Public Trust Board
Public Trust Board Meeting to be held on Friday 7th November 2014 from 1:30 pm to 4:00 pm in RAB Thomas Lecture Theatre, Post Graduate Medical Centre, County Hospital AGENDA Presentation to Endoscopy Team at Stafford No. Agenda Item Purpose PROCEDURAL ITEMS 1 Chairs welcome and apologies Information 2 Declarations of Interest Information 3 Minutes of the meeting held on: Approval rd a) 3 October 2014 b) 14th October 2014 (extraordinary) 4 Matters arising via the Post Meeting Action Log Approval 5 Chairman’s Opening Comments Information 6 Report from the Chief Executive Information QUALITY AND SAFETY 7 Quarter 1 Patient Experience Report Consideration 8 Mid-Year Research and Innovation Report Consideration STRATEGY 9 Integrating Health Services in Staffordshire Consideration ACCOUNTABILITY AND PERFORMANCE 10 Stabilisation Plan Approval 11 Month 6 Performance Report Consideration 12 Month 6 Finance and Contracting Report Consideration GOVERNANCE Summary of Changes to Policies: Standing Financial Instructions, Scheme of Reservation 13 Approval Delegation of Powers Standing Orders 14 Monthly NTDA Compliance Return – Sept 2014 Approval Committee Assurance Reports: Shadow Council of Governors (26th Sept) 15 Trust Executive Committee (24th Sept, 8th Oct) Consideration st Finance and Efficiency Committee (31 Oct) Audit Committee (31st Oct) CLOSING MATTERS 16 Questions from the Public DATE AND TIME OF NEXT MEETINGS Friday 5th December 2014, 1.30 pm Boardroom, Trust Headquarters, Royal Stoke University Hospital 1 Agenda of Public Trust Board th 7 November 2014 Lead/s Enclosure Mr J MacDonald Mr J MacDonald Mr J MacDonald Verbal Verbal Enclosed Ms C Rylands Mr J MacDonald Mr M Hackett Enclosed Verbal Enclosed Mrs L Rix Prof T Fryer Enclosed Enclosed Mr A Butters To follow Mr C Adcock Mrs H Lingham Mr C Adcock To follow Enclosed Enclosed Mr C Adcock Ms C Rylands Enclosed Ms C Rylands Enclosed Mr J MacDonald Mr M Hackett Mr J Marlor Mr B Collins Enclosed / Verbal Public Trust Board Minutes of the Meeting held on Friday 3rd October 2014 at 1.30 pm in the Boardroom MINUTES Voting Members present: Mr J MacDonald Professor A Garner Mr J Marlor Mr A Smith Brigadier N Young Mr C Adcock Mr R Courteney-Harris Mr M Hackett Mrs H Lingham Mrs E Rix Ms R Vaughan JMc AG JMa AS NY CA RCH MH HL ER RV Chair Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Director of Finance Medical Director Chief Executive Chief Operating Officer Chief Nurse Acting Director of Human Resources Non-Voting Members of the Board present: Mr D Simons DS Mr S Allen SA Mr M Bostock MB Designate Non-Executive Director Director of Strategy and Business Systems Director of IT Members of Staff In Attendance: Mr A Ashcroft Mrs N Hassall Mr J Roberts Mrs C Rylands AA NH JR CR Communications Manager Corporate Governance Manager (minute taker) Grant Thornton Head of Corporate Affairs/Company Secretary Mr S Burgin Mr R Collins Mr J Simpson SB RC JS Non-Executive Director Non-Executive Director Director of Corporate Services Members of the Public Press 6 2 Apologies: In Attendance: No. 1 088/2014 Agenda Item PROCEDURAL ITEMS Chair’s Welcome and Apologies Mr MacDonald welcomed members of the Board, public and press to the Trust Board meeting. Apologies were received from Mr S Burgin, Non-Executive Director, Mr R Collins, Non-Executive Director, and Mr J Simpson, Director of Corporate Services. Mr MacDonald welcomed the team from Imaging to the meeting. Dr Britton informed the Board that the imaging team have been running the ISAS accreditation scheme for the past two years and UHNS is only one of three large hospitals to achieve it. Dr Watson explained the ISAS scheme which has been set up under UCAS and UHNS are one of 18 organisations in the UK to achieve the accreditation. Dr Watson stated that the while the scheme is currently voluntary it is expected to become mandatory in Minutes of Public Trust Board 3 October 2014 DRAFT VERSION Action the near future. He explained that the scheme has 237 standards, 33 domains and involved 1000 pieces of evidence and not just provides accreditation, but acknowledges the commitment to delivering a quality service. He stated that the work has embedded an ongoing cycle of building in quality domains and improving service. It was noted that the accreditation involved the whole of Imaging with the creation of nine separate working groups. Mrs Turner explained some of the benefits from the scheme, including turnaround times for reporting being under control and bringing an increased skill mix into the department for the reporting of plain films. Other benefits included an expanded audit group with audits taking place across the directorate and increased research activity with two research radiographers trying to instigate in house research. It was noted that another benefit is the easy extension to Stafford site where the scope of the accreditation can be expanded to include Stafford. The Board were informed that the scheme involved reviewing patient information and included regular feedback from the Patient Council, with twice yearly reports being developed to request feedback on what areas of the service could be improved as well as GP engagement evenings being held. The team have also developed SharePoint to enable easier document control as well as the system being used for blogs, discussion boards and notice boards for staff. It was noted that the team would also like to develop SharePoint further to create automatic reminders for policy review. Mr MacDonald stated that it was pleasing to note that the scheme captured support from across the whole of the department. Mr MacDonald queried how the discussions with Stafford were going and Dr Britton stated that these were going well with a positive approach being put forward with a clear structure in place. Mr Smith queried where the work regarding culture and communication could be taken further forward and Dr Britton stated that the accreditation never stops and is a rolling programme so the next steps are to incorporate Stafford which will take approximately a year. In addition staff development and competencies are being developed, with a patient experience lead being involved to improve communications with patients. 2. Declarations of Interest 089/2014 There were no declarations of interest. 3. To approve the Minutes of the Public Trust Board held on 4th July 2014 090/2014 It was noted that Mrs Sandra Simmonds was in attendance at the meeting, not Mrs Soper and Mr Adcock stated that he has provided Mrs Rylands with some slight changes to the minutes as follows: Minute 083/2014 to read: Mr Adcock stated that the Trust is slightly ahead of plan to date and year to date the Trust has not met the activity on which the income was based due to a number of factors. He stated that the Trust is £600k below SLA plan but this has not yet been finalised. Mr Adcock stated that there has been challenge in delivery of business case assumptions. Non-elective activity pressures were contributing to this and these were not translating into an improved financial position and he believed that the Trust is triggering the non-elective threshold and therefore being paid at a marginal rate….. Mr Adcock added that a deep dive forecast review is to also to take place each quarter by the Finance and Efficiency Committee. Minute 087/2014 to read: Mr Hackett stated that in response to Mr Syme’s first comment, the Trust is paid at a marginal rate of 30% if it goes over the threshold level. Mr Adcock confirmed that this was correct, and the Trust would trigger the threshold if activity levels per the UHNS forecast are delivered, and not that of the Commissioners. Minutes of Public Trust Board 3 October 2014 DRAFT VERSION With the exception of the above amendments, the minutes of the meeting held on 4th July 2014 were agreed as an accurate record. 4. To consider any Matters Arising from the Action Log 091/2014 Action 3 – It was noted that this action was complete with awareness being raised regarding hand washing particularly in non-clinical areas. Action 9 – It was noted that a partial response had been received regarding readmissions which highlighted that a lot of the readmissions were not related to their original admission and further information is to be provided within the next outcomes report. Action 12 – It was noted that the stabilisation plan will be brought to the November Board meeting. Action 14 - Mrs Rix stated that RCAs are shared with patients when it is appropriate to do so. 5. Chairman’s Opening Comments 092/2014 Mr MacDonald welcomed one of the new Non-Executives, Brigadier Young to the meeting and stated that Mr Burgin would be attending the following meeting. Mr MacDonald also welcomed Mrs Lingham, Chief Operating Officer to the meeting and informed the Board that Mr Smith has agreed to be the lead Non-Executive Director for End of Life Care. Mr MacDonald wished to formally congratulate the four divisional chairs which have been appointed and informed the Board of the Extraordinary Public Board Meeting due to take place on 14th Otober 2014 at 2.30 pm, to consider proposals around Stafford, which is currently being advertised in the local press. 6. Report from the Chief Executive 093/2014 Mr Hackett highlighted the following from the monthly report: • Outpatient new activity is growing by 17% with approximately 8,000 more new patients which links to the plans to continue to expand outpatient services. • Cancer 2 week wait demand continues to see a rise with 17% in Q1 with the highest peak in referrals in July at 1,519. This is a substantial growth in workload it is pleasing to note that standards are not slipping with the response from clinical teams being magnificent. • The Trust is delivering other indicators except for A&E and the Trust is continuing to work with the local health economy to improve A&E performance. Mr Hackett stated that there has been a growth in demand of 7.5% more emergency admissions per annum and a growth in A&E attendances of around 10%. The Trust is trying to improve the responsiveness of services and is looking to invest £2m in the health system to increase the amount of people working in the community and social care services to improve care from home support and placements where patients are stepped down to their normal area of residence. The focus of attention over the next few months will be to try to reduce the number of patients in hospital waiting for community care and in October a GP front of house service will be launched, which will be co-located in A&E. Mr Hackett stated that this initiative is one example of how UHNS is working with its partners to improve care for patients and the Trust has also been working with the CCGs regarding the 111 service to reduce referrals to hospital. Minutes of Public Trust Board 3 October 2014 DRAFT VERSION • • • • • • • • • • Mr Briggs and Dr Morgan have developed a pilot regarding elderly care beds which has resulted in improvements in the reduction of length of stay in hospital which is to be extended. This will be done via working with a local GP confederation to care for patients in alternative settings outside of hospital which can deliver a more personalised local service to patients and enable the release of beds at UHNS, with approximately 30-35 patients being able to be treated closer to home. The Trust is making changes to flow in the surgical assessment unit and by the end of October there will be a separation of the surgical assessment service from the surgical admission service improving the quality of service for patients. The Trust has had some success in recruiting nurses and in the past 18 months 742 nurses have been recruited to, and put into context, this is a third of the staff at Stafford Hospital. Mr Hackett stated that this is a credit to Mrs Rix as well as the leadership of ward sisters in getting people who want to work at UHNS, because they feel supported, trained and have development opportunities which is further proved by the low staff turnover. Mr Hackett stated that the additional nurses will be used across both Stafford and UHNS sites which will help to reopen beds at Stafford from 1st November 2014. The Trust Executive Committee have approved to appoint two more cardiologists which will enable a reduction in waiting times in cardiology and in turn will enable the Trust to intervene earlier. The Trust Executive Committee have also approved £1m investment in respiratory services which includes the appointment of additional specialist nurses and respiratory technicians to run a 7 day service across the hospital with additional consultants, more hot clinics and address outpatient demand. In addition, cancer patients will also be able to access more specialist nursing support. The Research and Development Department are holding an open day on Monday 20th October which Mr Hackett asked Board members to attend, which will provide an opportunity to see the type of research being undertaken within the hospital. Professor Spiteri and the research team have recruited the first patient worldwide for the PASSPORT study which reflects the growing strength of research. And the Oncology Research Team have been listed as one of the top three recruiters for the RavVA study. The Trust has approved a fifth MRI scanner to improve access for the local population In partnership with Wolverhampton and Burton an additional plastic surgeon and one replacement surgeon is to be appointed In order to support local hospitals more the Trust is moving care for neurology patients into South Cheshire where GPs have agreed to provide a new service in Nantwich to help alleviate waiting times in South Cheshire. Brigadier Young queried the reason for the 17% increase in referrals for cancer. Mr Courteney-Harris stated that there was no particular reason for this as the Trust is forewarned of any publicity campaigns and this has been a general increase, nationwide. Mr Courteney-Harris stated that more analysis is required to address whether the Trust is receiving more referrals due to actions being undertaken to reduce the number of late referrals and it needs to be established that these are legitimate, but he stated that, in general, the referrals are across a broad group and are not related to a specific area. Mr Hackett stated that over 60 patients a day are coming into UHNS with symptoms which may show signs of cancer and while many may not be related to cancer, the Board has invested in tackling issues in North Staffordshire and Stoke regarding the late presentation of patients. He stated that this is being addressed in part by the Minutes of Public Trust Board 3 October 2014 DRAFT VERSION increase in MRI and screening developments and expanding outpatients to ensure that GPs have a rapid service to establish whether it is cancer and treat patients promptly. Mr Smith queried, because of the unexpected nature in the increase, whether the Trust is able to forecast future demand based on the increase. Mrs Lingham stated that she is looking to include predictions regarding performance and access in terms of targets, as well as considering capacity which will go across all metrics. She added that this is also to be looked in context with the national picture and practice from other organisations is to be established which will help to predict capacity requirements going forward. Mr Courteney-Harris added that the cancer teams are good at trying to predict capacity for known campaigns, however it is difficult to predict how people will respond to them. The Board received and noted the Chief Executives Report. 7. 094/2014 QUALITY AND SAFETY Quality Report: Outcomes/Effectiveness Quarter 1 Mrs Rix discussed the report which reviews practice against compliance with regulatory standards. Mr Courteney-Harris stated that part of the report includes a review of the CQC intelligent monitoring process and describes how to manage these predictions in the future to try to predict ratings for the future and establish a rationale behind this. Mr Courteney-Harris stated that with regards to mortality there has been no real impact of the Trust’s trauma centre status and as a general principle the rate is reducing. Mr Courteney-Harris stated that the Trust is in the process of rolling out care bundles and in particular one regarding sepsis patients. Mr MacDonald queried whether the Quality Assurance Committee could review the number of deaths from sepsis and this was agreed. Mr Smith queried progress regarding end of life care following the discontinuation of the Liverpool Care Pathway. Mrs Rix stated that this has been discussed at the Quality Assurance Committee and with the palliative care team to discuss how to manage these patients so that the principles of a dignified and pain free death are not lost, and this has included reviewing the pathway so that it takes on these principles and is mindful to the issues raised from the Liverpool Care Pathway. Mr Smith queried how staff are being trained regarding this and how it has been communicated with patients. Mrs Rix stated that the Trust has end of life champions in place and Mr Courteney-Harris stated that a wider view of end of life care throughout the health system needs to be considered to ask why these patients are being treated in hospital and how they could be cared for in a more appropriate location. Mrs Rix stated that a health economy group is considering this and she stated that the group would welcome Mr Smith’s involvement regarding this. Brigadier Young stated that although sepsis is sometimes attributed to poor care, whether there is work and research being undertaken to distil the link between sepsis and antibiotic resistance. Mr Courteney-Harris stated that antibiotic resistance is a big issue and the Trust is very active in looking at this. He stated that while there are some complex patients with resistant infections, the Trust does have an infectious diseases unit to enable staff to get the right advice with a strong microbiological lead, and usage is monitored carefully. Mr Courteney-Harris stated the other issue is monitoring usage within the local health economy and Mrs Rix stated that there is a local health economy group of antimicrobial stewardship and she added that GPs are actively looking to reduce antibiotics. Mrs Rix stated that the Trust screens all Minutes of Public Trust Board 3 October 2014 DRAFT VERSION RCH/LR patients for multi-resistant strains as well as MRSA so that it can act and isolate patients straight away. Mr MacDonald queried the increase in freedom of information requests and Mr Courteney-Harris stated that while a large number of these relate to the Mid Staffordshire integration, there has also been a national increase. Mr Allen stated more than 50% of the requests are of a commercial nature. Mr Hackett stated that the Trusts HSMR score shows that the Trust has 200 less deaths than expected and bearing in mind the complexity of patients seen, this is a massive achievement from the clinical teams. The Board received the report and noted the following: • The Intelligent Monitoring Report (IMR) indicators will be included as part of the Patient Care Improvement Programme (PCIP). A paper will be presented to the Quality and Safety Forum, outlining the new governance arrangements, the role of the Quality Improvement Groups (to support the implementation of the PCIP) and revised terms of reference for the Quality and Safety Forum. The paper is scheduled to be presented at the Quality and Safety Forum October 2014. • The Compliance Steering Group terms of reference are currently under review to support the implementation of the clinical assurance framework. The IMR indicators will be included as part of the quality and safety measures that support the clinical assurance framework. The paper will be presented at the Compliance Steering Group with roll out of the revised framework scheduled for November 2014. • The Information Governance Team is currently targeting staff who have not received information governance training during the past 18 months. Directorate Management Teams are to ensure staff are released to attend the training sessions. • In response to the audit results, the WHO Sub Group has developed an escalation process to ensure improved compliance with the full completion of the checklist. This will be rolled out during quarter 2. 8. Revalidation and Appraisal Report 095/2014 Mr Courteney-Harris stated that all doctors are required to undergo an annual appraisal which is a contractual requirement and the General Medical Council require doctors to revalidate themselves every 5 years and undergo a yearly appraisal. Mr Courteney-Harris stated that Dr Nick Coleman is now the Responsible Officer for this and the paper discusses a small number of doctors who are not taking part in this process, with a large amount of time being spent on chasing up these doctors to inform them of the employment requirements and moral/professional obligations. Mr Courteney-Harris stated that the Trust is looking to seek a more robust process in regards to this, and stated that as part of the contract the Trust can stop pay progression if this is not undertaken and, in addition, doctors have four hours a week to gather information as part of their appraisal via their SPA and this will also be enforced. Mr Courteney-Harris stated that while the Trust is seeking to introduce these measures to enable more power for this to be enforced, it is not expected to use them. Brigadier Young queried whether the solution would be to refer matters to the GMC. Mr Courteney-Harris stated that the Trust can do so in extreme circumstances as part of non-engagement but that this process is to be enacted before that stage. Brigadier Young queried if the doctors who are non-compliant are at similar stages of their careers and Mr Courteney-Harris stated that there are certain groups where it is Minutes of Public Trust Board 3 October 2014 DRAFT VERSION difficult to get cooperation i.e. doctors towards the end of their career, but it does not solely relate to that staff group. Mr Marlor queried how many of the 11% who had not completed their appraisal had been reported to the GMC and Mr Courteney-Harris stated that the Trust has not reported anyone to the GMC, with the reasons for non-completion relating to timing of the appraisal. Mr Hackett stated that the Board should support the proposals and understand that the Trust has a conduct policy in place and that it is reasonable, appropriate and proportionate to apply the conduct policy to this. Mr Simons queried if the appraisal process is onerous and Mr Courteney-Harris stated that it is managed via an electronic system which can be laborious but if doctors spent an hour a week reflecting on their practice and uploading information, it would be manageable. Mr Smith stated that he endorsed the proposal as it ultimately protects patients but queried the sentence regarding amending contracts of other doctors and Mr Courteney-Harris agreed to discuss this further with Ms Vaughan. The Board received the report, considered the key recommendations as set out within section 4 of the report and noted the following: 1) the strategy to improve compliance amongst doctors who currently are not engaging using the tools available in their employment contracts. While there will always be legitimate reasons for delay or cancellation, doctors currently not complying will only do so if they perceive that action will be taken if they do not. 2) The Board approved the following approach: • All doctors should be allocated an appraisal month, during which they will be expected to complete their appraisal each year. This follows NHS England guidance. • The current distribution will be changed so that there is a more equal spread across the winter months. No doctor will have their date changed by more than 1 month. • Doctors who do not choose an appraiser by the end of July will have one allocated to them. • Doctors who do not complete their appraisal during the allocated month will receive advisory warnings as outlined in the NHS England guidance. • Those who do not complete within the appraisal year without an acceptable explanation will have their pay progression deferred and an immediate job plan review by the Medical Director to reduce their SPA allocation. Consideration should be given to amending the contracts of other doctors to include similar financial penalties. 9. 096/2014 ACCOUNTABILITY AND PERFORMANCE Performance Management Framework Mr Allen discussed the context of the framework in that the Board seeks assurance in a number of ways via external and internal systems and processes looking at performance and this framework describes how the Trust will set out systems and processes to manage performance. He stated that this includes a broader approach than the previous framework and incorporates quality management frameworks and is clearer about the respective roles within the organisation and is not solely focused on Board responsibilities. He stated that the framework is clear about the escalation process when performance is not acceptable and has tried to draw on best practice. Minutes of Public Trust Board 3 October 2014 DRAFT VERSION Mr Simons queried whether this covers any softer issues in the KPIs/metrics. Mr Allen stated that the framework deals with performance in a more rounded fashion so it is not compartmentalising, and in addition a review will focus on softer intelligence to drill down into the underlying reasons and cultural factors. Mr MacDonald stated that an earlier discussion was held regarding how the Quality Assurance Committee can have more of a focus on softer issues and this needs to be incorporated into the document. Mrs Lingham stated that the key issue for the framework is how to implement it into staff culture so that performance is embedded in a positive way. Ms Vaughan stated that this approach dovetails with the organisational development strategy regarding systems processes and does not stand alone. Mr Adcock stated that the best way for engagement is for people to be involved in setting objectives and their plans to meet them which comes back to the organisational development. Mr MacDonald stated that within the organisation is a hierarchy of measures and the Board needs to be assured that these measures of hierarchy have been put in place. The Board approved the Accountability and Performance Framework for 2014/15, recognising the links to organisational development, the softer and predictive measures and the hierarchy to be developed over time. 10. Month 5 Performance Report 097/2014 Mrs Lingham stated that while the Trust is challenged in achieving the A&E 4 hour target, some areas are within the target and performing well, with the pathway for paediatric emergency access in August being achieved at 98.5% and paediatric minors 4 hour compliance performance at 96.2%. She stated that the integration of the GP front of house service should improve performance and the Trust is expecting 98% compliance regarding this. Mrs Lingham stated that the area in which the Trust is challenged is the majors part of the Emergency Department which is predominately around capacity and discharge arrangements. She stated that she is working on crystallising key actions to be taken as a health economy in order to improve overall performance and sustain performance. The areas being focussed on include the ‘back door’ in terms of discharge to assess initiatives and patients being assessed in a setting more appropriate to their requirements and looking at attendances to hospital with changes to 111 pathways and the expansion of GP initiatives in terms of ‘front door’ alignment. Mrs Lingham stated that those two things will have most significant impact on the 4 hour target and other issues being concentrated on include the number of patients seen in an ambulatory setting. Mrs Lingham stated that the Trust has joined a national network regarding this with some real wins for patients and families and stated that the network will provide organisational system help. Mrs Lingham stated that the Trust has been experiencing levels of demand for cancer patients at a level not previously experienced, and while the Trust is managing well it is always vulnerable and work is being focussed on the areas the Trust is doing well in as well as those not so well to ensure performance is maintained. Mrs Lingham stated that a lot of effort is to be put into the cancer pathway to ensure the Trust delivers best practice and what it needs to deliver to sustain performance and predict future demand. Mrs Lingham stated that the Trust has a strong performance against the 18 weeks target, and while a lot of organisations are struggling with this, the Trust is not only delivering 18 weeks at an aggregate level but is actually achieving it at specialty level. Minutes of Public Trust Board 3 October 2014 DRAFT VERSION Mr Courteney-Harris stated that while the Board is well versed regarding A&E performance, the Board should be assured that staff are continuously working hard and the key is to achieve the target consistently and it is pleasing to note that the Trust is now getting more positive engagement of how to make this work. Mrs Lingham stated that the Trust is bringing together a number of schemes to improve the trajectory going forward and this is crucial across the health economy. Mr MacDonald queried the fact that a number of community beds were closed last week and during those three days the Trust achieved over 95%. Mrs Lingham stated that this aligns to the fact that the majors area is bringing down the organisational score and while one issue is capacity the other issues are about behaviours and cultural issues around how quickly things can be undertaken and prioritisation of patients. Mr Courteney-Harris stated that the danger when everyone puts something in to achieve this, it becomes unsustainable. Brigadier Young stated that the greater number of handoffs regarding decisionmaking suggests a lack of leadership or confidence to be assured that they are doing the right thing and queried whether this is a wider issue of staff confidence in leadership. Mr Courteney-Harris stated that there are too many people who can influence decisions at various levels and the Trust needs to be clear of the discharge pathway and who can influence it and who can not. Mrs Lingham stated that a lot relates to trusting other professionals to make a decision and trust is also needed between partners. The Board received the report and noted the following: 1. The Trust’s Performance in August 2014 and the key indicators of the 4 hour wait standard and Cancer 62 days are the key risk which shows the Trust in material breach of the NHS TDA Accountability Framework. 2. The Board still need to be assured that the actions being taken against key risks areas are being delivered and are resulting in improvements mitigating the performance risk in 2014/15 as led by the COO a stabilisation plan and A&E recovery plan, will come to November Board. 3. The key financial risks are underperformance against the following standards: 4 hour wait, ambulance handover, 18 weeks admitted, diagnostic 6 week (underperformance in Q1), cancer 62 days, and appointment slot issues. 4. The HR Director is addressing the shortfalls in appraisal rates to reach the required thresholds within the agreed trajectory. 11. Month 5 Finance and Contracting Report 098/2014 Mr Adcock stated that the forecast review had not been completed in time for inclusion in the financial report and the final report is to be circulated to the Board members. Mr Adcock stated that to date, performance is in line with plan and the Trust is over recovering on income against plan by £800,000. He stated that the key component is that £0.5 m relates to pass through costs and makes no contribution to the Trust’s bottom line. The financial implications from over activity is not proportionate due to triggering the non-elective activity threshold and there is also a large over performance on excess bed days. Mr Adcock noted other items associated with Mid Staffordshire which are also pass through costs. Mr Adcock stated that the Divisions are projecting a material increase in the recovery of income and this is to be reviewed and discussed in detail at the Finance and Efficiency Committee at the end of October. Mr Adcock stated that expenditure is Minutes of Public Trust Board 3 October 2014 DRAFT VERSION HL/ CA RV CA £700,000 overspent with pay more or less in line and if the pass through costs are excluded the Trust is underspent on pay to date. He stated that work is being completed to validate the correlation of activity levels with non-pay budgets. Mr Adcock noted good progress in the last month against the Trust’s CIP to get to the £30 m target although this has been impacted on by the heavy over performance and the Finance and Efficiency Committee will continue to be advised of risks through the monthly reporting arrangements. Mr Marlor queried the figures being reported to the NTDA and the projected delivery of £16.9 m deficit. Mr Adcock confirmed this was the case as discussed at the Finance and Efficiency Committee meeting. Mr MacDonald stated that another drill down will be undertaken for Q2 to establish how robust the Trust is with regards to its predictions. Mr Marlor queried when the Trust will apply for cash support and Mr Adcock stated that it will follow the same process as for last year with the process to begin in October and a paper being taken to the Finance and Efficiency Committee at the end of October 2014. Mr Smith queried the contracting position and Mr Adcock stated that while there has been an agreement to achieve monthly flex and freeze dates, this is not enforceable and as a result a number of disputed items have been closed with some queries which are being worked through with commissioners and it is hoped to carry over fewer disputes in the future. Mr Smith queried the cost improvements and how the Divisions were to assess the impact on quality in order to close the £3-£4m gap this year. Mr Adcock stated that the Trust will continue to follow the QIA process and for the next year the Trust is not expecting a material change to the process. Mr Hackett stated that £12 - £15 m has already been identified for next year and this will be populated over next 6 months. He added that there is always a gap at the beginning of year and the question is how to narrow that. Mr Hackett stated that by the end of March 2015 the Trust will have saved £58m in the previous two years. 12. 099/2014 13. 100/2014 Mr MacDonald summarized that while there remain to be pressures in place, the Trust is still predicting its current plan outturn and the drill down into Q2 will be important. CA The Board noted the content of the financial position report, the risks identified and endorsed the mitigation strategy. The Board asked for a in depth review of the Q2 to be completed and reported via Finance and Efficiency Committee to the Board. CA STRATEGIC ISSUES 2025Vision It was noted that the 2025Vision is to be discussed at the Extraordinary Board Meeting on the 14th October. GOVERNANCE Annual Audit Letter Mr Roberts presented the annual audit letter and provided a look back over the year. He discussed the statutory framework, the national context and the findings for UHNS. Minutes of Public Trust Board 3 October 2014 DRAFT VERSION The following findings for UHNS were highlighted: • Unqualified financial statements opinion • Qualified 'adverse' VFM conclusion • Qualified limited assurance opinion on Quality Accounts • Section 19 referral issued Mr Hackett queried whether the Trust will have an adverse opinion in future due to forecasting a deficit and Mr Roberts stated that while it would look to reduce an adverse opinion it would relate to specific issues but that the challenge and risk would be outside of UHNS’s control. Mr Adcock stated that while the Trust continues to have a deficit budget a Section 19 referral will still be made. Mr Marlor queried how the accounts from Mid Staffordshire would impact on UHNS and Mr Roberts stated that it will involve the balance at the end of March 2015. The Board supported the development of an action plan to address the outstanding issues outlined within the report which is to be presented and monitored by the Audit Committee. 14. Monthly NTDA Compliance Return – August 2014 101/2014 The Board approved the returns and agreed the actions to reduce risk to compliance. 15. Committee Assurance Reports 102/2014 Trust Executive Committee (10th September) Mr Hackett stated that he had nothing further to add to the report. Quality Assurance Committee (12th September) Mr Smith stated that the Committee received a presentation from the Chief Pharmacist regarding medicines optimisation and the Committee thanked Mr Fox for his time as Chair. Audit Committee (17th September) There was nothing further to add to the report. Finance and Efficiency Committee (26th September) Mr Marlor stated that he had nothing further to add to the report. The Board noted the Trust Executive Committee, Quality Assurance Committee, Audit Committee and Finance and Efficiency Committee reports. 16. 103/2014 CLOSING MATTERS Questions from the Public Dr Ryan queried the closure of beds at Longton Cottage hospital and whether the Trust was aware of any plans to encourage/re-open the beds. Mr Hackett stated that that would be for consideration of the Community Trusts but UHNS’s view is that 240 patients are waiting in hospital and community hospital beds who are waiting for assessment and the ability to assess these types of patients in facilities outside of hospital needs consideration. Mr Hackett stated that the closure of beds at Longton Cottage is temporary and the community provider is looking to appoint more nurses to staff their community beds and their recruitment plans will need to be communicated Minutes of Public Trust Board 3 October 2014 DRAFT VERSION to the wider health system. Mr McCann queried whether it remained Mr Hackett’s view of the cancer/end of life tender to stop the process. Mr Hackett stated that the Trust’s view is that it should focus on patients first and partnerships second and it believes that NHS hospitals and providers deserve the opportunity to work in partnership with CCGs to improve care for patients. He stated that the public have spoken on this and indicated their opposition to the procurement and the Trust Board is working with commissioners to review the process to enable NHS providers to work at solutions with a number of cancer services to improve integration of care. Mr Hackett stated that it is the Board’s view that this can be carried out better by working in partnership rather than by adversarial procurement. Mr Hackett stated that with regards to the end of life tender it is supportive of the idea as too many patients pass away in hospital compared to other parts of the country and these patients would have a more dignified experience if they were being cared for in a setting outside hospital. Mr Hackett stated that the issues regarding end of life care were very different to the cancer procurement issues. Mrs Edgeller raised three questions to the Board: 1) She stated that the people in Stafford are fighting for the maintenance of a full maternity unit and paediatrics department. She stated that Mr Jeremy Hunt stated that a review should take place before the transfer of maternity services takes place which seems to have been overtaken by UHNS. She queried whether the transfer of services would be undertaken before the review takes place. 2) A&E is in crisis at UHNS and throughout the country and she queried whether it was true that in April 2015 a Consultant-led GP service would be in place from 10.00 pm – 8.00 am at Stafford with A&E remaining open from 8.00 am until 10.00 pm. Mrs Edgeller stated that when a patient from Stafford attended A&E at UHNS she had a considerable wait and wanted assurance that these problems will be addressed. 3) She queried who sits on the Board for Stafford as she thought that there were two representatives for Stafford. Mr MacDonald stated that in terms of the third question, no person on the Board sits to represent one constituency and stated that during the appointment of the two new Non-Executive Directors, expressions of interest from those residing in Stafford were requested. He stated that Mr Burgin is from Stafford as is Mr Simons but their remit is as part of a Unitary Board to look across the whole of the Trust and not as part of a specific constituency. Mr MacDonald added that the Trust is establishing a new Shadow Council of Governors which will include people from Stafford for them to bring perspectives and views of patients from Stafford and that the Governors would help to ensure engagement with the wider community. Mr Hackett stated that in terms of the second question, the TSA were called into Stafford in 2013 based on the hospital declaring itself as clinically and financially unviable in 2012. He stated that following the Mid Staffordshire Board stating that they were not viable the TSA were appointed to look at the options which included maintaining Stafford as is, through to making it into an outpatients department and concluded, following intense lobbying by the UHNS Board, with proposals for the people of Stafford to retain A&E as is and expand a number of medical and elderly services. Mr Hackett stated that in response to demand on hospital services the Trust is of the view that A&E needs to be maintained and operate on its current hours and this will be improved by putting in a consultant delivered A&E for the time the department is open, for the first time ever. He stated that the introduction of a GP out of hours service when A&E is not open is a fantastic development which Mr Jeremy Lefroy and Mr Andrew Donald deserve credit for. Mr Hackett stated that the consequence for the vast majority of people means that children will have first line Minutes of Public Trust Board 3 October 2014 DRAFT VERSION medical care in Stafford by local GPs and older people will also have advice from a doctor who as access to the local facilities. Mr Hackett added that this is also to be backed up with the use of Hospital at Home which is in place at Stoke and North Staffordshire, for adult patients and also for children, managed by a dedicated team of experts which will benefit the population of Stafford. Mr Hackett stated that in terms of the first question, the issue of Consultant-led Obstetrics Unit and Paediatrics is clearly contentious and something which the public is concerned about. He stated that the TSA concluded that after the review of the number of births at Stafford and the predicted population growth, a full-time 24/7 obstetrics service for women needing intervention was considered not viable due to the level of births being insufficient for modern standards to enable the sufficient training of doctors. Mr Hackett stated that the Secretary of State announced the review but has said that it will be undertaken but to be cover a national picture rather than for Stafford, looking at a number of obstetrics units across the country which are small in nature. He stated that Stafford Hospital had 1742 births at the end of 2012/13 which in broad terms equates to three or four births a day which is very small and has an impact on the long-term sustainability issues. Mr Hackett stated that the review will be undertaken but if there are safety issues from 1st November when UHNS will operate hospital, the Board would not risk the lives of patients if an alternative can be put in place. He stated that any changes would be temporary to maintain safety but this decision has not yet been made. Mr Syme stated that while he understands the anxieties about Stafford and their campaigners, he would not disrupt the running of a hospital. He stated that he was amazed that the Stafford campaigners had set up a protest on UHNS property and considers it to be irresponsible. Mr MacDonald stated that the Trust can not forcibly move people and the Trust needs to follow due process. Mr Syme stated that the improvements for respiratory is brilliant but stated that the focus is within community respiratory services which are causing concern. He stated that while the Trust has experienced a 17% increase in cancer services he is still hearing of people being ‘lost’ in the system which is not being addressed. He added that there are also no services for chronic disease management and clinical psychology services. Mr Courteney-Harris stated that the Trust does not disagree of the need to look at the whole of the cancer pathway including all the elements mentioned, and that it is not just a local problem. Mr Hackett stated that the Trust is open to looking at improving cancer care and chronic disease management and that in the past, organisational boundaries may have contributed to the segmentation of pathways but that the Chief Executives have agreed to work together, following the same code of conduct to follow so that open discussions can be undertaken in partnership to make a significant difference. Mr Syme queried the A&E discharge and throughput and stated that discharge of patients seems to be due to a lack of coordination. He queried whether discharge would remain a clinical matter. Mr Hackett stated that it would and it is felt that the process needs to go back to basics, whereby if the Consultant feels the patient is ready for discharge, the patient is subsequently discharged rather than bureaucracy taking over. Mr Hackett stated that both he and the Chief Executive of the Community Trust feel that the bureaucracy needs to change and highlighted that Mrs Rix and her colleagues in the community are working on reviewing discharge processes with a focus on getting patients to their place of residence and supporting them at home as well as enabling them to be assessed for ongoing health needs and promote independence. Mr Hackett stated that there is a real willingness for coordination of services and this will be evidenced by further joined up communications and plans between the CCGs and UHNS. Minutes of Public Trust Board 3 October 2014 DRAFT VERSION Mr Syme queried how the partnerships would be enforced when the community have had to take out 40 beds, have 26 too few District Nurses and is also short on GPs, and queried how the public could have confidence that the partnerships will work. Mr Hackett stated that one example is that on 7th October GPs are being brought into A&E to relieve pressure on A&E, in order to address the third of patients who should not be attending A&E and should see their GP. He stated that he had met with the CCGs who have agreed collectively to have a forum with lay members and NonExecutive Directors to everyone to account for the delivery of a shared plan and pooling of resources. Mr Hackett stated that an announcement will be made in the next few weeks regarding how resources are to be spent to improve discharge with initiatives for ambulatory emergency centres and measures to support general practice being part of the four or five big things to be addressed. Mr MacDonald stated that the issue of social care and the local authority also has a role, and the Trust needs to build on its partnerships. Mr Biard queried whether the discharge procedures at UHNS will concurrently look at Stafford patients and if a similar model would be used. Mr MacDonald stated that as a general principle the Trust is looking at working in an integrated way to try to ensure consistency and quality of care. He stated that while there may be different solutions due to differences in community services, discussions have already started. Mr Courteney-Harris stated that the issues will be similar in principle and agreement will be required across the whole of the area to ensure the same consistency of care and processes are in place regarding discharge. Mr MacDonald stated that the Board does not view the hospitals separately and Mrs Rix stated that the Trust aims to provide the best care possible for patients wherever they are and the Board has an equal responsibility for all patients regardless of where they reside. Mr Blackhurst queried the introduction of the GP front of house service and queried what is different with the service this time from when it has previously been suggested. Mr Hackett stated that patients are to be brought into A&E, triaged and then either directed to the GP service or A&E. He stated that this time a clear specification of who is responsible for what is in place with conversations being also held with Stafford Out of Hours. Mr Hackett added that another different is that UHNS is to be responsible for running the service rather than hosting it and the A&E Consultants are supportive of this taking place. Mrs Lingham stated that a service similar to this has been introduced previously but the difference is the integration of the service which is not being run separately. She stated that the benefit is seeing patents at the ‘front door’ and then deciding which service they need to attend which aligns with excellent practice and she stated that she felt assured that this will be successful. Mrs Lingham stated that the service will not be run as a 24/7 service as evidence does not suggest that this is necessary, but this will be evaluated on a weekly basis so that it can flex and change in response to the needs of the local population. Mr Blackhurst queried when the new name for the Trust will be announced and Mr Hackett stated that this will be announced on 14th October 2014. Mrs Edgeller queried whether the Ambulance Services in West Midlands have been negotiated with in regards to the A&E capacity issues and Mr Hackett stated that they have and that a public and patient involvement forum will be responsible for feedback arrangements with Mr Lee Washington having agreed to come and discuss the creation of a patient transport forum to help re-design services. Mr McCann queried the claim that the Trust’s 88% 4 hour performance is the worst in England. Mr Hackett stated that while it was not the worst, it was not the best and the worst performance for the last week, nationally, was about 71%, with Stafford achieving 77%. He stated that the Trust is in the bottom 10 organisations and Mr Minutes of Public Trust Board 3 October 2014 DRAFT VERSION MacDonald stated that this is something which the Trust is not proud of. DATE AND TIME OF NEXT MEETING Extraordinary Public Board Meeting: Tuesday 14th October 2014, 2.30 pm RAB Thomas Lecture Theatre, Postgraduate Medical Centre, Stafford Hospital Friday 7th November 2014, 1.30 pm RAB Thomas Lecture Theatre, Postgraduate Medical Centre, Stafford Hospital Minutes of Public Trust Board 3 October 2014 DRAFT VERSION Extraordinary Public Trust Board Minutes of the Meeting held on Tuesday 14th October 2014 at 2.30 pm in the Dinwoodie Lecture Theatre, Post Graduate Medical Centre, Stafford Hospital MINUTES Voting Members present: Mr J MacDonald Mr S Burgin Mr R Collins Professor A Garner Mr J Marlor Mr A Smith Mr N Young Mr C Adcock Mr R Courteney-Harris Mr M Hackett Mrs H Lingham Mrs E Rix Ms R Vaughan JMc SB RC AG JMa AS NY CA RCH MH HL ER RV Chair Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Director of Finance Medical Director Chief Executive Chief Operating Officer Chief Nurse Acting Director of Human Resources Non-Voting Members of the Board present: Mr S Allen SA Mr M Bostock MB Mr D Simons DS Mr J Simpson JS Director of Strategy and Business Systems Director of IT Designate Non-Executive Director Director of Corporate Services Members of Staff In Attendance: Mr C Bown Mr A Butters Mrs N Hassall Mrs C Rylands Mr P Wilson Managing Director – Stafford Project Director Corporate Governance Manager (minute taker) Head of Corporate Affairs/Company Secretary Project Director CB AB NH CR PW Apologies: In Attendance: Members of the Public Press No. 1 104/2014 62 2 Agenda Item PROCEDURAL ITEMS Chair’s Welcome and Apologies Mr MacDonald welcomed members of the Board, public and press to the Trust Board meeting. No apologies were received. Mr MacDonald stated that the meeting represented a new start in providing hospital services for the local area and explained that Mr Hackett will start by discussing the new Vision and how Stafford fitted into this. This would be followed by an opportunity for public questions before the Board considered the proposed transfer proposals. Mr MacDonald stated that if approved by the Board, the proposal would be considered by Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION Action other statutory authorities before going to the Secretary of State. Mr MacDonald stated that the current Trust Board will represent the new Trust and will have a responsibility to provide services across both hospitals. He stated that following the appointment of two new Non-Executive Directors, the representation now covers a wider catchment area, although it will remain a unitary Board. Mr MacDonald stated that letters will be going out in the near future to current Mid Staffordshire (MSFT) members asking them if they would like to join the new Trust or Royal Wolverhampton (RWT) and that the new Trust will be seeking to elect a Shadow Council of Governors drawn from a wider catchment area to reflect the wider governance responsibilities of the Trust Board. 2. Declarations of Interest 105/2014 There were no declarations of interest. 3. ITEMS FOR DISCUSSION Future Integration of Services in Staffordshire 106/2014 Mr Hackett provided a presentation to the Board on the future of health services in Staffordshire. He stated that the challenges which Mid Stafford has faced for the past decade have resulted in uncertainty around its future and that the events at Stafford have been a touchstone for improving quality and safety of services, not only within the NHS, but in the world. These have created an impetus to bring health services in England up to the standard of some of the best in the world, although there remain further challenges to address. Mr Hackett stated that staff have worked under uncertainty for some time given the changes to take place affecting both patients, public and staff in the local hospitals within Staffordshire. Mr Hackett stated that following Sir Robert Francis QC, reporting on the Stafford enquiry, the Trust Special Administrators (TSAs) were appointed who consulted on service proposals. This concluded in Autumn 2013, followed by the Secretary of State’s decision in February 2014 to accept the recommendations of report and undertake a review of the future of consultant-led obstetrics services. He stated that the Secretary of State was legally required to announce a binary decision and as such the Secretary of State supported the proposals in their entirety. Mr Hackett stated that 1st November 2014 will signal the creation of a new NHS Trust, with new investment being made into the Staffordshire health system which will enable more investment to open more beds at Stafford, buy new equipment and refurbish wards, along with refurbished theatres and more car parking. He stated that the new integrated Trust, called the University Hospitals of North Midlands, will be a single Trust with two hospitals of equal importance. Mr Hackett stated that the Trust will receive over £250 m of investment into the hospitals which is twice the amount the TSA estimated. UHNS had fought to attract more resource to the area and Mr Hackett commended the Support Stafford Hospital group who have helped to provide the energy to attract the increased resource which is greater than anything received elsewhere within England. He stated that this will help to stabilise services at Stafford and ensure they are resilient. Mr Hackett stated that after including the investment provided to the Royal Wolverhampton Trust, the total reaches £300m which will enable the area to develop world class care and provide stability for staff. Mr Hackett stated that from the 1st November 2014, the Mid Staffordshire Foundation Trust (MSFT) name will no longer exist and neither will the name of University Hospital of North Staffordshire (UHNS); instead the new Trust will be called University Hospitals of North Midlands NHS Trust (UHNM). He stated that this Trust will Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION incorporate the activities of UHNS and the majority of MSFT with some services from MSFT transferring to Royal Wolverhampton Trust, in accordance with the Secretary of State’s decision. Mr Hackett outlined the following benefits for Stafford: • Refurbishment of A&E which will double in size and reduce overcrowding. He stated that A&E will be led by consultants who have paediatric and adult training, with modern trained doctors who are able to deal with a range of conditions. • Improved outpatient facilities which will offer new services for outpatients with an increased amount of emergency clinics being offered to the local population • Closed wards will re-open within the next three months and an upgrade of medical wards will be undertaken. There will be double the amount of single rooms and at least £3 m will be spent on upgrading current facilities in order to improve privacy and dignity and space around beds. The operating theatres will be upgraded and more diagnostic imaging will be developed including a new MRI scanner • New services will be delivered in Stafford, particularly for eye surgery, orthopaedics and the creation of a frail elderly unit which are designed to improve access, reduce unnecessary travelling and ensure services are integrated between both hospitals and within the community, providing a better service for patients • Investments in IT will enable more seamless care to be provided over the next one to three years, by integrated IT systems supported with an investment of £12 m Developments at Stoke • 64 more adult beds will be created • A new orthopaedic centre will be created with 56 beds • There will be two new operating theatres • Further capacity will be provided for maternity and critical care, to be delivered no later than end of March 2015 • 300 more parking spaces will be created, as well as more car parking at Stafford • Creation of a new 28 bedded children’s ward Mr Hackett discussed the service developments and stated that in Spring 2015, the transfer of acute inpatient surgery from Stafford to Stoke will take place followed by the move of inpatient paediatrics. He stated that specialist medical services will be reviewed with a view to move some services during 2015 and that the temporary closure of consultant-led maternity will take place in January 2015, with a Midwifery led unit being opened at Stafford before that time. Mr Hackett stated that while he realised that these moves are an emotive subject, the priority for the Board is the safety of patients and sustainability of services going forward. He stated that 9/10 patients will continue to receive care locally at Stafford and improvements will be put into place for other services. Mr Hackett stated that the vast proportion of children will be seen locally in Stafford and babies will still be born in Stafford, as well as there being more, safe, choices for Stafford patients. Mr Hackett discussed the new services at Stafford which will include orthopaedics, dermatology, eye surgery and a frail elderly assessment unit. He stated that the Board is working with local Clinical Commissioning Group (CCG) to develop these services forward. Mr Hackett stated that these changes will provide an opportunity to expand the hospitals and stated that Mr Lefroy has been supportive in getting the resources which has led to negotiated substantial improvement of the TSA investment. He Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION stated that the Board has fought for the people of Stoke and Stafford in order to be able to deliver safer care and facilities and to ensure that patients can be treated in a more local environment. Mr Hackett stated that one of the other opportunities related to staff, as Stafford is losing staff and this needs to stop. He stated that effort is being put into improving services which will provide the opportunity to develop and grow and will in turn lead to staffing stabilising at Stafford. Mr Hackett stated that over 220 nurses have been recruited in the last two months in order to rejuvenate staffing and the proposals have the aim of the newly integrated Trust becoming a place where staff will come to learn, research and work and provide higher standards of care for patients within the next five years. The Board members noted the presentation. 4. Public Questions 107/2014 Mr MacDonald invited questions from the public to the Board members. Mrs Bill stated that she had lived in Stafford for the past 81 years and asked for the hospital not to be named the County Hospital, as there used to be a County Asylum in Stafford. Mr MacDonald stated that the name of the hospital was considered and agreed, following consultation, with staff and local authorities where both agreed County Hospital was an appropriate name. Mr Lefroy discussed the transfer of services and stated that while he understands that there is to be a ‘double lock’ on ensuring the quality of services at transfer, he urged the Board to undertake an independent, external, assessment for the obstetrics and paediatrics moves, ideally by the Royal Colleges to ensure that services provided will be safe. Mr Lefroy also asked about the proposals for a doctor-led overnight service at A&E to be provided jointly between the CCG and the integrated Trust. Mr Lefroy questioned the movement of specialised medical services in 2015 and stated that it thought that the acute medical services would remain at Stafford and he asked Board members to define these services. Mr Courteney-Harris stated that up until a month ago UHNS was concentrating on the transaction to ensure that a smooth transition takes place, with clinical leaders currently working on plans to change services. He stated that the process will be internal arrangement where Mr Courteney-Harris and Mrs Rix will seek assurance that the moves are safe, which will then be reviewed by a sub-committee of the Board. He added that he is also involved in two weekly meetings with the National Trust Development Authority (NTDA) to assure them that the service transfers are safe and in addition an independent Medical Director, Nurse Director with previous experience of transferring services, have been sought to ensure that the services are safe and will meet any Royal College standard, for both sites. Mr Hackett stated that the feasibility of extending the A&E hours has been considered and there is no service or financial reason to do so. He added that the Board however, are committed to working with Dr Houlder and the CCG, to look at developing a more coordinated out of hours GP service, located within the A&E Department. Dr Houlder stated that the CCGs are currently out to procurement regarding this which will offer patients in Stafford a service that they have not previously had. Mr Hackett stated that regarding medical services, these will remain at Stafford through the retention of A&E and acute medicine and ensuring that there are acute medical facilities for the elderly as well as young adults. He stated that specialist Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION medicine will affect a number of services regarding ways in which inpatient care is delivered and will relate to complex respiratory, gastroenterology and cardiac conditions. Mr Hackett stated that the cardiology team at UHNS is 18 strong and specialises in a range of services with one or two staff on call 24 hours a day. They will provide support to local physicians but when patients are really ill, they will be treated in Stoke. Mr Hackett stated that at Stafford there are four cardiologists who cannot provide the same depth in expertise or skills as at UHNS and the staff will therefore integrate with the team at Stoke. Mr Hackett stated that a proportion of gastroenterology patients will look to be moved to Stoke e.g. specialist liver disease and inflammatory bowel conditions which will benefit the people of Stafford and there will also be some patients with complex respiratory conditions who would be treated at Stafford due to the requirement for intensive care doctors. Mr Hackett stated that the larger teams will help to bring tertiary hospital services to the local population, although there will be times when some patients will have to travel so that they receive better, more appropriate, specialised care. Mr Courteney-Harris stated that the Trust is not alone in having these conversations, and it is being done nationally to maintain the specialist rotas in smaller hospitals. He added that where possible services will be kept at Stafford. Mr Ogden asked whether the Board could commit to never discharging patients (from the Stafford area) if they were being treated at Stoke, after the time of public transport. Mrs Rix stated that the Trust has worked hard to look at how transport can be provided for those patients who do not have it, after hours of public transport and the Board is committed to looking at the transport links throughout the day as well as ensuring assistance is provided to patients if they do not have access to transport at night. Mrs Howell stated that one of her biggest concerns is, while she does not disagree with the safety aspects or improving quality of services, the lack of evidence from both CCGs and others in completion of the risk impact assessments before any transfer of services take place. She stated that the public need to be assured that there is sufficient capacity and resources to deal with the transfers and she added that she has heard that the ambulance service cannot cope at the moment, with UHNS ambulances being delayed going into A&E where there is frequently over a 4 hour wait. Mrs Howell stated that she has concerns that the Ambulance Service do not have the resources for the extra investment required for additional ambulances and that there also needs to be more investment in community services to ensure that support packages at home are in place. She stated that the risk impact assessments need to also consider the journey from Stafford to Stoke. Mrs Howell queried the delay in the publication of the KPMG report which will also have implications on the integrated Trust and queried when this would be published and the reasons for its delay. Mr Hackett stated that the TSA published extensively, as part of their consultation, detailed impact assessments. He stated that the outcome of the work led to suggestions and specific recommendations which will be met in full and that the recommendations which apply to the CCG and Ambulance Service, will be put in place before transfer of services take place. Mr Hackett stated that the last thing the Board will do is put patients at risk. Mr Hackett stated that the travel issues were well documented in the TSA document and it was considered that the increased journey time is outweighed by the improvements in services which was confirmed in an independent review. Mr Hackett stated that he understands the emotion, but the journey from Stafford to Stoke is no greater than it is in other areas. Mr Hackett stated that with regard to A&E, neither hospital is currently meeting the 4 hour target and plans are in place to address this. He stated that the hospital is to be rejuvenated by opening up wards which are currently closed due to loss of staff, and more nurses will be put into both hospitals in order to acheive this. Mr Hackett stated that the Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION delays in A&E are not associated with the transfer of services between sites and that the current hospital is in a situation where the quality and safety issues need to be improved. The Board can not ignore this and has a duty of guardianship to listen to concerns and issues but also a higher duty to ensure services are operated safely, with any changes being made for the right reasons. Mr Hackett stated that the distressed health economy review has been led by NHS England and the NTDA and he stated that he understands the report is due to be published in November. Mr Hackett stated that he believed the reason for the delay has been due to the time taken to coordinate the responses from the national bodies to bring the conclusions together from the eleven reviews. Mr Draper queried the point made earlier in the meeting regarding the new NonExecutive Director appointment and while considering the geography of the integrated Trust, he queried why gender was not considered as the Board is male dominated. Mr Draper stated that the Francis Report is of public concern and queried how UHNS and Stafford and Surrounds CCG operate in regard to accountability and transparency, and whether an action plan has been put in place to deal with the Francis recommendations. Mr Draper stated that the suggestion of recruiting Shadow Governors suggests that the integrated Trust is aiming for Foundation Trust status and queried when it is expected that the application will be ready to be submitted. He stated that the Carer Act 2006 laid down the reconfiguration of back office services and while the Secretary of State had signed off the proposals, he considered this not to be legal. Mr MacDonald stated that when recruiting the new Non-Executive Directors, gender was considered and as such three female candidates were interviewed with two females on the interview panel. He stated that he is conscious that there are currently no female Non-Executive Directors and this will continue to be considered in the future. Mr MacDonald stated that the Shadow Council is being put into place as the Board recognises the benefits this provides in the wider conversation with the local population. He stated that there are current Shadow Governors in place at Stoke and it is proposed to go through a process for Governors from the whole of the surrounding area and not just from Stafford. Mr MacDonald stated that his view regarding Foundation Trust status is that if the Trust provides a high quality service which is financially viable then it will become a Foundation Trust, if it does not it will not. Mrs Rix stated that following the Francis report the Trust looked at the recommendations and considered those which were applicable with an update of progress also being received. She stated that one element from the report which has made the biggest difference is nurse staffing and that the Trust meets the NICE guidance and will continue to meet this across the integrated Trust. Mr Powdrill stated that he is a Blood Biker serving Staffordshire and Shropshire and over the last 12 months he has experienced a similar situation in the neighbouring hospitals from Telford and Shrewsbury, where they have undergone reorganisation. He stated that he supports Mr Hackett when talking about quality of services and the recognition that specialist work cannot happen in every hospital. Mr Powdrill queried what specialist services are going to be concentrated in within both hospitals. Mr Courteney-Harris stated that UHNS is a major trauma centre covering North Wales and is a major centre for specialist care not only within Staffordshire, but Cheshire and Shropshire. Mr Courteney-Harris stated that as outlined in the 2025Vision, there is a need to develop tertiary services and amalgamate services with other areas which cannot be delivered at every hospital. Mr Hackett stated that some new facilities will be created around endoscopy and the two hospitals working together is a major service improvement. Mr Hackett stated that he sees Stafford as taking the lead in increased bowel screening and looking to be a centre of excellence for training of nurses and doctors. Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION Dr Hubbard stated that given most paediatric oncology patients make a positive decision to have their shared care at UHNS closer to home, she queried whether the Board can provide assurance that extra provision of paediatric specialities will be in place for those additional patients who will be given the same choice to have their care closer to home. Mr Courteney-Harris stated that in order to provide these opportunities a critical mass of children requiring the services is required and as such many currently go to Alder Hey or Birmingham. Mr Courteney-Harris stated that the Trust is working to provide as many services as possible locally with the specialist paediatricians and paediatric gastroenterologists available. He stated that one of the issues is that money is going out of the local health system to other areas and by expanding our services, it will keep the money within Staffordshire and allow patients the choice to have their care local to them. Mrs Phillips queried whether the extra money being received is to be repaid. Mr Adcock stated that the money is for a combination of things but is not repayable. He stated that the £80 m is a capital investment and the remainder is revenue funding, with some to fund the costs of making changes and some to provide the cost of providing ongoing services. Mr Adcock stated that it is new additional money and is on top of existing allocations. Mrs Stanley questioned the capacity at UHNS and discussed the issues encountered when requesting bed statistics. She suggested that these highlight that UHNS has not got beds available and that as of 3rd September, there were 16 patients waiting for a bed, with the trauma beds full and patients being sent to Manchester and Sheffield and with other patients being sent to Leighton for non-elective surgery. She queried that if staffing levels are high why staff members are saying they are short staffed and that there is a high turnover. Mr Hackett stated that an additional 130 beds are being created with appropriate staffing for that reason. He added that 40 to 60 beds at Stafford have been closed because they could not be staffed and these will be reopened. Mr Hackett stated that the reason these cannot be staffed is because of the uncertainty over the hospital and that people do not want to work at Stafford, with around 10 to 12 members of nursing staff being lost per month. He added that these staff are not being replaced at the same rate and have not been for the past 18 months. Mr Hackett stated that conversations with staff have identified issues such as too many agency staff being in place and too much uncertainty. Mrs Rix added that a recruitment campaign is in place with the intention to spread resource across the two sites and that 106 newly qualified nurses have been recruited from Staffordshire and Keele with overseas nurses being recruited to supplement this. Mrs Rix stated that the Trust is open and transparent in reporting staffing levels, which is published on the website as well as reported to central government. Mrs Rix stated that the Trust has a high level of staff on every shift, every day although there are times when wards are under pressure and the Trust endeavours to mobilise staff from other areas to support these wards. She stated that the Trust identifies patient dependency on a daily basis and is flexible with the resource. Mrs Rix stated that the NICE nursing standard suggests a ratio of 1:8 with the UHNS ratio exceeding this at 1:6 patients. Mr Porter stated that he felt it was a shame that Mrs Maggie Oldham was not at the meeting, and offered thanks to her for her support. He stated that he did not recall any problems in paediatrics and maternity at Stafford and that he took issue with the comments regarding that. Mr Porter added that he would not want to have to travel to Stoke when he could be treated at a local hospital and stated that even six beds in A&E would be preferable so that patients are not sent to UHNS. Mr Porter added that a Paediatric Assessment Unit is required now. Mr Porter stated that he is aware that 250 births take place at Litchfield with 58 mothers being transferred out of the unit and that a risk assessment regarding transfer of mothers in labour from Stafford to Stoke was required, along with the staff who would join them. Mr Courteney-Harris stated Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION that proper teams would be in place for those eventualities and that while these occurrences can be minimised by screening, if they do occur a robust transfer will take place with appropriate staffing. Mr Courteney-Harris stated that teams are already working on ensuring that facilities are in place and Mr Hackett stated it is hoped to introduce a GP service so that a service can be offered 24 hours a day to support parents, by GPs who are competent in dealing with kind of issues. Mrs Porter queried why more money could not be used for paediatrics and maternity given the £300 m being received. She stated that she has been talking to patients regarding the Midwifery Led Service in Lichfield, which is a well-run unit although she believed there to be a high number of ambulance service ‘blue lighters’ out of the unit, with a suggestion of a few coroner reports. She stated that further to Mr Hackett’s quote of the TSA report and impact assessments, that the changes which should happen should be underpinned by care in the community and by the ambulance service. Mrs Porter stated that she has been in discussions with care in the community and the ambulance service who are not ready for the transfers and they have not received the money to take these patients. Mrs Porter stated that the transfer date is coming close and these services are required to be in place beforehand, with appropriate impact risk assessments separate to those of the TSA being required before services are moved. Mr Hackett stated that he agreed with Mrs Porter and stated that no moves are to take place unless it is safe to do so, which it is not yet but it will be. Mr Hackett stated that the Trust is in a better position to discuss the service transition plans now and will engage with groups regarding these, and stated that these will not happen if the right ambulance and community facilities are not in place. Mrs Simpkins stated that she met with Mr Hackett in August and stated that she was informed that the clinical risk assessments would be made available to her which has not occurred. She stated that these need to be made available to the public and that the health impact assessments from the TSA did not take into account the journey and geography of patients. Mrs Simpkins queried progress with the use of two ambulances to transfer patients and queried whether the name change of the integrated trust would result in a lot money in creating new signage, stationery etc. Mrs Simpkins queried that as Mr Hackett is CEO designate, whether it should mean that all positions on the Trust Board should be reassessed and re-interviewed. Mr MacDonald stated that UHNS is acquiring Mid Staffordshire and because UHNS will no longer reflect the new Trust the name is being changed. He stated that it is similar for Royal Wolverhampton who are acquiring Cannock and that it is not about dissolving both Trusts; the Mid Staffordshire Trust is to be dissolved and the UHNS Trust Board will remain. Mr MacDonald stated that in terms of the name, plans will look to phase in the new name in order to reduce the amount spent on rebranding. Mr Hackett stated that it was not possible to share the clinical risk assessments earlier along with the service transition plans. He stated that it had been hoped to share these in September but due to the scale of the financial investments these have had to be discussed at senior levels in Government. He stated that these can now be shared with the public and staff within the integrated Trust. Mr MacDonald requested the last few questions to be taken at once, at which point the Executive Directors would provide a response before concluding the public questions. Mrs Hawkins queried, considering the comments regarding the uncertainty within Stafford Hospital, how UHNS could be more proactive in addressing this after Day 1. She also queried the provision of critical care level 3 services and the gastroenterology and cardiac service and what conditions would continue to be treated at Stafford as well as who would be responsible for running the Stafford site. Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION Mrs Edgeller stated that she was quite pleased about the good news for Stafford and stated that when talking about the inability to recruit staff, more good messages needed to be provided from the top to get the message out that it is a good hospital. She added that there was no mention of the maternity unit in the Francis report and provided an open invitation to Mr Hackett to meet with the Committee of the Support Stafford Hospital Group. Mr Small queried when the new beds would be opened. Mr Jackson stated that if patient safety is the mantra why Stafford was originally downgraded to a limited service and queried what is being put in place to maintain safe standards. He queried whether any members of the Board were local to Stafford and who would be the organisation responsible for scrutinising whether services are safe. Mr Jackson queried the composition of the Board and whether there were any vested interests. Mr Courteney-Harris stated that the Stafford site will provide level 1 and 2 beds and will not provide a level 3 service unless it is required to stabilise a patient before transfer. He stated that further consideration needs to be given to the current medical services in place and this will be done though working with the physicians to understand which services can continue. Mr MacDonald stated that two of the Non-Executive Directors on the Board are from Stafford but added that as it is a Unitary Board, the individual Directors do not represent individual constituencies. He stated that the Care Quality Commission will scrutinise the safety of services and any interests of Board members are declared and available to the public, including the sub-committees they serve. Mr Hackett stated that the closure of A&E was a decision which was made two to three years ago because it could not be staffed and Mr MacDonald stated that the Trust is trying to put in services which are safe and supported by the expertise and experience from staff in across the new Trust. Mr MacDonald stated that he appreciated that not all the answers would satisfy the questioners but that he hoped that the discussion was found to be helpful. He stated that the Board members would take a 10 minute break at which point the Board will reconvene to consider the transfer proposals. 5. Board Discussion 108/2014 Mr MacDonald stated that the Board would be considering a couple of items, the first being the 2025Vision. Mr Hackett stated that the 2025Vision has been formulated following consultation and engagement with different stakeholders and includes the integration of Stafford. Mr Hackett stated that Appendix 1 summarised the comments received and the associated responses of how these are going to be actioned going forward. The 2025Vision sets a clear direction of the Trust and Mr Hackett outlined the objectives for the next three years: • Delivering quality excellence for patients • Delivering our obligations to the taxpayer • Achieving excellence in education and training • Creating an integrated trust with Stafford. Mr Hackett stated that the need to deliver cost and productivity is recognised and the Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION vision sets out the environment which the Trust will be facing and the services which will define the new Trust at a local, regional and national level. He added that it also addresses the issues around how hospitals in the future can increasingly support general practice and deliver more care in local settings with significant investments in research identified. Mr Hackett stated that this also sets out how the organisation will be run in the future and how the Trust needs to change organisational and individual behaviour with a number of strategies setting the right direction of staff working for the Trust and those patients relying on the Trust to provide their care. Mr MacDonald stated that the document had already been discussed by the Trust Board and asked the Board members whether they agree to approve the 2025Vision with authorisation to communicate this more widely. The Trust Board approved the 2025Vision and supported the next key steps for the Chief Executive to lead: • To communicate the final version to staff and stakeholders. • To develop a series of critical success factors (CSFs) linked to the strategic objectives at Trust Board level to establish clear three year CSF which the Trust Board set and use to monitor and manage the delivery of key steps towards the Vision. • To ensure the Trust’s IBP is produced for service, financial and quality development for 2015/16 – 2019/20. 6. Consideration of Transfer Proposals 109/2014 Mr Butters discussed the purpose of the transfer agreement which is a legal document as a result of the discussions with the Trust, NTDA and wider stakeholders which underpins the financial and commercial arrangements of the transaction. He stated that if approved, it will transfer the relevant assets, employees, liabilities and contracts to UHNS (UHNM) to provide the services set out in the TSA clinical model. Mr Butters stated that the other key partner is the other receiving Trust which is Royal Wolverhampton with some of the assets, employees, liabilities and contracts going to them. This is subject to a separate agreement. Mr Butters stated that the agreement supports the 2025Vision of the Trust and will enable the Trust to be better placed to support secondary and tertiary services and will underpin the delivery of service changes. Mr Butters highlighted a couple of points regarding the service plans: 1) Transport arrangements between sites. Agreement has been reached regarding the provision of two ambulances, one based at Stafford and one based at Stoke to enable the transfer of patients between sites. In addition, from 1st October there has been a service in place to transfer staff between the sites. The CCG is leading discussions regarding public transport links between the two sites and it is recognised these are issues of importance. 2) With regards to the public questions of whether the whole health system is ready for the service transfers – the Trust has been working with the Local Transition Board which all other relevant partners in the health economy attend, to make sure that there are coordinated plans in place. Mr Butters stated that the transfer agreement is signed by six parties and requires other services to be in place in a timely manner to underpin any service changes. Mr Butters stated that the employees are another essential element required to underpin any service changes and a culture is to be developed of one Trust, working Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION across two sites of equal importance, with a programme of staff engagement and development being put in place, with over 120 integration champions have been identified to help disseminate information between staff at both sites. Mr Butters stated that one of the concerns of the Board has been that in undertaking the integration, it should not worsen the Trusts position in terms of quality or finance and that the population of Stoke and Stafford should receive the same standard of care. Mr Butters stated that contract income has been agreed via a heads of terms with the CCGs that it will lend to a contract variation with Stafford and Surrounds, Cannock CCGs and associated CCGs to provide the activity for their population based on the splits of activity within the TSA model and will be paid in accordance with the national tariff and national contract terms and conditions. In addition, additional funding for transition, transaction and transformation of services has been negotiated for a three year period to underpin the service change process, in order to bring together the two sites. Mr Butters discussed the capital and stated that £80 m capital has been agreed from the NTDA which will be added to by £20 m from internally generated capital resources associated with the Stafford site. Mr Butters stated that over £70 m of this will be used at the Stafford site. Mr Butters stated that as UHNS will become responsible for providing services from 1st November, it will take liabilities from Mid Staffordshire with regard to contracts with employees and suppliers. Since UHNS is to take the majority of the employees the Trust has agreed to manage the legacy management office and this will not incur any financial detriment to UHNS. Mr Butters discussed the risks around the transaction and identified three key risks: 1) reputational damage and enhancing the reputation of Stafford. He stated that this is being managed through the detailed integration and service plans going forward with a system of assurance to enhance services. 2) UHNS is unable to attract staff in sufficient numbers or quickly enough. UHNS have already initiated a major recruitment campaign to ensure this does not happen and has already been actively supporting acute surgery, pathology, radiology and nurse staffing at Stafford in the last six months. 3) The facilities and services required outside the Trust need to be sufficiently coordinated and in place in time. This is being coordinated by the Trust Board. Service level agreements are in place between UHNS and Royal Wolverhampton to ensure the changes work smoothly and to ensure neither Trust suffers any detriment. Mr Butters stated that the paper sets out the key principles and highlighted that the lawyers are still looking at the final document. He added that other Boards and bodies are to consider their agreements this week which will then be passed through to Monitor and the Secretary of State for approval of the transfer order to transfer the assets and liabilities to UHNS and RWT. An MSFT ‘shell’ will retain criminal liabilities. Mr MacDonald asked Mr Simons, as chair of the Integrating Health Services in Staffordshire sub-committee, to provide the Board with his conclusions as to the assurances regarding the transfer. Mr Simons stated that the process has involved due diligence, reviewed financial planning, used a number of external advisors such as KPMG and EC Harris, as well as legal advice and is now at the service transition stage. He stated that the service transitions are subject to the ‘double-lock’ process and external review as well as confirm and challenge meetings with the other NonExecutive Directors to ensure they feel assured that the necessary processes have Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION been considered and that the services will be safe. Mr Simons stated that assurance is also to be provided to the NTDA which will ensure everyone knows what has been agreed to and that the process of assurance and reassurance will continue. Mr Burgin introduced himself to the public and queried how services at Stafford will be improved to ensure both sites have the same standards and what was in place to any address ‘hot spots’ with regards to resources at Stafford in the short term. Mr Simpson stated that the capital spend is very significant and that the due diligence has indicated a significant investment in building and backlog maintenance with £51 m being spent on the estate, and £10 m on medical equipment and updating facilities. He added that £12 m is also to be spent on IT across both Trusts which provides a substantial investment in improving the facilities. Mrs Rix stated that with regards to nursing, UHNS has already been supporting areas which have been fragile at Stafford, with the UHNS Deputy Chief Nurse supporting the team over the last six months at Stafford. She stated that the risk areas are known and staff will continue to be supported for the foreseeable future. Ms Vaughan added that the integration champions will help to support the process of integration to ensure that there is a level of resilience in place with a whole programme of development activity being undertaken across both sites. Ms Vaughan stated that although there will be two different cultures, work has already started to be undertaken to support staff on both sites in terms of leadership development. Mr Burgin stated that a process needs to be in place to measure and monitor success and Ms Vaughan stated that another cultural survey will be taken forward after integration to establish how effective this has been and address any areas for improvement. Mr Hackett stated that some of the best doctors and nurses will be working on the Stafford site from Day 1 and highlighted that Dr Hubbard, the Divisional Chair for Women and Children’s and Clinical Support Services is to spend time at the Stafford site in order to help to integrate leadership from Day 1. Mr Hackett stated that in addition Clinical Directors will be in place at Stafford who Mr Chris Bown, Managing Director, will work with, along with weekly visits by Mrs Helen Lingham, Chief Operating Officer to ensure the process of integration between operational teams takes place. Mr Hackett stated that senior staff will work across both sites supporting the commitment of two hospitals of equal importance and the organisational development resource shows this commitment. Mr Hackett added that the next Board meeting will share the results from the cultural survey which showed some positive things on both sites and some things which need to be worked on, in order to improve culture and attitudes. Mr Hackett added that the IT and estates teams have already started to integrate, as well as finance. Mr Simons state that there are tremendous opportunities in both hospitals, but queried how many staff are happy working at Stafford and wanting to stay there, rather than move to the Stoke site. Ms Vaughan stated that this has been discussed with staff members and for some cases there will be an opportunity to work in different areas and undertake different roles. Mr Young stated that given the challenging proposition to integrate both Trusts, whether any external bodies will be providing external assurance of progress and ensuring the milestones are being achieved on time. Mr Courteney-Harris stated that a Clinical Oversight Group is run by the NTDA with the aim of doing that to ensure satisfactory progress is being made, with discussions taking place every couple of weeks. Mr Courteney-Harris added that he is also discussing the timetable for the review of service transition plans, with the external Medical Director and Nurse Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION Director which is hoped to be completed by the end of December 2014. Mr Smith queried how the Board could be assured that it can obtain the money for capital developments given the pressures on the local health system and whether there are adequate resources within the management team to take the plans forward. Mr Butters stated that this has been discussed with the NTDA and detailed plans of the funding required have been discussed since July 2014. He stated that this includes a profile of when funds will be required to support the capital developments. He added that discussions are also to take place regarding the delegated limits of the Trust Board and the NTDA so that future developments can be agreed quickly in order to meet the timetable. Mr Adcock stated that a revised capital resource limit is required and the discussions regarding delegated limits will also continue. Mr Simpson stated that the capital programmes followed a P21 procurement exercise where Kier were successful and estates resource has already been secured for the Stafford site. Mr Marlor queried what is in place with regards to funding after the 29 month period. Mr Hackett stated that it would revert back to the normal NHS five year planning cycle working with the local CCGs. He stated that the money will provide a major impetus to make significant transformation changes and over the next 29 months both sites will look forward with more confidence as to how they can contribute to the health economy and make the hospital sustainable. Mr Hackett added that UHNS has also received a letter of support from the NTDA to keep the Trust able to maintain its statutory duties. Mr Collins queried the issues about quality of care and what role there is for patients in terms of monitoring the quality of care, particularly in the early part of the transition. Mrs Rix stated that this is important and UHNS has engaged HealthWatch to help consider this. They have set up a reference group to help to engage with patients. Mrs Rix added that the Patient Care Improvement Programme which was approved by the Board earlier in the year, looks to clinicians to help take patient experience forward, which has led to the creation of a young peoples panel as well as liaising with the voluntary sector organisations. Mr Hackett stated that for all service changes, the public need to be consulted. Mr Burgin referred to the earlier comment regarding the ‘toxicity’ of Stafford and stated that the Board needs to be behind making the hospital a success by motivating staff and building pride within the organisation. Mr MacDonald asked the Board to consider the transfer proposals. Mr Butters emphasised that by doing so the Board would be approving a legally binding contract for taking on the relevant assets, employees, services and liabilities from MSFT. The Trust Board approved the Transfer Agreement. Mr MacDonald apologised for the lack of loop system within the Lecture Theatre and said that this would be a high priority to have fixed. DATE AND TIME OF NEXT MEETING Friday 7th November 2014, 1.30 pm RAB Thomas Lecture Theatre, Postgraduate Medical Centre, County Hospital Minutes of Extraordinary Public Trust Board 14 October 2014 DRAFT VERSION PUBLIC TRUST BOARD – 3 OCTOBER 2014 POST MEETING ACTION LOG OUTSTANDING ACTIONS No Agenda Item Action 1. Quarter 4 Patient Safety Report 2. Staff Survey Results 3. ICT Strategy 4. National Inpatient Survey 2013 To include the severity grading of medication incidents and falls in future Patient Safety reports. The results of hand washing material audits will be communicated to improve staff perception on the availability of these facilities To undertake the objective clinically driven evaluation of the options for the Trust relating to future EPR system and that the outputs of evaluation will be brought back to the Board for approval. For the Quality Assurance Committee to monitor the top 2 or 3 areas on which to improve following the 2013 inpatient survey results. 5. National Inpatient Survey 2013 To include within the quarterly patient experience reports, the achievement of the progress on the actions from the survey and assess the impact on patient experience scores. 6. Quality Report: Patient Experience Q4 To include progress with meeting the goal to be within the top 10/20% for patient experience in future reports. Public Trust Board Post Meeting Action Log rd 3 October 2014 Lead Due Date ER 5/11/14 RV 31/08/14 MB 05/12/14 Action not due. ER 03/10/14 14/11/14 (QAC) Initial discussion taken place. Further consideration scheduled for the Quality Assurance Committee on 14th November. ER 03/10/14 ER 03/10/14 Completed Date RAG Status Position Statement Action not due: Patient Safety report due to be discussed at December’s meeting. 31/10/14 This has been communicated to staff and more awareness raised in non-clinical areas. Q1 Patient Experience Report states that ‘we will measure our improvement through the introduction of an in year survey reflecting some of the themes within the Annual Inpatient Survey. This will commence in September 2014.’ The Q2 Report should reflect this monitoring. Patient experience report included on November’s agenda. However the Associate Chief Nurse has been asked to clarify where this is covered within Q1 Report or to ensure that it is made explicit within Q2 Report. Information awaited from Head of Quality, Safety and Compliance and requested again 21/10/14. The assurance statements for CIPs have been reviewed and confirm and challenges have been held with the health economy. This has also been received at the Quality Assurance Committee. 7. Quality Account 13/14 To share the information regarding readmissions with the Trust Board. RCH 24/07/14 8. Quality Account 13/14 To take the assurance statements to the Quality Assurance Committee which divisional teams are required to authorise. ER/ RCH 11/07/14 31/10/14 9. 5 Year People Strategy AA/RV 30/09/14 31/10/14 10. Capacity Plan Progress HL 03/10/14 7/11/14 Stabilisation plan being produced which addresses capacity demands and included on November’s Board meeting. 11. Month 1 Performance Report To consider sharing learning from RCAs with patients involved. ER 31/07/14 3/10/14 RCAs are shared with patients when it is appropriate to do so. 12. Quality Report: Outcomes/Effe ctiveness To set a similar staged achievement target for the right place, first time CQUIN for inclusion within the next report. ER 9/1/15 To be included within the next Compliance and Effectiveness report which will be presented to the Trust Board in January. 13. Publication of Nursing and Midwifery Staffing Levels – May 2014 To further discuss how the staffing levels evidence could be used for research purposes and bring such proposals back to the Board. ER/AG 30/09/14 This has been delayed due to unforeseen absence of the Chief Nurse. However, a meeting date for re-visit is being arranged. 14. Month 2 Performance Report HL 30/09/14 This remains ongoing; the Chief Operating Officer is in the process of undertaking a review of what is required. 15. Questions from the Public JS 5/12/14 Work on this assessment is nearing completion, initial views are that the Trust is To consider producing a summary of the vision and strategy for both staff and members of the public highlighting any important high level messages. To provide quarterly updates on the capacity plan progress outlining what productivity savings have been delivered as well as the ongoing work with partners and new capacity. To take forward the suggestion of introducing a single, standardised report which is to be considered at the Urgent Care Board. To provide an assessment of the new car parking guidance at a future Board Public Trust Board Post Meeting Action Log rd 3 October 2014 A summary publication has been produced and is awaiting publication. meeting, stating what the Trust currently meets and addressing those areas which it does not. 16. Questions from the Public To work with Mrs Mawby regarding revisit the FEAU. already compliant with many areas of the new guidelines, a formal update will be provided at the December board This has been delayed due to unforeseen absence of the Chief Nurse. However, a meeting date for re-visit is being arranged via the Associate Chief Nurse. ER 31/10/14 Action Lead Due Date The Quality Assurance Committee to review the number of patients dying as a result from sepsis. RCH/ LR 21/11/14 Head of Quality, Safety and Compliance asked to include this on the next QAC agenda (14/11/14). To distribute the final finance report including the forecast review to Board members. CA 17/10/14 Verbal update to be provided at the meeting. In depth review into Q2 to be completed and reported via FEC to the Board. CA 31/10/14 Verbal update to be provided at the meeting. ACTIONS AGREED 3 OCTOBER 2014 No 17. 18. 19. Agenda Item Quarter 1 Outcomes Report Month 5 Finance and Contracting Report Month 5 Finance and Contracting Report Public Trust Board Post Meeting Action Log rd 3 October 2014 Completed Date RAG Status Position Statement EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: Public Trust Board Chief Executive’s Report Mark Hackett, Chief Executive Mark Hackett, Chief Executive Date: 6 7th November 2014 Not applicable Purpose To brief the Board on progress and achievement of the key targets in 2013/14 around operational performance, financial management, strategic management and quality and safety developments. Link to Strategic Priorities Delivering quality excellence for patients. Delivering our obligations to the taxpayer. Achieving excellence in education and training. Creating an integrated trust with Stafford. Executive Summary Decision Approval Information NHS Trust Development Authority (NTDA) The NHS Trust Development Authority (TDA) collate our performance against the three key domains of Quality, Finance and Sustainability which comprise our overall Trust rating which are published by the TDA. A poor rating and failure of key standards will result in increased scrutiny and intervention from the TDA. We have assessed our delivery and performance against the standards within the Quality Domain, and our predicted rating in September 2014 (Q2) is a score of 5, which is the best rating possible. However, in September the Trust continued to fail the A&E 4 hour wait and the Cancer 62 Day standard, with the Trust under increasing scrutiny from our regulator and commissioners to improve and deliver these standards. Continued failure of these targets is likely to negatively impact and reduce on our Quality Domain score when the TDA undertake their moderation process. These failures have prevented us from delivering the top score of 6. Contracts Awarded 1. Award of contract for Cardiac Catheter Lab Consumables for 2 years plus a 12-month optional extension, at a total cost of £4,400,882 including vat. Annual value £2,200,441 including vat, provided by x12 Suppliers. Approved by the Chair on 22nd October 2014. 2. Award of contract Interventional Radiology Consumables, for 2 years plus a 12-month optional extension at total cost of £2,560,398 including vat. Annual value £1,280,199 including vat, provided by x7 suppliers. Approved by Chair on the 10th October 2014. 3. Extension of contract for Year 3 of the Siemens Managed Service, at a total cost of £1,680,000 including vat. Supplied by Siemens. Approved by the Chair on 24th October 2014. 4. Extension of contract for Respiratory Consumables & Equipment for 1 year period, at a total cost of Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 £1,200,000 including vat. Supplied by Philips Respironics, Electromedical. Approved by the Chair on 7th October 2014. Resmed, B&D and Operational Performance Further details on our latest performance can be found within our Month 6 Performance Report. However, as headlines I am pleased to report that the Trust is continuing to deliver a number of its key operational and contractual standards, including: • • • • • • The 18 Week access targets for all pathways and specialties The Trust had no patients waiting over 52 weeks for treatment. Diagnostics tests >6 weeks – now achieved for the second consecutive month Achievement of seven out of eight national cancer standards with only 62 day treatment not secured The Trust delivered three out of the four cancelled operations standards with the fourth being above target due to more patients being cancelled in the month as the Trust continues to experience surges in trauma demand The Trust is evidencing strong delivery of quality standards including the friends and family test for inpatients, mortality, C-Difficile and MRSA. There were some areas that fell below our expectations and the target was underachieved. The Trust continues to experience a growth in demand significantly in excess of planned activity levels resulting in capacity pressures which is a key risk to the delivery of the A&E 4 Hour Wait target. In September 2014, 2,257 patients waited longer than four hours resulting in a performance of 85.1%, a further deterioration on the previous month. However, the Emergency Department is continuing to evidence delivery of high quality emergency services, excellent patient care and experience. In August 2014 82% of our patients stated they would be either "Extremely Likely" or “Likely” to recommend the service to Friends or Family in addition to complaints and incidents remaining low. The Trust has launched, in partnership with Staffordshire Doctors Urgent Care, an Urgent Care Centre (UCC) within the UHNS Emergency Department. Staff from this service will provide a front of house clinical streaming service, designed to replace the triage for adults in the first instance, and a GP led minor illness service, which will operate both in and out of hours. The aim of the service is to provide alternative and more appropriate services for a percentage of patients that attend the Emergency Centre, as well as releasing the emergency nursing/medical time to deal with the more complex patients. The opening hours of this new service are: • • Streaming Nurses - 8am – 10pm Monday to Friday/9am to 10pm weekends and bank holidays Urgent Care Centre – 9am-11pm Monday to Friday/10am to 11pm weekends and bank holidays UHNS@Home The UHNS@Home service is performing well. There has been a continued improvement against target referrals and BNS, for the last two weeks there has been an average of 35 on service. Furthermore: • • • • • Additional staff recruitment will enable us to roll out discharge to assess scheme this month and deliver increased capacity On Thursday 9 October designated clinical leads met to discuss how we can further increase use of the service The Service will roll out to Stafford in January 2015 and will deliver 4/5 patients in service, increasing to ten by June 2015. With immediate effect current UHNS@Home team will extend borders to take Stafford out of area patients and map capacity demands against resource Immediately, patients from the Mid Staffordshire area will be placed on a UHNM service I have asked that the OPAT team is incorporated into the UHNS@Home service and its service extended to Stafford Hospital Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 Health Economy Working I will be discussing with the CCG leadership and our clinicians in medicine ideas to either vertically integrate GP/community services with the acute sector or how we can provide clinicians to deliver more primary care delivery. The reason for this is that we are experiencing severe difficulties in recruitment into primary care doctors in Stoke-on-Trent. We need to deliver new innovative workforce models which counteract this to ensure we get better early intervention to patients to avoid hospital admission or re-admission. I will keep you appraised of this in subsequent reports since I am concerned this is one of the root causes and increased demand. Capacity To improve capacity on the Royal Stoke site I have approved the following capital schemes to help in 2014/15: • • • • The £15.6m development of the 54 bed ward development at Lyme Building, which will house two new orthopaedic theatres and wards. A £350k redevelopment of the discharge lounge in Trent Building to improve the capacity for stretchers and their patients. A £1m investment in the Poswillo Suite to create a new local anaesthetic day case consultant unit to free up space in Lyme Theatres and Day Case Unit. A £1m investment in the Trent Building to convert the current gastroenterology offices into an ambulatory emergency centre and to relocate the gastro offices in to the therapy are on the ground floor of the Trent Building. The County Hospital site will see the full capacity opened in November 2014: • • • A new medical ward. The relocation of day surgery cases from UHNS to Stafford Hospital and 24-30 day beds We plan to open in June 2015 the vacated obstetric ward as a medical /rehabilitation facility of 20-24 beds These changes will enable us to reduce bed occupancy at Royal Stoke and create theatre capacity across the Trust. Theatres Over the last three to four months our colleagues in theatres have been working with staff to improve staff morale, recruitment and theatre productivity under Stephen Merron’s leadership. Key achievements in September 2014 have been: • • • • • • • Internal Professional Standards now in place to aid staff satisfaction Senior Clinical Theatre Manager and Theatre Matron - both posts shortlisted and interviews taken place Following a review of stock and supplies there is now a standardised approach to stock ordering and storage Daily sharing and monitoring of recovery delays across all ward areas to encourage ownership and actions as appropriate Revised divisional management capacity structure, including introduction of a new clinical flow coordinator role Launch of Theatres Communication Engagement Strategy Theatres environment issues are all now addressed with the exception of the bespoke light panels. The company who provide these (Sky Factory,) have not yet been able to confirm that they can install these as previously planned in the ceilings in theatres and a further site visit in scheduled for mid-September Further actions for the coming two months include: • Launch of theatres media communication strategy Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 • • • • On-going work to achieve HR performance metrics, with a particular focus on staff appraisal and statutory and mandatory training Introduction of Theatre Employee of the Month Theatres succession planning and development strategy to be developed Organisational Development and HR stakeholder meeting to be organised, with a view to developing a strategy for the future In addition, all theatre vacancies are now recruited to with staff being in post at the end of September 2014. Additional recruitment for new business case approved theatre expansion is on-going and international recruitment has secured an additional five WTE qualified staff, who started this month. Products and Services for Patients in Staffordshire Staff have been invited to participate in a major new innovation initiative designed to invent, develop and implement new products and services for patients in Staffordshire and more widely. The process will involve a cross-section of participants from the health sector and academia in Staffordshire, plus invited external experts, entrepreneurs and investors. The process will culminate in a “Dragon’s Den” style event at which the business proposals we develop will bid for funding and resources from UHNS and other funders. We will be providing more information throughout October and November in the preparation for the first event. Please contact Tammy Holmes ([email protected]) for further information and to register. Equality and Diversity Plans The Trust Executive Committee reviewed progress with our equality and diversity plans. Our five year People’s Strategy approved in 2014 supports our equality and diversity agenda stating ‘we will continue to promote equality and diversity within the workforce and the value it brings’. This is supported by a wide range of staff engagement and involvement initiatives co-ordinated by the Trust Equality and Diversity Employment Group. Evidence so far suggests: • • • • • From our NHS staff survey results, UHNS is better than average for acute trusts for the number of staff receiving equality and diversity training The number of employee support advisors have increased to support staff who may feel they have been treated inappropriately at work A support group has been established for all staff with carer responsibilities outside work The Whistleblowing Policy has been renewed in line with Speak Up For a Healthy NHS guidance and communicated to staff New guidance for managers on dealing with dignity at work has been developed I really support this agenda for change because we must develop a more diverse workforce where everyone can maximise their opportunities for achievement, development and being treated fairly. The Trust Board received the annual revalidation / appraisal report which shows UHNS is achieving well on this agenda with 89% of doctors working in UHNS completing an appraisal. Acknowledging their will always be legitimate reasons why someone cannot achieve an appraisal – for example, long term sickness – we must ensure everyone completes an appraisal. I take a simple view – it is staff members’ job to ensure they are appraised as a doctor and I expect it to occur. If it is not completed then it is a straightforward contract issue (where there is no legitimate reason) and they will be dealt with by the Trust’s disciplinary procedure where appropriate. In the coming year, we will be looking at how we can improve the quality of appraisals since these are far too variable. Key Developments and Achievements • The Trust was awarded by Staffordshire County Council a silver award for its efforts to be an outstanding employer in Staffordshire. We were up against all public and private sector bodies in the country and this is no mean feat. It is a reflection of the partnership working we have with our staff and their staff representatives on a People’s Strategy which is committed to an open, honest, values-based culture which supports transparency, communication, engagement, support, training and development and top class performance delivery. Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 • • • • Mr Justin Lim has been appointed as Clinical Director for Orthopaedics. We also announced this month that four new divisional clinical directors which means our divisional boards new will be led by these excellent clinical leaders. Deonne Lee, Nuclear Medicine Lead, has been named Employee of the Month for October. The Department has recently been through a number of major projects that Deonne has been pivotal in delivering. The directorate recently completed its successful ISAS accreditation, which Deonne helped to achieve. The CT Imaging Department Assistants have been named Team of the Month for October. The diligence and dedication demonstrated by the assistants within CT scan is outstanding. Without their contribution, the immense work load placed on CT would not be achievable in such a safe and professional manner. o The Trust has been nominated for the Health Education West Midlands Apprenticeship Recognition Awards 2014 Employer of the Year. In addition, the four apprentices working at the Academy have also been nominated, they are Kylie Dentith – Non Clinical Level 3; Claire Fowler – Non Clinical Level 2; James Harvey – Non Clinical Level 3 and Louisa Kahn – Non Clinical Level 2 Congratulations to Elizabeth Williamson and the Pathology Clinical Trials team who have been named as the Research & Development employees of the month. Flu Vaccinations The Flu Vaccination has been open to all staff from Wednesday 1 October. We did very well last year and I hope even more of our staff will take the time to attend one of the sessions, which run until the end of the year. Influenza is dangerous, highly contagious and largely preventable. Individuals could carry and pass on the virus to others without having any symptoms, so even though they consider themselves healthy, they might be risking the lives of others. Quality and Safety performance We have made some good progress with Leighton Hospital on paediatric bronchoscopes and sleep studies. Although the numbers are small, it is still a good way of building clinical links. More than 1,000 alcohol dependant patients were kept out of our A&E through a support project. Alcoholics en route to UHNS have benefited from a project allowing them to 'dry-out' for the night in a small unit in the neighbouring Harplands mental health centre. Care Quality Commission In October 2013, the Trust was rated a Band 5 (higher level of achievement) in the CQC intelligent board monitoring. By July 2014, we had dropped to Band 3 (lower achievement) mainly due to a number of elevated clinical issues. John Oxtoby has led work to improve on these elevated clinical risks which relate to, for example, re-admission after elective procedures. The work undertaken by John’s team and the clinical directors I am pleased to report has reduced these risks with the CQC and we are anticipating a return back to Band 5 next time they report. This is because our clinical teams have responded to these risks with positive, practical changes to patient management, again demonstrating our organisation commitment to continuous improvement in patient quality. Mortality Reduction The Trust’s Mortality Reduction Action Plan is continuing to work with our HSMR continuing to reduce. Thanks to John Oxtoby and Liz Rix’s leadership, we have been rolling out a number of patient care bundles in COPD, heart failure, sepsis and community-acquired pneumonia. The results, for example, in sepsis have been remarkable with changes made reducing mortality dramatically by more than 300% in one year. Surgical Assessment Pathways Our Surgical Division have been working on changes to our surgical assessment pathways. A paper has been presented to our Trust Executive Committee to support a complete redesign of the service linked to a major revenue investment to ensure we are compliant with national standards in this area. Many UK Trusts are not complying with these standards and the changes and investment will result in us being one of the leading UK hospitals in this area. Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 Mid Staffordshire FT Integration Last week we signalled a new direction and major investment for Staffordshire’s hospital services as we enter the final approval processes for the creation of a single new NHS Trust. The Board met to agree our integration with Mid Staffordshire NHS Foundation Trust to become the new University Hospitals of North Midlands NHS Trust (UHNM) in November, with the hospitals renaming to become the County Hospital (Stafford) and the Royal Stoke University Hospital (Stoke-on-Trent). The new Trust comes with a £250m boost. I believe this is a moment of major, positive change for the people of Staffordshire and the many committed NHS staff in our hospitals. I particularly want to welcome on board the Stafford Hospital teams who have shown such resilience and dedication during what has been a prolonged and difficult period of uncertainty in the recent history of Mid Staffordshire NHS Foundation Trust. Together, we will see: At Stafford… • • • • • • • • The refurbishment of A&E to double the space and reduce overcrowding. Expanded outpatient facilities especially for emergency access clinics Opening and refurbishing more wards and operating theatres Double the number of single rooms with ensuite facilities A new MRI scanner A refurbished midwife-led maternity unit with a modern birthing pool The development of new services such as eye surgery A new frail elderly assessment service (Stafford). At Stoke… • • • • • • • The re-commissioning of several wards to create an additional 64 beds 12 additional beds in the new critical care unit The creation of a new Orthopaedic Centre with 56 new beds New operating theatres in a new state-of-the art unit The opening of 12 new maternity beds and the expansion of the neonatal unit The completion of new car parks with over 300 additional spaces The opening of a new 28-bed children’s ward We are planning a series of welcome events throughout November and a welcome letter, together with a welcome leaflet, is also being posted this week to MSFT staff who are assigned to transfer under TUPE to the new UHNM. England’s Chief Inspector of Hospitals, Professor Sir Mike Richards, published his report on a focussed inspection at Mid Staffordshire NHS Foundation Trust. The Care Quality Commission carried out the inspection, between 30 June and 2 July, at the request of Monitor, the Trust Development Authority (TDA) and the Trust Special Administrator (TSA). The inspection looked specifically at whether the Trust’s clinical services, at both Stafford and Cannock Chase Hospitals, were safe and sustainable. It concluded that while services were safe, staffing levels were only just adequate in some areas at that time, particularly on medical wards. During the inspection some examples of high quality care were found, but staff, who were seen to be caring and committed to their roles, were fatigued due to the relentless external scrutiny on the trust and uncertainty about the future. The Trust had difficulties recruiting and retaining medical and nursing staff because of continuing uncertainties about its future and its previous poor reputation. There was a significant reliance on using temporary nursing and medical staff, all of which was seen to have a destabilising influence across the organisation. Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 From 1 November 2014 management arrangements will be established at Stafford Hospital to take the hospital, as part of the new trust, through a transition with the aim of establishing a single integrated management structure for the new organisation by 1 April 2015. Management integration will be influenced by the timings of the clinical service reconfigurations and the state of readiness of the UHNS management teams. The leadership at Stafford Hospital will be provided by a Managing Director (Chris Bown) and a transitional executive team. Below are key responsibilities of the Stafford Executive Management Team: • • • • • Managing Director – Provides the overall leadership of Stafford Hospital’s performance and to stabilise the post- merger environment, ensuring a safe and effective service during the transition to a fully integrated management structure on 1 April 2015. Medical Director – Provides the overall medical leadership, supported by the Clinical Directors, to the hospital ensuring high standards of clinical practice and safe standards of care. In addition the Medical Director will be fully involved in supporting the clinical service reconfigurations and developing the new patient pathways with clinical colleagues at Stafford Hospital and UHNS. Director of Nursing – Provides professional leadership to the nursing and allied health professions working at Stafford Hospital and work closely with the Director of Operations on the day to day delivery of effective patient services. In particular the Director of Nursing will proactively manage the delivery of safe nursing establishments needed to deliver high standards of care and be the primary link to patient involvement activities. The UHNS Chief Nurse will provide professional leadership to the Director of Nursing. Director of Operations – Provides the overall leadership and management of operational delivery across Stafford Hospital including access targets e.g. RTT, A&E, patient flow and budget management. The Director of Operations will be supported by two Associate Directors of Operations (Medicine, Specialised and Surgery) who will provide operational management on a day to day basis. HR and Finance Managers – Provides the professional Human Resource and Finance advice to the Stafford Executive Management Team and management of on-site HR/Financial services. 2025Vision • UHNS is currently participating in a global research study into the formation of a Clostridium Difficile vaccine. Patients need to have had two inpatient hospitalisations in the last 12 months or due an inpatient hospitalisation of at least 72 hours in the next 60 days. For more details contact Sarah Dawson Research Nurse on 01782 675396. • Consultant Microbiologist Dr Jeorge Orendi was interviewed on BBC Radio Stoke on Thursday about the Ebola outbreak in West Africa. Dr Orendi talked about danger of the virus, its symptoms and how it is treated. He also discussed how hospitals like UHNS are equipped in preparation for any outbreak of infectious diseases. It is important, as a regional centre, that we fulfil our role and lead by example to others in the NHS. • Professor Hawkins recently attended an international conference in Boston. Commercial pharmaceutical company Quintiles were in attendance and gave Professor Hawkins very positive feedback about the UHNS Neurology research team. • The Waste Project Group has made some good progress with the Neurology Clinic for close monitoring of medication use resulting in a saving of £32,544 on high cost medicine Natalizumab. These funds are refunded back to the directorate. Congratulations to the team. • I want to thank Dr Ingrid Britton, Dr Nick Watson and thee team for the ISAS accreditation. It’s a fabulous achievement. The Royal College of Radiologists have congratulated the department and we should thank all those involved for their hard work and commitment in helping Imaging to achieve this awar • Professor Murray Brunt, holder of Keele’s Chair of Clinical Oncology has been appointed the Clinical Research lead (CRL) for cancer for the National Institute for Health Research (NIHR) Clinical Research Network for the West Midlands. The West Midlands CRN is the largest of the 15 networks in England since their re-organisation in April this year. The importance of cancer research is recognised as a separate division in all 15 networks. • I am delighted with the improved productivity in Pre-Ams and the £162k contribution to the CIP for the division/directorate. To support future business cases, the team will need to develop a series of options Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 • • • • • • • • • • • • • • • we could explore to address developing Pre-Ams clinics for all MSFT people in Stafford/extending operating times or days it operates. Well done to Nicola Woodward and the Directorate of Anaesthesia, Critical Care, Theatres, PreAMS & Pain Management University Hospital’s award winning Orthodontics Department have collected two more honours. The team, led by Clinical Lead in Orthodontics Mr John Scholey, were recognised twice at the British Orthodontic conference. The team won the awards for best Audit and best Scientific Paper of the Year. The team have won numerous awards over the last six years, including Mr Scholey collecting the prestigious Maurice Berman Award for Clinical Excellence last year Jane Kirby, Health Promotion Specialist for the North Staffordshire Breast Screening Service, was interviewed promoting the benefits of mobile breast screening units across North Staffordshire. This is a service that gets a great deal of praise and rightly so. Linda Hough from Macmillan was interviewed on Friday 10 October about Cancer support available at UHNS. The Pharmacy team attended the HSJ awards. Although they didn’t scoop the ultimate prize, it is always important to remember that being shortlisted is a very big achievement. My thanks to Sue Thomson and the team for their efforts. The Trust has completed our first Robotic prostatectomy. Lyndon Gommersall and all those involved are to be congratulated for making this happen at UHNS. It is a real testament to the team that they have made this very big project happen. As Lyndon says, we now have a long journey of learning, improving and perfecting many aspects of this service. Ruth Salt, Critical Care Research Nurse, was awarded a prize at the recent CALORIES investigator meeting for the best monitoring visit, the trial team stated that it was ‘a pleasure to monitor at this site and wished every site were as accommodating, helpful and efficient’. The Critical Care research team are now within the top ten recruiting centres internationally with their work in the EUROTHERM3235 trial (European study of therapeutic hypothermia for ICP reduction after traumatic brain injury). Last month we rightly highlighted the fabulous Fractured Neck of Femur service. There are a number of people I want to give special mentions to. They include Phil Roberts and his team, who wrote the revised theatre SOP suggesting that patients with such fractures should be preferentially placed on a list provided that the surgical expertise was available. Dr M Browne, Ward 226 and the ANPs who supports the busiest NOF service in the UK virtually single handed. The Coroner will be visiting the Trust on 29 October, along with some GPs in Stone, to see the improvements we are making, especially in ICT. I want to thank Malik Kodampur, Consultant Gynaecology Oncologist for the creation of a new one-stop post-menopausal bleeding clinic which will improve dramatically our care for patients I have approved a sixth consultant orthodontist post with an advanced dental nurse post to release consultant time to enable more new patients to be treated A second consultant thoracic post has been approved to strengthen our thoracic service and more towards compliance with national specialised services standards due in 2018. This will enable us to provide a much more effective cancer surgical service over 52 weeks; expand capacity and support our partner hospitals better in MDTs. We will be discussing with both Leighton and Burton greater partnerships in this service The Trust Executive Committee supported a case for the replacement of catheter laboratory equipment at UHNS which will increase cath lab sessions from 35 to 41 per week including Sunday working. This will result in the decommissioning of the current Mid Staffordshire laboratory since there will be an enhanced single service at UHNS I have approved a sixth new plastic surgeon post which will enable the service to expand to meet local patient and GP demands in Nantwich, Telford, Macclesfield and UHNS. The post will develop more than £100,000 profit for the Trust. The work with Burton is progressing positively and we anticipate a further appointment following the securing of this arrangement. I have reviewed a five-year strategic direction with the service and this will be going to TEC shortly. Meanwhile, I have asked the service to develop immediately further day case operating at Stafford Hospital I wish to thanks the Child Health directorate for their excellent work on developing a strategic partnership with Alder Hey on children’s paediatric general surgery and urology. We are committed to providing this service at UHNS and will seek to develop the service plan by December 2014 Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 • • • I am delighted to announce we have appointed three new paediatric orthopaedic consultant posts. These are part of our plans for the development of services at Stafford Hospital and the wider Trust. The level of candidates was of an incredibly high standard. This makes our service now one of the largest in England. We will be working with Wolverhampton, Shrewsbury, Leighton and Macclesfield to develop consulting services and use the new 218 ward facility to develop our paediatric orthopaedic service for the region. I see this as a major step forward for our 2025Vision around children’s services I wish to thank Robert Kirby, Undergraduate Dean, for his excellent work on developing a service level agreement structure for clinical directorates on undergraduate education which was agreed at TEC. This will define precisely directorate commitments to undergraduate education and their resources in budgets and will become operational on 01/04/15. Robert will be working with clinical divisions on implementing this We have submitted a competitive bid with the Royal Liverpool and Clatterbridge Cancer Centre for the provision of PET-CT for commissioners across Cheshire, Staffordshire, Shropshire, Liverpool and Lancashire. This is a tri-partite partnership with UHNS as lead provider Information Technology Our vision for IT will be based on the needs of our patients, public and professionals working within the hospital and in community settings. The Trust needs to transform its services over the next five years to meet ever rising patients’ expectations and patient safety, experience and outcomes; to meet a minimum of 5-7% pa productivity improvement across all hospital services; support integrated care pathways across hospital and community and to deliver resilience sustainable IT infrastructure which supports the needs of all service users. This will truly mean we must transform our current capacity and capability of staff, system and platforms in IT to enable us to secure these goals. This will mean we will need a more competent, effective and skilled workforce which will expand following the integration with Mid Staffordshire Foundation Trust (MSFT). It will also mean we will need to integrate systems between hospitals as we develop closer service partnerships with Mid Cheshire Foundation Trust (MCFT) and other acute and community providers. The Trust must move towards an electronic hospital information system which will be secured by 2020, which eradicates the need for paper based systems, storage and referral of records and develops a software system which can develop decision support for our health professions to enable them to more productive, agile and flexible in their working arrangements and practices. This will result in a radical shift away from the use of administrative and clerical staff supporting data entry, quality resource and referral to a truly information driven organisation where all our staff contribute to our data entry as a by-product of all the activities they are involved in or support for patient care. The future arrangements for patient care will require patients and their relatives to use our information systems much more fully and for us to develop new systems which engage them in their care. This will improve our responsiveness; reduce the need for out-patient attendances by 20% and enable us to provide greater support for them. The move towards a greater academic development of the trust will result in new research informational systems to support clinical research which will be integrated with our service needs. These changes will require substantial investment over by 2020. The trust will commit to around £20m investment in the development, maintenance and improvement of our IT systems by 2020 to ensure we can truly meet the needs of our patients, stakeholders and the public. Key Recommendations The Board is asked to receive the report for information. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 Author: Mark Hackett, Chief Executive Executive Lead: Mark Hackett, Chief Executive Chief Executive’s Report Version 1 EXECUTIVE SUMMARY FRONT SHEET Agenda Item: 7 Meeting: Public Trust Board Date: 7th November 2014 Title: Quality Report: Patient Experience Quarterly Report (Quarter 1) Author: Director of Nursing – Quality and Safety Executive Lead: Chief Nurse and Medical Director Other meetings Quality and Safety Forum, Trust Executive Committee presented to: Purpose This report updates the Trust Board on progress in improving the patient experience Decision through learning from complaints, results from the friends and family question, quality Approval walkabouts and patient/family comments. Information Link to Strategic Priorities Delivering quality excellence for patients Delivering our obligations to the taxpayer Achieving excellence in education and training Creating an integrated trust with Stafford Executive Summary The Patient Experience Report encompasses an update on the Keogh Domains of caring and responsive and the CQC outcome standards regarding respecting and involving people who use services, care and welfare of people who use services, co-operating with other providers and complaints. The findings of the Dementia Pathway Study, completed by Engaging Communities Staffordshire are presented with a range of recommendations for consideration and approval. The report also highlights the key findings of the West Midlands Quality Review Service (WMQRS) Formative Review of the Care of Frail Older People: North Staffordshire and Stoke on Trent Health Economy During quarter 1 2014 the Trust has received 183 complaints compared to 204 in quarter 1 (2013), 199 in quarter 2 (2013) and 187 in quarter 3 (2013) and 219 in quarter 4 (2013/14). The majority of complaints are received by the medical (43%) and surgical (44%) divisions reflecting the highest volume of patient activity. The majority of complaints received during the quarter (44%) relate to all aspects of clinical treatment. During quarter 1 the Trust has underachieved the target footfall of 25% of inpatients responding to the Friends and Family question on discharge, with a footfall of 20.2%, 19.2% and 22.2% for April, May and June respectively. The Trust has consistently achieved a score of over 70 during the quarter. The Trust has underachieved the quarter 1 target footfall of 15% of patients responding to the Friends and Family who have been discharged from A&E, with a footfall of 3.7%%, 1.1% and 2.5% for April, May and June respectively. The Trust has now implemented a call based system, Netcall, which contacts patients who have attended A&E at home within 48 hours of their discharge. Since implementation the A&E response rate has improved to 19.1% in July. During quarter 1, 4 clinical areas have received a Quality Visit. The areas have shown many areas of good practice and some areas for improvement. The report presents the findings and recommendations of two external reviews namely the Dementia Pathway Study, co-ordinated by Engaging Communities Staffordshire, and the West Midlands Quality Review Care of Frail Older People. Q1 Patient Experience Report October 2014 Key Recommendations Board is asked to receive this report and: approve the top 3 priorities to improve patient experience, namely discharge/medication, communication and care and comfort, including food and nutrition. note the results of the PLACE inspection and support the initiatives implemented to improve food and nutrition. approve the initiatives to reduce the incidence of AKI support the escalation process to reduce the time to respond to complaints. support the additional corporate resource being allocated to the Friends and Family initiative in order to improve both footfall and score. approve the recommendations within the Dementia study co-ordinated by Engaging Communities Staffordshire and support implementation through the Dementia Steering group. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications Q1 Patient Experience Report October 2014 QUALITY REPORT: PATIENT EXPERIENCE QUARTERLY REPORT (QUARTER 1) September 2014 CONTENTS 1. Introduction 2 2. Patient Experience – Our Ambition 3 3. PLACE Inspection 2014 4 4. A Focus on Food and Nutrition 5 5. A Spotlight on Acute Kidney Injury 7 6. Complaints 8 6.1 Complaints Received 8 6.2 Learning From Complaints 11 6.3 Ombudsman Update 12 The Friends and Family Test 13 7.1 Background 13 7.2 Inpatient Response Rate 13 7.3 A&E Response Rate 15 7.4 Combined Response Rate 16 7.5 FFT Comparative Analysis 17 8. A Patient Story 19 9. Quality Walkabouts 21 9.1 Ward 222 (Respiratory) 21 9.2 Haemodialysis Unit 21 9.3 Ward 104/105 (Day Case Unit) 21 9.4 Ward 228 (Muscular Skeletal and Neurosurgery) 21 10. Dementia Pathway Study Patient and Carer Experience 22 11. What patients say about their care 23 12. West Midlands Quality Review Service WMQRS Formative Review of the Care of Frail Older People: North Staffordshire and Stoke on Trent Health Economy 24 13. Excellence In Practice Accreditation Scheme 25 14. Conclusion 26 7. 1 Introduction 1.1 This Quality Report provides a quarterly update on Patient Experience which encompasses the Keogh domains of caring and responsive and the CQC outcome standards of respecting and involving people who use services, care and welfare of people who use services, co-operating with other providers and complaints as identified in the table below. Keogh Domain Safety Effective Caring Responsive Well Led CQC Outcome Standards Outcome 7: Safeguarding people who use services from abuse Outcome 9: Management of medicines Outcome 10: Safety and suitability of premises Outcome 11: Safety, availability and suitability of equipment Outcome 12: Requirements relating to workers Outcome 13: Staffing Outcome 21: Records Outcome 2: Consent to care and treatment Outcome 5: Meeting Nutritional needs Outcome 8: Cleanliness and infection control Outcome 14: Supporting staff Outcome 1: Respecting and involving people who use services Outcome 4: Care and welfare of people who use services Outcome 6: Co-operating with other providers Outcome 17: Complaints Outcome 16: Assessing and monitoring the quality of service provision Quarterly Board Report Patient Safety Report Patient Outcome Report Patient Experience Report Patient Experience Report All Reports 1.2 This report emphasises our ambition with regards to Patient Experience and identifies the priority areas for improvement. It presents the results of the 2014 PLACE inspection and provides a focus on food and nutrition as a vital element of health and recovery from illness. The report provides a spotlight on Acute Kidney Injury. The report provides an update on the number and type of complaints we have received during quarter 1 and some of the lessons we have learnt from these. The report presents the progress with the implementation of the Friends and Family Test and how we compare with other Trusts. It summarises the outcome from Quality Walkabouts completed during the first quarter 1.3 The findings of the Dementia Pathway Study, co-ordinated by Engaging Communities Staffordshire are presented with a range of recommendations for consideration and approval. 1.4 The report also highlights the key findings of the West Midlands Quality Review Service (WMQRS) Formative Review of the Care of Frail Older People: North Staffordshire and Stoke on Trent Health Economy. 2 Setting Our Ambition for Patient Experience 2.1 The Trust is committed to ensuring that every patient we treat receives the highest quality of care that is safe, effective and delivered by sufficient, well trained and compassionate staff. Clinical teams will be supported to deliver care which is free from avoidable harm, which is underpinned by research and best practice, and which is focused upon improving the health and wellbeing of our patients and their family. However, we believe that the way people experience their journey through our hospital can be more important to them than how clinically effective their care has been. Enhancing our patient experience therefore is a key goal in all our quality improvement initiatives. 2.2 Through our own focus groups we have identified the areas that matter most to our patients, their relatives and carers and we have mapped these to the 6 C’s described in Developing a Culture of Compassionate Care (2012). We have interpreted patient comments into the following specific critical success factors. 6 C’s Competence Commitment Courage Care Communication Compassion Our critical success factors based on what our Patients Want To ensure there are sufficient, compassionate and well trained staff. To ensure staff make patient’s well-being their priority. To ensure staff act as the patients advocate and challenge on their behalf. To ensure patients receive appropriate and timely care that manages their condition or supports a dignified death according to their individual needs. To ensure care is delivered in a clean, safe and comfortable environment. To ensure staff listen to patients and provide emotional support. To ensure patients are given appropriate and timely written and verbal information on which they can make informed decisions To have their voice heard, to be valued for their knowledge and skills and to be able to exercise real choice about treatments and services To ensure staff treat patients with dignity and respect their religious and cultural needs. To ensure family members and carers are supported throughout the patients illness and in bereavement In understanding our patients views and reviewing comments from the Annual Inpatient Survey, we have identified our top 3 priorities for improvement, namely, discharge/medication, communication and care and comfort, including food and nutrition. 2.3 Our overall objective is that patients and families will experience the highest levels of care, attention and involvement and UHNS will be their healthcare provider of choice. Our ambition is that patient experience will be in the top 20% of all NHS hospitals by 2015. We will measure our improvement through the introduction of an in year survey reflecting some of the themes within the Annual Inpatient Survey. This will commence in September 2014. The table below identifies the aspects of our top 3 priorities we will measure. Priority Discharge/ medication Communication Care and Comfort Aspects of measurement Written or printed instructions for after leaving hospital. Contact details for post discharge queries . Understandable information about the purpose and side effects of take home medicines Confidence and trust in the doctors and nurses. Doctors or nurses talking in front of patients Receiving conflicting information. Involvement in decisions about care Receiving information and responding to questions about care and treatment. Informing about outcome of procedure Opportunity to discuss care in private. Waiting time for a bed Noise at night Help from staff to eat Quality and choice of hospital food Pain Control Time to respond to a call bell. Emotional support Privacy and dignity Sufficient staff 2.4 The Trust has now established a corporate Patient Experience group which is Chaired by Melissa Hubbard, Paediatric Consultant. The group will meet on a monthly basis, the first meeting is in September when an improvement plan will be agreed with timescales for delivery. Progress will be formally monitored by the Quality and Safety Forum and progress will be shared with the Board on a Quarterly basis through the Patient Experience Report. The Board are asked to approve the top 3 priorities to improve patient experience. 3 PLACE Inspection 2014 Background The 2014 PLACE inspection which replaced the PEAT (Patient Environment Action Team) initiative in 2013 took place on 19th March. The Trust was given six weeks’ notice of the week within which the PLACE inspection was required to take place. The inspection was undertaken by three teams comprising patient representatives, managers from UHNS, Sodexo, Estates, Facilities and Nursing plus an external validator from another Trust. Patient representatives took on the formal role of Patient Assessors and were recruited through various forums including HealthWatch; PALS; Trust’s Patient Experience Manager and Patient Advocates. Volunteers who had either recently been a patient or whose family member had recently been a patient were also invited. The three teams assessed eleven wards on the site by splitting into three distinct areas of the site as follows: West Building, Maternity and Cancer Centre including external areas Trent, Lyme and Renal Buildings including outpatients Main Building new hospital including A&E. Score sheets for each ward and area assessed were completed by the inspection teams at the end of each inspection area covering the four compulsory domains including: Cleanliness and Hygiene Food Privacy, Dignity and Well Being Condition, Appearance and Maintenance The Trust received the results of the inspection in July and the scores were published nationally at the end of August 2014. The table opposite shows UHNS’s scores for the 2014 inspection and are compared with the scores achieved in the 2013 inspection. ELEMENT Cleanliness & Hygiene Food Privacy and Dignity and Well Being Condition, Appearance and Maintenance UHNS 2014 Score % 99.17 National Average 2014 % National Average 2013 % 97.25 UHNS 2013 Score % 99.38 85.35 91.51 88.79 87.73 93.84 95.36 84.98 88.87 96.84 91.97 94.44 88.75 95.74 The table shows that UHNS has achieved scores above the national average in all areas with the exception of food where one of the food components in relation to “food quality” scored “amongst the worst” in the national league tables. It is important to note, however, that due to changes in the assessment methodology and scoring, the 2014 results for Food and for Privacy Dignity and Wellbeing are not considered to be directly comparable with 2013. Meal Service The scores for meal services were directly affected by the changes associated with the application of new weightings applied to the meal scores in 2014, making it difficult to make comparisons to results achieved in 2013. However issues were raised on the day about the quality of vegetables available and their texture, look and taste. Sodexo are addressing these issues as part of their regular food tasting and menu reviews involving Trust managers, Sodexo and Dietitians. The scores for food tasting and privacy and dignity have decreased this year. It should be noted, however that the PLACE inspection in 2013 was an initial pilot and following the pilot there was a change in a number of the questions in each of the questionnaires, most notably those relating to food and privacy and dignity. This has had a negative impact on UHNS’s PLACE scores in these categories. The Trust has developed a comprehensive improvement plan addressing the issues recorded at inspection and the following section describes the initiatives being implemented to improve nutrition and the meal time experience. 4 A Focus on Food and Nutrition at UHNS Meal Service and Nutritional Update The Trust’s Contract Performance Management (CPM) team have been working collaboratively with Trust dietitians and Sodexo Managers to continually improve the patient meal experience at the Trust. These improvements have been informed by patient involvement and have responded directly to feedback from patients and their families/carers about the quality, choice and availability of the patient meal service on offer at the Trust. Dietitians Supporting Quality Nutrition is a vital part of patient care and requires support from many specialities within the Trust; dietitians are ideally placed to make links with other staff to support the infrastructure for nutrition at UHNS. Meal Service Initiatives There are several means by which dietitians provide information to others in the Trust about nutritional issues and also how the dietitians are kept informed of any issues, complaints or other feedback in relation to food. In response to feedback received, the Trust has implemented a range of initiatives to improve the meal service, including: Three week menu cycle to help with patients who are in hospital and have menu fatigue Fresh fruit on menus Snack boxes and out of hours menu Catering for your Needs booklet Nutritional screening as required Food portion options on menus Training for ward staff and Sodexo Supervisors at ward level Nutrition Steering Group examines issues in oral, enteral and parenteral nutrition. There are links with other steering groups such as Dementia and Tissue Viability. Adverse incidents, trends, alerts and NICE guidance are discussed and action plans devised where necessary. Discussions have included the introduction of nutrition screening tools and bedside magnets to alert staff to patient’s dietary needs such as Gluten free or food allergy The Trust is reviewing other Trusts best practice systems and processes for meal ordering with a view to introducing them at UHNS – subject to cost and availability. This includes an electronic menu for patients to choose from at their bedside including pictorial menu choices. Questionnaires, Surveys and Monitoring of Meal Service A patient catering survey is distributed to patients in partnership with Sodexo. Patients are asked about the last meal they ate and the overall standard of the meal, comments are discussed and reviewed at the catering/dietitians group meeting and action is taken where appropriate. The graph below shows the 2013/14 quarterly responses regarding menu choice, meal service and meal experience. 92 91 90 89 88 87 86 85 84 83 A Focus on Food and Nutrition continued Q1 Q2 Q3 Q4 Menu choice Meal Service Meal experience Menu Review In response to comments received, the Trust has also: Improved the food allergy pathway to assist staff in getting the right food for patients Translated the new Cultural menu in to Urdu, Guajarati, Hindi, Punjabi and Bengali. Delivered a children’s nutrition week to promote nutrition and launch a child specific nutrition information pack. Revised the menus structure and types of menus needed for special diets, out of hours food provision and snack provision Implemented a programme to encourage completion of patient menus to ensure we are meeting patients preferences. Estates and Facilities Matron The Trust is in the process of appointing an Estates and Facilities Matron. This role is in place in several other Trusts nationally and has been used to develop and maintain excellent partnership arrangements with the Trust, patients and FM service providers elsewhere. Initiatives introduced by the Matron in other Trusts have included the electronic patient meal ordering system and working with staff at ward level in ensuring effective communications and feedback are in place to help support the patient meal service at the Trust. The Board are asked to support the initiatives implemented to improve food and nutrition. Training Training is delivered to Trust and Sodexo staff, either by offering ‘bite size’ sessions by dietitians or by linking into established sessions such as band 5 nurse preceptor training. An e-learning module for staff involved in nutrition screening has also been introduced. Quality Nurses The Trust has introduced Quality Nurses on every ward. The role of the Quality Nurses is to ensure consistent standards are achieved in relation to specific elements of patient care. The Trust dieticians and the CPM team are working closely with the Quality Nurses in relation to the patient meal service to ensure consistent systems and processes are followed at every ward level. 5 Spotlight on Acute kidney Injury Acute Kidney Injury (AKI) is a condition whereby a patient experiences a sudden loss the AKI nurse who will offer advice on clinical management of the patient, guidance on of kidney function. It is associated with increased mortality, increased length of stay, chronic morbidity and increased healthcare costs. Furthermore, it has been estimated that 20-30% of cases are both avoidable and preventable. AKI is a broad clinical syndrome which has a number of causes including dehydration and sepsis. However detection of the condition remains difficult since deterioration of kidney function is not always immediately evident. Nationally, a major concern has been raised through the NCEPOD report, ‘Adding Insult to Injury’ that AKI is not always appropriately identified and reported by medical staff. Early identification and treatment of AKI results in better outcomes for patients and a reduction in length of stay. The Trust has formed a Transformation Group which aims to reduce the incidence of Acute Kidney Injury across the organisation. The group will develop an e-learning package, implement a quarterly programme of audits, introduce a medication information leaflet and develop of an AKI alert system. We have also recruited an AKI lead nurse. This nurse will take the lead on the delivery of the AKI training packages, promote awareness of AKI through prompt identification of patients with the condition and encourage shared learning through the implementation of an RCA (Root Cause Analysis) process. The initial focus of the work will on reducing the incidence of hospital-acquired Acute Kidney Injury at stage 3. These patients will be identified by 6 Complaints 6.1 Complaints Received expectations in relation to completion and presentation of the RCA and suggest preventative steps to follow for future cases. At the same time the nurse will also assess patients with AKI at stage 2 and provide advice and guidance with a view to preventing any further deterioration in kidney function, and therefore further reduce the number of patients achieving AKI stage 3. In order to achieve a reduction in the number of preventable hospital-acquired AKI cases it will be necessary to adopt a similar approach to that which was adopted in relation to pressure sores. As such the expectation will be that each case of AKI 3 will be reported via Datix and an RCA will be requested. Potentially preventable, hospital-acquired AKI stage 3 cases will be heard by the AKI Steering Group and learning points shared throughout the Trust. The Board are asked to support the initiatives to reduce the incidence of AKI For the purpose of this report, complaints are categorised as being a written or verbal complaint not resolved within 24 hours to 5 days. These are what we often refer to as ‘formal’ complaints where resolution cannot be found at an informal stage. The data below relates to 2013/14. Chart 1 No of Complaints Complaints Opened By Quarter 2013/14 240 220 200 180 160 219 204 Qtr 1 199 Qtr 2 187 Qtr 3 Chart 1 shows the number of complaints received by quarter. During the first quarter of 2014/15 the Trust has received 183 formal complaints. This is a decrease from the same period the previous year 2013/14 in which there were 204 complaints recorded. 183 Qtr 4 2013/14 Qtr 1 2014/15 Chart 2 Chart 2 shows the number of complaints received per 10,000 episodes. The chart indicates a reduction during each month of quarter 1. Chart 3 2014/15 Quarter 1 Complaints Opened by Clinical Division 18 10% 5 3% 80 Medicine 43% Surgery 80 44% Chart 3 shows the 183 complaints as opened by clinical division during quarter 1 of 2014/15. The complaints are allocated to the lead division although there may be cross boundary issues. The chart shows that the majority of complaints are equally shared between the medical and surgical divisions which reflects the areas of highest activity Clinical Support Services Other Chart 4 below shows that 56 complaints were opened in June which was a decrease on May with a marginally decreasing trend since April 2013. Chart 4 2013/14 65 62 56 Jun-14 77 May-14 70 Apr-14 72 Mar-14 52 Feb-14 61 Jan-14 Sep-13 74 Dec-13 64 Nov-13 67 Oct-13 68 Aug-13 59 Jul-13 64 Jun-13 81 May-13 90 80 70 60 50 40 30 20 10 0 Apr-13 No of Complaints Complaints Opened by Month 2014/15 Chart 5 shows that across the Trust the top 83% of complaints year to date fall into 5 complaint types with 152 of the 183 coming from these categories. Chart 6 overleaf shows the remaining complaint categories which were responsible for 31 (17%) of the 183 complaints received Chart 5 Quarter 1 2014/15 Top 83% of Complaints By Type 7.7% All aspects of clinical treatment 8.2% Admission, transfer & discharge arrangements 44.3% 10.9% Appt delay / cancellation (outpatients) Communication/informati on to patients (written and oral) Attitude of staff 12.0% Chart 6 Quarter 1 2014/15 Bottom 17% of Complaints by Type 0.6% 0.5% Appt delay/cancellation (inpatients) 1.1% General nursing 4.9% 1.1% Aids & appliances, equipment premised (including access) Not Specified 1.1% Other Personal records (including medical and/or complaints) 1.1% Patients privacy and dignity Policy and commercial decisions of Trusts 2.7% 3.8% Patients property and expenses Chart 7 below shows the top 8 themes within the top 83% of complaints received throughout the year. These sub-types relate predominantly to clinical care. Chart 7 Quarter 1 2014/15 - Main Complaints by Sub-Type 6 Suitability of treatment/procedure 6 25 Diagnosis Poor attitude 6 Failure to follow agrees procedure 7 Between patients/ relatives and staff Tests/procedures 9 14 10 Problems with discharge arrangements Condition of patient on discharge Chart 8 overleaf shows that in June 2014 the average response time for complaints closed in the month was 68 days compared to 50 days in May which is above the 44 day average response time since the increased focus on complaints commenced in July 2012. During quarter 1 the Trust implemented a robust escalation process to improve the response times to complaints. Chart 8 Chart 9 below shows that for quarter 1 2014/15, of the 177 complaints closed 24% (n=43) were upheld and 41% (n=73) were partly upheld whilst 18% (n=32) of complaints remain unclassified. The total of upheld and partly upheld complaints for the quarter is 65%. The unclassified category reflects the need to update the relevant field within Datix at the conclusion of the investigation. Chart 9 Quarter 1 2014/15 Outcomes of Closed Complaints 32 18% 43 24% 29 17% Upheld Partly Upheld Not Upheld 73 41% . Not Classified 6.2 Learning From Complaints One of the most important aspects of the complaints process for the Trust is to learn lessons and make changes to enhance the experience for our patients, carers and relatives. The section below gives examples of improvements made as a direct result of complaint investigations in quarter 1. A number of complaints have been anonymised and shared with nursing staff on the wards for educational purposes in order to improve care and communication in the future. Junior doctors have been reminded that they must clearly document x-ray results that need checking after the patient has left the accident and emergency department and on arrival to the receiving ward. Nursing staff have been reminded to monitor blood sugar levels at regular intervals following a high urinary ketone reading in order that appropriate treatment can be expedited. Staff have been reminded to ensure call bells are always within reach, the importance of storing drugs appropriately including insulin and to ensure that patients are promptly supplied with diet and fluids All new doctors are educated as part of their induction, on the requirement to accurately communicate and document information. A consultant has undertaken a restructure of secretarial staff and recruited additional staff to ensure answerphone messages are responded to promptly. The Trust is undertaking a project to implement an electronic prescribing system that will reduce medication errors. A portable MRI scanner has been sourced and an additional consultant radiologist has been appointed to reduce diagnostic waiting times. An Email address has been introduced to enable patients to leave their enquiries regarding imaging appointments A new telephone system is on order which informs patients they are in a queue. Telephone systems have been upgraded and now give an engaged tone to let the person ringing the ward know that the telephone is busy. Receptionists have been asked to observe patients waiting for admission and ensure that any issues regarding their comfort are identified and resolved. Volunteers are undertaking an audit of a reception ‘booking in’ pathway for monitoring and evaluation. Extra clinics have been set up in outpatients to ensure there are more slots available for patients. Comfortable and pressure relieving chairs are being purchased in two departments Ward nurses have been reminded about the need to assess patients sensory needs and to carry out regular denture care Medical and nursing staff have been reminded of the Trust Policy regarding wearing name badges and identification cards and ensuring that these are visible at all times. 6.3 Ombudsman and comeback numbers In Q1 there were 5 new ombudsman investigations. 3 final reports were received by the UHNS with the following outcomes: 1 case partially upheld requiring an apology and action plan 1 case partially upheld requiring an action plan and a payment to the complainant of £750 for ‘injustice’ due to cancelled appointments and delays in treatment. 1 case not upheld The Board are asked to note the reduction in the number of complaints received and the changes in practice in response to complaints. The board are asked to support the escalation process to reduce the time to respond to complaints. 7. The Friends and Family Test 7.1 Background The Friends and Family Test (FFT) is a simple, single question survey that asks patients to what extent they would recommend the service they have received at a hospital department to family or friends who needed similar treatment. All data collected is used to calculate a score (the Net Promoter Score). Scoring ranges from extremely likely to extremely unlikely. Based on the response, respondents fall into one of three categories: detractors, promoters or passives. Detractors are unhappy patients who could potentially damage the trust through negative word-ofmouth. Passives are individuals who are satisfied but are vulnerable to competition, and when calculating the Net Promoter Score, passives are discounted. Promoters are loyal and enthusiastic patients of the UHNS and will promote the Trust. To calculate the Net Promoter Score, we subtract the percentage of detractors from the percentage of promoter respondents. The goal is to have a high Net Promoter Score with 75 considered a good score and a CQUIN target of 70 or above. 7.2 Inpatient Response Rates Chart 10 2013/14 % Footfall YTD % FootFall Jun-14 Apr-14 May-14 Mar-14 Jan-14 Feb-14 Dec-13 Nov-13 Oct-13 Sep-13 Aug-13 Jul-13 Jun-13 Apr-13 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% May-13 % Footfall FFT - Inpatient % Footfall Year to Date 2014/15 2014/15 Target Footfall Chart 10 shows the response rate for adult inpatient wards from April 2013 to June 2014. The response rates described as ‘footfall’ are the numbers of patients completing the questionnaire within 48 hours of discharge. There is requirement to achieve at least 25% in quarter 1 and at least 30% in quarter 4. The chart shows that the Trust has underachieved against the target for each month in quarter 1. The Trust is planning to allocate additional corporate resources to this initiative commencing in September. Chart 11 Chart 11 shows that the Net Promoter Score for adult inpatients was consistently above the required 70 until June 2014 when it dipped to 65. FFT - Inpatient Score Year to Date 2014/15 85 FFT Score 80 75 70 65 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 60 2013/14 FFT Score 2014/15 Ytd Score Target Score Chart 12 FFT - Inpatient Responses - April to June 2014 Extremely 62 3% 14 5 1% 0% Likely 25 1% Likely 386 20% Chart 12 demonstrates that throughout quarter 1 75% of our inpatients were extremely likely to recommend our services to a friend or family. Neither likely nor Unlikely Unlikely 1499 75% Extremely Unlikely Don't Know The breakdown of responses for quarter 1 2014 can be seen below: Adult Inpatients Extremely Likely Likely Neither Likely nor Unlikely Unlikely Extremely Unlikely Don’t Know 514 475 510 1499 102 139 145 386 12 10 40 62 1 5 8 14 1 1 3 5 10 6 9 25 Apr May June Total 7.3 A&E Response Rate Chart 13 2013/14 % Footfall Jun-14 May-14 Apr-14 Feb-14 Mar-14 Jan-14 Dec-13 Oct-13 Nov-13 Sep-13 Jul-13 Aug-13 May-13 Jun-13 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Apr-13 % Footfall FFT - A&E % Footfall Year to Date 2014/15 2014/15 YTD % FootFall Target Footfall Chart 13 shows the footfall for A&E from April 2013 to March 2014. This represents the number of patients who completed the FFT questionnaire within 48 hours of being discharged from A&E. This excludes patients transferred to an inpatient ward and those who leave the department prior to assessment or treatment. There is a requirement to achieve at least 15% in quarter 1 and at least 20% in quarter 4. Chart 14 Until recently, the A&E Department has been relying on a paper-based system which has proved time consuming and impractical. The fall in footfall has also had an impact on the score. In June the FFT score in A&E was 36, a fall from 76 in April. FFT - A&E Score Year to Date 2014/15 80 70 FFT Score 60 50 40 30 20 10 2013/14 FFT Score Ytd Score Jun-14 Apr-14 May-14 Mar-14 Feb-14 Jan-14 Dec-13 Nov-13 Oct-13 Sep-13 Aug-13 Jul-13 Jun-13 May-13 Apr-13 0 2014/15 Target Score The Trust has now implemented a call-based system NETCALL. NETCALL contacts patients who have attended A&E at home within 48 hours of their discharge. The call is made to the patient’s mobile or land line number, and is a computerised recording asking the patient if they would like to complete the FFT question. The patient gives their answers either verbally or using their number key pad to select their preferred option. When an option is chosen the patient will be given the opportunity to make comments and additional questions can be asked. Since implementation, the Trust has seen an improved response rate in A&E during July achieving 19.1% against the target of 15%. Chart 15 Chart 15 demonstrates that throughout quarter 1 67% of patients attending the A&E Department were extremely likely to recommend our services to a friend or family. FFT - A&E Responses - April to June 2014 20 4% 88 18% 13 3% 20 4% Extremely Likely 18 4% Likely Neither likely nor Unlikely Unlikely 319 67% Extremely Unlikely The breakdown of responses for quarter 1 2014/15 can be seen below: A&E April May June Total Extremely Likely 185 44 90 319 Likely 29 18 41 88 Neither Likely nor Unlikely 5 1 14 20 Unlikely 6 6 8 20 Extremely Unlikely 2 2 9 13 Don’t Know 8 5 5 18 7.4 Combined response Rates for Inpatients and A&E Chart 16 and 17 below show the combined footfall and scores for adult inpatients and A&E. Chart 17 FFT - Combined Score Year to Date 2014/15 FFT- Combined % Footfall Year to Date 2014/15 20.0% FFT Score 15.0% 10.0% 5.0% 0.0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 % Footfall 25.0% 2013/14 % Footfall Target Footfall 2014/15 80 75 70 65 60 55 50 45 40 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Chart 16 2013/14 YTD % FootFall FFT Score Ytd Score 2014/15 Target Score 7.5 FFT Comparative Analysis The following charts provide a comparison between the UHNS FFT performance compared with selected national Trusts (our “peers”) and the rest of the UK (“other”). Chart 18 Chart 19 FFT - Inpatient Scores - April 2013 to June 2014 FFT - Inpatient Footfall % - April 2013 to June 2014 Cambridge University… Coventry & Warwick Southamprton University Royal Devon & Exeter Leicester University Other Central Manchester Derby Hospitals UHNS Sheffield Teaching UHB Nottingham University… 0 UHNS Royal Devon & Exeter Central Manchester Cambridge University… Derby Hospitals Coventry & Warwick Leicester University Sheffield Teaching Other Southamprton University UHB Nottingham University… 20 40 60 80 100 0% FFT Score 10% 20% 30% 40% 50% FFT % Footfall Chart 18 shows that UHNS is ahead of the Inpatient target score of 70 year to date for inpatient areas and ranked fourth amongst our peers and all other trusts in the UK Chart 19 shows that year to date Inpatient footfall rates are marginally below the 25% threshold and that we are at the bottom of the league compared to our peers and all other remaining trusts combined Chart 20 Chart 21 FFT - A&E Scores - April 2013 to June 2014 FFT - A&E Footfall % - April 2013 to June 2014 Royal Devon & Exeter Coventry & Warwick Other UHNS UHB Sheffield Teaching Cambridge University… Derby Hospitals Central Manchester Leicester University Southamprton University Nottingham University… 0 UHNS Southamprton University UHB Central Manchester Sheffield Teaching Other Leicester University Derby Hospitals Coventry & Warwick Cambridge University… Nottingham University… Royal Devon & Exeter 20 40 60 80 0% Chart 22 20% 30% FFT % Footfall FFT Score Chart 20 shows that UHNS is below the target score of 70 year to date for A&E patients and are currently joint third lowest amongst our peers and all other trusts in the UK 10% Chart 21 shows that year to date A&E footfall rates are below the target and we are bottom of the league compared to our peers and all other remaining trusts combined. Chart 23 FFT - Combined Scores - April 2013 to June 2014 FFT - Combined Footfall % - April 2013 to June 2014 UHNS Central Manchester Southamprton University Other Sheffield Teaching UHB Leicester University Coventry & Warwick Derby Hospitals Cambridge University… Royal Devon & Exeter Nottingham University… Coventry & Warwick Cambridge University… Royal Devon & Exeter Central Manchester Leicester University UHNS UHB Sheffield Teaching Derby Hospitals Southamprton University Nottingham University… 0 20 40 60 80 0% 10% FFT Score 20% 30% 40% FFT % Footfall Chart 22 shows that UHNS is below the target score of 70 year to date for ALL patients and are currently ranked in the middle when compared with our peers and all other trusts in the UK Chart 23 shows that year to date combined footfall rates are below the 20% target and that UHNS is currently bottom of the league compared to our peers and all other remaining trusts combined Chart 24 Chart 25 FFT - Combined Footfall % - June 2013 to June 2014 FFT - Combined Scores - By Quarter April 2013 to June 2014 80 70 60 50 40 30 20 10 0 35.0% 26.5% 25.0% UHNS Jun-14 Apr-14 Mar-14 Jan-14 Feb-14 Dec-13 Other May-14 7.1% 6.1% Jun-13 0.0% Oct-13 5.0% 15.8% Nov-13 10.0% Sep-13 15.0% 24.5% 16.9% Jul-13 20.0% Aug-13 FFT % Footfall 30.0% Qtr 2 Qtr 3 Qtr 4 2013/14 Peers Chart 24 shows the trend in our combined response rates over the past 13 months compared with our peers and the rest of the UK. Qtr 1 UHNS Other Qtr 1 2014/15 Peers UHNS Trend Chart 25 shows the quarterly combined FFT scores for UHNS compared to our peers and all other trusts. The chart demonstrates that in quarter 1 2014/15, whilst UHNS were below the target of 70 with combined scores of 69, we were ahead of our peers and the rest of the UK. The Board are asked to support the additional corporate resource being allocated to the Friends and Family initiative in order to improve both footfall and score. 8 A Patient Story – Getting to the heart of it! “In 2001, due to chronic heart disease I had an Implantable Cardioverter Defibrillator, (ICD). (a device implanted within the chest which keeps the heart rate strong and regular). The batteries powering the device are intended to last for up to 5 years, although in my case this is somewhat lower owing to the need for constant pacing and the number of leads. The device automatically records both its activity and that of my heart and as a routine I am are subject to an electronic download of this data. The download also monitors the state of the batteries. The majority of my downloads are undertaken at home with a remote monitor connected on “dial-up” through the domestic telephone line. At the end of December 2013, I undertook a routine download. I received no feedback from the download. This is not an issue for me as I am in the habit of contacting the Heart and Lung Department for a report. However, I have recommended that patients should have an option to a routine report, as “no news” is not always considered “good news”. In the middle of the following January, I received defibrillation therapy from the device…..The Coronary Care Unit indicated that the battery was very close to its minimum parameter. A couple of weeks later, I telephoned Pacing and was concerned to be told they had still not received advice from Coronary Care of both the therapy and battery condition. I was directed to transmit a download of data. This confirmed the state of the battery and I was to be reviewed at 3 months. In May I was called into Pacing for a Technician-led download, when it was determined the battery had fallen below the minimum parameter. Consequently, I had to attend a Pre-admission Clinic before a replacement implant later that month. For both me and other patients to whom I have spoken, the Pacing Section provides excellent support as a frontline service. Staff are always helpful and willing to support and give advice on the telephone. The section could very well be an exemplar to other sections of the hospital. The Pre-admission review includes a blood sample. Over the last 14 years I have found that members of the Cardiology teams are very skillful I am told I should have been supplied! Moreover, both PN’s and DN’s do not have the appropriate dressings. It really shouldn’t be for the patient to suffered many painful attempts in other wards and departments. The appointment time for my procedure was 12.00 noon, with fasting for 6 hours beforehand. I was asked to bring my own packed sandwiches for a meal after the event, although food would otherwise be provided if necessary. After the procedure and a recovery perio, I was able to join a number of patients in a lounge for a further recovery period. The patients raised several aspects of their care. However, all of us were extremely satisfied with the service and care we received whilst in this section of the Heart and Lung Department. Pain relief: As this was my 4th implant I was very much aware that for some time after the procedure I would feel little pain as I would still benefit from the anaesthetic. However, I knew I would be in severe pain some hours later. I asked about pain relief for when I was discharged, but was told I really needed to have asked when I booked in, but in any case only paracetamol would be supplied. There was a general comment by patients that not enough attention is given to discharging them with adequate pain relief, sufficient until a GP can be contacted. Medication on Discharge: I have not been in a situation of being discharged requiring additional medications, apart from antibiotics. As a result, I have not experience the issues reported by many fellow patients in being discharged with too few days supply of new medications. Access to the GP to present any discharge letters and arrange a prescription cannot always be achieved in under the timeframe for which medication has already been supplied. There also seems to be some variation in the short-term quantities prescribed by the hospital. Dressings on Discharge: Over the last half year, I have been discharged from hospital twice after surgical procedures. On neither occasion have I been supplied with replacement dressings. This has left me between the hospital and Practice Nurse (PN) or District Nurse (DN) struggling to obtain the necessary replacements, as on the one hand I am not supplied and on the other from the receiving hospitals for transport other than by Ambulance, for which they would have to bear a cost. In the event these ensure that adequate and appropriate dressings are available for wound management. Dispensing of Prescriptions: Many fellow patients reported to me that prescriptions they receive on discharge or at out-patient clinic can only be dispensed at the pharmacy on the UHNS site, other community pharmacies are not enabled to accept them. This has been determined only after the patient has returned home and as a result, they or a carer must return to the hospital to have the prescription dispensed. Some of the clinicians do advise patients of this limitation when prescribing, but not all. Patients should have a choice in their dispensing pharmacy, especially if they build a trusting, long term relationship with the pharmacist. Transfer to Community Services or GP for follow-up: On discharge from the hospital patients are provided with advice of the treatment and necessary follow-up care, to hand to patients were not transferred, they were found beds at UHNS, whilst their beds at the originating hospital remained empty. We were told by staff that the problem of transferred patients not being collected was very common Follow-up Service by District Nurses: In view of my previous experiences, I arranged support from the District Nursing service, before I was admitted, so I would not have to rely on the availability of practice nurses. I had no problems arranging an initial wound check 2 days after probable discharge. The DN that attended was excellent in providing treatment and advice. She arranged a further visit some days later and left suitable dressings for self-application. The care I received was everything I had hoped for and expected, so I congratulate and thank the District Nursing Service. Overall, I feel that the whole experience of my ICD implant by minor surgery was provided by all parties in an entirely satisfactory manner. With my average admission rate of twice per year over the last 14 years, over a variety of departments and wards, I feel most comfortable with Cardiology. After discharge, in the main I couldn’t wish for better service than I received from the District Nurses. 9 Quality Walkabouts During quarter 1, the following wards have been visited, a summary of these visits are described below. 9.1 Ward 222 (Respiratory) Good practice The ward had completed all the key actions from the last walkabout, including, ensuring a ward information leaflet was available and clear signage on the importance of hand hygiene. Formal complaints have decreased in 2013/14, and the Ward Manager explained there is always a senior staff nurse available to try and address any concerns or issues immediately. Areas for improvement More timely response to the buzzer for entry to ward Poor and marked paintwork were noted both on the ward and in the patient/relative room. There was a lack of any pictures or soft furnishings in the patient-relative room. 9.2 Haemodialysis Good Practice Patients were extremely appreciative of the nursing care offered on the ward Staff enjoyed building relationships with patients The ward was exceptionally clean and tidy Areas for improvement: Some patients felt uncomfortable with the lay out of the foot rests on the beds. Staff should check with patients that they are comfortable at the beginning of treatment. 9.3 Ward 104/105 (Day Case Unit) Good Practice: Staff are dedicated and committed to the specialty and have a strong team approach Appraisals were up to date and staff commented they have a good process in place to ensure appraisals are undertaken Areas for Improvement To ensure that the Quality Board is updated To review and update the Patient Information Leaflets To review the patient journey from the wards to theatre focusing on patient experience and waiting times. Clinical Assurance Framework 9.4 Ward 228 (Muscular Skeletal and Neurosurgery) Good Practice: The ward staff were warm and welcoming. An excellent appraisal rate of 96.7%, and a strong focus of training and development. Staff demonstrated strong compassion for their patients and a strong focus providing a conducive environment. Areas for Improvement To refresh the Ward Quality Board with more relevant and up to date information. To monitor ward cleanliness as part of the monthly Infection Control audits To repair the hand gel dispenser at the entry to the ward. To escalate the issue of the lack of televisions on the ward 10 Dementia Pathway Study Patient and Carer Experience The Trust commissioned Engaging Communities Staffordshire to seek patient and carers studies concerning their journey into accessing services at UHNS. The overall objectives of the study UHNS. The communication that John has had with the hospital has been mixed. John says that the hospital has given him specific information on vascular dementia and its was to find: Recommendations to improve experience for users Recommendations to improve signposting and information provision. The study leads engaged with Community Interest Groups, visited wards, held an interactive event in the hospital, and undertook a public awareness campaign. The study leads interacted with over 100 people and carried out in-depth interviews with 23 people who care for people with dementia. This section provides a high level summary of the report. Mary and John’s Story Mary’s husband, John (pseudonyms used) was diagnosed with dementia in the community and she is his main carer. On two occasions John needed to come to UHNS to have day surgery under general anaesthetic. He was referred by his GP, who made the hospital aware of his dementia condition. The appointment letters offered for transport by ambulance to be booked but Mary was happy to pay for a taxi instead. Overall Mary described the support that she received from UHNS as ‘very good’. All the staff were knowledgeable and treated both Mary and John with dignity. Because of John’s dementia Mary was able to stay with him as long as possible, she was able to go with him to the theatre door and stay with him in the recovery room afterwards. As she was with John the whole time Mary was able to help staff to interpret his needs. The communication with staff was good, and they explained the effects of the anaesthetic on dementia sufferers very well so Mary could be well prepared. Advice on postoperative care was also clear, and a nurse checked that Mary and John had enough support in the community. symptoms and that they have always listened to his questions. However, he felt that the hospital were not proactive in giving information and that he got information only because he asked detailed questions. When Jane was on the ward the butterfly symbol was used, but Tom has never completed a ‘this is me’ document. Tom felt that he was supported as a carer but that staff did not always listen to his advice about his wife’s care. Tom feels that the care that Jane gets from the Outpatients Department at UHNS is ‘very good’ but is concerned that when Jane is on a ward the staff do not always have the right understanding and knowledge to deal with her in the best way. Tom believes that he has got the most information and advice from Approach and thinks that staff could benefit from all having training with Approach. Although the hospital was helpful in telling Tom about Approach and other groups, he felt that the hospital could offer more direct support. Tom felt that the hospital did not give Jane enough aftercare when she was discharged. The word cloud below uses analysis to visually represent some of the main themes and comments obtained as part of the research. The cloud shows the prominence of the “involvement of carers”, “communication” and “dignity and respect” Tom and Janes Story Tom cares for his wife Jane (pseudonyms used) who has vascular dementia. Jane was first diagnosed by her GP and was then sent to Recommendations The report made the following recommendations: To give patients and carers interim advice, information and support as early as possible to cope with symptoms they are experiencing. To introduce systems to ensure that information and support is offered proactively “Staff are wonderful but information is not passed on properly from one member of staff to another”. “Every individual of the ward team were professional, competent, and caring”. “My stay on (ward) was brilliant & the nicest to all people with dementia and their carers. To ensure consistent levels of nursing care To ensure patients are given support to eat or drink where necessary and their fluid levels monitored carefully. To further enhance systems to ensure patients with dementia are given support to place meal orders if needed. To ensure that where appropriate bed rails are in use To ensure appropriate communication particularly with regards to highly vulnerable patients. To support carers as partners in care through initiatives such as flexible visiting time, support with transport and regular communication and updates from appropriate members of staff. To implement the Dementia Care Pathway and Framework Guidelines Systematically and Universally To ensure the butterfly symbol is used uniformly across the organization. To avoid frequently moving patients with dementia between wards Where movement between wards is necessary the reasons why should be fully explained to both the patients and their carers as a matter of course. Carers should be proactively informed about any ward movements and all efforts should be made that it is at an appropriate time of day. A process should be put in place to ensure that ‘this is me’ document is used for all relevant patients ward I’ve stayed on in the NHS. All the staff were very friendly & polite, nothing was too much trouble. The ward desk was very helpful and closed my appointment very quickly. The discharge lady was good & very polite”. “Only the food was a let down. If they had what you ordered it was either just warm or cold by the time it was receive. There wasn’t a great deal of choice for main courses. All the staff on the ward were very helpful & cheerful & would join in a conversation with patients if they had time. If more staff were on duty I think patients would recover quicker than when staff are only about when called. I cannot find a single fault with them all”. “All staff were extremely polite & helpful & very caring & compassionate. They work extremely hard under immense pressure but always have a smile a lovely ward thank you”. “Superb nursing staff pharmacy on discharge”. but delay in I was told by the Dr at 8.30am that I could go home but he said I could stay until 2pm when I could get a lift home. But I felt rushed by nurses to leave asap bar from 1 nurse who was understandable. “I was told to come in the morning at 7 a.m. Where in fact my allocated slot was for late afternoon. We had to sit in a waiting area still with a back problem for several hours before being seen. It would be more convenient with less discomfort if I was told to come in at noon”. The Board are asked to approve the recommendations above and support implementation through the Dementia Steering group. 12 “I was very satisfied with the care I received & the expertise of the Drs. The nurses are caring & attentive & very cheerful”. West Midlands Quality Review Service WMQRS Formative Review of the Care of Frail Older People: North Staffordshire and Stoke on Trent Health Economy The formative review of the care of frail older people in the North Staffordshire and Stoke on Trent Health Economy took place on 20th March 2014. Formative review visits were agreed, with the aim of improving quality of life, quality of care and outcomes for frail older people and their families, and in particular: Identifying areas which are working well Identifying where improvements are needed Informing future commissioning intentions Sharing good practice and expertise. The review used a framework for the care of frail older people which has the following main areas: Conditions and therapeutic interventions Preventative and supportive interventions Care (health and social care) Responses to urgent need Cross – cutting patient care Underpinning issues. During the course of the visit reviewers met service users and carers and representatives of a wide range of service providers and commissioners and asked what was working well, whether plans were in place and, in the view of reviewers, what changes were needed. Other areas of good practice included: access to a review by a Consultant Geriatrician, an assessment by the nursing team and a full multi-disciplinary team of allied health professionals. Older adults in-reach service A range of discharge pathways The reviewers were particularly impressed that UHNS had trained 20 Health Care Assistants with the specific competences in the care of older people with dementia. The Trust received the final report in June 2014 which commented on all aspects of care within the health economy. The Trusts Frail Elderly Assessment Unit (FEAU) was reviewed as part of the “response to urgent need” aspect. The WMQRS identified many areas of good practice and commented that, “FEAU had been recognized as a ‘centre of excellence’, with a ‘Gold Standard for Excellence in Practice Accreditation Award’ assessed by Teesside University in 2013. The service has also been shortlisted in 2013 for the NPSA awards for acute care of the older adult”. The WMQRS also identified where change was required. They recognized the need for closer integration between acute and community care of older people consultants was already being discussed within the Trust. Reviewers suggested the skill mix of the overall medical staffing model should be carefully considered, including the possibility of recruitment of additional Physicians Assistants. The Formative Review Report was discussed at the Quality and Safety Forum and an action plan is being developed by the Elderly Care Directorate. 13 Excellence In Practice Accreditation Scheme The Board will recall that the Accident and Emergency (A&E) Department has been through an 18 month journey of improvement to achieve Excellence In Practice Accreditation which based on ensuring effective communication, collaboration and team building. The Scheme is delivered in partnership with Teesside University and following external scrutiny and assessment of 6 standards, namely: Working in organisations Collaborative working User Focused care Continuous quality improvement Performance management Measuring efficiency and effectiveness A score is awarded for each standard and an award determined as described below. Award 1-2 3 4 5 Level Bronze Silver Gold Platinum The A&E department were the first department nationally to have attempted this programme. The Accident and Emergency team were assessed on DATE and at the end of the second day were delighted when they were told they had achieved the a level 5 Platinum Award. The EPAS Assessment Team wrote stating, “we would like to formally thank you and your colleagues for the wonderful hospitality provided to us during the Emergency Department final Excellence in Practice Accreditation visit. As discussed, in recognition of the excellent leadership, team working and partnerships aimed at providing an innovative patient-centred approach and patient-lead service, the panel would like to award the Team the Excellence in Practice Award Star 5 Platinum. To achieve the highest rating that of 5 stars, which has only been awarded to 3 other teams in the 10 years of EPAS, is a truly outstanding and remarkable achievement across the service. As reviewers we were extremely impressed by the high levels of person-centred care, compassion and the dedication of the teams to provide safe, quality evidencebased care and services. The high standards of evidence reinforced from multiple sources (service users, carers, staff and a vast array of stakeholders) enabled us as reviewers to triangulate our findings, conclusions and recommendations. We believe that based on our experiences the remarkable achievements are associated with the authentic leadership and management, excellent communication, shared vision and genuine engagement of the majority of staff, stakeholders and service users/carers”. 14 Conclusion and Recommendations 14.1 In conclusion, the report shows the focus the trust has on improving the patients experience. The wide range of qualitative information summarized within this report is used on a weekly basis by clinical managers to demonstrate and drive improvements in practice. The regular Quality Walkabouts demonstrates our continued focus on improving our patients experience and patient safety. Board is asked to receive this report and: approve the top 3 priorities to improve patient experience, namely discharge/medication, communication and care and comfort, including food and nutrition. note the results of the PLACE inspection and support the initiatives implemented to improve food and nutrition. approve the initiatives to reduce the incidence of AKI support the escalation process to reduce the time to respond to complaints. support the additional corporate resource being allocated to the Friends and Family initiative in order to improve both footfall and score. approve the recommendations within the Dementia study co-ordinated by Engaging Communities Staffordshire and support implementation through the Dementia Steering group. EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: Public Trust Board R&D Update Q1 (2014/15) Professor Tony Fryer Prof Gavin Russell Date: 8 7th November 2014 Executive Committee Purpose To present a summary of R&D activity for 2014/15 Q1 and an update on progress with R&D Strategy and key R&D Metrics and Performance Indicators. Link to Strategic Priorities Delivering quality excellence for patients Delivering our obligations to the taxpayer Achieving excellence in education and training Creating an integrated trust with Stafford Executive Summary 2013/14 Q4 summary Decision Approval Information Recruitment to clinical trials On a study by study basis, UHNS consistently tops the rankings for patients recruited into studies and continues to perform well against national and international competition. Recent examples from 2014/15 Q1 include: • • • • • • • • Stroke: UHNS was the highest recruiting hyperacute stroke research centre in the country and has been recognised as one of the top four recruiting centres globally for the ENCHANTED trial. Obstetrics and Gynaecology: UHNS were in the top ten recruiting centre globally (out of over 50 centres) for the PREP Study, which seeks to develop a predictive model for pregnant women at risk of developing early onset pre-eclampsia. Respiratory Medicine: A study led by Professor Monica Spiteri was identified as an exemplar of good practice in Public and Patient Involvement in research. The team secured a prestigious National Institute for Health Research Invention for Innovation award that aims to develop and contruct a simple analyser to measure biomarkers for chronic obstructive pulmonary disease in saliva to enable patients to monitor changes in their condition at home. The project was driven by patient needs from the start and patients contributed to the practical design of the study. Obstetrics and Gynaecology@ in May 2014, UHNS was recognised as the centre of the month for recruitment to the MI-Quit study, which examines whether providing support to stop smoking via mobile phone text messages might help pregnant women who smoke to quit. Stroke: UHNS was listed as the top recruiter internationally for the TICH-2 Trial, which looks at the role of transexamic acid in reduction of bleeding in the acute phase of haemorrhagic stroke. Anaesthetics: Research nurses joined forces to recruit over 130 patients to the SNAP trial within just two days. Oncology: The oncology team were identified as the top recruiter in Europe for the PRESENT study, with 40% of the total UK recruits. Respiratory Medicine: UHNS was ranked as top UK recruiter and second internationally for the Research and Development Update Q1 November 2014 PASSPORT study. The team has since progressed to the top spot internationally, exceeding their target by 340% Academic Development The R&D Department launched the first internal grant funding scheme, in collaboration with UHNS Charity and the Guy Hilton Asthma Trust. The scheme is aimed at supporting the development of home-grown research ideas with a view to providing the pilot data required for a full NIHR grant application. Bids are currently being peer reviewed with a view to announcing the successful bids within the next month. The team continues to work with new researchers to develop ideas for funding and continues to strengthen links with external collaborators. An example of this is the ongoing work with SSOTP in which the academic team are supporting a service evaluation of the use of Geriatricians in GP practices. The study focuses on recording changes in admissions, healthcare usage and prescription costs in complex multimorbid patients that have had a comprehensive geriatric review in the community. The team will report on the findings in July and December 2014. Education links • Work is on-going in partnership with the Healthcare Careers and Skills Academy, Staffordshire University and Stoke-on-Trent College to develop an accredited course for non-clinical research staff based on core competencies. This is the first of its kind in England. • From September 2014, the R&D Department will be a mandatory placement as part of the curriculum for Student Nurses and Midwives in all 3 years of training. It is believed to be the first in the country to have research embedded in training in this way. • Workshops are being developed in key skills such as grant writing to support new researchers and provide support for existing academics in order to improve the quality of grant submisstions. • Links are being developed with Keele University to provide projects and clinical supervision for intercalating medical students. There are also developing ties between R&D and the academic junior doctor programme to provide an end-to-end process for developing home-grown academics of the future. 2014/15 Q1 progress against Annual Plan targets From the R&D Strategy and Trust Annual Plan, the targets for research and development activity focused on two main strands: 1. Commercial Development: This will focus on increasing commercial clinical trials activity & income, improving links with commercial partners, enhancing our commercialisation and intellectual property portfolio, with concomitant investment in the infrastructure to support this growth. 2. Academic Development: This will concentrate on significantly increasing the number of clinical academics, developing a proactive programme of grant submissions, with the Heath Services Research Unit, linked to local clinical priorities, developing our own Clinical Trials Unit expertise and creating an Clinical Academic Facility on the hospital site. Consequently, the focus of R&D activity has been to support these developments. Progress in this regard is outlined below: 1. Commercial Development & Clinical Trials Business Case posts Key elements include for the commercial development associated with the R&D business plan to date include: • Commercial Development Team, Second Commercial Development officer started in Aug 2014 followed by a Commercial Development Lead in Sept 2014 and by administrative support (currently out to advert). • Research Services Manager: Secondment opportunity to lead the research funding projects to maximise income through streamlining invoicing, improving transparency and incentivise Research and Development Update Q1 November 2014 researchers. • Marketing & Publicity Officer: Joint post with UHNS Charity being developed to improve the profile of research at UHNS internally & externally. Overall, since the approval of the business case, the number of research nurses has almost doubled, reflecting increased commercial clinical trials business. Income & Activity West Midlands Clinical Research Network (portfolio clinical trials) The UHNS full year allocation and recruitment target has recently been confirmed. The total income allocated is £1.96M with a patient recruitment target to portfolio clinical trials of 3534. Recruitment in Q1 was 716 against a target of 885 (81%), reflecting the challenging recruitment climate nationally & regionally (WM recruitment at M4 was 82%). Commercial clinical trials The commercial clinical trials portfolio is increasing with 8 new trials opening within 2014/15 Q1 (against a pro rata target of 8.4). Furthermore, the pipeline is healthy and success rate increasing significantly with around 50% of Expressions of Interest being converted to successful placement of business with UHNS. There will be a lag period for this to be reflected in income, though the commercial income for Q1 (£142k) is consistent with expectations given they cyclical invoicing schedule for commercial and grant income. WM Clinical Research Network data indicates that UHNS is above average in terms of the proportion of commercial trials relative to total studies open (25% vs a regional average of 20%), illustrating the UHNS R&S Strategy emphasis on expanding the commercial trial portfolio. Governance This continued to perform well with 94% of projects being approved within 15 days (target: 80%). Furthermore, 98% of study amendments are processed within the required 35 days. Ranking UHNS ranking figures for the updated Guardian rankings for patient recruitment (51) and number of studies open (43) were below target, though these are always a year behind and represent performance for 2013/14. 2. Academic Development Business Case posts Phase 1 of the recruitment of clinical academics include the following key posts: • Chair in Interventional Cardiology, with associated clinical academic support team; a key component of the aim to develop the first of the integrated clinical-academic units outlined in the 2025 Vision, alongside the development of a process for honorary academic posts for the existing research active cardiology team. (Job packs being finalised) • Clinical Research Fellow in Laboratory Medicine. To support the UHNS research linking renal, metabolic and cardiovascular multi-morbidities. Appointed Sept 2014. Further clinical academic posts being developed in metabolic medicine, respiratory medicine, orthopaedic and imaging to align with UHNS priorities within the 2025 Vision and Keele strengths, as per the Strategy. These posts seek to build critical mass in the three integrated clinic-academic service areas: 1. Cardiovascular and respiratory 2. Trauma and orthopaedics 3. Metabolic medicine Income & Activity NIHR Research Capability Funding (RCF) income is a marker of total NIHR grant income. For 2014/15, this is on target to over-perform by 63% (£226k against a target of £139k). Furthermore, the pipeline for new grants is promising (value £1.26M for Q1 against a target of £1.05M; 20% above target), including 5 new Fellowship applications against a Q1 pro rata target of 1.2. Furthermore, new grant submissions have included 7 new academic researchers as applicants at Q1 (pro rata target 4.2). Grant submission success rate for the previous 12 months (rolling average) is also above target at 27. Total grant income is above target at £199k against a Q1 pro rata target of £100k. Ranking UHNS ranking for NIHR grant income has improved from 69th in 2013/14 to 55th currently against a 2014/15 target of 60th. Research and Development Update Q1 November 2014 Annual Plan Summary and performance against targets As part of the 5-year R&D Strategy, the Annual Plan outlines the key targets for 2014/15: • • • • • • • • £1.2M of commercial income. 33 commercial clinical trials contracts. £400k of NIHR grant income. £139K of Research Capacity Funding. Ranked 60th or higher for Research Capacity Funding Ranked 34th or higher for patient recruitment with 4050 patients being recruited to at least 127 studies. At least 80% of R&D approvals processed within 15 days. 110 local study leaders comprising including at least 93 principal investigators (local leadership of research studies originating elsewhere) and at least 17 chief investigators (home-grown research studies). While accuracy of these figures will become more robust as the year progresses due to the quarterly invoicing schedules for some income streams, at Q1 performance against these targets is as follows: • commercial income • commercial clinical trials contracts • NIHR grant income • Research Capacity Funding income • Research Capacity Funding ranking • Guardian recruitment ranking • Guardian studies ranking • R&D approvals • Principal investigators • Chief investigators (new) Key Recommendations £142k (target £245k) 35 (target 33) £134k NIHR + 65k non-NIHR grant income (target £100k) £56.6 (target £34.7k) 55th (target 60th) 51st (target 42nd) 43th (target 34th) 94% (target >80%) 125 (target 93) 7 new (Q1 pro rata target 4.2) To review and comment on the performance against the Annual Plan targets for 2014/15. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications x x Implications Implications Implications Research and Development Update Q1 November 2014 x EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: 11 Public Trust Board Date: 7th November 2014 Month 6 Performance Report Rachel Bayley, Assistant Director of Performance & Jane King, Performance Manager Helen Lingham, Chief Operating Officer N/A Purpose Decision Provides a summary of the Trust performance at month 6 (September), and year to date, against the key national standards and contractual standards agreed with Approval CCGs for 2014/15. Information Link to Strategic Priorities Deliver safe, appropriate and effective patient care Efficiency driven by innovation, teaching, research and education Be efficient and financially stable Build a positive reputation and play a key role in the wider economy Executive Summary Indicators reported within the Performance Report are consistent with the Trust Development Authority (TDA) Planning Guidance for NHS Trust Boards and The Accountability Framework for NHS Trust Boards 2014/15. The Performance at a Glance section is based on the known indicators within the TDA Oversight Model, where by NHS Trusts are awarded monthly ratings based on their performance against Quality, Governance and Finance standards. Key areas of Risk: • 4 Hour Wait Standard – Performance continues to remain static between 86-88%, with continued demand pressures, restricted flow through the organisation and bed capacity as key factors impacting on delivery. The LHE SMART plan has been refreshed to focus on 7 key areas under the 3 themes of: demand management, in-hospital objectives and exit from the acute Trust. In addition, a number of schemes/actions have been agreed and are being implemented by the local health economy as part of the winter resilience and operational funds to support delivery of the SMART plan and achievement of the standard. The Trust is continuing to evidence that it is providing high quality emergency services and a good experience for patients, with 81.8% of patients in September stating that they were extremely likely or likely to recommend the Trusts’ Emergency Department (ED) to their family and friends. • 12 Hour Trolley Waits in A&E - Fourteen 12 hour trolley waits occurred in September. The Trust has continued to experience growth in demand significantly in excess of planned activity levels in September resulting in capacity and patient flow pressures across the Trust which has impacted on the Trust's ability to admit patients in a timely manner. An underlying theme of access to a side rooms has emerged, which either contributed to, or directly resulted in a number of the breaches in September. An investigation was undertaken earlier in the year by the Associate Chief Nurse to determine if there are any actions that can be taken to mitigate the risk of a future breaches occurring relating to side rooms. An action from the review is currently being Executive Summary Front Sheet undertaken to revisit the side room policy with Infection Control to ensure immediate and timely access to side rooms. • Ambulance Handover Delays >60 minutes – In September 10 patients exceeded 60 minutes from ambulance arrival to being triaged by an Emergency Department nurse. In the main, breaches of the standard occur when the volume of patients within the ED rises to peak levels, there are surges in demand and or the acuity of patients is the ED increases. The median time to triage for patients attending the Emergency Department by ambulance has deteriorated to 7 minutes in September. There are two standards relating to ambulance handover and at month 6 the Trust has made a provision of £107k for any contractual penalties relating to these standards. A business case to support additional staffing to undertake Rapid Assessment and Triage of patients within the ambulance assessment area, which is expected to improve performance against these standards, was approved at the Trust Executive Committee in July and recruitment to these additional posts is currently underway. • Cancer 62 Day standard – Demand pressures and underperformance against internal targets which ensure efficiency of the diagnostic phase of the pathway are key factors impacting on performance. At present variability of histopathology performance is a risk. Commissioners have issued a contract query in relation to the underperformance, and the Trust have agreed a remedial action plan which focuses on delivery against trajectory, and of internal reporting turnaround standards for Histology and Imaging. Escalated performance management arrangements will remain in place until performance is improved to the threshold level and sustained. Further information regarding on-going actions can be seen on page 6 of the report. Key Recommendations 1. To note the performance in September 2014, the key indicators of the 4 hour wait standard and Cancer 62 days are the key risk which shows the Trust in material breach of the NHS TDA Accountability Framework. 2. To be assured that the actions being taken against key risks areas are being delivered and are resulting in improvements mitigating the performance risk in 2014/15 as led by the COO. 3. To note the key financial risks are underperformance against the following standards: 4 hour wait, 12 hour trolley waits, ambulance handover, 18 weeks admitted, diagnostic 6 week (underperformance in Q1) and cancer 62 days. 4. The HR team continues to seek confirmation from managers that appraisals are being arranged and undertaken in a timely fashion, to ensure compliance with the Trust target. The CEO has reiterated this message in the October bulletin which is issued to all employees. Those wards and departments reporting difficulties with compliance have been identified and managers have been asked to address shortfalls with immediate effect. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Quality Financial Legal Workforce Implications Implications Implications Implications Executive Summary Front Sheet PERFORMANCE REPORT September 2014 “We will be a leading centre in healthcare driven by excellence in patient experience, research, teaching and education.” Author: Rachel Bayley, Assistant Director of Performance, Jane King Performance Manager Executive Lead: Vivien Hall, Chief Operating Officer Title of Report: Performance Report Version 1 CONTENTS No Title Page 1 Trust Performance at a glance 2 2 Activity 3 3 Emergency Care Pathway 4 4 Elective Care Pathway 5 5 Cancer Pathway 6 6 Staffing and Organisational Development 7 7 Exception Reports 8 1 Trust Performance at a Glance Key indicators from the NHS Trust Development Authority Accountability Framework for NHS Trust Boards & Planning Guidance 2014/15 The performance at a glance indicators have been grouped to report an overall rating based on the monthly performance. Detailed monthly performance data for the indicators can be seen on the appropriate page within this report. Summary In September the monthly RAG rating for the grouped national operational performance standards and NHS Trust Development Authority metrics has improved/maintained compared to the previous month with the exception of: • 4 Hour Wait Standard - continued underperformance of this standard • Cancer 62 day - continued underperformance against the main standard of 62 days from GP referral to first definitive treatment and underachievement in month against the 62 Day Screening standard. • Organisational Development - a marginal improvement in the sickness absence rate and a decrease in performance for apprasials was seen in September. • There has been a deterioration in performance against Quality standards in September due to a never event occurring in month 4 Hour Wait standard YTD A&E 4 Hour Wait R Q2 Forecast 87.3% Performance continues to remain static between 86-88%, with continued demand pressures, restricted flow through the organisation and bed capacity as key factors impacting on delivery. Access YTD 18 Weeks - Non-admitted 18 Weeks - Admitted 18 Weeks - Incomplete Pathways RTT Waits of more than 52 weeks Diagnostic tests >6 weeks 97.2% 91.7% 96.4% 0 1.29% The LHE SMART plan has been refreshed to focus on 7 key areas under the 3 themes of: demand management, in-hospital objectives and exit from the acute Trust. In addition, a number of schemes/actions have been agreed and are being implemented by the local health economy as part of the winter resilience and operational funds to support delivery of the SMART plan and achievement of the standard. The Trust continued to achieve all the 18 week standards in September. Cancer 2 Week Wait Cancer 31 Day YTD Cancer 2 WW - GP referral Cancer 2 WW - GP referral - breast symptoms G Q2 Forecast 97.9% 95.6% Cancelled Operations YTD Cancelled operations rebooked <28 days Urgent operations cancelled 2nd time G Q2 Forecast 0 0 There continues to be no reported breaches against either of the cancelled operations standards. The diagnostic standard was again achieved in September and the year to date position has improved although it remains above target. Nationally this standard is measured monthly and not YTD . YTD 31 Day - 1st treatment 31 Day - 2nd or subs treatment - Surgery 31 Day - 2nd or subs treatment - Drugs 31 Day - 2nd or subs treatment - Radiotherapy Both the Cancer two week wait standards have been achieved in month and continue to be achieved year to date. G Q2 Forecast G Q2 Forecast 97.6% 98.0% 99.7% 98.6% Cancer 62 Day YTD 62 Day - Urgent GP referral 62 Day - Urgent GP referral - Screening All of the 31 Day standards have been achieved in the month of September and continue to be met YTD. A Q2 Forecast 81.2% 90.4% Demand pressures and underperformance against internal targets which ensure efficiency of the diagnostic phase of the pathway are key factors impacting on performance. At present variability of histopathology performance is a risk. Commissioners have issued a contract query in relation to the underperformance, and the Trust have agreed a remedial action plan which focuses on delivery against trajectory, and of internal reporting turnaround standards for Histology and Imaging. 30 Day Re-Admissions A YTD 30 Day emergency readmissions - NEL 30 Day emergency readmissions - Elective Organisational Development Q2 Forecast 106 123 The non-elective re-admissions is rated Green in month, however, the elective re-admissions has risen significantly and is rated Red and both are rated RED year to date (as per HED data). A YTD Sickness absence rate (days lost) Staff turnover (12 month rolling average) Appraisal rates (12 month rolling average) 3.85% 7.88% 90.7% Q2 Forecast N/A N/A N/A There was a marginal improvement in sickness absence in September. Actions are being taken to improve sickness rates across the Trust, see page 7 for further details. Appraisal rates deteriorated slightly in September. See page 7 for details of actions being taken to improve performance against this standard. Key Risks: Resilience of performance against the 4 hour wait standard, has not yet been achieved. Resilience of performance against the62 day standard, has not yet been achieved. Escalated performance management arrangements will remain in place until performance is improved to the threshold level and sustained. Patient Experience/Safety/Outcomes A YTD Adult Inpatients Scores from Friends & Family Test - Mthly A&E - Scores from Friends & Family Test Mthly C-Difficile MRSA Never Events HSMR - (May 13 -Apr 14) SHMI - YTD (July 12 - June 13) 74 38 30 2 2 84.2 1.07 Q2 Forecast N/A N/A Four out of the seven indicators are being achieved YTD or monthly (where applicable) with the A&E Friends & Family Test underachieving in September. Unfortunately, the Trust is reporting a never event in September, please see page 8 for further details. Mitigating Strategy: Delivery of the LHE Urgent Care SMART Recovery Plan and the supporting schemes within the LHE Winter Resiliance and operational funds, actions overseen by the LHE System Resilience Group. Risk Rating High Trust has an action plan in place and has delivered a number of these in the last 3 months resulting in improvements across the 62 day pathway. Actions continue to focus on ensuring sufficient capacity is in place to meet demand. High 2 ACTIVITY YTD ACTIVITY 14/15 - Month 5 Total SLA Daycases ACT VAR VOL % Activity 13/14 29,834 29,708 -126 0% 26,266 7,158 7,081 -77 -1% 6,162 149 195 46 31% 225 Sub Total 37,141 36,984 -157 0% 32,653 Non Elective 32,515 33,400 885 3% 30,990 Non Elective Non Emergency 10,049 10,328 279 3% 10,074 Sub Total 42,564 43,728 1,164 3% 41,064 2,573 3,173 600 23% 2,988 Non Elective Excess Bed Days 10,092 13,938 3,846 38% 11,069 Non Elective Non Emergency Excess Bed Days 684 711 27 4% 933 Sub Total 13,349 17,822 4,473 34% 14,990 New Outpatients 74,197 83,252 9,055 12% 74,503 Follow -up Outpatients 170,809 165,032 -5,777 -3% 156,297 Outpatient Procedures 29,476 31,395 1,919 7% 25,679 274,482 279,679 5,197 2% A&E 62,036 65,141 3,105 5% Sub Total 62,036 65,141 3,105 5% 60,251 Non FCEs 160,220 177,340 17,120 11% 168,174 Sub Total 160,220 177,340 17,120 11% 168,174 Elective Inpatients Regular Daycase Excess Bed Days Sub Total COMMENTARY It should be noted that the figures quoted are still subject to final validation following the closure of activity and finance freeze dates. Initial month 6 figures have recently become available and after calculating accruals and provisions it is 256,479 showing an overall contractual over performance of £2.757m against the TDA plan. This position includes accruals for un-coded activity / provisions against penalties, emergency threshold claw 60,251 back and CQUIN underachievement. 3 EMERGENCY CARE PATHWAY Executive Lead: Chief Operating Officer Emergency Care Indicators Demand (A&E only): A&E Attendances Contracted daily volume A&E Attendances Daily Average September A&E Attendances Peak 22/9/14 329 355 438 NEL Admissions Contracted daily volume September NEL Admissions Daily Average September Total NEL Admissions 175 179 5382 A&E Total Attendances September Over 4 Hour Wait 10,678 2257 Exception Report 4 hour wait standard Performance: • Monthly performance throughout 2014 has remained static between 86%-88%, • Performance was more challenged at the start of September, with an improving trend throughout the month and performance in excess of 90% during the last week of the month. Key Factor impacting on performance • Continued high demand in excess of contracted levels – During Q2 daily attendances on average were 354, which is +25 per day and +175 per week in excess of contracted levels. The Trust ED staffing levels are based on 340 attendances per day. • Flow through the organisation - The Trust needs to build on the improvement achieved to date against discharge targets with a focus on maximising complex discharges. In addition, the Trust has an excessive number of patients in acute beds awaiting exit from the Trust including unmet demand, and patients medically fit awaiting an assessment. In September the Trust had an average of 47 unmet demand per day and 143 patients medically fit for discharge but awaiting assessment. Target Month YTD Q2 Forecast 4 hour wait (LHE) 95% 85.1% 87.3% Unplanned re-attendance rate* 5% 6.9% N/A N/A Left without being seen rate* 5% 4.1% N/A N/A Time to initial assessment: 95th percentile* 15mins 67 N/A N/A Time to treatment decision: median* 60mins 76 N/A N/A 0 14 18 <100 107 106 46 38 N/A 3.5% 2.40% 2.20% Trend Accident & Emergency Number of 12 hour trolley waits in A&E 30 Day emergency readmissions - Non-Elective (Mth - June 2014, YTD12 month rolling average) Net Promoter - A&E (national benchmark is 71, NTDA accountability framework target is 46) Delayed Transfers of Care N/A Ambulance Clinical Handovers >30 minutes but <60 minutes of arrival at A&E - 0 369 2001 Key actions include: Number of patients The Local Health Economy (LHE) SMART plan has been in place since May 14, however it has been rrevised to take into account learning from the original plan, and the outcomes from the June review of the urgent care system undertaken by the Emergency Care Intensive Support Team. Clinical handover >60 minutes of arrival at A&E - Number of patients 0 10 37 There are 7 key priorities within the plan, which are considered as having the greatest impact upon the system, under the 3 distinct themes NTDA Accountability Framework Over-ride Scores - underperformance against these standards has greater impact on the Trust rating. summarized below. As reported in the previous report, UHNS has refreshed its demand and capacity modelling for 2014/15 in response to the significant demand seen by the Trust in Q1, in excess of the original planned levels. This modelling has formed the basis of the LHE Resilience plans for October - March and plans submitted for use of the winter resilience and the operational resilience funds support delivery of the SMART plan objectives. Trends 1. Demand Management - focused on increasing and promoting alternative services away from the acute Trust to reduce demand in line with contract levels. 2. In hospital Objectives - focused on delivery of UHNS capacity plans schemes to increase and maximise bed capacity. Implementation of Ambulatory Emergency Care at scale to ensure patients are seen in the most appropriate setting and reduce demand on the main Emergency Department. UHNS are focused on optimising discharged across the Trust with a targeted approach, daily discharge targets in place for each ward area , and reduction of length of stay in order to create capacity and flow within the organisation. 3. Exit from Acute Trust – the LHE will implement Discharge To Assess during Q3/4, with the scheme expected to realise a reduction in LoS and excess bed days, increase complex discharges by up to 12 per day enhancing system flow. The project has been accelerated and timescales and the detail of the project are being finalised. However, stage 1 of the project has been implemented but needs to be extended, phase 2 is estimated to be implemented in the next 4 weeks, and stage 3 in the next 6 – 8 weeks. Dates to be determined. Performance Against the SMART Plan • AEC – The Trust has delivered its target to implement 18 hot clinic slots per week. • Performance against A&E clinical indicators was outside of the threshold but the trend is improving: o Time to initial assessment (15 mins) – improvement from an average of 97 minutes at the start of the month to 38 minutes at month end. o Time to treatment (60 mins) – improvement from an average of 90 minutes at the start of the month to 60 minutes at month end. Discharges: • performance against the ECIST best practice standard of 35% of discharges by 1pm, is on average 29% per week in September • The Trust increased its S&T discharge volumes in September, and in the main achieved the weekday target and weekend targets. o Target 610 S&T (weekday) – improvement from 542 the first week in the month to 643 in the last week of the month. o Target 154 S&T (weekend) – improvement from 199 the first week in the month to 236 in the last week of the month. • However, the Trust is underperforming against the complex discharge target with an average of 173 per week against the weekly target of 215. Reportable 12 Hour Trolley Waits in A&E- RCA's have been completed for the fourteen events which took place in September. The lessons learned and action plans will be reported through the Trust's Quality & Safety Forum and the SI Panel with Clinical Commissioning Groups (CCG's). See page 8 for further details. 4 Elective Care Pathway Executive Lead: Chief Operating Officer Commentary 18 Weeks: September has seen the sustained delivery of all the standards and in particular performance for the admitted standard was again achieved across all specialties. The inpatient backlog rose again in September and continues to rise in October with current levels at the highest this year. Reportable and Urgent Cancelled Operations Performance: The number of cancelled operations continues to be above plan for 14/15 and in September saw an increase in the number of patients cancelled at the last minute. Elective Pathway Indicators Target Month YTD 18 Weeks - Non-admitted 95% 97.5% 97.2% 18 Weeks - Admitted 90% 93.3% 91.7% 18 Weeks - Incomplete Pathways 92% 95.6% 96.4% 0 0 0 Diagnostic tests >6 weeks <1% 0.23% 1.29% 90% of women have seen a midwife or an obstetrician for health & social care assessment of needs / risk by 12 weeks 6 days of their pregnancy 90% 91.2% 93.0% Trust to ensure that “sufficient appointment slots” are made available on the Choose and Book system - slot issue rate of < 0.04 (incl Stafford & Cannock data) 0.04 Not Available N/A Actions: As noted on page 4, the actions being taken by the local health economy and Trust are focused on reducing pressure and demand on the Acute ED and acute beds, and creating capacity and flow within the Trust. Thus, the actions included within the LHE SMART plan and the schemes that are being progressed as part of the Winter Resilience and Operational funds will support the reduction of cancelled operations. In addition, the Trust Executive Committee has recently supported the expansion of the Critical Care Department and the increased capacity is due to be opened in December 2014. The Trust is continuing to roll out of the STEP project (Surgical Theatres Efficiency Programme) 0 0 0 0 0 0 107 549 Cancelled Operations Cancelled operations rebooked <28 days Urgent operations cancelled 2nd time Reduction in the number of cancelled operations (baseline 2013/14) 807 Total number of Urgent cancelled operations (baseline 2013/14) 59 1 8 <100 146 123 60 74 N/A 90% 99.9% 81.3% 98% 99.29% 99.6% Patient Experience 30 Day emergency readmissions - Elective (Mth - June 2014, YTD-12 month rolling average) Appointment Slot Issues (ASIs) Net Promoter - Adult Inpatients (national benchmark is 71, NTDA accountability framework target is 60) Data for this standard is provided via the Choose and Book (CaB) system which is external to the Tust. There are currently data quality issues with the figures being reported which are under investagation Theerfore, it is not possible to report the September position at this time. Reporting Standards Results of all plain film x-ray diagnostics will be provided to the GP no more than 5 working days after the date of the imaging appointment Results of all non-obstetric ultra-sounds will be provided to the GP no more than 5 working days after the date of the imaging appointment Diagnostics tests >6 weeks The Trust has successfully delivered the remedial actions put in place in response to the underachievement of the standard in quarter 1. However, performance deteriorated in September compared to the previous month but remains within the 1% standard. Trend Access 0 tolerance to RTT Waits of more than 52 weeks Key Factor impacting on performance The increase in non-elective demand, in particular surges of trauma demand, has impacted on elective services that require in patient beds resulting in an increase in cancellations of elective operations. Trauma and Orthopaedics, Cardiothoracic Surgery, Neurosurgery and Urology have been the most affected and account for 56% of the total cancellations. Cancellations resulting from a lack of beds and critical care beds accounts for 40% (222) of the cancellations. In addition, 83 cancellations have occurred as a result of priority emergency patients. Q2 Forecast N/A NTDA Accountability Framework Over-ride Scores - underperformance against these standards has greater impact on the Trust rating. Plain film diagnostics provided to GPs <5 days The performance against the Plain film diagnostics provided to GPs <5 days standard improved significantly in September 2014. Demand for all diagnostic reporting has been challenged in 2014 due to increased activity levels particularly non-elective, inpatient and cancer activity all of which is a clinical priority over routine plain film reporting. In addition, there are capacity challenges, despite investment in the medical workforce, due to difficulties in recruitment to posts. To maintain performance the Imaging Directorate had been outsourcing plain film reporting for a number of months. In July and August 2014 the external provider did not have sufficient capacity to meet demand which resulted in a drop in performance. However, in September performance improved considerably and is now back on track with 99.9% of plain films being reported to GP’s within 5 days. 5 Cancer Pathway Executive Lead: Chief Operating Officer Cancer Pathway Indicators Commentary Demand Total 2 week wait referrals September 1295 Reduction in referrals in September 1.1% Highest ever peak of 2ww referrals in July Total 2 week wait breast symptom referrals August 175 Target Month YTD Q2 Forecast 2 WW - GP referral to 1st outpatient cancer 93% 98.1% 97.9% 97.9% 2 WW - GP referral to 1st outpatient - breast symptoms 93% 98.9% 95.6% 95.6% 31 Day - Diagnostic to 1st treatment 96% 99.6% 97.6% 97.6% (including 2 breaches), the year to date remains above the 90% standard. 31 Day - 2nd or subsequent treatment - Surgery 94% 97.5% 98.0% 98.0% Exception Report - Cancer 62 Days 31 Day - 2nd or subsequent treatment - Drugs 98% 100% 99.7% 99.7% 31 Day - 2nd or subsequent treatment - Radiotherapy 94% 98.5% 98.6% 98.6% 62 Day - Urgent GP referral to treatment 85% 81.1% 81.2% 81.2% 62 Day - Urgent GP referral to treatment - Screening 90% 87.5% 90.4% 90.4% 62 Day - Urgent GP referral to treatment - Consultant Upgrade ** 93% ** 92.1% 95.4% 95.4% 62 Day Screening - The standard was underachieved in September (provisional) due to the small volume of patients Performance • The Trust has underperformed against the standard since January and is currently underachieving its recovery trajectory. • Actions taken by the Trust improved performance in June, but delivery has plateaued at circa 3% below the standard, with circa 4 breaches per month in excess of the target. • The risk cancer sites affecting performance are: Urology, Lung, Lower GI, Gynaecology and Head & Neck. • Q2 provisional performance is currently at 81.7%. Q3 performance is currently estimated at 82.6% • Nationally performance against the 62 day standard has been challenged throughout 2014, and this has continued in August (note national performance is 1 month behind the reporting period), with a national performance of 84%. However, UHNS performance was below the national average. • In addition, performance across the region against the 62 day standard has been challenged, in Q1, 3 out of 5 Trusts failed the 62 day standard, including UHNS. Key factors affecting delivery of the standard • Demand continues on a growing trend with a circa 15% increase compared to the previous year. In July the Trust saw a significant peak in 2ww referrals, as expected the volume of referrals dropped slightly in August and September in line with seasonal trends, however demand has peaked again in October with the highest ever number of 2ww referrals seen by the Trust (1560). • The Trust has been unable to deliver key internal targets to ensure efficiency of the overall pathway, in particular due to demand and capacity pressures in Histopathology and Imaging, in part as a result of the increase in referrals noted above, and difficulties in the recruitment to hard to fill posts in these areas which is a national issue. ** Contractual target, no national standard 62Day Recovery Trajectory *provisional, **Prediction UHNS August 2014 Performance Against The National Performance for August 2014 Aug-14 Actions and Improvements: The Trust is working with CCGs and a contract query has been issued due to the underperformance against the standard. A Remedial Action Plan has been agreed which is focused on delivery against the trajectory, and delivery of the following internal standards: • 70% of 2ww referrals seen within 7 days • 80% of histology reporting within 7 days biopsies and 10 days resections • 95% diagnostic investigations/imaging for patients on a cancer pathway within 14 days from request to report. Trend National Standard UHNS August 2014 National August 2014 2ww 2ww Breast Symptom 31 Day 1st Treatment 62 Day GP Referrals 62 Day Screening 93.0% 98.1% 93.0% 93.0% 98.6% 93.3% 96.0% 97.6% 97.8% 85.0% 82.2% 84.0% 90.0% 94.9% 94.2% Performance management arrangements and monitoring of the pathway has been escalated throughout the year, which will continue until delivery is improved to the threshold level and sustained, including: • Daily meetings to review the 62 day Patient Tracking Lists (PTL) with specialty teams, during the course of a week all patients on the PTL are reviewed, weekly cancer meetings, to provide oversight of performance and areas of concern/risk. • Weekly Performance meeting with the Chief Operating Officer and senior team with oversight of cancer performance. Actions taken by the Trust are now resulting in the following improvements: • Outpatients – the Trust is sustainability delivering the internal standard noted above, with performance circa 10% in excess of the target. The Trust has a live demand and capacity modelling tool which specialties use on an operational basis to monitor and ensure sufficient capacity is in place to meet demand levels on an on-going basis. • Histology – Performance had significantly improved in excess of the recovery trajectory to the agreed target level, but since the end of July has deteriorated due to continuing vacancies within the team, and capacity constraints as a result of unexpected high sickness levels coupled with the summer holiday period. weekly performance is variable and the service need to embed improvements to ensure a consistent improvement in performance. At present Histology have 4 consultant vacancies, with a new consultant commencing at the start of November. A workforce plan is in place and the Trust is continuing with recruitment, which has attracted 2 candidates which are due to be interviewed early in November. In addition the team are continuing with remedial actions including: treatment initiatives, and outsourcing where possible. • Imaging –Imaging have a recovery trajectory in place to ensure that all diagnostic tests for patients on a cancer pathway are completed in 14 days, including the scan and the associated report. Performance has been significantly challenged against the internal standard through July and August, however the performance has drastically improved throughout September. 6 Staffing & Organisational Development Executive Lead: Director of Human Resources Commentary Sickness a) HR teams have analysed sickness patterns. Staff focus groups have been held and recommendations made to address Divisional issues. b) Checks are being carried out to ensure frequent sickness episodes are being managed according to Trust Policy Statutory and Mandatory Training - Letters were sent: to Directorates staff in their areas be brought up to date with statutory and mandatory training by 30 Sept 14. Those Directorates still underperforming against the 95% target have been asked to submit a trajectory showing when they will achieve the target Trainers have been asked to ensure locally delivered training is included in statutory and mandatory training rates. Additional e-learning modules are being developed and released for use. Appraisal Rates - Directorates are notified of the number of appraisals they need to complete to attain the 95% target. Letters were issued to Directorates requiring an improvement in perfomance by 30 Sept 14. Those Directorates still underperforming against the 95% target have been asked to submit a trajectory detailing when they will achieve the target and to confirm appraisal dates are in diaries. Specific dates have been allocated for all consultant appraisals Trends Staffing & OD Indicators Target YTD YTD Sickness absence rate (days lost) 3.39% 3.85% ↓ Long-term sickness rate (30+ days absence) 2.60% 2.36% ↔ Frequent sickness rates (4 or more episodes of absence) 3.35% 3.54% ↑ 11% 7.88% ↓ 95% 95.0% ↑ 95% 89.90% ↑ 95% 90.11% ↑ 95% 88.32% ↑ 95% 90.06% ↓ Appraisal Rates - Administrative and Clerical 95% 90.69% ↓ Statutory and Mandatory Training 95% 82.60% ↓ 63.3% 62.00% ↑ Staff turnover (12 month rolling average) Appraisal rates (12 month rolling average) - Consultant Medical Staff Appraisal rates (12 month rolling average) - Trust (excl Consultant Medical Staff). Of which…. Appraisal Rates - Qualified Nursing Staff Appraisal Rates - Add Prof Scientific and Technic; Allied Health Professionals; Healthcare Scientists Appraisal Rates - Additional Clinical Services; Estates and Ancillary Pay costs as a % of income (target: monthly 63.8%, annual 63.3%) NHS staff engagement (Target = 2014 National average for acute trusts) Staff Friends and Family Test - combined result from all questionnaires (Target = Q1 result as a baseline measure ) Equality and diversity Measured Annually 61% 61% ↔ Measured Annually % of year 5 students, retained into F1 posts (excluding Stafford and Shrewsbury) [Annual Measure] 50.00% 43% ↑ % of F1 students retained into F2 Posts [Annual Measure] 50.00% 32% ↓ 7 September Exception Reports Please Note: The exception reports for the 4 hour wait standard (page 4) and the cancer 62 day standard (page 6) are provided within the main body of the report. Indicator: Ambulance handover >60 minutes of arrival at A&E Executive Lead: Chief Operating Officer Target Month Year to Date Q2 Forecast Current Performance 0 10 37 Explanation of Performance and Actions In September 10 patients exceeded 60 minutes from ambulance arrival to being triaged by an Emergency Department nurse, the details are listed below. Research has shown that patients who wait a significant length of time in the Emergency Department have increased mortality and length of stay. Maintaining patient safety remains a key priority for the Emergency Department (ED). • 1 breach occurred following a surge of attendances to the Department • 1 breach occurred when there were capacity issues across the Trust and patients were waiting for a medical bed. • 3 breaches occurred on a day when 369 patients attended the Emergency Department, attendances greater than 340 are considered a significant peak and impacts on flow with the ED. A sustained peak in attendances (166) occurred in the 5 hours prior to the arrival of these three patients • 3 breaches occurred on a day when the Trust was experiencing capacity issues and patients waited in the Department for beds thus impacting on capacity within the Emergency Department. • 2 breaches occurred on a day when 438 patients attended the Emergency Department, attendances greater that 340 are considered a significant peak and impacts on flow within the Emergency Department (ED). A sustained peak in attendances (97) occurred 3 hours prior to the arrival of these patients and a further 2 hours following. The median time to triage for patients attending the Emergency Department by ambulance for September is 7 minutes. The Department endeavours to sustain its hard work and commitment to achieve the Clinical Quality Indicator for Emergency Departments standard of less than 15 minutes to nurse triage. Indicator: 12 Hour Trolley Waits in A&E Executive Lead: Chief Operating Officer Target Month Year to Date Q2 Forecast Current Performance 0 14 18 Explanation of Performance and Actions Fourteen 12 hour trolley waits occurred September. Research has shown that patients who wait a significant length of time in the Emergency Department have increased mortality and length of stay. The Trust recognises and is committed to delivering a 'zero tolerance' stance to patients remaining on a trolley for an unacceptable amount of time. The Trust has continued to experience growth in demand significantly in excess of planned activity levels in September resulting in capacity and patient flow pressures across the Trust which has impacted on the Trust's ability to admit patients in a timely manner. An underlying theme of access to a side rooms has emerged, which either contributed to, or directly resulted in a number of the breaches in September. An investigation was undertaken earlier in the year by the Associate Chief Nurse to determine if there are any actions that can be taken to mitigate the risk of a future breaches occurring relating to side rooms. An action from the review is currently being undertaken to revisit the side room policy with Infection Control to ensure immediate and timely access to side rooms. In addition the Local Health Economy actions within the resilience and stabilisation plan aim to reduce occupancy rates in the acute trust which will improve access to inpatient beds for patients requiring admission. Root Cause Analysis (RCA's) were undertaken for all events which will identify lessons learnt and action required and will be presented to the Quality & Safety Forum and the Serious Incident Panel held with the Clinical Commissioning Groups (CCG's). .Indicator: Never Event Executive Lead: Chief Nurse Target Month Year to Date Q2 Forecast 0 1 2 Explanation of Performance and Actions The Trust logged a Never Event on 18th September 2014 relating to an incident that originated on 28th June 2014. The incident involved a retained swab following an emergency caesarean section. The patient was discharged from hospital and passed the swab seven weeks after delivery. In the intervening weeks the patient visited the GP who prescribed treatment for an infection and then again after the event where she was examined with no lasting harm identified. Current Performance All staff were alerted to the event via the Risk Management Panel meeting and an alert memo emailed to all staff by the Clinical Director. A RCA has been commenced by the Deputy Head of Midwifery/Divisional Matron and the Quality and Risk Manager for Obstetrics and Gynaecology. Accounts of involvement in care from all staff at the maternity unit and the GP surgery have been requested and the Directorate are working closely with the Trust Risk Management department to finaise the RCA and associated outcomes/recommendations which will be presented at the Trust Risk Management Panel 27th November 2014. 8 EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: Public Trust Board Date: 7th November 2014 Finance Report - Month 6 2014/15 Sarah Preston, Operational Director of Finance Rob Jones, Assistant Director of Finance – Financial Management Chris Adcock, Director of Finance Finance and Efficiency Committee Trust Executive Committee TJNCC Purpose The purpose of this report is to set out the Trust’s financial and contracting performance for the period ending 30th September 2014, including: • Income and expenditure • CIP delivery • Balance sheet and cash flow • Capital programme • Financial risks • Year and forecast Link to Strategic Priorities Delivering quality excellence for patients. Delivering our obligations to the taxpayer. Achieving excellence in education and training. Creating an integrated trust with Stafford. Executive Summary • • • 12 Decision Approval Information The Trust’s financial performance to the end of September was £16k better than planned This was as a result of an over recovery on in come and an underspend on pay costs reduced by an overspend on non-pay costs leading to an EBITDA of £489k below plan This was mitigated by depreciation and other costs being £505k below plan. Key Recommendations The Board is asked to agree the content of the financial position report; the risks identified and endorse the mitigation strategy to secure our financial position in 2014/2015. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications Author: Sarah Preston, Operational Director of Finance & Rob Jones, Assistant Director of Finance Executive Lead: Chris Adcock, Director of Finance Month 6 Finance Report Version 1 EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: 11 Trust Board Date: 7th November 2014 Finance Report September 2014 - Month 6 2014/15 Sarah Preston, Operational Director of Finance Rob Jones, Assistant Director of Finance – Financial Management Chris Adcock, Director of Finance Trust Executive Committee Finance and Efficiency Committee TJNCC Purpose The purpose of this report is to set out the UHNS’s financial and contracting Decision performance for the period ending 30th September 2014, including:Approval • Income and Expenditure • CIP Delivery • Balance Sheet and Cash Flow • Capital Programme • Financial Risks Information • Year End Forecast The Trust referred to in this report relates to UHNS only and does not include any details relating to Stafford Hospital or the merged Trust, UHNM. Link to Strategic Priorities Deliver safe, appropriate and effective patient care Efficiency driven by innovation, teaching, research and education Be efficient and financially stable Build a positive reputation and play a key role in the wider economy Executive Summary • The Trust's financial performance to the end of September was £16k better than planned. • This was a result of an over recovery on income and an underspend on pay costs reduced by an overspend on non pay costs leading to an EBITDA of £489k below plan. This was mitigated by depreciation and other costs being £505k below plan. • The Trust's Year End Forecast at the end of September is in line with the planned deficit of £16,944m. Key Recommendations The Committee is asked: • To note the content of the financial position report along with the risks and mitigations identified. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications Author: Sarah Preston Executive Lead: Chris Adcock Title of Report: Finance Report M06 – September 2014 Version 1 EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: 13 Public Trust Board Date: Summary of Changes to Policies: Standing Financial Instructions Scheme of Reservation and Delegation of Powers Standing Orders Claire Fidler, Assistant Director of Finance – Chief Accountant Claire Rylands, Head of Corporate Affairs / Company Secretary Chris Adcock, Director of Finance Compliance Steering Group Trust Executive Committee Finance & Efficiency Committee Audit Committee Purpose To present a summary of changes to key corporate governance policies for approval. Decision Approval Information Link to Strategic Priorities Delivering quality excellence for patients. Delivering our obligations to the taxpayer. Achieving excellence in education and training. Creating an integrated trust with Stafford. Executive Summary Please note due to the size of these documents, they have been made available to Board members in electronic format only. Standing Financial Instructions / Scheme of Reservation and Delegation of Powers These policies have been reviewed and updated. Colleagues internally at the Trust have been consulted with as applicable (Finance Department, Supplies & Procurement Department, HR Department and Company Secretary). Sections relating to internal audit and counter fraud have been reviewed by the Trust’s internal auditor and counter fraud service provider – Baker Tilly. Within the electronic versions of these documents, changes have been highlighted for ease of reference. The list below details the general changes that have been made: 1 General formatting changes and changes to layout to make easier to read and follow Updated to reflect latest policy template Previously Standing Orders, Scheme of Reservation & Delegation of Powers and Standing Financial Instructions have been included as one policy, it has now been split into 3 policies with the Company Secretary being responsible for Standing Orders and the Finance department being responsible for the Scheme of Reservation & Delegation of Powers and Standing Financial Instructions Author: Claire Fidler, Chief Accountant and Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Chris Adcock, Director of Finance Summary of Changes to Policies Version 1 Reworded some sections to make the section clearer and easier to understand Included within the authorisation structure for non-pay costs is a ‘Budget Administrator’ with an authorisation value of up to £5,000 and amended Budget Manager limit to £25,000 (from £10,000) Additional detail has been provided (section 4.2.2 to 4.2.8) to define the roles of Budget Administrator, Budget Manager and Budget Holder No changes have been made in relation to the external auditors appointment, changes will be required at a future date when regulations change where trusts appoint own auditors Policy F04 Budgetary Control has been incorporated within the SFIs as oppose to having this as a separate policy Additional details have been included regarding the revenue business case process (section 4.6) and capital business case process (section 13.5) and approval levels All authorised signatories will be required to sign to confirm that they have read and understood the SFIs and Scheme of Reservation and Delegation of Powers. We will also provide all authorised signatories additional guidance which will include the key areas within the SFIs and Scheme of Reservation and Delegation of Powers. Standing Orders As described above, this policy was previously included within F01 Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions (SFIs). The policy has been updated and amended to reflect the current G01 template including the following; - An updated Statement on Trust Policies - Procedural information moved to appendices - Statement, Scope, Education/Training Plan for Implementation and Monitoring and Review Arrangements included - Definitions updated to ensure they reflect current practice The policy has been updated throughout to recognise current practice as well as current Board subcommittees and their functions. In addition references to ‘officer member’ and ‘non officer member’ have been changed to Executive Director and Non-Executive Director in order to avoid confusion. The name of the new integrated Trust is also reflected within the Introduction. With the exception of the above, the remainder of the policy remains unchanged. The Board should note that the policies have been taken through the appropriate process for approval. Key Recommendations The Board is asked to approve the changes to these policies. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications 2 Author: Claire Fidler, Chief Accountant and Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Chris Adcock, Director of Finance Summary of Changes to Policies Version 1 EXECUTIVE SUMMARY FRONT SHEET Agenda Item: Meeting: Title: Author: Executive Lead: Other meetings presented to: 14 Public Trust Board Date: 7th November 2014 NTDA Monthly Self Certification Returns Claire Rylands, Head of Corporate Affairs / Company Secretary Mark Hackett, Chief Executive n/a Purpose The enclosed document set out the Boards declaration of compliance against the governance requirements which are monitored by the NTDA. The information relates to September 2014. Link to Strategic Priorities Delivering quality excellence for patients Delivering our obligations to the taxpayer Achieving excellence in education and training Creating an integrated trust with Stafford Executive Summary Decision Approval Information The NTDA has established an oversight model which requires non-Foundation Trusts to submit a monthly self-certification declaration which is signed off by the Board. Within the enclosed declaration, there are some risks to compliance which have been identified. These relate to: Finance: The Board is satisfied that the Trust is currently a going concern in line with standard definitions, however longer term this will be confirmed through the final agreement of medium term cash support arrangements. The Trust was successful in its application for cash support required within the 2013/14 financial plan (confirmed by the ITFF in March 2014) and will be submitting a further application in 2014/15 in line with the updated 5 year plan. A further letter of support for this has been received from the TDA. The same internal governance processes which supported the application process in 2013/14 will be applied to the 2014/15 submission. Governance: The Board is committed to compliance with all known targets, however key risks relate to sustainable delivery of: 4 hour wait standard Performance: Monthly performance throughout 2014 has remained static between 86%-88%, During August performance was in excess of 90% for 11 days during the period, with the 95% standard only delivered on two days at the start of the month. The SMART plan and the new monies are aligned to supporting the revised 4 hour wait recovery trajectory detailed below. Q1 Q2 Jul NTDA Compliance Return – September 2014 October 2014 Aug Sep Oct Nov Dec Jan 15 Feb Mar Actual LHE Trajectory 87.7% 86.9% 88% 87.3% 85.1% 88% 87% 85% 87% 88% 90% 90% 92% 95% Key Factor impacting on performance Continued high demand in excess of contracted levels – During Q2 daily attendances on average were 354, which is +25 per day and +175 per week in excess of contracted levels. The Trust ED staffing levels are based on 340 attendances per day. Flow through the organization - The Trust needs to build on the improvement achieved to date against discharge targets with a focus on maximising complex discharges. In addition, the Trust has an excessive number of patients in acute beds awaiting exit from the Trust including unmet demand, and patients medically fit awaiting an assessment. In August we had an average of 7 complex delays per day and 147 patients medically fit for discharge but awaiting assessment. Key actions include: LHE SMART plan has been in place since May 14, however whilst this did achieve an improvement in performance it was recognized that it has not delivered a material change in delivery against the 95% threshold. Consequently the SMART plan has been revised to include learning from the original plan, and the outcomes from the June review of the urgent care system undertaken by the ECIST. There are 7 key priorities within the plan, which are considered as having the greatest impact upon the system, under the 3 distinct themes summarized below. The plans submitted for use of the winter resilience fund and the operational resilience funds support delivery of the SMART plan objectives: 1. Demand Management - focused on increasing and promoting alternative services away from the acute Trust to result in avoidance of emergency attendances and admissions to reduce demand in line with SLA levels, key Schemes include: o Enhanced clinical triage into the NHS 111 service –undertaken by an advanced nurse practioner, with the aim of promotion of alternative services. o GP front of house model - was implemented from the 7th October which saw the co-location of the current out of hour’s service with UHNS to provide patient streaming at the front door of A&E. At present the service is seeing circa 25 patients per day increasing up to a potential 50 per day. 2. In hospital Objectives - focused on delivery of UHNS capacity plans schemes to open additional, and or, release beds. To improve discharge processes and reduce length of stay to optimise bed usage and create flow across the Trust, key schemes include: o o Ambulatory Emergency Care – Implementation of an AEC model to ensure that patients are seen in the most clinically appropriate setting, which will reduce demand on the acute emergency service and streams patients to other alternative providers. Focused increase at UHNS on discharge of patients to release beds and create flow UHNS are currently focused on optimising discharged across the Trust with a targeted approach and daily discharge targets in place for each ward area. - Simple and timely discharges per day: 122 Monday – Friday, 77 Saturday – Sunday, - Complex discharge targets have been increased from 30 per day to 35 per day Monday – Friday and 20 per day on the weekend. The Trust is working to sustain the ECIST best practice standards including increasing discharges earlier in the day. Monitoring against discharge targets is included within the weekly SMART plan dashboard. o Additional Bed Capacity through the reconfiguration of the site, and refurbishment of ward space previously used as a non-clinical area, implementation of a step down model and purchase of beds at Stadium Court with medical cover provided by Aruna. o Exit from Acute Trust – focus on discharge to assess outside of the acute setting, to improve timeliness and increase of discharges, in particular complex discharges. NTDA Compliance Return – September 2014 October 2014 o Discharge to assess pilot With Stoke-on-Trent city council. 3. Exit from Acute Trust – the LHE will implement Discharge To Assess during Q3/4, with the scheme expected to realise a reduction in LoS and excess bed days, increase complex discharges by up to 12 per day enhancing system flow. The project has been accelerated and timescales and the detail of the project is currently being finalised in a meeting between LHE leaders on 20th October. However, stage 1 of the project has been implemented but needs to be extended, phase 2 is estimated to be implemented in the next 4 weeks, and stage 3 in the next 6 – 8 weeks. Dates to be determined. Oversight of the use of the resilience funds, progress and delivery of the schemes within the plans, and the impact of these on the overall performance against the 4 hour standard will be undertaken by the newly established System Resilience Group (reformed Urgent Care Working Groups), which is supported by a an Urgent Care Operational Group. Performance Against the SMART Plan – The KPI dashboard was revised in August in line with changes to the plan and was reinstated from the beginning of September, therefore the below performance relates to the weeks in September against revised KPIs: AEC – The Trust has delivered its target to implement 18 hot clinic slots per week. Performance against A&E clinical indicators for initial time to assessment and treatment, was out with the threshold across all four weeks in the month however there was a reduction in both with an improving trend o Time to initial assessment (15 mins) – improvement from an average of 97 minutes at the start of the month to 38 minutes at month end. o Time to treatment (60 mins) – improvement from an average of 90 minutes at the start of the month to 60 minutes at month end. Discharges: Trust performance against the ECIST best practice standard is on average 29% per week in September, and marginally below target compared to the standard of 35%. The Trust increased its S&T discharge volumes in September, and in the main achieved the weekday target and weekend targets. o Target 610 S&T (weekday) – improvement from 542 the first week in the month to 643 in the last week of the month. o Target 154 S&T (weekend) – improvement from 199 the first week in the month to 236 in the last week of the month. However, the Trust is underperforming against the complex discharge target with an average of 173 per week against the weekly target of 215. The Trust slightly reduced the number of patients with an >14 day LoS per week in September, with an improving trend. In addition, to respond to the predicted demand levels through the remainder of this year, the Trust is continuing to develop a stabilisation plan to address service demand predictions; capacity and income and expenditure needs to ensure the Trust will deliver its contractual objectives and ensure its service and financial recovery in 2014/15 are secured. Cancer 62 day standard Performance The Trust has underperformed against the standard since January and is currently underachieving its recovery trajectory. Actions taken by the Trust improved performance in June, but delivery has plateaued at circa 3% below the standard. Performance in August was 82.2%, with Q2 provisional performance at 81.7%. Nationally the A&E standard was underachieved in August at 84%, however UHNS performance was below the national average. Performance across the region against the 62 day standard has been challenged, in Q1 3 out of 5 Trusts failed the 62 day standard, including UHNS. NTDA Compliance Return – September 2014 October 2014 Actual Trajectory * Provisional. Q1 80.7% Q2 *81.7% Jul 81.9% 82.5% Aug 82.2% 85.4% Sep *81.1% 85.4% Key factors affecting delivery of the standard Demand continues on a growing trend, with the Trust experiencing its highest ever number of 2ww referrals in July 1527, the volume of referrals dropped slightly in August but this is expected in line with seasonal trends. Overall demand is circa 15% higher in 2014 compared to the previous year. The Trust has been unable to deliver key internal targets to ensure efficiency of the overall pathway, in particular due to demand and capacity pressures in Histopathology and Imaging. Actions and Improvements: Actions being taken by the Trust are focused on increasing capacity in the diagnostic phase of the pathway, to respond to demand pressures and to ensure delivery of internal set targets including: 70% of 2ww referrals seen within 7 days 80% of histology reporting within 7 days biopsies and 10 days resections 95% diagnostic investigations/imaging for patients on a cancer pathway within 14 days from request to report. Performance management arrangements and monitoring of the pathway have been escalated throughout the year in response to the performance and these will continue until delivery is improved to the threshold level and is sustained. Arrangements include: Daily review meetings chaired by Divisional Deputy Associate Directors and the Cancer Services Team, to review the 62 day PTL at patient level with specialty teams. Throughout the week all patients on the PTL are reviewed. Weekly cancer meetings, to provide oversight of performance and areas of concern/risk. Weekly Performance meeting with the Chief Operating Officer and senior team with oversight of cancer performance. Actions taken by the Trust are now resulting in the following improvements: Outpatients – the Trust is sustainability delivering the internal standard noted above, with performance circa 10% in excess of the target. The Trust has a live demand and capacity modeling tool which specialties use on an operational basis to monitor and ensure sufficient capacity is in place to meet demand levels on an ongoing basis. Histology – Performance had significantly improved in excess of the recovery trajectory to the agreed target level, but has subsequently reduced back to the recovery trajectory level due to unexpected high sickness levels, coupled with summer holiday period, despite continuing remedial actions including: treatment initiatives, outsourcing where possible and recruitment in line with the workforce plan. There has been a subsequent improvement in performance during September, however weekly performance is variable and the service need to embed improvements to ensure a consistent improvement in performance. Imaging –Imaging have a recovery trajectory in place to ensure that all diagnostic tests for patients on a cancer pathway are completed in 14 days, including the scan and the associated report. Performance has been significantly challenged against the internal standard through July and August, however the performance has drastically improved to recovery trajectory levels and this has been sustained since the end of August. The Trust is working with CCGs and a contract query has been issued in relation to performance against the standard. The Trust has agreed that the existing actions being taken to improve performance against the above areas formulate the basis of Trusts Remedial Action Plan. IG Toolkit The overall score has increased from 73% to 84%. The number of requirements at level 2 or above has increased from 42 to 43. However, as the Trust declared 1 requirement at level 1, the overall grade is NTDA Compliance Return – September 2014 October 2014 deemed as Not Satisfactory. This related to Information Governance Mandatory Training. A target of 95% of staff having received IG training within each 12 month period, is required as part of the toolkit submission. For 2013/2014 the Trust’s current position was 80% of all staff (including bank staff). A number of initiatives were implemented to support the Trust in achieving the 95% target. A review of the IG training plan has taken place in preparation for the delivery of training during 2014/2015. The online training pack has been updated and is now available to all staff. A number of additional face to face training sessions are being organized from October to March. The training plan and % will continue to be monitored via the Trust Information Governance Steering Group and at Performance Reviews. Key Recommendations The Board is asked to approve the returns and agree the actions to reduce risk to compliance which are summarised above. Corporate Impact Assessment (please tick any which are impacted on / relevant to this paper) Financial Legal Workforce Quality Implications Implications Implications Implications NTDA Compliance Return – September 2014 October 2014 Delivering for Patients: the 2014/15 Accountability Framework for NHS trust boards Monthly self-certification requirements Compliance with Monitor licence requirements for NHS Trusts – September 2014 Licence Condition Compliance Compliant 1 Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions) 2 Condition G7 – Registration with the Care Quality Commission 3 Condition G8 – Patient eligibility and selection criteria 4 Condition P1 – Recording of information Compliant 5 Condition P2 – Provision of information Compliant 6 Condition P3 – Assurance report on submissions to Monitor 7 Condition P4 – Compliance with the National Compliant Tariff 8 Condition P5 – Constructive engagement concerning local tariff modifications 9 Condition C1 – The right of patients to make choices 10 Condition C2 – Competition oversight Compliant 11 Condition IC1 – Provision of integrated care Compliant Compliant Compliant Compliant Compliant Compliant Comment where non-compliant or at risk of non-compliance Board statements – September 2014 For each statement the Board is asked to confirm the following: For CLINICAL QUALITY, that Response 1 The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the Yes TDA’s oversight (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. 2 The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements. 3 The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements. For FINANCE, that 4 The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards in force from time to time.Ba For GOVERNANCE, that Yes Yes Response Risk The Board is satisfied that the Trust is currently a going concern in line with standard definitions, however longer term this will be confirmed through the final agreement of medium term cash support arrangements. The Trust was successful in its application for cash support required within the 2013/14 financial plan (confirmed by the ITFF in March 2014) and will be submitting a further application in 2014/15 in line with the updated 5 year plan. A further letter of support for this has been received from the TDA. The same internal governance processes which supported the application process in 2013/14 will be applied to the 2014/15 submission. Response Yes 5 The board will ensure that the trust remains at all times compliant with has regard to the NHS Constitution. 6 All current key risks have been identified (raised either internally or by external audit and assessment bodies) and Yes addressed – or there are appropriate action plans in place to address the issues – in a timely manner. 7 The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of Yes severity, likelihood of it occurring and the plans for mitigation of these risks. 8 The necessary planning, performance management and corporate and clinical risk management processes and Yes mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily. 9 An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance Yes framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk). 10 The board is satisfied that plans in place are sufficient to Risk ensure ongoing compliance with all existing targets (after The Board is committed to compliance with all known targets, however key risks relate to the application of thresholds) as set out in the relevant sustainable delivery of: GRR; and a commitment to comply with all known targets 4 hour wait standard Performance: going forwards. • • • Monthly performance throughout 2014 has remained static between 86%-88%, During August performance was in excess of 90% for 11 days during the period, with the 95% standard only delivered on two days at the start of the month. The SMART plan and the new monies are aligned to supporting the revised 4 hour wait recovery trajectory detailed below. Actual LHE Trajectory Q1 Q2 Jul Aug Sep 87.7% 86.9% 88% 87.3% 85.1% 88% 87% 85% Oct Nov Dec Jan 15 Feb Mar 87% 88% 90% 90% 92% 95% Key Factor impacting on performance • Continued high demand in excess of contracted levels – During Q2 daily attendances on average were 354, which is +25 per day and +175 per week in excess of contracted levels. The Trust ED staffing levels are based on 340 attendances per day. • Flow through the organization - The Trust needs to build on the improvement achieved to date against discharge targets with a focus on maximising complex discharges. In addition, the Trust has an excessive number of patients in acute beds awaiting exit from the Trust including unmet demand, and patients medically fit awaiting an assessment. In August we had an average of 7 complex delays per day and 147 patients medically fit for discharge but awaiting assessment. Key actions include: LHE SMART plan has been in place since May 14, however whilst this did achieve an improvement in performance it was recognized that it has not delivered a material change in delivery against the 95% threshold. Consequently the SMART plan has been revised to include learning from the original plan, and the outcomes from the June review of the urgent care system undertaken by the ECIST. There are 7 key priorities within the plan, which are considered as having the greatest impact upon the system, under the 3 distinct themes summarized below. The plans submitted for use of the winter resilience fund and the operational resilience funds support delivery of the SMART plan objectives: 1. Demand Management - focused on increasing and promoting alternative services away from the acute Trust to result in avoidance of emergency attendances and admissions to reduce demand in line with SLA levels, key Schemes include: o Enhanced clinical triage into the NHS 111 service –undertaken by an advanced nurse practioner, with the aim of promotion of alternative services. o GP front of house model - was implemented from the 7th October which saw the colocation of the current out of hour’s service with UHNS to provide patient streaming at the front door of A&E. At present the service is seeing circa 25 patients per day increasing up to a potential 50 per day. 2. In hospital Objectives - focused on delivery of UHNS capacity plans schemes to open additional, and or, release beds. To improve discharge processes and reduce length of stay to optimise bed usage and create flow across the Trust, key schemes include: o o Ambulatory Emergency Care – Implementation of an AEC model to ensure that patients are seen in the most clinically appropriate setting, which will reduce demand on the acute emergency service and streams patients to other alternative providers. Focused increase at UHNS on discharge of patients to release beds and create flow UHNS are currently focused on optimising discharged across the Trust with a targeted approach and daily discharge targets in place for each ward area. - Simple and timely discharges per day: 122 Monday – Friday, 77 Saturday – Sunday, - Complex discharge targets have been increased from 30 per day to 35 per day Monday – Friday and 20 per day on the weekend. The Trust is working to sustain the ECIST best practice standards including increasing discharges earlier in the day. Monitoring against discharge targets is included within the weekly SMART plan dashboard. o Additional Bed Capacity through the reconfiguration of the site, and refurbishment of ward space previously used as a non-clinical area, implementation of a step down model and purchase of beds at Stadium Court with medical cover provided by Aruna. o Exit from Acute Trust – focus on discharge to assess outside of the acute setting, to improve timeliness and increase of discharges, in particular complex discharges. o Discharge to assess pilot With Stoke-on-Trent city council. 3. Exit from Acute Trust – the LHE will implement Discharge To Assess during Q3/4, with the scheme expected to realise a reduction in LoS and excess bed days, increase complex discharges by up to 12 per day enhancing system flow. The project has been accelerated and timescales and the detail of the project is currently being finalised in a meeting between LHE leaders on 20th October. However, stage 1 of the project has been implemented but needs to be extended, phase 2 is estimated to be implemented in the next 4 weeks, and stage 3 in the next 6 – 8 weeks. Dates to be determined. Oversight of the use of the resilience funds, progress and delivery of the schemes within the plans, and the impact of these on the overall performance against the 4 hour standard will be undertaken by the newly established System Resilience Group (reformed Urgent Care Working Groups), which is supported by a an Urgent Care Operational Group. Performance Against the SMART Plan – The KPI dashboard was revised in August in line with changes to the plan and was reinstated from the beginning of September, therefore the below performance relates to the weeks in September against revised KPIs: • • • • • • • AEC – The Trust has delivered its target to implement 18 hot clinic slots per week. Performance against A&E clinical indicators for initial time to assessment and treatment, was out with the threshold across all four weeks in the month however there was a reduction in both with an improving trend o Time to initial assessment (15 mins) – improvement from an average of 97 minutes at the start of the month to 38 minutes at month end. o Time to treatment (60 mins) – improvement from an average of 90 minutes at the start of the month to 60 minutes at month end. Discharges: Trust performance against the ECIST best practice standard is on average 29% per week in September, and marginally below target compared to the standard of 35%. The Trust increased its S&T discharge volumes in September, and in the main achieved the weekday target and weekend targets. o Target 610 S&T (weekday) – improvement from 542 the first week in the month to 643 in the last week of the month. o Target 154 S&T (weekend) – improvement from 199 the first week in the month to 236 in the last week of the month. However, the Trust is underperforming against the complex discharge target with an average of 173 per week against the weekly target of 215. The Trust slightly reduced the number of patients with an >14 day LoS per week in September, with an improving trend. In addition, to respond to the predicted demand levels through the remainder of this year, the Trust is continuing to develop a stabilisation plan to address service demand predictions; capacity and income and expenditure needs to ensure the Trust will deliver its contractual objectives and ensure its service and financial recovery in 2014/15 are secured. Cancer 62 day standard Performance • The Trust has underperformed against the standard since January and is currently underachieving its recovery trajectory. • Actions taken by the Trust improved performance in June, but delivery has plateaued at circa 3% below the standard. • Performance in August was 82.2%, with Q2 provisional performance at 81.7%. • Nationally the A&E standard was underachieved in August at 84%, however UHNS performance was below the national average. • Performance across the region against the 62 day standard has been challenged, in Q1 3 out of 5 Trusts failed the 62 day standard, including UHNS. Q1 80.7% Actual Trajectory * Provisional. Q2 *81.7% Jul 81.9% 82.5% Aug 82.2% 85.4% Sep *81.1% 85.4% Key factors affecting delivery of the standard • Demand continues on a growing trend, with the Trust experiencing its highest ever number of 2ww referrals in July 1527, the volume of referrals dropped slightly in August but this is expected in line with seasonal trends. Overall demand is circa 15% higher in 2014 compared to the previous year. • The Trust has been unable to deliver key internal targets to ensure efficiency of the overall pathway, in particular due to demand and capacity pressures in Histopathology and Imaging. Actions and Improvements: Actions being taken by the Trust are focused on increasing capacity in the diagnostic phase of the pathway, to respond to demand pressures and to ensure delivery of internal set targets including: • 70% of 2ww referrals seen within 7 days • 80% of histology reporting within 7 days biopsies and 10 days resections • 95% diagnostic investigations/imaging for patients on a cancer pathway within 14 days from request to report. Performance management arrangements and monitoring of the pathway have been escalated throughout the year in response to the performance and these will continue until delivery is improved to the threshold level and is sustained. Arrangements include: • Daily review meetings chaired by Divisional Deputy Associate Directors and the Cancer Services Team, to review the 62 day PTL at patient level with specialty teams. Throughout • • the week all patients on the PTL are reviewed. Weekly cancer meetings, to provide oversight of performance and areas of concern/risk. Weekly Performance meeting with the Chief Operating Officer and senior team with oversight of cancer performance. Actions taken by the Trust are now resulting in the following improvements: • Outpatients – the Trust is sustainability delivering the internal standard noted above, with performance circa 10% in excess of the target. The Trust has a live demand and capacity modeling tool which specialties use on an operational basis to monitor and ensure sufficient capacity is in place to meet demand levels on an ongoing basis. • Histology – Performance had significantly improved in excess of the recovery trajectory to the agreed target level, but has subsequently reduced back to the recovery trajectory level due to unexpected high sickness levels, coupled with summer holiday period, despite continuing remedial actions including: treatment initiatives, outsourcing where possible and recruitment in line with the workforce plan. There has been a subsequent improvement in performance during September, however weekly performance is variable and the service need to embed improvements to ensure a consistent improvement in performance. • Imaging –Imaging have a recovery trajectory in place to ensure that all diagnostic tests for patients on a cancer pathway are completed in 14 days, including the scan and the associated report. Performance has been significantly challenged against the internal standard through July and August, however the performance has drastically improved to recovery trajectory levels and this has been sustained since the end of August. The Trust is working with CCGs and a contract query has been issued in relation to performance against the standard. The Trust has agreed that the existing actions being taken to improve performance against the above areas formulate the basis of Trusts Remedial Action Plan. 11 The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit. Risk. The overall score has increased from 73% to 84%. The number of requirements at level 2 or above has increased from 42 to 43. However, as the Trust declared 1 requirement at level 1, the overall grade is deemed as Not Satisfactory. This related to Information Governance Mandatory Training. A target of 95% of staff having received IG training within each 12 month period, is required as part of the toolkit submission. For 2013/2014 the Trust’s current position was 80% of all staff (including bank staff). A number of initiatives were implemented to support the Trust in achieving the 95% target. A review of the IG training plan has taken place in preparation for the delivery of training during 2014/2015. The online training pack has been updated and is now available to all staff. A number of additional face to face training sessions are being organized from October to March. The training plan and % will continue to be monitored via the Trust Information Governance Steering Group and at Performance Reviews. 12 The board will ensure that the trust will at all times operate Yes effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies. 13 The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and Yes 14 The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan. Yes Signed on behalf of the Trust: Print Name Date CEO Mark Hackett, Chief Executive, University Hospitals of North Midlands NHS Trust 31/10/14 Chair John MacDonald, Chairman, University Hospitals 31/10/14 of North Midlands NHS Trust Shadow Council of Governors– Summary Report to the Trust Board Meeting held on Friday 26th September 2014 Report to: Public Trust Board Agenda item: 15 1. Introduction This report provides a summary of the business covered and decisions taken during the meeting held on the 26th September 2014. 2. Learning from Quality Walkabouts and Clinical Assurance Reviews The Associate Chief Nurse – Quality and Safety provided the Council with an overview of the recent Quality Walkabouts and Clinical Assurance Framework visits. It was noted that the Clinical Assurance Reviews will formally commence from April 2015, and that the results from the Quality Walkabouts and Clinical Assurance Framework visits will be analysed, with an improvement plan developed and implemented. These will be monitored by the Compliance Steering Group and any themes from a corporate level included within the Corporate Compliance Action Plan. It was agreed that clear proposals of the feedback and assurance from the walkabouts and clinical assurance framework visits would be received at a future meeting in order to provide the visiting team and ward area with information to complete the feedback loop. The Council received and noted the report. 3. Governors Activity and Issues (including feedback from the Patient Council) Mr Loades discussed the report which highlights the Governor activities which have taken place since June 2014 as well as any issues or concerns raised by the Governors, including updates on some of the information requested at the last meeting/workshop. The issues raised within the report included: • Update Regarding Pending Legal Action • UHNS Food Provision • Complaints Analysis – Top 3 Complaints since June 2014 and Outcomes The Council received and noted the report. 4. Surgical Services Issues and Actions Mr Dawson discussed some issues he had encountered since May 2014 and the Director of Nursing – Service Improvement and Business Development outlined some of the actions being taken within surgery to improve patient experience. It was agreed that a sub-group of the Council would be set up to review the actions being taken within surgery, in order to provide assurance of the actions being taken. Committee Assurance Report – Shadow Council of Governors th Meeting of 26 September 2014 5. Outcome of Distressed Health Economy Review It was agreed that the Director of Strategy and Business Systems would provide an update on the distressed health economy review to the Governors at their workshop in October 2014. 6. Cancer Procurement Update The Director of Strategy and Business Systems presented a brief update on the Cancer Procurement process. 7. Mid Staffordshire NHS Foundation Trust The Project Director provided an update on the integration with Stafford. 8. Annual Report and Accounts The Council received the annual report and accounts for 2013/14. 9. Summary from the Public Trust Board Meeting July 2014 The Council received the summary from the Public Trust Board meeting held in July 2014 for information. 10. Notes from the Shadow Council of Governors Workshop held on 25th July 2014 The Council received the summary from the Workshop held on 25th July 2014 for information. Committee Assurance Report – Shadow Council of Governors th Meeting of 26 September 2014 Trust Executive Committee 24th September and 8th October Report to: Public Trust Board Agenda item: 15 1. Meeting held on 24th September 1.1 Improving and Sustaining PFI Contractors Performance The Committee received this report which sets out: • proposals to support the education of users of the services provided under the PFI contract; • monitoring and management arrangements in place; • key performance indicators, including response times, incorporated within the PFI contract. The Committee received the report for information, noting that its key messages would be incorporated within a briefing document for the Clinical Divisions and Central Functions. The briefing document will be produced in conjunction with the Trust's Communications Team alongside a Communications Plan. In addition, the Committee agreed the following actions: • To ensure that any consequences on the unitary payment from future business cases are included within the Divisional Assurance Statements. • To set out the chain of command in relation to service level and to invite estates and facilities to attend Divisional Boards to discuss this. • To ensure that service specifications and user guides are available on every ward/department so that they know what standards to expect along with their responsibilities and who they need to contact if these are not met. • To provide feedback to the divisions regarding how they are meeting the performance indicators to ensure that they can address any key issues or problems. 1.2 Clinical Quality Review Group Framework The Committee were presented with the proposed new Clinical Quality Review Group (CQRG) Framework between the Clinical Commissioning Group and University Hospital of North Staffordshire NHS Trust (UHNS) for the management and review of quality at Stafford Hospital during the transitional period and for 2015/2016. To summarise; the arrangements are that the current Mid Staffs Clinical Quality Review Meeting (CQRM) would cease and be replaced by a transitional CQRM commencing in October 2014 and ending in March 2015. Terms of Reference for the transitional CQRM were presented to the Committee for information. The Committee concluded their discussion with agreement to the new arrangements, including the Terms of Reference and Membership. It was agreed that the Chief Nurse will provide the Committee with updates on progress as required during the transitional period. 1.3 Progress Report UHNS@Home The purpose of this report was to provide a progress report on UHNS@Home service against performance targets and identify key actions to be taken to reach the required position against forecasted bed day savings. Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1 The Committee agreed the proposed additions to the targeted plan and supported the roll out of services at Mid Staffs. The Committee also agreed that clinical leads be identified by Clinical Directors to assist in implementation of the targeted plan with a further update to be brought to the next meeting. It was agreed that Mr Briggs would discuss with Mr Hackett, the contractual arrangements with Hospital@Home and there will be a review of current discharge planning by Mrs Adamson and nominated clinical leads. 1.4 GP Led Care (GPLC) Pilot Phase 2 Development of Community / Nursing Home Based Service This case was presented to the Committee for approval of a pilot of GP led services on ward 80 and 81 to be outsourced to external providers. Following discussion, the Committee approved ‘Option 3’ as set out within the proposal, to provide 33 subacute beds and operate the GPLC model. In conclusion the Committee also noted the following: • That further discussions were required regarding financing. • The governance framework needs to be agreed by the Medical and Nurse Director before implementation to include assurance that patients are safe and receive high quality care. • To further develop the introduction of step down to home. 1.5 Month 5 Finance Report The Committee were presented with the latest report detailing the financial position as at Month 5. This was presented to the Board in October. In concluding their discussion the Committee noted the content of the financial position report, the risks identified and endorse the mitigation strategy. 1.6 Business Case Preparation and Approval Process This paper set out key amendments to the business case preparation and approvals process which is required for the approval of all business cases in line with the Trust’s Standing Financial Instructions. These changes are required to improve the quality of cases submitted for approval, enhance and streamline aspects of the assurance process associated with propositions, and reflect the enhanced role of Divisions in the decision making and crucially, assurance processes. The key issues set out in the paper were as follows: • Introduction of a standard finance and activity template to accompany the Divisional assurance statement and Quality Impact Assessment. • Clarification of the process in relation to cases which are not independently financially viable. • Clarification of approval limits relating to the approval of business cases. • Establishment of the mandatory process (6 steps) which must be followed to secure approval of business cases in all instances. Divisional Management Teams are accountable for ensuring the completion of this process. • Changes to the process for approval by the Executive Approvals Group – Divisional Management Team members (AD mandatory) are required to present Divisional/Directorate business cases in person. The Committee noted and approved the amendments to the Trust’s business case preparation and approvals process. Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1 1.7 Budget Setting Framework The purpose of this paper was to set out the Trust’s framework around budget setting for 2015/16. Budget setting is a cornerstone of integrated business planning; both as part of day to day business and looking further ahead in mounting a successful bid to become a Foundation Trust. The paper covers the following budget setting elements: • Activity and resource alignment • Tariff assumptions • Cost inflations assumptions • Expenditure budgets • Efficiency (CIP) requirements • Stafford Hospital Integrated Budgets • Timetable The Committee approved the budget setting framework and timetable and agreed the following: • To bring a paper to a future Committee regarding budget setting and the links to the annual plan and production plans • To discuss budget setting with the divisional/directorate management teams and divisional boards 1.8 Standing Financial Instructions and Scheme of Reservation and Delegation of Powers The Committee were presented with these key governance policies which have recently been reviewed and updated. It was noted that colleagues internally had been consulted with as applicable (Finance Department, Supplies & Procurement Department, HR Department and Company Secretary). Sections relating to internal audit and counter fraud have been reviewed by the Trust’s internal auditor and counter fraud service provider – Baker Tilly. The Committee approved the policies noting that they would be progressed to the Trust Board for final approval. 1.9 2014/2015 Month 5 CIP Update The Committee were presented with an update on progress against the Cost Improvement Programme as at month 5. It was noted that the PMO will continue to seek further assurance on existing schemes through the weekly Accountability Reviews and support the Divisions in identifying further opportunities to close the gap and enable focus to move towards scoping the content and framework for delivery of the 2014/15 programme. The Trust Executive Committee noted the contents of the report and supported the improved focus on delivery of the remaining schemes and mitigations to bridge the projected gap to target for the year. 1.10 ICO Submission This report highlighted to the Committee items which were being handled in liaison with the Information Commissioners Office. The recommendations were approved by the Committee. 1.11 UHNS PLACE Inspection 2014 – Update and Scores Briefing Note The report summarised the background behind PLACE inspections, what is included in the inspections, areas inspected and results achieved showing the national average and where UHNS came in comparison to this. The report included an action plan summarising the issues noted on the day of the most recent inspection including actions associated with the lower than national average food scores this year. Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1 The report refers to the recently issued Department of Health Food Standards and the recommendations within these standards which the Trust will need to consider. The Committee considered and approved the action plan which the PLACE sub-group are addressing. 1.12 Quality & Safety Forum Report The Committee received a summary report from the Quality & Safety Forum detailing business covered at their meeting held in August 2014. Featured within this summary were the following items: • • • • • • • • • • • • • • • Introduction of new technique – Bollard Mini Plates Dementia Care Delivery Plan Urology Alliance Key Conclusions Infection, Prevention and Control Monthly Update Infection Control Annual Report Quarter 1 Patient Safety Report Monthly Mortality Review Overview Report – July 2014 Monthly Falls Report – July 2014 Monthly Sharps Incident Report – June 2014 Monthly Complaints Report – June 2014 Monthly Quality Assurance Report – June 2014 Q1 Compliance and Effectiveness Report NHSLA Update – UHNS Position Statement CQC Intelligent Monitoring Report Use of Medical Devices and Equipment Policy 1.13 Equality and Diversity Report The purpose of this report was to provide a report on the Equality and Diversity of the workforce, review progress in 2013/14 and set out actions for 2014/15 and beyond. The report contained a number of key highlights including findings of the recent staff survey. The report also set out a detailed action plan which is based on the analysis of the workforce information set out in Appendix 2 and the results of the NHS Staff Survey 2013. The Committee approved the report and action plan. 2. Meeting held on 8th October 2014 2.1 Summary of Executive Approvals Group th The Committee received three summary reports from the Executive Approvals Group for the meetings held on 8 nd th September, 22 September and 7 October. Items discussed were as follows: th 8 September: • Review of Tender Process • Updates on Business Cases: - Plastic Surgery Expansion - Thoracic Service Expansion - Orthodontics - Consultant Colorectal Surgeon nd 22 September: • PET / CT Update • Updates on Business Cases: Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1 - Cardiology Expansion EPR Business Case th 7 October: • PET / CT Update • Stafford Out of Hours Service • Update on Business Cases: - Chronic Pain Consultant - Cardiology Expansion - EPR Business Case 2.2 Respiratory Business Case The Committee were asked to consider this case which sought approval for the UHNS phase two Respiratory development programme; this programme is exclusive of Mid-Staffordshire activity and seeks in isolation to resolve the significant capacity and performance issues currently within the service at UHNS. The Committee approved the proposal, subject to support services assumptions being identified. The Committee also supported the recruitment of the resource outlined within the case. 2.3 Orthodontics Business Case The Committee were asked to consider this case which sought approval to proceed to the appointment of a Replacement Consultant Orthodontist, plus an additional (6th) substantive Consultant Orthodontist with Therapist support. The Committee approved the Income & Expenditure plans subject to confirmation of payment from the commissioners. 2.4 Thoracic Surgery Expansion Business Case This case sought the Committee’s approval for expansion of Thoracic Surgery, with investment being sought for the following resource: • • • • Thoracic Surgeon (1wte) Thoracic Anaesthetist (1wte) Supporting Theatre Team, Pre-Assessment & Therapies (3.34wte) Supporting Administration Staff (1wte) The Committee approved the proposal, supporting the expansion and recruitment of the resource outlined within the case. 2.5 Cardiology Expansion – Replacement of Cath Lab and Sessional Expansion This case was presented to the Committee seeking approval for: • • • Replacement of the current Pacing Lab at UHNS (lab 2) with a fully functional Catheter Lab, to be housed in the existing lab location Expansion of the current number of weekly commissioned catheter lab sessions from 35 to 41 (inclusive of Sunday working), through expansion of the department staff resource and uplift of non-pay budget. This includes commissioning of 2 additional recovery trollies. Linking to the above catheter lab expansion appointment of a joint Consultant post The Committee approved the proposal, supporting the replacement of the pacing suite and increase in staff and non-pay resource to increase the number of operational catheter lab sessions and noting that the impact on capacity is to be included within the stabilisation plan. Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1 2.6 Plastics Business Case This case was presented to the Committee to seek approval to proceed to the appointment of: • • • A replacement Consultant Plastic Surgeon th One additional (6 ) Consultant Plastic Surgeon One new Trust Grade The Committee approved the income and expenditure plans subject to associated support services costs being confirmed. 2.7 EPR Business Case This case was presented to the Committee for approval for the award of for the provision of a fully integrated Electronic Patient Record (EPR) solution for the new, merged Trust for the next five years. Following debate, the Committee noted that the case should highlight that and the end of the final year, another procurement exercise would need to take place. Following this, the Committee approved the business case subject to scrutiny and approval by the Board. 2.8 SLA Presentation The Committee were presented with a draft Service Level Agreements between Keele University Medical School and UHNS Directorates and Departments. The Committee noted that UHNS is the main teaching hospital for Keele University Medical School. There are curricular requirements for levels and intensity of teaching, which can be met by monies (SIFT) already allocated. The proposed SLA formalised what is already happening in most units. It will allow directorates to plan for SIFT allocation within their teams and will allow individual consultants to have their teaching activity recorded in job plans. Medical students will be guaranteed planned teaching sessions. Continuing success of the medical school and its graduates will ensure on-going reputation of UHNS and should lead to improved recruitment of Keele graduates to UHNS posts. The Committee agreed that the Service Level Agreements should be agreed between UHNS Directorates and Departments and Keele University Medical School. 2.9 Ambulatory Emergency Care The purpose of this paper was to provide the Trust Executive Committee with an update on the Ambulatory Emergency Care (AEC) project. The presentation sets out the Ambulatory Emergency Centre: • • • • Vision Function Benefits Timeframes for Delivery The Committee discussed the project and concluded that the approve the vision and plan to achieve the proposals. They agreed for a review on progress to be brought back to the Committee in November. 2.10 Strategic Development of Paediatrics Services including Paediatric Surgery This paper was presented to the Committee to advise them of current discussions with regards to the development of UHNS’ specialist paediatric services and to seek support for a significant expansion of the Trust’s paediatric surgical services with a proposal as to how this expansion can be delivered through an alliance/partnership model. Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1 The Committee noted the direction of travel as set out within this paper and supported the expansion of specialist paediatric surgery and urology services at UHNS. Author: Claire Rylands, Head of Corporate Affairs / Company Secretary Executive Lead: Mark Hackett, Chief Executive Summary of Trust Executive Committee Version 1
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