draft - north tees and hartlepool nhs foundation trust · 2018-01-24 · the ce reported that the...

Board of Directors Meeting

Thursday, 25 January 2018 at 1.00 pm

Boardroom University Hospital of North Tees Draf

t

Glossary of Terms

Strategic Aims and Objectives

Strategic Aims

Putting Patients First – to create a patient centred organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery.

Integrated Care Pathways – to develop and expand the portfolio of services to provide integrated care pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare.

Service Transformation – to improve and grow our healthcare services to continually review the needs of our healthcare community and transform services. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes.

Manage our Relationships – to ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

Maintain Compliance and Performance – to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

Health and Wellbeing – to embrace the health and well being of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the commissioning of services from the Trust.

Strategic Objectives

Maintain Compliance and Performance – assurance around compliance with standards, performance indicators and requirements within the Terms of Authorisation. Requirement to provide Board regulation and self certification on a quarterly and annual basis in accordance with Monitors Terms of Authorisation.

Seasonal Pressures – requirement to ensure preparedness for seasonal winter pressures.

Reduce Hospital Acquired Infections – supports the Trust’s key strategic theme of; Maintain Compliance and Performance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of the Trust business.

Effective Board Governance – corporate oversight and scrutiny will continue to be provided by key management structures; 1. Board of Directors, 2. Executive Team, 3. Trust Directors Group.

Training – ensuring the workforce is appropriately trained.

Draft

Workforce – absence management, ensuring we have adequate staffing levels that provide safe and effective care to our patients. Momentum – Pathways to Healthcare – delivery of a new healthcare system for the people of Easington, Hartlepool, Sedgefield and Stockton. Putting Patients First / Patient Safety – to create a patient-centred organisation by engaging and enabling staff to add value to the patient experience, demonstrated through patient safety, service quality and LEAN delivery. Finance – to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

Draft

PG/BB 18 January 2018 Dear Colleague A meeting of the Board of Directors will be held on Thursday, 25 January 2018 at 1:00 pm in the Boardroom, University Hospital of North Tees. Yours sincerely

Paul Garvin Chairman

Agenda

Led by

1. (1.00pm) Apologies for absence Chairman 2. (1.00pm) Declaration of Interest Chairman 3. (1.00pm) Minutes of the meeting held on, 30 November 2017 (enclosed) Chairman 4. (1.05pm) Matters Arising Chairman Items for Information 5. (1.10pm) Chairman’s Report (enclosed) Chairman 6. (1.20pm) Chief Executive’s Report (enclosed) J Gillon 7. (1.30pm) Board of Directors Declaration of Interests and Fit & Proper Persons Declaration (enclosed) B Bright Draf

t

Quality 8. (1.35pm) Safety, Quality and Infection Prevention Report (enclosed) J Lane 9. (1.45pm) Maternity Position Statement (enclosed) J Lane Strategic Management 10. (1.55pm) Capital Programme Performance Quarter 3: 2017/18 (enclosed) R Toole Performance Management 11. (2.05pm) Financial Performance Report as at R Toole - 31 December 2017 (enclosed) 12. (2.15pm) Compliance and Performance Report (enclosed) L Taylor Governance 13. (2.25pm) Learning from Deaths Quarter 3: 2017/18 (enclosed) D Dwarakanath 14. (2.35pm) Any Other Notified Business Chairman 15. Date of Next Meeting (Thursday, 29 March 2018, Boardroom, University Hospital of North Tees)

Draft

____________________

* voting member

North Tees and Hartlepool NHS Foundation Trust

Minutes of a meeting of the Board of Directors held on Thursday, 30 November 2017 at 1.00pm

at the University Hospital of North Tees

Present: Paul Garvin, Chairman* Chairman Brian Dinsdale, Non-Executive Director* BD Rita Taylor, Non-Executive Director* RT Steve Hall, Non-Executive Director* SH Jonathan Erskine, Non-Executive Director* JE Kevin Robinson, Non-Executive Director* KR Julie Gillon, Chief Executive* CE Robert Toole, Director of Finance* DoF Deepak Dwarakanath, Medical Director* MD Alan Sheppard, Director of Workforce DoW Julie Lane, Director of Nursing, Patient Safety and Quality* DoN,PS&Q Graham Evans, Chief Information and Technology Officer CI&TO Julie Parkes, Director of Operations DoO Lynne Taylor, Director of Performance and Planning DoP&P Barbara Bright, Company Secretary CS In attendance Sarah Hutt, Assistant Company Secretary (Note taker) BoD/3551 Apologies for Absence There were no apologies for absence reported. BoD/3552 Declarations of Interest There were no declarations of interest on open agenda items. BoD/3553 Minutes of the meetings held on, 26 October 2017

Resolved: that, the minutes of the meeting held on, 26 October 2017 be confirmed as an accurate record.

BoD/3554 Matters Arsing

a. BoD/3511 Chairman’s Report – Director Changes The Chairman reported that Robert Toole had been appointed as the Director of Finance on an interim basis with effect from 30 October 2017.

Resolved: that, the information be noted. Draf

t

2

BoD/3555 Chairman’s Report

a) Financial Position The Chairman reported on the financial pressure being faced by the Trust and outlined the main causes, which included reduced levels of activity, reduced income from A&E following the reconfiguration of Emergency and Urgent Care Services, increases in costs including drugs, and being behind plan on the Cost Reduction Target programme. The Trust was working with NHSI in respect of financial recovery plans which were being led by the newly appointed DoF. The Trust’s performance against other key indicators and metrics was very good, however, going forward more efficient ways to deliver care, without compromising on quality and safety would need to be found, which may alter how some services would be delivered in future and would involve difficult decisions being made in the coming weeks. JE, Non-Executive Director sought clarity regarding the involvement of the Board in the difficult discussions and subsequent decisions. The Chairman explained that the Board Seminar scheduled for 14 December would be used to discuss financial recovery in advance of further engagement with NHSI to ensure a position was agreed, before any budget planning for 2018/19 could commence b) Collaborative Working The Chairman reported that the Chief Executive, Medical Director and Chairs from County Durham and Darlington NHS Foundation Trust, South Tees Hospitals NHS Foundation Trust and the Trust had met to further advance collaborative working particularly in respect of vulnerable services. It was agreed that the Medical Directors for each trust would lead on this work, and a letter of commitment had been drafted but was still to be agreed. A further meeting was scheduled for 4 December 2017. c) Armed Forces award The Chairman reported that the Trust had successfully achieved a Silver Award as part of the Armed Forces Employer Recognition Scheme, which was presented at Redworth Hall Hotel. The Trust was one of 25 employers in the region to receive the award, recognising the commitment to support this group of staff. d) Shining Stars The Chairman reported that planning was underway for the 2018 Shining Stars, staff recognition event which would take place on 8 June 2018. The event was solely possible through generous sponsorship from local businesses, negating any cost to the Trust. There were 12 award categories, which were always gratefully received by nominated members of staff. e) Care Quality Commission (CQC) Unannounced Inspection The Chairman placed on record his thanks to the DoN,PS&Q and her team following an unannounced inspection by the CQC that had taken place between 21-23 November. Initial feedback had been positive. f) PWC event The Chairman reported that he had attended a very useful event in respect of the future of regulation in the NHS which was hosted by PwC. Speakers included David Behan, Chief Executive of the CQC, and Stephen Hay, Director of Regulation for NHSI. It was expected

Draft

3

that place based and patient based regulation would be introduced, however, major legislative change was unlikely for the next 5 years.

Resolved: (i) that, the information be noted; and (ii) that, the Board Ward visits scheduled for 14 December be re-

arranged and replaced with a Financial Recovery session. BoD/3556 Chief Executive’s Report

a) Sustainability and Transformation Partnership (STP) update The CE provided an update in respect of collaborative working as part of the Sustainability and Transformation (STP) Plans. A regional meeting took place on 21 November to discuss vulnerable services which was attended by representatives from trusts, CCGs and other relevant bodies. The meeting was positive and it was agreed that a mandate would be developed for the relevant organisations to sign up to.

b) Hartlepool Matters The CE reported that the draft Hartlepool Matters Implementation Plan, a piece of work led by independent chair, Dr Colin-Thomé in partnership with Hartlepool Borough Council, the Trust and CCG was presented at a public meeting on 2 October. The Plan reviewed health and care services in Hartlepool focusing on four main areas of work. Findings to date had largely been positive and it was noted that circa 94% of the Trust’s contacts with patients in Hartlepool were carried out in the Community and not in an acute hospital setting. However, the under-utilisation of the Birthing Centre at the University Hospital of Hartlepool, was subject to further discussion in addition to maternity and elective services in Hartlepool, which would be referred to the Audit and Governance Committee of Hartlepool Borough Council. It was noted that 40% of elective care delivered by the trust is carried out at Hartlepool.

c) CCQ Unannounced Inspection

The Chief Executive reported that as part of their inspection regime, the CQC carried out an unannounced inspection at the Trust between 21 and 23 November. Areas visited included Medicine, A&E, and Maternity Services. Informal feedback had largely been positive, however, a formal ‘ratings’ meeting was not expected until the end of January 2018. The planned ‘well led’ inspection would take place between 19 and 21 December. The Trust was also part of an unannounced inspection that took place at the Rosedale Centre in Stockton, a step down facility operated by the local authority. The formal report was expected, however, initial feedback was positive.

d) NHS Providers Conference The CE reported that a number of trust representatives had attended the annual NHS Providers Conference that took place between 7 and 8 November. The theme for the conference was the pressure being faced by the NHS, and the requirement for system wide collaboration to tackle the major challenges and find long term solutions.

e) Synexus The CE reported that a Memorandum of Understanding had been signed in partnership between the Trust, Synexus and Teesside University (GP Paul Williams attended the signing event) regarding the Clinical Research facility established in the Middlefield Centre.

Draft

4

f) Commissioners The CE reported that Executive colleagues had met with the CCG to discuss the financial situation. It was a challenging meeting but it was hoped that an agreed way forward could be reached.

g) North East Chamber of Commerce The CE reported that she had met with Eamonn Leavey from the North East Chamber of Commerce to explore new links with universities in respect of educational levies, and to explore commercial opportunities with local businesses.

h) Winter Resilience funding The CE reported that as part of the Budget announcement £350 million would be available for winter resilience. It was hoped that funding was available to all categories of trusts and not just those under performing. The Trust had a number of schemes in respect of the frail elderly care pathway which required funding.

Resolved: that, the information be noted. BoD/3557 Safety, Quality and Infection Prevention Report The DoN,PS&Q presented the Safety, Quality and Infection Prevention Report and drew members’ attention to the key points. The number of patient falls had increased from the previous month with 124 falls in September compared to 106 falls in August. Focused work was on-going; areas for improvement had been identified regarding assessment and onward referral for at risk patients. The number of pressure ulcers had decreased with 13 in September compared to 25 in August, 10 of which were grade 2 or above. Focused work continued including pressure ulcer collaboration which had multi-disciplinary involvement and was proving successful. Ward 26 was an exemplar area with an overall reduction of 75% of ulcers in the last 12 months. A new daily care plan was being rolled out across the Trust in respect of pressure ulcer prevention. KR, Chair of the Infection Prevention Control Committee commended the good work in respect of pressure ulcers and queried whether this would be rolled out further in the Trust. The DoN,PS&Q confirmed that it was being rolled out into other areas and part of its success had been due to the involvement of medical and nursing staff. The Trust had reported one case of Clostridium Difficile (C-Diff) in October with zero cases in September, taking the year to date total to 20, against the annual trajectory of 13 cases. Three cases submitted for appeal via the appeal process with the Commissioners had been upheld, which would reduce the year to date total to 17. A further two cases would be submitted for appeal in December. There was one case of Trust-attributable MRSA in October and zero cases in September. Following investigation the case was found to be unavoidable. There were three cases of Trust-attributable MSSA in October and two cases in September; four cases of Trust-attributable E.coli in October and two in September; two cases of Klebsiella species bacteraemia in October and three in September, and zero cases of Pseudomonas aeruginosa bacteraemia in October and September.

Draft

5

The DoN,PS&Q explained that MSSA bacteraemia and E.coli would form part of the Single Oversight Framework monitoring in 2018/19. A collaborative forum had been established with representatives from trusts, CCGs, NEAS, public health, local authorities, NHS England and NHS Improvement to achieve the required 50% reduction in gram negative bacteraemia by 2020. This included E.coli, Klebsiella and Pseudomonas Aeruginosa. The overall hand hygiene compliance score was 97% for October, exceeding the Trust’s internal target of 95%. BD, Chair of the Audit Committee sought clarity regarding scores from the joint audit undertaken by Audit One and the Trust IPC team, which had been requested by the Audit Committee due to the discrepancy in scores previously. To compare the information in more detail it was agreed that both sets of scores would be shared with the Audit Committee and provide assurance. The Trust’s mortality position continued to improve, with the latest HSMR value at 99.87 (September 2016 to August 2017), from the rebased 100.46 (August 2016 to July 2017), and the latest SHMI value 109.42 (April 16 to March 17) from the rebased 110.28 (March 16 to February 17). Both values remained within the ‘as expected’ range. The Trust had 99 complaints in October 2017, of which 12 were Stage 3 - formal complaints, and the Trust’s response rate for Stage 3 complaints in September was 93%. JE, Non-Executive Director sought to understand any trends or themes in respect of the complaints data, with comparative data for previous years. RT, Chair of the Patient Safety and Quality Standards (PS and QS) Committee confirmed that this level of detail was provided at PS and QS for analysis. The registered nurse fill rate had consistently remained above 80% for both day and night duty, with all areas adhering to the red rules. There were seven Staff, Patient Experience and Quality Standards (SPEQS) visits undertaken in October, with an overall score of 92.58%. RT, Chair of the PS and QS Committee sought assurance that Governors were still involved in the programme of visits and that visits were carried out at ad hoc times and days to avoid complacency by staff. The DoN,PS&Q explained that visits were carried out on an ad hoc basis and did include the Governors, however, any out of hours visits would be undertaken by senior nursing staff only. RT, Chair of the PS and QS Committee commended the refreshed Main Reception incorporating friends and family tests comments as wall art.

Resolved: (i) that, the content of the report be noted; and (ii) that, the position in respect of hospital acquired infections and new

trajectories added to future reports be noted; and (iii) that, the on-going work in respect of pressure ulcers and falls be

noted; and (iv) that, a report in respect of the joint Audit One and Trust IPC Team

hand hygiene audit be presented to the Audit Committee.

BoD/3558 Nursing and Midwifery Workforce Report The DoN,PS&Q presented the Nursing and Midwifery Workforce Report, a bi-annual report. The National Quality Board set out expectations to provide high quality, compassionate care and improved outcomes with a focus on care hours per patient per day. The Carter Report published in 2016 highlighted the need for live electronic rosters across the NHS to enable

Draft

6

the right numbers of staff being in the right place at the right time and that patients receive the correct level of care. The Trust had recently implemented the Safe Care Live tool which provides live data on a shift by shift basis to analyse staffing needs and allocate staff to the areas of need. The Tool had initially been rolled out to In Hospital Care, and the next phase would include Maternity and Paediatrics. The Trust had 60.98 wte Registered Nurse (RN) vacancies and 4.35 wte Registered Midwife (RM) vacancies, with an additional 22.21wte RNs and 9.2wte RMs on maternity leave at the end of October. The DoN,PS&Q explained that the pre-registration student nurses and student midwives who were appointed in September were included in the vacancies, in addition to the overseas nurses who were yet to obtain their NMC registration. Occupancy levels were 97.90% in October against the recommend level of 85%, however, safe staffing levels were maintained above 80%. It was noted that there were some data inaccuracies in the report regarding average fill rate and a revised position was tabled. Workforce models were reviewed to ensure appropriate staffing was in place and following the opening of the Integrated Urgent Care Centre skill mix was adjusted for staff in Rapid Assessment, EAU, and Ambulatory Care. As part of winter planning it was agreed that the winter resilience ward would be nurse led, which was very successful during winter 2016/17. A number of recruitment activities were on-going including bi-annual recruitment days with a new concept of Recruitment Centres also being explored. Overseas recruitment to the Philippines continued, and a further trip was scheduled in June 2018 as the calibre of Filipino nurses was high. The Trust was pleased to welcome 24 student nurses from Sunderland University in September. A lot of work was being undertaken in respect of retaining the current nursing workforce by providing career development opportunities, RN development days and physical skills practice days. Progress had been made to reduce the usage of temporary and agency nursing staff. Work was on-going to finalise the Enhanced Care Team to provide the right skills in the right place at the right time. BD, Chair of the Finance Committee acknowledged the significant improvement being made in respect of the use of agency and bank staff. The C,I&TO sought to understand the data in respect of the average fill rates. The DoN,PS&Q explained that there was a national requirement to report the data in a specific way, which was based on planned and actual staffing levels, however, the data obtained from SafeCare Live provided a more robust way of establishing staffing models supported by live patient demand rostering. RT, Chair of the PS and QS Committee sought to understand how staff were adapting to the Safe Care tool and having to meet staffing requirements in the areas of greatest need. The DoN,PS&Q explained that the Tool provided a visual red, amber, green indicator of where additional staffing was required, which was accepted by staff.

Resolved: (i) that, the reduction in agency and temporary staffing be noted; and (ii) that, the nursing recruitment activity be noted; and

(iii) that, the work in respect of safe staffing levels be noted; and

Draft

7

(iv) that, the winter resilience arrangements be noted. BoD/3559 Compliance and Performance Report The DoP&P presented the Compliance and Performance Report for the month of October against indicators from the Single Oversight Framework and foundation trust licence conditions. The Corporate Dashboard and reporting framework was reflective of both the mandatory performance frameworks for 2017/18 and additional internal reporting requirements, including the Lord Carter Model Hospital Review. The Sustainability and Transformation Funding (STF) conditions for 2017/18 related solely to achievement of the control total, and arrangements for allocating 30% STF related to delivery of the 4 hour standard and Primary Care Streaming, 15% each respectively. In October performance against key operational standards and trajectories remained challenging. Emergency activity saw a slight increase of 2.64% when compared to the same period last year, and included 846 patients who were treated via Ambulatory Care, which equated to 22.64% of the total emergency admissions. There had been a decrease of category 1 patients of 34.12% when compared to the same period last year, which was largely anticipated following the opening of the Integrated Urgent Care Service (IUCS). On aggregate overall urgent care activity saw a net increase of 85.73% compared to the same period last year, with admissions increasing by 34.51%. Performance against the emergency care standard was 98.09% in October against the national requirement of 95%. In October, the Integrated Urgent Care Service reported 5,519 attendances and 292 admissions at UHNT, and 4,545 attendances and 231 admissions at the University Hospital of Hartlepool (UHH) site. The Trust achieved 99.47% compliance against the 2 hour Integrated Urgent Care standard. The Trust saw an improvement against the Referral to Treatment (RTT) standard reporting at 94.74% for October against the 92% standard, and above the national average of 89.10%. There were no over 52 week waits. Median and 92nd percentile waits remained relatively consistent and within target, reporting lower than the national average. Streaming in A&E was working well, with 23.74% of A&E attendances being redirected to the Integrated Urgent Care Centre with less serious conditions, providing greater capacity in A&E to treat more complex patients. Although the establishment of the Integrated Urgent Care Centre provided a better patient pathway, it generated less income for the Trust. Ambulance hand over times were kept to a minimum, with only 2 handovers greater than 30 minutes, and none greater than 60 minutes in October. In comparison, the North East average handovers greater than 30 minutes reported at 45 (range 2 -234), with the average over 60 minutes reporting at 2 (range 0-27). Bed pressures continued in October with occupancy reporting at an average of 87.90%, above the recommended 85%. Delayed Transfers of Care (DTOC) had reduced in October reporting at 2.75%, an average of 17 per day; however, it still continued to impact on bed occupancy levels. The Trust was focusing on stranded patients with lengths of stay over 7 days to improve discharge processes, and a clinically led audit was underway to support a preferred clinical model going forward. The MD provided context in respect of stranded patients, which equated to 46-50% of beds, approximately 250 patients. The DoO explained that there were various pieces of work on-going in respect of the frail elderly pathway to potentially reduce the requirement for admission to hospital. The CE added that it would be worth exploring where the BCF integrated monies were being invested, as having a different system wide infrastructure would allow such patients to be managed differently in community

Draft

8

settings. The Trust continued to experience significant pressures within the delivery of the cancer standards across all tumour groups, however, all Cancer standards were achieved in September including the 62 day referral to treatment standard which reported at 86.79%, and provisionally achieved in October at 87.39%. The pressures to achieve this standard remained due to patient choice, complex pathways and delays across tertiary centre pathways, particularly within Gynaecology and Urology pathways. The Chairman sought assurance that the delays occurring across tertiary pathways were not disproportionately disadvantaging Trust patients. The DoP&P confirmed that this was not the case, all patients were treated equally. Diagnostic pathways continued to be monitored closely to ensure early diagnosis and maximum contribution to RTT pathway management and reduction in waiting times. The Trust achieved 100% in October against the 99% national standard. The Model Hospital dashboard had been updated to include reports across various specialities which had been shared with the relevant directorates to interrogate the data allowing comparison and analysis. The Trust had also taken up the opportunity to work with NHSI as part of the Delivery Productivity Programme (DPP), which sought to support trusts in improving their financial performance by focusing on recurrent and sustainable operational productivity improvements. This work was being launched at kick off meetings with individual directorates which NHSI were supporting. JE, Non-Executive Director sought clarity regarding timescales of the DPP. The DoP&P explained that work stream meetings had already commenced and it was anticipated projects would be for 30, 60 or 90 days. In each workstream there was an executive lead, a clinical lead, operational lead and support from both the Project Management Office (PMO) and Finance. The New to Review ratio was improving at 1.12 in September (latest available position) against the target of 1.45. Performance against the New Outpatient DNA rates reported above the target of 5.40% at 8.53%, and the Review DNA rates reporting at 10.60% above the target of 9%. It was noted that the telephone reminder service had been temporarily suspended in October due to technical issues. In October the number of non-medical cancelled operations reported at 0.48% against the target of 0.80%. All patients were re-appointed within 28 days, and no urgent procedures had been cancelled for a second time. Work was on-going to reduce avoidable admissions. The aggregate emergency readmission rate reported at 8.20% against an internal stretch target of 7.77%. Changes to the Single Oversight Framework had been released which would be incorporated into the Corporate Dashboard going forward as applicable. The Chairman queried whether financial penalties would also be removed from the Single Oversight Framework as readmission rates were due to be removed. The DoP&P explained that going forward they would no longer fall within that framework.

Resolved: (i) that, the corporate dashboard and performance against the Single Oversight Framework and key national indicators be noted; and

(ii) that, the on-going operational performance and system risks be noted; and

(iii) that, the Urgent and Emergency Care impact to income be noted.

Draft

9

BoD/3560 Financial Performance Report as at 31 October 2017 The DoF presented the Financial Performance Report as at 31 October 2017, drawing members’ attention to the current position. The Trust had received a year to date Use of Resources (UoR) rating of 3, which was deterioration against the planned rating of 1, prompting investigation and review by NHSI. The DoF outlined a number of causative factors, including non-delivery of the Cost Reduction Target programme, dual site operating, reduced income and activity levels, and a number of non-recurrent funding items coming to an end. The Trust’s in month position was a deficit of £1.573m, and year to date deficit of £13.296m, which was £7.042m behind the Trust’s internal plan and £10.930m behind the plan submitted to NHSI, excluding Sustainability and Transformation Funding (STF). As the Trust was not achieving its control total, it had been unable to recover a total of £3.094m STF to date. Income was behind plan by £2.907m with NHS clinical income behind plan by £2.815m, Non NHS clinical income behind by £0.179m, and Non clinical income ahead of plan by £95k. Income from non-elective activity had reduced year on year. It was noted that the CCGs were not operating away from plan and the Trust would need to maximise as much income as possible from the system. The DoF reported that he had met with the Director of Finance from the CCG in respect of an income recovery dispute from 2016/17, it was hoped that a position would be agreed the following week otherwise it was likely arbitration would be explored between both parties. Pay year to date expenditure was ahead of plan by £78k, however had worsened in month by £31k. Costs were marginally higher in Month 7 due to the new junior doctor rotation. Agency expenditure had reduced year on year by £1.7m, and the Trust remained within the NHSI agency ceiling. Non-pay was overspent by £4.5m, non-pay CRT was behind plan by £3.5m and STF income was behind plan by £2.406m. Increased drug costs and general supplies and services contributed to the position. This was further impacted by the treatment of creditor accruals in 2016/17. No STF income had been assumed against the planned income of £2.406m adding further variance to plan. At Month 7, £583K of savings had been delivered against the internally phased target of £1.128m with the CRT programme being significantly behind plan; delivery was reviewed on a weekly basis by the Executive Team. The Trust’s cash balance was £18.7m, which was £3.9m behind plan and was of concern. A monthly Cash Committee had been established to monitor achievement of the cash plan and facilitate the control of working capital. BD, Chair of the Finance Committee reiterated the concern in respect of managing the Trust’s cash balance which had been the subject of discussion at the Finance Committee and needed to be monitored closely. The strategic finance session scheduled for Thursday, 14 December was welcomed. BD, further expressed concern in respect of the relationship with HAST CCG and seeming reluctance to meet with Non-Executive counterparts, having only met once. It was agreed that a letter would be sent to the CCG to pursue this matter. Dr Posmyk Boleslaw, Chair of HAST CCG agreed that it was essential to work together and would provide his support. It was essential that budgets were effectively managed going forward, without jeopardising quality or clinical outcomes, and that spending was restricted and contained in all areas. The success with the clinical coding work was noted, which contributed to securing correct

Draft

10

income and the accurate recording of patient co-morbidities. The Chairman reiterated the importance of system wide working, expressing concern regarding the long term sustainability of the Trust and its ability to declare as a going concern for 2018/19. SH, Non-Executive Director reminded members that many of the issues being faced currently were predicted by the Board previously, and plans to mitigate them had included the new hospital project, which was stopped from proceeding. It was imperative that the CCG and the Trust worked in harmony. JE, Non-Executive Director added that it was likely radical changes would be required which would need the support from key stakeholders. The Trust’s planned capital allocation for 2017/18 had been revised from £22.2m to £21.9m, following agreement by the Finance Committee, which comprised: £6.0m internally generated ‘block capital’; £14.7m for the infrastructure and energy centre upgrade loan; £150k additional capital from charitable donations, and £1.0m PDC allocation relating to the Integrated Urgent Care Service. At Month 7, the Trust had spent £4.4m against a plan of £11.9m, which was largely due to a delay in invoices being received from suppliers against orders placed. Resolved: (i) that, the financial position at Month 7 be noted; and

(ii) that, a request for a further Non-Executive meeting be sent to HAST CCG.

BoD/3561 Workforce Report The DoW presented the Workforce Report for quarter 2, drawing members’ attention to key areas. The Trust headcount had increased to 5,614 in quarter 2, an increase of five when compared to the baseline at 31 March 2017. The sickness absence rate for quarter 2, reported at 4.39%, which was lower than the figure at the end of March 2017 of 4.99%. The cost of sickness absence for quarter 2 was £1,477,377 which was an increase of £30,936 from quarter 1, however, was £133,889 lower when compared to quarter 2 in 2016/17. The top three reasons remained as stress / anxiety, musculoskeletal and gastro related sickness and it was noted that the Trust had a comprehensive sickness absence strategy. Occupational Health had transferred to the Workforce Directorate facilitating quicker referrals for staff. To support managers in managing sickness absence there was training to have difficult conversations with staff. The DoW reported that a neighbouring trust had recruited to roles to centrally manage sickness absence, rather than line managers resulting in a significant drop in sickness absence rates and cost of sickness absence to the organisation. BD, Chair of the Finance Committee requested that further information be presented to the Finance Committee to analyse the potential savings in detail. The Chairman requested to know how many trust staff had been sacked due to breach of contract in respect of sickness. The DoW explained none; however, they would have employment terminated due to ill health. A further seven nurses from the Philippines had arrived at the Trust in July 2017, with a further cohort expected to arrive imminently. In respect of the establishment of a new FM Company – North Tees and Hartlepool Solutions, a dedicated workforce workstream had been established and included representatives from workforce, employee relations, education and payroll. A total of 700 staff had been identified as being eligible to transfer to the new company. Staff briefing sessions would continue through December to provide further updates and answer any post consultation questions.

Draft

11

The Stockton 0 to 19 service would transfer from the Trust to Harrogate and District NHS Foundation Trust on 1 April 2018, following Stockton Borough Council’s notification to re-procure the service. The existing staff would be subject to TUPE and would transfer to the new provider in readiness of the go live date. RT, Chair of the PS and QS Committee sought assurance regarding staff’s willingness to transfer to the new 0 to 19 service provider. The DoN,PS&Q confirmed that the staff had been engaged with and were comfortable with the transition to the new provider, who had good infrastructure and support mechanisms in place. SH, Non-Executive Director sought clarity regarding the new provider’s ability to provide the same level of safeguarding arrangements as currently being provided. It was agreed that this would be explored and assurance provided to the PS and QS Committee. A significant amount of work had been undertaken over the last 15 months in respect of the Trust’s volunteering service following the appointment of a dedicated Volunteer Coordinator in May 2016. The Trust currently had 147 volunteers, in addition to those supporting RVS, Radio Stitch and League of Friends, which equated to c. 550 hours per week. There were plans to increase numbers further and to expand the areas volunteers could support. Weekly inter-professional simulations continued to take place in a number of departments and monthly sessions based on Sepsis, Acute Kidney Injury, and Haemorrhage continued. Core Medical Trainees had also received simulations in addition to Third Year trainees who had received training on Neurological Emergencies and patients with reduced conscious levels. A Simulation Open Day was held in October allowing staff the opportunity to review the department and the services on offer, which was well received. Due to the regional Streamlining project a number of mandatory training topics had changed frequency to be in alignment with other trusts, which had resulted in a drop in compliance for a number of topics. Appraisal compliance levels had fallen to 76% against the target of 95%, and continued to be an area of focus. The Performance and Behaviour Framework was due to be rolled out to replace the Knowledge and Skills Framework improving management of the process. The quarter 2 Staff Friends and Family Test results were disappointing with only 76 completed questionnaires received. Of the results 77.6% of staff would recommend the Trust as a place to receive care or treatment and 15.8% of staff who would not, and 61.8% of staff would recommend the Trust as a place to work, whereas 23.7% would not. The reluctance of staff to complete the forms was noted, one of the main reasons being they didn’t believe comments remained anonymous, and it was acknowledged that this needed to be addressed. JE, Non-Executive Director expressed concern at the low numbers of staff completing the survey and the reasons why they were reluctant to do so. The Culture Group would be picking this up by reviewing themes to get clear visibility regarding the Trust as an employer, and would feed this back at a future meeting. The Trust’s People Forum had been renamed as Our Voice and was intended to provide a further method of engagement for staff to raise any issues and exchange views. The initial meetings of the rebranded group had been positive. The DoW reported that following his recent appointment he had also assumed the role of Freedom to Speak Up Guardian for the Trust, acting as an independent and impartial source of advice for any employee wishing to disclose concerns.

Resolved: (i) that, the content of the report be noted, and (ii) that, a formal thanks be placed on record to the CS and Paul

Wharton in respect of the Trust’ volunteering service; and (iii) that, detailed information be provided to the Finance Committee for

analysis in respect of sickness management.

Draft

12

BoD/3562 Guardian of Safe Working Hours The MD presented the Guardian of Safe Working Hours Report for quarters 1 and 2. The new Junior Doctor Contract 2016 outlined that a quarterly report be provided to the Board of Directors in relation to the safe working of doctors within the Trust. The new contract went live for foundation year one trainees on 7 December 2016, with other training grades following on a transitional basis. An overview of compliance was provided and the overall number of exception reports was 33 for the reporting period, which was due to the increased numbers of trainees now on the new contract. Main issues included late finishes due to handovers and late running ward rounds, and rota gaps prompting discussion. There was also dissatisfaction regarding time off in lieu for any extra hours worked being given instead of being paid. The Trust was taking part in a regional pilot to develop a regional bank for medical trainees, similar to that established for nursing staff. Overall there were no significant exceptions resulting in fines and there were no major concerns relating to safe working hours.

Resolved: (i) that, the content of the report be noted; and (ii) that, the exception reporting be noted.

BoD/3563 Board of Directors and Council of Governors Meeting Schedules 2018 The 2018 schedule for Board of Directors and Council of Governor meetings were provided for information. Resolved: that, the information be noted. BoD/3564 Any Other Notified Business

a. HUG Visits Bill Johnson, the Healthcare User Group (HUG) Representative reported that since the last meeting a visit had been undertaken to the Integrated Urgent Care Centre at the University Hospital of Hartlepool, which had been very positive. Patients and staff were satisfied with the service being provided.

b. CCG Feedback Dr Bolesaw noted comments in respect of place based commissioning; the positive comments in respect of the Hartlepool Health Plan, particularly that 94% of patient contacts in Hartlepool were made in community settings. Feedback regarding the improved pathway for patients with the Integrated Urgent Care Centres was noted. He acknowledged the improving mortality position, which was pleasing In respect of collaborative Non-Executive Director working, he explained that there had been some long-term sickness amongst CCG counterparts, however, was hopeful a refreshed approach would commence in 2018/19. BoD/3565 Date and Time of Next Meeting

Resolved: that, the next meeting be held on Thursday, 25 January 2018, at 1.00pm in the Boardroom, University Hospital of North Tees.

Draft

13

BoD/3566 Exclusion of Press and Public

Resolved: that, representatives of the press and other members of the public be excluded for the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1(2), Public Bodies (Admission to Meetings) Act 1960).

The meeting closed at 3.15pm. Signed: Date:

Draft


Meeting of the Board of Directors

25 January 2018

Report of the Chairman

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Manage Our Relationships

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Effective Board Governance

1. Introduction

1.1 The Chairman’s Report aims to provide information to the Board of Directors on key local, regional and national issues.

2. Key Issues and Planned Actions

2.1 Consultant Appointment

The following consultant appointment has been made since the last meeting:

Dr Paul Davidson, Consultant Cardiologist

2.2 Committee in Common

The Committee in Common met on 11 December 2017. This was a very positive meeting with the major focus being on vulnerable services and the Medical Directors were tasked with looking at developing a sustainable clinical model for the future. Members also decided to increase the frequency of meetings so that progress was maintained.

2.3 Care Quality Commission Well-Led Visit

I wish to pass on my thanks to all members of staff for the efforts during the recent Care Quality Commission (CQC) visits. We received some very positive feedback.

The CQC commented that the Trust had:-

• A clear vision and strategy• A positive culture• Evidence of working collaboratively with partners• Risk management strategies had improved and become more embedded and

there was on-going work to differentiate between a ‘risk’ and an ‘issue’• Strategies were becoming more predicted and prepared for changes• The CQC supported the development of quality improvement processes to ensure

the organisation was fit for the futureTheir report is due to go to the CQC grading panel during week commencing 29 January 2018 and the Trust should receive a response soon after.

Draft

3. Recommendations

3.1 The Board of Directors is asked to note the content of this report.

Paul Garvin Chairman

Draft



25 January 2018

Report of the Interim Chief Executive Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Putting Patients First; Valuing our People; Transforming our Services; Health and Wellbeing.

1. Introduction 1.1 The Chief Executive‟s Report provides information to the Board of Directors on key local,

regional and national issues.

2. Key Issues and Planned Actions 2.1 Sustainability and Transformation Partnership (STPs) update

Progress continues to be made in relation to the Sustainability and Transformation Partnership (STP) with Alan Foster providing leadership on the planning to merge the three Cumbria and North East STPs and to ensure a new identity and focus. An oversight group is being brought together to take forward governance arrangements for the STP. The work on the Better Health Programme remains relevant and further effort is being put into the transition to STP. Collaboration to sustain clinical services for the future with a focus on health services in the Tees Valley is still a priority for the Trust working closely with representatives from South Tees Hospitals NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust. This is being progressed via the Committee in Common, which last met on 11 December 2017, with further meetings scheduled on a regular basis in 2018.

2.2 Cumbria & North East England STP Optimisation of Acute Hospital Services

Moving Towards a Mandate

One of the key work programmes of the STP is to optimise acute hospital services and to support this the region‟s Accountable Officers and Clinical Leaders agreed to meet, in early September 2017, to identify those services that are currently, or likely to become, vulnerable to continuing provision in relation to clinical workforce and quality provision, and consider how these services may be optimally provided within a locality/sub-regional or regional level as most appropriate. A desk top process culminated in a clinical event held in November 2017 attended by at least 70 system and clinical leaders. This resulted in a common list of vulnerable acute hospital services alongside the underlying drivers for change and a broad consensus on a „mandate with a defined scope’ recognising that this will be a high level direction of travel and not a comprehensive detailed plan.

Identifying and gaining agreement on a collective list of vulnerable services across the full region is the start of the process. Engagement with local authorities, Health and Wellbeing Boards and key stakeholders will take place led by CCG Accountable Officers/Medical Directors/CCG Clinical Leads.

Draft

2

2.3 NHS Improvement Quarterly Review Meeting 11 December 2017

The NHS Improvement relationship team meets quarterly with the Executive Directors,

the purpose of these meetings is for a meaningful conversation to be held about the current situation of the trust, the key challenges being faced, how these might be addressed and a review of the progress the trust has made against these.

A meeting was held on 11 December 2017 where the agenda focussed on the Trust‟s

current financial performance, specifically in respect to Single Oversight Framework Segmentation; and future support requirements.

NHS Improvement recognised, on the whole, the excellent performance of the Trust with

regard to quality of care, operations and change although work and regular meetings will continue over the coming months regarding financial performance.

2.4 Winter Funding and Resilience

Further funding for the NHS was announced as part of the autumn statement. Although not all “new” money, £350m has been made available for winter pressures across the country. The Trust submitted a bid against the national allocation to support the frail elderly pathway; the Clinical Commissioning Group submitted a bid on extending primary care hours and Tees Esk and Wear Valley Trust a bid on Enhanced CAMHS Crisis Service of which all were successful.

The Trust is currently in the grip of winter pressures although in the period leading up to Christmas the Trust continued to perform well compared to other Trusts nationally. However, like the majority of Trusts in England, the period following Christmas has been very challenging, with persistent surges in activity and resilience beds required to accommodate such, which resulted in a reduction in the 4 hour standard delivery in the first week of January, although this has improved as the month has progressed. The reasons for this are multi-factorial and again mirror the national picture. As expected during this period, the Trust implemented its Winter Management Plan, escalating processes and deploying staffing resources accordingly. A review of non-urgent operative procedures and outpatient activity was undertaken to safeguard core emergency services and concentrate on optimising safety.

Staff responded positively in support of the plan. They should be commended and thanks put on record by the Board of Directors for their resilience and support, putting patients first during this difficult time.

2.5 Influenza

The latest Public Health England (PHE) statistics published on 11 January 2018 show that seasonal flu levels have continued to increase across the UK. The statistics show at the beginning of January there has been a 78% increase in the GP consultation rate with flu like illness, a 50% increase in the flu hospitalisation rate, and a 65% increase in the flu intensive care admission rate. The main strains circulating continue to be flu A (H3N2), A(H1N1) and Flu B. In the last few weeks there have been a number of cases of patients in the Trust who have been reported positive for influenza.

PHE and the Department for Health have launched the „Catch It, Bin It, Kill It‟ campaign. The campaign includes radio, press and digital advertising to inform the public about the steps they can take to protect themselves and reduce spread of the virus by practising good respiratory and hand hygiene. All frontline healthcare workers have been encouraged to take up the offer of the flu vaccine if they haven‟t already, with renewed calls for compulsory vaccination for all frontline NHS staff.

Draft

3

2.6 Care Quality Commission (CQC) Well Led Announced Inspection

Following the planned inspection of „well led‟ by the Care Quality Commission which took place between 19 and 21 December 2017, the Inspectors provided high level feedback acknowledging the clear vision and strategy, the Trusts openness, honesty and transparency, some of the improvements that have made since the last inspection and also the challenges the organisation faces within the local and national NHS agenda. The Trust will receive a draft report in the New Year, and will have a short period of time to review for factual accuracy. Once the final report is received this, along with the rating, will be shared and made publicly available.

2.7 Care Quality Commission (CQC) Appreciative Review with Hartlepool Local

Authority

Hartlepool Local Authority is one of 12 local authority areas taking part in a programme of local system reviews of health and social. These reviews, exercised under the Secretaries of State's Section 48 powers, include a review of commissioning across the interface of health and social care and an assessment of the governance in place for the management of resources. They have been triggered due to concern nationally over the outlying position on delayed transfers of care and how Integrated Better Care Fund monies are used in the system. The review in Hartlepool took place over a 14 week period and involved all stakeholders and users of the service, including the Trust. The review concluded with a report released for appraisal of factual accuracy and a Local Summit for partners being held on Thursday 7 December 2017 where feedback was provided and consideration given to opportunities for improvements. Following this, Hartlepool Local Authority along with partners have developed an action plan, and submitted to the Department Health on behalf of the local system on 11 January 2018. This plan will be formally approved at Hartlepool Health and Wellbeing Board in March.

2.8 North East Chamber of Commerce (NEECC) The Trust has continued to meet with Partners and Key Leaders within NEECC to maximise opportunities to improve processes, communications approaches, benchmarking and workforce impact in the Trust and across the Region.

3. Recommendations

The Board of Directors is asked to note the content of this report. Julie Gillon Interim Chief Executive Draf

t

1



25 January 2018

Executive Summary

Board of Directors Declaration of Interests and Fit and Proper Persons Declaration

Report of the Company Secretary

Strategic Aim and Objective (The full set of Trust Aims can be found at the

beginning of the Board Reports) Putting Patients First; Valuing our People; Transforming our Services; Health and Wellbeing

1. Introduction 1.1 In accordance with Annex 7, of the Trust’s Constitution, the Board of Directors of NHS

Foundation Trusts are required to declare interests that may conflict with their position as a director or non-executive director of the Trust. Interests are to be declared at an open meeting of the Board, minuted as such, recorded in a register which is referred to in the Trust’s Annual Report, and which is available for inspection by the public.

1.2 The ‘fit and proper persons’ standard is part of the requirements of the Health and

Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) which places a duty on NHS Providers not to appoint a person or allow a person to continue to be an executive director or equivalent, or a non-executive director under given circumstances. For existing appointments, assessment of continued fitness for the role must be undertaken on an annual basis, this is to be facilitated by completion of a fit and proper person declaration and recorded in the register.

1.3 A register of the annual declarations is attached at appendix 1.

2. Recommendations 2.1 The Board is requested to:

note the contents of the appended updated register; and

note that the register will be referred to in the Annual Report 2017/18 and will be available for public inspection.

Barbara Bright Company Secretary Draf

t

Declaration of Interest by Chairman, Non-executive and Executive Directors of North Tees and Hartlepool NHS Foundation Trust

Name Directorship including non-executive directorships held in private companies or PLCs (with the exception of dormant companies)

Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS

A position of authority in a charity or voluntary body in a field of social care

Any connection with a voluntary or other body contracting for NHS services

Signed Fit and Proper Person Dec

Mr Paul Garvin Chairman

None None None None Daughter Insolvency Partner at Wardhadaway (Trust’s Legal Advisors)

Mr Brian Dinsdale Non-executive Director

Board Director of the Thirteen Housing Group – from 8 September 2014

None None None None

Mrs Rita Taylor Non-executive Director

None None None None None

Mr Stephen Hall Non-executive Director

Director, Trading Company for North Tees and Hartlepool NHS Foundation Trust

None Shareholder in Regional Training Partners Limited

Trustee, AdAstra Academy Trust, Hartlepool

None

Mr Kevin Robinson Non-executive Director

None None None Consultant with Auriola Consulting (Justice Services)

Mr Jonathan Erskine Non-executive Director

Executive Director of European Health Property Network

None None None Self Employed Research Consultant Honorary Research Fellow Centre for Public Policy & Health, School of Medicine, Pharmacy & Health, Durham University.

Mr Alan Foster Chief Executive / STP Lead

Director, Trading Company for North Tees and Hartlepool NHS Foundation Trust Non-Executive Director of North East and North Cumbria Academic Health Science Network

None None None

Honorary Colonel 201 Field Hospital (Volunteers) Niece employed by GP Federation

Draft








Mrs Julie Gillon Interim Chief Executive


Dr Deepak Dwarakanath Executive Director

None None None Vice president role for Medical/ Educational Charity

None

Mrs Julie Lane Executive Director


Dr Graham Evans Executive Director

None None None Designated Board member for Health Call

None

Mr Alan Sheppard Interim Executive Director


Mr Robert Toole Interim Executive Director

Director of RDT Management Services Limited

None None None None

Mrs Julie Parkes Interim Executive Director

None None None Parish Councillor Ovington Parish Council

None

Mrs Lynne Taylor Interim Executive Director


Mr Peter Mitchell Executive Director

Seconded to North Tees and Hartlepool Solutions LLP as Managing Director

None None None None

Mrs Barbara Bright Company Secretary

None None None None Company Secretary for Optimus Health Ltd (Trading Company of North Tees and Hartlepool NHS FT operating Panacea (Outpatient Pharmacy) Company Secretary for

Draft








North Tees and Hartlepool Solutions Limited Liability Partnership

Draft

1



25 January 2018

Executive Summary

Safety, Quality and Infection Prevention Report

Report of the Director of Nursing, Patient Safety and Quality

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Putting Patients First

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Putting Patients First/Patient Safety

1 Introduction

1.1 The safety, quality and infection prevention report highlights aspects of patient safety and experience along with the healthcare associated infection performance position and ongoing work.

2 Safe

2.1 Patient Falls, October 2017 (104) and November 2017 (119)

2.2 Pressure Ulcers, September 2017 (13) and October 2017 (19)

2.3 Clostridium difficile - The Trust is reporting five Trust attributed cases of Clostridium difficile infections for November 2017 and one case in December 2017.

2.4 MRSA bacteraemia - The Trust is reporting no Trust attributed cases of MRSA bacteraemia for November and December 2017.

2.5 MSSA bacteraemia - The Trust is reporting three Trust attributed cases of MSSA bacteraemia for November 2017 and one case in December 2017, compared with the previously reported three in October 2017.

2.6 E.coli bacteraemia - The Trust is reporting six Trust attributed cases of E.coliinfections for November 2017 and three for December 2017, compared with the previously reported four in October 2017.

2.7 Klebsiella species bacteraemia – The Trust is reporting three Trust attributed cases of Klebsiella species bacteraemia for November 2017 and none for December 2017, (two reported in October 2017).

2.8 Pseudomonas aeruginosa bacteraemia – The Trust is reporting no Trust attributed cases of Pseudomonas aeruginosa bacteraemia for November and December 2017, the last reported case was in July 2017.

2.9 Hand hygiene - The overall Trust compliance scores for hand hygiene for November and December 2017 is 97%; this exceeds the Trust internal target of 95%.

Draft

2

3 Caring

3.1 The Trusts ‘Would Recommend’ for Friends and Family returns decreased to 95.26% for December 2017 from 95.59% in November 2017. The percentage of patients who stated they ‘Wouldn’t Recommend’ increased to 1.44% in December 2017 from 1.26% in November 2017.

4 Effective

4.1 The latest HSMR value is now 99.72 (November 2016 to October 2017) from the rebased 99.52 (October 2016 to September 2017), this new value continues to remain inside the ‘as expected’ range; the national mean is 100. The Trust crude mortality rate for HSMR has decreased to 3.41% from the rebased 3.46%.

4.2 The latest SHMI value is 108.01 (July 2016 to June 2017), this has decreased from the previously value of 109.07 (June 2016 to May 2017), the value maintains the Trust in the ‘as expected’ range. The Trust crude mortality rate for SHMI is now 3.48%.

5 Responsive

5.1 The Trust has received 102 complaints in November 2017, of which 15 were Stage 3 formal complaints (14.71%) and 78 complaints in December 2017, of which 13 were Stage 3 formal complaints (16.67%)

5.2 The Trust’s response rate for stage 3 complaints for October was 100% and for November 2017 is 95%

6 Well-Led

6.1 The registered nurse fill rate has consistently remained above 80% for both day and night duty with all areas adhering to the red rules ensuring maintenance of safe staffing.

7 Care Quality Commission (CQC) Well Led review

7.1 The Trust underwent a planned well led CQC review 19 to 21 December 2017 following the unplanned review which took place in October as part of the revised CQC inspection regime.

7.2 The Trust expects to receive a draft report early in 2018 outlining the findings of the review and the Trusts CQC rating.

8 Recommendation

8.1 The Board of Directors is asked to note the content of the report, the current HSMR and SHMI values and the Trusts quality indicators.

8.2 The Board are asked to note the information in relation to the CQC Well Led Review undertaken in December 2017 and work underway to improve performance.

Julie Lane Director of Nursing, Patient Safety and Quality

Draft

3



25 January 2018

Safety, Quality and Infection Prevention Report


1 Introduction/Background

1.1 The purpose of this report is to inform the Board of Directors of aspects of quality, patient safety and experience along with healthcare associated infection performance.

1.2 The Trust Safety and Quality Dashboard (see appendix 1), utilises the CQC domains of Safe, Caring, Effective, Responsive and Well-Led. The dashboard allows users, to see month on month trending.

Safe

2 Falls data for 2017-18 – In-hospital (data up to 30 November 2017)

2.1 For the reporting periods of October 2017 the Trust has seen 104 falls (73 falls with no Injury, 29 falls with injury no fracture and 2 falls with fracture) and, 119 (86 falls with no Injury, 33 falls with injury no fracture and 0 falls with fracture) during November 2017.

2.2 When benchmarked against April to November 2016 data, the Trust has experienced a total of 36 more falls, 881 (April to November 2017) against 845 (April to November 2016).

2.3 Focused work has been undertaken by the lead nurse for unplanned care, due to the rise in the overall number; areas for improvement have been identified with regard to assessment and onward referral.

3 Pressure Ulcers 2017-18 – In-hospital (data up to 31 October 2017)

3.1 For October 2017 the Trust experienced 19 pressure ulcers of which 16 were grade 2 and above, this has increased from September 2017, where the Trust reported 13 pressure ulcers of which 10 were grade 2 and above.

3.2 When benchmarked against April to October 2016 data, the Trust had experienced a total of 5 more pressure ulcers, 120 (April to October 2017) against 115 (April to October 2016).

3.3 Work is being undertaken to identify any trends in pressure ulcer incidence. Revised documentation has been developed and a new SSKIN daily care plan for pressure ulcer prevention has been rolled out across the trust. Compliance is monitored bi-monthly by audit.

4 Never Events

4.1 There have been no never events in this reporting period.

Draft

4

5 NHS Safety Thermometer (data covering October and November 2017)

5.1 The Trusts overall Harm Free care in October 2017 was 98.53% this has decreased from 98.79% in September 2017. The Trusts overall New Harm increased from 1.21% in September 2017 to 1.47% in October 2017.

5.2 The Trusts overall Harm Free care in November 2017 was 97.34% this has decreased from 98.53% in October 2017. The Trusts overall New Harm increased from 1.47% in October 2017 to 2.66% in November 2017.

5.3 The areas that have influenced the increase of 1.19% in new harms are falls and

catheter acquired urinary tract infection.

6 Healthcare Acquired Infections (data covering November and December 2017)

6.1 Clostridium difficile - The Trust is reporting five Trust attributed cases of Clostridium difficile infections for November 2017 and one case in December 2017, compared with the previously reported one in October 2017. Improvement actions in place are focused around the themes identified in the NHS Improvement report relating to environmental cleanliness, antibiotic stewardship, point of care practices including hand hygiene and clinical leadership. A comprehensive plan is in place and is shared regularly with commissioners and NHS Improvement.

6.2 MRSA bacteraemia - The Trust is reporting no Trust attributed cases of MRSA bacteraemia for November and December 2017, compared with the previously reported one in October 2017.

6.3 MSSA bacteraemia - The Trust is reporting three Trust attributed cases of MSSA

bacteraemia for November 2017 and one case in December 2017, compared with the previously reported three in October 2017.

6.4 E.coli bacteraemia - The Trust is reporting six Trust attributed cases of E.coli

infections for November 2017 and three, compared with the previously reported four in October 2017.

6.5 Klebsiella species bacteraemia – The Trust is reporting three Trust attributed cases

of Klebsiella species bacteraemia for November 2017 and none for December 2017, compared with the previously reported two in October 2017.

6.6 Pseudomonas aeruginosa bacteraemia – The Trust is reporting no Trust attributed

cases of Pseudomonas aeruginosa bacteraemia for November and December 2017. 6.7 Hand hygiene - The overall Trust compliance score for hand hygiene for November

and December 2017 is 97%; this exceeds the Trust internal target of 95%.

Caring

7 Family and Friends Test (FFT) (data up to 31 December 2017)

7.1 The Trusts ‘Would Recommend’ for Friends and Family returns decreased to 95.26% for December 2017 from 95.59% in November 2017. The percentage of patients who stated they ‘Wouldn’t Recommend’ increased to 1.44% in December 2017 from 1.26% in November 2017.

Draft

5

Effective

8 Mortality - Hospital Standardised Mortality Ratio (HSMR)

8.1 The latest HSMR value is now 99.72 (November 2016 to October 2017) from the rebased 99.52 (October 2016 to September 2017), this new value continues to remain inside the ‘as expected’ range; the national mean is 100.

8.2 The Trust crude mortality rate for HSMR has decreased to 3.41% (November 2016 to October 2017) from the rebased 3.46% (October 2016 to September 2017).

9 Mortality - Summary Hospital-Level Mortality Indicator (SHMI)

9.1 The latest SHMI value is 108.01 (July 16 to June 17), this has decreased from the

previously unreported value of 109.07 (June 16 to May 17), the value maintains the Trust in the ‘as expected’ range. The Trust crude mortality rate for SHMI is now 3.48%.

9.2 The Trust crude mortality rate has decreased to 3.48% (July 16 to June 17) from 3.52% (June 16 to May 17).

Responsive

10 Trust complaints performance (data covering November and December 2017)

10.1 The Trust received 102 complaints in November 2017 of which 15 (14.71%) were

stage 3 requiring a formal response from the Chief Executive. In December 2017 the Trust received 78 complaints of which, 13 (16.67%) require a formal response from the Chief Executive.

10.2 The Trust has continued to make improvements in complaint resolution. The complainant is given three choices of how the complaint is dealt with including local resolution, formal meeting within the area or a formal response from the Chief Executive. For April to December 2017, the spilt of all complaints are: Stage 1 – Informal 71.90%, Stage 2 – Formal meeting 9.97%, Stage 3 – Formal response from the Chief Executive 18.13%.

10.3 The Trust’s response rate for stage 3 complaints for October 2017 was 100% and for

November 2017 is 95%

Well-Led

11 Nursing and Midwifery Workforce (data covering November and December 2017) 11.1 Registered Nurse/Midwife day shift fill rates across inpatient areas for the month of

November 2017 was 84.97%with the night duty fill rate for November 2017 being 91.50%.

11.2 Registered Nurse/Midwife day shift fill rates across inpatient areas for the month of December 2017 is 81.61% down from 84.97% in November 2017. The night duty fill rate for December 2017 is 92.02% up from 91.50% in November 2017.

11.3 Variances in percentage fill rates occur for a number of reasons including staff

vacancies, sickness and maternity leave and in some areas higher than planned fill rates due to increased acuity and care needs of the patient group.

Draft

6

12 Staff, Patient Experience and Quality Standards (SPEQS) (data covering November and December 2017)

12.1 For the month of November 2017, there was a total of 10 SPEQS visits conducted (7 in-patient and 3 Outpatient), with an overall SPEQS score of 93.81%, this has increased from 92.95% in October 2017 where 6 visits were conducted (6 in-patient and 0 Outpatient).

12.2 For the month of December 2017, there was a total of 10 SPEQS visits conducted (8 in-patient and 2 Outpatient), with an overall SPEQS score of 93.78%, this has increased from 93.81% in November 2017 where 10 visits were conducted (7 in-patient and 3 Outpatient).

13 Care Quality Commission Well-Led Review

13.1 The Trust underwent a planed well led CQC review 19 to 21 December 2017 following the unplanned review which took place in October as part of the revised CQC inspection regime.

13.2 There were ten reviewers who interviewed a number of staff including the Trust Chairman, Chief Executive, Executive and Non-Executive Directors. The focus being on a number of areas including how the organisation is managed and governed, Quality Improvement and management of risk based on intelligence from engagement meetings, local and nationally held data.

13.3 The Trust expects to receive a draft report early in 2018 outlining the findings of the review and the Trusts CQC rating.

14 Trust Occupancy

14.1 The following table demonstrates the Trusts occupancy throughout the financial year, with the December 2017 occupancy reaching 94.19% with Quarter 3 occupancy being 91.37%.

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Trust actual

89.47% 97.76% 89.20% 88.23% 92.45% 92.63% 87.90% 91.94% 94.19%

14.2 For additional information please refer to the Compliance and Performance Board report.

15 Recommendation

15.1 The Board of Directors is asked to note the content of this report, the current HSMR and SHMI values and the Trust quality indicators.

15.2 The Board are asked to note the information in relation to the CQC Well Led Review undertaken in December 2017 and work underway to improve performance.

Julie Lane Director of Nursing, Patient Safety and Quality

Draft

7

Appendix 1

Draft



25 January 2018

Executive Summary

Maternity Position Statement


1. Introduction

1.1 In November 2017 the government announced a new maternity strategy to reduce the number of stillbirths. The plan sets out the intention of referring to the new NHS Safety Investigator, the Healthcare Safety Investigation Branch (HSIB), all cases of stillbirths early neonatal deaths and severe brain injuries.

1.2 The HSIB will standardise how investigations are undertaken in a bid to ensure

lessons are learned and shared as quickly as possible and therefore improve outcomes.

1.3 The government is also brining forward the ambition to halve rates of stillbirth,

neonatal and maternal deaths and brain injuries from 2030 to 2025.

2. Background

2.1 In April 2017 the Department of Health (DH) introduced NHS Resolutions and an Early Notification Scheme for maternity incidents and maternity contributions.

2.2 The Trust has been reporting Early Notifications since April 2017 which is mandatory within 30 days of the incident. These and all stillbirths are reviewed as part of a panel from the obstetric team, who seek external reviews as required.

2.3 In 2016- 2017 the Trust reported

• Total babies born – 3026 • Stillbirths 17 • Early Neonatal Deaths 5 • Late Neonatal Deaths 0

Of these 77% were booked under consultant care and 33% under midwifery care.

3. Summary of Findings

There were a number of factors noted in regards to these cases including

• Primigravida ( first pregnancy ) 35% • Substance Misuse 12% • Late Bookers 6% • Known Intrauterine growth restricted 12% • Significant Maternal Morbidity 24 %

Draft

• Poor Attenders 6% • Multiple Admissions 0% • Smokers 59% • History of recurrent Reduced fetal

Movements in this pregnancy 24%

All stillbirth cases were in the antenatal period with only one case being identified as likely to be avoidable.

In 2017-18 year to date 7 stillbirths have been reported which is a significant reduction on the previous year.

Reduction of stillbirths, brain injuries and improved outcomes for mother and baby are primary focuses of the Local Maternity System which was established in March 2017 following publication of the Better Births document in 2015

4. Recommendations

The Board of Directors is asked to note the revised national strategy to reduce stillbirth, neonatal and maternal deaths and brain injuries from 2030 to 2025.

The Board is asked to note the requirement for Early Notification to NHS resolutions The Board is asked to note the findings in regard to stillbirths and neonatal deaths in 2016-2017 and the significant reduction year to date in reported stillbirths within the organisation.

Julie Lane Director of Nursing, Patient Safety & Quality

Draft



25 January 2018

Executive Summary

Maternity Position Statement


1. Introduction

1.1 In November 2017 the government announced a new maternity strategy to reduce the number of stillbirths. The plan sets out the intention of referring to the new NHS Safety Investigator, the Healthcare Safety Investigation Branch (HSIB), all cases of stillbirths early neonatal deaths and severe brain injuries.

1.2 The HSIB will standardise how investigations are undertaken in a bid to ensure lessons are learned and shared as quickly as possible and therefore improve outcomes.

1.3 The government is also brining forward the ambition to halve rates of stillbirth,

neonatal and maternal deaths and brain injuries from 2030 to 2025.

2. Background

2.1 In April 2017 the Department of Health (DH) introduced NHS Resolutions and an Early Notification Scheme for maternity incidents and maternity contributions. The Early notification of maternity incidents asked all trusts to report all maternity incidents that occur on or after 1 April 2017 which are likely to result in severe brain injury, defined as:

Babies born at term (≥37 completed weeks of gestation), following labour, with a severe brain injury diagnosed in the first seven days of life with one or more of the following:

• Diagnosed with grade III hypoxic ischaemic encephalopathy (HIE); • Actively therapeutically cooled; • Have all three of the following signs: decreased central tone; comatose;

seizures of any kind

2.2 In the same year NHS Resolutions published a ‘Five years of Cerebral palsy Claims, A thematic review of NHS Resolution Data. This paper identifies that ‘Overall the NHS is the safest healthcare system out of 11 western countries and giving birth in England is generally very safe. Within England, in 2015, there were 664,777 live births and the trend of reducing rates of stillbirths and neonatal deaths continued, with 3.93 stillbirths per 1000 total births and 1.71 neonatal deaths per 1000 live births. These improvements occurred despite increasing obesity rates, increasing average maternal age and the highest recorded number of live births to women born

Draft

outside of the UK (27.5%)’. They do however acknowledge that avoidable errors within maternity services still occur.

2.3 The Trust has been reporting Early Notifications since April 2017 which is mandatory

within 30 days of the incident. These and all stillbirths are reviewed as part of a panel from the obstetric team, who seek external reviews as required.

An annual review is undertaken of all

• Stillbirth – no signs of life after 23+6 weeks • Early neonatal death – death within 7 days • Late neonatal death – death 7-28 days

In 2016- 2017 the Trust reported

• Total babies born – 3026, (Not including fetal death before 23+6 weeks; in-utero transfers; known fetal abnormalities, birth weight <500g as per CMACE report).

• Stillbirths 17 • Early Neonatal Deaths 5 • Late Neonatal Deaths 0

Of these 77% were booked under consultant care and 33% under midwifery care.

3. Summary of Findings

There were a number of factors noted in regards to these cases including

• Primigravida ( first pregnancy ) 35% • Substance Misuse 12% • Late Bookers 6% • Known Intrauterine growth restricted 12% • Significant Maternal Morbidity including Gestational Diabetes,

BMI 48 • Poor Attenders 6% • Multiple Admissions 0% • Smokers 59% • History of recurrent Reduced fetal

Movements in this pregnancy 24%

All stillbirth cases were in the antenatal period with only one case being identified as likely to be avoidable. This case was investigated as a serious incident and is being managed through NHS resolutions.

In 2017-18 year to date 7 stillbirths have been reported which is a significant reduction on the previous year.

Reduction of stillbirths, brain injuries and improved outcomes for mother and baby are primary focuses of the Local Maternity System which was established in March 2017 following publication of the Better Births document in 2015

Draft

3.1 The Board of Directors is asked to note the revised national strategy to reduce stillbirth, neonatal and maternal deaths and brain injuries from 2030 to 2025.

The Board is asked to note the requirement for Early Notification to NHS resolutions

3.2 The Board is asked to note the findings in regard to stillbirths and neonatal deaths in 2016-2017 and the significant reduction year to date in reported stillbirths within the organisation.

Julie Lane Director of Nursing, Patient Safety & Quality

Draf

t

1



25 January 2018

Executive Summary

Capital Programme Performance 2017/18

Report of the Director of Estates & Facilities Presented by the Director of Finance (Interim)

Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports)

Manage our relationships

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports)

Finance

1. Introduction 1.1 The 2017/18 capital programme allocation was agreed at £21.9m comprising £6.0m

internally generated depreciation, £14.7m advanced loan for the Major Engineering Infrastructure Replacement Scheme, £1m PDC for the Integrated Urgent Care Centres and £150K donated funds. The NHS Improvement Compliance Framework requires that a minimum of 85% and a maximum of 115% of the original capital allocation should be spent on a monthly basis. Only goods and services that have been received or invoiced may be counted as expenditure. At the end of Q3, expenditure (invoices and accruals) was £8.7m, which is 54% of the Trust’s planned spend of £16.0m YTD (end of Q3).

A further delay to the progression of the energy centre project has resulted in the anticipated current financial year spend for the project now being limited to £9m. The £5m remaining spend for the energy centre project will be in 2018/19. The overall anticipated capital programme spend for the 2017/18 year has now reduced to £15.3m.

2. Key Issues & Planned Actions 2.1 The Major Engineering Infrastructure Replacement Scheme is progressing well and

costs remain below budget allocation. The first phase of work involving the upgrade of the electrical infrastructure is complete with the electrical switchgear installed and energised within the new substations. The second phase of work concerns the construction of a new energy centre and full planning consent and building control approval have been received. Design work was completed last year and tender invitations were issued in October 2016 with tenders being returned in January 2017. Evaluations and clarifications took place in January and February and a recommendation was made to the Project Board in March 2017 to award the contract to NG Bailey Limited. Following expiry of the compulsory standstill period and without any challenge against the award, NG Bailey Limited were advised of their appointment as principal contractor for the scheme and the construction work commenced in July 2017. Work is progressing with a 12 week delay due to NG Bailey Limited changing their building and civil works sub-contractor. NG Bailey Limited continue to work to

Draft

2

reduce the overall time delay. However, this is anticipated to have the effect of reducing the current financial year spend for the project from £12m to £9m.

Completion of the new energy centre is anticipated to be Autumn 2018, with de-

commissioning of the old boiler house and demolition of the old boiler house chimney anticipated to be completed by the end of March 2019. The anticipated combined outturn cost for the electrical infrastructure project and the energy centre remains consistent at £22m.

2.2 Business cases are nearing completion for the infrastructure replacement projects to replace the fire alarm system and lift replacement on the UHNT site. Competitive bids have been returned from multiple bidders for the fire alarm replacement to improve cost and time certainty within the business case submission that will be presented to the Capital Management Group for a decision in January 2018. The UHNT lift replacement business case has followed the same process and is anticipated to be submitted for a decision in February 2018.

2.3 The significant elements of the programme to comment upon are:

• Financial expenditure was aligned to the annual programme and capital cash flow projections/expenditure is behind plan with respect to the annual financial forecast.

• Completed schemes have been within overall planned programme end timescales, budget allocations with good outcomes and positive feedback.

3 Recommendation

3.1 The Board is requested to receive this report and note the position on capital schemes up to 31 December 2017.

Prepared by Peter Mitchell Director of Estates and Facilities Reviewed and Presented by R D Toole Director of Finance (Interim) Draf

t

3



25 January 2018

Capital Programme Performance 2017/18

Report of the Director of Estates and Facilities Presented by the Director of Finance (Interim)

1. Introduction/Background 1.1 To provide an update as at 31 December 2017 (Quarter 3) on the progress of

delivering the 2017/18 capital programme.

2. Main content of report 2.1 The four work-streams of Medical Equipment, ICT, Service Development and Estates

Backlog Maintenance have performed as anticipated in Quarter 3. A narrative summary of each work-stream is shown in Appendix 1.

2.2 Significant work has been undertaken on the Major Engineering Infrastructure

Replacement Project and the programme of work has progressed well. There is currently a 12 week delay to the programme due to NG Bailey Limited changing their building sub-contractor. Work is underway to reduce this delay. However, this is anticipated to have the effect of reducing the current financial year spend for the project from £12m to £9m.

2.3 The Estates Backlog Maintenance programme has continued to plan with

improvements being made to the patient environment under the ward decant programme, as well as improving infection control measures by installing additional wash hand basins, upgrades to dirty utility rooms and ward storage.

3. Conclusion/Summary

3.1 The significant elements of the programme to comment upon are:

Financial expenditure is not in-line with the annual programme. The Major

Engineering Infrastructure Replacement scheme is progressing however with a 12 weeks allowable and recoverable delay due to NG Bailey Limited changing their building and civils sub-contractor, work is underway to reduce this delay ensuring August 2018 end date is delivered. However, this is anticipated to have the effect of a variation to planned phasing of work in progress milestone payments reducing the current financial year spend for the project from £12m to £9m.

3.2 The overall financial summary for the period to 31 December 2017 is presented at

Appendix 2.

4. Recommendation 4.1 The Board is requested to receive this report and note the position on capital schemes.

Prepared by Peter Mitchell Director of Estates and Facilities

Draft

4

Reviewed and Presented by R D Toole Director of Finance (Interim)

Draft

5

Appendix 1 - Work Stream Reports 1. Medical Equipment 1.1 Four new Diathermies and fifteen new patient trolleys have been purchased to replace

old equipment in the Endoscopy unit. 1.2 A replacement Biopsy machine and Ultrasound machine have been purchased for the Breast Screening Unit. 1.3 Orders have been placed for replacement patient monitors in the main theatre

suite at UHNT. This will achieve compliance with the Royal College of Anaesthetists’ recommendations that patients are continually monitored between Induction rooms, operating theatre and recovery area.

1.4 Two replacement ultrasound machines have been installed in theatres for use by the anaesthetists. 1.5 Two replacement cement removal systems have been purchased to replace the older models currently in use in theatres. 1.6 A new operating table has been installed in theatres North Tees. 1.7 5 new washer/ driers have been delivered for use in community dental clinics. 1.8 3 non-invasive ventilators have been delivered for ITU and will be commissioned for

use during week commencing the 8 January 2018 as will three ventilators for the respiratory wards. Additionally, 3 new ventilators for the respiratory wards have been purchased.

2. Information Communication & Technology 2.1 The Capital ICT allocation for 2017/18 was split into three main streams, one of which

supports the wider EPR programme for mobile working and the second and third are to replace “legacy” systems (i.e. those systems approaching “end of life”), to ensure continuity of normal business functions within ICT.

2.2 The entire wired network has been completely replaced on the North Tees site giving

greater bandwidth capability. The network at the Hartlepool site is now undergoing upgrade, with 75% of the end point switches having been replaced and the Core equipment replacement scheduled for February. Wi-Fi connections have been updated in the majority of clinical areas at UHNT, with upgrading in OPD being currently in progress. Non clinical areas such as corridors and restaurant will be completed in the next financial year.

2.3 Work continues on the replacement of “legacy” telephones and a project is due to start

to replace dedicated fax machines with an electronic faxing system. New video-conferencing equipment has been installed in the two boardrooms, providing the latest technology, and a centralised multi point VC system is just about to “go live”.

3. Digital Strategy – Electronic Patient Record 3.1 The delivery of the Trust’s Digital Strategy continues. The EPR project team has some

key deliverables throughout 2017/18 and 2018/19. These include implementing the functionality to allow for the new emergency dataset to be collected and submitted and the introduction of active clinical notes, allowing for the inclusion of clinical information to be input directly into the patients EPR, thus reducing the reliance on paper records. This work will commence within Accident and Emergency during Q4 2017/18. In Q1

Draft

6

(2018/19), the Trust will start electronic prescribing within TrakCare on inpatient wards. This will require full commitment from both clinical and admin staff in order to provide the relevant support. The process will be phased in gradually and a timescale of six months for completion is anticipated.

3.2 Work is progressing well on the production of the Global Digital Exemplar Fast Follower (GDEFF) funding agreement. The first visit to our GDE partner site is taking place on 5 January 2018. This will result in plans and governance arrangements being agreed. As part of the funding approval process, NHS Digital will be visiting the Trust in the forthcoming weeks to discuss our digital ambitions with senior leaders across the organisation.

3.3 The latest audit report on the continuous testing around the Digital Programme

Management controls found that the governance, risk management and control arrangements provided a good level of assurance and that the risks identified are being managed effectively. A high level of compliance with the control framework was also found to be taking place.

4. Service Developments 4.1 Improvements have been undertaken in the Breast Screening Unit and Breast Clinic to

provide the following facilities:-

• An additional waiting area in order to segregate symptomatic and screening ladies. This achieves compliance with the requirements of the National Breast Screening Programme and allows increased flexibility in the allocation of symptomatic clinics.

• Re-provision of manager’s office, thus releasing space for additional waiting area.

• Consultant office which has provided private workspace for the increased team of Consultant Radiologists and Consultant Practitioners. This is a new facility which will aid recruitment and retention of staff.

• Improvements to doctors base within the breast OPD, and installation of interactive VDU to monitor patient flow and status. These improvements increase the efficiency of the consulting rooms and help with patient flow.

4.2 Some high level planning was undertaken and a draft business plan prepared for the

potential refurbishment and expansion of the Rapid Access Lounge and inter-related relocation of the Wheelchair Services Department. It is envisaged that these will be considered further when capital service development funds are more readily available.

4.3 High level planning has been undertaken to inform a business case for the potential

establishment of a hand surgery unit at UHH.

5. Estates Programme 5.1 Energy Centre Replacement

The contract terms and conditions have been formally signed off by the Trust and N.G. Bailey Limited. The order for the works has been raised and regular monthly invoices for the work are to be issued to the Trust from NG Bailey Limited.

All monthly payment valuations are independently validated and certified by Currie and Brown Limited who are filling the role of Cost Advisor to the Trust on this project.

Draft

7

NG Bailey Limited (NGB) decided to replace their building sub-contractor in August 2017. Interserve Limited are now carrying out the major excavations, civil works and building elements of the project. A revised detailed project plan has been developed by NG Bailey Limited. Whilst this change of sub-contractor is anticipated to delay the project completion by up to 12 weeks, NG Bailey Limited continue to work to reduce this delay to the overall completion date and reduced year end spend. The current position is that the latest programme (without mitigations) predicts a year end spend of £9m against a planned year end spend of £12m.

These figures and projections are subject to the effect of winter weather and overall progress on site.

Regarding progress on site, the NGB team have returned to site 1 week early from the Christmas break. Further plans are in place over the coming months to help reduce the overall programme delay. The major excavation and soil removal from site works are now complete until the later landscaping stage of the project. To date, over 2,153 wagon trips have taken place removing over 86,000 tonnes of soil from site. Excavation works to form the below ground tunnel routes that will link the energy centre to the existing hospital street are now complete. Work continues to form the second above ground service link to the Hospital along the side of the former day nursery and extending to the Tower block. The concrete pour for the energy centre basement slabs and basement walls have now been largely completed. The recent rain has created a build-up of water within the lower sections of the site. Water pumps are now in place to allow progress on site. All water pumped off site is strictly monitored and recorded in accordance with the requirements of Northumbrian Water discharge permit.

The contractor’s hours of work on site are limited by Planning Constraints to 8am till 6pm Monday to Friday and 9am till 1pm on Saturday’s.

NG Bailey Limited have arranged a letter drop to provide our potentially affected local neighbours with a point of contact for any issues that are raised during the works. The installation of 125kW of solar panels to the Podium roof is now complete. Approval to bring the solar panels into operational use is anticipated to be provided by Northern Power grid by 12th January 2018. This is the first phase of solar panel installation which will be followed by a further 125kW of solar panels that will be installed on the new energy centre roof during the summer of 2018. Once all this work has been completed it is anticipated that 10%-15% of the UHNT site’s electricity demand will be powered by solar renewable energy.

5.2 Other Infrastructure Replacement projects include:-

5.2.1 The fire alarm replacement scope of works, specification and tender

documentation has now been completed. An OJEU compliant procurement

process commenced on the 29 September 2017.

Tender responses have been received via Cardea from 5 bidders. The tender bid prices ranged from £1.2m+VAT (£1.44m incl. VAT) to £1.6m +VAT (£1.8m incl. VAT).

Draft

8

These bids have been reviewed by the external advisor team for technical and commercial compliance and the Trust Project Team (including the Trust Fire Officer) completed the quality evaluation assessment on the 12 December 2017. A round of clarification questions to the bidders was issued by the Trust on the 20 December 2017. Bidder responses have now been received by the Trust and a final review of the clarification responses will take place. It is intended that a business case will be presented to the Capital Management Group for a decision in January 2018.

5.2.2 The project team has commissioned a report from external engineering lift

specialist advisors to review the condition of the existing UHNT lifts and to provide a recommendation on the replacement/refurbishments that are necessary to improve the reliability and effectiveness of the UHNT lifts. Preparation of the tender documentation has been completed and an OJEU compliant procurement process commenced week commencing 11 December 2017. The scope of works includes two bed evacuation lifts within Tower block. It is anticipated that competitive bids will be returned for inclusion within a business case and presented to the Capital Management Group for a decision in February 2018.

5.2.3 A new Entinox and nitrous oxide gas replacement manifold for the UHNT site

has being installed to replace the end of life plant and provide resilience for medical gas services.

Further quotations for the replacement of the medical air plant are being

obtained via the procurement department and it is anticipated that competitive bids will now be returned for inclusion within a business case to be presented to the Capital Management Group for a decision in Quarter 4 (previously end of January 2018).

5.3 Backlog maintenance

5.3.1 The ward decant programme was completed in Q3. A programme of work was

undertaken on wards 26,27,31,40,41,42,24,25,29,36,and 37. In addition to deep cleaning, upgrading work was undertaken in most areas to include “Dementia-friendly” decoration, signage and clocks, additional wash hand basins and LED lighting and improvements to dirty utility rooms and storage facilities.

5.3.2 A new replacement fire alarm system has been installed in the Middlefield Centre

and residential/office blocks. This is to replace the existing obsolete fire alarm system for which spare parts are no longer available.

5.3.3 The Tower Block lower ground corridor, providing patient internal access to

Endoscopy, Lung Health and Urology Departments has been upgraded, including partial flooring replacement, redecoration, LED lighting, wall protection and installation of CCTV.

5.3.4 Following positive feedback from previous work undertaken, further

improvements have been made in the A&E Department, with LED light fittings being installed in all of the consulting/examination rooms.

5.3.5 Within the Medical Physics Department at UHH, a new replacement radio

pharmacy isolator has been installed within refurbished accommodation. This equipment provides a clean environment in which to prepare radiopharmaceuticals and also provides protection for the handler against radiation. The majority of radiopharmaceuticals are used for diagnostic imaging procedures.

Draft

9

5.3.6 UHH General Out patients - approximately one third of the roofing has been

replaced. This has addressed the worst area where leaks were numerous and frequent. Significant capital investment is required to replace areas of roofing throughout the estate.

5.3.7 The accommodation for the Single Point of Access Team (SPA) at UHH has

been extended to provide additional capacity for this expanding team. The team provides clinical triage and administrative support to 18 community nursing services and the bed bureau. They are co-located with the local authority Earlier Intervention Team.

5.3.8 Various improvements have been undertaken to increase compliance with the

Disability Discrimination Act (DDA). These improvements include anti-slip stair nosing, tactile paving and drop-kerbs at various locations throughout the estate and the installation of additional hearing loops and nurse call pull cords.

5.3.9 The end of life x-ray machine within room 1 at the UHNT has been replaced.

During the down time the room has been refurbished to improve the patient environment. The new room layout and machine arrangement has improved patients flow through the room.

Draft

10

Appendix 2 North Tees and Hartlepool NHS Foundation Trust Capital Programme 2017/2018 - as at 31 December 2017

Capital Plan/Actual/Commitment Report December 2017

Budget allocation

Orders raised

and paid on capital

branch points

Payroll Revenue to

Capital transfers

Current month

Accruals

Invoices, payroll

and Accruals Total YTD

Outstanding Orders

Total annual commitment

Sum of Uncommitted

/ (Over-committed)

Estates 205,000 49,145 0 2,929 -8,092 43,982 26,240 70,222 134,778

598,500 305,921 0 5,042 164,336 475,299 137,345 612,643 -14,143

356,500 273,011 0 0 33,201 306,212 55,966 362,178 -5,678

11,739,000 3,676,463 0 0 23,505 3,699,968 6,351,271 10,051,239 1,687,761

2,981,000 922,535 315,699 0 424 1,238,658 840,526 2,079,184 901,816

45,000 14,562 0 0 6,292 20,854 19,289 40,143 4,857

Estates Total 15,925,000 5,241,637 315,699 7,970 219,667 5,784,973 7,430,636 13,215,609 2,709,391 IT 230,000 0 0 96,485 0 96,485 0 96,485 133,515

793,000 239,554 0 67,122 37,480 344,156 68,410 412,566 380,434

2,464,000 214,001 391,990 0 768 606,760 669,871 1,276,630 1,187,370

0 0 0 0 0 0 0 0 0

IT Total 3,487,000 453,555 391,990 163,607 38,248 1,047,400 738,281 1,785,681 1,701,319

Medical Equipment 2,307,000 918,898 0 -2,929 286,242 1,202,212 785,520 1,987,731 319,269

Medical Equipment Total 2,307,000 918,898 0 -2,929 286,242 1,202,212 785,520 1,987,731 319,269 Service Development 0 -1,818 0 0 0 -1,818 0 -1,818 1,818

0 251 0 0 0 251 45 296 -296

0 48,589 0 0 0 48,589 7,999 56,589 -56,589

0 103,323 0 10,215 0 113,538 0 113,538 -113,538

0 368 0 0 4,679 5,047 7,084 12,131 -12,131

Service Development Total 0 150,713 0 10,215 4,679 165,607 15,128 180,735 -180,735 Other Revenue to Capital Transfer 0 0 0 351,734 0 351,734 0 351,734 -351,734

0 0 0 -52,398 56,920 4,522 0 4,522 -4,522

Other Revenue to Capital Transfer Total 0 0 0 299,336 56,920 356,257 0 356,257 -356,257

Donated 150,000 8,230 0 161,950 0 170,179 0 170,179 -20,179

Donated Total 150,000 8,230 0 161,950 0 170,179 0 170,179 -20,179

(blank)

0

(blank) Total 0

21,869,000 6,773,032 707,689 640,150 605,756 8,726,627 8,969,565 17,696,193 4,172,807 Draft

11

Source of Funding £'000

Internally Generated Depreciation 6,021

Loan - Energy Centre 14,698

Loan - Clinical Strategy (not submitted yet) - STP 0

PDC for IUCS 1,000

Donated Funds Original Allocation 150

Subtotal: Per Board Report 21,869

Additional Charitable Funds (donations during year) 0

Total Allocation 21,869

Draft

12

Capital Forecast Report December 2017

Invoices, payroll and

Accruals Total YTD

Forecast Jan-18

Forecast Feb-18

Forecast Mar-18

Total actual plus

forecast

Estates Estates - Backlog Maintenance 475,299 79,983 2,045 12,273 569,599

Estates - Compliance 306,212 60,431 1,000 1,000 368,643

Estates - PLACE 20,854 2,340 0 0 23,194

Estates - Energy Centre 3,699,968 1,000,273 1,250,000 1,250,000 7,200,241

Estates - Infrastructure Upgrade 1,238,658 88,711 36,000 54,544 1,417,912

Estates 43,982 8,435 0 0 52,417

Estates Total 5,784,973 1,240,172 1,289,045 1,317,817 9,632,007

IT ICT 344,156 167,370 0 43,501 555,027

ICT - PAS/EPR 606,760 932,208 45,000 424,310 2,008,277

IT Refresh 96,485 0 0 133,515 230,000

SHOULD BE ON 1383 0 0 0 0 0

IT Total 1,047,400 1,099,578 45,000 601,326 2,793,305

Medical Equipment Medical Equipment 1,202,212 910,463 0 8,400 2,121,074

Medical Equipment Total 1,202,212 910,463 0 8,400 2,121,074

Service Development Service Development -1,818 0 0 0 -1,818

Service Development - Clinical Strategy 251 0 0 0 251

Service Development - Middlefield Centre 48,589 0 0 0 48,589

Service Development - Urgent Care Centre Phase 1 113,538 0 0 0 113,538

Service Development - Urgent Care Centre Phase 2 5,047 0 0 0 5,047

Service Development Total 165,607 0 0 0 165,607

Other Revenue to Capital Transfer Other Revenue to Capital Transfer 351,734 0 0 83,265 434,999

To be recoded at M10 4,522 0 0 0 4,522

Other Revenue to Capital Transfer Total 356,257 0 0 83,265 439,522

Donated Donated 170,179 0 0 0 170,179

Donated Total 170,179 0 0 0 170,179

8,726,627 3,250,213 1,334,045 2,010,808 15,321,693

Draft



25 January 2018

Financial Performance Report as at 31 December 2017

Report of the Director of Finance (Interim)

1. Introduction

1.1 Trust’s financial performance for December 2017 (Month 9).

Use of Resources

The Trust has received a year to date UoR rating of 3, calculated as follows:

2. Key Issues & Planned Actions

Headline Financial Position

2.1 The Trust’s month 9 December position is a deficit of £(2.6)m, which is £(1.4)m behind trust profiled budget (excl. STF) and NHSI submitted plan by (£2.5)m.

2.2 The year to date position is a deficit of £(18.5)m which is £(10.3)m behind Trust profiled plan (excl.STF) and NHSI submitted plan by £(16.0)m. This position

Plan Actual

Capital service cover rating 1 4

Liquidity rating 1 1

I&E Margin rating 1 4

Distance from financial plan 1 4

Agency rating 2 1

Overall 1 3

NHSI

Plan

(£'000s)

Trust

Internal

Plan

(£'000s)

Actual

(£'000s)

Variance -

NHSI Plan

(£'000s)

Variance

- Trust

Internal

Plan

(£'000s)

NHSI

Plan

(£'000s)

Trust

Internal

Plan

(£'000s)

Actual

(£'000s)

Variance

- NHSI

Plan

(£'000s)

Variance -

Trust

Internal

Plan

(£'000s)

Income excluding STF 23,135 23,298 22,783 (352) (516) 208,147 212,316 207,342 (805) (4,974)

Total Pay Expenditure 15,936 16,827 17,031 (1,095) (204) 143,502 150,719 150,690 (7,188) 29

Total Non Pay Expenditure 6,693 6,783 7,478 (785) (695) 60,234 61,716 67,467 (7,233) (5,751)

EBITDA 506 (312) (1,726) (2,232) (1,414) 4,411 (119) (10,815) (15,226) (10,696)

Post EBITDA Items 563 897 844 (281) 53 6,952 8,071 7,674 (722) 397

Trading Surplus/(Deficit) (57) (1,208) (2,570) (2,513) (1,361) (2,541) (8,190) (18,489) (15,948) (10,299)

Optimus Health LTD 0 (7) 2 2 9 0 (60) (60) (60) 0

0

Total Consolidated

Surplus/(Deficit) excl. STF

(57) (1,215) (2,568) (2,511) (1,352) (2,541) (8,250) (18,549) (16,008) (10,299)

STF Income 688 688 0 (688) (688) 4,470 4,470 0 (4,470) (4,470)

Total Consolidated

Surplus/(Deficit) incl. STF

631 (527) (2,568) (3,199) (2,040) 1,929 (3,780) (18,549) (20,478) (14,769)

North Tees & Hartlepool

NHS Foundation Trust -

Statement of

Comprehensive Income -

Month 8

Current Month £000's Year to Date £000's

Draft

2.3

2.4

2.5

2.6

2.7

2.8

2.9

assumes no achievement of planned Sustainability and Transformation Funding (STF) income.

Optimus has an in month surplus of £2k and a YTD deficit of £(60)k, with the combined Group accounts an in month deficit of £(2.6)m and YTD deficit of £(18.5)m.

Operating Income (excluding STF)

Income is behind plan by £(5.0)m YTD at Month 9, which is a further adverse position of £(0.5)m compared to the previous month.

NHS Clinical Income is the key area of underperformance on Income year to date. The main issues include non-delivery of the planned commercial income generation (CRT); under delivery against a centrally aligned target, relating to the MSK impact on the Orthopaedic elective programme; and demand and income in A&E being lower than anticipated.

Expenditure - Pay

The year to date Pay Expenditure is lower than plan by £29k, though adverse in-month by £204k. Agency expenditure for the year now totals £3.1m (including locums) and Bank expenditure totals £3.1m. This expenditure is largely offset by significant underspends on substantive Nursing and Midwifery staff. Month 9 Pay Expenditure was £323k higher than the Month 1-8 average. This includes for winter costs.

Expenditure - Non Pay

Year to date operational Non-Pay Expenditure is adverse by £5.8m. CRT aligned to Non Pay is behind plan by £4.1m (including centrally held unidentified CRT). General Supplies and Services are adverse by £0.7m, which represents a £0.1m improvement in month, whilst drugs are adverse by £0.9m, worsening by £73k in month.

STF Income

STF income is behind plan by £4.5m. As the year to date financial target has not been met no STF income is assumed to have been achieved.

Cash

2.10 The Trust’s cash balance is £12.9m which is £8.3m behind plan.

Nov-17

NHSI

Plan

Nov-17

actual

Nov-17

Variance

Dec-17

NHSI

Plan

Dec-17

actual

Dec-17

Variance

£'000s £'000s £'000s £'000s £'000s £'000s

21,596 17,282 (4,314) 21,248 12,917 (8,331)Draft

Balance Sheet – Statement of Financial Position

2.11 Assets - There have been additions of £3.6m within the month on non-current assets, total expenditure year to date is £8.7m this is £(8.9)m behind plan. Receivables and accrued income have decreased slightly in month. Negotiations to agree and clear significant inter NHS balances with South Tees NHS FT and local CCG’s are on-going and still not resolved.

2.12 Inventories are valued at £8.4m at the end of Month 9. (Stock-take being undertaken in January 2018).

2.13 Liabilities - Trade payables are £16.1m, which is a decrease of £0.6m in month and is £0.8m less than the opening balance of £16.9m. This decrease is due to a deliberate increase in creditor payments in December 2017 in order to reduce the aged creditor position.

2.14 The Trust has drawn £10.0m against its planned capital loan agreement - £4.0m in 2016/17 and £6.0m in 2017/18

Capital

2.15 As at Month 9 the Trust has YTD spent £8.7m against the YTD plan of £16m.

3. Recommendation

3.1 Note the financial position at the end of December 2017.

R D Toole Director of Finance (Interim)

Draft

Operational Finance ReportReporting the financial position covering the period

1st April 2017 to 31st December 2017

Draft

Executive SummaryThe Trust’s month 9 December position is a deficit of £(2.6)m, which is £(1.4)m behind trust profiled budget (excl. STF) and NHSI submitted plan by (£2.5)m. The year to date position is a deficit of £(18.5)m

which is £(10.3)m behind Trust profiled plan (excl.STF) and NHSI submitted plan by £(16.0)m. This position assumes no achievement of planned Sustainability and Transformation Funding (STF) income.

Operating Income (excluding STF)

Income is behind plan by £(5.0)m YTD at Month 9, which is a further deterioration of £(0.5)m compared to the previous month. NHS Clinical Income is the key area of underperformance on Income year to date.

This position is based on actual income for Months 1 to 8 (Month 1 to 7 data frozen and flex Month 8 data). Income is accrued to forecast levels for Month 9. The main issues are demand and income in A&E and

Urgent Care being lower than anticipated; plus limited delivery of the planned commercial income generation (CRT).

Expenditure - Pay

The year to date Pay Expenditure is lower than plan by £29k, though adverse in-month by £204k. Agency expenditure for the year now totals £3.1m (including locums) and Bank expenditure totals £3.1m. This

expenditure is largely offset by significant underspends on substantive Nursing and Midwifery staff. Month 9 Pay Expenditure was £323k higher than the Month 1-8 average in part due to winter pressures.

Expenditure - Non Pay

Year to date operational Non-Pay Expenditure is adverse by £5.8m. CRT aligned to Non Pay is behind plan by £4.1m (including centrally held unidentified CRT). General Supplies and Services are adverse by

£0.7m, though this represents a £0.1m improvement in month, whilst drugs are adverse by £0.9m, worsening by £73k in month.

STF Income

STF income is behind plan by £4.5m. As the year to date financial target has not been met no STF income is assumed to have been achieved.

Capital

Capital additions year to date are £8.7m with 2017/18 commitments of £9m (forecast of £6.5m i.e. £2.5m of commitments to c/fwd to 2018/19), taking expected capital spend in 2017/18 to £15.3m. The capital

additions plan for 2017/18 is £21.9m.

Assets

Debtors have remained consistent at £22.9m in December.

Liabilities

Liabilities have increased by £1.3m in December due to increase in capital creditors, PDC creditor and revenue accruals.

Cash

The cash balance at the end of December is £12.9m which is slightly behind the cash forecast paper that was briefed at Finance Committee on 30th November 2017 of £14.1m. Weekly cash committee

meetings are in place. Draft

Statement of Comprehensive Income (SoCI)Reporting period: 1st April 2017 to 31st December 2017

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

NHS Clinical Income 253,905 256,746 21,036 20,606 (430) 191,582 188,000 (3,581) 190,589 191,680 1,091

Non NHS Clinical Income 6,689 6,960 547 581 34 5,289 5,165 (124) 6,923 7,085 162

Non Clinical Income (excluding STF) 18,461 20,625 1,715 1,596 (119) 15,445 14,177 (1,268) 18,857 18,750 (107)

Total Income 279,055 284,331 23,298 22,783 (516) 212,316 207,342 (4,974) 216,369 217,515 1,146

Medical And Dental 44,553 46,195 3,854 4,193 (339) 34,632 37,050 (2,418) 35,118 35,596 (478)

Qualified Nursing, Midwifery And Health Visiting 62,999 64,165 5,331 5,212 119 48,067 45,853 2,214 46,322 45,193 1,129

Qualified Scientific Therapeutic and Technical 19,096 19,015 1,568 1,539 29 14,310 13,688 622 14,185 13,515 671

Qualified Healthcare Scientists 6,049 6,594 550 518 32 4,945 4,769 176 5,079 5,069 10

Healthcare Assistants and Other Support Staff 22,834 22,236 1,880 2,128 (248) 16,483 18,412 (1,928) 15,698 18,310 (2,612)

Managers and Infrastructure support 35,839 41,376 3,434 3,429 6 31,070 30,811 259 31,270 30,425 845

Pay CRT 0 (144) 18 0 18 (164) 0 (164) (465) (38) (427)

Vacancy Factor CRT 0 0 0 0 0 (0) 0 (0) (1,125) 0 (1,125)

Other Pay* 258 1,142 192 13 179 1,376 108 1,269 105 104 1

Total Pay Expenditure 191,628 200,580 16,827 17,031 (204) 150,719 150,690 29 146,187 148,173 (1,986)

Drugs 8,331 4,944 412 485 (73) 3,708 4,657 (949) 3,990 4,337 (348)

Clinical Supplies and Services 25,263 26,250 2,215 2,380 (164) 19,702 20,067 (365) 22,009 20,197 1,812

General Supplies and Services 4,200 23,686 1,959 1,849 111 17,816 18,458 (642) 17,010 16,318 692

Purchase of healthcare from other bodies 1,828 2,413 201 290 (89) 1,810 1,882 (73) 796 1,190 (394)

Non Pay CRT 0 (10,414) (437) 0 (437) (4,062) 0 (4,062) 452 (179) 630

CNST 11,034 11,096 925 907 17 8,322 8,166 157 7,468 7,468 (0)

Other Non Pay expense 17,660 7,808 355 415 (60) 3,355 3,171 183 356 1,904 (1,548)

68,316 65,783 5,631 6,326 (695) 50,651 56,402 (5,751) 52,081 51,236 845

High Cost Drugs And Devices 12,312 11,065 1,152 1,152 0 11,065 11,065 (0) 9,858 9,857 1

Total Non Pay Expenditure 80,628 76,849 6,783 7,478 (695) 61,716 67,467 (5,751) 61,939 61,093 846

Total Expenditure 272,256 277,428 23,610 24,509 (899) 212,435 218,157 (5,722) 208,126 209,266 (1,140)

EBITDA 6,799 6,903 (312) (1,726) (1,414) (119) (10,815) (10,696) 8,243 8,248 5

Depreciation 6,135 6,171 514 474 40 4,628 4,266 362 4,566 4,566 0

Impairment 0 0 0 0 0 0 0 0 0 0 0

Interest Receivable (48) 0 0 (6) 6 0 (27) 27 (82) (39) (43)

Interest Payable 482 502 42 35 7 376 250 126 111 114 (3)

PDC 4,088 4,088 341 341 0 3,066 3,185 (119) 2,903 2,903 0

Interest and capital charges 10,657 10,761 897 844 53 8,071 7,674 397 7,498 7,544 (46)

Operating Surplus/(Deficit) (3,858) (3,858) (1,208) (2,570) (1,361) (8,190) (18,489) (10,299) 745 704 (41)

STF Income 6,876 6,876 688 0 (688) 4,470 0 (4,470) 0 0 0

Total Trust Surplus/Deficit 3,018 3,018 (520) (2,570) (2,049) (3,720) (18,489) (14,769) 745 704 (41)

Optimus Health LTD 0 (79) (7) 2 9 (60) (60) 0 4 (69) (73)

Total Consolidated Surplus/Deficit 3,018 2,939 (527) (2,568) (2,040) (3,780) (18,549) (14,769) 749 635 (114)

Key Messages

Income

Clinical activity remains behind plan and 2016/17 levels for most

PODs.

17/18 Commercial income (CRT) targets not being met.

Pay

Pay costs remain in line with planned levels. Agency costs continue

to fall.

Non Pay

Non pay (operating) budgets continue adverse - with unidentified

CRT.

NHSI Annual

Plan (£'000s)

Annual Budget

(£'000s)

Current Month £000's Year to Date £000's 2016/17 M8 £'000

Draft

Appendix 6

Statement of Financial Position (SoFP)Reporting the position as at 31st December 2017

March 2017

Plan

(NHSI) Prev Month Actual Group Actual

£'000s £ 000's £'000s £'000s

Assets

Assets, Non-Current

Intangible Assets, Net 83 64 55 52

Property, Plant and Equipment, Net 121,711 130,375 123,128 126,307

PFI: Property, Plant and Equipment, Net 167 96 97 88

NHS Receivables (Related Party), Non-Current 1,305 2,237 1,418 1,363

Assets, Non-Current, Total 123,266 132,772 124,698 127,810

Assets, Current

Inventories 8,398 7,000 8,378 8,404

Trade and Other Receivables, Net, Current 8,617 4,028 8,151 8,535

Non NHS Trade Receivables, Current 14,577 11,642 14,797 14,369

Cash and Cash Equivalents 20,118 21,346 17,176 12,542

Cash 184 250 110 385

Assets, Current, Total 51,894 44,266 48,612 44,236

Total Assets 175,160 177,038 173,311 172,045

Liabilities

Liabilities Current

Deferred Income, Current (621) (142) (2,659) (2,929) (271)Provisions, Current (424) (720) (233) (232) 1

Creditors and accruals (29,173) (20,619) (34,106) (34,607) (501)

Capital Creditors, Current (807) (1,930) (578) (797) (219)

PFI leases, Current (162) (169) (162) (162) 0

PDC dividend creditor, Current (113) (326) (794) (1,135) (341)

Liabilities Current, Total (31,300) (23,906) (38,531) (39,862) (1,331)

Net Current Assets (Current Assets less Current Liabilities) 20,594 20,360 10,081 4,373

Liabilities, Non-Current

Deferred Income, Non-Current (103) 0 (116) (113)

Loans, Non-Current, non Commercial (4,000) (13,959) (10,000) (10,000)

PFI/LIFT leases, Non-Current (158) (42) (40) (25)

Provisions, Non-Current (1,187) (878) (1,190) (1,184)

Liabilities, Non-Current, Total (5,448) (14,879) (11,345) (11,322)

Total Assets Employed 138,412 138,253 123,434 120,862

Taxpayers' and Other EquityTaxpayers' Equity

Public dividend capital 130,906 130,906 131,905 131,905

Retained Earnings (Accumulated Losses) 5,727 6,053 (10,249) (12,822)

Revaluation Reserve 1,779 1,294 1,779 1,779

Total Taxpayers' And Other Equity 138,412 138,253 123,434 120,862

NHS Debtors Non-NHS

Debtors

NHS Creditors Non-NHS

Creditors

0-30 days 1,336,044 251,872 15,809 3,212,634

31-60 days 648,544 32,612 239,074 3,979,004

61-90 days 724,690 51,744 215,165 2,315,807

over 90 days 6,400,033 832,601 2,526,701 4,632,624

Cash receipted/paid between AP/AR close and month end 0.00 0.00 0.00 -201,479.51

9,109,311 1,168,829 2,996,750 13,938,590

Key Messages

Assets

Capital additions year to date are £8.7m with 2017/18 commitments of £9m (forecast of £6.5m i.e. £2.5m of commitments to c/fwd to 2018/19), taking expected

capital spend in 2017/18 to £15.3m. The capital additions plan for 2017/18 is £21.9m,

Debtors have remained consistent at £22.9m in December.

Cash has reduced by £4.4m in December. There was no further loan drawdown in December.

Liabilities

Liabilities have increased by £1.3m in December due to increase in capital creditors, PDC creditor and revenue accruals.

Financial Metrics

Debtor days have improved by 4 days in comparison to the year to date 2016/17 and creditor days have increased by 12 days. Note the cash position has also

steadily reduced over the same period due to deficits being incurred. Draft

Statement of Cash Flow (SoCF)Reporting period: 1st April 2017 to 31st December 2017

March 2017 October 2017 November 2017

£'000s £'000s £'000s

Surplus/(deficit) from operations (including Optimus) 5,712 (12,943) (15,141)

Non-cash flows in operating surplus/(deficit)

Depreciation and amortisation, total 5,744 3,792 4,266

Impairment losses / (reversals) 0 0 0

Non-cash flows in operating surplus/(deficit), Total 5,744 3,792 4,266

Operating Cash flows before movements in working capital (including Optimus) 11,456 (9,151) (10,875)

Increase/(Decrease) in working capital

Amortisation of PFI credit 0 0 0

On SoFP pension liability - employer contributions paid less net charge to the SOCI 0 0 0

Income recognised in respect of capital donations (cash and non-cash) (98) (158) (170)

(Increase)/decrease in trade and other receivables (2,733) 353 24

(Increase)/decrease in Non NHS Trade Receivables (2,354) (220) 208

(Increase)/decrease in inventories (58) 20 (7)

Increase/(decrease) in deferred income (3,661) 2,051 2,318

Increase/(decrease) in provisions (4,237) (189) (195)

Increase/(decrease) in trade and other payables inc accruals and capital creditors 6,258 4,688 5,398

Increase/(decrease) in other liabilities (899) 0 0

Other movements in operating cash flows 0 0 0

Net cash generated from / (used in) operations 3,674 (2,607) (3,298)

Cash flows from investing activities

Interest received 47 21 27

Purchase of financial assets 0 0 0

Proceeds from sales of financial assets 0 0 0

Purchase of intangible assets 0 0 0

Proceeds from sales of intangible assets 0 0 0

Purchase of property, plant and equipment and investment property (10,291) (5,091) (8,727)

Proceeds from sales of property, plant and equipment and investment property 0 0 0

Receipt of cash donations to purchase capital assets 98 158 170

PFI lifecycle prepayments (cash outflow) 0 0 0

Prepayment of PFI capital contributions (cash payments) 0 0 0

Cash movement from acquisitions of business units and subsidiaries (not absorption transfers) 0 0 0

Cash movement from disposals of business units and subsidiaries (not absorption transfers) 0 0 0

Net cash generated from/(used in) investing activities (10,146) (4,912) (8,529)

Cash flows from financing activities

Public dividend capital received 0 1,000 1,000

Public dividend capital repaid 0 (2,844) (3,185)

Loans from Department of Health - received 0 0 0

Loans from Department of Health - repaid 0 0 0

Other loans received 4,000 6,000 6,000

Other loans repaid 0 0 0

Other capital receipts 0 0 0

Capital element of PFI, LIFT and other service concession payments (343) (119) (134)

Interest paid 0 (215) (250)

Interest element of PFI, LIFT and other service concession obligations (141) 0 0

PDC dividend (paid)/refunded (154) 681 1,022

Cash flows from (used in) other financing activities

Net cash generated from/(used in) financing activities 3,362 4,503 4,453

Increase/(decrease) in cash and cash equivalents (3,110) (3,015) (7,375)

Opening Cash 20,302 20,302

Closing Cash 20,302 17,287 12,927

Key Messages

Overall Cash Position

The cash balance at the end of December (Month 09) is £12.9m which is slightly at variance to the cash forecast paper that was

briefed at Finance Committee on 30th November 2017 of £14.1m.

Weekly cash committee meetings are in place to improve cash management and short term solutions to improve liquidity are being

investigated.

Capital Cash outflows

The capital forecast at December has been determined by responsible Capital Scheme Managers.Draft

Category YTD

Ledger

Total

£'000's

Forecast

Jan-18

£'000's

Forecast

Feb-18

£'000's

Forecast

Mar-18

£'000's

Total actual

plus

forecast

£'000's

Previous

month

forecast

Estates 44 8 0 0 52 52

Estates - Backlog Maintenance 475 80 2 12 569 561

Estates - Compliance 306 60 1 1 369 364

Estates - Energy Centre 3,700 1,000 1,250 1,250 7,200 12,639

Estates - Infrastructure Upgrade 1,239 89 36 55 1,418 1,798

Estates - PEAT 21 2 0 0 23 19

Estates Total 5,785 1,240 1,289 1,318 9,632 15,434

ICT 344 167 0 44 555 452

ICT - PAS/EPR 607 932 45 424 2,008 1,635

IT Refresh 96 0 0 134 230 199

IT Total 1,047 1,100 45 601 2,793 2,286

Medical Equipment 1,203 858 0 8 2,069 2,046

Service Development (2) 0 0 0 (2) (2)

Service Development - Clinical Strategy 0 0 0 0 0 0

Service Development - Middlefield Centre 49 0 0 0 49 49

Service Development - Urgent Care Centre Phase 1 114 0 0 0 114 105

Service Development - Urgent Care Centre Phase 2 5 0 0 0 5 0

To be recoded M10 5 0 0 0 5

Service Development Total 170 0 0 0 170 152

Other Revenue to Capital Transfer 352 0 0 83 435 650

Donated 170 0 0 0 170 150

Grand Total 8,727 3,197 1,334 2,011 15,269 20,718

0

5,000

10,000

15,000

20,000

25,000

Q1 Q2 Q3 Q4

Capital plan against actual

Capital internal plan

Capital additions andforecast

Capital previous monthadditions and forecast

Draft

Pay ExpenditureReporting period: 1st April 2017 to 31st December 2017

WTE Budget Budget (£'000s) Actual (£'000s)

Variance

(£'000s) Budget (£'000s) Actual (£'000s)

Variance

(£'000s)

Medical And Dental 544 507 3,854 4,193 (339) 34,632 37,050 (2,418)

Qualified Nursing, Midwifery And Health Visiting 1,527 1,427 5,331 5,212 119 48,067 45,853 2,214

Qualified Scientific Therapeutic and Technical 445 444 1,568 1,539 29 14,310 13,688 622

Qualified Healthcare Scientists 157 147 550 518 32 4,945 4,769 176

Healthcare Assistants and Other Support Staff 877 875 1,880 2,128 (248) 16,483 18,412 (1,928)

Managers and Infrastructure support 1,512 1,415 3,434 3,429 6 31,070 30,811 259

Pay CRT 18 0 18 (164) 0 (164)

Vacancy Factor CRT 0 0 0 (0) 0 (0)

Other Pay* 6 6 192 13 179 1,376 108 1,269

Total Pay Expenditure 5,068 4,821 16,827 17,031 (204) 150,719 150,690 29

Budget (£'000s) Actual (£'000s) Variance (£'000s)

Accident and Emergency 5,040 5,281 (241)

Anaesthetics 13,151 13,169 (18)

Central Expenditure (40) 40

Chief Executive 1,094 1,255 (161)

EAU & Ambulatory Care 7,576 8,089 (513)

Endoscopy 2,452 2,372 80

Estates 9,307 9,362 (55)

Finance 2,397 2,395 2

Finance Charges 225 225

I&TS 3,163 2,980 183

In Hospital Care 17,795 18,380 (585)

Medical Director 310 416 (106)

Nursing and Patient Safety 2,718 2,806 (88)

Obstetrics and Gynaecology 8,874 8,650 224

Orthopaedics 8,142 8,339 (197)

Out of Hospital Care 23,674 23,095 579

Outpatients 836 821 15

Paediatrics 10,203 10,331 (128)

Pathology 5,403 5,532 (129)

Pharmacy 2,977 3,142 (165)

Radiology 7,159 6,812 347

Research and Development 647 674 (27)

Reserves 1,045 1,045

Strategy, Operations and Performance 1,976 1,972 4

Surgery and Urology 8,867 9,461 (594)

Urgent Care Services 1,894 1,800 94

Winter 200 65 135

Workforce 3,591 3,528 63

Total Pay Expenditure 150,716 150,687 29

WTE Contracted


Year to Date £000's Key MessagesPay Expenditure is month is adverse by £204k, although underspent year to date by £29k.

Pay Expenditure in Month 9 was £324k higher than the M1-8 average spend, £503k higher than

the corresponding M9 expenditure in 2016/17. £182k of this relates to Urgent Care services and

there is a £169k increase due to the 2017/18 1% pay award. This demonstrates that the Trust is

largely constraining the underlying pay position, without making any significant reduction in the

run rate.

Agency spend for the year now totals £3.1m and bank spend totals £3.1m. This is a reduction of

£2.3m compared to the Month 9 position in 2016/17.

The Trust's sickness absence rate of 5.13% in December was the highest it has been in the

financial year, 0.34% worse than the previous highest month, November.

Pay CRT in Corporate areas is behind plan by £248k year to date. A number of Corporate

Directorates are underspent and therefore need to realign CRT with realised savings.

Pay CRT in Clinical Directorates is on plan, however £1.3m of the £1.6m achieved year to date

has been saved through non-recurrent vacancies.

14.5

15.0

15.5

16.0

16.5

17.0

17.5

18.0

18.5

19.0

Q1 Q2 Q3 Q4 Q1 Q2 Q3

2016/17 2017/18

Pay Trend

PayExpenditure£m

4,000

4,200

4,400

4,600

4,800

5,000

5,200

Q1 Q2 Q3 Q4 Q1 Q2 Q3

2016/17 2017/18

Plan vs Contracted WTE

WTE Budget

WTEContracted

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

Pay Budget vs Actual

CumulativeBudget £m

CumulativeActual £m

Draft

Non-Pay Expenditure

Reporting period: 1st April 2017 to 31st December 2017

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

Budget

(£'000s)

Actual

(£'000s)

Variance

(£'000s)

Computer Equipment 2,932 245 271 (26) 2,197 2,586 (389) Accident and emergency 44 57 (13) 406 481 (75)

CNST 11,096 925 907 18 8,322 8,166 156 Anaesthetics 363 473 (110) 3,402 3,791 (389)

Drugs 5,285 440 524 (84) 3,964 5,025 (1,061) Central Expenditure (92) 69 (161) (826) 773 (1,599)

External Contract Staffing 497 29 (93) 122 432 364 68 Chief Executive 22 32 (10) 200 263 (63)

Housekeeping 4,320 354 342 12 3,235 3,134 101 EAU & Ambulatory Care 129 158 (29) 1,160 1,409 (249)

Clinical Supplies 26,723 2,234 2,387 (153) 20,339 20,592 (253) Endoscopy 143 130 13 1,285 1,203 82

Establishment Expenses 2,393 200 185 15 1,794 1,969 (175) Estates 754 845 (91) 6,771 6,995 (224)

Miscellaneous (inc. Central CRT) (4,038) (298) 98 (396) (2,642) 990 (3,632) Finance 104 (29) 133 1,251 1,241 10

Premises and Fixed Plant 12,162 1,016 1,073 (57) 9,090 9,460 (370) Finance Charges 1,798 1,796 2 16,525 16,451 74

Postage, Printing and stationary 1,550 131 161 (30) 1,160 1,207 (47) I&TS 171 186 (15) 1,392 1,607 (215)

Purchase of Healthcare Services 2,721 228 317 (89) 2,036 2,089 (53) In Hospital Care 1,234 1,301 (67) 12,006 12,946 (940)

Redundancy and Early Retirements 5 58 (58) 4 132 (128) Medical Director 4 3 1

Training 615 48 26 22 470 585 (115) Nursing and Patient Safety 20 40 (20) 183 205 (22)

Travel and subsistence 1,518 125 116 9 1,143 995 148 Obstetrics and Gynaecology 159 266 (107) 1,464 1,819 (355)

Operational (excluding passthrough) Total 67,779 5,677 6,372 (695) 51,544 57,294 (5,750) Orthopaedics 427 458 (31) 3,858 4,198 (340)

Out of Hospital Care 657 690 (33) 5,462 5,705 (243)

High Cost Drugs (Passthrough) 9,067 1,105 1,105 10,172 10,172 Outpatients 26 21 5 225 209 16

Passthrough Total 9,067 1,105 1,105 10,172 10,172 Paediatrics 183 203 (20) 1,572 1,744 (172)

Pathology 445 552 (107) 3,934 4,440 (506)

Operational Total 76,846 6,782 7,477 (695) 61,716 67,466 (5,750) Pharmacy 61 68 (7) 524 663 (139)

Radiology 422 464 (42) 3,801 3,992 (191)

Depreciation and Amortisation 6,171 514 474 40 4,628 4,266 362 Research and Development 2 2 17 28 (11)

Finance Costs 502 42 35 7 376 250 126 Reserves 69 69 506 506

PDC 4,088 341 341 3,066 3,185 (119) Strategy, Operations and Performance 11 1 10 101 90 11

Non-Operational Total 10,761 897 850 47 8,070 7,701 369 Surgery and Urology 180 225 (45) 1,466 1,665 (199)

Urgent Care Services 243 242 1 2,188 2,300 (112)

Grand Total 87,607 7,679 8,327 (648) 69,786 75,167 (5,381) Winter 14 (14) 16 (16)

Workforce 101 60 41 910 931 (21)

Grand Total 7,676 8,324 (648) 69,787 75,168 (5,381)

Key Messages

Non-Pay Expenditure is adverse by a total of £(5.4)m. This is attributed to a £(5.8)m adverse operational spend and a £0.4m benefit on

non-operational expenditure.

The largest driver of the adverse variance is unidentified CRT, which totals £3.7m across Medicines Management, Procurement,

Clinical Pathways and other Non-Pay related savings targets.

Non-Pay spend in December was £28k lower than the year to date average spend. Non-Pay costs are £697k higher than the

corresponding month in 2016/17. Specific areas where costs have increased include Clinical Supplies, High Cost Drugs (Offset with

corresponding increase in income) and Premises and Fixed Plant. A proportion of this relates to the accruals released in 2016/17 where

costs have been subsequently incurred.

Month 9 continued to see a rise in expenditure relating to seasonal variation, for example in Utility bills. This trend is expected to

continue during the coming months due to the cold weather that has been experienced recently.

Drugs spend (excluding passthrough) is on average £59k per month higher in 2017/18 compared to M1-9 in 2016/17. A key reason

driving this variance is increased antibiotic price rises due to national shortages on specific drugs.

Non-Recurrent spend in month includes a £25k increase in expenditure related to NEHODS testing in Pathology. This price rise was

unexpected and is being challenged with the provider.

Current Month £000's Year to Date £000'sAnnual

Budget

(£'000s)


Draft

Cost Reduction Target (CRT)Reporting period: 1st April 2017 to 31st December 2017

Plan Actual Variance Plan Actual Variance

A&E 15 41 26 136 129 (7)

Anaesthetics 89 55 (34) 803 123 (680)

Central Expenditure 83 (83) 750 (750)

Central Income 277 179 (98) 2,490 2,073 (417)

Chief Exec 7 1 (6) 60 2 (58)

EAU 25 48 23 227 97 (130)

Endoscopy 17 10 (7) 153 150 (3)

EOD 7 1 (6) 65 4 (61)

Estates 111 67 (44) 932 590 (342)

Finance 19 (19) 168 (24) (192)

HR 6 7 1 56 42 (14)

ICT 23 28 5 211 237 26

In Hospital Care 128 209 81 1,150 1,484 334

Medical Director 1 1 6 6

Nursing and Patient Safety 12 1 (11) 109 (458) (567)

Obs and Gynae 24 56 32 217 210 (7)

Orthopaedics 43 108 65 541 699 158

Out of Hospital Care 100 167 67 756 1,024 268

Outpatients 4 (3) (7) 37 27 (10)

Paediatrics 25 100 75 221 7 (214)

Pathology 38 48 10 344 150 (194)

Pharmacy 13 22 9 119 65 (54)

Radiology 42 68 26 377 39 (338)

Strategy O&P 8 10 2 75 102 27

Surgery and Urology 36 108 72 323 298 (25)

Urgent Care (25) (25) (298) (298)

Total CRT 1,153 1,307 154 10,326 6,778 (3,548)

Plan Actual Variance Plan Actual Variance

Corporate 57 35 (22) 514 272 (242)

DQIP 167 167 1,500 1,500

Estates 86 46 (40) 743 345 (398)

Income 169 45 (124) 1,492 849 (643)

Non-Pay 236 115 (121) 2,271 985 (1,286)

Pathways 83 (83) 750 (750)

Pay 192 870 678 1,552 2,562 1,010

Medicines Management 163 29 (134) 1,510 265 (1,245)

Subsidiary Company (6) 6

Total CRT 1,153 1,307 154 10,326 6,778 (3,548)

Key Messages

Year to date savings total £6.8m. This includes savings associated with

temporary staffing cost reduction. Previously these have not been included

in savings totals and therefore an in-month adjustment has been actioned.

Total banked benefits for the full financial year total £8.6m. This consists of

£5.5m CRT defunded and £3.1m reduction in temporary staffing spend.

Non-Pay savings remain substantially behind plan, with £1.0m delivered

year to date against a target of £2.3m. Delivery of this target is unlikely to be

achieved by year end.

Medicines Management savings are also behind plan. £0.3m has been

delivered against a year to date target of £1.5m. Further taxpayer savings

have been identified and achieved that relate to pass through drugs,

however these are unable to be classed as a CRT as there no benefit to the

Trust despite considerable application of resource. Full benefit accrues by

default to CCGs. As such the Trust has sought a agreement of a gain share

arrangement for biosimilar drugs has been agreed with commissioners and

is expected to be formalised imminently, meaning recurrent savings in the

region of £0.5m full year effect will be accessible. The contracting team

continue to actively chase the commissioner for a signed contract variation.

The £1m target associated with patient pathways remains unachieved.

Corporate CRT is behind plan, although a number of Directorates have

agreed for plans to be defunded and improvement is expected in this

category.

Current Month (£'000s) Year to Date (£'000s)

Current Month (£'000s) Year to Date (£'000s)

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

Medicines Management

CumulativePlan

CumulativeActual /Forecast

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Non-Pay/Procurement

CumulativePlan

CumulativeActual/Forecast

£0

£1,000,000

£2,000,000

£3,000,000

£4,000,000

£5,000,000

£6,000,000

£7,000,000

TotalBankedSavings

InternalPlan

NHSI Plan

Trust Monthly Banked Benefits

£0

£100,000

£200,000

£300,000

£400,000

£500,000

£600,000

£700,000

£800,000

Ap

r-1

6

Jun

-16

Au

g-1

6

Oct

-16

Dec

-16

Feb

-17

Ap

r-1

7

Jun

-17

Au

g-1

7

Oct

-17

Dec

-17

2016/17 2017/18

Temporary Staffing

Agency &Locum

BankDraft

1



25 January 2018

Executive Summary

Compliance and Performance Report Report of the Interim Director of Planning and Performance

Strategic Aim and Strategic Objective: Putting Patients First 1. Introduction/ Purpose

1.1 The Compliance and Performance Report highlights performance against a range of indicators against the Single Oversight Framework and the Foundation Trust terms of licence for the month of December and Quarter 3 (Q3) 2017/18. The Corporate Dashboard and reporting framework reflects both the mandatory performance frameworks for 2017/18 and the additional internal reporting requirements, including the Lord Carter Model Hospital review and key objectives.

1.2 This report must be read in conjunction with the additional information as detailed in

the Safety, Quality and Infection Prevention Performance Report, the Human Resources (HR) Report and the Finance and Contract Report.

2. Key Highlights/ Issues/ Risks

2.1 Performance against the emergency care standard under achieved in December reporting at 94%, however recovered the position in Q3 reporting at 96.18%. The Trust’s performance has remained within or above the national average, reporting 7th position nationally and first regionally. Full details are described in section 3 of the main report.

2.2 On aggregate, the overall A&E activity (Type 1 and Type 3) indicates the Trust has

seen a net increase of 97.4% (n=21,207) during Q3 compared to the same period last year, reflecting the opening of the Integrated Urgent Care Services on both hospital sites, with admissions via A&E increasing by 31.2% (n=1540). Overall emergency admissions increased by 1.78% (n=200) across the organisation.

2.3 The Trust has reported 93.20% against the 92% RTT standard for the month of

December and 94.04% for Q3 period. 2.4 The Trust continues to experience significant pressures within the delivery of the

cancer standards across all tumour groups. In November the Trust underachieved against the 62 day referral to treatment standard reporting at 84.83% however recovered the position in December and quarter 3 reporting 92.13% and 88.10% respectively (December and Q3 tentative position).

2.5 The Trust under achieved against the 99% Diagnostic standard for December reporting

at 98.62% however achieved Q3 reporting at 99.49%. 2.6 In December non-medical cancelled operations reported at 1.46% (n=44) above the

target of 0.80%. Unfortunately, due to significant pressures across both December and January, and reduced elective lists during the Christmas period, the Trust has been unable to reappoint 9 patients within 28 days. No ‘urgent’ procedures were cancelled for a second time.

Draft

2

2.7 Bed occupancy rates have remained high across the December period, reporting an average of 94.19%, peaking at 98.46%, despite the opening of up to 32 escalation beds to absorb the additional admissions.

2.8 The Trust has performed well against key operational efficiency measures, however with New DNA rates reporting above target. Further work is on-going to improve efficiencies supported by the Delivering Productivity Programme.

3. Key Challenges 3.1 Continuous and sustainable achievement of key access standards across elective,

emergency and cancer pathways, alongside a number of variables outside of the control of the Trust within the context of system pressures and financial constraints.

3.2 Delivery against the Lord Carter operational efficiency recommendations and

associated cash releasing savings. 4. Conclusion 4.1 The Trust has performed relatively well against the majority of key operational

standards during December and Q3, despite the considerable challenges associated with on-going operational, clinical, financial and system wide pressures. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements.

4.2 Whilst the Trust has robust governance processes in place for the monitoring and

management of all performance standards there is recognition that current pressures across the whole health economy may ultimately impact on consistent and sustainable delivery, therefore presents an on-going risk.

4.3 This risk is outlined within the Trust’s Risk Register and Board Assurance Framework, with supporting mitigation and recovery plans, alongside internal and external governance assurance processes.

5. Recommendations 5.1 The Board of Directors is asked to note:

The detail in the Corporate Dashboard and performance against the Single Oversight Framework requirements and the key national indicators for December and Q3 2017/18.

Review of the Trust’s SOF segmentation, linked to the governance measures and triggers for concern and current financial performance.

The on-going operational performance and system risks to regulatory key performance indicators and the intense mitigation work that is being taken forward to address these going forward.

The due diligence in assessing on-going compliance across both current and new performance requirements, as illustrated in regular seminars and committee discussions.

Lynne Taylor Interim Director of Planning and Performance

Draft

3



25 January 2018

Compliance and Performance Report

Report of the Interim Director of Planning and Performance

Strategic Aim and Strategic Objective: Putting Patients First 1. Introduction/ Purpose 1.1 The Compliance and Performance Report highlights performance against a range of

indicators against the Single Oversight Framework and the Foundation Trust terms of licence for the month of December and Quarter 3 (Q3) 2017/18. The Corporate Dashboard and reporting framework reflects both the mandatory performance frameworks for 2017/18 and the additional internal reporting requirements, including the Lord Carter Model Hospital review and key objectives.

1.2 This report must be read in conjunction with the additional information as detailed in the Safety, Quality and Infection Prevention Performance Report, the Human Resources (HR) Report and the Finance and Contract Report. This report will concentrate on the operational performance only.

1.3 Appendix 1 illustrates the trend and variance analysis against targets/trajectory

profiles; with due consideration given to both positive and negative variances and progress against monthly, annual and in year improvement targets. Appendix 2 illustrates a high level view of the Corporate Dashboard and progress against key performance indicators. Appendix 3 illustrates the Single Oversight Framework (SOF) and the triggers of governance concern.

2. Performance Context 2.1 In December and Q3 the overall performance against key operational standards and

trajectories remain challenging. 2.2 Emergency Activity (including GPs) across the organisation has seen a slight

increase of 1.78% (n=200) in Q3 compared to the same time last year.

2.3 The overall emergency activity in Q3 included 2440 patients who were treated via

Ambulatory Care, equating to 22.14% of the total emergency admissions. 2.4 A&E attendances (Type 1 only) saw an overall decrease of 31.27% (n=5457) in

comparison with the same Quarter last year though mindful of a change to the emergency care pathway with the opening of the Integrated Urgent Care Services. Admissions via A&E and the Urgent Care Centre (Type 1 and 3 combined) reported a 49.35% (n=1540) increase compared to the same Quarter last year.

2.5 The Integrated Urgent Care Services activity in Q3 reported 17,310 attendances at

the North Tees site, including 958 admissions, with the Hartlepool site reporting 13,666 attendances and 729 admissions (aggregate 30,976 attendances; 1687 admissions).

Draft

4

2.6 Performance against the emergency care standard under achieved in December

reporting at 94%, however recovered the position in Q3 reporting at 96.18%. The Trust’s performance has remained within or above the national average, reporting 7th position nationally. Full details are described in section 3.

2.7 The Trust is committed to sustainable achievement and continuous improvement

against all access targets. Appropriate mitigation plans are in place where appropriate to manage the position in line with set targets and to provide assurance with regard to remedial action and on-going improvement.

3. Compliance Indicators

3.1 Referral to Treatment (RTT) Pathways

3.1.1 The Trust has reported 93.20% against the 92% RTT standard for the month of December and 94.04% for Q3 period.

3.1.2 National RTT data, November position (latest published data) indicated the Trust

performed above the national average which reported at 89.50%. See Appendix 1, ‘Index 5 - Benchmarking’.

3.1.3 Median and 92nd percentile waits have remained relatively consistent and within

target, reporting lower than the national average, demonstrating that more patients are generally waiting less than 18 weeks.

3.1.4 The Trust reported no over 52 week waits. 3.1.5 The Trust recognises that the planned reduction in elective activity over the

December and January periods, with the need to cancel further electives to absorb emergency pressures, will have an impact on RTT performance. A full recovery plan is under development, which includes initial discussions with commissioners to adjust the planned activity in 2018/19 to absorb the expected backlog.

3.2 Emergency Care Standards 3.2.1 The Trust under achieved the ‘4 hour arrival to discharge or admission’ standard in

December reporting at 94% against the 95% standard however achieved the Quarter 3 position reporting at 96.18%.

3.2.2 Graph 1 demonstrates the Trust’s performance has remained above the national

average for December.

Graph 1 – Trust Comparison to National and Regional Position

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

North Tees And Hartlepool NHS Foundation Trust North East Average EnglandDraft

5

3.2.3 The NHS England published statistical report for the A&E 4 hour standard indicates

that only 4 out of the 137 acute providers with a Type 1 A&E department achieved the standard in December 2017.

3.2.4 Appendix 1 ‘Index 5’ reports that, as such, the England average reported at 85.1%,

below the 95% standard, in December. The North East position reported at 89.6%, with no regional Trust achieving the standard.

3.2.5 Whilst Q3 saw a decease in Type 1 only A&E attendances of 31.27% (n=5457) in

comparison with the same Quarter last year, this is in the main due to the opening of the Integrated Urgent Care services which has reduced the number of minor patients attending the Type 1 A&E department. The Integrated Urgent Care Services activity in Q3 reported 17,310 attendances at the North Tees site, including 958 admissions, with the Hartlepool site reporting 13,666 attendances and 729 admissions (aggregate 30,976 attendances; 1687 admissions).

3.2.6 Therefore on aggregate, the overall A&E activity (Type 1 and Type 3) indicates the

Trust has seen a net increase of 97.4% (n=21,207) during Q3 compared to the same period last year, with admissions increasing by 31.2% (n=1540).

3.2.7 The Trust achieved 98.45% (Q3) compliance against the 2 hour Integrated Urgent

Care standard “once clinically streamed, patients to be treated within 2 hours”, which is an excellent achievement within the third quarter of this new service going live. Split by site, Hartlepool achieved 99.63% and North Tees achieved 97.51%.

3.2.8 Streaming in A&E is proving successful with 880 (20.52% of total Type 1 A&E

attendances) patients redirected into the Integrated Urgent Care Centre (IUC) in December with less serious conditions, allowing capacity within A&E to treat more complex patients.

3.2.9 The process for streaming to alternative services from the IUCs is an evolving

process, taking into account the IUCs treat minor illnesses, minor injuries and ‘out of hour’ services. The role of the Patient Process Facilitator has now been implemented to support the Clinical Streamer and is having a positive effect. Table 1 demonstrates the number of patients streamed to other services from the IUC’s in December, 344 patients in total, 3.04% of total attendances.

Table 1 – Streaming within the IUCs (December 2017)

3.2.10 December and Q3 continues to experience bed pressures, with occupancy reporting

at 94.19% and 91.37% respectively, peaking at 98.46% despite the opening of up to 32 escalation beds on a daily basis to absorb the additional admissions. Graph 2 indicates the month on month occupancy over the past two years has remained above the national recommended standard of 85%, reflective of the pressures within the system.

Source of Streaming Total Attendances% of total

attendances

Streamed from Urgent Care to A&E 198 1.76%

Streamed from Urgent Care to Dentist 33 0.29%

Streamed from Urgent Care to GP Extended Hub 15 0.13%

Streamed from Urgent Care to Other Services 75 0.66%

Streamed from Urgent Care to Pharmacy 23 0.20%

Total Streamed within Urgent Care 344 3.05%

11282Draft

6

Graph 2 – Trust Occupancy by month

3.2.11 Delayed Transfers of Care (DTOC) reported at 2.96% for December and 3.04% for Q3, indicating a downward trend, averaging at 15 per day. Graph 3 highlights the month on month percentage of delayed transfers of care (per 10,000 bed days).

Graph 3 – Delayed Transfers of Care by month

3.2.12 The significant pressures on emergency care services led to a number of ambulance

handover delays in December, with the Trust reporting 50 ambulance handovers greater than 30 minutes and 4 greater than 60 minutes (source North East Ambulance Services), however with a number of recording and process issues impacting on the reported performance. In comparison, the North East average reported at 136 (range 49-305), with the average over 60 minutes reporting at 26 (range 0-116). The Trust’s overall performance in December indicated 82.37% of ambulance handovers (valid) within 15 minutes.

3.2.13 The Trust reported 41.9% ambulance turnaround times (valid) within 30 minutes

during December in comparison the North East’s position at 35.6%, with individual provider performance ranging between 29.2% and 41.9%.

3.3 Cancer Standards (Q3 un-validated position)

3.3.1 The Trust continues to experience significant pressures within the delivery of the cancer standards across all tumour groups. In November the Trust underachieved against the 62 day referral to treatment standard reporting at 84.83% however recovered the position in December and quarter 3 reporting 92.13% and 88.10% respectively (December and Q3 tentative position).

Draft

7

3.3.2 The Trust struggled to accommodate all patients within 62 days during the month of

November due to multiple reasons such as complex pathways, patient choice, delays across Tertiary pathways and some capacity issue.

3.3.3 Table 2 demonstrates performance against the 62 day referral to treatment cancer

standard.

Table 2 – Trend Performance against Cancer Standards

3.3.4 The latest published data (November position) indicates the national average for the 62 day urgent referral to treatment standard reporting at 82.3%. The Northern England Cancer Alliance (NCA) reported 86.19% against the target of 85%, with four out of the nine regional organisations under achieving the standard. Comparative data against national and local data can be seen in Table 3 below.

Table 3 – National and regional position against cancer 62 day referral to treatment

3.3.5 The Trust has implemented a number of actions to support the improvement of the 62

day cancer standard in alignment with the NHS England 62 Day Cancer Standard – Operating Model and Recovery Plan.

3.3.6 The Trust has dedicated significant resource to the recovery of the cancer standards,

however recognises that there are pressures outside of the organisation’s control that can still impact on delivery, requiring a system wide approach to improving pathway management, including patient choice to delay diagnosis/treatment and specialist capacity.

3.3.7 A monthly ‘cancer liaison’ meeting takes place with local commissioners, GP

representatives and members of the cancer management team to ensure effective two way communication of issues affecting pathway management, performance and system overview and development.

Standard Target Q1 Q2 Oct 2017 Nov 2017 Dec 2017

(Unvalidated)

Q3

( Unvalidated)

Two Week rule 93% 91.86% 93.84% 95.53% 93.08% 94.65% 94.43%

Breast Symptomatic 93% 94.00% 97.24% 98.27% 96.72% 96.27% 97.16%

31 day 1st Treatment 96% 99.70% 97.65% 98.57% 98.57% 99.06% 98.69%

31 day Subsequent - Surgery 94% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

31 day Subsequent - Drug 98% 99.42% 100.00% 100.00% 100% 100.00% 100.00%

62 day referral to treatment 85% 85.51%

(176/25.5 breaches)

83.20%

(193.5/32.5 breaches)

87.80%

(61.5/7.5 breaches)

84.83%

(72.5/11 breaches)

92.13%

(63.5/5 breaches)

88.10%

(197.5/23.5

breaches)

62 day Upgrade (shadow standard) 85% 77.78% 100.00% 100.00% 100.00% 100.00% 100.00%

62 day Screening 90% 96.61% 95.45% 100.00% 97.17% 97.01% 98.04%

S Tyneside Sunderland N Cumbria Gateshead Newcastle Northumbria S TeesNorth Tees &

Hartlepool

Durham &

DarlingtonNCA National

Breast 100 (1/1) 0 (0/0.5) 100 (11/11) 95.38 (31/32.5) 100 (17/17) 100 (24/24) 100 (14.5/14.5) 100 (14/14) 96.83 (30.5/31.5) 97.95 (143/146) 95.2

Lung 60 (4.5/7.5) 40 (1/2.5) 75 (6/8) 85.71 (6/7) 75 (12/16) 100 (5.5/5.5) 86.49 (16/18.5) 88.46 (11.5/13) 77.27 (8.5/11) 79.78 (71/89) 71.9

Gynae 71.43 (2.5/3.5) 100 (4.5/4.5) 100 (5.5/5.5) 88 (11/12.5) 100 (4.5/4.5) 87.5 (3.5/4) 72.22 (6.5/9) 71.43 (2.5/3.5) 50 (1.5/3) 84 (42/50) 77

Upper GI 100 (3.5/3.5) 87.5 (3.5/4) 87.5 (7/8) 33.33 (0.5/1.5) 71.43 (7.5/10.5) 90 (4.5/5) 87.5 (14/16) 80 (4/5) 77.78 (3.5/4.5) 82.76 (48/58) 75.2

Lower GI 100 (1/1) 90.91 (10/11) 75 (9/12) 50 (1/2) 78.95 (7.5/9.5) 92.31 (6/6.5) 90.32 (14/15.5) 40 (2/5) 70.37 (9.5/13.5) 78.95 (60/76) 72.6

Uro (exc testes) 100 (0.5/0.5) 88.51 (38.5/43.5) 86.67 (19.5/22.5) 90.91 (10/11) 62.26 (16.5/26.5) 54.55 (12/22) 75.81 (23.5/31) 83.02 (22/26.5) 78.57 (5.5/7) 77.69 (148/190.5) 78

Haem (exc AL) 100 (1.5/1.5) 81.82 (4.5/5.5) 100 (8/8) 100 (2.5/2.5) 100 (4/4) 100 (1/1) 84.62 (5.5/6.5) 100 (3/3) 60 (3/5) 89.19 (33/37) 79.6

Head & Neck 50 (0.5/1) 100 (5/5) 66.67 (2/3) 0 (0/0) 71.74 (16.5/23) 100 (1/1) 73.91 (8.5/11.5) 0 (0/0) 60 (1.5/2.5) 74.47 (35/47) 67.1

Skin 0 (0/0) 100 (4.5/4.5) 95 (19/20) 0 (0/0) 98.39 (61/62) 100 (2/2) 100 (26.5/26.5) 100 (1.5/1.5) 97.33 (36.5/37.5) 98.05 (151/154) 95.4

Sarcoma 0 (0/0) 0 (0/0) 100 (0.5/0.5) 0 (0/0) 70 (3.5/5) 0 (0/0) 50 (0.5/1) 100 (0.5/0.5) 0 (0/0.5) 66.67 (5/7.5) 65.7

Brain/CNS 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 100 (1/1) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 100 (1/1) 100

Other 0 (0/0) 0 (0/0) 100 (2/2) 0 (0/0) 0 (0/0) 0 (0/0) 100 (2.5/2.5) 100 (0.5/0.5) 100 (1/1) 100 (6/6) 72

All 76.92 (15/19.5) 88.27 (71.5/81) 89.05 (89.5/100.5) 89.86 (62/69) 84.36 (151/179) 83.8 (59.5/71) 86.56 (132/152.5) 84.83 (61.5/72.5) 86.32 (101/117) 86.19 (743/862) 82.3Draft

8

3.3.8 The Northern England Cancer Alliance has recently announced the Trust will receive

support with the appointment of a service improvement lead shared with a local Tertiary Centre.

3.3.9 The latest Audit One report gave ‘substantial assurance’ around governance, risk

management and control arrangements in relation to the cancer waiting list management, tracking and escalation processes. Full compliance with the agreed control framework was found to be in place.

3.4 Diagnostic Waiting Times 3.4.1 Diagnostic pathways continue to be monitored closely to ensure maximum

contribution to RTT pathway management and to reduce waiting times. The Trust under achieved against the 99% national standard in December reporting at 98.62% however recovered the position in Q3 reporting at 99.49 %.

3.5 Health Care Associated Infections 3.5.1 The Trust reported 1 case of Clostridium Difficile in December however the

cumulative position of 26 exceeds the trajectory. Work continues to identify reasons for the increase including genetic typing and environmental screening. A programme of support from NHS Improvement is under discussion, with recommendations awaited and an external independent visit has taken place to include review of the current actions to mitigate risk, appropriateness of the antibiotic stewardship activities and compliance with national guidance around sampling, testing and management of cases.

3.5.2 The Trust reported no cases of MRSA in December however the cumulative position

reports at 3 (1 case reported in October). This standard is no longer included in the Single Oversight Framework. However there is an expectation of zero tolerance towards MRSA cases.

3.5.3 MSSA and E Coli are now included in the revised Single Oversight Framework.

December position reports 1 case of MSSA with a cumulative position of 17, whilst 3 cases of E Coli were reported in December with a cumulative position of 36.

4. Lord Carter – Productivity and Efficiency 4.1 The following section provides a summary of the Trust’s compliance against a

number of key operational indicators, supported by the Health Evaluation Data (HED) benchmarking data available in Appendix 1. The report indicates the Trust is performing above or within expected for the majority of indicators and also demonstrates improvement in indicators where performance has previously been below the national average.

4.2 The NHS Improvement (NHSI) Model Hospital dashboard has made a number of

updates to include reports across specialties. Updates are on-going with a proposed digital information service which is to be provided by NHSI to support the NHS to identify and realise productivity opportunities. NHS Trusts are able to explore their comparative productivity, quality and responsiveness, to provide a clearer view of improvement opportunities. Whilst some variation in Trust activity is expected and warranted, Lord Carter and the Model Hospital believes this offers support to Trusts to identify and tackle unwarranted variation.

4.3 To support operational delivery, all available reports have been distributed to

specialties to allow interrogation and understanding of data. Comparison and analysis can then be made within the cost and weighted activity units for pay and non

Draft

9

pay to establish where directorates sit within a set of headline productivity metrics. Exception and variation will be provided to the Planning, Performance and Compliance Committee meeting for Board. Operational Performance metrics are all included within the Corporate Dashboard.

4.4 The Trust has also taken up the opportunity to work with NHSI as part of the

Productivity Delivery Programme. This programme seeks to support Trusts in improving their financial performance through two main developments. These involve a greater focus on recurrent and sustainable operational productivity improvements and piloting the use of additional NHS resources across a number of NHS Trusts.

5. Outpatient Attendance Indicators 5.1 The aggregate New to Review ratios reported at 1.22 in November (latest available

position), showing a positive performance against the current target of 1.45 and a relatively consistent downward trend.

5.2 The Trust’s performance against ‘New’ Outpatient DNA rates reported above the

agreed target of 5.40%, at 8.83% with ‘Review’ DNA rates reporting at 10.24% against the 9% target, however with further work on-going across directorates as part of the Lord Carter work to deliver additional improvements.

6. E-Booking (ASIs) 6.1 Latest available data for November 2017 indicates the Trust reported within the 4%

target, at 1.80%. In comparison, the regional position reported at 13.4%, with the national position reporting at 21.3%.

6.2 In line with the NHS Digital requirements, the Trust is working with both CCG and GP

colleagues to improve the take up of e-booking and move to full electronic referring by April 2018, ahead of the National contract deadline of October 2018.

7 Cancelled Operations 7.1 In December non-medical cancelled operations reported at 1.46% (n=44) above the

target of 0.80%. Unfortunately, due to significant pressures across both December and January, and the planned reduction of elective lists during the Christmas period, the Trust has been unable to reappoint 9 patients within 28 days. No ‘urgent’ procedures had been cancelled for a second time.

8. Readmissions

8.1 The Trust recognises emergency readmissions as an area requiring further work, in line with national drivers to reduce avoidable admissions. The Trust is currently reporting emergency readmission rates at 8.42% post emergency admission, with the internal target set at 9.73%, and 3.80% post elective admission, set against a zero tolerance (November 2017 position, latest available data). The aggregate emergency readmission rate reports at 6.39% against the internal stretch target of 7.70% (based on peer average and year on year improvement).

8.2 In general, the Trust has demonstrated a relatively positive position against its overall

operational efficiency performance indicators, which is attributed to the constant effort by service lines and clinical teams to improve quality, efficiency and patient safety and experience. However there are further opportunities to improve efficiency and productivity across the organisation and these continue to be explored through the Lord Carter programme of work and DPP workstreams.

Draft

10

9. Out of Hospital 9.1 The Corporate Dashboard includes a number of Transforming Community Services

Indicators, to provide an overview of the progress being made in delivering improvements across community care with further developments expected in 2017/18.

10 Community Information Dataset (CIDS) 10.1 Performance indicators for Community Services, with data completeness used as a

measure for the three elements of Referral to Treatment (RTT), referral information and treatment activity information, with a target of 50% completeness remaining for 2016/17.

10.2 August position (latest available data) indicates the Trust has achieved all three CIDs

targets for the period, reporting 96.92% against RTT data, 96.82% for Referral data and 95.48% against the activity data. A target of 50% is set for all three indicators.

11. Contract Key Performance Indicators 11.1 The Trust agreed a significant number of key performance measures for 2017/18

within the NHS standard and local contract negotiations. In line with the NHS England Commissioning Board structure, these are reported to multiple commissioning bodies including:

Clinical Commissioning Groups

Area Team

Local Authority

Specialist Commissioning

Public Health 11.2 The KPIs cover quality requirements across both acute and community services, with

financial penalties attached against non-compliance. The Trust reports performance to the commissioners on a monthly basis.

11.3 The Trust performed relatively well across the majority of the contract KPIs during

Q3. The main areas of pressure are reflective of the Trust’s overall position on key STP access targets including cancer waits and specialty level RTT performance.

11.4 Performance against the contract KPIs for all commissioners are available via a link

within the Corporate Dashboard.

12. NHS Improvement (NHSI) 12.1 Single Oversight Framework (SOF) - Segmentation

12.1.1 Whilst reporting mechanisms have not been confirmed by NHSI, the expectation is

that all Trusts will continue to be rated in this vein. The Trust currently remains in Segment 2, however is subject to on-going review in line with the SOF Governance measures and triggers for concern, see Appendix 3.

12.1.2 A meeting was held on 11 December 2017 where the agenda focussed on the Trust’s

current financial performance, specifically in respect to Single Oversight Framework Segmentation; and future support requirements.

Draft

11

12.1.3 NHS Improvement recognised, on the whole, the excellent performance of the Trust

with regard to quality of care, operations and change although work and regular meetings will continue over the coming months regarding financial performance. See Board financial report and current ‘ Use of Resources’ rating.

12.1.4 The Sustainability and Transformation Funding (STF) conditions for 2017/18 relate to

achievement of the control total, however with 30% allocated to performance related delivery of the 4 hour standard (15%) and Primary Care Streaming (15%), subject to the overall control total being met. Performance against STF can be found in ‘Index 7’.

12. Conclusion/Summary

12.1 The Trust has performed relatively well against the majority of key operational standards during December and Q3, despite the considerable challenges associated with on-going operational, clinical, financial and system wide pressures. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements.

12.2 Whilst the Trust has robust governance processes in place for the monitoring and

management of all performance standards there is recognition that current pressures across the whole health economy may ultimately impact on consistent delivery, therefore presents an on-going risk.

12.3 This risk is outlined within the Trust’s Risk Register and Board Assurance

Framework, with supporting mitigation and recovery plans, alongside internal and external governance assurance processes.

13. Recommendations 13.1 The Board of Directors is asked to note:

The detail in the Corporate Dashboard and performance against the Single Oversight Framework requirements and the key national indicators for December and Q3 2017/18.

Review of the Trust’s SOF segmentation, linked to the governance measures and triggers for concern and current financial performance.

The on-going operational performance and system risks to regulatory key performance indicators and the intense mitigation work that is being taken forward to address these going forward.

The due diligence in assessing on-going compliance across both current and new performance requirements, as illustrated in the regular seminars and committee discussions.

Lynne Taylor Interim Director of Planning and Performance Draf

t

ID

Ap

r 17

Ma

y 1

7

Ju

n 1

7 QTR 1

Ju

l 17

Au

g 1

7

Se

p 1

7 QTR 2

Oc

t 17

No

v 1

7

Dec

17 QTR 3

Ja

n 1

8

Fe

b 1

8

Ma

r 18 QTR 4

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

Actual 94.19% 94.39% 94.12% 94.24% 93.17% 93.52% 94.12% 93.61% 94.74% 94.20% 93.20% 94.04%

Variance 2.19% 2.39% 2.12% 2.24% 1.17% 1.52% 2.12% 1.61% 2.74% 2.20% 1.20% 2.04%

Target 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2

Actual 5.4 5.4 5.3 5.4 4.9 6.3 5.4 5.4 5.4 5.4 6.7 5.7

Variance -1.8 -1.8 -1.9 -1.8 -2.3 -0.9 -1.8 -1.8 -1.8 -1.8 -0.5 -1.5

Target 28.00 28.00 28.00 28.00 28.00 28.00 28.00 28.00 28.00 28.00 28.00 28.00

Actual 15.60 16.30 16.40 16.10 17.40 17.40 16.30 17.00 15.70 16.00 17.00 16.10

Variance -12.40 -11.70 -11.60 -11.90 -10.60 -10.60 -11.70 -11.00 -12.30 -12.00 -11.00 -11.90

Target 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 0 0 0 0 0 0

Variance 0 0 0 0 0 0 0 0 0 0 0 0

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 97.71% 98.10% 98.93% 98.24% 98.33% 97.61% 96.90% 97.63% 98.09% 96.71% 94.00% 96.18%

Variance 2.71% 3.10% 3.93% 3.24% 3.33% 2.61% 1.90% 2.63% 3.09% 1.71% -1.00% 1.18%

T00 Target 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15

Actual 00:38 00:35 00:30 00:34 00:22 00:27 00:39 00:30 00:25 00:23 00:49 00:21

Variance 00:23 00:20 00:15 00:19 00:07 00:12 00:24 00:15 00:10 00:08 00:34 00:06

Median 00:05 00:06 00:06 00:06 00:05 00:05 00:07 00:06 00:06 00:06 00:07 00:06

T00 Target 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00

Actual 00:49 00:52 00:42 00:47 00:49 00:48 00:49 00:49 00:51 00:58 01:05 00:57

Variance 00:11 00:08 00:18 00:13 00:11 00:12 00:11 00:11 00:09 00:02 00:05 00:03

T00 Target 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Actual 5.41% 4.95% 5.56% 5.30% 5.57% 6.67% 6.06% 6.09% 6.36% 4.21% 5.97% 6.02%

Variance 0.41% -0.05% 0.56% 0.30% 0.57% 1.67% 1.06% 1.09% 1.36% -0.79% 0.97% 1.02%

T00 Target 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Actual 2.48% 2.20% 1.85% 2.18% 2.07% 1.67% 2.07% 1.94% 1.62% 2.30% 3.06% 2.46%

Variance 2.52% 2.80% 3.15% 2.82% 2.93% 3.33% 2.93% 3.06% 3.38% 2.70% 1.94% 2.54%

T01 Target 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00

Actual 05:18 04:50 03:59 04:30 04:29 05:18 05:26 05:10 04:48 05:40 06:31 05:12

Variance 00:30 01:10 01:12

T02 Target 0 0 0 0 0 0 0 0 0 0 0 0

Actual 2 2 1 5 0 1 6 7 2 1 53 56

Variance

T02 Target 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 0 0 0 0 4 4

Variance

T01 Target 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 0 0 0 0 0 0

Variance

T00 Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%

Actual 100.00% 98.55% 100.00% 99.42% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance 2.00% 0.55% 2.00% 1.42% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

T00 Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

Actual 100.00% 100.00% 100.00% 100.00% 90.91% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance 6.00% 6.00% 6.00% 6.00% -3.09% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00%

T00 Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual No pts 66.67% 83.33% 77.78% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Variance -18.33% -1.67% 15.00% 15.00% 15.00% 15.00% 15.00% 15.00% 15.00% 15.00%

T00 Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Actual 95.65% 96.36% 98.11% 96.61% 96.15% 90.91% 100.00% 95.45% 100.00% 97.17% 97.01% 98.04%

Variance 5.65% 6.36% 8.11% 6.61% 6.15% 0.91% 10.00% 5.45% 10.00% 7.17% 7.01% 5.45%

T00 Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 84.69% 81.60% 89.92% 85.51% 86.40% 77.63% 86.79% 83.20% 87.80% 84.83% 92.13% 88.10%

Variance -0.31% -3.40% 4.92% 0.51% 1.40% -7.37% 1.79% -1.80% 2.80% -0.17% 7.13% -1.80%

T00 Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%

Actual 100.00% 100.00% 99.11% 99.70% 98.13% 96.06% 97.89% 97.65% 98.55% 98.55% 99.05% 98.69%

Variance 4.00% 4.00% 3.11% 3.70% 2.13% 0.06% 1.89% 1.65% 2.55% 2.55% 3.05% 1.65%

T00 Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

Actual 89.57% 93.08% 92.61% 91.86% 93.18% 93.46% 94.92% 93.84% 95.53% 93.08% 94.65% 94.43%

Variance -3.43% 0.08% -0.39% -1.14% 0.18% 0.46% 1.92% 0.84% 2.53% 0.08% 1.65% 0.84%

T00 Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

Actual 90.75% 94.55% 95.54% 94.00% 98.22% 95.74% 97.67% 97.24% 98.27% 96.72% 96.27% 97.16%

Variance -2.25% 1.55% 2.54% 1.00% 5.22% 2.74% 4.67% 4.24% 5.27% 3.72% 3.27% 4.24%

* Data collection, validation and reporting processes prevent these standards from achieving a more timely result

** Data extracted directly from Trak, further validation has been undertaken on 14/07/2017 with amendments to May, June and Q1

Note: Cancer data is rounded up to one decimal place to reflect the National Cancer Waiting Times reporting

T00

12RTT incomplete pathways wait (92%)

T00

80RTT incomplete pathways wait (Median)

A&E left without being seen - Type 1

T00

83RTT incomplete pathways wait (92nd percentile)

T01

15RTT incomplete pathways >52 week wait

T00

01Emergency Care 4 hr standard

A&E Time to Initial Assessment -Ambulance

arrivals (95th percentile) - Type 1

A&E Time to Initial Treatment (Median) - Type 1

A&E unplanned returns within 7 days - Type 1

Breast Symptomatic Two week Rule (New Rules)*

A&E Time to departure (95th percentile) - Type 1 **

Number of ambulance handovers between

ambulance and A&E waiting more than 30 minutes

Number of ambulance handovers between

ambulance and A&E waiting more than 60 minutes

A&E 12 Hour Trolley waits - Type 1

New Cancer 31 days subsequent Treatment (Drug

Therapy)*

New Cancer 31 days subsequent Treatment

(Surgery)*

New Cancer 62 days (consultant upgrade)*

New Cancer 62 days (screening)*

New Cancer GP 62 Day (New Rules)*

New Cancer Current 31 Day (New Rules)*

New Cancer Two week Rule (New Rules)*

Appendix 1 - Single Oversight Framework (Index 1) Menu

Draft

ID

Ap

r 17

May 1

7

Ju

n 1

7 QTR 1

Ju

l 17

Au

g 1

7

Sep

17 QTR 2

Oct 1

7

No

v 1

7

Dec 1

7 QTR 3

Jan

18

Feb

18

Mar 1

8 QTR 4

Target 0 0 0 0 0 0 0 0 0 0 0 0

Cumulative 0 0 0 0 0 2 2 2 3 3 3 3

Variance 0 0 0 0 0 2 0 2 1 0 0 3

Target 2 3 4 4 5 6 7 7 8 9 10 10

Cumulative 6 9 13 13 15 19 19 19 20 25 26 26

Variance 4 6 9 9 10 13 12 12 12 16 16 16

Target 4 8 10 10 11 14 14 14 16 18 19 19

Cumulative 2 3 7 7 8 8 10 10 13 16 17 17

Variance -2 -5 -3 -3 -3 -6 -4 -4 -3 -2

Target 8 12 15 15 19 22 26 26 27 33 34 34

Cumulative 2 5 9 9 14 22 23 23 27 33 36 36

Variance 6 7 6 6 5 0 3 3 0 0

Target 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%

Actual 96.67% 100.00% 96.55% 96.72% 95.24% 94.44% 94.55% 94.70% 89.47% 88.89%

Variance 16.67% 20.00% 16.55% 16.72% 15.24% 14.44% 14.55% 14.70% 9.47% 8.89%

Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%

Actual 87.50% 100.00% 100.00% 95.45% 100.00% 75.00% 100.00% 100.00% 90.00% 100.00%

Variance 12.50% 25.00% 25.00% 20.45% 25.00% 0.00% 25.00% 25.00% 15.00% 25.00%

Target 9.73% 9.73% 9.73% 10.00% 9.73% 9.73% 9.73% 10.00% 9.73% 9.73%

Actual 11.46% 12.03% 12.02% 12.01% 11.07% 10.66% 11.57% 10.07% 12.27% 8.42%

Variance 1.73% 2.30% 2.29% 2.01% 1.34% 0.93% 1.84% 0.07% 2.54% -1.31%

Target 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Actual 4.83% 4.16% 3.84% 4.27% 3.28% 3.66% 4.72% 3.89% 4.31% 3.80%

Variance 4.83% 4.16% 3.84% 4.27% 3.28% 3.66% 4.72% 3.95% 4.31% 3.80%

Target 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70%

Actual 8.94% 8.93% 8.75% 8.99% 8.20% 7.77% 8.80% 8.26% 8.97% 6.39%

Variance -1.24% -1.23% -1.05% 1.29% -0.50% -0.07% -1.10% 0.56% -1.27% 1.31%

Target 15.60% 15.60% 15.60% 15.60% 15.60% 15.60% 15.60% 15.60% 15.60% 15.60% 15.60% 15.60%

Actual 11.98% 11.06% 14.17% 12.43% 9.79% 14.85% 11.67% 12.06% 13.66% 12.33% 12.96% 12.99%

Variance 3.62% 4.54% 1.43% 3.17% 5.81% 0.75% 3.93% 3.54% 1.94% 3.27% 2.64% 2.61%

Target 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

Actual 2.70% 4.30% 2.70% 2.70% 3.33% 2.30% 3.10% 1.80%

Variance 1.30% -0.30% 1.30% 1.30% 0.67% 1.70% 0.90% 2.20%

Target

Actual 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Variance

Target 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00%

Actual 83.78% 85.13% 96.64% 96.36% 97.45% 95.66% 96.09% 96.40% 96.62% 95.24% 95.58% 95.81%

Variance 13.78% 15.13% 26.64% 22.20% 27.45% 25.66% 26.09% 26.40% 26.62% 25.24% 25.58% 25.81%

Target 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00%

Actual 79.59% 81.05% 96.28% 94.88% 95.45% 94.82% 92.34% 94.22% 90.74% 96.08% 93.13% 93.95%

Variance 9.59% 11.05% 26.28% 21.57% 25.45% 24.82% 22.34% 24.22% 20.74% 26.08% 23.13% 23.95%

Target 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00% 70.00%

Actual 76.47% 72.73% 100.00% 95.92% 100.00% 95.83% 100.00% 98.77% 94.20% 100.00% 97.22% 97.11%

Variance 6.47% 2.73% 30.00% 19.29% 30.00% 25.83% 30.00% 28.77% 24.20% 30.00% 27.22% 27.11%

Target 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 0 0 0 0 9 9

Variance 0 0 0

Target 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00%

Actual 99.84% 99.95% 98.76% 99.49% 99.66% 99.29% 99.95% 99.64% 100.00% 99.75%

Variance 0.84% 0.95% -0.24% 0.49% 0.66% 0.29% 0.95% 0.64% 1.00% 0.75%

Target 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

NHSI Trajectory 4.30% 4.20% 4.00% 4.00% 3.75% 3.60% 3.50% 3.50% 3.40% 3.30% 3.20% 3.20%

Actual 3.74% 4.25% 3.56% 3.86% 3.17% 3.05% 3.15% 3.12% 2.75% 3.39% 2.96% 3.04%

Variance 0.24% 0.75% 0.06% 0.36% -0.33% -0.45% -0.35% -0.38% -0.75% -0.11% -0.54%

Target 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

Actual 4.20% 4.07% 4.34% 4.34% 4.45% 4.51% 4.34% 4.34% 4.79% 5.08%

Variance 0.70% 0.57% 0.84% 0.84% 0.95% 1.01% 0.84% 0.84% 1.29% 1.58%


** Data error corrected

T00

16MRSA - Bacteraemia (Cumulative)***

T00

17

Clostridium Difficile Patients - diagnosed after 72 hours

all ages (Cumulative)***

T00

37

Methicillin Sensitive Staphylococcus Aureus (MSSA)

(Cumulative)***

T00

38E-Coli (cumulative)***

T00

93

Stroke admissions 90% of time spent on dedicated

Stroke unit*

T00

94High risk TIAs assessed and treated within 24 hours *

T00

25Readmission rate 30 days (Emergency admission)

T00

26Readmission rate 30 days (Elective admission)

T01

19Readmission rate 30 days (Total)

T02

08Emergency c-section rates

T00

95ASI's - (No SLOT analysis)**

T00

18Eliminating Mixed Sex Accommodation

T01

21

Friends & Family - (Ward)

[National Score based on % ‘extremely likely’ to recommend to

F&F]

T01

22

Friends & Family - (A&E)


F&F]

T01

23

Friends & Family - (Birth)


F&F]

T01

00

Readmission within 28 days of non medical cancelled

operation *

T01

16

Number of patients waiting less than 6 weeks for

diagnostic procedures

T00

74Sickness absence % *

T01

03Delayed Transfers of Care

Appendix 1 - Single Oversight Framework (Index 2)

Menu

Draft

ID

Ap

r 17

Ma

y 1

7

Ju

n 1

7 QTR 1

Ju

l 17

Au

g 1

7

Se

p 1

7 QTR 2

Oc

t 17

No

v 1

7

Dec

17 QTR 3

Ja

n 1

8

Fe

b 1

8

Ma

r 18 QTR 4

Target 72.27% 71.21% 72.35% 72.09% 71.81% 73.36% 70.32% 71.85% 72.40% 73.15%

Actual 73.28% 73.52% 73.45% 73.56% 71.36% 71.04% 61.19% 67.80% 74.44% 74.60%

Variance 1.01% 2.31% 1.10% -0.45% -2.32% -9.13% 2.04%

Target 86.72% 85.97% 87.01% 86.74% 88.21% 88.47% 85.78% 87.52% 86.57% 86.77%

Actual 87.88% 88.07% 88.25% 88.24% 86.15% 86.03% 75.46% 82.49% 85.37% 86.48%

Variance 1.16% 2.10% 1.24% -2.06% -2.44% -10.32% -1.20% -0.29%

Target 92.50% 92.50% 92.50% 92.50% 92.50% 92.50% 92.50% 92.50% 92.50% 92.50%

Actual 94.62% 96.35% 94.09% 95.11% 93.79% 93.86% 97.07% 94.96% 92.62% 96.77%

Variance 2.12% 3.85% 1.59% -2.61% 1.29% 1.36% 4.57% -2.46% 0.12% 4.27%

Target 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80%

Actual 0.31% 0.41% 0.29% 0.34% 0.69% 0.64% 0.64% 0.66% 0.48% 1.07% 1.46% 0.98%

Variance -0.49% -0.39% -0.51% -0.54% -0.11% -0.16% -0.16% -0.26% -0.32% 0.27% 0.66% -0.26%

Target 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 0 0 0 0

Variance 0 0

Target 7.93% 7.05% 7.56% 7.50% 8.82% 6.58% 7.49% 7.50% 7.55% 7.10%

Actual 7.26% 6.72% 7.35% 7.10% 8.62% 8.23% 8.58% 8.50% 3.57% 3.23%

Variance -0.40% 1.00%

Target 25.66% 29.05% 26.59% 27.47% 25.81% 27.48% 29.34% 27.99% 31.25% 31.81%

Actual 24.63% 25.21% 24.48% 25.00% 23.67% 26.26% 26.54% 25.50% 35.95% 38.94%

Variance -1.03% -3.84% -2.11% 2.47% -2.14% -1.22% -2.80% 2.49% 4.70% 7.13%

Target 60.86% 55.66% 50.69% 55.66% 51.94% 54.97% 49.86% 52.65% 52.84% 51.40%

Actual 49.25% 53.87% 53.10% 52.41% 55.00% 47.47% 43.37% 48.57% 42.14% 49.26%

Variance -11.61% -1.79% 2.41% 3.25% 3.06% -7.50% -6.49% 4.08% -10.70% -2.14%

Target 10.86% 8.56% 8.86% 9.80% 10.00% 12.58% 12.54% 12.07% 11.93% 10.43%

Actual 11.19% 10.89% 11.50% 11.30% 7.33% 10.77% 11.65% 9.93% 11.79% 14.75%

Variance 0.33% 2.33% 2.64% -1.50% -2.67% -1.81% -0.89% 2.14% -0.14% 4.32%

Theatre data from Sep-17 unvalidated, because of system changeover from Theatreman to TrakCare

T00

67Operation Time Utilisation

T00

68Run Time Utilisation

T01

82Planned Session Utilisation

T00

71Cancelled (Non medical)

T01

18Cancelled Urgent Operations for second time

T00

70Cancelled on day of operation

T00

64Late Start %

T00

65Early Finishes %

T00

66Session overruns (>30 minutes)

Appendix 1 - Single Oversight Framework (Index 3)

Menu

Draft

ID

Ap

r 17

Ma

y 1

7

Ju

n 1

7 QTR 1

Ju

l 17

Au

g 1

7

Se

p 1

7 QTR 2

Oc

t 17

No

v 1

7

Dec

17 QTR 3

Ja

n 1

8

Fe

b 1

8

Ma

r 18 QTR 4

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 100.21% 99.87% 99.72% 99.94% 100.29% 99.93% 99.88% 100.03% 100.27% 100.23% 98.35% 99.67%

Variance 5.21% 4.87% 4.72% 4.94% 5.29% 4.93% 4.88% 5.03% 5.27% 5.23% 3.35% 4.67%

Target 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00%

Actual 26.11% 18.08% 22.90% 22.35% 21.98% 22.12% 16.94% 21.76% 21.71% 17.02% 12.62% 17.24%

Variance 9.11% 1.08% 5.90% 5.35% 4.98% 5.12% -0.06% 4.76% 4.71% 0.02% -4.38% 0.24%

Target 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 95.00% 93.50% 93.50% 93.50% 95.00%

Actual 93.00% 100.00% 100.00% 97.56% 98.60% 100.00% 100.00% 99.54% 100.00% 96.82% 95.40% 97.50%

Variance -0.50% 6.50% 6.50% 5.10% 6.50% 6.50% 4.54% 6.50% 3.32% 1.90% 2.50%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Actual 83.19% 78.65% 74.57% 78.30% 69.29% 71.04% 70.49% 70.34% 72.09% 95.68% 98.15% 88.72%

Variance -6.81% -11.35% -15.43% -11.70% -20.71% -18.96% -19.51% -19.66% -17.91% 5.68% 8.15% -1.28%

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.46% 99.85%

Variance 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 4.46% 0.00% 5.00%

Target 18.30 18.30 18.30 18.3 18.30 18.30 18.30 18.3 18.30 18.30 18.30 18.3

Actual 4.00 4.00 4.00 4.00 5.00 5.00 4.00 4.00 4.00 2.00 5.00 4.00

Variance -14.30 -14.30 -14.30 14.3 -13.30 -13.30 -14.30 14.3 -14.30 -16.30 -13.30 14.3

Target 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%

Actual 96.82% 96.42% 95.98% 96.42% 97.48% 95.74% 96.70% 96.65% 97.97% 96.92%

Variance 46.82% 46.42% 45.98% 46.42% 47.48% 45.74% 46.70% 46.65% 47.97% 46.92%

Target 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%

Actual 95.56% 95.73% 96.51% 95.96% 96.75% 97.38% 96.35% 96.85% 97.81% 96.82%

Variance 45.56% 45.73% 46.51% 45.96% 46.75% 47.38% 46.35% 46.85% 47.81% 46.82%

Target 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%

Actual 97.25% 94.74% 95.28% 95.70% 95.65% 95.83% 95.01% 95.50% 97.61% 95.48%

Variance 47.25% 44.74% 45.28% 45.70% 45.65% 45.83% 45.01% 45.50% 47.61% 45.48%

Target 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%

Actual 97.25% 94.74% 95.28% 95.22% 95.65% 95.83% 95.01% 95.50% 97.61% 95.48%

Variance 47.25% 44.74% 45.28% 45.22% 45.65% 45.83% 45.01% 45.50% 47.61% 45.48%

Target 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%

Actual 86.62% 86.17% 83.33% 86.10% 88.79% 86.72% 80.00% 85.03% 84.82% 84.51%

Variance 36.62% 36.17% 33.33% 36.10% 38.79% 36.72% 30.00% 35.03% 34.82% 34.51%


** Percentage greater than 100% possible, when total number of appointments offered exceeds the number of patients (please note September and Qtr 2 position updated)

T01

11Diabetic Retinopathy Screening **

T01

84

TCS 19 - % of Community Patients that have had an

unplanned admission LOS <=2 days (Defined set of

conditions)

T01

85

TCS 24 - % of Patients achieving improvement using a

EQ5 validated assessment tool

T01

86

TCS 35 - % of standard wheelchair referrals completed

within five days

T00

84

The % patients treated within 18 weeks of referral to

audiology (Hpool site)

T00

85Audiology non admitted wait (92nd percentile)

T00

13CIDs- Referral to Treatment information*

T00

14CIDs -Referral information*

T00

15CIDs- Treatment Activity Information*

T01

05Patient Identifier Indicator *

T01

06End of Life measure *

Appendix 1 - Out of Hospital Monitoring Framework (Index 4)

Menu

Draft

Nov-17 National North EastNorth Tees &

HartlepoolS Tyneside Sunderland N Cumbria Gateshead Newcastle Northumbria S Tees

Durham &

Darlington

RTT

Incomplete Pathways waiting <18 weeks 89.5% 94.20% 96.0% 94.8% 89.2% 94.0% 94.9% 93.7% 91.1% 92.8%

Half of patients wait less than 7 weeks 5.4 weeks 5 weeks 5 weeks 8 weeks 6 weeks 6 weeks 6 weeks 7 weeks 5 weeks

Half of admitted patients wait less than 10 weeks 6 weeks 5 weeks 10 weeks 13 weeks 12 weeks 8 weeks 10 weeks 6 weeks 9 weeks

19 out of 20 patients wait less than 33 weeks 26 weeks 18 weeks 26 weeks 34 weeks 26 weeks 23 weeks 28 weeks 27 weeks 28 weeks

Half of Non admitted Pathways waited less than 6 weeks 3 weeks 5 weeks 5 weeks 7 weeks 5 weeks 6 weeks 6 weeks 4 weeks 4 weeks

19 out of 20 patients wait less than 24 weeks 16 weeks 16 weeks 18 weeks 25 weeks 25 weeks 18 weeks 21 weeks 19 weeks 17 weeks

A&E

A&E 4 hour target (December 17) 85.1% 89.6% 94.00% 88.9% 83.7% 86.1% 90.7% 92.9% 91.4% 93.2% 85.2%

Cancer 62 Day Standard

Breast 95.20 97.95 (143/146) 100 (14/14) 100 (1/1) 0 (0/0.5) 100 (11/11) 95.38 (31/32.5) 100 (17/17) 100 (24/24) 100 (14.5/14.5) 96.83 (30.5/31.5)

Lung 71.90 79.78 (71/89) 88.46 (11.5/13) 60 (4.5/7.5) 40 (1/2.5) 75 (6/8) 85.71 (6/7) 75 (12/16) 100 (5.5/5.5) 86.49 (16/18.5) 77.27 (8.5/11)

Gynae 77.00 84 (42/50) 71.43 (2.5/3.5) 71.43 (2.5/3.5) 100 (4.5/4.5) 100 (5.5/5.5) 88 (11/12.5) 100 (4.5/4.5) 87.5 (3.5/4) 72.22 (6.5/9) 50 (1.5/3)

Upper GI 75.20 82.76 (48/58) 80 (4/5) 100 (3.5/3.5) 87.5 (3.5/4) 87.5 (7/8) 33.33 (0.5/1.5) 71.43 (7.5/10.5) 90 (4.5/5) 87.5 (14/16) 77.78 (3.5/4.5)

Lower GI 72.60 78.95 (60/76) 40 (2/5) 100 (1/1) 90.91 (10/11) 75 (9/12) 50 (1/2) 78.95 (7.5/9.5) 92.31 (6/6.5) 90.32 (14/15.5) 70.37 (9.5/13.5)

Uro (exc testes) 78.00 77.69 (148/190.5) 83.02 (22/26.5) 100 (0.5/0.5) 88.51 (38.5/43.5) 86.67 (19.5/22.5) 90.91 (10/11) 62.26 (16.5/26.5) 54.55 (12/22) 75.81 (23.5/31) 78.57 (5.5/7)

Haem (exc AL) 79.60 89.19 (33/37) 100 (3/3) 100 (1.5/1.5) 81.82 (4.5/5.5) 100 (8/8) 100 (2.5/2.5) 100 (4/4) 100 (1/1) 84.62 (5.5/6.5) 60 (3/5)

Head & Neck 67.10 74.47 (35/47) 0 (0/0) 50 (0.5/1) 100 (5/5) 66.67 (2/3) 0 (0/0) 71.74 (16.5/23) 100 (1/1) 73.91 (8.5/11.5) 60 (1.5/2.5)

Skin 95.40 98.05 (151/154) 100 (1.5/1.5) 0 (0/0) 100 (4.5/4.5) 95 (19/20) 0 (0/0) 98.39 (61/62) 100 (2/2) 100 (26.5/26.5) 97.33 (36.5/37.5)

Sarcoma 65.70 66.67 (5/7.5) 100 (0.5/0.5) 0 (0/0) 0 (0/0) 100 (0.5/0.5) 0 (0/0) 70 (3.5/5) 0 (0/0) 50 (0.5/1) 0 (0/0.5)

Brain/CNS 100.00 100 (1/1) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 100 (1/1) 0 (0/0) 0 (0/0) 0 (0/0)

Other 72.00 100 (6/6) 100 (0.5/0.5) 0 (0/0) 0 (0/0) 100 (2/2) 0 (0/0) 0 (0/0) 0 (0/0) 100 (2.5/2.5) 100 (1/1)

All 82.30 86.19 (743/862) 84.83 (61.5/72.5) 76.92 (15/19.5) 88.27 (71.5/81) 89.05 (89.5/100.5) 89.86 (62/69) 84.36 (151/179) 83.8 (59.5/71) 86.56 (132/152.5) 86.32 (101/117)

Appendix 1 - Benchmarking (Index 5) Menu

Draft

Appendix 1 - Benchmarking (Index 6) Menu

Draft

ID

Ap

r 17

May 1

7

Ju

n 1

7 QTR 1

Ju

l 17

Au

g 1

7

Sep

17 QTR 2

Oct 1

7

No

v 1

7

Dec 1

7 QTR 3

Jan

18

Feb

18

Mar 1

8 QTR 4

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 97.71% 98.10% 98.93% 98.24% 98.33% 97.61% 96.90% 97.94% 98.09% 96.71% 94.00% 97.31%

Variance 2.71% 3.10% 3.93% 3.24% 3.33% 2.61% 1.90% 2.94% 3.09% 1.71% -1.00% 2.31%

Target

Compliance

Variance

Incen

tive

Quarter 1

Incentive

Quarter 2

Incentive

Quarter 3

Incentive

Quarter 4

Incentive Annual Incentive

*Based on achievement of control totals

To achieve the performance requirement in Q2, trusts will need to achieve the higher of performance of 90% or their performance in Q2 16-17

Awaiting confirmation from NHSI

T0001 Emergency Care 4 hr standard

T0211 Implement streaming in A&E Department

£1,031,400

15.0% Apportioned based on front door streaming to GPs £154,800 £206,100 £309,600 £360,900 £1,031,400

15.0% Apportioned based on A&E 4 hour performance £154,800 £206,100 £309,600 £360,900

Appendix 1 - Sustainability and Transformation Funding (Index 7) Menu

Draft

Appendix 2Published Date & Time

18/01/2018 09:10

Measure Period Target Act QTR Cum Trend Measure Period Target Act Cum Trend

A&E New to Review ratio (cons led) Nov 17 1.45 1.22

Emergency Care 4 hr target Dec 17 95% 94.00% 96.18% 97.31% Outpatient DNA (new) Dec 17 5.40% 8.83%

Outpatient DNA (review) Dec 17 9.00% 10.24%

Cancer Act Q3 Cum Average depth of coding Nov 17 3.01 5.96

Length of Stay Elective Sep 17 3.26 1.78

New Cancer 31 days subsequent Treatment (Drug Therapy)* Dec 17 98% 100.00% 100.00% 99.78% Length of Stay Emergency Sep 17 4.34 3.77

New Cancer 31 days subsequent Treatment (Surgery)* Dec 17 94% 100.00% 100.00% 98.56% Day case Rate Sep 17 75.46% 74.15%

New Cancer 62 days (consultant upgrade)* Dec 17 85% 100.00% 100.00% 93.33% Pre - Op Stays Dec 17 4.50% 1.37%

New Cancer 62 days (screening)* Dec 17 90% 97.01% 98.04% 97.08% Cancelled (Non medical) Dec 17 0.80% 1.46%

New Cancer GP 62 Day (New Rules)* Dec 17 85% 92.13% 88.10% 85.22%

New Cancer Current 31 Day (New Rules)* Dec 17 96% 99.05% 98.69% 98.55% Bed Occupancy New Cancer Two week Rule (New Rules)* Dec 17 93% 94.65% 94.43% 93.34% Revised Occupancy Hartlepool Dec 17 85% 81.57%

Breast Symptomatic Two week Rule (New Rules)* Dec 17 93% 96.27% 97.16% 96.07% Revised Occupancy North Tees Dec 17 85% 95.30%

Revised Occupancy Trust Dec 17 85% 94.19%

RTT Milestones Delayed Transfers of Care Dec 17 3.50% 2.96%

RTT incomplete pathways wait (92%) Dec 17 92% 93.20% 94.04% 96.96% Delayed bed days Dec 17 948 503

Excess bed days Nov 17 1477 1188

DiagnosticsNumber of patients waiting less than 6 weeks for diagnostic procedures Dec 17 99% 98.62% 99.49% 0.00% Readmission rate 30 days (Emergency admission) Nov 17 9.73% 8.42%

Readmission rate 30 days (Elective admission) Nov 17 0.00% 3.80%

Community Information Dataset Readmission rate 30 days (Total) Nov 17 7.70% 6.39%

CIDs- Referral to Treatment information* Nov 17 50% 96.92%

CIDs -Referral information* Nov 17 50% 96.82% HRCIDs- Treatment Activity Information* Nov 17 50% 95.48% Sickness absence % * Nov 17 3.50% 5.08%

Staff turnover ratio Nov 17 10.00% 12.35%

HCAICumulative

YTD TargetMandatory Training Compliance Dec 17 80.00% 84.00%

Clostridium Difficile Patients - diagnosed after 72 hours all ages*** Dec 17 1 1 10 26

Access to Healthcare for People with Learning Disabilities Dec 17 0.00%

CQC Registration Dec 17 0.00%

Measure Period Target Act Cum Trend Measure PeriodRevenue

Position

CIP

Delivery

HSMR Mortality Rates (HSMR) Oct 17 100.00 99.72 ACCIDENT AND EMERGENCY Dec 17

HSMR - Weekend Oct 17 100.00 105.50 ANAESTHETICS Dec 17

Mortality rate (SHMI) Jun 17 100.00 108.01 CHIEF EXECUTIVE Dec 17

Mortality rate (SHMI) - {High relative risk CCS's} Jun 17 3 EAU & AMBULATORY CARE Dec 17

EDUCATION,LEARNING & DEVELOPMENT Dec 17

Eliminating Mixed Sex Accommodation Dec 17 0 0.00% ENDOSCOPY Dec 17

ESTATES Dec 17

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) Nov 17 58.40 62.50 FINANCE Dec 17

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Nov 17 34.48 28.92 HUMAN RESOURCES Dec 17

Emergency admissions for acute conditions that should not usually require hospital

admissionNov 17 177.00 157.80 OUT OF HOSPITAL CARE Dec 17

Unplanned hospitalisation for respiratory tract infections in under 19s Nov 17 84.54 62.29 IN HOSPITAL CARE Dec 17

MEDICAL DIRECTOR Dec 17

Patient Safety Incidents (All Grades) {per 100 admissions} Nov 17 6.80 14.05 NURSING AND PATIENT SAFETY Dec 17

Patient Safety Incidents that resulted in Serious Harm - {% of total PSIs} Nov 17 60.00% 9.98% OBS AND GYNAE Dec 17

Complaint response times Nov 17 79.00% 95.24% ORTHOPAEDICS Dec 17

OUTPATIENTS Dec 17

Corporate & Departmental Risks (Red) Dec 17 5 PAEDIATRICS Dec 17

Electronic Discharge Summaries within 24 hours (incl. A&E) Dec 17 95.00% 81.76% PATHOLOGY Dec 17

Grade 3 Pressure sores (Hospital only) Oct 17 1 2 PHARMACY Dec 17

Grade 4 Pressure sores (Hospital only) Oct 17 0 0 RADIOLOGY Dec 17

Total Falls (Hospital Only) Nov 17 92 119 RESEARCH AND DEVELOPMENT Dec 17 -Falls with Fracture (STEIS Reportable) Nov 17 0 0 STRATEGY, OPERATIONS AND PERFORMANCE Dec 17

VTE* Nov 17 95% 97.94% SURGERY AND UROLOGY Dec 17

Hand washing Compliance Dec 17 95% 97.00% TRANSFORMATION Dec 17 - -Cumulative

YTD TargetTOTAL DIRECTORATE Dec 17

MRSA - Bacteraemia (Cumulative)*** Dec 17 0 0 0 3 TRANSFORMATION Dec 17

Methicillin Sensitive Staphylococcus Aureus (MSSA) (Cumulative)*** Dec 17 1 1 19 17 TRANSFORMATION Dec 17

E-Coli (cumulative)*** Dec 17 1 3 34 36 UNALLOCATED CIP Dec 17 -OVERALL PORTFOLIO TOTAL Dec 17

Friends & Family CONTINUITY OF SERVICES RISK RATING

Friends & Family - (Ward)

[National Score based on % ‘extremely likely’ to recommend to F&F]Dec 17 70-100% 95.58% CAPITAL SEVICING CAPACITY (50%) Nov 17

Friends & Family - (A&E)

[National Score based on % ‘extremely likely’ to recommend to F&F]Dec 17 70-100% 93.13% LIQUIDITY RATIO (50%) Nov 17

Friends & Family - (Birth)

[National Score based on % ‘extremely likely’ to recommend to F&F]Dec 17 70-100% 97.22% I&E MARGIN (25%) Nov 17

VARIANCE IN I&E MARGIN (25%) Nov 17

OVERALL FINANCIAL RISK RATING Nov 17

Provisional

Compliance & STP Monitoring - Responsive Lord Carter/ Model Hospital - Effective

Finance - Our Money Quality - Caring & Safe

Draft

Single Oversight Framework – Governance Measures and Triggers for Concerns

Theme Information used Triggers

Quality of care • CQC information

• Other quality information to inform our view of a

provider (see Appendix 2)

• 7-day services

• CQC ‘inadequate’ or ‘requires improvement’ assessment in one or more of:

- ‘safe’

- ‘effective’

- ‘caring’

- ‘responsive’

• CQC warning notices

• Any other material concerns identified through, or relevant to, CQC’s

monitoring process, eg civil or criminal cases raised, whistleblower

information, etc

• Concerns arising from trends in our quality indicators (Appendix 2)

• Delivering against an agreed trajectory for the four priority standards for 7-

day hospital services

Finance • Sustainability

o Capital service cover

o Liquidity

• Efficiency

o I&E 14 margin

• Controls

o Performance against plan

o Agency spend

• Value for money information

Poor levels of overall financial performance (average score of 3 or 4)

Very poor performance (score of 4) in any individual metric

Potential value for money concerns

Operational

performance

NHS Constitution standards

Other national targets and standards

For providers with Sustainability and Transformation Fund (STF) trajectories in

any metric: failure to meet the trajectory for this metric for at least two

consecutive months (quarterly for quarterly metrics), except where the provider

is meeting the NHS Constitution standard

For providers without STF trajectories: failure to meet any standard for at least

two consecutive months

Strategic change Review of sustainability and transformation plans

and other relevant matters

Material concerns with a provider’s delivery against the transformation agenda,

including new care models and devolution

Leadership and

improvement

capability

Findings of governance or well-led review

undertaken against the current well-led framework

Third party information, eg Healthwatch, MPs,

whistleblowers, coroners’ reports

Organisational health indicators

Operational efficiency metrics

CQC well-led assessments

Material concerns

CQC ‘inadequate’ or ‘requires improvement’ assessment against ‘well- led’.

14 Income and expenditure, or surplus/deficit margin

Appendix 3

Draft

1



25 January 2018

Executive Summary

Learning from Deaths Report

Report of the Medical Director

Strategic Aim Putting Patients First

Strategic Objective

Putting Patients First / Patient Safety

1. Introduction

1.1 In March 2017, the National Quality Board (NQB) published national guidance “Learning from Deaths: A Framework for NHS Trust and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care”. The guidance provides requirements for Trusts to implement as a minimum in order ensure there is a focused approach towards responding to and learning from deaths of patients in our care.

1.2 This report provides details of the numbers of deaths that have occurred in the Trust since April

2017. It also provides the current position in relation to mortality case reviews that have been undertaken in relation to compulsory requirements in line with the Trust policy alongside additional reviews that have been undertaken.

1.3 The information presented in this report includes an overview of learning to date, including

positive findings as well as areas that have been identified for further development.

2. Key Issues & Planned Actions

2.1 The Trusts HSMR value in the latest period has decreased to 99.72, the SHMI is currently 108.01, both have now been within the expected range for 5 or more consecutive quarters.

2.2 Of the compulsory case reviews identified in the Trusts policy 81% have been reviewed to date; the pending reviews are those which have primarily been identified over quarter 3. Updates on pending reviews will be provided in future reports.

2.3 11 cases were identified as serious incidents, prior to case review. Of these, 5 have been

reviewed and 2 were identified as being avoidable. There are a further 6 cases where the investigations are ongoing and updates will be provided in the next report.

2.4 The Trust is working in close in partnership with Primary Care, Local Authorities, CCGs and a

number of other external stakeholders in order to identify where strategic changes can be initiated to support planning and the provision of end of life care across all areas of health and social care.

2.5 The reviews have identified many cases where there has been excellent care provision.

Significant numbers of frail, elderly patients are admitted to the Trust and in the majority of these cases there is evidence of safe, effective and responsive care provision.

2.6 There are areas where continued improvements are needed; these have been identified and

each has ongoing monitoring in place. The Trust Outcome, Performance, Delivery Operational

Draft

2

Group and the Patient Safety and Quality Standards Committee seek further assurance in relation to these areas in line with their terms of reference.

3. Recommendations

3.1 The Board of Directors are asked to note the content of this report and the information provided in relation to the reduction in the Trusts mortality rates.

3.2 The Board are asked to note the on-going work programme to reduce mortality rates within the organisation.

Dr D Dwarakanath

Medical Director

Draft

3



25 January 2018

Learning from Deaths Report

Report of the Medical Director

1. Introduction/Background 1.1 In March 2017, the National Quality Board (NQB) published national guidance “Learning from

Deaths: A Framework for NHS Trust and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care”. The guidance provide requirements for Trust to implement as a minimum in order ensure there is a focused approach towards responding to and learning from deaths of patients in our care.

1.2 The Trust strives to improve the care provided to all of our patients; the overall aim is to identify,

understand and implement improvements where any issues are related to the provision of safe and effective quality care. It is considered that if such safety and quality improvements are initiated effectively and embedded, then the mortality statistics will naturally show improvement.

1.3 The information presented in this report provides an overview of learning from deaths that has

been obtained from mortality reviews undertaken by the Trust. The Trust policy identifies some key areas where all deaths will be reviewed and also identifies that additional randomly selected cases will also be included in the review process. Some compulsory review areas have small numbers, therefore learning is presented as a summation of all reviews to reduce the risk of identifying cases directly.

2. Mortality Data

2.1 Information related to mortality is gathered from data provided routinely by the Trust to a national system where all hospital episode statistics (HES Data) is collated. Hospital Standardised Mortality ratio (HSMR) examines information covering 56 diagnostic groups that are identified as accounting for 80% of hospital deaths nationally. This information is used to calculate an overall HSMR taking into account, gender of the patient, age, how the patient was admitted (emergency or elective), levels of deprivation, how many times they have been admitted as an emergency in the last year, if palliative care was provided and various details relating to presenting complaint on admission.

2.2 This calculation is undertaken nationally and provides the Trusts overall HSMR. The latest HSMR value is 99.72 (November 2016 to October 2017) a slight increase from 99.52 (October 2016 to September 2017), this new value continues to remain inside the „as expected‟ range for the 7th consecutive quarter.

2.3 The Trust currently resides 69th from the 137 Trusts, nationally, on its HSMR value.

2.4 The Summary Hospital-level Mortality Indicator (SHMI) is a ratio between the number of actual (observed) deaths to the “expected” number of deaths for an individual Trust, including deaths in hospital and up to 30 days following discharge. The ratio is calculated with consideration of gender, age, admission method, admissions in the last year and diagnosis being treated for the last admission. Draf

t

4

2.5 The ratio is calculated nationally and provides the trusts overall SHMI. The latest SHMI value is 108.01 (July 2016 to June 2017), this has decreased from a value of 109.07 (June 2016 to May 2017), the value maintains the Trust in the „as expected‟ range for the 5th consecutive quarter.

2.6 The Trust has improved from the highest SHMI value in the country, to the 27th highest.

3. Mortality reviews 3.1 The Trust uses an electronic system to record mortality case reviews that are undertaken; this

system is also used by other trusts in the region and is based on the “PRISM” methodology, one of the review tools recommended in the national guidance. This is a structured review of a case record, carried out by clinicians not involved in the patient‟s care, to determine whether there were any problems in care. Case record review is undertaken routinely to learn and improve in the absence of any concerns, with all directorates undertaking their own specialty based mortality and morbidity meetings. This is because it can help identify issues where there are no initial concerns. It is also used where concerns exist, such as when bereaved families or members of staff raise issues about care.

3.2 The Trust policy identifies that all in-patient deaths and those in the Accident and Emergency department are included in the scope of the mortality reviews. Since April the Trust has reported the following deaths:

3.3 The Trust policy identifies specific cases where a compulsory review is required; these include:

• Where requests are made by families to undertake a case review.

• Where staff request a case review.

• All deaths in the Intensive Care Unit (ICU).

• All deaths linked to complaints about significant concerns in relation to clinical care.

• All deaths linked to Serious Incident investigations.

• All deaths where the patient was admitted for elective treatment.

Compulsory case reviews are also undertaken for the following cases, which are linked to specific national review processes, some of these reviews are not yet recorded in the Trust mortality system and this is an area of ongoing development:

• All deaths where a patient has a registered Learning Disability (LD) – in conjunction with the Learning Disability Mortality Review Programme (LeDeR).

• All maternal deaths – in conjunction with M-BRRACE-UK.

• All deaths where the patient has a severe mental illness – in conjunction with local Mental Health Trusts as required; this definition to be agreed nationally and the identification of these cases will be agreed in partnership with local Mental Health Trusts.

Draft

5

• All child deaths (up to 18th birthday) – in conjunction with the Child Death Overview Panel (CDOP) process

• All stillbirths – in conjunction with nationally agreed Perinatal Mortality Review tool.

There are also additional reviews that are undertaken either as a random selection or in response to requests internal or external to the Trust.

3.4 Where a patient‟s death immediately raises concern this should be reported and escalated through the Trusts incident reporting process, implementing Duty of Candour procedures as required. This includes informing senior staff of the case and the identified concerns; the details of the case will then be considered in line with the national Serious Incident framework and reported to the Trusts commissioners. A case record review is completed as part of the investigation process.

Since April 2017 there have been 11 cases reported and investigated as serious incidents, all of these were identified prior to mortality reviews being completed. Of these cases 5 have been investigated and 2 cases were considered to be avoidable deaths. The remaining 6 investigations are currently in progress and the overall outcome will be reported in the next report.

3.5 The data presented in the appendix provides detail of all case reviews undertaken since April 2017. There are cases that may not have been identified immediately but have come to light as a result of the receipt of complaints and family requests through the Trust Bereavement survey; as a result there are some reviews pending completion. The following table provides a summary of the data by financial quarters for 2017-18.

Q1 Q2 Q3 Total

Total deaths in scope 357 329 432 1118

Deaths in compulsory criteria 40 34 47 117

Compulsory case reviews completed (no.) 39 27 29 95

Compulsory case reviews completed (%) 98% 80% 72% 81%

Compulsory reviews pending 1 7 18 22

Additional reviews completed 72 47 28 147

Total of reviews completed (no.) 111 74 57 242

Total of reviews completed (%) 31% 22% 14% 22%

Reviewed Deaths considered avoidable (no.) 1 1 0 2

Reviewed Deaths considered avoidable (%) 1% 1% 0% 1%

Reviewed Deaths considered not preventable (no.) 110 73 57 240

Reviewed Deaths considered not preventable (%) 99% 99% 100% 99%

4. Learning from reviews 4.1 Strategic learning

4.1.1 Many of the patients who die in our care are frail and elderly having been admitted for care at the end of their lives. The Trust along with Primary Care (General Practitioners) and the Clinical Commissioning groups (CCGs) has identified that in cases where there has been little or no planning for what is going to happen during the last days of life this may lead to patients being

Draft

6

admitted to hospital for treatments or interventions that may be both potentially intrusive and distressing as well as clinically futile. With planning this could have been avoided.

As a result the Trust has been promoting the use of Emergency Healthcare Plans (EHCP) and use of the “Deciding Right” recommendations to ensure there is a multidisciplinary team (MDT) approach to this across community and hospital environments. The Trust is planning to support this further through development of a model of care relating to “Frailty in the Community”; this is in partnership with Primary Care, Local Authorities, CCGs and a number of other external stakeholders. In order to increase and enhance the use of EHCPs the Trusts Specialist Palliative Care team are working with local nursing homes to provide education and support to staff. This will enable them to develop plans with patients and families that reflect what they want to happen in the final days of life and where they want to be. This is part of a larger, long term project examining an overarching “whole community” approach towards end of life planning and care provision.

4.2 Positive learning from reviews

4.2.1 As a result of the Trust undertaking multidisciplinary reviews of cases it has been identified that there are many areas of good practice that are regularly reported; it is agreed that the following areas of good practice are worthy of note:

The Trust has added a learning disability “flagging system” to the electronic patient record. It is now confident that it can identify the majority of these patients and can provide the necessary level of support during their admissions; as a result the Trust can also readily recognise when a patient with learning disability dies in our care. Following a visit to the Trust by the North East & Cumbria Learning Disability Network this flagging system for people with learning disabilities has been recognised at a national level and is being progressed through NHS Digital.

The Learning Disability team have identified that some of the overseas nursing staff may not have had contact or experience with patients with learning disabilities. As a result of this the team now provide an education session during the induction programme for overseas nursing staff; as this progresses the team are planning to offer this to medical staff from overseas.

Reviews have reinforced the need for professionals to continue to actively promote smoke free homes where there are children; smoking is a risk factor linked with premature births, stillbirths and sudden infant deaths. The Trust has a very active smoking cessation team that already work in close collaboration with the maternity services to promote smoking cessation in families. There is also significant ongoing work across all areas of the NHS in relation to smoking cessation, co-sleeping and other risk factors to sudden infant death, as this is major public health concern.

The maternity team have, as a result of reviewing trends in neonatal deaths, identified the benefits of delaying cutting the umbilical cord when premature births occur; research has advised that this can help premature infants by increasing their blood volume.

Reviews of stillbirths have been in place for some time; however the maternity team have recognised that often parents may only receive feedback following the internal review and have not been directly involved in the review process itself. The team have recognised that this needs to change and have started to invite families to be part of the review, if they wish to be involved.

There are many cases where there has been appropriate escalation to senior staff and the critical care team; this has allowed effective multidisciplinary decision making about proposed interventions or treatments and where necessary consideration about the need to refer patients to external centres for more advanced levels of care.

The Intensive Care Unit (ICU) team have identified from their reviews that there have been occasions when local processes may not have been followed in full when considering the futility of ongoing treatment and commencement of comfort care and when brain stem

Draft

7

testing may be necessary. As a result local guidance has been made more accessible. Support from the Trusts Senior Nurse for Organ Donation is also a vital tool for staff; regular updates are provided regarding guidance and communication with families for staff in ICU as well as the Accident and Emergency Department.

There is regularly excellent or good communication with patients and families in relation to decision making at the end of life; this is frequently fully documented in the records.

Case reviews have identified the need to involve the Trust‟s Specialist Palliative Care team as early as possible when it is identified that a patient may be reaching the end of their life. As a result of changing to an electronic referral process the team have increased the numbers of patients being reviewed whilst in hospital. This provides additional support to patients and their families; as well as ward staff providing care to patients who are reaching the end of their life. Where possible fast track discharges are arranged to support patients who may wish to die at home or in a hospice. The Trust feels that the appropriate use of the team enhances the quality of care to these patients and their families during such a difficult time. The feedback from families has supported this improvement; the Trust asks families to provide feedback through a “Family Voice” document and the trust bereavement survey also provides another opportunity for feedback for families whose loved one has died in the hospital.

There is regular communication with the Coroner in relation to cases where clinical staff need to discuss a cause of death. Where a death is reviewed at an inquest the Trust has reviewed its processes for gathering information and providing support for staff who may be involved.

The Trust is also a member of the Regional Mortality Group; this group has been running for 3 years, providing an opportunity for Trusts to share learning from the ongoing mortality work and also to examine areas of development that can be introduced across the region. This group also provides an aspect of “peer” review in relation to overall mortality review processes and policies. The group is attended by all NHS Trusts in the region thereby enabling regional comparisons to be undertaken in relation to the numbers of reviews and assessment of avoidable deaths.

4.3 Areas under development

4.3.1 As a result of completed case reviews the Trust recognises there are occasions where the quality of care could have been improved:

There are many case reviews where monitoring of the National Early Warning Scores (NEWS) and fluid balance were completed effectively and in a timely manner. However there are also cases where this could have been improved. Some of these deaths have been investigated as serious incidents and the learning has been shared with the Trusts Commissioners as well as NHS England. As a result of these incidents the Trust has:

o Reviewed education and learning for all grades of staff in relation to NEWS and fluid monitoring.

o Used scenarios to enhance training in the Trust‟s Simulation Suite as well as training drills in clinical areas.

o Reviewed and updated the monthly audits in relation to both areas of learning; these are reviewed through a Quality Reference Group that has been established within the Trust.

Communication has been identified as an area for improvement; this can be more problematic during transfer of a patient between clinical teams or ward. In order to impact on this the Trust has developed a policy in relation to clinical handover; this policy aims to support communication between clinical staff when there is a change in staff; and also support robust communication when there is a need to escalate concerns to senior staff. This policy requires each area to have a written procedure for all grades of staff detailing

Draft

8

handover of care or escalation procedures; compliance monitoring is to be monitored through the Trusts Audit and Clinical Effectiveness Committee.

The learning disability team recognised that when planning care at the end of life, the involvement of the carers can be just as important as involving the family members, although family members should also be asked their views of patients‟ needs as it may differ from the carers. The learning disability team have now included this in the educational sessions for clinical staff stressing how important it is to listen to what both family and carers have to say to provide a considered plan of care for the patient. Progress in relation to this will be monitored through future reviews of patients with learning difficulties.

The maternity and neonatal teams have also considered how they share information with parents if premature labour occurs. They have identified that the information given may not always be clear about the potential outcome for the baby, and may provide false expectations and hope in some cases. In view of this they are currently looking at what is discussed and how it is explained to families in a sympathetic but realistic way. The maternity team will assess the impact of this in relation to future cases reviewed.

During cases reviews it has been identified that there may not always be good information in relation to ongoing illnesses (comorbidities) that patients may have as well as the problem that has required their admission to hospital. In order to support clear documentation and communication of co-morbidities, the Trust has undertaken a review of documents used when a patient is first seen by a doctor on arrival. Several changes and additions have been made in order to assist staff in recording this information more easily and effectively. There are several other areas of work that have been established to support improvements in this area; these include departmental restructures and appointments of clinical leads for sub-specialities. The Clinical Coding team have also been undertaking regular reviews and audits of coding to ensure this is completed to the highest quality. To date the changes have improved the recording of co-morbidities; whilst this assists in improved information and statistical analysis for those patients who have died; a more important additional benefit is the improved communication with other healthcare professionals, including GPs in relation to our patients who are discharged. There continues to be further work undertaken to assess the impact of the various changes made and this is being monitored through the Trusts Executive team.

5. Conclusion/Summary 5.1 The Trusts HSMR value in the latest period has decreased to 99.72, the SHMI is currently

108.01, both have now been within the expected range for 5 or more consecutive quarters.

5.2 Of the compulsory case reviews identified in the Trusts policy 81% have been reviewed to date; the pending reviews are those which have primarily been identified over quarter 3. Updates on pending reviews will be provided in future reports.

5.3 11 cases were identified as serious incidents, prior to case review. Of these, 5 have been

reviewed and 2 were identified as being avoidable. There are a further 6 cases where the investigations are ongoing and updates will be provided in the next report.

5.4 The Trust is working in close in partnership with Primary Care, Local Authorities, CCGs and a

number of other external stakeholders in order to identify where strategic changes can be initiated to support planning and the provision of end of life care across all areas of health and social care.

5.5 The reviews have identified many cases where there has been excellent care provision.

Significant numbers of frail, elderly patients are admitted to the Trust and in the majority of these cases there is evidence of safe, effective and responsive care provision.

Draft

9

5.6 There are areas where continued improvements are needed; these have been identified and each has ongoing monitoring in place. The Trust Outcome, Performance, Delivery Operational Group and the Patient Safety and Quality Standards Committee seek further assurance in relation to these areas in line with their terms of reference.

6. Recommendations

6.1 The Board of Directors are asked to note the content of this report and the information provided in relation to the reduction in the Trusts mortality rates.

6.2 The Board are asked to note the on-going work programme to reduce mortality rates within the organisation.

Dr D Dwarakanath Medical Director

Draft

10

Appendix 1

Pending

Review

Additional

Reviews

Total

reviewedOverall

No. No. No. No. % No. No.

Apr 17 9 0 13 22 17% 0 22

May-17 16 0 21 37 29% 1 36

Jun-17 14 1 38 52 50% 0 52

Quarter 1 39 1 72 111 31% 1 110

Jul-17 9 2 25 34 33% 1 33

Aug-17 13 2 15 28 27% 0 28

Sep-17 5 3 7 12 10% 0 12

Quarter 2 27 7 47 74 22% 1 73

Oct-17 13 8 23 36 30% 0 36

Nov-17 10 4 5 15 12% 0 15

Dec-17 6 6 6 3% 0 6

Quarter 3 29 18 28 57 14% 0 57

Jan-18

Feb-18

Mar-18

Quarter 4

Totals 95 22 147 242 22% 2 240

North Tees and Hartlepool NHS Foundation Trusts Mortality Review Data 2017-18

0% 100%

357 40 98% 1% 99%

80% 1% 99%329 34

432 47 72%

1118 117 81% 1% 99%

182 12 50% 100%

129 14 71% 100%

121 21 62% 100%

82% 3% 97%

103 15 93% 100%

120 8 63% 100%

105 15 87% 100%

No. % % %

Month of death

Total No of

deaths - In-

Patient & A&E

Deaths meeting

inclusion criteria

Deaths reviewed meeting

inclusion criteria

Deaths judged as

avoidable(>50%

likelihood of avoidability

Deaths reviewed judged

as not preventable

128 16 100% 3% 97%

126 9 100% 100%

104 11

Draft

draft - north tees and hartlepool nhs foundation trust · 2018-01-24 · the ce reported that the...

Documents