board of directors 31 july 2019 - royal berkshire hospital · 2019 and 22 july 2019 sue hunt 8.2....

Board of Directors 31 July 2019

MEETING31 July 2019 09:30

PUBLISHED24 July 2019

Agenda

Location Date Owner Time

Seminar Room, Trust EducationCentre, Royal Berkshire Hospital

31/07/19 09:30

Board Meeting - Part 1

Topic

1. Opening and Apologies for Absence Graham Sims

2. Staff Story (Verbal) Mary Sherry 09:30

3. Patient Story (Verbal) Janet Lippett 09:40

4. Health & Safety Story (Verbal) Nicky Lloyd 09:50

5. Minutes of 29 May 2019 and Outstanding Actions Schedule andDeclarations of Interest

Graham Sims 10:00

6. Executive Team Peformance Update

6.1. Chief Executive's Report Steve McManus 10:10

6.2. Integrated Performance Report Nicky Lloyd 10:20

6.3. Integrated Care Partnership Performance Update AndrewStatham

11:10

7. Changes to the Constitution Caroline Lynch 11:20

Continued on the next page...

Agenda

Location Date Owner Time

Seminar Room, Trust EducationCentre, Royal Berkshire Hospital

31/07/19 09:30

8. Minutes of Board Committee Meetings and CommitteeUpdates

11:25

8.1. Finance & Investment Committee 20 May 2019, 17 June2019 and 22 July 2019

Sue Hunt

8.2. Quality Committee 10 May 2019 and 9 July 2019 HelenMackenzie

8.3. Audit & Risk Committee 15 May 2019 John Petitt

8.4. Charity Committee 20 May 2019 and 9 July 2019 Graham Sims

8.5. Workforce Committee 10 July 2019 (Verbal) Julian Dixon

9. Board Work Plan Caroline Lynch

10. Date of Next Meeting and Close:Wednesday 25 September 2019, 09.30 - 13:30

Graham Sims

Agenda Item 5

Minutes of the Board – 29 May 2019 1

BoardWednesday 29 May 20199.30 – 13.30Seminar Room, Trust Education Centre, Royal Berkshire Hospital

Members Present

Mr. Graham Sims (Chair)Mr. Steve McManus (Chief Executive)Ms. Caroline Ainslie (Director of Nursing)Dr. Bal Bahia (Non-Executive Director)Dr. Lindsey Barker (Medical Director)Mr. Julian Dixon (Non-Executive Director)Mr. Don Fairley (Director of Workforce)Mr. Brian Hendon (Non-Executive Director)Mrs. Sue Hunt (Non-Executive Director)Mrs. Helen Mackenzie (Non-Executive Director)Mrs. Nicky Lloyd (Chief Finance Officer)Mr. John Petitt (Non-Executive Director)Ms. Mary Sherry (Chief Operating Officer and Deputy Chief Executive)

In attendance

Mrs. Caroline Lynch (Trust Secretary)Mrs. Victoria Parker (Director of Communications & Engagement)Mr. Andrew Statham (Director of Strategy)

There were eight governors, eight members of staff and four members of the public present.

The Director of Nursing highlighted that, as part of the Thames Valley partnership, the Trust had participated in Phase 2 to develop and progress the Nursing Associate role. The Director of Nursing introduced two of the three Nursing Associates that had completed the programme and presented them with their certificates. Jo Sandy, Practice Educator, gave an overview of the work undertaken to support Nursing Associates as part of their programme. This included working with local colleges. The first cohort of Nursing Associates had assisted in shaping the role as well as raising awareness of the new role. The Director of Nursing highlighted that the Quality Committee had received a report setting out how Nursing Associates were deployed into the Trust. The Board congratulated the Nursing Associates on completing their programme.

The Director of Nursing introduced Pedro, Nursing Associate. Pedro gave an overview of his experience in dealing with a patient who was admitted with a Urinary Tract Infection (UTI) and developed pneumonia. The patient did not respond to treatment and a decision was taken to refer the patient for palliative care. Pedro explained that he had undertaken a recent placement in a hospice that had prepared him to deal with palliative care patients. The patient was asked where she would like to pass away and arrangements were made. Pedro advised the difficulties experienced by the patient’s family, particularly, when the patient improved temporarily and then subsequently deteriorated. Pedro advised that staff

Minutes


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provided support to the family as well as the patient. The Board thanked Pedro for presenting the patient story.

The Chief Finance Officer introduced Joao Pedro Silvamatias, Health & Safety Advisor and Jean Sangha, Matron, Midwifery. The team gave a presentation on exposure of staff to Nitrous Oxide. This included the benefits as well the concerns in relation to chronic or prolonged exposure. The Health & Safety Advisor highlighted the areas of the Trust where Nitrous Oxide was used as well the recommendation from the 2014 Care Quality Commission (CQC) inspection in relation to action needed to improve the ventilation system on the delivery suite. The Board noted the steps taken since the inspection included investment in Anaesthetic Gas Scavenger System (AGSS) and Air Handling Unit (AHU) and exposure of staff to Nitrous Oxide being consistently below Work Exposure Limit, and therefore, compliance with COSHH regulations 2002. The Health & Safety Advisor advised that engineering controls had been installed in the Delivery Suite to ensure the protection of staff, patients and relatives (both directly and indirectly) exposed to Nitrous Oxide.

Further work was currently on-going to ensure consistent adoption of best practices, and improve the quality of data available for assurance and risk management purposes. The Board thanked the team for their presentation. It was agreed a further update would be submitted to the Board later in the year. Action: N Lloyd

71/19 Minutes: 27 March 2019 and Matters Arising Schedule

The minutes of the meeting held on 27 March 2019 were approved as a correct record and signed by the Chair.

There were no declarations of interest.

The matters arising schedule was noted.

Minute 34/19 (02/19): Minutes 30 January 2019 and Matters Arising Schedule: Chief Executive’s Report: The Chief Finance Officer advised that final confirmation was still awaited from NHS Improvement in relation to ICS transformation funding.

Action: N Lloyd

Minute 37/19: Integrated Care System (ICS) Update: The Chair advised that he would discuss the need to ensure that ICS engagement events were linked with the membership engagement programmes with the ICS Chairs. Action: G Sims

72/19 Chief Executive’s Report

The Chief Executive introduced the report and highlighted that the Trust had been shortlisted for a patient experience award by CHKS. The Chief Executive highlighted the 180 years of the Royal Berkshire Hospital had been celebrated earlier in the day. In addition, the annual Staff Excellence Awards had taken place on 23 May 2019. There had been 12 categories for the awards and the Board had celebrated the evening with winners, highly commended as well as community partners.

The Chief Executive advised that the Trust had hosted its first LGBT+ staff forum during May 2019.

The Chief Executive advised that there had been challenges in relation to the Trust acceptance of its control total. Following discussion with local system and NHS


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Improvement’s regional team the Trust had been able to bridge the gap in relation to the financial position and a revised control total had been accepted. This would enable the Trust to access capital funding. The Chief Executive advised that the financial challenge remained and KPMG had been engaged by the Trust to assist with the development of a two year transition plan.

The Medical Director highlighted that, as part of the Joint Academic Board, that a challenging process for departments had been undertaken. Departments were required to demonstrate their excellence in three core areas: clinical outcomes, education and research. Following a robust process there had been eight departments shortlisted in Round 1 with two departments receiving the first awards of University Department of Cardiology and University Department of Emergency Medicine. The Medical Director presented the teams with their certificates. The Board congratulated the teams.

The Chief Executive highlighted that the Medical Director had also been invited to receive an Honorary Degree of Doctor of Science from the University of Reading for her work in establishing the Joint Academic Board. The Board congratulated the Medical Director.

The Chief Executive advised that a future Board seminar would be arranged with the Vice Chancellor of the University of Reading. Action: L Barker

73/19 Annual Review of Integrated Performance Report (IPR) and Performance Trajectories 2019/20

The Chief Operating Officer advised that a review of all domains in the IPR had been undertaken with the relevant leads. The Chief Operating Officer highlighted the changes in relation to targets as set out in the report. The Board noted that shadow reporting on some A&E standards were included in the current IPR.

The Chief Operating Officer advised that there had been challenges in relation to A&E performance due to increased activity. The DM01 standard was complex and during 2018/19 there had been significant issues to demand and equipment issues. The Board noted that MRI and cardiology equipment had been included in the capital plan for 2019/20.

The Board noted that, in relation to the workforce metrics, the target for mandatory training would be reduced to 85% for Quarter 1 and Quarter 2 only. Action: M Sherry

The Chief Operating Office highlighted that, in relation to outpatients’ data, some traditional metrics had been removed, and due to the number of transformation programmes in place, it was proposed that further metrics would be added throughout Quarter 1. The Board noted that a detailed review of DM01 would be undertaken and a further update provided to the next meeting. Action: M Sherry

74/19 Integrated Performance Report (IPR)

The Director of Workforce introduced the IPR and advised that the Trust had performed well in terms of both patient experience and patient safety metrics. New reporting criteria for C.Diff. had been set for 2019/20. As a result of these changes the Trust reported six Trust apportioned cases of C. Diff, in April 2019 against a target of 24. Of these six cases, three were Hospital Onset Healthcare Associated (HOHA) and three were Community Onset Healthcare Associated (COHA). Of the three cases reviewed, none were as a result of a lapse in care. The Director of Workforce highlighted that the Trust was one of five acute trusts to have been shortlisted for a Comparative Health Knowledge System (CHKS) patient experience award. The Board noted that mixed sex accommodation remained a


–

challenge for the Trust due to fluctuation in demand although there had been a reduction during April 2019.

The Director of Workforce advised that mortality remained as expected despite increased acuity. The Medical Examiner role also went live at the end of April 2019. The stroke service remained in Band A and all stroke metrics had been achieved during April 2019. The A&E standard remained a challenge for the Trust. However, the Trust performed well when benchmarked against local trusts. In relation to the 62 day cancer standard there had been higher than anticipated performance in March 2019 and all cancer access standards had been achieved during Quarter 4 2018/19 with the exception of the 31 day subsequent radiotherapy. The Trust’s performance against the elective diagnosis wait times standard, DM01, remained challenged. The Chief Operating Officer confirmed that a detailed review was on-going to look at actions that could be taken to support the standard. Action: M Sherry

The Director of Workforce advised that appraisal rate was 88.6%, the highest for 11 months. Turnover had decreased to 13.6%, the lowest it had been since April 2018. The Director of Workforce highlighted that the next overseas recruitment campaign would be Milan in June 2019.

The Director of Nursing gave an overview of the challenge in relation to the new reporting criteria for C. Diff. The Trust’s objective for 2019/20 had been set at 24 cases. Due to the changes made to the reporting and apportioning process there would be a potential impact on the number of cases apportioned to the Trust. The Board noted that, in relation to mixed sex accommodation breaches, the majority occurred in the Acute Medical Unit (AMU) and related to demand. However, the teams were focused on maintaining privacy and dignity of patients and feedback was sought from patients and they were kept continually informed. The Director of Nursing advised that a review of transfer of care out of the midwifery led unit had been completed and actions were being implemented such as four hourly rounding. The unit had also seen a higher number of first time mothers.

The Chief Operating Officer advised that, in relation to A&E performance, there had been significant change in activity with the unit seeing 400 patients on some days. Work was on-going to understand the activity change. Recovery actions included budget realignment to fund ED medical staff overnight at weekends as well as reviewing the increased demand against workforce. A comprehensive data review would be undertaken in the next two weeks. Action: M Sherry

The Board noted that the Berkshire wide urgent and emergency care strategy would consider demographics of patients, and therefore, the service provision for the future.

The Board noted the Health & Safety indicators. The Chief Finance Officer confirmed that the allocation of the capital programme had included a focus on risks in relation to the Corporate Risk Register.

The Chief Operating Officer advised that changes to pay rates for radiotherapy staff had impacted on the radiotherapy element of the cancer pathway. A further update on this issue would be submitted to the Quality Committee. Action: M Sherry

The Chief Finance Officer advised that the Trust was on target in relation to Month 1 financial performance. There had been an increase in pay costs in April as a result of Clinical Excellence Awards and one off Agenda for Change payments. In the revised finance report there would be a full year performance focus on QiPP delivery. Delivery of capital spend and cash flow was also being monitored.


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The Chief Finance Officer advised that work was on-going in relation to improve forecasting and the on-going demand and capacity work would support this.

75/19 Integrated Care System (ICS) Update

The Director of Strategy introduced the report that included the latest ICS delivery report and highlighted the progress made. The Director of Strategy advised that, in relation to the system financial position, a 2 year recovery plan was being developed.

76/19 NHS Improvement (NHSI) Self-Certification Statement 2019/20

The Chief Finance Officer introduced the report that set out the self-certification statements that were prepared as part of the Annual Plan process.

The recommendation was that the Board should answer the statements as ‘confirmed’. The Board approved the recommendations in relation to each of the statements.

77/19 Board Assurance Framework

The Trust Secretary introduced the Board Assurance Framework (BAF) that set out the risks to the Trust’s strategic objectives. The Trust Secretary advised that a significant amount of work had been undertaken over the last few months and the document had been reviewed at Board sub-committees as well as at the recent Board seminar.

The Trust Secretary highlighted that the BAF was a ‘live document’ and each of the Board sub-committees would consider the BAF alongside the Corporate Risk Register at regular intervals. The focus on gaps in assurance would then inform future Board and Board committee agendas. The Trust Secretary advised that the three most significant risks for the Trust were transformation, work as part of system and finance.

78/19 Corporate Risk Register

The Director of Nursing introduced the Corporate Risk Register (CRR) that had been reviewed recently by the Audit & Risk Committee. The Director of Nursing highlighted that C.Diff would be added to the CRR as part of the next review cycle.

79/19 Standing Financial Instructions (SFIs)

The Chief Finance Officer introduced the SFIs that had been reviewed by the Audit & Risk Committee. The Board noted that only minor changes had been made to reflect the change in role title from Director of Finance to Chief Finance Officer. The Board noted that there were no other changes of substance. The Board approved the SFIs.

The Chief Finance Officer advised that as part of the Finance Matters programmes it was anticipated that further changes would be made to the SFIs before the next review cycle.

80/19 Minutes of Board Committee Meetings

The Board received the minutes of the Finance & Investment Committee held on 18 March and 15 April 2019. The Chair of the Committee advised that the May meeting focused on April financial performance and received the revised finance template acknowledging the effort to produce a more user friendly version. The Committee also received an update on the Finance Matters programme.


–

The Board received the minutes of the Quality Committee held on 9 April 2019. The Chair of the Quality Committee advised that the Committee had received a detailed update on CRAB methodology and had received the Quality Account and discussed the lack of progress achieved in relation to the priority related to car parking that had been carried forward for 2019/20.

The Board received the minutes of the Audit & Risk Committee held on 13 March 2019 and 1 May 2019. The Chair of the Committee advised that, at the May meeting, the Committee had focused on the approval of the internal audit plan, received an update on Cyber security and had reviewed and recommended the risk appetite statement and SFIs for approval. The Committee had also reviewed the BAF and CRR.

The Board received the minutes of the Charity Committee held on 13 March 2019. The Chair of the Charity Committee highlighted that the Board of Directors were Trustees of the Charity. At the May meeting, the Committee had discussed the development of strategy for the Charity that would be reviewed later the year prior to submission to the Board. In addition, the Committee would be reviewing the financial controls for the Charity at its next meeting.

The Board received the minutes of the Workforce Committee held on 15 April 2019. The Chair of the Workforce Committee highlighted that the Committee had received the Guardian of Safe Working Annual Report and had received the Health & Wellbeing Strategy and noted the number of initiatives currently on-going.

81/19 Information Item: Board Work Plan

The Board received the work plan.

82/19 Date of Next Meeting

It was agreed that the next meeting would be held on Wednesday 31 July 2019 at 9.30am.

The Board formally thanked Lindsey Barker, Medical Director, who would be retiring from the Trust at the end of June 2019. The Chair highlighted that Lindsey’s significant contribution would be missed by the organisation

Chair

Date

Board Schedule of Matters Arising and Outstanding Actions Agenda Item 5

July 2019

Board Date Board Minute

Subject Decision Owner Expected Submission

Update

29 May 2019 Health & Safety Story

It was agreed a further update would be submitted to the Board later in the year in relation to management of exposure to Nitrous Oxide.

N Lloyd Item included on the work plan

29 May 2019 71/19 (34/19, 02/19)

Minutes: 27 March 2019 and Matters Arising Schedule: Minutes 30 January 2019 and Matters Arising Schedule: Chief Executive’s Report:

The Chief Finance Officer advised that final confirmation was still awaited from NHS Improvement in relation to ICS transformation funding.

N Lloyd Further email confirmation now received from NHS Improvement to confirm that Transformation monies will be forthcoming. Confirmation received from BOB ICS that £1m of monies are allocated to RBFT. Cash not yet transacted. However, confirmation is now received.

29 May 2019 71/19 (37/19)

Minutes: 27 March 2019 and Matters Arising Schedule: Integrated Care System (ICS) Update

The Chair advised that he would discuss the need to ensure that ICS engagement events were linked with the membership engagement programmes with the ICS Chairs.

G Sims Discussed with Chairs who are consulting with their CEOs and communication teams although general feel was that this has been superseded by ICP/ICS structural evolution and so will not go ahead in the Autumn. Item scheduled for a further discussion at the next Chair meeting on 31st July 2019.

29 May 2019 72/19 Chief Executive’s Report

The Chief Executive advised that a future Board seminar would be arranged with the Vice Chancellor of the University of Reading.

J Lippett Work on-going to confirm a date for this.

Board Schedule of Matters Arising and Outstanding Actions Agenda Item 5

July 2019

29 May 2019 73/19 Annual Review of Integrated Performance Report (IPR) and Performance Trajectories 2019/20

The Board noted that, in relation to the workforce metrics, the target for mandatory training would be reduced to 85% for Quarter 1 and Quarter 2 only.

The Board noted that a detailed review of DM01 would be undertaken and a further update provided to the next meeting.

M Sherry

M Sherry

Under review as part of considering deep dive findings

Item included as part of the Integrated Performance report.

29 May 2019 74/19 Integrated Performance Report (IPR)

The Chief Operating Officer confirmed that a detailed review of DM01 was on-going to look at actions that could be taken to support the standard.

Recovery actions included budget realignment to fund ED medical staff overnight at weekends as well as reviewing the increased demand against workforce. A comprehensive data review would be undertaken in the next two weeks.

The Chief Operating Officer advised that changes to pay rates for radiotherapy staff had impacted on the radiotherapy element of the cancer pathway. A further update on this issue would be submitted to the Quality Committee.

M Sherry

M Sherry

M Sherry

Completed. Included as part of the Integrated Performance report.

Item included as part of the Integrated Performance report.

Item to be submitted to future Quality Committee.

1

Title: Chief Executive’s Report

Agenda item no: 6.1

Meeting: Board of Directors

Date: 31 July 2019

Presented by: Steve McManus, Chief Executive

Prepared by: Caroline Lynch, Trust Secretary

Purpose of the Report To update the Board with an overview of key issues since theprevious Board meeting.

To update the Board with an overview of key national and localstrategic environment and planning developments

This includes items that may impact on policy, quality and financialrisks to the Trust.

Report History None

What action is required?

For information and discussion: the Board is asked to note the report.

Assurance Information Discussion/input Decision/approval

Resource Impact: None

Relationship to Risk in BAF:

Strategic objectives This report impacts on (tick all that apply)::Provide the highest quality care Invest in our staff and live out our values Drive the development of integrated services Cultivate innovation and transformation Achieve long-term financial sustainability Well Led Framework applicability: Not applicable

1. Leadership 2. Vision & Strategy 3. Culture 4. Governance

5. Risks, Issues & Performance

6. Information Management

7. Engagement 8. Learning & Innovation

PublicationPublished on website Confidentiality (FoI): Private Public

2

Key Issues

1. Provide the Highest Quality Care

1.1. During early June, NHS Improvement carried out a Use of Resources review to assess how efficiently and sustainably we are using our resources. The Care Quality Commission (CQC) carried out a number of focus groups with staff and governors ahead of a three day unannounced visit to the Trust in early July. 12 inspectors spent time at the Royal Berkshire Hospital, Windsor Dialysis Unit and West Berkshire Community Hospital. The CQC inspectors’ feedback had highlighted that the Trust was very welcoming, staff were highly committed, caring and made decisions that were patient focused which was excellent feedback.

1.2. The CQC will also be visiting the Trust from 30 July 2019 to 1 August 2019 to carry out the Well Led Inspection.

1.3. Our volunteers, play an important role in providing services to patients, visitors and staff, and together give over 1000 hours of their times every week. They offer support on wards, welcome patients and visitors, driving our buggy service, act as patients on our nurse training courses as well as a whole host of other roles to help support the hospital. It was fantastic to have over 100 of our volunteers attend the hospital in June for the Royal Berkshire Hospital’s annual celebration supper to recognise the hard work and commitment they make to the Trust. We greatly value their skills and knowledge that they bring to their role in the hospital and thank them for the time they give up to support the community.

2. Invest in our staff and live out our values

2.1. Nev Davies, Consultant Orthopaedic Surgeon, has recently completed the ‘Race to the

Stones’, a 100km ultra non-stop marathon, to raise funds towards the Royal Berkshire

Hospital Trauma and Orthopaedics department’s new children’s surgical outpatients’ facility.

Nev, who won the Royal Berks Charity Award at the recent Staff Excellence Awards has

successfully raised over £7,000 towards this facility with Support from the Royal Berks

Charity. It is fantastic to see staff members living out the Trust values with such commitment.

2.2. Our Organisational Development Team received the Healthcare People Management Award

(HPMA) for Excellence in Organisational Development for our ‘What Matters’ Programme.

This achievement recognised the hard work and contribution of everyone involved in making

our values and behaviours culture such a success.

2.3. Our current cohort of Project SEARCH students graduated from the current programme in

July 2019. Our students are an important part of our staff teams and it is an important role for

the Trust to offer training, development and future opportunities for your people with learning

disabilities in our local community. Overall, Project SEARCH has successfully supported 60

students since its launch in 2012, with 27 of the students now working at the Trust.

3. Drive the Development of Integrated Service

3.1. Collaborative working has been an increasing element of health policy over recent yearsthrough such publications as the NHS Long Term Plan. Locally, the system has seen the creation of a number of structures including the Berkshire West Integration Programme (BW10), the Berkshire West Integrated Care System (BWICS) and Buckinghamshire, Oxfordshire and Berkshire West Sustainability and Transformation Partnership (BOB STP). These arrangements have been created at different times and with a range of partners in Berkshire West and our wider geography.

3.2. The NHS Long Term Plan states the aspirations to have Integrated Care Systems (ICSs) that bring together both health and care covering populations of 1-3 million by April 2021.

3

3.3. In June 2019, it was announced that BOB STP would become one of three new Integrated Care Systems. As the system continues to develop and mature we will expect to see the evolution of the governance structures that support this, with new structures such as the Delivery Oversight Group having been established. David Clayton has been appointed to the role of Independent Chair of BOB ICS. David has extensive experience in Board level roles within the NHS and is currently the Independent Chair of the Epsom and St Helier Improving Healthcare Together 2020-30 Board and the Chair of the Kent, Surrey and Sussex Academic Health Sciences Network (AHSN). David will work with Fiona Wise, ICS Executive Lead, and the Chief Executives of constituent organisations, to support and promote partnership working, whilst ensuring appropriate levels of independent oversight and assurance of ICS decisions and delivery of strategic priorities.

3.4. BWICS will now become Berkshire West Integrated Care Partnership and a launch event took place on the 18 July 2019. These changes will see an opportunity to streamline and improve the working arrangements locally and provide a single forum for closer working between health and local authorities. It is expected that the changes made will:

Facilitate better working between health and social care with a resulting positive impactin the provision of end to end services across health and social care.

Through closer working arrangements strengthen relationships, develop betterunderstanding of the associated issues, provide a platform for the development ofintegrated health plans and inform Joint Strategic Needs Assessments.

Provide an opportunity for better elective member engagement.

3.5. The NHS is seeing the development of Primary Care Networks (PCNs) that will support care closer to home and designing local systems that are appropriate for the population they serve. The Trust will work closely with 14 of these networks. However, it is important to bring people together to help design how these local systems will work. In Berkshire West we have held ‘Design our Neighbourhood’ events in both Newbury in early July and Reading on the 30 July 2019.

4. Cultivate Innovation and Transformation

4.1. A recent volunteer role that we have introduced is that of a pharmacy runner that helps deliverspecialised medicines to our oncology patients and also general medicines across the Royal Berkshire Hospital site. Our volunteer pharmacy runners have already made a positive difference and this is a great example of transformation being delivered locally by our pharmacy and volunteers to support efficiency opportunities and help improve patient pathways.

4.2. As part of the NHS England (NHSE) Global Digital Exemplar (GDE) Programme, the Trust has implemented Electronic Prescribing and Inpatient Documentation on patients’ Electronic Patient Records (EPR). Work is also on-going to digitalise outpatient records. The Trust had recently achieved a level 5 in digital maturity awarded by the Healthcare Information and Management Systems Society (HIMSS) and are now looking towards the next stage of our digital journey.

4.3. The Board had recently approved a two year capital investment plan including adding key modules for integrated surgery and maternity to the EPR and linking key medical equipment giving immediate access to clinical information such as vital signs and anaesthetic charts. We will also look to introduce a patient portal giving patients’ access to pre-operative assessment, discharge letters and maternity documents. IT Infrastructure will also play an important part by supporting wireless, mobile working and speed of access and security over the next two years of its digital journey.

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5. Achieve Long-Term Financial Sustainability

5.1. We held our Annual General Meeting (AGM) on Tuesday 16 July in the Trust Education Centreat the Royal Berkshire Hospital. We looked back over the 180 years of history of the Royal Berkshire Hospital, and viewed a film that celebrated the rich history of the hospital. We also gave an overview of the vision of our future plans for the Trust. Our Chief Finance Officer presented the 2018/19 financial statements and a look forward to 2019/20 financial performance. The recording of our AGM will shortly be available on our website for anyone that would like to view this.

5.2. We have delivered our Quarter 1 financial position. However, due to increasing demand for our services there are challenges to delivering our full year 2019/20 plans.

5.3. At the beginning of July 2019, we were asked by NHS Improvement (NHSI) to submit revised capital plans with 20% less spend for 2019. We have worked together with colleagues across the Berkshire West, Oxfordshire and Buckinghamshire Integrated Care System, and we have identified some slippage, although, following a risk assessment we have only been able to offer up 7%.

Title: Integrated Performance Report

Agenda item no: 6.2


Date: 31 July 2019

Presented by: Nicky Lloyd, Chief Finance Officer

Prepared by: Performance Team

Purpose of the Report The purpose of this paper is to provide the Board of Directors with an analysis of quality performance to the end of June 2019.

Report History None


The Board is asked to note the report.










July 2019

Integrated Performance Report

The purpose of this paper is to provide the Board of Directors with an analysis of quality

performance to the end of June 2019. The report covers performance against the NHS

Improvement (NHSI) Risk Assessment Framework as well as national and local key

performance indicators.

Contact:

Caroline Ainslie, Director of Nursing

Janet Lippett, Medical Director

Mary Sherry, Chief Operating Officer

Don Fairley, Director of Workforce

Nicky Lloyd, Chief Finance Officer

Contents

Integrated Performance Report Page 2

Introduction Page 3

NHSI Compliance Page 4

Summary Page 5

1. Patient Safety Page 6

Harm Free Care / Incidents Reporting Page 7

Safeguarding Page 8

2. Patient Experience Page 9

3. Clinical Effectiveness Page 11

Mortality Page 12

Clinical Outcomes Page 16

4. Access

Emergency Waiting Times Page 19

Outpatient Experience Page 21

Waiting Times Page 23

Admitted Patient Experience Page 25

Theatres Patient Experience Page 26

Outpatient Experience Page 27

5. Workforce Page 29

6. Staffing Data Page 30

7. Health and Safety Indicators Page 31

8. Finance Page 33

The purpose of this report is to provide assurance to

the Board of Directors on compliance against the

NHS Improvement Risk Assessment Framework,

national and local key performance indicators.

It acknowledges significant and notable

achievements, and highlights and discusses areas of

concern or where performance has a less than

favourable forecast.

Introduction


NHSI Compliance (Access)


CQC - Excellence

CARE - Excellent

Accident & Emergency (A&E)

o Performance against the A&E 4 hour standard continues to be challenged and in June is reported at 86.4% combined (83.1%

Type 1 only).

o The key focus for the Trust remains on service improvement across the whole pathway to secure sustainable performance and

improved patient experience. This continues to be both internal work regarding our pathway management and resource

deployment and with system partners to address the drivers of demand and reduce onward pathway blocks.

o Whilst tactical operational work remains a daily high priority we are also in progress with a deep dive into the cause of

increasing demand and acuity and this is already the subject of consideration at system level. We have secured support from

NHSI in this work.

o The Emergency Department estate and facilities has long been a concern with several small scale improvement projects

delivered over the last few years. Given the recent further increase in demand and consequent pressure on this service the

issue of the Estate will now be taken up to the integrated management risk committee for consideration for inclusion on the

corporate risk register.

Cancer Waiting Times (May 19)

o Performance against the Two Week Wait, 31 Day FDT and subsequent drug treatment have been achieved in May.

o The 62 Day performance has dipped just below the 85% target (84.9%) in May. However subsequent review has identified an

incorrectly reported pathway which brings the Trust above 85%. This will be rectified in the Q1 refresh reporting.

o We will continue to work closely with local commissioners, NHS Improvement and the Thames Valley Cancer Network in

relation to the 62 day standard sustainability as well as implementation of the new 28 day diagnosis standard.

18 Weeks Referral To Treatment (RTT)

o The Trust remains compliant against the RTT 92% standard for June 2019.

Diagnostic Monitoring (DM01)

o The Trust remains non compliant against the 99% DM01 standard. This is subject to deep dive scrutiny.

June 2019 Summary


CQC - Excellence

CARE - Excellent

24/07/2019 Page 5

Provide the highest quality care

• Our patients continue to positively respond to our Patient Surveys.

• The Trust mortality metrics continue to report at as expected levels in SHIMI and CRAB.

• Most Safety and Patient Experience metrics continue to perform well and show a stable trend. However we are currently over target on Clostridium difficile (C.diff) since the national

change in counting of C.diff.

• There were Two Never Events reported in June.

• Areas of on-going concern:

o A&E Access: Performance has deteriorated in June as the department remains under pressure. Recovery actions being worked through including support form NHSI and system

partners.

o Our diagnostic waiting times performance remains non-compliant. Whilst improvement has been made in some areas, new areas of concern emerged in May. Operational teams

are working to identify short and medium term recovery actions and the Trust will continue to work with our partners to identify long term solutions.

o Both of these are subject to deep dive review currently.

Invest in our staff and live out our values

• Job redesign work continues to be developed and will build further momentum through this year’s transformation programmes.• As we continue to develop a focus on ‘releasing time’ to see how we can streamline our processes, release time from meetings, respect and value each individual’s time, to give more

time back to doing the doing, this will link to care group review, finance matters and the developments with KPMG as a restructuring and transformation partner.

Drive the development of integrated services

• Both RBHT and ICS transformation programmes continue to develop through an integrated system working approach including consideration of how various teams can work more

collaboratively, with discussions currently active with transformation teams.

• In early July a Berkshire West Integrated Care Partnership launch event took place and our GPs are working through the first major change to the way surgeries operate since 2004 as

they come together to form groups of Primary Care Networks (PCNs).

Cultivate innovation and transformation

• The Trust continues to progress the next steps of our Digital Hospital Programme and how transformation will be enabled through the use of technology.

• During June work began to implement phase 1 of our text reminder and letter delivery solution. The technical enablement is expected to complete and be in use Trustwide by the end

of August 2019. This work is intended to act as a catalyst for further Transformation which will be delivered through the Trust Outpatient Transformation and Modern Administration

programmes.

• Work continues with KPMG to drive a programme of transformation focused on efficient use of time and resources across the Trust.

Achieve long-term financial sustainability

• At the end of M3 the Trust has reported results £0.05m ahead of Control Total.

• As at the 10th July 2019, the Trust had delivered £2.9m of savings (YTD) against a budgeted cost saving of £3.1m. Month 2 delivered £1m aga inst a forecast of £0.9m.

• As at 10 July, the value of our identified schemes in 19/20 is £13.7m. The Trustwide target for CIPs is £16.8m.

1. Safety Summary

Integrated Performance Report Page 6 24/07/2019 Page 6

Infection Control:

Under the new reporting criteria there have been 4 Trust apportioned (TA) cases of Clostridium difficile (C.diff) reported for June 2019.

The upper limit for 2019/20 is set at 24 cases and to date, 13 TA cases have been reported. Of the 4 reported during June, 1 was reported as a COHA

(Community onset, Healthcare associated) whilst the remaining 3 were reported as HOHA’s (Hospital onset, Healthcare associated).

• The 1 COHA case has undergone a review and no lapses from an RBFT management perspective were identified.

• Case reviews for the HOHA cases are currently in progress to determine whether any lapses in care have occurred.

1 Trust Acquired Meticillin Sensitive Staphylococcus Aureus (MSSA) bacteraemia was reported in June 2019 (6 in May 2019) and a review has not

identified any lapses in care. Of the 6 TA cases reported in May 2019, reviews of 5 cases did not identify any lapses whilst the remaining case awaits

review.

10 TA Escherichia coli (E.coli) bacteraemia were reported in June 2019; reviews have been undertaken and no lapses in care or common themes have been

identified. 1 TA Klebsiella (source unknown) and 0 TA Pseudomonas bacteraemia were reported in June 2019.

Never Events:

There have been two Never Events reported in June. Both are under review. Following completion of the investigations the findings and identified

learning will be presented and discussed at Quality Committee.

Mental Health:

Mental health related attendances to the Emergency Department (ED) reduced to 288 in June from 323 in May 2019.

Children and Young People’s (CYP) mental health attendances reduced to 46 in June from 50 in May 2019.

9 patients detained under the Mental Health Act (MHA): 7 Section 2, 2 Section 5(2). 2 people were brought in to ED on a Section 136.

62 of 101 child safeguarding concerns raised by the Trust (61%) were for CYP who presented with mental health issue or for parental mental health issues.

46 were seen by Children & Adolescence Mental Health Services (CAMHS) and 16 were due to parental mental health disorder. 4 hour breaches

attributed to Mental Health: 1 (CAMHS).

24 Datix related to mental health - common themes:

Aggression – 15. 9 of these attributed to one 16 year old. Aggression directed at parents, staff and on two occasions threats to families on the ward. One

occasion resulted in ward equipment including computer being damaged.

Absconded – 3. One was a patient detained under Section 2, returned to the Emergency deptartment within 12 hours.

Self Harm – 1 CAMHS patient head banging on wall.

2 adult safeguarding concerns raised against the Trust: one related to pressure damage and limited information on discharge. One to possible rough

handling during a procedure – neither was taken forward as safeguarding by local authority.

CQC – Teamwork / Integrity

CARE - Aspirational

1. Safety – Provide the highest quality care



CARE - Aspirational

Harm Free CareTarget

variance

Infection Control Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

Meeting the C.Diff objective 2 1 1 1 1 0 3 2 0 6 3 4 ▲ N 2 2

C.Diff due to lapses in care 1 1 0 0 1 0 0 0 0 1 0 2 ▲ N 0 2

C.Diff (Cummulative) 8 9 10 11 12 12 15 17 17 6 9 13 - N 24 -11

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

MSSA surveillance (trust acquired) 0 3 0 3 1 2 7 1 4 2 6 5 ▼ - - -

Ecoli (trust acquired) infections 3 4 7 2 5 4 5 5 5 7 2 36 ▲ - - -

Target Type: N - National / L - Local / H - Hospital

Incidents ReportingTarget

variance

Falls and Ulcers Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

Pressure Ulcer Incidence per 1 000 bed days 0.89 0.36 0.53 0.76 0.55 0.64 0.87 0.46 0.76 0.31 0.30 0.25 ▼ N 1.00 -0.75

Category 2 Pressure Ulcers 17 7 10 11 10 11 17 10 11 6 11 4 ▼ N - -

Category 3 or 4 avoidable pressure ulcers (SI) 0 0 0 3 0 2 2 0 3 0 2 0 ▼ N 0 0

Patient Falls per 1 000 bed days 5.0 3.6 4.0 4.6 4.3 4.3 4.1 4.1 4.2 3.9 3.8 3.3 ▼ N 5.0 -1.7

Patient falls resulting in Harm (SI) Avoidable 0 0 0 0 1 0 0 0 0 0 1 1 ◄► - - -


Incidents ReportingTarget

variance

Other Incidents Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

Patient safety incidents reported (approved) 752 677 611 701 682 719 773 653 609 617 701 701 ◄► - - -

Number of incidents reported (unapproved) 94 61 59 65 71 81 95 91 75 0 60 86 ▲ - - -

Patient Safety Incidents/100 Admissions 9.2% 8.3% 8.2% 7.9% 8.0% 9.7% 9.1% 8.6% 7.3% 7.3% 8.1% 9.1% ▲ N 7.0% 2.1%

All serious incidents (SI) 4 3 6 6 7 4 8 3 6 1 7 8 ▲ - - -

Never Events 0 1 1 1 1 1 0 1 0 0 0 2 ▲ N 0 2


Target

Target

Actual

Actual

Actual Target


1. Safety – Provide the highest quality care


CARE - Aspirational

Health and Safety Indicators Target

variance

Health and Safety Indicators

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type Month +/-

Number of detentions under the Mental Health Act to the

RBH 8 7 7 8 7 7 5 6 2 8 5 9 ▲ - - -

Number of DOLS (Deprivation of Liberty) applications

applied for 3 3 1 8 11 7 7 7 2 4 9 5 ▼ - - -

Number of DOLS (Deprivation of Liberty) applications

granted1 0 1 0 0 0 0 0 0 1 0 1 ▲ - - -

Number of Child Safeguarding concerns raised by the

Trust62 63 103 71 89 94 108 97 115 80 134 101 ▼ - - -

Number of Adult Safeguarding concerns raised by the

Trust20 21 28 25 29 30 29 26 33 25 36 32 ▼ - - -

Number of Safeguarding concerns raised against the Trust5 1 5 3 4 0 2 1 3 2 1 2 ▲ - - -


SafeguardingTarget

variance

Safeguarding Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

% of relevant staff who have had Safeguarding Children

Level 1 Training93.3% 92.1% 92.6% 93.9% 93.4% 92.6% 92.8% 92.8% 93.5% 94.5% 94.4% 94.5% ▲ N 95.0% -0.5%


Actual Target

Actual Target

2. Patient Experience Summary


29 complaints were received in June and 16 were closed (6 in Planned Care, 7 in Urgent Care and 3 in Networked Care). Analysis of the

29 new complaints has shown that Clinical Treatment (15) and Communication (12) were the top two themes. Of the complaints closed

in June; 5 were well founded and 4 were partially well founded. We are awaiting outcomes for 7 complaints; these are being actively

sought.

Patient Advice and Liaison Service (PALS) - Planned Care received the highest number of PALS, at a total of 93 (86 informal PALS

concerns and 7 concerns originating from GP surgeries directly). Out of the 244 PALS concerns where we have been contacted by the

patient or relative/carer, 49 of these related to Head and Neck and 30 to Emergency Care. The main themes across all of the PALS

received were communication and consultation (96), administration (82) and clinical treatment (52).

66 compliments were logged by the Patient Relations Team, 11 in Networked Care, 8 in Planned Care, 45 in Urgent Care and 2 in Other.

There was an increase in mixed sex accommodation breaches which relates directly to increased demand in the emergency department

and subsequent admissions to the Acute Medical Unit (AMU). The teams are focused on open communication with patients are carers

and protecting patients privacy and dignity.


CARE - Aspirational


2. Patient Experience – Provide the highest quality care


CARE - Aspirational

Target

variance

Patient Complaints Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Number of Complaints 25 20 23 19 28 21 23 28 28 14 17 29 ▲ - - -

Complaints avg response (days) 27 22 25 30 27 24 25 27 26 26 23 22 ▼ L 25 -3

Number of complaints returned for a

second review- - - - - - 1 1 0 0 3 3 ◄► - - -

Number of Patient Advisory Liaison

Service (PALS) concerns237 156 185 236 236 147 219 218 284 232 256 244 ▼ - - -

Number of Complaints to Ombudsman 0 0 0 1 0 0 0 0 0 0 0 0 ◄► - - -

Number of Complaints upheld by

Ombudsman0 0 0 0 0 0 0 0 0 0 0 1 ▲ - - -

Number of compliments recieved to

Patient Relations Department7 75 101 12 35 9 71 0 30 20 25 66 ▲ - - -


Surveys and FeedbackTarget

variance

Trust Patient Survey Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Friends and Family Test (FFT) Response

Inpatients41.8% 47.0% 42.4% 52.0% 51.1% 40.3% 50.8% 47.7% 51.1% 48.3% 49.2% 52.4% ▲ N 30.0% 22.4%

FFT Recommendation Rates Inpatients 99.6% 99.6% 99.8% 99.7% 99.3% 99.6% 99.8% 99.4% 99.6% 99.8% 99.8% 99.8% ▼ N 98.0% 1.8%

FFT Recommendation Rates Maternity 95.8% 97.4% 96.6% 96.3% 97.0% 96.8% 96.5% 97.4% 98.2% 96.8% 96.8% 97.3% ▲ N 95.0% 2.3%

Single sex accommodation - breaches 49 79 - - - - - - - - - - ▼ N - -

Single sex accommodation - breaches

(Excluding Emergency Department

Observation Bays)

- - 41 62 64 105 138 87 166 37 64 105 ▲ N 0 105


Actual

Actual Target

Target

3. Clinical Summary


• Trust mortality, as a crude percentage of admissions, remains as expected, as does the national Summary Hospital-level Indicator (SHMI);

although it remains higher than we aspire to.

• In surgery, risk adjusted mortality and complications remain better than expected overall. An in-depth analysis of Interventional Cardiology

procedure mortality has revealed a number of data issues. General Surgery complication rates have improved and are now as expected and

Urology complication rates are under review. We suspect changes to the emergency pathway and labelling of ‘hot clinic’ patients atinpatient has resulted in this flagging.

• In Medicine, the management of the deteriorating patient is to be a key theme for 2019/20, aligned to trust priorities and working with

colleagues in various sub-specialty areas of medicine. From July 2019 specialty specific reports will be issued directly to clinical teams to

increase awareness and focus on the areas with the highest incidence of triggers.

• The births on the Midwifery Led Unit (MLU) have increased despite needing to close on 4 occasions. The home birth team whilst working

with less team members have still managed to achieve the 4% standard of all births. The term admission to the neonatal unit rate has

increased. Monthly reviews of cases are completed to identify if all admissions are appropriate. The Unit had to undertake diversion once in

June with 0 women being affected.

• The hyperacute stroke service are meeting the admitting targets for Door to needle and Scans. Access to Stroke Ward has dropped below

the target due to capacity challenges for patients that require an onward transfer of care, i.e. for Community Based Neuro Rehabilitation

Therapy (CBNRT) and the Early Supported Discharge (ESD) service. This has resulted in the Stroke Sentinel National Audit Programme

(SSNAP) rating dropping to “B”. These are subject to intensive work with system partners. The transfer in of the Speech and LanguageTherapy (SALT) services this year has enabled closer oversight and support to this team and remains the subject of review to continue to

improve timely access to the service including its contribution to the delivery of the stroke standards on which there is has been some

improvement in June.

• MINAP “door to balloon” is reported a month in arrears. The Trust did not achieve the standard in May due to 2 breaches. Both patients

were self-presenters to ED. Discussed at MINAP meeting with ED team to feedback.

CQC - Effective CARE - Excellent

Crude mortality percentage has increased in June 2019. The volume of deaths are higher than the same time last year whereas the volume of

discharges has decreased. Summary Hospital-level Mortality Indicator (SHMI) remains as expected. Please note NHS Digital have started to publish

SHMI monthly - April 2018 to March 2019 will be published late August 2019.

The Mortality Surveillance Group (MSG) continues to monitor possible or probable avoidable harm related to hospital care and shares learning points

across the Trust. The new Clinical Outcomes Review System (CORS) reporting is now in use and will support the Medical Examiner process and the

structured judgement review (SJR).

3. Clinical – Consistently Delivering Quality Care and Healthcare Outcomes



Trust Mortality

Mortality Reviews April – June 2019

In April – June 2019 there were 389 deaths of which 21% (80) triggered as requiring full mortality review. To date, 27 reviews have been

completed: 96% had exemplary care and nothing further could have been done; 4% identified some suboptimal care, but this would have made no

difference to the outcome for the patients; and none had some suboptimal care which may or may not have made a difference to the outcome for

the patient.

The themes this quarter were:

• Respect / DNACPR / End of life Care (4)

• Clinical Investigations / tests (3)

• Drug errors / delays (3)

• Lack of consultant review (2)

In 2019-20, improving recognition of the deteriorating patient is a quality priority for the Trust. Improvement work planned includes: promotion of

‘safety huddles’; continued embedding and training around ReSPECT forms; focused teaching from our Outreach Team on recognising

deterioration; and reflective post-cardiac arrest reviews.

Individual learning points are discussed at specialty clinical governance meetings and shared at the Mortality Surveillance Group.

The following pages report CRAB mortality and morbidity.




Learning from Deaths



Both perioperative Risk Adjusted mortality and complications for our overall case-mix are better than expected.

Interventional cardiology continues to alert for peri-procedure mortality. Repeated deep dives have revealed a number of issues: attribution of

operating surgeon whilst under another inpatient team and capture of co-morbidities impacting on operative/procedural risk. Following a clinical

review of each case and cleansing of the coded data we are planning a retrospective rerun of the CRAB data to assess the impact. We are looking to

embed this process as part of the mortality review system. General Surgery have previously alerted for complications - this is no longer the case.

Urology are alerting for complications especially in areas of haematoma and urinary retention. Following initial review by the clinical team, we believe

changes to emergency pathways with the Hopkins hot clinic may be contributing to the complications being flagged. This will now be further analysed.

CQC – Excellence / Integrity

CARE - Excellent

Perioperative Care Mortality Overall Perioperative Risk Adjusted Mortality (30 day & in-hospital)

Overall Perioperative complication rate

Complications




CARE - Excellent

Medical ward based care

The number of medical inpatients with 4 or more adverse triggers continues to be higher than the UK Norm. The mortality rate for medical inpatients

with 4 or more adverse triggers has been consistently below the UK norm.

The same 4 triggers (Sepsis, Hospital acquired pneumonia, Acute kidney injury and Shock or cardiac arrest) are consistently above the UK norm (see

below).

Working with the clinical leads for these key areas we have identified a potential significant over recording clinically of some of these conditions. We

are now undertaking focused reviews in care of the elderly and respiratory linking in with QIPPs already being undertaken and working with

microbiology and the sepsis team to bring renewed focus on these patients, their correct identification and treatment – This very much aligns with the

trust focus on improving patient safety.

% of medical ward admissions with > 4 triggers Mortality of medical ward admissions with > 4 triggers

3. Clinical – Provide the highest quality care



CARE - Excellent

Monitoring Clinical OutcomesTarget

variance

Maternity Care Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Women giving birth: 1:1 delivery of care 100.0% 99.0% 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ◄► N 98.0% 2.0%

Midwife : birth ratio (utilised workforce) 1:29 1:29 1:28 1:27 1:27 1:27 1:28 1:25 1:26 1:27 1:27 1:27-

L 1:30

Caesarean Sections - Elective 16.1% 16.2% 12.9% 16.4% 17.6% 13.5% 13.4% 11.7% 12.9% 13.6% 14.8% 13.9% ▼ N 12.0% 1.9%

Homebirths - No of deliveries

(proportion of total) 2.0% 3.0% 2.0% 3.0% 3.0% 3.0% 4.3% 4.5% 1.7% 2.8% 4.0% 5.0% ▲ N 4.0% 1.0%

MLU No of deliveries (proportion of

total) 20.0% 17.0% 17.0% 13.0% 15.0% 22.0% 16.0% 19.0% 17.0% 16.0% 16.0% 19.0% ▲ N 20.0% -1.0%

No of times women diverted 0 0 2 4 0 0 0 0 0 0 0 0 ◄► N 0 0

Percentage of Unexpected NICU

admissions over 37 weeks3.0% 3.3% 3.0% 5.1% 7.8% 4.5% 4.8% 6.5% 5.8% 4.5% 5.3% 6.4% ▲ N 5.0% 1.4%

Number of births 422 416 402 448 411 400 415 378 403 426 394 391 ▼ N - -



variance

Other Clinical Indicators Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

VTE Risk Assessment 96.8% 96.8% 95.9% 97.3% 96.5% 97.3% 95.3% 96.9% 96.1% 97.7% 95.8% 95.2% ▼ N 95.0% 0.2%

VTE Incidence (Hospital & Community

Acquired)45 55 44 62 58 31 71 69 76 62 59 36 ▼ N - -

Datix: Number of VTE Incidence

(Hospital Acquired)0 0 0 1 0 0 1 0 0 0 0 0 ◄► N - -

Datix: % VTE Incidence (Hospital

Acquired)0.0% 0.0% 0.0% 1.6% 0.0% 0.0% 1.4% 0.0% 0.0% 0.0% 0.0% 0.0% ◄► N - -


Actual Target

Target Actual

3. Clinical – Provide the highest quality care



CARE - Excellent


variance

Stroke Care Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Proportion of patients spending 90% of

their inpatient stay on a specialist stroke

unit (national target)

86.0% 85.0% 89.0% 82.0% 82.0% 72.0% 77.0% 65.0% 74.0% 87.0% 74.0% 75.0% ▲ N 80.0% -5.0%

Proportion of stroke patients scanned

within 12 hours of hospital arrival93.0% 88.0% 95.0% 92.0% 96.0% 94.0% 98.0% 92.0% 93.0% 87.0% 93.0% 96.0% ▲ N 0.0% 96.0%

Proportion of people with high risk TIA

fully investigated and treated within

24hrs (IPM national target)

92.0% 87.0% 94.0% 83.0% 71.0% 82.0% 63.0% 71.0% 81.0% 100.0% 100.0% 94.0% ▼ N 90.0% 4.0%

Average Length of Stay (LOS) from

admission to discharge (days)12 11 15 15 14 17 16 15 19 13 16 15 ▼ N 14 1.0

Door to needle time <60mins 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ◄► N 95.0% 5.0%

Proportion of S&LT communication

assessments <72 hrs100.0% 100.0% 90.0% 90.0% 86.0% 86.0% 82.0% 79.0% 82.0% 100.0% 70.0% 90.0% ▲ N 95.0% -5.0%



variance

Cardiac Care Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Myocardial Ischaemia National Audit

Project (MINAP): Call to Balloon target

less of than 150 minutes

100.0% 100.0% 100.0% 100.0% 89.0% 100.0% 100.0% 93.0% 100.0% 100.0% 100.0% ◄► N 82.0% 18.0%


Project (MINAP): Call-to-Balloon target

of less than 120 minutes

88.0% 100.0% 93.0% 100.0% 89.0% 82.0% 100.0% 93.0% 90.0% 100.0% 100.0% ◄► N 86.0% 5.7%


Project (MINAP): Door-to-Balloon target

of less than 90 minutes

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 89.0% 88.0% ◄► N 97.0% 3.0%


Actual Target

Actual Target

4. Access Summary


24/07/2019 Page 18

• Deep Dive reviews into the Emergency 4 hour and Diagnostic (DM01) standards have been undertaken through June/July 2019 and have been

included as part of the July Trust Board agenda. Papers included within board packs.

A&E performance - (Deep Dive)

Performance against the 4 hour standard has deteriorated further in June reporting 86.4% against the 95% standard. Month on month attendance

and admission numbers remain high when compared to the same month in the previous year.

Delayed Transfers of Care (DToC)

• The proportion of admitted patients formally reported as DToC has increased in June. Whilst the total number has not increased significantly

over the previous month both the number of lost bed days and overall proportion of occupied beds has shown a significant increase. This

corresponds with a high number of stranded (>7days) and super stranded (>21 days) patients reported in June. This is contributed to by a

number of significantly complex cases and particular resource issues in each Local Authority. This is subject to escalation at DASS level and at

A&E DB.

Cancer Performance - May

• 62 day in-month performance missed the standard by 1 breach. Subsequent validation (post-submission deadline) has identified one patient

incorrectly classified as a breach and will be remedied for the Q1 position.

• Improving 31 day subsequent radiotherapy performance, expect further improvement in June post validation.

Cancer Performance - June

The June position is currently being validated and is therefore not final. We expect to be compliant with the 2WW standard. Risk remains around

the 62d standard due to ongoing PET-CT pressures.

Cancer Performance - Residual Risk

• Increasing pressure on both the Endoscopy and Dermatology services with extremely limited capacity.

• PET-CT. There are growing concerns related to the provision of the current PET-CT service (Tertiary) which is reporting a waiting time of up to 4

weeks. This has been raised with OUH and TVCA and a solution is being sought with In-Health.

• Pathology remains a key area of focus (review and reporting of specimens timeframes) Improvement is expected by mid-June but knock on

impact will be felt on pathways until August due to the upfront delay caused.

• MRI and CT equipment fragility continues to pose a performance risk.

• Impact of substantive staffing vacancies in relation to Radiotherapy. Recovery and transformation plan in progress, including recent successful

recruitment.

Referral To Treatment (RTT)

• The Trust remains compliant with the 92% standard. During April/May, as part of the Trust Data Quality and Assurance Programme an

externally supported technical review of our automation process was undertaken and scored well. Over the summer period work will

commence to complete a data quality tidy up exercise of the full RTT PTL as part of the final phase of transition to the Digital Pathways Solution.

Diagnostic Monitoring (DM01) – (Deep Dive)

• The diagnostic standard remains a significant challenge for the Trust. There has been a small improvement in June. However remains

significantly below the 99% expectation. Deep consideration will be given to actions for each modality to agree where it is viable to target

recovery actions, balancing these with financial constraints and emergency cancer demand.

CQC - Excellence

CARE - Excellent

Cancer

RTT

DM01

A&E

4. Access – Provide the highest quality care.

CQC - Excellence

CARE - Excellent


Type 1 performance in June has improved from the previous

month, although has remained challenging at 86.4%.

• The department continues to see a steady increase in patients conveyed over the

age of 70yrs. It is the highest change proportion.

• For 2019 YTD Comparing June 2018 to June 2019 there is an increase of 11% of

over 70yrs presentations to ED. This is a 45% increase when comparing June from

2019 to 2015.

• Pressure has increased in ED as follows:

• When comparing June 2019 to June 2018, ED has seen a

2.5% increase in attendances.

• The volume of patients streamed to the GP streaming

service has been one of the lowest months since its

opening. This is mainly due to a reduction in

presentations to ED for minor illness. The service has also

not had full staffing and therefore has had to shut on

numerous occasions.

• Ambulance handovers were slightly down in June

averaging 94 handovers per day.

A&E ExperienceTarget

variance

Waiting Times: A&E Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

A&E 4hr Limit (RBH combined) 95.6% 95.8% 93.7% 87.9% 88.2% 86.1% 89.4% 89.6% 90.6% 91.3% 92.6% 86.4% ▼ N 95.0% -8.6%

A&E 4hr Limit (RBH combined) - QTR 95.08% 87.41% 89.92% 90.13% ▲ N 95.0% -

A&E 4hr Limit (Type 1 only) 95.0% 95.48% 92.9% 85.6% 86.1% 83.2% 87.1% 87.5% 88.5% 89.0% 90.8% 83.1% ▼ N 95.0% -11.9%

A&E 4hr Limit (Type 1 only) - QTR 0.0% 0.0% 94.4% 0.0% 0.0% 85.0% 0.0% 0.0% 87.7% 0.0% 0.0% ▲ N 95.0% -

A&E Type 1 (number) 9881 8925 9263 9827 9741 9423 9350 8685 9630 9052 9710 9551 ▼ - - -

A&E Type 1 conversion to admission rate (%) 29.9% 32.3% 31.5% 32.0% 31.7% 33.3% 35.1% 34.0% 33.8% 33.0% 32.4% 30.0% ▼ - - -

A&E Type 1: Majors & Resus (number) 6955 6493 6842 7085 7065 7191 7309 6839 7385 6920 6932 7000 ▲ - - -

A&E Type 3: Streamed (number) 1051 944 680 673 577 830 824 882 1091 963 978 963 ▼ - - -

Trolley Waits: 12 hour decision to admit (DTA) 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

Ambulance Handover : 30 Minutes 2 28 38 106 92 125 144 51 73 92 75 ▲ N 0 75

Ambulance Handover : 60 Minutes 0 1 2 4 10 2 20 2 5 7 6 ▲ N 0 6


Actual Target

Jun-18 Jun-19 % Difference

Attendances 9312 9551 2.50%

Admissions 2840 2863 0.81%

Breaches 382 1612 321%

CQC - Excellence

CARE - Excellent 4. Access – Provide the highest quality care.


2873 handovers were received into ED.

Acuity remained high with various pockets of increased demand.

Average 93 ambulances per day.

• Breach analysis shows an increase in ED Delays, particularly overnight.

This is a mixture of being unable to fill the extra Dr shift over night and

the demand which is causing overcrowding. On average 63% of ED

delays have a primary breach reason of overcrowding.

• Changes in ways of working has seen a dramatic improvement in

arrival to assessment time with recent increases in demand we have

not been able to remain within the 15 minute standard.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Monday 23 12 12 12 15 10 7 15 10 21 17 22 24 24 23 25 25 24 24 24 16 24 23 18

Tuesday 19 11 7 7 14 12 4 12 10 16 27 20 17 30 27 26 17 26 22 33 26 22 21 21

Wednesday 16 11 8 15 10 9 9 7 14 28 26 25 20 21 22 24 19 25 32 22 17 18 21 20

Thursday 12 17 8 6 7 9 11 10 11 9 16 29 25 25 28 28 25 22 24 23 22 24 17 17

Friday 12 17 6 10 9 8 4 15 12 9 16 21 19 27 16 25 26 24 32 19 23 18 18 25

Saturday 17 22 20 12 10 10 10 12 15 15 23 33 23 28 24 29 25 36 30 30 31 26 31 27

Sunday 26 24 9 19 15 17 10 15 14 15 19 22 23 30 27 28 27 22 24 29 22 24 21 30

Arrival Time - Hourly Analysis

Rule 1 Rule 2 Rule 3 Rule 4

n n n n

Ambulance attendances

This week 6 wk avg.

708 697

Rule 1 Rule 2 Rule 3 Rule 4

n n n n

40 46

Ambulance handover (over 30 minutes)

This week 6 wk avg.

0

10

20

30

40

50Arrival to Assessment

CQC - Excellence

CARE - Excellent 4. Access – Provide the highest quality care.


Shadow Reporting

- Proposed Standards



CQC - Excellence

CARE - Excellent

28 Day

Diagnosis

31 Day -

Aggregated

62 Day -

Aggregated May 2019 - 91.8% 85.1%

Outpatient ExperienceTarget

variance

Cancer Pathways Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Cancer 2 week wait: cancer suspected - QTR 0.0% 0.0% 94.8% 0.0% 0.0% 96.8% 0.0% 0.0% 96.3% 0.0% 0.0% 96.1% ▼ N 93.0% 3.1%

Cancer 2 week wait: breast patients - QTR 0.0% 0.0% 95.9% 0.0% 0.0% 98.5% 0.0% 0.0% 96.3% 0.0% 0.0% 96.1% ▼ N 93.0% 3.1%

Cancer 31 day wait: to first treatment - QTR 0.0% 0.0% 96.6% 0.0% 0.0% 98.0% 0.0% 0.0% 96.9% 0.0% 0.0% 96.6% ▼ N 96.0% 0.6%

Cancer 31 day wait: drug treatments - QTR 0.0% 0.0% 99.0% 0.0% 0.0% 99.6% 0.0% 0.0% 98.6% 0.0% 0.0% 99.3% ▲ N 98.0% 1.3%

Cancer 31 day wait: surgery - QTR 0.0% 0.0% 96.4% 0.0% 0.0% 98.4% 0.0% 0.0% 95.2% 0.0% 0.0% 90.1% ▼ N 94.0% -3.9%

Cancer 31 day wait: radiotherapy - QTR 0.0% 0.0% 94.8% 0.0% 0.0% 94.4% 0.0% 0.0% 92.6% 0.0% 0.0% 83.1% ▼ N 94.0% -10.9%

62 day consultant upgrade: all cancers - QTR 0.0% 0.0% 90.0% 0.0% 0.0% 64.0% 0.0% 0.0% 69.7% 0.0% 0.0% 70.0% ▲ - - -

62 Day GP Ref - QTR 0.0% 0.0% 75.1% 0.0% 0.0% 85.1% 0.0% 0.0% 85.1% 0.0% 0.0% 84.9% ▼ N 85.0% -0.1%

62 Day screen Ref - QTR 0.0% 0.0% 94.4% 0.0% 0.0% 86.0% 0.0% 0.0% 92.1% 0.0% 0.0% 82.4% ▼ N 80.0% 2.4%



variance

Cancer Pathways Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Cancer 2 week wait: cancer suspected 94.4% 95.0% 95.1% 95.9% 98.0% 96.6% 93.3% 98.2% 97.3% 96.4% 97.1% 94.8% ▼ N 93.0% 1.8%

Cancer 2 week wait: breast patients 96.4% 96.8% 94.5% 97.4% 99.5% 98.6% 97.8% 98.4% 93.0% 96.6% 94.9% 96.6% ▲ N 93.0% 3.6%

Cancer 31 day wait: to first treatment 94.5% 96.3% 98.7% 97.9% 98.5% 97.5% 98.2% 96.6% 95.8% 96.1% 96.3% 97.6% ▲ N 96.0% 1.6%

Cancer 31 day wait: drug treatments 98.9% 97.7% 100.0% 100.0% 100.0% 98.2% 98.9% 98.4% 98.2% 100.0% 100.0% 98.0% ▼ N 98.0% 0.0%

Cancer 31 day wait: surgery 94.4% 100.0% 96.4% 98.3% 97.7% 100.0% 90.3% 100.0% 97.1% 93.3% 91.7% 88.9% ▼ N 94.0% -5.1%

Cancer 31 day wait: radiotherapy 93.3% 96.8% 94.5% 95.6% 91.8% 96.3% 94.3% 97.1% 85.4% 78.9% 81.6% 89.6% ▲ N 94.0% -4.4%

62 day consultant upgrade: all cancers 92.3% 77.8% 100.0% 50.0% 77.8% 62.5% 75.0% 0.0% 68.0% 66.7% 85.7% 57.1% ▼ - - -

62 Day GP Ref 71.0% 71.4% 83.0% 86.5% 87.0% 80.7% 83.1% 85.3% 87.0% 84.6% 84.9% 87.5% ▼ N 85.0% 2.5%

62 Day screen Ref 100.0% 93.3% 92.3% 81.3% 100.0% 82.6% 95.6% 86.7% 92.3% 89.5% 86.7% 70.0% ▼ N 80.0% -10.0%

Incomplete 104 day waits 6 7 9 8 6 10 11 11 8 7 10 9 ▼ N 0 9


Actual Unvalidated Target

Actual Unvalidated Target



CQC - Excellence

CARE - Excellent

18 weeks RTTTarget

variance

Waiting Times: 18 weeks RTT Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

18 Weeks: incomplete pathways (%) 92.4% 92.6% 92.5% 93.2% 92.6% 92.5% 92.2% 92.3% 92.3% 92.5% 92.8% 92.8% ◄► N 92.0% 0.8%

18 Weeks: incomplete pathways (number) 32738 32537 31408 30994 30105 29974 29916 29253 28843 29850 28979 28615 ▼ N - -

18 weeks complete patients (Admitted clock

stops)1866 1934 2326 2418 2691 2427 3037 2739 2806 2729 2974 2540 ▼ N - -

18 weeks complete patients (Non Admitted clock

stops)6338 5266 5552 5634 6130 5234 6884 5869 6102 5629 6146 6046 ▼ - - -

52 Weeks - Admitted 0 0 0 0 0 0 0 0 0 0 0 0 ◄► - 0 0

52 Weeks - Non-admitted 0 0 0 0 0 0 0 0 0 0 0 0 ◄► - 0 0

52 Weeks - Incomplete 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

Diagnostics Waiting < 6 weeks (DM01) (%) 97.6% 98.4% 99.1% 98.8% 98.5% 97.0% 94.8% 98.1% 97.6% 95.7% 95.1% 95.6% ▲ N 99.0% -3.4%

Diagnostics in 6 weeks: active (number) 4934 4814 5027 4938 5373 5304 5336 5612 5529 5169 5519 5272 ▼ N - -

Diagnostics in 6 weeks: seen (number) 6136 6021 5641 6866 6228 5438 8232 6576 6402 5904 6127 6596 ▲ N - -


Actual Target


4. Access –Provide the highest quality care.

CQC - Excellence

CARE - Excellent

Admitted Patient ExperienceTarget

variance

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

TypeMonth +/-

Percent of Ambulatory Care of Non elective

Admissions30.1% 32.3% 31.0% 28.2% 23.4% 22.4% 23.6% 29.2% 29.6% 25.4% 25.9% 24.7% ▼ N - -

Number of Delayed Transfers of Care (No. of

patients)70 84 70 73 77 100 89 132 115 113 102 105 ▲ N - -

Number of Delayed Transfers of Care (Lost bed

days)617 741 592 600 658 900 719 1153 934 831 851 948 ▲ N - -

Delayed Transfers of Care (%) 3.7% 4.8% 3.8% 3.6% 3.7% 4.2% 2.7% 4.7% 4.7% 5.1% 4.8% 6.0% ▲ N 3.5% 2.5%

Average non-elective length of stay - excluding 0

day LOS (Length of Stay)5.9 5.8 5.7 6.0 5.9 6.1 6.1 7.3 6.4 6.3 5.9 5.9 ▼ N - -


Actual Target



CQC - Excellence

CARE - Excellent

Placeholder – Graphics under development

Theatres Patient ExperienceTarget

variance

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

TypeMonth +/-

Hospital Cancelled Ops on day of surgery - non

clinical (Numbers)15 25 11 13 34 12 18 17 6 19 23 27 ▲ - - -

Hospital Cancelled Ops on day of surgery - non

clinical (Percentage)0.3% 0.6% 0.3% 0.3% 0.8% 0.4% 0.3% 0.4% 0.2% 0.5% 0.6% 0.7% ▲ - - -

Cancelled Ops not re-scheduled < 28 days 0.0% 0.0% 0.0% 0.0% 2.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ◄► N 5.0% -5.0%

Urgent Operations Cancelled 2nd time 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

In List Theatre Utilisation 86.6% 87.7% 86.5% 88.6% 86.9% 85.7% 87.1% 88.2% 88.4% 87.5% 87.3% 88.2% ▲ L 90.0% -1.8%

Sessional Theatre Utilisation 88.0% 92.0% 96.0% 92.0% 93.0% 91.0% 94.0% 93.0% 92.0% 93.0% 92.0% 91.0% ▼ L 90.0% 1.0%

Daycase (DC) Admissions 3618 3480 3261 3719 3629 2940 3690 3265 3461 3416 3586 3220 ▼ - - -

Elective (EL) Admissions 568 542 594 657 645 508 502 535 595 545 596 552 ▼ - - -

Average elective length of stay - excluding 0 day

LOS2.6 2.7 2.8 2.8 2.5 2.6 2.9 2.5 2.7 2.9 2.6 2.7 ▲ L - -


Actual Target



CQC - Excellence

CARE - Excellent

Placeholder – Graphics under development


variance

Waiting Times: Outpatient Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target

TypeMonth +/-

Number of New Attendances 16108 15998 14541 14444 17084 16584 13135 16452 15223 16427 15446 16084 ▲ - - -

Number of Follow Up Attendances 31430 32078 30787 30966 34743 33298 26226 33900 29827 31362 30607 31656 ▲ - - -

Appointments cancelled by RBFT (number) 3618 4052 3956 4003 4710 4955 4289 5229 4539 4765 4790 4685 ▲ - - -

Appointments cancelled by patient (number) 3043 2970 2820 3106 3502 3520 2813 3365 3166 3108 2991 3250 ▼ - - -

DNA Trust Level 4178 4239 4109 4380 4960 4753 3992 4877 4277 4159 4163 4709 ▲ - - -

DNA Rate 7.3% 7.3% 7.5% 7.9% 7.9% 8.3% 8.0% 7.9% 7.2% 7.4% 8.0% 8.0% ◄► - - -

New to Follow Up Ratio 1.9 2.0 2.0 1.9 1.9 1.9 1.9 1.8 1.8 1.9 1.9 1.8 ▼ - - -

% Advice and Guidance 82.3% 89.7% 89.2% 87.6% 75.2% 83.6% 82.3% 89.6% 87.5% 89.3% 86.4% 86.6% ▲ - 1 0

% Appointments at Virtual clinic 4.2% 3.9% 3.8% 3.5% 3.5% 3.7% 3.6% 3.6% 3.8% 4.1% 4.7% 4.4% ▼ - - -

Actual Target

5. Workforce – Invest in our staff and live out our values.

Appraisal Rate – Appraisal rate improved slightly over the month to 88.2% reflecting follow-up action by DOW. Urgent Care jumped to 91.3% compliance and

Corporate was stronger by over 2% points.

Completed Mandatory Training – Mandatory and Statutory Training (MAST) compliance rose above 89% for the first time ever! The recently added Health and

Safety continues to improve and finished the month at 86% - up 4.5% points on the month.

Rolling 12-month Sickness Absence – The Workforce Team have continued with the programme of targeted intensive training options for managers, in areas

who have some of the highest sickness rates as well as providing the standard bookable training. The first tranche are progressing well and we will be moving on

to implement stage 2 of the programme in due course. We will in the medium/longer term be looking to widen this programme to cover managers who have an

identified need for this training option, based on an on-going evaluation of those areas with higher absence levels.

Vacancy Rate – The current vacancy rate has increased in June it reached 10.33 % against a the Trust target of 7%. However due to our successful recruitment

campaigns in 2018 / 2019 overseas recruitment of EU and NON EU has excelled showing Quarter 1 offers exceeding 113 appointments made for band 5 nurses.

Note: Cost Improvement Programme (CIP) WTE reductions are not in the current budget, which increases vacancies.

Agency Spend – Agency spend reduced in the month of June. Temporary staffing are working with NHSP to increase the numbers onto the bank for the

specialisms within Nursing, agency spend increases in areas such as Urgent Nursing when requirements escalate. Spend within AHP will be reducing by

September with requirements reducing due to vacancies being filled. Temporary staffing continue to work with NHSP to increase the number of shifts worked

by bank staff to avoid the continued use of agency.

Rolling 12-month Turnover – The Trusts turnover figure is 14.3%, showing an upward trend. Within the BOB recruitment and retention meetings we are

conducting a mapping exercise around aligning processes and benefits that we offer within our BOB region such as accommodation schemes and financial

support, as well as the reason behind the movement of employees to identity the behaviours of individuals that move around trusts.


CQC - Integrity / Excellence

CARE - Resourceful / Excellent

Caring CultureTarget

variance

Workforce Indicators Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

Appraisal rate 86.8% 86.9% 85.8% 85.1% 85.3% 87.1% 87.3% 88.4% 87.4% 88.6% 87.8% 88.1% ▲ L 90.0% -1.9%

Completed Mandatory Training 88.0% 87.7% 86.7% 87.4% 87.4% 87.9% 88.3% 88.3% 88.4% 87.5% 88.6% 89.1% ▲ L 85.0% 4.1%

Rolling 12 month Sickness absence 3.3% 3.3% 3.3% 3.3% 3.3% 3.3% 3.3% 3.2% 3.2% 3.2% 3.2% 3.2% ◄► L 3.3% -0.1%

Vacancy rate 7.0% 8.3% 8.3% 7.2% 7.1% 7.4% 7.3% 7.3% 7.0% 8.7% 9.2% 10.3% ▲ L 7.0% 3.3%

Agency spend % of total staff cost 3.9% 4.1% 3.7% 3.8% 3.3% 2.4% 3.9% 3.4% 3.3% 2.9% 3.3% 3.0% ▼ L 3.7% -0.7%

Rolling 12 month Workforce Turnover 14.6% 14.4% 14.9% 14.4% 14.2% 14.8% 14.6% 14.3% 14.5% 13.6% 13.9% 14.3% ▲ L 14.5% -0.2%


Target Actual


6. Staffing Data – Invest in our staff and live out our values.

CQC - Integrity / Excellence

CARE - Resourceful / Excellent

Caring CultureTarget

variance

Staffing Data Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

% Fill rate of Registered Nurse Shifts (RN) 91.7% 90.3% 90.7% 92.7% 94.2% 90.5% 92.6% 89.4% 88.8% 91.3% 92.5% 93.2% ▲ N 90.0% 3.2%

% Fill rate of Care Support Worker Shifts (CSW) 107.1% 109.2% 108.1% 107.8% 106.8% 107.3% 109.5% 110.1% 107.8% 113.6% 113.5% 112.6% ▼ N 90.0% 22.6%


Target Actual

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reportable incidents: June saw a patient harm and a staff harm

incident reported to the HSE. This has been reported by the Trust as a Serious Incident with an investigation currently being undertaken.

Health and Safety inspections/advisory visits: The available inspection time this month was committed to completing the inspections of the hub

sites. The reduction in inspections this month is due to classifying these as single inspection rather than multiples inspections.


7. Health and Safety IndicatorsCQC – Teamwork / Integrity

CARE - Aspirational

Health and Safety IndicatorsTarget

variance

Incidents Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Target Type

Month +/-

RIDDOR reportable Incidents 3 1 2 6 4 2 5 2 2 1 2 2 ◄► - -

Total non clinical incidents reported 70 49 39 79 83 69 77 72 49 55 66 79 ▲ - -

Abuse/V&A (Patient to staff) 24 18 10 28 47 38 31 30 20 18 32 33 ▲ - -

Body fluid exposure/needle stick injury 16 5 8 24 15 16 18 17 11 10 13 14 ▲ - -

Building works 19 7 2 15 8 5 11 8 4 7 11 20 ▲ - -

Slips and Trips 5 9 4 2 4 3 1 4 9 7 2 8 ▲ - -

Musculoskeletal - Inanimate object 0 3 4 2 5 2 1 1 3 3 1 4 ▲ - -

Staff receiving H&S related training Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Month +/-

Manual Handling non patient every 3 years 90.3% 88.9% 89.6% 83.4% 90.4% 90.7% 91.9% 92.0% 92.3% 92.2% 91.5% 92.7% ▲ > 90.0% 2.7%

Conflict Resolution 85.1% 85.3% 85.1% 83.4% 83.4% 82.5% 82.8% 81.4% 81.6% 79.9% 80.6% 83.9% ▲ > 90.0% -6.1%

Fire (Annual) 86.0% 84.6% 84.2% 83.4% 85.4% 85.3% 86.8% 86.0% 87.1% 87.0% 87.4% 88.3% ▲ > 90.0% -1.7%

Nursing and AHP Manual handling training

every 3 years90.4% 90.3% 90.1% 90.5% 90.3% 91.1% 90.8% 90.7% 91.1% 90.5% 89.8% 90.7% ▲ > 90.0% 0.7%

Doctors manual handling training every 3 years 60.9% 64.3% 65.5% 68.4% 71.3% 71.3% 70.8% 72.4% 74.7% 75.0% 74.5% 75.7% ▲ > 90.0% -14.3%

Health and Safety Training - - - - - - - - - 77.7% 82.3% 86.5% ▲ - -

Health and Safety inspections/advisory visits - - - - - - - - - 18 27 6 ▼ - -

Health and Safety Indicators Target

variance

Civil and Enforcement Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun DoT Month +/-

Personal Injury claims 1 0 1 1 0 1 0 0 0 0 0 1 ▲ - -

Interaction with Regulators 0 0 0 1 0 0 0 0 0 0 0 0 ◄► - -


Actual Target

Actual Target

The Overall RAG rating (Red, Amber, Green) is a subjective risk rating determined by the Head of Engineering. By using a variety of records and

information, it is an agreed but subjective view of the key item as an overall risk view.

The Datix risk assessment accounts for entries which highlight a particular risk in that key item category and using the Datix matrix for scoring.


7. Health and Safety IndicatorsCQC – Teamwork / Integrity

CARE - Aspirational

8. Finance Summary


Month 3 2019/20

Income and Expenditure

Performance against control total: The Trust performance is £0.05m ahead of Control Total for YTD at £(4.55)m against £(4.60)m target. The Trust is

focusing upon changes to capacity in line with the 2019/20 QIPP plan. The Trust Use of Resources Rating was 1 at year end. It is currently 3, which is in line

with the 2019/20 plan.

Patient care Income: Patient income is £0.86m favourable to plan. Elective and Non-Elective activity is overall above plan, within this Berkshire West

activity is significantly above the plan within the cost form of contract that the Trust has with the CCG. We are reviewing the in year implications of tariff

changes for non elective care.

Other Income: The M03 YTD position includes £1.29m centrally funded MRET monies and £1.63m PSF monies, included in this is an additional £ 0.58m

bonus PSF relating to 18/19. It is important to note that this income is excluded when calculating performance against the control total target. Education

Training Grants and Other Funding income is £(0.50)m behind plan, partially driven by release of income accrual. Work is on -going with R&D to ensure

the correct capture of income.

Pay: Pay fell compared to M02, due to reduction in temporary staffing spend. Nursing overspend is largely attributable to Urgent Care front door

demands, and unachieved QIPP across the organisation. Bed Closure plans need to be realised to enable savings to be made. Medical staffing is £0.11m

under budget YTD, however there are a number of specialties that are overspent and this will be addressed within the demand and cap acity work. The

Trust will focus on stress-testing run rates of pay aligning with activity levels.

Non Pay: Non pay is overspent against plan by £(0.33)m. The Non Pay excluding Drugs variance is £0.19m favourable. Drug income below plan by £(0.51)m

YTD. Miscellaneous expenditure is above plan by £(0.20)m YTD. £(0.90)m relates to unallocated QIPP.

Balance Sheet

Cash position: Cash is below plan as the plan anticipated Q4 PSF monies to be received in M02. However cash remains strong due to high levels of

accruals within the cost base. Typically the Trust operates with c£1m in its day to day bank accounts following payment of daily/weekly commitments and

holds up to £30m in short term investments through the Government Banking Service (GBS). £15.2m of PSF was received on 15 th July 2019 , pushing the

M05 forecast cash to above £50m.

Debtors: Non NHS Debtor Days are significantly better than plan. NHS Debtor days are behind plan. This is driven by higher NHS receivables due to the

post financial year end award of bonus PSF in 2018/19 and lower levels of revenue in non-NHS lines.

Creditors: Creditor days are over plan. Work continues through Finance Matters to ensure Purchase Order receipting is completed in a timely manner to

enable payment to terms.

Capital plan: At Month 3 the Trust has spent £2.54m of its capital programme (including £0.11m of donated capital ). The Trusts has committed an

additional £5.68m.

CQC - Excellence / Integrity

CARE - Resourceful

8. Finance Summary



CARE - Resourceful

Title: Deep Dive for Trust Board on DMO1 and Performance

Agenda item no: 6.2


Date: 31 July 2019

Presented by: Mary Sherry, Chief Operating Officer

Prepared by: Sarah Webster, Care Group Director of Operations, Planned CareMandy Claridge, Care Group Director of Operations, Urgent CareMary Sherry, Chief Operating Officer

Purpose of the Report To share with the Board a report being presented to EMC which sets out the prevailing circumstances and issues relating to delivery of the DM01 diagnostic standard.

Work is in progress to take forward the conclusions and next steps set out in the paper both internally within the Trust and via Planned Care Board, ICP Delivery Group and the ICP Unified Executive

This includes work in progress to determine the resource and financial implications of the current situation and developing trends.

Work on this will continue and incorporate comments from Trust Board.

Report History Executive Management Committee – 22 July 2019


To Board of Directors is asked to note and comment on the report.


Resource Impact: None at present time


1. Leadership √ 2. Vision & Strategy √ 3. Culture 4. Governance

5. Risks, Issues & √Performance




of 21

Purpose of this paper:

To brief the Trust Board on the drivers behind recent DM01 performance and options

for recovery

1. Background

1.1 The diagnostics standard measures 13 modalities managed across 3 care groups. The

standard requires the Trust aggregate waiting list to demonstrates that (at month end) 99%

of patients should have a waiting time of no more than 6 weeks.

1.2 For the purposes of this deep dive exercise we have focussed on outlying modalities that are

the most challenged.

1.3 The following points are important to note:

All 13 modalities* contribute to the delivery the trust aggregate position

The standard is based on the snap shot waiting list position (not numbers seen) at month

end ie at the end of each month how long have patients been waiting (covering booked and

unbooked patients)

To reliably deliver 99% at Trust aggregate level means that all modalities need to strive to

deliver 100% and any marginal variations across the 13 modalities can compromise that

Trust level aggregated delivery

In practice this means that our tolerance is c. 50 patients in total across all modalities who

may show at > 6 weeks on the waiting list at each month end (on average our waiting list

size is c. 5000)

The under performance over the previous 12 months has not been a consistent single issue

failure, it has been a collection of issues affecting a number of the modalities at varying

times throughout the period, not a single problem that has remained unsolved

Predominantly the most affected modalities are high volume and are heavily reliant on

equipment and/or have a well documented capacity (people) issue

Typically the most affected specialties are also balancing delivery of emergency and cancer

work and these balancing decisions are absorbed into the operational management decision

making that supports the delivery of the balance scorecard of standards

This crystalises as follows:

o Predominantly equipment issue: MRI

o Predominantly resources with occasional equipment issues: Cardio

o High volume demand plus pressure on cancer and urgent/emergency pathways:

MRI, CT and Gastroenterology

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o Occasional underperformance as a result of lost capacity (equipment or capacity):

CT, Audiology, Peripheral Neurophysiology (EMG), Sleep Studies,

Diagnostics Waiting Li s t Performance By Modal i ty

Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19

MRI 99.40% 95.30% 93.20% 96.50% 98.00% 94.20% 98.30%

CT 99.40% 99.70% 97.00% 99.90% 98.40% 100.00% 99.20%

NON_OBSTETRIC_ULTRAS 99.90% 100.00% 99.80% 100.00% 99.90% 99.60% 100.00%

DEXA_SCAN 100.00% 100.00% 92.30% 94.80% 100.00% 100.00% 100.00%

AUDIOLOGY_ASSESSMEN 96.10% 97.80% 95.10% 98.00% 98.20% 97.80% 95.40%

ECHOCARDIOGRAPHY 97.80% 92.40% 88.40% 99.70% 99.10% 94.20% 97.80%

PERIPHERAL_NEUROPHY 98.70% 97.00% 98.50% 100.00% 98.00% 91.50% 58.20%

SLEEP_STUDIES 100.00% 95.80% 97.20% 100.00% 86.10% 91.80% 77.10%

COLONOSCOPY 95.20% 90.60% 90.10% 93.60% 88.70% 88.90% 80.90%

FLEXI_SIGMOIDOSCOPY 93.20% 91.20% 93.70% 97.20% 91.70% 87.20% 89.00%

CYSTOSCOPY 97.70% 98.00% 94.10% 100.00% 98.70% 99.20% 95.20%

GASTROSCOPY 95.40% 96.30% 93.30% 97.60% 90.70% 85.20% 87.60%

URODYNAMICS - - - - - - -

Diagnostics Waiting List By Modality

Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19

MRI 1513 1626 1809 1790 1679 1581 1573

CT 864 883 904 961 1085 871 956

NON_OBSTETRIC_ULTRAS 1241 1161 945 1048 975 895 905

DEXA_SCAN 85 97 91 97 79 62 67

AUDIOLOGY_ASSESSMEN 491 460 385 458 490 495 499

ECHOCARDIOGRAPHY 279 263 302 289 325 309 364

PERIPHERAL_NEUROPHY 77 67 65 46 100 142 153

SLEEP_STUDIES 6 24 36 35 36 49 48

URODYNAMICS 0 0 0 0 0 0 0

COLONOSCOPY 273 255 284 298 212 225 329

FLEXI_SIGMOIDOSCOPY 148 125 126 179 145 141 181

CYSTOSCOPY 133 99 135 115 155 128 146

GASTROSCOPY 263 242 254 296 248 271 298

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June’s data

Diagnostic Test Name

Total

Waiting

List

Number

waiting

6+

Weeks

Number

waiting

13+

Weeks

Percentage

waiting 6+

weeks

%

within

6

weeks Month

MRI 1357 43 1 3.2% 96.8% Jun-19

CT 891 4 0 0.4% 99.6% Jun-19

NON_OBSTETRIC_ULTRASOUND 1114 1 0 0.1% 99.9% Jun-19

DEXA_SCAN 70 0 0 0.0% 100.0% Jun-19

AUDIOLOGY_ASSESSMENTS 488 15 0 3.1% 96.9% Jun-19

ECHOCARDIOGRAPHY 294 2 0 0.7% 99.3% Jun-19

PERIPHERAL_NEUROPHYS 170 46 2 27.1% 72.9% Jun-19

SLEEP_STUDIES 39 2 0 5.1% 94.9% Jun-19

URODYNAMICS 0 0 0 Jun-19

COLONOSCOPY 332 68 0 20.5% 79.5% Jun-19

FLEXI_SIGMOIDOSCOPY 146 21 0 14.4% 85.6% Jun-19

CYSTOSCOPY 84 2 0 2.4% 97.6% Jun-19

GASTROSCOPY 287 30 0 10.5% 89.5% Jun-19

5272 234 3 4.4% 95.6% Jun-19

2. Modality review

2.1 Each modality has completed a deep dive into the drivers for current performance and

reviewed the conditions that would be necessary to enable achievement with the DM01

standard within the next 2-3 months.

2.2 The table below summarises the position per key modality and further detail for each is

included within the appendices.

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Modality Cause of current

performance

Level of difficulty

associated with short

term recovery

Cost associated with

short term recovery

(if known/applicable)

MRI Significant growth in

demand (routine and

cancer); Equipment

failures

Medium – reliant on

additional sessions

£96k over 4 months

followed by costs to

sustain

Audiology Historic capacity

limitations; Referral

backlog due to one-off e-

referral & ENT processing

issues

High – no scope for

additional sessions nor

locum availability

-

Echo-cardography Increasing scan

complexity; staff shortages;

equipment failures


additional sessions

and recruitment

(recruitment currently

positive)

To be calculated

Peripheral

Neurophysics

Significant growth in

demand; removal of

Saturday additional

sessions


additional sessions

£9k over 5 months

Sleep studies Fluctuating spikes in

demand; admin errors

Cosnultant Vacancy

Medium – internal D&C

review underway to

rebalance capacity

-

Gastroenterology Significant growth in

demand (routine and

cancer); significant

capacity limitations

High – reliant on

further additional

sessions and

additional physical

capacity

£176k over 4 months

followed by costs to

sustain

3. Summary of initial findings

3.1 There are some longer term low/no cost service improvements that the modality teams are

working to implement, including service redesign, outpatient transformation, and

administrative reviews.

3.2 However in the short and medium term there are significant cost pressures associated with

recovery and sustaining improved DM01 performance.

3.3 Three recurring themes across most modalities include:

3.3.1 Significant growth in demand particularly when combined with demand for urgent cancer

services on the same services. Where urgent cancer referrals have been prioritised, waiting

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times for routine appointments on the DM01 pathways have extended beyond the 6 week

standard.

3.3.2 Limited substantive capacity to meet the combined growth in demand, with reliance on

high cost additional sessions required to both maintain current performance and further

costs required for immediate recovery.

3.3.3 Equipment and estates constraints; these have been considered as part of the capital

plan for 19/20 where possible.

4. Conclusion and next steps

a) To discuss and consider the current approach re: prioritisation of cancer/emergency access

vs DM01 and to validate the necessity to continue this approach

b) Services to continue to clinically review waiting lists and complete Quality Impact

Assessments where appropriate to document impact of not improving DM01 waiting times

c) Services to continue to develop and deliver long term action plans to increase capacity within

challenged services at low/no cost where possible

d) Following EMC and Trust Board to consider the position regarding DM01 delivery and

approach going forward

e) To take this deep dive and outcome of the discussions described into the ICS Diagnostics

Programme for further strategic work

Appendices:

1) MRI Deep Dive

2) Audiology Deep Dive

3) ECG Deep Dive

4) Peripheral Neurophysics Deep Dive

5) Sleep Studies Deep Dive

6) Gastroenterology Deep Dive

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Appendix 1 – MRI Deep Dive

Introduction:

Over the last six years the demand for MRI scanning has risen by >40%, driven by changing population

demographics and advances in both imaging technology and clinical application. The below graph illustrates

patterns of demand, capacity and activity over the past two years.

There has been no increase in in-house MRI scanner provision since 2009; however, over the last few years,

a number of initiatives and productivity gains have been introduced to manage increasing demand and meet

the diagnostic waiting time target. These include:

Increase in the hours of operation from 7.5 to 12.0 hours per day, Monday to Friday

Demand management through clinical vetting of all referrals

Introduction of weekend working (although this has remained ad hoc due to the national shortage ofqualified Radiographers and local recruitment challenges)

Review and redesign of workflow processes (LEAN), including external review (Newton, Four EyesInsight/PWC)

Review of protocols to reduce scanning times

Additional evening/weekend incentive lists

Outsourcing to the private sector

Commercial rental scanner support (Alliance Medical) now at 7-days per week

These initiatives had allowed the department to maintain DM01 performance but recent clinical developments,

combined with scanner reliability issues, have resulted in MRI performance falling below 99% since end

December 2018.

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The current waiting list position as of end May ‘19 is detailed below:

0-<1 week 1-<2

weeks

2-<3

weeks

3-<4

weeks

4-<5

weeks

5-<6

weeks

Over 6

weeks

Total

MRI scans

Imaging Magnetic Resonance Imaging 220 448 360 231 191 94 301,574

Patients still waiting - exclude patients

w aiting for a planned diagnostic

test/procedure

Reasons for not achieving include:

A 50% increase in cancer 2ww referrals over the last year, which impacts on number of available‘routine’ slots

Introduction of mpMRI Pelvis/Prostate scanning to comply with NICE guidelines (currently c.20referrals per week)

Limitation on the scan types that can be scheduled on the WBCH mobile scanner and the commercialrental scanner, which causes a disparity in waiting times between the main RBH site and the spokefacilities

On-going reliability and image quality issues with the ageing WBCH mobile and delays to itsreplacement. The new unit was due to be commissioned in June ‘19 but now won’t be available untilOctober/November ‘19

Limited availability of commercial scanner support due to national pressures on MRI capacity acrossthe UK

The above have placed additional strain on a system already challenged by demand and capacity issues.

At the end of May the DM01 position for MRI had recovered from 92.8% in January ‘19 to 98.1%. Since May, additional steps have been taken to further address the waiting time. These include:

Replacement of the Alliance rental scanner with a relocatable unit, equipped with a new scanner. Thiswill increase the range of scans performed on the unit, removing some pressure from the main site

Agreement with West Berks CCG to remove direct access to MRI Knee scanning for patients >50years of age. This will go live during July/August, reducing demand by c.600 scans p.a.

Increase in the number of weekend lists, as staffing levels improve

Trajectory for recovery:

July August Sept Oct Nov

Number

Number of procedures by month necessary to achieve 99%

2208 2208 2134 2208 2134

Number of procedures planned

Capacity (RBH, WBCH & BRK) 2024 1950 1900 2000 1900

Unused slots

0 0 0 0 0

Additional capacity

Private sector - BIH 80 80 80 80 80

Additional lists 0 12 12 12 12

Other - Alliance rental 66 176 242 330

Costs

£8150 £20,900 £28,548 £38,748 t.b.c.

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Sustainability – list what is required to maintain the DM01:

Continued availability of ad hoc rental days to meet fluctuations in demand

Opportunity to outsource to Rutherford, currently dependent on suitable IT infrastructure, protocoldevelopment etc. Currently under investigation

Long term solution will be the completion of the WBCH MRI project, scheduled for 2021, which willprovide a new build equipped with two additional MRI scanners

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Appendix 2 – Audiology Deep Dive

2015 2016 2017 2018 2019

0

100

200

300

400

500

600

Average referrals

Apr-18

May

-18

Jun-1

8

Jul-1

8

Aug-18

Sep-1

8

Oct

-18

Nov-

18

Dec-18

Jan-1

9

Feb-1

9

Mar

-19

Apr-19

May

-19

93

94

95

96

97

98

99

100

DM01 compliance

The average compliance was 17/18: 98.8% 18/19: 97.2%

Reasons for not achieving

Currently the aspect of audiology not achieving the 6 week standard is patients waiting for Audiology Balance

assessments. Over the last few months the number, whilst relatively small has been increasing and

represents almost all of the longer waits in Audiology. A limited number are due to patient choice, difficult to

achieve in such a short time frame.

However there have been 2 issues causing delays in referrals reaching the booking team;

A change was made external to audiology whereby referrals were being e-sent to Audiology, the team

were not aware of this change in process. Message centre in boxes were not configured causing

referrals not to show to the team.

A large volume of M-modal letters had been waiting for processing in ENT CAT and it is anticipated

that a number of referrals will be generated for audiology.

Currently we do not know the extent of the problem due the issues with referrals and are expecting the

position to get worse. By the time the referrals reach audiology they have already breached.

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Recovery

The balance clinic is a very specialised clinic and only a few clinicians can do this and there is no scope for

these clinicians to do additional sessions.

The patients are being triaged to bring some in for shorter appointment times to do initial history and basic

diagnostics. These patients are being seen as 45 mins slots to clear the immediate; not all will be appropriate

for this but will help. The team have been asked in anyone would be able to do some overtime and this has

been discussed with the Care Group Finance Director.

There is a plan to reorganise the balance clinic but this will not happen this quarter.

We are exploring the use the locums, however this is very difficult due the specialist nature of the balance

clinics.

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Appendix 3 - Echo-cardiography Deep Dive

1. Introduction

1.1 Cardiac Physiology is an extremely busy service at the RBFT, with over 50,000 different diagnostic tests being conducted each year; for both Out and In-patients.

1.2 An area of development and concern is that of Echocardiography; that currently sees a large variety of different types of scan. But increasingly more complex imaging is required, in line with updated guidance and protocols.

1.3 These changes have increased the complexity of these scans and the new physiology valve clinics have increased the time required to conduct them. This is further exacerbated by the volume and ability of the current hardware to do them.

1.4 Echocardiography capable physiologists are a limited resource, with a national shortage.

1.5 The RBFT has been fortunate with staff retention and has limited use of locums to support the service for the last 15 years.

1.6 However, in recent months our ability to recruit and retain has been challenging.

1.7 A bench-marking exercise has highlighted that we are competing with neighbouring organisations that offer financial benefits and improved support structures that we find difficulty in matching.

1.8 This exercise itself has also caused reduced moral, by learning about the different pay structure elsewhere within our region.

1.9 Our Echocardiography hardware is in constant use and of an age where breakages or failures routinely occur.

1.10 Service contracts have not been renewed with the company since 2012; this was part of a CIP programme to save. On-site repairs are carried out by the medical engineering team.

1.11 If local repair not achievable, the hardware is frequently out of action awaiting parts, off-site repair. With the delays in funding etc., further exacerbating the time the hardware is out of action.

1.12 In March 2019, 3 Echo’s failed simultaneously, resulting in the cancellation of Out-patient clinics, reduced activity and subsequently impacting on the DM01.

1.13 Current hardware is still serviceable and supported, and therefore was given a low risk score by Medical engineering. However, the frequency of failure, the time taken for re-commissioning is significantly affecting the department’s performance and finances.

1.14 The risk was uprated, and an emergency CIG was approved to replace defunct kit and increase the number of assets available.

1.15 The new and replacement kit is due to be on site at the end of July 2019.

2. Activity

2.1 During October 2017 the out-patient waiting list was practically zero, with all patients booked into

appointments well within the 6 week, DM01, target.

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2.2 Out-patient activity reduced during November 2017 and February 2018 due to failure of equipment

leading to loss of capacity and cancellation of patients. Extension of wait times and impacting on the

DM01.

2.3 This was followed by a sustained period of recovery. And prompted a Capital request for 2018/19. This

request was rejected based on the current hardware being supported and serviceable.

2.4 A similar episode has occurred in December 2018, and we continue to see a loss of activity and

cancellation of appointments. Extension of waiting times, and encroachment on the DM01 target.

2.5 We currently have over 400 patients waiting to be booked.

3. Ability and availability

3.1 Herceptin patients requires myocardial strain imaging, this is in line with changes in the treatment

protocol. The time taken to undertake these studies is now doubled, furthermore we currently only have 2

machines capable to carry-out these studies. And are based at the RBH.

3.2 We are also unable to exam other patients at outreach clinics, such as anyone with a more than mild

valve problems, patient with pulmonary hypertension and Cardiomyopathy due to the imagining quality of

the machines and the need to do a in depth scan.

3.3 These machines are basic and have been unsupported by any maintenance thus no software upgrades

either. To sum up we can only do the ‘normal’ patients on the outreach machines now, everyone else has

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to come to RBH. Thus patients attend at the outreach clinics (referred from GP’s) and we have to re-refer

them into RBH.

4. Repairs and engineering.

4.1 We have many aging machines that are becoming unreliable. This last year has seen the loss of at least 1

machine at any one time, with the occasional loss of 2, and the extreme events whilst repairs are carried

out.

4.2 The current hardware is still supported and serviceable; however the reliability is somewhat poor with

increasing spending to operationalize the equipment.

Service Contracts RepairsProbe

repairs/replacment

2010/11 £8,840 £0 £0

2011/12 £8,840 £0 £0

2012/13 £9,282 £0 £0

2013/14 £0 £1,035 £945

2014/15 £0 £27,992 £4,398

2015/16 £0 £15,818 £8,725

2016/17 £0 £14,474 £0

2017/18 £0 £19,708 £6,600

2018/19 £0 £31,105 £19,250

Total £26,962 £110,132 £39,918

Echocardiography service and repair costs

5. Recommendations, recovery and sustainability.

5.1 We have 2 major reasons why the DM01 is not being achieved.

- Due to equipment failures, robustness, repair times and lack of resilience.

- Due to staff shortages and ability to recruit.

5.2 Equipment has been approved and ordered, the delivery of these new machines is expected the last week

of July 2019. And commissioned ready for use in August.

5.3 With 2 senior members of staff retiring, and another 2 moving region (all in July/August) we find ourselves

with further risk, however recent recruitment has seen a high quality field of applicant.

5.4 Once equipment and new staff in place we expect recovery of this standard.

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Appendix 4 - Peripheral Neurophysics Deep Dive

2 year pattern of activity referral

Average per month 17/18 - 89 18/19 – 74:

Current waiting list

153 (76 booked outside of 6 week target)

Current activity by modality

75 per month

Current demand

Usually 85 per month, but current spike at 140 per month YTD

Reasons for not achieving

Historically the department has used as hoc sessions on Saturdays to meet fluctuating demand. Since March

the additional sessions have not been approved. It was highlighted at the time that this would cause DM01

breaches – and at the time this risk was accepted.

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Recovery

Trajectory for recovery :

1. By August including resources required

2. No cost longer term option to achieve

Appointment of Neuro-technician linked to EEG Business case could increase capacity

One-stop shop for Carpal tunnel EMG – using physio EMG technicians (minimal cost)

Sustainability: what is required to maintain DM01 performance

Additional EMG technician to do CT EMGs as described above – 1-2 sessions extra per weekB7 – cost = 0.2WTE = approx. £10K per year

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Appendix 5 – Sleep Studies Deep Dive

Introduction

Respiratory Physiology is a busy service at the RBFT that conducts a wide variety of diagnostics for both in and out-patients, which include but are not limited to: Oximetry, Spirometry, Histamine Challenges, Cardio Pulmonary Exercise Testing (CPET) and Pulmonary Function Tests (PFT’s).

The team also monitor and manage the Obstructive Sleep Apnoea (OSA) pathway way. With assessment and titration of the patients’ ventilation sleep device, Continuous Positive Airway Pressure (CPAP).

The department has seen rapid growth over the last 5 years, going from 2 staff members in 2015 to 6 staff members’ year to date.

Recruitment and retention has not been problematic, due to strong leadership, good team work and an excellent development programme.

An increase in the number of patients on the OSA management pathway is primarily due to the fact that OSA is more widely understood by health care professions and the public alike. Coupled with the fact that treatment, CPAP, is a lifelong therapy, with continued monitoring required.

Due to the increasing size of the population and obesity, a leading cause of OSA, the number of patients on our treatment list is likely to continue to grow. More patients start therapy then are stopping.

This increase was identified previously and steps have been put in place to managing them differently, in attempts to improve efficiency and cope with growth across all diagnostic modalities.

In 2018 we commenced a transformation programme of remote monitoring; this has been highly successful, resulting in a 33-50% time reduction in conducting CPAP reviews. This is planned to expand to the majority of the patients utilising OSA therapy.

The kit we utilise is serviced and of good standard, recently we purchased more diagnostic equipment in order for us to undertake more diagnostics within our spoke sites.

More resources, human, will be required to efficiently provide these services within the spoke sites.

Activity

From April 2017 until November 2018, activity remained static, with occasional peaks in

referrals, followed by a reactive response in the provision of additional capacity and slots.

The monitoring of this was delayed, and this reactive response would unfortunately result in a

reduction in compliance of the DM01 target.

Whilst we have seen a rise in referrals, the activity increase in November 2019 is in fact

erroneous; EPR data capture had improved demonstrating a more accurate picture of our

activities.

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Data quality still remains an issue, but the above increase is a more representative illustration of

activity.

Increasing demand on other diagnostics, including spirometry, has led to the demand on the

total service to struggle. Where balancing out waits and clinical priorities hasn’t helped to

address the DM01 compliance target.

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Au

g-1

7

Se

p-1

7

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Fe

b-1

8

Ma

r-1

8

Ap

r-1

8

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Se

p-1

8

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Fe

b-1

9

Ma

r-1

9

Ap

r-1

9

Ma

y-1

9

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

DM01 compliance

Our breach reasons are as of a result of three primary reasons:

No capacity.

Administration errors.

Patient choice as they do not see this as an essential test.

Breach assessment

A set clinic template is in place to allow direct booking into clinic slots; on occasions we see

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referrals outstrip our capacity with spikes in referrals.

Our service covers all spoke sites and in-patient activity as well. Nursing staff are less likely to

undertake diagnostic assessments, instead referring to the physiology team to support. This is

activity that is not previously counted or accounted for.

When no capacity is available; time-tables, clinic space and personal are reviewed to provide

additional ad hoc capacity and mop up those patients.

With changes in activity, further capacity demand modelling is required to be undertaken to

address the increasing frequency of these ad hoc sessions.

The process to triage referrals results in delays in booking patients, on occasions the triaged

referrals get collated and additional capacity is sort too late to prevent breaches.

Our administrative processes need to be reviewed in order to streamline and make this process

more effective.

We have also seen administrative errors, where patients have been booked outside of breach

target. PTL review discovered this practice has happened on several occasions and steps are

now in place to avoid this.

There have been several occasions where patients have been referred and are not available to

attend their appointment due to not being available or on holiday.

Recommendations, recovery and sustainability.

We have 2 major reasons why the DM01 is not being achieved.

Due to miss-match of capacity and demand for sleep appointments.

Due to administration processes and occasional errors of booking outside of breach.

We have limited impact on patients not attending due to prior arrangements.

Hosting a large variety of different diagnostics, we need to conduct a complete service capacity

and demand review, in order to identify gaps, balance waiting times and increase clinic slots for

sleep diagnostics.

We will need to review the human resources available to carry out diagnostics in a responsive

manner across all trust sites.

We need to work with the ICS and our community partners to review new ways of working,

reduce wasted appointments.

Administration processes need to be reviewed and refined to improve the efficiency of the

pathways.

Development of SOPs and guides to support and prevent future issues.

Work towards reducing DNA rates, and support missed appointments, especially those who are

holiday.

Continue to improve on data quality.

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Action plans

Action Owner Deadline

Undertake a capacity and demand review for

diagnostics, identifying gaps and rebalance

slots.

RW 01.08.19

Following the above exercise, review staffing

establishment to ensure key service standards

can be met with current workforce.

RW/MU 15.08.19

Review spoke clinic ability with existing work

force.RW/MU 15.08.19

Internally review the pathway to seek

improvements in responsiveness.JA/MU 15.08.19

Continue to build upon the ResMed remote

monitoring pathway to reduce face-to-face

reviews and release time to focus on other

diagnostics.

MU 15.08.19

Review staffing role and responsibilities and

Banding of positions.RW/MU 15.08.19

Continue to improve on data quality and

capture within EPR.JA 15.08.19

Continue to develop and enhance activity and

performance monitoring, work with informatics

to develop a dashboard through TIPs

RW/JA 15.08.19

Develop CAT SOP’s to ensure pathway and

responsibilities are clear and understood.RW/JA 15.08.19

Continue our work with the Primary Care

Networks to develop diagnostic hubs to

support point of care diagnostics.

RW/MU Medium - term

Work with the ICS to provide appropriate

training, and therefore quality, for spirometry in

the community and practices. Thus releasing

time to undertake more appropriate diagnostics

at the RBFT.

RW/MUMedium –

term

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Appendix 6 – Gastroenterology Deep Dive

8 year pattern of 2WW activity referral

Due to the continued growth in 2ww demand, we are constantly allocating an increased percentage of all

lists to possible cancer patients. This increase allows for 1st appointments straight to test and post outpatient

referred to test. The result of this is an inability to deliver the 6 week diagnostic standard for many routine

patients.

Current demand and capacity

The table below summarises the capacity deficit across sub-specialties compared to the expected weekly demand during 19/20:

OP New per week

Sub-specialty DemandSubstantive

Capacity

Gap

(excess)

2WW 60 23 -37

IBD 6.7 8 1

Liver 7.2 6 -1

Routine 31.9 17 -15

Viral Hep 6.2 7 1

TOTAL 112 61 -51

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The data indicates a significant and increasing gap in 2WW and Routine capacity, with a combinedcapacity gap of c.50-60 slots per week based on average data.

We are currently sourcing a level of additional sessional capacity which has been directed towards cancerperformance to enable us to achieve the cancer 2WW target first appointment; unfortunately this is at theexpense of routine appointments.

We would require a further additional 10-15 lists per week to meet the 6 week DM01 target whilstcontinuing to meet the cancer 2WW standard. This is on top of the existing level of additional sessionsand it is unlikely that we would be able to fill these further additional slots. We would also be limited byclinic room capacity.

The Demand and Capacity modelling completed with KPMG suggests that, based on current ways ofworking, we are short 3-4 WTE consultants.

Other contributory factors:

POD commitments – requires 1 session per week

Ward round commitments on Sidmouth (weekend cover) – requires 2 sessions per week

Additional winter ward round cover implemented for winter 2018/19 – requires 1-2 sesison per

week from December to February

Recent reduced uptake in additional sessions due to pension challenges.

Reduction in surgical uptake due to cancer theatre pressures.

Recovery

Trajectory for recovery

3. By August including resources required:

a. Additional 15 lists per week to reduce backlog at an additional cost of £11k per week

between now and August (assuming additional rate of £850 per session). Note: there is a

significant risk around uptake of these lists alongside the cancer 2ww additional sessions

already being undertaken, and lack of physical space to run this level of additional activity.

Sustainability – what is required to maintain DM01 performance beyond August

1. Immediate option

a. Additional 10-15 lists per week to sustain performance depending on growth, at an

additional cost of between £8-£11k per week / £416k-£517k FYE

2. No cost longer term option to achieve:

a. Significant service transformation will be required to meet ongoing and future demand at

low/no cost. Options and trajectory currently being developed as the next phase of KPMG

Demand and Capacity work.

Title: Deep Dive for Trust Board on Emergency Care and Performance

Agenda item no: 6.2


Date: 31 July 2019

Presented by: Mary Sherry, Chief Operating Officer

Prepared by: Mandy Claridge, Care Group Director of Operations, Urgent CareMary Sherry, Chief Operating Officer

Purpose of the Report To share with the Board a report recently presented to EMC which sets out the recent pattern of urgent and emergency care activity and issues affecting performance against the 4 hour standard.

Work is in progress to take forward the conclusions and next steps set out in the paper both internally within the Trust and via A&E Delivery Board, the ICP Delivery Group and the ICP Unified Executive, mindful of the need to tackle this via a dual track of strategic solutions through the UED strategy development and also tactical solutions to alleviate current pressure and contribute to the 2019/20 winter plan.

This includes work in progress to determine the resource and financial implications of the current situation and developing trends.

Comments from the Board will be incorporated into this work


To Board of Directors is asked to note and comment on the report.


Resource Impact: None at present time


1. Leadership √ 2. Vision & Strategy √ 3. Culture 4. Governance

5. Risks, Issues & √Performance




Purpose of this paper:

• To brief the Board on the drivers behind recent Emergency Department activity andsubsequent 4 hour quality standard performance

1. Background

1.1 The Emergency Department at Royal Berkshire Foundation Trust has experienced a deteriorating performance against the 4 hour standard when comparing Quarter 1 2019 to Quarter 1 2018. Achievement of the 4 hour quality standard has significantly deteriorated, in a far higher percentage than the increase in activity.

1.2 The department has seen a 3% increase in activity in quarter 1 moving from 302 attendances per day in quarter 1 in 2018 to 313 in the same period this year. Peak attendances last year were around 360 and this year 381 with this Monday 15th July being the highest at 393.

1.3 The effect of these peaks can lead to the demand on the department outstripping the available staff

1.4 More significantly the Trust has seen 19.47% increases in ambulance arrivals when comparing Q1 2018 to Q1 in 2019, this that equates to 15.7 more ambulances each day.

1.5 The age profile of patients arriving has changed with a very slight reduction in those under 50 and a 14% increase in those over 70 years old.

1.6 Acuity has also increased within the Emergency Department, some of which is due to the ‘minor illness’ patients being streamed over to the Primary Care Unit.

1.7 The Intensive Care Unit has increased occupancy by 15% over plan particularly level 3 care (the most complex) This is in addition to a stepped change in demand for emergency Cardiac Care and Primary Angioplasty.

1.8 Patients with complex mental health needs arriving in the Emergency Department has also meant that on several occasions there has been a requirement to close the Observation Ward.

1. This deep dive review sought support from Public Health England and our Ambulance Providers toascertain the cause of the increase

ED deep Dive Page 1

2. Ambulance Perspective

2.1 Our Ambulance Provider South Central Ambulance Service (SCAS) do not report any significant difference to the Trust compared with any other hospital within their region

2.2 SCAS have experienced a progressive increase in demand, and are currently 7.5% above demand for this time last year. This equates to approximately 800 additional calls across the organisation per week.

2.3 Some the increase can be attributed to NHS Pathways system changes, which is a National model, and not one that can be influenced locally.

2.4 They have also experienced a similar increase in respiratory and cardiac conditions across the region along with an increase in trauma.

2.5 As of the 1st July SCAS rolled out a new HCP and Inter facility transfer policy, whereby GPs and health care providers have the option for a category 1 call. Again this is accounting for some increased Cat 1 activity, but they are monitoring this, as it is still early days for a new process.

2.6 Post code analysis would suggest the growth is all from our local area.

ED deep Dive Page 2

3 Public Health Perspective

3.1 The RBFT and NHSE/I asked whether Public Health England (PHE) held any information that could elucidate any population demographic characteristics and changes that could explain changes in the experiences felt in the Emergency Department and wider hospital. It was queried whether the population was changing to one that is more like inner city populations.

3.2 Combining Trust catchment estimates with the latest ONS mid-year population estimates shows a marked year on year growth in all the age ranges above 50 years. This is particularly marked in those aged 85 and above, averaging 3% growth per year, which is at the upper end of change seen amongst Trusts in the South East. Given the increased risk of admission as people age, this consistent growth in the population aged 50 and above could have a significant impact.

2013 2014 2015 2016 2017 Avg number growth per year

Avg % growth/year

0-5 40,144 39,830 39,576 39,157 38,571 -393 -1.02%

6-19 82,054 83,190 84,401 85,924 87,650 1399 1.60%

20-34 94,639 93,808 92,142 91,345 91,831 -702 -0.76%

35-49 107,759 107,624 107,413 107,227 107,062 -174 -0.16%

50-64 85,028 86,483 88,222 89,789 91,942 1729 1.88%

65-84 65,167 66,942 68,125 69,337 70,574 1352 1.92%

85+ 9,801 10,158 10,377 10,754 11,147 337 3.02%

3.3 Ethnicity data show that the catchment population of the RBH is closer to the England average than

the South East in general. This can indicate that there will be challenges of higher prevalence of cardiovascular conditions, reduced primary care usage and higher ED usage.

Ethnicity & Language indicators, 2011, %

RBH England South East

Black and Minority Ethnic (BME) Population 13.8 14.6 9.3

Population whose ethnicity is not 'White UK' 20.1 20.2 14.8

Population who cannot speak English well / at all 1 1.7 0.9

Source: ONS Census, 2011

3.4 Rough sleeping; another measure of inner-city status and pressure on NHS services is rough

sleeping. The annual census in November shows a significant increase in rough sleeping in Reading and West Berkshire Councils between 2010 and 2018.

2010 2011 2012 2013 2014 2015 2016 2017 2018 Reading 6 5 4 8 12 16 22 31 25 West Berkshire 5 6 11 8 23 15 14 20 18 Total 11 11 15 16 35 31 36 51 43

3.5 In summary; The RBH catchment has seen marked growth in the numbers of people aged 50 and

above. The output area classification describes a mixed urban and suburban population with pockets of significant deprivation. In parallel, the numbers of rough sleepers have significantly increased. There has been some movement of deprived communities away from inner city London and it is likely that some of these people will have moved to the catchment population of RBF

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4 Primary Care

4.1 The Trust has not seen a significant increase in GP referrals and the CCG have assured us that additional appointments are available within primary care.

4.2 Some GP practices have seen an increase in attendance when comparing Jan 2018 to July 2018 and Jan 2019 to July 2019 2 GP practices have seen the most growth and our CCG partners are currently working with their data to understand the changes

GP Referrals by GP Practice Last Year This Year Variance

GROVELANDS MEDICAL CENTRE 257 351 94

BROOKSIDE PRACTICE 233 335 102

WOKINGHAM MEDICAL CENTRE 278 296 18

UNIVERSITY HEALTH CENTRE 247 292 45

MILMAN ROAD SURGERY- DR MITTAL 279 224 -55

WESTERN ELMS SURGERY 176 217 41

CIRCUIT LANE SURGERY 137 200 63

TILEHURST SURGERY PARTNERSHIP 252 186 -66

TILEHURST VILLAGE SURGERY 236 186 -50

BALMORE PARK SURGERY 150 185 35

LODDON VALE PRACTICE 215 183 -32

WOODLEY PRACTICE 91 150 59 4.3 Further data of the 2 highest growth practices are shown below

Note: Figures tabulated are total attendances from 1st Jan 2019 to 14th Jul 2019 (this year) as compared to 1st Jan 2018 to 14th Jul 2018 (last year)

Attendances by Complaint Last Year This Year Variance Attendances by Age Last Year This Year Variance Attendances by Triage Category Last Year This Year Variance

Unwell 77 97 20 1 month 10 19 9 Immediate Resuscitation 0 1 1

Chest Pain 22 34 12 2months to 5 Years 52 77 25 Very Urgent 20 12 -8

Abdominal Pain 21 30 9 6 years to 10 Years 8 17 9 Urgent 206 286 80

SOB 23 26 3 11 to 16 years 16 22 6 Standard 29 51 22

Pyrexia 12 19 7 17 to 50 Years 90 99 9 Non-Urgent 2 1 -1

Diarrhoea or Vomiting 10 16 6 51 to 75 Years 51 80 29 Unknown 0 0 0

Skin Problem 7 14 7 > 75 Years 30 37 7

Limb Injury 10 11 1 Total 257 351 94

Eye Problem 8 8 0

Head Injury 6 8 2

Injury 3 2 -1

Unknown 58 86 28

Note: Figures tabulated are total attendances from 1st Jan 2019 to 14th Jul 2019 (this year) as compared to 1st Jan 2018 to 14th Jul 2018 (last year) Note: GP Referrals are totals for the two conmparison periods

Attendances by Complaint Last Year This Year Variance Attendances by Age Last Year This Year Variance Attendances by Triage Category Last Year This Year Variance

Unwell 79 95 16 1 month 7 13 6 Immediate Resuscitation 2 0 -2

Abdominal Pain 25 29 4 2months to 5 Years 42 39 -3 Very Urgent 8 18 10

SOB 8 26 18 6 years to 10 Years 19 30 11 Urgent 201 249 48

Chest Pain 18 22 4 11 to 16 years 12 32 20 Standard 21 64 43

Limb Injury 7 22 15 17 to 50 Years 74 101 27 Non-Urgent 1 3 2

Head Injury 9 13 4 51 to 75 Years 59 81 22 Unknown 0 1 1

Pyrexia 11 10 -1 > 75 Years 20 39 19

Diarrhoea or Vomiting 4 7 3 Total 233 335 102

Skin Problem 8 6 -2

Eye Problem 2 5 3

Injury 1 4 3

Unknown 61 96 35

BROOKSIDE PRACTICE

GROVELANDS MEDICAL CENTRE

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5 Impact of the Activity Growth

5.1 Performance against the 4 hour quality standard has deteriorated at a far greater degree than the increase in activity, 3452 breaches in quarter 1 2019 to 1528 in 2018.

5.2 Contributory factors have been examined;

5.2.1 Staffing: ED staffing is profiled against activity demand and is reviewed annually. This year a further investment was made to increase weekend night staffing. However as the below demonstrates there remains a gap between available staff and demand, particularly at weekends and evenings. There are elevated breach numbers in this time period.

5.2.2 Senior support is often challenged with Consultants often occupied in Resus with complex patients (due to acuity/ambulance arrivals) and also increasingly staying throughout the night to meet the late evening acute demand. Royal college guidance suggests a ratio of 1 consultant per 3600/4000 attendances, which for the RBHFT would imply 28 whole time equivalent (WTE) consultants for a department that is classed as large (sees over 110 000 new attendances/annum).

5.2.3 From a model hospital view the ED is currently one of the most efficiently staffed in the country (note ‘efficient’ for model hospital = cost effective = potentially too few staff = staff under pressure of excess demand). Currently the ED team are working with HR to develop a workforce strategy, that will look to new ways of working, developing a multi-professional workforce, plus recruitment and retention strategies.

5.2.4 Mental Health: Although breach numbers are low for Mental Health patients the impact is felt within the observation bay, and increasingly it has been necessary to close the unit when a particularly aggressive patient is being cared for, we currently admit approximately 20 patients per day through this environment for assessment and these patients then either breach or put additional demand on the hospital beds.

5.2.5 Generally numbers of mental health attendees are remaining at 300 per month however high complexity of patients has increased in those brought in by police on a section 136 from 19 in year to 44 in the last 11 months.

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5.2.6 There has also been an increase of young adults who stay in ED to await a CAHMs assessment / tier 4 specialist beds who put additional pressure on staff. Datex reporting of challenging behaviour self-harm and absconding has increased.

5.2.7 Previous comparators would suggest we are an outlier in both 136 and mental health attendees. Berkshire Healthcare Trust (our mental health provider) is acknowledged as being an outlier in their management of cluster 8 patients (Personality disorders with chaotic lifestyles who tend to self-harm)

5.2.8 Acuity: Numbers of patients attending are sicker and requiring majors cubicles for treatment, the average treatments and assessment for an ambulance arrival is 45 minutes of medical time.

Although 2019 is a YTD running total it shows the increase in CAT3 year on year and decrease in CAT 5 (Minor illness) CAT1 = Resus Cat 2 & 3 Majors Cat 4 = Minors Cat 5 = Minor Illness

5.2.9 ICU: in general ICU activity has seen a step change over the last year with the department running at 15% over plan this year. In particular in terms of acuity where we have seen the numbers of level 3 patients increase significantly in comparison with previous years. This correlates with data demonstrating a 20% increase in the number of patients on ventilation over the same period.

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5.2.10 There are potentially a number of reasons for this; patients are more medically complex as the population is getting older and chronic illness are more prevalent, increased intervention such as thrombolysis on more acute patients. In addition, both patients and their relatives’ expectations are increasing

5.2.11 Space: The current Emergency Department was built in 2002 to accommodate 65, 000 patients annually, yet in 2017 the unit had attended to over 125 810 patients (Care Quality Commission, 2018). The Department is therefore categorised as a large ED (expected attendances >110 000). This mismatch in real estate manifests in capacity constraints and frequent departmental overcrowding with an adversely negative impact on length of stay, serious incidents, high quality patient care and staff well-being (ED overcrowding, 2016)

5.2.12 Our current estate within ED is:

Type Number Majors Area 11 beds (+1 bay for MH patients)

STAT (Senior Triage Assessment and Treatment)

8 (+ ambulatory chair area)

Resuscitation Area 4 beds Observation Ward 8 beds (+ ambulatory chair area)

Paediatrics 6 beds (+ ambulatory chair area) Minors area 1 HCA investigation bay (ECG, bloods)

3 cubicles for doctor assessment 3 cubicles for ENPs

1 treatment room, 1 Eye/ENT room, 1 side room

5.2.13 Analysis has shown that once the department has more than 70 patients higher breach numbers occur as there is limited trolley space to provide necessary treatments. Of late that number has increased to up to 100 patients in the department some evenings

ED attendance by Hour BandHeat Map Activity of 70 and over

00Hr 01Hr 02Hr 03Hr 04Hr 05Hr 06Hr 07Hr 08Hr 09Hr 10Hr 11Hr 12Hr 13Hr 14Hr 15Hr 16Hr 17Hr 18Hr 19Hr 20Hr 21Hr 22Hr 23Hr47 39 31 27 20 19 18 23 29 35 53 66 84 92 102 93 82 75 72 80 82 77 71 6354 38 32 28 30 25 24 21 30 44 65 69 71 81 80 87 81 76 76 84 94 92 86 7970 58 49 47 51 45 45 41 43 51 59 68 63 68 70 74 78 71 78 91 82 74 65 5436 25 26 19 21 19 17 17 18 32 42 45 59 65 64 62 58 50 52 68 63 59 54 4542 34 33 31 27 21 16 13 20 35 45 62 64 66 60 61 61 65 65 63 55 53 55 4737 33 34 32 28 26 24 21 30 38 48 66 73 85 90 93 91 83 85 96 90 86 87 7966 61 66 64 54 50 45 39 42 42 45 52 60 76 77 83 84 69 64 61 65 64 60 5339 26 19 17 15 13 13 21 23 37 53 61 66 73 85 79 77 76 80 87 91 89 76 6856 51 47 34 31 26 27 33 39 49 59 59 66 72 76 81 77 72 77 85 81 78 71 7062 63 54 56 55 48 45 45 41 53 54 63 59 41 24 6 0 0 0 0 0 0 0 0

ED Breaches by Hour band (attn Hour)Heat Map Breaches of 3 and over

00Hr 01Hr 02Hr 03Hr 04Hr 05Hr 06Hr 07Hr 08Hr 09Hr 10Hr 11Hr 12Hr 13Hr 14Hr 15Hr 16Hr 17Hr 18Hr 19Hr 20Hr 21Hr 22Hr 23Hr1 1 1 1 1 1 1 2 2 4 6 2 1 3 8 10 9 4 3 2 3

1 1 2 1 1 6 3 2 5 4 6 4 7 8 9 4 3 4 26 3 3 2 1 3 2 2 3 3 5 3 5 7 2 2 5 2 1

3 1 1 1 2 2 2 5 6 2 21 2 1 1 2 1 2 1 2 1 3 1 2 11 2 2 1 1 2 4 3 8 6 4 6 12 7 6 8 10 910 5 5 3 3 3 2 1 2 1 1 1 2

1 1 2 1 1 4 7 2 2 2 3 7 5 5 4 42 2 1 3 1 2 1 1 2 4 3 6 4 3 4 8 3 13 9 65 9 3 5 4 1 1 1

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5.2.14 Bed delays: 18% (617) of the breaches have been due bed delays, compared with 165 same period last year. Flow improves when length of stay is reduced; an accurate marker is the number of patients on the Stranded list i.e. those are patients with a length of stay over 7 days.

5.2.15 Flow improves when the stranded number is 230 or below, this year it has been steady at an average of 260, of which 100 have stayed for 21 days or more. Ideally we are working to target the 230 total (>7 & >21 days) and drive >21 days down towards 70 if we can.

5.2.16 Experience over Q1 is that in the face of an increasingly acute front door and therefore an increase in the proportion of admissions requiring acute (and longer) pathways of care and/or complex discharge pathways there is an increased need to constantly improve how we care for these patients in respect of ensuring each and every action is speedily taken and any wasted time in pathways is reduced

5.2.17 Work is in progress to reorganise our integrated discharge team who work in support of the wards and also to implement ward based roles in support of clinical staff. The consultation that supported this work is now complete and we are now in progress to implement new roles and strengthen these arrangements.

6 Conclusions

6.1 The combined impact of the analysis shown in this paper is that at Reading in our ED our staffing, estate and ED/hospital processes are struggling to cope in this level of pressure; this level of pressure means that all parts of our processes need to continuously be working at the optimum in order to keep our system in balance as any one of them can knock us an generate high breaching ie long waits and poor patient experience.

6.2 The increasing elderly population as shown within our Pubic Health data with both chronic and acute respiratory and cardiac conditions have placed additional demand on both our ambulance provider and ED, given the demographic growth, this pressure is likely to be sustained into the future.

6.3 To note, our findings are broadly in line with national context in terms of activity and performance.

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7 Mitigations

7.1 Our focus is on both immediate/tactical actions and controls to support departments and wards to work as efficiency as they can in the present circumstances together with work strategically across the ICS and with system partners to develop responses to the demand pressures descried in this paper. Examples of some of our actions are shown below.

7.2 A proactive split of ED to ensure minors flow is protected and streamed appropriately supported a safety initiative whereby all patients are seen and assessed within 15 minutes. This has been a positive addition to our existing STAT process for ambulances. We are working with ED team to ensure that this model is always consistently deployed as sometimes this can be variable.

.

7.3 Regular safety huddles within ED with multidisciplinary team to continually monitor the flow situation and ensure all actions are being taken to optimise pathways and use of space

7.4 Change of hours to deliver a senior site team presence until 23.00 hrs to help support flow within the peak periods of demand with a focus on patient movement out of the ED

7.5 Proactive recruitment of Physicians Associates into medical staff gaps and supporting the development of new roles, i.e. an advanced ED paramedic practitioner, who has become one of the first paramedic independent prescribers in the UK. ED coders to support admin roles in releasing clinician time to care.

7.6 Weekly review of performance and staffing with clinical team to plan forthcoming week and proactively learn

7.7 Daily review of all stranded patients by Matrons, with weekly review by Senior Team, engagement with National Programme to reduce long length of stays

7.8 A continued focus on admission avoidance wherever possible to ensure optimum use of beds including a continue look at how pathways can continuously look at how overnight stays are avoided where it is safe to do so (known as Same Day Emergency Care (SDEC) and subject to national recommendations. Surgery is doing extremely well with this with further work needed in medical specialties.

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8 Next Steps

8.1 Continue to develop the workforce transformation plan to look to close the gap between demand and staffing

8.2 Work with the estates team to examine any further opportunities (and they will likely be at the margins) to develop a short term space plan; in addition make STP and national connections to start to identify any other sources of major funding to contribute to a long term development plan for the ED/front door estate

8.3 Further intensify the work on stranded and longer length of stay to improve flow with Matron and Senior review including full implementation of roles on wards to work in support of clinical staff to focus on pathway management

8.4 Continue work with system partners in Local Authorities and Berkshire Healthcare Foundation Trust to unblock complex pathways and DTOC particularly care provision and any remaining high ijpact changes not yet embedded

8.5 Continue work with ICS partners to look at GP practices with increased attendees

8.6 Support the ICS in moving Primary Care Streaming back to the Emergency Department, enabling a greater flexibility of workforce investment

8.7 Development of system wide winter plan through A&E DB and development and the continued development of the IC UEC Strategy to ensure that long term strategic solutions are being sought

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Title: June Finance Update

Agenda item no: 6.2


Date: 31 July 2019

Presented by: Nicky Lloyd, Chief Finance Officer

Prepared by: Michael Clements, Deputy Director of Finance – Central Finance

Purpose of the Report To update the Board on the Financial Performance of the Trust in June 2019

Report History Executive Management Committee – 22 July 2019

Finance & Investment Committee – 22 July 2019


The Board of Directors is asked to NOTE the report




Strategic objectives This report impacts on (tick all that apply)::

Provide the highest quality care Invest in our staff and live out our values Drive the development of integrated services Cultivate innovation and transformation Achieve long-term financial sustainability Well Led Framework applicability: Not applicable






1 Summary

1.1 The Trust has reported results £0.05m ahead of revised NHS Improvement (NHSI) Control Total

(a) Performance against year to date budget is £0.12m favourable

(i) Income £0.19m ahead of plan driven by activity and additional accrual for NHSE Specialised Commissioning contract. This over performance has been partially offset by reduced drug and Private Patients

(ii) Pay £(0.12)m over budget driven by Nursing and AHPs

(iii) Non Pay £(0.22)m over budget driven by drugs

1.2 The Trust has recognised Provider Sustainability Funding (PSF) and Marginal Rate Emergency Tariff (MRET) income to M03, £2.93m, including an additional PSF award of £0.58m relating to 2018/19

2 Conclusion and Next Steps

2.1 The committee is asked to NOTE the report

3 Attachments

3.1 The following are attached to this report:

(a) Appendix 1 – Chief Finance Officer Report

Financial Performance Cip Performance

People Cash, Capital and other KPIs

QIPP Performance

8. Finance – Achieving Financial Sustainability

Page 1


CARE - Resourceful

Finance summary dashboard – Month 3 2019/20Red – diamond

Amber – triangle

Green - circle

Note: Green circle means actual is within +/-1% of plan, amber

triangle is from 1-5%, and red diamond is more than 5% ahead of or

adverse to plan

Note: Debt includes £2.01m

overseas visitors and

£1.11m Oxford University

Hospital both of which

continue to be addressed

under Finance Matters

Data source: Trust Ledger Systems, Transformation Tracker and Finance Team

Pay cost to activity ratio M9 18/19 M10 18/19M11 18/19M12 18/19 M1 19/20 M2 19/20 M3 19/20

Pay as % of activity income 71.16% 72.15% 75.33% 68.52% 79.49% 72.23% 68.78%

Key Metrics Actual Plan

Cash £30.29m £37.39m

IPP Debtor Days 20 37

Creditor Days 33 24

NHS Debtor Days 5 4

Inventory Days 26 25

RAG

Capital Programme

Actual &

Committed

YTD

Plan YTD

Total Trust Funded £8.11m £5.58m

Total Donated £0.11m £0.59m

Grand Total £8.22m £6.17m

RAG

Actual Plan Plan

Income (incl pass through) £107.53m £106.96m £443.47m

Pay £63.65m £63.46m £251.01m

Non Pay (incl pass through) £43.62m £43.29m £171.94m

Surplus/(Deficit) -£1.68m -£1.80m £12.54m

Control Total -£4.55m -£4.60m -£1.50m

RAG

Year to date

2

Key Messages from Chief Finance Officer Month 3 2019/20

Income and Expenditure

• Performance against control total

– The Trust performance is £0.05m ahead of Control Total for YTD at £(4.55)m against £(4.60)m target. The Trust is focusing upo n changes to capacity in line

with the 2019/20 QIPP plan. The Trust Use of Resources Rating was 1 at year end. It is currently 3, which is in line with the 2019/20 plan.

• Patient care Income

– Patient income is £0.86m favourable to plan. Elective and Non-Elective activity is overall above plan, within this Berkshire West activity is significantly above

the plan within the cost form of contract that the Trust has with the CCG. We are reviewing the in year implications of tarif f changes for non-elective care

• Other Income

– The M03 YTD position includes £1.29m centrally funded MRET monies and £1.63m PSF monies, included in this is an additional £0 .58m bonus PSF relating to

18/19. It is important to note that this income is excluded when calculating performance against the control total target. Ed ucation Training Grants and Other

Funding income is £(0.50)m behind plan, partially driven by release of income accrual. Work is on -going with R&D to ensure the correct capture of income

• Pay

– Pay fell compared to M02, due to reduction in temporary staffing spend. Nursing continues overspend is largely attributable to Urgent Care front door

demands, and unachieved QIPP across the organisation. Bed Closure plans need to be realised to enable savings to be made. Med ical staffing is £0.11m under

budget YTD, however there are a number of specialties that are overspent and this will be addressed within the demand and cap acity work. The Trust will

focus on stress-testing run rates of pay aligning with activity levels

• Non Pay

– Non pay is overspent against plan by £(0.33)m. The Non Pay excluding Drugs variance is £0.19m favourable. Drug income below plan by £(0.51)m YTD

Miscellaneous expenditure is above plan by £(0.20)m YTD. £(0.90)m relates to unallocated QIPP.

Balance Sheet

• Cash position

– Cash is below plan as the plan anticipated Q4 PSF monies to be received in M02. However cash remains strong due to high leve ls of accruals within the cost

base. Typically the Trust operates with c£1m in its day to day bank accounts following payment of daily/weekly commitments an d holds up to £30m in short

term investments through the Government Banking Service (GBS). £15.2m of PSF was received on 15 th July , pushing the M05 forecast cash to above £50m.

• Debtors

– Non NHS Debtor Days are significantly better than plan. NHS Debtor days are behind plan. This is driven by higher NHS receiv ables due to the post financial

year end award of bonus PSF in 2018/19 and lower levels of revenue in non-NHS lines

• Creditors

– Creditor days are over plan. Work continues through Finance Matters to ensure Purchase Order receipting is completed in a tim ely manner to enable payment

to terms

• Capital plan

– At Month 3 the Trust has spent £2.54m of its capital programme (including £0.11m of donated capital) . The Trusts has committed an additional £5.68 m

3

Trust Cash position M03 2019/20

Key messages

• The planned cash level spiked upwards in M02 due to

expected Q4 18/19 PSF monies. £15.2m of PSF

monies were received on 15th July 2019

• Closing cash position is £30.3m, a decrease of £3.1m

from the opening position

• The maximum cash level in month was £57.7m, and

the minimum was £29.9m, therefore no particular in-

month concerns around timing of receipts vs

payments but this should be closely monitored to

determine if there are any intra-month pinch points

going forward

• Following feedback from F&I in May capital payments

are now shown separately to other supplier payments

Data source: Trust Finance Team

4

Patient Income Summary – Trust level M03 2019/20

Data source: Trust Ledger Systems

Red – diamond

Amber – triangle

Green - circle

Key messages

• YTD Mth 3 Total Patient Income - £0.86m ahead of budget.

• The main variances within this are favourable variances of

+£1.26m against Non Elective, +£0.61m against Outpatients

and +£0.30m against Elective (including Day case). These are

offset by an adverse variance of £(0.91)m against Other

Patient Income, which is largely due to adjusting income in

respect of Berks West CCG back down to the phased contract

plan value, by £(1.14)m.

• The actions to be taken include monitoring of Berks West

CCG activity wait times and associated income, as this is

currently running considerably above the contracted level,

as noted above.

Actual Plan Plan

Daycase £7.86m £8.16m £35.34m

Elective £6.07m £5.47m £23.05m

Outpatients £19.64m £19.03m £79.77m

Non-elective £26.66m £25.40m £103.59m

A&E £5.97m £5.86m £23.50m

Drugs & Devices £10.64m £11.14m £44.77m

Other patient income £21.54m £22.45m £92.23m

Total patient income £98.38m £97.52m £402.24m

Year to date

RAG

5

Patient Activity Summary – Trust level M03 2019/20


Red – diamond

Amber – triangle

Green - circle

Key messages

• By POD (Point Of Delivery), and on a YTD basis, the activity

variances against Plan greater than +/-1% are as follows:

• Daycase is (4.1)% (414 Spells) behind Plan

• Elective is +3.8% (+60 Spells) ahead of Plan

• Outpatients are +1.8% (+2,343 Atts) ahead of Plan

• Non-elective is +1.6% (+175 Spells)

• A&E is +6.0% (+1,925 Atts) ahead of Plan

Actual Plan Plan

Daycase 9,630 10,044 42,580

Elective 1,652 1,592 6,700

Outpatients 135,941 133,598 559,729

Non-elective 11,454 11,279 45,997

A&E 34,141 32,216 129,292

Maternity (OP and IP) 6,002 6,052 25,013

Year to date

RAG

6

Non-Elective Summary – Trust level M03 2019/20


7

Other Income Summary – Trust level M03 2019/20


Red – diamond Amber – triangle Green - circle

Key messages

• YTD M3 Other Income is £(0.29)m behind plan.

• The key drivers for this include shortfalls in

income from R&D of £(0.31)m, Education &

Training of £(0.19)m, Other operating income of

£(0.10)m, offset by a favourable Grants and

other similar funding variance of +£0.42m –which in turn is mainly due to additional post

year-end 18/19 PSF of £0.58m.

• Total Other Income includes £1.05m 19/20 PSF

monies and £1.29m of YTD NHSE MRET central

funding monies.

Actual Plan Plan

Education & Training £3.08m £3.27m £13.64m

R&D £0.10m £0.41m £1.64m

Grants £3.44m £3.02m £14.91m

Rental £0.15m £0.16m £0.57m

Sales of Goods & Services £0.29m £0.32m £1.25m

Non patient care to other bodies £1.67m £1.75m £7.03m

Other operating income £0.42m £0.52m £2.18m

Total other income £9.15m £9.44m £41.23m

Year to date

RAG

8

Pay Summary – Trust level M03 2019/20


Red – diamond

Amber – triangle

Green - circle

Key messages

• Pay is £(0.19)m overspent against budget YTD, but delivering a

favourable position of £0.09m in M03

• The Month 3 overspends in Nursing and PAMs were partially

offset by continuing underspend in Admin & Management and

Scientists

• Medical staff underspends continue in Urgent and Networked

Care Groups

• Actions continue to be taken for the development and delivery of

pay QIPP schemes within the Care Groups

Actual WTE Plan WTE

Permanent 4,829.42 5,078.34

Bank 163.31 129.69

Agency 72.17 120.16

Total 5,064.90 5,328.19

Year to date

RAG

Actual Plan Plan

Substantive £59.53m £59.48m £234.49m

Bank £2.16m £1.55m £7.01m

Agency £1.96m £2.44m £9.52m

Total £63.65m £63.46m £251.01m

Pay Cost

Year to date

RAG

9

Nursing Pay – Trust level M03 2019/20

Key messages

• Nursing Pay is overspent against budget YTD by £(0.67)m

• Emergency Care front door accounts for £(0.21)m of the YTD position

due to demand pressures.

• ICU nursing spend reduced in M03, yet YTD overspent by£(0.12)m.

This has been caused by the increased number of ICU beds open

above budgeted level (15 beds vs. 13 budgeted)

• Unallocated pay CIP in UCG account s for £(0.11)m YTD

• Lack of planned bed closures in Acute Medicine has lead to overspend

against budget

• Orthopaedics nursing is £(0.08)m overspent YTD. Orthopaedics is

completing demand and capacity planning work.

• Networked Care nursing CIPs continue to be carefully managed within

the area

• Actions: Continue to focus on bed capacity-based QIPPs and demand

capacity planningData source: Trust Ledger Systems

Red – diamond

Amber – triangle

Green - circle

Actual WTE Plan WTE

Permanent 2,188.10 2,322.35

Bank 163.31 129.29

Agency 31.10 50.70

Total 2,382.51 2,502.34

Year to date

RAG

Actual Plan Plan

Substantive £22.66m £22.08m £87.48m

Bank £2.03m £1.55m £7.01m

Agency £0.48m £0.87m £3.08m

Total £25.17m £24.50m £97.57m

Pay Cost

Year to date

RAG

10

Nursing Pay – ICU M03 2019/20

Key messages

• ICU nursing spend YTD overspent by£(0.08)m. This is a

reduction on the M02 position by £0.03m.

• The number of level 3 patients reduced considerably in

M03 compared to M02

• Actions: ICU to continue to de-escalate where possible

and regularly review high-cost temporary staffing

requirements


11

AHP, Scientists and Pharmacists Pay – Trust level M03 2019/20

Key messages

• AHPs, Scientists and Pharmacists continue to be overspent against

budget £(0.21)m YTD, but was £0.05m favourable to plan in M03

• The YTD position is driven by Urgent Care (Radiographers) and

Networked Care (Pharmacists, Therapists and Scientists)

• Action: Reconciliation of WTE budget to YTD position

• Action: Review of opportunities to develop QIPP within this staff

group


Red – diamond

Amber – triangle

Green - circle

Actual

Average WTE

Plan Average

WTE

Permanent 663.18 686.09

Bank 0.00 0.00 ### ###

Agency 23.46 35.27

Total 686.64 721.36

Year to date

RAG

Actual Plan Plan


Bank £0.00m £0.00m ## ## £0.00m

Agency £0.43m £0.45m £1.66m

Total £8.23m £8.02m £31.89m

Pay Cost

Year to date

RAG

12

Medical Pay – Trust level M03 2019/20


Red – diamond

Amber –triangle

Green - circle

Key messages

• Medical Pay is underspent against budget by £0.11m YTD

• Staffing resource issues in Networked Care continue to be a major driver

to the financial position

• In Planned Care BCC, Ophthalmology and Orthopaedics are overspent YTD

by £(0.07)m, £(0.06)m and £(0.06)m respectively

• Junior Medic costs in Corporate areas are giving rise to £(0.06)m

overspend. This requires further investigation

• Action: continue with demand and capacity modelling within Planned Care

(Ophthalmology and Orthopaedics as the first specialties)

Actual WTE Plan WTE

Permanent 637.97 680.71

Locum 29.01 22.20

Agency 12.18 14.18

Total 679.16 717.09

Year to date

RAG

Actual Plan Plan


Locum £0.92m £1.01m £4.48m

Agency £0.87m £0.80m £3.53m

Total £18.23m £18.34m £72.42m

Pay Cost

Year to date

RAG

13

Pay Summary - Agency – Trust level M03 2019/20

Key messages

• Agency remains within the NHSI agency

cap YTD.

• In month we have seen an increase of

£(0.04)m in Medical agency spend based

on the M02 position, largely within

Integrated Medicine due to sickness and

vacancy cover.

• Nursing agency costs have decreased in

month compared to the M02 position,

most notably in ICU (£0.05m) due to

reduction in activity.

• Admin and Management Agency spend

remains variable, with a £0.03m

reduction in spend compared to M02,

largely due to IM&T confirmation of

accrued capital costs

• The actions to be taken to ensure the

reduction in spend continues are to

include linking together demand levels,

beds open and activity demand capacity

planning


Agency

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

+/- on

Prior

Year

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Medical 338 311 432 298 347 317 276 294 357 310 322 251 293 45

Nursing 193 180 177 179 135 122 83 208 123 156 145 199 138 55

Management &

Admin119 152 156 123 107 122 21 158 77 (284) 47 123 92 27

Other Clinical 100 148 110 138 177 115 99 154 120 153 120 127 101 (1)

Other Non

Clinical0 2 3 2 3 5 4 3 18 3 4 0 0 0

Total 750 793 877 740 769 681 482 817 695 338 638 700 624 126

14

Pay Summary – Additional Sessions – Trust level M03 2019/20

Key messages

• At Trust level additional session

payments have reduced from the M02

position and when compared to the

same period last year

• All Care Group areas decreased in spend

from M02.

• Corporate Services additional session

payments have increased marginally in

M03

• On-going Demand and Capacity reviews

by specialty will continue to minimise

the use of additional sessions where

activity can be undertaken within plain

time


15

Non Pay Summary – Trust level M03 2019/20

Key messages

• Non Pay is overspent against budget YTD £(0.33)m

• Drug costs are above plan by £(0.52)m YTD. Drug income

below plan by £(0.51)m YTD

• Miscellaneous expenditure is above plan by £(0.20)m

YTD. £(0.90)m relates to unallocated QIPP

• The actions to be taken are to continue to develop QIPP

programmes, to gain the assurance that the full

programme will deliver in year and continue spending

within budget

• All areas are to ensure that non-pay expenditure aligns

with levels of activity undertaken


Red – diamond

Amber – triangle

Green - circle

Actual Plan RAG Plan

Drugs £12.35m £11.83m £47.82m

Clinical Supplies £10.92m £11.16m £43.40m

General Supplies £1.66m £1.84m £7.35m

Establishment Expenses £0.98m £0.96m £3.75m

Other Establishment Expense £4.71m £4.77m £19.08m

Premises Costs £5.23m £5.31m £21.26m

Depreciation £4.15m £4.04m £16.46m

Leases £0.75m £0.71m £2.83m

Miscellaneous £2.88m £2.68m £9.99m

Total Non Pay £43.62m £43.29m £171.94m

Year to date

QIPP Reporting – M3

16

Progress

• The total QIPP target for the year remains at £16.88m

• The plan value has increased from £13.39m to £13.67m leaving

a gap of £3.2m. This is a result of new projects identified under

the Digital Hospital totaling £188k with 100% initial RAGs.

• After risk adjusting the schemes the forecast in-year value is

£11.36m.

• The top 10 programs comprise 85% of the total programs.

Risks and mitigations

• There remains a £5.52m QIPP gap in terms of assurance of

delivery. As the year progresses, the risk of delivery against the

target increases. This highlights the need to pursue stretch

targets against key schemes as per the Financial Recovery Plan.

Current In Year risk

adjusted forecast £m 5.52 0.69 1.25 9.42 16.88

Previous In Year risk

adjusted forecast £m 6.17 0.22 0.97 9.51 16.88

Note: Black is the value of the gap between the risk adjusted delivery

(£11.35m) and the target delivery (£16.88m)

Top 10 Programmes By Full Year Forecast Target Delivery

£'000 RAG FYE PYE

Risk Adjusted

Forecast

National Procurement 78.42 1,400.0 1,400.0 1,400.0 1,097.9

Patient Flow/Flexible Bed Base 51.61 1,421.0 1,385.3 1,382.2 713.3

Local Procurement Transformation 96.21 1,335.0 1,364.9 1,430.3 1,376.0

Networked Care Projects 94.52 1,391.0 1,228.4 1,219.1 1,152.3

Planned Care Projects 96.63 1,268.0 1,108.9 1,102.9 1,065.7

Medicines Optimisation 104.32 983.0 1,108.3 1,108.3 1,156.2

Digital Hospital 94.16 1,100.0 1,107.7 1,001.5 943.1

Commerical and Income 65.38 827.0 993.6 982.5 642.4

Women's, Children's and Young People 86.56 874.0 939.4 939.3 813.1

Estates and Facilties Projects 104.38 709.0 861.3 712.9 744.2

Top 10 Total 11,308.0 11,497.8 11,278.9 9,704.2

% of Total Programmes 67% 83% 83% 85%

Plan

Actual Plan RAG Plan

Recurrent £2.53m £2.76m £12.14m

Non Recurrent £0.40m £0.49m £1.53m

Unidentified £3.21m

Total £2.93m £3.25m £16.88m

QIPP

Year to date

17

Appendices Chief Finance Officer

Report

June 2019

Appendix (i) Statement of Comprehensive Income

Appendix (ii) Statement of Financial Position

Appendix (iii) Care Group and Corporate Financials

Appendix (iv) Use of Resources Risk Rating

Appendix (v) Reconciliation of Reported Finances to Control Total Performance

18

Appendix i: I&E Detail – Trust level M03 2019/20


Red – diamond

Amber – triangle

Green - circle Actual Plan Plan

Activity Income £86.78m £85.09m £1.69m 1.99% £352.36m

Pass through £10.64m £11.14m -£0.51m -4.57% £44.77m

Other patient income £0.96m £1.28m -£0.32m -24.80% £5.12m

Other income £9.15m £9.44m -£0.29m -3.08% £41.23m

Total Income £107.53m £106.96m £0.57m 0.54% £443.47m

Permanent £58.60m £58.46m -£0.14m -0.24% £230.00m

Bank/Locum £3.09m £2.57m -£0.52m -20.25% £11.49m

Agency £1.96m £2.44m £0.48m 19.50% £9.52m

Total Pay £63.65m £63.46m -£0.19m -0.29% £251.01m

Drugs £12.35m £11.83m -£0.52m -4.41% £47.82m

Other Clinical Supplies £10.92m £11.16m £0.24m 2.18% £43.40m

Other operating expenses £16.20m £16.26m £0.06m 0.39% £64.25m

Total Non Pay £39.47m £39.25m -£0.21m -0.55% £155.48m

EBITDA £4.41m £4.24m £0.17m 4.07% £36.97m

Depreciation £4.15m £4.04m -£0.11m -2.82% £16.46m

Interest £0.07m £0.13m £0.06m 46.53% £0.49m

PDC £1.81m £1.81m £0.00m 0.06% £7.26m

Surplus/(Deficit) -£1.68m -£1.80m £0.12m 6.46% £12.54m

Control Total -£3.24m -£4.00m £0.76m -18.94% -£1.50m

RAGVariance

Year to date

19

Appendix ii: Balance Sheet, Cash & Capital –Trust level M03 2019/20

Data source: Trust Ledger Systems and Finance Team

Red – diamond

Amber – triangle

Green - circle

Actual Plan RAG KPI

NHS Debtor Days 5.48 4.11 4.11

IPP Debtor Days 20.34 37.07 30

IPP Overdue Debt £m 4.87 #DIV/0! 0

Inventory Days 25.81 25.19 14.00

Creditor Days 33.19 23.82 30

BPPC NHS (YTD) number 41.44% 85.00% 85.00%

BPPC NHS (YTD) £ 58.17% 85.00% 85.00%

BPPC Non-NHS (YTD) number 89.36% 85.00% 85.00%

BPPC Non-NHS (YTD) £ 85.80% 85.00% 85.00%

As at 31 Mar

19 Working Capital

Actual Plan Variance

Prior

Month Movement

261.86 Non-current Assets 260.26 262.69 (2.43) 260.42 (0.16)

36.61 Current Assets (excl Cash) 39.97 24.24 15.73 36.48 3.49

43.10 Cash & Cash Equivalents 30.29 37.39 (7.10) 33.39 (3.10)

(70.09) Current Liabilities (66.78) (56.53) (10.25) (66.75) (0.03)

(14.66) Non-current Liabilities (13.13) (17.32) 4.19 (14.63) 1.50

256.82 Total Assets Employed 250.61 250.47 0.14 248.91 1.70

2019

Audited

Accounts Statement of Financial Position

Year to date

Actual Committed Plan Variance

RAG on

YTD

RAG on

YTD

6.91 Estates - Major Projects 0.35 2.60 0.40 2.55

3.03 Estates - Compliance 0.00 0.10 0.40 (0.30)

10.78 IM&T 1.23 1.55 2.00 0.78

8.77 Medical Equipment 0.94 1.43 1.13 1.24

0.17 Other 0.02 0.00 0.05 (0.02)

29.66 Total Capital Expenditure 2.54 5.68 3.98 4.24

31 Mar 2019

Audited

Accounts Capital Expenditure

Year to date

20

Appendix iii: Care Group and Corporate Financials M03 2019/20

Data source: Trust Ledger Systems and Finance Team Red – diamond Amber – triangle Green - circle

Actual Plan Plan


Pay £21.93m £21.48m £85.83m


Surplus/(Deficit) -£24.68m -£24.14m -£95.98m

Urgent Care Group

Year to date

RAG Actual Plan Plan


Pay £18.31m £18.28m £71.45m



Planned Care Group

Year to date

RAG

Actual Plan Plan


Pay £14.15m £14.09m £56.05m



Networked Care Group

Year to date



Pay £6.28m £6.67m £25.49m


Surplus/(Deficit) £72.67m £71.45m £302.69m

Corporate

Year to date

RAG

Actual Plan Plan


Pay £2.98m £2.94m £12.19m



Estates and Facilities

Year to date



Pay £1.21m £1.21m £4.79m



IM&T

Year to date

RAG

21

Appendix iv: Use of Resources Rating M03 2019/20


Use of Resources

Actual

YTD ending

30 June 2019

Capital Service, total £m (-ve) (3,477)

Revenue Available for Capital Service £m (+/-ve) 4,371

Capital Service Cover metric 0.0x 1.26

Capital Service Cover rating Rating 3

Working capital balance (for use in FSRR rating calculation) from SoFP £m (+/-ve) (3,478)

Operating Expenses within EBITDA, Total from SoCI £m (-ve) (103,119)

Liquidity metric Days 91 (3.07)

Liquidity rating Rating 2

Adjusted financial performance surplus/(deficit) £m (+/-ve) (1,625)

Total Income from SoCI £m (+ve) 107,422

I&E Margin - Actual YTD 30 June 2019 % -1.51%

I&E Margin rating Rating 4

I&E Margin - Actual YTD 30 June 2019 % -1.51%

I&E Margin - NHSI Annual Plan YTD 31 March 2019 % -2.10%

I&E Variance from NHSI Plan % 0.59%

I&E Variance From NHSI Plan rating Rating 1

Agency metric % -13.66%

Agency rating Rating 1

Use Of Resources Rating after overrides Rating 3

(Weighting ratio is 20%)

22

Appendix v: Reconciliation of Reported Finances to Control

Total Performance M03 2019/20


23

Navigation Key

Legend for tables Definition

Green rating: Unless otherwise specified, green means within 1% of plan/target (either

greater or less than) - In the case of cash and creditor days, there is no boundary on variances in excess of plan

(e.g. if creditor days target is 30 and actual creditor days are 31, this is will be green rated

and if creditor days are 56, this will also be green rated)

- In the case of debtor days, there is no boundary on variances less than plan (e.g. if debtor

days target is 30 and actual debtor days are 29, this is will be green rated and if debtor days

are 5, this will also be green rated)

Amber rating: Unless otherwise specified, amber means between 1% and 5% of plan/target

(either greater or less than)

Red rating: Unless otherwise specified, red means 5% more than plan/target or 5% less than

plan/target

Better than last month

Worse than last month

No change from last month

Table metrics

1. All figures are in £’M to 2 decimal places unless otherwise specified

2. References to Plan refer to the Control Total as filed in May 2019 with NHS Improvement

3. Forecast is a rolling 2+10, 3+9 forecast and is updated each month to reflect the latest position

Title: Integrated Care Partnership Performance Update (ICP) Agenda item no: 6.3 Meeting: Board of Directors Date: 31 July 2019 Presented by: Andrew Statham, Director of Strategy Prepared by: William Wilkins, Associate Director of Strategy

Purpose of the Report To provide the board with an update on the progress of the Berkshire West Integrated Care Partnership

Report History Executive Management Committee on 22 July 2019


The Board is asked to note the contents of the report.

Assurance Information ✓ Discussion/input Decision/approval



Obtaining a regular progress update on the ICP is a key measure of assurance against the risks flagged in Strategic Priority 3 – Drive thedevelopment of integrated care

Strategic objectives This report impacts on (tick all that apply):: Provide the highest quality care

Invest in our staff and live out our values

Drive the development of integrated services ✓Cultivate innovation and transformation

Achieve long-term financial sustainability

Well Led Framework applicability: Not applicable

1. Leadership ✓ 2. Vision & Strategy ✓ 3. Culture 4. Governance ✓

5. Risks, Issues & ✓Performance

6. InformationManagement

7. Engagement ✓ 8. Learning &Innovation

Positive – supports boards understanding of progress of the ICP

Publication Published on website No Confidentiality (FoI): Private Public ✓

1 Background and purpose:

1.1 This paper introduces the latest performance report from the Berkshire West Integrated Care

System (BWICS) presented earlier this month to the Unified Executive.

1.2 The Board has previously received a number of these reports.

1.3 The Board will note that BWICS has now changed to become Berkshire West Integrated

Care Partnership (BWICP) with a launch event held on the 18th July 2019, which was well

attended and included representatives from health, local government and the third sector.

The new working arrangements will provide an opportunity to streamline and improve the

working of local arrangements, providing a fora for closer working between health and local

authorities. The proposed arrangements have a number of advantages:

(i) Better inclusion of the care delivery chain with the inclusion of local government,

including the Chief Executives of our local authorities

(ii) A potential reduction in people required to attend meetings, freeing up senior

management time.

(iii) Provides a fora for the development of integrated health plans and may support the

development and understanding of the Joint Strategic Needs Assessment.

(iv) Provides the opportunity to strengthen relationships and develop understanding.

(v) Will facilitate discussion of the broader care agenda with the PCNs

(vi) Provides an opportunity for Elected Member engagement

(vii) Provides the opportunity to reduce duplication and release management cost.

2 Performance

2.1 Appended to this report is the latest ICS delivery report which highlights the progress made

2.2 BWICS has rated itself as amber on performance and quality against the Five Year Forward View and the NHS Long Term plan. A&E performance, diagnostics and cancer waiting times remain challenged for the system.

2.3 The system integrated quality overview shows 4 areas rated amber and Maternity assessed as green.

2.4 The ICS continues to score red on the system financial position despite the CCG’s net riskbeing reduced to £3m as a result of post year-end balance sheet review and confirmation of additional allocations. Work continues with the CFOs and Directors of Strategy creating a two year financial turnaround plan.

2.5 Of the 7 priority programmes 6 have been assessed as amber, an increase in one, with only diagnostics strategy continuing to be rated as red. July saw the Primary Care Networks go live as planned on the 1st, achieving 100% population coverage.

3 Key forthcoming activities:

3.1 A number of programmes are requiring additional and or different resourcing to take them to the next phase in the coming months, including Integrated MSK Services and System Diagnostic Strategy.

3.2 After a short delay video conferencing appointments in physiotherapy are due to commence with discussions being had with targeted specialties to move additional activity to West Berkshire Community Hospital rather than see them be treated out of the area. Work will continue to plan, on a specialty basis, for the transformation of outpatient services.

3.3 The work to develop the Primary Care Networks will continue in the coming months, building on the Primary Care Summit held in July, with the aim of having a transformation programme being in place by the end of September.

3.4 Work will continue to develop the 2 year system recovery plan, linked with organisations. Work will also include sharing detailed CIP/QIPP plans

3.5 The draft digital strategy is due to be presented to the Population Health and Digital Development Board. The required analytics capability to support planning and transformation will be scoped.

3.6 Work to continue to implement the virtual transformation team will continue.as will work on the business case and planning for in-housing business intelligence.

3.7 Over the next quarter the patient flow programme will be extended to cover mental health services and paediatrics.

3.8 The next quarter will see the final test and rollout of the live bed modelling system.

3.9 A deep dive will be taking place in the next quarter on the Workforce Strategy and workstreams are underway to support new roles in primary care.

4 Recommendation to board:

4.1 The Board are asked to note the contents of this report.

5 Attachments:

5.1 Appendix 1: ICS delivery report

Berkshire West ICS

Integrated Programme Report

July 2019

RAG rating criteria

RAG rating Initiation Implementation Delivery

Blue Project completed, benefits realised and evaluated

Green

• All project paperwork completed and KPIs set out that are SMART. EQIAs and otherimpact assessments completed. Project hasbeen signed off to proceed with delivery.

• Strong delivery plan with clear timescalesand milestones for implementation. Fullresponsibility and ownership from projectteam.

• In delivery and on track. Expected to deliverall intended benefits and savings, shown byactuals against forecast each month.

Amber/Green

• Project has been scoped, resourcesidentified, implementation plan developed.Any other project paperwork has also beencompleted or in final stages.

• Project awaiting sign off from formalgovernance processes.

• Delivery plan good with KPIs and metricsagreed.

• All major and most minor risks mitigated.

• In delivery with milestones hit but data notyet available to show performance againsttrajectory or impact of remedial action.

Amber

• Project has been scoped, implementationplan has started to be developed.

• Plan in place but not considered strong,responsibility has been accepted and workhas started.

• Implementation is progressing with noformal milestone plans or minor riskshighlighted.

• Some elements of plan have minor slippage.• Some unmitigated risks to delivery.

• In delivery and expected to deliver 80% ofplanned benefits and savings.

• In delivery but off trajectory. Remedial actionplanned which should bring us back ontotrajectory.

Red

• Project has not been fully scoped toconsider objectives, KPIs, financials,interdependencies, resource profile etc.

• No plan, no identified KPIs, no acceptedresponsibility.

• Planned activities are at high risk of notdelivering to timescale.

• Mitigating actions have not beenimplemented.

• Significant unmitigated risk to delivery.

• Delivery not commenced or commencedsignificantly behind plan.

• Forecast benefits and savings not likely todeliver or will deliver less than 80% againstplan.

• Significantly off trajectory with no plan inplace to move back onto trajectory.

3

System Overview

System Delivery Overview July 2019

Priority Programme RAG Items for UE attention

UEC Delivery Model A Deep dive scheduled for August UE and September Clinical Oversight Group

Outpatients Transformation A Exec Sponsor confirmed as Janet Lippett

Integrated MSK A Update planned for August UE

Primary Care Neighbourhoods A Primary Care summit event on 9th July

Diagnostics Strategy R Lack of resource to support delivery of priority project – UE to support with resourcing (SRO + 2x FTE) or whether this project is no longer a priority

Population Health & Digital Development Board

A Resource request for UE to approve, to continue driving forward PHM programme

Place based shared functions A Update planned for August UE to set out the proposed virtual joint transformation team and resourcing

FYFV/ LTP:Performance

FYFV/ LTP:Quality

System Financial Position

A

A

R

A

A

R

A&E performance, diagnostic standard and cancer waiting time standards remain challenged for the system.

In year status Forward statusCommentary

Areas to note include pressure damage, falls, workforce training, complaints, clinical concerns, better births initiative.

Net risks include risks related to RBFT bridge to control total. Risk sharing is based on the CCG and RBFT each taking a 50% share of RBFT’s risks and mitigations. The CCG’s risks and mitigations are shared 40% RBFT and 60% CCG. The CCG’s net risk reduced to £3m at month 2 as a result of post year end balance sheet review and confirmation of additional allocations.

System Integrated Performance Overview July 2019

Programme RAG Areas of concern (R rated) Actions to improve delivery

PERFO

RMANCE

Urgent & Emergency Care

• A&E Performance• 111 Call Answer Performance

A&E: A&E performance improved slightly in month 1 despite the Easter break. This improvement followed on from the 2 week system wide improvement event known as the "Re-set Fortnight" during which all parts of the system worked together to improve patient flow through the system. Commitments included earlier discharges, increased week-end discharges and a reduction in stranded patients. Directors also visited wards across RBFT and BHFT to provide support escalating and unblocking issues. RBFT continue to focus on their Patient Flow programme minimising delays across the patient pathway and ensuring that patients are streamed directly to the most appropriate service.

111 Call answer performance continued to improve through March and into April. SCAS maintain a focus on their recruitment challenges in the Call Centre and are tightly managing sickness and other forms of absence. Abandoned call rates also improved in April.

Elective / Planned care

• Diagnostic Waiting Times• RTT Performance

Diagnostic performance remains challenged in April with the backlog of patients waiting over 6 weeks increasing in April. Recently performance has been affected due to the breakdown of an MRI scanner in April and increased demand in endoscopy services.

RBFT has achieved the RTT standard for the year for incomplete pathways. There have been no 52 weeks breaches at the trust in April.

Cancer • Cancer Waiting TimesCancer performance for April has been challenged with RBFT not achieving the national standard for 31day subs surgery, 31day subs radiotherapy and 62 day GP referral waits.

System Integrated Quality Overview July 2019

Programme

RA

G Areas of concern Actions to improve delivery

QU

ALI

TY

Patient Safety

Pressure Damage/FallsFallsCdiffMSA

RBFT and BHFT to engage with a task and finish group arranged by the CCG regarding falls and pressure damage inclusive of sharing learning and developing strategies for reduction across both provider areas. All providers have received their annual thresholds for Cdiff RBFT- 24, GWH, 47, HHFT 60. From April 1st there were changes made by PHE / NHSi to the reporting and apportioning process, which would potentially have an impact on the number of cases that are “apportioned” to the Trusts. To summarise, new guidance outlines how cases will be apportioned as follows: Using the new guidance HOHA Hospital onset healthcare associated (3 or more days after admission) & COHA Community onset healthcare associated, within 2 days of admission.MSA for the RBFT continues to be a challenge, assurance is provided that there has been no increase negative impact in patient experience.

Clinical Effectiveness

Workforce Training

Workforce remains a high priority on Risk Registers. A number of initiatives for both recruitment and retention have been undertaken, inclusive of overseas and local recruitment days. The HR teams working closely with managers to ensure sickness is monitored and managed within policy. There has, however, been a significant improvement in relation to nursing attrition rates in comparison with the previous year. As with the production of the interim People Plan, the workforce strategy for the system will align with national direction.

ExperienceComplaintsClinical concerns

RBFT have faced challenges with the capacity of the patient relations steam, however this is now resolved and the Trust anticipate an increase in response time. HHFT detailed an increase of 28% with the main themes being within the medical directorate, in relation to communication and treatment- actions include process and training.

Maternity

Better Births InitiativeImproving birth rateMaternal MorbidityClosure of Rushey

• The Continuity of Carer programme, Blossom team, commenced end of June will provide antenatal, intrapartum and postnatal care to women in the RG2 area who meet the criteria. There is a plan to expand the criteria when the team is fully established however a number of women are now within the cohort and receiving this service. The plan is to work towards a target of 20% of women to have access to this service. The focus; continuity of carer; improvement in women’s experience of services; outcomes for key target areas; normal vaginal birth and initiation of breastfeeding. The pilot will be reviewed for the first time after 6 months then at intervals thereafter. • Focus on improving home birth rate: RBFT are working to improve the awareness of the home birth service and targetwomen suitable for a home birth to improve rates. May and June had 4% of births being in the womans home which is an excellent result despite there being vacancies in the home birth team. Various initiatives are taking place to improve recruitment to this team including use of existing resource from the wider community service.• Maternal Morbidity: Significant major blood loss – focus on cases of over 1500mls and over 2000mls, cases reviewed everymorning with obstetrics colleagues. • Issues around the current commissioning regarding CO monitors to assist with smoking cessation in pregnancy. Various

initiatives being considered to resolve this issue.

ICS Finance report

Financial review – M2 data

ICS Resource Plan

Transformation FundingWe are awaiting confirmation that £2m transformation funding will be made available to BWICS for 2019/20. If the funding is available, it is expected that it will be used as follows:• £1m will transfer to RBFT to support the underlying deficit• £460k for ED streaming – any savings up to £250k as a result of reviewing the service model will be transferred

to RBFT to support the underlying deficit with any further savings being used to support the CCG’s underlyingdeficit.

• £350k for the ICS programme with any underspend resulting from the revised ICP governance to be held by theCCG as a mitigation against the deficit.

PHM FundingSome of the PHM funding received in 2018/19 has been carried forward to 2019/20 and it will be used for the purpose for which it was intended. In order to support the underlying deficit of RBFT £200k has been released but must badged against activities linked to PHM/Connected Care.

Progress tracker

Other work completed by CFO Group in the last month:

• Continue to liaise with NHSE/I regarding system transformation funding andsystem control total options.

• Review of recovery plan progress with Directors of Strategy.• Individual organisational recovery plan action e.g. KPMG work with RBFT and

CCG review of Menu of Opportunities, etc.• Action to secure finance team input to all programme boards.

Priorities for next 2 months:

• Continue to develop the 2 year system recovery plan including individualorganisation plans.

• Run the “Systems Drivers of the Deficit Review” with support from NHSE&I• Agree the outline of the 5 to 10 year financial strategy to sit alongside the longer

term plan submission due in Autumn 2019.• Focus on costing data quality to include in the system costing model.• Establishing the BWICS finance leadership within the new STP CFO’s group – first

meeting 8 July 2019.• Develop a shared view on potential costs of increased demand and how this can

be funded from within existing budget.• Work with programme boards to understand how the finance team can support

decision making.

July 2019

Status R

Commentary

• Net risks include the risks related to the RBFT bridge to control total i.e. aroundadditional CIPs and transformation funding.

• Risk sharing is based on the CCG and RBFT each taking a 50% share of RBFT’srisks and mitigations. The CCG’s risks and mitigations are shared 40% RBFT and 60% CCG.

• The CCG’s net risk reduced to £3m at month 2 as a result of post year end balancesheet review and confirmation of additional allocations.

• Any cost risk associated with increased demand has not yet been captured.• The CCG will not have any flexibility to support delivery of provider control totals in

2019/20 due to the level of net risk .• Individual organisation continue to be reviewed at FRG on a monthly basis with

system support for delivery agreed as appropriate .

Communications & Engagement Progress Report July 2019

Programme Objectives• Define, develop and describe a compelling and coherent narrative that illustrates the ICS’s vision, clearly illustrating the way in which closer collaboration is working to

improve health and care for the people of Berkshire West.

• Progress against plan since last update to UE

• Newbury H&WB Board. Excellent presentation on PCNs and introduction of

three of the 4 clinical directors. Commitment in the room from all to support

‘designing our neighbourhoods’ work stream.

• Collaborative piece with East Berks & London Irish Rugby on safe sleeping with

infants ‘Lift the baby’ campaign – end of June

• News release on PCNs issued 01/07.

• First person feature (Cathy Winfield) in local media w/b 08/07 - Design our

Neighbourhoods,

• ICS newsletter issued 01/07

• Attendance at Reading Wellbeing forum on 04/07 Thursday and Reading Youth

Parliament to broaden our stakeholder engagement

Planned activity

• Reading 10/07 Invites are going to the local authority, BHFT, ReadingIntegration Board. There’s been agreement from 6 of the new CDs that they willbe attending.

• Planning for summer events aimed at more grass roots level including PPGs,Patient leaders, voluntary sector, district nurses, social care etc

• Media features planned – 4 week rolling programme

Risk / issue Mitigation Owner

Ensuring appropriate stakeholders available to attend DON events Work with locality managers and CCG directors to obtain information in advance of invitations

Victoria Parker/Sally Moore

Exec Sponsor Victoria Parker SRO Victoria Parker Programme/Project Lead Sally Moore

9

ICS Priority Projects – oversight provided by Unified Executive

Strategic priority projects interdependencies matrix – Q1 snapshot

10

UEC Strategy Outpatients Transformation Integrated MSK Primary Care

NeighbourhoodsDiagnostics

Strategy

Population Health and Digital

Development

Integrated place-based shared

functions

UEC Strategy

No No Yes – development of UEC hubs and same day access

Yes – will link to same day emergency care and 7 day working agenda

Yes – using intelligence from PHM, risk stratification and HIU

None so far

Outpatients Transformation

No No – but reduction in outpatients will come out of MSK project and be counted there

Possibly – moving care closer to home

None so far Yes – using intelligence, PHM approach and segmentation to inform interventions

None so far

Integrated MSK

No – activity is planned Yes – reduction of appointments both in and out of RBFT

Yes – PCNs will need to adhere to referral to triage and shared decision making

Yes – Direct Access MRI

Possibly – depends on requirements for long term service model

None so far

Primary Care Neighbourhoods

Yes – same day demand management

Potentially – depends on where service delivery happens

Yes – first contact physios

Possibly – depends on development of strategy

None so far – PHM will support PCNs

None so far

Diagnostics Strategy

Yes – access to same day emergency care

Yes – to be scoped Yes – Direct Access MRI

Yes – access to diagnostics within PCNs

Possibly – using intelligence to inform strategy development

Yes – will need resource to drive programme forward

Population Health and Digital Development

Yes – as the analytics and PHM approach develops

Yes – interventions in outpatients and use of PHM in long term conditions

None so far Yes - PCNs delivering local interventions and adopting PHM approach

None so far Yes – will need resource to drive programme forward

Integrated place-based shared functions

Yes – if resource released

None so far None so far No – PCN capacity and resources funded elsewhere

Yes – if resource released

Yes – inhousing of BI from CSU

Where there are interdependencies / impacts on the other priorities

ICS

stra

tegy

prio

rity

proj

ects

UEC Strategy / Delivery Model – Progress Update

Project status A

Programme ObjectivesTo develop a tailored UEC strategy for BW including the case for change and recommendations. To consult and engage with a wide range of stakeholders to agree the final strategy, develop an implementation plan and deliver the agreed transformation change.

Progress against plan:• UEC Strategy Development group established and Terms of Reference agreed• Strategy outline structure and draft outline implementation plan agreed• Work programme under development to act as a scoping document for all

elements to be covered by the strategy and will be signed off at July AEDBmeeting

• Skills for Health session held and UEC Workforce Group being established• SROs agreed for each element of the plan to drive development

Milestones this month

• Task and Finish group to be established to bring together data and intelligenceto frame the strategic discussion

• Core development group to meet weekly to drive development of strategy• SROs to develop “plans on a page” for their element of the strategy• Further development of work plan for delivery/implementation• Voluntary sector engagement event with Reading Voluntary Action on 4.7.19

Milestones next month

• Further work on localised BW UEC strategy• Timeline for presentation/engagement with key groups

• 7 July Clinical Oversight Group• 24 July ICP Delivery Group• 8 August ICS Unified Executive• 24 September ICP Leadership (if required)

Action required from enablers:• Strong links required with Paediatric Programme Board, Long Term Conditions

Board and Population Health and Digital Development Board• Support required to populate work programme/scoping document for

paediatrics and mental health


Resourcing development and delivery of strategy Resourcing requirements currently under discussion MS/SB

Securing engagement and buy in from all system partners including Primary Care

Robust communications plan Strategy Development Group

July 2019

Exec Sponsor Mary Sherry SRO Mary Sherry Programme/Project Lead Maureen McCartney/ Carolyn Lawson

Projects

Q1 Q2 Q3 Q4

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

UEC Strategy / Delivery Model

Strategy Development Group established

Skills for Health workshop held

Engage with Delivery Group

Engage with Clinical Oversight Group

Outline strategy and approach agreed with Unified Executive

ICP Leadership sign off if required

Wider engagement activities

Short term changes for winter implemented





Activity milestone Decision made/Change approvedChange implemented Action taken D Dependency on enabler Evaluation/reviewKEY:

UEC Strategy / Delivery Model – Milestone Plan As of June 2019

Outpatients Transformation – Progress Update

Programme Objectives• Overall – to deliver a modern outpatients service for the people of Berkshire West and to reduce outpatient activity on the RBH site by 50%• 2019/20

• To reduce activity on the RBH site by 7% by the end of 2019/20 thereby releasing c.£500k of resource inside RBFT;• To develop business cases (with Estates) and make decisions on substantive shifts of activity off the RBFT site to Townlands and Bracknell;

Progress against plan

Milestones this month• Challenge and confirm meetings on specialty plans to take place with escalation where necessary – meetings

have taken place and actions agreed for each specialty where engagement needs addressing.• Pilot for video conferencing appointments in Physio to begin – pilot did not start due to operational

pressures in physio. Pilot will start in July and additional specialties will come on board soon after. • In principle decision on next steps for Townlands site (Estates Board on 10 June ) – RBFT Estates Board made

an in principle decision to seek to occupy the whole of Townlands. Business case now in development.• Agree approach to start to measure in-clinic (e.g. throughput utilisation ) – work still underway.• Define ICS contribution to STP wide outpatients programme – initial BOB ICS-wide meeting held to scope

system priorities. Likely areas include Ophthalmology outpatient delivery and developing clinicutilisation measures.

• Scope out video conferencing between in-patient services at Prospect Park hospital and GPs – meeting on 20June – initial meeting held. Needs further discussion with GP IT.

Milestones next month• Discussions with targeted RBFT specialties to move additional activity to

West Berkshire Community Hospital to enable more patients to be treated there rather than out of area. Engagement started with relevant Newbury PCNs as well;

• Launch of video-conferencing in RBFT• Finalise speciality by speciality plans and timescales for transformation in

Q3 and Q4;• Initial meeting of Townlands development working group and establish

timelines for business case development;• Escalation to RBFT Executive potential options for taking cost out in

particular specialties.

Action required from enablersAction• Finance – support with taking cost out the RBFT from releasing

resources from outpatient transformation to be owned by care group management.

To note• IT, Estates and Finance – to support development of Townlands

business case. Representatives are included on the working group


Challenge with taking cost out of the system Linking outpatient transformation work with demand and capacity planning in RBFT. Escalation of decisions to RBFT Executive to consider where cost can be taken out and implication thereof.

Raghuv Bhasin

Engagement with certain specialties remains poor Escalation through RBFT Care Group Management and issues flagged with RBFT COO and CEO. Clinical Lead (Outpatients) engaging with specialty clinical leads.

Raghuv Bhas

July 2019

Project status AExec Sponsor Janet Lippett SRO Raghuv Bhasin Programme/Project Lead Kathy Green

Apr-18 Jul-18 Oct-18 Jan-19 Apr-19 Jul-19 Oct-19 Jan-2025,000

27,000

29,000

31,000

33,000

35,000

37,000

39,000 Volume of activity on RBH site

OP Activity on RBH site Stylised trajectory

Outpatients Transformation – Milestone Plan

Projects

Q1 Q2 Q3 Q4


Outpatients Transformation

Agreement of specialty by specialty plans for implementing three key interventions – Patient Initiated Follow-Up, Referral Streaming and Telephone Clinics

Start scoping of PIFU at BHFT

Lunch and learn session for referral streaming implementation

Go live with video conferencing pilot at RBFT(Phase 1)

EMC paper for skill mix review in Outpatients

Agree delivery plan with Care groups for the first three key interventions

Go live with Advanced Advice and Guidance

Go live with video conferencing pilot (phase 2)

Publish the next How to guides, remote monitoring and one stop

Evaluate video conferencing pilot so far

Demand and capacity planning in RBFT undertaken

DAWN phase 2 go live in Gastro, Neuro, Respiratory and Derm

Agreement of speciality by speciality plans for remote monitoring, improving GP referrals and one-stop shops

Public engagement regarding outpatient changes as part of wider engagement

New MSK and Dermatology pathways implemented

Operational planning for outpatient transformation for 20/21


As of June 2019

Integrated MSK Service – Progress Update

Programme Objectives: The expected outcomes of a redesigned MSK pathway are to support a change in direction for MSK. It requires moving away from the traditional view of a single disease under the medical model, moving towards a holistic approach, seeing the patient as a whole rather than the condition they seek help for. It is expected that the ICS partners will work in collaboration to collectively deliver these interventions.The interventions are: i) Upskilling of primary care via Primary Care Networks; ii) First Contact Physio (FCP); iii) Shared Decision Making; iv) MSK Community Specialist Service (CSS) and Triage; and v) Additional Conservative Treatment.

Progress against plan

Following the approval of the business case by the Unified Executive in May 2019, The team is now focussed on activities required to deliver implementation of the programme by December 2019. Progress in June:

• Draft job description for GP Champions circulated for final review andadvertising in July

• First Contact Physio job description circulated to the Primary Care Networks todiscuss next steps

• Triage and Community Specialist Workshop planning to define servicespecification

• Draft job description for MSK Pathway Director circulated for final review andadvertising in July

The following are the milestones for July 2019:

• Advertising of GP Champions• Advertising of MSK Pathway Director post• Community Specialist Service and Triage workshop on 24 July• Identification of training requirements for the programme• Shared Decision Making PIN finishes

Milestones next month(Must be SMART)

• Service specification for triage and Community Specialist Service to be signedoff by Planned Care Programme Board

• Defining the operational details for the new service• Defining the data collection methodology• Triage IFR and data collection process defined

Action required from enablers

Not applicable.


No representation on the project team by primary care as providers • GP Champion post to input into the project implementation• Dr Abid Irfan to join the project team

SRO

Recruitment of the clinical workforce to meet a December start remains a risk

• The project team has escalated this to executive level (26.06.19) SRO

July 2019

Project status AExec Sponsor Andrew Statham SRO Shairoz Claridge Programme/Project Lead Karen Grannum

Integrated MSK (Phase 1) – Milestone Plan

Projects

Q1 Q2 Q3Q4

May Jun Jul Aug Sep Oct Nov Dec

COMMISSIONING CONTRACTS MOBILISATION SERVICE STARTS

Governance and Approvals

• FBC to UE 09/05

• FBC to Leadership 16/05

• Refresh FBC

• Papers 04/06

• PCPB

• CCC 11/06

• RBFT 13/06

• MSK Board

• Planned Care

Programme Board

(PCPB)

• RBFT Board

• BHFT Board

• MSK Board

• CCC

• RBFT Board

• BHFT Board

• UE

• PBPB

• MSK Board

• PCPB

• TIPS

• RBFT Board

• BHFT Board

• MSK Board

• CCC

• RBFT Board

• BHFT Board

• PBPB

• MSK Board

• PCPB

• Pre-launch checklist (UE

approval)

• UE

• CCC

• RBFT Board

• BHFT Board

• MSK Board

• CCC

• RBFT Board

• BHFT Board

• PCPB

Commissioning

Draft service specs: GP training & engagement, triage, SDM, FCP, CSS

Provider Assurance statements: GP training & engagement, triage, SDM, FCP, CSS

SDM PIN

SOPs

Contract variation

SDM award

DES

Senior Manager/Managing Director

Start recruitment process: write JD, agree host employer, agree banding

Advert closesContinue recruitment process: shortlist, interviews and offer

Complete recruitment process: references & DBS

Comms Comms

SERVICE STARTS

FCP Start recruitment process

Advert closes

Provider assurance statement

Continue recruitment process

Complete recruitment process Comms Comms

Triage

Start recruitment process

Design IFR

Letters to providers


SOPs

New IFR TVPC

Gov body adopts IFR

Letter to providers (1)

GP comms

Continue recruitment process


GP comms

Complete recruitment process – all staff in post

Tested new referral route


GP comms

Comms

CSSStart recruitment process


SOPs

Job plans

Confirm premisesClinical space fitted out

IT fitted

IT tested

All recruitment completeComms

Business Processes Data sharing processes Tracking process Dashboard designed

and approved Data flow test Comms

D

D

As of June 2019

Primary Care Neighbourhoods – Progress Update July 2019

Programme ObjectivesTo be defined at first two Programme Board meetings. Programme Board has now agreed five key programme elements which are to be considered further at the Primary Care Summit meeting on 9th July; programme objectives will be built around these. The five areas are sustainability, PHM driving proactive care, neighbourhoods taking holistic approach to maintaining health and wellbeing, integrated care planning through MDTs embedded in neighbourhoods, extended services in primary care and integrated MDTs working within neighbourhoods to meet same day care needs.

Progress against plan(KPIs – performance, quality or financial)Ongoing transformation programme to be in place by end of September, in the mean time Programme Board will oversee progress on established workstreams (e.g. workforce, estates strategy development, enhanced access). Programme to be based on delivering first stages of a roadmap for transformation which in turn will reflect a local maturity matrix for PCNs to be developed through the Primary Care Summit meeting on 9th July, the Design our Neighbourhood events and the next Programme Board meeting.

Actions to date have focussed on the agreement and formal approval of PCNs which went live as planned on 1st July 2019. Structures for collaboration and ICP representation now being agreed between PCNs.

Milestones this month• Configurations approved, workforce baselining completed and Network

Agreements signed enabling PCNs to go live as planned on 1st July 2019. 100% population coverage achieved.

• No national mandatory DSA issued so using existing Enhanced Access DSAfor extended hours. Have met with PCNs regarding extended hours delivery plan and now finalising rotas.

• Primary Care Programme Board met for first time on 12th June 2019.• Newbury Design our Neighbourhoods event took place on 27th June 2019.• Agreement of delivery plan for Extended Hours DES• PCN representation arrangements not yet confirmed but discussion has

progressed.

Milestones next month• Primary Care Summit meeting – 9th July 2019• Reading Design our Neighbourhood event – 10th July 2019• Agree initial approach to social prescribing link workers with Clinical Directors• Schedule quarterly meetings and other regular points of engagement with PCNs

Action required from enablers

To be defined.


Previous risk of not achieving 100% coverage did not materialise. Risk register now to be developed by Primary Care Programme Board.

Project status AExec Sponsor Jim Kennedy SRO Helen Clark Programme/Project Lead Matthew Chilcott

Primary Care Neighbourhoods – Milestone Plan

Projects

Q1 Q2 Q3 Q4


Primary Care Neighbourhood

Development

Disseminate national guidance and share CCG interpretation of requirements with all practices

PCN applications to CCG by 15th May

Share applications with partners and review at

PCCC

Confirm approval of

configuration by 7th June

PCNs to complete Network Agreement

PCNs to sign Data Sharing Agreement

PCNs to confirm

representation arrangements for key ICS meetings

Primary Care Programme Board initial meeting

Newbury Design our

Neighbourhood Event

Extended Hours Delivery arrangements agreed with PCNs

PCNs ‘Go Live’ – 1st July 2019

Follow-up Primary Care Summit Meeting to inform

development of work

programme

Agree approach to

social prescribing link workers with Clinical Directors

Quarterly meetings with

PCNs scheduled and

other engagement arrangements confirmed

Reading Design our

Neighbourhood Events

Primary Care Programme Board work programme in

place

Design our Neighbourhood follow-up events with broader

stakeholders

As of June 2019

Diagnostic Strategy – Progress Update July 2019

Programme Objectives: The aim of the Berkshire West ICS is to develop a comprehensive strategy for diagnostic and imaging services. The objective of the proposed review is to a) Develop a shared understanding of current need, provision, performance and cost of diagnostic services for patients in Berkshire West, b) Develop a shared understanding of the future demand for diagnostic services and the cost of these services if the current model of care persists. c) Explore opportunities for addressing gaps identified in a) and b) and the costs associated with pursuing these. d) Explore enablers to delivering pathway improvements in c. including operating model, contract form, payment, IT etc.

Progress against plan (KPIs – performance, quality or financial)The objective of this programme is to develop a clear strategy and to identify potential quick wins in order to inform 20/21 planning. With this in mind a project plan for commencement in September has been developed and key actions have been completed • A draft scope and resource plan for the diagnostic review has been developed• Potential team members from RBFT including clinical involvement have been

identified and agreed• A millstone based plan has been developed• Contact has been made with NHSI’s OcProc team to identify whether they may

be able to support the review with existing literature and resources• Work has been agreed to explore potential system financial opportunity from

curtailing direct access MRI

Milestones this month(Must be SMART)• Development of the scope of work and project plan by 1st May – completed• Identification of likely resources to complete the work by 1st May – completed• Contact with NHSI to identify potential support for the work by 1st May – in

progress• Milestone plan by 6th June – completed

Milestones next month(Must be SMART)• Revised scope following comments by ICS members – by 1st August• Identification of supporting project resource from transformation team or a

decision by UE to curtail the project – by 11th July• Identification of support from NHSI – by 1st August• Proposal to UE on how to bridge gap between project requirements and

existing resource – by 1st August• Identification of data requirements – by 21st August

Action required• At present no project resources have been identified for this priority by the ICS

programme team despite flagging this gap since the May report a discussion at UE last month. While the project has been in formation stage this has been a manageable risk but this must be addressed for the ICS to make progress. This is becoming a critical issue given the desire to explore benefits from curtailing direct access MRI

• It will be essential to secure and SRO, dedicated project managementresource (1 FTE) and data analytics capability (1FTE) in order for this project to deliver. Wider stakeholder representation on a steering group from ICS members (e.g. one senior member from each party) will also be essential

• ICS UE members comments on the draft scope of work would be welcomed atthis stage


Project resources Resources to be identified from ICS transformation teams Sam Burrows

Specialist data analysis required to complete the work may not be It may be possible to secure this from the CSU in housing work Andrew Statham

Project status RExec Sponsor Andrew Statham SRO TBC – request made to ICS PMO Transformation Resource TBC – request made to ICS

PMO

KEY:

Projects

Q1 Q2 Q3 Q4


Diagnostics Strategy

Identification and allocation of project resource

Agree scope and case for change

Data gathering (including literature review on potential for modality shifts

Assess current

and future capacity by

type

Complete demand

assessment incl. upside and downside scenarios

Conduct options

appraisal and cost options

UE discussion of options and recommendat

ions

Implementation planning

Implement changes and savings begin

Direct access MRI

Agree scope and case for change

Agree changes at UE

Implement changes and

savings begin

Evaluation/review

Diagnostics Strategy – Milestone Plan

Activity milestone Decision made/Change approvedChange implemented Action taken D Dependency on enabler Evaluation/review

As of June 2019

Population Health & Digital Development – Progress Update July 2019

Programme Objectives• Align ICS infrastructure, intelligence and interventions, and provide oversight and assurance on delivery of ICS population health and digital strategies.• Oversight of the Optum PHM Programme, Connected Care Programme, LHCRE and ICS Digital Strategy• Support development of PHM approach in other ICS strategic priorities and Programme Boards

Progress against plan / deliverables

GOVERNANCE - PHDDB meetings attended well and members are proactive in requesting updates from various programmes to

ensure alignment with objectives- PHDDB looking to formalise link with IG group

DIGITAL STRATEGY- Currently in development for sign off in July, and will inform milestone plans for overall programme

INFRASTRUCTURE- Following approval of the Digital Strategy, implementation plans will be developed, starting with VOIP and wifi

INTELLIGENCE- Optum support on PHM programme concludes, with recommendations for next steps and implementation roadmap- Joint PHE and NHS analytics group developing capability requirements

INTERVENTIONS- Compiling list and timeframes for ICS project interventions which have digital elements to feed into milestone plan

Milestones this month• Final Optum workshop for progress update and outcomes from

local clinical interventions on 16th May – completed• Draft PHM roadmap developed, ready to be presented at ICS

Boards – in progress• Continue development of milestone plan – in progress• Agreement on Optum roadmap options at next PHDDB on 20th

June – completed• Analytics visioning workshop on 25th June, outputs to be

presented in July to UE and PHDDB• Presented PHM to Surrey Heartlands Academy Forum with

positive response from across the system and NHSE -completed

Milestones next month• Draft Digital Strategy presented to PHDDB on 25th July, this

will need further alignment as we move to ICP • Scope system analytics capability to support with planning and

transformation, as well as PHM approachAction required from enablers

- ICS Programme Boards and strategic priority projects to complete digital requirements form - Digital innovation ideas (eg. Using apps to monitor long term conditions) to be proposed via PHDDB for

consideration- Share PHM approach with PCNs to embed within their development of neighbourhoods


PHM programme requires resourcing to continue to drive programme at pace Define requirements as part of Optum recommendations KS/AS

LHCRE programme is not clear on whether it is focused technology or transformation, and how it links to existing Connected Care work

Feed back to and invite LHCRE leads to PHDDB for discussion AG

Engagement with PCNs on PHM approach and clinical interventions Link with Primary Care Transformation Programme Board and summit meeting on 9th July for opportunities to work together

AG

Project status AExec Sponsor Alex Gild SRO Alex Gild Programme/Project Lead Shirley Lee

Population Health & Digital Development – Milestone Plan

Workstreams

Q1 Q2 Q3 Q4


Digital StrategyPresent draft strategy at PHDDB

Strategy signed off at PHDDB

Implementation plans to be developed for workstreams

Infrastructure Develop plan for VOIP

Develop plan for SSO and standardised wifi

Intelligence

Mail drop to Berkshire residents on

secondary use of data

Inhousing of CSU BI function –

process starts

Analytics visioning workshop

Inhousing of CSU BI analytics

Interventions Live bed state – phase 1

Go live with Outpatients

video conferencing

pilot

DAWN implement-

ation

Go live with Advanced Advice & Guidance

IT and testing in place for iMSK

Population Health

Management

Draft roadmap developed

Optum PHM programme completed

Roadmap for PHM

approach approved


As of June 2019

Integrated place-based shared functions

Programme ObjectivesThe overall aim of the programme is to ensure that the ICS has sufficient capability and capacity in its shared non-clinical functions to support the delivery of the Long Term Plan and the 7 strategic priorities identified for the year ahead. It is expected that the programme will contribute to system financial sustainability through supporting effective transformation and/or by securing cash releasing savings related to increased efficiency through delivery at place based scale.

Please note that the programme currently excludes the ICP governance review , work around commissioning functions at STP level and primary care transformation.

Progress against planThe programme of work and detailed plan is currently in the initiation stage, with the exception of two individual projects, which are more developed. KPIs have not yet been developed, but it is anticipated that they will be in the following categories:• Programme KPIs related to measuring the breadth of programme delivery.• Service related including effectiveness and efficiency of redesigned services, staff

recruitment and retention, etc.

Shared Transformation Resource (RBFT and BWCCG) – SRO Mary/Sam tbc: Agreement reached on progressing a virtual team with a 60 day programme of work concluding in August 2000

Intelligence and Analytics Project – PHDBB leading initial work with sub-project for BI in-housing from CSU (SRO Ashmita Chandra) progressing to business case stage in Q1.

Milestones next month (July 2019)Transformation • Implement virtual team as per 60 day planBI in-housing• Submit final in-housing business case to NHSE for proof of concept (approval will

require TUPE and stranded cost data to be included).Other • Revisit shared back office work to develop a pipeline of activity for the remainder of the

year• Meet with CSU and BOB STP to review the in-housing programme

Milestones next month (August 2019)Transformation • Finalise the implementation of the virtual team as per 60 day planBI in-housing• Response from NHSE on business case and commencement of planning the in-housing

process and design of the function (alongside work of the PHDDB).Other • Presentation of opportunities to UE.

Enablers• This programme of work is a key enabler for delivery of the ICS 7 key strategic priorities.• It also links with another enabler, Shared Estate and the One Public Estate/Berkshire

Property Partnership sponsored review of RBFT admin estate.

Notes• In order for funding/staff time to be reinvested in developing our support function

capability and capacity, the benefits case for our redesigned shared functions must be stronger than the case for using cash releasing savings to help close the underlying deficit.

• The in-housing of the BI service from CSU is part of a wider programme which hasbeen led by the CCG CFO. This includes in-housing of Finance and Provider (completed) Performance Management (to completed 1 September 2019). Details are available on request.


Loss of key staff/corporate knowledge during a period of change. Engagement with staff in designing the new function and regular briefing regarding progress and timescales.

Individual project leads.

Policy changes (particularly in relation to the development of BOB STP commissioning functions and the future of CSUs)

Clear rational for place-based functions; continued pace of change and continued briefing up to NHSE/I.

Exec Lead

July 2019

Project status AExec Sponsor Rebecca Clegg SRO Various related to projects Programme/Project Lead Various related to projects

Integrated Shared Functions – Milestone Plan

Projects

Q1 Q2 Q3 Q4


Shared Transformation

Resource

CEOs approve

recommendation to develop a virtual joint

team

Individual organisational governance/ approval including

consideration of process for appointments and resourcing implications

Implement 60 day plan

(appoint single head of team, appoint exec lead, agree admin

resource, agree finance team role and resourcing

Intelligence and Analytics project

Submission of initial business case to NHSE

Submission of final business case to NHSE

Approval of business case by NHSE

Start of TUPE process

Completion of TUPE process

BI team in-housed

Evaluate capability and capacity of current team

Resolve capacity gaps and align to programme boards

As of June 2019

25

Programme Board reports – including Programme Board led ICS strategic priorities

A&E Delivery Board Report (1/3)

Project status AMBER

Programme Board Projects

Project Objectives Achievements so far Milestones next quarter KPIs RAG

High Intensity Users

To oversee development of a new model of care to support patients with frequent, potentially clinical inappropriate contact with health and social care services, often in high acuity settings.

Working Group established. Terms of Reference agreed. Learning from previous pilots and other approaches nationally captured.Approach agreed to identifying those individuals potentially making contact with services across health and social care.

Identify the top 250 most frequent users of services (starting with those services with a Connected Care feed).Clinicians to review and cross match to identify those users having frequent contact with multiple services.Once the patient cohort is understood consider a future model of care that can be tailored to meet the needs of these individuals.

To reduce the activity and cost associated the cohort of patients having frequent unplanned contact with UEC services across BW.

A/G

Community Reablement

To work in partnership across BW to provide high quality, consistent reablement services enabling every person to maximise their potential in the right place at the right time.

2 day Quality Improvement event held and common set of goals agreed.PID signed off and phasing agreed.Audit of existing project work underway.Initial set of KPIs drafted.Agreed trial of Therapy Outcome tool (Activity Performance Measure.Draft pathway mapped and reviewed.

Review of service specification by end Jul-19.Sampling of data relating to patient’s experience.Development of Communications strategy.

Under development A/G

Risks, issues & mitigations• IG issues may delay identification of system wide High Intensity Users, CSU

asked to support• Community reablement project focusing on long term improvement but system

recognition that short term improvements to mitigate impact of limited capacity are required

Action required from enablers / other programme boards • Digital board may be asked to support IG issues if these cannot be resolved• …• …

July 2019

Chair Mary Sherry Clinical Chair Dr A Ciercierski





Patient Flow programme

A programme of work aimed at maximising safe patient flow through the acute Trust and encompassing Same Day Emergency Care, Emergency Medicine, Acute Medicine and interface services, Acute Surgical services and Acute inpatient wards.

Workstreams defined and leads identified. Programme scoping completed and draft work programme presented to AEDB.Improvement work underway and RBFT using new QI tool the “Success Model”.

Expand improvement work and programme to cover mental health services and paediatrics.Progress delivery of key objectives.

Reduction in LOS between 0.25 and 0.5 days per wardReduced staff turnoverIncrease in week-end discharge numbers

A/G

Stranded patients

To deliver a further 8% reduction in the number of stranded patients occupying acute beds.

32% reduction delivered in 2018-19

Weekly Directors meetings shifting focus to stranded patients.New NHS E reporting mechanism for acute trusts and BHFT asked to scope how this could be applied to community settings.LLOS event on 10th July – system to be represented.

Achievement of stranded patient trajectory agreed with NHS I

A/G

Risks, issues & mitigations• Rising acuity of patients at RBFT as the system increasingly manages more

complex individuals outside of the hospital setting and the significant reductionin 18-19 will mean that the 19-20 improvement trajectory for stranded patientswill be challenging.

Action required from enablers / other programme boards • Delivery of the stranded patient trajectory will require a system effort and

support of partners across BHFT, Adult Social Care and the voluntary sector

July 2019

Chair Mary Sherry Clinical Chair Dr A Ciercierski





Bed Modelling The bed modelling project has the following objectives;• Agree and implement new

streamlined process formoving patients from an acuteto a community rehab bed

• Design and implement a newsystem wide live bedmanagement system

• Implement short termimprovements to neuro rehabcapacity and intensification ofgeneral rehab capacity

• Longer term redesign ofsystem wide neuro rehabmodel

• Future system wide bedreconfiguration in tandem withUEC strategy development.

Short term improvements to neuro rehab capacity and intensification of general rehab capacity delivered on schedule.

Report to be received on proposals for longer term changes to system wide neuro rehab pathway.Final test and rollout of live bed modelling system.

Reduce days delayed awaiting specialist neuro rehabilitation

A

Risks, issues & mitigations• Further interim improvements required to the neuro rehab pathway to mitigate

current waits.

Action required from enablers / other programme boards • Neuro rehab proposal from the LTC Programme Board

July 2019

Chair Mary Sherry Clinical Chair Andy Ciercierski

Planned Care Integrated Programme Board Report (1/2)



Cancer Transformation

Deliver the Cancer standards as set out by in the Long Term Plan and Thames Valley Cancer Alliance while meeting the statutory cancer targets

Plans in place for:• FIT Testing• QIS Round 2• Cancer Quality Award Scheme• Cancer Care Reviews• South Reading project rolled out

CCG widePlans being developed• Vague Symptoms• Risk stratified Pathways• HIE• Living beyond Cancer

• Practices sign up to QIS• CQAS GP pilot scheme set up• FIT Screening went live in June and CRUK

will support with raising awareness.• New Cancer CCG Cancer framework is

completed incorporating the Long Term Plan• New Cancer Dashboard is developed

• 2 week wait• 31 day• 62 day

G

Ophthalmology Transform Ophthalmology services to streamline existing pathways and reduce waste within the system

• Embedded Health Harmonie toprovide a community service thathas good working relationshipswith RBFT

• Developed the Triage Businesscase

• Worked with RBFT as part of theDemand and Activity workstreams

• Review existing working arrangementsbetween Health Harmonie and RBFT toensure they are contractual sound

• Develop the finance aspect of the triagebusiness case (similar to the MSK businesscase) to ensure investment in new serviceresults in cost out of the system

• Review capacity and demand modellingcompleted by RBFT Ophthalmology team

• Reduce inappropriatereferrals

• Enable RBFT to meet currentdemand

• Take cost out of thesystem/meet demand (TBAfollowing review of financeaspect of the business case)

A

Dermatology Reopen routine Dermatology Services at RBFTTransform the service to ensue the system, has a sustainable service for the future

• Successful Tele-derm andconsultant triage service in placeand working well

• Full system working to deliver asolution to the substantiveconsultant recruitment issues

• GP Alliance Business casecompleted and approved atPlanned Care

• 2 substantive posts recruited too,with the remaining post still underdiscussion

• Restart Clinical workshop to be held in July toreview pathway by pathway restart plan witha view to re open pathways by November

• GP Alliance business case to move 4500appointments to Primary Care beingreviewed at Planned Care Board

• Continue to work with other NHS partnersthat have been affected by the closure

• Re start the Dermatologyservice as soon as possiblein line with directive fromCCG Governing Body

• Dermatology 2ww Cancertargets

R

Risks, issues & mitigations• Dermatology may not recruit. Workshop in place to explore wider system

working with Hampshire, Oxford and Frimley

Action required from enablers / other programme boards

July 2019

Project status GREENChair Shairoz Claridge Clinical Chair Abid Irfan

Planned Care Integrated Programme Board Report (2/2)



Adult Hearing Deliver an integrated end to end pathway for adult hearing services.

• Developed a clinical model inconjunction with primary andsecondary care clinical leadswhich provides a much betterservice to patients.

• Business case written and takento Planned Care ProgrammeBoard outlining the options forprocuring this new service

• Business case approved byPlanned Care Programme Board

• Business Case approved byGoverning Body

• Develop clinical service specification withprimary and secondary care colleagues

• Define cost envelope with Financecolleagues

• Review procurement options with thecontracts team and agree the mostappropriate route

• Reduction of duplicationacross the pathway (ear wax,replacement hearingaids/consumables, life timepathway

• Cost savings due to patientsbeing on the correctcomplex/non complexpathway

• Better patient experience

G

Phlebotomy • Develop a new model for deliveringphlebotomy services acrossBerkshire West that is financiallysustainable, flexible toaccommodate future changes inlandscape, better for patients andreduces the number of walk inappointments at RBFT

• Project scope agreed by workinggroup

• Patient survey completed inconjunction with Healthwatch

• Gathering and understanding the data• Building a case for change

• Case for change document toJuly Planned CareProgramme Board

A

July 2019

Project status GREENChair Shairoz Claridge Clinical Chair Abid Irfan

Mental Health and Learning Disabilities Delivery Board Report (1/3)

Project status GREEN


Project Objectives Achievements so far Milestones next quarter KPIs

RAG

S117 Carry out a full needs assessment to of the BW section117 cohort to ensure we commission services that meets the need of this group in a cost effective manner:The key changes proposed are as follows:1. To reduce the number of placements in

residential care in the next three years.2. Robust placement reviews for all clients funded

100% by the CCG to ensure the placementswhere safe, appropriate and deliver value formoney.

3. Review the Locked Rehabilitation pathwayjointly with Berkshire Healthcare FoundationTrust to develop and commission theseservices that deliver value for money.

4. Develop alternative crisis models to preventpeople with Dementia from being sectioned.When in crisis and support them to preventcrisis or when a crisis occurs.

1. A case Manager has started that willmanage the section 117 placements

2. Additional Reviews of 60 high costplacements has commenced, since lastmonth a further 3 reviews completed., and 2patients new packages agreed at panel.Reported to date have taken place saving asum of 266K by month 2.

3. A system wide workshop to review changesto the Section 117 paperwork and matrix hasbeen organised

4. Additional savings have been identified withtwo draft proposals:

a. to review patients and re-commissioning of Locked rehabServices.

b. To commission a specialistDementia Unit

Both papers need additional work on analysis and assurance of finance information provided.

1. To review a further 20clients.

2. Additional work ontwo further savingsoptions around dataand finance analysisbefore taking intoprogramme boards.

3. Hold and implementthe S117 workshop toimprove quality ofassessmentpaperwork

Green

Risks, issues & mitigations• Two new proposals will require co-production with the Mental Health Trust as

well as the Local Authorities in order to deliver the savings.• Work with 3 Local Authorities can be slow as incentive to review existing 100%

health funded cases is low, requiring persistence and good systems.

Action required from enablers / other programme boards • Sign up at from the Mental Health Programme Board, Joint Commissioning

Board and Finance committees• A number of service users engagement event will need to be planned.• Market Testing event to take place.

July 2019

Chair Katrina Anderson Clinical Chair Angus Tallini




Project Objectives Achievements so far Milestones next quarter KPIs

RAG

Mental Health Crisis Pathway

The 5 aims of the review are to:a. Hear and appreciate the views of a wide

range of stakeholders to understand theeffectiveness of MH crisis services.

b. Identify opportunities to streamline andimprove services and processes to bettersupport and respond to needs;

c. Identify service provision Gaps andpressures that will need to be addressed inthe design of a new approach or model.Including exploring models to supportpeople with Dementia in their own home toprevent crisis and support them when incrisis that would prevent admission toinpatient services.

d. Enable the CCG and partners to meet theNHS Long Term plan transformation goalsfor crises service improvements

e. Test and model ways to reduce A&Eattendances and where possible reduce theimpact on other key services e.g. TVP,SCAS

1. A crisis review scoping document havebeen developed and approved through theprogramme board governance.

2. Transformation bids were prepared andagreed at MH programme board for:

a. Adding more resource to theCRHTT offer that will manage andimprove a crisis phone lineresponse

b. Explore alternative Crisisresponse to current POS andCRHTT

c. Adding nursing resource in twospecialisms (substance misuseand young adults – 16+) to thepsych liaison service at RBFT, tobe Core 24.

3. Winter review of mental health supportheld with system partners identifying keyactions.

Set up stakeholder eventsReview the patient feedback already collatedStart analysis of service information for key services, including• Service specifications• Performance information• Finance informationCreate a data dashboard of information mapping the pathway of patients

Green

Risks, issues & mitigations- Coproduction work with partners requires significant support- Reliance on information from BHFT to analyse current service offer

Action required from enablers / other programme boards• Sign up at from the Mental Health Programme Board, Joint Commissioning

Board and Finance committees• A number of service user engagements event will need to be planned.• Market Testing event to take place.

July 2019





Project Objectives Achievements so far Milestones next quarter

KPIs RAG

Wellbeing Service/PCMH

The Development of a Primary Care Mental Health (PCMH) pathway in line with Shifting Settings of Care for Berkshire West patients will improve the quality and early accessibility of mental health care for the population. The primary care model or offer will therefore focus on:• Preventing escalation of needs by providing

early help as soon as possible• Supporting recovery away from secondary and

acute mental health care• Being integrated within the newly established

GP Alliances services in the CCG area• Being integrated within a secondary and acute

MH Care service offer (Pathway)• Being both multi-agency and multi-professional

1. Project has been refreshed and a newscoping document drafted that outlines thefull ambition of the work beyond theremedial work in the CPE front door.

2. ICS project governance is now establishedand the work will be managed and led on aBerkshire West ICS foot print only.

3. Researched alternative models across thecountry to support the wider more ambitiousnature of the project refresh.

4. Outline of GP engagement plan drafted5. Integration of IAPT service and CPE

partially completed

Finalise a PCMH offer model for discussion with stakeholdersBegin GP engagement concerning modelContinue with BHFT integration of 2 front doors to one (IAPT & CPE)

Driving up recovery ratesImproved self-care (decreasing reliance on medical input)Decreasing demand on secondary and acute care

Amber

Risks, issues & mitigations• GP engagement crucial to the primary care integration• Crucial to link the review of the CMHT service underway in BHFT to this PCMH

offer.

Action required from enablers / other programme boards • Primary Care board support for the model• Need to test the possible finance modelling and business case

July 2019


Long Term Conditions Programme Board Report

Project status Amber



Diabetes To increase the numbers (TBC) of patients meeting the three treatment targets and thereby reduce long-term cost to the system.

Digital Structured Education provider agreed.Clinical model for Type 1 Service in final draft.

Finalise practice variation programme including self-assessment guide and practice visit programme.Agree next steps on Type 1 Service.

Number of people achieving all 3 Treatment Targets

CVD Atrial Fibrillation (AF) Project

Improve management of people with AF in primary care thereby avoiding exacerbation and ultimately reducing the number of strokes.

11 strokes avoided in 2019/20.

Roll out of Phase 1 across Wokingham – education and quality improvement activities in place Targets agreed within the Prescribing Quality Scheme (PQS) ensuring alignment

To commence roll out Phase 2 Soft launch of virtual MDT

To increase identification of high risk patients Reduction in number of strokes – 11 in 2019-20.

Post stroke/neuro- rehabilitation

Ensure timely access to neuro-rehabilitation to reduce length of stay (TBC) and improve outcomes.

Mapping of current service model/pathways Proposal for enhanced Community Based Neuro-rehabilitation Team (CBRNT)Identification of options to increase system flow

Agreement of approach for forthcoming winter in terms of provision of additional capacity.Development of medium-term business case for revised service.

Reduction in waiting times (TBC) for neuro-rehabilitation and improved outcomes for patients.

Respiratory – COPD

More intensive support for people with exacerbation of COPD Review of pulmonary rehabilitation capacity and outcomes

Targets agreed within the PQS ensuring alignment Engagement with primary care underway to increase identification of COPD patients.

Option appraisal for spirometry Review use of digital option to support self management and rehabilitation

Increased case finding to improve prevalence Increased referral to and completion of Pulmonary Rehab (TBC)

Care and Support Planning (CSP)

Roll out of CSP for all patients with LTCs in Berkshire West

Primary Care survey to underpin baselines

• Development of CSP template• Roll out of training for primary care

Number of people receiving LTC CSP Reduction in number (TBC) clinical contacts for patients who have had CSP

Risks, issues & mitigations• Primary care engagement and commitment as PCNs evolve – continued strong engagement of

CCG GPs will help mitigate this.• Outcomes are longer term and financial and resource benefits are difficult to quantify in the

shorter term - working with RightCare colleagues and others to quantify.

Action required from enablers / other programme boards • Seeking more engagement with digital board to ensure collective working on

priorities.

June 2019 – no update provided for July

SRO Raghuv Bhasin Clinical Chair Dr Heike Veldtman Transformation Lead Sarah Bow

Primary Care Transformation Programme Board


Risks, issues & mitigations• …• …• …

Action required from enablers / other programme boards • Map interdepencies from other programme boards• …• …

July 2019

Chair Helen Clark Clinical Chair Jim Kennedy



Establish Primary Care Programme board

• To agree terms of reference forthe programme board.

• To define and agree the workprogramme of the board

First meeting took place on 12th June 2019 and Terms of Reference review.

Five key areas identified around which local maturity matrix for PCNs to be developed with work programme reflecting early stages of a roadmap to achieve this.

Oversight of existing workstreams previously monitored by Primary Care Commissioning Committee now picked up by the Programme Board.

• Host Primary Care Summit todevelop a broader system vision forPrimary Care Networks

• Define the work programme anddevelop project plans for eachworkstream.

Work programme defined with key projects listed - milestones, deliverables and benefits identified.

A

ICS Workforce Group incorporating the Training Hub

Project status Green



ICS Workforce Management and facilitation of place based system wide workforce bids

Development of common workforce frameworks and practices

Sharing of good practice within the place based and BOB

Support and development of underpinning workforce groups and pathways including : UEC: Cancer: Primary Care: Social Care: MH

Management of three place based system wide Workforce projects:MSK FPC Practitioner upskilling: Transformation Teams upskilling: Workforce Planning common framework Skills for Health 6 Step

Deep dive into several key work streamsCancer. MH social care

Development of two workforce groups to facilitate the cancer and UEC discussion.

System for engagement and partnership with key stakeholders for HEE funded workforce funds

Facilitated workforce planning and discussion system wide including though not exclusive to the below:

• Capacity for 25% increase ofpre registration nursing studentsacross the system an NHS Longterm Plan commitment :

• Discussion of Frailty Frameworkand its impact on the placebased system:

• First draft upskilling programme forband 6/7 PT’s in partnership withOBU

• Agreement of utilisation oftransformation upskilling projectfunds

• Scoping of all educationprogrammes for Pt upskilling intoFPC practitioners.

• All seven workshops includingplenary session completed

• First meeting of the A/E workinggroup to look at support workforcefor the UEC workforce.

• Deep dive session HR DirectorsWorkforce Strategy.

Development of a robust training and development offer in partnership with the MSK Transformation project Group

Agreed education programme and support for the FPC Practitioner

Support and engagement of workforce groups as part of the workforce 6 Step project including UEC: BHFT: RBHFT: Social Care: Cancer

Risks, issues & mitigations• No agreement on the MSK model and therefore MSK educating training and support• Lack of progress with the transformation agenda leading to no movement on the

transformation team upskilling

Action required from enablers / other programme boards • System wide engagement within the new ICP and the partners to develop the

workforce agenda and facilitate collective priorities and work streams

July 2019

SRO Maggie Neale Clinical Chair Debbie Simmons

ICS Workforce Group (incorporating the Training Hub)

Project status Green



Training Hub Delivery of MOU and KPI’s as designated by Health Education England in the terms and conditions for the Training Hub.

Management and delivery of the Training Hubs projects as designated and funded by HEE

Support and facilitation of the Education and Training and development for the PCN’s including supporting the new roles as designated by the PCN’s.

Sharing of good practice within the place based system and BOB

Working in partnership with the Berkshire west CCG primary Care team to support the workforce agenda and the development of new primary care roles

Development of a BW Training Hub website to facilitate the Training and Development for the Primary Care Teams address as below: www.berkshirewesttraininghub.org.uk

Reformed GPN forums across the whole of Berkshire West with subjects covered to date as below:

• New models of Education for Nurses• Discussion and development of the

Community and Primary Care nursingproject

Training Needs Analysis undertaken an series of workshops planned and booked to support the TNA requests these include though are not exclusive to:• Wound management• HCA updating• Immunisations• Infection Controls• Bandage workshops

In partnership with the LTC Board agreement of key training needs for the workforce moving forward: Including spirometry updating and transference onto the new ARTP register

• Training Hub website focuswellbeing and the prevent agenda

• Provisional agenda for remainder2019/20 for GPN forums set

• Training programme set andavailable to book on the TrainingHub website

• First wave of spirometryrevalidation training commenced,commencing with an actionlearning set for all nurses/HCA’sundergoing assessment

• Work streams underway to supportnew roles in primary care with theCCG primary Care Commissioningteam

Quarterly reporting into HEE for the MOU and KPI’s including student placement data

Training Hub website constantly updated and reflective of TNA requirements.

Development of a robust training and development offer for the primary care teams and data on the update of such training across each quarter

Transfer of all relevant spirometry delivering nurses/HCA’s to the new ARTP register.

Risks, issues & mitigations• The development of a new model of Training Hub across BOB could reduced the

ability to deliver the work streams identified above.• Lack of funding for the Training Hub could result in a diluted and ineffectual service.

Action required from enablers / other programme boards • ICSP System wide engagement with development of training and development

for the primary care teams. Engagement required with the LTC and Planned carehoard. The Primary Care UEC and Cancer workforce groups

July 2019

SRO Maggie Neale Clinical Chair Debbie Simmons

Title: Changes to the Constitution

Agenda item no: 7


Date: 31 July 2019

Presented by: Caroline Lynch, Trust Secretary

Prepared by: Hannah Travers, Deputy Trust Secretary

Purpose of the Report To set out the proposed changes to the Constitution in respect of an amendment to the composition of public governors.

Report History The proposed changes were approved by the Council of Governors on 29 May 2019.


The Board of Directors is asked to approve the amendment to the Constitution.




N/a







1 Background

1.1 The Constitution sets out that the composition of the Council of Governors should be reviewed every three years by the Council of Governors to ensure that:

“The interests of the community served by the Trust are appropriately represented

The level of the representation of the public constituencies, the classes of the staff constituency and the appointing organisations strikes an appropriate balance having regard to their legitimate interest in the Trust’s affairs.”

1.2 The Council of Governors at its meeting on 29 May 2019 considered the recommendation from the Membership Committee in relation to the composition of the Council of Governors. The Council of Governors approved the recommendation to amend the composition of public governors by increasing the number of public governor for the Wokingham constituency to 4 governors (currently 3). The Council of Governors also approved the recommendation to decrease the number of East Berkshires & Borders by one governor (currently 3 governors).

1.3 The Board is asked to approve this amendment to the Constitution. The relevant extract from the Constitution is attached as appendix 1.

2 Conclusion and Next Steps

2.1 The Board is asked to approve the amendment to the Constitution.

3 Attachments

3.1 The following are attached to this report:

(a) Appendix 1 – Extract from Constitution

9.5 The Council of Governors of the Trust is to comprise:

9.5.1 fifteen Public Governors, from the following public constituencies:

9.5.1.1 Reading –five Public Governors;

9.5.1.2 Wokingham – four Public Governors;

9.5.1.3 West Berkshire and borders – three Public Governors;

9.5.1.4 East Berkshire and borders – two Public Governors

9.5.1.5 South Oxfordshire – one Public Governor;

9.5.2 six Staff Governors from the following classes:

9.5.2.1 registered medical practitioners and registered dentists. – one Staff Governor;

9.5.2.2 registered nurses and midwives – one Staff Governor;

9.5.2.3 allied healthcare professionals / professional and technical – one Staff Governor;

9.5.2.4 healthcare support workers and ancillary – one Staff Governor;

9.5.2.5 managers and administrative and clerical – one Staff Governor;

9.5.2.6 volunteers – one Staff Governor;

9.5.3 three Local Authority Governors, to be appointed one each by Reading Borough Council, Wokingham Borough Council and West Berkshire Council;

9.5.4 five Partnership Governors appointed by partnership organisations.

Agenda Item 8.1

1

Finance and Investment CommitteeMonday 20 May 201912.00 – 14.55Boardroom, Level 4, Royal Berkshire Hospital

Members Mrs. Sue Hunt (Non-Executive Director) (Chair)Ms. Caroline Ainslie (Director of Nursing)Mr. Brian Hendon (Non-Executive Director) Mrs. Nicky Lloyd (Chief Finance Officer)Mr. John Petitt (Non-Executive Director)Ms. Mary Sherry (Chief Operating Officer)

In AttendanceMr. Alistair Burnett (Senior Manager, KPMG)Mr. Mike Clements (Deputy Director of Finance – Central Finance)Mr. Richard Jenkins (Deputy Director of Finance – Contracts)Mrs. Caroline Lynch (Trust Secretary)Mr. Andrew Statham (Director of Strategy) (from minute 78/19)

ApologiesMr. Steve McManus (Chief Executive) Mr. Graham Sims (Chair of the Trust)

67/19 Declarations of Interest


68/19 Minutes: 15 April 2019 & Matters Arising Schedule

The minutes of the meeting held on 15 April 2019 were approved as a correct record and signed by the Chair subject to the following amendments:

Minute 57/19: Budget and Control Total 2019/20: The last sentence of the first paragraph would be amended to read: “This included uncommitted reserves, ICS transformation funding, additional QiPP challenge as well as transition funding and a reduction of the control total from NHSI.”

The second sentence of the second paragraph would be amended to read: “However, the Care Group budgets for 2019/20 would remain as previously seen by the Committee and approved by the Board.”

The Committee received the matters arising schedule.

Minute 51/19: Minutes 18 March 2019 & Matters Arising Schedule: The Trust Secretary highlighted some of the difficulties in relation to rescheduling future meetings to ensure the most up to date financial information was available to the Committee. It was suggested that this should be discussed with the Chair and the Chief Finance Officer. Action: C Lynch

Minutes

2

Finance & Investment Committee May 2019

Minute 53/19: QiPPs Update and Procurement Programme Update: The Chief Finance Officer confirmed that IT spend and suppliers over £1m were linked with Digital Hospital benefits realisation.

[Section exempt under s43].

Minute 57/19: Budget and Control Total 2019/20: The Chief Finance Officer advised that confirmation of ICS transformation monies was still awaited from NHS Improvement.

Action: N Lloyd

69/19 April Finance Update

The Chief Operating Officer introduced the report and highlighted some of the changes made to the template. The format would be replicated at Care Group and corporate level to ensure areas were aware of the Trust level view of financial performance. The Deputy Director (Central Finance) advised that the detailed report to the Board would include a summary of Care Group performance in full.

The Committee queried whether capital spend could be detailed at Care Group level. The Chief Finance Officer advised that capital spend would be difficult to detail at Care Group level but was categorised by projects and compliance. The Committee noted that pay costs versus activity had been included in the revised format to demonstrate the relationship between expenditure and activity. The Chief Finance Officer advised that, in relation to aged receivables, discussions were on-going directly with other NHS organisations in relation to invoices in dispute. The Committee noted that the increase in pay for April related to Clinical Excellence Awards (CEA) and NHS Agenda for Change top of spine point payments.

The Committee noted the top 10 QiPP schemes in the report. It was agreed that the Chief Operating Officer and Chief Finance Officer would discuss these further.

Action: N Lloyd/M Sherry

Capital payments would be set out separately to supplier payments in future reports. Action: N Lloyd

70/19 QiPPs Update

The Committee noted that as at 13 May 2019, £0.79m of savings had been delivered against a forecast of £0.78m. The value of identified schemes for 2019/20 was £13.47m against a target of £16.9m. As at Month 1, there was £3.4m of unidentified schemes The Chief Operating Officer advised that QiPP reporting would be reviewed via KPMG and new governance arrangements.

71/19 Finance Matters

The Chief Finance Officer introduced the report that set out the launch and progress to date on the Finance Matters programmes. The Chief Finance Officer highlighted that the Royal Berks Charity would also be added to the proposed work streams set out in the report. The Committee noted that the Finance Matters programme was aligned with the Care Group review and work being undertaken by KPMG. The Chief Finance Officer advised that sessions were being arranged with staff in order to further understand staff survey results for the finance department. Any themes would then be included in the next Finance Matters session.

72/19 Restructuring Partner Update

3


The Committee noted the report that set out the revised governance arrangements for the Trust’s restructuring programme. It was agreed that the terms of reference for the Restructuring & Transformation Delivery Group (RTDG) would be circulated to the Committee. Action: C Lynch

The Committee discussed the impact of the establishment of both ROC and RTDG in relation to items submitted to the Committee. It was noted that ROC would escalate any issues to the Committee as appropriate.

73/19 Capital Programme 2019/20

The Deputy Director of Finance (Central Finance) introduced the report that set out the Capital Plan for 2019/20 and the subsequent four years. The Committee noted that estates projects spend had been restricted to account for planning works required. The Deputy Director of Finance (Central Finance) advised that both IM&T and medical equipment allocations were below the requested figure. Equipment had been prioritised within this allocation and further work was required with IM&T to prioritise the capital spend within this allocation. It was noted that the Digital Hospital business case would be submitted to the Committee and Board during June 2019. It was agreed that the Chair would meet with the Chief Operating Officer and Chief Finance Officer to discuss the business case ahead of submission to the next meeting. Action: S Hunt

The Committee discussed whether the proposed capital spend for 2019/20 would be achieved. The Chief Finance Officer advised that there would be a focus on capital spend each month. The Committee noted that previously capital spend had been restricted in relation to receipt of Provider Sustainability Fund (PSF) monies. However, the Chief Finance Officer had removed this restriction. In addition, a new project manager had been engaged in the estates team and master planning would support the estates capital spend. The Committee discussed the importance of stabilising the estates infrastructure as well as addressing areas previously highlighted at the last Care Quality Commission (CQC) inspection. The Chief Finance Officer confirmed that project management costs would be included into all estates projects and capital spend prioritisation for all areas had been linked to departmental risk registers.

It was agreed that the Chief Finance Officer would submit a report to the Committee in relation to business cases approved during 2018/19. Action: N Lloyd

74/19 Acute Contract Update

The Deputy Director of Finance (Contracts) introduced the report and advised that approval was sought to sign the contract with NHSE Specialised Commissioning [Section exempt under s43].

The Committee noted that NHSE Specialist Commissioning Public Health and Secondary Dental 2019/20, Berkshire East and Oxford contracts would be submitted to the next meeting for approval. Action: N Lloyd

The Committee agreed that a recommendation should be submitted to the Board to approve the NHSE Specialised Commissioning contract for 2019/20 [Section exempt under s43].

Action: N Lloyd

75/19 Pathology Capital Works on RBFT site

4


The Chief Finance Officer introduced the report and highlighted the actions taken to date in relation to the Pathology project. The Chief Finance Officer confirmed that the Berkshire Surrey Pathology Services (BSPS) had been notified and updated in relation to the project. [Section exempt under s43].

It was agreed that an update should be submitted to the Board with further information as requested by the Committee. The Committee supported the recommendations as set out in the report. Action: N Lloyd

76/19 Procurement for the Replacement of Camera Stacking Systems

The Chief Finance Officer introduced the report that sought approval to procure the replacement of the camera stacking systems. [Section exempt under s43] The Chief Finance Officer confirmed that an options appraisal exercise had been undertaken and procurement rules adhered to.

The Committee agreed that a recommendation should be submitted to the Board to approve the replacement of the camera stacking systems subject to confirmation as to whether the costs included or excluded VAT. Action: N Lloyd


78/19 Mobile MRI Contract Extension

The Chief Finance Officer introduced the report that sought approval to extend and amend the current MRI contract by 18 months [Section exempt under s43]. The Committee noted that this would support daily capacity until a permanent MRI was in place at West Berkshire Community Hospital. Following this, the mobile MRI would be relocated to Bracknell Healthspace.

The Committee agreed that a recommendation should be submitted to the Board to approve the contract extension subject to the Chief Finance Officer confirming the 3 month notice period of the contract in the letter of intent. Action: N Lloyd

79/19 MSK Update

The Director of Strategy introduced the business case presented by the ICS programme team. The Trust had raised concerns in relation to the oversight of the proposed solution and management of clinical pathways. Further work was on-going in relation to governance and oversight aspects. The Committee noted that the Chief Finance Officer had reviewed the financial analysis in the business case in detail. However, further work would be undertaken in relation to contractual element of the proposal. The proposal was to redirect patients from December 2019.

The Committee discussed the impact on the Trust and other providers in relation to the proposal. The Committee supported the financial element of the business but noted that the oversight and governance elements would need to be strengthened. A further update would be submitted to the next meeting ahead of submission to June Board.

Action: A Statham 80/19 CQC Use of Resources

The Director of Nursing introduced the report that set out the work carried out to date and the timeline for the Use of Resources inspection on 5 June 2019. The Director of Nursing highlighted the need for the Executive team and heads of department to ensure they were familiar with Model Hospital data.

5


81/19 Work Plan Review

It was agreed that the work plan would be discussed with the Chair and Chief Finance Officer. Action: C Lynch


83/19 Key Messages for the Board

Key issues to draw to the attention of the Board included:-

April finance performance and revised template for the finance report discussed indetail

Proposed actions for the Pathology project received and discussed in detail

Recommendations to be submitted to the Board to approve the following:- 2019/20 NHSE Specialised Commissioning contract Procurement for the replacement of Camera Stacking system Procurement for the current sterilisation contract extension Extension of the mobile MRI contract

MSK Update received


It was agreed that the next meeting would be held on Monday 17 June 2019 at 10.00am.

SIGNED:

DATE:

Agenda Item 8.1

1

Finance and Investment CommitteeMonday 17 June 201910.10 – 13.05Boardroom, Level 4, Royal Berkshire Hospital

Members Mrs. Sue Hunt (Non-Executive Director) (Chair)Ms. Caroline Ainslie (Director of Nursing)Mr. Brian Hendon (Non-Executive Director) Mrs. Nicky Lloyd (Chief Finance Officer)Mr. Steve McManus (Chief Executive) Mr. John Petitt (Non-Executive Director)Mr. Graham Sims (Chair of the Trust) Ms. Mary Sherry (Chief Operating Officer)

In AttendanceMrs. Heather Allan (Director of IM&T) (for minutes 90/19 and 91/19)Dr. Bal Bahia (Non-Executive Director)Ms. Amanda Grossman (Head of Programme Delivery (for minute 90/19)Mr. Richard Jenkins (Deputy Director of Finance – Contracts)Mrs. Caroline Lynch (Trust Secretary)Mr. Mike Robinson (Associate Director of Infrastructure (for minutes 90/19 and 91/19)Dr. Jon Swinburn (Chief Clinical Information Officer (for minute 90/19)Mr. Andrew Statham (Director of Strategy) (for minute 92/19)



86/19 Minutes: 20 May 2019 & Matters Arising Schedule

The minutes of the meeting held on 20 May 2019 were approved as a correct record and signed by the Chair subject to the following amendment:

Minute 73/19: Capital Programme 2019/20: The third sentence of the second paragraph would be amended to read: “The Committee noted that previously capital spend had been constrained to match the quarterly receipt of Provider Sustainability Fund (PSF) monies.”


Minute 68/19 (57/19): Budget and Control Total 2019/20: The Chief Finance Officer advised that that formal conformation of ICS transformation monies was still awaited from NHS Improvement. Action: N Lloyd

Minute 69/19: April Finance Update: The Chief Finance Officer confirmed that capital payments would be set out separately to supplier payments in the Month 3 finance report.

Action: N Lloyd[Section exempt under s43].

Minutes

2

Finance & Investment Committee June 2019

87/19 May Finance Update

The Chief Finance Officer introduced the report and advised that May performance was £0.92m adverse to control total. Income was off plan by £0.4m and both pay and non-pay were over budget. The Committee noted that Provider Sustainability Funding (PSF) and Marginal Rate Emergency Tariff (MRET) of £1.56m had been recognised in Month 2. QiPP delivery was slightly ahead of plan. The Chief Finance Officer confirmed that work was on-going to review the non-pay issues.

Further work was also on-going in relation to closing month end. The Committee discussed the timing of meetings in relation to this. It was agreed that this would be considered as well as timing of future Board meetings. Action: C Lynch

The Committee discussed the focus on aged receivables. The Chief Finance Officer advised that members of the finance team had been allocated to accounts with specific issues in order to resolve these. In relation to overseas debt, a credit controller had been engaged for a 6 month period in order to clear the backlog of old invoices. However, there were now good controls in place in relation to forward overseas business.

The Committee considered the new format of the finance report and requested the following amendments and additions:

A cash flow bridge showing monthly movements in cash

Capital payments to be separate from general payments

Year to date capital spend versus plan

Top five largest overspend by area

Bed days per month over budget including ICU bed days open and total spend

Year to day activity by plan versus actual activity versus payroll spend

Drug costs as a percentage of drug income

Surplus/deficit to control total for both year to date plan and actual

Year to date QiPP performance Action: N Lloyd

It was agreed that the Chief Finance Officer would provide a verbal update at the Board seminar on Month 2 position. Action: N Lloyd

88/19 QiPPs Update

The Committee noted that as at 12 June 2019, £1.8m of savings had been delivered year to date against a forecast of £0.78m. Month 2 had delivered £1m against a forecast of £0.9m. The Chief Operating Officer advised that two areas that under-delivered against their forecast were pathology and patient flow. The patient flow programme was due to be discussed at the next Restructuring & Transformation Delivery Group (RTDG) and this included the plan to close a ward at the end of June 2019. The Committee recommended that future QiPPs updates should include year to date plan versus year to date delivery.

Action: N Lloyd 89/19 Acute Contract Update

The Deputy Director of Finance (Contracts) introduced the report and advised that following discussions with East Berkshire Clinical Commissioning Group (CCG) an indicative activity plan and associated contract for 2019/20 had been agreed. [Section exempt under s43].

The Deputy Director of Finance (Contracts) advised that updated indicative activity plans for 2019/20 had been shared with associate CCG commissioners and offers had been received with the exception of Oxfordshire CCG. It was proposed that Buckinghamshire, North Hants and North East Hants and Farnham would be submitted to the July meeting for

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approval along with the North West Surrey Contract. Action: N Lloyd

The Committee noted that, in relation to Berkshire Healthcare Foundation Trust (BHFT), as an Integrated Care System (ICS) partner, work was on-going to simplify invoice processes and to undertake quarterly reconciliations. [Section exempt under s43].


The Committee agreed that a recommendation should be submitted to the Board to approve the contracts for East Berkshire CCG and BHFT for 2019/20. Action: N Lloyd

90/19 Digital Hospital Business Case

The Chief Operating Officer advised that the business case related to Years 3 and 4 of the Digital Hospital Programme, previously approved by the Board in 2017. The Committee noted that the business case had been discussed in detail by the Executive Management Committee and benefits realisation had been a key focus. The Chief Operating Officer highlighted that the capital allocation for the Digital Hospital Programme over the next two years supported the Trust’s strategic direction.

The Committee discussed clinical engagement in the Digital programme. It was noted that, the successful ‘go-live’ in 2018 had engaged all groups of staff. In relation to the next phase maternity had been engaged already and further engagement was needed with the theatres team.


The Committee noted the capital layout for Years 3 and 4 of the Digital Hospital Programme. It was agreed that the Chief Finance Officer would consider the appropriateness of the contingency in relation to capital and the Digital Hospital Programme. Action: N Lloyd

The Committee discussed benefits in relation to the Digital Hospital Programme. The Chief Operating Officer highlighted that there were both non-cash and cash releasing benefits. However, it was difficult to quantify benefits although work was on-going in relation to this. The Committee discussed the importance of Post Project Evaluation (PPE). The Chief Finance Officer advised that she was currently reviewing the business case process. It was agreed that this review would include a clear expectation of a PPE for all significant investments and ensure this process was applied to Phase 2 of the Digital Hospital Programme. Action: N Lloyd

The Committee agreed that a recommendation should be submitted to the Board to approve the business case. Action: M Sherry


92/19 MSK Update

The Director of Strategy introduced the report and advised that the ICS project team had developed a report that provided proposals as to how quality, finance and operational risks would be managed as well as how the revised service would mandate referral to secondary care, including diagnostics, via the triage function. The Director of Strategy highlighted the on-going work in relation to contracting and procurement.


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The Committee agreed that a recommendation should be submitted to the Board to approve the proposed amendments to governance and risk managements and to endorse the recommendations of the Committee in relation to the business case.

Action: A Statham

93/19 Sleep and Home Ventilation Services Provision

The Chief Finance Officer introduced the report that sought approval to award a 5 year contract for CPAP consumables and devices to Resmed [Section exempt under s43].The Committee noted that 5 year contracts were usual via the SBS framework.

The Chief Finance Officer advised that the procurement strategy was currently being developed as part of the on-going accreditation of procurement. The result of the accreditation would be available during June 2019.

The Committee agreed that a recommendation should be submitted to the Board to approve the contract. Action: N Lloyd

94/19 Board Assurance Framework

The Trust Secretary introduced the Board Assurance Framework and advised that the finance section had been updated to separate the estates and finance elements. It was agreed that Model Hospital would be scheduled on the work plan. Action: N Lloyd


It was agreed that the work plan would be updated to include a quarterly review of the Board Assurance Framework and the Commercial Strategy being submitted to the July meeting. Action: C Lynch


97/19 CQC Use of Resources

The Director of Nursing advised that the Trust had received a focused list of questions following the recent CQC Use of Resources inspection. A response was currently being co-ordinated. Action: C Ainslie


Key issues to draw to the attention of the Board included:-

May finance performance discussed in detail

Recommendations to be submitted to the Board to approve the following:- Acute contract update Digital Hospital business case Sleep & Home Ventilation Services provision contract


MSK Update received


It was agreed that the next meeting would be held on Monday 22 July 2019 at 10.00am.

SIGNED:

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DATE:

Agenda Item 8.2

1

Quality Committee Friday 10 May 201910.05 – 10.50Boardroom, Level 4, Royal Berkshire Hospital

Members Mrs. Helen Mackenzie (Non-Executive Director) (Chair)Ms. Caroline Ainslie (Director of Nursing)Dr. Lindsey Barker (Medical Director)Mr. Julian Dixon (Non-Executive Director)Mr. Steve McManus (Chief Executive) Ms. Mary Sherry (Chief Operating Officer)Mr. Graham Sims (Chair of the Trust)

In AttendanceMs. Katie Elcock (Head of Governance & Improvement) (for minute 17/19)Mrs. Hannah Travers (Deputy Trust Secretary)

ApologiesMr. John Petitt (Non-Executive Director)



28/19 Draft Quality Account 2019/20

The Director of Nursing provided an overview of the draft Quality Account and advised that no issues had been identified in the audit report issued by external auditors.

The Committee highlighted that the target for improvement of patient experience in relation to car parking had not yet been included in the quality priorities. The Chief Executive advised that as part of estates master planning the Trust had commissioned work in relation to a transport strategy and a draft report had recently been received. Further work was due to take place in relation to the draft report and any changes to car parking would need to be scheduled to ensure that changes did not take place during the Winter period. The Committee recommended that the draft report and action plan be submitted to the next meeting. In addition, the report should also highlight the number of appointments that were now taking place at other sites. Action: T Middleton

The Committee recommended that the target for improvement for patient experience of car parking be amended to read ‘To develop an agreed and resources action plan’.

Action: K Elcock

In relation to summary performance of car parking quality targets not being achieved during 2018/19, the Director of Nursing highlighted that any risks were included on the Board Assurance Framework.

The Committee approved the draft Quality Account for 2019/20.

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Quality Committee May 2019

The committee noted that the priorities for 2019/20 would be reported in detail throughout the year and baselines were being developed during Q1.

29/19 Clinical Harm Review: Cancer Outcomes & Actions Taken

The Medical Director introduced the report that highlighted processes for managing clinical harm reviews and summary from the Clinical Harm Review Board. The Committee noted that during 2018/19 there were 196 pathways meeting the criteria for review. Following review, 125 had demonstrated no harm and 26 low harm. 45 were still due to be reviewed, with 32 from Quarter 4. The Committee noted that the majority of reviews demonstrating no harm related to patients that had delayed treatment by choice.

The Medical Director highlighted themes identified that had attributed to extended delays on a cancer pathway. These included patient choice and tertiary care input. In addition, in house diagnostics capacity and specialist PET-CT scans carried out by an external partner had also attributed to delays.

The Committee noted the challenges in relation to the PET-CT scan waiting times and that NHS England were currently tendering for an increased service. Shadow reporting for the 28 day standard had also commenced for cancer diagnosis and it was expected that the new focus on the early part of the pathway would reduce waiting times.

The Committee recommended that a patient representative should be included on the Clinical Harm Review Board or that the patient should be invited as part of the review process. Action: L Barker

The Committee reviewed the 62 day target for cancer diagnosis and discussed whether patients were prioritised based on the severity of their symptoms. The Medical Director confirmed that at Clinical Multidisciplinary Team (MDT) meetings patients were reviewed based of their acuity of need.


The Committee noted the work plan. The Chief Operating Officer highlighted the Transformation Strategy would be circulated to the Committee for comments prior to submission to the Board Seminar in June and the Committee in July 2019.

Action: M Sherry31/19 Key Messages for the Board

It was agreed that key issues to draw to the attention of the Board included:

Draft Quality Account 2019/20 reviewed and approved


It was agreed the next meeting would be held on Tuesday 9 July 2019 at 14.00

SIGNED:

DATE:

Agenda Item 8.2

1

Quality Committee Tuesday 9 July 201914.05 – 16.10Boardroom, Level 4, Royal Berkshire Hospital

Members Mrs. Helen Mackenzie (Non-Executive Director) (Chair)Ms. Caroline Ainslie (Director of Nursing)Mr. Julian Dixon (Non-Executive Director)Dr. Janet Lippett (Medical Director)Mr. John Petitt (Non-Executive Director)Mr. Steve McManus (Chief Executive)

In AttendanceMrs. Mandy Claridge (Care Group Director of Operations, Urgent Care)Mrs. Hannah Travers (Deputy Trust Secretary)Ms. Clare Yates (Head of Transformation) (for minute 44/19)

ApologiesMs. Mary Sherry (Chief Operating Officer)



34/19 Minutes: 9 April 2019 and 10 May 2019 and Matters Arising Schedule

The minutes of the meeting held on 9 April and 10 May 2019 were approved as a correct record and signed by the Chair.

The Chair queried whether the audits that Trust had not participated in related to intermediate care. The Medical Director would circulate the list of audits and confirmation as to why the Trust did not participate in these audits. Action: J Lippett

The Committee noted the matters arising schedule.

Minute 29/19: Clinical Harm Review: Carter Outcomes & Actions Taken: The Medical Director would confirm whether a patient leader had been invited as a representative on the Clinical Harm Review Board. Action: J Lippett

35/19 Annual Update of Serious Incident (SI) Themes

The Committee received the Serious Incident (SI) annual report that provided an overview of the key themes and risks arising from incidents along with lessons learned and actions taken to mitigate identified risks.

The Committee noted that 66 SIs had been reported to the Clinical Commissioning Group (CCG) during 2018/19. Seven of those reported related to Never Events (NE), three of which related to unintentional administration of medical air, one a retained swab, two guidewire and one wrong site surgery. The Director of Nursing advised that seven SIs had

Minutes

2

Quality Committee July 2019

been referred to the Healthcare Safety Investigation Branch (HSIB) following national changes to maternity investigations. The Trust was still awaiting outcomes for all seven SIs that had been referred.

The Director of Nursing highlighted that a comparison of themes could be provided as there had been an increase compared to the previous year. Action: C Ainslie

The Committee discussed the two NEs that had taken place in the current financial year and queried whether actions had been put in place to mitigate against a further NE. The Director of Nursing advised the Trust was sharing learning with staff to mitigate against the risk of further NEs occurring. In addition, the Trust was working in partnership with local trusts to investigate joint SIs and share learning as well as attending patient safety learning events.

36/19 CNST Incentive Scheme

The Director of Nursing introduced the CNST Incentive Scheme report and advised the Trust was required to self-certify progress against 10 actions. The self-assessment was due to be submitted to NHS Resolution on 15 August 2019 and the Trust was compliant with all 10 actions. The incentive scheme would enable the Trust to recover circa £695k from its annual contribution to NHS Resolution.

The Committee reviewed the responses to the 10 actions and recommended that further narrative was provided against questions 1, 2, 4 and 9 to provide a clearer view of evidence for each action. Action: M Claridge

The Committee queried who the identified Board level champion was in relation to safety champions being able to escalate locally identified issues. The Director of Nursing confirmed that she was the Board level champion.

The Committee agreed that, subject to the narrative being updated, a recommendation should be submitted to the Board to approve the CNST Incentive Scheme self-assessment

Action: H Mackenzie

37/19 Seven Day Services Self-Assessment

The Medical Director provided an update on the seven day services self-assessment that had been submitted to NHS Improvement (NHSI) on 28 June 2019. This incorporated a full data refresh as the initial submission in February 2019 had been based on figures from 2018.

The Medical Director advised that the Trust was compliant with three of the four priority standards. The standard related to 14 hours to first consultant review for 90% of emergency admissions had not been achieved. An improvement plan had been developed following review of the self-assessment. Actions identified had included improvement in recording on the Electronic Patient Record (EPR) and a review of job plans where patients may not be seen due to workload or timing of ward rounds. In addition, a working group was being set up to review the patient pathways to provide clarity as to when a case did not require consultant review. Once the pathways had been approved these would be recorded on EPR as substitutes for face to face review.

The Medical Director advised that an update would be submitted to the Committee on a bi-annual basis. Action: J Lippett

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38/19 2018 Inpatient Survey

The Director of Nursing introduced the findings of 2018 Inpatient Survey carried out by Picker during July 2018. The Committee noted that the Trust had scored positively in 62 questions. 61 of which were consistent with feedback received during the previous two years.

The Director of Nursing highlighted that feedback in relation to ‘got enough to drink’ had decreased in comparison to the previous year. It was considered that this was a result of the heat wave in July 2018 when the survey was distributed.

The Committee noted that priorities for the next year included a focus on discharge; further information on medications and whether additional health or social care services were required. The Care Group Director of Operations, Urgent Care, highlighted that transformation work was already underway to improve discharge from the hospital. In addition, all programmes were reviewed at the Restructuring and Transformation Delivery Group.

The Director of Nursing highlighted that all departments had action plans where areas of improvement had been identified. The Committee noted that the next survey was scheduled to take place in Summer. Therefore, this may impact actions that had been completed following the previous survey.

The Committee requested more patient experience information and it was agreed that the Director of Nursing would circulate the annual patient experience report as this provided an overview of initiatives that had been undertaken during 2018/19. Action: C Ainslie.

The Director of Nursing agreed that an update on the action plan would be provided to the Committee in January 2020. Action: C Ainslie

The Committee recommended that, going forward, the Clinical Admin report should be included in the Integrated Performance Report. Action: M Claridge

39/19 Board Assurance FrameworkThe Committee reviewed the Board Assurance Framework and discussed whether the stroke service was a gap in assurance. The Medical Director advised that there was not sufficient capacity in external resources. This had resulted in the gap. The Committee highlighted there was a gap in patient experience feedback. It was recommended that this should be included as a gap in assurance. Action: H Travers

The Committee discussed the recent CQC visit and whether there had been any gaps in assurance identified. The Director of Nursing highlighted that the official report would not be available until late autumn. However, the Trust had received some feedback in relation to renal services that was currently being reviewed.

The Committee recommended that external assurances should be included in the controls column. Action: H Travers

40/19 Corporate Risk Register

The Committee reviewed the Corporate Risk Register. The Chief Executive highlighted that, in relation to pathology service and quality standards, although performance had improved over the past 18 months there was high staff turnover. In addition, some staff were employed by Berkshire & Surrey Pathology Service (BSPS) and staff morale was

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quite low. The Chief Executive advised that he would raise this with the BSPS Board. Action: S McManus

It was recommended that the risk related to management of consistently high numbers of mental health patients presenting to Emergency Department, Paediatric wards and admitted to adult wards should be reviewed to ensure that mitigating actions and controls were still relevant. Action: M Claridge

41/19 Private Sector Referrals from NHS

The Medical Director introduced the report that highlighted that doctors could continue private practice alongside working in the NHS and this would be included in their job plans. However, a patient would be required to request a switch from the NHS to the private sector although this only happened in a few cases each year. The Committee noted that if a doctor initiated a conversation with a patient about switching to the private sector this was also reportable to the General Medical Council.

The Committee discussed whether there were concerns in relation doctors undertaking too much private sector activity. The Medical Director confirmed that any doctor undertaking additional activity over the advised amount would be raised as part of their annual appraisal. In addition, any additional private sector activity required approval by the Medical Director.

The Chief Executive highlighted that, as part of the Commercial Strategy, the Trust may wish to incentivise doctors; to repatriate private practice back to the Trust as a commercial benefit and this could be included in doctors’ job plans.


42/19 Quality Account Priorities Update

The Committee noted the report.

43/19 Quality Assurance and Learning Committee Exception Report

The Director of Nursing introduced the report and highlighted that in relation to the Clostridium Difficile (C. diff) new reporting standards had been set for 2019/20. The Trust had reported 9 cases against the upper limit of 24. The Director of Nursing was also in discussion with the CCG regarding the observation ward as patients on the ward were classed as inpatients and this could have an impact on the number of reported cases.

The Medical Director highlighted NICE guidance recommended routinely offering HIV testing to patients in a high risk area attending the emergency department. The Trust had, in consultation with the Sexual Health team and discussion at the Clinical Outcomes and Effectiveness Committee, agreed not to offer this option as the take up rate would be low. In addition, if a patient was diagnosed then there would be a need to provide the option of counselling that was not currently available. The Committee noted that only 1 out of 20 trusts in high risk areas were currently offering this option.

44/19 Transformation Strategy

The Head of Transformation gave an overview on feedback received following discussion at Board. This had included messaging and language in the strategy should be clear and understandable. In addition, it was recommended that a smaller number of priorities were set and that the strategy cross-referenced to the other enabling strategies. The model

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identified would also need to be compatible with the KPMG work that had being undertaken.

The Committee noted that the Transformation strategy would have short, medium and long terms plans and enable staff to make small scale changes in their areas. In addition, it would include the application of methodology and would need to be reviewed at a system level.

The Head of Transformation advised that the next iteration of the Transformation Strategy would be submitted to the Board of Directors during Autumn. Action: M Sherry

45/19 Travel and Transport Plan

The Chief Executive provided an overview of the Travel and Transport plan and advised that an external company was undertaking a data collection on site until mid-July 2019. Once the data had been analysed the Trust would be developing a strategy and implementing changes from November 2019 onwards.

The Chief Executive highlighted that there would be some difficult decisions to make in relation to who would be able to park on the Trust site. However, the Trust would engage with staff to discuss and keep them informed of the development of the Travel and Transport plan.

In addition, the Chief Executive advised that the Trust would need to work collaboratively with Reading Borough Council as they had introduced a local transport plan that included a green energy/low carbon footprint. The Committee noted that if the Council did impose a local emission charge zone this could have an impact on staff retention.

A number of short term actions were being reviewed including discussions with Reading buses about improving the bus route for Mereoak Park and Ride to align with staff shift patterns as well as continued discount on local transport. Longer term actions included reviewing whether the multi-storey car park would only be used by patients and visitors as well as additional disabled and drop-off zones being made available in West Drive.

The Chief Executive highlighted the Travel and Transport plan would be discussed in further detail at a future Board meeting. Action: T Middleton

The Committee sought confirmation as to whether the external company had previously undertaken a similar exercise at a previous acute trust. Action: T Middleton

It was agreed that the presentation would be circulated to the Committee for information. Action: H Travers


The Committee noted the work plan.


It was agreed that key issues to draw to the attention of the Board included:

Annual update on Serious Incidents (SIs) received

CNST Incentive Scheme reviewed and recommended for approval subject to minorwording update

2018 inpatient survey outcomes reviewed.

Seven Day Services Self-Assessment received.

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Travel and Transport Plan update received.


It was agreed that the next meeting would be held on Tuesday 8 October 2019 at 14.00.

SIGNED:

DATE:

Agenda Item 8.3

1

Audit & Risk CommitteeWednesday 15 May 20199.30 – 10.40Boardroom, Level 4, Royal Berkshire Hospital

MembersMr. John Petitt (Non-Executive Director) (Chair) Mr. Brian Hendon (Non-Executive Director) Mrs. Helen Mackenzie (Non-Executive Director) (up to minute 93/19)

In attendanceAdvisorsMs. Anna Blackman (Partner, PwC)Ms. Lorraine Bennett (Local Counter Fraud Manager) (up to minute 86/19)Mr Ben Sherriff (Partner, Deloitte)Mr. Paul Thomas (Senior Manager, Deloitte)Ms. Alice Wainwright (Manager, PwC)

Trust StaffMs Caroline Ainslie (Director of Nursing) (up to minute 93/19)Mr. Mike Clements (Deputy Director of Finance – Central Finance)Mrs. Angela Gardiner (Group Financial Controller)Mrs. Nicky Lloyd (Chief Finance Officer) Mrs. Caroline Lynch (Trust Secretary)Mr. Steve McManus (Chief Executive)Mr. Graham Sims (Chair of the Trust)Mrs. Hannah Travers (Deputy Trust Secretary)

Apologies

85/19 Declarations of Interests

There were no declarations of interests.

86/19 Counter Fraud Work Plan 2019/20


The cost was in line with the previous year. The Committee queried whether the fee could be reduced. The LCFM advised that the cost could not be amended. However, the overall cost could be considered throughout the year. The Committee approved the work plan for 2019/20.

87/19 External Audit Report including Financial Statements and Quality Account

The Partner, Deloitte introduced the external audit report and highlighted that a key area of focus was value for money. However, subject to appropriate disclosure in the Annual Report and Annual Governance Statement it was not anticipated that there would be any matters

Audit & Risk Committee

Audit & Risk Committee Minutes 2

Audit & Risk Committee Minutes 15 May 2019

within the audit report in relation to the Trust’s arrangements for securing the economy, efficiency and effectiveness in the use of resources.

The Senior Manager, Deloitte, advised that there had been significant changes to both the Annual Report Manual (ARM) and the Group Accounting Manual (GAM) for 2018/19 Annual Report and Accounts which had presented a number of challenges this year. In relation to property valuations, property specialists from Deloitte had been engaged to review the assumptions and methodology used to value the estate. Their opinion was that the estimates were reasonable and outputs of the valuations were good. Therefore, no issues had been raised. The Senior Manager, Deloitte, confirmed that, in relation to management override of controls, no issues had been identified as part of the audit.

The Committee noted that the Trust would need to prepare for the implementation of IFR16, leases, for 2020/21due to the scope and potential complexity of work required. The Chief Finance Officer confirmed that the finance team would be working with auditors in relation to this. The Committee discussed the future of HFMS Ltd. The Chief Finance Officer highlighted that a full review of taxation would be undertaken and advice was being sought. A further update would be provided to the September meeting. Action: N Lloyd

The Senior Manager, Deloitte, advised that there had been no factual uncorrected misstatements above the clearly trivial threshold and no corrected misstatements identified that impacted surplus or control total. The Senior Manager, Deloitte, highlighted that a presentational item within operating expense would be resolved with the finance team after the meeting. Action: P Thomas

The Committee noted that an unqualified audit opinion would be given by Deloitte and that the financial statements presented a true and fair view.

The Senior Manager, Deloitte, introduced the findings and recommendations from the 2018/29 Quality Report and highlighted that the scope of the audit was to support a ‘limited assurance’ opinion based on NHS Improvement’s procedures. As part of the review Deloitte had undertaken sample testing of three indicators; two mandated indicators; A&E 4 hour wait times, 62 day cancer wait times and the local indicator, selected by governors, Summary Hospital-level Mortality Indicator (SHMI). The Committee noted that an unmodified limited assurance opinion would be issued for the A&E 4 hour wait times and 62 cancer wait times. In relation to the SHMI indicator, only minor issues had been noted in testing. The Committee noted that the Copeland's Risk Adjusted Barometer (CRAB) system implemented by the Trust would support SHMI data quality. In addition the appointment to the Medical Examiner role would also ensure mortality data would be reviewed at individual patient level.

88/19 Head of Internal Audit Opinion

The Director, PwC, advised that the Head of Internal Audit Opinion (HOIA) was ‘generally satisfactory with some improvements required’. The Director, PwC, highlighted that, as part of the Cyber review, progress had been made by the Trust in relation to a number of improved security measures. However, further work was required. In relation to the Business Continuity Management draft findings assurance had been received in relation to systems and processes in place. However, it was anticipated that a medium risk finding would be issued for this review.



89/19 Annual Report 2018/19

The Trust Secretary introduced the Annual Report 2018/19 and advised that some further changes were required including the section on pensions information and two amendments to the Annual Governance Statement. Following this, a detailed proof read of the document would be undertaken. The Committee suggested that all diagrams in the documents should be clearly referenced. It was agreed that the Committee would forward any further comments to the Trust Secretary. Action: All

The Committee agreed that a recommendation should be submitted to the Board to approve the Annual Report 2018/19 subject to the amendments discussed.

90/19 Financial Statements 2018/19

The Chief Finance Officer introduced the financial statements 2018/19 and highlighted performance in relation to the previous year in relation to income, operating expenses, pay costs, agency spend, non-current assets and cash. The Chief Finance Officer confirmed that no significant changes had been made to the Trust’s accounting policies.

The Committee noted the report that confirmed the Trust had adequate resources to continue in operational existence for the foreseeable future and that, on that basis continued to adopt the going concern basis in preparation of the accounts.

91/19 Quality Account

The Chair of the Quality Committee confirmed that the Quality Committee had recommended the Quality Account for approval. The Quality Committee had discussed the Quality Account priorities that had not been achieved as well as considering stretch targets for 2019/20. The Committee noted that the priority related to car parking would be carried forward as a priority for 2019/20.

The Committee agreed that a recommendation should be submitted to the Board to approve the Quality Account 2018/19.

92/19 Management Letters of Representation

The Committee received the management letters of representation in relation to the Financial Statements and Quality Account.

The Committee expressed its thanks to the Corporate Governance, Quality Governance and Finance teams for their work in the production of the Annual Report, Quality Account and Financial Statements.

93/19 Reference Cost Pre-Submission Report

The Chief Finance Officer introduced the report and advised that the reference cost submission was a mandated cost collection exercise. The final submission would be in July 2019. The Chief Finance Officer advised that the Getting It Right First Time (GIRFT) work and Model Hospital would identify where the Trust was an outlier. In addition, a work stream in the Finance Matters programme would also focus on this.


It was agreed that the next meeting would be held on Wednesday 18 September at 9.30am.



95/19 Private Meeting with External Audit

A private meeting with Deloitte was held.

96/19 Private Meeting with Internal Audit

A private meeting with PwC was held.

97/19 Private Meeting of the Committee

It was agreed that a meeting of the Committee was not required as there were no specific issues for discussion.

Chair:

Date:

Agenda Item 8.4

1

Charity CommitteeMonday 20 May 201915.30 – 17.15Room 3, Level 4, Royal Berkshire Hospital

PresentMr. Graham Sims (Chair of the Trust) (Chair)Mr. Jonathan Barker (Public Governor, Reading)Ms. Hazel Cowper (Charity Director)Mrs. Nicky Lloyd (Chief Finance Officer)Dr. Sunila Lobo (Public Governor, Reading)

In attendanceMrs. Caroline Lynch (Trust Secretary)Mrs. Victoria Parker (Director of Communications and Engagement)Mrs. Hannah Travers (Deputy Trust Secretary)

Apologies Mr. Steve McManus (Chief Executive)



17/19 Minutes for Approval: 13 March 2019 and Matters Arising Schedule

The minutes of the meeting held on 13 March 2019 were approved as a correct record and signed by the Chair.


The Committee agreed that the following actions would be carried forward:

Minute 03/19: Charity Directors Report: The Terms of Reference would be reviewed at the next meeting. Action: C Lynch

The Charity Director advised that she would attend the next Estates Management Committee to review potential opportunities for Charity funding. Action: H Cowper

Minute 11/19: Charity Director’s Report: Information on the role of the Trustee would be produced to ensure Board members were aware of their liabilities, responsibilities and accountability. This information would also be provided to future Board members at induction.

Action: H Cowper/C Lynch

External advertising of the Charity would be reviewed and an update provided at the next meeting. Action: H Cowper

Minutes

Minutes of the Charity Committee – 20 May 2019 2

Minutes of the Charity Committee May 2019

Minute 13/19: Management Accounts: The Committee recommended that rental charges for Melrose House should be included in the Charity accounts going forward.

Action: N Lloyd

The Committee discussed the number of issues highlighted in the Charity Director’s report that would need to be reviewed and actions identified. These included the Charity risk register, annual plan and gift aid. Action: H Cowper

The Committee requested that the draft budget should be submitted to the next meeting for approval. Action: H Cowper

The Charity Director would provide the Trust Secretary with information on where the Charity Director’s report had previously been published. Action: H Cowper

18/19 Charity Director’s Report

The Charity Director provided an overview of the financial position of the Charity. During 2018.19, £1,159m had been spent against an annual plan of £2,340m. The Charity Director highlighted that the run rate of the Charity was £700k per annum without fundraising activities taking place.

The Committee discussed whether the Charity could target different groups to increase funds as income received was £282k less than expected. [Section exempt under s43].

The Committee discussed funds received from legacies [Section exempt under s43].

The Chief Finance Officer highlighted that a Finance Matters work stream would be established for the Charity. This would enable experts in the finance and procurement team to support the Charity with their financial accounts going forward. It was recommended that the guideline for fund managers would need to be updated to incorporate Finance Matters.

Action: H Cowper

The Committee recommended that an update should be provided at the next meeting on the Finance Matters work stream, the budget and the strategy. A task and finish group would be established to review these prior to submission to the next Committee.

Action: H Cowper/ N Lloyd/ C Lynch

In addition, it was recommended that Charity Governance would be included on the work plan for the September meeting. Action: C Lynch

The Committee noted that the Chief Finance Officer was currently reviewing alternative locations for the Charity team. Action: N Lloyd

It was agreed that the Knowledge & Training fund would need to clarify that requests for research funding should include a statement that alternative options had been considered prior to a Charity funding request. In addition, funding requests to the Charity should align with the Trust’s strategic objectives.

The Committee noted that current governance processes, including business continuity and Standing Financial Instructions, would be extended to the Charity. Action: N Lloyd


Minutes of the Charity Committee – 20 May 2019 3

Minutes of the Charity Committee May 2019

The Director of Communications and Engagement highlighted that, due to capacity issues within the team, it had not been possible to increase fundraising events as previously discussed.

The Committee approved the Knowledge and Development Fund Terms of Reference pending a member of the finance team being included as a panel member. In addition, the form would need to be updated to align with the Trust’s terms of reference template. Action: H Cowper


The Committee discussed the format of the Charity Risk Register and recommended that this be updated to align with the Trust’s format and entered on the Datix system. The Trust Secretary highlighted that the scoring of each risk would need to be considered by the Integrated Risk Management Committee. Action: H Cowper

19/19 Management Accounts

The Chief Finance Officer gave an overview of the Charity Accounts and highlighted the financial statements of the Charity had been audited as part of the Trust’s Group Accounts. The Committee noted that the format of the Charity finance report would be updated to align with the Trust’s finance report. Action: N Lloyd

It was agreed that the Chief Finance Officer would confirm if the £940k capital expenditure related to the LINAC. Action: N Lloyd

The Charity Director highlighted that a review of all gift aid since 2016 was being undertaken, [Section exempt under s43].

The Chair of the Trust recommended that the Charity Director meet with staff as appropriate to review issues highlighted to ensure that these were resolved. Action: H Cowper

20/19 Charity Committee Work Plan

The Committee recommended that an update on Charity Governance and the restructure of the Charity team be included on the workplan. In addition, the Trust Secretary recommended that the work plan would be aligned with the Trust format. Action: C Lynch


It was agreed that the next meeting would be held on Tuesday 9 July 2019 at 11.30.

SIGNED:

DATE:

Agenda Item 8.4

1

Charity CommitteeTuesday 9 July 201911.40 – 12.30Room 3, Level 4, Royal Berkshire Hospital

PresentMr. Graham Sims (Chair of the Trust) (Chair)Mrs. Nicky Lloyd (Chief Finance Officer) (from minute 24/19)Dr. Sunila Lobo (Public Governor, Reading)Mr. Steve McManus (Chief Executive)

In attendanceMrs. Angela Gardiner (Group Financial Controller)Mrs. Victoria Parker (Director of Communications and Engagement)Mrs. Hannah Travers (Deputy Trust Secretary)

Apologies Mr. Jonathan Barker (Public Governor, Reading)



23/19 Minutes for Approval: 20 May 2019 and Matters Arising Schedule

The Chair reflected on the challenges faced by the Charity in recent months and expressed significant concern in relation to the inconsistent local leadership of the Charity and its overall operation was unsatisfactory for a Charity with over £5m of liquid assets. The Chair asked that the Committee agree to a pause of three months to enable executive leadership to review the entire modus operandi, management and strategy of the Charity and, to submit an update to the Committee and Board during October 2019. Consultation on all aspects would be undertaken in the interim and a review of the constitution and terms of reference of the Charity would also be reviewed by the Trustees. The Chair also requested that during this period, more oversight was given to ensure the safe and steady work of the charity was maintained.

The minutes of the meeting held on 20 May 2019 were approved as a correct record and signed by the Chair.

The Committee received the matters arising schedule and noted that a number of actions were in progress or outstanding. The Chair highlighted that any critical actions would be reviewed and the work plan would be updated to conclude any outstanding actions by the next meeting. Action: V Parker/G Sims / C Lynch

Minutes

Minutes of the Charity Committee – 9 July 2019 2

Minutes of the Charity Committee July 2019

24/19 Charity Director’s Report

The Director of Communications and Engagement advised that a new Charity Director had not yet been recruited. Short term solutions were being considered to enable the Charity to operate effectively over the next quarter.

The Director of Communications and Engagement gave an overview of events that were scheduled to take place during 2019/20. These included a winter ‘Walk for Wards’ and a London to Paris bike ride. In addition, it was confirmed that Jacobs the Jewellers would also continue to support the Charity going forward.

The Committee noted that the Charity team would be relocated to sit with the Finance team. However, it was noted that this would not be on the main hospital site and management would need to ensure the team were still connected with hospital staff. The Committee recommended that the Executive team and senior management should ensure that, going forward, the Charity was highlighted as part of team meetings. Action: V Parker

The Committee noted that, in relation to legacies, the Charity had received circa £99k against a target of £700k. The Director of Communications and Engagement would provide an update on legacies at the next meeting. Action: V Parker

In relation to the Knowledge and Development Fund, promotional material had been circulated across the Trust. It was agreed that further material could be circulated to raise awareness of the fund and that specific areas of focus could also be identified. This included staff required to undertake a project as part of their final year of the Henley Business School programme.

Action: V Parker

The Committee discussed funding requests received and whether best value for money was taken into account when funds were authorised by the Charity. The Chief Finance Officer advised that Fund Managers were currently able to purchase products and then request reimbursement from the Charity fund. However, embedding the team within the finance directorate would improve governance processes as the Charity team could use their expertise going forward.

The Committee recommended that a robust finance process was required to ensure that the Charity was following the same governance processes as the Trust. Action: N Lloyd

25/19 Management Accounts

The Group Financial Controller introduced the report and advised that the Charity fund balance was approximately £5m.

The Committee discussed interest accrued on gift aid received and queried whether this could be increased. The Chair highlighted that the Charity required enough liquidity to cover running costs on an annual basis. The Group Financial Controller would review safe harbour options that were available for the Trust including stocks and shares. Action: A Gardiner


The Committee sought clarity on the 2019/20 budget as this had yet to be submitted to the Committee. The Chief Finance Officer highlighted that running costs could be predicted for the financial year. However, a number of fund plans were still outstanding that would provide clarity on the expected expenditure of the Charity.

Minutes of the Charity Committee – 9 July 2019 3

Minutes of the Charity Committee July 2019

The Chief Finance Officer provided an overview of the items related to the £940k as this did not relate to the LINAC. This had included medical (£582k) and non-medical equipment (£171k) as well as buildings (ward refurbishment £161k).

The Group Financial Controller would confirm when the funds for the LINAC had been released as this had been over a period of two financial years. In addition, the Committee recommended that a forecast on funds was made available to provide improved oversight of when funds were spent going forward. Action: A Gardiner

The Committee discussed fundraising for smaller projects versus fundraising for large scale projects such as the LINAC. The Chief Executive highlighted that the site masterplanning would be developed during the Autumn and suggested that the Charity could launch a major capital appeal related to the development of the site. The Committee discussed using £2m of Charity funds for the major capital appeal.

The Chief Executive suggested that all Fund Managers should attend a face to face mandatory training session over the next six months to ensure adherence to Trust processes. It was agreed that if a Fund Manager did not attend the fund would be included in the ‘general’ fund.

26/19 Charity Committee Work Plan

The Committee suggested that the Charity lead would liaise with the Chair to review the workplan to ensure items were prioritised as appropriate for the next meeting.

Action: V Parker27/19 Date of Next Meeting

It was agreed that the next meeting would be held on Tuesday 2 October 2019 at 11.00.

SIGNED:

DATE:

Agenda Item 9Board Work Plan

Focus Item Lead Freq May-19 Jul-19 Sep-19 Nov-19

Other / Governance

Chief Executive Report SM EveryCorporate Risk Register CAi Bi-AnnuallyBoard Assurance Framework CL Bi-AnnuallyWell Led Framework Action Plan Update SM Bi-AnnuallyIntegrated Performance Report Exec EveryIPR Metrics Review MS AnnuallyAnnual Report and Accounts and Quality Account

CAn/ Cai/CL Annually

NHSI Annual Self-Certification NL/CL AnnuallyFreedom to Speak Up Annual Report JP AnnuallyN&R Committee Update CL QuarterlyStanding Orders Review CL AnnuallyHealth & Safety Annual Report NL AnnuallyReview of the meeting GS EveryBoard Work Plan CL Every

Provide the HighestQuality Care

Quality Strategy CAi AnnuallySkill Mix Review CAi AnnuallyWinter Plan MS AnnuallyPathology JL/NL OnceSeven Day Services Self-Assessment JL Bi-AnnuallyHealth & Safety Story NL EveryStaff Story CAI/JL EveryPatient Story CAI/JL EveryCNST Incentive Scheme CAI AnnuallyBalanced Strategy Scorecard AS Bi-Annually

Invest in our Staffand live out our

Values

Staff Survey Results DF AnnuallyAnnual Revalidation Report JL Annually

Achieve Long-TermFinancial

Sustainability

Chief Finance Officer Report NL EveryFinance Strategy NL OnceQuarterly Forecast NL Quarterly2019/20 Contract NL Annually2019/20 Budget NL Annually2019/20 Capital Plan NL AnnuallyOperating Plan AS AnnuallyCQC Use of Resources CAi AnnuallyStanding Financial Instructions Review NL Annually

Drive theDevelopment of

Integrated Services ICS Update AS Every

Cultive Innovationand Transformation

Transformation Strategy MS Once

board of directors 31 july 2019 - royal berkshire hospital · 2019 and 22 july 2019 sue hunt 8.2....

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