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Trust Public Board of Directors Meeting - 30 July 2015 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 30 July 2015 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge- Chairman

Members:

Mrs H Strawbridge (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr Paul Love (PL), Dr Ian Reynolds (IR), Prof. M Watkins (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms C Warner (CW), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mrs J Smalley (JS)

Opening business No Topic Format Presenter

1 Welcome, Introduction & Apologies Apologies: Dr A Smith, Mr F Gillen, Mrs E Wood

Verbal HS

2 Declarations of Conflicts of Interest Verbal All

3 Patient Story Verbal NED

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Minutes of previous meeting – 28 May 2015 Paper 1 HS

7 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting - 30 July 2015 of 2

Strategic Items for assurance 8 Integrated Corporate Performance report Paper 3 JK

9 Corporate Risk Register, BAF and Assurance log Paper 4 JW

Items for approval 10 2014/15 - Trust Charitable Funds - Annual Accounts Paper 5 JK

11 Use of seal Paper 6 MM

12 Quality account and report 2014/15 – stakeholder feedback Paper 7 JW

Sub Committee reporting for assurance

13 Quality & Governance Committee Assurance report - May 2015 Paper 8 MW

Items for information 14 Pensions Charter Paper 9 MM

Closing business

15 • Any Other Business • Identification of New Risks (incl. Health & Safety) • Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting - 28 May 2015

Page 1 of 8

Minutes Trust Public Board of Directors Meeting Thursday 28 May 2015 - 10:00 hours Chair Mrs H Strawbridge- Chairman Administration Mrs A Williams– EA to Executive Director of IM&T Members in attendance: Mrs H Strawbridge HS Chairman Mr K Wenman KW Chief Executive Mr R Davies RD Non-Executive Director Mr T Fox TF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Prof. M Watkins MW Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Dr A Smith AGS Executive Medical Director Non Members: Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Mrs N Casey NC Head of Governance Miss A Hanson AH Deputy Director of HR Council of Governors Mr R Care RC Council of Governors No Agenda Item Action 1.0 Welcome, Introduction & Apologies 1.1 1.2 1.3

HS welcomed Nicole Casey, Amy Hanson, Neil Le Chevalier and Rae Care to the meeting. Apologies were received from Emma Wood and Jenny Winslade. HS advised the Board that this would be Robert Davies last Trust Board of Directors Meetings and thanked RD for all his hard work and commitment to the Trust.


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2.0 Declarations of Conflict of Interest 2.1 There were no declarations of conflict of interest. 3.0 Patient Story 3.1

Patient stories were ready by HH and TF.

4.0 Report from the Chairman 4.1 4.2 4.3

HS referred to the three recent Staff Award events, feedback from staff was very positive and HS was pleased to report that old and new SWASFT came together as one. Thanks were extended to all staff who helped to organise the ceremonies. Non-Executive Interviews are taking place 29 May 2015 and 1 June 2015. There are 2 vacancies and 11 applicants. Following the interviews recommendations will be taken to the Council of Governors Meeting on 16 June 2015 and then confirmation will be shared with the Board. The Trust continues with the trial on Dispatch on Disposition which is producing positive results.

5.0 Report from the Chief Executive 5.1 5.2

KW reported that discussions have taken place with the Anthony Marsh, Chief Executive from West Midlands Ambulance Trust as he is keen to trial the Dispatch on Disposition. KW noted that compared to performance and finance in other local NHS organisations the Trust had done well. HS added that the Monitor website was showing the Trust to have breached their provider license, it was confirmed that this has now been corrected and was a mistake by Monitor and is now showing as green and no issues identified.

6.0 Questions from the Public, Council of Governors and Staff 6.1 There were no questions raised.


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7.0 Action Point Register 7.1 7.2 7.3 7.4 7.5 7.6 7.7

Action 10.2.2 Corporate Risk Register: JW will present this to the July 2015 Trust Board of Directors. Action 8.1.5 Presentation from Health Watch Gloucestershire: HS noted that this would be presented at a future Council of Governors Meeting. HS confirmed that it was not a duty of the governors to be involved in the communication and strategy of the Trust. Action closed. Action 10.6.2 Committee Assurance Reports: HS advised that the meeting scheduled to discuss sickness reporting is now not necessary and the action can be closed. Action 8.1.5. Communications and Engagement Strategy: MW advised that the Strategy was scheduled to go to the next Quality and Governance meeting in August but the meeting had now been cancelled. HS asked that this was presented at the Trust Board of Directors meeting in July 2015. ACTION: CW to present the Communications and Engagement Strategy to the July 2015 Trust Council of Governors meeting. Action 9.8.9: Patient Safety and Patient Experience Report: MW advised that the Friends and Family TEST (FFT) response is still low. NC added that this will now be promoted on the back of the patient safety leaflets to attract more responses. ACTION: JW to report back at the July 2015 Trust Board of Directors Meeting. Action 2: Care Quality Commission: It was noted that this will come to the Trust Board Seminar in June 2015. All other actions were noted.

JW CW JW MM

8.0 Performance

8.1 Update on Dispatch on Disposition/8 Week NHS England Report 8.1.1 8.1.2

KW advised that a call had been scheduled with NHS England on 28 May 2015 to discuss the trial but unfortunately this was cancelled. ACTION: KW to request the production of a report to demonstrate the data of the trial in simple terms which will be useful for the public. KW added that the trial was showing positive results and at no stage have any patients been harmed or had any reduction in their safety. KW stated there had been an improvement in performance for hear and

KW


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8.1.3. 8.1.4 8.1.5 8.1.6 8.1.7 8.1.8 8.1.9

treat but there is still work to be done on Red 19. The Trust uses NHS Pathways in the East and West Divisions which means more patients can be dealt with using Hear and Treat. MW asked why the North results were not as good. KW advised that this is because North Division uses AMPDS. See and Treat results have decreased to 35% and See and Convey has decreased to 51%. KW noted that a significant number of incidents have been resolved during the trial period using telephone advice. Resource allocations were fewer which meant that incidents were being managed without an ambulance response. KW reported that the Trust together with AACE are still continuing discussions with the Secretary of State regarding an alternative to the Red 2 target. There has been positive feedback from staff during the trial and there are noticeable changes in the behaviours of staff, particularly within the Clinical Hubs who have to deal with calls in a different way. HS was reassured by the fact that the Trust is delivering a safe service and the results were positive.

8.2 Integrated Corporate Performance Report 8.2.1 8.2.2 8.2.3 8.2.4 8.2.5

JK presented the ICPR report which illustrated that the Dispatch on Disposition trial has identified a number of benefits to the Trust, there have been improvements to performance, a reduction in resource allocations and more incidents are being resolved by telephone advice or a referral to a more appropriate service. JK reported that Red 1 performance in April 2015 was above the national performance target of 75%. Both Red 2 and A19 were under the national targets, but measures have been introduced to improve performance and the Trust is working towards performing at 70% for Red 2 by the end of June 2015. RC asked whether performance on Red 2 was affected by the impact of DX014 and JK confirmed that it was. KW confirmed that the activation rates were not unique to the Trust.


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8.2.6 8.2.7 8.2.8 8.2.9 8.2.10 8.2.11 8.2.12 8.2.13 8.2.14

Activation rates increase within most Trusts especially over the bank holiday periods. HS thanked everyone for the tremendous achievements the Trust had produced with the performance of Red 1. UCS - The Trust Board of Directors noted that Gloucestershire Out of Hours service went ‘live’ on 1 April 2015. KPIs were discussed and JK gave assurance that JW is leading on these and there is strong governance in place to monitor and improve KPIs. AS advised that the Trust has an excellent relationship with the GPs and are ensuring robust rotes are in place for the Allied Health professionals, Assistant \Nurse Practitioners and Emergency Care Practitioners. NHS 111 Service 60 second call answering and call abandonment rates - JK reported that call answering and call abandonment performances were significantly low for the month of April 2015. Discussions have taken place with stakeholders and they have been informed that there has been no harm caused patients during their care. JK advised that Somerset OOHs and NHS 111 will be transferred to a new service provider with effect from 1 July 2015. Workforce - the Trust continues to have difficulties recruiting frontline staff. Sickness absence levels have increased. An action plan has been developed to monitor sickness levels and this incorporates robust processes for facilitating the return to work of staff. Trusts Financial position - The Trust Board of Directors noted the cost pressures that need to be addressed. Staff Appraisals – The Staff Appraisal target has dropped to 50.42% due to operational pressures. MW added that staff who have not had an appraisal will have their appraisal completed first. ACTION: EW to submit an appraisal review report to the Quality and Governance Committee in August 2015. The Trust Board of Directors took the Integrated Corporate Performance Report for assurance.

EW


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8.3 Board Assurance Framework

8.4.1 KW presented the Board Assurance Framework. The new BAF is being developed and will be shared at the June 2015 Seminar and presented to the Board in July 2015. ACTION: The updated Board Assurance Framework will be presented at the July 2015 Trust Board of Directors Meeting.

MM

9.0 Governance 9.1 Corporate Risk Register

9.1.1 9.1.2 9.1.3 9.1.4 9.1.5

KW advised that the Corporate Risk Register had not yet been presented to the Director Group; he explained that all risks were rag rated after mitigation. HS asked about the timeline and reviewing the action deadline. KW confirmed this would be reviewed at the Director Group meeting and would be completed by end of June 2015. RD raised discussion regarding the current consequence score and asked why some risks were rated so high. MM advised that some risks needed to be rated that high, but suggested that the likelihood score was the score to focus on. MM added that whilst updating the BAF he will be reviewing the definitions of the Risk Register. RD asked FG whether the IT Service Failure Risk rating would decrease from 20. FG confirmed that it would and suggested that step deadlines are incorporated in the register. The Trust Board of Directors took assurance from the Risk Register and agreed that this should be reviewed again at the next Trust Board Seminar. ACTION: MM to bring the Risk Register back to the June 2015 Trust Board Seminar.

MM

9.2 Major Incident Plan

9.2.1 To be discussed at the Confidential meeting.

9.3 Patient Experience Annual Report

9.3.1 9.3.2

NC presented the Patient Experience Annual Report which had previously been received by the Quality and Governance Committee. Compliments have increased to 41%. Complaints had increased to 24%.


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9.3.3 9.3.4 9.3.5 9.3.6 9.3.7 9.3.8

There were 52 Serious Incidents confirmed during the year which is a reduction from the year before. NC advised that changes have been made to the Serious Incident process to make it more efficient and timely. A decision group has been set up which consists of the Head of Governance, Patient Safety Manager and the Senior Clinical On Call Manager. The group meets weekly to discuss potential, serious and moderate harm incidents. Adverse Incidents have increased by 30% compared to the year before. NC advised that the 25 day deadline for complaint investigations is a challenge and the Trust is looking to modify this to 35 day response. The total numbers of serious incidents in December 2014 were discussed and it was agreed that the presentation of the figures need amending. ACTION: NC to update the table. NC advised that a proactive apology had been introduced for incidents where no moderate or serious harm was caused to patients, but where they may have not received a good service so a letter is sent. NC confirmed that this had been well received. RD asked for clarity regarding the ten files sent to the Ombudsman. NC confirmed that this was at their request and agreed to re word this section. ACTION: NC to amend the Ombudsman section of the report and present a report on Ombudsman Referrals to the Quality and Governance Committee in August 2015 and to the next Trust Board of Directors Meeting on 30 September 2015. Deep dive on Complaint performance process to go to the next Q&G meeting.

NC NC

9.4 Item moved to the confidential board 9.4.1 To be discussed in the Confidential section of the meeting.

9.5 Committee Assurance Reports 9.5.1. Audit Committee

9.5.2 9.5.3

TF presented the Audit Committee Assurance Reports following the meetings of 9 April 2015 and 20 May 2015. RD referred to the three current committees that delegates responsibility for essential business and asked that the Remuneration Committee be added as another committee. The Trust Board of Directors accepted the Audit Committee Assurance


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Report and took assurance from it. 9.5.2 Quality and Governance Committee 9.5.2.1 Quality and Governance Committee Assurance Report was deferred to the

July 2015 Trust Board of Directors Meeting. ACTION: NC to review the Assurance Report ready for submission.

NC

9.6.2 Minutes of Previous Meeting 26 March 2015 9.6.3 The Minutes of the 26 March 2015 were approved as an accurate record of

the meeting.

10.0 Any other Business 10.1 None reported 11.0 Identification of New Risks (incl. Health & Safety)

11.1 No new risks were identified.

12.0 Identification of New Legislation 12.1 No new legislation was identified.

13.0 For Information-committee meeting final minutes

13.1 13.2 13.3

The following were noted for assurance: Audit Committee – 15 January and 9 April 2015 Quality and Governance 12 March 2015 It is also to be noted that the following committee meetings have been held since the last meeting of the Trust Board of Directors Meeting on 26 March 2015: Quality and Governance Committee - 14 May 2015 Annul Accounts - Audit Committee - 20 May 2015 Annual Accounts - Confidential Board of Directors - 20 May 2015

Signed: _________________________________________________________________ (Chair) Dated:

Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

29 May 2014 10.2.2Corporate Risk

Register

The Board of Directors approved the proposed

changes to the Corporate Risk Register. HS added

that the Board of Directors should undertake Risk

Training and a review of Directorate Registers.

JP/MM 30/10/2014

Update Scheduled for April 2015.

Update 28/05/2015 JW will

present this to the July 2015 Trust

Board of Directors

ACTION COMPLETE

25 September 2014 10.5.3

Patient Safety and

Experience Report

2014/15 Period 2

VJ commented on the correlation between the

number of incidents and Duty of Candor cases and

suggested that it would be appropriate for this to be

included in this report, JW agreed

JW 27/11/2014

Presented at March Board -

26.03.15.

ACTION COMPLETE

25 September 2014 10.5.3

Patient Safety and

Experience Report

2014/15 Period 2

Regards the availability of advocacy services. JW

advised that more work would need to be done

around what was available to both staff and patients.

JW 27/11/2014

Presented at March Board

26.03.15.

ACTION COMPLETE

27 November 2014 10.2.3Corporate Risk

Register

HH asked whether, if the mitigating action did not

affect the risk rating, why the mitigating actions were

being taken. JW accepted the feedback and agreed

to discuss this further with the Risk Group at their

next meeting.

JW 29/01/2015

Update: 20/07/15

Risk Watch now meetinbg bi-

monthly. BAF mapped to risk

register. Risk Register to

befocused on assurnace and

mitigating actions. Procurement

of new platform in Quarter 4 of

2015/16

27 November 2014 10.4.3

Patient Safety and

Experience Report

2014/15 Period 3

HS asked that when it stated ‘outside the agreed

timeframe’ that the required timeframe was added.

JW confirmed this would be done for future reports.

JW 29/01/2015


26.03.15.

ACTION COMPLETE

02 February 2015 8.1.5

Communications and

Engagement

Strategy

HS commented that is was good to see the

assurance given and requested that the Strategy is

presented to the Quality and Governance Committee.

ACTION: CW to submit the Communications and

Engagement Strategy to the next Quality and

Governance Committee in March 2015. CW 12/03/2015

Update: Presented to Board in

March 2015 Quartlerly reporting to

Q&G in Place. Presentated to

Council of Governors in July

2015.

ACTION COMPLETE

Trust Public Board Meeting Action Point Register - 2014/15

At each Trust Public Board Meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This

document has been created to keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each meeting along with action points which have been completed since

the last meeting.

Page 1 of 3 P:\Meetings\Board & Committee Meetings\Board of Directors\Board Papers\2015-16\5. 30 July 2015 - public & conf\Public\2. Action point register\Trust Public Board APR 2014-15

02 February 2015 9.1.14 ICPR

Monitor compliance focuses on minor injuries

and learning disabilities. HS on behalf of the Trust

Board asked that the Quality and Governance

Committee has a deep dive into learning

disabilities. ACTION: JW to add this to a future

Quality and Governance Committee Agenda.

JW 26/03/2015


26.03.15.

ACTION COMPLETE

02 February 2015 10.1.2

Board Assurance

Framework 2014/15

ACTION: It was agreed that HS would ask the

Audit Committee to go through some of the

strands of the Board Assurance Framework in

depth and report back to the Trust Board. HS 09/04/2015

Update: 20/07/2015

BAF stands to be included in work

prograame for 2015/16. Work

programme to be approved on 6

August 2015

02 February 2015 10.6.12 Training Report

ACTION: The Trust Board of Directors noted that

a brief on Training is being submitted to the

Quality and Governance Committee in March 2015

and the Trust Board of Directors requested a

report following that meeting. EW to forward.

EW 26/03/2015

Action complete - sent with

Chairmans Brief 19

ACTION COMPLETE

26 March 2015 9.8.9

Patient Safety and

Experience Report

2014/15 – February

2015

It was noted that the Friends and Family Test (FFT)

response is low. HS on behalf of the Trust Board of

Directors requested a report on FFT be presented to

the Quality and Governance Committee. Responses

are low and the small percent of returns by staff is

concerning. ACTION: JW and MW to discuss prior

to the next Quality and Governance Committee. JW/MW 14/05/2015

Update: to be picked up at Q&G

in August 2015

26 March 2015 9.10.6

Corporate Risk

Register

KW asked that in the next review reflect on

whether RAG ratings should be post risk.

ACTION: MM and JW to discuss further at Risk

Watch and review the heading of Current Risk

Rating and whether this should be Forecast

instead. The Risk Register is to be brought for

review to the Trust Board Seminar in April 2015.

MW/JW 30/04/2015

RAG rating completed on the

residual risk assessment. Risk

Register and BAF discussed at

April Seminar and piloted at June

Seminar.

ACTION COMPLETE


26 March 2015 12.1

Care Quality

Commission

Inspections - The

New Approach

The Care Quality Commission received for

information could be brought forward to the Trust

Board Seminar in April 2015. JW had agreed with

the Executive Directors that they would form a group

that will oversee the assessment as the Trust gets to

the new framework. The wider framework would be

reported to the Quality and Governance Committee.

HS would like to see that at the Trust Board Meeting

in the first instance and then report back to Quality

and Governance Committee. MW requested that it

was noted that the Trust is preparing for this and that

it is a risk. ACTION: JW to ensure the risk actions

are updated on the Risk Register.

JW 30/04/2015

Update provided to the June

seminar. CQC risk register

reported to the Directors group.

ACTION COMPLETE


Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

28 May 2015 8.1.1Dispatch on

Disposition

KW to request the production of a report to demonstrate the data

of the trial in simple terms which will be useful for the public.KW 30/07/2015

Update 28/07/2015: NHS England advised there was no

report to be released to the public at this time.

ACTION COMPLETED

28 May 2015 8.2.13 ICPREW to submit an appraisal review report to the Quality and

Governance Committee in August 2015.EW 06/08/2015

Update: Scheduled for Quality and Governance - 6

August 2015

28 May 2015 8.4.1Board Assurance

Framework

The updated Board Assurance Framework will be presented at

the July 2015 Trust Board of Directors.MM 30/07/2015

Update: Scheduled for Board 30/07/2015

ACTION COMPLETED

28 May 2015 9.1.5Corporate Risk

Register

MM to bring the Risk Register back to the June 2015 Trust Board

Seminar.MM 25/06/2015 Brought to June Seminar

ACTION COMPLETED

28 May 2015 9.3.5Patient Experience

Annual ReportNC to update the table. NC 01/07/2015

Table updated.

ACTION COMPLETED

28 May 2015 9.3.7Patient Experience

Annual Report

NC to amend the Ombudsman section of the report and present

a report on Ombudsman Referrals to the Quality and

Governance Committee in August 2015 and to the next Trust

Board of Directors Meeting on 30 September 2015.

NC 30/09/2015Update: Scheduled for Quality and Governance in August

and Board in September 2015

28 May 2015 9.5.2.1

Quality and

Governance

Committee

NC to review the Assurance Report ready for submission. NC 01/07/2015

Update: Assurance report has been reviewed and added

to the Board agenda

ACTION COMPLETED

Trust Public Board Meeting Action Point Register - 2015-16

At each Trust Board Meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This document has been created

to keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each meeting along with action points which have been completed since the last meeting.

Trust Board of Directors Meeting

Page 1 of 1

Trust Board of Directors Meeting 23 July 2015

Title: Integrated Corporate Performance Report (ICPR)

Prepared by: Jessica Hodgman, Director of Planning and Performance and Paul Quick, Performance Manager

Presented by: Jennie Kingston, Deputy Chief Executive/Executive Director of Finance

Main aim: For the Board of Directors to receive the Integrated Corporate Performance Report for assurance

Recommendations: For assurance

Previous Forum: N/A

This report references:

Board Assurance Framework

BAF 05-14 to BAF 08-14 Directorate Business Plans

Finance

Implications

(including Statutory or Legal References)

Reports performance against the Trust statutory and contractual targets

Integrated Corporate Performance Report

June 2015

Title of originator/author: Paul Quick, Performance Manager

Jessica Hodgman, Director of Planning and Performance

Name of responsible director: Jennie Kingston, Deputy Chief Executive/Executive Director of Finance

Date issued: 23 July 2015

SWASFT Integrated Corporate Performance Report

INTEGRATED CORPORATE PERFORMANCE REPORT Page 2 of 61

1. Introduction

1.1. The South Western Ambulance Service NHS Foundation Trust (SWASFT) monthly Integrated Corporate Performance Report (ICPR), reports performance by exception and focuses on action being taken by the Trust to address off plan performance.

1.2. The Integrated Corporate Performance Report is structured as follows:

Reported in the ICPR Monthly Reported in the Confidential

Addendum

• A Performance Dashboard summarising performance across all metrics;

• Ambulance National Quality Measures, covering Patient Safety, Effectiveness and Experience;

• Ambulance National Clinical Quality Indicators;

• Local standards and thresholds agreed with NHS Commissioners;

• Internal Trust Key Performance Indicators (KPIs);

• Resource Performance Measures, covering REAP level, service line activity, financial position and capacity and capability metrics;

• A&E and PTS activity levels are reported within this report;

• Trust performance against the Monitor Compliance Framework (and subsequently Risk Assessment Framework);

• Analysis of the Trust Carbon Footprint (including vehicle carbon emissions);

• Right Care 2.

• The position against the A&E, OOH and NHS 111 commissioning contracts;

• CQUIN performance;

• Performance ‘deep dives’ as appropriate.

Mapping to the 2015/16 Trust Corporate Objectives, Acquisition Pledges and the NHS

Outcomes Framework

1.3. Appendix A shows how the performance metrics included within the ICPR map to the Trusts

Corporate Objectives and the five domains of the NHS Outcomes Framework.

1.4. For each of the five domains, the Trust has identified the metrics best placed to provide

assurance of delivery. The NHS Commissioning Board document ‘Everyone Counts: Planning for Patients 2013/14’ sets out the principles behind the approach to planning clinical led commissioning. This guidance states that NHS outcomes will inform NHS planning and Commissioners will be expected to prioritise improvements against all domains.

1.5. The five domains are as follows:

Domain 1: Preventing People from Dying Prematurely;

Domain 2: Enhancing the Quality of Life for People with Long Term Conditions;

Domain 3: Helping People to recover from periods of Ill Health or following Injury;

Domain 4: Ensuring that People have a Positive Experience of Care;

Domain 5: Treating and Caring for People in a Safe Environment and protecting them from Avoidable Harm.

SOUTH WESTERN AMBULANCE SERVICE NHS FOUNDATION TRUST

INTEGRATED CORPORATE PERFORMANCE REPORT

PAGE 3 of 61

2. Performance Exceptions

2.1. The ICPR focuses on exceptional performance and aims to provide the Trust with an early warning of deteriorating performance.

2.2. The four reporting categories assigned to individual performance metrics contained within the ICPR are as follows:

No Concerns: Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance;

Early Warning: Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period;

Improvement Expected: Performance in the reporting period is below target but there is evidence that performance is improving AND/OR there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category;

Real Concerns: Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance.

2.3. There is a direct link between the exception category assigned to individual performance metrics and the level of detail and assurance provided in the ICPR. Appendix B sets out the Trust approach to reporting performance exceptions and specifies the level of information and assurance required by the Board of Directors.

Table 1: Performance Exception Overview in the Reporting Period

Early Warning

Green 1, Green 2 and Green 4 call performance in June 2015 was below target;

The staff turnover rate remains high at 14.90% at the end of June 2015 (reducing to 14.01% excluding redundancies);

Staff Appraisal rates were below the internal KPI target of 85% but this is linked to the Red 2 Measures to Improve Performance Plan.

No Concerns

Red 1 performance in June 2015 was above (better than) the national performance target of 75%. This remains a very challenging target;

Green 3 call performance was above (better than) local KPI levels for June 2015;

Percentage of A&E calls abandoned are lower (better) than local thresholds;

Time to answer calls were below (better than) the local threshold measures for the 50

th and 95

th

percentile metrics in June 2015;

ROSC following cardiac arrest was above (better than) local thresholds;

Stroke patients receiving the appropriate care bundle is above local thresholds;

Outcome from cardiac arrest, survival to discharge rates, are above local thresholds;

Urgent Care Service QR12: In the county of Somerset performance for Urgent and Less Urgent Base Consultations and for Less Urgent Home Visits were above (better than) the 95% performance targets.

Urgent Care Service QR12: In the county of Gloucestershire performance for Less Urgent Base Consultations was above (better than) the 95% performance target.



Early Warning (continued) No Concerns(continued)

Tiverton UCC performance against the 4 hour

treatment time was above the 95% target;

Information Governance Toolkit is on plan to deliver level 2 performance;

Compliance with Infection Prevention and

Control.

Real Concerns

A&E (999) Activity levels (demand) is higher than contracted volumes and significantly higher than the levels for 2014/15;

The number of frontline operational

vacancies, particularly in the North Division, is having a significant and sustained impact on performance although the Operating Plan for A&E shows an improvement in October 2015;

NHS 111 call answering performance is below the 95% national KPI level in June 2015;

NHS 111 call abandonment rates were above (worse than) KPI levels in June 2015;

961 of operational resource time were lost to

handover delays at acute hospitals in June 2015.

Improvement Expected

Red 2 and A19 performance were below (worse than) national targets in June 2015 however measures are being introduced to deliver improvements in performance;

Re-contact rates following telephone advice and following treatment at scene were higher (worse than) the local performance threshold;

Outcome from STEMI PPCI, patients receiving primary angioplasty commencing within 150 minutes;

Outcome from Stroke, patients receiving thrombolysis at an hyper-acute centre within 60 minutes is below (worse than) local thresholds;

Acute STEMI patients receiving the appropriate care bundle was marginally below the local threshold;

Urgent Care Service QR12: In the county of Somerset performance for Urgent Home Visits was partially compliant in June 2015 against the 2 hour response time target at 93.57% against the 95% performance target;

Urgent Care Service QR12: In the county of Dorset performance for Urgent Home Visits was partially compliant in June 2015 against the 2 hour response time target at 94.80% against the 95% performance target.

Urgent Care Service QR12: In the county of Gloucestershire performance for Urgent Base Consultations was partially compliant in June 2015 against the 2 hour response time target at 90.76% against the 95% performance target.

Urgent Care Service QR12: In the county of Gloucestershire performance for Urgent Home Visits was non-compliant in June 2015 against the 2 hour response time target at 89.44% and partially compliant for Less Urgent Home Visits against the 6 hour response target at 93.83%;

Some PTS KPIs in the BNSSG contact are below agreed levels but are showing improvement;

Sickness levels across the trust are higher than planned however actions within the A&E Operating Plan for 2015/16 are targeted to deliver appropriate reductions in hours lost to sickness.



3. Summary of Benchmarked Position based on May 2015 Data 3.1. The following benchmarking data compares the performance of the Trust with other

ambulance services in England. Benchmarking data is only available for May 2015 and not for June 2015.

National Benchmarking Against Other Ambulance Trusts 3.2. National averages for Red 1 and A19 performance were above the national targets in May

2015 but below national target for Red 2 performance. National Red 1 and A19 performance has improved considerably upon the levels reported in the year ending 31 March 2015.

3.3. Across the country other ambulance services are reporting lower than anticipated activity

growth at the start of 2015/16 and in some cases reductions in overall activity levels. This is not the case in SWASFT, where activity levels continue to be above contracted levels during the first three months of 2015/16 particularly in the North Division.

National Average Performance – Rolling 12 Months Review

Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

Red 1 72.50% 70.86% 73.23% 72.70% 72.11% 71.80% 66.02% 71.53% 72.04% 73.41% 75.63% 76.72%

Red 2 70.76% 68.81% 70.94% 69.98% 69.86% 68.38% 60.98% 67.55% 67.55% 69.58% 72.37% 73.22%

A19 94.85% 94.07% 94.96% 94.41% 93.99% 93.58% 90.06% 93.23% 93.47% 94.12% 95.03% 95.22%

3.4. Following the introduction of the Dispatch on Disposition trial, SWASFT reported Red 1

performance above the national performance target in both April and May 2015.

3.5. SWASFT was however below the national average performance for Red 2 in May 2015 (66.25% against a national average of 73.22%) and A19 performance (91.76% against the

national average of 95.22%). As detailed later in this report, performance against both

of these metrics has been impacted by the introduction of Dispatch on Disposition

and this impact needs to be taken into account in comparing the performance of

SWASFT with other ambulance services that are not Dispatching on Disposition. At

the current time this trial is only being run by SWASFT.



May 2015 in Month Benchmarking Against Other Ambulance Trusts



Year to Date Benchmarking Against Other Ambulance Trusts 3.6. For the period April 2015 to May 2015 SWASFT was above both the national average and

the national performance target for Red 1.

3.7. National average performance for Red 1 and A19 was above 75%, with Red 1 at 76.17%

and A19 at 95.17%. The national average performance for Red 2 was below the 75% target at 72.80%.



4. Monitor’s Risk Assessment Framework 4.1. Monitor uses the Governance Rating, incorporating information across a number of areas,

to describe their views of the governance of the Trust. Monitor generates this rating by considering a range of information set out in 4.4 below and forms a view as to whether this is indicative of a potential breach of the governance condition. Full details of these areas can be found at Appendix C.

4.2. Within the Integrated Corporate Performance Report each month an internal assessment, based on the forecast quarter end performance figures, is reported for the Access and Outcomes Metrics element of this overall assessment.

4.3. Where the Trust breaches a target(s), Monitor uses the sum of each metric’s weighting to calculate a Service Performance Score. Where this score is 4.0 or greater, this represents a governance concern. Where the Trust breaches a target systematically (i.e. a national performance breach for three consecutive quarters) this also triggers a governance concern as shown in the table below, an extract from Diagram 15 in Monitor’s Risk Assessment Framework:

Indicator Driver of Governance Concern

Ambulance Response Times

Breaches:

Either category A 8-minute response time targets (Red 1 and Red 2) for a third successive quarter; or

Category A19 minute response time target for a third successive quarter

Minor Injury Unit Waiting Times

Breaches:

4 Hour Waiting Time target breached for a third successive quarter

4.4. The overall Governance Risk Rating includes:

A Service Performance Score (based on a score of 0.0 to 4.0 with 0.0 representing strong performance and no concerns);

CQC Information;

Third Party Reports: Adhoc reports from GMC, the Ombudsman, Commissioners, Healthwatch England, Auditors, Health & Safety Executive, Patient Groups, Complaints, Whistle-blowers, etc;

Quality Governance Indicators: Patient metrics, staff metrics and cost reduction plans;

Financial Risk: Continuity of Services Risk Rating is provided under the financial section of this report (based on a score of 0.0 to 4.0 with 4.0 representing the strongest financial performance).

Quarter 1 2015/16

4.5. The Trust delivered Red 1 performance above national target levels for Quarter 1 of 2015/16, but performance for both Red 2 and A19 were below target levels.

Quarter 2 2015/16 Forecast Performance

4.6. Based on additional measures being introduced as part of the Measures to Improve Performance (MIP) Plan, the Trust is forecasting delivery of Red 1 in Quarter 2.

4.7. Red 2 performance has been impacted by Dispatch on Disposition. The Trust has been

able to agree a position with NHS Commissioners that recognizes this consequence for performance management purposes.

4.8. The Trust is currently forecasting Red 2 performance above 70% in the East and West

Divisions for Quarter 2 and a small improvement on the Quarter 1 Red 2 performance in the North Division. Securing Red 2 performance across the Trust in Quarter 2 is going to be a significant challenge as activity is considerably higher than plan in the North and there are ongoing frontline vacancies in this Division.



5. Accident and Emergency (999) Performance

Accident and Emergency (999) Activity Levels 5.1. The Trust has a single A&E contract for 2015/16, based on a contract currency of

‘incidents’, covering all operational areas of the Trust. The contract for 2015/16 incorporates

an uplift in incidents of 3.29% compared to the actual incident numbers reported in 2014/15.

5.2. Incident volumes during the month of June 2015 in isolation were 2.48% above contract.

Further information on the incident numbers can be found in Section 10 of this report. High activity levels have a direct impact on A&E operational performance.

5.3. Trust activity and performance is monitored across 3 Divisions:

West Division: Kernow CCG, NEW Devon CCG and South Devon & Torbay CCG;

East Division: Somerset CCG and Dorset CCG;

North Division: Bath & North East Somerset CCG, Bristol CCG, South Gloucestershire CCG, Wiltshire CCG, North Somerset CCG, Swindon CCG and Gloucestershire CCG.

Table 1: Comparison of Activity against the Contract in the month of June 2015

Actual Activity

June 2015

Contract Activity

June 2015 % Variance

West Division A&E Incidents

24,891 25,030 -0.56%

East Division A&E Incidents

18,682 19,319 -3.30%

North Division A&E Incidents

29,088 28,106 +3.49%

Total

A&E Incidents 74,249 72,455 +2.48%

5.4. Activity is up 4.43% when compared to June 2014 and 6% higher in Q1 of 2015/16 than in Q1 of 2014/15.

Table 2: Activity in the month of June 2015 compared to June 2014

Actual Activity

June 2015

Actual Activity

June 2014 % Variance

West Division A&E Incidents

24,891 24,069 +3.42%

East Division A&E Incidents

18,682 21,801 -2.98%

North Division A&E Incidents

29,088 24,870 +6.10%

Total

A&E Incidents 74,249 71,098 +4.43%

The Source of Accident and Emergency (999) Activity Increases

5.5. When comparing the activity volumes year on year the source of the activity increase can be identified. Whilst there has been growth in the number of incidents received from the public calling 999, this increase is in line with contracted volumes. The most significant proportionate increase is in activity transferred to 999 from NHS 111. This is 21.4% higher in Q1 of 2015/16 compared to Q1 of the previous year.



Table 3: Source of the Activity Increase comparing this year to last

Source of Incident April to June 2014 April to June 2015 Variance

Public Incidents 147,209 152,458 +3.6%

NHS 111 Incidents 30,938 37,560 +21.4%

HCP Incidents 32,386 33,161 +2.4%

Total Incidents 210,533 223,179 +6.0%

5.6. The source of the increase varies by CCG however the increase in NHS 111 activity

transferred to the 999 service in the North Division is significantly higher than the increase in the East and West Divisions.

5.7. Table 4 below compares activity volumes for the past four weeks at a CCG level and looks at the percentage movement in incident volumes for each source of incident.

Table 4: Source of Activity Increase by CCG (2015/16 YTD compared to 2014/15 YTD)

CCG Public

Incidents NHS 111 Incidents

HCP Incidents All

Incidents

BANES +2.3% +45.0% +6.5% +9.2%

Bristol +5.8% +32.5% +1.0% +9.5%

Dorset -1.5% +1.4% +2.5% -0.6%

Gloucestershire +3.5% +39.8% -5.1% +7.8%

Kernow +4.3%

+118.2% (new service

launched in Oct 2014)

-18.6% (linked to launch of NHS 111 service in

Oct 2014)

+7.6%

NEW Devon +3.5% -5.5% +1.0% +1.6%

North Somerset +7.1% +40.1% +5.5% +12.1%

Somerset +4.8% -2.4% -2.6% +2.5%

S Devon & Torbay +2.0% -1.5% -3.1% +0.6%

South Glos +7.2% +46.9% -6.5% +12.4%

Swindon -3.9% +63.9% +0.0% +2.8%

Wiltshire +0.2% +34.7% -5.3% +5.4%

Total +3.6% +21.4% +2.4% +6.0%

5.8. It should be noted that the growth in NHS 111 incident volumes in the West Division will

have been impacted by the staged launch of the NHS 111 service in the county of Cornwall during 2014/15, therefore comparable figures for the previous year are not available, but the comparison is provided in the table above for information.

5.9. NHS 111 originated incidents currently account for approximately 15% to 16% of all ambulance incidents on a weekly basis, however this varies from 18% in the North Division compared to around 14% in the East and West Divisions.



Table 5: Percentage of Ambulance Incidents from NHS 111 – Week Ending 5 July 2015

Mon Tue Wed Thu Fri Sat Sun Total

Trust 13.80% 12.92% 13.42% 12.90% 12.29% 19.52% 21.63% 15.35%

North 15.33% 15.34% 15.68% 16.42% 14.01% 23.27% 26.74% 18.31%

East/West 12.86% 11.44% 11.86% 10.66% 11.12% 16.90% 18.38% 13.42%

5.10. The Trust introduced additional clinicians to operate within the SWASFT North Clinical Hub

during June 2015 to review calls transferred by NHS 111. This clinical support was in addition to the current Clinical Support Desk which already undertakes clinical reviews of Green incidents (including NHS 111 incidents) in the North Division.

5.11. Following a meeting between the Trust, NHS Commissioners and Care UK (the NHS 111 Provider in the North Division) it has been agreed that SWASFT will seek to assist by identifying a cohort of clinicians to act as Floorwalkers in the Care UK Hub. The objective of this action is to reduce the volume of inappropriate Red calls passed to the 999 service for an 8 minute emergency response. At the same time SWASFT is introducing additional Floorwalkers into the SWASFT NHS 111 Hub as part of the Measures to Improve Performance Plan.

Dispatch on Disposition 5.12. In February 2015 SWASFT was given Secretary of State approval to pilot a new way for

ambulance services to respond to 999 calls. This is called ‘Dispatch on Disposition’.

5.13. The changes to the dispatch process do not apply to those incidents which are identified as immediately life-threatening (Red 1 incidents) where an ambulance resource will continue to be dispatched immediately. The trial provides call handlers a small amount of extra time, for non-Red 1 incidents, to triage the patient over the telephone before dispatching an ambulance. The additional telephone triage time provides an opportunity to identify the most clinically appropriate response and in some cases this may not be an ambulance response, and patients may be better served by an immediate referral to another service (e.g. local GP, pharmacy or a walk-in centre).

5.14. A robust governance and monitoring process has been agreed with NHS England throughout the trial. During the trial period NHS England have strict oversight and monitoring of the results and an on-going assessment of the impact of the change. The focus is on maintaining clinical safety and quality.

5.15. Dispatch on Disposition has changed the way the Trust reports Red 2 and A19 performance, Due to this, SWASFTs performance for both Red 2 and A19 cannot be directly compared to other ambulance services in England. This position is recognized nationally and locally by the CCGs who contract 999 services from the Trust

5.16. The trial has already identified a number of benefits to the ambulance service during the short period it has been in place. Based on an assessment against the 12 week period immediately prior to the implementation of Dispatch on Disposition the Trust has seen:

Improvements to Red performance as follows:

Performance % 12 Weeks Pre-Trial

Performance % YTD 2015/16

Variance

Red 1 71.90% 76.55% +4.65%

Red 2 66.17% 66.82% +0.65%

A19 91.36% 91.82% +0.46%



Reductions in inappropriate resource allocations:

Frontline Operational Resource Allocations per Incident

12 Weeks Pre-Trial 2015/16 YTD Variance

Red 1 Incidents 2.02 2.08 +0.06

Red 2 Incidents 1.47 1.45 -0.02

All Green Incidents 1.39 1.20 -0.19

More appropriate allocations leading to a reduction in the number of ambulance resources ‘stood down’ following mobilisation;

Improvements in the proportion of incidents resolved with telephone advice or referral to a more appropriate service;

Percentage of Incidents Resolved with Telephone Advice

12 Weeks Pre-Trial 2015/16 YTD Variance

Hear & Treat % 10.60% 13.94% +3.34%

A positive impact on staff experience.

5.17. In recognition of the impact of Dispatch on Disposition on reported Red 2 performance the Trust has received a Contract Variation from NHS Commissioners. Whilst the national target for Red 2 performance remains unaltered at 75%, the Contract Variation confirms that NHS Commissioners require SWASFT to deliver a minimum of 70% Red 2 performance for 2015/16. Performance reporting within the Integrated Corporate Performance Report will, going forward, monitor SWASFT against both the national performance target of 75% and the local variation of 70%.

Demand Management

5.18. The Trust has engaged in a round of meetings during Quarter 1 of 2015/16 with each CCG to review and agree performance trajectories and local Right Care actions.

5.19. A Demand Management Plan has been agreed with NHS Commissioners. This Plan

focuses on:

Transfers to 999 from NHS 111 Providers;

Reviewing Care Home activity;

Frequent Callers as part of a trust wide CQUIN scheme;

Specified reductions in hospital handover delays;

Actions to improve the contribution of Community Responders;

Identification of locations within the health community which may benefit from the introduction of a Public Access Defibrillator.



6. Ambulance National Quality Measures

6.1. This section provides a monthly summary of performance against each of the Ambulance National Quality Measures. The definition and national target for each measure is provided in Appendix C.

Accident and Emergency Service Line: Category A Performance: Red 1 (75%) Performance Exception Status: The Trust delivered Red 1 performance above national target levels in June 2015 and delivered Red 1 performance above 75% for Quarter 1 of 2015/16

• The Trust is contracted by NHS Commissioners to deliver performance of 75% at a whole Trust level.

• Red 1 performance for the month of June 2015 was 75.29%, 0.29% above the national target.

• The Trust has an internal trajectory to deliver Red 1 performance of 76.00% for the year ending 31 March 2016. As at the end of June 2015 the Trust was 0.67% ahead of this trajectory.

Risk Assessment: The Trust is forecasting that Red 1 performance will continue to be delivered above national target levels for the duration of 2015/16.

Actual Performance

Variance to National

Target

Variance to Internal

Trajectory

Month: June 2015 Actual Performance

75.29% 0.29% (0.75)%

Quarter One 2015/16 Actual Performance

76.55% 1.55% 0.67%

Year to Date 2015/16 Actual Performance

76.55% 1.55% 0.67%

Year End 2015/16 Forecast (1 April 2015 to 31 March 2016)

76.16% 1.16% 0.16%



6.1. In June 2015 the Trust responded to 75.29% of all Red 1 incidents within 8 minutes, 81.27% within 9 minutes and 85.69% within 10 minutes. 95.65% of Red 1 incidents received a response on scene within 15 minutes.

6.2. All Red 1 incidents where the 8 minute response target is missed are reviewed every day by

Operational Managers to identify any learning or barriers to performance that can be addressed to improve future Red 1 performance.

Red 1 Performance by Clinical Commissioning Group (CCG) – June 2015

June 2015 Red 1 Performance Map

Accident and Emergency Service Line: Category A Performance: Red 2 (75%) Performance Exception Status: Improvement Expected Performance in June 2015 was below the national performance target of 75%. An Improvement is expected following agreement of the MIP

Reason(s) for the performance exception category assigned in the reporting period: • The Trust is contracted by NHS Commissioners to deliver performance of 75% at a whole Trust level.

• The Trust delivered Red 2 performance of 65.89% in June 2015.

• Current Performance is linked to Dispatch on Disposition.

• The Trust has received a contract variation from Commissioners. For performance management purposes the Trust needs to deliver 70% performance for Red 2 in 2015/16.

Risk Assessment: The Trust is implementing a ‘Measures to Improve Performance Plan’ (MIP) during Quarter 2 of 2015/16 which will impact on all areas of Red performance including Red 2. The risk to performance delivery has been assessed by the Trust. The two biggest risks to delivery are Demand and Recruitment.

Actual Performance


Target

Variance to 70%

Adjusted Target


65.89% (9.11)% (4.11)%


66.82% (8.18)% (3.18)%


66.82% (8.18)% (3.18)%


70.00% (5.00)% 0.00%

Clinical

Commissioning

Group

No. of

Incidents

June 15

Red 1 %

June 15

No. of

Incidents

2015/16

Red 1 %

2015/16

Kernow 148 71.62% 403 75.19%

South Devon & Torbay 76 81.58% 207 80.68%

NEW Devon 220 81.82% 616 84.25%

Somerset 114 74.56% 356 80.62%

Dorset 199 82.91% 619 84.01%

North Somerset 54 88.89% 167 76.65%

Bath & NE Somerset 41 65.85% 118 75.42%

Bristol 149 73.83% 441 72.34%

South Gloucestershire 45 75.56% 160 66.88%

Gloucestershire 154 64.94% 508 69.29%

Wiltshire 97 67.01% 314 64.33%

Swindon 57 68.42% 180 77.78%

TRUST 1,356 75.29% 4,093 76.55%



23,184

25,091

24,194

20,000

21,000

22,000

23,000

24,000

25,000

26,000

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

April May June July August September October November December January February March

Red 2 Performance

Red 2 Incidents Red 2 Performance % 2014/15 Red 2 Performance % 2015/16 Red 2 Performance Target

Red 2 Performance by Clinical Commissioning Group (CCG) – June 2015

June 2015 Red 2 Performance Map

Accident and Emergency Service Line: Category A Performance: A19 (95%) Performance Exception Status: Improvement Expected Performance in June 2015 was below the national performance target of 95%.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust is contracted by NHS Commissioners to deliver performance of 95% at a whole Trust level.

• The Trust delivered A19 performance of 91.07% in June 2015.

Risk Assessment: Service Developments to deliver improvements in Red performance are incorporated within the A&E Operating Plan for 2015/16 including maximising the benefits from the Dispatch of Disposition behaviours. The Trust is implementing a ‘Measures to Improve Performance Plan’ (MIP) during Quarter 2 of 2015/16 which will impact on all areas of Red performance including Red 2. The risk to performance delivery has been assessed by the Trust.

Clinical

Commissioning

Group

No. of

Incidents

Jun 15

Red 2 %

Jun 15

No. of

Incidents

YTD

Red 2 %

YTD

Kernow 2,703 60.45% 7,588 62.22%

South Devon & Torbay 1,314 71.08% 4,110 71.51%

NEW Devon 3,691 71.50% 11,227 71.77%

Somerset 2,301 65.02% 6,552 66.74%

Dorset 3,602 69.68% 10,565 70.99%

North Somerset 1,005 57.61% 3,044 61.10%

Bath & NE Somerset 687 65.50% 2,214 66.03%

Bristol 2,310 68.40% 7,064 68.12%

South Gloucestershire 1,031 54.32% 3,294 58.11%

Gloucestershire 2,540 65.20% 7,930 64.04%

Wiltshire 2,010 58.66% 5,943 58.39%

Swindon 948 73.42% 2,847 76.64%

TRUST 24,194 65.89% 72,469 66.82%



Actual Performance


Target

Variance to Internal

Trajectory


91.07% (3.93)% (3.97)%


91.82% (3.18)% (3.20)%


91.82% (3.18)% (3.20)%


93.00% (2.00)% (2.07)%

24,475

26,464

25,487

20,000

21,000

22,000

23,000

24,000

25,000

26,000

27,000

85.00%

87.00%

89.00%

91.00%

93.00%

95.00%

97.00%

99.00%

April May June July August September October November December January February March

A19 Performance

A19 Incidents A19 Performance % 2014/15 A19 Performance % 2015/16 A19 Performance Target

A19 Performance by Clinical Commissioning Group (CCG) June 2015

June 2015 A19 Performance Map

Clinical

Commissioning

Group

No. of

Incidents

Jun 15

A19 %

Jun 15

No. of

Incidents

YTD

A19 %

YTD

Kernow 2,836 84.70% 7,965 86.58%

South Devon & Torbay 1,390 96.40% 4,315 95.78%

NEW Devon 3,902 92.08% 11,796 92.53%

Somerset 2,382 89.13% 6,863 90.44%

Dorset 3,798 94.52% 11,171 94.59%

North Somerset 1,059 88.67% 3,211 89.60%

Bath & NE Somerset 728 90.52% 2,332 91.47%

Bristol 2,459 94.51% 7,505 95.66%

South Gloucestershire 1,076 93.22% 3,454 94.21%

Gloucestershire 2,694 89.72% 8,438 89.91%

Wiltshire 2,107 86.14% 6,257 86.85%

Swindon 1,005 95.72% 3,027 96.30%

TRUST 25,487 91.07% 76,426 91.82%



Exception Report – Red Performance in June 2015

6.3. In response to performance in Quarter 1 of 2015/16 the Trust has developed a ‘Measures to Improve Performance’ (MIP) plan for Quarter 2 of 2015/16. The MIP focuses actions in the following areas:

Abstraction Management;

Rota’s and Relief;

Staff Training;

Clinical Hub;

Demand Management;

Call Cycles;

Procedures and Processes;

Communications (internal and external);

Actions carried forward from Quarter 1;

Other Identified Actions.

6.4. The actions identified above are in addition to those already identified within the A&E Operating Plan for 2015/16. The A&E Operating Plan provides a detailed list of Service Developments and associated actions to be completed during the year. Progress against this plan is monitored through the A&E Service Line Group and updates provided to Directors on a regular basis.

6.5. The table below summarises the key actions.in the MIP

Planned Mitigating Action

being taken by the Trust Timescales for Action

Performance Improvement /

Impact Expected

Abstraction Management

Increased Operational focus on

all Abstractions

• A renewed focus on Sickness Management.

• Implementation of Trust agreed TOIL policy including payments to staff in replacement for TOIL where appropriate.

• Identify all ‘other’ abstractions that can be reduced/removed.

• Increased managerial rigour for unauthorised absences.

• Review of current annualised hours contracts.

• Daily resourcing information provided through the Trust Resourcing team.

• Weekly Resource Management Meetings held across the Trust.

• Delivery of reductions in frontline operational sickness levels at or below improvement trajectories agreed for 2015/16.

• Reduction in levels of inappropriate abstractions.

• Increase resource hours on the road..

Rotas and Relief

Review of current ‘relief’ profile

• Review allocation and application of relief shifts

• Improve the flexibility of current relief arrangements to better match resources to demand.

• Specific focus on improving the cover available to meet the peak periods of demand for ambulance services (weekends).

• Initial review by Operational Managers for local changes to be completed by the end of July 2015.

• Identification of any changes to be incorporated within longer term rota reviews to be completed by the end of August 2015.

• Appropriate allocation of ‘relief’ capacity within a rota plan will improve resilience in operational resources, particularly at peak periods of demand.

• The initial workstream for Operational Managers is to identify any local changes that may be introduced through minor amendments to current rotas in the short term.

• The more significant changes may be required to be incorporated into a larger scale rota review for operational resources in some locations.






Impact Expected

Call Cycles

Review Call Cycles

• Time at acute hospitals between the handover of the patient and a crew becoming clear for their next incident.

• Individual performance data to be reviewed

• Operational Officers to visit acute hospitals to identify any barriers to SWASFT personnel becoming clear for their next incident

• Management information and benchmarking data produced for Operational Officers to review in July 2015.

• Individual performance review meetings to be held with staff

• Operational Officers to visit acute hospitals during July and August 2015

• Tdentify outliers in call cycle times.

• Deliver improvements in performance including appropriate training and support where required.

• Remove barriers to turning around patients at acute hospitals.

• Improvements in the average call cycle for conveyed incidents by reducing inappropriate time lost at acute hospitals when a handover of a patient occurs.

Demand Mitigation

Joint action with 12 CCGs to

manage demand to contracted

levels

• Focus on 999 calls transferred from NHS 111

• Review of local care, residential and nursing homes with high levels of ambulance activity

• Improve the engagement within the local health community to support Community Responder schemes.

• Identification of locations that would benefit from the location of a Public Access Defibrillator.

• Identification of activity undertaken by SWASFT which would more appropriately be directed elsewhere (e.g local falls support services, Community Nurses).

• Demand Management Plans to be delivered during 2015/16. Timescales set.

• Additional clinical resources introduced into North Clinical Hub during June 2015 to review the appropriateness of incidents referred to the ambulance service by the NHS 111 service.

• Introduction of Floorwalkers in Care UK Hub from mid-August.

• A shared understanding of the current performance and local challenges;

• Agreement of additional actions that can be supported by individual CCGs to assist the Trust in delivering Red performance;

• Identify any areas where the Trust and CCG can work together

• Working with NHS 111 Providers to review the volume of calls and particularly the appropriateness of red calls being transferred to the ambulance service.

Clinical Hub

Enhanced Deployment Process

for Community Responders

within the Clinical Hub

• Community Responder Groups provide valuable support to SWASFT resources particularly within rural areas across the South West.

• Recruitment to increase the Resilience

• Changes to the current deployment process for Community Responders within the Clinical Hub will deliver a more timely allocation of incidents in these rural locations.

• Revised SOP for Community Responder deployment to be completed and introduced by the end of July 2015.

• Improved availability and improvements in the timeliness of allocation to Community Responders will enable them to provide additional support and response to emergency incidents across the South West.






Impact Expected

Other Identified Actions

Introduction of third party

resources to support SWASFT

operational frontline resources

• In light of the current vacancies in frontline positions the Trust has commissioned third party, private ambulance resources to support the Trust

• These resources will fulfil operational duties under the governance and control of SWASFT to increase available cover at key periods.

• Additional third party operational resources to be introduced during Quarter 2 of 2015/16.

• Introduction of additional operational resources across the Trust, particularly in North Division, to offset current vacancies.

• The level of third party resources will be managed to reflect the vacancy position, reducing in line with the Trust recruitment plans for 2015/16.



Urgent Care Service Line

QR12: Urgent and Less Urgent Base Site and Home Visit Consultations Performance Exception Status: Improvement Expected: The Trust is expecting both standards to be met and move to full compliance on all Out of Hours contracts.

Reason(s) for the performance exception category assigned in the reporting period:

• Urgent Consultations at Base Sites (Treatment centres) were fully compliant against the NQR in the reporting period in the counties of Dorset (95.40%, 83 of 87 appointments) and Somerset (96.55%, 56 of 58 appointments) and partially compliant in Gloucestershire (90.76%, 108 of 119 appointments).

• For Less Urgent Consultations at Base Sites the Trust was fully compliant in all three counties in June 2015.

• Trust performance for Urgent Home Visit consultations started within 2 hours was partially compliant in the counties of Dorset (94.77%, 272 of 287 consultations) and Somerset (93.57%, 131 of 140 consultations) and non-compliant in Gloucestershire (89.44%, 161 of 180 consultations).

• Trust performance for Less Urgent Home Visit consultations started within 6 hours was fully compliant in the counties of Dorset (96.85%) and Somerset (97.54%) and partially compliant in Gloucestershire (93.83%).

• Actions being taken to deliver improvements in both Home Visits and Treatment Centre performance are detailed in the exception report below.

• The Trust was successful in winning the tender for the entire Out of Hours Service in the county of Gloucestershire and the full service went ‘live’ on 1 April 2015.

• Following a tender exercise in 2014/15, the Out of Hours service for the county of Somerset was transferred to a new service provider with effect from 1 July 2015.

Risk Assessment: • The expectation is that these standards will be delivered. The Trust continues to report exceptions on an

individual basis to commissioners at the contract meetings.

June 2015 Performance Actual Performance Variance to National Quality

Requirement

Dorset Somerset Gloucester Dorset Somerset Gloucestershire

Urgent Base Consultations started within 2 Hours Month: Performance (95%)

95.40% 96.55% 90.76% 0.40% 1.55% (4.24)%

Less Urgent Base Consultations

started within 6 Hours Month: Performance (95%)

97.54% 97.99% 97.04% 2.54% 2.99% 2.04%

Urgent Home Visit Consultations started within 2 Hours Month: Performance (95%)

94.77% 93.57% 89.44% (0.23)% (1.43)% (5.56)%

Less Urgent Home Visit Consultations started within 6 Hours Month: Performance (95%)

96.85% 97.54% 93.83% 1.85% 2.54% (1.17)%

Urgent Base Consultations started within 2 Hours Year to Date Performance (95%)

93.35% 94.22% 86.85% (1.65)% (0.78)% (8.15)%

Less Urgent Base Consultations started within 6 Hours Year to Date Performance (95%)

97.25% 97.43% 96.41% 2.25% 2.43% 1.41%

Urgent Home Visit Consultations started within 2 Hours Year to Date Performance (95%)

93.03% 91.31% 84.76% (1.97)% (3.69)% (10.24)%

Less Urgent Home Visit Consultations started within 6 Hours Year to Date Performance (95%)

95.02% 96.92% 92.41% 0.02% 1.92% (2.59)%



PAGE 21 of 61

Urgent Consultations at Base Sites (Treatment Centres)



Urgent Home Visits



PAGE 23 of 61

Planned Mitigating Action being

taken by the Trust

Timescales for

Action


Impact Expected

The Trust has reviewed the level of activity

being classified as Urgent in the counties of

Somerset and Dorset.

Following this initial review the Trust has undertaken a clinical review of patient records during the same period and identified a number of areas for further investigation to improve triage quality including:

Additional training/support for clinicians on use of the triage system;

Enhancements to current forms/systems to support the triage process;

Individual training/support where appropriate.

Initial report presented to NHS Commissioners in April 2015.

Follow up clinical review paper provided to NHS Commissioners in May 2015.

Actions arising from this review to be undertaken during Quarter 1 and Quarter 2 of 2015/16.

Appropriate reduction of the proportion of incidents classified as Urgent will enable more effective resource deployment and improve the capacity of the service to deliver performance against the National Quality Requirement 12.

Dorset specific actions:

As part of the Treatment Centre and Home Visit review undertaken in April 2015 the Trust has identified that a review of operational resource profiles for both Treatment Centre and Mobile Resources is required.

Review of current resource profiles against the demand profiles for the Out of Hours service has identified a small number of key areas that are to be investigated.

Any revisions to resource profiles will be identified and introduced in Quarter 2 of 2015/16 in consultation with NHS Commissioners

Initial report presented to NHS Commissioners in April 2015.

Follow up clinical review paper provided to NHS Commissioners in May 2015.

Resource review scheduled to be completed by the end of June 2015 with a view to introducing revised resourcing in Quarter 2 of 2015/16.

More appropriate resource profiling will increase the available capacity for Home Visits and Treatment Centre appointments during periods of peak demand in the Out of Hours service.

Performance Management of Teams and

Individuals in all three counties:

Analysis of performance benchmarking information for Out of Hours Dispatchers and Clinicians;

Increased coaching and improvement plans will be introduced for individuals where appropriate;

Utilisation of ‘live’ performance management tools and operational staff with specific responsibilities for performance management and monitoring;

Assessment and training for Out of Hours Dispatchers.

Current reports provide information for individual and team performance assessment.

Dedicated Performance Managers within the Out of Hours service have been introduced to support the performance management process.

Identify coaching opportunities to support staff.

Performance managers are to deliver an increased focus on performance of individuals and enable timely identification of any issues to be addressed on a daily basis.

‘Live’ management reports were introduced in Quarter 4 of 2014/15 designed to capture recurrent issues and themes and identify any areas for service change or improvement.



Planned Mitigating Action being

taken by the Trust

Timescales for

Action


Impact Expected

Retrospective Review of Incidents where

Performance Targets are Missed

Retrospective review of incidents where a performance target is missed for both Home visits and Treatment Centre appointments.

Daily review of the reasons for missing performance target will identify any recurrent challenges in the service to inform future development plans, process or resource profile changes.

Daily reports produced detailing all incidents where performance targets are missed.

Daily review of incident details then undertaken by Operational Managers.

Identification of the reasons for the service missing performance targets will assist in the development of bespoke performance improvement actions for the service in each of the three counties.

In the county of Gloucestershire this information is particularly important as the service develops its understanding of demand patterns for this new service in 2015/16.

Review of Activity Profiles and Associated

Resource Profiles in Gloucestershire

Resource profiles in the Gloucestershire Out of Hours service are to be reviewed to make sure that the most appropriate resource profiles are currently being used to support performance for Home Visits and Treatment Centre appointments.

Utilise all available information following the launch of the service in April 2015 to inform future resource profiles for mobile and base centre resources.

Review of the activity profiles for Home Visits and Treatment Centre appointments for April 2015 and May 2015 is to be completed by the end of June 2015.

Activity profiles and performance data will be assessed alongside resource plans to insure they are fit for purpose. Where variances are identified changes to resource profiles will be introduced in Quarter 2 of 2015/16.

Deliver the optimum resource profiles to match the demand for both Home Visits and Treatment Centre appointments in the county of Gloucester.

Evidence based decisions on resource profiles will deliver improved capacity and resilience to current resourcing at peak periods of demand.

Introduction of Additional Weekend Treatment

Centre Resources in Gloucestershire

Ahead of the planned resource profile review, the Trust is introducing additional weekend treatment centre clinicians into Gloucester and Cheltenham in June 2015.

These additional resources are to meet the increased demand profiles currently being seen within these specific units and will deliver improved performance against the treatment time targets in these locations.

Introduction of additional treatment centre clinicians into Gloucester and Cheltenham in June 2015.

Improved resourcing during the busy weekend period will increase the available capacity to meet the required treatment time targets for patients.



NHS 111 Service : 60 Second Call Answering and Call Abandonment Rates Performance Exception Status: Real Concerns: The trust did not deliver call answering or call abandonment targets in June 2015.

Reason(s) for the performance exception category assigned in the reporting period: • Call answering performance during June 2015 was significantly below KPI levels across all four counties.

• Call answering performance within the NHS 111 service continues to be extremely challenging, particularly resourcing sufficiently to manage the spikes in demand experienced during the weekends.

• Whilst resource plans were introduced to deliver sufficient resources to meet the required activity levels, the current level of vacancies, and short notice abstractions impact detrimentally on the number of call advisors required to maintain performance at the 95% level against the 60 seconds call answering target.

• The Urgent Care Service Line work programme for Quarter 1 of 2015/16 includes a number of actions specifically targeted at delivering performance improvements in call answering. These actions are detailed within the exception report section of this report.

• Following meetings with NHS Commissioners during June 2015 the Trust is developing performance improvement plans and trajectories relating to call answering performance for the remainder of the financial year. These plans will be subject to additional investment in resilience for call advisors and clinicians by both SWASFT and NHS Commissioners during 2015/16.

• The Trust continues to compare well nationally on other contracted KPIs including the percentage of patients advised to attend an Emergency Department or transferring a call to the 999 service.

• Following a tender exercise in 2014/15, the NHS 111 service for the county of Somerset was transferred to a new service provider with effect from 1 July 2015.

Risk Assessment: The Trust is working with Commissioners to improve call answering target without compromising good performance on the other metrics including transfers to 999 or advising patients to attend an ED.

Actual

Performance

Variance to Quality

Requirement Target

Percentage of Calls Answered Within 60 Seconds - KPI Target 95% Month: June 2015 Performance

Dorset 70.81% (24.19)%

Devon 58.54% (36.46)%

Cornwall 58.07% (36.93)%

Somerset 61.60% (33.40)%

Percentage of Telephone Calls Abandoned 30 seconds after the recorded message - KPI Target 5% Month: June 2015 Performance

Dorset 7.01% 2.01%

Devon 12.07% 7.07%

Cornwall 12.11% 7.11%

Somerset 10.67% 5.67%

Percentage of Calls Answered Within 60 Seconds - KPI Target 95% Year to Date Performance

Dorset 70.95% (24.05)%

Devon 60.69% (34.31)%

Cornwall 61.92% (33.08)%

Somerset 62.70% (32.30)%

Percentage of Telephone Calls Abandoned 30 seconds after the recorded message - KPI Target 5% Year to Date Performance

Dorset 7.92% 2.92%

Devon 12.65% 7.65%

Cornwall 12.50% 7.50%

Somerset 12.52% 7.52%



Planned Mitigating Action being taken

by the Trust Timescales for Action

Performance Improvement / Impact

Expected

Demand Management & Resource Planning

Review the Profile and Current Rota

Patterns for Call Advisors and

Clinicians

• Revised rotas for Call Advisors and Clinicians were introduced across the NHS 111 service with effect from 1 July 2015

• New rotas aim to improve operational cover at peak periods of demand and deliver a more favourable pattern of working for both call advisors and clinicians.

• Discussions are on-going relating to additional investment in Call Advisors

• Dependent on the outcome of these discussions with NHS Commissioners the Trust has identified further additional resource patterns that can be introduced to deliver improvements in call answering and reductions in call abandonment rates.

Outside consultants were engaged by SWASFT to undertake a full review of rotas, in consultation with staff. This review was completed in May 2015.

New rota patterns have been provided to staff and were introduced with effect from 1 July 2015.

Further additional rota patterns have been developed for discussion with NHS Commissioners

The aim is to deliver improved call answering capacity at the peak periods in the service demand.

By delivering more favourable rota patterns this will also assist with the recruitment of both call advisors and clinicians to fill the current gaps in resources and reduce the high levels of staff turnover currently being experienced in the NHS 111 service.





Performance Improvement / Impact

Expected

Source of NHS 111 Calls:

• Review activity to identify the source of calls

• Proactive management of identified frequent callers and management of repeat calls whilst waiting for a clinician to call back.

Frequent caller management reviews are undertaken monthly.

On-going work with the local health community to reduce activity to the NHS 111 service as a result of limited or lack of alternative services in the health community.

Increase the capacity of the current resources to answer calls, particularly during periods of peak demand.

Staff Recruitment

Recruitment of additional Call

Advisors and Clinical Supervisors

and revise shift patterns

• Based on the revised rota patterns and discussions with NHS Commissioners the Trust is developing a Recruitment Plan for NHS 111 Call Advisors and Clinicians throughout Quarter 2 and Quarter 3 of 2015/16.

• The level of this recruitment will be dependent on the outcome of discussions with NHS Commissioners regarding additional investment during Quarter 2 of 2015/16.

On-going recruitment to fill vacancies. The majority of current vacancies relate to part-time evening and weekend positions.

Additional recruitment plans to be developed during Quarter 2 of 2015/16.

To deliver improved call answering and provide greater resilience to meet shortfalls in resourcing at short notice.

Increase in current establishment of call advisors and clinicians to provide additional resilience to the NHS 111 service, particularly during the weekend peak periods of demand.

Operational Management

Performance Management of Teams

and Individuals:

• Benchmarking information.

• Productivity reviews.

• Increased call auditing and coaching.

• Introduction of Clinical Floorwalkers.

• An enhanced focus on managing individual performance.

Weekly productivity and call answering performance reports available for individual call takers and teams.

Identify coaching opportunities to support staff and improve morale.

Deliver performance improvements including improved call answering performance.



Urgent Care Service Line

Tiverton Urgent Care Centre 4 Hour Waiting Time Target Performance Exception Status: No Concerns The Trust achieved 99.86%. Performance is consistently high and above target levels.

Reason(s) for the performance exception category assigned in the reporting period: • Following a successful tender process the Trust signed a 21 month contract to operate the Urgent Care

Centre in Tiverton. The Trust took over operational control of the Unit on 8 July 2014.

• The primary performance measure within the contract is the 4 hour waiting time standard (this is the same target for acute trust Emergency Departments).

• In June 2015, 1,398 of the 1,400 patients attending the Unit were seen within the 4 hour target giving performance of 99.86% against the 95% performance target.

Risk Assessment: • Performance against the 4 hour target continues to be monitored on a daily basis and is expected to be

maintained above the 95% target levels.



7. Ambulance National Quality Indicators (AQI)

7.1. This section provides a summary of performance against each of the National Ambulance Clinical Quality Indicators. The definition for each is provided in Appendix C.

7.2. There are no national targets for 2015/16 however all ambulance Trusts are required to use a consistent set of national indicators to evidence

improvements in the quality of service. The indicators reported in the ICPR fall into two groups as follows:

Nationally defined system and clinical indicators;

Locally determined service experience indicators to meet the national requirement to report on how the experience of users of the ambulance service is captured, to publicise the results and to show what has been done to improve the design and delivery of services in light of the results.

7.3. The Trust has agreed performance thresholds for each of the indicators within the Accident and Emergency contract for 2015/16. These

performance thresholds are designed to monitor performance and highlight at an early stage any deterioration in performance and are reviewed annually with NHS Commissioners.

7.4. The Trust continues to participate in national working groups to help develop revised guidance for both the Clinical and System Indicators to

try and deliver improvements in data quality and reporting consistency for all ambulance trusts in England. It is hoped that greater consistency will increase the level of confidence when comparing and benchmarking Trust performance against other ambulance trusts.

Table 3: AQI System Indicators

AQI Trust Performance Performance vs Local Thresholds

(where appropriate) Benchmark Exception Reporting

Calls abandoned

Call Abandonment Rate June 2015

0.90% Year to Date

0.71% Local Threshold

1.50%

National Average

May 2015 0.44%

No concerns in the reporting period: % abandoned is lower (better) than local threshold.





Time Taken to Answer calls

April to June 2015 50

th 2 secs

95th

15 secs 99

th 58 secs

Local Thresholds 50

th 3 secs

95th

19 secs 99

th 60 secs

No national average figures

available for this metric

No concerns in the reporting period: % abandoned is lower (better) than local threshold.

Time from call categorisation to arrival at scene

April to June 2015 50

th 7.2 mins

95th

23.7 mins 99

th 38.4 mins

Local Thresholds (to be reviewed with NHS

Commissioners)

No national average figures

available for this metric


In the more rural areas of the Trust, the 95th

and 99th

percentile measures are in the lower quartile compared to other ambulance trusts due to greater distances to travel.

Actions being undertaken within the A&E Operating Plan for 2015/16 to improve performance against this metric are included within the Red Performance Plan detailed earlier in this report.

Further work on local issues continues to identify barriers to delivering reduced time to treatment and any actions are added to the action plan under the supervision of the A&E Service Line Group.

Re contact with the Ambulance Service following telephone advice

June 2015 12.94%

Year to Date 13.72%

Local Threshold 11.00%

National Average

May 2015 7.05%


As part of the current review process within the Trust, a review of the reasons for re-contacts is undertaken monthly within the Clinical Hub.

A regular clinical review of the re-contacts is undertaken and reported to the ACQI Sub Group (which meets on a bi-monthly basis) for overview to identify any other trends or areas to be addressed.

Nationally reported figures for ambulance trusts show considerable variance, between 2.10% and 14.00% for the year ending 31 March 2015.

The large variance in national performance raises concerns over the comparability of data being reported against these metrics by ambulance services. The National Ambulance Informatics Group is leading on a review of the data and calculation processes for all ambulance trusts.





Re contact with the Ambulance Service following treatment at scene

June 2015 5.90%

Year to Date 5.86%


National Average

May 2015 5.11%


In the reporting period re-contact rates following treatment at scene were higher than the local threshold.

There are considerable variances in the figures reported nationally by ambulance trusts against this metric. For 2014/15 re-contact rates varied between 3.7% and 7.7%.

A similar review of the data quality and consistency is being undertaken through the National Ambulance Informatics Group. An initial assessment of the processes and data used by ambulance trusts for these metrics was completed in January 2015, but the Trust is awaiting information on any changes to the national metrics as a result of this initial exercise.

Following the completion of the national review, SWASFT will undertake benchmarking reviews against the best performing ambulance trusts in England for the re-contact metrics to identify any best practices which may be introduced to improve performance during 2015/16.

Patients Managed Appropriately– Calls Closed with Telephone Advice

June 2015 12.04%

Year to Date 12.56%


National Average

May 2015 9.55%

No Concerns

In the reporting period with percentage of managed calls resolved by telephone advice were higher (better) than the local threshold.

Patients Managed Appropriately– Calls Closed without the need for Transport to A&E (Emergency Departments)

June 2015 52.87%

Year to Date 52.42%


National Average

May 2015 37.00%

No Concerns

SWASFT remains the ambulance trust with the highest (best) non conveyance rate in England.

For 2015/16 the Trust is committed to the delivery of Right Care across all incidents and therefore performance against Trust trajectories for Right Care is provided within the Right Care section of this report.

Progress against the identified actions within the Right Care action plans is also included within the Right Care section of this report.



Table 4: AQI Clinical Indicators

AQI Trust Performance in

reporting period

Performance vs Local Thresholds

(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Return of spontaneous circulation following cardiac arrest

Mar 2014 to Feb 2015 24.94%


National Average

Apr 2014 – Feb 2015 27.23%

No concerns in the reporting period the Trust was above the local threshold.

The Research and Audit Department are undertaking a Quality Improvement Initiative which will raise the awareness of the new post ROSC care bundle, provide benchmark data on compliance with the care bundle and examine barriers to implementation.

Return of spontaneous circulation following cardiac arrest (Utstein)

Mar 2014 to Feb 2015


45.00%

National Average

Apr 2014 – Feb 2015 49.10%

No concerns in the reporting period the Trust was above the local threshold.

Linked to the Research and Audit Department work identified above as the Utstein Group is a subset of the

patients within the overall ROSC metric calculation.

Outcome from acute STEMI - (PPCI)

Mar 2014 to Feb 2015 77.57%


National Average

Apr 2014 – Feb 2015

86.97%

Improvement Expected: All Divisions

The Clinical Development Officers will work with the Research and Audit Department to understand areas where improvements can be realised and support local clinical staff who attend PPCI meetings.




reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from Acute STEMI – Care Bundle

Mar 2014 to Feb 2015


90.00%

National Average

Apr 2014 – Feb 2015 80.23%


The local performance threshold for 2015/16 has been increased from 85.00% to 90.00%.

The Trust continues to report performance significantly higher than the national average, but for the period April 2014 to February 2015 the Trust was marginally below the 90.00% target at 89.10%.

Trust actions to deliver performance improvements against this metric are expected to see improvements during 2015/16. These actions include additional training and awareness of care bundles for frontline clinicians.

Outcomes from Stroke for Ambulance Patients – FAST (Face, Arms, Speech, Time to Call 999)

Mar 2014 to Feb 2015 54.83%


National Average

Apr 2014 – Feb 2015 59.06%


Performance against this metric is challenging due to the very rural nature of the geographical area covered by SWASFT with longer distances to travel to Hyperacute Centres, particularly in the areas of Cornwall, East Somerset and North East Somerset.

At present performance for the rolling 12-month period the Trust is 2.17% below the local performance threshold of 57.00%.

The Trust reviews responses in all operational areas (including multiple responses, back up times and on scene times) and how the type of response impacts on the times to Hyperacute centres.

Outcome from Stroke for Ambulance Patients – Care Bundle

Mar 2014 to Feb 2015 97.63%


National Average

Apr 2014 – Feb 2015 97.10%

No concerns in the reporting period: performance is higher (better) than local threshold




reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from Cardiac Arrest – Survival to Discharge

Mar 2014 to Feb 2015 9.90%


National Average

Apr 2014 – Feb 2015

8.21%


Outcome from Cardiac Arrest – Survival to Discharge (Utstein)

Mar 2014 to Feb 2015 28.40%


National Average

Apr 2014 – Feb 2015 25.89%




8. NHS Commissioner Local Standards and Thresholds

8.1. This section includes those standards and thresholds agreed with local NHS Commissioners as part of the 2015/16 contract negotiations. The definitions are set out in Appendix C.

Table 5: NHS Commissioner Standards and Targets for 2015/16

Measure Local

Target

June

2015

Quarter 2

Forecast

Green 1 Calls 90% 76.47% 79.00%

Green 2 Calls 90% 76.36% 80.00%

Green 3 Calls 90% 91.73% 94.25%

Green 4 (999) Calls 90% 70.02% 72.25%

Green 4 (HPC) Calls 70% 64.13% 64.50%

Compliance with Infection Prevention and Control Standards at Ambulance Stations 75% 82.00%

Compliance with Infection Prevention and Control Standards for Double Crew Ambulances 75% 82.00%

Vehicle Deep Cleaning Compliance with Schedule 90% 92.40%

Green Incident Performance Performance Exception Status: Improvement Expected: Performance against the locally agreed targets for Green 1, Green 2 and Green 4 incidents was below local targets.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust failed to deliver the Green 1, Green 2 and Green 4 local performance targets in June 2015.

• Performance improvements are expected for Green incidents as a result of actions being taken to improve Red Performance during Quarter 2 of 2015/16 as detailed earlier in this report.

• Following the introduction of the Dispatch on Distribution Pilot the Trust will be reviewing all areas of resource dispatch and response times. This change of process will focus on delivering the most appropriate response to meet the clinical need of the patient for all incidents within the Trust which includes Green incidents.

• By reducing the number of inappropriate deployments of operational resources the Trust is looking to increase the availability of resources to respond to all incidents, including Green incidents which will improve the response times to these less critical incidents.




Impact Expected

• Actions to improve performance

identified within the Quarter 2 MIP for

2015/16 including the introduction of

new operational resources.

The Trust is reviewing all operational resources as part of the Q2 MIP for 2015/16.

Through the Dispatch on Disposition Trial the Trust is looking at more effective and efficient ways to allocate and deploy ambulance resources.

Improved deployment and allocation of operational resources will increase the Trust response and conveying capacity in 2015/16.



Handover Delays at Acute Hospitals Performance Exception Status: Real Concerns: Operational time lost to Handover Delays at Acute Hospitals has a significant impact on the Trust by reducing the required resources available to respond to Emergency Incidents. During June 2015 the Trust lost in excess of 961 hours of operational resource time due to Handover Delays.

Reason(s) for the performance exception category assigned in the reporting period: • Individual incidents and extended delays at acute hospitals are managed on a day to day basis and are

subject to locally agreed handover escalation procedures.

• Across the South West the pressures within the Emergency Department resulted in extended handover times for some patients with a total of 961 ambulance operational resource hours lost in June 2015.

• This represents a slight improvement on May 2015 (1,045 hours), but this still equates to in excess of 32 hours, on average, lost per day due to delays at hospitals in excess of the 15 minutes target.

• There were a total of 825 handover delays in excess of 30 minutes in June 2015, of which 65 were over 60 minutes in length.

• In terms of the impact on operational resources, there were two hospitals where the Trust lost in excess of 100 operational resource hours in June 2015 –Royal Cornwall Hospital (177 hours) and Derriford Hospital (105 hours).

• Handover delays are subject to a fining regime for 2015/16.

• The Trust continues to work closely with NHS Commissioners in targeting hospitals with consistently long delays particularly during periods of high activity levels. Four hospitals have been prioritised based upon consistently high delays.

June 2015 Year to Date

Operational Time Lost to Handover Delays in Excess of 15 Minutes

961 Hours 3,108 Hours

Number of Handover Delays between 30 and 60 Minutes 760 Incidents 2,454 Incidents

Number of Handover Delays in Excess of 60 Minutes 65 Incidents 320 Incidents



Planned Mitigating Action being taken by

the Trust Timescales for Action


Impact Expected

Local action plans to manage and reduce the volume of handover delays are agreed with each of the acute hospitals. These include:

• Internal escalation plans

• Confirmed patient overflow areas for periods of high demand;

• Procedures to divert patients to neighbouring acute trusts during times of excessive demand;

• Local meetings between the ambulance service, acute trust leads and NHS Commissioners to agree local actions.

Operational service managers meet regularly with each acute hospital and agree appropriate handover action plans to address local issues.

Monthly meetings are held between Operational Managers from the Trust and acute hospitals to review handover delay figures.

Early identification of issues and/or concerns and identification of any actions required to resolve.

Management of handovers in line with the

Trust Standard Operating Procedure

(SOP).

On-going management of delays to the Trust SOP.

Maximise resources available to respond to 999 calls by reducing the level of operational time lost to delays at acute hospitals.

Outcome aimed at improving patient safety.

Identified as a Commissioner priority for

2015/16

The 12 CCGs have identified handover delays as a priority demand management area.

Royal United Hospital Bath has been identified as an area of good practice.

Top 4 hospitals are to be targeted during 2015/16.

Hospital Handover delay reduction targets are included in the Demand Management Plan agreed with NHS Commissioners in July 2015.

A reduction in the ambulance operational time lost to handover delays between 30 and 60 minutes is expected as a result of these improvements.

A zero tolerance approach to delays in excess of 2 hours to be implemented.



9. Patient Transport Contract 2015/16 Key Performance Indicators

Table 6: PTS Service Line: Bristol, North Somerset and South Gloucestershire KPIs 2015/16

Measure YTD

Performance Measure

YTD

Performance 1a Patients living up to 10 miles away from the treatment centre (Band A) should not spend more than 60 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

92.56%

9a Patient satisfaction with the level of service received from the provider = assessed through the annual patient satisfaction survey (Green >85%, Amber 75-85%, Red <75%)

97.80%

1b Patients living over 10 miles and up to 35 miles away from the treatment centre (Band B) should not spend more than 90 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

96.18%

9b NHS Commissioners to be satisfied with the level of service (Green = no issues or minor concerns resolved within 1 month) (Amber = minor issues and not resolved within 1 month or major issues resolved within 1 month) (Red = major issues not resolved within 1 month)

100.00%

1c Patients living over 35 miles away from the treatment centre (Band C) should not spend more than 120 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

100.00% 9f Telephone answering (Green >95%, Amber 85-95%, Red <85%)

94.83%

2a Patients should not arrive more than 45 minutes before their booked arrival time (Green >90%, Amber 80-90%, Red <80%)

89.21%

10a Agreed activity performance report received in correct format and on time within 10 working days of the start of the following month

100.00%

2b Patients should not arrive after their booked arrival time (Green >97%, Amber 87-97%, Red <87%)

90.62%

10b Activity and finance queries are acknowledged within 3 days of receipt and resolved within 28 days from the date of the query

100.00%

3a SWASFT is to arrive to collect patients from the agreed location within 45 minutes of the outwards journey time (Green >90%, Amber 80-90%, Red <80%)

89.73%

12h Nil Serious Untoward Incidents (SUIs). Any SUIs are to be reported and action plans put in place – in line with NHS Bristol standard and timeframes (reported immediately; investigated within 24 hours and lessons learnt shared, then closed within 60 working days of the incident) (Green - No SUIs, Amber – SUIs reported but resolved within timeframe, Red SUIs reported but not resolved within timeframe)

100.00%

3a SWASFT is to arrive to collect patients from the agreed location within 75 minutes of the outward journey time (Green >90%, Amber 80-90%, Red <80%)

95.28%

12d Compliance with the agreed SWASFT complaints procedure – full response made in a timely manner agreed with the complainant (assessed quarterly)

100.00%

8c Pick-up time to be confirmed by text, email or personal phone call to the patient within a week of the appointment (phone call being the preferred method (assessed quarterly)

100.00%

3b A summary of reasons and actions to be provided, for each month, for all cases where collection was outside (i.e. later) of the KPI limits. This may include case by case analysis as deemed necessary.

Compliant



10. Right Care, Right Place, Right Time 2

10.1. The Trust is committed to delivering the Right Care to all patients, in the Right Place at the Right Time. Working closely with NHS Commissioners the Trust introduced the Right Care, Right Place , Right Time 2 initiative during 2014/15 to deliver the highest quality of clinical care to patients in the most appropriate treatment locations using the most appropriate treatment pathways.

10.2. In 2014/15 the Right Care 2 initiative was successful in reducing the number of patients

conveyed to Emergency Departments across the South West and in agreement with NHS Commissioners is working to deliver further improvements in appropriate management of patients in 2015/16.

10.3. The Trust aims to achieve further improvements through a combination of Trust-wide

schemes which will benefit the whole of the South West and the need for delivering localised actions/changes to meet the needs within each CCG area.

10.4. In order to understand the local requirements the Trust is undertaking meeting with each

CCG during Quarter 1 of 2015/16 to identify the specific focus for local work streams in 2015/16. The identified actions and progress will then be monitored within the Right Care action plans throughout the year with regular feedback and meetings provided to each CCG through the Trust Right Care leads.

10.5. As part of the extension of the Right Care 2 initiative the Trust has committed to deliver a

further improvement in the percentage of incidents managed without a conveyance to an Emergency Department. This commitment would see the non-conveyance rate increase from 54.05% for 2013/14 (when the Right Care 2 initiative was introduced) to 55.05% for 2015/16. The Trust already has the best non conveyance rate in the country for ambulance trusts and therefore this represents an additional improvement.

10.6. Performance against the 2015/16 target of 55.05% will be monitored in the Integrated

Corporate Performance Report each month. As at the end of June 2015 the Trust reported a non-conveyance percentage of 57.83% which was 2.78% ahead of the target.



10.7. Some of the areas of Trust-wide focus for 2015/16 include:

HCP call management. The Trust will be running a pilot from August in the Dorset Single Point of Access;

Utilisation of GPs in the Clinical Hub to work alongside 999 call handlers to support clinical decisions made during the telephone triage of patients. This will assist in identifying the most appropriate care pathway for the patient at the earliest opportunity;

Refresh and/or improve the clinical assessment skills for Paramedic. The trust has introduced a Right Care Award as part of the CPD for Paramedics which focusses on the appropriate management of patient care outside of Emergency Departments;

Review of the current process for the management of calls received by the ambulance service from other Healthcare Professionals. The purpose of this scheme will be to insure that the most appropriate use of the local Directory of Services and treatment pathways is being used by Healthcare Professionals where they are available.

10.8. During the meetings with CCGs during Quarter 1 of 2015/16 further local actions have been

agreed with NHS Commissioners to identify the local priorities for the Right Care initiative in each health community across the South West for 2015/16.

10.9. In addition to the Trust-wide scheme the Trust is holding a further action log of local plans to

be delivered in agreement with each CCG during 2015/16, progress against these plans are discussed with NHS Commissioners at a CCG level on a regular basis. These regular meetings with NHS Commissioner will aim to:

Remove any identified barriers to delivering the Right Care for the patient – identified through internal and external feedback to the Right Care team;

Ensure all appropriate services are available and accessible within the local Health Community;

Identify any additional projects or process changes which may assist in the most appropriate management of patients within the local area;

Develop links between the local Right Care Champions and the Clinical Development Team to co-ordinate all local activity to support the Right Care programme;

Maintain a full and clear Directory of Services of available facilities within the local health community and information on how and when these facilities may be accessed by ambulance resources.

10.10. The delivery of Right Care will be supported by the rollout of the new Electronic Patient

Clinical Record across the Trust which continues in 2015/16. This new system will provide staff with access to additional information to support clinical decisions at scene and provide access to information on the alternative services available within the local area to best meet the clinical needs of the patient.



11. Internal Trust Headline Performance Indicators for 2015/16

11.1. The performance metrics set out in the table below are included in the ICPR as the internal Trust headline measures for 2015/16.

Metric Internal

Target June 2015

Quarter 1

Forecast

Staff Appraisal Completion 85% 56.12%

On-going Compliance with Care Quality Commission Regulations and Quality Risk Profile

Compliant Green Green

Information Governance Toolkit Level 2 Green Green

Implementation of the Equality Delivery System (EDS)

On Plan Green Green

Environmental Strategy & Work Programme On Plan Green Green

Delivery and Assessment of Environmental Impact Pilots

On Plan Green Green

NHS Constitution and Staff Pledges On Plan Green Green

11.2. Trust performance against the internal 85% staff appraisals target has dropped to 56.12% in June 2015, predominantly due to operational pressures seen as a result of the Trust operating at REAP level 4 for extended periods throughout 2014/15 and into the first Quarter of 2015/16.

12. Trust Resource Performance Measures

12.1. This section includes resource measures specified by the Trust as having a significant impact on performance and delivery:

The Resource Escalatory Action Plan (REAP) level;

Service line activity;

The Trusts financial position;

Capacity and Capability.

Resourcing Escalatory Action Plan (REAP) Level 12.2. The Trust weekly REAP assessment takes into account the following measures:

A&E actual activity levels compared to contracted activity levels;

Performance against national performance targets and local performance trajectories;

Clinical Hub call answering performance;

Frontline staff sickness levels;

Average turnaround times at acute hospitals (Handover and Wrap Up times);

Local weather forecasts;

Other issues impacting on operational delivery:

o Winter pressures;

o Local events;

o ICT/System upgrades;

o Other national/local risks to operational delivery.

12.3. The Trust moved to REAP level 4 in December 2014 and has remained at REAP level 4 through to the end of June 2015 due to the significant levels of activity seen across the Trust. The Trust continues to review REAP levels on a weekly basis.



Service Line Activity 12.4. The activity currency for the A&E Contract for 2015/16 are detailed below:

Accident and Emergency activity is measured for contracting and performance

management purposes. For 2015/16 the Trust is contracted on the basis of ‘incidents’.

Incidents are defined as any unique call resulting in the ambulance service providing a service which could include telephone advice only or referral to another service where appropriate.

Incidents are split into three categories:

o Hear & Treat/Refer – those incidents that were resolved by providing clinical advice over the telephone (without an ambulance resource attending the scene) or where the caller was referred to a more appropriate service (e.g. to contact the NHS 111 service);

o See & Treat/Refer – where an ambulance resource arrives at the scene of an incident and the patient is treated without the need to convey the patient. This may include referring the patient to an alternative care pathway (e.g. to visit their GP) where appropriate to best meet the needs of the patient.

o See & Convey – where an ambulance resource arrives at the scene of an incident and following treatment by the ambulance service, at least one patient requires conveyance. This measure includes all conveyances, therefore the See & Convey figure is often split between Emergency Department (type 1 and type 2) and non-Emergency Department destinations.

Accident and Emergency Service Line Incidents by Month:

Actual Contracted Variance %

April 2015 72,409 70,832 2.23%

May 2015 76,521 73,781 3.71%

June 2015 74,249 72,455 2.48%

Year to Date 223,179 217,068 2.82%

Accident and Emergency Service Line Incidents by CCG:

Actual Contracted Variance % Actual Contracted Variance %

Kernow CCG 8,389 8,333 0.67% 24,513 24,344 0.69%

NEW Devon CCG 12,030 12,099 -0.57% 36,191 36,674 -1.32%

South Devon & Torbay CCG 4,472 4,598 -2.74% 13,520 13,845 -2.35%

Somerset CCG 7,295 7,285 0.14% 21,646 21,521 0.58%

Dorset CCG 11,387 12,034 -5.38% 34,696 35,983 -3.58%

Bath & North East Somerset CCG 2,001 1,915 4.49% 6,252 5,869 6.53%

Bristol CCG 6,186 6,094 1.51% 19,134 18,249 4.85%

North Somerset CCG 2,704 2,575 5.01% 8,302 7,708 7.71%

South Gloucestershire CCG 2,784 2,559 8.79% 8,757 7,979 9.75%

Gloucestershire CCG 7,436 7,234 2.79% 22,554 21,767 3.62%

Swindon CCG 2,548 2,480 2.74% 7,386 7,383 0.04%

Wiltshire CCG 5,429 5,249 3.43% 16,017 15,746 1.72%

Total 74,249 72,455 2.48% 223,179 217,068 2.82%

In Month Year to Date

RAG ratings: Green Less than 4% above contract, Amber 4% to 6% above contract, Red greater than 6% above contract.



Trust Financial Position

12.1. The financial position reported at the end of June 2015 is included within this report. Financial headlines for the period 1 April 2015 to 30 June 2015 are set out below. The full financial appendices are included at Appendix G.

12.2. The Trust delivered a Continuity of Services Risk Rating of 4.00 in line with plan at the end of June 2015.

Metric June 2015

Debt Service Cover 6.71

Liquidity Ratio 11.41

Continuity of Services Risk Rating 4.00

12.3. The financial information is based on the third month of the financial year and includes the

actual and year end forecast position for the Trust against the Financial Plan 2015/16.

12.4. The Trust delivered a surplus of £110k at the end of month three against a planned surplus of

£150k. This position includes an under-spend on pay relating to vacancies offset by the use of overtime, agency and third parties. The forecast position is a surplus of £100k compared to plan of £500k.

12.5. The adverse position against plan reflects the risk of fines being levied by commissioners for

the failure of performance targets (Red 2 and A19) as set out in the A&E contract. This has been offset in part by timing variances and slippage in developments.

12.6. The Trust has a cash balance of £29,865k as at 30 June 2015. 12.7. The annual Cost Improvement target for 2015/16 is £7,899k. The Trust is forecasting delivery

of the CIP plans.

12.8. The Capital Plan for 2015/16 is £14,691k. Month three is ahead of plan by £39k against a year to date plan of £3,871k being 101% of plan.

Capacity and Capability

Key Performance Indicator June

2015

YTD

2015/16

Staff Sickness % YTD (Target 4%) 4.93% 5.23%

Staff Turnover Rate 14.90%

Staff Turnover Rate (excluding redundancies) 14.01%

Trust Total Staffing (WTE) 3,906.92

Trust Total Funded Establishment (WTE) 4,052.81

Total Staffing vs Funded Establishment (WTE) (145.89)

Trust Total Vacancy Rate (%) -3.60%

Operational Qualified Establishment (WTE) 1,560.92

Operational Qualified Vacancy Rate (%) -8.27%

Operational Non-Qualified Establishment (WTE) 928.91

Operational Non-Qualified Vacancy Rate (%) +5.17%



Staff Numbers and Turnover 12.9. As at 30 June 2015 the Trust reported an establishment of 3,906.92 Whole Time Equivalents

(WTE) against a funded establishment of 4,052.81 WTE. The Trust therefore has 145.89 WTE vacancies (3.60%) compared to the funded establishment.

12.10. On-going recruitment continues for additional frontline resources to address residual vacancies across the Trust. A further 4% of additional frontline resource was deployed by way of bank, agency and overtime.

12.11. In the past 12 months the Trust has filled 143 Paramedic vacancies, 62 of these new

Paramedics have been recruited within the past 6 months.

Graduate Recruitment Update 12.12. Following the offers made to our graduate candidates this has resulted in 132 accepted offers

of employments, with 2 candidates still remaining to confirm acceptance. 12.13. Of the 132 accepted offers, 93 are external candidates and 39 OU’s. An additional 20

candidates are still to be assessed, with the majority being undertaken in July 2015.

Paramedic Candidate Attraction

12.14. In addition to the efforts to attract new graduates and develop Paramedics, the Trust has also worked with a creative design agency to develop a new candidate attraction strategy and campaign designed to attract qualified Paramedics to the organisation.

12.15. The new Paramedics campaign went live in June 2015 and a bespoke campaign including

press, online and social media marketing has been developed for the Trust which will run over the summer months. This campaign is supported by employee engagement initiatives designed to keep candidates warm and informed throughout the recruitment and onboarding process.

Management of Sickness Absence

Performance Exception Status: Improvement Expected: Performance in the reporting period is significantly above (worse than) plan, however actions identified in the A&E Operating Plan for 2015/16 are targeted to deliver improvements in sickness abstractions.

Reason(s) for the performance exception category assigned in the reporting period: • Sickness absence levels are higher than plan in June 2015 at 5.93% compared to the internal 4% target.

Planned Mitigating Action being taken by the Trust Timescales for Action

Following a comprehensive review further changes have been

made to the Trusts Sickness Absence Policy.

A Sickness Management Action Plan has been developed to monitor the delivery of associated initiatives, including training of managers, changes to systems and reporting methods and improved staff communication about the impact of absence. All Operational Officers and Managers have been briefed in a series of Operational Leadership Days held in May and June 2015.

Being delivered between April 2015 and August 2015

Active reconsideration of all staff on long term sickness against temporary secondments and alternative duties is being undertaken regularly with a database maintained to ensure that staff are matched to suitable assignments where these exist throughout the Trust.

This process ensures that all options are considered to assist rehabilitation of staff back to the workplace. A new process to

On-going



facilitate this has been developed.

A paper has been presented to the Deputy Directors Group and then to the Directors Group. The system is currently being implemented for August 2015

Stress management procedures have been reviewed, resulting in better signposting for staff and managers to available support services as well as the re-launch of an improved stress risk assessment tool.

Complete

Occupational Health services are now being provided by Optima due to Capita withdrawing from the contract. Existing KPIs are being met and further KPIs will be agreed at the contact review at 6 months.

Monthly KPI monitoring against contract

The Health and Wellbeing consultation has now concluded and the business case was presented to Directors on 14 July 2015. Health and Wellbeing forums are now been established across the Trust to discuss the response to this consultation. This feedback will inform the design and implementation of the Trust’s Health and Wellbeing Strategy.

On-going



Appendix A: ICPR Mapping Matrix: Trust Performance Measures for 2014/15 and the five National Outcome Framework Domains

Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading

Key Contributions sought by

NHS Commissioners

Ambulance National

Quality Measures

Ambulance National Clinical

Quality Indicators (ACQIs)

Local Standards

and Targets

Effectiveness Domain 1: Preventing people from dying prematurely

• Earlier diagnosis;

• Improving early management in community settings;

• Improving acute services and treatment;

• Preventing recurrence after an acute event

Red 1 Performance; Red 2 Performance; A19 Performance.

Time to Treatment for life-threatening calls; Re-contact rates following telephone advice/referral; Re-contact rates following treatment at scene; All ACQI Clinical Indicators.

Resourcing Escalatory Action Plan (REAP) levels; A&E service activity volumes.

Domain 2: Enhancing the quality of life for people with long term conditions

• Improvements in primary care

• Putting patients in charge and giving them ownership of their care

• Coordination and continuity of care

Urgent Care Service National Quality Requirements.

UCS CQUIN schemes as agreed with local NHS Commissioners.

Domain 3: Helping people to recover from periods of ill health or following injury

• Keep people out of hospital when better care can be delivered in other settings

• Ensures effective joined up working between primary and secondary care

• Delivers high quality and efficient care for people in hospital

• Coordinates care and support for people following discharge from hospital

Ambulance calls closed with telephone advice; Ambulance calls closed with telephone advice or managed without transport to an Emergency Department; Stroke patients receiving an appropriate care bundle; ST-Elevation Myocardial Infarction (STEMI) patients receiving an appropriate care bundle.

Right Care, Right Place, Right Time; A&E CQUIN schemes as agreed with local NHS Commissioners; PTS CQUIN schemes as agreed with local NHS Commissioners.

Patient Experience

Domain 4: Ensuring that people have a positive experience of care

• Rapid comparable feedback on the experience of patients and carers

Annual Quality Account;

Time to answer emergency calls; Emergency call abandonment

Patient Experience: Making Experience Count (MECS)



Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading


NHS Commissioners

Ambulance National

Quality Measures



Local Standards

and Targets

• Building a capacity and capability in both providers and commissioners to act on patient feedback

• Assessing the experience of people who receive care and treatment from a range of providers in a coordinated package

Urgent Care Service: Call abandonment rates; calls answered within 60 seconds of the introductory message; Definitive clinical assessments within time appropriate to their condition.

rates; Patient Experience;

reported, investigated and closed; Patient Advice and Liaison Service (PALS) incidents reported, investigated and closed; Compliments received; Patient satisfaction surveys in A&E, UCS and PTS service lines; A&E CQUIN schemes as agreed with local NHS Commissioners; PTS CQUIN schemes as agreed with local NHS Commissioners.

Patient Safety Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

• Commissioners will use the National Quality Dashboard to identify any potential safety failures

Annual Quality Account; Compliance with Care Quality Commission Regulations; NHS Litigation Authority – Level 1. Central Alerts (CAS);

Patient Experience; Re-contact rates following telephone advice; Re-contact rate following treatment at scene.

No. of incidents and time lost to Handover Delays at acute hospitals; No. of incidents and time lost to delays in Handover to Clear times for ambulance resources;



Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading


NHS Commissioners

Ambulance National

Quality Measures



Local Standards

and Targets

Adverse Incidents (AI) reported, investigated and closed; Security Incidents (SIRS) reported, investigated and closed; Serious Incidents identified, investigated and closed; Never events.

Compliance with Medicines Management Audit Standards; Compliance with Infection Prevention and Control Standards; Vehicle Deep Clean Compliance with Schedule.



Appendix B: Trust Approach to the Management of Performance Exceptions in 2014/15

Early Warning Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period The focus of the ICPR is on providing the Board of Directors with information on trends, forecasting and mitigating actions being taken by the Trust.

No Concerns Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance

The focus of the ICPR is on providing the Board of Directors with ongoing assurance that performance can be maintained.

Real Concerns Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance The focus of the ICPR is on agreeing remedial action which may be escalated to Board level. Remedial actions are therefore likely to have Trust wide consequences

Improvement Expected Performance in the reporting period is below target but there is evidence that performance is improving and/or there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category.

The focus of the ICPR is on providing the Board of Directors with sufficient detail in order to provide an appropriate level of assurance. This will include detail contained within individual action plans as necessary.



Appendix C: National Measures Definitions and Glossary

National Ambulance Quality Measures

Performance

Measure

2014/15

Target Definition Aim of the Target

How the Target is

measured

Red 1 75% Quarterly

Calls that are identified as the most time critical response and cover cardiac arrest patients who are not breathing and do not have a pulse and other severe conditions such as airway obstruction

To deliver better outcomes for patients by achieving a faster response for those patients with immediately life-threatening conditions

The percentage of Red 1 calls receiving an emergency response at scene within 8 minutes

Red 2 75% Quarterly

Calls that may be life-threatening but less time critical then Red 1 calls.

To deliver better outcomes for patients by achieving a faster response for those patients with life- threatening conditions

The percentage of Red 2 calls receiving an emergency response at scene within 8 minutes

A19 95% Quarterly

Calls that may be life-threatening (Red 1 and Red 2 calls) receive a response at scene which is able to transport the patient in a clinically safe manner.

To deliver better outcomes for patients with life-threatening conditions by ensuring they receive a response at the scene which is able to transport the patient if required.

The percentage of life-threatening calls receiving an ambulance able to transport the patient within 19 minutes

Monitor Risk Assessment Framework

Published on 27 August 2012 the Risk Assessment Framework (RAF) sets out Monitor’s approach to overseeing the sector under new rules. The RAF explains how Monitor will assess individual NHS Foundation Trusts’ compliance with two specific aspects of their work:

The Governance Risk Rating;

The Continuity of Services Risk Rating.

Monitor will regularly consider the planned and actual financial performance and will use a Continuity of Services Risk Rating to assess financial risk. The metric focuses on financial elements only and comprise of two financial metrics:

Liquidity – days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown;

Capital Service Capacity – the degree to which the organisation’s generated income covers its financial obligations.

Monitor will use the thresholds set out in the diagram below to assign a rating of 1, 2, 3 or 4 to each of the two components once they have been calculated. The Continuity of Services Risk Rating is the average of the two figures, rounded up.



Monitor will primarily use the Governance Rating, incorporating information across a number of areas, to describe their views of the governance of the Trust. They will generate this rating by considering the following information regarding the Trust and whether it is indicative of a potential breach of the governance condition:

Category Metrics Governance concern triggered by

CQC Information

CQC judgments CQC warning notice issued

Civil and/or criminal action initiated

Access and Outcomes Metrics

For ambulance trusts, Category A response times (Red 1, Red 2 and A19 performance)

For minor injury units (eg Tiverton) compliance to the Emergency Department 4 hour wait target

Three consecutive quarters’ breaches of a single metric or a service performance score of 4 or greater

Third Party Reports

Ad hoc reports from GMC, the Ombudsman, commissioners, Healthwatch England, auditors reports, Health & Safety Executive, patient groups, complaints, whistle-blowers, medical Royal Colleges etc.

Judgment based on the severity and frequency of the reports.

Financial Risk

Continuity of Services Risk Rating.

Breaching any continuity of service license condition as a result of governance

Inadequate planning processes.

Quality Governance Indicators

Patient Metrics

o Patient satisfaction

Staff metrics

o High executive team turnover

o Satisfaction

o Sickness/absence rate

o Proportion temporary staff

o Staff turnover

Aggressive cost reduction plans

Material reductions in satisfaction, or increase in sickness or turnover rates

Material increases in proportion of temporary staff

Cost reductions in excess of 5% in any given year.

Monitor uses performance against a limited set of national measures of access and outcome objectives as indicators or governance and as a trigger to detect potential governance issues.

For ambulance trusts each will be monitored quarterly around the national performance standards. SWASFT also operate the contract for Tiverton Minor Injuries Unit, therefore in addition to the ambulance performance standard the 4 hour waiting time target for Emergency Departments is also included within the quarterly reports to Monitor, the reports include:

Targets and Indicators Threshold Weighting

Category A call – emergency response within 8 minutes, comprising Red 1 calls Red 2 calls

75% 75%

1.0 1.0

Category A call – ambulance vehicle arrives within 19 minutes 95% 1.0



Targets and Indicators Threshold Weighting

Minor Injury Units – patient waiting time less than 4 hours 95% 1.0

Certification against compliance with requirements regarding access to health care for people with a learning disability1

N/A 1.0

Where the Trust breaches a target(s), Monitor will use the sum of each metric’s weighting to calculate a Service performance Score. Where this score is 4.0 or greater, this will represent a governance concern. Where the Trust breaches a target systematically (i.e. a performance breach for three consecutive quarters) this will also represent a governance concern. The Governance Rating could represent one of three broad views:

Monitor will assign a Green rating if no governance concern is evident;

Where Monitor identifies potential material causes for concern with the Trust’s governance in one or more of the categories (requiring further information or formal investigation), Monitor will replace the Trust’s Green rating with a description of the issues and the steeps (formal or informal) Monitor is taking to address;

Monitor will assign a Red rating if they take regulatory action.

In assigning an appropriate governance risk rating, Monitor will be informed by the seriousness of the issue, information they already have concerning the situation, the effectiveness of the Trust’s initial response to the situation and the time-critical nature of the situation:

1 Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All

(DH, 2008)



Ambulance Clinical Quality Indicators

Ambulance Quality

Indicator

What is the Indicator Measuring & Why

is it Measured? Measure

Local

Performance

Threshold

2014/15

Call Abandonment Rate

The call abandoned rate is a marker of patient experience. A high call abandoned rate is not safe and may reflect a high level of clinical risk for patients

% of calls received that abandoned before being answered. 1.50%

Time to Answer Calls

The time until a call is answered represents a period of clinical risk to the patients prior to assessment from trained ambulance service personnel. Many adverse events are related to initial delays in care and many emergency conditions are time-sensitive therefore the time before a patient begins treatment represents a clinical risk.

Average time (in seconds) to answer 999 calls presented to the Trust switchboard. Measured at the 50

th,

95th and 99

th

percentiles

50th 3 secs

95th 19 secs

99th 60 secs

Time from Call Categorisation to Arrival at Scene

The period before being seen by a health professional represents a period of clinical risk and anxiety for the patient. By encouraging earlier definitive care and reducing delays in treatment this indicator seeks to improve health outcomes and patient experience for all patients with life threatening conditions.

Time for the first emergency response vehicle to arrive at scene for A category Incidents measured to 50

th, 95

th and 99

th

percentiles

To be confirmed

Re-Contact with the Ambulance Service following Telephone Advice

Patients may re-contact the ambulance service because their condition has worsened. However in some cases there may be further contact due to an incorrect initial telephone diagnosis or poor explanation by clinical staff. Unplanned re-contact is a marker of the accuracy of initial telephone assessment in identifying those patients requiring an escalation of care or likely to experience deterioration.

% of unplanned re-contact within 24 hours following initial telephone advice.

11.00%

Re-Contact with the Ambulance Service following Treatment at Scene

Ambulance staff will always use the most appropriate treatment pathways based on their clinical assessment of the patient on scene. However patients may re-contact the ambulance service because their condition has worsened or they have received a poor explanation. Unplanned re-contact is a marker of the accuracy of initial treatment at scene in identifying those patients requiring an escalation of care or likely to experience deterioration.

% of unplanned re-contact within 24 hours following treatment at scene

5.50%

Patients Managed Appropriately (Right Care, Right Place, Right Time) – Calls Closed with Telephone Advice

Providing clinically appropriate pre-hospital care through clinical telephone advice may result in better outcomes for patients and a more efficient use of ambulance resources. This can include advice from Nurses within our Clinical Hubs and advice about other NHS facilities the patient could attend themselves (Minot Injury Units, etc.)

% of calls that are managed through telephone advice without the need for an ambulance resource arriving on scene

7.50%



Ambulance Quality

Indicator



Local

Performance

Threshold

2014/15

Patients Managed Appropriately (Right Care, Right Place, Right Time) – Calls Closed without the need for Transport to A&E (Emergency Departments)

Providing effective pre-hospital care allows for better care for the patient; such as care being delivered closet to home. A reduction in avoidable emergency patient journeys and admissions to hospitals whilst responding to and conveying those patients who would not be suitable for treatment at the scene or through clinical telephone advice.

% of calls that are managed through without the need for an ambulance resource arriving on scene, or onward transport to major Emergency Department

52.00%

Return of spontaneous circulation following cardiac arrest

The aim of this indicator is to reduce the proportion of patients who die from out of hospital cardiac arrest. It reviews patients who were in cardiac arrest but, following resuscitation, have a pulse on arrival at hospital. Improvement in ROSC rates informs the effectiveness of pre-hospital response and intervention. The ROSC is calculated for two patient groups:

The overall rate measures the overall effectiveness of the pre-hospital response and intervention for all out of hospital cardiac arrest patients;

The rate for the Utstein comparator group applies to a sub-set of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival.

% of resuscitated cardiac arrest patients that had a Return of Spontaneous Circulation (ROSC) at the point of handover of clinical care of the patient to the hospital

24.00%

Return of spontaneous circulation following cardiac arrest (Utstein)

% of resuscitated cardiac arrest patients that had a Return of Spontaneous Circulation (ROSC) at the point of handover of clinical care of the patient to the hospital – where the arrest was witnessed and the initial rhythm was VF or VT.

45.00%

Outcome from acute STEMI - (PPCI)

Early access to reperfusion and other assessment for care interventions are associated with reductions in mortality and morbidity for inpatients suffering an ST elevation myocardial infarction (STEMI) mortality and morbidity. This is evidenced in both NSF and CHD and National Infarct Angioplasty Project Gateway 9116 (2008) and Mending Hearts and Brains (2006).

% of patients suffering a STEMI receiving Primary Percutaneous Coronary Intervention (PPCI), also known as primary angioplasty, within 150 mins of call.

84.00%

Outcome from Acute STEMI – Care Bundle

% of patients suffering a STEMI who receive an appropriate care bundle.

90.00%

Outcomes from Stroke for Ambulance Patients - FAST

Patients should be arriving at the hyper-acute stroke centre as soon as possible so that they can be rapidly assessed for thrombolysis, with this being delivered following a CT scan in a short but safe time frame. This has been demonstrated to reduce mortality and improve recovery. Eligibility criteria, particularly in relation to the therapeutic time window, will vary between local services, depending on the availability of local expertise e.g. intra-arterial clot lysis. This indicator supports the NICE national

% of patients assessed face to face and provided a FAST (Face, Arms, Speech, Time to Call 999) positive response and were potentially eligible for thrombolysis that arrive at hospitals with a Hyper Acute Stroke Centre within 60 mins of the call.

57.00%



Ambulance Quality

Indicator



Local

Performance

Threshold

2014/15

Outcome from Stroke for Ambulance Patients – Care Bundle

quality standard that indicates this is an effective measure of the ambulance service’s contribution to the stroke pathway.

% of suspected stroke patients assessed face to face who receive an appropriate care bundle

97.00%

Outcome from Cardiac Arrest – Survival to Discharge

Survival to discharge is where a patient is able to be discharged from hospital and continue recovery after a cardiac arrest. The indicator measures the effectiveness of the whole urgent and emergency care system in managing out of hospital cardiac arrest. Survival to discharge is calculated for two patient groups:

The overall survival rate measures the overall effectiveness of the urgent and emergency care system in managing care for all out of hospital cardiac arrest patients;

The Utstein survival rate applies to a sub-let of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival.

% of patients who had resuscitation (Advanced or Basic Life Support) commenced/continued by the ambulance service following an out-of-hospital cardiac arrest.

9.00%

Outcome from Cardiac Arrest – Survival to Discharge (Utstein)

% of patients who had resuscitation (Advanced or Basic Life Support) commenced or continued by the ambulance service following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was bystander or emergency medical service witnessed and the initial rhythm was VF or VT.

27.00%



NHS 111 Service Quality Requirements

Quality

Requirement What is the Indicator Measuring? Measure

National Quality

Requirement

Standard

QR1 National Quality Requirement performance reporting

Providers must report regularly to NHS Commissioners on their compliance with the national Quality Requirements

Trust compliance with reporting requirements against the national Quality Requirements

Compliance

QR2 NHS 111 Consultations to GP surgeries by 08:00 next working day

Providers must send details of all out of hours consultations to the practice where the patient is registered by 08:00 the next working day

Percentage of NHS 111 consultations where details are provided to GPs by 08:00 next working day

Greater than 95%

QR3 Systems for exchange of information on patients with predefined needs

Providers must have systems in place to support and encourage the regular exchange of information between all those who may be providing care to patients with predefined needs (including e.g. patients with terminal illness)

Trust compliance with system requirements and exchange of information

Compliance

QR4 Audit of patient contacts to review clinical performance of individuals working in the service

Providers must regularly audit a random sample of patient contacts. This sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service

Trust compliance with audit requirements for to review clinical performance

Compliance

QR5 Regular Audit of Patient Experience

Providers must regularly audit a random sample of patients’ experiences of the service

Compliance with patient experience audits on a regular basis

Compliance

QR6 Compliance with NHS Complaints procedure principles

Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints procedure

Compliance with NHS complaints procedure principles

Compliance

QR7 Ability to match capacity to demand

Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service, especially at periods of peak demand, such as Saturday and Sunday mornings, and the third day of a Bank Holiday weekend. They must also have robust contingency policies for those circumstances in which they may be unable to meet unexpected demand.

Compliance

QR8 call answering performance

Initial Telephone Call into the NHS 111 service should be handled promptly.

Percentage of abandoned telephone calls. Time taken for the call to be answered by a person within 60 seconds of the end of the introductory message.

Less than 5% of calls abandoned.

More than 95% of calls answered

within 60 seconds



Quality


National Quality

Requirement

Standard

QR9 telephone triage performance

Providers must have a robust system for identifying all immediate life threatening conditions and, once identified, those calls must be passed to the ambulance service within 3 minutes.

Providers that can demonstrate that they have a clinically safe and effective system for prioritising calls must meet the required standards for clinical assessment.

Compliance with system requirements for passing calls to the ambulance service. Where required patient call backs are commenced within 10 minutes

Compliance

Greater than 95%

QR13 provision of interpretation services when required

Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired sight.

Compliance with service provision within 15 minutes of initial contact.

Compliance

QR14 compliance with Information Governance Toolkit

Providers must demonstrate the online completion of the annual assessment of the Information Governance Toolkit at level 2 (satisfactory) or above and that this is audited on an annual basis by Internal Auditors using the national framework.

Compliance with IG Toolkit Requirements at level 2.

Compliance

QR15 compliance with Department of Health Information Governance SUI Guidance

Providers must demonstrate that they are complying with the Department of Health Information Governance SUI Guidance on reporting Information Governance incidents appropriately.

Compliance with Department of Health guidance on the reporting of Information Governance incidents appropriately.

Compliance



Urgent Care Services Quality Requirements

Quality


National Quality

Requirement

Standard

QR1 National Quality Requirement performance reporting

Providers must report regularly to NHS Commissioners on their compliance with the national Quality Requirements

Trust compliance with reporting requirements against the national Quality Requirements

Compliance

QR2 Out of Hours Consultations to GP surgeries by 08:00 next working day

Providers must send details of all out of hours consultations to the practice where the patient is registered by 08:00 the next working day

Percentage of out of hours consultations where details are provided to GPs by 08:00 next working day

Greater than 95%

QR3 Systems for exchange of information on patients with predefined needs

Providers must have systems in place to support and encourage the regular exchange of information between all those who may be providing care to patients with predefined needs (including e.g. patients with terminal illness)

Trust compliance with system requirements and exchange of information

Compliance

QR4 Audit of patient contacts to review clinical performance of individuals working in the service

Providers must regularly audit a random sample of patient contacts. This sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service

Trust compliance with audit requirements for to review clinical performance

Compliance

QR5 Regular Audit of Patient Experience

Providers must regularly audit a random sample of patients’ experiences of the service

Compliance with patient experience audits on a regular basis

Compliance

QR6 Compliance with NHS Complaints procedure principles

Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints procedure

Compliance with NHS complaints procedure principles

Compliance

QR7 Ability to match capacity to demand

Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service, especially at periods of peak demand, such as Saturday and Sunday mornings, and the third day of a Bank Holiday weekend. They must also have robust contingency policies for those circumstances in which they may be unable to meet unexpected demand.

Compliance

QR10 face to face triage performance

Face to Face Clinical Assessment: Providers must have a robust system for identifying all immediate life threatening conditions and, once identified, those calls must be passed to the ambulance service within 3 minutes.

Providers that can demonstrate that

Compliance with system requirements for passing calls to the ambulance service. Start definitive clinical

Compliance



Quality


National Quality

Requirement

Standard

they have a clinically safe and effective system for prioritising calls must meet the required standards for clinical assessment.

At the end of the assessment, the patient must be clear of the outcome, including (where appropriate) the timescale within which further action will be taken and the location of any face-to-face consultation.

assessment for urgent calls within 20 minutes of the patient arriving at the centre Start definitive clinical assessment for all other calls within 60 minutes of the patient arriving at the centre Compliance with assessment requirements.

Greater than 95%

Greater than 95%

Compliance

QR11 patient treatment requirements

Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most appropriate location. Where it is clinically appropriate, patients must be able to have a face-to-face consultation with a GP, including where necessary, at the patient's place of residence.

Compliance with patient treatment requirements.

Compliance

QR12 face to face consultation within agreed timescales

Face-to-Face Consultations (assessed for both patient home visits and patients visiting a treatment centre) must be started within the appropriate timescales, after the definitive clinical assessment has been completed.

Emergency calls within 1 hour Urgent calls within 2 hours Less Urgent calls within 6 hours

Greater than 95%

Greater than 95%

Greater than 95%

QR13 provision of interpretation services when required

Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired sight.

Compliance with service provision within 15 minutes of initial contact.

Compliance

Note: Following the introduction of the NHS 111 service with effect from February 2013, the Out of Hours service are no longer required to report on QR 8 (call answering performance) and QR9 (definitive clinical assessment by telephone) as these areas are now under the remit of the NHS 111 service provider contracts.



Appendix D: Local Measures Definitions and Glossary

A&E Local Key Performance Indicators

Measure 2014/15

Local Target Definition

How the Target is

measured

Green 1 90%

These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 20 minutes.

Monthly performance vs KPI monitoring

Green 2 90%

These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 30 minutes


Green 3 90%

These are calls which are assessed as lower acuity calls requiring a response at normal road speeds within 60 minutes or a phone assessment within 30 minutes (a clinician calling back for a secondary telephone triage to establish the most appropriate care pathway for the patient).


Green 4 (999) 90%

These are calls where presenting conditions are not serious and therefore not life threatening and do not require an emergency response. These calls should receive a clinical response within 60 minutes


Green 4 (HPC) 70%

The Green 4 category includes all responses made by the Trust to requests from Healthcare Professionals to undertake urgent transfers of patients within a 1, 2 or 4 hour time window


Non Conveyance Rate

n/a Incidents that are completed without the need to convey a patient to an Emergency Department at an acute hospital.

Monthly performance vs local trajectory and KPI

targets



Appendix E: Board Assurance

Board Assurance

Framework (BAF)

Integrated

Performance

Report

Annual Cycles and

Records

Committee

Assurance

Medicines

ManagementEnd of Life

Research

and AuditSepsis CQUIN

Clinical audit plan CE CE All

PS PE PS

CQC registration

compliance

PS PS All

CE PE All

CE PS All

Safeguarding PS PE

PS

PECritical Assurance

RolesCritical assurance roles appointed to include: Caldicott Guardian, Senior Information Risk Owner, Accountable

Officer for Controlled Drugs, and Board Champions

Where and how the Board has received assurance at key forums against key performance indicators and objectives

plus documenting external assurance and an assurance evaluation tool

NHSLA compliance

Codes of conduct

Risk RegistersCorporate Risk Register reviewed at each Board meeting; all risk registers, including directorate, reviewed annually

(cross referenced on BAF)

Code of governance

Quality

Governance

Reviews

Quality reviews of Trust arrangements against negative assurance about other trusts: eg Mid Staffs. Action plans

developed and monitored

Board DevelopmentBoard development and training register is maintained for all Board members. Regular annual training includes: risk

management; health and safety; and information governance

Clinical and governance policy and strategy

Governance checklist initiative designed to provide a quick assessment of the governance requirements for any new

function or initiative

Quality Board Assurance

Governance Reporting

Each Board commitee is chaired by a Non Executive Director (NED); an action point register and minutes from each

committee are reviewed by the Board of Directors at each meeting

Governance

Checklists

The new Integrated Corporate Performance Report, from February 2013, provides the Board with assurance

against a set of contractual and statutory metrics on a monthly basis. The report focuses on peformance exceptions

and provides the Board with an early warning of metrics that are of concern across the Trust.

Regulatory

Framework

The Regulatory Framework contains details of all statutory and regulatory targets with details of which forum they

should be presented to.

Board, and each of its committees, has an annual cycle of business, reviewed and revised at the start of each

year;and a record of all business conducted detailing review, approval or referral of key documents

The following working groups provide assurance to the Quality and Governance Committee:

Health and Safety

Accident statistics, risk assessments, health,

safety and security indicators

Aggregated review of serious and other incidents,

safeguarding, MECs, claims; and identification of trends

and lessons learned; as well as review of compliance

with key targets such as CQC outcomes

Clinical

Effectiveness

The Board of Directors uses a variety of mechanisms to seek assurance that the Trust is meeting its corporate objectives;

identifies and manages any risks; and remains compliant with its statutory and regulatory targets

Assurance Mechanisms

Quality and Governance

Committee

Develop and implement effective

quality and governance assurance

systems and processes

Audit Committee

Review and seek assurance on the effectiveness of

processes in place for the management of

arrangements for Governance, Risk Management,

Clinical Assurance, Internal Control, and Financial

Reporting; and to ensure the Trust and its auditor

remain compliant with Monitor's Audit Code for NHS

Foundation Trusts (terms of authorisation)

Finance and Investment

Committee

Review financial planning,

cost improvements,

investments and financial

performance

Information governance

Learning from

Experience

Patient experience

Infection

Prevention and

Control

Resuscitation

PS

Clinical guidelines

HR key indicators

Infection prevention and

control

Infection Prevention and Control policies, procedures and guidelines; clinical efficiency and best practice. The work of the

Group is supported by a set of sub groups:

Air

Ambulance

Clinical

Vehicle

Equipment &

Uniform Working

Corporate and Directors' risk registers

Identification of risk

The Quality Strategy and Quality Account are each structured around five priorities: patient safety (PS); patient experience

(PE); clinical effectiveness (CE); access; and value for money

Ambulance Clinical Quality indicators Assurance framework

Quality account

Identification of legislation

Health and safety KPIsMedicines management plan

The following quality reports and action plans are received at each Quality and Governance committee meeting and used as mechanisms of

quality assurance. Highlighted boxes show which quality priority they meet:

Appendix Fi - Clinical Dashboard 2015/16 Month: Jun-15 Year: 2015/16

National

TargetTrend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4

Red 1 Category A - Red 1 Performance 75.00% 76.46% 78.97% 75.12% 75.29% 76.46%

Red 1Category A - Red 1 Time to Treatment - 95th percentile of time from call connect to an emergency response

arriving at the scene of the incident (mins)n/a 13.9 13.3 14.4 14.1 13.9

Red 2 Category A - Red 2 Performance 75.00% 66.80% 68.26% 66.25% 65.90% 66.80%

A19 A19 Performance 95.00% 91.83% 92.67% 91.76% 91.07% 91.83%

Performance

Threshold

2015/16

Trend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

CO1.1 Call Abandonment Rate (% of calls abandoned before answering) 1.50% 0.71% 0.74% 0.48% 0.90%

CO1.2Re-Contact Rate Following Discharge of Care (unplanned re-contact with the ambulance service

within 24 hours of discharge of care by clinical telephone advice)11.00% 13.72% 13.97% 14.19% 12.94%

CO1.2Re-Contact Rate Following Discharge of Care (unplanned re-contact with the ambulance service

within 24 hours of discharge of care following treatment at scene)5.50% 5.86% 5.88% 5.81% 5.90%

CO1.8Time to Answer Emergency Calls - Median time spent between call connect and call answer

(seconds)3 2 2 2 3

CO1.8Time to Answer Emergency Calls - 95th percentile of times from call connect and call answer

(seconds)19 15 15 12 19

CO1.8Time to Answer Emergency Calls - 99th percentile of times from call connect and call answer

(seconds)60 58 54 52 68

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for immediate life

threatening (cat A) calls - Median time spent to arrival of a qualified health professional (mins)n/a 7.2 7.1 7.3 7.3

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for cat A calls - 95th

percentile of times to arrival of a qualified health professional (mins)n/a 23.7 23.0 23.9 24.2

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for cat A calls - 99th

percentile of times to arrival of a qualified health professional (mins)n/a 38.4 36.9 39.7 38.6

CO1.10Ambulance calls closed with telephone advice or managed without transport to A&E departments

(where clinically appropriate) - calls closed with telephone advice7.50% 12.56% 12.92% 12.73% 12.04%

CO1.10Ambulance calls closed with telephone advice or managed without transport to A&E departments

(where clinically appropriate) - incidents managed without the need for transport to A&E52.00% 52.42% 52.09% 52.28% 52.87%

CO1.11 Number of Emergency Patient Journeys n/a - 104,699 34,371 35,641 34,687

Performance

Threshold

2015/16

TrendRolling 12

MonthsMar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15

CO1.3Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital

(overall)24.00% 24.94% 26.07% 18.65% 25.69% 25.00% 24.71% 28.62% 26.91% 21.31% 26.33% 24.93% 27.38% 23.40%

CO1.3Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital

(Utstein Comparator Group)45.00% 46.01% 52.54% 33.33% 52.83% 42.22% 48.15% 38.00% 54.90% 35.56% 48.78% 46.81% 53.19% 42.90%

CO1.5

Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients suffering a STEMI

and who, following a direct transfer to a PPCI centre, primary angioplasty commences within 150

minutes of call

84.00% 77.57% 78.62% 78.45% 79.13% 88.07% 80.00% 77.93% 76.64% 77.50% 74.55% 74.36% 72.03% 74.80%

CO1.5Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients suffering a STEMI

and who receive an appropriate care bundle90.00% 89.10% 89.74% 89.02% 93.89% 85.14% 89.94% 85.96% 90.53% 89.70% 88.24% 89.22% 88.57% 88.40%

CO1.6

Outcome from Stroke for Ambulance Patients - % of Face Arm Speech Test (FAST) positive stroke

patients (assessed face to face) potentially eligible for stroke thrombolysis, who arrive at a

hyperacute stroke centre within 60 minutes of call

57.00% 54.83% 55.93% 55.63% 59.66% 57.81% 63.11% 58.12% 55.31% 53.23% 51.60% 50.79% 48.72% 49.20%

CO1.6Outcome from Stroke for Ambulance Patients - % of suspected stroke patients (assessed face to

face) who receive an appropriate care bundle97.00% 97.63% 98.14% 97.30% 98.65% 96.56% 97.96% 97.33% 98.10% 97.10% 96.86% 97.59% 97.88% 98.00%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate 9.00% 9.90% 12.15% 7.44% 12.15% 10.18% 10.59% 8.58% 10.74% 7.59% 14.33% 9.21% 8.11% 8.50%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate 27.00% 28.40% 36.84% 22.92% 33.96% 25.00% 30.77% 20.00% 36.00% 13.33% 46.34% 23.40% 25.53% 25.50%

Improving Trend

No Change

Reducing Trend

Performance for the Clinical Indiciators is monitored against a rolling 12 month performance for the Trust

Ambulance Performance Targets

Ambulance Clinical Quality Indicators - Clinical Indicators

Ambulance Clinical Quality Indicators - System Indicators

Performance Thresholds detailed above have been agreed locally with Commissioners and performance against these thresholds will be monitored within this report throughout 2015/16.

Appendix Fii - A&E Local Performance Targets Month: Jun-15 Year: 2015/16

KPI Trend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4

Green 1Percentage of calls that are serious, but not life threatening, receiving an emergency response within 20

minutes90.00% 78.95% 82.71% 75.41% 76.47% 78.95%

Green 2Percentage of calls where presenting conditions are serious, but there is a less clinical need, receiving

and emergency response within 30 minutes90.00% 79.75% 80.92% 78.62% 76.36% 79.75%

Green 3Percentage of lower acuity calls which receiving a response within 60 minutes or a telephone assessment

within 30 minutes90.00% 94.19% 95.04% 93.42% 91.72% 94.19%

Green 4 (999)Low acuity calls received from the public receiving a response at normal road speed within 1 hour

(East/West Division Only)90.00% 72.23% 74.27% 70.22% 73.24% 72.23%

Green 4 (HPC)Low acuity calls received from Healthcare Professionals that receive a response at normal road speeds

within a agreed time window (1, 2 or 4 hours in length depending on acuity) (East/West Division Only)70.00% 64.06% 67.85% 60.23% 64.13% 64.06%


Activity Percentage of Incidents through Hear & Treat Pathway - 13.85% 13.54% 14.13% 13.90% 13.85%

Activity Percentage of Incidents through See & Treat Pathway - 36.02% 35.78% 36.24% 36.10% 36.02%

Activity Percentage of Incidents through See & Convey to Non Emergency Department Locations - 7.79% 7.90% 7.68% 8.19% 7.79%

Activity Percentage of Incidents through See & Convey to Emergency Departments - 42.34% 42.78% 41.95% 41.81% 42.34%

Non

ConveyancePercentage of Incidents Closed without Conveyance to Emergency Departments 55.05% 57.66% 57.22% 58.05% 58.19% 57.66%


Handover

DelaysTime lost to Chargeable Handover Delays in excess of 15 minutes (hrs) 0 3,108 1,102 1,045 961 3,108

Handover

DelaysNumber of Chargeable Handover Delays between 30 minutes and 60 minutes 0 2,454 876 818 760 2,454

Handover

DelaysNumber of Chargeable Handover Delays in excess of 60 minutes 0 320 153 102 65 320


A&E Contract A&E Actual Incidents vs Contracted Incidents 100.00% 102.82% 102.22% 103.71% 102.48% 102.82%

Contract Activity

Ambulance Performance Targets

Right Care, Right Place, Right Time 2

A&E Service Line Key Performance Indicators

Appendix Fiii - PTS KPIs and Local Performance Targets Month: Jun-15 Year: 2015/16

KPI Trend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

1aPatients living up to 10 miles away from the treatment centre (Band A) should not spend more than

60 minutes on the vehicle on either an outward or return journey90.00% 92.56% 93.28% 93.07% 91.49%

1bPatients living over 10 miles and up to 35 miles away from the treatment centre (Band B) should not

spend more than 90 minutes on the vehicle on either an outward or return journey90.00% 96.18% 97.16% 95.95% 95.41%

1cPatients living over 35 miles away from the treatment centre (Band C) should not spend more than

120 minutes on the vehicle on either an outward or return journey90.00% 100.00% 100.00% 100.00% 100.00%

2a Patients should not arrive more than 45 minutes before their booked arrival time 90.00% 89.21% 88.37% 90.28% 89.01%

2b Patients should not arrive after their booked arrival time 97.00% 90.62% 91.80% 90.00% 90.10%

3aSWASFT is to arrive to collect patients from the agreed location within 45 minutes of the outward

journey time90.00% 89.73% 90.88% 88.86% 89.52%

3aSWASFT is to arrive to collect patients from the agreed location within 75 minutes of the outward

journey time90.00% 95.28% 95.52% 95.05% 95.28%

8cPick up time to be confirmed by text, email or phone call to the patient within a week of the

appointment (phone call being the preferred method (assessed quarterly)100.00% 100.00% 100.00% 100.00%

9aPatient satisfaction with the level of service received from the provider - assessed through the

annual patient satisfaction survey85.00% 97.80% 97.80% 97.80% 97.80%

9b NHS Commissioners to be satisfied with the level of service 100.00% 100.00% 100.00% 100.00%

9f Call answering performance 95.00% 94.83% 95.72% 93.94% 95.50%

10aAgreed activity performance report received in correct format and on time within 10 working days of

the start of the following month100.00% 100.00% 100.00% 100.00%

10bActivity and finance queries are acknowledged within 3 days of receipt and resolved within 28 days

from the date of the query100.00% 100.00% 100.00% 100.00%

12h

Nil Serious Untoward Incidents (SUIs) - Any SUIs to be reported and action plans put in place - in

line with NHS Bristol standard and timeframes (reported immediately, investigated within 24 hours

and lessons learnt shared, then closed within 60 working days of the incident)

100.00% 100.00% 100.00% 100.00%

12dCompliance with the agreed SWASFT complaints procedure - full response made in a timely

manner agreed with the complainant (assessed quarterly)100.00% 100.00% 100.00% 100.00%

3b

A summary of reasons and actions to be provided, for each month, for all cases where collection

was outside of the KPI limits (i.e. later than agreed timeframes). This may include case by case

analysis as deemed necessary

100.00% 100.00% 100.00% 100.00%

Patient Transport Services - Bristol, North Somerset and South Gloucestershire - 2015/16

Contract KPIs

Appendix Fiv - Urgent Care Services Quality Requirements Month: Jun-15 Year: 2015/16

QR YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

QR1 Providers must report regularly to NHS Commissioners on their compliance with the Quality Requirements Compliance Compliant Compliant Compliant Compliant

QR2Providers must send details of all consultations (including appropriate clinical information) to the practice where

the patient is registered by 8.00 a.m. the next working day. 95.00% 88.86% 87.68% 88.59% 90.50%

QR3Providers must have systems in place to support and encourage the regular exchange of information between

all those who may be providing care to patients with predefined needsCompliance Compliant Compliant Compliant Compliant

QR4Providers must regularly audit a random sample of patient contacts (audit should provide sufficient data to

review the clinical performance of each individual working within the service)Compliance 0.76% 0.76% 0.67% 0.88%

QR5 Providers must regularly audit a random sample of patients' experiences of the service 1.00% 0.40% 0.49% 0.63%

QR6Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints

procedureCompliance Compliant Compliant Compliant Compliant

QR7Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for

their contracted serviceCompliance

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

QR8a No more than 5% of calls abandoned before being answered 5.00% 7.92% 8.51% 8.06% 7.01%

QR8b Calls to be answered within 60 seconds of the end of the introductory message 95.00% 70.95% 73.22% 68.87% 70.81%

QR9a All immediately life threatening conditions to be passed to the ambulance service within 3 minutes 100.00% 93.10% 75.00% 100.00% 100.00%

QR9b Patient callbacks must be achieved within 10 minutes 100.00% 18.55% 22.05% 16.98% 16.38%

QR13Patients unable to communicate effectively in English will be provided with an interpretation service within 15

minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or

impaired sight

100.00% 100.00% 100.00% 100.00% 100.00%

QR14Providers must demonstrate the online completion of the annual assessment of the Information Governance

Toolkit at level 2 or above and that this is audited on an annual basis by Internal Auditors using the national

framework

Compliance Compliant Compliant Compliant Compliant

QR15Providers must demonstrate that they are complying with the Department of Health Information Governance

SUI Guidance on reporting of Information Governance incidents appropriately.Compliance Compliant Compliant Compliant Compliant














Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant







impaired sight

100.00% 100.00% 100.00% 100.00% 100.00%



framework




Due to the timing of this report the data relating to QR5 is not yet available for June 2015, this information will be included within the July 2015 report.

Urgent Care Services - NHS 111 Dorset


Urgent Care Services - NHS 111 Devon














Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant







impaired sight

100.00% 100.00% 100.00% 100.00% 100.00%



framework

















Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant







impaired sight

100.00% 100.00% 100.00% 100.00% 100.00%



framework




Urgent Care Services - NHS 111 Somerset



Urgent Care Services - NHS 111 Cornwall



QR2Percentage of Out of Hours consultation details sent to the practice where the patient is registered by 08:00 the

next working day95.00% 97.70% 99.85% 99.88% 91.40%




review the clinical performance of each individual working within the service)Compliance Compliant Compliant Compliant Compliant

QR5 Providers must regularly audit a random sample of patients' experiences of the service Compliance Compliant Compliant Compliant Compliant




their contracted serviceCompliance Compliant Compliant Compliant Compliant

QR10aAll immediately life threatening conditions (walk in patients) to be passed to the ambulance service within 3

minutes of face to face presentation95.00% n/a n/a n/a n/a

QR10bDefinitive Clinical Assessment for Urgent cases presenting at treatment location to start within 20 minutes - not

applicable to this service as a separate clinical assessment is not carried out between presentation and clinical

consultation at walk-in-centres

95.00% n/a n/a n/a n/a

QR10bDefinitive Clinical Assessment for Less Urgent cases presenting at treatment location to start within 60 minutes -

not applicable to this service as a separate clinical assessment is not carried out between presentation and

clinical consultation at walk-in-centres

95.00% n/a n/a n/a n/a

QR10d At the end of an assessment, the patient must be clear of the outcome Compliance Compliant Compliant Compliant Compliant

QR11Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most

appropriate locationCompliance Compliant Compliant Compliant Compliant

QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00% n/an/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

QR12 Urgent Consultations (presenting at base) started within 2 hours 95.00% 93.40% 92.81% 92.59% 95.40%

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 97.30% 96.90% 97.39% 97.50%

QR12 Emergency Consultations (home visits) started within 1 hour 95.00% n/an/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

QR12 Urgent Consultations (home visits) started within 2 hours 95.00% 93.00% 91.53% 93.11% 94.80%

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 95.00% 95.55% 93.21% 96.90%



impaired sight


Urgent Care Services - Dorset Out of Hours

Following the introduction of the NHS 111 Service in the counties of Dorset and Somerset on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.

Any appropriate incidents are then transferred to the Urgent Care Services in Dorset and Somerset for action. As a result QR8 and QR9 are no longer applicable to the Urgent Care Services in Dorset and Somerset with effect from March 2013.




next working day95.00% 97.15% 99.93% 99.98% 89.55%















95.00% n/a n/a n/a n/a




95.00% n/a n/a n/a n/a




QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00%n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)



QR12 Emergency Consultations (home visits) started within 1 hour 95.00%n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)





impaired sight


Following the introduction of the NHS 111 Service in the counties of Dorset and Somerset on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.


Urgent Care Services - Somerset Out of Hours




next working day95.00% 99.81% 99.46% 100.00% 100.00%















95.00% 53.66% 52.00% 62.50% 50.00%




95.00% 83.64% 79.31% 88.46% 86.15%




QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00% 77.78%100.00%

(3 cases)

75.00%

(4 cases)

50.00% (2

Cases)



QR12 Emergency Consultations (home visits) started within 1 hour 95.00% 60.00%66.67%

(3 cases)

50.00%

(4 cases)

66.67%

(3 cases)





impaired sight



Percentages of Cases completed within 4 Hours 95.00% 99.66% 99.30% 99.85% 99.86%

Urgent Care Services - Tiverton Minor Injuries Unit


Urgent Care Services - Gloucester Out of Hours

Following the introduction of the NHS 111 Service in the counties of Gloucestershire on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.

Appendix Fv - A&E Local Performance Targets Month: Jun-15 Year: 2015/16

National

TargetYTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Sickness Staff Sickness Level 4.00% 5.30% 5.38% 5.00% 4.93%

Appraisals Staff Appraisals Completed within 12 month period 85.00% 55.95% 50.42% 55.95% 56.12%

Infection

ControlCompliance with Infection Prevention and Control Standards at Ambulance Stations 75.00% 82.00% 93.00% 86.00% 82.00%

Infection

ControlCompliance with Infection Prevention and Control Standards for Double Crew Ambulances 75.00% 82.00% 79.00% 82.00% 82.00%

Vehicle Deep

CleanVehicle deep cleaning compliance with schedule 90.00% 92.40% 93.60% 92.30% 92.40%

YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Patient Safety Adverse Incidents reported relating to medication administration, prescription and supply errors 155 54 54 47

Patient Safety Central Alert System (CAS) received 21 8 6 7

Patient Safety Central Alert System warnings (outside deadline) 5 3 0 2

Safety

MeasuresNumber of Moderate Incidents Reported 6 6 1

Safety

MeasuresNumber of Moderate Incidents Currently Under Investigation 6 6 4

Safety

MeasuresNumber of Adverse Incidents Reported 1,658 568 559 531

Safety

MeasuresNumber of Adverse Incidents Closed 1,814 513 597 704

Safety

MeasuresNumber of Adverse Incidents Currently Under Investigation 2,174 2,016 1,892

Safety

MeasuresNumber of Security Incident Reported (SIRS) 77 61 74

Safety

MeasuresNumber of Security Incidents Closed 63 83 51

Safety

MeasuresNumber of Security Incidents Currently Under Investigation 66 42 32

Safety

MeasuresSerious Incidents Identified in Month 18 4 12 2

Safety

MeasuresSerious Incidents Investigated and Presented to Panel 10 2 5 3

Safety

MeasuresSerious Incidents Currently Under Investigation 14 10 4

Safety

MeasuresNever Events' Identified in Month (included in Serious Incidents figure above) 0 0 0 0

Patient

ExperienceNumber of MECS Reported 373 134 121 118

Patient

ExperienceNumber of MECS Closed (resolved with the Complainant and all investigations completed) 344 117 105 122

Patient

ExperienceNumber of MECS Resolved (with the Complainant but internal investigation ongoing) 8 8 5

Patient

ExperienceNumber of MECS Open (not resolved with the complainant and currently under investigation) 109 128 102

Patient

ExperienceTotal PALS Reported 232 77 82 73

Patient

ExperienceTotal PALS Closed 204 67 72 65

Patient

ExperienceTotal PALS Currently ongoing 21 18 20

Patient

ExperienceCompliments Received 543 164 171 208

Local Indicators

Patient Experience

South Western Ambulance Service NHS Foundation Trust - Financial Summary Dashboard Appendix G

Better Payment Practice Code KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Better Payment Practice Code NHS (Value) % 95% 96.43% 88.40% 102.11% 96.63% 96.43% >95% <95%

Better Payment Practice Code NHS (Volume)

%95% 94.58% 97.00% 92.00% 95.00% 94.58% >95% <95%

Better Payment Practice Code Non NHS

(Value) %95% 90.96% 95.22% 89.52% 86.92% 90.96% >95% <95%

Better Payment Practice Code Non NHS

(Volume) %95% 96.10% 96.51% 96.02% 95.78% 96.10% >95% <95%

Other Key Financial Metrics KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debtors >90 Days Past Due as a % of Total

Debtor Balances5.00% 22.76% 5.60% 5.26% 22.76% 22.76% <5% >5%

Creditors >90 Days Past Due as a % of Total

Creditor Balances5.00% 0.95% 0.79% 0.00% 0.95% 0.95% <5% >5%

Capital Expenditure as a % of Plan (Min) 85.00% 101.01% 366.52% 129.98% 97.73% 101.01% >85% <85%

Capital Expenditure as a % of Plan (Max) 115.00% 101.01% 366.52% 129.98% 97.73% 101.01% <115% >115%

Continunity of Services Risk Rating KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debt Service Cover 6.71 7.06 6.78 6.71 6.71 >2.501.25 to

2.50<1.25

Debt Service Metric Score 4.00 4.00 4.00 4.00 4.00

Liquidity 11.41 14.71 15.68 11.41 11.41 >0.00 -7.00 to

14.00<-14.00

Liquidity Metric Score 4.00 4.00 4.00 4.00 4.00

Continuity of Services Risk Rating 4.00 4.00 4.00 4.00 4.00

Comments:Aged debtors over 90 days at the end of June 2015 totalled £704k. This amount includes NHS ORCP Funding Invoices of £524k for 2014/15 which are past 90 days due.

South Western Ambulance Service NHS Foundation Trust Appendix Gi

2014/15

Outturn

Statement of Comprehensive Income Actual Budget Variance Actual Budget Variance Actual

Period Ending 30/06/2015

Month 3

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Income:

A&E Income (45,647) (45,691) 44 (182,761) (182,856) 94 (178,039)

UCS Income (7,101) (7,153) 52 (23,213) (23,557) 344 (24,341)

PTS Income (967) (971) 3 (3,851) (3,882) 32 (3,869)

HART Income (1,643) (1,643) - (6,573) (6,573) - (6,574)

Other Income (1,712) (1,109) (603) (11,882) (9,891) (1,991) (16,599)

Total Income (57,070) (56,567) (504) (228,280) (226,759) (1,522) (229,439)

Expenditure:

Employee Benefits (Pay) 42,405 42,400 5 1 169,449 169,913 (464) 1 164,224

Drugs 203 251 (48) 554 909 (355) 753

Medical 1,195 1,072 123 2 4,901 4,282 619 5,919

ICT 1,123 1,257 (134) 2 4,913 4,984 (71) 8,289

Estates 1,633 1,613 20 2 6,789 6,434 355 6,922

Fleet Expenses 1,282 928 354 2 4,913 4,597 316 4,872

Fuel 1,468 1,543 (75) 5,839 6,007 (168) 6,398

Vehicle Insurance 504 519 (14) 2,067 2,073 (6) 1,546

Vehicle Leasing 193 140 52 633 560 73 755

Education & Training 179 679 (501) 2 1,513 1,686 (173) 1,809

Other 3,618 2,814 803 1 13,200 11,094 2,106 1 13,936

Total Operating Expenses 53,802 53,218 584 214,771 212,539 2,232 215,423

EBITDA (3,268) (3,348) 80 (13,509) (14,219) 710 (14,016)

Profit/Loss on Asset Disposal - - - - - - 77

Depreciation 2,689 2,691 (2) 11,057 11,198 (142) 10,150

Impairments - - - 300 300 - 1,974

Total Operating (Surplus)/Deficit (579) (657) 79 (2,153) (2,721) 568 (1,816)

Total Interest Receivable (22) (18) (4) (87) (65) (22) (95)

Total Interest Payable 29 31 (3) 114 126 (12) 124

PDC Dividend 462 494 (32) 2,025 2,060 (35) 1,627

Net (Surplus)/Deficit (110) (150) 40 (100) (600) 500 (159)

Comments:1 Use of third parties to offset vacancies

2 Timing of expenditure against plan

Year to Date Forecast

South Western Ambulance Service NHS Foundation Trust Appendix Gii

31-Mar-15

Statement of Financial Position Actual Actual Budget Variance Actual Budget Variance

Period Ending 30/06/2015

Month 3

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Non-Current Assets

Property, Plant & Equipment & Intangible Assets, Net 83,371 84,580 84,552 28 87,215 87,163 52

Trade & Other Receivables Non-Current 397 421 391 30 259 373 (114) -

Total Non-Current Assets 83,768 85,001 84,943 58 87,474 87,536 (62)

Current Assets -

Inventories 2,207 2,149 2,030 119 2,280 2,280 -

NHS Trade Receivables, Current 1,162 2,197 825 1,372 1,200 1,200 -

Non NHS Trade Receivables, Current 596 653 350 303 475 475 -

Other Receivables, Current 758 509 593 (84) 526 610 (84)

Prepayments, Current, Non-PFI related 2,309 3,909 2,520 1,389 1 2,095 2,085 10

Other Financial Assets, Current 154 1,783 864 919 69 69 -

Cash and Cash Equivalents 34,062 29,865 30,483 (618) 26,009 26,040 (31) -

Current Assets 41,248 41,065 37,665 3,400 32,654 32,759 (105)

Non Current Assets Held for Sale - - - - -

Total Current Assets 41,248 41,065 37,665 3,400 32,654 32,759 (105)

TOTAL ASSETS 125,016 126,066 122,608 3,458 120,128 120,295 (167)

Current Liabilities -

Deferred Income (398) (2,693) (1,077) (1,616) (75) (75) -

NHS Trade Payables (272) (92) (260) 168 (250) (250) -

Non-NHS Trade Payables (3,378) (2,788) (2,250) (538) (3,100) (3,100) -

Capital Accruals (2,996) (3,684) (3,535) (149) 250 (717) 967

Other Liabilities (5,264) (5,173) (5,270) 97 (5,750) (5,100) (650)

Borrowings (497) (497) (496) (1) (481) (481) -

Other Financial Liabilities (10,763) (9,773) (8,257) (1,516) 2 (9,296) (9,233) (63)

PDC Dividend Payable, Current - (363) (494) 131 - - -

Provisions for Liabilities and Charges (7,265) (7,033) (6,975) (58) (6,684) (6,705) 21 - -

Total Current Liabilities (30,833) (32,096) (28,614) (3,482) (25,386) (25,661) 275

Net Current Assets/(Liabilities) 10,415 8,969 9,051 (82) 7,268 7,098 170

TOTAL ASSETS LESS CURRENT LIABILITIES 94,183 93,970 93,994 (24) 94,742 94,634 108

Non-Current Liabilities -

Finance Leases, Non-Current (604) (605) (604) (1) (605) (604) (1)

Long Term Borrowings (2,218) (2,218) (2,217) (1) (1,746) (1,745) (1)

Other Financial Liabilities, Non-Current (228) (100) (90) (10) - - -

Provisions, Non-Current (4,216) (4,020) (4,016) (4) (4,274) (4,168) (106)

Trade and Other Payables, Non-Current - - - - - - - -

Total Non-Current Liabilities (7,266) (6,943) (6,927) (16) (6,625) (6,517) (108)

TOTAL ASSETS EMPLOYED 86,917 87,027 87,067 (40) 88,117 88,117 -

Represented By

Public Dividend Capital 43,025 43,025 43,025 - 43,025 43,025 -

Income & Expenditure Account 35,771 35,969 36,008 (39) 36,720 36,719 1

Revaluation Reserve 8,121 8,033 8,034 (1) 8,372 8,373 (1)

TOTAL TAXPAYERS EQUITY 86,917 87,027 87,067 (40) 88,117 88,117 -

Comments:

1 Prepayments above plan due to profile of insurance payments compared to plan

2 Profile of accruals against plan

Year to Date Forecast

Appendix Giii

Month End 30/06/2015 Period 3

2014/15

Annual CIP Target 7,899

Total CIP Identified 7,899

Total Savings Delivered YTD 1,975 8.33%

CIP Target YTD 1,975

Ref CIP Description

Identified

Annual

Saving

Savings

Delivered

YTD

Target

Savings

YTD

YTD

Variance

Forecast

Outturn

Annual

Target

Forecast

Variance

RAG

RatingComments

1 A&E Modernisation 3,600 900 900 0 3,600 3,600 0 GREEN

2 UCS Modernisation 937 234 234 0 937 937 0 GREEN

3 Staff Turnover 1,400 350 350 0 1,400 1,400 0 GREEN

4 Non Pay Expenditure Review 1,000 250 250 0 1,000 1,000 0 GREEN

5 Fuel Cost Reduction Action Plan 750 188 188 0 750 750 0 GREEN

6 Dividend 212 53 53 0 212 212 0 GREEN

Total 7,899 1,975 1,975 0 7,899 7,899 0

South Western Ambulance Service NHS Foundation Trust

Overall CIP 2014/15 Summary Dashboard

Trust Board of Directors Meeting 30 July 2015

Page 1 of 1

Trust Board of Directors’ Meeting 30 July 2015

Title: Board Assurance Framework update

Prepared by: Marty McAuley, Trust Secretary Vanessa Williams, Head of Risk and Patient Safety

Presented by: Jenny Winslade, Executive Director of Nursing and Governance

Main aim: To provide the Board of Directors with the updated Risk Register, Board Assurance Framework and Compliance Map

Recommendations: The Board of Directors is requested to take assurance from the Risk Register, Board Assurance Framework and Compliance Map

Previous Forum: None


Board Assurance Framework BAF05-14 Directorate

Business Plans

Implications (including Statutory

or Legal References) Department of Health Guidance

Confidential

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Proximity RiskL = Long term (3 years - 5 years)M = Medium term (1 year - 3 years)S = Short term (less than 1 year)O = Ongoing risks

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X X X

Potential reduced resource levels within A&E service line at times of peak demand.

Directors Group to consider whether, based on current level of resources, that risk score increases to 4x5 and risk transferred to the Director of Operations as relates to resource availability.

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SERIOUS(4)

LIKELY(4)

16 ●Centralisation of the Resource Operations Centre (ROC) and GRS implemented across Trust;●Workforce plan;●Weekly Resource Management Group (RMG) conference calls;●Workforce Planning Establishment Group (WPEG) in place to review workforce forecasting, plans and actions;●Provision of staff by third parties, agencies, bank and overtime;●Deployment of clinically qualified managers to frontline duties,as required;•Management reports provided to CPR, Directors Group and Quality and Governance Committee;•Absence Management Training being delivered as part of Leadership and Management development programme;● Sickness Plan rolled out to all managers and operational officers;●University Liaison Officer appointed to actively recruit students;●National recruitment marketing campaign;●Revised handover delay reporting procedure and SOP agreed with Commissioners and implemented;●Proposal agreed for additional conversion from ECA to Paramedic;●REAP escalation plan in place;●Recruitment Plan in place;●As at 2 June 2015, 78% of annual leave had been booked within Ops;•Dispatch on Disposition.•New assessment tool for 999 Call Advisors to improve quality of selection which should have a positive impact on retention.

V.SERIOUS (5)

POSS (3) 15 ●Payment of relocation incentives;●Additional bank staff being appointed;•Implement actions contained within Staff Survey Action Plan (EW);●Rolling programme for OU students;●Trust agreed replacement for OU course with UWE;●Ongoing dialogue with Commissioners regarding handover delays being led by CSU;●Health and Wellbeing business case being written by Safeguarding lead;●International recruitment programme - recruitment of 20 additional Czech paramedics;●Common CAD to enable resources to be moved around to meet demand (Oct2015);●Payment of incentivised shifts;●Consideration of increased payments for bank staff;●Recruitment plan in place to achieve Corporate establishment by October 2015 (East and West divisions);●PR firm appointed to market the Trust as an employer;•Increased use of private ambulance services for 999 calls;•Increase use of Dispatch on Disposition (Phase 2) (Sept 2015).

Sep-15 V. SERIOUS (5)

POSS (3) 15 S CO1, CO2, CO3, CO4

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(111

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X X X

Potential failure to meet performance against national benchmarking for call answering (95% within 60 seconds) could result in call abandonment, affecting service quality, patient safety and experience, reputation, contractual non-compliance and have financial implications.

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SERIOUS (4) POSS (3) 12 •Daily telephony performance reports;•Ongoing recruitment and training of Call Taking staff and Clinical Supervisors;•Weekly Call Taker performance reports;●Quality Development Plan, trajectory and monthly meetings;●Automated Caller Dispatch Queues (ACDQ) implemented in both 111 hubs;●Development of Performance Management Framework for call answering;●Executive and management leadership strengthened;●Review of staff profiling complete;●Recruitment campaign targetted at specific demographics;●Review and analysis of data to inform modelling and activity profiles;●Introduction of Integrated Voice Response (IVR);●Introduction of Non-Pathways Agents (NPA);●Performance Recovery Plan in place;●Review of source of activity, specifically inappropriate callbacks and abandonments;●Provision of management information;●Increased audit capacity;●Review of clinical delivery model complete.

SERIOUS(4)

ALMOST CERTAIN

(5)

20 •Weekly monitoring of performance;●Review of core cover and staff absence;●Implement actions within Performance Recovery Plan;●Ongoing work with key stakeholders, specifically looking at patient pathways;●Additional resources to meet anticipated uplifts in demand;●Ongoing recruitment to funded establishment;●Performance management of all staff through productivity metrics;●Further development of IVR;●Review framework for providing feedback to staff on call taking;•Staff engagement plan;•Separation of Dorset from Devon and Cornwall services;•Devon and Cornwall 111 review with Commissioners;•Dorset 111 Service Business Plan.

Mar-16 SERIOUS(4)

LIKELY (4) 16 S CO1, CO2, CO3, CO4

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X X X

The potential for not achieving and sustaining A19 target which could impact on patient safety, staff experience, financials and Monitor's Risk Assessment Framework.

New draft risk (split out from joint performance target risk)

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SERIOUS (4) LIKELY (4) 16 • A&E service line operating plan approved and monitored at A&E service line • Annual Accountability Agreement monitored quarterly• Effective capital programme in place for vehicles and equipment • Trust workforce strategy focused on frontline staff•Effective and fully staffed Clinical Hub with rolling recruitment programme;●Implementation of Enhanced Pre Hospital Care within Clinical Hubs;●Developments identified within MAVIS implemented;● Trust wide hospital handover SOP agreed with Commissioners;●Modelling A19 performance and demand and use of agency paramedics and private ambulance services to address establishment levels;●Dispatch on Disposition;•Daily monitoring of A19 performance;•'Measures to Improve' Plan.

SERIOUS(4)

ALMOST CERTAIN

(5)

20 • Ongoing internal monitoring and improvement;•Implementation of A&E Business Programme;●Assess impact of Dispatch on Disposition;●National review of REAP;●ImplementaCon of A&E Operating Plan;•Re-modelling on A19;•Confirmation of national AQI guidance notes to AACE (August 2015);•Development of A19 improvement plan;•Dispatch on Disposition Phase 2 agreed for September 2015;•Sustained focus on Red 2 which will have positive impact on A19.

Mar-16 SERIOUS(4)

LIKELY (4) 16 M CO1, CO2, CO3, CO4

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8C ↑

Confidential

Corporate Strategic Risk Register equal to or greater than 15

22 July 2015 (18 significant risks )Key: Text highlighted blue indicates the changes that have been made to the Risk Register since it was last presented to the Board of Directors.

MEAP = Mitigation Escalatory Action Plan

Confidential


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Potential loss of contracts for UCS may result in:• Loss of synergy between service lines and patient pathways;• Strengthened position of competitors;• Opens the Trust to competition for other service lines;• Poor staff morale;●Additional financial pressure.

Note: Trust has given notice on two 111 contracts - extended until Sept 2016 (+ 6 months option).

Risk to be transferred to Directors RR following presentation of Corporate RR to Board.

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V.SERIOUS (5) POSS (3) 15 • Effective performance management system in place;• Regular performance meetings with Commissioners;●Commercial principles in place;• TUPE applicable for directly employed staff;• Local performance targets have been negotiated with Commissioners;•Gloucester OOH Service mobilised;•Urgent Care MEAP developed;•FIC review tender financials for any service line;●Trust attends Urgent Care Review Boards;●Business Development Manager appointed and tender lead identified;●Director of Urgent Care and senior leadership team fully engaged;•Signed contracts until 2018 for Dorset and Glos OOH services and Dorset 111.

SERIOUS(4)

POSS (3) 12 •Action Plan in place to deliver performance targets;• Contract discussions ongoing between UCS Service Line, Finance and Commissioners;•Implementation of revised performance management system;●Review of non medical clinical workforce;●Review of UCS structure;●Consideration of integration opportunities.

Mar-16 SERIOUS(4)

POSS (3) 12 M CO3, CO4

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The potential national increase in bandings for Paramedics from 5 to 6 could create a significant financial cost to the Trust.

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V.SERIOUS (5) LIKELY (4) 20 The Trust's Chief Executive is working on this nationally with the Association of Ambulance Chief Executives.

V.SERIOUS (5)

LIKELY (4) 20 ●Awaiting outcome of national discussions. Residual risk scoring remains the same until further clarification is received;●Element of national pay review negotiations;•Sub group of National Staff Council due to make recommendations in November 2015;•PEEP recommendations on BSc suggests implementation from 2021/22.

Mar-16 V. SERIOUS (5)


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Potential failure to deliver in year and outstanding Statutory and Mandatory Education to all relevant staff as a result of REAP levels, activities and vacancies.

Directors Group to consider whether forecast risk score should be increased to 4x4 in light of recent decision ref Q2 SME

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men

t

SERIOUS(4)

LIKELY(4)

16 ●Extended training day;●Trajectory in place with monthly reporting to the Directors Group;●Included within Annual Accountability Agreement and monthly progress reported through Performance Management Framework;●Divisional REAP levels;●Weekly monitoring by the Resource Management Group (RMG);●Training exception reports presented to Quality and Governance Committee;●Overtime provided to assist in completion of training;●Training plan for 2015/16 approved by Directors Group;●Mandatory training workbook issued to all staff for completion within 6 months;●New Learning Development Officer structure implemented;•SME courses being run on overtime in Q1 with a review in Q2;•Placement educators in place.

SERIOUS(4)

ALMOST CERTAIN

(5)

20 ●Director of Operations and Head of Education developing plan to address outstanding training (10 days to take place in 2015/16 to address SME from 2014/15) and future training moving forward;●Review of OOH, 111 and SPoA structures;●Business case for dedicated training positions within Hubs being developed;●Review of ECS training for 2015/16;•All staff to be provided with 2 hours overtime to complete workbooks and 2 hours overtime to complete e-learning;•Trust paying for Bank staff to attend SME training;•Agreement in place for every member of frontline staff to have an 'on the road' assessment during 2015/16.

Mar-16 SERIOUS(4)


Exe

cutiv

e D

irect

or o

f HR

and

Gov

erna

nce

20/0

9/20

13

HR

816

↔

Maj

or IT

Ser

vice

Fai

lure

X X

Major ICT service failure of clinical hub and/or radio and mobile data may lead to potential business continuity risk in A&E, UCS or PTS.

Exe

cutiv

e D

irect

or o

f IM

&T

SERIOUS(4)

POSS (3) 12 ●ICT Strategy action plans in place to deliver agreed business continuity arrangements;●Card System and manual practices defined and in place to support loss of computer systems;●Uninterrupted Power Systems and Generators in situ covering critical ICT Services within clinical hubs;• Fallback plans cover Minor, Major and Critical faults;● BCM Strategy and outline plan agreed;• Virtual CAD implemented and tested (East and West Hubs);• Test of East Hub fall back arrangement;●Production and implementation of timely ICT business continuity plans;•Clinical Hub business continuity lead;•IT on call rota;●Generator testing has taken place in East and West Hubs;●North Clinical Hub Duty Managers trained in new Fall Back arrangements;●North Hub exercise took place in March 2014 - no issues raised;●New C3 contract signed;●PTS Fall back tested;●Ongoing support in relation to Estates development and employee IT infrastructure.

SERIOUS(4)

ALMOST CERTAIN

(5)

20 ● Staff to be trained and plans tested (Sept 2015, FG);• Deliver IG Toolkit plan for 2015/16 (March 2016, FG);• Deliver IT work programme for 2015/16 (March 2016, FG);•Review of core network underway in HQ including links to Acuma House (Sept 2015, FG);•Quality meeCngs with 'gold' suppliers to be scheduled (June 2015, FG),●CAD Implementation (September 2015);●Clinical Hub review with dedicated project manager;●Implementation of actions arising from serious incident investigation relating to IT failures;●Hub rationalisation;●Clinical Hub fallback Business Continuity Plan in final development before approval;●East and West Hub Duty Managers to receive training on fallback arrangements;●Generator testing programme to be developed for North Division.

March 2016

SERIOUS(5)

POSS (3) 12 L CO1, CO2, CO3, CO4

Exe

cutiv

e D

irect

or o

f IM

&T

12/0

2/20

07

ICT

199

↔

Ope

ratio

nal R

esou

rces

(UC

S)

X X X

Potential reduced resource levels within UCS service line at times of peak demand.

Exe

cutiv

e D

irect

or o

f HR

and

Org

anis

atio

nal

deve

lopm

ent

SERIOUS(4)

LIKELY(4)

16 ●Centralisation of the Resource Operations Centre (ROC) and GRS implemented across Trust;●Workforce plan;●Provision of staff by third parties, agencies, bank and overtime;●Recruitment tracker in place for 111 staff which is meeting the trajectory;•Management reports provided to CPR, Directors Group and Quality and Governance Committee;•Absence Management Training being delivered as part of Leadership and Management development programme;● Sickness Plan rolled out to all managers and operational officers;●Recruitment Plan in place;•New assessment tool for 111 Call Advisors to improve quality of selection which should have a positive impact on retention (June 2015).

V.SERIOUS (5)

LIKELY (4) 20 •Implement actions contained within Staff Survey Action Plan (EW);●Ongoing dialogue with Commissioners regarding handover delays being led by CSU;●Health and Wellbeing business case being written by Safeguarding lead;●GP engagement programme;●Advanced Nurse Practitioner development;●Rota review with 111 staff;●Implementation of incentivised shifts;•Negotiation of contract for 111.

Nov-15 V. SERIOUS (5)


Exe

cutiv

e D

irect

or o

f HR

and

Gov

erna

nce

20/0

9/20

13

HR

815

(B)

↔

Perf

orm

ance

Tar

gets

Red

2

X X X

The potential for not achieving and sustaining Red 2 target which could impact on patient safety, staff experience, financials and Monitor's Risk Assessment Framework.

New draft risk (split out from joint performance target risk)

Chi

ef E

xecu

tive

SERIOUS (4) LIKELY (4) 16 •Robust business plan and corporate objectives monitored by Directors Group;•Effective and fully staffed Clinical Hub with rolling recruitment programme;●Implementation of Early Exit procedure within Clinical Hubs;●Standard Operational Procedure regarding deployment of Responding Officers in place since January 2014;●Individual OM trajectories developed, disseminated and monitored;●Implementation of Enhanced Pre Hospital Care within Clinical Hubs;●Roll out of Public Automatic Defibrillators;●Roll out of Airwave Responder Pagers;●Developments identified within MAVIS implemented;●Trust wide hospital handover SOP agreed with Commissioners;●Use of agency paramedics and private ambulance services to address establishment levels;●Dispatch on Disposition;•Measures to Improve plan in place to recover performance to 70% by end of Q2;•Appointment of Joint Liaison post with St Johns Ambulance regarding events management;

SERIOUS(4)

LIKELY (4) 16 • Ongoing internal monitoring and improvement;•Implementation of A&E Operating Plan;●Implementation of divisional Operational Implementation Plans;●National review of performance targets by research organisation;●Assess impact of Dispatch on Disposition;●National review of REAP;●ImplementaCon of A&E Operating Plan;•Review of demand management with CCGs ;•Measures to Improve Performance Plan (Q2);•Weekly and daily cross directorate performance meetings.

Mar-16 SERIOUS(4)

POSS (3) 12 M CO1, CO2, CO3, CO4

Qua

lity

Ris

k W

atch

11.0

5.20

15

D78

8B ↑

Confidential


Ris

k Ti

tle

Qua

lity

Ris

k

Perf

orm

ance

Ris

k

Fina

ncia

ls R

isk

Risk Description

Acc

ount

able

Dire

ctor

Orig

inal

Con

sequ

ence

Sc

ore

Orig

inal

Lik

elih

ood

Scor

e

Orig

inal

Ris

k R

atin

g

Controls in Place

Cur

rent

Con

sequ

ence

Sc

ore

Cur

rent

Lik

elih

ood

Scor

e

Cur

rent

Ris

k R

atin

g

Action Summary

Act

ion

Dea

dlin

e

Fore

cast

Con

sequ

ence

(p

ost a

ctio

ns)

Fore

cast

Lik

elih

ood

(pos

t act

ions

)

Fore

cast

risk

ratin

g (p

ost a

ctio

ns)

Prox

imity

Ris

k

Cor

pora

te O

bjec

tives

Ris

k So

urce

Dat

e ad

ded

to re

gist

er

Ref

Ris

k R

atin

g M

ovem

ent

(sin

ce la

st u

pdat

e)

Incr

ease

in A

ctiv

ity

X X X

Changes in daily and hourly spread of demand within all service lines impacting on ability to respond, funding, patient care and experience, performance and staff experience.

Chi

ef E

xecu

tive

SERIOUS (4) POSS (3) 12 •Use of rolling average for activity commissioning;•Activity reports sent to Commissioners on a monthly basis;•Daily monitoring of activity growth and impact of NHS 111 on A&E;•Signed contracts which have activity growth embedded within the terms;●Implementation of handover SOP.•Revised Demand Management Plan for Clinical Hub implemented;•Escalatory Management Plan reviewed and updated;•Independent review of performance activity;●Provision of staff by third parties, agencies, bank and overtime;●111 Quality Development Plan;●Ongoing work with stakeholders and other providers of services;●Revised Interhospital Transfer Procedure implemented;●Annual demand review within contract;●Right Care 2;●'Choose well' campaign;●Introduction of additional Clinical Supervisors within Hubs;●111/999 Liaison Group in place;●Trust position on activity for 2015/16 provided to Commissioners;•Continuation of ECP trial in Cornwall;•Commissioners agreed demand management plan.

SERIOUS(4)

LIKELY (4) 16 •Performance to be monitored through contract meetings;●Review of performance activity against demand;●Review activity profiles;●Review source of activity, specifically inappropriate callbacks and abandonments;●Review of data to inform modelling;●Additional resources to meet anticipated uplifts in demand including agency and private providers;●National review of REAP;●Continuation of Dispatch on Disposition - phase 2 (Sept 2015);●Review impact of S.136;●Continue to work with 111 providers;•Review of demand management with CCGs;•Use of private and agency resources utilised at peak times;•Review of status plan management;•Revised standby procedure to be implemented within North division;•Negotiation of 2016/17 contract.

Mar-16 SERIOUS(4)

LIKELY (4) 16 M CO1, CO2, CO3, CO4

Stra

tegi

c Fo

rwar

d P

lann

ing

Ris

k R

egis

ter

24 S

ept 2

012

F786 ↔

Cor

pora

te F

inan

cial

s

X

Adverse financial variances within Urgent Care Service line impacting on the overall financial position of the Trust. Variance due to a mixture of non-recurrent issues relating to the re-profiling of resources to activity and the slippage in the delivery of cost improvement schemes.

Exe

cutiv

e D

irect

or o

f Nur

sing

and

G

over

nanc

e

SERIOUS (4) LIKELY (4) 16 ●Stabilisation of 111 performance;●Robust management of abstractions;●Ongoing budget monitoring;●UCC contract signed;•Staff engagement plan in place;●Financial controls in place;•Recovery plans in place for 111;● 2015/16 budget setting finalised.

SERIOUS(4)

LIKELY (4) 16 ●Implementation of rota changes;●Review of services provided by SPoA;●Further work to be conducted on OOH rotas;●Review of penalty arrangements;●Review of cost per call;●Deliver revised Performance Recovery action plan;●Review of UCS structure including management structure;•Reconciliation of GRS, ESR and local rotas;•Gloucestershire OOH weekly performance review.

Mar-16 SERIOUS(4)


Dire

ctor

s G

roup

18 J

uly

2014

N85

0

↔

Empl

oym

ent L

egis

latio

n Li

tigat

ion

X

Litigation claims of unfair dismissal, discrimination or breach of contract as a result of dismissal or redeployment could :● have financial implications;• affect organisational reputation;• have significant resource implications for senior management and HR resources to respond to litigation claims, grievances and staff complaints.

Risk to be transferred to Directors Risk Register

Exe

cutiv

e D

irect

or o

f HR

and

O

rgan

isat

iona

l dev

elop

men

t

MOD (3) LIKELY (4) 12 • Organisational change policy;• Compliant with employment law and good practice;• Ongoing and regular review of employment policies to ensure employment law changes are reflected;• Grievance process is transparent and appropriate to seniority of management in Trust structure to board level;• ET training delivered to senior managers and ongoing change management support and advice from HR. • Deputy Director of HR overseeing all employment litigation cases;• Legal advice and TUPE training provided to senior managers;●Following an ET case, lessons learned are strengthened via feedback through the management structure.

MOD (3) LIKELY (4) 12 • Priority of resources reviewed quarterly (Ongoing, AH);• Escalate risks as appropriate (Ongoing, AH);• Management of change programme/development of career support processes;●Legal services review underway.

Mar-16 MOD (3) LIKELY (4) 12 M CO3, CO4

HR

Ris

k R

egis

ter

H54

2

↓

Aud

it C

ompl

ianc

e

X

Failure to meet call taking audit compliance could have the potential to compromise patient safety and the requirements of software licences.

Exe

cutiv

e D

irect

or o

f Nur

sing

an

d G

over

nanc

e

SERIOUS (4) LIKELY (4) 16 ●Executive leadership and management strengthened;●Board approved Quality Development Plan;●Interim additional CQI team in place (on temporary basis);●Model of CQI revised utilising Senior Call Advisors to undertaken 500 audits per month within 111.

SERIOUS(4)

LIKELY (4) 16 ●Review of Audit process underway including structure, frequency and performance management;●Review of UCS structure underway;●Review of Clinical Hub structure;● NHS Pathways review implementation;●Business case submitted;●A&E Business Plan;•Feedback to staff in place.

March 2016

SERIOUS(4)

LIKELY (4) 16 S CO1, CO2, CO3, CO4

Ris

k W

atch

04/0

6/20

14

N85

1

↔

Impa

ct o

f REA

P Le

vels

, and

Sum

mer

, W

inte

r and

Pea

k pr

essu

res

X X X

Increased REAP levels as a result of a threat to national performance indicators leading to:-•over activity against contract ; •slippage to training programme deliveries and other workstreams, including cancellation of priority meetings dependent on REAP levels, winter pressures and weather;•increased demand on three core services;•impact on delivery of business plans;•impact on resilience within the Trust.

Trust currently at REAP 4Directors Group agreed to update risk score as a result of REAP level movement

Chi

ef E

xecu

tive

SERIOUS(4)

LIKELY (4) 16 • Effective escalatory process with clear command and control process in place;• Performance management arrangements in place to monitor achievement of objectives;• Business Continuity arrangements and processes in place;• Weekly review of performance including assessment of REAP level by DIrector of Operations;•Demand Management Plan for Clinical Hub;•Updated escalatory management plan;•New REAP monitoring introduced for NHS 111 service provided by the Trust;•Revised REAP escalation plan implemented with divisional REAP levels;•Measures to Improve Performance plan.

SERIOUS(4)

LIKELY (4) 16 • Ongoing discussions with Commissioners at C&P meetings to review activity and demand profile in each CCG area and agree actions to mitigate increase in demand including the review of alternative pathways;• Executive Gold meetings convened as required (Ongoing, KW);●Emergency Planning Recovery Resilience Group reviewing REAP levels;●Dispatch on disposition continuing (Phase 2);●National review of REAP going to NDOG in Q2;•Meeting with all Strategic Resilience Groups to establish working arrangements and escalation plans.

Mar-16 SERIOUS(4)

UNLIKELY (2) 8 L CO1, CO2,

CO3, CO4

Ris

k R

egis

ter R

evie

w D

ay 2

007

22/0

2/20

07

EP

218

↔

Confidential


Ris

k Ti

tle

Qua

lity

Ris

k

Perf

orm

ance

Ris

k

Fina

ncia

ls R

isk

Risk Description

Acc

ount

able

Dire

ctor

Orig

inal

Con

sequ

ence

Sc

ore

Orig

inal

Lik

elih

ood

Scor

e

Orig

inal

Ris

k R

atin

g

Controls in Place

Cur

rent

Con

sequ

ence

Sc

ore

Cur

rent

Lik

elih

ood

Scor

e

Cur

rent

Ris

k R

atin

g

Action Summary

Act

ion

Dea

dlin

e

Fore

cast

Con

sequ

ence

(p

ost a

ctio

ns)

Fore

cast

Lik

elih

ood

(pos

t act

ions

)

Fore

cast

risk

ratin

g (p

ost a

ctio

ns)

Prox

imity

Ris

k

Cor

pora

te O

bjec

tives

Ris

k So

urce

Dat

e ad

ded

to re

gist

er

Ref

Ris

k R

atin

g M

ovem

ent

(sin

ce la

st u

pdat

e)

Perf

orm

ance

Tar

gets

Red

1

X X X

The potential for not achieving and sustaining the Red 1 target which could impact on patient safety, staff experience, financials, Monitor's Risk Assessment Framework and the Quality Premium Payment.

Chi

ef E

xecu

tive

V.SERIOUS (5) POSS (3) 15 •Robust business plan and corporate objectives monitored by Directors Group;•Effective and fully staffed Clinical Hub with rolling recruitment programme;•Implementation of Trust wide REAP levels;●Implementation of Early Exit procedure within Clinical Hubs;●Standard Operational Procedure regarding deployment of Responding Officers in place since January 2014;●Clinical Floor walkers within 111 to prevent inappropriate Red 1 dispositions;●Implementation of Enhanced Pre Hospital Care within Clinical Hubs;●Roll out of Public Automatic Defibrillators;•Development of divisional Operational Implementation Plans;●Roll out of Airwave Responder Pagers;●Developments identified within MAVIS implemented;●Red 1 performance trajectory agreed with each CCG;● Trust wide hospital handover SOP agreed with Commissioners;●Use of agency paramedics and private ambulance services to address establishment levels;●Dispatch on Disposition;•Daily review of Red 1 'misses';•Trust achieving Red 1 (77% as at 1 June 2015).

V. SERIOUS (5)

POSS (3) 15 • Ongoing internal monitoring and improvement;•Implementation of A&E Business Programme;●National review of performance targets by research organisation;●Assess impact of Dispatch on Disposition;●National review of REAP;●ImplementaCon of A&E Operating Plan.


UNLIKELY (2) 10 M CO1, CO2,

CO3, CO4

Dire

ctor

s G

roup

27/1

1/20

12

D78

8

↓

Han

dove

r Del

ays

at H

ospi

tal -

Impa

ct o

n Pa

tient

Sa

fety

and

Res

ourc

es

X X

Increasing number of handover delays in acute hospital trusts potentially resulting in delays in attending patients who require emergency and urgent assessment, treatment and/or conveyance affecting clinical care and patient safety. In addition the handover delays impact on the ability to provide a timely conveying resource to patients assessed by a clinician as requiring conveyance to hospital affecting patient safety and experience and staff morale.

Chi

ef E

xecu

tive

V.SERIOUS (5) ALMOST CERTAIN (5)

25 •Provision of Bronze Commander to ED;•Joint working between Trust and acute trusts to resolve issue through local action plans between OMs and Commissioners;• Clinical Notice issued to ensure that observations and continuity of clinical care continues whilst patients are waiting in handover area;•Clinical Supervisor call-back to manage risk of delayed responses;•Implementation of delayed handover SOP to introduce 30 minute handover (incorporated within Contracts) when there is a risk to patient safety;•REAP in place with recent review (Dec 2014);•24/7 Logistics Cell in place to escalate handover delays as appropriate;●Strategically deployed trolleys placed in acute hospitals to improve turnaround times;●Triggers for implementation of delayed handover SOP reviewed;●Issue highlighted to CSU by Director of Operations;●Trust wide hospital handover SOP agreed with Commissioners;●Automatic implementation of handover SOP when Trust is at REAP 4;•Reviewing handover delays with individual CCGs;•Monthly contract Boards discuss handover delays and take appropriate action.

V. SERIOUS (5)

POSS (3) 15 ●Continue to monitor situation and submit adverse incident reports for each handover delay of more than 90 minutes;•Review of handover procedure with Commissioners;•OMs liaising with acute hospital trusts;●Contract discussions;●Mid year review of handover delays in accordance with contract clause;●Trust monitoring impact of implementation of ECS on handover times;•Introduction of NEWS scoring system;Demand Management Plan agreed with Commissioners in reduction of handover delays.

Sep-15 V. SERIOUS (5)

POSS (3) 15 M CO1, CO2, CO4

Ris

k A

sses

smen

t

11 A

pril

2013

D80

5

↔

Clin

ical

Hub

Rat

iona

lisat

ion

X X

Implementation of new CAD and triage system and estates project with changes to each element could impact on short term quality and performance.

Exe

cutiv

e D

irect

or o

f IM

&T

SERIOUS (4) POSS (3) 12 ●Project Group●Programme Board includes attendance from Estates Programme Manager;●Weekly meetings with Clinical Hub managers;●Programme workbook monitored by Programme Board;●Dedicated project team in place;●Trust has previous experienced of transferring to new triage systems;●Communications Strategy developed;●Head of Terms agreed for new North hub premises;

V.SERIOUS (5)

POSS (3) 15 ●Ongoing monitoring by Project team;●Ongoing positive liaison with CAD supplier●Escalate issues through the Programe Board;●Testing to take place locally to enable quick installation and reduce testing at new estate (July 2016);●Clinical Hub layout to be agreed (October 2015);●Information on handover and arrival screens being disseminated internally and externally (September 2015);●Implementation of MIS training (Sept 2015);●Implementation of Telephony Platform (July 2016);●Roll out of NHS Pathways in North division (March 2016).

Jul-16 V. SERIOUS (5)

UNLIKELY (2) 10 S C01, C02,

C04

Dep

uty

Dire

ctor

of F

inan

ce

5 D

ecem

ber 2

014

D87

5

↔

Wor

kfor

ce

Inte

grat

ion

Issu

es

X

Outstanding A4C Appeals

Exe

cutiv

e D

irect

or o

f H

R a

nd O

rgan

isat

iona

l D

evel

opm

ent

V.SERIOUS (5) LIKELY (4) 20 •Appropriate legal representation in place. V. SERIOUS (5)

POSS (3) 15 •On-going liability review by solicitors and Trust. Mar-16 V. SERIOUS (5)

RARE (1) 5 M

CO4

Sta

ff G

rieva

nces

24.1

2.10

HR

47

↔

Cos

t Im

prov

emen

t Str

ateg

y

X X

Non achievement of the 5 year cost improvement strategy targets could result in:-• lack of investment in service infrastructure;• a trigger of downside scenarios;• compromised delivery of national targets;● non delivery of Financial Plan.

Dep

uty

Chi

ef E

xecu

tive/

Exe

cutiv

e D

irect

or

of F

inan

ce

V.SERIOUS (5) POSS (3) 15 •Strict controls on costs and monitoring of budgets;• Downside scenario planning identified in IBP;• 5 year strategy robustly detailed;• Established Governance framework in place;• Finance and Investment Committee monitor CIS at each meeting;• Implementation plans developed with clear accountability identified and implemented;• Recognition Agreement in place and ongoing dialogue with staffside;• Ongoing programme of station visits by Board members;• Trust Strategy Days;•Workforce Planning aligned to CIS programmes;●IBP updated and disseminated;•2 year and 5 year Monitor Plans in place (2014/15);•1 year Operational Plan in place (2015/16);•Budget setting for 2015/16 finalised.

V. SERIOUS (5)

POSS (3) 15 • In the event of downside instigate MEAP or CEAP;•Monitoring of implementation plans;•Undertake review of operational remodelling;• Review local OM budget savings (ongoing, NLC);●Delivery of enabling strategies;●Quality Impact Assessments to be signed off for each CIP;●Implementation of updated IBP;• Implementation of A&E Operating Plan being led by Director of Operations;●Budget setting for 2015/16 to be finalised;•Quarterly monitoring against 1 year Monitor Operational Plan.

Mar-16 SERIOUS(4)

POSS (3) 12 M CO1, CO2, CO3, CO4

Chi

ef E

xecu

tive

9 D

ecem

ber 2

010

F677 ↔

Confidential


Ris

k Ti

tle

Qua

lity

Ris

k

Perf

orm

ance

Ris

k

Fina

ncia

ls R

isk

Risk Description

Acc

ount

able

Dire

ctor

Orig

inal

Con

sequ

ence

Sc

ore

Orig

inal

Lik

elih

ood

Scor

e

Orig

inal

Ris

k R

atin

g

Controls in Place

Cur

rent

Con

sequ

ence

Sc

ore

Cur

rent

Lik

elih

ood

Scor

e

Cur

rent

Ris

k R

atin

g

Action Summary

Act

ion

Dea

dlin

e

Fore

cast

Con

sequ

ence

(p

ost a

ctio

ns)

Fore

cast

Lik

elih

ood

(pos

t act

ions

)

Fore

cast

risk

ratin

g (p

ost a

ctio

ns)

Prox

imity

Ris

k

Cor

pora

te O

bjec

tives

Ris

k So

urce

Dat

e ad

ded

to re

gist

er

Ref

Ris

k R

atin

g M

ovem

ent

(sin

ce la

st u

pdat

e)

Terr

oris

t Act

ivity

X X X

Terrorist activity (including cyber threats) could affect delivery of Trust services and impact on its business continuity.

Potential for Trust resources to be utilised for terrorist activities

Current National Terrorist Threat Level is at SEVERE (an attack is highly likely)

Chi

ef E

xecu

tive

V.SERIOUS (5) POSS (3) 15 ●Major Incident Plan in place and reviewed annually;●Staff training in CBRNE;●Special Operations Response Teams (SORT) teams formed and trained;• Trust has a strong track record and experience of dealing with major incidents and events;• AACE national agreement on mutual aid;• Annual training exercise in programme;• Trust HART teams have received extensive training;• Trust Commander training for Bronze, Silver and Gold officers;•Members of Enhanced Ambulance Intervention Team Cadre have received training;• Implementation of National Ambulance Service Command and Control guidance;•REAP escalation process;•Dedicated on call tactical advisors within Resilience team;•Implementation of Trust wide National Interagency Liaison Officers (Technical Advisors);●Engagement with other agencies through Local Resilience Forums;●PREVENT training delivered to trainers for roll out;●Introduction of Joint Emergency Services Interoperability Programme (JESIP);●Revision of Maraudering Terrorist Firearms Incidents training completed;●New Commander package developed following review of Commander Policy;•Exercise and planning for a potential IT related incident;●Delivery of JESIP training programme.

V. SERIOUS (5)

POSS (3) 15 • Implement recommendations arising from exercises and incidents (lessons learned) (ongoing, NLC);●Trust to review compliance with PREVENT requirements (JW);●Commander training to take place for newly appointed Operational Officers;●Recruitment of additional SORT and Ambulance Intervention Team (AIT) (NLC );●PREVENT workplan and training strategy to be developed by Safeguarding Lead;●Roll out of PREVENT training (March 2015 and ongoing);●Trust Resilience team leading on 2 National Counter Terrorism Exercises;●Initial Operations Response (IOR) - training of all operational staff in dry decontamination underway;●PREVENT included within SME training for 2015/16 and WRAP trainers identified;•Review of JESIP programme by HMIC (June 2015).


POSS (3) 15 O CO1, CO2, CO3, CO4

Ass

uran

ce F

ram

ewor

k

29/0

5/20

09

EP

004

↔

M = Medical DirectorateNG = Nursing and Governance DirectorateHR = Human Resources DirectorateD = Delivery DirectorateMC = Marketing and Communications DirectorateFP = Finance and Performance DirectorateCE = Chief Executive

R = ResilienceT = TrainingF = FinanceO = Operations

Key: Text highlighted blue indicates the changes that have been made to the risk register since it was last presented to any other forum.

Ris

k Ti

tle

Risk Description Controls in Place

Lack

of C

omm

issi

oner

Con

verg

ence

Commissioners support required to meet the financial and planning assumptions set out in the IBP and LTFM. Key elements of the risk are that:-• Activity growth is in excess of the base case scenario;• Activity growth is not funded;• Inflation is higher than base case scenario;• Negative tariff is higher than -2%.

●Active engagement at all levels between the Trust and its lead Commissioner in progressing Commissioner Convergence.● Consolidated action plan for FT●Eric Gatling's letter of 16 February 2010• Letter to Anthony Farnsworth dated 22/02/2010• Operational Plan update to Board 25/02/2010• Executive Officer review with Strategic Health Authority 23/02/2010• Operating Framework Meeting 01/03/2010•Board meeting 25/02/2010 to review decision•Board to Board with Strategic Health Authority took place 19/03/2010• Formal written confirmation of Commissioner Convergence received from Commissioners May 2010.

Corporate Risk Register equal to or greater than 15

Closed Risks

Dec

omm

issi

onin

g

The loss of contracts for PTS leaves the Trust with residual costs that need to be mitigated and could result in loss of reputation

•Regular meetings with Commissioners •Performance monitoring in place.• Corporate Performance Report• Department of Health letter states NHS to be preferred provider for a world class service• Transformational Steering Group leading on business plans

NH

S 11

1 Te

nder

Fina

ncia

l

Not winning the NHS 111 service may impact on:-• core services ;• other contracts;• finances.

Following tender announcement this risk is to be reviewed at next Quality Risk Watch meeting.

Acq

uisi

tion

/ M

erge

r Acc

ount

ing

Fina

nce

Impact and consequences of unplanned transactions arising from the necessary compliance of merger accounting rules that arise from the transaction between SWAST and GWAS

Risk reduced from 15 following feedback from SWASFT Deputy Finance Director. Transfer to Directors Risk Register.

Risk closed following feedback from Directors Group 08.01.2013

Staf

f Pro

filin

g

Saf

ety,

Ser

vice

Inte

rrup

tion,

RE

AP

Potential staff profiling issues within 111 Hub affecting performance delivery.

New draft risk.

Atte

ndan

ce, H

ealth

and

Wel

lbei

ng

High level of absence (particularly within some 111 areas) which may result in:-•resource implications;•health and wellbeing of staff being compromised;•impact on patient care and service delivery;•significant financial cost pressures.

Ada

stra

AB

Pla

tform

X X

Han

dove

r Del

ays

at H

ospi

tal -

Impa

ct o

n R

esou

rces

X X

NH

S 11

1 Im

pact

X X

Action Summary

Act

ion

Dea

dlin

e

Man

ager

Cor

pora

te

Obj

ectiv

es

Con

sequ

ence

(c

urre

nt)

Like

lihoo

d (c

urre

nt)

• Ongoing meetings with lead Commissioners• Development of high level cost benefit analysis for Commissioner investment•HDD Stage 2 to be completed in June 2010.

Jun-10

Dire

ctor

of F

inan

ce a

nd P

erfo

rman

ce a

nd D

eput

y C

hief

Exe

cutiv

e CO1, CO2, CO3, CO4

CAT(5)

LIKELY(4)


Closed Risks

•Service Modernisation Programme being developed.•Robust Tenders produced where required •Expert advice sought where required.

Mar-11

Dire

ctor

of F

inan

ce a

nd

Per

form

ance

and

Dep

uty

Chi

ef

Exe

cutiv

e

CO3, CO4

CAT(5)

POSS(3)

Act

ing

CE

O/E

xecu

tive

Dire

ctor

of

Fina

nce

and

Per

form

ance

V.SERIOUS (5)

POSS (3)

15 •Senior Project Manager in place;•Partnership agreement to put bid in with strong key players from Region;

SERIOUS(4)

Fina

nce

MOD (3) ALMOST CERTAI

N (5)

15 •Monitoring international accounting rules and guidance issued by DoH on how to account for the transaction between the two trusts.•Identification of this work stream through the integration planning

V. SERIOU

S (5)

Exe

cutiv

e D

irect

or o

f Nur

sing

SERIOUS (4)

ALMOST CERTAI

N (5)

20 ●Executive and management leadership strengthened;●Recruitment of additional staff;●Review of rotas.

SERIOUS(4)

Exe

cutiv

e D

irect

or o

f HR

SERIOUS (4)

POSS (3)

12 •Management reports provided to CPR, Directors Group and Quality and Governance Committee;•Occupational Health review and KPIs introduced;•Absence KPIs and scorecards;•Sickness Work

SERIOUS(4)

Potential delays to upgrade of Adastra AB Platform which could affect the delivery of SPOA and 111

Exe

cutiv

e D

irect

or o

f IM

&T

V.SERIOUS (5)

POSS (3)

15

X

Delays experienced by ambulance crews in handing over patients at acute trusts will result in an adverse impact on the resources available to respond to life threatening emergency calls

Chi

ef E

xecu

tive

V.SERIOUS (5)

LIKELY (4)

20

X

Impact of NHS 111 on A&E delivery as a result of working with a variety of providers and interfacing services, both in terms of growth in activity (anticipated to be between 10% - 20% increase) and also the ability of 111

Chi

ef E

xecu

tive

V.SERIOUS (5)

POSS (3)

15

Ris

k R

atin

g (m

itiga

ted)

Dire

ctor

ate

Func

tion

Ref

Dat

e C

lose

d

Clo

sed

By?

Rea

son

for

Clo

sure

20 FP F

FIN

179

13.0

5.20

10

Risk Watch

Letter received from Commissioners confirming Commissioner Convergence.


Closed Risks

15 10 FP F

Fina

nce

Dire

ctor

ate

Ris

k R

egis

ter

FIN

03

LIKELY(4) 16 •

Ongoing engagement with Commissioners;• Prepare for infrastructure and estates to be ready to

Jun-12 SERIOUS(4)

POSS (3) 12

UNLIKELY (2) 10 •Seek

advice from SWSHA to confirm method of accounting for this transaction.•Review accounting policies to assess impact on Trust financial position and impact on organisation to

Dec-12 SERIOUS(4)

RARE (1) 4

ALMOST CERTAI

N (5)

20 ●Implementation of rota review;●Appointment of additional part time staff.

SERIOUS(4)

POSS (3) 12

LIKELY (4) 16 October

2014SERIOUS

(4)UNLIKELY

(2) 8

●Dedicated 111 AB Platform Proposal;●111 Mobilisation Plans;●Adastra Revised Proposal for Joint AB;●Proposal approved at Deputy Directors Group;●Ongoing engagement with Provider;

MOD (3) POSS (3) 9 ●Complete

upgrade.Dec-14 V. SERIOUS (5)

●Internal and external reporting and monitoring systems developed and implemented;• New handover procedure agreed with Commissioners (SWASFT area);●Capacity Manage

V. SERIOU

S (5)

LIKELY (4) 20 ●Continue to

monitor situation and submit adverse incident reports for each handover delay of more than 90 minutes;•Trust working with Commissioners on patterns of admission for healthcare professionals calls;•Review of escalatory procedure for diverts;

Mar-15 SERIOUS(4)

•Robust Performance Framework for monitoring trends•Early escalation process to Commissioners and Providers;• 111/999 Liaison Group in place considering modelling arrangements;•

V. SERIOU

S(5)

POSS (3) 15 •Ongoing

negotiations with Commissioners as part of contracts for 2014/15;•Implementation of REAP as required;•Continue to work with 111 providers;•Review of Demand Management Plan to allow for re-triage of 111 calls at higher levels of demand;●Demand Activity Assessment in North Division;


↔Transferred from finance RR at Risk watch on 19/10/09 Detail from Finance Directorate - speak to Jon James

M CO1, CO2, CO3, CO4

Dire

ctor

of I

M&

T

27/0

1/20

12

IMT7

12 ↔

S

AO

19

DoH

22.1

0.12

F47

(GW

AS

T R

ef)

↓


Ris

k W

atch

4 Ju

ne 2

014

N84

8 new

merged with 111 performance risk - agreed by Directors Group July 2014


Dire

ctor

of H

R

22.0

9.20

11

HR

709

↔

Risk merged with Workforce Establishment Levels risk. As agreed by Directors Group 12 August 2014

POSS (3) 15 M CO1,

CO3

Dire

ctor

s G

roup

9 Ju

ly 2

014

ICT8

49 ↓

POSS (3) 12 L CO1,

CO2, CO4

AO 9

Chi

ef E

xecu

tive

31/0

1/20

07

OP

S 1

76

risk merged with

workforce establishmen

t risk (renamed Opera:onal resources)

POSS (3) 15 M CO1,

CO2

Dire

ctor

s G

roup

26/0

9/20

12

D78

9

↔

risk merged with F786 16.03.2014

Joint Board Assurance and Risk

Report

July 2015

Title of originator/author: Marty McAuley, Trust Secretary Vanessa Williams, Head of Patient Safety and Risk

Date issued: July 2015

1. Introduction

1.1 The purpose of the joint Risk and Board Assurance report is to enable the Board to have meaningful discussions about the management of key strategic risks that could impact upon the achievement of long term, strategic priorities. The report will continually evolve and will require regular review and update in order for its content, and the framing of strategic risks, to remain live.

1.2 This report is composed of three parts which taken together should enable the Board to take

assurance from the range of activities undertaken and the evidence provided. The three key parts are the:

Corporate Risk Register - The Trust’s Risk Management Strategy sets out the process for the

management of the risk registers. The Quality Risk Watch Group is responsible for reviewing the content of the risk registers, quality assuring and proposing changes to risks. This group last met on 7 July 2015. The Corporate Risk Register was presented to the Directors Group.

Board Assurance Framework - The BAF will provide a simple but comprehensive method for

the effective and focused management of the principle risks to meeting the strategic objectives of the Trust and provide a structure for the evidence to support the Annual Governance Statement. The highest rated risks from the Corporate Risk Register have been explored in more detail for the Board of Directors to be able to gain the assurance that they require that the risks are being effectively managed.

Compliance Log – Based on the principles of the old-style BAF, the compliance log is a

repository of evidence of the work of the key corporate committees and the Bard that can be used as an evidence source for the Board to take assurance from. It is mapped against the 5 key questions of the CQC.

2. Risk Register 2.1 The May 2015 Corporate Risk Register had 19 risks identified on it. The July 2015 Corporate

Risk Register has 20 risks identified on it. Within the Risk Register July 2015 there are a number of amendments to make the Board aware of.

Risk Change

Operational Resource Risk divided into two – one relating to A&E and one to UCS service line.

Operational Resources (A&E) Proposal for likelihood score to reduce to 3. Urgent Care Services Contract Proposal for likelihood score to reduce to 3 and risk

to transfer to the Directors Risk Register. Performance Targets A19 Proposal for likelihood score to increase to 5. Employment Legislation Litigation Proposal for Consequence score to reduce to 3.

This was based on the value of ET claims. Performance Targets Red 1 Proposal for likelihood score to reduce to 3 as Red 1

performance currently being met. Operational Resource Directors Group to consider whether, based on

current level of resources that risk score increases to 4x5 and risk transferred to the Director of Operations as relates to resource availability.

SME Training Directors Group to consider whether forecast risk score should be increased to 4x4 in light of recent decision ref Q2 SME

3. Risk Scoring Consequence score

1 2 3 4 5 Severity Descriptors Negligible Low Moderate Serious Very Serious Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Almost

Certain

Rare Unlikely Possible Likely Almost Certain

Negligible 1 2 3 4 5

Low 2 4 6 8 10

Moderate 3 6 9 12 15

Serious 4 8 12 16 20

Very Serious 5 10 15 20 25 4. Assurance scoring

How much Full 3 Partial 2 Minimal 1

Basis External verification 3 Internal verification 2 Self-assessment 1

Timeliness Within last 3 months 3 3 and 9 months 2 9 months + 1

Rigour Strong 3 Moderate 2 Weak 1

Score Level of assurance

0 – 5 Weak – very limited reliance

6 - 8 Moderate – limited reliance

9 - 12 Strong – strongly relied upon

5. Risk register mapping against the strategic goals

Strategic Goal 1: Safe, Clinically Appropriate

Responses

RAG RATING JULY 2015

RAG RATING MAY 2015

Risk description Current Forecast Current Forecast Operational Resources (A&E) 15 15 20 15 Operational Resources (UCS) 20 15 20 15 Call answering performance (111) 20 20 20 20 Major IT Service failure 20 12 20 12 Performance Targets Red 2 16 12 16 16 Performance Targets A19 20 16 16 16 Increase in Activity 16 16 16 12 Call Audit Compliance 16 16 16 16 Impact of REAP Levels, and Summer, Winter and Peak pressures 16 8 16 8

Performance Targets Red 1 15 10 15 15 Handover Delays at Hospital - Impact on Patient Safety and Resources 15 15 15 15

Clinical Hub Rationalisation 15 10 15 10 Terrorist Activity 15 15

15 15

Strategic Goal 2: Right People, Right Skills, Right

Values


RAG RATING MAY 2015

Risk description Current Forecast Current Forecast Delivery of Statutory and Mandatory Education 20 12 20 12 Employment Legislation Litigation 12 12

16 16

Strategic Goal 3: 24/7 Emergency and Urgent Care


RAG RATING MAY 2015

Risk description Current Forecast Current Forecast UCS service contract 12 12

20 20

Strategic Goal 4: Creating Organisational

Strength


RAG RATING MAY 2015

Risk description Current Forecast Current Forecast National position on paramedic banding 20 15 20 20 Corporate financials 16 12 16 12 Workforce Integration Issues 15 5 15 5 Cost Improvement Strategy 15 12

15 12

6. Current risk profile

7. Heat Map overview of July 2015 risk register 7.1 Of the 18 risks that were identified on the corporate risk register, based on their current

scores, six risks were scored as 20, five were scored as 16 and seven were scored as 15. The same risks are then mapped on their forecast score.

July 2015 – CURRENT SCORE

July 2015 – FORECAST SCORE

8. Top Risks in July 2015 8.1 In May 2015, there were six risks that were highest based on their current score. They were

then reduced to the top three by their forecast score. 8.2 Based on the July Risk Register, there are eight risks that were the highest based on their

current risk score. They were then reduced to four by their forecast score and these are then explored in more detail.

May 2015

Risk Current Score Forecast score Operational Resources 20 15

Call Answering Performance (111) 20 20

Urgent Care Services Contract 20 20

National Position On Paramedic Bandings 20 20

Delivery of Statutory and Mandatory Education 20 12

Major IT Service Failure 20 12 July 2015

Risk Current Score Forecast score Call Answering Performance (111) 20 20

Performance Targets A19 20 16



Major IT Service Failure 20 12

Operational Resources (UCS) 20 15

Increase in Activity 16 16

Audit Compliance 16 16

9. Proximity risks 9.1 Each risk that is identified in the Corporate Risk Register is assessed against a timescale to

the impact of the risk being realised. Below is detail of each risk grouped by their proximity.

Ongoing C F

Terrorist Activity 15 15

Short term (Less than 1 year) C F

Operational Resources (A&E) 20 15

Operational Resources (UCS) 20 15

Call Answering Performance (111) 20 20



Corporate financials 16 12

Audit Compliance 16 16

Clinical Hub Rationalization 15 10

Medium term (1-3 years) C F

Urgent Care Services Contract 20 20

Performance Targets Red 2 16 16

Performance Targets A19 16 16

Increase in Activity 16 12

Employment Legislation Litigation 16 16

Performance Targets Red 1 15 15

Handover Delays at Hospital - Impact on Patient Safety and Resources 15 15

Workforce Integration Issues 15 5

Cost Improvement Strategy 15 12

Long term (3-5 years) C F

Major IT Service Failure 20 12

Impact of REAP Levels, Winter, Summer and Peak pressures 16 8

10. Board Assurance - Deep Dive: Call Answering Performance (111) Date added: 30 April 2013

Risk Owner: Executive Director of Nursing and Governance Risk Description Potential failure to meet performance against national benchmarking for call answering (95% within 60 seconds) could result in call abandonment, affecting service quality, patient safety and experience, reputation, contractual non-compliance and have financial implications.

Risk Score – CURRENT Risk Score – FORECAST

Consequence Likelihood Risk Score Consequence Likelihood Risk Score

SERIOUS (4)

ALMOST CERTAIN (5) 20 SERIOUS (4) LIKELY (4) 16

Rationale for current score • Reputational • Regulatory

Rationale for forecast score

• Reputational • Regulatory

Overall Assurance Score

How much assurance

Basis for assurance Timeliness Assurance Score

Partial assurance

(2)

External verification (3)

Within last 3 months (3)

8 - MODERATE LIMITED RELIANCE

Rationale for current score • Internal Audit completed in May 2015 • 3 moderate and 1 low action identified through audit

History of the risk

Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current 20 20 20 20 20 20 20 20

Forecast 12 12 12 12 16 16 20 16

History of the assurance

Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current - - - - - - 7 8

Graph showing history of the risk and assurance

Controls in place • Daily telephony performance reports • Ongoing recruitment and training of Call Taking staff and Clinical Supervisors • Weekly Call Taker performance reports • Quality Development Plan, trajectory and monthly meetings • Automated Caller Dispatch Queues (ACDQ) implemented in both 111 hubs • Development of Performance Management Framework for call answering • Executive and management leadership strengthened • Review of staff profiling complete • Recruitment campaign targeted at specific demographics • Review and analysis of data to inform modelling and activity profiles • Introduction of Integrated Voice Response (IVR) • Introduction of Non-Pathways Agents (NPA) • Performance Recovery Plan in place • Review of source of activity, specifically inappropriate callbacks and abandonments • Provision of management information • Increased audit capacity • Review of clinical delivery model complete

Assurance Source Evidence of Assurance Assurance

Score New business case for Dorset

Business case approved by Directors 2

Further work with Devon and Cornwall Commissioners to improve the service

Devon and Cornwall trajectory for improvement approved 2

NHS 111 updates to each Directors' Group Minutes 1 Weekly UCS Implementation group Minutes 1 NHS 111 Quality Development Plan to Q&G in January 2015

Committee assurance Minutes of committees 2

SMT engagement with, and attendance at UCS /111 commissioner Contract Review meetings from May 2014

Minutes 1

Amber/Medium Internal Audit Report External Assurance provided by Internal Audit report 3

Actions due by March 2016

• Weekly monitoring of performance • Review of core cover and staff absence • Implement actions within Performance Recovery Plan • Ongoing work with key stakeholders, specifically looking at patient pathways • Additional resources to meet anticipated uplifts in demand • Ongoing recruitment to funded establishment • Performance management of all staff through productivity metrics • Further development of IVR • Review framework for providing feedback to staff on call taking • Negotiation of 111 contract • Staff engagement plan • Trajectory agreement with Commissioners • Dorset and Devon & Cornwall 111 services have been separated

View from Director

• Recent intelligence sharing summit with commissioners and NHSE agreed that there is no

evidence of harm due to call answering performance • Regular messages are played at busy times to inform those callers who may have an emergency

to dial 999 • Regular messages at busy times advise those who simply need health advice to hang up and use

NHS Choices or call back later • Clinical support ensures that the clinical queue is well managed • Splitting Dorset from the blended model has significantly improved performance in Dorset • Business case for Dorset sets out a clear plan and improvement trajectory in return for adequate

funding • Staff are informed and keen to develop the service should commissioners agree to additional

funding. This will assist in staff retention • Trajectory for improvement agreed with Devon & Cornwall Commissioners • Close partnerships with OOH GP services ensure that patients who need a GP are dealt with

promptly

11. Board Assurance- Deep Dive: Performance Targets A19 Date added: 11 May 2015

Risk Owner: Chief Executive Risk Description The potential for not achieving and sustaining A19 target which could impact on patient safety, staff experience, financials and Monitor's Risk Assessment Framework. Risk Score – CURRENT Risk Score – FORECAST

Consequence Likelihood Risk Score Consequence Likelihood Risk Score SERIOUS

(4) ALMOST

CERTAIN (5) 20 SERIOUS (4) LIKELY (4) 16

Rationale for current score • Forecast of performance


• Forecast of performance

• Implementation of MIP


How much assurance


Partial

(2)

Internal verification

(2)



Rationale for current score • MIP weekly monitoring meeting chaired by the Chief Executive • CQUINN reporting to Q&G • CCG engagement • Internal Audit due to commence on Dispatch on Disposition

History of the risk

Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current 20 20 20 20 20 20 16 20

Forecast 16 16 12 12 12 12 16 16


Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current - - - - - - - 7


Controls in place monitored quarterly • A&E service line operating plan approved and monitored at A&E service line • Annual Accountability Agreement monitored quarterly • Effective capital programme in place for vehicles and equipment • Trust workforce strategy focused on frontline staff • Effective and fully staffed Clinical Hub with rolling recruitment programme • Implementation of Enhanced Pre Hospital Care within Clinical Hubs • Developments identified within MAVIS implemented • Trust wide hospital handover SOP agreed with Commissioners • Modelling A19 performance and demand and use of agency paramedics and private ambulance

services to address establishment levels • Dispatch on Disposition Assurance Assurance Source Evidence of Assurance Assurance

Score MIP weekly monitoring meeting chaired by the Chief Executive Minutes of meeting 1

Neil Le Chevalier met all 12 CCGs to share information on performance Minutes of meeting 1

Right Care 2 – performance reported to commissioners Commissioners reports 2

A&E service line meeting monthly Minutes of meeting 1 CQUIN Programme agreed for 2015/16, to be monitored by commissioners – reported through Q&G

Committee Assurance 2

Operational Resilience and Capacity Plan 1 Roll out of My Performance tool for staff 1

Actions due by Sep 2015 • Ongoing internal monitoring and improvement led by the Chief Executive • Implementation of A&E Business Programme • Assess impact of Dispatch on Disposition – phase II in September 2015 • National review of REAP • Implementation of A&E Operating Plan • Re-modelling on A19 • Confirmation of national AQI guidance notes to ACCE in August 2015 • Development of A19 improvement plan • MIP

View from Director

• Daily monitoring of A19 performance • MIP chaired by the Chief Executive • Action plan that is being followed • Sustained focus on Red 2 will have a positive impact on A19 • Internal Audit planned for Dispatch on Disposition

12. Board Assurance - Deep Dive: Increase in Activity Date added: 24 September 2014

Risk Owner: Chief Executive Risk Description Changes in daily and hourly spread of demand within all service lines impacting on ability to respond, funding, patient care and experience, performance and staff experience. Risk Score – CURRENT Risk Score – FORECAST

Consequence Likelihood Risk Score Consequence Likelihood Risk Score SERIOUS (4) LIKELY (4) 16 SERIOUS (4) LIKELY (4) 16

Rationale for current score • Financial • Impact on performance


• Financial • Impact on performance


How much assurance


Partial

(2)


(2)



Rationale for current score

• Dispatch on Disposition continues with Phase II to being in September 2015 • Commissioner agreed action plan to manage demand

History of the risk

Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current 16 16 16 16 16 16 16 16

Forecast 10 10 10 10 12 12 12 16


Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current - - - - - - 7


Controls in place

• Use of rolling average for activity commissioning • Activity reports sent to Commissioners on a daily basis • New daily dashboard reporting available • Daily monitoring of activity growth and impact of NHS 111 on A&E • Signed contracts which have activity growth embedded within the terms • Implementation of handover SOP • Revised Demand Management Plan for Clinical Hub implemented • Escalatory Management Plan reviewed and updated • Independent review of performance activity • Provision of staff by third parties, agencies, bank and overtime • 111 Quality Development Plan • Ongoing work with stakeholders and other providers of services such as Care UK • Revised Interhospital Transfer Procedure implemented • Annual demand review within contract • Right Care 2 • ‘Choose well' campaign • Introduction of additional Clinical Supervisors within Hubs • 111/999 Liaison Group in place • Trust position on activity for 2015/16 provided to Commissioners • Continuation of ECP trial in Cornwall • Commissioners agreed demand management plan

Assurance Source Evidence of Assurance Assurance

Score Agreed plan by Commissioners on what they can do to manage demand Plan 2

Daily dashboard and MIP Dashboard 1 MIP weekly meeting chaired by the Chief Executive Meeting minutes 1

Actions due by March 2016

• Performance to be monitored through daily dashboard and contract meetings • Review of performance activity against demand • Review activity profiles • Review source of activity, specifically inappropriate callbacks and abandonments • Review of data to inform modelling • Additional resources to meet anticipated uplifts in demand including agency and private

providers • National review of REAP • Continuation of Dispatch on Disposition – phase II September 2015 • Review impact of S.136 • Continue to work with 111 providers • Review of demand management with CCGs • Use of private and agency resources utilised at peak times • Review of status plan management • Revised standby procedure implemented within North division • New meal break arrangements being developed • Negotiation of 2016/17 contract

View from Director

• Commissioners have agreed to an action plan of the things that they can do to manage demand • Focus in the North division who have seen the biggest increase in demand • Internally we understand where the demand is coming from and so we have placed more

clinicians in the hub to help manage the demand • Dispatch on Disposition Phase II in September 2015 will have a positive impact on A19

performance due to the increase in hear and treat

13. Board Assurance- Deep Dive: Audit compliance Date added: 4 June 2014

Risk Owner: Executive Director of Nursing and Governance Risk Description Failure to meet call taking audit compliance in 111 and 999 could have the potential to compromise patient safety and the requirements of software licences. Risk Score – CURRENT Risk Score – FORECAST

Consequence Likelihood Risk Score Consequence Likelihood Risk Score SERIOUS

(4) LIKELY (4) 16 SERIOUS (4) LIKEY (4) 16

Rationale for current score • Safety • Regulatory compliance


• Safety • Regulatory compliance


How much assurance


Minimal

(1)


(2)



Rationale for current score

• Business cases put to the Commissioners for consideration • Increase in call audit activity • Internal Audit to be commissioned to look at Call Audit

History of the risk

Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current - 16 16 16 16 16 16 16

Forecast - 16 16 16 16 16 16 16


Score May 2014

July 2014

Sep 2014

Nov 2014

Jan 2015

Feb 2015

May 2015

July 2015

Current - - - - - - - 6

Controls in place

• Executive leadership and management strengthened • Board approved Quality Development Plan • Interim additional CQI team in place (on temporary basis) • Model of CQI revised utilising Senior Call Advisors to undertaken 500 audits per month within

111

Assurance Assurance Source Evidence of Assurance Assurance

Score Call audits are reported to commissioner on a monthly basis Commissioner report 2

Commissioner report on a monthly basis for moderate harm, serious incidents and datix. There have been no incidents

Commissioner report 2

Intelligence gathering – message to NHS England that there are no links between patient safety and call answering/audit

Reports produced 2

Actions due by June 2015

111 • Review of Audit process underway including structure, frequency and performance management • Review of UCS structure underway • Review outcome of NHS Pathways review • Business case submitted 999 • Review of Clinical Hub structure • A&E Business Plan View from Director

• Formal review of call audit compliance is carried out at contract meeting and through the

commissioner reporting arrangements • Big increase in the number of call audits that are taking place but this is less than the levels

specified in the contract • The business cases being considered by the Commissioners will enable an increase in audit

capacity for 111 • Call Audit Compliance to be added to the scope of UCS Audit • Clinical hub review will enable consideration of audit capacity in 999

14. Recommendation

The Board is asked to take assurance from the joint Board Assurance and Risk Register

Marty McAuley Trust Secretary

Board Assurance Log

SAFE: that people are protected from abuse and avoidable harm

Board May 2015:

• 20145-15 Quarter 4 - Serious Incident report

Quality & Governance

May 2015:

• Safeguarding annual report. • Safety and Security Highlight report • Patient Safety and Experience Annual Report • Friends and Family Test update • Minutes of Safeguarding Group • Minutes of Health and Safety Group

Audit Finance & Investment

EFFECTIVE: that people's care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence

Board May 2015:

• Action from Quality Account


May 2015:

• Clinical Effectiveness highlight report • Quality highlight report • Quality Report Approved and Annual Report reviewed • Minutes of Clinical Effectiveness Group


CARING: that staff involve and treat people with compassion, kindness, dignity and respect

Board May 2015

• Patient Experience 2014/15 Annual Report


May 2015:

• Patient Safety and Experience Annual Report • Friends and Family Test update


RESPONSIVE: that services are organised so that they meet people's needs Board

Quality and Governance

May 2015:

• HR and Wellbeing highlight report • Learning and Development highlight report • Revised Learning Disability Programme • Experimental Learning Forum Minutes

Audit Finance and Investment

WELL LED: that the leadership, management and governance of the organisation assures the delivery of high-quality person centred care, supports learning and innovation and promotes an open and fair culture Board April 2015:

• Monitor Operational Plan 2015/16 • Monitor 2014/15 Quarter 4 Monitoring Return • 2014/15 Q4 Board Governance Assurance

May 2015:

• Annual accounts and Annual report approved


May 2015:

• Deep Dive - Information Governance • Deep Dive - Environmental Management &

Carbon Reduction • Corporate Risk Register • Quality and Annual report reviewed

Audit April 2015:

• Board Assurance Framework Internal Audit • Information Governance Toolkit Internal Audit • Draft Annual Governance Statement approved • Internal Audit plan 2015/16 approved • Counter Fraud Work Plan 2015/16 • Standing items: Counter Fraud update and

External Audit update

May 2015:

• Annual accounts and Annual report approved

Finance & Investment

April 2015:

• Presentation on Estates Strategy • A&E business plan considered • Finance strategy • Committee self-assessment completed • Annual review of the Protected Asset Register

• Procurement Policy approved

Trust Public Board of Directors Meeting 30 July 2015

Page 1 of 1

Trust Public Board of Directors Meetings 30 July 2015

Title: Trust Charitable Funds Annual Accounts 2014/15 and Letter of Representation

Prepared by: Martin Ford - Income Accountant

Presented by: Jennie Kingston-Deputy Chief Executive/Executive Director of Finance

Main aim: The 2014/15 Trust Charitable Fund Annual Accounts for the year ended 31 March 2015 and the Letter of Representation are being presented to the Trust Charitable Funds Committee for consideration on 30 July 2015 prior to the Board of Directors meeting. Subject to the Annual Accounts and Letter of Representation being recommended by the Committee, the Board of Directors will be asked to approve:

1) Charitable Fund Annual Accounts 2014/15 2) Letter of Representation

A verbal update on the outcome of the Committee will be provided to the Board of Directors.

Recommendations: The Board of Directors is asked to approve: 1) the Trust Charitable Fund Annual Accounts

2014/15 2) Letter of Representation

Previous Forum: Trust Charitable Funds Committee 30 July 2015

Trust Headquarters Abbey Court

Eagle Way Exeter Devon

EX2 7HY

Tel: 01392 261500 Fax: 01392 261510

Website: www.swast.nhs.uk

Our ref: JK1383.kr PricewaterhouseCoopers LLP Princess Court 23 Princess Street Plymouth PL1 2EX Dear Sirs This representation letter is provided in connection with your independent examination of the financial statements of South Western Ambulance Service Foundation Trust Fund (the “charity”) for the year ended 31 March 2015 for the purpose of expressing an opinion as to whether the financial statements are consistent with underlying accounting records, have been properly prepared in accordance with United Kingdom Generally Accepted Accounting Practice (UK GAAP), and have been prepared in accordance with the Charities Act 2011 and Regulation 8 of The Charities (Accounts and Reports) Regulations 2008. We confirm that the following representations are made on the basis of enquiries of management and staff of the charity with relevant knowledge and experience and, where appropriate, of inspection of supporting documentation sufficient to satisfy ourselves that we can properly make each of the following representations to you. We confirm, for all trustees at the time the trustees’ report is approved, to the best of our knowledge and belief, and having made the appropriate enquiries, the following representations: Financial Statements We have fulfilled our responsibilities, as set out in the terms of the independent examination engagement letter dated 9 March 2015, for the preparation of the financial statements in accordance with UK GAAP, the Charities Act 2011 and The Charities (Accounts and Reports) Regulations 2008; in particular the financial statements are consistent with underlying accounting records in accordance therewith. All transactions have been recorded in the accounting records and are reflected in the financial statements. All grants, donations and other income have been notified to you and where the receipt is subject to specific terms or conditions, we confirm that they have been recorded in restricted funds. There have been no breaches of terms or conditions during the period in the application of such income.

We confirm that to the best of our knowledge all income receivable by the charity during the accounting period has been included in the financial statements. Where material, gifts in kind and intangible income have been included at a reasonable estimate of their value to the charity or at the amount actually realised. Significant assumptions used by us in making accounting estimates, including those surrounding measurement at fair value, are reasonable. All events subsequent to the date of the financial statements for which UK GAAP requires adjustment or disclosure have been adjusted or disclosed. Information Provided Each trustee has taken all the steps that he or she ought to have taken as a trustee in order to make himself or herself aware of any relevant audit information and to establish that you (the charity’s independent examiners) are aware of that information. We have provided you with:

• Access to all information of which we are aware that is relevant to the preparation of the financial statements such as records, documentation and other matters;

• Additional information that you have requested from us for the purpose of the independent examination; and

• Unrestricted access to persons within the charity from whom you determined it necessary to obtain audit evidence.

So far as each trustee is aware, there is no relevant audit information of which you are unaware. Fraud and non-compliance with laws and regulations We acknowledge our responsibility for the design, implementation and maintenance of internal control to prevent and detect fraud. We have disclosed to you the results of our assessment of the risk that the financial statements may be materially misstated as a result of fraud. We have disclosed to you all information in relation to fraud or suspected fraud that we are aware of and that affects the charity and involves:

• Management; • Employees who have significant roles in internal control; or • Others where the fraud could have a material effect on the financial statements.

We have disclosed to you all information in relation to allegations of fraud, or suspected fraud, affecting the charity’s financial statements communicated by employees, former employees, analysts, regulators or others.

We have disclosed to you all known instances of non-compliance or suspected non-compliance with laws and regulations whose effects should be considered when preparing financial statements. Related party transactions We confirm that the ultimate controlling party of the charity is South Western Ambulance Service NHS Foundation Trust. We confirm that there are no related parties to disclose. All transfer of resources, services or obligations between the charity and these parties have been disclosed to you, regardless of whether a price is charged. We are unaware of any other related parties, or transactions between disclosed related parties. Related party relationships and transactions have been appropriately accounted for and disclosed in accordance with the requirements of FRS 8, “Accounting and Reporting by Charities: Statement of Recommended Practice” or other requirements the Charities Act 2011 and The Charities (Accounts and Reports) Regulations 2008. We confirm that we have identified to you all employees with emoluments over £60,000, as defined by “Accounting and Reporting by Charities: Statement of Recommended Practice”, and included their emoluments in the financial statement disclosures. Employee Benefits We confirm that we have made you aware of all employee benefit schemes in which employees of the charity participate. Contractual arrangements/agreements All contractual arrangements (including side-letters to agreements) entered into by the charity have been properly reflected in the accounting records or, where material (or potentially material) to the financial statements, have been disclosed to you. Litigation and claims We have disclosed to you all known actual or possible litigation and claims whose effects should be considered when preparing the financial statements and such matters have been appropriately accounted for and disclosed in accordance with UK GAAP. Taxation We have complied with the taxation requirements of all countries within which we operate and have brought to account all liabilities for taxation due to the relevant tax authorities whether in respect of any corporation or other direct tax or any indirect taxes. We are not aware of any non-compliance that would give rise to additional liabilities by way of penalty

or interest and we have made full disclosure regarding any Revenue Authority queries or investigations that we are aware of or that are ongoing. In managing the tax affairs of the charity, we have taken into account any special provisions such as transfer pricing, debt cap, tax avoidance disclosure and controlled foreign companies legislation as applied in different tax jurisdictions. We confirm that to the best of our knowledge, throughout the year, the charity has acted within its charitable objectives and therefore there are no activities on which the charity should be accounting for direct taxes. As minuted by the Board of Directors at its meeting on 30 July 2015. ................................................................................ Trustee For and on behalf of South Western Ambulance Service Foundation Trust Fund 30 July 2015

Trust Public Board of Directors Meeting - 30 July 2015

Page 1 of 3


Title: Use of the Trust Seal in connection with a new Underlease, new Licence and new Lease for Social Dispatch Points at Chippenham Hospital, Melksham Hospital and Salisbury Medical Practice

Prepared by: Jeff Evenett, Head of Estates

Presented by: Neil Le Chevalier, Director of Operations

Main aim: To request approval for use of the Trust seal in accordance with the requirements of the Trust constitution

Recommendations: The Board of Directors is asked to note this paper and approve the use of the Trust seal



Board Assurance Framework BAF15-14 Directorate

Business Plans

Implications (including Statutory

or Legal References) Compliance with Trust Constitution


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Use of the Trust Seal – Social Dispatch Points at Chippenham Hospital, Melksham Hospital and Salisbury Medical Practice 1. Background 1.1. The Trust constitution contains the following requirement in relation to the use of the

Trust seal: 10.2.1 The common seal of the Trust shall not be fixed to any documents unless the

sealing has been authorised by a resolution of the Board of Directors or of a committee, thereof or where the Board of Directors has delegated its powers in accordance with the Scheme of Delegation.

2. Chippenham Hospital Social Dispatch Point 2.1. In December 2013 the Trust entered into a new underlease for the use of rooms

and emergency vehicle parking space at Chippenham Hospital. 2.2. The Counterpart Underlease for the Social Dispatch Point will be executed under

seal and the approval of the Trust Board of Directors will be required for the use of the Trust seal.

3. Melksham Hospital Social Dispatch Point 3.1. In December 2013 the Trust entered into a new licence for the use of rooms and

emergency vehicle parking space at Melksham Hospital. 3.2. The Counterpart Licence for the Social Dispatch Point will be executed under seal

and the approval of the Trust Board of Directors will be required for the use of the Trust seal.

4. Salisbury Social Dispatch Point 4.1. In February 2014 the Trust entered into a new lease for the sole use of a rest room

incorporating a kitchenette and WC plus an external parking space for one emergency vehicle with a shoreline vehicle charger at the new Medical Practice in Salisbury.

4.2. The existing Social Dispatch Point in this area of Salisbury is at the St John

Ambulance premises in Roman Road. Tenure is by means of a simple annual rolling licence and notice has been served to terminate the licence.

4.3. The new Lease for the Social Dispatch Point will be executed under seal and the

approval of the Trust Board of Directors will be required for the use of the Trust seal.


Page 3 of 3

5. Recommendation 5.1. The Board of Directors is asked to note this paper and approve the use of the Trust

seal in connection with:

a. a new Counterpart Underlease relating to the use of rooms and emergency vehicle parking space at Chippenham Hospital in Wiltshire;

b. a new Counterpart Licence for the use of rooms and emergency vehicle parking

spaces at Melksham Hospital;

c. a new Lease for the use of a room and emergency vehicle parking space at Salisbury Medical Practice.

Neil Le Chevalier Director of Operations


Page 1 of 3

Trust Public Board of Directors Meeting 30 July 2015 Title: Quality Account and Report 2014/15 – Stakeholder Feedback

Prepared by: Helen Braid, Interim Compliance Manager

Presented by: Jennifer Winslade, Executive Director of Nursing & Governance

Main aim: To inform Directors of the issues highlighted in responses received from stakeholders as part of the Quality Account and Report 2014/15 consultation exercise and seek agreement to the responses to be made.

Recommendations: The Board of Directors is asked to approve the draft responses to stakeholders who commented upon the Trust’s draft Quality Account and Report 2014/15.

Previous Forum: This paper has not been presented to any other forum.


Board Assurance Framework BAF22-14

Directorate Business Plans

Nursing and Governance

Implications


Page 2 of 3

Quality Account and Report 2014/15 – Stakeholder Feedback 1. Background 1.1 Each year the Trust is required to publish a Quality Account which meets with the

requirements of the NHS Act 2009 and the NHS (Quality Accounts) Amendment Regulations 2012.

1.2 A requirement of the Quality Account process is that Clinical Commissioning

Groups, Health Overview &Scrutiny Committees (HOSCs) and Local Healthwatch organisations within the Trust’s operating area are consulted upon the draft document, with their comments being published verbatim in the final version of the document.

2. Consultation Exercise 2.1 The Trust is required to provide stakeholders with 30 days to comment on the draft

Quality Account. This timeframe is scheduled into the production schedule to ensure that as much year-end information can be included in the draft and that there is sufficient time to enable feedback to be considered prior to the document being audited and approved.

2.2 In February 2015 the External Relationships Manager commenced the

engagement process and informed stakeholders that the formal consultation period would run from 13 April through to 12 May 2015. On 13 April 2015 each stakeholder was provided with the draft document.

2.3 Responses were received from the South West Commissioning Support Unit and

NHS Dorset. A joint response was received from HOSCs in North Division and individual responses were received from Healthwatch and HOSCs across East and West Division. All of these responses are included verbatim in the published version of the Quality Account.

2.4 A joint response was also received Healthwatch organisations in North Division.

However, this was not submitted until 1 June 2015 which was after the Quality Account had been approved and laid before Parliament. It was not possible, therefore, to include this response in the Quality Account.

3. Queries and Issues Highlighted


Page 3 of 3

3.1 The consultation responses received contained a number of queries about the information in the draft document or about the Trust’s services in general and it is proposed that a response is made to these issues.

3.2 The queries are set out at Annex A together with a proposed response. 3.3 It will be noted that a number of queries relate to data not being available within

the document. Due to the tight timescales in meeting reporting requirements, not all year-end data was available when the draft was circulated, but this information has been included in the final version.

3.4 In addition, a number of responses indicated that stakeholders would be interested

to learn the outcome of the Dispatch on Disposition pilot, whilst others were keen to learn of the Trust’s proposals to address performance levels. Accordingly, draft responses to these responses are also included at Annex A.

4. Next Steps 4.1 It is proposed that a copy of the final Quality Account is provided to each

stakeholder. In addition, those stakeholders who responded to the consultation draft should be thanked for their contribution and provided with: • the Trust response to all individual queries; • an overview of the Trust’s proposals to address performance levels; and • confirmation that they will receive a briefing on the outcome of the Dispatch on

Disposition pilot. 4.2 The feedback received from stakeholders will also be considered during the

planning process for the 2015/16 Quality Account and Report. 5. Recommendations 5.1 The Board of Directors is asked to approve the draft responses to stakeholders

who commented upon the Trust’s draft Quality Account and Report 2014/15. Helen Braid Interim Compliance Manager

Submi&ng Organisa.on

Subject Area Detail Proposed Response

Quality Priori,es 2014/15It would be good to see more outcome focused data as well as from other pa,ent safety ini,a,ves during the year.

This will be considered for the Quality Account for 2015/16

Quality Priori,es 2014/15Commissioners would like to have seen the plans on how SWASFT will improve performance for 2015/16, where priori,es were not fully achieved.

The only sepsis priority not achieved was a reduc.on in reported incidents. The work around this shows that this is unlikely to be achieved, as the more we work to raise awareness, the more incidents we are likely to receive. Based on this, it would be difficult agree a plan for a reduc.on.

Quality Priori,es 2014/15 -‐ Electronic Care System

Commissioners will be interested to note the long term success of this project, with suppor,ng data highligh,ng improved client care. Commissioners would encourage the Trust to be bolder in the roll out of the ECS.

An update on the progress of this project will be included in future Quality Accounts.

Quality Priori,es 2014/15 -‐ Primary Angioplasty

Commissioners are looking forward to being advised of the outcome of this work.

The findings of this work were reported in the final version of the Quality Account. Updates will be included in future Quality Accounts.

Quality Priori,es 2014/15 -‐ Friends & Family Test

Commissioners would like to have seen more specific ac,ons and outcomes in rela,on as to how pa,ent feedback from the ini,a,ve is used.

The response rate for the FFT during 2014/15 was very low, equa.ng to less than 1% of pa.ents who were not conveyed. The responses have been overwhelmingly posi.ve, with less than 5 of the responses being less than completely posi.ve. In these cases, the pa.ent were contacted regarding their concerns.

Quality Priori,es 2014/15 -‐ Percutaneous Coronary Interven,on

The Quality Account states the baseline, but does not confirm what the ouPurn performance is following the interven,ons taken to increase it.

Although this informa.on was not available for the draT, it is included in the final version.

Quality Priori,es 2015/16Commissioners would like to see more specific and measurable quality outcomes set for these priori,es.

Following the publica.on of the draT Quality Account for consulta.on, specific and measurable outcomes have been agreed for the 2015/16 priori.es and these have been included in the final version.

Quality Priori,es 2015/16 -‐ Paediatric Big 6

Commisioners request that SWASFT consider as a measurement of achievement, an overall reduc,on in conveyances / admissions of the Big 6 condi,ons.

The text of the Quality Account cannot be changed once it has been published. However, we can confirm that the focus of the Big 6 scheme is on providing further educa.on to ambulance clinicians. However it has two main purposes:-‐1. Enable pa.ents to be safely assessed and remain on-‐scene.2. Iden.fy pa.ents who have red flags to ensure that they are appropriately conveyed to hospital.Un.l the project becomes established, we cannot reliably predict whether the rate of conveyance would increase or decrease. The 2015/16 Account will include reference to the impact that the ini.a.ve has had on the overall reduc.on in conveyances/admissions of the Big 6 condi.ons.

Quality Account & Report 2014/15 -‐ Stakeholder Comments and QueriesAssurance Statements Ac.on Plan

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Quality Priori,es 2015/16 -‐ Frequent Callers

More considera,on needs to be given to what success will look like for both the organisa,on and the high users of SWASFT services -‐ par,cularly care homes. Commissioners would like to see examples and evidence of how this has made a posi,ve impact on this group of clients and how this has helped capacity in the service.

The CSU and commissioners will receive quarterly evidence as part of monitoring of the 2015-‐16 frequent caller CQUIN.

KPIsMore detailed explana,ons on how SWASFT plans to improve performance during 2015/16 would provide further assurance to the public as well as commissioners.

At the start of the year the Trust developed an A&E Opera.ng Plan, aimed at reconciling planned ac.vity levels with na.onal performance targets and the financial plan. This has provided the Trust with a work programme for 2015/16 and is par.cularly focused on servicing capacity requirements. The Trust delivered Red 1 performance in Q4 of 2014/15 and in Q1 of 2015/16. In Quarter 1 2015/16 the Trust implemented a measures to improve performance plan (MIP), aimed at improving performance. The ac.ons implemented were assessed as being successful. However, the variance in performance widened during the .me period due to factors outside of the Trust’s control, meaning that the plan did not bridge the actual gap. The contribu.ng factors to this addi.onal gap were demand and resourcing levels. This plan was shared with commissioners. The Trust is now working with Commissioners and the Commissioning Support Unit to develop a new improvement plan (MIPQ2), with ac.ons from both the Trust and its commissioners aimed at improving performance.

Right CareIt would be helpful to iden,fy by commissioner the variance in ac,vity and conveyances from 2013/14 to 2014/15 as the effect varies considerably across the commissioned service areas.

This level of detail is more appropriate for the Trust's Integrated Corporate Performance Report (which is published monthly with Board papers) than the Quality Account.

Right Care

Commisioners would request that further informa,on is presented in the 2015/16 Quality Account in order to demonstrate to stakeholders the posi,ve impact of the programme, including number of pa,ents treated at the scene (including home) or re-‐directed and answered sa,sfactorily.

This will be included in the 2015/16 Quality Account.

Right CareCommissioners would like to see fully developed local plans with clearly defined deliverables for 2015/16.

All local Right Care 2 plans have now been agreed following held in quarter 1 (15/16) with all CCGs except Bristol CCG. Bristol mee.ng scheduled for 13 August 2015.

Local repor.ng progress against plans con.nues on a monthly basis.

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NHS PathwaysCommissioners wish to see the early implementa,on of NHS Pathways within North Division.

This is subject to the Computer Aided Dispatch project which will be commenced in September 2015

Opera,onal Resilience and Capacity Planning

There is no men,on of the locally agreed and funded / centrally funded schemes or their outcomes.

Commissioners have received a monthly report on all local and regional schemes throughout the year. Considera.on will be given as to whether informa.on about these schemes should be included in future Quality Accounts.

NHS111The Quality Account does not make men,on of the fact that SWASFT has now given no,ce on the contracts for Devon and Cornwall.

This was not included in the consulta.on draT of the Quality Account, but has been included in the final version.

Na,onal and Local Clinical Audits

Commissioners feel it would be good to show the learning gained from these and how this will be taken forward in 2015/16.

An annual report on the work of the Research, Audit and Quality Improvement func.on is produced and summarises findings and plans for the forthcoming year which arise form that work. This document is currently awai.ng Commifee approval.

NRLS

Commissioners request the provision of further explana,on around the varia,on in data between repor,ng periods and assurance that the NRLS data is now being iden,fied and uploaded appropriately.

Due to a temporary change in personnel there was a .me limited issue with informa.on being uploaded to the NRLS system, the temporary member of staff misunderstood the requirement to upload the data despite a briefing to the contrary. The Trust will ensure that this key informa.on is reiterated during any handover should the permanent postholder require temporary cover in the future.

NRLSThe Quality Account does not explain any highlighted themes or learning derived from the repor,ng.

Themes and learning arising from Adverse Incidents are reported within the Trust’s bi-‐monthly Pa.ent Safety and Experience Report which is presented to each Quality and Governance Commifee, the Trust Board of Directors and Commissioners. The Trust did not include this informa.on within the Quality Account as it would be a duplica.on. As stated within the Quality Account, the Trust’s Experien.al Learning Forum conducts focused reviews of themes iden.fied from trends in adverse incidents and feedback.

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NRLS

Concern has been expressed regarding the rise in number of incidents reported as severe harm and deaths in the laPer half of 2014/15 and as to whether SWASFT is confident that the causes are understood and being fully addressed in 2015/16.

The Trust reported 31 serious incidents on STEIS during the first 6 months of the year and 21 during the second 6 months. During 2014/15 when serious incidents were uploaded to the NRLS they were coded based on the ini.al Da.x Report. Following an SI mee.ng, which takes place on conclusion of the inves.ga.on, they should then be re-‐submifed with any revised severity ra.ng which then forms the final ra.ngs for the year. Unfortunately during the lafer 6 months of the year this did not take place which subsequently gave the impression that a higher number of severe harm or death incidents taking place. This was recently iden.fied and the incidents re-‐submifed which has resulted in the figure of severe harm incidents for the first half of the year being one and the second half being four. It should be noted that of the 52 serious incidents confirmed by the Trust during the year following inves.ga.on only five were rated as being significant. To address the issue that took place during year we have now produced a clear flowchart demonstra.ng the procedure to follow in rela.on to NRLS uploads before and aTer the SI inves.ga.on.

Pa,ent Experience

Although some pa,ent stories were included there could have been more examples given to demonstrate the high level of public and pa,ent engagement and could have been an opportunity to demonstrate this in more detail from the pa,ent perspec,ve.

Considera.on will be given to the number of pa.ent stories to be included in future Quality Accounts.

Pro Ac,ve Apology ProcessCommissioners would appreciate an understanding of how this has impacted on the experience of pa,ents and carers in the incident / complaints process.

Of the 85 proac.ve apologies, 3 apologies led to plaudits and one to posi.ve feedback from the pa.ent regarding the ambulance crew. Two of the apologies led to complaints, however in both cases the complaints were not related to the apologies but to a separate part of the incident.

NHS

Dorset

CCG No issues to address.

To be thanked for their contribu.on and provided with the final version of the Quality Account & Report 2014/15

Health

Watch

Cornwall

NHS111 Was expec,ng to see more details in the Quality Account regarding 111 performance as we are aware of missed targets in this service.

Further to the publica.on of the consulta.on draT, more detail regarding NHS111 performance has been included in the Quality Account including 2014/15 data.

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NHS111

Note that data is not available to indicate whether the Trust is compliant in respect of audi,ng pa,ent experiences of the service and we would be keen to engage with the Trust as to whether their findings are compara,ve to its findings in rela,on to where people go if they are seeking non-‐urgent medical treatment.

The data was not available at the .me that the consulta.on draT was issued. However, the data is included in the final document.

Pa,ent ExperienceWill be launching on-‐line pa,ent feedback centre and hope that this will provide a source of experience data to understand the needs of service users.

Pa,ent ExperienceWill share any pa,ent feedback with the SWASFT Pa,ent Engagement Team.

Pa,ent ExperienceWould like to see further results from the Friends & Family Test in next year's Account.

This will be included in the 2015/16 Quality Account.

Pa,ent Experience Would appreciate the results of Pa,ent Experience Surveys.An overview of the findings from the Pa.ent Experience Surveys of NHS111 and GP Out of Hours was included in the final version of the Quality Account.

Pa,ent ExperienceWould like to see informa,on regarding Pa,ent Reference Groups including terms of reference, objec,ves, findings and subsequent ac,ons.

The Trust is intending to u.lise exisi.ng pa.ent reference groups, rather than establising an ambulance specific group, due to the challenges of being inclusive across such a wide geographic area. However, a Sign up to Safety plan will be developed during quarter 2 and it is intended to use staff and pa.ent feedback to help develop this.The Trust has established a group for adults with Learning Disabili.es and plan to increase the contact with this group.

Response TimesHealthwatch Somerset is concerned about the ‘Right Time’ sec,on of the ‘Right Care, Right Place, Right Time’ ini,a,ve especially as there is no men,on of any response ,mes in the Account

Reference to response .mes is included in the Key Performance Indicator Sec.on of the Quality Account which includes repor.ng on Red 1, Red 2 and A19 as well as the impact of the Dispatch on Disposi.on pilot. 999 Performance is also reported by Clinical Commissioning Group area. Performance against Quality Requirements for GP Out of Hours and the NHS111 Services (which include .me related indicators) are also included.

Response TimesHealthWatch Wiltshire seek assurances that plans are in place to try and ameliorate the downturn in Red2 and A19 performance.

See performance response below

Quality Priority 2014/15 -‐ Sepsis

There appears to be no evidence of findings, which could significantly enhance and enlighten this element of the QA. Given the seriousness of sepsis, some indica,on of a con,nuing, audited focus which includes older people would be welcomed.

The outcome of this work was not available at the draT consulta.on stage but has been included in the final version of the Quality Account.

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The Pa.ent Engagement Team would welcome any pa.ent experience data as this can be used a part of the Trust's rou.ne analysis to assess the pa.ent experience.



Quality Priority 2014/15 -‐ Electronic Care System

Healthwatch supports the trust in its valua,on of the Electronic Care System, but the lack of evidence suppor,ng its deployment across the trust, par,cularly in the North, hampers an ability to comment more posi,vely. Healthwatch Bristol would like to know if the Electronic Care System has been implemented in Bristol, as that impacts on the wider local health care system.

ECS has not yet been deployed in Bristol but the system was rolled out following a na.onally agreed business case. A training and deployment schedule is being developed for the North and deployment is an.cipated between January and November 2016.

Quality Priority 2014/15 -‐ Primary Angioplasty

Improvements in primary angioplasty was again a worthy objec,ve but Healthwatch Gloucestershire is unable to make a realis,c comment as no data is presented.

Although this informa.on was not available for the consulta.on draT, it is included in the final version.

Quality Priority 2014/15 -‐ Friends & Family Test

Healthwatch North Somerset suggested it would be helpful to know the percentage of FFT cards completed and report it in the Account.

The response rate for the FFT during 2014/15 was very low, equa.ng to less than 1% of pa.ents who were not conveyed. The responses have been overwhelmingly posi.ve, with less than 5 of the responses being less than completely posi.ve. In these cases, the pa.ent were contacted regarding their concerns.

Quality Priori,es 2015/16HealthWatch Somerset ques,ons whether there are enough staff to undertake the work commitment.

The capacity to complete each priority is factored into the planning for each one

Quality Priori,es 2015/16 -‐ Paediatric Big Six

The data driving some aspects of it appear out of date.Data colle.on in this area is challenging, and the informa.on used is the latest available.

Quality Priori,es 2015/16 -‐ Frequent Callers

Priori,sing Frequent Callers is worthwhile for the Trust, but is it a top level priority in terms of the popula,on size?

It is a top priority in terms of the excep.onallly high impact of a very small popula.on size.

Statements of Assurance from the Board

It is felt that sec,on 2.2, 2.3 and 2.4 are rather clumsy and repe,,ve.

The wording in these sec.ons is required from all NHS trusts and cannot be changed.

Staff SurveyWhy is there a drop in the staff recommenda,ons to work for SWAST. Is it the above average stress levels, together with the over-‐worked staff on the roads?

The individual metric for staff recommending the trust as a place to work was unchanged year on year and we perform befer on this area when compared to the rest of the ambulance sector. The measure that was published in the quality account was a measure that recorded a mean score and this was made up of a number of different indicators. Therefore there is no evidence that increased stress is adversely impac.ng on this measure and in fact the Trust performs well on this measure despite the increased demand on our services.

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Serious Incidents

The majority of serious incidents rela,ng to Clinical Hubs took place within the North Division and relate to cross-‐boundary issues. It is presumed that the North Division includes Bristol? Has any underlying reason for this varia,on been iden,fied?

There has been a higher number of Serious Incidents in the North Division Hub. The Trust currently has two CAD and triage systems. The North System can some.mes require manual adjustments which introduces the poten.al for human error. In addi.on demand and resource issues are greater in the north placing demand on the the North Clincal Hub. There is a plan to harmonise the CAD and traige systems. There have been two cross boundary issues with South Central Ambulance Sta.on (SCAS) these have been reviewed and an engagement plan with SCAS to improve the Memorandum of Understanding has been recommended.

Na,onal and Local Clinical Audits

Na,onal and local audits which the Trust has par,cipated in are included and the ensuing Quality Improvement Programme noted. However it's unclear what the audits found which generated this QIP. Pain management has been cited a couple of ,mes. Is that included in the Na,onal Ambulance Clinical Quality Indicator programme audit?

Currently the ACQI programme includes one indicator which has a pain management element. This is the STEMI care bundle, which includes whether a pa.ent suffering with an ST Eleva.on Myocardial Infarc.on has had their pain assessed twice and whether analgesia was given. Whilst an important pa.ent group, this only represents a small subset of the pa.ents we afend, many of whom are in pain. The work that has generated the focus on pain management as a quality improvement topic has resulted from a variety of areas, including previous clinical audit work on the management of fractured neck of femur and also paediatric pain. In addi.on one of the newer na.onal clinical performance indicators (NCPIs -‐ not to confused with ACQIs) is looking at the management of fractured lower limbs, currently the majority of the English ambulance services, including SWASFT, are performing well under 50% on the pain assessment and management element of this indicator.

GeographyIt would help if the document is clear as to the geographic areas covered by North, East and West Divisions.

This will be included future versions of the Account.

Pa,ent SafetyCould the number of pa,ent incidents reported rela,ng to safety be presented as a percentage.

The 1,450 pa.ent safety incidents which were iden.fied during 2014/15 represent 16.52% of the total number of adverse incidents reported. This figure will be provided. Considera.on as to how data is presented in future Quality Accounts will be considered during prepara.on for next year's document.

Joint H

ealth

Watch Respo

nse -‐ G

loucestershire, B

ristol, N

orth Som

erset, Swindo

n and Wiltshire



Pa,ent Safety

In 2014/15 the table showing incidents reported to NRLS as death needs more context. Healthwatch Bristol would like to know what the issues were, what learning if any has emerged as an outcome and were any of these Bristol pa,ents?

One of the serious incidents involved a pa.ent with pancrea..s and acute liver failure for whom the incorrect disposi.on was reached resul.ng in a delay in treatment. Individual factors were found to be the cause leading to individual learning and shared learning for other staffThe second serious incident also involved individual error and learning involving the need to speak to/listen to the pa.ent directly where possible. Issues were also raised with NHS Pathways to improve the triage systemThe third of the serious incidents was an obstetric case which was recorded as High by NRLS ( which may indicate death) but the pa.ent is not deceased. The ra.ng has since been updated following comple.on of the SI review. This case involved a disciplinary for the staff member concerned and development of a new clinical protocol for communica.on with healthcare professionals. None of the pa.ents were from Bristol.

Performance Data in the KPI table only goes as far as Quarter 3.Quarter 4 data was not available at the .me the consulta.on draT was issued. It is included in the final version.

PerformanceHealthWatch notes that the geography of the Trust has seen elements of the Account favouring specific areas only.

Individual priori.es are developed annually based upon areas which the Trust believes are important for that year's Quality Account. The majority of these will be Trust wide but it may be that a par.cular issue has presented in one or more areas which require specific ac.on to address them.

Quality StrategyIt is not clear of the extent that Compliments, Concerns, Complaints and research outcomes influence the quality strategy.

Specific examples are not men.oned in the Quality Strategy. However, there is a strong focus in the document (due for review in 2015) on Trust mechanisms for learning to improve quality

ACQIsAs ACQI data only goes up to October 2014 it is unclear if performance has been sustained, also whether there's geographical varia,on and how Bristol compares to the rest.

Data for these indicators is not currently available aTer October 2014. The longer .meframe for the produc.on of this clinical data is due to the manual nature of the collec.on process and the delays experienced in collec.ng some of the data from third party sources. However, ACQI data is provided each year in the Quality Account, with a comparison with the previous year also being provided.

Quality Priori,es 2014/15Although progress has clearly been made we are unable to sa,sfy ourselves on the levels of achievement without corresponding data.

Although this informa.on was not available for the consulta.on draT, it is included in the final version.

Wai,ng Times Would have expected comment on the issues of wai,ng ,mes and the impact for the ambulance service and A&E departments.

Handover delays are an ongoing issue for the Trust and discussed regularly with commissioners. Further detail on the process for managing these and for maintaining quality will be included in the next Quality Account

Health

Watch North Som

erset

Joint H

ealth

Watch Respo

nse -‐ G

loucestershire, B

ristol, N

orth Som

erset, Swindo

n and

Wiltshire



Severe Harm IncidentsPage 24 shows a surprisingly high incident of severe harm but figures do not correspond with those given on page 27.

Serious incidents (page 27) are categorised using the NRLS ra.ng. subsequent to the ini.al idtnfiica.on of the incdent and upon inves.ga.on of the SI the actual effect that the incident had on the pa.ent may not necessarily be 'severe' and can be categorised under one of the other severity ra.ngs.

NHS111It would be useful to know how appropriate NHS111 dispatches are and the level of reported incidents related to these dispatches.

This will be considered in the next Quality Account

PerformanceBreach of response ,mes in the last two quarters is a cause for concern. The report quotes ‘assurance of ac,on ‘but omits to detail how improvement is to be achieved.

PerformanceThere is concern about poor performance in North Somerset compared to other areas served by the Trust.

Health

Watch North Som

erset In February 2015 the Trust was asked to pilot, on behalf of NHS England, a new way of

priori.sing and dispatching ambulance resources known as ‘dispatch on disposi.on’. The new way of dispatching had a number of objec.ves including: • Reducing the number of inappropriate ambulance responses by increasing the percentage of pa.ents treated by telephone advice. • Improving the accuracy of triage of ambulance incidents, ensuring the most appropriate and .mely response to meet the pa.ent’s clinical needs. • Improving the response to the most cri.cal, life-‐threatening ambulance incidents (Red 1 incidents). • Improving performance against the na.onal ambulance response .me targets (Red 1, Red 2 and A19). Dispatch on Disposi.on has led to evidenced improvements in Hear and Treat rates, a reduc.on in resource alloca.ons per incident, no deteriora.on in re-‐contact rates and no pa.ent safety incidents. As a result the Trust has received Secretary of State authorisa.on to con.nue indefinitely, and further ambulance trusts will be added to the pilot. However there has been an unintended consequence on Red 2 Performance. Analysis of this informa.on has been shared with NHS England and Professor Keith Willef has accepted there has been a nega.ve impact of around 5% on Red 2 performance, but that the benefits of Dispatch on Disposi.on for pa.ents outweighs the performance impact. Trust commissioners monitor Trustwide as well as local varia.ons in performance.



Stakeholder EngagementHealthwatch North Somerset is disappointed that South West Ambulance Service has not ac,vely engaged with Healthwatch North Somerset.

The Trust Chairman, Trust Secretary and Stakeholder Engagement Manager met with Healthwatch in June. The Trust was also represented at the April mee.ng. Engagement will con.nue.

Pa,ent SurveysWe would like the Trust to consider the use of independent data gathering on its services which should give unbiased and honest feedback, which we would be happy to support them with.

The Trust has previously employed the Pa.ents Associa.on to support the gathering of data from pa.ents. The result was a number of videos and audio recordings of pa.ent stories. These stories have been used as part of the 'Pa.ent Voice at the Board' Project.This exercise was limited to one year due will not be replicated with the Pa.ents Associa.on however pa.ent stories will con.nue to be a regular Baord agenda item. The Trust would be suppor.ve of any pa.ent experience data being collected and shared were appropriate.

Pa,ent SurveysIt is disappoin,ng to see reference to the Pa,ent Experience Surveys in the drak QR but no details about the number received during the year or of the contents.

This informa.on was not available at the .me the consulta.on draT was circulated. It is, however, included in the final version.

Pa,ent EngagementAn easy read version of the Quality Account would ensure greater accessibility for the general public.

The Trust's Pa.ent Engagement Manager has begun to translate some key Trust documents into Easy Read to support pa.ents in accessing Trust informa.on more readily. The Trust will consider producing an Easy Read version of the Quality Account in future years.

Health

Watch

Plym

outh

Partnership WorkingWould welcome an opportunity to work more closely with the local management of SWASFT covering the Plymouth area to enable service development to include the pa,ent experience.

This invita.on will be passed to the Plymouth opera.onal team

Document FormatAre hopeful that the final format of the Quality Account will not be in text alone.

The Trust's Pa.ent Engagement Manager has begun to translate some key Trust documents (including the annual Pa.ent Safety and Experience Report) into Easy Read to support pa.ents in accessing Trust informa.on more readily. The Trust will consider producing an Easy Read version of the Quality Account in future years.

Future Contract ChangesWe are concerned about the poten,al for disrup,on by future decisions about changes to the delivery of NHS 111 and the associated GP Out of Hours services.

We will con.nue to monitor the situa.on and provide updates as and when they become available

Dispatch On Disposi,onWould be interested to understand further whether the pilot has had a posi,ve impact in reducing the number of ambulances deployed unnecessarily.

The outcome of the Dispatch on Disposi.on pilot will be reported to all HOSCs.

Health

Watch North Som

erset

Health

Watch North Som

erset

Health

Watch Torbay

Borough of Poo

le Health

& Social

Care Overview & Scru,

ny

CommiPee



Quality Priori,esWill be interested to understand what is achieved in the priority areas of Sign up to Safety; Paediatric Big Six; and Frequent Callers.

Progress and achievements in respect of the Quality Priori.es will be included in the 2015/16 Quality Account & Report.

Quality Priority -‐ Frequent Callers

With regard to the Frequent Callers priority, the CommiPtee considers that this may be an area where they can influence how local services work together in an efficient way.

We would welcome support regarding this prioirty.

Bristol Peo

ple

Scru,n

y Co

mmission

No issues to address.To be thanked for their contribu.on and provided with the final version of the Quality Account & Report 2014/15

Cornwall H

ealth

& Social Care

Scru,n

y Co

mmiPee

No issues to address.To be thanked for their contribu.on and provided with the final version of the Quality Account & Report 2014/15

Isles of Scilly

Health

&

Overview

Scru,n

y Co

mmiPee

Finance

The CommiPee would welcome more specific work done on the cost of providing urgent and non-‐emergency services to the islands. We feel that this would make the Trust bePer placed to provide seamless and integrated service provision.

This will be considered and a response provided to the HOSC

Dispatch on Disposi,onWould be interested to see the outcome of the Dispatch on Disposi,on Pilot.

This will be reported to all HOSCs.

Paramedic Cars at GP Surgeries

Would be interested to see the outcome of the ini,a,ve currently being trialled in Wiltshire to base paramedic cars at GP surgeries in order to increase the number of emergency vehicles present in rural areas.

This will be considered and a response provided to the HOSC

Partnership WorkingThe CommiPee encourages the Trust to con,nue to work closely with Gloucestershire Fire & Rescue Service for the benefit of the people of Gloucestershire.

The Trust intends to maintain and strengthen its partnership working with stakeholders across the region.

Joint N

orthern

Area HOSC -‐

North

Somerset

No issues to address,To be thanked for their contribu.on and provided with the final version of the Quality Account & Report 2014/15

Borough of Poo

le Health

& Social

Care Overview & Scru,

ny

CommiPee

Joint N

orthern Area HOSC -‐

Gloucestershire



Joint

Northern

Area HOSC

Electronic Pa,ent Clinical Record

Would like to see the EPCR introduced into Wiltshire as soon as prac,cal.

At the present .me it is an.cipated that the EPCR will be introduced across Wiltshire during the early part of 2016.


Page 1 of 4


Title: Board Assurance Paper – Quality and Governance Committee

Prepared by: Jennifer Winslade, Executive Director of Nursing and Governance

Presented by: Mary Watkins, Non-Executive Director

Main aim: The paper is to share with the Trust Board of Directors the business of the Quality and Governance Committee on 14 May 2015

Recommendations: Members of the Board of Directors are requested to take assurance regarding the business conducted at the committee meeting

Previous Forum: This paper has not been presented to any other forum



BA05-14 Directorate Business Plans

Nursing & Governance Directorate

Implications (including Statutory or Legal References)

Good governance practice


Page 2 of 4

Board Committee Assurance Report 1. Introduction

1.1 The Trust Board of Directors has three committees to which it delegates

responsibility for essential business: • Quality and Governance; • Finance and Investment; and • Audit.

1.2 Each of these committees is chaired by a Non-Executive Director and operates an

annual cycle of business to ensure statutory, regulatory, strategic, and operational objectives are achieved. In order to provide assurance that this work is undertaken, and that Board committees operate effectively, a report is prepared following each committee meeting and presented to the Board of Directors.

2. Assurance Report 2.1 Assurance Document (includes deep dives)

Further assurance requested by Committee

Information Governance The Committee sought reassurance with regard to benchmarking against other Trusts regarding the Information Governance Toolkit. It was confirmed that the Trust have benchmarked correctly against the Toolkit.

Environmental Management & Carbon Reduction

The Committee sought reassurance from the Environmental and Sustainability Manager with regard to the Sustainable Development Management Plan top 10 actions which will be rolled on from last year to the current year and queried how this would be monitored. It was confirmed that a deep dive will be undertaken for the next year and to be added to the highlight report. The Committee sought reassurance from the Sustainable Development Management Plan that the Trust will be able to save money and costs. It was confirmed that this was the case.

Governance Assurance Paper

No further assurance requested.

Corporate and Executive Directors Risk Registers



Page 3 of 4

2.2 Documents for Approval

Document Approved or approved subject to amendment

Any challenge or change requested

None. 2.4 Highlight Reports

Document Further assurance requested by Committee

Clinical Effectiveness No further assurance requested. Quality No further assurance requested. HR & Wellbeing The integrity of the data presented in the

appraisal update was queried and the committee sought assurance regarding the data supplied. The Committee seeks further assurance regarding the data.

Safeguarding (incl Safeguarding Adults and Children’s Section 11)

The Committee asked for a deep dive for the next time rather than as an agenda item.

Learning & Development The Committee asked EW for assurance on training and this was given by EW.

Safety and Security The Committee sought clarification on the Care Homes Policy. The Health, Safety and Security Manager assured the Committee the Trust understood our responsibility within the Policy. No further assurance was requested.

Patient Safety & Experience Annual Report to include Friends and Family Test


Revised Learning Disability Programme


Communication and Engagement No further assurance requested. Dispatch on Disposition No further assurance requested.


Page 4 of 4

2.5 Documents for information 2.5.1 The following documents were presented to the Committee for information:

• Clinical Effectiveness Group Minutes 19 February 2015 • Experiential Learning Forum Minutes 8 December 2014 • Risk Watch Register • Health and Safety Group Minutes 3 December 2014 • Information Governance 6 February 2015 • Safeguarding Group 26 March 2015

2.6 Issues referred to Executive Directors Group 2.6.1 None. 3. Recommendations

3.1 Members of the Board of Directors are requested to take assurance regarding

the business conducted at the committee meeting of 14 May 2015. Mary Watkins Chair of Quality and Governance Committee

Trust Public Board of Directors Meeting – 30 July 2015

Page 1 of 2


Title: NHS Pension Scheme Employer’s Charter

Prepared by: Marty McAuley, Trust Secretary

Presented by: Marty McAuley, Trust Secretary

Main aim: The purpose of this paper is to share with the Board the charter that has been jointly produced by the Department of Health, NHS Pensions and NHS Employers.

Recommendations: The Board is asked to receive a copy of the charter and note its requirements.




Directorate Business Plans

Implications (including Statutory or Legal References)

Trust Public Board of Directors Meeting – 30 July 2015

Page 2 of 2

NHS Pension Scheme Employer’s Charter 1. Introduction

This document has been jointly produced by the Department of Health, NHS Employers and NHS Pensions to set out the role and responsibilities required from each Scheme employer to enable successful administration of the NHS Pension Scheme.

2. Role of the Board 2.1 The introduction to the Charter states that

“This Charter is intended for those with Board accountability in addition to those human resources, payroll and pensions staff who undertake operational scheme administration activities. Please ensure that all appropriate individuals within your organisations receive a copy.”

3. Recommendation 3.1. The Board is asked to receive a copy of the charter and note its requirements. Marty McAuley Trust Secretary

V5 06/2015

2

Contents

This document contains information relevant to Scheme employers. It is organised under the following headings:

Foreword

Introduction

1: Who is this document for?

2: The role of the Scheme employer

2.1 - Nominating a local Scheme administrator

2.2 - Administration of pension events

2.3 - Collection and submission of contributions

2.4 - Providing information to NHS Pensions

2.5 - Providing information to Scheme members

3: Consequences of non-compliance

4: The role of NHS Pensions

5: When will this charter be updated?

6: Meaning of abbreviations used

3

This document has been jointly produced by the Department of

Health, NHS Employers and NHS Pensions to set out the role and

responsibilities* required from each Scheme employer to enable

successful administration of the NHS Pension Scheme.

The NHS Pension Scheme is governed by rules laid down in

regulations agreed by Parliament:

• The National Health Service Regulations 1995 (as amended)

• The National Health Service Regulations 2008 (as amended)

• The National Health Service Pension Scheme Regulations 2015

• And associated transitional provisions – The National Health

Service Pension Scheme (Transitional and Consequential

Provisions) Regulations 2015

These regulations are also bound by all primary legislation that has

relevance to Occupational Pension Schemes. This means that the

roles and responsibilities outlined within this document are a legal

requirement to which all Scheme employers must fully comply.

The Public Service Pensions Act 2013 (the 2013 Act) introduced the

framework for the governance and administration of public service

pension schemes and provided an extended regulatory oversight by

The Pensions Regulator. Codes of practice provide practical guidance

in relation to the exercise of functions under relevant pension’s

legislation and set out the standards of conduct and practice

expected from those who exercise those functions.

The effective administration of the NHS Pension Scheme requires

successful and timely interaction between employers and NHS

Pensions. The Department of Health and NHS Employers have worked

with NHS Pensions in recent years to improve not only the quality of

service that you and scheme members receive, but also the manner in

how we all communicate in administering the Scheme’s regulations.

The Employer Charter is a key description of your roles and

responsibilities that will enable improved administration within all

our organisations. It aims to provide you, as employers, with total

clarity on your local scheme administration requirements and has

summarised what you can expect from NHS Pensions.

This Charter is intended for those with Board accountability in

addition to those human resources, payroll and pensions staff who

undertake operational scheme administration activities. Please ensure

that all appropriate individuals within your organisations receive

a copy. Your support in working in partnership with NHS Pensions

Introduction

4

to collectively meet the Charter’s objectives will be to the benefit of all

concerned.

Adherence to this Charter is vital if scheme members are to receive timely

and accurate pensions. The current level of organisational change and

budgetary pressures further reinforce the requirement for improved and

more efficient administration.

NHS Pensions welcome your comments on this Charter as we aim to

develop its content over time (as a living document) in a manner that

supports you in administering the scheme.

Separate documents called ‘The NHS Pensions Service Charter’ and the

‘NHS Pension Scheme Member Charter’ have been produced by the NHS

Business Services Authority with the intent to compliment and support the

Employer’s Charter. These documents were also produced in partnership

and agreed by the Department of Health, NHS Employers and the National

Employers Pensions Group. They detail NHS Pensions’ and members’ roles

and responsibilities with regards to the NHS Pension Scheme. You can find

these documents on the NHS Pensions website.

This document is important as the respective role and responsibilities of NHS Pensions and Scheme employers continue to evolve over time from a number of different perspectives. For instance:

• There have been changes to legislation that demand up to date accurate mandatory data.

• The provision of accurate membership and service information are key elements to successfully produce Annual Benefit Statements.

• Increase in demand from Pension Scheme members to obtain timely and accurate membership information.

• The technology used for administration is changing.

* This document outlines what the responsibilities of Scheme employers are at a high level. It does not include the specific lower level details about how each of these duties should be performed.

5

This document is applicable to all Scheme employers. This includes all NHS organisations, GP Practices and non NHS employers who have access to the Scheme.

As appropriate within these organisations this document should be used by:



HR Director / Finance Director (or the Director with lead responsibility for the local administration of NHS Pension Scheme matters) who is accountable for the delivery and resourcing of local administration of the Scheme.

HR administrators who need to be aware of the organisation’s responsibilities in regard to the NHS Pension Scheme to be able to inform the staff employed within their organisation as necessary. The NHS Pension Scheme can and should be used as a key part of an employer’s recruitment and retention program as it provides valuable staff benefits.

Pension administrators who are responsible for the day to day administration of the Scheme.

Outsourced providers who provide a pension administration service on behalf of a Scheme employer.

Payroll administrators within organisations from where pension data is provided to NHS Pensions.

6


Scheme employers play a vital role in the administration of the NHS Pension Scheme. Their local administrative duties requires the fulfilment of these primary activities:

• Appointing a named person(s) who is responsible for the day to day administration of the NHS Pension Scheme within your organisation.

• Undertaking the necessary administration procedures for: - New members of staff who wish to join (or opt out of) the NHS Pension Scheme; - Members of staff who leave the organisation and either retire, defer their membership or obtain a refund (if eligible).

- Any members of staff who die whilst in NHS employment.

• Collecting employer and employee Scheme contributions and submitting them on a monthly basis to NHS Pensions. This includes ensuring that the correct contribution bandings are applied.

• To provide accurate, timely membership data, and information about Scheme members currently or previously within their organisation (where available) to NHS Pensions on a standard basis or in response to a request. (This includes undertaking reconciliation between employer held and NHS Pensions held data).

• Provide Scheme members with information about the Scheme, their individual benefits and other basic retirement information.

• Undertake financial accounting requirements (e.g. Greenbury).

Each of these activities is now broken down and explained in further detail in the subsequent sections.

Note: To undertake the activities listed above it is important that local adminstrators regularly keep abreast of NHS Pension Scheme changes which are outlined in Employer Newsletters and on the NHS Pensions website. Employers who use ESR should also refer to the best practice guidance available on K-Base.

7

2.1 - Nominating a local Scheme administrator

Every Scheme employer must nominate: 1. A lead person(s) who is responsible for the day to day administration of the duties outlined in this guide and will act as the main point of contact with NHS Pensions 2. A named senior accountable officer. Any changes in responsibility should be notified to [email protected]

Please note that this information is held in an NHS Pensions database which is used for communication and administration purposes.

The amount of resource needed to locally administer the NHS Pension Scheme is dependent on the size of your organisation. Small organisations, such as GP Practices, should be able in most cases to incorporate these duties as only one part of someone’s overall responsibilities. Larger NHS organisations may need to have one, or more, dedicated full time Pension Officer(s).

The funding, and resourcing of these roles is the responsibility of your organisation’s management and budget holders.:


Note: If your payroll and pensions administration has been outsourced NHS Pensions requires contact details for:

• who is accountable within your organisation for the local administration undertaken by the outsourcing organisation

• who is undertaking the actual administration within the provider.

Outsourcing does not remove an organisations accountability under the Scheme’s Regulations. Therefore, the Scheme employer must ensure that staff involved in the administration of the Scheme are suitably competent.

8

2.2 - Administration of pension events

The table below outlines the primary ‘pensions events’ which Scheme employers must undertake as part of their local administration responsibilities.

Pension Event Main Undertakings Main Forms Required Relevant Notes Timescale

New Starters (Joiners)

The member should be automatically enrolled unless they are ineligible.

Determine which Scheme the member of staff will join.

Provide copy of the relevant Scheme Guide to Scheme Member on employment.

Determine any information about member relevant to administering the NHS Pension Scheme.

Complete ESR or Joining form to join the Scheme (and SD65 if Direction Body)

Required information by NHS Pensions:• Start date• Tiered contribution rate• Whole time/part time• Employment type• Capacity code• Standard hours (if part time)• Census information• Actual hours (if part time)• Name• National Insurance number• Title• EA code

New Starters also include those who decide to latterly opt in , those who become eligible or Bank re-joiners.

NHS Pensions has produced a new employee joiner questionnaire available on the NHS Pensions website. Use of this ensures that all pertinent information needed to join (or opt out of) the Scheme is collected by the Scheme employer.

Within the first month of member joining the Scheme.

Opting out Employers should not provide a member with an opting out form. Members can use a work or home PC to obtain their own opt out form (SD502).

Members must complete part 1 of the SD502.

You must complete part 2.

A general guide for completion of form SD502 is available for employers on our website.

Within one month of receiving the form.

Transfer In Issue the Transfer In Guide on request from a member.

If transfer required complete part 2 of Form A in the Transfer In Guide and return to member.

Within 12 months of joining the Scheme (1995 Section).

Within 12 months of being eligible to join the Scheme (2008 Section and 2015 Scheme).

9


Increasing Pensions Provide members with information on ways to increase NHS Pension benefits (Buying Additional Pension (AP), Money Purchase (AVC) or Early Retirement Reduction Buy Out (ERRBO)).

Set up necessary deductions and payments from payroll.

If member chooses:

a) AP, then employer should complete Part B of form AP1 and send to NHS Pensions for approval. Then establish if application is agreed and set up deductions.

b) AVC, then employer should work with the chosen provider and complete the required paperwork after the member is accepted to make the necessary deductions and payments to them

c) If ERRBO, please ask the member to complete the ERRBO expression of interest form and send to NHS Pensions.

Information for members on increasing pension benefits is provided on the NHS Pensions website at www.nhsbsa.nhs.uk/Pensions

Dependent on option chosen by member.

Estimates Sign post members to TRS/ABS. If unavailable then provide an estimate through Pensions Online (POL).

If no TRS/ABS produce estimate using Pensions Online. Employers with no access to Pensions Online* will need to complete form AW295 and submit to NHS Pensions.

*or are unable to access a members’ record

The main reasons that estimates cannot be produced through Pensions Online is because of data errors. When possible ensure that membership records are up to date when using this system.

NHS Pensions statutory target is 30 working days. Employers should seek to provide members with estimates in a timely manner and at least three months before the members retirement date (if this is known).


10


Total Reward Statement/Annual Benefit Statement

Ensure all member records are up to date for the latest financial year.

Correct any outstanding data issues for previously submitted updates.

Respond to NHS Pension email and POL notification queries.

Clear outstanding SM8s (exceeding whole time)

ESR: When utilising ESR ensure that records match NHS Pensions records wherever possible.

Pensions Online:Employer error handling – Use Pensions Online to update member records to current year, when a record has not been updated.

Non POL users:Respond to data email queries.

The cleaner the employers data, the less estimates will require calculating via Pensions Online.

Employers can redirect the member to the TRS website.

Year end updateslegal requirement for Officer members - Within two months of the end of the financial year. Returns must be supplied no later than the 31 May for the relevant year.

Legal requirement for Practitioners and non GP Providers – Within one month of the end of the financial year immediately following the financial year to which it relates.

Annual Allowance HMRC legislation requires that member records are updated by employers by 6 July, following the end of the pension year. This will enable NHS Pensions to provide a Pension Savings Statement to members who exceed the Annual Allowance.

ESR: When utilising ESR ensure that records match NHS Pensions records wherever possible.

Pensions Online:Employer error handling – Use Pensions Online to update member records to current year, when a record has not been updated.

Non POL users:Respond to data email queries.

If employers do not meet HMRC’s requirement to supply information, then HMRC may impose fines on that employer of:

• Up to £300 where the information has not been provided.

• An additional fine of up to £60 a day for each day the information is late.

Year end updateslegal requirement for Officer members - Within two months of the end of the financial year. Returns must be supplied no later than the 31 May for the relevant year.

Legal requirement for Practitioners and non GP Providers – Within one month of the end of the financial year immediately following the financial year to which it relates.

11


PrematureRetirements(Redundancy)

Obtain estimate for employee.

Close down employment status and submit retirement application.

Obtain redundancy estimate from Pension Online (or NHS Pensions if necessary) at least three months before expected retirement date.

Complete and forward form AW8 three months before retirement (and AW171 if the Award needs to be revised because of updated details).

Redundancy factors for calculating costs are available on the NHS Pensions website.

Three months before retirement.

Ill Health Retirees Collect appropriate medical evidence in connection with potential requests for ill health retirement and submit form to determine eligibility.

If Serious Ill Health then complete appropriate form if requested by the employee.

Complete form AW33E (then complete AW8 once notification received that application has been accepted).

Complete form AW341 to commute existing Ill Health benefits (if serious Ill Health).

Only one application can be made for retirement. For instance members may not have concurrent ill health and age retirement applications.

Ill health applications should be made as soon as applicable for the benefit of the member.(Note: The timing of an ill health application is very important and should ideally be submitted well before paid sick leave ends).

Bereavement Provide information to Next of Kin or Legal Representaives on procedures to claim benefits.

Pay short term death benefits to dependants of deceased members.

Close Employment Record.

Send completed forms to NHS Pensions.

Complete form AW135 for Initial Survivor benefits.

Complete form AW9 or AW11 for survivor benefits.

Complete form AW158 for Child Allowance.

If member is in the 2008 Section employers should contact NHS Pensions to obtain the Life Assurance Lump Sum value.

Bereavement applications should be made as soon as applicable.


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Retirees Provide a copy of the Retirement Booklet to Scheme member.

Close down employment status and submit fully completed retirement application.

Complete and forward form AW8 three months before retirement.

Complete form AW171 if the Award needs to be revised because of updated details.

It is good practice for members to receive an estimate of their benefits before commencing the retirement process. (This includes verifying the Guaranteed Minimum Pension if applicable).

Three months before retirement date.

Scheme Leavers Provide the Leaving Early and Transferring Out Guide to Scheme member.

Leaving details from either ESR or SD55Ton POL or leaver excel spreadsheet for non POL users

Leavers also include employee terminated, employee opt outs, and moving between different Scheme employers.

Complete form SD55T via Pensions Online or the leavers spreadsheet available on the NHS Pensions website. If this information is submitted via ESR then check data accuracy.

Within one month of leaving.

Note – NHS Pensions will only accept current versions of all forms on receipt (as listed on the NHS Pensions website or available from the Stationery Orderline). Any submissions made on old forms will not be accepted. NHS Pensions will exercise discretion for short periods (or where reasonable) after any forms are changed and will ensure that employers are informed when new versions are published via the Employers Newsletter.


2.3 - Collection and submission of contributions

The Scheme employer must:

• Assign the member to the correct pension tier based on their pay.

• Collect the correct member contributions as determined by their tier rate and collect any applicable additional contributions (such as Additional Pension or ERRBO).

• Submit both the employer and employees contributions due in a prompt and accurate manner no later then the 19th of the month following their deduction, (where the 19th is a weekend or bank holiday payment must be submitted to arrive before the weekend or holiday). Scheme employers should note that this is a legal requirement and contributions should always be submitted as soon as it is practicably possible. You do not need to wait until near the deadline. Employers should always reconcile the amount being paid to NHS Pensions with payroll details before submission.

• Late payment of contributions will incur interest and an administration charge.

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2.4 - Providing information to NHS Pensions

Successful administration of NHS Pensions is completely dependent

on the accuracy and updatedness of membership records. This

enables information to be provided to members quickly and

eventually for their pension’s benefits to be paid on time and

accurately.

The way that the administration is organised means that NHS

Pensions is completely dependent on obtaining membership

information from Scheme employers to hold in their central

administrative database and processing systems.

It is therefore imperative that all Scheme employers must provide accurate service data and information about Scheme members currently (or previously) within their organisation to NHS Pensions on a regular, timely basis or in response to an information request. Specifically this requires:

• The submission of the annual return of service and salary details (by ESR, POL SD55s or annual update Excel spreadsheet) by no later than two months (Officers) or 13 months (Practitioners) after the end of the financial year. This information (shown in the table below) must be included where applicable:

- Membership details:• Employee contributions• Employee pensionable pay• Employer contributions• Employer pensionable pay• Employee gross rate of pay• AVC contributions• Non pensionable days (number of, and dates)• Number of part time hours/session worked• Number of part time deemed hours/sessions• Additional pension contributions• Change to start date

- Any changes to membership details in year:• Pension start date• Date of change• Whole time/part time indicator• MHO or Special Class status• Actual hours/sessions• Bank indicator• Contribution rate• NI number• Employment type• Standard hours for the grade


• Submission of relevant changes to NHS Pensions (by POL e-form SD55E or ESR) within a month of those changes being notified to the local administrator or effective. These include:

• Reverse terminations • Opt out cancellation • Bank leaver cancellation • Personal details : - National Insurance number - Name - Date of birth - Date of birth verification - Address - Title - Gender - Former name - Job code

• Scheme employers to provide adhoc service and salary information promptly where reasonable (within a maximum of 20 working days) when requested by NHS Pensions (whether by email, telephone or via Pensions Online).

• Undertaking reconciliation between employer held and NHS Pensions held data.

• Scheme employers to complete, authorise and submit application forms to NHS Pensions for members as listed in the previous section.

• The provision of information in line with relevant Government Legislation such as those relating to personal taxation (i.e Annual Allowance or Life Time Allowance).

• Informing members to contact their pension payment provider when they take up employment (and establish eligibility of them returning to the Scheme).

Note: NHS Pensions will return received data errors to employers via Pensions Online or reconciliation reports.

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2.5 - Provide information to Scheme members

Employers should:

• Be able to answer questions from Scheme members about the NHS Pension Scheme. (Remember, NHS Pensions provides a range of information on its website, Ask Us and a helpline if you don’t know the answer to a particular query).

• Provide Scheme information to new appointees by giving them a copy of the relevant Scheme Guide and informing them that, without exception, they are automatically members of the Scheme unless they opt out following enrolement.

• Provide information to Scheme members about the value of the current pension benefits by referring them to their TRS/ABS or providing them with an estimate through Pensions Online (or by requesting one from NHS Pensions if this is not possible).

• Provide Scheme information to leavers by giving them a copy of the Leaving Early and Transferring Out Guide to inform them of the different options in regard to their pension.

• Tell re-employed retirees (under normal pension age) or ill health Tier 2 retirees to contact their pension payment provider regarding abatement.

• Ensure members are kept informed of any changes to the Scheme that may affect them, using information provided by NHS Pensions. Making members aware that:

• There are options to increase their pension such as by buying Additional Pension or ERRBO.

• Previous pension provision must be transferred into the NHS Pension Scheme (if required) within the relevant timeline.

• They will give up several valuable benefits if they choose to opt out of the NHS Pension Scheme.

• They must register their unmarried partner with NHS Pensions (where applicable) if they want benefits to be paid to that partner after their death.

• Their pension is affected when they are on unpaid leave of absence, enter into a salary sacrifice arrangement or take a career break.


• Educate members on options for planning how and when to retire, e.g. pension calculations and options for flexible retirement.

• Make members aware of the benefits of the NHS Pension Scheme throughout their careers. The key benefits which should be communicated to staff are:

- The NHS Pension Scheme is a defined benefit contributory pension scheme. It is one of the most important and valuable benefits available to eligible staff. The employer makes a substantial contribution towards the cost of the pension.

- The NHS Pension Scheme not only provides the member with a regular income after retirement, but also provides their family or other dependants with financial protection after the member dies.

- All eligible staff, both full time and part time, are automatically members of the Scheme unless they elect to opt out.

- If the member becomes too ill to work, they may receive their pension early.

- The member can increase their pension benefits by buying an Additional Pension. They may also be able to transfer in benefits* from another scheme.

- The NHS Pension Scheme will pay a lump sum if the member dies before retirement and we may pay children’s and dependants’ pensions.

- The member can choose to have part of their pension paid as a lump sum at a ratio of 1:12 (give up £1 pension for an extra £12) lump sum.

- The pension is index linked to protect its value against the effects of inflation.

Note: Scheme employers should not under any circumstances provide financial advice to Scheme members. Only factual information about the rules of the Scheme, the potential value of the members benefits and the impact of any decisions they may make (such as losing Death Benefits by opting out) should be discussed.

*This could be membership or a pension credit

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3: Consequences of non-compliance

Both NHS Pensions and employers are bound by the obligations of the statutory regulations and must work together to adhere to their requirements. The principle ones contained in the Occupational Pension Schemes (Disclosure of Information) Regulations require:

• The payment of pension benefits within 30 days of entitlement. (To comply Scheme employers should ensure that retirement application forms are completed and forwarded to NHS Pensions around three months before the date of retirement and that necessary membership information is accurate and up to date).

• Provision of estimates of retirement benefits to members within two months of request.

(To comply Scheme employers must submit annual returns in accordance with the timescales. Employers must provide estimates to members on request through Pensions Online where a TRS/ABS statement is not available).

• The Occupational Pension Schemes (Transfer Values) Regulations require NHS Pensions to calculate a Cash Equivalent Transfer Value within three months of request.

(To comply Scheme Employers must ensure that data is kept up to date and that accurate information is provided to NHS Pensions promptly on request).

193) Consequences of non-compliance

Failure to comply with your requirements

Scheme employers who do not carry out their responsibilities in a timely and accurate manner can have a detrimental effect on their employees. For instance, if membership records are not adequately maintained then NHS Pensions may not be able to pay out benefits on retirement to members or we may not be able to provide accurate information to inform financial planning or enable transfers to be undertaken.

Scheme employers should note that it may not always be possible for NHS Pensions to later repair a situation which has had a detrimental impact on a member’s pension position through the employer failing to carry out their responsibilities at the correct time.

Cases of member dissatisfaction can result in referrals to the Pensions Ombudsman or the Pensions Regulator and they have the power to impose fines on schemes and employers (and their individual managers) who do not comply with Scheme requirements.

Further to this the DH and NHS Pensions will escalate any serious instances of mis-adminstration or malpractice of the NHS Pension Scheme as appropriate depending on the nature of the issue.

In particular, failure by Scheme employers to provide accurate and timely member information as required by NHS Pensions, will result in appropriate escalation with the DH, NHS Protect and senior NHS Management as applicable. This is consistent with the guidelines set out by the Pensions Regulator in regard to effective record keeping.

Employers should note that NHS Pensions will not accept some incorrect incoming data. NHS Pensions will continue to inform employers about any data errors via the POL notice board, error handling and the reconciliation reports.

Contributions that are not paid on time will incur an administration and interest charge. The standard rate of interest is a daily rate of CPI +3%, compounded annually, and applies to contributions due but unpaid on and after 1 April 2014.

The administration charge is not a ‘penalty charge’, but reflects the cost to NHS Pensions of recovering late payments, which is currently borne by all employers.

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4: The role of NHS Pensions

NHS Pensions’ role as central administrator of the NHS Pension Scheme is to maintain accurate membership records for Scheme members during their career and use this information to provide benefit calculations and payments when required.

To do this they are completely dependent on the work of Scheme employers and the information they provide. NHS Pension provides the following functions to work effectively with Scheme employers and support them to jointly administer the NHS Pensions Scheme:

NHS Pensions will:

• Accurately calculate and pay NHS Pension Scheme entitlements within 30 days of retirement.

• Provide a dedicated help line and email address to answer any queries you have about administrating the Scheme. If NHS Pensions are not able to answer your query immediately they will respond to you within five days.

Employer email address - [email protected] Employer Helpline – 0300 330 1353 Member Helpline – 0300 330 1346

• Provide a dedicated help line and email address to answer any queries from Scheme members about the NHS Pension Scheme.

The target to respond to all queries made within 48 hours (and all postal correspondence within 15 working days).

• Provide you with detailed information about administering the Scheme via the NHS Pensions website.

• Provide you with scheme information for members (whether posters, guides, leaflets etc) to meet our collective disclosure responsibilities.

• Provide you with the necessary tools whether manual or system based to enable you to administer the Scheme quickly and efficiently. (Note: NHS Pensions will continue to make improvements to these tools to improve local administration - subject to the availability of resources and other organisational priorities).

• Provide regular information to you about administering the Scheme via the monthly Employers Newsletter. These newsletters will be the standard method that NHS Pensions keeps nominated Pensions Administrators up to date with important changes or news about the Scheme. An email will be sent to all named administrators and senior officers accountable held within the NHS Pensions database when a newsletter is available. Other staff can subscribe to receive the newsletter as needed.

214) The role of NHS Pensions

(Scheme employers are also advised to subscribe to NHS Employers Workforce Bulletin which contains information about the NHS Pension Scheme from a HR and strategic application perspective).

• Provide information on request to members in line with statutory time limits. These are outlined in the Member’s Charter available on the NHS Pensions website.

• Attend established regional pension forums to discuss Scheme administration issues and update/consult with you on Scheme developments.

• Listen to your feedback and use it to work more effectively together in the future.

• Continue to organise a National Group where the Chairs from each regional forum or specialist group can meet to discuss important pensions issues i.e. changes to strategy.

Note: NHS Pensions will over time as appropriate update and amend the information it provides as required* by changes to the Scheme Regulations and the adaption of procedures in order to adopt these changes and/or improve the administration of the Scheme. They will inform employers when this is the case and consult where necessary.

(* NHS Pensions is obligated to provide information under what is known as Disclosure Legislation. Scheme employers are provided with information to pass on to Scheme members as part of these requirements.)

http://www.nhsemployers.org/about-us/our-communications/nhs-workforce-bulletin

http://www.nhsemployers.org/about-us/our-communications/nhs-workforce-bulletin

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This Charter is intended to be a living document which will be updated as new legislation is introduced or administration changes are made. Scheme employers will be informed about any changes or revisions agreed and consulted where necessary.

The version on the NHS Pensions website will be the latest, most up to date version so employers are advised to check on a regular basis (if they have previously downloaded or printed out copies ) that they have the most recent version. Any revisions will be notified to employers via the Employer’s Newsletter.

The DH, NHS Employers and NHS Pensions welcome any feedback or suggestions on any part of this guide and its contents. Feedback can be sent to [email protected]

5: When will this Charter be updated?

Note: In the absence of any updates this guide will be subject to the minimum of an annual review by the DH, NHS Employers and NHS Pensions.

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ABS Annual Benefit Statement

DH Department of Heath (Workforce Directorate) – The Policy Team who set the rules and policies (in consultation with Trade Unions and NHS Employers) of the NHS Pension Scheme on behalf of the Secretary of State.

ERRBO Early Retirement Reduction Buy Out

ESR Electronic Staff Records.

NHSE NHS Employers represents the collective interests of NHS Organisations.

NHSP NHS Pensions is a service provided by the NHS Business Services Authority on behalf of the DH to centrally administer the NHS Pension Scheme.

POL Pensions Online

TRS Total Reward Statement


This guide has been jointly produced by the Department of Health, NHS Pensions and NHS Employers.