 5 5 5 5 Yes

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Risk Heat Map by Delivery Area Incl. Corporate Risk Register Reference

Delivery Area 2 - Eliminate unwarranted variation & improve LTC management

Consequence →

Likelihood ↓ 1. Negligible 2. Minor 3. Moderate 4. Significant 5. Critical

1. Rare

2. Unlikely

3. Possible 2.1.2, 2.4.1 3.1.1

4. Probable

5. Almost certain

Delivery Area 3 - Achieve better outcomes and experiences for older people

Consequence →


1. Rare

2. Unlikely

3. Possible R638, R752, R551

2.1.2, 3.1.1, R569,

4. Probable 5.2.2, 5.2..3,

5. Almost certain

Delivery Areas 4 - Improve outcomes for children and adults with mental health needs

Consequence →


1. Rare

2. Unlikely R804

3. Possible 4.1.1

4. Probable 5.2.2

5. Almost certain

Delivery Area 5 - Ensure we have safe, high quality sustainable acute services

Consequence →


1. Rare

2. Unlikely R804 R753, 5.5.1

3. Possible EW1.1, EW4.1, 5.4.1, 5.9.1, 5.9.3, R188,R842

5.2.1, R736, R790

4.1.1

4. Probable R370 R818, EE1.1, EE1.2, EE1.3, EE2.1

IP2.1, IP4.4, IP5.5, EE2.2, 5.9.2, 5.10.1, R665, R751, R815

5.2.2, 5.2.3, R822

5. Almost certain

117

Enabler - Estates

Consequence →


1. Rare

2. Unlikely R784 R544, R567 R846

3. Possible EE1.1, EE1.2, EE1.3, EE2.1,

R149, R450, R695

EE2.3, R785, R773,

4. Probable R819 R151 R655, R527 R41, R445, R190, R847, EE2.2, R822

5. Almost certain R532

Enabler - Workforce

Consequence →


1. Rare

2. Unlikely EW1.2, EW5.1

3. Possible ED1.1, R350, EW1.1, W4.1 R399

4. Probable R751, R815

5. Almost certain

Enabler - Digital

Consequence →


1. Rare

2. Unlikely

3. Possible ED1.1 R672, R790

4. Probable ED1.2

5. Almost certain

Improving the present

Consequence →


1. Rare IP6.3

2. Unlikely

3. Possible 2.4.1, 5.9.1, 5.2.1, 5.4.1, 5.9.3,

R736

4. Probable IP6.2 5.9.2, 5.10.1, IP4.4, IP6.1

IP2.1, R822

5. Almost certain

118

Appendix 1: Corporate Risk Register Key (High – Extreme)

Corporate Risk Register (Extreme) (FT= Forecast/Target in year only) Ref Subject Exec Residual Target Target date

41 The Management of Legionella and Pseudomonas at the Hillingdon Hospital Jeremy Philpot 20 (C5xL4) Prev: (20) - 29/11/2017

10 (C5xL2) 30/04/2020

190 Tower & Podium Mains Electrical Distribution Panel, Sections A, B & C Jeremy Philpot 20 (C5xL4) Prev: (9) - 24/02/2016

10 (C5xL2) 31/01/2019

445 The Management of Legionella and Pseudomonas at the MVH site Jeremy Philpot 20 (C5xL4) Prev: (15) - 27/03/2018

10 (C5xL2) 30/04/2020

532 Non-compliance and single points of failure (resilience) with piped medical air systems at Hillingdon (ITU, Theatres, Tower and A&E).

Jeremy Philpot 20 (C4xL5) 4 (C4xL1) 31/03/2019

822 Underlying Financial Performance 2018/19 Matt Tattersall 20 (C5xL4) Prev: (15) - 22/05/2018

15 (C5xL3) 31/03/2019

847 Annexe Wards Jeremy Philpot 20 (C5xL4) Prev: (16) - 24/12/2018

4 (C4xL1) 30/11/2022

815 Increasing workload and Higher acuity requiring additional medical cover. Abbas Khakoo 16 (C4xL4) 4 (C4xL1) 30/03/2019

751 Gaps on Junior doctors rotas Abbas Khakoo 16 (C4xL4) 4 (C2xL2) 30/06/2020

527 5-yearly Test & Inspection (Periodic Inspection) of Electrical Distribution system Jeremy Philpot 16 (C4xL4) 4 (C4xL1) 31/01/2021

655 Inefficient and life expired Heating Ventilation AC (HVAC) plant on Hillingdon Hospital requires urgent renewal. Jeremy Philpot 16 (C4xL4) 4 (C4xL1) 31/03/2022

665 Lack of capacity Joe Smyth 16 (C4xL4) Prev: (20) - 18/04/2017

12 (C4xL3) 30/11/2018

773 Life expired single steam main pipe running from Estates complex to Hillingdon Hospital main site. Jeremy Philpot 15 (C5xL3) 10 (C5xL2) 31/03/2019

785 Provision of heat/hot steam to the entire hospital Jeremy Philpot 15 (C5xL3) 10 (C5xL2) 31/08/2019

569 Failure/delay in escalation of deteriorating patients and non Critical Care Outreach cover 24/7 Abbas Khakoo 12 (C4xL3) 4 (C4xL1) 28/02/2019

818 Oxygen prescribing Abbas Khakoo 12 (C3xL4) 2 (C1xL2) 31/03/2019

672 Multiple sources for recording and managing patient clinical indicators Matt Tattersall 12 (C4xL3) 4 (C4xL1) 31/12/2018

695 Main Theatres Ventilation Systems Jeremy Philpot 12 (C4xL3) 4 (C4xL1) 31/03/2024

736 Delivery of non invasive ventilation outside of the Intensive Care Unit. Abbas Khakoo 12 (C4xL3) 8 (C4xL2) 31/12/2018

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Corporate Risk Register (Extreme) (FT= Forecast/Target in year only) Ref Subject Exec Residual Target Target date

450 Ventilation in ITU Jacqueline Walker 12 (C4xL3) Prev: (16) - 13/04/2018

8 (C4xL2) 31/01/2019

149 Containment of Fire Matt Tattersall 12 (C4xL3) Prev: (8) - 10/08/2017

4 (C4xL1) 31/03/2020

151 Provision of Emergency Lighting at the Hillingdon Hospital Jeremy Philpot 12 (C3xL4) Prev: (9) - 29/03/2016

3 (C3xL1) 31/03/2020

551 Medicine Storage Abbas Khakoo 10 (C5xL2) 4 (C4xL1) 31/01/2019

846 Potential vertical spread of fire through the Hillingdon Tower block. Matt Tattersall 10 (C5xL2) 5 (C5xL1) 28/11/2025

753 Cross infection from patients presenting with Carbapenemase-producing Enterobacteriaceae (CPE) Jacqueline Walker 10 (C5xL2) 5 (C5xL1) 30/04/2019

638 Low level of care provided around continence. Continence national audit carried out in 2007 and 2010 - Non compliant and scoring in the bottom lower quarter. Significant non compliance with faecal incontinence nice guidelines.

Jacqueline Walker 9 (C3xL3) 6 (C3xL2) 30/06/2019

842 Age and reliability of Mammography Unit Joe Smyth 9 (C3xL3) 3 (C3xL1) 31/07/2019

188 Incomplete / Inadequate Record Keeping Abbas Khakoo 9 (C3xL3) 4 (C2xL2) 29/03/2019

464 Trust Management and Maintenance of Safety in the use of Medical Devices Matt Tattersall 9 (C3xL3) Prev: (2) - 01/06/2017

4 (C2xL2) 30/06/2019

350 Suboptimal maternity staffing levels within midwifery, obstetrics and anaesthetics Jacqueline Walker 9 (C3xL3) Prev: (12) - 31/08/2017

6 (C2xL3) 31/03/2019

399 Nursing staffing levels in the Trust Jacqueline Walker 9 (C3xL3) Prev: (12) - 29/08/2018

6 (C3xL2) 29/03/2019

544 Management of Control of substance Hazardous to Health (COSHH) Risk assessments. Matt Tattersall 8 (C4xL2) Prev: (12) - 23/01/2018

4 (C4xL1) 31/03/2019

790 Unauthorised access and disclosure of patient information Matt Tattersall 8 (C4xL2) Prev: (12) - 08/01/2019

4 (C4xL1) 30/04/2019

804 Safeguarding Children Supervision Jacqueline Walker 8 (C4xL2) 4 (C4xL1) 31/12/2018

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Date of meeting:30th January 2019 Agenda item 23

Report title: Learning from Deaths (LFD), Q2 2018/19 Report to Public Board

Report authors: A Khakoo, Medical Director Barbara North, Learning from Deaths Nurse

Report sponsor: A Khakoo, Medical Director


The Board is asked to 1. Note that quarterly reporting of deaths falling within certain criteria to the Trust Board is

a requirement from NHS Improvement2. Note and comment on the report.3. Agree and/or amend the proposed next steps


STRATEGIC PRIORITY: f) Improving the present – Implement year 2 of the Quality and Safety ImprovementStrategy: Aim 3 - Working towards no preventable deaths

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Learning from Deaths (LfD) Report for Q2 2018-2019

As part of the National Mortality Review programme each hospital in England will publish a quarterly dashboard summary of what it is doing to review the case notes of patients who have died. Each hospital will select some notes for deeper structured judgment reviews (SJRs) to identify potentially avoidable deaths and learning themes for improving practice. They will also have to set out plans on how to involve bereaved people more in this process and to share information with them. In the first wave of quarterly dashboards very few “avoidable” deaths have been reported by trusts (BMJ 2018; 361:k969).

Recognising the delay in submitting the Q1 2018-19 report, the Medical Director wanted to bring the Q2 report to the Trust board earlier than the planned March 2019.

Learning from Deaths Audit Figures for Q2 18/19

Total No. Deaths

Total notes identified for SJR

Total sent to reviewers

Total No. of SJR’s returned to date

Score 1

Definitely Avoidable

Score 2 Strong Evidence of Avoidability

Score 3

Probably Avoidable (more than 50:50)

Score 4

Possibly avoidable but not very likely (less than 50:50)

Score 5

Slight evidence of avoidability

Score 6

Definitely not avoidable

LD*

Deaths

Q2 181 20 19 19 0 0 0 3 4 12 1

LD* = Learning Disability

Q2: 20 notes (11% of all inpatient deaths during this period) were identified for SJR using the criteria set in the LfD policy. Of these 19 have been sent to SJR reviewers all have been returned. 1 SJR has not been requested for Q2 as yet, because the white notes cannot be located. There was 1 LD inpatient death in Q2; this was reported to the Head of Safeguarding to enter on to LeDeR data base. The Head of Information has enabled a LD flag on PAS in order that staff use it to highlight patients with LD.

The aim is from April 2019 75% all deaths that need a SJR will be reviewed within 30 days and the remainder within 60 days.

Sharing Lessons

Of the deaths reviewed in Q2 12 were definitely not avoidable (score 6), 4 had slight evidence of avoidability (Score 5), 3 were possibly avoidable (score 4). The 1st of these 3 patients had a Glasgow (physiological classification score) score of 3-4 and a background of COPD and Atrial Fibrillation in view of this an early discussion with ITU should have been considered. The 2nd was a

0

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Inpatient Deaths

SJR's identified

SJR's requested

SJR's returned

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patient who was an emergency admission for fractured neck of femur who developed a surgical site infection which was promptly recognised and washed out, had other prompt treatment and good post-operative care, however patient had multiple co-morbidities and high mortality risk (this features as part of our surgical site infection data reviewed at Infection Control Committee). 1 case was originally scored as probably avoidable (score 3), this case involved significant upper airway bleeding, emergency management was provided and an urgent referral to a tertiary centre was in progress during which time the patient suffered a cardiac arrest before he could be moved. The case has been reviewed by two senior clinicians and the Medical Director who made the decision that the correct score was 4 and would not be a SI, and the SJR learning process was followed.

The Learning from Deaths (LfD) lead nurse is to present lessons learnt regarding gaps in care or poor care and good practice to the Sisters meeting and Care Accounts for them to cascade to staff, also the Medicine Governance Meeting and the Matrons meeting. The Mortality Lead (the Medical Director) issues a summary which is part of the agenda of all Divisional Boards, and is sent separately to all Consultants and junior doctors. The LfD nurse reports that she is available to give more details on individual cases.

All Divisional presentations of Score 4 cases, all Score 3 and below which are not declared as SIs, as well all the summaries will be kept by the LfD nurse for CQC evidence.

Key learning and actions from Q2 SJRs

Over the past 2 quarters at least 3 reviewers have commented on the need for more clarity around Speech and Language (SALT) reviews. As an example one inconsistency noted: “Patient admitted with swallowing difficulties, SALT review requested, and also a request to push fluids. SJR says patient should have been on strict NBM until SALT review had taken place. Nursing staff realised inconsistency and asked medical staff for clarification.” These examples were triangulated by the Head of Therapies with other Datix incidents and “themes” presented to the Patient Safety Committee in January 2019. This review highlighted that there have been 8 Datix incidents over the preceding 6 months related to a lack of timely SALT review despite earlier entry into the medical records. As SALT are not part of the daily Board rounds, the Nervecentre IT system on all inpatient wards is being adapted to identify those patients requiring referral to ensure that these timely referrals are followed through. As an additional action ward matrons will be sent a reminder to ensure safety of swallowing prior to the SALT review. SALT will review Datix incident reporting over the next 6 months to relating to delayed referrals, and any other themes, and present back to Patient Safety Committee.

There were many examples of excellent and comprehensive documentation by medical teams, and examples of good End of Life nursing care, including keeping patient comfortable and regular mouth care, and examples of good symptom control. There were also many examples of good

0

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Qtr 1 Qtr 2

Score 6

Score 5

Score 4

Score 3

Score 2

Score 1

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discussions with families at every stage, with discussions about preferred place of death, active planning, liaison, and consultations regarding other wishes.

The pathway, emergency management and emergency contacts for upper airway bleeding are being reviewed in conjunction with London North West Hospitals Trust.

In one case the Operation Consent form did not mention ‘Risk of Death’ and this has been shared as part of the Theatre Safety Huddle.

On occasions there has been suboptimal documentation in relation to mental capacity, with comments such as “confused” being used with no further detail. This is being fed into the Learning package for the Mental Capacity Act / Deprivation of Liberty.

Issues to be/being addressed

1. The tracking of white notes continues to be an issue; this has been taken to The ClinicalRecords Committee for review.

2. Sending out of SJR’s to appropriate Consultants is still slightly behind schedule despitesupport from Medical Director and some Consultants to get up to date. However, the LfDprocess is still on track to deliver the timescales already set out above for April 2019.

3. More Consultants are needed to be SJR reviewers, after April 2019 at least 20% ofinpatient deaths will be required for Structured Judgement Review. This is in progress.

Proposed next steps

1. Medical Examiners are to be introduced nationally in April 2019, the Royal College ofPathologists and NHS England has acknowledged that in some trusts a medical examiner may notbe in post by April 2019, however they expect to see that these trusts will be working towards thisand have a plan in place. This will require extra resources, as this will involve senior medicalscrutiny of all inpatient deaths (as referenced in Q1 2018-19 report).

This request will need to be aligned with the need for a Trust Mortality Lead, which is currently the Medical Director, and has been since the LfD process was introduced.

2. The National Quality Board guidance is that best practice is to review deaths for all inpatientswho are discharged but die within 30 days and this has been escalated to the Clinical QualityGroup meeting with the CCG to help the Trust to identify these deaths (as referenced in Q1 2018-19 report).

3. From April 2019, the percentage of deaths that will be reviewed within the SJR process willincrease to 20% of all cases, subject to future guidance relating to the Medical Examiner role. Thiswill consist of those that meet the set criteria in the LfD policy (comprises on average 10-12% ofdeaths), with a “top up” to 20% using specific themes. The theme for Q1 of 2019-20 will be caseswith sepsis.

5. The next Board Report will cover 2018-2019 Q3 and Q4 cases, along with compliance with the30 day reporting standard (last Trust Board paper November 2018 it was agreed that by April 201975% of all deaths will be reviewed within 30 days of death, the remainder within 60 days).

6. The next Mortality Surveillance Group will review an SJR datix platform which helps with dataanalysis and better review of narrative fields. This has Royal College of Physician endorsement.

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Report title: Annual Report on Safe Working Hours- Doctors in Training

Report from: Dr A Andi, Guardian of Safe Working Hours


Reason for item:

This is the annual report for 2018 (covering November 2017-October 2018) which provides assurances to the Board on the progress being made to ensure that doctors’ working hours are safe. Appendix 1 contains the report for 2018 covering the period May 2018 to August 2018.

Summary:

The 2016 national contract for juniors requires a Guardian of Safe Working Hours (GoSW) to act as a champion for safe working and monitor the exception reporting system.


Receive and approve the report. The Board is also asked to note that going forward the GoSW reporting to the Trust Board will be an update in May 2019 and the Annual Report in November 2019, rather than the Quarterly Report received up to now.

Links to Trust strategic priorities:

f) Improving the present – A&E 4 hour standard – 18 week Referral to Treatment –Meet cancer targets – Complete CQC action plan – Implement year 2 of Quality andSafety Improvement Strategy – Maintain finance and use of resources score of 3 –Meet control total

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1. Purpose, Background & Governance

1.1. This is the second GoSW annual report. In this report, the Board will be updated on issues relating to the working hours of trainee doctors. The periods of cover are November 2017 to October 2018. These reports are intended to provide an overview and assurance of the Trust’s compliance with safe working hours for doctors in training and to detail any areas of concern.

1.2. In line with the terms and conditions of service (TCS) of the 2016 junior doctor contract medical staffing at the Trust have updated junior doctors’ rotas; issued all trainees with work schedules and managed the exception reporting system. Trainees working outside their expected work schedule or rostered hours are encouraged to complete an electronic exception report using the DRS4 Skills for Health exception reporting software platform and meet with their clinical supervisor to discuss strategies to minimise recurrence. Additional hours worked are compensated with time off in lieu or payment issued retrospectively.

1.3. The GoSW oversees the exception reporting process, acts as the champion of safe working hours and works to provide assurance, to both doctors and employers, that doctors in training are safely rostered and are enabled to work hours that are safe and compliant with the TCS. The GoSW has a three year appointment and receives 1.5 job planned programmed activities to undertake this role.

2. Analysis

2.1. A total of 367 workload related exceptions were reported in 2017/18.

2.2. Fourteen were highlighted as immediate safety concerns. These were

addressed immediately by Consultant supervisors and assurance provided that no

patients came to harm.

2.3. The majority of exceptions were reported due to doctors working over and above

their hours. Foundation Year 1 doctors were the largest cohort to report the need to

stay beyond their contracted hours due to workload (242).

2.4. High frequency reporting specialties included General Surgery (112) and Care of

the Elderly (111). In General Surgery measures have been taken to address

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workforce pressures and the introduction of Hospital at Night and electronic rostering

systems have assisted in mitigating the risks associated with rota gaps.

2.5. A total of £3,232.94 in fines were levied. The fine related to one specialty trainee

doctor in Orthopaedic Surgery and was levied due to beaches of the 72 hour working

week limit and minimum rest period between shifts. A breakdown of the fine is shown

in Table 1.

Table 1: Breakdown of fines levied for working hours breaches in 2017/18

Date of fine

Speciality Grade Working hours breach

Total fine Balance to Guardian

09/11/2017 Orthopaedics Specialty

Trainee

8 2,746.60 1,489.24

09/11/2017 Orthopaedics Specialty

Trainee

72 3,216.04 1,743.70

2.6. To date fine monies have been spent on delivering two resilience training

courses that were open to all doctors at the Trust.

2.7. There were no work schedule reviews.

3. Junior Doctor ForumA forum has been established meeting on a quarterly basis. Attendance rates have

been suboptimal and limited in the range of doctors that have attended to date.

However the group have been helpful when opinions on difficult matters have been

sought and I believe that the attendees have valued the opportunity to ask questions

about the new contract. Conversations with regional Guardians seem to suggest

poor participation of junior doctors in such meetings is a national issue.

4. SummaryException reporting continues to provide valuable information about the hours and

the workload of the junior doctor workforce. An extensive amount of work has gone

into transitioning all doctors in training to the new contract over the last 12 months

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and I would like to acknowledge the good work carried out by the medical staffing

team.

5. Next StepsWhilst the exception reporting system is established and has become more stable

over the last 12 months further work is needed on developing systems for processing

and reviewing reports that will be sustainable in the future; this is in progress.

Implementation of the electronic Health Roster for doctors by end March 2019 will

allow much better visibility of unfilled shifts, and better calculation of these gaps.

The data collected by the GoSW is used by the Divisions in planning safe medical

staffing, and by the Director of Medical Education and Medical Director in proactively

addressing Junior Doctor concerns in relation to workload and patient safety issues.

There is now enhanced visibility of the data at the Workforce Transformation

Strategy Board. Furthermore, commencing in April 2019 there will be a more

representative Junior Doctor Representative Group / Junior Doctor Forum in line with

the recommendations of the publication “Junior Doctor engagement: views from the

frontline”, published jointly by the London Clinical Senate and Faculty of Medical

Leadership and Management, endorsed by NHS England.

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Wednesday 30 January 2019 Agenda item 25

Report title: Safer Staffing – Planned and Actual Staffing Levels (nursing)

Report author: Vanessa Saunders, Deputy Director of Nursing - Safeguarding, Workforce and Clinical Standards

Report sponsor(s): Jacqueline Walker, Director of Patient Experience and Nursing

Board Action required: The Board is asked to note the report, specifically:

- The analysis of this paper is that although average shift fill rates were lower thanprevious month there was little change in average Care Hours Per Patient Day(CHPPD). In addition, despite reports of suboptimal staffing on individual shifts, safetyindicators (rate of falls and hospital acquired pressure ulcers) remained stable andwithin Trust target levels.

- THH: average fill-rates were above 90% of plan. With respect to RNs, averagestaffing levels did not exceed 100% of the agreed template; the HCA fill rate continuedits trajectory towards levels planned.

- MVH: average fill rates showed a downward trend which was linked with reducedactivity over the Christmas period; the stable CHPPD demonstrates that the nursingtime available per patient was not reduced.

- RN vacancies increased by three whole time equivalents on each site compared toNovember however HCA vacancies reduced on the Hillingdon site and continued tobe stable at Mount Vernon. Recruitment activity is summarised in Appendix 2.

- Pinewood Ward closed in December with its staff reallocated, predominantly toFleming Ward.

Reporting is by exception (Appendix 2) where indicators have varied significantly from target and/or increased management action is required to mitigate risk.


STRATEGIC PRIORITY:

Delivery Area 5: Ensure we have safe, high quality sustainable acute services Equality and Diversity: There are no implications arising from the report.

Financial Impact: There are no financial implications arising from the report

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1. Overview

The report provides the Board with an overview of the average nurse staffing levels (actual levels against planned levels, expressed as a percentage) for December, together with average Care Hours Per Patient Day (CHPPD). CHPPD is calculated by adding hours of registered nurse/midwives (RN/RM) and the hours of health care assistants (HCA) and dividing by the number of patients at 23.59 hours; it is reported split by RN/RM and HCA, and as a total.

To provide context, vacancy and turnover data for the areas covered is also provided; a suite of Nurse Sensitive Outcome Indicators (NSOIs) for each ward is detailed in Appendix 1. This information is triangulated with other intelligence and where there is a need for enhanced surveillance or scrutiny, this is reflected in the R.A.G. rating. Wards scored as amber were:

• Fleming ward: rationale includes a proportion of the beds being escalationcapacity with associated reliance on temporary staffing, and suboptimal staffingreports for specific shifts

• Labour ward: suboptimal staffing incidents

Actions underway to mitigate pressures and risk are summarised in the exception report (Appendix 2).

2. Staffing levels against plan

Average fill levels overall moved closer to plan. The trend towards plan for HCAs on the Hillingdon site continued for the fourth consecutive month, for both day and night shifts. The average fill rate was less than 10 percent above plan, compared to the high of 152.5% (night shifts) reported in August. Although there was uplift in HCA levels on selected wards following the establishment review earlier in the year, the continued improvement trajectory demonstrates the positive impact of the strengthening of controls in place at divisional and corporate level to review staffing demand, capacity and flexible deployment.

Average CHPPD were stable compared to previous month. With fill rates moving towards planned levels, there has been an overall slight reduction in CHPPD compared to levels in August, as would be expected. However this is minimal.

A validated electronic tool is used to assess and record patient acuity levels and available staffing on each ward on every shift, the outcome of which is discussed at the Trust capacity and safety huddles. Where staffing is shown to be below optimum levels, staff are redeployed from other areas wherever possible, or additional staffing arranged. Underlying the monthly averages reported in the data, there have been individual shifts where available staffing was not considered to be in line with actual demand. There were a total of 26 suboptimal staffing incidents raised during December, across 9 clinical areas. One of these was reported as causing low harm, the remaining 25 incidents were not linked with any adverse event.

It is always anticipated that maintaining adequate staffing will be a challenge in December, with cold weather, seasonal illnesses and extended holiday periods all

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potentially impacting on staffing demand and capacity. Regarding patient acuity, analysis of the overall acuity-dependency scoring reported via SafeCare for December reveals very stable results, with no significant change compared to the previous two months. Although overall rates did not increase, there was an increase in the number of additional Registered Nurse duties requested however this was associated with specific patients on Alderbourne and Kennedy rather than a general increase. Equally, the monthly staff sickness rates in Medicine and surgery did not increase in December.

Steps had been taken to reduce the risk of reduced fill rates in December. The staffing rosters were prepared well in advance and reviewed by the Assistant Directors of Nursing prior to being approved. They ensured all shifts had senior, experienced nurses on duty and that annual leave remained within agreed levels. The Occupational Health department continued to drive uptake of the flu vaccine among staff, with drop-in clinics and departmental visits resulting in over 73% of Trust staff being vaccinated by the end of December, which is reported as the 4th best rate across London. There was high presence of senior staff, including during the holiday period – the Director of Nursing personally visited clinical areas on Christmas day.

Despite the above, where rota gaps did occur, filing them proved difficult, especially over the Christmas period. This led to an increased use of “off framework” agencies (these are agencies outside our usual providers and attract a higher fee). From the end of December staff from Trinity ward at Mount Vernon transferred to Hillingdon to support with staffing.

a) Average fill rates and monthly trends

Site Summary Data December 2018

Day Night Average fill rate RN/RM

Average fill rate Care staff

Average fill rate RN/RM

Average fill rate Care Staff

Hillingdon 90.7% 106.05 95.4% 108.9% Mount Vernon 84.2% 89.2% 82.2% 92.5%

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b) Average Care Hours Per Patient Day and monthly trends

Site Summary Data December 2018

Care hours Per Patient Day Cumulative count of patients @ 23.59

RN/RM hours per patient day

HCA hours per patient day

Overall hours per patient day

THH 12272 5.4 3.4 8.8 MVH 776 4.5 3.7 8.3

3. Vacancies and turnover

The tables and graphs below show the number of vacancies (budgeted establishment minus filled posts), new starters and leavers for the inpatient areas covered by this report, over the last six months. The data is provided by Workforce Information and the Head of Resourcing, and is in relation to the clinical areas listed in Appendix 1 and does not represent the vacancy or turnover position for the entire nursing and midwifery staff group.

There was an upward in-month trend in RN vacancies, of three whole time equivalents on both sites in December. The overall RN vacancy trend over the last six months however is downward, despite establishments having been increased to support supervisory status for Ward Managers. This is reflective of the continued recruitment drive.

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c ) Vacancy and turnover trends for inpatient areas

4. Conclusion

December brought spikes in patient acuity on specific wards along with the challenge of maintaining staffing during the holiday period. Despite these additional pressures, average shift fill rates saw planned reduction in excess use of HCAs where appropriate; CHPPD were stable. There is a continued reliance on temporary staffing to achieve these rates however vacancies are reducing, with some areas at or near establishment. Focussed recruitment campaigns are being delivered by close working between nursing leaders and human resource partners. Reported suboptimal staffing incidents were assessed and actioned by senior nursing staff to maintain patient safety. Nurse-sensitive outcome indicators were in line with previous months.

It is reasonable to conclude that nurse staffing levels across inpatient areas in December were overall in line with need.

Vacancies and turnover for inpatient areas

THH 2017/18 July Aug Sep Oct Nov Dec MVH 2017/18 July Aug Sept Oct Nov DecRN/RM Vacancies 125.3 123.67 144.94 136.83 113.91 116.97 RN/RM Vacancies 10.19 9.19 9.31 9.66 9.17 12.17HCA Vacancies 44.13 45.49 59.42 60.6 62.06 53.4 HCA Vacancies 6.33 6.33 5.11 4.31 2.31 2.31RN/RM Starters 12 9 13 14 6 7 RN/RM Starters 1 0 1 0 2 0RN/RM Leavers 10 6 14 10 10 8 RN/RM Leavers 0 0 3 1 2 1HCA Starters 15 5 0 12 5 8 HCA Starters 0 0 0 1 2 0HCA Leavers 1 2 7 3 2 3 HCA Leavers 0 0 0 0 0 0

020406080

100120140

July Aug Sep Oct Nov Dec

THH Vacancies

RN/RM Vacancies

HCA Vacancies

0.002.004.006.008.00

10.0012.0014.0016.00

July Aug Sept Oct Nov Dec

MVH Vacancies

RN/RM Vacancies

HCA Vacancies

0

5

10

15

20

May Jun Jul Aug Sep Oct

THH Starters and Leavers

RN/RM Starters

RN/RM Leavers

HCA Starters

HCA Leavers0

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1 2 3 4 5 6

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RN/RM Leavers

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HCA Leavers

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Report title: Safer Medical Staffing Update

Report from: A Khakoo Medical Director/ R Stanfield Deputy Director of People & OD


Reason for item:

This paper provides an update on the issues, including: • Strengthening risk management and governance;• Providing safe cover over seven days: new roles and ways of working;• Current medical staffing gaps and actions;• Physician Associate expansion;• Next steps.


Discuss and note the report

Links to Trust strategic priorities:

f) Improving the present – A&E 4 hour standard – 18 week Referral to Treatment –Meet cancer targets – Complete CQC action plan – Implement year 2 of Quality andSafety Improvement Strategy – Maintain finance and use of resources score of 3 –Meet control total

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1. Purpose of this paper

The purpose of this paper is to update the Trust Board on current issues in relation to Safer Medical Staffing together with the actions in place to address them. This follows the previous paper to the Board in January 2018. The Board is asked to note that the report concentrates on non-elective care.

Introduction

This paper provides an update on the issues, including:

• Strengthening risk management and governance;• Providing safe cover over seven days: new roles and ways of working;• Current medical staffing gaps and actions;• Physician Associate expansion;• Next steps.

Risk Management and Strengthened Governance

3.1. Risk management and immediate actions Two extreme risks in relation to medical staffing have been identified on the Trust Corporate Risk Register; these are:

1. Gaps on Junior Doctors Rotas; and,

2. Increasing Workload and Higher Acuity Requiring Additional Medical Cover.

Specific actions are identified for both these risks and organisation-wide workstreams delivery of which will support a substantial reduction in risk.

Similar concerns were seen in the GMC National Training Survey for 2018, which reported a number of patient safety alerts related to out of hours working and showed the Trust to be a red outlier in a number of domains relating to out of hours working especially in relation to General Medicine. This resulted in a site visit by Health Education England (HEE) in September 2018. HEE issued two immediate mandatory requirements at this visit in General Medicine and Acute Medical Unit (AMU). An action plan has been produced to address these issues, which is detailed within section 4. The response from HEE to the plan is supportive, provided that these changes take place and there is evidence that it is improving the working and training experience of the trainees. There is regular, ongoing dialogue with HEE to share concerns and solutions and inform progress. A more proactive approach to risk identification is being adopted, based on engagement with trainees in all specialties. The Director of Medical Education (DME) is leading this work, utilising the Local Faculty Groups. A full update will be provided to the Board from the DME in the March 2019 Medical Education Report, which will be prior to the next GMC survey.

3.2 Strengthened governance

The Workforce Transformation Steering Board (WTSB) has a line of sight to the Trust Board, via the Finance & Performance Committee. The WTSB terms of reference have now been amended to include medical workforce issues and specifically the issues associated with risk. The WTSB will be able to triangulate data from the Guardian of Safe Working Report, updates to the risks on the Risk Register and HEE / GMC surveys, Physician Associates and specialised Nursing workforce to allow better monitoring and a more joined up and skills-based approach to the medical tasks that the Trust requires. Medical Director and Divisional Director attendance at the WTSB has been agreed with appropriate time to discuss the key issues, particularly those solutions that require organisation-wide action.

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The strengthened governance in this area will also help ensure that future risks are identified. Other potential risks that are being quantified are: the potential requirement for resident on-call registrars in surgery to provide appropriate support for more junior trainees and the recruitment to orthopaedic SHO grades.

4. Providing Safe Cover Over Seven Days: New Roles and Ways of WorkingA number of solutions are being pursued in parallel to improve safe cover at evenings and weekends in particular. Junior doctors are an active part of planning all the processes described below.

4.1 Electronic systems development HealthRoster HealthRoster for medics is now rolled out for junior doctor rosters for the majority of specialties. Remaining areas will be rolled out by Spring 2019. This allows all rotas and rota gaps to be identified on a single electronic system.

Patchwork Patchwork (formerly Locum Tap) is an end to end (shift being published to payment) app which is NW London wide and allows a much larger bank pool of doctors. As of 23rd January 2019, it has been linked into HealthRoster so there is early and easy single point visibility of all vacant medical shifts advertised across a London-wide (currently predominantly NW London) medical staff bank. Vacant shifts are thus now being advertised at 12 weeks ahead, with outstanding shifts escalated to agency 4 weeks before the shift. Experience of other provider trusts is that this will lead to a significant increase in the uptake of bank doctors thereby reducing reliance on agency doctors. The active bank list (internal and external) has grown substantially during December 2018.

Appendix 1 includes further data on the Patchwork app.

The overall result is earlier booking of shifts, better fill rates and with bank staff often providing better care than the variable quality of agency doctors. There is also a significant cost-saving.

4.2 Hospital at Night (HAN) Initiative Supporting the Medical workforce with non-medical staff There is funding for 2.5 whole time equivalent WTE technician support for procedures such as cannulation, urinary catheter insertion and venepuncture. These posts will work overnight and be fully recruited to by end March 2019. This will be supplemented by extended administrative support to the Clinical Site Practitioners (CSPs) until midnight 7 days a week also in place by the same date – this will also support the nursing workload.

HEE is supporting the Trust and has provided funding (£70,000) for educational purposes; this will include training the new technicians in basic procedures, team based simulation training for the HAN team, funding for prescribing courses for CSPs (currently only 40% of the CSPs are nurse prescribers) and some equipment to support this.

4.3 Improving the Medical workforce cover The recruitment to the second tier of medical registrars (a preferred option as it solves some daytime workforce gaps e.g. Care of the Elderly and allows a Royal College of Physician Chief Registrar post to be funded) but is proving to be challenging and is now being taken forward by an external recruitment company, using international recruitment, successful at a neighbouring Trust for their Emergency Department (ED). CVs are expected by the first week in February 2019 with a 5 month lead in time. Good candidate CVs for 6 vacant Medicine SHOs have come in the past 1 week with a 4 month lead in time, and this will help resolve the permanent SHO gaps, which will stabilise the out of

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hours SHO workforce and further SHO expansion presents an option if the middle grade recruitment is not successful

In the intervening period and until full recruitment can be realised, the division of Medicine is rostering additional junior doctor support overnight and at weekends. The twilight and weekend long day shifts are mostly filled (> 90%) but the overnight shifts are mostly unfilled.

The extended opening of a separately medically (middle grade) staffed Ambulatory Emergency Care Unit (AECU) dealing with up to 25% of the acute take between 8am and 8pm (from February 2019 10pm) seven days per week. Currently this is staffed for 90% of the shifts including weekends and reduces the rest of the on call burden of work of the on take medical team.

An additional Medicine consultant works at weekends 7am-1pm (bank).

In Surgery there is funding for an additional middle grade long day, but this shift has a 70% fill rate - 50% bank: 50% agency.

4.4 Other measures From February 2019, the updated National Early Warning Score (NEWS) policy will come into effect. This includes NEWS-2 (most up to date version), a senior nurse led SBAR (Situation, Background, Assessment, Recommendation) approach to amber NEWS calls which will reduce the average out of hours medical time spent dealing with these calls (audits show on busy nights this can be up to 7 hours) by about one-third. December 2018 and January 2019 have been spent in delivering nurse training and modifying the NEWS alert system.

Better induction to the AMU and on call element of the training posts (as well as the specialty element) is now in place and will enhance safe delivery of medical care.

Ongoing recruitment to 24/7 Critical care outreach nursing is progressing; this currently has 2.5 WTE vacancies.

5. Current Medical Workforce Gaps and ActionsIn the past year, the Trust through its Medical Productivity Group has significantly reduced vacant rota gaps by earlier recognition of leavers and more proactive recruitment, i.e. better tracking of posts. As an example, in General Surgery this has led to zero gaps in their SHO rota. This due diligence will continue in 2019-20.

The Trust is currently working to source 14 WTE doctors from overseas, for Anaesthetics, Surgery, Paediatric, and Medicine. A working group, chaired by Divisional Director for Surgery is working through training programmes and retention for this recruitment campaign.

There is more detail on current medical staffing vacancies (and any actions) in the table in Appendix 2 to this report. The key gaps and issues are summarised below by Division.

Surgery & Anaesthetics Key gaps are seen in the following areas:

• Orthopaedic SHO rota;

• Registrar grade in anaesthetics;

• Junior registrars in Surgical Assessment Unit (SAU);

• Breast Consultant;

• ITU Consultant gaps;

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Solutions include: creation of Safety Fellows to support overnight cover; overseas recruitment; developing the Advance Nurse Practitioner role to support ward cover; and service reviews where necessary, e.g. urology and breast services.

Women’s & Children’s Key gaps and service pressures are seen in the following areas:

• Obstetrics & Gynaecology (O&G) middle grade;

• O&G SHO;

• Paediatrics, including Emergency Department (ED).

Solutions include: effective use of Bank and current staffing to cover gaps; rolling adverts; overseas recruitment; use of midwives to undertake newborn baby checks, freeing up an SHO from doing these; funding one of the Emergency Gynaecology Unit nurses to undertake an early pregnancy scanning course. This will enable the nurse to perform scans independently, either holding specific Emergency Gynaecology Clinics, or covering those vacated by Consultant leave, strengthening the cover in the department.

Cancer and Clinical Support Services Key gaps are seen in the following areas:

• Microbiology Consultant – although two consultant posts have successfully beenfilled;

• Dermatology, including paediatrics, allergy and MOHS (a type of surgery);

• Radiology.

Solutions include: developing suitable and more attractive job role in Microbiology to attract to the remaining position; relocation of the majority of dermatology to the Tudor Centre has helped mitigate the loss of the Skin Centre; dermatology service review will be undertaken if the allergy consultant cannot be recruited; specialist nursing roles have been extended further to support surgical dermatology; a further reporting radiographer has now completed training, providing services previously provided by a consultant; outsourcing reporting; and continued recruitment and retention premia for sonographers, which has been effective.

Medicine Key gaps are seen in the following areas:

• Stroke – SHO vacancy;

• Gastroenterology – SHO and SPR vacancy;

• Elderly Medicine – consultant and SHO vacancies;

• Cardiology – SHO vacancies

• High Intensity Care Unit (HICU) – SHO vacancies

• Neurology and Neuro-rehabilitation – consultant vacancies

• Diabetes – consultant and SHO vacancies

• Emergency Department and AMU;

Solutions include: overseas recruitment, plans to create job shares with other departments in order to make the post more attractive, including shared AMU/specialty posts, and expanding the use of Physician Associates.

6. Expanded use of Physician Associates (PAs)

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Plans for statutory regulation of PAs were announced October 2018, by the Secretary of State for Health and Social Care. This means that they will in due course be able to prescribe, which will significantly unlock their potential.

Divisions are currently recruiting PAs on an ad hoc basis. In the longer term a structured, streamlined recruitment process for PAs will be developed, for example, targeted recruitment event once or twice a year in conjunction with Brunel University. A target for recruiting a specific number of new PA posts is to be considered, suggested number is six new posts per year.

• Vascular plan to recruit a PA instead of a FY doctor. Looking to recruit a PA inorthopaedics.

• Surgery/Urology have both expressed interest, the funding of this would need tocome from either Trust grade posts or other unfilled gaps.

• Two PA posts being created within Stroke Services: one in Stroke rehabilitation(CNWL) and one for the Stroke unit. These will be funded by converting anunfilled Specialist Nurse post and a Trust Grade post.

• Care of the Elderly (COTE) also plan to convert at least one of their Trust gradeposts to a PA post, this has been discussed with Clinical Specialty Lead/COTEConsultant

• Cardiology has recruited a new PA (one of the first graduates from Brunel).

• AMU and ED also have new PA posts.

7. Next stepsKey next steps are:

• Successful implementation of Patchwork and Health Roster

• Ensure the actions for the out of hours workforce detailed in section 4 arerealised over the next 6 months

• Use the next meeting of the WTSB to review the workforce gaps identified insection 5 and ensure the actions with timescales are appropriate and aligned.

• Continue to provide high quality training, involve junior medical staff in sharingthe problems and solutions, and identify as well as act on current and potentialfuture risk

• Achieve successful high quality overseas recruitment in all the areas highlightedin this Report

• Align Consultant job plans to non-Elective work to support the delivery of safemedical care

• Expand use of Physician Associates by addressing the skills gaps, rather than a“instead of” junior doctor or primarily finance based approach

• Use an effectively constituted WTSB to strengthen governance arrangements,including monitoring risks (now and future); also undertaking a more extensiveworkforce review giving the emergence of other specialist nursing and alliedhealth professional roles, recognising that the Medical workforce in its currentform is unsustainable

• Through the Divisions and WTSB strengthen assurance around medical staffingsupporting the workstreams (specifically 18 week RTT, Cancer Performance andHillingdon Health Care Partners), which are not covered in this report.

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Report title: Committee Chairs – Reports back to Board

Report author: Michael Sims Trust Secretary

Report sponsor: Richard Sumray Chair



Note the reports back on assurances from Committees that key areas of compliance or progression of strategic objectives for the Committees were being achieved subject to any stated escalations to Board;

Finance & Performance Committee – Richard Sumray Quality & Safety Committee – Lis Paice Audit & Risk Committee – Richard Whittington Charitable Funds Committee – Richard Sumray Nominations Committee – Richard Sumray Remuneration Committee – Soraya Dhillon


STRATEGIC PRIORITY:

None

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Finance and Performance Committee December 2018 and January 2019 – Chair R Sumray

Financial position, financial improvement and recovery Detailed scrutiny of the Trust’s financial position and delivery of the Financial Improvement Plan has continued. Board should be assured that the monthly finance reports it receives are looked at in great detail at Committee level before coming to Board. Whilst the format of financial reporting remains good the Trust still “lags” in being able to provide a thorough analysis in its commentary. The Committee has also, on behalf of the Board, scrutinised the NHSI Undertakings performance in December. Overall the Committee is beginning to see that actual spend is much more in line with that projected which is positive and indicates better financial grip and control.

Performance Management Performance reporting to FPC in January contained some SPC charts for indicators, but the overall format of the report remains the same as that presented to Board. there is work to do in tandem with the Quality and Safety Committee to get the right indicators to the right meeting with the right analysis. The Chairs will be meeting officers to progress.

Estates review The Committee has approved the development of a short to medium term strategy to show how the Estate would be best used and kept in operation pending any new hospital development at the Brunel site. This reflects the critical condition of the Trust’s estate and the CE has also recommended that a regular report on its condition is presented to Board meetings to ensure all Board members are sighted on critical estates issues as they develop or unfold.

Escalations to the Board by the Committee – Legionella, Alternate Board Members

Board should be made aware of challenge that exists to in eradicating Legionella

Committee Terms of reference should state that an alternate voting NED or Executive Board Member not usually on the Committee can attend in place of another voting Board Member, but a “substitute” person does not count for voting purposes

Quality and Safety Committee December 2018 and January 2019 – Chair L Paice

Strategy Quality and Safety Improvement monitoring focused on the theme of ensuring people receive care in the right place

Divisional Review There was feedback on the Medicine Division with a focus on overall quality performance, learning from audits and divisional risk. In November the Committee had a presentation from the Emergency Division and were not fully assured that leadership was able to demonstrate it had all monitoring arrangements in

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place that it should do is escalating this to Board for decision.

Performance The Committee has now had two months of SPC chart reporting. Whilst this remains a work in progress the Board should be assured that the Committee is looking in detail each month now at detailed qualify and safety headline reporting in a more consistent and organised way. The Chair of QSC together with the Chair of FPC need to meet with staff in order to ensure the right suite of indicators is prepared to allow both Committees to review performance in the right place and avoid overlaps.

Internal and External Assurance The Committee is receiving summaries of meetings or their minutes in order to be able to scrutinise and then assure itself that the appropriate governance regime in terms of assurance is taking place.

Escalations to the Board by the Committee – ED leadership and monitoring arrangements – the Committee wished to bring to the attention of the Board tiots view that it was not assured by ED leadership that appropriate monitoring arrangements for services were fully in place and seeks guidance on decisions about next steps.

Nominations Committee January 2019 – Chair R Sumray

The Committee reviewed the structure, size and composition of the Board of Directors for both Executive and Non-Executive posts in light of the five Directors moving on to different roles over December and January. It has recommended changes to the composition of the Executive to be considered at the January Board meeting.

Escalations to the Board by the Committee – none

Remuneration Committee January 2019 - Chair S Dhillon

Chief Executive Performance Development Review The Committee approved the PDR objectives for the newly appointed CEO up until 31st March 2019

Escalations to the Board by the Committee - none

Audit & Risk Committee January 2019 - Chair R Whittington

Financial exception reporting and corporate governance Assurance was received that appropriate financial processes had been followed and the Committee reviewed a series of standard compliance reports in relation to providing assurance on corporate governance

Internal Audit and Counter Fraud Services The Committee was able to assure itself that the programmes of work set for 2018-19 was

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generally on target

External Audit The Committee was able to assure itself that the proposals from the external auditor for the year-end audit were appropriate and that the Executive were planning how it would ensure the delivery of the Annual Report and Accounts would take place in time for the May Board meeting. A review of progress will take place at the April meeting

Escalations to the Board by the Committee – Risk Management

The Committee agreed to escalate its concerns on non-assured risks in general and on the ability to treat legionella in the water pipes in particular, asking that the Board consider a separate report on these risks. Since that decision the CE has confirmed that the Executive will review all non-assured risks and report back to the Board on actions that will take place thereafter

Charitable Funds Committee– Chair R Sumray

No meeting since November.

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Report title: Minutes of Committee Meetings

Report author: Michael Sims, Trust Secretary

Report sponsor: Richard Sumray, Chair



Note the minutes of meetings of Committees of the Board since last reported in November (minutes included in the separate Appendices pack)


STRATEGIC PRIORITY:

None

Summary of Meetings - update until 22 January 2019

Committee Meeting date 2017

Minutes included in Part I Board Papers

Notes on exclusion

Charitable Funds 18 June Yes Audit & Risk 15 October Yes Quality and Safety 19 November Yes Charitable Funds 20 November Not yet Awaiting clearance March meeting Finance & Transformation 20 November Yes Redacted in relation to contracts Nominations 20 November No Relates to individual staff members Remuneration 20 November No Relates to individual staff members Quality and Safety 17 December Yes Finance & Performance 18 December Yes Redacted in relation to contracts Nominations 9 January Not yet Awaiting clearance March meeting Remuneration 9 January No Relates to individual staff member Audit and Risk 14 January Not yet Awaiting clearance April meeting Quality and Safety 21 January Not yet Awaiting clearance February meeting Finance & Performance 22 January Not yet Awaiting clearance February meeting

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the hillingdon hospitals nhs foundation trust part i (open) … › ... › 2019 ›...

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