a meeting of the board of directors will take place … · bod 03 october 2019: agenda (pum) a...

BoD 03 October 2019: Agenda (PUM)

A MEETING OF THE BOARD OF DIRECTORS

WILL TAKE PLACE ON 3rd OCTOBER 2019, 9.00AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

No Item Sponsor Ref 1. Apologies and Welcome:

Apologies:

T Lake, Chairman

Verbal

2. To receive any Declarations of Interests related to agenda items Verbal

3. To approve the Minutes of the meeting of the Board of Directors held in public on 4th September 2019

19/10/03/03

4. To approve the Action Log in relation to progress to date and review any outstanding actions

19/10/03/04

Strategic Aim: Patients: will experience outstanding care

5. To receive a Presentation relating to the Trust’s approach to Diversity, Equality & Inclusion for its staff and patients

S Ned, Director of Workforce

C Brotherston-Barnett, Equality, Diversity &

Inclusion Lead

Presentation

6. To receive and approve the Chair’s Logs for the Quality & Governance Committee held on 25th September 2019 including :- • approval of the Policy for Clinical and Non-Clinical

Photography and Video Recordings: Confidentiality, Consent, Copyright and Storage (Chair’s Log 28th August 2019)

R Moore Chair, Quality &

Governance Committee

19/10/03/06 19/10/03/06i 19/10/03/06ii

7. To receive and review the Chair’s Log on any escalation issues from the Executive Team (ET)

Dr R Jenkins, Chief Executive Verbal

8. To receive and approve the Quarterly Medical Directorate Report

Dr S Enright, Medical Director 19/10/03/08

Strategic Aim: People: will be proud to work for us 9. To endorse the report on Celebrating our People

E Parkes Director of Comms &

Marketing 19/10/03/09

Strategic Aim: Performance: we will achieve our goals sustainably 10. To receive and approve the Chair’s Logs from the Finance &

Performance Committee:- • 26th September 2019

F Patton, Chair of Finance & Performance Committee 19/10/03/10

11. To review the Integrated Performance Report (Month 05)

B Kirton, Chief Delivery Officer& Deputy Chief

Executive 19/10/03/11

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BoD 03 October 2019 Agenda (PUM)

No Item Sponsor Ref 12. To receive and approve a report on the Trust’s preparations

for dealing with an Exit from the EU B Kirton, Chief Delivery Officer& Deputy Chief


13. To receive and approve a report on NHSE Emergency Preparedness Core Standards for 2019/20: Self-assessment



Strategic Aim: Partners: we will work with partners to deliver better, more integrated care

14. To receive and review the monthly report from the Chairman T Lake, Chairman 19/10/03/14

15. To receive and review the monthly report from the Chief Executive, including an update on the South Yorkshire and Bassetlaw Integrated Care System (ICS)

Dr R Jenkins, Chief Executive

19/10/03/15

16. To receive an update on the Barnsley Integrated Care Partnership


Executive Verbal

17. To receive and review the Quarterly Communications Update



18. To receive and review the latest Intelligence report



19. To invite questions from members of the public relating to items on today’s meeting agenda. Members will be invited to raise questions relating to items on the meeting agenda at the Chair’s discretion.

T Lake, Chairman Verbal

20. In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

Date of next meeting: - 7th November 2019, starting at 9.00am.

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MINUTES OF A MEETING OF THE

BOARD OF DIRECTORS HELD ON THURSDAY 5 SEPTEMBER 2019 at 9.30 AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

PRESENT: Mr T Lake Chairman, Chair Dr R Jenkins Chief Executive Officer Dr S Enright Medical Director Mr R Kirton Chief Delivery Officer & Deputy Chief Executive Mr C Thickett Director of Finance Mrs J Murphy Director of Nursing Mrs E Lavery Joint Associate Director of HR & OD Mr F Patton Non-Executive Director Mr N Mapstone Non-Executive Director Mr P Hudson Non-Executive Director Mrs R Moore Non-Executive Director Mrs K Firth Non-Executive Director Mrs S Ellis Non-Executive Director IN ATTENDANCE: Mr T Davidson Director of ICT Mr K Haynes Interim Trust Secretary Miss L Watson Executive PA to CEO/Chairman – minute taker Mrs T Rastall Head of Learning & Organisational Development – item 19/141 Mr J Ramsay Interim Service Manager, CBU 1 – item 19/141 Mr J Bannister Deputy Medical Director - item 19/145 OBSERVERS: Mr T Conway Public Governor, Barnsley Constituency Mr T Dobell Public Governor, Barnsley Constituency Mrs A Moody Lead & Public Governor, Barnsley Constituency Mr G Portier Head of Nursing Quality – Staff Observer Mrs T Radnall Head of Patient Safety & Quality – Staff Observer APOLOGIES:- Ms E Parkes Director of Communications Mr S Ned Director of Workforce 19/136 APOLOGIES & WELCOME

As Chair, Mr Lake welcomed members and attendees to the September Board meeting, together with Governors and Staff Colleagues as observers. Apologies were noted as above.

ACTION

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

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19/137 TO RECEIVE ANY DECLARATIONS OF INTEREST The standing declarations of interests from Mr Patton, Mrs Firth and Mr Thickett as Directors of Barnsley Facilities Services Limited (BFS) were noted.

19/138 TO RECEIVE AND APPROVE THE REGISTERS OF INTERESTS The Register of Interests for the Board of Directors, Trust Key Decision Making Staff and BFS Ltd Key Decision Making Staff were presented to Board today for approval. Due to time constraints at the meeting, it was agreed any changes/amendments required to be made to the registers were to be forwarded to Mr Haynes who will ensure the changes are reflected on the register. The Chairman reiterated the deadline for papers for the Board of Directors meetings will be no later than 4.00 pm on Wednesday the week prior to Board with the exception of Finance & Performance and Quality & Governance Chairs logs. Any papers received after this time will not be accepted for inclusion within the pack.

19/139 MINUTES OF THE LAST MEETING The minutes of the meeting held in public on 4 July 2019 were reviewed and accepted as an accurate record. Agreement was given for item 19/125 to replace “robust” with “ambitious”.

LJW

19/140 ACTION LOG All outstanding actions from the previous meetings were reviewed with updates noted accordingly with further updates in relation to:- • 19/122 – It was agreed the report highlighting costings along with

any potential consequences if the Trust are to provide funding for DBS checks to be circulated as a matter of urgency. Mr Ned to circulate this information on his return.

• 19/107 – Discussions were held at the Governors’ Quality & Governance Sub-Group meeting, action to be closed.

• 19/109 – Medical Director’s Quarterly Report – to be discussed at the Finance & Performance Committee in October, action to be closed. Professor Mason to present at October meeting of Governors’ Finance & Performance Sub-Group in October.

• 19/110 - Annual report on safeguarding children and adults – Mr Haynes to check the status of this action.

SN KH

19/141 STAFF STORY RELATING TO THE TRUST’S APPRENTICESHIP SCHEME Mrs Rastall and Mr Ramsey were in attendance to present the staff story on the apprenticeship scheme that is currently in place within the Trust. Mrs Rastall informed national data has been released showing Barnsley as achieving 1.6% within the South Yorkshire area of employing staff on the apprenticeship scheme with the majority of apprentices obtaining substantive posts within the Trust. Mr Ramsey joined the Trust as an apprentice in 2007 at the age of 17 where his first placement was based in the Human Resources Department. In 2018 he acquired a substantive contract within the same department and remained here until 2017. During this time he was

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based within the Financial Accounts section before moving into a Junior Role within Management Accounts and later as a Management Accountant for CBU1. In 2017 he applied for and was successful in securing the position of Operational Support Manager for CBU1 -Cardiology & Respiratory Medicine, presently being the Interim Service Manager. During this time he was also a Staff Governor for the Trust whilst at the same time studying for his Masters Degree in Health and Social Management. All Board members praised the apprenticeship scheme undertaken within the Trust noting the incredible achievements, acknowledging this is a credit to the team for the commitment and support provided. Mrs Rastall was asked to convey the gratitude of the Board to the Vocational Training Team. The Board thanked Mr Ramsey for the presentation and congratulated him on his achievements within the Trust wishing him well for the future.

19/142 CHAIRS LOG FOR THE QUALITY AND GOVERNANCE COMMITTEE (Q&G) The Chair’s Log from the committee meeting held in August 2019 was received and reviewed. Mr Hudson, Committee Chair (in the absence of Mrs Moore at Q&G), presented the report highlighting a number of issues which included:- • The committee received a presentation from the Frailty Team one

year on following the implementation of a number of improvements to the service. Key highlights included the place of the evidence based comprehensive assessment for older adults and its positive impact on the management of frail patients. It was noted a more holistic approach is now provided to the care given within Care of the Elderly. One of the improvement noted is patients being discharged home in a more timely manner.

• The committee discussed the implications of the increase in the number of CQUINs from two to five along with the possible implications for the resourcing of Clinical Audit.

• The monthly update on BAF/CRR was received, noting it was now appropriate to consider a refresh of the Board Assurance Framework.

• Key points raised from the IPR were the 4 hour access target which had been narrowly missed at 93.5%, noting significant pressures within ED.

• Agreement was given at the Patient Safety and Harm Group that a review of local falls prevention and reduction of workstreams is to be undertaken in light of continuing incidents and harm reported from falls and resulting in inquests.

• The Committee approved the policy for Clinical and Non Clinical Photography and Video Recordings with a recommendation for approval at the Board of Directors meeting in October.

• An update on the National Emergency Laparotomy Audit (NELA) confirming the NELA Lead has developed an approach requiring both surgeons and anaesthetists to jointly review patient’s suitability for surgery.

• A verbal Mortality Report was received by the Committee reporting a higher than expected in Respiratory of HSMR to May 2019, it will take some months before any action that has been taken will

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be fully reflected in the ratio. It is thought this issue is around coding rather than actual care, assurance was given that work has been ongoing since May to verify this.

• The committee noted the NHSi Medical Staffing and Safeguarding Report showing the position against the current establishment. It was observed that for the purposes of monitoring supply and demand that it would be helpful if the report going forward could provide information on Programmed Activities by specialty.

In discussion, Mrs Firth raised a query within the July Chair’s log relating to deep tissue injuries acquired from patients sitting in specialised chairs whose pressure relieving properties were no longer effective and whether replacements had now been provided. Mrs Murphy explained the issue has now been rectified with the addition of new more suitable specialised chairs which are now in place and in use. Mr Lake confirmed that the delegated authority which had been given to the Quality & Governance Committee to review the NHS Resolution Maternity Incentive Scheme Year Two compliance self assessment statement had been signed off by the Chief Executive and submitted on time. The report was received and noted by Board Members.

19/143 CHAIRS LOG EXECUTIVE TEAM Dr Jenkins drew the following items to the attention of Board:- • The flu vaccination campaign will commence shortly and is

anticipated to be delivered to Board Members in October. • The Annual Staff Survey is due to commence in early October, and

following an increase in response rates demonstrated by a neighbouring Trust, it has been decided that the 2019 Annual Staff Survey will be conducted using their more succesful method of an all paper led approach.

• The Medway Implementation Steering Group was held earlier in the week noting the Trust is on track to deliver the project on time. Work is on going regarding staff training which was also discussed at the Finance & Performance Committee.

• The minutes of the last Board meeting stated the Trust were under pressure to reduce the capital spending, however this has now reverted back to the initial capital plan.

Mrs Ellis asked if there was a PR process for the Staff Survey and how this is linked in with the Pulse Survey. Dr Jenkins confirmed previous feedback from last years results have been taken into account. The verbal report was received and noted by Board Members.

19/144 TO RECEIVE AND APPROVE THE QUARTERLY MORTALITY REPORT Dr Enright presented the mortality report with the following areas being highlighted:- Crude mortality – year to date figures are noted to be favourable to plan, latest analysed data to the end of July 2019 is recorded as 15.47 in

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month and 20.30 year to date. SHMI – figures include all in hospital deaths and deaths 30 days after discharge, the latest available data published in August 2019 for the period Quarter 4 (April – March 2018) is currently 99.3. HSMR – the latest data up to May 2019 is reported as 96.91 for the preceding 12 month period, noting Barnsley are well matched when benchmarked with peer groups. Disease mortality – As previously reported an increasing trend in the Sepsis HSMR had been identified and investigated using the elevated HSMR methodology. Actions are now in place to ensure senior coder verification and senior clinical review for the use of the sepsis code. It was also reported that the learning from deaths group had been alerted to a higher than expected HSMR for 131 – Respiratory failure. Investigation of the data showed the number of actual deaths recorded at 16 against the expected number 9. It was noted that there was a substantial amount of work on-going relating to the pathways and protocols for the use of Non Invasive Ventilation following a presentation at the Learning from Deaths group meeting in May 2019. It was explained that this work although enacted would not have impacted upon the data and that there was to be a further review at the upcoming Clinical Effectiveness Group. Fractured neck of femur – following an alert from the number of actions for last year, considerable improvements have been made confirming Barnsley best practice tariff has improved. Mr Lake commented that within the Quality Report, the repair of fractured neck of femur is recorded at 1.2%. Dr Enright confirmed the figure is the best practice tariff and actions have been put in place for the two under performing areas against national benchmark. Overall, fractured neck of femur has shown good improvement in the past year and it is hoped this trend remains through the 2019 mortality data. Learning from deaths – the latest data shows assessment of excellent and good care in 71.79% of care assessments reviewed. Dr Julian Humphrey is in post as the Lead Medical Examiner with BHNFT being on track to deliver the service in 2019/20. In discussion, Mrs Ellis felt that whilst she appreciated that the letter in the pack papers from Dr Julian Humphrey was addressed to medical staff, she felt that the opportunity should be taken to publicise the introduction of this national initiative more widely within the Trust. It was agreed to ask the Director of Communications to publicise the initiative within the Trust. Mr Patton observed that it was interesting to see that the crude mortality data had dropped. Dr Enright confirmed this is being looked into, and in particular the weekend mortality data. Discussions have been held with Dr Jenkins & Dr Enright in relation to the data and it was agreed that a further update be given at the next Board of Director’s meeting in October. Mrs Firth asked if it was appropriate to the have the sample of individual comments under the “Good Care” section from the structured judgement

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reviews within the paper. Dr Enright explained the level 3 care is related to Intensive Care treatment involving more than one consultant so this information is required to be included. The Board noted and received the report.

19/145 TO RECEIVE AND APPROVE THE DOCTORS’ APPRAISAL & REVALIDATION ANNUAL REPORT Mr Bannister was in attendance to present the Doctors’ Appraisal and Revalidation Annual Report. The Board was asked to accept and approve the report and sign off the Statement of Compliance to confirm that BHNFT, as a designated body, is in compliance with regulations. The key findings highlighted within the report were:- • As at 31 March 2019, BHNFT had 272 doctors for whom BHNFT

are the designated body, it was noted appraisals were not carried out on only 4 doctors.

• For the 2018/19 appraisal year, 50 doctors were scheduled to revalidate, 10 were noted to have been deferred. The reasons for this were all noted to be legitimate with plans in place of an agreed timeframe.

• The Trust achieved 98.5% in date appraisal for 2018/19, 1.5% higher than 2017/18.

The report confirms processes are continually improving to provide support to all doctors not in training. The Trust provides good quality, robust medical appraisals adhering to the recommendations made by the General Medical Council (GMC). The Board acknowledged the excellent results that have been achieved and thanked Mr Bannister for his contribution to the successful outcome. The Board agreed the annual compliance statement should be signed off by the Chair on behalf of the Trust.

19/146 TO ENDORSE THE QUARTERLY REVIEW OF THE BOARD ASSURANCE FRAMEWORK 2019/20 Mr Haynes presented the quarterly review of the Board Assurance Framework noting the monthly review at the Trust Governance Committees and regular update by each Executive Director. The changes in the quarter were highlighted noting no new risks had been included. In relation to Risk 1869, it was confirmed a recent appointment has been successful for a Locum Consultant in Stroke Services which will allow extra sessions to be provided for continuity of service. The Board noted and received the report.

19/147 TO ENDORSE THE QUARTERLY REVIEW OF THE CORPORATE RISK REGISTER 2019/20 Mr Haynes presented the quarterly review of the Corporate Risk Register highlighting the high and extreme risks. The risks closed and reduced during the quarter and further mitigations on the register were requested to ensure they reflect the current position. Discussions were

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held relating to:- • Following discussion at the Quality & Governance Committee, risk

2167 needs to be included within the Board Assurance Framework. • Mr Kirton informed a number of groups have been implemented in

readiness for the EU Exit. A national briefing session has been arranged in London, a verbal update outlining the latest position will be presented to the October Board of Director’s meeting. All Board members were in agreement that the risk for a “no deal” exit from the EU has increased and therefore is required to be reported as a 15+.

The Board noted and received the report.

KH

19/148 CELEBRATING OUR PEOPLE Dr Jenkins presented the report in the absence of Ms Parkes in particular highlighting the Brilliant Awards. The Awards are presented by both the Chairman & Chief Executive which are noted to be received positively by individuals as well as the whole teams. Both Dr Jenkins and the Chairman commented how difficult it is to select just one worthy winner from all the excellent nominations of staff and the varied teams within the Trust. The Board received and noted the paper.

19/149 TO RECEIVE & REVIEW A REPORT/UPDATE ON THE SERVICE IMPACT OF HMRC PENSION ANNUAL ALLOWANCE ARRANGEMENTS Mrs Lavery presented the HMRC Pension Allowance report in the absence of Mr Ned. The paper provided a brief explanation of the tax allowance applied to the NHS Pensions scheme savings and the challenges this may create for service delivery. It was felt that the report was useful as a background document to ensure the Board are sited on the complexity of the current issues. Mr Hudson advised the meeting that he had had recent discussions with Mr Ned in respect of this issue and it is clear the Trust continued to address the issue and ensure engagement with those members of staff affected. He pointed out that at the end of the day this was a matter for the individuals concerned and the primary issue for the Trust was to mitigate against the impact of any reduced service contribution from the staff affected. Mr Kirton advised that NHS Improvement has asked for an assessment of the risk to service delivery and that as a worse case scenario it had been estimated that there may be a 20 – 25% effect on capacity if the staff affected decline additional work. This information will be circulated to Board members following the meeting. Mr Kirton also explained that a weekly update is also provided at the Executive Team meeting as a regular standing agenda item. Following discussion, it was agreed that consideration of the issue would benefit from a more comprehensive paper setting out the potential risks to service delivery, an exploration of the options that were being proposed in the national consultation and actions which the Trust were

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taking. It was agree that Mr Ned be asked to provide a paper in advance of the next Board meeting for members consideration. It was also agreed that whilst the Trust was actively engaged with the senior members of staff affected and had provided support in the form of independent financial advice it remained the individual’s responsibility to resolve the matter for themselves. The Trust’s overall responsibility remains to ensure as little disruption to service delivery, staff and colleague wellbeing and performance as necessary.

SN

19/150 TO RECEIVE & APPROVE THE TRUST’S ANNUAL HEALTH & SAFETY REPORT 2018/19 Mr Kirton introduced the Health and Safety Annual report, noting this was the first time being presented at Board. The report is compiled each year and has sections from all areas that are presented by the Trust’s bi-monthly Health & Safety Group. The Trust has had no visits or enforcement action served in 2018/19. There were 1558 incidents reported in 2018/19, a 55% increase on last year, attributable to the high activity within the Trust along with a better reporting of incidents. Mrs Moore raised concern regarding the incidences of violence and abusive behaviour highlighted in the Annual Report. Whilst training and support is provided to staff, Dr Jenkins explained that regrettably given the nature of the service provided it was impossible to eradicate incidents of violence and abuse towards staff members. Nevertheless, it was agreed that the Trust cannot afford to become complacent in this matter and Dr Jenkins agreed to ensure that a thematic deep dive of the incidents of violence and abusive behaviour was undertaken with a view to ensuring that the Trust is taking all the necessary steps that it can. The outcome of this review would be reported to the Board in due course once completed. Mr Patton stated that at the F&P committee there is a focus on people and the H&S paper provided a lot of information that is not routinely available to the Finance & Performance Committee. It was explained that whilst health and safety information is regularly reported through the Quality & Governance Committee it was considered that this would be helpful for the Finance & Performance Committee also. The Board noted and received the report.

RJ

19/151 TO RECEIVE A REPORT REGARDING COMPLETION OF THE ANNUAL “FIT & PROPER PERSON” TEST

It was noted that the Trust is required to assure the CQC that the Fit and Proper Person Test requirements are met by reviewing on an annual basis that Directors/Non-Executive Directors are fit to perform their role. The Board noted the satisfactory completion of the annual checks for Board Directors for 2019.

19/152 CHAIR’S LOG FOR THE FINANCE & PERFORMANCE COMMITTEE (F&P) The Chair’s Log from the committee meeting held in August 2019 was received and reviewed. Mr Patton presented the report and highlighted a number of key issues:-

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• At month 4 the Trust has a consolidated year to date deficit position of £0.411m, against a plan of £1.550m, which is £1.139m favourable to plan. It was noted that this position is distorted due to the accrual of the Planned Provider Sustainability Funding monies. Therefore, it was noted that whilst the Trust is £1.139m favourable at present, the forecast year-end position remains on target at £0.379m ahead of plan due to the NHSI accounting requirements for the prior year PSF bonus money. Year to date, the CIP program is £0.029m ahead of plan.

• Capital expenditure was noted to be £1.032m adverse to plan, work is currently ongoing with BFS to implement a plan bring this back in line.

• 4 hour Performance continues to remain excellent at 93.5% with Barnsley noted to be one of the best performing Trusts in the area. However the cancer target for June was not compliant ,reported at 85.8% . This was due to issues within breast symptomatic and 62 day referrals.

• Sickness has seen a slight increase from June to 4.31% and training has seen a decrease standing at 90.7%.

• The committee received an update on various ICT issues including Medway System C.

• BAF & CRR were reviewed from a finance and performance perspective and noted the changes within both documents.

Mr Thickett added there is a high cash balance at the moment due to the Trust receiving the 2018/19 PSF monies which were received towards the end of last month ,which will be seen in September. It was also noted the creditors are starting to be cleared on a phased basis. The Board noted and received the report.

19/153 TO RECEIVE AND APPROVE THE CHAIRS LOG FROM THE AUDIT COMMITTEE HELD 17 JULY 2019 The Chair’s Log from the committee meeting in July 2019 was received and reviewed. Mr Mapstone presented the report highlighting a number of issues to note which included:- • The requirement for the Trust’s Business Conduct and Declarations

of Interests Policy to reflect the NHSE June 2017 guidance. It was noted that this was a substantial amount of work which is currently being undertaken by the Trust Secretary.

• The committee discussed the internal audit progress report. Limited assurance has been provided on the short term cancellation of out patient appointments noting around 60% of cancellations are requested by the Trust. This issue has also been raised at the Finance & Performance Committee and further information has been requested.

• The committee discussed a recent fraud case at the Trust, assurance was given that all monies have been recovered and controls have been strengthened. The case is on going.

The Board noted and received the report.

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19/154 INTEGRATED PERFORMANCE REPORT (Month 04) Mr Kirton presented the IPR noting it had been discussed in detail at Quality & Governance and Finance & Performance Committees. The report is a reflection of how busy activity is within the Trust, noting a large increase in numbers which is putting pressure on the system which will be a challenge moving forward. The following key points were highlighted:- Performance • The Trust marginally missed the 4 hour access standard at 93.5%

for July. • A presentation on the 4 hour target has recently been delievered to

the Executive Team which will be shared with Board Members. • Cancer targets for June were not compliant at 85.8% due to

capacity issues within the Breast Service. Quality • Two SI’s were reported in the month, a delay in diagnosis and sub-

optimal care. • Two incidents resulting in severe harm in July were reported. • 18 Category two hospital acquired pressure ulcers reported, four as

a result of lapses of care, noting this figure is the same as June. • There have been three hospital acquired device related pressure

ulcers, two of which as a result from lapses in care. • The friends & family test remains an issue within ED. • Cases of Clostridium-difficile were reported as 6, however this had

increased to 10 within a few weeks. Mrs Murphy informed an urgent meeting with the Stakeholders has been held to understand the reasons why and to implement an action plan to improve the situation as well as looking to have an external review of the Trust’s practices.

People • The Mental Health Plan has recently signed off at the Finance &

Performance Committee. • The Vivup report has shown more staff are now accessing the

counselling service which is provided free of charge. • The Trust has seen an increase in sickness levels to 4.31%. Finance • Following discussions at the last Board meeting around differential

variance, these risks have now been split to provide clearer information for income and activity.

Discussions were held around GP Streaming and confirmation was provided that work is on going with partners to work through what is expected of the service. Mr Kirton informed a meeting will be taking place soon with Partners to discuss this in further detail.

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Mr Mapstone raised a query regarding sickness figures which were quoted in the Quality and Governance minutes of June, which stated only 37% of staff take sickness absence. Mrs Lavery to look into and confirm the figures are correct, which will need to be reported via Finance & Performance. Mrs Firth noted a change in the performance chart, the figure shows an adverse position which should be red. This would be amended. Dr Jenkins informed Board members the Place Based Reviews are taking place next week where a presentation will be given on the performance of Trust. The Board noted and received the report.

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19/155 TO RECEIVE AND REVIEW THE QUARTERLY REPORT ON THE TRUST’S OBJECTIVES As agreed at Board in March 2019, Mr Kirton provided a quarterly update on the progress against the Trust’s objectives. Presentation of the report was noted to have been delayed as no Trust Board took place in August. The report had been included for information noting overall the Trust has progressed with the objectives outlined. Some challenges were encountered however assurance was given that mitigation plans have been implemented wherever possible which will be monitored during the year. Following discussion Mrs Murphy agreed to amend the objective relating to Medical Devices regarding the incidents of pressure ulcers resulting from a medical device. The Board noted and received the report.

JM

19/156 TO RECEIVE AND REVIEW AN UPDATE REPORT ON THE TRUST’S CYBER SECURITY ARRANGEMENTS Mr Davidson presented the report on Cyber Security, giving assurance to the Board of Directors that the Trust mitigates any risk and vulnerability to ensure a strong security system is in place, protecting the systems and the data of the Trust. Mr Hudson queried whether the Trust have done everything possible in terms of reducing risk. Following discussion, Dr Jenkins explained the risks are unusual as the Trust can only mitigate to a certain degree and the risk of attack is extremely high as the working environment is constantly changing. This will be discussed in further detail outside the meeting. The Board noted and received the report.

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19/157 TO RECEIVE AND REVIEW THE ANNUAL REVIEWS OF THE EFFECTIVENESS OF BOARD COMITTEES:- In accordance with the Terms and Reference for Board Committees, each committee is required to produce and present to Board an annual report. All contributors were thanked for the work throughout the year, including everyone involved with the reporting groups, which continued to work well and be essential to the effectiveness of the Committee and the Trust’s governance systems. The reports included updates on the Terms of Reference, work plans and self assessment feedback. The

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following were presented today highlighting the key points:- Quality and Governance Committee • Medical engagement for the Clinical Effectiveness Group was noted

to have increased but there are still issues relating to attendance for the Patient, Safety and Harm Group.

• Attendance within the Terms of Reference was noted to be under review.

• Names given to Audit Committee in relation to membership • Work will continue with the Audit Committee and names have been

provided in relationship to the membership. • The minor update to the Terms of Reference to the Quality &

Governance Committee was noted and agreed. Finance and Performance Committee • Terms of Reference have been amended. • Effectiveness of the committee continues to improve with the main

areas to develop being more focus on the people agenda • A list of meeting behaviours has been agreed which participants are

required to adhere to. Audit Committee • The Committee was noted to be well attended. • Relationships have been maintained with external and internal

auditors and counter fraud service. The Board noted and received all three annual review reports.

19/158 REPORT OF THE CHAIRMAN The Chairman’s report was received and noted which provided a brief summary of key meetings and events which have recently been attended on behalf of the Trust. Following the presentation at Board last month by the Assistive Technology Team, Mr Lake explained that he had arranged a visit to the Assistive Technology Service which he had found extremely informative and impressive. The Board noted and received the report.

19/159 REPORT OF THE CHIEF EXECUTIVE (including an update on the South Yorkshire and Bassetlaw Integrated Care System (ICS)) Dr Jenkins provided an overview of recent meetings and events that have recently been undertaken on behalf of the Trust, including an update on the work and progress of the Integrated Care System. An invitation to all Directors to attend a briefing session by the ICS on 7 October 2019 has been received by the Trust and Dr Jenkins suggested this would be useful for Board Members to attend. If, due to prior commitments this is not convenient, then the slides will be circulated for any Director who cannot attend. The Board noted and received the report.

19/160 TO RECEIVE AND REVIEW THE HOSPITAL SERVICES REVIEW, SOUTH YORKSHIRE & NORTH DERBYSHIRE

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Dr Jenkins presented the Hospital Service Review paper explaining that South Yorkshire & Bassetlaw (SYB) health and care systems have been considering how to support the long term sustainability of acute hospital services in SYB. Following a long process of analysis of various options, these have now been completed and have been discussed by Accountable Officers, CEOs and Medical Directors of the acute providers. CCGs have agreed to delegate decision making on issues related specifically to the Hospital Services Review to the Joint Committee of Clinical Commissioning Groups (JCCCG) at the end of September. In particular, the final report which CCG Governing Bodies and Trust Boards were being asked to consider was based on an approach to addressing long term sustainability issues which was based on transformation as a means of ensuring sustainability, and only considered service reconfiguration in circumstances where there is an immediate risk of safety issues. However, it was noted that the report acknowledged that if transformation failed to address workforce issues in the medium to long term then reconfiguration may need to be considered. Following discussion there was a general agreement with the proposed way forward, namely that service change through transformation would be the preferred approach, with service reconfiguration where there was an immediate risk of safety issues. The Board noted the report and asked that Dr Jenkins feedback the Board’s comments as appropriate.

19/161 TO RECEIVE AN UPDATE ON THE BARNSLEY INTEGRATED CARE PARTNERSHIP Mr Kirton provided a verbal update in relation to Barnsley Integrated Care Partnership. It was noted there is one Primary Care Network within the Barnsley area to co-ordinate actively across the District which is supported by the six neighbourhoods. Consultation with SWYPFT is ongoing looking at how support can be aligned within the networks and confirmation was given that Barnsley signed off the primary care network/neighbourhood specification. Mr Lake recently attended a meeting where Barnsley CCG verbally updated attendees and agreed to circulate any written, information upon receipt. The verbal report was noted and received by Board members.

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19/162 TO RECEIVE AND REVIEW THE LATEST INTELLIGENCE REPORT The intelligence report was reviewed and noted in the absence of Ms Parkes which provided a brief overview of NHS Choices reviews and ratings. The Board received and noted the paper.

19/163 QUESTIONS FROM MEMBERS OF THE PUBLIC Mr Lake opened the meeting for questions from observers/members of

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the public who were in attendance today. Mr Portier raised concerns due to his previous experience working in Mental Health in relation to violence and aggression, commenting that not all staff fully understand or appreciate the true extent of Mental Health. Mr Conway informed he has noticed a higher presence of police around the Trust recently and wondered if this was for any particular reason. Dr Jenkins confirmed has not been made aware of any concerns regarding the higher police presence. To note, quarterly meetings with the Chief Superintendent from South Yorkshire Police are held to provide an update on all relevant matters for the Trust.

Mr Lake thanked members, attendees and observers for attending the Board Meeting which was formally closed at this point.

19/164 DATE AND TIME OF NEXT MEETING The next meeting of the Board of Directors was confirmed for Thursday 3 October 2019 commencing at 9.00 am in the Lecture Theatre, Barnsley Hospital NHS Foundation Trust. In accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

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REPORT TO THE BOARD OF DIRECTORS

REF: BoD 19/10/03/04

SUBJECT: BOARD ACTION LOG

DATE: OCTOBER 2019

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information Strategy

PREPARED BY: Keith Haynes, Interim Trust Secretary SPONSORED BY: Trevor Lake, Chairman PRESENTED BY: Trevor Lake, Chairman STRATEGIC CONTEXT

To ensure that actions emerging from Board meetings are progressed and reported to Board in a timely manner.

EXECUTIVE SUMMARY

Current action log arising from Public Board meetings as attached.

RECOMMENDATION(S)

The Board of Directors is asked to: a) note and approve reported progress and any verbal updates and b) review any outstanding actions

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Key to RAG status Red Action overdue or no update provided Amber Update Provided but action not complete Green Update provided and action complete BoD 04 July 2019: Action Log

Subject: Board Action Log Ref: BoD 19/10/03/04 ACTIONS ON AGENDA: Table 1 Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG status

19/139 05.09.19 Minutes of the last meeting

Under item 19/125 change the word robust to ambitious LJW October 19 06.09.19 Complete Green

19/142 05.09.19 Chairs log for Quality and Governance

Policy for Clinical and Non Clinical Photophraphy & Video Recordings to be added to the agenda for October Board for

approval.

KH October 19 24.05.19 Complete – October Board Agenda Green

19/144 05.09.19 Quarterly Mortality Report

Medical Examination System - Agreement by all members

was made for Barnsley Communications to publicise the initiative within the Trust.

EP October 19 25.09.19 – Communications will

promote once the medical examiner service is established.

Amber

Crude Mortality Data - following a decrease in the figures SE confirmed this is

being looked into, in particular, the weekend mortality.

Update to be presented at the next Board of Director’s

meeting in October.

SE October 19 25.09.19

Full report on analysis of weekend crude mortality rates included in the mortality paper to Q & G 25 September 2019.

Green

19/1947 05.09.19 Quarterly Review of

Corporate Risk Register 2019/20

Risk 2167 to be included within the Board Assurance

Framework. KH October 19 25.09.19 Incorporated on the Board

Assurance Framework. Green

19/149 05.09.19 HMRC Pension

Allowance Arrangements

Comprehensive paper setting out the potential risks to

service delivery, an exploration of the options that were being proposed in the national consultation and

actions which the Trust were taking. Paper to be provided in advance of the next Board

meeting for members consideration.

SN October 19 25.09.19 October Board Meeting –

Further update report to Private Board.

Green

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Key to RAG status Red Action overdue or no update provided Amber Update Provided but action not complete Green Update provided and action complete BoD 04 July 2019 :Action Log

19/150 05.09.19 Annual Health and Safety Report 2018/19

Dr Jenkins agreed to ensure that a thematic deep dive of the incidents of violence and abusive behaviour towards

staff colleagues was undertaken with a view to ensuring that the Trust is

taking all the necessary steps that it can. The outcome of

this review would be reported to the Board in due course

once completed.

RJ December 19

Scope of review to be determined and identification of external reviewer to be sought

Amber

19/154 05.09.19 Integrated Performance Report (Month 4)

The presentation recently delievered at the Executive Team meeting on 4 hour targets to be circulated to

Board Members

BK October 19 September 19

Complete – Circulated to Board Members. Green

Following a query raised re sickness figures quoted in the

Quality and Governance minutes of June – Mrs Lavery

to look into & confirm the figures are correct, will need to

be reported via Finance & Performance.

EL October 19 September 19

Complete – answer confirmed by Emma Lavery the

percentage of staff taking no sick leave has remained at

37%.

Green

Performance chart – figure shows an adverse position

therefore needs to be changed to red.

BK October 19 September 19 Complete. Amber

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19/155 05.09.19 Quarterly report on the Trust’s Objectives

Following discussion Mrs Murphy agreed to amend the objective relating to Medical

Devices regarding the incidents of pressure ulcers

resulting from a medical device.

JM October 19

We have exceeded the zero target this year, we will provide the numbers of device related ulcers and any learning monthly whilst utilising Quality Improvement to make improvements and set trajectories for next year.

Amber

19/156 05.09.19 Cyber Security Awareness

The risks are unusual as the Trust can only mitigate to a

certain degree and the risk of attack is extremely high as the

working environment is constantly changing. This will be discussed in further detail

outside the meeting.

TD October 19 September 19

Cyber security risks have been reviewed and will stay with a target of high risk, due to the transitory nature of the risk.

Green

19/161 05.09.19 Barnsley Integrated Care Partnership Group

Mr Lake to circulate information to Board Members following a recent meeting of

the ICPG.

TL October 19 Update to be provided following the ICPG Meeting on 26.09.19 Amber

ACTIONS COMPLETED & CLOSED SINCE LAST MEETING: Table 2 – N/A Minute

ref Meeting


19/123

04.07.19

Action log

The HMRC Pensions issue for high earning staff was agreed for updates to be

provided within the Medical Directors Report.

SE September19

September 19

September Board meeting – agenda item on Public Board. Green

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Due to the potential workforce impact on service

provision this item was agreed to be discussed in

the Finance and Performance Committee.

KHa August 19 September 19 As above Green

19/124 04.07.19 Patient/staff story – Assistive Technology

It was agreed due to time restraints for the

presentation to be circulated to all Board members and any questions or queries in relation to be fed through Dr Enright who will collate and feedback the information.

SE

Sept 19 08.08.19 Innovation presentation circulated to Board Members. Green

19/125

04.07.19

Chairs Log Q&G – 11 pressure ulcers

Feedback to provide a full understanding of the lapses in care and how these have been addressed to provide assurance, to be presented

through Quality & Governance as well as the

Trust Board.

RM/ KHa Sept 19 July 2019

Detailed Q1 Pressure Ulcers Report to 24 July Q&G

meeting, providing comprehensive review of all pressure ulcers in the review period, including trust wide

themes and actions. Referenced in Chair’s Log for

meeting.

Green

Chairs Log Q&G – Paper to ET update on equipment issues re

pressure ulcers

Paper to be presented as a matter of urgency to ET following the root cause

analysis showing a failure in the equipment currently in

use.

AB 10.07.19 10.07.19

Complete – Verbal update provided to the Executive Team on 10th July 2019.

Also as above – July Q&G meeting provided with update

on medical devices related pressure ulcers.

Green

19/127

04.07.19

Infection prevention – annual report

Ms Parkes and Mrs Fisher to arrange a meeting to discuss

further communications to ensure compliance with

infection control standards.

EP Sept 19 August 2019

Complete. Preparations underway to support Mrs

Fisher and the Trust with key messages during Infection

Control week , 13 – 19 October 2019

Green

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19/128 04.07.19 Celebrating our people

Ms Parkes suggested it maybe worthwhile having the excellent feedback displayed

for staff to access, Ms Parkes agreed to determine the best way to achieve this.

EP Sept 19 August 2019

‘Shout Out’ e-communication to be re-launched from

September to ensure feedback and nominations for Brilliant

Awards are shared and celebrated within the Trust.

Green

19/129 04.07.19 Chairs Log – F&P Apprenticeship report update to be forwarded onto Mrs S

Ellis FP Sept 19 07.08.19 Report provided to Mrs Ellis. Green

Update for the 38 day inter provider transfer to be made available to cascade to the

Governors.

BK Sept 19 08.08.19 Complete – presentation at F&P Governors meeting on

08.08.19 Green

19/30 (Cont)

Data Quality Group Minutes to be included within the

Audit Committee TD August 19 12.07.19 Minutes sent to Nick Mapstone. Green

19/13 04.07.19 Report of the chairman Revised timetable of the

Council of Governors meetings to be circulated.

TL Sept 19 August 09 Schedule of meetings for

remainder of 2019 and for 2020 circulated.

Green

19/107 06.06.19 Chairs log Quality and Governance Committee

Meeting to be arranged between RS/NM to discuss the benefits of having a 6

month SHIMI audit.

RM July 2019

04.07.19

Work is on going with Dr Jenkins and Dr Enright to seek an understanding of 6 data set questions. Once this was been

completed, feedback will be provided to the relevant committees. This will be

reviewed in advance of the Council of Governors Quality and Governance Committee where an explanation will be

presented. 05.09.19 – Discussed at the

Council of Governors Meeting – action to be closed.

Green

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19/109 06.06.19 Medical Director’s Quarterly Report

Paper to come to September Private Board re future

funding arrangements for R&D following on from

annual report on R & D.F & P 27/6/19. Also look at the

possibility of a board development session in the future involving Professor

Mason and Professor Adebajo.

SE/KHa Sept 19 28.06.19

Full discussion of finances at F&P on 27 June 2019 as part

of the annual report. F&P agree to progress with phase 2 of R&D Development. Plan for

a patient story and R&D presentation at an up coming

board? September. 04.07.19 – Agreement was

given that this will be presented at a Board Briefing Session in September or October 2019.

05.09.19 – To be discussed in Finance and Performance

Committee in October.

Green

19/109 Cont

Professor Mason to present at October meeting of Governors’ Finance & Performance Sub-Group in October.

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ROLLING TRACKER OF OUTSTANDING ACTIONS: Table 3 red = overdue Minute

ref Meeting


19/122 04.07.19 Minutes of the last meeting

Report to highlight costings along with any potential

consequences if the Trust are to provided funding for DBS checks, will be brought back

to September Board.

SN Sept 19 26.09.19

Follow-up to be provided at October Board meeting

05.9.19 - It was agreed the report highlighting costings

along with any potential consequences if the Trust are to provide funding for DBS checks to be circulated as a matter of urgency. Mr Ned to circulate this information on his return. 26.09.19 Update circulated to Board Members. Action now

complete.

Green

19/110 06.06.19 Annual report on

safeguarding children and adults

Further discussions to discussion the action plan for

the WRAP Level 3 HM (AB) July 2019 28 June

2019

Email circulated to CBU leads – on going.

04.07.19 – Mrs Bielby confirmed work is on going with

CBU Leads.

Amber

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Abbreviations/acronyms: • ACS – Accountable Care System • BAF – Board Assurance Framework • CCG – Clinical Commissioning Group • CQC – Care Quality Commissioning Group • CIP – Cost Improvement Programme • Comms – Communications • CRR – Corporate Risk Register • Dir – Director • EqIA – Equality Impact Assessment • ET – Executive Team • F&P – Finance & Performance Committee • FPSG – Finance & Performance Sub-Group (Governors) • ICT – Information & Communications Technology • IPR – Integrated Performance Report • Q&G – Quality & Governance Committee • QGSG – Quality & Governance Sub-Group (Governors) • VTE – Venous Thromboembolism

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REPORT TO THE BOARD OF DIRECTORS REF: BoD 19/10/03/06 SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT

DATE: 3 October 2019

PURPOSE: Tick as

applicable Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Keith Haynes, Interim Trust Secretary SPONSORED BY: Philip Hudson, Non Executive Director/Committee Chair PRESENTED BY: Philip Hudson, Non Executive Director/Committee Chair STRATEGIC CONTEXT

The Quality & Governance Committee (Q&G) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of quality and safety across the Trust in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on quality and safety matters to the Board of Directors.

EXECUTIVE SUMMARY

This report provides information to assist the Board on obtaining assurance about the quality of care and rigour of governance. From the Q&G Committee Meeting on the 25th September 2019, the following issues were addressed and flagged for assurance:

• Regular review of the Board Assurance Framework and Corporate Risk Register • Review of quality issues in the Integrated Performance Report • Report on Mortality • Report on NHSI Medical Staff Safeguarding report • Nursing & Midwifery Safe Staffing Report • Sub-committees’ Chairs Logs These items have been reviewed to provide assurance to the Trust Board. For the purpose of assurance, the Chair’s Log below sets out the range of issues reviewed and assurance provided. There is nothing specifically that the Committee wishes to escalate to the Board and which the Board is not already aware of. RECOMMENDATION(S)

The Board is asked to receive and review the attached Log.

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Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: BoD 19/10/03/06 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee (Q&G) Date: 25th September 2019 Chair: Ros Moore

Ref Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or

Committee

Recommendation / Assurance/ mandate to

receiving body

1. D1 (Discharge Form) Presentation

The Committee received an excellent presentation from Dr Bullas and the D1 Implementation Team. Dr Bullas explained the purpose of the Discharge Summary which provided details of the patient’s treatment and care whilst in hospital together with any plans for onward treatment. This was provided to the patients GP on discharge, copied to the patient. Dr Bullas explained that the performance target was to have 90% of D1s provided within 24 hours of discharge – currently the Trust was achieving 85% within the first 24 hours of discharge. Dr Enright reminded the Committee that this had been a challenging area for the Trust and subject of discussion with the CCG. Dr Bullas explained that due to the difficulty encountered by users in preparing the D1 using the ICE system, a programme had been developed using a SharePoint platform as an interface with ICE which was now being piloted on Ward 21 with initial positive feedback from junior doctor users. The plans to roll out the pilot across all wards remain to be confirmed.

Board of Directors For assurance

2. Executive Team Chair’s Log

In a verbal report of items raised by the Executive Team, the Committee was appraised of recent discussions relating to Pensions Task & Finish Group Meeting, current operational performance, the success of the Trust’s participation in the World Patient Safety Day on 17 September, and the Sepsis Event that was taking place in the Education Centre today.


3. BAF and CRR Monthly update to Board Assurance Framework and Corporate Risk Register received. Upcoming of Corporate Risk Register by Executive Team noted.


4. Mortality Report The Committee noted current data on mortality as follows: Board of For assurance

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Committee


receiving body

• Crude mortality – latest analysed data to August 2019 in 17.06 in month and 19.70 year to date

• SHMI – to March 2019 (Q4) was 99 • HSMR – latest data from CHKS is to June 2019 and reports

97.92 for preceding 12 month period • Learning from deaths – latest data shows excellent and good

care in 71% of care assessments reviewed. For Sepsis HSMR the decrease noted in April (below average) has shown increase to 110.56 in June. There is on-going review and analysis of sepsis coding and in September the senior coders are checking compliance with the process. The effect of the earlier deep dive and work on coding can be seen in the Sepsis HSMR SPC chart where performance remains within the upper and lower warning limits. Respiratory failure HSMR now at 154 in June compared with 175 in February. The work in relation to Non Invasive Ventilation (NIV) was noted with CEG review of NIV planned for October. Pleasing progress in relation to Neck of Femur HSMR was noted, with an Orthopaedic Collaboration Event planned for 27 September where progress and further improvements will be evidenced. Work in relation to NELA (National Emergency Laparotomy Audit) continues. Following a query at September Board meeting about reduction in weekend mortality, the Medical Director explained that weekend mortality is the ratio of deaths per 1000 admissions at the weekend. The data presented confirmed that the number of weekend admissions had increased in June and the number of deaths decreased in July by comparison with the same period last year and previous months. Both had contributed to the lower than expected year to date weekend crude mortality, particularly in July.

Directors

5. Integrated Performance Report (Month 05)

Key points from the Month 5 IPR included: • Clostridium difficile – 13 cases reported in-year (4 in August) to

date against a standard of 19 cases. The Trust has commissioned an external review of systems and processes in


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Committee


receiving body

order to ensure improvement. See also Chair’s Log for Infection Prevention and Control for September 2019 confirming further actions.

• Falls – favourable progress noted with lowest number of falls for the year reported in August – 49 falls reported. The current identifiable cause for the reduction in falls appears to be related to implementation of the of the three high impact actions associated with the falls CQUIN.

• Pressure ulcers – a total of 14 category 2 hospital acquired pressure ulcers acquired in August, a decrease of 4 from last month. Review to be undertaken of device related pressure ulcers target.

• Emergency access – the Trust failed the 4 hour emergency access standard for second consecutive month at 91.3%. ED attendances were 5% above plan with emergency admissions also above plan. A number of days saw in excess of 300 inpatients per day attend A&E.

• Cancer 2 week access remains challenging due to short-term impact of previously reported breast radiology capacity challenges.

6. Performance Meetings Chair’s Log

The Committee was pleased to note that a Nursing Associate has been accepted on to the Florence Nightingale Programme.


7.

Patient Safety & Harm Group

Chair’s Log Confirmation that a Prevention of Future Deaths Report (PFD) will not be issued to the Trust as previously advised following an HM Coroner Inquest earlier in the year. SSNAP Action Plan Update – noted that during the period April – June 2019 5 of the 10 domains have shown an improvement in performance. The Committee that it would wish to have a presentation on Stroke Services post implementation of HASU working arrangements – say December 2019. Policy Approval The Committee approved the Policy for the Development of Trust Approved Documents (Policies, Clinical Guidelines and Procedures) subject to minor amendments for ratification of the Board (November 2019 meeting).


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Committee


receiving body

8. Clinical Effectiveness Group Chair’s Log

Getting it Right First Time (GIRFT) – Diabetes. CEG received a short presentation providing an outline of ongoing action points following the GIRFT visit in May 2019. Pleasing to note that the GIRFT Programme Lead for diabetes had urged the department to share good practice with neighbouring Trusts.


9. Infection Prevention and Control Group Chair’s Log

Noted Clostridium Difficile actions (linked to 5 above) - External review planned. Review of CDT policy, Visits to wards, review of cleaning standards. Scheduled interviews with antibiotic pharmacist and clinical directors.

Board of Directors Board

of Directors For assurance

10. Nursing & Midwifery Safe Staffing Report

Reported that for Care Hours Per Patient Day for the last benchmark in the Model Hospital in May 2019 the Trust value is 8.3 which is in quartile 3 (mid high 25%), the national median is 8.1 and the peer median is 8.0. The Safe Care module is being rolled out from 11 September on 4 wards and further over the next 12 months. This will enable the CHPPD to be more easily calculated on a daily basis. Red risk relates to staffing vacancies in paediatric ED.


11. NHSi Medical Staffing Safeguards Report

Total Medical Staffing fill rates confirmed at 95%. Following discussion at last meeting detail on Programmed Activity included in report (in order to better understand demand and capacity) - with plan to show trends going forward. Main changes reported included CBU3 recruitment and commencement of FY3s, CBU 2 specialty doctors commenced in Anaesthetics and Consultant Ophthalmologist, CBU3 Consultant in O&G.


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REPORT TO THE BOARD OF DIRECTORS REF: BoD 19/10/03/06i

SUBJECT: POLICY FOR CLINICAL AND NON-CLINICAL PHOTOGRAPHY AND VIDEO RECORDINGS:CONFIDENTIALITY, CONSENT, COPYRIGHT AND STORAGE

DATE: OCTOBER 2019 PRIVATE & CONFIDENTIAL

PURPOSE:


applicable For decision/approval √ Assurance √ For review Governance √ For information Strategy

PREPARED BY: Maxine Harrison, Operational Lead Radiology Systems, Medical Photography & Office Manager

SPONSORED BY: Nicola Beaumont, Associate Director of Operations (CBU3)

PRESENTED BY: Maxine Harrison, Operational Lead Radiology Systems, Medical Photography & Office Manager

STRATEGIC CONTEXT

This is a new policy detailing how the organisation controls and protects all clinical and non-clinical recordings, regardless of how they were acquired, protecting against information security breaches by identifying who may make clinical recordings and the procedures to be followed when making, distributing and storing those recordings.

EXECUTIVE SUMMARY Aim of the Policy The aim of the policy is to provide a framework where clinical and non-clinical recordings can be captured and used within the Trust whilst preserving a patients right to confidentiality and protecting the organisation from financial hardship as a result of misuse of these recordings. Objectives of the Policy

• Ensure the patient’s consent is obtained where appropriate, accurately recorded and accessible when recordings are accessed and that when used as part of treatment or teaching the consent is respected.

• Only authorised copies of recordings are made and distributed • To protect the rights to confidentiality of patients where it’s appropriate to obtain recordings

without consent – e.g. SPA patients and the unconscious patient • Ensure compliance with procedures for the medico legal aspects of a patients treatment in

relation to medical recordings • Control who can record and what equipment can be used to make recordings in the Trust.

It’s incredibly easy for staff and patients to take unsolicited, non-consented and non-diagnostic pictures and videos with little regard for the person’s right to confidentiality.

• Ensure all clinical recordings are stored securely and transferred to other organisations securely, maintaining the patient’s original level of consent given at the time of recording.

• Ensure all clinical recordings are captured in a standardised manner and appropriately demonstrate the condition they set out to demonstrate.

• Ensure the Trust and staff is protected from the risk of prosecution under the Data Pack

Protection Act as a result of misuse of clinical recordings. Conclusions A number of Datix reports have been submitted over several months regarding staff taking photographs on personal devices and without patient consent. The ease of access to personal recording devices in a clinical setting has led to a culture of making recordings of patients with little regard for consent, confidentiality, image standardisation and safe storage. Transfer and sharing of recordings via digital means is also easy and can have devastating consequences. This policy will provide a framework to safeguard consent, confidentiality, quality of recordings and Trust reputation.

RECOMMENDATION(S)

There is no other Trust policy that defines the acquisition and proper use of clinical and non-clinical recordings. The Quality & Governance Committee is asked to approve this policy.

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Barnsley Hospital NHS Foundation Trust

Policy for Clinical and Non-Clinical Photography and Video Recordings:

Confidentiality, Consent, Copyright and Storage

Version V2.0 Author(s) Laura Marcato, Medical Photographer

Maxine Harrison, Line Manager Name of responsible committee Information Governance Committee Date issued: Review date: Target Audience All staff capturing or handling images of

patients

EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all, both as a major employer

and as a provider of Health Care. This Policy Document has therefore been equality

impact assessed by the Health Care Governance Committee to ensure fairness and

consistency for all those covered by it regardless of their individual differences, and

the results are shown in Appendix 1.

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BHNFT Policy for Clinical Photography and Video Recordings of Patients by Trust Staff

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Contents

1. INTRODUCTION ............................................................................................................................. 4

2. OBJECTIVE ...................................................................................................................................... 4

3. SCOPE .............................................................................................................................................. 5

4. POLICY ............................................................................................................................................. 5

4.1 The Financial impact of non-compliance of this policy ................................................ 5

4.2 Confidentiality .......................................................................................................................... 5

4.3 Consent ...................................................................................................................................... 6

4.4 Anonymity ................................................................................................................................. 9

4.5 Copyright ................................................................................................................................... 9

4.6 Provision of Medical Photography Services .................................................................... 9

4.7 Obtaining clinical recordings out of hours ....................................................................... 9

4.8 Recordings made with personal devices ....................................................................... 10

4.9 Storage of recordings .......................................................................................................... 10

4.10 Storage and retention of historic images ..................................................................... 11

4.11 Quality of clinical photography ....................................................................................... 11

4.12 SPA and Medico-legal recordings .................................................................................. 11

4.13 Release of images ............................................................................................................... 11

4. 14 Patients and general public taking recordings within the Trust ........................... 12

4.15 Non Clinical Recordings .................................................................................................... 13

4.16 Tissue Viability ..................................................................................................................... 13

5. ROLES AND RESPONSIBILITIES ............................................................................................. 14

6. List of References .......................................................................................................................... 15

7. Glossary of Terms used within the document ........................................................................... 19

8. Bibliography .................................................................................................................................... 20

9. Appendices ..................................................................................................................................... 26

Appendix 1: EQUIA ........................................................................................................................ 26

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Appendix 2: Legislation ................................................................................................................. 34

Appendix 3: Consent for Publication of Medical Images and Videos ..................................... 35

Appendix 4: Consent forms for IMPAX ....................................................................................... 36

Appendix 5: Retention period at BHNFT .................................................................................... 40

Appendix 6: Photography and/or Video Consent and Release Form for Non-Medical Purposes .......................................................................................................................................... 41

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1. INTRODUCTION This policy applies to ALL recordings in possession of staff relating to undertakings at Barnsley Hospital NHS Foundation Trust (BHNFT), regardless of how they were acquired, or for what purpose. Images from other Trusts, either received or obtained on behalf of the Trust, must be controlled and protected in the same way and staff must be responsible custodians. All recordings of patients, which illustrate a patient’s condition or an aspect of treatment, are part of that patient’s medical record and protected under the Data Protection Act (1998). Capturing standardised images of patients can prove to be an invaluable asset in patient management, diagnosis and treatment, in particular for visually oriented disciplines due to its ability to provide accurate records of a patient’s appearance. Clinical images for inclusion in their medical records improve patient care and are an integral part of both inter and intra-disciplinary network. When specific procedures are followed, photographs may also be invaluable medico legal documents to be used in court as evidence (IMI, 2006a). Clinical images can be used for non-therapeutic purposes such as research, publication and medical education: this is what the General Medical Council (GMC) defined as secondary use of clinical photography (General Medical Council, 2002). With the ready availability of devices such as digital cameras, tablets and smart phones, for both still and video images, recordings can easily be taken by staff. As a consequence, patients, visitors and staff may be vulnerable to breaches in confidentiality and those taking recordings may be breaching the Data Protection Act (1998) thus leaving themselves open to prosecution.

2. OBJECTIVE The Trust needs to ensure that consent, recording, storing and use of recordings will comply with the requirements of the Copyright, Designs and Patents Act (1988), the Data Protection Act (1998), the Human Rights Act (1998), the Mental Capability Act (2005), the Care Act (2014) and the Six Caldicott Principles (The Caldicott Report, 1999). A full list of Acts of Parliament pertaining to the recordings of patients can be found in Appendix 2. The Trust needs to protect it’s employees and the organisation from disciplinary action as a result of an information security breach by identifying who may make clinical recordings and clarify the procedures to be followed in relation to making those recordings. The Trust needs to ensure that the highest possible image quality is always achieved. This policy does not include Close Circuit Television (CCTV) recordings of public areas on the organisations’ premises. For more information on CCTV please view BHNFT Privacy Notice (BHNFT, 2017a).

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3. SCOPE This policy applies to all employees of Barnsley Hospital NHS Trust.

4. POLICY 4.1 The Financial impact of non-compliance of this policy A serious breach of the Data Protection Act may lead the Information Commissioners Office to issue the organisation with a penalty notice up to £500,000. Both individuals and the organisation can face prosecution under the Act, receiving a fine and a criminal record. Furthermore, there is a high risk of litigation by patients for the misuse of clinical images which could result in substantial financial damages to the Trust. Non-compliance with this policy by any person working for the Trust may result in disciplinary action being taken in accordance with the Trust’s disciplinary procedure (BHNFT, 2015b). 4.2 Confidentiality The principles of confidentiality are articulated in the Data Protection Act (1998) and the General Data Protection Regulations (GDPR). Confidentiality is the patient’s right but may be waived by the patient or by someone legally entitled to do so on their behalf. Breach of confidentiality is treated as serious professional misconduct and may result in disciplinary action. Additionally, such a breach could result in unlimited financial damages for the Trust and criminal proceedings against the individual. In order to ensure that the patient’s right to confidentiality is preserved, BHNFT requires that:

• The patient’s explicit consent is obtained for the original recording and for its use as part of treatment or for teaching and that such consent is accurately recorded in the patient’s records.

• Only authorised copies are made.

• Prior to publication in journals, books, internet or elsewhere or for any use other that as described above, the subject’s permission for the specific use proposed must be sought and a specific written consent must be obtained.

However, even if the NHS Constitution commits to privacy and confidentiality, the right for confidentiality is not an absolute right (Department of Health, 2013). Data Protection Act (1998) and Caldicott Principles (The Caldicott Report, 1999) provide a

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framework to ensure personal data is shared appropriately, accurately and only when strictly necessary to improve care and support or to prevent abuse. Clause 45 of the Data Protection Act (1998) is particularly relevant to clinical photography, because it deals with what is defined as “supply of info”: the act states that personal information should be shared as soon as any concerns about safeguarding are perceived. While it is always necessary to respect people’s privacy, in certain occasions the interest served by disclosure of personal information outweighs the one served by protecting confidentiality: any use of confidential information must be justified and kept to a minimum; disclosure of personal data is permitted only when absolutely necessary and is regulated by the relevant legislation; access to personal data must be on a strict need-to-know basis (The Caldicott Report, 1999). 4.3 Consent Obtaining a valid consent for medical recordings is a general legal and ethical principle that reflects the right of patients to determine what happens to their own bodies. 4.3.1 Explicit consent Explicit consent for a specific use must be sought by all employees for all recordings undertaken on behalf of the Trust, whether or not the subject of the recordings is identifiable. In the case of minors or those who lack full capacity, the parent, guardian or court-appointed representative must consent on their behalf. This should be appropriately recorded in the patient’s medical records/notes. Medical Photographers should ensure that appropriate consent procedures are in place and that data is not used either inappropriately or in ways that fall outside the terms of the informed consent to which patients have agreed (IMI, 2006b). Explicit consent is considered valid if three conditions are satisfied: the patient needs to receive and understand adequate information about the photographic session, the patient must be competent to deliberate about the possible outcomes and the patient’s consent must not be coerced, manipulated or influenced by others (GMC, 2002). There are three levels of explicit consent: • Medical record use only • Clinical teaching purposes • Publication purposes The Trust requires oral consent for medical record use and teaching purposes, but written consent for publication purposes. If consent for electronic publication purposes is given, it should be made clear to the patient that once the recording is in the public domain there is no opportunity for effective withdrawal of consent.

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A refused consent should be respected and documented. Informed consent for publication should only be obtained for a specific use (Appendix 3). When clinical recordings of patients are carried out by any Trust staff, consent procedures must be followed. When requesting medical recordings (to be taken by the Medical Photography Department), it is the requester’s responsibility to obtain the correct level of consent and record this appropriately on the request. 4.3.2 Recordings without consent Recordings without consent may be prescribed in certain circumstances such as suspected physical abuse (SPA) of a child or abuse against a vulnerable adult, where it is unlikely that the parent or guardian/next of kin will give consent and the recording of injuries can be demonstrated to be in the patient’s best interest. Written Consultant authority is required in such cases and immediate referral should be made to the Trust’s Safeguarding Team. If a patient lacks capacity to give consent, but it is felt that in certain circumstances it would be in the patients’ best interests, refer to the Trust’s Mental Capacity Policy (BHNFT, 2017b) for guidance on assessing capacity and relevant guidance on best interests. Recordings of an unconscious patient may be taken provided consent is obtained from the patient before the recordings are released. The patient must be told that the recordings have been taken and, if they do not consent, the recordings must not be used for purposes other than being entered into a patient’s medical records. In cases where it is not possible to obtain consent prior to the recordings (e.g. the patient is unconscious when they enter the Trust), recordings can be carried out at the request of a consultant (who deems it in their best interest) (IMI, 2006c). If the patient subsequently dies, the images will not be destroyed, but will be removed from the patients electronic record (IMPAX) and safely and securely stored in a Trust server for the minimum required length of time (section 4.10). For guidance relating to recordings of emergency treatment and of unconscious patients please refer to the GMC guidance (2011). 4.3.3 Withdrawal of consent Patients have the right to withdraw consent for the use of their recordings at any time. If a patient decides to withdraw consent, the recordings must not be used for purposes other than medical records and the withdrawal of consent must be recorded. It is the duty of the clinician requesting the images to ensure that records are appropriately updated. In the case of electronic publication, it should be made clear to the patient that once the recording is in the public domain there is no opportunity for effective withdrawal of consent.

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Patients should be informed that recordings committed to their medical records will not be redacted, withdrawn or destroyed outside of the timescales laid down for the lawful storage of medical records (section 4.10). 4.3.4 Deceased people: recordings made when the patient was alive When a patient dies, UK Data Protection does not apply anymore; however, the duty of Confidentiality survives the death of a patient. The GMC (2011) suggests to always follow the patients’ wishes, provided that there is no reason to believe that consent was withdrawn before they died. Therefore, recordings can be still used for the consented use only. Permission should be sought for any new use outside the terms of the existing consent from the next of kin or personal representative. If a patient dies before a retrospective consent can be obtained, the images can only be released with the consent of the deceased’s next of kin or personal representative. However, if a patient consented for publication purposes, before releasing non-anonymised recordings in the public domain, BHNFT staff are required, for courtesy and medical ethics, to consider the worthwhileness of the case and the likelihood of causing harm and offence to the relatives for example, if a recording includes information about a genetic condition, or other information about the patient’s family. 4.3.5 Deceased people: recordings made when the patient was deceased No recordings can ever be made when a deceased patient is under medico-legal investigation. It is responsibility of the Medical Photography Department to contact the mortuary to investigate whether or not a deceased patient is under the Coroner’s jurisdiction. Recordings of organs, body parts and tissues to assist the cause of death do not require a specific consent. However, the pathologist in charge of the Post-Mortem examination must provide patient’s next of kin or personal representative a full explanation of the need of the recordings alongside the consent for the examination itself. UK Data Protection does not apply to dead patients but duty of Confidentiality survives their the death; however, the guidelines of the Royal College of Pathologists (2007) suggested that recordings could be considered a “use” of tissue in a legal argument. Therefore, in case of recordings for publishing purposes, whether or not the patient is identifiable, a specific consent must be obtained from the patient’s next of kin or personal representative alongside the consent for the Post-Mortem examination. Recordings for educational purposes do not require consent, provided that they do not include images that might identify the person. However, the recordings should previously be discussed with the Medical Photography Department to evaluate the worthwhileness of the case, which should be of extraordinary teaching values, and no likelihood of causing harm and offence to the patient’s relatives if identified.

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4.4 Anonymity A recording must not be altered in any way to achieve anonymity in order to avoid the need for the asking of a patient’s consent. Blacking out of the eyes in a photograph is not a sufficient or acceptable means of achieving anonymity of the patient as the patient may have other distinguishing features such as a tattoo or a distinctive scar. 4.5 Copyright The Trust holds the copyright and reproduction rights of all existing recordings made of its patients and on its premises. It is important that in any contract for publication the copyright in the recording remains with the Trust otherwise the Trust may find itself unable to protect the patients’ interests by exercising control over further publication of the recording. Those signing contracts with book, journal or other publishers have a responsibility to delete from the contract any suggestion that the copyright will pass to the publishers permanently. Copyright can be given to the publishers for one publication only. Before leaving the employment of the Trust, staff must seek specific permission to retain recordings for teaching purposes from the Healthcare Governance Committee. The Trust may grant such permission subject to the retention of copyright and reproduction rights. 4.6 Provision of Medical Photography Services The Medical Photography Department is fully digital and paper requests are not accepted. Requests for photography are made on ICE and resultant images can be viewed on IMPAX. Access to Medical Photographs stored in IMPAX is restricted to those users who have a legitimate clinical need to access them in order to protect patient confidentiality. 4.7 Obtaining clinical recordings out of hours When the Medical Photography Department is closed and it would be detrimental to the patient to delay photography (e.g. SPA), recordings maybe taken following previously agreed local procedures. All procedures include the following conditions:

• Recordings must be taken using Trust owned and controlled equipment and must not leave the Trusts’ premises

• Photographic training must be provided by the Medical Photography Department.

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• Images taken must be safely stored prior to being uploaded to IMPAX according to local procedures in accordance with this Policy.

4.8 Recordings made with personal devices Personally owned storage devices (USB or data sticks), smart phones, personal digital cameras, tablets or other devices must never be used to capture and/or store images or recordings. Anyone making recordings of patients on any other devices which are not Trust owned and controlled equipment face disciplinary action and leave themselves open to prosecution (BHNFT, 2015a) (Data Protection Act, 1998) (Human Rights Act, 1998). If any unauthorised recording does take place, those taking the recordings will be asked to delete them. Clinical recordings supplied by a patient from their personal mobile phone can be included in the patient’s EMR, provided that an oral consent is obtained from the patient for the intended use and recorded in the patient’s medical notes. However, it should be noted that the Medical Photography Department cannot guarantee confidentiality and security prior to storage or prove audit trails to verify the integrity of the recordings if required to do so by external agencies (IMI, 2014a). 4.9 Storage of recordings To prevent any misuse and to allow an immediate disclosure, when needed, robust systems must be in place for logging and storing clinical recordings in accordance with the Data Protection Act (1998) and the Data Handling Procedures in Government: Final Report (2008). All recordings taken by the Medical Photography Department are properly logged with a form which states their level of consent (Appendix 4) and stored within the BHNFT’s clinical images database (IMPAX) for viewing by authorised clinical staff. To comply with all local and NHS policies in connection with the management of clinical recordings, it is desirable that all clinical illustrative images and videos are contained within the BHNFT’s Image Database. Recordings taken by clinical staff outside the Medical Photography Department should be sent to Medical Photography to be uploaded into the Trust’s Database. This procedure will ensure that:

• Authorised staff should be able to access photographic patient records instantly, at any PC connected to the Trust network via a secure web browser

• Disclosure requests for clinical recordings can be met (required by The Access to Health Records Act 1990)

• Recordings will be stored on a managed system where their access can be monitored and tracked to minimise the risk of misuse

• The consent levels for clinical recordings are clear to clinical staff – reducing the risk that that they will be misused

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Under no circumstances, should patient recordings be permanently held on flashcards or unencrypted devices such as memory sticks, discs, laptops or desktops. Digital recordings must be removed from cameras as soon as possible after capture and uploaded to the clinical imaging database. Photographic memory cards cannot be encrypted and therefore must not be taken away from the Trusts’ premises. Only after clinical recordings are stored on the Trust’s Image Database, the individual capturing the recordings is absolved of any further storage responsibility. 4.10 Storage and retention of historic images All recordings are retained within the Trust for the required length of time for legal, operational, research and safety reasons: BHNFT has adopted the minimum retention periods for records set out in the Records Management NHS Code of Practice (IGA, 2016). The length of time for retaining records depends on the type of record: it is the duty of the Medical Photography Department to regularly monitor the retention, disposal and destructions of photographic and videographic records in accordance to the relevant Trust’s guidelines (BHNFT, 2013) (Appendix 5). 4.11 Quality of clinical photography The quality of the recordings produced in a hospital has a direct impact on patient care and “poor quality data can disrupt funding, damage the reputation of the organisation and individuals and lead to flawed clinical, administrative and planning decisions” (BHNFT, 2015c, p3). Staff should ensure that recordings that they capture are of adequate quality. Members of staff in doubt should seek professional assistance from the Medical Photography Department. Authorised images taken by any staff other than Medical Photographers should be regularly audited by the Medical Photography Department to ensure that the quality is acceptable and adequate for their purpose. Regular audit of images ensures that acceptable quality is achieved and maintained. 4.12 SPA and Medico-legal recordings Forensic recordings may be required by the police, Coroners and solicitors. It is of paramount importance to ensure the integrity and the authenticity of the recordings, through an audit trail of every change made to the images, from the capture moment to the time when they are presented in court. 4.13 Release of images 4.13.1 Patient Requesting Images

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On the occasion that recordings are requested, the requester should be directed to BHNFT’s Access to Health Records Department. 4.13.2 Emailing Images Emailing recordings is permissible when using a nhs.net email account to send to another nhs.net email account. Emails can be sent to a non NHS.net email account only with written permission from the patient (BHNFT, 2015d). 4.13.3 Request for images from/to another NHS Trust If another NHS Trust requires recordings stored on BHNFT’s PACS, it is the responsibility of the requesting Trust’s PACS team to contact the BHNFT’s PACS team to request the release of these recordings. 4.13.4 Publishing images Specific consent should be obtained for clinical recordings to be published (Appendix 6). Please see section 4.3 for more information. 4.13.5 CD/DVD with patient images If a patient requires a copy of their recordings, a CD of high quality clinical images will be provided, following the local policy. Hard copy prints are no longer produced by the BHNFT’s Medical Photography Department. A log sheet, produced by Medical Photography, containing information regarding all CDs, both encrypted and non- encrypted, is kept in the Photographic Studio for audit purposes. 4.13.6 Screenshots Screenshots of clinical recordings are unsuitable for diagnosis due to their low resolution and are not to be included in the patients medical record. 4. 14 Patients and general public taking recordings within the Trust Recordings of patients, taken by their relatives, friends or by another patient, is forbidden in clinical areas to ensure that no other patients or member of staff is accidentally photographed. It is the responsibility of the senior member of nursing staff to supervise so that this does not happen.

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4.15 Non Clinical Recordings Anyone, whether Medical Photography staff or other staff, who wish to take non-clinical recordings must adhere to the following:

• Permission must be sought from the medical staff in charge of the area where recording is to take place.

• Where applicable written consent is obtained from the people whose recordings will appear in either the Trust communications or external publications. The consent is recorded on a BHNFT release form (Appendix 4) which is stored securely in the Medical Photography Department.

Professional freelance photographers might be employed to undertake general recordings on Trust premises, and may only be introduced to the premises in this capacity with the full knowledge and permission of an appropriate representative of the Trust management. Contracts with outside videographers/photographers should ensure that they waive ownership of copyright in the images they produce, particularly if consenting patients are included in the images, although they may still be allowed to retain the right to reproduce the images. Recording of patients or staff by members of the press, television or other media agencies should be subject to strict control and safeguards, and undertaken only with the consent of the Chief Executive. In no circumstances should a patient’s privacy be invaded. Patient’s informed consent must be obtained prior to filming and confidentiality must be respected. 4.16 Tissue Viability 4.16.1 Pressure ulcers / moisture lesions Any pressure ulcer and / or moisture lesion may be an indicator of neglect / abuse, therefore Medical Photography is of great value and can aid any potential investigation. BHNFT Pressure Ulcer Prevention and Management Policy (2019) states that:

• All patients with hospital acquired pressure ulcers category 2 and above, including moisture associated skin damage caused by incontinence, must have medical recordings taken of the pressure damage.

• All patients admitted with pre-existing pressure damage, category 2 and above including moisture associated skin damage caused by incontinence, must have medical recordings taken of the pressure damage.

If the pressure damage is present on admission, then a request for Medical Photography must be made by the accepting area. Out of hours, the same principles apply as in section 4.7. The same principles apply as per the earlier sections on consent / recording without consent / storage etc.

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NICE (2014) recommends documenting the surface area of all pressure ulcers in adults, and recommends the use of a validated measurement technique, such as photography, to assist in this process.

EPUAP (2014) also suggests considering the use of baseline and serial photographs to monitor pressure ulcer healing over time.

4.16.2 Wounds A comprehensive wound assessment will identify if there is a need for photographic evidence. Photographs are an important component of effective wound assessment and management, and provide a visual technique for assessing healing. Photography is also a useful way of measuring wounds when incorporating a scale. The IMI National Guidelines: Guide to Good Practice Wound Management (IMI, 2012) will provide further information and advice to staff using photography as an aid in wound assessment and management.

5. ROLES AND RESPONSIBILITIES The Healthcare Governance Committee will ratify this policy and subsequently monitor its effectiveness. The Information Governance Manager, under the Director of IT has delegated responsibility for the co-ordination and management of information governance. Senior Managers are accountable for the communication about compliance with Trust policy. Modality Lead for Plain Film, Fluoroscopy, Dental & Dexa is responsible for overseeing the implementation of this policy through appropriate local processes within Medical Imaging. The Medical Photography Team is responsible for providing day-to-day support and guidance in order to implement this policy. With the rise of ethical, legal, and social concerns, it is evident that the responsibility of the Medical Photographer does not end in producing accurate outcomes for medical records: Medical Photographers must be aware of their safeguarding role and responsibilities in correctly storing medical images. In 2014 the Institute of Medical Illustrators (IMI) published the Code of Professional Conduct for Professional Members. This document illustrates the standards required to maintain the highest professional practice and it defines the duty of care of the profession: “clinical photographers shall avoid causing harm or distress to patients, recognise their beliefs and cultural practice, and protect their rights and dignity” (IMI, 2014b, p7).

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All staff is responsible for ensuring that they comply with the provisions of this policy. Members of the Trust who are not professional photographers should also be aware of their own limitations when taking recordings that may subsequently be required for clinical or legal proceedings. Images taken by Medical Photographers are the preferred option within BHNFT. Students of all disciplines must not take or store recordings of patients under any circumstances.

6. List of References

BHNFT. (2013). Health Records Policy. 3rd ed. [online] Available from:

http://systems/pt/Policy%20One/H/Health%20Records%20Policy.pdf [Accessed 28

July 2017].

BHNFT. (2015a). Disciplinary Policy. 4th ed. [online] Available from:

http://systems/pt/Policy%20One/D/Disciplinary%20Policy.pdf [Accessed 28 July

2017].

BHNFT. (2015b). Data Protection Policy. 3rd ed. [online] Available from:

http://systems/pt/Policy%20One/D/Data%20Protection%20Policy.pdf [Accessed 28

July 2017].

BHNFT. (2015c). Information Security Policy. [online] Available from:

http://systems/pt/Policy%20One/I/Information%20Security%20policy.pdf [Accessed

28 July 2017].

BHNFT. (2017a). Privacy notice. [online] Available from :

http://www.barnsleyhospital.nhs.uk/documents/publication-scheme/making-a-

request/data-protection-act-1998-and-patient-confidentiality/privacy-notice/

[Accessed 28 July 2017].

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BHNFT. (2017b). Metal Capacity Policy. 2nd ed. [online] Available from:

http://systems/pt/Policy%20One/M/Mental%20Capacity%20Policy.pdf [Accessed 28

July 2017].

BHNFT. (2019). Pressure Ulcer Prevention and Management Policy. 3nd ed. [online]

Available from:

http://systems/pt/Policy%20One/P/Pressure%20Ulcer%20Prevention%20Policy.pdf

[Accessed 23 January 2019].

Cabinet Office. (2008). Data Handling Procedures in Government: Final Report.

[online] Available from:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach

ment_data/file/60966/final-report.pdf [Accessed 12 April 2018].

Department of Health. (2013). Information: To Share or not to Share. Government

response to the Caldicott Review. [online] Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/25175

0/9731-2901141-TSO-Caldicott-Government_Response_ACCESSIBLE.PDF


EPUAP. (2014). Prevention and Treatement of Pressure Ulcers: Quick reference

Guide. 2nd ed. [online] Available http://www.npuap.org/wp-

content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-

NPUAP-EPUAP-PPPIA-16Oct2014.pdf [Accessed 28 July 2017].

GMC. (2002). Making and using visual and audio recordings of patients. [online]

Available from :

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http://www.gmcuk.org/Making_and_using_visual_and_audio_recordings_of_patients

_2011.pdf_40338254.pdf [Accessed 28 July 2017].

GMC. (2011). Making and using visual and audio recordings of patients. [online]

Available from : https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-

doctors/making-and-using-visual-and-audio-recordings-of-patients [Accessed 12

April 2018].

Great Britain. Copyright, Designs and Patents Act: Elizabeth ll. (1988). London: The

Stationery Office.

Great Britain. Data Protection Act: Elizabeth ll. (1998). London: The Stationery

Office.

Great Britain. Mental Capability Act: Elizabeth ll. (2005). London: The Stationery

Office.

Great Britain. Care Act: Elizabeth ll. (2014). London: The Stationery Office.

IGA. (2016). Records Management Code of Practice for Health and Social Care

2016. [online] Available from: https://digital.nhs.uk/media/1158/Records-

Management-Code-of-Practice-for-Health-and-Social-Care-2016/pdf/Records-

management-COP-HSC-2016 [Accessed 28 July 2017].

IMI. (2006a). IMI National Guidelines. Non-accidental injuries. [online] Available

from: http://www.imi.org.uk/document/non-accidental-injuries [Accessed 28 July

2017].

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IMI. (IMI, 2006b). IMI National Guidelines. Consent to Clinical Photography. [online]

Available from:

http://www.imi.org.uk/file/download/2143/IMINatGuidelinesConsentMarch_2007.pdf


IMI. (2006c). IMI National Guidelines. Patient Confidentiality and Clinical

IllustrativeRecords. [online] Available from:

http://www.imi.org.uk/document/patientconfidentiality [Accessed 28 July 2017].

IMI. (2012). IMI National Guidelines: guide to Good Practice. Wound Managment.

[online] Available from:

http://www.imi.org.uk/file/download/4708/Wound_Management_Sep12.pdf


IMI. (2014a). IMI National Guidelines. A Guide to Good Practice. Mobile Phone

Photography Guidelines. [online] Available from:

http://www.imi.org.uk/document/mobile-phone-photography-jun-14 [Accessed 28

July 2017].

IMI. (2014b). A Code of Professional Conduct for Professional members. [online]

Available from: http://www.imi.org.uk/document/code-of-conduct [Accessed 28 July

2017].

NICE. (2014). Clinical Guideline [CG179]: Pressure ulcers: prevention and

management. 3rd ed. [online] Available from:

https://www.nice.org.uk/guidance/CG179 [Accessed 28 July 2017].

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Royal College of Pathologists. (2007). Questions and Answers: The Human Tissue

Act 2004. London.

The Caldicott Report. (1999). The journal of the Institute of Health Record

information and Management. 40 (2), 17-9.

7. Glossary of Terms used within the document BHNFT = Barnsley Hospital NHS Foundation Trust.

EPUAP = European Pressure Ulcer Advisory Panel.

GMC = General Medical Council.

Healthcare Governance Committee = A general term for the overall framework

through which NHS organizations are accountable for continuously improving

clinical, corporate, staff and financial performance.

ICE = Software used at BHNFT to request medical examination.

IGA = Information Governance Alliance.

IMI = Institute of Medical Illustrators.

IMPAX = Software used at BHNFT using a digital radiology imaging system.

Moisture lesion = a lesion caused by moisture (incontinence or perspiration) which

is in continuous contact with intact skin of the perineum, buttocks, groins, inner

thighs, natal cleft, skin folds and where skin is in contact with skin.

NHS = National Health Service.

NICE = National Institute for Health and Care Excellence.

PACS = Picture Archiving & Communication System. A computer network for

digitised radiologic images and reports.

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Pressure ulcer = a localized injury to the skin and/or underlying tissue usually over

a bony prominence, such as the heels, ankles, hips and tailbone, as a result of

pressure, or pressure in combination with shear or friction. People most at risk of

pressure ulcers are those with a medical condition that limits their ability to change

positions or those who spend most of their time in a bed or chair. Pressure ulcers are

also called ‘decubitus ulcers’ and, popularly, ‘bedsores’.

Recording(s) = refers to photography, video, audio and other illustrative recordings

of patients and concerns both original and copies of images in both digital and

analogue format.

sDTD = Suspected deep tissue damage.

SPA = Suspected Physical Abuse. Previously known as NAI (Non-Accidental Injury).

8. Bibliography

Berle, I. (2011). Privacy and Confidentiality: What is the Difference?, Journal of

Visual Communication in Medicine. 34 (1), 43-44.

BHNFT. (2015). Confidentiality Policy. [online] Available from:

http://systems/pt/Policy%20One/C/Confidentiality%20Policy.pdf [Accessed 28 July

2017].

BHNFT. (2015). Data Quality Policy. [online] Available from:

http://systems/pt/Policy%20One/D/Data%20Quality%20Policy.pdf [Accessed 28 July

2017].

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BHNFT. (2015). Record Management Policy. [online] Available from:

http://systems/pt/Policy%20One/R/Records%20Management%20Policy.pdf


BHNFT. (2016). Guidance on Court Attendance and Statement Writing in

Safeguarding Children and Young People. 2nd ed. [online] Available from:

http://systems/pt/Policy%20One/S/Safeguarding%20Children%20Policy.pdf


BHNFT. (2016). Trust Surveillance Camera Policy & Procedures. [online] Available

from: http://systems/pt/Policy%20One/S/Surveillance%20Camera%20Policy.pdf


BHNFT. (2016). Safeguarding Children Policy. 2nd ed. [online] Available from:

http://systems/pt/Policy%20One/S/Safeguarding%20Children%20Policy.pdf


BHNFT. (2017). Consent Policy. [online] Available from:

http://systems/pt/Policy%20One/C/Consent%20Policy.pdf [Accessed 28 July 2017].

BHNFT. (2017). Safeguarding Adults. 2nd ed. [online] Available from:

http://systems/pt/Policy%20One/S/Safeguarding%20Adults%20Policy.pdf [Accessed

28 July 2017].

BHNFT. (2017). Privacy and Dignity Policy. 2nd ed. [online] Available from:

http://systems/pt/Policy%20One/P/Privacy%20and%20Dignity%20Policy.pdf


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Bryson, D. (2013). Current issues: Consent for clinical photography. Journal of

Visual Communication in Medicine, 36 (1-2), 62-63.

Committee for the Accreditation of Medical Illustration Practitioners (CAMIP). (2014).

Application for the Regulation of Clinical Photographers by The Health Professions

Council. Summary Document. [online] Available from:

http://www.hpcuk.org/assets/documents/1000064Ecouncil_meeting_20040914_encl

osure05iii.pdf [Accessed 28 July 2017].

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Clinical Pathology, 56 (6), 426-428.

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Available from:

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Available from :

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d_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_09281

2.pdf [Accessed 28 July 2017].

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Department of Health. (2013). Information: To Share or not to Share. Government

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uk.org/Confidentiality___English_1015.pdf_48902982.pdf [Accessed 28 July 2017].

Great Britain. Human Rights Act 1998: Elizabeth ll. Article 8. (1998). London: The

Stationery Office.

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Usage of Medical Images. Journal of Visual Communication in Medicine, 29 (2), 76-

79.

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safeguarding services to children, young people, parents and carers. [online]

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2017].

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IMI. (2016). IMI National Guidelines. A Guide to Good Practice. Chaperone

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1.pdf [Accessed 28 July 2017].

Lau, C.K., Schumacher, H.H.A and Irwin, M.S. (2010). Patients’ Perception of

Medical Photography. Journal of Plastic, Reconstructive & Aesthetic Surgery, 63 (6),

507-511.

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publications/social-media-guidance.pdf [Accessed 28 July 2017].

Payne, K., Tahim, A., Mc Goodson, A., Delaney, M. and Fan, K. (2012). A Review Of

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9. Appendices Appendix 1: EQUIA

EQUALITY IMPACT ASSESSMENT TEMPLATE INITIAL ASSESSMENT STAGE 1 (part 1)

Department:

Medical Photography

Division:

Medical Imaging

Title of Person(s) completing this form:

Medical Photographers

New or Existing Policy/Service

New policy

Title of Policy/Service/Strategy being assessed:

BHNFT Policy for Clinical Photography

Implementation Date:

What is the main purpose (aims/objectives) of this policy/service?

This policy is to offer guidance to all staff to ensure that they are aware of the procedures to be followed in relation to all clinical photography in BHNFT.

The policy aims to comply with NHS England, Barnsley Hospital NHS Foundation Trust (BHNFT), GMC, IMI and Department of Health guidelines and frameworks, as well as with the relevant legislation:

The Access to Personal Files Act (1987) The Access to Health Records Act (1990) The Care Act (2014) The Children Act (1989 and 2004) The Copyright, Designs and Patents Act, (1988) The Criminal Justice and Public Order Act (1994) The Data Protection Act (1984 and 1998) The Mental Capability Act (2005) The Mental Health Act (1983) The Obscene Publications Act (1959) The Protection of Children Act (1978 and 1999) The Video Photographs Act (1984) Professions Supplementary to Medicine Act (1960) Clinical Negligence Scheme for Trusts (2001)

Will patients, carers, the public or staff be affected

Yes No If staff, how many individuals/which groups of staff are likely to be affected?

Patients X

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by this service?

Please tick as appropriate.

Carers X

All medical staff within the Trust Public X

Staff X

Have patients, carers, the public or staff been involved in the development of this service?


Patients X If yes, who did you engage with? Please state below:

Simon Ainsworth, Paula MacDonald, Maxine Harrison, Tinashe Sithole.

Written by Vicki Tisch and Laura Marcato

Carers X

Public X

Staff X

What consultation method(s) did you use?

Emails and Word documents with tracked changes.

DATA COLLECTION AND CONSULTATION 1a In relation to this service/policy/procedure – Do you currently record/have any of the following patient data?

Protected Characteristic Indicate yes or No If Yes – State where Recorded

Age Yes CRIS

Sex Yes CRIS

Ethnicity No

Religion or Belief No

Disability Yes CRIS

Sexual Orientation No

Gender Re-assignment No

Marriage & Civil Partnership Yes CRIS

Pregnancy & Maternity No

Carer Status No

Please indicate Yes or No

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Equality Impact Assessment Stage 1 PART 2

What does this data tell you about each of the above protected characteristics? Are there any trends/inequalities?

The above patient data is available to review, if required.

As this policy relates to images (electronic/paper) and recordings undertaken in Barnsley Hospital NHS Foundation Trust (BHNFT), there is no indication that it would negatively impact on particular protected characteristics.

What other evidence have you considered? Such as a ‘Process Map’ of your service (assessment of patient’s journey through service) / analysis of complaints/ analysis of patient satisfaction surveys and feedback from focus groups/consultations/national & local statistics and audits etc.

N/A

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Equality Impact Assessment Stage 1 PART 3

ACCESS TO SERVICES

What are your standard methods of communication with service users?


Communication Methods Yes No

Face to Face Verbal Communication X

Telephone X

Printed Information (E.g. leaflets/posters) X

Written Correspondence X

E-mail X

Other (Please specify)

If you provide written correspondence is a statement included at the bottom of the letter acknowledging that other formats can be made available on request?


Yes No

X

Are your staff aware how to access Interpreter and translation services?

Interpreter & Translation Services Yes No

Telephone Interpreters (Other Languages) X

Face to Face Interpreters (Other Languages) X

British Sign Language Interpreters X

Information/Letters translated into audio/braille/larger print/other languages?

X

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ACCESS

Please tick as appropriate

Is the building where the service is located wheelchair accessible? Yes No

Does the reception area have a hearing loop system? X

Does the building where the service is located have a unisex wheelchair accessible ‘disabled toilet?

X

Does the building have car parking space reserved for Blue Badge holders?

X

Does the building have any additional facilities for disabled people such as a wheelchair, hoist, specialist bath etc?

X

Does the building/hospital sire where the service is provided have access to prayer and faith resources?

X

EQUALITY IMPACT ASSESSMENT – STAGE 1 (PART 4)

Protected Characteristic

Positive Impact

High

Low

None

Negative Impact

High

Low

None

Reason/comments for positive Impact

Why it could benefit any/all of the protected characteristics

Reason/Comments for Negative Impact

Why it could disadvantage any/all of the protected

characteristics

Resource Implication

Yes / No

Men

Women

Younger People (17 –

25) and Children

High

The policy specifies how to obtain an informed consent from children.

It also informs members of the Trust on what to do in case of NAI photography.

Older people

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(60+)

Race or Ethnicity

Learning Disabilities

High

The policy specifies how to obtain an informed consent from patients with learning disabilities.

Hearing impairment

Visual impairment

Physical Disability

Mental Health Need

High

The policy specifies how to obtain an informed consent from patients with mental health requirements.

Gay/Lesbian/Bisexual

Trans

Faith Groups

(please specify)

Marriage & Civil

Partnership

Pregnancy & Maternity

Carer Status

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Other Group

(please specify)

Applies to ALL Groups

High

This policy applies to ALL images (electronic/paper) and recordings undertaken at Barnsley Hospital NHS Foundation Trust (BHNFT), regardless of protect characteristics.

The aim of this policy is to ensure that all images are treated according the appropriate legislation requirements.

BHNFT staff must commit to privacy and confidentiality.

Consent must be sought for all photography undertaken on behalf of the Trust: in the case of minors, or those who lack full capacity, the parent, guardian or court-appointed representative must consent on their behalf.

Consent must be informed and specific for its use.

INITIAL ASSESSMENT (PART 5)

Have you identified any issues that you consider could have an adverse (negative) impact on people from the following protected groups? IF ‘NO IMPACT’ IS IDENTIFIED Action: No further documentation is required. IF ‘HIGH YES IMPACT’ IS IDENTIFIED Action: Full Equality Impact Assessment Stage 2 Form must be completed. (a) In relation to each group, are there any areas where you are unsure about the impact and more information is needed?

No

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(b) How are you going to gather this information?

N/A

(c) Following completion of the Stage 1 Assessment, is Stage 2 (a Full Assessment) necessary? NO Assessment Completed By: Laura Marcato and Vicki Tisch Date Completed: 16/04/2018 Line Manager …………………………….. Date…………………………….. Head of Department ……………………… Date…………………………….. When is the next review? Please note review should be immediately on any amendments to your policy/procedure/strategy/service. 1 Year 2 year 3Year

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Appendix 2: Legislation

The Access to Personal Files Act (1987)

The Access to Health Records Act (1990)

The Care Act (2014)

The Children Act (1989 and 2004)

The Copyright, Designs and Patents Act, (1988)

The Criminal Justice and Public Order Act (1994)

The Data Protection Act (1984 and 1998)

The Mental Capability Act (2005)

The Mental Health Act (1983)

The Obscene Publications Act (1959)

The Protection of Children Act (1978 and 1999)

The Video Photographs Act (1984)

Professions Supplementary to Medicine Act (1960)

Clinical Negligence Scheme for Trusts (2001)

General Data Protection Regulations (2018)

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Appendix 3: Consent for Publication of Medical Images and Videos

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Appendix 4: Consent forms for IMPAX

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Appendix 5: Retention period at BHNFT

Type of record Retention Period

Pre digital/EPR (where images present the primary source of information for the diagnostic process)

• 30 years after date of photography

Children/young people

Child Protection

• Until patient/s 25th birthday (if patient was younger than 17 at time of photography)

• Until patient/s 26th birthday (if patient was 17 at time of photography)

• 8 years after death

• If the illness or death could have potential relevance to adult conditions or have genetic implications for the family of the deceased, keep for 30 years

Mentally disordered patients

(under Mental Health Act)

• 20 years after photography


Oncology patients



Maternity records

• 25 years from the birth of the last child

Safeguarding / SPA / Coroner’s investigation / Forensic records (Post Mortem findings)


Litigation

• 10 years after the file has been closed

Genetic condition / diagnosis of

Creutzfeldt-Jakob Disease

• 30 years from date of diagnosis, included deceased patients

All other types of photography


• after death

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Appendix 6: Photography and/or Video Consent and Release Form for Non-Medical Purposes

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REPORT TO THE BOARD OF DIRECTORS REF: BoD: 19/10/03/08

SUBJECT: MEDICAL DIRECTOR’S QUARTERLY REPORT

DATE: October 2019 (Q2: 2019/20)

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Andrew Wiles – Business Manager Dr Simon Enright – Medical Director Medical Directorate Department Heads

SPONSORED BY: Dr Simon Enright – Medical Director

PRESENTED BY: Dr Simon Enright – Medical Director STRATEGIC CONTEXT

To provide an overview on a number of the Medical Director’s activities and to record particular events, meetings or publications that the Medical Director would like to bring to the Board of Directors’ attention.

EXECUTIVE SUMMARY This report provides an update on the following key issues within the Medical Director’s portfolio: • Patient Safety • Clinical Audit, NICE and NCEPOD • Medical Education • Research and Development • Medical Appraisal • Miscellaneous / Key Projects (Medical Staffing and Mortality are discussed in detail in their own reports to Trust Board and Quality and Governance) The Directorate has continued to develop its people and processes since the previous report in June. A number of key staff changes, in particular in Medical Education, and developments are detailed in the paper. There have been a number of successes within all teams. A number of the Projects that the Directorate is leading on are now coming to a conclusion, in particular the ICE Filing and D1 projects. We continue to lead on a number of new developments including Clinical Guidelines/Policies and Junior Doctor induction. The Directorate is developing a clear work plan and expects significant improvements in all the areas described over the next year. RECOMMENDATION(S)

The Board of Directors is asked to receive, review and note the attached report.

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Subject: MEDICAL DIRECTOR’S QUARTERLY REPORT Ref: BoD 19/10/03/08 1. INTRODUCTION 1.1.1 Strategic Context 1.1.2 To provide a brief overview on the different areas and activities within the Medical

Director’s remit and to record particular events, meetings or publications that the Medical Director would like to bring to the Board of Directors attention.

1.2 Team 1.2.1 There have been a number of changes to the Medical Directorate team since the last

report in June. Dr Jo Beahan has been appointed to Deputy Medical Director and will work along side Mr Bannister, focussing on Medical Leadership and Job Planning. The appointment will mean that Dr Beahan will relinquish her role as Director of Medical Education. This has been catalyst to look at all roles associated with Medical Education, with a significant number of roles coming to the end of their tenure. Interviews for the vacant DME position will take place at the end of September. Following this we will interview to the other positions.

1.2.2 The previously agreed expansion of the Medical Education administration team has moved forward. A number of posts have been appointed to; we are due to finalise the remaining recruitment in the next couple of months.

1.2.3 In R&D, in line with the strategy, Adam Hawksworth has joined the Trust from Sheffield Teaching Hospitals. Adam joins the team as the Management/Research Accountant. Adam will also assist the wider Medical Directorate from a finance perspective.

2. PATIENT SAFETY AND QUALITY IMPROVEMENT 2.1 Team 2.1.1 The Lead Medical Examiner started at the end of August (Dr Julian Humphrey) 2.1.2 Medical examiner posts have been advertised in September and recruitment is taking

place 2.1.3 The Medical Examiner Officer (MEO) post was recruited to in August; Donna Goddard

was appointed to the role. 2.1.4 The Patient safety nurse B6 (Richard Clark) is leaving to take up a senior lecturers post

at Sheffield Hallam University. 2.1.5 The future leaders post holder, Donna Goddard completed her programme – a summary

of her work is included in section 2.13. 2.1.6 The post is out to advert but there will be a gap in the team pending appointment. The

post carries responsibility for Care Flow Vitals. Interim arrangements are being considered.

2.1.7 Dr Clare Ginnis has accepted the Role of QI clinical lead as an interim to test the concept of the Barnsley QI Hub. This will aim to consolidate the Trusts strategy for QI over the next few months.

2.2 Work Streams 2.2.1 Work plans for the team are in place and are aligned to the Trust’s governance structure.

To date there are over 20 work streams identified for the team including: • Quality Improvement Hub/Network • AHSN Innovation Strategy (draft proposal) • Improvement Academy advanced Q training • Patient safety alerts • Patient safety assurance reviews • Careflow vitals • Sepsis Screening • Sepsis antibiotic within an hour

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• Sepsis dashboard • Sepsis Task and Finish Group • Missed medicines • Mortality • Medical Examiner’s Office • Learning from deaths • Medical device e-competency recording • Medical device training needs analysis for ESR • Local safety standards for invasive procedures (LocSSIPs) • Safety huddles • Quality improvement training • Human factors • Resuscitation training • DNACPR audit

2.3 Key Priorities: 2.3.1 Clinical Conditions and Avoidable Harms: Sepsis, AKI (acute kidney injury) and VTE are

complex clinical conditions that can lead to life threatening status and the team are keen to maintain improvements.

2.3.2 Quality Improvement: The Team are seeking to move forward in developing a strategic approach to quality improvement that will complement the existing quality strategy, with the aim of developing this further in one combined Quality Governance and Quality Improvement strategy document in 2020.

2.3.3 The current model for improvement focuses on building capacity through training in QI methodology. Whilst this is still a priority there is a requirement for a focus on QI, either through and actual or virtual hub which will bring together the QI resource for the organisation. A draft proposal has been explored with the executive team and presented at the CBU development session.

2.3.4 Innovation: the team has commenced work with AHSN to work in partnership to link improvement and innovation together as a ‘first’ at Barnsley.

2.4 Care Flow Vitals (previously VitalPac) 2.4.1 Careflow Vitals usage has continued to expand within BHNFT with extra functionalities

successfully implemented. These include the inputting of ward based urinalysis results as well as routine blood glucose and ketone readings.

2.4.2 Extra localisation enhancements have been added to ensure Careflow Vitals reflects the needs of specific service requirements to ensure end users have the optimal systems in place to further benefit our patients.

2.4.3 Educational activities have been delivered to ensure sepsis and VTE functions are used effectively and future modules such as Dementia are currently being tested with a view to future roll-out.

2.4.4 Advanced planning and preparation has been completed and is in place for the next system upgrade to version 4.1 and trust wide deployment is expected in 2020.

2.4.5 A Paediatric stakeholder task and finish group has been formed to ensure Careflow Vitals is used optimally within CBU3 and to ensure effective usage amongst staff.

2.5 Quality Improvement 2.5.1 The outline vision has been presented to the Executive Team and implementation plans

are being developed in quarter three. BHNFT has a strong record of Improvement and the Innovation and Quality Improvement Hub is the next step to bring the QI experts and good practice together.

2.5.2 It will bring people, expertise, training, resources, virtual space and ethos together to facilitate improvement.

2.5.3 The aim is to build capability and capacity to expand to system wide work as well as grass roots improvements.

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2.5.4 Dr Clare Ginnis has been appointed to as the clinical lead for QI. Clare was previously the Patient Safety Fellow for QI at the Trust in 2016.

2.5.5 Dr Ginnis has submitted a bid for a QI Fellow to HEE (see section 2.13) 2.6 Sepsis 2.6.1 The Sepsis CQUIN has been replaced with reporting as part of the national standard

contract. • Compliance of 100% for screening has been maintained • Antibiotic administration within the hour is at 87.8% for Q1

2.6.2 The pilot of using unregistered staff to undertake blood cultures has proven successful with the Acute Response Team (zero contaminants). This is now being rolled out to other clinical areas with ED and AMU as a priority which should enable cultures to be taken prior to antibiotics in more patients thus enabling better antimicrobial stewardship.

2.6.3 Coding – the clinical lead continues to review notes in conjunction with the coding team when sepsis has been included. This includes a review of the medical record, culture results on Ice and vital signs on Care Flow Vitals

2.6.4 Sepsis Summit – An education day as part of the quarterly patient safety summit took place on Wednesday 25th September from 10am-3pm.

2.6.5 The group continue to monitor the time to antibiotics as per national contracting.

2.7 Mortality 2.7.1 Statistical and Learning detail is in the separate mortality paper which comes to Q&G on

a monthly basis and Trust Board on a quarterly basis. 2.7.2 The rolling HSMR to May 2019 is 96.9. 2.7.3 The SHMI for April 2018-March 2019 is 99.

2.8 Medical Examiners Office 2.8.1 The lead Medical Examiner (ME) for BHNFT, Dr Julian Humphrey, commenced in

August. 2.8.2 The Medical Examiner Officer (MEO) commenced in August 2019. 2.8.3 Four other consultants have completed the Medical examiner training (circa 25 hours

online) and recruitment is underway. 2.8.4 It is anticipated that BHNFT will fully implement the ME office by the end of Q3 2019/20. 2.8.5 The Medical Examiners Officer has completed the relevant MEO training and is currently

working on a SOP for the Medical Examiners Service. 2.8.6 The lead medical examiner independently scrutinises deceased patient’s medical

records to identify: • Any improvements in practice. • Areas of good practice • Referral to coroners • A need for Structured Judgement Reviews

2.9 Missed Medicines 2.9.1 A ‘Missed Meds Awareness Week’, w/c 29th July 2019, was held which was very

successful. It was led by Junaid Mobeen (pharmacist) who did a lot of engagement work around missed medicines.

2.9.2 Point prevalence audit has been used to show where current gaps lie (either prescribing, dispensing or administration). This Highlighted Acorn as an area that made big improvements and the Acorn team presented at the most recent task and finish group.

2.9.3 There has been excellent engagement from nursing staff in all area, especially from Surgery and the Acorn Unit.

2.10 Medical Devices 2.10.1 In addition to the 6 monthly CBU reports to PSHG, work is on-going to move the current

paper-based competency record system to an electronic system.

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2.10.2 This will compliment ESR and ensure that, for the first time in the organisation a comprehensive list of devices that staff are competent to use.

2.10.3 E-Form development is in progress and ready to be tested 2.10.4 BFS will place all user guides and manuals onto SharePoint. 2.10.5 Theatres have successfully tested the pilot system devised by IT. Further E-Form testing

is due to take place and work is being undertaken to move paper-based records onto the electronic system before rolling out to other areas.

2.10.6 This work will be completed in 2020.

2.11 Local Safety Standards for Invasive Procedures (LocSSIPs) 2.11.1 National Safety Standards for Invasive Procedures (NatSSIPs) was a high-level

document produced by NHS England which set out the key steps necessary to deliver safe care for patients undergoing invasive procedures.

2.11.2 BHNFT has worked towards having Local safety standards (LocSSIPs) in place. 2.11.3 An assurance review was approved at PSHG as compliant with the relevant patient

safety alert from 2016.

2.12 VTE 2.12.1 Assessment compliance has been sustained and the focus of the work is now on

learning from RCA’s. VTE assessment has been consistently >96% for the last 12 months.

2.12.2 Giving of information on prevention of VTE is being explored through inclusion in the discharge summary – once the D1 is delivered this will provide the link to information for patients.

2.13 Future Leaders Programme (Donna Goddard) 2.13.1 As a patient safety fellow Donna was involved in the following work as part of her

fellowship. 2.13.2 Worked with the medical lead for Acute Kidney Injury, improved AKI awareness within

the trust for all health care professionals. This included highlighting ‘Back to Basics’ with non-registered nurses, stressing the importance of accurate fluid balance management.

2.13.3 As a result of this work the trust has made a dramatic improvement in Hospital Standardised Mortality Rate (HSMR), for AKI over a two year period and is now in the top three trusts in England for AKI deaths.

2.13.4 Specific changes are: • Planned and implemented a trust AKI awareness week. • Introduced a daily electronic alerting process for patients who have been identified

with an AKI. With the results being sent to the Acute Response Team for early intervention and management of AKI

• Delivery of Human factors training utilising Team STEPPS • Co-implemented NEWS 2 training within the trust • Developed an escalation process for non-compliance of VTE assessment • Completed training and become competent in Structured Judgement Reviews (SJR) • Completed Training in Human Factors • Post Graduate Certification Clinical Education – 1 year course at Leeds University • HEE training including, Structure and Power Dynamics in the NHS, Effective

Meetings, Quality Improvement, Human Factors and Patient Safety, Human factors and Communication

2.13.5 The trust is benefitting from the fellowship further as Donna is the new MEO, working with the Medical Examiner and within the PS&QI team and alongside the Bereavement Office. Skills and knowledge from the PGC- CE will be used to develop and deliver training to junior doctors, particularly with regards to the correct completion of Medical Certificates of cause of death (MCCD).

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2.14 QI Bronze and Human Factors Training 2.14.1 In line with the three-year strategy to deliver training to 30% of key staff, further cohorts

have been added into the ‘to be trained’ numbers. The team has a self-imposed stretch target to achieve 50%, during 2020/21.

2.14.2 Training Compliance – the following table provides some Key Training and QI targets for the patient safety team

Training Training Target

Training Section

2018/19 Q4 2019/20 Q1 2019/20 Q2

Jan Feb Mar Apr May Jun Jul Aug

*BLS 90% 1 MAST 83.82% 83.72% 84.43% 86.71% 85.35% 83.61% 80.92%

*ILS 90% 1 MAST 79.7% 79.3% 85% 90.1% 89.8% 89.5% 87.7%

*pILS 90% 1 MAST 79.46% 78.57% 82.06% 87.27% 88.59% 93.4% 89.62%

Human Factors 30% 2 QIT 44.1% 45.5% 46.1% 40.7% 44.1% 45.4% 46.1%

VTE Training 30% 2 QIT 43.39% 42.77% 44.04% 32.58% 46.83% 47.76% 49.13%

QI Bronze 30% 3 QIT 35.29% 36.84% 37.82% 46.44% 34.47% 36.3% 37.32%

2.14.3 *The Executive Team are due to receive a paper outlining the plans to improve

mandatory training compliance in key medical staff, particularly bank staff at the Trust who form the majority of Doctors who are non-compliant. This will include:

• Streamlining the process for passporting compliance from other organisations • Review of requirements by specialty – including an assessment for requirements

for BLS • Potential for recognition of superseding qualifications for current life support

trainers (e.g. ATLS and ALS)

3. CLINICAL AUDIT 3.1 Clinical audit activity and progress from Q1 (April to June) 2019 3.1.1 Number of registered on-going/active projects (as at 23 September 2019):

Priority

CBU 1 Nationally

mandated 2 Locally mandated

3 Local high priority

4 Low priority Total

1 30 20 14 12 76 2 28 2 9 20 59 3 10 1 29 17 57 Corporate 14 9 4 - 27

82 32 56 49 219

3.1.2 Number of projects completed/closed/removed from programme:

Priority

CBU 1 Nationally

mandated 2 Locally mandated

3 Local high priority

4 Low priority Total

1 - 11 5 14 30 2 3 1 2 7 13 3 2 - 2 10 14 Corporate 2 - 1 2 5

7 12 10 33 62 3.1.3 There were 62 clinical audits completed during Q1 (2019/20). All P1 to P3 audits 29/62

(47%) have been presented and have action plans registered with the clinical audit department. The remaining 33 P4 audits are managed at a CBU level.

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3.1.4 There were seven national audit reports available during this three-month period: National Ophthalmology Cataract Surgery Year 3, National Hip Fracture Database (NHFD) Facilities Audit 2018, National Hip Fracture Database (NHFD) Audit, National Neonatal Audit Programme (NNAP) 2017, National Neonatal Audit Programme (NNAP) 2016, National CQUIN: Antimicrobial Stewardship for Sepsis 2018/19 Q4 and National CQUIN for Sepsis 2018/19 Q4.

3.2 NICE update 3.2.1 During Q1 (2019/20), 42 pieces of NICE guidance were published or updated. As of 23

September 2019: Guidance Number

Not applicable to Trust 18 Applicable and full compliance achieved 10 Applicable and assessment/actions on-going 6 Awaiting response 6 For information only (terminated appraisal) 2

Total: 42 3.2.2 Three quality standards were published or updated.

Standards Number Not applicable to Trust 1 Applicable and full compliance achieved 1 Applicable and assessment/actions on-going 1

Total: 3 3.3 NCEPOD update 3.3.1 The Trust is currently participating in the following NCEPOD studies; data collection is on

going: • Dysphagia in Parkinson’s disease • Out of hospital cardiac arrest

3.3.2 The national report for Mental Healthcare in Young People and Young Adults (2019) was published on 12 September 2019 and circulated to relevant specialties to assess the recommendations from the report. 3.3.3 All other studies are awaiting national report. 3.4 Audit Committee Evaluation 3.4.1 A comment was made following a review and evaluation of the Audit Committee:

“A challenge for all NHSFT audit committees is to keep up the focus on clinical audit and try to ensure it moves into working in a manner akin to external and internal audit (given it is part of the overall assurance mechanism of the Trust). As a suggestion, could clinical audit move to a more cyclical approach of a Clinical Audit Plan (noting a lot of audits are nationally mandated, but for locally selected audits are they key ones for BHNFT?), monitoring of the delivery of the Clinical Audit Plan in year at the AC and then some form of final report for the May meeting summarising work done and assurance that the Committee can then ensure is reflected in the AGS and Annual Report”.

3.4.2 The Clinical Audit manager has reviewed the above and has referred to the NHS Audit Committee – Healthcare Financial Management Association (HFMA) table, which was provided by the Audit Committee chair. The mandated clinical audit programme is set nationally and forms a large proportion of the workload for the clinical audit team at BHNFT. In addition to this, all Trust priorities are agreed through various groups and committees: • Falls Prevention Group • Deteriorating Patient Group

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• VTE Committee • Accreditation processes etc.

3.4.3 These are set and approved at the beginning of the financial year. The clinical audit programme/plan is added to throughout the year with specialty-specific priority audits, as agreed by the relevant CBU. All the completed clinical audit projects are reported on through the Trust-approved governance process, i.e. through the CBU governance meetings and up to CEG. An annual report is provided to CEG, Q&G and to the Audit Committee.

3.4.4 The Clinical Audit manager plans to meet with the Audit Committee chair and the Medical Director to describe the department’s processes and timelines in more detail and to agree a way to provide the Audit Committee with the relevant information required.

3.5 CQUINs 3.5.1 This year there has been a significant increase in the number of CQUINs that require

support from the Clinical Audit department. Last year the department supported two CQUINs with a total of eight report submissions required. This year the department is supporting eight, with a total of 30 report submissions required. The department was unable to forward plan for this work stream as the CQUINs schedule was not made available until after the start of the financial year nor the number of CQUINs it included.

3.5.2 The facilitation from the clinical audit team required to reconcile and track the notes and undertake data collection, validation and analysis of the audits on a weekly basis has increased significantly. In conjunction with the Nursing Directorate the Executive Team are due receive a paper that looks at the impact of this and options that are available to deal with the increased workload.

3.6 National Emergency Laparotomy Audit (NELA) 3.6.1 On 31 August 2019, NELA Leads received notification that we are a potential outlier for

risk adjusted 30 day mortality rate for NELA. 3.6.2 A paper was taken to ET, which included an overview of the potential outlier details, an

action plan and key learning points. A detailed action plan is in place and will be led by Mr Ghosh, who is clinical lead for Emergency Laparotomy. Work is on-going to improve full completion of the correct documentation in an accurate and timely manner.

3.6.3 There are plans for increasing input from the Emergency Department and Radiology teams to improve the pathway. The Anaesthetists are becoming increasingly involved in patient’s selection, optimisation and decision to operate; Dr Tim Orr is leading this work on behalf of the Anaesthetists. Mr Ghosh will be updating CEG on progress every three months. It is worth noting that the Trust is performing well on the best practice tariff (BPT) for emergency laparotomy. To qualify for the BPT the following must be adhered to: ‘Trusts may qualify for the BPT, if 80% of their NELA high risk patients had a Consultant Surgeon and a Consultant Anaesthetist present during surgery and were admitted directly to critical care. The same patient needs to have received both elements of care’.

4. MEDICAL EDUCATION 4.1 Team 4.1.1 The restructure of the Medical Education administration team is now complete and

current team members have all commenced in their new roles. This left four posts to recruit to and the Band 3 and Band 4 posts have both been appointed; the two remaining Band 6 posts are due to go out to recruitment in the near future. The new structure will ensure the team has the capacity to deliver the key outcomes required from our external partners; HEE and the medical schools.

4.1.2 The majority of medical roles within Medical Education are now due for renewal. This includes: • Director of Medical Education (DME) • Undergraduate Directors • Undergraduate Leads • College Tutors

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4.1.3 As described earlier the resignation of the DME, Dr Beahan, following her promotion to Deputy Medical Director has meant that we need to speed up recruitment to this post. Interviews for the DME role are scheduled for the end of September. Following this appointment, cascading down, we will then recruit to the Undergraduate Directors, Undergraduate Leads and College Tutors.

4.2 Junior Doctor Induction 4.2.1 The August Induction was very successful. Very few issues were reported and the

trainees commented on how smooth the process was. Adaptations to the programme have meant that induction is now streamlined and delivers key messages to new starters.

4.2.2 We continue to refine processes and learn from each induction, planning will begin in November for the February rotation.

4.3 Postgraduate 4.3.1 Due to successful ARCP outcomes for all of our Foundation trainees in 18/19, HEE

allocated us an additional three Foundation Year one posts for 19/20. These posts will work across Acute and Primary care.

4.3.2 Work is underway to ensure that all new medical starters to the trust receive a comprehensive welcome and induction. GMC survey results showed improvements in most areas and the work we did at February changeover, this was reflected in the survey outcomes. Action plans are being worked through with each speciality.

4.3.3 Funding was received from Central Government to improve Junior Doctor rest facilities and work is currently being planned to meet these objectives.

4.3.4 Dr Eastwood has secured HEE funding to deliver regional teaching for trainees returning to practice after time out of training.

4.4 Undergraduate (inc. Nicosia Medical Students) 4.4.1 The undergraduate team have been busy working to adapt placements to meet the new

curriculum changes. The new extended clinical placements (ECP) module will be introduced from January 2020.

4.4.2 At Barnsley we have chosen specialities which have been lost from the curriculum and face current trainee shortages to recruitment to try to encourage students to look at these as future career choices. The ECPs we will deliver are Frailty, Public Health, Microbiology and Dermatology.

4.4.3 The student virtual learning environment, which is a bespoke package developed by Dr Hughes, was launched last month and has been well received by students. The system allows the team to advertise learning opportunities, for students to keep record of their learning history and for tutors to manage the sessions they deliver and upload any relevant presentations.

4.4.4 A meeting was held with Sheffield Hallam to discuss placement capacity for their Physician Associate course which recommences in January 2020 as a masters course. We have agreed to work with them to ensure that placement requirements are met.

4.4.5 The team successfully delivered the second Introduction to Medicine course in the summer and eighteen students took part in the week, the feedback from students was excellent and all commented that the course had reinforced their choice to pursue careers in the NHS.

4.4.6 We welcomed eight Nicosia students to join us for their Clinical years in August 2019. They will be with us for two years, these students join the four students who commenced in 2018 and are now in their final year of rotation. A successful Observed Structured Clinical Examination (OSCE) was delivered in July.

5. RESEARCH AND DEVELOPMENT 5.1 Update 5.1.1 Board Update – the R&D team are due to give an update to Trust Board in December

2019 about the R&D strategy going forward and current performance. Pack

5.1.2 Research awareness day – the team are planning a Research Awareness Day on the 10th of October. It’s aimed at clinical staff already engaged in research, interested in undertaking research at Barnsley Hospital, or who are aspiring new researchers. The day will include: • how to get involved in research • our current activity within the Trust and future aspirations • how clinicians are supported in undertaking research • the team’s involvement with industry partners • training opportunities for clinicians • understanding the patient perspective in being involved in research

5.1.3 Over fifty people have expressed and interest in attending the day.

5.2 Review 5.2.1 The research portfolio has grown significantly along with its complexity, 13 new studies

have been opened so far in 2019/20, with a further 17 in setup. The proportion of new studies which are commercially sponsored makes up 50% of all studies being undertaken.

5.3 Recruitment 5.3.1 The CRN set the Trust a recruitment target of 585 participants to recruit into clinical trials

listed on the national portfolio during 2019/20. So far we have recruited 302 an average monthly recruitment of 60. At this point in the year we are achieving 138% against target.

5.4 Patient Appointments 5.4.1 Patient follow up forms a large proportion of workload, with some studies requiring follow

up for a number of years. The amount of time required for follow up is an important consideration when agreeing to host clinical trials as this can be time consuming with little financial benefit to the Trust. The R&D team have performed 1170 follow up visits so far in 2019/20.

5.5 Commercial Research 5.5.1 The number of commercial clinical trials the Trust is participating in or is selected to

participate in continues to grow. At present there are 21 active commercial studies that are being undertaken or are in setup. This represents 31% of all studies.

5.6 Staffing 5.6.1 In line with the R&D expansion strategy we have recruited a new member of the team.

Adam Hawksworth has joined the Trust from Sheffield Teaching Hospitals. Adam joins the team as the Management/Research Accountant. Adam will also assist the wider Medical Directorate from a finance perspective.

5.6.2 Work is on-going to recruit to the rest of the roles agreed as part of the expansion strategy.

6. MEDICAL APPRAISAL AND RAISING CONCERNS 6.1 Annual Appraisal and Revalidation Board Report 6.1.1 The report was presented by Mr Jeremy Bannister at Quality and Governance Board on

24th July and went to Board on 5th September. The following is a brief of the latest performance.

6.2 Appraisal Performance 6.2.1 At July 31st 2019, 98.3% of doctors were in date with their appraisals. This breaks down

to • Consultants : of 140 doctors 139 are in date = 99.3% • SAS grades : of 43 doctors 41 are in date = 95.3%

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• LAS doctor : none overdue 6.2.2 Three doctors overdue, reasons for all being overdue are acceptable to the Responsible

Office, Dr Enright. 6.2.3 Appraisals in date by CBU - correct at 31st July 2019 from appraisal notifications and

updating of ESR • CBU 1 : Medicine - 98.8% • CBU 2 : Surgery - 97.5% • CBU 3 : Women’s, Children’s & Clinical Support - 100%

6.3 New Appraiser Recruitment 6.3.1 We currently have eight confirmed applications and one tentative for Medical Appraiser

training, we hope to achieve 10 overall. 6.3.2 MIAD are delivering the training, commencing with online modules in September and

one day on site training on 17th October 2019. 6.3.3 Of 10 applicants overall, 5 are Consultants and 5 SAS doctors.

6.4 Appraisal Quality Assurance 6.5.1 We have 5 appraisers who are working with Mr Bannister to QA the MAG forms and

provide feedback on our appraisers using the NHS England PROGRESS Tool. Each appraiser has 3 of their MAG forms 'QA’d' and the average score and comments are fed back on their Annual Individual Appraiser Performance Report.

6.6 Responsible Officers Awareness Group (ROAG) 6.6.1 In line with the Trust governance procedures the Medical Director chairs a group that

considers and investigates any issues or complaints made against Doctors. The group every month and includes HR, the Deputy Medical Director and administration support. The group monitors any individual where a concern has been raised and works through actions to respond to any concerns.

6.6.2 The output of this group forms of the basis of discussions at the quarterly meeting with the Trusts GMC liaison officer.

7 Medical Directorate Projects / Task and Finish Group Involvement 7.1 Fractured neck of femur group: 7.1.1 Considerable progress as evidenced in latest Hip Fracture BPT data has been made

since an alert status was received relating to 2017. It is realised that although we are seeing real time improvements we may not see the impact of this on the NHFD until 2020.

7.1.2 The improving trends are evidenced in the Hip Fracture BPT (best practice tariff) overview data based on 269 cases averaged over a 12 month period ending June 2019.

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7.1.3 BHNFT received notification from the National Hip Fracture database (NHFD) of an alert

status for the calendar year 2018 for a higher than expected case mix adjusted mortality. Mean mortality nationally for 2018 was 6.1%. BHNFT was at 8.7% adjusting to 9.6% for case mix. Although this is not ‘outlier’ status a NOF mortality action plan has been implemented by orthopaedics.

7.1.4 Despite a challenging 2018, the team should be congratulated on their hard work in improving the care and outcomes for frail hip fracture patients.

7.1.5 HSMR: • June 2018 the rolling HSMR was 126.65 • January 2019 the rolling HSMR was 98.09 • June 2019 the rolling HSMR is 94.29

7.2 ICE filing implementation 7.2.1 The ICE Filing project continues. The majority of specialties are now trained on ICE

Filing, and it is expected that all but one department, Trauma and Orthopaedics, will be complete by the end of September.

7.2.2 The ICE Filing Steering Group has signed off changes to the dashboard which will mean that all clinicians are measured on ICE Filing performance. Due to the way that the ICE System works, some clinicians, Consultants in particular, were having request made in their name, when they had not had any interaction with the patient. This meant that individual clinician performance was being measured in an inequitable. The new dashboard puts the onus on the discharging team to make sure all ICE results are filed in a timely manor.

7.2.3 As reported previously the Executive Team has signed off investment to develop Histopathology requesting into the ICE system. This has met with some delay; however this has been escalated to the Director of ICT.

7.3 D1 Task and Finish Group 7.3.1 D1 performance remains consistently high, averaging above 85%. It is not thought that

performance will improve significantly until the new eForm is implemented, given the constraints of the ICE system.

7.3.2 The development of the eForm has continued. A pilot has been undertaken on the Gastroenterology Ward, the results of which are being collated at the moment. Roll out to the wider organisation is expected to commence from mid October.

7.3.3 As reported previously, when the eForm has been implemented it is expected that both performance (beyond 90% compliance) and quality will significantly improve. Also, a major benefit is the speed by which the form can be completed. It is expected that we will be able to reduce the time it takes for a Junior Doctor to complete the form from roughly 20 minutes to 10 minutes. This will have a massive impact on a Junior Doctors time, allowing them to spend more time on clinical duties.

7.4 Secure Clinical Messaging 7.4.1 Crash Bleeps – the new SwissPhone Crash Bleep solution continues to work well.

There have been no complaints with the working of the system and no incidences of the messages not getting through.

7.4.2 Secure Clinical Messaging – we have begun the roll out of the 'non-urgent’ system. In the August rotation all new doctors rotating received a LG smartphone that allows them to be contacted through a number of means. The devices can be bleeped, called or texted using Google Hangouts. There have been no complaints about the system and any teething problems have been worked through. The Executive Team are due to receive a paper on future roll out of the system.

7.5 Clinical Guidelines and Policies 7.5.1 As previously reported in May 2019 the Medical and Nursing Directorates are working on

an improved system to collate and retrieve Clinical Guidelines, Policies and Procedures.

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7.5.2 The policy which governs this system and process has been signed off by Q&G. In particular, the requirements for the content and format of these documents has been set out, which will improve document control and user retrieval.

7.5.3 The team are now in the process of systematically working through the project plan to deliver the changes. The IT system is now virtually complete and will enable users to retrieve documents in a much quicker and more efficient way.

7.5.4 The majority of the work to deliver the project will be the coordination of the collation of existing documents. It is expected that this will be complete in January 2020. There is then further work required to make sure each of the documents is in date, to be updated if not, and is correctly formatted. The recruitment to the Band 2 to administer this process is now complete and the person has started in post.

7.6 Medical and Clinical Leadership 7.6.1 As described above Dr Beahan has been appointed Deputy Medical Director. One of Dr

Beahan’s responsibilities will be to develop a programme for the development of Medical and Clinical Leadership.

7.6.2 In order to develop for the future, we are developing a programme over the next few months that will target: • New Consultants – group already established • Established Consultants – been in role for three to five years plus • Clinical Leads – a mandatory workshop every month that will look at key aspects of

the role, including but not limited to: - Job Planning - Quality Improvement - Data Management - Finance and Contracting - Strategy and Business Planning - Board Governance and Assurance - Patient Safety - Performance and Metrics - CQC - Integrated Care Systems

• Senior Clinical Leaders – access to leadership courses for Senior Clinical Leaders, in particular Clinical Directors (e.g. Kings Fund).

7.6.3 We will bring a paper to the Executive Team over the next few weeks outlining the proposals and requirements of the programme.

7.7 South Yorkshire and Bassetlaw Integrated Care System (ICS) 7.7.1 The Hosted Network proposals continue to develop and move forward. As previously

described the Trust was selected to be the host for the Urgent and Emergency Care (UEC) network.

7.7.2 The ICS team and regional leads from each Trust has recently appointed clinical leads to each of the five hosted networks. Dr Rob Atkinson, current Clinical Director of CBU1 at Barnsley, has been appointed to lead the hosted network for Gastroenterology at Rotherham. Dr Atkinson will relinquish his role within CBU1 to take this on a 4 PA basis. We would like to congratulate Dr Atkinson on this appointment.

7.7.3 Further recruitment is planned over the next couple of months to a number of roles to support each network, including: • Network Manager • Administration Support • Analyst Support

8 Conclusion 8.1 Conclusion

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8.1.1 The Directorate has continued to develop its people and processes since the previous report in June. A number of key staff changes, in particular, the new Deputy Medical Director and the changes in Medical Education are detailed in the paper. There have been a number of successes within all teams. A number of the Projects that the Directorate is leading on are now coming to a conclusion, in particular the ICE Filing and D1 projects. We continue to lead on a number of new developments including Clinical Guidelines/Policies and Junior Doctor induction. The Directorate is developing a clear work plan and expects significant improvements in all the areas described over the next year.

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BoD October2019: Celebrating our People

EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD 19/10/03/09

SUBJECT: CELEBRATING OUR PEOPLE

DATE: OCTOBER 2019

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Communications

SPONSORED BY: Richard Jenkins, Chief Executive

PRESENTED BY: Emma Parkes, Director of Marketing & Communications

To provide an update to the Board on the Trust’s Brilliant Award winners as part of the reward and recognition process for celebrating the excellent work within the hospital.

The Trust employs over 3,500 people, each of whom play an integral role in the hospital’s overall performance and successful achievement of strategy and objectives. Each month, the Trust recognises staff who are nominated by colleagues and the public by presenting three Brilliant Staff Awards as part of a monthly award scheme which recognises individuals or teams that have gone above and beyond their role. There are three award categories: - Individual Brilliant Award (nominated by any member of staff) - Team Brilliant Award (nominated by any member of staff) - Public Brilliant Award (taken from feedback received by members of the public)

Each month the Chairman and Chief Executive jointly agree the winners, who are then presented with a certificate by the Chairman at a surprise presentation which is then promoted throughout the Trust. The Brilliant Staff Awards are sponsored by ISS who provide food and hospitality services for the Trust.

This paper will highlight the winners and nominees within each award for the previous month.

The Board is asked to review the content of this report.

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Subject: CELEBRATING OUR PEOPLE REPORT Ref: BoD 19/10/03/09

1. STRATEGIC CONTEXT

This report provides the Board with an understanding of the Trust’s winners and nominees for the monthly Brilliant Staff Awards. The Brilliant Awards are a key part of the Trust’s recognition of our people. Winners are celebrated across the Trust in a variety of communications media, including online on the Hub and on display in the main Reception area. Winners are also celebrated externally via social media.

. 1. INDIVIDUAL BRILLIANT AWARD

Winner: Gail Guest, Sister Gail has been the foundation of the Ear Nose and Throat (ENT) department that has grown into what it is today. Striving to do her best to ensure that the ENT service delivers high quality care to patients, in a working environment that considers the needs and adjustments of the staff that work within it in a fair and just way. Gail has worked on ENT since 1994 and has developed a fantastic, successful aural care service that is very much patient-orientated. She is held in high regard by her patients for the high quality and individualised care she delivers. This is reflected in the mountain of chocolates she receives at Christmas. Gail is kind and funny and has her own unique sense of style. She is an enthusiast for the 40's era; this is often reflected in her ever changing glamorous hair styles. Everyone has fond memories of Gail's charity work where she gave the performance of her life on stage at the Civic to raise funds for Tiny Hearts. Gail is a genuinely wonderful person. As a team we have laughed and cried with her throughout the years. Although we will still see Gail, she will be moving into CBU 2 shortly and we as a team feel it would be unjust to allow the contributions she has made to the ENT department go by without recognition. The department will not be the same without her.

1.1 Nominees: Kelly Fearn, Nurse Practitioner Kelly never fails to go above and beyond within her role and to help other members of staff. Kelly is very friendly, approachable and caring. In 2017 a small group of assistant practitioner's started within the pre-assessment department. Kelly trained the Trainee Associate Practitioners (TAPs) within work time but often used her own time to prepare information packs etc. for our training (which she delivered herself), as well as mock exams and other training packages. Kelly has helped me personally through a very tough medical condition. I was off from work for a number of months during my training. Kelly always stayed in touch and along with lead nurse Joanne, they made sure I had enough time within work hours to complete my uni work and get back up to date, in time, so that I could graduate with my peers. Kelly is acting as lead nurse whilst the lead nurse has temporarily moved to another department. Kelly still makes time to over look all the notes that Assistant Practitioners and Nurses have pre assessed, and always directs us in the right way. As well as helping in reception and assessing patients herself, Kelly never complains about all the work that she has. She always has a smile on her face and is always more than happy to help and give advice. I feel Kelly is an amazing person and really deserves this award!

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Julie Wilson, Auxiliary Nurse As Julie's manager, I received the following piece of feedback from the Lead Nurse in Emergency Department with regards to Julie's professionalism and ability to truly make a difference in assisting the nursing team to maintain patient safety but also enabling them to provide patient care. I am extremely proud of every one in my nursing team as they work so hard and tirelessly every day with a smile on there faces; on this occasion Julie went the extra mile and was able to demonstrate this value in an unfamiliar working environment and within an unfamiliar team. Well done! 'I wanted to express my gratitude to one of your staff members. She came down to 1:1 a patient. I personally asked her to keep her distance but to ensure that he wasn’t doing anything to harm himself/relatives/other patients. When she came down she was nothing but polite to myself and the other staff and assisted greatly building a rapport with the patient and safeguarding him and the other people in the department. I cannot thank her more, I think she should be exceptionally proud of herself and would be proud of her if she was on my team.' Deborah Dowle, Sister Deborah has been nothing but nice and encouraging to me. I started work in September last year and was very nervous. Deborah was very welcoming and made my first week at work amazing. I cant begin to thank her enough she has gave me the push I needed and support to do my nurse training and I now believe in myself again. She goes above and beyond her job role and nothing is ever too much trouble and I will be forever grateful to her, she deserves a mention without a doubt and I probably won’t be the first to say this but she is brilliant. Angela Wheater, Gynaecology Specialist Nurse Angie is one of the kindest nurses I have ever met. She comes to work day in day out and never really gets thanked for the care she gives because of the job she is in. She always treats patients with the upmost kindness and respect for their decisions, she gives her job 100% and she deserves to be recognised for all her hard work. Lauren Bannister, Programme Manager Lauren was appointed as programme manager for the breast radiography in January and since that time has worked very hard to deliver a top quality service for the women attending the breast unit for imaging. She has coped with staff losses and illness whilst very new in her role, which has put increased pressure on her from both a workload and staff management perspective. She is always helpful and cheerful and patient care remains her focus at all times.

Nicola Moug, Unit Lead Nicola is the lead on the unit where I work. In the past few months a relative has been told he had cancer and needed chemo and surgery and at the same time another relative has also been told she has bone cancer. As you can imagine with working, having children to care for and then looking after and hospital visiting life has been extremely stressful. Nicola is an amazing example of family friendly thinking, she helped me alter my hours on a certain day to enable me to take my relative to chemo and when my relative was transferred back to Barnsley she helped me to put a plan into place so that she could carry on her treatment at home instead of having to stay in Barnsley Hospital a further six weeks. She goes well beyond her role and I think she should be recognised for this as she portrays your family values immensely. She is a credit to Barnsley Hospital.

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Andrea Squires, Service Development Manager Andrea is the manager of our waiting list coordinator team, she goes above and beyond for us everyday to ensure that problems are dealt with quickly and promptly. Any help that we need she is the first person to be there! Working in a busy department its great to have such a brilliant manager, she is definitely a professional role model to us and to other staff she manages. She deserves to be acknowledged!

2. TEAM BRILLIANT AWARD

Winner: Ward 19 My team deserves a Brilliant Ward for completely championing patient safety and getting the care right. Ward 19 has managed to reduce the amount of falls it has on a monthly basis and also reduce hospital acquired pressure ulcers, where there has been NO Lapses in care since February 2019, through sheer hard work and getting the care right. Team work is at the forefront of driving patient safety and I am completely proud of my team in how they showcase this. Elderly care nursing provides its challenges and my team face these head on with sheer tenacity and dedication. I am one proud Lead Nurse.

2.2 Nominees:

Phlebotomy Outpatients In all of the years I've worked in phlebotomy, in fact within the NHS, I've never known it to be so busy, whist unfortunately, so heavily understaffed, all unavoidable I would add. I am so incredibly proud to be a member of this team, we've kept going through the worst shifts some of us have ever experienced and we've done it day after day whilst keeping a smile on our faces and delivering fantastic patient care. So whilst its been one of the most challenging few months its also been some of the best team work I've experienced and it really does show what can be achieved even in the moments it felt impossible, so to every member of phlebotomy outpatients I'm so incredibly honoured to call you all my work mates. Joanne Smith and the Endoscopy Team in collaboration with Joanne Thornton, Clinical Audit Achieving JAG accreditation for the Trust. Coronary Care Unit (CCU) The CCU team is a dedicated specialised team of hard working staff. We have undergone many changes recently, managing with low staffing levels, and no ward manager, we have continued to provide high levels of care to our high dependency patients. Our staff work hard, working extra shifts, as it is a specialist area with specialist skills we try and support each other as a team to benefit our patients and relatives. We have just received a thank you card from one of our patients and I write this on her behalf, the card states: ‘I would be grateful if you could please pass this card to the person who deals with the hospital awards. I would like to nominate the CCU to be recognised as a centre of excellence and also to be nominated as the best ward.’ Breast Radiography Team This team has been under a lot of pressure with staff losses and sickness. This has affected every team member yet they have continued to go the extra mile and deliver an excellent service with a smile. They are always patient focussed and compassionate

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Custard Fest 2019 Fundraising Five Claire Finnerty and Tom Davidson had an idea to sit in custard. They were supported by three other colleagues - Jade Booth, Adele Foley and Mike Lees, making a fundraising team of five. All five were dunked, dowsed and drenched in custard. The activity enabled colleagues from across the Trust to get involved in a fun afternoon and also helped to raise awareness of the Charity. Their fundraising target was £1,000, but they raised a collective £2,047! The Charity team are extremely proud of all our fundraisers but believe that anyone who goes to the extent of generating an original idea, turning it into a fantastic success and sitting in custard deserves an award!

Antenatal Admin Team I would like to nominate the Antenatal Admin Team for a Brilliant Award. They have worked above and beyond this year covering for staff shortage and supporting each other and the women who use our service. We want them to know that we appreciate them and the department wouldn't function without their dedication. Well done team and thank you for all your hard work.

3. PUBLIC BRILLIANT AWARD

Winner: Yasmeen Akhtar – Mental Health Midwife Following some feedback from a patient we felt as a team a nomination was essential. Yasmeen supported a lady through a challenging pregnancy who wrote:

‘Mental wellbeing midwives and people like Yaz will hopefully be available to all women that need support during their pregnancy as they can literally change people’s lives and help women make the right choices for themselves. Not everyone is blessed with easy pregnancies no matter the reason why and mental support is so vital for women that go through the nicest period in their lives that can be tough at same time. It’s a blessing to have your own baby and all women deserve this chance.’ With support and regular contact over time, the lady was, in her own words, “fully prepared mentally and physically to welcome my little baby”.

3.1 Nominees: Stoma Nurse Team I would like to nominate the Stoma nurse team. I was on ward 32 and SHDU all the staff on there deserve this award too as they were absolutely wonderful. However the care, support, understanding, the shoulder to cry on, encouragement has been second to none and is still on going from all the Stoma nurses. When your life is completely turned upside down by emergency surgery, a cancer diagnosis and a stoma you need empathy and that came in bucket loads. I will be forever grateful. Christen Sausby and Team I am nominating christen of the diabetic and endocrine clinic. This lady is a fantastic nurse who not only makes you feel welcome but goes out of her way to make any members of staff feel like they belong. Patients that come through the clinic always ask for her and say that she always as time for them any time night or day she greets them with a smile and knows them by name. Every one has nothing but goodness to say about this lady and I personally feel that I’m glad to be a member or her team with the way she behaves everyone can’t help but do there best for her and the unit.

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REPORT TO THE BOARD OF DIRECTORS REF: BoD: 19/10/03/10 SUBJECT: FINANCE & PERFORMANCE ASSURANCE REPORT

DATE: September 2019

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval x Assurance For review Governance For information Strategy

PREPARED BY: Francis Patton, Non-Executive Director, Chair Finance & Performance Committee

SPONSORED BY: Francis Patton, Non-Executive Director, Chair Finance & Performance Committee

PRESENTED BY: Francis Patton, Non-Executive Director, Chair Finance & Performance Committee

STRATEGIC CONTEXT

The Finance & Performance Committee (F&P) is one of the key sub committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of financial matters, operational performance and people in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on financial and performance matters to the Board of Directors

EXECUTIVE SUMMARY KEY: £k = thousands £m = millions

The aim of this report is to critically analyse and evaluate the financial and operational performance of the Trust in order to provide assurance to the Board. This will be accomplished by:

- critically analysing and reviewing the financial performance in order to identify any opportunities or threats

- critically analysing and reviewing the Cost Improvement Programme (CIP) in order to get assurance that it is on plan and will deliver the planned savings

- critically analysing and reviewing the corporate performance in order to ensure that the Trust is delivering the optimum performance safely and negating any penalties

- critically analysing the key people data and reviewing delivery of the People Strategy.

- reviewing business cases at the six months anniversary in order to ensure that they are delivering planned benefits

- critically analysing and reviewing the Board Assurance Framework (BAF) in order to ensure any risks to the strategic plan are identified and mitigated.

In terms of the finances the month five year to date position is a deficit position of £0.547m, against a plan of £14820m, which is £0.935m favourable to plan. In terms of the CIP programme £0.655m was delivered in month against a plan of £0.521m, £0.133m ahead of plan, year to date CIP is £2.605m against a plan of £2.442m, which is £0.163 ahead of plan. The cash position at the end of the month is £11.763m, which is £10.763m ahead of plan. The capital expenditure as at month 5 was £1.664m, which is £1.331m adverse to plan. In terms of performance the Trust continues to do well although the 4 hour emergency access was 91.3% in August, cancer delivered an improved performance in July at 87.8% with issues with breast symptomatic. and 38-day referral and the committee received an excellent presentation on how the pathway was being reengineered. The validated position for RTT shows delivery in August at 93.5% and

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Diagnostic wait performance remains compliant with 99.9% of patients accessing diagnostics with 6 weeks. In terms of People sickness is running at 3.85% (down on July by 0.44%) which is the first time that sickness has been Amber since September 2018, training is at 90.3% (a decrease of 0.4%) and appraisals at 92.8%. From an ICT perspective the committee received an update on Medway System C and ePMA. The committee received benefits realisation appraisals for the Bed Reconfiguration project and for NHSP both of which showed good returns both financially and in terms of quality and staff morale. The committee received and signed off the Workforce Disability Equality Standards report and the Annual Disciplinaries, Grievances, Bullying and Harassment report and signed both of these off. Finally the committee reviewed the latest BAF and CRR from a finance and performance perspective and noted the changes on both documents.

RECOMMENDATIONS

This report therefore recommends that: - The Board notes the financial performance in month five. - The Board notes the month five recovery against the CIP target and that the Trust is now

delivering against target. - The Board notes the continuing good delivery of operational performance and the work

undertaken on reengineering the cancer pathways. - The Board notes the key workforce performance metrics. - The Board notes the ongoing delivery of Medway System C. - The Board notes the good work undertaken on Bed Reconfiguration and use of NHSP. - The Board notes the sign off of the WDES and the Annual report on Disciplinaries, Grievances,

Bullying and Harassment. - The Board takes assurance that the BAF/CRR are being regularly reviewed.

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Subject: Finance & Performance Committee Assurance Report Ref: BoD: 19/10/03/10

CHAIR’S LOG: Chair’s Key Issues and Assurance Model

Committee / Group Date 26th September 2019 Chair Finance and Performance Committee September 2019 Francis Patton, Non Executive Director KEY: £k = thousands / £m = millions

Log Ref Agenda Item Issue and Lead Officer

Receiving Body, i.e. Board or Committee

Recommendation/ Assurance/ mandate to receiving body

1. Finance

At month five the Trust has a consolidated year to date deficit position of £0.547m, against a plan of £1.482m, which is £0.935m favourable to plan. Planned Provider Sustainability Funding has been accrued in full and in addition to this £0.379m has been accrued in relation to further 2018/19 bonus monies, which NHSI have requested be reflected in the 2019/20 position. The forecast for the yearend remains to be £0.379m ahead of plan due to the NHSI accounting requirements for the prior year PSF bonus money. CIP is £2.605m against a plan of £2.442m, which is £0.163m favourable to plan. The cash position at the end of the month is £11.763m, which is £10.763m ahead of plan. This is as a result of underspent capital programme, the need to carry £3m owing to the DH in loan repayments, and outstanding creditors which are being wound down over the coming months. A forward projection, by month, of the cash balance will be included within the half year report. The capital expenditure as at month 5 was £1.664m, which is £1.331m adverse to plan and the committee requested a full plan at the October on how we intend to get on track for the yearend. The committee also discussed the continued excellent performance against agency spend and the locum spend and commended the team on the way that they are developing the finance reports to give a better level of understanding. Next month’s meeting will be the half year review and will include forecasting where we think the Trust could finish the full year and there is an open invitation to all members therefore to attend the October committee meeting.

Board For information and Assurance

2. CIP

Month 5 saw actual savings of £654,988 against a plan of £521,000 resulting in an over achievement of £133,988. Cumulative savings to date are £2,604,864 against a plan of £2,442,000 which gives a year to date positive variance of £162,864. The forecast overall programme position against target has increased since last month from £5,390,818 to £5,946,314 (a rise of c.£555k) which leaves a deficit of £0.797m against the £6.74m target. In comparing the programme forecast value to this point last year, the value was £7.7m with a gap of £0.770m to the £8.5m target so the programme value is £1.78m. However, it is important to note that the Rates Scheme (£500k) was still in the programme at this stage last year which was falsely inflating the forecast value and in fact was removed in November of 2018. Recurrency ratio has remained static at 75% but if the nonrecurrent activity overtrade that

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has been added to date is converted to recurrent this will increase the ratio to 87%. There are 85 schemes in the programme (a rise of 16 schemes since last month). There has been a small shift in schemes over the last month with one scheme moving to full maturity. The value of schemes at full maturity has shifted from £5,080,931 to £5,438,427 representing an increase of £357,496. In terms of remaining pipeline schemes, there is currently £507,887 of schemes at maturity level 1 & 2 which reflects the new schemes identified last month coming into the programme. This has brought the ratio of the schemes at full maturity down from 94% last month to 91% this month. There was 84% of the programme value at full maturity at the same point last year. The risk to the programme has reduced since last month with the addition of £555k in scheme values leaving a gap of £797k to target. The new schemes are being worked up now which should contribute to reducing the gap even further.

3. IPR

The committee reviewed the IPR focusing on the key performance indicators around patient access, people and finance. The Trust continues to deliver access to services in a timely manner for our patients. In terms of key messages: -

- The trust failed to deliver the 4 hour emergency access standard for the second consecutive month at 91.3%. Emergency department attendances were 5% above plan with emergency admissions also 5% above plan in August. The trust saw a number of days where in excess of 300 patients per day attended the department. Despite this position, the Trust continues to deliver in the top 10% of acute trusts, nationally

- RTT:18 week referral to treatment access continues to be delivered in excess of the 92% incomplete standard at 93.5%. Individual specialty level non-compliance was observed in Orthopaedics, Oral & Maxillofacial Surgery, General Surgery and Urology

- Cancer: The Trust delivered an improved position in July with 62 day access compliant in excess of the 85% standard at 87.8%. 2 week access remains non-compliant due to the short-term impact of breast capacity challenges in radiology. 31 day standards were compliant at 100%. The shadow 38 day inter-provider transfer standard remained non-compliant with a slight decline in delivery at 55.9%. The Chief Delivery Officer presented a detailed analysis and plans to address performance going forward which gave background detail on performance to date broken down by pathway, pulled out each pathway challenges and then identified how the team were going to re-design pathways to improve performance. Once this work is completed there will be a material improvement in the time taken for each pathway. The committee complimented the team on what appears to be some excellent work and look forward to the

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improvements. One area of discussion generated was around the MRI scanner which is nearing the end of it’s life and it was decided to review the 5 year capex plan at the next meeting as part of the finance half year review.

- Diagnostic Waits: Access to diagnostic services remained strong in July with 99.9% of diagnostic tests accessed within 6 weeks

4. ICS Performance Report The committee received the September Performance Report for the ICS.

5. Business Cases

The committee received two benefits realisation papers one for bed reconfiguration and one for NHSP phase 1 and 2. It was acknowledged by the management team that both papers were to a degree work in progress but outlined the key benefits to date.

- Bed Reconfiguration – in summary this paper outlined the benefits delivered as helping deliver the 4 hour access target, reducing length of stay/medical outliers, costing less than originally budgeted even with a higher workload, helping maintain elective surgery, reducing use of bank/agency staff, improving safety and finally improving staff morale.

- NGSP phase 1 and 2 – in summary this paper outlined that the migration to NHS Professionals has provided the additional benefits of collaboration across the ICS and horizon scanning of comprehensive management information through the dedicated expertise of a regional business analyst team; the identification of opportunities for continuous improvement and the reduction of unwarranted variation, reducing competition through the available workforce and the creation of an effective regional bank; the collaborative use and management of agency where required has brought a cost reduction through volume discounts and stronger purchasing power of the group along with reduced individual Trust resource requirements. Regionally the Trust has benefitted from the regional management of temporary staff complaints and incidents of all bank and agency workers through the provision of a dedicated nurse manager. NHS Professionals also provide comprehensive assurance in relation to compliance with mandatory training, DBS checks and Occupational Health requirements. The change in provision has ensured Trust staff now receive weekly pay and that bespoke incentive schemes can be developed and managed by the Trust and NHS Professionals team.

6. People

In terms of workforce the reporting continues to evolve, and the committee complimented the team on the improvements made so far: -

- Sickness: There has been a decrease in August by 0.4% to 3.85%. This is the first time sickness has been in an amber position since September 2018, and is slightly lower than in the same month last year when it was at 3.98%. The latest available national average sickness absence rate is 4.06% as at April 2019 which

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is similar to the Trust which was at 4.07%. This month’s report contained more recent comparative sickness absence data for local Trusts. Management of the sickness hot spot areas within CBUs continues to be monitored monthly at People & Engagement Group. An internal audit review of sickness absence management through the Occupational Health referral process has been completed and the audit findings will be discussed at the People and Engagement Group in October. The main reason for sickness absence remains stress, anxiety, depression and other psychiatric illness, with 1447.18 FTE days lost in July. Occupational Health KPI’s decreased in July 2019 with 38 out of 145 referrals not offered an appointment within 10 days of referral.

- Headcount for month is 3903. The actual FTE is recorded as 3202.63. The funded establishment FTE is 3223.35. The number of open vacancies in month actively being recruited to are 149.38 FTE.

- Turnover decreased on last month by 0.68% to 6.27%. In the first quarter of this year there were 134 leavers and 133 starters. Promotion is still the top reason given for leaving. 20 Band 5 Nurses left during the 1st quarter and the reasons will be analysed as part of NHSI retention programme.

- Mandatory Training compliance has decreased again for the third consecutive month to 90.3% and continues to be just above the 90% compliance target. The topic with the highest compliance is Moving & Handling Back Care Awareness (once only) at 97.2%. The topic with the lowest compliance is Resuscitation Adult BLS at 80.9%

- This year’s 3 month’s appraisal window closed on 30 June 2019. The reported appraisal rate has increased by 1.6% to 92.8%, meaning the 90% compliance target has been exceeded.

- The committee also received an update on “hotspot” sickness absence support. The ‘Hotspot’ initiative identifies and targets service areas across the Trust where there is consistently high levels of sickness. For an area to be included as a Hotspot, they need to have a monthly sickness percentage in excess of 4% for six consecutive months. Once an area is identified as a Hotspot they will receive more targeted and intensive support from HR. This additional support includes at least monthly meetings with the manager and matron of the relevant area to discuss in detail their sickness cases and agree actions plans. This intensive support from HR should help managers identify effective next steps for each case and ensure the Trust’s sickness policy is being followed, including appropriate OH referrals, regular review meetings for long term sickness and progression to formal stages of the sickness policy where appropriate. In addition to intensive HR support for managers of Hotspot areas, there is also Welfare Wednesday’s, which Pack




is where the Matron for an area will contact those employees off sick on a Wednesday. By using this Hotspot method to identify individual areas with consistently high sickness it means the intensive HR support is focussed on those areas in most need of it, which should in turn reduce the Trust’s overall sickness rates.

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7.

Workforce Disability Equality Standard (WDES) Report and Action Plan

The committee received the WDWS report and action plan. The Workforce Disability Equality Standard (WDES) is a set of 10 specific measures (metrics) that will enable NHS organisations to compare the experiences of disabled and non-disabled staff. It uses workforce data from the electronic staff record (ESR) and responses from certain questions within the annual NHS Staff Survey. Similar to the Workforce Race Equality Standard, the WDES has been included in the NHS standard contract, and performance outcomes may well be considered during Care Quality Commission’s (CQC) inspections / reviews under their ‘Well Led’ domain theme. This is our first reporting of our performance against the WDES and the indicators provide a baseline from which we can develop our work in reducing disparities between disabled and nondisabled staff. The outcomes of the metrics have helped us to identify key actions that we will take. The accompanying action plan detailed the actions to be taken in 2019-20. Delivery of the action plan will be monitored by the People and Engagement Group. The Committee accepted and approved the WDES Report and Action Plan and approved submission of the data externally to be publicised on the Trust’s website by the reporting deadline of 30th September 2019.

8.

Annual Disciplinary, Suspensions and Professional Registration Referrals including Bullying and Harassment and Grievances Report

The committee received, discussed and noted the report and agreed that this information would form part of the Workforce report on a quarterly basis to review trends.

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9. ICT

The committee received the usual ICT Strategy update with key areas covered as follows: -

- System C Medway EPR project: We are currently on track for the Medway Programme go-live April 2020. Significant work has been completed to configure outpatient clinics for data migration 2 milestone. Medway Mondays will start 23rd September 11.30-13.30 every Monday until go-live in April. A new “Get Fit for Medway” poster campaign will commence shortly. Key points raised at the steering group were that in terms of signed off Hospital Numbers we are going to continue to use our existing hospital number system, it was agreed how we are going to Stream and group Outpatient Clinics, there was some challenge regarding concerns of having outpatient clinics configured by the Data Migration gateway date, this has subsequently been achieved on time and date, there was discussion regarding ICE inter-operability between Medway and ICE our order communications and Lab reporting solution, it was decided to not implement this for go-live, but continue to try and drive down the costs and consider post go-live, finally there were concerns regarding numbers of trainers and rooms booked. It was agreed Medway would have priority on rooms during the training delivery periods in February and March. Basic training would be delivered by other ICT functions who have already received higher levels of training for Medway.

- ePMA (electronic prescribing and meds administration): NHS England have contacted us to understand whether we are still in a position to spend E-prescribing funding if it becomes available. This might lead to announcements regarding funding approval.

- D1 Discharge Eform:Go-live is planned 7th October 2019 following full user acceptance testing and CCIO/Pharmacy sign off.

Board For information and Assurance

10. BAF/Corporate Risk Register

Both the BAF and Corporate Risk register were reviewed and the committee noted and agreed the changes to both the BAF and Corporate risk register. Board For information

and Assurance

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SUBJECT: Integrated Performance Report: August 2019

DATE: October 2019

PURPOSE:

Tick as applicable Tick as applicable


PREPARED BY: Ben Brewis – Deputy Director of Operations

SPONSORED BY: Bob Kirton – Chief Delivery Officer

PRESENTED BY: Bob Kirton – Chief Delivery Officer

STRATEGIC CONTEXT Strategic Objective 1 – Patients will experience safe care Strategic Objective 3 – People will be proud to work for us Strategic Objective 4 – Performance Matters EXECUTIVE SUMMARY

1. Patient Access:

Emergency access & Patient Flow: The trust failed to deliver the 4 hour emergency access standard for the second consecutive month at 91.3%. Emergency department attendances were 5% above plan with emergency admissions also 5% above plan in August. The trust saw a number of days where in excess of 300 patients per day attended the department. Despite this position, the Trust continues to deliver in the top 10% of acute trusts, nationally RTT: 18 week referral to treatment access continues to be delivered in excess of the 92% incomplete standard at 93.5%. Individual specialty level non-compliance was observed in Orthopaedics, Oral & Maxillofacial Surgery, General Surgery and Urology Cancer: The Trust delivered an improved position in July with 62 day access compliant in excess of the 85% standard at 87.8%. 2 week access remains non-compliant due to the short-term impact of breast capacity challenges in radiology. 31 day standards were compliant at 100%. The shadow 38 day inter-provider transfer standard remained non-compliant with a slight decline in delivery at 55.9%. Detailed analysis and plans to address will be shared with finance and performance committee in September Diagnostic Waits: Access to diagnostic services remained strong in July with 99.9% of diagnostic tests accessed within 6 weeks

2. Quality of Care:

2.1 Patient Safety: Infection Prevention and Control: Four confirmed cases of Clostridium Difficile were reported in August. The Trust has commissioned an external review of systems and processes in order to ensure improvement Deaths: There were two deaths subject to investigation in August. One subject to a serious incident investigation and one to be investigated by HSIB Four serious incidents were reported in the month: Pack

• Delayed diagnosis of cancer (incident occurred in July 2019) • Inpatient fall resulting in fracture (incident occurred June 2019) • Treatment delay (incident occurred in July 2019) • Intrapartum stillbirth Pressure Ulcers: There have been a total of 14 category 2 hospital acquired pressure ulcers reported in August, this has decreased by 4 from last month. The lapses in care have increased by 3 from last month. There have been 2 hospital acquired device related pressure ulcers, neither of these resulted from lapses in care and were both in relation to casts applied after surgical procedures. Falls In August, there were 49 inpatient falls reported, 5 were repeat falls. This is the lowest number of falls for the last 12 months. There were two falls that resulted moderate harm. The only identifiable cause for significant reduction in falls could be the success of clinical areas implementing the 3 high impact actions of the falls CQUIN. We will continue to monitor this through the FALLS CQUIN work and monthly falls reporting to identify themes and learning. 2.2 Patient Experience: During July the Trust received 25 new complaints. The primary theme was clinical care and treatment. The percentage of cases closed within agreed timeframe or agreed extension for the month was 100%. The average number of working days to investigate complaints was 59 days. 95% of complaints closed within July were upheld or partly upheld. The PA&C Team dealt with 216 concerns and 58 general enquiries (total 274) during the month.

3. People: Sickness: There is a decrease in month by 0.44% to 3.85%. This is the first time sickness has been in an amber position since September 2018, and is slightly lower than in the same month last year when it was at 3.98%. The latest available national average sickness absence rate is 4.06% as at April 2019 which is similar to the Trust which was at 4.07%. Management of the sickness hot spot areas within CBUs continues to be monitored monthly at People & Engagement Group. An internal audit review of sickness absence management through the Occupational Health referral process is currently underway and the final report is due in September 2019 Staff Turnover: Staff Turnover decreased on last month by 0.68% to 6.27%. In the first quarter of this year there were 134 leavers and 133 starters. Promotion is still the top reason given for leaving. 20 Band 5 Nurses left during the 1st quarter and the reasons will be analysed as part of NHSI retention programme Mandatory Training: Mandatory Training has dipped again for the third consecutive month to 90.3% and continues to be just above the 90% compliance target. The topic with the highest compliance is Moving & Handling Back Care Awareness (once only) at 97.2%. The topic with the lowest compliance is Resuscitation Adult BLS at 80.9% Staff Appraisal Rate: Staff Appraisal Rate has increased by 1.6% to 92.8% , meaning the 90% compliance target has been exceeded. Feedback is being obtained on the new appraisal e-form and the quality of appraisal discussions to review at P&EG

4. Finance: • The overall financial position is £0.935m favourable to plan • Total income is £2.702m favourable to plan year to date. Clinical income variances being within

elective, daycase, non-elective and outpatients. • CIP achievement is favourable to plan by £0.163m year to date • Cash is £10.763m favourable to plan • Capital expenditure is £1.331m less than plan

RECOMMENDATIONS The Board of Directors are asked to receive and endorse the latest IPR

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Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Bob Kirton

`

August 2019

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Exe

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ve S

um

mar

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1. Purpose of the Report:

The purpose of this report is to inform the Trust Board and sub-committees of the latest position against key performance indicators, including operational and

quality requirements mandated nationally, metrics detailed in the NHSi oversight model and those identified within the BHNFT Operational Plan for 2019/20. In

addition, it provides Trust Board with information relating to activity delivered and finance, which are key drivers for sustainability.

This report details the latest validated information available.

A high level view of the Trust’s performance is available in the at a glance summary. Further details on the domains of quality, people, patient access and finance

are available in more depth as part of the wider document.

2. Background and Introduction:

The well-led framework used by NHSi identifies effective oversight by Trust Boards as essential to ensuring Trusts consistently deliver safe, sustainable and high

quality care for patients.

BHNFT provides an integrated performance report to Trust Board each month for assurance. The report outlines key performance against a number of quality,

operational, financial and activity based indicators. The purpose of the report is to ensure Trust Board has timely and robust oversight of performance in key

areas along with actions being taken to address required improvements.

Executive Summary August 2019

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1 2 3 9 10 16 17 18 19 20 21

Capital Plan

The overall financial position is £0.935m favourable to plan

Total income is £2.702m favourable to plan year to date. Clinical income variances being within elective, daycase, non elective and outpatients.

CIP achievement is favourable to plan by £0.163m year to date

Cash is £10.763m favourable to plan

Capital expenditure is £1.331m less than plan

There is a decrease in month by 0.44% to 3.85%. This is the first time sickness has been in an amber position since September 2018, and is slightly lower than

in the same month last year when it was at 3.98%. The latest available national average sickness absence rate is 4.06% as at April 2019 which is similar to the

Trust which was at 4.07%. Management of the sickness hot spot areas within CBUs continues to be monitored monthly at People & Engagement Group. An

internal audit review of sickness absence management through the Occupational Health referral process is currently underway and the final report is due in

September 2019

Mandatory Training has dipped again for the third consecutive month to 90.3% and continues to be just above the 90% compliance target. The topic with the

highest compliance is Moving & Handling Back Care Awareness (once only) at 97.2%. The topic with the lowest compliance is Resuscitation Adult BLS at 80.9%

Staff Appraisal Rate has increased by 1.6% to 92.8% , meaning the 90% compliance target has been exceeded. Feedback is being obtained on the new appraisal

e-form and the quality of appraisal discussions to review at P&EG

Staff Turnover decreased on last month by 0.68% to 6.27%. In the first quarter of this year there were 134 leavers and 133 starters. Promotion is still the top

reason given for leaving. 20 Band 5 Nurses left during the 1st quarter and the reasons will be analysed as part of NHSI retention programme

Referral To Treatment (18 weeks)

Pat

ien

t A

cce

ssP

eo

ple

Fin

ance

Emergency Access

Planned Cash Position

Planned Financial Position

Income

Cost Improvement Programme

Cancer

Diagnostic Waits

Sickness Absence

Mandatory Training

Staff Turnover

Staff Appraisal Rates

The trust failed to deliver the 4 hour emergency access standard for the second consecutive month at 91.3%. Emergency department attendances were 5%

above plan with emergency admissions also 5% above plan in August. The trust saw a number of days where in excess of 300 patients per day attended the

department. Despite this position, the Trust continues to deliver in the top 10% of acute trusts, nationally

18 week referral to treatment access continues to be delivered in excess of the 92% incomplete standard at 93.5%. Individual specialty level non-compliance was

observed in Orthopaedics, Oral & Maxillofacial Surgery, General Surgery and Urology

The Trust delivered an improved position in July with 62 day access compliant in excess of the 85% standard at 87.8%. 2 week access remains non-compliant due

to the short-term impact of breast capacity challenges in radiology. 31 day standards were compliant at 100%. The shadow 38 day inter-provider transfer

standard remained non-compliant with a slight decline in delivery at 55.9%. Detailed analysis and plans to address will be shared with finance and performance

committee in September

Access to diagnostic services remains strong with 99.9% of patients receiving tests within 6 weeks of referral

Patients Partnerships People Performance

BHNFT At-a-Glance August 2019

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1 2 9 10 16 17 18 19 20 21Q

ual

ity

Patient

Experience

Clinical

Effectiveness

HSMR - Rolling 12 month July 18 - June 19 97.9

SHMI - Latest month March 2019 - 99.3

Complaints

During August the Trust received 25 new complaints. The complaints were allocated as follows: CBU 1 – 11, CBU 2 – 11, CBU 3 – 1 and Corporate Services 2. The primary theme was clinical care and

treatment. The percentage of cases closed within agreed timeframe or agreed extension for the month was 100%. The average number of working days to investigate complaints was 66 days. 77% of

complaints closed within August were upheld or partly upheld. The PA&C Team dealt with 150 concerns and 73 general enquiries (total 223) during the month.

Falls

For this month there were 49 inpatient falls reported Trust wide, 5 were repeat falls. This is the lowest number of falls for the last 12months. There were two falls that resulted moderate harm, these occurred

on Ward 18 and Acorn Unit. The only identifiable cause for significant reduction in falls could be the success of clinical areas implementing the 3 high impact actions of the falls CQUIN. We will continue to

monitor this through the FALLS CQUIN work and monthly falls reporting to identify themes and learning.

Incidents

Deaths

• Intrapartum stillbirth (Ref: SI 2019/17411 logged August)

• Baby death (incident to be investigated by HSIB)

Four serious incidents reported in the month:

• 2019/17247 – Delayed diagnosis of cancer (incident occurred in July 2019)

• 2019/18437 – Inpatient fall resulting in fracture (incident occurred June 2019)

• 2019/17836 – Treatment delay (incident occurred in July 2019)

• 2019/17411 – Intrapartum stillbirth

Pressure Ulcers:

There have been a total of 14 category 2 hospital acquired pressure ulcers reported this month, this has decreased by 4 from last month. The lapses in care have increased by 3 from last month.

There has been 2 hospital acquired device related pressure ulcers, neither of these resulted from lapses in care and were both in relation to casts applied after surgical procedures.

Themes of lapses in care are; completing skin assessment in AMU and ineffective pressure relief of heels. All clinical areas have been given posters detailing how to provide effective pressure area relief for

patients’ heels.

The RCAs found no lapses in care in the cause of pressure ulcers resulting from casts.

NB There are 2 outstanding RCAs still going through the governance process. One is a category 2 which will be presented on 19th September. The other is a category 4 and will be presented on 26th September.

Patient Safety


BHNFT At-a-Glance August 19

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Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateYear-End

Forecast Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

Falls 785 (<) 65 BHNFT 119 321 385 58 53 83 72 70 66 72 76 71 55 70 49

Repeat Falls n/a BHNFT 18 57 - 12 8 13 14 14 11 19 17 17 5 13 5

Falls resulting in moderate harm or above 20 (<) 1 BHNFT 3 19 23 1 3 1 2 1 1 0 1 0 1 1 2

Hand washing 95% (>) National 97% 96% 98.9% 99% 99% 95% - - - - 94% 97% 97% 96% 99%

Pressure Ulcers category 2 (Lapses in care) G < 30, R >30 0 BHNFT 11 23 - 2 5 5 4 7

To eliminate pressure ulcers resulting from medical devices resulting in lapses of care. 2 9 4 3 0 2 0

Q - Hospital Acquired Clostridium Difficile 19 (<) 1 NHSE 6 10 16 2 3 1 2 0 2 2 1 1 2 2 4

Q - Serious Incidents - NHSE 6 10 - 4 9 9 4 2 2 5 2 0 2 2 4

Q- Total Number of Incidents Resulting in Death 0 0 National 2 3 - 0 2 0 1 0 0 0 0 1 0 0 2

Q-Total Number of Incidents Resulting in Severe Harm 0 0 National 2 5 - 1 3 1 1 1 1 0 1 0 2 2 0

Q- FFT Response Rate ED G >= 10%, R < 10% BHNFT 1.8% 2.5% - 1.3% 1.5% 6.2% 3.1% 0.4%

Q - FFT Response Rate IP G >= 10%, R < 10% BHNFT 37% 35% - 32% 35% 38% 44% 31%

Q- FFT Response Rate MAT G >= 10%, R < 10% BHNFT 47.7% 47.1% - 32.6% 39.9% 61.6% 45.2% 50.2%

Q- FFT Positivity Rates - EDG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 87% 92% 90% 97% 95% 91% 66% 79% 61% 84% 86% 94% 95% 88% 81%

Q- FFT Positivity Rates - IPG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 98% 98.2% 98% 96% 98% 97% 97% 97% 99% 98% 98% 98% 99% 98% 98%

Q- FFT Positivity Rates - OPG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 95.7% 95.4% 95% 98% 94% 94% 93% 96% 94% 96% 94% 96% 95% 96% 96%

Q- FFT Positivity Rates -StaffG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 71.1% 72.1% 82.0%

Complaints closed within target or agreed extension % G >90%, A >=70%-90%, R <70% (>) BHNFT 100% 100% 91.1% 100% 97.1% 96.9% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q- Single Sex Breaches 0 0 National 0 0 - 0 0 0 0 0 0 0 0 0 0 0 0

Q - Duty of Candour Breaches 0 0 National 0 0 - 0 0 0 0 0 0 0 0 0 0 0 0

Q - VTE Screening Compliance G>= 95%, R < 95% NHSE 98.3% 98.3% 97.9% 98.6% 97.6% 97.2% 98.6% 98.1% 98% 97.8% 98.1% 98.2% 98.5% 98.2% 98.5%

Q - Sepsis-Antibiotics given within Hour of diagnosis G >= 90%, R < 90% National 92.9% 87.8%

Q - HSMR (Rolling 12 months) Latest Data is June 2019 - - - 109.8 106.6 104.9 103.3 102.8 100.5 99.2 96.9 96.9 97.9

Crude Mortality (Number of Deaths) - - - 80 78 80 102 114 96 92 100 88 79 65 69

SHMI (Rolling 12 months) Latest Data is March 2019 - - - 103.0 101.0 99.3

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets which will be RED if the target is not

achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule for 2019/20 to be defined and included in IPR from May 2019

Quality Performance Scorecard

Patient Safety

Patient Experience

Clinical

Effectiveness

Patients will experience safe care


5Pack

People and Patient Access Scorecard

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to Date Forecast Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

People will be proud to work for us

Staff Turnover (Rolling 12 months) G <=10%, A >10%-11%, R >11% (<) BHNFT 6.6% 9.0% 8.8% 9.2% 9.1% 9.3% 9.0% 9.1% 9.1% 8.9% 9.0% 8.6% 7.7% 7% 6.3%

Staff Appraisal Rate G >90%, A >=70%-90%, R <70% (>) BHNFT 92.0% 98% 90% 92.2% 92.2% 91.9% 91.2% 90.7% 90.2% 89.9% 7.6% 31.4% 86.5% 91.2% 92.8%

Mandatory Training G >90%, A >=85%-90%, R <85% (>) BHNFT 90.5% 90.9% 90% 86% 86% 87.9% 88.4% 88% 89% 90.3% 90.9% 91.3% 91.2% 90.7% 90.3%

Sickness Absence (In Month)G <=3.75%, A >3.75%-4.25%, R >4.25%

(<)BHNFT 4.08% 4.12% 4.34% 4.14% 4.17% 4.45% 4.27% 5.03% 4.85% 4.63% 4.12% 4.10% 4.02% 4.31% 3.85%

Performance matters - Key Performance Indicators

RTT Incomplete Pathways (July 19) 92% (>) National 94.7% 94.7% 94% 95.1% 95.9% 95.3% 95.1% 95.7% 95.6% 95.2% 95.0% 94.7% 94.3% 93.5%

Q - Cancer 2 Week Waits 93% (>) National 91.4% 90.4% 93.8% 94.9% 93.5% 95.2% 96.2% 96.4% 95.6% 95.6% 93.4% 94.8% 85.8% 87.8%

Q - Symptomatic Breast 2 Week Waits 93% (>) National 79.4% 72.7% 90% 92.0% 94.7% 92.2% 93.6% 94.4% 95.3% 94.6% 92.1% 94.9% 48.4% 57.9%

Q - 31 Day - 1st Definitive Treatment 96% (>) National 94% 96% 98.5% 100% 100% 97% 99% 99% 94% 99% 95% 92% 97% 100%

Q - 31 Day - Subsequent Treatment (Surgery) 94% (>) National 97% 97% 98.5% 100% 100% 100% 100% 91% 100% 83% 91% 100% 100% 100%

Q - 31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q - 38 Day - Inter-Provider Transfer 85% (>) BHNFT 65.5% 62.7% 75.6% 93.1% 61.5% 62.1% 92.3% 66.7% 50.0% 58.6% 61.9% 63.6% 70% 55.9%

Q - 62 Day - GP Referral to Treatment 85% (>) National 80.8% 82.9% 86% 87.7% 91.4% 85.7% 87% 85.4% 94% 89.2% 93.2% 78.0% 73.3% 88.8%

Q - 62 Day - Screening Referral to Treatment 90% (>) National 90.2% 92.5% 90% 71.4% 73.3% 92.0% 78.6% 89.5% 93.8% 100% 100% 79% 100% 100%

Q - 62 Day - Consultant Upgrade to Treatment 85% (>) BHNFT 85.7% 89% 95% 100% 81% 86% 100% 91% 100% 100% 100% 100% 75% 94%

Emergency % Patients Waiting <4 Hours 95% (>) National 92.4% 94% 95% 98.6% 95.4% 97.4% 96.7% 91.1% 92.9% 96% 96% 95.6% 95.6% 93.5% 91.3%

Average Length of Stay - Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 2.84 2.69 - 2.44 2.94 2.60 3.14 2.88 2.32 2.72 2.65 2.20 2.94 3.00 2.67

Average Length of Stay - Non-Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 3.06 3.08 - 3.40 3.26 3.19 3.12 3.48 3.37 3.38 3.07 3.16 3.06 3.04 3.07

Re-admissions % (Validated) 8% BHNFT - 7.1% 6.8% 6.2% 7.7% 7.5% 8.4% 7.2% 8.5% 8.6% 7.9% 8.7% 7.7%

Cancelled Operations - Breaches of the 28 day rule 0 0 National 0 0 - 0 0 0 0 0 0 0 0 0 0 0 0

Cancelled Operations - Sitrep Reportable 0.8% BHNFT 0.8% 0.5% 0.4% 0.6% 0.3% 0.4% 0.3% 0.8% 0.2% 1.1% 0.5% 0.7% 0.4% 0.7% 0.5%

DNA Outpatient DNA RatesG <=7.2%, A >7.3%-8.5%, R >8.6%

(<)7.2% BHNFT 6.6% 6.7% 7% 7% 6.9% 7.0% 7.3% 6.4% 6% 6.5% 6.8% 6.9% 6.7% 6.6% 6.7%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets which will be RED if the target is not

achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

NOTE: National Indicators such as Cancer, RTT, Cancelled Ops, etc. are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

All other indicators are classed as Achieved or Failed with the exception of all Workforce KPIs, Average Length of Stay & DNA rates which detail the tolerances applied in the Target column.

Operational

Efficiency

Workforce

Elective Access

Cancer


6Pack

Patients will experience safe care (Quality & Experience)

Nursing Staffing Fill Rate (Quality Strategy - Goal 4: Building on Capacity and Capability)

Ward 1786% 84% 97% 149% 2.8 2.4 5.2

Registered Nurses

Ward 1872.1% 91.0% 97% 93.1% 2.6 2.8 5.4

Registered Midwives

Ward 19 Elderly 74.0% 85.3% 93.7% 104.4% 2.3 4.0 6.3

Unregistered health care/midwifery care assistants

Ward 20 ASU 64.5% 106% 97% 132.3% 2.3 5.0 7.3

Unregistered nursing/midwifery auxiliaries.

Ward 21 70.2% 92% 100.0% 129% 2.4 3.0 5.4

Ward 22 Diabetes/E

ndo

75.3% 110.5% 100.0% 117.9% 2.7 2.9 5.6

Ward 23 Frailty Unit 76.9% 115.1% 98.4% 117.6% 3.3 4.9 8.3

Ward 2487.8% 97.9% 95.2% 106.5% 4.6 3.5 8.1

Ward 29 SSU 82% 93.7% 103.1% 100% 2.6 1.9 4.6

Ward 30 General Medical

88% 100% 91.9% 100% 2.5 2.0 4.5

AMU91.0% 110.1% 94.4% 146.4% 5.3 4.6 9.9

CCU71.2% 80.8% 98% - 11.9 1.7 13.6

Ward 31 SA 82.6% 100.2% 98.3% 147.2% 3.2 3.6 6.9

Ward 3286.9% 114.2% 99.9% 100.0% 3.4 3.8 7.2

Ward 3384.4% 97.7% 93.3% 124% 2.6 4.0 6.7

Ward 3470.0% 72% 81% 103.2% 6.5 4.5 11.0

ITU92% 92% 96% - 29.7 2.6 32.2

SHDU94% 74% 95% - 17.6 3.9 21.5

AN/PN 100% 100% 99% 100% 7.9 2.1 10.0

Birthing Centre 98% 94% 100% 96.9% 27.3 4.2 31.5

Gynae Inpatient

Ward

100% 100% 100% 100% 3.9 3.9 7.8

Ward 15 NNU 106% 103% 93% 117.6% 11.2 1.7 13.0

Ward 37 79% 130% 57% 49.0% 8.2 2.9 11.1

430 - GERIATRIC MEDICINE

303 - CLINICAL HAEMATOLOGY

300 - GENERAL MEDICINE

320 - CARDIOLOGY

Ave fill rate

Care staff

(%)


320 - CARDIOLOGY

Ave fill rate

Registered

BHNFT is committed to ensuring that levels of nursing staff, match the acuity

and dependency needs of patients in order to provide safe and effective care.

Nurse staffing includes:

307 - DIABETIC MEDICINE

Care Staff

Registered

Nurses/Midw

ives

Overall

A monthly nurse staffing paper is presented to the Quality and Governance

Committee. This paper presents in depth information on all aspects of nurse

staffing including; vacancies, bank and agency usage, risk areas and

mitigation of risk. The paper also triangulates nursing staffing against a heat

map of harm. There is a full discussion at each meeting regarding this paper.

Ward

name

Night Care Hours Per PatientDay

SpecialtyAve fill rate

Registered

Nu

rsin

g St

affi

ng

Fill

Rat

e

301 - GASTROENTEROLOGY

100 - GENERAL SURGERY

420 - PAEDIATRICS

This allows for contingency plans to be made where the roster identifies that

the planned staffing falls short of the minimum requirement, for example

where there are vacant nursing posts or staff appointed have not started in

post. These contingency plans can include: moving staff from a shift which

is above the minimum required level, moving staff from another ward/area

which is above the minimum required level, or the use of flexible/temporary

staffing from the Trust’s internal bank or via an external nursing agency.

There are 9 wards whereby staffing levels fell below 80% this

month work is on-going to review the data as it is believed that

due to the NHS professionals interface roll out that some shifts

have not appeared in health roster. This is the highest risk on the

risk register for the NHS professionals interface project and is

mainly affecting the medical wards.

The Care Hours per Patient Day (CHPPD) which is an indicator of staffing

requirements however has remained stable with an overall for the month of

8.1 which is in line with national average.

340 - RESPIRATORY MEDICINE

The Trust uses an e-rostering system with duty rosters created eight weeks in

advance to ensure the levels and skill mix of the nursing staff on duty are

appropriate for providing safe and effective care.

Ave fill rate

Care staff (%)

430 - GERIATRIC MEDICINE

501 - OBSTETRICS

502 - GYNAECOLOGY

422 - NEONATOLOGY

192 - CRITICAL CARE MEDICINE

192 - CRITICAL CARE MEDICINE

501 - OBSTETRICS

110 - TRAUMA & ORTHOPAEDICS



110 - TRAUMA & ORTHOPAEDICS

100 - GENERAL SURGERY


7 Pack

Performance Matters (KPIs)Operational Efficiency

The Trust failed to deliver the Emergency access standard in the month of January at 91.1%. Activity is now 14% above plan for emergency department attendances and 6% above plan for non-elective admissions. Year to date, delivery is at 94.7% with a organisational effort focusing on the delivery of the 95% standard at year end

Comments:

Bre

ast

Sym

pto

mat

ic

Diagnostic access remains strong. One 6 week diagnostic breach was observed for DEXA scanning as a result of technical issues with the scanner which have now been

resolved.

The Trust continues to validate readmissions via a daily process which feeds in to quarterly reconciled

position with Barnsley CCG. Clinical audit of readmissions in key areas have demonstrated that there are no

clinical concerns and that activity around ADT processes are in place and accurate, supported by the daily

validation process.

DN

A R

ate

s

Re

-ad

mis

sio

ns


7.8% 7.1%

7.8%

6.8% 7.1% 7.6%

7.2% 7.3% 7.0% 6.9% 7.0% 7.3% 6.4%

6.0% 6.5% 6.8% 6.9% 6.7% 6.6% 6.7%

0%

2%

4%

6%

8%

10%

% o

f D

NA

Rat

es

DNA Rates

New Follow Up Total Standard 2017/18

Cancelled Operations target is '0'

0.4%

0.8%

1.1%

0.6%

0.4%

0.6%

0.8% 0.8% 0.6%

0.3% 0.4%

0.3%

0.8%

0.2%

1.1%

0.5%

0.7%

0.4%

0.7% 0.5%

-0.1%

0.1%

0.3%

0.5%

0.7%

0.9%

1.1%

1.3%

1.5%

% o

f C

ance

lled

Op

era

tio

ns

Cancelled Operations

28 Day Breaches % Cancelled Ops Standard

Cancelled Operations Target '0'

7.5% 7.1% 8.0% 7.6% 8.1%

7.1% 7.2% 7.8% 7.1% 6.8% 6.2% 7.7% 7.5%

8.4% 7.2%

8.5% 8.6% 7.9%

8.7% 7.7%

0.00%

5.00%

10.00%

Cumulative Validated Re-admissions

0.7% 0.8%

1.0%

0.1% 0.2%

0.5%

0.0% 0.0%

0.5%

0.1%

0.5% 0.3% 0.2%

0.0% 0.0% 0.1%

0.0% 0.1% 0.3%

0.1%

0.0%

0.5%

1.0%

1.5%

2.0%

Pe

rce

nta

ge o

ver

6 w

ee

ks

Diagnostic Tests over 6 Weeks

Standard Actual % 1920

8Pack

Performance Matters (KPIs)


Emergency Access and Patient Flow (1)

Co

mm

en

tary

A&

E 4

Ho

ur

Wai

t

• August saw high demand for urgent and emergency care services with very high ED attendances and non-elective admissions. Long term plans are being drawn up to develop a resource profile which acknowledges an emerging 300

attendances per day as the new norm. August saw an increase in staffing issues compounded by a decrease in availability of regular middle grade locum support which have been addressed in September. Pressure for inpatient beds

has been a challenge in August with a regular reliance on escalation capacity to flex to meet the demand of non-elective admissions.

•Project plan agreed by executive team to undertake a Trust wide role out of ProWard. The implementation plan is in place with an agreed trajectory of all medical wards utilising ProWard by end December 2019. ProWard is an

electronic whiteboard solution to track patient flow in clinical areas. The concept supports analysis of data sets including stranded patients and length of stay and also red and green days in a patient’s journey.

• The ‘longstaywednesday’ process has now been rolled out across the Trust. This is a multidisciplinary process to review all patients with a length of stay over 21 days. The collaboration takes place between partners from SWYFT,

medical staff, social services and the Trust Discharge Matron.

• Business case to support new staffing model and ways of working for the therapy ‘home first’ concept being presented to ET in July 2019. If agreed this will enable occupational therapy assessments to take place prior to patients

being deemed medically fit.

85.5%

89.9% 91.1%

90.3%

93.0%

95.4%

92.1%

97.2%

98.6%

95.4%

97.44% 96.70%

91.09%

92.85%

96.04% 95.97% 95.64% 95.56%

93.45%

91.26%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

0

2000

4000

6000

8000

10000

12000

Within 4Hrs Total Activity Target 4h Emergency Access PerformanceStandard

9Pack




A&E benchmarking

A&

E 4

Ho

ur

Wai

t -

Be

nch

mar

kin

g

Am

bu

lan

ce H

and

ove

rsIn

pat

ien

t A

cuit

y -

Am

ber

(EW

S sc

ore

5-6

)

Acuity analysis shows an expected increase as measured by EWS scores above. This is reflected in increased bed occupancy and mitigated by the flexible use of inpatient capacity

Inp

atie

nt

Acu

ity

- R

ed

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

No. Ambulance Handover Times (Pre-validated YAS)

No. between 15 & 30 mins No. between 30 & 60 mins No. between 60 & 120 mins No. over 120 mins Not recorded

EWS = Amber only

10Pack




ED Delivery Dashboard V4

Tru

st B

ed

Occ

up

ancy

(M

ed

ical

)

Len

gth

of

Stay

(Sp

ell)

GP

Str

eam

ing

11Pack



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - July 2019Validated Position

CommentsSpecialty <18 >18 Total %

CARDIOLOGY 476 5 481 98.96%DERMATOLOGY 1128 56 1184 95.27%E N T 1079 58 1137 94.90%GASTROENTEROLOGY 705 3 708 99.58%GENERAL MEDICINE 100 0 100 100.00%GENERAL SURGERY 1612 171 1783 90.41%GERIATRIC MEDICINE 168 0 168 100.00%GYNAECOLOGY 1040 30 1070 97.20%OPHTHALMOLOGY 1307 77 1384 94.44%ORAL SURGERY 1256 176 1432 87.71%OTHERS 805 42 847 95.04%RESPIRATORY MEDICINE 302 6 308 98.05%RHEUMATOLOGY 297 8 305 97.38%TRAUMA AND ORTHOPAEDICS 1040 127 1167 89.12%UROLOGY 674 70 744 90.59%Total 11989 829 12818 93.53%

Co

nsu

ltan

t 1

8 W

ee

k R

efe

rral

to

Tre

atm

en

t

Incompletes - Standard 92%

At the end of July overall Trust performance was 93.6%, compared with the

target of 92%, which made Barnsley Hospital the fifth highest performing trust in

the country. The specialties which weren’t compliant with the target were Oral

Surgery, Orthopaedics, General Surgery, and Urology. The loss of an operating

theatre during 2019 has impacted adversely upon performance across all surgical

specialties and this has been compounded in recent months by the reluctance of

consultants to undertake extra-contractual sessions due to the pension taxation

implications. Recovery plans have been formulated for the non-compliant

specialties and it expected that compliance will be regained by October for

specialties other than oral surgery.

90% 92.37% 92.21% 93.16% 93.37% 93.57% 94.35% 94.70% 95.08% 95.86% 95.32% 95.06% 95.71% 95.59% 95.20% 94.8% 94.74% 94.27% 93.53%

80%82%84%86%88%90%92%94%96%98%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Incomplete Pathways

Actual Standard

12Pack



Regulatory Performance - Cancer

Inte

r p

rovi

de

r Tr

ansf

er

Bre

ast

Sym

pto

mat

ic

All

Can

cer

2 W

ee

k W

aits

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

38 Day Inter-Provider Transfers July shows a decrease in performance (55.9%) from the gradual improvement over the previous 3 months (Apr 61.9% / May 63.6% / Jun 70.0%) in the 38 day standard. This is below the target of 85.0% and is due to 15 of 34 patient transfers occurring beyond day 38 of pathways. Breaching specialties consist of Gynaecology (1), Lung (6), Skin (1), Upper GI (3), Urology (4). Reasons include close proximity of investigations to MDT resulting in 7 day delay, medical reasons resulting in the delay of diagnostic testing, inefficient pathway and some patient choice. Transformational changes to diagnostic pathways will be completed in December and January with an anticipated impact on 38 day compliance by January and February's validated figures (IPR publishing in March and April 2020)

13Pack



Regulatory Performance - Cancer

Graph to follow from Cancer services

Graph to follow from Cancer services

62

Day

Can

cer

Targ

ets

62

Day

Can

cer

Targ

ets

60%

65%

70%

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Urgent GP Referral to Treatment

Actual Standard

0%

20%

40%

60%

80%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Screening Programme

Actual Standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Consultant Upgrades

Actual Standard

14Pack



Further Information2 Week Wait

In July all specialties, with the exception of Breast (58.3%), Head & Neck (88.2%) and Lower GI (90.5%) achieved the two week standard target of 93.0% with the Trust achieving an overall position of 87.8%. Breaches for Breast (65) were due to known

capacity issues. A recovery plan has been delivered during July and August with a recovered position expected in September. Head & Neck (11) and Lower GI (19) were due to a mixture of patient choice and clinic capacity issues.

Breast Symptomatic

Due to known capacity issues, poor performance early in the month meant the validated position for July was non-compliant at 57.9% against a target of 93.0%. As per the recovery trajectory, breast symptomatic 2 week access displayed an expected

improvement on a weekly basis throughout the remainder of the month with w/c 15th 72.5%, 22nd 86.7% and 29th 91.7%. Early indications shown unvalidated August figures continue this projection with the overall monthly position standing at a

greatly improved 83.3% and September will demonstrate recovery. Actions taken to address include a new 12 week tracker and forecasting tool, which allows a greater level of insight in to the specific clinica days where additional capacity is required.

On this basis, detailed capacity plans have driven the placement of additional radiology support in order to ensure the robustness of the service going forward. An additional substantive consultant appointment is anticipated in November 2019 and

short-term locum support has been supported in the interim.

62 Day GP Referral to Treatment

The validated July performance for the 62 day cancer pathway standard was compliant at 88.8% against a target of 85.0%.

62 Day Screening Referrals to Treatment

The validated July performance for the 62 day cancer pathway standard for the Trust was compliant at 100.0% against an 90% target.

62 Day Consultant Upgrade to Treatment

The validated July performance for the 62 day cancer pathway standard for the Trust was compliant at 93.8% against an 85% target.

15Pack

High Level Summary Sickness - there is a decrease in month by 0.44% to 3.85%. This is the first time sickness has been in an amber position sin ce September 2018, and is slightly lower than in the same month last year when it was at 3.98%. The latest available national average sickness absence rate is 4.06% as at April 2019 which is similar to the Trust which was at 4.07%. Management of the sickness hot spot areas within CBUs continues to be monitored monthly at People & Engagement Group. An internal audit review of sickness absence management through the Occupational Health referral process is currently underway and the final report is due in September 2019. Staff Turnover— Turnover decreased on last month by 0.68% to 6.27%. In the first quarter of this year there were 134 leavers and 133 starters. Promotion is still the top reason given for leaving. 20 Band 5 Nurses left during the 1st quarter and the reasons will be analysed as part of NHSI retention programme. Mandatory Training - Mandatory Training has dipped again for the third consecutive month to 90.3% and continues to be just above the 90% compliance target. The topic with the highest compliance is Moving & Handling Back Care Awareness (once only) at 97.2%. The topic with the lowest compliance is Resuscitation Adult BLS at 80.9%. Staff Appraisal Rate - has increased by 1.6% to 92.8% , meaning the 90% compliance target has been exceeded. Feedback is being obtained on the new appraisal e-form and the quality of appraisal discussions to review at P&EG.

16 Pack

People - Trend Analysis

Sick

nes

s (T

rust

wid

e)St

aff

Turn

ove

r (1

2 M

on

ths)


Please the latest Sickness absence benchmarking data is only avaliable upto December 2018

17 Pack

Performance MattersActivity

18/19 19/20 19/20

Actual Plan Actual Variance %

Elective Daycases 11,398 11,446 12,061 615 5%

Elective Inpatients 1,473 1,437 1,561 124 9%

Elective Total 12,871 12,883 13,622 739 6%

Non Elective Total 16,176 17,192 17,977 785 5%

Maternity Pathway Total 2,670 2,634 2,675 41 2%

A&E Total 39,713 41,614 43,661 2047 5%

Outpatients Total 137,342 133,942 148,133 14191 11%

* Please note excess bed days are not included in these figures. 2019/20 Activity Plan

2019/20 Activity Actual

2019/20 Activity Plan 2019/20 Activity Plan

2019/20 Activity Actual 2019/20 Activity Actual

Act

ivit

y

Day

Cas

es

Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

Ele

ctiv

e In

pat

ien

ts

No

n-E

lect

ive

Inp

atie

nts


18 Pack

Performance MattersActivity

2019/20 Activity Plan 2019/20 Activity Plan

2019/20 Activity Actual 2019/20 Activity Actual

Comments:

2019/20 Activity Plan

2019/20 Activity Actual

Ou

tpat

ien

ts

The main area of over performance is outpatient activity:

New attendances are over performing by 2,641 mainly in General Surgery +437, Ophthalmology +512,

T&O +462

and Dermatology +471.

Follow up attendances are over performing by 11,472 mainly in Dermatology +1,073, Anticoagulant

+2,278, Ophthalmology 3,474 and Retinal screening +2,945.

Day case over performance is Urology +176, Gastroenterology +222 and Dermatology +169. The main

area of under peformance is Clinical Haematology -156.

Elective The main area of over performance is Gynaecology +70 and General Surgery +44. T&O is

under performing by -36.

Non-elective main over performance is in CDU +200 and Endocrinology +200. The main areas of under

achievement are Paediatrics -186 and Obstetrics -104.

Mat

ern

ity

Pat

hw

ay

A&

E A

tte

nd

ance

s


19 Pack

SUMMARY

Item RAG

1

2

3

4

5

Comments

Medway Data Quality To be decided To be decided

Action

The Trust now has a well-established Data Quality Group that aims to ensure the Trust’s core electronic patient record system is up-to-date and accurate. This group comprises operational and ICT staff and reports directly into senior operational

groups on progress and ensures delivery of action plans associated with emergent and pre-existing data quality issues

Clinic Cleanse

Referral Management - Management of

multiple pathways from the same referral.

We are working on mitigating the risk of data quality issues arising

when migrating to Medway (SystemC). Currently we are working

closely with the SystemC team to map all our data correctly,

validating review list patients, patient addresses and revisiting the

use of the Trust's PTL to validate patients. This work is being

overseen by the Data Quality Group and Trust Operations Group.

Comments

% of clinics configured in Lorenzo identified as requiring modification, as part

of capacity planning process

Referral APP Ratio

Referral to Treatment Validation Failing specialties at month end 4 specialties are failing out of 15

Process of validation currently under review. The Trust is

currently achieving 93.53%, this is reducing compared to previous

months.

Outpatient missing and incomplete coding. Average outpatient tariff / patient record Average tariff: £99.39

We are currently auditing our outpatient outcome recording

processes to ensure the correct codes are recorded. This work is

dovetailing with developments in ICT to make outpatient outcome

slips electronic, thus also working towards our Paperless agenda.

A review of clinic configuration ( new and exsisting) will take place

as part of Data Quality Group and Business Planning task and finish

groups to improve configuration accuracy, and to aid in the

configuration of clinics on Medway EPR (as part of funtional design

groups) by informing a new standard operating procedure for

requesting and configuring clinics.

Report looked at weekly and any errors reported. This will remain

amber as will always be an on-going task.

21.33%

Current position is 129.19%

Metric Metric Current Position


20 Pack

Performance - "At a glance"

Month

Plan

Month

Actual

Variance

%Variance Plan YTD Actual YTD

Variance

%Variance

Month

Plan

Month

ActualVariance % Variance Plan YTD

Actual

YTD

Variance

%Variance

ACTIVITY LEVELS (PROVISIONAL)

Elective inpatients 282 325 15.25% 43 1,437 1,561 8.63% 124 CIP £'000 £'000 £'000 £'000 £'000 £'000

Day Cases 2,301 2,336 1.52% 35 11,446 12,061 5.37% 615 Income 85 617 625.29% 532 425 1,773 317.06% 1,348

Outpatients 26,171 27,640 5.61% 1,469 132,749 146,862 10.63% 14,113 Pay 278 68 -75.54% (210) 1,227 452 -63.16% (775)

Non-elective inpatients 3,588 3,570 -0.50% (18) 17,245 17,988 4.31% 743 Non-Pay 158 (30) 118.99% (188) 790 380 -51.90% (410)

A&E 7,970 8,720 9.41% 750 41,614 43,661 4.92% 2,047 Total CIP 521 655 25.62% 134 2,442 2,605 6.65% 163

Other (excludes direct access tests) 8,611 8,243 -4.27% (368) 42,989 44,044 2.45% 1,055

Total activity 48,923 50,834 3.91% 1,911 247,480 266,177 7.55% 18,697 SOFP £'000 £'000 £'000 £'000 £'000 £'000

Capital Spend (593) (294) 50.42% 299 (2,995) (1,664) 44.44% 1,331

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Inventory 2,721 3,356 23.34% (635)

Elective inpatients 869 917 5.54% 48 4,405 4,894 2.96% 489 Receivables 12,655 15,892 25.58% (3,237)

Day Cases 1,434 1,341 -6.53% (94) 7,094 7,630 7.56% 536 Payables (inc. Accruals) (15,125) (26,535) -75.44% 11,410

Outpatients 2,748 2,827 2.86% 79 13,853 14,842 7.14% 989 Other Liabilities (348) (1,417) -307.18% 1,069

Non-elective inpatients 6,508 6,483 -0.39% (25) 31,367 32,026 2.10% 659

A&E 1,138 1,237 8.64% 98 5,944 6,202 4.34% 258 Cash & Loan Funding £'000 £'000 £'000

Other Clinical 4,608 4,524 -1.81% (84) 23,049 22,656 -1.71% (393) Cash 1,000 11,763 1076.30% 10,763

Risks & Penalties 0 0 0 0 (1,000) (1,000) Loan Funding (70,426) (68,374) 2.91% 2,052

PSF Funding 734 734 -0.05% (0) 3,258 3,637 11.63% 379

Other 1,406 1,597 13.60% 191 7,030 7,815 11.17% 785 KPIs

Total income 19,446 19,659 1.10% 213 96,000 98,702 2.81% 2,702 EBITDA % 3.33% 2.26% -32.21% -1.07% 1.46% 2.43% 66.08% 0.97%

Surplus / (Deficit) % 0.35% -0.69% 298.57% -1.04% -1.54% -0.55% 64.10% 0.99%

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000 Receivable Days 19.4 24.7 27.32% -5.3

Pay (13,385) (13,637) -1.88% (252) (67,533) (68,813) -1.90% (1,280) Payable (excluding accruals) Days 63.1 82.7 30.96% 19.5

Drugs (1,340) (1,273) 5.03% 67 (6,700) (6,596) 1.55% 104 Payable (including accruals) Days 63.1 112.3 77.87% 49

Non-Pay (4,073) (4,306) -5.71% (233) (20,365) (20,899) -2.62% (534) Use of Resource metric 3 3 0.00% 0

Total Costs (18,798) (19,215) -2.22% (417) (94,598) (96,308) -1.81% (1,710)

EBITDA 648 444 -31.47% (204) 1,402 2,394 70.76% 992

Depreciation (483) (483) 0.07% 0 (2,402) (2,414) -0.50% (12)

Non Operating Expenditure (97) (97) 0.06% 0 (482) (527) -9.34% (45) Consolidated

Surplus / (Deficit) 68 (136) 300.75% (203) (1,482) (547) 63.09% 935 excl charity

Payable days are total op exps, less total pay, add back lead units and agency control total

Payables are Trade & Other only

Performance - Financial Overview Performance - Financial Overview


Page 21 of 22 Pack

Summary Performance:Commentary Key to RAG Rating The RAG rating applied to Variance % is based on the following criteria: • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan

The key points derived from this table are as follows: • Total activity is favourable to plan year to date across all points of delivery.

• CIP achievement is favourable to plan by £0.163m year to date.

• Total income is £2.702m favourable to plan year to date. Clinical income variances being within elective, daycase, non elective and outpatients.

• Operating costs are £1.710m adverse to plan in total. Pay is £1.280m adverse, non-pay costs are £0.534m adverse.

• EBITDA is £0.992m favourable to plan.

• Depreciation and finance costs are broadly to plan.

• The overall financial position is £0.935m favourable to plan. This is distorted by £0.379m bonus PSF money relating to 2018/19 which is unplanned and accounted for in 2019/20.

• Capital expenditure is £1.331m less than plan.

• Inventory is £0.635m above plan.

• Total receivables incl. prepayments are £3.237m higher than plan.

• Total payables incl. accruals are £11.410m higher than plan.

• Cash is £10.763m favourable to plan.

• Debtor days are 24.7 year to date, which is 5.3 days adverse to plan.

• Payable days are 82.7 year to date which is 19.5 days adverse to plan. Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future

payments, the timing of these payments is uncertain.

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SUBJECT: EU-EXIT “NO DEAL” UPDATE DATE: OCTOBER 2019 PRIVATE & CONFIDENTIAL

PURPOSE:


applicable For decision/approval Assurance √ For review √ Governance √ For information √ Strategy √

PREPARED BY: Mike Lees, Head of Business Security SPONSORED BY: Dr Richard Jenkins, Chief Executive Officer PRESENTED BY: Bob Kirton, Chief Delivery Officer STRATEGIC CONTEXT For the past two and a half years, central government including the DHSC have been continuing a significant programme of work to ensure that the UK will be ready for a EU-Exit (Brexit) in all scenarios, including a now increasing possibility of ‘no deal’ outcome on 31st October 2019. Although there has been a significant political pause whilst parliament was in recess, now exacerbated by the extended prorogue of the House, planning on a regional and national basis is continuing. The fluidity of the situation has increased with Supreme Court hearings, party conference season, possible recall of Parliament and mounting speculation of a general election.

The Business Security Unit continues to 'horizon scan' in respect of the risks to the Trust and BFS of an probable 'no deal' EU-Exit and monitoring the Government's on-going preparations should the UK leave the EU without any deal on 31st October 2019. Further to the previous papers and updates to the Board, this latest paper (September 23rd) provides the most recent information and assurance that the Trust is taking action to ensure we are as prepared as possible whatever the scenario. The Operational Readiness Guidance, NHS England & Improvement (NHS&I) advice and attendance at every organised workshop ensures the foundation of Trust and BFS planning and readiness.

EXECUTIVE SUMMARY The “no deal” risk (entry 2121) remains one of the Trust’s current concerns and is regularly reviewed through the Trust governance processes. A well publicised commentary on events in both Parliament and Europe with the likelihood of a “no deal” has been maintained and sharpened by the current parliamentary and legal dynamics. The political momentum is leaning towards further discussions with the EU with NHS&I planning assumptions centred on the ‘No-Deal’ probability. Trust management leads continue to work closely in partnership with all professional colleagues and peers both nationally and regionally to ensure that issues affecting all NHS organisations are considered and to ensure that efforts are not duplicated or vital topics lost. Operation Yellowhammer has been well researched and its conclusions built into the Trust planning and assessments. The Trust’s Business Security Unit continues to network with EPRR colleagues, working in Pack

partnership, on EU-Exit preparations for the NHS. The latest meeting and discussions took place at the LHRP meeting on 9th September 2019 followed by an EPRR operational meeting in the afternoon. This multi-agency approach and monitoring can be linked into our current business continuity planning alongside our more flexible adaptive approach. With Parliament still prorogued and a possibility of re-call, the government and regional approach outlined in the guidance continues to be followed with the below actions:

• Brexit lead for the Trust continues to be the Chief Delivery Officer • Identify any increased risks or threats to the Trust associated with the UK leaving the EU

with ‘No-Deal’. • The BSU continues to provide regular updates with daily monitoring of EU-Exit intelligence

and news reports. • Local business continuity arrangements via BC-Lite continue with possible response options.

A number of exercise scenarios have been tested on a regional basis with the Trust actively involved.

• The regional approach as advised by the South Yorks EPRR SRO was updated at 9th September 2019 meeting attended by the Deputy Director of Operations and Head of BSU with NHSE&I continuing to plan under a national Gold Commander.

• The Managing Director of BFS attended an Estates and Facilities expert working group in August facilitated by NHS&I. This allowed useful intelligence to be accrued for Trust planning.

• Weekly Brexit steering group chaired by the Chief Delivery Officer is to review latest political and operational aspects and meetings resumed on 23rd September 2019

• Group membership remains unchanged with local and regional contacts maintained • Meetings held with Barnsley NHS CCG and BMBC. • Updates to be issued via committees, Board and communications plan following an August

review meeting which involved a ‘confirm and challenge’ in respect of key risks. • Brexit risk register continues to be maintained and updated

RECOMMENDATION(S)

To receive this latest update. Discuss, note and make any further recommendations for actions to be taken.

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EU-Exit ‘No Deal’ Risk Assessment BHNFT / BFS

1

MJL – OFFICIAL- SENSITIVE

Risk Register for: EU-Exit ‘No Deal’ Issues Date completed: 7th January 2019 reviewed 23rd September 2019 (Updates received from DHSC, CCG, NHSE, NHSI, PHE, LHRP & LRF) Organisations: Barnsley Hospital NHS Foundation Trust & Barnsley Facilities Services

Risk N

o

Description of risk Assessment Controls/ contingencies in place

Work to be completed to mitigate risk

Risk Consequences

Impact

Likelihood

Description Lead Due by

1. Medicines Possibility of stock outs in UK medicines supply chain due to stockpiling of medication by suppliers and / or hospitals prior to the exit date. AMBER

Unable to provide required medication to patients. Delays to patient treatment Trust reputation Pharmacy procurement impacts Financial impact for Trust

4

3

Initially follow guidance issued by Commercial Medicines Unit. Manage the issue internally via Pharmacy and MMC, either switching to alternative supplier or if possible alternative drugs. Rapid communication of issues and solutions to prescribers and end users. DHSC National Contingency Plans Monitoring & updates via Area Prescribing Committee

Identify single source, EU supply chain medicine lines then ensure stocks of these lines are managed closely. Established by NHSE&I that a number of lines have possible shortfalls. Many of these are due to failures in manufacturing, distribution and unrelated to the EU-Exit scenario. These failures have origins in far East and are non-EU related. Continuous monitoring at

Michael Smith / Richard Semley

Oct 2019

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2

PSNC liaising with government to protect from impacts of supply issues. DHSC monitoring & warning. Ethics Committee to be formed if required Links with CCG & Primary Care established National guidance & meetings attended, agreements in place Close monitoring of stocks, use of ‘Exend’ programme to monitor local stocks Exercise ‘No Deal’ held 4th March 2019 Regional exercise attended 5th September 2019 Operation Wellington re. traffic disruption on eastern road networks. ‘Temperature Check’ with NHSE & I Additional stock and warehousing.

national and local levels. Work continuing with Medicines Management Group. Extension of action plans to flag specific shortages Work ongoing to risk assess specific drug requirements Email updates to clinicians in respect of possible drug shortages.

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3

As Table 2

2. Risk of unlicensed medicine stock outs in Europe and UK when they do. Possibility that export companies’ licenses won’t allow them to export to non-EU countries (UK post exit) leaving us unable to obtain previously available medication. Certain unlicensed imports are classified as controlled drugs which require Home Office approval for importation. This can add weeks to the import process with a higher risk of stock shortages associated with these lines. AMBER

Unable to provide required medication to patients.

3 4 Rational for using these medicines to be examined and identify whether UK licensed alternatives are available (unlikely). Purchase a ‘ring fenced’ stock of these lines Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I Local & regional networks National & regional meetings Actions continuing in relation to ensuring proactive monitoring of supplies of non-licensed products

Additional stock purchased. Continuous monitoring at national and local levels. Continuous monitoring at national and local levels. Work continuing with Medicines Management Group.


Oct 2019

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4

3. Homecare; medication supply for selected BHNFT patients is delegated to a third-party supplier. Their preparedness for EU-Exit is an unknown AMBER.

In the event of a supply failure, patients may have to be repatriated to BHNFT care. Additional pressure on pharmacy resource and pharmacy may not stock the required medication.

3 3 Ethics Committee to be formed if required Links with primary care National & regional guidance, events and meetings Close monitoring of stocks Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I

BHNFT made visits to homecare companies and established 6 weeks stock being held. Monitoring of social care and nursing home provision.


Oct 2019

4. Clinical Trials R&D Income and Performance - Unable to

complete and recruit to studies meaning that service is unable to meet income generation targets in 2019/20

- Unable to procure correct medicines to

Given the way in which R&D is self-funding there could be a situation. Trials could be pulled if the sponsor decides to pull out of UK. Patients who have started on a particular treatment could have it stopped as

3

4

Sponsors (Pharma Companies) responsibility for maintaining business continuity. MHRA will be the regulatory body for CTIMPS, UK organisation. Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I’

Calculating impact on income of studies which are instigated by Europe based companies – circa £60k to £130k.

Andrew Wiles - Business

Manager Emma Goodwin - Head of R&D

Oct 2019

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5

complete clinical trials currently in train

AMBER

a result of EU-Exit (? Side effects)

5. Workforce Capability to provide safe and correct staffing levels AMBER

Trust not able to recruit staff from EU as before EU staff leave organisation at short notice causing staffing issues and impact on patient care Lack of information on where EU staff work in Trust Confusion over application for settled status/pre-settled status Lack of assistance/communication to EU staff causes them to have low

3

4

Regular updates to EU-Exit group on immigration rules. Ensure all EU recruitment completed by 29th March Communication with EU staff on what the rules are on settled status and how to apply Workforce Reports run to identify areas where EU staff work and which staff groups impacted Communication on timescales to EU staff in deal and no deal scenarios Regular updates on developments through Comms team. Direct communication/indirect communication with EU staff so feel valued and informed

Updates from HR on ongoing recruitment and from Medical Staffing HR to liaise with Communication team on promoting timescales and application process HR Workforce team to produce regular workforce composition updates in relation to EU staff HR to inform Comms of updates Legal advice obtained on direct/ indirect communication with EU staff that does not breach GDPR ‘Drop-In’ sessions for staff

Karl Hickman HR

Sept 2019

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6

morale/leave

Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I’ Regular meetings with LA Social Services re. adult social care provision and fragility of market

to be continued and FAQs published for relevant staff. Regular communication with staff Monitoring of settled status applications.

6. Pathology Failure to provide Pathology tests and Blood or Blood Products due to lack or interrupted supply of reagents, consumables and service/repair parts- as a result of lack of supply and transportation issues Failure to transport samples from GP locations to the Trust in the event of a fuel shortage Assurance not received from all suppliers for the

Impact on safety of patients – inadequate treatment Impact on patient experience Delays to treatment/surgery/discharges Cancellation of surgery/treatment Inability to take blood for patients Delay to providing Blood Products and Blood

3

4

Microbiology- Consumables and reagents stock for up to 1 week. Managed service contract in place with Biomeriux. Assurance received for reagents and consumables. Cellular Pathology- Consumables and reagents stock for up to 1 week. Blood Transfusion- Blood products stock for up to 1 month Consumables and reagents stock for up to 6 weeks Blood Sciences- Consumables and reagents stock for up to 6 weeks

Assurance from BFS regarding supply of gas and electricity and waste removal Assurance from procurement for the purchase of consumables Seek assurance from suppliers not included within a managed service contract Seek continuing assurance from NHS Blood Transfusion for their contingency plans Consider stocks of some reagents and consumables based on

Dan Firth, Acting Quality Manager/Dep. BRILS Manager

Sept 2019

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7

supply of reagents and consumables following EU-Exit. Risk Register Entry 2121 AMBER

Components Impact on organisational reputation Financial impact Provision of care and treatment of patients

Managed service contract in place with Siemens. Siemens reviewing possibility of having additional storage units in the UK to stockpile reagents, consumables and spare parts Phlebotomy Consumables stock for up to 1 week Trust Task & Finish Group established Weekly update meetings Resilience Framework for BC response if required Support from NHSE & I, LRF, LHRP & regional procurement team Core compliance framework completed Training for staff – major incidents/Silver Team/Log-Keepers Robust patient flow and management processes

assurance given from suppliers Seek continuing assurance from Courier Logistics regarding business continuity in the event of a fuel shortage Updates from BRILS Business and Service Manager Business continuity document and escalation process in place Attendance at BC-Lite training to review planning.

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8

Government technical notices Adaptive BC Framework & training

7. Business Security Increased organisational EU-Exit pressures impede Trust major incident response capabilities Risk Register Entry 2121 YELLOW

Negative impact on response capabilities Unable to fulfil statutory requirements Impact on organisational reputation Provision of care and treatment of patients

2

3

Task & Finish Group established. Weekly update meetings continuing/ Resilience Framework for BC response if required Support from NHSE & I, LRF, LHRP & regional procurement team Core compliance framework completed CBRNe audit completed Training for staff – major incidents/Silver Team/Log-Keepers Robust patient flow and management processes Government technical notices

Continue with EU-Exit monitoring processes. Test & exercise response Continued BC-Lite training to December 2019 Continuing rollout of BC-Lite Plans to include corporate departments Recent update of Resilience Framework – fully circulated Stakeholder & staff communication FAQ sessions with team briefings Weekly Task & Finish Meetings Continuation of winter planning – attendance at

Mike Lees Head BSU

Sept 2019

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9

Adaptive BC Framework Exercise Escorial – live exercise Peer review of planning during 2018/19 + extensive BC Audit completed Circulation of Operation Yellowhammer report

meetings to brief and update Silver training during October to include EU-Exit required response Operational guidance to be revisited during October. Attendance at further EU-Exit events during October.

8. Demand & Capacity Increases in demand associated with wider impact of EU-Exit no deal i.e. reduction in general H&SC provision and/or EU staff are affected YELLOW

Impact of patient safety Impact on patient experience Possible delays to treatment Impact on Trust reputation Possible financial impact for Trust

3

2

Regular patient flow meetings Local escalation plans in place Demand and surge discussions with local partners Information flow in respect of local H&SC provision Regular winter planning meeting Monitoring of influenza

Continue with EU-Exit monitoring processes. Test & exercise via T&F Group & LHRP OPEL framework & procedures Regular updates to T&F group Continued local monitoring and liaison with LHRP, NHSE & LRF Winter planning meetings

Bob Kirton CDO (AEO)

Sept 2019

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trends and use of recent 2019 Australian data Briefings to staff

continuing

9. Financial Financial Impacts to Trust/BFS YELLOW

Only minor impacts identified across NHS horizon to date. Acknowledged as a possible ‘rising tide’ risk as countdown to no deal EU-Exit continues.

2

3

Task & Finish Group established Weekly update meetings Regular ET & Board updates Robust financial management Government financial updates Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I

Continue with EU-Exit monitoring processes via NHSE&I updates. Test & exercise via T&F Group & LHRP Stakeholder & staff communication Weekly Task & Finish Meetings

Chris Thickett DoF

Sept 2019

10 Equipment, Supplies and Procurement Possibility of stock and supplies shortages and disruption or delays

Unable to provide required medication to

3

3

DHSC National Contingency Plans Monitoring & updates via

Continue with EU-Exit monitoring processes. Test & exercise via T&F

Michael King Head of Procurement

Sept 2019

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11

in supplies AMBER

patients. Delays to patient treatment Trust reputation Pharmacy procurement impacts Financial impact for Trust

regional work group Liaison with government to protect from impacts of supply issues. DHSC monitoring & warning. Links with NHS Supply Chain ‘Working Together’ Group National guidance & advice Close monitoring of stocks Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I On call staff to operate 24/7 for deliveries. Operation Wellington re. traffic disruption on eastern road networks. As Table 2

Group & LHRP Continue updates from national and regional work groups Regular updates to T&F group Continued local monitoring and liaison with LHRP, NHSE & LRF BFS member of national expert working group for EFM. Useful conduit for monitoring catering, cleaning and infrastructure.

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12

11 Fuel Shortages or disruption to fuel supplies. YELLOW

Staff impact issues for travel to and from work Patient treatment cancelled or delayed Community & home visits cancelled Trust heating and power disruption

2

3

Trust Fuel Shortage Plan National Emergency Plan for Fuel (NEP-F) Communication with staff LRF & LHRP guidance and advice Multi-agency planning and support Exercise ‘No Deal’ held 4th March 2019 ‘Temperature Check’ with NHSE & I Operation Wellington re. traffic disruption on eastern road networks to and from Immingham. As Table 2

Continue with EU-Exit monitoring processes. Test & exercise via T&F Group & LHRP National monitoring Regular updates to T&F group Continued local monitoring and liaison with LHRP, NHSE, NHSI & LRF Operation Wellington continued planning

Mike Lees BSU

Sept 2019

12 Public Health Post ‘No Deal’, possible delays in communication around crisis management and

Related to Risk 7 and incident response. Possible direct

2

3

EU-Exit Task & Finish Group established Weekly update meetings

Continue close liaison with BMBC Public Health and Public Health England Regular updates to and

Mike Lees BSU Liaison with IP&C Team

Sept 2019

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13

divergence of procedures in the case of disease outbreak. YELLOW

consequences to acute trusts Negative impact on response capabilities Unable to fulfil statutory requirements Impact on organisational reputation Provision of care and treatment of patients

Resilience Framework for human/animal outbreak response Support from NHSE, LRF, LHRP & regional procurement team Core compliance framework Training for staff – major incidents/Silver Team/Log-Keepers Robust patient flow and management processes Government public health information Exercise Escorial – 2018 Exercise Mohawk – 2018 Exercise Alhambra – 2017/18 Peer review of pandemic planning during 2018

from CCG Stakeholder & staff communication including IP&C FAQ sessions with team briefings Weekly Task & Finish Meetings Continuation of winter planning Update of Resilience Framework

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TABLE 2 – NATIONAL/REGIONAL MITIGATION & CONTROL MEASURES

Medicines Equipment Supplies

• Increased supply channel volumes, primary aim to protect and prioritise the NHS

• General supplies situated upstream • Supplies & Vaccines robustly managed nationally • Dedicated NHS supply channels for time critical supplies • Use of buffer mechanisms to maintain uninterrupted

supplies • National 6 weeks stockpile as a buffer • Transport and air freight arrangements in hand for short

timescale products • Prioritisation of medical supplies – additional shipment

channels • Hull and Immingham ports – access and egress not easy.

Multiagency liaison taking place to ease transport. Trust monitoring Operation Wellington re. traffic disruption.

• 35% more additional stock in place – 40,000 pallets. • National & Regional communication structures in place • Risk assessment scoped against daily, weekly & regional

NHSE&I returns. • Trust/BFS attended all EU-Exit exercises and workshops,

two further events to be attended in October 2019. • BFS member of NHSE & I regional EFM ‘expert’ group

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Rating as per BHNFT/BFS Standard Risk Matrix - Likelihood and Impact Scoring Scales

Overall risk key

Negligible

Minor - G

Moderate - Y

Major - A

Catastrophic - R

IMPACT

L 5 Almost Certain Y A R R R I 4 Likely Y A A R R K 3 Possible G Y A A R E 2 Unlikely G Y Y A A L 1 Rare G G G Y Y I H O O D

1 Negligible

2 Minor

3 Moderate

4 Major

5 Catastrophic

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REPORT TO THE BOARD OF DIRECTORS

REF: BoD: 19/10/03/13

SUBJECT: NHS ENGLAND EPRR CORE STANDARDS FOR 2019/20

3 OCTOBER 2019 PRIVATE & CONFIDENTIAL

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval X Assurance For review Governance X For information Strategy

PREPARED BY: Mike Lees – Head of Business Security

SPONSORED BY: Bob Kirton – EPRR Accountable Emergency Officer (AEO)

PRESENTED BY: Mike Lees – Head of Business Security

STRATEGIC CONTEXT 2-3 sentences

Annually health provider organisations that receive NHS funding must carry out a self-assessment against the NHS England Core Standards for Emergency Preparedness, Resilience & Response (EPRR). This is then reviewed at a full joint meeting of the South Yorkshire Local Health Resilience Partnership (LHRP) attended by the Trust Accountable Emergency Officer and Head of Business Security. The self assessment matrix, statement of compliance including action plan for 2019/20 are attached for information and Board approval. The 2019 ‘Confirm and Challenge’ meeting with NHS England and other South Yorkshire health provider AEOs will take place on 25th November 2019.. The full assurance process for 2019 is for consideration by ET, Trust Board approval in September and submission to NHS England within the requested timeframe of 31st October 2019.

QUESTION(S) ADDRESSED IN THIS REPORT

There are number of minimum standards which the Trust as a provider of NHS funded care must meet. The Accountable Emergency Officer (AEO) of the Trust is responsible for ensuring that the standards are met.

The NHS Core Standards for Emergency Preparedness, Resilience and Response have also been checked against our current compliance and cover the following areas:

Confirmation of a Trust accountable emergency officer (AEO)

Ability to share resources during major incidents

Have plans to set out coordinated arrangements along with response plans for worst case scenarios.

Incident response plans must be in line with published guidance and NHS governance

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SMT:\Board\Templates & Agenda\NHSE Core Standards 2019 Page 2 of 2_

arrangements.

Staff awareness and training alongside command and control arrangements and identified incident room(s).

Robust business continuity arrangements (Barnsley BC-Lite) generally aligned to national guidance

Governance is fully covered within the Resilience Framework and associated policy.

Severe weather and climate adaption deep dive review

Assurance is provided by self-assessment with the assurance framework now a formal control process administered by NHS England. The Trust has already previously taken part in peer reviews of major incident plans along with the provision of a training and exercise schedule.

The self-assessment matrix is attached, and any areas of action are summarised on the titled sheet and to be accepted as enhancements and not remedial.

CONCLUSION AND RECOMMENDATION(S) Following this assessment, the Trust demonstrates a ‘Substantial Compliant’ level.

It is recommended that the self-assessment and compliance statement receive approval by the Board at a public meeting and be forwarded to NHS England for the information of the Local Health Resilience Partnership (LHRP)

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Please select type of organisation: 1 Publishing Approval Reference: 0007191

Core StandardsTotal

standards applicable

Fully compliant

Partially compliant

Non compliant Overall assessment: Fully compliant

Governance 6 6 0 0Duty to risk assess 2 2 0 0Duty to maintain plans 14 13 1 0Command and control 2 2 0 0Training and exercising 3 3 0 0Response 7 7 0 0 Instructions:Warning and informing 3 2 1 0 Step 1: Select the type of organisation from the drop-down at the top of this pageCooperation 4 7 0 0 Step 2: Complete the Self-Assessment RAG in the 'EPRR Core Standards' tabBusiness Continuity 9 9 0 0 Step 3: Complete the Self-Assessment RAG in the 'Deep dive' tabCBRN 14 13 1 0 Step 4: Ambulance providers only: Complete the Self-Assessment in the 'Interoperable capabilities' tabTotal 64 64 3 0 Step 5: Click the 'Produce Action Plan' button below

Deep DiveTotal


Fully compliant

Partially compliant

Non compliant

Severe Weather response 15 13 2 0Long Term adaptation planning 5 5 0 0

Total 20 18 2 0

Interoperable capabilitiesTotal


Fully compliant

Partially compliant

Non compliant

MTFA 28 0 0 0HART 33 0 0 0CBRN 32 0 0 0MassCas 11 0 0 0C2 36 0 0 0JESIP 23 0 0 0Total 163 0 0 0

Acute Providers

Interoperable capabilities: Self-assessment not started

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD/19/10/03/14

SUBJECT: CHAIRMAN’S REPORT DATE: October 2019

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval

Assurance


PREPARED BY: Trevor Lake, Chairman SPONSORED BY: N/A PRESENTED BY: Trevor Lake, Chairman

To report particular events, meetings, publications and decisions that the Chairman would like to bring to the Board’s attention.

This report is a brief summary of key meetings and events attended by the Chairman.

• The Trust continues to perform in line with expectations at this stage of the year with a favourable financial performance to plan.

• The Trust presented its Annual General and Public Members Meeting on 13th September • The Trustees of Barnsley Hospital Charity met in September and noted that the Charity

continues to enjoy the benefits of significant fundraising activity in general.

The Board of Directors is asked to receive and note this report.

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Subject: CHAIRMAN’S REPORT Ref: BoD/19/10/03/14 1. STRATEGIC CONTEXT

1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chairman since the last meeting and a review of any key updates. The items below are not reported in any order of priority.

2. BARNSLEY HOSPITAL POSITION

2.1 The Trust has a favourable financial position against its plan position as at the end of August, period 5 of the new financial year, and continues to deliver it’s CIP against plan.

2.2 The capital programme still remains slightly underspent as at period 5, although not

unusual at this stage of the financial year.

3. COUNCIL OF GOVERNORS

3.1 The Trust welcomed Governors to the Council of Governors Quality sub group on 18th September, the Council of Governors meeting on 12th September and the AGM on 13th September.

3.2 Alongside the standing agenda items of updates from the Lead Governor, Chief

Executive, Chairman and Chairs of the Governors’ sub-groups the Governors received a presentation on the role of external audit and key audit findings for 2018-19 from Mr Gareth Mills of Grant Thornton the external audit Engagement Lead and a proposed draft of the updated membership strategy for review.

3.3 The Governors’ Nominations Committee met on 4th September and recommended the

extension of service of three of the Non-Executive Directors as per the proposal which was subsequently approved by the Council of Governors meeting. It also considered the review report and recommended the proposal regarding Non-Executive Directors’ Remuneration which was also subsequently approved by the Council of Governors meeting.

3.4 The Trust acknowledged Gwyn Morrit and Michelle Bailey standing down as Co-opted

Advisor and Public Governor respectively and thanked them for their service to the Trust and to the Council of Governors.

4. NEWS AND EVENTS:

4.1 In addition to the Trust Board and the Well Led workshop development session with

Board members I attended the Council of Governors, the Nominations Committee , the Quality sub-group, the Trustees meeting and the AGM in September as well as attending several formal, informal and ad-hoc visits and meetings.

4.2 These included visits to Ward 17, Emergency Department, Renal Unit, Pharmacy,

attending the September BFS Board meeting, meeting with UK Engage to review the Governor election process for 2019/2020 and attending the Sepsis Conference at the Trust. I attended a conference call meeting of SYB ICS Acute Chairs in Common Committee and a conference call meeting with NHSI Leadership Academy assessors team.

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4.3 In conjunction with the HR team and the Nomination Committee of the Council of

Governors I chaired both the shortlisting and then the recruitment panel for the Associate Non-Executive Director role and I also chaired the recruitment panel for a Consultant in Otolaryngology (ENT), which was successful in appointing to the role.

4.4 The Chief Executive and I hosted the Barnsley Integrated Care Partnership Group

meeting continuing to develop the local agenda with our partners and other key stakeholders for improving patient care in Barnsley and developing new and innovative ways to reduce A&E demand and to improve our patients discharge process.

5 Barnsley Hospital Charity

5.1 Barnsley Hospital Charity continues to enjoy the benefits of significant fundraising activity in general and is well on the way to achieve the goal of raising the required funds for the Tiny Hearts appeal. At the end of August 2019:

Tiny Heart’s Donations £8,273.90 Other Charity Donations £6,177.66

Tiny Hearts Appeal Total £917,965.78 Tiny Hearts Fund Balance £208,455.91

Trevor Lake, Chairman October 2019

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD/19/10/03/15

SUBJECT: CHIEF EXECUTIVE’S REPORT DATE: OCTOBER 2019

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval

Assurance


PREPARED BY: Dr Richard Jenkins, Chief Executive SPONSORED BY: Dr Richard Jenkins, Chief Executive PRESENTED BY: Dr Richard Jenkins, Chief Executive

To report particular events, meetings publications and decisions that the Chief Executive would like to bring to the Board’s attention.

This report is a brief summary of key meetings and events attended by the Chief Executive.

The Board of Directors is asked to receive and note this report.

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Subject: CHIEF EXECUTIVE’S REPORT Ref: BoD/19/10/03/15 1. STRATEGIC CONTEXT

1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since the last meeting and highlight a number of items of interest. The items below are not reported in any order of priority.

2. BARNSLEY HOSPITAL

2.1 Quarter 2 Place-based review On 11th September, Bob Kirton and I met with Sir Andrew Cash and other ICS

colleagues. There was a detailed discussion of cancer standard delivery in view of the difficulties with achieving these standards in the last few months. A presentation outlined the pathway redesign work done by our cancer teams which will transform the approach taken across the major tumour pathways. For the second half of the meeting, partners from across Barnsley attended and a range of presentations were made outlining some of the excellent work that is going on to improve early diagnosis through to living with and beyond cancer. A letter summarising the review will be received in due course and then shared with the Board.

2.2 Hospital Activity

The peak summer activity has settled somewhat and staffing levels in the Emergency Department are more robust. As a consequence, performance against the emergency care standard has improved over the last month. Our inpatient wards continue to perform well and flex ward beds have been used at times to support higher demand. Overall, activity is above expected across most points of delivery.

2.3 SAFER week 16-20th September

The patient flow team have launched the intensive roll-out of the SAFER care bundle with a daily stand in the Colliers restaurant to promote this. SAFER is a way of working that should improve consistency of care across our wards and help support patients to have a better planned and timely discharge. This will be rolled-out across all medical wards before Christmas.

2.4 World Patient Safety Day 17th September

The Trust celebrated this day with involvement from a wide range of teams. There was extensive social media activity to portray a typical day in the hospital.

2.5 Barnsley Facilities Services (BFS) Board 2.6 Trevor Lake and I attended the BFS Board on 16th September. As BFS is wholly-

owned by BHNFT, it was important for us to observe the functioning of the subsidiary. The meeting was extremely well organised and provided good levels of assurance and challenge.

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2.7 Annual General Meeting (AGM) 13th September The Trust AGM outlined the achievements of our staff during 2018-19 and looked ahead to 2019-20. Staff from maternity services presented a very powerful patient story centred around sepsis in pregnancy.

2.8 Clinical Business Unit (CBU) Showcase 13th September

CBU and corporate teams put together a showcase of the work that each department has delivered or is working on. Each CBU had a stand and attendees rotated around each stand to get a rapid summary of the work being undertaken. The session went very well and I was struck by both the extent and quality of the work. Whilst some of this work fits into stated objectives of the Trust, there was a lot of additional ‘bottom-up’ work that the teams were developing which augurs well for the future.

3. SOUTH YORKSHIRE AND BASSETLAW (SYB) SHADOW INTEGRATED CARE SYSTEM (ICS) ACTIVITIES

3.1 Integrated Care System (ICS)

Attached to this paper is the update from the ICS CEO. Operational and financial performance across the ICS are reviewed through the Finance and Performance Committee. The ICS is required to submit a draft 5 year plan by the end of September and a final plan by 14th November in line with national timescales.

4. PARTNERSHIP WORKING WITH OTHER ORGANISATIONS

4.1 Acute Federation Executive Timeout

I convened a Timeout of the executive teams of the Acute provider trusts in the ICS on 6th September. The hospitals will need to work more closely together over the timescale of the Long Term Plan and so it was important for the executive directors to begin to work more closely and to develop stronger relationships. The day was generally felt to have been very productive and some of the outputs will come through Boards to inform parts of the 5 year plan being produced by the ICS.

5 SUMMARY OF MEETINGS/EVENTS ATTENDED

• On 9th September I chaired the QUIT steering group • I attended a Healthcare Financial Management Association meeting for Chief

Executives on 24th September. • I gave a talk on medical leadership to the British Association of Physicians of Indian

Origin on 14th September. 6 Forthcoming events (as of 25th September)

6.1 Implementation of HASU reconfiguration for Barnsley patients

The final component of the HASU reconfiguration goes live on 1st October. From that date, local people with a stroke will be taken directly to their nearest HASU, which will be Pinderfields Hospital, Doncaster Royal Infirmary or the Royal Hallamshire Hospital, so they can receive urgent best practice treatment. In July, similar changes were made in Rotherham and these went very well. The Barnsley ‘go-live’ has been informed by the Rotherham experience.

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6.2 I will be attending the Barnsley CCG AGM on 26th September.

6.3 Barnsley will host a one day ‘Orthopaedic Collaboration Event’ which I will open on

27th September. This event has been put together by Claire Lawson, Advanced Nurse Practitioner, who has led recent exemplary work to improve care for patients with a broken hip.

6.4 Dan Jarvis, MP for Barnsley Central and Mayor of Sheffield City Region, has arranged

to visit some of our wards on 27th September. Dr Richard Jenkins Chief Executive September 2019

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1

South Yorkshire and Bassetlaw Integrated Care System CEO Report

SOUTH YORKSHIRE AND BASSETLAW INTEGRATED CARE SYSTEM

10 September 2019

Author(s) Andrew Cash, Chief Executive, South Yorkshire and Bassetlaw Integrated Care System

Sponsor

Is your report for Approval / Consideration / Noting

For noting and discussion

Links to the STP (please tick)

Reduce inequalities

Join up health

and care

Invest and grow primary and

community care

Treat the whole person, mental

and physical

Standardise acute hospital

care

Simplify urgent

and emergency

care

Develop our workforce

Use the best technology

Create financial sustainability

Work with patients and the

public to do this

Are there any resource implications (including Financial, Staffing etc)?

N/A

Summary of key issues

This monthly paper from the South Yorkshire and Bassetlaw Chief Executive provides a summary update on the work of the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) for the months of July and August 2019. Recommendations

The SYB Collaborative Partnership Board (CPB) and SYB ICS Health Executive Group (HEG) partners are asked to note the update and Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

Enclosure B

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2

South Yorkshire and Bassetlaw Integrated Care System CEO Report

SOUTH YORKSHIRE AND BASSETLAW

INTEGRATED CARE SYSTEM

10 September 2019 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System for the months of July and August 2019. 2. Summary update for activity during July and August 2019 2.1 Place Reviews The Quarter One reviews to better understand the breadth of work and innovation in services of each of the five Accountable Care Partnerships in South Yorkshire and Bassetlaw ICS are now complete. In the first round, each Partnership focused on good practice and issues where additional support would be helpful. In Bassetlaw, discussions centred on the delivery of children’s services and the support that has been put in place to deliver improvements, such as the children’s integrated commissioning hub, the innovative ‘Take 5’ initiative being rolled out across schools and enhancements to Special Educational Needs and Disabilities (SEND) arrangements. The focus in Barnsley was on the strong overall performance across services in the town, noting some areas of challenge and also the integration work getting underway in the Dearne Valley and the Acorn Unit, RightCare Barnsley and the Flow Management Office at Barnsley Hospital. In Doncaster, there was discussion on progress against performance on areas such as cancer and urgency and emergency as well how healthcare planning is well-embedded in the overall Doncaster Strategic Plan and work to align joint commissioning with the Local Authority is well advanced. As well as a review of performance across services Rotherham, discussions centred on some of the joint initiatives underway, such as the Trauma and Resilience Service set up to support people who have been affected by child sexual exploitation and the nationally recognised Social Prescribing Service led by the voluntary sector. The Sheffield review covered a range of areas including the in-year reduction in the level of delayed transfers of care and the development of an integrated provider management team for “lifespan” mental health services and noted the excellent work underway on employment and health. It also heard about the model of community assets in primary care and some of the operational and financial challenges in the city. In each of the Quarter One review meetings it was clear from the discussions that there is real energy and ambition to integrate care with some tangible examples of excellent practice which we will share across and beyond the ICS. Quarter Two review meetings, which will follow a revised approach following learning from the first round, get underway this month.

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2.2 South Yorkshire and Bassetlaw ICS Review In the last three years we have evolved from a Sustainability and Transformation Partnership in to an Accountable Care System and now one of the first and most advanced Integrated Care Systems in England. Throughout this time we have built on our excellent foundation of working together and started to deliver real and tangible improvements for our population. We have much to celebrate and the work across the System is now captured in a formal Review of our work between 2016 and 2019. I am sharing an advance copy of the Review (see attached) with members to inform our discussions on the System’s response to the NHS Long Term Plan at our meeting on 10th September 2019. This gives a solid foundation for us to build on as we set out the next phase of our ambition and how we will deliver the commitments of the NHS Long term plan and the priorities which are important for South Yorkshire and Bassetlaw. Work has been underway over the summer pulling together our SYB next steps Health and Strategy, coordinated by our cross-system task and finish group and with wide engagement. We will share our first draft of this with our peers across North East and Yorkshire and NHS England and Improvement with a view to publishing our plan at the end of November. 2.3 National and Regional ICS Leaders Update The North East and Yorkshire STP/ICS Leaders Network met in July and in addition to operational performance and feedback from NHS Executive meetings, discussions focused on the capital reduction exercise, the People Plan, Operational Model and EU Exit preparations.At the national STP/ICS Leaders Development event on 18th July, which was led by Dominic Hardy, Director of Primary Care and System Transformation, NHS England and NHS Improvement and Dido Harding, Chair of NHS Improvement there were keynote items from Andy Burnham, Mayor of Greater Manchester and Julian Kelly, Chief Financial Officer, NHS England and NHS Improvement. The session also included breakout discussions on the role of Primary Care Networks and Local Government, Long Term Plan implementation framework, community engagement, system leadership and the new operating model.

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2.4 Capital Update including £57.5 million New Funding for Primary Care South Yorkshire and Bassetlaw Integrated Care System was one of the beneficiaries in the Prime Minister’s £850 million NHS capital spending pledge announcement in August, with primary care across our region awarded £57.5 million of new funding to improve facilities. The £57.5m for South Yorkshire and Bassetlaw is funding for which the South Yorkshire and Bassetlaw Integrated Care System submitted a bid in 2018. Work will now be undertaken, at pace, through the primary care work-stream to update the business case. The successful funding bid included our plans to:

Create integrated services hubs bringing together primary care, community care and social care under one roof in purpose built settings, offering the ability to deal with a wide range of issues affecting local communities in one location

Improve GP practice facilities so that they are able to meet the minimum requirements needed to become a ‘training practice’, which means we will be able to train more primary care staff in South Yorkshire and Bassetlaw

Undertake significant refurbishment and extension of existing primary care facilities so they are flexible and adaptive spaces which allow a wider range of health and wellbeing services to patients

Join up local services and therefore improve the use of digital in primary care In addition there is a further increase in the national capital limit of £1 billion which will allow organisations to revert to their original capital plans if they were funded from the Trusts own income or reserves or where a business case or programme funding has been approved by Department for Health and social Care. The ICS had a meeting with the national team on 15 August to assess our Estates Strategy. We must achieve a ‘good rating’ to access the £57.5m primary and community care capital. An announcement is expected during September. 2.5 Brexit Update for South Yorkshire and Bassetlaw Following publication of the NHS Operational Guidance in December 2018 each NHS organisation has been required to appoint a European Union (EU) Exit Senior Responsible Officer (SRO) who is responsible for the organisation’s planning and preparedness for leaving the EU and is responsible for engaging in wider system level preparedness. The UK is currently scheduled to leave the EU on 31st October 2019 at 23:00hrs (GMT). Over the summer months, organisations have continued to update and revise their plans and to ensure that work on the six key national workstreams remains ongoing within their locality. SROs and their planning teams have been invited to attend a follow up briefing and exercise on 5th September 2019 to receive updates on national planning progress and to test planning assumptions and organisational plans to date. In addition to this, planning for the UK’s departure from the EU has continued with multi-agency partners in the form of fortnightly Strategic Coordination Groups (SCGs) led by the Local Resilience Forum to ensure that both preparedness and response phases are collaboratively led by the system. The SCGs will increase in frequency as we move closer to the current leave date. In March, NHS organisations were asked to provide an update on their current level of preparedness and to provide assurance that the actions detailed in the operational guidance document had been completed or were underway. The assurance level provided by each organisation in March is detailed below. A further assurance process will be conducted at the end September.

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2.8 Mental Health Provider Alliance To enhance closer collaboration and joint working between the four mental health providers that deliver services to the population of South Yorkshire and Bassetlaw, a system wide Mental Health Provider Alliance model is being established. The Alliance will aim to improve integration across specialised and non-specialised care pathways, create opportunities to re-invest resources into local community services that best meet the needs of individuals and complement ‘right-sized’ specialised inpatient provision. The providers involved are; Nottinghamshire Healthcare NHS Foundation Trust, Rotherham, Doncaster and South Humber NHS Foundation Trust, Sheffield Health and Social Care NHS Foundation Trust and the South West Yorkshire Partnership NHS Foundation Trust. 2.9 Acute Providers Advertisements for the Hosted Network clinical leadership and manager posts have closed, with sifting and interviewing taking place over the next six weeks. Trusts have produced first outlines of the work programmes and governance for the Networks, with the final versions being signed off once the new clinical leads are in place. A paper laying out the final recommendations from the Hospital Services Review is being discussed by each CCG Governing Body during August and September. The recommendations focus on building the Hosted Networks for all the Hospital Service Review services, and taking forward further discussions on reconfiguration of paediatrics services and potentially maternity services at Bassetlaw. The acute provider executive teams are holding an all-day Time Out session on 6th September, to agree the direction of travel for collaboration between the acute trusts over the next 3-5 years. As the System develops its contribution to the Long Term Plan, the acute providers will take stock of what has worked best in collaboration so far, identify clinical priorities to focus on for the next few years, and discuss the different approaches to collaboration that are possible as the ICS matures. 2.10 ICS Guiding Coalition and the Long Term Plan We met with our Guiding Coalition on 9th July to build on the work we set in motion three years ago when we came together to develop our Sustainability and Transformation Plan. The event offered partners an opportunity to hear updates on progress against our plans and to consider the key themes within the NHS Long Term Plan, published earlier this year, to inform our refreshed vision and ambition for the South Yorkshire and Bassetlaw Integrated Care System Five Year Plan. Partners’ contributions are crucial in shaping the refreshed plan and feedback from the session is being analysed alongside that from the many conversations we have been having this year with the public, staff and partners. The findings are being used by the team developing the SYB ICS refreshed Five Year Plan. Our next Guiding Coalition is scheduled for the morning of Tuesday 8th October where we will share the findings from the final engagement report and our draft refreshed vision in our Five Year Plan. All feedback will inform the final submission of the Plan on November 15th 2019. Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System Date 3 September 2019

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BoD October 2019: Quarterly Communications update/ p1

EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 19/10/03/17 SUBJECT: QUARTERLY COMMUNICATIONS REPORT DATE: OCTOBER 2019

PURPOSE:



PREPARED BY: Andy Leppard, Digital Communications Specialist SPONSORED BY: Richard Jenkins, Chief Executive PRESENTED BY: Emma Parkes, Director of Marketing & Communications

To provide an update to the Board on the activity of the Trust’s Communications function within the previous quarter.

The report presents actions taken in the previous quarter within the communications and marketing function to build positive perceptions of the Trust internally and externally. The report covers the following areas:

• Strategic communications and engagement • Internal communications • External communications and reputation management • Barnsley Hospital Charity

Actions taken by the Communications function in the last quarter have continued to build a positive reputation for the Trust, with positive proactive media stories being placed during the quarter and ensuring balanced coverage with opportunity to comment on reactive media requests.

The Board is asked to review the content of this report.

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Subject: QUARTERLY COMMUNICATIONS REPORT Ref: BoD:19/10/03/17

1. STRATEGIC CONTEXT

1.1 This report provides the Board with an overview of communications and stakeholder

engagement activity during the previous quarter.

2. STRATEGIC COMMUNICATIONS AND ENGAGEMENT 2.1 The Communications function has continued to protect and enhance the Trust’s

reputation. Positive stories have been proactively placed in the media and factual statements provided where appropriate.

2.3 The Communications function has continued to participate in partnership working on a

wide variety of projects and have contributed to various public health initiatives including our lead role in contributing to developing a smokefree Barnsley.

3. INTERNAL COMMUNICATIONS AND ENGAGEMENT

3.1 Annual Flu Campaign

The Communications function have supported the extensive planning for this year’s influenza vaccination campaign. Assets produced are multiple videos and poster design which feature Barnsley Hospital staff members using the nationally designed campaign artwork. This approach maximises the authority of the messaging while still managing to “make it local”.

3.2 Medway

The Communications team have continued to support the Medway Project team maintain engagement and visibility of their activities throughout the period. A range of themes supporting the project work have been developed, including a “My Medway” series of articles which tell stories of the benefits of change through the lens of individuals with varying roles and levels of involvement with the project.

3.3 NHS Staff Survey

The communications team have proactively supported the launch of the national NHS Staff survey and will continue to do so throughout the duration of the completion window.

3.4 Hospital Hub

The team has been continuing to develop the Hub over the quarter, with a renewed focus on transferring content from the old intranet server. There have been significant improvements to how Team Brief questions and answers are published on the Hub. They are now entirely searchable, available in a single location, and available to read on the Team Brief article each month shorty after the live session. The team continue to add help articles and work with teams to optimise their content.

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The following graph highlights the number of unique news items posted over the quarter:

3.6 Trust Approved Documents The Communications function is involved in a project in partnership with the Risk and Governance team to bring robust governance to all officially approved documents on the hub. The demo produced by the team has been universally praised by everyone who has tested it and the aim is to be able to replace the current Policy Warehouse in Quarter 3 2019-20.

4. EXTERNAL COMMUNICATIONS / EVENTS

4.1 Awareness events and campaigns

The Communications function has supported teams to promote their own initiatives though various “awareness” weeks and days in this period. • Acute kidney Injury (15 July)

The team helped the Critical Care team promote their “AKI Awareness Week”. This was an opportunity to raise the visibility of the team and deliver a new pathway for people with potential Acute Kidney Injuries.

• Organ Donation Week – 2 September

The team delivered a sustained week long media focus, promoting the core messages of: ‘don’t wait, become a donor now’; ‘organ donation is changing to an opt-out system in Spring 2020’; and ‘Share what you want to do with loved ones’. Activity included coverage on two case studies in print media, significant social media activity in alignment with the national campaign hashtag, information throughout the hospital site and a visit to Shafton school with case study Mahmud Nawaz to talk to children about organ donation.

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• World Patient Safety Day (17 September)

The team supported the Patient Safety team to celebrate the inaugural World Patient Safety Day. This was a great success. The team used a “twitter takeover” to launch their own twitter account. Over a 24 hour period they drove lots of engagement with staff and external organisations, telling all about the many activities staff at the hospital do every day to support a safe culture of patient care.

• SAFER Patient Flow Bundle (14 September)

The same week in September the Communications team also supported the Patient Flow Team to launch their SAFER Patient Flow Bundle across the organisation. Twitter was again used to generate maximum awareness and effect and the team report very high levels of awareness and engagement as they toured the hospital during the week.

• Social media information campaigns ran in support of the following national

awareness opportunities: - Missed Medicines Awareness Week 29 July – 2 August - Breastfeeding Awareness Week 5-9 August - World Suicide Prevention Day 10 September (including supporting the

Barnsley Metropolitan Borough Council campaign “AlrightPal”) - Falls Awareness Week this week 23-27 September - Eye Health Week 23-27 September

4.2 Annual General and public Members Meeting (AGPMM) The team managed the production and running of the annual event. The meeting,

attended by a range of staff and stakeholders, provided the Trust with an opportunity to publicly present the annual report and accounts for the previous financial year and hear from our staff and patients.

4.3 Traditional Media Coverage

The Trust has benefitted from significant positive media coverage across the quarter. The Barnsley Chronicle has printed 45 positive articles and statements about the Trust within the quarter, proactively issued by the team. The coverage resulted in an opportunity to view figure of over six million during the period.

These included articles about the clean air and parking, a large case study about an

organ donor as part of our organ donation week campaign, and a story about a patient who we diagnosed and treat for sepsis during her pregnancy. She later provided a more detailed story as the patient story at our AGPMM.

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4.2 Barnsley Hospital News

The last edition (Summer 2019) of Barnsley Hospital News was issued to a circulation of circa 33,000 people. Significant articles included the first public announcement of our Children’s ED project, and a spotlight on Pathology.

4.2 Casualty24/7

The second series of Casualty 24/7 aired on Channel 5 over the summer. Each of the twelve episodes had more than 1 million viewers, taking the top slot for broadcast domestic television in the 9pm Wednesday schedule on may of those occasions. Filming for a third series began in late August with the support of the Emergency Department.

4.3 Social Media

The team have continued to encourage teams to set up their own Twitter accounts and to “work out loud”. This strategy has generated increased engagement and follower growth for the main hospital Twitter account. Followers on Twitter are growing steadily and an increasing number of teams are working with the Communications team for advice around using social media to promote their work and activities. Teams have been supported to establish their own private Facebook groups to support communities of staff, for example, a private group for the “Emerald Team” of community midwives enables them to connect with mum’s to be and parents of newborns.

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5. BARNSLEY HOSPITAL CHARITY

The Tiny Hearts appeal currently stands at a total of £917,965, with the aim of achieving the target of £1million within this financial year. An appeal close down plan has been developed and a proposal to extend the remit of the original appeal with a residual fund to include all babies and children is currently being drawn up. Preliminary discussions have taken place with the Extended Executive Team in August 2019. From this consultation, three potential appeals – breast unit equipment, critical care equipment and a dementia unit have been identified. These are currently being worked into proposals for the next Trustees meeting in December 2019. Work is continuing to develop the role of Volunteers in supporting the Charity. The Volunteers are already well engaged with fundraising and have organised and participated in a series of internal and external events. Further activities they are supporting include taking an incubator into the community for a ‘Tiny Hearts on Tour’ campaign and running seasonal stalls in November and December.

Upcoming events include supporting the first birthday of our Neonatal Unit and World Prematurity day (15 Nov), a Wild at Heart event where participants undertake Bear Grylls style activities (16 Nov) and a Fire and Ice walk where those brave enough walk over hot coals and broken glass (24 Nov).

6. CONCLUSION

6.1 The function has again had a positive quarter, continuing to proactively manage the Trust’s reputation by delivering timely and appropriate messaging to a variety of audiences.

The Trust has benefitted from a large number of positive media stories in the Barnsley Chronicle and wider region. Relationships with the Barnsley Chronicle continue to be positive, with the publication affording the Trust the opportunity to provide comment on all related articles and working in partnership on the publication of the Barnsley Hospital News.

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 19/10/03/18 SUBJECT: INTELLIGENCE REPORT DATE: OCTOBER 2019

PURPOSE:



PREPARED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNICATIONS SPONSORED BY: DR RICHARD JENKINS, CHIEF EXECUTIVE PRESENTED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNICATIONS

To provide a brief overview of NHS Choices reviews and ratings together with information on relative key developments, news and initiatives across the national and regional healthcare landscape which may impact or influence the Trust’s strategic direction.

Summary of content:

• MY NHS/NHS Choices Feedback – September 2019 • Standardisation of National Safety Alerts • National Audit Office (NAO) Annual Audit Proposals • National Freedom to Speak up Month • Sheffield CCG announce new Chair • Virgin Care and an NHS provider secure an £85m joint community services project

The Board of Directors is asked to receive the contents of this report for information.

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Subject: INTELLIGENCE REPORT Ref: BoD: 19/10/03/18

*please note that this is not an exhaustive report, submissions welcome to [email protected] Release Type

Detail Impact/ Action/

My NHS/ NHS Choices

NHS Choices User Rating – 4.5* (5* is Excellent) Feedback First ever visit to A&E At 79 years of age I consider myself to have been lucky not to have had the occasion to visit before. The department was unbelievably busy but the attention and care given by all members of staff was excellent. Kindness and care was given to all that I observed whatever condition they had come with. I was treated until I was able to go home. I had a breathing problem and was told to come back anytime if had the need. I cannot thank the staff enough and the paramedics do a sterling job. Well done Barnsley Hospital you deserve recognition. Grateful thanks to all. Visited in September 2019. Excellent from point of entry to admission Cannot compliment all the staff at A&E enough for how I was dealt with having turned up there with cardiac problems. Fantastic doctor took every precaution and admitted me to the cardiology ward where my friendly and professional care continued from both the night and day shifts. Start to finish all a credit to the NHS. Visited in September 2019. Revelation I was admitted to ward 33 almost immobile with what felt like a major back problem. I was immediately met with lovely compassionate people from the paramedics who picked me up to the many staff on the ward who all cared and tried to make everyone in the ward feel comfortable and they assured me I would get better. Saw some lovely care of the elderly with complex problems and I left feeling much better in myself but also reassured of the professional care given to the most vulnerable. This might not be the most swish hospital in the country but I’d choose it over any other as the staff are second to none. NHS at its best. Thank you. Visited in September 2019.

Potential impact on reputation / All postings responded to / Board to note for information Director of Comms to circulate to staff as appropriate.

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Release Type


National – patient safety

Standardisation of National Safety Alerts All safety alerts issued by national bodies are to be standardised under a single template in an effort to eradicate confusion. The government plans to require all organisations that issue safety alerts to use a single agreed template overseen by the National Patient Safety Alerting Committee. The new national patient safety alerts will be sent to trusts, pharmacies, GP practices and mental health providers with some alerts targeted to specific sectors. Providers will be expected to have in place senior oversight to ensure action is taken on alerts and, under the new system, the Care Quality Commission will be inspecting safety alerts and organisational responses.

Board to note for information. Director of Nursing & Quality and Medical Director to monitor and report

National – audit

National Audit Office (NAO) Annual Audit Proposals The NAO is planning changes to the code auditors must follow when auditing public bodies, including NHS trusts and CCGs, with an increased focus on whether they are achieving value for money and an expectation of clearer and more timely reporting. The plans would require auditors to report on:

• Financial sustainability – “How the body plans and manages its resources to ensure it can continue to deliver its services”

• Governance – “How the body ensures that it makes informed decisions and properly manages its risks and finances”;

• Improving economy, efficiency and effectiveness – “How the body uses information about its costs and performance to improve the way it manages and delivers its services.

In their audit reports for the 2018-19 financial year, 41 foundation trusts had a “material uncertainty” paragraph to draw attention to the going concern disclosure in those financial statements. These trusts comprise 29 per cent of the turnover of England’s FTs. Seventy-eight trusts had a reference to “material uncertainty in relation to [being a] going concern”.

Board to note for information. Director of Finance to monitor and report

National – people

National Freedom to Speak up Month October sees the start of a national campaign by the National Guardian’s Office (NGO), which calls on NHS organisations to increase awareness of how staff can raise concerns at work. Every NHS trust in England has a freedom to speak up guardian who can help staff to speak up. Last year, over 6,700 cases were raised to guardians.

Board to note for information

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Release Type


During the month, NHS organisations will aim to raise awareness of speaking up. Staff can also find out who their organisation’s guardian is on the NGO website. Barnsley Hospital NHS Foundation Trust is actively involved throughout the month. The campaign can be followed on twitter through the hashtag #speakuptome

Regional

Sheffield CCG announce new Chair Sheffield CCG announced the appointment of local GP Terry Hudsen following an election involving the governing body members. Dr Hudsen started his new role on 2 September and took over from Tim Moorhead, who stepped down at the end of August after seven years in the role. Dr Hudsen has worked as a GP in Sheffield for six years and has been a GP member of the governing body since 2017. He is currently GP principal at the University of Sheffield health service.

Board to note for information

Regional

Virgin Care and an NHS provider secure an £85m joint community services project North East Hampshire and Farnham and Surrey Heath clinical commissioning groups (CCG) gave the five-year contract across the two home counties to incumbent providers Frimley Health Foundation Trust and Virgin Care Services Limited. Virgin Care have run the CCGs’ adult community services since 2012. The contract runs from April 2020 until the end of March 2025, with two options to extend for one year.

Board to note for information.

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