open to members of the public and the press)s3-eu-west-1.amazonaws.com/files.royalfree.nhs.uk/... · TRUST BOARD AGENDA (open to members of the public and the press)DATE: Wednesday

TRUST BOARD AGENDA(open to members of the public and the press)

DATE: Wednesday 21 December 2016

TIME: 1300 -1400 (approx.)

VENUE: Boardroom, Chief executive’s office2

ndfloor, Royal Free Hospital

Royal Free Hospital

Distribution

CHAIR: Dominic Dodd Chairman of the trust board

TRUST BOARD MEMBERS:Stephen Ainger Non-executive directorMary Basterfield Non-executive directorDeborah Oakley Non-executive directorJenny Owen Non-executive directorProf Anthony Schapira Non-executive directorDavid Sloman Chief executive

Caroline Clarke Chief finance officer and deputy chief executive

Prof Stephen Powis Medical director

Kate Slemeck Chief operating officerINVITED TO ATTEND

Dr Mike Greenberg Divisional director of women’s and children’sservices

David Grantham Director of workforce and organisationaldevelopment

Prof George Hamilton Divisional director of surgery and associatedservices

Peter Ridley Director of planningEmma Kearney Director of corporate affairs and communicationsAndrew Panniker Director of capital and estatesDr Steve Shaw Divisional director of urgent careDr Robin Woolfson Divisional director of transplant and specialist

servicesHester WainMr Joe Adams

Deputy director of patient safety and riskPatient representative, patient safety programme(for item 2016/218 only)

Alison Macdonald Board secretary (minutes)Rebecca Longmate Deputy director of nursing (for director of nursing)

APOLOGIES Deborah Sanders Director of nursingCOPY FORINFORMATION:

Governors (agenda only)

Angela AttahInterim trust secretary

TRUST BOARD MEETING1

The next meeting of the trust board will take place on Wednesday 21 December 2016 at 1300 in the boardroom,executive offices, 2nd floor, Royal Free Hospital.

Dominic DoddChairman

A G E N D A

ITEM LEAD PAPER

ADMINISTRATIVE ITEMS

2016/213 Apologies for absence – Deborah Sanders D Dodd

2016/214 Declaration of interests D Dodd 1.

2016/215 Minutes of meeting held on 23 November 2016 D Dodd 2.

2016/216 Matters arising report D Dodd 3.

2016/217 Record of items discussed at the Part II board meeting on 23November 2016

D Dodd 4.

PATIENT SAFETY AND EXPERIENCE

2016/218 Quality improvement/patient safetyPatient’s story - Joe Adams, patient representative, patient safetyprogramme

S PowisH Wain

2016/219 Patients’ voices D Oakley

ORGANISATIONAL AGENDA

2016/220 Quality account 2016/17 outline process and timetable S Powis 5.

2016/221 Nursing/midwifery staff monthly report (October 2016) D Sanders 6.

2016/222 Appointment of responsible officer S Powis 7.

OPERATIONAL AGENDA

2016/223 Chair’s and chief executive’s report D Dodd /D Sloman

8.

2016/224 Trust performance dashboard K Slemeck 9.

2016/225 Financial performance report C Clarke 10.

Governance and regulation: reports from board committees

2016/226 Finance, investment and performance committee (15 December) D Dodd Verbal

2016/227 Shadow group board (8 December 2016) D Dodd 11.

2016/228 Patient safety committee (24 November 2016) S Ainger 12.

2016/229 Audit committee confirmed minutes (15 September 2016) D Oakley 13.

2016/230 Clinical performance committee (24 October 2016) A Schapira 14.

2016/231 Patient and staff experience committee - terms of reference J Owen 15.

1 In accordance with the Health & Social Care Act 2012, all Trust Board meetings must be held in public. All decisions which require the board’scollective approval can only be made at a Trust Board (or a Part II meeting held in closed session to discuss confidential matters).

OTHER BUSINESS

2016/232 Questions from the public D Dodd

2016/233 Any other business D Dodd

2016/234 Date of next meeting – 25 January 2017 D Dodd

Paper 1

Register of interests – trust board December 2016 1

REGISTER OF INTERESTS OF MEMBERS OF THE BOARD OF DIRECTORS

Executive summary

The trust constitution requires trust board members to declare interests which are relevant andmaterial to the NHS board of which they are a member. The register of interests is presented ateach board meeting.

The chairman has amended his declaration of interests since the last board meeting.

Action required

Board members are asked to provide an update if they have any other changes in interests notnoted in the attached.

Board members are asked to declare any interests which are relevant to matters on the boardagenda.

The board is asked to ratify the updated register, subject to any further changes made.

Public Patient andCarer involvement

The register will be made available to the public.

Report From Dominic Dodd, chairmanAuthor(s) Alison Macdonald, board secretaryDate 9 December 2016

Report to Date of meeting Attachment number

Trust Board 21 December 2016 Paper 1

Version 9Updated 14/11/16

Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public.

REGISTER OF THE INTERESTS OF MEMBERS OF THE TRUST BOARD

Board Member andpositionDate of latestamendment/confirmedcorrect

Directorships,including non-executive directorshipsheld in privatecompanies or PLCs(with the exception ofthose of dormantcompanies)State whendirectorshipcommenced

Ownership or part-ownership of privatecompanies, businessor consultancies likelyor possibly seeking todo business with theNHSState when interestacquired

Majority orcontrolling shareholdings inorganisations likelyor possibly seekingto do business withthe NHSState when interestacquired

A position ofauthority in a charityor voluntaryorganisation in thefield of health andsocial care

State when positionaccepted

Any connection with avoluntary or otherorganisationcontracting for NHSservices


Researchfunding/grants thatmay be received byan individual or theirdepartment

State whenfunding/grantcommenced

Interests in pooled funds that are underseparate management (any relevantcompany included in this fund that has apotential relationship with the Trust mustbe declared)

State when interest acquired

Dominic Dodd,Chair8/4/16

Director ofUCLPartners

1

ImprovementDirector forNHSI’s financialspecial measuresprogramme,assigned toCroydon HealthServices.

Member of NHSI’sChairs’ AdvisoryGroup. Unpaidposition.

Nil Nil Trustee, TheKing’s Fund.Unpaid position

Nil Nil

1The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.




Directorships,including non-executive directorshipsheld in privatecompanies or PLCs(with the exception ofthose of dormantcompanies)

State whendirectorshipcommenced











Non-executive directors

Stephen AingerNon-executivedirector5/1/16

Chair DownshireHill Residents’Association.

Nil Nil Nil Nil Nil Nil



Deborah Oakley,non-executivedirector13/5/16

Medicines andHealthcareProductsRegulatoryAgency Non-ExecDirector

Nil Nil Nil Medicines andHealthcareProductsRegulatoryAgency Non-Exec Director

Nil I work for Veritas InvestmentManagement. The firm investsmoney on behalf of clients. Clientportfolios are invested in varioushealthcare companies whichmay do business with the trustand with the NHS more broadly.These investments include butare not limited to: SonicHealthcare; Roche; Novartis;GlaxoSmithKline, United Health,Alphabet, Oracle and others.Clients also invest in pooledfunds which are managedexternally and invest in a broadrange of healthcare companieswhich may do business with thetrust and the NHS.I and my family have personalholdings in pooled funds whichare managed externally andinvest in a broad range ofhealthcare companies whichmay do business with the trustand the NHS.I do not have any directinvestments in companies whichmay do business with the trust orwith the NHS.
















Jenny Owen,non-executivedirector6/4/16

Nil Nil Nil Board memberof Housing andCare 21

Trustee ofAlzheimer’sSociety

Housing 21 andCare 21

Alzheimer’sSociety

Nil Nil

ProfessorAnthony SchapiraNon-executivedirector13/5/16

Upper HampsteadWalk Residents’Association.AHV Schapira Ltd

Non-executivedirector, Ministryof Justice

Nil Nil Parkinson’sDisease SocietyResearchStrategy Group

Nil MedicalResearchCouncil,Wellcome Trust,Parkinson’sDisease Societyand othercharitablesources ofresearch funding

Nil

Executive directors

Caroline ClarkeDeputy chiefexecutive &director offinance11/4/16

Member, AdvisoryBoard to TheLearning Clinic

Nil Nil Trustee

Royal FreeCharity (1/4/16)

Nil Nil Nil
















Professor

Stephen Powis,

medical director

16/5/16

Director of HSL

(appointed by

RFL)

Nil Nil Employee of

UCL

Trustee

Peter Samuel

Trust

Trustee

Healthcare

Management

Trust

Trustee

Moorhead Renal

Trust

Trustee

Royal Free

Charity (1/4/16)

Member ofgoverning body,Merton NHSClinicalCommissioningGroup

Trustee

Healthcare

Management

Trust

Moorhead RenalTrust and variousother sources ofcharitable fundingheld bycolleagues withinthe academicrenal department

No individualfunding butcollaborate onresearch withinacademicresearchdepartmentfunded by avariety of sourceseg MRC, KidneyResearch UK.

Nil

Deborah SandersDirector ofnursing16/1/13

Nil Nil Nil Board member,The Royal FreeHospital Nurses’Home of RestTrust

Nil Nil Nil
















Kate Slemeck,executive directorof operations7/4/16

Nil Nil Nil Nil Husband worksfor Canon whoprovide thetrust’s managedprint service.

Nil Nil



David SlomanChief executive15/11/16

Director,

UCLPartners2

Trustee/Non-executive director,Skills for Health

Chair of North

Central London

Sustainability and

Transformation

Plan

Nil Nil LondonProcurementPartnershipboard member.

Relative whoworks for Ernst &Young

Member of HSJ’sProduct AdvisoryBoard

Member of NHSImprovementCEO AdvisoryGroup (January2016)

Membership ofDeloitteAcademy

Member ofinternationaladvisory board ofThe NationalInstitute forHealth ResearchCollaboration forLeadership inApplied HealthResearch andCare (NIHRCLAHRC)

Nil Nil

2The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.
















Non-voting directors

David Grantham

Director of

Workforce and

OD

7/4/16

Nil Nil Nil Board Member

and Treasurer

London

Healthcare

People

Management

Academy –

March 2013

Chair of NHS

Employers

Medical

Workforce

Forum – August

2010

Board MemberHealth EducationNorth and EastLondon(HENCEL) – July2014Board Memberand TreasurerLondonStreamliningProgramme(s) –March 2014

Nil Nil
















Mike Greenberg

Divisional director

women’s,

children’s and

imaging services

7/4/16

Nil Nil Nil Nil Relative of COOof Optum Labs, asubsidiary ofOptum

Nil Partner with HCA in Wellington

Diagnostic and Outpatient

Centre LLP since 2007

George Hamilton

Divisional director

surgery and

associated

services

Nil Nil Nil Nil Consultantshares in W.Docwhich is affiliatedwith theWellingtonHospital.

Nil Nil

Emma Kearney

Director of

corporate affairs

and

communications

Director, EK

Consulting Ltd

Nil Nil Nil Nil Nil Nil

Andrew Panniker

Director of capital

and estates

Nil Nil Nil Nil Director, Royal

Free Charity

Development Co

Nil Nil

Peter Ridley

Director of

Planning

Nil Nil Nil Nil Nil Nil Nil
















Steve Shaw

Divisional director

urgent care

7/4/16


Will Smart

Chief information

officer

8/4/16


Robin Woolfson,

Divisional director

transplant and

specialist

services


Paper 2

1

MINUTES OF THE TRUST BOARD

HELD ON 23 NOVEMBER 2016

Present

Mr D DoddMr S AingerMs C ClarkeMs D OakleyMs J OwenProf S PowisMs D SandersMs K SlemeckMr D Sloman

ChairmanNon-executive directorChief finance officer and deputy chief executiveNon-executive directorNon-executive directorMedical directorDirector of nursingChief operating officerChief executive

Invited to attendMr D GranthamDr M GreenbergMs E KearneyMr A PannikerMr P RidleyDr S ShawMs A Macdonald

Director of workforce and organisational development (from 2016/158)Divisional director for women’s, children’s and imaging servicesDirector of corporate affairs and communicationsDirector of capital and estatesDirector of planningDivisional director – urgent careBoard secretary (minutes)

Others in attendanceDr C LaingMs MM DevaneyMrs J Dewinter

Associate medical director – patient safety (for item 2016/199)Head of patient safety and risk (for item 2016/199)Lead governor and elected patient governor

2016/194 APOLOGIES FOR ABSENCE AND WELCOME Action

Apologies for absence were received from:

Prof A Schapira Non-executive directorProf G Hamilton Divisional director for surgery and associated servicesDr R Woolfson Divisional director, transplant and specialist services

The chairman welcomed those present to the meeting.

2016/195 DECLARATION OF INTERESTS

The report on the register of interests was noted and entries confirmed to becorrect. No director had any further interests to declare.

2016/196 MINUTES OF MEETING HELD ON 19 OCTOBER 2016

The minutes were accepted as an accurate record of the meeting.

2016/197 MATTERS ARISING REPORT

The matters arising report was noted and the following update provided.

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2

2016/170 falls information

The medical director confirmed that clinical quality data, including information onfalls, was presented regularly to commissioners via the clinical quality reviewgroup.

2016/198 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 19OCTOBER 2016

The report was noted.

2016/199 QUALITY IMPROVEMENT/PATIENT SAFETY – PATIENT SAFETYPROGRAMME OVERVIEW AND UPDATE

Dr Chris Laing, associate medical director – patient safety and Ms M M Devaney,head of patient safety and risk were in attendance for this item. The associatemedical director updated the board on progress on the patient safety programmesince the board had agreed to the ‘sign up for safety’ programme in December2014. This had attracted funding from the NHS Litigation Authority. The initialperiod had been spent on putting the right framework, support and governance inplace. The patient safety board was chaired by the chief finance officer andreported to the patient safety committee and ultimately to the board. The patientsafety vignettes presented to each board meeting kept patient safety high on theagenda and visible. There were a number of patient safety work streamsincluding falls, acute kidney injury, identifying the deteriorating patient, diabetes,surgical safety and VTE prevention. Achievements included:

On 16 December there would have been no surgical never events for six monthsThere had been no cardiac arrests at Barnet Hospital since April 2016There had been no fall with harm for 800 days on a ward where this hadpreviously been an issueThe partnership with DeepMind on the Streams acute kidney injury app

The programme had now been in place for three years and it felt like the seeds forimproving patient safety had been planted in very fertile ground with an excellentcentral team supporting clinical colleagues at operational level.

The head of patient safety and risk added that the agreement of the qualitystrategy and milestones would be complementary to the patient safetyprogramme.

Mr Ainger, non-executive director and chair of the patient safety committee,commented that the patient safety team were doing an excellent job and that atriangulated and evidence based approach was in place.

Ms Owen, non-executive director, asked whether the delirium pathway wasincluded in the programme. The associate medical director – patient safety saidthat it was not at present part of the formal programme. The director of nursingadded that the dementia care group was looking at enhanced care which wouldinclude the delirium pathway. The chief finance officer noted that there was apatient representative on the patient safety programme board which wasextremely helpful.

The chairman asked about sharing with and learning from other organisations and

Paper 2

3

the head of patient safety and risk responded that the team were part of a numberof London wide and national patient safety fora.

The chairman asked if there was more the board could do to promote and supportpatient safety. The associate medical director – patient safety suggested thatthere was a role in influencing leadership further down the organisation and thehead of patient safety and risk added that staff would like to know that their effortsin this area were appreciated. The chairman commented that the board neededto put some thought into how this could be done better.

2016/200 PATIENTS’ VOICES

The medical director read out an email received from a hepatology patient, whohad not wished to make a formal complaint but wanted to know that the trust hadlearned from his experience. The senior matron for the service met with him andprovided a response to each of his concerns. He was worried about a nursesneezing and coughing near to him; the matron explained that the nurse in chargehad assessed that the nurse was well enough to be working directly with patients.He was concerned that his portacath (device used to draw blood and givetreatments) had not been flushed causing it to block. This was dealt with at thetime by a specialist nurse, who took the opportunity to train the doctor and nursingstaff on the shift how to deal with a portacath. The wider nursing team had alsobeen made aware of how to escalate dealing with a portacath, if unsure. Thepatient also noted that there were delays in responding to call bells. The matronconfirmed that the ward were not meeting the target for responding to call bellsand arranged for spot checks and weekly audits until there was an improvement.Finally he was concerned about the clerking delay (history and examination ofpatient) on his admission. The matron had contacted the consultant whoexplained that the doctors were dealing with patients who required more urgentcare and treatment.

The medical director then read out a compliment from the son of a patient onRowan ward at Barnet Hospital. This stated that the overall care was excellentbut the family particularly wanted to highlight the excellent care of a newlyqualified nurse who was professional, pleasant, positive, approachable andhugely influential in making the mother’s stay more bearable.

The board also received a copy of a letter from an elderly patient who wanted tobe discharged from hospital without further delay. The director of nursing saidthat it was a sobering thought that many patients in their 80’s were in the lastthousand days of their lives and keeping them in hospital longer than they neededto be was taking a valuable resource from them.

Ms Oakley, non-executive director, would present the patients’ voices item at thenext meeting.

MsOakley

2016/201 NORTH CENTRAL LONDON SUSTAINABILITY AND TRANSFORMATIONPLAN

The director of planning presented this item. He stated that now that the STP hadbeen published the key was to ensure that the individual organisations’ two yearplans were consistent with the STP.

The chief executive stated that he had two roles in relation to the STP, asconvenor of the STP and as RFL chief executive. The STP had been a

Paper 2

4

constructive development in terms of encouraging the constituent organisations tolook beyond their own interests to those of the wider health and social caresystem. The STP had three strands: health; social care and financialsustainability.

There were two value propositions: a real focus on productivity within institutionsand across the system; and to design a health rather than sickness mode. Theplan had been built from the bottom up, with strong clinical input. However public,patient and staff engagement and transparency could have been better and it wasimportant to start tackling this now.

Mr Ainger, non-executive director, was surprised that communications around thepublication of the plan had not focused on integrated care and symptom basedpathways as this would have been a much more powerful message.

Ms Owen, non-executive director, commended the progress that had been madeand stated that this was the way that the NHS now needed to do business. Sheadded that it was important to set aspirational goals.

The chief executive stated that it was important to move away from planning onan annual or biannual basis and that it would also be helpful to stop the annualcontract negotiation process. He added that the STP put the right people in theroom, grappling with the right questions.

Ms Oakley, non-executive director, asked what the implications were for RFL andwhere the £70m investment would come from. The chief executive said that eachinstitution was currently looking at what contracted activity was needed next year,but currently there was no agreement. The next step would be to look at the STPinterventions and assumptions and apply them to the plans. There would be animpact on demand and capacity; cost and prices. There would still be anunanswered financial problem with a level of risk and agreement would need to bereached about how to handle these.

The board supported the North Central London sustainability and transformationplan.

2016/202 NURSING AND MIDWIFERY STAFFING MONTHLY REPORT

The director of nursing presented the report which covered September 2016 andnoted planned versus actual hours was 1.5% less actual than planned across allthree sites. There had been 13 shifts or part shifts out of more than 3000 wherethe nurse: patient ratio was below 1:8 on a day shift or 1:11, with no patient safetyincidents reported.

There had been a sustained reduction in agency staff, with more substantive staffbeing recruited. Three years ago, 330 nurses had been recruited in a year; so farthis year there had been 1000 new nurses. Currently the net position was thatthere were approximately 140 more joiners than leavers. New recruits weresettling in well.

The Allocate e-rostering system was now in place in all areas and being used tomanage rotas actively. A strong control environment was in place with all agencybookings having to be agreed by a divisional director of nursing, using a riskbased approach. However the risk areas in terms of not being able to reduceagency were the emergency department, where more capacity was shortly to beopened at Barnet Hospital and ITU which was currently operating at full capacity

Paper 2

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and where there was a high turnover and vacancy level.The board had asked about FFT in the emergency department at the last meetingand the director of nursing commented that the patient and staff experiencecommittee were currently reviewing FFT and how to tackle this in the emergencydepartment would be fed into this review.

Mr Ainger, non-executive director, asked where the new nurses were coming fromand whether agency had reduced in line with the levels of recruitment. Thedirector of nursing responded that nurses were being recruited from a wide rangeof sources, in the UK as well as overseas. The trust had also been verysuccessful in recruiting newly qualified nurses who had trained at RFL. It wasdifficult to make a direct connection between the reduction in agency and netrecruitment as during this period additional capacity had been opened whichrequired additional staff.

Ms Owen, non-executive director, noted that there had been more shifts thannormal failing below the 1:8/11 ratio and asked where the trust was in relation tothe NHS Improvement £29m control total for agency staff.

The chief finance officer responded that there was a realistic prospect of beingable to meet the control total, depending on how winter impacted on staffing.

The chairman suggested including the following in future papers: retention levels,net recruitment and funded establishment.

The board agreed that the report provided sufficient assurance that the nursestaffing levels were meeting the needs of patients and providing safe care.

Directorofnursing

2016/203 CHAIR AND CHIEF EXECUTIVE’S REPORT

The chief executive drew particular attention to the Chase Farm Hospitalredevelopment which continued to be ahead of schedule and on budget.

Ms Owen, non-executive director, asked about follow up from the Institute forHealthcare Improvement (IHI) awayday and asked whether the board couldreceive a report with key elements from the day, next steps and governance. Thechief executive stated that governance should be at board level and there wouldbe a report to a future board meeting.

The board noted the report.

Medicaldirector

2016/204 TRUST PERFORMANCE DASHBOARD

The chief operating officer noted that A&E and cancer performance haddeteriorated during the past month. There were particular problems with A&Eperformance at Barnet Hospital but it was hoped that the new facility which wouldbe opening shortly would help. Barnet CCG were commissioning ‘discharge toassess’ which would also assist. The chief executive stated that Barnet CCG’sapproach and support had been exemplary.

The chief operating officer reported that the trust continued to be non-compliantwith the 62 day cancer standard, but was getting closer to compliance. The chiefexecutive added that work on regaining cancer compliance was sustainable andwould enable a return to business as usual but referrals would continue toincrease, meaning that this would continue to be a challenge.

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2016/205 FINANCIAL PERFORMANCE REPORT

The chief finance officer reported the trust was £38.3m adverse to plan at the endof October 2016. The reasons for this were as reported the previous month,notably the loss of prior year income of £17m, alongside under-achievement ofthe private patients unit income, underperformance against activity income, payoverspends and a high level of outsourcing costs. The underlying theme was thatthe system could not afford the level of activity currently going through hospitals.The trust’s cash position continued to be a matter for serious concern.

The board noted the report.2016/206 SHADOW GROUP BOARD REPORT


2016/207 FINANCE INVESTMENT AND PERFORMANCE COMMITTEE REPORT

The board noted the report from the committee.

2016/208 PATIENT SAFETY COMMITTEE REPORT

The board noted the report from the committee.

2016/209 AUDIT COMMITTEE

Ms Oakley, chair of the committee, reported that the audit committee hadapproved the external audit plan for 2016/17, together with the internal auditprogramme. The committee had also received an update on cyber securityfollowing the internal audit report and heard that there was a plan in place to becompleted by 31 March 2017. This would be followed with testing.

The chairman suggested that it would be helpful for the board to have adiscussion of cyber security in January 2017.

Medicaldirector

2016/210 QUESTIONS FROM THE PUBLIC

There were no questions from the public.

2016/211 ANY OTHER BUSINESS

Patient and staff experience committee

Ms Owen, chair of the committee reported that there would be a report to theJanuary board on patient engagement and participation.

Directorofnursing

2016/212 DATE OF NEXT MEETING

The next trust board meeting would be on 21 December 2016 at 1300 in theboardroom, executive offices, 2nd floor, Royal Free Hospital.

Agreed as a correct record

Signature …………………………………..date 21 December 2016…………………………….Dominic Dodd, chairman

Paper 3

Matters arising – trust board 21 December 2016

Trust BoardMatters Arising report as at 21 December 2016

Actions completed since last meeting of the Trust Board

MinuteNo

Action Lead Complete Board date/agenda item

Outstanding

FROM TRUST BOARD HELD ON 23 NOVEMBER 20162016/202 NURSING AND MIDWIFERY STAFFING

MONTHLY REPORTInclude retention levels, net recruitment and fundedestablishment in future reports.

D Sanders Reports will be revised accordingly

2016/203 CHAIR AND CHIEF EXECUTIVE’S REPORTReport on IHI to future board meeting. S Powis Update included in December Chair/CEO

report. Agenda item for January 2017 boardmeeting.

2016/209 AUDIT COMMITTEEReport on Cyber security for January 2017 boardmeeting.

S Powis Agenda item for January 2017 board meeting.

2016/211 ANY OTHER BUSINESSReport on patient engagement and participation toJanuary board meeting.

S Powis Agenda item for January 2017 board meeting.

FROM TRUST BOARD HELD ON 19 OCTOBER 20162016/180 NURSING AND MIDWIFERY STAFFING

MONTHLY REPORTInclude further information on net recruitmentposition in the next report.

Consider how FFT could be captured in theemergency department.

D Sanders Update provided – netrecruitment of 140positive.

FFT was currently beingreviewed at the patientand staff experiencecommittee

Paper 3

Matters arising – trust board 21 December 2016

2016/181 DIRECTOR OF INFECTION PREVENTION ANDCONTROL QUARTERLY REPORTMs Oakley asked if more information about theantibiotic CQUIN could be included in the nextreport.

Ms Owen, non-executive director, asked for moreinformation about the review of the PFI contract

D Sanders

A Panniker

Next report due January 2017

Review in progress, update to be provided toboard in December 2016

FROM TRUST BOARD HELD ON 28 SEPTEMBER 20162016/170 Questions from the public – falls information

Raise this at CQRG S Powis/D Sanders

Update provided – clinicalquality data, including fallsinformation, presentedregularly tocommissioners via theCQRG meeting.

FROM TRUST BOARD HELD ON 27 APRIL 20162016/77 Patient safety committee report

Board to receive training on corporatemanslaughter

S Powis Session provided 23November 2016

FROM TRUST BOARD HELD ON 6 APRIL 20162016/54 Chairman and chief executive’s report

Progress reports on pathology joint venture to theshadow group board and finance and performancecommittee.

M Dinan Agreed at May shadow group board that thisshould be programmed for July, following acustomer/investor annual review. Deferred toSeptember as HSL annual accounts notreceived. Report discussed at financeinvestment and performance committee inSeptember and further work required. Nowprogrammed for January trust board meeting.

Paper 4

Confidential trust board meeting update – trust board 21 December 2016

ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 23 NOVEMBER2016

Executive summary

Decisions taken at a confidential trust board are reported where appropriate at the next trustboard held in public. Those issues of note and decisions taken at the trust board’s confidentialmeeting held on 23 November 2016 are outlined below.

• RFL digital strategy (some aspects of this are included in this month’s chair’s and chiefexecutive’s report; there is a further report in the confidential part of the meeting (as it iscommercially sensitive) which will be reported to the next public board.

• Shadow group report – there is a summary report in the public board agenda• North Middlesex University Hospital partnership update – information is included in this

month’s chair’s and chief executive’s report• The board approved an application to access the Department of Health’s revolving

working capital facility

The board also had a detailed discussion of the trust’s financial position and discussed the trustperformance report.

Action required

For the board to note.

Report From D Dodd, chairmanAuthor(s) A Macdonald, board secretaryDate 9 December 2016



Paper 5

1

Development of the 2016/17 quality account

Executive summary

The Trust has a legal obligation to submit an annual report covering progress made duringthe year to improve the quality of their services, as well as the requirement to submit a list ofquality priorities for the coming year. It is the expectation that the quality priorities aredeveloped from stakeholder engagement and consultation.

It is anticipated that the 2016/17 quality account will be developed as in previous years andin order to achieve this, a significant amount of preparation and engagement will be required.

The attached information outlines the development plan and timeline for completion of the

quality account 2016/17 to meet the submission deadline.

Action required/recommendation

The board is asked to approve the development plan and timeline for the 2016/17 qualityaccount.

Trust strategic priorities and business planning objectives

supported by this paper

Board assurance risk

number(s)

1. Excellent outcomes – to be in the top 10% of our peers on

outcomes

2. Excellent user experience – to be in the top 10% of relevant

peers on patient, GP and staff experience

4. Excellent compliance with our external duties – to meet our

external obligations effectively and efficiently

5. A strong organisation for the future – to strengthen the

organisation for the future

CQC Regulations supported by this paper

Regulation 17 Good governance



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2

Risks attached to this project/initiative and how these will be managed (assurance)

There are no identified risks attached to this project. Plans are in place to ensure that the

submission deadline is met.

Equality analysis

• No identified negative impact on equality and diversity

Report from Professor Stephen Powis- medical director

Author(s) Karen Gordon: Head of clinical governance and performanceDawn Atkinson: Deputy director of clinical governance and performance

Date 14 December 2016

References

Paper 5

3

Development of the 2016/17 quality accounts

Since the introduction of the quality account in 2010, there remains a legal obligation for the

Trust to submit an annual quality report outlining:

• What our trust is doing well

• Where improvements in quality of our services is required

• What our priorities for improvement are for the coming year; and how we have

involved service users, staff and others in determining those priorities for

improvement

The guidance specifically outlining the requirements for the quality account has not been

published from as yet, however it is anticipated that there will not be any major changes from

previous years.

The Development plan

The development of our 2016/17 quality account provides us with the opportunity to

illustrate both national changes and our emerging new organisational architecture in which

we will continue to operate in the future. This will be influenced from our steps to deliver on

the NHS Five Year Forward View and intention to have shadow group status from April

2017.

As in previous years, the three executive leads and associated committees for patient safety,

patient experience and clinical effectiveness will continue to influence the development of

the quality account; especially around the review of progress in achieving the 2016/17

quality priorities and the suggestion of quality priorities for 2017/18.

quality domain executive lead relevant committee

Clinical effectiveness Sonia Renwick Clinical performance Committee (CPC)

Patient experience Chandi Velodi Patient and Staff Experience (PSEC)

Patient safety Chris Laing Patient Safety Committee (PSC)

Furthermore, the quality account will be the key document which incorporates the principles

outlined in the quality strategy with the central theme of putting our patients and families at

the heart of how we design and deliver care to improve outcomes. The account will also

include a section on key successes which will be developed in partnership with our four

clinical divisions.

Process of engagement

In order to set our high level quality priorities for 2016/17, a series of engagement exercises

will be held with key stakeholders and key committees. The main stakeholder event is

planned for the 13 January 2017 and invitees will include members of the Council of

governors, Healthwatch and Commissioners.

Paper 5

4

The event plans to showcase quality improvement initiatives as well as creating the forum for

key stakeholders to feedback on what additional priorities should be considered for 2017/18.

Further events will specifically be held for patients and staff in February 2017.

Timeline for quality account completion

The 2016/17 quality account must be published by 30 June 2017. Appendix A presents a

detailed timetable and reporting schedule which will be followed to meet the submission

deadline. An overview is presented below, highlighting specific information for the trust

board.

Month What will be presented

December 2016 Signing off the development plan and delegating authority to the TrustExecutive Committee (TEC)

January 2017 Stakeholder’s event showcasing quality improvement and qualityaccount consultation.

March 2017 First draft quality account 2016/17 report for comments, prior to widerdistribution for consultation with key stakeholders

April 2017 Second draft quality account 2016/17 (which includes stakeholdercomments) for further comments

May 2017 Final report to be signed off by the trust board

Appendix A: Quality Account Development plan and reporting schedule for 2016/17

December 2016 January 2017 February 2017Week of05/12/16

BHOSC 05/12/16 Report submitted tothe committee updating on progressmade to address comments raised by thecommittee in QA 2015/16.

Week of09/01/17

RFH: 13/01/17 Stakeholders engagementprocess including CoG, CCGs and Healthwatch for their initial comments forpriorities for 2017/18

Week of06/02/17

CFH: date TBC Stakeholdersengagement process (staffand patient focus)

Week of13/12/16

CGCRC: 16/12/16. Report presenting anoverview from the clinical divisions onprogress on QA reporting

Week of16/01/17

CPC: 16/01/17. Progress report onquality account priorities 2016/17 andsuggestions for 2017/18 QA priorities

Week of20/02/17

BH: date TBC Stakeholdersengagement process (staffand patient focus)

Week of19/12/16

TEC: 20/12/16. Report outlining theapproach and development plan for theQA 2016/17

CoG: 19/01/17. Consultation onpriorities for 2017/18 using memberssurvey feedback for consideration May 2017

TB: 21/12/16. Sign of the developmentplan and reporting schedule and delegateauthority to TEC

Week of23/01/17

PSEC: 25/01/17. Update report onprogress on quality account priorities andsuggestions for the 2017/18 priorities

Week of08/05/17

TEC: 09/05/17. Final draftQA for approval

PSC: 26/01/17. Update report onprogress on quality account priorities andsuggestions for the 2017/18 priorities

Week of15/05/17

CoG: 16/03/16. Finaloverview on the QA 2016/17

March 2017

Week of06/03/17

TEC: 07/03/17. Update report onprogress on quality account priorities andsign off the priorities for 2017/18

Week of22/05/17

TB: 23/05/17 Finalratification of the qualityaccount 2016/17April 2017

Week of13/03/17

CoG: 16/03/17. Feedback fromstakeholders event on priorities for2017/18 and choosing an indicator fortesting for 2016/17

Week of24/04/17

PSEC: 24/04/17 Review on progressachieved from 2015/16 and agreedpriorities for 2016/17

AC: 23/05/17 Finalratification of the qualityaccount 2016/17 prior tosubmission to Monitor

Week of20/03/17

PSC: 23/03/17 Feedback on agreedpriorities for 2017/18 and final QA2015/16 priorities update

TEC: 25/04/17 Draft quality account for2015/16 using Q4 data (wherepossible)with stakeholders comments

BHOSCCGCRCCoGPSCPSECTECTB

Barnet Health Overview & Scrutiny Comm.Clinical Governance Clinical Risk CommitteeCouncil of GovernorsPatient Safety CommitteePatient and Staff Engagement CommitteeTrust Executive CommitteeTrust Board

Week of27/03/17

TB:29/03/17 Initial draft QA report usingQ3 data(without stakeholders feedback)

TB: 26/04/17 Draft quality account for2015/16 using Q4 data (where possible)with stakeholders comments

Page 1 of 2

Monthly report of Nursing staffing levels October 2016

Executive summary – including resource implications

The overall trust summary of planned versus actual hours for October was 2% less actualhours than planned:

Site specific data is as follows:• Barnet hospital 3% less actual hours than planned

• Chase Farm hospital 5% less actual hours than planned

• Royal Free hospital 1% less actual hours than planned

In October out of a minimum of 3,100 shifts there were 7 shifts reported where the nurse:patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. There were noreported patient safety incidents on these occasions.

Action required

The board is requested to

• consider if the report provides sufficient assurance that the nurse staffing levels aremeeting the needs of patients and providing safe care




number(s)


outcomes



3. Excellent financial performance – to be in the top 10% of

relevant peers on financial performance





CQC outcomes supported by this paper

1 Respecting and involving people who use services

4 Care and welfare of people who use services



Page 2 of 2

5 Meeting nutritional needs

7 Safeguarding people who use services from abuse

8 Cleanliness and infection control

9 Management of medicines

13 Staffing

14 Supporting staff


Equality analysis


Report from Deborah Sanders, Director of Nursing

Author(s) Deborah Sanders, Director of Nursing


References: Supporting NHS providers to deliver the right staff, with the right skills, in theright place at the right time – Safe, sustainable and productive staffing, July 2016,https://www.england.nhs.uk/ourwork/part-rel/nqb/

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1

Introduction

This report provides information on planned versus actual nurse staffing for October 2016and an update on progress with the reduction in use of agency nursing and midwifery staff.

Planned versus actual staffing

The overall trust summary of planned versus actual hours for October was 2% less actualhours than planned:

Site specific data is as follows:• Barnet hospital 3% less actual hours than planned• Chase Farm hospital 5% less actual hours than planned• Royal Free hospital 1% less actual hours than planned

Planned versus actual staffing

The tables below show that planned versus actual hours by ward for registered nurses andmidwives and healthcare assistants.

Ward Beds

Registered nurse to

patient ratio

Day Shift

Percent of actual vs

total planned shifts

(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

9 West 33 1:4 100% 103% 153% 86% 2 0 95%

9 North 33 1:4.7 91% 94% 83% 84% 4 0 91%

11 West 22 1:4.8 96% 120% 136% 152% 5 0 93%

11 South 19 1:3.8 80% 99% 109% 94% 4 0 89%

11 East 24 1:4.8 87% 100% 96% 155% 1 1 94%

10 East 24 1:3.4 90% 97% 92% 97% 4 0 87%

10 South 25 1:6.25 94% 107% 92% 102% 4 0 86%

5 East B 24 1:5 99% 100% 102% 119% 1 0 96%

Mulberry 13 1:5 105% 101% 86% 106% 2 0 84%

Transplantation and Specialist Services October 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

10 North 32 1:5.3 98% 100% 97% 100% 4 0 100%

8 West 36 1:5.1 93% 100% 95% 99% 5 1 100%

8 North 32 1:4 93% 98% 92% 100% 9 0 91%

10 West 27 1:5 98% 101% 97% 100% 1 0 100%

8 East 26 1:4.3 97% 98% 94% 100% 5 0 95%

6 South 28 1:4 98% 100% 99% 99% 2 0 83%

ITU (RF) vary 1:1/1:2 99% 99% 95% 91% 1 0 n/a

ED (RF) n/a n/a 102% 112% 63% 73% 2 0 83%

ED(BH) n/a n/a 95% 99% 89% 98% 5 0 80%

UCC (CF) n/a n/a 107% 126% 57% n/a 0 0 n/a

Adelaide 25 1:6.25 86% 87% 92% 151% 0 0 50%

Capetown 36 1:5.1 94% 121% 124% 170% 9 1 100%

CCU 8 1:2 99% 103% n/a n/a 1 1 88%

ITU (BH) vary 1:1/1:2 96% 106% 100% 81% 0 0 n/a

Juniper 24 1:4.8 95% 99% 98% 152% 4 0 80%

Larch 22 1:5.5 115% 97% 102% 150% 2 0 60%

Olive 22 1:5.5 96% 101% 97% 91% 2 0 65%

Palm 22 1:5.5 97% 99% 97% 120% 3 0 88%

MSSU 48 1:4.8 92% 114% 115% 203% 8 0 90%

Rowan 24 1:4.8 71% 93% 156% 148% 3 0 89%

Spruce 24 1:6 75% 96% 85% 95% 1 0 88%

Walnut 24 1:6 96% 100% 112% 248% 3 0 83%

Urgent Care October 2016

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2

Galaxy ward

The registered nurse planned versus actual for Galaxy, paediatric ward at Barnet has shown61% for day shifts and 80% for night shift. The recommended staffing for a paediatric wardis:

• Unstable patients; mental health patients assessed as posing a risk to themselvesand others: 1:1 Nursing care (or more if required)

• High Dependency patients: 2:1 Nursing care

• General paediatric patients: 4:1 Nursing care (RCN )

The staffing is flexed depending on the number of patients on the ward and the dependency.The tables below show the occupancy and staffing for Galaxy during October. As well asregistered nurses there are also band 3 paediatric support workers who take a caseload ofsuitable patients under the supervision of the registered nurse. These are not shown in thenumbers below. The matron reviews staffing requirements on a daily basis. During Octoberthere were shifts where nurses from Starlight (when occupancy allowed) and the matron andward sister worked on the ward to augment the numbers below. Practice educators andspecialist nurses also provided additional support to then numbers below. The head ofnursing and the matron have provided assurance that there were no shifts that fell below therequired staffing levels.

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

12 Wesr 15 vary 103% 123% 132 184% 1 0 n/a

12 South 16 1:4 95% 99% 98% 100% 2 0 100%

12 Eas t B 12 vary 91% 84% 50% 61% 0 0 100%

Private Practice October 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

5 north A 18 1:4.5 97% 100% 98% 94% 1 0 92%

7East A 20 1:5 98% 97% 128% 137% 2 0 85%

7 East B 13 1:4.3 107% 119% 100% 97% 3 0 84%

7 West 32 1:4 95% 103% 108% 122% 5 0 86%

7 North 24 1:4.7 121% 123% 98% 103% 1 0 91%

Beech 24 1:6 87% 95% 95% 100% 3 0 74%

Canterb'y 25 1:6.25 68% 63% 57% 85% 0 0 92%

Cedar 24 1:4 60% 95% 141% 146% 4 0 80%

Damson 24 1:6 82% 101% 94% 138% 2 0 89%

Wel'gton 39 1:6.5 92% 98% 87% 100% 2 0 97%

Surgery and Associated Services October 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

6 North 20 1:4 99% 93% 100% n/a 0 0 n/a

5 South 31 1:8 98% 96% 94% 92% 0 0 91%

Neona te RFH vary 85% 99% 70% 87% 0 0 n/a

Galaxy 30 1:4 61% 80% 98% 58% 1 0 n/a

Neona te BH vary 80% 80% n/a n/a 0 0 n/a

Willow 16 1:5.3 102% 155% 112% 197% 3 0 86%

Victoria 48 1:8 84% 85% 90% 98% 0 0 94%

Womens and Childrens October 2016

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3

Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Number of patients onward at midnight

16 20 18 16 19 12 12 14 17 21 11 7 13 11 12

Of which were HDU 0 0 0 0 0 0 1 1 2 3 2 0 0 1 1

RN’s day shift 4 3 5 4 5 3 6 5 5 5 5 5 4 5 5

RN’s night shift 5 4 5 5 5 5 4 5 5 5 6 5 5 5 5

Date 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Number of patientson ward at midnight

14 14 17 22 22 15 17 16 16 20 22 13 11 16 18 15

Of which were HDU 0 0 4 3 3 3 2 2 2 3 3 2 2 0 0 0

RN’s day shift 5 4 6 5 5 4 6 5 4 4 5 5 5 4 4 4

RN’s night shift 4 5 5 5 5 7 5 4 5 4 5 5 5 5 4 5

Safe staffing

In October out of a minimum of 3,100 shifts there were 7 shifts reported where the nurse:patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. On Damson therewere 2 night shifts where the ratio was 1:12.5 with 3 nursing assistants. This was due to lastminute sickness and it was not possible to replace the shift. On Beech there were 5 nightshifts where the ratio was 1:12 with 3 nursing assistants. Again this was due to last minutesickness. There were no reported patient safety incidents associated with this.

Registered nurse agency staff

On 1 September 2015 Monitor wrote to the trust advising of the rules for nursing agencyspending and setting out the spending ceiling for the trust. The rules are an annual ceilingfor total nursing agency spending for each trust and a mandatory use of approvedframeworks for procuring agency staff. The rules apply to all NHS trusts, NHS foundationtrusts receiving interim support from the Department of Health and NHS foundation trusts inbreach of their licence for financial reasons. All other NHS foundations trusts have beenstrongly encouraged to comply.

On 19 October 2015 Monitor wrote to the trust confirming that the agreed ceiling of nurseagency pay as a % of total nurse pay for the Royal Free London was 9.8% by March 2016with a further reduction in April 2016. The further reduction % of nursing pay by agency hasnot yet been issued rather the trust has been sent an overall control total of £29 million onagency pay (all staff groups).

The divisional nurse directors, heads of nursing and matrons have further increased controlsover agency usage and this combined with the new starters and the roll out of e-rosteringhas led to a sustained decrease in the use of agency staff.

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4

The financial summary for all staff groups against the control total is shown in below:

Recruitment

A key driver to reducing agency cost is recruitment to substantive posts. There are currently322 nursing and midwifery recruits in the pipeline, 88 have agreed start dates and 234 arebeing processed. We continue to hold 2 assessment centres a month alongside one openday a month. Working with our recruitment partners we have recently successfully usedSkype to interview and appoint 4 candidates in the Philippines and are considering this forfuture campaigns. The net position of starters v leavers for nursing and midwifery staff forthis financial year, to November, is a positive balance of 188.91 with a breakdown shown inthe table below:

Nursing and Midwifery Registered WTE

Starters WTE 447.21

Leavers WTE 338.65

Net Starters WTE 108.56

Healthcare Assistants

Starters WTE 174.35

Leavers WTE 94.00

Net Starters WTE 80.35

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Trust strategic priorities and business planning

objectives supported by this paper


number(s)

1. Excellent outcomes – to be in the top 10% of our peers

on outcomes

X

2. Excellent user experience – to be in the top 10% of

relevant peers on patient, GP and staff experience

X

3. Excellent financial performance – to be in the top 10%

of relevant peers on financial performance

X

4. Excellent compliance with our external duties – to meet

our external obligations effectively and efficiently

X

5. A strong organisation for the future – to strengthen

the organisation for the future

X

Appointment of Responsible Officer

Executive summary

Under medical revalidation, doctors must demonstrate their fitness to practice to the GeneralMedical Council (GMC) at least once every five years. As a designated body for medicalrevalidation, the Royal Free London NHS Foundation Trust is required to nominate or appoint asenior licensed doctor to act as its Responsible Officer (RO) and oversee the revalidationprocess.

The trust medical director Professor Stephen Powis has acted as RO since December 2010. Aspart of the trust’s development of its group structure, the board agreed in September 2016 thatProfessor Powis would step down as RO, and a new RO would be recruited.

Dr Jane Hawdon, a consultant neonatologist, has now been recruited as RO through anexternally advertised, competitive process.

Action required

The board is asked to approve Dr Hawdon’s appointment as RO commencing January 9th 2017.

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Report from Steve Powis, medical director

Author(s) Steve Powis, medical director



Equality analysis


Paper 8

1X:\ Chair and CEO report 21 December 2016

CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

Executive summary

This is a combined chairman’s and chief executive’s report containing items ofinterest/relevance to the board.

Action required

The board is asked to note the report.

Report From D Dodd, chairman and D Sloman, chief executiveAuthor(s) A Macdonald, board secretaryDate December 2016



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CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

A TRUST DEVELOPMENTS

CHASE FARM HOSPITAL REDEVELOPMENT UPDATE

The Chase Farm Redevelopment build programme continues to run on time and on budget,with a topping out ceremony planned for January 2017. The sale of Parcel A to LindenHomes has been completed, and the team are now looking at options to maximise the valueof the remaining Parcel (B) which will be vacated after the new hospital is completed.Revenue savings are being tracked on a monthly basis. The activity projections in the FullBusiness Case are being refreshed, after which income projections and detailed workforceplans will be confirmed. Consolidation of services has continued with the closure of Mapleblock, which will release savings and facilitate changes to working practices.

ROYAL FREE HOSPITAL EMERGENCY DEPARTMENT UPDATE

The Royal Free Emergency Department redevelopment is being undertaken under twocontracts. The first has been completed, which provided a new dedicated paediatrics'emergency department and waiting area, new staff facilities and office accommodation and anew ambulatory care unit.

Contract 2 started on 26 September 2016 and will be comprised of three phases. The firstphase of the construction works will deliver Part 1 of majors, a new reception desk, and therapid assessment and treatment area including new LAS handover facilities. Phase 2 willprovide a new imaging facility including two x-ray rooms and one CT suite, and a six beddedresuscitation unit. The final phase completes the majors facility and delivers a new 30bedded CDU, which replaces the temporary facility. Phase 1 is currently taking place, whichis particularly challenging from both a build and operations perspective due to the live natureof the environment, the adjacencies of the MRI and the challenges of the infrastructure. Theclinical and project teams are working closely to maintain clinical operations at all times andto ensure progression of the works.

PEARS BUILDING

Construction of the Pears Building, which will be home to the expanded UCL Institute ofImmunity and Transplantation (IIT), is now due to start at the RFH in early 2017.

More than 50 local residents, members of staff, patients and local councillors attended apublic consultation on the construction of the Pears Building on 30 November.

At the meeting attendees heard about the plans for the new building and how theconstruction project will be managed. They were also given the opportunity to ask questionsabout the plans.

Construction of the new building, which will be built next to the Royal Free Hospital, isexpected to begin in Spring 2017. The Pears Building will be home to the expanded UCLInstitute of Immunity and Transplantation (IIT), where researchers are developing newmedicines for conditions such as cancer and type 1 diabetes.

At the meeting the trust responded to questions about the research taking place at the IIT,as well as access to the site during construction and parking arrangements at the hospital. A

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patient at the meeting also spoke about the life-saving care she has received from clinicalstaff at the IIT.

The director of capital and estates chaired the meeting and Hans Stauss, head of thedepartment of immunology, and representatives from Wilmott Dixon and Hopkins Architectsresponded to queries.

There is another consultation event planned for 9/10 January – this will be an exhibition withdetails of the basement impact report of the Pears Building. Attendees of the exhibition willbe able to leave comments to which the trust will respond.

B REGULATION

NHS IMPROVEMENT/MONITOR QUARTERLY MONITORING – Q2 2016/17

The letter has not yet been received from NHS Improvement confirming the Q2 monitoringposition. As reported last month, the trust’s shadow segmentation under the SingleOversight Framework is 2 (where 1 is the best rating and 4 is the worst). This means thatNHSI will offer targeted support in areas where the trust is challenged.

C BOARD AND COUNCIL MATTERS

NON EXECUTIVE DIRECTOR APPOINTMENTS

As reported at the last meeting, the council of governors agreed to the appointment of twonew non-executive directors, both of whom have accepted the three year appointments.

Mary Basterfield joined the trust on 1 December and is a qualified accountant. She iscurrently chief financial officer for the UK and Ireland at global media, digital marketing andcommunications group Dentsu Aegis Network, and former chief financial officer ofHotels.com.

Akta Raja, who will join the trust in January 2017, has a background as a corporate lawyerand investment banker and is currently a partner at Ansor Ventures, a firm that incubatesstart-ups.

D LOCAL NEWS AND DEVELOPMENTS

DEEPMIND TECHNOLOGY PARTNERSHIP

The RFL and British technology company DeepMind announced a landmark partnership on22 November 2016. This followed discussion by the board at its meeting on 19 October2016.

The five-year landmark agreement will see some of the best minds in healthcare andtechnology working together to transform care through a mobile clinical application calledStreams, which will deliver improved outcomes by getting the right data to the right clinicianat the right time. Like breaking news alerts on a mobile phone, the technology will notifynurses and doctors immediately when test results show a patient is at risk of becomingseriously ill, and provide all the information they need to take action.

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Following prototype testing, as well as registration with the Medicines and Healthcareproducts Regulatory Agency (MHRA), this first version of Streams is ready to be deployed toRFL clinicians early in 2017.

Under the new five-year partnership, additional features such as clinical task managementwill be added to Streams and it will be used to support clinicians in caring for patients at riskof other illnesses such as sepsis and organ failure.

The partnership will also introduce an unprecedented level of data security and audit. Alldata access is logged, and subject to review by the RFL as well as DeepMind Health’s nineIndependent Reviewers. In addition, DeepMind’s software and data centres will undergodeep technical audits by experts commissioned by its Independent Reviewers.

Furthermore, DeepMind is developing an unprecedented new infrastructure that will enableongoing audit by the RFL, allowing administrators to easily and continually verify exactlywhen, where, by whom and for what purpose patient information is accessed.

The infrastructure that powers Streams is built on state-of-the-art open and interoperablestandards, allowing the RFL to have other developers build new services that integrate moreeasily with their systems. This will dramatically reduce the barrier to entry for developers whowant to build for the NHS, opening up a wave of innovation - including the potential for thefirst artificial intelligence-enabled tools, whether developed by DeepMind or others.

FLU VACCINATION CAMPAIGN

Every year, the influenza vaccination is offered to NHS staff as a way to reduce the risk ofstaff contracting the virus and transmitting it to their family members as well as patients.Healthcare workers may transmit the illness to patients even if they are mildly or sub-clinically infected as flu is a highly transmissible infection.

The occupational health department are leading the delivery of the vaccinations across thetrust.

Vaccination clinics are being held on all sites, and staffare offered the vaccination at induction days and chiefexecutive’s briefing meetings. There is also a dailywalk-in vaccination clinic at the occupational healthdepartments at RFH and CFH. Peer vaccinators havebeen recruited to vaccinate colleaguesRecently a 48 hour ‘jabathon’ took place resulting inover 300 members of staff having their jab in supportof the event. The event was made possible by the OHnurses and peer group flu vaccinators who provided48 hours of continuous cover to be on hand tovaccinate staff.

The ‘jabometer’ displayed on the landing page ofFreenet gives the overall vaccination rate as at 12December being 45% of staff. This is a greatimprovement on the level reached at the end of2015/16 which was 28%.

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ROYAL FREE LONDON LECTURE SERIES 2016/17

A series of special lectures have been confirmed to take place over the coming weeks. Thelectures will be an opportunity to share, with an invited audience, the trust’s aspirationaround six key themes:

• Clinical innovation• Population and whole system partnerships• Clinical standards• Developing clinical and quality leadership• Strategy for clinical support• Group structure

In addition to RFL speakers, a number of prestigious experts from across the world arebeing invited to take part.

The first event, which was held at the headquarters of the King’s Fund, focussed on clinicalinnovation and the trust’s recently announced partnership with technology companyDeepMind.

LUNG CANCER TEAM WINS HSJ AWARD

The RFL lung cancer team has won a Health Service Journal award after developing a newlung biopsy method.

The biopsy team, led by Dr Sam Hare, consultant radiologist and lead for chest imaging,won the acute sector innovation award, ahead of eight other nominees. They wererecognised for developing the new ambulatory lung biopsy service, based at BH, whichenables the vast majority of patients to be discharged just 30 minutes after their biopsy. Themethod also allows biopsy patients who suffer a collapsed lung to be treated at home as out-patients.

Funding has been awarded by NHS England to support other trusts to implement this newmethod of lung biopsy and to improve care for lung cancer patients. The money, which willbe shared among a number of trusts in north central London including the RFL, has comefrom the National Diagnostic Capacity Fund.

PATIENT FRIENDS AND FAMILY TEST (FFT) UPDATE

The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feedback on their care and treatment to enable hospitals and other providers to improveservices. It asks patients whether they would recommend hospital wards, A&E departmentsand maternity services to their friends and family if they needed similar care or treatment.

The FFT results are reviewed by the patient and staff experience committee and reported toevery public meeting of the trust board.

The tables below show the combined scores for all sites and then the results by site forNovember 2016.

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Royal Free Londoncombined data

% likely/extremely likely torecommend November 2016

(range: 0 – 100%)

Number of patient responses

In-patient 89% 1401

A&E 82% 4689

Barnet Hospital % likely/extremely likely torecommend November 2016

(range: 0 – 100%)


In-patient 88% 429

A&E 78% 2423

Antenatal care 90% 31

Labour and birth 99% 158

Postnatal hospital ward 98% 163

Postnatal community care 100% 133

Out-patients 94% 275

Chase Farm Hospital % likely/extremely likely torecommend November 2016

(range: 0 – 100%)


In-patient 94% 151


Royal Free Hospital % likely/extremely likely torecommend – November 2016

(range: 0 – 100%)


In-patient 88% 717

A&E 86% 2266

Antenatal care 92% 13

Labour and birth 99% 72

Postnatal hospital ward 90% 72

Postnatal community care 100% 133


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*The postnatal community care question is only reported as a whole trust figure and not splitby site.

COMMUNICATIONS REPORT

Media coverage

Positive

During November the trust featured positively in broadcast media and national newspapersfollowing the announcement of our partnership with technology company DeepMind. Thisincluded a story on the BBC’s website, a news item on the hour on the Today Programme,BBC News at One, the top story on BBC London 6.30pm News, second story on BBCLondon 10.30pm News and the BBC News Channel. Other positive coverage included, TheEvening Standard, The Times and The Telegraph.Earlier in the month, Eva Ratz, volunteer at the trust, was awarded a Pride of Britain Awardand celebrated in local and national press as well as on ITV News. The Barnet papers alsocovered a story about a retiring porter at Barnet Hospital and The Jewish Chronical coveredthe opening of our travel clinic.

Negative

Negative coverage about our partnership with DeepMind included stories from the MailOnline, Financial Times and some specialist/trade publications.The Mail Online and The Mirror ran a story about a patient who was left paralysed after anoperation at the Royal Free Hospital.

Figure 1 shows the number of positive stories that the trust had during November. The trustwas mentioned in 63 positive stories for November.

Figure 1

57

42

0

10

20

30

40

50

60

Royal Free Hospital Barnet Hospital Chase Farm Hospital

Royal Free Hospital Barnet Hospital Chase Farm Hospital

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Figure 2 shows how much this positive coverage would cost if these pieces were paid foradvertorials, the total cost would be £193,739.81 for November.

Figure 2

Figure 3 shows the sentiment of our press mentions split as positive, neutral and negative.The sentiment of our coverage is analysed through the tone of our mentions.

Figure 3

November Royal FreeHospital

BarnetHospital

Chase FarmHospital

Total

Positive 57 4 2 63

Neutral 149 4 4 157Negative 32 0 0 32

Total 238 8 6 252

Figure 4 shows how many media requests the trust received and how many statements andwebsite stories the external and digital communications team issued during the month ofNovember.

Figure 4

Figure 5 shows the daily breakdown of the trust’svolume of news stories compared to how manypeople they reached. Reach can be calculated ashigher if the trust is mentioned in national coveragecompared to local. There is a spike for reach andvolume on 23 November, as national, local and

broadcast media reported on our partnership with DeepMind. There is also a spike on 14

£191,526.42

£1,677.12 £536.27£0.00

£50,000.00

£100,000.00

£150,000.00

£200,000.00

£250,000.00

Royal Free Hospital July Barnet Hospital July Chase Farm Hospital July

RFL value November 2016

Royal Free Hospital July Barnet Hospital July Chase Farm Hospital July

November Trust total

Statements 9Mediarequests

44

Websitestories

17

Paper 8


November as The Guardian ran a story on Pauline Cafferkey and the trust was mentioned ina story about NHS finances in the Mail Online.

Figure 5

Figure 6 shows the number of reactions (likes) and comments our posts received, and thenumber of times they were shared across the month of November.

Paper 8


• The spike on 13 November shows the reaction to a post about pharmacy porter

Harold Rollins retiring after 48 years working at Barnet Hospital. This post

reached 2,896 people.

• The spike on 23 November shows the reaction to a post about the Royal Free

Hospital and Barnet Hospital A&E departments being extremely busy. This post

reached 3,880 people.

• The spike on 29 November shows the reaction to a post about the Royal Free

Hospital’s first mention on BBC EastEnders in relation to the Phil Mitchell liver

transplant storyline. This post reached 2,258.

Twitter activity - November• Total number of followers: 11,879• Increase of 291 compared to October

2016• Percentage increase YOY: 28.31%• No. of posts: 271• Most retweeted tweet: Our medical

director Prof Stephen Powis explainshow our new app developed withDeepMind will work (30 retweets)

• Most clicked tweet: Our medical directorProf Stephen Powis explains how ournew app developed with DeepMind willwork (80 clicks)

• Most liked tweet: Our medical directorProf Stephen Powis explains how our new app developed with DeepMind willwork (49 likes)

• This tweet reached 18,572 people.

LinkedIn activity

Figure 7 shows the number of clicks our posts received over November.

Figure 7

• The spike on 23 November shows the reaction to a post about our partnership

with DeepMind. This post reached 7,555 people.

Paper 8


• The spike on 24 November shows the reaction to a post about the lung cancer

team at the Royal Free London winning a Health Service Journal award. This

post received reached 7,179 people.

Internal communications

During November, the digital and internal communications team pushed the “RFL jabathon”across the trust, to encourage staff to get their flu jab. Due to the push from thecommunications and the peer flu vaccinators, 332 staff members were vaccinated duringthe jabathon. We have vaccinated 45% of staff, this is considerably better than last year’scampaign which vaccinated 28% of staff.

The image below reveals the uptake in clinical staff across the trust and how many moreclinical staff members need to be vaccinated to reach our sequin target.

Figure 8 shows a breakdown of how many items the internal communications teamuploaded to our staff intranet, Freenet, during September, October and November.

Figure 8

Landing page news Landing page notices Freenet news Events

September 38 28 46 12

October 35 19 39 17

November 36 18 30 15

01020304050

RFL Intranet three months

Paper 8


Figure 9 shows how many stories and notices the internal communications team publishedin the monthly staff magazine, Freepress and the weekly staff e-letter Freemail.

Figure 9

November Total stories andnotices

Freenet 103

Freepress 18

Freemail 65

Managers’ briefing 27

Figure 10 shows how many briefings and visits the internal communications team arrangedduring the month of November.

Figure 10

November Total amount

Chief executivebriefing

4

Executive shadowing 1

Go-see visits 4

In this time the internal communications team also:

• Provided internal communication support for key trust improvement projects, the

2020 vision transformation programme and the financial improvement programme.

• Promoted the 2016 NHS staff survey and the actions taken to date in response to the

last two years’ feedback as part of the staff experience retention plan.

• Launched the winter flu campaign to help vaccinate as many staff as possible,

including organising and promoting a 48-hour jabathon.

• Worked closely with the relevant staff groups to promote Healthy Living Week and

launch a range of activities to celebrate Black History Month.

• Continued to support the redevelopment of Chase Farm Hospital.

• Provided communications advice and assistance for key IT projects due to launch in

2017, including EDSE, EPMA and critical care.

SECRETARY OF STATE

Secretary of State for Health, Jeremy Hunt, has launched a nationwide campaign to raiseawareness of the symptoms of sepsis among parents and carers of children aged 0-4. Thecampaign, which is part of a bigger drive led by NHS England to tackle sepsis, was launchedwith a ministerial visit to the Royal Free London NHS Foundation Trust. Sepsis is one of thekey programmes in the trust’s patient safety programme and the trust has had some successin tackling this. The Secretary of State visited the newly opened paediatric emergencydepartment and met patients and staff.

At a national level, posters and leaflets are also being widely distributed to inform parentsabout the symptoms of sepsis and encouraging them to go to A&E immediately or call 999 iftheir children display any of the following.

Paper 8


E NATIONAL NEWS AND DEVELOPMENTS

CARE QUALITY COMMISSION BOARD MEETING – 16 NOVEMBER 2016

Below is a summary of the issues discussed at the CQC board meeting.

Chief executive’s report

On the 13th October the Care Quality Commission (CQC) published The state of health careand adult social care in England 2015/16.The CQC anticipates the National Audit Office’s follow up Value for Money study of the CQCto start in December with the output published in the early summer next year.

2016/17 Q2 Corporate performance and finance report

• In March the CQC finished rating all Acute Trusts (non-specialist) and in June, Acute(specialist), Mental Health, Community Health and Ambulance Trusts.

• As the CQC increase their activity, there has been a corresponding increase inbreaches. Locations in-breach for over a year are prioritised for inspection and if theselocations receive an overall rating of inadequate they will go into special measures.

• Findings from the CQC’s biannual survey show 90% of respondents from hospitalsagreed or strongly agreed standards helped them to improve the quality of theirservices.

• In Q2 there were 6 trust re-inspections; all were rated as requires improvement priorinspection. On re-inspection one trust became inadequate, one remained as requiresimprovement and four improved and are now good.

• CQC is taking a number of measures to improve the timeliness of inspection reports.• The CQC is working with NHS Improvement to understand their proposed assessment

approach and how they are going to operationalise the assessment. Until this is inplace, the CQC says there is a risk over their ability to jointly consult in December atthe level of detail required to allow publication of full guidance in April 2017, and beginimplementation afterwards as committed. The CQC have offered NHS Improvementadditional policy resources if required.

Medium term plan

• To ensure the CQC can deliver their new strategy published in May of this year withina reduced budget envelope (to reduce by £32m by 2020), the CQC is developing amedium term financial plan, an underpinning strategy implementation plan, and anannual business plan for publication in March 2017.

• With the CQC’s main source of funding switching from the Department of Health tofees paid by providers, the CQC is aware of the need for them to use their resourcesas efficiently as possible to ensure they provide value for money. The medium termfinancial plan will underpin the delivery of these targets.

NHS IMPROVEMENT BOARD MEETING – 24 NOVEMBER 2016

Below is a summary of the issues discussed at the NHS Improvement board meeting.

Update on sustainability and transformation plans (STPs)

• NHS Improvement (NHSI) listed the following as the next steps for STPs:o Areas need to consider how to implement their strategies with the capital and

revenue funding available.

Paper 8


o Operational plans need to make the first two years of STPs ‘real’. Throughoutthis process, it will be important to see an improvement in the capital andrevenue position compared with 2016/17.

o The collaborative work throughout STP preparation should support the earlieragreement of operational plans and the brought forward planning table(signing for 2017/18 to 2018/19 by the end of the calendar year). This earlieragreement will enable greater focus on the implementation of STPs in thenew year.

o The delivery of STPs represents a significant leadership challenge. Capacityand capability at local level are required and NHS England is currentlyreviewing the necessary national and regional support.

o The remaining unpublished STPs are expected to be published over thecoming months.

Quarterly performance of the NHS provider sector

• NHSI discussed their released quarter two (Q2) finance and operational performancefigures for the provider sector:

o The Q2 net deficit for the sector is £648m, compared to £461m at Q1. This is£968m better than at Q2 2015/16 and £18m worse than at the same time of2014/15.

o Including the £1.8 billion of sustainability and transformation funding (STF),the sector has forecast to end the year with a deficit of £669m, £89m worsethan plan.

o Against forecast, the aggregate deficit at month six is marginally over plan by£22 million. The sector was £5m ahead of plan at Q1. 71 providers reportedan adverse variance against plan at Q2. The overall net adverse variancewas largely driven by: Cost Improvement Plans that were £92m under forecast delivery Bed days lost due to delayed transfers of care rising by 35%

compared to Q2 last year Agency costs exceeding plan by almost 16% Adverse variance of £195 million for non-pay items. In particular, costs

of drugs and clinical supplies significantly exceeded plan.• 142 (60%) of 237 providers are reporting a deficit, compared to 153 (65%) at Q1 and

182 at Q2 in 2015/16.• Overall, 118 providers are forecasting a year-end deficit• At Q2, 227 providers have accepted their 2016/17 control totals, giving them access

to STF. The funding has been included by 221 out of 227 trusts in their forecastoutturn.

Improvement report

NHSI and the CQC have been working together on a refreshed well-led frameworkwhich will form the basis both for the Leadership and Improvement Capability themein NHSI’s Single Oversight Framework and well-led assessment. NHSI say they aremaking good progress towards agreeing a shared structure of questions,characteristics, and good practice. They plan to issue a joint consultation on theproposed well-led framework in mid-December.

Paper 9

Page 1 of 2

Monitor risk assessment framework report

Executive summary

This paper summarises the trust’s performance against the metrics in the Monitor Risk

Assessment framework and sets out our improvement plans, where appropriate.


For information




number(s)


outcomes

X



X



X



X


Regulation 4 Requirements where the service provider is an individual or partnership

Regulation 5 ⃰ Fit and proper persons: directors

Regulation 6 Requirement where the service provider is a body other than a partnership

Regulation 7 Requirements relating to registered managers

Regulation 8 ⃰ General

Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 15 Premises and equipment

Regulation 16 Receiving and acting on complaints


Regulation 18 Staffing

Regulation 19 Fit and proper persons employed

Regulation 20⃰ Duty of candour

Regulation 20A⃰ Requirement as to display of performance assessments

Care Quality Commission (Registration) Regulations 2009 (Part 4)

Regulation 12 Statement of purpose

Regulation 13 Financial position


Trust board - public 21 December 2016 Paper 9

Paper 9

Page 2 of 2

Regulation 14 Notice of absence

Regulation 15 Notice of changes

Regulation 16 Notification of death of a service user

Regulation 17 Notification of death or unauthorised absence of a service user who is

detained or liable to be detained under the Mental Health Act 1983

Regulation 18 Notification of other incidents

Regulation 19 Fees

Regulation 20⃰ Requirements relating to termination of pregnancies

Regulation 22A⃰ Form of notifications to the Commission


Equality analysis


Report from

Kate Slemeck, Amy Caldwell-Nichols, Temi Salami

14 December 2016

References

Monitor Risk Assessment DashboardMonth: November 2016

Summary

Risk Assessment Framework Summary A&E Performance against 95% Standard

Month Trend QTD Month Trend QTD

Royal Free London NHS FT Green1 Green1 Royal Free London NHS FT R R

Royal Free Hospital Green1 Green1 Royal Free Hospital R R

Barnet Hospital & Chase Farm Hospital Green1 Green1 Barnet Hospital & Chase Farm Hospital R R

C. difficile Performance against Trajectory 18-weeks RTT Performance

Month Trend QTD Month Trend QTD

Royal Free London NHS FT G G Royal Free London NHS FT G G

Royal Free Hospital G G Royal Free Hospital G G

Barnet Hospital & Chase Farm Hospital G G Barnet Hospital & Chase Farm Hospital G G

Cancer Performance against Targets2

Month Trend QTD

Royal Free London NHS FT R R

Royal Free Hospital R R

Barnet Hospital & Chase Farm Hospital R R

1Monitor framework adjustment applies218-weeks RTT and Cancer are reported for August 16

November 2016 Monitor Risk Assessment Scorecard October 2015 to November 2016

Royal Free London NHS Foundation Trust

Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Jun-16 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target WeightingRolling

Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 93.4% 87.8% 90.2% 91.0% 91.3% 89.99% 87.92% 89.77% 85.49% 84.99% >= 95% 1.0 High

**C difficile number of cases against plan 5 0 0 0 0 2 0 2 0 0 Q1 <= 17 1.0 Low

**Maximum time of 18 weeks from point of referral to treatment inaggregate for patients on an incomplete pathways

86.7% 89.6% 92.2% 92.2% 92.2% 92.0% 92.1% 92.1% 92.2% Compliant >=92% 1.0 Low

**Cancer: two week wait from referral to date first seen

All cancers 96.2% 92.9% 94.6% 93.0% 95.1% 93.8% 94.1% 94.3% 95.3% Compliant >=93%

Symptomatic breast patients 96.4% 89.1% 97.3% 94.5% 92.78% 94.0% 94.7% 93.8% 94.7% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 99.2% 98.1% 100.0% 97.6% 97.5% 95.8% 96.5% 96.6% 97.8% Compliant >=96% 1.0

**All Cancer 31 day second or subsequent treatment -surgery 100.0% 99.1% 100.0% 98.9% 97.1% 100.0% 100.0% 98.8% 100.0% Compliant >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%radiotherapy 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94%

**All Cancer 62 days wait for first treatment:from urgent GP referrals: 73.3% 72.6% 85.8% 82.6% 78.9% 76.0% 78.0% 77.7% 73.7% Fail >=85%from a screening service 93.0% 83.3% 92.2% 94.9% 96.8% 96.7% 90.9% 94.9% 80.0% Compliant >= 90%

Compliance with requirements regarding access to healthcare for people with learning disabilities

Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant CompliantMeeting the

6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating: Green1 Green1 Green1 Green1 Green1 Green1 Green1 Green1 Green1 Green1

Green: a service performance score of <4.0 and <3 consecutive quarters' breaches of a single metric

Weighting: 2 3 2 2 3 2

Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric

* Denotes actual data for April 2016**18-weeks and Cancer data is not available for April 2016Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory

2015/16

1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary

Low

High

1.0 Medium

1.0

1.0

2016/17

Medium


Royal Free London Hospital

Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target WeightingRolling

Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 93.3% 89.5% 90.7% 92.1% 92.7% 84.9% 89.9% 84.1% 86.5% >= 95% 1.0 High

**C difficile number of cases against plan 4 0 0 0 0 0 0 0 0 Q1 <= 8 1.0 Low


All cancers 98.7% 97.4% 96.9% 96.4% 96.2% 96.7% 96.5% 96.3% Compliant >=93%

Symptomatic breast patients 98.8% 95.0% 98.2% 94.4% 96.3% 96.6% 95.7% 97.8% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 98.5% 96.5% 95.5% 95.0% 92.8% 93.0% 93.6% 96.0% Compliant >=96% 1.0

**All Cancer 31 day second or subsequent treatment -surgery 100.0% 100.0% 98.1% 92.3% N/A 100.0% 96.2% 100.0% Compliant >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%radiotherapy 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94%

**All Cancer 62 days wait for first treatment:from urgent GP referrals: 72.6% 69.8% 79.7% 71.1% 68.6% 71.6% 70.4% 62.7% Fail >=85%from a screening service 92.6% 92.6% 91.7% 100.0% 94.1% 76.5% 89.1% 71.4% Fail >= 90%


Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant CompliantMeeting the 6

criteria1.0 Low

Monitor overall governance thresholds: Trust Rating: Green1 Green1 Green1 Red Green1 Green1 Green1 Green1 Green1


Weighting: 2 3 3 4 3



2015/16


1.0 Low

1.0 Low

1.0 High

High


Barnet Hospital


Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 91.5% 82.2% 91.3% 87.6% 84.5% 86.5% 86.2% 81.8% 79.1% >= 95% 1.0 High

**C difficile number of cases against plan 1 0 Compliant Compliant 2 0 2 0 0 Q1 <= 7 1.0 Low


All cancers 94.5% 91.0% 91.7% 94.6% 92.2% 92.5% 93.1% 94.4% Fail >=93%


**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=96% 1.0

**All Cancer 31 day second or subsequent treatment -surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%radiotherapy N/A N/A N/A N/A N/A N/A N/A N/A N/A >=94%

**All Cancer 62 days wait for first treatment:from urgent GP referrals: 76.0% 75.5% 80.0% 79.7% 80.6% 83.0% 81.0% 85.4% Fail >=85%from a screening service 100.0% 91.7% 100.0% 100.0% 100.0% 100.0% 100.0% 71.4% Compliant >= 90%


Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Meeting the 6

criteria1.0 Low

Monitor overall governance thresholds: Trust Rating: Green1 Green1 Red Green1 Green1 Green1 Green1 Green1 Green1


Weighting: 2 3 4 3 3 3 3 3 3



2015/16


1.0 High

1.0 Low

1.0 High

Low

2016/17


Chase Farm Hospital


Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >= 95% 1.0 Low

**C difficile number of cases against plan 0 0 0 0 0 0 0 0 0 Q1 <= 0 1.0 Low


All cancers 95.5% 90.8% 89.9% 94.1% 93.9% 93.7% 93.9% 95.6% Compliant >=93%


**All cancers: 31 day wait from diagnosis to first treatment 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=96% 1.0 Low

**All Cancer 31 day second or subsequent treatment -surgery 100.0% 96.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%radiotherapy N/A N/A N/A N/A N/A N/A N/A N/A N/A >=94%

**All Cancer 62 days wait for first treatment:from urgent GP referrals: 69.1% 72.3% 80.4% 91.9% 83.9% 83.3% 86.9% 73.5% Fail >=85%from a screening service 80.0% 52.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >= 90%


Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant CompliantMeeting the

6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating: Green1 Green1 Green1 Green1 Green1 Green1 Green1 Green1 Green1


Weighting: 1 2 2 0 2


* Denotes actual data for March 2016**18-weeks and Cancer data is not available for March 2016Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory

2015/16


1.0 High

1.0 Low

1.0 High


Other Satellite Sites


Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours >= 95% 1.0

**C difficile number of cases against plan Q1 <= 0 1.0


All cancers 93.4% 79.7% 82.8% 96.6% 89.3% 90.3% 92.0% 95.8% Fail >=93%

Symptomatic breast patients 91.7% 42.9% 80.0% N/A 100.0% 100.0% 100.0% 100.0% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% 100.0% 100.0% N/A N/A 100.0% N/A Compliant >=96% 1.0 Low

**All Cancer 31 day second or subsequent treatment -surgery >=94%drug >=98%radiotherapy >=94%

**All Cancer 62 days wait for first treatment:from urgent GP referrals: 50.0% 84.8% 100.0% 100.0% N/A 0.0% 75.0% N/A Fail >=85%from a screening service 94.8% 100.0% 91.4% 90.0% 96.7% 97.2% 95.3% 92.3% Compliant >= 90%


Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Meeting the

6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating:


Weighting: 2 2



2016/172015/16


1.0 High

1.0

1.0 High

April 2016 Performance against Recovery Trajectory

Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust A&E 95% Trajectory 92% of patients with incomplete pathways waited less than 18-weeks RTT 52 week breaches

The A&E trajectory delivers compliance against the 95% standard from June 16 and each month thereafter to September 16, from October 16 the trust returns to non-compliance (as a result of winter pressures) for the remainder of 2016/17. The trust's Chief Operating Officer is currently reviewing the delivery date of June 16 against the quarter 1 forecast delivery-risk, following this review the trajectory may be amended.

Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust Cancer - 62 day wait from urgent GP referral 99% of patients on a diagnostic pathway within 6 weeks

The Cancer 62 day trajectory delivers compliance against the 95% standard from June 16 and each month thereafter to the end of 2016/17. The trust's Chief Operating Officer is currently reviewing the delivery date of June 16 against the quarter 1 forecast delivery-risk, following this review the trajectory may be amended.

Performance measured against trajectoryThe graphs presented below represent the trust's actual performance ("measure") against externally submitted trajectories ("trajectory") during the course of 2015/16 and those trajectories submitted in respect of 2016/17. For 2016/17 the data will be refreshed with each month's actual performance against trajectory. Where a negative variance (underperformance) is recorded against trajectory, or important contextual information is required, this will appear beneath each relevant chart.

90%

92%

94%

96%

98%

100%

Ap

r-1

5

Ma

y-1

5

Jun

-15

Jul-

15

Au

g-1

5

Se

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5

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v-1

5

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5

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6

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r-1

7

Patients with diagnostic pathways to have waited less than 6-

weeks - Percentage of Trust Compliance

Measure Trajectory

60%

70%

80%

90%All Cancer 62 Days Wait for First Treatment

Urgent GP Referrals

Measure Trajectory

80%

85%

90%

95%

100%

A&E - 95% of patients admitted, transferred or discharged

within 4-hours

Measure Trajectory

80%

85%

90%

95%

Patients with incomplete pathways to have waited less

than 18-weeks - Percentage of Trust Compliance

Measure Trajectory

0

50

100

150

200

250

No of 52 week Breaches

Measure Trajectory

April 2016 High Risk Ratings

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital A&E 95% Standard A&E 95% Standard A&E 95% Standard A&E 95% Standard

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet & Chase Farm Hospital Chase Farm Hospital 92% of patients with incomplete pathways waited less than 18-weeks 92% of patients with incomplete pathways waited less than 18-weeks 92% of patients with incomplete pathways waited less than 18-weeks 92% of patients with incomplete pathways waited less than 18-weeks

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All Cancer 2 week wait All Cancer 2 week wait All Cancer 2 week wait All Cancer 2 week wait

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Symptomatic breast 2-week wait Symptomatic breast 2-week wait Symptomatic breast 2-week wait Symptomatic breast 2-week wait

Risk Rating - High

86%

88%

90%

92%

94%

De

c-1

4

Jan

-15

Fe

b-1

5

Ma

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5

Ap

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Patients with incomplete pathways to have waited less than 18-


Measure Target

86%

88%

90%

92%

94%Patients with incomplete pathways to have waited less than 18-


Measure Target

80%

85%

90%

95%

100%


within 4-hours

Measure Target

80%

85%

90%

95%

100%

A&E - 95% of patients admitted, transferred or

discharged within 4-hours

Measure Target

80%

85%

90%

95%

100%

A&E - 95% of patients admitted, transferred or

discharged within 4-hours

Measure Target

88%

90%

92%

94%

96%

98%

100%

Cancer: 2 week wait (All Cancer)

Measure Target

84%

86%

88%

90%

92%

94%

96%

98%


Measure Target

88%

90%

92%

94%

96%

98%


Measure Target

70%

75%

80%

85%

90%

95%

100%

Cancer: 2 week wait (Symptomatic Breast)

Measure Target

70%

75%

80%

85%

90%

95%

100%


Measure Target

75%

80%

85%

90%

95%

100%


Measure Target

86%

88%

90%

92%

94%

De

c-1

4

Jan

-15

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5

Ma

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Patients with incomplete pathways to have waited less than 18-


Measure Target

80%

85%

90%

95%

100%


within 4-hours

Measure Target

84%

86%

88%

90%

92%

94%

96%

98%


Measure Target

70%

75%

80%

85%

90%

95%

100%


Measure Target

April 2016 High Risk Ratings

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Cancer - 62 day wait from urgent GP referral Cancer - 62 day wait from urgent GP referral Cancer - 62 day wait from urgent GP referral Cancer - 62 day wait from urgent GP referral

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Cancer 62 days from screening Cancer 62 days from screening Cancer 62 days from screening Cancer 62 days from screening

60%

70%

80%

90%

100%

All Cancer 62 Days Wait for First Treatment

Urgent GP Referrals

Measure Target

55%

65%

75%

85%

95%


Urgent GP Referrals

Measure Target

60%

65%

70%

75%

80%

85%

90%


Urgent GP Referrals

Measure Target

60%

70%

80%

90%

100%

Cancer 62 Days Wait for First Treatment

Screening

Measure Target

60%

70%

80%

90%

100%


Screening

Measure Target

0%

20%

40%

60%

80%

100%


Screening

Measure Target

50%

60%

70%

80%

90%

100%


Urgent GP Referrals

Measure Target

0%

20%

40%

60%

80%

100%


Screening

Measure Target

April 2016 Low Risk Ratings

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Number of C. difficile infections against plan Number of C. difficile infections against plan Number of C. difficile infections against plan Number of C. difficile infections against plan

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All cancers: 31 day wait from diagnosis to first treatment All cancers: 31 day wait from diagnosis to first treatment All cancers: 31 day wait from diagnosis to first treatment All cancers: 31 day wait from diagnosis to first treatment

Royal Free London NHS Foundation Trust Royal Free HospitalAll Cancer 31 day second or subsequent treatment for radiotherapy All Cancer 31 day second or subsequent treatment for radiotherapy

Risk Rating - Low

Summary:The following indicators have been rated Low risk primarily on the basis that at trust level there is good headroom against the standard. However the trust requires compliance to be achieved at every hospital every month and quarter. The C. difficile charts have a black line separating the data pre and post April 15, this reflects the change in counting methodology applied by Monitor from that date. From April 15 only infections relating to "lapses in care" are included for the purposes of the Monitor risk assessment.

88%

90%

92%

94%

96%

98%

100%

All Cancers: 31 Day Wait from Diagnosis to First Treatment

Measure Target

90%

92%

94%

96%

98%

100%

All Cancer 31 Day Second or Subsequent Treatment

Radiotherapy

Measure Target

94%

95%

96%

97%

98%

99%

100%


Measure Target

90%

92%

94%

96%

98%

100%


Radiotherapy

Measure Target

93%94%

95%

96%

97%

98%99%

100%


Measure Target

0

1

2

3

4

5

C-Difficile

Measure Target

0

1

2

3

4

C-Difficile

Measure Target

01234567

C-Difficile

Measure Target

94%

95%

96%

97%

98%

99%

100%


Measure Target

0

1

2

C-Difficile

Measure Target

April 2016 Low Risk Ratings

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital

All Cancer 31 day second or subsequent drug treatment All Cancer 31 day second or subsequent drug treatment All Cancer 31 day second or subsequent drug treatment All Cancer 31 day second or subsequent drug treatment

Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All cancer 31 day Second or Subsequent Treatment Surgery All cancer 31 day Second or Subsequent Treatment Surgery All cancer 31 day Second or Subsequent Treatment Surgery All cancer 31 day Second or Subsequent Treatment Surgery

97%

98%

99%

100%


Drug

Measure Target

97%

98%

99%

100%


Drug

Measure Target

97%

98%

99%

100%


Drug

Measure Target

0%

20%

40%

60%

80%

100%


Surgery

Measure Target

90%

92%

94%

96%

98%

100%


Surgery

Measure Target

90%

92%

94%

96%

98%

100%


Surgery

Measure Target

0%

20%

40%

60%

80%

100%


Drug

Measure Target

80%

85%

90%

95%

100%


Surgery

Measure Target

High Risk Indicators Commentary and Exception Report

Month: October 2016

Risk Assessment Framework - commentary

Trust performance overview

The table below summarises the performance against standard by site and by trust. Compliance is being delivered against all standards with the exceptionof:

• A&E

• 62 day cancer from a GP referral

• 62 day cancer from a screening service

PeriodReported Indicator

Description Standard STF AllRoyalFree

BarnetChaseFarm

Other

Nov-16 AE Patients admitted, transferred or dischargedwithin 4 hours

95% 90% 85.0% 86.5% 79.1% 100.0%

Nov-16 C DifficileCases

Lapses in care <=0 0 Compliant Compliant Compliant Compliant Compliant

Oct-16 RTT Patients on incomplete pathways waitingless than 18weeks

92% 92% 92.2%

Oct-16 Cancer 2 week waits - All cancers 93% 95.3% 96.3% 94.4% 95.6% 95.8%

2 week waits - Symptomatic breast 93% 94.7% 97.8% 92.9% 94.2% 100.0%

31 day waits diagnosis to first treatment - Allcancers

96% 97.8% 96.0% 100.0% 100.0%

31 day waits diagnosis to first treatment –Surgery

94% 100.0% 100.0% 100.0% 100.0%

31 day waits diagnosis to first treatment -Drug

98% 100.0% 100.0% 100.0% 100.0%

31 day waits diagnosis to first treatment -Radiotherapy

94% 100.0% 100.0%


Month: October 2016

62 day waits from GP referral to treatment 85% 78.2% 73.7% 62.7% 85.4% 73.5%

62 day waits from screening service referralto treatment

90% 80.0% 71.4% 71.4% 100.0% 92.3%

The Strategic Transformation Fund (STF)For 2016/17 NHS Improvement has allocated additional funding from the STF to trusts delivering against agreed target recovery trajectories. Ourtrajectories for all indicators are summarised in the table below – green indicates that we have met the trajectory, red that we have not.

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

A&E 4 hour standard 90% 92% 93% 95% 95% 95% 92% 90% 91% 91% 92% 92%

18-weeks RTT Incomplete Pathways 90% 91% 91% 92% 92% 92% 92% 92% 92% 92% 92% 92%

18-weeks RTT Volume of 52 Weeks

Breaches 5 5 5 5 5 5

0 (out-

turn 2) 0 0 0 0 0

99% of Diagnostic Pathways to be

Seen within 6-weeks99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%

Cancer 62 days from GP Referral79.7% 75.2% 76.1% 77.4% 78.1% 74.4% 78.2% 83.8% 85.2% 85.3% 85.2% 85.2%


Month: October 2016

A&ETo address our continuing performance issues, we are implementing our Safer, Faster, Better programme. Key achievements for this month include:

• Surgical AEC pilot at RF site scoped and plan developed for implementation (w/c 19th Jan for Abscess pathway),

• RF Navigator role scoped and pilot due to start 23rd January 2016,

• SAFER bundle implemented on Rowan, 9W, 7N & 7W wards,

• All discharge to assess and step down beds now open and fully utilised,

• SOP for patient choice written and pending implementation, and

• Communications for the programme designed and implementation has started.

The Barnet AAU development is still on schedule for opening in mid-December.

Cancer 62 day GP and ScreeningCancer 62 day performance for October was below trajectory and we anticipate that November will also be below trajectory. This month we have:

• Near finalised hot reporting across all our prostate cancer clinics;

• Implemented a new one-stop clinic for HPB patients; and

• Piloted a new tele-dermatology service for roll-out in December and January.

Paper 10

FINANCE PERFORMANCE REPORT 2016/17 – Month 8

Executive summary

The Trust delivered an actual deficit of £44.3m at end of November; this was £47.4m worse than its planned

surplus of £3.1m. Key factors driving the year to date variance from plan are

1. Income adjustments relating to prior year of £18.1m

2. Income provisions relating to this financial year of £6.7m

3. Under performance in clinical activity income

4. Over spend on pay mainly relating to use of agency to cover medical pay vacancies

5. Over spend on non-pay mainly due to outsourcing. We also have increased patient transport costs

due to change of supplier.

6. Under recovery of PPU income resulting in reduced contribution

7. Slippage against savings target

8. STF funding loss of £7.6m


For Discussion



Board assurance risk number(s)






Equality analysis


Report from Caroline Clarke

Author(s) Senior Finance Team

Date 12th December 2016



Financial Performance ReportNovember 2016

1

FINANCIAL PERFORMANCE EXECUTIVE SUMMARY

November 2016

Measure Description Status Position Trend Variation

Normalised

Net Surplus /

(Deficit)

Net income and

expenditure excluding

profit from fixed asset

disposals and fixed asset

impairments

Net surplus/(deficit) in month:

Plan (£0.4m), Actual (£9.6m),

Variance (£9.1m) adverse

Net surplus/(deficit) YTD:

Plan (£14.0m), Actual

(£61.4m), Variance (£47.4m)

deficit

NHS Clinical Income: The year to date (YTD) clinical income values as at 30th

November shows an under performance positon of (£33.6.m) which primarily

relates to prior year credit notes issued.

Other Income: (£0.9m) adverse from plan in month and (£8.6m) adverse YTD. The

adverse variance relates primarily to private patient reduced activity and pharmacy

wholesaling.

Pay excluding Integration: (£2.4m) adverse from plan in month and (£7.2m)

adverse YTD. Overspend is mainly due to use of agency to cover medical pay

vacancies and unallocated CIP targets.

Non-Pay excluding Integration & TEDD: (£0.1m) adverse from plan in month and

(£7.1m) YTD. Key overspent areas are outsourcing, patient transport and

unallocated CIP targets.

Integration: £0.1m favourable in month and £1.6m favourable YTD.

CIP Savings

Savings against the

recurrent CIP savings

plan. The plan includes

both cost efficiency or

income generation

schemes.

CIP in month:

Plan £4.3m, Actual £6.4m,

Variance £2.1m favourable

CIP year to date:



Actual delivery of plans in M8 was of £6.4m, which is £2.1m favourable when

compared to plan.

Capital

Expenditure

Year to date cumulative

expenditure in non-

current assets.

CAPEX in month:


Variance £1.1m adverse

CAPEX year to date:



Capital expenditure for the month is £7.5m which is £1.1m higher than plan.

All programmes are back on track and forecast to be witin CAPEX limit.

Cash

Cash held with the

government banking

service and in commercial

banks.

Cash flow in month:

Plan £1.5m, Actual (£1.7m),

Variance £3.3m adverse

Cash balance:


Variance (£5.0m) adverse

Cash at end of November was £12.0m against a plan of £17.0m. The cash balance

was below the planned level due to lower than expected receipts of the prior year

NHS over performance, debts relating to the GP Lead programme and the current

year deficit. On a positive note the Trust secured an advance of £10m on the

December SLA from NHS Barnet on the 1st December which will help pay key

suppliers.

The £12m cash balance reflects the Income and Expenditure deficit position and

non-recovery of NHS debts.

2015/16

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Capital Service Cover 1 1 1 1 1 1 2 3

Liquidity 4 4 4 4 2 2 4 4

Normalised I&E Margin 1 1 1 1 1 1 1 2

I&E Margin Plan Variance 2 2 2 2 3 1 4 4

Overall 2 2 2 2 2 1 2 3

Monitor

Financial

Sustainability

Risk Rating

(FSRR)

Monitor measures an

organisations financial

risk on a scale of 1-4 with

4 being the lowest risk

and 1 the highest risk.

2016/17 Actual 2016/17 Plan

Monitor FSSR: Trusts with a Normalised I&E margin of less than -1% are rated as 1

for this metric. A rating of 1 on any metric means the overall rating cannot exceed

2.

0

2

4

6

8

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

£m

Plan

Actual

0

2

4

6

8

10

12

D e c… J a n… F e b…

M a r… A p r… M a y… J u n… J u l… A u g… S e p…

O c t… N o v…

£m

Plan

Actual

0

50

100

150

D e c… J a n… F e b…

M a r… A p r… M a y… J u n… J u l… A u g… S e p…

O c t… N o v…

£m

Plan

Actual

-30

-25

-20

-15

-10

-5

0

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

£m

Plan

Actual

A

R

G R

A

R

2

Paper 11

Shadow group board report – Board December 2016

SHADOW GROUP BOARD REPORT

Executive summary

The Shadow Group Board (SGB) met on 8 December 2016.

The key issues discussed were:

- an update on provider, partner and system stakeholder discussions;- the next steps for standing up the group structure;- the trust’s approach to primary care;- the Global Digital Exemplars programme;- progress of the centralisation of sterilisation and decontamination services;- an update on HSL; and- discussion of potential land sales.

Action required

To note.

Trust strategic priorities and businessplanning objectives supported by this paper

Board assurance risk number(s)

3. Excellent financial performance – to be inthe top 10% of relevant peers on financialperformance

5. A strong organisation for the future – tostrengthen the organisation for the future


Regulation 12 Statement of purposeRegulation 13 Financial position

Equality impact assessment

No identified negative impact on equality and diversity

Report From Dominic Dodd, chairmanAuthor(s) Tom Snowdon, planning managerDate 13 December 2016



Paper 12

Page 1 of 3

Final

Report from patient safety committee held 24 November 2016

Executive summary

The patient safety committee met on 24 November 2016. The key matters of interest wereas follows:

Patient safety metrics - medical errorsThe committee received its summary of performance against key patient safety metrics,noting that there had been an increase in the reporting of medication errors. However, it wasunderstood that this increase had been seen across all the trust’s hospitals and did not relateto an increase in severity and as such was not related to a decline in safety.

The chair noted that the committee had asked for granularity on medication error data forsome time, adding that one of the closed serious investigations reports to be discussed lateron in the meeting had been attributed to a medication error. The associate medical directorfor patient safety reported that a major review of such data had been undertaken recently bythe pharmacist for clinical governance and a report on this (level of harm, type of error etc.)would be presented at the meeting in January, alongside a paper outlining the benefits ofelectronic prescribing.

Closed serious incidents investigations (SI)At each meeting, members choose which closed SI investigation reports they would like todiscuss in the context of actions for improvement, lessons learned and shared learning.

A discussion was had on SIs where the trust was clearly at fault and the legal position onthis, particularly in terms of fairness for the patient and the option of financial settlements /compensation outside of formal litigation. The head of legal services reported that onconfirmation of an SI, the legal team would proactively report it to the NHS LitigationAuthority but this was in the event that there could be a potential clinical negligence claimagainst the trust. The chair welcomed greater insight on this and asked the head of legalservices to ascertain what the trust’s policy was in cases of an early recognition of a clear atfault SI, and to report back to the committee in due course.

Incident reporting and learning (including serious incidents and never events) policyThe committee ratified the policy as it stood, noting that it would be subject to further revisiononce the trust’s new group structure had been established.

Care Quality Commission (CQC)The committee agreed the removal of two satellite sites from the trust’s CQC registration.

Maternity services integrated action planThe committee was pleased to see the good progress made against implementation of theaction plan but noted that challenging conversations were continuing to held with IT inrelation to a number of IM&T-related actions where slow progress had been made.



Paper 12

Page 2 of 3

Final

The committee agreed to the formal closure of the maternity action plan in light of the goodprogress made to date and, going forward, the monitoring of outstanding actions through therelevant risk register / action plans and groups, and noted that Barnet CCG was inagreement. Both the director of nursing and chair noted their thanks to the staff withinmaternity services for all their hard work over the last year and for the many improvementsmade.

The medical director considered that the first wave of clinical practice groups was likely to befocused on women and children’s services, and recognised that maternity services inparticular was an excellent example of where to focus initial efforts in this regards.

Action required

The board is asked to note the report.




number(s)


outcomes

x



x



x



x





























Regulation 19 Fees

Paper 12

Page 3 of 3

Final




N/A

Equality analysis


Report from Stephen Ainger, non-executive director and chair of the patient safety

committee

Author(s) Veronica Jackson, committee secretary


Paper 13

Page 1 of 2

Confirmed minutes of the Audit Committee

Executive summary

The confirmed minutes of the audit committee held on 15 September 2016 are attached for

information at Appendix 1.

Action required

The board is asked to note the minutes.




number(s)


outcomes

x



x



x



x



x






















Paper 13

Page 2 of 2










Regulation 19 Fees




Any risk would be outlined in the report.

Equality analysis


Report from Deborah Oakley, non-executive director and chair of the audit committee



1 FINAL Last update 22.11.16

FINAL

Minutes of the Audit Committee 15 September 2016

Present: Ms Deborah Oakley Non-executive director (committee chair) Mr Stephen Ainger Non-executive director Ms Jenny Owen Non-executive director In attendance: Ms Caroline Clarke Chief financial officer Ms Lubna Dharssi Assistant director of finance – financial control Mr Neil Thomas Mr Dean Gibbs Mr Stevan Burtenshaw Ms Gemma Higginson

Head of internal audit - KPMG Senior manager, internal audit - KPMG Senior consultant - RSM Consultant – RSM

Mr Luke Price Mr Charles Martin

Consultant – RSM Engagement manager - PricewaterhouseCoopers

Ms Julie Dawes Mr Peter Ridley Mr Tosh Mondal Mrs Emma Kearney Mr David Grantham Ms Veronica Jackson

Interim trust secretary Director of planning Interim chief information officer and data protection officer (for item 38-16/17 only) Director of corporate affairs and communication (for item 40/16-17 only) Director of workforce and organisational development (for items 59-60/16-17 only) Committee secretary (minutes)

ACTION

33/16-17 APOLOGIES FOR ABSENCE

Members: No apology Attendees: Mike Dinan – Director of financial improvement Lynn Pamment - Engagement leader, PricewaterhouseCoopers David Foley – Head of fraud risk services, RSM The chair noted that Dean Finch had resigned from the board and welcomed Peter Ridley and Luke Price who were new to the meeting.

34/16-17 DECLARATIONS OF INTEREST

The audit committee board members confirmed no change to their declarations.

35/16-17 MINUTES OF THE AUDIT COMMITTEE MEETING HELD ON 25 MAY 2016

The minutes were agreed as a true record of the meeting.

ACTION LOG AND MATTERS ARISING

36/16-17 Review open actions log (for noting)

The committee reviewed the action log:

11/16-17(a) – this would be closed. 19/16-17 – would be ready for the meeting in November. 21/16-17 – would be expanded to include the gifts and hospitality register. The

assistant director of finance – financial control stated that a review of the register of


FINAL

interest etc. should be undertaken on an annual basis, so the committee may wish to consider whether this needed to be done more frequently. Robust checks that all staff were declaring, even if this was a nil return, was also needed. She agreed to bring a paper on to the meeting in January at which point the recommendations from the local counter fraud review would have been implemented.

26/16-17 – it was confirmed that the Royal Free Charity was still funding the patient Wi-Fi. The assistant director of finance – financial control would check whether this applied to all the trust’s hospital sites and whether there was an end date to this agreement. The chief finance officer declared that she was a trustee of the Royal Free Charity.

29/16-17(a) – this would be addressed at the patient and staff experience committee and, therefore, would be closed off the audit committee action log.

120/15-16 – the assistant director of finance – financial control had updated the paper to provide additional detail. However, this was still not addressing the committee’s concerns regarding additive work and also adding another site to an existing contract. She requested that details addressing these points and providing assurance as to how value for money had been obtained be added to the report.

126/15-16 – members had requested additional information; this would be included in the report when next presented to the committee in January 2017.

88/15-16(a) – the chair asked that this be addressed at the meeting in November. 45/15-16 – this was completed.

LD

LD

LD

LCFS

37/16-17 Matters arising

There was no matter arising.

38/16-17 Information security (cyber security and national data guardian security review)

The committee welcomed Mr Mondal to the meeting who was acting as the interim chief information officer following the departure of Will Smart. He updated the committee on the outcome of two reviews; CSC’s cyber security team’s review of the trust’s information systems and a self-assessment against the the national data guardian’s (NDG) security review. The following was noted:

i. CSC’s cyber security team’s review of the trust’s information systems – the interim chief information officer explained that CSC was a consulting group that had been asked to provide an in-depth analysis of the trust’s current infrastructure and security, and to provide recommendations for improvement. He added that a copy of the full report was available on request.

An action plan was in place which was overseen by the trust’s head of infrastructure with the aim of ensuring all actions would be completed within 90 days, i.e. the end of the year. Oversight of the action plan would be provided by the information governance group. He confirmed that all actions would be completed by the end of the year, and that the committee could assume that was the case unless it heard otherwise.


FINAL

In response to a question from the chief finance officer on how the trust fared against other trusts on this issue, it was noted that CSC had found a similar picture elsewhere.

In summing up, the committee noted

ii. NDG security review – the interim chief information officer had provided a list showing the trust’s position in relation to the NDG’s 10 security standards. The chair thanked him for this but stated that she had hoped to see greater detail and assurances in the report. She requested that a more comprehensive report, for example what was the proportion of the number of staff that underwent annual confidentiality training in handling PID against data security standard 1, be taken to the November meeting. She would speak with the interim chief information officer in advance of the meeting to ensure that the level of detail in the report met the committee’s expectations.

A risk had been added to the board assurance framework (BAF) on cyber security following the audit committee’s recommendation and subsequent approval at the board. The interim chief information officer reported that good progress had been made in addressing the greatest risks, with much of the technical work completed, and was confident this risk had been mitigated for where possible. As such, his view was that the risk score could be reduced to 12 / 16.

TM

DO

PR

39/16-17 Notice of discussion of items marked ‘for information’ (by exception)

Members and attendees would decide which items they would like to discuss as the chair progressed through the agenda.

OTHER ASSURANCE ITEMS

40/16-17 Well led governance review assessment process and proposal for next steps

The chair had spoken with the head of internal audit in advance of the meeting and discussed whether the well led governance review could be postponed in light of the new group model governance arrangements and the assurance provided by way of the recent CQC inspection where the trust’s leadership, management and governance (are services at this trust well led?) were rated as good. The head of internal audit supported the postponement, noting that other trusts had taken the decision to postpone their well-led review on the back of positive CQC results, but added that another less intensive but probing self-assessment may be helpful in the interim and could provide a baseline for development of the group governance. Ms Owen, non-executive director considered the following needed to be factored in; capacity to undertake the review and the costs involved, including the use of external provider. Her view was that internal audit’s suggestion of a good quality self-assessment would suffice at this stage. The interim trust secretary noted that she was aware of two trusts that had undertaken the well led review and factored the group model within that.

The committee agreed that a paper outlining the alternatives was not needed. Instead a recommendation from the committee to postpone the review, given it considered that adequate sources of assurance were already available, would be made to the board. A review of group governance would be required once the transition was completed. The chief finance officer agreed that some form of self-assessment was needed however and that this should be done before the end of the year.

DO JD

INTERNAL AUDIT

41/16-17 Progress report and technical update

Ms Owen, non-executive director considered the update on the principles for engaging


FINAL

people and communities to be very helpful. She added that the next patient and staff experience committee meeting in October would focus specifically on patient engagement and involvement but with the remit broadened to include membership and embedding the quality strategy. Key speakers from Northumbria Healthcare NHS Foundation Trust and East London NHS Foundation Trust would be joining the meeting to talk about their experiences and work in this area in order to help the committee understand the scale of the work needed and ambition for the trust in this regards.

The committee suggested that assurance was needed on the impact on the trust and the NHS more widely of leaving the European Union. It appreciated that any such paper would be brief as there were many unknowns at the stage but that it would be helpful to consider the strategic headline issues, e.g. staffing, access to treatment and regulation. The director of planning agreed to draft a paper for the board.

The director of financial operations would take a paper on the national tariff proposals for next year and the NHS Improvement price comparator tool to the finance, investment and performance committee.

The internal audit review into the trust’s non-emergency patient transport review had been deferred at the request of management until March 2017. Ms Owen, non-executive director would touch base with the director of facilities on the status of the new service provision and KPIs, particularly as the director of planning had recommended the closure of the patient transport risk on the BAF.

PR MD

42/16-17 Follow up recommendations

The committee was pleased to note that there was no red rated recommendation that was more than six months overdue. There was, however, a total of 27 outstanding overdue recommendations, which was fewer than those reported in May. The head of internal audit suggested this could still be improved upon.

The director of planning was now the executive lead for the data quality - cancelled operations recommendation.

43/16-17 Internal audit review – electronic prescribing medicines administration (EPMA) programme management

The committee received internal audit’s review of how the trust had applied the lessons learned from the patient administration system (PAS) / patient master index lessons learned report to the e-prescribing and medicines administration (EPMA) programme. An overall assessment of ‘Partial assurance with improvements required’ (Amber-Red) was given; this was lower than management’s expectation of Amber-Green.

It was noted that the implementation of EPMA had been postponed (now expected March 2017). In terms of the financial implications, the committee noted that this had been taken into account in the trust’s forecast. Development of the final business case had also been delayed. The director of planning noted that a revised draft was presented at the recent capital management group, and February was mooted as a potential date for the final version. It was noted that a slower testing / pilot period was needed. The committee enquired whether the knock-on effect to other projects and to CIP programs had been factored in. The chief finance officer responded that the latest financial projections took account of the delay.

KPMG confirmed that despite the postponement, the completion dates for the recommendations identified still stood and these were considered realistic. KPMG would only report back on the recommendations in the event there had been significant slippage against them.

KPMG


FINAL

44/16-17 Internal audit review – serious incidents

The committee received internal audit’s review of the trust’s processes for reporting and responding to serious incidents and was pleased to note the positive rating of ‘Significant assurance with minor improvement opportunities’ (Green-Amber). Mr Ainger, non-executive director had requested that a copy of the report be taken to the patient safety committee the following week for information, adding that it would be helpful to reconcile the results of that review with the findings from the CQC inspection where the trust was rated as ‘requires improvement’ for the safety domain.

45/16-17 Internal audit review – BMI profit share / Kings Oak Hospital profit share agreement

The committee received a report outlining the work undertaken by internal audit in relation to the profit share agreement between the trust and BMI healthcare limited (BMI) for the financial years to 30 September 2014 and 30 September 2015.

The committee noted the longevity of the contract.

46/16-17 Process for the assessment of internal audit effectiveness 2015-16

A procurement exercise was underway for the trust’s internal audit provision so the committee considered whether, in light of this, there was any value in undertaking the assessment. It agreed to approve the process for the assessment pending the outcome of the procurement exercise.

EXTERNAL AUDIT

47/16-17 Progress report

It was noted that all the trust’s service level agreements were signed by the end of May 2016 which was earlier than last year. The committee was content with the quality report recommendations, and the chair stressed the need to ensure that the timescales were adhered to. It was agreed that the recommendations would be followed up on an exception basis to ensure the committee did not lose sight of them.

PwC

48/16-17 Outcome of the assessment of external audit effectiveness 2015-16

The last two assessments had raised the same issue of improving external audit’s engagement with the council of governors. PwC reported that they had held a 2.5 hour governors’ development session in April but attendance had been poor, with only seven governors having attended. They would reflect on this issue in their audit plan 2016/17 which was due to presented to the committee in November, but were open to advice from trust colleagues on how engagement could be improved further. Furthermore, it was noted that PwC were due to attend the council of governors meeting in November.

LOCAL COUNTER FRAUD SPECIALIST

49/16-17 Progress report including follow up recommendations

It was noted that he committee was pleased to see the inclusion of the management action


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tracker, and following circulation of the report noted that two further actions had been completed, one was in progress, and five were awaiting status updates (which had since been received).

The committee noted there was one action which was ‘subject to negotiation’ as local counter fraud wanted to ensure that the right and sufficient in-depth checks were being undertaken.

The chair requested that the committee focus on the pre-contract procurement review actions in more detail at the November meeting.

Mr Ainger, non-executive director was concerned to note that there was no standalone procurement policy, particularly in light of the financial risks associated with the redevelopment of Chase Farm Hospital, and from the view of the trust’s individual rather than shared procurement. RSM noted that the development of a procurement policy was underway and was expected to be completed by the end of the year. This would be reflected in the trust’s standing financial instructions (which required updating).

Ms Owen, non-executive director noted the frequent recovery of personal payments which were essentially small amounts and asked whether potentially the bigger issues, and therefore larger contributions, were being missed. RSM reported that when compared to other trusts, the RFL was typical in terms of the monies recovered from lower paid staff but considered this fair challenge, adding that the trust was progressive in terms of its payment recovery but that very few referrals relating to procurement and contractors were being seen. RSM agreed to provide a chart in the next report showing the main areas where recovery had been made.

RSM RSM

50/16-17 Final LCFS annual report 2015-16

The committee noted the final report and was pleased to see the inclusion of the management action tracker.

51/16-17 Process for the assessment of local counter fraud effectiveness 2015-16

A procurement exercise was underway for the trust’s local counter fraud provision so the


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committee considered whether, in light of this, there was any value in undertaking the assessment. It agreed to approve the process for the assessment pending the outcome of the procurement exercise.

Ms Owen, non-executive director noted the difficulty in rating questions 7 and 8 of the assessment because the local counter fraud fee was not shown in the counter fraud annual plan. RSM explained that the fee was omitted from the plan because it had to be shared with NHS Protect. Ms Higginson would send the fee details to the committee secretary dependent on the outcome of the procurement exercise.

Question 10 would be amended to read, ‘’The LCF team consider the clear and comprehensive reporting of the results of their investigations when reporting to the audit committee.’’

VJ / GH VJ

GOVERNANCE

52/16-17 Board assurance framework

The director of planning introduced this item explaining that the BAF had been reformatted in particular to be structured around themes, and with sources of assurance, gaps and mitigations added. However, there was more work to do and he would be reviewing the sources of assurance with executive leads, followed by a more formal review with the board. The trust executive committee had reviewed the BAF earlier that week and were content with the closure of three risks (patient transport (1b/3b), general staff experience (2b), overhead coverage for specialised services (6b)), but requested that the risk around A&E targets needed to be rescored to 5 (likelihood) x 3 (impact). Comments were sought from the committee; the general consensus was that the format was much improved. However, Mr Ainger, non-executive director was concerned about the individual elements of each risk being ranked the same and made a preference for greater granularity. The director of planning had considered this but the aim was to try and not create a framework that resembled a corporate risk register. He agreed that there were elements of the wider risks that had different risk profiles and therefore offered to reformat the framework so the risks were ranked at an individual level for discussion at a future board meeting. As part of that cycle, a decision would need to be made as to which board committee would have overall lead responsibility for the framework. Audit and counter fraud colleagues considered that the number of risks was similar to those seen on other BAFs. Ms Owen, non-executive director stated that the patient and staff experience committee would have welcomed the opportunity to review the patient transport risk before its closure and removal from the BAF. The director of planning would check what the process for the review of the BAF risks by individual board committees was, and agreed not to recommend closing a risk until it had been reviewed by the relevant committee.

It was suggested that a ‘transitional risk’ should be added to that on the group model. The director of planning would consider how to incorporate this into the framework.

In relation to the risk on cybersecurity (8b), the committee considered that the monitoring and review of information governance incidents should not be the responsibility of the patient safety committee (this was a legacy issue subsumed from the previous risk, governance and regulation committee). A decision needed to be made on where this responsibility should best sit in order to provide the required assurance to the board.

The chair raised the issue of future assurance items for discussion at the committee, noting that both the annual clinical audit processes update and the revised cyber security paper would be presented at the next meeting. No other assurance report was requested.

The director of planning noted the challenge in showing how the board was getting assurance from the BAF. He would consider taking a paper on this specifically to a future

PR PR PR PR SP/SA PR


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shadow group board meeting.

53/16-17 Patient safety committee minutes – March and May 2016

The minutes were noted.

54/16-17 Clinical performance committee minutes – April 2016


55/16-17 Patient and staff experience committee minutes – April 2016


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56/16-17 Tender waivers: pharmacy, supplies and projects

The chair requested that an additional column be added to the report to provide assurance in respect of value for money.

LD

57/16-17 Losses and special payments

The committee noted the latest losses and special payments summary. To date, total losses and special payments amounted to

AUDIT COMMITTEE

58/16-17 Outcome of the assessment of audit committee effectiveness 2015-16

The committee received the results of its self-assessment exercise and where appropriate areas for future improvement. The following was noted:

All non-executive directors (NEDs) were content with the current process for their ongoing personal development.

Mr Ainger considered that a member of the audit committee needed to be a chartered accountant. The committee appreciated that it had successfully delivered the trust’s annual report and accounts 2015-16 without a qualified accountant, but noted the reputational risk should a financial accounting error occur in the future. The head of internal audit also supported the inclusion of a qualified accountant as a committee member. He suggested that one possible solution would be the recruitment of an independent member with the necessary qualification. The trust was in the process of recruiting two NEDs but it was not clear whether either of these had chartered accountancy qualifications. In the event neither had the necessary expertise, the committee were supportive of having a lay member on the committee who was an accountant and also independent from the trust. The interim trust secretary agreed to circulate the NED job specification to members after the meeting.

DO, VJ

JD


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WHISTLEBLOWING

59/16-17 Incidents of whistleblowing

The committee noted that more general learning in terms of whistleblowing incidents was needed, for example training staff to undertake the investigations, a clear process on how to best gather evidence, and how to ensure staff received feedback and were satisfied with the outcome of an investigation.

DG

60/16-17 Revised speaking up policy and procedure (incorporating raising concerns and whistleblowing)

The paper highlighted the changes that had been made within the trust’s existing whistleblowing / raising concerns policy. The committee was asked to note one change in particular in relation to supporting staff, namely that the trust would not tolerate harassment or victimisation of a member of staff who raised a concern, and that they would not be affected detrimentally in terms of promotion etc. The committee was pleased to note that the national guardian’s conference had rated the trust’s policy highly. A question was raised as to whether staff knew the process for whistleblowing. The committee’s attention was drawn to the flowchart (appendix A) which clearly outlined the number of routes staff could take to raise a concern. Both the internal and external whistleblowing webpages would be kept under review. The committee approved the changes.

6116-17 REFLECTIONS AND IMPROVEMENTS FOR NEXT TIME

There was no comment.


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62/16-17 BOARD REPORTING

Due to the close timing of the audit committee and the September trust board, the chair would provide a verbal update at the next board meeting. A written report would be provided to the board in October and would cover the following:

Recommendation to postpone the well led governance review The outcome of the cyber security review noting that the recommendations arising

would be completed by the end of the year and Outcome of the internal audit reviews. Discussion on the BAF Approved the revised whistleblowing policy. Recommendation to include a lay person with chartered accountancy qualifications

on the audit committee membership dependent upon the new NED recruitment.

63/16-17 PRIVATE MEETING BETWEEN AUDIT COMMITTEE MEMBERS AND AUDITORS AND COUNTER FRAUD OFFICERS

A brief private meeting was held.

Date of next meeting: 10 November 2016, 0900 – 1130, boardroom, Royal Free Hospital

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Report from clinical performance committee held 24 October 2016

Executive summary

The clinical performance committee met on 24 October 2016. The key matters of interestwere as follows:

THE 100,000 GENOME PROJECT

The committee received a presentation on the 100,000 Genomes Project, a project aiming toimprove the diagnosis and increase the trust’s understanding of cancer and rare diseases.Specific reference was made to the cost of sequencing, the clinical and scientific benefits ofgenetic diagnosis in rare diseases, the project methodology, recruitment including dataprotection, long term vision and the key challenges, both current and future.

The committee welcomed the interesting presentation, noting that the trust was a majorplayer in the 100,000 Genome Project which would bring significant benefits to patients andoffered the potential to diagnose diseases more precisely in future.

Mortality and patient safety indicators reportThe committee received its regular performance report, noting that in terms of mortality risk,the trust’s summary hospital-level mortality indicators (SHMI) and hospital standardisedmortality ratio (HSMR) performance remained good and was below the control limit.

A process of reformatting and reviewing the content of the report was underway. The chairsuggested that the committee would be content to be guided by the associate medicaldirector for clinical performance as to the revised content and format of the report. Herequested a brief paper outlining the recommendations for the committee’s consideration betaken to the January 2017 meeting.

DATA DEEP DIVES ALREADY UNDERTAKEN AND PLANNED

The associate medical director for clinical performance had undertaken a deep dive on thepatient safety indicator on postoperative respiratory failure which had consistently signalled ahigh level relative risk at the Royal Free site for several years. The chair considered thereport to be very helpful and reassuring.

A discussion was had on those other indicators where a deep dive of the data would behelpful to provide further assurance to the committee. The committee agreed to a deep diveon pressure ulcers with a report taken to the April 2017 meeting. The associate medicaldirector for clinical performance also agreed to do an in-depth analysis of pneumonia cases.

The chair noted it was evident that data quality was a theme that had through many of themeetings, particularly as issues with coding had shown the trust to be outliers in many areas.He appreciated this was a complex issue but considered that the committee needed greaterinsight on coding and assurance on the steps for ensuring that high quality data would be



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captured in future. It was noted that the trust’s internal auditors were conducting an externalreview of the trust’s data quality, albeit from a financial perspective, but there could berecommendations related to coding more generally. It was agreed that a presentation oncoding, including that related to internal audit’s findings and action taken, would be providedat the April 2017 meeting.

KEY POST AND UNDERGRADUATE EDUCATION FINDINGSa. Undergraduate medical student feedback

The committee received the undergraduate medical student feedback report noting that asteady improvement had been seen, and Block 3 2015-16 had the best performance with noreds which was reflective of the hard work of the sub-dean of the medical school, UCL. Thecommittee noted that specific action plans were in place to address those red rated areas.

b. Post-graduate medical education (PGME)The committee also received an update on the 2016 GMC national trainee survey results,including the identification of priority areas for improvement in the quality of PGME. It notedthe key highlights which included six patient safety concerns having been raised across thetrust which had been investigated and were now closed, one bullying / undermining alert thathad since been resolved with both parties happy, and an increase in green (positive) outliers(44 compared to 25 the previous year). In terms of success, it was noted that cardiology onthe Royal Free site had reduced all red outliers from 2015 and achieved a green outlier forfeedback. In addition, trauma and orthopaedics on both sites had fared well, havingincreased green outliers from zero in 2015 to 2 each in 2016.

There had, however, been an increase in red (negative) outliers (81 compared to 54 theprevious year). There were a number of indicators that had been a surprise, handovers forexample, but others were expected. Steps were being taken to address the quality issuesthat were raised. The recommendations for improvements were also noted.

The chair thanked the director of PGME for the excellent work in this area which wasimportant in ensuring patient care and safety.

CHANGE TO THE COMMITTEE’S MEMBERSHIPThe committee noted that the chief executive had stood down as a member of CPC due tocommitments with his role as chair of the North Central London Sustainability andTransformation Plan programme. The chair requested that the committee formally record itsthanks to him for his helpful contributions during his time as a member.

The committee’s terms of reference were updated accordingly and agreed by way of chair’saction outside of the meeting. A copy of the revised terms of reference is attached atAppendix 1.

Action required

The board is asked to note the report and to ratify the revised terms of reference.




number(s)


outcomes

x




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Regulation 19 Fees




N/A

Equality analysis


Report from Prof Anthony Schapira, non-executive director and chair of the CPC



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Appendix 1

CLINICAL PERFORMANCE COMMITTEETERMS OF REFERENCE

Overview and purpose

The clinical performance committee is a committee of the trust board. It is responsible forseeking and securing assurance that the trust’s clinical services, research efforts andeducation activities achieve the high levels of performance expected of them by the board,namely “outcomes consistently in the top 10% in the UK versus relevant peers.”

Scope

• Clinical outcomes, including three trust clinical priorities - (C.difficile rates, MRSArates and HSMR) - and clinical performance metrics for each clinical business unit.

• Research productivity and educational effectiveness.• Quality Accounts.• Outcomes achieved and management approach taken (including, but not limited to,

accountabilities, processes, clinical governance arrangements, audit, information,training and development, consequences).

Responsibilities

• Recommend to the board the outcome measures that should be tracked at both theoverall trust and individual service line level.

• Monitor those outcomes on a quarterly basis at both trust and service line level.• Determine whether there is unequal performance across patient groups and seek

assurance that plans are in place to achieve greater equality of clinical outcomes.• Seek assurance that the management approach to achieving consistent high

performance is robust and therefore likely to justify confidence in future performance.• Alert the board or another appropriate forum (e.g. the patient safety committee and

audit committee) in a timely way to clinical, research and educational performancethat falls short of the trust’s standards or to concerns about underlying managementapproaches.

• Seek to understand lessons learned through comparison between service lines thatperform well and those that perform less well.

Membership

Chair: non-executive directorMembers:

Attendees:

one other non-executive directormedical directordirector of nursingassociate medical director for clinical performanceassociate medical director for revalidationlead nurse for clinical performancedeputy director of clinical governance and performancedivisional director, or divisional director of operations or deputy director ofnursing for EACH divisionchief information officerdirector of qualitythree governors

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Coordinator: committee secretaryQuorum: three members, at least one non-executive director and one executive member

Frequency

The committee will meet quarterly.

Reporting arrangements

The committee will provide a quarterly report to the trust board which will include service lineperformance on key outcome indicators relative to relevant external benchmarks.

Approved by

Agreed by committee: October 2016Approved by trust board: December 2016

Terms of Reference review: Annually

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REPORT FROM PATIENT AND STAFF EXPERIENCE COMMITTEE - REVISED TERMS

OF REFERENCE

Executive summary

At its meeting on 17 October 2016, the committee noted that the chief executive had stooddown as a member of PSEC due to commitments with his role as chair of the North CentralLondon Sustainability and Transformation Plan programme.

The committee’s terms of reference were updated accordingly and agreed by way of chair’saction outside of the meeting. A copy of the revised terms of reference is attached atAppendix 1.

Action required

The board is asked to ratify the revised terms of reference.




number(s)



x









Risks attached to this project/initiative and how these will be managed (assurance)As outlined in the report.

Equality analysis


Report from Jenny Owen, non-executive director and chair of the committee





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Appendix 1

PATIENT AND STAFF EXPERIENCE COMMITTEE

TERMS OF REFERENCE

Overview and Purpose

The trust’s corporate strategy sets out our aims to provide world class care and expertise in

the form of excellent clinical care, research and teaching. By “world class” we mean to begin

by being in at least the top 10% of hospitals in England for:

clinical quality customer satisfaction financial performance

The patient and staff experience committee is a committee of the board. It is responsible for

seeking and securing assurance on performance in relation to the experience of patients and

staff, to monitor performance in relation to key outcomes set by the Care Quality Commission

and to ensure that there is a clear performance and governance framework against these,

which is linked to clear consequences for both good and poor performance.

Scope

• The experience of both inpatients and outpatients.• The morale, engagement and commitment of staff.• Outcomes and management approach taken (including, but not limited to,

accountabilities, processes, information, training & development, consequences).

Responsibilities

• Recommend to the board the right measures of patient and staff experience that shouldbe tracked at both the overall trust and individual service line level

• Monitor patient and staff experience outcomes on a quarterly basis at both trust andservice line level

• Determine whether there is unequal performance across patient groups and staff groupsand seek assurance that plans are in place to achieve consistent performance

• Seek assurance that the management approach to achieving consistent highrecommendation and staff engagement rates is robust and therefore likely to justifyconfidence in future performance

• Alert the board or another appropriate forum (e.g. the patient safety committee) in atimely way to patient and staff experience that falls short of the trust’s standards or toconcerns about underlying management approaches or to cross-cutting improvementopportunities

• Seek to understand lessons learned through comparison between service lines thatperform well and those that perform less well

• To assume responsibility for role-modelling positive behaviours and leadership• Have oversight of the trust’s strategy for end of life care with key performance indicators

for end of life care to be incorporated in patient and staff outcomes monitored by thecommittee

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Membership

Chair: non-executive director

Members: one other non-executive director;

director of nursing;

chief operating officer

Attendees: divisional director, divisional director of operations or deputy director of

nursing for each division;

director of workforce and organisational development;

chief information officer;

three governors;

deputy director of patient experience;

a representative from the Royal Free Charity;

associate medical director – user experience;

director of quality.

Coordinator: patient affairs administrator; committee secretary (minutes)

Quorum: three members, at least one non executive and one executive member

Frequency

The committee will meet quarterly

Reporting

The committee will provide a quarterly report to the trust board which will include service line

performance on key indicators, relative to relevant external benchmarks.

Agreed by committee: October 2016

Approved by trust board: December 2016

Review date: Annually

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