A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE … · 2. To review the Register of Interests and receive any further declarations of interests : 15/07/P02 . 3. To . approve

BoD July 2015: 00 Agenda

A MEETING OF THE BOARD OF DIRECTORS

WILL TAKE PLACE ON THURSDAY 02 JULY 2015, 9AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

No Item Sponsor Ref

1. Apologies and Welcome

S Wragg, Chairman

2. To review the Register of Interests and receive any further declarations of interests

15/07/P02

3. To approve the Minutes of the meeting of the Board of Directors held in public on 11 June 2015 15/07/P-03

4. To approve the Action Log in relation to progress to date and review any outstanding actions 15/07/P-04

Strategic Aim 1: Patients will experience safe care

5. To receive and review latest Patient Flow results K Dunwell Medworxx Presentation

6. To receive and support the Chair’s Log and assurance from the Quality & Governance Committee

H McNair Director of Nursing &

Quality

15/07/P-06

15/07/P-07 7. To ratify the Trust’s response to Savile Report

8. To receive the monthly report on the Trust’s Mortality Ratios Dr R Jenkins Medical Director 15/07/P-08

9. To review the Chair’s Log on any escalation issues from the Executive Team

D Wake Chief Executive

Strategic Aim 2: Partnership will be our strength

10. To note the monthly report from the Chairman S Wragg, Chairman 15/07/P-10

11. To note and endorse monthly report from Chief Executive D Wake, Chief Executive 15/07/P-11

12. To receive the latest Agenda and approved Minutes of the Council of Governors

S Wragg, Chairman 15/07/P-12

Strategic Aim 3: People will be proud to work for us Strategic Aim 4: Performance matters

13. To receive and endorse the Chair’s Log and assurance from the Finance & Performance Committee

F Patton Committee Chair 15/07/P-13

14. To review the integrated performance report (month 2) Executive Team 15/07/P-14

15. To note intelligence reporting/horizon scanning for the Board E Parks

Director of Comms & Engagement

15/07/P-15

Cont/…

BoD July 2015: 00 Agenda

No Item Sponsor Ref

16. In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. Date of next meeting - 06 August 2015, 9am Signed: ………..…………………… Chairman

Please see reference section at back of papers for key to business plan and glossary of terms/acronyms

REF: 15/07/P-02

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

BoD July 2015: 02(i)_Register of Interests

SUBJECT: REGISTER OF INTERESTS

DATE: JULY 2015

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information Strategy

PREPARED BY: Carol Dudley, Secretary to the Board SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT 2-3 sentences

To support the Trust’s ethos of transparency in all matters, including the financial interests of the Board of Directors and senior management.

QUESTION(S) ADDRESSED IN THIS REPORT

CONCLUSION AND RECOMMENDATION(S)

The Board is asked to review:

• the Registers of Interests of the Board of Directors, collated in accordance with the National Health Service Act 2006 (as amended by the Health & Social Care Act 2012) and the Trust’s Constitution

• the Register of Directors for the Executive Team and Clinical Directors, in accordance with the Board’s agreed good practice and as recommended by the Audit Committee.

It should be noted that whilst every effort is made to assist Directors’ declarations, it is the responsibility of each individual to ensure that his or her interests are declared in a timely and appropriate manner. The Board may wish to note that a Register of Interests is also held for the Council of Governors. The Registers will be presented to the Audit Committee and are available for public inspection.

BoD July 2015: 02(i)_Register of Interests

REFERENCE/CHECKLIST

• Which business plan objective(s) does this report relate to?

• Has this report considered the following stakeholders?

Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor

• Has this report reviewed the Trust’s compliance with:

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc)

Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Is this report supported by a communications plan?

Yes

Not applicable

To be developed

• Has this report (in draft or during development) been reviewed by any Board or Executive committees within the Trust?

CGC

NCGRC

Audit Committee

Finance Commitee

ET

• Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees

• Where applicable, state resource requirements:

Finance: Other:

NHS Constitution: In determining this matter, the Board should have regard to the Core principles contained in the Constitution of:

• Equality of treatment and access to services • High Standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: To be the best integrated healthcare organisation of choice for our local communities and beyond.”

02(ii) Register of Interests_BoD June 2015 Signed: Secretary to Board Page 1 of 4 Dated: 26 June 2015

BARNSLEY HOSPITAL NHS FOUNDATION TRUST REGISTER OF BOARD OF DIRECTORS’ INTERESTS (JUNE 2015)

EXECUTIVE DIRECTORS Entry No 1 DIRECTOR Date of

appointment INTERESTS Date interest registered2

Date entry reviewed

31 Mr Stuart Diggles - Interim Director of Finance April 2014 • Owner & Director, TASK Finance Limited 26 June 2014 08 January

2015

34 Dr Richard Jenkins - Medical Director January 2015 • None 07 January 2015 08 January

2015

32 Karen Kelly - Director of Operations

01 July 2014 (exec) • None 01 July 2014 08 January

2015

24 Heather Mcnair – Director of Nursing & Quality

05 December 2011 • None 08 December

2011 08 January

2015

30 Ms Diane Wake - Chief Executive

28 October 2013 • None 08 November

2013 08 January

2015


BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF BOARD OF DIRECTORS’ INTERESTS (JULY 2015) NON EXECUTIVE DIRECTORS Entry No 1 DIRECTOR Date of

Appointment INTERESTS Date interest registered2

Date entry reviewed

25 Mrs Suzy Brain England OBE – Non Executive Director

01.01.2012 - 31.12.2014 - 31.12.2017

19 January 2012 08 January

2015

• Chair, Derwent Living Housing Association

• Peer Assessor & Trainer, Institute of Directors

• Lay Chair, Yorkshire Deanery

• Founder and Director, Cloud Talking on-line Mentoring

19 September 2012

22 Mrs Linda Christon – Non Executive Director

01.01.2010 – 31.12.2012 – 31.12.2015

• Independent Board Member, St Leger Homes 26 October 2011 08 January

2015

• Member, Ethics panel with South Yorkshire Police & Crime Commissioner

31 December 2014

08 January 2015

35 Mr Nicholas Mapstone – Non Executive Director

01.04.2015 - 31.12.2017

• Director, Nick Mapstone Management Solutions Limited

• Associate, for 360 Assurance • Specialist Advisor,

for Care Quality Commission

April 2015


Entry No 1 DIRECTOR Date of


Date entry reviewed

36 Ms Rosalyn Moore – Non Executive Director

01.04.2015 - 31.12.2017

• Trustee, Association for Perioperative Practitioners

• Chief Executive Officer, Parish Nursing Ministries UK

April 2015

17 Mr Francis Patton – Non Executive Director & Deputy Chair

01.01.2008 - 31.12.2009 - 31.12.2010 - 31.12.2013 - 31.12.2016*

• Chairman, The Cask Marque Trust

14 January 2008

08 January 2015

• Treasurer, All Party Parliamentary Beer Group

• Senior Lecturer (part time), Leeds Metropolitan University

• Non Executive Director The BII (British Institute of Innkeeping)

23 June 2009 June 2014

• Managing Director Patton Consultancy 26 August 2010

• Non Executive Director, SIBA, The Society of Independent Brewers

September 2010

• Director, Fleet Street Communications December 2010

• Chairman, Barnsley Hospital Support Services Limited

24 May 2012

• Director, Cyclops Limited (charitable organisation)

15 September 2014


Entry No 1 DIRECTOR Date of


Date entry reviewed

19 Mr Stephen Wragg – Chairman

01.01.2009 - 31.12.2011 - 31.12.2014 - 31.12.2017*

• Non Executive Director, Barnsley Premier Leisure Trading 7 January 2009

08 January 2015

• Sole Director, Wragg Consulting Limited 20 May 2010

• Labour Party, Member 29 June 2011

• Director, 360 Engagement Ltd 18 October 2011

• Governor, Darton College

12 December 2011

• Trustee, Barnsley Civic

15 December 2011

Notes: 1 Entry numbers to run consecutive by date order 2 Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chief Executive or Nominated Officer * Subject to annual review/renewal

Signed: Secretary to the Board 02(iii) Register of ET_Dirs_CDs JUN 2015 Page 1 of 2 Dated: 26 June 2015

BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF EXECUTIVE TEAM & CLINICAL DIRECTORS’ INTERESTS (June 2015)

Entry No 1 NAME / POST Date of

appointment INTERESTS Date interest

registered Date entry reviewed

15 Dr Akhilesh Bowry – Clinical Director, CBU2

December 2011 2 None 02 February

2012 08 January

2015

31 Mr Jason Bradley – Director of ICT 1st March 2012 None 08 January

2015

23 Mrs Lorraine Christopher – Associate Director of Estates & Facilities 23 Feb 2009

Director, Barnsley Hospital Support Services Limited (BHSS) Familial interest: a) Capita Symonds Ltd

Sister = Director b) Harrison Thompson & Co Ltd

Husband = Sales Director

15 Aug 2013

25th May

2013 29th June

2013

08 January 2015

16 Miss Meenakshi Dass – Clinical Director, CBU6

December 2011 2

Member, Urogynae Advisory Board for Astellas company

December 2014

08 January 2015

38 Mr José Fernandez – Associate Director of HR&OD May 2015

32 Dr Dyfrig Hughes – Clinical Director, CBU1 March 2013 2 None 08 January

2015

21 Dr Kapil Kapur – Clinical Director, CBU3

December 20112 None 08 January

2015

36 Ms Angela Keeney – Interim Associate Director of Corporate Affairs

May 2014 None 08 January 2015

35 Mr Robert Kirton – Director of Strategy & Business Development

May 20143 a) Non Executive Director,

Medipex (acting for Trust) b) Director, BHSS

July 2013 15 Aug 2013

08 January 2015

Signed: Secretary to the Board 02(iii) Register of ET_Dirs_CDs JUN 2015 Page 2 of 2 Dated: 26 June 2015

Entry No 1 NAME / POST Date of

appointment INTERESTS Date interest

registered Date entry reviewed

37 Ms P McLaren - Assoc Director, Operations (June 2015)

September 2014

Director, Alchemy RP Limited

December 2014

08 January 2015

32 Ms E Parkes – Director of Communications & Marketing March 20144 None 08 January

2015

30 Mr Martin Wickham – Clinical Director, CBUs 4&5 March 20122 Director, Wickham & Taylor Ltd 23 June 2014 08 January

2015 Notes:

1 Entry numbers to run consecutive by date order 2 Where applicable Clinical Director appointment dates show date of original appointment as Divisional Director/ Divisional Medical Director;

and transitionto new Clinical Business Unit (CBU) structure 2014 3 Previously Interim Director of Transformation from June 2013 4 Previously Associate Director of Communications from April 2013

REF: 15/07/P-03

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

MINUTES OF A MEETING OF THE BOARD OF DIRECTORS

ON 11 JUNE 2015 EDUCATION CENTRE, BARNSLEY HOSPITAL

PRESENT: Mrs S Brain England OBE Non Executive Director Mrs L Christon Non Executive Director Mr S Diggles Interim Director of Finance & Information Mr N Mapstone Non Executive Director Ms R Moore Non Executive Director Mr F Patton Non Executive Director Dr R Jenkins Medical Director Mrs K Kelly Director of Operations Mrs H McNair Director of Nursing & Quality Ms D Wake Chief Executive Mr S Wragg Chairman

IN ATTENDANCE: Mr J Bradley Director of ICT Mrs L Christopher Associate Director of Estates & Facilities Ms C E Dudley Secretary to the Board & Governors Ms D Firth Matron, Emergency Department * Mr J Fernandez Associate Director of HR Dr K Kapur Clinical Director, General & Special Medicine (CBU3) Mr R Kirton Director of Strategy & Business Development Ms P McLaren Interim Director of Communications & Marketing Mr M H Wickham Clinical Director, Diagnostics & Clinical Support services and Surgical Services (CBUs 4&5) (* attended for Minute 15/100)

15/96 APOLOGIES & WELCOME

Members and attendees were welcomed. It was also noted that, as a courtesy, apologies had been received from Dr Bowry and Miss Dass, Clinical Directors.

ACTION

15/97 DECLARATIONS OF INTEREST None.

15/98 MINUTES OF LAST MEETING (15/06/P-03) The Minutes of the meeting of the Board of Directors held in public on 07 May 2015 were reviewed and accepted as a true record.

15/99 ACTION LOG (15/06/P-04) The action log, showing progress on matters arising from the last and previous meetings held in public, was reviewed and noted. Updates on several issues were included in the agenda. The new format of the Log was noted and welcomed, making status of actions more easily identifiable.

BoD July 2015: 03_Bod Minutes (June PUM) Page 2 of 9

15/100 PATIENT’S STORY Ms Firth presented an encouraging patient’s story, involving an elderly patient, referred to as Mrs A. Until a few months ago, Mrs A had been living in her own home, which she had given up to move into a care home having recognised her growing support needs. More recently she had been brought into the hospital when she became unwell. The Emergency Department (ED) team was quickly able to assess that the prognosis was not good for Mrs A and, despite demands on the ED and beds at the time, unanimously agreed to move her into a single room on the Clinical Decisions Unit (CDU) to give her privacy and comfort in her last days. Every effort was made to contact Mrs A’s son; he did not live in Yorkshire and it took numerous attempts before he could be reached on his mobile, on holiday at Whitby. Mr A drove straight over to be with his mum and was with her when she passed away peacefully four days later. During this time the team – and a host of other staff – were mindful of Mr A’s needs as well as those of his mum. Having broken off from his holiday, Mr A had driven to Barnsley in his campervan. When they heard of his position, the security team contacted him to recommend the best place for the van to be parked on site and monitored it as part of their regular duties. Staff from the domestic and volunteers’ teams ensured he had refreshments every day in his mum’s room and provided him with a digital radio when he mentioned that the room, whilst comfortable (but not intended for long stays) was very quiet and quite isolating. Although the outcome was a sad one, Mr A was very appreciative of the care extended to his mum and to him and the extra lengths staff clearly went to, to ensure their last days together were as comfortable and peaceful as possible. He said that he could not have wished for better end of life care for his mum. The story illustrated the responsiveness of the Trust’s staff and services to patients’ needs: from using the CDU for end of life care for Mrs A, to looking after her son’s needs too. The Chairman had received tremendous feedback from another family who had also appreciated the care provided on the CDU. The Board thanked Mrs Firth for presenting her story and asked that their thanks be shared with the staff involved as well. The Chairman reminded members that a Patient’s Story was presented at the top of each agenda to set the context for the Board’s discussions and decisions.

15/101 INFECTION PREVENTION & CONTROL PROGRAMME/ (15/06/P-06) ACTION PLAN 2015/16 Mrs McNair presented and expanded on the draft plan and confirmed that it contained essential elements to ensure the Trust’s compliance with the requirements of the Hygiene Code and maintain (and improve) the current good performance on Infection Prevention & Controls (IP&C) across the site. Unusually, due to timing demands, the Plan had come direct to the Board without having been reviewed by the Quality & Governance Committee but had been scrutinised by the IP&C team. In response to a query from the Chief Executive, Mrs McNair confirmed that the draft did not currently include reference to improvements proposed for the Trust’s isolation facilities, as discussed by the Executive Team recently, but these would be added in before the Plan was issued. Mrs Brain England drew attention to the Sharps Control week featured in the Plan and highlighted the incidence of needlestick injuries. This was an area of concern to her, which, through the Audit Committee, she had asked to be reviewed further. Mrs Christon, as Chair of the Quality & Governance

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Committee (Q&G), advised the Board that needlestick injuries were monitored by the Sharps and Health & Safety Groups and escalated up to Q&G accordingly; a range of work was being progressed to raise awareness around and prevention of these injuries. Subject to the above, the Plan was approved.

15/102 QUALITY & GOVERNANCE (Q&G) COMMITTEE (15/06/P-07) The Chair’s Log from the recent Q&G Committee meeting held on 27 May 2015 was received and reviewed. The Board noted and supported the different approach now agreed, to support improvements to the Urology Services. Dr Jenkins advised that whilst this did differ from the approach previously endorsed by the Board, the planned direct recruitment would support expanded partnership working with Mid Yorkshire and Sheffield Teaching Hospitals and give the Trust more control over the service, enabling development of better services for patients at Barnsley and opportunity for further service development in the future. Expansion of these services would be phased, with recruitment as the first step and future service developments being subject to presentation and evaluation of business cases through the Trust’s usual governance systems. The Chair’s Log also drew attention to pressures on 7-day services if not fully funded and the need to consider the long term strategic challenges to the nursing and midwifery staffing levels. Mrs McNair assured the Board that nurse staffing levels continued to be constantly monitored although there were pressures in some speciality areas. Mrs Kelly confirmed that the escalation ward, ward 29, had closed (w/c 8 June), which would alleviate some pressures. Ms Wake also advised that whilst this would release staff back to their normal duties, management needed to be conscious of other knock on effects of the closure, such as an increase in medical outliers and the need for close adherence to policy to ensure continued good care of these patients and good management of their length of stay. The Chairman advised that Q&G had been extremely concerned about the risks to 7-day services, which had supported improvements in key performance areas such as the Hospital’s Standardised Mortality Ratio (HSMR). At its last meeting, the Board had agreed that the Trust should continue to run 7-day services despite the associated financial risks. Discussions on funding options were continuing, both internally and externally. With regard to the update on stroke services, Dr Jenkins affirmed that the service had been included in the recent regional audit and regularly participated in the SSNAP audits (Sentinel Stroke National Audit Programme) run by the Royal College of Physicians. The Trust had not benchmarked well historically but Dr Jenkins was expecting latest reports to show improvements, although the regional resilience review was likely to identify the lower numbers of patients treated at Barnsley, which could impact on service levels in the future. He emphasised that this would not be a risk to local stroke care overall, albeit the first few dates of immediate care for stroke patients may be directed to more specialist centres rather than small district general hospitals. All of the issues escalated in the Log were noted, as were the latest Policies approved by the Committee Mrs Brain England undertook to raise the highlighted service risks at the next meeting of the Audit Committee.

SBE


15/103 BOARD ASSURANCE FRAMEWORK (BAF) 2015/16 (15/06-08) The draft BAF for 2015/16 was presented and reviewed. Ms Keeney advised that it had been previously reviewed by Q&G and the Finance & Performance Committee (F&P), both of which had endorsed the draft. F&P had requested one change: to include four months of rolling statistics to help monitor trends. The Board agreed that this approach would be useful. A number of specific items were expanded in discussion, in response to which Ms Keeney undertook to (a) review the risk assessment against Objective 1 (financial risks moved from red to amber in March/April – should still be red), and (b) take account of recent central direction on bank and agency staff, which could impact on delivery of the Workforce Strategy, for the next iteration. The BAF was approved for 2015/16. It was emphasised that it would remain a ‘live’ document subject to change in year if/when new risks were identified. Ms Wake stressed that it was equally important to take risks off of the BAF in a quick and timely manner when appropriate.

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15/104 EXECUTIVE TEAM (ET) CHAIR’S LOG (Tabled) Contrary to the agenda (marked as nil return), Ms Wake reported four items from the latest Executive Team meeting for the Board’s attention: a) Urology – as discussed under Q&G Chair’s Log. b) Uncoded outcomes in outpatients – Mrs Kelly reported that, due to clerical

absences and shortages to support logging of patients attending multiple clinics, there was now a notable backlog of outcomes not fully recorded. An action plan had been developed to address this, including use of volunteers to encourage more patients to self check-in (freeing up more time for reception staff to deal with outcome logging), improved systems to ensure daily logging and a team working on the backlog to reduce same by end of June.

c) Complaints response time – Mrs McNair advised that despite recent improvements, the Executive Team was not satisfied with current response times to complaints in terms of compliance with internal standards and, importantly, response to patients. It was acknowledged that some complaints were more complex than others and would take more time to resolve. It had been proposed that these should be managed differently and more realistically, with complainants aware of the different systems and clear timescales involved. Additional support was being provided for one Clinical Business Unit (CBU) currently struggling with timeliness of responses; this should also ease with the new approach. Discussions to date had highlighted the need for more work on sharing awareness and learning from complaints and patient feedback; this would lead to more work ahead.

d) Working Together: support services – Mr Kirton would be taking a presentation on this to the Executive Team shortly. The Chairman would appreciate a briefing too, to support discussions on this issue at the next meeting of the Working Together Chairs’ group.

The reported items were noted and Ms Wake affirmed that the Board would receive updates as work progressed.

BK


15/105 COMMUNICATIONS & ENGAGEMENT STRATEGY (15/06/P-10) – 2015-2019 Ms Parkes was welcomed back to the meetings, having recently returned to work from maternity leave. Ms McLaren presented the Strategy as part of her handover as interim Director of Communications & Marketing and sought the Board’s approval of the Strategy, previously presented and supported by the Executive Team and F&P. Members noted that the Strategy would be supported by an action plan, which would include measurable actions and deadlines and would be updated regularly through the communications quarterly report. The quarterly report would also include an update on membership activities. Whilst the Strategy was appreciated, for completeness the Chairman would have liked some dates included. It was agreed that the Strategy should be expanded to include reference to the measurability provided in the separate action plan. Subject to the requirement noted above, the Strategy was approved.

PMcL

15/106 CHAIRMAN’S REPORT (15/06/P-11) The Chairman’s report on a range of issues and activities undertaken since the last meeting was received and noted. In discussion several points were highlighted:

• The annual review of the Constitution was about to commence. Any comments for consideration in the review or expressions of interest to be involved in the working group to be led by Ms Keeney would be welcomed.

• In his discussions with the new Director of Public Health for Barnsley, the main themes had been shared aims, the hospital’s role in health prevention, health inequalities across Barnsley and a request for a hospital champion for smoking cessation (to be identified by the Chief Executive). It was noted that Dr Jenkins would also be meeting the Director shortly. Mrs Brain England suggested it would be useful to explore discussions on workforce related issues too if/when possible.

Reports were invited from the Non-Executive Directors and Mrs Christon shared feedback from her recent visit to the Sugar Cube Café, which had been a well attended event and very informative.

15/107 CHIEF EXECUTIVE’S REPORT (15/06/P-12) The Chief Executive’s report was noted, providing information on a number of internal, regional and national matters. Ms Wake drew attention to the success of this year’s Rainbow Run, in terms of both attendance and promoting health and wellbeing. The report also included an update on consultant appointments. Dr Jenkins provided more detail on current trends around recruitment, with low levels of vacancies in medical staff overall, some specialist areas still struggling (reflecting the national position), and plans to improve the appointment process to make it quicker but still as robust and effective.

15/108 FINANCE & PERFORMANCE COMMITTEE (F&P) (15/06/P-13) Mr Patton presented the Chair’s Log, following the F&P Committee meeting held in May. He expanded on several issues, including a number of Policies approved by the Committee and approval of both the updated Estates


Strategy and the Workforce Strategy (full copies available for Board members on request). He also advised that he and Mr Diggles would be working together to review the reporting format for the Committee, particularly to develop the front sheet to be more informative. The outcomes from this work would be shared with the Chairman and Chief Executive for possible application with other meetings if appropriate. Issues highlighted in the Log included the Committee’s discussions on performance (activity in Trauma & Orthopaedics and the continuing impact of the escalation ward), progress on the cost improvement plan (disappointing for April-May and an area of focus going forward), the importance of data accuracy (reflecting earlier Board discussions around RTT and outpatient outcomes), and sign off of two business cases. Mr Bradley reported progress on the Lorenzo system since the Committee’s meeting, with the maternity module “live” from 1st June. He expressed particular thanks to the maternity team who had worked very hard on the business change elements to support a smooth transition. He believed BHNFT was the first Trust to have moved to phase 2 deployment. In relation to the Committee’s concerns around the CIP, Mr Mapstone believed that the Committee’s key question was whether or not the Trust was confident the programme could get back on track. Mr Diggles clarified that the slow progress related largely to validation of savings and development of plans to maturity level 4 (ready for implementation). Savings validation had been impacted by other demands on the Finance team around the year end and the unexpectedly protracted contract cycle but was now being progressed. it was not an ongoing capacity issue within Finance. Mr Kirton advised that a clear message had been sent to all teams to ensure CIPs were developed to level 4 as quickly as possible. Work was also ongoing to identify further plans to build headroom into the programme overall and in readiness for 2016/17. With reference to the contract, Mr Patton drew attention to the main commissioner’s (CCG) reversion to mid-month payments. This seemed contrary to the practice within most neighbouring trusts; it was symptomatic of the difficult relationship with the CCG and had triggered the need for an earlier drawdown of cash. Ms Wake advised that the position had been escalated as far as possible and would also be raised with the local MPs she would be meeting the following day. The Committee had also received an overview of the steering group’s plans to address the current levels of DNAs (did not attend). It was noted that this had been an area of concern raised by the Governors too at a recent sub-group meeting. Whilst F&P had appreciated the intention of the plans, some members were aware of similar proposals presented previously that had made little impact. Ms Wake was conscious that DNAs were a huge problem across the NHS and it would be difficult to make significant improvements but the Trust had identified the problem areas internally and was trying to work with community partners too. Dr Jenkins and Mrs Kelly iterated some of the key areas of focus. Progress would continue to be monitored closely by F&P.

15/109 INTEGRATED PERFORMANCE REPORT (IPR) (15/06/P-14) The integrated performance report for month 1 2015/16 was received and reviewed. Mrs Kelly advised that work was continuing on the report’s format with internal and external support to improve it further. Mrs Kelly and Mrs McNair expanded on issues of particular note from the month 1 report, for performance and quality, including:


• <4 hours target – the ED had experienced unprecedented pressures, with more than 100 additional patients attending daily. This was higher than at other trusts and management were liaising with neighbouring trusts to identify any different approaches across their communities and learning for Barnsley. May (month 2) and Quarter (Q1) were currently on track to achieve target but it would be very challenging. Mrs Kelly confirmed that a report on staffing in ED had been received and approved by the Executive Team. The paper had recognised the national shortage of registrar grades in emergency medicine and outlined revised rotas for medical staffing and working with nursing staff to expand the roles of the nurse practitioners. Mrs McNair alerted the Board to growing risks of these specialist nurses being attracted to other trusts offering higher pay rates for the same roles. Whilst this was contrary to earlier discussions within the Working Together (WT) group, it was agreed that the Trust would have to give the matter further consideration as it was important to retain these valuable and valued staff. It was also agreed that a briefing note be provided for the Chief Executive and Chairman, to take to their next WT meetings. Mrs Kelly had recently learned of the risk of similar issues within the radiography team. She would check this further and add to the briefing if appropriate.

• Continuing focus on DNAs and RTT, as discussed previously, with improvements in operational efficiencies expected to start to show in the IPR as work progressed. The Board was also aware of the recently announced changes to the 18 weeks pathway. Mrs Kelly clarified that this would now be treated as one measurement (rather than three targets) and work was ongoing to determine the specific requirements for future reporting. It was anticipated that neither staff workload nor the target threshold (currently 90%) would be reduced.

• Good performance around cancer pathways, with new systems in place shortly to support more up to date monitoring.

• Staffing remained an issue in some areas although the vacancy panel continued to be robust in terms of challenging grades requested to ensure the right mix was being sought.

• Sickness absence had increased slightly and Mr Fernandez advised that the HR teams continued to work closely with the CBUs around compliance on management of sickness absence.

• Other staffing issues included appraisals (just started for 2015/16, so low numbers at this stage but would grow) and mandatory training (being raised within CBU performance reviews).

• Reporting on events had increased, with the Trust now just under the top quartile. This was a good step but work was progressing to ensure further improvements. The two never events previously reported to the Board were now formally recorded in the IPR. Dr Jenkins outlined a third event recently identified, which was being investigated and would be reported on more formally next month. Mr Mapstone drew attention to the Friends & Family Test (FFT) response rate. Mrs McNair explained that the response in ED had dropped as a result of withdrawal of the token collection system (a national directive)

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KK


and that the focus for FFT had changed as reported to Q&G. Patient feedback continued to be gained from the FFT narrative response alongside a range of other systems across the Trust.

Looking at the financial section, Mr Diggles advised that the main movements around income reflected a shortfall in elective and day cases (often experienced around the Easter holiday period), over activity in ED and non-elective, and pay pressures and some non-pay pressures in Trauma & Orthopaedics (being reviewed). The overall deficit at month 1 was £286,000 worse than plan but there had been good performance in consumables against plan and a better cash position than forecast. The changed payment date from the CCG would add to pressures for month 2, with a lower than expected cash position going forward. The Trust was pushing hard to recover the variance against budget and further data available in May showed the Trust slightly ahead on month 2 income and some potential improvement in month 1 after validation. The CCG had expressed a view that the Trust would receive funding for higher ED levels as payment was received for patients seen but this would be impacted by thresholds and pressures on 7-day services. The opening position for 2015/16 was noted.

15/110 INTELLIGENCE REPORTING/HORIZON SCANNING (15/06/P-15) The latest report was received and noted. Ms McLaren advised that the communications team was still working on the requested tracker to sit alongside the report monthly. It was due to be presented to the Executive Team shortly and should be appended to the next report to the Board. Mr Mapstone asked about the Trust’s progress on discharging people before noon. Ms Wake advised that progress had been slow to date but the Board was pleased to learn that the issue had been identified as a clinical workstream within the Listening Into Action programme. The Chairman reported on feedback from the NHS Confederation Annual Conference. Whilst nothing specific had been featured in terms of future direction for the NHS, public announcements had included the changes on 18 week pathway (as mentioned earlier) and the Lord Carter Report, with increased focus on procurement. The latter could be particularly challenging for the Trust as a lot of good work had already been achieved in this area. During the meeting the Chairman also shared a news bulletin on Mr David Bennett’s intent to step down from Monitor later in the year and plans for Monitor and the Trust Development Authority to work together under one overarching Chief Executive in future.

EP

15/111 ANY OTHER BUSINESS AND DATE OF NEXT MEETING a) Public Comments

Mr Unsworth, Public & Lead Governor, made three comments:

• he affirmed the Governors’ concerns regarding the relationship with the CCG and funding for 7-day services. One governor was scheduled to attend the CCG Patient Council’s next meeting to raise the issue and Governors would like to offer their support in other ways if possible;

• he congratulated all the staff involved with the HEART Awards earlier in the month. It had been a superb event and another great opportunity to recognise some of the Trust’s excellent staff, and


• noted that there was still scope for acoustics in the room to be improved; some members had been difficult to hear at the back.

b) Ms Williams, a member of a new local interest group “38 degrees”, thanked the Board for a very useful meeting and for the kind welcome extended to her on arrival. She hoped to attend more meetings in the future.

c) Date of next meeting The next meeting of the Board of Directors was confirmed for 2nd July 2015, commencing at 9am. In accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: 15/07/P-04

BoD July 2015: 04_Action Log PUM

SUBJECT: BOARD ACTION LOG

DATE: JULY 2015

PURPOSE:




PREPARED BY: Carol Dudley, Secretary to the Board SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT



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

Subject: Board Action Log Ref: 15/07/P-04

Key to RAG status Action overdue or no update provided Update Provided but action not complete Update provided and action complete BoD: July 2015: 04_Action Log PUM/p1

ACTIONS ON PUBLIC AGENDA Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG

status

15/92 15/61 (and 15/32)

May & April 2015

Integrated Performance Report

DNAs reduced following extensive action; overview report on improvements to date and plans for continuing work to be presented to F&P

Director of Operations

May 2015 (F&P)

May 2015 (F&P)

Presented to F&P Committee and reported via Chair’s Log (May 2015). Keep on Board action log pending final resolution/confirmation via F&P – see agenda item 13 for latest update

15/110 & 15/91

June & May 2015

Intelligence Reporting/Horizon Scanning

Development of tracker to show actions against strategic initiatives.

Director of Comms & Marketing

June 2015 Agenda item 15 refers

(monthly Horizon Scanning report)

15/67 April 2015 Executive Team Chair’s Log

Trust response to Savile report to be developed

Director of Nursing &

Quality

May/June 2015

July 2015

May/ET June /Q&G

Completed: Outcome reported via Q&G Chair’s Log and separate report. Agenda items 6 & 7 refer

15/63 April 2015 Patient flow audits 1&2

Outcomes from review of shorter stays (2-4 days) to be reported to Exec Team and subsequently shared with Board


July 2015 (Board)

July 2015 (Board) Agenda item 5 refers

ACTIONS COMPLETED & CLOSED SINCE LAST MEETING Minute

ref Meeting

date Item Action Owner Due date

Done Date Progress report RAG

status

15/109 June 2015 Integrated Performance report

Briefing to be prepared on pay levels and recruitment issues re specialist nursing staff, to other trusts (WT). To be expanded for radiology if pertinent.

Director of Nursing &

Quality (& Dir of

Operations)

June 2015

June 2015

Completed: briefing note provided to Chair/CEO ahead of WT meetings re nursing staff. Not relevant re radiology.

15/105 June 2015 Communications & Engagement Strategy – 2015-19

Text to be incorporated to add reference to dates/action plan

Interim Dir of Comms & Marketing

June 2015

June 2015

Completed: published with 5 year strategy


Minute ref

Meeting date Item Action Owner Due

date Done Date Progress report RAG

status

15/104 June 2015 Exec Team Chair’s Log - Working Together (WT)

Briefing to be drafted for CEO/Chair re support services in readiness for next WT discussions.

Dir of Strategy & Business

Development

June 2015

June 2015

Completed: briefing note provided to Chair/CEO ahead of WT meetings

15/103 June 2015 Board Assurance Framework 2015/16

Changes requested re - amber/red finance rating (March/ April) for Objective 1 - central direction on bank and agency staff; impact on workforce strategy

Assoc Dir of Corporate

Affairs

June 2015

June 2015

Completed: reflected in latest iterations presented at Q&G and F&P June 2015

15/101 June 2015 Infection Prevention & Control – Action Plan/ Programme 2015/15

Reference to isolation facilities to be included, before Plan is issued.

Dir of Nursing & Quality

June 2015

June 2015 Completed

15/63 April 2015 Patient flow audits 1&2 Option to share presentation at Health & Wellbeing Board (H&WB) to be explored

Medical Director

May/Jun 2015

Confirmed June 2015

June: confirmation received that this item will be on the H&WB agenda for 13 October.

15/53 March 2015 Finance & Performance Committee

Benefits realisation on Lorenzo to be reported to F&P via business case process

Dir of Strategy & Business

Development / Dir of ICT

25 June 2015 July 2015 Actioned: Report received and

reviewed at F&P June 2015

ROLLING TRACKER OF OUTSTANDING ACTIONS Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG

status

15/89 May 2015 Communications & Marketing

Options for developing a Barnsley App in co-operation with local partners (local authority, Sixth Form College or University) to be explored

Director of Comms & Marketing

Sept 2015

Director of Comms & Marketing to pursue; action pending (after School/University summer break)


Minute ref

Meeting date Item Action Owner Due date Done

Date Progress report RAG status

15/75 April 2015 Integrated performance report

a) Winter Pressures plan to be revised for 2015/16

b) Report on ASIs (appointment slot issues) to be reviewed at ET shortly


May/June 2015

Work ongoing. Winter planning group to be established shortly. Work on ASI will be integral to Outpatients review

15/74 April 2015 Finance & Performance Committee (F&P) Chair’s Log

Contract negotiations, including funding for 7 day services.

Executive Team

May 2015 Ongoing: Monitored through ET

and F&P

15/48 March 2015 Information Governance Toolkit

a) Penetration and cyber testing to be progressed for internal and hosted systems.

Director of ICT

July 2015

June update: Cyber security has been presented to ET and will be reviewed further at Audit Committee (deferred to July). July update: Penetration test scheduled for September.

b) Interagency information sharing agreement: assurance to be provided on dissemination of Agreement

May 2015

June update: Information Governance Group reviewed process for dissemination in May, and is developing collaborative training materials with CCG, BMBC and SWYPFT to ensure consistent messages across organisations, with a meeting on 23rd June to agree the material. July update: outcomes of meeting awaited but on track.

15/14 Jan 2015 Integrated Performance – quality

Learning from SI re maternity medication error to be shared with Board when known (expected March/April)

Dir of Nursing & Quality

March/ April 2015

Feedback not yet received from CCG. Meeting taking place on mid-June - deferred

abbreviations:

• ASI – Appointment Slot issues • ET – Executive Team • DNA – Did Not Attend • F&P – Finance & Performance Committee • Q&G – Quality & Governance Committee • WT – Working Together

BoD July 2015/ Q&G Chair’s Log: June 2015

REPORT TO QUALITY & GOVERANCE COMMITTEE REF: 15/07/P-06 SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT

– CHAIR’S LOG DATE: July 2015

PURPOSE: Tick as

applicable Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Linda Christon, Non Executive Director/Committee Chair & Carol Dudley, Secretary to Board & Governors

SPONSORED BY: Linda Christon, Non Executive Director/Committee Chair PRESENTED BY: Heather McNair, Director of Nursing & Quality STRATEGIC CONTEXT The purpose of the Quality & Governance (Q&G) Committee is to assist the Board in obtaining assurance that high standards of care are provided and any potential or actual risks to quality are identified and robustly addressed at an early stage. KEY ISSUES ADDRESSED IN THIS REPORT • Issues that require escalation to the Board • The assurance the Committee can give to the Board that effective action is being taken to

address issues of concern and that effective scrutiny and monitoring is in place CONCLUSION AND RECOMMENDATION(S) The Committee would like to bring the following items to the Board’s attention for the purpose of providing assurance: • continued good performance on HSMR • Trust’s response to the Savile Report • annual reports for 2014/15 from Clinical Audit and Health & Safety • the annual Fire Statement (for approval) • outcomes and continuing work on the outcomes for Barnsley from the Care Quality

Commission’s thematic inspection re “Right Here, Right Now” Publication (Mental Health Crisis Review)

Matters requiring escalation are: • Ongoing concerns re falls (but note also useful thematic review) • Timings for production of integrated performance report • DNAs (did not attend) – impact on quality to be included in ongoing review • appointment review list (work ongoing) The Committee recommends the Board to: • note the matters outlined in the Chair’s Log for assurance and escalation • ratify the Trust’s response to the Savile Report (separate agenda item) • approve the Fire Statement for sign off by the Chief Executive on behalf of the Trust • note the Committee’s approval and receipt of the Policies and updated Strategies listed under

section 10


REFERENCE/CHECKLIST

• Which business plan objective(s) does this report relate to? All


Tick all applicable boxes Patients BCCG Other –

Staff BMBC Please state:

Governors Monitor


Tick all applicable boxes Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution, etc)


The Trust’s sustainability strategy


Tick all applicable boxes

Yes • Has this report (in draft or during development) been reviewed and supported by any Board or Executive committee within the Trust?

Audit

Not Applicable Finance & Performance

To be developed Quality & Governance

ET

• Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committee(s)

• Where applicable, state resource requirements

Finance:

Other: NHS Constitution In determining this matter, the Board should have regard to the Core principles contained in the Constitution of:

• Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best value • Accountability through local influence and scrutiny

The Board will also have regard to the Trust’s core vision statement: “To be the best integrated healthcare organisation of choice for our local communities and beyond”

BoD July 2015/ Q&G Chair’s Log: June 2015 p3

Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: 15/07/P-06 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee Date: 24 June 2015 Chair: Linda Christon

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

Board or Committee Recommendation/ Assurance/

mandate to receiving body

1 Nursing & Midwifery staffing

Ward 29 now closed and pressures eased with staff returning to normal duties. Some vacancies continue across Trust but new staff taking up appointments during next few months. Concerns noted re retention of specialist nursing staff in Emergency Department, and implications in terms of staff retention, service quality and cost implications highlighted. Approach to retention to be revisited.

Board of Directors Board to note current status generally and concerns re specialist nursing. F&P asked to consider cost implications of loss of specialist nursing staff. F&P Committee

2 Did Not Attends (DNAs)

Based on feedback from June Board, ongoing work on DNAs noted. Committee highlighted associated quality issues, including safeguarding, some work on which already progressed in 2014/15 and will be absorbed into quality agenda in 2015/16.

Board of Directors Escalated to Board to request quality issues picked up by the workstream on DNAs alongside financial impact.

3 Integrated Performance Report (IPR)

a) Timing: Production of IPR remains an issue: received less than 24 hours prior to Committee’s meeting. Board of Directors Escalated to Board, to be factored into

ongoing development of IPR b) Mortality ratios: improved, good performance for final

rolling 12 months 2014/15 noted - below target of 105, although year to date position had been lower previously.

Board of Directors For Board to note; will be addressed by Medical Director in future reporting

c) Patient safety: Continuing focus on falls needed; must be reduced. Should improve as Falls Policy and Strategy become more embedded and transition to multifactorial assessment tool. Good paper received (separately) on thematic review of falls. Progress will continue to be monitored via Falls Group and reported to Q&G through Patient Safety & Quality. Committee also expressed concerns re avoidable Grade 3 hospital acquired pressure ulcer

Board of Directors For Board to note

d) New CQUIN: to be introduced later this year on use of Clinical Utilisation Tool. Tool will set clinical criteria to support assessment for discharge from hospital. Will also provide useful data to support discussions around whole health economy needs for Barnsley.

Board of Directors For Board to note


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

Recommendation/ Assurance/ mandate to receiving body

4

Board Assurance Framework

New risk added under objective 1 (safe care) in view of patients awaiting review appointments, Work ongoing to ensure swift action, led by Director of Operations

Board of Directors Escalated to Board to note; work ongoing

5 Savile Report Trust response noted; full report to be presented to Board (see separate agenda item). Board of Directors Board to ratify submitted response

6

CQC “Right Here, Right Now” publication (Mental Health Crisis Review)

Barnsley Summary report received. Focus was on older adults and the inspection was impressed with support provided at BHNFT overall, particularly with Clinical Decision Unit facilities able to provide support for dementia patients. Some community-wide improvement areas noted and Trust is working closely with partners to support this.

Board of Directors Board to note for assurance

7 Risk Management Group (RMG)

RMG Chair’s Log identified value of trained administrators (loggists) to support emergency resilience processes; good assurance for the Trust but must be mindful of continuity needs with changes in staff. Increasing levels of violence/abuse towards staff also noted: an issue for Finance & Performance to explore further.

Board of Directors

Finance & Performance

Board to note for assurance F&P to note and review

8 Clinical Audit Annual Report

Progress for 2014/15 noted and plans for 2015/16. The audit plans are owned by the CBUs; the Clinical Audit tem remains committed to support them to help demonstrate provision of safe and effective healthcare.

Board of Directors Board to note for assurance

9 Fire Statement The annual Fire Statement for 2014/15 was received and endorsed and is attached for Board’s formal approval to comply with mandatory requirements.

Board of Directors Board to approve for sign off - copy appended

10 Policies & Strategies

The new or significantly revised policies listed below were received and approved by the Committee:

• Medical Gas Policy • Safeguarding Adults Policy • Pressure Ulcer Policy • Nutrition Policy • Resuscitation Policy • Female Genital Mutilation Policy • Serious Incident Policy • Working at Height Policy • Confined Spaces Policy • Provision & Use of Work Equipment Policy • Electrical Safety Policy

Board of Directors For assurance




Some require minor amendments (largely dates and references) to be actioned before the Policies can be uploaded onto the Policy Warehouse. The larger than usual volume of policies presented included several previously deferred by the Committee, pending completion of EQIA assessment.

Two updated strategies were also noted: Quality Strategy and Dementia Strategy.


Annual Statement of Fire Safety 2014/2015 NHS organisation: Barnsley Hospital NHS Foundation Trust

I confirm that for the period 1st April 2014 to the 31st March 2015, all premises which the organisation owns, occupies or manages have fire risk assessments undertaken in compliance with the regulatory Reform (Fire Safety) Order 2005, and (please tick the appropriate boxes):

1. There are no significant risks arising from the fire risk assessments.

2. The organisation has developed a programme of work to eliminate or reduce to a reasonably practicable level the significant risks identified by the risk assessment.

3. The organisation has identified significant risks, but does not have a programme of work to mitigate those significant risks.

4. Where a programme to mitigate significant risks has not been developed, please insert the date by which such a programme will be available, taking account of the degree of risk.

5.

During the period covered by this statement, the organisation has/has not* been subject to any enforcement action by the fire and rescue authority.

Please outline details of enforcement action in Annex A Part 1.

6.

The organisation has/has not* any on-going enforcement action pre-dating this Statement.

Please outline details of on-going enforcement action in Annex A Part 2

7. The organisation achieves compliance with the Department of Health’s fire safety policy by the application of Firecode or some other suitable method.

Chief Executive: Diane Wake

Non Clinical Risk Advisor (H&S) Gillian Lammas

Contact Details:

E-mail: [email protected]

Telephone: 01226 432 140

Mobile: n/a

Signature of Chief Executive:

Date:

Completed statement to be retained for future audit

*Delete as appropriate

mailto:[email protected]


ANNEX A

Part 1 – Outline any enforcement action taken during the past 12 months and the action taken or intended by the organisation. Include, where possible, an indication of the costs to comply.

Part 2 – Outline any enforcement action on-going from previous years and the action the organisation has taken so far. Include any proposed action needed. Include an indication of the cost incurred so far and, where possible, an indication of costs to fully comply.

NHS Organisation: Barnsley Hospital NHS Foundation Trust

Date: 6th May 2015


SUBJECT: JIMMY SAVILE INVESTIGATIONS: ‘LESSONS LEARNT’: BHNFT ACTION PLAN

DATE: JULY 2015

PURPOSE:


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

PREPARED BY: Gill Feerick, Head of Quality & Clinical Governance

SPONSORED BY: Heather McNair, Director of Nursing & Quality

PRESENTED BY: Heather McNair, Director of Nursing & Quality

STRATEGIC CONTEXT On 26 February 2015, Kate Lampard published her second report following investigations into the abuse of individuals by Jimmy Savile on NHS premises. The 'Lessons Learnt' report looks into Jimmy Savile's role as both a volunteer and a fundraiser in the NHS. The report makes recommendations for Trusts to improve their policies and practice including access, volunteering, safeguarding, complaints and governance. Monitor required all Trusts to review their current practice against the recommendations and to develop an action plan in response. QUESTION(S) ADDRESSED IN THIS REPORT What action is required by the Trust? CONCLUSION AND RECOMMENDATION(S) The ‘Lessons Learnt’ report contains 14 recommendations of which 13 have been accepted in principle by the Secretary of State for Health. There is a requirement for all Trusts to review their current practice against the recommendations and to develop an action plan in response. BHNFT has undertaken a gap analysis against the relevant recommendations and has developed an action plan to address any identified gaps in assurance. The action plan was reviewed by the Executive Team and approved by the Patient Safety & Quality Group on 10 June 2015 prior to submission to Monitor on 15 June 2015. Completion of the actions will be monitored by the Patient Safety & Quality Group. The Board of Directors is asked to ratify the attached action plan.

REFERENCE/CHECKLIST • Which business plan objective(s)

does this report relate to?


Tick all applicable boxes Patients BCCG Other – Staff BMBC Please state:

Governors Monitor



Legal requirements (Acts, HSE, NHS Constitution, etc) Equality, Diversity & Human Rights The Trust’s sustainability strategy


Tick all applicable boxes √ Yes • Has this report (in draft or during

development) been reviewed and supported by any Board or Exec committee within the Trust?

Audit Not Applicable Finance & Performance

To be developed

√ Quality & Governance ET



Finance: Other:

NHS Constitution In determining this matter, the Board should have regard to the Core principles contained in the Constitution of:



Report on actions in response to Kate Lampard’s report into Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile

NAME OF TRUST: Barnsley Hospital NHS Foundation Trust

Issue identified Planned Action Progress to date Due for completion Issue identified

R1 All NHS hospital trusts should develop a policy for agreeing to and managing visits by celebrities, VIPs and other official visitors. The policy should apply to all such visits without exception.

To develop a VIP, Celebrity, Media and Other Official Visitors policy to govern all such means of access to Trust staff and patients on Trust premises

Policy is in draft and progressing through the Trust’s governance process

Est approval within 3 months although communication around same will be shared as soon as possible.

Lack of formalised protocol for handling access by this high-profile visitor group.

R2 All NHS trusts should review their voluntary services arrangements and ensure that:

• they are fit for purpose;

• volunteers are properly recruited, selected and trained and are subject to appropriate management and supervision; and

Towards the end of 2014 the Trust’s Voluntary Services Policy was reviewed and updated and this will be rolled out internally to staff teams.

We have a comprehensive recruitment and iduction training programme for volunteers. Volunteers have DBS checks and attend a 1 day induction if they work in clinical areas and receive an induction handbook if they work in non clinical areas. Volunteers work to a role outline and have local

Policy agreed by PEG, Q&G and to be placed on policy warehouse.

Rolled out via internal communications to key staff groups.

Revised training programme implemented

Complete

1 July 2015

Complete

• all voluntary services managers have development opportunities and are properly supported.

supervision in the area they are deployed.

Management of voluntary services sit with the Head of Patient Experience and day to day management falls to the voluntary services coordinator, Band 4 and Administrator, Band 2.

Explore options to join NAVSAM (National Association of Vol Managers). Links with BMBC voluntary services network group.

August 2015

R4 All NHS trusts should ensure that their staff and volunteers undergo formal refresher training in safeguarding at the appropriate level at least every three years.

Volunteers who stay with the Trust for longer than 3 years do not routinely attend refresher training.

Volunteers are provided with a copy of the revised Volunteers’ Induction Handbook when this is revised approximately every 12-18 months.

August 2015 Work with Learning and Development to develop a programme for refresher training for volunteers who work in clinical areas and stay with theTrust for longer than 3 years.

R5 All NHS hospital trusts should undertake regular reviews of:

• their safeguarding resources, structures and processes (including their

Compliant

The hospital completes an annual section 11 report that is submitted to the local children’s safeguarding board for scrutiny. In

N/A N/A None

training programmes); and

• the behaviours and responsiveness of management and staff in relation to safeguarding issues to ensure that their arrangements are robust and operate as effectively as possible.

addition the submission is challenged by the Chair of that Board in the form of an interview. This has just taken place in March 15 and no concerns were identified. Section 11 covers the statutory duties the Trust is requited to comply with in terms of safeguarding children to ensure the correct resources, structures, processes etc. are in place. In addition an annual report is submitted to the Board and regular work is monitored by the steering group which is chaired by the executive lead for safeguarding.

A training programme is in place and training figures are monitored monthly by the safeguarding department and are reviewed as part of the safeguarding steering group agenda. A training strategy is in place outlining the required level of training and how it can be accessed for all staff groups.

The safeguarding lead for

the organisation sits on the local LSCB and chairs the internal safeguarding steering group. She is also sits on the Trust Board ensuring commitment to safeguarding from the highest level of the organisation.

An annual audit programme is in place and monitored by the safeguarding steering to ensure staff are following procedure, have the knowledge to undertake their role and ensure effective safeguarding practice is in place. Action plans are developed and monitored as a result of these audits. Relevant audits are also monitored through the LSCB Quality and Assurance sub group.

Policy, Procedure, Protocols and guidance are available to assist and guide staff through safeguarding children processes.

The Safeguarding Team encourage, train and support

staff to ensure there is a culture within the Trust that sees Safeguarding as being everyones responsibilty

Advice is available out of hours by contacting the Paediatrician on call, EDT and/or Police.

The Trust has a listening culture and regularly seeks the views of staff and patients. Staff can raise concerns with confidence.

R7 All NHS hospital trusts should undertake DBS checks (including, where applicable, enhanced DBS and barring list checks) on their staff and volunteers every three years. The implementation of this recommendation should be supported by NHS Employers.

The Trust took the decision in 2014 to carry out criminal record checks on eligible post holders every year in the form of an annual self declaration instead of every three years via a DBS check. A sample audit of personal files, to ensure that declarations are completed and filed appropriately, will be undertaken during 2015/16. A mandatory field will be added to the electronic appraisal logging system for 2016/17.

Implemented Annual Appraisal process commencing 1 April 2015

Undertaking DBS checks every three years is not currently a requirement of the NHS employment check standard. The current agreed Trust process for DBS checks provides safeguarding assurances to the Trust.

R9 All NHS hospital trusts should devise a robust trust-wide policy setting out how access by patients and visitors to the internet, to social networks and other social media activities such as blogs and Twitter is managed and where necessary restricted. Such policy should be widely publicised to staff, patients and visitors and should be regularly reviewed and updated as necessary.

Compliant

Access to the Trust and Charity websites are restricted to approved staff only. Social Media guidance has been issued to all staff as part of the Communications and Engagement Strategy. Social media sites for the Trust and Charity are monitored and concerns escalated to the social media owners (FB, Twitter) providers for direct action.

N/A N/A None

R10 All NHS hospital trusts should ensure that arrangements and processes for the recruitment, checking, general employment and training of contract and agency staff are consistent with their own internal HR processes and standards and are subject to monitoring and oversight by their own HR managers.

Contract and agency staff are looked after across the Trust by individual departments. Project team to be set up cross Trust to ensure arrangements and processes for contract and agency staff are in place and are consistent. Recommendations for changes to current process to be identified by the project team.

Project team to be set up in May 2015

March 2016 None

R11 NHS hospital trusts should review their recruitment, checking,

Processes are audited every week and on a monthly/quarterly basis.

Current state March 2016 None

training and general employment processes to ensure they operate in a consistent and robust manner across all departments and functions and that overall responsibility for these matters rests with a single executive director.

There is overall oversight at CBU Performance Reviews, Finance & Performance Committee and Board level. Current responsibility rests with Director of Operations and Interim Director of Communications.

R12 NHS hospital trusts and their associated NHS charities should consider the adequacy of their policies and procedures in relation to the assessment and management of the risks to their brand and reputation, including as a result of their associations with celebrities and major donors, and whether their risk registers adequately reflect such risks.

To ensure that the VIP, Celebrity, Media and Other Official Visitors policy adequately recognises the potential risks associated with these individuals and groups.

Risks identified in the draft Celebrity, Media and Other Official Visitors policy and will be recorded on the corporate risk register in due course

Est approval within 3 months although communication around same will be shared as soon as possible.

Lack of formal identification of the risks by association.

R13 Monitor, the Trust Development Authority, the Care Quality Commission and NHS England should exercise their powers to ensure that NHS hospital trusts,(and where applicable, independent hospital and care organisations), comply

N/A N/A N/A N/A

with recommendations 1, 2, 4, 5, 7, 9, 10 and 11.

R14 Monitor and the Trust Development Authority should exercise their powers to ensure that NHS hospital trusts comply with recommendation 12.

R14 Monitor and the Trust Development Authority should exercise their powers to ensure that NHS hospital trusts comply with recommendation 12.

N/A N/A N/A N/A

I confirm that this NHS foundation trust Board reviewed the full recommendations in Kate Lampard’s lessons learnt report

SIGNED:

Diane Wake

DATE: 15th June 2015

CE NAME: Diane Wake

Please return to [email protected] by 5pm Monday 15 June 2015. If you have any questions or queries you may also use this email address to send them to us.

mailto:[email protected]


SUBJECT: MORTALITY

DATE: JULY 2015

PURPOSE:



For review Governance For information √ Strategy

PREPARED BY: Alicia Gray, Interim Information Manager SPONSORED BY: Dr Richard Jenkins, Medical Director PRESENTED BY: Dr Richard Jenkins, Medical Director STRATEGIC CONTEXT 2-3 sentences

Meets the requirement to provide high quality and safe services: Strategic Objective 1c.

KEY POINTS ADDRESSED IN THIS REPORT

What are the latest mortality figures for both Hospital Standardised Mortality Ratio (HSMR) and Summarised Hospital Mortality Indicator (SHMI)?


The latest 12 months rolling HSMR includes data to the end of March 2015 and is 102.24. The rate continues to be below the target HSMR figure of 105.

Recommendations The Committee is asked to receive the report and note the latest data on mortality rates.


does this report relate to? Meets the requirements to provide high quality and safe services: Strategic Objective 1c.


Tick all applicable boxes √ Patients BCCG Other – √ Staff BMBC Please state:

Governors √ Monitor


Tick all applicable boxes √ Regulators (eg Monitor / CQC)

√ Legal requirements (Acts, HSE, NHS Constitution, etc) √ Equality, Diversity & Human Rights The Trust’s sustainability strategy


Tick all applicable boxes √ Yes • Has this report (in draft or during



To be developed

√ Quality & Governance ET


High mortality is a patient safety indicator and a risk to patient safety. High mortality may adversely affect the Trust’s reputation.


Finance: Other:




Board July 2015: Mortality Page 1

Subject: MORTALITY Ref: 15/07/P-08

1 STRATEGIC CONTEXT

This report covers performance on mortality ratios and action plans, which relate to Strategic Objective 1c: Patients will experience safe care.

2 INTRODUCTION

2.1 This report provides the latest available mortality figures and an update on the mortality action plan.

2.2 The mortality figures presented include

• The provisional Summarised Hospital Mortality Indicator (SHMI) values for October 2013 – September 2014.

• The latest rolling 12 month Hospital Standardised Mortality Ratio (HSMR) position including the latest month’s data for March 2015 is 102.24.

3. SUMMARY HOSPITAL MORTALITY INDICATOR

3.1 The provisional SHMI figure for the latest period (October 2013 – September 2014) is 103.2 and is within expected confidence levels.

95

100

105

110

115

120

125

Q4

2012

/13 Q1

2013

/14 Q2

2013

/14 Q3

2013

/14 Q4

2013

/14 Q1

2014

/15 Q2

2014

/15 Q3

2014

/15

SHMI: Barnsley NHSFT Rolling 12 Month Target

Target Trajectory National


4. HOSPITAL STANDARDISED MORTALITY RATIO 4.1 Latest Rolling 12 Months, HSMR for Yorkshire and Humber Non Specialist

Trusts are presented below. The 12 Month rolling HSMR for March 2015 is 102.24. BHNFT figures are highlighted in green. This is also the 2014/15 Year to date position.

4.2 The monthly trend for HSMR is shown below. The Trust target for the 2014 Calendar year was 105. The target for 2015 is 100.


5. CRUDE MORTALITY RATES FOR BARNSLEY HOSPITAL NHSFT 5.1 Crude Mortality Rates (latest month May 2015)

Financial Year No. of Deaths

No. of Discharges*

Crude Mortality Rate per

1000 Discharges*

Weekend Crude

Mortality Rate per

1000 Admissions**

2007/08 1052 37651 27.94 2008/09 1062 40028 26.53 31.28 2009/10 1072 42583 25.17 31.85 2010/11 1051 40914 25.69 30.06 2011/12 1012 42023 24.08 28.08 2012/13 1034 42588 24.28 29.13 2013/14 1021 42551 23.99 31.10 2014/15 967 41948 23.05 29.12 2015/16 147 7032 20.90 * Excludes Daycases, unless a death ** Deaths/Admissions on a weekend

5.2 Statistical Process Control (SPC) Chart, Crude Mortality Rate, BHNFT

5.3 The Crude Mortality figures show a significant spike of deaths in the Trust during the winter. This picture is reflected in national figures where there was a 25% increase in the number of deaths over the same period based on a five year average. The peak winter mortality was approximately twice the pre-winter rate. Levels have now returned to the baseline.


6. NEXT STEPS 6.1 The 2014-15 mortality target of less than 105 has been delivered but over the

majority of the year the mortality rate has been static. In order to achieve the lower target of 100 in 2015-16, additional work is required. This work will be organised in three domains - care processes, casemix and coding.

A) Care processes - this will be led by the Deteriorating Patient Group which is

focussing on deterioration, fluid balance, sepsis and acute kidney injury. In addition, a pneumonia bundle will be launched shortly. This work will be informed by the continuous mortality review process.

B) Case mix - this work will look at how the health economy can ensure that

appropriate end of life care processes are in place such that the system does not default to admit people to hospital to die when they have previously made an alternative choice of preferred place of death. Further implementation of the Amber Care Bundle will support this work.

C) Coding - the newly formed coding improvement group will focus on ensuring

that each episode of care is properly and completely coded. This will focus on depth of coding to include all relevant co-morbidities, linked to the Charlson Index, and ensuring that all appropriate palliative care codes are captured.

6.2 This work will continue to be overseen by the Mortality Steering Group led by

Dr McAndrew, Associate Medical Director.


BoD July 2015: 10_Chairman Report2015

SUBJECT: CHAIRMAN’S REPORT

DATE: JULY 2015

PURPOSE:




PREPARED BY: Stephen Wragg, Chairman SPONSORED BY: PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT



The Board of Directors is asked to: a) receive, note and support this report b) invite and note any further reports on their activities from the wider Non Executive team.

BoD July 2015: 10_Chairman Report





Governors Monitor





Tick all applicable boxes Yes • Has this report (in draft or during



To be developed

Quality & Governance ET



Finance: Other:




BoD July 2015: 10_Chairman ReportJuly 2015 p1

Subject: CHAIRMAN’S REPORT Ref: 15/07/P-10 1. INTRODUCTION

1.1 This report is intended to give a brief outline of some of the work and activities undertaken as Trust Chairman over the past month and highlight a number of items of interest.

1.2 The items reported are not shown in any order of priority. 2. TRUST POSITION

2.1 As is reported in other papers in this Board meeting, our turnaround plan continues to progress and we are now in the second year of the plan. I have no doubt that this year will be more difficult than the first, but we must push hard to deliver the savings and work towards the future sustainability of the Trust.

2.2 We must continue to give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and we will turn this current situation around. I will keep reiterating this message as I think it should be constantly in people’s minds. Whilst we are bringing about our return to stability, we must not compromise on quality of care and patient safety.

2.3 We must also give confidence to our staff that the Trust is doing everything it can to improve patient experience and the quality of care our patients receive. In addition we have to pay tribute to all our staff for the work they are doing to conceive new ideas to deliver better care, but also the work that they have done to bring our transformation to life.

3. MONITOR SELF CERTIFICATION

3.1 Board members, including the CEO and I, reviewed and approved the Board’s Corporate Governance Statement on 25th June. This was required to be submitted on behalf of the Trust in support of the 2015/16 annual plan. The self-certification followed the usual format, seeking affirmation of our confidence in the systems and standards of good corporate governance in place to support delivery of our services and regard for Monitor’s guidance on governance, and continuing provision of training for our governors. Clearly our response also reflected the current enforcement notices against the Trust for breach of Licence although it is hoped these will be lifted in year.

4. REMUNERATION AND TERMS OF SERVICE COMMITTEE (RATS)

4.1 The committee met to review the shortlist of applicants for the Director of Finance post on 25th June. It was agreed that the applications did not reach the standard that we were looking for.

4.2 With that in mind the CEO and I put a verbal proposal to RATS to move us forwards.

BoD July 2015:10_Chairman Report p2

4.3 The proposal which was agreed by RATS is to extend the current Interim consultancy contract on a part time basis until December and at the same time promote the Deputy Director of Finance to take up the gap.

4.4 The Deputy Director of Finance will have a robust development plan in place with a view to him being appointed as full time Director of Finance in December this year. I am sure that you will all be pleased that we have decided to develop our own staff into this role, and that you will give him your full support.

5. COUNCIL OF GOVERNORS

5.1 The general meeting of the Council of Governors took place on 11th June, where we were pleased to welcome Zubair Warraich to his first meeting, and welcome back Dave Thomas. We also welcomed Chris Millington to his first meeting as a partner governor.

5.2 The meeting heard an overview of the budget for 2015/16 presented by Stuart Diggles and Karen Kelly gave Governors an understanding of her role as Director of Operations. A third new public Governor, Alan Scattergood will be taking up his role shortly.

5.3 Governors were also able to reflect on the very successful Heart Awards evening that had taken place the previous Friday.

6. NEWS & EVENTS 6.1 On 2nd June I once again represented the Trust at the Barnsley District Football

Association dinner where I presented the trophies and received a cheque for £500 for the Hospital Charity.

6.2 3rd, 4th and 5th June I attended the NHS Confederation Conference in Liverpool where I heard amongst others Secretary of State for Health Jeremy Hunt set out his agenda for the next year, and Simon Steven CEO of NHS England also speaking about reducing costs.

6.3 5 June, as already mentioned above was the Heart Awards evening, which again showcased our staff at their best. Once again it was an amazingly successful evening and my thanks go to all the staff who delivered the event for us, but particularly Carole Wickham who led the organisation of the event.

6.4 On 16th June with the CEO, I went to the NHS Providers event in London. The highlight of these conferences for me was the update given by Chris Hopson, CEO of NHS Providers (slides attached). Simon Stevens also gave a presentation, where the clear message was that the NHS has moved further towards quality than we can afford, and they are now looking to redress the balance. Unfortunately Jeremy Hunt cancelled at the last minute as he had to attend Parliament for a vote.

6.5 On 17th June, I met three other Chairs from the Working Together group to discuss our view of the programme as it is now. The Chairs are preparing a strategic paper to go to the next Chair/CEO meeting, setting out what we expect of the programme and the pace that we expect it to be delivered.

6.6 On 23rd June I once again hosted a meeting of the regional NHS Chairs, where we discussed amongst other things the Very Senior Manager issue raised by the Secretary of State and the development of commissioning.

BoD July 2015:10_Chairman Report p3

7. BARNSLEY HOSPITAL CHARITY 7.1 It has been my pleasure to receive a number of cheques for the Tiny Hearts Charity

this month; Stainborough Rotary Club had made Tiny Hearts the charity of the year under their President Trevor Smith. The Perrigo Foundation saw the DVD about Tiny Hearts on YouTube and made a donation of £18000, and Howard Crawshaw of Triford Motors ran a number of events to raise funds for Tiny Hearts.

7.2 The new means of giving to the Charity by text has seen an increase in use recently, which is welcomed.

Stephen Wragg CHAIRMAN July 2015

CHAIRS AND CHIEF EXCECUTIVES NETWORK POLICY UPDATE

16 June 2015

Chris Hopson Chief Executive

What will we cover?

Quick overview

Money

Announcement flurry

Strategic direction of travel

Straight through to allow single dialogue at the end

What will we cover?

Quick overview

Money

Announcement flurry


What has changed since we last met in March?

1. General election returned Conservative majority, reappointed SofS,

and a largely new ministerial team

2. Increased national intervention to create better grip: temporary staffing,

VSM pay, management consultancy spend, Monitor RAF consultation

3. New regulatory approach to look at quality, access and finance triangle with 18 weeks targets revised, safe staffing paused and CQC looking at efficiency

and quality

4. 2014/15 outturn finances far worse than plan at £822m aggregate provider deficit – currently planned to worsen to

£2.1bn by end of 2015/16

5. Difficult tariff round resulting in ETO/DTR choice and further national

work on specialised commissioning costs and new U&EC payment system being

accelerated

6. 5YFV cemented as the direction of travel with new vanguards on acute care

models and U&EC

What is the current mood music?

June 2015 Mar 2015

Time to deliver • Out of pre-election stasis • Clear post-election direction

of travel emerging • Expectations on sector to

deliver

Nov 2014

Mind the Gap Bridging gaps between (i) funding &

demand (ii) views of the

centre

Under the cosh on finances and

performance, but potential alignment

behind a 5 year view, difficult as it may be

The next parliament – “from one to three” • 5YFV posits significant rise in

difficulty of provider strategic task

• From keep operational ship upright with CIP driven Nicholson Challenge

• To: o Keep operational ship upright o Find completely new way to deliver

share of £22bn savings o Co-lead your local health and social

economy and your institution’s journey to new models of care

From my presentation in December 2014

To deliver what?

• To:ooo Keep operational ship uprighto Find completely new way to deliver

share of £22bn savingso Co-lead your local health and social

economy and your institution’s journey to new models of care

Ship has to be righted first…then kept upright

£822m deficit, getting rapidly worse, and series of missed performance targets

What will we cover?

Quick overview

Money

Announcement flurry


Straight through to allow single dialogue at the end

Money

14/15 finances 15/16 finances 15/16 tariff round

15/16 planning guidance

Spending review

16/17 tariff round

2014/15 finances far worse than plan

Source: (Monitor & TDA 2014/15)

Revenue cuts to block contracts and tariff + unplanned growth in pay and non-pay costs + under delivery of CIPs contributing to

significantly more community, ambulance, mental health trusts in deficit and 60% of acute providers in deficit.

Deteriorated rapidly during the year

Finances getting a lot worse, fast

593

-108

-822

-2100

-2500

-2000

-1500

-1000

-500

0

500

1000

Aggregate Provider

sector surplus /

deficit (£m)

2015/16 2014/15 2013/14 2012/13

Source: Monitor, TDA figures to 2014/15, NHS Providers estimate 2015/16

15/16 operational plans show scale of deterioration

Source: NHS Providers survey 2015

Leading to consistent universal pressure – one example

“To support [genuine parity of esteem between mental and physical health], we expect each CCG’s spending on mental health services in 2015/16 to increase in real terms,

and grow by at least as much as each CCG’s allocation increase.”

Source: NHS Providers survey 2015

At a time when investment and support is needed

It is not acceptable for people with mental health problems to be treated differently to those with physical health problems. These findings must act as a wake-up call to our public services. We found some excellent examples of services in areas joining-up and providing effective care, with staff committed to working to make sure people in a crisis received the help they needed. Dr Paul Lelliott, Deputy Chief Inspector, CQC

The Care Quality Commission’s findings highlight three key areas that must be addressed: better staff training, improved compassion, and a more joined up approach between NHS providers, commissioners, local authorities, primary and social care, so that those needing mental health care have timely access to the appropriate type of care they need, when they need it.

Potential ways of closing the financial gap

“The financial deal requested by the NHS” – £2bn for 2015/16 via Autumn Statement and £8bn for this parliament Scale of challenge on public finances and other public services We’ve done our bit in Government – NHS do yours & get on with it “Now that taxpayers have shown their commitment to the NHS in an extra £10bn, the time for the discussion on whether that’s the right amount has passed” (Jeremy Hunt, June 2015)

Inject more money

Recognition amongst some system leaders that time has now come to debate whether current NHS offer is affordable on current NHS finances but others unwilling Nibbling at edges may be possible but no political appetite at all, at this point, for serious open debate on NHS offer

Flex NHS offer to meet the finances

Perceptions of “plenty to go for”; “NHS not done what rest of public sector or other national health systems have done” 2-3% annual savings from efficiencies and new care models over time is not unreasonable.

NHS strains every sinew to close gap

What does “straining every sinew” look like as of today?

Review 2015/16

business plans

Force down cost of agency

staffing

Review quality / staffing balance

Create formal efficiency

programme

First steps on coherent plan for £5bn of £22bn by 2019/20

• Lord Carter of Coles was appointed Chair of the NHS Procurement and Efficiency Board in June 2014. First major piece of work is the adjusted treatment index to compare hospital efficiency.

• The metric includes assessments of procurement costs, staff rostering, theatre productivity, staff numbers and mix, IT and other non-pay spend. Has been developed with cohort of 22 trusts.

• Interim report suggests NHS could save up to £5bn per annum by 2019/20: £2bn by improved workflow and containing workforce costs, £3bn through improved hospital pharmacy and medicines optimisation and estates and procurement management.

• All hospital trusts will be given individual savings targets, from January 2016. NHS Providers working with Lord Carter to help ensure work is co-designed, of practical use, and not co-opted into a stick to beat the service

Top down requirement or bottom up support?

“Whilst I am reluctant to set detailed targets I believe we could make savings of up to £5bn per annum by 2019/20 provided there is political and managerial commitment to take the necessary steps. There is a delicate balance to be made between hospitals taking ownership and accountability for their own costs, and the level of support, incentives and intervention provided by DH, NHS England, TDA and Monitor. My own personal thoughts are that a regulatory approach will probably fail to capture the imagination and engagement of hospital boards. It is more important that boards take ownership themselves and collaborate with each other to identify and share best practice. That said, I do believe they need support, and this support needs to be seen as helpful and non-directive”

Monitor business plan reviews

• Visit 43 FTs with largest deficits.

• Challenge plans to identify further savings and efficiencies

• Executive-led challenge session to agree what stretching revisions to plans, but reserve right to use legal powers

• Monitor financial performance against these revised plans for the rest of the year in some detail.

• Some of you feel you face Hobson’s choice: Insist on a realistic plan and risk incurring Monitor ire now Agree what Monitor “think” plan should be, fail to deliver and incur ire later

• Monitor senior leaders say they clearly want the former • Please alert us if you feel you are being forced into the latter

Some very knotty problems here……

Phasing the extra £8 billion Government needs it back ended, NHS needs it front ended

Restoring financial balance Recovery takes much longer that deterioration Ability of DH to centrally support likely size of provider deficit

No serious plan yet to realise sufficient short term savings Agency staff savings will help but…

Serious savings will take time to realise Easy savings already realised Capability, capacity, time needed to realise Carter, new care models savings etc

Meanwhile, every year, tariff drops whilst demand and costs rise 4%

Crystal ball: our best prediction • Herculean effort to improve 2015/16:

Government will insist “no more money” Agency staff actions etc will help but… Likely end year range £1.0bn to £2.5bn… To cover deficits DH will require HMT bail out

• Tensions likely to rise:

Between central Government and DH Between system leadership and providers Between DH/NHSE and Monitor / TDA

• Pointed dialogue on “need more now” vs what’s realistic for providers to achieve when

• Danger that centre takes even greater control to “ensure providers deliver”

What should we be doing? Five thoughts to discuss

Where we are in the political cycle / rhythm

The need for providers to stretch every sinew….and be seen to stretch every sinew

Calling for more money will not work at this point nor will calling for a reduction in the NHS offer

Therefore foster honesty and realism by telling it as it is, privately at first and publicly if needed later

Continue to deliver as effectively as possible (operations and transformation) until there is full alignment on a realistic view of what providers can actually deliver

National Tariff 2015/16 and into 2016/17

Very difficult 2015/16 tariff and contracting round

Working through detail for 2015/16 • Implications for DTR once final prices agreed

Avoiding the same issue in 2016/17 • Early engagement on where 16/17 fits in

five year efficiency ask of £22bn • CNST • Development of new group to look at

specialised service costs and prices • Review of legislation around objection

methodology? • Pressures to make books balance via tariff

will still be enormous

Impact of new Monitor leadership unknown

What will we cover?

Quick overview

Money

Post election announcement flurry


Post election priorities

• Ongoing commitment to quality of care, compassion and patient safety • Supporting individual members of workforce to provide excellent care

- lots of staff on campaign trail saying how stretched they are • Providing right quality of care for older people and people needing

specialist care. Added dimension of asking how wider society, not just health and care system, can support older people

• Step change in quality of GP services and out of hospitals services more generally. Sense of really making this change happen.

• Focussing very early on money - money in 15/16 and efficiency savings over next 5 years

• Public recommitment from SofS and PM to 24/7 NHS

Flurry of announcements

INTERVENTION Increased monitoring Increased conditions

Increased basket of trusts getting ‘attention’

SUPPORT Provider sustainability

directorate National action to cap spend

Mgmt consultancy

cap

Ambulance & 18 wks targets

NICE Safe staffing

Agency staffing cap

Very Senior Manager Pay

Monitor 43 site business

plan visits

RAF financial measures

CQC & efficiency

Success regime for

LHEs

Single leader for Monitor

and TDA

What does the flurry mean? The NHS has a large system wide performance and finance problem….

….the centre of Government is putting significant pressure on NHS system leaders to sort the problem out quickly …

….NHS system leaders therefore need to be seen stretching every sinew, including “taking the pain everyone else has” on issues like VSM and management consultancy….

….there are competing views on the reasons for the problem: it’s either the demand / money gap playing out or “insufficient provider will and lack of leadership capability”…

….some, including the centre of Government, believe that reasserting grip is the best way to sort the problem out…

…those who don’t are finding it difficult to resist, because of the need to do something and this is what the centre wants…

….everyone also now acknowledges that the Government got the post Francis quality not money emphasis wrong and that the balance needs to be restored.

Questions raised by the flurry

Approach

How will proposals impact accountability of individual providers to regulators and other statutory players; and what will they mean for institutional autonomy and the FT model? What is the statutory basis for these measures, and will these initial changes lead to wholesale changes that alter the whole shape of the current system? When, where and how do we draw a line in the sand?

Practicality

How workable are the proposals in terms of likely bureaucratic burden on regulators and providers? What is the knock on effect on regimes, frameworks and organisations outside of the direct purview of the flurry Will all this actually solve or help solve the problem?

What will we cover?

Quick overview

Money

Announcement flurry


Looking from two ends of the telescope….

NHS trusts and foundation trusts



Five Year Forward View is the direction of travel

Renewed focus on three gaps

• The health and wellbeing gap; addressing health inequalities and supporting the public to make healthy choices

• The finance and funding gap; addressing the growing gap between growth in demand and expectations and the available resources

• The care and quality gap; addressing unwarranted variability in quality across the country.

Transformation can not be delayed

“Oh Lord, make me virtuous, but not yet” St Augustine

Time to deliver: from compass to roadmap

NHS Providers briefing:http://www.nhsproviders.org/resource-library/nhs-providers-briefing-success-regime-raf-rtt-5yfv-and-speeches/

The Five Year Forward View is increasingly the….

Strategic branding and “wrapper” for what

the NHS does

Governance mechanism for bringing NHS system

together

Blueprint for the transformation we need

to achieve

Potential for confusion!

Key 5YFV developments since we last met……….

Near completion of 5YFV governance mechanisms

Launch of fourth vanguards: acute care

Pivot of Willetts UEC Review into UEC vanguards

Creation and announcement of success regime

5YFV New Models of Care gaining momentum

Multi-agency support for people in care homes and to help people stay at home Using new technologies and telemedicine for specialist input Support for patients to die in their place of choice

Enhanced health in care homes

Coordinated care for patients with long-term conditions Targeting specific areas of interest, such as elective surgery Service line franchises and chains/groups in particular

New approaches to acute care

Integrated primary, hospital and mental health services working as a single integrated network or organisation Sharing the risk for the health of a defined population Flexible use of workforce and wider community assets

Integrated primary and acute care systems

Blending primary care and specialist services in one organisation Multidisciplinary teams providing services in the community Identifying the patients who will benefit most

Multispecialty Community Providers

NHS England

Develop new system wide indicators Implement recommendations of the Keogh review at pace Support existing system resilience groups

Urgent and emergency care

Acute care models vanguard

Rather than automatically assuming that centralised, ‘bigger is better’ we want to test new ways of sustaining local NHS hospital services, with more sharing of medical expertise across sites, and more efficiency from shared back office administration.” Simon Stevens

• Primary and acute care systems (PACs) are unlikely to become the majority future model for acute services across England. Alongside these PACs models of vertical integration forms of horizontal integration should be explored to support the sustainability of acute care, in particular for services with low volumes of patients or services where there are national or local staff shortages.

• The horizontal integration models can apply to single service lines, multiple service lines or whole institutions. As set out in the Dalton review, these new models include Accountable Clinical Networks, specialty franchises, management groups and chains.

• Key questions are • How do you deliver clinically and financially sustainable high quality acute services to maintain

local access for patients and their families? How does this differ for urban and rural locations? • How can service franchises, management chains and/or other similar arrangements help codify

and replicate effective clinical and managerial operating models in order to reduce avoidable variations in the cost and quality of care?

• Primary and acute care systems (PACs) are unlikely to become the majority future model for acute services across England. Alongside these PACs models of vertical integration forms of horizontalintegration should be explored to support the sustainability of acute care, in particular for serviceswith low volumes of patients or services where there are national or local staff shortages.

• The horizontal integration models can apply to single service lines, multiple service lines or whole institutions. As set out in the Dalton review, these new models include Accountable Clinical Networks, specialty franchises, management groups and chains.

• Key questions are• How do you deliver clinically and financially sustainable high quality acute services to maintain

local access for patients and their families? How does this differ for urban and rural locations?• How can service franchises, management chains and/or other similar arrangements help codify

and replicate effective clinical and managerial operating models in order to reduce avoidablevariations in the cost and quality of care?

Urgent & Emergency Care vanguard The UEC Vanguard group will: • comprise a small number of enthusiastic and

energetic participating systems, drawn from across different geographies, working as a group;

• receive early access to tools and guidance developed through the UEC review;

• have a strong focus on unblocking current system constraints and national barriers to change, e.g. information sharing and payment methods;

• enjoy clear commitment and sponsorship from the national NHS bodies and their CEOs;

• benefit from direct practical support, through an expanded role for ECIST working under the aegis of the new care models programme. Professor Sir Bruce Keogh and Professor Keith Willett will provide clinical leadership for the UEC Vanguard programme;

• access to transformation funding.

NHS Providers engaging at all levels of the 5YFV

GOVERNANCE Sitting on NCM Board, Workforce Advisory board, Finance and Efficiency Board, National Information Board subgroups; overall 6ALB CEOs stakeholder group

IMPLEMENTATION Working with Lord Carter review team; David Williams DH DG Finance on regional workshops for £22bn savings plan; Monitor Economics to input and co-design national work; TDA and Monitor on design workshop for success regime

ENGAGEMENT Helping ALBs to design planfor engaging the provider sector early to ensure best chance of success and momentum

Big issues 5YFV in early days of grappling with……….

Joining up the dots into a coherent whole

Marrying today’s operations with tomorrow’s strategic transformation

Getting from small number of individual vanguards to consistent, universal, movement to new care models

Funding the transformation including building the required capability

Building and enabling right relationships including national / local and whole system local relationships




Existing model of provision

Changing needs

Rising demand

Need to innovate

Financial pressure

Our existing models of care are under pressure

Existing model characterised by (1) Fragmentation (health & social care; primary and secondary, physical and mental health), (2) Medicalisation (treatment not

prevention and wellness promotion; medical model of care), (3) Hospitalisation (intervenionist models, acute domination), (4) Specialisation, (5) Historical

precedent of where things are and what people do

Leading to a strategic ferment for new approaches

Holistic patient led care

Prevention and self care, medicalise

only when necessary

Care closer to home, hospitalise

only when necessary

Integrate care to cross traditionally

fragmented boundaries

Switch from individual

institution to local system focus

Patients and pathways, not systems and structures

Harness innovation e.g. technology

Move from specialist to

generalist, e.g. older people’s care

Break away from existing bricks and

mortar

New relationships to build

“If you are thinking of doing work with primary care, then clear your diary”

NHS Foundation Trust CEO

“If you think you have agreed something with a practice or a federation then

double-check if you agreed it with each individual partner…or it may turn out

that you have agreed nothing”

NHS Foundation Trust CEO

Safety nets or strategic partners for primary care?

Safety nets Partners

Federating to provide scale and more coherent voice Strategic partnerships with Trusts and FTs to share back office functions, freeing up GPs to be GPs Ward walks and clinician to clinician relationships becoming currency of service redesign

The Wild West of single handed practices waiting for retirement FTs and Trusts step in as emergency caretaker where practices have 'huge difficulties recruiting and retaining GPs, racking up huge locum costs and looking at rapidly decreasing profits to the extent they didn't think it was sustainable’ Suspicion and distrust of trusts/FTs

NHS Providers – three quick final things

Influence voice balance

Influence Voice

Support Professional

Healthcare cost recovery

A new partnership to enable trusts to improve cost recovery • Estimated that two thirds of the funds trusts are entitled to recover

when treating patients who have been involved in a non-fault third party road accident

• Moving into pilot phase to enable members to make the most of cost recovery with a straightforward free service to help our members transform and improve cost recovery performance

• A number of trusts have gone live • We are now approaching ten trusts as our pilot phase – and would

welcome members who are keen to embrace

A date for the diary… NHS Providers parliamentary reception

Tuesday 8 December, 4.30-6.30pm, following the December chairs and chief executives meeting House of Commons, Members’ Dining Room A networking event with your local politicians , hosted by Rt Hon Margaret Hodge MP. Further details to follow.

NHS Providers annual lecture

Wednesday 16 September, 6pm Institute of Mechanical Engineers A lecture by Sir David Nicholson on his reflections on the operational, financial and leadership issues facing the NHS. Further details to follow.

What I Haven’t Covered

Specialised commissioning

Smith Review of leadership and improvement

Rose Review of NHS Leadership

Devo Manc and Devo other

places

Future of commissioning

Impact of social care cuts

THANK YOU

Q&A

Images from Googleimages & HSJ

Impact of social care cuts

“My NHS Trust has become the conscience of the Local Authority – they cut their budget, cut my revenue, but ask me to keep the

lights on for the services our population need”

NHS Provider NED

Source: ADASS infographics

What next for commissioning in general?

commissioning This is the process by which bodies such as CCGs, NHS England and local authorities assess the needs of people in an area, determine priorities, design and source appropriate services, and monitor and evaluate their performance. Commissioning is often confused with contracting, procurement and tendering. These activities may form part of the commissioning process when an external supplier is charged with delivering the services or functions being commissioned. However, commissioning is not synonymous with contracting, procurement or tendering, and it can take place without these activities.

Source: RCP Glossary

[kuh-mish-uh-ning n]

Increased transparency on CCG capability

Patient group outcomes • LTCs • Maternity &

children • Mental health • Older people • Generally healthy

Capability • Resilience • Transformation

Publish CCG ratings on NHS Choices for:

And renewed interest in CCG capacity and capability

Source: Nuffield Trust Leader’s panel survey (March 2015)

What should the purpose of commissioning in the NHS be and

how can it add value?

How does our current conception of commissioning or the way it is practised differ from that ideal

purpose?

What are the best examples of commissioning systems in: The NHS now and historically; Other

countries; Other sectors?

What features of those systems are at the root of their success?

Commissioning

What would help?

Increased alignment not

duplication and confusion

Strategic commissioning not

contracting

Long term thinking not in-year

thinking

Risk shares not risk transfers

Supportive not adversarial behaviours

Innovating not destabilising

Transparent and accountable

Part of system leadership and co-ordination

Contracts as a backstop to

relationship, not the focus

Capability and behaviours

Capacity

BoD July 2015: 11_Chief Executive’s Report p1


SUBJECT: CHIEF EXECUTIVE’S REPORT

DATE: JULY 2015

PURPOSE:



PREPARED BY: Diane Wake, Chief Executive

SPONSORED BY: Diane Wake, Chief Executive

PRESENTED BY: Diane Wake, Chief Executive

STRATEGIC CONTEXT

To report particular events, meetings or publications that the Chief Executive would like to bring to the Board’s attention.



The Board of Directors is asked to receive and note this report.






Governors Monitor








To be developed




Finance: Other:





Subject: CHIEF EXECUTIVE’S REPORT Ref: 15/07/P-11

1. INTRODUCTION 1.1 This report is intended to give a brief outline of some of the key activities undertaken

as Chief Executive since last month’s report and highlight a number of items of interest.

1.2 The items below are not reported in any order of priority. 2. WORKING TOGETHER PROGRAMME

2.1 The Chief Executive attended the Working Together Programme meeting on 1st June 2015. Agenda items at the meeting included:

• review of Progress – areas of the programme that were going well and areas where improvements could be made

• key learning points

• new models of acute care collaboration

• organisational models

• the way forward and next steps 2.2 The next meeting of the Working Together Programme is scheduled for 6th July 2015.

3. NHS CONFEDERATION CONFERENCE

3.1 This year’s Confederation was attended by Stephen Wragg, Chairman; Diane Wake,

Chief Executive; Karen Kelly, Director of Operations and Richard Jenkins, Medical Director. The conference was held over three days and key speakers included, Sir Andrew Cash OBE, Deputy Chair NHS Confederation and Sir David Dalton, Chief Executive, Salford Royal NHS Foundation Trust, and the Right Honourable Sir Jeremy Hunt, Secretary of State for Health.

4. BARNSLEY HOSPITAL CHARITY AWARDS 4.1 On Friday 5th June 2015 the Trust held its annual Barnsley Hospital Charity HEART

Awards to celebrate the fantastic success of our staff at Barnsley Hospital. 4.2 This was the sixth consecutive year we have celebrated the HEART Awards and once

again it proved to be a fantastic night celebrating the successes of all teams and individuals across the Trust.

4.3 The Board of Directors would like to congratulate all the nominees and the full list of the HEART Award winners are as follows:

• Brilliant Individual Staff Award – Barbara Falconer • Brilliant Team Staff Award – Ward 24 and the Chemotherapy Unit • Individual Outstanding Achievement Clinical – Dr Daniel Raw • Individual Outstanding Achievement Non-Clinical – Louise Pemberton • Innovation Award – Endoscopy Team • Partnership Working – Dementia Nurse Team and the Alzheimer’s Society

Team • Patient Safety – Mortality Review Group • Patient’s Choice Award – Neonatal/Special Care Baby Unit • Team Outstanding Achievement Clinical – Emergency Department


• Team Outstanding Achievement Non-Clinical – Procurement Team • Volunteer of the Year – Sarah Calvert, Volunteer Women’s Services • Governors’ Award – Janet Curry • Chief Executive’s Award - Frail Elderly Team • Chairman’s Award - Terri Mcniffe

5. NHS PROVIDERS CHAIRS AND CHIEF EXECUTIVE MEETING 16TH JUNE 2015 5.1 The Chief Executive together with the Chairman attended the NHS Providers Chairs

and Chief Executives Meeting on 16th June 2015 in London. The agenda for the day included:

• Strategic and Policy Update and Dialogue – A presentation from NHS Provider’s Chief Executive, Chris Hopson on strategic and policy issues affecting NHS providers.

• Update on the Five Year Forward View – a session facilitated by the Chief Executive of NHS England, Simon Stevens which gave members an update on the Five Year Forward View and the NHS Care Models Programme.

6. START OF THE YEAR CONFERENCE 18TH JUNE 2015 6.1 The Chief Executive together with the Chairman and members of the Executive Team

and the Board of Directors attended a Start of the Year Conference on 18th June 2015. The conference had been arranged by Barnsley Clinical Commissioning Group and the aim of the conference was to facilitate the System Transformation Analysis and Redesign Tool as an enabler for a Multispecialty Care Provider model of Care in Barnsley.

7. BARNSLEY COLLEGE EXCELLENCE AWARDS 25TH JUNE 2015 7.1 The Chief Executive together with the Chairman attended the annual Barnsley College

Excellence Awards on the evening of 25th June 2015 at the Metrodome in Barnsley. 8. THE PATIENT REPORTING AND ACTION FOR A SAFE ENVIRONMENT (PRASE)

PROJECT 8.1 The Trust is part of an exciting project supported by the Health Foundation called

PRASE. Information about patient safety is collected from patients or the patient’s representative using a detailed questionnaire that is administered by volunteers. The questionnaire captures the patient’s perception of patient safety. The results of the questionnaires are then discussed at multidisciplinary ward team meetings and an action plan is produced.

8.2 Wards 17 and 32 are piloting PRASE and this will then be rolled out to other wards. This is an effective way of involving patients in helping to make our hospital safer.

9. CONSULTANT APPOINTMENTS 7.1 I would like the Board of Directors to note the progress on the following Consultant

appointments:-

• The interviews for Consultant in Orthopaedics were held on 17th June 2015 and I am pleased to advise the Board of Directors that the post was successfully recruited to.

• The interviews for Consultant in Acute Medical Unit were held on 8th June 2015 and I am pleased to advise the Board of Directors that the post was successfully recruited to. The post will cover six sessions on the Acute Medical Unit and four sessions in Diabetes and Endocrinology.


• The replacement post for Consultant in Histopathology has been advertised with a closing date of 19th July 2015. The shortlisting and interview dates are to be confirmed.

• The post for two Consultants in Emergency Medicine has been advertised with a closing date of 17th May 2015. The interview date has been scheduled for 7th July 2015.

Diane Wake Chief Executive July 2015


BoD July 2015:12(a)_Council of Governors

SUBJECT: COUNCIL OF GOVERNORS

DATE: JULY 2015

PURPOSE:




PREPARED BY: Carol Dudley, Secretary to the Board SPONSORED BY: Stephen Wragg, Chairman PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT

The role and responsibilities of the Council of Governors and the Board’s responsibilities of working with and providing support to the Council.

KEY ISSUES ADDRESSED IN THIS REPORT

To illustrate how the Council of Governors continues to hold the Non Executive Directors to account. To evidence information provided by the Board to the Governor, and the Board’s listening and responding to questions and comments from the Governors. Affirm training provided to Governors

CONCLUSION AND RECOMMENDATION(S) The latest agenda (from General Meeting held in June 2015) and approved minutes (April 2015) are attached, to illustrate how the Board and Governors continue to work together to support development of services to patients. They also reflect some – but not all – of the ways in which the Governors and Board meet the requirements:

- for the Board of Directors to listen to and take account of the view of the Council of Governors

- to provide both information and training to governors - for the Council of Governors to hold the Non Executive Directors to account - Governors’ responsibilities for appointment on Non Executive Directors

The Board is asked to receive and note this report.

CoG June 2015: 12(b)_CoG Agenda Jun15

GENERAL MEETING OF THE COUNCIL OF GOVERNORS OF BARNSLEY HOSPITAL NHS FOUNDATION TRUST

5.30-7.30pm, 11 June 2015

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

1. Apologies & Welcome

2. To invite comments from members of the public

3. To receive any declaration of interests

4. To approve the Minutes of the Meetings held on 16 April 2015 ENC 3

5. To consider any matters arising from the Minutes of the last meeting

6. To receive an overview of the 2015/16 Budget Presentation – Mr S Diggles, Interim Director of Finance & Information

7. To receive a report from the Nominations Committee ENC 7 – Mr S Wragg, Chair of Nomination Committee

8. To receive a briefing on the role of the Director of Operation Presentation – Mrs K Kelly, Director of Operations

9. To receive a report from the Trust’s Chairman, Mr S Wragg ENC 9

10. To receive a report from the Lead Governor, Mr J Unsworth ENC 10

11. To receive an update report from the Trust’s Chief Executive, Ms D Wake ENC 11

12. Subgroup reports: a) To receive and endorse the latest report of the Strategic Sub-groups ENC 12a

– Mr D Brannan & Mr J Ramsey, Sub-Group Chairs b) To approve appointment of sub-group Chairs & Lead/Deputy Lead Governors ENC 12b

– Mr S Wragg, Chairman

13. To receive and note reports from the Board of Directors ENC 13 – latest Board Agenda and Minutes (meetings held in public) – latest integrated monthly performance report

14. To consider any topics raised by Governors – items highlighted in pre-meeting

15. Any other business, including: – matters raised by the public – date of next General Meeting, 6th August 2015 (5.30-7.30pm)

Signed: ……………….….. Chairman

COUNCIL OF GOVERNORS – JUNE 2015 REF: CG/15/06/03

03

MINUTES OF A GENERAL MEETING OF THE COUNCIL OF GOVERNORS HELD ON 16 APRIL 2015, 5.30PM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL Present: Mr P Ardron Partner Governor, Sheffield Universities

Mr D Brannan Partner Governor, Voluntary Action Barnsley Mrs P Buttling Public Governor, Barnsley Public Constituency Mr A Conway Staff Governor, Volunteers Mr A Dobell Public Governor, Barnsley Public Constituency Mr A Grierson Public Governor, Barnsley Public Constituency Ms R Hewitt Staff Governor, Clinical Support Services Mr M Jackson Partner Governor, Joint Trade Unions Committee

Mr B F Leabeater Public Governor, Barnsley Public Constituency Ms G Morritt Staff Governor, Nursing & Midwifery Ms A Moody Public Governor, Barnsley Public Constituency Mrs J O’Brien Public Governor, Barnsley Public Constituency Mr H Patel Public Governor, Barnsley Public Constituency Cllr J Platt Partner Governor, Barnsley MBC Mr J Ramsey Staff Governor, Non Clinical Support Staff Mrs C Robb Public Governor, Barnsley Public Constituency Mr F Skorrow Public Governor, Barnsley Public Constituency Mr T Smith Public Governor, Barnsley Public Constituency Mr J Unsworth Lead & Public Governor, Barnsley Public Constituency Mr S Wragg Trust Chairman

In attendance: Mrs S Brain England OBE Non Executive Director Ms C Dudley Secretary to the Board Dr R Jenkins Medical Director Mrs K Kelly Director of Operations

Mr R Kirton Director of Strategy & Business Development Ms P McLaren Interim Director of Marketing & Communications

Mr N Mapstone Non Executive Director Mrs H McNair Director of Nursing & Quality Ms R Moore Non Executive Director Ms D Wake Chief Executive

Apologies: Mrs J Gaines Public Governor, Barnsley Public Constituency Mr W Kerr Public Governor, Barnsley Public Constituency Mr P Lleshi Partner Governor, Barnsley Together Mrs D Murray Partner Governor, Barnsley College Mr R Raychaudhuri Staff Governor, Medical & Dental Mrs L Sanderson Staff Governor, Nursing & Midwifery Mr L Steenson Public Governor, Public Constituency O (out of area) Mr D Sykes Public Governor, Barnsley Public Constituency

CG/15 21 APOLOGIES & WELCOME The Chairman welcomed Governors, Directors, and senior managers to the meeting. Apologies were noted as above.

Action

CoG June 2015: 03 CoG Apr Mins page 2 of 7

CG/15 22 DECLARATIONS OF INTEREST None.

CG/15 23 COMMENTS FROM THE PUBLIC None.

CG/15 24 MINUTES OF LAST MEETING (Enc 4)

The Minutes of the General Meetings held on 5th February and 5th March 2015 were received and accepted as a true record.

CG/15 25 MATTERS ARISING The following updates were noted:

• CG 15/02 – Overflow car park No issues had been identified on the report to date but the matter would be revisited if/when further information became available.

• CG 15/05 – Emergency Department statistics Requested information expected shortly.

• CG 15/08 – Yorkshire Ambulance Service (YAS) data Cllr Platts advised that the query re availability of YAS data had been brought up at recent meetings of the Health & Wellbeing Board and was being progressed by the local Clinical Commissioning Group (CCG).

• CG 15/08 – Membership Newsletter Mrs O’Brien expressed concerns that, despite assurance at the last meeting, the new-style newsletter had been issued in the Barnsley Chronicle without prior notice to members. The lack of notice to Members was acknowledged; Ms McLaren explained that it had been – and still was – intended to write to members regarding the newsletter and an invitation to join a new lottery being established for the Hospital Charity. The latter had been delayed (should be resolved within the next four weeks), hence the letter had not yet been issued but it would be going out shortly and members’ response to the change in publication of the newsletter would be taken into account ahead of future issues. Whilst response to the newsletter had been very positive feedback to date and there had been a slight uptake in membership too, Ms McLaren did apologise for the order of events and the Chairman confirmed that such an incident would not happen again when Governors were given assurance on something.

SW

CG/15 26 2015/16 BUSINESS PLAN (Enc 5) The Council received and noted the 2015/16 Annual Plan and the objectives therein. Mr Kirton expanded on the report and reminded Governors that the Plan was based on year two of the Trust’s Five Year Plan (the subject of discussion at several Governors’ meetings), the first year of which had included some significant achievements, including: development of the quality strategy, improvements in delivery of the 4 hour target, good progress on the turnaround plan, implementation of a new central computer system Trust-wide, development of the birthing suite and successful accreditation of a Bronze Award for Investors in People. Mr Kirton confirmed that progress on the 2015/16 Plan would be provided on a quarterly basis through the Trust’s performance reporting systems. This


approach would support the Governors’ role of holding the Non Executive Directors to account. Governors were pleased to note that, prior to official publication (which would be subject to approval by the regulator, Monitor), an overview of the Plan would be cascaded Trust-wide, following its launch at next Team Brief session, led by the Chief Executive. In response to questions from the Governors, Mr Kirton reminded the meeting of how the Plan was built, which included seeking input from the Governors as well as other internal and external stakeholders (staff, the CCG, Local Authority, other community partners, etc). It was suggested and agreed that in future years it would be helpful if Governors’ input could be shown more clearly. Mr Kirton also confirmed that the objectives would be RAG rated (red/amber/green) in the quarterly reporting and that copies of the formal Annual Plan, when published, would be circulated to all Governors.

BK

BK

CG/15 27 QUALITY REPORT / ACCOUNT (QA) (Enc 6) Mrs McNair expanded on the submitted report, reminding Governors of their involvement with development of the priorities and indicators for 2014/15 and 2015/16. More detailed liaison on the QA had been led via the Governors’ sub-groups, at the latest of which the Governors had identified Falls as their chosen indicator for audit. As stated in the enclosure, the draft 2014/15 Quality Report would be distributed to Governors shortly for comment. It was agreed that, following similar practice in previous years, the Finance & Performance sub-group would be authorised to draft and submit a formal response on behalf of the wider Council of Governors.

Govs

CG/15 28 SERIOUS INCIDENTS (SIs) (Enc 7)

Mrs McNair presented the six monthly report on serious incidents (SIs). The report, which had been presented to the Board in March, had been expanded at the Governors’ request to provide more information on outcomes of the root cause analyses undertaken against all SIs. One recent outcome had been the publication of the Patient Safety Bulletin to share learning from SIs (and other reporting routes) Trust-wide; the Bulletins could be shared with Governors if required. Governors requested and received further information on several of the cases outlined in the report. From discussion, key points included assurance on the focus given by the Trust to dementia training for all staff, to ensure awareness on every ward and clinical area; the value of learning from the reported incidents, and the scope of the issues reported – which included all pressure ulcers (now deemed SIs on a national basis) and falls. Governors were aware of the workstreams ongoing in these areas and the focus on prevention of as well as responding to incidents. The report was received with thanks.

CG/15 29 NON EXECUTIVE DIRECTORS Mrs Brain England provided a useful overview on the role and responsibilities of a Non Executive Director (NEDs). She emphasised that it was not just one of attending Board meetings but was a busy role, with all postholders deeply committed to the role over and over their agreed hours. She also stressed that NEDs held the same responsibilities and duties of


any other Director of the Trust, 24/7, and explained just some of the ways that she and her fellow NEDs worked hard to gather the knowledge required to help them deliver their roles effectively and the broad scope of the diverse duties undertaken by the team – from liaising with Governors, attending a series of meetings, to chairing Appeal Panels. Mr Dobell queried what Governors could do more and/or differently to deliver their roles of holding the NEDs to account. The meeting was reminded of the importance of opportunities available to challenge NEDs on delivery of the Trust’s business plan, which had been enhanced with the restructuring of the Board and Governors’ reporting structure in 2014, opportunity to observe NEDs at Board meetings, Governors’ participation in 360 evaluation of NEDs, the Nomination Committee’s role in appraisals as well as presentation of formal reports on the NEDs’ performance to the wider Council of Governors. Mr Smith, Deputy Lead Governor, encouraged Governors to attend training national and regional training on issues such as holding the NEDs to account too. The Council also welcomed the Trust’s two newest NEDs to the meeting – Ms Moore and Mr Mapstone, both of whom gave an overview of their background, their fields of experience and interest and the way in which they intended to work within the team to help continue the Trust’s future progress and development. Ms Moore and Mr Mapstone said they felt privileged to be on the Board.

CG/15 30 CHAIRMAN’S REPORT (Enc 9) The Chairman’s report was received and noted. It provided commentary and updates on a range of activities, items of interest and Board discussions since the last General Meeting. The report also invited expressions of interest for the sub-group lead roles as well as the Lead and Deputy Lead Governor roles. Several issues were expanded in discussion: • In addition to Mr Spence’s resignation, two other governors had resigned

recently. Mr Kerr, for personal reasons, and Mr Sykes due to work pressures. The Chairman would be writing to convey the meeting’s sincere thanks and best wishes to all three Governors. In accordance with the Trust’s Constitution, the consequent vacancies would be offered to candidates not appointed at the last elections.

• It was agreed that it would be timely to review the Constitution to address, at least, options for the model rules currently applied for the elections. Mr Grierson requested, and it was agreed, that the terms of office for Governors be including in the review too. He suggested that it would be more cost effective and could be more constructive for the Governors in post too, to consider 4-year rather than 3-year terms. Governors would have opportunity to join the working group for the Constitution review, to be led by the Associate Director of Corporate Affairs; further information would follow when the review was due to commence.

• The Chairman drew attention to the annul HEART Awards, being held on 5th June. These were a popular and valued opportunity to say a huge ‘thank you’ to just some of the terrific staff and volunteers working across the hospital. Tickets would be going on sale shortly.

SW


The report was noted and Governors confirmed their support for the process for the annual review of the sub-group Chairs/Vice Chairs and Terms of Reference and the roles and responsibilities of the Lead/Deputy Lead Governors, and supported the process for review of the Constitution.

CG/15 31 LEAD GOVERNOR’S REPORT (Enc 10) The Lead Governors’ report on activities since the last meeting and items of interest for the Council was received and noted. Mr Unsworth highlighted: • The HEART Awards – and opportunity for all Governors to be involved

with the shortlisting process to be held at Barnsley College on 14 May. Ms McLaren outlined the aim of this new process, to widen the involvement of Governors and other stakeholders and give more opportunity to recognise all the staff nominated for an award, not just the ‘winners’ on the awards’ evening. This was appreciated;

• the recent NHS Providers event, a more detailed report on which was tabled by Mrs Buttling who had attended. Mrs Buttling outlined key elements from the presentations and discussion on the day, including implications of the Five Year Forward View issued by NHS England, the increasing focus on person centred care, the role of Healthwatch and the impact of the General Election. Mrs Buttling encouraged Governors to attend future events; they were interesting and provided a useful networking opportunity too.

CG/15 32 CHIEF EXECUTIVE’S REPORT (Enc 11) The Chief Executive’s report was received and noted. Ms Wake drew attention to the update on the ongoing contract negotiations, which were all the more challenging in terms of supporting the Trust’s delivery of the second year of the turnaround plan. Ms Wake also reported on further changes proposed for the Executive Team following Ms Brearley’s recent departure and a part-time secondment opportunity for Mrs Kelly with Sheffield Teaching Hospitals. It was emphasised that Mrs Kelly’s loyalties and responsibilities would remain first and foremost with BHNFT and that the secondment could be terminated without notice if required to support Barnsley’s services. With regard to HR, Ms Wake explained that that it was not intended to replace Ms Brearley’s role on a “like for like” basis immediately but to address the component parts differently going forwards, ensuring that all aspects continued to be effectively managed by the Executive Team, supported by a new role of Director of People (12 months fixed term contract) – linked to the Listening in Action journey outlined in the CEO’s report. Governors noted the initial proposals outlined. It was also noted that work continued for a substantive appointment to the role of Director of Finance & Information; this would be going out to advertisement again with support from a search consultancy and interviews to be held some time in June/July. Other issues reported including the peer review on the trauma unit (Ms Wake affirmed that the lead on spinal injuries rested with Sheffield Teaching Hospitals as the major trauma centre for the region), continuing work with the Working Together Programme, progress on the reported SI, and success of the Bronze Award accreditation for IiP, as mentioned earlier.


Mr Brannan drew attention to the reported success of several individuals: Professor Adebajo (Silver level Clinical Excellence Award) and Sarah Stables (winner of a prestigious 2015 Royal College of Midwifery Award).

CG/15 33 SUB-GROUP REPORTS (Enc 12) Mr Brannan, for Finance & Performance (F&P), and Mr Ramsey and Mrs Robb, for Quality & Governance (Q&G), presented and expanded on the reports from their respective sub-groups. Key aspects included the continuing review of performance via F&P, ongoing focus on sickness absence, recruitment success in nursing and radiology, continuing reduction in the typing backlog reported previously, and consideration of progress of the 2014/15 quality account and agreement on the indicator for audit as mentioned earlier. Mr Brannan also drew attention to the proposal mooted by the sub-group to extend sub-group meeting times (with a strict cut-off point at 7.30pm) to support wider discussions: this was approved by the Council of Governors with immediate effect. For Q&G, Mrs Robb confirmed that the sub-group had supported proposals to withdraw Governor attendance at the Trust's Patient Experience Group, in view of regular review of the Q&G Committee’s Chair’s Log and attending of the Committee Chair/executive lead. Mr Grierson referenced the “Hello my name is…” initiative, which he had seen in operation in other hospitals and which had been very well received. Mr Ramsey also provided a verbal update from the Q&G sub-group’s more recent meeting in April, which had included receipt of the Learning from Experience Q3 report and an update on the Trust’s work on the prevention and management of pressure ulcers (copy minutes available on request for all Governors).

CG/15 34 BOARD OF DIRECTORS (Enc 13) The agenda (April), Minutes (March) and latest integrated performance report as presented to the Board of Directors meeting held in public in April 2015 were received and noted.

CG/15 35 ISSUES RAISED BY GOVERNORS No additional items were raised from the Governors’ private meeting held immediately prior to the General Meeting; most issues had been covered in discussion.

CG/15 36 ANY OTHER BUSINESS • Public Comments

a) Terms of Office As an ex-public Governor, Mrs Richardson supported the suggestion to revise Governors’ terms of office from 3- to 4- years if possible. She believed the extra year would be helpful as it can take considerable time to fully grasp the complex role of a Foundation Trust governor.


b) Newsletter Mrs Richardson advised that she had not received the Hospital Newsletter issued two weeks ago within the Chronicle. Ms McLaren would investigate this further as all copies of the newspaper that week should have had a copy inserted.

c) New NEDs Mr Conway raised an additional question to the two new Non Executive Directors: why Barnsley? Ms Moore referred to her Yorkshire roots, which had made Barnsley of particular appeal to her, and Mr Mapstone expressed his interest in protecting the future of district general hospitals, as well as his knowledge of Barnsley through other work carried out in the region.

CG/15 37 DATE OF NEXT MEETING There being no further business the meeting ended at 7.25pm. The date of the next meeting was confirmed 16th April 2015, 5.30-7.30pm.

BoD June 2015: 13_FPC Chairs log (JUNE)

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: 15/07/P/13

SUBJECT: FINANCE & PERFORMANCE ASSURANCE REPORT

DATE: JULY 2015

PURPOSE:



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

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

PRESENTED BY: Nick Mapstone, Non Executive Director, for Finance & Performance Committee

STRATEGIC CONTEXT

The current financial environment for the Trust continues to be extremely challenging and it is essential that the Board is assured that both the financial and the general performance of the Trust are effectively managed and that the Trust remains viable. The Finance & Performance Committee (F&P) has been put in place under the new Governance structure to provide assurance to the Board of Directors in relation to complex financial and operational matters following detailed analysis and challenge of both the financial and operational reports received.

KEY ISSUE(S) ADDRESSED IN THIS REPORT The areas that the committee focused on in this month were financial performance, the cost improvement plan (CIP), outpatients performance and uncoded spells. That said the meeting also covered a paper on reference costs, a review of performance on Procurement SLAs (service level agreements), the workforce dashboard (and specifically appraisals, mandatory training and sickness levels), a business case evaluation and a new business case for Print Managed Services, and updates on DNAs (did not attends) and engagement with the CCG (Clinical Commissioning Group). The committee also received three policies - two new and one revised. CONCLUSION AND RECOMMENDATION(S)

Financial performance for the month and year to date has improved on month one with the Trust moving from being down on its budgeted deficit in month one to being £10,000 better than budgeted on its deficit after two months. That said the budget remains very stretching particularly with ongoing concerns about seven day working and resilience monies so the committee pressed for more work to be done on the level of CIPs planned and how fast they could be brought online. In terms of the CIP plan, it had improved from the month one position and is only £79,757 behind plan at month two, with 60% of schemes now at maturity level four. Following the discussion on finances the CIP plan needs to develop more quickly both for the £6.7m target in the budget and the £9.2m stretch target to allow for issues arising from the problems with CCG funding and therefore there will be a detailed quarterly review at the July F&P meeting. Outpatients was discussed in detail with a number of issues raised which the committee will again review in more detail in July but which could have an effect on financial performance and needs monitoring closely. In terms of uncoded spells, the backlog position continues to improve at a pace but with some financial risks still acknowledged. The meeting received a paper on reference costs which it is recommending to the Board and also a paper on Procurement SLAs, which have had substantial development to get us in a much better position. In terms of appraisals all of the Clinical Business Units (CBUs) felt that the 90% target could be achieved by the end of June and they were reasonably confident on mandatory training performance; sickness levels have also improved with the Trust being amber for the quarter (4% or below) for the first time in the past few years.

BoD June 2015: 13_FPC Chairs log (JUNE)

The business case evaluation for Electronic Patient Records (EPR) benefits was showing a benefit of £193,000 but more work is needed to ensure business ownership of delivery of all benefits. A business case for the Managed Print services was presented and was signed off and recommended to Board. DNAs remain an area of focus and the relationship with the CCG remains strained despite Trust efforts to engage positively.

Two new policies and one revised policy were signed off. The Board is asked to note the risks identified to year end performance, CIP delivery and Outpatients performance. The Board is also requested to accept F&P’s recommendations to accept the Managed Print Services contract and to note the following policies approved by the Committee:

- Induction Policy - Mediation Policy - Criminal Records Checks


does this report relate to? All



Governors Monitor








To be developed




Finance: Other:




BoD June 2015: 13_FPC Chairs log (JUNE) 3 of 4

Subject: Finance & Performance Committee Assurance Report Ref: 15/07/P/13

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group Date Chair Finance and Performance Committee 25 June 2015 Francis Patton, Non Executive Director Log Ref



1. Cost Improvement Plans (CIP)

The first two months have seen a relatively good performance against CIP targets achieving 89% of Monitor plan. Improvement in maturity levels since last month were noted, with 60% CIPs at level 4 maturity. There has been some slippage on phasing but not against year end target. The committee will undertake a full review next month, in its quarterly reporting. Lead Officer: Director of Strategy & Business Development


2. Reference Costs

Reference cost process reviewed and endorsed, with the same approach and guidance principles to be applied as last year. The Committee noted that Internal audit reviewed the Trust’s arrangements for preparation of reference costs in 2014; the report provided significant assurance. Outcomes to be presented to Board next month. Lead Director: Interim Director of Finance & Information


3. Integrated Performance Report (IPR)

• Issues with follow up ratio for outpatients identified potential financial penalties; remedial work ongoing and wider review of outpatients overall to follow.

• Timing issues continue around preparation of IPR; will be addressed as part of continuing work to finalise improved format. New CBU template also being prepared and will be trialled with CBU4 in July.

• Uncoded spells reported to Board previously; update showed significant reduction from backlog. Still presents a financial risk to income.

Lead Officer: Director of Operations

Board of Directors To note issues and work ongoing.

BoD June 2015: 13_FPC Chairs log (JUNE) 4 of 4

Log Ref



4. Business Cases - Managed Print Services

Committee reviewed and endorsed outcomes of competitive procurement process for provision of managed print services completed. Preferred supplier identified and due diligence processes followed. Managed print services should provide estimated cash releasing savings of c£100,000 annually. Contract would be for a 5 year period, with total cost of c£850,000 (subject to final pre-contract negotiations). The proposal has been reviewed and supported by both the Executive Team and the Finance & Performance Committee. Lead Director: Director of ICT

Board of Directors

Board is asked to approve award of the contract to the identified contractor based on the recommendations of the Executive Team and Finance & Performance Committee.

5. DNA (did not attend) update

Action plans for workstreams under the remit of the DNA umbrella steering group received and noted. Continuing work will be integral to outpatients review (per 4 above). Lead Director: Director of Operations

Board of Directors

Board is asked to note the concerns around RTT data accuracy. The Committee will require ongoing updates from the steering group and speedy delivery of a solution.

6. Policies

The Committee approved the following new Policies, all of which had been reviewed and recommended by the Workforce Steering Group: - Induction Policy

(subject to final amendment to ensure IG included in all inductions – for permanent and temporary staff)

- Mediation Policy - Criminal Records Checks Policy Lead Officer: Associate Director of HR&OD

Board of Directors For assurance – to note

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: 15/07/P/14

SUBJECT: MONTHLY INTEGRATED TRUST BOARD REPORT – REPORT PERIOD MONTH 2

DATE: JULY 2015

PURPOSE:


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

PREPARED BY:

SPONSORED BY: Stuart Diggles, Interim Director of Finance & Performance Karen Kelly, Director of Operations Heather McNair, Director of Nursing & Quality

PRESENTED BY: Stuart Diggles, Interim Director of Finance & Performance Karen Kelly, Director of Operations Heather McNair, Director of Nursing & Quality

STRATEGIC CONTEXT

The attached report is the latest version Template for the integrated performance report to give the Board and its committees a full overview of Quality and Performance against key indicators. The report will include trends and actions needed if any indicators are non compliant.


1. What is the current Quality and Performance compliance of the Trust 2. What are the trends in our Quality and Performance 3. How do we benchmark against other organisations in our network 4. Actions to address non compliance against key indicators


The Board of Directors is asked to receive and consider the contents of the report.

REFERENCE/CHECKLIST · Which business plan objective(s)


· Has this report considered the following stakeholders?

Tick all applicable boxes P Patients P BCCG Other – Staff BMBC Please state:

Governors P Monitor

· Has this report reviewed the Trust’s compliance with:

Tick all applicable boxes P Regulators (eg Monitor / CQC)

P Legal requirements (Acts, HSE, NHS Constitution, etc) P Equality, Diversity & Human Rights P The Trust’s sustainability strategy

· Is this report supported by a communications plan?

Tick all applicable boxes Yes · Has this report (in draft or during


Audit P Not Applicable Finance & Performance

To be developed


· Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committee(s)

· Where applicable, state resource requirements

Finance: Other:


· Equality of treatment and access to services · High standards of excellence and professionalism · Service user preferences · Cross community working · Best value · Accountability through local influence and scrutiny


May 2015

INTEGRATED PERFORMANCE REPORT

Created By: Management Information Services Title of report: Integrated Performance Report Executive Lead: Karen Kelly

Page 1

No Title Page

1 Front Page 1

2 Contents Page 2

3 Executive Summary 3

4 Summary 4 - 5

5 Quality and Patient Experience (QPE) 6 - 8

6 Monitor 9

7 Clinical Business unit (CBU) 10

8 Emergency 11

9 Elective 12

10 Outpatients 13

11 Cancer 14

12 Commissioning for Quality Innovation (CQUINS) N/A

13 Activity 15

15 Finance 16 - 19

16 Heatmap 20 - 21

17 Safety Thermometer 22

18 Staffing 23

Contents Page

Page 2

Domains Trend Location

Area:

Amber 1/4 3/4 ↔ Summary

Page:

4 - 5

Area:

Red 1/1 0/1 ↑ Emergency

Page:

11

Area:

Amber 2/4 2/4 ↑ Elective

Page:

12

Area:

Red 0/8 8/8 ↓ Cancer

Page:

14

Area:

QPE

#REF! 5/11 5/11 ↔

Area:

2015/17394 ↑ QPE

Page:

6 - 8

Area:

1/4 3/4 ↓ Finance

Page:

16 - 19

Area:

Green 0/1 1/1 ↔ QPE

Page:

6 - 8

Area:

↔ Staffing

Page:

N/A

Operational efficiency

DNA rates continue to be higher than expected for the Trust. The Access policy has been ratified and a roll out training plan in its use is in place.

Further in-depth task and finish groups have been tasked with examining areas such as physio, T&O and paediatrics which have consistently high

DNA rates. A paper of work so far is being presented to F&P in June.

Task and finish groups have been established to address specific areas impacting on the ASI position. These groups feed into a steering group

which reports to the Operations Group meeting. There are particular areas impacting on the Trust position that currently sit outside the Trust

control e.g. Ophthalmology and these are being worked through with the service providers. A paper of work so far was presented to F&P in

May.

Cancer

Despite initial figures, the GP 62 day target for May is now non compliant. Breach analysis includes 2 local breaches where the pathway

exceeded the target by 2-4 days. This is unacceptable and reflects poor scheduling of treatments despite escalation. 62 day breaches in May

were seen in Head and Neck (3), UGI (2), Colorectal (1), Lung (1) and Urology (4).

Shared pathway performance remains poor with approximately 50% of pathways breaching and a number of referrals made to Sheffield after

Day 62.

The forecasted (and as yet unvalidated) Q position for all targets indicates compliance but pressure remains due to the potential for reallocation

of shared pathways by the tertiary centre.

Additionally the locally agreed Consultant Upgrade target is non-compliant but this is reflective of a small number of accountable pathways and 1

shared breach.

Emergency Access

Elective Access

RTT: CBU4 has in excess of 450 pts on the PTL with past TCI dates . These pathways are currently being amended and it is anticipated that the

CBU4 will achieve the 92% target at the end of June.

Diagnostic Waits: There were 7 breaches of the 6 week wait for Diagnostics in May - 1 x Cystoscopy, 4 x CT, 2 x Cardiology. The 2 Cardiology

breaches were transoesophageal echocardiograms (TOE) which are performed by a Consultant Cardiologist every other week and are dependent

upon the Consultant’s availability. The breaches were as a result of sessions being cancelled due to study/annual leave.

Cancelled Ops: Cancelled ops are within target with no breaches of the 28 day rule. 3 cancellations, all due to lack of theatre time. 1 x late start, 2

x previous pt more complex.

Theatre Utilisation Rates: Theatre utilisation rates remain high

Performance did meet the required standard for May. Continued additional support in place to provide additional clinical and patient flow

support in the evenings to recover performance and deliver June and the Quarter 1.

Executive summary

Year/Quarter to Date Performance Latest Month

Comments Performance (Latest Month)Performance (FYTD)

Page:

6 - 8

Serious Incidents: Three SIs were logged in May (one was a Grade 3 Pressure Ulcer):

2015/16615

Finance

Overall income is £0.3m favourable to plan; increased activity and income on elective, non-elective and day case offset by lower activity and

income around outpatients.

Pay costs £0.5m are adverse to plan due to the cost of higher activity levels and costs incurred around system resilience and escalation beds

which are not fully funded by the wider system. Non-pay costs are £0.2m favourable to plan, mainly driven by drugs costs which will to some

extent relate to the lower activity levels in outpatients.

CIP delivery is £0.1m behind plan and relates to the slower start of delivery of a number of schemes and due to differences on the phasing of

savings.

Deficit is in line with plan at £2.9m.

Cash position is £2.5m favourable to plan and results from improvements to the inventory, receivables and payables positions when compared to

plan.

Staffing

Sickness has fallen to 3.9% across the Trust. After recalibrating the figures for the last quarter it is the first time that sickness has remained below

4%. Mandatory Training continues to be below target but has risen slightly in May, CBUs have advised that they have plans in place to reach 90%.

Appraisals continue to be actioned and CBUs have confirmed that outstanding meetings have been diarised for the month of June to be

completed.

MortalityHSMR for the latest period remains on track for the 2014-15 target of 105. Latest data reported is February 2015.

This SI relates to a patient who suffered an un-witnessed fall resulting in a large bruise to her eye and cut to her forehead. A CT head scan

showed a subdural haematoma. The patient died.

Incident grading: The proportion of no harm incidents (93%) is above the national average for other Acute Trusts.

Incidents resulting in severe harm: Two of these incidents were logged as SIs (see above for information).

The third incident was a delay/failure to diagnose - The patient presented to the ED with heaviness in right leg and backache. The patient was

triaged to see Care UK (out of hours GP). Patient represented the following day with a right sided hemiplegia caused by a haemorrhagic CVA.

(The patient was on Warfarin).

This SI relates to a patient who was commenced on warfarin in 2012 by a vascular surgeon. The warfarin was meant to be discontinued in 2013

but this was not effectively communicated to the Trust anticoagulant service. The patient was admitted to hospital in May 2015 with a persistent

headache. The patient was over coagulated (INR = 5) and a CT head scan revealed a subdural haematoma.

Quality and patient

experience

Falls including multiple falls: There has been little improvement in May with regard to the number of inpatient falls. HoN, CBU 3 continues to

lead on the implementation of the Falls Strategy and Policy. There was 1 fall resulting in moderate harm on ward 29 and 1 fall on Ward 20

resulting in severe harm (2 subdural haematomas). This incident has also been logged as a Serious Incident (SI 2015/17394).

Pressure Ulcers: 1 Grade 3 avoidable Pressure Ulcer on Ward 24. Two of the 6 Grade 2 Pressure Ulcers were on the same patient on ward 19.

Both were acquired before the patient passed away.

Patient Safety

RTT Admitted

RTT Non-Admitted

6 weeks wait

RTT Incomplete pathways

HSMR

14 GP

14 BS

31 FDT

31 STS 31 STC

62 GP

62 SC

62 UG

Ave LoS - Elective

Ave LoS - Non-Elective

28 Days cancellation

Outpatient DNA Rates

Under 4 hour wait

Note: The YTD circles are composite indicators based on the individual KPI's listed on the summary sheet. Each indicator is evenly weighted within its domain and a score is given based on the YTD performance with green = 1 , amber = 2 and red = 3. The score is then aggregated to give an overall rag rating for the domain. Example: Operational efficiency has four indicators. A composite score of <5 the circle would be Green,5-8 the circle would be amber, >8 the circle would be red. the current score is 6 so the circle is amber.

Staff turnover Appraisals

Sickness absence

Mandatory training

Cash and Funding

Surplus/ Deficit

Total income

Total CIP

Med errors causing harm

MRSA

C Diff

Never Events

VTE

SI's

% incidents causing harm

Medication incidents

Falls

M falls

P Ulcers 3&4

14 GP

14 BS

31 FDT

31 STS

62 GP

62 SC

62 UG

RTT Admitted

RTT Non-Admitted

6 weeks wait

RTT Incomplete pathways

Ave LoS - Elective

Ave LoS - Non-Elective

28 Days cancellation

Outpatient DNA Rates

Under 4 hour wait

MRSA

C Diff

Never Events

VTE

SI's % incints

Medication incidents

Falls

M falls

P Ulcers 3&4

Cash and Funding

Surplus/ Deficit

Total income

Total CIP

HSMR

Staff turnover

Sickness absence

Appraisals Mandatory training

% incidents causing harm

Serious incidents

Serious incidents

31 STC

Page 3

47 11 10 9 8 7 6 5 4 3 2 1 0

Reporting Month

Executive lead : Karen Kelly

Domains KPI Measure Target Set ByYear/Qrt

to DateJun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Trend

RTT Admitted A > 90% National 96.9% 93.4% 94.9% 94.9% 94.6% 92.4% 94.5% 94.2% 98.3% 95.4% 94.9% 96.9% 96.8%

RTT Non-Admitted A > 95% National 97.5% 98.2% 97.7% 97.0% 97.4% 96.7% 100.0% 97.2% 96.6% 96.6% 98.2% 97.7% 97.3%

RTT Incomplete pathways A > 92% National 91.9% 96.1% 96.2% 96.2% 95.8% 94.2% 93.2% 94.4% 93.0% 94.5% 92.5% 91.3% 92.5%

Diagnostics patients waiting more than 6 weeks? A < 0 National 9 249 194 192 69 20 18 60 84 3 16 2 7

14 Day- Cancer Two Week Wait Q > 93.0% National 98.7% 93.6% 93.8% 91.0% 93.3% 96.7% 97.7% 98.5% 99.6% 98.6% 99.3% 99.3% 98.2%

14 Day - Symptomatic Breast Two Week Wait Q > 93.0% National 94.6% 97.0% 95.3% 97.0% 94.2% 97.0% 95.8% 98.1% 94.3% 98.8% 95.7% 96.3% 93.1%

31 Day - First Definitive Treatment Q > 96.0% National 99.3% 100.0% 100.0% 98.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.7% 98.8% 100.0%

31 Day - Subsequent Treatment (Surgery) Q > 94.0% National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

31 Day - Subsequent Treatment (Chemotherapy) Q > 98.0% National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

62 Day - GP Referral to Treatment Q > 85.0% National 85.7% 89.4% 94.5% 88.6% 83.3% 83.5% 91.7% 94.4% 81.4% 82.5% 89.9% 88.0% 83.0%

62 Day - Screening referral to Treatment Q > 90.0% National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

62 Day - Consultant Upgrade to Treatment Q > 85.0% BHNFT 94.7% 83.3% 100.0% 75.0% 92.3% 75.0% 100.0% 66.7% 100.0% 100.0% 88.9% 100.0% 83.3%

Emergency Access Total % Patients who waited < 4 Hrs A > 95.0% National 94.0% 97.3% 97.3% 96.4% 97.1% 96.6% 95.5% 90.3% 93.7% 96.2% 97.3% 91.7% 96.3%

Average length of stay - Elective A <G <=2.42, A >2.42 to 2.67, R

>2.67BHNFT 2.85 2.59 2.34 3.04 2.60 2.40 2.78 2.44 2.72 3.14 2.63 2.46 3.24

Average length of stay - Non-Elective A <G <=3.44, A >3.44 to 3.69, R

>3.69BHNFT 3.35 3.51 3.48 3.50 3.46 3.52 3.57 3.95 3.67 3.53 3.60 3.10 3.62

Patients admitted within 28 Days following cancellation A < 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0

Outpatient DNA Rates A < 10.0% BHNFT 11.1% 11.4% 9.7% 9.8% 9.9% 9.9% 12.3% 12.4% 12.1% 10.9% 10.9% 11.2% 11.0%

RAG and Measure

Descriptions

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E

targets which will be RED if the target is not achieved)

GREEN Achieved Target

< Less is Good

> More is Good

Q Quarter to date

A Annual to date

Operational efficiency

Summary - PerformanceMay-15

Performance Matters

Elective Access

Cancer

Page 4

11 10 9 8 7 6 5 4 3 2 1 0

Reporting Month

Executive lead : Heather McNair

Domains KPI Measure Target Set ByYear/Qrt

to DateJun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Trend

MRSA Bacteraemia (Hospital acquired) A < 0 NHS E 0 0 0 0 0 0 0 0 0 0 0 0 0

Hospital Acquired Clostridium Difficile A < 13 NHS E 1 0 1 2 2 3 1 2 0 1 1 1 0

Friends & Family Test % reported extremely likely or likely to

recommend a family member EDQ >

85%

From April 15BHNFT 83.6% 92.1% 94.0% 82.5% 94.5% 96.7% 94.7% 80.6% 88.7% 92.7% 90.3% 89.0% 78.3%


recommend a family member Inpatients ServicesQ >

85%

From April 15BHNFT 97.3% 97.5% 98.0% 97.8% 96.9% 96.4% 95.3% 95.6% 97.9% 97.0% 97.0% 96.7% 97.8%


recommend a family member Outpatient areasQ >

85%

From April 15BHNFT 94.5% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 98.9% 90.1%


recommend a family member MaternityQ >

85%

From April 15BHNFT 98.1% 96.5% 98.2% 98.2% 98.0% 98.2% 97.5% 98.1% 98.1% 97.3% 97.3% 97.1% 99.0%

Falls A < 515 National 135 58 55 73 75 57 58 75 85 86 76 68 67

Multiple Falls A < 128 National 30 5 4 21 8 9 9 11 21 21 19 16 14

Falls resulting in moderate harm or above A < 1(20 Year) National 1 1 0

Hospital Acquired avoidable Pressure Ulcers 3&4 A < 0 National 2 4 4 1 1 7 1 0 1 2 1 1 1

Never Events A < 0 NHS E 2 0 0 0 0 0 0 0 0 0 0 2 0

VTE Screening Compliance A > 95% NHS E 95.2% 96.7% 96.9% 96.0% 97.1% 96.1% 95.1% 95.5% 95.6% 95.5% 95.8% 95.1% 95.3%

Number of Serious Incidents A < 66 NHS E 9 4 3 3 2 1 7 4 4 6 7 6 3

Incidents - Deaths A < 0 National 0 0 0 0 1 2 1 0 1 5 0 0 0

Incidents - Severe A < 0 National 3 0 2 1 1 1 0 0 0 1 2 0 3

Percentage of Incidents Causing Harm A < 28% BHNFT 8.1% 11.1% 11.4% 7.8% 7.8% 7.4% 8.0% 8.2% 7.5% 11.9% 6.7% 9.3% 6.9%

Medication Incidents - Causing harm A < 10 National 3 1 1 0 0 1 1 0 1 3 1 2 1

HSMR (Rolling 12 month) A < 105 National 103.6 102.5 103.5 102.7 102.8 102.6 101.7 101.1 102.7 103.6 N/A N/A N/A

SHMI (Rolling 12 month) Q < 105 National 103.2 103.7 103.2

Staff turnover (Rolling 12 month) A <G <=10%, A >10%-

11%, R >11%BHNFT 8.9% 6.9% 6.6% 6.9% 7.2% 7.5% 8.1% 7.9% 7.9% 7.9% 8.9% 9.1% 9.7%

Appraisals (Rolling 12 month) A >G >90%, A >=70%-

90%, R <70%BHNFT 78.5% 84.8% 90.5% 91.9% 92.6% 92.9% 93.1% 92.6% 92.3% 91.9% 91.5% 87.4% 69.7%

Mandatory Training (Rolling 12 month) A >G >90%, A >=85%-

90%, R <85%BHNFT 84.8% 85.5% 86.4% 85.5% 86.0% 85.4% 84.8% 84.4% 83.4% 82.8% 82.3% 82.2% 84.3%

Sickness absence (Rolling 12 month) A <G <=3.5%, A >3.5-4%,

R >4%BHNFT 4.4% 4.2% 4.1% 4.3% 4.4% 4.5% 4.7% 5.1% 4.8% 4.6% 4.0% 3.9% 4.0%

RAG and Measure

Descriptions

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E

targets which will be RED if the target is not achieved)

GREEN Achieved Target

< Less is Good

> More is Good

Q Quarter to date

A Annual to date

Workforce

Summary - QualityMay-15

Patients will Experience safe care.

Mortality

Quality and

patient experience

Patient Safety

Page 5

1 0 46 47

Reporting Month

Heather McNair / Richard Jenkins

Target /

BenchmarkingApr-15 May-15

Current

Qtr FYTD12 month

Trend

ED 85.0% 89.0% 78.3% 83.6% 83.6%

Inpatient Services 85.0% 96.7% 97.8% 97.3% 97.3%

Outpatient areas 85.0% 98.9% 90.1% 94.5% 94.5%

Maternity Services 85.0% 97.1% 99.0% 98.1% 98.1%

Total Number of Complaints N/A 26 9 35 35

Complaints closed within target 90.0% 55.0% 63.0% 60% 60%

Complaints reopened N/A 3 2 5 5

Find/Assess 90.0% 91.0% 97.5% 91.0% 91.0%

Investigate 90.0% 100.0% 100.0% 100.0% 100.0%

Refer 90.0% 100.0% 100.0% 100.0% 100.0%

Falls43 Per Month

(515 Year)68 67 135 135 600

Multiple Falls11 Per Month

(128 Year)16 14 30 30 149

Han

d

Was

h

Handwashing 100% 99.6% 99.6% 99.6% 99.6% 0.95

Completion of WHO Surgical

checklist100%

Grades 3 & 4 Post 72 hours 0 1 1 2 2

Grade - 2 Post 72 hours 0 3 6 9 9

Single Sex Breaches 0 0 0 0 0

Hospital Acquired Clostridium

Difficile 13 1 0 1 1

MSSA Surveillance 0 0 0 0

MRSA 0 0 0 0 0

Ecoli -Total hospital Surveillance 2 3 5 5

Medicine Reconciliation 90%

Quality and Patient ExperienceMay-15

Executive lead :

Falls

Co

mp

lain

tsD

em

enti

a

% reported extremely likely or likely

to recommend to a family member

Pat

ien

t Ex

pe

rien

ce

Notes

To be developed for inclusion in future

reports

Pre

ssu

re

ulc

ers

Infe

ctio

ns

To be developed for inclusion in future

reports

Falls including multiple falls; The Trust continues to undertake focus ed work on the reduction of falls in hospital. The Head of Nursing, CBU 3 continues to lead on the implementation of the Falls Strategy and Policy which has now been approved and is being monitored through governance processes. A new multifactorial risk assessment has been piloted in clinical areas and it is planned to roll this out to all areas in August 2015 following education and training of staff. Falls are also one workstream of Listening in Action and aims and objectives for t is work stream have now been set and are being implemented. There was 1 fall resulting in moderate harm on ward 29 and 1 fall on Ward 20 resulting in severe harm (2 subdural haematomas). This incident has also been logged as a Serious Incident (SI 2015/17394). Pressure Ulcers: Work continues to ensure that the incidence of pressure ulcers at all grades is reduced. Education and Training is being rolled out by facilitator as per plan. Through Listening in Action an education and awareness raising campaign is planned that will focus on the care of heels to prevent pressure damage occurring. The Grade 3 avoidable Pressure Ulcer was on Ward 24 following admission through AMU, this has been subject to root cause analysis (RCA)and actions implemented to prevent reoccurrence. Whilst there were six Grade 2 Pressure Ulcers this month there was no pattern or theme to these following RCA. There was one patient on ward 19 who was very ill and subsequently died who developed two of the six reported pressure ulcers, full interventions were implemented for this patient to prevent skin breakdown including the hiring of a Dolphin mattress (used for very high risk patients ) . Patient Experience; ED FFT: With effective from 1st April 2015 the Trust had to withdraw the token system within ED and revert back to a paper based response methodology. The results of this are apparent in May's figures however work is on going to look at how this can be improved going forward. Complaints: There has been an 8% improvement in May's performance increasing the average FYTD to 60% which demonstrates a significant improvement on the year end position of 35% for 2014/15.

Page 6

Reporting Month


Target /

BenchmarkingApr-15 May-15

Current

Qtr FYTD12 month

Trend

HSMR 105 103.6

Prevention of Future Death Reports

– Notifications Received0 0 1 1 1

VT

E

VTE Screening Compliance 95% 95.1% 95.3% 95.2% 95.2%

Incidence of Medication Errors - All33

(400 Year)33 25 58 58

Incidence of Medication Errors -

No adverse outcome

20 per month

(241 Year)23 15 38 38


Near misses63 8 9 17 17


Causing harm

1 Per month

(10 Year)2 1 3 3

Never Events 0 2 0 2 2

Serious Incidents66

(2014/15 Outturn)6 3 9 9

Death 0 0 0 0 0

Severe 0 0 3 3 3

Moderate N/A 8 5 13 13

Low N/A 48 33 81 81

No Harm N/A 603 597 1200 1200

Percentage of Incidents Causing

Harm9.3% 6.9% 8.1% 8.1%

Total (NPSA Reported) Surveillance N/A N/A 0 0

Total (All)616

(7400 Year)669 638 1307 1307 ` 8633

One month behind normal reporting

schedule

Mo

rtal

ity Data not available

Pat

ien

t

safe

tyIn

cid

en

t gr

adin

g

Executive lead :

Patient SafetyMay-15

Me

dic

atio

n in

cid

en

tsSe

rio

us

inci

den

ts

Notes

Mortality: HSMR for the latest period remains on track for the 2014-15 target of 105. The latest data includes Feb and shows a rolling 12 months HSMR of 103.63 and April to February HSMR of 103.55 which are both within the Trust target for 2014-15 of 105. The March provisional data published 19th June indicates the current rolling 12 months/YTD HSMR of 102.24 HSMR rolling 12 months HSMR BHNFT calendar YTD Serious Incidents Three SIs were logged in May (one was a Grade 3 Pressure Ulcer): 2015/16615 This SI relates to a patient who was commenced on warfarin in 2012 by a vascular surgeon. The warfarin was meant to be discontinued in 2013 but this was not effectively communicated to the Trust anticoagulant service. The patient was admitted to hospital in May 2015 with a persistent headache. The patient was over coagulated (INR = 5) and a CT head scan revealed a subdural haematoma. 2015/17394 This SI relates to a patient who suffered an un-witnessed fall resulting in a large bruise to her eye and cut to her forehead. A CT head scan showed a subdural haematoma. The patient died. Incident grading: The proportion of no harm incidents (93%) is above the national average for other Acute Trusts. Incidents resulting in severe harm: Two of these incidents were logged as SIs (see above for information). The third incident was a delay/failure to diagnose - The patient presented to the ED with heaviness in right leg and backache. The patient was triaged to see Care UK (out of hours GP). Patient represented the following day with a right sided hemiplegia caused by a haemorrhagic CVA. (The patient was on Warfarin).

Not available

Page 7

Reporting Month


Nursing staffing table

Nurse Staffing Fill RateMay-15

Executive lead :

Notes

Nursing Staffing Commentary: BHNFT is committed to ensuring that levels of nursing staff, match the acuity and dependency needs of patients in order to provide safe and effective care. Nurse staffing includes: Registered Nurses Registered Midwives Unregistered health care/midwifery care assistants Unregistered nursing/midwifery auxiliaries. The Trust uses an e-roistering system with duty rosters created eight weeks in advance to ensure the levels and skill mix of the nursing staff on duty are appropriate for providing safe and effective care. This allows for contingency plans to be made where the roster identifies that the planned staffing falls short of the minimum requirement, for example where there are vacant nursing posts or staff appointed have not started in post. These contingency plans can include: moving staff from a shift which is above the minimum required level, moving staff from another ward/area which is above the minimum required level, or the use of flexible/temporary staffing from the Trust’s internal bank or via an external nursing agency. The areas that currently have the most vacancies in nursing are in CBU 1 including wards 20, wards 34 and the emergency department. A recruitment campaign is on-going.

14 502 - GYNAECOLOGY 100.0% 95.3% 100.0% 99.9%

17 320 - CARDIOLOGY 90.2% 99.0% 100.0% 151.6%

18 340 - RESPIRATORY MEDICINE 84.5% 99.4% 100.0% 147.3%

19 430 - GERIATRIC MEDICINE 79.5% 86.5% 100.0% 104.8%

20 430 - GERIATRIC MEDICINE 64.3% 93.7% 100.0% 121.0%

AMU 300 - GENERAL MEDICINE 80.0% 93.7% 100.0% 99.2%

23 300 - GENERAL MEDICINE 88.4% 89.9% 97.8% 225.8%

24 370 - MEDICAL ONCOLOGY 104.0% 119.7% 100.0% -

28 301 - GASTROENTEROLOGY 85.5% 81.9% 98.4% 121.0%

31 100 - GENERAL SURGERY 85.1% 111.1% 100.0% 88.0%

32 100 - GENERAL SURGERY 84.3% 118.5% 100.0% 96.8%

34 110 - TRAUMA & ORTHOPAEDICS 76.0% 115.5% 102.4% 120.4%

ITU 192 - CRITICAL CARE MEDICINE 85.4% 52.2% 93.1% -

SHDU 192 - CRITICAL CARE MEDICINE 99.7% 60.7% 98.1% -

CCU 320 - CARDIOLOGY 88.9% 98.9% 101.1% -

AN/PN 501 - OBSTETRICS 94.5% 100.0% 98.4% 97.4%

Birthing Centre 501 - OBSTETRICS 93.1% 86.6% 95.1% 76.6%

37 171 - PAEDIATRIC SURGERY 90.7% 100.0% 97.2% 100.0%

15 170 - CARDIOTHORACIC SURGERY 91.0% 65.0% 93.5% 87.1%

Average fill

rate -

Average fill

rate - care

Day Night

Specialty Ward name Average fill

rate -

Average fill

rate - care

Page 8

1 0 46 47

Reporting Month


Target Apr-15 May-15Current

QtrFYTD

12 month

Trend

This month, Last

month

↑ = Got Better

↓ = Got Worse

All Cancer 2 Week Wait 95.0% 99.3% 98.2% 98.7% 98.7% ↓

Breast Symptomatic 93.0% 96.3% 93.1% 94.6% 94.6% ↓92.51%

Diagnostic to 1st treatment 96.0% 98.8% 100.0% 99.3% 99.3% ↑

Subsequent Treatment (Surgery) 94.0% 100.0% 100.0% 100.0% 100.0% ↔

Subsequent Treatment (Drugs) 94.0% 100.0% 100.0% 100.0% 100.0% ↔

Urgent GP referral to treatment 85.0% 88.0% 83.0% 85.7% 85.7% ↓

Screening Programme 90.0% 100.0% 100.0% 100.0% 100.0% ↔

Admitted - % treated within RTT 90.0% 96.9% 96.8% 96.9% 96.9% ↓

Non-Admitted - % treated within

RTT95.0% 97.7% 97.3% 97.5% 97.5% ↓

Incomplete Pathways % still

waiting92.0% 91.3% 92.5% 91.9% 91.9% ↑

ED

ED - Total Time in ED - 4 hours or

less95.0% 91.7% 96.3% 94.0% 94.0% ↑

Hospital Acquired Clostridium

Difficile

13

(year end)1 0 1 1 ↓

20

Ref

erra

l to

Tre

atm

ent RTT

Monitor

Notes

Can

cer

Rep

ort

ing

31 Day

62 Day

May-15

Cancer Reporting: Despite initial figures, the GP 62 day target for May is now non compliant. Breach analysis includes 2 local breaches where the pathway exceeded the target by 2-4 days. This is unacceptable and reflects poor scheduling of treatments despite escalation. 62 day breaches in May were seen in Head and Neck (3), UGI (2), Colorectal (1), Lung (1) and Urology (4). Shared pathway performance remains poor with approximately 50% of pathways breaching and a number of referrals made to Sheffield after Day 62. The forecasted (and as yet unvalidated) Q position for all targets indicates compliance but pressure remains due to the potential for reallocation of shared pathways by the tertiary centre. Additionally the locally agreed Consultant Upgrade target is non-compliant but this is reflective of a small number of accountable pathways and 1 shared breach. RTT: CBU4 has in excess of 450 pts on the PTL with past TCI dates . These pathways are currently being amended and it is anticipated that the CBU4 will achieve the 92% target at the end of June. ED: Performance standard achieved for May, continued additional support in place to provide additional clinical and patient flow support in the evenings to recover quarter 1 performance and deliver June and the Quarter.

Page 9

Reporting Month May-15

Executive lead : Karen Kelly 1 3 4 6 T YCancer information below is a

month behind reporting

scheduleTarget CBU 1 CBU 3 CBU 4 CBU 6 Trust wide

FYTD

Trustwide

All Cancer 2 Week Wait 95.0% 100.0% 99.0% 100.0% 99.3% 99.3%

Breast Symptomatic 93.0% 96.3% 96.3%

Diagnostic to 1st treatment 96.0% 100.0% 98.4% 100.0% 98.8% 98.8%

Subsequent Treatments 94.0% 100.0% 100.0% 100.0% 100.0%

Urgent GP referral to treatment 85.0% 90.9% 88.8% 66.7% 88.0% 88.0%

Screening Programme 90.0% 100.0% 100.0% 100.0%

Consultant Upgrades 80.0% 100.0% 100.0% 100.0% 100.0%

Admitted - % treated within RTT 90.0% 96.8% 99.3% 94.5% 100.0% 96.8% 96.9%

Non-Admitted - % treated

within RTT95.0% 98.2% 97.9% 97.1% 98.2% 97.2% 97.5%

Incomplete Pathways % still

waiting92.0% 95.8% 98.2% 87.9% 94.6% 92.5% 91.9%

Clinical Business Unit

Notes

Can

cer

Rep

ort

ing

- A

pr

15

31 Day

62 Day

RTT

RTT

Cancer Reporting: Despite initial figures, the GP 62 day target for May is now non compliant. Breach analysis includes 2 local breaches where the pathway exceeded the target by 2-4 days. This is unacceptable and reflects poor scheduling of treatments despite escalation. 62 day breaches in May were seen in Head and Neck (3), UGI (2), Colorectal (1), Lung (1) and Urology (4). Shared pathway performance remains poor with approximately 50% of pathways breaching and a number of referrals made to Sheffield after Day 62. The forecasted (and as yet unvalidated) Q position for all targets indicates compliance but pressure remains due to the potential for reallocation of shared pathways by the tertiary centre. Additionally the locally agreed Consultant Upgrade target is non-compliant but this is reflective of a small number of accountable pathways and 1 shared breach. RTT: CBU4 has in excess of 450 pts on the PTL with past TCI dates . These pathways are currently being amended and it is anticipated that the CBU4 will achieve the 92% target at the end of June.

Page 10

1 0 46 50

Reporting Month

Karen Kelly

Target Apr-15 May-15 Qtr to dateYear End

ForecastTrend

Emergency Department

Attendances6795 6759 13554 81324

Seen within 4 hours 95% 91.7% 96.3% 94.0% 94.0%

% Under 15 mins 55.2% 66.3% 60.6%

% Between 15 and 30 mins 13.8% 12.6% 13.2%

% Between 30 and 60 mins 1.3% 1.1% 1.2%

% Between 60 and 120 mins 0.2% 0.1% 0.2%

Over 120 mins (SI) 0.0% 0.0% 0.0%

% Not Recorded 28.5% 19.8% 24.3%

Total Ambulance Handovers 1917 1839 3756

Am

bu

lan

ce

Ambulance to ED Handover Time

Emergency Care PathwayMay-15

Executive lead :

Notes

Acc

iden

t &

Emer

gen

cy

Ambulance Information Summary Table

Notes: Performance did meet the required standard for May. Continued additional support in place to provide additional clinical and patient flow support in the evenings to recover performance and deliver June and the Quarter 1. 4 Hour Target Achievement Local Trust Benchmark Week Ending

Doncaster and

Bassetlaw Hospitals

NHS Foundation

Trust

Sheffield

Teaching

Hospitals NHS

Foundation Trust

The Rotherham

NHS

Foundation

Trust

Barnsley

Hospital NHS

Foundation

Trust

Harrogate &

District NHS

Foundation

Trust

Airedale

NHS

Foundation

Trust

01/03/2015 92.2% 88.4% 90.1% 92.5% 96.5% 95.5%

08/03/2015 93.2% 89.5% 92.9% 99.1% 98.0% 96.2%

15/03/2015 96.3% 94.5% 93.2% 98.5% 98.3% 97.8%

22/03/2015 94.6% 89.8% 90.4% 98.6% 96.1% 97.4%

29/03/2015 92.2% 95.5% 79.7% 96.4% 97.7% 94.5%

05/04/2015 91.5% 94.0% 88.9% 87.8% 96.8% 97.0%

12/04/2015 93.6% 96.1% 93.7% 88.2% 95.5% 97.1%

19/04/2015 94.8% 93.8% 93.3% 95.2% 95.9% 96.8%

26/04/2015 95.3% 92.1% 94.0% 98.2% 96.7%

03/05/2015 94.6% 92.1% 98.5% 94.3% 95.1% 98.1%

10/05/2015 94.7% 96.0% 97.2% 92.6% 97.1% 91.8%

17/05/2015 96.2% 96.0% 96.9% 96.3% 96.2% 97.1%

24/05/2015 96.2% 96.7% 97.7% 97.6% 97.5% 96.3%

31/05/2015 96.0% 94.7% 97.7% 97.8% 97.6% 96.6%

07/06/2015 96.4% 94.8% 96.5% 95.0% 95.5% 95.3%

Total

Handovers0-15 mins

15-29

mins

30-59

mins60+ mins

No

Handover

Time

Total

Breaches

Accepted Breaches

(30+ unchallenged)

Jun-14 1791 1552 158 13 0 68 171 1

Jul-14 1683 1419 176 19 0 69 195 1

Aug-14 1730 1496 143 9 0 82 152 1

Sep-14 1745 1481 137 8 1 118 146 0

Oct-14 1844 1467 178 15 3 181 196 1

Nov-14 1898 1559 232 21 0 86 253 0

Dec-14 1963 1520 274 55 8 106 337 37

Jan-15 1838 1447 273 36 4 78 313 16

Feb-15 1595 1310 209 16 1 59 226 4

Mar-15 1756 1402 233 24 2 95 259 1

Apr-15 1917 1058 264 45 4 546 313 21

May-15 1839 1220 231 21 2 365 254 5

Page 11

1 0 46 47

Reporting Month

Karen Kelly


Qtr FYTD12 month

Trend

RTT -Admitted - % treated within

RTT90.0% 96.9% 96.8% 96.9% 96.9%

RTT - Non-Admitted - % treated

within RTT95.0% 97.7% 97.3% 97.5% 97.5%

RTT - Incomplete Pathways % still

waiting92.0% 91.3% 92.5% 91.9% 91.9%

0 Tolerance to RTT waits of more

than 52 weeks0 0 0 0 0

Diagnostic Tests Numbers waiting

over 6 weeks (DM01)0 2 7 9 9

Diagnostic Tests Numbers waiting

over 6 weeks %0.0% 0.1% 0.3% 0.2% 0.2%

% Cancelled Operations 0.8% 0.6% 0.3% 0.5% 0.5%

Urgent Operations - Cancelled

Twice0 0 0 0 0

Cancelled Operations - Breaches of

28 day Rule 0 0 0 0 0

Theatre utilisation - Day TBC 87.8% 83.6% 85.7% 85.7%

Theatre utilisation - Main TBC 96.6% 95.4% 96.0% 96.0%

Theatre utilisation - Trauma TBC 92.2% 94.9% 93.6% 93.6%

Admitted, non admitted and incompletes by spec

Admitted, non admitted and incomplete table by spec

Thea

tre

Uti

lisat

ion

Elective Care Pathway

Executive lead :

Notes

Ref

erra

l to

Tre

atm

en

tC

ance

lled

Op

erat

ion

sMay-15

Dia

gno

stic

s

RTT: CBU4 has in excess of 450 pts on the PTL with past TCI dates . These pathways are currently being amended and it is anticipated that the CBU4 will achieve the 92% target at the end of June. Diagnostic Waits: There were 7 breaches of the 6 week wait for Diagnostics in May - 1 x Cystoscopy, 4 x CT, 2 x Cardiology. The 2 Cardiology breaches were transoesophageal echocardiograms (TOE) which are performed by a Consultant Cardiologist every other week and are dependent upon the Consultant’s availability. The breaches were as a result of sessions being cancelled due to study/annual leave. Cancelled Ops: Cancelled ops are within target with no breaches of the 28 day rule. 3 cancellations, all due to lack of theatre time. 1 x late start, 2 x previous pt more complex. Theatre Utilisation Rates: Theatre utilisation rates remain high

Specialty Name <18 18+ total % <18 18+ total % <18 18+ total %General Surgery 103 7 110 93.6% 318 14 332 95.8% 2043 424 2467 82.8%Urology 36 0 36 100.0% 99 8 107 92.5% 607 149 756 80.3%Trauma & Ortho 181 6 187 96.8% 234 6 240 97.5% 1150 58 1208 95.2%ENT 47 6 53 88.7% 534 9 543 98.3% 1203 114 1317 91.3%Oral 55 1 56 98.2% 81 0 81 100.0% 1164 5 1169 99.6%General medicine 26 0 26 100.0% 11 0 11 100.0% 275 4 279 98.6%Gastro 19 0 19 100.0% 177 2 179 98.9% 1156 11 1167 99.1%Cardiology 2 0 2 100.0% 240 10 250 96.0% 635 13 648 98.0%Dermatology 83 1 84 98.8% 176 2 178 98.9% 1131 23 1154 98.0%Respiratory 1 0 1 100.0% 194 1 195 99.5% 285 8 293 97.3%Rheumatology 3 0 3 100.0% 58 0 58 100.0% 300 12 312 96.2%Geriatric Medicine - - - - 44 0 44 100.0% 218 2 220 99.1%Gynaecology 38 0 38 100.0% 219 4 223 98.2% 619 35 654 94.6%Other 43 0 43 100.0% 286 18 304 94.1% 1301 116 1417 91.8%Total 637 21 658 96.8% 2671 74 2745 97.3% 12087 974 13061 92.5%

Admitted - Target 90% Non-Admitted - Target 95% InCompletes - Target 92%

Page 12

1 0 46 47

Reporting Month

Karen Kelly

Target Apr-15 May-15 QTD FYTD

GP Written Referrals - made N/A 3929 3782 7711 7711

GP Written Referrals - seen N/A 3522 3463 6985 6985

GP referral rate year on year +/-

2014/15 & 2015/2016NA -24 -217 -241 -241

Total referral rate year on year +/-

2014/15 & 2015/16NA -923 -949 -1872 -1872

New outpatient appointment DNA

rate10.0% 11.9% 10.1% 10.9% 10.9%

11.00%

Follow-up outpatient appointment

DNA rate10.0% 11.0% 11.4% 11.2% 11.2%

11.00%

Total outpatient appointment DNA

rate10.0% 11.2% 11.0% 11.1% 11.1%

11.00%

Appointment slot issues 0 1334 1283 2617 2617

Appointment slot issues % 4.0% 30.9% 30.4% 30.7% 30.7%

Top 10 Specialties (GP Referrals Received and Seen)

Specialty

ENT 595 526 Top ten specialities with highest number of ASI's for current month

Dermatology 489 362 Specialty Mar-15 Apr-15 May-15 Trend FYTDGeneral Surgery 378 289 Orthopaedics 180 138 158 296

Gynaecology 347 254 Ophthalmology 155 181 133 314

Cardiology 321 242 Children's & Adolescent Services 109 130 130 260

T&O 261 248 Diagnostic Endoscopy 181 145 129 274

Breast Surgery 220 221 GI and Liver (Medicine and Surgery) 178 122 127 249

Gastroenterology 159 195 Cardiology 140 83 98 181

Paediatrics 148 88 Urology 127 94 85 179

Urology 136 197 Dermatology 1 67 73 140

Other Specialties 628 750 Surgery - Not Otherwise Specified 109 79 70 149

Total 3682 3372 Rheumatology 0 6 58 64

GP Referrals

Received

GP Referrals

Seen

DN

A r

ates

Outpatients

Executive lead :

Notes

May-15G

P r

efer

rals

Slots Issues through Choose & Book: Task and finish groups have been established to address specific areas impacting on the ASI position. These groups feed into a steering group which reports to the Operations Group meeting. There are particular areas impacting on the Trust position that currently sit outside the Trust control e.g. Ophthalmology and these are being worked through with the service providers. A paper of work so far was presented to F&P in May. DNAs: DNA rates continue to be higher than expected for the Trust. The Access policy has been ratified and a roll out training plan in its use is in place. Further in-depth task and finish groups have been tasked with examining areas such as physio, T&O and paediatrics which have consistently high DNA rates. A paper of work so far is being presented to F&P in June.

Provider Percentage

AIREDALE NHS FOUNDATION TRUST 13.18%

BARNSLEY HOSPITAL NHS FOUNDATION TRUST 30.44%

BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST 12.19%

CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST 13.20%

DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST 34.51%

HARROGATE AND DISTRICT NHS FOUNDATION TRUST 23.84%

HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST 18.45%

LEEDS TEACHING HOSPITALS NHS TRUST 30.37%

MID YORKSHIRE HOSPITALS NHS TRUST 31.71%

NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST 34.08%

SHEFFIELD CHILDREN'S NHS FOUNDATION TRUST 17.39%

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST 17.58%

THE ROTHERHAM NHS FOUNDATION TRUST 22.44%

YORK TEACHING HOSPITAL NHS FOUNDATION TRUST 2.97%

Page 13

1 0 46 47

Reporting Month



QtrFYTD

12 month

Trend

This month, Last

month

↑ = Got Better

↓ = Got Worse

All Cancer 2 Week Wait 95.0% 99.3% 98.2% 98.7% 98.7% ↓

Breast Symptomatic 93.0% 96.3% 93.1% 94.6% 94.6% ↓92.51%

Diagnostic to 1st treatment 96.0% 98.8% 100.0% 99.3% 99.3% ↑

Subsequent Treatment (Surgery) 94.0% 100.0% 100.0% 100.0% 100.0% ↔

Subsequent Treatment (Drugs) 94.0% 100.0% 100.0% 100.0% 100.0% ↔

Urgent GP referral to treatment 85.0% 88.0% 83.0% 85.7% 85.7% ↓

Screening Programme 90.0% 100.0% 100.0% 100.0% 100.0% ↔

Consultant Upgrades 85.0% 100.0% 83.3% 94.7% 94.7% ↓

Screening to Offer of 1st

Assessment <=3 weeks90.0% 97.1% 95.7% 96.5% 96.5% ↓

Screening to 1st Assessment 90.0% 91.2% 87.0% 89.5% 89.5% ↓

Screening to issue of normal

results <=2 weeks90.0% 97.6% 97.3% 97.5% 97.5% ↓

Breast Screening figures are one month behind reporting month

CancerMay-15

31 Day

62 Day

Can

cer

Rep

ort

ing

Breast Screening

Notes

Despite initial figures, the GP 62 day target for May is now non compliant. Breach analysis includes 2 local breaches where the pathway exceeded the target by 2-4 days. This is unacceptable and reflects poor scheduling of treatments despite escalation. 62 day breaches in May were seen in Head and Neck (3), UGI (2), Colorectal (1), Lung (1) and Urology (4). Shared pathway performance remains poor with approximately 50% of pathways breaching and a number of referrals made to Sheffield after Day 62. The forecasted (and as yet unvalidated) Q position for all targets indicates compliance but pressure remains due to the potential for reallocation of shared pathways by the tertiary centre. Additionally the locally agreed Consultant Upgrade target is non-compliant but this is reflective of a small number of accountable pathways and 1 shared breach.

Page 14



14/15

Actuals 15/16 Plan

15/16

Actual Variance % Elective day case spells Emergency spells

Elective Day cases 3,712 3,648 3,708 60 1.6%

Elective Inpatients 624 602 660 58 9.7%

Elective Total 4,336 4,250 4,368 118 2.8%

Non Elective 6,155 5,843 6,172 329 5.6% elective inpatient spells Other activity

Non Elective Total 6,155 5,843 6,172 329 5.6%

Maternity Pathway 964 1,031 1,120 89 8.7%

Other Activity Total 964 1,031 1,120 89 8.7%

A&E Attendances 13,521 13,553 13,559 6 0.0%

A&E Total 13,521 13,553 13,559 6 0.0% A&E attendances outpatient attendances

Outpatients 40,375 39,305 36,935 -2,369 -6.0%

Outpatients Total 40,375 39,305 36,935 -2,369 -6.0%

* Please note excess bed days are not included in these figures.

Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

2015/16 Activity Plan

2015/16 Activity Actual 2014/15 Outturn

Activity

Elective Inpatients - main over performance in Urology with 27 spells above plan

Non Elective Inpatients - main over performances are in CDU, Medicine and Paediatrics

Outpatients - underperformance is across most specialties. Main underperformances are Orthodontics (-223, -46%), Endocrinology (-291, -35%) and Diabetes (-338, -36%)

Page 15


Stuart Diggles

Month

Plan

Month

Actual

Variance

%

Variance Plan YTD Actual YTD Variance

%

Variance

ACTIVITY LEVELS

Elective inpatients 342 420 22.7% 78 703 783 11.4% 80

Day Cases 1,776 1,800 1.3% 24 3,648 3,708 1.6% 60

Non-elective inpatients 3,406 3,567 4.7% 161 6,793 7,581 11.6% 788

Outpatients 21,727 18,283 -15.9% -3,445 44,253 38,746 -12.4% -5,506

A&E 6,876 6,762 -1.7% -114 13,553 13,559 0.0% 6

'Clinical' Activity 34,129 30,832 -9.7% -3,297 68,950 64,377 -6.6% -4,573

Other (excludes direct

access tests)

10,026 8,412 -16.1% -1,614 20,479 18,468 -9.8% -2,011

Total activity 78,284 70,075 -10.5% -8,208 158,379 147,223 -7.0% -11,157

CIP £'000 £'000 £'000 £'000 £'000 £'000

Income 146 144 -1.4% -2 278 261 -6.1% -17

Pay 101 78 -22.8% -23 199 152 -23.6% -47

Non-Pay 129 134 3.9% 5 253 238 -5.9% -15

Total CIP 376 356 -5.3% -20 730 651 -10.8% -79

INCOME £'000 £'000 £'000 £'000 £'000 £'000

Clinical (Activity) 8,378 8,804 5.1% 426 16,887 17,475 3.5% 588

Other Clinical 3,212 3,180 -1.0% -32 6,433 6,323 -1.7% -110

CQUINS 274 274 0.0% 0 548 548 0.0% 0

Risks & Penalties 0 -128 -128 0 -262 -262

Business Cases 144 130 -9.7% -14 288 417 44.8% 129

Other 1,598 1,553 -2.8% -45 3,189 3,092 -3.0% -97

Total income 13,606 13,813 1.5% 207 27,345 27,593 0.9% 248

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000

Pay -9,792 -9,929 1.4% -137 -19,576 -20,075 -2.5% -499

Drugs -1082 -986 8.9% 96 -2164 -2024 6.5% 140

Non-Pay -3591 -3510 2.3% 81 -7162 -7144 0.3% 18

Total Costs -14,465 -14,425 0.3% 40 -28,902 -29,243 -1.2% -341

Finance

Executive lead :

April 2015 Commentary The RAG rating applied to Variance % is based on the following : • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan • Overall clinical activity is behind plan year to date. The main driver is a

shortfall on Outpatient activity which impacts across all relevant CBUs. Other areas of clinical activity are favourable to plan year to date. The areas of favourable activity are those that attract a higher rate of tariff.

• Direct Access tests were excluded from the other category as the large variances in these figures skew the overall activity variance. The other variances do not necessarily have a direct correlation to income due to elements which are not paid on a tariff basis.

• CIP achievement year to date is adverse to plan. This is due to a slower start of delivery from a number of schemes and due to phasing of certain elements of the CIP profile on a month by month basis. The impact of phasing is estimated to be £50k.

• CIP delivery is expected to remain adverse to plan for the next few months as schemes are driven through to delivery.

• Clinical activity based income is £0.6m favourable to plan. The main favourable variances are elective , non-elective and planned same day income, £0.7m favourable to plan, outpatient income is £0.3m adverse to plan.

• CQUIN income is currently accrued in line with plan. • Risks and penalties of £0.3m have been incurred year to date and relate

mainly to RTT incomplete pathways, A&E performance in April 2015 and the current position on follow ups being over agreed ratio.

• Business case income is £0.1m favourable to plan due to receipt of resilience funding not included within the plan. There is however a significant adverse pay cost variance as not all resilience requirements were funded for April 2015.

• Other income is slightly adverse to plan.

• Operating costs are adverse to plan. Pay is £0.5m adverse to plan which is driven by £0.3m of resilience spend in April 2015, of which £0.2m is not funded and continued pressures of additional beds being open to satisfy patient demand and activity.

• Drugs costs are £0.1m favourable to plan and is related to the lower activity levels around out patients.

• Non-pay is in line with plan.

Page 16


Stuart Diggles

Finance

Executive lead :

Month

Plan

Month

Actual

Variance

%

Variance Plan YTD Actual YTD Variance

%

Variance

£'000 £'000 £'000 £'000 £'000 £'000

EBITDA -859 -612 28.8% 247 -1,557 -1,650 -6.0% -93

Depreciation -477 -479 -0.4% -2 -954 -955 -0.1% -1

Restructuring & Other -42 0 100.0% 42 -84 0 100.0% 84

Financing Costs -148 -137 7.4% 11 -295 -273 7.5% 22

SURPLUS/(DEFICIT) -1526 -1228 19.5% 298 -2,890 -2,878 0.4% 12

SOFP £'000 £'000 £'000 £'000 £'000 £'000

Capital Spend -58 -85 46.6% -27 -135 -147 8.9% -12

Inventory 1,672 1,565 6.4% 107

Receivables & Prepayments9,734 8,897 8.6% 837

Payables & Accruals -15,180 -16,285 7.3% 1,105

Deferred Income -1,209 -936 -22.6% -273

Cash & Loan Funding £'000 £'000 £'000 £'000 £'000 £'000

Cash 1,464 3,987 172.3% 2,523

Loan Funding -21,215 -21,215 0.0% 0

KPIs

EBITDA % -6.31% -4.43% 29.8% 1.88% -5.69% -5.98% -5.0% -0.29%

Deficit % -11.22% -8.89% 20.7% 2.33% -10.57% -10.43% 1.3% 0.14%

Receivable Days 20.7 18.9 8.6% 1.8

Payable (including accruals)

Days

78.3 84.0 7.3% 5.7

Continuity Of Service

Rating

1 1 0.0% 0

May 2015

• EBITDA is adverse to plan by £0.1m. • Restructuring and finance costs are favourable to plan. Depreciation

charges are basically in line with plan.

• The overall deficit is in line with plan.

• Capital expenditure is slightly overspent to plan. • Inventory is £0.1m lower than plan. • Total receivables including prepayments are £0.9m favourable to plan. • Total payables incl. accruals are favourable to plan by £1.1m and

recognises continued management of the cash position. • Deferred income is £0.3m adverse to plan and is due to differences to

the opening position assumed in the plan.

• Cash is £2.5m favourable to plan and mainly results from the improvement to inventory, receivables and payables.

• Debtor days are 18.9 year to date, which is 1.8 days favourable to plan. • Payable days 84.0 year to date which is 5.7 days favourable to plan. • The Continuity of service rating remains a 1

Page 17


Stuart Diggles

Finance

Executive lead :

BHNFT income analysis clinical income per day

BHNFT income Clinical income per day

pay as a % of clinical income

Pay as % of clinical income

• income analysis - this graph analyses the split of income on a monthly basis and demonstrates the variability of clinical income.

• Clinical income per day - this is broadly ahead of plan and relates to the increased activity levels in the higher value areas of care.

• Pay as a % of clinical income is favourable to plan and relates to the increased activity levels in the higher value areas of care more than off setting the increased pay costs.

0

2

4

6

8

10

12

14

16

£m

Actual Income Analysis

Clinical Business Case Other

300

320

340

360

380

400

420

440

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

£k

Clinical Income Per Day

Clinical/day Plan clinical/day

60%

65%

70%

75%

80%

Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16

%

Pay as a % of Income

Pay as a % of Income Plan Pay as a % Plan Income

Page 18


Stuart Diggles

Finance

Executive lead :

Agency run rate - Trust CIP achievement

Agency run rate CIP achievement

Deficit Trend analysis

Deficit treand analysis

• Agency run rate - this graph indicates that the agency costs have been running at a lower rate than those towards the end of the prior year and have decreased since the prior month.

• CIP Achievement - recognises the under achievement to plan year to date, which is expected to continue over the next few months as commented above.

• Deficit trend analysis - this graph demonstrates the underachievement in April 2015 recovering back to plan.

-

200

400

600

800

1,000

£k

Agency Monthly Spend

Year 2016 Year 2015 Year 2014

0

1000

2000

3000

4000

5000

6000

7000

8000

Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16

£k

CIP Achievement - Cumulative

CIP Actual CIP Plan

-12

-10

-8

-6

-4

-2

0

£m

Deficit Trend Analysis

Deficit Plan Deficit

Page 19



Trend Arrow: Latest Month v Previous Month

↑= Got Better ↓= Got Worse

CDU MRSA C-Dff Number of

Serious

Incidents

occurring in

month

Incidents -

Deaths

Incidents -

Moderate

Incidents -

Severe

Never

events

Medication

Incidents -

Causing harm

Falls -

Adverse

Outcome

Multiple

Falls -

Adverse

Outcome

Pressure

Ulcers 2

Pressure

Ulcers 3

Pressure

Ulcers 4

Single Sex

Breaches

Trust Trust 2 ↑ 3↑ 3 ↓ 1 ↑ 15 ↑ 4 6 ↑ 1

CDUED 1 ↓Ward 19 1 ↑ 2↓

Ward 20 1 ↓ 1 ↓ 2 1

Ward 23 1 1 ↓Ward 34 1 Ward 33 2 ↓ 1

Day Surgery

ICU

SHDU 1

ITU

Theatres

AMU 1 ↓ 1 ↓ 1 ↓ 1 CCU 1 ↓

Ward 17 1 ↓Ward 18

Ward 24 1 ↓ 1 1 ↓ 1 ↓Ward 27

Ward 28 2 ↑ 1 ↑

SDA

Ward 29 1 2 ↓Ward 31Ward 32 1 ↓ 1 ↓

Medical imaging

Outpatients 1 ↓

Labour Suite

Ward 14

Ward 37

Birthing Centre

Heat Map: Quality Indicators

General & Spec Med

Theatres, Anaesth &

Critical care

Diagnostic and Clinical

Support

Womens, Children &

GUM

Emergency, Ortho &

Care Services

General & Spec Surg

Page 20



Indicator Name

Serious Incidents

Moderate Harms

Severe harm

Medication Incident

Comment

The 1 medication incidents resulting in harm are

As above – severe harm: 1 medication incident – failure to discontinue warfarin (SI 2015/16615 – AMU)

2015/16615 11/05/15 06/05/15 Drug incident - failure to discontinue warfarin CBU3 - AMU

2015/17394 18352 19/05/15 16/05/15 Fall resulting in 2 subdural bleeds CBU 1 - Ward 20

The 3 moderate harm incidents are as follows:

1 fall on ward 29 resulting in a dislocated foot and toes

1 grade 3 avoidable hospital acquired pressure ulcers

1 delay in diagnosing cancer in surgical OPD (this was logged as an SI in June)

Heat Map: Quality Indicators

The 3 severe harm incidents are as follows:

1 fall on ward 20 resulting in 2 subdural haematomas (May SI 2015/17394)

1 delay/failure to diagnose - Presented to the ED with heaviness in right leg and backache; triaged to see Care UK (out of hours GP). Patient represented the following day with a right sided hemiplegia caused by a

haemorrhagic CVA. (ED matron gathering further information – discussed at patient safety panel)

1 medication incident – patient was prescribed warfarin as ‘lifelong’ in 2012. In 2013 vascular surgeon documented that warfarin was to be discontinued. Patient continued to take warfarin until admission due to

headaches in May 2015. CT revealed bilateral subdural haematoma (May SI 2015/16615 – AMU)

Page 21

Reporting as at: May-15

Executive lead :

Key Issues Target May-15 Apr-15Rolling 12

MonthsTrend

12 Month

Trend

Sickness Absence Rate 3.50% 4.0% 4.3% 4.4%

Staff Turnover 7 - 10 % (0.58-0.83 %) 1.8% 0.7% 9.7%

Mandatory Training 90% 84.3% 82.2%

Appraisal Rates - Medical 90% 93.8% 95.9%

Appraisal Rates - Non Medical 90% 26.4% 7.4%

Recruitment - Medical 76 Days 100.0% N/A

Recruitment - Non Medical 56 Days 83.3% 84.2%

Vacancy levels FTE Budget FTE Contracted Variance Maternity Count Sickness

Trust 2,724.3 2545.0 6.6% 88 4.0%

Diagnostic and Clinical Support

Services CBU481.0 415.0 13.7% 10 4.3%

Women's & Children's & GUM

Services CBU99.4 88.1 11.4% 0 1.5%

Theatres, Anaesthetics and Critical

Care Services CBU482.3 432.3 10.4% 15 4.9%

Trust Sickness: Year V Year

Estates & Facilities – Current restructure. Out to advert for Facilities Operative, Support Officer and Medical Engineering Technician.

CBU 1 – 11 newly qualified staff nurses due to start Sept, 2 Sisters and 4 staff nurses start in July. Further requests to recruit pending from

ED Lead Nurse (6 Staff nurses split between adult and paediatrics).

CBU 5 –– Biomedical Assistant starts 21 June, Biomedical Scientists at pre-employment stage, Ultrasonographers out to advert. 5

Radiographers started 1 June, one remains at pre-employment stage, and further advert out, closes 18 June.

Comments

Staffing and Organisational Development

Karen Kelly

High Level Summary Sickness - Sickness has fallen to 3.9% across the Trust, 01% lower than in May 2014, sickness absence figures were recalibrated from March to May 2015 – in the last three months sickness was under 4% - first time the Trust has been amber for a full quarter. There continue to be breaches to the sickness absence policy on: Return to works (RTW) - continue not be done in a timely manner, SAN forms still not being completed and low take up of the OHU fastrack referral service for D&V, MSK and stress . The HR and OHU teams are targeting areas where these are not taking place. Staff Turnover - Overall remains low at 1.84%. In specific CBUs where there has been a recent spike in turnover rates, leavers in the last 6 months have been requested to complete an Exit Questionnaire and/or attend HR for an interview to gather information to help inform future recruitment and retention strategies for those CBUs. Mandatory Training - Mandatory training has risen slightly to 84% but is still below target. Appraisals Medical - Appraisals Non Medical - Appraisals continue to being completed from April to June 2015 with deadline end of the month. HR have sent reminder emails to managers with low compliance. Recruitment - General - 12 campaigns completed in May, 2 outside the timeline standard of 56 working days giving a figure of 83% compliance due to one position being put on hold and the other due to a review of banding. Recruitment - Medical -Consultant in COTE, CBU 1. Please note that this post did not have any applicants.

3.00

3.50

4.00

4.50

5.00

5.50

6.00

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

%

Month

Trust Sickness: Year 'v' Year

Total 12/13

Total 13/14

Total 14/15

Total 15/16

Target

Page 22

BoD July 2015: HORIZON SCANNER p1


SUBJECT: HORIZON SCANNER

DATE: July 2015

PURPOSE:



PREPARED BY: EMMA PARKES, DIRECTOR OF COMMUNICATIONS & MARKETING

SPONSORED BY: DIANE WAKE, CHIEF EXECUTIVE

PRESENTED BY: EMMA PARKES, DIRECTOR OF COMMUNICATIONS & MARKETING

STRATEGIC CONTEXT

To provide a brief overview of key developments and initiatives across the national and regional healthcare landscape which may impact or influence the Trust’s strategic direction.

ISSUE(S) ADDRESSED IN THIS REPORT

Are any of these developments likely to affect the Trust’s business? Are sufficient actions in place to address any areas of concern or opportunity?

SUMMARY AND RECOMMENDATION(S)

Summary: • MY NHS/NHS Choices for June • Monitor and TDA Joint CEO • NHS Stress Survey • CQC Mental Health Report Outcomes • • Recommendations: The Board of Directors is asked to receive the contents of this report for information.


REFERENCE/CHECKLIST

• Which business plan objective(s) does this report relate to?


Tick all applicable boxes Patients BCCG Other –

Staff BMBC Please state:

Governors Monitor



Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution, etc.)


The Trust’s sustainability strategy



Yes • Has this report (in draft or during development) been reviewed and supported by any Board or Executive committee within the Trust?

Audit

Not Applicable Finance & Performance

To be developed Quality & Governance

ET



Finance:

Other: NHS Constitution In determining this matter, the Board should have regard to the Core principles contained in the Constitution of:

• Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best value • Accountability through local influence and scrutiny • Parliamentary Health Service Ombudsman details failings in complaints handling by NHS trusts • Feasibility study into the case for all NHS estate to have free Wi-Fi for patients • Forecast NHS deficit • Predicted number of Trusts in deficit • ‘New Deal’ for GPs • Private Healthcare seeking increased role on NHS • Local healthwatch budgets cut • New rules for non-EU workers earning less than £35,000 could impact NHS



Subject: INTELLIGENCE MONITORING/HORIZON SCANNING JUNE 2015 Ref: 15/07/P-15

*please note that this is not an exhaustive report, submissions welcome to [email protected]

Date of publication/ organisation

Detail Impact/ Action/ Owner / Will Board be involved?

My NHS/NHS Choices

UDATE FOR THE MONTH OF JUNE (1* is poor, 5* is excellent) My NHS: All indicators ‘OK’, 97% Patients recommend Barnsley Hospital of the 691 patients responding to FFT. NHS Choices: Overall rating 4* (5* is Excellent). Patient post following a visit in June 2015:

“gastroscopy

i felt very anxious about the procedure itself, I had a very short wait until I was seen by the initial member of staff who took my details and explained the procedure. I felt reassured that I was in good hands first impressions do count. The waiting room was clean and tidy it had a peaceful feel about it. It was nice to see the notice about not eating in the waiting room as the patients were fasting this makes you feel care about. The member of staff who collected me from the waiting room and supported me throughout the procedure and afterwards was fantastic I cannot find words to describe how good at their job they were. There was another member of staff and the doctor in the room who were also very kind and supportive. The only slight moan would be I would have liked a bit more information from the doctor about what he had seen but then I should have asked. Very clean department ....... Thank you you were all excellent.”

Potential impact on reputation / All postings responded to / Board to note for information

11.06.15 HSJ

Monitor and the NHS Trust Development Authority are to work much more closely together and under a single leader, with a new chief executive appointed by the end of the year. The two organisations will not formally merge this year, however they will be moving to work much more closely together under a single chief executive. David Bennett, the current Chief Executive of Monitor, will begin overseeing the transition however he will not remain the permanent Chief Executive, with a new appointment expected to be made later this year. The join between the organisations has been described as “a closer relationship”, but further details of what this will mean have yet to be announced.

Potential impact on future ways of working/reporting / Board to note for information

12.6.15 The Guardian

A survey has revealed that NHS staff are more likely to feel stressed because of their job than any other public sector workers. The survey was carried out as part of a broader investigation into staff wellbeing and was completed by 3,700 public and voluntary sector staff. 61% of healthcare professionals who took part in the research reported feelings stressed all or most of the time, while 59% said they feel more stressed this year than last year. The survey also revealed that NHS workers are the least likely to take a break during a working day, with 26% not taking a break at all, and just 1 in 10 getting more than half an hour. The majority of NHS workers (96%) also work beyond their contracted hours, doing an average of five extra hours per week.

Potential to impact on staff morale and engagement /Associate Director of Human Resources to monitor and triangulate with NHS Staff Survey results and Workforce Strategy.




12.06.15 CQC

A report from the Care Quality Commission has found that A&E staff are often unsympathetic to patients suffering a mental health crisis and judgmental about injuries they have inflicted on themselves. The regulator found that unhelpful attitudes among doctors and nurses towards people having delusions or panic attacks or contemplating suicide compounds their mental distress. An inquiry by a CQC team concluded that while some parts of England treat people experiencing a crisis well, “far too many people in crisis have poor experiences due to service responses that fail to meet their needs and lack basic respect, warmth and compassion”. Evidence for the report was submitted by more than 1,750 people who had been through a crisis, and inspections of services to help them in 12 areas of England. Just 14% of the patients surveyed said the care they received provided the right response and helped resolve their mental health crisis. Another 42% said it had helped a bit, while 40% said the care they had received was not right and had not helped them resolve their crisis. In relation to Barnsley, the CQC found that services provided to people experiencing a mental health crisis in Barnsley were delivered by a number of partner agencies that were committed to working together to achieve the best outcomes for people with an emphasis on early intervention and identifying people’s needs at the earliest opportunity. Across the pathway they found a dedicated and committed staff group who demonstrated a willingness to develop and provide services for people in crisis. Staff were passionate about their roles and responsibilities and this was observed across all teams we met. The sharing of electronic care records between the acute trust and the mental health trust remained a challenge but this was high on the agenda of both the commissioners and providers.

No significant issues raised, no negative impact on reputation / Nursing Directorate will review specific findings in relation to Barnsley

15.06.15 HSJ

The Future of NHS leadership inquiry has recommended there should be fewer NHS organisations to avoid management talent being spread too thin. It has also called for the publication of a list of acute trusts that are not sustainable as standalone organisations that has been drawn up by the NHS Trust Development Authority but kept confidential. This should be published by the end of July. The review suggests that these organisations should then be taken over by successful trusts, incorporated into hospital chains or run as franchise operations.

Board to note in relation to 5 year strategy / Director of Communications and Marketing to feedback on list when it is published, expected end July 2015.

17.06.15 Daily Telegraph

A report from the Parliamentary Health Service Ombudsman, details failings in complaints handling by NHS trusts. The report contains the details of 163 investigations into unresolved complaints made over a two month period last year. The Ombudsman said that of 618 complaints made during October and November 2014, 41% were upheld. Around 80% of its investigations are about the NHS in England whilst others concern government departments and their agencies. The report finds that of the wide range of unresolved complaints the Ombudsman looks at, many could be resolved by the organisations locally.

Impact on patient experience/ potential Trust reputational impact / Director of Nursing and Quality to note in relation to Complaints processes




17.06.15 The Guardian

The government’s National Information Board (NIB) has commissioned a feasibility study into the viability of turning the whole NHS estate in the country into a massive free Wi-Fi zone.

NHS England sees great advantages for patients and staff in pressing ahead with the change. Senior figures there believe it could revolutionise NHS services, with staff then able to use many more devices to remotely monitor the health of people with long-term conditions.

It is envisaged the Wi-Fi could enable patients to book appointments and repeat prescriptions and to access their medical records and NHS Choices website, together with completing patient surveys, the FFT and if necessary, to make a complaint all while they are there.

The Mount Hospital in Leeds is about to start offering not only free Wi-Fi to older patients with dementia and mental health problems in four of its wards, but also to provide tablet computers for them and their carers to use to help pass the time.

All to note. Director of ICT to monitor and report outcome/progress to Board.

18.06.15 HSJ

Experts have warned that patients could end up waiting longer for treatment as acute trusts try to tackle an expected overall deficit of more than £2bn this year. HSJ analysis of finance reports from May and June for 142 acute trusts, including specialist trusts, reveals that 80% have forecast they will end 2015/16 in deficit. In quarter one of 2015/16 the overall forecast deficit for the year was £2.1bn, much higher than was forecast at the same point last year. For the 137 trusts for which last year’s forecasts were available, the projection at this point in 2014/15 was a £654.4m deficit. This year the same group is forecasting a deficit of £1.9bn.

To note in relation to Turnaround Plan.

18.06.15 HSJ

The Department of Health issued £874m in bailouts to trusts in 2014/15. £518.3m was paid to NHS trusts and £204.1m to foundation trusts in “additions public dividend capital revenue support NHS temporary” and a further £151.6m was paid to 13 NHS trusts as “policy payments” over the financial year as “support for the provision of health services”. Under DH rules, the £518.3m trust payments and £204.1m to FTs – labelled as “temporary” payments – must either be repaid in the same year, or reclassified as “permanent” revenue support after a DH subcommittee has approved it. Data showed the DH agreed to £439m of the total becoming “permanent” revenue support in 2014/15.

To note in relation to Turnaround Plan

19/06/15 The Guardian

Health secretary Jeremy Hunt unveiled his “new deal” for GPs, promising a package of measures designed to ease their workload and make the profession more attractive to young doctors starting their medical careers. He has pledged to ensure the recruitment of 1,000 “physician associates” into GP practices by 2020. They will be among 5,000 extra clinical staff Hunt wants England’s 8,500 surgeries to hire over the next few years to enable the NHS to help primary care services cope with the increasing challenge posed by an ageing population. He is also encouraging practices to take on more nurses, physiotherapists and other qualified staff to help free up more consultation time for GPs.

He will commit to ensuring that general practice receives more money, but only if GPs change the way they work and embrace seven-day patient access.

Potential impact on future ways of working / To note in relation to 5 Year Strategy

http://www.theguardian.com/society/nhs




19/06/15 Financial Times

Private health companies are seeking talks with ministers and health service leaders to secure a bigger role in providing NHS care. Just under £7bn was spent by the NHS on buying services from private providers in 2013/14 but the sector believes hundreds of millions of pounds of additional investment by companies could be unlocked if there was a more stable operating environment. The introduction of the health and social care bill in 2010 appeared to pave the way for a bigger role for private companies through “any willing provider”, however an investigation by the BMJ found that just 6% of around 3,500 contracts it examined had been awarded through competitive tender.

Impact on future delivery of services / to note in relation to 5 year strategy

19/06/15 HSJ

Almost a third of councils cut local Healthwatch budgets in 2015/16 by an average of 14%. Interviews with 147 of 148 local Healthwatch branches revealed that 10 councils were identified as having cut local Healthwatch budgets by more than the reduction in their overall grant, while one is expected to increase. Using its powers as a statutory adviser, Healthwatch England has written to these councils to seek assurance that statutory activities can be provided under the reduced 2015/16 budgets and has asked for contingency plans should resources prove insufficient. Local authorities must respond within 20 working days and their responses will be published.

Director of Communications and Marketing to monitor published list and report back on local / regional issues.

The Guardian

Royal College of Nursing predicts new rules for non-EU workers earning less than £35,000 will cause chaos for healthcare services.

New immigration rules that will mean lower-earning non-EU workers being deported will exacerbate the shortage of nurses in the UK and cost the NHS tens of millions in recruitment, the government has been warned by nursing leaders. Under the new rules, non-EU workers who are earning less than £35,000 after six years in the UK will be deported.

The RCN urged the Home Office to add nurses to the list of shortage occupations, exempt from the rules, and reconsider the salary threshold and has warned this could have a significant impact on the health service.

Research released by the RCN to coincide with its annual congress in Bournemouth, suggests that up to 3,365 nurses, who cost £20.19m to recruit, could be affected. But it says that figure could spiral by 2020, particularly, if workforce pressures lead to increased international recruitment, in which case 29,755 nurses, costing more than £178.5m to recruit, could be affected.

All to Note. Director of Nursing and Quality to monitor potential future impact.

http://www.theguardian.com/society/nhs

XX Reference – July 2015

REFERENCE SECTION


2015/16 ANNUAL PLAN


SCHEDULE OF ACRONYMS

Additional acronyms may be added as appropriate/on request

A A&E Accident and Emergency A4C / AfC Agenda for Change

ACCEA Awards Committee for Clinical Excellence Awards

ACE Acute Care of the Eldery ACS Additional Clinical Services AEC Ambulatory Emergency Care AHP Allied Health Professions AHSN Academic Health Science Network AMU Acute Medical Unit ANP Advance Nurse Practitioner AOA Annual Organisational Audit AQuA Advancing Quality Alliance

ARCP Annual Review of Competence Progression

AUP Acceptable Use Policy B

BAEM British Association of Emergency Medicines

BBE Bare below the elbows BCCG Barnsley Clinical Commissioning Group

BHNFT Barnsley Hospital NHS Foundation Trust

BHSS Barnsley Hospital Support Services BMA British Medical Association BMBC Barnsley Metropolitan Borough Council BMJ British Medical Journal BoD Board of Directors BWCC Barnsley Women and Children’s Centre C CAP Community Acquired Pneumonia CASU Controls Assurance Support Unit CAUTI Catheter-Associated Urinary Tract

Infection CBU Clinical Business Unit CCG Clinical Commissioning Group CCU Coronary Care Unit C. diff Clostridium Difficile CDU Clinical Decision Unit CE / CEO Chief Executive / Chief Executive Officer

CEMACH Confidential Enquiry into Maternal and Child Health

CHAI Commission for Health Audit and Improvement

CHD Coronary Heart Disease CHI Commission for Health Improvement

CHKS CHKS – name of company providing statistical/benchmarking data

CIP Cost Improvement Programme (also known as efficiency programme)

CLAHRC Collaboration for Leadership in Applied Health Research and Care

CLAUDE Clinical Audit Data Base CMO Chief Medical Officer CMT Clinical Management Team CNST Clinical Negligence Scheme for Trusts COG Council of Governors COO Chief Operating Officer

COPD Chronic Obstructive Pulmonary Disease

COSHH Control of Substances Hazardous to Health

CPA Clinical Pathology Accreditation CPD Continuing Professional Development CPE Clinical Performance & Effectiveness

CPEC Clinical Performance & Effectiveness Committee

CPMS Central Portfolio Management System CPT Capital Planning Team CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

CRS Commissioner Requested Services CSSD Central Sterile Services Department CSU Clinical Service Units D DB Designated Body DDA Disability Discrimination Act Do ICT Director of ICT DoH Department of Health

DoHR&OD Director of Human Resourses and Organisational Development

Do N&Q Director of Nursing and Quality DHSC Directorate of Health & Social Care DH / DoH Department of Health

DIPC Director of Infection Prevention & Control

DMD Divisional Medical Director DNA Did Not Attend DNAR Do Not Attempt Resusitation DPM Department of Psychological Medicine DNR Do Not Resusitate DSEU Day Surgery & Endoscopy Unit E EBA Employer Based Awards

EBITDA Earnings before interest, taxes, depreciation and amortisation

ECIST Emergency Care Intensive Support Team

ECN Emergency Care Network ED Emergency Department EDD Estimated Date of Discharge EDS2 Equality Delivery System ENT Ear, Nose & Throat EPAP Emergency Pathway Action Plan EPR Electronic Patient Records EqIA Equality Impact Assessment ESR Electronic Staff Record ET Executive Team EWS Early Warning Score EWTR European Working Time Regulation F F&P Finance & Performance Committee

FABULOS Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen, Sepsis Six

FBC Full Business Case FCE/FCSE Finished Consultant Episode FFCE First Finished Consultant Episode


FFT Friends and Family Testing FT Foundation Trust FTN Foundation Trust Network FQA Framework of Quality Assurance G GMC General Medical Council GP General Practitioner GUM / GU Med Genito-Urinary Medicine

H

HAPPY Harmonised Approval Process Pan Yorkshire

HCA Health Care Assistant HES Hospital Episode Statistics HSE Health & Safety Executive H&S Health & Safety HDU High Dependency Unit HR Human Resources HRG Health Resource Group (finance) HSC Health Service Circular HSMR Hospital Standardised Mortality Ratio I I&E Income and Expenditure ICU Intensive Care Unit (also known as ITU)

IFRS International Financial Reporting Standards

IIP Investors in People IHP Improving Hospital Partnerships IPC Infection Prevention & Contr IR1 Incident Reporting form

IRMER Ionising Radiation - Medical Exposure Regulations

ISS ISS Mediclean – cleaning contractors at the Trust

IT Information Technology

ITU Intensive Therapy Unit (also known as ICU)

IV Intravenous IWL Improving Working Lives J

JNCC Joint Negotiating and Consultation Committee

JTUC Joint Trade Union Committee KL KPI Key Performance Indicator LA Local Authority LCRN Local Clinical Research Network LAC Local Awards Committee LDP Local Development Plan LHC Local Health Community LIFT Local Improvement Finance Trust LINks Local Involvement Networks LOS Length of Stay LPMS Local Portfolio Management System LRC Learning and Resource Centre LTC Long Term Conditions M M&S Medical & Surgical MAG Model Appraisal Guide MDA Medical Devices Agency MDT Multi-Disciplinary Team ME Management Executive

MHRA Medicines &Medical Healthcare Regulatory Agency

MINAP Myocardial Infarction National Audit Programme

MRI Magnetic Resonance Imaging MTAS Medical Training Application Service N

NCEPOD National Confidential Enquiry into Perioperative Deaths

NED Non Executive Director NEWS National Early Warning Score NHS National Health Service NHSE National Health Service England NHSE National Health & Safety Executive

NHSLA National Health Service Litigation Authority

NORCOM North Derbyshire, South Yorkshire and Bassetlaw Commissioning Consortium

NCISH National Confidential Inquiry into Suicide and Homicide

NICE National Institute for Clinical Excellence NIMG NICE Initiation and Monitoring Group NIHR National Institute for Health Research NPAT National Patients Access Team NPSA National Patient Safety Agency NRLS National Reporting & Learning System NSF National Service Framework O OBC Outline Business Case OH Occupational Health

OJEC Official Journal of the European Communities

OPERA Older Persons Early Rehabilitation Assessment

OPT Operational Performance Team OT Occupatinal Therapy PQ PA Professional Activities (4 hours)

PACS Picture Archiving & Communications Systems

PALS Patient Advice & Liaison Services PAS Patient Administration System PBR / PbR Payment by results (tariff system) PCT Primary Care Trust PEAT Patient Environment Action Team PGME Post Graduate Medical Education PIU Planned Investigation Unit

PLACE Patient Led Assessment of the Care Environment

PLICS Patient Level Information & Costing Systems

PMG Performance Management Group PPG Patient Participation Group PPI Public & Patient Involvement PR Public Relations PROMS Patient Reported Outcome Measures PSM Patient Services Manager PTS Patient transport services Q&G Quality & Governance Committee

QA Quality Assurance Quality Account

QIPP Quality Innovation Prevention & Productivity

QSIEB Quality and Safety Improvement & Effectiveness Board


R R&D Research and Development RAF Risk Assessment Framework RATS Remuneration and Terms of Service

RCPCH Royal College of Paediatrics and Child Health

RCP Royal College of Physicians

RFT Rotherham Hospital NHS Foundation Trust

ROCA Register of Controls Assurance RPST Risk Pooling Assessment for Trusts RST Revalidation Support Team RTT Referral to Treatment S SABS Safety Alert Broadcast System SALT Speech and Language Therapy SAS Staff and Associate Specialist SAU Surgical Administration Unit

SCH Sheffield Children’s Hospital NHS Foundation Trust

SDA Surgical Decision Area SHA Strategic Health Authority SHMI Standardise Hospital Mortality Indicators SHO Senior House Officer SI Serious Incident SIFT Service Increment for Training SLA / SLAM

Service Level Agreements / Service Level Agreement Monitoring

SOA Strategic Options Analysis SUI Serious Untoward Incident (old term)

SoS Secretary of State SPA Supporting Professional Activities SPC Statistical Process Control SpR Specialist Registrar SSD Sterile Services Department SSR Strategic Services Review

STH Sheffield Teaching Hospitals NHS Foundation Trust

STEIS Strategic Health Authority Executive Information System

SYSHA South Yorkshire Strategic Health Authority

SWYPFT South West Yorkshire Partnership Foundation Trust

TUV TDA NHS Trust Development Authority

TIGER The Information Governance Education Recognition Award

TTO Tablets to Take Out TWWMIB Together We Will Make It Better VDI Virtual Desktop Infrastructure VTE VenousThrombo-Embolism WXYZ WCA Wider Controls Assurance WLI Waiting List Initiative WTE/wte whole time equivalent Y&H Yorkshire & the Humber YTD Year to Date

Documents

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE … · 2. To review the Register of Interests and receive any further declarations of interests : 15/07/P02 . 3. To . approve