agenda - dbth.nhs.uk · we are in the ‘evaluation stage’ of the procurement exercise and expect...

Board of Directors Meeting Held in Public To be held on Tuesday 17 March 2020 at 09:15hrs

in the Fred and Ann Green Board Room, Montagu Hospital

AGENDA

LEAD ACTION TIME / ENC

TIME/MINS

A MEETING BUSINESS 9:15

A1 Apologies for absence SBE Note Verbal

10

A2 Declarations of Interest

SBE Note Verbal

Members of the Board and others present are reminded that they are required to declare any pecuniary or other interests which they have in relation to any business under consideration at the meeting and to withdraw at the appropriate time. Such a declaration may be made under this item or at such time when the interest becomes known. A3 Actions from previous meeting

SBE Review A3

B PRESENTATION

No Presentation

C STRATEGY

9:25

C1 ICS Update

RP Note C1

5

D QUALITY, PERFORMANCE AND SAFETY

09:30

D1 Quality and Performance Report

RJ Note D1

25

D2 COVID‐19 Update RJ Note D2 15

E CAPACITY AND CAPABILITY

10:10

E1 Freedom to Speak Up – Update Paula Hill – Freedom to Speak Up Guardian

KB Note E1 15

E2 Annual Report from the Guardian for Safe Working Jayuant Dugar – ENT Consultant, Surgery and Cancer Division

KB Note E2 10

BREAK

10:35

F FINANCE AND CONTRACT MATTERS

10:50

F1 Finance Report – February 2020 JS Note F1

15

G GOVERNANCE AND RISK 11:05

G1 Chairs Assurance Logs for Board Committees Finance and Performance Committee – 25 Feb 20

NR

Note G1

5

G2 Terms of Reference for Board Committees

‐ Audit and Risk Committee ‐ Finance and Performance Committee ‐ Quality and Effectiveness Committee

SBE Approve G2 5

H INFORMATION ITEMS (To be taken as read)

11:10

H1 Chair and NEDs’ Report

SBE Note H1

5

H2 Chief Executive’s Report

RP Note H2

H3 Minutes of the Finance and Performance Committee – 28 January 2020

NR Note H3

H4

Board Work Plan

SBE Note H4

I OTHER ITEMS

11:15

I1 Minutes of the meeting held on 18 February 2020

SBE Approve I1 5

I2 Any other business (to be agreed with the Chair prior to the meeting)

SBE Note Verbal

I3 Governor questions regarding the business of the meeting (10 minutes)*

SBE Note Verbal 10

I4 Date and time of next meeting: Date: 21 April 2020 Time: 09:15am Venue: Board Room, Doncaster Royal Infirmary

SBE Note

Verbal

I5 Withdrawal of Press and Public

Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

SBE Note Verbal

J MEETING CLOSE

11:30

*Governor Questions The Board of Directors meetings are held in public but they are not ‘public meetings’ and, as such the meetings, will be conducted strictly in line with the above agenda. For Governors in attendance, the agenda provides the opportunity for questions to be received at an appointed time. In respect of this agenda item, the following guidance is provided: • Questions at the meeting must relate to papers being presented on the day. • There is no need for questions to be submitted in advance, although this may mean

that it is not always possible to provide an answer at the meeting. In such cases a response will be provided to the Governor following the meeting and added as a ‘post meeting note’ to the minutes of the meeting.

• Questions will be taken in rotation and limited to one question per Governor, to ensure those wishing to raise questions have equal opportunity, within the limited time available (10 minutes in total).

• Members of the public and Governors are welcome to raise questions at any other time, on any other matter, either verbally or in writing through the Trust Board Office, or through any other Trust contact point.

Suzy Brain England, OBE Chair of the Board

Action notes prepared by: Jeannette Reay Updated: 24/02/2020

Action Log A3

Meeting: Public Board of Directors

Date of latest meeting: 18 February 2020

KEY

Completed On Track

In progress, some issues Issues causing progress to stall/stop

No. Minute No. Action Lead Target Date

Update

1. P19/7/19 Virtual Meetings - The potential to improve the Trust’s systems for streaming and conference calling meetings between the Trust’s three sites would be examined.

KA October 2019

December 2019

March 2020

Update - The initial business case was heard at the Corporate Investment Group (CIG) meeting in November 2019. The advice from the CIG was that the Trust should use a competitive tender process to ensure value for money. We are in the ‘evaluation stage’ of the procurement exercise and expect to confirm the successful bidder by the end of March.

2. P19/11/B1 Freedom to Speak Up – The FTSUG agreed to provide some anonymised case studies to a future Board meeting.

KB March 2020

Complete / Close – Included on agenda for March 2020 Board meeting.

3. P19/12/E1 Workforce Plan - Information on how the local community was involved in workforce planning and recruitment would be provided to future updates for the Board.

KB July 2020

Action notes prepared by: Jeannette Reay Updated: 24/02/2020

4. P20/01/B1 Council Motion on Climate and Biodiversity Emergency - A Board workshop would be planned to further explore Climate Change and Biodiversity – looking at what could be done immediately and what could be done in the future.

KEJ May 2020

5. P20/02/D1 Quality and Performance Report – Information on weekend discharges would be provided to the Finance and Performance Committee.

DP March 2020

Complete / Close – Added to the F&P work plan for reporting in March 2020.

6. P20/02/D1 Quality and Performance Report – Board members would be advised on how to complete their SET training electronically.

JR March 2020

Complete / Close – Colleagues were advised of the electronic option, and how to use, on 24 February 2020. Those preferring to retain the paper methodology would be provided with the SET booklet once it had been updated.

7. P20/02/E2 National Staff Survey Benchmarking Results - The results of the staff survey would be shared with Governors.

JR / KB March 2020

Complete / Close – The results were emailed to Governors on 24 February 2020 and included at the Governor Briefing Session on 3 March 2020.

8. P20/02/H6 Information Items / Board Work Plan - The Board work plan would be updated to include year-end items from finance.

JR / JS March 2020

Complete / Close – The work plan was updated with year-end reporting requirements.

9. P20/02/I3 Governor Questions – Upon invite, future Board guests would be asked to steer clear of the use of acronyms – or be requested to provide an explanation of any included in their presentations.

JR March 2020

Complete / Close – This would be adopted as the standard approach when inviting guest presenters to future meetings.

10. P20/02/I3 Governor Questions – Information on digital transformation would be considered for a future Governor Briefing session.

JR / KA March 2020

Complete / Close – Added to the forward topics plan for Governor Briefing sessions.

Title ICS Update – February 2020

Report to Board of Directors Date 17 March 2020

Author Richard Parker, Chief Executive

Purpose Tick one as appropriate

Decision

Assurance

Information X

Executive summary containing key messages and issues

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 month of February 2020.

Key questions posed by the report

The information is to note.

How this report contributes to the delivery of the strategic objectives

Information in support of partnership working.

How this report impacts on current risks or highlights new risks

Performance metrics – highlighting areas of risk - are included in the dashboards at the end of the report.

Recommendation(s) and next steps

The Board is asked to note the update from the ICS.

C1

1

Chief Executive Report

Collaborative Partnership Board

March 2020

Author(s) Andrew Cash, System Lead

Sponsor

Is your report for Approval / Consideration / Noting

For noting

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 month of February 2020.

Recommendations

The SYB ICS Collaborative Partnership Board (CPB) 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

2

South Yorkshire and Bassetlaw Integrated Care System CEO Report

CHIEF EXECUTIVE REPORT

March 2020

1. Purpose


2. Summary update for activity during February 2020

2.1 Coronavirus (Covid 19)

At the time of writing my report, the Department of Health and Social Care, NHS England and Improvement and Public Health England is still in the first phase of the Government’s response to the coronavirus outbreak; containing the virus. The plan has four phases. Containing the virus, delaying its spread, researching its origins and cure, and finally mitigating the impact should the virus become more widespread.

The UK is extremely well prepared for these types of outbreaks – we are one of the first countries in the world to develop a test for the new virus. Public safety is the top priority and colleagues across the ICS are incredibly busy planning, preparing and acting across their organisations and in local communities to what is a fast moving and unprecedented situation.

2.2 NHS Integrated Care Development Day

I attended a whole-day session on integrated care development with senior colleagues from across the country at the King’s Fund on 27th February. The event also included expert speakers and covered:

The progress to date of ICSs and Sustainability and Transformation Partnerships sincetheir announcement in 2016

Common challenges and success factors in designing and implementing improved caremodels and more collaborative system-wide leadership and governance

How NHS England and NHS Improvement can encourage deeper and broader partnershipduring 2020/21, including moves to a ‘system by default’ operating model

Led by Richard Murray, Chief Executive, The King’s Fund and including NHS England Chair, Lord David Prior, the session was a timely opportunity to reflect on the journey of ICSs so far and to consider how best to approach the challenges ahead with colleagues facing the same issues, risks and opportunities.

2.3 Launch of the South Yorkshire and Bassetlaw Integrated Care System Five Year Plan

Following the collaborative development of the SYB ICS Five Year Plan, we will officially launch the Plan on Tuesday 11th March. While we published the Plan in January, the launch will disseminate and raise greater awareness of it across the partnership and with the wider public. In addition to partners supporting the launch with their own internal communications, there is widespread social media activity planned to drive traffic to the ICS website where people can find out more and read the detail.

3

2.4 Yorkshire Ambulance Service Hub

Yorkshire Ambulance Service’s new Doncaster ambulance station will officially open at the end of March, marking a significant milestone in developments for the Trust.

The station will replace outdated facilities and also introduce a new way of working which is designed to improve quality and performance for patients. Doncaster is the first ‘hub and spoke’ model introduced by the Trust and is where emergency and Patient Transport Service vehicles will be taken to be thoroughly cleaned, re-stocked and for any necessary repairs or maintenance. The work is carried out by a dedicated team, freeing up clinicians to focus their time on patients.

This system is known as Ambulance Vehicle Preparation and is already used in Wakefield, Leeds and Huddersfield. It leads to improved vehicle availability, cleaner vehicles and allows crews to get on the road sooner at the beginning of their shifts. The new model is expected to lead to improved response times for patients, improved infection control and improved conditions

2.5 SYB ICS Shadow Board

The first cohort of the SYB ICS Shadow Board Programme will graduate this month. There are 14 senior colleagues on the Shadow Board, all who are aspiring Directors in System roles from commissioning and provider organisations, regulator and arms’ length bodies. They were nominated by their Chief Executive.

The programme combined learning with the benefits of deep experiential learning as participants prepared and participated in three simulated Board meetings (the Shadow Board). The Shadow Boards ran in alignment with the taught modules for the duration of programme, enabling participants to implement and embed their learning in a safe space and gain experience of what it is like to be a Board or Governing Body member.

One of the purposes of the Shadow Board development was to identify senior talent for the ICS going forward and following graduation, that pipeline is now in place. Participants have fed back that they found the programme worthwhile and feel better prepared to take on Director roles. The next steps for the participants will be determined by them and following their very positive feedback, the ICS will now consider the benefits of running a further cohort later in the year.

2.6 Cardiac Rehabilitation Research

I am delighted to let you know that the ICS is supporting a new research project which aims to increase patient uptake of cardiac rehabilitation programmes as part of the NHS long-term plan. Working together, researchers from Sheffield Hallam and Northumbria Universities, the British Heart Foundation and Sheffield Teaching Hospitals are trying to understand which services patients would prefer to receive and how they would like to receive them.

Currently patients who have had a cardiac event are offered, in most parts of the UK, a ‘one size fits all’ rehabilitation package with only 50% of people taking them up. As set out in the NHS Long Term Plan, we want to increase the uptake from 50% to 85% in the next 10 years and in supporting the project we hope to contribute to making a long lasting difference to the SYB population and the wider UK population.

2.7 Complex Lives

The Complex Lives work that is being led by Chris Marsh from Doncaster Metropolitan Borough Council is the subject of a Co-Design workshop on 26 March 2020 at the Keepmoat Stadium in Doncaster.

At the recent Collaborative Partnership Board, ICS partners agreed a focus on Complex Lives as one of the three shared priorities for joint work between the Health system and Local Authorities (the others being Physical Activity and Social Isolation).

4

The agreed initial focus of the work on Complex Lives is on strengthening the relationship between homelessness/rough sleeping and health services. This will build on the excellent practice that is already under way across South Yorkshire and Bassetlaw, and will seek to go further into sustainable new care models that can respond to the scale and quite unique nature of the issues affecting people locked in a cycle of rough sleeping, addiction, offending behaviour, poor mental and physical health, often underpinned by childhood and adult trauma. As you know there is also a focus on ensuring we can work with and learn from each other across the SYB footprint, recognising that this is clearly a shared and significant challenge in places.

The last update to the CPB outlined the basis of a partnership approach with the Office of the Police and Crime Commissioner (PCC) in South Yorkshire, acknowledging the crucial interdependence of the criminal justice system in this work. We have made further progress on this front and the Violence Reduction Unit at the PCC’s office has agreed to support and help fund the co- design process that we have planned to take this work forward. This partnership will be important at strategic and operational level as the work progresses.

2.8 Performance Scorecard

The attached scorecards show our collective position at February 2020 (using predominantly December 2019 and January 2020 data) as compared with other areas in the North of England and also with the other nine advanced ICSs in the country.

We are now green in four of the ten constitutional standards, having turned red for six week diagnostics and two week cancer breast waits. The four green are a two week cancer waits, 31 day cancer waits, Early Intervention in Psychosis (EIP) and IAPT recovery. Our overall performance as a System, while still below the constitutional standard in four areas, still remains one of the better ICSs in the country.

Also attached is a new ‘on a wall’ view of performance statistics showing system level activity and performance. The purpose is to provide an at a glance view for colleagues less directly involved with some of the key performance measures or those who don’t routinely access reports and dashboards. It is set to print as an A3 poster presentation to be displayed in local offices and can also be used as a high level summary for briefings. This format replaces the Integrated Operational Report (IOR) which we have previously used to produce the monthly summary for my report to the ICS. We will no longer have routine access to statistics for areas outside of the North East and Yorkshire and therefore this will be the new format in my report going forward, including the comparator information about the other three systems in NEY Region.

Finally, at month 10 the Year to Date position is £0.5 million ahead of plan. One organisation is forecasting a deficit against plan and we are looking at how we can offset this with over-performance in other organisations in order to balance as a system. Another provider posted a significant in month and year to date deficit in month 10 and have identified mitigating actions to deliver a balanced position at year end. This has therefore added risks to balance as a system at the year end.

Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System

Date 5 March 2020

This page is intentionally blank

1 | 1 | 1 |

Urgent and Emergency Care

82.9% of people

waited less than four hours to be admitted

or discharged

General Practice Workforce FTE

Cancer

Elective

-4.1% GPs

-3.0% Other direct patient care (Allied Health Professionals)

0.9% Admin staff

-2.4% Nurses

112 patients have

been waiting more than 52 weeks

5.5% of patients

had a diagnostic test within 6 weeks

93.3% of patients

were seen within two weeks of urgent

referral

How are we performing in the North East & Yorkshire?

Mental Health

Learning Disabilities & Autism

5,984 AHCs in Q2

84% of annual

health checks carried out

compared to expected trajectory

609,115 patients are

waiting to be seen by a consultant led service

Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19), LDA (Dec19); OAPs represent Spec Comm patients only; AHCs represent Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.

87.7% of hospital

handover delays were carried out within 30

minutes

56 patients waited

more than 12 hours in A&E from decision to admit to admission

39.9% children and young

people with a mental health

condition accessed community mental

health services

50.9% people

who completed psychological

therapies treatment are now moving to recovery

78.6% of patients

were treated within 62 days

one year cancer survival index

(95% standard) (567,709 planned) (0 tolerance)

(50% standard)

(100% target) (0 tolerance) (1% standard)

(93% standard) (85% standard) (33.3% standard)

(4,286 versus 4,467 plan) (3,088 versus 3,164 plan) (2,326 versus 2,398 plan) (11,357 versus 11,255 plan)

with a learning disability or

autism are reliant on inpatient care

(Q3 plan 305; Q4 CYP 31)

55% (adult) and

70% (children)

Community / post admission

Care and Treatment

Reviews were carried out

(75% adults; 90% children standards) (Q2 trajectory 7,124)

C&NE

71.9% WY&H

73.0%

HC&V

72.1%

(73.3% national)

4.77% people

with depression and/or anxiety

received psychological

therapies

(5.31% target)

23 children

319 adults

(0 tolerance by 2021)

19% of Specialised

Commissioned patients (29 cases) are inappropriate

out of area placements

6,540 bed days

were occupied by patients

inappropriately placed in a hospital

bed out of their area

SY&B

72.2%

(<5% standard)

2 | 2 | 2 | Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19), LDA (Dec19); OAPs represent Spec Comm patients in Dec19 at region level due to low numbers; AHCs represents Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.


83.9% of people


or discharged


Cancer

Elective

-3.5% GPs


1.4% Admin staff

-2.0% Nurses

30 patients have


5.7% of patients


90.2% of patients


referral

How are we performing in Cumbria and the North East?

Mental Health


2,504 AHCs in Q2

90% of annual





87.6% of hospital


minutes

26 patients waited





health services

50.0% people



80.0% of patients



(50% standard)



(1,570 versus 1,627 plan) (1,149 versus 1,172 plan) (795 versus 813 plan) (4,257 versus 4,197 plan)



(Q3 plan adults 127; CYP tbc)

67% (adult) and

67% (children)


Care and Treatment


(Q2 trajectory 2,797)

4.65% people



therapies

(5.31% target)

11 children

133 adults


2,000 bed days





C&NE

71.9%

(73.3% national)

(75% adults; 90% children standards) (<5% standard)

19% of region’s

Specialised Commissioned

patients (29 cases) are inappropriate


3 | 3 | 3 | Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19), LDA (Dec19) OAPs represent Spec Comm patients in Dec19 only at region level due to low numbers; AHCs represents Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.


77.0% of people


or discharged


Cancer

Elective

-5.8% GPs

2.6% Other direct patient care (Allied Health Professionals)

2.6% Admin staff

-2.4% Nurses

26 patients have


14.7% of patients


94.6% of patients


referral

How are we performing in Humber, Coast and Vale?

Mental Health


673 AHCs in Q2

74% of annual





73.7% of hospital


minutes

29 patients waited





health services

53.9% people



71.5% of patients



(50% standard)



(670 versus 711 plan) (527 versus 540 plan) (558 versus 544 plan) (1,919 versus 1,870 plan)




67% (adult) and

0% (children)


Care and Treatment


(Q2 trajectory 912)

5.11% people



therapies

(5.31% target)

2 children

62 adults

(<5% standard)


845 bed days




(73.3% national)


HC&V

72.1%

(75% adults; 90% children standards)

19% of region’s






85.1% of people


or discharged


Cancer

Elective

-1.6% GPs


0.7% Admin staff

0.0% Nurses

1 patients have


1.4% of patients


94.6% of patients


referral

How are we performing in South Yorkshire and Bassetlaw?

Mental Health


908 AHCs in Q2

85% of annual





88.7% of hospital


minutes

1 patients waited





health services

50.0% people



79.7% of patients



(50% standard)







75% (adult) and

N/A (children)


Care and Treatment



4.97% people



therapies

(5.31% target)

3 children

45 adults

(<5% standard)


1,225 bed days




(73.3% national)


SY&B

72.2%


19% of region’s




5 | 5 | 5 | Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19); LDA (Dec19) OAPs represent Spec Comm patients in Dec19 only at region level due to low numbers; AHCs represents Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.


84.2% of people


or discharged


Cancer

Elective

-5.3% GPs


-0.6% Admin staff

-4.3% Nurses

55 patients have


1.6% of patients


95.7% of patients


referral

How are we performing in West Yorkshire and Harrogate?

Mental Health


2,004 AHCs in Q2

85% of annual





96.6% of hospital


minutes

0 patients waited





health services

51.1% people



80.0% of patients



(50% standard)



(1,296 versus 1,368 plan) (882 versus 922 plan) (626 versus 635 plan) (3,263 versus 3,283 plan)



(Q4 plan adult 78; CYP tbc)

40% (adult) and

100% (children)


Care and Treatment



4.66% people



therapies

(5.31% target)

7 children

83 adults


2,470 bed days




(73.3% national)


WY&H

73.0%


19% of region’s




1

Chief Executive Report

Collaborative Partnership Board

March 2020

Author(s) Andrew Cash, System Lead

Sponsor

Is your report for Approval / Consideration / Noting

For noting

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 month of February 2020.

Recommendations

The SYB ICS Collaborative Partnership Board (CPB) partners are asked to note the updateand Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

Enclosure B

C1

2

South Yorkshire and Bassetlaw Integrated Care System CEO Report

CHIEF EXECUTIVE REPORT

March 2020

1. Purpose


2. Summary update for activity during February 2020

2.1 Coronavirus (Covid 19)

At the time of writing my report, the Department of Health and Social Care, NHS England and Improvement and Public Health England is still in the first phase of the Government’s response to the coronavirus outbreak; containing the virus. The plan has four phases. Containing the virus, delaying its spread, researching its origins and cure, and finally mitigating the impact should the virus become more widespread.

The UK is extremely well prepared for these types of outbreaks – we are one of the first countries in the world to develop a test for the new virus. Public safety is the top priority and colleagues across the ICS are incredibly busy planning, preparing and acting across their organisations and in local communities to what is a fast moving and unprecedented situation.

2.2 NHS Integrated Care Development Day

I attended a whole-day session on integrated care development with senior colleagues from across the country at the King’s Fund on 27th February. The event also included expert speakers and covered:

The progress to date of ICSs and Sustainability and Transformation Partnerships sincetheir announcement in 2016

Common challenges and success factors in designing and implementing improved caremodels and more collaborative system-wide leadership and governance

How NHS England and NHS Improvement can encourage deeper and broader partnershipduring 2020/21, including moves to a ‘system by default’ operating model

Led by Richard Murray, Chief Executive, The King’s Fund and including NHS England Chair, Lord David Prior, the session was a timely opportunity to reflect on the journey of ICSs so far and to consider how best to approach the challenges ahead with colleagues facing the same issues, risks and opportunities.

2.3 Launch of the South Yorkshire and Bassetlaw Integrated Care System Five Year Plan

Following the collaborative development of the SYB ICS Five Year Plan, we will officially launch the Plan on Tuesday 11th March. While we published the Plan in January, the launch will disseminate and raise greater awareness of it across the partnership and with the wider public. In addition to partners supporting the launch with their own internal communications, there is widespread social media activity planned to drive traffic to the ICS website where people can find out more and read the detail.

3

2.4 Yorkshire Ambulance Service Hub

Yorkshire Ambulance Service’s new Doncaster ambulance station will officially open at the end of March, marking a significant milestone in developments for the Trust.

The station will replace outdated facilities and also introduce a new way of working which is designed to improve quality and performance for patients. Doncaster is the first ‘hub and spoke’ model introduced by the Trust and is where emergency and Patient Transport Service vehicles will be taken to be thoroughly cleaned, re-stocked and for any necessary repairs or maintenance. The work is carried out by a dedicated team, freeing up clinicians to focus their time on patients.

This system is known as Ambulance Vehicle Preparation and is already used in Wakefield, Leeds and Huddersfield. It leads to improved vehicle availability, cleaner vehicles and allows crews to get on the road sooner at the beginning of their shifts. The new model is expected to lead to improved response times for patients, improved infection control and improved conditions

2.5 SYB ICS Shadow Board

The first cohort of the SYB ICS Shadow Board Programme will graduate this month. There are 14 senior colleagues on the Shadow Board, all who are aspiring Directors in System roles from commissioning and provider organisations, regulator and arms’ length bodies. They were nominated by their Chief Executive.

The programme combined learning with the benefits of deep experiential learning as participants prepared and participated in three simulated Board meetings (the Shadow Board). The Shadow Boards ran in alignment with the taught modules for the duration of programme, enabling participants to implement and embed their learning in a safe space and gain experience of what it is like to be a Board or Governing Body member.

One of the purposes of the Shadow Board development was to identify senior talent for the ICS going forward and following graduation, that pipeline is now in place. Participants have fed back that they found the programme worthwhile and feel better prepared to take on Director roles. The next steps for the participants will be determined by them and following their very positive feedback, the ICS will now consider the benefits of running a further cohort later in the year.

2.6 Cardiac Rehabilitation Research

I am delighted to let you know that the ICS is supporting a new research project which aims to increase patient uptake of cardiac rehabilitation programmes as part of the NHS long-term plan. Working together, researchers from Sheffield Hallam and Northumbria Universities, the British Heart Foundation and Sheffield Teaching Hospitals are trying to understand which services patients would prefer to receive and how they would like to receive them.

Currently patients who have had a cardiac event are offered, in most parts of the UK, a ‘one size fits all’ rehabilitation package with only 50% of people taking them up. As set out in the NHS Long Term Plan, we want to increase the uptake from 50% to 85% in the next 10 years and in supporting the project we hope to contribute to making a long lasting difference to the SYB population and the wider UK population.

2.7 Complex Lives

The Complex Lives work that is being led by Chris Marsh from Doncaster Metropolitan Borough Council is the subject of a Co-Design workshop on 26 March 2020 at the Keepmoat Stadium in Doncaster.

At the recent Collaborative Partnership Board, ICS partners agreed a focus on Complex Lives as one of the three shared priorities for joint work between the Health system and Local Authorities (the others being Physical Activity and Social Isolation).

4

The agreed initial focus of the work on Complex Lives is on strengthening the relationship between homelessness/rough sleeping and health services. This will build on the excellent practice that is already under way across South Yorkshire and Bassetlaw, and will seek to go further into sustainable new care models that can respond to the scale and quite unique nature of the issues affecting people locked in a cycle of rough sleeping, addiction, offending behaviour, poor mental and physical health, often underpinned by childhood and adult trauma. As you know there is also a focus on ensuring we can work with and learn from each other across the SYB footprint, recognising that this is clearly a shared and significant challenge in places.

The last update to the CPB outlined the basis of a partnership approach with the Office of the Police and Crime Commissioner (PCC) in South Yorkshire, acknowledging the crucial interdependence of the criminal justice system in this work. We have made further progress on this front and the Violence Reduction Unit at the PCC’s office has agreed to support and help fund the co- design process that we have planned to take this work forward. This partnership will be important at strategic and operational level as the work progresses.

2.8 Performance Scorecard

The attached scorecards show our collective position at February 2020 (using predominantly December 2019 and January 2020 data) as compared with other areas in the North of England and also with the other nine advanced ICSs in the country.

We are now green in four of the ten constitutional standards, having turned red for six week diagnostics and two week cancer breast waits. The four green are a two week cancer waits, 31 day cancer waits, Early Intervention in Psychosis (EIP) and IAPT recovery. Our overall performance as a System, while still below the constitutional standard in four areas, still remains one of the better ICSs in the country.

Also attached is a new ‘on a wall’ view of performance statistics showing system level activity and performance. The purpose is to provide an at a glance view for colleagues less directly involved with some of the key performance measures or those who don’t routinely access reports and dashboards. It is set to print as an A3 poster presentation to be displayed in local offices and can also be used as a high level summary for briefings. This format replaces the Integrated Operational Report (IOR) which we have previously used to produce the monthly summary for my report to the ICS. We will no longer have routine access to statistics for areas outside of the North East and Yorkshire and therefore this will be the new format in my report going forward, including the comparator information about the other three systems in NEY Region.

Finally, at month 10 the Year to Date position is £0.5 million ahead of plan. One organisation is forecasting a deficit against plan and we are looking at how we can offset this with over-performance in other organisations in order to balance as a system. Another provider posted a significant in month and year to date deficit in month 10 and have identified mitigating actions to deliver a balanced position at year end. This has therefore added risks to balance as a system at the year end.

Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System

Date 5 March 2020

This page is intentionally blank

1 | 1 | 1 |


82.9% of people


or discharged


Cancer

Elective

-4.1% GPs


0.9% Admin staff

-2.4% Nurses

112 patients have


5.5% of patients


93.3% of patients


referral

How are we performing in the North East & Yorkshire?

Mental Health


5,984 AHCs in Q2

84% of annual





Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19), LDA (Dec19); OAPs represent Spec Comm patients only; AHCs represent Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.

87.7% of hospital


minutes

56 patients waited





health services

50.9% people



78.6% of patients




(50% standard)



(4,286 versus 4,467 plan) (3,088 versus 3,164 plan) (2,326 versus 2,398 plan) (11,357 versus 11,255 plan)



(Q3 plan 305; Q4 CYP 31)

55% (adult) and

70% (children)


Care and Treatment


(75% adults; 90% children standards) (Q2 trajectory 7,124)

C&NE

71.9% WY&H

73.0%

HC&V

72.1%

(73.3% national)

4.77% people



therapies

(5.31% target)

23 children

319 adults


19% of Specialised

Commissioned patients (29 cases) are inappropriate


6,540 bed days




SY&B

72.2%

(<5% standard)

2 | 2 | 2 | Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19), LDA (Dec19); OAPs represent Spec Comm patients in Dec19 at region level due to low numbers; AHCs represents Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.


83.9% of people


or discharged


Cancer

Elective

-3.5% GPs


1.4% Admin staff

-2.0% Nurses

30 patients have


5.7% of patients


90.2% of patients


referral

How are we performing in Cumbria and the North East?

Mental Health


2,504 AHCs in Q2

90% of annual





87.6% of hospital


minutes

26 patients waited





health services

50.0% people



80.0% of patients



(50% standard)



(1,570 versus 1,627 plan) (1,149 versus 1,172 plan) (795 versus 813 plan) (4,257 versus 4,197 plan)




67% (adult) and

67% (children)


Care and Treatment



4.65% people



therapies

(5.31% target)

11 children

133 adults


2,000 bed days





C&NE

71.9%

(73.3% national)


19% of region’s






77.0% of people


or discharged


Cancer

Elective

-5.8% GPs

2.6% Other direct patient care (Allied Health Professionals)

2.6% Admin staff

-2.4% Nurses

26 patients have


14.7% of patients


94.6% of patients


referral

How are we performing in Humber, Coast and Vale?

Mental Health


673 AHCs in Q2

74% of annual





73.7% of hospital


minutes

29 patients waited





health services

53.9% people



71.5% of patients



(50% standard)







67% (adult) and

0% (children)


Care and Treatment


(Q2 trajectory 912)

5.11% people



therapies

(5.31% target)

2 children

62 adults

(<5% standard)


845 bed days




(73.3% national)


HC&V

72.1%


19% of region’s






85.1% of people


or discharged


Cancer

Elective

-1.6% GPs


0.7% Admin staff

0.0% Nurses

1 patients have


1.4% of patients


94.6% of patients


referral

How are we performing in South Yorkshire and Bassetlaw?

Mental Health


908 AHCs in Q2

85% of annual





88.7% of hospital


minutes

1 patients waited





health services

50.0% people



79.7% of patients



(50% standard)







75% (adult) and

N/A (children)


Care and Treatment



4.97% people



therapies

(5.31% target)

3 children

45 adults

(<5% standard)


1,225 bed days




(73.3% national)


SY&B

72.2%


19% of region’s




5 | 5 | 5 | Reporting periods: UEC (Jan20), Hospital handovers (Jan20) Data is unpublished for internal management information only. Elective & Cancer (Dec19), Cancer Alliance (2017). MH (Nov19, metrics represent rolling quarters; CYP metric represents 12 month rolling due to low numbers), Workforce (Sep19); LDA (Dec19) OAPs represent Spec Comm patients in Dec19 only at region level due to low numbers; AHCs represents Q2 19/20. Standards or plans are shown in brackets. Data largely shows commissioner based performance, except U&EC.


84.2% of people


or discharged


Cancer

Elective

-5.3% GPs


-0.6% Admin staff

-4.3% Nurses

55 patients have


1.6% of patients


95.7% of patients


referral

How are we performing in West Yorkshire and Harrogate?

Mental Health


2,004 AHCs in Q2

85% of annual





96.6% of hospital


minutes

0 patients waited





health services

51.1% people



80.0% of patients



(50% standard)



(1,296 versus 1,368 plan) (882 versus 922 plan) (626 versus 635 plan) (3,263 versus 3,283 plan)



(Q4 plan adult 78; CYP tbc)

40% (adult) and

100% (children)


Care and Treatment



4.66% people



therapies

(5.31% target)

7 children

83 adults


2,470 bed days




(73.3% national)


WY&H

73.0%


19% of region’s




Title Integrated Performance Report

Report to Trust Board Date 17 March 2020

Author Rebecca Joyce, Chief Operating Officer

Tim Noble, Medical Director

David Purdue, Director of Nursing, Midwifery and AHPs


Decision

Assurance x

Information


This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the main performance area for NHSi compliance for January 2020 including:

Cancer 62 day classic, measured on average quarterly performance

4hr Access, measured on average quarterly performance

18 weeks measured on monthly performance against active waiters, performance measured on the worst performing month in the quarter

Diagnostics performance against key tests

Infection control measures, C Diff and MRSA Bacteraemia The Quality report highlights the ongoing work with Care Groups and external partners to improve patient outcomes and a focus on mortality rates. The report contains a review of 7 day services against the National Standard.

D1


Key Questions for the Board are:

Is the Trust maintaining performance against agreed trajectories with our CCGs and in the context of national standards?

Is the Trust providing a quality service for the patients?

Are NEDs assured that the actions being undertaken to address underperformance and maintain current standards are robust and deliver the agreed improvements?


This report supports all elements of the strategic direction by identifying areas of good practice and areas where the Trust requires improvements to meet our expectations.


F&P6 Failure to achieve compliance with performance and delivery aspects of the Single Oversight Framework, CQC and other regulatory standards F&P15 Commissioner plans do not come to fruition and do not achieve the required levels of acute service reduction F&P5 Failing to address the effects of the agency cap


The Board is asked to consider the report.

Local Target Actual VarianceLocal

TargetActual Variance Target Actual Variance

A&E: Max wait four hours from arrival/admission/transfer/discharge Jan 20 95% 80.2% 81.7% 90.0% 84.8% -5.2% 92.0% 88.46% -3.5% 95.0% 88.3% -6.7%

Max time of 18 weeks from point of referral to treatment- incomplete pathway Jan-20 92% 74.2% 83.7% 90.00% 88.8% -1.2% 92.0% 88.8% -3.2%

Waiting list size (from 1/4/19) - 18 Weeks referral to treatment -Incomplete

PathwaysJan-20 .N/A .N/A .N/A 31,599 29,943 -1656 31,199 29,943 -1256

% waiting less than 6 weeks from referral for a diagnostics test Jan-20 99% 94.6% 95.8% 99.0% 95.4% -3.6% 99.0% 95.4% -3.6% 99.0% 95.4% -3.6%

31 day wait for diagnosis to first treatment- all cancers Dec-19 96.0% 96.4% 96.0% 96.0% 100.0% 4.0% 96.0% 99.7% 3.7% 96.0% 99.6% 3.6%

31 day wait for second or subsequent treatment: surgery Dec-19 94.0% 97.3% 91.6% 94.0% 100.0% 6.0% 94.0% 100.0% 6.0% 94.0% 100.0% 6.0%

31 day wait for second or subsequent treatment: anti cancer drug treatments Dec-19 98.0% 99.8% 99.3% 98.0% 100.0% 2.0% 98.0% 100.0% 2.0% 98.0% 100.0% 2.0%

62 day wait for first treatment from urgent GP referral to treatment Dec-19 85.0% 78.2% 78.0% 84.9% 85.1% 0.2% 85.0% 85.8% 0.8% 85.0% 86.1% 1.1%

62 day wait for first treatment from consultant screening service referral Dec-19 90.0% 85.0% 85.2% 90.0% 88.2% -1.8% 90.0% 86.5% -3.5% 90.0% 87.0% -3.0%

ED Attendances Jan-20 N/A N/A N/A 14320 140716

Daycase Activity - Discharges Jan-20 .N/A .N/A .N/A 4,243 4,334 91 41,556 41,391 (165)

Other Elective Activity - Discharges Jan-20 .N/A .N/A .N/A 679 713 34 6,948 7,342 394

Outpatient new activity (Contracted levels achieved) Jan-20 .N/A .N/A .N/A 11,716 12,344 628 115,486 115,735 249

Outpatient Follow Up activity (Contracted levels achieved) Jan-20 .N/A .N/A .N/A 23,680 25,750 2,070 233,432 237,664 4,232

Ambulance Handovers Breaches -Number waited <= 15 Minutes Jan-20 .N/A .N/A .N/A 78.9% 64.9% -14.0% 67.66%

Ambulance Handovers Breaches -Number waited >15 & <30 Minutes Jan-20 .N/A .N/A .N/A 20.9% 34.2% 13.3% 31.41%

Ambulance Handovers Breaches-Number waited >30 & < 60 Minutes Jan-20 .N/A .N/A .N/A 0.2% 0.7% 0.5% 0.76%

Ambulance Handovers Breaches -Number waited >60 Minutes Jan-20 .N/A .N/A .N/A 0.0% 0.2% 0.2% 0.17%

Proportion of patients scanned within 1 hour of clock start (Trust) Nov-19 48.0% .N/A .N/A 48.0% 48.3% 0.3% 48.0% 47.8% -0.2% 48.0% 48.3% 0.3%

Proportion directly admitted to a stroke unit within 4 hours of clock start Nov-19 75.0% .N/A .N/A 75.0% 67.2% -7.8% 75.0% 56.3% -18.7% 75.0% 55.4% -19.6%

Percentage of eligible (according to RCP Guideline minimum threshold) given

Thrombolysis (Trust)Nov-19 90.0% N/A N/A 90.0% 100.0% 10.0% 90.0% 100.0% 10.0% 100.0% 100.0% 0.0%

CURRENT MONTH YEAR-TO-DATE YEAR END FORECAST

Activity

National

Target

National

Benchmarking

Peer

Benchmarking Category Indicator

Latest

Month

Reported

Cancer

NHSI Compliance

Framework

Stroke

Ambulance

Handover Times

NOTES 2Trend Rating (In

Development)Trend Graph (April 17 - stated month)

Percentage treated by a stroke skilled Early Supported Discharge team Nov-19 40.0% .N/A .N/A 40.0% 83.3% 43.3% 24.0% 78.5% 54.5% 24.0% 78.2% 54.2%

Percentage discharged given a named person to contact after discharge Nov-19 95.0% .N/A .N/A 95.0% 98.1% 3.1% 80.0% 97.3% 17.3% 80.0% 98.6% 18.6%

Cancelled Operations (For non-medical reasons) Jan-20 N/A 1.1% 1.0% 1.7% 0.7% 0.8% 1.2% 0.4% 0.8% 1.3% 0.5%

Cancelled Operations-28 Day Standard Jan-20 .N/A .N/A 0 2 2 0 9 9

Out Patients: DNA Rate Jan-20 7.5% 6.79% .N/A 7.6% 10.0% 2.4% 7.6% 10.3% 2.6% 7.6% 10.2% 2.6%

Out Patients: Hospital Cancellation Rate Jan-20 .N/A .N/A 4.5% 13.6% 9.1% 4.5% 13.7% 9.2% 4.5% 15.8% 11.3%

Theatre Utilisation Jan-20 .N/A .N/A 87.0% 85.1% -1.9% 87.0% 83.9% -3.1% 87.0%

Clinic Utilisation Jan-20 .N/A .N/A 95.0% 88.4% -6.6% 95.0% 89.9% -5.1% 95.0%

Emergency Readmissions within 30 days (PbR Methodology) Dec-19 .N/A .N/A 6.3% 6.4%

Length of Stay (21 Days) - Number of Patients As at 30/01/2020 Jan-20 N/A N/A 71 63 -8 63

Length of Stay (21 Days) - Number of days As at 30/01/2020 Jan-20 N/A N/A 2530 2530

DTOC -Total Delays Dec-19 N/A N/A N/A 314

DTOC - Total Whole Bed Days Dec-19 N/A N/A N/A 21630

DTOC - % Dec-19 2.81% 4.08% 3.0% 1.45% -1.55%

Infection Control C.Diff Jan-20 .N/A .N/A 4 3 -1 37 40 3

Infection Control MRSA Jan-20 .N/A .N/A 0 0 0 0 1 1

HSMR (rolling 12 Months) Sep-19 100 100.0 83.6 -16.4 100.0 98.9 -1.1

HSMR : Non-Elective (rolling 12 Months) Sep-19 100 100.0 98.6 -1.4

HSMR : Elective (rolling 12 Months) Sep-19 100 100.0 112.4 12.4

Never Events Jan-20 0 0 0 0 3 3

Sis Jan-20 7 50

2019-20 Pressure Ulcers Dec-19 56 13 71

2019-20 Pressure Ulcers

(Severe Harm SI)Dec-19 0 23

Safe

Effective

Stroke

Theatres &

Outpatients

N/A

N/A

N/A


(Other)Dec-19 13 48

Falls that result in a serious Fracture Jan-20 0 3

SPECIFIC THEMES :

% of patients achieving Best Practice Tariff Criteria Dec-19 51.0% 50.0% 50.1%

36 hours to surgery Performance Dec-19 52.9% 55.9% 56.4%

72 hours to geriatrician assessment Performance Dec-19 92.2% 90.8% 91.5%

% of patients who underwent a falls assessment Dec-19 98.0% 96.2% 96.6%

% of patients receiving a bone protection medication assessment Dec-19 100.0% 97.2% 97.3%

% who underwent a pre-operative AMTS Assessment (Delirium Assessment) Dec-19 100.0% 96.7% 95.9%

Mortality-Deaths within 30 days of procedure Dec-19 0.0% 6.1% 6.0%

NHS England NHFD Benchmarking

95.70%

95.80%

97.20%

62.10%

Fractured Neck

of Femur

Safe

N/A

N/A

Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust PERFORMANCE EXCEPTION REPORT – January 2020

1

(A) 4hr Access Target

Trust

The 4 hour access target was not met in January 2020 with 84.8% achievement against a target of 95% ‐

in comparison to 90.14% in January 2019. The Trust managed 16106 ED attendances across sites and

streams, during January 2020. This is 1140 more patients than in January 2019, a 7.08% increase. 2450

patients were not treated within 4 hours – this is 974 more than in January 2019. Breach reasons are

outlined below with the main two categories remaining “Review by A&E doctor” and “Medical beds”.

The team has developed a full recovery plan to support the department to get back on track with performance. The key performance issues remain at DRI with better performance at Bassetlaw and Mexborough. The full 4 hour action plan was agreed in September 2019, and key updates for January 2020 include:

∙ All action plans for ED including recovery, organisational development & CQC action plans have

been presented to the Chief Operating Officer during January 2020 & progress will be monitored

through fortnightly ED recovery meetings.

∙ VCF submitted for 2 x replacement consultants to ensure continuation of substantive workforce

– awaiting approval

Doncaster Royal Infirmary

The 4 hour access target was not met in January 2020 with 78.19% achievement against a target of 95%

‐ in comparison to 88.72% in January 2019. DRI managed 9136 ED attendances across streams, during

January 2020. This is 235 less patients than in January 2019 seeing a decrease of 2.5%

In January 2020 18.64% of attendances were streamed from FDASS compared to 14.56% streamed in January 2019


2

Bassetlaw District General Hospital The 4 hour access target was not met in January 2020 with 89.72% achievement against a target of 95%

‐ in comparison to 90.12% in January 2019

BDGH managed 4447 ED attendances across streams during January 2020. This is 205 more patients

than in January 2019 seeing an increase of 4.83%

In January 2020 10.34% of attendances were streamed from FDASS compared to 7.94% streamed in

January 2019.

Due to demand and workforce challenges the introduction of the navigation nurse and early senior

assessment has been delayed until March 2020.

Mexborough Urgent Treatment Centre

The 4 hours access target was met in January 2020 with 100% against a target of 95% in comparison to

100% in January 2019

MUTC managed 2523 attendances during January 2020. This is 1353 more patients than in January 2019

seeing an increase of 86.84% compared to January 2019

Since the commencement of the MUTC in December 2019, the service has seen a 28.31% increase in

attendances within the first month, this includes an increase of 44.17% of paediatric attendances within

the same time frame.

Ambulance Breaches

Month Hospital

Total

Arrivals by

Ambulance

Less Than

15 Minutes

(Includes

15:00:00)

% Less than

15 Minutes

Between

15 & 30

Minutes

% Between

15&30

Minutes

Total Waits 30‐60

Minutes 2019‐20

% Waits 30‐60

Minutes 2019‐20

Total Waits over 60

Minutes 2019‐20

% Waits over 60

Minutes 2019‐20

Longest Wait (Hours

and Minutes) 2019‐

20

Total % Over 30

including all them

over 60 2019‐20

Doncaster Royal

Infirmary 2389 1676 70.15% 693 29.01%14 0.59% 6 0.25% 01:30 0.84%

Bassetlaw Hospital 998 523 52.40% 465 46.59% 9 0.90% 1 0.10% 01:10 1.00%

Trust 3387 2199 64.92% 1158 34.19% 23 0.68% 7 0.21% N/A 0.89%

Jan‐20

A total of 20 patients at DRI and 10 patients at Bassetlaw didn’t achieve the standard of number of patients waiting over 30 minutes for handover. 7 of those patients were over 60 minutes and a root cause analysis has been completed to ensure there was no harm to those patients. Bassetlaw saw an increase of 5.7% in ambulance attendances from January 2019. In addition, resus activity and acuity remain high on the Bassetlaw site, creating a higher dependency in ED. EMAS have confirmed conveyance rates have not increased however skill mix on the ambulance vehicles have changed with an increase in technical staff of duty. Doncaster saw a decrease of 7% of ambulance arrivals from January 2019. Bed availability has impacted on incoming flow, particularly early evening.


3

Although reducing, Doncaster is still experiencing a level of ‘batching’ of patients from YAS, particularly between 16:00 – 18:00. YAS confirmed this continues to be due to an increase in category 2 patients across Doncaster during the day resulting in all crews commencing at 16:00 responding to category 3, 4 & 5 calls simultaneously, which has meant an increased number of crews arriving at once. Although this has significantly improved there are still instances that impact on Ambulance performance. Collaboration between the services to improve the situation will continue.

(B) Referral to Treatment (RTT) The January 2020 position represents an improved position on December 2019 with a performance of 88.8% against a trajectory of 90%. Whilst behind plan, an improvement of 2% has been made in month and is in line with the additional recovery actions planned in January 2020. Diagnosis of January position

A number of specialties performing very strongly and above 95% ‐ Gynaecology, Breast,

Haematology, Paediatrics, Vascular.

Significant improvement in Dermatology, General Medicine, Respiratory, ENT, Care of the

Elderly, now all delivering beyond their trajectories

Steady progress in Ophthalmology, Trauma and Orthopaedics, Cardiology, Diabetes and

Endocrinology, General Surgery – albeit all remain below planned trajectory

A number of specialties not yet showing the required improvement, but with action plans still to

be fully realised with activity starting later in February – Urology, Oral Surgery and

Rheumatology.

Main Risk Areas: ‐ Trauma and Orthopaedics

‐ Ophthalmology

February 2020 Focus

Additional recovery plans by sub speciality requested for all areas of concern

Central Trust Actions:‐

o Protection of elective operating through winter o Additional information reports to enable targeted validation

o Additional validation support to divisions

o Additional booking support from central OP to divisions

Monitoring & Leadership

o Refreshed senior leadership in Surgery & Medicine

o Weekly cabinet meeting with COO, Head of Performance, Head of Information, Surgery

GM, DCOO – Medicine, DCOO – Elective, Head of Management Accounts

o Weekly Performance Meeting with Head of Performance and DCOO – Elective – with

each business manager

o Weekly meetings for “high risk” specialties with COO


4

The following table summarises the position by specialty compared to the national target of 92%

Specialty Under 18 Weeks 18 Weeks + Total Percentage

GENERAL SURGERY 2151 240 2391 90%

UROLOGY 1514 211 1725 87.8%

TRAUMA & ORTHOPAEDICS 5113 964 6077 84.1%

ENT 2515 338 2853 88.2%

OPHTHALMOLOGY 2046 309 2355 86.9%

ORAL SURGERY 1654 287 1941 85.2%

GENERAL MEDICINE 1773 159 1932 91.8%

CARDIOLOGY 1675 217 1892 88.5%

DERMATOLOGY 1738 77 1815 95.8%

RESPIRATORY MEDICINE 902 96 998 90.4%

RHEUMATOLOGY 662 164 826 80.1%

GERIATRIC MEDICINE 209 14 223 93.7%

GYNAECOLOGY 1254 34 1288 97.4%

BREAST SURGERY 292 2 294 99.3%

CLINICAL HAEMATOLOGY 143 4 147 97.3%

DIABETIC MEDICINE 611 86 697 87.7%

MEDICAL OPHTHALMOLOGY 321 20 341 94.1%

NEPHROLOGY 121 8 129 93.8%

ORTHODONTICS 102 3 105 97.1%

PAEDIATRIC CARDIOLOGY 101 8 109 92.7%

PAEDIATRICS 521 13 534 97.6%

PAIN MANAGEMENT 308 14 322 95.7%

PODIATRY 183 15 198 92.4%

UPPER GI SURGERY 76 26 102 74.5%

VASCULAR SURGERY 468 29 497 94.2%

Grand Total 26574 3361 29935 88.8%

Incomplete Pathways January 2020 December 2019

Total (Trust) 29943 30093

% under 18 Weeks (Trust) 88.8% 86.8%

Total (Doncaster CCG) 18077 18215

% under 18 Weeks (Doncaster CCG) 89.3% 87.1%

Total (Bassetlaw CCG) 5938 5949

% under 18 Weeks (Bassetlaw CCG) 89.1% 87.5%


5

A fuller analysis of the position against recovery plan is included in Appendix 1 which covers:

RTT Performance by specialty against trajectory

Waiting List size by specialty against trajectory

40+ week waiters – 2019/20

52 week breaches – 2019/20

Service level commentary highlighting areas of risk / focus

52 Week Breaches During January 2020, the Trust reported 1 x 52 week breach for:‐

ENT – Doncaster CCG

A full breach report has been completed. The patient was not visible on the PTL due to an incorrect clock stop being recorded in the patient pathway. RTT training will mitigate against further similar breaches, however the Trust does acknowledge a continued risk of breaches being identified until the training has been fully rolled out and new practices implemented.

(C) Diagnostics The Diagnostic target was not met for January 2020 with 95.4% achievement against a target of 99%.

Exam Type <6W >=6W Total Performance Longest Breach

(weeks)

MRI 1715 363 2078 82.53% 13

CT 2323 1 2324 99.96% 6

Non‐Obstetric Ultrasound 3156 3 3159 99.91% 7

Barium Enema 0 0 0 ‐

DEXA 147 0 147 100.00% ‐

Audiology 228 9 237 96.20% 11

Echo 203 0 203 100.00% ‐

Nerve Conduction 155 22 177 87.57% 15

Sleep Study 39 0 39 100.00% ‐

Urodynamic 58 29 87 66.67% 35 (incorrect clock stop)

Colonoscopy 261 1 262 99.62% 13

Flexible Sigmoidoscopy 105 0 105 100.00% ‐

Cystoscopy 375 14 389 96.40% 8 (x3)

Gastroscopy 330 0 330 100.00% ‐

Total 9095 442 9537 95.37% 35


6

Performance for the Trust, NHS Doncaster and NHS Bassetlaw is outlined below:

Waiters <6W Waiters >=6W Total Performance

Trust 9095 442 9537 95.37%

NHS Doncaster 5963 348 6311 94.49%

NHS Bassetlaw 2219 51 2270 97.75%

Missed Targets:

MRI – 82.53% ‐ 363 breaches out of 2078 waiters. Service has seen 2 peaks in demand over the last 4 months as demonstrated below – both figures are unprecedented for demand. The Division has provided a full MRI recovery plan

Month September 19 October 19 November 19 December 19 January 2020

Total No of Referrals

1782 2032 1711 1684 2152

Performance 99.58% 99.38% 97.58% 87.82% 82.53%

To demonstrate to source of the referrals, the following tables break down demand per CCG for January 2020 in comparison to the previous 6 months.

Total MRI Referrals

CCG % Change (Jan Vs July‐Dec average)

02X (Doncaster) +18.7%

02Q (Bassetlaw) +29.7%

TOTAL +20.2%

GP MRI Referrals

CCG % Change (Jan Vs July‐Dec average)

02X (Doncaster) +26.4%

02Q (Bassetlaw) +33.2%

TOTAL +25.8%

Audiology – 96.20% ‐9 breaches out of 237 waiters. This is an improvement on last month’s performance. The team continue to monitor capacity and where possible undertake additional activity to manage demand.

Urodynamic – 66.67% ‐29 breaches out of 87 waiters. This is an improved position from last month, however a full performance recovery has not been achieved in January 2020. This was mainly due to the cancellation of multiple sessions in January 2020 due to defective equipment and planned / unplanned absence in the department. The Division has been asked for a further recovery plan.


7

Cystoscopy – 96.4% ‐ 14 breaches out of 389 waiters. This is an improved position from last month. The service reported a significant increase in demand during November & December 2019 which has had an impact on service delivery during January 2020. Demand will be monitored during January 2020.

(D) Cancer Performance December 2019 All nationally reported measures were achieved in Cancer performance for December 2019, with the exception of 62 day screening where we achieved 87.5%. Cancer Performance – December 2019

Standard Target Local Performance

31 Day Classic 96% 100%

31 Day Sub – Surgery 94% 100%

31 Day Sub – Drugs 98% 100%

62 Day – IPT Scenario Split 85% 85.1%

62 Day 50/50 Split 85% 86.4%

62 Day – Local Performance (local measure only) 93.2%

62 Day – Shared Performance only 50/50 Split (local measure only) 38.1%

62 Day Screening 90% 87.5%

62 Day Consultant Upgrades (local measure only) 85% (local) 97.1%

Cancer Performance by Specialty – December 2019

31 Day ‐ Classic

31Day Sub ‐ Surgery

31 Day Sub ‐ Drugs

31 Day Sub ‐ Palliative

62 Day – Classic 50/50 split

62 Day – Day 38 IPT split

62 Day Screening

62 Day Consultant Upgrades

Operational Standard

96% 94% 98% 94% 85% 85% 90%

85% (locally agreed target – no national standard)

Breast 100% 100% 100% 100% 100%

Gynaecology 100% 81.8% 80%

Haematology 100% 100% 87.5% 100%

Head & Neck 0% 0% 0%

Lower GI 100% 78.9% 73.7% 0% 100%

Lung 100% 25% 25% 100%

Skin 100% 100% 100%

Upper GI 100% 88.9% 88.9%

Urological 100% 73.5% 70.6%

Performance 100% 100% 100% 86% 85.1% 87.5% 91.7%


8

Cancer Performance Exceptions – December 2019

CWT Standard

Tumour Group

Performance against standard

High Level View

62 day

(using 6

scenario

data)

Gynaecology 80% 1 Patient – delay to diagnostics (patient choice) H&N 0% 1 patient ‐ IPT late in pathway (RP5 day 56 compounded by outpatient

capacity inadequate (treatment planning) Lower GI 66.7% 4 patients – 1 Complex diagnostic pathway, 2 IPT late in pathway, 1 delay to

diagnostics Urology 80% 4 patients – 1 Health care provider delay resulted in IPT late in pathway, 1

Patient initiated choice, 2 delay to diagnostic tests Lung 28.6% 3 patients – 1 Health care provider delay to diagnostics resulted in IPT late in

pathway, 1 IPT late in pathway, 1 Complex diagnostic pathway lead to IPT

late in pathway

(E) Stroke Performance November 2019 The Direct Admission to Stroke Unit target was not met in November 2019 with 67.2% achievement against a target of 75%. This is an improvement on last month’s performance. The scan within 1 hour target was met in November 2019 with 48.3% against a target of 48%.

Direct Admission within 4 Hours

Bassetlaw CCG

Doncaster CCG

Barnsley CCG

Rotherham CCG

Other CCG Total

Yes 14 22 1 2 0 39No 4 10 0 2 3 19Grand Total 18 32 1 4 3 58Performance 77.8% 68.8% 100.0% 50.0% 0.0% 67.2%

Breach Breakdown

Category Sub Category Total

Organisation Stroke Staff Availability 1

Stroke Unit Bed Availability 2

Pathway

Delay in Transfer from ED 6

Delay ‐ transport BDGH to DRI 3

Delay at CT Scan 0

Clinical

Patient Presentation: secondary / late diagnosis of stroke. 6

Patient Needs 1

Exclude – Hospital Stroke 1

Longest delay for direct admission: 4 days, 20 hours, 59 minutes – ‘no stroke symptoms mentioned at triage, not thought to be stroke in ED, CT head completed but not because of stroke symptoms, initially for RAPT assessment then referred to Stirling Ward. Re‐referred several days later to stroke unit.


9

(F) Cancelled Operations The cancelled operations on the day (for non‐clinical reasons) target was not met in January 2020 with 1.67% achievement against a target of 1%. This equated to 88 operations being cancelled.

CCG Name Apr‐ 19

May‐19

Jun‐ 19

Jul‐ 19

Aug‐19

Sep‐19

Oct‐ 19

Nov‐19

Dec 19

January 20

Year to Date

TRUST 0.83% 0.98% 0.91% 1.47% 0.91% 1.13% 1.63% 1.26% 1.41% 1.67% 1.23%

Of which Theatre Cancellations

0.39% 0.52% 0.59% 0.96% 0.66% 0.66% 0.51% 0.79% 0.93% 0.85% 0.68%

Of which Non‐Theatre Cancellations

0.43% 0.46% 0.32% 0.51% 0.25% 0.47% 1.13% 0.47% 0.49% 0.82% 0.54%

NHS DONCASTER CCG 0.77% 1.11% 1.05% 1.15% 0.92% 1.11% 1.58% 1.25% 1.42% 1.83% 1.22%


0.38% 0.56% 0.65% 0.93% 0.70% 0.68% 0.46% 0.82% 0.81% 1.01% 0.70%


0.38% 0.56% 0.40% 0.23% 0.22% 0.43% 1.12% 0.43% 0.61% 0.81% 0.52%

NHS BASSETLAW CCG 1.02% 0.79% 0.85% 2.53% 1.04% 1.15% 1.91% 0.97% 1.11% 1.57% 1.29%


0.65% 0.44% 0.76% 0.94% 0.66% 0.53% 0.52% 0.62% 1.01% 0.44% 0.65%


0.37% 0.35% 0.09% 1.59% 0.38% 0.62% 1.39% 0.35% 0.10% 1.14% 0.65%

Category Sub Category Total

Non Clinical Cancellations on the Day

Insufficient Time (clinical reasons) 12

No Surgeon (x4 delayed abroad due to weather) 11

Equipment Issues 7

Anaesthetist Sickness 6

No Elective Bed (plans in place for Feb / March 2020 to reduce bed cancellations) 5

No Theatre Staff (plan to block book agency staff going forward to reduce this) 5

No Critical Care Bed / Staff 4

Other Urgent Cases 2

Non‐Theatre Cancellations (further breakdown required) 36

28 Day Cancellations

Month: Site: Spec: TCI Date: 28 Day Breach Date:

New Date: Cancellation Reason: CCG:

Jan 2020 DRI Ophthalmology 16/12/19 14/01/2020 27/01/2020 No Consultant 02X00

Breach Reason Due to sub‐specialisation of procedure only 2 consultants able to undertake – both off due to sickness. Patient was treated on the first day of return of the consultants.

Jan 2020 MMH Pain Management

17/12/19 15/01/2020 28/04/2020 Equipment Failure 02X00

Breach Reason RF machine required broke on the day of appointment. Equipment needed to be fixed before further appointment could be arranged. Equipment fixed 17/02/2020 however staffing not available to offer additional capacity to book in patient before new date.


10

Length of Stay (21 Days) DBTH continues to achieve length of stay targets with 63 patients reported as per the Discharge Patients Tracking List (DPTL) submission on 30th January 2020, against a target of 71 patients, with an average LOS over both sites at 40.1 days – an increase from December 2019.


Appendix 1 Introduction This report explores the performance against the RTT Recovery Plan and some key metrics

underpinning the position

The Trust has implemented a recovery plan to get back to the national 92% standard by the end of

the financial year. In January 2020 the performance was 88.8% against a recovery plan trajectory of

90%. This is a 2% increase from last month. The main drivers of the position were:

A number of specialties performing very strongly and above 95% ‐ Gynaecology, Breast,

Haematology, Paediatrics, Vascular.

Significant improvement in Dermatology, General Medicine, Respiratory, ENT, Care of the

Elderly, now all delivering beyond their trajectories

Steady progress in Ophthalmology, Trauma and Orthopaedics, Cardiology, Diabetes and

Endocrinology, General Surgery – albeit all remain below planned trajectory

A number of specialties not yet showing the required improvement, but with action plans

still to be fully realised with activity starting later in February – Urology, Oral Surgery and

Rheumatology.

Key areas of focus for February 2020 include:

Additional recovery plans by sub speciality requested for all areas of concern

Central Trust Actions:‐

o Protection of elective operating through winter o Additional information reports to enable targeted validation

o Additional validation support to divisions

o Additional booking support from central OP to divisions

Monitoring & Leadership

o Refreshed senior leadership in Surgery & Medicine

o Weekly cabinet meeting with COO, Head of Performance, Head of Information,

Surgery GM, DCOO – Medicine, DCOO – Elective, Head of Management Accounts

o Weekly Performance Meeting with Head of Performance and DCOO – Elective – with

each business manager

o Weekly meetings for “high risk” specialties with COO

RTT & Waiting List – Performance vs Trajectories The following table gives the CCG breakdown for RTT and PTL achievement for January 2020 rated

against recovery trajectories (waiting list trajectories are at Trust level only).

Incomplete Pathways January 2020 December 2019

Total (Trust) 29943 30093

% under 18 Weeks (Trust) 88.8% 86.8%

Total (Doncaster CCG) 18077 18215

% under 18 Weeks (Doncaster CCG) 89.3% 87.1%

Total (Bassetlaw CCG) 5938 5949

% under 18 Weeks (Bassetlaw CCG) 89.1% 87.5%


Appendix 1 The full specialty level table below highlights the current position for RTT achievement and Waiting List size. For January 2020, the RTT recovery trajectory was not achieved (88.8% achievement against a target of 90%). However, the waiting list positon has decreased since last month and the Trust is currently 1664 patients below month end trajectory of 31599

TFCSpecialty

RTT (16

Aug 19 )

RTT

Aug 19

Wg List

Aug 19

RTT

Sept 19

Wg List

Sept 19

RTT

Oct 19

Wg List

Oct 19

RTT

Nov 19

Wg List

Nov 19

RTT

Dec 19

Wg List

Dec 19

RTT

Jan 20

Wg List

Jan 20

RTT

Feb 20

Wg List

Feb 20

RTT

Mar 20

Wg List

Mar 20

Trajectory 100GENERAL SURGERY 84.8% 82.0% 2776 82.0% 2776 82.0% 2776 84.3% 2776 86.6% 2776 88.9% 2776 91.2% 2776 93.7% 2776

Actual 84.8% 2808 85.6% 2741 88.1% 2780 88.2% 2537 88.7% 2399 90.0% 2391

Trajectory 106UPPER GI SURGERY 69.5% 69.5% 130 69.5% 130 73.3% 130 77.0% 130 82.0% 130 87.0% 130 90.0% 130 93.4% 130

Actual 69.5% 82 72.8% 81 78.3% 75 75.5% 102 79.6% 103 74.5% 102

Trajectory 101UROLOGY 82.9% 79.5% 1638 82.9% 1630 84.4% 1622 85.9% 1614 87.4% 1606 88.9% 1598 90.4% 1595 92.4% 1592

Actual 82.9% 1646 83.7% 1688 83.9% 1757 86.4% 1777 87.1% 1759 87.8% 1725

Trajectory 103BREAST SURGERY 97.3% 97.3% 481 97.3% 481 97.3% 481 97.3% 481 97.3% 481 97.3% 481 97.3% 481 98.0% 481

Actual 97.3% 255 97.3% 260 99.4% 324 100.0% 343 100.0% 261 99.3% 294

Trajectory 107VASCULAR SURGERY 90.4% 89.0% 618 89.2% 593 90.1% 568 91.1% 543 92.0% 518 93.0% 493 94.0% 468 95.9% 448

Actual 90.4% 643 93.1% 591 93.0% 564 92.5% 562 91.9% 517 94.2% 497

Trajectory 110

TRAUMA &

ORTHOPAEDICS83.1% 84.3% 6549 84.5% 6452 84.6% 6355 86.2% 6258 87.8% 6161 89.3% 6064 90.9% 5967 92.6% 5868

Actual 83.1% 6646 84.1% 6440 84.3% 6308 84.2% 6158 82.8% 6027 84.1% 6077

Trajectory 320CARDIOLOGY 85.2% 88.5% 2123 88.5% 2102 88.5% 2081 89.5% 2060 90.5% 2039 91.0% 2018 91.5% 1997 92.0% 1977

Actual 85.2% 2144 87.3% 2058 87.6% 2099 87.8% 2027 87.6% 1941 88.5% 1892

Trajectory 120ENT 82.1% 81.2% 3164 80.9% 3164 81.1% 3164 81.3% 3164 81.4% 3164 81.6% 3164 81.8% 3164 82.1% 3164

Actual 82.1% 3147 82.7% 3117 83.9% 3128 83.5% 2980 84.0% 2969 88.2% 2853

Trajectory 130OPHTHALMOLOGY 85.7% 84.5% 3084 85.0% 3035 85.5% 2986 86.0% 2937 87.0% 2888 88.0% 2839 89.0% 2790 90.5% 2742

Actual 85.7% 3133 84.7% 3022 85.8% 3112 85.2% 2685 84.9% 2629 86.9% 2355

Trajectory 140 ORAL SURGERY 89.4% 90.4% 1911 89.8% 1911 90.3% 1911 90.9% 1911 91.4% 1911 91.9% 1911 95.5% 1911 93.4% 1911

Actual 89.4% 1559 89.2% 1714 90.5% 1725 88.3% 1935 85.1% 1927 85.2% 1941

Trajectory 143ORTHODONTICS 91.0% 90.0% 110 91.0% 105 92.0% 100 93.0% 95 94.0% 90 95.5% 85 97.0% 80 98.9% 78

Actual 91.0% 100 91.1% 101 92.5% 70 92.2% 64 93.2% 88 97.1% 105

Trajectory 191

PAIN

MANAGEMENT 97.4% 95.8% 404 96.0% 404 96.2% 404 96.4% 404 96.6% 404 96.8% 404 97.5% 404 98.7% 404

Actual 97.4% 305 95.4% 324 96.1% 294 96.3% 296 96.7% 304 95.7% 322

Trajectory 300GENERAL MEDICINE 78.8% 78.8% 2223 78.8% 2191 81.1% 2159 83.4% 2127 85.7% 2095 88.0% 2063 90.3% 2031 92.7% 2000

Actual 78.8% 2255 79.0% 2144 79.0% 2189 83.1% 2083 86.0% 1950 91.8% 1932

Trajectory 303

CLINICAL

HAEMATOLOGY98.5% 95.2% 215 95.6% 210 96.0% 205 96.4% 200 96.8% 195 97.2% 190 97.6% 185 98.5% 182

Actual 98.5% 194 98.8% 160 96.6% 183 98.1% 162 96.5% 141 97.3% 147

Trajectory 307DIABETIC MEDICINE 82.4% 84.4% 700 84.5% 690 84.6% 680 86.8% 670 89.0% 660 91.2% 650 93.4% 645 96.3% 640

Actual 82.4% 670 85.7% 684 87.8% 730 86.1% 682 84.8% 683 87.7% 697

Trajectory 330DERMATOLOGY 93.5% 93.5% 1954 93.9% 1935 94.2% 1916 94.6% 1897 94.9% 1878 95.3% 1859 95.6% 1840 96.3% 1825

Actual 93.5% 1973 93.3% 1913 93.3% 2439 93.0% 2051 92.3% 1607 95.8% 1815

Trajectory 340

RESPIRATORY

MEDICINE 87.5% 88.4% 1043 87.5% 1015 88.5% 987 89.5% 959 90.5% 931 91.5% 903 92.5% 875 94.0% 854

Actual 87.5% 1071 89.9% 997 89.6% 983 89.1% 973 89.0% 970 90.4% 998

Trajectory 361NEPHROLOGY 98.1% 92.4% 153 92.4% 149 93.3% 145 94.3% 141 95.2% 137 96.1% 133 97.0% 129 98.1% 126

Actual 98.1% 157 96.7% 153 95.5% 136 96.9% 127 97.7% 128 93.8% 129

Trajectory 410RHEUMATOLOGY 78.9% 78.4% 982 78.4% 969 78.5% 956 78.6% 943 78.7% 930 78.8% 917 78.9% 904 79.5% 888

Actual 78.9% 995 79.9% 969 81.2% 964 79.2% 924 78.8% 888 80.1% 826

Trajectory 420PAEDIATRICS 92.9% 93.3% 717 94.0% 717 94.5% 717 95.0% 717 95.5% 717 95.6% 717 95.7% 717 96.0% 717

Actual 92.9% 566 95.5% 558 97.1% 522 95.7% 533 96.3% 520 97.60% 534

Trajectory 321

PAEDIATRIC

CARDIOLOGY 89.0% 89.0% 152 89.0% 152 90.0% 152 91.0% 152 92.0% 152 93.5% 152 95.0% 152 96.6% 152

Actual 89.0% 127 92.2% 141 89.6% 119 93.9% 115 95.9% 121 92.7% 109

Trajectory 653PODIATRY 91.3% 91.3% 228 91.3% 227 91.8% 226 92.2% 225 92.7% 224 93.1% 223 93.6% 221 96.3% 220

Actual 91.3% 229 92.0% 201 93.3% 212 92.2% 192 92.8% 209 92.4% 198

Trajectory 430

GERIATRIC

MEDICINE89.5% 88.1% 235 89.5% 234 89.9% 233 90.3% 232 92.8% 231 94.2% 230 96.6% 227 98.1% 225

Actual 89.5% 237 91.7% 229 89.4% 241 86.3% 227 87.4% 231 93.7% 223

Trajectory 460

MEDICAL

OPHTHALMOLOGY90.6% 85.0% 321 85.0% 321 87.0% 321 90.0% 321 92.0% 321 92.5% 321 93.5% 321 94.3% 321

Actual 90.6% 235 84.5% 193 90.1% 230 94.9% 257 93.7% 284 94.1% 341

Trajectory 502GYNAECOLOGY 95.8% 96.1% 1568 96.2% 1543 96.3% 1518 96.4% 1493 96.5% 1468 96.6% 1443 96.7% 1418 97.3% 1394

Actual 95.8% 1593 96.5% 1592 95.5% 1655 95.8% 1385 95.8% 1328 97.4% 1288

Trajectory TRUST TOTAL 85.7% 86.1% 32609 86.2% 32407 87.1% 32205 88.1% 32003 89.1% 31801 90.0% 31599 91.0% 31397 92.0% 31199

Actual 85.7% 32811 86.4% 32362 87.10% 32277 87.20% 31296 86.80% 30093 88.80% 29935


Appendix 1 40+ week waiters – 2018/19 / 2019/20

The number of 40+ week waiters has decreased since December 2019 and January 2020 saw the second lowest number of 40+ waiters this year with 76 patients in this cohort. With the requirement of weekly ICS submissions to demonstrate all patients at 45+ weeks have a clear plan in place and all mitigating actions are being taken to prevent a 52 week breach, long waiters continue to be tightly managed through a weekly performance meeting with Divisions led by the Head of Performance and Deputy COO and a separate patient level tracking meeting lead by Data Quality. This meeting ensures all long waiters have a plan and the team works to reduce the numbers waiting over 40 weeks. 52 week breaches – 2018/19 / 2019/20

The number of 52 week breaches has decreased significantly this financial year, however, there remains a risk of further “historic“ breaches being identified through validation until the waiting list is entirely “clean” with all patients inputted by staff fully trained on RTT. Training and education is underway. During January 2020, the Trust has reported 1 x 52 week breach for Doncaster CCG for an ENT patient. A full breach report has been completed. The patient was not visible on the PTL due to an incorrect clock stop being recorded in the patient pathway.

Quality & Patient Safety ‐ Executive Summary Board of Directors

February 2020

The data contained with this report reflects performance up to and including: January 2020 (HSMR

period – November 2019)

Safety

Please note: Patient Safety incidents are subject to initial scoping, investigation and conclusion, therefore the

data can sometimes change upon the conclusion of the investigation, once all facts and outcomes are known.

The information and data provided in the BIR are accurate at the month end.

In July 2019, NHS improvement changed the definition of Patient safety to be about maximising the

things that go right and minimising the things that go wrong. It is integral to the NHS' definition of

quality in healthcare, alongside effectiveness and patient experience.

At DBTH, Patient Safety incidents are subject to initial scoping, investigation and conclusion,

therefore the data can sometimes change upon the conclusion of the investigation, once all facts

and outcomes are known. The information and data provided in the BIR are accurate at the month

end.

Serious Incidents There have been 21 Serious Incidents reported as Care Issues, year to date including four Never

Events. Two of these Serious Incidents are being investigated by the Healthcare Safety Investigation

Branch (HSIB). There is a further third incident being investigated by HSIB but this doesn’t meet the

threshold for a Serious Incident.

Two new Serious Incidents for care issues were reported in February 2020. These are a Never event, where insulin was withdrawn from a pen device and the patient received an accidental overdose of insulin. The second incident was when a patient had a central venous line wrongly sited in the carotid artery. Both incidents are being investigated with patients and staff being supported through the process. Falls There have been a total of 49 falls with moderate or severe harm to patient’s this year. Four cases

were escalated as a Serious Incident due to the significance of harm suffered by the patient and the

lapse in the care we provided. In February 2020 there were 2 falls resulting in severe harm and 1 fall

resulting in moderate harm, which are being investigated using the Trust Multi‐disciplinary Inpatient

Falls Investigation Tool (MiFIT).

Work continues with the new falls accreditation, which was introduced on 1 April this year. This

focuses on the proactive work the inpatient areas can do to reduce falls (audit, education and falls

link champions training). End of year accreditation will be shared at the planned celebration event

on 27 May.

Learning from falls will be the focus in the March Sharing How We Care Newsletter. This will include

all the relevant points covered in the revised Royal College of Physicians National Audit of Inpatient

Falls (2019).

Hospital Acquired Pressure Ulcers There have been 82 hospital acquired pressure ulcers (HAPU), Category 2 and above this year to

date. Of these cases, 27 were escalated as a Serious Incident due to the harm and lapse in the care

we provided. The main theme from the Pressure Ulcers was availability of equipment. Following a

successful business case, static mattresses and chairs have now been replaced in the Trust, with 150

additional dynamic mattresses on loan for 3 months. The business case for the purchasing of the

dynamic mattresses has now been approved, which has reduced the amount of patients waiting for

the equipment. On 20 February 2020, there were no patients on the waiting list for a dynamic

mattress.

The Trust previously had an internal dashboard system to report HAPU to the skin integrity team and

a large scale piece of work to integrate the dashboard into datix‐web completed mid‐December,

with further modifications continuing to ensure consistency in reporting and avoid duplication for

clinical areas. This has resulted in a rise in incidents being reported, but is in line with the NHS

improvement recommendations around reporting of HAPU.

Work is continuing with the new skin integrity accreditation, which was introduced on 1 April this

year. This focuses on the proactive work the inpatient areas can do to reduce HAPU (audit,

education and champions training). Additional dates have been provided to meet the demand for

training.

Mapping event took place with the CCG and senior nursing team on 29 January, concluding in

proposed changes in the reporting and investigating of HAPU. This will put the Trust in alignment

with the NHSi patient safety strategy and NHSi pressure ulcer prevention strategy. The paper was

approved by the Clinical Governance Committee on 21 February 2020 and will be presented to the

Acute Clinical Quality Review Group on 10 March 2020.

Infection Prevention and Control

Clostridium difficile There have been 42 cases of Clostridium difficile with 29 cases hospital onset, hospital acquired

(HOHA) and 13 cases community onset, hospital acquired (COHA). There have been no lapses in care

identified from the patients. All antibiotic prescribing has been appropriate.

Learning is also included in the IPC memo sent to all Trust staff, which has highlighted that known

patients with CDiff are being tested when they do not have symptoms. A process has been agreed

that only registered nurses can agree to sample. The functionality of ICE is being reviewed to ensure

only appropriate samples are tested.

The deep clean annual plan has been agreed and the process to ensure beds are available for

cleaning to take place.

MRSA bacteraemia There was one case of MRSA bacteraemia in October 2019, with no lapse in the care of the patient identified. MRSA Colonisation There have been 12 cases of MRSA colonisation year to date.

Patient Experience

There have been 448 formal complaints, year to date (1st April 2019‐ 28th February 2020). 48 formal

complaints were received so far in February which is at the high end of normal variation. The top

themes from the formal complaints were treatment, staff attitude and behaviour and diagnosis

which are monitored through the patient experience and engagement committee (PEEC).

There are 49/146 complaints are overdue at the time of writing. In response to the overdue

complaints, the whole complaints process was mapped in November 2019. Further work to improve

the process has continued with a third date held in January 2020. The new process will launch in

April 2020 and is hoped to improve the current overdue complaint response position. The PALS

team are trialling a new RAG (Red, Amber, Green) rating system which will be pivotal to the new

process.

The Friends and Family Test (FFT), is due to relaunched nationally from 1st April 2020. Work has

continued on developing the new FFT card to allow better feedback about care. Posters promoting

FFT have been approved at PEEC in February, and will be circulated accordingly. PALS team will be

collating FFT data from April 2020, and will be focussing on both the quantitative and qualitative

aspects of the data.

Social media comments will be included in the monthly patient experience report from March, the

Head of Patient Safety and Experience has been working closely with the Communications team

helping to further triangulate the patient experience data.

Welcome boards for all adult areas, helping to communicate information to patients and their

families were completed across adult wards in September 2020. The paediatric welcome boards

have now been completed and will be put into place, once the fire‐works in the children’s hospital is

complete. Work is ongoing on the maternity and emergency department boards.

Sharing How We Care for You bedside information continues to be promoted to help guide patients

and families on the key messages of what they need to know. Since this work was completed,

complaints about communication are no longer in the top three themes.

Mr Sewa Singh ‐ Medical Director

David Purdue ‐ Deputy CEO/DoNMAHP

2016 2017 2018 2019

January 116.80 99.21 94.86 106.54

February 99.94 97.73 105.44 97.97

March 90.54 97.37 88.42 101.62

April 105.91 88.50 98.90 101.36

May 101.15 96.60 92.08 93.49

June 80.27 93.67 90.32 99.97

July 92.56 97.73 107.78 106.56

August 100.27 87.52 95.03 113.43

September 90.26 95.34 90.42 84.56

October 90.29 88.66 97.08 102.64

November 88.98 82.30 99.42 88.78

December 82.30 93.52 80.68

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20

Trust 1.47% 1.62% 1.36% 1.20% 1.28% 1.49% 1.12% 1.49% 1.26% 1.91% 1.93% 1.44%

DRI 1.55% 1.62% 1.36% 1.14% 1.30% 1.60% 1.15% 1.32% 1.22% 2.04% 1.89% 1.26%

BDGH 1.51% 1.91% 1.65% 1.61% 1.43% 1.36% 1.20% 2.36% 1.64% 1.71% 2.42% 1.57%

HSMR Trend (monthly) Crude Mortality (monthly) - Feb 2020 (Month 11)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) - November 2019 (Month 8)

Overall HSMR (Rolling 12 months) HSMR - Non-elective Admission (Rolling 12 months) HSMR - Elective Admission (Rolling 12 months)

98.06

90

92

94

96

98

100

Jan

18

- D

ec 1

8

Feb

18

- J

an 1

9

Mar

18

- F

eb 1

9

Ap

r 1

8 -

Mar

19

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

97.98

90

92

94

96

98

100

Jan

18

- D

ec 1

8

Feb

18

- J

an 1

9

Mar

18

- F

eb 1

9

Ap

r 1

8 -

Mar

19

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

104.64

40

50

60

70

80

90

100

110

120

Jan

18

- D

ec 1

8

Feb

18

- J

an 1

9

Mar

18

- F

eb 1

9

Ap

r 1

8 -

Mar

19

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Crude Mortality(Trust)

0.5%

2.5%

4.5%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Crude Mortality(BDGH)

1.0%

1.5%

2.0%

2.5%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Crude Mortality(DRI)

Current YTD reported SI's (April-Feb 20) 55 51

Current YTD delogged SI's (April-Feb 20) 5 6

Serious Incidents - Feb 2020 (Month 11)(Data accurate as at 05/03/2020)

Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed.

Overall Serious Incidents

Number reported SI's (Apr-Feb 19)

Number delogged SI's (Apr-Feb 19)

Themes

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Pressure Ulcers - Cat 3 & 4 (HAPU) per 1000 occupied bed days

0.000.020.04

0.06

0.080.100.12

0.140.16

0.180.20

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Care Issues per 1000 occupied bed days

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/19

Dec

/19

Jan

/20

Feb

/20

Serious Falls per 1000 occupied bed days

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days

Reported Si's per 1000 occupied bed days - Previous years performance

0

2

4

6

8

10

12

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Number Serious Incidents Reported(Trust & Divisions)

Clinical Speciality Services Medicine

Surgery & Cancer Children & Families

Number Reported SI's Number Reported SI's - Previous years performance

Standard Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD

2019-20 Infection Control - C-diff 44 Full Year 9 11 17 3 2 5 42 HOHA 7 7 12 1 2 3 29

2018-19 Infection Control - C-diff 39 Full Year 6 2 7 5 0 5 20 COHA 2 4 5 2 0 2 13

2019-20 Trust Attributable 12 0 0 0 0 0 0 0

2018-19 Trust Attributable 12 0 0 1 0 0 0 1

Standard Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD

2019-20 Serious Falls 6 Full Year 3 0 0 0 1 1 4

2018-19 Serious Falls 10 Full Year 1 1 3 1 0 1 6

Standard Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD

2019-20 Pressure Ulcers 56 Full Year 18 20 34 7 9 16 54


(Severe Harm SI)9 6 11 0 0 0 15


(Other)9 14 23 7 9 16 39

Infection Control C.Diff - Feb 2020 (Month 11)

(Data accurate as at 5/03/2020)

Pressure Ulcers & Falls that result in a serious fracture - Feb 2020 (Month 11)

(Data accurate as at 05/03/2020)

Please note: At the time of producing this report the number of serious falls reported are prior to the RCA

process being completed.

Please note: At the time of producing this report there are 17 PU's

awaiting RCA

0

10

20

30

40

50

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

C-diff

2019-20 C-diff Cumulative total 2019-20 CoHa Cumulative Total 2019-20 HoHa Cumulative Total

2018-19 C-diff Cumulative total Standard

0

2

4

6

8

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Falls that result in a serious fracture

2019-20 Falls Cumulative Total 2018-19 Falls Cumulative Total

Standard

0

5

10

15

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Trust Attributable C-diff

2019-20 Trust Attributable Cumulative Total

2018-19 Trust Attributable Cumulative Total

Month

`

3

1

0

0

3

0

4

3

0

0

0

2

2

4

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

2019/20 4 4 11 7 8 9 4 4 5 5 3 64

2018/19 10 7 9 6 7 13 11 4 10 6 4 3 90

2019/20 5 4 1 4 0 2 5 3 1 1 3 29

2018/19 2 6 1 1 7 1 2 0 2 3 9 2 36

Number referred for

investigation

YTD

Outcomes

YTD

Complaints & Claims - Feb 2020 (Month 11)Data accurate as at 05/03/2020

Complaints

Complaints - Resolution Perfomance (% achieved resolution within timescales)

Complaints Closed - OutcomeParliamentary Health Service Ombusdman (PHSO)

Number of cases referred

for investigationNumber Currently Outstanding

Feb-20 0 4

Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current investigations that have not gone over

deadlines are excluded data.

2017/18 7

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Not Investigated

Outstanding

2018/19 9

Fully / Partially Upheld

Not Upheld

No further Investigation

Not Investigated

Case Withdrawn

Outstanding

4Not Upheld

Outstanding

Claims

Clinical Negligence Scheme for Trusts (CNST) Not including

Disclosures

Liabilities to Third Parties Scheme (LTPS)

Please note: At the time of producing this report the number of claims reported are provisional and prior to validation

2019/20

February 2020Complaints Received

Risk Breakdown

20 Working Days

40 Working Days

90 Working Days

Year to DateComplaints Received

Risk Breakdown

0

10

20

30

40

50

60

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Complaints Received

Complaints Mean UCL LCL

0

10

20

30

40

50

60

70

80

90

100

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Concerns Received

Concerns Mean UCL LCL

30%40%50%60%70%80%90%

100%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Complaints Resolution Performance

0.00

0.20

0.40

0.60

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Number of CNST Claims per 1000 Occupied bed days

Claims per 1000 occupied bed days Claims per 1000 occupied bed days - Previous years performance

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20

Complaints Upheld 7 4 8 6 8 4 4 8 3 5 7

Complaints Partially upheld 21 31 23 14 24 14 24 14 13 13 16

Complaints not upheld 4 5 19 2 12 10 9 7 4 12 8

Outcome not reported 14 6 0 0 0 0 0 0 5 5 11

0

5

10

15

20

25

30

35

Act

ual

Nu

mb

er

Closed Complaints - Outcomes


Number of complaints received - 2019/20 6 1 1 0 1 2 1 1 0 4 1 18

Number of complaints received - 2018/19 5 3 3 2 3 1 3 1 0 0 1 2 24

Diagnosis 7Staff attitude & behaviour 6

Communication 6

Competence 4Nursing - ADL 3Diagnostic Tests 2Medication 2

Hospital Environment 2

Treatment 4

Admissions/transfers/discharge procedure/sleeper out 1Other 1Patient equality, diversity and safety 1Nutrition & Hydration 1Medical records 1Complaint Handling 1Nursing - Continence 1Pain Management 1


Number of Datix Incidents Reported - 2019/20 33 29 35 33 29 33 36 38 27 24 35 352

Number of Datix Incidents Reported - 2018/19 25 31 42 34 27 27 25 52 34 26 32 34 389


Number of Serious Incidents Reported - 2019/20(including de-logged)

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

Number of Serious Incidents Reported - 2018/19(including de-logged)

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

Datix Incidents & Serious Incidents Duty Of Candour (Doc)

Childrens & Young People - Quality Metrics

Feb 2020 (Month 11)(Data accurate as at 5/3/2020)

Complaints

Thematic breakdown (Apr 19 - Feb 2020)

The main complaint theme is “Diagnosis” (15.91%), which breaks down to:

• Missed diagnosis (4)

• Time taken to make a diagnosis (1)

• Alleged wrong diagnosis (1)

• Disagreement between professions/organisations (1)

The second main complaint theme is around “Staff Attitude and Behaviour” (13.64 %)

• Abruptness/rudeness (1)

• Staff conduct / disposition (1)

• Inappropriate comments/staff calling patient by an inappropriate name (1)

• Insensitive to patient needs (2)

• Allegation of rough handling of patient (1).

Please note that a direct correlation between the number of complaints received and the subjects within thematic breakdown can not been made as most of the complaints have more

than one subject noted.

There have been 4 incidents within Children and Young Persons which have triggered Duty of

Candour to be completed. This was reported and the Verbal discussion completed in 75% of

cases (3/4), and Letter 1 in 50% of the records (2 out of 4). Letter 2 has been completed on

both of the closed records (100%).

Please note: An incident which has caused moderate, severe or patient death requires DoC to be completed

0

5

10

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Accident & Emergency

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

Friends & Family - Feb 2020 (Month 11)(Data accurate as at 11/03/2020)

InpatientsPlease note: At the time of producing this report no further benchmarking data is available from NHS England.

0%5%

10%15%20%25%30%35%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Response Rates (%)

Trust Rate NHS England Yorkshire & the Humber

0.930.940.950.960.970.980.99

1

Jan

/19

Feb

/19

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Likely to recommend (%)


0%

2%

4%

6%

8%

10%

12%

14%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

De

c/1

9

Jan

/20

Feb

/20

Response Rates (%)


0

0.2

0.4

0.6

0.8

1

1.2

Jan

/19

Feb

/19

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Likely to recommend (%)


Executive summary - Workforce January 2020 (Month 10)

Sickness absence January's sickness absence figure has reduced to 4.97% following a rise last month to 5.06% which back to a similar level as the same period last year with the cumulative figure now being 4.61%. The seasonal increase in short term absence has occurred with a reduction in the proportion of long term absences.

AppraisalsThe annual appraisal figure remains around 85% compliance as at the end of January. Children and Family Division and Estates and Facilities have both improved their appraisal rates with all corporate directorates being above 90% compliance.

SET SET compliance remains at a high level, now at 87.03% as at the end of January 2020 which continues to demonstrate excellent progress.with all corporate directorates being above 90% and all Divisions being above 82%. More detailed reports are shared at QEC and WERC.

CG & Directorate Sickness Absence - January 2020 (Q4)

RAG: Below Trust Rate - Above Target - Above Trust Rate

Abs Rate = 4.97% LT Abs Rate = 2.98

Days Lost = 7871.568,561.60

Sickness Absence Occurences

0%

1%

2%

3%

4%

5%

6%

7%

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

Target - 3.50% % 18/190

5

10


Over 12 mths12 Months+ 18/19

0

10

20

30


Over 6 Months6 Months+ 18/19

0

100

200

300


Over 28 Days28Days - 6mths 18/19

100

200

300


BF +1000BF +1000 18/19

Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate

Doncaster & Bassetlaw Teaching Hospitals NHS FT 7472.02 4.59% 7048.71 4.19% 6,804.81 4.18% 7,191.30 4.28% 7,049.72 4.21% 6,866.74 4.26% 7,473.28 4.43% 7,702.49 4.62% 8,698.46 5.06% 8,561.60 4.97% 77,149.90 4.61%

Chief Executive Directorate 0.00 0.00% 0.00 0.00% 3.00 0.57% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.83 0.15% 0.00 0.00% 0.00 0.00% 0.00 0.00% 46.00 0.83%

Children & Families Division 1071.72 6.17% 760.56 4.22% 859.39 4.93% 903.82 5.02% 972.57 5.48% 1,006.19 5.93% 964.19 5.33% 947.34 5.23% 1,063.47 5.66% 1,036.79 5.58% 10,297.48 5.75%

Clinical Specialist Division 2022.81 4.88% 2007.09 4.62% 1,703.88 4.04% 1,848.87 4.25% 1,666.38 3.83% 1,631.24 3.87% 2,040.47 4.62% 2,035.15 4.66% 2,216.97 4.92% 2,081.51 4.61% 19,647.84 4.51%

Directorate Of Strategy & Improvement 16.19 5.16% 3.73 1.21% 4.00 1.44% 0.00 0.00% 2.00 0.89% 1.00 0.46% 0.00 0.00% 4.00 2.05% 13.00 6.44% 8.00 3.51% 65.67 2.65%

Education and Research Directorate 48.84 2.34% 795.57 3.78%

Estates & Facilities 955.75 6.82% 954.29 6.76% 838.10 6.22% 710.33 5.10% 751.60 5.48% 619.51 4.75% 610.94 4.62% 891.57 6.72% 960.83 6.96% 952.02 6.77% 8,279.10 6.03%

Executive Team Board 54.00 2.13% 40.00 1.55% 81.40 3.31% 65.00 2.51% 31.00 1.02% 39.00 1.41% 5.00 0.16% 3.00 0.10% 8.00 0.24% 51.00 1.52% 258.40 0.88%

Finance & Healthcare Contracting Directorate 13.97 0.34% 10.27 0.25% 86.61 2.12% 99.63 2.36% 170.47 3.97% 92.00 2.23% 150.88 3.55% 289.80 6.98% 223.61 5.26% 197.45 4.74% 1,507.00 3.60%

IT Information & Telecoms Directorate 30.23 1.55% 32.84 1.68% 20.92 1.05% 1.00 0.05% 37.14 1.77% 63.77 3.22% 74.49 3.69% 64.23 3.13% 121.64 5.72% 78.37 3.61% 500.60 2.43%

Medical Director Directorate 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.48 0.08%

Medicine Division 1747.65 4.04% 1602.56 3.60% 1,704.19 3.99% 1,975.55 4.51% 1,813.04 4.16% 1,792.01 4.28% 2,059.92 4.70% 1,974.50 4.57% 2,421.69 5.47% 2,365.98 5.32% 19,743.16 4.53%

Nursing Services Directorate 59.12 2.84% 16.90 0.79% 11.80 0.56% 49.31 1.94% 63.90 2.52% 86.05 3.50% 80.58 3.17% 159.01 6.29% 91.91 3.51% 113.00 5.21% 815.35 3.84%

People & Organisational Directorate 142.80 4.36% 87.52 2.52% 97.35 2.84% 186.33 5.27% 185.43 5.15% 143.40 4.09% 171.20 4.57% 146.63 4.23% 126.15 3.56% 51.60 2.80% 708.01 3.90%

Performance Directorate 288.54 5.68% 285.40 5.46% 259.95 4.96% 205.20 3.78% 262.07 4.85% 149.09 2.87% 151.02 2.83% 103.92 1.90% 177.07 3.09% 202.16 3.51% 2,213.69 4.10%

Surgery & Cancer Division 1069.25 4.06% 1247.56 4.57% 1,134.23 4.28% 1,146.25 4.17% 1,094.13 4.01% 1,243.46 4.74% 1,163.75 4.25% 1,083.35 4.05% 1,274.12 4.61% 1,374.89 4.95% 12,271.56 4.52%

Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate

Doncaster & Bassetlaw Teaching Hospitals NHS FT 7472.02 4.59% 7048.71 4.19% 6,804.81 4.18% 7,191.30 4.28% 7,049.72 4.21% 6,866.74 4.26% 7,473.28 4.43% 7,702.49 4.62% 8,698.46 5.06% 8,561.60 4.97% 77,149.90 4.61%

Add Prof Scientific and Technic 290.19 5.75% 283.59 5.44% 117.98 2.36% 127.89 2.49% 197.74 3.82% 212.54 4.26% 258.74 5.05% 309.23 5.97% 326.23 6.08% 260.20 4.82% 2,465.73 4.76%

Additional Clinical Services 2202.11 6.27% 2267.64 6.21% 1,888.27 5.31% 2,245.04 6.14% 1,956.43 5.41% 2,023.04 5.76% 2,323.87 6.30% 2,333.20 6.47% 2,690.78 7.23% 2,645.10 7.08% 23,132.85 6.37%

Administrative and Clerical 1226.32 3.90% 961.43 2.94% 1,134.26 3.54% 1,077.69 3.23% 1,090.35 3.27% 1,022.30 3.20% 1,078.69 3.27% 1,290.64 3.98% 1,402.94 4.17% 1,307.28 3.87% 12,811.74 3.90%

Allied Health Professionals 145.04 1.51% 244.07 2.47% 189.86 2.01% 154.65 1.60% 177.11 1.80% 143.47 1.47% 248.17 2.44% 230.43 2.31% 246.09 2.40% 188.36 1.84% 2,277.60 2.30%

Estates and Ancillary 984.09 6.92% 1016.50 7.13% 964.81 7.09% 839.83 5.99% 846.30 6.12% 764.67 5.80% 756.66 5.65% 958.93 7.13% 1,109.30 7.94% 1,185.15 8.40% 9,467.23 6.83%

Healthcare Scientists 84.80 2.34% 74.84 1.99% 64.35 1.77% 63.25 1.69% 102.85 2.73% 173.92 4.85% 100.61 2.71% 85.80 2.39% 162.81 4.48% 97.21 2.70% 1,013.00 2.75%

Medical and Dental 275.00 1.65% 276.48 1.60% 345.95 2.08% 309.36 1.81% 342.66 1.98% 276.30 1.67% 265.15 1.53% 239.97 1.39% 233.08 1.29% 179.21 0.99% 2,946.58 1.71%

Nursing and Midwifery Registered 2264.47 4.80% 1924.17 3.95% 2,099.33 4.47% 2,373.58 4.91% 2,336.27 4.85% 2,250.49 4.89% 2,441.38 4.98% 2,254.28 4.64% 2,527.22 5.06% 2,699.08 5.41% 23,035.17 4.76%

Students 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.00%

Jan-20

Jan-20Dec-19

May-19

May-19 Cumulative

Apr-19

Apr-19

Jun-19

Jun-19

Jul-19

Jul-19

Aug-19

Aug-19

Sep-19

Sep-19

CumulativeOct-19

Oct-19

Nov-19

Nov-19

Dec-19

Long term / Short Term

0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%

Apr

May Jun Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Short term%

Long Term%

CG & Directorate SET Training - January 2020 (Q4)


% Compliance

Doncaster & Bassetlaw Teaching Hospitals NHS FT 87.03%

Chief Executive Directorate 96.48%

Children & Families Division 88.66%

Clinical Specialist Division 88.76%

Directorate Of Strategy & Improvement 98.61%

Education and Research Directorate 95.56%

Estates & Facilities 88.83%

Finance & Healthcare Contracting Directorate 94.55%

IT Information & Telecoms Directorate 90.29%

Medical Director Directorate 94.44%

Medicine Division 84.12%

Nursing Services Directorate 90.10%

People & Organisational Directorate 94.31%

Performance Directorate 90.09%

Surgery & Cancer Division 82.89%

SET Training

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


18/19 % Target - 90% Staff Suvey 2019 - 90%

CG & Directorate Appraisals - January 2020 (Q4)


Appraisal AFC Reviews

AFC 12 Months (NHSI)

% Completed

Doncaster & Bassetlaw Teaching Hospitals NHS FT 84.80

Chief Executive Directorate 100.00

Children & Families Division 80.99

Clinical Specialist Division 85.57

Directorate Of Strategy & Improvement 100.00

Education and Research Directorate 94.20

Estates & Facilities 90.79

Finance & Healthcare Contracting Directorate 95.97

IT Information & Telecoms Directorate 97.10

Medical Director Directorate 100.00

Medicine Division 80.40

Nursing Services Directorate 92.96

People & Organisational Directorate 96.00

Performance Directorate 90.78

Surgery & Cancer Division 82.03

M&D 12 Months (NHSI)

% Completed








M&D 15 Months

% Completed








0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


18/19% Target - 90% Staff Survey 2019

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


18/19% Target - 90% Staff Survey 2019

CG & Directorate Seasonal Appraisals - January 2020 (Q4) *as at 31/07/2019


% Completed





Directorate Of Strategy & Improvement 100.00

Estates & Facilities 81.92

Finance & Healthcare Contracting Directorate 94.93

IT Information & Telecoms Directorate 97.18



Nursing Services Directorate 95.00

People & Organisational Directorate 100.00

Performance Directorate 91.45


FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount

Staff Group

Add Prof Scientific and Technic 169.56 186.00 167.69 184.00 169.49 186.00 167.29 184.00 166.04 183.00 165.19 183.00 167.16 184.00 170.22 187.00 170.62 189.00 173.12 191.00 173.21 192.00 174.33 193.00

Additional Clinical Services 1,179.19 1,422.00 1,171.11 1,417.00 1,171.01 1,417.00 1,180.63 1,427.00 1,184.53 1,432.00 1,182.27 1,432.00 1,167.33 1,418.00 1,208.35 1,461.00 1,215.69 1,468.00 1,200.51 1,451.00 1,195.24 1,446.00 1,207.04 1,462.00

Administrative and Clerical 1,049.10 1,276.00 1,049.10 1,276.00 1,049.52 1,275.00 1,053.74 1,281.00 1,055.49 1,277.00 1,074.21 1,296.00 1,076.87 1,299.00 1,082.98 1,306.00 1,077.94 1,303.00 1,078.21 1,306.00 1,086.55 1,312.00 1,083.67 1,309.00

Allied Health Professionals 321.74 373.00 319.46 371.00 319.30 371.00 318.84 371.00 313.30 366.00 315.25 368.00 320.09 372.00 328.80 380.00 332.40 383.00 333.56 384.00 329.86 380.00 330.07 379.00

Estates and Ancillary 483.25 688.00 483.25 688.00 479.25 684.00 472.53 681.00 453.50 654.00 452.10 653.00 452.10 655.00 446.87 648.00 447.83 644.00 445.46 639.00 451.74 648.00 451.55 650.00

Healthcare Scientists 122.59 139.00 122.58 139.00 120.99 138.00 121.23 138.00 121.53 138.00 120.53 137.00 121.53 138.00 119.53 136.00 119.63 136.00 120.10 137.00 116.19 133.00 116.19 133.00

Medical and Dental 555.43 587.00 556.57 589.00 555.17 587.00 557.18 589.00 554.67 587.00 549.81 582.00 564.12 599.00 567.04 599.00 570.31 603.00 578.27 613.00 580.82 616.00 581.17 618.00

Nursing and Midwifery Registered 1,580.60 1,848.00 1,574.57 1,842.00 1,568.95 1,835.00 1,570.37 1,836.00 1,561.56 1,827.00 1,560.07 1,826.00 1,555.97 1,821.00 1,565.60 1,830.00 1,612.09 1,879.00 1,620.10 1,885.00 1,605.86 1,867.00 1,612.02 1,870.00

Students 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Grand Total 5,471.05 6,529.00 5,461.47 6,519.00 5,440.75 6,501.00 5,431.19 6,496.00 5,427.95 6,482.00 5,422.09 6,482.00 5,426.06 6,486.00 5,485.31 6,540.00 5,544.41 6,603.00 5,563.96 6,621.00 5,536.41 6,593.00 5,568.06 6,628.00

Mar-19Feb-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

Title Emergency Planning – Update on COVID 19


Author Rebecca Joyce, Chief Operating Officer


Decision

Assurance X

Information


On 31 December 2019, Chinese authorities notified WHO of an outbreak of pneumonia in Wuhan City - later classified as a new disease: COVID-19. On 30 January 2020, COVID-19 was declared a “Public Health Emergency of International Concern” by WHO. The infection has now spread through many countries and numbers of cases in the UK are growing. As at 11th March 2020, 456 positive cases have been confirmed in the UK and 6 deaths. This paper will outline

Background to the COVID 19 outbreak

The national and regional strategy

The national and regional planning approach

The Trust management approach


Is the Trust Board assured from the steps being taken to develop a plan to tackle the outbreak both internally and with partners, at regional and national level? Is the Trust Board assured of the Command and Control structures established?


D2

Effective emergency planning, preparedness, resilience and response (EPPR) is a core part of the Trust’s business and delivery of this requirement in line with legislation supports the safe delivery of the Trust’s vision to become the “safest Trust in England, outstanding in all we do”.


The report outlined the new risk of COVID 19 for DBTH organization which will be added to the risk register.


The Board is asked to:

Debate the report and be assured of planning and command and control arrangements for COVID 19

COVID 19 – Report to the Trust Board 17 March 2020 Introduction On 31 December 2019, Chinese authorities notified WHO of an outbreak of pneumonia in Wuhan City - later classified as a new disease: COVID-19. On 30 January 2020, COVID-19 was declared a “Public Health Emergency of International Concern” by WHO. The infection has now spread through many countries and numbers of cases in the UK are growing. As at 11th March 2020, 456 positive cases have been confirmed in the UK and 6 deaths. This is a rapidly evolving situation changing day to day. The Trust is responding to this high level outbreak through the adapted use of its Influenza Pandemic Policy, part of the Trust’s wider Major Incident Policies. The Trust plans for such eventualities though its Emergency Preparedness, Planning and Response arrangements. Alongside responding to the impact for our populations in Bassetlaw and Doncaster, infection rates amongst our staff are likely to follow the impact on the wider population, meaning we are developing a plan to meet the challenge with reduced staffing numbers. The Trust has established a Command and Control structure and this paper will outline:

1. Background to the COVID 19 outbreak 2. The national strategy 3. The national and regional planning approach 4. The Trust management approach

1. Background

• The lack of population immunity and the lack of a vaccine means COVID-19 has potential to spread extensively.

• The main symptoms of COVID-19 are a cough, a high temperature and, in severe

cases, shortness of breath and pneumonia

• The vast majority of people will have a mild-to-moderate, self-limiting illness.

• A minority of people will develop complications severe enough for hospital care, most often pneumonia. In a small proportion, the illness may be severe enough to be fatal.

• Individuals with severe respiratory problems: will be at greater risk plus those with underlying health conditions such as uncontrolled diabetes and renal immuno-compromised patients.

• As at 11th March 2020, 456 positive cases have been confirmed in the UK and 6 deaths.

2. National Strategy

• A level Four incident has been declared, NHSE/I have established an Incident Management Team - seven days a week, working closely with Department of Health and Social Care, Public Health England and other government departments

• System-wide response plans for pandemic influenza, focused on the continuity of public and critical services and the stability of the economy, have been adapted for COVID-19.

• A national action plan was published on 3 March 2020. It contains 4 main stages:

• Contain: detect early cases, follow up close contacts, and prevent the disease taking hold in this country for as long as is reasonably possible.

• Delay: slow the spread in this country, if it does take hold, lower the peak

impact and push it away from the winter season.

• Research: Better understand the virus and the actions that will lessen its effect on the UK population; develop innovative responses including diagnostics, drugs and vaccines; use the evidence to inform the development of the most effective models of care.

• Mitigate: Provide the best care possible for people who become ill, support hospitals to maintain essential services and ensure ongoing support for people ill in the community to minimise the overall impact of the disease on society, public services and on the economy.

The national strategy and discussions are also focusing on:

• Wider social measures that will be explored as part of the plan subject to how the infection develops: for example, guidance on self-isolation for high risk groups, consideration of “social distancing” measures.

• Further measures to support the NHS: for example, final year medical, nursing and AHP students are being considered to being able to practice alongside qualified staff, temporary suspension of performance standards, the reduction of routine elective operating and outpatients and a potential national volunteer plan.

• The national approach outlines that planning draws on the idea of a “reasonable worse case” (RWC) scenario. This is not a forecast of what is likely to happen, but means the national team are ready to respond to a range of scenarios.

3. National and Regional Management Approach

• Weekly national calls for all CEOs with the national NHS England team have been established. Daily teleconferences at Doncaster and Bassetlaw level are in place. Partnership working on emergency planning across the region is well established

through the Local Health Resilience Partnership. These arrangements ensure a multi-agency, coordinated response.

• The Trust is receiving significant guidance and daily information on the developing situation from national and regional bodies.

• Patients requiring hospitalisation thus far have been managed within the national specialist Infectious Diseases centre. As the numbers increase, it is anticipated DBTH will care for local COVID 19 cases, with appropriate infection control measures to keep patients and staff safe from the risk of infection.

• National requirements for all NHS organisations have been set out to ensure the optimal and coordinated approach to managing the spread of COVID 19 over the coming weeks.

• Additional testing capacity nationwide is being brought online w/c 10/3/2020 to ensure a higher volume of tests can be dealt with as quickly as possible.

• Doncaster and Bassetlaw patients who have suspected COVID 19 are being swabbed through one of the Coronavirus PODS, located outside the Emergency Departments at Bassetlaw Hospital and Doncaster Royal Infirmary. A very small number of swabs have tested positive and all cases are self-isolating at home.

4. Trust Management Approach The Trust will be managing the COVID 19 outbreak in line with the Trust’s Influenza Pandemic Policy (refreshed January 2020). In line with the national approach, the Trust will be adapting this to respond to the outbreak. Four principles underpin the approach

• Precautionary – plan for an initial response that reflects the level of risk, based on information available at the time, accepting the uncertainty that will initially exist.

• Proportionality – plan to be able to scale up or down in response to the emerging epidemiological, clinical and virological characteristics of the virus and its impact at the time.

• Flexibility – plan for the capacity to adapt to local circumstances that may be different

from the overall UK picture – for instance in hotspot areas. A weekly senior Covid 19 Planning Group has been established to develop the Trust Wide Action Plan for COVID. This planning is underway, with a plan to be finalised w/c 16/3/2020. Given the expected increased patient demand and the likely high numbers of DBTH staff having to self-isolate in line with the infection curve of the wider population, it will be necessary to cease non-essential activities and slow down or stop non urgent outpatients and electives at an appropriate point. The Trust wide planning is focused on the following themes:

Medical pathways and surge plans

Critical care and theatres plan

Approach to elective work

Approach to testing

Infection Control – training and FIT testing

Education and Training

Supplies and Equipment

People Plan

Individual departmental/ Divisional plans

Communication Plan The Trust is collaborating with partners on areas of the plan that interface with our primary care, community and local government partners. The Trust is working with public health partners on planning data to establish potential reasonable best case and worse case scenarios of the population infected. This is not a forecast of what is likely to happen, but means we are ready to respond to a range of scenarios. Additionally an internal dedicated COVID team is being established to ensure dedicated time to manage the outbreak as effectively as possible. An internal Command and Control Structure has been established as outlined in the diagram below:

5. Conclusion This is a rapidly evolving situation. The Trust is putting all arrangements in place to ensure high quality care is maintained for patients. It will be essential to support our staff well through this challenge and teams are working to ensure planning is as robust as possible and well-coordinated with partners. The Board is asked to:

Debate the report and be assured of planning and command and control arrangements for COVID 19

1

Title Freedom to Speak Up Index Report and Case Studies

Report to Board of Directors Date March 2020

Author Paula Hill, Freedom to Speak Up Guardian


Decision

Assurance X

Information

Executive summary

This paper is for presentation to the Board of Directors to provide assurance on matters relating to the Freedom to Speak Up strategic direction and operational practice. It gives particular focus to the 2019 FTSU Index Results and discusses a selection of case studies that are in line with the findings of the report. Appendix A is provided to allow a visual understanding of the information provided. Overall the FTSU Index Results are very positive and the improvement seen across all four questions shows how staff awareness has been influenced by some of the strategic, partnership work that was implemented in 2019. Although this work is still in its infancy, the Trust has seen a significant increase in the number of FTSU cases being raised. There is also evidence of greater collaboration across all areas of the Trust which has resulted in increased preventative work and support for line/middle managers. This increased engagement and training and development has improved staff awareness and confidence in Speaking Up whilst also influencing staff perceptions of the culture at DBTH. However, the report shows that some directorates have not performed as well as others across all of the four FTSU Index questions. These results are in keeping with the rest of their Staff Survey Results overall for these areas. Understanding the detail of the Index results and considering this against the trend in FTSU

cases being raised provides an opportunity for focussed engagement, to work with divisions

and corporate functions to support their Staff Survey action plans, to ensure all staff feel

empowered and encouraged to Speak Up as part of “Business as usual” at DBTH.

E1

2


How do we celebrate the improvements in our “Speak Up” Culture, demonstrating where and how staff are empowered and feel confident to raise concerns? “Sharing Success”.

How do we lead by example, evidencing our actions and behaviors, supporting those areas where improvements are still required?

How do we continue to improve our response to FSTU concerns, ensuring timely and appropriate action?


Continuing to improve our FTSU culture, improving our staff voice, speaking up numbers and in turn patient safety and staff experience will have a direct impact on our ability to achieve our Vision: To be the Safest Trust in England, Outstanding in all we do. Increasing Board awareness of the FTSU Index results and providing context on the FTSU cases currently being supported at DBTH demonstrates the early positive impact of the new FTSU strategy and its associated work streams.


Failure to improve staff morale leading to(i) Recruitment and retention issues(ii) Impact on reputation(iii) Increased staff sickness levels - This report identifies risks in relation to some staff perceptions of the culture of the trust (relating to fairness and fear of reprisal). However, it also demonstrates improvements in this area across a number of directorates. In addition the report positively identifies areas where progress has been made in relation to increasing our FTSU numbers but also highlights concerns in relation to timeliness and appropriate action in the management of some cases.


Board members are asked to consider the information in this report and use it to inform open discussion both within the Board and across wider teams. Board members are asked to support the celebration of the FTSU Index results and to commit to wider engagement for teams where further support is required. Board members are asked to commit to timely management of FTSU cases within their areas. Board members are asked to commit to continually driving forward a positive FTSU Culture at DBTH through the demonstration of open “Speak Up” behaviours.

3

Introduction In 2015, (following the Mid Staffordshire Inquiry), Sir Robert Francis conducted a “Freedom to Speak Up Review” which led to a range of recommendations and principles to guide NHS practice in relation to the development of Speaking Up Cultures. The report highlighted the importance of cultures that embrace transparency and support raising concerns in order to improve patient safety and staff experience. This report led to the implementation of the National Guardians Office (NGO) who in turn, provide guidance and support to NHS Trusts in relation to Freedom to Speak Up practices. The report also acknowledged that a positive Speak Up Culture is one of the key elements of ensuring outstanding patient safety and a safe and effective workforce, as this ensures staff can raise concerns in a supportive environment in which they feel they can contribute to, and provide outstanding care. The NHS contractual requirements in relation to Freedom to Speak Up are monitored by the Care Quality Commission (CQC), who assess the Trusts Freedom to Speak Up Culture during inspections, under the Well Led Framework, integral to Key Line of Enquiry 3. Although the NGO has found no obvious correlation between the CQC rating of a Trust and the number of concerns raised, the 2018 Freedom to Speak Up (FTSU) Guardian Survey suggests a correlation between a Trusts overall CQC rating and FTSU Guardian perceptions of speaking up cultures. In October 2019 the National Guardians Office (NGO) published a FTSU Index Report which also suggests evidence of a correlation between a Trusts FTSU Index scores and their overall CQC outcome rating. The introduction of the FTSU Index sees the feedback from the NHS Staff Survey used to aggregate a meaningful score to measure both organisational culture and staff understanding of Speaking Up processes. The FTSU index is calculated as the mean average of responses to four questions from the NHS Annual Staff Survey.

The survey questions that have been used to make up the FTSU index are:

% of staff responded "agreeing" or "strongly agreeing" that their organisation treats staff

who are involved in an error, near miss or incident fairly (question 17a)

% of staff responded "agreeing" or "strongly agreeing" that their organisation

encourages them to report errors, near misses or incidents (question 17b)

% of staff responded "agreeing" or "strongly agreeing" that if they were concerned about

unsafe clinical practice, they would know how to report it (question 18a)

% of staff responded "agreeing" or "strongly agreeing" that they would feel secure

raising concerns about unsafe clinical practice (question 18b)

4

What this means at DBTH Doncaster and Bassetlaw Teaching Hospitals Trust (DBTH) is committed to providing outstanding care and governance. For this standard to be maintained the Trust actively acknowledges the need for an open and responsive “Speak Up” Culture, where staff feel confident to raise concerns. The Trust openly supports the implementation of Sir Robert Francis’s recommendations following the Mid Staffordshire enquiry and has therefore had a Freedom to Speak Up Guardian in place since October 2016. Being free and feeling safe to speak up in the NHS requires a focus on driving forward a positive Speak Up culture that provides all staff with the opportunity to make a real difference. In order to drive this culture forward, DBTH has recently ratified a new Freedom to Speak Up Strategy that adopts a partners approach to making Speaking Up, business as usual across the organisation. DBTH has a robust approach to utilising the Annual Staff Survey as a positive staff engagement tool and as such, has committed ongoing time and resource to providing an appropriate divisional and organisational response to the feedback they receive. However, this work has not previously required a focus on the four questions now identified as the FTSU Index markers. Applying this new focus shows where significant improvements have been made from 2018 to 2019 and where further support is still required. FTSU Index Overall Organisational Results

Number Question 2018 2019

17a % of staff responded "agreeing" or "strongly agreeing"

that their organisation treats staff who are involved in an

error, near miss or incident fairly

55%

60%

17b % of staff responded "agreeing" or "strongly agreeing"

that their organisation encourages them to report errors,

near misses or incidents

86.1%

88%

18a % of staff responded "agreeing" or "strongly agreeing"

that if they were concerned about unsafe clinical

practice, they would know how to report it

92.3%

93%

18b % of staff responded "agreeing" or "strongly agreeing"

that they would feel secure raising concerns about

unsafe clinical practice

68.1%

72%

Mean

Average

Index score 75.85% 78.25%

5

Results and Learning

Measuring culture using the FTSU Index is a new concept for Trusts and it is important to

acknowledge that overall scores can be significantly affected by single or multiple sub

divisional or departmental responses. It is also important to acknowledge that this is a small

section of the overall staff survey outcome measures.

Overall the 2019 DBTH Freedom to Speak Up Index Scores are extremely positive, showing an

increase of 2.4% overall, from 75.85% to 78.25%. The Index results saw an increase across all

four questions, with the largest increase for questions 17a and 18b relating to fairness and

feeling safe to Speak Up. This is a very positive result and suggests a positive progression

towards an open and transparent Speaking Up culture (appendix a).

Questions 17b and 18a were already considerably higher scoring and therefore a smaller

increase in results for these questions is still very positive. Although question 18a has a strong

result of 93% overall, it is important to note that only the Children and Families Division were

rated above the Trust average with a result of 97%. It is also important to note that when

considering the sub set of results in order to fully understand staff knowledge and

perceptions in individual departments, a more detailed, mixed picture can be seen (appendix

a).

Six divisions or corporate functions had scores significantly below the Trusts average (rated

red) for their response to question 17a (perception of fairness). However, when individual

department responses are considered many of the responses are positive, but the aggregated

score is significantly influenced by one or two very low scores (31%) from some areas. This is

across both clinical and non-clinical areas (appendix a/full staff survey).

In addition five divisions or corporate functions had scores below the Trusts average (rated

red or amber) across all four questions, indicating that staff do not feel that there is an open

and transparent culture in which they feel encouraged and enabled to Speak Up. However, it

is important to note that these divisional scores are influenced in the same way as described

above and are representative of their overall Staff Survey results for these areas (appendix a).

On the whole, most of the divisional or corporate function FTSU scores, correlate with their

performance across the Staff Survey overall. However, there are a few exceptions, with some

sub areas (Locality 2) scoring very low on their index scores and performing very well across

other areas. It is also important to note that the FTSU Index scores do not mirror the safety

culture scores (provided in the Staff Survey Reports) as this score is derived from a varied

number of questions and only includes questions 17a and 18b from the FTSU index range.

Considering wider influences of age and gender, 16 - 20 year olds scored lower across the

FTSU Index questions, otherwise there was no significant difference noted across age groups.

Although, interestingly, the response to question 17a (perception of fairness) slightly reduces

as age increases. There was also no significant difference between gender responses.

6

Across the four FTSU Index questions, it is interesting to note that there were however

significant differences in responses dependant on Job Pay Banding. This variance ranged from

66.75% at Band 1 to 88.25% from Band 7/8’s which then reduced again as it progressed

through the medical grades.

Improvement Opportunities

Overall the 2019 FTSU Index results are very positive, showing an improvement in staff

perception of our Speaking Up Culture. A significant improvement within the overall score is

in line with the very positive results experienced across the Staff Survey as whole and

demonstrates an increased staff understanding of the ongoing organisational development

work and their role in supporting this agenda.

With significant increases in the results for being treated fairly and feeling safe to raise

concerns, the survey demonstrates the positive perceptions of staff in relation to reporting

near misses, incidents and concerns.

There are however some key areas that provide an opportunity for focussed engagement, to

work with divisions and corporate functions to support their Staff Survey action plans, to

ensure all staff feel empowered and encouraged to Speak Up as part of “Business as usual” at

DBTH.

In some cases FTSU Index markers will not be prioritised as part of the action planning process

due to the varied nature of responses and the amount of improvement work required. Where

these action plans do not include the FTSU markers, it will still be crucial to continue to

improve staff understanding of how to “Speak Up” and raise concerns, which will improve

practice and in turn influence responses to question 18a across the organisation.

7

Appendix A

The following tables show the FTSU Index ratings provided within the 2019 annual staff survey results. These tables demonstrate divisional and

departmental aggregated scores across questions 17a, 17b, 18a and 18b. Finally they indicate the impact of these ratings on the trusts FTSU

index score overall, using the following codes.

FTSU Score code

Influences score positively

Influences score negatively

Neutral influence on score

* Data not available so score aggregated over 3 questions only

2019 FTSU Index Division and Corporate Function Results:Question: Executive C & Fam C Special E & Facil F & Com IT Med Dir Medicine Nurs Dir P&OD Perform Surg & C

17a * 52% 64% 52% 54% 58% * 64% 65% 73% 53% 56%

17b 100% 90% 92% 79% 87% 89% 82% 89% 93% 87% 74% 85%

18a 94% 97% 95% 85% 80% 85% 94% 95% 94% 92% 82% 94%

18b 88% 77% 76% 60% 52% 55% 78% 75% 76% 78% 60% 72%

FTSU Score 94.00% 79.00% 81.75% 69.00% 68.25% 71.75% 84.67% 80.75% 82.00% 82.50% 67.25% 76.75%

No sub level information (locality 2) is available for Executive Directorate, P&OD, Medical Directorate, Nursing Directorate, Finance &

Contracting or IT & Telecommunications.

8

The available sub directorate information is presented below in the Locality 1 Staff Survey order.

Children & Families:

Question:

Children &

Family Care

Group -

Mangage

Childrens GU MedicineWomens &

Maternity

17a 38% 59% 60% 47%

17b 73% 92% 83% 92%

18a 87% 98% 100% 97%

18b 60% 81% 75% 75%

FTSU Score 64.30% 82.39% 79.40% 77.65%

Clinical Specialties:

Question:

Anaes Critical

Care & Pain

Mangement

Clinical

Therapies

Medical

Imaging

Outpatient &

Clinical AdminPathology

Pharmacy &

Medicines

Management

Theatres &

Day Surgery

17a 55% 72% 65% 61% 77% 76% 45%

17b 90% 91% 92% 92% 95% 94% 91%

18a 96% 96% 95% 100% 90% 94% 94%

18b 76% 80% 72% 87% 76% 72% 72%

FTSU Score 79.41% 84.86% 81.32% 84.92% 84.48% 84.11% 75.66%

9

Estates and Facilities

Question:Estates

Directorate

Facilities

Directorate

17a 56% 52%

17b 79% 79%

18a 68% 87%

18b 59% 60%

FTSU Score 65.44% 69.35%

Medicine:

Question: A&E Acute Med CardiologyCare of the

ElderlyDermatology

Diabetes &

Endocrinology

Emergency

Care Group

Management

HaematologyMedical

GastroPalliative Care Renal

Respiratory

MedicineRheuma

Specialty

Services Care

Group -

Mangement

Stroke

17a 58% 62% 65% 59% 71% 53% 65% 75% 70% 83% 85% 63% 82% * 75%

17b 81% 90% 96% 87% 82% 90% 88% 92% 91% 95% 95% 91% 85% 100% 83%

18a 96% 93% 96% 100% 96% 91% 91% 96% 88% 100% 100% 96% 100% * 94%

18b 72% 75% 79% 79% 75% 59% 83% 67% 68% 90% 78% 77% 77% 64% 79%

FTSU Score 76.68% 79.94% 83.99% 81.26% 80.76% 73.13% 81.78% 82.25% 79.20% 92.20% 89.54% 81.99% 85.84% 81.82% 82.85%

Performance:

Question:

Patient

Admin

Support

Services

Performance

Management

17a 49% 73%

17b 70% 91%

18a 82% 83%

18b 59% 62%

FTSU Score 65.10% 77.38%

10

Surgery & Cancer:

Question: Breast Dental Endoscopy ENT

Gastro

Intestinal

Surgery

OphthalmolSurgical

Audiology

Surgical Care

Group -

Management

Trauma &

OrthopaedicsUrology Vascular

17a 43% 63% 63% 54% 63% 62% 37% 52% 50% 59% 58%

17b 71% 86% 82% 94% 84% 89% 82% 88% 86% 86% 96%

18a 96% 89% 97% 94% 96% 88% 90% 100% 96% 89% 87%

18b 57% 65% 78% 69% 72% 73% 68% 75% 71% 68% 88%

FTSU Score 66.97% 75.73% 79.85% 77.74% 78.51% 78.14% 69.33% 78.72% 75.73% 75.67% 82.00%

Additional perspective is also gained from considering the results by banding and Professional Groups as follows.

Banding:

Question: Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8a Band 8bBand 8c, 8d &

9Consultant

Doctors in

training

Qualified

Medics

Specialty

Doctor

Very Senior

Manager

17a 49% 50% 55% 68% 61% 63% 69% 74% 83% 97% 64% 61% 55% 59% *

17b 79% 81% 86% 89% 91% 93% 94% 97% 100% 100% 88% 81% 92% 83% 91%

18a 84% 91% 88% 87% 96% 97% 97% 100% 96% 100% 94% 90% 100% 93% *

18b 55% 66% 65% 67% 75% 78% 84% 82% 78% 97% 78% 69% 69% 50% 82%

FTSU Score 66.68% 71.92% 73.77% 77.52% 80.62% 82.87% 86.07% 88.30% 89.14% 98.40% 80.90% 75.40% 79.02% 71.32% 86.36%

Professional Group:

Question:

Add Prof

Scientific and

Technic

Additional

Clinical

Services

Administrativ

e and Clerical

Allied Health

Professionals

Estates and

Ancillary

Healthcare

Scientists

Medical and

Dental

Nursing and

Midwifery

Registered

17a 69% 56% 55% 70% 53% 68% 63% 63%

17b 93% 91% 81% 93% 76% 90% 86% 93%

18a 93% 97% 85% 97% 84% 94% 94% 98%

18b 78% 77% 61% 78% 59% 77% 72% 81%

FTSU Score 83.32% 80.23% 70.52% 84.53% 68.05% 82.10% 78.57% 83.67%

11

Case Studies

In keeping with the results of the FTSU Index, DBTH has seen a sustained increase in the

number of concerns being reported quarterly. This has seen 9 cases raised in quarter 3 and

9 cases (27 individuals - to date) in quarter 4. Although there is a consistent increase in the

number of cases being raised, there is a significant variance in the type of case, the amount

of action required and time that cases remain open for action plans to be completed. This

can range from a few weeks to more than nine months.

The range of staff raising concerns is inclusive of both the clinical and non-clinical workforce

and includes medical staff and learners as well. In addition to the individual concerns raised

collective concerns have been heard through facilitated discussions in two areas of the

Trust. These are still ongoing.

FTSU cases have been raised across all sites and divisions within the Trust and additionally

key themes are now beginning to emerge. A number of concerns relate to estates and

facilities and come under the umbrella of staff experience more often than patient or staff

safety.

Patient safety concerns have been raised both individually about staff behaviour towards

patients and as part of broader departmental concerns. In other cases patient safety has

been raised under the umbrella of safe staffing.

Bullying and harassment has been cited as the reason for raising concerns in two cases and

a lack of values and respect in teams in two others. 3 of these cases resulted in the person

leaving the Trust or transferring roles.

HR themes are twofold with some staff raising concerns as they feel unsupported in the HR

processes that they are experiencing, even though the processes are wholly appropriate. On

occasions these staff have not been happy with the outcome or progression of the case.

There have also been concerns raised with regard to how managers respond to and deal

fairly with requests for flexibility in work patterns, carer support, response to sickness

absence and career progression. The majority of these cases have identified some element

of relationship breakdown.

In addition to the above a number of HR related concerns were raised, as staff felt that that

it was inappropriate for their cases to be open for more than 6 months. Staff also felt that

this detrimental to their ability to perform well at work.

2 complex cases have required significant input and continue to require organisational

support to address the action plans required. In addition 3 cases are currently underway to

support collective groups of staff. This will theoretically change the number of concerns

total to more than 27 for quarter 4 (this is in line with the 2019 NGO recommendation to

count every person separately).

12

The following are provided as a selection of case studies and do not cover all of the areas

discussed above.

Case Study 1 and 2 (Estates and facilities)

Case Study 1 (Staff experience) was raised anonymously by a member of staff at Bassetlaw

Hospital. The concern was about the lack of feminine hygiene disposal facilities in the toilets

there, particularly in main reception.

The concern was escalated to estates and facilities and a prompt response was received in

relation to the action they could and would take. Disposal bags were provided in the toilets

where bins would not fit and clinical waste bins were provided in the main toilet areas.

All three sites were also checked and the new regime rolled out in other areas such as

Doncaster Education Centre as well.

Unfortunately as the concern was raised anonymously feedback could not be provided to

the staff member who raised the concern and instigated the improvement.

Case Study 2 (Patient and staff experience) was raised by a staff member in the old west

block in December 2019. The concern was about patient and staff comfort in the cold. The

heating was not performing as it should on the wards and the staff in adjoining non clinical

rooms were extremely cold. I visited and the temperature on the ward was low and in the

non-clinical rooms it was not conducive with being at work.

The concern was escalated to estates and facilities and a prompt response was received in

relation to the action they could and would take. This saw the delivery of emergency

heaters, initially for the ward to improve patient comfort and secondly to the adjoining

rooms to support staff comfort.

The concern identified a longer term issue with the heating in the non-clinical room as this

had been raised numerous times before. It was therefore decided to provide piped heating

to this area and the work was scheduled for February 2020.

Patients and staff were happy with the outcome of the response and the support they

received.

Case Study 3 (Patient Safety)

Case Study 3 was raised by an individual staff member who had concerns about the

inappropriate behaviour of another staff member towards one of their patients. This was

initially raised to the line and then senior managers of the division and only became a FTSU

concern when the staff member was unhappy with the outcome of the investigation and

raised concerns again.

13

A robust collaborative investigation was completed by senior managers to explore the

patient safety concerns, however, the concerns were not substantiated although some

learning was identified for the staff and managers on the unit.

The staff member who raised the concerns was supported to explore what had happened

and consider what their own expectations of an outcome would be. The staff member was

then supported through the investigation feedback process and is now receiving support for

their own health and wellbeing as one of the measures instigated to support their return to

work.

Case Study 4 (Bullying and Harassment/ lack of values and respect)

Case Study 4 was raised by a member of staff who felt they could no longer work at the

Trust due to the behaviours and unfair treatment they received from their line manager.

The staff member raised her concern to one of the guardians to explain why they felt they

could not stay at DBTH. This was then escalated for support with managing remaining at

work throughout their notice period.

The senior manager for the division was involved in the concern and the situation was

explored with the manager and the staff member. It was felt that it was too late to change

the outcome for the staff member and they were unable to return to work to be line

managed by the same individual throughout their notice period. This resulted in sick leave.

Learning was identified and the appropriate HR process was followed in relation to

supporting the manager’s development and future practice.

Case Study 5 (Patient, staff and public safety/Staffing/Systems and processes)

Case Study 5 was originally raised as a concern in June 2019. The concern related to a

reduced number of staff working to cover gaps in the department’s establishment and the

impact that this was having on staff morale, workforce sustainability and performance.

The concern also identified issues with a lack of safety systems to support patient, staff and

public safety as there had been a change in process but no policies and procedures had

been updated. Initially one member of staff felt that this was a concern but over time this

has been collaborated by the rest of the team.

Other managerial issues were identified as part of the process and an action plan has been

put in place to cover of these areas. However, due to failure to recruit and inaction in

relation to updating policies and procedures the staff still feel unsupported and continue to

14

have concerns about working without breaks, covering shifts to support colleagues and

safety around lone working outside agreed practice.

The senior manager for this area is working to support both staff and management to reach

a safe and workable solution given the constraints of recruitment and resource availability

to support management. This case remains ongoing.

Conclusion

In conclusion, a review of the Freedom to Speak Up Index results from the 2019 Annual Staff

Survey showed a positive result overall, with the Trust’s FTSU index score increasing by

2.4%. There was an increase across all four questions, with the greatest increases against

questions 17a and 18b, relating to the organisations culture.

These positive results suggest that staff have an increased awareness of FTSU matters and

understood when and how to raise their concerns. However, they also show where further

improvements can be made in relation to perceptions of fairness and fear of reprisal. These

results offer an opportunity to provide structured support in the identified areas as part of

our Staff Survey Action Plan.

The information provided within the case studies shows that staff are increasingly willing to

share their concerns across a wide range of issues and although some of these cases would

not traditionally have been considered as FTSU or Whistleblowing cases, they are in keeping

with the DBTH strategy for FTSU, working to create a culture where staff feel they can

proactively Speak Up about anything that worries them. This provides evidence of our

journey towards making FTSU at DBTH business as usual.

In addition, the themes identified throughout the case studies provides us with a key focus

for our FTSU work throughout 2020.

1

Title Report from the Guardian for Safe Working

Report to Board of Directors Date March 2020

Author Dr Jayant Dugar, Guardian for Safe Working


Decision

Assurance √

Information √


The 2016 national contract for junior doctors encourages stronger safeguards to prevent doctors

working excessive hours, during negotiations on the junior doctor contract agreement was reached on

the introduction of a 'guardian of safe working hours' in organisations that employ or host NHS trainee

doctors to oversee the process of ensuring safe working hours for junior doctors. The Guardian role was

introduced with the responsibility of ensuring doctors are properly paid for all their work and by making

sure doctors aren’t working unsafe hours.

The 2016 contract continues to be implemented with 204 junior doctors employed by this Trust on the

2016 contract as at the time of this report. This contract changes how safe working is delivered

compared to previous contract. This relies on exception reporting by junior doctors and proactive

changes by the Trust to avoid unsafe working. This report includes the quarter October to December

2019 together with the annual report for 2019. For the quarter, exception reports have been submitted

by individuals across Surgical, Children & Family and Medicine Divisions. A total of 27 exception reports

have been raised within this quarter of which 1 has been related to Education and 1 to lack of service

support.

With regard to the annual report it summarizes the quarterly reports previously submitted. It should be

noted that the exception reporting in this Trust (DBTH) is lower than comparable organisations in the

region – 76 exception reports were submitted during the year – the report details the specialties and

grade of doctor exception reporting. The table below details the nature of the exception report.

Nature of exception Number

Education 3

Service support 4

Hours 65

Pattern 4

6 exceptions from hours breach were to do with missed breaks which did not result in any fine as per

rules.

E2

2

Attention is drawn to the need to update rest facilities, on call rooms and the Doctors Mess and the need

to have consistent collection of data for rota gaps and locum and bank usage to monitor the safe

working. This will be accurate once erostering is in place which is currently in the process of being

implemented.

The Guardian is required to provide the Board of Directors with quarterly reports including an annual

report. No gross safety issues have been raised with the Guardian by any trainee.

The Guardian for Safe Working advises that that the trainees have safe working practice as designed by

the 2016 contract.


Is the Board assured that the Trust has safe working in place for doctors in training?


People - As a Teaching Hospital we are committed to continuously develop the skills, innovation and leadership of our staff to provide high quality, efficient and effective care.

Junior doctors will have improved support and education through the implementation of the new junior

doctor’s contract which is designed to ensure doctors are working safely and receiving the appropriate

training. By having appropriately trained doctors patients will receive a good experience whilst receiving

care.


Workforce - By having a safe workforce we remain an attractive employer to current trainees and to help future recruitment.


The Board of Directors are asked to note the quarterly update and the annual report and be assured that

trainee doctors have a safe working practice as envisaged by the 2016 contract.

Quarterly Report on Safe Working for Doctors and Dentists in training

October 2019 – December 2019

1. Introduction

This report sets outs the information from the Guardian of Safe Working as part of the 2016 Terms and

Conditions for Junior Doctors to assure the board of safe working for junior doctors. This report is for the

period 1st October 2019 to 31st December 2019.

The Board should receive a quarterly report from the Guardian as per 2016 contract, which will include:

Aggregated data on exception reports (including outcomes), broken down by categories such as specialty, department and grade

Details of fines levied against departments with safety issues

Data on rota gaps / staff vacancies/locum usage

A qualitative narrative highlighting areas of good practice and / or persistent concern.

2. High level data

Number of posts contracted by DBH(inc. 125 LU doctors*) 204

Number of posts contracted by other Organisations 163

Number of doctors / dentists in training on 2016 TCS 137

Lead Unit Doctors

No of doctors in Doncaster GP Training Scheme 49

No of doctors in North Notts GP Training Scheme 17

Ophthalmology Training 13

ENT Training 12

General Surgery Training 34

Total 125

Amount of time available in job plan for guardian to do the role: 2 PAs

Admin support provided to the guardian (if any): through HR ad-hoc

Amount of job-planned time for educational supervisors: 0.25 PAs per trainee


3. Exception reports

2019 No. exceptions raised No. exceptions

outstanding No. exceptions

resolved No. exceptions

unresolved

October 8 2 7 1

November 15 2 12 2

December 4 1 3 0

Total 27 5 22 3

No exception reports from both the GP training schemes for which the trust is the lead employer.

For this quarter, exception reports have been submitted by individuals across Surgical, Children & Family and

Medicine Divisions. A total of 27 exception reports have been raised within this quarter of which 1 has been

related to Education and 1 to lack of service support.

These are low numbers of exception reports compared to other hospitals. I have had no indication that

exception reporting is being discouraged. The Director of Education and I have been encouraging the junior

doctors to exception report at all engagements.

4. Work schedule reviews

No work schedule reviews have been initiated in this quarter.

5. Vacancies – training grade rotation

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

Medicine 11 9 6 4 4 4 4 6.2 3.6 3.2 3.2 3.9

Elderly Med 4 4 1 1 1 1 1 1.4 1.4 0.4 0.4 0.4

Renal 0 0 0 0 0 0 0 1 1 1 1 0

Emergency medicine

2 2.4 2.4 1 1 1 1 5.9 5.9 6.1 5.6 7

Obs & Gynae 10.4 10.6 9 2.2 2.2 2.2 3.6 7.1 6.9 7.4 7.4 9.4

Paediatrics 1 2.1 1.6 2.7 2.7 2.7 2.7 2.2 1.8 2.2 2.2 2.2

GU Medicine 0 0 0 0 0 0 0 1 1 1 0 0

General Surgery 1 1 1 0 0 0 2 0.7 0.5 0.2 0.2 1.2

Urology 0.4 0.4 0.4

Trauma & Ortho 0.2 2.2 1 2 2 2 2 1 2 1 1 1

ENT 1 1 1 1 1 1 1 1 0 1 1 1

ICT 1 1 1 1 0

Radiology 1 1 1 1 1 1 3 3 3 0 0 0

Anaesthetics 4.4 0.4 0.4 0 1 1 1 1 1 0 0 0

Total 36 33.7 24.4 14.9 15.9 15.9 21.3 32.5 29.1 24.9 23.4 26.5


The vacancies in most specialties have remained fairly constant. The GP rotations also are fairly well recruited to.

6. Locum and bank usage

The data below details bank and agency shifts covered by training grade doctors.

Reason for Shifts Oct-19 Nov-19 Dec-19

Additional Session (Clinical) 31 51 36

Annual Leave 12 10 40

Compassionate/Special leave 4 3 1

Extra Cover 14 25 21

Induction 2

Maternity/Pregnancy leave/Paternity 4 5 8

Restricted Duties 9 9 14

Seasonal Pressures 9 9

Sick 68 52 59

Study Leave 13 18 4

Vacancy 1160 1021 1101

Grand Total 1317 1203 1293

Agency - Shifts Oct-19 Nov-19 Dec-19

Acute Medicine 6 5 16

Anaesthetics and Critical Care 5 5 4

Anaesthetics and Theatres 10 2

Anaesthetics and Maternity 5 1 2

Care of the Elderly 76 82 89

Emergency Medicine 325 278 262

Endocrinology and Diabetes 18 23

ENT/ENT Theatre 67 53 67

Gastroenterology 3

General Medicine 3

General Surgery 71 54 53

Obstetrics and Gynaecology 12 26 21

Orthopaedic and Trauma Surgery 218 138 110

Paediatrics and Neonates 47 52 61


Agency - Shifts Oct-19 Nov-19 Dec-19

Renal 18 19 25

Respiratory Medicine 45 42 18

Stroke Medicine 25 23 19

Grand Total 933 796 775

Internal - Shifts Oct-19 Nov-19 Dec-19

Acute Medicine 44 32 60

Anaesthetics 46 55 52

Anaesthetics and /Critical Care 4 3

Anaesthetics and Theatres 6 1

Anaesthetics Maternity 7 1 7

Care of the Elderly 1

Dermatology 2

Emergency Medicine 135 150 218

Endoscopy - Medicine 1

Endoscopy - Surgical 12 20 12

ENT 13 6 3

Gastroenterology 5

General Medicine 1 2

General Surgery 13 10 16

Genitourinary Medicine 3 14 13

ITU 9 12

Obstetrics and Gynaecology 25 16 24

Ophthalmology 13 22 13

Oral and Maxillofacial Surgery 4 3

Orthopaedic and Trauma Surgery 25 15 19

Paediatrics and Neonates 11 15 23

Renal Medicine 3

Respiratory Medicine 5 8 29


Internal - Shifts Oct-19 Nov-19 Dec-19

Stroke Medicine 1

Urology 11 23 12

Grand Total 384 407 518

The locum cover in stroke medicine and diabetes has gone up possibly due to gaps in non training grades

who help cover the rota as there seems to be low vacancies in training grades.

7. Fines

No fines have been levied in this quarter. There have been no fines in the year.

8. Qualitative information

It is reassuring that no instance of immediate safety concern (ISC) has been brought to my notice by junior

doctors on 2002 or the 2016 contract. I have been assured by the medical recruitment department that all

doctors are rostered on a rota which is compliant with 2002 and 2016 contracts as applicable.

I participated in a walk around the on call rooms in DRI with Deputy Director Education and Director of Estates

,it was agreed that the facilities were in a poor shape and plans would be drawn up to update this.

It should also be noted that the junior doctors contract is changing further and some of these impact rotas

in ED which will require more doctors to allow a safe and compliant rota.

9. Engagement

I organised a meeting of the Junior Doctor Forum with plannners to agree plans for junior doctor mess and

rest facility in tower block at DRI on 15th November.

I have also attended 2 trainee induction meetings and 1 management trainee forum meetings to engage with

the junior doctors.

10. Software System

Trust has invested in a new Erostering and exception reporting system from Allocate software. The roll out of Erostering is slow. Once this is in place the assurance for safe and efficient rostering will increase.

11. Issues arising & Actions

1. The increase in trainees and new system may require a review of administrative support to

monitor and analyse exception reporting.

2. The rest facilities for junior doctors at both sites must by prioritised to keep good morale and

safe and rested trainee doctors.

3. The on call rooms needs updating – this plan needs to be drawn up urgently and implemented.

12. Recommendation

The Board of Directors can be assured that the trainee doctors have a safe working practice as envisaged in the 2016 contract.

ANNUAL GUARDIAN REPORT ON ROTA GAPS AND VACANCIES

1

DOCTORS AND DENTISTS IN TRAINING 2019

1. Executive summary

This annual report for 2019 summarizes the quarterly reports previously submitted. The exception

reporting in DBTH is lower than comparable organisations in the region.

The rest facilities, on call rooms and Doctors Mess are in urgent need of update.

There needs to be consistent collection of data for rota gaps and locum and bank usage to monitor

the safe working. This will be accurate once erostering is in place.

2. Introduction

This report sets outs the information from the Guardian of Safe Working as part of the 2016 Terms

and Conditions for Junior Doctors to assure the board of safe working for junior doctors. This report

is for the period January – December 2019.

High level data

Jan-march Apr-Jun July-Dec

Number of posts contracted by DBH 204 204 204

Number of posts contracted by other Organisations 163 163 163

No. of doctors / dentists in training on 2016 TCS 137 137 137

Lead unit with DBTH holding contracts

Lead Unit Doctors:

No of doctors in Doncaster GP Training Scheme 49

No of doctors in North Notts GP Training Scheme 17

Ophthalmology Training 13

ENT Training 12

General Surgery Training 34

Total 125


2

Annual Vacancies in training grade

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

Medicine 11 9 6 4 4 4 4 6.2 3.6 3.2 3.2 3.9

Elderly Med 4 4 1 1 1 1 1 1.4 1.4 0.4 0.4 0.4

Renal 0 0 0 0 0 0 0 1 1 1 1 0

Emergency med 2 2.4 2.4 1 1 1 1 5.9 5.9 6.1 5.6 7

Obs & Gynae 10.4 10.6 9 2.2 2.2 2.2 3.6 7.1 6.9 7.4 7.4 9.4

Paediatrics 1 2.1 1.6 2.7 2.7 2.7 2.7 2.2 1.8 2.2 2.2 2.2

GU Medicine 0 0 0 0 0 0 0 1 1 1 0 0

General Surgery 1 1 1 0 0 0 2 0.7 0.5 0.2 0.2 1.2

Urology 0.4 0.4 0.4

Trauma & Ortho 0.2 2.2 1 2 2 2 2 1 2 1 1 1

ENT 1 1 1 1 1 1 1 1 0 1 1 1

ICT 1 1 1 1 0

Radiology 1 1 1 1 1 1 3 3 3 0 0 0

Anaesthetics 4.4 0.4 0.4 0 1 1 1 1 1 0 0 0

Total 36 33.7 24.4 14.9 15.9 15.9 21.3 32.5 29.1 24.9 23.4 26.5

*Total gaps, number of shifts uncovered over the year, average no. of shifts uncovered per week information

was not collected.

The vacancy data is very similar to last year.

Annual exception reporting summary

Nature of exception Number

Education 3

Service support 4

Hours 65

Pattern 4

Specialty Number

Medicine 14

Surgery 21

Urology 10

Paediatrics 18

A&E 3

Obs & Gynae 8

GP 1

Anaesthetics 1

Total 76

Grade Number

Foundation1 24

Junior FY2-ST3 44

Senior 7

GPVTS 1


3

6 exceptions from hours breach were to do with missed breaks which did not result in any fine as per

rules. The data for locum and bank usage is not collated as the formats are different and it’s not

possible to analyze it.

3. Issues arising & actions taken to resolve issues

The gaps in the rota are quite variable and dependent on the HEE. GP trainees vacancies have

improved and this year’s intake is oversubscribed but there are gaps in senior years. This year

the gaps have been about average. Some divisions are in process of filling this gaps with

international training schemes ( MTI) or specialty doctors.

The exception reporting and workplan review in medicine has resulted in a safer work schedule

with reduced exception reports in Medicine.

The quality of rest facilities and doctors mess was clearly identified as a issue in’ We care for

junior doctors’ group ,exit meetings with trainees, and walk around inspection. There is some

funding available from HEE and a business case is being prepared for additional funding to

improve these facilities.

The doctors mess in BDGH has been taken over to improve ED. Alternative facilities have been

promised but no plans have yet been finalized.

4. Summary and recommendations

I am assured that all trainee rotas are legal under 2016 contract. This is also borne out by exception

reporting.

I would strongly urge implementing erostering system to allow safe rostering and identify gaps on a

realtime basis. This has been purchased and is in the process of implementation.

I would urge the trust to invest in improving on call rooms, rest facilities and junior doctors mess to

ensure a safe, rested workforce. This will also have appositive impact on recruitment.

I would like to assure the board that the junior doctors have a safe working and learning

environment.

1

Title Financial Performance – Month 11 – February 2020

Report to Trust Board Date 17th March 2020

Author Alex Crickmar – Deputy Director of Finance

Jon Sargeant - Director of Finance


Decision

Assurance

Information X


The Trust’s deficit (before PSF, FRF and MRET) for month 11 (February 2020) was £219k which is a favourable

variance against plan of £400k in month (the Trust’s financial position was a £1.5m surplus in month including

PSF, FRF and MRET which is £400k favourable against plan). The cumulative position to the end of month 11 is a

£15.2m deficit (before PSF, FRF and MRET), which is £522k favourable to plan (the Trust’s YTD financial position

is a £1.7m deficit including PSF, FRF and MRET which is £522k favourable against plan). The Trust’s in month

financial position was £274k favourable to forecast.

The Trust is now expecting to deliver its control total at year end.


Is the Board assured by actions taken to bring the financial position back in line with plan?


This report relates to strategic aims 2 and 4 and the following areas as identified in the Trust’s BAF and CRR.

F&P 1 - Failure to achieve compliance with financial performance and achieve financial plan and subsequent cash implications

F&P 3 - Failure to deliver Cost Improvement Plans in this financial year

F&P 19 - Failure to achieve income targets arising from issues with activity

F&P 13 - Inability to meet Trust's needs for capital investment

F&P – 14 - Reduction in hospital activity and subsequent income due to increase in community provision

F&P 16 - Uncertainty over ICS financial regime including single financial control total

F1

2


Update on risk relating to delivery of 2019/20 financial plan.


The Board is asked to note:

The Trust’s deficit (before PSF, FRF and MRET) for month 11 (February 2020) was £219k which is a

favourable variance against plan of £400k in month (the Trust’s financial position was a £1.5m surplus in

month including PSF, FRF and MRET which is £400k favourable against plan). The cumulative position to

the end of month 11 is a £15.2m deficit (before PSF, FRF and MRET), which is £522k favourable to plan

(the Trust’s YTD financial position is a £1.7m deficit including PSF, FRF and MRET which is £522k

favourable against plan). The Trust’s in month financial position was £274k favourable to forecast.

The achievement with regards to the Cost Improvement Programme.

3

FINANCIAL PERFORMANCE

P11 February 2020

The Trust’s deficit (before PSF, FRF and MRET) for month 11 (February 2020) was £219k which is a favourable

variance against plan of £400k in month (the Trust’s financial position was a £1.5m surplus in month including PSF,

FRF and MRET which is £400k favourable against plan). The cumulative position to the end of month 11 is a £15.2m

deficit (before PSF, FRF and MRET), which is £522k favourable to plan (the Trust’s YTD financial position is a £1.7m

deficit including PSF, FRF and MRET which is £522k favourable against plan). The Trust’s in month financial position

was £274k favourable to forecast.

The month 11 the income position is £1,069k favourable to plan in month, with a £4,105k favourable YTD position.

The over performance in month relates to both clinical and non-clinical income, which in month are £815k and

£254k favourable to plan.

The main movements within the clinical income variance against plan in month are due to;

An under performance in both elective income of £96k and in day cases of £36k against plan.

Outpatients were £37k behind plan and non-PbR Drugs were favourable to plan by £278k in month.

Emergency income was £210k behind plan, however A&E over-performed against plan by £139k.

Note : The income figure excludes £744k relating to 18/19 post accounts allocation of PSF

The in-month expenditure position was £558k adverse to plan, of which pay was £195k adverse to plan, non-pay

£1.6m adverse to plan and reserves £1.2m favourable to plan. The YTD expenditure position at the end of Month 11

is £4m adverse to plan (with pay £417k favourable to plan and non-pay/reserves £4.4m adverse to plan).

Capital expenditure is £7.3m behind budget YTD with spend of £11.8m against the YTD budget of £19.1m. YTD spend

is £0.6m behind the forecast. The in month capital spend for month 11 was £3.2m against an in month budget of

£3.5m. This was an underspend in month of £0.3m against plan, however in month spend was £0.4m ahead of

forecast.

The cash balance at the end of February was £27.1m (January: £25.7m). The increase of cash in month is mainly as a

result of receipt of PDC Dividend relating to capital schemes of £2.9m and increase in capital creditors of £1.9m to

£4.4m.

In February 2020, CIP savings of £1,177k are reported, against a plan of £1,904k, an under achievement of £727k in

month. Year to date the Trust has delivered savings of £9.3m versus plan of £11.3m an under-delivery of £2m.

Income Group Annual BudgetIn Month

BudgetIn Month Actual YTD Budget YTD Actual

Commissioner Income -338,437 -28,032 -28,569 -537 F -308,799 -307,792 1,006 A

Drugs -19,606 -1,513 -1,791 -278 F -17,972 -19,228 -1,256 F

PSF, FRF and MRET -15,296 -1,715 -1,715 0 F -13,579 -13,579 0 F

Trading Income -38,612 -3,609 -3,863 -254 F -35,354 -39,210 -3,856 F

Grand Total -411,951 -34,869 -35,938 -1,069 F -375,704 -379,809 -4,105 F

YTD VarianceIn Month

Variance

Expenditure type

In Month

Budget

In Month

Actual

YTD

Budget

YTD

Actual

Annual

Budget

Pay 23,226 23,421 195 A 252,388 251,971 -417 F 277,981

Non-Pay 8,900 10,498 1,597 A 106,651 117,549 10,899 A 113,267

Reserves 612 -622 -1,234 F 6,922 449 -6,474 F 13,168

Total Expenditure Position 32,739 33,296 558 A 365,961 369,968 4,008 A 404,416

In Month

Variance

YTD

Variance

1. Month 11 Financial Position Highlights

The Board is asked to note:

The Trust’s deficit (before PSF, FRF and MRET) for month 11 (February 2020) was £219k which is a

favourable variance against plan of £400k in month (the Trust’s financial position was a £1.5m surplus in

month including PSF, FRF and MRET which is £400k favourable against plan). The cumulative position to the

end of month 11 is a £15.2m deficit (before PSF, FRF and MRET), which is £522k favourable to plan (the

Trust’s YTD financial position is a £1.7m deficit including PSF, FRF and MRET which is £522k favourable

against plan). The Trust’s in month financial position was £274k favourable to forecast.

The achievement with regards to the Cost Improvement Programme.

2. Recommendations

BOARD OF DIRECTORS – 17 MARCH 2020

CHAIR’S ASSURANCE REPORT

FINANCE AND PERFORMANCE COMMITTEE – 25 FEBRUARY 2020

Overview: Although receiving the normal finance and performance agenda, this meeting was focused in particular on

looking at the probable year end outturn and then looking at provisions, in both finance and performance

terms, to ensure activity and pace of delivery did not stutter or pause at the financial year end and instead

progress to meet key targets and efficiencies continued smoothly through into the following year.

Again, we discussed performance thoroughly, looking in particular at the Emergency Department four-hour

access data and unpacking in some detail the referral to treatment position, both subjects being a cause for

some ongoing concerns. We received a detailed RTT progress report from Claire Jenkinson, Deputy Chief

Operating Officer – Elective, Jodie Roberts, Deputy Chief Operating Officer – Non-Elective, and Laura

Fawcett, General Manager, Surgical and Cancer. We were pleased to note progress over recent weeks as the

recovery plan begins to gain traction and grateful for the candid and helpful discussion that gave us

confidence that this difficult area was being dealt with to the best of our ability.

The financial projected outturn was considered and we noted positive news that the overall control total

remained within reach provided focus was maintained and current progress sustained.

We considered workforce data and discussed further plans to maximise the potential of the deployed HR

software “Allocate”, asking for a presentation to be brought to this committee in the near future. The

software will assist with standardising Agency budget management processes across different specialties

which currently prefer to use their own methods.

F+P received and noted the current risk register, the relevant risks having been considered actively with each

paper received at the meeting.

AGENDA ITEM / ISSUE

COMMITTEE UPDATE NEXT ACTION LEAD TIMESCALE

Minutes and Actions from previous meetings

The Committee approved the minutes from the previous meeting and noted progress on actions being assured that all were appropriately tracked

None N/A N/A

Integrated performance report

The Committee was assured by the report

A review would be taken of the increase in diagnostic referrals.

RJ March meeting

G1

A quarterly report would be provided on Non-Medical Waits. A progress update report would be provided in June 2020.

April meeting June meeting

Deep dive – RTT progress

The Committee received the presentation, noted progress and was assured by the current position

None N/A N/A

Financial performance


A review of QI financial savings would be undertaken. A paper would be provided on Going Concern at the March meeting.

JS March meeting March meeting

2020/21 budget setting and control total


None N/A N/A

Financial technical papers


None N/A N/A

Workforce Management


The cost benefits of recruitment and advertising would be added to the Workforce Report.

KB March meeting

Corporate Risk Register

The Committee was partially assured by the report and requested a fuller covering paper and more timely submission of the risk register, which had only been received the previous evening.

More detailed covering report for next submission of the risk register

Company Secretary

March meeting

Information Items

The meeting also received and noted the minutes of a number of sub-committees

None N/A N/A

No escalations were received by the Committee and there were no escalations to the Board

KEY

CLOSED

ASSURED

PARTIALLY ASSURED / SOME ACTION TO TAKE

NOT ASSURED / ACTION REQUIRED

of 8

Audit and Risk Committee (ARC)

Terms of Reference

Name Audit and Risk Committee (“the Committee”).

Purpose To provide the Board of Directors (“the Board”) with a means of independent and objective review of internal controls and risk management arrangements relating to:

Financial systems;

The financial information used by the Trust;

Controls and assurance systems;

Risk management;

Health and Safety, Fire and Security;

EPRR;

Compliance with law, guidance and codes of conduct; and

Counter fraud activity.

Responsible to The Committee reports to the Board. The Chair of the Committee is responsible for reporting assurance to the Board on those assurance matters covered by these Terms of Reference. The minutes of the Committee shall be submitted to the Board of Directors. The Chair of the Committee will report to the Board after each meeting and shall draw to the attention of the Board any issues that require disclosure to the Council of Governors, or require executive action. The Committee will present a written annual report to the Board summarising the work carried out during the financial year and outlining its work plan for the future year.

G2

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Delegated authority

The Committee is a Non‐Executive Committee and holds no executive powers other than those specifically delegated in these Terms of Reference.

The Committee is authorised to investigate any activity within its Terms of Reference. It is further authorised to seek any information it requires from any employee of the Trust and all employees are directed to co‐operate with any request made by the Committee. The Committee is authorised by the Board to secure legal or independent professional advice, or to request the attendance of external advisers with relevant experience and expertise if it considers this necessary.

Duties and work programme

1 Integrated Governance, Risk Management and Control

1.1 The Committee shall review the effectiveness of the system of integrated governance, risk management and internal controls, to satisfy the Board that its approach to integrated governance remains effective.

1.2 Determine the actions, controls and audits/reviews required to provide Non‐Executives and the Board with robust assurance regarding the reported financial position going forward; and to maintain the confidence of governors, regulators and the public. Undertake ongoing review of the implementation and effectiveness of these.

1.3 The Committee will review the adequacy of:

i. all risk and control related disclosure statements (in particular the Annual Governance Statement and Declarations of Compliance made to NHSI) together with any accompanying Head of Internal Audit statement, external audit opinions or other appropriate independent assurance, prior to endorsement by the Board;

Board of Directors

Audit & Risk

Health & Safety Group

Finance & Performance Quality & Effectiveness

Information Governance Group

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ii. the underlying assurance processes that include the degree of achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of related disclosure statements;

iii. the policies and procedures for ensuring compliance with relevant regulatory, legal and code of conduct requirements; and

iv. the arrangements, policies and procedures for all work related to fraud and corruption (but shall not be responsible for the conduct of individual investigations); and

v. The operating of, and proposed changes to, the Board of Directors standing orders, standing financial instructions, the constitution, codes of conduct, scheme of delegation and standards of business conduct.

1.4 In carrying out this work the Committee will primarily utilise the work of

Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurance from executive directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

2 Internal Audit

2.1 The Committee shall monitor the effectiveness of the internal audit function established by management that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Committee, Chief Executive and Board. This will be achieved by: i. consideration of the provision of the Internal Audit service, the cost of

the audit and any questions of resignation and dismissal; ii. review and approval of the Internal Audit strategy, operational plan

and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the Assurance Framework;

iii. consideration of the major findings of internal audit work (and management’s response), and ensure co‐ordination between the Internal and External Auditors to optimise audit resources;

iv. oversee the effective implementation of internal and external audit recommendations;

v. ensuring that the Internal Audit function is adequately resourced and have appropriate standing within the organisation; and

vi. annual review of the effectiveness of Internal Audit.

3 External Audit

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3.1 The Committee shall review the work and findings of the External

Auditor whom are appointed by the Council of Governors and consider the implications of and management’s responses to their work. This will be achieved by: i. consideration of the appointment and performance of the External

Auditor in accordance with the Trust specification for an External Audit Service, informed by NHSI’s Audit Code for NHS Foundation Trusts;

ii. discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan ensuring co‐ordination, as appropriate, with other External Auditors in the local health economy;

iii. discussion with the External Auditors of their local evaluation of audit risk and assessment of the Trust and associated impact on the audit fee;

iv. review of all External Audit reports, including agreement of the annual audit letter, before submission to the Board and review of any work carried outside the annual audit plan, together with the appropriateness of management responses; and

v. review of the annual audit letter and the audit representation letter before consideration by the Board.

4 Other Assurance Functions

4.1 The Committee shall review the findings of other significant assurance

functions, both internal and external to the organisation, and consider their implications to the governance of the organisation. These may include, but will not be limited to: any reviews by Department of Health Arms’ Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Resolution, Health and Safety, Shared Business Services etc.); professional bodies with responsibility for the performance of staff; or functions (e.g. accreditation bodies, etc.) relevant to the Terms of Reference of this Committee.

4.2 In addition, the Committee will review the work of the other Committees within the organisation whose work can provide relevant assurance to the Committee’s own scope of work.

5 Management

5.1 The Committee shall request and review reports and assurance from directors and managers on the overall arrangements for governance, risk management and internal control.

5.2 They may also request reports from individual functions from within the organisation as appropriate.

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6 Financial Reporting

6.1 The Committee shall review the Annual Report and Financial Statements

before recommendation to the Board, focusing particularly on:

i. the wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee;

ii. compliance with accounting policies and practices; iii. unadjusted mis‐statements in the financial statements; iv. major judgemental areas; v. significant adjustments resulting from the audit; vi. the clarity of disclosures; and vii. the going concern assumption.

6.2 The Committee should also ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Board.

7 Counter Fraud Arrangements 7.1 The Committee shall ensure that there is an effective counter fraud

function established by management that meets the NHS Counter Fraud standards and provides independent assurance to the Committee, Chief Executive and Board. This will be achieved by:

i. review the adequacy of the policies, procedures and plans for all

work related to fraud, bribery and corruption; ii. ensuring effective co‐operation with the Counter Fraud function and

that it has appropriate standing within the Trust; iii. receipt of quarterly reports and an annual report from the Local

Counter Fraud Specialist (LCFS) on counter fraud activity and investigations;

iv. ensuring compliance with Section 24 of the NHS National Contractregarding fraud and NHS Standards for Providers as required by the NHS Counter Fraud Authority.

8 Other areas of work

8.1 Information Governance:‐ The Committee shall receive reports and

review assurance from directors and managers on the overall arrangement for compliance with Information Governance Standards.

8.2 Health and Safety, Fire and Security:‐ The Committee shall receive reports from relevant directors and officers, including the Local Security Management Specialist, on the arrangements for compliance with relevant health and safety, fire and security standards.

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8.3 EPRR:‐ The Committee shall receive reports from the Trust’s Emergency

Planning Officer on Emergency Preparedness, Resilience and Response, including the proposed statement of compliance arising from the annual self‐assessment against NHS England’s Core Standards return.

9 Special Assignments

9.3 The Committee shall commission and review the findings of any special

assignments required by the Board.

10 Performance

10.3 The Committee shall request and review reports and assurance from directors and managers on the overall arrangements for reporting compliance with:

i. the Trust’s corporate objectives; ii. NHSI’s governance standards and declarations, including the review

of areas of non‐compliance in the context of NHSI’s “comply or explain” philosophy; and

iii. key performance objectives as appropriate but not to duplicate the work of QEC or F&P

11 Risk Management

11.3 The Committee will provide assurance to the Board that the Risk

Management Strategy is being complied with, including, but not limited to, reviewing Risk Registers. The Committee shall request and review reports and assurance from directors and managers on effects of arrangements to identify and monitor risk. The Board will retain the responsibility for routinely reviewing specific risks.

12 Workplan

12.3 The Committee’s annual work plan is an appendix to these Terms of Reference, and is subject to annual review by the Committee.

Policy approval

The Committee has responsibility for approving the following policies:

Fraud, Bribery & Corruption Policy and Response Plan;

Standards of Business Conduct and Employees Declarations of Interest Policy.

Chair A Non‐Executive Director, appointed by the Board of Directors, will chair the Committee.

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Membership Four Non‐Executive Directors. Time served needs to be removed agreed by the committee and needs to be 2 out of the 4 NEDs for quoracy.

One of the Non‐Executives shall have recent and relevant financial experience.

Each Non‐Executive shall normally not serve more than three years as a Committee member, unless the requirement for one of the members to have recent and relevant financial experience is compromised.

The Trust Chair of the Trust shall not be a member of the Committee.

In attendance Director of Finance

Deputy Director of Finance

Company Secretary

Local Counter Fraud Specialist

Appropriate internal and external audit representatives

Security Management Specialist

Corporate Governance Officer (Minutes)

Other trust staff as appropriate / requested

The Chief Executive, executive directors or other officers will be required to attend at the request of the Committee, for issues relevant to their areas of responsibilities. Two public governors, nominated by the Council of Governors, will be invited to attend the Committee, as observers. The Chair and Chief Executive of DBTH will be invited to attend at least annually.

Secretary Trust Board Secretary (supported by Corporate Governance Officer)

Voting Matters will generally be decided by way of consensus. Where it is necessary to decide matters by a vote then each member will have one vote. The Chair will have a casting vote.

Quorum Two members.

Attendance requirements

Committee members must attend at least 50% of meetings.

Frequency of meetings

No less than quarterly and more frequently as required. At least once per year, the Committee should meet with the external and internal auditors, without management being present, to discuss matters relating to its responsibilities and issues arising from the audit.

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The External Auditor and Head of Internal Audit may request a private meeting if they consider that one is necessary. They will also have direct access to the Chair of the Committee.

Papers Papers will be distributed a minimum of five clear working days in advance of the meeting.

Permanency The Committee is a permanent Committee.

Reporting Committees

Health and Safety Committee Information Governance Steering Group

Circulation of minutes and other reporting requirements

The Governor observers shall report to the Council of Governors on a quarterly basis regarding the work of the Committee, any matters needing action or improvement and the corrective actions to be taken. Following the Council of Governors appointment of the External Auditors, the Committee shall report to the Council of Governors regarding the reappointment, termination of appointment and fees of the External Auditors.

Date approved by the Committee: 6 February 2020

Date approved by the Board of Directors: 18 February 2020

Review date: February 2021

1

Finance and Performance Committee

Terms of Reference

Name Finance and Performance Committee (“the Committee”).

Purpose The Committee will carry out its duties as an assurance Committee of the Board of Directors (“the Board”) in reviewing systems of control and governance specifically in relation to operational performance and financial planning and reporting. It is supported by the Audit and Risk Committee which provides the oversight arm of the Board, reviewing adequacy and effectiveness of controls. The work of the Committee is aligned to the Trust’s Strategic Objectives and is organised to provide assurance on the progress towards the True North Objectives:

- To provide outstanding care and improve patient experience; - Everybody knows their role in achieving the vision; - Feedback from staff and learners in top 10% in UK; - In recurrent surplus to invest in improving patient care.

Responsible to The Board. The Chair of the Committee is responsible for reporting assurance to the Board on those matters covered by these terms of reference through a regular written report. The minutes of the Committee shall also be submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the Council of Governors, or may require executive action. The Committee will present a written annual report to the Board summarising the work carried out during the financial year and outlining its work plan for the future year.

Relationship to other Committees

The Committee will receive information and assurances from the Trust’s internal management and operational Committees as required. This includes Capital Monitoring Group, Corporate Investment Group, Effectiveness and Efficiency Committee and Workforce, Education and Research Committee. However the only Committee that is a sub‐Committee of Finance and Performance Committee will be the Cash Committee.

2

It is important that the Committee minimises areas of overlap with the Audit and Risk Committee. Therefore, the following specific areas of responsibility will be excluded from the Finance and Performance Committee agenda: Audit – external and internal; Standing Financial Instructions and Scheme of Delegation oversight; Local Counter Fraud Specialist work.

Delegated authority

The Committee is a Committee of the Board and holds those powers specifically delegated to it by the Board and set out in these terms of reference. The Committee is authorised to investigate any activity within its terms of reference. It is further authorised to seek any information it requires from any employee of the Trust and all employees are directed to co‐operate with any request made by the Committee. The Committee may make a request to the executive for legal or independent professional advice and request the attendance of external advisers with relevant experience and expertise if it considers this necessary. The Committee will operate at a strategic level as the executive is responsible for the day to day operational financial delivery and performance management of the Trust.

Board of Directors

Finance and Performance

Corporate Investment Group Capital Monitoring

Committee

Audit & Risk Quality & Effectiveness

Capital Monitoring Committee

Efficiency andEffectiveness Committee

Workforce, Education and Research Committee

Cash Committee

3


(1) To review reports relevant to the Committee that relate to the following matters:

‐ current financial and operational performance and reporting; ‐ financial forecasts, budgets and plans in light of trends and

operational expectations; ‐ workforce performance such as vacancy levels, sickness rates and

roster performance; ‐ plans and processes for the implementation of Effectiveness and

Efficiency Improvement Plans; ‐ the Trust’s financial strategy, in relation to both revenue and capital, ‐ sensitivity and scenario analysis to support financial planning; ‐ major Trust investment plans, maintaining oversight of investments; ‐ any innovative, commercial or investment activity eg proposed joint

ventures; ‐ any specific risks in the Board Assurance Framework relevant to the

Committee; and provide assurance to the Board in respect of their delivery. (2) To consider and review any items identified by, or escalated to the

Committee relating to Enabling Strategies that are monitored through the corporate objectives and reported to the Board of Directors.

(3) To consider and agree on behalf of the Board:

‐ appropriate measurements to review to provide assurance by which operational and workforce performance is managed in line with the Single Oversight Framework and strategic objectives of the Trust;

‐ appropriate targets and tolerances by which measurements can be assessed, including updated forecasts where necessary, in order to monitor performance in line with the Single Oversight Framework and stated objectives of the Trust;

‐ the Trust’s Investment Policy and Procurement Strategy; ‐ any significant variations to the Trust’s existing procurement

methodology in accordance with the Standing Orders; ‐ NHSI quarterly declarations; ‐ accounting policies.

(4) To receive, consider and make recommendations to the Board for the final decision on proposals and their respective funding sources for significant transactions which would: ‐ materially change the Trust’s service provision;

4

‐ seek to merge or partner with another organisation(s) which would change the Trust’s independent status; ‐ be transactions that extend beyond the levels of delegation of the Chief Executive.

(5) To supervise the setting and monitoring of significant contracts. (6) To make arrangements as necessary to:

‐ ensure that all members of the Board and senior officers of the Trust maintain an appropriate level of knowledge and understanding of key financial issues;

‐ undertake a review of the Committee’s effectiveness on an annual basis.

(7) To approve terms of reference and membership of reporting sub‐

Committees and oversee the work of those sub‐Committees.

Chairing arrangements

The Chair will be chosen by the Board from among the non‐executive members of the Committee. The Vice‐Chair will be a non‐executive director chosen by the Committee when necessary.

Membership Three NEDs

Director of Finance

Chief Operating Officer

Director of People and Organisational Development

In attendance Director of Strategy and Transformation (non‐voting)

Company Secretary


Other Trust staff as appropriate / requested

Governor observer

Secretary Company Secretary (supported by Corporate Governance Officer)


Quorum Three members and at least two NEDs.


Monthly, with other meetings convened as necessary.

Papers Papers will be distributed three clear days in advance of the meeting.

5

Permanency This is a permanent Committee of the Board.

Reporting Committees

None

Circulation of minutes

Board of Directors

Sub‐Committee Cash Committee

Committee Minutes provided

Capital Monitoring Group

Corporate Investment Group

Efficiency and Effectiveness Committee

Workforce Education and Research Committee (WERC)

Date approved by the Committee: January 2020

Date approved by Board of Directors: March 2020

Review date: February 2021

of 4 February 2020

Quality and Effectiveness Committee

Terms of Reference

Name Quality and Effectiveness Committee (“the Committee”)

Purpose The Committee will carry out its duties as an assurance Committee of the Board of Directors (‘’the Board”) in reviewing systems of control and governance specifically in relation to clinical quality and governance and organisational effectiveness. It is supported by the Audit and Non‐clinical Risk Committee which provides the oversight arm of the Board, reviewing adequacy and effectiveness of controls.

The work of the Committee is aligned to the Trust’s Strategic Objectives and is organised to provide assurance on the progress towards the True North Objectives:

- To provide outstanding care and improve patient experience; - Everybody knows their role in achieving the vision; - Feedback from staff and learners in top 10% in UK; - In recurrent surplus to invest in improving patient care.

Responsible to The Board. The Chair of the Committee is responsible for reporting assurance to the Board on those matters covered by these terms of reference through a regular written report. The minutes of the Committee shall also be submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the Board of Governors, or may require executive action. The Committee will present a written annual report to the Board summarising the work carried out during the financial year and outlining its work plan for the future year.

Relationship to other Committees

The Committee will receive information and assurances from the Trust’s internal management and operational Committees as required. This includes Clinical Governance and Quality Committee, Patient Experience Committee and Workforce and Education Committee as shown below.

Board of Directors

Quality & Effectiveness

Workforce & Education Clinical Gov & Quality Patient Experience

Finance & Performance Audit & Non-clinical Risk

of 4 February 2020

Delegated authority

The Committee is a Committee of the Board and holds those powers specifically delegated to it by the Board and set out in these terms of reference. The Committee is authorised to investigate any activity within its terms of reference. It is further authorised to seek any information it requires from any employee of the Trust and all employees are directed to co‐operate with any request made by the Committee. The Committee may make a request to the executive for legal or independent professional advice and request the attendance of external advisers with relevant experience and expertise if it considers this necessary. The Committee will operate at a strategic level as the executive is responsible for the day to day delivery of Trust services and management of its workforce.


(1) To review reports relevant to the Committee that relate to the following matters:

‐ the Trust wide quality objectives as part of the QI Strategy, ‐ the clinical risk management framework and any controls and

assurances against relevant clinical risks on the Board Assurance Framework,

‐ the effectiveness of clinical governance, clinical risk management and clinical control,

‐ promoting an honest and open reporting culture, ‐ disclosure statements (in particular the Quality Report and Declarations

of Compliance made to NHSI), prior to endorsement by the Board, ‐ the CQC Essential Standards of Quality and Safety as part of the internal

assurance process, ‐ compliance with licensing standards of the Care Quality Commission, ‐ any improvement reviews/notices from the Care Quality Commission

and other external assessors, ‐ clinical data and patient identifiable information to ensure that it is in

accordance with the Caldicott Guidelines and relevant legislation and guidance,

‐ adverse clinical incidents, complaints and litigation and examples of good practice and learning,

‐ the QPIA process for Efficiency and Effectiveness Improvement Plans, ‐ infection control, ‐ mortality, ‐ comments, compliments and complaints, ‐ safety of medical devices, ‐ workforce matters including workforce planning, staff engagement and

experience, training, education and development, staff wellbeing ,

of 4 February 2020

equality and diversity, employee relations and HR and OD systems and processes,

and provide assurance to the Board in respect of their delivery.

(2) To consider and review any items identified by, or escalated to the Committee relating to Enabling Strategies that are monitored through the corporate objectives and reported to the Board of Directors.

(3) Through the Clinical Governance & Quality Committee, the Committee

will obtain assurance that clinical governance strategies and plans are embedded and that the clinical governance function is adequately resourced and has appropriate staffing.

(4) To undertake thematic reviews and deep dives into quality, governance

and workforce related issues. (5) To ensure that the Trust has reliable, up‐to‐date information about

what it is like being a patient experiencing care administered by the Trust.

(6) To approve terms of reference and membership of reporting sub‐Committees and oversee the work of those sub‐Committees.

(7) To hold the Divisional Directors to account clinical quality and

governance in their areas.

Chairing arrangements

The chair will be nominated from among the non‐executive members of the Committee. The vice‐chair will be the Medical Director.

Membership Three members, appointed by the Board from amongst the Non‐executive Directors (other than the Chairman of the Trust).

Medical Director

Director of Nursing, Midwifery and Allied Health Professionals

Director of People and Organisational Development

In attendance Director of Strategy of Transformation (TBC)

Deputy Director of Nursing & Midwifery and Allied Health Professionals

Deputy Director for Quality and Governance

Clinical Governance and Professional Standards Co‐ordinator

Company Secretary


Other Trust staff as appropriate / requested

Two governors

Secretary Company Secretary (supported by Corporate Governance Officer).

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Quorum Three members, including the chair or vice‐chair.


Once every two months.

Papers Papers will be distributed a minimum of three clear working days in advance of the meeting, but ideally a week before.

Permanency The Committee is a permanent Committee.

Sub‐Committees

Clinical Governance & Quality Committee Patient experience Committee Workforce and Education Committee

Date agreed by the Committee:

January 2020

Date approved by the Board of Directors:

February 2020

Review date:

February 2021

H1

Title Chair’s and NEDs’ Report


Author Suzy Brain England, Chair of the Board


Decision

Assurance

Information x


The report covers the Chair and NEDs’ work in February and March 2020.


N/A


The report relates to all of the strategic objectives.


N/A


That the report be noted.

Chair’s and NEDs’ Report – March 2020 Introductory Meetings Following the announcement of Dr Noble’s appointment as Medical Director we met to exchange thoughts on what the next few months may hold. We talked priorities, opportunities and challenges and along with other colleagues I offered my support to Tim. Today I extend a warm welcome to him as he joins his very first Board of Directors meeting as Medical Director.

Since my last report I have also met with partners from DAC Beachcroft, the Trust’s solicitors. Our paths crossed on one of their regular relationship meetings with Richard and as we hadn’t formally met we took the opportunity to agree a future get together. We spoke about their current service offer, the range of support

offered to the Trust and considered the ways in which we work together and the outcomes we would hope to achieve. Other Meetings My commitment to work within the South Yorkshire & Bassetlaw ICS and at Place continues. I recently met with David Crichton, Chair of Doncaster Clinical Commissioning Group, to consider the ways in which non-executive directors can engage and contribute to effective leadership and scrutiny at place to support delivery of integrated care. I have also discussed with Kevan Taylor, SY&B ICS System Lead for Workforce & Health how best to engage NEDs and governors in ICS business and he has committed to seek the views of other Chairs on this matter. I have also held 1:1 meetings with my non-executive directors; the NEDs are busy supporting and championing specific areas of responsibility within the Trust so it’s a great opportunity to catch up personally and for them to share progress with me.

Company Secretary Recruitment Following the short-term secondment of Jeannette Reay to the role of Head of Corporate Assurance/Company Secretary a recruitment campaign to secure a permanent appointment is now underway. Ahead of the closing date of 1 March Richard and I were contacted by a number of prospective candidates to gain an insight into the role, the Trust and its ambitions ahead of their applications. The interviews for this post will take place on Wednesday 18 March, when a stakeholder panel consisting of a cross selection of directors, non-executive directors and governors will support the appointment panel, comprising of myself, Richard Parker, Hazel Brand (Lead Governor) and Matt Kane as an external assessor. Jeannette Reay will return to her substantive post of Emergency Planning Officer with effect from this week, where along with routine emergency planning matters she will support the Trust’s Covid 19 planning. I would like to take this opportunity to thank Jeannette for her support over the last nine months. CT Suite Ahead of the opening of the CT Suite I was able to visit the recently competed project with our Director of Estates and Facilities, Kirsty Edmondson-Jones and Phil Colebourne, Project Manager. This is an exciting development for the Trust, which has been made possible by the fundraising efforts of Doncaster Cancer Detection Trust. To mark their amazing contributions over the years and in memory of their founder, Jeannette Fish MBE, the suite will be named The Jeannette Fish CT Suite. Visit to the Rapid Assessment Programme Team At the beginning of March I spent some time with Clayton Cecil, Clinical Lead Physiotherapist in the Rapid Assessment Programme Team. Whilst observing the work of the team I particularly noted the excellent provision of dedicated, patient centred care and for that I would like to extend my appreciation for the great work that goes on not just whilst I was there but throughout Team DBTH each and every day. Governor Briefing Finally, on 3 March I attended the Governor Briefing, the event was well attended and the agenda included the following presentations: Maintaining Confidentially – Paula Hill, Freedom to Speak Up Guardian

Meet your Partner Governor - Prof Rob Coleman, Dr Jackie Hammerton and Alexis Johnson Staff Survey Results – Jayne Collingwood, Head of Leadership & Organisational Development David Purdue supported the final element of the session when he provided updates on those “hot topic” items – Covid 19, CQC Report –including the next steps, Workforce Plans (Women & Children & Diagnostic Imaging Services) and finally he spoke of the anticipated changes to Bassetlaw’s “Front Door” and the current state relating to the potential new hospital build. At the end of the session governors were invited to join the HEAR Masterclass “Breaking the Silence” presented by David Beeney. David shared his personal journey of living with mental health issues. He now actively works to reduce the stigma of mental health in the workplace, working with employers to understand how they can support their workforce and implement strategies to support mental well-being at work. NED Report Kath Smart In her role as Audit & Risk Committee Chair, Kath attended the Yorkshire Audit Chairs conference which is aimed at keeping audit knowledge and information up to date and relevant. It provided an opportunity to discuss Audit Committees in the NHS and also contributes to Kath's CPD portfolio. Kath has shared information on risk appetite from this session with the Trust, in preparation for reviewing DBTH's Risk Strategy and Board Assurance Framework. Kath has also participated in a conference call with KPMG and NED colleagues, to ensure all are aware of, sighted on and involved in the Internal Audit Planning for 2020/21. Along with other NEDs Kath has completed her Statutory and Essential Training and attended her annual Fire Lecture. She also attended two lunchtime lectures on the staff survey outcome and on DBTH Digital Strategy. It was very positive to hear from the Trust’s clinical digital team who are supporting clinical staff with the continued Nervecentre roll out and 'Axe the Fax'. Kath has had 1:1 meetings with the Company Secretary and the Director of Nursing to discuss changes and improvements to the Trust Board Assurance Framework and the Corporate Risk Register. She also attended February's Finance & Performance Committee. Pat Drake Since the last Board report Pat has visited the Paediatric and Neonatal Units to observe new initiatives. She has chaired the pre-met for the Quality & Effectiveness Committee where the agenda for March’s meeting was agreed and considered key agenda items for future planning.

She attended February’s Finance and Performance meeting and met with Mandy Dalton, to discuss learning from deaths. Pat was able to join the Governors Briefing session at the start of this month and heard from the inspirational speaker, David Beeny held later that day on the subject of dealing with mental health issues in the workforce. Finally, she attended Sewa’s retirement farewell on 11 March and was able to join with many colleagues to give him a very fitting send off. Sheena McDonnell This month Sheena has been preparing for the upcoming Charitable Funds and Fred and Ann Green Committee meetings. She has committed to undertake the Qi Coach training and has held the first session in preparation for those dates throughout March, April and June 2020. Sheena has had 1:1s this month with the Chair as part of ongoing updates and Karen Barnard discussing the approach to board development amongst other things. Along with other NEDs Sheena took part in a review of the 2020/21 Internal Audit Plan and finally she attended the Trust Ethics Committee Mark Bailey Since Mark joined the Trust on 10th February 2020 he has attended February’s Board meeting and various introductory meetings with Executive and Non-Executive colleagues. He has toured the Doncaster and Bassetlaw sites and has plans to familiarise himself with Montagu following today’s Board meeting. Mark has attended the recent Governor Briefing session and observed a consultant interview, alongside his NED colleague, Neil Rhodes. Going forward Mark will join the Quality & Effectiveness, Audit & Risk and Charitable Funds Committees and act as Digital Champion. His Trust and NHS Provider’s Non-executive induction training are both scheduled for later this month.

H2

Chief Executive’s Report March 2020

Our Trust receives ‘Good’ rating from the Care Quality Commission (CQC)

I am happy to share that our organisation has been rated ‘Good’ by the Care Quality Commission

(CQC), following inspections which took place in September and October 2019.

The CQC report published on Wednesday 19 February, recognised a number of areas of quality care,

practice and improvement at the Trust. Reflecting an overall positive picture, this latest report

means that in addition to an overall Trust rating of ‘Good’, each individual hospital site we operate

also shares the same accreditation.

The CQC assesses trusts against seven key ‘domains’ which are described as ‘safe’, ‘effective’,

‘caring’, ‘responsive’, ‘well-led’, ‘use of resources’ and ‘quality’. Improving upon the previous

inspection, the Trust has been rated good for six of the seven standards, with one domain, Safe,

rated as ‘Requires Improvement’. Although it is not unusual for Acute Trusts to be rated as Requires

Improvement’ we are working hard for this area to also move to ‘Good’ on our journey to be

outstanding.

During their unannounced inspection which began 3 September 2019 and concluded 10 October

2019, the CQC observed many examples of high quality care and emphasised in their report the

improvements made since their last visit. Amongst a variety of departments highlighted within the

report, the Trust’s cross-site urgent and emergency services received particular praise having

improved in seven domains.

Inspectors also described clinicians as demonstrating good infection prevention and control practice,

as well as emphasising a culture of learning at the Trust in order to improve safety. Most

importantly, the visitors highlighted how caring and compassionate health professionals within the

organisation are, as well as noting how well they work together, guided by a shared sense of

purpose.

While a predominately positive report, the CQC have pointed to areas where we need to continue to

improve, such as staffing and training amongst certain colleagues, which the Trust is continuing to

address.

As Chief Executive, I am extremely pleased that the Trust has been recognised as ‘Good’ by the Care

Quality Commission (CQC) – this is an achievement which reflects the hard work, commitment and

expertise of our colleagues, who go above and beyond ever day in the delivery of high quality care

and treatment.

As an organisation, I believe we should be extremely proud that the inspectors described colleagues

as being caring, supportive of each other and compassionate to both patients, their family and loved

ones. As the CQC visited a wide variety of services, they identified areas which we will need to

enhance, and we are in no doubt that we have more work ahead of us in order to realise our vision

to become the safest trust in England.

The Trust is on an improvement journey, and on which I am pleased to reflect upon some

remarkable progress. Now we must ensure that we do not get complacent and instead maintain this

standard for our communities, as well as push on towards achieving our plan to always

deliver outstanding care. Given the progress we have made in a few short years, I am confident that

this is an entirely achievable destination that we will be celebrating before too long.

The reports are published on the CQC website at https://www.cqc.org.uk/provider/RP5

Celebrating our best ever Staff Survey results

The Staff Survey is the most consistent and accurate way

that we have of measuring team morale, as well as giving

us a deep insight into our working environments. Each

year, this questionnaire is sent via Picker to colleagues so

that, as a Trust, we can gain a better understanding of

what it is like to work here, what we are doing well and

also what we need to change for the better.

I am enormously pleased that this year we have registered

our highest ever Staff Survey completion rate (just under 60%), continuing a trend of increasing the

number of participants for the seventh year in a row. I am also very pleased to report that in all 11 of

https://www.cqc.org.uk/provider/RP5

the overall themes within the survey, responses are more positive than compared with the year

before – a fantastic reflection on Team DBTH and the improvements we have made together

throughout the past number of years.

I am also delighted to share with you the news that our Trust has one of the most improved results

of any acute NHS provider in the country – an incredible achievement.

This doesn’t mean however that we can’t improve further. The Staff Survey highlights clear areas

where things can be better, as well as things that we can, and will, do differently. Each Division and

Directorate within the Trust has been tasked with creating their own plans in response to what their

respective part of the Staff Survey has told them, and how they can work with colleagues to make

positive changes throughout the year.

Welcoming Sir Simon Stevens, Chief Executive of the NHS

Earlier this month, the Trust welcomed Simon Stevens, Chief Executive of NHS England and Improvement to Doncaster Royal Infirmary.

Met by a number of colleagues from across the hospital, Simon visited our Department of Critical Care, in addition to our Emergency Department. Throughout we discussed our activity and challenges during winter, as well as our preparations for coronavirus, related staffing, beds as well as our links with social care.

Coronavirus and Team DBTH

Government actions to contain and delay the spread of Coronavirus (COVID-19) are well underway

and as a Trust, we are no different. This week (10 March), we have convened meetings of senior

managers and clinicians to discuss our approach, response and strategy to manage patients

presenting with COVID-19.

As an organisation, we are committed to ensuring that we are as prepared as possible if the number of confirmed cases and hospital admissions rise, with plans to create capacity and ease staffing pressures, stand down any non-essential meetings, conferences and training and explore contingencies which may be required in areas like accommodation, access to our sites, parking and catering.

I want to thank colleagues for their diligent work so far, in particular our urgent and emergency care teams for ensuring that our NHS 111 ‘Pods’ are operational and residents are sign-posted appropriately. I would also like to extend a special mention to our Infection Prevention and Control colleagues who have been working tirelessly to ensure our response falls in-line with national, and fast-moving, guidance.

As our geographical areas remain largely unaffected so far, our biggest challenge presently is

managing the understandable anxiety of our communities, and it is important to reiterate to our

patients and visitors that our hospitals are currently operating as normal. I am aware of an increase

of calls to our contact centres (and thank staff for their handling of this matter), as well as other

correspondence, but for Team DBTH the message is clear - it is business as usual.

We will continue to prepare for any potential cases of the virus, as well as work with our partners

and communicate with our local residents.

Ground-breaking medical education scheme is nominated for pair of national

awards

A scheme which brings first-year emergency medicine students from Nepal to the Trust, to

participate in two years of study and practise, has been nominated for a pair of Health Service

Journal (HSJ) awards.

Quality Improvement Medical Education and Training (QiMET) was established by Dr Prakash Subedi,

Dr Naushad Khan and Dr Jill Aylott, with the goal of addressing current workforce gaps within the

medical profession by creating an international rotational educational system, for the benefit of all

participating organisations and countries.

In simple terms, QiMET allows doctors in training from the Chitwan Medical College in Nepal, and,

after preparatory work, to undertake clinical posts at Doncaster Royal Infirmary and Bassetlaw

Hospital. The students train for two years in the UK, gaining experience within a number of medical

specialities and disciplines, before returning back to Nepal to complete their studies. In early

February, the first six students were placed at DBTH.

In addition to the potential benefit for patients, QiMET also offers significant financial savings for

participant hospitals by reducing demand for temporary medial staff.

I want to congratulate our colleagues within QiMET and wish them the very best of luck. This

programme of work is extremely exciting and, if successful, could have a profound effect on how we

educate clinicians, not just in the UK and Nepal, but globally. The hard work of Dr Subedi and Dr

Khan to bring this scheme to Doncaster and Bassetlaw cannot be overstated and as a Trust we are

proud to regulate the UK arm of QiMET and I can’t wait to see what the future holds for this ground-

breaking partnership.

Both QiMET and Hybrid International Emergency Medicine (HIEM) have been nominated for two

HSJ’s Value Awards – these categories are ‘Operations and Performance Initiative of the Year’ and

‘Specialist Service Redesign Initiative’ with the winners announced in late May.

Chequer Road Clinic services will move at the end of the month

Mammography, Audiology and Children’s Speech and Language Therapy services provided by the

Trust will be moving from the Chequer Road Clinic on 27 March 2020.

Throughout the past number of years, the Trust’s town centre premises have become unfit for purpose making clinical work difficult to carry out.

Seeking to resolve this issue, the Trust will be moving the three services currently based at Chequer Road to the following locations:

Audiology will move less than two miles away to The Sandringham Practice (SandringhamRoad, Intake, Doncaster, and South Yorkshire, DN2 5JH)

Mammography (also known as breast screening) and Children’s Speech and LanguageTherapy will move less than a third of a mile to Devonshire House (Cavendish Court, SouthParade, Doncaster, DN1 2DJ).

The above services will close their doors at their current location on Friday 27 March and will reopen at their new venues two days later on Monday 30 March.

The new clinic locations have been re-designed for the services which will be provided, to ensure a smooth continuation of access and care for patients. This includes the building of new sound rooms for Audiology, as well as the purchase of new Mammography equipment to improve and enhance screening for service-users.

Existing and new patients will be notified of the change of venues ahead of their appointments and contact numbers for the services will remain the same. Both new clinics will offer on-site car parking, as well as being accessible via regular bus routes.

Five Year Plan for South Yorkshire and Bassetlaw Integrated Care System

(ICS)

The South Yorkshire and Bassetlaw Integrated Care System (ICS) has launched its Five Year Plan, with

the ambition to help 1.5 million people to lead healthy lives.

The ICS plans to significantly invest in, and improve healthcare for local people - including aims to

reduce the number of preventable deaths and illness that are caused by smoking, obesity and

mental illness.

Click here to see the full Five Year Plan or watch the video below for a very brief overview of the ICS.

https://www.healthandcaretogethersyb.co.uk/application/files/6015/7045/0668/SYBICS_LTP_Slides_27_September_WORK_IN_PROGRESS.pdf

Finance and Performance Committee – 28 January 2020 Page 1 of 13

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FINANCE AND PERFORMANCE COMMITTEE

Minutes of the meeting of the Finance and Performance Committee Held on Tuesday 28 January 2020 in the Boardroom, Doncaster Royal Infirmary

Present:

Neil Rhodes, Non-Executive Director (Chair) Karen Barnard, Director of People & Organisational Development Pat Drake, Non-Executive Director Rebecca Joyce, Chief Operating Officer Jon Sargeant, Director of Finance Kath Smart, Non-Executive Director

In attendance: Kirsty Edmondson-Jones, Director of Estates and Facilities (Part FP20/01/C6) Jeannette Reay, Head of Corporate Assurance/Company Secretary Katie Shepherd, Corporate Governance Officer (Minutes) (KAS)

To Observe: Bev Marshall, Governor

Apologies: None ACTION

FP20/01/A1

Welcome and Apologies for Absence (Verbal)

Neil Rhodes welcomed the Members and attendees and there were no apologies for absence.

FP20/01/A2 Conflict of Interest

No conflicts of interest were declared.

FP20/01/A3 Action Notes from Previous Meeting (Enclosure A3) The following updates were provided; Action 1 – It was advised that a review of the Enabling Strategy Deep Dives was underway and that the Executive Team would discuss this as part of a time out day on 5 February 2020; Action 2 – The Committee agreed to move the action to the work plan, therefore this action would be closed; Action 4, 7, 8, 9, 12, 19 and 20 – On the basis that these items would be included at the January 2020 meeting, these actions would be closed; Action 14 – On the basis that this took place at the December 2019 Board of Directors meeting, this action would be closed;

FP20/01/A1– FP20/01/G8

FINAL


Action 16 – On the basis that Alex Crickmar confirmed that Escrow was accounted for within the ICT contracts budget, this action would be closed; Action 18 – On the basis that an assessment had taken place on the current position of urgent transfer of patients, and there was no risk identified at present and previous issues had been mitigated, this would not be added to the Corporate Risk Register. This action would be closed;

The Committee:

- Noted the updates and agreed, as above, which actions would be closed.

Action: Katie Shepherd would update the Action Log.

KAS

FP20/01/A4 Request for Any Other Business (Verbal) None.

FP20/01/B1 Integrated Performance Report – December 2019 (Enclosure B1) Rebecca Joyce provided the highlights of the report including: 4 Hour Access

- There was an achievement of 82.26% against a national target of 95%. This was due to a 13.21% increase in attendance in December 2019 compared to December 2018, however is better than the national average at 79.8%, and five Type 1 Trusts currently performing below 50%;

- Key actions would be taken at DRI including:

Work to increase the number of emergency pathways available so that the patient would take a more determined pathway with rapid specialist input depending on the condition;

The implementation of an Operational Hub in ED in which the clinical team hold a 2-hour huddle to assess key issues to improve the focus of four-hour access throughout the day;

Consultant Leadership and team working across the department. These plans would be accelerated to deal with any issues and there would be a focus on delivery of patient care;

- A review would be taken on staff working patterns and demand which would lead to changes to match resource to demand;

Jon Sargeant asked what the governance process was around assessment so that it would not impact income adversely. Rebecca Joyce confirmed that this was an initial proposal however a full proposal would go to Executive Team to be signed off if it was deemed a robust process. Kath Smart noted that it was understandably a difficult and challenging task, but asked for clarification if Rebecca Joyce had oversight of the fuller action plan and deliverability and what pace it would work at. Rebecca Joyce advised that now the new Deputy Chief Operating Officer, Jodie Roberts was in post she would provide that close senior leadership required to assist within the coordination of delivery. The Committee noted


that a cultural change would take time, however agreed that the plan would assist with that change. Pat Drake asked for clarification if the Trust used outliers, where a patient would be admitted onto a ward that differed to what they were being treated for. Rebecca Joyce advised that the Trust had utilised these during December. It was noted that this slowed down discharging of patients. A discussion took place regarding the ambulance handover figures reporting. Rebecca Joyce advised that she had discussed this with YAS. It was noted that this was due to the 4pm handover period within YAS which then resulted in a high-number of ambulances presenting at once, however some practicalities had been agreed to resolve this. Diagnostics

- The target for December 2019 was not met with an achievement of 96.2% against a target of 99%;

- There had been a significant increase in demand for MRI and a full analysis had

been required to understand where it was coming from; Cancer

- All reportable cancer targets were met; Stroke

- The direct admission to Stroke Unit was not met in October 2019 with an achievement of 55.6% against a target of 75%; however other areas were performing well;

Cancellations

- The cancellations on the day for non-clinical reasons target was not met in December 2019 with an achievement of 1.41% against a target of 1%, which equated to 64 operations being cancelled;

Kath Smart asked who the Patient Flow Steering Group reported to. Rebecca Joyce advised that the Executive Lead for Patient Flow was David Purdue.

- A review would be under taken of weekend discharges at Bassetlaw. It was agreed that Rebecca Joyce would provide a deep dive presentation on Dr Dr in April 2020.

Action: Rebecca Joyce would present a deep dive on DrDr which would include overview of the overall OP Programme (review of 19/20 plus future plans) but with a particular deep dive on DNAs reduction (via DrDr) and cancellations.

RJ

The Committee:

- Noted the Integrated Performance Report – December 2019.

FP20/01/B2 RTT Plan (Enclosure B2) Rebecca Joyce provided The Committee with an overview of the briefing paper which outlined the 18-week RTT Performance position at 31 December 2019. The delivery of


92% was linked to the year-end financial deal, with £1million achievable with the delivery of 92%, and £250k achievable if 91% was reached. Bev Marshall asked for clarification on what had been built into the financial plan. Jon Sargeant confirmed that the current forecast is based on a non-delivery of 92% RTT. The core issues were discussed including the underperformance in a number of big specialities: Trauma & Orthopaedics, Ophthalmology, Oral Surgery, Cardiology and Dermatology. It was noted that the reason Trauma & Orthopaedics had been underperforming was because of cancelled planned surgery due to inconsistency of booking patients for surgery. This had been resolved, however it had an impact on the RTT position. Other issues include that planned outsourcing volumes had not been achieved, and reduced elective operating to do trauma pressures. Finally, the issues had been as a result of a reduction in elective activity at Bassetlaw. The recovery plan outlined that there would be additional outsourcing during the period January-March 2020. A discussion took place about the financial impact of outsourcing and it was confirmed by Jon Sargeant that this may affect the financial forecast. Rebecca Joyce advised that although this was a high-risk plan, it was achievable, and had met with each speciality that was behind trajectory to create the recovery plans. It was noted that there was strong leadership arrangements in place. A discussion took place about senior clinician buy in to the plan. Rebecca Joyce noted that there were areas that presented challenges, however there were many areas in which good engagement had been received. The achievement trajectory required an achievement of 89% by 31 January 2020, 91% by 29 February 2020 and 92.5% by 31 March 2020. It was noted that today’s rate was 87.15% The Committee noted that there would only be two Committee meetings before year-end and therefore advised that issues be escalated sooner than those meeting. Rebecca Joyce advised that the RTT Recovery will be discussed on a weekly basis as an Executive Team. Kath Smart asked for an update on the RTT/Validation Plan that had been brought to the Committee previously. Rebecca Joyce advised that there was still some issues and some planning would take place to resolve this however education on validation was ongoing.

Action: Antonia Durham-Hall and Jodie Roberts to be invited to the Committee to discuss RTT progress in Surgery and Cancer Division, specifically Trauma & Orthopaedics.

RJ

The Committee:

- Noted the RTT Plan.

FP20/01/C1 Stroke Performance Metrics – Proposed Changes (Verbal) Rebecca Joyce advised that she had received the proposed changes to the Stroke performance metrics from the Stroke Team, and the ‘at a glance charts’ would go from five reports to nine:

Seen by specialised stroke clinician within 1 hour;

Proportion scanned within 1 hour of clock start;

% of appropriate patients given thrombolysis within 1 hour;

% of appropriate patients receiving thrombectomy within 6 to 12 hours;


Proportion directly admitted to hyper acute stroke unit within 4 hours of clock start;

% of all conscious stroke patients to receive a swallow screen within 4 hours of admission;

% of patients receiving a nursing and therapy assessment within 24 hours of admission;

All patients to have been assessed within 72 hours of admission;

% appropriate patients assessed by a stroke skilled ESD team within 48 hours. The Committee noted that this was too many and that Rebecca Joyce should discuss further with the Stroke Team to reduce the highlighted reports down further to approximately three-to-four.

Action: Rebecca Joyce to liaise with the Stroke Team to further reduce down the proposed changes to the Stroke Performance Metrics within the Integrated Performance Report.

RJ

The Committee:

- Asked that the proposed changes to the Stroke Performance Metrics be reduced and presented at a later meeting.

Matthew Bancroft arrived at the meeting.

FP20/01/C1 Financial Performance – December 2019 (Enclosure C1) Jon Sargeant provided an update on Month nine, including:

- The Trust had a deficit of £584k which was favourable against plan of £1,937k in month;

- The income position was £335k favourable to plan in month, with a £1,228k favourable YTD position;

- Capital expenditure was £5.7m behind plan YTD with spend of £6.6m against the

YTD plan of £12.3m;

- £3.9m had been removed from the capital programme this year due to the risk of the Trust not being able to deliver the plan as a result of the main contractor for the fire protection work going into administration, causing a significant delay to the current works;

Jeannette Reay arrived at the meeting.

- An issue arose during January 2020 relating to Microsoft Windows 7 going out of support. The Trust has a server that is still run on Windows 7. Ken Anderson is currently dealing with this issue and expects that the support will be extended for another year as this is also the case in other organisations;

- There was a cash balance at the end of December 2019 of £27.4m.


The Committee:

- Noted the Financial Performance Report for December 2019.

FP20/01/C2 Finance Recovery Plan for 2019/2020 Update (Verbal)

A discussion took place regarding the financial recovery position for 2019/20 and how it had progressed. Jon Sargeant expects that the target will be met, however had concerns of the impact to reach the control total for 2020/21. A discussion took place regarding the issue with next years control total. Jon Sargeant advised that he would write to the ICS about this as it is incorrect. The Committee agreed that targets should be set at the start of 2020/21 to ensure that they are achievement. A discussion took place on the expectations of those departments that achieve their targets as opposed to those that don’t achieve them. Jon Sargeant advised that he would like to incentivise the targets but is not sure how this would be achievable. A discussion took place about PLICS, Model Hospital and GIRFT, particularly in the delay in data for GIRFT. Neil Rhodes noted that it needs to be clear on the different between cashable and non-cashable savings. Jon Sargeant advised that where some places had made savings they had been directly reinvested into those services. It was noted that a grip needed to be taken on this.

The Committee:

- Noted the update on the Financial Recovery Plan for 2019/20 update.

FP20/01/C3 International Financial Reporting Standards 16 – Leases (Enclosure C3) Matthew Bancroft provided the Committee with information that a new accounting standard would come into effect for private companies from 1 January 2020 and NHS organisations from 1 April 2020. This is thought to have a significant impact on the presentation of the Trust’s financial statements from 2020/21 and beyond. The overall effect would be the removal of ‘operating leases’ being all leases on the balance sheet i.e. all leases will become ‘financial leases.

The Committee:

- Noted the International Financial Reporting Standards 16 – Leases Paper

FP20/01/C4 Bad Debts (Enclosure C4) Matthew Bancroft informed the Committee that the Trust had reviewed its detailed aged debtors, and in line with best practice recommended that a number of invoices be written off. No invoices had been written off by the Trust for three years, therefore it was agreed that a review would take place annually of debts. The invoices recommended for write-off were provided in the 2018/19 accounts, and would not negatively impact the performance against the control total in 2019/20.

Action: KAS to add Review of Bad Debts to the work plan.

KAS


The Committee:

- Noted the Bad Debts paper and agreed to write off the debt as outlined in the paper.

FP20/01/C5 Operational Framework/Plan 2021 Update (Verbal) Jon Sargeant advised the Committee that the National Guidance had not yet been received, however provided a brief update on the expectations of the guidance including changes to targets and financial implications. The National Guidance was expected week commencing 20 January 2020.

The Committee:

- Noted the update on the Operational Framework/Plan 2021.

FP20/01/C6 Estates and Facilities Q3 KPI Report (Enclosure C6) Kirsty Edmondson-Jones noted that since the circulation of the Estates and Facilities Q3 KPI Report she had received an updaed appraisal report, and therefore the figure was 90.32%, and not 71% as previously thought. It was noted by the Committee that they weren’t in receipt of any other departments Quarterly KPI reports. Kirsty Edmondson-Jones advised that it isn’t unusual for Board to be sited on Estates and Facilities KPI’s. It was agreed that future reports would not include Management Information (sickness absence, SET and appraisal) data. The Committee agreed to note the Estates and Facilities Q3 KPI Report and asked Kirsty Edmondson-Jones for an update on:

- Catering - Portering - Steris/HSDU

Catering It was noted that Sodexo had been issued with a Performance Warning Notice as they achieved 93% patient satisfaction against a target of 95%. An investigation would take place as the majority of the concerns came from patients on Ward 1. Kirsty Edmondson-Jones is awaiting the final proposal for the Bassetlaw Site however advised that the area will be a ‘proud to serve Costa’ café/coffee shop that isn’t Costa itself but does serve their products. This would also include a new offer of ‘Comfort Kitchen’ which would provide a plant based option of food each day. This would include fewer choices per day, however the menu would be themed and roll on a two week cycle. This proposal would go to Executive Team tomorrow for approval with the works planned to take place by June/July 2020. The Committee noted that this would result in an additional six months staff/visitors having below standard options due to the fridges not working. It was discussed that many customers aren’t aware that there are sandwiches available upon request and it was advised that better signage be available to options of sandwiches available. Kath Smart noted that staff at Bassetlaw she had spoken to didn’t know why Costa Machine and fridges had been removed from the hot kitchen, therefore it was agreed


that communications should go out once the proposal had been approved to inform staff of the changes to take place. Portering It was confirmed that the Trust has a total of 109 wheelchairs currently (62 at Doncaster, 28 at Bassetlaw and 19 at Montagu). An assessment has been taken and an additional 95 wheelchairs are required, 69 of which are additional and the remaining are replacements. The cost of a wheelchair is £500 each, and a decision has been taken to purchase several bariatric wheelchairs that cost £750 each. The proposal would go to the Medical Equipment Group in early February 2020. All wheelchairs have been fitted with RFID and Ken Anderson has confirmed that the tracking of wheelchairs will go live in February 2020 which will significantly improve the turnaround times to responses at all sites. Pat Drake noted that there should be an exception comment where there have been seen to be big delays in moving patients. This would be added to future reports. Steris Update Further to the update presented at the last meeting, a meeting had taken place with Steris on 17 January 2020. There had been a discussion that a review would be undertaken on specific equipment required back within the agreed turnaround times. If there are refinements to the contract there would be a change to the cost of the service also. It was noted that since the issues over the Christmas period Steris had met the 95% KPI in the first week on January 2020. Fire Works It was confirmed that the Fire Brigade have been in the previous week as part of a periodic check on progress. It was noted that they have been informed of the delay of the Fire Works due to the contractor going into administration. The Fire Brigade were happy with progress and will return in a few weeks to carry out a further check. Kirsty Edmondson-Jones advised that there is every intention to rescind the Fire Improvement Notice, and would allow the Trust to continue with the rest of the programme.

FP20/01/D1 Workforce Report (Enclosure D1) Karen Barnard highlighted the key points from the Workforce Report for Month 9, including:

- The Trust had a vacancy rate of 8.6% against a target of 5%;

- Sickness absence rates had risen to 5.06%;

- The data from the model hospital portal had not been updated since the last report; so comparisons were made to data uploaded in August 2019;

- The first cohort of nurses from the Philippines had started with the next cohort due to start in February 2020;

Pat Drake asked if the nurses from the Phillipines had to pay for their NHS care in the first year of living/working in the UK. Karen Barnard didn’t have the answer but would provide post meeting.


- A paper would be presented to the Executive Team tomorrow regarding

international recruitment of medical staff;

- Agency spend was reasonably good;

- The contract with Holt Doctors was due to end this year, therefore

collaborative work had started between DBTH and three other Trusts to agree a

provider. It was noted that operational input would be required during this

process;

An in depth discussion took place regarding open beds and agency spend. The Committee asked for assurance that procedures were tight. Karen Barnard confirmed that since a New Associate Director of Nursing had been in post, issues had been identified with the management of workforce, where gaps hadn’t previously been escalated. The Committee requested that data be added to the Workforce Report on month by month performance in addition to the cumulative total. Jon Sargeant noted that the implementation of Allocate (rostering system) is key to identifying why agency is being used i.e. required for addition work or sick leave. It will also give the ability to look ahead instead of just reviewing the past. Karen Barnard advised that many other Trusts have fully implemented Allocate and has asked Allocate for examples of best practice where this has been implemented within medical teams. It was noted that it would not be fully implemented by year end. It was agreed that there would be standard procedures for the use of Allocate as Jon Sargeant advised that some areas that it is in use for nursing staff use it in a slightly different way. A discussion took place regarding the proposed centralisation of Booking Teams, Rostering, Medical HR, Recruitment to address key underlying issues, however now work had been undertaken on this yet. It was suggested that there be a presentation on Allocate during the next financial year.

Action: Karen Barnard to confirm if the nurses from the Philippines working at the Trust have to pay for their NHS care within their first year.

KB

Action: The Committee requested that data be added to the Workforce Report on agency spend by Division shown month by month in addition to the cumulative total.

KB

Action: A presentation on Allocate (rostering system) to be provided to the Committee to show the benefits of its use in clinical practice.

KB

The Committee:

- Noted the Workforce Report.

FP20/01/D2 Recruitment Timescales (Enclosure D2) Karen Barnard provided a paper on Recruitment and Selection Reporting and KPI’s. The Trac Recruitment System was implemented in June 2019. Trac (recruitment system) was introduced in June 2019 and allows for better reporting on recruitment and selection


data, than was achievable with NHS Jobs. Trac is increasingly being used by NHS Trusts to manage the recruitment process more productively. It was noted that there is masses of data that can be reported and used from Trac. Karen Barnard highlighted that there was a mixed mode of recruitment within the organisation including:

- Centralised recruitment; - Recruitment that take place within Divisions; - Cohort recruitment.

One of the KPIs that was discussed related to length of the recruitment process, and it was agreed that 17 days for ‘time taken from the offer confirmed with the successful candidate to the complete of all required pre-employment checks by the recruiting manager (individual notice period not-included) was too long and could be shortened. It was noted that there was a sizable number of vacancies advertised between 1 May 2019 and 22 January 2020. The Committee noted that the report has given confirmation of what was previously thought, and that some areas take longer to recruit than others. Kath Smart asked how the data will be used to change practice and what support will be given to the Divisions to do so. Karen Barnard advised that all pre-employments checks would be managed by Central Recruitment which would allow movement at pace. The production of this data will highlight where there are blockers so that assistance can be given to manage stages that aren’t moving at the pace they should. Karen Barnard asked for clarification on how the Committee would like future reporting presented. It was agreed that future reports received would be split by Division/Corporate Directorate (as reported on in the paper), along with a separate report split by staff group, included data from the rolling 12-month period. It was agreed that cohort recruitment be reported separately to allow for differentiation between the high numbers recruited during cohort recruitment, over a longer period. It was agreed that a quarterly report be received by the Committee on Recruitment and Selection Reporting and KPI’s.

Action: KAS to add to the work-plan the expectation of a quarterly report on Recruitment and Selection Reporting and KPI’s.

KAS

The Committee:

- Noted the update on Recruitment Timescales.


FP20/01/E1 Corporate Risk Register (Enclosure E1) Jeannette Reay advised the Committee that a large piece of work was underway to review the risk management processes within the Trust. The process of receiving updates directly from Executives with risk responsibilities was still taking place. Not all updates had been received prior to the meeting however there had been no changes to scoring. There had been the addition of one risk from Ken Anderson, Acting Chief Information Officer relating to Multiple Software Systems.

The Committee:

- Noted the Corporate Risk Register.

FP20/01/E2 Board Assurance Framework (Enclosure E2) Jeannette Reay advised the Committee that a large piece of work was underway to review the risk management processes within the Trust. The process of receiving updates directly from Executives with risk responsibilities was still taking place. A discussion took place regarding the duplication of risks on the Corporate Risk Register (CRR) and Board Assurance Framework (BAF). Jeannette Reay advised that the detail in the Corporate Risk register was accurate and that the BAF Framework had information on that could be removed. Jeannette had liaised with Fiona Dunn regarding the move to Datix to manage risks, however the team didn’t feel confident in the move to it just yet, and training would take place with the Executive Team prior to doing so. Kath Smart highlighted that the distinctive changes to the CRR and BAF could be made prior to the move to Datix. Jeannette Reay advised that due to timings of meetings, the BAF workshop wouldn’t take place until after the Board of Directors meeting in April 2020.

The Committee:

- Noted the Board Assurance Framework.

FP19/12/E3 Terms of Reference (Enclosure FE) Jeannette Reay provided an updated draft Terms of Reference, and highlighted that ‘workforce’ had been added since the last meeting where it highlighted that it wasn’t mentioned. It was advised that where it stated ‘Audit and Non-clinical Risk Committee’, it be changed to ‘Audit and Risk Committee’. The Executive Team were having a time-out day on 5 February 2020 to agree the Enabling Strategies, which would then be reflected in the Terms of Reference. It was agreed that the Terms of Reference would be agreed at the February 2020 Committee meeting, to be signed of at the Board of Directors meeting in March 2020, pending amendments post the Executive Team Time-Out day on 5 February 2020.


It was agreed that the Terms of Reference for all Committee meetings would be reviewed annually in February.

Action: The Terms of Reference would be amended with the outcome of the Enabling Strategies decision at the Executive Team Time-Out on 5 February 2020 and ‘Audit and Non-clinical Risk Committee’, to be changed to ‘Audit and Risk Committee’ in the Terms of Reference. Action: The Terms of Reference would be agreed and signed off at the Board of Directors meeting in March 2020. Action: A review of the Committee Terms of Reference would take place annually at the February 2020 meeting. To be added to the Committee Work Plan.

JR JR KAS

The Committee:

- Agreed to sign off the Terms of Reference subject to the amendments to be made to the Enabling Strategies section. The Terms of Reference would go to Board of Directors March 2020 meeting for sign off.

FP20/01/F1 Escalation (Verbal) No issues were identified for escalation to/from:

- F1.1 F&P Sub-Committees; - F1.2 Board Sub-Committees; - F1.3 Board of Directors.

FP20/01/G1 Sub-Committee Meetings (Enclosure F1): The Committee noted the minutes of the:

- Capital Monitoring Group – 21 November 2019 - Cash Committee – 15 November 2019 and 13 December 2019 - WERC – 04 November 2019 - Efficiency and Effectiveness Committee – 06 January 2020

FP20/01/G2 Minutes of the meeting held on 16 December 2019 (Enclosure G2)

The Committee:

- Noted and approved the minutes from the meeting held on 16 December 2019.

FP20/01/G3 Steris Update (Enclosure G3)

The Committee:

- Noted the Steris Update.


FP20/01/G4 Sodexo Contract Monitoring Statistics (Enclosure G4)

The Committee:

- Noted the Sodexo Contract Monitoring Statistics.

FP20/01/G5 Rates Rebate (Enclosure G5)

The Committee:

- Noted the update on Rates Rebate.

FP20/01/G6 Fire Works Update (Enclosure G6)

The Committee:

- Noted the Fire Works Update.

FP20/01/G7 Committee Work Plan (Enclosure G7)

The Committee:

- Noted the Committee Work Plan.

FP20/01/G8 Any Other Business (Verbal)

There was no request for any other business.

FP20/01/G8 Date and time of next meeting (Verbal)

Date: Time: Venue:

Tuesday 25 February 2020 09:00 – 13:00 The Board Room, Doncaster Royal Infirmary

DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

AGENDA ITEM LEAD FREQUENCY NEXT DUE

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Chair's Welcome and Apologies for Absence Suzy Brain England Each Meeting Next Meeting

Declaration of Interests Company Secretary Each Meeting Next Meeting

Conflict of Interests Register Company Secretary Annually May-20

Action Log - Update on Actions from Previous Meetings Company Secretary Each Meeting Next Meeting

Various - As Agreed by Chair Various Each Meeting Next Meeting

Executive Team Objectives - Setting Richard Parker Annually Jun-20

Executive Team Objectives - Quartely Updates Richard Parker Quarterly Apr-20 Q3 / Q4 Q1 / Q2

NHS Long Term Plan Richard Parker As Required Consider Nxt Mtg

CQC David Purdue As Required Consider Nxt Mtg

Budget Setting/Business Planning/Annual Plan Jon Sargeant/Marie Purdue Annually Mar-20 Final

NHSI Plan Jon Sargeant/Marie Purdue Annually Apr-20 ?

Committees in Common Company Secretary As Required Consider Nxt Mtg TOR

SY&B Pathology Programme Richard Parker As Required Consider Nxt Mtg ?

Quality and Performance Report Becky Joyce Each Meeting Next Meeting Jan Feb Mar Apr May Jul Aug Sept Oct

Report from Guardian for Safe Working Jayuant Dugar Quarterly Feb-20 Ann Rpt

Maternity CNST David Purdue (Lois Mellor) Annually Jul-20

The NHS Patient Strategy Sewa Singh (Cindy Storer) Annually Jul-20

Winter Plan Becky Joyce Annually Oct-20

Workforce and Recruitment Plan Karen Barnard Annually Jul-20

Thematic P&OD Report Karen Barnard Each Meeting Next Meeting FTSU

Workforce Race Equality Standards Karen Barnard Annually Jul-20

Workforce Disability Equality Standards Karen Barnard Annually Jul-20

Estates and Facilities Report Kirsty Edmondson-Jones Annually Apr-20 Ann Rpt Q1

ERIC Return Kirsty Edmondson-Jones Annually Jun-20

Staff Survey Results Karen Barnard Annually Feb/Mar-20

Staff Survey Action Plan Karen Barnard Annually Apr-20

Mixed Sex Accommodation Kirsty Edmondson-Jones Annually TBC

EU Exit Becky Joyce As Required Feb-20

Finance Report Jon Sargeant Each Meeting Next Meeting Feb Mar Apr May Jun Aug Sept Oct Nov

Control Total Jon Sargeant Annually Jan 2020

Use of Trust Seal Richard Parker/Company Secretary As Required Consider Nxt Mtg

CCG Contracts Jon Sargeant Annually Private?

Reference Costs Jon Sargeant Annually Private?

NHS Providers Licence Self-Assessment / Certification Company Secretary Annually May-20

SO's SFIs, Standards of Business Conduct, Board Powers Jon Sargeant/Company Secretary Annually Apr-20

Board Assurance Framework Company Secretary Each Meeting Nov-19 Q4

Corporate Risk Register Company Secretary Quarterly Jan-20 Q4 Q1 Q2

Chair's Assurance Log for Finance and Performance Cttee Neil Rhodes Each Meeting Next Meeting Feb Mar Apr May Jun Jul Sept Oct Nov

MEETING DATES

ANNUAL BOARD CYCLE OF BUSINESS

COMMITTEE BUSINESS

PUBLIC SESSION

STRATEGY

PRESENTATIONS

QUALITY PERFORMANCE AND SAFETY

GOVERNANCE AND RISK

FINANCE AND CONTRACT MATTERS

CAPACITY AND CAPABILITY

H4

Chair's Assurance Log for Quality Effectiveness Cttee Pat Drake Bi-Monthly Dec-19 Mar May Jul Sept Nov

Chair's Assurance Log for Audit and Risk Cttee Kath Smart Quarterly Nov-19 May Jul Nov

Chair's Assurance Log for Charitable Funds Cttee Sheena McDonnell Quarterly Dec-19 Mar Jun Sept

Terms of Reference for Finance and Performance Cttee Neil Rhodes Annually Oct-20

Terms of Reference for Quality and Effectiveness Cttee Pat Drake Annually Oct-20

Terms of Reference for Audit and Risk Cttee Kath Smart Annually Oct-20

Terms of Reference for Charitable Funds Cttee Sheena McDonnell Annually Oct-20

Board Effectivess Review Company Secretary Annually TBC

Annual Report of the Finance and Performance Cttee (inc Effectiveness Review) Neil Rhodes Annually May-20

Annual Report of the Quality Effectiveness Cttee (inc Effectiveness Review) Pat Drake Annually May-20

Annual Report of the Audit and Risk Cttee (inc Effectiveness Review) Kath Smart Annually May-20

Annual Report of the Chaitable Funds Cttee (inc Effectiveness Review) Sheena McDonnell Annually May-20

Board Cycle of Business (inc Meeting Dates) Company Secretary Each Meeting Next Meeting

Chair and NEDs' Report Angela O'Mara Each Meeting Next Meeting

Chief Executive's Report Company Secretary Each Meeting Next Meeting

Minutes of the Finance and Performance Committee Company Secretary Each Meeting Next Meeting Jan Feb Mar Apr May Jun, Jul Aug Sept Oct

Minutes of the Quality and Effectiveness Committee Company Secretary Bi-Monthly Jan-20 Jan March May Nov

Minutes of the Audit and Risk Committee Company Secretary Quarterly Jan-20 Feb/March Jul

Minutes of the Charitable Funds Committee Company Secretary Quarterly Dec-20 Dec Mar Jun Sept

Minutes of the Management Board Company Secretary Each Meeting Next Meeting Jan Feb Mar Apr May Jun July, Aug Sept Oct

Minutes of the Council of Governors Company Secretary Each Meeting Next Meeting Oct Jan Apr Jul

ICS Update Richard Parker Each Meeting Next Meeting

Bassetlaw Integrated Care Partnership Bulletin Company Secretary As Required Consider Nxt Mtg Bulletin Bulletin Bulletin Bulletin Bulletin Bulletin Bulletin Bulletin Bulletin

Minutes of the Previous Meeting Company Secretary Each Meeting Next Meeting Feb Mar Apr May Jun July Sept Oct Nov

Any Other Business Suzy Brain England Each Meeting Next Meeting

Governor Questions Suzy Brain England Each Meeting Next Meeting

Date and Time of Next Meeting Company Secretary Each Meeting Next Meeting Apr May Jun July Sept Oct Nov Dec Jan

Withdrawal of Press and Public Suzy Brain England Each Meeting Next Meeting

Planned for Future Meeting(s)

Items Added to Individual Meetings as Required

OTHER ITEMS

Not Considered as Planned

Presented as Planned

ITEMS FOR INFORMATION

Board of Directors – Public Meeting – 18 February 2020 Page 1 of 14

BOARD OF DIRECTORS – PUBLIC MEETING

Minutes of the meeting of the Trust’s Board of Directors held in Public on Tuesday 18 February 2020 at 09.15 in the Board Room, Bassetlaw Hospital

Present:

Suzy Brain England OBE - Chair of the Board (In the Chair) Mark Bailey – Non-Executive Director Karen Barnard - Director of People and Organisational Development Pat Drake - Non-Executive Director Sheena McDonnell – Non-Executive Director Richard Parker OBE – Chief Executive David Purdue – Deputy CE and Director of Nursing and Allied Clinical Health Professionals Neil Rhodes – Non-Executive Director and Deputy Chair Jon Sargeant – Director of Finance Sewa Singh - Medical Director

In attendance: Ken Anderson – Acting Chief Information Officer (P20/02/B1) Katie Dowson – Director of Digital, Doncaster CCG and PLACE (P20/02/B1) Claire Jenkinson – Deputy Chief Operating Officer (for Becky Joyce) Graham Moore – Clinical Lead, Orthotics (P20/02/B2) Marie Purdue – Director of Strategy and Transformation Jeannette Reay – Head of Corporate Assurance / Company Secretary Emma Shaheen – Head of Communications and Engagement

Public in attendance:

Peter Abell – Public Governor Hazel Brand – Public Governor David Cuckson – Public Governor Gina Holmes – Staff Side Chair Lux Lynn – Molnlycke Healthcare Steve Marsh – Public Governor James McHale – Molnlycke Healthcare Sheila Walsh – Public Governor

Apologies: Becky Joyce – Chief Operating Officer Kath Smart – Non-Executive Director

Suzy Brain England welcomed Mark Bailey to his first meeting of the Board of Directors’, as a Non-Executive Director of the Trust.

ACTION

P20/02/A2 Declaration of Interests (Verbal)

Mark Bailey had provided his interests to the Trust Board Office.

P20/02/A2 – P20/02/J DRAFT

I1


No additional declarations were noted.

The Board:

- Noted the Declaration of Interests pursuant to Section 30 of the Standing Orders.

P20/02/A3 Actions from Previous Meetings (Enclosure A3)

The following updates were provided: Action 1 – Virtual Meetings / Business Case for IT – An update would be provided to the March 2020 meeting of the Board of Directors’. Action 2 – Perfect Week – On the basis that an update would be provided at item D2, this action could be closed. Action 3 – FTSU – An update would be provided to the March 2020 meeting of the Board of Directors’ . Action 4 – Mexborough Theatres and Day Case Income – Jon Sargeant provided information on the number of cases at Mexborough between months one to ten: there had been 8360 cases including pain cases, 152 laser procedures and 37 elective cases. On the basis that any follow up information would be provided to the Finance and Performance Committee, this action could be closed. Action 5 – Psychological Services – On the basis that information would be provided to the March 2020 Quality and Effectiveness Committee meeting, this action could be closed. Actions 6 and 7 – Workforce Plan and Climate and Biodiversity – These items were not due until July 2020 and May 2020. Action 8 – Climate and Biodiversity – On the basis that an update had been provided to the Council of Governors on 30 January 2020, this action could be closed.

The Board:

- Noted the updates and agreed which actions would be closed.

P20/02/B1 Doncaster Place Digital Strategy (B1 + Presentation)

Katie Dowson, Director of Digital and Doncaster CCG and PLACE, provided information on:

- The Doncaster Digital Place Strategy (circulated with agenda); - The Digital Work Stream; - Working together – examples of work to date; - The Place plan vision and digital vision collaboration principles; - The ability for Doncaster people to maximise their own health and well-being; - Ambition for one digital front door; - Digital programmes – connected digital services, sharing records, access and

engagement and intelligence and analytics; - A request for DBTH support to target key action areas; - Supporting Doncaster People – better, faster information, choice, empowerment,

control and experience;


- Supporting health and care professionals – right information, right place, right time, better communications between providers, time saving, empowerment, reduction of duplication and access to WIFI;

- Funding (strategy not yet funded). Members noted the aspiration that digital would be an integral part of health care work in the future, getting the simple things right (including WIFI and connectivity) so that a focus could be placed on digital innovation within three years. Digital would be an enabler to changing healthcare provision and change processes would need supporting with staff communications to explain the benefits. The size of the task and resource limitations were acknowledged – with conflicting programmes, access to the right people at partner organisations, and a lack of capital funding being cited as challenges. The Board noted that investment may be requested in the short term, which may show benefits in the longer term. Patient concerns on confidentiality of care records were noted and the Board was advised that consent models and sharing agreements were in place – supported by continued communications to assure the public on these systems. The way forward for patients to access their records was still being determined. Ken Anderson commented that the scope of the strategy was right – with a focus on digital (people and patient focused), rather than IT Data sharing – that would be crucial in moving forward and the next step would be to agree the top priorities for action.

The Board:

- Received and noted the presentation on the Doncaster Place Digital Strategy; - Supported the partnership working in this area to improve the patient

experience.

P20/02/B2 Orthotic NHS England Survey Results (Presentation)

Graham Moore, Clinical Lead for Orthotics, provided information on:

- The process for obtaining and benchmarking data; - NHSE/NHSI national led programme including 18 Trusts; - Information from a patient survey based on eight questions - shared between the

Trusts; - The data for DBTH – based on 300 patients; - Difficulties with follow up with patients who had experienced waits; - Some staff shortages during the survey period; - A positive response overall, with high percentages rating the service four, or five

stars; - The improvement plan arising from the exercise; - The current position, including a financial saving; - Currently at 20 weeks wait, with an ambition to reduce this to six weeks; - Links with Derby University on 2 April 2020, Wirral University Teaching hospital on

Masters and Coventry University on a degree programme, with students matching the 2:1 Physiotherapy programme.

Members welcomed the presentation, acknowledging the services’ positive response to the workforce challenge and the support that it provided to patients.


The Board:

- Received and noted the presentation on Orthotic NHS England Survey Results.

P20/02/C1 ICS Update (Enclosure C1)

The Board noted the performance report from the ICS – based on October and November 2019’s data. The ICS continued to perform well – being the top performing ICS reported. No system was currently achieving the National ED standard and there continued to be challenges on the RTT position.

The Board:

- Noted the update from the ICS.

P20/02/C2 South Yorkshire and Bassetlaw Five Year Strategy Plan (Enclosure C2)

The Board were reminded that the Trust had contributed to the development of the Strategy Plan throughout 2019 and the paper described the priorities and the final strategic plan to be submitted at the beginning of April 2020. The Trust’s annual plan for submission would need to be consistent with the Strategy. A detailed query regarding individual organisations achievements) was raised – as it suggested that work was still being undertaken in isolation. It was noted that the ambition was for joint work to develop future programmes for adoption by all partners going forward.

The Board:

- Noted the South Yorkshire and Bassetlaw Five Year Strategy Plan.

P20/02/D1 Quality and Performance Report (Enclosure D1)

The December 2019 data (enclosure D1) had been considered by the Finance and Performance Committee, and by the Quality and Effectiveness Committee at the meetings on 28 January 2020. The following points were highlighted to the Board: Performance

- Four hour access performance was at 82.3%. EDs had continued to be challenged by increased attendances and high levels of acuity.

- The national picture also looked challenged, with DBTH still performing above average.

- The provision at Montagu Hospital’s front door had changed to an Urgent

Treatment Centre – resulting in a significant increase in cases seen. This had been managed well.


- A full recovery plan has been developed which had the support of the CCG. Themes were around leadership and operational grip, patient pathways and cohorts of patients, a review of workforce and roles, and an increase in streaming at Bassetlaw Hospital.

- RTT there was an ambitious RTT recovery plan and December’s position had fallen

short which had been disappointing. Significant recovery planning had subsequently taken place.

- For January 2020, the revised target of 88.4% had been met with a performance of 88.8%.

- There remained a risk to achieving 92% by the end of March 2020 but recovery plans for divisions were understood and were being well led by clinicians, supported by clear governance.

- An improved approach to the administration of patient lists was being undertaken – to ensure that patients were treated in chronological order, an understanding of the bottlenecks in performance had been gained, and work was taking place with partners (including the independent sector) to reduce waiting times.

- NHSI/E’s Intensive Support Team had examined the plans for some of the Trust’s specialities and had provided assurance that the recovery plans were sound.

- Some specialities were above 92% - Daily monitoring was showing improvements. - The patient treatment list had fallen substantially which was affecting

performance.

- Diagnostic performance was at 96% against a 99% target. - A full recovery plan was in place for Urodynamics – showing a 17% Improvement

since December 2019. - The number of patients being provided with MRIs had greatly increased (by 3000),

providing challenges on workload.

- All National Cancer targets were being achieved.

The Board commended the achievement on cancer targets. The continued challenges with ED activity and the required improvement in RTT performance were noted and Neil Rhodes advised that the Finance and Performance Committee had been assured by the improvement plans in place for these areas. Neil Rhodes was to meet with senior clinicians in Trauma and Orthopaedics and Ophthalmology to gain a detailed understanding of their plans.

The Trust would continue to look at RTT and waiting lists in future planning. The number of attendances was likely to continue to rise and there was a need for the Trust to understand future impacts of this. Alongside the blended tariff (which meant that increased activity would not result in increased income) there would be a need for system working and a continued focus on cost reduction.


Quality and Safety

- The HSMR figure for September 2019 showed an improvement (83.6%). Elective HSMR, which had been rising was now reducing.

- The work undertaken in late 2019 was showing results – the Trust continued to scrutinise all elective deaths.

- There had been no lapses in care. - A full report on HSMR had been provided to the January 2020 Quality and

Effectiveness Committee meeting.

The Board concluded that HSMR has stabilised and there was an expectation that this would continue to drop.

- A lot of work undertaken with the CCG on Hospital acquired pressure ulcers. - Work was focused on learning and training. - Audits highlighting where mattresses were unavailable were undertaken and the

Trust now had sufficient mattresses to meet demand.

Members noted that a lot of work had been undertaken on the complaints processes and improving reporting/actions. A full report on this was to be provided to the Quality and Effectiveness Committee in March 2020.

ACTION – Information on weekend discharges would be provided to the Finance and Performance Committee.

DP

Workforce

- SET training was at 86%. - Preparations for the 2020 appraisal season were in place. - A detailed update on resuscitation training would be provided to the Quality and

Effectiveness Committee. - An unusual spike in staff sickness during December 2019 (particularly long term

sickness) – on which detailed analysis was taking place. - Low numbers of appraisals in maternity – for which action plans had been

developed. - The new SET training booklet was being finalised.

ACTION – Board members would be advised on how to complete their SET training electronically.

JR

The Board:

- Received and noted the Quality Performance Report for December 2019;

- Noted the verbal update on January 2020’s performance; - Recognised the maintenance of quality services during times of increased activity

and pressure; - Recorded thanks to staff for their continued support during times of increased

activity and pressure.


P20/02/D2 Perfect Week Update / Where Best Next? (Enclosure D2)

The Board noted that the Trust had undertaken the ‘Where Best Next’ initiative during the week of 14 January to 21 January 2020. The principles previously used in the ‘Perfect Week’ initiatives had been adopted:

- Plan for discharge from the start. - Involve patients and families in discharge decisions. - Establish systems and processes for frail people. - Embed multidisciplinary team reviews. - Encourage a supported ‘Home First’ approach.

Staff had been tasked to ask themselves the underpinning question ‘Where Best Next?’ for the Trust’s patients, in everything that they did during the week. David Purdue took the Board through the paper, highlighting the preparations undertaken, the approach, findings, and recommendations for the future. Staff and departments had been given permission to do things differently and, where issues had been encountered during the week, responses had been immediate with staff working to develop real time resolutions. Members welcomed the culture provided – noting that staff could often be constrained by a highly regulated environment – so it was important to provide a culture of freedom Within manageable risk wherever possible. Work to capture new rules/ways of working would be undertaken. One of the key findings was that discharges before noon (rather than 10am) should perhaps be a Trust aim. Medicines dispensing from the discharge lounge had been trialled during the week and this had worked well, so the system had been adopted. ‘At a Glance’ boards were now in place throughout Bassetlaw Hospital. There had been some issues with discharges as the Trust had been unable to discharge to three local care homes. Members noted the crucial part that the Trust’s partners played in flow and discharges. The initiative would be run every Tuesday going forward, with a full week undertaken each quarter. The Trust would look to run the ‘Where Best Next’ initiative for front door services in the coming months. A focused piece of work on theatre capacity for dealing with emergencies would also be undertaken.

The Board:

- Noted the update on Perfect Week.

P20/02/D3 Best Practice Guidance for Flu Vaccinations – Compliance (Enclosure D3)

In March 2019 new guidelines for flu vaccinations were published and all Trusts were requested to complete the Healthcare Worker Flu Vaccination Best Practice Management Checklist and publish it at Board.


The Checklist showed what the Trust had done, and what it would do next. The processes had been subject to Qi. Members noted that the Trust had historically performed well in flu vaccination rates, with the 2018/19 outturn being 75% of frontline workers (against a national update of 70.3%). The 2019/20 performance currently stood at 78.7% for the Trust. Members noted that colleagues who had received the vaccination outside of the Trust should advise Karen Barnard so that they could be accounted for in the figures.

The Board:

- Noted the Trust’s compliance with Flu vaccination requirements.

P20/02/E1 Annual Plan – National Guidance, Progress on ICS Control Total, Internal Work (Verbal)

The Board noted that the technical guidance for the annual planning round had recently been published. A submission was required which included system wide, rather than just organisational performance. 50% of Financial Recovery Funding would be dependent on system performance going forward. The operational instructions in the guidance included an improvement in winter flow, 92% bed occupancy, and that the peak number of beds for winter should become the norm for the year. There was currently debate on the practicalities of the latter requirement and this could change going forward. No specific target for RTT was provided in the guidance but the cancer targets remained the same. For finance there was absolute confirmation that revenue cash loans would be converted to PDC and the Board was advised that this would result in a cost pressure t. The Trust was fully engaged with, and working to agree final contracts with its CCGs – to allow for submission of the initial plan on 27 February 2020 (prior to final submission at the end of April 2020). The ICS had requested that DBTH work be completed early in April 2020, but this may not be possible due to contracting negotiations. Specific things to work through included the altered cost base and control total (formally announced to the ICS as £6.3m), that the CNST funding benefit had been taken by the centre creating a difference in actual staff cost increases to that provided for (a national issue) and shared CIPs – which it was agreed must benefit the whole system and share risks equally. A detailed update on the annual plan data for submission would be provided to the Finance and Performance Committee meeting on 25 February 2020.

The Board:

- Noted the update on preparations for the Annual Plan – 2020/21.


P20/02/E2 National Staff Survey Benchmarking Results (Presentation)

The embargo had been lifted on the staff survey results at 10am on 18 February 2020. Karen Barnard presented the results, highlighting:

- A high response rate (59% against 54% for prior year / 47% national average). - A significant improvement in 65 of the survey questions (24 unchanged). - Just 1 with a declining score (hours worked). - 7% increase in colleagues recommending the Trust as a place to work. - 5% increase in colleagues happy to recommend the Trust to friends and family for

treatment. - 76% of colleagues recognising care of patients to be the organisation’s top priority. - The most improved Trust (from the league table of 38 comparator organisations).

A small number of areas for redress would be targeted for focused improvement:

- Patient voice. - Staff voice. - Team working. - Staff wellness and mental wellbeing. - Adjustments for staff with a disability.

Further work on Divisional data and individual (anonymised) comments would take place. The Board recognised this great news story and the hard work supporting its achievement. The importance of the positive culture shift that this captured was highlighted, and all agreed that this must be harnessed in order to continue to move forward with even greater improvement ambitions. The Board recorded its thanks to staff. The Trust’s Communications team would lead on publicising the results and on ensuring that the Board’s thanks were disseminated to teams throughout the organisation.

ACTION - The results of the staff survey would be shared with Governors.

JR / KB

The Board:

- Noted the National Staff Survey Benchmarking Results.

P20/02/F1 Finance Report – 31 January 2020 (Enclosure F1)

The Board noted that, At the end of month ten:

- The cumulative position was slightly ahead by £123k. - The Trust was on plan for the year-end. - Income for Emergency care was slightly above plan. - CIP was behind plan by £660k although significant amounts had been delivered in

the month and there was an expectation that the year-end target would be met. Cash and capital:


- The cash position was strong. - Payments from the centre had been received earlier than anticipated. - The capital forecast had been changed to reflect an underspend on fire

improvement works – which would be carried forward into 2020/21. - The remaining capital should be spent within the year.

Key Risks: The key remaining risks are:

- RTT - £1m of funding from the CCG was contingent on meeting the 92% target – a recovery plan was in place to achieve this.

- A 91% achievement would provide the bulk of the monies. - £600k worth of funding from NHSE for outsourcing work had been provided to

Bassetlaw CCG but the DBTH work related to Doncaster residents so there was a risk that this would not be received.

The Board concluded that the forecast was to deliver the 2019/20 financial plan by the year-end.

The Board:

- Received and noted the Finance Report for January 2020; - Received and noted the forecast financial position and risks to the delivery of the

control total; - Noted the achievement towards the Cost Improvement Plan.

P20/02/G1 Chairs’ Assurance Logs for Board Committees (Enclosure G1)

P19/02/G1(i) Finance and Performance Committee – 28 January 2020

Neil Rhodes confirmed, as reported and captured during the Board meeting, that a detailed review of the Quality and Performance Report (P19/12/D1) and detailed discussions on the Trust’s finances and action plans (P19/12/F1) had been undertaken by the Committee. No other matters were highlighted for the Board’s attention.

The Board:

- Noted the update from the Finance and Performance Committee meeting held on 28 January 2020.

P19/02/G1(ii) Quality and Effectiveness Committee – 28 January 2020

The Board noted and welcomed the new reporting format. Pat Drake confirmed, as reported and captured during the Board meeting, that a detailed review of the Quality and Performance Report (P19/12/D1) had been undertaken by the Committee. No other matters were highlighted for the Board’s attention.


The Board:

- Noted the update from the Quality and Effectiveness Committee held on 28

January 2020.

P19/02/G1(iii) Audit and Risk Committee – 5 February 2020

Sheena McDonnell highlighted the key points considered by the Committee:

- Committee confidence on the progress of actions from the two audit reports which had been provided with partial assurance.

- A requirement for senior staff throughout the Trust to provide information on their declarations of interest – the processes for which would need the support of Divisions.

The Board:

- Noted the update from the Audit and Risk Committee held on 5 February 2020.

P20/02/G2 Corporate Risk Register (Enclosure G2)

The Board noted the register dated 31 January 2020 – which had been considered by the January and February meetings of Board Committees and had been approved by the Management Board at its meeting on 10 February 2020. A new risk relating to end of life support for multiple software systems used by the Trust had been added to the register. The Board noted the intention for future registers to be created directly from the electronic Risk Management system (Datix).

The Board:

- Received and noted the Corporate Risk Register dated 31 January 2020.

P20/02/G3 Board Assurance Framework (Enclosure G3)

The Board noted the framework dated 31 January 2020 – which had been considered by the January and February meetings of Board Committees and had been noted by the Management Board at its meeting on 10 February 2020. The Board noted that a Board workshop would take place in April 2020 to refresh the style and content of the Board Assurance Framework – and to align to the Trust’s updated Strategic Objectives.

The Board:

- Received and noted the Board Assurance Framework;


P20/02/H1-H6

Information Items (Enclosures H1 – H6)

The Board:

- Noted the Chair and NED’s Report; - Noted the Chief Executive’s Report. - Noted the minutes of the Quality and Effectiveness Committee meeting held on

11 December 2019.

- Noted the minutes of the Finance and Performance Committee meeting held on 16 December 2019.

- Noted the meeting schedule for 2020. - Noted the Board work plan.

Board Appointments The Board noted the new Board appointments – Mark Bailey as Non-Executive Director and Dr Tim Noble as Medical Director. Sewa Singh The Board thanked Sewa Singh for his contribution to the Trust, noting that he had been a great colleague to work with and that all would be sad to see him leave. A small gift was provided from members of the Board and all wished him the very best in his retirement. Sewa Singh responded that it had been a privilege to work for the Trust, with Board colleagues and with staff throughout the organisation. He recalled being interviewed by David Cuckson and was pleased that he had been able to fulfil the pledges that he had made when taking up the post of Medical Director. He felt content to leave now as he considered the Board to be ‘in good hands’ and the Trust to be ‘in good hands’. Sewa Singh wished the Board and the Trust the very best going forward. Meeting Schedule Due to the annual leave of the Chair and Deputy Chair there was a requirement to move the October 2020 meeting date. It was likely that this would move to the week commencing 26 October 2020.

ACTION – The Board work plan would be updated to include year-end items from finance.

JR / JS

P20/02/I1 Minutes of the Meeting held on 17 December 2019 (Enclosure I1)

The following amendments to wording were requested (changes in bold italics):

- Hospital acquired pressure ulcers: 69 above a grade 2, 3 or 4 had been reported to date.

- Falls: Serious Incident reports had not yet been undertaken completed. - Safer Nursing Tool: The This looked at nursing care hours per patient day

recorded. - The results showed that the Trust had 30 more nurses than predicted as being

required to run its wards effectively during the assessment period.


The Board:

- Received and Approved the Minutes of the Public Meeting held on 14 January 2020, subject to the amendments above.

P20/02/I2 Any Other Business (Verbal)

No other items of business were raised.

P20/02/I3 Governor Questions Regarding the Business of the Meeting (Verbal)

P20/02/I3(i) Hazel Brand Reference P20/02/B1 – Hazel Brand welcomed the presentation but raised concerns that the work on the digital strategy did not feel particularly patient focused and did not appear to account for wider determinants of health, or work with external partners (eg Councils and the Police). There was a request that presenters spell out acronyms when first used at future meetings.

ACTION – Upon invite, future Board guests would be asked to steer clear of the use of acronyms – or be requested to provide an explanation of any included in their presentations.

JR

P20/02/I3(ii) Peter Abell Peter Abell concurred with the comments on the digital transformation presentation and raised further concerns that, being led by Doncaster CCG and PLACE could lead to the exclusion of Bassetlaw Hospital and would not maximise the use of internal expertise – which had been evidenced as effective in leading local initiatives (eg E Observations). Richard Parker commented that organisational initiatives would continue to be led internally but that there also a need for system level work. The future alignment of CCGs to the ICS was likely to clarify the leadership of system projects. There was a plea for a simple message to be given out for the Public.

ACTION – Information on digital transformation would be considered for a future Governor Briefing session.

JR / KA

P20/02/I3(iii) Sheila Walsh In response to a detailed query, it was confirmed that the clock started on trolley waits when the patient was referred to a speciality, and was accepted by the speciality. Any time waiting in an ambulance was not included in the data.

P20/02/I3(iv) David Cuckson David Cuckson thanked Sewa Singh for his work with the Governors – noting his regular presence at Governor meetings and responses to Governor questions.


The Board:

- Noted the comments raised, and information provided in response.

P20/02/I4 Date and Time of Next meeting (Verbal)

The Board:

- Noted the date and time of the next meeting:

Tuesday 17 March 2020 9:15am The Fred and Ann Green Board Room, Montagu Hospital

P20/02/I5 Withdrawal of Press and Public (Verbal)

The Board:

- Resolved that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

P20/02/J

Close of meeting (Verbal)

The meeting closed at 12.30.

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