COUNCIL OF GOVERNORS MEETING · 7/24/2018 · CHAIR OF MEETING: Lena Samuels, Chair GOVERNORS: See Members of the Council of Governors (overleaf) IN ATTENDANCE: Nigel Chapman, NED

COUNCIL OF GOVERNORS MEETING (open to Trust members, members of the public, and the press)

DATE: Tuesday 24 July 2018

TIME: 18.30h to 21.00h VENUE: Dolman Room 1

Shaw House Church Road Newbury Berkshire RG14 2DR

STATUS: Meeting in public CHAIR OF MEETING: Lena Samuels, Chair GOVERNORS: See Members of the Council of Governors (overleaf) IN ATTENDANCE: Nigel Chapman, NED

Mike Hawker, NED Priya Singh, NED Will Hancock, Chief Executive Philip Astle, Chief Operating Officer

Melanie Saunders, Director of HR and OD Professor Helen Young, Director of Patient Care and Service Transformation

Steve Garside, Company Secretary Ellen Millington, Manager, Grant Thornton APOLOGIES: Paul Ader, Public Governor – Oxfordshire Sabrina Chetcuti, Partner Governor – CCGs Anne Crampton, Partner Governor – LAs

Colin Godbold, Public Governor - Berkshire ***** FUTURE MEETING DATES: 3 October 2018 (public)

10 January 2019 (public) 6 February 2019 (private – Annual Strategy Workshop)

Current Members of the Council of Governors (26/26) Name

Constituency Current term

Paul Ader Public - Oxfordshire (1) To 28/02/2020Andy Bartlett Public – Hampshire (2) To 28/02/2021Sabrina Chetcuti Partner (CCGs – North) (2) To 30/06/2019David Chilvers Partner (CCGs – South) (2) To 30/06/2019Jeanette Clifford Partner Governor (Local Authority) (1) To 30/09/2020 Anne Crampton Partner Governor (Local Authority) (1) To 31/03/2021 Richard Coates Public – Hampshire (2) To 28/02/2020Professor Robert Crocker Public - Buckinghamshire (1) To 28/02/2021 Emma Crozier Staff - NEPTS and Logistics Field (1) To 28/02/2021 Mark Davis Public - Berkshire (1) To 28/02/2020Bernadette Devine Public - Buckinghamshire (1) To 28/02/2021 Lynn Dove-Dixon Staff - Corporate/support/other (1) To 28/02/2021 David Drew Partner (Air Ambulance Charities) (1) To 30/09/2020 Bob Duggan Public – Buckinghamshire (3) To 28/02/2021Jim Dunderdale Staff – Contact Centres inc.111 & EOC (1) To 28/02/2021 Frank Epstein Public - Berkshire (1) To 28/02/2020Colin Godbold Public – Berkshire (2) To 28/02/2021Stephen Haynes Public - Oxfordshire (1) To 28/02/2021 Keith House Partner (Local Authority) (3) To 28/02/2021Loretta Light Public - Oxfordshire (1) To 28/02/2021 Barry Lipscomb Lead/Public Governor – Hampshire (2) To 28/02/2020David Luckett MBE Public - Hampshire (1) To 28/02/2020Charles McGill MBE Public - Hampshire (1) To 28/02/2021 Kate Moss Staff - 999 Operations – North (1) To 28/02/2021 Tony Nicholson Public - Hampshire (1) To 28/02/2021 David Palmer Staff – 999 South (3) To 28/02/2021

AGENDA – COUNCIL OF GOVERNORS – 24 JULY 2018 18.30pm – 21.00pm

***PLEASE DIRECT QUESTIONS / COMMENTS THROUGH THE CHAIR***

No. Item Time Method1. OPENING BUSINESS 1.1 Chair’s Introduction, including Apologies for Absence

(Lena Samuels)

18.30 (Verbal)

1.2 Declaration of Interests (Lena Samuels)

to note any new interests, including those relevant to the meeting

http://www.scas.nhs.uk/wp-content/uploads/Register-of-Council-of-Governors-interests.pdf

18.31 (Verbal)

1.3

Approval of the minutes of the meeting held on 16 April 2018 (Lena Samuels)

to approve the minutes of the last formal CoG meeting

18.32 Enc. A

1.4 Matters arising from the meeting held on 16 April 2018 (Steve Garside)

to note progress with the actions arising from the last formal CoG meeting

18.33 Enc. B

2. COUNCIL OF GOVERNORS DEVELOPMENT

2.1 Council of Governors Development – Next Steps (Lena Samuels)

to consider next steps following the “Being a Well-Led Council of Governors” workshop held on 5 June 2018

18.35* Enc. C

3. REPRESENTING THE INTERESTS OF THE MEMBERS OF THE TRUST AS A WHOLE AND THE INTERESTS OF THE PUBLIC

3.1 Governor Engagement Feedback (All Governors)

to receive feedback from governors engagement activity that should be addressed during the course of the meeting:

o public governors (Berkshire, Buckinghamshire, Hampshire and Oxfordshire)

o staff governors o partner governors

19.00* (Verbal)

3.2

Report from the Membership and Engagement Committee (Mark Davis)

to receive an update on the work of the sub-committee

19.15 Enc. D

4. HOLDING THE NEDS TO ACCOUNT FOR THE PERFORMANCE OF THE BOARD 4.1a

Chief Executive’s Report including Performance and CQC Inspection Update (Will Hancock; Philip Astle; Professor Helen Young; Melanie Saunders)

to receive a report on key current issues

19.20* Enc. E

4.1b Chief Executive’s Report including Performance and CQC Inspection Update - Questions (Governors; NEDs)

questions from governors, primarily to the NEDs

19.30* Verbal

4.2 Annual Accounts and Annual Report 2017/18 including Auditors’ Reports (Mike Hawker; Professor Helen Young; Grant Thornton)

to receive the Annual Accounts and Report, including Auditor’s reports

to receive the outcomes of the audit of the governor selected quality indicator

20.00* Enc. F

5. OTHER ITEMS FOR INFORMATION/DISCUSSION BY EXCEPTION 5.1 Non-Executive Director Activities

(Priya Singh) an overview of activities undertaken over the past three

months

20.20 Enc. G

5.2 Company Secretary’s Report (Steve Garside)

to receive an update on matters of interest

20.30 Enc. H

5.3 Lead Governor’s Report (Barry Lipscomb)

to note a report on activities undertaken by the Lead Governor since the previous meeting on 16 April

20.35 Enc. I

6. CLOSING BUSINESS 6.1 Any Other Business including Questions from

Members/Observers (Lena Samuels)

to note any items of additional business, including those notified by the governors and Trust members to the Company Secretary no less than two working days prior to the meeting

o Deputy Lead Governor position (Bob Duggan) o electronic papers (Frank Epstein) o information sharing with Governors (Jim

Dunderdale)

20.40 (Verbal)

6.2

Agenda Planning for Next Meeting (All Governors)

to consider any key topics for the next meeting, including in relation to addressing Governor Engagement Feedback

20.55 (Verbal)

6.3 Date and Time of Next Meeting (Lena Samuels)

to note that the next formal meeting in public will be held on Wednesday 3 October 2018 at Shaw House, Newbury, commencing at 18.30pm

21.00 (Verbal)

*suggested priority items

GOVERNOR FUNCTIONS AND DUTIES Governor general functions This meeting

Hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors (see below)

Represent the interests of the members of the Trust as a whole and the interests of the public

Governor specific duties

Receive annual accounts, auditor’s report and annual report Appoint and, if appropriate, remove the external auditor Contribute to the development of the annual plan Appoint and, if appropriate, remove the Chair Appoint and, if appropriate, remove the other Non-Executive Directors Decide remuneration and terms of conditions for Chair / other Non-Executive Directors Approve appointment of Chief Executive Approve significant transactions (as defined in the Trust Constitution) Approve an application to enter into a merger, acquisition, separation or dissolution Decide whether the Trust’s non-NHS work would significantly interfere with its ‘principle purpose’

Approve amendments to the Constitution

ENCLOSURE A

MINUTES OF THE MEETING HELD ON 16 APRIL 2018

Enclosure A

COUNCIL OF GOVERNORS

Meeting: Council of Governors

Date of Meeting: 24 July 2018

Title of Paper: Minutes of the Council of Governors meeting held on 16 April 2018

Presented by: Lena Samuels, Chair

Paper for Debate, Decision or Information:

Approval

Main Aim: To ensure good governance practice in confirming that the minutes ofthe 16 April 2018 meeting represent an accurate record of businessundertaken

Summary of key points for consideration:

These minutes, in draft form, were initially circulated to governors on 2May 2018. They are produced by the Company Secretary and issueddirectly to the Council of Governors without any separate, priorreview.

Recommendations or Outcome Required :

Approval

Previous Forum: N/A

Statutory Requirements Met:

N/A

Contact in case of query concerning this paper:

Steve Garside, Company Secretary, 01869 365032

Unapproved Minutes CoG – 16/4/2018 Page 1 of 12 Author: SG

ENCLOSURE A Unapproved minutes of the twenty seventh formal/in public meeting of the South Central Ambulance Service (SCAS) NHS Foundation Trust Council of Governors (CoG) held on Monday 16 April 2018 at Shaw House, Newbury Governors present (19/26): Paul Ader (Public Governor – Oxfordshire); Andy Bartlett (Public Governor – Hampshire); Sabrina Chetcuti (Partner Governor – CCGs); Councillor Jeanette Clifford (Partner Governor – LA); Richard Coates (Public Governor - Hampshire); Anne Crampton (Partner Governor (LA); Emma Crozier (Staff Governor); Professor Bob Crocker (Public Governor – Buckinghamshire); Mark Davis (Public Governor – Berkshire); David Drew (Partner Governor - Air Ambulance); Jim Dunderdale (Staff Governor); Frank Epstein (Public Governor – Berkshire); Colin Godbold (Public Governor – Berkshire); Steve Haynes (Public Governor – Oxfordshire); Loretta Light (Public Governor – Oxfordshire); Barry Lipscomb (Public Governor – Hampshire & Lead Governor); Charles McGill (Public Governor – Hampshire); Tony Nicholson (Public Governor – Hampshire); David Palmer (Staff Governor) Governors apologies received (6/26): Bernadette Devine (Public Governor – Buckinghamshire); Lynn Dove-Dixon (Staff Governor); Bob Duggan (Public Governor - Buckinghamshire); Councillor Keith House (Partner Governor (LA); David Luckett (Public Governor – Hampshire); Kate Moss (Staff Governor) Governors not present (1/26): David Chilvers (Partner Governor – CCGs) Directors/Executives in attendance: Sumit Biswas (NED/Deputy Chair); Ilona Blue (NED/Senior Independent Director); Les Broude (NED); Nigel Chapman (NED); Mike Hawker (NED); Will Hancock (Chief Executive) - part; James Underhay (Deputy Chief Executive); Philip Astle (Chief Operating Officer); Melanie Saunders (Director of HR and OD); Steve Garside (Company Secretary); ‘Bukola James-Adeyemi (Senior Administrator) Directors/Executives observing: Priya Singh (NED); Anne Stebbing (NED); Natasha Dymond (Assistant Director of HR) Directors/Executives apologies received: Lena Samuels (Chair); Professor Helen Young (Director of Patient Care and Service Transformation) Opening Business

1.1 - Chair’s Introduction, including Apologies for Absence Sumit Biswas, in his role of Deputy Chair, and chairing the meeting in the absence of Lena Samuels, welcomed all to the meeting. The CoG was introduced to Anne Crampton, Local Authority Partner Governor, attending her first meeting following her recent appointment by the South East England Councils body. Sumit Biswas explained that Lena Samuels had a clash of dates on this occasion and was taking a period of well-deserved annual leave. He also referenced the graphic in the papers that reinforced


the importance of Governors holding the Non-Executive Directors (NEDs) to account, and asked this to be reflected in how the discussions evolved during the course of the meeting. Apologies were noted from Lena Samuels, Professor Helen Young, Keith House, Bob Duggan, Bernadette Devine, David Luckett, Lynn Dove-Dixon and Kate Moss. Sumit Biswas advised that, in light of correspondence over the last few days regarding a number of issues associated with Community First Responders (CFRs) and the SCAS Charity, he would be willing to donate some of the meeting time to discussing these issues, although that could potentially mean shorter time being available for other agenda items. The CoG indicated their wish to spend some time on the CFR and SCAS Charity issues, and agreed that they would be discussed directly after the Chief Executive’s Report. 1.2 - Declaration of Interests No new or additional interests were declared to those that had been declared previously, and which were disclosed on the Trust’s public website as part of the Board and CoG Registers of Interests. 1.3 - Approval of the minutes of the meeting held on 11 January 2018 The CoG APPROVED the minutes of the previous meeting with two particular amendments: page 2, section 1.6, bullet point 2 – “schemes” to be replaced by “scheme co-ordinators” page 3, section 2.1a, bullet point 5 – a footnote to the minutes to be added to reference the

actual number of hours lost at Queen Alexandra Hospital in Portsmouth due to handover delays

Action 1.3 Steve Garside to amend the minutes of the meeting held on 11 January 2018 to reflect the comments made by Governors in respect of sections 1.6 and 2.1a.

1.4 - Matters arising from the meeting held on 11 January 2018 Steve Garside advised that he would take the paper as read and invite comments. David Palmer asked about the action regarding the audit of the local clinical quality indicator selected by Governors (Sepsis). Steve Garside confirmed that he had been assured by senior colleagues in the Quality and Patient Care Directorate that there were no issues with the selected indicator and that Grant Thornton would be commencing their audit imminently. In relation to action 6.1b, Philip Astle explained that establishing a reference number for NHS111 callers would not be beneficial, given the information on the caller that already exists, and would cost valuable time in carrying out the clinical assessment. Paul Ader asked whether there could be a further discussion at the next meeting regarding the comment (against action 6.1a) that “the majority of the public will consider the NHS111 service and the “doctors” of the out of hours service as part of the same organisation”. Action 1.4 Philip Astle to explain more about the public’s perception that the NHS111 (provided by SCAS) and out of hours (provided by doctors/another organisation) services in Hampshire are provided by the same organisation (i.e. SCAS) and how the risks of any confusion can be mitigated in order to preserve the Trust’s reputation.

Holding the NEDs to Account for the Performance of the Board

2.1a – Chief Executive’s Report including Performance Update The Chief Executive reported that, following a very difficult winter period, which had been discussed in some detail at the previous meeting, demand had been more manageable over the


last four to five weeks and as a result there had been an upturn in performance against the national standards. The Chief Executive, reflecting on the first four months of the Ambulance Response Programme (ARP), expressed a view that SCAS had made a positive start against the new regime of targets and was on track, for the first time, to deliver all four standards in the month of April. The CoG was informed that the Trust was one of only three Ambulance Trusts to be participating in the Global Digital Exemplar programme and that detailed proposals would be developed over the next couple of weeks. The CoG noted the comprehensive written report provided by the Chief Executive. 2.1b – Chief Executive’s Report including Performance Update – Questions A range of questions were asked by Governors, with answers given, including: staff survey outcomes – Jim Dunderdale expressed a personal view that it was incorrect to

describe the outcomes of the 2017 staff survey as “very positive”, and that morale in NHS111 was lower than ever with a number of staff members having left the service.

The Chief Executive responded that the Senior Management Team was in no way complacent about the various staffing challenges being faced, and that there remained much work to do.

ARP performance – Loretta Light asked the NEDs to provide more detail on the performance in

the Thames Valley, including an overview of the actions being taken to improve response times

Ilona Blue advised that the Board continued to closely monitor regional variances in performance and that the Thames Valley was a particular area of focus. She noted that Buckinghamshire, for example, had relatively high levels of rurality and that the Trust had a challenge not only in terms of optimising its resource allocation, but also recruiting new staff and reducing its reliance on private providers. Mike Hawker highlighted parts of West Oxfordshire as another area where rurality provided a challenge in terms of being able to meet the response times. Ilona Blue added that she was acutely aware that, if Portsmouth and South East Hampshire was taken out of the reported performance figures (for illustrative purposes), the performance in Hampshire would be boosted further and that the gap in performance between the Thames Valley and Hampshire would therefore be even starker. Ilona Blue offered a view that, in the longer term, the ARP model should help in terms of response times and patient outcomes. Philip Astle asked the CoG not to lose sight of the fact that 80% of activity fell into the category 2 and 3 areas, and that on a year-to-date basis performance in this respect was stronger in the Thames Valley than in Hampshire. Nigel Chapman advised that the Board interrogated operational performance very thoroughly, and that it was clear that there were further refinements to make to the Trust’s deployment model in terms of the balance between vans and rapid response vehicles. He noted that SCAS was short on a number of targets and that the importance of the category 3 and 4 targets should not be underplayed. Mike Hawker stated that the Board had a very clear understanding of the cases where the target had been missed and the impact on patient outcomes.

Global Digital Exemplar – David Drew asked for more information about the Trust’s status as a

Global Digital Exemplar, and whether ARP was saving more lives


Ilona Blue advised that the term ‘Global Digital Exemplar’ had been established by NHS England, and despite the perception that the title could create the reality was that SCAS had an opportunity to access funding for some very important digital transformation projects that would hopefully benefit patients and staff. Ilona Blue stated that it was too early in the ARP regime to draw conclusions as to the extent to which improved clinical outcomes were being delivered, and Mike Hawker questioned whether (despite the plethora of data available and SCAS’ ‘helicopter view’ approach) organisations were sufficiently joined up to be able to track the outcomes and benefits. Bob Crocker asked the Trust, in light of the performance challenges, to ensure that it made the best possible use of its significant number of Community First Responders, noting that he had been available for thirty hours in the last week and not deployed once.

mutual aid – Tony Nicholson provided feedback of a recent case where a patient had been

transferred from NHS111 to 999, and then conveyed to Basingstoke Hospital. He noted that the patient had been very satisfied with their experience and that the conveyance had been provided by South Western Ambulance Service NHS Foundation Trust. Tony Nicholson asked how satisfied the NEDs were with their oversight of mutual aid arrangements.

Ilona Blue advised that mutual aid had not necessarily been discussed recently by the Board but that she was aware that SCAS had provided support to both London Ambulance Service and South Western Ambulance Service (Salisbury incident) in the last couple of months. The Chief Executive expressed surprise that South Western Ambulance Service had been responding on behalf of SCAS in the Basingstoke area given that this was not necessarily a bordering area. He noted that where Trusts were responding across borders (which was relatively common) the service tended to be seamless and had no adverse implications for the patients.

Air Ambulance Charities – Barry Lipscomb noted the discussions at the recent Board meeting

regarding potential changes to the operating models of the two Charities. He asked, given the importance of the work of the Air Ambulance Charities, and notwithstanding any commercial sensitivities, whether a short briefing could be issued to Governors outlining the proposals. The Chief Executive confirmed that he was happy to do so.

David Drew advised that the Chief Executive of the Hampshire and Isle of Wight Air Ambulance Charity would be happy to attend the next formal meeting on 24 July, subject to other CoG agenda commitments, and present an overview of his vision for the Charity

Action 2.1b The Chief Executive to issue a short briefing to the Council of Governors setting out details of potential changes to the operating models of the two Air Ambulance Charities, including any specific implications for SCAS.

clinical outcomes – Steve Haynes noted the strong focus on response times, but asked how

well sighted the NEDs were on issues such as hear and treat, and see and treat, both designed to treat patients closer to home and avoid unnecessary hospital conveyances.

Ilona Blue responded that the monthly Integrated Performance Report had historically included metrics on non-conveyance, see and treat, and hear and treat, and that the NEDs were trying to understand what was happening in more detail following the introduction of ARP.

future priorities – Steve Haynes noted that SCAS was now in the second year of a two year

contract with commissioners and asked NEDs to outline any specific areas of focus


Mike Hawker stated that there would be a continuing focus on collaboration through the Sustainability and Transformation Planning and Integrated Care Systems processes, and that SCAS still had a major role to play in terms of helping patients to receive good medical outcomes without the need to attend hospital. In this respect, Nigel Chapman highlighted the clinical judgements made by staff and the importance of the Board being fully assured in relation to incidents and complaints.

2.2 – SCAS Charity and Community First Responders Further to the earlier discussions, Sumit Biswas stated that a period of time would now be allocated to discuss topics that had been the subject of recent email activity. *** In respect of the 2016/17 SCAS Charity Annual Accounts, which had been presented to the Board at its January meeting and subsequently submitted to the Charity Commission, Nigel Chapman (Chair of the Charitable Funds Committee) advised that there had been some helpful observations about a number of presentational aspects. He also noted that: the timing of producing the SCAS Trust and SCAS Charity Accounts had not been aligned,

resulting in provisional numbers regarding the Charity being included in the Trust Accounts and then updated figures (albeit not material) being reported in the subsequent Charity Accounts; this approach would need to be reconsidered going forward

in terms of recharging, it needed to be clarified that the SCAS Charity did not directly employ

any individuals and that the costs of those two individuals who worked exclusively for the Charity were recharged by the Trust

on reflection, the narrative around the treatment of the £150k Cabinet Office grant in the

Accounts could have been clearer the scrutiny given to the 2016/17 SCAS Charity Annual Accounts had made the Charitable

Funds Committee mindful of the need to improve the presentational aspects going forward; however, it needed to be reinforced that there were no issues with the accuracy of the reported, and audited, figures for the income and expenditure

Mike Hawker, a fellow member of the Charitable Funds Committee, offered a view that better proof-reading of the draft Accounts had been required, and that there was a resourcing issue to address in terms of the quality of the financial/accounting service provided by SCAS to the Charity. He added that there was no doubt that the Accounts showed a ‘true and fair view’ of the financial position of the Charity, and that part of this result had been achieved by his feedback around the need to more closely match income with expenditure in the accounting period concerned. Bob Crocker stated that he was confused about the comment that the Charity did not employ staff given that this was exactly what was done by the Air Ambulance Charities. Nigel Chapman responded that, whilst two members of staff (1.6 full time equivalent) worked exclusively for the Charity, they were not directly employed by the Charity but instead by the Trust with their associated costs then charged to the Charity. Frank Epstein expressed his gratitude to Nigel Chapman for his comments, and asked what the £30k recharge referred to in the email exchange related to. In addressing this point, and a further comment made by David Palmer, Nigel Chapman stated that he would circulate a definitive list of the costs SCAS charged against the Charity as part of the services it provided. Action 2.2a Nigel Chapman to confirm what SCAS recharges back from the SCAS Charity as part of the support services it provides.

***


Sumit Biswas asked Philip Astle to address a further thread of email activity in respect of oxygen supplies. Philip Astle advised that there were instances when oxygen supplies would run relatively low, generally linked to the Trust trying to optimise supplies and be financially efficient. He noted that this was a balancing act and that SCAS could potentially be vulnerable in periods of very exceptional demand. He added that supplies were reviewed on a continuous basis and that as far as he could ascertain, when investigating Frank Epstein’s concerns, the Trust had never run completely out of oxygen. Philip Astle informed the CoG that Community First Responders could replenish their supplies of oxygen if required, but that in light of the concerns that had been raised, he was going to commission a review of the whole system for monitoring and re-ordering oxygen supplies. Sumit Biswas confirmed that this particular issue had been in his sights for months and asked Philip Astle whether the concerns were exclusive to CFRs or whether they also extended to front-line staff. Philip Astle stated that all of the reports related to CFRs in one particular geographical area and that front-line staff were aware that they could either exchange supplies or top them up at a resource centre. In terms of timescales, Philip Astle advised that his review, which would cover the whole of the SCAS region, had just commenced and would take approximately one month dependent on other emerging priorities. Both Mike Hawker and Ilona Blue confirmed that, as part of their leadership walkarounds, the issue of running out of oxygen supplies had never been raised. Bob Crocker stated that CFRs were wary of not taking the last supplies of oxygen ahead of paramedics and would therefore log off if this situation arose. Frank Epstein added that a new ordering process had not been successful – particularly in terms of the smaller oxygen bottles – and that the problems essentially occurred during periods of peak demand. Sumit Biswas asked for Philip Astle to provide an update on his review at the May Board meeting. Action 2.2b Philip Astle to provide an update on his review of oxygen supplies at the May Board meeting in public.

*** Moving on to a third Charity/CFR related topic, Frank Epstein referred to the discussion at the March Board meeting in public regarding the decision to consolidate 150 individual CFR scheme accounts into seven accounts covering Berkshire, Buckinghamshire, East Hampshire, West Hampshire, Oxfordshire, Military and Co-Responders, and the Central Charity. He stated that this approach did not have universal support from the CFRs, and that whilst he would have preferred to have raised this with the Charity Chief Executive she was yet to have visited his scheme area. Nigel Chapman informed the CoG that the Charitable Funds Committee had discussed this issue extensively and had decided that, on balance, a consolidation of the accounts represented the best way forward. He noted that the Charity Chief Executive had gone out of her way to engage with schemes, and that it was clear that there were a range of views amongst the CFRs on this issue. Nigel Chapman advised that the decision had been taken for reasons beyond purely administrative efficiency and was aimed at ensuring that the CFRs received the best possible support for their fundraising activity. He noted that, whilst some schemes were well positioned in terms of funds, others were less so, and that it was unfair for any scheme to be penalised through a lack of capacity to raise funds.


Nigel Chapman stated that the Charity Chief Executive had held a number of meetings with CFR schemes across the South Central region to discuss this particular issue and others. He noted that, on the whole, people understood the rationale for consolidating the accounts, not least because it would free up some management time for the Charity Chief Executive to work even closer with the CFRs and support their fundraising activity. Sumit Biswas commented that he hoped that the CoG was appreciative of the time allocated to discuss these topics, and that he considered it appropriate to have done so. 2.3a – SCAS Workforce and Organisational Development – A Briefing on Current Issues Melanie Saunders opened the item by discussing workforce plans, and particularly recruitment and attrition. She noted the approach to integrated workforce planning, the data based on the first eleven months of the year, and the fact that it had been a challenging year for all four core areas in terms of having the required level of resources in place. Melanie Saunders informed the CoG that recruitment was impacted by a range of complex factors, including what the Trust needed, what it could realistically attract, and what it could afford. She also noted that there was also a tendency for front-line PTS staff to develop and then seek opportunities in 999. The CoG was informed that the Trust was broadly on-track to achieve its planned level of recruitment in 999, but that some recruitment activity had been halted earlier in the year as further recruits could not be absorbed into the workforce. Melanie Saunders noted the particular challenges of recruiting into NHS111 and the Emergency Operations Centres, including local competition and the fact that SCAS had a high requirement for part-time (e.g. evenings and weekends) working. In terms of PTS, the CoG was told that it had been a pretty good year from a recruitment perspective, but with some further work to do. Melanie Saunders highlighted that a range of actions were in place to further improve recruitment and retention, a number of which were shaped by geography; these included: a home-working trial in the NHS111 service, which could potentially be extended to EOC dual roles across 999 and PTS (e.g. Emergency Care Assistant, Ambulance Care Assistant

etc.) recruitment open days a forthcoming rota review aimed, in part, at improving work/life balance Melanie Saunders discussed some of the factors impacting on the delivery of appraisals and the take-up of statutory and mandatory training, both of which had seen some improvement in the last year. In terms of the staff survey, Melanie Saunders informed the CoG that the Trust was far from complacent about the results but did want to recognise the efforts of the management teams. She noted that some of the improvement areas were still only at a score of less than 50% (e.g. feedback from patient/service users is used to make informed decisions) and that further action was required. Finally, Melanie Saunders highlighted some of the important work taking place in relation to organisational development. She noted that: the strategy was the Trust’s first written statement of intent in this area, and was underpinned

by four key ambitions (provider of choice, partner of choice, employer of choice, sustainable and dynamic organisation)


implementation of the strategy would take place over a period of two to three years, and be supported by other strategies such as those for Communications and Engagement, Health and Well-Being, and Digital Transformation.

2.3b - SCAS Workforce and Organisational Development – A Briefing on Current Issues - Questions The CoG held an extensive discussion on staff recruitment and retention. Jim Dunderdale expressed a view that SCAS had lost a significant number of staff in NHS111 over the last three to four years, at great cost, and that even a 50% reduction in attrition would have significant positive implications for the Trust. He also highlighted sickness absence, and the quality of management and their approach to staff welfare as particular challenges for the organisation, and stated that he had a range of emails from staff expressing their discontent. Nigel Chapman advised that he was interested in the comments made by Jim Dunderdale, and that the emails would provide more detail and granularity. He noted that, in terms of the big picture, the Board interrogated performance on recruitment and retention extensively and was consistently looking at new ways to attract and retain staff.

Nigel Chapman explained that Oxfordshire, for example, was an area of full employment, making recruitment hard (particularly with few levers around pay and reward) but further adding to the importance of looking after people.

Nigel Chapman advised that sickness absence was discussed at great length at most meetings of the Board, and that the significance of keeping in touch and supporting staff to return to work at the earliest opportunity had been acknowledged.

Ilona Blue informed the CoG that the Board looked very closely at the assumptions regarding abstractions (staff not available to work for a range of reasons) as part of the budget-setting process, and that the financial impact was significant. She added that, in terms of management capability, the staff survey and leadership walkaround programme provided some level of assurance for Board members, but that the Audit Committee had recently reviewed an Internal Audit report on Team Leader Development and had some concerns which were being explored further.

Colin Godbold stated that the Board needed to take note of the data points that were provided by Jim Dunderdale’s emails, particularly in relation to staff morale. In terms of workforce planning, he suggested that in order to understand the overall scale of the problem it would be helpful to have a clear picture of the longer-term optimum make-up of the workforce in each service area in addition to the in-year targets.

Tony Nicholson noted that there were some errors in the reported information with the variances in attrition (under/over plan) being treated inconsistently in the table.

Mike Hawker highlighted the bigger picture in terms of the use of private providers to address shortfalls in the workforce. He stated that private provision had emerged as a key component of SCAS’ resource planning, especially for the 999 service. In response to questions from Sabrina Chetcuti and David Drew, Ilona Blue advised that the Board periodically looked at the key themes from exit interviews, and that SCAS’ record in terms of sickness absence did not compare favourably with other Ambulance Trusts. She added that the relative position in terms of attrition levels in NHS111 compared with other call centres was not bad but that the benchmarks could not necessarily be viewed as aspirational. Drawing the discussions about recruitment and retention to a close, Melanie Saunders stated that: she would consider the data points that Jim Dunderdale’s information could provide for factual accuracy, the cost of training a new member of staff in NHS111 was more in the

order of £6-6.5k rather than £10k


the take-up of exit interviews was not as high as the Trust would like and further attention was being given to this

there had been a shift in outlook with people tending to plan their careers in blocks of two years rather than seeing their job as being ‘for life’

the reasons given by staff for leaving included work-life balance and, whilst this was a 24/7 service, it was hoped that the rota review would redress some of the balance in this respect

areas for particular future management focus included NHS111, sickness absence and health and well-being

A range of other questions were asked by Governors, with answers given, including: staff survey/health and well-being – Jim Dunderdale expressed a view that SCAS was not

supporting its staff and that he had emails from thirty members of staff suggesting as much; he confirmed that he would be happy to meet with Melanie Saunders to go through these

Paul Ader noted that three of the top ten improvement areas in the staff survey had scores of less than 50%, and asked whether there could have been definition related problems with some of the questions. Melanie Saunders responded that this was a possibility and that, for example, staff often had different interpretations of what constituted “senior management”. Ilona Blue added that this was a national staff survey and that the outliers would be looked at, but that some of the measures were quite hard to shift and improve

OD Strategy – Barry Lipscomb asked whether the Trust had the buy-in and support of the

Trade Unions and Staff Representatives. Melanie Saunders stated that the Unions were fully engaged with, and supportive of, the emerging strategy and that generally speaking employer/Union relationships were good

Values Based Behaviour Sets – Colin Godbold asked whether the behaviour sets, and indeed

all elements of the OD Strategy, were applicable to a wider stakeholder group than just staff. Ilona Blue, citing the example of the Trust’s values (caring, professionalism, innovation, teamwork), advised that these were Trust-wide and would also apply to volunteers.

In conclusion, Melanie Saunders confirmed that one of her team members would liaise with Jim Dunderdale to understand his feedback in greater detail and particularly any key themes. Mike Hawker noted that the Leadership Walkaround Programme helped to identify any issues and concerns. He also acknowledged that, whilst there was high attrition, there were numerous cases of individuals being recognised for their long service or progressing their careers with SCAS. Sumit Biswas stated that it had been an excellent discussion on workforce and one that needed to be returned to at a future meeting. Reports from Council of Governors Committees and Groups

3.1 – Report from the Nominations Committee Steve Garside presented an overview of the report; in particular, he noted that the level of Governor contribution to this round of Chair and NED appraisals had probably been the most significant to date. He thanked the Governors for completing the two on-line surveys and noted that the report set out some of the overall key outcomes of the appraisals as well as the business and development objectives that had been agreed for 2018/2019. Loretta Light asked about the relaunch of the informal NED:Governor buddying scheme. Steve Garside advised that the scheme would be relaunched in the next few weeks and would essentially be driven by geography, given the current focus on local care systems. He added that each NED would also be assigned with a specific portfolio area and that Governors would be able to contact a NED if they had a question in relation to this.


Barry Lipscomb assured the Governors that, aside from the ratings given to the Chair, he had discussed all of the comments made in the free text boxes of the survey with Alastair Mitchell-Baker as part of a very comprehensive process. 3.2 – Report from the Membership and Engagement Committee Mark Davis drew the attention of Governors to the minutes of the last meeting held on 1 February, adding that the next meeting on 30 April would look in more detail at the support available for Governors at engagement events. James Underhay highlighted the importance of Governors providing feedback to the Trust post event, and Mark Davis asked new Governors, and particularly those from the Staff Constituency, to consider joining the Committee. Action 3.2 Governors (especially those from the Staff Constituency) to contact Steve Garside if they would like to join, or attend a meeting of, the CoG Membership and Engagement Committee.

Other Items for Information/Discussion

4.1 – Governor Activities A number of Governors provided feedback from recent activities undertaken in relation to the Governor role, including: Sabrina Chetcuti and Jeanette Clifford reflected on their involvement in a recent ‘keeping in

touch’ meeting with the CQC; they noted that this had been both informal and quite general, and had played in some of the observations from a meeting with staff members held just before the session with Governors

Bob Crocker advised of a number of talks regarding CFRs, including one with the Women’s Institute

Frank Epstein advised that he had attended the SCAS CFR Conference on 14 April and had found this to be well organised and worthy of being repeated next year. Nigel Chapman responded that the possibility of making this an annual event was being looked into, and that he too had been very impressed with the event, which had featured a range of operational and clinical (e.g. cardiac arrest, Sepsis etc.) subjects

Philip Astle informed the CoG that a debrief had taken place following the conference; he noted that the feedback was positive with a range of suggestions for improvement, and that planning for the next conference had already started

4.2 – Non-Executive Directors Activities The CoG noted the comprehensive paper/presentation from Ilona Blue setting out some of the activities she had undertaken over the last three months. 4.3 – Company Secretary’s Report Steve Garside presented an overview of his report, including noting that he was seeking volunteers to support the Chair and himself with the planning for the 5 June workshop. Action 4.3 Governors to contact Steve Garside if they would like to personally contribute to the planning of the 5 June CoG/Board workshop.

Richard Coates referred to the reference in the report (CoG Development Action Plan) that there was “little evidence that questions raised/comments made by Governors at CoG meetings arise out of engagement with Trust members and members of the public”. He stated that, in terms of his own contributions at meetings, 95% of these were driven by engagement with the public. Steve Garside


agreed to note this comment but added that it was not necessarily consistent with conversations he had held with other Governors. 4.4 – Lead Governor’s Report Barry Lipscomb stated that his report was self-explanatory and that he would take it as read. Steve Haynes advised, as a new Governor, that he did not understand the comments made in the report regarding the Lead Governor’s reluctance to comment further beyond what was written. Barry Lipscomb responded that he did not consider it to be helpful to go into too much detail, advising the Governors that he had personally suffered in relation to what he had said previously in his role of Lead Governor. Steve Haynes informed the CoG that he wished for his concerns to be registered given that the report was in the public domain and Barry Lipscomb did not wish to elaborate in more detail. Barry Lipscomb indicated that he would be more comfortable discussing his comments in a confidential meeting of the CoG. Sumit Biswas advised that it would be helpful for Barry Lipscomb to at least set out the substance of his concerns in this meeting in public. Barry Lipscomb responded that he would feel a sense of trepidation around doing this, and Sumit Biswas therefore suggested, in light of this, that it would be helpful for his concerns to be explored in greater detail at the CoG/Board working meeting on 5 June. Sabrina Chetcuti informed the CoG that Barry Lipscomb’s report, and the subsequent conversation, implied that that there was unspoken business and that she felt uncomfortable about this. She suggested that a discussion should at least take place in private at the end of tonight’s meeting. David Palmer asked Barry Lipscomb about his comments regarding the Lead Governor role and SCAS not sharing his interpretation of it. Barry Lipscomb responded that he did not believe that much progress was being made with the discussion about his report, but advised that in his view the Trust did not see the Lead Governor role in the way that he did. In conclusion, Steve Garside, and particularly for the benefit of the new Governors, advised that SCAS had an agreed and long established Lead Governor role description – last presented in April 2017, but also available on the Governors portal. He explained that this extended the role beyond being a point of contact for NHS Improvement to include other duties and that he considered that the Trust fully supported, and could evidence, the delivery of the duties listed in the role description. 4.5 – Council of Governors Review 2017/2018 Steve Garside explained that he had circulated the document previously as it formed part of the content of the 2017/18 Annual Report and he had particularly wanted Governors to check and confirm their attendance data. The CoG APPROVED the 2017/18 Review, noting that any further comments on the priorities for 2018/19 could be discussed at the CoG/Board working meeting on 5 June. Closing Business

5.1 – Any Other Business including Questions from Members/Observers A number of items of other business were discussed: Colin Godbold noted the discussion at the March Board meeting regarding long waits and the

current absence of any definitions under ARP. He asked whether adopting definitions which suggest a wait of two or three hours for lower category calls is “not a long wait” would be seen as acceptable by the public and if the public relations aspect of this had been considered


Ilona Blue commented that she had raised this particular issue at the Board meeting, and that she was concerned that there had been an absence of reporting long waits since the introduction of ARP. She noted that she had asked for some assurance to be provided at the next meeting including detail regarding the length of the tail Philip Astle advised that there would be a national review of ARP in the coming weeks, with official long wait definitions expected to be communicated. He added that he believed that these would be very similar to those proposed by SCAS (and referred to at the March Board meeting), being a combination of time and percentile.

David Drew advised that he had attended a conference on emergency planning and resilience a few weeks ago and that the Emergency Planning Officer at Hampshire County Council had highlighted pandemic flu as their number one current priority. He asked whether the flu vaccination could be a contractual requirement for SCAS staff, subject to some appropriate exemptions.

Action 5.1 Melanie Saunders to consider whether an annual influenza vaccination should be a contractual requirement for all SCAS staff, subject to some appropriate exemptions.

Frank Epstein highlighted Saturday 19 May as a busy day for Windsor due to the Royal

Wedding, and noted that a number of volunteers would be on hand to support the Trust with their work. He added that the Windsor CFR Group had produced a very informative video that he would forward to Steve Garside for circulation

Barry Lipscomb thanked Sumit Biswas for his chairing and stated that it had been a very good meeting. Sumit Biswas thanked attendees for their contribution, noting a range of helpful thoughts, ideas and comments. 5.2 – Date and Time of Next Meeting It was noted that the next formal meeting in public would be taking place on Tuesday 24 July 2018.

ENCLOSURE B

MATTERS ARISING FROM THE MEETING HELD ON 16 APRIL 2018

Enclosure B




Title of Paper: Matters arising from the meeting held on 16 April 2018

Presented by: Steve Garside, Company Secretary


Information

Main Aim: To ensure good governance practice in confirming that the actionpoints from the 16 April 2018 Council of Governors meeting are in hand / have been delivered.


There were eight actions arising from the previous meeting on 16 April2018; seven of these have been fully completed and one requires averbal update at the meeting.


To note progress with the actions from the previous Council of Governors meeting

Previous Forum: An update is presented at each Council of Governors meeting


N/A



Enclosure B Page 1 of 3 Author: SG

Enclosure B - Matters Arising Schedule – Council of Governors Meeting 24 July 2018 ACTIONS AGREED AT 16 APRIL 2018 COUNCIL OF GOVERNORS MEETING Ref No Agenda Topic Summary of Action Required Lead Due Date Status

Action 1.3

Minutes of the meeting held on 11 January 2018

Steve Garside to amend the minutes of the meeting held on 11 January 2018 to reflect the comments made by Governors in respect of sections 1.6 and 2.1a.

SG 24/7/18 Action completed The minutes of the 11 January meeting have been amended to reflect the comments made by Governors as part of the approval process.

Action 1.4

Matters arising from the meeting held on 11 January 2018

Philip Astle to explain more about the public’s perception that the NHS111 (provided by SCAS) and out of hours (provided by doctors/another organisation) services in Hampshire are provided by the same organisation (i.e. SCAS) and how the risks of any confusion can be mitigated in order to preserve the Trust’s reputation.

PA 24/7/18 Verbal update required Philip Astle will address this action verbally at the meeting.

Action 2.1b

Chief Executive’s Report including Performance Update

The Chief Executive to issue a short briefing to the Council of Governors setting out details of potential changes to the operating models of the two Air Ambulance Charities, including any specific implications for SCAS.

WH 24/7/18 Action completed A short briefing was circulated to the Governors on 11 July.

Action 2.2a

SCAS Charity and Community First Responders

Nigel Chapman to confirm what SCAS recharges back from the SCAS Charity as part of the support services it provides.

NC 24/7/18 Action completed A short briefing was circulated to the Governors on 11 July.

Action 2.2b

SCAS Charity and Community First Responders

Philip Astle to provide an update on his review of oxygen supplies at the May Board meeting in public.

PA 24/5/18 Action completed An update was provided in the Chief Operating Officer’s Board paper – circulated to Governors on 18 May.


Ref No Agenda Topic Summary of Action Required Lead Due Date Status

Action 3.2

Report from the Membership and Engagement Committee

Governors (especially those from the Staff Constituency) to contact Steve Garside if they would like to join, or attend a meeting of, the CoG Membership and Engagement Committee.

CoG ASAP Action completed No responses received. The committee continues to have seven members (no Staff Governors).

Action 4.3

Company Secretary’s Report

Governors to contact Steve Garside if they would like to personally contribute to the planning of the 5 June CoG/Board workshop.

CoG ASAP Action completed Barry Lipscomb, Paul Ader, Colin Godbold and Steve Haynes all contributed to the planning of the 5 June workshop.

Action 5.1

Any Other Business Melanie Saunders to consider whether an annual influenza vaccination should be a contractual requirement for all SCAS staff, subject to some appropriate exemptions.

MS 24/7/18 Action completed This is an issue that the Trust has been considering for some time, factoring in the views of clinicians and staff, and taking on board the latest guidance. The National Institute for Clinical Excellence (NICE) committee has, for example, expressed reservations about the ethical and legal implications of making vaccination a mandatory requirement for health workers. They have noted that qualitative evidence indicates that such policies can negatively affect staff morale, leaving staff feeling disempowered, lacking autonomy and resentful of the perceived undermining of their professional work ethic. On balance the Trust does not


consider mandating the vaccine within SCAS to be in the best interest of maintaining and continuing to foster good employee relations with our workforce. However, this will continue to be kept under review.

Key for leads SG Steve Garside, Company Secretary PA Philip Astle, Chief Operating Officer WH Will Hancock, Chief Executive NC Nigel Chapman, NED (Chair of Charitable Funds Committee) CoG All Governors MS Melanie Saunders, Director of HR and OD

ENCLOSURE C

COUNCIL OF GOVERNORS DEVELOPMENT – NEXT STEPS

Enclosure C




Title of Paper: Council of Governors (CoG) Development – Next Steps

Presented by: Lena Samuels, Chair


Decision

Main Aim: To agree next steps in the CoG development process by way of considering a proposal from the external facilitator


The CoG held a workshop on 5 June, attended by Board members, asa starting point in developing the CoG and further strengthening itseffectiveness. The workshop was shaped by a Governor survey, and this survey, aswell as the outcomes of the 5 June session (individual and groupexercises), have been considered by the external facilitator. Aproposal for next steps in the process is now put forward forconsideration by the Governors.


To consider the proposal and agree next steps in terms of a series of future events designed to further develop the SCAS CoG

Previous Forum: 5 June 2018 workshop


N/A



Page 1 of 3

COUNCIL OF GOVERNORS 24 JULY 2018

ENCLOSURE C

COUNCIL OF GOVERNORS DEVELOPMENT – NEXT STEPS BACKGROUND

1 The SCAS Council of Governors (CoG) and Board of Directors participated in an

externally facilitated workshop on 5 June 2018, entitled “Being a Well-Led Council of Governors”.

2 The workshop was informed by a Governor survey undertaken in advance of the

evening, and further views and perspectives were then expressed during the workshop as a result of the individual and group exercises.

3 The survey was completed by 23 of the 26 Governors (88%), and the workshop

was attended by 20 Governors (77%) and all fifteen (100%) of the voting Board members.

4 The purpose of this paper is to propose the next steps in the development

process. It has been produced by one of the external facilitators of the workshop, John Bonney, who SCAS would like to work with going forward in order to provide the necessary expertise and continuity.

5 Additionally, Appendix 1 shows the results of the Governor survey for

information. STATEMENT FROM JOHN BONNEY, DIRECTOR, ALENDI CONSULTING

Analysis of emerging themes 6 Both the survey and 5 June session reveal some important themes and issues

going forward:

There is clearly a widespread commitment to the development process and early feedback from both groups (Governors and Board members) following 5 June demonstrates an appetite for more skills and team-based development. The level of engagement in the survey and for the training reinforces this view.

It is clear that a minority of Governors remain unsure of their role or are

actively seeking to work beyond it. However others recognise when the latter occurs and are keen to see more role discipline.

Governors are often frustrated by the formality of meetings and the time

constraints. Often it is felt discussion is truncated because of these factors. For some this is exacerbated by some Governors continually returning to

Page 2 of 3

particular “pet” projects that consume time and exclude coverage of other matters.

From the survey results some Governors are hesitant to speak up because

of their lack of experience or the team dynamic that prevails.

Whilst the governor/NED buddying arrangements are newly established there is a sense that this and other offline activities helps build understanding and confidence amongst the governors.

There is a growing sense that the agenda of council meetings is controlled

by the directors, this leads to a suspicion that items are presented more positively than might be the actual case. Governors have an appetite for more involvement in agenda setting and ownership of the meeting.

Overall there is good personal support for the Chair and the Company

Secretary and palpable backing for their approach to developing the CoG. Proposed next steps 7 In recent months members of the CoG have undertaken a survey of views

around performance and a team development session with directors. This has produced considerable evidence on the views of Governors as to their role, relationships and behaviour. In addition governors have offered candid views on the performance of the group and areas for improvement.

8 In light of this evidence, and the commitment in the Governor’s development

plan, we propose a development programme that focuses on the three key areas that emerge from the findings: conduct, roles and relationships and operation.

9 The first session will focus on how the CoG conducts itself to be most effective.

This will explore the behaviours and approach that ensures an open and constructive environment. We will examine the evidence from the survey and use the current values of the organisation to structure a practical session which develops a series of personal commitments around conduct. The intention is the product from these sessions will be owned collectively by the group and committed to individually.

10 The second workshop will focus on role clarity and the relationships between

governors, NEDs and the membership. We will work to identify what helps each group function more effectively and how the other groups best support them. Again, as a starting point, we will examine the findings from the survey and the development event. Separate sessions for NEDs and Governors will be undertaken to allow both groups express their views candidly. The product will provide a précis of key issues emerging and practical steps to building more productive relationships.

11 The final session will bring the CoG and the entire Board together to build on the

work done around behaviours and relationships. The workshop will create a vision of what “Well Led” means in practical terms and where the Board and CoG are at present. The session will also focus on solution building to make improvements and gain commitment to making change.

12 A key element of the programme is to engage all governors and give them

ownership of issues needing improvement and the solutions that are developed. The individuals sessions are designed not only to build on each other but also to be flexible enough should significant new issues surface during the activities.

Page 3 of 3

CONCLUSION AND RECOMMENDATION 13 The CoG is asked to consider the report from John Bonney in relation to the

proposed next steps in the CoG development process. John Bonney Director Alendi Consulting Ltd 5 July 2018

60.87% 14

21.74% 5

17.39% 4

Q1 Type of GovernorAnswered: 23 Skipped: 0

TOTAL 23

Public

Staff

Partner

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

Public

Staff

Partner

1 / 26

"Being a Well-Led Council of Governors" - Governor Survey SurveyMonkey

43.48% 10

8.70% 2

17.39% 4

4.35% 1

26.09% 6

Q2 Period served as a SCAS GovernorAnswered: 23 Skipped: 0

TOTAL 23

< 6 months

6 months - 1year

1 - 2 years

2 - 3 years

> 3 years

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


< 6 months

6 months - 1 year

1 - 2 years

2 - 3 years

> 3 years

2 / 26


30.43% 7

17.39% 4

60.87% 14

Q3 Sub-committees of which a member (please only tick the option(s)that applies to you)

Answered: 23 Skipped: 0

Total Respondents: 23

Membership andEngagement...

NominationsCommittee

None

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Membership and Engagement Committee

Nominations Committee

None

3 / 26


40.91% 9

54.55% 12

4.55% 1

0.00% 0

0.00% 0

Q4 I have a clear understanding of the role of an NHS Foundation TrustGovernor, including the various statutory duties.


TOTAL 22

1. Fully agree

2. Somewhatagree

3. Neitheragree nor...

4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree

3. Neither agree nor disagree

4. Somewhat disagree

5. Wholly disagree

4 / 26


36.36% 8

50.00% 11

13.64% 3

0.00% 0

0.00% 0

Q5 I am clear about the ways in which I, and the wider CoG, dischargethe various statutory duties.


TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

5 / 26


27.27% 6

18.18% 4

31.82% 7

18.18% 4

4.55% 1

Q6 I consider that the CoG has the right mix of skills, experience,knowledge and diversity in the context of the statutory duties and

challenges facing the Foundation Trust.Answered: 22 Skipped: 1

TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

6 / 26


18.18% 4

63.64% 14

9.09% 2

9.09% 2

0.00% 0

Q7 I have been equipped by the Trust with the skills and knowledgerequired to deliver the Governor role (e.g. through induction, ongoing

initiatives etc.).Answered: 22 Skipped: 1

TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

7 / 26


22.73% 5

59.09% 13

18.18% 4

0.00% 0

0.00% 0

Q8 I believe that the CoG carries out its work in accordance with theSCAS values (teamwork, professionalism, innovation and caring).


TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

8 / 26


13.64% 3

40.91% 9

18.18% 4

27.27% 6

0.00% 0

Q9 The CoG works together as a unit and in accordance with the tone setby the Chair.


TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

9 / 26


9.09% 2

45.45% 10

31.82% 7

13.64% 3

0.00% 0

Q10 Key relationships (e.g. between Governors and the Chair/NEDs)work well.


TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

10 / 26


27.27% 6

40.91% 9

22.73% 5

4.55% 1

4.55% 1

Q11 I believe that I make an effective and valuable contribution.Answered: 22 Skipped: 1

TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

11 / 26


27.27% 6

36.36% 8

31.82% 7

4.55% 1

0.00% 0

Q12 Either directly as a committee member, or through the reporting toCoG meetings, I believe that the CoGs committees work effectively and

operate within their terms of reference.Answered: 22 Skipped: 1

TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

12 / 26


13.64% 3

36.36% 8

27.27% 6

18.18% 4

4.55% 1

Q13 The CoG communicates with, and listens and responds to, members(public/staff) and other stakeholders effectively.


TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

13 / 26


4.55% 1

36.36% 8

40.91% 9

18.18% 4

0.00% 0

Q14 The CoG has an effective development plan which will ensure that itis equipped to meet future challenges.


TOTAL 22

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

14 / 26


9.52% 2

42.86% 9

19.05% 4

19.05% 4

9.52% 2

Q15 Effective processes are in place enabling sufficient debate on keyissues where assurance is sought.


TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

15 / 26


28.57% 6

61.90% 13

0.00% 0

9.52% 2

0.00% 0

Q16 The quality of information provided about the Trust and itsperformance allows me to discharge my role.


TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

16 / 26


33.33% 7

47.62% 10

19.05% 4

0.00% 0

0.00% 0

Q17 The quality of papers and presentations to the CoG enables me tounderstand the Trust in order to gain assurance.


TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

17 / 26


14.29% 3

42.86% 9

19.05% 4

23.81% 5

0.00% 0

Q18 The level of discussion on individual issues is sufficient for me togain assurance/discharge my role.


TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

18 / 26


42.86% 9

28.57% 6

14.29% 3

14.29% 3

0.00% 0

Q19 Decision-making processes are clear in meetings.Answered: 21 Skipped: 2

TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

19 / 26


33.33% 7

33.33% 7

33.33% 7

0.00% 0

0.00% 0

Q20 Governors have appropriate development opportunities available tothem.


TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

20 / 26


52.38% 11

23.81% 5

9.52% 2

14.29% 3

0.00% 0

Q21 I understand the procedures for escalating matters internally.Answered: 21 Skipped: 2

TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

21 / 26


9.52% 2

52.38% 11

28.57% 6

4.76% 1

4.76% 1

Q22 Governors have a good involvement in developing strategy (e.g.through the annual strategy workshop).


TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

22 / 26


19.05% 4

33.33% 7

14.29% 3

28.57% 6

4.76% 1

Q23 There are appropriate and effective ways for Governors to apprisethemselves of the views of members and the general public and

represent their interests.Answered: 21 Skipped: 2

TOTAL 21

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

23 / 26


25.00% 5

35.00% 7

20.00% 4

15.00% 3

5.00% 1

Q24 The CoG has sufficient and effective opportunities to hold the NEDsto account for the performance of the Board of Directors.


TOTAL 20

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

24 / 26


35.00% 7

40.00% 8

10.00% 2

15.00% 3

0.00% 0

Q25 Governors can identify key performance issues and ask relevantquestions.


TOTAL 20

1. Fully agree

2. Somewhatagree


4. Somewhatdisagree

5. Whollydisagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


1. Fully agree

2. Somewhat agree



5. Wholly disagree

25 / 26


Q26 Any further comments you would like to add including anything tohelp us improve the SCAS CoG.


26 / 26


ENCLOSURE D

REPORT FROM THE MEMBERSHIP AND ENGAGEMENT COMMITTEE

Enclosure D




Title of Paper: Report from the Membership and Engagement Committee

Presented by: Mark Davis, Chair of the Membership and Engagement Committee


Information

Main Aim: To present an update report from one of the two formal sub-committees of the Council of Governors; in this case the Membership and Engagement Committee.


A report is presented from the Membership and EngagementCommittee and a verbal commentary will be provided by Mark Davis. The report covers the outcomes of the last meeting on 30 April 2018and an overview of future plans.


To note the report from the Membership and Engagement Committee

Previous Forum: April 2018


N/A


Steve Garside, Company Secretary – 01869 365032

Page 1 of 8


ENCLOSURE D

REPORT FROM THE MEMBERSHIP AND ENGAGEMENT COMMITTEE BACKGROUND

1 The Membership and Engagement Committee (MEC) is one of two committees of the

Council of Governors (CoG). Given that one of the two main general statutory duties of ALL Governors is to represent the interests of Trust members (public and staff) and the public, this is a vitally important committee that “makes recommendations and reports to the Council of Governors about membership recruitment, engagement, communications, involvement and representation”.

2 The current membership of the committee is as follows:

Mark Davis, Public Governor (Berkshire) (Committee Chair) Barry Lipscomb, Lead and Public Governor (Hampshire) Bob Duggan, Public Governor (Buckinghamshire) Paul Ader, Public Governor (Oxfordshire) David Luckett, Public Governor (Hampshire) David Drew, Appointed Partner Governor (Air Ambulance Charity) Frank Epstein, Public Governor (Berkshire)

3 We have vacancies for additional Governors to join the committee, and in particular we would welcome the involvement of Staff Governors as the remit of the committee includes staff member engagement and not just public member engagement.

4 The committee would like to strongly encourage all Governors, as part of their statutory

duties, to actively contribute to the Governor engagement programme in the second half of the year. This is important in demonstrating that questions asked at CoG and Board meetings in public arise from engagement with members and members of the public.

REPORT FROM MEETING HELD ON 30 APRIL 2018

5 The MEC last met on 30 April 2018, and the minutes of the meeting are now presented at

Appendix A. These are unconfirmed minutes and will be considered/approved at the next MEC meeting.

6 In receiving the minutes the CoG is asked to note that:

the programme of engagement events for 2018/19 is available on the Governors portal; Governors can sign up to attend events by contacting Monica Moro, the Membership and Engagement Manager

it is vitally important the Governor provide feedback on / record the outcomes of their

engagement activity so that the Trust can be clear on the views expressed by constituents and act accordingly

Page 2 of 8

the 2017/18 Annual General Meeting is taking place this year in Buckinghamshire on 27 September, and the 2018 Annual Members Meeting will also be held in Buckinghamshire at a date shortly to be confirmed

the 2018 Membership and Patient Care Survey has been launched and the results will be considered by the MEC at their next meeting; the survey usually provides some very helpful insights for the Trust to consider

Vanessa Casey, SCAS Charity Chief Executive, again attended the meeting to provide

an update on the activities of the Charity. The important role that CFRs play in relation to fundraising was noted

Monica Moro provided assurance that SCAS would be compliant with the new General

Data Protection Regulations in relation to its membership data. 7 The next meeting will take place on Tuesday 4 September, at 6pm in Newbury. CONCLUSION

8 The MEC continues to review Governor engagement activity and consider the most

effective strategies for engagement. Mark Davis MEC Chair and Berkshire Public Governor 5 July 2018

Page 3 of 8

APPENDIX A - MEMBERSHIP AND ENGAGEMENT COMMITTEE MINUTES 30.4.2018

Minutes of the twenty-sixth meeting of the South Central Ambulance Service NHS Foundation Trust Membership and Engagement Committee held on 30 April 2018 at Shaw House, Newbury Present: Mark Davis, Public Governor (Berkshire) (Committee Chair)

Barry Lipscomb, Lead and Public Governor (Hampshire) Bob Duggan, Public Governor (Buckinghamshire) Paul Ader, Public Governor (Oxfordshire)

David Luckett, Public Governor (Hampshire) - part David Drew, Appointed Partner Governor (Air Ambulance Charity)

In attendance: Lena Samuels, Chair

James Underhay, Director of Communications and Engagement Steve Garside, Company Secretary Vanessa Casey, SCA Charity, CEO Monica Moro, Membership and Engagement Manager

‘Bukola James-Adeyemi, Minute taker

Apologies: Frank Epstein, Public Governor (Berkshire) MEC18/01 Chair’s Welcome, Apologies for Absence and Declaration of Interests The Committee Chair welcomed all to the meeting and apologies were noted from Frank Epstein.

No new interests were declared. MEC18/02 Minutes and Matters Arising from Meeting of 1 February 2018 The minutes of the previous meeting were approved without amendment. It was agreed that most of the actions from the meeting had been completed, and verbal updates were provided for the following: 17/32 – subset of actions, activities, and messages Paul Ader stated that the notes from his meeting with James Underhay had been circulated by the Committee Chair; however, it was noted that not everyone had received them. He informed the Committee that the notes had now been shared with Sumit Biswas and Nigel Chapman as the Non-Executive Directors (NEDs) who were working with the Trust’s Assistant Director of Communications on the development of the overall Communication and Engagement Strategy. Paul Ader stated that he hoped that the proposed framework within which Governors could engage with members and the public in a more effective way would be included in the emerging new Communications and Engagement Strategy. It was noted that Loretta Light and Steve Haynes, Public Governors for Oxfordshire, had agreed to participate in an Oxfordshire engagement pilot scheme if the Committee approved it. Paul Ader stated that the key to the success of the pilot scheme is access to relevant local data. In addition, he pointed out that, currently, the Committee operates to a relatively narrow remit and that a wide remit is needed to consider and direct the membership and engagement activities of public Governors as an integral part of the engagement activities and campaigns carried out by SCAS. The Committee approved the proposed pilot scheme in Oxfordshire to test whether Governors can work in a ‘directed way’ on specific issues. Monica Moro agreed to support the scheme and provide Paul Ader with the contacts he needs for the scheme.

Action 18/02a Paul Ader to set-up a pilot scheme in Oxfordshire to test whether Governors can work in a ‘directed way’ on specific issues and Monica Moro to provide him with the contacts he needs for

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The Committee noted that the Executives will provide guidance on wider issues that may come up. 17/33a – Engagement feedback from the appointed Governors from the Clinical Commissioning Groups, and the Local Authority It was clarified that this action stemmed from the Council of Governors (CoG) not getting snapshot highlights on on-going issues from the appointed partner Governors’ patch/constituency at its meetings. Steve Garside stated that the last CoG agenda was structured in terms of a) public b) staff and c) partner, so it can be used to gather relevant intelligence; however, the response was quite lean across the board. Paul Ader suggested that appointed partner Governors can be asked to provide written answers to the following:

the main thing that has happened which is relevant to SCAS since the last meeting in my organisation, what is the one thing that is likely to impact on SCAS during the period

before the next CoG meeting? It was advised that this could be included in the CoG papers and other Governors can build on it. Lena Samuels stated that it would help steer the thinking of appointed partner Governor to be prepared to provide information that is current and relevant to SCAS and that the framework can be used at a later stage for other Governors. In the light of the above, David Drew agreed to give a 1-2 minutes verbal update on three key points at the next CoG meeting in public as well as in writing; it is hoped that this would help the new Governors set the scene. 17/33b – wording around the Charity, and staff engagement and Governors election for inclusion in the Terms of Reference The Committee agreed that Steve Garside should finalise and circulate the MEC Terms of Reference in line with the comments made at the last meeting.

MEC18/03 Update on final position re: 2017/18 Engagement Activity Monica Moro stated that the paper was self-explanatory, and it was taken as read. In response to a question on engagement activity information and notification, Monica Moro explained that this is outlined in paper 4b. However, she mentioned that timely and relevant information is communicated to event organisers/chairs and volunteers. Lena Samuels highlighted that at a recent meeting with the Committee Chair, Steve Garside, and Monica Moro the engagement toolkits on the Governors portal were discussed and that Monica Moro would circulate to the CoG after it is fine-tuned. The Committee was informed that the Governors portal is a simple and basic website and cannot support some suggested search engine add-ons. Paul Ader enquired about the event calendar on the portal including if it can be synchronised with Governors’ private diaries. He promised to look into this and would let other Governors know how to synchronise their dairies with the event calendar. Lena Samuels informed the Committee of her meeting with Nic Morecroft, Community First Responder (CFR) Manager and that a list of CFR events will be forwarded to Monica Moro for inclusion in the event calendar on the portal. Thereafter, she advised Monica Moro to resend the event calendar as an aide memoire to the CoG.

the scheme. Feedback on progress to be provided at the next meeting.

Action 18/02b Steve Garside to finalise and circulate the MEC Terms of Reference in line with the comments made at the last meeting.

Page 5 of 8

On David Drew’s question about events which are not on the calendar, Monica Moro explained that the Trust receives about 250 requests annually for school visits but are only able to satisfy about 70 requests. She mentioned that primary school visits are not suitable for Governors but would be happy for Governors to visit colleges and secondary schools to talk about membership while the Recruitment Team focuses on career with the Trust. On staff Governor Engagement, Steve Garside asked Monica Moro for an overview of the staff Governors engagement plan. Monica Moro stated that one of the plans is to have Kate Moss, staff Governor 999 Operation, North, attend team meetings at the ambulance stations whenever she can, this will give her the opportunity to introduce herself. It was noted that Monica Moro is still trying to shoot some videos on staff Governors for use during the Trust’s Corporate Inductions. The Committee Chair asked how the MEC can help engage with staff. It was clarified that the Committee’s role is to support staff Governors to engage with staff and suggest resources. James Underhay suggested that at some point the Committee can have a staff themed meeting and invite one or two staff Governors to a future meeting to share their ideas on staff engagement.

MEC18/04 Review of 2017/19 Membership and Public Engagement Strategy (year 2) Update on progress of the 2017/19 Membership and Engagement Strategy David Drew advised that a weekly, bi-weekly, or monthly update on campaigns and events should be provided, so decisions can be made on what is coming up in the next six weeks. The Committee considered the following red rated activities particularly for the stated reason of “No admin support”:

What would you do in the event of an emergency? SCAS Diabetes Awareness Roadshows SCAS Healthy and Safe Bingo events SCAS Youth website.

Barry Lipscomb suggested that the Committee might have to escalate its concern about the lack of support and resources to the Board. However, it was pointed out that a lot of other Trusts organise similar events and the Committee may have to prioritise these activities. Monica Moro informed the Committee that the Trust partners with other health organisations to come up with events; for instance, the partnership with Slough Borough Council on Diabetes Awareness. She stated that the one of the benefits of the partnership is the recruitment of more Black and Minority Ethnic groups. Lena Samuels pointed out that there may be some knowledge gap that the Trust is likely not aware of; it was advised that Monica Moro should share updates on some of the activities to review their RAG status. In response to the help required, Monica Moro stated that the most urgent need is to get the partner Governors to organise talks for various groups in their constituency to ascertain the issues in those areas. Paul Ader suggested that Monica Moro should write a short paper on the five key themes and present it to the CoG; this will be on what she has been doing and what will be done in these areas, as well as its relevance to SCAS. Monica Moro informed the Committee that she had organised a Dementia themed Community Engagement Forum in all SCAS counties and one was done in partnership with Portsmouth University. In addition, the Committee was informed of her work with a clinician from Milton Keynes Ambulance Station and the partnership with Open University to work on elderly care.

Action 18/03 The Committee to invite one or two staff Governors to a future meeting to share their ideas on staff engagement.

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Lena Samuels advised that Monica Moro should put together a brief fact sheets on the various themes to share with the CFRs. Steve Garside asked about the Annual Members Meeting (AMM), Monica Moro explained that it is going to be held in Buckinghamshire but would not be on the same day as the Annual General Meeting. The Committee advised that Monica Moro should consider a joint AMM event with other services. The Committee Chair advised that Monica Moro should put together a wish list of what needs to be done and put it up for discussion, so Committee members can help.

On Barry Lipscomb’s concern about CFRs’ public engagement, Vanessa Casey informed the Committee that she is working alongside the CFR Manager and the SCA CFR schemes to put together the CFR’s event calendar and that it would be circulated to Governors in due course. The Committee Chair stated it would be helpful to get communication out to the CoG to get in touch with their local CFR schemes and find out what they are doing and share some messaging. Paul Ader asked whether Vanessa Casey and Monica Moro can explore getting the CFR scheme engagement calendar onto the portal; this can be a sub-calendar and labelled by county. Also, he mentioned that the CFR Manager should be invited to join the Committee. The Committee Chair agreed to invite the CFR Manager to join the Committee as well as share the local CFR coordinators’ contact details; so, Governors can contact them regarding working together.

Paul Ader asked whether there is a mechanism for people who have been involved with the Trust in other ways to stay on and network via the SCAS 100 Virtual Club. Vanessa Casey informed the Committee that the Charity is at the point of rolling out its SCA Charity email accounts for CFRs. An overview from the Committee Chair and the Membership and Engagement Manager of the issues discussed at a recent engagement review meeting The Committee Chair updated on the outcome of his meeting with Lena Samuels, Steve Garside, and Monica Moro on engagement which was circulated to MEC members some weeks back, these included:

Review of the presentation on the portal Develop a new Governor pack when they come on board, i.e. ‘what to do’, ‘what to say’ etc. Review of the event T-shirt to make Governors stand out Professional name badges – Monica Moro to issue name badges for events to Governors

The Committee Chair agreed to resend the email detailing the outcome of this meeting. Thereafter, he asked the Committee to consider the list of the things to do and requested for volunteers.

In addition, it was agreed that the Committee should also review the post-event forms to help the Trust in the delivery of events.

Action 18/04(i) Monica Moro to put together a wish list of what needs to be done for the Annual Members Meeting and put it up for discussion, so Committee members can help.

Action 18/04(ii) The Committee Chair to invite the CFR Manager to join the Committee as well as share the local CFR coordinators’ contact details; so, Governors can contact them regarding working together.

Action 18/04(iii) The Committee Chair to resend the email detailing the outcome of his meeting with Lena Samuels, Steve Garside, and Monica Moro on engagement.

Page 7 of 8

Information available to Governors re: events This agenda item has been discussed during the “Update on final position re: 2017/18 Engagement Activity”. MEC18/05 2018 Membership and Patient Care Survey – planning Monica Moro asked the Committee for comments before finalising the survey. The Committee was informed that only two people contacted her with their comments. Paul Ader suggested that Monica Moro should circulate his comments as others may find it easier to comment on the survey. It was agreed that the timescale for submission of comments is by the end of next week. It was noted that the survey would take a few minutes to complete.

MEC18/06 South Central Ambulance (SCA) Charity - Update Vanessa Casey updated the Committee on the following:

SCA Charity is now part of the NHS 70 initiative which would be launched in a week or two; the platform would provide the opportunity to receive donations as well as engage in a mass participation event across the UK

Currently, the Charity’s future strategy is now in the planning The Charity continues to work with its CFR schemes and closely engaging with the

communities The Charity held a successful CFR conference and had positive feedback and ideas for the

future from attendees – this would now be held on an annual basis. Paul Ader raised a concern about fundraising for the general pot; Vanessa Casey mentioned that this is one of the reasons why it is important to find out what the next campaign would be and how to facilitate it. Lena Samuels commended the Charity for now being able to track its spending better. Vanessa Casey stated that a lot of work had gone into updating the Charity’s database. She added that it is now important for the Charity to maintain its relationship with the CFR communities and the public. Barry Lipscomb asked whether there is any uncovered area by CFR schemes in the SCAS areas. Vanessa Casey stated that there are, and it something the Charity would investigate. She informed the Committee that the Charity is also looking to recruit volunteers who do not want to be CFRs but help with events and fundraising. David Drew enquired about the use of funds which was a concern raised at the last CoG meeting: he stated that there is need for the funds to be treated quite sensitively and not randomly redistributed. He added that the messages and comments passed to donors are very crucial. Lena Samuels resonated that SCAS serve all those counties within which funds are raise and that the Trust is not sectorial in the quality of care delivered to its service users. Vanessa Casey stated the Charity is currently looking at giving the CFRs the right information and messages when fundraising. Paul Ader mentioned that when money is raised, the Charity needs to explain the options of how it would be spent and give donors the choice to decide. Vanessa Casey stated that the new scheme accounting would beneficial as it allows the schemes to work across different routes, share their practices and support each other including working on initiatives together. Vanessa Casey informed the Committee that currently, the CFR schemes have raised around £200 -£250k and the Charity as a whole has raised around £350k.

Action 18/05 Monica Moro to recirculate the sample ‘Member and Patient Satisfaction Survey – 2018’ with Paul Ader’s comments to the Committee for their comments. The timescale for submission of comments is by the end of next week.

Page 8 of 8

The Committee was informed of the fundraising roles of Mayors in different counties and that some raise about £25 - £35k per year for their selected charity with specific needs. Vanessa Casey advised that the Charity would explore this area and coordinate the CFR schemes in a cohesive way. MEC18/07 Revised Meeting Dates/Programme of Business 2018/19 The Committee noted the dates of future meetings and approved the Programme of Business. MEC18/08 Any Other Business Update on General Data Protection Regulation (GDPR) and membership implications Monica Moro updated the Committee on progress and mentioned that the Trust is required to inform its FT members on the following:

“what membership data we hold for them” “why we hold their data” “what we use their data for” “legal justification for holding their data”

In addition, she stated that the information on the GDPR will be included in the winter edition of the Foundation Times. It was noted that there might be changes to the Constitution and Steve Garside will be advising. Monica Moro informed the Committee that she is seeking legal advice from NHS Providers. Furthermore, the Committee was informed that the Trust would have to spend about £4k to contact the FT members, advising them of the GDPR requirements. On a question regarding FT members who are unable to respond, Monica Moro stated that by default it would be assumed that they are happy with their data and the Trust will retain it; this will be outlined in the FT policy.

Update on the response to Hampshire Governors’ email with regard to the February Foundation Times Monica Moro informed the Committee that no response was received from the members of the public in Hampshire. Key messages for reporting to next CoG meeting It was agreed that the Committee Chair and Steve Garside will discuss this outside of the meeting. Others Bob Duggan enquired about the NED/CoG buddying arrangement, Lena Samuels responded that it is being finalised and would be rolled out in due course. Finally, the Committee appreciated James Underhay for his contributions in the last six years while James Underhay thanked the Committee for their dedication and devotion. MEC18/09 Date of Next Meeting It was noted that the next meeting would be held on 4 September in the Newbury area.

ENCLOSURE E

CHIEF EXECUTIVE’S REPORT INC. PERFORMANCE UPDATE

Enclosure E




Title of Paper: Chief Executive’s Report including Performance and Care Quality Commission Inspection Update

Presented by: Will Hancock, Chief Executive (supported by Philip Astle, Professor Helen Young and MelanieSaunders as appropriate)


Information

Main Aim: To update the Council of Governors on a range of issues anddevelopments affecting the Trust. The report is shaped around the key themes used by the regulator NHS Improvement to assessproviders:

operational performance quality of care strategic change finance and use of resources leadership and improvement capability


Governors are encouraged to direct questions on any issues raisedby the report to the Non Executive Directors present.


Note

Previous Forum: A Chief Executive’s Report is presented at every Council of Governors meeting as a standing agenda item


N/A



Page 1 of 7

COUNCIL OF GOVERNORS MEETING – 24 JULY 2018

CHIEF EXECUTIVE’S REPORT INCLUDING PERFORMANCE AND CARE QUALITY COMMISSION (CQC) INSPECTION UPDATE

PURPOSE

1 The purpose of my report is to keep the Council of Governors (CoG) abreast of key matters

for the Trust. Governors are also strongly encouraged to read the papers for the 19 July Board meeting in public, which were circulated on 10 July, and can also be accessed below.

https://www.scas.nhs.uk/public-board-meeting-19-july-2018/

EXECUTIVE SUMMARY / TOP THREE ISSUES FOR BOARD ATTENTION

2 The three areas that I would particularly like to bring to the Governors attention are:

Organisational Development (OD) Strategy – this was due to be presented at the Board meeting in public on 19 July, and the Trust has been extremely active in the last few months in ensuring that we successfully implement a number of the priority initiatives included in the new strategy. In overall terms, the strategy is designed to enable us to deliver our overarching Trust Strategy. It has four themes – to be a Provider of Choice, Employer of Choice, Partner of Choice and to be well led and sustainable.

service delivery – we need to continue to draw on the development of our people, as

referenced above, and our engagement with partners, to ensure that we deliver the best possible patient outcomes for those using SCAS services, be it 999, 111, Integrated Urgent Care (IUC) or Patient Transport Services

Care Quality Commission (CQC) inspections – August will be a busy time for the Trust

with at least two CQC inspections, and we must make sure that we are as prepared as possible prior to the visits and well placed to showcase the great work that SCAS does.

OPERATIONAL PERFORMANCE

NHSI ‘Single Oversight Framework’ 3 We remain in segment 1 (maximum autonomy) under NHSI’s Single Oversight Framework

(SOF) regulatory approach, the highest possible category. Performance on the Ambulance Response Programme (ARP) standards will now be formally taken into account as part of the SOF assessment from September, following a period where Trusts were allowed to focus on embedding the requirements of the programme.

NHS 999 performance 4 The Integrated Performance Report in the July Board meeting in public papers (also

circulated by the Company Secretary on 30 June with a covering Governor briefing note) showed that we successfully achieved five of the six ARP standards in May. This followed an even better month in April with all six targets delivered.

Page 2 of 7

5 Demand for our emergency services has been slightly below plan but we have reacted quickly in terms of the allocation of resources.

6 Hospital delays affect our performance much more dramatically under ARP than they used

to previously. In May we saw a 20% reduction in delays, freeing up resource and supporting us to respond more quickly to incidents. We still lost c840 hours, split almost equally between the North and South of our patch. There is no complacency in our commitment to ensuring that the underlying issues contributing to handover delays are addressed on a sustainable basis, and this remains as one of the biggest risks on our Corporate Risk Register.

7 May’s performance on ARP is shown below, and the Chief Operating Officer will update the

Governors on June performance at the CoG meeting.

Performance Measure – Overall SCAS level

May‐18 Year to date Full year

Actual Plan RAG Actual Plan RAG Forecast Plan RAG

Cat 1 Mean ‐ 7 Minute Target

00:06:53 00:07:00 G 00:06:44 00:07:00 G 00:07:00 00:07:00 G

Cat 1 90th Percentile ‐ 15 Minute Target

00:12:26 00:15:00 G 00:12:09 00:15:00 G 00:12:15 00:15:00 G

Cat 2 Mean ‐ 18 Minute Target

00:15:36 00:18:00 G 00:14:56 00:18:00 G 00:15:15 00:18:00 G

Cat 2 90th Percentile ‐ 40 Minute Target

00:31:20 00:40:00 G 00:29:33 00:40:00 G 00:29:45 00:40:00 G

Cat 3 90th Percentile ‐ 2 Hours

02:01:23 02:00:00 R 01:50:37 02:00:00 G 02:00:00 02:00:00 G

Cat 4 90th Percentile ‐ 3 Hours

02:54:30 03:00:00 G 02:44:12 03:00:00 G 03:00:00 03:00:00 G

Actual Plan RAG Actual Plan RAG Forecast Plan RAG

Thames Valley

Cat 1 Mean ‐ 7 Minute Target North

00:06:46 00:07:00 G 00:06:43 00:07:00 G 00:07:00 00:07:00 G

Cat 1 90th Percentile ‐ 15 Minute Target North

00:12:24 00:15:00 G 00:12:21 00:15:00 G 00:12:15 00:15:00 G

Cat 2 Mean ‐ 18 Minute Target North

00:14:29 00:18:00 G 00:14:13 00:18:00 G 00:15:15 00:18:00 G

Cat 2 90th Percentile ‐ 40 Minute Target North

00:28:37 00:40:00 G 00:27:39 00:40:00 G 00:29:45 00:40:00 G

Cat 3 90th Percentile ‐ 2

01:50:38 02:00:00 G 01:46:32 02:00:00 G 02:00:00 02:00:00 G

Page 3 of 7

Hours North

Cat 4 90th Percentile ‐ 3 Hours North

02:37:57 03:00:00 G 02:40:44 03:00:00 G 03:00:00 03:00:00 G

Hampshire

Cat 1 Mean ‐ 7 Minute Target South

00:07:02 00:07:00 R 00:06:45 00:07:00 G 00:07:00 00:07:00 G

Cat 1 90th Percentile ‐ 15 Minute Target South

00:12:24 00:15:00 G 00:11:39 00:15:00 G 00:12:15 00:15:00 G

Cat 2 Mean ‐ 18 Minute Target South

00:17:06 00:18:00 G 00:15:54 00:18:00 G 00:15:15 00:18:00 G

Cat 2 90th Percentile ‐ 40 Minute Target South

00:35:10 00:40:00 G 00:32:31 00:40:00 G 00:29:45 00:40:00 G

Cat 3 90th Percentile ‐ 2 Hours South

02:12:45 02:00:00 R 01:56:20 02:00:00 G 02:00:00 02:00:00 G

Cat 4 90th Percentile ‐ 3 Hours South

03:23:45 03:00:00 R 02:51:47 03:00:00 G 03:00:00 03:00:00 G

NHS 111 performance 8 NHS111 call answer performance is continuing to improve, following the very challenging

winter period, with 87% of calls answered within the required time during May, compared with the target of 95% (nationally the average performance was 85%). The targets relating to outcomes (i.e. call abandonment, and referrals to an Emergency Department) are better and indeed generally better than the national average. The main priorities for the Senior Management Team continue to be recruitment and retention and sickness absence management.

Patient Transport Service (PTS) performance 9 PTS performance – both in terms of call answer and contractual key performance indicators

- is continuing to improve, with current levels generally the best that we have seen in the last twelve months. This is particularly encouraging given that we are aware that we can improve the efficiency of some of our processes and that we have an exciting transformation programme underway.

QUALITY OF CARE

Care Quality Commission (CQC) inspections - SCAS 10 We have recently been advised of two forthcoming inspections of the Trust by the CQC:

a well-led inspection of the Trust in mid-August. This will particularly focus on the quality of our overall strategic vision, leadership, governance and engagement at the Corporate level.

an inspection of our NHS111 services in early August. This will be undertaken over two days with a focus on both Bicester and Otterbourne clinical co-ordination centres.

Page 4 of 7

11 Both inspections provide a fantastic opportunity to showcase our leadership, our services and the great work of our staff. There is also the potential for a further unannounced inspection of some, or all, of our other services including 999 and PTS.

12 At the time of writing, we are still awaiting details of who the CQC would like to meet for the

well-led inspection on 14-16 August. We know that a focus group meeting was held with a group of Governors in March and it is possible that they would again wish to meet with a selection of Governors.

CQC – Local System Reviews 13 I have made reference previously to the Local System Reviews. The aim of these reviews

is to understand how effectively people and patients move through the health and social care system, with a particular focus on the interfaces between different services.

14 Following the reports that were previously issued for the reviews of Bracknell Forest and

Oxfordshire, a third report, on Hampshire, was published recently1. In terms of the positives, this acknowledged that there is a system-wide commitment to serving the people of Hampshire and that partnership working is improving. A range of improvement areas were identified including:

system leaders must review all service provision to ensure the delivery of more

equitable services across Hampshire the system must streamline discharge processes across Hampshire; this needs to

include timely assessment and provision of equipment to reduce delayed discharges from hospitals

the Health and Well-being Board should consider how to make the system better

coordinated and form stronger links with the two Sustainability and Transformation Partnerships.

system leaders must develop a comprehensive health and social care workforce

strategy for Hampshire in conjunction with the independent sector, and working in partnership with financial, housing and transport strategies.

the, health and social care system, must work with the independent sector, and nursing

home, care home and domiciliary care providers to improve relationships and develop services that meet demand across Hampshire.

a comprehensive communications strategy should be developed to ensure health and

social care staff understand each other’s roles and responsibilities and all agencies are aware of the range of services available across Hampshire.

15 We will continue to work with our partners in Hampshire as part of SCAS contributing to

addressing the various improvement areas. FINANCE AND USE OF RESOURCES

Financial performance 16 After the first two months of the year we remain on track to deliver the 2018/19 budget of a

£764k deficit (which is also the control total we have agreed with NHSI). Achieving a highly challenging annual cost improvement programme of £7.2m will be vital to this and therefore I am pleased that we have succeeded our targets for the first two months of the year, without compromising the quality of our patient services.

1 https://www.cqc.org.uk/sites/default/files/20180618_local_system_review_hampshire.pdf

Page 5 of 7

STRATEGIC CHANGE

SCAS Strategic and Operational Planning 17 As Governors will know we went through a major strategy refresh process last year which

culminated in an updating of our Strategic Plan 2017-2022. We shared the updated plan with Governors and I would also particularly like to highlight a staff and public facing version of the 2018/19 Operating Plan which sets out some of our key priorities for the current year. This can be found at: http://www.scas.nhs.uk/wp-content/uploads/SCAS-plans-for-2018-19.pdf

Integrated Care Systems 18 We continue to be appropriately engaged in all of our local Integrated Care Systems (ICS),

with key Executive Directors, Managers and Non-Executive Directors assigned to help shape and inform our contribution.

19 Any key developments at a system level - such as the CQC local system review of

Hampshire reported earlier in my report – will be brought to the attention of Governors. The informal NED:Governor buddying arrangements also provide an opportunity for Governors to be appropriately kept abreast of progress and key issues.

Global Digital Exemplar (GDE) 20 Governors will be aware that we were successful in our bid to become a GDE. We have

identified eight individual projects as part of our involvement in the programme over the next couple of years, covering:

‘vehicle as hub’ (essentially providing wi-fi capability on ambulances, facilitating inter-

communication between Trust devices and benefiting electronic patient reporting system connectivity)

‘Livelinks’ (using remote links to reduce conveyancing, for example in relation to patient falls)

electronic patient reporting acute interface (using technology to seamlessly transfer

data / service user information to Acute Hospitals)

electronic patient reporting developments (extended use and optimisation of the electronic patient reporting functionality across the SCAS fleet)

business intelligence development (to support outcomes improvement and capacity management, and predictive demand simulation to ensure appropriate resource levels to meet ambulance targets)

IUC (NHS111) and health systems integration (increasing remote review and treatment where clinically appropriate, avoiding unnecessary hospital conveyances)

automation (improving productivity and efficiency, including through further automation of our dispatch processes)

telephony enhancements (enhancing the SCAS telephony application to enable greater connectivity within SCAS and between organisations within the health system).

21 We have now held our first Programme Board meeting and updates on progress will be

reported through to the Board via my Chief Executive’s Report.

Page 6 of 7

LEADERSHIP AND IMPROVEMENT CAPABILITY (WELL-LED)

Organisational Development (OD) Strategy 22 We discussed the key aspects of our new OD Strategy at the last CoG meeting and this,

together with an implementation action plan, was due to be approved at the July Board meeting in public.

23 I have personally identified four main areas of particular focus for the remainder of 2018:

Staff appraisals (take-up and quality) Statutory and mandatory training Health and Well-being Team Leadership Development

24 One of the objectives of the OD Strategy is for SCAS to become an ‘employer of choice’.

As part of this the Executive Team has made four ‘pledges’ directly to staff:

to equip managers with the tools and skills to conduct meaningful appraisals which add value to your working life

to continue to invest in leadership development to provide high quality leadership for you and your teams

to continue to review and improve working practices that better enable you to maintain your health and wellbeing

to create opportunities for you to talk to your senior leaders, encouraging two way communication and feedback.

Staff Awards/Recognition 25 We recently celebrated the 70th birthday of the NHS, and I would like to thank Loretta Light,

Public Governor for Oxfordshire, for taking time to come and address a group of staff at Northern House in Bicester (as well as cut the cake!).

26 I would like to formally acknowledge those members of staff who have completed twenty

years of service in the NHS. The Trust is holding two Long Service Award events to mark the occasion; the first took place on 2 July and the second will be held on 24 September. Again, thank you to Tony Nicholson and Chas McGill (Public Governors for Hampshire) for attending the 2 July event.

27 I would also like to pay tribute to Mike Jukes, a community first responder (CFR) in

Bransgore. Mike has been a CFR since 2005 and has been recognised in this year’s Queen’s Birthday Honours List, with a British Empire Medal for Services to Emergency Response and Fundraising.

CONCLUSIONS

28 The Trust has made a very good start to the new financial year, and I would like to pay

tribute to the hard work, commitment and dedication shown by our staff and volunteers. Lead Director: Will Hancock, Chief Executive Author: Steve Garside, Company Secretary Date: 11 July 2018

Page 7 of 7

GLOSSARY FOR ARP PERFORMANCE STANDARDS

Category 1: Time critical life-threatening event needing immediate intervention and/or

resuscitation Category 2: Potentially serious conditions that may require rapid assessment, urgent on-

scene intervention, and/or urgent transport Category 3: Urgent problem that needs treatment to relieve suffering and transport or

assessment and management at scene with referral where needed within a clinically appropriate timeframe.

Category 4: Problems that are not urgent but need assessment (face to face or telephone)

and possibly transport within a clinically appropriate timeframe. 999 or 111 calls that may require a face to face ambulance clinician assessment.

ENCLOSURE F

ANNUAL ACCOUNTS AND ANNUAL REPORT 2018/19 INCLUDING AUDITORS REPORTS

Enclosure F




Title of Paper: Annual Accounts and Annual Report 2017/18 including Auditors’Reports

Presented by: Mike Hawker (Audit Committee Chair), Professor Helen Young(Director of Patient Care), Ellen Millington (Manager, Grant Thornton)


Receive and discuss

Main Aim: To receive the 2017/18 Annual Report and Accounts, andassociated auditors reports, in accordance with the governors’ statutory duties

To receive and consider the outcomes of the audit of the governorselected quality indicator


A link is provided to the 2017/18 Annual Report, which contains theAnnual Accounts, and the two audit reports from the external auditors,Grant Thornton. http://www.scas.nhs.uk/wp-content/uploads/SCAS-Annual-Report-2017-18-dps.pdf A report is also included from Grant Thornton; this covers the outcomes of their audit of the governor selected quality indicator onsepsis.


Receive

Previous Forum: Annually, every July


Yes



Page 1 of 2


ENCLOSURE F

ANNUAL ACCOUNTS AND ANNUAL REPORT 2017/18 INCLUDING AUDITORS’ REPORTS

BACKGROUND

1 The statutory duties of the governors include to “receive the Foundation Trust’s

annual accounts and annual report, and any report of the auditors on them” at a meeting of the Council of Governors (CoG).

2 The meeting of the CoG “should be convened within a reasonable timescale

after the end of the financial year but must not be before the annual report and accounts have been laid before Parliament”.

3 SCAS’ annual report and accounts for 2017/18 were laid before Parliament at

the end of June. ANNUAL REPORT AND ACCOUNTS 2017/18

4 Following the external audit process applied by Grant Thornton, and

consideration by the Trust’s Audit Committee, the SCAS Board approved the 2017/18 Annual Report and Accounts at its Board meeting in public on 24 May 2018.

5 The Annual Report submitted to NHS Improvement and subsequently laid before

Parliament includes the Annual Accounts and Annual Quality Report. A version can be accessed through the following link:

http://www.scas.nhs.uk/wp-content/uploads/SCAS-Annual-Report-2017-18-dps.pdf

REPORTS OF THE AUDITORS 6 There are two reports from the auditors, Grant Thornton, which are addressed

for the attention of the Council of Governors – a report on the audit of the financial statements, and a report on the audit of the Quality Report.

7 The two reports can be seen in the Annual Report (see link above) on pages

numbered 258 and 262 respectively. Both are ‘clean’ audit reports and report no adverse issues.

GOVERNOR SELECTED LOCAL QUALITY INDICATOR

8 In a process earlier in the year, the governors selected “to improve the

recognition of Sepsis in adults” as the local quality indicator for external audit review.

Page 2 of 2

9 The report from Grant Thornton on the outcomes of their review of the governor selected local quality indicator is attached.

10 Representatives from Grant Thornton will be in attendance at the meeting on 24

July to discuss their findings. RECOMMENDATIONS

11 The CoG is asked to:

receive the 2017/18 Annual Report, containing the Annual Accounts and Annual Quality Report, and the two audit reports from the External Auditors

note that the Annual Report, containing the Annual Accounts and Annual

Quality Report, will be presented at the Annual General Meeting on 27 September 2018 in Buckinghamshire.

consider the attached report from the external auditors, Grant Thornton,

including the outcomes of their review of the governor selected quality indicator (recognition of Sepsis in adults).

Steve Garside Company Secretary July 2018

© 2018 Grant Thornton UK LLP | Report to the Governors on the Quality Report for South Central Ambulance Service NHS Foundation Trust | 2017/18

Report to the Governors on the

Quality ReportYear ending 31 March 2018

South Central Ambulance Service NHS Foundation Trust

24 May 2018

© 2018 Grant Thornton UK LLP | Report to the Governors on the Quality Report for South Central Ambulance Service NHS Foundation Trust | 2017/18 2

Contents

Section Page

1. Headlines 3

2. Compliance with regulations 3

3. Consistency of information 4

4. Data quality of reported performance indicators 5

5. Fees 8

Appendices

A. Form of limited assurance report

The contents of this report relate only to those matters which came to our attention during the conduct of our normal audit procedures which are designed for the purpose of expressing

our opinion on the financial statements. Our audit is not designed to test all internal controls or identify all areas of control weakness. However, where, as part of our testing, we identify

control weaknesses, we will report these to you. In consequence, our work cannot be relied upon to disclose all defalcations or other irregularities, or to include all possible improvements

in internal control that a more extensive special examination might identify. This report has been prepared solely for your benefit and should not be quoted in whole or in part without our

prior written consent. We do not accept any responsibility for any loss occasioned to any third party acting, or refraining from acting on the basis of the content of this report, as this report

was not prepared for, nor intended for, any other purpose.

Grant Thornton UK LLP is a limited liability partnership registered in England and Wales: No.OC307742. Registered office: 30 Finsbury Square, London, EC2A 1AG. A list of members

is available from our registered office. Grant Thornton UK LLP is authorised and regulated by the Financial Conduct Authority. Grant Thornton UK LLP is a member firm of Grant

Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. Services are delivered by the member firms. GTIL and its member firms are not agents

of, and do not obligate, one another and are not liable for one another’s acts or omissions.

Your key Grant Thornton

team members are:

Paul Grady

Engagement Lead

T: 020 7728 3219

E: [email protected]

Ellen Millington

Audit Manager

T: 020 7728 3379

E: [email protected]


HeadlinesThe Quality Report

The Quality Report is a mandatory part of a foundation trust’s Annual Report. Its specific

aim is to encourage and improve the foundation trust’s public accountability for the quality

of the care it provides. It allows leaders, clinicians, governors and staff to show their

commitment to continuous, evidence-based quality improvement, and to explain progress

to the public.

Purpose of this report

This report to governors summarises the results of our independent assurance

engagement on your Quality Report. It is issued in conjunction with our signed limited

assurance report, which is published within the Quality Report section of your Annual

Report for the year ended 31 March 2018.

In addition, this report provides the findings of our work on the indicator you selected for us

to perform additional substantive testing on to support your governance responsibilities.

In performing this work, we followed NHS Improvement's 'Detailed requirements for

external assurance for quality reports 2017/18' ('Guidance').

The output from our work is a limited assurance opinion on whether anything has come to

our attention which leads us to believe that:

• the Quality Report is not prepared, in all material respects, in line with the criteria set

out in the ‘NHS foundation trust annual reporting manual 2017/18’ and supporting

guidance;

• the Quality Report is not consistent, in all material respects, with the sources specified

in NHS Improvement's 'Detailed requirements for external assurance for quality reports

2017/18’; and

• the indicators in the Quality Report identified as having been the subject of limited

assurance in the Quality Report have not been reasonably stated, in all material

respects, in accordance with the ‘NHS foundation trust annual reporting manual

2017/18’ and supporting guidance.

Conclusion

Our work on your Quality Report is substantially complete although we are finalising our

procedures in respect of:

• obtaining a letter of representation from management

Subject to this, we are proposing to issue an unqualified opinion on your Quality Report.

The text of our proposed limited assurance report can be found at Appendix C.

Key messages

• We confirm that the Quality Report has been prepared in all material respects in line

with the requirements of the ‘NHS foundation trust annual reporting manual 2017/18’

and supporting guidance.

• We confirm that the Quality Report is not materially inconsistent with the sources

specified in NHS Improvement's Guidance.

• Our testing of two indicators included in the Quality Report found no evidence that

these two indicators were not reasonably stated, in all material respects, in accordance

with the ‘NHS foundation trust annual reporting manual 2017/18’ and supporting

guidance.

• Our testing of the indicator selected by the governors found no evidence that this

indicator was not reasonably stated, in all material respects, in accordance with

relevant guidelines on calculation. In line with NHS Improvement's Guidance, we do not

express any assurance in respect of this indicator.

Acknowledgements

We would like to thank the Trust staff for their co-operation in completing this engagement.


Compliance with regulations

We checked that the Quality Report had been prepared in line with the requirements set out in the ‘NHS foundation trust annual reporting manual 2017/18 and supporting

guidance.

Compliance with regulations and Consistency of information

Requirement Work performed Conclusion

Compliance with regulations We reviewed the content of the Quality Report against the

requirements of the ‘NHS foundation trust annual reporting manual

2017/18’ and the supporting guidance ‘Detailed requirements for quality

reports for foundation trusts 2017/18‘.

Based on the results of our procedures, nothing has come to our

attention that causes us to believe that, for the year ended 31 March

2018, the Quality Report is not prepared, in all material respects, in line

with the criteria set out in the NHS foundation trust annual reporting

manual 2017/18 and supporting guidance.

Consistency of information

We checked that the Quality Report had been prepared in line with the requirements set out in the ‘NHS foundation trust annual reporting manual 2017/18 and supporting

guidance.

Requirement Work performed Conclusion

Consistency with other

sources of information

We reviewed the content of the Quality Report for consistency with

specified documentation, set out in the auditor's guidance provided by

NHS Improvement. This includes the board minutes and papers for the

year, feedback received on the Quality Report, survey results from staff

and patients and the Head of Internal Audit opinion.

Based on the results of our procedures, nothing has come to our

attention that causes us to believe that, for the year ended 31 March

2018, the Quality Report is not consistent, in all material respects, with

the sources specified in NHS Improvement’s 'Detailed requirements for

external assurance for quality reports 2017/18'.

Other checks We also checked the Quality Report to ensure that the Trust's process

for identifying and engaging stakeholders in the preparation of the

Quality Report has resulted in appropriate consultation with patients,

governors, commissioners, regulators and any other key stakeholders.

Overall, we concluded that the process has resulted in appropriate

consultation.


Data quality of reported performance indicatorsWe undertook substantive testing on certain indicators in the Quality Report.

Selecting performance indicators for review

The Trust is required to obtain assurance from its auditors over three indicators.

NHS Improvement requires that we select two indicators from a list of three mandated indicators that are relevant to this Trust.

These two indicators are subject to a limited assurance opinion in line with the requirements set by NHS Improvement. We have to report on whether there is evidence to suggest that they have not been reasonably stated in all material respects in accordance with the ‘NHS foundation trust annual reporting manual 2017/18’ and supporting guidance.

In line with the auditor guidance, we have reviewed the following indicators: • Category 1 (C1) – Life-threatening calls – the mean average response time across all incidents coded as C1 that received a response on scene; and• Category 2 (C2) – Emergency calls – the mean average response time across all incidents coded as C2 that received a response on scene.

These indicators were selected from the subset of mandated indicators following discussion with the Assistant Director of Quality and Patient Care. These were considered to be the mostuseful indicators for us to test given that this was the first year that response times had been reported under the new Ambulance Response Programme (ARP) indicators.

In 2017/18, NHS foundation trusts also need to obtain assurance through substantive sample testing over one additional local indicator included in the Quality Report, selected by the governors of the Trust. Although the Trust’s external auditors are required to undertake the work, this indicator does not form part of the limited assurance report.

In line with the auditor guidance, we have reviewed the following local indicator: • To improve the recognition of sepsis in adults.

Data quality of reported performance indicators


Data quality of reported performance indicators – Indicators subject to limited assurance report


Indicator & Definition Indicator outcome Work performed Conclusion

Category 1 (C1) – Life-threatening calls

– the mean average response time

across all incidents coded as C1 that

received a response on scene.

The target mean average response time

is 7 minutes or less for this category of

call.

7:19 minutes We documented and walked through the process used to

collect data for the indicator. We checked that the indicator

presented in the Quality Report reconciled to the underlying

data.

We then tested a sample of 25 items in order to ascertain the

accuracy, completeness, timeliness, validity, relevance and

reliability of the data, and whether the calculation of the

indicator was in accordance with the definition.

Completeness and timeliness are not considered to be risks in

relation to this indicator as the data is recorded automatically in

real-time by the Computer-Aided Despatch (CAD) system. All

calls are categorised upon being answered and are

automatically recorded by the CAD system.

No reliance has been placed on the work of internal audit in

relation to the testing of this indicator.

Based on the results of our procedures,

nothing has come to our attention that causes

us to believe that, for the year ended 31 March

2018, the indicator has not been reasonably

stated in all material respects in accordance

with the ‘NHS foundation trust annual reporting

manual 2017/18’ and supporting guidance.

Category 2 (C2) – Emergency calls – the

mean average response time across all

incidents coded as C2 that received a

response on scene.

The target mean average response time

is 18 minutes or less for this category of

call.

17:24 minutes We documented and walked through the process used to

collect data for the indicator. We checked that the indicator

presented in the Quality Report reconciled to the underlying

data.

We then tested a sample of 25 items in order to ascertain the

accuracy, completeness, timeliness, validity, relevance and

reliability of the data, and whether the calculation of the

indicator was in accordance with the definition.

Completeness and timeliness are not considered to be risks in

relation to this indicator as the data is recorded automatically in

real-time by the Computer-Aided Despatch (CAD) system. All

calls are categorised upon being answered and are

automatically recorded by the CAD system.

No reliance has been placed on the work of internal audit in

relation to the testing of this indicator.

Based on the results of our procedures,

nothing has come to our attention that causes

us to believe that, for the year ended 31 March

2018, the indicator has not been reasonably

stated in all material respects in accordance

with the ‘NHS foundation trust annual reporting

manual 2017/18’ and supporting guidance.


Data quality of reported performance indicators – Local indicator not subject to limited assurance report


Indicator & Definition Indicator outcome Work performed Conclusion

To improve the recognition of sepsis in

adults.

You identified improving recognition of

sepsis in adults in your 2016/17 Quality

Report as one of your key priorities for

2017/18.

You selected this area to be subject to

audit in your Council of Governors

meeting in December 2017.

There is no nationally-defined indicator in

relation to this priority, but you had

implemented new processes in-year for

recording data in relation to adult

patients presenting with a primary

condition of sepsis and calculating a

National Early Warning System (NEWS)

score.

You asked us to verify through sample-

testing that data supporting your

conclusion that you had met your key

priority had been recorded correctly.

In line with the requirements of NHS

Improvement’s Guidance, this indicator

is not subject to a limited assurance

opinion. We do not provide the

governors with any formal assurance in

relation to whether this indicator is fairly

stated.

You have reported that you

have met your key priority of

improving recognition of

sepsis in adults.

We documented and walked through the process

used by the Trust to collect data for the indicator.

We checked that the indicator presented in the

Quality Report reconciled to the underlying data.

We then tested a sample of 25 items in order to

ascertain the accuracy, completeness, timeliness,

validity, relevance and reliability of the data.

We reviewed data that had not been included in

the indicator and concluded that this had been

appropriately excluded – for instance if the

patients were under 18 or the primary condition

was not sepsis.

Timeliness is not considered to be a risk in

relation to this indicator since the data is recorded

in real time on the CAD system to ensure that

appropriate responses are put in place.

Based on the results of our procedures we did not

identify any material issues in relation to the

calculation of this indicator or the six dimensions

of data quality.


Fees

Fees, non audit services and independence

Fees for our work on the Quality Report

We confirm below our final fees charged for this work.

Proposed fee Final fee

Assurance on your Quality Report Included within our overall audit fee of £41,900


Form of limited assurance reportIndependent Practitioner's Limited Assurance Report to the Council of

Governors of South Central Ambulance Service NHS Foundation Trust on the

Quality Report

We have been engaged by the Council of Governors of South Central Ambulance

Service NHS Foundation Trust to perform an independent limited assurance

engagement in respect of South Central Ambulance Service NHS Foundation Trust’s

Quality Report for the year ended 31 March 2018 (the “Quality Report”) and certain

performance indicators contained therein against the criteria set out in the ‘NHS

foundation trust annual reporting manual 2017/18’ and additional supporting guidance

in the ‘Detailed requirements for quality reports 2017/18' (the 'Criteria').

Scope and subject matter

The indicators for the year ended 31 March 2018 subject to the limited assurance

engagement consist of the national priority indicators as mandated by NHS

Improvement:

• Category 1 calls – mean response time of 7 minutes; 90th percentile response time of

15 minutes; and

• Category 2 calls – mean response time of 18 minutes; 90th percentile response time

of 40 minutes.

We refer to these national priority indicators collectively as the 'Indicators'.

Respective responsibilities of the directors and Practitioner

The directors are responsible for the content and the preparation of the Quality Report

in accordance with the criteria set out in the 'NHS foundation trust annual reporting

manual 2017/18' and supporting guidance issued by NHS Improvement.

Our responsibility is to form a conclusion, based on limited assurance procedures, on

whether anything has come to our attention that causes us to believe that:

• the Quality Report is not prepared in all material respects in line with the Criteria set


guidance;

• the Quality Report is not consistent in all material respects with the sources

specified in NHS Improvement’s 'Detailed requirements for external assurance for

quality reports 2017/18’; and

• the indicators in the Quality Report identified as having been the subject of limited

assurance in the Quality Report are not reasonably stated in all material respects in

accordance with the 'NHS foundation trust annual reporting manual 2017/18' and

supporting guidance and the six dimensions of data quality set out in the ‘'Detailed

requirements for external assurance for quality reports 2017/18’.

We read the Quality Report and consider whether it addresses the content requirements

of the ‘NHS foundation trust annual reporting manual 2017/18’ and supporting

guidance, and consider the implications for our report if we become aware of any

material omissions.

We read the other information contained in the Quality Report and consider whether it

is materially inconsistent with:

• Board minutes for the period 1 April 2017 to 25 May 2018;

• papers relating to quality reported to the Board over the period 1 April 2017 to 25

May 2018;

• feedback from commissioners dated 02/05/2018;

• feedback from governors dated 11/01/2018;

• feedback from local Healthwatch organisations dated 08/05/2018;

• feedback from the Overview and Scrutiny Committee dated 09/05/2018;

• the Trust’s complaints report published under regulation 18 of the Local Authority

Social Services and National Health Service Complaints (England) Regulations

2009, dated 17/05/2018;

• the national staff survey dated 06/03/2018;

• the Care Quality Commission inspection report dated 20/09/2016;

• the Head of Internal Audit’s annual opinion over the Trust’s control environment

dated 19/04/2018; and

We consider the implications for our report if we become aware of any apparent

misstatements or material inconsistencies with those documents (collectively, the

“documents”). Our responsibilities do not extend to any other information.

The firm applies International Standard on Quality Control 1 (Revised) and accordingly

maintains a comprehensive system of quality control including documented policies and

procedures regarding compliance with ethical requirements, professional standards and

Appendix A


applicable legal and regulatory requirements.

We are in compliance with the applicable independence and competency requirements

of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of

Ethics. Our team comprised assurance practitioners and relevant subject matter

experts.

This report, including the conclusion, has been prepared solely for the Council of

Governors of South Central Ambulance Service NHS Foundation Trust as a body, to

assist the Council of Governors in reporting South Central Ambulance Service NHS

Foundation Trust’s quality agenda, performance and activities. We permit the

disclosure of this report within the Annual Report for the year ended 31 March 2018,

to enable the Council of Governors to demonstrate they have discharged their

governance responsibilities by commissioning an independent assurance report in

connection with the indicators. To the fullest extent permitted by law, we do not accept

or assume responsibility to anyone other than the Council of Governors as a body, and

South Central Ambulance Service NHS Foundation Trust for our work or this report,

except where terms are expressly agreed and with our prior consent in writing.

Assurance work performed

We conducted this limited assurance engagement in accordance with International

Standard on Assurance Engagements 3000 (Revised) ‘Assurance Engagements other

than Audits or Reviews of Historical Financial Information’ issued by the International

Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance

procedures included:

• evaluating the design and implementation of the key processes and controls for

managing and reporting the indicators

• making enquiries of management

• limited testing, on a selective basis, of the data used to calculate the indicators tested

against supporting documentation

• comparing the content requirements of the 'NHS foundation trust annual reporting

manual 2017/18' and supporting guidance to the categories reported in the Quality

Report; and

• reading the documents.

A limited assurance engagement is smaller in scope than a reasonable assurance

engagement. The nature, timing and extent of procedures for gathering sufficient

appropriate evidence are deliberately limited relative to a reasonable assurance

engagement.

Limitations

Non-financial performance information is subject to more inherent limitations than

financial information, given the characteristics of the subject matter and the methods

used for determining such information.

The absence of a significant body of established practice on which to draw allows for the

selection of different, but acceptable, measurement techniques that can result in

materially different measurements and can affect comparability. The precision of

different measurement techniques may also vary. Furthermore, the nature and methods

used to determine such information, as well as the measurement criteria and the

precision of these criteria, may change over time. It is important to read the Quality

Report in the context of the criteria set out in the 'NHS foundation trust annual

reporting manual 2017/18' and supporting guidance.

The scope of our limited assurance work has not included governance over quality or

non-mandated indicators, which have been determined locally by South Central

Ambulance Service NHS Foundation Trust.

Our audit work on the financial statements of South Central Ambulance Service NHS

Foundation Trust is carried out in accordance with our statutory obligations. This

engagement will not be treated as having any effect on our separate duties and

responsibilities as South Central Ambulance Service NHS Foundation Trust’s external

auditors. Our audit reports on the financial statements are made solely to South Central

Ambulance Service NHS Foundation Trust's members, as a body, in accordance with

paragraph 24(5) of Schedule 7 of the National Health Service Act 2006. Our audit work

is undertaken so that we might state to South Central Ambulance Service NHS

Foundation Trust’s members those matters we are required to state to them in an

auditor’s report and for no other purpose. Our audits of South Central Ambulance

Service NHS Foundation Trust’s financial statements are not planned or conducted to

address or reflect matters in which anyone other than such members as a body may be

interested for such purpose. In these circumstances, to the fullest extent permitted by

law, we do not accept or assume any responsibility to anyone other than South Central

Ambulance Service NHS Foundation Trust and South Central Ambulance Service NHS

Foundation Trust’s members as a body, for our audit work, for our audit reports, or for

the opinions we have formed in respect of those audits.

Appendix A


Conclusion

Based on the results of our procedures, as described in this report, nothing has come to

our attention that causes us to believe that, for the year ended 31 March 2018:

• the Quality Report is not prepared in all material respects in line with the Criteria set


guidance;

• the Quality Report is not consistent in all material respects with the sources

specified in NHS Improvement’s 'Detailed requirements for external assurance for

quality reports 2017/18’; and

• the indicators in the Quality Report identified as having been subject to limited

assurance have not been reasonably stated in all material respects in accordance with

the 'NHS foundation trust annual reporting manual 2017/18' and supporting

guidance.

[Signature] – to be added

Grant Thornton UK LLP

Chartered Accountants

30 Finsbury Square

London

EC2A 1AG

[Date] – to be added

Appendix A

© 2018 Grant Thornton UK LLP | Report to the Governors on the Quality Report for South Central Ambulance Service NHS Foundation Trust | 2017/18

© 2018 Grant Thornton UK LLP. All rights reserved.

‘Grant Thornton’ refers to the brand under which the Grant Thornton member firms provide assurance, tax and advisory services to their clients and/or refers to one or more member

firms, as the context requires.

Grant Thornton UK LLP is a member firm of Grant Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. GTIL and each member firm is a

separate legal entity. Services are delivered by the member firms. GTIL does not provide services to clients. GTIL and its member firms are not agents of, and do not obligate, one

another and are not liable for one another’s acts or omissions.

grantthornton.co.uk

ENCLOSURE G

NON-EXECUTIVE DIRECTOR ACTIVITIES

Enclosure G




Title of Paper: Non-Executive Director Activities

Presented by: Priya Singh, Non-Executive Director


Discussion

Main Aim: To help governors develop a greater understanding of the activities undertaken by the Non-Executive Directors, and the outcomes that result from this in terms of the NED “holding to account” role


Today’s presentation is from Priya Singh, who will take any questions from the governors


Note

Previous Forum: April 2018 (standing agenda item)


N/A



Enclosure GUpdate on NED Activities

Priya Singh, Non-Executive Director

Q1 2018/19

Council of Governors Meeting – 24 July 2018

Purpose of this item:

• To highlight some of the activities undertaken by a particular NED in the last 2‐3 months

• To explain the outcomes that have resulted from these NED activities, including assurance / added value

• To help develop governors’ understanding of the role of the NED

• To take questions from the governors

2

Induction

I was appointed by the CoG and my term of office commenced on 1 April 2018. As part of a comprehensive induction programme I have:

• Held introductory meetings with the Chair, Executive Directors, CompanySecretary, and Equality and Diversity Manager

• Held a further meeting with the Director of HR and OD to understand theTrust’s Freedom to Speak Up arrangements (as part of my NED portfolio role)

• Met with the Trust’s other Non‐Executive Directors

• Visited the Emergency Operations Centre (999 and 111)

• Participated in a 999 crew ride‐out

• Attended both Board (29 March) and CoG (7 February) meetings prior toofficially starting

Selection of Q1 activities undertaken by Priya Singh:

3

Selection of Q1 activities undertaken by Priya Singh – cont’d:Board, Board committee and CoG meetings• Attended 26 April Board Seminar, which focused on a range of strategic

items, including:• an overview of Emergency Preparedness, Resilience and Response (EPRR) arrangements

(inc. Manchester terrorist attack learning)

• preparation for a Care Quality Commission inspection, and

• an update on development of the Trust’s Organisational Development Strategy

• Attended 28 June Board Seminar, which focused on:• the Trust’s approach to risk management and risk assurance

• further CQC inspection preparation, and

• the longer‐term SCAS estates strategy

3

Selection of Q1 activities undertaken by Priya Singh – cont’d:Board, Board committee and CoG meetings cont’d• Attended 19 April Audit Committee meeting

• Attended 4 May Audit Committee meeting (review of 2017/18 AnnualAccounts)

• Attended 28 June Quality and Safety Committee meeting

• Attended 16 April CoG meeting (as an observer)

• Attended 5 June CoG/Board workshop – “Being a Well‐Led Council ofGovernors”

Others• Attended NHS Providers NEDs Networking Meeting on 20 April

3

ENCLOSURE H

COMPANY SECRETARY’S REPORT

Enclosure H




Title of Paper: Company Secretary’s Report

Presented by: Steve Garside, Company Secretary


Information

Main Aim: To update the Governors on a range of matters


The report covers: progress with implementation of the CoG Development

Action Plan progress taking forward the discussions regarding future

representation on the CoG an update on SCAS’ nomination for representation on the

NHS Providers’ Governor Advisory Committee the outcomes of the consultation over the NHS

Improvement Board declarations updated Non-Executive Director portfolios and Governor

buddying arrangements communications since the last meeting.


To note and consider the report

Previous Forum: April 2018


Yes



Page 1 of 8


ENCLOSURE H

COMPANY SECRETARY’S REPORT

PURPOSE

1 The purpose of the report is to:

present an update on progress with implementation of the CoG Development Action Plan

present an update on progress taking forward the discussions regarding future representation on the CoG

provide an update on SCAS’ nomination for representation on the NHS Providers’ Governor Advisory Committee

advise on the outcomes of the consultation over the NHS Improvement Board declarations

acknowledge the updated Non-Executive Director portfolios and Governor buddying arrangements

highlight communications since the last meeting. CoG DEVELOPMENT ACTION PLAN

2 The CoG approved a Development Action Plan at the January meeting. An update on

progress implementing the seven recommendations is presented at Appendix A. 3 The plan needs to be updated to reflect the CoG development programme which began

with the joint CoG/Board working meeting on 5 June. The earlier paper on the agenda is relevant to this. In the meantime I am asking Governors to:

recommendation 2 - contact me if they would like to observe a meeting of one of the

Board’s committees (Audit, Quality and Safety, Charitable Funds) and/or participate in a crew ride-out or call centre visit

recommendation 5 - highlight to me if there are topics – relevant to the Governor role –

which they feel may benefit from an additional briefing session/workshop GOVERNOR REPRESENTATION

4 I am taking forward the arrangements for establishing a new Community First Responder

(CFR) Governor role on the SCAS CoG. Work has started on developing a role outline and considering the process required for making such an appointment (this is likely to require the support of an external, independent electoral services provider). The intention is to elect a Governor in late 2018 with the term of office commencing on 1 March 2019 (i.e. to align with the terms of office for elected public and staff governors).

5 It was agreed that we would continue to explore further opportunities to have representation

from the mental health sector, and from younger people, on the SCAS CoG. I have carried out some further research and intend to reconvene the Task and Finish Group in due course to give this further consideration.

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NHS PROVIDERS GOVERNOR ADVISORY COMMITTEE

6 As Governors will be aware, the SCAS nomination for the position of Ambulance sector

representative on NHS Providers’ (NHSP) Governor Advisory Committee was Colin Godbold.

7 Sadly Colin was not successful, as the existing member - Robert Alabaster from North East

Ambulance Service – was re-elected. I have used this as an opportunity to send our congratulations to Robert and confirm that we would be keen to input prior to meetings and also receive details of the outcomes of meetings. In this respect, I circulated to SCAS Governors on 5 June a report Robert produced following the GAC meeting on 18 May.

NHS IMPROVEMENT BOARD DECLARATIONS

8 I would like to thank Governors for their comments on three declarations that the Board was

required by NHS Improvement to consider, approve and publish. The declarations covered:

compliance with the Trust’s provider license the training of Governors corporate governance arrangements

9 The Board was required to consider and approve the declarations “having regard to the

views of Governors”. I received positive responses from Governors on all three declarations; in response to feedback on the training of Governors declaration, we have taken further subsequent action by rolling out the revised NED:Governor buddying arrangements and also by inviting the more established Governors (i.e. those who had not gone through a recent induction programme) to have an Emergency Operations Centre visit and/or participate in a crew ride-out.

10 The three declarations were published in the May and July Board meeting in public papers. NON-EXECUTIVE DIRECTOR PORTFOLIOS AND GOVERNOR BUDDYING

11 In May I circulated details of the refreshed informal NED:Governor buddying arrangements.

Reflecting the current focus on local care systems, and our discussions at the February Strategy Workshop, each Governor has been assigned to the NED (or NEDs in the case of Buckinghamshire) who leads on the NED stakeholder engagement in their particular geography.

12 The buddying scheme is an informal arrangement – best served through discussions when

the NED and Governor are both in attendance at a Board or CoG meeting - and might cover the following scenarios as an example:

an opportunity for NEDs to update Governors on key issues in their specific local care

system an occasional conversation where, following attendance at a public Board meeting, a

Governor wishes to understand a bit more about decision-making processes and how a NED gained assurance over a particular issue

an opportunity for a Governor to join a NED on a station walkabout; again, to help develop an understanding of what a NED is looking for

where a governor may like a NEDs perspective on issues that have been raised by the governor’s constituency during engagement activity

13 NEDs have also been allocated with some additional portfolio areas for them to

champion/seek further assurance from the Executive Directors. These will also provide Governors with an opportunity to discuss a particular issue (relevant to the Governor role) with a NED if the Governor feels that they may have a gap in knowledge or assurance.

14 Appendix B provides a reminder of the allocations.

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COMMUNICATIONS SINCE THE PREVIOUS MEETING ON 16 APRIL 2018

15 Since the papers were issued for the previous meeting on 16 April the Company Secretariat

has communicated with the CoG on a range of issues, including the following:

Date Communication

25 April Circulated copy of Chief Executive’s letter to all staff – “Working together to achieve our ambition to become world class”

1 May Circulated the latest (M12) Integrated Performance Report (with briefing)

2 May Circulated minutes of 16 April CoG meeting in public 4 May Circulated a link to CQCs report following the inspection of

Portsmouth Hospitals NHS Trust 14 May Circulated details of the refreshed NED:Governor informal

buddying scheme 17 May Circulated details of updated NED portfolios and areas of

special interest 18 May Launched Governor feedback survey, aimed at informing the

planning of the 5 June CoG/Board workshop 18 May Circulated papers for the 24 May Board meeting in public 1 June Circulated minutes of 24 May Board meeting in public 5 June (a) Advised on the outcomes of NHS Providers’ election to the

Governor Advisory Committee 5 June (b) Circulated a report from the Ambulance Sector representative

on the Governor Advisory Committee 5 June Circulated a briefing on changes to the working of NHS

Improvement and NHS England 30 June Circulated the latest (M2) Integrated Performance Report (with

briefing) 26 June Circulated latest Governor Focus bulletin issued by NHS

Providers. 27 June Circulated agenda for the 24 July CoG meeting in public, having

agreed this with the Lead Governor 11 July Advised of two CQC inspections in August – well-led and

NHS111 10 July Circulated papers for the 19 July Board meeting in public 11 July Circulated briefing from NHS Providers on the appointment of a

new Secretary of State for Health and Social Care Various - media Highlighted media coverage including in relation to:

performance in Buckinghamshire performance in Andover lifesaving paramedics Portsmouth Hospitals NHS Trust CQC report

RECOMMENDATIONS TO THE COUNCIL OF GOVERNORS 16 The Council of Governors is asked to note the report. Steve Garside Company Secretary 12 July 2018

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APPENDIX A – COUNCIL OF GOVERNORS DEVELOPMENT ACTION PLAN – UPDATE ON ACTIONS (AS AT 5 JULY 2018)

Previously presented at 11 January and 16 April 2018 CoG Meetings

Area Agreed actions Status as at 5 July 2018

Governor understanding of the Governor role Governor role is prescribed in the

Monitor “Your Statutory Duties” document

SCAS reinforces role through induction and meeting agendas/papers

Main challenge for Governors is framing questions appropriately (i.e. within the context of the Governor’s duties) and avoiding straying into operational detail.

1. A workshop should be convened to support Governors in formulating appropriate questions within the context of their role and duties. Key/topical issues could be used as practical examples to work through in shaping questions. Consideration could be given to external support/facilitation (e.g. NHS Providers).

Action in hand/ongoing This will, in part, be covered by the CoG/Board workshop on 5 June. Additionally, the Induction Event for new Governors on 11 January included a session on how to frame appropriate questions within the context of the Governor role. Consideration is being given to extending this session for other Governors.

Governor understanding of SCAS and the NED role Mechanisms are in place to support

Governors understanding of SCAS and the NED role, including through induction, buddying arrangements, presence of NEDs at meetings, opportunities to participate in EOC visits, ride-outs etc.

2. SCAS will extend its arrangements to allow each Governor the opportunity to attend one of the following meetings each year as an observer in order to further develop an understanding of the NED role:

o Audit Committee o Quality and Safety Committee o Charitable Funds Committee

Action completed/ongoing SCAS has invited all Governors to attend a meeting of one of its Board committees. At the time of writing seven Governors have taken up this invitation and have either already attended a meeting or will do so in the near future. Those who have already attended are: Richard Coates (Charitable Funds), Loretta Light (Charitable Funds) and Colin Godbold (Quality and Safety).

Meeting effectiveness Feedback is sought and considered

after each meeting of the CoG Very positive feedback was received

about the previous meeting on 4 October (continue to assess on a meeting by meeting basis)

Little evidence that questions raised/comments made by Governors

3. The Membership and Engagement Committee to continue to explore opportunities for effective member/public engagement, and to make recommendations to the full CoG as appropriate.

Action ongoing This continues to be an area of focus for the Membership and Engagement Committee.

Page 5 of 8

at CoG meetings arise out of engagement with Trust members and members of the public.

General communication outside of meetings General communication outside of

meetings is considered to be good and keeps Governors suitably up-to-date

Forewarning of possible high-profile media coverage is greatly valued

Communication (including ‘for information’ purposes) can sometimes give rise to a high volume of questions from Governors to the Company Secretary (see below).

N/A N/A

Process for questions outside of meetings Governors have, on average, a

monthly formal opportunity to ask questions of the NEDs (e.g. CoG and Board meetings) and this way such questions, and their answers, can be documented formally to demonstrate the Trust’s governance system

It is also acknowledged that, from time to time, a question may require an answer outside of the cycle of meetings. Governors need to communicate all questions through the

4. The Company Secretary to develop a short protocol/guidance notes to cover the process of Governors raising, and receiving answers to, questions.

Action outstanding This will be developed in the coming weeks.

Page 6 of 8

Company Secretary so that they can be properly recorded and addressed; questions need to be relevant to the Governor role and not stray into management/operational territory

Given constraints over the time available at CoG meetings (impacted by the size of the CoG, and the important and broad agenda to be delivered), additional briefing sessions could be arranged where Governors consider that they need further information in order to be able to deliver their roles

5. Governors to highlight to the Company Secretary whether there are topics – relevant to the Governor role – which may benefit from an additional briefing session/workshop.

Action ongoing At the time of writing, no Governors have indicated that there are topics – relevant to the Governor role – which may benefit from an additional briefing session/workshop.

Engagement between Governors and Members Well documented that this is extremely

challenging and remains an area of focus for the Membership and Engagement Committee

Further work required to raise the profile of individual Governors with their constituency members.

6. The Foundation Times publication will be used to profile a particular Governor or Governors in each edition, with tailored messages for their constituencies.

Action completed/ongoing The Foundation Times publication will continue to be used to include a profile on a particular Governor(s). The Spring edition had a specific focus on the new staff Governors.

General It is important to understand the views

of each individual Governor, in an uninhibited way, on matters associated with the Council of Governors and their role:

o what works well? o what works less well? o how can we improve?

7. A survey to be undertaken (e.g. Survey Monkey) of Governors to obtain their views on a range of issues associated with the functioning of the Council of Governors and their roles. Timing of survey to be assessed (e.g. post elections/new governor induction etc.).

Action completed A survey was carried out in May to help inform planning for the CoG/Board workshop on 5 June. This attracted a response rate of 88% and some excellent insights which need to be taken forward and considered, in conjunction with actions agreed at the 5 June workshop.

Page 7 of 8

APPENDIX B – NED / GOVERNOR BUDDYING ALLOCATIONS – FROM MAY 2018 Geographical Area

NED* Governors

Berkshire West

Sumit Biswas

Sabrina Chetcuti; Jeanette Clifford

Buckinghamshire including Milton Keynes

Ilona Blue / Les Broude

Bob Crocker; Bernadette Devine; Bob Duggan

Oxfordshire Nigel Chapman

Paul Ader; Emma Crozier; Steve Haynes; Loretta Light; Kate Moss

Hampshire South West Mike Hawker

Keith House; Barry Lipscomb; Chas McGill; David Palmer

Hampshire South East incl. Portsmouth

Lena Samuels

Andy Bartlett; David Chilvers; Richard Coates; David Luckett

Berkshire East & Frimley Priya Singh

Anne Crampton; Mark Davis; Frank Epstein; Colin Godbold

Hampshire North and Mid

Anne Stebbing

Lynn Dove-Dixon; David Drew; Jim Dunderdale; Tony Nicholson;

PROFILE AREAS AND OBJECTIVES *Each NED has a series of specific profile areas for which they take strategic responsibility for seeking assurance on from the Executive Directors. This is set within the values based framework that provides the foundation upon which the appraisal process for the organisation sits. Name Profile Area Objectives Sumit Biswas Internal Business Cases Provide strategic oversight and accountability for internal businesses

cases as they arise Ilona Blue Staff Welfare Champion the welfare of staff, seeking assurance in the areas of

Human Resources and Organisational Development Undertake a scrutiny and supportive role with regards to

internal/external business cases Les Broude Whistleblowing/Freedom to Speak Up

Process Assurance Statutory and Mandatory Training /

Education and Professional Training

Take strategic oversight for the Whistleblowing/Freedom to Speak up Process, seeking assurance that this is operating effectively

Take strategic oversight for Statutory and Mandatory, and Education and Professional Training, seeking assurance that arrangements are in place to achieve compliance

Nigel Chapman Volunteers including Community First Seek assurance that the Trust is connecting with its volunteers such

Page 8 of 8

Responders that they feel more closely aligned to the Trust’s values and its direction of travel

Mike Hawker Business cases Serious Incidents Requiring

Investigation (SIRIs)

Undertake a scrutiny and supportive role with regards to business cases

For specific SIRIs, as agreed with the Chair, take a role in seeking assurance regarding the robustness of the investigation and the identification/application of learning

Lena Samuels Equality and Diversity Communications and Engagement

Seek assurance that the Trust is fully and effectively discharging its obligations in respect of equality and diversity

Undertake a supportive role in ensuring that the Trust is communicating and engaging with the media and other key stakeholders as effectively as possible

Priya Singh Whistleblowing/Freedom to Speak Up Deliver strategic oversight for cases of Whistleblowing and Freedom to Speak Up in line with the NED Freedom to Speak Up role

Anne Stebbing Emergency Preparedness Provide strategic oversight for Emergency Preparedness, Resilience and Response

ENCLOSURE I

LEAD GOVERNORS REPORT

Enclosure I




Title of Paper: Lead Governor’s Report

Presented by: Barry Lipscomb, Lead Governor (and Public Governor for Hampshire)


Information

Main Aim: To present a report from the Lead Governor, highlighting key activitiesundertaken since the previous CoG meeting


The report presents a record of key activities undertaken by the current Lead Governor, Barry Lipscomb, since the previous CoG meeting on16 April


Note

Previous Forum: N/A


N/A



Page 1 of 1


ENCLOSURE I

LEAD GOVERNOR’S REPORT The following is a record of key activities undertaken by the Lead Governor since the papers for the last Council of Governors (CoG) meeting (16 April) were issued: Date

Activity

16 April Attended the Council of Governors meeting 22 April Wrote to all Governors seeking feedback on the 16 April Council of Governors

meeting 27 April Teleconference with Chair, Deputy Chair and Company Secretary to review 16

April Council of Governors meeting 30 April Attended meeting of the Membership and Engagement Committee 24 May Attended NHS Providers Governors Focus Event 31 May Teleconference with Chair and Company Secretary to discuss planning for the 5

June joint Council of Governors/Board Workshop 5 June Attended the joint Council of Governors/Board Workshop 27 June Teleconference with Company Secretary to agree agenda for the 24 July

Council of Governors meeting Set against our principal defined duties as Governors, my main reflections after 14 months in the Lead Governor role are:- 1 That Governors continue to deliver most of our principal defined duties, with a high

standard of personal commitment to their role. 2 I retain significant long standing reservations about the level of resource given to the

Membership Office, which is charged with providing the appropriate support for Governors in seeking to discharge their engagement role in the communities we serve. I have given notice of and will have voiced those concerns at CoG earlier in the meeting.

3 As ever, I have the highest admiration and gratitude for the superb professional care

delivered by our frontline operational staff. It is rare these days to read a newspaper or watch a news programme without seeing a story of the Ambulance Service doing excellent and often dangerous work somewhere in the UK and the SCAS are very much part of that.

Barry Lipscomb Lead Governor 11 July 2018

Documents

COUNCIL OF GOVERNORS MEETING · 7/24/2018 · CHAIR OF MEETING: Lena Samuels, Chair GOVERNORS: See Members of the Council of Governors (overleaf) IN ATTENDANCE: Nigel Chapman, NED