PUBLIC - MAY 2019

02 May 2019, 13:00 to 15:00BOARD ROOM, TRUST HEAD QUARTERS

Agenda1. Apologies for Absence: Mark Waller 1 minutes

2. Declarations of Interest 1 minutes

Hardy Russell

3. Minutes of the Meeting held on 4 April 2019 3 minutes

Hardy Russell

3a. DRAFT PUBLIC BOARD MINUTES APRIL - HO, LF.pdf (17 pages)

4. Matters Arising and Actions Update Report 10 minutes

Discussion

Hardy Russell

4. Public Action Log -MAY.pdf (1 pages)

5. ITEMS FOR REVIEW AND ASSURANCE 40 minutes

Information

5.1. Chief Executive ReportDiscussion

Glen Burley

5.1 2nd Mayl 2019 - Board public CEO Report V1.pdf (5 pages)

5.2. Integrated Performance ReportInformation

Jane Ives

5.2 Integrated Performance Report.pdf (6 pages)

5.2.1. Quality

Information

Lucy Flanagan

5.2.1Month 12 Integrated Board Report LF.pdf (5 pages)

5.2.2. Activity Performance

Information

Jon Barnes

5.2.2 TB Report Month 12 2018-19.pdf (10 pages)

5.2.3. Workforce

Information

Susan Smith

5.2.3Workforce Report - final.pdf (3 pages)

5.2.4. Finance Performance

Information

Howard Oddy

5.2..4 Month 12 Integrated Board Report FINAL VERSION - Income Adj (Repaired).pdf (17 pages)

5.3. One Herefordshire - Urgent Care Programme Board UpdateInformation

Jon Barnes

5.3 Board Report - 1H UCPB update April 2019 (1).pdf (7 pages)

5.4. Mortality ReportInformation

David Mowbray

5.4 Mortality Report.pdf (13 pages)

5.4a Mortality Dashboard - April.pdf (1 pages)

6. ITEMS FOR APPROVAL 15 minutes

6.1. STP Operational PlanAlan Dawson

Herefordshire and Worcestershire STP 1920 Operational narrative plan.pdf (4 pages)

HW STP Operational Plan 2019-20 Final Submitted.pdf (33 pages)

7. ITEMS FOR NOTING AND INFORMATION 30 minutes

Information

7.1. Summary Report on Safe Working HoursDavid Mowbray

7.1 Board report April 2019 GOSW.pdf (3 pages)

7.2. HSE Improvement NoticesErica Hermon

HSE Improvement Notice Report.pdf (5 pages)

7.3. Committee Summary Reports

7.3.1. Clinical Quality Committee Summary Report 28 March 2019

Christobel Hargraves

7.3.1 CQC Summary report Mar19.pdf (3 pages)

7.3.2. Charity Trustee 21 March 2019

Frank Myers

7.4.2 Draft CT Minutes 21.03.2019.pdf (5 pages)

7.4. Committee Minutes

7.4.1. Clinical Quality Committee - 28 February 2019

Christobel Hargraves

8. Any Other Business 5 minutes

9. Questions from Members of the Public 15 minutes

10. Acronyms

11. Date and Time of Next Meeting: 23 May 2019 at 1.00 pm in the Board Room, THQ

WYE VALLEY NHS TRUSTMinutes of the Board of Directors Meeting

Held on 4 April 2019 at 1.00 pmBoard Room, Trust Headquarters, Hereford County Hospital

Present:

Russell Hardy RH Chairman Glen Burley GB Chief Executive Andrew Cottom AC Non-Executive DirectorLucy Flanagan LF Director of NursingChristobel Hargraves CH Non-Executive Director (NED) Richard Humphries RH Non-Executive Director (NED) Jane Ives JI Managing DirectorDavid Mowbray DM Medical DirectorFrank Myers, MBE FM Non-Executive Director (NED)Howard Oddy HO Director of Finance & Information

In attendance:Jon Barnes JB Chief Operating OfficerAli Bolton AB Service Improvement Lead – For Item 6.2Jake Burdsall JBu Chief Clinical Information Officer – For Items 5.5

and 5.6Alan Dawson AD Director of Strategy and PlanningErica Hermon EH Associate Director of Corporate Governance /

Company SecretaryVal Jones VJ Executive Assistant (For the minutes)Sue Smith SS Director of Human Resources

The Going the Extra Mile Award – Employee of the Month – This had been awarded to Louise Turnbull-Simpson. The Chairman read out a precis of the reason why Louise had been put forward for this award.

The Going the Extra Mile Award – Team of the Month - was awarded to the Intensive Care Unit Team. The Chairman read out the email detailing the reason why the Team had been put forward for this award. The Managing Director would be presenting the award to the Team on 5 April.

Minute Action

BOD01/04.19 Apologies for Absence

Apologies were received from Mark Waller, Non-Executive Director.

BOD02/04.19 Quorum

The meeting was quorate.

BOD03/04.19 Declarations of Interest

Mr Hardy (Chairman) advised that he was now the Chairman for George Eliot Hospital.

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BOD04/04.19 Minutes of the meeting held on 7 March 2019

Resolved – that the minutes of the meeting held on 7 March 2019 be confirmed as an accurate record and signed by the Chairman.

BOD05/04.19 Matters Arising and Action Log

The Staff Survey results were discussed at the Board Workshop held that morning. The emotional wellbeing of staff was the main focus in the year ahead. Violence and aggression was also discussed, which again was a focus for the Trust.

The Trust were investing in EPR, EMIS Community computer system and E-prescribing which was the right thing to do for our patients but often did not generate income for the Trust.

Resolved – that the action log be noted.

BOD06/04.19 Chief Executive’s Report

The Chief Executive (CEO) presented his report and the following key points were highlighted:

(a) Improvements in Flow - The graph showing the metric comparison for the Trust showed the improving line for A&E performance. The opening of the Ambulatory Medical Unit (AMU) had improved flow by delivering seven day ambulatory care.

(b) NHS Long Term Plan – Potential Changes to Legislation – There were potential changes to Foundation Trusts (FT) around capital spending controls in line with NHS Trusts. Although Wye Valley were not a FT, we are in a Foundation Group. The CEO felt that the Group should be able to approve capital spending and Business Cases. The CEO felt that the Hutted Ward Business Case had taken longer than needed - an FT would have been able to streamline this process. The need to demonstrate governance processes were in place to enable the right choices to be made was noted.

(c) New Urgent Care Measures – The CEO felt that the proposals to use different measures of urgent care performance should still include the 4 hour standards. NHSE had also announced that Jeff Worrall was the new Director of Performance and Improvement.

(d) Further integration between NHSI and NHSE – The joining together of NHSI and NHSE was noted.

(e) System Financial Escalation and 2019/20 Contract Discussions – The ongoing discussions regarding the contract negotiations was noted which would be discussed further within the Finance Report.

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(f) Learning From Deaths - The Care Quality Commission had recently published a report based on their experiences of how Trusts have implemented the Learning From Deaths guidance after this first year of operation.

(g) Revd Hargraves (NED) noted that the Clinical Quality Committee had discussed the need to look at the bereavement process and had highlighted the good progress made regarding mortality. The Director Of Nursing (DON), the Medical Director and Mortality Project Manager were discussing how to bolster the existing bereavement model with existing resources and to improve the current accommodation.

(h) Revd Hargraves (NED) questioned if there was any ongoing additional work to enable the improving A&E performance to be sustainable. The CEO advised that there were various projects taking place trialling changes to find what make the most impact. The Chief Operating Officer (COO) advised that the AMU was the largest single change with the rapid assessment model in the Emergency Department making a positive improvement.

(i) Mr Cottom (NED) felt that the Trust were discriminated against due to the financial system which did not allow the Trust to achieve financial stability and felt that the Regulator should be given more freedom to allocate resources where they were needed. The CEO advised that he believed in the way that the financial regime was set up as it was founded on Trusts being able to breakeven.

Resolved – that the Chief Executive’s report be received and noted.

BOD07/04.19 Integrated Performance Report

The Managing Director presented the review of Key Performance Indicators and the following key points were noted:

(a) The Trust achieved 85% performance in A&E which was below the 95% expected, but this was now about the average for NHS performance. This was due to a combination of a number of factors over the last months. This had also impacted on quality measures with a reduction in the number of non-critical moves and the ability to discharge patients earlier if they are on the correct pathway throughout their stay.

(b) The ambition by the end of March had been to have no patients waiting over 52 weeks for their operation. There were however four patients outstanding, who will all be treated in April, and this was mainly due to patient choice. There was a much lower risk of patients breaching in March with an improving RTT position.

(c) The level of staff appraisals has dropped but this is being well managed through the Finance & Performance Committee meetings. The new Terms and Conditions for Agenda For Change has reinforced the link between appraisals and pay progression.

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(d) The revised offer for Bank Nurses is proposed to go live at the beginning of May. The plan is to move around 35% to 50% of nurses on the Bank. Although some staff will gain and some will lose, the new offer provides equity for all, a quarterly bonus scheme and weekly pay.

(e) Mr Myers (NED) questioned what process was in place to ensure that appraisals were effective. The Managing Director advised that the Staff Survey showed an improvement on the number of staff advising that they found them more useful. The Staff Engagement sessions held last year also asked staff their opinions on appraisals. The Head of HR had been working on ensuring that a standardised approach was taken across the Trust which was due to go live shortly.

(f) Revd Hargraves (NED) noted that three years ago we were advised that appraisals were being undertaken but not always recorded on ESR and queried whether there was now confidence that this occurred. The Director of Human Resources (DHR) advised that a review had shown that not all managers were updating this information. Feedback had been provided to ensure managers were undertaking valuable appraisals and entering this onto ESR.

(g) The Chairman highlighted the improvement in performance figures from last year when English patients were at 74%. The COO advised that the figures for March were awaited but had improved on this figure, and the 70 - 80 patients waiting over 52 weeks for surgery (the highest figure being one hundred and sixty six) had reduced to four. The CEO acknowledged the excellent progress that had been made and also that no harm had been caused to patients waiting over 52 week, but noted that this was still not acceptable to have patients waiting this length of time.

Resolved – that the review of Integrated Performance Report be received and noted.

BOD08/04.19 Quality

The DON presented the Quality Report and the following key points were noted:

(a) The Trust had trialled a new approach to providing training to teams on the management of the deteriorating patient and had held an improving clinical practice week on Lugg Ward with specialist teams going to the location rather than staff coming to the classroom. This had been evaluated very well by staff. Lugg Ward have also embraced the new EPR and Order Coms System and managed patients in “real time” for admission, discharge and moves.

(b) Compliance with VTE assessment remained at circa 90% which was comparative to other Trust in the region, although with a desire to improve further. An Audit carried out in March showed that patients had received VTE prophylaxis although this had not been recorded on the computer system.

(c) There had been a couple of surgical Serious Incidents relating to thrombosis. The guidelines for VTE prophylaxis prior to surgery had been reviewed and reissued.

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(d) The Clinical Quality Committee received a deep dive on pressure ulcers. This showed a 70% reduction in pressure ulcers acquired through our care with only 8 compared to 27 last year. This was due to specialist oversight, earlier intervention and improved clinical practice.

(e) There had been an increase in the number of moisture associated cases of skin damage. This increase had coincided with a change in products. As a consequence, a Task and Finish Group had been set up to review this.

(f) The Quality Priorities (QP) for 2019/20 had been finalised and a review of the performance indicators to measure these was underway. These indicators would form the basis of a monthly report through to the Clinical Quality Committee meeting.

(g) Mr Cottom (NED) questioned how the monitoring and progress of QP were being fed up to the Board of Directors and where these were signed off. The DON advised that the QP for 2019/20 had been presented to the Board of Directors previously and approved at the Clinical Quality Committee. Progress against the 2018/19 QP had been periodically reported to the Clinical Quality Committee with a summary report provided to the February meeting. The Chairman was in agreement for the Clinical Quality Committee to recommend the QP (as the Board of Directors had had previous sight).

(h) Mr Myers (NED) was pleased that the Trust were trialling bed and chair sensors but questioned how successful they were. The Chairman suggested that the DON speak with the team at South Warwickshire NHS Foundation Trust, who had done a lot of work around bed sensors in particular to ensure best practice and learning from others. The DON advised that the use of sensors was discussed at the Clinical Quality Committee as there had been an increase in falls on Arrow Ward which was not unexpected as it had moved to become a Frailty Ward. A review of whether the number of falls was in the expected range compared to other frailty areas had been requested. The Medical Director advised that the Herefordshire Council were reviewing the efficacy of sensors.

Resolved – that the Quality Report be received and noted.

BO09/04.19 Activity Performance

The COO presented the Activity Performance Report and the following key points were noted:

(a) The six week rolling average for admissions this year (patients staying at least one night) was 265 compared to 233 last year. The Chairman noted that this equated to a 15% increase which was a large number to additionally deal with.

(b) The graph on Total Elective Activity showed the high number of patients that had been treated during 2018/19 compared to 2017/18. This was due to being able to keep Theatres open and a good flow of patients.

(c) There had also been a significant increase in a rolling three month period on the number of ambulance conveyances. During February this year the figure was 1800 compared to around 1600 last year. The Trust was under pressure due to these numbers, but was coping as previously discussed.

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(d) The graphs for patients waiting over 40 weeks showed that they had been falling since August with a stabilising RTT position. This ideally now needed to occur for patients waiting over 18 weeks.

(e) Breast Symptomatic – The Trust did not achieve this target for January or February but had recovered in March with no patients waiting over 2 weeks by the end of March. There had been a 12% growth in referrals but no associated increase in breast cancer. The Trust is reviewing all options and how to manage referrals more effectively and to increase our capacity and responsiveness.

(f) Revd Hargraves (NED) highlighted that another Trust was working with GPs around breast symptomatic 2WW referrals to ensure they were being appropriately referred. The COO advised that this was the form that Wye Valley Trust have adopted and was seeing positive results.

(g) Mr Cottom (NED) asked whether the A&E Consultants posts had previously been advertised. The Medical Director advised that these were serial adverts as there were few responses. Middle Grade posts were being recruited to but the Trust was struggling to fill Consultant vacancies. The CEO advised that figures showed that there were more A&E Consultants in training than ever before, which should improve future prospects.

Resolved – that the Activity Performance Report be received and noted.

BOD10/04.19 Workforce

The DHR presented the Workforce Report and the following key points were noted:

(a) Vacancy rates had reduced to 6.9%. Appraisals were at 87.8% (just below the 90% target. Due to concern around appraisal compliance, a range of actions had been put into place, detailed within the report.

(b) Sickness absence was a concern which has increased year on year for the last three years. This was discussed at the Board Workshop on how to improve this figure.

(c) Recruitment and Retention for nurses was a real success with 32.7 WTE starting since January with another 62 in the pipeline to start between now and August. This would reduce our vacancy rate to 35 WTE if all commenced in post, which would make the Trust a much more attractive place to work.

(d) Support Worker Academy – This was in place to support the career development for HCA staff.

(e) Staff Engagement –The Managing Director will be meeting 400 staff across the workforce chosen at random. Also Staff Matters was just being launched. The CEO advised that staff engagement was very important and had been discussed in detail at the Board Workshop. Mr Myers (NED) asked that the NEDs been included in the circulation of Staff Matters.

SS

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(f) Mr Cottom (NED) noted that vacancies, in terms of total numbers, was increasing. The DHR advised that she could provide a breakdown of numbers if required. There had been a spike in turnover in November and December but the ward changes needed to be factored in this. We lost sixteen staff at the highest point and were now down to two a month.

Resolved – that:

(A) The Workforce Report be received and noted.

(B) The Director of Human Resources would include the NEDs on the circulation list for Staff Matters.

SS

BOD11/04.19 Finance Performance

The Director of Finance & Information (DFI) presented the Finance Performance Report and the following key points were noted:

(a) In month 11, the Trust reported a cumulative deficit of £33.4m which was £8.9m worse than the trajectory required to meet the control total plan of £27.2m deficit. There was a deficit of £2.9m in month 11.

(b) Nurse agency costs were down to £534k in month. The forecasted CPIP was now £9.8m.

(c) The current outturn forecast remains at £36.2m although a number of issues still remained to be resolved. This included the funding for Sodexo staff pay award which the Trust had been informed may now not be available, but which the Trust had written to the Department Of Health and NHSI about. The contract dispute around PbR from last July was still ongoing.

(d) The Trust had spent £9.8m on capital, £3.8m of which was against the core programme. The Trust had finally received their capital allocation at the end of March.

(e) The Chairman queried whether the Trust would meet the end of year income plan of £195m. The DFI advised that this was dependent on a number of factors but was currently below this figure.

(f) The CEO questioned if the Trust would be informed of the outcome of the dispute by 11 April. The DFI confirmed that there was a specific timespan for the investigation and for the production of the report, with 11 April being the final deadline.

Resolved – that the Finance Performance Report be received and noted.

BOD12/03.19 One Herefordshire - Urgent Care Programme Board Update

The COO presented the One Herefordshire - Urgent Care Programme Board (UCPB) Update and the following key points were noted:

(a) The UCPB was maturing well with dedicated support. The table, included within the report, showed the programmes that were planned to attribute changes.

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(b) The Valuing Patients time workshop held on 22 March developed a set of values and principles, with a further two workshops scheduled over the next two months. Discussions were held around what was important to staff rather than imposing national tools.

(c) The Chairman noted the need to ensure that, across Herefordshire, we have a One Herefordshire narrative on the care that we want and to move away from the silo aspect to a unified view.

(d) Revd Hargraves (NED) questioned, with such a large programme, where concerns lay. The COO advised that this was around schemes that are nationally defined. The plan was to define values with each clinical team and how to achieve them.

(e) The Chairman noted the importance of ensuring best practice and adopting someone else’s approach if appropriate.

Resolved – that the One Herefordshire - Urgent Care Programme Board Update be received and noted.

BOD13/04.19 Mortality Report

The Medical Director presented the Mortality Report and the following key points were noted:

(a) SHMI had reduced to 106.01. The HSMR had reduced to 105.60. The weekend HSMR was 107.08, with the Trust 60th out of 134 Acute NHS Trusts.

(b) Due to further reductions for Pneumonia, CCF and Septicaemia, these groups were now reporting less than the expect number of deaths for this period and were therefore no longer outlier groups.

(c) There had been a rise in the HSMR for deaths attributed to fracture neck of femur (FNF). The issues were around the slow movement of patients from the Emergency Department to the correct ward, not getting patients to theatre in time and no Orthogeriatrician. All these areas were being worked upon with a new FNF pathway in place and a locum Orthogeriatrician starting in post.

(d) Co-morbidity coding for live and deceased patients continues to improve with The Royal Wolverhampton NHS Trust asking the Trust to share their good practice with them in this area.

(e) None of the fifty-five patients with COPD (selected by the Trust and GP practices) who were most frequently admitted to the Trust over the winter period were admitted to secondary care this winter.

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(f) The Managing Director noted that we have been an outlier for FNF previously and questioned what we had learnt from this. The Medical Director advised that lessons had been learnt and that the Trust had lost an Orthogeriatrician, with a review to see if there was any statistical evidence to prove that this had contributed to the increase in numbers.

(g) Mr Humphries (NED) noted the improvement in mortality figures achieved despite the rising demand and pressure on staff and services and felt that this was worthy of celebrating.

(h) Mr Myers (NED) raised concern that care bundles were still an issue despite a lot of work carried out in this area. The Medical Director advised that care bundles were one of the Quality Priorities for next year to embed. The CEO noted the use of digital systems to support some of the implementation.

Resolved – that the Mortality Report be received and noted.

BOD14/04.19 Digital Systems Development Update

The DFI presented the Digital Systems Development Update and the following key points were noted:

(a) Flexible training opportunities are being offered on Pathology Order Communications (OCS).

(b) EPR Phase 2 – A plan for implementation was expected next month, with a number of items coming on stream in the next few months.

(c) EMIS Community was progressing well and will go live in the next week in three areas.

(d) The Chief Clinical Information Officer (CCIO) advised that nurses were engaged with the OCS and found the system intuitive. A number of HCA staff who had not used the system before were able to log in and use the system, with staff finding it a real benefit regarding visibility of tests etc. The functionality of results not yet signed off had not been switched on but was planned to commence shortly. Due to the timescale for typing some patient letters, clinicians were getting some results back in advance of letters.

(e) The Managing Director questioned if the plan to get Malinko rolled out to therapy staff and the Homefirst Service was on track along with the updates to systems required. The DFI advised that this system had proved to be more problematic than initially expected with additional resources allocated to try to resolve these issues.

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(f) The CEO advised what the next stage was. The CCIO advised that rolling out Version 14 was the next project, which should improve speeds as it runs through Chrome, along with having a mobile platform. Pilots are being planned for the additional options.

(g) Mr Myers (NED) questioned how many mobile devices were available for Community Workers. The DFI advised that it was between 300 and 350.

Resolved – that the Digital Systems Development Update be received and noted.

ITEMS FOR APPROVAL

BOD15/04.19 Electronic Prescribing and Medicines Administration Business Case

The Medical Director presented the Electronic Prescribing and Medicines Administration Business Case and presentation and the following key points were noted:

(a) The Chairman noted that the net revenue costs were £558k, with the depreciation accounting for around £350k of this. The CEO highlighted that the non-cash releasing elements included saving Junior Doctors time, more time with patients and many more benefits.

(b) The CCIO confirmed that this was something that Clinicians had wanted for a long time which produced huge advantages and safety benefits, agreeing that there were also benefits that could not necessarily be quantified such as a reduction in length of stay for patients.

(c) Mr Cottom (NED) felt that the description (in the Business Case) of one of the “expected benefits” should state “use” rather than “enforcing” Trust formulary policy. The Medical Director advised that staff would not be able to continue to using the formulary without using this system.

(d) The Managing Director questioned whether there was a link with the system to Primary Care prescribing systems. The Medical Director advised that due to limited finances, this was not part of the current project scope.

(e) The Chairman noted that this investment was right for patients although there was a cost for us.

Resolved – that the Electronic Prescribing and Medicines Administration Business Case be received and approved.

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BOD16/04.19 Nurse Associate Tender Evaluation Report

The DHR presented the Nurse Associate Tender Evaluation Report and the following key points were noted:

(a) The report was recommending the award of contract for the provision of Nursing Associate Apprenticeship Training Providers to the University of Worcester and the Open University for a three year period.

(b) Mr Humphries (NED) reiterated his Declaration of Interest that he was a visiting Professor at the University of Worcester.

(c) Mr Myers (NED) asked for clarity around how this worked contractually. The DHR advised that the contract was with Worcestershire Health and Care NHS Trust (WHCNT) who were hosting the hub, the Trust was part of the STP hub. A decision would be made by the Trust twice a year on the number of apprentices being sent through, (minimum of ten each time), using the Apprenticeship Levy to cover these costs. My Myers (NED) had concerns regarding the relationship between the Trust and the contract holder. The DHR advised that we had worked with them on another project for three years without any concerns, with the DHR being responsible for this contract.

(d) The Associate Director of Corporate Governance suggested having an SLA with WHCNT to formalise the contract. The Managing Director advised that as WHCNT were holding the contract on behalf of everyone, this was not required. The DHR advised that the Trust booked places directly negating any risk and therefore only paid for the number of apprentices we sent onto the course.

Resolved – that the Nurse Associate Tender Evaluation Report be received and approved.

BOD17/04.19 Improvement Methodology Review and Recommendations

The Director of Strategy and Planning and the Service Improvement Lead (SIL) presented the Improvement Methodology Review and Recommendations and the following key points were noted:

(a) An Improvement Review had been carried out across the three organsiations (Wye Valley Trust, South Warwickshire NHS Foundation Trust (SWFT) and George Eliot Hospital (GEH)), with nearly fifty staff interviewed. The report describes where we are with this process and QSIR.

(b) Common themes included service improvement being embedded in teams, with staff feeling that there were not staff who could “train the trainer”.

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(c) The Recommendations were: Recommendation 1 – Implement QSIR as a standard improvement approach across the group, Recommendation 2 – Present the group improvement approach to each Board during a workshop session to provide clarity and stimulate support for the programme, Recommendation 3 – Align improvement programme with organisational and divisional objectives, Recommendation 4 – Recognise, support and celebrate smaller improvement projects, Recommendation 5 – Align service improvement resource to divisions, where appropriate and practical to do so and Recommendation 6 – Provide group-wide leadership for service improvement approach.

(d) The CEO noted that this report had been discussed at the SWFT and GEH Board meetings this week. It was important to discuss improvement in the wider sense and not have separate silos. The recommendation was for group-wide leadership which the SIL was leading on.

(e) The DON felt that Recommendation 3 was very important, with service improvement aligning to Trust Objectives. Mr Humphries (NED) felt that this demonstrated the practical benefit of being part of a Foundation Group with this Trust playing a leadership role. Mr Cottom (NED) raised his concern around the plan to ensure that this became “business as usual”. The SIL would welcome this becoming “business as usual” and advised that around fifty staff had been trained in the Gold Programme and around sixty to seventy on the Silver Programme, and felt that more staff could be trained on the Silver Programme as it was held “in house”. The Medical Director noted the need to ensure that teams co-ordinated work in line with Trust and local objectives.

Resolved – that the Improvement Methodology Review and Recommendations 1,2,3,4,5,6 be received and approved.

BOD18/04.19 Financial Plan 2019/20

The DFI presented the Financial Plan 2019/20 and the following key points were noted:

(a) The Chairman advised that this had been discussed in the Board Workshop.

(b) The Trust had been offered a Control Total of £17.253m deficit for 2019/20 by NHSI. The plan included the assumption of the contracts with Herefordshire CCG and Powys LHB which have not yet been signed. Additional income was needed in order to deliver the required RTT and there was a risk around tariff and how this applies to Wales.

(c) Capital is in short supply in the NHS currently and the Trust has made significant investments. This was a challenging Financial Plan, one that assumed levels of activity built in and achievement of the CPIP, but felt to be achievable if the risks were managed appropriately.

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(d) The CEO was not happy with the pace of change on the Community Contract but had reluctantly had to accept this. He also proposed to improve waiting time figures and so funding outsourcing was included within the contract (although the Trust did not make money from this).

(e) The Chairman noted the figures in the Income and Expenditure Budget spreadsheet which showed that the Trust would be on a total operating income of £208m compared to £192m for last year. Even with the Trust delivering on £208m and the largest CPIP in the Midlands, we would still end up with a £35m operating deficit due to being a District General Hospital with a low population density offering a wide range of services which needed to be recognised.

(f) Mr Humphries (NED) was unhappy about approving a deficit budget, with the NHS nationally expected to deliver patient care within the budget required, noting the difficulties the Trust had over juggling conflicting priorities with the finances available. The Chairman noted that if we had not carried out additional work, our waiting times would have declined considerably and we would have been seen to be a failing Trust. The CEO noted that the Control Total Regime gives us permission to have a bottom line deficit. We are therefore meeting our financial duties to our Regulators by approving this plan.

(g) Revd Hargraves (NED) queried what the terminology “outsourcing administration team” meant which was included within the pack. The DFI advised that this was regarding the volume of outsourcing we are undertaking, with a team set up to cover the identification and production of records for these patients. This was budgeted for next year (having been an overspend in 2018/19). The DON also advised that two out of the three Community Hospitals had required investment in nurse staffing due to their baseline staffing not being correct.

(h) Mr Cottom (NED) felt that this was a fairer reflection of our responsibilities and that the Executive Team should be commended on this. The CEO advised that it was unwise to stop elective activity at the current time and this would be reviewed at the Board of Directors if ever requested to do so.

Resolved – that the Finance Plan 2019/20 be received and approved.

ITEMS FOR NOTING AND INFORMATION

BOD19/04.19 Impact of EU Exit (No Deal) on the Trust

The DFI presented the Impact of EU Exit (No Deal) on the Trust Report which was taken as read.

Resolved – that the EU Exit (No Deal) on the Trust Report be received and noted.

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COMMITTEE SUMMARY REPORTS

BOD20/04.19 Clinical Quality Committee Summary Report 28 February 2019

Revd Hargraves (NED and Chair of the Clinical Quality Committee) presented the Clinical Quality Committee Summary Report 28 February 2019 and the following key points were noted:

(a) The Chair of the Clinical Quality Committee, DON and Medical Director had met to discuss the quality of KPIs. A further meeting would be held in due course.

Resolved – that the Clinical Committee Summary Report 28 February 2019 be received and noted.

BOD21/04.19 Audit Committee Summary Report 21 March 2019

Mr Cottom (NED and Chair of the Audit Committee) presented the Audit Committee Summary Report 21 March 2019 and the following key points were noted:

(a) The Internal Audit Plan was approved which Mr Cottom (NED and Chair of the Audit Committee) felt required a wider assurance view.

(b) The Self-Assessment results of the Committee were discussed. One question asked if the Board of Directors read and took note of the issues raised by the Audit Committee. Some of the NEDs felt that there was no discussion held at the Board of Directors meeting and there was no proof that appropriate engagement on the report was held. Mr Cottom (NED and Chair of the Audit Committee) did not feel this was the case and had no concerns. The Chairman and Mr Cottom (NED and Chair of the Audit Committee) would meet to discuss this issue further. The Chairman went on to reiterate to Board Members never to feel embarrassed to ask any questions around the reports presented, even if this was outside of their competence.

RH/AC

Resolved – that:

(A) The Audit Committee Summary Report 21 March 2019 be received and noted.

(B) The Chairman and Mr Cottom (NED and Chair of the Audit Committee) would meet to discuss the NEDs concerns around lack of discussion of Audit Committee Reports at the Board of Directors meetings.

RH/AC

BOD22/04.19 Foundation Group Strategy Sub-Committee Meeting Summary Report – 18 March 2019

Mr Humphries (NED and NED representative for the Foundation Group Strategy Sub-Committee) presented the Foundation Group Strategy Sub-Committee Meeting Summary Report 18 March 2019 and the following key points were noted:

(a) It was felt that the Committee were progressing well with good discussion held around procurement.

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(b) There was some concern that there were delays in approving of some items due to the Audit Committee not approving them. The CEO felt that the Group itself should be making things happen more quickly and not other Committees.

Resolved – that the Foundation Group Strategy Sub-Committee Meeting Summary Report – 18 March 2019 be received and noted.

COMMITTEE MINUTES

BOD23/04.19 Clinical Quality Committee – 31 January 2019

Resolved - that the Clinical Quality Committee minutes – 31 January 2019 be received and noted.

BOD24/04.19 Any Other Business

The Associate Director of Corporate Governance (ADCG) advised that the HSE had carried out an inspection at the Trust on 12 March. The focus was on medical sharps and exposure to blood borne virus. The Trust had been issued with two improvement notices. One was given to AMU and one to A&E around a risk assessment of sharps available and audit and managements processes in the Trust. The Trust had been given until the end of June to rectify the issue around the risk assessment and the end of September for the audit process. Legal action would be taken against the Trust if these were not actioned.

Mr Myers (NED) questioned if needles with a retractable cover were available why these were not always used. It was noted that for some procedures a needlesafe device (retractable cover) is not available because of the nature of the procedure and in these instances a risk assessment should exist. The ADCG advised that input from the whole organisation was required for these actions included a streamlined process on what sharps were available. The ADCG would provide an action plan for the May Board of Directors.

EH

Resolved – that:

(A) The Any Other Business was received and noted.

(B) An action plan on the improvement notices from the HSE visit on 12 March would be presented to the May Board of Directors meeting.

EH

BOD25/04.19 Questions from Members of the Public

Appraisal rates – I understand that the “New Agenda for Change” will tie staff progression through pay bands to appraisal. This will no doubt improve compliance rates, however it is a shame that monetary gain rather than the desire to improve may become the driver of the process.

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Q1. Audit Committee – It was disturbing to read that £300,000 had been mistakenly paid to Primecare in 2016. The report states that “The Audit Committee is content that all appropriate steps have been taken”. Why has it taken so long for this to be reported on and what exactly was being “liquidated”?

A2. Mr Cottom (NED and Chair of the Audit Committee) advised that this issue had been discussed previously in the private section of the Board of Directors meeting. The DFI advised that the Trust had spent two and a half years trying to recover this money. It only became apparent two months ago of the financial situation of Primecare in 2016, with all monies paid to them going straight to RBS. An action from this event was for the Trust to review the financial wellbeing of all third parties providing services.

Q2. Violence and aggression towards staff – The member of the public did not feel that the question asked at the previous meeting covered all the areas highlighted and wanted to know the details of the scale of the problem and the actual consequences taken against perpetrators.

A2. The CEO advised that this issue had been discussed in the Board Workshop and linked to Staff Survey results. The results showed that staff were more concerned about lack of support from onsite security staff, which was being reviewed. Datix was another forum for raising issues. Action was taken against the perpetrators but the CEO did not have the number of cases taken to court. The Chairman reiterated the Trust’s zero tolerance of violence and aggression in the organisation.

Q3. Fracture Neck of Femur Patients – Last month’s Mortality Report and again this month, it is mentioned that the Trust’s fracture neck of femur patients was significantly higher than the national equivalent figure. This has been discussed in the meeting already, but are there any other comments that the Board of Directors would like to make around this issue.

A3. The Medical Director advised that the figures were reported retrospectively and these numbers were already reducing. The issues were around not getting patients to an appropriate ward and then onto theatre quickly enough. Both these issues are being addressed. The Orthogeriatrician had also been replaced and an improvement already being seen in numbers.

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Q4. Retention of Consultants – The retention of some older Consultants is at risk as they reach the cap of their pension fund contributions. If this is correct, can a full explanation of the problem be given? Has the Trust carried out a risk assessment of this problem and what are the possible implications?

A4. The Medical Director advised that due to the tax changes in 2016, the annual allowance of your increase in pension per year becomes less if you earn over a specific amount and you can only have a certain amount in your pension. At some stage, it may not be financially sustainable to continue paying into your pension. This may stop Consultants working over their basic hours due to the high tax that they would be paying, which was a real threat to the Trust as we rely on these additional hours. The CEO expected that a way of mitigating this would be agreed nationally as experienced members of staff would not want to be lost across the NHS. The Trust were also reviewing the age profile of our Consultants to ensure that we have an attractive programme to recruit to posts.

Resolved – that the Questions from the Members of Public be received and noted.

BOD26/04.19 Date of next meeting

The next meeting was due to be held on 2 May 2019 at 1.00 pm in the Board Room, Trust Headquarters.

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WYE VALLEY NHS TRUSTACTIONS UPDATE: BOARD OF DIRECTORS, THURSDAY 2 MAY 2018

AGENDA ITEM ACTION LEAD COMMENTBOD09/03.19Activity Performance07.03.19

(B) The Chief Operating Officer would include the length of stay for patients in the Ambulatory Medical Unit within future reports.

JB Completed – within report.

BOD10/04.19Workforce04.04.19

The Director of Human Resources would include the NEDs on the circulation list for Staff Matters.

SS Completed.

BOD24/04.19Any Other Business04.04.19

An action plan on the improvement notices from the HSE visit on 12 March would be presented to the May Board of Directors meeting.

EH Completed – on agenda.

ACTIONS IN PROGRESSBOD19/07.18IM&T Strategy06.07.18

A timeline of when projects commenced would be included within future IM&T Strategy Reports.

HO Timeline to be included in next iteration of strategy – due in 2019.

BOD05/09.18Matters Arising and Action Log06.09.18

The EPR and Fast Follower Update on the training numbers and options would be included during implementation of Phase 2 in 2019.

HO Planning for phase 2 has commenced and the training issue will be addressed in this plan. Due - Spring 2019

BOD11/03.19Finance Performance07.03.19

(B) The Director of Finance & Information would review the Nursing (overspends) & underspends graph as this was not ideal for identifying areas of concern.

HO This table will be refined when we report on the 2019/20 financial position.

BOD21/04.19Audit Committee Summary Report 21 March 201904.04.19

The Chairman and Mr Cottom (NED and Chair of the Audit Committee) would meet to discuss the Auditors concerns around lack of discussion of Audit Committee Reports at the Board of Directors meetings.

RD/AC Meeting arranged for 2 May 2019.

ACTIONS REFERRED TO BOARD OF DIRECTORS SUB-COMMITTEESN/A N/A N/A N/A

REPORTS SCHEDULED FOR FUTURE MEETINGSN/A N/A N/A N/A

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BOARD OF DIRECTORS

Report to: Board of Directors Agenda item: 5.1Date of Meeting: 2nd May 2019Title of Report: Chief Executive’s Update Report

Status of report:(Approval, position statement, information, discussion)

For Information

Report Approval Route: Trust Board

Lead Executive Director: Glen Burley, Chief Executive

Author: Glen Burley, Chief Executive

Appendices:1. Purpose of the report

To update the Board on the reflections of the CEO on current operational and strategic issues.

2. Recommendations

For information

3. Executive Director Assurance

Assurance can be provided that the information within this update report is accurate and up to date at the time of writing.

4. Please state which element of the Trust’s Objectives the report relates to:

1. Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

6. Reduce the financial deficit by delivering our financial plan

2. Improve urgent care by delivering the A & E standard and providing more services across seven days

7. Improve the quality and sustainability of our services by implementing our clinical strategy

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

8. Care for people nearer to home by transforming our community services with our One Herefordshire partners

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

9. Improve our effectiveness through the delivery of our Digital Strategy

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

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1) 2018/19 - A year of Improvement

We are at that point in the year where we are finalising the Annual Report and hence looking back at the successes and challenges of 2018/19. Amid all of the challenges that the Trust faces, it is really positive to look back on a period where we delivered so many improvements. Our improved CQC rating, significantly reduced mortality rates, reduced elective waiting times, improved flow in urgent care and our improved National Staff Survey Results are the most impressive headlines. But these are even more impressive in the context of delivering the highest levels of planned (elective) care despite significant increases in demand for urgent care all alongside the biggest efficiency improvement programme of any NHS provider in the Region (for the second year running).

The Board, and more importantly our fantastic staff should be very proud of their achievements.

2) Contract with Herefordshire CCG 2018/19

The longstanding contractual dispute between the Trust and Herefordshire CCG moved a little further forward this month. The independent ‘expert’ determined that the MoU that we jointly signed at the start of the year was still valid. As a consequence the matter now rests with our regulators for resolution. Depending on their views, this will result in the Trust’s financial position either improving or worsening. So we are no clearer on the financial impact. The dispute stemmed from the fact that the Trust and CCG could not agree on the levels of activity required to deliver safe care or on how the system financial deficit should be handled. As a result we felt that we should use the national contract ‘payment by results’ methodology to equitably define the responsibilities of the commissioner and the provider. It may well be that NHSI and NHSE, who now share a Regional Director lead may conclude that this is still the fairest way to resolve the matter.

3) Contract with Herefordshire CCG 2019/20

As I reported at last month’s Board, we have also been trying to reach agreement on a contract for this financial year. At the point of writing this note, these discussions had not concluded.

There two parties again had to use independent ‘experts’ to conclude on some technical disagreements. Whilst these were broadly concluded in our favour, the resulting contract is unaffordable to the CCG who are apparently, unlike the Trust, unable to plan for a deficit this year. The Trust has two issues to balance. Firstly the need to deliver enough activity to further improve planned care waiting times and to deliver safe urgent and community care. Secondly, the need to manage the cost of delivering this care offset by enough income to deliver no worse a position that our planned deficit.

Whilst achieving waiting times standards is technically a commissioner responsibility, Herefordshire’s waiting times are so poor that the need to improve them became a requirement imposed on the Trust by the CQC. We are determined to ensure that the significant progress we have made over the past year will not be undone by allowing waiting times to slide back further.

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In addition to the detrimental impact on patients, it is far more expensive to try to manage a long waiting list if we have to avoid breaches of the national 52 week wait maximum.

As with last year’s funding dispute, we are now turning to our regulators to advice on an acceptable course of action.

4) Implementing Integrated Care

There is a lot happening at the moment in many parts of the NHS to put in place the building blocks to support implementation of the NHS Long Term Plan (LTP). Whilst Integrated Care Systems have all but replaced Sustainability and Transformation Partnerships, they will be given greater freedom as they demonstrate maturity. At a more local level, we will see the ‘Place’ model taking forward local system improvement. In Herefordshire and Worcestershire there are 2 ‘Places’ defined by the two counties.

We are currently discussing with partner organisations, how we will work together at Place level. Key to this will be clinical engagement in both secondary and primary care.

5) Primary Care Networks (PCNs)

The mandated full coverage of primary care networks is a policy which has moved quite quickly following the publication of the LTP. By July, every part of the country will have to have in place collaborations of GP practices which cover populations of 30,000 to 50,000 people. If they are not in place by this deadline, the contracts for primary care staffing will default back to CCGs.

As a consequence, we now have what looks like a final configuration to cover our local Place. National policy suggests flexible approaches to the way that PCNs will function. In some cases these will develop to employ a wider range of clinical staff, including nurses, therapists and pharmacists. In others they will collaborate with local NHS Trusts to develop workforce solutions jointly.

6) Latest Going the Extra Mile Awards (GEM) Winners – March 2019

Employee of the Month – March – Louise Nuttall

“I attended my first booking appointment at Green croft children’s centre on Friday 15th March 2019. I was a bit stressed on arrival as I got lost and wasn’t too sure where I was going. The Community Midwife team rang me to say the midwife that was due to run the clinic was off sick and they were sending someone from Ross on Wye. Louise got to the children’s centre and we had my appointment. I feel that Louise demonstrated compassion, accountability, respect and excellence. My personal circumstances are that I have two children already, with my late husband. I am now pregnant with my new partner’s child. My last birth my husband was undergoing chemotherapy and during the emergency section, he passed out which was quite stressful as I was his main (and only) carer. Louise showed compassion and respect listening and reassuring me and giving me information on a midwife that deals with birth traumas. I felt for Louise. I know some times we juggle things in the NHS, but she had to come from Ross on Wye,

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no doubt with a whole day of her own planned to cover someone’s work, and part way through the appointment the iPad my information went into stopped working. She just carried on, going through all the information and showed accountability and excellence. She said she would put all my information in when she got back and ring me that evening. I wasn’t actually expecting her to ring, but she did.

I do believe she should be considered for employee of the month, especially as in my eyes she demonstrated all the CARE values. It’s difficult to explain in words, but I can only say I wish she was going to be my midwife all the way through.”

Team of the Month – Acute Medical Unit Team

“I would like to nominate every member of the AMU team for this award as I believe that over the last few months they have all, in their own way, gone above and beyond in their daily duties to ensure that our patients receive the best of care despite the many daily challenges they have faced since opening in December.

Even prior to opening, a lot of groundwork was completed (alongside their daily duties) by Housekeepers and Ward Clerks to ensure a smooth transition, ensuring that all of our documentation, signage and stock were available on the first day to ensure seamless care for our first patients.

Since opening I have been further amazed by the staff resilience, flexibility and ‘can do ’attitude. It has seemed as if it didn’t matter what problem you could find for them, they would come up with a solution or adaptation and simply carry on with their duties as if this was acceptable!

Not all of our equipment had arrived or was available for use immediately. Common sense and practical ability shone through; boxes were adapted as bins, trollies for shelves, cupboards on trollies for drug trollies. Drug rounds were completed with a bunch of 50 keys rather than the more efficient 2 master keys that were long awaited and finally arrived a month after we received our first patient! D.I.Y. skills were discovered and utilised to assemble equipment and shelving.

Due to these many daily challenges, productivity and efficiency were compromised but still nothing was too much for the staff. Standards were maintained, tea and blankets given to the chilly patients due to heating issues, ear plugs and chats for the patients who couldn’t sleep due to noisy vents, offers for extra shifts to be covered were gratefully received, staying on late to get things done became the norm for a while, the list is endless.

I am proud to be currently leading a team who have displayed such compassion, commitment, and professionalism, providing excellent care whilst almost being obstructed at every turn. They have continued to smile, retain their humour and support each other, further evidencing their dedication to ensuring that AMU is an area to be proud to be working in and a safe and efficient area for patients to be treated in.

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Now that we are settled in to our new Unit and the efforts from staff in those initial weeks have enabled us to make a difference to the overall patient experience, I feel this nomination would go a long way towards recognising the altruistic hard work that has been put in by AMU staff.”

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BOARD OF DIRECTORS 

Report to:  Board of Directors  Agenda item:  5.2 

Date of Meeting:  2 May 2019 

Title of Report:  Integrated Performance Report & Dashboard – February 2018/19 Month 11

Status of report: (Approval, position statement, information,  discussion) 

Information 

Report Approval Route:   

Lead Executive Director:  Jane Ives, Managing Director 

Author:  Jane Ives, Managing Director 

Lucy Flanagan, Director of Nursing 

Jon Barnes, Chief Operating Officer 

Sue Smith, Director of Human Resources and Organisational Development 

Howard Oddy, Director of Finance 

Appendices:  None 

 Purpose of the report 

 To inform the Board of the performance of the Trust against a range of indicators, including operational performance against NHS Constitution targets, as at the end of February 2019 (Month 11).  

 

Recommendations 

 For the Board to consider performance against a range of Key Performance Indicators (KPIs) and to note the actions that are being taken to address areas of non‐compliance. 

 

Managing Director Opinion 

 At the beginning of the new financial year it is a good time to look back on progress that has been made over the last year and there are been some impressive improvements in performance.  There has been solid progress against our 2018/19 quality priorities; particularly notable is the drop in mortality which is the most improved in the NHS for an acute hospital showing a drop from 123.8 to 104.8 over the last 18 months. In addition elderly patients are now staying in hospital for a shorter time and more are being discharged directly back to their homes to continue their recovery.   Our workforce has delivered over 6% more activity across emergency, elective and outpatient pathways although the Trust has not been paid for over £8m of this additional work. This has been provided for in our draft accounts but is still subject to regulatory final arbitration.  On RTT a 7% improvement over the year has meant that 80% of patients were treated with 18 weeks. We continue to discuss with regulators the ambition for improvement for the current year, but this is as yet unresolved.  In A&E last March 75% of patients were treated within 4 hours and this had improved to 85% by March 2019 and has moved WVT into the middle of performance table for the Midlands region.  

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  Our  stroke  service has been  scored as  a C  rating  in  the  latest  SSNAP  audit  showing  improvement, but further still to go.  Performance on cancer standards  is the one area that has fallen back from good performance  last year, and whilst still in line with national performance benchmarks this can be improved and and is a focus for the coming year.  Our workforce performance  indicators have also shown steady progress through the year with turnover down  from  13%  to  11.6%,  vacancies  down  from  7.6%  to  6.8%  (including  staffing  the  new  AMU)  and agency as a proportion of the pay bill has dropped from 12.8% to 9.4%. There has been no improvement on sickness levels which have ended the year as they started and again is a focus for the current year.  Financially  the Trust delivered a £10m CPIP which  is one  (if not  the)  largest  in  the  region, however our deficit has grown due to the contract dispute and failure to secure PSF monies.   

Please state which element of the Trust’s Objectives the report relates to: 

 

    1. Reduce the variation in the quality of care we 

provide and avoidable death rates by delivering on our quality priorities 

√ 6. Reduce the financial deficit by delivering our financial plan 

√

2. Improve urgent care by delivering the A & E standard and providing more services across seven days 

√ 7. Improve the quality and sustainability of our services by implementing our clinical strategy 

√

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards 

√ 8. Care for people nearer to home by transforming our community services with our One Herefordshire partners 

√

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention 

√ 9. Improve our effectiveness through the delivery of our Digital Strategy 

√

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning. 

√    

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Standard Target set

Current data

month

Month actual

Trend Year to date

Trend (April 2017 to

date)

Cancer 62 days urgent referral to treatment 85% N January 79.1% 80.6%

Cancer 62 days urgent referral to treatment (38 day breach reallocation) 85% N December 76.6% 80.8%

Cancer 62 day referral to treatment from screening 90% N January 53.8% 79.6%

Faster Diagnosis Standard - 28 days

Referral to Treatment - Open Pathways (92% in 18 weeks) - English Standard 92% N February 77.9%

Referral to Treatment - Open Pathways (95% in 26 weeks) - Welsh Standard 95% N February 82.9%

Diagnostic waiters, 6 weeks and over - DM01 1% N February 0.1%

A&E maximum 4 hour wait from arrival to departure 95% N February 75.5% 75.3%

StandardTarget

set

Current data

month

Month actual (£k)

TrendYear to

date (£k)

Trend (April 2017 to

date)

I&E surplus margin (NHSI oversight measure) Breakeven / Surplus N February -£2,886 -£33,403

I&E surplus margin (actuals versus deficit plan)Fav / (Adv) Variance vs

PlanL February -£2,886 -£33,403

I&E surplus margin (actuals versus plan) Actual v Plan N February -£888 -£12,583

Total income (actual versus plan) Actual v Plan L February -£910 -£6,604

Pay expenditure (actual versus plan) Actual v Plan L February -£89 -£4,671

Non pay expenditure (actual versus plan) Actual v Plan L February £110 -£1,307

CIP (actual versus plan) Actual v Plan L February -£122 -£869

Capital service capacity - Degree to which the provider's generated income covers its financial obligations

Actual N = 4

Liquidity (days) - Days of operating costs held in cash or cash-equivalent forms including wholly committed lines of credit available for drawdown

Actual N = 4

Financial efficiency

I&E margin - I&E surplus or deficit / total revenue Actual N = 4

Distance from financial plan - Year-to-date actual I&E surplus/deficit in comparison to Year-to-date plan I&E surplus/deficit

Actual N = 4

Agency Spend - Distance from provider's cap Actual N = 4

Financial Compliance

April - February

Regulatory Performance Measures

Mandatory from April 2019, WVT to shadow monitor in 2018/19

Wye Valley NHS TrustTrust Key Performance Indicators (KPIs) - 2018/19

April - February

Value for Money

Financial sustainability

Responsiveness

April - February

Financial controls

April - February

April - February

Target Type Performance Against Target (Status) Activity Performance Only

N National Meeting Target Over 5% above Target

C CQUIN Not Meeting Target 5% above to 2% below Target

L Local More than 2% below Target to 5% below Target

Over 5% below Target

   

  

Section 1 ‐ Trust Key Performance Indicators

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Standard Target set

Current data

monthPlan Actual

YTD Variance

(%)

Trend (April 2017 to

date)

Type 1 & Type 3 ED attendances (activity v plan) < Plan L February 4,641 4,691 5.5%

Non Elective Activity - Adult Acute < Plan L February 1,401 1,507 3.6%

Non Elective Activity - Paediatric Acute < Plan L February 276 338 3.5%

Non Elective Activity - Obstetrics < Plan L February 171 162 -4.5%

Total Non Elective Activity (Excl A&E) < Plan L February 1,848 2,007 2.8%

Referrals (MAR - 2018/19 v 2017/18) L -9.7%

Outpatient Activity - New attendances Plan L February 6,832 6,879 4.0%

Outpatient Activity - Follow Up attendances Plan L February 18,849 17,794 0.0%

Total Outpatient Activity Plan L February 25,680 24,673 1.1%

Elective Inpatient Activity Plan L February 383 365 14.4%

Daycase Activity Plan L February 2,283 2,564 10.9%

Total Elective Activity Plan L February 2,666 2,929 11.3%

Community Contacts2017/18 Outturn L February 19,860 15,394 -17.5%

Community Bed Days2017/18 Outturn L February 2,234 2,063 7.2%

Standard Target set

Current data

month

Month actual

Trend Year to date

Trend (April 2017 to

date)

Ambulance turnaround within 30 minutes (WMAS) 98% L February 54.9% 53.7%

Ambulance turnaround over 60 minutes (WMAS) 0% L February 2.1% 2.8%

Time to be seen (average from arrival to time seen - clinician) < 15 minutes N February 01:32

A&E Quality Indicator - 12 hour trolley waits 0 L February 2 12

A&E - % of admitted patients admitted within 4 hours (arrival to discharge) 90% L February 50.6% 43.4%

Cancer 2 week GP referral to 1st outpatient appointment 93% N January 89.7% 91.3%

Cancer Urgent referrals for breast symptoms 93% N January 0.0% 34.3%

Cancer 31 day diagnosis to treatment 96% N January 80.4% 91.1%

Cancer 31 day second or subsequent treatment (drug) 98% N January 100% = 100%

Cancer 31 day second or subsequent treatment (surgery) 94% N January 50.0% 84.0%

Cancer consultant upgrade (62 days decision to upgrade) 85% L January 84.0% 90.8%

Cancer 62 day pathway: Harm reviews - number of breaches over 104 days L January 4 43

% Last minute non-clinical cancelled ops (elective) 0.80% N February 2.9% 1.6%

Breaches of the 28 day readmission guarantee (%) 0% N February 6.8% 26.3%

Breaches of the 28 day readmission guarantee (Numbers) 0 N February 4 92

Urgent operations cancelled more than once 0 N TBC

RTT 52(+) week waiters - All patients 0 N February 24

RTT 40(+) week waiters - All patients L February 351

Delayed Transfers of Care (acute only; pts as % of occ beds) <3.5% N January 5.8%

Delayed Transfers of Care (community only; pts as % of occ beds) <3.5% N January 11.4%

Stroke Indicator - % spending >90% of their stay on a stroke unit 80% N January 89.2% 78.2%

Stroke Admissions - Admitted to Stroke ward within 4 hours of presentation 65% L January 53.3% 28.3%

Stroke Admissions - CT Scan within 12 hours 100% N December 95.0% 93.0%

% of people who have a TIA who are scanned and treated within 24 hours 60% N February 43.5% 38.9%

April to January

Cancelled Operations

A&E Quality Indicators

Cancer

Planned Care - Acute & Community

Responsiveness

Referral to Treatment

Access

Activity

Urgent Care

In Month

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Standard Target set

Current data

month

Month actual

Trend Year to date

Trend (April 2017 to

date)

Emergency 0 day LOS - General & Acute specialties (Adults only) 35% L February 25.5% 25.8%

ALoS - General & Acute Emergency Inpatients (Acute episodes only) 4.5 L February 4.5 4.6

ALoS - General & Acute Elective inpatients 2.5 L February 3.3 2.9

Elective - Theatre Utilisation (Needle To Recovery Less Overruns) 90% L February 76.1% 77.4%

Elective - Daycase Rate 85% L February 86.8% 87.3%

BPT - Fracture Neck of Femur 80% N December 0% 17%

Bed occupancy - G&A Wards (Acute Site) 90% L February 100.3% 104.4%

Bed occupancy - Community Wards 90% L February 90.1% 91.0%

DNA Rate (Acute Clinics) 4% L February 6.1% 6.6%

Clinic Utilisation - Consultant Led Clinics Only 95% L February 92.5% 93.2%

% of patients waiting over 6 weeks without a date (month end snapshot) 0% L February 7.8% =Number of patients waiting longer than 16 weeks over their due appt date 0% L February 5.9%

Smoking at Delivery 11% N February 15.9% 13.0%

% of women who have seen a midwife by 12 weeks and 6 days of pregnancy 90% N February 83.2% 86.8%

% of women inititating breastfeeding 80% N February 77.8% 82.5%

Caesarean section - Elective 13% N February 16.7% 14.8%

Caesarean section - Emergency 15% N February 23.0% 18.7%

Standard Target set

Current data

month

Month actual

Trend Year to date

Trend (April 2017 to

date)

Turnover (rolling 12 months - Trust Level) 10% L 11.5%

Sickness Absence (%) 3.5% L February 5.2%

Vacancy Rate 5% L February 7.0%

Agency (agency spend as a % of total pay bill) 6.4% L February 8.9%

Appraisal rate - all 90% L February 83.1%

Mandatory Training 90% L February 86.6%

Midwife to birth ratio - last 12 months 1:30 N March 1:30 =

Standard Target set

Current data

month

Month actual

Trend Year to date

Trend (April 2017 to

date)

Mortality - SHMI 100 N 106.01

Mortality - HSMR 100 N 105.6

Emergency readmissions within 30 days of discharge (G&A only) 5.9% L January 5.4% 6.3%

Number of >AD+1 MRSA Bacteraemia 0 N February 0 = 1

Number of E.Coli Bacteraemia 0 L February 2 14

Number of >AD+2 clostridium difficile cases 18 N February 2 22

Clostridium difficile cases – lapses in care 0 L February 0 = 5

Number of MSSA Bacteraemia 0 L February 0 = 2

Number of Klebsiella 0 L February 0 = 3

Hand Hygiene 95% L February 97%

Outpatients

Workforce Measures

Maternity

Rolling 12 MonthsWorkforce

Quality

December 2017 to November 2018

Safe

December 2017 to November 2018

Clinical Outcomes

Local Performance Targets and Measures

Inpatients

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StandardTarget

set

Current data

month

Month actual Trend

Year to date

Trend (April 2017 to

date)

Complaints resolved within agreed timeframe 90% L February 100%

Number of complaints L February 25 267

% Written complaints rate (complaints / WTE) L February 0.94%

Number of complaints reopened 25 L February 3 51

Number of complaints referred to Ombudsman 6 L February 0 = 3

Duty of Candour L February 6 76

Patient ward moves emergency admissions (Acute - more than 2 moves) L February 10.0% 11.2%

Same Sex Accommodation Standard breaches 0 N February 25 205

Friends and Family Test - Response Rate (A&E) 25% C February 4.4%

Friends and Family Test - Response Rate (Inpatients) 30% C February 22.2%

Friends and Family Test - Response Rate (Community) 30% L February 89.2%

Friends and Family Test - Response Rate (Maternity) 30% L February 16.4%

Friends and Family Test Score - A&E recommended by Patients 95% N February 91%

Friends and Family Test Score - Inpatients recommended by Patients 95% N February 98% =Friends and Family Test Score - Community recommended by Patients 95% L February 99% =Friends and Family Test Score - Maternity recommended by Patients 95% L February 88%

Staff Friends & Family Test % recommended - care 85% N Qtr 2 80%

Standard Target set

Current data

month

Month actual

Trend Year to date

Trend (April 2017 to

date)

Safety Occurrence of any Never Event 0 N February 0 = 2

Potential underreporting of patient safety incidents L February 535 6571

Safety Thermometer - Harm Free 95% N February 95.8% =VTE Risk Assessment 95% N January 91.4%

Pressure ulcers (confirmed avoidable Grade 3,4) 0 N February 0 = 5

Number of patient falls in inpatient areas 348 L February 27 493

Number of patient falls in community hospitals 276 L February 15 229

Number of patient falls in inpatient areas (per 1000 bed days) 6.6 N February 4.04

Number of falls with moderate harm and above 0 L February 1 = 11

Dementia assessment and referral: the number and proportion of patients aged 75 and over admitted as an emergency for more than 72 hours:

The proportion of patients aged 75 and over to whom case finding is applied within 72 hours following emergency admission with a length of stay > 72 hours

90% N February 52.8%

The proportion of those identified as potentially having dementia or delirium who are appropriately assessed,

90% N February 0%

The proportion of those with a diagnostic assessment where the outcome was positive or inconclusive who are referred on to specialist services

90% N February 0%

Sepsis screening - A&E (% screened) 90% L Qtr 2 100% =Sepsis screening - Inpatients (% screened) 90% L Qtr 2 100% =Number of SIs reported 150 L February 8 66

Medication Errors (with harm) <10% L February 12.0%

Cleaning Standards: Contract clean (Sodexho) 85% L February 90.7% 89%

Cleaning Standards: Clinical Clean (Nursing) 90% L February 96.0% 90.8%

% compliance with WHO checklist 100% N Oct-Dec 100.0% =

Reducing Harm

Experience

Patient Experience

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The infection control team are committed to the national ambition to achieve the Gram negative bacteraemia target reduction of 50% by 2021, the WVT target is no more than 9. The gram negative infections include pseudomonas, klebsiella and e coli. The team are working closesly with system partners to achieve this ambition and are currently focussing on urinary catheter management, invasive device management and hydration. We currently have a robust post infection review process to determine the causes of infection and any lessons that can be learnt. The team are currently working on strengthening the visibility of the learning from these reviews.

Although the trust was above trajectory for clostridium difficile cases at the end of year with 24 cases against a trajectory of 18 it is pleasing to note that the lapses in care associated with these case remained below trajectory (also 18).

The rules for clostridium difficile reporting change significantly in 2019/20 in the main, to add a prior health care exposure element for community onset cases and reducing the number of days to apportion hospital onset healthcare associated cases from admission day plus two days to admission day plus one day. As a consequence NHSI have set Wye Valley a trajectory of 36 cases for the period 2019/20.

Ensuring patient and carer complaints are answered in a timely manner has fallen below the required standard during March, as from next month the team will report on the percentage of complaints responded to within 25 days as there remains a concern that extensions are being sought when a more timely response should have been possible. The number of reopened complaints also suggests that further work is required in addressing the quality of our initial response to complainants.

During the last 3 months there has been an increase in medication errors causing harm. Early analysis showed a particular issue in relation to insulin management and as a consequence the team have conducted a cluster review of these incidents to determine what lessons can be learnt; this will be formally presented to Clinical Quality Committee in May. Further analysis of the other medications inicidents has identified that the errors relate to administration of medication rather than prescribing and in particular delayed and missed doses. Further analysis is under way.

The trust is still experiencing a high number of mixed sex breaches; 13 in coronary care, 7 in intensive care and 3 from our stroke unit.

During March nine serious incidents were reported, a summary of which is detailed below; There was a delay in diagnosing a myocardial infarction which has resulted in left ventricular impairment Two category 3 pressure ulcers Three patient falls - one fall on a ward resulting in a fractured neck of femur, a fall in the car park for a

patient who left the outpatient department unattended and a fall in the emergency department which resulted in the patient sustaining a sub dural haematoma

A dermatology patient was placed on the wrong patient pathway (lesion pathway) rather than cancer pathway and therefore appropriate follow up was not initiated

An ophthalmology delay leading to a deterioration in eye sight Patient developed meningitis post epidural for c section

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In eight out of nine cases verbal duty of candour was provided, the one outstanding was a legitimate exception. In all nine cases a written apology has been provided. Two of the nine cases have resulted in a formal complaint which might indicate further work is required in terms of duty of candour with patients and our communication with them.

There has been a never event which occurred on the 29th March, this does not feature on the table above as the date links to the day the event is reported externally; in this case the 1st April and will therefore feature next month. This involved a patient requiring oxygen being unintentionally connected to an Air supply. The full investigation is currently underway. This is the most commonly reported never event in the NHS and even when all safety measures to prevent occurrence are put in place human factors may still play a part and the risk of reoccurrence cannot be fully mitigated. The final report will include an options appraisal considering all available solutions for consideration by the Trust. In the interim all areas, including those that have previously been exempt from the safety guidance have implemented the same standard of practice; these include all safety measures previously required as part of the safety alert and additionally for air flow meters to be locked away in the patient’s bedside locker unless the patient is being actively nebulised. The patient did not come to harm as a consequence of this incident, although was transferred to critical care for other medically related reasons.

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The run rate cost of agency has fluctuated over the year, particularly with the use of Tier 3 and also Thornbury agency workers although a reducing trend overall. The agency arrangements have provided price savings of £1m and volume savings delivered £0.6m. The latter was also in a year of opening and nursing new additional beds.

Day RN FillDay HCA Fill

Night RN Fill

Night HCA Fill

RN CHPPD

HCA CHPPD Overall CHPPD

Women's Health 91.5% 85.2% 100.3% 99.9% 5.0 5.6 10.6Maternity Ward 100.0% 97.3% 100.0% 89.4% 3.8 3.1 6.9Childrens Ward 83.4% 100.2% 7.1 7.1

Lugg Ward 99.6% 98.4% 98.9% 102.2% 2.7 3.0 5.8Arrow Ward 112.6% 110.5% 101.0% 122.5% 3.1 3.9 7.0Wye Ward 110.5% 81.2% 108.6% 103.0% 3.7 4.2 7.9

Frome Ward 111.2% 101.1% 110.5% 105.5% 3.7 3.4 7.1Cardiac Care Unit 103.1% - 100.6% 9.2 0.8 10.0

Leominster Community Hospital 94.2% 95.4% 101.5% 97.8% 1.9 3.8 5.7

Bromyard Community Hospital 101.4% 130.0% 100.0% 145.1% 3.0 4.6 7.6

Ross Community Hospital 94.7% 99.3% 100.0% 100.7% 1.9 3.5 5.3

Leadon Ward 113.6% 83.7% 101.5% 103.2% 3.2 3.1 6.3Teme Ward 110.1% 68.6% 100.0% 80.6% 3.7 3.7 7.4

Monnow Ward 85.6% 107.9% 100.1% 102.2% 2.9 3.6 6.6Redbrook Ward 108.2% 81.2% 104.0% 141.9% 3.5 3.7 7.2

Special Baby Care Unit 86.6% - 97.7% - 14.0 1.1 15.0

Intensive Care Unit 93.5% 84.5% 21.2 0.0 21.2Gilwern

Assessment Unit 109.1% 93.8% 101.6% 109.7% 3.3 4.7 8.0

Acute Medical Unit 103.1% 105.5% 136.6% 153.8% 4.1 3.1 7.2

The safer staffing return for March is included for information. High fill rates can be seen particularly in those areas where the wards were reconfigured Arrow, Frome and AMU. Frome’s increase relates to a higher number of NIV patients than anticipated. AMU an Arrow are concerned that baseline establishments have not been set at a level that matches paitent case mix. The acuity and dependency audit data is now available and check and challenge sessions have been arranged with the senior nursing teams during the forthcoming month.

At the last Board meeting there was a general discussion about the progress against the 2018/19 quality priorities, included in the tables below is a brief sumary of the achievements. The Quality Account will be presented to the late May Board meeting where a more detailed review is provided.

A number of the priorities are continuing into 2019/20 to ensure sustainability and these were presented to Board last month and were the subject of more detailed discussion at Clinical Quality Committee at its April meeting.

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Safe Achievements:

Reducing avoidable death rates

1. Developed a Mortality Strategy which focused on understanding the factors which contributed to the increased mortality rates

2. Established mortality team to manage the roll out of the Mortality project. The project is based on QI principles, focuses on working alongside clinicians to improve clinical pathways

3. There has been a continued improvement in performance and confidence in improving system wide pathways

Focus on improved identification, treatment and management of the deteriorating patient

1. NEWS2 launched and implemented across acute and community Hospitals. Included NEWS2 E learning for all clinical staff. For staff who undertake vital signs, scenario based sessions developed and monitored for compliance

2. Clinical Practice Week tested, taking micro session to ward based staff. Included testing e obs in the clinical area

To ensure timely identification and treatment of sepsis

1. NEWS2 implemented in ED to ensure 100% screening compliance. Antibiotics within 1hr remains circa 60%

2. Progress with outcomes as shown by improved KPI’s for sepsis and reduction in HSMR and SHMI

3. Recruitment and appointment of Lead Nurse for Sepsis

Effective Achievements

Reducing variation in clinical practice by focusing on complying with best practice care bundles

1. Audit completed demonstrating lack of compliance across organisation

2. Development of group to lead the review of care bundles

3. Education & communication to raise awareness of why care bundles are used

4. Clinical champion identified to lead care bundle work with the medical workforce

Improve discharge planning, ensuring discharge is timely and respects patient’s wishes

1. Wednesday review - all patients who stay over 7 days

2. Hospital at Home service developed

3. Project progress reported at Urgent care delivery board and One Herefordshire

Improve urgent care delivery

1. Performance Indicators produced monthly

2. Urgent care projects which focus on improvement reviewed as part of Wye Valley way.

3. COO is the SRO for the One Herefordshire Urgent Care Programme Board

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Caring Achievements

Ensure that harm reviews are undertaken for patients who have to wait longer than expected

1. Process in place for Clinical review of all patients who have exceeded waiting times.

2. Joint Harm review process established with Commissioners

3. Cancer pathway breaches pathway and reporting established

Enhance care for vulnerable patients with a particular focus on dementia and learning disability

1. Dementia Training rolled out across organisation

2. Progress with One Herefordshire dementia plan

3. Implementation plan to achieve NHSI Learning Disability Standards for acute trusts

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Activity Summary for March 2019:

3a. Acute activity: (RTT and non-RTT)

Contract Activity Monitoring

0

50

100

150

200

250

300

350

400

450

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

Elective

Actual plan

0

1000

2000

3000

4000

5000

6000

7000

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

New Outpatient Attendances

Actual plan

0

2000

4000

6000

8000

10000

12000

14000

16000

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

Follow Up Outpatient Attendances

Actual plan

0

500

1000

1500

2000

2500

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

Emergency

Actual plan

0

500

1000

1500

2000

2500

3000

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

Daycase

Actual plan

0

1000

2000

3000

4000

5000

6000

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

Accident & Emergency

Actual plan

A&E demand has grown to 6.4% above 2017/18, previously (6.1% in February and January). On average, there have been 304 more attendances each month in 2018/19 than the previous financial year. Year-on-Year Activity Variance(The following data excludes community and endoscopy cases to assess the activity demand across acute services)

‘Total elective’ (inpatient and day-case) activity this year to date is 6.55% over the same period in 2017/18.

Total Outpatient activity is 6.86% over 17/18 with 14,935 more appointments to date.

Month 17/18 18/19 17/18 18/19 17/18 18/19 17/18 18/19 17/18 18/19 17/18 18/19 17/18 18/19Apr 1,630 1,739 1,396 1,478 234 261 39 67 16,932 17,974 4,988 5,739 11,944 12,235May 1,844 1,913 1,500 1,598 344 315 25 62 20,455 20,253 6,064 6,445 14,391 13,808Jun 1,882 1,934 1,554 1,551 328 383 72 67 19,328 19,342 5,554 6,268 13,774 13,074Jul 1,894 1,970 1,597 1,610 297 360 57 29 17,390 19,616 5,114 6,244 12,276 13,372Aug 1,630 1,800 1,391 1,533 239 267 33 12 16,951 18,797 4,727 5,816 12,224 12,981Sep 1,821 1,809 1,513 1,489 308 320 14 26 17,732 18,723 5,638 5,933 12,094 12,790Oct 2,054 2,142 1,723 1,804 331 338 33 30 18,863 21,180 6,079 7,009 12,784 14,171Nov 2,191 2,091 1,819 1,678 372 413 37 59 20,615 20,642 6,768 6,687 13,847 13,955Dec 1,562 1,727 1,312 1,433 250 294 49 50 15,102 16,553 4,929 5,481 10,173 11,072Jan 1,788 1,998 1,571 1,624 217 374 49 53 19,560 20,901 6,441 6,815 13,119 14,086Feb 1,699 2,003 1,452 1,632 247 371 73 64 16,942 18,897 5,224 6,157 11,718 12,740Mar 1,803 2,100 1,547 1,683 256 417 110 92 17,948 19,875 5,857 6,723 12,091 13,152

YTD 21,798 23,226 18,375 19,113 3,423 4,113 591 611 217,818 232,753 67,383 75,317 150,435 157,436Variance

Total Outpatient New Follow Up

6.86% 11.77% 4.65%

Total Elective Day Case OutsourcedElective

6.55% 4.02% 3.38%20.16%

Section 3 - Chief Operating Officer, Performance Exceptions

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‘Daily Triggers’

13 days (42%) in March were red rated for ED attendances, including 2 days where the volumes exceeded 200 total attendances. 24 days (77%) had a red rating for ambulance conveyances.

Measures for bed occupancy (general and acute wards) and stranded (7 day LOS) patients were performing well through the opening 20 days of the month. As the pressure in ED continued, both did eventually experience red rated days in the last week of March.

Super stranded (21 day LOS) patients has shown considerable improvements with all but one day (97%) showing a green rating (under 58 actual). The total volume of Delayed Transfers of Care remained stable in the month with 10 days (32%) reporting a green rating.

Acute Medical Unit

Average length of stay in March was 1.26 days which is a marginal gain on February (1.27) and a significant reduction from January (1.57) which has resulted in clear flow benefits.

2/10 36/138

3b. A&E standard:

85.1% of A&E attendances [4,503 of 5,294] achieved the 4 hour target against a national standard of 95% as the Trust recorded its best performance of the year. The recovery trajectory was 88.4%.

The two graphs below demonstrate the pressure on both the Emergency Department and acute inpatient bed base.

ED Attendances

Emergency Adult admissions(adult admissions with a length of stay of one or more nights)

Ambulance Conveyances

March saw the second highest volume of conveyances ever with 1,921 falling just below December’s 1,969. Through 2018/19 there was a total of 21,897 conveyances which was 1,881 more than the 20,016 seen in 2017/18. That difference is higher than the average monthly volume in 18/19 which was 1,825 and 157 more than 17/18 (1,668).

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[$-10809]0

[$-10819]0

[$-10829]0

[$-10839]0

[$-10849]0

[$-10859]0

[$-10869]0

[$-10879]0

[$-10889]0

[$-10899]0

[$-10809]01.03.2019[$-10809]03.03.2019[$-10809]05.03.2019[$-10809]07.03.2019[$-10809]09.03.2019[$-10809]11.03.2019[$-10809]13.03.2019[$-10809]15.03.2019[$-10809]17.03.2019[$-10809]19.03.2019[$-10809]21.03.2019[$-10809]23.03.2019[$-10809]25.03.2019[$-10809]27.03.2019[$-10809]29.03.2019[$-10809]31.03.2019

Daily number of Ambulance Conveyance

The complete programme of work overseen by the One Herefordshire Urgent Care Programme Board is discussed in more detail later in these Board papers.

We continue to progress appointments to the medical vacancies within the Emergency Department. A recent consultant appointment on a 12 month contract and a locum consultant for ad-hoc cover has been received well. The Middle Grade appointments continue to be challenging though one further middle grade has been recruited. It is considered these posts will enhance the senior clinical leadership within the Emergency Department.

There has been a significant improvement in 4 hour performance during March, delivering 85.1% in month, despite an average 60 ambulances per day (see above). Total breach count for March was 791, compared to 1150 for February 2019.

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3c. RTT 18 week standards:

English commissioned performance:

The Trust’s (English) performance for the month was 80.02% (77.9% - February) against an agreed trajectory of 81.8% and standard of 92% of incomplete pathways waiting under 18 weeks.

Welsh commissioned performance:

The Trust’s performance for March was 83.8% against a standard of 95% of incomplete pathways waiting under 26 weeks. Last month was 82.9%.

Patient’s waiting for treatment over 40 weeks:

The graphs below show the number of patients (English and Welsh) waiting over 40 weeks since April 2017. The numbers of all patients waiting over 40 weeks has fallen by over 59% since its peak in August 2018 with a reduction of 69 since last month.

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apr mai jun jul aug sep okt nov des jan feb mar0

50

1002017/18 2018/19Part 1 B - Non Admitted Over 40 Weeks

apr mai jun jul aug sep okt nov des jan feb mar0

200

400

600

800

10002017/18 2018/19Part 2 - Incomplete Pathways Over 40 Weeks

Patient’s waiting for treatment over 52 weeks:

4 patients were waiting over 52 weeks for treatment at month end which is 20 less than last month. All of these patients are English and from Herefordshire. There has been a reduction of 127 patients since the peak volume of 131 in July 2018.

The Trust is expected to maintain that no further patients will be waiting over 52 weeks for treatment in 2019/20.

English ‘52 week’ recovery trajectory:

Welsh ‘52 week’ recovery trajectory:

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Harm Reviews for patients waiting over 52 weeks for treatment:

Status of Harm Reviews – July 2017 to end of March 2019

CommissionerTotal Patients Identified for Harm Review

Harm Reviews Completed

Harm Reviews Overdue (TCI in

the past)

Harm Reviews Not Yet Due

(TCI or OPA on future date)

Harm Reviews not required

(patients DNA’d,

declined surgery etc)

Patients assessed as having come to

harm

English 974 542 143 6 283 0

Welsh 251 148 29 0 74 0

Total 1225 690 172 6 357 0

3d. Diagnostics:

The Trust achieved the Diagnostic standard of less than 1% of patients waiting over 6 weeks at month end with performance at 0% after reporting no breaches.

3e. Cancer standards (February 2019):

Measure Std Type Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 18/19 17/18Trajectory 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0%Actual 93.8% 89.9% 84.5% 91.7% 86.8% 92.0% 94.9% 94.2% 95.9% 89.7% 91.8% 91.3% 94.7%

Trajectory 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0%Actual 85.7% 30.2% 46.3% 61.5% 17.2% 2.8% 14.0% 41.7% 20.8% 0.0% 5.0% 29.6% 83.9%

Trajectory 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0%Actual 97.4% 94.0% 98.0% 96.9% 93.8% 89.8% 89.3% 86.2% 85.2% 80.4% 91.0% 91.1% 96.3%

Trajectory 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0%Actual 75.0% 85.7% 92.9% 89.5% 83.3% 100% 76.5% 100% 87.5% 60.0% 83.3% 86.2% 93.5%

Trajectory 88.5% 86.0% 86.5% 86.7% 85.8% 85.8% 86.4% 86.4% 85.3% 85.3% 86.5% 85.4%Actual 79.5% 76.3% 88.2% 87.9% 84.5% 78.9% 73.6% 80.7% 78.0% 79.1% 77.3% 80.4% 86.1%

Breast 85% Actual 88.0% 100% 100% 100% 88.9% 81.8% 88.2% 77.8% 66.7% 100% 88.2% 90.1% 96.9%Gynaecology 85% Actual 100% 100% 85.7% 100% 100% n/a 66.7% 77.8% 75.0% 90.0% n/a 84.2% 71.4%Haematological 85% Actual 100% 50.0% 100% 90.0% 57.1% 60.0% 100% 0.0% 100% 100% n/a 80.9% 87.9%Head & Neck 85% Actual 100% 0.0% 66.7% 50.0% 100% 0.0% 0.0% 50.0% 33.3% n/a 0.0% 32.0% 50.0%Lower GI 85% Actual 50.0% 52.0% 50.0% 100% 71.4% 83.3% 33.3% 87.5% 60.0% 40.0% 66.7% 62.7% 69.5%Lung 85% Actual 100% 100% 60.0% 66.7% 100% 83.3% 0.0% 80.0% 66.7% 100% 40.0% 74.4% 74.2%Sarcoma 85% Actual n/a n/a n/a n/a n/a n/a n/a 0.0% 0.0% n/a 100% 33.3% 92.3%Skin 85% Actual 100% 91.7% 100% 95.2% 100% 89.7% 100% 89.7% 100% 90.9% 87.5% 95.0% 94.5%Upper GI 85% Actual 0.0% 100% 58.3% 100% 50.0% 66.7% 83.3% 50.0% 75.0% 62.5% 77.8% 71.4% 71.4%Urological 85% Actual 76.2% 73.1% 76.5% 74.3% 80.0% 76.5% 62.5% 82.9% 68.4% 70.6% 78.9% 74.6% 87.0%Other 85% Actual n/a 100% n/a n/a n/a n/a n/a 100% 66.7% 100% n/a 83.3% 81.8%

Trajectory 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Actual 100% 75.0% 100% 71.4% 87.5% 66.7% 100% 85.7% 84.6% 53.8% 75.0% 79.3% 96.4%

Trajectory 87.0% 90% 90% 90% 92% 92% 94% 94% 100% 100% 100% 94%Actual 96.8% 90.9% 90.5% 95.0% 93.3% 100% 92.7% 85.2% 85.7% 84.0% 100% 91.4% 91.9%

Trajectory 87.0% 90% 90% 90% 92% 92% 94% 94% 100% 100% 100% 94%Actual 100% n/a 100% n/a n/a n/a n/a n/a n/a n/a n/a 100% 88.9%

2018/19

Cancer 62 Days Screening 90%

Cancer 62 Days Upgrades 85%

Cancer 31 Days Rare cancers 85%

Cancer Two Week Waits 93%

Two Week Waits (Breast Symptomatic)

93%

Cancer 31 Days 96%

Cancer 31 Days Subsequent Treatments

98%

Cancer 62 Days 85%

The Trust achieved the following ‘Cancer targets’:

Cancer ‘62 days upgrades’

The Trust failed the following ‘Cancer Target’:

Cancer ‘Two Week Waits’ Two Weeks ‘Breast Symptomatic’ Cancer ‘31 days 1st treatment’ Cancer ‘62 days’ Cancer ‘31 Days Subsequent Treatments’ Cancer ‘62 days screening’

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Cancer ‘62 days’

37.5 out of 48.5 patients in total were treated for their cancer within 62 days in February. There were 11 breaches as the Trust failed to meet the 85% threshold for either the existing 62 day (77.3%).

‘62 day cancer’ target breaches as follows:

Breast 1 Lower GI 1.5 Skin 1Upper GI 1 Urological 4 Head + Neck 1Lung 1.5

The Trust continues to struggle to achieve its 62 day target. Meetings with the 3 teams that are causing the most breaches are continuing and each have developed recovery plans to improve compliance. This picture is replicated across the Cancer Alliance.

Cancer ‘Two Week Waits’ & Cancer Two Weeks ‘Breast Symptomatic’

Cancer ‘Two Week Waits’ performance was 91.8%, the main driver for this was the ongoing issues with the Breast pathways. However this is an improvement on the January position and is likely to continue to improve with the target being met in April

The Cancer Two Weeks ‘Breast Symptomatic’ standard has not been achieved in any month from 2018/19 with performance in February improved slightly to 5%. Performance for March will be improved further with all patients booked within 2 weeks by the end of the month. The service continues to be challenged and performance may deteriorate once again in the coming weeks and months. Work continues to both better manage demand and to find a robust and substantive solution to the capacity and demand gap.

Cancer ’31 Days First Treatments’

91% of patients were treated within 31 days of a decision to treat (target 96%). The 7 breaches were from Lower GI (1), Skin (2) and Urology (4).

RCAs and Harm Reviews

RCAs & Harm Reviews - 62 and 104 day breaches:

RCA and Harm Review position Dec 2018 - Feb 2019:

Month 62 day breaches – RCAs104 day breaches – RCA +

harm reviewHarm outcome

December 15 2 Awaiting outcome

January 12 6 Awaiting outcome

February 11 7 Awaiting outcome

Total 38 15

Site 62 days 104 days Breach reasons Actions

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Breast 2 0 Mix of OP capacity, Worcester diagnostics and Theatre capacity

Team have developed an action plan to address current issues.

Colorectal 9 1 Mix of theatre capacity, WVT diagnostics (endoscopy and radiology) and patient instigated delays

Team have developed an action plan to address current issues.

Dermatology 3 0 1 data transfer delay +2 biopsy capacity

Capacity being reviewed on an ongoing basis

Gynaecology 1 0 Pathology delay Nil

Head & Neck 4 2 Complexity of pathway, processes within pathway + theatre capacity + tertiary

Working with Worcester to improve pathway

Haematology 0 0

Lung 2 1 Complexity of pathway None

Sarcoma 0 0

Upper GI 2 2 All tertiary None

Urology 15 7 Diagnostic capacity (TRUS and template biopsies), processes and radical prostatectomy capacity at Cheltenham

Agreed process to improve pathway timing starting to show an improvement from December. Increased robotic time at Cheltenham agreed.

3f. Cancelled Operations:

23 of 2,268 (1.01%) operations were cancelled at the last minute in March as the Trust failed the standard of 0.8%. 13 operations were not rebooked within 28 days (59.09%) which fails this measure.

Both standards were failed as a direct result of pressure on inpatient capacity and theatre recovery.

3g. Stroke/TIA:

Stroke performance (% of time spent on Stroke Unit) is calculated using national SSNAP data.

89.5% (34 of 38) patients spent 90% of their time on a Stroke ward in month as the Trust achieved the 80% standard. Performance for the financial year achieved 79%.

27.3% (9 from 33) of ‘high-risk’ TIA patients were scanned and treated within 24 hours of referral in month which is a failure of the 60% threshold. 2018/19 performance was 37.9%.

The Sentinel Stroke National Audit Programme [SSNAP] data is collected by the Trust to provide timely information to clinicians, commissioners, patients, and the public on how well stroke care is being delivered and can be used as a tool to improve the quality of care that is provided to patients.

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This is submitted nationally and Trusts are graded from A to E (A being the highest performing) based on multiple quality parameters across the stroke pathway.

For Quarter 2 2018/19 the Trust had fallen to a Grade D, performance for Quarter 3 2018/19 has seen the Trust’s performance return to a Grade C.

3h. Delayed Transfers of Care (DTOC) (February 2019)

Total Delays Acute Community Health Social

A (Completion of Assessment) B (Public Funding) C (Further non-acute NHS care) D (i) (Residential Home) D (ii) (Nursing Home)

E (Care Package in Own Home) F (Community Equipment) G (Patient or Family Choice) H (Disputes) I (Housing)

Headline

By Code (This FY)

At the time of completion of this report March data was not available (due on 26th April).

543 bed days were lost to delayed transfers of care in February 2019 with 260 in the Acute setting and 283 in the Community. The monthly total was a reduction of 264 days over January and 69 fewer than February 2018.

Care Packages in Own Home (E) has remained the largest delay reason in each month since May 2018 following 204 reported in February. Further Non-Acute NHS Care (C), Residential Home (D i) and Nursing Home (D ii) were the largest delay reasons thereafter and accountable for 71, 70 and 67 days respectively.

Key Actions:

The Trust has seen continued improved flow across acute and community beds, with the Length of Stay at Community Hospitals coming down to 14 days or below at all sites.

Following a spell of lower delays for patients to return to Powys (both social care and Powys beds), a sharp increase to double figures was noted in early April. This was challenged by the Trust with some effect noted and Powys bed delays markedly reduced in response

Bi-weekly Length of Stay reviews continue, with both 7 day and 21 day stranded performance also significantly improved and maintained for much of March 2019.

Further improved integrated discharge working seen with the return of the Hospital Liaison Team to the acute site office.

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16/17 17/18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Threshold

Budgeted Establishment 2911.2 2932.1 2932.1 2918.8 2929.5 2876.9 2872.8 2858.7 2852.6 2865.2 2862.1 2876.6 2915.1 2930.1 2929.4

Substantive Staff in Post 2638.3 2707.8 2707.8 2681.4 2667.7 2662.4 2659.2 2668.1 2694.1 2711.4 2708.3 2696.4 2711.2 2719.5 2743.6

Vacancy 272.9 224.3 224.3 237.4 261.7 214.5 213.6 190.6 158.4 153.9 153.8 180.3 203.9 210.5 185.8

Starters 589.6 498.2 26.8 23.0 18.3 25.8 45.5 86.0 70.5 42.3 33.1 25.4 39.3 47.2 41.9 525.1

Leavers 372.7 346.0 40.6 34.4 28.8 30.0 94.5 30.3 44.8 19.5 35.3 39.1 19.9 32.9 42.9 492.9

Turnover 14.6% 12.9% 12.9% 13.0% 13.2% 12.0% 12.6% 12.6% 11.7% 11.3% 11.4% 11.9% 11.8% 11.5% 11.6% 12.1% <=10% >15%

Vacancy Rate – Total 9.4% 7.6% 7.6% 8.1% 8.9% 7.5% 7.4% 6.7% 5.5% 5.3% 5.2% 6.1% 6.9% 7.0% 6.3% 6.8% <=5% >10%

Agency Spend % Pay Bill 14.9% 12.8% 12.8% 10.6% 11.2% 9.7% 10.2% 10.9% 9.5% 8.0% 9.3% 8.4% 10.0% 8.9% 9.4% 9.9% <=6.4% >11.4%

Sickness Absence Rate 4.2% 4.6% 4.6% 4.6% 4.2% 4.3% 5.0% 4.7% 4.7% 5.1% 4.9% 4.8% 5.5% 5.2% 4.6% 4.8% <=3.5% >8.5%

Appraisal – All 90.1% 89.4% 89.4% 88.8% 91.3% 92.3% 92.7% 88.3% 86.1% 86.0% 87.0% 87.0% 85.5% 83.1% 83.2% 87.7% =>90% <85%

Core Skills 85.8% 88.5% 88.5% 88.3% 90.1% 90.1% 90.0% 87.0% 85.4% 85.9% 85.6% 85.6% 86.2% 86.6% 87.7% 87.5% =>90% <85%

Training (% - In Month)

Staff Numbers (FTE)

Turnover (% - Rolling 12 Months)

Vacancy (% - In Month)

Agency Spend (% - In Month)

Sickness (% - In Month)

Appraisals (% - In Month)

Section 4 - Director of Human Resources & Organisational Development, Performance Exceptions

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AppraisalsAppraisals have been flagged as a concern this month – the following charts outline the appraisal compliance by Division and by Staff group across the Trust, alongside tables showing the outstanding appraisal numbers.

The largest fall in compliance is within in surgical services, currently at 78.3% - currently out of 862 staff, only 675 have had an appraisal therefore 187 are outstanding.

Add ProfScientific and

Technic

AdditionalClinicalServices

Administrativeand Clerical

Allied HealthProfessionals

Estates andAncillary

HealthcareScientists

Medical andDental

Nursing andMidwiferyRegistered

Reviews Completed % 85.1 81.7 88.1 77.5 88.8 73.7 88.3 80.7

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Appr

aisa

l %

Rolling 12 Month Appraisal Rates by Staff Group - April 2018 to March 2019

The 5 areas with less than 65% compliance are listed below - if these outstanding appraisals were to be completed, the compliance rate would immediately increase to 85.15%.

Areas < 65% CompliantHead Count

Appraisals Completed

%

Specialist Nursing (Surgical) Service 5 2 40.0

Endocrinology & Diabetes Service 10 6 60.0

Discharge & Medical Day Case Service 13 8 61.5

Day Surgery & Pre-Op Service 22 14 63.6

Radiology Service 85 55 64.7

70

27

77

76

187

Outstanding Appraisals by Division -March 19

Clinical Support Services

Corporate

Integrated Care

Medical

SurgicalClinical Support

Services Corporate Integrated Care Medical Surgical

ReviewsCompleted % 82.6 91.5 84.6 85.2 78.3

70.0

72.0

74.0

76.0

78.0

80.0

82.0

84.0

86.0

88.0

90.0

92.0

94.0

Appr

aisa

l %

Rolling 12 Month Appraisal Rates by Division - April 2018 to March 2019

15

110

71

4791524

147

Outstanding Appraisals by Staff Group -March 19

Add Prof Scientific and Technic

Additional Clinical Services

Administrative and Clerical

Allied Health Professionals

Estates and Ancillary

Healthcare Scientists

Medical and Dental

Nursing and MidwiferyRegistered

2/3 46/138

A range of actions have been put in place by the Head of Education & Development with immediate effect, which will be further reviewed at both Strategic Workforce Committee and Trust Management Board.

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I&E Performance against Budget Plan YTDAt the end of March (month 12), the Trust reported a cumulative deficit of £42.1m (after taking account of donated assets, impairments and Provider Sustainability Funding). Prior to adjustments, the Trust reported a 43.6m deficit.

This position reflects the outcome of the Expert Determination, which found against the Trust in terms of our ability to unilaterally move back to the PbR funding regime. However, the Expert Determination did not determine where or how the £6m deficit and the £2.5m cost of delivering RTT should be accounted – therefore, in discussion with NHSI, the Trust has included the value of the invoices relating to the dispute, together with a prudent accrual, in order to reflect the fact that the issue might not be satisfactorily resolved. The issue continues to be discussed with NHSI.

Before taking account of the Provider Sustainability Fund (PSF), this financial position was £16.1m worse than the control total plan of £27.2m deficit.

Although the Trust was not eligible to claim either the financial element of the PSF of £3.1m, or the A&E PSF of £1.3m, the Trust was awarded £1.14m PSF on 18th April, as part of the NHSI year-end process. This has resulted in a cumulative variance of £19.3m from the overall control total trajectory (including PSF) of £22.8m deficit.

The table below shows the monthly run rate position, resulting in the cumulative deficit of £42.1m (net of technical adjustments). No further material changes are now expected between these Month 12 Management Accounts and the year-end Statutory Accounts.

Outturn

Section 5 - Director of Finance, Performance Exceptions

STATEMENT OF COMPREHENSIVE INCOME - To Month 12 - 31st March 2019 - 2018/19

CURRENT MOVEMENTANNUAL INBUDGET CURRENT

PLAN BUDGET ACTUAL VARIANCE MONTH

£000 £000 £000 £000 £000

Contract & PbR Income 153,622 153,622 159,897 6,275 2,2631,000 1,000 0 (1,000) (90)5,000 5,000 0 (5,000) (449)

PbR Excluded Drugs 16,062 16,062 15,837 (225) 35Non Contracted Activity (NCA's) 1,643 1,643 1,462 (181) (224)Other Income for Patient Care 9,133 9,133 8,552 (581) (396)Donations For Non Current Assets 200 200 423 223 100Radiology MES 50 50 0 (50) (4)24 Bedded Ward 1,161 1,161 0 (1,161) (387)Other Non Patient Income 7,455 7,455 7,208 (246) (91) Total Operating Income 195,325 195,325 193,379 (1,946) 756

Pay Expenditure 136,422 136,422 140,783 (4,361) 311Non Pay Expenditure 57,870 57,870 67,393 (9,524) (8,199)Excluded Drugs 15,601 15,601 15,153 447 (47)

Total Operating Expenditure 209,893 209,893 223,329 (13,437) (7,935)

EBITDA (14,567) (14,567) (29,950) (15,383) (7,179)

Depreciation 5,041 5,041 5,032 9 2Gain or loss on asset disposal 0 0 359 (359) (359)Interest Receivable 58 58 64 6 3Interest Payable on Loans 2,202 2,202 2,700 (498) (13)Interest Payable on PFI 5,627 5,627 5,627 (0) 0Dividends on PDC 0 0 0 0 0

Operating Surplus/ (Deficit) (27,379) (27,379) (43,603) (16,224) (7,547)

Technical Adjustments

Donated Assets - Additions 200 200 423 (223) (100)Donated Asset Depreciation (356) (356) (386) 30 102Donated Assets Adjustment (156) (156) 37 (193) 2

Net impact of asset impairments 0 0 (359) 359

Adj. financial performance retained Surplus/ (Deficit) (27,223) (27,223) (43,281) (16,058) (7,545)

PSF

A&E 1,326 1,326 0 (1,326) (155)Financial Control 3,095 3,095 1,141 (1,954) 781

Additional PSF Funding 4,421 4,421 1,141 (3,280) 626

(22,802) (22,802) (42,140) (19,338) (6,919)

YEAR TO DATE

Estimated Overperformance on reverting to NT

All values in £000's M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 TotalIncome 14,835 14,871 15,278 15,325 18,053 16,026 16,280 16,474 15,636 16,289 16,231 18,080 193,379

Pay 11,470 11,364 11,245 11,603 12,273 11,626 11,659 11,594 11,570 12,053 11,722 12,605 140,783Non Pay 4,733 5,182 4,678 4,885 4,798 5,049 5,288 4,964 5,131 5,045 5,101 12,539 67,393Excluded Drugs 1,377 1,344 1,221 1,166 1,385 1,111 1,530 1,157 1,207 1,084 1,226 1,344 15,153

EBITDA (2,745) (3,019) (1,866) (2,329) (403) (1,760) (2,197) (1,241) (2,272) (1,893) (1,818) (8,409) (29,950)

Depreciation & Interest 1,038 1,088 1,074 1,068 1,073 1,088 1,069 1,070 1,074 1,073 1,094 1,844 13,653Donated Assets Adjustment (11) (11) (11) (11) 19 202 (24) (25) (26) (25) (24) (16) 37Net impact of fixed asset revaluations and impairments (359) (359)

Deficit Prior to PSF (3,772) (4,096) (2,929) (3,386) (1,495) (3,050) (3,242) (2,286) (3,320) (2,941) (2,888) (10,237) (43,281)PSF 0 0 0 0 0 0 0 0 0 1,141 1,141Deficit Including PSF (3,772) (4,096) (2,929) (3,386) (1,495) (3,050) (3,242) (2,286) (3,320) (2,941) (2,888) (9,096) (42,140)

M4 includes pay award at £238k (fully funded in local budget) M5 includes pay award arrears M1-M3 at £615k (fully funded in local budget)

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During March, the outturn deteriorated from a forecast value of £36.2m deficit (as per the month 11 report) to the current confirmed value of £43.3m deficit, a deterioration of £7.1m. This was totally as a result of the accrual relating to the disputed PbR activity and income, plus £440k which related to the Agenda for Change pay award for PFI staff, which ultimately was not paid by the DoH.

The overall variance of £16.0m from the control total may be summarised as follows:

Income £1.9m – this can be broadly summarised as being due to the shortfall on PFI A4C funding of £0.4m and various contract and non-contract income budgets £1.4m;

Pay - £4.3m - Medical Staffing £3.7m and Nurse staffing £2.1m, partially offset by slippage in Earmarked Reserves (£1.5m); Non Pay - £9.5m – this includes the £8.5m accrual for non-resolution of the contractual dispute with the CCG; Other adjustments - £0.9m – this includes the higher rate of interest at £0.5m, charged on borrowing against historic debt and the loss on the sale of Ledbury Road.

Other specific in year operational cost pressures, included within this position, include the following:

£1.1m winter pressures related costs in the form of the 24 extra beds provided from the end of December; £0.9m additional investment in ED to respond to continuous increase in demand; £0.5m staffing for Day case overspill £0.2m from the temporary use of the Vanguard Unit.

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Income Performance and Contracting – Point of Delivery INCOME - BY PATIENT CLASS

ANNUAL BUDGET

MOVEMENT IN CURRENT

MONTH

BUDGET ACTUAL VAR. % VAR.£ 000's £ 000's £ 000's £ 000's Var £ 000's

Contract IncomeDaycase 16,972 16,972 17,503 530 3% 192Elective 10,715 10,716 11,883 1,166 11% 16Emergency 37,733 37,733 41,337 3,604 10% 1,476Outpatients 23,205 23,205 21,400 (1,805) -8% (144)Accident & Emergency 8,230 8,230 9,038 808 10% 31Pathology 3,122 3,122 3,156 33 1% 2Diagnostics 2,716 2,716 2,882 166 6% 1Critical Care 3,256 3,256 3,893 637 20% 117PbR Excluded Drugs 9,266 9,266 10,081 815 9% 110Other Variable & Blocked 22,311 22,311 17,993 (4,318) -19% (127)Community Contract 32,736 32,736 32,008 (729) -2% (64)Any Qualified Provider 268 268 268 (0) 0% (0)

Non Contract IncomeInter Trust SLAs - Cross Charges 8,259 8,259 7,869 (390) -5% (60)Central Funds 4,564 4,564 4,340 (224) -5% (224)Business Unit Service Income 7,455 7,455 7,208 (246) -3% (92)Named Patient Panel Drugs 3,106 3,106 2,099 (1,007) -32% (187)Donations For Non Current Assets 200 200 423 223 111% 100Radiology MES 50 50 0 (50) -100% (4)24 Bedded Ward 1,161 1,161 0 (1,161) -100% (387)

Total Operating Income 195,325 195,326 193,380 (1,946) -1% 755

PSF Income 4,421 4,421 1,141 (3,280) -74% 626

TOTAL OPERATING INCOME INCLUDING PSF 199,746 199,747 194,521 (5,226) -3% 1,381

INCOME

YEAR TO DATE

At the end of March, there was an adverse variance of £1,946k against the pre-PSF income plan and an in month positive movement of £755k.

Activity across all points of delivery recorded in March recorded an over achievement against the income plan. Outpatients reported an improved position in month but remained under plan year to date.

Private sector activity remained behind plan in month, with some of the shortfall compensated by additional WLI activity undertaken on-site but at a cost not budgeted for in terms of additional WLI expenditure.

The volumes of activity delivered the following RTT performance:

Start of year

position

Commissioned Contracted

Plan *

Year End Actual

Position

EnglishRTT Performance vs 92% Standard 75.20% 81.80% 80.02%Number of patients waiting >52 wks 104 119 4

WelshRTT Performance vs 92% StandardNumber of patients waiting >52 wks 27 ** 0 0Number of patients waiting >36 wks 350 ** 0 52* HCCG under a block contract Welsh Commissioners PBR** Figures as end of June when funding agreement concluded

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Income Performance and Contracting – Contract AnalysisINCOME - BY CONTRACT

ANNUAL BUDGET

MOVEMENT IN CURRENT

MONTH

BUDGET ACTUAL VAR. % VAR.£ 000's £ 000's £ 000's £ 000's Var £ 000's

CCG Commissioning SLAsNHS Herefordshire CCG - Current MOU 121,275 121,275 129,775 8,500 7% 2,334

1,000 1,000 0 (1,000) -100% (90)5,000 5,000 0 (5,000) -100% (449)

NHS Herefordshire CCG RTT Over Performance 2,497 2,497 0 (2,497) -100% (435)NHS Shropshire CCG 5,030 5,030 5,290 260 5% 24NHS Worcestershire CCG 2,263 2,218 2,729 511 23% (14)NHS Gloucestershire CCG 1,337 1,382 1,323 (59) -4% (18)NHS Telford & Wrekin CCG 266 266 159 (107) -40% (19)Non Contracted Activity (NCA's) 1,643 1,643 1,462 (181) -11% (224)Any Qualified Provider (AQP) 268 268 268 (0) 0% (0)

LHB Commissioning SLA'sPowys LHB 14,901 14,901 15,205 304 2% (191)Aneurin Bevan LHB 1,980 1,980 1,917 (63) -3% (49)Welsh Specialised Commissioning 118 118 149 31 26% 29

Other Commissioning SLA'sNHSE - Specialised 5,765 5,765 5,720 (45) -1% (86)NHSE - Local Area Team 3,961 3,961 3,605 (356) -9% (47)NHSE - Armed Forces 203 203 245 42 21% 8Public Health 2,494 2,494 2,474 (20) -1% (20)Commissioner QIPP/Overperformance (609) (609) (0) 609 -100% 609Contract Variations 1,140 1,140 1,119 (21) -2% 248

Inter Trust SLAs (Cross Charge)NHS Herefordshire CCG 1,457 1,457 1,457 (0) 0% 0Gloucestershire Hospitals FT 3,820 3,820 5,127 1,307 34% 119Overperformance Excluded 1,500 1,500 0 (1,500) -100% (125)Powys Trust 1,024 1,024 973 (51) -5% 312gether MH Trust 251 251 251 0 0% (0)Other Cross Charges 207 207 61 (146) -70% (85)

Central Funding & TrainingNational & Regional Funding 0 0 0 0 0% 0Education & Training 4,564 4,564 4,340 (224) -5% (224)

OtherBusiness Unit Service Income 7,455 7,455 7,208 (246) -3% (92)Named Patient Panel Drugs 3,106 3,106 2,099 (1,007) -32% (187)Donations For Non Current Assets 200 200 423 223 111% 100Radiology MES 50 50 0 (50) -100% (4)24 Bedded Ward 1,161 1,161 0 (1,161) -100% (387)

Total Operating Income 195,325 195,325 193,379 (1,946) -1% 755

PSF Income 4,421 4,421 1,141 (3,280) -74% 626

TOTAL OPERATING INCOME INCLUDING PSF 199,746 199,746 194,520 (5,226) -3% 1,381

INCOME

YEAR TO DATE

Estimated Overperformance on reverting to National Tariff

Contract SummaryAs previously reported, the Trust had altered the payment regime with Herefordshire CCG for 2018/19. However, the formal Expert Determination concluded that the Trust could not terminate the contract variation.

To recap, the original block contract with HCCG was valued at £123m. A further £6m of system risk was also included in the income plan for 2018/19 with no agreement on how this would be funded. Given the significant rise in emergency activity and the requirement to improve access times for patients on a waiting list, the Trust treated the increased activity and sought payment for the work. Clearing long waiting patients would have generated additional income of £2.5m under a PbR regime.

As indicated above, the Trust has taken a prudent approach and reflected the ED initial conclusion but has included an accrual in order to offset the invoices raised to HCCG. In the meantime, the Trust is still discussing the matter with NHSE/I.

There are no material disputes with other commissioners. The Trust has received confirmation that the cross border funding agreement for HRG4+ has been resolved for 2018/19 and we have now received the full £300k as confirmed funding.

.

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Performance against Cost Budgets

Pay

Pay was £4.3m overspent. The tables, shown within the run rate section of this report (below), show that much of this adverse variance is driven (i) by the cost of staffing escalation areas, and (ii) the volume of agency usage being above that provided in Divisional agency budgets.

Nursing agency, Medical agency and WLI payments all increased in month.

Non-pay

Operational non pay moved favourable against budget by £254k. The two key elements of this was £148k against private sector sub-contracting and £116k slippage in Earmarked Reserves.

At the end of the year, £1.5m of the total £4.2m budget set up for outsourcing to the Private Sector remained unspent. MSSE and Implants ended the year with significant overspends owing to the level of work completed internally.

The cost pressure (to the Trust) from the element of the national pay award carried through into the PFI contract shows as a variance, as does the pressure experienced throughout the year in respect of utility costs.

Interest payable on loan financing continued to deteriorate the position below the level of EBITDA.

The impairment also showed a significant adverse movement, although this is adjusted out in respect of a measure against the Control Total.

To Month 12 - 31st March 2019 - 2018/19

MOVEMENTANNUAL IN

CURRENTBUDGET BUDGET ACTUAL VARIANCE MONTH

£000 £000 £000 £000 £000Pay

Directors & Sen. Managers =>Band 8 4,331 4,331 4,388 (57) (11)Medical & Dental 39,209 39,209 42,910 (3,702) (487)Nurses & Midwives 54,491 54,491 56,607 (2,116) (99)AHPs 10,561 10,561 10,714 (153) (2)Pharmacists 1,356 1,356 1,507 (151) (6)Professional, Technical, Scientific 7,087 7,087 6,998 89 (8)Managers/Technical >Band 5 2,717 2,717 2,638 79 (5)Clerical <=Band 5 13,497 13,497 13,484 13 59Other Pay 686 686 634 51 10Apprenticeship Levy 500 500 500 0 0CEA's 403 403 403 0 0Redundancy Pay 0 0 0 0 0Unallocated CPIP - Pay 82 82 0 82 143Earmarked Reserves - Pay 1,504 1,504 0 1,504 717

136,422 136,422 140,783 (4,361) 311Non Pay

Drugs 3,484 3,484 4,042 (558) (80)Excluded Drugs 15,601 15,601 15,153 447 (47)Med & Surg Supplies 10,806 10,806 11,738 (932) 34Implants & Accessories 1,699 1,699 2,061 (362) (19)Other Clinical Supplies 2,285 2,285 2,224 61 49Clinical Services contracts 4,777 4,777 5,184 (406) 20Private Sector Sub-Contracting 4,161 4,161 2,703 1,459 148PFI Contract 9,500 9,500 9,903 (403) (8)Transport & Travel 2,806 2,806 2,821 (15) (5)Establishment expenses 4,497 4,497 5,137 (640) (34)I.T. 1,902 1,902 1,919 (16) 6Trust Overheads (inc. Insurance) 6,307 6,307 6,316 (8) 5Other Non Pay 3,793 3,793 3,733 61 69Hoople 1,120 1,120 1,115 5 0Unallocated CPIP - Non Pay 0 0 0 0 0Provision 0 0 8,500 (8,500) (8,500)Earmarked Reserves - Non Pay 732 732 0 732 116

73,471 73,472 82,547 (9,077) (8,246)Depreciation 5,041 5,041 5,032 9 2(Gain) or loss on asset disposal 0 0 359 (359) (359)Interest Received 58 58 64 6 3Interest Payable on Loans 2,202 2,202 2,700 (498) (13)Interest Payable on PFI 5,627 5,627 5,627 (0) 0Dividends Payable 0 0 0 0 0Sub Total 12,812 12,812 13,653 (841) (368)

GRAND Total Expenditure 222,705 222,705 236,983 (14,278) (8,303)

YEAR TO DATEHEADING

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Directorate Performance – Variance against £22.8m Budget Plan

This table summarises the distribution of the variance from budget plan and the resulting performance by area.

Clearly the issue of commissioning funding has impacted significantly on the Divisions and the corporate adverse income variance is largely attributable to the funding source for the budget required to open the AMU.

The position regarding Medical and Nursing overspends caused the majority of the pressure experienced in the Surgical and Medical Divisions.

This table shows that 22% of the overall bottom line adverse variance related to the inability to accrue and receive PSF performance funding.

Divisional financial positions were reviewed, and performance was managed, through the monthly F&PE meetings and, at a granular level, through the work of Management Accounts with individual budget managers across the Trust throughout the year.

DIRECTORATE POSITIONS - To Month 12 - 31st March 2019 - 2018/19

IntegratedClinical

Surgical Medical Care Support

Estates and

Facilities PFI Corporate£000 £000 £000 £000 £000 £000 £000

Income NHS Income (5,394) (2,205) (780) (642) (2) 6 (23)Non NHS Income 6 (26) (0) (30) 27 0 (137)PbR Income 0 0 0 0 0 0 7,479Excluded drugs 375 (521) (1) (77) 0 0 0

(5,013) (2,752) (782) (750) 25 6 7,319

Pay Directors & Sen. Managers =>Band 8 (43) (28) 10 (26) (15) 0 44Medical & Dental (1,641) (1,911) (40) (176) 0 0 68Nurses & Midwives (910) (965) (424) (30) 0 0 213AHPs (10) 4 (77) (80) 0 0 10Pharmacists 0 2 0 (153) 0 0 0Professional, Technical, Scientific 46 (12) 4 65 (23) 0 9Managers/Technical >Band 5 37 11 0 3 1 0 28Clerical <=Band 5 (127) 8 (60) (46) 28 0 211Other Pay 0 (5) (6) (6) 68 0 0Cost Pending Capitalisation 0 0 0 0 0 0 0Redundancy Pay 0 0 0 0 0 0 0Unallocated CPIP - Pay (331) (108) 1,119 (257) (20) 0 (321)Earmarked Reserves - Pay 0 0 0 0 0 0 1,504

(2,980) (3,003) 526 (706) 38 0 1,767

Non Pay Drugs (161) (366) (39) 8 3 0 (3)Excluded Drugs (205) 885 1 (234) 0 0 0Med & Surg Supplies (728) (176) (79) (106) 44 72 41Implants & Accessories (368) (0) (0) 6 0 0 0Other Clinical Supplies (6) 119 (54) 15 (9) 0 (4)Clinical Services contracts (221) (11) (2) (167) (8) 0 2Private Sector Sub-Contracting 1,459 0 0 0 0 0 0PFI Contract 0 0 0 0 3 (406) 0Transport & Travel 64 (20) (42) (21) (12) 0 16Establishment expenses 77 (2) (31) (23) (608) 36 (90)I.T. (19) (21) (1) (26) 3 5 43Trust Overheads (inc. Insurance) (39) (38) (6) (14) (7) 0 94Other Non Pay (37) 48 (11) (15) 49 (7) 34Hoople 0 0 0 0 0 0 5Interest Received 0 0 0 0 0 0 6Interest Payable on Loans 0 0 0 (0) 0 0 (498)Depreciation 0 0 0 0 0 (0) 9Provision 0 0 0 0 0 0 (8,500)Earmarked Reserves - Non Pay 0 0 0 0 0 0 732(Gain) or loss on asset disposal 0 0 0 0 0 0 (359)

(185) 420 (263) (576) (542) (300) (8,472)

Subtotals (8,178) (5,335) (519) (2,032) (479) (295) 614Total Variance from Plan Prior to PSF and Donated Dep'nDonated AssetsImpairmentA&EFinancial ControlTotal PSF FundingTotal Variance from plan

(193)

(19,336)

(4,361)

(9,917)

(16,223)

(1,326)

(3,279)(1,954)

359

(1,945)

Variance from Plan £000's

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Agency Ceiling Controls

The Trust has an agency ceiling cap of £8.39m for the year. Expenditure for the year totalled £13.6m, therefore exceeding the cap by £5.2m.

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Nursing Cost Run Rate

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD TotalsCommercial Agency 690 703 538 616 620 558 537 516 522 649 534 608 7,091Bank 309 292 292 313 350 291 265 254 247 256 251 258 3,378Substantive 3,734 3,660 3,684 3,737 3,982 3,311 3,692 3,718 3,748 3,881 3,789 3,849 44,785Pay Award 0 0 0 0 112 567 112 112 112 112 112 112 1,351Nursing Expenditure 4,733 4,655 4,514 4,666 5,064 4,727 4,606 4,600 4,629 4,898 4,686 4,827 56,605

Nurses & Midwives 18/19 £'000s

The table above shows the run rate of nursing costs by month. The run rate has increased back to £4.8m in month with an increase in the monthly cost of both agency and substantive.

The graph to the left shows these same values (but with the pay arrears restated and mapped back to the months they relate to).

The trend of agency has reduced (although there has been significant fluctuation month on month). The cost of substantive has increased.

Nursing budgets as a whole were £2.1m overspent in the locations shown in the table to the right. This includes unfunded escalation areas. It should be noted that the agency premium budget partly compensates for overspends against substantive establishment budgets.

Nursing (overspends) & underspendsA & E (921)DC Overspill (565)Frome (483)Arrow Ward (362)Lugg Ward (349)Redbrook Ward (341)Wye Ward (331)Ross - Nursing (276)CAU (229)Leadon (Surgical) Ward (224)Bromyard - Nursing (217)Leominster - Nursing (216)Theatre Suite (144)Women's Health (131)Monnow (Surgical) Ward (116)Other (23)City Locality Team - City 113Virtual Ward - Hospital at Home 138A & E GP Streaming 196Agency premium budget provision 2,365M12 overspend (2,116)

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Medical Staffing Cost Run Rate

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD TotalsCommercial Agency 473 490 454 484 609 403 431 444 460 443 418 484 5,593Substantive/NHS locums 3,069 2,985 2,844 3,065 2,927 3,130 3,162 3,088 3,069 3,210 3,148 3,374 37,071Pay Award 41 41 41 41 41 41 246Medical Expenditure 3,542 3,475 3,298 3,549 3,536 3,533 3,634 3,573 3,570 3,694 3,607 3,899 42,910

Medical 18/19 £'000s

The table above shows the run rate for Medical Staffing costs by month. Expenditure increased again in month 12, in respect of both agency and substantive staff (the latter including WLIs).

The graph to the left shows that the cost trend on medical agency has reduced over the year; however, this has not resulted in a reduction to the bottom line monthly cost trend of medical staffing as a whole, as substantive costs and additional payments have increased (volume and price).

Medical staffing as a whole was £3.2m overspent at month 12 with the distribution of this shown in the table to the right.

Medical Budget (overspends) & underspendsMS - A & E (667)MS - Paediatrics (520)MS - Acute Medicine (466)MS - Orthopaedics (463)MS - Gen Surg (458)MS - Medicine (369)MS - Anaesthetics (353)MS - Community Paeds (229)MS - Obs & Gynae (205)A & E GP Streaming (198)MS - Respiratory (147)Other (128)MS - Radiology (119)Other (5)Education & Development 50MS - Urology 51PDS - Gaol Street 65Agency Premium budget provision 461M12 overspend (3,702)

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Substantive Medical Staffing Additional Payments

The Trust spent £2.1m on WLI payments for increased activity above core capacity and £3.7m on payments to substantive consultants for cover (including vacancies).

WLI payments increased by £0.5m in year and other payments by £0.5m, thus increasing the cost base by £1.0m on the prior year.

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Cost & Productivity Improvement Plan (CPIP)

This table shows the Trust has delivered the highest level of CPIP to date during 2018-19 at £10m, which was a considerable financial achievement.

Planned values eventually increased to £11m as underspends on base budgets were moved into the programme.

Volume reduction on Agency, VAT optimisation on Medical Agency and some elements of Procurement savings fell short of their planned values.

CIP Performance By Programme£000's

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Admin 38 38 (0) 38 38 (0)AHP's 47 47 (0) 47 47 (0)Back office and Admin 70 60 (10) 70 60 (10)Bed Reduction 1,253 1,253 0 1,253 1,253 0CNST Maternity 153 233 80 153 233 80Corporate 220 220 (0) 220 220 (0)Drugs 241 229 (12) 241 229 (12)Estates 160 142 (18) 160 142 (18)Income 544 462 (82) 544 462 (82)Medical Staffing 916 579 (337) 916 579 (337)Non pay 1,586 1,417 (169) 1,586 1,417 (169)Nursing 1,688 1,433 (255) 1,688 1,433 (255)Pay 1,659 1,656 (3) 1,659 1,656 (3)Prescribing 50 0 (50) 50 0 (50)Prior Year FYE of schemes delivering 928 924 (4) 928 924 (4)Productivity 137 128 (9) 137 128 (9)Prof & Tech 20 0 (20) 20 0 (20)SL Income 4 4 0 4 4 0SLA's 76 0 (76) 76 0 (76)Transport 15 8 (8) 15 8 (8)VAT Optimisation Agency 352 163 (189) 352 163 (189)Master Vend 843 1,010 167 843 1,010 167YTD Plan Gap 81 81Totals 10,919 11,000 10,007 (912) 11,000 10,007 (993) 81

CIP Performance By Area£000's

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Surgical Division 3,839 3,486 3,332 (507) 3,486 3,332 (154) (331) (485)Integrated Care Division 1,300 2,419 2,133 833 2,419 2,133 (286) 1,119 833Medical Division 2,666 2,550 2,014 (652) 2,550 2,014 (535) (108) (643)Support Services 1,809 1,539 1,531 (278) 1,539 1,531 (8) (257) (265)Corporate 840 562 575 (265) 562 575 12 (321) (308)Estates 465 445 422 (43) 445 422 (23) (20) (43)

0 0 0 0

Totals 10,919 11,000 10,007 (912) 11,000 10,007 (993) 81 (912)Variances (993) 81

Delivery Planning

1819 Current Forecast Performance Month 12 Year To Date Performance

1819 Current Forecast Performance Month 12 Year To Date Performance

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The graph below illustrates the progress made towards achieving this high value against plan. The ‘spike’ on delivery in month 7 resulted from the mapping of prior month underspends through to the programme.

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M12

Summary Capital ProgrammeYTD

Expenditure£k £k £k

Core Schemes

EstatesBacklog 400 359 41Hutted ward replacement - fees to GMP, planning and enabling 2,444 2,319 125Hutted office decant c/fwd 543 523 20Emergency Surgical Assessment Area 27 20 7Ross Lift replacement + p/fund 2nd lift, Leominster Lift refurb 18 14 4Project Management - Estates 155 154 0Rehab gym co-location Wye Ward 0 0 0Ophthalmology treatment room 159 160 (1)Lionel Green asbestos removal (if major scheme not progressed) 95 95 0Slippage assumption 0 0 0Orchard site car park - advance of hutted ward replacement 140 31 109Estates - Other 79 64 15Sub Total - Estates 4,060 3,739 320

Clinical EquipmentITU monitors and ventilators 195 195 0Endoscopy rolling scope replacement 24 24 0C Arm Pod surg 60 60 0ED Monitoring equipment 77 78 (1)Equipment - Other 334 326 8Sub Total - Equipment 689 682 7

IM&TMalinko Scheduler £130k (EMIS moved to PDC finance) 106 106 0Mobile working for 0 - 25 tender HV 0 0 0Central virtual server replacement 216 199 17Client ICT hardware refresh (rolling programme) 155 149 6Ophthalmology EPR system 0 0 0OPMAS replacement (Chemocare) 0 0 0Deliver new WAN contract 92 99 (7)Roster system 9 7 2IM&T other 126 77 50Sub Total - IM&T 705 637 68

Contingency 1 0 1

Total Core schemes (funded through emergency capital) 5,454 5,058 396

Major schemesMain EPR (phase II, Year 1) 2,197 2,197 0Total Major schemes 2,197 2,197 0

Total Capital plan, Local Schemes 7,651 7,255 396

DonatedMisc. donated equipment 400 423 (23)Total Donated Assets 400 423 (23)

Central PDC schemesCyber security (cfwd from 17/18) 121 121 0NHS Wifi secondary care 205 205 0AMU (24 beds) 3,600 3,600 0HSLI - Community EMIS 500 458 42Histopathology Cancer Transformation Programme 20 20 0Pharmacy system upgrade 12 12 0GDE Fast Follower (Year 1) 250 126 124Total Central PDC schemes 4,708 4,542 166

Total Capital Programme 12,759 12,219 539

Plan 18/19 Variance

Capital - Overview

Capital Year end Position

Core schemesThe Trust spent £5,058k on core capital schemes in 2018/19. This was £396k less than planned. This underspend helped to manage the Trust’s Capital Resource limit (CRL) at year end, after accounting for finance lease repayments for the Radiology MES.

Major schemesCapital expenditure for the year on EPR phase 2 was £2,197k. This was in line with the latest plan.

In terms of the hutted ward replacement scheme, the Trust is in ongoing discussions with NHSI on the next steps and timescale of approval of the revised OBC (submitted in early March 2019).

Central PDC schemesA total of £4,542k was spent against PDC funded central schemes. This was £166k less than planned. The under spend related to EMIS (£42k) and GDE Fast follower (£124k). The Trust expects to be able to carry this funding forward to utilise on the continuation of those schemes in 2019/20.

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Cash Flow Position

Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual ActualCashflow Analysis Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 2018/19

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000Surplus / (Deficit) from Operations (2,980) (3,533) (2,256) (2,702) (783) (2,143) (2,650) (1,557) (2,652) (2,278) (2,213) (8,476) (34,223)Adjust for non-cash items:Depreciation 391 358 387 375 393 381 379 380 380 389 390 830 5,032Income recognised in respect of capital donations 0Impairments 0 0 0 0 0 0 0 0 0 0 0 359 359Provisions (17) (16) (17) (17) (16) (223) 0 0 0 0 0 (117) (423)Operating Cash flows before working capital (2,606) (3,191) (1,886) (2,344) (407) (1,985) (2,271) (1,177) (2,272) (1,889) (1,823) (7,404) (29,255)Working capital movements:(Inc.)/Dec. in inventories 256 38 88 (134) 137 9 125 174 (437) 233 (39) (52) 398(Inc.)/Dec. in current assets (703) 0 1,458 (300) (448) 1,680 (6,715) 1,713 1,089 (3,238) 2,690 4,091 1,317Inc./(Dec.) in trade and other payables 3,393 0 (2,140) 3,010 (4,178) (833) 2,859 (1,137) (327) 2,808 (3,219) 1,286 1,522(Inc.)/Dec. in current provisions (11) 0 0 0 0 (8) 0 (8) 0 0 0 (3) (30)Net cash inflow/(outflow) from working capital 2,935 38 (594) 2,576 (4,489) 848 (3,731) 742 325 (197) (568) 5,322 3,207Capital investment:Capital expenditure (307) (463) (568) (310) (544) (1,128) (1,638) (2,526) (509) (357) (586) (1,968) (10,904)Capital receipts 17 16 17 17 16 223 0 0 0 788 0 117 1,211Net cash inflow/(outflow) from investment (290) (447) (551) (293) (528) (905) (1,638) (2,526) (509) 431 (586) (1,851) (9,693)Funding and debt:Interest Received 4 4 4 4 7 6 5 5 (0) 10 8 5 61Interest Paid (652) (733) (690) (698) (686) (713) (695) (697) (551) (838) (708) (476) (8,137)PDC Received 0 0 0 0 0 0 750 1,357 1,948 544 (544) 532 4,587DH loans - received 3,063 1,831 3,020 2,522 6,472 1,665 6,697 4,144 1,124 2,750 10,225 1,784 45,297DH loans - repaid 0 0 (171) 0 (659) (235) 0 (171) 0 0 (657) (237) (2,130)Capital element of finance lease rentals 0 0 0 0 0 0 0 0 0 0 0 (813) (813)PFI/LIFT etc capital (548) 0 (274) (274) (274) (274) (274) (274) (274) (274) (274) (274) (3,288)Net cash inflow/(outflow) from financing 1,867 1,102 1,889 1,554 4,860 449 6,483 4,364 2,247 2,192 8,050 521 35,577Net cash inflow/(outflow) 1,906 (2,498) (1,142) 1,492 (564) (1,593) (1,157) 1,403 (209) 537 5,073 (3,412) (164)

Cash at Bank - Opening 4,931 6,837 4,339 3,197 4,689 4,125 2,532 1,375 2,778 2,569 3,106 8,179 4,931Cash at Bank - Closing 6,837 4,339 3,197 4,689 4,125 2,532 1,375 2,778 2,569 3,106 8,179 4,767 4,767

The table summarises the cash flow position reported to NHSI on a month by month basis for 2018/19. It identifies in-year cash movements including the impact of the deficit on cash together with movements in working capital and capital expenditure. It also includes repayments of capital loans and loans taken out to enable the Trust to maintain liquidity.

The total cash deficit in 2018/19 including interest was £29.3m. In addition, the Trust spent £9.7m on capital expenditure and £3.2m of working capital was utilized to help fund the cash position. The cash balances held reduced by £0.165m. Net revenue borrowing was £35.6m. The working capital position worsened significantly in March due to income accrued with the host CCG relating to QIPP non-delivery and RTT activity being offset by a bad debt provision.

For the year to date, the Trust has incurred cash outflows in relation to its operating position, capital expenditure, loan repayments and interest payments totalling £57.4m. The main source of funding to cover cash outflows are loans from the DHSC for capital investment and deficit support.

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SoFP (Balance Sheet)

Revenue Loans

In order for the Trust to continue to operate whilst incurring a deficit, it is necessary to draw down loans from the DHSC in order to enable sufficient cash availability. The Trust’s annual financial plan identifies revenue loans to be drawn on a monthly basis.

In order to draw down monthly loans, the Trust Board is required to provide a resolution to confirm their agreement to the loan. The resolution detailed identifies borrowing requested for April 2019 and also identifies the requirement for loans to be taken in May 2019.

The loan is made up of the following elements:

April deficit support, £3,092k

The Trust Board is requested to note and approve the loan.

Board Resolution

Statement from the Managing Director and Director of Finance of Wye Valley NHS Trust regarding the Trust Board approval of loan reference DHPF/ISUCL/RLQ/2019-03-04/A

Due to the need to take an urgent decision on the 3 April 2019 and submit the relevant paperwork to the Department of Health, we have acted on behalf of the Trust Board. This is in accordance with the Trust's Standing Orders.

We recommend that a loan totalling £3,092,000 is taken, repayable in full on 18 April 2022, and approve the loan on behalf of the Board.

In line with Schedule 1 of the loan documentation, we also:

• approve the terms of, and the transactions contemplated by, the Finance Documents to which it is a party and resolving that it execute the Finance Documents to which it is a party;

• authorise the Director of Finance to execute the Finance Documents to which it is a party on its behalf; and

• authorise the Director of Finance to sign and dispatch all documents and notices including the Utilisation Request.

• Confirm our undertaking to comply with the Additional Terms and Conditions.

It is also anticipated that further loans to support the revenue deficit will be required in 2019/20 in accordance with the annual plan. Trust Board is requested to authorise the Managing Director and Director of Finance to take action to execute those loans.

Jane Ives, Managing Director, Wye Valley NHS Trust

Howard Oddy, Director of Finance, Wye Valley NHS Trust3 April 2019.

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Statement of Financial Position

2017/18Month 12 Accounts M12 Plan M12 YTD M12 Var. Plan Actual Variance

£000s £000s £000s £000s £000s £000s £000sNON-CURRENT ASSETS:Property, Plant and Equipment 74,880 9,288 11,091 (1,803) 9,288 11,091 (1,803)Intangible Assets 9,459 92,827 78,205 14,622 92,827 78,205 14,622Trade and Other Receivables 206 0 264 (264) 0 264 (264)TOTAL Non Current Assets 84,545 102,115 89,560 12,555 102,115 89,560 12,555CURRENT ASSETS:Inventories 3,426 3,212 3,028 184 3,212 3,028 184Trade and Other Receivables 12,049 12,666 10,677 1,989 12,666 10,677 1,989Cash and Cash Equivalents 4,931 1,799 4,767 (2,968) 1,799 4,767 (2,968)TOTAL Current Assets 20,406 17,677 18,472 (795) 17,677 18,472 (795)TOTAL ASSETS 104,951 119,792 108,032 11,760 119,792 108,032 11,760CURRENT LIABILITIESTrade and other payables (23,156) (19,548) (25,551) 6,003 (19,548) (25,551) 6,003Other financial liabilities 0 (4,018) 0 (4,018) (4,018) 0 (4,018)Provisions (43) (3) (44) 41 (3) (44) 41Borrowings: PFI obligations (3,289) (3,445) (3,445) 0 (3,445) (3,445) 0Borrowings: finance leases (70) (96) (76) (20) (96) (76) (20)Borrowings: DH revenue loans (14,333) (37,340) (38,092) 752 (37,340) (38,092) 752Borrowings: DH capital loans (2,130) (3,355) (3,505) 150 (3,355) (3,505) 150Total Current Liabilities (43,021) (67,805) (70,713) 2,908 (67,805) (70,713) 2,908NET CURRENT ASSETS/(LIABILITIES) (22,615) (50,128) (52,241) 2,113 (50,128) (52,241) 2,113TOTAL ASSETS LESS CURRENT LIABILITIES 61,930 51,987 37,319 14,668 51,987 37,319 14,668NON-CURRENT LIABILITIES:Borrowings: PFI/LIFT obligations (45,230) (41,783) (41,786) 3 (41,783) (41,786) 3Borrowings: finance leases 0 (108) (861) 753 (108) (861) 753Borrowings: DH capital loans (15,182) (30,259) (13,964) (16,295) (30,259) (13,964) (16,295)Borrowings: DH working capital / revenue support loans (53,387) (51,967) (73,270) 21,303 (51,967) (73,270) 21,303Borrowings: DH revolving working capital facilities (18,479) (18,479) (18,479) 0 (18,479) (18,479) 0Other financial liabilities 0 (641) 0 (641) (641) 0 (641)Provisions (1,044) (958) (989) 31 (958) (989) 31Total Non-Current Liabilities (133,322) (144,195) (149,349) 5,154 (144,195) (149,349) 5,154ASSETS LESS LIABILITIES (71,392) (92,208) (112,030) 19,822 (92,208) (112,030) 19,822TAXPAYERS EQUITYPublic dividend capital 22,030 22,030 26,617 (4,587) 22,030 26,617 (4,587)Revaluation reserve 16,928 17,520 14,092 3,428 17,520 14,092 3,428Income and expenditure reserve (110,350) (131,758) (152,739) 20,981 (131,758) (152,739) 20,981TOTAL (71,392) (92,208) (112,030) 19,822 (92,208) (112,030) 19,822

2018/19 Year to Date 2018/19 Full Year

Non-Current AssetsThese reflect the audited 2017/18 year-end accounts and 2018/19 Month 12 draft final position.

Current AssetsCurrent assets have reduced compared to month 11. There has been a reduction in cash of £3.4m. Debtors have reduced by £4.3m compared to month 11 reflecting a provision included against the accrual of £8.5m of income from the CCG for QIPP non delivery and RTT. Other debtors and prepaid income have reduced.

Current LiabilitiesCurrent liabilities increased by £8.4m compared to month 11. £6.3m of this related to the categorisation of DHSC loans due between less than and greater than 1 year. The balance relates to the increase in trade creditors over the period.

Non-Current LiabilitiesNon-current liabilities reduced in month 11 by £4.5m which reflects the categorisation of some loans as due within 1 year offset by an increase in overall loans relating to the March revenue loan.

Taxpayers EquityOverall taxpayer equity is negative reflecting the Trust's accumulated deficits in the retained earnings reserve. The movement in taxpayer’s equity in month 11 was £11.4m and reflects the increase in I&E deficit for month 12 plus the impact of impairments on asset values on the revaluation reserve less £0.5m of PDC received to support capital investment.

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Debtors and CreditorsBETTER PAYMENT PRACTICE CODE

NHS Non-NHS NHS YTDNon-NHS

YTD NHS Non-NHS

Number of Invoices paid in Period 137 4067 1334 50547 1,068 56,949% of Invoices paid within target 45.99% 51.04% 25.94% 44.44% 28.0% 45.0%

Value of Invoices paid in period (£000s) 788 6,053 9,416 99,152 7,231 99,063% of value paid within target 32.36% 32.89% 55.95% 57.06% 57.0% 60.0%

OUTSTANDING DEBTS

Host Other Welsh Non-NHS Private Total£000s £000s £000s £000s £000s £000s £000s

Current 3,219 2,047 1,596 215 4 7,081 2,8901 Month 1,216 947 92 18 9 2,282 1,4672 Months 1,063 95 119 45 2 1,324 687Over 3 Months 3,165 445 1,312 623 4 5,549 6,534Unallocated Credits (12) (830) (392) (6) 0 (1,240) (2,890)Total Value Outstanding 8,651 2,704 2,727 895 19 14,996 8,688

Last Month 3,198 3,648 1,412 847 32

Age of Debt

2017/18

Debt outstanding as at end of the Month Previous Month

BPPCPerformance against the PSPP target of 95% of invoices paid within 30 days remains poor due to the Trust’s challenging working capital position.Non NHS expenditure constitutes the majority of spend and performance against the payment target by value was 44% in Month 12 and 57% for the year to date. This is broadly consistent with previous months.NHS Expenditure is much lower and PSPP performance is 56% when measured in terms of invoice value but 26% in terms of invoice numbers for the year to date. The figures for month 12 are 46% and 32% respectively. These values indicate a small number of high value invoices that remain outstanding for longer than 30 days.

Aged DebtThe total value of outstanding debtors as measured by invoices raised increased from £8.7m to £15m. Over three-month old debt is £5.5m compared to £6.5m in month 11. This mainly relates to outstanding debts with Herefordshire CCG and Welsh NHS bodies.The increase in accounts receivable is £5.4m with Herefordshire CCG, £1.3m with Welsh NHS bodies and a reduction of £0.9m with other NHS organisations.The increase in debtors reflects the high volume of outstanding invoices with the host CCG relating to the contract dispute.

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BOARD OF DIRECTORSReport to: Board of Directors Agenda item: 5.3Date of Meeting: 2 May 2019Title of Report: One Herefordshire - Urgent Care Programme Board UpdateStatus of report:(Approval, position statement, information, discussion)

Position statement / Information

Report Approval Route:Lead Executive Director: Jon Barnes - Chief Operating OfficerAuthor: Jon Barnes - Chief Operating OfficerAppendices:

1. Purpose of the reportTo provide an update on the work of the One Herefordshire - Urgent Care Programme Board and progress against the work streams it supports.

2. RecommendationsTo receive the report and discuss the collective actions being taken to deliver a recovered position against the A&E 4 hour standard.

3. Executive Director OpinionThis paper provides an overview of the One Herefordshire Urgent Care Programme Board’s (UCPB) progress to date. March has been a much better month for urgent care and performance against the 4-hour standard was also much improved at 85%. The drivers for that improvement are complex but the work within the Emergency Department, the new Acute Medical Unit, the Front Door Frailty Team and the reduction in ‘stranded’ and DTOC’ numbers all clearly played a major part in that improvement. The focus for the coming months will be building on the ‘Valuing Patients time’ workshops and strengthening the ambulatory care approach across primary, secondary and community care.

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4. Please state which element of the Trust’s Objectives the report relates to:

1. Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

6. Reduce the financial deficit by delivering our financial plan

2. Improve urgent care by delivering the A & E standard and providing more services across seven days

7. Improve the quality and sustainability of our services by implementing our clinical strategy

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

8. Care for people nearer to home by transforming our community services with our One Herefordshire partners

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

9. Improve our effectiveness through the delivery of our Digital Strategy

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

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BOARD OF DIRECTORSReport to: Board Of Directors Agenda item: 5.4Date of Meeting: 2 May 2019Title of Report: Mortality Report – April 2019Status of report:(Approval, position statement, information, discussion)

No Mortality Committee – To Be Approved

Report Approval Route: Mortality Committee Lead Executive Director: David MowbrayAuthor: Chris BeaumontAppendices: 1- Dashboard

1. Purpose of the report

For information and to provide an update on the implementation of the mortality strategy. The report includes performance in relation to mortality rates with analysis of trends and variation. In addition it includes the number of mortality reviews undertaken for the previous month with key learning derived from the process.

2. Recommendations

The Board is asked to note:

1. Monthly Headlines SHMI (rolling 12 month January 2018 – December 2018) has reduced by 1.2 to the lowest ever reported 104.81. HSMR (rolling 12 month January 2018 – December 2018) has also fallen to 103.2, with a reduction of 2.39. 7th consecutive reduction in deaths attributed to CCF of 4.59 to 92.27. This is the lowest reported HSMR for CCF deaths. Sepsis deaths has fallen to the lowest ever reported and for the 14th consecutive month to 94.83 (HSMR rolling 12 month

January 2018 – December 2018). A reduction of 5.36 in the HSMR (rolling 12 month January 2018 – December 2018) for deaths attributed to #NOF reduction

to 169.40. Community Hospitals audit complete has been completed for each site, with the draft reports out for review with both

primary and secondary care key stakeholders. Benchmarking against the recent National Guidance for Learning from Deaths highlights the progress made by Wye Valley

NHS Trust with areas of excellent implementation.

3. Executive Director Opinion

The Mortality Committee has not met during the month of April and therefore this report has not been through that process. At the time or reporting the medical director is on annual leave and the director of nursing has reviewed the report. The report is an accurate position of the trusts mortality position and details the work of the outlier groups. The report contains the LeDeR information as requested by the Chair. The Board are asked to note the continued improvement in sepsis deaths and the work intended to review community hospital mortality.

4. Please state which element of the Trust’s Objectives the report relates to:

1. Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

X 6. Reduce the financial deficit by delivering our financial plan

2. Improve urgent care by delivering the A & E standard and providing more services across seven days

7. Improve the quality and sustainability of our services by implementing our clinical strategy

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

8. Care for people nearer to home by transforming our community services with our One Herefordshire partners

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

9. Improve our effectiveness through the delivery of our Digital Strategy

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

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Introduction

This monthly report aims to provide an update on the progress of implementation of the Mortality strategy. The report includes performance in relation to mortality rates, focussing on trends and variation identified, which includes the number of mortality reviews undertaken for the previous month with key learning.

2. Monthly Headlines SHMI (rolling 12 month January 2018 – December 2018) has reduced by 1.2 to the

lowest ever reported 104.81. HSMR (rolling 12 month January 2018 – December 2018) has also fallen to 103.2, with a

reduction of 2.39. 7th consecutive reduction in deaths attributed to CCF of 4.59 to 92.27. This is the lowest

reported HSMR for CCF deaths. Sepsis deaths have fallen to the lowest ever reported, for the 14th consecutive month, to

94.83 (HSMR rolling 12 month January 2018 – December 2018). A reduction of 5.36 in the HSMR (rolling 12 month January 2018 – December 2018) for

deaths attributed to #NOF to 169.40. A Community Hospitals audit has been completed for each site, with the draft reports

out for review with both primary and secondary care key stakeholders. Benchmarking against the recent National Guidance for Learning from Deaths highlights

the progress made by Wye Valley NHS Trust with areas of excellent implementation.

3. Trust-wide Mortality Strategy Implementation Update

This section outlines the areas within the Mortality Strategy where progress has been delayed or inhibited, and the mitigations put in place to continue to support the implementation.

An escalation meeting occurred earlier this month to discuss the key actions and steps to developing a High Dependency Unit. The following key actions are in progress to support the short term interim HDU, working towards a purpose built facility.

Short term – Theatre Recovery

A final review of the Standard Operating Procedure. Ordering of the mobile screens to support the dedicated bed space.

Medium term – HDU / CCU hybrid

A review of nursing levels and the development of a plan to up-skill nursing staff on CCU. Development of a Standard Operating Procedure to manage patient flow and admission

criteria to the hybrid area.

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Long term – Purpose built facility

A review of the draft building layout and plans by Infection Control and other key stakeholders.

In order to maintain momentum, there will be a further meeting planned for mid-May.

At the end of March, the regional Emergency Care Intensive Support Team (ECIST) supported a two day workshop. This was attended by Wye Valley NHS Trust multi-disciplinary representatives including medics, therapists and nursing from ED, CAU and AMU.

The output of the workshop was 10 locally identified ‘changes’ that would be tested during the week commencing 8th April 2019.

The week was designed to trial different ways of working to support better care for patients, improve flow across the all three areas and enable staff to feel more in control. The changes included allocating specific roles to both identified medics and nurses in order to both co-ordinate the department and for nursing to ensure hourly observations (where required) were carried out. CAU was to be returned to being an assessment unit, and AMU identified two patients for discharge before 10am every day, which were worked up by the night team and supported by an earlier therapists visit.

The week followed a PDSA process where review meetings were held three times a day and processes were reviewed and changed/improved iteratively constantly.

It is important to note that this week was the busiest in the last 3 years for total number of weekly adult admissions with 289 in total, two of these days having had 200+ attendances.

Some of the high level metrics at the end of the week were as follows;

Constant 4hr performance of 80% or above throughout the week during what was our busiest week for over a year.

AMU – Thursday 11th April LoS was down to 0.7 as opposed to the average the week before of 1.4.

CAU – Thursday 12th April – reached 0.2 as opposed to the average the week before of 0.6.

As these changes were department owned and carried out with no additional resource, the changes will continue.

This month has seen an additional substantive Consultant recruited to our ED department, with a further two middle grade posts recruited as well.

All other work streams are progressing within the time scales indicated.

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4. Mortality Outlier Groups – Update

Respiratory:

Acute Bronchitis: Rolling 12 month January 2019 – December 2019 HSMR – 126.03 (↑ 12.55)

Pneumonia: Rolling 12 month January 2019 – December 2019 HSMR – 91.13 (↑2.17)

COPD: Rolling 12 month January 2019 – December 2019 HSMR – 115.42 (↓ 0.74)

Data Summary:

There has been a significant rise of 12.55 in the rolling 12 month (January 2018 – December 2018) HSMR for Acute Bronchitis. This is due to a total of 15 deaths, 3 more than expected deaths in the time period.

A small rise of 2.17 in the rolling 12 month HSMR (January 2018 – December 2018) has been observed for deaths attributed to Pneumonia, although this remains below the expected levels.

#NOF: Rolling 12 month January 2019 – December 2019 HSMR – 169.40 (↓ 5.36)

Data Summary:

A reduction of 5.36 in the rolling 12 month HSMR (January 2018 – December 2018) for deaths attributed to fractured neck of femur. There were 38 deaths for this period, against an expected 22. The data from February 2019 indicates that the length of time to theatre continues to increase and remains significantly above the national average.

CCF: Rolling 12 month January 2019 – December 2019 HSMR – 92.27 (↓ 4.59)

Data Summary:

This month has seen the 7th consecutive reduction in the rolling 12 month HSMR (January 2018 – December 2018) to 92.27. This is the lowest ever reported mortality rate for CCF patients. There were three less deaths than the expected 37. Both the HSMR and SHMI remain under the expected levels.

5. Community Hospitals – Ross, Bromyard and Leominster

Data Summary:

Bromyard: Rolling 12 month January 2019 – December 2019 HSMR – 124.46 (↓ 38.24)

Ross: Rolling 12 month January 2019 – December 2019 HSMR – 191.66 (↑4.32)

Leominster: Rolling 12 month January 2019 – December 2019 HSMR – 246.94 (↑5.28)

Based on the forthcoming changes to SHMI, we will be reporting our HSMR and SHMI by site. Due to the small numbers of actual and expected deaths, there can be large in-month spikes of the SHMI and HSMR.

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A full detailed understanding of the data is being undertaken to ensure we are responding to changes appropriately. This analysis will be discussed at the first Community Mortality Steering Group, and subsequently in next month’s report.

Highlights:

Below is a summary of the actions taken so far, in order to understand our current position and the areas for improvement within our community sites;

Audits of previous 12 months deaths from each of the Community Hospital sites. Bromyard Community Hospital – Complete Ross and Leominster Community Hospitals– draft reports out for review.

Initial themes and findings from audits include: Handover process between the Acute and Community sites. Ongoing management plan. Record keeping including documentation of assessments and

escalations. Extended length of time between reviews End of Life care – earlier identification and completion of documentation

at both the acute and community sites. Plans to set up a steering group to specifically focus on community hospitals, which will

capture the actions for improvement with clear accountability for each action. Long term aim is to review all deaths in the community hospitals to ensure all learning is

captured.

Next Actions:

Here is a summary of the key actions to be taken in the next month:

Develop an action plan to capture the issues, improvements and specific actions with accountable leads for each.

Understand data and ensure it accurately represents our activity at each site. Commence pilot for clinicians, with involvements from the GP’s, to review deaths in the

Community Hospital.

6. Learning from Deaths

This month has seen 95.8% of the 72 deaths reviewed, through our Mortality Review process, with an additional 8 second stage reviews conducted. A full description of the learning and themes will be part of next month’s Learning from Deaths dashboard.

A quality audit of the completed Structured Judgement Reviews were conducted this month, with feedback to reviewers, to ensure we maintain a high level of review and extract key learning.

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Following a recent report from the Care Quality Commission, outlining the national guidance for the implementation of Learning from Deaths, a bench-marking exercise was undertaken. The findings highlighted some keys areas for development, including our Bereavement Services, but also examples of excellent progression.

Following review by the Medical Examiners, there has been significant developments with the Mortality Review IT system. There is a planned pilot for the Medical Examiner screening and the 1st stage Structured judgement Reviews later this month.

This section aims to summarise the current activity of Wye Valley NHS Trust for mortality alerts and audits. The table below includes both internal and external alerts with a short summary of the current actions.

Exception Reporting

This section of the report will aim to provide further detail and analysis of any significant changes or trends that could potentially affect the implementation of the Mortality Strategy.

This month there are no new exception reports.

7. Alerts and Audits (Internal and External) Summary

Area: Type: Body: Date Covered: Deadline: Status: Actions / Summary:

Ross Community Hospital

InternalWVT / CCG

July 2017 – June 2018

NADraft

Report

Cohort of deaths reviewed by Primary and Secondary care.

Report drafted. To be circulated to Ross GPs for their involvement in in developing the final report, following a similar model

to Bromyard CH audit.

Leominster Community

HospitalInternal

WVT / CCG

July 2017 – June 2018

NA Reviewed

Cohort of deaths to be reviewed by Primary and Secondary care 2/5/19

Involvement with GPs to follow a similar model to Bromyard and Ross CH audits

Nursing Home Admissions

Internal WVT / CCG

TBC NA PlannedReview of Nursing Home admission for

continuous learning.

Quality Review of SJR’s

Internal WVTSept 2018 – Nov

2018NA Completed Feedback sent to reviewers.

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Mortality Rates by Wye Valley NHS Trust Sites:

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Mortality Outlier Metrics

Crude Mortality (per diagnostic outlier groups):

Fractured Neck of Femur: Overall Performance Run Chart

Summary:

The length of time to theatre, for fractured neck of femur patients, continues to rise for January and February 2019. There remains a static position in the 30 day mortality, which is significantly above the national average.

The 'Overall Performance' run-chart shows:

• Mean time to surgery: The chart shows the average number of hours between admission to A&E and surgery, for all patients operated that month. The graph also shows the national average for comparison. NICE guidelines recommend that surgery should take place on the day of admission to hospital or the following day. This is because it is uncomfortable, undignified and distressing to be confined to bed with a hip fracture and patients are unable to get up out of bed until they have had the operation. This recommended time for surgery may not be possible for some patients – for instance if they have medical problems which need other treatment first to make them well enough for surgery.

• Crude 30-day mortality: The graph shows the proportion of patients who died in the first 30 days. It takes time to cross-check these figures so this graph cannot show the last few months. We also show a national average line for reference. However, some hospitals have patients who are older or frailer than those in other parts of the country. These hospitals might expect a slightly higher number to die after hip fracture, so the ‘crude 30-day mortality’ graph may not be reliable when comparing different hospitals’ performance.

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This Month(Mar 19)

Last Month(Feb 19)

This Month (Mar 19)

Last Month(Feb 19)

This Month (Mar 19)

Last Month(Feb 19)

72 67 69 (95.8%) 55 (86.5%) 8 16

This Quarter Last Quarter This Quarter Last Quarter This Quarter Last Quarter

213 212 183 (86.5%) 195 (91.9%) 39 26

Learning from Deaths Dashboard

Total Number of Deaths (In Hospital Deaths)

Total Deaths Reviewed Total Deaths with a Second Review

Summary of the total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology.

0

10

20

30

40

50

60

70

80

April May June July August September October November December January February March

Number of Deaths (In Hospital) Number of Reviews

Number of Second Reviews Target - 75% Review

Please note that the summary of the ‘learning’, based on the reviews, will be combined in the next month’s report.

LeDeR Programme:

Please see Appendix 1 for a full update on the LeDeR programme.

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Appendix 1: Learning Disability Mortality Review (LeDeR) Programme

Introduction

The Learning Disability Mortality Review Programme (LeDeR) Steering Group has been established and is meeting every 2 months.

A key part of the LeDeR Programme is to support local areas to review the deaths of people with learning disabilities. The Programme is developing and rolling out a review process for the deaths of people with learning disabilities, helping to promote and implement the new review process, and providing support to local areas to take forward the lessons learned in the reviews in order to make improvements to service provision. The LeDeR Programme will also collate and share the anonymised information about the deaths of people with learning disabilities so that common themes, learning points and recommendations can be identified and taken forward into policy and practice improvements.

Reviewers

All reviewers are expected to have completed the LeDeR reviewer training before being allocate any cases to review. Since January 2018 there have been two training sessions. Since November 2018 training has been transferred to an online E-learning platform (https://www.lederlearning.co.uk)

Herefordshire currently has a pool of 6 trained reviewers though there are two more staff members undertaking the e-learning.

We have trained reviewers from the local authority, CCG, WVT and 2Gether Mental Health Foundation Trust.

Reviewers have to undertake the role in addition to their day to day responsibilities. We do have a small amount of money available to pay for an independent reviewer when there is a clear need for independent and objective oversight of the process.

New reviewers are always welcome. If anybody is interested please contact the Local Area Contact – John Burgess – john.burgess@nhs.net

Reviews

Since the LeDeR programme went live in Herefordshire in November 2017 there have been 25 notifications of death of learning disabled people. Two of the completed reviews have moved on to a multi-agency review.

There remains a small backlog of reviews but we are taking steps to clear this. Monthly assurance calls take place with NHS England.

It is expected that once a death has been notified then it should be allocated to a reviewer within 2 months.

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Reviews to date:

LeDeR progress in Herefordshire

Total number of deaths notified 25

Total number of review completed 10

Total number of review in progress 8

Total number of reviews not allocated 7

Outcomes and actions from reviews

Of the 10 LeDeR reviews that have been completed two have needed to progress to a Multi-Agency Review (MAR). Details of the learning and actions taken from these MAR’s can be found below.

All other reviews have identified satisfactory care and support with no obvious or significant failing identified, though a clear issue that comes up regularly is that of poor communication between system partners.

In two reviews it was noted that there had been excellent communication and joint working between all agencies and care providers. Community teams worked closely to ensure that the final weeks of the individuals’ life were comfortable and spent at home surrounded by the people they knew and where they felt most comfortable.

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Multi Agency Review Outcomes

RL Multi Agency Review 4th March 2019

Learning Action Responsible

Best Interest Decision meetings need to be minuted properly and the minutes and outcome shared with all involved agencies.

Review of training needs for staff around Mental Capacity Act and Best Interest Decision Making process

All agencies

Returning to his home (Eastbank Care Home) – more effort should have been put into trying to get RL home. This option was removed during the BID meeting. The manager and staff of Eastbank have learned from this experience and are now working to facilitate a return to Eastbank of another patient who is at end of life.

Health and social care staff should work with providers to facilitate a return to the home environment.

All agencies

Delays to discharge – there were a number of avoidable delays around discharging RL to an appropriate placement. Discharge should have been a priority even if that meant an initial step down to an appropriate nursing home, with a secondary move once funding and primary care / support needs had been assessed and agreed.

Health and social care professionals should work together to facilitate discharge from hospital at the earliest opportunity.

Social care staff / Continuing Healthcare staff

Additional support on the ward – Care staff from Eastbank were supporting RL to eat and drink but when funding for Eastbank ceased and staff could no longer attend this level of support for RL, in part to reduce the risk of aspirating, was unable to be provided by nursing / ward staff. Contact with the Local Authority and/ or / Clinical Commissioning Group

Should have been made to seek temporary funding for this support.

Support staff / family or carer’s should not be discouraged from assisting patients to eat or drink whilst they are inpatients

If additional support for ward staff is necessary to provide reasonable support to a patient with learning disabilities then social care and/or CCG should be contacted.

Ward staff – Wye Valley NHS Trust

Hospital Passports should be in clear view and available for all hospital staff to refer to. They should not be kept out of site in patient lockers etc.

Ward staff should be reminded of the importance of the Hospital Passport and make full use of them.

LD Liaison Nurse, Wye Valley NHS Trust

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SC Multi Agency Review 25th June 2018

Learning Action Responsible

It was noted that although SC had a Hospital Passport this did not appear to be used by ward staff

Hospital / ward staff need to be reminded and encouraged to make the best use of Hospital Passports for learning disabled patients

Rhiannon Mainwaring / LD Liaison Nurse / WVT

Discussion took place regarding the need for a flagging system on hospital IT systems so that learning disabled people can be identified at the earliest opportunity

Rhiannon Mainwaring informed the meeting that steps are being taken to develop this system - Purple Butterfly but there are issues around consent before peoples name are added to a list

Rhiannon Mainwaring / WVT / NHS Digital

It was reported that there were delays with regard to Continuing Healthcare nurses providing information about assessments

Herefordshire CCG will remind CHC staff of the importance of communicating fully with colleagues from other agencies with regard to timescales, delays and outcomes of continuing healthcare checklists and assessments

Hereford CCG / Nikki Warman

There was poor communication from the GP surgery when contacted by the reviewer

Herefordshire GP’s should be informed / reminded of the LeDeR programme and the fact that The LeDeR programme is part of a suite of programmes previously known as confidential enquiries. It has approval from the Secretary of State under section 251 of the NHS Act 2006 to process patient identifiable information without the patient’s consent. The reference number for this is 16/CAG/0056.

CCG – Primary Care Lead

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Indicator Description/Notes Data month Deaths in Month Trend ChangeDirection of

TravelTrend - April 2016 to latest

reported month

First Look

Crude Mortality-all % of Deaths by Admissions 56

Crude Mortality-Emergency % of Deaths by Emergency Admissions 54

Latest Static

Crude Mortality-all % of Deaths by Admissions 66 -0.19

Crude Mortality-Emergency % of Deaths by Emergency Admissions 64 -0.44

Indicator Description/Notes Data month Month Actual Acute Trust rank Trend ChangeDirection of

TravelTrend - April 2016 to latest

reported month

SHMI Dec-18 104.81 96 of 137 -1.2

SHMI Weekday Dec-18 105.71 100 of 137 -2.03

SHMI Weekend Dec-18 106.9 77 of 137 1.32

HSMR 103.2 73 of 134 -2.39

HSMR Weekday 102.62 81 of 134 -3.11

HSMR Weekend 104.9 59 of 134 -0.25

Data month HSMR SHMIObeserved/Expected Deaths

HSMR

Actual Deaths SHMI

Trend (HSMR)

Change (HSMR)

Direction of Travel HSMR

Trend - April 2016 to latest reported month

115.42 120.15 28/24 44 -0.74

91.13 91.46 127/139 168 2.17

126.03 105.18 15/12 24 12.55

92.27 98.82 34/37 45 -4.59

94.83 91.77 99/104 128 -1.89

169.40 151.09 38/22 42 -5.36

144.97 106.35 23/16 25 20.00

151.19 101.92 22/12 26 -24.08

Data month Value Peer MeanTrend - April 2016 to latest

reported month

13.41 12.35

5.87 5.65

18.33 15.18

5.79 5.14

0.32 0.24

* Direction of Travel is based on 3 month average vs previous 3 months average

(Please note this is first look data and subject to change - Static position is below)

8 of 134

Co-morbidity Scores - Live patients 10 of 134

Co-morbidity Scores - Deceased Patients

Outlier Groups - HSMR,Rolling 12 months

CCS Group/Origin of Alert

Chronic Obstructive Pulmonary Disease (Outlier)

Pneumonia (Outlier)

Acute Bronchitus (Outlier)

Congestive Heart failure (Outlier)

Septicemia (Outlier)

Aspiration pneumonitis (Cusum Alert)

Depth of Coding - Live Patients 42 of 134

Palliative Care Coding 110 of 134

Obs. 1207 v Exp. 1140.5

Obs 897 v Exp 865

Obs 310 v Exp 286

Obs. 728 v Exp. 705

Obs. 545 v Exp. 531

Urinary Tract Infection (CQC Alert)

Coding

Indicator Acute Trust rank

Depth of Coding - Deceased Patients

Dec-18

49 of 134

Cusum/External Alerts

Outlier Alerts

Rolling 12 month Hospital Standardised Mortality Ratio

Dec-18

Obs. 183 v Exp. 174

Fractured Neck of Femur (Internal)

Dec 2018 (HSMR), Dec 2018 (SHMI)

Rolling 12 month Standardised Hospital Mortality Indicator (inc. post 30 days

discharge patients)

Mortality Dashboard

Mortality Indicators

Mar-18

Observed/Expected Deaths

Month Actual

1.3%

3.8%

Feb-181.9%

6.1%

020406080

100120140160180

HSMR(56)

HSMR (all)

HSMR (Weekdays)

HSMR (Weekends)

SHMI

SHMI (Weekdays)

SHMI (Weekends)

Chronic Obstructive Pulmonary Disease(HSMR)

Pneumonia

Acute Bronchitus

Congestive Heart failure

Septicemia

Urinary Tract Infection

Fractured Neck of Femur

Wye Valley All Acute Trusts

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Apr-1

4

Jun-

14

Aug-

14

Oct-1

4

Dec-

14

Feb-

15

Apr-1

5

Jun-

15

Aug-

15

Oct-1

5

Dec-

15

Feb-

16

Apr-1

6

Jun-

16

Aug-

16

Oct-1

6

Dec-

16

Feb-

17

Apr-1

7

Jun-

17

Aug-

17

Oct-1

7

Dec-

17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct-1

8

Dec-

18

Feb-

19

Crude Mortality - SPC Chart, April 2014 to date

Total Mean UCL LCL

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Report to: Board of DirectorsDate of Meeting: 2 May 2019Title of Report: STP Operational PlanStatus of report:(Approval, position statement, information, discussion)

Approval

Report Approval Route:Lead Executive Director: Director of Strategy and PlanningAuthor:Appendices:

1. Purpose of the reportIn addition to provider operational narrative plans, the 19/20 Planning Round also required STPs to produce a system-wide Operational Narrative Plan. The process for development of the STP Operational Plan is detailed in this paper, along with the key timelines to ensure submission of the final plan to the regulators on 11th April 2019.

2. Recommendations To approve the Draft Herefordshire and Worcestershire STP 19/20 Operational Narrative Plan To note the governance arrangements in place to oversee delivery of the Herefordshire and

Worcestershire STP 19/20 Operational Plan

3. Executive Director Opinion

4. Please state which element of the Trust’s Objectives the report relates to:

1. Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

6. Reduce the financial deficit by delivering our financial plan

2. Improve urgent care by delivering the A & E standard and providing more services across seven days

7. Improve the quality and sustainability of our services by implementing our clinical strategy

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

8. Care for people nearer to home by transforming our community services with our One Herefordshire partners

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

9. Improve our effectiveness through the delivery of our Digital Strategy

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

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1. Development of the 19/20 STP Operational Narrative Plan

During Autumn 2018 a series of stock-take meetings with each STP workstream, with the main aims being to:

1. Clarify the deliverables for each of the STP programmes – in terms of their respective contribution to the ‘triple aims’ – both for 18/19 and in terms of priority setting and planning for 19/20

2. Confirm the resourcing and governance arrangements within each programme – and identify any gaps that could impact on delivery

Each stock-take was informed by a ‘key lines of enquiry’ (KLOE) document that was completed prior to the meeting and formed the basis of discussion. The KLOE assessed each programme against the following criteria:

Confirmation of a functioning/active programme board Clear set of deliverables for 18/19 and the status of delivery Evidence of the development of priorities and plans for 19/20 Evidence of material contribution to triple aims – improving finance, performance and quality Readiness to achieve requirements set out in the planning round Evidence of effective programme governance Initial view of the sufficiency of resource – at this point to produce robust plans

The stocktakes were undertaken with the intention that these would be the starting point for the 19/20 planning process – and enable the Herefordshire and Worcestershire PMO to undertake an initial assurance review on behalf of the STP Programme Board in order to highlight any issues at an early point in the process.

2. 19/20 STP Operational Narrative Plan requirements

The table below sets out the requirements as detailed in the planning guidance;

System priorities and deliverables

Key priorities and deliverables for the system population in 2019/20 including for local specialised services

Plans to work together to deliver these priorities within the available resources

Activity assumptions What are the agreed activity assumptions for the system Degree of alignment of system activity to organisational plans and

challenges to delivery Considerations for in-year management of demand

fluctuationsCapacity planning Approach to capacity planning at a system-level including winter

planning Alignment of capacity and activity assumptions

Workforce Evaluation of workforce requirements, identification of gaps and development of plans to fill them

System financial position and risk management

Key risks to delivery of the 2019/20 system control total Alignment of incentives and removal of financial barriers to

integrated care Arrangements for financial risk management

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Efficiencies Key system-wide efficiencies and how partners will work together to achieve them

Alignment of system-wide efficiencies for 2019/20 with long- term transformation priorities

The impact of efficiencies on quality of care The final 19/20 STP Operational narrative plan is attached as Appendix 1.

3. 19/20 STP Operational Narrative Plan sign-off process

The table below indicates the arrangements in place for system-wide sign-off of the plan:

Action By whom Timeline StatusDevelopment of the Draft 19/20 STP Operational Narrative Plan based on the outputs from the stock-take meetings

H&W PMO 1st February Complete

Review and amendments of chapters, including workstream ‘plans on a page’

Programme SRO and Directors of Finance

7th February Complete

Review of complete narrative plan STP Programme Directors and STP Chief Executives

8th February Complete

1st draft submission to NHS E/I NHS E/I 19th February CompleteCommence work to ensure alignment between provider Operational Narrative Plans and STP Operational Narrative Plans

H&W PMO and Providers PMOs/planning leads

19th February – 31st March

Complete

Submission of 1st draft to STP Partnership Board for review and comment

STP Partnership Board

19th February Complete

Further SRO review of the workstream ‘plans on a page’ to ensure the key deliverables reflect the work programme in 19/20, including national requirements, with key milestones to ensure delivery

Programme SRO 5th March Complete

Feedback from regulators on draft narrative plan

NHS E/I Expected w/c 5th March. Not received ahead of final submission.

Incomplete

Review of complete narrative plan STP leaders 15th March CompleteSubmission of next iteration of the narrative plan to STP Partnership Board for final comments

STP Partnership Board

19th March Complete

Organisation-level sign-off CEOs End April On-goingFinal submission to NHS E/I NHS E/I 11th April Complete

4. Governance arrangements to oversee delivery of the 19/20 STP Operational Plan

The existing Executive PMO meeting and STP Delivery Group will be dissolved and a Delivery and Assurance Group formed (DAG). The H&W Delivery and Assurance Group will be responsible to the STP/ICS Executive and will have direct links with the Finance, Quality and Performance Forums. The group will provide over-arching assurance, enabling and ensuring delivery of the STP work programme focusing on key deliverables that align with financial, quality and performance targets. The DAG will be chaired by the CCGs’ Accountable Officer for a period of 3-6 months whilst the proposed ICS governance arrangements are established.

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Primary function of DAG is to:

• Oversee and gain assurance on Programme Delivery across all workstreams.• Provide an independent review of plan development and delivery against STP priorities through

scrutiny and challenge.• To provider assurance that programme delivery structures are in place, ensuring these are

adequately resourced and removing barriers to implementation.• Ensuring interdependencies, risks and unintended consequences are identified and assurance is

received that these are being managed.

Effective reporting arrangements will be established to ensure that the STP/ICS Executive is assured/informed of progress via a monthly reporting “Dashboard” and Escalation Report. The DAG will also provide monthly feedback to programmes in the form of a standard report, to include overall assurance rating on the basis of the highlight report or deep-dive with a written explanation for the rating given and a response to any escalations.

5. Appendices

Appendix 1: Draft 19/20 STP Operational Narrative Plan v 3.0

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Draft Operational Plan 2019/20 V4.0

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Contents

2

Pages

Chapter 1: Introduction

• 18/19 reflections• ICS journey• Approach for 19/20

2-5

Chapter 2: 19/20 key priorities

• Key priorities and deliverables for the system population in 2019/20• Plans to work together to deliver these priorities within the available resources

6-20

Chapter 3: Approach to system-wide operational planning

• Approach to alignment of system activity to organisational plans and challenges to delivery

• Approach to capacity planning at a system-level • Approach to alignment of incentives and removal of financial barriers to

integrated care • Arrangements for financial risk management • Key system-wide efficiencies and how partners will work together to achieve

them • Alignment of system-wide efficiencies for 2019/20

21-25

Chapter 4: Workforce

Evaluation of workforce requirements, identification of gaps and development of plans for fill them

26-28

2/33 91/138

Chapter 1: Introduction

3

• 18/19 reflections• ICS journey• Approach for 19/20

3/33 92/138

IntroductionThis Operational Plan sets out our 2019/20 commitments as the Herefordshire and Worcestershire STP. As we evolve towards an Integrated Care System(ICS) we set out in this plan how we will transform our system and services in 2019/20 to improve performance, clinical and financial sustainability, and theexperiences and outcomes of our patients and populations working collectively to address our challenges across the Health and Care System.

Our STP/emerging ICS vision is that local people will live well in a supportive community, with joined up care underpinned by specialist expertise anddelivered in the best place by the most appropriate people. During 2018/19 we further developed and continued to embed our STP infrastructure that willenable us to deliver this, as a core component of delivering the NHS Triple Aim. We:

• Have delivered a consistent quality improvement methodology across the system, training 125 people as Quality, service improvement & Redesignpractitioners

• Engaged with General Practice to deliver the GP Forward View, alongside the development of our neighbourhood teams and primary care hometeams which are the foundation of our primary care networks

• Jointly developed our Mental Health workforce plan, to develop sustainable services that will help drive parity of esteem

• Tested our approach to capitation based contracts, through cap and collar and block arrangements

• Developed a single STP financial recovery plan on the basis of ‘cost out’, with a defined set of deliverables and underpinned by STP PMO

• Piloted the West Midlands ICS Development Programme, agreeing our ICS development plan and our future ICS operating model and appointing tokey posts such as STP Director of Performance.

We continue to develop our plans to become an ICS by 2021, developing our ICS operational delivery model as well as our Digital, Population HealthManagement, and Primary Care Strategies. This operational plan focuses on how we will transform our services and our workforce in 2019/20, improvingperformance and delivering financial efficiencies on the basis of system ‘cost-out’. It does require significant progress on transformation in-year, as amilestone within our journey towards an ICS and our delivery of the NHS Long Term Plan.

Key to delivery of this plan is:

• A new relationship between commissioners and providers, working in partnership to plan, deliver and transform services, in order to improve qualityand performance and deliver financial efficiencies.

• Increasing integration between providers, across both health and social care (Triple Integration), to provide seamless services but also to reduceduplication and drive efficiencies

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Herefordshire and Worcestershire STP/ICS Vision

“Local people will live well in a supportive community with joined up care underpinned by specialist expertise and delivered in the

best place by the most appropriate people”

A sy

stem

too

relia

nt o

n em

erge

ncy

acce

ss a

nd

beds

whe

re p

eopl

e be

lieve

that

hos

pita

l is

the

best

pla

ce to

be

whe

n yo

u ar

e un

wel

l

Invest in primary, community and mental

health services

Reduce pressure on hospital beds and slow

the loss of independence

Use our capacity better across all key

services

Reduce the volume of work that has limited

clinical benefit or marginal return

Reduce unwarranted variation across

primary and secondary care

Improve health outcomes and support

independence for longer

Put prevention, self care and personal

resilience at the heart of our plans

Improve access and performance

by better use of capacity

Return the system to financial

balance

A system that is built around care close to hom

e, w

here hospital beds are only used where som

ebody cannot be cared for safely in their ow

n environment

Through our ‘Triple Integration’ approach

Improve resilience, capacity and

sustainability of general practice

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2019/20: Our PrioritiesDuring 2019/20 our focus remains on delivering the NHS Triple Aim, as we implement the requirements of the NHS Long term Planand deliver ‘triple integration’, across primary and specialist care, health and mental health, and health and social care. We haveidentified a number of priority transformation programmes which we will deliver through our STP and emerging ICS workstreamsoverseen by the STP Partnership Board:

• Prevention - Shifting our individual and collective focus towards population health, strengthening our contribution to improving prevention and reducing health inequalities, and maximising our role in influencing population and behaviour change.

• Developing our primary care networks, as part of integrated out of hospital services across health, mental health, and social care services underpinned by resilient communities.

• Creating a robust Children and Young Peoples Transformation Programme, improving childhood immunisation rates and providing integrated holisticprimary care and community care to improve outcomes and reduce urgent care activity.

• Urgent care – Underpinned by developments in our out of hospital care offer and integration across primary and specialist care to reducing our urgent careactivity as well as increasing the proportion managed through a ‘same day emergency care’ approach.

• Delivering the new standards for specialist care, delivering 24/7 access to sustainable services such as stroke.

• Elective care and cancer – Using opportunities identified through RightCare, Model Hospital and GIRFT, ddeliver new models of care and workforce models,including First Contact Practitioners and optometrists to redesign our pathways and deliver RTT. Achieving our cancer access targets and embeddingsurvivorship.

• Mental Health and Learning Disability services – Deliver IAPT in long term conditions, increased access to 24/7 crises care, and personalised carearrangements for people with complex needs.

• Continue to implement via the Local Maternity System, the recommendations of Better Births and Saving Babies Lives Care Bundle to deliver the nationalambitions to reduce neonatal deaths, stillbirths, maternal deaths and neonatal brain injuries.

• Implementing our workforce strategy, creating new roles and workforce models to improve recruitment and retention to underpin clinical sustainability andimprove financial efficiency.

• Implementing a digital programme that will deliver information sharing as well of digital delivery of frontline care, interlinked with an embedded approach topopulation health management.

• Deliver our STP financial recovery plan – working collectively to deliver financial efficiencies and take ‘cost out’ of the system.

• Refine and deliver our ICS development plan, through a new operating model at ICS, place and primary care network level.

• Delivery of the 92 Transformation Assurance Statements ensuring sign-off through STP governance arrangements and underpinned by the PMO

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7

Establishment of system wide governance structures(phased in and starting to become operational from April 2019)

ICS Partnership BoardForum for joint discussions, partnership

work & consensus building

Clinical Strategy GroupDevelop and deliver

clinical strategy

ICS System Performance Forum

Proactively monitors & reports system performance issues

ICS Executive Executive decision making

and oversight group

4 CCGs Joint Commissioning

Committee in CommonStrategic commissioning/system

management decision making

Part

ners

hip

Deci

sion

mak

ing

Man

agin

g th

e bu

sine

ss

The STP recognises that as well as the financial challenges we have important performance and quality challenges to address. The approach to improving quality and performance is detailed on each workstream slide in Chapter 2 and delivery will be overseen bythe new system wide operating model during 19/20 as detailed below.

ICS FinancialLeadership Forum

System wide financial recovery and cost out/ delivery of system control total as

per MOU

ICS Quality ForumSystem wide quality monitoring, merging existing CCG & Trust quality monitoring

groups

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8

Chapter 2: 2019/20 Key Priorities• Key priorities and deliverables for the system

population in 2019/20• Plans to work together to deliver these priorities

within the available resources

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 2020

1 2 3 4

Achievement of 2020 accelerated cancer targets (28-days from referral to definitive diagnosis)

Agree STP trajectory with main providers

Implementation of pathway changes across cancer pathways to support delivery of 28-day target including implementation of best practice timed diagnostic pathways

Achievement of 28-day target

Implementation of Living With and Beyond Cancer strategy including stratified follow-up in breast, colorectal and prostate.

Development of person-centered follow-up pathway for breast cancer and implementation

Development of person-centred follow-up pathways for colorectal and prostate cancer

Implementation of holistic needs assessments (HNA) at key stages of all cancer pathways

Implementation of treatment summaries across all cancer pathways

Implementation of best practice pathways across all cancer pathways

Review of current cancer pathways and development of action plans to improve pathways

Implementation of best practice cancer pathways

19/20 Delivery Plan – Cancer 18/19 achievements

Transformational Funding• Accountability Framework signed off. STP Cancer Plan (narrative

and action plan) and baseline activity for Living With and Beyond Cancer metrics submitted to WMCA on 27th December 2018.

Implementation of best practice pathways• discussions on-going to implement BPP across all cancer pathways; Living with and Beyond Cancer• working groups established and taking forward key pieces of work

to improve services Governance• review functionality and governance of Cancer BoardsPerformance• agreed quality performance metrics for cancer

19/20 expected outcomes: contribution to improving quality, performance and financial recovery• Quality – Quality outcomes and metrics confirmed;• Performance –Achievement of 28-day and 62-day target;• Pathway development – Implementation of best practice pathways across STP cancer pathways;• Living with and Beyond Cancer – Implementation of person-centered follow-up pathways for breast, colorectal and

prostate; • Prevention and early diagnosis – Working with PHE and primary care to improve earlier presentation; • Financial Recovery Programme – Will contribute to the financial recovery programme through stratified follow-up

work and re-designed pathways for PSA monitoring• Workforce – Align workforce requirements across STP cancer services with overarching workforce strategy;• Diagnostics – Align STP diagnostic and digital requirements with STP, regional and national programmes;• Reporting/Assurance – To embed Verto across the STP in the development of robust systems to monitor delivery of

outcomes.

19/20 key risks Mitigating actions

Workforce challenge - recruitment and retention of skilled staff with specific clinical competencies Key workforce gaps to be identified and included in STP Workforce Strategy

Funding allocation – resource to implement new pathways and develop the LWBC agenda Proposals in place for staff recruitment

Organisational commitment to implementation of change in cancer pathways Cancer Boards to be fully sighted on delivering the outcomes identified within the STP Cancer PlanAssurance through Elective Care and Cancer Executive (local) and STP Partnership Board

SRO: Dr. Carl Ellson (WCCG)

Programme Lead: Anita Roberts (WCCG) / Sarah Southerby (HCCG)

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

S117 / Special Placements Opportunities to reduce package costs and length of stay The STP to deliver its trajectory for zero inappropriate acute out-of-area placements by 2021.

MH Crisis Pathways To improve pathway navigation across all mental health crisis pathways, with the aim of supporting patients to access the right service first time through a single crisis telephone triage.

Reduce pressure on A&E and other statutory services

Dementia Diagnosis Programme - Year 2 (2019-20) At least two thirds (67%) of people with dementia, aged 65 and over, to receive a formal diagnosis .

Empower and improve the capacity of primary care to diagnose.

SMI Physical Health Checks AT least 50% of people on GP SMI registers receive a comprehensive physical health check every year, and followed up for treatment as indicated. The comprehensive physical health check is made up of 12 tests.

Work with Primary Care to support delivery of nationally set targets and demonstrate the range of tests are applied

IAPT Expansion By March 2020 IAPT services will be providing timely access to treatment for at least 22% of those who could benefit (people with anxiety disorders and depression)

Delivery of IAPT LTC services Adult ADHD Service To provide a local service for adults with a diagnosis of ADHD to support the existing shared care

guideline.

Children and Young People accessing evidence-based interventions

Achieve national indicator of at least 35% of children and young people with a diagnosable mental health condition receive treatment from an NHS funded community mental health service .

Waiting times for CAMHS, referral to first appointment no more than 8 weeks, referral to treatment no more than 18 weeks

19/20 Delivery Plan – Improving Mental Health18/19 achievements

• Mental Health Liaison - Services in place for both Acute Trust in the STP. Worc services cover all-ages and Hfds has an adult with a separate CYP service.

• Physical health needs of people with SMI - CQUIN performance is on track to deliver 60% target with some further work to do with primary care

• Improving Access to Psychological Therapies- Improved position to meet all targets. Provision of service to people with long term conditions in development

• Early Intervention in Psychosis Service - Access target consistently met - a strength for the STP

• Crisis Resolution and Home Treatment - Services in place across footprint, with improvement to Places of Safety. Delivery of effective CRHTTs in line with national standards.

• Suicide Prevention Strategy - STP Suicide Prevention strategy in place with place-base action plans

• Children and Young People accessing evidence-based interventions - Place-based Local Transformation Plans in place

19/20 expected outcomes: contribution to improving quality, performance and financial recoveryContribution to quality:• Increase investment so all areas provide CRHTTs resourced to operate in line with recognised best

practice by 2020/21.• Continue to work towards the 2020/21 ambition of all acute hospitals having mental health liaison

services that can meet the specific needs of people of all ages including children and young people and older adults.

• Review all patients who are placed out of area to ensure that have appropriate packages of care and that packages can be offered within the STP footprint, which enables delivery of the FYFV requirement of zero placements outside the STP by March 2021.

• Dementia - improve early dementia diagnosis to 66.66% with a robust post diagnosis service.• Ensure increase in mental health workforce in 2019/20 meeting the assured STP-level workforce plan.• Continue to develop the pathway to align with expanded Perinatal Mental health services in

Herefordshire and Worcestershire

Contribution to performance: – as per NHSE requirements set out in 5 year MHFV and 2019/20 deliverables.

SRO: Jo-Anne Alner (HCCG)

Programme Leads: Jenny Dalloway (WCCG) / Jade Brooks (HCCG)

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19/20 Delivery Plan – Improving Mental Health19/20 key risks Mitigating actions

Workforce - recruitment and retention Workforce Plan in place with clear trajectory for workforce growth. Various schemes in development to address recruitment and retention.

Delivery of MH FYFV priorities to the nationally determined timelines without additional investment

Programme of development timetabled across next 5 years to make effective use of the MHIS and achieve MH FYFV in that timeframe. Joint opportunities across the STP explored and efficiencies identified. As appropriate, local evidence is collected to support rationale where a national model is not suitable for the local area, e.g. Core 24/7 MH Liaison.

Workforce – access to training places for IAPT to address the gap from current to the national ambition

Local target for IAPT trainees in place. Links to HEE and the educational establishments improving so that places are secured. Growth in the number of expected trainees includes the LTC IAPT. Digital offer of IAPT growing and further work required to understand the impact on need for IAPT trainees.

Provider engagement Good engagement at STP, and at local level. Opportunities to involve further providers are explored as part of specific pieces of work, e.g. Dementia Strategy.

SRO: Jo-Anne Alner (HCCG)

Programme Leads: Jenny Dalloway (WCCG) / Jade Brooks (HCCG)

Mental Health Investment Standard Required growth Planned growth

Herefordshire 6.2% 6.3% / £2.6m

Redditch and Bromsgrove 6.4% 6.7% / £1.5m

South Worcestershire 8.9% 9.2% / £3.5m

Wyre Forest 8.8% 9.1% / £1.4m

Across the Herefordshire and Worcestershire STP all four CCGs have confirmed that they are planning to meet the investment standard in 2019/20.There will be additional investment focussed on:

• IAPT (Herefordshire & Worcestershire)• CAMHS (Herefordshire & Worcestershire)• Crisis Care (Herefordshire & Worcestershire)• Early Intervention in Psychosis Service (Herefordshire)• Perinatal MH Services (Herefordshire & Worcestershire)• SMI Physical Health checks (Herefordshire & Worcestershire) • Memory Clinic (Worcestershire)• ADHD Services (Worcestershire)

The detailed plans will be reviewed by the STP Workstream to ensure compliance with the standard.

H&W Financial Recovery Programme Herefordshire £’000

Worcestershire£’000

19/20 Mental Health Crisis Pathway 110 161

19/20 S117 / Special placements 750 224

19/20 LTC IAPT - -

Grand Total 860 385

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Back Office• Integration of identified Back Office service across

the STP

STP Partnership Board to agree commissioning proposal and associated specification for the CSU to undertake an audit of current back office service arrangements of partners, and provide proposals on the potential savings that could be realised through shared delivery of services via different business models.(March 2019)

BOI Board review findings and proposals from commissioned work (June 2019) and make recommendations to the STP Partnership Board (July 2019)

Delivery plan which may include further work to be commissioned to be developed and commence implementation (October 2019)

Procurement• Savings related to review of common requirements

and collaborative procurement exercises

Completion and agreement of STP Procurement Workplan (includes Energy and Estates and Facilities projects) with individually allocated schemes, and organisational leads identified, with indicative timescales for delivery in built and savings profiled per month / per organisation based on estimated completion date.

Delivery of schemes (to include analysis of spend and scope of requirements); agree strategies for delivery of schemes; undertake procurement exercises; delivery of scheme; implementation; review and report savings.

Provide support to other workstreams requiring Procurement activity (e.g. E&F, transport). Estates and Facilities Management• Co-locating WHACT and WAHT facilities and estates

staff

Completion of staff consultation relating to co-location of estates and facilities staff from WHACT & WAHT Phase 1 – to commence Q1Bed in new co-located team and identify further working efficiencies through natural staff churn.

Estates and Facilities Management• Review contracts of services identified to gain

greater efficiencies• Explore PFI cross management opportunity with

Wye Valley Trust

Phase 1 – to commence Q1Review service contracts identified as part of 18/19 work plan (to be confirmed by 31st March 19)

Phase 2 – to commence Q2.Review opportunities for collaboration on services e.g. switchboard, helpdesk, EBME

Phase 3 – to commence Q3.Agreement between WAHT and WVT to pursue joint PFI Project Management unit

Transport• Route optimisation across all STP organisations

Route optimisation for Worcester Acute Trust Route optimisation for Health and Care Trust Route optimisation for Wye Valley Trust

19/20 Delivery Plan – Back Office and Infrastructure (BOI)

18/19 achievementsBack Office and Support services (BOS):• Review of BOS strategy covering 18/19 priorities and draft 19/20 plans • H&W CCGs’ completed negotiations with MLCSU for shared contract delivery of

certain back office services from April ‘19Procurement:• Work-plan developed to include supplier negotiations agreed• Savings target of 1.5% based on aggregated spend by supplier Estates and Facilities Management• Agreement in principle for WHCT and WAHT to co-locate estates & facilities teams• Agreement with procurement workstream on contracts being progressed

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

• Contribution to quality – improvement in patient experience through improvement in patient transport access and better aligned administration and support systems. Procurement at scale to ensure best value in terms of quality and cost.

• Contribution to performance – collaboration across back-office functions resulting in better resilience across teams, with increased capacity to support service delivery.

• Financial Recovery Programme – The BOI will contribute to the internal / provider Cost Improvement Programmes which form part of the STP financial recovery programme (slide 28).

SRO: Jill Robinson (WAHT), Programme Leads: Back Office: Hanna Taylor (WCCG), Procurement: Charlotte Kings (WHAT), Estates: Mark Fenton (WHCT), Transport: Nicki Kirkland (WCC)

Transport• Route optimisation work scoped• Development of Patient transport posters and leaflets

19/20 key risks Mitigating actions

Sufficient professional capacity to delivery the programmes of work Additional capacity required to deliver programmes will form part of the business case

Lack of engagement and sign-up from partners across the system in order to support delivery of the programmes Engagement with STP Partnership Board to ensure partner buy-in to the BOI approach

Insufficient focus on the cultural change required in order to deliver the new way of working Dedicated workstream as part of Workforce programme to support OD12/33 101/138

19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Personal Health Budgets• Increase in the number of people receiving a PHB• Ensure delivery of all new CHC home-based packages (excluding fast track),

using the personal health budgets model as the default delivery process

Rapid financial analysis to understand the financial benefit of moving to PHBs – work commenced Dec ‘18

All commissioned services transferred notional PHBs (community packages only) from 01/04

Market Management• Development of pricing framework

Explore opportunities for a joint contract managers post across Herefordshire and Worcestershire

Development of framework to ensure standard approach CHC Checklist• Ensure that in more than 80% of cases with a positive NHS CHC Checklist, the

NHS CHC eligibility decision is made by the CCG within 28 days from receipt of checklist

• No referrals breaching 28 days by more than 12 weeks in each reporting quarter, or by Q4 2019/20

On-going monitoring and reporting against national requirements

QIPPDevelop plans to incorporate Continuing Healthcare strategic improvementprogramme opportunities into QIPP for 2019/20

Development of 18/19 QIPP plans – complete in 18/19 Q4 and monitoring mechanisms in place

CHC assessmentsEnsure that less than 15% of all full assessments for NHS CHC funding take place in an acute hospital setting

On-going monitoring and reporting against national requirements Collaborative working with BCF staff

19/20 Delivery Plan – Continuing Healthcare18/19 achievements

18/19 QIPP• Delivery of 18/19 savings targets across Herefordshire and WorcestershireCHC framework• compliance with national CHC framework• Positive feedback from NHSE deep Dive re CHC eligibility CHC Quality Performance (QP) metrics • on track to deliver QP and improvement objectives to improve patient

experience and reduce discharge delaysNurse Reviews• No nurse review back-logSingle provider procurements• Benefits of single provider procurements coming to fruitionOpen referrals (Worcs) • 2/3rd reduction in open referrals when compared to March ’18Joint working• joint working across Herefordshire and Worcestershire to share good practice

and to explore opportunities for joint working. • Joint working and training with the Local Authority

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality • 85% of NHS Continuing Healthcare full assessments

not taking place in an acute hospital setting – Target 15%

• Ensure that in more than 80% of cases with a positive NHS CHC checklist, the NHS CHC eligibility decision is made by the CCG within 28 days from the receipt of the checklist – Target 80%

Contribution to performance• Compliance with national CHC framework - TBC Q4

18/19 to establish improvement requirements for 19/20 – National QP Metrics

• Increase in PHBs in-line with national requirements

19/20 key risks Mitigating actions

Market management – provider engagements Task & finish groups in place with 3 workstreams 1) framework for dom care 2) business case for complex care 3) Fair cost of care and inflationary uplifts. Individual contract meetings with providers in place.

PHBs – patients opting for a direct payment Engagement and communication with patients around the benefits of direct payments. PHB manager recruited, to commence April ‘19 to support patients’ decision making and on-going support.

Inter-agency disputes MDT Terms of Reference agreed with LA. All nurses and Social workers trained on procedures and expectations (delivered 1st March)

CHC growth due to aging population On-going monitoring and modelling to anticipate national trends

Financial Recovery Programme – the CHC contribution to the STP FRP is detailed below.

SRO: Helen Richardson (HCCG), Lisa Levy (WCCG)

H&W Financial Recovery Programme

H’shire£’000

W’shire£’000 Total

CHC Patient Reviews – Top 50 - 552 552Fast track – Patient choice & allocation policy - 200 200Provider engagement and market management - 250 250CHC Learning disability respite - 50 5018/19 FYE Patient reviews - 1,851 1,851CHC High Cost Case Management 200 - 200Grand Total 200 2,903 3,103

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Treatments of Limited Clinical Benefit Policies• Development of STP-wide policies

Alignment of treatment policies across the STP Implementation and monitoring of revised policies across the STP

Ophthalmology transformation• Implementation of integrated care solution across the STP

Embed the work undertaken in 18/19 to ensure sustainable delivery Facilitate the repatriation of patients to Herefordshire and Worcestershire

Musculo-skeletal (MSK) transformation • Development of integrated care solution

Consider & introduce optimal model including triage and FCPs within an integrated primary & community MSK service

Enhance working relationships through all tiers of delivery i.e. APOPs able to directly list and undertake follow-up Gynae, urology and uro-gynae transformation (Worcestershire)• Development of integrated care solution

Implementation of primary care top tips across the STP Development of community-based clinics

Dermatology transformation (Worcestershire)• Development of integrated care solution

Create 4-tier approach in line with the High Intervention work-books Shared learning across Herefordshire and Worcestershire

Gastroenterology transformation (Worcestershire)Development of consistent clinical pathways

Development of primary care top tips document for common GI conditions Development of a Clinical Assessment Service

Diabetes transformation • Development of new model of diabetes care

Explore benefits of creating a community based model with out-reach from acute clinicians

Neurology transformation • Re-design neurology services across the STP and pan-STP

Development of the case for change to describe i) the issues to be addressed, ii) the proposed future service model iii) specific changes expected and iv) the provider delivery model

Development of the programme approach and delivery plan Outpatient modernisation Implement new ways of delivering outpatients i.e. tele-medicine, alternatives to face-to-face follow ups

19/20 Delivery Plan – Elective Care18/19 achievements

Treatments of Limited Clinical Benefit Policies• Policy review and prior approval processes implemented resulting in reduction in

waiting list back-log and efficiency savings Ophthalmology transformation• Implementation of actions:- 1 (failsafe prioritisation processes and policies, 2

(clinical risk and prioritisation audit), 3 (eye health capacity review).• Development of integrated care solution, including expanding community

capacity to release acute capacity and address waiting listMusculo-skeletal (MSK) transformation• Business case for Implementation of First Contact Practitioner. • MSK triage deliveredGynaecology transformation (Worcestershire)• Reduction in demand through development of GP Top TipsDemand management• Reduction in activity through addressing unwarranted variation in primary care

and follow-ups• Roll out of Advice and Guidance to most specialties and e-Referral in placeDiabetes transformation• Super six community based modelNHSE High Intervention Handbooks• Waves 2 and 3 specialties engaged with reviewed pathways

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality (specific metrics at project level)• Improvement in patient experience through reductions in

outpatient, diagnostic and elective waiting lists• Reduction in the number of people having unnecessary

interventions• Improving patient outcomes through pathway re-design i.e.

development of community services and one-stop-clinics• No patients lost to follow-up• Cases for Change for Urology, Gynaecology, Gastroenterology,

Outpatients, MSK, FCP, Diabetes and Dermatology to improve quality of referrals, enhance self-management, optimise community services and latest technologies and reduce unnecessary FUps for patients

• Significant reduction in OP FUps anticipatedContribution to performance (specific metrics at project level)• Zero over 52 week waiters by 31.03.19• Reduction in the number of people waiting over 18 weeks• Appropriate and efficient use of diagnostics• Delivery of constitutional targets

H&W Financial Recovery Programme

H’shire£‘000

W’shire£’000

Total£’000

Ophthalmology 400 835 1,235MSK

605

1,500

2,,841

Gynaecology 197

Urology 200

Dermatology 159

Gastroenterology 180

Outpatients 500 1,000 1,500

Treatment policy 550 1,386 1,936Grand Total 2,055 5,457 7,512

NHSE High Intervention Handbooks• Wave 3,4 and 5 specialties will be scoped and

reviewedFinancial Recovery Programme – the elective care contribution to the STP FRP is detailed below.

SRO: Dr Carl Ellson (WCCG)

Programme Lead: Mari Gay (WCCG) / Joanne Alner (HCCG)

19/20 key risks Mitigating actions

Insufficient project and programme manager capacity to deliver the pathway re-design work Review of resources undertaken at the STP Elective Care Transformation meeting

Current waiting list backlog will reduce the expected level of savings in 19/20 Demand and capacity work undertaken by providers

Unable to realise the benefits of system ‘cost out’ Working with providers through Director of Finance forum14/33 103/138

19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 2020

1 2 3 4

Working jointly across the STP footprint to share good practice and consider local agreements to place across the footprint potentially offering greater opportunities for all patients.

Dashboard to be build to highlight problem areas so that resource can be allocated appropriately, information and learning shared across the STP footprint.

To continue the transforming care programme and monitor progress across the footprint.

Transforming care will continue to be monitored and reported via the LDSTP group and highlight reports on the basis of building the right support and regional objectives

To improve health access and outcomes for people with learning disabilities.

- Increased uptake of annual health checks through the use of Hospital Passports and ensuring appropriate use of the them by hospital staff.- Further develop the STOMP and STAMP programmes locally.

To engage with and develop the LD and wider workforce about learning disabilities and autism

Plan in place to roll out training for all staff on LD and Autism in line with the NHS 10 year plan and the standards .

To implement the learning disability standards for NHS Trusts including the flagging of learning disabilities on systems such as CareNotes and Framework-I.

Task and finish group established to address the LD standards and have designed a "reasonable adjustments "alert on our Trust electronic patient record system that means all services will see what should be considered for people with LD

Reduction in reliance on in-patient care for people with a Learning Disability and/or autism

Dynamic risk stratification process in place with a clear function of identifying those at risk of admission

19/20 Delivery Plan – Improving Learning Disability Care 18/19 achievements

Investment in LD services• Successful bid to HEE for a Learning Disability health professional to be

based within a Neighbourhood Team within Worcestershire to help improve awareness of staff, prevent hospital admission and promote inclusion of people with Learning Disability in primary care.

Joint working across Herefordshire and Worcestershire• Good working relationships between Herefordshire and Worcestershire

Learning Disability Services. • Engagement events held and well attended by workforce, people with LD

and family carers/providers. In 2017 a survey designed by the LD STP group was distributed and the results used to form and develop local actions.

Transforming Care• All patients on the TCP continue to be reviewed at the TCP panel

providing scrutiny to support timely discharge in line with our trajectory.

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality • Continuation of work around out of county placements• Prevention of escalation of need

Contribution to performance• Continued learning and action from Learning Disability Mortality Review reviews• Continue to deliver the 4 LD standards

Contribution to Financial Recovery ProgrammeLD workstream is not yet in a position to confirm its contribution to the delivery of the financial recovery aim, but work will continue to confirm the level of ambition i.e. opportunities to impact on admission avoidance

19/20 key risks Mitigating actions

Limited investment locally in community teams and as transforming care progresses there will be more people requiring support in the community who present with high risk behaviours . Constraints are financial, technological and also exclusion practices of some public/private organisations/services.

Dashboard will highlight problem areas so that resource can be allocated appropriately, information and learning shared across the STP footprint.

Workforce - staff recruitment and retention Plan in place to roll out training for all staff on LD and Autism in line with the NHS 10 year plan and the standards. Workforce issues will be key part of the plan enabling staff support and training.

SRO: Avril Wilson/Stephen Vickers (WCC)

Programme Leads: Liz Staples (WHCT) / John Burgess (HCCG)

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Variation in prescribing• Continuation of 18/19 work• Repeat prescribing management

Agreement of primary care contract to support delivery of medicines optimisation including reduction in clinical variation

Robust contract monitoring in place and routine review of prescribing data

Medicines Optimisation in Care Homes (MOCH) Monitoring impact of MOCH Programme

High Cost Drugs (PBRE) Agree contractual arrangement with acute trusts

Biosimilar adalimumab switch

Pathway re-design • Impact on medicines for pathway re-design

To ensure the use of medicines within revised and new pathways is in line with current commissioning arrangements

Joint system working• Development of an agreed programme of work

across acute, community and primary care

Medicines Optimisation Needs Assessment, including route of access to medicines

Out-Patient Modernisation – standardisation of approach to dispensing drugs

Scope the opportunity for a single Formulary across G5 Footprint Ensure appropriate pharmacy input into services is considered i.e. A&E, home care, personality disorder service and Primary Care Network

Review discharge meds supply and redesign pathways where opportunities to optimise outcomes are identified

Communication – maximising use of technologies

19/20 Delivery Plan – Medicines Optimisation18/19 achievements

Delivery of financial recovery programmes• Delivery of both high-cost drug biosimilar saving and

primary care prescribing savingsMedicines Optimisation in Care Homes (MOCH)• Initiation of the MOCH programme across the STPVariation in prescribing• Reduced variation in prescribing across primary careJoint system-wide working – pharmacy and medicines• Development of programme of work across Acute,

Community and Primary CareOver the counter medicines and not routinely prescribed medicines• Implementation of revised and aligned commissioning

policies

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality • Reducing unwarranted variation in prescribing• Antimicrobial stewardship - Proportion of antimicrobial

items as co –amoxiclav / cephalosporins / quinolones (<10%)

• Non-steroidal, anti-inflammatory drugs - Average daily quantity per Cost based STAR PU (<0.31)

• High-dose opioids - Average daily quantity per cost based STAR PU (<5.58)

• 2000 medication reviews in care homesContribution to performance• Reduction in care home admissions

H&W Financial Recovery Programme

H’shire£’000

W’shire£’000 Total

Care Home Pharmacists (MOCH)

2,500 5,500 8,000

Low Value Medicines

Over The Counter MedicinesClinical Decision SupportClinical variationHigh Cost Drugs (PBRE) 900 1,333 2,233Grand Total 3,400 6,833 10,233

19/20 key risks Mitigating actions

EU exit – medicines supply Continue to follow national advice regarding the impact of EU Exit

Risk to delivering the ambition financial saving across the STP On-going engagement with all providers 19/20 contracts for medicines optimisation

Financial Recovery Programme – the medicines optimisation contribution to the STP FRP is detailed below. The secondary care pharmacy contribution to the STP financial recovery programme is included in the provider cost improvement plans.

SRO: Simon Trickett (WCCG)Programme Leads: Jane Freeguard (WCCG) / Saran Braybrook (HCCG)

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Social Prescribing • Mainstreaming social prescribing

Evaluation of current social prescribing provision and presentation of findings to STP Prevention Boards to inform future models of delivery Implement Social Prescribing across the STP, applying the learning from the evaluation of current schemes Implement and evaluate social prescribing schemes in settings other than primary care

MECC Ensure that MECC is systematically rolled out across the workforce and set and agree targets for the % of trained Evaluation of the outcomes of training focused on practice change

Digital Inclusion and innovation Identify opportunities to fund improved access to training and online resources as part of digitalisation agenda to ensure inequalities do not widen

Implementation of wellbeing and lifestyle services• Smoking cessation• Health trainers (Herefordshire)• Pre-Diabetes and Diabetes

prevention programme (NDPP)

Development of a business case (CCG plus PH advice) to strengthen the smoking cessation offer to pre-op patients Strengthening good practice in tobacco control in local authorities including through CPD

Worcestershire: expanding the smoking cessation offer to family and friends in targeted areas

Confirmation of CCG funding for diabetes prevention programme at end of current contract – develop offer for eligible but non-engaged referrals

Falls prevention pathway alignment Evaluate the current offer and impact

Ensuring the effective provision of a falls pathway and a strength and balance offer to communities

Agree local authority and NHS future funding

Health Checks To increase uptake and targeting of NHS health checks, through commissioning and co-production to more effectively reach those most at risk who will derive greatest benefits

Healthy Living Pharmacies Engaging local pharmacy committee to maximise pharmacy contribution to the prevention offer

Embed Prevention in to all Programmes Agree governance to ensure prevention is embedded in all workstream delivery plans for 19/20 and beyond

19/20 Delivery Plan – Prevention & Self-care18/19 achievements

Prevention Dashboard – development of a prevention dashboard to monitor the outputs of the 19/20 programme of work.Social Prescribing- Herefordshire: 500 referrals/end Dec 2019. Closely aligned to Primary Home and strengths based community focused working. Worcestershire: 44 Practices involved in six pilot programmes aligned to neighbourhood teams. Over 700 referrals received and 500 patients received face to face or telephone support. MECC- Face to face on online offer updated across the STP and in the process of wide scale roll out. Train the trainer offer in placeHealthy Lifestyles- Diabetes prevention commissioned across the STP. Established a strategic partnership to develop self-care and prevention services across each county and focused on neighbourhood models of working. Care navigation in place. Digital Inclusion- Herefordshire: Skills development in place; includes training, grants for community led schemes, advice and events. Grants and schemes in place to increase access to WiFi. Worcestershire: Infrastructure of digital connectors and champions; Libraries (using PHRFG) training’ good partnership including Housing Associations and VCS.

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality and performance • Improve the identification and reach to patients most at risk of ill health.• Improve the quality of support and treatment for patients with risk

factors/LTCs.• Improve the quality of brief interventions designed to understand the

underlying health issues and to provide more effective support.• Reduce preventable demand on NHS resources.• Improve patient self-care.• Strengthen the prevention offer.• MECC – support how this is embedded across the NHS and wider system.

Enable people to access online advice and information through digital inclusion support.

• The effectiveness of healthy lifestyle programmes.• Strengthen the smoking cessation offer to pre-op patients.

Financial Recovery ProgrammeThe Prevention & Self-care worksteam will not make a direct contribution to the STP’s 19/20 Financial Recovery Programme, but will support and contribute to delivery of the indicative values detailed on slide 28

SRO: Karen Wright (HCC), Frances Howie (WCC)Programme Lead: Karen Wright

Our approach in 19/20• Work with LA.• Work with VCS to ensure links

with social prescribing.• Working with Primary Care

networks to embed prevention.

19/20 key risks Mitigating actions

Ending of PH grant March 20.Continued uncertainty about PH commissioning in the light of the NHS 10 year plan.NHS does not strengthen its prevention investment.Lack of NHS strategic leadership on the prevention agenda.

Strong engagement of DPHs in NHS plans and deliveryEnsure rigour on return for PHRFG investment.Ensure 5 year and 10 year delivery plans include increased NHS investment in prevention.Ensure rigour on holding NHS to account for prevention.17/33 106/138

19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Delivery of the Five Year Framework for GP Contract Reform:• Primary Care Network DES & Network Agreement• Roles Reimbursement Scheme• QOF Reform • Network Financial Entitlements - £1.50 per head

- On-going Support in place for practices to develop PCNs- Des Registration completed & network coverage confirmed- Delegation of Extended Hours DES- Vision for PCNs articulated- Development of an ICS Primary Care Strategy- Testbed site for future reform

Implementation of GPFV Local Delivery Plans:• Workforce• Workload• Access

Evaluate effectiveness of GPFV projects across STPImplementation of Workforce Action Plan – focus on GP Recruitment & Retention SchemesEnhance General Practice Support Team to include Herefordshire practicesReview during 2019\20 feasibility of commissioning an integrated service encompassing Out of Hours, GP streaming and NHS 111 Clinical advice service.Implement 111 direct booking into core and extended hours

Sustainable, at scale general practice Establishment of a Primary Care Commissioning Committee in common with effect from April 2019. Development of GP Provider Board to ensure a strong, consistent and fully representative voice at system level.

STP approach to commissioning & contracting of general practice to support ongoing investment to deliver new models of care and reduce unwarranted variation

Support the integration of integration of community and primary care teams via the PCN DES.

Delivery of the local Promoting Clinical Excellence contract and Herefordshire Outcomes Framework to support primary care networks and reduce unwarranted variation.

Digital-first Primary Care - Identify and review systems and technology in place to promote and encourage self care in order to release capacityin general practice.

- Expansion of Online Consultation and NHS App pilots - Ensure that the STP Digital plan has a focus on Primary Care and is consistent across the STP to ensure equitable

access for patients.

Implementation of the ETTF Schemes for Primary Care Estates development

-Further development of the STP Estates strategy with a focus on general practice at scale and PCNs to deliver new models of care.

National :Implementation of STP GPFV Primary Care Workforce Plan• Additional 5000 GPs by 2020• Additional 5000 other healthcare workers by 2020

- Continue to promote and strengthen recruitment and retention initiatives across general practice, including GP portfolio development, General Practice Nursing, consistent Practice Manager training, Apprenticeships and Advanced Clinical Practitioner roles.

- Work with other NHS organisations to support General Practice career development and develop programmes to up skill our current workforce.

19/20 Delivery Plan – Developing Sustainable Primary Care 18/19 achievements

• Delivery of GPFV 5 year Local Delivery Plans - Transformation Funds Investment of £3pph in Herefordshire through the Herefordshire Outcomes Framework and bids to Improve Access at scale using £1.50 per head being reviewed.

• Care navigation / Signposting – Year 2 roll out of Wakefield model in Herefordshire and the locally developed Worcestershire model – evaluation underway to inform aligned approach in 19/20.

• Improving Access to General Practice Services – integrating access to both routine & urgent 7 day access -100% population coverage in place through 3 hubs and full data sharing in place in Herefordshire and through 10 hubs and full data sharing in Worcestershire.

• STP approach to commissioning & contracting of general practice to support ongoing investment to deliver new models of care and reduce unwarranted variation- Outcomes based approach developed across all providers to support service delivery at a population (30 – 50k) level in Herefordshire and 2 year Promoting Clinical Excellence contract for groups of practices 30 – 50k population in Worcestershire.

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality – Development of Primary Care Networks and local peer support will ensure general practice sustainability and consistency of service by allowing clinical and non-clinical best practice to be shared. Resilience programme and Improving Quality Supporting Practices initiatives are proven to enhance quality of care through improved QOF achievements, more effective Prescribing and Clinical Education. Contribution to performance – Reducing Unwarranted Variation across General Practice via local frameworks will contribute to improved performance. Improved QOF achievement via Improving Quality, Supporting Practices programme.Financial Recovery Programme – The Primary Care programme will not make a direct contribution to the STP’s 19/20 Financial Recovery Programme, but will contribute via the Primary Care Excellence Contract, i.e. peer review of referrals, innovative ways of delivering follow-ups, stretch AF targets to prevent strokes, reduction in emergency admissions

SROs: Simon Trickett (WCCGs, Mike Hearne (HCCG)

Programme Leads: Lynda Dando (WCCG) / Lesley Woakes (HCCG)

19/20 key risks Mitigating actions

Workforce – Risk of widening gap of workforce, particularly GP workforce Roles Reimbursement Scheme attached to PCN Network Agreement DES. Alternative solutions to support the workforce gap are being explored by an STP Recruitment and Retention Task and Finish group.

Inter-operability of external services such as 111 direct booking into general practice does not meet the needs of patients and general practice.

Work closely with general practice providers of Improved Access and external providers to ensure all aspects of inter-operability are considered and how this will enable patients better access. 18/33 107/138

19/20 Delivery Plan – Integrated Primary Care and Community Services

18/19 achievementsDevelopment of Integrated Care Teams- Development of locality governance structure- Development of outcomes framework and locality information

dashboard- Assertive approach to reducing admissions from Care Homes- Development of ‘road-map’ for Integrated Care System- Reduction in variation in A&E attendances and NEL admissionsIntegrated Care of Older People Services- Development of strategy- MOU developedReduction in community beds (Herefordshire- Reduction of 22 beds from Hillside Rehabilitation Centre

19/20 expected outcomes: contribution to improving quality, performance and financial recoveryContribution to quality and performance- Reduction in A&E attendance and emergency admissions- Reduction in emergency bed days- Reduction in delayed discharge- Reduction in elective outpatient and inpatient activities- Improved patient experience by ensuring that people are treated and cared for in a safe, effective and appropriate way- Improved staff satisfaction through support network and workforce development

Financial Recovery Programme

H&W Financial Recovery ProgrammeHerefordshire

£’000Worcestershire

£’000Total£’000

Integrated Primary Care and Community Services 1,746 3,400 5,146Grand Total 1,746 3,400 5,146

SROs: Sarah Dugan (WHCT), Jane Ives (WVT). Programme Leads: Ruth Lemiech (WCCG) / Alison Talbot-Smith (HCCG), Sue Harris (WHCT)

19/20 key risks Mitigating actions

Workforce capacity / sustainability Recruitment of wide range of staff to support GPs / NTs as outlined in DES

Delivery of financial savings Roll out of bets practice and learning from practices where savings have been delivered.

Integrated IT solution Digital strategy in place from May 2019 will guide implementation of integrated solutions.

19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Outcomes framework and operational dashboard developed Shared outcome framework across STP in place from May 2019 Dashboards populated and regular reporting at STP, Place & Neighbourhood level

Population health approach Full engagement with NHSE development programme to deliver system-wide benefits Development and utilisation of population health packs (inc. top 2 and 5 % high utilisation)

STP Clinical Sustainability Strategy Capacity and capability requirements to support left shift as part of H&W Clinical Sustainability Strategy understood and implemented

Strengthened integrated team working, supporting establishment of Primary Care Networks

Plans implemented to address variation in capacity and competency (W’shire) MDTs in place (locality based in Herefordshire) across health, Mental health, primary and social care Co-location of multi-disciplinary teams accessed via a SPA, supporting primary care networks Local Authority alignment of social workers (Herefordshire) Specialist Nurses provide educational input and support integrated teams including mental health Increased proactive care including anticipatory care plans, high intensity users and care homes

Review function and capacity of Community Hospitals (inc. beds) Review need, functions and capacity to develop recommendations Implementation including engagement

Urgent Crisis response to include optimisation of WMAS and NHS 111 SPA available within each Neighbourhood Team

Rapid response to urgent care in place, including dedicated medical support, with further integration of H@H and Home First Service (Hereford)

Establishing links with GP OOHs, 111 and IUCs Shared patient records across services in support of the integrated model

Processes for monitoring and acting on system outcomes and record sharing mechanisms in place

Roll out of Frailty Pathway ICOPE:To increase accurate coding and Advanced Care Planning in Primary care – Qtr 4 (Worcestershire) Embed CGA and Rockwood clinical frailty scale across WAT and WHaCT – Qtr 4 Locality GP Frailty specialists virtually integrated with secondary care specialists

End of Life Care Roll out of ReSPECT

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19/20 Delivery Plan – Maternity18/19 achievements

• Implementation and development of the Local Maternity System - a number of trajectories agreed and in place with activity monitoring to track progress against delivery.

• Development of a jointly commissioned, jointly provided maternity service across the STP footprint – Maternity Clinical Specification agreed by LMS Board. Further discussion has taken place at Joint Commissioning Committee and will be added to Acute Trust Contracts once approval is received.

• Continuity of Carer Plans – First teams have gone live in Herefordshire and Worcestershire with a further team planned. It is expected to deliver the trajectory by March 2019.

• Saving Babies Lives Bundle – localised action plan produced to support achievement.• Successful funding bids

- Saving Babies Lives, NHSE Transformational funds- Perinatal Mental Health in Herefordshire- STP Digital Investment- HEE training bid x 2

19/20 expected outcomes: contribution to improving quality, performance and financial recovery• Contribution to Quality

- meet agreed trajectory for reduced numbers of stillbirth and neonatal deaths during 2019/20- meet the agreed national trajectory of 35% of women booked onto a Continuity of Carer pathway in 2019/20- meet the agreed target of 100% of women who have a personalised pregnancy plan by 2020- meet the ambition of 25% of women giving birth in a midwifery setting in 2019/20- women will be offered three choices of place of birth from 2019/20

• Contribution to Performance- work towards reducing smoking prevalence at time of delivery to 10% in 2019/20- work towards reducing pre-term births to 13% in 2019/20- work towards a 20% reduction in morbidity and mortality including stillbirth, neonatal deaths, perinatal mortality,

maternal deaths and brain injuries by 2020 and by 50% by 2025- increase women on Continuity of Carer pathway to 20% in March 2019 and to 35% by 2020

• Contribution to Financeit Is recognised that there are increasing capital requirements and that the programme of work is not cost neutral to organisations which requires a level of efficiency. Should any savings /efficiencies be realised it has been agreed by the STP Partnership Board that these will be utilised within the LMS programme to fund any service change.

19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Implementation of a joint clinical specification across STP footprint with common reporting and data collection

Review and update current specification CCGs to include in 2019/20 contract

Maintain choice and increased personalisation of maternity careAll women will be offered 3 choices of place of birth 100% of women will develop their own maternity care plan

Single Point of Access (Badgernet Electronic Modules)Maternity digital health records to be offered to 20,000 eligible women in 20 accelerator sites across England, rising to 100,000 by October 2019Implement electronic maternity record at WAHT

Deliver full implementation of Saving Babies Lives Care Bundle (v2) by 31 March 2020

Roll out Saving Babies Lives Care Bundle

Implement pathways for Level 3 Perinatal Mental Health Continue to deliver against agreed plan for access to specialist perinatal mental health services Establish clear strategic plans for specialist perinatal mental health services engaging with the regional perinatal mental health network

Reduce Smoking prevalence at time of delivery to 10% in 2019/20 Offer all women who smoke during pregnancy, specialist smoking cessation support to help them quite. Increase the number of women receiving Continuity of Carer to 35% by March 2020 with 75% of women in vulnerable groups on a CoC pathway

Commence implementation of enhanced and targeted CoC model to help improve outcomes for the most vulnerable mothers and babies.

Support both acute trusts to achieve 10% rebate on maternity CNST premium Share good practice and action plans to support both acute trusts to achieve 10% rebate All maternity services to begin UNICEF Baby Friendly Accreditation by March 20

Base line data / Share action plans and good practice

Increase the number of babies born in the correct unit according to their gestational age

Work with Specialist commissioners and Maternity & Newborn networks to improve access to neonatalCritical care cots

Agree pathways between WVT and WAHT for level 1&2 neonatal care

19/20 key risks Mitigating actions

Long term Maternity and medical workforce Explore different roles and workforce models

Access to neo-natal critical care cots for STP wide population Work with Specialist Commissioners and both acute trusts to agree pathways

Lack of end to end IT EPR system at WAHT which integrates with Wye Valley and wider regional units Seek alternative written method of communication until electronic end to end system in place late 2020

Lack of consistent clinical pathways for level 3 PMHUnclear funding value 2019/20 for LMS PMO and not known if there are transformational funds

Work with Perinatal mental health teams to agree joint and consistent pathwaysIf funding not available, STP Partnership Board will need to agree how LMS will be managed

SRO: Dr Frances Howie (WCC)

Programme Leads: TBC

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Phase 2 – continuation of detailed assessment of potential STP stroke service models

Development of workforce plans

EIRA, QIA and DPIA Assessment

Financial Assessment

Pre-Consultation

Formal Consultation and outcome

CCG Governance Outcome of Pre-consultation and Clinical Senate Review and CCG decision re specification

NHS England Assurance Process Full Clinical Senate Review and Sense Check II

STP Capital Bid STP capital bid outcome

STP Stroke ServiceImplementation of 24/7 stroke services (100% of population)

Implementation of 7/7 TIA services

19/20 Delivery Plan – Stroke18/19 achievements

• Development and establishment of formally constituted H&W Stroke Programme Board (governance of assurance process)

• Phase 1 – Identification of potential service models- High level assessment and evaluation of

potential models- Strategic Sense Checks of potential models

• Phase 2 – Detailed evaluation of potential services models

- Development of clinical pathways- Bed and non-bed based modelling- Travel time analysis - Early communications and engagement (targeted

to staff)

19/20 expected outcomes: contribution to improving quality, performance and financial recovery• Contribution to quality and performance

- Delivery of 7-day services in line with National Standards- Standard 2 – Clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours of admission to hospital- Standard 6 – Timely 24 hours access, 7 days per week to consultant-directed interventions that meet the specialty guidelines- Standard 8 – All patients in high-dependency areas must be seen and reviewed by a consultant twice daily

• Achievement of key quality standards including- Time to scan within 1 hour- Time to thrombolysis within 1 hour- Time to HASU within 4 hours- 90% of time as an inpatient spent on a dedicated stroke ward- Achievement of all SSNAP domains at a rating of C or above

• Contribution to Financial Recovery Programme - The Stroke programme will not make a direct contribution to the STP’s 19/20 Financial Recovery Programme, but will contribute to the delivery of the Triple Aims to

improve quality and performance of care and services Improve population outcomes and reduce inequalities, improving Atrial Fibrillation (AF) and Hypertension identification and

management through the use of new technology

19/20 key risks Mitigating actions

Workforce Plan may not be deliverable due to national consultant shortages, recruitment and retention of staff

Workforce plans requested for each provider and workforce planning event scheduled for 12/02/19. Workforce models will include optimum use of extended roles, joint posts, rotational posts, new posts i.e. Nurse consultant etc.

Finance – affordability of workforce plan and no confirmed source of funding for STP capital bid to build dedicated unit at WRH (Model 4)

Detailed financial assessment being undertaken. Business case being developed to support capital bid.

No clear funding source for Capital Bid will result in centralised model at WRH being undeliverable (no capacity)

Escalated to STP and NHSE. Alternative sources of funding being investigated.

Services remain at risk due to current workforce issues Business continuity plans being developed across the STP to include joint posts, use of telemedicine.

Service Model- deliverability within time frame Business continuity plans to including trigger points, risk assessments and actions to be taken if not deliverable in timeframe.

Insufficient assurance across the system for preferred service model may result in failure to implement sustainable 7-day services

Clinical senate review of model 4 May 2019; Comms and Engagement Plan in place; Ongoing review of QIAs; Clinical engagement through H&W Stroke Programme Board; Assurance through H&W Stroke Programme Board.

SRO: Dr Carl Ellson (WCCG)

Programme Leads: Mari Gay / Anita Roberts (WCCG)

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19/20 Delivery Plan – Urgent Care - Herefordshire18/19 achievements

• Development of frailty front door scheme- Commenced December 2018 and showing promising results.

• Expansion of Home First- This scheme has been integrated with Hospital at Home service, supplying community –based rehabilitation.

• Delivery of Paramedic Pilot – scheme was looking at frail older people and provided a model of paramedic workforce development

• Improvement in joint working to address discharges – Integrated Complex Discharge Team (health & social care) in place

• Reduction in attendance from care homes – Integrated Care Home Improvement Team in place

• Reduction in non-elective admissions - Emergency admissions reduction by 5%

19/20 expected outcomes: contribution to improving quality, performance and financial recovery

Contribution to quality • Improved patient experience• Reduction in number of patient transfers within hospital• Improved identification of frailty and dementia• Improved response to frequent attendeesContribution to performance• Delivery of Emergency Access Standard target by 2020• Delivery of 0 over-30 minute ambulance waits• Elimination of 12 hour DTA breaches • Reduction in cancelled planned care due to lack of capacity • Reduction in delayed transfers of care• Reduction in stranded / super stranded patients

19/20 key risks Mitigating actions

Daily Operational/patient flow challenges poses risk to utilising assessment areas as surge capacity

Additional capacity opened in December 2018 and reconfiguration of bed numbers to specialities should aid a reduction in assessment areas being used in times of escalation.

Capacity to deliver transformation programmes of work has been challenging The programme of work for 19/20 will be implemented by Urgent Care Partnership Group, with strategic oversight by A&E Delivery Board.

Workforce vacancies across 7 days working (A&E, primary care and community services)

Recruitment underway. A&E Delivery Board to develop workforce plan that effectively addresses gaps (recruitment and retention). Results in 2018/19 provided a reduction in agency spend.

Financial Recovery ProgrammeThe Blended Payment for Emergency Care guidance indicates a default approach for Commissioning Urgent Care for the full financial year, thus taking the focus away from Financial Recovery. It is expected that the focus will be maximising and streamlining existing assessment services. Other savings are linked to the benefit realisation of avoiding the demand for urgent care, through effective primary care and community services.

H&W Financial Recovery ProgrammeTotal£’000

19/20 Urgent Care Programme £735

SRO: Jon Barnes (WVT)

Programme Leads: Jade Brooks (HCCG)

19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 2020

1 2 3 4

Integrated Urgent Care Procurement Full Integrated Urgent Care Procurement

Mobilisation of provision

Work with WMAS to reduce conveyances Contract signed with WMAS to include a greater percentage of See and Treat and optimise use of CAS and Star5 and Star6 in 111 and increasing investment to deliver this

Further development of community-based provision that paramedics can access (and update of Directory of Services)

Same Day Emergency Care (SDEC) Delivery of SDEC as per NHS Long Term Plan

Minor Injuries Units Review Review of minor injury provision and its function including community engagement Urgent out of Hospital care Work with high risk patients through PCNs – high intensity users, MDTs, anticipatory care planning, Rockwood,

ReSPECT and Care Homes. See integrated Primary and Community services

Development and agreement of urgent primary care offer across the primary care networks

Safe and timely Discharge Develop system-wide improvement plan following peer review

Implementation of plan including High Impact Change Model

Improvement in hospital flow Efficiency schemes that improve hospital flow, including support from ECIST, hospital at night.

19/20 Winter plan in line with national requirements Evaluation of 18/19 Winter plans and build learning into development of 19/20 Winter plans

Ensuring appropriate primary, community, social care and 111 capacity over the winter period

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Delivery of system priorities as set out in our system AEDB plan Delivery of system key priorities as overseen through weekly COO Group Delivery of remaining schemes overseen through AEOG

Manage Ambulatory Emergency Care, Frailty and Surgical assessment services to reduce cost of inpatient services

Operational focus on delivery and maximisation of services

Review Service Specifications for the following assessment services: PAU, MAU, ESTC and GAU.

Develop a robust timeline to review service specifications and work collaboratively with WHAT

Work collaboratively with WAHT to agree specifications in line with best practice Ensure delivery of streaming at front door of EDs to assessment areas Agree streaming model with the Trust and implement across both WRH and ALX sites

Ensure full utilisation of the GP streaming service Agree service specification and monitor weekly

Review and evaluate Urgent Care system including UTC pilot and MIUs

Review against national guidance and present recommendations to A&E Delivery Board.

Acute Trust to continue to improve flow inside hospitals through implementing ‘ improving patient flow guidance . No delay everyday processes embedded within acute trust.

Implementation of effective real time demand management system. 100% general wards to have ‘no delay’ implemented. 100% of patients on adult wards to have EDD. 33% of discharges before midday. Full roll out of discharge passport and criteria lead discharge.

19/20 Winter plan in line with national requirements Evaluation of 18/19 Winter plans and build learning into development of 19/20 Winter plans Ensuring appropriate primary, community, social care and 111 capacity over the winter period

19/20 Delivery Plan – Urgent Care - Worcestershire18/19 achievements

• Development of pilot Urgent Treatment Centre at Alexandra Hospital, Redditch- pilot commenced December 2018 to April 2019, embedded as part of the Emergency Department with triage to the UTC service.

• Utilisation of the Frailty Assessment Unit at Alexandra Hospital, Redditch- increased operational focus during this year with increase in working hours to 12/7 from January 2019. Reconfiguration of the overarching frailty services planned for February 2019 to provide supporting beds.

• Utilisation of Ambulatory Emergency Care Centre at Alexandra Hospital, Redditch and Worcestershire Royal Hospital – Agreed service specification and best practice operating model, compromised by using the area as surge capacity on the WRH site

• Improvement in discharges across all pathways – and reduction in DTOCs

• Reduction in stranded/super stranded patients

19/20 expected outcomes: contribution to improving quality, performance and financial recoveryContribution to quality • Improved patient experience• Reduction in number of patient transfers within hospital• Reduction in hospital acquired infection• Reduction in patients treated in the corridor • Eliminated 12 hour breaches Contribution to performance• Improved Emergency Access Standard Performance • Delivery of 0 over-30 minute ambulance waits• Reduction in cancelled planned care due to lack of capacity • Continued focus on delivering against ‘what our system looks like’ • Delivery of the L&D ‘front door streaming’ model • Reduction in inpatient Length of Stay and continued focus on reducing

number of super stranded patients • Improved utilisation of assessment areas, such as FAU, MAU• Increased levels of Same Day Emergency Care • Realisation of Benefits through additional acute trust bed capacity

19/20 key risks Mitigating actions

Daily Operational/patient flow challenges particularly at the Worcester Royal site poses risk to utilisingassessment areas as surge capacity

WAHT developing a protocol to ensure assessment areas are taken out of surge capacity. Reconfiguration changes between acute hospital sites will support improved patient flow.

Traction of transformation programmes of work are not progressed at pace All programmes of work for 19/20 will feature as part of the Service Development Improvement Plan and will be robustly monitored through the Contractual route

The transfer of activity to the Alex Hospital site may cause delays due to the lack of capacity and workforce at the Alex Hospital site ED.

Recruitment of additional staff to support the activity transfer. Monitored through daily assurance and AEDB dashboard.

Financial Recovery ProgrammeThe Urgent Care programmes of work will make a lesser contribution to the STP’s 19/20 Financial Recovery Programme than the previous year. The Blended Payment for Emergency Care guidance indicates a default approach for Commissioning Urgent Care for the full financial year, thus taking the focus away from Financial Recovery. It is expected that the focus will be maximising and streamlining existing assessment services.

H&W Financial Recovery ProgrammeTotal£’000

19/20 Consultant Connect - UEC 20019/20 Patient Transport 5019/20 Falls Response Service 11619/20 Same Day Emergency Care 1,193Grand Total 1,559

SRO: Mari Gay (WCCG)

Programme Leads: Jane Gordijn (WCCG)

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19/20 Key Deliverables 19/20 Key Milestones 19/20 delivery 20201 2 3 4

Completion of Digital Strategy 2019-2022 Strategy to gain formal approval via STP Partnership Board Strategy launch event Agree work plan/priorities

Local Integrated Health & Care Records Outline Business Case Full Business Case Begin implementation

Online Consultations Proof of Concept & Pilots Evaluation and Options Appraisal Implemented of preferred option

Personalisation, Personal Health Care record & NHS App development

Pilots and proof concept tests identified and trialled Evaluation Strategy and next steps agreed

HLSI Funded EMIS Community Rollout Maternity EPR Worcestershire Acute Hospitals Trust

19/20 Delivery Plan – Digital, Technology & Innovation18/19 achievements

• STP Digital work programme & governance established, along withwider H&W Digital Community inc frontline clinicians, GPs andInformation leads two successful workshops to date. Clear leadership forprogramme identified with SRO and Executive Director leads agreed andin place

• STP Digital Strategy Development – agreed by STP Programme Board tosucceed H&W LDRs. Significant progress made to deliver robust 3 yearplan for 2019-22 in Q1 2019 with focus on integrated care records andon-line consultations to deliver LTP objectives locally

• HLSI funded projects – STP wide agreed programme for HLSI projectsincluding accelerated rollout of EMIS Community, Maternity EPR, andprojects to improve digital maturity of key partners. Agreement todevelop OBC for integrated care record and work initiated

• Improving Infrastructure – HCSN rollout in Herefordshire,Worcestershire in progress, funds obtained to upgrade primary careestate and upgrades underway throughout year

• Interdependencies – mapping exercise across key workstreamscompleted, capital funding to allocated

19/20 expected outcomes: contribution to improving quality, performance and financial recovery• Contribution to quality – Patient data access and information sharing. Information and care continuity. Patients

access to own care records. Delivering assurance metrics, (patient care setting, DTOCs). Ensuring by 2022/23,the Child Protection Information system will be extended to cover all health care settings, including generalpractices.

• Contribution to performance – Delivering local targets linked to LTP e.g. roll-out of on-line consultations andMaternity Services maternity held records

• Financial Recovery Programme – Supporting the prevention of hospital admissions, delayed discharges,duplicate or an unnecessary assessment or visit being carried out, contributing to improvements andnew/innovative ways of delivering care – through development of digital/technology efficiencies.

• NHS Long Term Plan – Embracing the LTP ambitions, working towards: • Transforming outpatient services• Online Consultations • Availability of digital services/devices to staff • Digital booking options • Ensuringmental health digital strategy in place • Continue to progress the Global Digital Exemplar and Local Health &Care Record Exemplar programmes • Supporting the increased uptake of people’s digital interaction with thehealth service. This includes:• developing plans to ensure every patient with a long-term condition will have access to their health record

through the Summary Care Record accessed via the NHS App• a plan in place for digitally-enabled models of therapy for depression and anxiety disorders for use in IAPT

services across the NHS will be endorsed by NHS

19/20 key risks Mitigating actions

Capacity to deliver projects in timely manner Resources for digital delivering being mapped and assessed, PMO with leads developing monitoring framework

Gaining agreement to single priority for HLSI across all STP partners Digital Strategy will be used as key mechanism./tool to inform prioritisation

Match funding/resource in system for HLSI Match funding for current programmes sourced,19/20 funding further scoping

SRO: Rob Mackie (WHCT)

Programme Leads: Mike Emery (HCCG)

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Chapter 3: Approach to system-wide operational planning

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• Approach to alignment of system activity to organisational plans and challenges to delivery

• Approach to capacity planning at a system-level • Approach to alignment of incentives and removal of financial

barriers to integrated care • Arrangements for financial risk management • Key system-wide efficiencies and how partners will work together

to achieve them • Alignment of system-wide efficiencies for 2019/20

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System-wide approach to operational planning commenced in early December 2018. The timetable below shows the key meetings and key actions in order to agree activity assumptions, align system activity, agree approach to financial risk management and alignment of system-wide efficiencies for 2019/20.

2019/20 STP Approach to Financial Planning & Contracting

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19/20 STP Approach to Financial Planning & Contracting

Key principles

1 Robust and aligned plans are needed to address the significant performance and financial issues - whilst recognising the existing organisational statutory framework and accountability.

2 That CCG allocations are fixed – and represent the system affordability envelop.

3 The application of any growth in CCG allocations should be considered and agreed on a system basis in an open and transparent way. Applications needed to be considered against a set of pre-agreed criteria – such as addressing outturn issues, unavoidable cost pressures, national must-do’s

4 Improve system efficiency and productivity to deliver any increase in demand within existing resources - rather than increase the cost of provision still further. This would enable a proportion of growth funding to be applied towards reducing the deficit.

5 Agreement to address the deficit as far as is possible – and then make application for ‘allocation +’. Partners agree to work together to take advantage of the national opportunities for structural financial support.

6 Savings plans needed to be aligned – particularly between provider ‘CIP’ schemes and demand management schemes, to avoid overlap and duplication, and to test the plausibility of schemes.

7 That there is a shared financial objective to build regulator confidence through reduction of the system deficit and delivery of the triple aims

8 The final agreed system savings target needed to reflect a level of ambition – but be deliverable and show further improvement in subsequent years.

9 It may be necessary to consider disinvestment opportunities where it is clinically safe to do so when it is uneconomical to deliver services locally. The lead time and political impact of this needed to be considered carefully.

10 The attribution of risk needed to be fair and proportionate in accordance with the extent of control and accountability for delivery.

11 A commitment to reduce internal STP financial trading between organisations – to allow focus on cost reduction initiatives.12 That contracting issues are resolved internally – with escalation to chief executives where necessary .

The STP system leaders have signed up to set of key principles which underpin the approach to 19/20 financial planning and contracting. These key principles have been presented to each organisations’ decision-making body for endorsement. A summary of these key principles are described below.

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2019/20 STP Financial Recovery ProgrammeThe combined savings target for the STP organisations is per the table below – with status as confirmed on 11th April.

• The position per the table reflects 4th April Plan submissions and is subject to further updates on a weekly basis• All organisations are continuing work to fully identify their savings required and reduce the level of risk • Whilst the total of £65.2m is significant – this in itself is insufficient for all organisations to achieve their financial control totals.

Savings at this level result in a £51m shortfall to Control Totals.• The level of risk is acknowledged to be significant and CFOs are working collectively to support organisational delivery on joint

schemes and to identify further schemes and mitigations to resolve the remaining gap. • STP escalation measures are being agreed to develop a collective system response in the form of an STP financial recovery plan. This

plan will be completed by 30th June.

Savings Required

Low Risk Medium Risk High Risk Unidentified

£'000 £'000 £'000 £'000 £'000Worcs CCGs 30,506 19,280 6,644 4,582 - Worcs Acute 13,001 718 6,662 2,229 3,392 Worcs H&CT 3,204 410 1,919 400 475 Worcs Total 46,711 20,408 15,225 7,211 3,867

Herefordshire CCG 12,500 3,399 5,201 2,600 1,300 Wye Valley Trust 6,000 1,258 2,672 356 1,714 Herefordshire Total 18,500 4,657 7,873 2,956 3,014

STP Total 65,211 25,065 23,098 10,167 6,881

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2019/20 STP Financial Recovery Programme

Cost-out approach Aligning incentives Financial risk

Absorbing growth in demand through productivity & efficiency gains across the system

Need to ensure we focus on ‘Cost Out’

Financial Risk should be proportionate to influence

• CCG Controllable QIPP = CCG Risk, i.e. CHC & Prescribing

• Provider Controllable CIP = Provider Risk, i.e. Procurement + Back office costs

• Joint Cost Programmes = Required QIPP/CIP

CCG Risk = Demand Management

Provider Risk = Cost removal, Workforce delivering differently & Implementing new service

Consistent adoption of new care models Has to be a saving for the system or growth spend avoided

Management of capacity across primary, community and acute to make best use of resources and avoid premium costs

Need to ensure there a win/win for all parties

Changing the setting of care to release capacity in acute to allow for cost release or repatriation

Delivery of triple aim

Changes to the threshold for treatment where this is clinically appropriate; or

Reduction of system deficit

To decommission services altogether if there is no demonstrable added clinical benefit

Moving resources around system to enable delivery

Removal of inefficiencies and duplication in local service provision

Maximise income recovery = income paid to non-H&W Providers

The STP Financial Recovery Programme has been built on the principle of “cost-out and efficiency”, not “income”. The STP recognises that there is still a level of unmitigated risk in the system.The table below shows approach taken to cost-out, aligning incentives and financial risk.

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2019/20 Contract negotiations and control totals – position as at April

All CCGs and Trusts within STP have received 2019/20 control totals• CCGs have signalled as part of February draft plan submission acceptance – Worcestershire CCGs breakeven,

Herefordshire CCG £120k surplus, however have £7.1m of unmitigated financial risk

• Worcestershire Health and Care NHS Trust have accepted a control total of £1.956m surplus

• Wye Valley NHS Trust have accepted a control total of £17.253m deficit – this is predicated on contractual income from CCG being secured

• Worcestershire Acute Hospitals NHS Trust have declined to accept the control total £31.725m deficit – the Trust believe this is circa £20m short of where they expect to be based on a number of new wards being opened to get to a 92% hospital occupancy. This is an expenditure problem rather than an income problem.

Contract Negotiations 2019/20• Worcestershire CCGs with Worcestershire Health and Care NHS Trust – contract signed

• Worcestershire CCGs with Worcestershire Acute Hospitals NHS Trust – Contract value agreed following CEO/AO meeting. Final issue being resolved around diagnostics. Signatures expected 11th April 2019

• Herefordshire CCG and 2Gether NHS Foundation Trust – contract signed

• Herefordshire CCG and Wye Valley NHS Trust – financial plan agreed. Outstanding issue around RTT delivery. Expected signatures 11/12th April 2019.

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Chapter 4: Workforce• Evaluation of workforce requirements, identification of gaps and

development of plans for fill them

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Workforce challenges

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• Retaining staff within Herefordshire & Worcestershire • Recruitment challenges and high vacancy rates (RN/RMN and medical specialities and Primary Care)• Geographical rurality of Herefordshire & Worcestershire• Creating a consistent flexible/agile and digitally astute workforce fit for the future• An ageing workforce• Different exceptions of the younger workforce (i.e. increased part time working/flexibility and contract

hours)• Staff morale and lack of development opportunities• Cultural challenges within existing organisations and staff groups resistant to change• An uncertain supply of staff, lack of investment into training places nationally• National issues across UK, workforce not aligned to increasing demand• Preparing a workforce with no boundaries across organisations• Reducing the dependency of bank and temporary staffing• To ensure there is a more significant role for the voluntary and community sectors• A shift of workforce culture on prevention and self care utilisation and health coaching• Creating a multi disciplinary teams based around the person, supported by access to specialist support

(i.e. frailty team and teams with more diverse skill mix)• Increased investment in Mental Health and Learning Disability workforce.• To provide the correct level of workforce intelligence to support the challenges

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Workforce priorities

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Recruitment & Retention

Education, Training & Development

Leadership, Culture & OD Workforce Information, Planning & Intelligence

• Retain existing workforce• Recruit to support vacancies

and growth predictions (particularly Nursing)

• ‘Home Grow’ a future workforce, less resilience on overseas

• Maximise Apprenticeship• levy/ Bursaries across STP• Explore new training and

qualification route opportunities

• STP is marketed as an attractive ‘come here/stay here’ place to work

• Establish a flexible and agile workforce fit for 21st century to support new ways of working

• Review any inequalities in pay and progression

• Less reliant on agency and temporary Staffing

• Create a learning environment for career progression and personal development opportunities

• Appropriately upskill the current workforce

• Equip a workforce fit for the future and digitally trained

• Increase knowledge and skills of local people and support prevention and self care strategy

• Explore new joint training oppourtinies/methods including educational partnerships

• Increase the numbers, the knowledge and skills of volunteers

• Delivery new ways of learning• Develop agile and transferable

skills and straining across STP• Development and support of

new roles to address workforce gaps

• Develop a consistent system leadership model

• Ensure the STP has inspirational and dynamic leadership

• Drive positive cultural change

• Understand our vision and values and expected behaviours

• Ensure for the future leadership team

• Develop a system wide approach to OD and leadership across the STP

• Consistent approach to leadership, talent mapping and succession planning

• Health and wellbeing strategy across STP

• Explore new leadership and management initiatives

• Establish a well developed information platform

• Ensure we have the right intelligence to support new initiative and developments

• Strengthen workforce and service planning, quality with finance across the system to meet Triple Aim

• Monitor workforce data patterns and intelligence to support workforce transformation

• Recognise and act swiftly on diverse needs of workforce and planning staff movements (retirement/flexible working requests/turnover, vacancies/agency etc)

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BOARD OF DIRECTORSReport to: Board of Directors Agenda item: 7.1Date of Meeting: 2 May 2019Title of Report: Summary Report on Safe Working Hours: Doctors &

Dentists in TrainingPublic or Private Board (if applicable)

N/A

Report Approval Route:Lead Executive Director: Mr David Mowbray, Medical DirectorAuthor: Dr Laura TrothAppendices: N/A

1. Purpose and summaryTo inform the Board on progress made in implementing the new junior doctors contract and the work of the Guardian of Safe Working (GOSW).

2. Recommendations1. The Board notes the report from the GOSW

1. Please tick which element of the Trust’s Objectives the report relates to:Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

Reduce the financial deficit by delivering our financial plan

Improve urgent care by delivering the A & E standard and providing more services across seven days

Improve the quality and sustainability of our services by implementing our clinical strategy

Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

Care for people nearer to home by transforming our community services with our One Herefordshire partners

Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

Improve our effectiveness through the delivery of our Digital Strategy

Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

2. ImpactNo direct impact on partners of the Trust.

3. Resource implications:Not applicable to this report.

4. RiskI am pleased to report that since taking over my Guardianship role there has been a significant

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reduction in the number of immediate safety concerns reported by the juniors. Over the last 6 months no Immediate safety concerns were flagged on the system.

5. Executive Director OpinionThis report assures me that the interventions we have put in place since Laura’s commencement into the role (bolstered exceptions process, regular junior doctor sessions, new FY2 rota for surgery, improved leave arrangements) have largely served to eliminate the previous concerns raised. This will help in our quest to make WVT an “employer of choice” for the junior doctor workforce.

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These quarterly reports are integral to the new Junior Doctor’s contract and are intended to provide an overview and assurance to the Board of the Trust’s compliance with safe working hours for doctors across the Trust and to highlight and detail any areas of concern.

Since being appointed as GOSWH I have produced four reports. The purpose of this summary is to highlight the current issues and to also explain what we have done to counteract these risks within the Trust over that time period.

One of the roles of the GOSW is to provide reassurance to the Trust that doctors are working safely across the site as laid out in the 2016 terms and conditions of service. We have mapped our rosters in medicine against recent Royal College guidance. With the introduction of a roster coordinator we have seen an improvement in junior doctor satisfaction. Over the last few months the juniors have generally felt more supported in medicine and a new pattern of working has recently been introduced. The aim of this new working pattern is to improve ward cover over the weekends.

I am pleased to say that in the last 4 months we have had no exception reports. From the date of my last board report in November we have had 4 exception reports. All of which have been dealt with in a timely manner. None of these detailed any serious patient safety concerns.

I have worked hard at engaging both juniors and educational supervisors around the Trust to try and encourage a better environment for exception reporting. I still feel there are barriers to exception reporting within the Trust. However I have actively engaged all juniors regularly and feel that this has created environment where they feel able to report.

In my last Board report I detailed issues with annual leave and junior’s access to securing it successfully. Over the last 6 months this issue seems to be largely resolved. However I still feel one of the main issues in juniors securing annual leave is the lack of a computerised system. I feel a system such of this would aid us in improved transparency.

The two main areas of concern that have been highlighted through trends in the reports previously were Trauma and Orthopaedics and FY2/GPST Medical rosters. Since my last report we have agreed a roster review of both Trauma and Orthopaedic and medical rosters. We have now introduced a second tier in the orthopaedic roster and rolled out a new medical rota. So far these seem to be largely successful with much improved junior doctor satisfaction being reported to me at my regular meetings.

Overall I am pleased to announce there has been much improvement in responding to exceptions over this time. We have also worked very hard at addressing issues that have been highlighted within the reports, with ongoing projects focusing on all areas of concern.

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BOARD OF DIRECTORSReport to: Board of DirectorsDate of Meeting: 2 May 2019Title of Report: HSE Improvement NoticesStatus of report: For discussion and information.Report Approval Route: Executive Risk CommitteeLead Executive Director: Jane Ives, Managing DirectorAuthor: Erica Hermon, Associate Director Corporate GovernanceAppendices:

1. Purpose of the report

Health and Safety Executive (HSE) inspectors visited Hereford County Hospital on 12 March 2019 to assess the management of risks to staff from the use of medical sharps. They identified contraventions of health and safety law and consequently 2 improvement notices have been issued to the Trust in relation to poor standards of sharps management

2. Recommendations

The Board is invited to note and champion the action plan required to address the issues raised by the HSE.

3. Executive Director Opinion

Although there has been introduction of some safer sharps in the trust, we were unable to produce suitable and sufficient risk assessments for those activities that involve the use of non-safety devices including: lumbar puncture, insertion of a CVP line, tracheostomy and insertion of a chest drain. The trust is required to assess the tasks and identify whether safety devices may be used e.g. safer hypodermic needles for injecting local anaesthetic or the use of a safety scalpel. Where safety devices are not available, the risk assessment should identify the additional controls necessary for the production of a safe system for working with and disposing of sharps. There was also evidence of non-safety devices being used when safer devices were available e.g. using a hypodermic instead of a blunt fill needle to draw up injections.

The action plan being implemented by the Trust will ensure we comply with the measures required of the improvement notices. Failure to comply with the requirements of a Notice is a criminal offence which could result in imprisonment or a fine.

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4. Please state which element of the Trust’s Objectives the report relates to::

1. Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

6. Reduce the financial deficit by delivering our financial plan

2. Improve urgent care by delivering the A & E standard and providing more services across seven days

7. Improve the quality and sustainability of our services by implementing our clinical strategy

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

8. Care for people nearer to home by transforming our community services with our One Herefordshire partners

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

9. Improve our effectiveness through the delivery of our Digital Strategy

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

HEALTH AND SAFETY AT WORK ETC ACT 1974 HEALTH AND SAFETY (SHARP INSTRUMENTS IN HEALTHCARE) REGULATIONS 2013

1. Health and Safety Executive (HSE) inspectors visited Hereford County Hospital on 12 March 2019 to assess the management of risks to staff from the use of medical sharps. They identified contraventions of health and safety law and 2 improvement notices have been issued to the Trust in relation to poor standards of sharps management

2. Section 28(8) of the Health and Safety at Work etc. Act 1974 requires HSE to inform our employees about matters affecting their health and safety. Accordingly, they have sent a copy of the improvement notices and correspondence to the Unison Health and Safety Representative.

3. The action plan being implemented by the Trust will ensure we comply with the measures required of the improvement notices. Failure to comply with the requirements of a Notice is a criminal offence which could result in imprisonment or a fine. The action plan will ensure we have effective arrangements in place to address:

a. Improvement Notice One. The Emergency Department “have failed to make and give effect to such arrangements as are appropriate for the effective planning, organisation, control, monitoring and review of the preventative protective measures required to adequately manage the health risks of exposure to blood borne viruses to your employees from the use of medical sharps”. Compliance date: 30 September 2019.

Action Plan

(1) Ensure that the appropriate personnel are involved in the planning and implementation of a management system for controlling the risks from blood borne virus. We need to involve other members of the teams to assist with the risk assessment process including clinical practitioners using medical devices; health and safety representative

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(2) Adopt a systematic approach to the completion of risk assessments (RAs) that considers the risk from exposure to blood borne viruses. The risk assessments should identify the types of sharps needed to complete a task and whether all or some of them can be replaced to reduce risk.

(3) Identify where safe sharps are not available and ensure that our risk assessments devise safe system of work (SSOW) for working with and disposal of the sharp. The risk assessment should also consider foreseeable circumstances that may arise when, although available it is not reasonably practicable to use a safer device

(4) Where activities require work between 2 or more people, develop a system to ensure a system of work that incorporates a neutral zone to ensure that sharps are not handed directly from one person to another person.

(5) Establish a system which prioritises the completion of the risk assessments and the implementation of preventive and protective measures and where necessary consider the provision of temporary, interim controls.

(6) Ensure arrangements for the appropriate clinical personnel with the appropriate level of expertise are involved in the implementation of new clinical devices and for the reviewing requests for exemption.

(7) Establish arrangement for the effective means of communication and consultation to ensure employees are provided with information and training to ensure that they know how to work safely and without risks to health with the specific sharps equipment.

(8) Ensure arrangements for the employees have sufficient health and safety information so that control measures can be implemented effectively especially where patients bring their own devices into the trust or need assistance from community staff when using non-safety devices. The trust needs to ensure that arrangements are in place to develop a safe system of work, give appropriate information, training and equipment to deal with this situation.

(9) Ensure arrangements for the appropriate employees are included in the arrangements with clear roles and responsibilities for those involved and activities are co-ordinated e.g. someone from procurement to ensure that ordering of unauthorised non-safety devices is prevented both in the acute hospital and by the community teams.

(10) Ensure that the trust has arrangements for the effective monitoring and review of the effectiveness of the preventative and protective health and safety measures identified.

(11) Develop a system for checking that areas and departments have appropriately applied and remedial actions identified are implemented. This should include monitoring if suitable and sufficient risk assessments are completed and have been implemented.

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(12) Develop communications across the trust to identify good compliance with your procedures as well as identifying absent or inadequate procedures to ensure that these are not replicated elsewhere.

(13) Develop a system to interrogate incident data, for carrying out suitable investigations to identify trends and root causes and taking appropriate action to prevent a repetition of incidents involving medical sharps.

(14) Develop a system for communicating the findings from the investigations to all areas in the trust that use those specific devices in order that lessons may be learned.

b. Improvement Notice Two. The trust has “failed to make a suitable assessment of the risks to the health of your employees from exposure to blood borne viruses as a consequence of using medical sharps in the Acute Medical Unit at Hereford County Hospital. You have failed to identify where safety devices can reasonably be used during certain procedures e.g. during the insertion of a chest drain where you have not sufficiently explored the use of safety scalpels and safety hypodermics for the injecting of local anaesthetic”. Compliance date: 30 June 2019.

Action Plan

(1) Review or undertake an assessment of the risks to the health of trust employees from exposure to blood borne viruses as a consequence of working with medical sharps in the acute medical ward.

(2) Identify and assess those tasks where medical sharps are used and identify whether all or some of the devices can be substituted with safety devices e.g. insertion of a chest drain involves the use of scalpels and hypodermics.

(3) Where safety devices are not available the risk assessment should identify additional controls necessary for the production of safe systems for working with and disposing of sharps.

(4) Ensure there are arrangements for recording the significant findings of your assessment.

(5) Ensure the risk assessment are regularly reviewed e.g. following an inoculation injury to establish if additional controls can be implemented to prevent recurrence. When other arrangements identify that a new safety devices is available by discussing it with key personnel in procurement.

(6) Record the significant findings of the review of assessment in a way which represents an effective statement of hazards, risks and actions to be taken, to protect the health of employees and anyone else who may be affected by the risk, with, where appropriate, reference to other documents describing procedures and safeguards.

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(7) Ensure the key findings of the risk assessment are appropriately and regularly communicated to those employees undertaking this type of work.

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BOARD OF DIRECTORSReport to: Board of Directors Agenda item: 7.3.1Date of Meeting: 2 May 2019Title of Report: Clinical Quality Committee Summary Report of 28th March 2019 meetingStatus of report:(Approval, position statement, information, discussion)

For information

Report Approval Route: N/ALead Executive Director: Lucy Flanagan, Director of NursingAuthor: Christobel Hargraves, Chair of Clinical Quality CommitteeAppendices:

1. Purpose of the report

The Board of Directors are invited to receive and note the report.2. Recommendations

To note the contents of the report and consider any items highlighted for its attention.3. Executive Director Opinion

N/A4. Please state which element of the Trust’s Objectives the report relates to:

1. Reduce the variation in the quality of care we

provide and avoidable death rates by delivering on our quality priorities

6. Reduce the financial deficit by delivering our financial plan

2. Improve urgent care by delivering the A & E standard and providing more services across seven days

7. Improve the quality and sustainability of our services by implementing our clinical strategy

3. Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

8. Care for people nearer to home by transforming our community services with our One Herefordshire partners

4. Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

9. Improve our effectiveness through the delivery of our Digital Strategy

5. Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.

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Summary of Key Issues for Discussion

Divisional reports:

Surgical: There had been a continued improvement in reducing the number of patients waiting over 52 weeks for treatment -now down to four and a significant improvement in the numbers of patients waiting an endoscopy procedure with the exception of those waiting for colorectal procedures. Plans were in place to improve this position.

The National Troubled Families Unit had recognised the integrated work that the Health Visiting Service was undertaking.

Areas for improvement included VTE assessment compliance and Friends and Family responses. The Breast Symptomatic two week wait service was still causing significant concerns sometimes leading to waits of over 6 weeks but there had been a particular focus on working to resolve this issue with additional clinics being held. Leadon ward was an area of concern having had a significant fall with harm, a category 3 pressure ulcer and two cases of C-Diff.

Clinical Support: Priorities were the production of an audit programme that reflected their governance agenda and improving reporting of low and low harm incidents. There was also a focus on cleanliness particularly in Radiology where there were other concerns with regard to overall governance of the department.

The lack of an Acute Oncology Service was felt to be a risk but it was planned to be mitigated by recruiting to a specialist nursing post

Confidential Items:

The Committee was informed of the eight serious incidents that had been reported in February and also the two that were closed in month. The Committee requested that one of these closed incidents should be reviewed as it was not felt that the actions were complete.

Progress on the action plan relating to last year’s nasogastric tube never event was reviewed. There remained some concerns around training of locum/agency staff where further work was required.

Mortality Report: There continued to be a reduction in the SHMI (106.01) and the HSMR (105.60) and the weekend HSMR now comparing to the weekday rates (107.8). Specifically there had been a reduction in the HSMR rates for pneumonia, CCF and septicaemia but deaths following a fractured neck of femur remained a concern. There was now a particular focus on this area with a reduction in numbers expected.

Inpatient Falls Update Report: Falls rates had decreased consecutively over the last three months and were now lower than that for the last three years. However overall harm had increased but was still within natural variation. Focus was being placed on Arrow ward since its change of specialty as there had been an increase of falls. The success of the improvements to bathrooms at Leominster was noted as there had been a decrease in falls in this area.

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VTE Improvement Plan Update and Action Plan: Following the lack of assurance at the February meeting the Action Plan had now been split into ten work streams. A recent audit showed the Trust’s achievement of the 95% target of VTE assessment including detailed assessment of a random sample of patients. The problem seems to be that the VTE assessment is happening but not been correctly documented.

It was reported that there was a lack of resource available to undertake the appropriate management of this area and it was agreed to report back on how this would be addressed in June.

Pressure Ulcer Update Report: A new Skin Bundle was being trialled within the Trust as a result of an increased number of acquired Deep Tissue Injuries. Pressure alleviating equipment was also being looked at where necessary. However there continued to be a reduction of pressure ulcers requiring to be reported as SIs.

Clinical Effectiveness and Audit Committee Update: The Natsipps and Locsipps process had now been implemented across the Trust into the Divisions supported by a SOP. An audit process had been agreed with some audits already completed and a Trust wide one due to commence from April.

CQC Action Plan Update: A number of improvements were on track but some “must dos” had slipped so an increased focus was required as it was with some of the more challenging “should dos”.

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WYE VALLEY NHS TRUST

Minutes of the Charity TrusteeHeld on 21ST March 2019

Boardroom, Trust Headquarters, Hereford County Hospital

Present:

Frank Myers, MBE FM Charity Trustee Chair and NEDGlen Burley GB Chief Executive OfficerLucy Flanagan LF Director of NursingRussell Hardy RH Chairman Christobel Hargraves CH Non-Executive Director (NED)Erica Hermon EH Associate Director of Corporate Governance/

Company Secretary Richard Humphries RH Non-Executive Director (NED) – Dialed inHoward Oddy HO Director of Finance & InformationSue Smith SS Director of Human ResourcesMark Waller MW Non-Executive Director (NED)

In attendance:

Clive Andrews CA Associate Director of FinanceKatie Farmer KF FundraiserVici Whittall VW Executive Assistant for the minutes

Minute Action

CT001/03.19 Apologies for Absence

Apologies were received from Andrew Cottom, Non-Executive Director, David Mowbray, Medical Director, Steve Scotcher, Consultant Ophthalmologist and Jon Barnes, Chief Operating Officer.

CT002/03.19 Quorum

The meeting was quorate.

CT002/03.19 Declarations of Interest

None declared.

CT003/03.19 Minutes of the meeting

The minutes of the last meeting on 2nd October 2018 were accepted as an accurate record.

Resolved – that the minutes of the meeting held on 2nd October 2018 be confirmed as an accurate record and signed by the Chair.

CT004/03.19 Matters Arising and Action Log

Resolved – that the action update be received and noted.

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FINANCE

CT005/03.19 Quarter 3 2018/19 Finance Report

The Associate Director of Finance (ADF) presented and the following key points were noted:

a) The ADF highlighted the summary included on the front sheet of the report, noting that the aim was to maintain funds in balance at all times.

b) The ADF noted there was a net increase in resources of £151k in the first three quarters of the financial year.

c) The ADF noted the expenditure for Quarter’s 1 to 3 is slightly lower than in previous years reflecting the high value pending commitments in the accounts and that this is a finite resource that must be managed carefully.

d) The ADF noted the original costs identified for installation of the gamma camera were estimated to be £30k. This proved to be an under-estimate and the final costs are £112k and £65k of this is to be funded from charitable funds with the balance met by Trust capital resources. The high installation costs have been discussed at Audit Committee.

e) The Chairman noted the Committee should make the Director of Strategy and Planning aware of their concerns of the high installation costs of the gamma camera and the concerns of Audit Committee.

EH

Resolved – that:

(A) The Quarter 3 2018/19 Finance Report be received and noted.

(B) The Associate of Director of Corporate Governance will make the Director of Strategy and Planning aware of their concerns of the high installation costs of the gamma camera and the concerns of Audit Committee.

EH

CT006/03.19 Fundraising Update

The Fundraiser (FR) presented the Fundraising Update and the following key points were noted:

a) The FR noted the Born Sleeping Appeal (BSA) has exceeded the target sum required to carry out all of the building works and furnish all areas. At the time of writing, the total income stands at £120,000, £45,000 over target with further money still to come in.

b) The FR noted that Mercia will fund a “thank you” plaque.

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c) The Director of Finance (DFI) noted that the BSA has raised funds mainly through small scale fundraising projects.

d) The FR noted that phase 1, the counselling room, is underway and the overnight room will be larger than planned at no extra cost. The project has remained in budget.

e) The FR noted that the final stage, the delivery suite, is still scheduled to commence in March and to be completed by the end of April. Revd. Hargraves (NED) suggested inviting a celebrity to open this, noting this date will soon be here. The Communications Team need to advertise the date of the opening to enable staff to have the date in their diaries. This could link with the LMS website. The Director of Nursing (DoN) suggested inviting Sarah Jane Marsh, Chair of the NHS England Maternity Transformation Programme.

f) Mr. Myers (Chair and NED) asked if more resources could be made available to recruit a project manager. The DFI noted that this would be effective for large projects and for managerial support to help projects to progress. They could assist with organising meetings.

g) The Chairman noted that the BSA had been a successful and visible campaign. The momentum should be kept going into new projects.

KF

AD

Resolved – that:

(A) The Fundraising Update be received and noted.

(B) The Fundraiser to liaise with the Communications Team with opening date of the delivery suite.

(C) The Director of Strategy and Planning to investigate the possibility of more funds being made available to recruit a project manager.

KF

AD

CT007/03.19 The Next Campaign

The FR presented The Next Campaign and the following key points were noted:

a) The FR noted that she had received four ideas for the next campaign. She had asked for small scale projects but felt the suggested projects were too big. These were:-

An extension at Gaol Street Extending the MacMillan Renton Unit SCBU parents room Development of the urology diagnostic centre.

b) The FR noted that a small project may be a gym for rehab on Wye ward.

c) The Chief Executive Officer noted that he expected the combined education centre to be put forward as an idea.

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d) The Director of Human Resources (DHR) asked if charitable funds could sponsor scholarships. She noted that bursaries do not always cover the full cost of scholarships.

e) The Chairman noted we should seize the opportunity to make things happen. The FR gets little support. The Trust Executive Team must take responsibility and come forwards with ideas.

f) The DFI noted that small fundraising schemes could be taken through Executive Directors Meeting. It is disappointing that not all Executives attend this Committee. The Committee should revisit the process of how projects are chosen for charitable funds. Mr. Myers, ( Chair and NED) asked that by the next meeting on the 20th June that some conclusive decisions are made on delegating authority to Executives to recommend small projects

JI

JI

Resolved – that:

(A) The Next Campaign verbal update be received and noted.

(B) The Trust Executive Team to take responsibility and come forward with ideas for projects for the Fundraiser. Small fundraising schemes can be taken through Executive Directors Meetings.

(C) The Committee should revisit the process of how projects are chosen for charitable funds and by the next meeting on the 20th June that some conclusive decisions are made on delegating authority to Executives to recommend small projects

JI

JI

CT008/03.19 Charitable Bid for Patient Chairs

The DFI presented the Charitable Bid for Patient Chairs and the following key points were noted:

a) The DFI and DoN noted the charitable bid for patient chairs for tissue viability purposes. This is at a cost of £49k plus VAT. This has been agreed as an appropriate use of resources. The Charity Trustee approve the purchase of the patient funds.

Resolved – that the Charitable Bid for Patient Chairs be received and the purchase of patient chairs is approved by the Charity Trustee Committee

GOVERNANCE

CT009/03.19 Review Charity Trustee Effectiveness

The Associate Director of Corporate Governance provided a verbal update on the Review Charity Trustee Effectiveness and the following key points were noted:

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a) The Associate Director of Corporate Governance (ADCG) proposed to review the workings of the Charity Trustee using the same methodology as the review of the Audit Committee. This would be circulated to meeting attendees by the ADCG.

EH

Resolved – that:

(A) The Review of Charity Trustee Effectiveness be received and noted.

(B) The findings of the review into the workings of the Charitable Funds Committee, using the same methodology as the review of the Audit Committee, will be circulated to the attendees by the ADCG.

EH

CT010/03.19 Review Charity Trustee Terms Of Reference

The ADCG presented the Charity Trustee Terms Of Reference and proposed to review the Terms Of Reference to reflect the need for management scrutiny and recommendations prior to submission to the Charity Trustee.

EH

Resolved - that:

(A) The Review of Charity Trustee Terms of Reference be received and noted.

(B) The Associate Director of Corporate Governance would review the Charity Trustee Terms of Reference prior to resubmitting to the Committee for approval.

EH

CT011/03.19 Charity Trustee Workplan

The ADCG presented the Charity Trustee Workplan and proposed to ensure the work plan aligns with the management dates for significant Trust meetings

EH

Resolved – that:

(A) The Charity Trustee Workplan be received and noted.

(B) The ADCG will review the workplan to ensure it aligns with the management dates for significant Trust meetings.

EH

CT012/03.19 Any Other Business

There was no further business to note.

CT013/03.19 Date of next meeting

The next meeting is due to be held on 20th June at 1.00 pm in the Boardroom, Trust Headquarters, Hereford County Hospital.

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